Press and Publications

Books

Editors: Ioan Opris , Manuel F Casanova
Springer, December, 2017
DOI: 10.1007
ISBN: 978-3-319-29674-6
Print ISBN: 978-3-319-29672-2
Cerebrospinal fluid (CSF) from the basal cisterns transits into the brain through spaces that surround the vascular system of the brain; the so-called paravascular spaces (Virchow Robin Spaces), or paravascular pathway, which surround the arteries, veins, and capillaries. The passage of CSF through these paravascular spaces is driven by the cardiovascular and respiratory systems, and is more active at night during sleep. Their cumulative function is presumed to include the clearance (or “cleaning”) of metabolic wastes, which likely contributes to counteracting metabolic heat, via the “cooling” of the brain. This paravascular CSF transport system might be implicated in CSF shift edema that occurs in head injuries; hence, it may be the rationale behind why opening the cisterns to atmospheric pressure through cisternostomy, quickly decreases post-traumatic brain swelling. When this paravascular system is blocked or becomes somehow dysfunctional, the “cleaning” and “cooling” functions of this system may be impaired or completely stopped. This could result in the accumulation of metabolic wastes that cannot be removed within these spaces. In addition, a faulty brain cooling system might play a role in the modification of the molecular structures of proteins, thereby making them more difficult to be removed by the flow of CSF, thus aggravating the situation. Therefore, this may be a common underlying mechanism for many neurodegenerative disorders, and an aggravation factor for others. This avenue appears to be novel and promising toward the elucidation and treatment of a host of diseases. Chapter, "A Unified Physical Theory​ for CSF Circulation, Cooling and Cleaning of the Brain, Sleep, and Head Injuries in Degenerative Cognitive Disorders" authored by  Iype Cherian and Margarita Beltran​

Cerebrovascular Diseases (working title)
IntechOpen, February, 2020
Editors: Dr. Patricia Bozzetto Ambrosi, Dr. Rufai Ahmad, Mr. Auwal Abdullahi and Prof. Amit Agrawal

DOI:
10.1007
ISBN: 978-3-319-29674-6
Print ISBN: 978-3-319-29672-2

The function of the cerebrospinal fluid (CSF) has long been considered for mechanical protection and recently attributed to the supply of nutrients to the brain. However, we hypothesize that the brain is a water-cooled and water-cleaned system. Recent studies on the glymphatic pathways and the introduction of cisternostomy as a surgical procedure for traumatic brain injury reveal a vast and in-depth functionality of the CSF, which works in synchrony with the cardiopulmonary rhythms to act as a buffer for optimum cerebral function. The nasal sinuses are located around the suprasellar cistern, and the evaporating wet mucosa within them during the breathing contributes to local cooling, whereas the nocturnal activation of AQP4 channels allows CSF-ISF exchange. The resultant “cooling and cleaning” of the brain not only maintains a physiological equilibrium but also opens doors for understanding and treating pathophysiology underlying common degenerative and neuro-inflammatory diseases. This chapter describes the novel theory of brain cooling and cleaning and the clinical and experimental evidence to support this hypothesis.

Chapter "Brain Cooling and Cleaning: A New Perspective in Cerebrospinal Fluid (CSF) Dynamics" authored by Iype Cherian and Hira Burhan​

Hydrocephalus
Editor: Sadip Pant Co-editor: Iype Cherian
IntechOpem, February, 2012
DOI: 10.5772/1212
ISBN:978-953-51-0162-8
eBook (PDF) ISBN: 978-953-51-5212-5

Description of hydrocephalus can be found in ancient medical literature from Egypt as old as 500 AD. Hydrocephalus is characterized by abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles of the brain. This results in the rise of intracranial pressure inside the skull causing progressive increase in the size of the head, seizure, tunneling of vision, and mental disability. The clinical presentation of hydrocephalus varies with age of onset and chronicity of the underlying disease process. Acute dilatation of the ventricular system manifests with features of raised intracranial pressure while chronic dilatation has a more insidious onset presenting as Adams triad. Treatment is generally surgical by creating various types of cerebral shunts. Role of endoscopic has emerged lately in the management of hydrocephalus.

