Pakistan Journal Of Neurological Surgery https://pakjns.org/index.php/pjns <p>Pakistan Journal of Neurological surgery (PJNS) is an official Journal of the Pakistan Society of Neurosurgeons (PSN), Department of Neurosurgery, Punjab Insitute of Neurosciences (PINS) Lahore Pakistan. It has been in print since 1998.</p> <p>Journal archives: (<a href="https://pakjns.org/index.php/pjns/issue/archive">https://pakjns.org/index.php/pjns/issue/archive</a>)</p> <p>Journal Email: admin@pakjns.org</p> <p>Publisher link: (<a href="http://www.paksn.org/pjns/">http://www.paksn.org/pjns/</a>)</p> <p>Email: publisher.pakjns@paksn.org</p> Pakistan Society of Neurosurgeons (PSN). Website: https://www.paksn.org/pjns/. Email, Email: publisher.pakjns@paksn.org en-US Pakistan Journal Of Neurological Surgery 1995-8811 <p>The work published by PJNS is licensed under a Creative Commons Attribution-<a href="https://creativecommons.org/licenses/by-nc/4.0/" target="_blank" rel="noopener">NonCommercial 4.0 International (CC BY-NC 4.0).</a> Copyrights on any open access article published by Pakistan Journal of Neurological Surgery are retained by the author(s).</p> Need for Establishing a Joint-Stroke Centers with Neurosurgeons and Neurologists https://pakjns.org/index.php/pjns/article/view/985 Saman Shahid Muhammad Anwar Chaudary Copyright (c) 2024 Saman Shahid, Muhammad Anwar Chaudary https://creativecommons.org/licenses/by-nc/40/ 2024-06-13 2024-06-13 28 2 xi xii 10.36552/pjns.v28i2.985 Comprehensive Analysis of Spinal Dysraphism: Early Institutional Experience at Pediatric Neurosurgery of Punjab Institute of Neurosciences https://pakjns.org/index.php/pjns/article/view/951 <p><strong>Objective:</strong> To examine the demographic and clinical characteristics of pediatric patients presenting with spinal dysraphism.</p> <p><strong>Material and Methods:</strong> This retrospective study was conducted at the Department of Pediatric Neurosurgery, Punjab Institute of Neurosciences in Lahore and included data from patients aged &lt;16 years with spinal dysraphism over 7 months from March 2023 to September 2023. Data analysis was performed using SPSS version 27.0.</p> <p><strong>Results:</strong> Among 32 patients, age distribution: &lt;1 year (37.5%, mean age: 5.58±2.31 months), 1-4 years (25%, mean age: 3.25±0.6 years), 5-15 years (37.5%, mean age: 11±2.6 years). Gender: 22 males (68.75%), 10 females (31.25%). The most prevalent clinical presentations were Myelomeningocele (18.75%) and Meningocele (15.63%), both predominantly observed in patients under 1 year of age. Among the cutaneous findings, Fluid sacs (34.38%) and Tuft of Hair (15.63%) were the most common. In terms of other clinical findings, Lower Limb Weakness (50.00%) and Lower Limb Muscle Atrophy (21.88%) had the highest percentages.</p> <p><strong>Conclusion:</strong> The study revealed a diverse age distribution, with Myelomeningocele and Meningocele being common clinical presentations, especially in infants. Some of the physical signs of the condition included a fluid sac. a tuft of hair on the back, and weak and underdeveloped leg muscles.</p> Hassaan Zahid Muhammad Irfan Usman Ahmad Kamboh Asad Iftikhar Shah Hassan Ali Syed Shahzad Hussain Copyright (c) 2024 Hassaan Zahid, Muhammad Irfan, Usman Ahmad Kamboh, Asad Iftikhar Shah, Hassan Ali, Syed Shahzad Hussain https://creativecommons.org/licenses/by-nc/40/ 2024-06-01 2024-06-01 28 2 153 161 10.36552/pjns.v28i2.951 Computed Tomography Findings of Traumatic Brain Injury and its Assessment in a Teaching Hospital https://pakjns.org/index.php/pjns/article/view/979 <p>The objective of the study was to evaluate the frequency and findings of traumatic brain injury on computed tomography in Tertiary Care Teaching Hospital, Mardan Medical Complex.</p> <p><strong>Materials &amp; Methods:</strong>&nbsp;&nbsp;A prospective cross-sectional study from March 2023 to February 2024 was done in Mardan Medical Complex (MMC), Mardan. Non-probability convenience sampling technique was used with a sample size of 680. Data collection was done from the Radiology and Emergency departments with consent taken. Data descriptive statistical analysis was done through SPSS version 22.