Search

Objectives: To assess the knowledge, attitude and perception of post-graduate residents of neurosciences towards research ethics (RE) and research ethics committees (RECs). Methods: This prospective cross-sectional survey-based study was conducted by the Punjab Institute of Neurosciences, targeting post-graduate neuroscience residents throughout Pakistan during January and February, 2024. An English-language general questionnaire, designed to assess knowledge, attitudes, and perceptions of RE and RECs, was adapted to reflect local conditions. The collected responses were analyzed using the Statistical Package for Social Sciences (SPSS) to determine measures of central tendency, percentages, and frequencies. Results: Out of 241 residents, 64.3% were males. Sixty-eight percent respondents were from neurosurgery and 32% were from the field of neurology. Approximately 47% responses were from the province of Punjab. More than half (51.5%) of participants acknowledged the existence of a REC within their institution. A similar proportion (52.3%) claimed familiarity with ethical guidelines for research involving human subjects, only a slight majority (48.5%) demonstrated awareness of the specific functions carried out by RECs. Meanwhile, 44.5% expressed concerns that undergoing review by a REC could potentially delay research and pose additional challenges for researchers. Additionally, 27.4% of respondents admitted to considering the fabrication of data or results as acceptable. Conclusion: Our research uncovered a significant correlation between participants' perceptions of RE and RECs and their comprehension of ethical principles. These findings indicate that medical postgraduates with a deeper understanding or awareness of research ethics principles and RECs tend to hold more robust attitudes toward these aspects. [ABSTRACT FROM AUTHOR]

Background & Objective: Takotsubo cardiomyopathy (TCM), manifests as left ventricular dysfunction triggered by physical or emotional stress. It leads to higher morbidity in epileptic patients and can progress to complications. To find out the correlation between Takotsubo cardiomyopathy and epilepsy and to investigate pathophysiology and associated types of epilepsy. Methodology: This systematic review adhered to PRISMA guidelines and was sourced from the PubMed Central database. Search terms were pertinent to cardiomyopathy and epilepsy. Sixteen studies, comprising case reports and a case series were selected from 2000 to 2023 for data extraction. The quality evaluation was executed via the Joanna Briggs Institute Critical Appraisal checklist. Results: The review included 18 female patients with a mean age of 57.22 years. Predominant symptoms included tonic-clonic seizures (66.66%). Seizure-induced TCM pathophysiology implicates catecholamine surge, precipitating myocardial stunting and characteristic apical ballooning. Most patients had a history of epilepsy (38.88%). ECG findings showed tachycardia (38.88%) and ST-segment elevation (38.88%). Elevated troponin levels were noted in 83.33% of patients. Echocardiography showed reduced ejection fraction (72.22%), hypokinesia (38.88%) and akinesis (27.77%). Treatment involved Benzodiazepines (50%), Beta-blockers (61.11%) and Phenytoin (38.88%). The majority of patients showed improvement in echocardiography findings (55.55%) and ECG findings (11.11%). Conclusion: TCM in epilepsy patients evinces significant female predominance, with pathophysiology rooted in seizureinduced catecholamine surge. Early recognition in high-risk patients is essential in preventing complications. [ABSTRACT FROM AUTHOR]

Objective: To assess the clinical presentation, causative agents, and treatment outcomes in patients diagnosed with Elsberg syndrome (ES). Methods: A thorough literature search was conducted on the mentioned topic using PRISMA guidelines via PubMed, Google Scholar, and SCOPUS. Articles published between 2000 and 2023 were included using advanced search and Boolean strategy. A total of 19 case reports were included in the systematic review according to set criteria and after quality assessment. Results: The average age at presentation was 48.9 ± 18.9 years, with a male majority of 57.9%. Lower limb sensory deficit followed by bladder dysfunction were the two most common presenting symptoms in 52.63% and 47.37% patients, respectively. Sensory loss and vesicular rash were the most frequently found signs at presentation in 36.84% and 26.32% patients, respectively. Varicella zoster virus (VZV) and herpes simplex virus (HSV) were the most common infectious agents found equivocally in 36.84% cases each. Complete resolution with definitive treatment was seen in 84.21% of patients. The average follow-up duration was 5.16 months. Conclusion: ES should be considered as a differential in patients with a prior or recent history of HSV or VZV infection who present with signs and symptoms of acute lumbosacral myeloradiculopathy. Combination therapy with antimicrobials and corticosteroids has shown promising results targeting both the infectious and inflammatory aspects of the disease. [ABSTRACT FROM AUTHOR]

