Publications (41)58.35 Total impact
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Article: Analysis Of Changing paradigms of management in 179 Patients Over 12 Year Period & Proposal Of A New Management Algorithm.
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ABSTRACT: OBJECTIVE: To describe management and outcome in a large cohort of patients with spinal tuberculosis METHODS: 212 patients of spinal tuberculosis treated between Jan 1999-June 2011 of which, 179 patients were included (> 6 months follow-up, mean age- 34.8 years; age range 10-75 years). The cohort was divided into 2 groups (n = 89 and 90 respectively), Group I :1999-2003 and Group II: 2004-2011. RESULTS: There were 93 males. Mean age was 34.8 + 7.2 years (range: 10-75 years). Mean duration of symptoms was 2.4 months. Sensory-motor deficits were present in 167 (93.5%; 74 patients were paraplegic), 156 (87%) had pain, 127 (71.7%) had bladder involvement and extra spinal tuberculosis was present in 36 patients (22.3%). 92% were on prior chemotherapy, 1/5(th) of the total on second-line chemotherapy. Thoracic spine was commonest (n= 86, 57%), followed by cervical (n=50, 29%), craniovertebral junction (22, 15%) and lumbo-sacral spine (n= 20, 10.5%). 146 patients underwent surgery, 68% instrumented fusions and 16% circumferential fusions. Mean follow-up: 20.2 months (range 6-60 months). 89% improved in motor/sensory deficits, 71% improved in pain, 88% improved in bladder symptoms, paraplegia improved in 77%. Group II had higher incidence of cord compression (p<0.01), severe vertebral body (p<0.001) collapse and paraplegia (p<0.001). Group II underwent more instrumented surgeries (p<0.01), especially circumferential fusions (p<0.001). The improvement of paraplegia was better after 2004 (Group II). Bladder symptoms correlated with the timing of surgery (p<0.1) CONCLUSION: Medical treatment is the main stay, however radical, instrumented surgeries should be offered when indicated. Presence of paraplegia should not preclude surgery. A practical management paradigm is also suggested.World Neurosurgery 01/2013; · 0.68 Impact Factor -
Article: A rare case of ventricular diverticulum in a child with occipital encephalocele.
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ABSTRACT: Ventricular diverticula are dilatations of the ventricular system caused by stretching and protrusion of the ventricular wall as a result of severe chronic obstructive hydrocephalus. We report a case of lateral ventricular diverticulum arising from the occipital horn in a patient with occipital encephalocele. To the best of our knowledge, this is a first case of ventricular diverticulum in a patient with occipital encephalocele.Pediatric Neurosurgery 08/2012; 48(1):26-9. · 0.70 Impact Factor -
Article: Large pontine tubercular abscess treated surgically.
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ABSTRACT: Tuberculosis of the central nervous system (CNS) is a life threatening condition with 50% mortality in advanced disease and serious neurological deficits in those who survive. Tuberculous abscess is a rare manifestation of CNS tuberculosis, brainstem involvement being even rarer. The management of these conditions poses a great challenge to the treating physician. We report a case of large tubercular abscess of pons which increased in size on anti-tubercular treatment, but showed excellent improvement following craniotomy and aspiration.British Journal of Neurosurgery 07/2012; · 0.88 Impact Factor -
Article: Chiari III malformation with proatlas abnormality.
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ABSTRACT: Chiari III malformations are extremely rare hindbrain malformations that are associated with a high early mortality rate, or severe neurologic deficits in the survivors. They are characterized by an occipital or cervical encephalocele, along with anomalies commonly seen with the type II malformation. Chiari III in association with proatlas abnormality is very rare. Here we describe a patient with Chiari III malformation associated with occipital condyle hypoplasia.Pediatric Neurosurgery 03/2012; 47(4):295-8. · 0.70 Impact Factor -
Article: Delayed bilateral thalamic bleeding post-ventriculoperitoneal shunt.