</p> <p><strong>Results:</strong>&nbsp;&nbsp;A total of 680 patients were scanned including 471(69.26%) males and 209(30.74%) females. The frequency (389) (57.20%) of traumatic brain injury was high in age group 1-19 and least (60) (8.82%) in age group &gt;60. CT brain scan findings revealed 397(58.39%) normal and 283(41.62%) abnormal patients. In abnormal patients, the most common findings on CT were intra-axial hemorrhage 117(41.36%). The most common mode of injury was RTA 326(47.94%) followed by HOF 212(31.18%).</p> <p><strong>Conclusion:</strong>&nbsp;&nbsp;The study showed that in traumatic brain injury, the majority of the subjects were male as compared to female and the most common mode of injury was road traffic accidents followed by falls from height. The findings of intra-axial hemorrhage were the highest in all traumatic brain injuries</p> Ghazan Khan Mewat Shah Khurram Saleem Yasmeen Shifa A. Khan Muhammad Rizwan Copyright (c) 2024 Ghazan Khan, Mewat Shah, Khurram Saleem, Yasmeen, Shifa A. Khan, Muhammad Rizwan https://creativecommons.org/licenses/by-nc/40/ 2024-06-01 2024-06-01 28 2 162 169 10.36552/pjns.v28i2.979 A Study on Ocular Manifestations Seen in Patients with Cerebral Palsy https://pakjns.org/index.php/pjns/article/view/980 <p><strong>Background:</strong>&nbsp;&nbsp;Cerebral palsy (CP) encompasses various neurological disorders like abnormal brain development or permanent brain damage, impacting muscle tone, and motor function. This study assessed ocular manifestations in patients with CP, including visual acuity, refractive errors, ocular alignment, and anterior and posterior eye segments.</p> <p><strong>Materials &amp; Methods:</strong>&nbsp;&nbsp;This retrospective study was conducted at the Department of Ophthalmology Khyber Teaching Hospital (KTH) from 1st November 2022 to 30<sup>th </sup>September 2023. Data collected included detailed medical, ocular, and birth histories, age and gender of the patient, type of CP, visual acuity (VA) if possible, type of refractive error, ocular alignment and motility and anterior and posterior segments examination of the eyes. Data analysis was done using SPSS version 23.</p> <p><strong>Results:</strong>&nbsp;&nbsp;The study included 40 patients of which twenty-nine (72.5%) were male. The study found spastic CP to be the most prevalent in 23 (57.5%) patients followed by hypotonic CP 12 (30%) and mixed type 5 (12%). VA was examined in CP patients over 4 years with a mean VA of 0.6 and a range of 0.0 to 0.8 LogMAR. Strabismus was found in 33(82.5%) patients with esotropia being the most common in 21 (52.5%) patients, exotropia in 6 (15.0%) patients, and vertical deviation in 6 (15.0%) patients. Ocular motility defect of abduction deficit was found in 2 (5%) patients. Other findings included ptosis in 1(2.5%), nystagmus in 2(5%).</p> <p><strong>Conclusion:</strong>&nbsp;&nbsp;Most children with cerebral palsy exhibit ocular abnormalities, necessitating regular ophthalmic examinations to prevent life-long visual disabilities/complications and to support their overall development.</p> Nazli Gul Muhammad Rizwan Yasmeen Momina Haq Anam Haq Imran Ahmed Copyright (c) 2024 Nazli Gul, Muhammad Rizwan, Yasmeen, Momina Haq, Anam Haq, Imran Ahmed https://creativecommons.org/licenses/by-nc/40/ 2024-06-01 2024-06-01 28 2 170 176 10.36552/pjns.v28i2.980 Intracranial Meningioma; Assessment of Tumor Size and Clinical Feature on First Presentation https://pakjns.org/index.php/pjns/article/view/972 <p><strong>Objective:</strong> To assess the tumor size of intracranial meningioma on first presentation and their clinical features.</p> <p><strong>Materials &amp; Methods:</strong> A prospective review of patients undergoing meningioma resection at the Neurosurgery department, Jinnah Postgraduate Medical Center, Karachi was performed. The clinical records and imaging studies of 43 patients with intracranial meningiomas were analyzed. The data was collected for tumor size, location, first symptom, and clinical features.