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Objective: Terrorism-related bomb attacks on civilian population have increased dramatically over the last decade. Craniocerebral injuries secondary to improvised explosive devices have not been widely reported in the context of unarmored civilians. This series intends to report the spectrum of these injuries secondary to suicidal and implanted bombs as encountered at the Aga Khan University Hospital, Pakistan (AKUH). Further, a few pertinent management guidelines have also been discussed., Methods: The hospital database and clinical coding during a 5-year period were examined for head injuries secondary to terrorism-associated blasts. In addition to patient demographics, data analysis for our series included initial Glasgow Coma Scale, presenting neurological complaints, associated non-neurological injuries, management (conservative or operative) to associated complications, and discharge neurological status., Results: A total of 16 patients were included in this series. Among them 9 were victims of suicidal blasts while 7 were exposed to implanted devices. The patients presented with diverse patterns of injury secondary to a variety of shrapnel. A follow-up record was available for 12 of the 16 patients (mean follow-up: 7.8 months), with most patients having no active complaints., Conclusion: The results of this series show that civilian victims of suicidal and improvised bombings present with a wide range of neurological symptoms and injury patterns, which often differ from the neurological injuries incurred by military personnel in similar situations, and thereby often require individualized care.

Important reproductive events take place in the canine oviduct in the presence of increasing concentrations of progesterone (P4). To investigate the potential effects of P4 on the canine oviduct, the expression of nuclear (PR) and membrane (PGRMC1 and 2, mPRα, β and γ) P4 receptors was studied by quantitative RT-PCR and immunohistochemistry. Oviducts were collected from Beagle bitches after the onset of pro-oestrus and before the LH peak (Pre-LH), after the LH peak and before ovulation (Pre-ov) and on Days 1, 4 and 7 post-ovulation (n=6 bitches/stage). PR mRNA concentrations decreased from Pre-LH to Day 7 in the ampulla and isthmus, whereas both PGRMC1 and 2 mRNA levels increased over the same period. The main change in mPR expression was an increase in mPRβ and γ mRNAs at Day 7 in the isthmus. Furthermore, PR proteins were expressed in the nuclei of luminal epithelial, stromal and muscular cells, whereas the expression of PGRMCs and mPRs was primarily cytoplasmic and localised in the luminal epithelium. The immunostaining for PR decreased at Day 4 in the stroma and muscle, whereas it remained strong in the epithelium from Pre-LH to Day 7. PGRMC1 staining was strong at Days 4 and 7 whereas PGRMC2 was highly expressed from Pre-ov to Day 7. The most intense immunostaining signals for all three mPRs were observed at Day 7. Our results strongly support the hypothesis that P4 is an important regulator of oviductal functions in the bitch through complementary classical and non-classical P4 pathways.

Objective: To evaluate midazolam as an epidural analgesic in patients undergoing single-level microdiscectomy., Methods: This prospective case control study was carried out at the Aga Khan University Hospital, Karachi, from January 20 to September 20, 2007, on patients undergoing microdiscectomy. Cases (group A) received midazolam with saline, while controls (group B) received saline only, placed intra-operatively over involved nerve root. Post-operatively, patients were monitored for various variables. Data was analysed using SPSS 13.0 and groups were compared using student's t-test for continuous variables and chi square for categorical variables. P-value <0.05 was considered significant., Results: Patients in group A ambulated earlier (p = 0.005) and although they did not show significantly better post-operative pain control, but post-operative nausea and vomiting (PONV) score was better at six hours (p = 0.020). There was no difference in other variables such as requirement of analgesics, anti-emetics, hospital stay and complications., Conclusion: Midazolam may improve post-operative nausea and vomiting score, and may lead to earlier ambulation, without affecting patient's vitals, consciousness, lower extremity power or sensations, and is not associated with adverse effects.

Arachnoid cysts are congenital benign cysts accounting for approximately 1% of all intracranial mass lesions. Uncal herniation due to arachnoid cyst is a rare mode of presentation. It is hypothesized that only tension arachnoid cyst could cause the life-threatening condition that results from a progressive deterioration and worsening of a simple and usually congenital arachnoid cyst, associated with the formation of a "ball valve" at the point of an opening on the cyst wall. To-date only one case of an arachnoid cyst causing Uncal herniation has been reported to the best of our knowledge. We present a rare case of uncal herniation in a 60-year-old lady caused by a giant left temporal arachnoid cyst. She presented to us in emergency room after experiencing headaches since last one week followed by vomiting, seizures, and altered state of consciousness. She was operated immediately and marsupialization of the arachnoid cyst was performed. She showed good recovery. Although arachnoid cyst is a benign slowly growing pathology, it can lead to Uncal herniation as a "tension" arachnoid cyst, possible due to "ball-valve" mechanism. Elective treatment should be considered to prevent progressive significant enlargement of cyst.