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ABSTRACT: Ventriculoperitoneal shunt is one of the most common procedure done by neurosurgeon worldwide. We present a rare case of delayed intracerebral bleed post VP shunt and discuss the possible causes of intracerebral hemorrhage post ventriculoperitoneal shunt and bilateral thalamic bleed. The presumed cause in our case was shunt induced disseminated coagulation profile.Child s Nervous System 06/2011; 27(6):1025-7. · 1.54 Impact Factor -
Article: Association of matrix metalloproteinase-1 gene polymorphism with glioblastoma multiforme in a northern Indian population.
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ABSTRACT: Matrix metalloproteinase-1 (MMP-1) is known to be involved in the pathogenesis of glioma. It damages the extra-cellular matrix to produce invasiveness in cancer tissue, and hence has a direct effect in cancer invasion. The study aims to explore the association of single nucleotide polymorphism of -1607 MMP-1 gene with susceptibility to glioblastoma multiforme (GBM) in northern Indian subjects. One hundred and ten GBM patients and 150 healthy controls were included in this study. 1607 MMP-1 gene was studied by PCR-RFLP; different genotypes being combinations of 1G and 2G allele (1G/1G, 1G/2G and 2G/2G). 2G/2G genotype was significantly associated with GBM patients (OR, 2.24; P = 0.016; 95% CI, 1.16-4.30) as compared to controls. Prevalence of the 2G allele of -1607 MMP-1 polymorphism was significantly greater in GBM patients as compared to controls (62.3 vs 48.3%, OR, 1.76; P = 0.002; 95% CI, 1.23-2.52). This study suggests that the 2G/2G genotype and 2G allele of -1607 MMP-1 polymorphism are associated with an increased susceptibility for developing GBM.Journal of Neuro-Oncology 05/2011; 102(3):347-52. · 3.21 Impact Factor -
Article: An unusual case of 4 level spinal dysraphism: Multiple composite type 1 and type 2 split cord malformation, dorsal myelocystocele and hydrocephalous.
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ABSTRACT: The authors here have reported a rare case of a child with a complex spina bifida with two different levels of split cord malformation (SCM) type 1 and single level type 2, a non terminal myelocystocele, coccygeal dermal sinus, bifid fatty filum and hydrocephalus, which substantiates the neuroenteric canal theory and have further tried to highlight the importance of complete Magnetic resonance imaging (MRI) screening of the whole spine and brain with SCM to rule out other associated conditions. The patient was admitted with a leaking myelocystocele with bilateral lower limb weakness. MRI of whole spine with screening of brain was done. Patient underwent 5 operations in the same sitting- (According to classification given by Mahapatra et al.) removal of SCM type 1a at D7-8; removal of SCM type1c at L2-3; removal of SCM type 2 at D10; repair of non terminal myelocystocele at D6-D10; low pressure ventriculoperitoneal shunt on right side with excision of dermal coccygeal sinus; and, excision of bifid fatty filum. The clinicoradiological findings in our patient further substantiate the multiple accessory neuroenteric canal theory in the development of composite type of SCM. The physical and neurological signs of SCM and nonterminal myelocystocele should prompt the neurosurgeon to consider performing the screening MRI of whole spine with brain to rule out other composite types of SCM and hydrocephalus.Journal of Pediatric Neurosciences 01/2011; 6(1):58-61. -
Article: HEDGEHOG-GLI SIGNALING PATHWAY IN GLIOMAS: CORRELATION WITH HISTOLOGY, GENETIC ALTERATIONS, AND EXPRESSION OF STEMNESS MARKERS
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ABSTRACT: Brain tumors can arise following deregulation of signaling pathways normally activated during brain development. Sonic hedgehog-Gli1 (SHH-Gli1) is one such important pathway whose role has been well established in medulloblastomas; however, the few reports in gliomas have yielded conflicting results. Further, since the SHH-Gli1 pathway plays a critical role in nonneoplastic stem cells, its role in stem-like neoplastic cells needs further evaluation. Hence, in this study, we evaluated 102 gliomas for SHH-Gli pathway activity and correlated with histological type and grade, genetic alterations, and expression of stemness markers NANOG, OCT4, SOX2. The study was performed on 44 grade IV (GBM), 23 grade III (10 AA, 9 AO, 4 AOA), and 35 grade II (20 DA, 9 O, 6 OA) tumors. World Health Organization classification was done and genetic subsets defined based on TP53 mutation, EGFR amplification, and 1p/19q LOH. Real-time polymerase chain reaction was performed for expression of Gli1, SHH, PTCH, NANOG, OCT4, and SOX2. Western blot