CBNAAT: A Boon for Early Diagnosis of Tuberculosis-Head and Neck. Indian J Otolaryngol Head Neck Surg. 2018;70:572-577. [PMID: 30464918 DOI: 10.1007/s12070-018-1364-x]

CBNAAT: An Emerging Xpert in Diagnosis of Head and Neck Tuberculosis

Aims and Obctives

To compare FNAC, microscopy (ZN staining), histopathology and CBNAAT for diagnosis of head and neck tuberculosis, and to evaluate efficacy of CBNAAT in early diagnosis of tuberculosis in head and neck region.

Materials and methods

This prospective study was carried out in the department of otorhinolaryngology, JLN Medical College and attached hospital, Ajmer from August 2020 to September 2022. Thorough history and clinical examination of all patients presented with neck swelling was done. All relevant investigations including chest x-ray, mantoux test, ESR, FNAC, ZN staining, CBNAAT and histopathology were done and their efficacy was compared.

Results

Sensitivity and specificity of CBNAAT in detecting extra pulmonary tuberculosis was 85.19% and 91.30% respectively, and diagnostic accuracy was consistent with findings of FNAC and ZN staining (p < 0.001) for diagnosis of cervical lymphadenopathy.

Conclusion

CBNAAT has a promising role in early diagnosis of head and neck tuberculosis as well as other cases of smear negative tuberculosis such as MDR TB and TB-HIV and is optimal for the diagnosis of lymph node tuberculosis and helps in early identification and initiation of treatment. Sensitivity of CBNAAT scored twice as high in comparison with microscopy thus doubling the proportion of rapid diagnoses with important effect on the patient's outcome.

Rare clinical presentation of genital tuberculosis in an adolescent girl

Genital tuberculosis, a form of extrapulmonary tuberculosis (EPTB), exhibits distinct presentations. In the outpatient department, an adolescent girl reported severe pain and a feeling of heaviness in her lower abdomen for the past 6-7 days. An enlarged pelvic mass, resembling a 20-week pregnancy, was observed, seemingly originating from the pelvis. During the local examination, a transverse septum was felt in the lower vagina, with a vaginal length of 2-3 cm. The ultrasound revealed distension of the vagina with fluid containing fine internal echoes, indicating haematocolpos. MRI showed the uterus pushed upward and located at the level of the umbilicus, suggesting hydrocolpos. Based on these findings, a provisional diagnosis of transvaginal septum with haematocolpos was made. Under anaesthesia, a cruciate incision was made over the vaginal septum, resulting in the drainage of 700-800 mL of pus. The drained fluid was sent for microscopic examination, gram staining, acid-fast bacilli smear culture, and Cartridge-based nucleic acid amplification test (CBNAAT). The CBNAAT test confirmed the presence of tubercle bacilli. Antitubercular therapy was initiated, and on completion of the treatment, the girl experienced the onset of menarche. This is a typical case with an unusual presentation of EPTB. What makes this case noteworthy is its initial manifestation as haematocolpos, a condition that shares a similar clinical presentation with Müllerian anomalies.

Incidence, Diagnosis and Treatment of Otorhinolaryngological, Head and Neck Tuberculosis: A Prospective Clinical Study

Introduction  Tuberculosis is a disease of diversified presentation. It affects almost all organs in the body, and otorhinolaryngological, head and neck involvement is not an exception. Objective  To increase awareness about the different clinical presentations of otorhinolaryngological, head and neck tuberculosis, the techniques employed to diagnose it, and to assess the response to the treatment. Methods  We conducted a prospective study of 114 patients who presented primarily with otorhinolaryngological, head and neck tuberculosis. Routine blood investigations, chest radiographs, the tuberculin test, and sputum examination for the presence of acid-fast bacilli were performed in all cases. Site-specific investigations were performed in relevant cases only. The patients were treated according to the antitubercular treatment (ATT) regimen recommended by the Indian Ministry of Health and Family Welfare's National Tuberculosis Elimination Program (NTEP), and they were followed up clinically two and six months after starting the ATT. Results  Tubercular cervical lymphadenopathy was the most common clinical presentation (85.96%), followed by deep neck abscess (5.27%). Fine-needle aspiration cytology proved to be a reliable tool for the diagnosis of tubercular lymphadenopathy. Improvement at the end of 2 and 6 months of the ATT was observed in 90.35% and 96.50% of the cases respectively. Conclusion  The diagnosis of otorhinolaryngological, head and neck tuberculosis requires a high index of clinical suspicion, and the ATT proved to be very effective in reducing the severity of the disease.

