- Awake Craniotomy for Eloquent Area Lesions
Sandeep Inchanalkar, Anand Kakani, Shashank Joshi, NK Sharma, Keki E Turel
Objective : To review our ability to locate language, motor cortices during awake craniotomies for eloquent area lesions.
Patients and Methods : Eight patients with intraaxial lesions in or adjacent to eloquent brain areas were operated under awake conditions from Jan 2000 to Dec 2006. Cooperative patients between 18 and 50 years of age were selected for surgery. Six of them were Gliomas, one was Granuloma and one Cavernoma. The majority of patients (75%) presented with seizures. For skin incision a xylocaine and sensorcaine circumferential scalp block was given. Propofol infusion was used during the craniotomy and stopped for the cortical stimulation and tumour excision. Continuous neurological examination and intermittent white matter stimulation during tumour excision was carried out.
Results : All patients cooperated very well during the surgery and only two were drowsy with the sedation. Six of the lesions were located around the motor cortex and two were around Broca’s area. With cortical stimulation, speech areas were located in cases that had lesions in these areas. The primary motor cortex was identified in all cases. Six patients developed transient weakness during the excision, which later fully recovered. Total excision was achieved in 6 cases and a subtotal excision in 2 cases as they manifested neurological deterioration, albeit transient.
Conclusion : Intraoperative continuous neurological assessment during awake craniotomy facilitates safe eloquent area surgery.
Take Home Message : 1) Eloquent cortex can be reliably mapped during surgery during awake condition. 2) This technique will minimize postoperative neurological deficits while maximizing resection. 3) This technique has been found to be well tolerated with good case selection.
- Supratentorial Cortical Ependymoma : A Report of Two Cases and Review of Literature
AB Kakani, SP Inchanalkar, SS Joshi, NK Sharma, KE Turel
Abstract : Ependymomas are the gliomas arising from the ependymal cells lining the ventricles of the brain and the central canal of the spinal cord. Very few cases of supratentorial ependymomas located on the cortical surface without any connection to the ventricles have been reported. We present our experience with two such cases. One of our patients was 61 years old male who presented with features of raised intracranial pressure and frontal lobe signs. The other patient, a 25 year old female, presented with recurrent episodes of focal seizures and left hemiplegia. On MR imaging, both the patients had parenchymal lesions with solid and cystic components, distant from the ventricles. Both of them underwent gross total resection of the tumour mass. The diagnosis of ependymoma could only be made after microscopic and immunohistochemical studies in both our cases. The tumour tissue in both the cases was reactive for glial fibrillary acidic protein and epithelial membrane antigen on immunohistochemical analysis but not for synaptophysin and S-100. These findings were consistent with ependymoma. Thus ependymoma should be included in the differential diagnosis of parenchymal tumours of the supratentorial compartment, even if their location is distant from the ventricles.
- Therapeutic Challenges in Management of Stroke with Complications
N Nitin Kumar, NE Bharucha, Jyanti Mani
Background : Four cases of stroke presented to us with different clinical circumstances and complications. Their management and decision making posed a therapeutic dilemma since the data and guidelines for their management is limited at present.
First was a 64 year old lady with prosthetic mitral valve on oral anticoagulants, since 3 years, who presented with (R) basal ganglia bleeding with intraventricular extension without neuro deficits. What is the role of anticoagulants in this case? Second was an elderly 59 year gentleman with 1 month’s history of (R) basal ganglia haematoma who presented with DVT and pulmonary embolism. How should we manage DVT in the setting of an intracerebral bleed and what is the role of anticoagulants?
Third was a 65 year old gentleman with recent fracture of femur operated and followed by recurrent embolic stroke with a background of ischaemic cardiomyopathy who later presented with neurologic transformation of the infarcts. Role of anticoagulants and antiplatelets?
And lastly we have a 70 year old gentleman with RHD with MS with AF presenting with huge (L) MCA infarct. Role of anticoagulants?
Conclusion : These clinical circumstances are not very common. Therapeutic decision making is individualised depending on variables like age, systemic problems and associated complications. Data and guidelines for management of these cases are limited due to lack of large randomized studies for recommendations.
- DACA Aneurysm
Rajiv Kumar, CE Deopujari, R Shah
Aim : To evaluate the clinical, radiological, surgical findings and outcome in patients with DACA aneurysm.
Material and Methods : Over a period of 15 years, 16 cases of DACA aneurysm were retrospectively analysed.
Results : Fourteen patients were operated through interhemispheric approach, one patient operated through ptorimal approach, one patient embolized. Successful clipping was done in all 15 cases. One patient had stormy postoperative course due to vasospasm and died. One patient developed hydrocephalus and needed VP Shunt.
Conclusion : DACA aneurysm are uncommon and difficult aneurysm to clip. Proper strategy for surgery can be determined by evaluation of ACA complex on angiogram and CT and MRI localisation is extremely useful. with experience and microsurgical technique good results can be achieved.
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
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