Comparative analysis of supra-orbital keyhole approach and pterional approach for surgical clipping of intracranial anterior circulation aneurysms in patients with favorable Hunt and Hess grades

INTRODUCTION

Traditional large craniotomies have been the standard for aneurysm surgery. However, minimally invasive "keyhole" approaches have gained popularity for aneurysm clipping in recent years. This study focuses on Supra-Orbital Keyhole Approach (SOKHA),its use in clipping of aneurysms of the anterior Circle of Willis. Here we share the experiences of a tertiary care center regarding aneurysm clipping using SOKHA.

MATERIALS AND METHODS

We retrospectively reviewed 166 cases involving aneurysm clipping, with 62 patients undergoing SOKHA and 104 patients undergoing the pterional approach. Factors evaluated included patient demographics, aneurysm characteristics, incidence of intraoperative complications, temporary-clipping usage, and postoperative clinical outcomes. Glasgow Outcome Scale scores were utilized to assess clinical outcomes.

RESULTS

The study found that both the SOKHA and pterional approaches were similar in terms of age distribution, Hunt and Hess grades, and the incidence of hydrocephalus. The majority of aneurysms in both groups were anterior communicating artery aneurysms.Hydrocephalus was observed in 14.5 % of SOKHA cases and 13.5 % of pterional cases. Intraoperative aneurysm rupture occurred in 8.1 % of SOKHA cases and 7.7 % of pterional cases. There were no mortalities in the SOKHA group, while the pterional group had 1.92 % mortality rate. At the last follow-up, 77.4 % of SOKHA cases and 75.9 % of pterional cases had a favorable outcome (Glasgow Outcome Scale IV and V), with no significant difference.

CONCLUSION

SOKHA offers the advantage of potential cosmetic benefit with neurological outcomes comparable to those of the traditional pterional approach, in properly selected patients.

Contribution of Deep Cerebral Venous Anomaly to the Emergence of Nonaneurysmal Subarachnoid Hemorrhage as Opposed to Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

The exact reason of nonaneurysmal subarachnoid hemorrhage (SAH) is an enigma. The aim of this study is to identify if type III deep cerebral venous drainage is exclusively prevalent in patients with nonaneurysmal SAH and to enumerate the predictors of poorer outcome in these patients.

METHODS

All patients of age >18 years, presented at our centre with spontaneous SAH on noncontrast computed tomography head and were divided into 2 groups, aneurysmal and nonaneurysmal SAH after 4-vessel DSA. Based on the deep venous drainage pattern on both sides, basal venous drainage was found and classified into 3 types: type I, type II, and type III. The 3 groups were pitted against one another. Regression analysis were performed to predict the occurrence of nonaneurysmal-SAH with different types of basal vein.

RESULTS

There were 100 nonaneurysmal SAH cases and 103 aneurysmal SAH cases. The mean age of presentation was 47.8 ± 13.55 years with slight male predominance (52%). The patients with type III venous drainage have 2 times more risk of developing nonaneurysmal SAH (95% confidence interval = 1.21-4.31) as compared to those with aneurysmal SAH. On multivariate analysis, type III basal venous drainage, worse Hunt and Hess grade at presentation, extensive bleeding were predictors of an adverse outcome.

CONCLUSIONS

The presence of type III venous distribution is associated with a 2-fold increase in the probability of having nonaneurysmal SAH, as well as a 3-fold increase in the risk of developing poorer neurological sequelae.

Expanding the Horizons of Minimally Invasive Spine Surgery: Experience of the Destandau Technique for the Treatment of Multiple Spinal Diseases

OBJECTIVE

Minimally invasive spine surgery is rapidly gaining popularity because of its versatile nature. Traditionally, prolapsed disc has been the most common disease targeted using this technique. However, its usefulness for various other diseases has also been shown in studies. We present our experience of using this technique for various spinal diseases apart from prolapsed discs.

METHODS

This is a retrospective study in which patients operated on by a single surgeon from January 2019 to April 2023 were included. Cases that required conversion to open technique were excluded. Intraoperative findings and postoperative courses were obtained from patient records.

RESULTS

A total of 47 patients were included in the study, of whom 29 were male and 18 were female. The various diseases treated comprised intradural extramedullary (IDEM) tumors (n = 23), hypertrophied/ossified ligamentum flavum (n = 9), arachnoid cysts (n = 6), dermoid/epidermoid cysts (n = 4), detethering of cord (n = 3), and posterior cervical decompression for an ossified posterior longitudinal ligament (n = 2). The average duration of surgery was 2.1 ± 1.2 hours and the mean intraoperative blood loss was 138.4 ± 59.1 mL. The mean length of hospital stay was 2.3 ± 0.9 days. Two patients had superficial wound infection and none of the operated patients had cerebrospinal fluid leakage. Re-exploration was not required in any of the operated patients.

CONCLUSIONS

Minimally invasive techniques for dealing with multiple diseases involving the spine are as good as traditional open techniques, with some additional advantages of lesser tissue trauma, early return to work, and so on. However, one must overcome the steep learning curve before adopting them in day-to-day practice.

Clip Reconstruction of Fusiform A1 Segment Aneurysm Using Lateral Supraorbital Approach

Fusiform aneurysms of the anterior cerebral artery are a surgical rarity encountered only occasionally by a neurosurgeon.1,2 Seen most commonly in the vertebrobasilar territory, these aneurysms differ in pathophysiology and clinical presentation from their saccular counterparts. Arterial dissections and atherosclerosis are the leading causes of these aneurysms in young and elderly patients, respectively.3 Patients can present with symptoms related to mass effect/compression of adjacent structures or with ischemic symptoms apart from aneurysm rupture. Management of these aneurysms remains challenging owing to the lack of a distinct neck. Surgical options include clip reconstruction, parent vessel occlusion, or aneurysm trapping with4 and without1 bypass using a branch of the superficial temporal artery. Clipping techniques used for these aneurysms include the use of fenestrated clips, vessel wall reconstruction, and wrapping.5,6 However, due to enormous variations in aneurysm morphology, each case presents a unique challenge; hence neurosurgeons need to be aware of this important entity. Endovascular techniques including parent vessel occlusion or vessel-preserving techniques using coil or flow diverters have also been described,3 but clipping remains the preferred choice for most surgeons worldwide. In Video 1, we present a case of fusiform A1 segment aneurysm in a 34-year-old gentleman and demonstrate how the aneurysm was clipped using a lateral supraorbital approach. He made an uneventful recovery with subtle right lower limb weakness. This video shows the technique and utility of a minimally invasive skull base approach for dealing with a fusiform anterior circulation aneurysm.

An institutional study on accuracy of freehand cervical C1 C2 screws placement by knock and drill technique in craniovertebral anomalous bony anatomy: An evaluation of more than 600 screws based on SGPGI screw accuracy criteria

Purpose

To assess the accuracy of freehand cervical C1 C2 screws placement by knock and drill (K and D) technique in craniovertebral anomalous bony anatomy.

Materials and Methods

From January 2017 to December 2022, 682 consecutive C1 C2 screws in 215 patients with craniovertebral junction (CVJ) anomalies were enrolled. All patients underwent posterior fixation with K and D technique without any fluoroscopic guidance. The patient's demographic details, clinical details, radiological details, major intraoperative events, and postoperative complications were noted. The screws malposition grades and direction on CT images in the axial and sagittal plane were defined as new per proposed "SGPGI accuracy criteria." All patients had a clinical evaluation at 3-month follow-up.

