Press and Publications
Nicolas K Khattar, Fitri Sumardi, Ajmal Zemmar, Quinghua Liang, Haiyang Li, Yazhou Xing, Hugo Andrade, Jack L Fleming, Iype Cherian, Juha Hernesniemi, Joseph S Neimat, Robert James, Sunil Munakomi and Dale Ding.
Prakash Kafle, Babita Khanal, Iype Cherian, Dipak Kumar Yadav and Deepak Poudel
ABSTRACT: Background: Spinal cord injury causes serious disability among patients. More than 40 million people worldwide suffer from Spinal cord injury every year. Most of them are young men. More than10% of trauma victims sustain spine injury and have higher mortality than other injuries. Materials and Methods: This is a prospective observational hospital based study of traumatic spine injury cases admitted at Nobel Medical College Teaching Hospital, Biratanagr, Nepal from November 2017 to October2018. Results: Total of 352 cases were observed and 36 cases who meet the inclusion criteria for surgical intervention were analyzed. Most common affected age group was between 31-40 years with mean age of 40 years. Out of total cases, 81% were male. Most common cause for spine injury was road traffic accident. Cervical spine was the most common injury (66.7%) and C5- C6subluxation being common radiological diagnosis. ASIA-C neurology status (41.7%) on presentation being most common neurological status. Head injury was the most common associated injury. Anterior cervical discectomy and fusion was the most common surgical procedure performed. Superficial surgical site infections were observed in two cases and hardware failure was seen in one case. Conclusion: The epidemiology of traumatic spine injuries in eastern region of Nepal is similar with other developing countries. In present study, most common cause of spine injury was motor vehicle accidents followed by fall injuries and seen in male. Prevention of road traffic accident might decrease the incidence of spine injury there by reducing the national burden.
Sharanya Jayashankar, Sunil Munakomi, Vignesh Sayeerajan, Prakash Kafle, Pramod Chaudhary.
Ajmal Zemmar, Ahmed Al-Jradi, Vincent Ye, Ismail Al-Kebsi, Hugo Andrade, Emal Zemmar, Iype Cherian, Josue Avecillas-Chasin, AndreiV Krassioukov and Juha Hernesniemi
Iype Cherian, Salona Amatya and Hira Burhan
Lorenzo Giammattei, Mahmoud Messerer, Iype Cherian, Daniele Starnoni, Rodolfo Maduri, Ekkehard Kasper and Roy Thomas Daniel
Iype Cherian, Hira Burhan, Harshpreet Kaur and Rupesh Kumar Shreewastav
Sunil Munakomi, Binod Bhattarai and Iype Cherian
Yoko Kato, Yasuhiro Yamada, Akiyo Sadato, Mohsen Nouri, Iype Cherian, Teppei Tanaka and Joji Inamasu
Iype Cherian, Margarita Beltran, Alessandro Landi, Concetta Alafaci, Fabio Torregrossa and Giovanni Grasso
ABSTRACT:The controversies surrounding DC prompted the neurosurgical community to seek surgical solutions other than DC for suitable treatment of severe TBI. New perspectives have evolved as a result of the innovative contributions of Cherian et al., 21 who introduced the concept of performing a cisternostomy in the setting of severe TBI. This procedure is defined by opening the cisternal compartments surrounding the base of the brain and leaving a drain behind in the cistern, allowing the compartment to stay open to atmospheric pressure. …
Trichy N. Janakiram, Shilpee B. Sharma, Ekkehard Kasper, Onkar Deshmukh and Iype Cherian
ABSTRACT:Background Juvenile nasal angiofibromas (JNA) is a benign lesion with high vascularity and propensity of bone erosion leading to skull base invasion and intracranial extension. It is known to involve multiple compartments, which are often surgically difficult to access. With evolution in surgical expertise and technical innovations, endoscopic and endoscopic-assisted management has become the preferred choice of surgical management. Over the last four decades, various staging systems have been proposed, which are largely based on the extent of nasal angiofibroma. However, no clear guidelines exist for the stage-appropriate surgical management. In this study, we aim to formulate a novel staging system based on the analysis of high quality preoperative imaging and propose detailed surgical guidelines related to disease stages as observed in 242 primary cases of JNA. Methods A retrospective analysis of the case records of 242 primary JNA cases was performed at our center. Patients were staged according to various