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Papers by raj kumar
Journal of Neurosurgery, 1991
✓ Three cases of spinal intramedullary ependymal cyst, two at the thoracolumbar junction and one ... more ✓ Three cases of spinal intramedullary ependymal cyst, two at the thoracolumbar junction and one in the cervical spinal cord, are reported in women in their fifth to seventh decades. Neurological signs and symptoms were extremity dysesthesias, paresthesias, and weakness. Plain cervical and lumbothoracic x-ray films were normal for the patients' age. Magnetic resonance (MR) imaging demonstrated a rounded cystic intramedullary mass at the thoracolumbar junction in two cases and at C3–7 in one case. The signal intensity of the cyst contents approximated that of cerebrospinal fluid on T1- and T2-weighted images. Upon administration of gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA), MR imaging showed no enhancement in the cyst wall or cavity. Myelotomy and cyst drainage were performed in each case, and the neurological status of each patient improved. The lining of the cyst was biopsied in one of the three patients undergoing surgery and was composed of a single layer of cu...
Child's Nervous System, 2007
Lumbar disc herniation is mainly a disease of elderly people as degenerative changes progress wit... more Lumbar disc herniation is mainly a disease of elderly people as degenerative changes progress with age. Present retrospective analysis was performed on 742 patients of lumbar disc disease operated over 11 years. Of 742 cases aged 20 years or less, 25 has been evaluated to see the clinical features, radiological features, operative findings, and outcome of lumbar disc surgery. The incidence of lumbar disc herniation in pediatric and adolescent populations was 3.5% (aged 20 years or less). All patients presented with low back pain with or without radiculopathy (n = 25). Diagnosis was easily made on magnetic resonance imaging. Gross degenerative changes in disc and end plates were uncommon (16%) in this population. The trauma may not be a predisposing factor in most of them. In 88% (n = 22) of the cases, only 1 level was affected; the commonest was L4-5 (n = 13). Disc herniation was centrolateral in 72% (n = 18) and central in 28% (n = 7). Disc was mostly soft, hydrated, and rubbery in 92% (n = 23). Disc herniation were subligamentous in 80% (n = 20) and extruded in 4% (n = 1). Sixteen percent (n = 4) of the patients had disc bulge with intact annulus. Operative intervention in the form of simple discectomy offers good result in 92% (n = 23) cases irrespective of approach and method. Longer follow-up is mandatory because the chances of recurrence or another level involvement cannot be denied.
The American Journal of Sports Medicine, 1991
Pediatric Neurosurgery, 2007
Aim: To study the outcome and recurrence in supratentorial anaplastic ependymoma. Methods: Sixtee... more Aim: To study the outcome and recurrence in supratentorial anaplastic ependymoma. Methods: Sixteen cases of supratentorial anaplastic ependymoma were reviewed. The average age of presentation was 8.2 years ranging from 1 to 16 years of age. The mean duration between the onset of first symptoms to time of presentation was 4.2 months. Follow-up ranged from 5 to 58 months with a mean of 16.8 months. Results: Gross total excision of tumor was achieved in 14 cases, as judged on the basis of intraoperative impression and confirmed with postoperative contrast MR or CT scan. There were 2 unfortunate deaths in the series, one as result of disseminated intravascular coagulation in view of massive blood loss and the other child had evidence of central transtentorial herniation preoperatively which failed to recover. Postoperative cranial radiotherapy was offered to all the 14 remaining cases. Twelve of 14 cases showed evidence of recurrence at follow-up. Recurrence occurred as early at 6 month...
