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   Table of Contents - Current issue
July-December 2020
Volume 8 | Issue 2
Page Nos. 71-138

Online since Wednesday, February 3, 2021

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Indocyanine green video angiography in vascular neurosurgery p. 71
Jaspreet Singh Dil
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Aneurysm surgery during the COVID-19 pandemic: Ecstasy, agony and dilemma p. 73
Daljit Singh
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Effectiveness of cerebral bypass revascularisation procedures in adult cerebrovascular ischaemic stroke: Looking beyond COSS – A single surgeon's experience of 7 years p. 78
V R Roopesh Kumar, Vishwaraj Ratha, Rithesh Nair, S Karthikeyan, Adhithyan Rajendran, Ramya Soundararajan
Context: Adults with haemodynamic stroke secondary to cerebrovascular ischaemic events, continue to develop stroke despite optimum medical management. Aims: This study aims to identify patients with adult ischaemic stroke presenting with significant haemodynamic failure based on radiological and molecular imaging and perform Revascularisation procedure to prevent further stroke. Settings and Design: This is a retrospective database analysis of patients with CVOD requiring cerebral revasularisation procedure from 2013 to 2019. Materials and Methods: Twenty-two adult patients with age ranging from 26 to 72 years presenting with recurrent transient ischaemic attacks (TIAs) were evaluated for haemodynamic insufficiency by neuroimaging and acetazolamide challenged single-photon emission computed tomography perfusion. Those with decompensated haemodynamic insufficiency underwent cerebral revascularisation with superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. Results: Of the 22 patients, in 12 patients, the procedure was done electively and in remaining 10 patients as emergency (<48 h of the onset of symptoms). Ninety-one per cent of the patients recovered well without any further TIAs. Neurological worsening was observed in 4.5%. Two patients who presented with refractory migraine like symptoms improved dramatically without further headaches. Uneventful wound complications were associated in 9% of cases. Follow-up radiological evaluation showed good graft patency in 95% (21/22) patients. The single case of graft thrombosis developed new MCA territory infarct requiring prolonged rehabilitation for the neurological deterioration. Conclusion: Cerebral revascularisation with STA-MCA bypass in selected patients with impending haemodynamic insufficiency results in good outcome and prevents further strokes despite continuing optimum medical therapy.
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Dual microcatheter technique for coil embolisation of irregular and wide-necked intracranial aneurysms: A case series p. 87
Amit Kumar Sharma, Anita Jagetia, Arvind Kumar Srivastava, Daljit Singh
Background: The endovascular coiling of ruptured aneurysms with complicated geometry presents a significant treatment challenge, especially with the non-availability of adequate sized coils and balloon/stent. The dual microcatheter technique is an alternative treatment for stent-assisted coiling in acutely ruptured wide-necked aneurysms because of no antiplatelet therapy. Objective: We report our initial experience with the use of a dual microcatheter technique in seven patients. The technique provided an efficient strategy for treating aneurysms with complicated configurations and high risks. Patients and Methods: We describe a technique used to treat seven patients with irregular shaped and wide-necked aneurysms. In the initial attempts at embolisation, coil instability within the aneurysm or significant impingement of coil loops on the parent artery was observed. The advancement of a second microcatheter into the aneurysm allowed two coils to be braced across the aneurysmal neck before the detachment of either coil. This technique permitted successful coil treatment. Conclusion: The dual microcatheter technique is a safe and effective treatment for acutely ruptured wide-necked aneurysms due to few treatment-related complications and mortality rate.
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Posterior communicating artery aneurysms: Analysis of predictors of surgical outcome p. 91
Sumeet Narang, Harpreet Kaur, Jaspreet Singh Dil, A Raja
Background: Although aneurysms of the posterior circulation are not as common as those of the anterior circulation, the threat they pose can be reduced with timely surgical intervention. The study analyses factors that influence the outcome in surgically clipped posterior communicating artery (PCoA) aneurysms. Methods: A retrospective analysis of 85 cases of surgically clipped PCoA aneurysms was carried out, taking into consideration, the presenting signs and World Federation of Neurological Societies (WFNS) grade at admission, the timing of the surgery and the outcome of the surgery as per the Glasgow Outcome Scale. Results: About 56.8% of cases were clinically WFNS Grade I at admission. About 75.9% of all patients and 90% of patients who were Grade I and 74% of patients who were Grade II had a good recovery as per the Glasgow Outcome Scale. The overall mortality was 6.9%, and all patients who did not survive despite surgery were initially WFNS Grade IV patients. Conclusion: A higher or clinically worse WFNS grade of subarachnoid haemorrhage at the time of admission in patients with PCoA aneurysms predicts a poor surgical outcome, regardless of the timing of the surgery.
