Sanjay Behari

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lakhnau, Uttar Pradesh, India

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Publications (160)211.1 Total impact

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    ABSTRACT: The authors present a case of 15 years male child who presented with neck pain and progressive ascending quadriparesis. Magnetic resonance imaging showed lytic mass involving C5 and C6 vertebra with soft tissue extension. Surgical excision of mass done using anterior cervical approach. Postoperatively, patient showed improvement in spasticity and power. Histopathological examination of mass was suggestive of juvenile xanthogranuloma (JXG). At 6 months follow-up, patient was improving without any evidence of recurrence. Only 12 cases of JXG of spine have been reported till date including only four cases involving the cervical spine and among these four cases only two were of pediatric age group.
    01/2015; 10(1):57. DOI:10.4103/1793-5482.151525
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    ABSTRACT: An 11-year-old boy presented with holocranial headache associated with vomiting and heaviness in right paranasal region. On examination, he had left sided upper motor neuron type facial palsy along with a subtle ipsilateral hemiparesis (grade 4/5 Medical Research Council). Magnetic resonance imaging brain revealed a contrast enhancing large well-defined extra-axial mass lesion in right middle cranial fossa with extension into the infratemporal fossa. The mass was excised in two stages. Histopathology was suggestive of clear cell meningioma (CCM). Supratentorial pediatric CCM is a rare entity. The case is discussed along with review of literature on this rare clinico-pathological entity.
    01/2015; 10(1):53. DOI:10.4103/1793-5482.151520
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    ABSTRACT: Trends in pre- and postoperative fluid, electrolyte and osmolarity changes, and incidence of diabetes insipidus (DI) were assessed in pediatric patients with anterior visual pathway gliomas (AVPGs). Thirty-three patients with AVPGs (age < 16 years) were divided into two groups: (1) no hypothalamic involvement [NHI; n = 17 (51.5 %) including optic (5, 15.2 %); chiasmal (5, 15.2 %); and optico-chiasmal (7, 21.2 %)] and (2) hypothalamic involvement [HI; n = 16 (48.5 %) including chiasmal-hypothalamic (12, 36.4 %) and optico-chiasmal-hypothalamic (4, 12.1 %)]. Frontotemporal transylvian decompression/biopsy was undertaken in 32 patients, while one patient (with severe diencephalic syndrome) was treated conservatively. Their endocrinal and fluid/electrolyte balance, serum osmolarity, and DI status were noted. Chi-square test compared clinical/endocrinological parameters, and unpaired T test evaluated mean daily water/electrolyte changes (p value < 0.05: significant). Significant visual deterioration (perception of light (PL) positive (left: n = 4; right: n = 4) and PL negative (left: n = 5; right: n = 5) was encountered due to optic atrophy. Larger lesions (>3 cm), hydrocephalus [(NHI: n = 7, 41.18 %; HI: n = 12, 75 %), endocrinopathies (p = 0.047), Na(+)/K(+) derangements, and preoperative DI (n = 8, p = 0.004)] were present in the group HI. Increased postoperative urine output (almost double in those with hypothalamic involvement) and hypernatremia/hyperkalemia were seen in group HI until the sixth postoperative day (p < 0.05). Two patients with progressive hypernatremia without increased urine output showed dehydration on central venous pressure monitoring and improved with vasopressin administration. Five patients [NHI: n = 4 (23.5 %); HI: n = 1 (6.3 %)] had neurofibromatosis types I and 3 (NHI: n = 1, 5.9 %; HI: n = 2, 12.5 %) had a diencephalic syndrome. Hypothalamic infiltration significantly increases the incidence of DI and fluid and electrolyte disturbances. Strict vigilance over postoperative fluid balance is mandatory during the first postoperative week. Rapidly rising serial serum sodium values without increased urine output mandates immediate central venous pressure measurement to detect DI associated with dehydration.
