Unit Cost Analysis of PET-CT at an Apex Public Sector Health Care Institute in India

SH Gajuryal, A Daga,¹ V Siddharth,¹ CS Bal,² and S Satpathy¹

Abstract

Context:

PET/CT scan service is one of the capital intensive and revenue-generating centres of a tertiary care hospital. The cost associated with the provisioning of PET services is dependent upon the unit costs of the resources consumed.

Aims:The study aims to determine the cost of providing PET/CT Scan services in a hospital.

Methods and Material: This descriptive and observational study was conducted in the Department of Nuclear Medicine at a tertiary apex teaching hospital in New Delhi, India in the year 2014-15. Traditional costing methodology was used for calculating the unit cost of PET/CT scan service. The cost was calculated under two heads that is capital and operating cost. Annualized cost of capital assets was calculated using methodology prescribed by WHO and operating costs was taken on an actual basis.

Results: Average number of PET/CT scan performed in a day is 30. The annual cost of providing PET/CT scan services was calculated to be 65,311,719 Indian Rupees (INR) (US$ 1,020,496), while the unit cost of PET scan was calculated to be 9625.92 INR (US$ 150). 3/4th cost was spent on machinery and equipment (75.3%) followed by healthcare personnel (11.37%), electricity (5%), consumables and supplies (4%) engineering maintenance (3.24%), building, furniture and HVAC capital cost (0.76%), and manifold cost (0.05%). Of the total cost, 76% was capital cost while the remaining was operating cost.

Conclusions: Total cost for establishing PET/CT scan facility with cyclotron and chemistry module and PET/CT scan without cyclotron and chemistry module was calculated to be INR 610,873,517 (US$9944899) and 226,745,158 (US$3542893), respectively. (US$ 1=INR 64)

Key Messages: The cost of establishing and operating PET/CT scan facility is quite substantial. Therefore, focus should be on optimal utilisation of resources and this requires constant monitoring of resource flow in the facility. This cost analysis can also be used for planning a similar facility in a similar setting.

Keywords: Cost analysis, PET/CT scan, traditional costing, unit cost

Kathmandu Declaration on Cysticercosis : Towards Eradication

Basant Pant1 , Sharad Onta2 , Sushil Nath Pyakurel3 , Biraj Man Karmacharya4 , Bimal Kumar Nirmal5 , Ana Flisser6 , Marshall Lightowlers7

ABSTRACT

In December 2018, an international conference on cysticercosis was held in Kathmandu,Nepal with the theme, “Towards Eradication”. With the collaboration and participation of human-health and animal-health related organizations, the culmination of this event was the Kathmandu Declaration on cysticercosisrealizing an urgency to take action for its prevention and management.Of the 10 points mentioned in the declaration, all of the keynote speakers and participants on the conference endorsed the activities on commitment for eliminating cysticercosis, urgedthe government to internalize its primary responsibility and role in controlling cysticercosis, and called for the stakeholders for multisectoral collaboration. The authors believe that this declaration and further action definitely strive towards meeting the theme of the conference to eradicate cysticercosis with collaboration among multiple sectors. Several important strategies are also outlined in this article by expanding the statements on the declaration that must be implemented to achieve the targeted goal.

Keywords: Cysticercosis; Eradication; HCC; Conference

Concept of Good Death: Moving toward Peace of Mind

Basant Pant

Chairman & Head of Department, Department of Neurosurgery, Annapurna Neurological Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

Global Scenario

Death is inevitable and it’s the ultimate truth that those who are born will die. Medical science have made tremendous amount of progress in the past 200 years and have delayed the death from a statistical prospective from last few decades with new generation of medicines and technologies. But all those people born in the world till now died and will be dying. On an average 0.38 million people are born in the world every day and 0.15 million are dying with a growth rate of 1.1% per annum.1,2 We are adding 140 million people every year. Here is a gross inequality of population growth in developed and developing world being 4 times more children in the developing world because children are taken as asset who can help then in farm as well as other household activities. Although this growth in developing countries is tremendously not affecting increment in poulation because of high rate of death rate of under 5 children in the developing world which is 149/1000 on an average in compassion to 79/1000 in the developed world.3

Incidence of intracranial aneurysm associated with pituitary adenoma

B Pant ¹, K Arita, K Kurisu, A Tominaga, K Eguchi, T Uozumi

Abstract

The incidence of intracranial aneurysm associated with pituitary adenoma is not definitely established although reported higher than in general population. This study was designed to find the existence of such association in a large series of pituitary adenoma cases. A retrospective study of 467 cases of pituitary adenoma (mean age: 41 +/- 15 years) was done. All patients underwent cerebral angiography at least of anterior circulation, detailed hormonal study, and 155 cases had additional magnetic resonance (MR) angiography. Twenty-five cases (5.4%) of pituitary adenoma (mean age 52 years) had intracranial aneurysm, 97% on anterior circulation, and 12% had multiple aneurysms. Two cases presented with aneurysmal rupture and the rest were incidental. Aneurysm was more frequently seen with increasing age (p < 0.001) and the age distribution resembled that of aneurysm among general population. Although the combination was most frequent among nonfunctioning adenoma (8.8%), and least frequent among prolactinoma (2.4%), this association was again due to age factor. There was no association between hormone secretion, size and invasive nature of the tumor. The results showed no association between intracranial aneurysm and pituitary adenoma. Our speculation is that such occurrence is merely a chance factor and the risk is no greater than that among general population.

Endoscopic resection of intraventricular ependymal cyst presenting with psychosis

B Pant ¹, T Uozumi, T Hirohata, K Arita, K Kurisu, T Nakahara, K Inai

Abstract

Background: Intracranial ependymal cysts are rare lesions generally located in the cerebral parenchyma, juxtraventricular region, or subarachnoid space; but no case of a purely intraventricular ependymal cyst has been reported.

Case report: A case of intraventricular ependymal cyst presenting with symptoms of psychosis is reported. The patient's symptoms resolved almost completely following endoscopic resection of the cyst. The embryologic basis of the development of an ependymal cyst inside the ventricle and its histologic characteristics are discussed. Possible mechanism of psychosis in this case is also discussed.

Conclusion: Minimally invasive techniques, as in this case, may be useful in refractory psychotic cases with cystic lesions.

Usefulness of three-dimensional phase contrast MR angiography on arteriovenous malformations

B Pant ¹, M Sumida, K Arita, A Tominaga, F Ikawa, K Kurisu

Abstract

Prospective three-dimensional phase contrast (3D-PC) MR angiography was obtained in 34 patients with arteriovenous malformations (AVM) and comparison was made between digital substraction angiography (DSA) and three-dimensional time-of-flight (3D-TOF) methods. Velocity encoding (VENC) for 3D-PC was adjusted to 60 and 10 cm/sec., and was changed only when adequate information was not obtained. VENC 60 cm/sec. demonstrated the main feeders in 100 % of cases and the nidus in 86 % of cases whereas VENC 10 cm/sec. showed the draining vein in 78 % of cases. The detection rate of feeder, nidus and drainer was 60 %, 40 % and 13 % respectively by the TOF technique. The mean size of the nidus as compared with DSA as standard was 130 % with MRI,108 % with 3D-PC and 92 % with the TOF technique and this difference was not statistically significant. 3D-PC was clearly superior in detecting AVM in the presence of hemosiderin, hematoma or surgical clips. It also showed gradual disappearance of the lesion after radiosurgery We found 3D-PC superior to 3D-TOF in the diagnosis, therapeutic planning and follow-up of AVM.

Intraventricular Taenia solium neurocysticercosis: a report of three cases

B Pant ¹, B Devleesschauwer, P Shrestha, I Shrestha, N Praet, P Dorny

Abstract

Neurocysticercosis (NCC), caused by the pork tapeworm Taenia solium, is reported to be a common condition in Nepal. So far imaging diagnosis was mainstay of the diagnosis. In this paper, we report three patients presenting with neurological symptoms due to intraventricular NCC. We have diagnosed the causative agent as T. solium on molecular basis. Further research is warranted to assess the actual health impact of T. solium in Nepal.

Usefulness of two-dimensional time-of-flight MR angiography combined with surface anatomy scanning for convexity lesions

B Pant ¹, M Sumida, K Kurisu, K Arita, F Ikawa, K Migita, M Kutsuna, T Uozumi

Abstract

Thirty-eight patients with convexity lesions were studied prospectively with the two-dimensional time-of-flight (2D-TOF) magnetic resonance angiography (MRA) method. Of these 21 cases had additional surface anatomy scanning (SAS) and 7 cases had three-dimensional phase contrast (3D-PC) MRA. The findings were compared during surgery and the predictability of 2D-TOF evaluated. 2D-TOF was obtained with 2 mm slice thickness after the administration of contrast media for routine magnetic resonance imaging (MRI). Cortical veins were visualized with a good resolution with a scan time of only 5 minutes. The tumor was also visible in the background, due to enhancement, and thus the tumor-vessels relation was shown. Slow-flow vessels were also adequately seen. SAS was done at the same sitting with fast spin echo (FSE) with a scan time of 3 minutes. Once both images were incorporated, information on gyri and their relation to the lesions and vasculature could be obtained from a single image. We found 2D-TOF alone, or at times in combination with SAS, useful for planning of operation for convexity lesions.

Current status of epilepsy surgery in Nepal

B. Pant, P. Shrestha, Sudan Dhakal, Rup K Sainju

Abstract

Epilepsy surgery could not be started in Nepal till recently because we lacked know-how on epileptic zone localization. With the guidance of Prof. K Arita and Prof. T Hori we could start this surgery from 2002. Now we are performing surgery on our own but still have limitation in regards to case selection. At present Kathmandu Model Hospital is the only institute providing surgery for non-lesional cases. We have operated on 11 cases of non-lesional epilepsy of which 9 were temporal lobe epilepsy and 2 were drop attacks. Engel class I result could be achieved in 7 and class II in 2 cases. Both of the drop attack cases underwent complete corpus callosotomy and had no further atonic seizure. One patient had transient hemiparesis and there was no mortality or permanent morbidity. Achieving good result especially in the initial phase is important to convince the medical community to accept this treatment modality. Initial failure will lead to lack of enthusiasm, referral and even restriction on the program. In this regards we have been able to prepare groundwork for future development of epilepsy surgery. Epilepsy surgery can be an acceptable and cost-effective method of treatment for intractable seizure in countries having similar socio-economic scenario.

Cerebral venous thrombosis secondary to hyperthyroidism: A case report

Authors

• Basant Pant, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

• Malika Bajracharya, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

• Avinash Chandra, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

• Ramita Bati, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

• Reema Rajbhadari, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

• Sameer Acharya, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

• Pranaya Shrestha, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

• Resha ShresthaAnnapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

• Pravesh Rajbhandari, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

• Robin Bhattarai, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Abstract

Cerebral Venous Thrombosis (CVT) is a rare form of Stroke characterized by thrombus formation in the cerebral veins. CVT is a result of various reasons among which the hyperthyroidism is not so frequently encountered. This is probably the first case report published from Nepal. The aim of this case report is to give the message that persistent severe headache in patient with hyperthyroidism can be the red flag and needs to be investigated further. We present a case of a 35 years old female who presented with complaints of severe headache and persistent in nature associated with vomiting since 5 days. She was a diagnosed subacute thryroiditis and under medicine from 1 month before presenting to us. Her Magnetic Resonance Venography (MRV) brain showed venous thrombosis within superior saggital sinus, left transverse sinus and sigmoid sinus. Her thyroid function test showed pretreatment T3 of 2.98 ng/ml T4 of 1.02 mg/ ml and TSH of 0.12 μIU/L. She was kept on anticoagulants and other supportive measures. The patient showed improving status with the conservative management.

Overcoming the Challenges of Epilepsy in Nepal- From Grassroots to Advanced level

Authors

• Sharad Hari Gajuryal, Department of Public Health, Annapurna Neurological Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

• Shreejana Maharjan, Department of Psychiatry, Annapurna Neurological Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

• Koji IidaEpilepsy Center, Department of Neurosurgery, Hiroshima University Hospital ,Hiroshima, Japan

• Basant PantDepartment of Neurosurgery, Annapurna Neurological Institute & Allied Sciences, Maitighar,Kathmandu, Nepal

Abstract

Epilepsy is considered to be one of the common neurological disease with a high public health concern in recent years. The burden of epilepsy is also high affecting the patients and their care givers physically, mentally as well as socio economically. This burden seems very high in low- and middle –income countries with high rate of treatment gap resulting in higher number of morbidity and mortality. There are various challenges in low-middle income countries to overcome the treatment gap. Sustained and coordinated action prioritizing epilepsy from the rural setting to the advance setting can help in tackling the challenges. This article focuses on the challenges of epilepsy treatment in low-middle income country like Nepal and discusses the ways forward to overcome it.Keywords: Epilepsy; Treatment Challenges; Nepal

A case of postpartum chronic subdural hematoma

Suyasha Rajbhandari | Pritam Gurung | Gopi Nepal | Samir Acharya | Basant Pant

Abstract

Intracranial subdural hematoma following spinal anesthesia is an infrequent occurrence and has variable presentation. Due to rarity, it may often be misdiagnosed as post-dural puncture headache. In this report, we describe a case of a 25-year-old woman who presented with a headache following lower segment cesarean section after spinal anesthesia.

KEYWORDS: chronic, Postpartum, subdural

Remote Cerebellar Hemorrhage Complicated after Supratentorial Surgery: Retrospective Study with Review of Articles

Jae-Suk Park, M.D., Jeong-Hyun Hwang, M.D., Ph.D., [...], and Yeun-Mook Park, M.D., Ph.D.

Abstract

Remote cerebellar hemorrhage is a rare postoperative complication. It can occur after infratentorial or supratentorial craniotomies, later being more common. Remote cerebellar hemorrhage is considered to be a self-limited and benign condition. The exact pathophysiology of remote cerebellar hemorrhage remains unclear, but reports have suggested an association with excessive loss of cerebrospinal fluid. We report a case of remote cerebellar hemorrhage after supratentorial craniotomy for large convexity meningioma without excessive loss of cerebrospinal fluid.

Key words: Cerebrospinal fluid, Craniotomy, Meningioma, Neurosurgery, Remote cerebellar hemorrhage

Evaluation of multiplex PCR using MPB64 and IS6110 primers for rapid diagnosis of tuberculous meningitis

Sunil Prasad Lekhak ¹, Laxmi Sharma ², Reema Rajbhandari ², Pravesh Rajbhandari ², Resha Shrestha ², Basant Pant ²

Abstract

Tuberculous meningitis (TBM) is one of those most serious manifestations of extra-pulmonary tuberculosis and prompt diagnosis and treatment is required for better clinical outcome. It is difficult to diagnose due to lack of rapid, sensitive, and specific tests. Newer methods, which are easy and reliable, are required to diagnose TBM at an early stage. Thus our aim was to evaluate the Multiplex polymerase chain reaction (PCR) technique, using primers directed against the insertion sequence IS6110 and MPB64 gene for the detection of Mycobacterium tuberculosis in Cerebrospinal fluid (CSF), for rapid diagnosis of TBM patients. 102 CSF samples were analyzed from patients suspected with TBM along with a control group of 10 patients having other neurological disorders. CSF sediments were analyzed individually for M. tuberculosis DNA by Multiplex PCR using two set of primers targeting insertion sequence IS6110 and gene MBp64, which is very specific for MTBC. Out of 37 patients diagnosed with TBM clinically, MPB64 PCR was positive in 22, IS6110 PCR was positive in 28, both PCR using Multiplex were positive in 34 and Microscopy was positive in one. Thus Sensitivity of MPB64 PCR, IS6110 PCR, Multiplex PCR and Microscopy were found to be 62.3%, 75.4%, 91.8% and 2.7% respectively. In non TBM group PCR was negative in all cases hence, the specificity was 100%. Multiplex PCR system using primers targeting IS6110 and MPB64, for the detection of M. tuberculosis DNA in CSF samples, has high sensitivity than any one of them alone, and could be used for the early detection of TBM in CSF samples.

Keywords: IS6110; MPB64; Multiplex polymerase chain reaction; Mycobacterium tuberculosis; PCR; Primers; TBM; Tuberculous meningitis.

Cytotoxic effect of selected wild orchids on two different human cancer cell lines

Pusp Raj Joshi ^1 2, Mukti Ram Paudel ¹, Mukesh Babu Chand ³, Shreeti Pradhan ¹, Krishna Kumar Pant ¹, Giri Prasad Joshi ¹, Manoj Bohara ², Sven H Wagner ⁴, Basant Pant ², Bijaya Pant ¹

Abstract

Majority of the orchid species are used in the traditional medicines for the treatment of several diseases. They are the sources of polysaccharides, phenanthrenes, bibenzyl derivatives, revesteral, stilbenoids and polyphenol compounds. This study explored the cytotoxic activity of seven wild orchid species and identification of medicinally active compounds. The extracts of orchid species were screened for cytotoxic effect on the human cervical cancer cells (HeLa) and human glioblastoma cells (U251) using an MTT assay. The medicinally active compounds of high cytotoxic extracts were identified by GC-MS resulting in many stilbenoids and phenolic derivatives. The extract of Dendrobium transparens (DTs) and Vanda cristata (VCw) showed high cytotoxic effect towards the HeLa and U251 cell lines (IC₅₀ of DTs: 382.14 μg/ml and 75.84 μg/ml respectively and IC₅₀ of VCw: 317.23 μg/ml and 163.66 μg/ml respectively). This study concludes that they could be used as cancer therapeutics.

Keywords: Bioactive compounds; Bioactive plant product; Biological sciences; Botany; GC-MS; MTT assay; Natural product; Orchids; Pharmaceutical science; Plant biology

Cerebral circulation in moyamoya disease: a clinical study using transcranial Doppler sonography

Z Muttaqin ¹, S Ohba, K Arita, T Nakahara, B Pant, T Uozumi, S Kuwabara, S Oki, K Kurisu, T Yano

Abstract

Transcranial Doppler sonography was performed on eight patients diagnosed as Moyamoya disease. Angiographically, the patients-four adults (mean age 42) and four children (mean age 7.7)-underwent a complete six- or five-vessel angiographic study. The results showed the following: (1) Despite the presence of stenosis, all middle cerebral arteries showed very low-flow velocity compared to their ipsilateral distal internal carotid arteries. In adult cases, the difference was very significant (p < 0.02). (2) Relatively high-flow velocity was observed in the posterior cerebral arteries of children, and in the ophthalmic arteries of adult cases. (3) In several occasions, very low-flow velocity values were still detected despite the fact that with angiography, the respective arterial segments were hardly opacified. The relation and discrepancy between these results and the angiographic findings, and the potential application of transcranial doppler in assessing and grading the severity of moyamoya disease are discussed.

A Case of Cushing’s Disease Accompanied by Rathke’s Cleft Cyst: The Usefulness of Cavernous Sinus Sampling in the Localization of Microadenoma

Kazunori Arita, M.D., Tohru Uozumi, M.D., Akihiko Takechi, M.D., Taizo Hirohata, M.D., Basant Pant, M.D., Keiji Kubo, M.D., and Koshi Tanaka, M.D.

Abstract

A 42-year-old man presented with classical symptoms of Cushing's disease. Endocrinological examinations indicated the presence of a adrenocorticotropin-(ACTH) producing pituitary adenoma. Magnetic resonance imaging showed a cystic sellar lesion, which had features of a Rathke's cleft cyst, whereas the adenoma was not depicted. The ratio of blood ACTH concentration between cubital vein, left, and right cavernous sinus was I: 1.4: 20. During transsphenoidal surgery, in addition to the Rathke's left cyst, a tiny adenoma was detected beneath the left pituitary lobe. Cavernous sinus sampling is a useful auxiliary in the localization of an ACTH-producing adenoma, as in this case

Intrathecal baclofen therapy in severe head injury, first time in Nepal, a technique suitable for underdeveloped countries

Prabin Shrestha, Hridayesh Malla, Basant Pant, Takaomi Taira1

Abstract 

Intrathecal baclofen (ITB) has been found to be helpful not only for spasticity but also for unconsciousness in a vegetative patient. This is the first case of ITB in Nepal, and here we discuss the effectiveness of ITB for spasticity in a patient in vegetative state. We also discuss about a simple technique for ITB used in Nepal where baclofen pump is not available. Here, we present a case of a 40-year-old male patient who had severe head injury with diffuse axonal injury treated conservatively. He went on to a vegetative state and subsequently developed severe spasticity of all the limbs. ITB was started under the guidance of one of the authors , Prof. Taira. Baclofen was injected to the spinal intrathecal space through a catheter which is used for spinal anesthesia. Spasticity improved significantly and his higher mental function also showed signs of improvement. He finally became fully conscious and well oriented. ITB is very useful in cases of severe spasticity and vegetative condition, a state of unconsciousness lasting longer than a few weeks. Even with a simple technique in the absence of baclofen pump, ITB can be used with its optimum effect.