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A hospital-based study of stroke-related mortality p. 95
Masaraf Hussain, Shriram Sharma, Baiakmenlang Synmon, Yasmeen Hynniewta
Background: Stroke is the second-most common cause of mortality worldwide. Stroke-related mortality data are needed for following health trends and for planning health policy. Objective: The objective is to determine the incidence of stroke-related mortality in 1 year, to study the demographic profile and risk factors of stroke mortality, and to study the complications due to stroke leading to mortality. Materials and Methods: We conducted a retrospective hospital-based study for stroke-related mortality that had occurred between March 2019 and March 2020. The data were reviewed for demographic profile, co-morbidities and complications which had occurred during hospital stay. Results: A total of 51 patients had stroke-related mortality, mostly involving the age group of 41–50 years. There was a male pre-dominance of stroke-related mortality, except in the oldest (>80 years) age group. Haemorrhagic stroke had higher mortality, as compared to ischaemic stroke, with a lower mean age of mortality. Hypertension and alcohol consumption were the most common co-morbidities for haemorrhagic stroke-related morbidities, while dyslipidaemia, diabetes mellitus, smoking and cardiac illness were more common in ischaemic stroke-related mortality. Aspiration pneumonia was the most common complication in stroke-related mortalities. Conclusion: The study has shown a concerning trend of stroke-related mortality involving younger age group. Aggressive treatment of co-morbidities and complications is necessary to reduce mortality due to stroke.
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Effectiveness of speech and language therapy and spontaneous recovery in anomic aphasia p. 101
K Sandhya
Introduction: Anomia is a problem with naming objects. Anomic aphasia, also called as anomia or amnesic aphasia, is characterised by word-finding difficulties in the absence of major syntactic impairment. Objectives: To determine the effectiveness of therapy techniques in recovery of language abilities in a patient with anomic aphasia. Materials and Methods: Prospective study of a patient diagnosed with anomic aphasia secondary to ischaemic stroke, whose response and progress was followed from the time of presentation, along the course of therapy with techniques including semantic feature analysis (SFA) and phonological component analysis (PCA), and scored according to the guidelines of Manual for Adult Non-Fluent Aphasia Therapy in Kannada (MANAT-K). Results: Significant improvement was noted in the patient's naming skills, with an increase in almost 20% in the score in confrontation naming, responsive naming, and word fluency, post-therapy, as compared to pre-therapy. Conclusion: Although there is contribution of spontaneous recovery in the betterment of a person with aphasia, timely planned therapy brings about a marked improvement in the patient's language abilities.
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Statistical corner: Using R to build, analyse and plot clinical neurological datasets p. 107
Mikko Jaakko Pyysalo, Teemu Vesterinen
Introduction: In the field of medical research, large volumes of data need to be analysed accurately, and it is crucial to pre-process the data before it can be analysed. The 'R' environment is a programming language and environment for statistical computing and graphics suitable for the analysis of data sets. Objectives: To provide examples on how to utilise the R language for data processing, and its usefulness for medical researchers. Materials and Methods: Two real world datasets, ie, data for: 'Effect of Morning Blood Pressure Peak on Early Progressive Ischemic Stroke: A Prospective Clinical Study' and data for: 'Impact of early surgery of ruptured cerebral aneurysms on vasospasm and hydrocephalus after SAH: our preliminary series' have been used to present an example for two different approaches for the process of data analysis using R. Results: Accurate and tidy data sets were obtained. Conclusions: R is a reliable environment for the processing of large data sets.
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Diagnosis and treatment of basilar artery perforator aneurysm: A 20-year review with proposed treatment guidelines p. 113
Sibhi Ganapathy, TS Lingaraju
Introduction: Aneurysms of the vertebrobasilar system comprise approximately 10%–15% of all intracranial aneurysms and most occur at the bifurcation of the basilar artery. Posterior circulation perforator artery aneurysms are sparsely reported in the literature. The natural history of these rare lesions remains unclear and their diagnosis and management are not well defined. Materials and Methods: All case reports and case series from the past 20 years were analysed, and the results tabulated. Based on broad trends, guidelines were proposed for management. Results: Forty-two cases from 22 case reports and case series were analysed. Most were managed endovascularly, with a complication rate approaching 43%. Observation was another popular treatment option with however a comparable morbidity of 42% only surgery proved to be better overall. Aneurysm size was inversely correlated with complication rate with smaller lesions more prone to rupture and complications. The nature of the perforating artery was also found to be a factor, where direct brain stem perforators from the upper two-third of the basilar artery were found to be difficult to treat both by surgery and endovascular methods, leading to significant failures and complications as compared to the wider circumflex perforating arteries. Conclusion: Scarce published literature that addresses the limited understanding of the natural course of this entity lead to difficulties in proposing broad-based recommendations that are fail proof. Nevertheless, we hope this analysis of 20 years of data helps in shedding light on this difficult disease and its possible treatment options along with risks and outcomes.