Objectives: To analyze the efficacy of K-line in surgical planning of approach selection for ossification of posterior longitudinal ligament (OPLL) and outcomes assessment by Nurick grading and Modified Japanese Orthopaedic Association (mJOA) scores. Methods: This is a retrospective case series study conducted at the Departments of Neurosurgery, Punjab Institute of Neurosciences, Lahore in the months of January and February 2024. Patients with complete records were considered. Google Form was used for data. Nurick grading and Modified Japanese Orthopaedic Association (mJOA) scores were calculated for each patient pre- and post-operatively. K-line assessment was done on computerized tomography (CT). Data analysis was performed using Microsoft excel in terms of frequency and percentages. Results: This study included ten patients with the mean age at presentation was 48.20 ± 9.37 years. Preoperative Nurick grading in our patients was Grade-V (five patients), Grade-IV (two patients) and Grade-III (three patients) with mean of 4.2 ± 0.91 SD whereas six months follow-up Nurick grading was Grade-V (three patients), Grade-IV (three patients) and Grade-III (four patients) with the mean of 3.90 ± 0.87 SD, which indicates neurological improvement. Types of OPLL present in our patients were segmental (4, 40%), continuous (3, 30%), mixed (2, 20%) and localized/ others (1, 10%). There were 2 (20%) K-line (+) and 8 (80%) K-line (-) cases. Anterior approach was used in 2 (20%) cases whereas posterior approach was used for the rest of 8 (80%) cases. Mean preoperative mJOA was 10.30 ± 2.45 and mean postoperative mJOA was12.40 ± 2.01 at 6-month follow up, which indicates improvement in our cases. Conclusion: K-line is a useful radiological indicator in selecting anterior versus posterior approach for patients with cervical OPLL in terms of Nurick grading and mJOA scores. [ABSTRACT FROM AUTHOR]

Aneurysmal bone cysts are locally invasive, benign lesions usually found in the spine or metaphysis of long bones. They can be primary (idiopathic) or secondary to other bone pathologies. Primary aneurysmal bone cyst usually occurs in the first two decades of life. We report a 12 years old male, a known case of Type-1 diabetes mellitus, with lower back pain radiating to the right lower limb for the past two months following a fall. There were no neurological deficits, although straight leg raises and Faber's tests were positive. Neuroimaging suggested an enhancing 7 x 8 mm lesion involving the lamina of the first sacral vertebra with protrusion into the spinal canal. Bone scan ruled out metastatic pathology. Excision of the lesion with laminectomy and foraminotomy was done. Histopathology was suggestive of aneurysmal bone cyst. The patient is living a healthy life. Upfront surgical excision without preoperative embolization and expensive medical therapies can be an option in resource-limited settings. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the surgical outcomes of delayed microsurgical clipping for ruptured intracranial aneurysms (RICAs) of anterior circulation. Methods: This retrospective, cross-sectional study assessed the surgical outcomes of 50 patients who underwent surgical clipping for "ruptured aneurysms" with subarachnoid haemorrhage after the 21st post-bleed day, from May 01, 2022, till May 01, 2023, at the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore, Pakistan. Results: The mean age of patients was 49.66 ± 6.231 years with a female preponderance of 54%. Out of 50 cases, 21 were midline aneurysms (42%), followed by left-sided laterality in 16 cases (32%). Aneurysm of the anterior communicating artery was the most common accounting for 42% of the patients. Forty-nine patients returned home after first postoperative week without deficits, with a success rate of 98%. Seizures, surgical site infection and cerebrospinal fluid leak were noted in 6%, 4% and 2% patients, respectively. Conclusion: Delayed clipping in RICAs after the 21st post-bleed day is advocated, especially in resource-constrained settings. Meticulous surgical technique and asepsis are responsible for great postoperative outcomes. [ABSTRACT FROM AUTHOR]