Status of serum vitamin D and neurological disorder in Nepalese population: a prospective study

Avinash Chandra1, Basant Pant1, Ayush Chandra2, Pooja Prakash3, Reema Rajbhandari1, Sharad Gajuryal1, Pranaya Shrestha1, Samir Acharya1, Pravesh Rajbhandari1, Resha Shrestha1

Abstract

Background: Recently, there has been a surge in research worldwide on vitamin D. based on international level, Vit. D has shown positive correlation with cardio-cerebrovascular disorders. Regarding possible role of vitamin D there is paucity of research in low- and middle-income nations that are nearer to the equatorial area. Despite of abundant sunlight exposure, Asian people are developing hypovitaminosis D need a special consideration to avoid excessive and unnecessary usage of it. This study aims to detect the situation of vitamin D in Nepalese population and secondly to find out the suitable normalized reference range for serum vitamin D in multi-ethnic Nepalese population.

Methods: A hospital based prospective study was conducted using purposive sampling technique to select 107 subjects. In-vivo and in vitro bio-physiological method was used to collect serum vitamin D level.

Result: The present study showed that 32% of participants had deficit (< 15 ng/mL), 48% of subjects had insufficient (15 to < 30 ng/mL) and 20% of participants had sufficient serum level of Vitamin-D (> 30 ng/mL). Study showed that there is a lower degree of positive relationship of body mass index (r = 0.162, P = 0.094) and significant association of history of chronic illness (χ2 = 0.10, P = 0.03), timing of occurrence of stroke (χ2 = 11.41, P = 0.017) and diagnosis (χ2 = 21.19, P = 0.011) with serum vitamin-D level at P < 0.05.

Conclusion: There is a direct significant association of serum vitamin D with socio-demographic variables when international unit is considered. Neurological disorder showed positive association with serum vitamin D level.

Key words: Serum vitamin D, Neurological disorder, Deficiency, Incidence

Effect of surgery on gonadal function of premenopausal women with pituitary adenomas other than prolactinomas

KAZUNORI ARITA, ToHRU UOZUMI*, TAKASHI YANG, KAORU KURISU, TAlzo HIROHATA, KuNIKI EGUCHI, ATu5HI TOMINAGA, BASANT PANT, Koji IIDA, AND HITOSHI KAWAMO

 Abstract

The effects of surgery on pituitary-gonadal function were investigated in women with pituitary adenomas other than prolactinomas. The subjects were 46 women of premenopausal age with a pituitary adenoma. Twenty tumors were GH producing, 19 were nonfunctioning, and 7 were adrenocorticotropin producing adenomas. The surgery was performed mainly via the transsphenoidal route, with the aim of eradicating the tumor and preserving pituitary function. The menstrual cycle was preserved postoperatively in 9 out of 10 (90%) patients with regular preoperative menstruation. Menstrual disturbance was seen in 36 (78.3%) cases preoperatively. The causative factors for menstrual disturbance were gonadotropin impairment and hyperprolactinemia in GH producing and nonfunctioning adenoma. Excessive hormonal secretion itself is a major causative factor for menstrual disturbance in GH and ACTH producing adenoma. Regular menstruation was restored following surgery in 20 out of 36 (55.6%) patients with menstrual problems. The predicting factors for postoperative recovery of menstruation are: size of adenoma less than 40 mm, period of amenorrhea less than 5 years, and preoperatively preserved gonadotropin secretion. In addition, preoperative hyperprolactinemia was also a predicting factor in women with nonfunctioning adenoma. Thus, even in patients with pituitary adenomas other than prolactinoma, the restoration of menstruation is highly achievable when surgery is performed with attention to preserving pituitary function.

Key words: Gonadal function, Menstrual disor ders, Pituitary adenoma.

Hypophonia as only presenting symptom in myasthenia gravis - a diagnostic dilemma in poor countries: a case report

Avinash Chandra ¹, Basant Pant ²

Abstract

Introduction: The autoimmune disease myasthenia gravis can mimic a variety of neurological disorders leading to a delay in diagnosis and treatment. In the older population, due to confusion with signs of the ageing process or comorbidities due to ageing, there are many underdiagnosed or misdiagnosed cases of myasthenia gravis. A majority of myasthenia gravis symptoms appear as ocular or motor symptoms and there are very few cases of bulbar symptoms. We present a case of myasthenia gravis with only hypophonia as a clinical feature.

Case presentation: We present a case of a 51-year-old Madheshi woman whose only complaint was sudden onset of hypophonia which later showed a fluctuating nature throughout the daytime. There was only reduced pitch in her voice with no nasal tone or dysarthria (so-called dysphonia), which created a diagnostic dilemma. Later, a neurological examination and other relevant investigations suggested myasthenia gravis.

Conclusions: Sudden onset and focal neurological deficit can raise the diagnostic dilemma of myasthenia gravis. Relevant laboratory tests and clinical examinations are important to diagnose this disease properly. In resources-deprived nations like Nepal, where several investigations are expensive and access to them is difficult, it becomes very difficult to achieve a solid diagnosis for rare presentations of diseases.

Keywords: Autoimmune; Bulbar; Case report; Hypophonia; Myasthenia gravis.

A case report of chronic encapsulated intracerebral hematoma

Y Suyama ¹, H Kajikawa, K Yamamura, S Sumioka, M Kajikawa, S Tsuji, B Pant, E Ohama

Abstract

Chronic encapsulated intracerebral hematoma is a rare clinicopathological entity. The authors reported a case of a 52-year-old male who presented with progressive sensory disturbance of the left extremities three weeks prior to admission. Plain CT and MRI scans revealed a subcortical mass in the right temporal lobe associated with extensive peritumoral edema and intratumoral hemorrhage (mixed intensity on T1WI, low intensity on T2WI). There was a ring-like enhancement with GdDTPA. These findings strongly suggested metastatic melanoma associated with intratumoral hemorrhage. During the operation, the mass appeared partly at the surface of the brain and was easily extirpated totally. Histologically, the specimen showed chronic encapsulated hematoma with a thick, fibrous capsule and there was no evidence of neoplasm. The postoperative course was uneventful and follow up CT scan showed disappearance of the mass and the surrounding edema. The relevant literature was reviewed, and the pathogenesis of this entity was discussed.

Acute stroke management: The plight of Nepal

Avinash Chandra ¹, Pravesh Rajbhandari ², Basant Pant ²

When acute ischemic stroke presents within the time window of 3–4.5 hours, it can be treated with IV tissue plasminogen activator (tPA) with the best outcomes.1 Stroke exhibits a decreasing trend in high-income countries, e.g., stroke has decreased to the third leading cause of death or disability in the United States. Robust economy, wide coverage of health insurance, better public health education, and effective health care policies are some important factors that have helped to curb disease progression. On the other hand, the incidence of stroke exhibits an increasing trend in low-income countries like Nepal.2 Due to the limited resources available, and outdated and ineffective public health policies in these nations, access to standard health care to all is nearly impossible. Stroke care units are an essential ingredient underpinning the safe implementation of stroke thrombolysis. Through this article, we have attempted to share our experience, as well as the results on acute stroke management.

Delivery of primary neurosurgical care in developing countries--scope for mutual cooperation

B Pant ¹

Abstract

As with other specialized services there is an ever increasing gap in neurosurgical care between developed and developing countries. The need for neurosurgery has always been present in developing countries, but the recent introduction of computed tomography has identified many previously undetected cases, increasing the number of patients seeking treatment. However, developing countries suffer severe shortages of trained manpower, proper equipment, and expertise to initiate the services to meet this demand. In contrast, some developed nations are experiencing a surplus of neurosurgeons leading to problems in case exposure. A well-designed cooperative project between these countries can answer some of these problems, becoming an ideal example of mutual benefit.

Epidemiology and Pattern of Traumatic Brain Injuries at Annapurna Neurological Institute & Allied Sciences, Kathmandu, Nepal

Nicola Newall ^1 2, Sharad Gajuryal ², Sangita Bidari ², Ashmita Karki ², Prashmita Karki ², Peter Bodkin ³, Basant Pant ²

Background

Traumatic brain injury (TBI) constitutes a major health and socioeconomic problem worldwide. It represents the greatest contribution to death and disability among all trauma-related injuries globally. TBIs are a leading cause of death and disability in Nepal, despite improvements in safety regulations and implementation of strict drunk driving laws. We describe the epidemiology of patients with TBI following admission to our hospital. We discuss the implementation of specific strategies to reduce its incidence.

Methods

We conducted a retrospective cross-sectional study of patients presenting to Annapurna Neurological Institute & Allied Sciences (ANIAS), Kathmandu, with a TBI between September 2018 to September 2019.

Results

One-hundred and sixty-seven patients presented with a TBI. The most common age groups were younger than 15 years old and 15–25 years old, and the majority were male (73%). The commonest cause of TBI was road traffic accidents (RTA) (59%). Drivers riding motorcycles were the predominant mechanism of RTA (38%). Helmet use was seen in 57% of patients riding 2-wheelers. Alcohol consumption was reported in 22% of all patients. Skull fractures were the most common diagnosis. Most patients were managed conservatively (84%).

Conclusions

TBI should be recognized as an important public health problem in Nepal. TBI is responsible for a considerable number of neurosurgical admissions to ANIAS. Our study showed patients most vulnerable to TBI are males younger than 25 years old. The implementation of stricter traffic rules and regulations, helmet law enforcement, and public education programs may be helpful in decreasing the number of TBI.

HLA-B27 Typing Using Simple Allele Specific PCR in Suspected Spondyloarthritis Patients Visiting Different Hospitals of Kathmandu

Anil Kumar Sah1 *, Pragya Hatawal2 , Sandip Shrestha2 , Laxmi Sharma1 , Laxmi Sen Thakuri1 , Riju Dahal3 , Shreeya Parajuli3 , Prabin Nepal3 , Pravesh Rajbhandari3 and Basant Pant3

Abstract

Background: Human leucocyte antigens-B27 is products of genes found at the human major histocompatibility complex class I molecule, associated with a several rheumatic disease. There is a marked variation of association between spondyloarthritis and HLA B27 surface antigen. This association encouraged in testing of HLA-B27 antigen as one of the diagnostic tools in this inflammatory disease. The study was conducted with the aim to perform HLA-B27 typing by means of simple allele specific PCR in suspected spondyloarthritis (SpA) patients.

Methods: The whole blood samples of the suspected SpA patients were collected from different hospitals and DNA was extracted. HLA-B27 Typing was performed by sequence specific primer PCR (SSP-PCR).

Results: A total 112 and 25 sample of suspected spondyloarthritis and healthy population were involved in this study, Out of 112 suspected spondyloarthritis patients 23.2% (n=26/112) were HLA-B27 positive; similarly in 25 healthy specimens 4% (n=1/25) were positive for HLA-B27. HLA-B27 were positive in 69.2% and 30.8% (8/26) in the 15-40 and >40 years age group respectively (p=0.54), and 76.9% and 23.1% in male and female respectively (p=0.15). Clinical characteristics; inflammatory low back pain, morning stiffness and enthesitis of the patient were significantly associated with HLA-B27 Typing (p<0.05).

Conclusion: Present research output confirmed the significance of HLA-B27 allele as a novel and rapid molecular marker for diagnosis of spondyloarthritis also in Nepalese patients.

Keywords: Spondyloarthritis (SpA) • HLA-B27 • Sequence specific primer (SSP-PCR)

Organizing a Health Camp: Management Perspective

Sharad Hari Gajuryal1 , Sandhya Gautam2 , Narayan Satyal3 , Basant Pant4

Abstract

Health camps or outreach clinics are the effective strategies adopted by both government and nongovernment organizations, associations, and societies with various interests and scope. A wellorganized health camp with a concentration on the various principles of planning, coordination, collaboration, tools, and techniques will not only make the health camp successful but also aids in improving the health status of the unreached community who are often deprived of basic to advance health care facility due to different circumstances.

Keywords: Health Camp; Management; Medical Camp; Outreach clinic; Rural Camp

Histopathological analysis of central nervous system tumors; an observational study

Trishna Kakshapati1 , Ranga B. Basnet2 , Basant Pant3 , Dipti Gautam1

ABSTRACT

Background: Though the central nervous system tumor comprises ~2% of all the tumors, an overall increase has been observed especially in less developed countries. This increase in the incidence may be due to exposure of population to various risk factors or improved diagnosis with advancement in the ancillary studies. This study aims to provide a single centre histopathological spectrum of this type of tumor.

Materials and Methods: A retrospective cross sectional study on a series of cases was performed in the Department of Pathology, Annapurna Neurological Institute & Allied Science , Maitighar, Kathmandu, Nepal from April 2013 to Jan 2016. Data were analyzed using SPSS version 21.0.

Results: A total of 221 brain and CNS tumors (125 females and 96 males) were studied. The mean age at diagnosis was 77 years. The most common tumor was meningioma(67 cases, 30.3%), followed by astrocytic tumor (57 cases, 25.7%) and pituitary adenoma(30 cases,13.6%). The frequency of WHO grade I, II,III and IV tumor were 94 cases (55%), 34 cases (19.9%),10 cases (5.8%), and 33 cases (19.3%) respectively. The astrocytic tumor was most frequent tumor in children (7/20 cases, 37 %).

Conclusion: This study showed the most common CNS tumor to be meningioma followed by astrocytic tumors and pituitary adenoma. The spectrum of CNS tumor in children showed divergent histologic pattern according to the age. In age group 0-10 years embryonal tumors were common whereas 12-20 years age group showed propensity towards astrocytoma as in adults.

POLYMERASE CHAIN REACTION USING THE MPB64 FRAGMENT FOR DETECTION OF MYCOBACTERIUM TUBERCULOSIS COMPLEX DNA IN SUSPECTED TB CASES

Ritambhara Aryal1, Anil K. Sah1, Deepak S. Paudel1, Bishnu Joshi1, Sunil P. Lekhak1, Reema Rajbhandari1, Bal Hari Poudel2, Bijaya Pant1, Ganesh Prasad Neupane1, Basant Pant1

ABSTRACT

Background: Various primers have been used for detection of Mycobacterium tuberculosis complex (MTBC) DNA using Polymerase chain reaction (PCR). The MPB64 gene has been demonstrated to be a highly specific target for MTBC detection.

Aims & Objectives: To detect MTBC DNA using MPB64 primers in clinical specimens of Nepalese patients suspected to have tuberculosis (TB).

Materials and Methods: DNA was extracted from 44 clinical specimens of patients suspected of having TB and MPB64 targeted PCR was performed. Results: Bands comprising 240 base pair (bp) of MPB64 sequence were present in 15 of the 44 clinical samples, of which 4 were pulmonary and the remainders were extra-pulmonary samples. The overall positivity of MPB64 targeted PCR was 34.1%.

Conclusion: PCR targeting the MPB64 fragment has a potential of detecting the MTBC DNA and has potentially valuable clinical applications in early detection of TB in Nepal. Key Words: MPB64; Tuberculosis; Extra- Pulmonary Tuberculosis; Polymerase Chain Reaction

A Case of Sellar/Suprasellar Neurocysticercosis Mimicking a Craniopharyngioma

Sasa Shakya, Pritam Gurung, Dinuj Shrestha, Pravesh Rajbhandhari, Basant Pant

Abstract

Neurocysticercosis (NCC) commonly presents with seizures in developing countries such as Nepal. It may also present with raised intracranial pressure due to obstructive hydrocephalus when cyst is located in the fourth ventricle or foramen of Monro. There are four main stages of NCC (1) Vesicular, (2) Colloidal vesicular, (3) Granular nodular, and (4) Nodular calcified. The colloidal vesicular stages can cause arachnoiditis and thus can cause hydrocephalus whereas obstructive hydrocephalus is usually caused by racemose type of NCC. This case was a suprasellar cyst mimicking craniopharyngioma, supported with clinical history of poor visual acuity, endocrine abnormality, suggested radiological findings by computed tomography scan, and magnetic resonance imaging. Suprasellar NCC was confirmed only by intraoperative findings and histopathology report.

Keywords: Craniopharyngioma, neurocysticercosis, sellar, suprasellar

Result of Pallidotomy in Parkinson’s Disease in Nepal

Resha Shrestha, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Takaomi Taira, MD, PhD Department of Neurosurgery Tokyo Women’s Medical University, Tokyo, Japan

Pranaya Shrestha, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar,

Kathmandu Pravesh Rajbhandari, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Sudan Dhakal, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Samir Acharya, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Chandra Prakash Limbu, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Basant Pant, MD, PhD Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Abstract

Surgical treatment of Parkinsons disease (PD) has already been an established treatment. Currently pallidotomy, Deep Brain Stimulation (DBS) of Globus pallidus internus (GPi) and Subthalamic nucleus (STN) are available mode of surgical treatment of PD. We have included all patients of idiopathic Parkinosons disease who underwent pallidotomy in Annapurna Neurological Institute and Allied Sciences since 2014. The demographics of the patients have been shown and the patient’s improvement has been shown by Unifi ed Parkinsons Disease Rating Score (UPDRS). We have found that pallidotomy is still a promising surgical modality but it is advised to perform either unilaterally or staged bilaterally with at least 3 months gap inbetween.

Key Words: pallidotomy, parkinsons disease, UPDRS

Epidemiologic profiling for stroke in Nepal: Endeavour towards establishing database

Resha Shrestha @avi_neuro., MS¹, Avinash Chandra, MD¹, Samir Acharya, MS¹, Pranaya Shrestha, MS¹, Pravesh Rajbhandari, MS¹, Reema Rajbhandari, MD¹, Sharad Gajuryal, MBBS¹, Basant Pant, MD, Ph D¹

Abstract

Background

Stroke is the second most common cause of death and disability worldwide. The burden of stroke is increasing in an exponential manner in low-income countries like Nepal. Despite this fact, the data of actual stroke patients in Nepal is very scarce. 

Aims

To collect and form a common and robust database online and to call the global community to in this regard.

Methods

An electronic medical health record (MHR) was formed. Each patient at admission was assigned a unique identifier number in which all the information including diagnosis was stored which could be retrieved at the desired time. 

Results

This prospective study was carried from 2016 January through 2018 May. More than 500 patients were identified as stroke of both types (total admitted patients 3942). Majority was (63%) were identified as ischemic stroke. Hypertension was present in 87.1% in hemorrhagic and 59.3% in ischemic stroke. Risk factors like smoking and alcohol were moderately prevalent (27 % smoking and alcohol consumption in ischemic and 30.9% smoking and 36.1% alcohol consumption in hemorrhagic population). Poor outcome was associated with presence of diabetes (OR: 1.31, 95% CI: 0.52-3.33, male sex (OR=1.53, 95% CI: 0.70-3.33). 

Conclusions

This epidemiologic study is established on a proper electronic database with majority of information stored and secured with good safety and privacy rules and is the first time ever done in Nepal. Common database on the global basis is necessary for stroke or cerebrovascular disorder.

Transient Cortical Blindness after Digital Subtraction Angiography of Cerebral Vessels

Shreeya Parajuli, MBBS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Pravesh Rajbhandari, MBBS, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Sameer Acharya, MBBS, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Basant Pant, MD, PhD Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Abstract

Transient blindness following cerebral angiography is a rare but known entity. We report a case of transient cortical blindness after cerebral angiography. The patient presented with ischemic stroke and the angiography was performed to rule out carotid artery stenosis. The patient, however, gradually regained his vision over a period of 3 days. This article is to understand one of the most unusual complications that may occur while performing angiography.