Chapter 3, "Clinical presentation of Hydrocephalus" authored by Sadip Pant and Iype Cherian

Articles

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.
Published 2019

ABSTRACT: Background Cerebral venous thrombosis (CVT) is a rare cerebrovascular disorder, comprising <1% of all strokes. The incidence of CVT is higher in females but a small number of cases suggest that men have a higher risk for CVT in high elevation. The aim of this retrospective cohort study is to investigate this gender-related relationship and to describe the baseline characteristics and treatment outcomes of patients who suffered CVT at high altitude in eastern Nepal. Methods We conducted a retrospective analysis of 21 consecutive patients with CVT at a tertiary care center in Nepal from July 2017 to January 2018. Clinical data, radiologic characteristics, therapeutic strategies, and outcomes were analyzed. The Glasgow Outcome Scale (GOS) at discharge was reported for each patient. Result The study cohort comprised 21 patients (76% males) with a mean of 56 years. Medical comorbidities included hypertension (76%) and diabetes mellitus (57%). All patients received low-molecular-weight heparin therapy (LMWH). Eight patients (38%) underwent decompressive craniectomy while the remaining 13 (62%) were treated with medical therapy alone. The GOS at discharge was 5 in 57%, 2-4 in 33%, and 1 in 10%. Conclusion In our series, men were found to have a higher risk for CVT at high altitude. The reversal in the gender ratio could be related to elevation, but could also be confounded by alcoholism. Increasingly sophisticated imaging techniques, such as computed tomography venography (CTV) and magnetic resonance venography (MRV), have facilitated the diagnosis of CVT. LMWH is a safe and easily accessible treatment option, especially in developing countries. Further studies are needed to assess the incidence and prevalence of CVT in the developing world, to establish the gender-related trends.

 

Prakash Kafle, Babita Khanal, Iype Cherian, Dipak Kumar Yadav and Deepak Poudel
Published 2019

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.

ABSTRACT: Background: Herein we report a rare case of acute liver failure due to levetiracetam, which has been considered to have an excellent safety profile with minimal hepatic side effects. Case presentation: A 55-year-old male patient presenting with sudden onset dizziness, slurring of speech and headache was operated for posterior fossa cerebellar hematoma. His post-surgical period was complicated by development of icterus with elevation of liver enzymes. After ruling out common inciting factors, it was decided to stop levetiracetam which was given prophylactically for preventing seizures owing to presence of external ventricular drain. From the next day patient had dramatic improvement in liver functions and sensorium. Conclusions: We would like to highlight this side effect that is potentially life threatening, though rare, of levetiracetam, which is very commonly used in today’s practice and fast superseding all other time-tested antiepileptics.
 
 

Ajmal Zemmar, Ahmed Al-Jradi, Vincent Ye, Ismail Al-Kebsi, Hugo Andrade, Emal Zemmar, Iype Cherian, Josue Avecillas-Chasin, AndreiV Krassioukov and Juha Hernesniemi
Published 2019

ABSTRACT: Background: There is scant literature describing the management of acute spinal injury in pregnant patients. Here, we report our experience with five cases of pregnant patients including three females who suffered acute traumatic spinal cord injuries (SCIs). Methods: This retrospective study evaluated five pregnant women presenting with traumatic spinal injuries over a 16‑month period. All were assessed using the International Standards for Neurological Classification of Spinal Cord Injury Patients and the American Spine Injury Association Impairment Scale (AIS). Results: Three patients sustained SCIs: two cervical spine (C4 AIS‑A and C5 AIS‑B) and one thoracolumbar junction fracture dislocation (T11 AIS‑A). Two patients required surgical stabilization during pregnancy, with one undergoing surgery after delivery. All three patients subsequently delivered healthy newborns. The remaining two patients without neurologic deficits at admission were treated conservatively; one had a healthy child, whereas the other patient aborted the baby due to the initial trauma. Conclusions: Our study demonstrates that the same surgical principals may be applied to pregnant women as to routine patients with SCIs. Further studies with greater patient data should be performed to better develop significant guidelines for the management of pregnant patients with spinal injuries.
 