The Indian Journal of Pediatrics, 2005
To see the difference in clinical profiles, radiological findings and surgical outcome of the gro... more To see the difference in clinical profiles, radiological findings and surgical outcome of the group 1 split cord malformation and meningomyelocele (SCM with MMC) from group 2 (SCM without MMC). 46 patients of SCM were selected from a total of 138 cases of spinal dysraphism. They were divided into two groups, based on presence or absence of MMC. Group I (SCM with MMC) n =19 patients and Group II (SCM without MMC) n=27 patients. A detail clinical evaluation and MR screening of whole spine of all cases was performed. All patients underwent surgical detethering of cord. After an average follow-up of 1.7 years, the operative results were clinically assessed and statistical significance was calculated. Male to female ratio was 1:09. Mean age of presentation was 3.6 years. Cutaneous markers like tuft of hair, cutaneous haemangioma, etc, had a higher incidence in group II in comparison to group I (50% vs 10.5%). The incidence of motor deficits was significant in group I in comparison to group II (63% vs 40%). The incidences of sensory loss, trophic ulcers, sphincteric dysfunction and muscle atrophy were relatively more common in group I patients, while neuro-orthopedic deformities such as congenital telepes equinovarus (CTEV), scoliosis and limb shortening were more frequent (67%) in group II children as compared to group I (53%). Type I SCM has higher incidence in group I children. Low lying conus were found in 47% patient of group I, while in group II it was noticed in 69%. The associated cranial anomalies like hydrocephalus, ACM and syrinx, were slightly higher in group I patients. At surgery, dysgenetic nerve roots, neural placode, arachnoid bands and atrophic cord were seen mainly in group I. Postoperative complications like, CSF leak, pseudomeningocele and meningitis were more commonly encountered in group I patients. The patients of group II showed better operative outcome compared to group I cases. Incidence of SCM with MMC amount to 41% of total SCM cases. Progressive neurological deficit was higher in this group (SCM with MMC) in comparison to the group harboring SCM without MMC. In view of a significant association of SCM in MMC cases, associated with other craniospinal anomalies, a thorough screening of neuraxis (by MRI) is recommended to treat all treatable anomalies simultaneously for desired outcome.
The Indian Journal of Pediatrics, 2005
Objective : A retrospective analysis of 50 hydrocephalic children having a minimum follow-up of 6... more Objective : A retrospective analysis of 50 hydrocephalic children having a minimum follow-up of 6 months was carded out to see their etiology, clinical features, complications, incidence of shunt revisions, outcome and the variation from their Westem counterparts. Methods: Clinical features, image findings and treatment of all the cases were recorded from their discharge summaries. Record of shunt revision complications and outcome was maintained by the principal author. The data of all the cases were analyzed. Results: The age of children varied from 1 month to 12 yr (mean 2.2 yr). The most common etiology of hydrocephalus was aqueductal stenosis in 18 (36%) children. Post infective hydrocephalus, either of post-tubercular meningitis (TBM) or following bacterial meningitis, remained the cause in 15 children (30%). Congenital TORCH infection was responsible for 3 cases of hydrocephalus making infective etiology as the cause in 18 (36%) cases. Intra 4 = ventricular neurocysticercus cyst caused blockade of CSF pathway in 2 children. 15 out of 50 children required shunt revision, either due to infection (8,16%) or shunt obstruction (7, 14%). Multiple shunt revisions were required in 2 children only. These revisions were required due to infection, obstruction or malfunction of the shunt. Conclusions : Infective etiology is responsible for hydrocephalus in significant number of children (36%). The possibility of TORCH infection, as a cause of hydrocephalus should be considered even amongst the children of screened mothers during antenatal checkup. Pure intra 4 th ventricular neurocysticercus cysts (without intraparenchymal cyst), though rare, can manifest with outlet obstruction. Incidence of shunt revision using Chhabra's medium pressure shunt is very high in children at an average follow up of 1.6 yr. Post infective hydrocephalus is a major cause of delayed milestones, contributing to mental retardation.
The Indian Journal of Pediatrics, 2003
Objective : To fetch out the factors responsible for ascites, following shunt CSF diversion in ca... more Objective : To fetch out the factors responsible for ascites, following shunt CSF diversion in cases of intracarnial lesions. Four children developing ascites/abdominal psuedocyst following ventriculoperitoneal shunt were analyzed to see the factors responsible for such complication. Methods: Records of 4 cases developing ascites were studied retrospectively. These children developed ascites at 8 months, 6 months, 1 year and 1 year 2 months interval following their shunt installation. Resut$ : The primary etiology of hydrocephalus was demonstrated as thalamic glioblastoma, choroid plexus papillomas of third ventricle, post tubercular meningitis hydrocephalus and suprasellar craniopharyngioma. Conclusion : The proposed etiology of ascites in these cases was peritoneal metastasis from thalamic glioblastoma through ventriculoperitoneal shunt in first case, excessive production of CSF by choroid plexus papilloma in second, infection in the third case and craniopharyngioma causing excessive production of CSF in the fourth child. All the children were treated by reasonable laparotomy and fenestration of cyst along with the repositioning of shunt tip at another site.