    Child s Nervous System 12/2014; 31(3). DOI:10.1007/s00381-014-2606-1 · 1.16 Impact Factor
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    ABSTRACT: Surgical management of foramen magnum (FM) tumors is challenging by virtue of their location and vital neurovascular relationships. The ideal approach to anterior/anterolateral tumors continue to evoke controversy even in the modern era. In this article, we present and discuss our experience in the surgical management of these tumors. This retrospective study includes 29 consecutive patients (mean age 36.6 years, M: F = 2.63:1) of extramedullary tumors at the surgical foramen magnum, operated at our center, between 2007 and 2012. Their mean duration of symptoms was 14. 6 months. A majority of the patients presented with motor symptoms (quadri/paraparesis, n = 21, 72.4%), neck pain with/without suboccipital radiation (n = 16, 55.2%) and sensory symptoms like tingling/numbness (n = 16, 55.2%). There were nine extradural (31%) and 20 intradural tumors (69%). Most of the tumors were located posterolateral to the neuraxis (n = 13, 44.8%). Nerve sheath tumors (n = 11, 38%) and meningiomas (n = 5, 17.2%) were the most commonly encountered histologies in our series. The standard posterior approach was the most frequently employed surgical approach (n = 20, 69%). Operative mortality and morbidity were 3.4 and 18.9%, respectively. At a mean follow-up of 27.3 months, 13 out of the 18 available patients improved. A majority of the foramen magnum tumors are amenable to excision via the standard posterior approach. Small anterior dural-based meningiomas/recurrent tumors may require a lateral approach like the far lateral approach.
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    ABSTRACT: Background:In some cases of spontaneous subarachnoid hemorrhage (SAH), the cause of bleed remains obscure on initial evaluation. These patients may harbor structural lesions. We aim to determine the utility of repeat angiogram in these subsets of patients.Methods:In this prospective study, patients with SAH with a negative computed tomographic angiogram (CTA) and digital subtraction angiogram (DSA) were included. A repeat angiogram was done after 6 weeks of initial angiogram. Patients were divided into perimesencephalic SAH (PM-SAH) and diffuse classic SAH (Classic-SAH) groups. Outcome was determined by modified Rankin score (mRS).Results:A total of 22% (39/178) of all SAH were angio-negative. A total of 90% (n = 35) of these were in Hunt and Hess grade 1-3. A total of 22 patients had PM-SAH and 17 had a Classic-SAH. Repeat angiogram did not reveal any pathology in the PM-SAH group, whereas two patients with Classic-SAH were found to have aneurysms. At 6 months follow-up, 95% patients of PM-SAH and 83.3% of Classic-SAH had mRS of 0.Conclusion:Repeat angiogram is probably not necessary in patients of PM-SAH and they tend to have better outcome. Classic-SAH pattern of bleed is associated with fair chances of an underlying pathology and a repeat angiogram is recommended and these cases and they have poorer outcome.
    Surgical Neurology International 08/2014; 5:125. DOI:10.4103/2152-7806.138367 · 1.18 Impact Factor
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    ABSTRACT: Background: Aneurysms of proximal (A1)-segment of anterior cerebral artery (ACA) constitute <1% of all intracranial aneurysms. Aim: Management dilemmas of A1-segment aneurysms were studied utilizing a new classification based upon their location on the longitudinal and circumferential axis of A1-segment. Setting and Design: Tertiary care referral center. Materials and Methods: This is a retrospective analysis of 14 patients (0.98%; mean age: 38.02 ± 15.74 years) with A1-segment aneurysms. The data collected included clinical features, computed tomography (CT) scan and CT-angiography (CTA)/digital subtraction angiography (DSA) findings, modified Hunt and Hess (H and H) grade, surgical steps and difficulties encountered. Results: The modified Hunt and Hess (H and H) grades in the 14 patients were: grade I in two, grade II in two, grade III in four, grade IV in five and grade V in 1. The mean ictus-admission duration was 5.07 ± 2.30 days (range: 1-10 days). Multiple aneurysms were two. Thirteen patients underwent clipping and one, wrapping. Bilateral lateral ventricle hemorrhage occurred in 8 (66%) patients and frontal intracerebral hematoma in 2 (16.66%) patients. In one patient, the aneurysm could only be detected following the third angiogram. A1-aneurysms were classified as proximal (n = 6), distal (n = 7), and mid-segment (n = 1); and, anterior (n = 2), posterior-inferior (n = 7) and posterior-superior (n = 5). Follow-up (range: 6 months-10 years, mean: 2.9 years) recovery (assessed using Modified Rankin's score or mRS) correlated with preoperative status. The preoperative H and H grade and follow-up mRS status were as follows: H and H I (n = 2): mRS 0 (asymptomatic, n = 2); H and H II (n = 2): mRS 1 (minor symptoms without disability, n = 2); H and H III (n = 4):mRS 1 (n = 2) and mRS 2 (slight disability but performing unassisted activities of daily living, n = 1); H and H IV (n = 5): mRS 3 (moderate disability, requiring help for daily living but unassisted walking, n = 2) and mRS 4 (moderately severe disability, requiring help for daily living and walking, n = 2). One patient each from H and H grade III, IV and V died (mRS 6) during treatment due to severe vasospasm, pneumonitis and septicemia. Conclusions: A1-segment aneurysms have unique properties: rupturing of small-sized aneurysms; multiplicity; undetectable on initial imaging; frontal lobar/intraventricular bleeding; origin from main trunk and not bifurcating points; neck obscuration by A1-trunk; close proximity to perforators; and, associated A1-segment and ACA anomalies. A new classification identifies surgical difficulties inherent in different sites of origin of A1-aneurysms.