existing staging systems as well as our own new staging system, and outcome variables were compared with respect to intraoperative blood loss, multiple staged operations, and tumor recurrences. Operative records were studied and precise endoscopic surgical guidelines were formulated for each stage. Results Comparing the intraoperative blood loss seen in stages of various classifications, it was found that intraoperative blood loss correlated best and statistically significantly with stages in the newly proposed Janakiram staging system when compared to the existing staging systems. Staged operations were performed in a total of 7/242 patients, and there was a significant association between the requirement of a staged operation and tumor extent (Fischer’s exact test, P < 0.001). Tumor recurrence was seen in 22 cases and the pterygoid wedge was found to be the most frequent site of recurrence initially. As the extent of resection improved with better surgical technique over time, recurrences were only found in superior orbital fissure, around the internal carotid artery, and in the middle cranial fossa. Conclusion This new Janakiram staging system is based on preoperative imaging data from one of the largest JNA case series reported thus far. Respective guidelines reliably stratify patients into treatment groups with definite surgical approaches and predicts outcome. Improved surgical approaches in the modern endoscopic era have redefined JNA management with improved outcome. This study shows the importance of precise presurgical imaging and the choice of the most suitable surgical approach in reducing morbidity and mortality in JNA surgery.
Iype Cherian, Margarita Beltran, Ekkehard Kasper, Binod Bhattarai, Sunil Munokami and Giovanni Grasso
ABSTRACT:Background: Cerebrospinal fluid (CSF) transport across the central nervous system (CNS) is no longer believed to be on the conventional lines. The Virchow-Robin space (VRS) that facilitates CSF transport from the basal cisterns into the brain interstitial fluid (ISF) has gained interest in a whole new array of studies. Moreover, new line of evidence suggests that VRS may be involved in different pathological mechanisms of brain diseases. Methods: Here, we review emerging studies proving the feasible role of VRS in sleep, Alzheimer′s disease, chronic traumatic encephalopathy, and traumatic brain injury (TBI). Results: In this study, we have outlined the possible role of VRS in different pathological conditions. Conclusion: The new insights into the physiology of the CSF circulation may have important clinical relevance for understanding the mechanisms underlying brain pathologies and their cure.
Iype Cherian, Antonio Bernardo and Giovanni Grasso
ABSTRACT:Objective: Traumatic brain injury (TBI) is one of the major challenges in health care, representing the third most frequent cause of death. Current optimal management is based on a progressive, target-driven approach combining both medical and surgical treatment strategies. Here we describe cisternostomy, an emerging surgical treatment for TBI treatment. Methods: Cisternostomy is a novel technique that incorporates knowledge of skull base and microvascular surgery. By opening the brain cisterns to atmospheric pressure, the technique could decrease the intracranial pressure due to a backshift of the cerebrospinal fluid (CSF)from the swollen brain to the cisterns through the Virchow-Robin spaces. Results: An increasing number of evidence has demonstrated a paravascular pathway that facilitates CSF flow from the subarachnoid space through the brain parenchyma. This network of paravascular channels, termed as “glymphatic” pathway, reduces considerably its activity following TBI thus participating in the development of brain edema formation. Cisternostomy, by opening the brain cisterns to atmospheric pressure could decrease the intracerebral pressure due to a backshift of CSF through the Virchow-Robin spaces.results CONCLUSIONS: In the current common practice, the surgical measures for TBI include external ventricular drainage insertion and decompressive craniectomy. There is evidence that both of these measures reduce intracranial pressure but the effect on the outcome, particularly in the long term, is equivocal. A new line of evidence supports cisternostomy as an emerging surgical treatment for TBI.