was done for SHH and Gli1 protein expression. There was inverse correlation of high Gli expression (.1.5) with histological grade (51% grade II, 22% grade III, and 16% grade IV). Two-thirds of GBMs with high Gli showed EGFR amplification versus 25% with low Gli. High Gli1 was associated with expression of SHH and PTCH in 97% and 81% cases, respectively. A significant correlation of high Gli1 with stemness markers was also noted. Thus, 93% of gliomas with high Gli1 had expression of stemness markers versus 38% with low Gli. This study confirms the presence of an active ligand-driven SHH-Gli pathway in a subset of gliomas of all types with inverse correlation to grade. The positive correlation of Gli1 with stemness markers possibly indicates that more differentiated progeny of tumor cells may be reverting to a “stem-like status” by activation of this pathway.NEURO-ONCOLOGY. 11/2010; 12(iv7-iv25-Neuro Oncol (2010) 12(suppl 4): iv7-iv25 doi:10.1093/neuonc/noq116.s2):116.s2. -
Article: Calvarial tuberculosis: Uncommon manifestation of common disease--a series of 21 cases.
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ABSTRACT: Tuberculosis is an endemic disease in developing countries like India. It can involve almost any part of human body. One such, albeit rare, is the extra pulmonary manifestation - tuberculosis of calvaria. There have been many isolated case reports and short series published on this unusual presentation. The aim of this presentation is to acquaint the reader with the varied presentation; to emphasise the role of prompt surgical debridement; as also to stress the role of complete anti-tubercular drug therapy in the management of this rare disease. A retrospective analysis of a total of 21 patients over a period of 10 years period (July 1995 to June 2005). All patients were screened for the evidence of primary pulmonary tuberculosis. As part of their radiological workup, they were subjected to either a CT scan-head or MRI-brain. All patients were surgically managed at the institute. ATT was prescribed for 18 months. Follow-up period ranged from 6 months to 8 years. All patients improved following the completion of therapy with no evidence of recurrence. Calvarial tuberculosis is endemic in developing countries. This disease mainly affects the young population. With the rising incidence of AIDS, neurosurgeons all over the world are more likely to be exposed to this disease. CT-head and MRI-brain is the mainstay for radiological diagnosis. Definitive diagnosis rests on a biopsy report. Surgical debridement followed by anti-tubercular therapy for 18 months is the mainstay of the management of this unusual presentation.British Journal of Neurosurgery 10/2010; 24(5):572-7. · 0.88 Impact Factor -
Article: Bilateral thalamic glioma in a 6-year-old child.
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ABSTRACT: Bithalamic gliomas are extremely rare tumors of central nervous system. Although they are usually benign in nature, their outcome is poor because of the involvement of thalamic nuclei and inadequate surgical excision. Surgery is usually done to get tissue for diagnosis. Role of radiotherapy and chemotherapy is questionable. They are unique in their metabolic and neuroradiological properties. We report herein a 6-year-old male of bithalamic astrocytoma (WHO grade 2) who presented with raised intracranial pressure and tremors in right upper limb. The child had a very huge bithalamic mass which was debulked through the interhemispheric transcallosal approach in order to reduce the mass effect. He had a stormy post-operative course to recover gradually.Journal of Pediatric Neurosciences 01/2010; 5(1):45-8. -
Article: Multiple neural tube defects in the same patient with no neurological deficit.
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ABSTRACT: Congenital deformities involving the coverings of the nervous system are called neural tube defects (NTDs). NTD can be classified as neurulation defects, which occur by stage 12, and postneurulation defects. Cervical meningocele and myelomeningocele are rare spinal dysraphic lesions. Unlike lumbosacral dysraphic lesions, there is often no neurologic deficits and thus the subtle features of cervical cord tethering may be overlooked on imaging. The presence of meningomyelocele and/or encephaloceles at multiple (two or more) sites along the vertebral axis is a very rare event occurring in <1% of cases. Less than 10 cases have been described in the published literature. We are reporting a case of multiple NTD in same patient with no neurological deficit.Journal of Pediatric Neurosciences 01/2010; 5(1):52-4. -
Article: A review of studies on targeting interleukin 4 receptor for central nervous system malignancy.
