Eastern Green Neurosurgery

“It’s not just a News bulletin”

Eastern Green Neurosurgeryis a mirror of Neurosurgery at B&C Hospital

Department of Neurosurgery B&C Medical College Teaching Hospital

Issue: 01. April. 2019

Editorial Board

Editor – in – Chief

Pankaj Raj Nepal, FCPS

Department of Neurosurgery

B & C Medical College Teaching Hosptial

Birtamode, Jhapa

Executive Editors

Karuna Tamrakar Karki, MS, MCh



Birtamode, Jhapa

Dinesh Kumar Thapa, MBBS



Birtamode, Jhapa

Editors

Archana Chaudhary Nepal, MBBS, MD

Department of Forensic Medicine


Birtamode, Jhapa

Sapana Gautam Thapa

Resident Ditetian

Apollo Hospital, India

Members

Birat Thapa Magar, MBBS



Birtamode, Jhapa

Arbindra Kumar Yadav, MBBS



Birtamode, Jhapa

Manohar Kumar Ray, MBBS



Birtamode, Jhapa

Eastern Green Neurosurgery

1 egneuro Volume 01, 2019

egneuro Volume 1, Issue 1, 2019

Table of Content:

Editorial

Pankaj Raj Nepal

1

Review of Neurosurgical services at B&C Hospital in last 3 years

Dinesh Kumar Thapa

2

BE-FAST FASTER ANDFASTEST

Karuna Tamrakar (Karki)

7

Technical challenge in MCA bifurcation aneurysm clipping

Pankaj Raj Nepal

11

Management of Galassi type 3 Arachnoid cyst- A Case Report

Birat ThapaMagar, Dinesh K. Thapa, Karuna Tamrakar Karki, Pankaj Raj

Nepal

17

Eastern Green Neurosurgery OriginalArticle


egneuro 01: 02-05, 2019

Editorial

Pankaj Raj Nepal, FCPS

Head of Department, Department of Neurosurgery, B & C Medical College

Teaching Hosptial, Birtamode, Jhapa.

We have brought the first issue of

“Eastern Green Neurosurgery”. The aim of

this news letter is not just to give the success

stories of neurosurgical cases at B & C

Hospital; rather, to give the actual mirror of

the neurosurgical care being provided and

create an academic plateform.

The present face of the department is as

follow:

1. Dr. Pankaj Raj Nepal: Head of

Department

2. Dr. Karuna Tamrakar (Karki):

Consultant Neurosurgeon

3. Dr. Dinesh K. Thapa: Registrar in

Neurosurgery

4. Dr. Birat Thapa Magar: senior

Medical officer

5. Dr. Dipesh Neupane: Medical Officer

6. Dr. Srijana Neupane: Medical Officer

7. Dr. Arbindra Kumar Yadav: Medical

Officer

8. Dr. Manohar Kumar Ray: Medical

Officer.

By working in this part of the world, we are

exposed to the challenge of the variety of

neurosurgical cases from trauma of head and

spine to the complex tumor and vascular

neurosurgical cases. Teaching of Prof.

Upendra P. Devkota seems to be very effective

to me as even with this small neurosurgical

team we are able to produce accepted result

when compared to the results of better centers

of the world.

Though, it has already been a year for me

running neurosurgical department in this

institute as a head of department, but the

department was not established by me, but

rather by the team from Annapurna

Neurological Institue and Allied Sciences

(ANIAS) in early months of 2015 which was

led by Prof. Dr. Basanta Panta.

B&C Hospital is a up growing huge project of

the far eastern Nepal which is a 750 bedded

with 50 bedded ICU. Almost all the faculties

and facilities are available including 1.5tesla

MRI, 16 slice CT scanner. Now the new

project of “ Eastern Cancer Hospital” is

running and probably will be completed soon.

There are seven operating theatre running

smoothly, with one dedicated theatre for the

complex neurosurgical cases which harbors

the Pentero 900 microscope.

Eastern Green Neurosurgery OriginalArticle


egneuro 01: 02-06, 2019

Review of Neurosurgical services at B&C Hospital in last 3

years

Dinesh K. Thapa1

1Department of Neurosurgery, B & C Medical College Teaching Hosptial, Birtamode,

Jhapa.

