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Deepak Kumar Gupta and Ashok K. Mahapatra

Object

A terminal myelocystocele is a rare form of spinal dysraphism in which the hydromyelic caudal spinal cord and the subarachnoid space are herniated through a posterior spina bifida. In their study of 17 cases, the authors attempt to develop treatment guidelines for patients suffering from this condition.

Methods

Seventeen patients (age range 2 months–5 years) underwent surgery during a 7-year period. Surprisingly, nine of 17 patients had no neurological deficits. Among these nine asymptomatic cases, three patients had a dermal sinus and two had a skin dimple, whereas one had congenital talipes equinovarus deformity (CTEV). Among the eight patients with neurological deficits, seven had lower-limb weakness (two had complete paraplegia), and one patient had urinary incontinence and constipation. Four patients each had a dermal sinus and CTEV; interestingly, one infant had an accessory phallus. Radiologically, eight patients had pure myelocystoceles, and a diagnosis of lipomyelocystocele was made in nine instances on the basis of magnetic resonance images. All patients underwent surgery. The meningocele sacs were excised, and the bands tethering the myelocystocele sac to the meningocele sacs were incised, with as little damage to the roots as possible. Two patients experienced postoperative CSF leakage (one required reexploration), and two others had subcutaneous CSF collection. No patient had deterioration of the neurological condition after surgery.

Conclusions

The authors present the largest study of patients with terminal myelocystocele to date and emphasize that the possibility of this condition must be kept in mind when addressing all congenital lumbosacral masses. The authors assert that myelocystoceles and lipomyelocystoceles should be kept in the same category and recommend early surgery in all cases.

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Ashok K. Mahapatra and Deepak Kumar Gupta

Object

Split cord malformations (SCMs) are rare anomalies of the spinal cord. A total of 254 cases of SCM were treated surgically at the authors' center during a period of 16 years.

Methods

Patients' demographic profiles, imaging studies, operative details, complications, and surgical outcomes were evaluated retrospectively. A new classification based on intraoperative findings is proposed.

The mean age of the patients was 7.3 years (female/male 1.5:1). Type I SCM was seen in 156 patients (61.4%) and 98 patients (38.6%) had Type II SCM. Skin stigmata were present in 153 cases (60%); hypertrichosis, being the most common, was seen in 82 cases (32.3%). Asymmetrical lower-limb weakness and sphincter disturbances were present in 173 (68.1%) and 73 (33%) cases, respectively. Of the symptomatic cases, 39% (68 of 173) showed improvement in motor power, 57.9% (33 of 57) experienced sensory improvement, and 27.3% (20 of 73) regained continence. None of the 38 patients in the asymptomatic group had postoperative neurological deterioration. The neurological status was unchanged in 63% of the cases. A new subclassification of Type I SCM is proposed, based on intraoperative location of a bone spur causing the split, which may have a bearing on surgical dissection and outcome. Based on the authors' experience with 25 cases of Type I SCM, they have classified the disorder into four subtypes: Type Ia, bone spur located in the center with duplicated cord above and below the spur (12 cases); Type Ib, bone spur at the superior pole with no space above it (four cases); Type Ic, bone spur at the lower pole with large duplicated cord above (three cases); and Type Id, bone spur straddling the bifurcation with no space above or below the spur (six cases). The risk of injury to the hemicords is highest in the Id subtype (four of six patients in this group deteriorated neurologically in the present series, whereas none with subtypes Ia–c worsened).

Conclusions

The authors present the largest series on SCMs so far reported in the world literature The risk of neurological deficits developing increases with age; hence, all patients with SCM should be surgically treated prophylactically even if they are asymptomatic. This new classification is easy to use and remember and takes into account the use of intraoperative findings that may have a bearing on surgical outcome.

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Raj Kumar, Rupant K. Das and Ashok Kumar Mahapatra

Object

Tuberculosis is ubiquitous in its presence and in its myriad manifestations. Despite several advances, it often poses a diagnostic dilemma. The aim of this study was to evaluate the efficacy of the QuantiFERON assay in the diagnosis of Pott disease.

Methods

In this study, 70 consecutive patients with vertebral collapse underwent a battery of investigations including radiological evaluation (MR imaging and chest and spine radiography), routine blood workup (hemoglobin, total leukocyte count, differential leukocyte count, and erythrocyte sedimentation rate), enzyme-linked immunosorbent assay (ELISA) for tuberculosis, a bone scan and the QuantiFERON assay, perioperative evaluation, and bacteriological studies. The patients were then classified as having tuberculosis on the basis of positive smear or culture, a biopsy consistent with tuberculosis, or a therapeutic response to antituberculosis chemotherapy on follow-up. The efficacy of the investigations, both individually and in combination, were evaluated.

Results

Tuberculosis was diagnosed in 51 patients, and 19 had vertebral collapse that was attributable to other causes. Based on the authors' data, sensitivity of the QuantiFERON assay in the diagnosis of tuberculosis of the spine was 84% and specificity was 95%. In combination with radiological criteria, bone scan, and ELISA, the QuantiFERON assay was predictive of tuberculosis in 90% of cases (46 patients).

