Bangladesh Journal of Neurosurgery

Meninges: The Mother of the Brain-Etymological and Philosophical aspects

2023-01-17T05:44:42+00:00

The meninges are protective coverings around the whole central nervous system comprising of three layers, from outside inwards, Dura mater, Arachnoid mater and Pia mater. These three terms are derived from Latin, where ‘mater’ means mother. Why this motherhood has been implicated while naming these layers, carries a very interesting history and a strong philosophical background. Dura mater (Tough mother), Arachnoid mater (Spider-like mother) and Pia mater (Tender mother)-all of them cover the central nervous system and possess functional significance not less than that of a protective mother. Ancient Arabic scientists observed those facts and named them accordingly in Arabic. Later they were translated into Latin and are in practice till now. While studying various facts regarding the central nervous system, the etymology and philosophy of ‘maternalization of the meninges’ draws immense attention.

Bang. J Neurosurgery 2022; 12(1): 3-5

Management of Postoperative Discitis Following Lumber Discectomy

2023-01-17T07:58:38+00:00

Background: There is no established protocol for the treatment of postoperative lumbar discitis. There are still so many controversies regarding the treatment of postoperative discitis.

Materials and Methods: A total of 23 cases of postoperative discitis were treated from July 01, 2018 to June 30, 2021 for a period of 3 years. Initially all the patients were treated conservatively with complete bed rest, antibiotic therapy and analgesics. Most of the patients were improved clinically but who did not respond to conservative treatment for at least 4 weeks were treated surgically.

Results Out of 23 patients, 11 (48%) patients showed significant clinical improvement after 4 weeks of starting treatment. 12 patients who failed to improve by conservative treatment were selected for surgical treatment. Among them in 5 (22%) patients only surgical debridement were done and in remaining 7 (30%) patients surgical debridement and posterior fixation were done. Most of the patients were improved by conservative treatment and among two groups of surgical treatment the fixation group showed early clinical improvement.

Conclusions Early diagnosis and appropriate management is the key for effective treatment of postoperative discitis. Conservative management leads to an excellent result in majority of cases. Surgical intervention with or without posterior fusion is helpful when conservative treatment fails.

Bang. J Neurosurgery 2022; 12(1): 6-11

Correlation between Perfusion-Weighted Magnetic Resonance Imaging (MRI) Features with Histopathological Grading of Glioma

2023-01-17T08:25:12+00:00

Background: Gliomas are the most common primary neoplasm of the brain. It histopathologically grades I to IV. I and II are low grade while III, IV are high grade. Low-grade gliomas are usually subject to either strict follow-up or surgery. The treatment for high grade gliomas is typically surgery, followed by concomitant radiation therapy and chemotherapy. Conventional MRI has limitations for the grading of gliomas. In addition to conventional MRI techniques, a variety of new techniques such as perfusion-weighted MRI which noninvasively measures cerebral perfusion that can be used for better assessment of glioma. This will be helpful for therapeutic approach and counseling about prognosis of the patient.

Methods: This cross sectional observational study was conducted in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University from IRB clearance to 18 months. The patients who fulfill the selection criteria were enrolled in this study. Written informed consent was taken from the patients and/or the legal guardian/ responsible family members after completely explaining to them the procedure and the purpose of the study. Patient’s data was collected in questionnaire/data collection sheet. The privacy of the patient was strictly maintained and the patient’s information will not be disclosed to any source. The study data will only be used for the purpose of this scientific study. This study was not causing any additional harm to the patients. All the patients were evaluated by a standard conventional contrast-enhanced study with perfusion-weighted image on Siemens 3 Tesla MRI. The histopathological grading of the tumor was done as per the WHO classification of 2007. Then correlation was done between PWI finding and WHO histopathological grading.