Neurosurgery was started in Far-Eastern Nepal as Department of Neurosurgery at

B&C Hospital in early 2015. Prof.Dr.Basant Pant played a key role to establish and

give astounding start with all technical supports possible. Dr. Chandra P Limbu and I

joined the institute at the beginning from ANIAS. Since last one year the department

is led by Dr. Pankaj Raj Nepal, who is one of the finest trainee of Prof. Upendra P.

Devkota.

The set up of the operating theatre is allowing us to do almost all types of

neurosurgical procedures. In last three years there were 336 head injuries cases

among which acute subdural hematoma was the commonest one. There were 48 cases

of cervical spine injuries cases admitted over this duration. Hemorrhagic stroke

requiring surgical procedure were 46 followed by 11 cases of malignant MCA

infarction. Tumors were of different types and were 83 cases during this period.

Aneurysms were 46 in number who underwent clipping.

Keywords: Head injury, aneurysms, hemorrhagic stroke, malignant MCA infarction

Neurosurgery was started in Far-

Eastern Nepal as Department of

Neurosurgery at B&C Hospital in early

2015 by signing memorandum of

understanding between Annapurna

Neurological Institute and Allied Sciences

(ANIAS) and B&C Medical College

Teaching Hospital to provide services in

door steps. The renowned senior

neurosurgeon and chairman of ANIAS,

Prof.Dr.Basant Pant played a key role to

establish and give astounding start with all

technical supports possible. Dr. Chandra P

Limbu and I joined the institute at the

beginning from ANIAS. Since last one

year the department is led by Dr. Pankaj

Raj Nepal, who is one of the finest trainee

of Prof. Upendra P. Devkota (Father of

Modern Neurosurgery of Nepal)2. Since its

start many patients had received different

kinds of neurosurgical as well neurological

support. It is situated in Birtamode, rapidly

growing small town of Far Eastern Nepal.

Our hospital is situated near the Indo-

Nepal border where Siliguri and

Biratnagar were the key referral centers

before. Being about two hours distant from

larger cities with neurosurgical facilities,

most trauma patients were unable to get

timely intervention. So we aimed to save

patients with trauma at our center though

all kinds of elective cases are in routine

schedule. Neurosurgery facility was

already in function on eastern part of

Nepal at Biratnagar and Dharan. 1

Thapa DK et al.


Hereby, I am briefly summarizing cases

managed surgically in different stream of

neurosciences at our center in last 3 years.

Head Injury:

The incidence of road traffic accident is

high all over Nepal and south Asia, where

about 7/100 000 population dies in

accident in 2011–20123. B&C Hospital is

located at the edge of East-West Highway

and similar to other parts of the country

this part is also prone to road traffic

accident. So the incidence of trauma

registry is high at our center. The diagrams

below summarize the overall scenario of

head injury patient who were managed

surgically.

Figure 1: Overall Head injuries cases

Figure 2: GOS at 6 weeks

Figure 3: Overall Subdural Hematoma

8%(28)

13%(43)

5%(17)

74%(248)

Head Injury (n=336)

Depressed Fracture Epidural Hematoma

Diffuse Axional Injury Sub Dural Hematoma

2015/16 2016/17 2017/18

69

82

59

24

36

2313

1911

GOS at 6 weeks5,4 3,2 1

90%(223)

10%(25)

Subdural Hematoma(248)

Acute Subdural Hematoma

Chronic Subdural Hematoma

Thapa DK et al.


Spinal Injuries:

We receive many patients in Emergency

Room with history of paresis or plegia of

lower limbs or all four limbs. Most of the

cases of cervical spine injuries were due to

RTA followed by fall from tree or height.

Most common level of subluxation was seen at

C5-C6, C6-C7. We are doing anterior fixation

as well as posterior fixation if needed. Most of

the cervical injuries got operated were of

ASIA B and C. Morbidity and mortality is

high among patients presented with neurology

of ASIA A.

Figure 4: ASIA Neurology of Operated cases

Figure 5: Frequencey of levels of cervical spine injuries

Cerebrovascular Diseases(CVD):

The incidence of CVA is in increasing trend

among Nepalese due to diet modifications and

lack of adequate physical mobility. We are

getting increasing number of admissions and

surgery done for it. The prevalence of

hemorrhagic stroke (HCVA) is higher than

Ischemic CVA (ICVA) at our center. Most of

the patients were diagnosed case of

hypertension with deferred taking medicines,

few are only associated with Diabetes or

cardiac diseases as well.

