Surgical cases of Tuberculosis of Central Nervous System

Tubercuolosis (TB) continues to be a major public health concern, especially in developing countries. TB is one of the top 10 causes of death worldwide . In 2016, 10.4 million people fell ill with TB; and 1.7 million died from the disease. In 2016, an estimated 1 million children became ill with TB and 250,000 children died of TB. 
Tuberculosis of central nervous system (CNS) can be treated effectively with anti-tubercular therapy (ATT). ATT duration for treatment of CNS TB is 12 months ( 2 months intensive phase and 10 months continuation phase). Some cases of CNS TB require neurosurgical intervention. I am presenting 3 cases of cranial TB where the presentations were unusual leading to delay in the diagnosis. All these three cases were effectively treated with neurosurgery along with ATT.

Patient 1 was a middle aged female with history of headace of long duration. CT scan of head revealed extradural collection beneath the frontal bone. The frontal bone was thickened. This was unusual as duration of symptom was in years and the bone above the lesion was thickened.

 Surgical image showing  pus coming out of frontal bone bur hole

As intensity of the headadche increased , patient was advised surgery. On craniectomy about 60 ml of pus came out under pressure. Patient became asymptomatic after surgery and ATT.

Patient 2 was a middle aged male with history of trauma and swelling over the vertex of skull about 15 days back. Patient was suspected to have scalp hematoma and swelling and was advised antibiotics and analgesics. CT scan showed a scalp swelling over the cranium. Patient underwent surgery and about 40 mL of pus was drained and it was sent for culture/ sensititivity, Gram stain , AFB stain. It came out positive for Staphylococcus. But, despite of prescribing antibiotic according to sensitivity, wound was not healing. Later, wound was re-explored and remaining pus drained out and bony osteomyelitis of the cranium was evident. Craniectomy of the pariental bone at the vertex was done and sent for histopathological examination. Biopsy was suggestive of tuberculosis.

                                                  Surgical image of the patient showing calvarial osteomyelitis

Patient's surgical wound healed with antibiotic and ATT. He became asymtomatic after taking ATT.

Patient 3 was a child of about 14 year age. He presented in emergency of my Institute with history of headache, vomiting, deterioration of conscious level, weakness of right half of body and recurrent seizures. CT scan of the brain and MRI of brain with contrast revealed intracranial subdural hypodense collections in interhemispheric fissure and left fronto-parietal convexity of brain.

                         Surgical image showing burr hole in the frontal bone and pus coming out of subdural space
Frontal region incision was made and single burr hole made in frontal bone under general anesthesisa. Dura was coagulated and incision made in dura. About 80 mL of thick pus came out under pressure. Patient improved after surgery and ATT.

Many types of neurotuberculosis have been described; most common intracranial forms are tuberculous meningitis and tuberculomas.Tuberculous brain abscess and subdural empyema are extremely rare manifestations of central nervous system tuberculosis. Subdural empyema or collection of pus in the subdural space is mostly pyogenic.  Intracranial tubercular subdural empyema is very rare in pediatric population. Various  diagnostic  modalities  and  treatment options  are  available  for  managing central nervous system tuberculosis (CNS  TB).   But, outcome  remains of CNS TB is poor as clinicians  face  many challenges  in  the  management  of  the  tubercular infection  of  the  brain  and  spinal cord.

Treatment of CNS TB is challenging due to lack of specific biochemical tests and inability to get the pathological sample from deeply located eloquent areas of CNS without causing any neurological deficit. Moreover, it is unnecessary to operate for biopsy in a patient who has presented with a very small granulomatious lesion in brain or spinal cord. In such as situations neuro-radiology helps in managing CNS TB and it may be the only source of establishing diagnosis and evaluating treatment response. Role of radiological investigation has expanded from the initial diagnosis to the therapeutic interventions. In some Muli-drug- resistant (MDR) CNS TB cases, stereotaxy or Ultrasonogram (USG) or CT guided biopsy helps in obtaining pathological sample and drug sensitivity testing. A regular clinical and neuro-radiological follow-up is mandatory during the entire course of anti tuberculous therapy to take prompt decisions to change ATT and to reduce morbidity and mortality associated with CNS TB.