Varied Presentation of Oropharyngeal Tuberculosis: Review of Cases

Tuberculosis (TB) is a chronic granulomatous infectious disease with 25% morbidity due to extrapulmonary form. Hence, knowledge about varied presentations of extrapulmonary oropharyngeal type may help in early diagnosis and management in acute as well as chronic settings. This article describes immunocompetent patients' presentation with varied oropharyngeal manifestations and later diagnosed with tuberculous tonsillitis and tuberculous abscesses with Pott's spine. The varied manifestation of oropharyngeal TB, which is supposed to be a chronic condition, may help in early diagnosis in acute and chronic settings.

ENT manifestation CCs in tuberculosis: a descriptive study

Background

An attempt was made to study ENT manifestations in tuberculosis.

Material and methods

A descriptive study was carried out among 200 patients with ENT manifestations of tuberculosis attending various departments at a government medical college hospital. Patients will be evaluated and followed up according to protocol. All patients diagnosed with tuberculosis were treated, according to the recent RNTCP guidelines using the CBNAAT testing.

Results

In the present study, 66% of patients with tuberculosis of the ear, nose, and throat region were females. Seventy-five percent of patients with tuberculosis of ENT and neck region were between the age group of 11 and 40 years. Cases of tubercular lymphadenitis (89.5%), tubercular laryngitis (4.5%), tubercular otitis media (3%), TB of the oral cavity (2%), and TB of the nose (1%) were seen. Painless lymph node enlargement was found in 91.62% of cases. Lymph node enlargement, hoarseness of voice, painless profuse otorrhoea, hearing loss, nasal obstruction, rhinorrhea, odynophagia, ulcers in the oral cavity, and tonsil enlargement were seen in patients of respective ENT tuberculosis. Concomitant pulmonary TB was found in 8.37% of cases of cervical TB, 100% of cases of laryngeal TB, 50% of cases of TB otitis media, 75% of cases of oral TB, and 50% of cases of nasal TB. Biopsy and CBNAAT have a promising role in tuberculosis management.

Conclusion

Early diagnosis of tuberculosis in ENT requires a high index of suspicion for patients non-responding to routine treatment

A Comparison Study of CBNAAT, Gene Xpert and Line Probe Assays in the Diagnosis of Tuberculosis in smear Negative Specimens

Tuberculosis (TB) is a serious and important public health issue to be addressed in India. Timely diagnosis of the drug resistance in tuberculosis is essential to ensure and initiate appropriate therapy. The detection of drug resistant Mycobacterium tuberculosis (MTB) in cases of smear-negative and clinical diagnosed pulmonary TB. A prospective case-control study was conducted on 473 pulmonary samples received at the tertiary care center from January 2019 to December 2019. All specimens were processed for microscopy and culture. CBNAAT- Gene Xpert and LPA Genotype MTBDRplus (VER 2.0) was used to confirm in smear-negative samples. Among the pulmonary samples, 52% smear-positive, and 48% smear-negative, 183 (43%) were found to be culture-positive by Lowenstein Jensen medium (LJ) and MGIT 960, 267 (63%) were positive CBNAAT and LPA n= 216 (51%) samples positive for the TUB band. The use of CBNAAT-Gene Xpert, Line Probe Assay Genotype MTBDR plus(VER 2.0) can be done from the samples directly and the diagnostic performance are more specific for detecting MTB in smear-negative specimens. This study suggests that LPA also helps in the diagnosis of MDR rapidly and in initiation of earlier treatment.