Most of the patients with HCVA needing

surgery were managed with craniotomy and

evacuation of hematoma and few needed

Decompressive Craniectomy (DC). The

surgical need for ICVA in malignant MCA

infarction is to protect further deterioration

due to swelling. We are all set to go for IV-

tPA and Mechanical Thrombectomy for the

possible case. There are many patients getting

2015/16 2016/17 2017/18

ASIA A 5 8 5

ASIA B 3 7 4

ASIA C 2 4 2

ASIA D 1 1 3

ASIA E 0 1 2

pat

ien

ts

ASIA Neurology

0 2 4 6 8

2015/16

2016/17

2017/18

Level of Cervical Spine Injuries

C7-T1 C6-C7

C5-C6 C4-C5

C3-C4 C2-C3

A-A CV Junction

Thapa DK et al.


to ER with in 1 hour of weakness, so these

patients will be in benefit with the service.

Figure 6: Frequencies of stroke who underwent

surgeries.

Central Nervous System Tumors:

The numbers of elective cases were not very

high due to high credibility capacity of locals

and choosing centers in bigger cities and

abroad. Though, we are performing all

possible surgeries for different kinds of CNS

pathologies

Figure 7: Distribution of tumors

Figure 8: Different types of tumors

Vascular Surgeries:

We are routinely performing vascular

surgeries for patients presenting with ruptured

Aneurysm, AVMs and Cavernomas. We also

encountered few cases of Dural Arterio

Venous Fistula (dAVF) and Cavernoma

associated with Developmental Venous

Anomaly (DVA). The diagram below presents

total vascular surgeries performed during the

period.

Figure 9: Distribution of Vascular operated cases.

Figure 10: Distribution of Aneurysms cases.

We are here to provide all kinds of

neurosurgical supports in this region aiming to

minimize mortality and morbidity of patients

believing in Time is Brain.

References:

1. Bhandari R, Mahato IP, Paudel M, Giri R. Head Injury – A Case Profile Study from

Eastern Region of Nepal. Health Renaissance 8(2): 11-13, 2010

2. Devkota UP, Aryal KR. Result of surgery for ruptured intracranial aneurysms in Nepal.

British Journal of Neurosurgery 15: 13-16, 2001.

12

2

15

3

19

6

Hemorrghic CVA Ischemic CVA

2015/16 2016/17 2017/18

Cranial Pathologies Spinal Pathologies

6419

27

1815

12 11

Tumor Classification

4

9

15

0 1

4

13

6

1 02

2015/16 2016/17 2017/18

Aneurysms AVMs Cavernomas Others

912

24

MCA Acom Pcom ICA

Aneurysms

Thapa DK et al.


3. Karkee R, Lee AH Epidemiology of road traffic injuries in Nepal, 2001–2013: systematic

review and secondary data analysis, BMJOpen 2016;6:e010757. doi: 10.1136/bmjopen-

2015-010757

Eastern Green Neurosurgery Review Article


egneuro 01: 07-10, 2019

BE-FAST FASTER ANDFASTEST

-Karuna Tamrakar (Karki) 1, MS, MCh.


Jhapa.

Annual incidence of stroke is 2.5%/1000 people or 200000 stroke /year. Every 5

seconds undergo stroke all over the world. 15-20 % die in first month of brain attack

and 75% lives with focal neurological deficit. Ischemic stroke is the most common

(85%) after hemorrhagic stroke and subarachnoid hemorrhage (15%). Among all 5

subtypes, large artery atherosclerosis, cardio embolism, small vessel occlusion, stroke

of other determined etiology, undetermined etiology, ischemic stroke carries poor

prognosis of increasing morbidity and mortality. Window of opportunity is a critical

time that need to be addressed to reverse neurological stroke symptoms either

partially or completely through active interventional approaches either noninvasive or

invasive methods. Thrombolysis has radically changed the prognosis of acute

ischemic stroke. Intravenous thrombolytic therapy with recombinant tissue

plasminogen activator (rtPA) is effective in reducing the neurological deficit. Time is

brain, either you be fast or faster and fastest, early or timely reperfusion therapy

within a time frame of 4.5 hours helps to restore normal neurological function.