</p> <p><strong>Results:</strong> There were 31 (72.1%) female and 12 (27.9%) male patients with a mean age of 45.6 years (std: 8.18 years). convexity and Parasagittal meningiomas had the highest frequency (32.6% and 30.2% respectively). The average tumor size was greater than 60mm (44.2%). Skull base tumors presented with a size of more than 60mm (60.0%), followed by convexity meningiomas (57.1%). The most common initial symptom was headache (46.5%) followed by seizures (11.6%). The patients presenting with a duration greater than 24 months (32.6%) had a size greater than 60mm (57.1%). Convexity and skull base meningiomas presented lately greater than 24 months of duration (50%), however, parasagittal meningioma generally presented earlier in less than 6 months of duration 53.8%.</p> <p><strong>Conclusion:</strong> Tumor size location, and clinical features at the first presentation are interlinked<strong>. </strong>Larger tumors were found on the first presentation, with headache and seizure being the most common clinical features. The location also contributed to the early or late presentation of meningioma patients. The association shown between the size and first symptom may be explained by a symptom's tolerance, location, and ongoing medical treatment.</p> <p style="text-align: justify;"><strong>Keywords: </strong> Meningioma, Excision, Space Occupying Lesion, Supratentorial, Clinical Features</p> Haris Hamid Iram Bokhari Arfa Qasim Bushra Maqsood Asra Aslam Farrukh javed Copyright (c) 2024 Haris Hamid, Iram Bokhari, Arfa Qasim, Bushra Maqsood, Asra Aslam, Farrukh javed https://creativecommons.org/licenses/by-nc/40/ 2024-06-13 2024-06-13 28 2 240 247 10.36552/pjns.v28i2.972 Patients Experiencing Cerebrospinal Fluid Leak After Undergoing Elective Posterior Fossa Surgery https://pakjns.org/index.php/pjns/article/view/986 <p><strong>Objective:</strong>&nbsp;&nbsp;This descriptive case series anticipated to explore the occurrence and related factors of CSF leaks in patients undergoing elective posterior fossa surgery, highlighting on identifying possible risk factors and exploring treatment modalities.</p> <p>&lt;<strong>Materials &amp; Methods:</strong>&nbsp;&nbsp;Included 97 patients undergoing elective posterior cranial fossa surgery at Lady Reading Hospital, Peshawar, from July 2021 and January 2022. Thorough patient demographics, surgical indications, and outcomes were precisely documented and investigated.</p> <p><strong>Results</strong><strong>:</strong>&nbsp;70 patients experienced symptoms for one month or fewer, whereas 27 patients underwent symptoms for longer durations, emphasizing a predominant manifestation of short-term symptoms. 43 patients had a BMI of 27 Kg/m<sup>2</sup> or less, even though 54 patients had a BMI exceeding 27 Kg/m<sup>2</sup>. With reference to patients with diabetes mellitus, 17 patients were diabetic, with the bulk, comprising 80 patients, being non-diabetic. 20 patients were hypertensive, while 77 patients were non-hypertensive. 46 patients were diagnosed with hydrocephalus, while 51 patients showed symptoms related to loss of consciousness. The study established that 15% of patients experienced CSF leaks postoperatively, with males including a greater proportion of affected individuals. <strong>Conclusion:</strong>&nbsp;&nbsp;The results highlight the significance of comprehensive preoperative assessments and surgical techniques to minimize the risk of CSF leakage. Whereas conservative methods such as re-suturing the wound and CSF lumbar drainage were first employed, surgical repair became compulsory in some cases. This exploration offers a valuable understanding of the incidence and management of CSF leaks succeeding posterior fossa surgery, proposing guidance for healthcare professionals in elevating patient outcomes.</p> Nafees Ahmad Khan Riffat Ullah Khan Mubbashir Ali Baig Usama Bin Zubair Muhammad Osama Copyright (c) 2024 Nafees Ahmad Khan, Riffat Ullah Khan, Mubbashir Ali Baig, Usama Bin Zubair, Usama Bin Zubair, Muhammad Osama https://creativecommons.org/licenses/by-nc/40/ 2024-06-13 2024-06-13 28 2 230 239 10.36552/pjns.v28i2.986 Awake Craniotomy Versus Surgery Under General Anaesthesia for Resection of Brain Tumour; A Systematic Review of Randomized Control Trials https://pakjns.org/index.php/pjns/article/view/923 <p><strong>Objectives:</strong> To evaluate the clinical evidence on the comparison of results between an awake craniotomy and general anesthesia surgery for brain tumor removal.