Changing Clinical Scenario of Tuberculous Otitis Media: A Case Series

Tuberculosis is a global health problem. Extrapulmonary tuberculosis remains to be a challenge in the diagnosis and treatment. Tuberculous otitis media being not so commonly diagnosed due to its varied presentation, early diagnosis and treatment remains to be a challenge. The aim of this study is to present the varied and unusual presentations and the importance of histopathological confirmation and new diagnostic tools like CBNAAT (cartridge based nucleic acid amplification test) which aids in the confirmation and to start anti-tubercular treatment (ATT). Five cases of tuberculous otitis media within a period of two years were included in the study. Among the five cases three cases presented with discharging sinuses, one with mastoid abscess and one with tuberculous otitis media with pulmonary origin. All five cases were confirmed with proper histopathological examination and two cases with CBNAAT (cartridge based nucleic acid amplification test) confirmation. Anti-tubercular treatment (ATT) was started and the patients were disease free. Tuberculous otitis media remains to be a rare complication of chronic suppurative otitis media and it has to be kept in mind while treating chronic suppurative otitis media. Classical presentations of tuberculous otitis media are not seen nowadays and the disease extending to the mastoid is the changing trend as the initial presentation. A proper suspicion with confirmation of the disease remains to be the gold standard for diagnosis and for treatment with anti-tubercular therapy.

Primary Laryngeal Tuberculosis Manifesting as Irregular Vocal Fold Lesion

Laryngeal tuberculosis is rare despite its close anatomical and physiological proximity to the lungs. It constitutes less than 1% of extrapulmonary tuberculosis. The symptoms of laryngeal tuberculosis are non-specific and mimic other laryngeal pathologies. The recent evolving and atypical endoscopic laryngeal features cause a diagnostic dilemma and delay in treatment. In this report, we presented three patients with distinct age and medical history, and hoarseness. Flexible videolaryngoscopy showed similar findings in the three cases, with irregular mucosa involving the entire length of the vocal fold, unilaterally in two cases and bilaterally in one. Mucosal waves were typically absent on laryngostroboscopy examination. The routine workup for pulmonary tuberculosis was unremarkable. The usage of Mycobacterium tuberculosis complex (MTBC) and rifampicin resistance (Xpert MTB/RIF) assay that detects Mycobacterium tuberculosis in the tissue biopsy specimens has helped in the rapid diagnosis of primary laryngeal tuberculosis and timely commencement of anti-tuberculous therapy. The clinical course and response to treatment were diverse in which two cases showed good response whilst the third developed disseminated tuberculosis despite optimal therapy.

Retrospective cohort analysis of survival of children living with HIV/AIDS in Mumbai, India

OBJECTIVES

To understand the survival in a cohort of children living with HIV/AIDS (CLHAs) and to study the factors associated with survival in CLHAs in government antiretroviral therapy (ART) centres in Mumbai, India.

DESIGN

This is a retrospective cohort analysis.

SETTING

Data from electronic ART records of children from 15 ART centres in Mumbai, Maharashtra, India.

PARTICIPANTS

2224 CLHAs registered in one of these ART centres from 2004 until October 2019. CLHAs up to the age of 18 at the time of registration were considered for these analyses.

PRIMARY AND SECONDARY OUTCOMES

We accessed the following data: date of test, date of initiation of ART, date of last follow-up, age at the time of registration, gender, potential route of infection, baseline CD4 counts, ART regimen, adherence and presence of co-infection (TB). We estimated the survival probabilities, plotted the Kaplan-Meier survival graphs and estimated HRs for mortality.

RESULTS

The mortality rate in our population was 22.75 (95% CI 20.02 to 25.85) per 1000 person-years. The 1-year survival was 0.92 (95% CI 0.91 to 0.93), 0.89 (95% CI 0.88 to 0.91) at 5 years and 0.85 (95% CI 0.83 to 0.87) at 10 years after initiation of ART. Children with adherence less than 80% had lowest survival in the first year (0.54, 95% CI 0.46 to 0.61). It reduced drastically at 5 and 10 years. After adjusting for demographic and clinical parameters, mortality was associated with poor adherence (<80%) (HR 11.70, 95% CI 8.82 to 15.53; p<0.001). However, CD4 counts of greater than 200 and age more than 1 year were protective.

CONCLUSIONS

Poor adherence to ART and low CD4 counts were significantly associated with higher mortality. Adherence counselling should be an important component of CLHA monitoring in all ART centres. It is also important to identify children early in the infection and start ART medications appropriately.

Diagnosis of anorectal tuberculosis by polymerase chain reaction, GeneXpert and histopathology in 1336 samples in 776 anal fistula patients

BACKGROUND

The association of tuberculosis (TB) with anal fistulas can make its treatment quite difficult. The main challenge is timely detection of TB in anal fistulas and its proper management. There is little data available on diagnosis and management of TB in anal fistulas.

