Biomedical subjects
N Nathoo
Publications and source records attributed to N Nathoo.
Cerebral blood flow changes in rhinogenic subdural empyema and the role of hyperaemia in brain swelling.
BACKGROUND: Previous studies have demonstrated that rhinogenic subdural empyema (SDE) generally has a good prognosis. Most patients are admitted with an altered level of consciousness or significant neurological deficit, but eventually have a good outcome. It is well known that intra-operative brain swelling may occur with subdural empyema. OBJECTIVE: To define cerebral blood flow (CBF) dynamics and determine the role of cerebral hyperaemia, if any, in intracranial SDE. METHODS: CBF dynamics were assessed in five patients (mean age 13.2 +/- 2.2 years) with unilateral rhinogenic convexity SDE documented on computer tomography (CT). Regional cortical blood flow (rCBF) was measured using a thermo-coupled sensor placed on the cortex at the time of surgery. Dynamic CT scans were performed to assess cerebral blood volume (CBV) quantitatively, while transcranial Doppler ultrasonography (TCD) was used to measure cerebral blood flow velocities (CBF velocities) both pre- and post-operatively for 21 days. The opposite 'normal' hemisphere served as a control for each patient. RESULTS: Post-operative rCBF and CBF velocities in the pathological hemisphere progressively increased to plateau at 96 hours. Cerebral blood volume was increased bilaterally, but to a greater extent in the pathological hemisphere and more so in grey than white matter. These haemodynamic changes, though clinically significant did not reach statistical significance (p>0.05). CONCLUSION: Our results suggest that the accompanying brain swelling in rhinogenic SDE is a complex event, with reactive cerebral hyperaemia possibly playing neuroprotective role. Furthermore, unilateral convexity empyema causes bilateral cerebral haemodynamic changes. Future studies are necessary to define the aetiology of brain swelling in intracranial SDE.
Intracranial malposition of a nasogastric tube following repair of choanal atresia.
Intracranial penetration during attempted nasogastric intubation is a rare, often lethal occurrence. We report the inadvertent introduction of a nasogastric tube intracranially in a neonate following repair of unilateral choanal atresia. Following manual removal of the tube, the patient made a good recovery.
Intracranial subdural empyemas in the era of computed tomography: a review of 699 cases.
OBJECTIVE: Intracranial empyemas are the most common form of intracranial suppuration seen in our unit and, despite modern antibiotic therapy and advanced neurosurgical and imaging facilities, these pus collections remain a formidable challenge, often resulting in significant morbidity and death. We present an analysis of our 15-year experience with this condition in the era of computed tomography. METHODS: A retrospective analysis of 4623 patients admitted with intracranial sepsis during a 15-year period (1983-1997) identified 699 patients with intracranial subdural empyemas. The inpatient notes for these patients were analyzed with respect to clinical, radiological, bacteriological, surgical, and outcome data. Statistical analyses were performed. RESULTS: The 699 intracranial subdural empyemas accounted for 15% of all admissions for intracranial sepsis during the study period. Young male patients in the second or third decade of life were most commonly affected (62%), and the mean age was 14.65+/-12.2 years. Almost all patients (96%) underwent surgery. Eighty-two percent of patients experienced good outcomes (Glasgow Outcome Scale scores of 4 or 5). A morbidity rate of 25.9% (including postoperative seizures) was noted, and 85 patients died (mortality rate, 12.2%). CONCLUSION: Intracranial subdural empyema, which is a neurosurgical emergency, is rapidly fatal if not recognized early and managed promptly. Early surgical drainage, simultaneous eradication of the primary source of sepsis, and intravenous administration of high doses of appropriate antibiotic agents represent the mainstays of treatment.
Cranial extradural empyema in the era of computed tomography: a review of 82 cases.