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ABSTRACT: Despite advances in biomedical sciences, the prognosis of patients with brain tumors remains poor. Effective treatment is lacking for these central nervous system (CNS) cancers. Targeted immunotoxins are a new class of therapeutic approaches that have emerged for the treatment of human cancers. In this approach, tumor antigen or cell surface receptor is targeted by a chimeric fusion protein consisting of an antibody or a ligand and a suicidal gene or toxin to kill tumor cells. In that regard, receptors for interleukin (IL)-4 (IL-4R) have been identified to be overexpressed on a variety of human CNS tumor cell lines and tissue samples including meningioma. In various studies, high grade brain tumor specimens and malignant brain tumor cell lines have been shown to overexpress high-affinity IL-4R, while normal brain samples or cell lines expressed lower levels of these receptors. The structures of IL-4R on CNS tumors have been studied, which demonstrate that these cells express predominantly type II IL-4R. These receptors are functional as IL-4 can cause signal transduction, inhibit growth of some tumor cell lines and increase expression of major histocompatibility antigens and intracellular adhesion molecular-1 (ICAM-1) on some tumor cells lines. To target IL-4R, a chimeric fusion protein composed of IL-4 and truncated Pseudomonas exotoxin has been developed. This cytotoxin is highly cytotoxic to IL-4R positive tumors in vitro and has been reported to be highly effective in pre-clinical animal model of human brain cancer. Several Phase I/II clinical trials for treatment of IL-4R positive cancers have been completed. This review article will summarize pre-clinical and clinical development of IL-4PE cytotoxin.Current Molecular Medicine 09/2009; 9(6):732-9. · 5.10 Impact Factor -
Article: Surgery for optic nerve injury: should nerve sheath incision supplement osseous decompression?
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ABSTRACT: Objective: To evaluate the benefits and risks of performing an optic nerve sheath incision to supplement standard osseous optic canal decompression for traumatic optic neuropathy. Methods: Before-after analysis of 57 cases undergoing optic nerve decompression at a tertiary referral centre from 1988-2006. Fifty-five cases had adequate post surgical follow-up for evaluation for improvement. Group A (n = 35) had decompression of the osseous optic canal and surgical slitting of the optic nerve sheath; Group B (n = 22) had osseous decompression alone. The groups were comparable for age, injury severity, and injury-surgery interval. Main outcome measure: Percentage visual improvement, which was calculated by conversion of the pre- and post-intervention visual acuity measurements to the logarithm of the minimum angle of resolution (logMAR) scale. Results: No significant recovery was noted in subjects with persistent complete blindness (PL-ve vision). In subjects with residual pre-op vision, the quantum of recovery was greater in Group A than in Group B (46% and 33% respectively, p = 0.10). The difference was especially evident in subjects with no optic canal/posterior orbit fracture (p = 0.07). Three cases with the sheath incision developed transient CSF rhinorrhea in the initial experience, but this was subsequently alleviated with modification of surgical technique. Conclusion: The addition of optic nerve sheath incision to osseous decompression may improve recovery in optic nerve injury, especially in subjects without optic canal fracture.Skull Base 07/2009; 19(4):263-71. · 0.66 Impact Factor -
Article: Effect of risk-stratified, protocol-based perioperative chemoprophylaxis on nosocomial infection rates in a series of 31 927 consecutive neurosurgical procedures (1994-2006).