AIM

To detect TB in fistula-in-ano patients were analyzed in different methods utilized.

METHODS

A retrospective analysis of different methods, polymerase chain-reaction (PCR), GeneXpert and histopathology (HPE), utilized to detect tuberculosis in fistula-in-ano patients, treated between 2014-2020, was performed. The sampling was done for tissue (fistula tract lining) and pus (when available). The detection rate of various tests to detect TB and prevalence rate of TB in simple vs complex fistulae were studied.

RESULTS

In 1336 samples (776 patients) tested, TB was detected in 133 samples (122 patients). TB was detected in 52/703 (7.4%) samples tested by PCR-tissue, in 77/331 (23.2%) samples tested by PCR-pus, 3/197 (1.5%) samples tested with HPE-tissue and 1/105 (0.9%) samples tested by GeneXpert. To detect TB, PCR-tissue was significantly better than HPE-tissue (52/703 vs 3/197 respectively) (P = 0.0012, significant, Fisher’s exact test) and PCR-pus was significantly better than PCR-tissue (77/331 vs 52/703 respectively) (P < 0.00001, significant, Fisher’s exact test). TB fistulas were more complex than non-tuberculous fistulas [78/113 (69%) vs 278/727 (44.3%) respectively] (P < 0.00001, significant, Fisher’s exact test) but the overall healing rate was similar in tuberculous and non-tuberculous fistula groups [90/102 (88.2%) vs 518/556 (93.2%) respectively] (P = 0.10, not significant, Fisher’s exact test).

CONCLUSION

This is the largest study of anorectal TB to be published. The detection of TB by polymerase chain-reaction was significantly higher than by histopathology and GeneXpert. Amongst polymerase chain-reaction, pus had a higher detection rate than tissue. TB fistulas were more complex than non-tuberculous fistulas but aggressive diagnosis and meticulous treatment led to comparable overall success rates in both groups.

Factors associated with survival in adult people living with HIV/AIDS (PLHAs) in Mumbai, India (2004-2019): A retrospective cohort study

Background:

Knowledge of factors that affect survival in People living with HIV/AIDS (PLHAs) on anti-retroviral therapy (ART) will help us develop and implement interventions to improve the clinical outcomes and survival in these individuals. The aim of this study was to estimate the survival in PLHAs on ART in the government ART programme in Mumbai, and the factors associated with survival in these individuals.

Methods:

It is a retrospective survival analysis of 28,345 adult PLHAs from 18 government ART centres in Mumbai (registration period 2004–2019). We estimated the mortality rates and their 95% confidence intervals [CIs], plotted the Kaplan Meier Survival curves, estimated incidence rate ratios (IRR) and hazard ratios (HR). There were done for the whole cohort and according to various demographic and clinical characteristics.

Results:

The mortality in PLHAs on ART was 9.04 per 1000 person years. The HR was significantly for those aged 50 years and more at the time of registration (HR: 3.01, 95% CI: 2.37, 3.83; P < 0.001), in those with baseline CD4 count of less than 200 higher hazard (HR: 1.83, 95% CI: 1.47, 2.27; P < 0.001), those with an adherence of 80–95% (HR; 5.58, 95% CI: 4.61, 6.75; P < 0.001) and adherence of <80% (HR: 9.37, 95% CI: 7.74, 11.33; P < 0.001). Furthermore, the hazard was significantly higher in those with TB compared those without TB (HR: 3.28, 95% CI: 2.87, 3.75; P < 0.001). Time from diagnosis (per month increase) to initiation of ART was not significantly associated with mortality.

Conclusions:

Increasing awareness about HIV testing and early detection of HIV in those who have high-risk behaviours, prompt diagnosis and management of TB among those infected, and developing and implementing strategies (such as enhanced counselling, telephone-based applications, messages, or reminders) to ensure ART adherence of more than 95% in those on ART will potentially help improve survival in PLHAs in India.

Xpert MTB/RIF Ultra and Xpert MTB/RIF assays for extrapulmonary tuberculosis and rifampicin resistance in adults

BACKGROUND

Xpert MTB/RIF Ultra (Xpert Ultra) and Xpert MTB/RIF are World Health Organization (WHO)-recommended rapid nucleic acid amplification tests (NAATs) widely used for simultaneous detection of Mycobacterium tuberculosis complex and rifampicin resistance in sputum. To extend our previous review on extrapulmonary tuberculosis (Kohli 2018), we performed this update to inform updated WHO policy (WHO Consolidated Guidelines (Module 3) 2020).