Results

Total 682 C1, C2 screws were placed in 215 patients for CVJ anomalies using K and D technique. The accuracy of screws placement by freehand technique was 84.46% (576/682). So with technique explained the rate of malplacement in simple (16.35%) and complex (15.19%) groups were almost comparable and comparison difference was not significant (P = 0.7005).

Conclusion

The freehand technique, as described, is effective in cases of anomalous bony anatomy, and it is mandatory in complex CVJ anomalies. The accuracy of screw placement and VA injury is comparable with major studies. This technique is supposedly cost-effective and less hazardous to both health-care workers and patients.

Stereotactic biopsy for brain lesions: Doing more with less

Objectives

Stereotactic biopsy (STB) is a potential diagnostic tool considering its minimal invasiveness, high diagnostic yield, and minimal associated complications. Over the years, various frame-based instrument systems and frameless stereotactic biopsy systems have emerged to be employed in clinical use. With this study, we intend to get more by doing less in the form of STB for the patients of doubtful intracranial lesions treated over the past 5 years. We also want to highlight the technique of performing the procedure under scalp block, which can be used as a versatile tool in many clinical scenarios. Stereotactic biopsies may be planned even in rural district-level health facilities. One-time investment to procure instruments and avail existing imaging can lead to establishing definitive diagnoses in many doubtful cases. This will result in lesser cost and early establishment of treatment. Independent risk factors determining the outcome, such as deep-seated lesions, associated edema, and intraoperative hypertension, were studied. Establishing the diagnosis helped in prognosticating the disease, explaining the natural progression of symptoms, and starting adjuvant therapy. This tissue biopsy would also help secure samples for research and molecular analysis.

Materials and Methods

Twenty patients underwent STBs at our institution between January 2018 and December 2022. We retrospectively analyzed patient characteristics, tumor pathology, surgical procedures, and outcomes, including the diagnostic value and surgery-related complications. These patients were followed up, and their progression-free and overall survival were analyzed. The need for adjuvant treatment was noted and analyzed. All procedures were performed using Cosman Roberts Wells® stereotactic frame. Pre-procedure magnetic resonance scans were performed at the time of admission. Contrast-enhanced computerized tomography (CT) scan after frame application was performed to identify targets and calculate the coordinates. A post-procedure CT scan was done to confirm the accessibility of the targeted lesion.

Results

The most common location of the tumor was a deep-seated thalamic lesion. A definitive diagnosis was established in 19 patients (95%) at the first STB. The diagnoses were glioma in 55% of cases, primary central nervous system lymphoma, tuberculosis, and demyelinating disorders in 10% of each, and a metastatic brain tumor in 1 (5%). The post-operative complications were all transient except in one patient with deterioration of motor weakness. The follow-up was noted, and modes of adjuvant treatment needed in these patients were recorded.

Conclusion

Stereotactic biopsy is a useful and effective method for achieving a definitive diagnosis and aiding in treating multifocal or small deep-seated lesions in or around eloquent regions.

Comparison of Cardiac Indices Using Two Different Concentrations of Topical Adrenaline during Endoscopic Transsphenoidal Pituitary Surgery: A Prospective Randomized Observational Study

Introduction  Adrenaline-soaked wicks are often employed to decongest nasal mucosa during transsphenoidal pituitary surgeries to ensure proper hemostasis and visibility of the operating field. Considerable debate exists regarding the optimum concentration of adrenaline that strikes a balance between hemostasis as well as the hemodynamic side effects of adrenaline. This study assessed cardiac indices like cardiac output and cardiac index using a FloTrac Vigileo cardiac output monitor to compare two different concentrations of adrenaline used for topical instillation. Materials and Methods  60 adult patients undergoing transsphenoidal pituitary surgery were randomly assigned to receive cotton wicks soaked in adrenaline solution (either 1:100,000 or 1:200,000) for nasal decongestion. Following a standardized anesthetic regime, a FloTrac Vigileo cardiac output monitor was attached with the invasive arterial line for precise monitoring and recording of cardiac indices (cardiac output and cardiac index). Additionally, quality of surgical field (as reported by the operating surgeon) blood loss, incidences of adverse hemodynamic events, and rescue drug usage were recorded. Results  No difference in cardiac outputs and cardiac indexes of the patients was observed during baseline to 55 minutes and at 80 minutes and onward, whereas difference rose to statistical significance at the time points of 60 minutes and 70 minutes ( p  < 0.05). Other parameters like stroke volume, stroke volume variation, and hemodynamic parameters were similar. Quality of the surgical fields (as reported by the surgeon), intraoperative bleeding, incidences of adverse effects, and frequency of rescue drugs usage were similar. Conclusion  Instillation of 1:100,000 dilution of adrenaline solution compared with 1:200,000 for nasal decongestion is associated with significant rise in cardiac output and cardiac index at 60 and 70 minutes of the surgery with similar blood loss and hemodynamic variables. Therefore, the lower concentration of adrenaline can be recommended for usage during transsphenoidal pituitary surgeries.

Factors predicting seizure outcome after surgical excision of meningioma: SOLID-C guideline for prophylactic AED

BACKGROUND

Seizures are commonly seen among meningioma patients and may cause impaired quality of life. These patients can be effectively treated with surgery. Still, many patients have persistent seizure episodes after surgery. The factors which are associated with worsening of seizure episodes remain critical in improving the quality of life for such patients. In this study, we aim to analyze the clinical and histopathological factors to predict the post excision seizure-outcome in meningioma and need of antiepileptic prophylaxis for these patients.

METHODS

Adult patients who underwent primary resection of meningioma at our institute between 2007 and 2020 were included in the study. Eligibility criteria were as follows: (i) Surgery for newly-diagnosed biopsy proven meningioma, (ii) Presence of pre-operative seizure (iii) A follow-up period ≥ 12 months.

RESULTS

Of the 1145 patients in this series, 333 patients were recruited in study. The major determinants of prophylactic anti-epileptic were tumour size (S), Oedema (O), location (L), inclusion body (I), antiepileptic drugs (D) and surgical complication (C). The factors independently associated with poor seizure control after surgical resection were presence of brain parenchyma invasion (p < 0.001), pre-operative use of > 2 antiepileptics (p = 0.016) and presence of intranuclear inclusion bodies (p = 0.001).

CONCLUSIONS

The identification and consideration of factors associated with prolonged seizure control after surgery may help us to guide treatment strategies aimed at improving the quality of life for patients with meningiomas. Authors have proposed a SOLID-C guideline to avoid the blanket approach of prophylactic AED in patients undergoing for meningioma resection.

Clinicoradiologic Risk Stratification and Outcome Assessment in Symptomatic Intracranial Arachnoid Cyst Managed Over Fifteen Years

BACKGROUND

Arachnoid cysts (ACs) are developmental anomalies formed by splitting the arachnoid membrane's layers. ACs contribute around 2% of all intracranial space-occupying lesions. ACs are more prevalent in children. Because of varied clinical presentation, there has been a constant need for clinicoradiologic risk stratification with a possible role in outcome prediction. The present study describes the management strategies and outcomes in symptomatic intracranial ACs.