Pediatric Neurosurgery, 2002
From July 1996 to August 2001, we operated on 23 children (age 4–12 years) with congenital atlant... more From July 1996 to August 2001, we operated on 23 children (age 4–12 years) with congenital atlantoaxial dislocation (AAD). Sixteen had reducible AAD and 6 had the fixed type, while a single patient had basilar invagination. Preoperatively, these children were divided into four functional grades depending on the level of neurological deficits and dependence on others for activities of daily living (Di Lorenzo grades I–IV). There were only 2 patients with no deficits (grade I), while 15 of the 23 children presented with severe neurological deficits and were completely dependent for all activities of daily living (grade IV). Stigmata suggestive of congenital AAD were documented in 6 children and radiological osseous anomalies in 18 children. Transoral decompression and posterior stabilization was performed in 7 children, while 16 patients underwent the posterior stabilization procedure only. All patients were immobilized with a hard cervical collar postoperatively. Six children develop...
Pediatric Neurosurgery, 2002
Objective: To describe the clinical features and surgical outcome of a combined anomaly, i.e. spl... more Objective: To describe the clinical features and surgical outcome of a combined anomaly, i.e. split cord malformation (SCM) with meningomyelocele (MMC), and to propose an addition to Pang’s classification of SCM to accommodate a combined form of anomaly. Methods: We retrospectively analyzed 16 cases of such a combination, out of a total of 106 cases of spinal dysraphism treated and studied prospectively for outcome at our center. The clinical profile and outcome of these cases are described. Results: All cases had SCM and MMC. Nine patients were males, and the mean age of presentation was 3.9 years. Twelve patients had Pang’s type I SCM and the other 4 were of type II. The MMC sac was lumbar in 11 cases. In all the patients, SCM was present either at the same level as the MMC or one to two segments above it. Nine patients had motor weakness, 6 had hypoesthesia, 4 had urinary incontinence and 3 had trophic ulcers. Nine patients had neuroorthopedic syndrome. All cases, except 3 (who w...
Pediatric Neurosurgery, 2004
A retrospective study of 22 children with intramedullary mass lesions (neoplastic and nonneoplast... more A retrospective study of 22 children with intramedullary mass lesions (neoplastic and nonneoplastic) was performed to see the frequency of different histotypes of tumors/lesions and the functional outcome in Indian children. The age of the children varied from 1.5 to 16 years with a median of 8 years. The male to female ratio was 2.7:1. The children having a minimum follow-up of 3 months and a complete clinicopathological record were entered into this study. McCormick functional grading was applied retrospectively to assess the preoperative grade and postoperative functional outcome of the children. Histopathologically, these 22 cases were astrocytomas (n = 6, 27.3%), ependymomas (n = 3, 13.6%), dermoids (n = 3, 13.6%), epidermoids (n = 2, 9.1%), ependymal cysts (n = 2, 9.1%), and myxopapillary ependymoma, neurenteric cyst, ganglioglioma, teratoma, tuberculoma and anteriovenous malformation one each (4.55%). Near-total or gross-total resection was achieved in 13 (59%) and subtotal r...
Pediatric Neurosurgery, 2005
Twenty-five children with benign intradural extramedullary tumors/lesions were retrospectively an... more Twenty-five children with benign intradural extramedullary tumors/lesions were retrospectively analyzed to see the frequency of different histotypes in this location and their variation from the Western world. The duration of symptoms, clinical profile and surgical outcome of these cases were evaluated. The age of children ranged from 1.5 to 18 years, with a mean age of 7.5 years. Thirteen amongst them were male. Follow-up ranged from 3 months to 5 years with a mean of 19 months. McCormick functional grading was used retrospectively to find out the functional outcome in these children. Sixty-eight percent of these cases presented with functional grade IV or V. The mean duration from the appearance of the first symptoms to admission to our hospital in these children was 13 months. Improvement in the functional grade following surgical excision was noted amongst all, except one, who presented with schwannoma, and did not improve from grade III even after a 14-month follow-up. Reoperat...
Pediatric Neurosurgery, 2002
Six cases of unusual neuroenteric (NE) cysts, occurring in children aged 15 months to 18 years, a... more Six cases of unusual neuroenteric (NE) cysts, occurring in children aged 15 months to 18 years, are reported here. Three of the cysts were extramedullary, while the other three were intramedullary. Two of the extramedullary cysts were located at the lumbosacral region, an unusual site. Only one patient had the cyst located in a ventral relation to the cord in the cervicothoracic region. None of the patients had communication with the mediastinum or intraabdominal viscera. Stigmata of spinal dysraphism were seen in three patients. All the children had variable neurological involvement and it was difficult to differentiate NE cyst from other causes of spinal cord or cauda equina lesion, particularly in the absence of some dysraphic marker. One patient presented with minimal neurological deficits and painful torticollis; this patient was suspected to have an atlantoaxial dislocation. All patients were investigated with MRI, and the only diagnostic feature of an NE cyst was an intradura...