Iype Cherian, Salona Amatya and Hira Burhan
Published 2018

ABSTRACT: Background: Intracerebral hemorrhage accounts for 10 to 20% of strokes. Based on the precise site and size of the hematoma, ICH can manifest a range of clinical and radiological deficits. The role of surgical removal of hematoma has by far been controversial, and despite large clinical trials, the efficacy of surgery remains controversial. In this paper, we descried our experience of ICH and its epidemiology along with the outcomes of patients undergoing surgical removal of hematoma secondary to ICH. Patient And Methods: A retrospective observational study was conducted from April to September 2018 in a tertiary care center in Nepal. 102 patients undergoing surgery using trans-cortical, trans-sylvian or endoscopic approaches were included, and their outcomes were assessed using a 5-point GOS at a 6-weeks follow-up. Results: A total of 102 patients were included in the study. Out of these, 54 were males(mean age: 54.7), and 48females (mean age: 56.13). Smoking was common in 42.2% of patients and alcohol intake (15.7%). The site of hematoma was 55.9% basal ganglia bleed and 44.1% hemorrhages of the frontal, occipital, parietal and temporal lobes collectively. Surgical outcomes at a 6-weeks follow up included a mortality of 11.8% (n=12), 27.5% (n=28) with moderate disability, and 60.8% (n=62) with good recovery. Conclusion: The etiology of ICH is attributed to a spectrum of modifiable and non-modifiable risk factors. Treatment strategies should focus on prevention of progression to secondary brain damage. Surgical intervention, if performed during the ideal time-window provides a good outcome in patients with ICH. Further studies are needed to evaluate the efficacy and best treatment strategy.
 

Lorenzo Giammattei, Mahmoud Messerer, Iype Cherian, Daniele Starnoni, Rodolfo Maduri, Ekkehard Kasper and Roy Thomas Daniel
Published 2018

ABSTRACT: Background: The available surgical options to control increased intracranial pressure and to limit secondary brain damage in the setting of severe traumatic brain injury (TBI) include decompressive craniectomy, cisternostomy, and other methods to divert cerebrospinal fluid (CSF) such as placement of an external ventricular drain. Methods: We discuss the rationale and the limitations of these surgical techniques based on preclinical and clinical evidence. A detailed description of the differences between ventricular CSF drainage and cisternal drainage is added based on recent hypotheses on TBI physiopathology and CSF circulation. Results: Cisternostomy seems a more physiological approach to the treatment of brain swelling, with the potential of effectively controlling intracranial pressure and reducing the effects of secondary brain damage. Conclusions: Further clinical studies need to be performed to validate the efficacy of this emerging surgical procedure for severe TBI.
 

Iype Cherian, Hira Burhan, Harshpreet Kaur and Rupesh Kumar Shreewastav
Published 2018

ABSTRACT: Introduction: The major emotions such as fear, anger, joy and sadness are created through a complex mechanism in the temporal lobe combining data from all the sensory inputs to the brain. However, these emotions may turn into extreme manifestations when the hypothalamus and the autonomic nervous system transform these emotions to panic, rage, orgasm/laughter and grief. The Papez circuit which is at play for this “different turn” may be inactivated or could be over ridden by forebrain activity, that is, sequencing. This probably was the reason to the old adage of counting to ten when one is emotional. In this article, we hope to look at the basis and the neurology behind this and formulate a method to overcome panic. Materials & Methods: A pilot study of 10 children aged 10 -16 was done on 16th October 2017. These children were shown pictures inducing fear and anger. A Visual Analogue Score (VAS) was used to determine the induced emotion. Next, the children were made to do sequencing tasks like mathematical calculations while viewing the similar graphics again. The new score was recorded and the data analyzed. Results: The most frequently recorded VAS (n=4) before sequencing was around 6.0, and between 3.0-3.5 post sequencing. The mean VAS without sequencing was 6.19 ± 0.91, which reduced to 3.65 ± 0.665. On comparing the individual VAS scores before and after sequencing, there was a general trend of a decreased VAS post-sequencing. The results were statistically significant with a p-value <0.05. Conclusion: The study indicated that some form of sequencing while perceiving the fearful or any emotional stimuli might blunt the emotion and may not produce extreme emotions. This would be an extremely interesting and useful piece of information for many who are in cutting edge professions and competitive sports. However, much study needs to be performed to further validate this initial conclusion. Journal of Nobel Medical College Volume 6, Number 2, Issue 11 (July-December, 2017) Page:29-34
 