METHODS

All biopsy-proven symptomatic patients who underwent surgical management over last 15 years were included in this study (January 2008-December 2022), while those with non-conclusive biopsies were excluded. Patients presenting with acute deterioration were managed in the emergency department with or without cerebrospinal fluid diversion and decompression of the AC. The microsurgical or endoscopic approach was the preferred surgical modality. Postoperative clinicoradiologic improvement was evaluated at 3 months follow-up visit.

RESULTS

A total of 108 patients were analyzed in this retrospective observational study. The median age of the patients was 27.5 years (range, 1 to 76 years). Headache was the most typical clinical presentation. Supratentorial ACs (n = 59, 54.6%) were higher than the infratentorial ACs (n = 49, 45.4%). Forty-seven patients belonged to the pediatric age group (<18 years), and seizure was their presenting complaint. In this observational study, there was no statistical difference in operative duration between microsurgical technique versus endoscopic decompression (P= 0.23).

CONCLUSIONS

ACs are uncommon brain lesions having a broad spectrum of symptoms. The location and clinical presentation of ACs decide the preferred surgical approach. Individuals in high-risk groups must be treated on priority to achieve long-term relief of symptoms.

Contralateral supraorbital eyebrow approach for tuberculum sellae meningioma

BACKGROUND

The main challenge in tuberculum sellae meningioma (TSM) resection is the safe dissection of the optic nerves, which many a times are compressed and distorted by the tumor. While intuitive, an approach from the side of predominant tumor extension makes tumor dissection from the medial surface of the ipsilateral optic nerve rather blind. We describe here a contralateral supraorbital eyebrow approach (c-SEA) to address this "blind spot."

METHOD

c-SEA was performed using a 2 × 2 cm craniotomy. The patient improved after surgery and postoperative imaging confirmed the totality of the tumor resection.

CONCLUSION

c-SEA can be an excellent minimally invasive option for asymmetric TSM.

Temporal profile of serum melatonin levels in paediatric pineal tumours subjected to surgery: newer insights

INTRODUCTION

Pineal tumours (PTs) are rare and histologically variable. Serum melatonin is a well-known product of this gland, albeit with uncertain clinical implications vis-à-vis its utility as a potential tumour marker. In particular, the temporal profile of serum melatonin during the disease course remains unclear and infrequently studied.

METHODS

Ten children with pineal tumours were prospectively studied over 2 years. Midnight serum melatonin levels were estimated before and after surgery (6-week postoperatively) and at the time of clinical-radiological progression. Different clinical, radiological, histological and treatment variables were correlated with the mean change in the pre- and postoperative serum melatonin levels using statistical methods.

RESULTS

Histopathologically, 5 of these cases (50%) were pineal cell tumours, while the rest were tumours of non-pineal cell origin. The mean preoperative serum melatonin level was 94.9 pg/ml (range 20-397 pg/ml), while the mean postoperative level was 69.6 pg/ml (range 45-156 pg/ml; in one case, the levels became non-detectable). Tumour histology (p = 0.04) and gender (p = 0.03) correlated with high preoperative serum levels. While the change in overall mean value did not have any statistical significance (effect size 0.29, p value 0.340), postoperative serum melatonin elevation was significant in tumours of non-pineal cell origin (large effect size 0.93, p value 0.004).

CONCLUSION

The serum melatonin may be affected by age, gender and symptom duration. However, the dynamic of serum melatonin in the perioperative period is largely dependent on the cell of origin of the PT.

Endoscopic intradural extramedullary lesion excision: Results of augmented duroplasty with artificial dura

Objectives

Prevailing techniques of dural closure in endoscopic spine surgery (ESS) for intradural extramedullary (IDEM) tumor excision increase the steep learning curve and operative time. We aimed to assess the efficacy of augmented duroplasty with artificial dura and share our initial experience of ESS for IDEM excision.

Materials and Methods

We retrospectively analyzed 18 (n = 18) consecutive patients of IDEM tumors operated by ESS using Destandau's endoscopic system. The pre-operative, post-operative, and at the latest follow-up clinical status were recorded in terms of Nurick's grades and the Oswestry Disability Index. Immediate post-operative complications and intraoperative findings were noted from hospital information system and patient records.

Results

The mean (± SD) age of patients was 40.3 ± 14.9 (range 19-64) years, with M: F ratio of 2:1. All the lesions were intradural and present at lumber (n = 6), thoracic (n = 9), and cervical (n = 3) regions. The average duration of surgery, blood loss, hospital stay, and duration of follow-up were 157 ± 45.3 (90-240) min, 168.8 ± 78.8 (30-300) mL, 4.29 ± 1.4 (2-7) days, and 19.3 ± 7.2 (7-36) months, respectively. There were no CSF leaks, wound-related complications, or material-induced adverse events.

Conclusion

In endoscopic IDEM excision, dural closure with artificial dura is efficient in preventing CSF leak. It shortens the steep learning curve and improves the surgical outcome due to technical ease.

An Institutional Experience and Literature Review on Iatrogenic Major Vascular Injury in Neurosurgery: Proposal of a Management Algorithm

Background

Major vessel injury is among the most dreaded complications of any neurosurgical procedure. Once intraoperatively tamponaded, it can present in the form of pseudoaneurysm, dissecting aneurysm or complete occlusion of vessel. These injuries are often associated with very high morbidity and mortality. The literature available on this topic is limited and our understanding remains limited.

Objective

In this article, we present our surgical experience with iatrogenic aneurysms and present a review of literature.

Methods and Material

We conducted a retrospective analysis of all patients with major vessel injury during surgery from a prospectively maintained database from January 2012 to February 2020.

Results

A total of 15 patients developed iatrogenic aneurysms following a major vessel injury during various neurosurgical procedures. The most common vessel injured was vertebral artery (n = 9) in craniovertebral junction (CVJ) anomalies and ossification of posterior longitudinal ligament (OPLL) followed by internal carotid artery injury (n = 5) in sellar and parasellar pathologies. One patient developed basilar artery injury during endoscopic third ventriculostomy (ETV). Eight patients had pseudoaneurysm and seven had dissecting aneurysm with or without complete thrombosis of the involved artery. A total of two patients died after vascular injury and remaining thirteen patients survived and discharged.

Conclusions

The adage "prevention is better than cure" applies most aptly in such cases. Any major vessel injury should be followed by immediate angiography and subsequent early management. The endovascular management is more favorable as these aneurysms are difficult to clip due to the absence of a neck and fragile wall.

Cerebellopontine Angle Epidermoids: Comparative Results of Microscopic and Endoscopic Excision Using the Retromastoid Approach”

Background Densely packed neurovascular structures, often times inseparable capsular adhesions and sometimes a multicompartmental tumor extension, make surgical excision of cerebellopontine angle epidermoids (CPEs) a challenging task. A simultaneous or an exclusive endoscopic visualization has added a new dimension to the classical microscopic approaches to these tumors recently.

Methods Eighty-six patients (age: 31.6 ± 11.7 years, M:F = 1:1) were included. Nineteen patients (22.1%) had a multicompartmental tumor. Tumor extension was classified into five subtypes. Sixty-two patients underwent a pure microscopic approach (72%) out of which 10 patients (16%) underwent an endoscope-assisted surgery (11.6%) and 24 patients (28%) underwent an endoscope-controlled excision. Surgical outcomes were retrospectively analyzed.