Keywords: ischemia, brain attack, stroke, thrombolysis

Stroke is defined as a rapid onset of

neurological deterioration caused by an

acute focal injury to the brain lasting for

more than 24 hours due to vascular cause.

Stroke results due to loss of blood supply,

devoid of oxygen and nutrients. It also

hampers in elimination of metabolic

wastes. These changes obstruct the normal

neuronal function that ultimately results

into neuronal death and necrosis. Brain

tissue is principally sensitive to these

changes.

Annual incidence of stroke is 2.5%/1000

people or 200000 stroke /year. Every 5

seconds undergo stroke all over the world.

15-20 % die in first month of brain attack

and 75% lives with focal neurological

deficit. Stroke is second leading cause of

death after coronary artery disease, third

leading cause of death in United State of

America. It is third most common cause of

disability in more than half of the stroke

survivors in age 65 and over. Economic

burden of stroke on the nation through

health care services, medications and

rehabilitation services. Loss of

productivity is around 33 million dollar

annually.

Ischemic stroke is the most common

(85%) after hemorrhagic stroke and

subarachnoid hemorrhage (15%). Among

all 5 subtypes, large artery atherosclerosis,

cardio embolism, small vessel occlusion,

stroke of other determined etiology,

undetermined etiology, ischemic stroke

Tamrakar et al.


carries poor prognosis of increasing

morbidity and mortality.

Occlusion of an intracranial vessel by an

embolus that arise at a distant site that

leads to hypoperfusion. Thrombus can lead

to ischemia or occlusion of an artery that

subsequently result into cerebral infarction

or tissue death. Ionic pump fails leading to

membrane depolarization and influx of

calcium ions and efflux of potassium ions.

Increase intracellular calcium trigger the

release of excitatory amino acids

neurotransmitter called Glutamate.

Ultimately excessive intracellular calcium

activates proteases, lipases and free

radicals results into progression of

ischemic cascade. Brain loses its ability to

produce energy (ATP) once blood supply

is interrupted leading to anerobic

metabolism. By- product, lactic acid

destroys normal acid-base balance. Loss of

vascular integrity results in a breakdown

of blood brain barrier and contributes to

cerebral edema that causes secondary brain

damage.

Increasing age, male gender, Asian people

are non-modifiable risk to develop

symptoms of stoke. Previous history of

myocardial infarction, transient ischemic

attack, peripheral vascular disease carries

additional risk. Cigarette smoking, high

blood pressure, diabetes mellitus,

excessive alcohol consumption,

hyperlipidemia, heart diseases like atrial

fibrillation, infective endocarditis, valvular

heart disease, paradoxical emboli,

congestive cardiac failure are modifiable

risk factors. Besides cardiac sources,

patients with atherosclerosis or dissection

in the carotid and vertebrobasilar tree,

hypertension induced small vessel

occlusive disease, systemic lupus

erythematosus, hematological diseases like

polycythemia, proteinC or S deficiency,

Factor V Leiden hypercoagulable state are

also at risk to develop brain attack.

How to identify early?

Ischemic core in brain tissue is destined to

die rapidly and penumbra is salvageable

brain area after restoration of blood blow.

This reinforces the need to educate health

professionals and the general public about

the stroke symptoms so that these patients

can be quickly identified and treated.

Signs and symptoms of stroke as shown in

table.

Tamrakar et al.


Table 1: BE FAST, FASTER, ANDFASTEST

BE-FAST

FASTER

AND FASTEST

B BALANCE imbalance F FACE drooping/

weakness

A Altered consciousness,

confusion

E EYE visual abnormality A ARM weakness N Numbness

F FACE drooping/weakness S STABILITY imbalance D Dizziness

A ARM weakness T TALKING slurring or

aphasia

F FACE drooping/ weakness

S SPEECHslurringor

aphasia

E EYE visual abnormality A ARM weakness

T TIME to act immediately R REACT immediately S Sudden Severe Headache

T TALKING slurring or aphasic

E EYE visual abnormality

S STABILITY imbalance

T TIME to act immediately

Treatment

Window of opportunity is a critical time

that need to be addressed to reverse

neurological stroke symptoms either

partially or completely through active

interventional approaches either

noninvasive or invasive methods.