Objective: Multiple techniques have been used to treat trigeminal neuralgia (TGN), including pharmacotherapy, radiosurgery, rhizotomy and microvascular decompression (MVD). Blood vessels are considered to be the most common cause of offense and compression to trigeminal nerve. We aimed to determine the causes of classic TGN and efficacy of MVD. Methods: This retrospective, cross-sectional study assessed the data of 53 patients, who underwent MVD at the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore, Pakistan, from May, 2022 to December, 2023. Information regarding patient demographics, clinical presentation, Barrow Neurological Institute Facial Pain Score (BNI-FPS), intra-operative findings, and postoperative complications were analyzed. Results: The mean age at presentation was 44.33±11.71 years. Unilateral facial pain was the consistent clinical presentation among all patients, with right-sided involvement in 67.92% patients. All patients had involvement of at least two divisions of trigeminal nerve; maxillary and mandibular nerve in 84.91% and 71.70% cases, respectively. BNI-FPS Grade-IVb was found among 49.09% patients on presentation. Arachnoid adhesions, superior cerebellar artery and superior petrosal vein were the most common causes of compression in 71.70%, 50.94% and 43.40% cases, respectively. About 94% patients were discharged home on first post-operative day without complications and with BNI-FPS Grade-I. Conclusions: Microvascular decompression is highly advocated in classic cases of TGN. In the absence of grossly visible offending vascular structure, arachnoid adhesions should be the thorough focus of address. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the precision and safety of a novel technique of free-hand frameless pinless AXIEMTM-based navigation guided biopsy of deep-seated brain lesions in a low-middle income country. Methods: This retrospective study included 45 patients who underwent free-hand frameless pinless AXIEMTM-based navigation guided biopsy of deep-seated brain lesions using the Medtronic-Stealth S7 system over a 5-year period (January 2019 to December 2023) at the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore, Pakistan. Results: A total of 45 patients were included in this study. There were 4 (8.9%) patients in the 1 to 20 years age group, 10 (22.2%) in 21 to 40 years, 24 (53.3%) in 41 to 60 years and 7 (15.6%) were above 60 years. Mean age (years) was 47.29 ± 17.192 SD. Mean time (minutes) for procedures was 37.87 ± 9.6 SD. There were 28 (62.2%) male and 17 (37.8%) female patients. Among patients reviewed in this study 2 (4.4%) had lesions in Corpus Callosum, 8 (17.8%) in Lobar region, 5 (11.1%) were Multiple/Metastatic and 30 (66.7%) were in Thalamus/Internal Capsule/Basal Ganglia. Size of lesions was less than 1 cm in 4 (8.9%) cases, 1-2 cm in 29 (64.4%) and 2 to 3 cm in 12 (26.7%) cases. There were 18 (40%) patients with lesions on the left side, 21 (46.7%) on the right side, 4 (8.9%) bilateral and 2 (4.4%) in the midline. Most cases were performed in local (40%) or local with IV sedation (48.9%) and a few in general anesthesia (11.1%). Biopsy results were successfully diagnostic in 40 (88.9%) and non-diagnostic in 5 (11.1%) patients. Glioblastoma WHO Grade IV was seen in 20 (44.4%) patients, Diffuse Astrocytoma WHO Grade II in 5 (11.1%), Anaplastic Astrocytoma WHO Grade III in 2 (4.4%), Pleomorphic Xanthoastrocytoma in 1 (2.2%), Lymphoma in 7 (15.6%) and Metastasis in 5 (11.1%) patients. Asymptomatic minor haemorrhage was seen in 3 (6.7%) patients, massive haemorrhage in 2 (4.4%), hydrocephalus in 1 (2.2%), surgical site infection in 1 (2.2%) and 38 (84.4%) patients had no complications. Conclusions: AXIEMTM-based Medtronic-Stealth S7 is a quick, reliable, real-time and secure neuronavigation system for taking a free-hand, frameless and pinless biopsy of deep-seated lesions in the brain. [ABSTRACT FROM AUTHOR]