Results: Measurement of relative cerebral blood volume in glioma patients was done in PW-MRI preoperatively. Out of the 35 tumors evaluated, 17 were found as low rCBV and 18 as high. Histopathological examination of glioma was done postoperatively. Among 35 tumors, 19 are low grade gliomas and 16 are high grade gliomas. For the correlation between relative cerebral blood volume in preoperative PW MRI and histopathological grading of glioma, Spearman’s Rank Correlation Coefficient Test was done. We found a significant positive coefficient value of r = 0.572 with a significant p-value of p = <0.001. A single cutoff relative cerebral blood volume value of 1.7 for low versus high grade glioma was found to be 77.8% sensitive and 88.2% specific.

Conclusion: The present study ascertains that histopathological grading of glioma is positively correlated with relative cerebral blood volume in PW MRI.

Bang. J Neurosurgery 2022; 12(1): 12-19

Endoscopic third Ventriculostomy for Malfunction of Ventriculoperitoneal Shunt; Our Experience

2023-01-17T08:47:33+00:00

Background: Ventriculoperitoneal (VP) shunt is a common procedure for treating hydrocephalus of various causes. Malfunction of VP shunt like obstruction, infection etc. are encountered with revision surgeries which may not have favourable outcome. Endoscopic third ventriculostomy (ETV) in such cases is challenging, and can be salvageable in appropriate cases.

Objective: Aim of the study is to analyze the role of endoscopic third ventriculostomy as an alternative to shunt revision for malfunctioning and infected ventriculoperitoneal (VP) shunts.

Method: We report 54 cases from 2012 to 2018 in private setup, retrospectively we analysed in all ages including children and adults. Minimum follow up period was 2 years.

Results: In 2 cases we did ETV twice and in 1 case of thalamic glioma where the patient was shunt dependent probably due to post radiotherapy adhesion ETV was successful. The success rate of ETV was 88.9% in our study.

Conclusion: Success rate of ETV depends on various factors and careful selection of patients; CSF infection and communicating hydrocephalus are of poor prognosis. ETV is the feasible alternative for the treatment of failed VP shunt cases in non-communicating hydrocephalus.

Bang. J Neurosurgery 2022; 12(1): 20-23

Drug-resistant Focal Epilepsy due to Focal Cortical Dysplasia: A Case Report

2023-01-17T08:56:24+00:00

Focal cortical dysplasias (FCDs) belong to the large spectrum of malformations of cortical development (MCDs) and represent the most common structural brain lesion in children with drug-resistant focal epilepsies submitted to surgical treatment. It is responsible for nearly half of intractable epilepsy cases in children and adults, and at the same time it is characterized by quite good treatment outcome. We describe a case where a young girl had been suffering from intractable epilepsy and was on two medicines. She was operated upon and was relieved of her symptoms. Her histopathological examination revealed focal cortical dysplasia. We have to keep in mind that FCD can present as low grade glioma and treat it carefully.

Bang. J Neurosurgery 2022; 12(1): 24-28

Apparent Provisional Diagnosis Validated by Histopathology: 2 Case Report that mimics TB Spine Conflict of interest: There is no Conflict of interest relevant to this paper to disclose

2023-01-17T09:09:08+00:00

Background: The incidence of atypical clinic-radiological presentations of spinal TB is on the upsurge. Lesions that share similar features should be evaluated thoroughly. Tissue diagnosis remains the only foolproof investigation to confirm diagnosis before initiation of treatment.

Methods: We present 2 cases who were provisionally diagnosed as a case of Tubercular spondylodiscitis based on clinic-radiological findings. After failure of response from anti tubercular drugs, they underwent operative management for decompression of neural elements and histological confirmation of the provisional diagnosis.

Results: Clinical features like back pain, weight loss, gait abnormalities with radiological features like Magnetic resonance imaging and GeneXpert, CT guided FNAC helps in early detection and initiation of treatment of spinal TB. But in our case, 58year old female and 13 years old male presented with clinic-radiological features consistent with Spinal TB. Histopathology and immunohistochemistry confirm that first case is due to Aspergillus Spinal Epidural Abscess (ASEA) and second case due to round blue cell neoplasm consistent with Ewings Sarcoma.