Thrombolysis has radically changed the

prognosis of acute ischemic stroke.

Intravenous thrombolytic therapy with

recombinant tissue plasminogen activator

(rtPA) is effective in reducing the

neurological deficit. rtPA should be

received within an hour after arriving to

the hospital but not more than 4.5 hours

after the onset of stroke symptoms. This

helps to Control propagation of ischemic

penumbra and reverse the deficit.

Endovascular stroke therapy for ischemic

stroke is much beneficial than IV

thrombolysis alone. Patients with ischemic

stroke with restricted perfusion imaging

with a proximal cerebral arterial occlusion

and salvageable tissue on CT perfusion

imaging falls in intervening criteria for

early thrombectomy. Interventional

mechanical devices like Solitaire FR stent

retriever had been producing better results

than with IV thrombolysis alone.

Mechanical thrombectomy devices

improve reperfusion instantly, and results

into early neurological recovery and

functional outcome. Studies have been

showing good results with combined use

of endovascular stroke therapy with

thrombolytic agents.

Since therapeutic window needed to

prevent is narrow, early identification and

Tamrakar et al.


early intervention is mandatory for

controlling propagation of ischemic

penumbra to reverse neurological deficit.

BNC hospital stroke group is ready to go

for intravenous thrombolysis and

interventional therapy to cure stroke. BNC

hospital is a multispecialty teaching

hospital with high quality imaging

facilities. BNC stroke group has been

specially trained for emergency

management and early identification of

stroke symptoms. It will cut down

intrahospital delay and brings diagnosis

within the short therapeutic window of

ischemic stroke. Our goal is to improve

delivery of aforementioned resources for

the best possible outcome.

Stroke awareness program

Lack of information of the population that

continues to ignore the main clinical signs

and absence of standard prehospital

care.Stroke awarenessis crucial for the

faster treatment and better results. Risk

factors control is another steps that has to

be initiate at community level. Cigarette

smoking, alcohol intake prohibition, Blood

pressure control, maintaining normal sugar

level, weight reduction, modifying

sedentary life, early identification and

treatment of cardiac and vascular causes.

Conclusions

Time is brain, either you be fast or faster

and fastest, early or timely reperfusion

therapy within a time frame of 4.5 hours

helps to restore normal neurological

function.

References

1. Andrews CE, Mouchtouris N, Fitchett EM, Al Saiegh F, Lang MJ, Romo VM, Herial

N, Jabbour P, Tjoumakaris SI, Rosenwasser RH, Gooch MR.J Neurosurg. 2019 Mar

29:1-8.

Eastern Green Neurosurgery Technical Note


egneuro 01: 11-16, 2019

Technical challenge in MCA bifurcation aneurysm clipping

-Pankaj Raj Nepal 1,FCPS

1Head of Department, Department of Neurosurgery, B & C Medical College

Teaching Hosptial, Birtamode, Jhapa.

Technical challenges in aneurysms can broadly be divided into general aneurysmal

management challenges and aneurysm specific challenges. Specifically, we usually

prefer to select the approach based on the presence or absence of temporal hematoma,

and the length of the M1 segment. In the presence of temporal lobe hematoma it is

wise to select the superior temporal gyrus approach, as hematoma evacuation is easy

and we usually find the M3 segment to trace back to find the aneurysm. Other

challenge lies while clipping the aneurysm. MCA bifurcation aneurysm seems to be

the most notorious type, because of its varied morphology. We may find them a

simple, multiple lobed, giant, fusiform, and occasionally its the M2 stuck to the neck

of the aneurysm or arising from its dome. For multiple lobed MCA bifurcation

aneurysm, the pearls of clipping is to think different lobes as a different aneurysms.

Keywords: Aneurysm, Microsurgical clipping, subarachnoid hemorrhage, middle

cerebral artery

Technical challenges in aneurysms can

broadly be divided into general

aneurysmal management challenges and

aneurysm specific challenges.

General challenges includes re- bleeding,

vasospasm, hydrocephalus, and the

medical complications like stunted

myocardium, neurogenic pulmonary

edema, ventilator associated pneumonia,

ARDS, infective complications like

urinary tract infection, other renal

complications, and so on.