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ABSTRACT: Although the use of prophylactic antibiotics has been shown to significantly decrease the incidence of meningitis after neurosurgery, its effect on extra-neurosurgical-site infections has not been documented. The authors explore the effect of risk-stratified, protocol-based perioperative antibiotic prophylaxis on nosocomial infections in an audit of 31 927 consecutive routine and emergency neurosurgical procedures. Infection rates were objectively quantified by bacteriological positivity on culture of cerebrospinal fluid (CSF), blood, urine, wound swab, and tracheal aspirate samples derived from patients with clinicoradiological features of sepsis. Infections were recorded as pulmonary, wound, blood, CSF, and urinary. The total numbers of hospital-acquired infections and the number of patients infected were also recorded. A protocol of perioperative antibiotic prophylaxis of variable duration stratified by patient risk factors was introduced in 2000, which was chosen as the historical turning point. The chi test was used to compare infection rates. A P value of <0.05 was considered significant. A total of 31 927 procedures were performed during the study period 1994-2006; 5171 culture-proven hospital-acquired infections (16.2%) developed in 3686 patients (11.6%). The most common infections were pulmonary (4.4%), followed by bloodstream (3.5%), urinary (3.0%), CSF (2.9%), and wound (2.5%). The incidence of positive tracheal, CSF, blood, wound, and urine cultures decreased significantly after 2000. Chemoprophylaxis, however, altered the prevalent bacterial flora and may have led to the emergence of methicillin-resistant Staphylococcus aureus. A risk-stratified protocol of perioperative antibiotic prophylaxis may help to significantly decrease not only neurosurgical, but also extra-neurosurgical-site body fluid bacteriological culture positivity.Neurosurgery 06/2009; 64(6):1123-30; discussion 1130-1. · 2.79 Impact Factor -
Article: Outcome after hemorrhage following Gamma Knife surgery for cerebral arteriovenous malformations.
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ABSTRACT: Although the effects of Gamma Knife surgery (GKS) on the risk of hemorrhage are poorly understood, a certain subset of patients does suffer bleeding after GKS. This study was undertaken to analyze the outcome of patients sustaining hemorrhage after GKS; it is the most feared complication of radiosurgical management of cerebral arteriovenous malformations (AVMs). Between May 1997 and June 2006, 494 cerebral AVMs in 489 patients were treated using a Leksell Gamma Knife Model B, and follow-up evaluations were conducted until June 2007 at the All India Institute of Medical Sciences in New Delhi. Fourteen patients who sustained a hemorrhage after GKS formed the study group. In most of these patients conservative management was chosen. The mortality rate was 0% and there was a 7% risk of sustaining a severe deficit following rebleeding after GKS. None of the patients sustained rebleeding after complete obliteration. Patients with Spetzler-Martin Grade III or less had increased chances of hemorrhage after GKS (p < 0.002). The presence of deep venous drainage, aneurysm, venous hypertension, or periventricular location on angiography was common in patients with hemorrhage after GKS. The risk of hemorrhage that remains following GKS for cerebral AVMs is highest in the 1st year after treatment. The present study showed a relatively good outcome even in cases with hemorrhage following GKS, with no deaths and minimal morbidity, further substantiating the safety and efficacy of the procedure.Journal of Neurosurgery 01/2009; 110(5):1003-9. · 2.96 Impact Factor -
Article: Brain death and organ donation in India, where do we stand? A personal experience.
Neurosciences 01/2009; 14(1):98-9. · 0.12 Impact Factor -
Article: Does hemorrhagic presentation in cerebral arteriovenous malformations affect obliteration rate after gamma knife radiosurgery?