Background. Developing countries, home to 80% of epilepsy patients, do not have comprehensive epilepsy surgery programs. Considering these needs we set up first epilepsy surgery center in Pakistan. Methods. Seventeen teleconferences focused on setting up an epilepsy center at the Aga Khan University (AKU), Karachi, Pakistan were arranged with experts from the University of Alberta Hospital, Alberta, Canada and the University of West Virginia, USA over a two-year period. Subsequently, the experts visited the proposed center to provide hands on training. During this period several interactive teaching sessions, a nationwide workshop, and various public awareness events were organized. Results. Sixteen patients underwent surgery, functional hemispherectomy (HS) was done in six, anterior temporal lobectomy (ATL) in six, and neuronavigation-guided selective amygdalohippocampectomy (SAH) using keyhole technique in four patients. Minimal morbidity was observed in ATL and, SAH groups. All patients in SAH group (100%) had Grade 1 control, while only 5 patients (83%) in ATL group, and 4 patients (66%) in HS group had Grade 1 control according to Engel's classification, in average followups of 12 months, 24 months and 48 months for SAH, ATL, and HS, respectively. Conclusion. As we share our experience we hope to set a practical example for economically constrained countries that successful epilepsy surgery centers can be managed with limited resources.

Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of Guidelines for the Management of Penetrating Brain Injury in 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on Guidelines for the Management of Penetrating Brain Injury and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI patients. Cerebral angiography is recommended in patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI patients.

Background: The management of cerebrospinal fluid (CSF) rhinorrhea has evolved over the last two decades. We present here a review of our 11-year data on CSF rhinorrhea and its management at a tertiary care hospital in a developing country, with particular reference to the diagnosis, surgical management and outcome of the disease., Methods: The medical charts of all patients with a diagnosis of CSF rhinorrhea over an 11-year period were reviewed. The etiology of CSF rhinorrhea was classified into three categories: spontaneous, iatrogenic and traumatic. All the patients were divided into three categories based on the type of management as conservative, intracranial and transnasal endoscopic groups., Results: A total of 43 patients fulfilled our inclusion criteria and were included in the final analysis. Eleven of the 43 patients were managed conservatively, while 22 underwent intracranial repairs; 10 patients had transnasal endoscopic repairs. The primary success rate for the transnasal approach was 70% compared to 86% for the intracranial repair. Blood loss, special care unit (SCU) stay and total cost were found to be significantly less in the transnasal endoscopic group. Computed tomography (CT) cisternography was found to have the highest sensitivity and specificity. Further, no postoperative complications were found in the transnasal endoscopic group, while five patients from the intracranial group developed various complications., Conclusions: We conclude that the transnasal endoscopic approach has comparable success rates with the intracranial approach and significantly lower morbidity.

Objective: To observe interdepartmental variation in the availability of resources and academic activities within the various neurosurgery programs of Pakistan., Methods: This was a proforma-based survey of neurosurgery trainees and young neurosurgeons of Pakistan, looking at the academic infrastructure and output of their programs. The proforma was filled by 36 respondents from 11 neurosurgery centers of the country. All these centers were accredited for neurosurgery training in Pakistan., Results: Out of the 36 respondents, 30 were completing a Fellowship training (FCPS) and six were enrolled for a Master in Surgery (MS) program. About 80% of the participants used the Youman's Textbook of Neurosurgery as a reference book. Only 40% of the candidates had access to more than one indexed neurosurgery journal. Structured academic sessions (e.g., journal clubs and neuropathology meetings) were lacking in a majority of the training institutes, 95% of the trainees had no microsurgical laboratory experience, and modern neurosurgical tools (frameless neuronavigation system, neuroendoscopy) were in use at a few centers only., Conclusion: Neurosurgery training in Pakistan is not uniform and wide variations exist between the programs at the centers evaluated. We recommend exchange programs between centers at national and international levels, to allow trainees to gain first-hand exposure to training components not available in their own center.