Neurosurgical Review, 2004
Five cases of intraventricular subependymal giant cell astrocytomas (SEGCA) were retrospectively ... more Five cases of intraventricular subependymal giant cell astrocytomas (SEGCA) were retrospectively reviewed. Records and detailed work-up of all five cases were well maintained in view of rare occurrence of these tumors. The five patients were males aged 10, 12 (2 cases), 14 and 18 years. The 18-year-old aged male had no stigmata of tuberous sclerosis (TSC) on examination, while the rest presented with features of TSC, intraventricular tumors and hydrocephalus. None of the five cases had renal tumors and did not reveal cardiac tumors. Skin manifestations like shagreen patches were present in two, facial angiofibromas in three, periungal fibromas in two, hypopigmented macules in two and ash-leaf spot in two patients. Fundoscopic examination revealed retinal astrocytomas in two cases only. Two of the five children did not have mental compromise. A child who started throwing seizures early (at 5 months of age) had severe mental retardation. Although SEGCA is a less vascular tumor, one tumor bled profusely intraoperatively; it was excised rapidly via the transcortical route to salvage the life of the child, though he was planned for the transcallosal route like the other cases. The tumor of another child was also very vascular. Four children survived surgery and required no shunt CSF diversion, while one died of severe ventriculitis and septicemia 3 weeks after surgery.
Child's Nervous System, 2002
Tubercular brain abscess (TBA) is a rare manifestation of CNS tuberculosis. It is characterised b... more Tubercular brain abscess (TBA) is a rare manifestation of CNS tuberculosis. It is characterised by an encapsulated collection of pus, containing viable tubercular bacilli without evidence of tubercular granuloma. PRESENTATION AND HISTORY: Patients may present with features of raised intracranial pressure and focal neurological deficit commensurate with the site of the abscess. A history of pulmonary tuberculosis may be present, as documented in one of our six cases; three of our six children developed TBA despite 3-weeks to 12-month courses of antitubercular chemotherapy prescribed for post-TBM hydrocephalus. Contrast CT head, MRI, MR spectroscopy is helpful in making the diagnosis and planning the treatment. TBA may be unilocular or multilocular on contrast CT scan. A relatively long clinical history and an enhancing capsule with thick wall are suggestive of TBA. Pyogenic abscess, however, has a thin rim on contrast CT. The capsule of TBA is formed of vascular granulation tissue containing acute and chronic inflammatory cells, particularly polymorphs. Proof of tubercular origin must be demonstrated either by presence of acid fast bacilli in culture or staining of pus or wall. Treatment options include simple puncture, continuous drainage, fractional drainage, repeated aspiration through a burr hole, stereotactic aspiration and total excision of the abscess. Total excision usually becomes necessary in multilocular noncommunicating and thick-walled abscesses. Antitubercular therapy is the mainstay of management. The development of fulminant tubercular meningitis is sometimes problematic following surgical excision of TBA, as seen in one of our four operated cases. Mortality is reported to be high despite progress in treatment, while five of the six children treated by us responded well to the treatment.
Child's Nervous System, 2001
Pediatric Neurosurgery, 2006
Objective: To evaluate the clinical profile, associated anomalies and surgical outcome of childre... more Objective: To evaluate the clinical profile, associated anomalies and surgical outcome of children with meningomyelocele (MMC)/lipomeningomyelocele. Methods: Out of a total of 181 cases of spinal dysraphism treated at our Institute between 1996 and 2004, 102 (56.35%) cases of MMC/lipomeningomyelocele were analyzed retrospectively and prospectively. The clinical profile and radiological findings of these children were recorded. Craniospinal MRI was the essential investigation and was done as a management protocol at our Institute for these children. Eighty-two out of 102 (80.3%) cases had pure MMC/lipomeningomyelocele and 20/102 (19.6%) had associated split cord malformation (SCM; complex spina bifida). All these children underwent surgery for their primary and associated malformations as indicated. They were clinically assessed over a mean follow-up period of 3.6 years ranging from 1.5 months to 8 years. No urodynamic or evoked potential studies were done to assess the sphincteric o...