Traditionally, culture for the mycobacterium is considered as gold standard for diagnosis of TB. But,  tuberculin  test,  biochemical  investigations and  AFB  stain  and  culture  of  the  cerebrospinal fluid  or  granulation  tissue  provide  little  support for the management of CNS TB or its sequelae.  There should be high index of suspicion for the CNS TB in a patient who is from an endemic region. There may be extensive tubercular involvement of CNS even  in  absence  of  the  history of pulmonary diseases,  tubercular  contact  or  any  other neurological  deficit.  It is difficult  to assess  the therapeutic response in the early follow up period in view of the lack of sensitive and specific tests. Vigilant clinical observation and imaging studies is required in the early follow up period to identify the  worsening  or  new  emerging  signs  in  the patients  of  CNS  TB.  Imaging  studies  are becoming  the  major  decisive  tools  for  the empirical  therapy  and  early  follow  up  of  the patients to evaluate the therapy.

Intracranial tubercular subdural empyema can be effectively treated with ATT and burr hole evacuation of pus. Close clinical observation, neuroradiological assessment with CT scan or MRI and prompt therapeutic interventions   are  necessary  for starting the empirical anti-tuberculous  therapy and early follow up of the patients to evaluate the therapeutic response. 

 In all these cases pus was negative for Acid Fast Bacillus (AFB). This is very common observation. So, high index of suspicion and close follow up is required in suspected cases of cranial TB. Clinical observation with empirical ATT is key in the management of CNS TB cases.

References

1.       An unusual presentation of neurotuberculosis: subdural empyema . Case report. Cayli SR, Onal C, Kocak A, Onmus SH, Tekinen A. J Neurosurg 2001 Jun; 94(6): 988-91

2.       Global tuberculosis report 2017, WHO ( www.who.int)

3.       Pediatric intracranial subdural empyema caused by Mycobacterium tuberculosis- a case report and review of literature. Banerjee AD, Pandey P, Ambekar S, Chandramouli BA. Child Nerv System. 2010, Aug: 26(8): 117-20.doi 10.1007/s00381-010-1157-3 Epub 2010 May 2

4.       Intracranial tuberculous subdural empyema: case report. Van Dellen A, Nadvi  SS, Nathoo N, Ramdial PK. Neurosurgery 1998, Aug; 43(2), 370-3.

5.        Vijaykumar B, Sarin K, Girija Mohan. Tuberculous brain abscess and subdural empyema in an immunocompetent child: Significance of AFB staining in aspirated pus. Ann Indian Acad Neurol. 2012, Apr-Jun, 15(2):130-133.

6.       Gautam VKS, Khurana S & Singh R. Diagnostic and therapeutic challenges in the surgical management of CNS tuberculosis. International Journal of Medicine and Health Sciences, 2013, Vol-2;Issue-2, 161-169. 

Concussion

Concussion means transient loss of consciousness due to head injury.
Concussion is also known as Mild Traumatic Brain Injury (MTBI). 
It may be described as alteration of consciousness without structural damage as a result of head trauma. 

It is transient loss of consciousness or alteration in mental status like alteration in conscious level,  disturbance of vision or balance due to head injury.

Trauma to the head may cause sudden linear or rotational movement of the brain.  This sudden acceleration and deacceleration  movements of the brain and brain stem disrupts the normal cellular activities in the brain ( including fornix, corpus callosum, temporal lobe, frontal lobe) and in the the reticular activating system of the midbrain.  

Although, concussion is considered as mild head injury but sometimes it has sequelae. Headache, confusion, amnesia, blurring of vision, dizziness, fatigue  may persist for some time.  More alarming long term sequelae are the cognitive impairment, sleeplessness, difficulty in concentration,  irritability, anger, behavioural abnormalities, or maladjustment in the work or studies.