Key Words: cortical blindness, digital subtraction angiography (DSA), Visual Evoked Potential

An Unusual Case of Penetrating Ocular Trauma with a Pressure Cooker Whistle

Dinesh Kumar Thapa¹, Shyam Vyas², Rohit Saiju³, Pravesh Rajbhandari4 , Basant Pant5

Abstarct

Worldwide blindness in 1.6 million people is due to ocular trauma. Trauma is the most common cause of unilateral loss of vision in developing countries and about 5 % of all bilateral blindness is directly due to trauma. In Nepal, ocular trauma is considered a major cause of unilateral blindness and caused 7.9 % of all blindness in Nepal. It is the second leading cause of blindness after cataract. Pressure cooker is a cooking utensil that works with high pressure and heat, consuming less time and fuel but as seemingly easy, the trouble handling with it could be horrible. It may cause serious injury to someone nearby. Here by, we would like to report a case that could rarely happen in kitchen as a worst accident.

Key words: Orbital injury, facial injuries, traumatic blindness, foreign body in eye.

Balloon Test Occlusion for an Option to Decide Whether Simple ICA Ligation is Better Option than Trapping and High Flow Bypass of The Giant ICA Cavernous Aneurysm

Saujanya RajbhandariDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Pravesh RajbhandariDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Pranaya ShresthaDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Basant PantDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Anish NeupaneDepartment of Radiology Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Abstract

Balloon Test occlusion (BTO) is a preoperative angiographic test used to estimate the risk of stroke after permanent therapeutic occlusion of an internal carotid artery (ICA) involved by aneurysms. Temporary balloon occlusion at the cavernous ICA aneurysm neck was performed in an attempt to assess the adequacy of cross flow from the opposite ICA. Adequate fl ow following BTO are preferred to have simple ICA ligation and incase of those who did not pass BTO trapping and high flow bypass is preferred .We have done Right ICA Ligation on our case report.

Keywords: 

Balloon test occlusion, Cavernous segment aneurysm (CSA), Digital subtraction angiography (DSA), Internal carotid artery

Vaccine Induced Acute Transverse Myelitis: A Case Report

Avinash ChandraAnnapurna Neurological Institute and Allied Sciences Kathmandu

Reema RajbhandariAnnapurna Neurological Institute and Allied Sciences Kathmandu

Samir AcharyaAnnapurna Neurological Institute and Allied Sciences Kathmandu

Priya GurungAnnapurna Neurological Institute and Allied Sciences Kathmandu

Basant PantAnnapurna Neurological Institute and Allied Sciences Kathmandu

Abstract

Acute transverse myelitis is a focal infl ammatory disorder of the spinal cord. One of the main etiologic factors include, multiple sclerosis, post-infectious and post-traumatic events although autoimmune phenomenon is the most common cause. Transverse Myelitis (TM) due to etiology other than Multiple Sclerosis has shown spinal cord involvement of two or more segments. Annually millions of active immunization with vaccines is carried out globally with few transverse myelitis caused because of the adverse reactions due to these vaccinations. In order to improve accuracy of reporting, research and diagnosis, the Transverse Myelitis Consortium Working Group (TMCWG) have produced criteria for the diagnosis of ATM. Here we report a case of TM in adult, diagnosed as TM consistent with the TMCWG criteria and probably this is the first ever been reported case from Nepal.

Keywords: Acute transverse myelitis, Autoimmune, Vaccine

Demographics and Pharmacotherapy in Neurocysticercosis: A hospital Based Study

Resha Shrestha1, Pranaya Shrestha1, Pravesh Rajbhandari1, Samir Acharya1, Avinash Chandra1, Sujat Dahal1, Joshan Neupane1, Pritam Gurung1, Basant Pant1

ABSTRACT

Introduction: Neurocysticercosis (NCC) is one of the commonest preventable cause of seizure. It is due to development of the larval form of Taenia solium. This disease is endemic in south east Asia including Nepal and has been considered as one of the neglected tropical disease.Methods: All the patients who came to Neurosurgical outpatient department (OPD) of Annapurna Neurological Institute and Allied Sciences (ANIAS) with the diagnosis of NCC with seizure during the study time frame were included in the study. The time frame of the study was January 1st 2017 till December 31st 2018. Results: There were 167 total cases of which 108 (64.7%) were male and 59 (35.3%) were female. Mean age was 27.9 years (SD 13.1 years, range 1 year to 66 years). Frequency of patients were in the age group 20-30 years followed by 10-20 years. In terms of number of lesions, 86% of the patients had single lesion while 14% had multiple lesionsMaximum number of cases had focal seizure with secondary generalization (46%). This was followed by focal seizure (28%). Most common antiepileptics was carbamazepine (51.5%).Mean duration of antiepileptics was 2.5 years (SD 1.47, Range 9 months to 6 years) and recurrence was noted in 7.78% of cases.Conclusion: NCC affects the productive age group with higher proportion being male patient. Single lesion is more prevalent. Proper measures for treatment and prevention of neurocysticercosis is essential and can lead to better control of this condition.

Keywords: Demographics; Neurocysticercosis (NCC); Pharmacotherapy.

Immunohistochemistry in Neurosurgery for Pathological Diagnosis: A Case Illustration of a Sellar

Prabin Shrestha, MD Department of Neurosurgery Graduate School of Biomedical Sciences Hiroshima University Hiroshima, Japan

Basant Pant, MD Department of Neurosurgery Kathmandu Model Hospital Kathmandu, Nepal

Hemav Rajbhandary, MD Department of Neurosurgery Kathmandu Model Hospital Kathmandu, Nepal

Sudan Dhakal, MBBS Department of Neurosurgery Kathmandu Model Hospital Kathmandu, Nepal

Samir Acharya, MBBS Department of Neurosurgery Kathmandu Model Hospital Kathmandu, Nepal

Sugiyama Kajuhiko, MD, PhD Department of Neurosurgery Graduate School of Biomedical Sciences Hiroshima University Hiroshima, Japan

Karisu Kaoru, MD, PhD Department of Neurosurgery Graduate School of Biomedical Sciences Hiroshima University Hiroshima, Japan

Abstract

Tumor Immunohistochemistry is an essential clinical and research tool in medical science. It helps in making specific diagnosis by detecting the lesion specific markers. It also helps in predicting the final outcome of a neoplastic lesion by detecting various prognostic markers. Thirty four years old male with a huge sellar and suprasellar lesion with cystic and solid component presented with bitemporal hemianopia and 3rd ventricle compression and hydrocephalus. Provisional diagnosis of non-functioning pituitary adenoma with a differential diagnosis of craniopharyngioma was made. Tumor was excised by craniotomy and the specimen sent for histopathological diagnosis. The report showed confusing result mentioning the presence of signs of pituitary adenoma and low grade astrocytoma. Glial fibrillary acidic protein (GFAP), a marker of astrocytic tumor and Ki-67 (MIB-I), a marker of cellular proliferation in neoplastic lesion were investigated by immunohistochemistry to confirm the diagnosis. The indirect method of immunostaining, LSAB (Labeled Strept Avidin Biotin method), was employed using the histofine SAB kit. Immunostaining showed absence of GFAP positive cells and about 1% of MIB-I labeling index suggesting the tumor was not of astrocytic origin and thus was pituitary adenoma. Lower expression of MIB-I was also in the favor of pituitary adenoma. The final diagnosis of pituitary adenoma was made by excluding the possibility of astrocytoma. Thus immunohistochemistry is helpful in such situation. The histopathological evaluation of any neoplastic lesion is not complete without immunohistochemistry.

Key words: astrocytoma, GFAP, immunohistochemistry, MIB-I, pituitary adenoma

Central Hyperthermia Treated with Baclofen in a Patient with Epidural Hematoma

Manoj BoharaDepartment of Neurosurgery Nepalgunj Medical College Teaching Hospital Nepalgunj

Prasanna K BoharaDepartment of Neurosurgery Nepalgunj Medical College Teaching Hospital Nepalgunj

Lalit ChaudharyDepartment of Neurosurgery Nepalgunj Medical College Teaching Hospital Nepalgunj

Basant PantDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Hospital Maitighar, Kathmandu

Abstract

Central hyperthermia is characterized by a rapid-onset elevated temperature, marked temperature fluctuation, and poor response to antipyretics and antibiotics. It is caused by impairment of the central thermoregulatory pathways and is associated with high morbidity and mortality. We report on a case of 31-year old male who sustained fall injury with massive epidural hematoma and a high-grade fever of 40°C on presentation. Following cranio to my and evacuation of hematoma, antipyretics and antibiotics were used for high-grade fever but were not effective. Baclofen was orally administered which effectively controlled the fever. Here, we also discuss the possible central mechanisms for this effect of baclofen and show that baclofen may be an effective treatment in central hyperthermia.

Keywords: Baclofen, Brain injury, Central hyperthermia, Fever

Central Pontine Demyelination: A Case Report

Manju Maharjan, MBBS Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Pranaya Shrestha, MBBS, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Avinash Chandra, MBBS, MD Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Jemesh S Maharjan, MBBS Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Basant Pant, MD PhD Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Abstract

Central Pontine Demyelination is a neurological disease caused by rapidly fl uctuating serum osmolality resulting in severe damage of the myelin sheath of nerve cells in the brainstem, more precisely in the area of pons. This condition is associated with electrolyte disorders, especially severe hyponatremia and its rapid correction. Its clinical course is characterized by alterations in the mental status to debilitating neurological status i.e. coma. Chronic hyponatremia and its correction, with or without evaluating safe limit could result in pontine demyelination. Demyelination might also occur with normal sodium levels, and even if serum sodium levels are corrected within safe limits. The objective of this case report is to give a broad perspective on Central Pontine Demyelination and to discuss about the different factors contributing to the demyelination and the various causes, pathophysiology and the management of this condition.

Key Words: central pontine demyelination, cerebral edema, hyponatremia, pons

Spinal Surgery in Nepal : A Brief Introduction

ShresthaPrabin, M. D.,Ph.D., PantBasant,M. D.,Ph. D., YamaguchiSatoshi,M. D.,Ph.D., KurisuKaoru,M. D.,Ph.D.

Background ofl Nepal

Nepal is a small landlockedcountry in south Asia locatedbetween 2 giantcountries, China and India.The Himalayas, a range of high rnountains, is locatedin the northern Nepal and serves as a border between Nepal and The Tibetan province of China. Lumbini, the holy birth placeof lord"Buddha" isone of the provincesof Nepal and ithelpsfromthe southern boundarywith India.The total population of Nepal isabout 28,OOO,OOOand the population growthrate isroughly 2%, [[btalfertility isabout 4 per wornan with a lifexpectancy of about 61 years,Medical technology in Nepal is not yet well advanced and some medical field surgently need development. Neurosurgery isone of these.

Chiari Malformation-I with Syringomyelia: A Non-specifi c Presentation and Surgical Consideration

Jemesh S Maharjan, MBBS Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal 

Pranaya Shrestha, MBBS, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Avinash Chandra, MBBS, MD Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Pravesh Rajbhandari, MBBS, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Samir Acharya, MBBS, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Resha Shrestha, MBBS, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Robin Bhattarai, MBBS, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Basant Pant, MD PhD Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Abstract

Chiari Malformation-I is a congenital disorder characterized by the anatomical defect of the base of skull with tonsillar herniation (≥5 mm) below the foramen magnum, which is detected on MRI. It has a diverse range of symptoms with nonspecifi c presentation leading to the chances of misdiagnosis and untimely recognition of the disorder. Syringomyelia is the most common result of Chiari-I. The selection of surgical or non-surgical management depends upon the patient symptoms and the presence of absence of Syringomyelia. The objective of this case report is to give a broad perspective on Chiari Malformation-I from the symptoms and clinical fi ndings obtained in a patient with Syringomyelia associated with Chiari Malformation-I and to discuss about the different surgical options as well as the psychological support required for the management of the condition.

Key Words: chiari malformation-I, posterior fossa decompression, syringomyelia, tonsillar herniation, syringo-subarachnoid shunt.

A Scalp Lump With Skull Erosion

Prabin Shrestha, MD, Ph.D Department of Neurosurgery Norvic International Hospital Thapathali, Kathmandu, Nepal

Hridayesh Malla, MBBS Department of Neurosurgery Norvic International Hospital Thapathali, Kathmandu, Nepal

Basant Pant, MD, Ph.D Department of Neurosurgery Norvic International Hospital Thapathali, Kathmandu, Nepal

Tuberculosis of the skull (TBS) is a rare condition. The reported incidence of TB skull is 0.2-1.3% of all cases of skeletal tuberculosis. Moreover, a case of scalp cold abscess extending upto epidural space with osteolysis of underlying skull is rarer. Painless fluctuant swelling forms the commonest mode of presentation.

EEG Based Carotid Endarterectomy: A Case Report

Rupendra Bahadur Adhikari, MBBS Department of Neurosurgery Norvic International Hospital Thapathali, Kathmandu, Nepal

Prabin Shrestha, MD, Ph.D Department of Neurosurgery Norvic International Hospital Thapathali, Kathmandu, Nepal

Basant Pant, MD, Ph.D Department of Neurosurgery Norvic International Hospital Thapathali, Kathmandu, Nepal

Abstract

Carotid endarterectomy (CEA) has been performed for over 6 decades for the treatment of stenotic and ulcerative lesions of the carotid artery. It improves the cerebral hypoperfusion caused by stenosis of the carotid artery or may prevents artery to artery embolism from ulceration of the atheroma. Although carotid stenting is getting more popular in the west, CEA is still a viable option in developing countries where interventional neuroradiology is not well developed. We report a case of a 60-year-old female who had several episodes of transient ischemic attacks (TIAs) in the past one month. The symptom included right sided hemiparesis and aphagia together with amourosis fugax. Investigations revealed 80% carotid stenosis of her left internal carotid artery. She underwent CEA under general anesthesia with intraoperative electroencephalography (EEG) monitoring. EEG reading was recorded after induction of general anesthesia, during clamping and after the completion of CEA. Special focus was given on the difference in height and rate of waves between the two hemispheres during clamping. Since there was no difference in right and left sided EEG even after test clamping, CEA procedure was carried out without a shunt. EEG based CEA as a useful tool to determine the need of temporary shunting during CEA surgery. The procedure also placed the surgeon at ease since he knew that the brain was not undergoing ischemia during surgery.

Key words: Carotid stenosis, CEA, EEG monitoring, TIA

Stereotactic Radiation for the Treatment of a Hypothalamic Hamartoma Accompanied with Intractable Seizures

Kazunori Arita, Kaoru Kurisu, Koji Iida, Ryosuke Hanaya, Tomohide Akimitsu, Seiichiro Hibino, Basant Pant, Masatake Hamasaki, Shoji Shinagawa

Abstract

Purpose: Seizures caused by hypothalamic hamartomas are usually difficult to control. Surgical removal of the lesion has been reported to be an effective therapy to control the seizures. However, surgical treatment can potentially damage the cranial nerves or the hypothalamus.

Case Report: This is a report of a patient who had intractable epilepsy due to an inaccessible hypothalamic hamartoma and was subsequently treated with stereotactically directed irradiation by using a gamma-knife unit. This 25-year-old man had a history of intractable gelastic and tonic-clonic seizures for the last 23 years. His seizures started with a transient atony of his trunk and extremities at age 6 months. Soon they became associated with gelastic attacks with utterances followed by short generalized tonic-clonic seizures and prolonged postictal drowsiness. He was referred to our department in August 1995, just after a seizure-related car accident. Usually, the seizures were generalized tonic-clonic convulsions following a gelastic attack, occurring 3–6 times a month while taking anticonvulsants such as carbamazepine (CBZ; 1,200 mg), valproate (VPA; 1,800 mg), and zonisamide (ZNS; 600 mg) daily. He also had automatic seizures presenting as oral automatisms, vomiting, and spitting, and these occurred once or twice a month. The blood levels of these drugs were above the minimal effective concentrations, There was no evidence of precocious puberty or any apparent mental retardation. Electroencephalography (EEG) revealed diffuse and dysrhythmic slow background activities and sporadic spike or spike-and-wave activities preferentially in the left frontal and parietal leads. Video-EEG monitoring showed generalized tonic-clonic seizures after a transient laughing attack accompanied by diffuse spike-and-wave bursts, which did not show any laterality. The current magnetic resonance imaging (MRI) as well as the MRI performed 30 months ago demonstrated a nonenhancing and non-progressive spherical mass -10 mm in diameter on the right side at the floor of the third ventricle. The lesion was irradiated with 36 Gy to the center and 18 Gy (50% isodose line) to the margin through a 4–mm and an 8–mm collimator. Two months after the irradiation, the frequency of the seizure attacks transiently increased. However, he has not had any seizures since 3 months after the therapy. Antiepileptic drugs (AEDs) have been reduced since 1 year after the irradiation. The MRI performed 1 year after the irradiation demonstrated a complete disappearance of the lesion. The patient has been seizure free for the last 17 months, with no neurologic or endocrinologic complications. The MRI examination 12 months after the irradiation showed a complete disappearance of the lesion.

Conclusions: Stereotactic irradiation by-,using a gamma-knife unit appears to be a promising therapeutic option for surgically inaccessible hypothalamic hamartomas associated with intractable seizures.

Surgical Treatment of Tardive Dystonia in Nepal: A Case Report

Resha ShresthaDepartment of Neurourgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Takaomi TairaDepartment of Neurourgery Tokyo Womens Medical University, Tokyo

Pranaya ShresthaDepartment of Neurourgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Pravesh RajbhanariDepartment of Neurourgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Sudan DhakalDepartment of Neurourgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Samir AcharyaDepartment of Neurourgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Basant PantDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Abstract

Tardive dystonia is a subtype of dystonia which is seen in patients receiving antipsychotic treatment for long period. Medical treatment of tardive dystonia is very complex and many cases do not respond well to currently available treatment and sometimes can be irreversible. Surgical treatments like pallidotomy and Deep Brain Stimulation (DBS) have shown some promising results. We report this case of Tardive Dystonia who benefitted from Pallidotomy. We believe this is the first case in Nepal.

Keywords: deep brain stimulation, pallidotomy, tardive dystonia

Feasibilty of Trans-sphenoidal Surgery for Pituitary Tumors with Parasellar and Suprasellar Extension

Pranaya Shrestha, MBBS Department of Neurosurgery Norvic International Hospital Kathmandu, Nepal

Prabin Shrestha, MD, PHD Department of Neurosurgery Norvic International Hospital Kathmandu, Nepal

Pravesh Rajbhandari, MBBS Department of Neurosurgery Norvic International Hospital Kathmandu, Nepal

Niu Guang Ming, MS, PhD Department of Neurosurgery Second affiliated hospital of Zhengzhou University Henan, China

Basant Pant, MD, PHD Department of Neurosurgery Norvic International Hospital Kathmandu, Nepal

Abstract

Trans-sphenoidal surgery (TSS) is preferred approach for surgical management of pituitary adenoma because of its simplicity, low morbidity and mortality. However, because of narrow surgical corridor of microscopic exposure, direct visualization of cavernous sinus sometime becomes difficult leading to incomplete excision of the tumors extended into the cavernous sinus. Several modifications of this approach have been made to expand the surgical field, but despite ample experience with transsphenoidal surgery, objective data on which tumor expansion and growth pattern allows for radical adenoma resection are still sparse. It is more so in the context of our country where neurosurgical service is very limited. Therefore we tried to study the feasibility of TSS in removing pituitary tumors with extrasellar extension. We also studied the significance of tumor size and consistency in predicting extent of surgical resection of these tumors. We found that more is the extrasellar extension of tumor, more difficult it is to completely resect it as expected. Similarly, we also found that tumor size and consistency also significantly influence the extent of surgical resection.