Results Headache (53.4%), hearing loss (46.5%), and trigeminal neuralgia (41.8%) were the leading symptoms. Interestingly, 21% of the patients had at least one preexisting cranial nerve deficit. Endoscopic assistance helped in removing an unseen tumor lobule in 3 of 10 patients (30%). Pure endoscopic approach significantly reduced the hospital stay from 9.2 to 7.3 days (p = 0.012), and had a statistically insignificant yet a clearly noticeable lesser incidence of subtotal tumor excision (0 vs. 10%, p = 0.18) with comparable cranial nerve deficits but with a higher postoperative cerebrospinal fluid (CSF) leak rate (29% vs. 4.8%, p = 0.004).

Conclusion Endoscope assistance in CPE surgery is a useful addition to conventional microscopic retromastoid approach. Pure endoscopic excision in CPE is feasible, associated with a lesser duration of hospital stay, better extent of excision in selected cases, and it has a comparable cranial nerve morbidity profile albeit with a higher rate of CSF leak.

Non-aneurysmal subarachnoid hemorrhage: Is the deep venous system the hidden culprit?

AIM

The exact cause of bleeding in non-aneurysmal sub-arachnoid hemorrhage (SAH) is yet to be established. The present study intends to evaluate the morphological variants of deep cerebral venous drainage, especially basal veins of Rosenthal (BVR), and to correlate if such a venous anomaly is associated with increased incidence of non-aneurysmal SAH.

METHODS

A prospective analysis of all the patients of age more than 12 years with spontaneous non-aneurysmal SAH and undergone 4-vessel DSA for the diagnosis of the source of bleeding was included in the study (n = 59). The anatomy of the basal venous distribution was evaluated and was divided into 3 different types, namely normal (Type A), normal variant (Type B), and primitive (Type C), based on DSA findings. The follow-up of these cases was noted. The three groups were compared with one another.

RESULTS

The median age of presentation was 51 years with slight male predominance (52%). Primitive venous drainage was associated with a poorer grade at presentation (p = 0.002), more severe bleed (p = 0.001), vasospasm (p = 0.045), and a poorer outcome at 6 months (p = 0.019). Hydrocephalous and vasospasm were seen in patients with primitive venous drainage. On multivariate regression analysis for poorer outcome, it was observed that a worse grade at presentation, extensive bleed, primitive venous drainage are independent predictors of an adverse outcome.

CONCLUSION

The presence of primitive venous drainage has a linear relationship with the development of non-aneurysmal SAH with multi-cisternal hemorrhage, worse grade at presentation, and unfavorable outcome.

An alternate surgical treatment of giant serpentine aneurysm of the middle cerebral artery: Resection and End-to-End anastomosis

A section of giant intracranial aneurysms can develop serpentine morphology, secondary to a peculiar near-complete intra-aneurysmal thrombosis. The resulting complex angioarchitecture, along with the atypical clinical presentations (mass effect/distal ischemia) seen, makes management of such aneurysms technically challenging. Such aneurysms are notoriously not amenable to endovascular treatment, and hence, the only remaining treatment option is a tailored microsurgical procedure (clipping/parent vessel occlusion or reconstruction/trapping/aneurysmorrhaphy) accompanied by a safety bypass (high-flow/low-flow/in-situ bypass, depending on distal circulation's dependence on proximal trunk with reference to aneurysm). Microsurgical plan can be executed either in a single-stage or in two stages (bypass followed by later-date aneurysm treatment). Superficial temporal artery - middle cerebral artery (STA-MCA) bypass with/followed by aneurysm trapping-decompression is the most routinely performed microsurgical procedure for such aneurysms. We herein present an operative video illustrating an alternate surgical treatment of one such giant serpentine aneurysm of the MCA: Resection and End-to-End anastomosis. A 20-year-old boy underwent microsurgery for a giant right MCA serpentine aneurysm. In view of the poor distal flow in the ipsilateral MCA territory, an STA-MCA bypass with aneurysm trapping-decompression was planned. Intraoperatively, the presence of a stretched and elongated ipsilateral MCA (secondary to aneurysm's mass effect), plus the relatively narrow neck of the thrombosed aneurysm, provided us a rare opportunity to execute the above-mentioned alternate treatment. Intra and postoperative angiography confirmed the anastomosis patency. The patient made an uneventful recovery. This can save operating time, eliminate donor artery-related morbidity, and offer a surgical alternate to the conventional strategy of STA-MCA bypass.

Hybrid Anterior Clinoidectomy in the Clipping of Paraclinoid Aneurysms: Technique, Utility and Case Illustration

BACKGROUND

Anterior clinoidectomy for aneurysm clipping is generally performed intradurally. Despite obvious advantages, accidental drill slippage or indirect damage from heat and bone dust remain major drawbacks.

OBJECTIVE

To demonstrate the surgical technique and utility of a combined extra- and intra-dural clinoidectomy in the clipping of dorsal wall paraclinoid internal carotid artery aneurysm.

MATERIAL AND METHODS

A case of dorsal wall paraclinoid aneurysm which was stuck to the anterior clinoid process on preoperative angiogram is presented. The surgical technique is shown stepwise, and the intricacies of the technique are described.

RESULTS

The hybrid clinoidectomy allowed for proper delineation of the aneurysm, mobilization of the optic nerve and intracranial proximal control on the clinoidal segment by dint of "apparent" intracranial ICA lengthening. This allowed the aneurysm to be clipped successfully and the patient made an uneventful recovery.

CONCLUSION

Hybrid clinoidectomy is a useful technique and must be learnt.

Lesional Temporal Lobe Epilepsy: Does the “Uncommon” Differ from the Common?

Objectives This study aims to evaluate the subgroup consisting of uncommon pathological entities presenting with temporal lobe epilepsy (TLE).

Methodology Twenty-four consecutively operated patients of lesional temporal lobe epilepsy were included in the study. Eleven cases were identified that had pathologies implicated as “uncommon” in previously done studies on the pathology of TLE. A subgroup analysis consisting of these uncommon lesions was done for clinical presentation and seizure outcome. The seizure outcome was assessed in terms of Engel and International League Against Epilepsy (ILAE) classification.

Results Nine different pathological entities were identified within the study group. The mean age at surgery was 18.6 years (range 2–30 years). The mean duration of epilepsy was 48.3 months and the average duration of follow-up was 39.2months. All patients had seizures as the only complaint except three. Three patients had focal-aware seizures, two had focal motor onset, and the rest all had focal-unaware seizures. Seven patients were seizure free and the average age at diagnosis for these patients was 15.4 years (range 2–24 years.). The duration of seizure in the postoperative seizure-free group was 29.7 months and it was 81 months for the other group. All the patients with persistent postoperative seizures had focal-unaware seizures preoperatively.

Conclusion Despite the small and heterogeneous nature of this subgroup of uncommon lesions causing temporal lobe epilepsy, the clinical presentation, prognostic factors, and seizure outcome are similar to the cohort of common pathologies, including mesial temporal sclerosis.

Thirteen-and-a-half Syndrome Secondary to the Brainstem Cavernoma

BACKGROUND

"Thirteen-and-a-half" is a newly described clinical syndrome characterized by the combination of the one-and-a-half syndrome with fifth and seventh cranial nerve nuclei involvement (1^1/2 + 5 + 7 = 13^1/2). To the authors' knowledge, this is the first report of the thirteen-and-a-half syndrome secondary to pontine cavernoma and, overall, only the second reported case of this syndrome in the literature till date.