Journal of Neurosurgery, 1991
✓ Three cases of spinal intramedullary ependymal cyst, two at the thoracolumbar junction and one ... more ✓ Three cases of spinal intramedullary ependymal cyst, two at the thoracolumbar junction and one in the cervical spinal cord, are reported in women in their fifth to seventh decades. Neurological signs and symptoms were extremity dysesthesias, paresthesias, and weakness. Plain cervical and lumbothoracic x-ray films were normal for the patients' age. Magnetic resonance (MR) imaging demonstrated a rounded cystic intramedullary mass at the thoracolumbar junction in two cases and at C3–7 in one case. The signal intensity of the cyst contents approximated that of cerebrospinal fluid on T1- and T2-weighted images. Upon administration of gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA), MR imaging showed no enhancement in the cyst wall or cavity. Myelotomy and cyst drainage were performed in each case, and the neurological status of each patient improved. The lining of the cyst was biopsied in one of the three patients undergoing surgery and was composed of a single layer of cu...
Child's Nervous System, 2007
Lumbar disc herniation is mainly a disease of elderly people as degenerative changes progress wit... more Lumbar disc herniation is mainly a disease of elderly people as degenerative changes progress with age. Present retrospective analysis was performed on 742 patients of lumbar disc disease operated over 11 years. Of 742 cases aged 20 years or less, 25 has been evaluated to see the clinical features, radiological features, operative findings, and outcome of lumbar disc surgery. The incidence of lumbar disc herniation in pediatric and adolescent populations was 3.5% (aged 20 years or less). All patients presented with low back pain with or without radiculopathy (n = 25). Diagnosis was easily made on magnetic resonance imaging. Gross degenerative changes in disc and end plates were uncommon (16%) in this population. The trauma may not be a predisposing factor in most of them. In 88% (n = 22) of the cases, only 1 level was affected; the commonest was L4-5 (n = 13). Disc herniation was centrolateral in 72% (n = 18) and central in 28% (n = 7). Disc was mostly soft, hydrated, and rubbery in 92% (n = 23). Disc herniation were subligamentous in 80% (n = 20) and extruded in 4% (n = 1). Sixteen percent (n = 4) of the patients had disc bulge with intact annulus. Operative intervention in the form of simple discectomy offers good result in 92% (n = 23) cases irrespective of approach and method. Longer follow-up is mandatory because the chances of recurrence or another level involvement cannot be denied.
The American Journal of Sports Medicine, 1991
Pediatric Neurosurgery, 2007
Aim: To study the outcome and recurrence in supratentorial anaplastic ependymoma. Methods: Sixtee... more Aim: To study the outcome and recurrence in supratentorial anaplastic ependymoma. Methods: Sixteen cases of supratentorial anaplastic ependymoma were reviewed. The average age of presentation was 8.2 years ranging from 1 to 16 years of age. The mean duration between the onset of first symptoms to time of presentation was 4.2 months. Follow-up ranged from 5 to 58 months with a mean of 16.8 months. Results: Gross total excision of tumor was achieved in 14 cases, as judged on the basis of intraoperative impression and confirmed with postoperative contrast MR or CT scan. There were 2 unfortunate deaths in the series, one as result of disseminated intravascular coagulation in view of massive blood loss and the other child had evidence of central transtentorial herniation preoperatively which failed to recover. Postoperative cranial radiotherapy was offered to all the 14 remaining cases. Twelve of 14 cases showed evidence of recurrence at follow-up. Recurrence occurred as early at 6 month...