Key words: parasellar extension, pituitary tumors, suprasellar extension, TSS

A Case Report of Lhermitte-Duclos Disease in a 10-Month-Old Child Presenting with Hydrocephalus

Abhishek TamrakarDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmanduhttps://orcid.org/0000-0001-6806-0243

Pritam GurungDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmanduhttps://orcid.org/0000-0003-2571-7270

Samir AcharyaDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmanduhttps://orcid.org/0000-0003-1223-1562

Pravesh RajbhandhariDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmanduhttps://orcid.org/0000-0001-6093-5850

Basant PantDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmanduhttps://orcid.org/0000-0003-1424-907X

Abstract

Lhermitte–Duclos Disease is a rare entity characterized by diffuse or focal enlargement of cerebellar folia. Clinical manifestations are usually related to a mass effect and secondary obstructive hydrocephalus. Increased intracranial pressure symptoms and cerebellar symptoms are the most frequent patient complaints. We present a 10-month-old male child with his mother who presented to the outpatient department with complaints of enlargement of size of head since the last one week. Magnetic Resonance Imaging scan revealed the features of Lhermitte–Duclos Disease involving the right cerebellar hemisphere with marked post contrast gyral enhancement. He underwent endoscopic third ventriculostomy. Lhermitte–Duclos Disease is very rare in early childhood and should be considered in the differential diagnosis of posterior fossa lesions.

Keywords: Cerebellar lesion, Dysplastic cerebellar gangliocytoma, Lhermitte–Duclos Disease

Vitamin-D in Nepal: are we really vitamin-D decient?

Avinash Chandra (  chandraavi@gmail.com ) Annapurna Neurological Institute and Allied Sciences https://orcid.org/0000-0002-3895-5369

Basant Pant Annapurna Neurological Institute and Allied Sciences

Reema Rajbhandari Annapurna Neurological Institute and Allied Sciences

Sharad Gajuryal Annapurna Neurological Institute and Allied Sciences Pranay Shrestha Annapurna Neurological Institute and Allied Sciences

Samir Acharya Annapurna Neurological Institute and Allied Sciences

Pravesh Rajbhandari Annapurna Neurological Institute and Allied Sciences

Resha Shrestha Annapurna Neurological Institute and Allied Sciences

Sujat Dahal Annapurna Neurological Institute and Allied Sciences

Abstract

Background: Recently, there have been a surge in research worldwide regarding relation of vitamin D with several diseases. Many neurological diseases like multiple sclerosis, Alzheimer’s disease as well as other diseases like cardiovascular disease have shown positive correlation with vit. D deciency measured according to the international level. Most of the research on possible role of vitamin D has been carried out in America and European nations, while there is paucity of research in low- and middle-income nations (LMICS) that are nearer to the equatorial area. In countries like Nepal, geographically they lie near to the equator and sunlight exposure is well enough and milk consumption is quite moderate. Thus, special consideration for vitamin D level in Asian population seems plausible. This will not only help us to cover the vitamin D decient population but will help us to avoid excessive and unnecessary usage of it.

Objectives: This study aims to detect the situation of vitamin D in Nepalese population and secondly to nd out the suitable normalized reference range for serum vitamin D in multi-ethnic Nepalese population.

Methodology: This was a hospital based prospective study. A prospective study was conducted using purposive sampling technique with in-vivo and in vitro bio-physiological method to collect serum vitamin D level. After rigorous inclusive and exclusive criteria, a total of 107 subjects were collected.

Result: The present study showed that 32% of participants had decit serum Vitamin-D level (30ng/mL). Study showed that there is lower degree of positive relationship of Body Mass Index (BMI) with Serum Vitamin-D level (r=0.162, p=0.094), History of chronic illness (χ2=0.10, p=0.03), timing of occurrence of stroke (χ2=11.41,p=0.017) and diagnosis (χ2=21.19, p=0.011) had signicant association with Serum vitamin-D level at p<0.05.

Conclusion: There is direct signicant association of Serum Vitamin D with socio-demographic variables when international unit is considered. Neurological disorder showed positive association with serum vitamin D level.

Get Well Soon Card: Self Help Program to Overcome Hospital Based Financial Barrier

Sharad Hari Gajuryal, 1 Narayan Satyal, 2 Sangita Bidari, 3 Shristi Panta, 3 Basant Pant4

ABSTRACT

Background: The health care cost is increasing not only in developed countries but also in developing countries. Although the modality of treatment has made significant progresses over the years, delivery of treatment is sometimes beyond the expectation of patient as well as inaccessible financially. Citizen from developing countries like Nepal have to pay out of their own pocket for even minor health issues. We initiated a new concept to bridge this gap between treatments and necessity of funds through crowd funding scheme.

Methods: This was a cross sectional prospective and observational study conducted at Annapurna Neurological Institute and Allied Sciences from July 2017 to April 2020. This study was conducted on “Get Well Soon “card which was a friendly gesture with monetary value provided by visitors to patients. This card was made available in hospital pharmacy without any hidden cost. A convenient sample survey on 100 participant including admitted patients as well as visitors in the hospital was conducted on their perception about Get well soon card before initiating this program.

Results: This innovative self-help scheme has been proven to be quiet successful in a short period of time with many supporters advocating in its favor. Total number of 1012 patients have been benefited from the card which was provided to them by their visitors and relatives during their hospitalization with purchase of card worth NRs. 1144500 (~$11445) during the study period.

Conclusion: Get Well Soon Card can be beneficial to those populations who are financially constrained and lack insurance for the treatment. This Cultural Revolution of crowd funding can be duplicated not only in Nepal, but also in different developing countries where out of pocket system is still prevailing.

Key Word: Crowd funding; Get well soon card; Health care financing; Self-help scheme.

Organizing a Medical Conference: Management Perspective

Sharad Hari Gajuryal Annapurna Neurological Institute & Allied Scienceshttp://orcid.org/0000-0002-0038-9955

Resha ShresthaAnnapurna Neurological Institute & Allied Sciences, Kathmandu, Nepal

Narayan SatyalAnnapurna Neurological Institute & Allied Sciences, Kathmandu, Nepal

Basant PantAnnapurna Neurological Institute & Allied Sciences, Kathmandu, Nepal

Abstract

It is an incredibly formidable as well as meritorious task to plan and implement a successful medical conference. Organizing a medical conference requires a tremendous amount of planning, preparation, lots of pre conference works, and working on logistics to achieve its vision and goal. The two most important aspects for the success of any event is planning and implementation which requires a plenty of brainstorming sessions and meetings, and for medical practitioners and academicians, we are confronted with the dual role of organizing the conference as well as regular work juggling. Despite the fact that medical conferences play a major role in ongoing professional development, academic growth, and networking, there is little guidance in form of literature for those who want to hold a  conference inbound or outbound. This paper seeks to incorporate all the possible steps, plans and procedures in order to organize a successful conference. 

Keywords: Medical Conference; Conference Management; Event management

Neurocysticercosis Presented with Acute Psychosis: A Case Report

Dinesh K ThapaAnnapurna Neurological Institute and Allied Sciences Kathmandu

Chandra P LimbuAnnapurna Neurological Institute and Allied Sciences Kathmandu

Ajit GurungAnnapurna Neurological Institute and Allied Sciences Kathmandu

Basant PantAnnapurna Neurological Institute and Allied Sciences Kathmandu

Abstract

Neurocysticercosis is the parasitic disease caused by ingestion of egg of Tinae Solium. The disease presents with spectrum of clinical manifestations like seizure, headache, neurological deficit and psychiatric symptoms such as psychosis. Even though most commonly patients of neurocysticercosis present with seizure, rarely, it may produce symptoms of neuropsychiatric disorder such as psychosis. Here, we are going to report a case of a patient who presented with features of acute psychosis. Later on with diagnostic imaging like CT and MRI, he was diagnosed as a case of multiple neurocysticercosis. He was then managed with anti psychotics, AEDs, Anti-helminthic drugs and steroids.

Keywords: Albendazole, cysticercosis, neurocysticercosis, psychosis, Taenia solium

 Associations Between Stroke Symptoms and Cognition in Nepal

Annette L Fitzpatrick, Rajeev Shrestha, Archana Shrestha, Rajendra Koju, Resha Shrestha Karmacharya, Basant Pant and Biraj Karmacharya

Abstract

Introduction: Low and middle income countries have the largest burden of stroke, accounting for more than 85% of stroke deaths globally. As many low- and middle-income countries, including Nepal, transition from communicable to non-communicable diseases (NCDs), the impact of stroke on cognition becomes increasingly important.

Methods: Data on cardiovascular risk factors and cognition were collected as part of the Dhulikhel Heart Study, a longitudinal study to evaluate risk factors for heart disease and stroke in Dhulikhel, a community outside of Kathmandu, Nepal. In Phase 1 of the baseline exam, 252 randomly-selected adults age 50 and older completed the Mini-Mental Exam (MMSE) and Digit Spans ( DST) forward and backward as part of a home interview. Mild stroke symptoms were collected by self-report the Questionnaire for Verifying Stroke-Free Status (QVSFS). Multiple linear regression evaluated associations between stroke symptoms and cognition adjusted for demographics (age, sex, education, religion, and ethnicity) and CVD risk factors (smoking, exercise, BMI, blood pressure, hypertension, and diabetes).

Results: Mean age of study participants was 62.4 years (SD 9.2) and 57.5% were women. The mean MMSE score (weighted for illiteracy) was 18.7 (SD 6.4) and 19% reported to have had at least one of five stroke symptoms (sudden one-sided numbness or weakness, sudden vision-loss, inability to express oneself or inability to understand). An increased risk of lower memory score was found with report of a previous episode of numbness (DST backward: B=-1.17, SE=0.34, p=0.001). Borderline associations (.05 < p<.10) were found between any stroke symptoms and Digit Span forward, numbness and MMSE, and numbness and DST forward. When adjusted for demographic and cardiovascular risk factors, significant associations were found between having experienced any stroke symptom and Digit Span backward (B=-1.46, SE=0.66, p=.03) as well as numbness (B=-1.75, SE=0.72, p=0.02).

Conclusions: Associations between previous stroke symptoms and reduced cognition emphasize the need to screen and treat persons with undiagnosed stroke or TIAs in low-resource settings. A reduction in modifiable vascular risk factors is also needed to reduce CVD and associated dementia.

Technical Notes and Result of Stereotactic Evacuation of Hematoma in Spontaneous Supratentorial Intracerebral Hematoma

Resha ShresthaDepartment of Neurosurgery Annapurna Neurological Institiute and Allied Sciences Maitighar, Kathmandu

Pranaya ShresthaDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Pravesh RajbhandariDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Samir AcharyaDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Sudan DhakalDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Chandra Prakash LimbuDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Avinash ChandraDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Basant PantDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Abstract

Primary intracerebral hematoma constitutes about 10-15% of all strokes and is associated with high mortality and severe disability. Surgical treatment of intracerebral hemorrhage is quite controversial. It is believed that minimal invasive stereotactic surgery may reduce hematoma volume and decrease secondary neurotoxicity. The technical note of stereotactic surgery has been illustrated. A retrospective study from March 2016 to March 2018 has been conducted and all patients who underwent stereotactic evacuation of hematoma were included in this study. Baseline characteristics of patients and outcome in terms of Glasgow Coma Scale (GCS) and Modified Rankin Scale (mRS) have been shown. We have found significant improvement in GCS postoperatively, however mRS did not improve immediately but was significantly better in three months follow up period.

Keywords: GCS, ICH, technical, mRS, stereotactic

Deep Brain Stimulation of bilateral Subthalamic nucleus (STN) following pallidotomy with Parkinsons crisis: A case report

Resha ShresthaDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Kathmandu

Pranaya ShresthaDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Kathmandu

Pravesh RajbhandariDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Kathmandu

Samir AcharyaDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Kathmandu

Basant PantDepartment of Neurosurgery Annapurna Neurological Institute and Allied Sciences Kathmandu

Abstract

We present a case of 57 years old patient with Idiopathic Parkinsons disease(PD) who had right sided Globus PallidusInternus (GPi) lesioning or pallidotomy as surgical treatment modality of PD. However this patient went into Parkinsons crisis postoperatively which is a rare form of complication. We had to admit in critical care for two weeks before he gradually improved and reached to preoperative state. This patient finally underwent deep brain stimulation(DBS) of bilateral Subthalamic nucleus (STN) and he has improved in terms of Unified Parkinson’s Disease Rating Scale(UPDRS) score.

Keywords: Pallidotomy, Parkinsons Crisis, STN DBS

Post-Traumatic Glioma: Report of A Case

Bivek Pokhrel, MBBS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Pranaya Shrestha, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Pravesh Rajbhandari, MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Avinash Chandra, MD Department of Neurology Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Basant Pant, PhD Chief of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu

Abstract

Development of malignant glioma after trauma is a rare occurrence. Trauma and scarring have been known to be the predisposing factor for the development of meningiomas. Many people have discussed about the development of glioma post trauma but without proper evidence of documents prior to trauma with no evidence of tumor. We present you a case with evidence of not having tumor during trauma.

Key Words: head trauma, malignancy, post-traumatic glioma

Propofol, An Alternative to Amobarbital in Wadas Test in Electro corticography Based Epilepsy Surgery for Determining Dominance of Brain

Pravesh RajbhandariAnnapurna Neurological Institute and Allied sciences Maitighar, Kathmandu

Pranaya ShresthaAnnapurna Neurological Institute and Allied sciences Maitighar, Kathmandu

Samir AcharyaAnnapurna Neurological Institute and Allied sciences Maitighar, Kathmandu

Resha ShrethaAnnapurna Neurological Institute and Allied sciences Maitighar, Kathmandu

Basant PantAnnapurna Neurological Institute and Allied sciences Maitighar, Kathmandu

Abstract

Amobarbital which is used rampantly for Wadas test is not available in Nepal and to find a dominant hemisphere in a functional Electro corticography (ECoG) based epilepsy surgery is a must. So we have used propfol under Digital Subtraction Angiography (DSA) for both cerebral hemisphere.

Keywords: DSA, ECoG, epilepsy surgery, Propofol, Wadas test

Brain Mass: A Case with Diagnostic and Treatment Dilemma

Prabin Shrestha, MD, PhD, Department of Neurosurgery, Norvic International Hospital, Kathmandu, Nepal

Samantha Tamrakar, MBBS, Department of Neurosurgery, Norvic International Hospital, Kathmandu, Nepal

Manish Kolakshyapati, MBBS, Department of Neurosurgery, Norvic International Hospital, Kathmandu, Nepal

Basant Pant, MD, PhD, Department of Neurosurgery Norvic International Hospital Kathmandu, Nepal

Abstract 

Histopathological evaluation is a must in any case of neoplastic lesion in human body. However, in certain circumstances, histopathological study becomes impossible and further treatment has to be carried out on the basis of other information and yet the plan of treatment may go towards correct direction. We present a 64 years old male patient presented with vague symptoms including headache, giddiness and general weakness. Computerized Tomography (CT) showed multiple mass lesion with edema. Primary central nervous system (CNS) infection and secondary metastatic lesions were excluded. Biopsy couldn't be done as refused by patient party. High dose of steroid for few weeks made the lesion disappear totally. Preliminary diagnosis of primary CNS lymphoma was made and planned for "wait and watch". There was recurrence of lesion after about 10 months which was treated with whole brain radiotherapy. Post radiation radioimages showed complete resolution of the lesion which further proved that the lesion was CNS lymphoma. Again patient was fine for some time and presented again with multiple brain lesions which was again in favor of CNS lymphoma again. Diagnosis of brain lesions without biopsy is uncertain.. However with careful and appropriate treatment plan, both correct diagnosis and treatment can be achieved even without biopsy.

The epidemiology and health burden of neurocysticercosis in tertiary hospital of Nepal

RB SahSchool of Public Health & Community Medicine, B P Koirala Institute of Health Sciences, Dharan

L SubediSchool of Public Health & Community Medicine, B P Koirala Institute of Health Sciences, Dharan

N PandeyDepartment of Internal Medicine, BP Koirala Institute of Health Sciences, Dharan

BP SahDepartment of ENT, BP Koirala Institute of Health Sciences, Dharan

S JhaDepartment of Forensic Medicine & Toxicology, BP Koirala Institute of Health Sciences, Dharan

U ShahDepartment of Microbiology, Sunsari Technical College PVT. LTD, Dharan

N JhaSchool of Public Health & Community Medicine, B P Koirala Institute of Health Sciences, Dharan

PK PokharelSchool of Public Health & Community Medicine, B P Koirala Institute of Health Sciences, Dharan

Abstract

Neurocysticercosis (NCC) is the most common parasitic infestation of the central nervous system and is one of the major public health problems in developing nations like Nepal. This study was conducted to find out total number of neurocysticercosis cases in BPKIHS from 2005 to 2013 AD and to know the duration for which cases were admitted and improvement seen in them. This is a hospital based retrospective study conducted from 31st March to 13th April 2014 to see the number of NCC in B P Koirala Institute of Health Sciences, Dharan of Nepal, a tertiary level referral hospital in the Eastern Nepal. It was study in which secondary data, consistent with the diagnosis of Neurocysticercosis was collected from the Medical Record Section of BPKIHS and reviewed. One hundred fourteen cases of neurocysticercosis were enrolled. The patients were predominantly males (nearly 63.2%) and it was more commonly seen in 2-20 years age group (42%). Most of the cases were from Sunsari District. Most of the patients (63.2%) were admitted in Medicine wards. Almost 90.4% of admitted Neurocysticercosis cases were improved in BPKIHS. The trend of Neurocysticercosis cases did not show any showed any consistent pattern in the past nine years. We conclude that the problem of Neurocysticercosis is common and has become a key public health concern for all.

Keywords: Epidemiology, Health Burden, Nepal, Neurocysticercosis

Initial experience with aneurysm coiling in Nepal

Pravesh Rajbhandari, Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences

Anish Neupane, Department of Radiology, Annapurna Neurological Institute and Allied Sciences

Saujanya Rajbhandari, Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo

Pranaya Shrestha, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences

Samir Acharya, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences

Resha Shrestha, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences

Reema Rajbhandari, Department of Neurology, Annapurna Neurological Institute and Allied Sciences

Avinash Sharma, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences

Sagar Upadhya, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences,

Pragya Dhungel, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences

Tariq Matin, Department of Neurointervention, Narayana Superspeciality Hospital, Gurugram, Delhi

Basant Pant, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences

Abstract

The aim of this study is to show the result of aneurysm coiling despite the difficulty in initiating neurointervention in Nepal. It is a retrospective study where only aneurysm that has undergone coiling are taken from 2017 to 2018.A total of eleven patients (male: female = 1: 10) with aneurysm were treated with Endovascular therapy. 9 cases were ruptured aneurysm while 3 were unruptured. 5 aneurysm were located in anterior circulation while 6 were located in posterior circulation. Out of eleven cases 4 were treated by simple coiling technique, while 2 underwent balloon assisted coiling, 3 stent assisted coiling, 1 pConus assisted coiling and 1 simple coiling and stent assisted coiling. Statistical analysis showed significant correlation between fisher grading scale with mRS score (P=0.013) suggesting lower fisher grade, and improved outcome similar to the result of prospective one year follow up of Barrow Ruptured Aneurysm Trial ( BRAT) study. With limited resources aneurysm coiling was performed at ANIAS with similar results to literature.

Keywords: Aneurysm coiling, Balloon assisted coiling, Digital subtraction angiography (DSA), Modified Rankin Scale (mRS), Stent assisted coiling

Mechanical Thrombectomy for Acute Ischemic Stroke in Nepal

Pravesh Rajbhandari, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Saujanya Rajbhandari, Department of Neurosurgery, Hyogo Medical College, Hyogo, Japan

Anish Neupane, Department of Radiology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Pritam Gurung, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Abstract

Stroke is one of the leading causes of mortality and the number one cause of dependency in the world. Endovascular therapy has emerged as promising treatment strategy in the patient with acute ischemic stroke due to large vessel occlusion in anterior circulation. Moreover, the time window for mechanical thrombectomy have also been expanded based on the recent DAWN and DEFUSE-3 trial. It is evident that this trend could dramatically increase the number of potential patients for the treatment. Moreover, advancement in stroke imaging have guided physicians to make wisest decision in identifying suitable patient who can get benefit from the recent treatment strategies. The stroke management is evolving and continues to improve, making better outcome of the patient possible. In context of our country Nepal, it is also necessary to educate and aware medical staffs including physicians, nurses, laboratory/ radiology personnel to design a proper acute stroke team to deliver successful therapy which will eventually make a sound impact in a large number of patients with stroke.