Plain CT scan of brain is the investigation of choice. It is normal in cases of concussion because it is a physiological impairment and so, no anatomical abnormality is seen on non-contrast CT scan of the brain. MRI of the brain is not required and  is unnecessary. MRI will demonstrate abnormalities in up to 25% of cases where CT is normal. But, I do not suggest MRI in cases of concussion because CT actually guides the treatment. So, if CT is normal there is nothing serious and no active neurosurgical treatment is required. MRI just adds to the apprehension of the patients and their relatives and it does not provide any additional information of any use to the neurosurgeon.

Symptoms usually resolve in approximately two weeks. But, symptoms may persist for longer period.

Every person with post traumatic concussion requires emotional support. 
Patient’s caregivers, family members, teachers and co-workers and colleagues must understand that some symptoms like irritability, headache, dizziness may be sequelae of concussion.  So,  a sympathetic and considerate attitude should be adopted towards the person who had suffered mild head injury with concussion and is experiencing long term sequelae of mild head injury. 
Symptomatic treatment of like dizziness may be trated with Betahistine or Cinnarazine. Headache is a common complaint and requires both medical and psychological support.
Neurotrophic vitamins like vitamin B complex, Methylcobalamin,  vitamin E are useful.  Anxiety, sleeplessness are very well managed with tablet Clonazepam 0.25 mg at night and Psychological support.

Spina Bifida, Spinal Dysraphism, Myelomeningocele and Meningocele

Spinal dysraphism means a spectrum of congenital anomalies of the spine and spinal cord.

Spina bifida is a common form of spinal dysraphism. The term spina bifida includes a wide variety of anomalies.
  
Congenital defect in the spine leads to spina bifida. This can be of two types: spina bifida occulta and spina bifida aperta.

In spina bifida aperta; visible lesion, like a swelling over the midline of the back may be noticed at the time of birth of a child. Such spinal dysraphism is known as Spinal Bifida Aperta.

But, a child may be having some abnormalty of the spine or spinal cord but without any externally visible lesion and overlying skin is intact, then it is known as Spina Bifida Occulta.  This defect of the vertebrae of the spine of a child may not be visible at the time of birth and there may be no visible exposure of meninges or neural tissue. And, there may be congenital defect only in the lamina of the vertebrae of the spine without any involvement of underlying spinal cord. This is known as spine bifida occulta.

But, in spina bifida aperta there is a visible or open defect in the spine. There may be congenital defect in vertebral arches with cystic distension of meninges which is filled with CSF and is known as Meningocele. If, in this congenital defect of the vertebral arches there is a cystic dilatation of meninges and cerebrospinal fluid along with neural tissue or spinal cord ( Myelon) , then it is known as Myelomeningocele. If Myelomengocele contains fat tissue, then it is known as Lipomyelomengocele.

Myelmeningocele is one of the congenital open neral tube defect present at the birth on the back of the newborn.

It is a common type of congental defect of the spine and its incidence is about 1 in 1,000 live births. Better nutrition and folic acid suplementatiion during the antenatal care of the mother decrease its occurrence.

Ultrasound study during the early antenatal care detects any occurrence of myelomeningocele in a fetus during pregnancy.

A newborn child should be assessed for any sensory or motor deficit due to meningocele or myelomeningocele. There may be associated congenital lesions, like cardiac lesions. Myelomeningocele may be associated with congenital hydrocephalus. So, MRI of the spinal cord and brain is investigation for choice for assessing a case of meningcele. MRI may show whether a swelling on the back of a child is only flled with CSF or does it contain any neural tissue. It detects any intraspinal extension, associated intrasinal dermoid, lipoma, dermal sinus, spina bifida, spinal dysrahism like duplication of the cord, any bony spur between the duplicated cord, Chiari malfomation, syrinx, hydrocephalus, thickened filum terminale, etc. So, MRI helps in diagnosis, surgical planning and predicting prognostic outcome.
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Arachnoid cysts, Ependymal cysts, Benign intracranial developmental cysts

Intracranial Benign Developmental Cysts

Arahnoid cysts and Ependymal cysts

It is very common observation in brain imaging to find small cysts inside the brain. These cystic areas resemble and look like areas of the brain with normal cerebrospinal fluid. Such incidental finding increase anxiety in the person in whom brain imaging was usually  done for some other purpose. Such cysts are usually arachnoid cysts or ependymal cysts.

