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Rajinder Kumar, Sarat P. Chandra and Bhawani Shanker Sharma

The management of intradiploic CSF collection is controversial. Although it is a benign lesion, even then delay in diagnosis and treatment may lead to significant morbidity. The authors report a very rare case of giant posttraumatic intradiploic pseudomeningocele involving the occipital bone, occipital condyles, and clivus. The pathogenesis and management of intradiploic CSF collection are discussed.

This 16-year-old boy presented with a history of enlarging swelling in the suboccipital region associated with headache, lower cranial nerve palsy, and features of high cervical compressive myelopathy. Investigations revealed a giant intradiploic lesion involving the occipital bone, condyles, and clivus associated with secondary basilar invagination, hydrocephalus, and syringomyelia. Intrathecal contrast administration did not reveal communication of intradiploic space with the subarachnoid space. A large occipital craniotomy was performed. A linear fracture and dural defect in the midline was identified, which was closed with fascial graft after removing the inner table of the skull. Cranioplasty was performed using the expanded calvarial bone. Ventriculoperitoneal shunt insertion was performed for hydrocephalus, and the patient improved remarkably.

Posttraumatic intradiploic CSF collection, although a benign condition, may present with severe complications if treatment is delayed. Early diagnosis and treatment is essential. The authors suggest that this condition should be treated early, as for growing skull fractures.

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Govindaraju Lakshmi Prasad, Manish Singh Sharma, Shashank S. Kale, Deepak Agrawal, Manmohan Singh and Bhawani Shankar Sharma

OBJECTIVE

Of the intracranial schwannomas, those arising from the vestibular nerves are the most common. Abducens nerve (AN) schwannomas are very rare, and there is limited literature on their optimal management. Therapeutic options include surgery and/or stereotactic radiosurgery. The aim of this study was to evaluate the role of Gamma Knife radiosurgery (GKRS) in these sixth cranial nerve (CN) schwannomas.

METHODS

The authors performed a retrospective analysis of patients who had undergone GKRS for intracranial tumors at their institute in the period from 2003 to 2010. Inclusion criteria were as follows: isolated AN paresis on presentation, a lesion along the course of the sixth CN, and imaging features characteristic of a schwannoma. Patients with other CN deficits and neurofibromatosis Type 2 were excluded. Symptomatic improvement was defined as the resolution of or an improvement in diplopia noted on a subjective basis or as an improvement in lateral eyeball excursion noted objectively on follow-up. A reduction in tumor volume by at least 20%, as noted by comparing the pre- and post-GKRS images, was deemed significant.

RESULTS

Six patients with a mean age of 37.1 years (range 17–55 years) underwent primary GKRS. There were 2 prepontine cistern, 3 cavernous sinus, and 1 cisterno-cavernous tumor. The mean duration of symptoms was 6.1 months (range 3–12 months). The mean tumor volume was 3.3 cm3 (range 1.5–4.8 cm3). The mean tumor margin radiation dose was 12.5 Gy (range 12–14 Gy), while the median margin dose was 12 Gy (50% isodose line). The median number of isocenters used was 5 (range 4–8). The brainstem received an average 8.35-Gy radiation dosage (range 5.5–11 Gy). The mean follow-up duration was 44.3 months (range 24–78 months). Symptoms remained stable in 1 patient, improved in 3, and resolved in 2 (total improvement 83%). Magnetic resonance imaging at the last follow-up showed a stable tumor size in 3 patients (50%) and a reduction in the other 3. Thus, the tumor control rate achieved was 100%. No new CN deficits were noted.

CONCLUSIONS

Abducens nerve schwannomas are rare intracranial tumors. They can be cavernous, cisternal, or cisterno-cavernous in location. Excellent tumor control rates and symptomatic improvement can be achieved with GKRS, which appears to be a safe and effective, minimally invasive modality for the treatment of such lesions. Therefore, it is reasonable to consider GKRS as the initial treatment of choice for this rare pathology. Long-term follow-up will be essential for further recommendations.

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Ambuj Kumar, Amandeep Kumar, Pankaj Kumar Singh, Shashwat Mishra, Kanwaljeet Garg and Bhawani S. Sharma

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Ashish Suri, Karanjit Singh Narang, Bhawani Shankar Sharma and Ashok Kumar Mahapatra

Object

The purpose of this paper was to study the visual outcome after surgery in patients with suprasellar tumors who experienced preoperative blindness in 1 or both eyes.

Methods

All patients with suprasellar tumors and no perception of light in 1 or both eyes and who underwent surgery between May 2002 and May 2006 were included in this retrospective study. Outcome was analyzed at discharge from the hospital and at follow-up. There were a total of 79 patients (51 males and 28 females, age range 5–70 years). There were 37 cases of pituitary adenomas, 19 craniopharyngiomas, 18 meningiomas, and 5 other tumors. Preoperatively 61 patients had uniocular blindness and 18 patients had binocular blindness. Of all 158 eyes, 97 (61.4%) were blind at admission and these eyes were analyzed. Sixty-three patients (79.7%) presented with headache and 14 (17.7%) with hypothalamic symptoms. Nearly one fourth (24%) of patients with a pituitary adenoma had a history of apoplexy. The duration of visual decline ranged from 3 days to 7 years, and the duration of blindness ranged from 1 day to 3 years. Patients underwent either transcranial or transsphenoidal tumor decompression.

