Role of substance P in cerebral edema and association with an estimated specific gravity of the brain and an outcome prediction in post-traumatic cerebral edema

Purpose

The study aims to evaluate the role of substance P in cerebral edema and outcomes associated with acute TBI.

Method

Patients with acute TBI who presented within 6 h and a CT scan showed predominantly cerebral edema were included in the study. Substance P level was assessed from a serum sample collected within 6 h of trauma. We also evaluated the brain-specific gravity using the Brain View software.

Result

A total of 160 (128 male) patients were recruited. The median serum substance P concentration was 167.89 (IQR: 101.09-238.2). Substance P concentration was high in the early hours after trauma (p = 0.001). The median specific gravity of the entire brain was 1.04. Patients with a low Glasgow coma scale (GCS) at admission had a high concentration of the substance P. In the univariate analysis, low GCS, elevated serum concentrations of substance P level, high Rotterdam grade, high cerebral edema grade, a high international normalized ratio value, and high blood sugar levels were associated with poor outcomes at six months. In logistic regression analysis, low GCS at admission, high cerebral edema grade, and elevated blood sugar level were strongly associated with poor outcomes at six months. The area under the receiver operating characteristic curve was 0.884 (0.826-0.941).

Conclusion

Serum substance P is strongly associated with the severity of cerebral edema after TBI. However, brain-specific gravity does not directly correlate with posttraumatic cerebral edema severity. Serum substance P does not influence the clinical outcome of traumatic brain injury.

Incidence, risk factors and impact of anemia after elective neurosurgery: A retrospective cohort study

Objectives

Anemia after surgery is common and is associated with adverse clinical outcomes. Understanding the incidence and risk factors for postoperative anemia is important to reduce anemia-related complications and blood transfusion. There is lack of data regarding postoperative anemia and its contributing factors in neurosurgery. This study evaluates the incidence and risk factors of postoperative anemia, and its impact on clinical outcomes.

Methods

This was a single centre, retrospective study of patients who underwent elective neurosurgery over seven months. Data regarding age, gender, body mass index, American Society of Anesthesiologists (ASA) physical status, diagnosis, surgery, preoperative hemoglobin, surgery duration, intraoperative blood loss and red blood cell (RBC) transfusion, dose of tranexamic acid, intraoperative fluid balance, years of surgeon's experience, postoperative hemoglobin, postoperative RBC transfusion, Glasgow Coma Scale (GCS) score at hospital discharge, and duration of postoperative intensive care unit and hospital stay were collected. Logistic regression was used to identify predictors of postoperative anemia.

Results

The incidence of postoperative anemia was 11.3% (116/1025). On univariate analysis; age, preoperative hemoglobin, surgery duration, gender, ASA grade, surgery type, and surgeon's experience were associated with postoperative anemia. Lower preoperative hemoglobin (p<0.001) and non-tumor surgery (p<0.001) were predictive of postoperative anemia on multivariate analysis. Postoperative anemia resulted in increased RBC transfusion (p<0.001) and lower GCS score at discharge (p=0.012).

Conclusions

Atleast one in ten patients undergoing elective neurosurgery develop postoperative anemia. Lower preoperative hemoglobin and non-tumor surgery predict anemia. Anemia results in increased RBC transfusion and lower discharge GCS score.

Spinal astroblastoma: a rare tumour in an unusual location

Astroblastomas are central nervous system tumours with unknown cell of origin and clinical behaviour. These tumours occur most commonly in cerebral hemispheres with spinal astroblastomas being very rare. We report a case of spinal astroblastoma which harboured MN1 alteration.

Gender Differences in Perceived Stress among Neurosurgeons: A Cross-Sectional Study

Purpose

Surgeons are subjected to enhanced levels of work-related stress and women are likely to face unique challenges due to sub-optimal representation. The present study was conceived with a primary objective to study the gender differences faced by surgeons and neurosurgeons in particular. The secondary objective was to assess the correlation between the various stress inducers and busters of normal working and daily life and the mental state of neurosurgeons.