Re- bleeding is high with the proximal

aneurysms, and the posterior circulating

aneurysms. For predicting vasospasm,

various articles are found in the literature,

of all modified Fischer’s grading is found

to be more user friendly.

Here we are discussing the technical

challenges we face in the setting of

ruptured MCA bifurcation aneurysms.

Preoperative challenge: managing the

blood pressure, and intracranial pressure is

the technical challenge.

Intraoperative challenge: we usually

prefer to select the approach based on the

presence or absence of temporal

hematoma, and the length of the M1

segment .

In the presence of temporal lobe

hematoma it is wise to select the superior

temporal gyrus approach, as hematoma

evacuation is easy and we usually find the

M3 segment to trace back to find the

aneurysm.

Nepal PR et al.


Figure 1: Giant MCA aneurysm with

temporal lobe hematoma

Figure 2: Left MCA bifurcation

aneurysm presented with left temporal

bleed extending to left putamen

Figure 3:Diffuse subarachnoid

hemorrhage

Diffuse subarachnoid hemorrhage in

ruptured MCA bifurcation aneurysms,

transsylvian approach is considered the

best, which is further seen as proximal to

distal dissection or distal to proximal

dissection. We prefer to select the

approach based on the length of the M1

segment. For cases of short M1 segment

proximal to distal and for longer M1

segment we go distal to proximal

approach.

like in hematoma case we went superior

temporal gyrus approach and in diffuse

SAH case we went transsylvian approach.

Figure 4: CT angiogram with right

MCA bifurcation aneurysm with short

M1 segment

Nepal PR et al.


These angiographies had the short M1

segments so we went the proxima to distal

sylvian dissection and traced back the

aneurysm from the M1 segment.

Challenge during clipping MCA

bifurcation aneurysm: Other challenge

lies while clipping the aneurysm. MCA

bifurcation aneurysm seems to be the most

notorious type, because of its varied

morphology. We may find them a simple,

multiple lobed, giant, fusiform, and

occasionally its the M2 stuck to the neck

of the aneurysm or arising from its dome.

Figure 5: Simple clipping technique

Simple aneurysms could be clipped easily

with a straight or angled clips. Here in the

above case it was the superior pointing

simple MCA bifurcation aneurysm and

was clipped with a straight clip.

Figure 6: Simple clipping with angled

clip

Similarly, this is an another example of a

simple aneurysm with its dome pointing

inferior. In this case the clipping was

amenable with an angled clip.

Nepal PR et al.


Figure 7: Modified clipping technique

for clipping multilobed aneurysm

For multiple lobed MCA bifurcation

aneurysm, the pearls of clipping is to think

different lobes as a different aneurysms. In

the above case, there was superior pointing

lobe and inferior pointing lobe. Inferior

pointing lobe was clipped with a simple

angled clip, however while clipping the

superior pointing lobe the M2 was in our

way, which made us to use the angled

fenestrated clip. It is always required to

secure the distal circulation in the M2, for

which either use of ICG dye or visually

confirming the patency of the vessel and

making sure it is not taken in the tip of the

clips is required.

Figure 8: Partial excision and clip

reconstruction for giant aneurysm

For Giant MCA bifurcation aneurysm,

various technique of clipping is described.

The pearls in its clipping is in creating a

secured flow from the M1 to M2 vessels.

If we study our angiography very

carefully, we usually find the vessels are

at the neck of the aneurysm and its the

dome which has ruptured. In this setting

tandam clipping or clipping with

intersecting clips could on the fundus with

Nepal PR et al.


creating the distal circulation by leaving

the cuff of tissue over the neck could be

very effective.

But occasionally we might find a case like

ours, where the giant aneurysm was

completely thrombosed and hard, and

blood found some way through the

aneurysm to get ruptured through the

fundus. In such setting no clips application

will work without removing the thrombus.

So, we performed the partial excision of

the wall of the aneurysm, and excision of

the thrombus inside and then clip

reconstruction . Three clips were used two

were stacked and one long angled to

occlude the aneurysm. In this case we had

to exchange the outermost stacked clip

with a longer clip to completely occlude

the aneurysm and the distal circulation was

made patent.