Objectives: To determine the effect of Bilateral Subthalamic Nucleus (STN) Deep Brain Stimulation (DBS) on drug reduction for Parkinson's disease (PD) in a low-middle-income country. Methods: This retrospective cohort study included 49 patients following interview based questionnaires who underwent bilateral STN DBS at the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore, Pakistan over five years (July 30, 2018 to June 29, 2023). Patients meeting the inclusion and exclusion criteria (49 patients) were selected and the effect of bilateral STN DBS on drug reduction was evaluated. Results: Following bilateral STN for Parkinsons Disease Levodopa equivalent daily dose (LEDD) and Unified Parkinson's Disease Rating Scale (UPDRS)-III results were statistically significant, with a P-value of 0.0001. Effect of DBS on UPDRSIV was 0.2751, which is statistically insignificant. LEDD reduced by 55.03% (P<0.0001), UPRS-III improved by 80.49% (P<0.0001), and UPDRS-IV improved by 1% (P<0.0001). Time spent with dyskinesia reduced by 17.54% (P<0.0001), whereas time spent off period reduced 22.44% (P<0.0001). Conclusion: When the disease is in its early stages and has not yet manifested advanced Parkinsons symptoms, bilateral STN DBS is an effective treatment option. It considerably reduces the need for levodopa and significantly improves the motor symptoms of rigidity, tremors, and bradykinesia. [ABSTRACT FROM AUTHOR]

Objectives: To determine the incidence of postoperative cerebrospinal fluid (CSF) leaks after endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenomas without sellar floor reconstruction (SFR). Methods: This retrospective observational study was conducted at Department of Neurosurgery, Punjab Institute of Neurosciences (PINS), Lahore, Pakistan from January, 2018 to December, 2022. It is a non-probability based consecutive case series. A total of 316 patients meeting the inclusion criteria were selected. Results: Among the 316 patients, 102 (32.3%) were male, while 214 (67.7%) were female. Mean age was 40.98±7.8 SD (range 23 to 65 years). Regarding size of pituitary adenomas, 19 (6%) were microadenomas and 297 (94%) were macroadenomas. Overall postoperative CSF (poCSF) leak in our patients was 2.8%. Among cases with poCSF leak, 4 (3.9%) were male and five were female (2.3%) with the P-value of 0.477. Regarding size of pituitary adenomas, only one (5.3%) microadenoma had poCSF leak whereas 8 (2.7%) macroadenomas had poCSF leak with the P-value of 0.432. Conclusion: Pituitary adenomas can be successfully treated with EETS without SFR in patients who do not experience intraoperative CSF leak. [ABSTRACT FROM AUTHOR]

Background and Objective: Chiari I Malformation-associated syringomyelia (CM) and idiopathic syringomyelia (IS) are often confused together. They require different diagnostic approach and treatment modalities; it is important to distinguish between the two. We aimed to evaluate the radiological and morphologic characteristics of CM and IS in adult and pediatric patients in Pakistani population. Methods: Our retrospective case series was conducted at the Department of Radiology, Punjab Institute of Neurosciences assessing the operated cases of CM and IS cases from January 2022 to December 2023. Preoperative morphologic and radiological data was collected for adult and pediatric patients. Results: Out of 16 patients, 75% were adults and four were children. Twelve patients were male. The mean age of adult patients at presentation was 30.50 ± 9.20 years. There were nine cases of Chiari I Malformation and seven cases of idiopathic syringomyelia. Craniocervical junction (CCJ) was the most common site of syrinx formation in adults (41.66%) in both Chiari I and IS groups. The mean size of syrinx in adults in IS was 7.842 ± 1.93 and in CM was 4.740 ± 0.45. Mean size of syrinx in children was 4.84 ± 0.48 mm. Moniliform shape was the most common form of syrinx in patients in both CM and IS groups. Conclusion: In the Pakistani population, this study focuses on the radiological characteristics of idiopathic syringomyelia (IS) and Chiari I Malformation (CM), both of which commonly exhibit a moniliform syrinx. The craniocervical junction was frequently involved in CM, but IS exhibited a wider, bigger syrinx. Accurate diagnosis as well as treatment depend on imaging. [ABSTRACT FROM AUTHOR]