Arachnoid Cysts

Arachnoid cyst is a benign intracranial developmental cyst which is between two split layers of arachnoid and it usually contains clear colurless CSF.

So, arachnoid cyst is a cyst containing CSF and it forms due to splitting of the archnoid membrane. These are benign congenital malformation.

It is usually an incidental finding.

They are commonly seen in Sylvian fissure, cerebellopontine angle, supracollicular area, vermian area, sellar and suprasellar area, etc. This may appear at any age from infancy and adolescence to adults.

Arachnoid cyst may remain asymptomatic throughout life, only to be diagnosed incidentally by a neuroimaging study. Imaging often shows remodelling of bone, and imaging characteristics exactly mimic CSF on CT and MRI in most cases.

Symptoms and signs of arachnoid cyst depend on its size and location inside the brain and spinal cord.

Recommendation for incidentally discovered arachnoid cyst in adults: a single follow up imaging study in 6-8 months is usually adequate to rule-out any increase in size. Subsequent studies only if concerning symptoms develop.

Sylvian fissure archnoid cyst may present with headache, seizures, dysarthria (speech problem),  focal bulge in temporal region, exophthalmos, papilloedema, and hemiparesis.  X-ray skull or CT scan may show evidence of expansion of the middle cranial fossa, elevation of the lesser wing of the sphenoid, forward protrusion of the greater wing the sphenoid bone and outward expansion and thinning of the temporal bone. But expansion of skull in relation to arachnoid cyst is not an indication for surgery , but mass effect, displacement of midline structures and presence of obsructive hydrocephalus are indications for surgical intervention for middle fossa arachnoid cysts.

On CT, arachnoid cyst appear as low density, smooth bordered lesions having attenuation values similar to that of CSF. The cyst wall has well-defined margins and does not enhance after intravenous injection of contrast agent.

MRI is better at demonstrating multiplanar relationship and characteristics of the lesion on T1, T2, FLAIR, Diffusion weighted images and contrast, MTR ( Magnetization transfer ratio), MRS ( MR spectroscopy), MRA ( MR angiography)study. It helps in differentiating arachnoid cyst from epidermoid, dermoid, lipoma, ependymal cysts, tumors like low grade glioma & metastasis, old hemorrhage, cavernoma, hydatid cyst, hemangioma, and infective granulomas.

On T1 weighted image arachnoid cyst appears hypointense and on T2 weighted image it appears hyperintense like CSF. On T1 weighted MRI ,  lipomas will appear hyperintense as fat appears hyperintense on both T1 and T2 weighted images.

The high protein content of a nonhemorrhagic tumour cyst will cause the cyst to appearslightly hyperintense to CSF on proton density images. The associated peritumoural oedema of cystic astrocytoma will look hyperintense on FLAIR image of MRI.

Ependymal cysts and epidermoid tumors appear isointense or slightly hyperintense to CSF on proton-density images. Epidermoid tumors are more likely to be lobulated, have less distinct margins, and encase rather than displace neighbouring structures. Diffusion-weighted imaging reflects the amount of Brownian motion of proteins which is greater in cystic than in solid lesions.

Sylvian fissure is the most common site for intracranial arachnoid cysts. Sylvian fissure arachnoid cyst may be of three types. It may be a small lenticular lesion at the anterior pole of the middle cranial fossa without any mass effect (Type 1) or quadrangular in shape reflecting a completely open insula (Type II) .  Type III sylvian fissure arachnoid cyst presents as large rounded area with significant compression of the brain. Displacement of the midline structures in type III cysts is an indication for surgical decompression.

Treatment of archnoid cyst

Adults with asymptomatic arachnoid cyst should be treated conservatively, even for large cysts without symptoms and signs or with only a complaint of headache. Only arachchnoid cysts which cause a mass effect or neurological deficit should be treated surgically.

In children, decompression of sylvian fissure archnoid cyst is more likely to lead to decreased parenchymal compression, cyst collapse, and subsequent resolution if intracranial hypertension and neurological deficits.