</p> <p><strong>Materials &amp; Methods:</strong> A systematic literature search was carried out using the PubMed, Cochrane Library, EMBASE, and MEDLINE databases using key terms such as awake craniotomy, awake brain surgery, awake craniotomy, anesthesia craniotomy, asleep craniotomy, asleep brain surgery, and general anesthesia. The PICO (Participant, Intervention, Comparison, and Outcome) approach was used to extract the studies contrasting the impact of awake craniotomy versus general anesthesia on outcomes included in this systematic review. PRISMA guidelines were followed throughout.</p> <p><strong>Results:</strong> 102 records were identified out of which 8 were included in the final qualitative synthesis (2 RCTs, Cohort). All reported neurological impairments in both groups, except 2. Six studies indicated early language abnormalities and early motor deficiencies. Six studies indicated early language abnormalities and early motor deficiencies. The mean operation time of the General Anesthesia group was more than that of Awake Craniotomy. Awake craniotomy surgery was associated with an average reduction of 4 to 8 days in the hospital.</p> <p><strong>Conclusion:</strong> Under GA, AC (add abbreviations of these) offers a workable substitute for craniotomy for individuals with gliomas penetrating expressive areas; awake craniotomy with electrical stimulation is linked to improved long-term neurological and language abilities as well as a shorter hospital stay.</p> Mahboob Khan Abdul Hameed Khan Farooq Sherzada Abdul Basit Khan Laila Ghaffar Nayyab Orakzai Copyright (c) 2024 Mahboob Khan, Abdul Hameed Khan, Farooq Sherzada, Abdul Basit Khan, Laila Ghaffar, Nayyab Orakzai https://creativecommons.org/licenses/by-nc/40/ 2024-06-13 2024-06-13 28 2 221 229 10.36552/pjns.v28i2.923 Impact of The Time Taken Before Surgery in Evaluating the Outcome of Extradural Hematoma https://pakjns.org/index.php/pjns/article/view/987 <p><strong>Objective:</strong>&nbsp;&nbsp;To assess the impact of the time taken before surgery in evaluating the outcome of extradural hematoma.</p> <p><strong>Materials &amp; Methods:</strong> &nbsp;A prospective observational study was done at the Department of Neurosurgery, Pakistan Institute of Medical Sciences (PIMS) Islamabad. Patients with extradural hematoma (&gt;20ml) as per calculation by the scale on axial images of a CT scan brain and scheduled for surgical intervention, aged 18 years to 60 years of either gender were included. Patients underwent surgical treatment as per indications and were scheduled for surgery. Time was recorded for injury, diagnosis, and surgery and calculated from the time of injury to the time of surgery.&nbsp;</p> <p><strong>Results:</strong>&nbsp;&nbsp;Overall mean age was 34.09 years with a higher proportion of males (66.7%). Post-surgery, disability was observed in 11.8% of cases and the overall mortality rate was 15.7%. Considering the overall outcomes, 74.5% of the patients had favorable results, whereas 25.5% had unfavorable outcomes. The timing of surgery significantly influenced outcomes (p &lt; 0.0001). Patients operated on within 1-6 hours post-trauma had no disability or mortality, with 70.6% favorable outcomes. In contrast, those operated on within 6-12 hours showed 11.8% disability, 11.8% mortality, and 23.5% unfavorable outcomes, with only 2.0% achieving favorable outcomes.</p> <p><strong>Conclusion:</strong>&nbsp;&nbsp;It is evident that a time interval of less than six hours between the traumatic incident and surgical intervention is strongly correlated with better results, including significantly lower rates of disability and mortality.