Paragangliomas are slow-growing, extra-adrenal neuroendocrine tumors with rare intracranial presentation. Although benign, they can be locally aggressive tumors causing bone destruction and compression related symptoms. We report the case of a 19 years old, normotensive female who presented with headache and vertigo for the past six months. Her examination showed right-sided conductive hearing loss and signs of cranial nerve X, vagus nerve palsy. Neuroimaging revealed a lobulated, extra-axial mass measuring 5.4 x 4.2 x 6.8 cm in right cerebellopontine angle (CPA). Subtotal surgical resection was achievable. Histopathology was suggestive of benign, non-secretory paraganglioma. The diagnosis of primary CPA was reached after ruling out other sources of paraganglioma in abdomen, pelvis and thorax. Radiotherapy was advised on follow up visit with no new post-operative deficits seen. Primary CPA paraganglioma should be included in the list of differentials of CPA lesions. Surgical excision in the absence of preoperative embolization of paraganglioma can be successful. [ABSTRACT FROM AUTHOR]

Chronic osteomyelitis of the skull base is a commonly reported pathology in existing scientific literature, but chronic osteomyelitis of the skull vault (COSV) is a rarely documented disease. We report the case of a 38 years old Afghan male with a presenting complaint of irregular swelling on the skull vault for six months. The patient had a history of head trauma one year back with a compound depressed fracture which had been surgically managed then. Physical examination revealed a 15 x 15 cm hard, immobile swelling with an old scar mark over the scalp. Neuroimaging was consistent with diffuse, bilateral frontoparietal swelling of bony origin, sparing underlying brain parenchyma. Surgically excision of the lesion was done through a bicoronal skin flap and cranioplasty done at the same time. Histological findings of the specimen reported chronic osteomyelitis. However, microbiology revealed no growth in culture. Patient was discharged on the second postoperative day uneventfully. This case turns minds into keeping skull vault osteomyelitis as differential diagnosis besides other spontaneous bony lesions; e.g. fibrous dysplasia, osteoma and giant cell tumours. [ABSTRACT FROM AUTHOR]

Brain abscess (BA) formation that may be due to due to Gram-positive bacteria commonly and less commonly due Gram-negative bacteria affects pediatric population. Most cases are secondary to the involvement of ear, nose, throat and sinuses (ENTS). We describe a rare case of a 14 year old patient presenting with generalized tonic clonic seizures for the last six months associated with fever, vomiting and headache. ENTS examination was normal. Neuroimaging was suggestive of multiple left fronto-pariettal space occupying lesions. Modified pterional craniotomy was done to excise the multiloculated, encapsulated lesion with yellow-green pus. Culture sensitivity yielded Proteus mirabilis. Patient was discharged from the hospital uneventfully. The diagnosis of multiple primary brain abscesses secondary to Proteus mirabilis is very rare and it should be considered in the list of differentials of multiple brain abscesses when the systematic examination is normal. Early surgical excision is the key to a successful outcome. [ABSTRACT FROM AUTHOR]

The article presents the 2023 annual report of the Punjab Institute of Neurosciences (PIN), one of the largest neurological healthcare facilities in the world. Topics discussed include surgical procedures done in emergency operation theatres at PINS in 2023, academic activities, and state-of-the-art facilities and equipment acquired by PINS despite being a government-funded institution.

Adrenal Gland Cysts are rare among all the pathologic cysts that occur in human beings; the pseudo-cyst variety even rarer. Adrenal pseudo-cysts are asymptomatic, non-functional, small, and incidentally discovered disease entities. Their clinical presentation is usually the result of their mass effects. Thanks to the advanced diagnostic technology, more such cases are being discovered timely and managed surgically, before life-threatening complications occur. Open surgical treatment remains the treatment of choice for giant cysts.

Alveolar soft part sarcoma is a very rare malignant neoplasm of peripheral muscular, adipose or neural tissue. Its occurrence, as a primary intracranial tumour, is even rarer. To the best of our knowledge, only nine cases of primary intracranial alveolar soft part sarcoma exist in English scientific literature. We attempt to write a comprehensive review on this poorly understood intracranial malignancy, with no evident systemic lesions, such as in the case of our 22 years old patient. In addition to absent definitive proof of benefit of radiologic or chemotherapeutic management, we highlight the role of surgery as the primary treatment. Younger patients with this tumour may have a worse prognosis than elderly patients.