Conclusions

None of the investigative modalities individually are efficacious enough to make a diagnosis of tuberculosis of the spine with such a degree of certainty as to to obviate the need for a tissue diagnosis or bacteriological confirmation. The ELISA, MR imaging of the spine, and bone scanning findings provide a reasonably certain diagnosis in 90% of cases, providing the grounds for starting a safe trial of antituberculous chemotherapy.

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Ravi Sharma, Manoj Phalak, Vivek Tandon and Ashok K. Mahapatra

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Deepak Agrawal, Naveen K. Gowda, Chandra S. Bal, Manish Pant and Ashok Kumar Mahapatra

Object. The authors sought to correlate the finding of medial temporal hypoperfusion (MTH) demonstrated on single photon emission computerized tomography (SPECT) with pediatric persistent postconcussion syndrome (PPCS) and to ascertain its usefulness in routine clinical practice.

Methods. Thirty consecutive children with minor head injury and features of PPCS underwent SPECT scanning within 72 hours of injury. Those children having MTH on SPECT were included in the test group (14 patients), and the remaining 16 children comprised the control group. At the end of a 3-month period SPECT scanning was repeated and the incidence of PPCS was assessed clinically in both groups.

Repeated SPECT scanning at 3 months revealed persisting MTH in 13 children (93%) in the test group; no child developed MTH in the control group. Twelve children were found to have PPCS in the MTH group compared with only two in the control group, and this was highly statistically significant (relative risk 6.86 [95% confidence interval 1.84–25.51], p = 0.0003).

Conclusions. There exists significant MTH in pediatric patients with PPCS, which would imply that medial temporal lobe damage (involving the hippocampus and related structures) may occur after minor head injury and could be responsible for the symptoms of PPCS observed in this group of patients. Brain SPECT scans may thus help in the early identification of children prone to develop PPCS, and serial SPECT scanning may serve as a platform for testing the efficacy of various neurobehavioral and pharmacological interventions in these patients.

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Deepak Agrawal, Naveen K. Gowda, Chandra S. Bal, Manish Pant and Ashok Kumar Mahapatra

Object

The authors sought to correlate the finding of medial temporal hypoperfusion (MTH) demonstrated on single photon emission computerized tomography (SPECT) with pediatric persistent postconcussion syndrome (PPCS) and to ascertain its usefulness in routine clinical practice.

Methods

Thirty consecutive children with minor head injury and features of PPCS underwent SPECT scanning within 72 hours of injury. Those children having MTH on SPECT were included in the test group (14 patients), and the remaining 16 children comprised the control group. At the end of a 3-month period SPECT scanning was repeated and the incidence of PPCS was assessed clinically in both groups.

Repeated SPECT scanning at 3 months revealed persisting MTH in 13 children (93%) in the test group; no child developed MTH in the control group. Twelve children were found to have PPCS in the MTH group compared with only two in the control group, and this was highly statistically significant (relative risk 6.86 [95% confidence interval 1.84–25.51], p = 0.0003).

Conclusions

There exists significant MTH in pediatric patients with PPCS, which would imply that medial temporal lobe damage (involving the hippocampus and related structures) may occur after minor head injury and could be responsible for the symptoms of PPCS observed in this group of patients. Brain SPECT scans may thus help in the early identification of children prone to develop PPCS, and serial SPECT scanning may serve as a platform for testing the efficacy of various neurobehavioral and pharmacological interventions in these patients.

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Ravi Sharma, Sachin A. Borkar, Manoj Phalak, Sumit Sinha and Ashok K. Mahapatra

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Manish Kumar Kasliwal, Shashank Sharad Kale, Aditya Gupta, Narayanam Anantha Sai Kiran, Manish Singh Sharma, Bhawani Shanker Sharma and Ashok K. Mahapatra

Object

Although the effects of Gamma Knife surgery (GKS) on the risk of hemorrhage are poorly understood, a certain subset of patients does suffer bleeding after GKS. This study was undertaken to analyze the outcome of patients sustaining hemorrhage after GKS; it is the most feared complication of radiosurgical management of cerebral arteriovenous malformations (AVMs).

Methods

Between May 1997 and June 2006, 494 cerebral AVMs in 489 patients were treated using a Leksell Gamma Knife Model B, and follow-up evaluations were conducted until June 2007 at the All India Institute of Medical Sciences in New Delhi. Fourteen patients who sustained a hemorrhage after GKS formed the study group. In most of these patients conservative management was chosen.

Results

The mortality rate was 0% and there was a 7% risk of sustaining a severe deficit following rebleeding after GKS. None of the patients sustained rebleeding after complete obliteration. Patients with Spetzler-Martin Grade III or less had increased chances of hemorrhage after GKS (p < 0.002). The presence of deep venous drainage, aneurysm, venous hypertension, or periventricular location on angiography was common in patients with hemorrhage after GKS.

Conclusions

The risk of hemorrhage that remains following GKS for cerebral AVMs is highest in the 1st year after treatment. The present study showed a relatively good outcome even in cases with hemorrhage following GKS, with no deaths and minimal morbidity, further substantiating the safety and efficacy of the procedure.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010