Ventriculoperitoneal shunting

Cystoperitoneal shunting

Cyst fenestration

Cyst excision

Skull may be very thin and may be even eggshell-like, so care must be taken in placing burrhole during surgery. The dura is bluish because of presence a large pool of fluid underneath. The exposed cyst wall may be clear and transparent; in some  areas  a web of milky thickening may be noted as a result of collagen reinforcement. The forntal lobe appears widely separated from the temporal lobe because of the failure of opercula to develop. So, the insula and branches of middle cerebral artery may be completely exposed after excision of the sylvian fissure arachnoid cyst. When the outer wall of the cyst is excised, clear CSF escapes. Long bridging veins may be observed either on the surface of the cyst or within the cyst. Bridging veins that traverse the cavity of the cyst do not have much support. Rupture of such unsupported veins account for high incidence of subdural hematoma associated with these cysts.

Fenestration of deep wall of cyst creates a communication between the sylvian fissure cyst and the chiasmatic cistern.

A significant number of middle cranial fossa arachnoid cysts are associated with bleeding hematomas which are usually venous in nature and result from tearing of bridging veins within or external to the cyst.  It may precipitate symptoms in a previously asymptomatic patient.

Arachnoid cyst in sella turcica

Sella turcica arachnoid cyst may be intrasellar or suprasellar. Suprasellar cysts are by far the more common. It may present with hydrocephalus, visual impairment, endocrine dysfunction ( hypopituitarism, stunted growth, etc), gait disturbance. A curious head nodding motion described as the “ bobble-head doll syndrome” has been described in suprasellar arachnoid cyst. The nodding or bobbing consists of irregular involuntary head motions in the anteroposterior direction occurring two to three times per second.The motion is reminiscent of that seen in dolls with a weighted head resting on a coiled spring; hence the name of this syndrome. Some degree of mental retardation is associated with this syndrome.

Treatment of suprasellar sella turcica arachnoid cysts are ;endoscopic ventriculostomy with concomitant fenestration of lamina terminalis, subfrontal cyst excision with communication to the basal cisterns, and transcallosal or transventricular cyst excision with concomitant cystoperitoneal shunting.

Treatment of intrasellar sella turcica arachnoid cysts is trans-sphenoidal approach with packing of sella with fat or fascia or muscle tissue.

Arachnoid cysts in Interhemispheric Fissure

Two types of arachnoid cysts occur near the midline in the supratentorial space.

1.       Interhemisheric cysts with associated partial or complete corpus callosal agenesis.It straddles the falx and extends equally on either side, compressing the medial surface of both hemispheres. A coronal MRI shows a “ bat-wing” appearance of the lateral horns and dorsal displacement of the third ventricle.

2.       Parasagittal cysts are usually not associated with agenesis of the corpus callosum. The cyst is strictly unilateral and is sharply limited by falx in the midline, thus it tends to be wedge shaped. There is a marked bulging of the frontal and parietal bones in the parasagittal area. The superior sagittal sinus and falx cerebri are considerably off the midline.

Cerebral convexity arachnoid cyst

In infants, it may present with progressive asymmetrical enlargement of head. MRI findings may mimic subdural hygroma, but without an enhancing membrane

In adults, the lesion may present with seizures, headache , papilloedemaand progressive contralateral hemiparesis.  Skull films  may show erosion of the inner table of the skull. CT scan shows biconvex or semicircular area of lucency over the convexity without an enhancing membrane. Surgical therapy consists of excision of the outer membrane of the cyst.

Quadrigeminal cistern arachnoid cysts

These cysts behave like pineal masses and present with hydrocephalus and Parinaud’s syndrome. Therapy consists of excision of the cyst wallthrough an occipital transtenorial approach, with or without insertion of cystoperitoneal shunt.  

Cerebellopontne angle arachnoid cysts

Clinical presentation of arachnoid cyst in CP angle may mimic that of an acoustic neuroma.