Herein, we report a case of a 69-year-old gentleman who presented with right middle cerebral artery territory infarction within 3 hours of onset of symptoms and underwent mechanical thrombectomy as a part of the treatment.

Keywords: Angiography, ; Middle Cerebral Artery (MCA), Mechanical thrombectomy, Thrombolysis in cerebral infarction (TICI)

Giant Spinal Epidermoid Tumor in a Child

Pravesh Rajbhandari, MBBS Norvic International Hospital Kathmandu, Nepal Pranaya Shrestha, MBBS Kathmandu Model Hospital Kathmandu, Nepal Prabin Shrestha, MD, PhD Norvic International Hospital Kathmandu, Nepal Basant Pant, MD, PhD Norvic International Hospital Kathmandu, Nepal

Spinal tumors are relatively uncommon in pediatric group. Intramedullary tumors are more common and neurodevelopmental tumors like dermoids and epidermoids were found to be the most common in this group in one study.3 Intramedullary tumors often present with gait disturbance, radilulopathy or myelopathy, bowel/bnladder disturbance etc.

Digital Subtraction Angiography a Door Opener for Neurosurgical Residents who want to Perform Neurointerventional Procedures

Rajbhandari P, Gurung P, Rajbhandari S, Shrestha D, Acharya S, Shrestha R, Shrestha P,Shrestha J, Sharma U, Mali S, Rajbhandari R, Neupane A, Pant B

Abstract 

Digital subtraction angiography (DSA) has been a fluoroscopic golden investigative tool to know the vascular angiography of the brain and spinal cord. The technique in performing this procedure exposes residents in accessing the major vessels, branches of the arch of aorta, selective angiography and diagnosing different vascular anomalies of brain and spine. They are also exposed to the knowledge of different diagnostic catheters, its manipulation, use of dye and radiation exposure and safety. We would like to share our experience in training and disseminating the knowledge of digital subtraction angiography to the residents.

Evaluation of multiplex PCR using MPB64 and IS6110 primers for rapid diagnosis of tuberculous meningitis

Sunil Prasad Lekhak , Laxmi Sharma , Reema Rajbhandari , Pravesh Rajbhandari , Resha Shrestha , Basant Pant 

Abstract

Tuberculous meningitis (TBM) is one of those most serious manifestations of extra-pulmonary tuberculosis and prompt diagnosis and treatment is required for better clinical outcome. It is difficult to diagnose due to lack of rapid, sensitive, and specific tests. Newer methods, which are easy and reliable, are required to diagnose TBM at an early stage. Thus our aim was to evaluate the Multiplex polymerase chain reaction (PCR) technique, using primers directed against the insertion sequence IS6110 and MPB64 gene for the detection of Mycobacterium tuberculosis in Cerebrospinal fluid (CSF), for rapid diagnosis of TBM patients.

102 CSF samples were analyzed from patients suspected with TBM along with a control group of 10 patients having other neurological disorders. CSF sediments were analyzed individually for M. tuberculosis DNA by Multiplex PCR using two set of primers targeting insertion sequence IS6110 and gene MBp64, which is very specific for MTBC.

Out of 37 patients diagnosed with TBM clinically, MPB64 PCR was positive in 22, IS6110 PCR was positive in 28, both PCR using Multiplex were positive in 34 and Microscopy was positive in one. Thus Sensitivity of MPB64 PCR, IS6110 PCR, Multiplex PCR and Microscopy were found to be 62.3%, 75.4%, 91.8% and 2.7% respectively. In non TBM group PCR was negative in all cases hence, the specificity was 100%.

Multiplex PCR system using primers targeting IS6110 and MPB64, for the detection of M. tuberculosis DNA in CSF samples, has high sensitivity than any one of them alone, and could be used for the early detection of TBM in CSF samples.

Micropropagation, antioxidant and anticancer activity of pineapple orchid: Dendrobium densiflorum Lindl

Bijaya Pant, 

Krishna Chand, 

Mukti Ram Paudel, 

Pusp Raj Joshi, 

Bir Bahadur Thapa, 

So Young Park, 

Sony Shakya, 

Laxmi Sen Thakuri, 

Sabari Rajbahak, 

Anil Kumar Sah, 

Manju Kanu Baniya, 

Prithivi Raj Gurung, 

Lasta Maharjan & 

Pravesh Rajbhandari 

Abstract

Micropropagation was successfully established in the pineapple orchid Dendrobium densiflorum for its conservation and future utilization in the anticancer drug discovery. Micropropagation was carried out via seeds culture on the MS medium. Furthermore, antioxidant and anticancer activities were explored through DPPH and MTT assays. For culture initiation, maximum seed germination (84%) was achieved on half-strength MS medium supplemented with 10% coconut water. Full-strength MS medium supplemented with 15% coconut water was found suitable for highest number of shoot formation from protocorms, while a maximum number of roots were developed on micro-shoots grown on the full-strength MS medium supplemented with 1.5 mg/L IBA. The combination of cocopeat, pine bark and sphagnum moss in the ratio of 2:1:1 was the best substrate used in acclimatization stage resulting in 92% survivability of acclimatized plantlets. Extract of wild plant’s stems (DDW) at 475.28 μg/mL concentration inhibited the 50% DPPH free radicals. Therefore, DDW at 369.16 and 470.97 µg/mL concentrations inhibited the growth of 50% cervical cancer cells (HeLa) and glioblastoma cells (U251) respectively. This research highlighted the micropropagation of D. densiflorum to be utilized in conservation and its potential anticancer drugs to be discovered in future.

Prevalence of Anxiety and its Associated Factors Among Patients Admitted at a Tertiary Neurosurgical Center in Kathmandu, Nepal

Sharad Hari Gajuryal

Basant Pant

Avinash Chandra

Sameer Acharya

Pravesh Rajbhandari

Gambhir Shrestha

Navalok Sharma Ghimire

Abstract

Introduction: The co-existence of anxiety disorders in patients with neurological and neurosurgical disease is in association with barriers to treatment and worsening medical outcomes. This study aims to identify the prevalence and correlation of anxiety in a tertiary neurological center in Kathmandu, Nepal.

 Methods: This was a hospital-based cross-sectional study conducted at a tertiary neurological center in Kathmandu in patients undergoing major neurosurgical procedure. A semi-structured questionnaire including socio-demographic characteristics and medical history were used to collect data. Nepali translated Hospital Anxiety Scale, AUDIT, and Fragesterum Questionnaire were used to assess the anxiety level, alcohol dependence and tobacco dependence among the participants respectively. Chi-square tests and multiple logistic regression were used to test the association of anxiety with independent variables.

Results: A total of 260 patients participated in this study with the mean age of 45.7 ( SD 17.9) years. Out of total participants, 174 (66.9%) were found to have anxiety. Anxiety was found to be associated with older age group (OR=0.333, 95% CI=0.19-0.58), low education level (OR=2.176, CI=1.28-3.70) and presence of at least one chronic disease other than neurological condition (OR=2.034, 95% CI=1.14-3.63).

Conclusions: This study revealed a high prevalence of anxiety in patient who are undergoing neurosurgical procedure. The need for a focused approach to mental health care within the hospital should be implemented with a friendly environment making better relationships between patient and healthcare staff.

Keywords: 

Anxiety ; Neurosurgical Patient; Psychiatry disorder

Vacuum-assisted en bloc resection of large convexity meningiomas

Benjamin D. Fox, Bartley D. Mitchell, Akash J. Patel, Katherine Relyea, Shankar P. Gopinath, Claudio Tatsui and Bruce L. Ehni 

ABSTRACT

Convexity meningiomas are common tumors encountered by neurosurgeons. Retracting, grasping, and mobilizing large convexity meningiomas can be difficult and awkward as well as place unwanted forces on surrounding neurovascular structures. The authors present a safe alternative to traditional retraction and manipulation methods by using a modified bulb syringe connected to standard surgical suction to function as a vacuum retractor. This technique allows for rapid, safe, en bloc resection of large convexity meningiomas with little to no pressure on the surrounding brain. The authors present an illustrative case and describe and discuss the technique.

Bilateral Striopallidodentate Calcinosis in Female: A case report

Arun KadelDepartment of Internal Medicine, Kathmandu Model Hospital, Kathmandu, Nepal

Avinash ChandraDepartment of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Reema RajbhandariDepartment of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Pranaya ShresthaDepartment of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Pravesh RajbhandariDepartment of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Abstract

Bilateral striopallidodentate calcinosis (BSPDC) is associated with many neurological and psychiatric abnormalities and most commonly present with extra pyramidal symptoms and can be idiopathic or associated with endocrinopathy, frequently with parathyroid disorders. Here we describe a case who presented with generalized seizure. During workup, the cause of seizure was found to be bilateral and symmetric, extensive, irregular, intraparenchymal calcifications involving the basal ganglia, thalamus and dentate nucleus, white matter in the frontal, parietal, and occipital lobes and dentate nuclei of cerebellum. On the basis of clinical features, investigations, and exclusion of other causes of intracranial calcification a clinical diagnosis of BSPDC was made. BSPDC should be considered in the differential diagnosis of endocrinopathy particularly parathyroid disorders, when associated with neurological and psychiatric abnormalities.

keywords: 

Bilateral striopallidodentate calcinosis, Fahr’s disease Cerebral calcification, Basal ganglia, Hypoparathyroidism

WALLENBERG'S SYNDROME IN YOUNG ADULTS: CASE REPORT

Thapa DK , Yadav CP , Limbu CP , Dhakal S

ABSTRACT

Wallenberg's syndrome which is also known as Lateral medullary syndrome and posterior inferior cerebellar artery syndrome is a very rare cause of cerebrovascular accident (CVA). This has variability of presentaon which cause the under diagnose for Wallenberg Syndrome. Generally ischemic CVA and especially medullary infarcon occurs in the old paents but here we report two cases of Wallenberg syndrome in young adults, first is 35 years male and second is 38 years female. KEY WORDS Ataxia, cerebrovascular infarcon, lateral medullary syndrome, medulla oblongata, wallenberg syndrome.

A Case Report of Angioplasty and Stenting Experience for Peripheral Arte-rial Disease of the Lower Limbs at Annapurna Neurological Institute

Sandeep Raj Pandey1, Anik Jha2, Sudikchya Acharya2, Sudan Dhakal2

1Department of Vascular Surgery, Annapurna Neurological Institute and Allied Sciences ,Maitighar,Kathmandu, Nepal

2Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences ,Maitighar,Kathmandu, Nepal

ABSTRACT

A therosclerosis leading to stenosis or blockage in the major vessels of lower extremities causes peripheral arterial disease(PAD). PAD may be asymptomatic in early stage. Butin late stage PAD present in the form of intermittent claudication (IC) or critical limbischaemia (CLI) . The Fontaine classification is commonly used to measure the severityof disease which is staged from l-asymtomatic to lV-gangrene. PAD can be treated by medical , endovascular and surgical managementThe purpose of this case report is to consider the effectiveness of primary stenting as a treatment management for peripheral artery disease of the lower extremities. 

Key words: Angioplasty; Stenting; Peripheral arterial disease. disease(PAD).

Extradural Hydatid Cyst of the Lumbo-Sacral Spine

Dr. Riju Dahal MBBS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences ORCID iD: https://orcid.org/0000-0002-9966-3204

Dr. Pritam Gurung MD Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences ORCID iD: https://orcid.org/0000-0003-2571-7270

Dr. Sujat Dahal MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences Maitighar, Kathmandu, Nepal

Dr. Resha Shrestha MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences ORCID iD: https://orcid.org/0000-0001-5827-0423

Dr. Samir Acharya MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences ORCID iD: https://orcid.org/0000-0003-1223-1562

Dr. Pravesh Rajbhandhari MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences ORCID iD: https://orcid.org/0000-0001-6093-5850

Dr. Pranaya Shrestha MS Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences

Dr. Basant Pant MD, Ph.D. Department of Neurosurgery Annapurna Neurological Institute and Allied Sciences ORCID iD: https://orcid.org/0000-0003-1424-907X

Abstract

Primary spinal hydatid cyst is a rare and uncommon entity but a signifi cant manifestation of hydatid disease. Here, we report a case of primary extradural hydatid cyst of the sacral region causing cord compression. Pre-operative differential diagnosis was that of Tarlov cyst owing to the radiological appearance and location of the cyst. The diagnosis of hydatid cyst was established intra-operatively which was later confi rmed by histopathology report. Hydatid cyst may not fall under differential diagnosis of extradural lesions of the spine due to its rarity but should be kept under high suspicion in endemic countries.

Key words: Extradural, Hydatid cyst, Spinal cord compression

Morphometric Analysis of the Posterior Cranial Fossa in Chiari Type | Malformation in Adults

Resha Shrestha1 , Mao-de Wang2 , Yu Xiao3 , Lei Qi3 , Basanta Pant4

ABSTRACT

Objective: The aim of this study is to measure the bony part of the posterior cranial fossa and correlate our clinical findings with the current literature.

Method: This study was conducted in the first affiliated Hospital of Xi’an Jiaotong University since January 2010 to February 2012. A total of 15 cases with adult Type 1 Chiari malformation (CMI) were included and various bony measurements were undertaken in the sagittal Magnetic Resonance Imaging (MRI). Thirty healthy controls were matched with their respective age and sex. The values of all the parameters measured for the patients and the control groups were assessed by independent sample Student’s T tests.

Results: The length of the clivus, anteroposterior diameter of posterior fossa and height of posterior cranial fossa in CMI were reduced in size compared to the control groups and it was statistically significant. (p value <0.001, 0.029 and 0.03, respectively). The anteroposterior diameter of foramen magnum was more (p value <0.001) and the tentorial angle was also steeper (p value<0.001) in CMI. Seven patients with CMI had associated syringomyelia.

Conclusion: Even with limited number of patients we could illustrate that the bony components of the posterior cranial fossa is underdeveloped in CMI. This study supports the current literature stating that CMI is the result of underdeveloped occipital somites and the paraxial mesoderm.

Keywords: Chiari Malformation; Posterior fossa, Syringomyelia

Electrocorticography with direct cortical stimulation for a left temporal glioma with intractable epilepsy

Resha Shrestha, Kuo Li, Wei Wang, Hai-ping Lian, and Mao-de Wang*

ELECTROCORTICOGRAPHY (ECoG), the intraoperative recording of cortical potentials, has played an important role in the surgical management of patients with medically intractable epilepsy. This technique is useful in epilepsy surgery to delineate margins of epileptogenic zones, guide resection, and evaluate completeness of resection.1 About one third of the patients with intractable epilepsy have obvious causes, such as tumor, sclerosis, or vascular malformation. However, the presence of tumor in the eloquent cortex like speech area makes it challenging to completely resect the tumor. ECoG-based surgery in conjunction with direct cortical stimulation in such cases helps surgical resection of tumor with no functional tissue affected, producing good surgical outcome. This report describes a case treated with ECoG-based surgery in combination with direct cortical stimulation.

Prospective study of transsphenoidal pituitarysurgery： is tumor volume predictor for the residual tumor?

Resha Shrestha ¹, Lei Qi, Gang Bao, Mao-de Wang

Abstract

Background: The presence of residual tumor after surgery for pituitary adenoma may necessitate further treatment. The suprasellar and parasellar extension of the tumor have been widely considered as the predictors for residual tumor. However there is scarcity of studies regarding the preoperative tumor volume and residual tumor. This study was conducted to evaluate if tumor volume could predict the outcome of transsphenoidal pituitary surgery.

Methods: A prospective study was designed and 48 patients who underwent transsphenoidal pituitary surgery within 1 year in the First Affiliated Hospital of Xi'an Jiaotong University were included in this study. The preoperative tumor volume and immediate postoperative tumor volume (within 4 - 7 days) were calculated in the contrast magnetic resonance imaging by using the formula of ellipsoid. All these volumes were divided into three subgroups, i.e. group 1, group 2 and group 3 with preoperative volume of less than 4 cm(3), 4 - 8 cm(3), and more than 8 cm(3) respectively. The parasellar and suprasellar extension of the tumor were also classified by Knosp and modified Hardy's classifications.

Results: Baseline characteristics were comparable. The preoperative tumor volume of more than 8 cm(3) (group 3, (12.1 ± 1.1) cm(3)) had increased risk on postoperative tumor residue (P < 0.01) than the other two groups ((2.1 ± 0.3) cm(3) and (6.1 ± 0.3) cm(3) in groups 1 and 2). The mean postoperative volume in group 3 patients ((2.2 ± 0.1) cm(3)) was significantly higher than the other two groups (P < 0.01).

Conclusion: Preoperative volume of more than 8 cm(3) can be considered as a predictor for postoperative residual volume.

Progress in neurosurgery: Contributions of women neurosurgeons in Asia and Australasia

Katharine J. Drummond , Eliana E. Kim, Esther Apuahe, Aneela Darbar , Shweta Kedia, Meng-Fai Kuo  , Elizabeth Lewis , Lynne Lourdes N. Lucena  , Wirginia Maixner  , Su Myat Mo  , Sarah Olson  , Woralux Phusoongnern , Resha Shrestha  , Lin Yan  , Gail Rosseau

Abstract

At the end of the first 100 years of neurosurgery as a specialty, it is appropriate to look back and then imagine the future. As neurosurgery celebrates its first century, the increasing role of women neurosurgeons is a major theme. This article documents the early women pioneers in neurosurgery in Asia and Australasia. The contributions of these trailblazers to the origins, academics, and professional organizations of neurosurgery are highlighted. The first woman neurosurgeon of the region, Dr. T.S. Kanaka of India, completed her training in 1968, not long after the trailblazers in Europe and North America. She heralded the vibrant communities of neurosurgical women that have developed in the vast and diverse nations of the region, and the many formal and informal groups of women in neurosurgery that have introduced and promoted talented women in the profession. Contributions of women neurosurgeons to academic medicine and society as a whole are briefly highlighted, as are their challenges in this male-dominated specialty. The region is home to many deeply conservative societies; in fact, some nations in the region have not yet trained their first woman neurosurgeon. The fortitude of these individuals to achieve at the highest levels of neurosurgery indicates great potential for future growth of women in the profession, but also demonstrates the need for initiatives and advocacy to reach the full potential of gender equity.

Customized Cost‑Effective Polymethyl‑Methacrylate Cranioplasty Implant Using Three-Dimensional Printer

Dabadi S, Dhungel RR, Sharma U, Shrestha D, Gurung P, Shrestha R, et al. 

Abstract

There is no doubt that many synthetic materials used in cranioplasty have given good result regarding patient’s calvarial shape. However, the use of these materials is costly to the patient and requires complex intraoperative process. There has been a long history regarding the use of acrylic bone cement called as polymethyl‑methacrylate (PMMA) as an implant due to its desirable properties. Here, we present three cases of simple, cost effective manually sculpted calvarial defect using three‑dimensional (3D) printer. Sharing the achievement and challenges, we want to focus that the 3D customized implant of PMMA can be used as bone substitute.

Keywords: Bone cement, cranioplasty, polymethyl‑methacrylate prosthesis, three‑dimensional printing

Study of Anterior Commissure-Posterior Commissure Distance among Nepalese Cohort

Sambardhan Dabadi, Raju Raj Dhungel, Pra09gya Dhungel, Pritam Gurung1 , Resha Shrestha1 , Samir Acharya1 , Pravesh Rajbhandhari1 , Pranaya Shrestha1 , Basant Pant

Abstract

The main aim of this study is to determine the anterior commissure-posterior commissure (AC-PC) distance in Nepalese population and have comparison of intercommissural length of Nepalese population with some other races. The 47 patients, with mean age of 50 years, included in the study had underwent DBS or Lesioning (Pallidotomy). Data were collected through the MRI imaging under DBS protocol and the manipulation, marking of AC and PC was done in Inomed Planning Software (IPS). The data revealed average AC PC distance of Nepalese population to be 24.86±2.08 mm, ranging from 16mm to 30mm. The study among 29 male and 18 female illustrated male to have longer AC PC as compared to female (25.38mm male, 24.02mm female). The results also confirmed age related changes in AC-PC distance which was linearly increasing with the age. Comparison of data from other studies revealed Nepalese population to have almost similar AC PC distance with Asian population, while that was longer in Caucasian and shorter in Hispanic Population.