    Neurology India 07/2014; 62(4):410-416. DOI:10.4103/0028-3886.141284 · 1.08 Impact Factor
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    ABSTRACT: Spinal intramedullary tuberculoma (SIT) is a rare manifestation of neurotuberculosis. Concurrent SIT and intracranial tuberculoma are further unusual. Most of these tuberculomas respond completely to medical therapy, and surgical excision is seldom required. In this report, we describe a 17-year-old boy who developed cervical intramedullary tuberculoma at C3-C6 level with a concurrent lesion involving the right cerebellar hemisphere while on treatment for tubercular meningitis. This patient had paradoxical increase in size of the cervical lesion even though the cerebellar lesion showed regression in size. In this article, we discuss the paradoxical response to anti-tubercular therapy in central nervous system tuberculosis, possible causes of nonresolution of tuberculoma on medical therapy and evaluate the role of surgery in these cases.
    Journal of Pediatric Neurosciences 05/2014; 9(2):162-5. DOI:10.4103/1817-1745.139336
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    ABSTRACT: Surgical excision of rare, large-to-giant posterior third ventricular (PTV) meningiomas [including velum-interpositum meningiomas (VIM; postero-superior venous complex displacement; without falco-tentorial attachment) and falco-tentorial meningiomas (FTM; falco-tentorial attachment; displacing major veins antero-inferiorly)] is extremely challenging. To study the management nuances in the excision of large-to-giant PTV meningiomas. Tertiary care referral center. Four patients with large (>3 cm; n = 2) and giant (>5 cm; n = 2) meningiomas (FTM = 2; VIM = 2, mean tumor size = 4.9 cm) underwent occipital transtentorial approach (OTT) for tumor excision. One also underwent a second-stage supracerebellar infratentorial (SCIT) approach. The side of approach was determined by lateral tumor extension and venous displacement (right = 3, left = 1). Near-total removal or subtotal excision (<10% remaining) with radiotherapy was performed in 2 patients each, respectively. At follow-up (mean: 14.75 months), clinical improvement without tumor recurrence/re-growth was achieved. Extent of excision was determined by position of great vein of Galen; tumor attachment to falco-tentorium or major veins; its consistency; its lateral and inferior extent; and, presence of a good tumor-neuraxial arachnoidal plane. OTT is the preferable approach for large-to-giant meningiomas as it provides a wider corridor and better delineation of tumor-neurovascular arachnoidal interface.
    Neurology India 05/2014; 62(3):290-5. DOI:10.4103/0028-3886.136934 · 1.08 Impact Factor
  • Sanjay Behari
    Neurology India 03/2014; 62(2):121-3. DOI:10.4103/0028-3886.132316 · 1.08 Impact Factor
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    ABSTRACT: Increased glycine concentration in the brain is associated with altered metabolism in cancer and can be detected by using in vivo MR spectroscopy. This has been proposed as a marker for grade IV gliomas; however, little is known about the potential significance and frequency of in vivo glycine observation. The purpose of this study was to examine the rate of occurrence and spatial distribution of glycine observation with respect to other MR imaging parameters. Data from volumetric whole-brain MR spectroscopic imaging of 59 subjects with glioma were analyzed with glycine included in the spectral model. The associations of the signal amplitude and spatial distributions of glycine with findings from contrast-enhanced T1, perfusion, and diffusion MR imaging were then examined. Glycine was detected in 24% of all studies, though with a wide range of signal amplitude and extent of the spatial distributions. While more commonly seen in grade IV tumors (42% of studies), relatively large concentrations were also detected in grade II and III gliomas. Coanalysis with other metabolites indicated a strong association with choline and that glycine was frequently seen to be overlapping with, and adjacent to, areas of high lactate concentration. Increased glycine was always associated with contrast enhancement and areas of increased cerebral blood flow, but without any clear association with other image parameters. Detection of increased glycine in gliomas appears to identify a subgroup of tumors and areas of increased proliferation.
    American Journal of Neuroradiology 01/2014; DOI:10.3174/ajnr.A3845 · 3.68 Impact Factor
  • 01/2014; 3(1):19. DOI:10.4103/2277-9167.131997
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    ABSTRACT: We report a rare case of a post-traumatic subdural hygroma occurring with a giant frontotemporal arachnoid cyst in a 6-year old child and discuss its pathogenesis and management implications. Awareness regarding the association of a subdural hygroma associated with an arachnoid cyst is of immense clinical importance as the former may precipitate intracranial hypertension in a previously asymptomatic arachnoid cyst and yet may remain undetectable on a CT scan.