Sunil Munakomi, Binod Bhattarai, Balaji Srinivas and Iype Cherian
ABSTRACT:Background: Glasgow Coma Scale has been a long sought model to classify patients with head injury. However, the major limitation of the score is its assessment in the patients who are either sedated or under the influence of drugs or intubated for airway protection. The rational approach for prognostication of such patients is the utility of scoring system based on the morphological criteria based on radiological imaging. Among the current armamentarium, a scoring system based on computed tomography (CT) imaging holds the greatest promise in conquering our conquest for the same. Methods: We included a total of 634 consecutive neurosurgical trauma patients in this series, who presented with mild-to-severe traumatic brain injury (TBI) from January 2013 to April 2014 at a tertiary care center in rural Nepal. All pertinent medical records (including all available imaging studies) were reviewed by the neurosurgical consultant and the radiologist on call. Patients’ worst CT image scores and their outcome at 30 days were assessed and recorded. We then assessed their independent performance in predicting the mortality and also tried to seek the individual variables that had significant interplay for determining the same. Results: Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute TBI with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift, and status of the peri-mesencephalic cisterns. Conclusion: We demonstrated in this cohort that though the Marshall score has the high predictive power to determine the mortality, better discrimination could be sought through the application of the Rotterdam score that encompasses various individual CT parameters. We thereby recommend the use of such comprehensive prognostic model so as to augment our predictive power for properly dichotomizing the prognosis of the patients with TBI. In the future, it will therefore be important to develop prognostic models that are applicable for the majority of patients in the world they live in, and not just a privileged few who can use resources not necessarily representative of their societal environment.
Iype Cherian, Antonio Bernardo, Giovanni Grasso and Sunil Munakomi
ABSTRACT:Cisternostomy is defined as opening the basal cisterns to atmospheric pressure. This technique helps to reduce the intracranial pressure in severe head trauma as well as other conditions when the so-called sudden “brain swelling” troubles the surgeon. We elaborated the surgical anatomy of this procedure as well as the proposed physiology of how cisternostomy works. This novel technique may change the current trends in neurosurgery.
Sunil Munakomi, Binod Bhattarai and Iype Cherian
ABSTRACT:In this case report, we discuss the microsurgical management of a Spetzler-Martin grade 5 arteriovenous malformation (AVM) in a young boy who presented with a hemorrhagic episode and had a high calculated risk of rebleeding. We also outline the rationale for choosing the management option.
Niran Maharjan, Sangeeta Shrestha, Binod Bhattarai and Iype Cherian
ABSTRACT: JCMSBackground and Objectives: Tracheostomy is electively performed in critically ill patients requiring prolonged respiratory support. The risk of transporting, the increasing associated cost and operative room schedule are some of the obstacles for wider acceptance of this procedure. The use of rigid selection criteria exclude many patients who would benefit of this approach. The present study was designed to determine the safety of open bedside tracheostomy (OBT) as a routine intensive care units (ICU) procedure without any selection criteria, considering its peri and postoperative complications.Materials & Methods: Retrospective medical chart review of all patients that underwent elective tracheostomy between June 2014 and January 2015.Results: The study group comprised 52 patients with a mean age of 40.4±15.1 years. The incidence of intra-procedure complications was 5.7% and post-procedure complications was 3.8%.Conclusions: Open bedside tracheostomy seems to be a safe and simple procedure, even when performed by a trained resident under controlled circumstances, and should be considered as an option for ICU patients.JCMS Nepal. 2015;11(1): 9-11
Sunil Munakomi, Binod Bhattarai and Iype Cherian
ABSTRACT:This is a case report of a neurologically intact patient following posttraumatic cervical spondyloptosis. We discuss the disease, management protocol and some surgical nuances to prevent any damage to the cord during different stages of its treatment.
Sunil Munakomi, Balaji Srinivas and Iype Cherian
ABSTRACT:Here we present a very rare case of a woman with a bone fragment in the third ventricle of the brain following compound-depressed skull fractures due to a road traffic accident. There are only few case reports of bullets and textiloma being removed from the third ventricle. Following operative removal of the fragment, the patient was started on cortisol, mineralocorticoid and thyroid hormone replacement. However, the patient eventually died of the severe traumatic hypothalamic insult.