Risk Factors Analysis on Traumatic Brain Injury Prognosis

Xiao-dong Qu, Resha Shrestha, and Mao-de Wang* Department of Neurosurgery, First Affiliated Hospital of Medical College of Xi’an Jiaotong University, Xi’an 710061, China

Abstract

Objective: To investigate the independent risk factors of traumatic brain injury (TBI) prognosis.

Methods: A retrospective analysis was performed in 885 hospitalized TBI patients from January 1, 2003 to January 1, 2010 in the First Affiliated Hospital of Medical College of Xi’an Jiaotong University. Single-factor and logistic regression analysis were conducted to evaluate the association of different variables with TBI outcome.

Results: The single-factor analysis revealed significant association between several variables and TBI outcome, including age (P=0.044 for the age group 40-60, P˘0.001 for the age group ı60), complications (P<0.001), cerebrospinal fluid leakage (P<0.001), Glasgow Coma Scale (GCS) (P<0.001), pupillary light reflex (P<0.001), shock (P<0.001), associated extra-cranial lesions (P=0.01), subdural hematoma (P<0.001), cerebral contusion (P<0.001), diffuse axonal injury (P<0.001), and subarachnoid hemorrhage (P<0.001), suggesting the influence of those factors on the prognosis of TBI. Furthermore, logistic regression analysis identified age, GCS score, pupillary light reflex, subdural hematoma, and subarachnoid hemorrhage as independent risk factors of TBI prognosis.

Conclusion: Age, GCS score, papillary light reflex, subdural hematoma, and subarachnoid hemorrhage may be risk factors influencing the prognosis of TBI. Paying attention to those factors might improve the outcome of TBI in clinical treatment.

Key words: traumatic brain injury; prognosis; risk factors

Initial Experience of Different Surgical Techniques in Temporal Lobe Epilepsy in Nepal

Basant Pant, MD, PhD Department of Neurosurgery Kathmandu Model Hospital Kathmandu, Nepal

Prabin Shrestha, MBBS Department of Neurosurgery Kathmandu Model Hospital Kathmandu, Nepal

Pranaya Shrestha, MBBS Department of Neurosurgery Kathmandu Model Hospital Kathmandu, Nepal

Kazunori Arita, MD Department of Neurosurgery Hiroshima University School of Medicine Hiroshima, Japan

Tomokatsu Hori, MD Department of Neurosurgery Tokyo Women’s Medical Univeristy Tokyo, Japan

Abstract

An initial experience of different surgical techniques in intractable temporal lobe epilepsy (TLE) secondary to mesial temporal sclerosis (MTS) is presented. We resorted to surgery in 4 cases of TLE when all other means of non-surgical treatment failed. There were 3 males and 1 female with the history of seizure ranging from 9 to 13 years. All patients were on an adequate dose of multidrug regimes despite which they were having frequent seizure incapacitating daily life. All patients underwent interictal scalp electroencephalography (EEG), and magnetic resonance imaging (MRI) including fluid attenuated inversion recovery (FLAIR) technique. None had sphenoidal or other invasive EEG techniques. One patient had single photon emission computerized tomography (SPECT) and video telemetry. In all cases MTS was found on the right side, presumed to be the non-dominant side by handedness. None of our patients were subjected to Wada test for language determination. On the surgical technique, a standard temporal lobectomy was done in 1, tailored temporal lobectomy in 1 and selective amygdalohippocampectomy (SAH) in 2 cases. There was no mortality or morbidity in this series and all patients are leading an active life. All patients were asked to continue with preoperative medication and gradual tapering of the dose was planned. Postoperative follow up ranged from 2 and a half years for the initial case to 8 months for the latest case. Surgical results included complete remission in 3 cases (Engel class I) and 1 patient with SAH had 1 episode of seizure 3 months following surgery (Engel class II). It is hard to draw any conclusions, given the small number of patients and the relatively short duration of follow-up, but an attempt is made to assess the feasibility of applying different surgical techniques in our setting. Since the preoperative work-up, intraoperative monitoring and postoperative follow-up needs to be tailored in the context of available resources, we discuss the need to critically judge different surgical techniques best suitable to our setting.

Key words: epilepsy, intractability, surgery, technique.

A case of postpartum chronic subdural hematoma

Suyasha Rajbhandari | Pritam Gurung | Gopi Nepal | Samir Acharya | Basant Pant

Abstract

Headache is a common presentation during postpartum period. Anesthesiologist, obstetrician, and neurosurgeon should be aware of the possibility of subdural hematoma in patient complaining of headache following spinal anesthesia.

KEYWORDS: chronic, Postpartum, subdura

Study of Anterior Commissure‑Posterior Commissure Distance among Nepalese Cohort

Sambardhan Dabadi, Raju Raj Dhungel, Pragya Dhungel, Pritam Gurung1 , Resha Shrestha1 , Samir Acharya1 , Pravesh Rajbhandhari1 , Pranaya Shrestha1 , Basant Pant

Abstract

Introduction: The main aim of this study is to determine the anterior commissure‑posterior commissure (AC‑PC) distance in Nepalese cohort and has comparison of intercommissural distance of Nepalese cohort with some other races.

Materials and Methods: The 47 patients, with mean age of 50 years, included in the study had undergone DBS or lesioning (Pallidotomy). Data were collected through the magnetic resonance imaging under DBS protocol and the manipulation, marking of AC and PC was done in Inomed Planning Software (IPS).

Results: The data revealed average AC‑PC distance of Nepalese cohort to be 24.86 ± 2.08 mm, ranging from 16 mm to 30 mm. The study among 29 males and 18 females illustrated male to have longer AC‑PC as compared to female (25.38 mm male and 24.02 mm female). The results also confirmed age related changes in AC‑PC distance which was linearly increasing with the age.

Conclusion: Comparison of data from other studies revealed Nepalese cohort to have almost similar AC‑PC distance with Asian population, while that was longer in Caucasian and shorter in Hispanic Population.

Keywords: Anterior commissure, deep brain stimulation, lesioning, Nepalese, posterior commissure

Oblique Clip Technique via Anterior Temporal Approach for Blood Blister Aneurysm of Distal Portion of Internal Carotid Artery

Pritam Gurung ¹, Yasushi Motoyama ², Ichiro Nakagawa ³, Hun Soo Park ³, Yasuo Hironaka ³, Young Su Park ³, Hideyuki Ohnishi ¹, Hiroyuki Nakase ³

Abstract

Background: Blood blister aneurysms (BBAs) of the internal carotid artery (ICA) are challenging vascular lesions for neurosurgeons because they are fragile and difficult to clip. They are commonly found at the dorsal wall of the ICA. Trapping is an alternative for these lesions, accompanied by vascular reconstruction. However, they are sometimes close to the posterior communicating artery and anterior choroidal artery.

Case description: A 30-year-old man presented with subarachnoid hemorrhage caused by rupture of a BBA in the right distal ICA. After construction of a high-flow bypass, the BBA was accessed via the standard pterional approach to end only in proximal clipping. Two weeks later, the remnant of the BBA showed a tendency to grow. Therefore, the anterior temporal approach was successfully used to obliterate the BBA using an oblique clip technique under direct inspection of patency of the perforators.

Conclusions: The anterior temporal approach to a BBA in the distal ICA is amenable to application of the oblique clip technique, which can provide direct inspection of the perforators emanating from the posteromedial wall of the ICA as well as obliteration of the pathologic wall. Furthermore, less retraction of the frontal lobe is also reasonable for avoidance of premature rupture of a fragile BBA.

Keywords: Anterior temporal approach; Blood blister aneurysm; Oblique clip technique.

Transient Augmentation of Intraoperative Motor Evoked Potentials During Middle Cerebral Artery Aneurysm Surgery

Pritam Gurung ¹, Yasushi Motoyama ², Tsunenori Takatani ³, Yoshiaki Takamura ⁴, Yasuhiro Takeshima ⁴, Ryosuke Matsuda ⁴, Kentaro Tamura ⁴, Shuichi Yamada ⁴, Fumihiko Nishimura ⁴, Ichiro Nakagawa ⁴, Young-Su Park ⁴, Masahiko Kawaguchi ⁵, Hideyuki Ohnishi ⁶, Hiroyuki Nakase ⁴

Abstract

Objective: To study clinical significance of augmentation of intraoperative motor evoked potentials (MEPs) during direct open surgery for middle cerebral artery (MCA) aneurysms.

Methods: Between 2009 and 2017, 134 MCA aneurysm surgeries were performed with intraoperative MEP monitoring. The frequency and cause of augmentation with >50% increase of MEP amplitude from baseline were studied. Factors associated with MEP augmentation were investigated.

Results: MEP augmentation was demonstrated in 9 patients. All 9 events were observed just after application of the temporary clip to the parent artery. The ratio of the maximum amplitude to baseline was 2.6 ± 1.1 at an mean of 2.4 ± 1.1 minutes after parent artery occlusion. Ten patients who did not show MEP augmentation after parent artery occlusion were compared with the patients showing MEP augmentation. The distance of the temporary clip point from the midline was smaller in patients with MEP augmentation compared with patients without MEP augmentation (P = 0.033).

Conclusions: MEP augmentation was thought to be an early ischemic sign preceding a significant decrease in MEPs during MCA aneurysm surgery. Transient augmentation of MEPs was more frequently observed in cases with a temporary clip applied to the more proximal part of the MCA.

Keywords: Augmentation of evoked potential; Middle cerebral artery aneurysm; Motor evoked potential; Temporary clipping.

Spontaneous resolution of isolated dissecting aneurysm on the posterior inferior cerebellar artery

K Korematsu ¹, S Yoshioka, E Abe, Y Nagai, Y Kai, M Morioka, J Kuratsu

Abstract

The authors report a rare example of an isolated dissecting posterior inferior cerebellar artery (PICA) aneurysm with spontaneous resolution. A 41 year-old male suffered sudden dizziness, nausea and vomiting. An angiogram and magnetic resonance imaging (MRI) detected an isolated PICA dissection. The patient was treated conservatively and recovered without any apparent neurological deficit. MRI detected the self-resolution of the dissecting aneurysm. Dissecting PICA aneurysms, especially non-haemorrhagic lesions, have the possibility of spontaneous resolution resulting in a favorable outcome. The treatment strategy for this vascular lesion may be decided based upon neuroradiological changes on careful follow-up.

Brain metastasis from renal urothelial carcinoma successfully treated by metastasectomy

Wen‑Kuei Fanga , Yeong‑Chin Joua *, Yuan‑Chang Daib , Pi‑Chan Koa , Ya‑Fang Huanga

Abstract

Upper tract urothelial cancer (UTUC) arises from the urothelial lining of the urinary tract. UTUC spreads in several different ways including direct invasion, lymphatic spread, and hematogeneous metastases. Regional lymph nodes are commonly the initial site of metastasis, followed by the liver, lung, and bone. Brain metastasis is uncommon in patients with urothelial carcinoma. Here, we report an uncommon case of kidney urothelial carcinoma with brain metastasis in a 55-year-old woman presenting with dysarthria with right side limb weakness. The patient recovered well after resection of the brain lesion without any sequelae after 1 year of follow-up.

Keywords: Brain, Metastasis, Metastasectomy, Urothelial cancer

Our Excursion with Surgical Conduct for Craniopharyngioma

Pritam Gurung1 , Bishal Shrestha1 , Jessica Kayastha1 , Resha Shrestha1 , Samir Acharya1 , Sudan Dhakal1 , Pravesh Rajbhandhari1 , Pranaya Shrestha1 , Ranga Bahadur Basnet2 , & Basant Pant1 .

ABSTRACT

Background: Craniopharyngioma, an epithelial tumor believed to arise from the remnants of Rathke’s pouch, portray approximately 1.2%-4.4% of all intracranial tumors. Due to its inherent domain in the skull base and its liaison with indispensable neurovascular structure, it has still remained an intimidating contest despite an improved dexterity among the neurosurgeons and refinement in neurosurgical gadgetry.Surgical corridor to come down in favor for is elected by the position of optic chiasm, extension of tumor and development of ACoM or ACA (A1).

Methods: A retrospective series study was conducted at Annapurna Neurological Institute and Allied Sciences between January 2016 and August 2021. A total of 20 patients who underwent surgery for histopathologically proven craniopharyngioma was enrolled. Majority of the surgery was performed via a pterional approach while two cases were addressed with a supra ciliary approach and one with a trans nasal trans septal transsphenoidal approach.

Result: The age of presentation among our study group ranged from 5 years to 46 years with a mean age of 28.2 years.The most frequent mode of presentation was headache associated with visual disturbances (visual acuity and visual field). Histopathological analysis disclosed an admantinomatous variant 15 cases and a papillary type in 5 cases. The use of Ommaya reservoir in few selective cases was escorted by the cystic ingredient of the lesion. An endeavor to aggressive surgical approach was accomplished, amidst, excision of tumor was subtotal in 9 %, near total in 36 % and gross total in 45 %. Diabetes insipidus was seen in 36%. We had to endure a case of mortality, who lamentably had a massive sub-arachnoid hemorrhage with a colossal PCA territory infarction on arrival. Post operatively, the mass effect evolved on account of PCA territory infarction.

Conclusion: The magnitude of resection of the tumor is affected by the extension of tumor, consistency of the lesion and position of optic chiasm. Even with an extensive resection, the prospect of recurrence is inordinately high.

Keywords: Craniopharyngioma; Outcome; Resection.

Trapping  and  Thrombectomyof  Giant  Thrombosed  Vertebral Artery Aneurysm via Bilateral Subocciptal Approach –Technical Note

Pritam Gurung1, Yoshihiro Kuga1, Yuji Kodama1, Katsushi Taomoto1, Hideyuki Ohnishi1

Abstract

Background: Giant aneurysms arising from the vertebral artery (VA) are rare; they represent 4% to 6% of all intracranial giant aneurysm. The natural history of thrombosedaneurysms is extremely poor. Most such lesions progressively enlarge and result in irreversible progression of neurological deficits and fatal sequelae through resultant compression of the brainstem. We present the clinical experience of giant thrombosed vertebral artery aneurysm successfully treated via a bilateral suboccipital approach. A 62 –year-old woman presented with slight dysarthria and ataxia for one year. Neurological examination showed right lateral gaze nystagmus, bilateral absent corneal reflex, absent gag reflex, bilateral dysdiadochokinesia, poor right finger nose test, and slightly poor tandem gait. MRI showed a 27 mm giant thrombosed left VA aneurysm with brain stem compression. We performed trapping of the aneurysm and thrombectomy through a bilateral suboccipital approach. First, the distal portion was clipped from the left side. Next, the proximal portion was approached from the right side. Thrombectomy was performed and after shrinkage of the aneurysm, the clips were applied involving some part of the aneurysm just distal to PICA.

Conclusion:The optimum treatment for aneurysm of this type is thought to be complete obliteration of the parent artery with trapping and thrombectomy to decompress the brainstem. Sometimes if PICA could not be preserved Occipital artery (OA)-PICA bypass should be considered.

Key words:Giant thrombosed aneurysm, Thrombectomy, Trapping, Vertebral artery

Different Trials in Mechanical Thrombectomy for Acute Ischemic Stroke

Pritam Gurung1 , Bishal Shrestha1 , Anish Neupane2 , Pravesh Rajbhandhari1

1 Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

2 Department of Radiology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

ABSTRACT

Acute Ischemic Stroke (AIS) is a leading cause of death and disability. It can be treated early with a favorable prognosis if intravenous recombinant tissue plasminogen activator (IV rt-PA) is given to eligible patients within 4.5 hours of its onset. For those patients who do not meet the criteria to undergo intravenous fibrinolysis, mechanical thrombectomy has been shown to be an effective alternative in patients presenting with occlusion of first segment of middle Cerebral artery (MCA) or of internal carotid artery (ICA), provided the intervention is performed within 24 hour according to previous trial. We herein review different randomized controlled trials on AIS undergoing mechanical thrombectomy.

Keywords:  Acute ischemic stroke; Anterior circulation; Intravenous recombinant tissue plasminogen activator; Mechanical thrombectomy.

A simple bracing technique to correct kinking of arterial branches to avoid ischemic sequelae during neurovascular surgery

Yasushi Motoyama, Yoshitaka Tanaka, Pritam Gurung1 , Ichiro Nakagawa, Young‑Soo Park, Hiroyuki Nakase

Abstract

Background: During microscopic procedures for neurovascular disease, we sometimes encounter kinking of arterial branches resulting in ischemic sequelae. A simple and useful technique that involves inserting a small, ball‑like prosthesis made of oxidized cellulose or shredded Teflon with fibrin glue that corrects the arterial branch kinking and avoids subsequent compromise is reported.

Methods: Between January and December 2014, three patients developed arterial kinking during microscopic procedures, including two in the caudal loop of the posterior inferior cerebellar artery during microvascular decompression for glossopharyngeal neuralgia and one in a branch of the middle cerebral artery (MCA) during clipping for an unruptured MCA aneurysm. Blood flow insufficiency was confirmed by microvascular Doppler ultrasonography (MDU) and indocyanine green (ICG) videoangiography. The prosthesis, which was made of shredded Teflon in two cases and oxidized cellulose in one case, was inserted into the crotch of the kinked arteries to correct the kinking of the arteries and restore the proper vascular shape and normal blood flow.

Results: The small, ball‑shaped prosthesis corrected the kinked arteries and maintained the proper shape, which was confirmed by ICG videoangiography and MDU during the operation and three‑dimensional computerized tomography angiography postoperatively. Postoperatively, the patients did not manifest any ischemic sequelae related to the kinked arteries.

Conclusion: The insertion of prostheses with fibrin glue into the crotch of a kinked artery for repair is considered a simple and useful method for correcting a kinked artery that avoids ischemic sequelae.

Key Words: Cerebral aneurysm, clipping, glossopharyngeal neuralgia, kinking, microvascular decompression, simple bracing technique

Microvascular decompression for glossopharyngeal neuralgia using intraoperative neurophysiological monitoring: Technical case report

Yasushi Motoyama, Ichiro Nakagawa, Tsunenori Takatani1 , Hun-Soo Park, Yukiko Kotani, Yoshitaka Tanaka, Pritam Gurung2 , Young-Soo Park, Hiroyuki Nakase

Abstract

Background: Glossopharyngeal neuralgia (GN) is a rare functional disorder representing around 1% of cases of trigeminal neuralgia. Lancinating throat and ear pain while swallowing are the typical manifestations, and are initially treated using anticonvulsants such as carbamazepine. Medically refractory GN is treated surgically. Microvascular decompression (MVD) is reportedly effective against GN, superseding rhizotomy and tractotomy. Methods: We encountered three patients with medically refractory GN who underwent MVD using intraoperative neurophysiological monitoring (IONM). The offending vessels were the posterior inferior cerebellar arteries, which were confirmed intraoperatively via a transcondylar fossa approach to be affecting the root exit zones of the glossopharyngeal and vagus nerves. As IONM, facial motor-evoked potentials (MEPs) and brainstem auditory-evoked potentials were monitored during microsurgery in all three patients. Pharyngeal and vagal MEPs were added for two patients to avoid postoperative dysphagia.

Results: GN disappeared immediately after surgery with complete preservation of hearing acuity and facial nerve function. Transient mild swallowing disturbance was observed in 1 patient without pharyngeal or vagal MEPs, whereas the remaining two patients with pharyngeal and vagal MEPs demonstrated no postoperative dysphagia.

Conclusion: Although control of severe pain is expected in surgical intervention for GN, lower cranial nerves are easily damaged because of their fragility, even in MVD. IONM including pharyngeal and vagal MEPs appears very useful for avoiding postoperative sequelae during MVD for GN.

