Corrigendum:The article published in Nepal Journal of Neurosciences 2018;15:10-18 by Amit Thapa et al was mistakenlypublished with wrong affi liation of some of the co-authors. The correct affi liation of the co-authors should read asBikram Shakya, MBBS, MS, MChLecturerDepartment of Neurological SurgeryKathmandu Medical College Teaching Hospital (KMCTH)Sinamangal, Kathmandu, NepalDipesh Kumar Yadav, MBBSMedical OfficerDepartment of Neurological SurgeryKathmandu Medical College Teaching Hospital (KMCTH)Sinamangal, Kathmandu, NepalKarjome Lama, MBBSMedical OfficerDepartment of Neurological SurgeryKathmandu Medical College Teaching Hospital (KMCTH)Sinamangal, Kathmandu, Nepal Abstract: We are witnessing changing patterns in stroke in our practice. Documenting changes in epidemiological profile are important for public health policy. We hereby present analysis of patients with stroke to stress upon the dynamics and update the improvement in their care. We retrospectively studied all patients with first time stroke presenting in Kathmandu Medical College Teaching Hospital during June 2012 till November 2015. Diagnosis was made on clinico-radiological basis with prospective follow up for at least 1 year from the event. Risk factors as well outcome in terms of Glasgow outcome score were studied. Statistical analysis was performed on SPSS. A total of 1017 patients of 16260 patients admitted to the hospital during the study period had first time stroke, a hospital based annual incidence of stroke of 64 per thousand admissions was hence calculated. Mean age was 55 years with 60.5% males. 503 patients (49.5%) had infarction with 20 patients having hemorrhagic conversion while 3 had TIA. 50.2% had hemorrhagic stroke. 56.7% females had ischemic stroke whereas 54.9% of males had hemorrhagic stroke (p=0.002). Common risk factors like HTN (54.7%), Smoking (41.5%), Alcohol (39.2%), dyslipidemia (34.1%) and DM (4.8%) were seen with stroke however, active smoker were more at risk of hemorrhagic stroke (p=0.000) while diabetic patients for ischemic stroke (p=0.000). Due to availability of neurosurgical services, 14.6% patient could undergo procedures like decompressive craniectomy, hematoma evacuation, CSF diversion procedures and carotid endarterectomy for stroke. 66.9% patients required surgical intervention within 48 hours of admission. We had 30 days mortality of 0.5% mortality in this series (majority in hemorrhagic stroke), however over 3 years duration of study mortality rose to 8.3% (majority in ischemic stroke). Almost 88.5% patients achieved mRS< Nepal Journal of Neuroscience, Volume 15, Number 1, 2018 11 2 over a period of 3 years. Persistent vegetative state was seen in 7.6% cases after 1 year. We observe a very high incidence of hemorrhagic stroke in general with higher than reported proportion of females being involved with ischemic stroke in our series. Most of the vegetative state conditions occurred in ischemic stroke patients however early mortality was common in hemorrhagic stroke. This change in pattern of stroke as well as need of surgical intervention mandates early involvement of neurosurgical services. Poor long term prognosis in ischemic stroke may be reversed by timely thrombolytic services and prevented by mitigating risk factors. Nepal Journal of Neuroscience 15:10-18, 2018

The effect of decompressive craniectomy (DC) on survival and functional outcome in traumatic brain injuries (TBI) is far from satisfactory. Additional modalities including cisternal drainage (CD) that provides good control of refractory intracranial pressure (ICP) intraoperatively need careful scrutiny. Two centre retrospective superiority study with one centre offering only standard decompressive craniectomy (DC) i.e. Group 1 and the other centre supplementing cisternal drainage (CD) to standard DC i.e. Group 2 was conducted. Consecutive patients with traumatic brain injury with signs of brain herniation or CT scan showing mass lesion or diffuse brain edema or midline shift or with GCS less than 9 or rapid fall in GCS over 2 points with persistently raised ICP of 25 mmHg over 15 minutes between August 2012 and July 2017 were included. The primary outcome was rating on Glasgow Outcome Scale (GOS) at 6 months post operatively, with GOS (1-3) categorized as ‘Unfavorable’ and GOS (4,5) as ‘Favorable’. Patients either received DC alone (Group 1=73 patients, 48.7%) or DC with CD (Group 2=77 patients, 51.3%). 107 (71.3%) severe, 36 (24%) moderate, and 7 (4.7%) mild head injuries cases received 72 unilateral and 78 bilateral DC. GOS 1 was observed in 32 DC only group (43.8%) and 22 DC plus CD group (28.6%) (p=0.052), an absolute risk reduction of 15.2% was found. Outcome (favorable sun favorable) against all strata of head injury severity, predominant radiological feature, laterality of surgery, and patient characteristics across the two groups were statistically not significant, however the groups were statistically significantly different on age and GCS at presentation (p=0.016 & 0.034 consecutively). Distinct survival benefit in patients with traumatic brain injury receiving cisternal drainage during decompressive craniectomy did not translate to better functional outcome.