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Basilar aneurysm and coarctation of the aorta p. 123
Shrikant K Kalbagwar, Pandurang S Barve, Trimurti D Nadkarni
A 31-year-old male presented with subarachnoid haemorrhage due to a basilar tip aneurysm associated with an incidental coarctation of the aorta (CoA). The aneurysm was treated with endovascular coiling. Patients with CoA frequently harbour intracranial aneurysms at a young age. The occurrence of basilar tip aneurysm associated with CoA is extremely rare. The relevant literature on the subject is discussed.
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Microsurgical clipping of anterior choroidal artery aneurysms: Tips and tricks p. 126
Kamlesh Kumar Singh, Vinod Kumar, Debish Anand, R Girish Menon
Anterior choroidal artery (AChoA) aneurysms are rare intracranial aneurysms which pose considerable challenge both for surgical clipping and endovascular coiling. The small size of the parent artery, variability in its point of origin from the internal carotid artery and the high rate of ischemic complications make AChoA aneurysms formidable surgical challenge. We present two cases of aneurysm highlighting the technical challenges involved in the microsurgical clipping of AChoA aneurysms.
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Traumatic distal anterior cerebral artery aneurysm in a 3-year-old child: An uncommon but notable case p. 130
Piyush Kumar Panchariya, Ghanshyam Singhal, Anita Jagetia, AK Srivastava
Aneurysm in paediatric population is a relatively less reported vascular pathology. In contrary to degenerative and dysplastic causes as in their adult counterpart, the mechanism lies either in a congenital defect in vessel wall or following some traumatic event. Traumatic intracranial aneurysms (TICA) are again not a common occurrence. TICAs constitute <1% of all intracranial aneurysms. They can occur following blunt or penetrating head trauma and are more common in the paediatric population. Traumatic aneurysms are typically associated with an acute episode of delayed intracranial haemorrhage with an average time from initial trauma to aneurysm haemorrhage of approximately 21 days. The youngest case reported for a traumatic distal anterior cerebral artery (ACA) aneurysm is of a 6-week old child due to shaken baby syndrome. We report an interesting and rare case of a traumatic distal ACA aneurysm in a 3-year-old child.
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Kissing aneurysms of the internal carotid artery p. 134
Amit Kumar Sharma, Anita Jagetia, Arvind Kumar Srivastava, Daljit Singh
Kissing aneurysms (KAs) are rare and cause various problems when clipping of these aneurysms is attempted because they often partially adhere to each other. A 65-year-old female presented with subarachnoid haemorrhage due to a ruptured aneurysm originating from the left internal carotid artery (ICA)-posterior communicating artery A. She also had an unruptured aneurysm arising from the bifurcation of a left ICA-anterior choroidal artery A. Intraoperative findings revealed that these were KAs. Surgical clipping was performed. The postoperative period was uneventful. In this case report, we would like to stress the rarity of KAs and the difficulty in the diagnosis and management of such cases.
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Foot drop – Common entity, uncommon aetiology p. 137
Rajendra Singh Jain, Yavnika Jain, Tushar Desai, Trilochan Srivastav
Foot drop is defined as the weakness of the tibialis anterior muscle and is frequently accompanied by weakness of the extensor hallucis longus and extensor digitorum longus. Dural arteriovenous (AV) fistula present mainly as progressive myelopathy, though it can also appear as amalgam of upper and lower motor involvement signs. Digital subtraction angiography is the definitive radiological procedure in the pre-treatment evaluation of vascular malformation. Treatment modalities include surgical resection or angiographically guided embolisation of malformation. We are reporting a case of spinal AV fistula presenting as unilateral foot drop, which showed significant improvement following the neuro-radiological intervention. Here, we report a rare presentation of spinal AV fistula as foot drop, showing good recovery following glue embolisation.
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