The Indian Journal of Pediatrics, 2005
To see the difference in clinical profiles, radiological findings and surgical outcome of the gro... more To see the difference in clinical profiles, radiological findings and surgical outcome of the group 1 split cord malformation and meningomyelocele (SCM with MMC) from group 2 (SCM without MMC). 46 patients of SCM were selected from a total of 138 cases of spinal dysraphism. They were divided into two groups, based on presence or absence of MMC. Group I (SCM with MMC) n =19 patients and Group II (SCM without MMC) n=27 patients. A detail clinical evaluation and MR screening of whole spine of all cases was performed. All patients underwent surgical detethering of cord. After an average follow-up of 1.7 years, the operative results were clinically assessed and statistical significance was calculated. Male to female ratio was 1:09. Mean age of presentation was 3.6 years. Cutaneous markers like tuft of hair, cutaneous haemangioma, etc, had a higher incidence in group II in comparison to group I (50% vs 10.5%). The incidence of motor deficits was significant in group I in comparison to group II (63% vs 40%). The incidences of sensory loss, trophic ulcers, sphincteric dysfunction and muscle atrophy were relatively more common in group I patients, while neuro-orthopedic deformities such as congenital telepes equinovarus (CTEV), scoliosis and limb shortening were more frequent (67%) in group II children as compared to group I (53%). Type I SCM has higher incidence in group I children. Low lying conus were found in 47% patient of group I, while in group II it was noticed in 69%. The associated cranial anomalies like hydrocephalus, ACM and syrinx, were slightly higher in group I patients. At surgery, dysgenetic nerve roots, neural placode, arachnoid bands and atrophic cord were seen mainly in group I. Postoperative complications like, CSF leak, pseudomeningocele and meningitis were more commonly encountered in group I patients. The patients of group II showed better operative outcome compared to group I cases. Incidence of SCM with MMC amount to 41% of total SCM cases. Progressive neurological deficit was higher in this group (SCM with MMC) in comparison to the group harboring SCM without MMC. In view of a significant association of SCM in MMC cases, associated with other craniospinal anomalies, a thorough screening of neuraxis (by MRI) is recommended to treat all treatable anomalies simultaneously for desired outcome.
The Indian Journal of Pediatrics, 2005
Objective : A retrospective analysis of 50 hydrocephalic children having a minimum follow-up of 6... more Objective : A retrospective analysis of 50 hydrocephalic children having a minimum follow-up of 6 months was carded out to see their etiology, clinical features, complications, incidence of shunt revisions, outcome and the variation from their Westem counterparts. Methods: Clinical features, image findings and treatment of all the cases were recorded from their discharge summaries. Record of shunt revision complications and outcome was maintained by the principal author. The data of all the cases were analyzed. Results: The age of children varied from 1 month to 12 yr (mean 2.2 yr). The most common etiology of hydrocephalus was aqueductal stenosis in 18 (36%) children. Post infective hydrocephalus, either of post-tubercular meningitis (TBM) or following bacterial meningitis, remained the cause in 15 children (30%). Congenital TORCH infection was responsible for 3 cases of hydrocephalus making infective etiology as the cause in 18 (36%) cases. Intra 4 = ventricular neurocysticercus cyst caused blockade of CSF pathway in 2 children. 15 out of 50 children required shunt revision, either due to infection (8,16%) or shunt obstruction (7, 14%). Multiple shunt revisions were required in 2 children only. These revisions were required due to infection, obstruction or malfunction of the shunt. Conclusions : Infective etiology is responsible for hydrocephalus in significant number of children (36%). The possibility of TORCH infection, as a cause of hydrocephalus should be considered even amongst the children of screened mothers during antenatal checkup. Pure intra 4 th ventricular neurocysticercus cysts (without intraparenchymal cyst), though rare, can manifest with outlet obstruction. Incidence of shunt revision using Chhabra's medium pressure shunt is very high in children at an average follow up of 1.6 yr. Post infective hydrocephalus is a major cause of delayed milestones, contributing to mental retardation.
The Indian Journal of Pediatrics, 2003
Objective : To fetch out the factors responsible for ascites, following shunt CSF diversion in ca... more Objective : To fetch out the factors responsible for ascites, following shunt CSF diversion in cases of intracarnial lesions. Four children developing ascites/abdominal psuedocyst following ventriculoperitoneal shunt were analyzed to see the factors responsible for such complication. Methods: Records of 4 cases developing ascites were studied retrospectively. These children developed ascites at 8 months, 6 months, 1 year and 1 year 2 months interval following their shunt installation. Resut$ : The primary etiology of hydrocephalus was demonstrated as thalamic glioblastoma, choroid plexus papillomas of third ventricle, post tubercular meningitis hydrocephalus and suprasellar craniopharyngioma. Conclusion : The proposed etiology of ascites in these cases was peritoneal metastasis from thalamic glioblastoma through ventriculoperitoneal shunt in first case, excessive production of CSF by choroid plexus papilloma in second, infection in the third case and craniopharyngioma causing excessive production of CSF in the fourth child. All the children were treated by reasonable laparotomy and fenestration of cyst along with the repositioning of shunt tip at another site.