Posterior fossa arachnoid cysts

Posterior fossa arachnoid cysts may present in the midline near the fourth ventricle or the cistrna magna, or paramedian area opposite the cerebellar hemisphere. X-ray skull may show a focal expansion of the occipital bone. Diffrential diagnosis of midline posterior fossa arachnoid cyst include mega cistern magna, Dandy-Walker malformation, epidermoid cyst, cystic glioma and hemangioblastoma.

Clival region arachnoid cysts

The clival region is uncommon site for intracranial arachnoid cyst. Although termed clival , the cyst may extend into the interpeduncular cistern or the cerebellopontine angle. The cyst displaces the midbrain and pons dorsally along with basilar artery.The cranial nerves are stretched , elongated , and draped around the cyst.

Other rare locations of arachnoid cysts are  intraventricular, diploic space, etc.

                                         Diagrammatic representation of 3 types of Sylvian fissure arachnoid cyts

Diagrammatic representation of probable mechanism of formation of ependymal cyst 

Two types of interhemisheric arachnoid cysts

   

Ependymal cysts

Ependymal cysts may mimic arachnoid cyst clinically and on imaging studies. They occur much less frequently than arachnoid cysts. They occur in central white matter of the frontal and temoporopatrietal lobes, causing progressive neurological deficits, seizures and features of raised intracranial pressure. The protein content of the cyst fluid is generally greater than that of the CSF; on MRI the cyst will typically appear isointense or slightly hyperintense to CSF on proton density images. The wall is lined by columnar or cuboidal cells with or without cilia. Blepharoplasts may or may not be identifiable , These cysts never communicate with the ventricular system. They are believed to arise by the sequestration of a small segment of the primitive ependymal lining into either the cortical mantle or the perimedullary mesh . treatment consists of drainage of the cyst and excision of its wall.

Sources

Neurosurgery, second edition, volume III Editors: Robert H.Wilkins and Setti S.Rengachary, McGraw –Hill, Chapter 374; Intracranial arachnoid and ependymal cysts by Setti S. Rengachary and Jerome D.Kennedy, pages 3709-3728

Wikipedia

Handbook of neurosurgery , Mark S Greenberg, 7^th edition, Thieme

Tuberculosis of Brain and Spine

I have published a book on Tuberculosis of Brain and Spine. This book is intended to apprise the readers about the strategy to diagnose and promptly treat tubercular infections of the brain, spinal cord and vertebral bodies of the spine. I have made an attempt to propose a method to effectively treat this disease in order to avoid morbidity and mortality associated with TB of central nervous system. Many patients of intracranial and spinal TB can be diagnosed and treated without any surgical intervention. I have incorporated sonme cases who were referred to me for neurosurgery, but they were cured completely without any surgery. So, this book is especially useful for the Physicians, Pediatricians, Orthopedicians , Neurologists and Neurosurgeons.

I need feedback of the readers and others who are involved in treating patients of Extrapulmonary Tuberculosis, So that I can further improvise my clinical approach for the better clinical management. 

Colloid Cyst

Colloid cysts are slow growing benign intraventricular tumor of anterior third ventricle. These constitute less than 1% of all intracranial tumors. It constitutes 14% of intraventricular tumors. It is commonest third ventricular tumor.
It is presumed that it originates from roof of third ventricle from rudimentary paraphysis ( evagination in roof of 3rd ventricle during development). It comprises of fibrous epithelial lined cyst filled with either mucoid or gelatinous or dense hyloid substance.
It is commonly seen in between age groups 20 and 40 years. Colloid cyst is usually located in the anterior third ventricle, at the level of foramen of Monro. It may block the cerebrospinal fluid ( CSF) flow causing symmetrical dilatation of both lateral ventricles and obstructive hydrocephalus. It may present insidiously or suddenly. Headache is a common presentation. Intermittent and postural nature of attacks are other common type of presentation. Drop attack due to sudden weakness of lower limbs with headache is also commonly seen in patients with colloid cyst.
Other common symptoms of colloid cyst are diplopia, gait disturbance, vomoting, disturbed mentattion, blurred vision, incontinence, and vertigo or dizziness.
Occurrence of intermittent symptoms is chracteristic of colloid cyst.
CT scan or MRI with contrast is able to detect a rounded lesion in the anterior third ventricle. Most clinicall significant cysts are more than 1.5 centimeter is size. It may show minimal enhancement or no enhancement on CT or MRI. So, the enlargement of both lateral ventricles and sparing of third and fourt ventricle along with a small globular intraventricular lesion at the level of Foramen of Monor should establish the diagnosis of colloid cyst.
Image 1: CT scan of the brain showing axial view of brain with a hyperdense lesion in the anterior third ventricle with enlargemtnt of both lateral ventricles.