CASE REPORT

A 20-year-old man presented with the clinical features suggestive of the thirteen-and-a-half syndrome, explained radiologically by pontine cavernoma. We operated him using a suboccipital transvermian approach and he is doing well at 2.5 years follow-up. Interestingly, his one-and-a-half syndrome has partially improved to left horizontal gaze palsy.

CONCLUSION

The clinical appreciation of the thirteen-and-a-half syndrome precisely localizes the lesion to ipsilateral dorsal pontine tegmentum. Neurosurgeons must be aware of the newly described "one-and-a-half- plus" syndromes as they help in a better understanding of pathoanatomy caused by different disease processes in the brainstem.

Trends in clinico-epidemiology profile of surgically operated glioma patients in a tertiary care center over 12 years—through the looking glass!

Background

Hospital-based cancer registries can provide information on the magnitude and distribution of cancers in a given hospital. Hospital-based brain tumor registry data, focusing on glioma, from a tertiary care rural neurological center is lacking in the scientific literature. This data can be useful in understanding the need for research and funding required for these specific brain tumors.

Data of patients operated for glioma, at our institute, was collected between January 2004 and December 2015. Patients’ clinical details and histopathological diagnosis were recorded. Data were analyzed and compared with that of previously published literature, and inferences were drawn on patterns of reporting and epidemiology.

Results

A total of 1450 cases of glioma, with a mean age of 39.3 (± 17.36 SD) years with males (66.6%) comprising more population as compared to females. Majority of patients 70.8% (n = 1027) belong to the economically active age group of country (18–60 years). Majority of cases (41.4%) were glioblastoma with the next common tumor (22.8%) being diffuse astrocytoma (n = 331) followed by pilocytic astrocytoma (6.2%) and oligodendroglioma (4.5%) in that order. While our data followed similar trends with other Indian data the average age of glioma was a decade younger to what is quoted earlier in Indian and international studies.

Conclusion

This data for glioma gives a glimpse of the prevalence of this tumor in a primarily rural population and highlights the need for a National Brain Tumor Registry with the need for the development of evidence-based policymaking and enhanced research into this particular ailment.

Anterior cervical meningocele with craniovertebral junction instability - A case report and literature review

Anterior meningocele involves herniation of meninges through an abnormal defect in the anterior vertebral column. The pathogenesis, natural history, and management strategy of anterior cervical meningocele (ACM) are uncertain. We report a case of ACM with high cervical instability in a case of neurofibromatosis 1. Unlike other reported cases, torticollis and instability due to ACM were the major concerns in this case. We aim to discuss the management strategy and surgical nuances of such cases.

"Extra-cranial proximal pica aneurysm - a rare and surreptious cause of posterior fossa sah: case report and review of literature"

BACKGROUND

Extra-cranial posterior inferior cerebellar artery (PICA) aneurysms are rare with only 22 cases been reported so far. Intra-dural type of extra-cranial PICA aneurysm is even rarer with few case reports available. We report a previously unreported type of proximal PICA aneurysm in which the PICA aneurysm had intra-dural location at the C2 vertebral level.

CASE DESCRIPTION

A 51 year old gentleman presented with sub-arachnoid haemorrhage and intra-ventricular haemorrhage, predominantly involving the fourth ventricle and had no focal neurological deficit. CT angiogram was negative however a dedicated four vessel angiogram demonstrated an abnormal extracranial origin of right PICA at C1-C2 level, with associated aneurysm in its proximal segment. A C1 posterior arch excision with partial C2 laminectomy and clipping of the aneurysm was done.

CONCLUSION

Aneurysm associated with extracranial intra-dural PICA origin is a rare cause of SAH, and may not be detected with CT angiography. Such cases often require dedicated four vessel angiography, with careful study for any possibility of extra-cranial aneurysm. This variant has important surgical implication and requires preservation of the Lateral spinal artery (LSA-PICA communication), and that such aneurysm approached only with posterior cervical exposure without the need of a craniotomy. Such cases remind us the need to have an in-depth understanding of the variations of the posterior circulation.

Clinicoradiological Features and Treatment Outcome of Supratentorial Intraparenchymal Epidermoid Cyst: A Report of Five Cases and Literature Review

Objectives  Intraparenchymal epidermoid cysts (IECs) are rare lesions. They represent less than 1% of the intracranial epidermoid cysts. The supratentorial IEC is a clinically and prognostically distinct subset. Given the rarity, most of the articles are case reports. We present a series of five cases of supratentorial IEC to characterize their clinical presentation and outcome, with emphasis on the surgical features.

Materials and Methods  We searched our database for all cases of intracranial epidermoid cysts operated between January 2005 and January 2020. Five patients were identified having IEC from the hospital information system and the neurosurgical operation record book. Standard craniotomy and decompression of the lesion were performed in all these patients. Standard postoperative care includes computed tomography scan of head on the day of surgery and magnetic resonance imaging of brain after 6 weeks to look for the residual lesion, if any. Subsequent follow-up visits in outpatient department to look for resolution of the presurgical symptoms.

Results  The mean age of the patients in our series was 28.8 years (range: 28–40 years.). All the five patients were male. Four patients had IEC involving frontal lobe and one in parietal lobe with a small occipital lobe extension. Seizure was the most common presenting complaint followed by headache. Complete excision was achieved in all the cases. All the three patients with seizure attained seizure freedom postlesionectomy. Focal neurological deficits resolved gradually in postoperative period. There was no recurrence of lesion during follow-up.

Conclusion  Supratentorial IEC most commonly affects young males, involve frontal lobe and present clinically with seizure. Complete surgical excision offers best outcome in the form of remission of seizure disorder.

Type I Chiari Malformation Without Concomitant Bony Instability: Assessment of Different Surgical Procedures and Outcomes in 73 Patients

OBJECTIVE

Posterior fossa decompression is the treatment of choice in type 1 Chiari malformation (CM-1) without bony instability. Although surgical fixation has been recommended by a few authors recently, comparative studies to evaluate these treatment strategies using objective outcome tools are lacking.

METHODS

Seventy-three patients with pure CM-1 (posterior fossa bony decompression [PFBD], n = 21; posterior fossa bony and dural decompression [PFBDD], n = 40; and posterior fixation [PF], n = 12) underwent a postoperative outcome assessment using Chicago Chiari Outcome Score (CCOS). Logistic regression analysis detected predictors of an unfavorable outcome.

RESULTS

Minimally symptomatic patients generally underwent a PFBD while most of the clinically severe patients underwent a PFBDD (p = 0.049). The mean CCOS score at discharge was highest in the PF (12.0 ± 1.41) and lowest in PFBDD group (10.98 ± 1.73, p = 0.087). Patients with minimal preoperative clinical disease severity (adjusted odds ratio [AOR], 4.58; 95% confidence interval [CI], 1.29-16.31) and PFBDD (AOR, 7.56; 95% CI, 1.70-33.68) represented risks for an unfavorable short-term postoperative outcome. Though long-term outcomes (CCOS) did not differ among the 3 groups (p = 0.615), PFBD group showed the best long-term improvements (mean follow-up CCOS, 13.71 ± 0.95), PFBDD group improved to a comparable degree despite a poorer short-term outcome while PF had the lowest scores. Late deteriorations (n = 3, 4.1%) occurred in the PFBDD group.

CONCLUSION

Minimally symptomatic patients and PFBDD predict a poor short-term postoperative outcome. PFBD appears to be a durable procedure while PFBDD group is marred by complications and late deteriorations. PF does not provide any better results than posterior fossa decompression alone in the long run.