Background:The excellent visualization and minimally invasive approach employed in endoscopic endonasal procedures has now revolutionized the pituitary surgery, replacing the transnasal microscopic technique worldwide. However, it involves major shift in hand-eye co-ordination from static 3 dimensional images of microscope to 2 dimensional endoscopic images hence demands training and inter-disciplinary approach. Here we present our experiences in learning and developing a safe endonasal transsphenoidal endoscopic approach to resect pituitary adenomas.Methods: This prospective study was jointly conducted in the departments of ENT and Neurologicals surgery Kathmandu Medical College, Nepal, from September 2014 to August 2016. The endoscopic approach to the sphenoid sinus was performed by an Otolaryngologist and ablative surgery by Neurosurgeon. The ease of procedure, intra operative challenges, surgical cure, post-operative cerebro spinal fluid (CSF) leaks and postoperative complaints were analyzed.Results: Sixteen consecutive patients with pituitary adenoma (macro adenoma=13, micro adenoma =3) were analyzed. There were three intraoperative CSF leak, managed successfully. Two patients developed transient diabetes insipidus and surgical cure rate was 90%. No case had to be switched over to traditional microscopic route due to technical failure. There was no mortality. Conclusions:The endoscopic endonasal transsphenoidal approach to pituitary tumors is a safe and minimally invasive procedure, which can be employed safely in any of our centers in Nepal, equipped with endoscopic sinus surgery and endoscopically trained ENT and Neurosurgeons. A multi disciplinary approach provides good access, greater tumor excision and excellent postoperative follow up.

Background: With advancing treatment of stroke patients, their mortality has decreased but morbidity and disability has increased. Hence, it becomes increasingly important to find the measures to improve these areas. The study aims to assess the quality of life (QOL) and disability in stroke survivors at least six months post stroke. Methods: Descriptive, cross sectional design was used to assess the QOL and disability in stroke patients attending Neuromedicine and Neurosurgery out-patient departments of Kathmandu Medical College. Data was collected purposively using interview from 155 respondents. QOL was assessed using Health Related Quality of Life in Stroke Patients (HRQOLISP-40) and disability was measured by using World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Analysis was done using Pearson’s correlation and Mann Whitney U test. Results: The QOL was found to be best in the ‘ecosocial’ and worst in the ‘soul’ domain. In disability, patients scored the best in ‘Getting along with people’ and ‘self-care’ domains and worst in the ‘life activities: school/ work’ domain. Respondents with hemorrhagic stroke, only one admission and those who did not exercise had better QOL. Patients with less than 10 years of formal education, those not earning and those with comorbidities had more disability. Correlation analysis showed better QOL with lesser age, higher monthly family income and higher Barthel index whereas higher disability was found in respondents with higher age and lower Barthel index. Conclusions: Disability in stroke patients needs to be addressed inorder to improve their QOL. The domains affected should be given attention during rehabilitation of stroke patients.

Background: One of the common neurosurgical conditions is depressed skull fracture. It could be simple or compound type. This study aims to assess the outcome of the patients with depressed skull fracture.Material and Methods: Retrospective cohort study of the patients admitted with depressed skull fracture after sustaining blunt head trauma was done. Data were collected with regard to age, sex, mode of injury, time delay, Glasgow coma scale (GCS), epilepsy, focal neurological deficit, CT scan findings, treatment given, infection and Glasgow outcome scale (GOS). Results: Total of 50 patients were included, of which 68% were male and 32% were female with mean age of 21.02 ± 18.78 years. Fall was the commonest mode of injury constituting 60% of patients, 80% of the patients presented within 12 hours of injury and 86% of them sustained mild head injury. Fracture was of compound type in 56% and simple type in 44%. Wound debridement and suturing was performed in 26% and Craniotomy and elevation was done in 42%. Dural tear was observed in 47% who were operated. Early epilepsy was seen in 4% and late epilepsy in 2% and infection rate of 2%. Outcome was Favorable in 98% patients. Significant correlation noted between admission GCS with GOS (p=0.006) whereas no correlation was seen between time of presentation with infection (p=0.09).Conclusion: Mild head injury was the commonest form of presentation. Most of the patients have unfavorable outcome and with low risk of infection and epilepsy. Good admission GCS correlated with favorable outcome.Keywords: blunt head trauma; depressed skull fracture; epilepsy; infection; outcome.

Materials and Methods: Results:Conclusion:

Background: Since 2012 we have been routinely conducting Kathmandu Medical College Teaching Hospital Ultrasound Trauma Life Support (KUTLS) courses. Unlike detailed examination of an organ with an ultrasound as performed by radiologist, we profess sonoscopic based problem solving approach for the clinician as he uses his stethoscope. The initial skepticism to use of sonoscope in a systematic methodical way has been seen to be fading.Objectives: We conducted a survey to see the change in knowledge and attitude of the clinicians to use of sonoscopy after a short focused but systematic training program.Methodology: We studied the questionnaire based feedback forms of the participants in the last 5 course of Kathmandu Medical College Teaching Hospital Ultrasound Trauma Life Support (KUTLS) workshop and analyzed the change in perception and understanding as well as improvement in scores of the post test.Results: A total of 152 delegates actively participated in five sessions workshops since 2012. The most common reasons to attend the workshop was to develop the skill with sonoscope, 95% participant did not have any past experience of sonoscopy. Almost 98% scored more than 75% in the post-workshop test compared to only 33% in the pre-workshop test suggesting fast learning curve among the learners. Almost 100% were convinced with the applicability of the USG and had wished to change their practice.Conclusion: A structured use of sonoscope would be helpful in clinical practice particularly in solving difficult questions urgently in trauma and Intensive Care Unit. Workshops and seminars help change attitude and practice of the participants even with no prior formal training in ultrasound.

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