</p> Aisha Adalat Lal Rehman Muhammad Mujahid Sharif Hamza Ejaz Kashif Ramooz Shafiq-ur-Rehman Jamil Copyright (c) 2024 Aisha Adalat, Muhammad Mujahid Sharif, Hamza Ejaz, Kashif Ramooz, Shafiq-ur-Rehman Jamil https://creativecommons.org/licenses/by-nc/40/ 2024-06-13 2024-06-13 28 2 248 255 10.36552/pjns.v28i2.987 Outcome Difference between Traumatic and Spontaneous Chronic subdural hematoma https://pakjns.org/index.php/pjns/article/view/961 <p><strong>Objective:</strong> To evaluate the effect of traumatic or spontaneous etiology on outcome of CSDH patients</p> <p><strong>Material and methods:</strong> It is retrospect case control study and was conducted in Liaquat University hospital. The duration of study was 1<sup>st</sup> Jan 2023 to 1<sup>st</sup>Jan 2024. The patient that was included in study was divide into two groups either spontaneous or old history of trauma less than 3 months. The Pre-operative and post-operative GCS were noted. The post-operative (on discharge) GOSE were noted.</p> <p><strong>Results:</strong> Total numbers of 32 patients with 16 in single group were included, the mean age was 60, out of which 65.6% were males. . After surgery, the mean GCS in spontaneous group was 9.62 and 12.81 in traumatic group (p-0.020). The post-operative GOSE in spontaneous group was mostly Grade I (Dead, 56.2%) and Grade VIII (upper good recovery, 62.5%) in traumatic group. The effect on GOES either spontaneous or traumatic is non-significant that p- 0.051, but the spontaneous CSDH has more chances of being dead as compare to traumatic CSDH and vice versa with Odd ratio of 1.2.</p> <p><strong>Conclusion:</strong> The spontaneous etiology holds grave outcomes as compare to traumatic etiology. Both etiologies do improve the immediate Post-operative GCS but the GOES grading worsens with spontaneous etiology. </p> Sanaullah Pathan Abdul Rauf Memon Peer Asad Aziz Muzafar Ali Bhand Suhail Ahmed Aghani Hameedullah Khan Zeeshan Nasir Copyright (c) 2024 Sanaullah Pathan, Abdul Rauf Memon, Peer Asad Aziz, Muzafar Ali Bhand, Suhail Ahmed Aghani, Hameedullah Khan, Zeeshan Nasir https://creativecommons.org/licenses/by-nc/40/ 2024-06-13 2024-06-13 28 2 203 210 10.36552/pjns.v28i2.961 Azathioprine vs. Methotrexate Effectiveness in the Treatment of Generalized Myasthenia Gravis (MG) https://pakjns.org/index.php/pjns/article/view/978 <p><strong>Objective:</strong> The current study investigated the effectiveness of Azathioprine versus Methotrexate in the treatment of generalized MG.</p> <p><strong>Methodology:</strong> An observational, open-label retrospective study was conducted in the Department of Neurology, Mayo Hospital, Lahore, Pakistan. All generalized MG patients with positive acetylcholine receptor antibodies (MGFA class II, III, or IV) aged <u>&gt;</u>16 years, were included. Group 1 (n=31) was taking the combination of oral Prednisolone and Azathioprine (AZA) and group 2 (n=31) was taking the combination of Prednisolone and Methotrexate (MTX). The clinical response was assessed by Myasthenia gravis activities of daily living (MG-ADL) score at the 3<sup>rd</sup>, 6<sup>th</sup>, 9<sup>th</sup>, 12<sup>th</sup>, &amp; 18<sup>th</sup> months.</p> <p><strong>Results:</strong> At 3<sup>rd</sup> month follow-up, the mean MG-ADL score was 2.97 (AZA) vs. 3.39 (MTX), after the 6<sup>th</sup> month, the score was 0.48(AZA) vs. 1.13 (MTX) (p-value=0.009)<strong>,</strong> after the 9<sup>th</sup> month: the score was 0.26 (AZA), vs. 0.97(MTX) (p-value=0.002)<strong>, a</strong>fter the 12<sup>th</sup> month, the score was 0.29 (AZA) vs. 0.74 (MTX) (p-value=0.079), after 15<sup>th</sup> month, the score was 0.16(AZA) vs. 0.65(MTX) (p-value=0.009) and after 18<sup>th</sup> month, the score was 0.42(AZA) vs. 0.52(MTX) (p-value=0.703).</p> <p><strong>Conclusion:</strong> Azathioprine is significantly more efficacious from the 6<sup>th</sup>, 9<sup>th</sup>, 12<sup>th</sup> and after the 15<sup>th</sup>-month follow-up as compared to Methotrexate in the treatment of MG; however, on the 18<sup>th</sup>-month follow-up, both steroid-sparing drugs were equally effective. There appears to be no difference in the effectiveness of Azathioprine versus Methotrexate in the treatment of generalized MG.</p> Sadaf Iftikhar Asfand Kousar Aysha Ghayyur Saman Shahid Adina Qaiser Copyright (c) 2024 Sadaf Iftikhar, Asfand Kousar, Aysha Ghayyur , Saman Shahid , Adina Qaiser https://creativecommons.org/licenses/by-nc/40/ 2024-06-13 2024-06-13 28 2 211 220 10.36552/pjns.v28i2.978