V K Khosla

Postgraduate Institute of Medical Education and Research, Chandīgarh, Union Territory of Chandigarh, India

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Publications (93)117.2 Total impact

  • [show abstract] [hide abstract]
    ABSTRACT: OBJECTIVE: The quality of life and functional outcome may be significantly impaired in patients of aneurysmal subarachnoid hemorrhage. The purpose of the present study was to assess the status of patients undergoing surgical clipping of intracranial aneurysms in a long term follow-up and to identify factors affecting outcome. METHODS: 494 patients who underwent clipping of their intracranial aneurysms with a minimum follow-up of one year after their discharge were studied. Preoperative factors such as age, Hunt & Hess grade, Fisher scale, time interval between ictus and surgery and site of aneurysm were recorded. The long term status was assessed by Glasgow outcome scale (GOS), modified Rankin Scale (MRS), Barthel Index (BI) and Mini-mental state examination (MMSE). RESULTS: Site of aneurysm and ictus-surgery interval did not have any effect on any parameter at long term follow-up. Majority of patients who were discharged continued to improve as measured by GOS, MRS and BI. However a significant proportion of patients had impaired MMSE at long term follow-up. Multivariate analysis showed a significant effect of age on MMSE and also a positive correalation between number of aneurysms and GOS. CONCLUSIONS: Most patients who survived and were discharged continued to improve in the postoperative period even though the immediate postoperative outcome was not favourable in many. However, a substantial subset had impaired cognitive function.
    World Neurosurgery 01/2013; · 1.77 Impact Factor
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    ABSTRACT: Cerebral vasospasm is the commonest cause for mortality and morbidity in patients following clipping of a ruptured aneurysm. Selective phosphodiesterase (PDE) inhibitor like sildenafil acts as a vasodilator. The objective of this study was to evaluate the safety and feasibility of oral sildenafil citrate in patients with symptomatic refractory vasospasm. A total of 832 patients with aneurysmal subarachnoid bleed were operated in 4 years. Two hundred and seventy-three patients had vasospasm. Of these, 72 patients had refractory cerebral vasospasm. Vasospasm was defined as refractory when institution of "HHH" failed to reverse the transcranial Doppler (TCD) values even after 24 hours. Computed tomography (CT) scan showed no infarct, hematoma, or hydrocephalus, and the serum electrolytes were within normal limits. They received 100-150 mg of sildenafil every 4 hours. Response was evaluated by 2-hourly TCD. Eight patients had sustained (TCD values normal for >48 hours) and four had temporary relief in vasospasm, as suggested. Four patients developed complications significant enough to terminate the therapy. Sildenafil citrate may be effective in patients with refractory symptomatic vasospasm. It calls upon the pharmacologists and scientists to discover newer supraselective PDE inhibitors, specific to PDE receptors in brain vessels.
    Surgical Neurology International 01/2012; 3:3. · 1.18 Impact Factor
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    ABSTRACT: Although the clinical profile of patients with PMN SAH is well documented, there are scarce data available for patients with nonaneurysmal n-PMN SAH. In the present study, the clinical characteristics of patients with n-PMN SAH were analyzed and compared with those of PMN SAH and aneurysmal SAH. Patients with spontaneous SAH, in whom the initial DSA or 3-dimensional CTA result was normal, underwent another investigation (CTA/DSA). If the results of both of these were negative, a second DSA was done after 4 to 6 weeks. Patients in whom even the second DSA failed to reveal an aneurysm or any other vascular abnormality were labeled as nonaneurysmal SAH. Within this group, 2 different types were identified: PMN SAH and n-PMN SAH. There were 61 patients in whom the results of the first DSA and CTA were both negative. In 2 of these patients, an aneurysm was demonstrated at a second DSA. Seven patients died before a second DSA could be done. After excluding these, there were 18 patients with PMN SAH and 34 with n-PMN SAH. There was no mortality in these patients; and at a mean follow-up of 1.8 years, all patients with PMN SAH and 94.1% of patients with n-PMN SAH had a good outcome. Associated comorbid illnesses were more frequent in patients with PMN SAH and n-PMN SAH as compared with the aneurysmal SAH patients. Once an aneurysm is definitely excluded, patients with n-PMN SAH have a good outcome, and like PMN SAH, have a benign clinical course. However, a second DSA is mandatory to avoid missing an aneurysm or any other vascular lesion.