Conclusion: This article highlights the importance of awareness of the different clinic-radiographic features of spinal lesions, which can mimic a Tubercular Spondylodiscitis. In order to avoid delayed diagnosis, clinicians must be aware of differential diagnosis from common to rare entity which may interfere with other clinical conditions.

Bang. J Neurosurgery 2022; 12(1): 29-36

Cerebellar Lipo Neurocytoma: Case Report and Review of the literature

2023-01-17T10:16:21+00:00

Background: Cerebellar liponeurocytoma is a rare tumor of the central nervous system occurring mainly in the posterior fossa, which shows divergent glioneuronal differentiation and lipidized neoplastic cells and has been considered as a distinct clinicopathological entity.

Case: Herein, we describe a 19-year-old male patient who presented to the hospital complaining of headache, nausea with balance difficulty. MRI revealed a contrast enhancing midline lesion of posterior fossa. After tumor resection, histological examination and immunohistochemistry were done and the diagnosis of cerebellar liponeurocytoma was confirmed.

Conclusion: Liponeurocytoma is a rare benign tumor with cerebellum is the typical site for it. The therapy of choice is surgery. Postoperative radiotherapy has to be discussed individually.

Bang. J Neurosurgery 2022; 12(1): 37-40

A young Female of Cowden Syndrome Presenting with Lhermitte- Duclos Disease: A Case Study

2023-01-17T10:00:11+00:00

Cowden Syndrome (CS) is a rare autosomal dominant inherited genetic disorder due to germline mutations in the phosphatase and tensing homologue (PTEN) tumor suppressor gene in chromosome 10 characterized by multiple hamartomata’s lesions of ectodermal, mesodermal and endodermal origin. Lhermitte-Duclos Disease (LDD), or dysplastic gangliocytoma, which is a benign hamartomata’s condition involving the cerebellum with less than 300 cases reported in the literature. Previous studies suggest an association between CS and LDD. We present here a case of a 28-year female patient presented at the emergency department of our hospital with severe headache associated with vertigo, vomiting & cerebellar ataxia. Papilledema was noted on fundoscopy. Non-attenuating hypodense mass lesion in posterior fossa was found in CT scan. MRI scan T1WI film revealed mixed intensity posterior fossa lesion and T2WI film revealed inhomogeneous hyperintense lesion with almost preserved cerebellar cortical striations. USG revealed numerous polyps in the gallbladder with cholelithiasis. Her facial skin has extensive trichilemmoma. Her symptoms improved after excision of posterior fossa lesion through suboccipital craniectomy and histopathology revealed dysplastic cerebellar gangliocytoma i.e., Lhermitte-Duclos disease. Using the Cleveland Clinic Adult Clinical Scoring for PTEN Testing, the patient had an 82-98% chance for a PTEN gene mutation. Finally, she along with her family was adequately counseled and was advised for regular screening and monitoring.

Bang. J Neurosurgery 2022; 12(1): 41-46

Invasive Sinu-Naso-Orbital Aspergillosis Following Dacryocystorhinostomy In An Immunocompetent Patient: A Rare Case Report And Literature Review

2023-01-17T10:13:16+00:00

Background: Invasive sino-naso-orbital aspergilloma is a rare disease with variable clinical features but in an immunocompetent patient it is rarely considered and often resulted in poor prognosis due to its diagnostic and therapeutic challenge. In this article we reported a rare case of invasive sinu-naso-orbital aspergillosis with intracranial extension following dacryocystorhinostomy (DCR). To our knowledge this is the only reported case in last 109 years.

Case Description: A 61 years old normotensive non diabetic male referred to us from an ophthalmologist with the complaints of retro-orbital pain followed by progressive dimness of vision later blindness on right eye after dacryocystorhinostomy.