OBJECTIVE: Intracranial suppurative disorders (abscesses and empyemas) continue to be common neurosurgical emergencies in South Africa. Cranial extradural empyema (EDE) occurs less frequently than its subdural counterpart but remains a potentially devastating disease process. We present our 15-year experience with this condition in the era of computed tomography. METHODS: Of the 4623 patients with intracranial sepsis who were admitted to the neurosurgical unit at Wentworth Hospital (Durban, South Africa) during a 15-year period (1983-1997), 76 patients with EDEs were identified. An additional six patients who were identified from our outpatient records were treated nonsurgically. Analyses were performed with respect to clinical, radiological, bacteriological, surgical, and outcome data. All information for this study was obtained from the computerized databank for the unit. Statistical analyses of the related pre- and postoperative clinical data were performed. RESULTS: The 76 patients with EDEs accounted for 1.6% of the total number of patients admitted for treatment of intracranial sepsis during the study period. Thirteen patients (15.8%) had infratentorial pus collections. Male patients predominated by a ratio of 2:1, and 66 patients were between the ages of 6 and 20 years (mean age, 16.56+/-9.87 yr). The origins of the sepsis were paranasal sinusitis for 53 patients (64.6%), mastoiditis for 16 patients, trauma for 5 patients, dental caries for 1 patient, and miscellaneous causes for 7 patients. The most common clinical presenting features were fever, neck stiffness, and periorbital edema. Surgery was performed in the form of burrholes for 21 patients, small craniectomies for 39 patients, and craniotomies for 5 patients. The additional five patients, while having drainage of their infected paranasal sinuses, had simultaneous drainage of their extradural pus collections by the ear, nose, and throat surgeon. The majority of patients (81 patients) experienced good outcomes (Glasgow Outcome Scale scores of 4 or 5). A single patient died after surgery (mortality rate, 1.22%). CONCLUSION: EDEs occur less frequently than subdural empyemas and are associated with better prognoses. Surgical drainage (burrholes), simultaneous eradication of the source of sepsis, and high-dose intravenous antibiotic therapy remain the mainstays of treatment. Selective nonsurgical management of small EDEs is possible, provided the source of sepsis is surgically eradicated. It is our opinion that EDE is a disease that should be managed without morbidity or death.
Traumatic intracranial aneurysms following penetrating stab wounds to the head: two unusual cases and review of the literature.
Two patients with rare complications of traumatic intracranial aneurysms following penetrating cranial stab wounds are described. One patient had a good outcome despite a secondary rupture of a traumatic proximal middle cerebral artery aneurysm, while the second patient had a traumatic basilar bifurcation artery aneurysm. To our knowledge neither the survival from a secondary rupture of a traumatic intracranial aneurysm, nor the development of a basilar bifurcation aneurysm secondary to a transcranial stab wound has been described previously. Furthermore, this is the first report of the technique of deep hypothermic cardiac arrest utilized to treat a traumatic false aneurysm. Traumatic intracranial aneurysms are a rare clinical entity, most often diagnosed after rupture and often resulting in fatal haemorrhage. A high index of suspicion needs to be maintained when managing patients with transcranial stab wounds. Early surgical intervention improves outcome by preventing initial aneurysmal rupture or rebleeding.
Cytokine expression in patients with treated congenital hydrocephalus: a preliminary report of five patients.
BACKGROUND: Previous studies have described the elaboration of cytokines in experimental models of congenital hydrocephalus using rats or mice. However, there have been no reports of similar studies in humans. OBJECTIVE: To determine the cytokine expression pattern in the cerebrospinal fluid (CSF) of patients with treated congenital hydrocephalus. DESIGN: A prospective study. SETTING: Wentworth Hospital, Durban, South Africa. SUBJECTS: Five patients (three infants and two older patients) with congenital hydrocephalus treated by means of a ventriculoperitoneal shunt. INTERVENTIONS: Immunophenotyping of peripheral blood was performed on a flow cytometer. The isolation, in-vitro stimulation of peripheral blood and CSF mononuclear cells, and intracellular cytokine determination by flow cytometry were performed. MAIN OUTCOME MEASURES: Peripheral blood and CSF cytokine measurements. RESULTS: Although not statistically significant, all measured mean cytokine levels in the peripheral blood of the infant group were consistently higher than that of the adult group. CSF cytokine levels in both groups were similar and unremarkable. CONCLUSION: No clear pattern of CSF cytokine elaboration, either type-1 (T helper 1) (Th1) or Type-2 (T helper 2) (Th2), could be demonstrated in either of the groups. The significance of higher peripheral blood cytokine levels in the infants is unclear, but may be age-related, and is not apparent in the CSF.