    12/2013; DOI:10.1016/j.ijnt.2013.11.003
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    ABSTRACT: Studies of brain tumors have identified altered tissue metabolism and water diffusion in MRI normal appearing tissue regions. In this retrospective study the relationship of these imaging measures with tumor grade in gliomas was investigated. MR spectroscopic imaging of whole brain and mean diffusivity (MD) measurements were obtained in subjects with untreated glioma and from normal control subjects. Mean metabolite values for N-acetylaspartate (NAA), total creatine (Cre), and total choline (Cho) were obtained in gray- and white-matter regions for the hemisphere contralateral to the tumor location, and MD values were obtained from contralateral normal-appearing white matter. Analyses tested for differences in mean values between subject groups while accounting for age. Analysis demonstrated increased NAA/Cre and MD, and decreased Cho/NAA for all tumor grades relative to control values. Differences between tumor grades were also observed for NAA, NAA/Cre, and Cho/NAA. Abnormal values of water diffusion were also observed, but with only a weak association between alterations in diffusion and tissue metabolites. This study supports previous observations of altered tissue metabolism and water diffusion in normal-appearing white matter while additionally finding differences of metabolite values in gray matter and an association with tumor grade.
    Journal of neuroimaging: official journal of the American Society of Neuroimaging 11/2013; 24(6). DOI:10.1111/jon.12063 · 1.82 Impact Factor
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    ABSTRACT: PURPOSE: To modify the generalized tracer kinetic model (GTKM) by introducing an additional tissue uptake leakage compartment in extracellular extravascular space (LTKM). In addition, an implicit determination of voxel-wise local arterial input function (AIF) C(p) (t) was performed to see whether these changes help in better discrimination between low- and high-grade glioma using dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI). MATERIALS AND METHODS: The modified model (LTKM) was explored and fitted to the concentration-time curve C(t) of each voxel, in which the local AIF C(p) (t) could be estimated by a time invariant convolution approximation based on a separately measured global AIF C(a) (t). A comparative study of tracer kinetic analysis was performed on 184 glioma patients using DCE-MRI data on 1.5T and 3T MRI systems. RESULTS: The LTKM analysis provided more accurate pharmacokinetic parameters as evidenced by their relative constancy with respect to the length of concentration-time curve used. In addition, LTKM with local AIF resulted in improved discrimination between low-grade and high-grade gliomas. CONCLUSION: LTKM with local AIF provides more accurate estimation of physiological parameters and improves discrimination between low-grade and high-grade gliomas as compared with GTKM. J. Magn. Reson. Imaging 2013;. © 2013 Wiley Periodicals, Inc.
    Journal of Magnetic Resonance Imaging 09/2013; 38(3). DOI:10.1002/jmri.24021 · 2.79 Impact Factor
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    ABSTRACT: To modify the generalized tracer kinetic model (GTKM) by introducing an additional tissue uptake leakage compartment in extracellular extravascular space (LTKM). In addition, an implicit determination of voxel-wise local arterial input function (AIF) Cp (t) was performed to see whether these changes help in better discrimination between low- and high-grade glioma using dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI). The modified model (LTKM) was explored and fitted to the concentration-time curve C(t) of each voxel, in which the local AIF Cp (t) could be estimated by a time invariant convolution approximation based on a separately measured global AIF Ca (t). A comparative study of tracer kinetic analysis was performed on 184 glioma patients using DCE-MRI data on 1.5T and 3T MRI systems. The LTKM analysis provided more accurate pharmacokinetic parameters as evidenced by their relative constancy with respect to the length of concentration-time curve used. In addition, LTKM with local AIF resulted in improved discrimination between low-grade and high-grade gliomas. LTKM with local AIF provides more accurate estimation of physiological parameters and improves discrimination between low-grade and high-grade gliomas as compared with GTKM. J. Magn. Reson. Imaging 2013;38:677-688. © 2013 Wiley Periodicals, Inc.
