Pakistan Journal Of Neurological Surgery

Exploring Gender Disparities in Carpal Tunnel Syndrome: A Comparative Analysis of Male-Female Ratios

Ubaid Ullah — 2024-06-13

Objective: To know about the gender disparities in carpal tunnel syndrome in the Neurosurgery and Orthopedics departments of Naseer Teaching Hospital and Maqsood Medical Complex.

Materials and Methods: This descriptive cross-sectional study was conducted in the Neurosurgery and Orthopedics department of NTH and MMC from 1^st January 2017 to 20^th March 2024. We included a total of 525 patients, both male and female from the age range of 16 years to 70 years presenting with complaints of pain and tingling sensation in their hands. All the included patients were diagnosed with cases of CTS based on clinical signs and symptoms and NCS. All the patients who had a joint pathology or any previous trauma to the wrist joint or pregnancy were excluded. The data was analyzed using SPSS (v 23.0).

Results: In our study; we observed that the mean age was 34.21 ± 7.685 and male-to-female frequency was 19.2% to 80.8% in a ratio that can be written as 1:4.2. The most common age group affected in females is 30-39 while in males the most common affected one was 40-49.

Conclusion: Our study concludes that the male-to-female ratio of median nerve entrapment was 1:4.2.

Comprehensive Analysis of Spinal Dysraphism: Early Institutional Experience at Pediatric Neurosurgery of Punjab Institute of Neurosciences

Hassaan Zahid — 2024-06-01

Objective: To examine the demographic and clinical characteristics of pediatric patients presenting with spinal dysraphism.

Material and Methods: This retrospective study was conducted at the Department of Pediatric Neurosurgery, Punjab Institute of Neurosciences in Lahore and included data from patients aged <16 years with spinal dysraphism over 7 months from March 2023 to September 2023. Data analysis was performed using SPSS version 27.0.

Results: Among 32 patients, age distribution: <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.

Conclusion: 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.

Computed Tomography Findings of Traumatic Brain Injury and its Assessment in a Teaching Hospital

Ghazan Khan — 2024-06-01

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.

Materials & Methods: 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.

Results: 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 >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%).

Conclusion: 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

A Study on Ocular Manifestations Seen in Patients with Cerebral Palsy

Nazli Gul — 2024-06-01

Background: 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.

Materials & Methods: This retrospective study was conducted at the Department of Ophthalmology Khyber Teaching Hospital (KTH) from 1st November 2022 to 30^thSeptember 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.

Results: 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%).

Conclusion: 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.

Intracranial Meningioma; Assessment of Tumor Size and Clinical Feature on First Presentation

Haris Hamid — 2024-06-13

Objective: To assess the tumor size of intracranial meningioma on first presentation and their clinical features.

Materials & Methods: 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.

Results: 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%.

Conclusion: Tumor size location, and clinical features at the first presentation are interlinked. 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.

Keywords: Meningioma, Excision, Space Occupying Lesion, Supratentorial, Clinical Features

Patients Experiencing Cerebrospinal Fluid Leak After Undergoing Elective Posterior Fossa Surgery

Nafees Ahmad Khan — 2024-06-13

Objective: 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.

<Materials & Methods: 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.

Results: 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/m² or less, even though 54 patients had a BMI exceeding 27 Kg/m². 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. Conclusion: 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.

Awake Craniotomy Versus Surgery Under General Anaesthesia for Resection of Brain Tumour; A Systematic Review of Randomized Control Trials

Mahboob Khan — 2024-06-13

Objectives: To evaluate the clinical evidence on the comparison of results between an awake craniotomy and general anesthesia surgery for brain tumor removal.

Materials & Methods: 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.

Results: 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.

Conclusion: 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.

Impact of The Time Taken Before Surgery in Evaluating the Outcome of Extradural Hematoma

Aisha Adalat — 2024-06-13

Objective: To assess the impact of the time taken before surgery in evaluating the outcome of extradural hematoma.

Materials & Methods: A prospective observational study was done at the Department of Neurosurgery, Pakistan Institute of Medical Sciences (PIMS) Islamabad. Patients with extradural hematoma (>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.

Results: 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 < 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.

Conclusion: 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.

Outcome Difference between Traumatic and Spontaneous Chronic subdural hematoma

Sanaullah Pathan — 2024-06-13

Objective: To evaluate the effect of traumatic or spontaneous etiology on outcome of CSDH patients

Material and methods: It is retrospect case control study and was conducted in Liaquat University hospital. The duration of study was 1^st Jan 2023 to 1^stJan 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.

Results: 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.

Conclusion: 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.

Azathioprine vs. Methotrexate Effectiveness in the Treatment of Generalized Myasthenia Gravis (MG)

Sadaf Iftikhar — 2024-06-13

Objective: The current study investigated the effectiveness of Azathioprine versus Methotrexate in the treatment of generalized MG.

Methodology: 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 >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^rd, 6^th, 9^th, 12^th, & 18^th months.

Results: At 3^rd month follow-up, the mean MG-ADL score was 2.97 (AZA) vs. 3.39 (MTX), after the 6^th month, the score was 0.48(AZA) vs. 1.13 (MTX) (p-value=0.009), after the 9^th month: the score was 0.26 (AZA), vs. 0.97(MTX) (p-value=0.002), after the 12^th month, the score was 0.29 (AZA) vs. 0.74 (MTX) (p-value=0.079), after 15^th month, the score was 0.16(AZA) vs. 0.65(MTX) (p-value=0.009) and after 18^th month, the score was 0.42(AZA) vs. 0.52(MTX) (p-value=0.703).

Conclusion: Azathioprine is significantly more efficacious from the 6^th, 9^th, 12^th and after the 15^th-month follow-up as compared to Methotrexate in the treatment of MG; however, on the 18^th-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.

Need for Establishing a Joint-Stroke Centers with Neurosurgeons and Neurologists

Saman Shahid — 2024-06-13