    Surgical Neurology 08/2008; 71(5):566-71; discussion 571,571-2,572. · 1.67 Impact Factor
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    ABSTRACT: Invasive intracranial aspergillosis remains a disease with high morbidity and mortality. The rapid increase in the incidence of this disease led us to review the literature and formulate a treatment protocol for such patients. An analysis of 46 patients with invasive intracranial aspergillosis is presented and the subgroups of extradural and intradural variety are evaluated with different treatment strategies. Patients with extradural form of disease had 100% survival, whereas antifungal chemotherapy preloading tends to provide a better outcome. Extradural aspergillosis does not need chemotherapy preloading, whereas intradural variant may have improved survival chances after preloading. Liposomal formulation has an advantage of shortened time duration for preloading, because the daily administration dose is 6 times higher than conventional preparation.
    Surgical Neurology 06/2008; 69(5):496-505; discussion 505. · 1.67 Impact Factor
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    ABSTRACT: An unusual complication following severe head trauma in two infants is described. 'Acute traumatic encephalocele' or 'extracalvarial herniation' is presented as an entity, different from 'growing skull fracture'. The acuteness of presentation and non-progressive calvarial fracture aperture, along with increasing size of herniated contents is the hall-mark of such pathology. Repair of dural defect with a patch after excision of gliosed brain provides satisfactory outcome.
    Brain Injury 10/2007; 21(10):1087-91. · 1.51 Impact Factor
  • K R Rathi, B D Radotra, V K Khosla
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    ABSTRACT: The accurate grading of astrocytic tumours is of prime importance because it is critical to the patient management and survival/outcome. Although internationally accepted WHO grading system of CNS tumours is based on histological features of H&E stained sections, yet there are cases where differentiation between grade II and grade III is difficult particularly when the biopsy is small. Proliferative index derived from MIB-1 immunostaining has been found to be useful in the distinction between various grades of malignancy. Formalin-fixed paraffin-embedded surgical specimens from 90 cases of astrocytic tumours, 30 each of low-grade astrocytoma (grade II), anaplastic astrocytoma (grade III), and glioblastoma multiforme (grade IV), were immunostained by standard indirect immunoperoxidase technique using MIB-1 monoclonal antibody. MIB-1 labeling index (MIB-1 LI) was calculated. The mean MIB-1 LI values of astrocytomas, anaplastic astrocytomas and glioblastomas were 1.75 +/- 1.5%, 8.74 +/- 6.2%, and 20.54 +/- 12.2% respectively and there was statistically significant difference between grade II and III (Unpaired "t" test, T value 5.907, p value < 0.001) and grade III and grade IV (T value 4.734, p value < 0.001). The statistical analysis also revealed that the mean MIB-1 LI increased with histological grade of malignancy (One way ANOVA test, p value < 0.001). This investigation further reinforces and corroborates the findings that MIB-1 LI is useful tool in assigning grading to the astrocytic tumours and hence in treatment modalities and should be used routinely.