References:

1. Devkota UP, Aryal KR. Result of surgery for ruptured intracranial aneurysms in Nepal.

Br J Neurosurg 15(1): 13-6, 2001

2. Fox J. Intracranial Aneurysms. New York: Springer-Verlag;1983.

3. Kassell NF , Torner JC , Haley EC Jr , Jane JA , Adams HP , Kongable GL . The

International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: overall

management results . J Neurosurg 73:18 – 36, 1990

4. Molyneux A , Kerr R ; International Subarachnoid Aneurysm Trial (ISAT) Collaborative

Group , Stratton I , Sandercock P , Clarke M , Shrimpton J , Holman R . International

Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular

coiling in 2143 patients with ruptured intracranial aneurysms: a randomized trial . J

Stroke Cerebrovasc Dis 11:304 – 314, 2002

5. Molyneux A , Kerr R ; International Subarachnoid Aneurysm Trial (ISAT) Collaborative

Group , Stratton I , Sandercock P , Clarke M , Shrimpton J , Holman R . International

Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular

coiling in 2143 patients with ruptured intracranial aneurysms: a randomized trial . J

Stroke Cerebrovasc Dis 11:304 – 314, 2002

Nepal PR et al.


6. Roka YB, Shrestha M, Puri PR, Adhikari HB. Surgery for Intracerebral Aneurysms in

Eastern Nepal: A New Beginning. Nepal Journal of Neuroscience 9:5-9, 2012

7. Sharma GR, Kausal P, Jha R, Khadka N, Adhikari DR, Bista P, Sultania PK. Outcome of

Microsurgical Clipping of Intracranial Aneurysms in Bir Hospital. Nepal Journal of

Neuroscience 8(2): 137-142, 2011

8. Wolstenholme J , Rivero-Arias O , Gray A , Molyneux AJ , Kerr RS , Yarnold JA ,

Sneade M ; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group .

Treatment pathways, resource use, and costs of endovascular coiling versus surgical

clipping after a SAH . Stroke 39:111 – 119, 2008

Eastern Green Neurosurgery Case Report


egneuro 01: 17-20, 2019

Management of Galassi type 3 Arachnoid cyst- A Case Report

-Birat ThapaMagar,MBBS1, Dinesh K. Thapa,MBBS1, Karuna

Tamrakar(Karki),MS, MCh1, Pankaj Raj Nepal, FCPS1


Jhapa.

Arachnoid cyst is a benign congenital lesion which can be located in various regions

like; suprasellar, sylvian, posterior fossa, spine & so on. The most common location

of arachnoid cyst is the middle fossa or sylvian fissure usually behind the greater

wing of sphenoid bone(50% ).Here we are presenting a case of a 59 year-old woman

brought to the emergency department with history of sudden onset loss of

consciousness associated with generalized tonic clonic seizure. CT-scanning of head

showed Galassi type 3 arachnoid cyst. She was managed with fenestration and partial

marsupialization of cyst with excellent outcome.

Keywords: Arachnoid cyst, marsupialization of cyst, fenestration of arachnoid cyst.

seizure

A 59 year-old woman brought to the

emergency department with history of

sudden onset loss of consciousness

associated with generalized tonic clonic

seizure few hours before presentation. On

arrival she was eye opening to pain,

incomprehensible sounds and flexon motor

response with pupils 3 mm bilaterally

reactive to light and plantar right sided up

going. Her vitals were stable.

After initial assessment & resuscitation,

Phenytoin was loaded and CT-scanning of

head was done, which showed – large CSF

intensity lesion in left sylvian region with

features of marked midline shift suggestive

of Galassi type 3 arachnoid cyst.

Figure 1: CT head on presentation

showing Galassi type 3 arachnoid cyst

with severe mass effect.

Baseline investigations were done &

patient was prepared for operation after

taking informed consent from the patient’s

party.

Right pterional craniotomy was done with

osteoplastic bone flap. Dura was opened in

curvilinear fashion based inferiorly.

A large cyst was identified filled with clear

fluid and vessels were all running in the

cyst wall. Cyst was seems to compress the

ThapaMagar B et al.


frontal and the temporal lobe and the

sylvian fissure was wide open exposing

the internal carotid artery and the middle

cerebral artery. The insular and the

opercular segments of the middle cerebral

artery was clearly seen in the basal part of

the cyst wall and was separated with the

perioptic cistern with a thin layer of intact

arachnoid membrane. The brain pulsation

was minimum before opening the cyst

wall.