Diagnosis and Intervention: His MRI reveals an isointense lesion in T1W and T2W image in right maxillary, ethmoidal sinus with orbital and retro-orbital and intracranial extension with heterogeneous contrast enhancement. Radiologist suggested a case of inflammatory pseudotumor and initially he was treated with steroid, due to lack of clinical response later antifungal was given but patient still was nonresponsive. The patient underwent right pterional craniotomy for biopsy and optic nerve decompression. Histopathology revealed aspergillus infection. Post-operatively he was treated with voriconazole.

Lessons: Invasive sino-orbital aspergillosis is rare in immunocompetent patients. Early diagnosis is critical for successful management. Due to difficulty of diagnosis and higher mortality and morbidity, our recommendation is- ‘a patient with nonspecific complaints or retro-orbital pain’ should prompt the physician to consider this diagnosis.

Bang. J Neurosurgery 2022; 12(1): 47-52

A Success Story of Cerebral Arteriovenous Malformation (AVM) Treated with Stereotactic Radiosurgery (SRS) in Bangladesh

2023-01-17T10:47:13+00:00

Purpose: To share a case of cerebral Arteriovenous Malformation (AVM) patient, treated with Stereotactic Radiosurgery (SRS) at Evercare Hospital Dhaka, treatment process and successful outcome.

Background: Arteriovenous malformation is an anomaly, mostly congenital due to a misfit in vasculogenic, where arteries and veins come to a direct connection. Treatment options include observation, embolization, microsurgery, Stereotactic Radiosurgery (SRS) either alone or in combination. This report describes our experience in treating a patient of AVM by SRS. Stereotactic Radiosurgery is an established modality to achieve desired nidus obliteration, excellent compliance being noninvasive, and reduced treatment-related morbidity. This case report also reviewed the literature in detail. After a thorough literature search, to the best of our knowledge, this shall be the first published case report of AVM successfully treated with SRS in Bangladesh.

Case Presentation: In March 2019, 25-years old male presented in Radiation Oncology OPD as a diagnosed case of AVM, having complaints of headache for two years. Headache was occasional and often associated with vertigo and dizziness. He had no neurologic deficit. A radiological assessment revealed a large (4.6x4.4cm) AVM in the left parieto-occipital lobe showing serpiginous enhancement with IV contrast. After routine workup, he underwent stereotactic Radiosurgery in March’2019. A dose of 23Gy was delivered to the malformation, including all nidus. Acute radiation toxicity was noted as transient hair loss only over the irradiated area and no other side effect. Radiological Assessment was done at six months, 1year, and 2.5 years. After having a stable size at six months, complete nidus obliteration was achieved at one year. His last visit to our OPD was in July 2021, with radiologically complete nidus obliteration without any significant clinical symptoms.

Conclusions: Linear Accelerator-based SRS is an excellent treatment option for AVM, encouraging clinical outcomes for carefully selected patients.

Bang. J Neurosurgery 2022; 12(1): 53-64

Management of Proptosis in a Case of Sphenoid-Orbital Meningioma

2023-01-17T10:59:31+00:00

Sphenoid-orbital meningiomas (SOMs) are difficult to completely resect because they involve the sphenoid wing, orbit, and cavernous sinus. As the tumor invades the optic canal, SOMs frequently present with visual deficits. The authors of this case report dealt with the case of a 65-year-old male patient who had right-sided proptosis. We diagnosed the patient, and his MRI revealed of him having SOM. The surgical approach was determined by the tumor's placement in the orbit and cranial cavity and its connections to the optic canal and optic nerve axis. Tumor was removed successfully by surgery. The patient retained a proptosis of less than 4 mm during the follow-up period. The visual acuity, visual field, and ocular fundus were examined during the follow-up. SOMs are notoriously difficult to treat surgically. The primary goal of surgery in symptomatic individuals with SOMs is to slow down the tumor's progression. Longer periods of post-operative follow-up is recommended to observe long-term results.

Bang. J Neurosurgery 2022; 12(1): 65-68

Evolution of Neurosurgery in Bangladesh

2023-01-17T06:03:27+00:00

Abstract not available

Bang. J Neurosurgery 2022; 12(1): 1-2