Category: Uncategorized

A Battle Against All Odds: Saving a 4-Month-Old’s Life

A 4-month-old child was brought to the emergency department at 7 a.m. with active seizures for the past two hours, refusal to feed since the previous night, and decreased responsiveness for the last 4–5 hours. The child was immediately assessed by the on-duty emergency doctor, and the ICU team was informed. Given the patient’s critical condition, he was sedated and placed on a ventilator. On pupillary examination, the left pupil was dilated, suggesting an intracerebral bleed.

The ICU doctor called me to inform me about the patient’s condition. After reviewing the history and examination findings, I advised the team to send blood samples for laboratory analysis, reserve blood and blood products, administer antiepileptics and antiedema medications, and perform an urgent CT scan. I informed them that I would reach the hospital shortly.

I arrived at the ICU within 20 minutes. The child was sedated, the anterior fontanelle was bulging, and the left pupil remained dilated. The CT scan revealed a large blood clot in the left side of the brain. We called the parents to discuss the child’s condition and the treatment plan. I explained the critical nature of the situation and the necessity of surgical intervention to remove the blood clot, which would require temporarily removing the skull bone to allow the brain swelling to subside. I also detailed the risks, including the possibility of death, weakness on the right side, speech impairment, prolonged hospitalization, and other potential complications. The parents requested some time to discuss the matter privately.

After 10 minutes, they returned and informed me they were ready to proceed with the surgery. However, during that interval, we received the blood test results, which revealed severe abnormalities in clotting function as the cause of the brain hemorrhage. I informed the parents that we could not proceed with surgery that day due to the high risk of excessive bleeding, which could result in the child’s death on the operating table. I explained that the bleeding parameters needed to be corrected first. Clotting factors were transfused, and the blood abnormalities were addressed.

When the brain is injured, it is crucial to treat it promptly to prevent further damage. It took us two days to stabilize the child’s bleeding parameters. I spoke with the father again, reiterating the increased risks, including the possibility of death, even with surgery. However, the father remained resolute, insisting that we proceed. “The child has fought for two days,” he said. “You should do your part and hope for the best. Don’t worry about other things; I will take care of them.”

The child underwent decompressive craniectomy. The skull bone was removed, and the blood clot was successfully evacuated. The surgery was uneventful, with minimal blood loss. After the procedure, the child was transferred back to the ICU on ventilatory support. Over the next two days, the child showed signs of improvement and was eventually weaned off the ventilator. He began feeding through a nasogastric tube. A few days later, he was transferred to the ward, where physiotherapy was initiated.

During follow-up visits, the child appeared healthier and more active. A month later, the skull bone was replaced. However, due to poorly developed skull bones, there were concerns that the bone flap might not survive. The parents were counselled about the possibility of requiring a revision surgery with artificial material. Again, the father’s confidence shone through. “We have come so far and will face whatever comes ahead,” he said.

The revision surgery was performed, and the child had an uneventful hospital stay, being discharged after five days. During subsequent follow-ups, bone absorption was noted, but we opted for continued observation. Three months later, the child returned with signs of developing bone over the skull, good limb movements, normal feeding, and a cheerful demeanor.

This case highlights the complexities of managing critically ill patients, especially children. As surgeons, we consider all possible outcomes—both good and bad—and communicate them transparently to families. A doctor always strives for the best for their patients, understanding that their name and career are on the line. In this case, the father’s unwavering positivity and confidence inspired our team, boosting our morale and giving us the courage to push boundaries and achieve the best possible outcome.

Hydrocephalus

An Unexpected Journey: Understanding Normal Pressure Hydrocephalus (NPH)

Walks in an elderly gentleman, slightly hunched over, leaning on a walking stick, supported gently by his wife, into my clinic. She looks worried but hopeful as she helps him take a seat, and they both turn to me with a mix of relief and anticipation.

You: “Hello, how can I help you both today?”