    Indian Journal of Pathology and Microbiology 10/2007; 50(4):754-8. · 0.68 Impact Factor
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    ABSTRACT: Histological analysis has limited value to predict biological behavior of meningiomas. We investigated the utility of cell proliferative indicator in the evaluation of histologically benign meningiomas. We selected 25 benign non-recurrent meningiomas, 15 benign recurrent meningiomas after complete surgical resection, 30 atypical meningiomas, and 15 anaplastic meningiomas out of 384 cases studied. MIB-1 Labeling Index was evaluated by two methods: Highest Labeling Index (HLI) and Random Labeling Index (RLI). There was no dependable histological parameter to predict recurrence among benign-looking meningiomas. HLI had significant difference when compared with RLI in all categories. The mean MIB-1 HLI values +/- SD were 3.47 +/- 2.0% for benign meningiomas, 5.08 +/- 4.0% for atypical meningiomas and 11.66 +/- 7.06% for anaplastic meningiomas. In comparison, the mean MIB-1 HLI of benign non-recurrent meningiomas were 2.66 +/- 1.7% and with recurrence were 4.21 +/- 2.78% (P = 0.0339). Using receiver operating characteristic, it was seen that neoplasm recurred with the MIB-1 HLI of > 2.6 having the sensitivity of 64.6% and specificity of 68% among benign (grade I) meningiomas. MIB-1 positive tumor cells were maximally aggregated at the periphery of excised specimen. MIB-1 HLI, integrated with standard histopathology can provide better information about the disease biological nature in benign meningiomas.
    Neuropathology 10/2007; 27(5):407-12. · 1.91 Impact Factor
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    ABSTRACT: Internal carotid artery (ICA) bifurcation aneurysms are relatively uncommon and frequently rupture at a younger age compared to other intracranial aneurysms. We have treated a total of 999 patients for intracranial aneurysms, of whom 89 (8.9%) had ICA bifurcation aneurysms, and 42 of the 89 patients were 30 years of age or younger. The present study analyzed the clinical records of 70 patients with ICA bifurcation aneurysms treated from mid 1997 to mid 2003. Multiple aneurysms were present in 15 patients. Digital subtraction angiography films were studied in 55 patients to identify vasospasm and aneurysm projection. The aneurysm projected superiorly in most of these patients (37/55, 67.3%). We preferred to minimize frontal lobe retraction, so widely opened the sylvian fissure to approach the ICA bifurcation and aneurysm neck. Elective temporary clipping was employed before the final dissection and permanent clip application. Vasospasm was present in 24 (43.6%) of 55 patients. Forty-eight (68.6%) of the 70 patients had good outcome, 14 (20%) had poor outcome, and eight (11.4%) died. Patients with ICA bifurcation aneurysms tend to bleed at a much younger age compared to those with other intracranial aneurysms. Wide opening of the sylvian fissure and elective temporary clipping of the ICA reduces the risk of intraoperative rupture and perforator injury. Mortality was mainly due to poor clinical grade and intraoperative premature aneurysm rupture.
    Neurologia medico-chirurgica 05/2007; 47(4):153-7; discussion 157-8. · 0.49 Impact Factor
  • Sunil K Gupta, Anand Kumar, Virender K Khosla
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    ABSTRACT: Two patients with giant dumbbell foramen magnum neurinomas are reported. The intradural component was located anterior to the cervicomedullary junction while the extradural and extraspinal portion of the tumor had grown large enough to present as a neck swelling. In both patients total surgical removal was achieved by a single-stage posterior midline approach. Both patients had complete neurological recovery.
    Neurology India 01/2007; 55(1):61-3. · 1.04 Impact Factor
  • Skull Base-an Interdisciplinary Approach - SKULL BASE-AN INTERDISCIP APP. 01/2007; 17.
  • Neuropathology 01/2007; 27(5):407-412. · 1.91 Impact Factor
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    ABSTRACT: Central neurocytomas are benign neuronal tumours generally found in the lateral or third ventricles. They are rare, comprising < 1% of all brain tumours. It is frequently confused with other tumours of the central nervous system particularly oligodendroglioma. The present study was done to analyse the histopathological features including immunohistochemical profile of these rare tumours. Eight cases were taken up for the study. Seven of the cases had an intraventricular location and one was located outside the ventricles. Increased intracranial pressure was the most common presenting symptom. Microscopically all tumours were composed of small uniform cells with perinuclear halos and regular round nuclei. The tumour in extraventricular location showed atypical features. Immunohistochemistry showed positivity for neuronal markers. The present series highlights the characteristic clinical and pathological findings of this rare brain tumour. Immunostaining for neuronal markers are essential for distinguishing them from other small round cell tumours of the brain.