Key Words: Glossopharyngeal neuralgia, intraoperative neurophysiological monitoring, lower cranial nerves, microvascular decompression

Quantitative analysis of the trajectory of simulated basilar apex aneurysms through the internal carotid artery to assess the need for an orbitozygomatic approach

Yasushi Motoyama1 & Yasuo Hironaka1 & Fumihiko Nishimura1 & Pritam Gurung2 & Ryota Sasaki 1 & Yasuhiro Takeshima1 & Ryosuke Matsuda1 & Kentaro Tamura1 & Ichiro Nakagawa1 & Young-Su Park1 & Hiroyuki Nakase

Abstract

Background: The aim of this study was to identify the correlation between the location of the internal carotid artery (ICA) and the need for an orbitozygomatic approach (OZA) when approaching a basilar apex (BX) aneurysm. Materials and methods By imaging the virtual trajectory to access the basilar artery (BA) through the ICA, the correlations among the height of the BX, the height and lateral breadth of the bifurcation of the ICA, and the need for removal of the orbital rim or zygomatic arch were investigated using three-dimensional computed tomography angiography (3DCTA) data of approximately 80 random samples not limited to BX aneurysms. Furthermore, the utility of 3D simulation to determine the need for the OZAwas verified using data from five patients with BX aneurysms. Results The height of the bifurcation of the ICAwas inversely correlated and the height of the BX was positively correlated with the need for the OZA (both p < 0.017). Among patients undergoing surgery, clipping was successfully performed without the OZA in two patients in whom the distance from the simulated skull point on the extended line from the BX through the bifurcation of the ICA was more than 4 cm from the zygoma and orbital rim.

Conclusions: It is necessary to determine the spatial relationship between the basilar artery and the ICA to decide whether the OZA is needed for surgery. Correlations of the height of the ICA and BX with the need for the OZA were not very strong individually, though they were significant. Therefore, simulation using 3DCTA appears to be important for planning the surgical approach for the treatment of BX aneurysms.

Keywords: 3DCTA . Basilar apex aneurysm . Orbitozygomatic approach . Internal carotid artery . 3D simulation

A case of Diabetes Striatopathy in an Elderly Female

Kailash Sah1 ,Pritam Gurung2, Avinash Chandra1 , Basant Pant2

1 Department of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

2 Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

ABSTRACT

Diabetes Striatopathy , also known as Non-ketotic hyperglycemic hemichorea or Chorea Hyperglycemia Basal Ganglia Syndrome is rare complication of uncontrolled diabetes. This syndrome has been reported more frequently in elderly Asian womenand symptom resolution is typically associated with serum glucose levels and plasma osmolarity normalization.Herein, we report a case of 75 years old female with CAD-TVD, Hypertension & Type -2 Diabetes Milletus under oral hypoglycemic drugs presented with intermittent involantary movement of face and upper limb who was managed for diabetic striatopathy and showed symptomatic improvement in third day of admission.

Keywords: Corpus straitum; Diabetes Striatopathy

Concept of Good Death: Moving toward Peace of Mind

Basant Pant

Chairman & Head of Department

Global Scenario

Death is inevitable and it’s the ultimate truth that those who are born will die. Medical science have made tremendous amount of progress in the past 200 years and have delayed the death from a statistical prospective from last few decades with new generation of medicines and technologies. But all those people born in the world till now died and will be dying. On an average 0.38 million people are born in the world every day and 0.15 million are dying with a growth rate of 1.1% per annum.1,2 We are adding 140 million people every year. Here is a gross inequality of population growth in developed and developing world being 4 times more children in the developing world because children are taken as asset who can help then in farm as well as other household activities. Although this growth in developing countries is tremendously not affecting increment in poulation because of high rate of death rate of under 5 children in the developing world which is 149/1000 on an average in compassion to 79/1000 in the developed world.

Orchids as Potential Sources of Anticancer Agents: Our Experience

Bijaya Pant1,2, Mukti Ram Paudel1, Pusp Raj Joshi1,2

1Central Department of Botany, Tribhuvan University, Kirtipur, Kathmandu, Nepal

2Annapurna Research Center, Maitighar, Kathmandu, Nepal

ABSTRACT

Cancer is the second leading cause of death globally and the cancer burden continues to grow, exerting tremendous physical, emotional and financial strain on individuals, families, communities and health systems. Many health systems in low- and middle-income countries are ill-prepared to manage this burden, and around the world large numbers of cancer patients do not have access to timely quality diagnosis or treatment. Natural products, especially originated from plants, have been applied as remedies to treat various diseases, including cancer, for thousands of years. Several anticancer agents derived from plants, such as paclitaxel (taxol), vinblastine, vincristine, camptothecin derivatives, podophyllotoxins, are in clinical use and a number of other promising agents are in preclinical or clinical development. A growing number of bioactive compounds with cytostatic and cytotoxic activities to treat cancer have been isolated from several orchid species. The Annapurna Research Center in collaboration with other academic institutions is engaged in identifying and exploring anticancer compounds in orchids of Nepal. The center has identified ten different orchid species which contain high phenol and flavonoid contents evidently showing anticancer activities in our in vitro assays against different cancer cell lines viz cervical cancer, lung cancer and brain tumor cell lines. These findings demonstrate that orchids which have been used in in various formulations in traditional medicine since ancient times qualify as potential source for novel drug candidates or starting points for further lead optimization towards clinical candidates for the most urgently needed treatment of aggressive types of cancer. This review paper highlights that in all likelihood; our contributions in orchid research here in Nepal could bring great relief to patients with cancer globally.

Key words: Cancer; Orchids; Anticancer compounds; Natural products

Biomedical Engineering in Nepal: Opportunities and Challenges

ChallengesSambardhan Dabadi1, Raju raj Dhungel1

1Department of Biomedical Engineering, Annapurna Neurological Institute and Allied Sciences

ABSTRACT

Biomedical engineering is the blend of engineering and medical science, professional with a combination of knowledge of various engineering discipline to improve health care and quality of life. While biomedical engineering formally came up as major course in 1950s, the course started in Nepal just a decade back with its importance being acknowledged and biomedical engineers have been recruited by various institutes. Accounting for artificial intelligence, robotic surgery, 3-d printing, which are believed to be the future of medical science, it is necessary to strengthen the biomedical engineering. This article aims to highlight the overview as well as opportunities and challenges of biomedical engineering in Nepal.

Keywords: Biomedical engineering; Medical devices, Technology

An Audacious Voyage during COVID-19 Pandemic in Management ofPatients with Aneurysmal Subarachnoid Hemorrhage at Tertiary Neurological Center in Nepal

Pravesh Rajbhandari1, Jayant Kumar Yadav1, Shilpa Giri1, Bishal Shrestha1, Jessica Kayastha1, Janam Shrestha1, Gopi Nepal1, Pritam Gurung1, Reema Rajbhandari2, Jitesh Shrestha3, Anusha Palikhe3, Shambhu Bahadur Karki3, Samir Acharya1, Resha Shrestha1, Sudan Dhakal1, Sharad Hari Gajuryal1, Pranaya Shrestha1, Basant Pant1

ABSTRACT

Introduction: Aneurysmal Subarachnoid Hemorrhage(SAH) is a neurosurgical emergency for which testing for COVID PCR was not an option and was unlikely to change the management of the case. Hence, all surgeries were performed without COVID PCR and Rapid Diagnostic Test (RDT) at our center for the welfare of the patient despite risks involved for the surgeons and supporting staff.

Methods: Data were collected retrospectively of all cerebral aneurysm patients who received treatment at Annapurna Neurological Institute and Allied Sciences during the covid pandemic between February 2020 to May 2021. Their demographic profile, clinical and imaging characteristics, treatment decision, postoperative complication, postoperative functional status in terms of Modified Rankin Scale were taken into consideration and analyzed.

Result: 63 patients were enrolled in study with patient age ranging from 9 years to 81 years. Male to female ratio was 1:3. Amongst them, 28% had hypertension. 82% underwent microsurgical clipping while three patients underwent coiling. Basilar Top aneurysm, Para clinoid aneurysm, PICA aneurysm underwent simple coiling. Wrapping, bypass and trapping were performed in 1,1, and 3 cases respectively. At the time of discharge, most of the patients (77%) achieved good functional recovery (mRS ≤ 2) while mortality was reported in 8% of patients. Based on our experience and limited dataset, posterior location of aneurysm, increasing Hunt-Hess Grade and modified fisher grade had poor prognosis, related with degree of cerebral vasospasm, and delayed cerebral ischemia.

Conclusion: Results from our study showed outcomes in surgical patients with aneurysmal SAH at par with international standards. COVID pandemic although posed initial difficulties, with proper guidelines and protocols in place, we were able to perform the emergency surgeries without compromising our standards.

Key Words : Aneurysm; Clipping; Coiling; Covid -19.

Azathioprine in the Treatment of Multiple Sclerosis: A Single Center Experience from Nepal

Reema Rajbhandari, Department of Neurology, Maharajgunj Medical Campus,Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Sasa Shakya, Department of Neurology, Annapurna Neurological Institute and Allied Sciences,Maitighar, Kathmandu, Nepal

Jayant Kumar, YadavDepartment of Neurology, Maharajgunj Medical Campus,Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Abhishek Tamrakar, Department of Neurology, Annapurna Neurological Institute and Allied Sciences,Maitighar, Kathmandu, Nepal

Sandip Kumar Jaiswa, Department of Neurology, Annapurna Neurological Institute and Allied Sciences,Maitighar, Kathmandu, Nepal

Pravesh Rajbhandari, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences,Maitighar, Kathmandu, Nepal

Avinash Chandra, Department of Neurology, Annapurna Neurological Institute and Allied Sciences,Maitighar, Kathmandu, Nepal

Abstract

Introduction: Azathioprine is used as an off - label drug for the treatment of multiple sclerosis. It is one of the oldest and most widely used immunosuppressants that targets T and B lymphocytes and thus reduces the relapse and slows down the disease progression with the almost same efficacy as the other disease modifying drugs for multiple sclerosis. But due to its side effect profile it isn’t used as a standard choice of treatment. However, its cost effectiveness and oral route of administration makes it a drug of choice in a low socioeconomic country. This paper highlights the diagnosis of Multiple Sclerosis based on McDonald’s criteria and treatment with Azathioprine.

Methods: It is a retrospective analysis was conducted among 32 patients suffering from Multiple sclerosis and treated with Azathioprine at tertiary neurological institue.Patients outcome was also documented reaching them individually.

Results: Among 19 patients all were female with highest prevalence among age group of 30-39 years old. 60% had relapsing remitting Multiple sclerosis, 45% of the patients present with ocular symptoms followed by 31% patients with lower limb weakness and spasticity. 30% did not develop any relapse, 15.8% patients developed one episode of relapse, 21.1% patients relapsed twice while 21.1% patients relapsed thrice during the study period. 85% patients showed signs of improvements with Azathioprine therapy in terms of decreased neurological residual deficits and less complication.

Conclusion: Azathioprine shows improvement, slows the rate of relapse with minimal evidence of side effects and no evidence of malignancy in patients with multiple sclerosis.

Keywords: Azathioprine, Interferon, Multiple Sclerosis

Correlation between White Blood Cell Count and Myocardial Infarction Mortality in Patients admitted at Tertiary Care Center of Philippines

Pratik Paudel, Department of Internal Medicine, Rizal Medical Center, Philippines

Mariano B. Lopez, Department of Cardiology, Rizal Medical Center, Philippines

Rakshya Gautam, Department of Internal Medicine, Alka Hospital, Lalitpur, Nepal

Abstract

Introduction: Coronary artery disease (CAD) continues to be a major cause of morbidity and mortality in developed as well as developing countries. This study aims to find out the correlation between elevated WBC and AMI mortality and also to enhance as an independent marker for higher risk for in-hospital patients which would finally help for risk stratification and better care for such presentation.

Methods: This is a retrospective research evaluating all adult patients with AMI who were admitted to Rizal Medical Center from January 1, 2016 to December 31, 2017. Clinical data were retrieved from the Medical Records Section and Department of Laboratory Medicine. Detailed history, physical examination and relevant investigations such as complete blood count and electrocardiographic results were reviewed. All data was managed by Microsoft Excel for windows and after collecting a sample size of 225 cases. Analysis was executed using SAS Software Version 9.3.

Results: Relationship existed between clinical outcome and white blood cell count. The patients with elevated WBC on comparison to patients with normal WBC had 3 times more risk of dying (discharged(5.8%)/died(18.7%), p value 0.028. The mean WBC for favourable clinical outcome was 11.87±4.85 S.D which is lower as compared to the poor clinical outcome averaged 13.87±6.20 S.D. (p .028 < .05).

Conclusion: The results indicate that patients with elevated white blood cell count would be more likely to have poor clinical outcome compared to patients who have normal white blood cell count. White blood cell count within 24 h of admission for an AMI is a strong and independent predictor of in-hospital mortality.

Keywords: Clinical Outcome, Myocardial Infarction, WBC

An Unusual Exhibit of Cervical Plasmacytoma with Trademarks of Cervical Myelopathy

Shilpa Giri, Department of Neurosurgery, Annapurna Neurological Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

Pritam Gurung, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Bishal Shrestha, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Pranaya Shrestha, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Basant Pant, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Abstract

We reported a case of a 76-year-old man presented with cervical neck pain since 16 days. He had also weakness of all limbs since 4 days, insidious in onset. MRI Cervical spine revealed an expansile lesion in C2-C3 vertebral level and C2 lamina pathological fracture. He was suspected as a case of multiple myeloma. However, the histopathology report revealed morphological features compatible with Plasmacytoma.

Keywords: Cervical spine, Cervical Myelopathy, Plasmacytoma

An Integrated Approach in COVID-19 Patient with High Oxygen Dependency Status

Jaya Satyal, Ayurveda Hospital, Nardevi, Kathmandu. Nepal

Kasi khatiwada, Ayurveda Hospital, Nardevi, Kathmandu. Nepal

Pratigya koju, Ayurveda Campus Teaching Hospital, Institute of Medicine, Tribhuwan University

Jhularam Adhikari, Ayurveda Hospital, Nardevi, Kathmandu. Nepal

Pradeep kc, Ayurveda Hospital, Nardevi, Kathmandu. Nepal

Abstract

Covid-19 has become a global pandemic leading towards thousands of death worldwide.It is infectious disease caused by a new corona virus called SARS-cov-2. WHO learned of the new virus on 31 december 2019 for the first time, following a report of cluster of cases of viral pneumonia in Wuhan, China. However, we report a presentation of covid infection in a 45 year old male in a covid hospital where he was treated with integrated approach i.e Allopathy,Ayurveda,TCM(Trad itional Chinese Medicine),Yoga and physiotherapy.During treatment Patient was kept on cpap for some days and got discharged after complete treatment.

Keywords: Allopathy, Ayurveda; Covid-19, Cpap, TCM

Scapular Stabilzation Exercises for the Management of Bilateral Snapping Scapula Syndrome

Mukesh Pokharel, Department of Physiotherapy and Rehabilitation, Annapurna Neurological Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

Rasmita Sharma, Department of Physiotherapy and Rehabilitation, Annapurna Neurological Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

Nabin Sapkota, Department of Physiotherapy and Rehabilitation, Annapurna Neurological Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

Bidur Bhurtel, Department of Physiotherapy and Rehabilitation, Annapurna Neurological Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

Avinash Chandra, Department of Neurology, Annapurna Neurological Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

Basant Pant, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Abstract

This case reports depicts the effect of scapular stabilization regimen for managing clinical symptoms of scapular dyskinesis presenting with crepitus during shoulder movement. A 35 old banker with history of peri scapular, shoulder and coracoid area pain with auditory joint noise visited our department. Scapular stabilization exercise regimen with emphasis on normalizing anatomical symmetry, scapular motor control was done for 40 mins, three times a week for 8 weeks. Follow up was maintained once a month after that or as per the need. Measurements included scapular deviations, muscle strength, pain intensity, quality of life and global rate of change. These changes were assessed at the beginning before the intervention, 8 weeks after treatment and during 1 year follow-up. Data shows favourable improvement on pain, strength , scapular symmetry and quality of life. Thus, it can be concluded that the scapular stabilization exercise is helpful in alleviating symptoms related to scapular dyskinesis and snapping scapula syndrome.

Keywords: Bursitis, Scapular Dyskinesis, Scapulothoracic Crepitus, Snapping

Engineering and Innovations in Neurosurgery

Sambardhan Dabadi, Department of Biomedical Engineering, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Raju Raj Dhungel, Department of Biomedical Engineering, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Saugat Acharya, Department of Biomedical Engineering, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Samir Acharya, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Janam Shrestha, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Sudan Dhakal, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Abstract

Introduction: Modern technology engineered and developed with artificial intelligence have significantly improved the nature of diagnosis and treatment of patients. Healthcare facility has changed significantly in the past few decades because of technological developments. Neurosurgery has been able to practise and enjoy a lot of technologically advanced tools in the past few decades. In context of Nepal, technologically sophisticated devices and tools ranging from neuro navigation, high speed cutting drills, intra operative neuro monitoring, deep brain stimulation, to high resolution magnetic resonance imaging are already introduced. In this paper, the literature review on currently available technologies used in neurosurgery, their significance in delivering a better health care and their usage in Nepal has been discussed. 

Keywords: Innovation, Neurosurgery, Technology

Accidental Injury in Children and its Clinical Pattern at Tertiary Neurological Center in Kathmandu

Sharad Hari Gajuryal, Department of Public Health, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Pranaya Shrestha, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Nicolla Newall, School of Medicine and Dentistry, University of Aberdeen, United Kingdom

Matrika Singh, Department of Public Health, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Manish Bikram Shah, Department of Orthopedics, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Basant Pant, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Abstract

Introduction: Accidental injury in children is a significant cause of morbidity and mortality worldwide. The burden of child injuries in Nepal is not well understood due to lack of research into its epidemiology. This study aims to identity the prevalence of accidental injury as well as its clinical pattern in a tertiary Neurological Center in Nepal.

Methods: A retrospective cross sectional study of pediatric patients presenting to Annapurna Neurological Institute with history of accidental injury between the period of 1 year. Data was collected using self-designed Performa which included socio-demographic profile, mode of injury, type of injury, place of injury and outcome.

Results : Out of total 232 patients, 130 patients (56.03%) had history of Road Traffic Accident whereas 102 patients (43.97%) had history of fall injury. Head injury was the major cause of road traffic accident and fall. Majority of patients had accidental injury at home (41%), most of the injury occurs at morning. Mainly, injury occur by falling from window and terrace (49%) and majority of RTA occurred among pedestrians. Less than half patients are admitted to the ward and total of (6.4%) patient died after having accidental injuries during hospitalization.

Conclusion: Pediatric accidental injury should be recognized as an important public health issue in Nepal. The high incidence of pediatric injury as a result of RTA and falls indicate the need for the identification of specific risk factors to reduce these injuries and implementation of stricter traffic rules and regulations and public education programs. A comprehensive injury registry in our set up seems to be important for formulating policies to reduce pediatric trauma burden

Keywords:  Accident, Accidental injury, Falls, Road trafffic accidents

Combined Acupuncture and Shirodhara as an Effective Treatment Approach in the Management of Progressive Bulbar Palsy: A Case Report

Jaya Satyal, Central Ayurveda Hospital, Nardevi, Kathmandu, Nepal

Pradeep KC, Central Ayurveda Hospital, Nardevi, Kathmandu, Nepal

Rachana KC, Department of Alternative Medicine, Annapurna Neurogical Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

Aabha Sharma, Department of Alternative Medicine, Annapurna Neurogical Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

Avinash Chandra, Department of Neurology, Annapurna Neurogical Institute & Allied Sciences, Maitighar, Kathmandu, Nepal

Abstract

Progressive bulbar palsy is a motor neuron disease with symptoms of dysarthria, dysphagia, sialorrhea with tongue muscle atrophy and fasciculation. A patient came to a tertiary neurological center with symptoms of dysphagia, dysarthria and excessive salivation from last 6 months. Patient stated that the several medications were tried including Tab. Riluzole and injection edaravone without any success. Hence the integrated approach of western and Eastern alternative therapy including Acupuncture and Ayurveda Shirodhara was started for 18 days. Patient was initially assessed via Dysphagia Score and NIH Dysarthria score before the commencement of the treatment session. This case demonstrates that the acupuncture and shirodhara can be an effective treatment approach for the management of progressive bulbar palsy.