Sunil Munakomi, Binod Bhattarai, Balaji Srinivas and Iype Cherian
ABSTRACT: Primary dural lymphoma is a subentity of primary leptomeningeal lymphoma which represents 0.1% of all non-Hodgkin’s lymphomas. Only five cases have been reported so far. We report a very rare case of primary dural-based lymphoma in a 14 year-old boy presenting with mass effect. The patient was managed with excision of the lesion and removal of the involved bone. Post-operatively, the patient showed good recovery. He was then referred to the oncology unit for further chemo-and radiation therapy. A high index of suspicion should therefore be kept in order to diagnose the condition in a timely fashion and then plan for appropriate management since diffuse large cell lymphoma has a relatively benign clinical prognosis.
Sunil Munakomi, Binod Bhattarai, Iype Cherian and Balaji Srinivas
ABSTRACT:Critical illness-related cortisol insufficiency is a known entity. However, there are instances where there is a normal serum cortisol level in an unresponsive patient with low Glasgow Coma Scale (GCS), even after thorough investigations to rule out other correctable entities. In patients with lesions in the vicinity of hypothalamus, especially basifrontal contusion and vascular lesions affecting anterior communicating artery (ACOM) territory, we propose to see the efficacy of fludrocortisone replacement on such patients.
Hirotoshi Sano, Akira Satoh, Yuichi Murayama, Yoko Kato, Hideki Origasa, Joji Inamasu, Mohsen Nouri, Nobuto Saito and Iype Cherian
ABSTRACT:Object: A modified World Federation of Neurosurgical Societies scale (m-WFNS scale) for aneurysmal subarachnoid hemorrhage (SAH) recently has been proposed, in which patients with Glasgow Coma Scale (GCS) scores of 14 are assigned to grade II and those with GCS scores of 13 are assigned to grade III regardless of the presence of neurologic deficits. The study objective was to evaluate outcome predictability of the m-WFNS scale in a large cohort. Methods: This was a multicenter prospective observational study conducted in Japan. A total of 1656 patients with SAH were registered during the 2.5-year study period, and the outcome predictability, using the Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores at discharge and at 90 days after onset, was evaluated by comparing the m-WFNS with the original WFNS scale. We focused on whether significant differences in these scores were present between the neighboring grades. Results: In the m-WFNS scale, significant difference between any neighboring grades was observed both in the mean GOS and mRS scores at 90 days except between grades III/IV. However, differences were not significant between grades II/III and between grades III/IV in the original WFNS scale. Conclusions: SAH-induced brain injury may be substantially severer in patients with GCS 13 than those with GCS 14, which may explain why grade III patients faired significantly worse than grade II patients by the modified WFNS scale. Although further validation is necessary, the m-WFNS scale has a potential of providing neurosurgeons with simpler and more reliable prognostication of patients with SAH.
Sunil Munakomi, Iype Cherian, Binod Bhattarai and Tamrakar Karuna
ABSTRACT: Arteriovenous malformation (AVM) of the scalp is an uncommon entity. Its management is difficult because of its high shunt flow, complex vascular anatomy, and possible cosmetic complications. The etiology of scalp AVMs that is, cirsoid aneurysm may be spontaneous or traumatic. Clinical symptoms frequently include pulsatile mass, headache, local pain, tinnitus; and less frequently, hemorrhage and necrosis. Selective angiography is the most common diagnosis method. Surgical excision is especially effective in AVMs and the most frequently used treatment method. Here, we present one such case where staged embolization, excision, and subsequent grafting was done.
Iype Cherian, Ghuo Yi and Sunil Munakomi
ABSTRACT: Practical scenario in trauma neurosurgery comes with multiple challenges and limitations. It accounts for the maximum mortality in neurosurgery and yet the developing countries are still ill-equipped even for an emergency set-up for primary management of traumatic brain injuries. The evolution of modern neurosurgical techniques in traumatic brain injury has been ongoing for the last two centuries. However, it has always been a challenge to obtain a satisfactory clinical outcome, especially those following severe traumatic brain injuries. Other than the well-established procedures such as decompressive hemicraniectomy and those for acute and or chronic subdural hematomas and depressed skull fractures, contusions etcetera newer avenues for development of surgical techniques where indicated have been minimal. We are advocating a replacement for decompressive hemicranictomy, which would have the same indications as decompressive hemicraniectomy. The results of this procedure has been compared with the results of decompressive hemicraniectomy done in our institution and elsewhere and has been proven beyond doubts to be superior to decompressive hemicraniectomy. This procedure is elegant and can replace decompressive hemicraniectomy because of low morbidity and mortality. However, there is a steep learning curve and the microscope has to be used. Based on the clinical experience and observation of acute neurosurgical service in tertiary medical centers in a developing country, the procedure of cisternostomy in the management of trauma neurosurgery have been elucidated in the current study. The study proposes to apply the principles of microvascular surgery and skull base surgery in selected cases of severe traumatic brain injuries, thus replacing decompressive hemicraniectomy as the primary modality of treatment for indicated cases. Extensive opening of cisterns making use of skull base techniques to approach them in a swollen brain is a better option to decompressive hemicraniectomy for the same indications.