Sunil Munakomi, Binod Bhattarai and Iype Cherian
Published 2017

ABSTRACT: Background: In developing nations like Nepal, spinal cord injury has multispectral consequences for both the patient and their family members. It has the tendency to cripple and handicap the patients, and burn out their caretakers, both physically and mentally. Furthermore, the centralization of health care with only a handful of dedicated rehabilitation centers throughout Nepal further places patients into disarray. This study was carried out as a pilot study to determine the modes of injury, age groups affected, clinical profiles and patterns of injury sustained, as well as the efficacy of managing a subset of patients, who have sustained cervical spine and cord injuries. Methods: This was a prospective cohort study comprising of 163 patients enrolled over a period of three years that were managed in the spine unit of College of Medical Sciences, Bharatpur, Nepal. Results: Road traffic accidents were implicated in 51% of these patients. 65% of them were in the age group of 30-39 years. Traumatic subluxation occurred in 73 patients with maximum involvement of the C4/5 region (28.76%). Good outcome was seen in patients with ASIA ‘C’ and ‘D’ with 55% of patients showed improvement from ‘C’ to ‘D’ and 95% of patients showed improvement from ‘D’ to ‘E’ at 1 year follow up. The overall mortality in the patients undergoing operative interventions was only 1.98%. Conclusions: The prevalence of cervical spine injuries in the outreach area is still significant. The outcome of managing these patients, even in the context of a resource limited setup in a spine unit outside the capital city of a developing nation, can be as equally as effective and efficient compared to the outcome from a well-equipped and dedicated spine unit elsewhere.
 

Yoko Kato, Yasuhiro Yamada, Akiyo Sadato, Mohsen Nouri, Iype Cherian, Teppei Tanaka and Joji Inamasu
Published 2017

ABSTRACT: Objective and Background To evaluate possible roles for indocyanine green (ICG)-based FLOW 800 software in surgical treatment of cerebral arteriovenous malformations (AVMs). Methods We perform ICG videoangiography several times for each step of AVM resection to elucidate feeders, drainers, and cerebral perfusion. Results Since 2010, 22 AVM surgeries in our department have been conducted using FLOW 800 intraoperatively. We demonstrated ICG angiograms, color-coded images, and semi-quantitative curves for AVMs. By reviewing all these modalities, we would define vascular structure of the AVM, proceed with resection, and finally recheck for any remnant. Conclusions ICG FLOW 800 software helps the surgeon to recognize feeding and draining vessels of an AVM intraoperatively. Further studies to evaluate semi-quantitative acquired data regarding blood flow and tissue perfusion are warranted.
 

Iype Cherian, Margarita Beltran, Alessandro Landi, Concetta Alafaci, Fabio Torregrossa and Giovanni Grasso
Published 2017

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. …

… The procedure of opening the basal cisterns can hence reduce the development of CSF shift edema by reopening the fluid pathways from the brain toward the basal cisterns via the Virchow-Robin spaces. 21 The surgical technique of opening the basal cisterns to release additional CSF to relax the brain and to facilitate intracranial surgery was popularized by Yasargil et al. 25 and forms one of the mainstays of surgical techniques in vascular and skull base surgery. …
… The idea of continued cisternal CSF drainage is also not new and has previously been used in the setting of acute aneurysmal SAH (aSAH) surgery. 21 The surgical procedure in itself (although new in trauma surgery) is a standard procedure that forms an integral part of skull base and vascular surgery. In cases of aSAH surgery, this procedure seems to be of paramount importance and the necessary steps of this surgical technique are similar to those of proposed cisternostomy in cases of severe TBI. …
 

Trichy N. Janakiram, Shilpee B. Sharma, Ekkehard Kasper, Onkar Deshmukh and Iype Cherian
Published 2017

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
Published 2016

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.

Giovanni Grasso and Iype Cherian Published 2016

Iype Cherian, Antonio Bernardo and Giovanni Grasso
Published 2016

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
Published 2016

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
Published 2016

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
Published 2015

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
Published 2015

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
Published 2015

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
Published 2015

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
Published 2015

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
Published 2014

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
Published 2014

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
Published 2014

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
Published 2013

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.

Iype Cherian
Published 2012

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, Ghuo Yi and Sanju Lama Published 2012

Iype Cherian, Sachet Shrestha, Moti Lal Panhani and Om Parkash Talwar
Published 2010

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
Published 2010

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.

Iype Cherian
Published 2010

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 Vikram Dhawan Published 2009
V Dhawan, Iype Cherian and N Mittal Published 2009

Iype Cherian and Sunil Munakomi
Published 2013

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.

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