OBJECTIVES

To estimate diagnostic accuracy of Xpert Ultra and Xpert MTB/RIF for extrapulmonary tuberculosis and rifampicin resistance in adults with presumptive extrapulmonary tuberculosis.

SEARCH METHODS

Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, 2 August 2019 and 28 January 2020 (Xpert Ultra studies), without language restriction.

SELECTION CRITERIA

Cross-sectional and cohort studies using non-respiratory specimens. Forms of extrapulmonary tuberculosis: tuberculous meningitis and pleural, lymph node, bone or joint, genitourinary, peritoneal, pericardial, disseminated tuberculosis. Reference standards were culture and a study-defined composite reference standard (tuberculosis detection); phenotypic drug susceptibility testing and line probe assays (rifampicin resistance detection).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias and applicability using QUADAS-2. For tuberculosis detection, we performed separate analyses by specimen type and reference standard using the bivariate model to estimate pooled sensitivity and specificity with 95% credible intervals (CrIs). We applied a latent class meta-analysis model to three forms of extrapulmonary tuberculosis. We assessed certainty of evidence using GRADE.

MAIN RESULTS

69 studies: 67 evaluated Xpert MTB/RIF and 11 evaluated Xpert Ultra, of which nine evaluated both tests. Most studies were conducted in China, India, South Africa, and Uganda. Overall, risk of bias was low for patient selection, index test, and flow and timing domains, and low (49%) or unclear (43%) for the reference standard domain. Applicability for the patient selection domain was unclear for most studies because we were unsure of the clinical settings. Cerebrospinal fluid Xpert Ultra (6 studies) Xpert Ultra pooled sensitivity and specificity (95% CrI) against culture were 89.4% (79.1 to 95.6) (89 participants; low-certainty evidence) and 91.2% (83.2 to 95.7) (386 participants; moderate-certainty evidence). Of 1000 people where 100 have tuberculous meningitis, 168 would be Xpert Ultra-positive: of these, 79 (47%) would not have tuberculosis (false-positives) and 832 would be Xpert Ultra-negative: of these, 11 (1%) would have tuberculosis (false-negatives). Xpert MTB/RIF (30 studies) Xpert MTB/RIF pooled sensitivity and specificity against culture were 71.1% (62.8 to 79.1) (571 participants; moderate-certainty evidence) and 96.9% (95.4 to 98.0) (2824 participants; high-certainty evidence). Of 1000 people where 100 have tuberculous meningitis, 99 would be Xpert MTB/RIF-positive: of these, 28 (28%) would not have tuberculosis; and 901 would be Xpert MTB/RIF-negative: of these, 29 (3%) would have tuberculosis. Pleural fluid Xpert Ultra (4 studies) Xpert Ultra pooled sensitivity and specificity against culture were 75.0% (58.0 to 86.4) (158 participants; very low-certainty evidence) and 87.0% (63.1 to 97.9) (240 participants; very low-certainty evidence). Of 1000 people where 100 have pleural tuberculosis, 192 would be Xpert Ultra-positive: of these, 117 (61%) would not have tuberculosis; and 808 would be Xpert Ultra-negative: of these, 25 (3%) would have tuberculosis. Xpert MTB/RIF (25 studies) Xpert MTB/RIF pooled sensitivity and specificity against culture were 49.5% (39.8 to 59.9) (644 participants; low-certainty evidence) and 98.9% (97.6 to 99.7) (2421 participants; high-certainty evidence). Of 1000 people where 100 have pleural tuberculosis, 60 would be Xpert MTB/RIF-positive: of these, 10 (17%) would not have tuberculosis; and 940 would be Xpert MTB/RIF-negative: of these, 50 (5%) would have tuberculosis. Lymph node aspirate Xpert Ultra (1 study) Xpert Ultra sensitivity and specificity (95% confidence interval) against composite reference standard were 70% (51 to 85) (30 participants; very low-certainty evidence) and 100% (92 to 100) (43 participants; low-certainty evidence). Of 1000 people where 100 have lymph node tuberculosis, 70 would be Xpert Ultra-positive and 0 (0%) would not have tuberculosis; 930 would be Xpert Ultra-negative and 30 (3%) would have tuberculosis. Xpert MTB/RIF (4 studies) Xpert MTB/RIF pooled sensitivity and specificity against composite reference standard were 81.6% (61.9 to 93.3) (377 participants; low-certainty evidence) and 96.4% (91.3 to 98.6) (302 participants; low-certainty evidence). Of 1000 people where 100 have lymph node tuberculosis, 118 would be Xpert MTB/RIF-positive and 37 (31%) would not have tuberculosis; 882 would be Xpert MTB/RIF-negative and 19 (2%) would have tuberculosis. In lymph node aspirate, Xpert MTB/RIF pooled specificity against culture was 86.2% (78.0 to 92.3), lower than that against a composite reference standard. Using the latent class model, Xpert MTB/RIF pooled specificity was 99.5% (99.1 to 99.7), similar to that observed with a composite reference standard. Rifampicin resistance Xpert Ultra (4 studies) Xpert Ultra pooled sensitivity and specificity were 100.0% (95.1 to 100.0), (24 participants; low-certainty evidence) and 100.0% (99.0 to 100.0) (105 participants; moderate-certainty evidence). Of 1000 people where 100 have rifampicin resistance, 100 would be Xpert Ultra-positive (resistant): of these, zero (0%) would not have rifampicin resistance; and 900 would be Xpert Ultra-negative (susceptible): of these, zero (0%) would have rifampicin resistance. Xpert MTB/RIF (19 studies) Xpert MTB/RIF pooled sensitivity and specificity were 96.5% (91.9 to 98.8) (148 participants; high-certainty evidence) and 99.1% (98.0 to 99.7) (822 participants; high-certainty evidence). Of 1000 people where 100 have rifampicin resistance, 105 would be Xpert MTB/RIF-positive (resistant): of these, 8 (8%) would not have rifampicin resistance; and 895 would be Xpert MTB/RIF-negative (susceptible): of these, 3 (0.3%) would have rifampicin resistance.