Pediatric Neurosurgery, 2002
From July 1996 to August 2001, we operated on 23 children (age 4–12 years) with congenital atlant... more From July 1996 to August 2001, we operated on 23 children (age 4–12 years) with congenital atlantoaxial dislocation (AAD). Sixteen had reducible AAD and 6 had the fixed type, while a single patient had basilar invagination. Preoperatively, these children were divided into four functional grades depending on the level of neurological deficits and dependence on others for activities of daily living (Di Lorenzo grades I–IV). There were only 2 patients with no deficits (grade I), while 15 of the 23 children presented with severe neurological deficits and were completely dependent for all activities of daily living (grade IV). Stigmata suggestive of congenital AAD were documented in 6 children and radiological osseous anomalies in 18 children. Transoral decompression and posterior stabilization was performed in 7 children, while 16 patients underwent the posterior stabilization procedure only. All patients were immobilized with a hard cervical collar postoperatively. Six children develop...
Pediatric Neurosurgery, 2002
Objective: To describe the clinical features and surgical outcome of a combined anomaly, i.e. spl... more Objective: To describe the clinical features and surgical outcome of a combined anomaly, i.e. split cord malformation (SCM) with meningomyelocele (MMC), and to propose an addition to Pang’s classification of SCM to accommodate a combined form of anomaly. Methods: We retrospectively analyzed 16 cases of such a combination, out of a total of 106 cases of spinal dysraphism treated and studied prospectively for outcome at our center. The clinical profile and outcome of these cases are described. Results: All cases had SCM and MMC. Nine patients were males, and the mean age of presentation was 3.9 years. Twelve patients had Pang’s type I SCM and the other 4 were of type II. The MMC sac was lumbar in 11 cases. In all the patients, SCM was present either at the same level as the MMC or one to two segments above it. Nine patients had motor weakness, 6 had hypoesthesia, 4 had urinary incontinence and 3 had trophic ulcers. Nine patients had neuroorthopedic syndrome. All cases, except 3 (who w...
Pediatric Neurosurgery, 2004
A retrospective study of 22 children with intramedullary mass lesions (neoplastic and nonneoplast... more A retrospective study of 22 children with intramedullary mass lesions (neoplastic and nonneoplastic) was performed to see the frequency of different histotypes of tumors/lesions and the functional outcome in Indian children. The age of the children varied from 1.5 to 16 years with a median of 8 years. The male to female ratio was 2.7:1. The children having a minimum follow-up of 3 months and a complete clinicopathological record were entered into this study. McCormick functional grading was applied retrospectively to assess the preoperative grade and postoperative functional outcome of the children. Histopathologically, these 22 cases were astrocytomas (n = 6, 27.3%), ependymomas (n = 3, 13.6%), dermoids (n = 3, 13.6%), epidermoids (n = 2, 9.1%), ependymal cysts (n = 2, 9.1%), and myxopapillary ependymoma, neurenteric cyst, ganglioglioma, teratoma, tuberculoma and anteriovenous malformation one each (4.55%). Near-total or gross-total resection was achieved in 13 (59%) and subtotal r...
Pediatric Neurosurgery, 2005
Twenty-five children with benign intradural extramedullary tumors/lesions were retrospectively an... more Twenty-five children with benign intradural extramedullary tumors/lesions were retrospectively analyzed to see the frequency of different histotypes in this location and their variation from the Western world. The duration of symptoms, clinical profile and surgical outcome of these cases were evaluated. The age of children ranged from 1.5 to 18 years, with a mean age of 7.5 years. Thirteen amongst them were male. Follow-up ranged from 3 months to 5 years with a mean of 19 months. McCormick functional grading was used retrospectively to find out the functional outcome in these children. Sixty-eight percent of these cases presented with functional grade IV or V. The mean duration from the appearance of the first symptoms to admission to our hospital in these children was 13 months. Improvement in the functional grade following surgical excision was noted amongst all, except one, who presented with schwannoma, and did not improve from grade III even after a 14-month follow-up. Reoperat...
Pediatric Neurosurgery, 2002
Six cases of unusual neuroenteric (NE) cysts, occurring in children aged 15 months to 18 years, a... more Six cases of unusual neuroenteric (NE) cysts, occurring in children aged 15 months to 18 years, are reported here. Three of the cysts were extramedullary, while the other three were intramedullary. Two of the extramedullary cysts were located at the lumbosacral region, an unusual site. Only one patient had the cyst located in a ventral relation to the cord in the cervicothoracic region. None of the patients had communication with the mediastinum or intraabdominal viscera. Stigmata of spinal dysraphism were seen in three patients. All the children had variable neurological involvement and it was difficult to differentiate NE cyst from other causes of spinal cord or cauda equina lesion, particularly in the absence of some dysraphic marker. One patient presented with minimal neurological deficits and painful torticollis; this patient was suspected to have an atlantoaxial dislocation. All patients were investigated with MRI, and the only diagnostic feature of an NE cyst was an intradura...