The authors report a rare case of extensive spinal epidural abscess in an immunocompromised young woman. The patient presented with low-grade fever, back pain, and progressive lower limb weakness. The MR imaging of her whole spine revealed an epidural abscess extending from C-1 to the sacrum. She was treated using a minimally invasive surgical technique and showed excellent recovery. The authors review the current literature along with different modes of surgical treatment available for this unusual clinical entity.

A 37-year-old woman presented with a 6 months history of headaches and memory impairment. Examination showed no neurological deficit with normal vision. MRI scans showed an enlarged optic chiasm. There was no dural or leptomeningeal enhancement or hydrocephalus. Open biopsy of the suprasellar mass showed non-caseating chronic granulomatous inflammation compatible with sarcoidosis. Systemic features of sarcoid were absent. Patient showed marked improvement on steroid therapy.

Background Context: Isolated tuberculosis (TB) of posterior elements is extremely rare. Only few cases are reported in literature but none described isolated spinous process involvement in the absence of disease process in any other part of the body., Purpose: The authors report a case of isolated tuberculous involvement of C2 spinous process, which to the best of our knowledge, is first such case report., Study Design: A case report of isolated C2 spinous process TB., Methods: Sixteen-year-old girl presented with two-month history of slow growing, painless lump at the back of her neck without any other symptoms. X-ray showed erosion of C2 spinous process. MRI also suggested an abscess., Results: Patient underwent incision and drainage of abscess and debridement of involved bone. Cultures and histopathology confirmed TB. Patient responded to antituberculous therapy., Conclusion: Posterior element TB is a rare condition but in countries where TB is common, its possibility should always be considered. Isolated TB of parts of posterior elements can occur in absence of disease elsewhere.

Stroke is the second leading cause of death worldwide. The aim of treatment in stroke patients is to prevent further neurologic deterioration and prevent recurrence. Despite all advances in medical treatment, morbidity and mortality in stroke patients is still very high. The other alternative is surgical treatment, which still lacks class 1 evidence. However there is recent reconsideration of this form of treatment and ongoing trials are showing some promising results. In this review the recent advances in surgical treatment of stroke will be discussed along with recommendations from the latest randomized trials.

Background: Ancient schwannoma is a rare variant of schwannoma, histologically showing atypical features that may result in erroneous diagnosis of a malignant tumor. There are only few reported cases in literature., Case Description: We report a case of a 34-year-old man who was found to have giant mediastinal tumor. He underwent thoracotomy to remove the mass, which was proven to be ancient schwannoma on histopathology., Conclusions: Clinical and radiological findings are important aids for further consideration of surgical removal of these potentially respectable tumors with good outcome.

In early 1990s, Jamison, Mosley and others concluded that a profound demographic and consequent epidemiological transition is taking place in developing countries. According to this classical model, by the year 2015, infectious diseases will account for only about 20% of deaths in developing countries as chronic diseases become more pronounced. These impending demographic and epidemiological transitions were to dominate the health sector reform agenda in developing countries. Following an analysis of fertility, mortality and other demographic and epidemiological data from South Asian and other developing countries, the paper argues that the classical model is in need of re-evaluation. A number of new 'challenges' have complicated the classical interplay of demographic and epidemiological factors. These new challenges include continuing population growth in some countries, rapid unplanned urbanization, the HIV/AIDS pandemic in Sub-Saharan Africa (and its impending threat in South Asia), and globalization and increasing marginalisation of developing countries. While the traditional lack of investment in human development makes the developing countries more vulnerable to the vicissitudes of globalization, increasing economic weakness of their governments forces them to retreat further from the social sector. Pockets of poverty and deprivation, therefore, persist giving rise to three simultaneous burdens for South Asia and much of the rest of the developing world: continuing communicable diseases, increasing burden of chronic diseases, and increasing demand for both primary and tertiary levels of health care services. While these complex factors, on the one hand, underscore the need for health sector reform, on the other, they make the task much more difficult and challenging. The paper emphasizes the need to revisit the classical model of demographic and epidemiological transition. It is argued that the health sector in developing countries must be aware of and effectively address these 'new challenges'. Although it has included data from many developing countries, the focus is primarily on South Asia.

The authors describe a sixty-four-year-old man who underwent coronary angiography for angina pectoris and was found to have a left coronary sinus aneurysm--an extremely rare malformation.

The authors describe a case of jellyfish sting that resulted in deep venous thrombosis of the leg and thigh of a thirty-five-year-old healthy man. The authors found no mention of this complication from jellyfish sting in the literature. Successful treatment measures are described.