ABSTRACT: The evolution of modern neurosurgical techniques in traumatic brain injury has been ongoing for the last two centuries. However it has always been a challenge to obtain an effective clinical outcome, especially those following severe traumatic brain injuries. Other than the well established procedures for acute and/ or chronic subdural hematomas and depressed skull fractures, newer avenues for development of surgical techniques where indicted have been minimal. Practical scenario in trauma neurosurgery comes with multiple challenges and limitations. In an emergency setup, primary management of traumatic brain injuries fall upon the on-duty resident or medical officer in training. Due to the emergent nature of the condition and time being an important variable, the experience of the operating surgeon as well as the severity of the injury become an important contributing factor in the disease prognosis. Based on clinical experience and observation of acute neurosurgical service in tertiary medical center in a developing country, a novel technique in the management of trauma neurosurgery have been elucidated in the current study. The study proposes to apply the principles of microvascular surgery and skull base surgery in selected cases of severe traumatic brain injuries. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-1, 1-6 DOI
Iype Cherian, Sachet Shrestha, Moti Lal Panhani and Om Parkash Talwar
ABSTRACT: A 48-year-old man presented with proptosis of the left eye, which on excisional biopsy proved to be primary adenosquamous carcinoma of the lacrimal gland. The lesion was excised radically by a limited frontotemporo-orbitozygomatic approach and any further surgeries, such as exenteration, were avoided in view of the patient’s wish to preserve the eye and vision. Long-term follow-up is planned to look for any metastasis or recurrence of the tumour. Primary adenosquamous carcinoma of the lacrimal gland is a very rare entity and, following a thorough literature review, only two cases of lacrimal gland adenosquamous carcinoma have been reported so far.
Cecilia Fernandes, Ayushi Agrawal, Binod Bade Shreshtha, Nikunj Yogi and Iype Cherian
ABSTRACT: A 12-year-old girl presented to Manipal Teaching Hospital with quadriparesis of 8 months’ duration. Examination revealed a hyperpigmented patch over the chest wall with overlying hypertrichosis, musculoskeletal anomalies, upper limb asymmetry and ipsilateral breast hypoplasia. MRI scan revealed cranio-vertebral junction anomaly and spina bifida occulta at the cervical spine level. Histopathological examination of the skin revealed findings consistent with Becker’s nevus. Based on the patient’s clinical presentation and investigations, a diagnosis of Becker’s nevus syndrome was made. However, she was managed conservatively as surgical intervention was not suitable in her case. The authors review Becker’s nevus syndrome and its clinical manifestations below.
ABSTRACT: The health scenario of western Nepal is bleak and especially the Neurosurgical facilities are poor. We started the Department of Neurosurgery in April 2008 and has been improvising to do various cases with good success rate. Although not very well equipped, we have tried to do our best and the results have been encouraging.
Iype Cherian and Sunil Munakomi
ABSTRACT: The evolution of modern neurosurgical techniques in traumatic brain injury has been ongoing for the last two centuries. However, it has always been a challenge to obtain an effective clinical outcome, especially in those following severe traumatic brain injuries. Other than the well-established procedures for acute and/or chronic subdural hematomas and depressed skull fractures, newer avenues for the development of surgical techniques, where indicated, have been minimal. The study proposes to apply the principles of microvascular surgery and skull base surgery in selected cases of severe traumatic brain injuries.