Wife: “Doctor, I’m so worried about him. He forgets almost everything that happens nowadays. He’s even on medication for Alzheimer’s, but things don’t seem to be improving.”

You: “I see. Can you tell me a bit more about his memory problems?”

She takes a deep breath, clearly eager to get this all out.

Wife: “He can remember things from his childhood like they happened yesterday, but when it comes to what we talked about even a few days back… nothing. And lately, he has these episodes where he’s unsteady on his feet, like he’s drunk. Sometimes, he even bumps into things.”

You nod, listening carefully.

You: “Does he have any issues with urination?”

Her eyes widen as she realizes she’d overlooked something.

Wife: “Yes! I forgot to mention that. He’s always rushing to the bathroom, can barely make it on time, and… well, at night, he has to wear diapers because he’s having accidents.”

You lean back, piecing the symptoms together in your mind. There’s a classic trio here—memory loss, gait disturbances, and urinary incontinence—that feels familiar.

You: “Thank you for sharing all of this. It sounds like he could have a condition known as Normal Pressure Hydrocephalus, or NPH. It’s different from Alzheimer’s, even though they share some symptoms.”

The wife looks puzzled, so you explain further.

You: “In NPH, excess fluid in the brain builds up slowly, expanding the ventricles—the fluid-filled spaces in the brain. This puts pressure on nearby areas that control memory, balance, and bladder control.”

Wife: “So, that’s why he’s having these problems?”

You: “Yes. In NPH, the temporal lobe, which is linked to memory, is on the sides of these ventricles, while the frontal lobe, which controls bladder function, lies in front. As for the balance issues, the motor areas that control walking are at the top.”

The wife nods thoughtfully.

Wife: “So what do we do next?”

The Diagnostic Journey

You: “The first step will be an MRI to see if there’s visible swelling in the ventricles. After that, if needed, we can perform a lumbar puncture, a procedure where we remove a small amount of cerebrospinal fluid to see if his symptoms improve.”

They both nod in agreement. You arrange the MRI and set a follow-up appointment.

Three Days Later

The couple returns, and you review the MRI results with them.

You: “Interestingly, the MRI appears normal, which sometimes happens in NPH cases. Let’s proceed with the lumbar puncture and see how he responds.”

The procedure goes smoothly, and after two hours, you conduct a few tests, noting a marked improvement in his MMSE (Mini-Mental State Examination) score and a steadier gait.

Wife: smiling “He’s walking better already!”

You: “That’s a great sign. We’ll monitor his progress over the next few days, but if his symptoms return, the next step would be a procedure to manage the fluid long-term.”

The Treatment Discussion

A few days later, they’re back in your office, eager to hear what’s next.

Wife: “So, is he cured?”

You: “For now, he’s improving, but without further intervention, the symptoms are likely to return. The long-term solution is a surgery called a ventriculoperitoneal (VP) shunt. This procedure diverts the excess fluid from his brain to his abdomen, where it can be absorbed.”

Wife: “Are there risks?”

You: “Every surgery has risks. With a VP shunt, possible complications include infection, shunt malfunction, and issues with fluid drainage. But with regular follow-ups, we can address these if they arise.”

The couple considers this, and after a moment, the wife squeezes his hand.

Wife: “Let’s do it.”

The Outcome

Two days later, he undergoes the VP shunt surgery without complications. A week after, the man who’d once struggled with every step returns for his follow-up.

You: “It’s great to see you walking so confidently!”

Patient: smiling “Feels good to be able to walk on my own again.”

His wife beams with relief.

A New Beginning

In the weeks that follow, his symptoms remain at bay, and he returns to his daily activities with newfound independence. His wife, though still vigilant, finally has some peace of mind.

This experience underscores the power of thorough diagnosis and the importance of considering all possibilities, especially when symptoms are complex. For those experiencing memory issues, unsteady gait, or urinary difficulties, it’s a reminder that conditions like NPH are manageable with the right care and treatment.