Keywords: Acupuncture, Ayurveda, Progressive bulbar palsy, Shirodhara

High Flow Bypass and Trapping of the Fusiform Aneurysm of Right Middle Cerebral Artery Using Y Graft: A Noble Surrogate

Bishal ShresthaDepartment of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Pritam GurungDepartment of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Tina BadinskUniversity of Zurich, Switzerland

Samridha MallaDepartment of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Samir AcharyaDepartment of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Basant PantDepartment of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Abstract

Fusiform aneurysms of the middle cerebral artery (MCA) are a very demanding vascular pathology for the neurosurgeons rendering to its complexity and perplexing to execute adequate clipping. On that account, trapping is a virtuous alternative for these lesions accompanied by vascular reconstruction.A 21-year-old gentleman presented with the chief complaints of headache and weakness of left side of upper and lower extremities with facial deviation toward left side and slurring of the speech since 4 months. Cerebral CT angiography showed fusiform dilatation involving the vessel in the right M1 segment of the MCA. After construction of high flow bypass (ECA-MCA) on superior and inferior trunk of the MCA using long saphenous vein graft in the form of Y shaped design, fusiform aneurysm was trapped. He was discharged on 12th post-operative day with mRS 1. High flow bypass and trapping is one of alternatives for the treatment of large fusiform shaped aneurysm in the MCA.

Keywords: Fusiform aneurysm, High flow bypass, Long saphenous graft, Y graft

Medical Device Maintenance: Prolonging the Use of Medical Device

Sambardhan Dabadi, Department of Biomedical Engineering, Annapurna Neurological institute & Allied sciences, Maitighar, Kathmandu, Nepal

Raju Raj Dhungel, Department of Biomedical Engineering, Annapurna Neurological institute & Allied sciences, Maitighar, Kathmandu, Nepal

Sharad Hari Gajuryal, Department of Hospital Administration, Annapurna Neurological institute & Allied sciences, Maitighar, Kathmandu, Nepal

Abstract

Procurement and installation of medical device and equipment involves a huge amount of finance in healthcare setting. The timely inspection and maintenance of medical device is as important as its design and development. Timely performed preventive maintenance (PM) prolongs the operative life, reduces the maintenance cost and increases the efficacy of the device. Planned preventive maintenance includes the schedules for inspection and maintenance of device so that any problem can be identified earlier and risk associated with device failure can be minimized.

Keywords: Medical device, Preventive maintenance

Correlation between Serum Calcium and In-Patient Mortality among Patients with Hemorrhagic and Non-Hemorrhagic Cerebrovascular Disease

Rakshya GautamDepartment of Internal Medicine, Alka Hospital, Lalitpur, Nepal

Belinda Lioba L. Mesina-NepomucenoDepartment of Neurology, Rizal Medical Center, Philippines

Pratik PaudelDepartment of Internal Medicine, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Abstract

 Introduction: Cerebrovascular disease is the second most frequent cause of death worldwide. This study was designed to access the correlation between ionized calcium and clinical outcomes of Cerebrovascular events.

Methods: The study included 225 cases diagnosed with cerebrovascular disease and undergone a CT scan. Calcium (ionized calcium) was measured within 1-2 hrs. Of sample collection. The time frame of the study was from December 2016 till December 2017.

Result: There were a total of 52 patients admitted as DVT, among which 26(50%) were male and 26(50%) were female. Twenty patients (38.5%) were COVID-19 positive and 32 (61.5%) were COVID-19 negative. Mean age for among those patients was 50.50±4.8 years, average hospital stay was 6.4±0.6 days, after anticoagulation therapy target INR was reached in 3.8±0.17 days and CVI was present in 14(70%) for COVID positive with DVT. Similarly, mean age was 46.80±3.3 years, average hospital stay was 4.6±0.3 days, after anticoagulation therapy target INR was reached in 3.3±0.21 days and CVI was present in 18(56.65%) with COVID negative with DVT.

Conclusion: Serum calcium was found to be associated with clinical outcome among stroke patients found to have infarction. High incidence of favourable clinical outcome among those who have normal level of serum calcium compared to those who have low serum calcium level was found.

Keywords: Acute Ischemic Stroke, Cerebral Infarction, Hemorrhagic Stroke, Serum Calcium

Challenges Faced for Botulinum Toxin Injection in the Treatment of Hemifacial Spasm and Blepharospasm: Our Experience in Tribhuvan University Teaching Hospital during COVID-19 Pandemic

Reema Rajbhandari, Department of Neurology, Maharajgunj Medical Campus , Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Jayant Kumar Yadav, Department of Neurology, Maharajgunj Medical Campus , Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Ragesh Karn, Department of Neurology, Maharajgunj Medical Campus , Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Rajeev Ojha, Department of Neurology, Maharajgunj Medical Campus , Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Bikram Gajurel, Department of Neurology, Maharajgunj Medical Campus , Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Abstract

Introduction: Hemi facial spasm (HFS) and Blepharospasm (BS) is a chronic distressing condition. Botulinum toxin (BoNT) injection is one of its treatment modality. Acquiring the injection and treating the patients overcoming the lockdown hurdles of COVID pandemic has been a major challenge.

Methods: Patients who were treated at Tribhuvan University Teaching Hospital (TUTH) Outpatient Department (OPD) during the COVID pandemic in 2020 and 2021 were included in this study.

Results: Out of 30 patients, 77% were female. 47% were diagnosed with BS whereas the rest with HFS. About 50% of them have had symptoms for an average of 2-5 years before receiving botulinum toxin injection. The mean Jankovic score for patients before BoNT was 2.31(SD: 0.66 range 1-4). 26 patients experienced a decrease in spasm within one week of BoNT injection and had symptomatic relief. The mean Jankovic score at week 1 was 0.63(SD: 1.09 range 1-3) and the difference was statistically significant (p<0.001). After 2 weeks of BoNT therapy, all patients experienced a decrease in spasm with symptomatic improvement. The mean Jankovic score at week 2 was 0.26(SD: 0.44 range 0-1) and the difference was statistically significant (p<0.001). In terms of side effects, 4 patients experienced paresis while 26 patients experienced no side effects. No other systemic side effects were reported.

Conclusion: BoNT injection has a good outcome for HFS and BS, despite its cost and the need for frequent injection. Importing the BoNT from India during the lockdown period of COVID pandemic and patients travelling within the country were challenges that were faced by the patients and doctors to achieve the result.

Keywords: Blepharospasm, Botulinum Toxin;, OVID Pandemic, Hemifacial Spasm

Economic Burden Associated with Neurocysticercosis at a Tertiary Care Neurological Center in Nepal

Samir Acharya, Department of Neurosurgery,Annapurna Neurological Institute & Allied Sciences ,Maitighar, Kathmandu,Nepal

Pravesh Rajbhandari, Department of Neurosurgery,Annapurna Neurological Institute & Allied Sciences ,Maitighar, Kathmandu,Nepal

Resha Shrestha, Department of Neurosurgery,Annapurna Neurological Institute & Allied Sciences ,Maitighar, Kathmandu,Nepal

Sudan Dhakal, Department of Neurosurgery,Annapurna Neurological Institute & Allied Sciences ,Maitighar, Kathmandu,Nepal

Pranaya Shrestha, Department of Neurosurgery,Annapurna Neurological Institute & Allied Sciences ,Maitighar, Kathmandu,Nepal

Sharad Hari Gajuryal, Department of Neurosurgery,Annapurna Neurological Institute & Allied Sciences ,Maitighar, Kathmandu,Nepal

Basant Pant, Department of Neurosurgery,Annapurna Neurological Institute & Allied Sciences ,Maitighar, Kathmandu,Nepal

Abstract

Introduction: Neurocysticercosis (NCC) is the most common parasitic disease of the central nervous system and is a major cause of epilepsy and neurological morbidity in humans in endemic areas of the world. This study was conducted to estimate economic burden of the paients due to Neurocysticercosis arriving at Tertiary Neurological center of Kathmandu,Nepal.

Methods: A cross sectional prospective study was conducted for 2 years among the patients with NCC at Tertiary Neurological Center in Kathmandu. Patients treatment plan and followup date were recorded and patient were categorized into four different groups depending on the frequency of followup and completion of treatment. Direct and indirect cost centers were catagorised and calculated accordingly. The cost was estimated in US dollar as of 2020.

Results: Out of 52 patients who were followed up completely for treatment, majority of patient were from age group 21-30 years . The total cost incurred for group 1, group 2, group 3 and group 4 were $468, $714, $ 1054 and $1986 respectively.The average cost per day for a patient with NCC was calculated to be $1.5.

Conclusion: This study suggests that Neurocysticercosis results in considerable monetary losses to patient in developing country like Nepal. The average loss of each individual accounted for around one half of per day capita income of Nepal. Various programs and poolicies shall be implemented to reduce the burden of NCC so as to reduce the economic burden associated to it.

Keywords: Cost analysis, Economic Burden, Neurocysticercosis

Acupuncture as a Rehabilitative Therapy in Patient with Multiple Sclerosis:A case Study

Jaya Satyal, Ayurveda Hospital, Nardevi, Kathmandu. Nepal

Pradeep KC, Ministry of Health and Population, Ayurveda Hospital, Nardevi, Kathmandu, Nepal

Rabindra Shrestha, Ayurveda Campus Teaching Hospital, Institute of Medicine, Tribhuwan University

Pratima Dhakal, Ayurveda Campus Teaching Hospital, Institute of Medicine, Tribhuwan University

Abstract

Acupuncture is a branch of TCM (Traditional Chinese Medicine) and has been practiced in China for more than 3000 years. It coordinates conventional Chinese needling strategies with Western clinical information on the cerebral cortex and has been demonstrated to be an extremely compelling method for treating Multiple sclerosis (MS) and other focal sensory system issues. A 42-year-old female patient who was diagnosed with MS was treated with Acupuncture therapy. This case shows that Acupuncture therapy can be complimentary treatment in Multiple Sclerosis. Acupuncture therapy that holds the possibility to extend treatment alternatives for MS in both ordinary and integrative treatments.

Tumoral Calcinosis in Distal Femur: First Documented Case in a Tertiary Medical Center in Philippines

Manish Bikram Shah, Department of Orthopaedics Surgery Annapurna Neurological Institute & Allied Sciences Maitighar, Kathmandu, Nepal

Malana June, Department of Orthopaedics, Cagayan Valley Medical Center, Cagayan, Philippines

Lasam Marco-Paolo, Department of Orthopaedics, Cagayan Valley Medical Center, Cagayan, Philippines

Abstract

Tumoral calcinosis is a rare clinical and histopathologic syndrome characterized by calcium phosphate deposition in peri-articular soft tissue regions, most commonly in the large joints of the hips, shoulders, and elbows. We present the case of a 49-year old female with 8 months history of gradual increasing, painless swelling along her left distal thigh. Plain radiography demonstrated a dense lobulated cluster of calcific nodules within soft tissues consistent with a diagnosis of tumoral calcinosis, as confirmed by histopathological examination. Using this case as illustration, the first case of such nature in our institution, we reviewed pertinent literature related to the management of tumoral calcinosis. Although the pathogenesis in tumoral calcinosis is controversial, the ideal management is surgical excision with complete removal of abnormal tissue to prevent recurrence and to focus on the reduction of serum phosphate levels.

Keywords: Distal femur, Tumoral calcinosis

Central Pontine Myelinolysis in Association with Correction of Hypokalemia with Asymptomatic Case of Gastroesophageal Reflux Disease

Subash Paudel, Department of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Avinash Chandra, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Bhavya Pahwa, University College of Medical Sciences and G.T.B. Hospital, New Delhi, India

Janam Shrestha, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Dinuj Shrestha, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Ayush Chandra, Tianjin Medical University, Tianjin, P.R. China

Abstract

This case report has described the patient having the central pontine myelinolysis (CPM) associated with hypokalemia correction with asymptomatic history of gastroesophageal reflux disease (GERD). It was suspected that due to GERD and vomiting there might be loss of electrolytes resulting to hypokalemia. The hypokalemia was corrected and patient was discharged from the tertiary neurological center in Nepal.Central Pontine Myelinolysis in Association with Correction of Hypokalemia with Asymptomatic Case of Gastroesophageal Reflux Disease.

Keywords: Central Pontline, GERD, Hypokalemia Myelinolysis, Neurology

Use, Abuse, and Associated Impacts of Alcohol on Health and Crimes in Nepal

Lata Gautam, Anglia Ruskin University, Cambridge, United Kingdom

Apil Bohara, Nepal Police, Police Headquarter, Kathmandu, Nepal

Jaya Satyal, Naradevi Ayurveda Hospital & Annapurna Neurological Institute and Allied Sciences, Kathmandu, Nepal

Agatha Grela, University of West London, Brentford, UK

Abstract

Alcohol is a socially acceptable and widely available drink in most countries. Its excessive consumption is linked to various health issues, increase in crime rate and even loss of life. This puts heavy strain in low-income countries like Nepal where full medical facilities are still out of reach for most of the population. Therefore, in this article, we have provided an overview of (i) the effect of alcohol on public health; (ii) trend data on alcohol seizures; (iii) alcohol (including methanol) positive forensic cases; and (iv) other alcohol associated crimes. Our analysis is drawn from a range of data types and sources, triangulating the collected data with alcohol specific academic and grey literature, a survey with students and insights from stakeholder engagements in Nepal. We have shown that alcohol has been associated with a range of health-related issues and crime types in Nepal. For example, alcohol was the most mentioned compound in the student survey (50.7%; n=418) followed by other drugs in Drugs Facilitated Sexual Assault cases. We have also discussed issues with adulteration, surrogates and sub-standard alcohol, highlighting the need for strict monitoring, regulations and extra vigilance about quality control of alcohol in circulation. This should be supported by public awareness campaigns on the use, abuse and impacts of alcohol.

Keywords: Alcohol use and abuse, Alcohol associated crimes, Health impacts

Modes of Non-invasive Respiratory Support Devices and their Significance in the Treatment of COVID-19

Sambardhan Dabadi, Department of Biomedical Engineering, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Raju Raj Dhungel, Department of Biomedical Engineering, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Saugat Acharya, Department of Biomedical Engineering, Annapurna Neurological Institute & Allied Sciences ,Maitighar, Kathmandu,Nepal

Pratik Poudel, Department of Internal Medicine, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Anik Jha, Department of Internal Medicine, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Jitesh Shrestha, Department of Anaesthesia, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu

Abstract

The Novel Coronavirus pandemic (COVID-19) is threatening people all over the world. Each country worldwide has been affected by COVID-19 and over 300 million people have lost their lives. Acute Respiratory Failure (ARF) is the main complication for COVID-19 patients.Various oxygen therapy devices such as oxygen concentrator, high flow nasal cannula, positive airway devices like continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) have much helped the patients to recover from the ARF. The use of these technology made it possible to avoid the severity of the disease and, consequently, the need for invasive ventilation and an intensive care unit (ICU).Different ways and techniques of using such devices and their significance have been mentioned in this study.

Keywords: Acute respiratory failure;, OVID-19, CPAP, Non-invasive ventilation, BiPAP

Caring of Neurosurgical Patients with External Ventricular Drain

Roshani Mahat, Department of Nursing ,Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Amita Moktan, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Sanskriti Thapa, Department of Nursing ,Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Ranju Devkota, Department of Nursing, Annapurna Neurological Institute & Allied Sciences ,Maitighar, Kathmandu,Nepal

Pravesh Rajbhandari, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Basant Pant, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Abstract

An external ventricular drain (EVD), also known as a ventriculostomy or extraventricular drain, is a device used in neurosurgery to treat hydrocephalus which can lead to raised intracranial pressure when the normal flow of cerebrospinal fluid (CSF) inside the brain is obstructed. An EVD is a flexible plastic catheter placed by a neurosurgeon or neurointensivist and managed by intensive care unit (ICU) physicians and nurses. The purpose of external ventricular drainage is to divert fluid from the ventricles of the brain and allow for monitoring of intracranial pressure Nurses are responsible for the care of patients who have external ventricular drains. This article explains how the drains work and discusses key nursing considerations for their management.

Keywords: Cerebrospinal fluid, External ventricular drain, ICP

Sexual Assault through a Forensic Lens: Understanding Drug Facilitated Sexual Assault Issues in Nepal

Lata Gautam, School of Life Sciences, Anglia Ruskin University, Cambridge, United Kingdom

Agatha Grela, School of Life Sciences, Anglia Ruskin University, Cambridge, United Kingdom

Jaya Satyal, Central Ayurveda Hospital, Kathmandu, Nepal

Abstract

Sexual assaults and drug facilitated sexual assaults (DFSA) are becoming a serious problem in Nepal. The increasing number of DFSA cases being reported in the country highlight the urgent need to focus our efforts on several areas, including: (i) capacity building on crime scene examination and forensic analysis of sexual assault cases, (ii) moral and sexual education, and public awareness programmes in schools, and (iii) revised policy and practice in handling of sexual assault cases. Therefore, our work is focused on understanding changing public perception and attitude in society as well as shifting behaviour among law enforcement agencies such as police and judiciary.

In relation to these issues, we have been working collaboratively for the past few years with different organisations and stakeholder groups. Some examples include: (i) running various events to increase awareness (e.g. TV programmes, newspaper articles and interviews, extra-curricular activities in schools); (ii) organising capacity building training to forensic scientists; and (iii) organising workshops to bring together a variety of stakeholders. Here, in this paper, we present our key insights, experience and lessons learnt from these activities. We highlight the need to expand the collaboration effectively among the key stakeholders due to the complex nature of DFSA cases. We also recommend increasing visibility and expansion of One Stop Crisis M

Keywords: Capacity Building; Drug Facilitated Sexual Assault; Forensic Science; Sexual Assault; Public Awareness.

Management of Tietze Syndrome: Acupuncture and Cupping as an Effective Treatment Approach: A Case Study

Satyal Jaya, Ayurveda Hospital, Nardevi, Kathmandu. Nepal

Shrestha Rakesh, Department of Physiotherapy, Annapurna Neurological Institute & Allied Sciences , Maitighar, Kathmandu, Nepal

Pradeep KC, Ayurveda Hospital, Nardevi, Kathmandu, Nepal.

Khatiwada Kashi, Ayurveda Hospital, Nardevi, Kathmandu, Nepal.

Nabina Rouniyar, Ayurveda Campus Teaching Hospital, Institute of Medicine, Tribhuwan University

Avinash Chandra, Department of Neurology, Annapurna Neurological Institute & Allied Sciences , Maitighar, Kathmandu, Nepal

Abstract

Tietze syndrome is a rare inflammatory disorder characterized by chest pain at costochondral junction with an idiopathic etiology. A patient came to the Central Ayurved Hospital Nardevi with an excruciating pain since 5 months. Patient stated that the several medications were tried without any success. Patient was further assessed via radiologically and laboratory. Results were within normal limits. Hence, patient was given 12 sessions of acupuncture along with cupping as the means for pain management. Patient was initially assessed via VAS (Visual Analogue Scale) before the commencement of the treatment session. This case demonstrates that the acupuncture can be an effective treatment approach for the management of Tietze syndrome.

Keywords: Acupuncture, Cupping Tietze, VAS

Application of Intraoperative Neurophysiological Monitoring: New insights

Pritam Gurung, Department of Neurosurgery , Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Sambardhan Dabadi, Department of Biomedical engineering , Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Raju Raj Dhungel, Department of Biomedical engineering , Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Basant Pant, Department of Neurosurgery , Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

Abstract

Various intraoperative neurophysiological monitoring (IONM) helps in assessing the integritry of neural pathways during the surgical treatment. IONM is an assistive tool to preserve the fuction of brain, brainstem, cranial nerve, spinal cord and peripheral nerves and a great assest for neurosurgeons. Different application of IONM includes: MEP, SSEP, ABR, VEP, BCR and AMR. Intraoperative neuromonitoring has become an integral part of the neurosurgery and is being routinely used in various operative cases. This paper discusses the application and benefit of IONM, with its role in delivering a high quality intra operative care to detect and prevent neurological deficits.

Keywords: Intraoperative; neurophysiological; monitoring.