Neurosurgical Review, 2004
Five cases of intraventricular subependymal giant cell astrocytomas (SEGCA) were retrospectively ... more Five cases of intraventricular subependymal giant cell astrocytomas (SEGCA) were retrospectively reviewed. Records and detailed work-up of all five cases were well maintained in view of rare occurrence of these tumors. The five patients were males aged 10, 12 (2 cases), 14 and 18 years. The 18-year-old aged male had no stigmata of tuberous sclerosis (TSC) on examination, while the rest presented with features of TSC, intraventricular tumors and hydrocephalus. None of the five cases had renal tumors and did not reveal cardiac tumors. Skin manifestations like shagreen patches were present in two, facial angiofibromas in three, periungal fibromas in two, hypopigmented macules in two and ash-leaf spot in two patients. Fundoscopic examination revealed retinal astrocytomas in two cases only. Two of the five children did not have mental compromise. A child who started throwing seizures early (at 5 months of age) had severe mental retardation. Although SEGCA is a less vascular tumor, one tumor bled profusely intraoperatively; it was excised rapidly via the transcortical route to salvage the life of the child, though he was planned for the transcallosal route like the other cases. The tumor of another child was also very vascular. Four children survived surgery and required no shunt CSF diversion, while one died of severe ventriculitis and septicemia 3 weeks after surgery.
Child's Nervous System, 2002
Tubercular brain abscess (TBA) is a rare manifestation of CNS tuberculosis. It is characterised b... more Tubercular brain abscess (TBA) is a rare manifestation of CNS tuberculosis. It is characterised by an encapsulated collection of pus, containing viable tubercular bacilli without evidence of tubercular granuloma. PRESENTATION AND HISTORY: Patients may present with features of raised intracranial pressure and focal neurological deficit commensurate with the site of the abscess. A history of pulmonary tuberculosis may be present, as documented in one of our six cases; three of our six children developed TBA despite 3-weeks to 12-month courses of antitubercular chemotherapy prescribed for post-TBM hydrocephalus. Contrast CT head, MRI, MR spectroscopy is helpful in making the diagnosis and planning the treatment. TBA may be unilocular or multilocular on contrast CT scan. A relatively long clinical history and an enhancing capsule with thick wall are suggestive of TBA. Pyogenic abscess, however, has a thin rim on contrast CT. The capsule of TBA is formed of vascular granulation tissue containing acute and chronic inflammatory cells, particularly polymorphs. Proof of tubercular origin must be demonstrated either by presence of acid fast bacilli in culture or staining of pus or wall. Treatment options include simple puncture, continuous drainage, fractional drainage, repeated aspiration through a burr hole, stereotactic aspiration and total excision of the abscess. Total excision usually becomes necessary in multilocular noncommunicating and thick-walled abscesses. Antitubercular therapy is the mainstay of management. The development of fulminant tubercular meningitis is sometimes problematic following surgical excision of TBA, as seen in one of our four operated cases. Mortality is reported to be high despite progress in treatment, while five of the six children treated by us responded well to the treatment.
Child's Nervous System, 2001
Pediatric Neurosurgery, 2006
Objective: To evaluate the clinical profile, associated anomalies and surgical outcome of childre... more Objective: To evaluate the clinical profile, associated anomalies and surgical outcome of children with meningomyelocele (MMC)/lipomeningomyelocele. Methods: Out of a total of 181 cases of spinal dysraphism treated at our Institute between 1996 and 2004, 102 (56.35%) cases of MMC/lipomeningomyelocele were analyzed retrospectively and prospectively. The clinical profile and radiological findings of these children were recorded. Craniospinal MRI was the essential investigation and was done as a management protocol at our Institute for these children. Eighty-two out of 102 (80.3%) cases had pure MMC/lipomeningomyelocele and 20/102 (19.6%) had associated split cord malformation (SCM; complex spina bifida). All these children underwent surgery for their primary and associated malformations as indicated. They were clinically assessed over a mean follow-up period of 3.6 years ranging from 1.5 months to 8 years. No urodynamic or evoked potential studies were done to assess the sphincteric o...