Pediatric Neurosurgery

Pediatric neurosurgery focuses on diagnosing and treating neurological conditions in children, from newborns to adolescents (up to 18 years old). It includes both conditions present at birth (congenital) and those that develop later (acquired). Common conditions treated by pediatric neurosurgeons include:

  1. Spinal Dysraphism (Spina Bifida): This is a condition where the spine doesn’t close properly. Children may have a swelling on the back, limb weakness, or abnormal skin marks. Surgery is needed to prevent further nerve damage as they grow.
  2. Hydrocephalus: This occurs when excess cerebrospinal fluid (CSF) builds up in the brain, increasing pressure inside the skull. It can be congenital (present at birth) or acquired (due to bleeding in the brain). Treatment options include placing a ventriculoperitoneal (VP) shunt or performing an endoscopic third ventriculostomy (ETV) to relieve the pressure.
  3. Brain Tumors: Brain tumors, which may be cancerous or non-cancerous, are common in children. Symptoms include headaches, vomiting, seizures, and balance or vision problems. Treatment involves surgery to remove the tumor, sometimes followed by chemotherapy or radiation therapy.
  4. Craniosynostosis: This condition happens when one or more skull bones fuse too early, restricting brain growth. Surgery is done to correct the skull shape and allow the brain to grow properly.
  5. Epilepsy and Seizures: Some children with epilepsy do not respond to medication. In such cases, surgery may be an option to help control their seizures.
  6. Head Injuries and Trauma: Children with traumatic brain injuries are usually managed with observation in the ward or ICU. In some cases, surgery is necessary. For young children (6 months to 2 years) with skull fractures, the fracture may enlarge over time and need surgical repair using a bone graft.

Adult Neurosurgery

Adult neurosurgery focuses on diagnosing and treating conditions of the brain, spine, and peripheral nerves in patients aged 16 and older. These conditions may be traumatic (caused by injury) or non-traumatic (due to diseases or other medical issues). Treatment can be surgical or non-surgical, depending on the severity and type of problem.

Traumatic Brain Injuries (TBI)

Traumatic brain injuries occur from events like road accidents, falls, or head injury due to assault. While neurosurgeons can’t undo the damage caused by the initial injury, they work to prevent further complications.

Most patients with TBI don’t need surgery but require close monitoring in an ICU to manage symptoms and prevent deterioration. Common treatments include medications to reduce brain swelling, anti-seizure drugs, and sometimes ventilatory support. If medical treatment fails, surgery may be necessary.

For patients with blood clots pressing on the brain (subdural or extradural hematomas), surgery is often needed to relieve the pressure. In severe cases, part of the skull may be temporarily removed to give the brain space to swell. This procedure, called decompressive craniectomy, helps protect the brain from further damage.

Non-Traumatic Brain Conditions

Non-traumatic brain conditions can present with headaches, vomiting, seizures, memory problems, balance issues, weakness, or visual disturbances. These symptoms might be due to brain tumors or other neurological issues and need further investigation.

In older adults, memory problems may indicate Alzheimer’s disease, and if combined with urinary urgency and difficulty walking, the condition could be Normal Pressure Hydrocephalus (NPH), which may require surgical intervention.

Spinal Conditions

Spinal problems such as disc degeneration, herniated discs, or spinal tumors are also common in adult neurosurgery. Symptoms include back pain, leg pain, weakness, and bowel or urinary issues.

Most patients with spinal problems are treated with medications, rest, and physiotherapy. However, if a patient suddenly develops weakness or trouble controlling their bladder, emergency surgery may be required to relieve pressure on the spinal cord. Conditions like spinal tumors usually require surgery.

Peripheral Nerve Conditions

Nerve compression, such as carpal tunnel syndrome or nerve injuries can cause numbness or tingling in the hands or feet. These conditions can often be treated with medications, injections, or surgery to relieve the pressure on the nerves.