AUTHORS' CONCLUSIONS

Xpert Ultra and Xpert MTB/RIF may be helpful in diagnosing extrapulmonary tuberculosis. Sensitivity varies across different extrapulmonary specimens: while for most specimens specificity is high, the tests rarely yield a positive result for people without tuberculosis. For tuberculous meningitis, Xpert Ultra had higher sensitivity and lower specificity than Xpert MTB/RIF against culture. Xpert Ultra and Xpert MTB/RIF had similar sensitivity and specificity for rifampicin resistance. Future research should acknowledge the concern associated with culture as a reference standard in paucibacillary specimens and consider ways to address this limitation.

A Rare Case of Parotid Gland Tuberculosis

Parotid gland tuberculosis is a very rare form of extrapulmonary tuberculosis, with less than 200 cases reported in literature. We describe a 10-year-old female who presented with a swelling in the left parotid region during the last month. CT scan neck revealed an abscess in the left parotid gland extending into the submandibular gland, muscles, and bone. Pus aspirated by FNAC showed acid fast bacilli in the ZN stain, and GeneXpert was positive for rifampicin-sensitive Mycobacterium tuberculosis. She was successfully treated with antituberculous therapy given for 6 months. Parotid gland tuberculosis, although rare, has a good prognosis with drug therapy. Surgery is rarely required.

Guidelines for Preoperative Testing for Neurosurgery in Coronavirus Disease 2019 (COVID-19) Era: Indian Viewpoint Amidst Global Practice

Preoperative testing and evaluation for coronavirus disease 2019 (COVID-19) have been an enigmatic challenge for the neurosurgical community during the pandemic. Since the beginning of the pandemic, laboratory diagnostic methods have evolved substantially, and with them has been the necessity for readily available, fast, and accurate preoperative testing methods. In this article, we provide an overview of the various laboratory testing methods that are presently available and a comprehensive literature review how various institutes and neurosurgical communities across the globe are employing them to ensure safe and effective delivery of surgical care to patients. Through this review, we highlight the guiding principles for preoperative testing, which may serve as a road map for other medical institutions to follow. In addition, we provide an Indian perspective of preoperative testing and share our experience in this regard.