The cyst cavity was approached by

opening the superficial layer of the

arachnoid membrane and then

fenestrations were made with the preoptic,

opticocarotid and caroticotentorial

cisterns. A good brain pulsation was

noticed and procedure was completed with

partial marsupialization of cyst wall.

Closure was done with primary dural

closure, repositioning bone flap and skin

closed in layers with a multihole suction

drain in subgaleal space.

Patient was gradually weaned off from

ventilator and extubated in ICU.

Postoperative course was uneventful.

Patient started mobilization from third day

with no focal neurological deficit. She got

discharged after cranial sutures were

removed.

MRI brain was done on the follow up of 3

month which showed centralized midline

with no further compression on the lobes

around the cyst. The volume of the cyst

was reduced and remaining cavity might

be secondary to underdeveloped lobes.

Figure 2: Surgical scar of the pterional

craniotomy.

Figure 3: Follow-up T2 weighted MRI

at three months showing centralized

midline and compressive effect in the

brain lobes.

Figure 4: Follow-up contrast enhanced

MRI showing no abnormal

enhancement.

ThapaMagar B et al.


Discussion:

Arachnoid cyst is a benign congenital

lesion which can be located in various

regions like; suprasellar, sylvian, posterior

fossa, spine & so on. The most common

location of arachnoid cyst is the middle

fossa or sylvian fissure usually behind the

greater wing of sphenoid bone(50% ). 1

Presentation of arachnoid cyst can vary

from SDH or bleed into cyst mass effect or

seizure. 1 Galassi et.al has described the

classification system of arachnoid cyst

based upon its size, shape &

communication with the cistern.2,3 Type I

sylvian arachnoid cyst has biconvex

appearance which is freely communicated

with cistern & are best managed

conservatively. Type II sylvian arachnoid

cyst are rhomboid shaped & partially

communicated with cistern. These are also

managed conservatively until there is acute

growth, bleed or other problems. Type III

sylvian arachnoid cyst are huge in size

with mass effect & no communication

with cistern, hence surgical treatment are

advised to deal this type of arachnoid

cyst.2,3

Various surgical treatments are available

& all of them have showed relatively

similar outcome in terms of its recurrence

& morbidity. Cystoperitoneal shunt,

marsupilization of cyst, fenestration of

cyst with the nearby cistern either

endoscopically or microsurgically,

arachnoidoplasty, are the various surgical

options available.4,5,6

In this case, this lady presented with the

features of raised ICP & seizure which

was dealt surgically with microsurgical

marsupilization & fenestration of cyst with

perioptic cisterns. The overall outcome

was good which can be appreciated in

follow up MRI scan.

Take Home Message:

Though arachnoid cyst is congenital

lesion, it can present any time in life with

different sorts of problem & appropriate

management can definitely help to

alleviate those symptoms.

References:

1. Piatt Jr JH. Unexpected findings on brain and spine imaging in children. Pediatr Clin

North Am. 2004;51:507-527.

2. Peraud A, Ryan G, Drake JM. Rapid formation of a multicompartment neonatal

arachnoid cyst. Pediatr Neurosurg. 2003;39:139-143

3. Galassi E, Tognetti F, Gaist G, et al. CT scan and metrizamide CT cisternography in

arachnoid cysts of the middle cranial fossa: classification and pathophysiologic

aspects. Surg Neurol. 1982;17:363-369.

4. Cincu R, Agrawal A, Eiras J. Intracranial arachnoid cysts: Current concepts and

treatment alternatives. Clin Neurol Neurosurg. 2007;109:837-843.

ThapaMagar B et al.


5. Spacca B, Kandasamy J, Mallucci CL, Genitori L. Endoscopic treatment of middle

fossa arachnoid cysts: a series of 40 patients treated endoscopically in two centres.

Childs Nerv Syst. 2010;26:163-172.

6. Shim K-W, Lee Y-H, Park E-K, et al. Treatment option for arachnoid cysts. Childs

Nerv Syst. 2009;25:1459-1466.

B&C Medical College Teaching Hospital, Birtamode, Jhapa, Nepal

Phone No: +977-23- 542242, e-mail: [email protected]

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