Is the Tradition of Nasal Packing Just an Illusion of Permanence or a Necessary Evil?

Background Nasal packing after an endoscopic endonasal approach (EEA) is a routine practice. There is a very urgent need for a level-I recommendation pertaining to the necessity of these packs and, if required, then the timing of its removal. However, the opponents of this practice mention its various disadvantages, among which infection is the most important. In our study, we have evaluated the bacteriological profile of the nasal packs, following endoscopic anterior skull base surgery.

Materials and Methods Thirty consecutive cases (2017–18) of anterior skull base pathologies operated by EEA were included, and preoperative nasal swab and postoperative period, the nasal packs were sent for microbiological culture. The colony of bacteria grew, and clinical condition, histopathology and demographic profile of the patients were noted.

Results Of the 30 patients, 40% (n = 12) showed an increase in nasal bacterial flora after packing, with methicillin-sensitive coagulase negative Streptococcus (MSCNS) in three patients, Escherichia fecalis (E. fecalis) in three patients, and methicillin-resistant coagulase negative Streptococcus (MRCNS) in two patients. Other rare organisms grew, including Acinetobacter baumanni with E. fecalis, Acinetobacter baumanni with MRCNS, Citrobacter koseni, and Escherichia fecium (E. fecium) with MRCNS and MRSA in one patient each.

Conclusion Packing increases the bacterial load of the nasal cavity. This bacterial flora can be a potential source of meningitis. We advocate that packing should be avoided, and if at all required, should be removed within 3 days. A routine practice of nasal swab in the preoperative period and culture of the packs may give information on the possible organism that may cause meningitis and the appropriate antibiotic sensitivity of the organism.

Venous corridors in gravity-assisted retractor-less occipito-transtentorial approach - Our experience of an avenue through the tentacles of pod

Background:

Occipital transtentorial approach for selected posterior third ventricular or retrosplenium region tumors provides an ergonomic and safe access. Over centuries, the opponents of this approach highlight the problem of postoperative visual field defect, related to the retraction of occipital lobe. The aim was to describe the surgical nuances of gravity-assisted retractor-less occipital-transtentorial approach (GAROTA) as a modification of originally described GAROTA to minimize the complications with a similar ease of surgery.

Methods:

In this study, we have retrospectively analyzed our prospectively maintained surgical databases of patients operated by occipito-transtentorial from 2015 to 2019. Demographic variables, preoperative and postoperative neurological deficits (especially visual field defect) were analyzed. Radiological data included relation of veins with tumor, presence of hydrocephalus, size, and extent of lesion.

Results:

Fifteen patients underwent GAROTA (right-sided extension, n = 7; left-sided extension, n = 4; and midline lesions, n = 4). Headaches (73.3%) and diplopia (40%) were the most common symptoms. No patient had any postoperative visual deficits in both short-term and long-term follow-up.

Conclusion:

A thorough anatomical knowledge of posterior third interhemispheric region in the semi-prone position is required for GAROTA. Meticulous arachnoid dissection around the deep venous complex and release of cerebrospinal fluid through the cisterns is required. Postoperative cortical vision loss may be prevented by following the key surgical principles in GAROTA.

A Prospective, Single-Blinded, Bicentric Study, and Literature Review to Assess the Need of C2-Ganglion Preservation - SAVIOUR's Criteria

Objective

Joint manipulation for craniovertebral junction instability is often hindered by the C2-ganglion (C2G). Our study aims to compare the surgical outcome among patients with or without C2G preservation and discuss the technical nuances.

Methods

We did a prospective, bicentric study and included all the operated patients with craniovertebral junction anomaly. The outcome was assessed by the Pain Numeric Rating Scale, Patient Satisfactions Score, and Stony Brook Scar Evaluation Scale. The fusion was assessed using Lenke fusion grade.

Results

One hundred seventy-one patients (88 in group A and 83 in group B) were included. The most common symptom was spastic quadriparesis (n = 165, 96.5%) with median Nurick grade 3.3. Thirteen patients had suboccipital numbness and 12 patients had paraesthesia. Mean blood loss in group A was 490 ± 96.2 mL and group B was 525 ± 45.7 mL; median operative time was 217.9 and 162.2 minutes in the groups A and B, respectively (p < 0.05). At the follow-up (median, 46.8 months), Lenke fusion grade A was achieved in 92.4% and grade B in 7.6%. A trend suggesting better functional outcomes (numbness, parestheisa, scar outcome, and postoperative ulcer formation) in group A was seen with all 6 patients, who underwent O-C2 fixation, developed pressure sore.

Conclusion

Our results support ganglion preservation, especially in the subset of patients where occipital plating is required. Although the study fails to show any statistical significance, we suggest that one should always start with an ‘intent’ of preservation as the functional outcome is better.

Endoscopic Third Ventriculostomy and Simultaneous Tumor Biopsy in Pineal Region Tumors using the "Single Burr Hole" Technique: An Analysis of 34 Cases

Background

Pineal region tumors often present with hydrocephalus. Endoscopic third ventriculostomy (ETV) and simultaneous tumor biopsy remain a minimally invasive procedure offering both diagnostic and therapeutic advantages in the management of these tumors. However, different operative techniques have been described in the literature.

Aim

The aim is to study the ETV success rate, diagnostic rate of simultaneous tumor biopsy, complications, and follow-up of patients of pineal region tumors managed with ETV and simultaneous tumor biopsy using the single burr hole technique.

Methods

The study was performed by retrospectively reviewing the records of patients of pineal region tumors managed by simultaneous ETV and tumor biopsy using a "single burr hole" technique from January 2012 to December 2019.

Results

Thirty-four patients (22 males and 12 females) with a mean age of 28.7 years were analyzed. ETV was successful in relieving hydrocephalus in 29 (87.8%) patients. Three patients needed a ventriculoperitoneal shunt, and one required Ommaya reservoir placement for persistent hydrocephalus. Histological diagnosis was successfully established in 26 (78.8%) patients. There were two procedure-related mortalities. Two patients underwent craniotomy and tumor excision subsequently. Radiotherapy was given to 11 patients, and 9 patients were managed by observation alone. The mean follow-up of our study was 15.8 months.

Conclusions

Simultaneous ETV and tumor biopsy using a single burr hole technique is a safe, minimally invasive procedure for the management of pineal region tumors.

Surgery in High-Grade Insular Tumors: Oncological and Seizure Outcomes from 41 Consecutive Patients

Background:

Insular high-grade gliomas are uncommon and constitute approximately 10% of all intracranial high-grade gliomas. Several publications in the recent years have thrown substantial light in the understanding of insular low-grade gliomas. However, there is a paucity of information concerning the spectrum of high-grade lesions affecting the insula, the mode of presentation vis-à-vis low-grade gliomas, and the survival rates to modern therapy.

Aims and Objectives:

We aim to highlight various clinical patterns, histo-pathological spectrum and the survival rates in patients with high-grade insular lesions. Also, we explore the factors that govern favourable outcomes.

Materials and Methods:

A retrospective study of 41 patients operated for high-grade insular tumors at our institute between March 2010 to December 2018 was done to evaluate the clinico-radiological features, surgical nuances, survival rates and seizure outcomes.