Results

At discharge from the hospital visual improvement was exhibited in 23 (29%) of 79 patients and 27 (27.8%) of 97 eyes. Improvement to serviceable vision occurred in 7 (8.9%) of 79 patients and in 8 (8.2%) of 97 eyes with pre-operative blindness. After surgery, visual improvement was noted in 15 (24.6%) of 61 patients with uniocular blindness and 8 (44.4%) of 18 patients with binocular blindness. However, serviceable vision was restored in 5 (8.2%) of 61 patients with uniocular and 2 (11.1%) of 18 patients with binocular blindness. Bivariate analysis revealed male sex, shorter duration of blindness, presence of apoplexy, sellar tumor extension, soft tumor consistency, operative evidence of hemorrhage in tumor, and tumor histopathology (pituitary adenoma) to have significant impact on the outcome. Multivariate analysis revealed duration of blindness for > 12 weeks, apoplexy, and sellar extension to have a significant impact on visual outcome.

Conclusions

The present study is the largest in the existing medical literature to evaluate the factors affecting visual outcome after surgery of suprasellar tumors with preoperative blindness.

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Chinmaya Dash, Raghav Singla, Kanwaljeet Garg and Bhawani Shanker Sharma

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Amol Raheja, Sumit Sinha, Neha Samson, Sanjeev Bhoi, Arulselvi Subramanian, Pushpa Sharma and Bhawani Shankar Sharma

OBJECTIVE

There has been increased interest in the potential importance of biochemical parameters as predictors of outcome in severe traumatic brain injury (sTBI).

METHODS

Of 107 patients with sTBI (age 18–65 years with a Glasgow Coma Scale score of 4–8 presenting within 8 hours after injury) who were randomized for a placebo-controlled Phase II trial of progesterone with or without hypothermia, the authors serially analyzed serum biomarkers (S100-B, glial fibrillary acidic protein [GFAP], neuron-specific enolase [NSE], tumor necrosis factor–α, interleukin-6 [IL-6], estrogen [Eg], and progesterone [Pg]). This analysis was performed using the sandwich enzyme-linked immunosorbent assay technique at admission and 7 days later for 86 patients, irrespective of assigned group. The long-term predictive values of serum biomarkers for dichotomized Glasgow Outcome Scale (GOS) score, functional independence measure, and survival status at 6 and 12 months were analyzed using an adjusted binary logistic regression model and receiver operating characteristic curve.

RESULTS

A favorable GOS score (4–5) at 1 year was predicted by higher admission IL-6 (above 108.36 pg/ml; area under the curve [AUC] 0.69, sensitivity 52%, and specificity 78.6%) and Day 7 Pg levels (above 3.15 ng/ml; AUC 0.79, sensitivity 70%, and specificity 92.9%). An unfavorable GOS score (1–3) at 1 year was predicted by higher Day 7 GFAP levels (above 9.50 ng/ml; AUC 0.82, sensitivity 78.6%, and specificity 82.4%). Survivors at 1 year had significantly higher Day 7 Pg levels (above 3.15 ng/ml; AUC 0.78, sensitivity 66.7%, and specificity 90.9%). Nonsurvivors at 1 year had significantly higher Day 7 GFAP serum levels (above 11.14 ng/ml; AUC 0.81, sensitivity 81.8%, and specificity 88.9%) and Day 7 IL-6 serum levels (above 71.26 pg/ml; AUC 0.87, sensitivity 81.8%, and specificity 87%). In multivariate logistic regression analysis, independent predictors of outcome at 1 year were serum levels of Day 7 Pg (favorable GOS—OR 3.24, CI 1.5–7, p = 0.003; and favorable survival—OR 2, CI 1.2–3.5, p = 0.01); admission IL-6 (favorable GOS—OR 1.04, CI 1.00–1.08, p = 0.04); and Day 7 GFAP (unfavorable GOS—OR 0.79, CI 0.65–0.95, p = 0.01; and unfavorable survival—OR 0.80, CI 0.66–0.96, p = 0.01).

CONCLUSIONS

Serial Pg, GFAP, and IL-6 monitoring could aid in prognosticating outcomes in patients with acute sTBI. A cause and effect relationship or a mere association of these biomarkers to outcome needs to be further studied for better understanding of the pathophysiology of sTBI and for choosing potential therapeutic targets.

Clinical trial registration no.: CTRI/2009/091/000893 (http://www.ctri.nic.in).

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Chinmaya Dash, Kanwaljeet Garg and Bhawani Shanker Sharma

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Ashish Suri, Rohit Kumar Goel, Faiz Uddin Ahmad, Ananth Kesav Vellimana, Bhawani Shankar Sharma and Ashok Kumar Mahapatra

Object

Neurocysticercosis (NCC) is the most common parasitic infestation of the central nervous system worldwide. In patients presenting with acute hydrocephalus due to intraventricular NCC, surgery is the only option. Still, there is no consensus regarding the optimal surgical strategy, although neuroendoscopic excision is a promising method. However, the literature regarding the use of this modality in fourth ventricular NCC is scarce. The authors describe a series of patients with fourth ventricular NCC treated endoscopically.

Methods

The clinical records of 13 patients with fourth ventricular NCC who had presented with hydrocephalus were retrospectively analyzed. A fourth ventricular cyst was completely excised in all patients by using a transventricular, transaqueductal “scope-in-scope” endoscopic technique. Twelve endoscopic third ventriculostomies and 1 septostomy had been performed.

Results

Shunt placement was avoided in all patients. There were minimal peri- and postoperative complications. The mean duration of follow-up was 22.3 months (range 3–41 months). All patients had an improved clinical outcome. Follow-up neuroimaging revealed no residual lesion and a decreased ventricle size in all patients.

Conclusions

The present series of patients with fourth ventricular NCC is the largest in the existing English-language medical literature. Endoscopic fourth ventricular cysticercal cyst excision along with internal cerebrospinal fluid diversion via endoscopic third ventriculostomy is an effective alternative to open microneurosurgical procedures and avoids shunt placement and its related complications.

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Raman A. Mahalangikar, Pankaj Kumar Singh, Shashwat Mishra and Bhawani Shanker Sharma