                                                       Image 1 source: radiopaedia.org

Neurosurgery is the definitive treatment. Lumbar Puncture ( LP) is contraindiacted due to risk of herniation. It should be treated surgically as there is risk of acute hydrocephalus and sudden neurological deterioration. Open transcranial surgery or endoscopic neurosurgery are the treatment options. Transcranial surgery may be transcallosal  or transcortical. Endoscopic neurosurgical excisison is the mainstay of treatment.
Trancortical approach involves reaching the third ventricle through right sided middle frontal gyrus. It is feasible when ventricles are enlarged.
Transcallosal approach involves approach to the 3rd ventricle either via the foramen of Monro or by interfornicial approach. This approach can be used even if ventricles are not enlarged. There is risk of venous infarction or fornicial injury in this approach.Injury to the fornisx is associated with memory deficits or behaviour abnormalities.

Reference
1. Handbook of Neurosurgery by Mark S Greenberg 7th Deition, Thieme publication
2. https://en.wikipedia.org/wiki/Colloid_cyst
3.radiopaedia.org

Prescription Audit

Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of care
against agreed and proven standards. The audit cycle includes the assessment of clinical management according to the standards of quality care and interventions then to re-measure the outcome to
make further improvements.
Aim of the audit is to identify & rectify the deficits and then improve. Monitoring , Assessment, Feedback, Discussion, Reassessment are important steps to make any improvement in medical management in healthcare organization.
The mistakes are bound to occur in situations where doctors are treating, reviewing the history, examining the patient as well as documenting the patient care. So, aim should be to improvise the process and not just the fault finding. Moreover, such audit should be done by the medical and para-medical professionals who are the stakeholders in medical management and understand the problems of the patient and doctors. So, medical audit or prescription audit is no way similar to financial audit. In prescription audit the standards should be according the evidence based medical practice. These standards should be achievable in that particular health care system.
The expected standards of an ideal prescription includes:
Prescription must contain the name of the patient , age and gender of the Patient.
Prescription card or note must be dated.
Prescription must be written in a legible manner where the dose, frequency and duration of treatment is clearly mentioned.
Each prescription must be signed by the doctor and doctors identity is clear.

The most common task done by doctors is the writing of prescription. This prescription bears the details of all the drugs including the instructions and name and signature of the physician. If not written appropriately it may loss to the patient including medication errors and adverse drug events
(ADE).
The doctors bears the legal responsibility for prescribing ethically and appropriately.

Prescription audit helps :
1. To prevent the practice of prescribing expensive, unnecessary , irrational and non-essential medicines by the physicians
2. To curtail the practice of writing costly branded drugs when the equally effective cheaper and generic drugs are available
3. To identify shortcomings in prescription writing
4. To reduce omissions in prescription writing by continuous evaluation and feedback to the doctors
5. To measure the extent to which information recorded on Out-Patient Card or In-Patient case file record sheet conforms to the guidelines for prescribing drugs.  Prescription audit measures the compliance with standards set by the health care organization.
6. To articulate measures to improve prescription practices of the doctors.
7.To understand the pattern currently being followed by the doctors and include the drugs in hospital formulary.

The prescription audit improves the prescribing practice in any hospital. Audit is a valuable tool for monitoring compliance to prescribing and administration standards and for encouraging continued improvement in clinical practice.
Physicians, nursing professionals and pharmacists have an important role in continuous evaluation, feedback and improving the quality of health care.
Prescription audit is an important mechanism to improve the quality of healthcare and makes medical care affordable to everyone.