Results:

Raised intracranial pressure was the most frequent clinical presentation (n=28/41, 68.3%). Nearly 60% of the patients (n=25) had involvement of all four Berger-Sanai zones. The high-grade tumors encountered in our series were: glioblastoma (n=15), gliosarcoma (n=3), and embryonal tumor, not otherwise specified in 3 patients, while 21 patients had grade 3 astrocytoma. 33 out of 41 patients (80.5%) in our study showed excellent seizure control (ILAE grade 1A) at follow-up. Clinical presentation with seizures (P = 0.01, HR=0.3), WHO grade IV histopathology (P = 0.04, HR=3.7) and development of recurrence (P = 0.05, HR=5.5) were found to be independent predictors of OS.

Conclusion:

Insular high-grade gliomas are commoner than thought and nearly half of these are grade IV tumors (51%). A presentation with seizures may indicate precursor low-grade gliomas and portend a better survival. A maximum “safe” surgical resection, keeping the postoperative quality of life in mind, should be the goal.

Traumatic Partial Posterior Cord Brachial Plexus Injury in a Patient with Aberrant Innervation of the Long Head of the Triceps by the Axillary Nerve: Implications in Nerve Transfer Surgery

Brachial plexus repair forms an unmet need in terms of posttraumatic rehabilitation, especially the young population, wherein the incidence of accidents is high. This leads to decrease in the number of functionally active years after the accident. We encountered an interesting case of posttraumatic posterior cord injury predominantly affecting the shoulder abduction beyond 15°. An electrodiagnostic study showed a complete lack of conduction within the axillary nerve with reduced conduction velocity in the radial nerve. We took the patient up for the long head of the triceps transfer to the anterior division of the axillary nerve transfer. Intraoperatively, we found that the long head branch was originating from the axillary nerve at the point of division. As it could not be used for neurotization, we transferred the medial head branch of the radial nerve to the axillary nerve. The patient started to show electroclinical improvement after 3 months of the surgery. A few similar cases have been published, as a cadaveric finding. We report this case to highlight the possibility and need for a high clinical suspicion and also to provide a possible treatment option, in such aberrant anatomy.

Anomalous pressure dependence of the electronic transport and anisotropy in SrIrO3 films

Iridate oxides display exotic physical properties that arise from the interplay between a large spin-orbit coupling and electron correlations. Here, we present a comprehensive study of the effects of hydrostatic pressure on the electronic transport properties of SrIrO3 (SIO), a system that has recently attracted a lot of attention as potential correlated Dirac semimetal. Our investigations on untwinned thin films of SIO reveal that the electrical resistivity of this material is intrinsically anisotropic and controlled by the orthorhombic distortion of the perovskite unit cell. These effects provide another evidence for the strong coupling between the electronic and lattice degrees of freedom in this class of compounds. Upon increasing pressure, a systematic increase of the transport anisotropies is observed. The anomalous pressure-induced changes of the resistivity cannot be accounted for by the pressure dependence of the density of the electron charge carriers, as inferred from Hall effect measurements. Moreover, pressure-induced rotations of the IrO6 octahedra likely occur within the distorted perovskite unit cell and affect electron mobility of this system.

Surgical excision of trigeminal (V3) schwannoma through endoscopic transpterygoid approach

Background:

Endoscopic endonasal transpterygoid (EET) approach is well suited for trigeminal schwannomas.

Case Description:

A 25-year-old female presented with the right hemifacial pain for 1 month. Examination revealed mild sensory loss to both touch and pain in the right V2 and V3 dermatomal distribution. On magnetic resonance imaging, a well-defined extra-axial lesion was seen in the right infratemporal fossa extending intracranially, widening the foramen ovale. Erosion of the lateral pterygoid plate was evident on computed tomography. Diagnosis of a trigeminal schwannoma was made and excision through endoscopic transnasal transpterygoid approach was planned. After adequate nasal decongestion, lateralization of the inferior turbinate followed by medialization of middle turbinate done to expose the posterior part of the lateral nasal wall. Sphenopalatine foramen was visualized and the branches of the sphenopalatine artery to turbinate were coagulated followed by partial inferior and middle turbinectomy. Next, antegrade uncinectomy, bullectomy, and middle meatal antrostomy performed. Anterior and posterior ethmoidectomy was done to gain access to the sphenoid sinus. Medial maxillectomy done, posterior maxillary sinus wall exposed and drilled to reach infratemporal fossa harboring the tumor. The lateral recess was further exposed to visualize the vidian and maxillary nerves. Palatine bone and pterygoid body along with the medial pterygoid plate were completely drilled to expose the tumor capsule, which was gently dissected off. Complete tumor excision was performed uneventfully.

Conclusion:

EET provides a good oncological and functional outcome. With a lesser risk of surgical morbidities, it is an excellent alternative to conventional skull base approaches to trigeminal schwannomas in the modern era.

Isolated Intraventricular Chronic Mucormycosis in an Immunocompetent Infant: A Rare Case with Review of the Literature

BACKGROUND

Mucormycosis of the central nervous system is an uncommon infection caused by saprophytic or parasitic fungi of the subphylum Mucormycotina and order Mucorales viz. Rhizopus, Mucor, and Rhizomucor. Isolated, chronic involvement of the central nervous system is a rare occurrence. To the best of our knowledge, isolated chronic ventricular involvement in an infant has not been reported previously. Isolated intracerebral mucormycosis is a disease of the immunocompromised patient, and to date only 6 cases have been reported in immunocompetent patients, including 2 pediatric cases.

CASE DESCRIPTION

We present the case of an immunocompetent infant presenting with features of increased intracranial tension. He underwent cerebrospinal fluid diversion and was found to harbor mucormycosis on histopathologic examination of intraventricular debris. We also present a brief review of the relevant literature.

CONCLUSIONS

Although mucormycosis is an acute fulminant infection, chronic isolated cerebral cases are known in the immunocompetent patient. Patients also may present with isolated hydrocephalus, and hence fungal infection must be ruled out in all, especially if a shunt is warranted.

Coexistent Cerebral Cavernous Malformation and Developmental Venous Anomaly: Does an Aggressive Natural History Always Call for Surgical Intervention?

Coexistence of cerebral cavernous malformations (CMs) and developmental venous anomaly (DVA) represents the most common form of mixed intracranial vascular malformations. Existing literature supports not only a possible causative role of DVA for de novo CMs but also a potentially detrimental effect on an associated CM, increasing the chances of hemorrhagic complications and growth in the latter. A 52-year-old gentleman presented to us with a 17-year long history of simple motor seizures on the left faciobrachial region. On magnetic resonance imaging (MRI) of the head, a 1.5 cm × 1.5 cm CM without any evidence of recent hemorrhage was identified in the left high frontal premotor area. There was a linear enhancement in the adjoining superior frontal sulcus on contrast MRI. On intra-arterial angiogram, this hyperintensity was confirmed to be a venous channel draining into the superior sagittal sinus. Thus, a diagnosis of cavernoma associated with a DVA was made. The patient was advised conservative treatment and he was doing well at follow-up. Unless diligently looked for, DVA associated with CM may be easily missed. The coexistence has pathophysiological and management implications. Despite the reported aggressive natural history, there is a scope for conservative treatment for these complex vascular malformations.