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ABSTRACT: Radiosurgery has been widely adopted for the treatment of cerebral AVMs. However radiosurgical treatment of patients with hemorrhagic presentation is fraught with risk of rebleed during latency period. The present study intends to analyze the obliteration rate, time to obliteration and chances of rebleed in patients with hemorrhagic versus non-hemorrhagic clinical presentation in cerebral arteriovenous malformations (AVMs) treated with gamma knife radiosurgery (GKS). Of all the patients with cerebral AVMs treated from May 1997 to June 2006, 157 patients with neuroimaging follow up with digital subtraction angiography harboring 160 AVM nidii formed the study group. The mean age of presentation was 28 years (range, 6-58 years); mean nidus volume being 3.64 cm3 (range, 0.011-36.6 cm3). The mean follow up period was 70 months (range, 13-121 months). All the patients were treated predominantly by primary GKS with use of adjunctive pre-GKS embolization in selected patients. A total of 103 (64%) patients presented with hemorrhage. There was no difference in the obliteration rate (69% versus 67%, p=0.672), mean latency period to obliteration (30 months versus 32 months, p=0.1989) and chances of hemorrhage (4.8% versus 3.5%, p=0.690) in patients with hemorrhagic as compared to non-hemorrhagic presentation. Prior hemorrhage does not affect the outcome after GKS in terms of obliteration rate, latency to obliteration as well as chances of hemorrhage during latency period. Gamma knife appears equally efficacious irrespective of the mode of clinical presentation in the management of cerebral AVMs; a concomitant use of pre-GKS embolization/surgery may be needed in patients with hemorrhagic presentation in selected cases, however.Clinical Neurology and Neurosurgery 07/2008; 110(8):804-9. · 1.58 Impact Factor -
Article: Neural tube defects at separate sites: further evidence in support of multi-site closure of the neural tube in humans.
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ABSTRACT: The presence of MMC at multiple sites or their association with encephalocele is a very rare event. Only few cases of multiple NTDs have been described in world literature in the form of isolated case reports. We report 4 cases of multiple NTDs. We also review the theories of etiopathogenesis of multiple NTDs. The multiple-site closure of NT theory is most useful in describing the occurrence of multiple NTDs in our cases.Surgical Neurology 03/2008; 71(3):353-6. · 1.67 Impact Factor -
Article: Multicentric cerebellopontine angle glioblastoma multiforme.
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ABSTRACT: Posterior fossa glioblastoma multiforme is a very rare childhood tumor with an extremely poor prognosis. There are only few cases of primary cerebellar glioblastoma described in the literature, and primary cerebellar glioblastoma presenting radiologically as a cerebellopontine angle mass lesion has not been reported previously. The authors report a multicentric glioblastoma multiforme in an 11-year-old child presenting predominantly as a cerebellopontine angle mass lesion, who finally expired 2 months after surgery. The presentation was very bizarre and the diagnosis was made only after histopathology examination.Pediatric Neurosurgery 02/2008; 44(3):224-8. · 0.70 Impact Factor -
Article: A clinical scoring system for neurological assessment of high cervical myelopathy: measurements in pediatric patients with congenital atlantoaxial dislocations.
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ABSTRACT: The assessment of response to treatment in pediatric patients with congenital atlantoaxial dislocation (AAD) is performed using a disability grading system but may be better determined by a score based on clinical parameters. This study proposes a scoring system based on a comprehensive neurological examination to assess surgical outcome in these patients. Sixty-seven patients with congenital AAD aged 14 years or younger were included and analyzed prospectively. A scoring system based on six factors (motor power, gait, sensory involvement, sphincteric involvement, spasticity, and respiratory difficulty) was designed at the beginning of the study and all patients were assessed using this score as well as the Di Lorenzo's grade preoperatively, postoperatively, and at the time of each follow-up visit. There was a very high incidence of occipitalized arch of atlas and fusion of the second and third cervical vertebrae in the irreducible variety. Most patients were classified in poor grades preoperatively; however, the changes in score were seen more often when using the scoring system we developed compared with the Di Lorenzo's grade. Our score also corroborated better with the clinical improvement. The clinical profiles of pediatric patients with AAD are similar with a higher incidence of atlas arch anomalies in patients with irreducible AAD. A scoring system based on clinical parameters is proposed for clinical evaluation of such patients. This system is easy to use and interpret and is more sensitive to the changes in the neurological status of patients.Neurosurgery 12/2007; 61(5):987-93; discussion 993-4. · 2.79 Impact Factor
Top co-authors
Top Journals
Institutions
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2002–2012
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All India Institute of Medical Sciences
- Department of Neurosurgery
New Delhi, NCT, India
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2007–2011
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Sanjay Gandhi Post Graduate Institute of Medical Sciences
- Department of Neurosurgery
Lucknow, Uttar Pradesh, India
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2000
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National Institute of Immunology
New Delhi, NCT, India
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