Intracranial tuberculous subdural empyema: case report.
OBJECTIVE AND IMPORTANCE: Many types of neurotuberculosis have been described; the most common intracranial forms are tuberculous meningitis and tuberculomas. We report a unique and as yet unreported form of neurotuberculosis, which is an intracranial tuberculous subdural empyema. CLINICAL PRESENTATION: A 59-year-old man who had been previously treated for pulmonary tuberculosis (TB) presented at our institution with a long-standing history of headaches. General and neurological examinations revealed no abnormalities. Radiography of the chest confirmed fibrotic lung changes caused by healed pulmonary TB. A cranial computed tomographic scan revealed a hypodense extra-axial collection with mass effect as well as adjacent osteitis and scalp swelling. INTERVENTION: The patient underwent craniectomy of the osteitic bone and drainage of 50 ml of fluid pus located subdurally. Microscopic examination of the bone and pus revealed tuberculous granulation tissue with numerous acid-fast bacilli identified using Ziehl-Neelsen stain. Mycobacterium TB bacillus was cultured from the pus at 42 days. The patient required two further operative procedures as well as a protracted course of anti-TB therapy. CONCLUSION: The patient eventually achieved a good recovery. We recommend surgical drainage of tuberculous subdural empyema to relieve mass effect and to obtain microbiological confirmation. Furthermore, surgical treatment should be combined with an 18-month course of anti-TB chemotherapy, during which period patient compliance should be closely monitored.
Spontaneous drainage of an infratentorial extradural empyema: case report.
We describe a 21-year-old male who presented with spontaneous drainage of an infratentorial extradural empyema secondary to mastoiditis. Following eradication of the primary source, the patient was commenced on high dose intravenous antibiotics. Serial computed tomography (CT) revealed complete resolution of the pus collection. Antibiotic therapy was successful and no neurosurgical intervention was necessary.
Infratentorial empyema: analysis of 22 cases.
OBJECTIVE: Infratentorial empyema is an uncommon form of intracranial suppuration that is usually secondary to neglected otogenic infection. The diagnosis is frequently delayed and often confused with that of meningitis. The associated mortality is distressingly high, yet it has, as a clinical entity, received scant attention in the literature. We present a 13-year experience of this condition. PATIENTS AND METHODS: From a retrospective analysis of 3865 patients with intracranial suppuration during a 13-year period, 22 patients with infratentorial empyema were identified. The inpatient notes for these patients were analyzed with reference to clinical, radiological, bacteriological, operative, and outcome data. RESULTS: Twenty-two patients with infratentorial empyema accounted for 0.6% of admissions caused by intracranial suppuration during the study period. Of these 22 empyemas, 13 were subdural and 9 epidural. Hydrocephalus was present in 17 (77.3%). Except for two epidural empyemas that did not warrant neurosurgical intervention, all patients underwent standard surgical management (wide posterior fossa craniectomy). Nineteen underwent mastoidectomy because the source of infection was otogenic. Concomitant and persistent hydrocephalus was treated aggressively. Five patients died (mortality rate of 22.7%). All fatalities had subdural empyemas, and all three patients with cerebellopontine angle extension of subdural purulent collections died. CONCLUSION: Although rare, infratentorial empyema, especially when subdural, is a lethal disease. Cerebellopontine angle extension of pus was a particularly ominous sign in our experience. Early surgical drainage via wide posterior fossa craniectomy, aggressive treatment of associated hydrocephalus, eradication of the primary source of sepsis, and, finally, intravenous high dosage of appropriate antibiotics form the mainstay of treatment.