"Contralateral Dry Eye in Hemifacial Spasm:" A New Clinical Sign

Hemifacial spasm (HFS) is a benign condition characterized by unilateral, involuntary, paroxysmal clonic and tonic contractions of the facial muscles. This condition usually results from a focal demyelination at the root entry zone of the 7^th cranial nerve secondary to a vascular loop compression, and hence, it responds to microvascular decompression (MVD) surgery, similar to trigeminal neuralgia. Herein, we report an interesting clinical finding of a contralateral dry eye in the case of HFS, which has not been described previously and discuss the possible underlying mechanisms. A 53-year-old man presented with a 6-month history of involuntary twitching movements of the left hemiface that persisted during sleep, consistent with the diagnosis of HFS. The patient's attempts to voluntarily control the troublesome involuntary left-sided eye blinking led to the development of dryness and reddening of the right eye. Corneal reflex, both direct and consensual, was intact bilaterally, and an ophthalmological examination ruled out the diagnosis of conjunctivitis. The patient underwent MVD of the facial nerve. To our surprise and validating our supposition, his contralateral conjunctival hyperemia and dry eye resolved within a day of surgery, along with complete resolution of the HFS. HFS can lead to the contralateral dry eye from the voluntary suppression of ocular blinking which resolves following MVD. We demonstrate this finding for the first time and believe its recognition may be of value in the patient management.

Public health crisis of road traffic accidents in India: Risk factor assessment and recommendations on prevention on the behalf of the Academy of Family Physicians of India

Roads are considered a sign of development bringing colossal benefits to community as socioeconomic and logistic facilitator. Yet, growth of road network has brought road crashes leading to civic pain from premature deaths of productive age group. In 2017, 16 citizens were killed and 53 injured every hour on Indian roads as per officially reported data, while a fair number go unreported. This is unacceptably high when compared with international standards. Risk correlates of road traffic injuries (RTIs) need to be redefined so as to form a continuum with other confounding factors that impact to take lives on road. Risk factors impacting RTIs vary from human components to the roles and responsibilities of healthcare stakeholders. We should have made roads safer for all citizens because a large percentage of population – children, pedestrians, cyclists, motorcyclists, and the elderly – are most vulnerable. A taskforce was set up by the Academy of Family Physicians of India to scientifically analyze the literature available to assess risks and put forward appropriate recommendations.

Trans-Sellar Trans-Sphenoidal Herniation of Third Ventricle with Cleft Palate and Microophthalmia: Report of a Case and Review of Literature

Trans -sellar trans-sphenoidal encephalocele is an extremely rare entity. We present the case of an 18-month old boy who presented with a trans-sellar, trans-sphenoidal encephalocele associated with cleft lip, cleft palate and microphthalmia. This patient was treated successfully by a trans-cranial extra-dural route. In this paper, we discuss the clinico-radiological findings as well as various surgical options in managing these rare lesions and briefly review the literature.

Efficacy of Double Drug Impregnated Autologous Coagulum Patch versus Single Drug Impregnated Autologous Coagulum Patch in Postoperative Pain Management after Spinal Surgery

Background:

Postoperative pain and cerebrospinal fluid (CSF) leak are common known complications of spinal surgery, both having a synergistic effect on each other. Thus, both need to be dealt simultaneously. Double drug impregnated autologous coagulum patch (DDIAC) is a novel method which reduced both incidences of postoperative CSF leaks as well as pain.

Methodology:

Twenty-seven patients undergoing lumbar disc surgery without instrumentation were included and randomized into DDIAC and single drug impregnated autologous coagulum patch (SDIAC) group. The patients were assessed postoperatively with visual analog scale (VAS).

Results:

There were 21 males and 6 females in the study. Seventeen (63%) patients got randomized for DDIAC patch application and other 10 (37%) patients entered the control arm group (SDIAC) patch use. Preoperative VAS was 5 in both the groups. The average postoperative VAS was 3.01 in DDIAC arm and 4.29 in control arm. The average analgesic shot required in the DDIAC group was 0.41 in 24 h and SDIAC group was 4.1 in 24 h. In DDIAC group, none of these patients had CSF leak from the surgical wound till discharge from the hospital. In the SDIAC group, one (10%, n = 10) patient had CSF leak.

Conclusions:

DDIAC patch was effective in controlling pain in the postoperative period; however, few patients may require analgesic shots for pain management. SDIAC patch may control some pain in the immediate postoperative period; however, this was not sufficient for a longer postoperative period.

Extraosseous Primary Intracranial Ewing Sarcoma/peripheral Primitive Neuroectodermal Tumor: Series of Seven Cases and Review of Literature

Background

The Ewing sarcoma peripheral PNET (ES-pPNET) is very rare small round cell tumour that involves the CNS as either a primary dural neoplasm or by direct extension from contiguous bone or soft tissue.

Materials and Methods

Biopsy proven cases of intracranial ES/pPNET with orbital involvement operated during Jan 2010-Jan 2014 were retrospectively included and their clinical data, operative and histological findings were reviewed from institutional oncology register.

Results

seven patients (4 males; 3 female) were studied with mean age at presentation of 13 years. Six patients had orbital involvement in one or other form. Surgical excision was gross total in five, near total in one, and subtotal in one patient. All patients received adjuvant therapy, only chemotherapy in 2, only Radiotherapy in four, both in one. MRI characteristics were studied in six patients. Four patients died with average survival of 33.2 months and three patients are having Progression free survival of average 23.3 months.

Conclusions

The EWS-pPNET is very rare tumour and very poorly described in literature. These tumours are showing special predilection for the frontotemporal dura and erode through the flat bone of cranium like orbital roof and lateral wall of the orbit. These tumours are aggressive, multi compartmental, vascular and very rapidly growing, so missing or overlooking the primary symptoms of dural stretching/bony involvement leads to delay in management and poor outcome.

Capsuloganglionic Germinoma: A Rare Site for Uncommon Childhood Tumor

Germ cell tumors (GCTs) are rare intracranial tumors with a strong predilection for children. Commonly, these tumors arise either in the suprasellar or the pineal region. The basal ganglia-thalamus complex represents a rare site of nonmidline intracranial GCTs. Such basal ganglionic GCTs have been reported to produce certain interesting clinico-radiological features, the knowledge of which may provide important diagnostic clues preoperatively. We present the case of a 9.5-year-old boy who presented with right hemiparesis and precocious puberty. Imaging revealed a heterogeneously enhancing mass involving the left capsuloganglionic region, sparing the thalamus. There was little perilesional edema and midline shift. Because of the deep location of the mass and a lack of mass effect, a neuronavigation-guided tumor biopsy was performed which unraveled a pure germinoma. The child was referred for adjuvant radiotherapy following an uneventful postoperative course. At the time of writing the report, the child was on radiotherapy and doing well.

An Infratentorial Pure Pleomorphic Xanthoastrocytoma Arising from Middle Cerebellar Peduncle: A Rare Location of an Uncommon Tumor

BACKGROUND

Pleomorphic xanthoastrocytomas are rare tumors of glial origin comprising <1% of all astrocytic tumors of brain. These tumors are rare in the infratentorial compartment and were not known to arise from the middle cerebellar peduncle.

CASE DESCRIPTION

We discuss the case of a 16-year-boy who presented with altered sensorium and features of increased intracranial pressure and was found to have a 4 × 4 × 3 cm mass arising from the middle cerebellar peduncle.

CONCLUSION

We also discuss the histopathologic features of these tumors suggesting their resemblance to other maldevelopmental tumors, the rarity of pure World Health Organization grade II pleomorphic xanthoastrocytoma in the infratentorial compartment, as well as the appropriate management.