    Indian Journal of Pathology and Microbiology 10/2006; 49(4):543-5. · 0.68 Impact Factor
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    ABSTRACT: Traumatic acute SDH in pediatric patients is a life-threatening situation. There is a severe increase in ICP caused by acute SDH or diffuse brain swelling or secondary to ischemic brain damage. In certain situations, conventional measures may fail to control such a rapid increase in ICP. The cases of 4 pediatric patients with cranial trauma with raised ICP, in whom hemicranial decompression was performed, are described. All patients had acute SDH with diffuse brain injury; in addition, 2 of them had associated massive infarcts. Three of them survived and had a favorable outcome. In certain situations, pediatric patients with cranial trauma may be offered hemicranial decompression as a surgical option. These children may have a better long-term outcome despite massive infarcts.
    Surgical Neurology 10/2006; 66(3):305-10; discussion 310. · 1.67 Impact Factor
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    ABSTRACT: Tuberculosis of the craniovertebral junction is an uncommon entity and its optimal management remains controversial. In this study, we present the evolution of management protocol of this disease in our institute in the past 3 decades. A total of 51 patients with craniovertebral junction tuberculosis presenting as atlantoaxial dislocation from 1978 through 2004 were reviewed. The disease was rated from Stage I to Stage III, depending on the radiological findings. All patients received antitubercular treatment for 18 months. In the initial period of this study (1978-1986), all patients (n = 10) underwent surgery, usually a posterior fusion. In the second period (1987-1998), patients with less severe disease (Stages I and II, n = 14) were managed with external rigid immobilization, whereas patients with severe disease (Stage III, n = 11) underwent either a transoral decompression with or without posterior fusion or posterior fusion alone. More recently (1999-2004), all patients (n = 16) in all stages (Stages I-III) have been managed without surgery by a rigid external immobilization. Except for two patients who died (one because of miliary tuberculosis, the other because of acute hydrocephalus), clinical recovery occurred in all. Follow-up imaging demonstrated radiological healing as well, with regrowth of the destroyed bone. The mainstay of management of tuberculosis of the craniovertebral junction is prolonged antitubercular treatment with a rigid external immobilization. Surgery is not necessary, even in patients with advanced stages of disease. Complete clinical and radiological healing occurs in all patients with conservative treatment.
    Neurosurgery 07/2006; 58(6):1144-50; discussion 1144-50. · 2.53 Impact Factor
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    ABSTRACT: We report a patient with an uncommon presentation in the form of massive bilateral calvarial hyperostosis with bi-parasagittal en plaque meningioma. The tumour was removed by bilateral fronto-parieto-occipital craniotomies. The patient was subjected to post operative radiotherapy to reduce the chances of recurrance. The management of such a case is a surgical challenge.
    Neurology India 07/2006; 54(2):210-2. · 1.04 Impact Factor
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    ABSTRACT: Ossification of ligamentum flavum in the thoracic region causing compressive myelopathy among middle-aged patients is a poorly described entity. Five patients of Indian origin with OYL are described. Their clinical presentations, surgical options, and long-term outcome are presented. Radiologic and clinical follow-up of one of the patient is described over a span of 10 years. Decompressive laminectomy and excision of the OYL is the commonly performed surgical procedure. A rapid neurologic improvement follows decompression. The persistent spasticity in certain patients is attributed to irreversible changes within the cord. The disease is thought to be progressive in nature. The prolonged follow-up of these patients suggests that the long-term prognosis is poor. Selective racial involvement and variable clinical presentations, with treatment options, are discussed.