    Journal of Magnetic Resonance Imaging 09/2013; 38(3):spcone. DOI:10.1002/jmri.24404 · 2.79 Impact Factor
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    ABSTRACT: Osteoblastoma (OB) is a rare bony neoplasm constituting around 1% of all primary bone tumors. Although the vertebrae and long bones are the most common sites affected by OB, skull remains a relatively uncommon site of occurrence. Aggressive variant of OB is histologically intermediate between an indolent conventional OB and a malignant osteosarcoma. To the best of our knowledge, aggressive osteoblastoma (AO) affecting the craniovertebral junction has not been previously described in the literature. In this report, we present a 34-year-old gentleman who presented with a mass involving the left side of the neck and oral cavity along with ipsilateral lower cranial nerve paresis. Computed tomography and magnetic resonance imaging scans of the craniovertebral junction revealed a heterogeneously enhancing expansile lesion with areas of destruction involving the clivus, left sided jugular foramen and left side of first two cervical vertebras. Angiography showed distortion of the V3 segment of the left vertebral artery and shift of the ipsilateral internal carotid artery. The tumor was maximally excised through far lateral approach. Histopathologic examination revealed a diagnosis of AO. The patient was referred for radiotherapy for the residual tumor and was doing well at 5 months follow-up.
    Journal of craniovertebral junction and spine 07/2013; 4(2):69-72. DOI:10.4103/0974-8237.128533
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    ABSTRACT: A wide variety of congenital anomalies are observed around the craniovertebral junctional area. However, hypertrophied unilateral lateral mass of atlas in association with chiari-1 malformation leading to myelopathy is extremely uncommon. Herein we report a case of 28-year-old female who presented to us with a high cervical compressive myelopathy. Imaging revealed bony hypertrophy involving right sided C1 lateral mass along with chiari malformation-type 1. She underwent transoral as well as posterior decompression followed by occipito-cervical fusion. The authors discuss their case in light of other such reported cases and present a review of the literature.
    Journal of craniovertebral junction and spine 07/2013; 4(2):73-5. DOI:10.4103/0974-8237.128534
  • Acta Neurochirurgica 06/2013; 155(8). DOI:10.1007/s00701-013-1776-z · 1.79 Impact Factor
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    ABSTRACT: BACKGROUND: This prospective study attempts to study the clinico-radiological differences between patients with syndromic AAD (SAAD), non-syndromic AAD (NSAAD), and AAD with Klippel-Feil anomaly (AADKFA) that may impact management. METHODS: In 46 patients with AAD [SAAD (including Morquio, Down, Larson and Marshall syndrome and achondroplasia; n = 6); NSAAD(n = 20); and, AADKFS (n = 20)], myelopathy was graded as mild (n = 17, 37 %), moderate (15, 32.5 %) or severe (14, 30.5 %) based on Japanese Orthopaedic Association Score modified for Indian patients (mJOAS). Basilar invagination (BI), basal angle, odontoid hypoplasia, facet-joint angle, effective canal diameter, Ishihara curvature index, and angle of retroversion of odontoid and vertebral artery (VA) variations were also studied. STATISTICS: Clinico-radiological differences were assessed by Fisher's exact test, and mean craniometric values by Kruskal-Wallis test (p value ≤ 0.05 significant) RESULTS: Incidence of irreducible AAD in SAAD (n = 0), NSA AD (11.55 %) and AADKFS (n = 18.90 %) showed significant difference (p = 0.01). High incidence of kyphoscoliosis (83 %) and odontoid hypoplasia (83 %) in SAAD, and assimilated atlas and BI in NSAAD and AADKFA groups were found. In AADKFA, effective canal diameter was significantly reduced(p = 0.017) with increased Ishihara index and increased angle of odontoid retroversion; 61 % patients had VA variations. Thirty-five patients underwent single-stage transoral decompression with posterior fusion (for irreducible AAD) or direct posterior stabilization (for reducible AAD). Postoperative mJOAS evaluation often revealed persistent residual myelopathy despite clinical improvement. CONCLUSIONS: Myelopathy is induced by recurrent cord trauma due to reducible AAD in SAAD, and compromised cervicomedullary canal diameter in NSAAD and AADKFA. SAAD in children may be missed due to incomplete odontoid ossification or coexisting angular deformities. In AADKFA, decisions regarding vertebral levels to be included in posterior stabilization should take into consideration intact intervening motion segments and compensatory cervical hyperlordosis. Following VA injury, endovascular primary vessel occlusion/stenting across pseudoaneurysm preempts delayed rehemorrhage.
    Acta Neurochirurgica 05/2013; 155(7). DOI:10.1007/s00701-013-1717-x · 1.79 Impact Factor

Publication Stats

1k Citations
211.10 Total Impact Points

Institutions

  • 1996–2014
    • Sanjay Gandhi Post Graduate Institute of Medical Sciences
      • Department of Neurosurgery
      Lakhnau, Uttar Pradesh, India
  • 2013
    • Indian Institute of Technology Kanpur
      • Department of Mathematics and Statistics
      Kānpur, Uttar Pradesh, India