    Surgical Neurology 05/2006; 65(4):377-84, discussion 384. · 1.67 Impact Factor
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    ABSTRACT: Development of a contralateral epidural haematoma during or immediately after cranial surgery is a well-described entity. However, in a case of acute subdural haematoma where the brain is usually tense, postoperative development of contralateral extradural haematoma is uncommon. We report two cases of contralateral extradural haematoma after decompressive surgery for acute subdural haematoma. We recommend routine postoperative CT immediately after cranial surgery for head trauma. This would help in timely detection and treatment of such a complication.
    British Journal of Neurosurgery 01/2006; 19(6):490-4. · 0.86 Impact Factor
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    ABSTRACT: Distal anterior cerebral artery (DACA) aneurysms are uncommon. Most authors have reported technical difficulties during surgery for these aneurysms, and a variety of surgical approaches have been advocated. Over a period of 5 years (1999-2003), 67 patients with DACA aneurysms were operated. Twenty-eight of these were operated on through the bifrontal basal anterior interhemispheric approach. Of the 28 patients, 68% were in poor clinical grade (Hunt and Hess grade III-V) and 89.3% had a Fisher grade III and IV on computed tomography scan. A surgical trajectory about 2 to 3 cm superior to the anterior cranial fossa floor led directly to the aneurysm. Proximal control was achieved before aneurysm dissection and parallel clipping. Good outcome (Glasgow Outcome Scale V and IV) was seen in 57.19 of the patients, 14.3% had a poor outcome, and 28.6% died. The cause of death in most patients was found to be a poor clinical grade, postoperative infarct, or presence of multiple aneurysms. The advantages of the bifrontal basal anterior interhemispheric approach were the following: (a) It provided the shortest and a direct trajectory to the aneurysm. (b) Proximal control of the parent A(2) vessels could be easily achieved. (c) Release of cerebrospinal fluid from basal cisterns could be done, if necessary. (d) There was a minimal distortion of or traction over the aneurysm.
    Surgical Neurology 11/2005; 64(4):315-9; discussion 320. · 1.67 Impact Factor
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    ABSTRACT: The use of wound drains in surgical practice, very often falls into the realm of habit, rather than science. The utility of a prophylactic drain in surgical wounds may be questionable, but this practice is not uncommon, despite complications. We report a case of fatal haemorrhage from the superior sagittal sinus, due to a closed negative suction drain of the craniotomy wound in an infant operated upon for a growing fracture skull.
    British Journal of Neurosurgery 09/2005; 19(4):352-4. · 0.86 Impact Factor
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    ABSTRACT: Spinal cord injury without radiographic abnormality (SCIWORA) is not uncommon among middle-aged and elderly people. It is less reported in adults as compared with children. This study was undertaken to find the incidence, magnetic resonance imaging (MRI) changes, and outcome of SCIWORA in adults and to demonstrate the prognostic value of MRI in SCIWORA. Forty adult patients who sustained SCIWORA for a period of 2 years (January 1999 to December 2000) were admitted to our hospital. Methylprednisolone was given in therapeutic doses, for a period of 24 hours, to those arriving within 6 hours of injury. Magnetic resonance imaging was performed within 72 hours of admission to the hospital. In all patients, sagittal, axial, and coronal T1, spin, and T2 images of MRI were obtained. Clinical status of the patient at the time of admission and discharge was correlated with MRI. Four patients (10%), who were in Frankel grade D, with no demonstrable injury on MRI, improved to Frankel grade E at the time of discharge. Two patients (5%) with cord edema and extraneural injury improved to a useful neurological grade (Frankel grades D or E), whereas 13 patients (32.5%) with MRI features of cord contusion and hemorrhage did not achieve useful neurological function. Spinal cord injury without radiographic abnormality contributes 12% of cases of spinal cord injury. Magnetic resonance imaging is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to pick up surgically correctable abnormality. Patients with minimal cord changes on MRI have the best outcome followed by those with cord edema. Patients with parenchymatous hemorrhage and contusion on MRI fare badly.
    Surgical Neurology 04/2005; 63(3):204-9; discussion 209. · 1.67 Impact Factor