Methods

The study was a cross-sectional, multi-centric study in which a structured questionnaire was sent to neurosurgeons through various neurosurgical forums of the country. A total of 93 complete responses were included in the study. The questions were broadly divided into four themes, demographic working data, stress inducers, stress busters, and questions to reflect the mental state of the respondent.

Results

There were 74 males and 19 females in the study, with an average age of 39.34 ± 8.57 years. Statistically significant gender differences were noted in rating the out-patient department (OPD) hours, lectures and seminars, performing and assisting surgeries, attending conferences and working in the intensive care unit (ICU), with women scoring lower than men for these activities. There were no significant gender differences in the mental state of the respondents. A strong correlation was found between scoring for performance and assisting of surgery and the mental state questions, and a strong negative correlation was noted between music, playing games, going to the gym, practicing yoga and the mental state questions, indicative of a protective effect.

Conclusions

There was no significant gender differences in the perceived stress levels among neurosurgeons. Women appeared more comfortable with certain normal activities of working. A strong negative correlation was reported for activities such as music, playing games, yoga, and going to the gym, indicating a protective effect.

Rare Consequence of Pituitary Apoplexy Surgery: Artery of Percheron Infarction

Management of pituitary apoplexy is multimodal. The surgical intervention followed by endocrinological management is the standard of care. Various vascular complications have been described in the literature after pituitary adenoma surgery. Artery of Percheron (AOP) infract is a rare finding. Few cases were reported in the English literature after the endoscopic approach for pituitary adenoma. We present a 55-year-old lady presented with sudden-onset headache followed by vision loss. She was evaluated with imaging and diagnosed pituitary adenoma with apoplexy. She underwent an endoscopic transnasal approach and decompression of the tumor. In the postoperative period, she developed bilateral ptosis with altered sensorium. Imaging showed infarction of bilateral paramedian thalamus and rostral midbrain, suggestive of AOP infarct. Gradually, the patient improved, and at 3 months of follow-up, she was conscious and obeying with partial improvement of ptosis.

Cysticercal brain abscess: a distinct entity mimicking pyogenic brain abscess in the colloidal vesicular stage

Cysticercal brain abscess is a rare entity with the clinical presentation and radiological findings closely mimicking a pyogenic abscess. We report three cases of cysticercal abscess presenting as solitary lesion in the brain with radiological appearance like an abscess. All the patients underwent excision of the lesion with histopathological diagnosis of cysticercal brain abscess with evidence of cysticerci in the colloidal vesicular stage. The clinical outcome was satisfactory after surgical excision. Cysticercal abscess, though rare, should be considered as a differential diagnosis of a solitary rim-enhancing lesion, mainly if the patients belong to the endemic zone of neurocysticercosis. Surgical excision with or without a short course of the anti-parasitic agent is the treatment of choice for the intracranial mass lesion with evidence of mass effect For the small lesion of cysticercal brain abscess or early stage of abscess, anti-parasitic medication and steroids can be considered.

The risks factor of recurrence after skull base hemangiopericytoma management: A retrospective case series and review of literature

OBJECTIVES

Skull base hemangiopericytomas are rare malignant meningothelial tumors involving anterior, middle, and posterior cranial fossa. The outcome of these tumors is inferior due to aggressive behavior and local recurrence. The study aimed to find out the factors affecting the early recurrence and the late recurrence.

METHODOLOGY

A retrospective study was performed over 15 years, and patients were included from a single neurosurgical unit. A total of 35 patients were recruited for analysis.

RESULTS

Twenty-five (71.4%) cases were in the posterior fossa, four (11.4%) cases in the middle cranial fossa, and three (8.6%) patients in the anterior cranial fossa. Fourteen (40%) cases underwent gross total excision, 21(60%) cases subtotal excision. Follow up available for 32 patients, and the median follow -up duration was 64 months (6-240 months). Progression-free survival for the gross total resection group was 104 months compared to 60 months for subtotal resection (p = 0.07). Nineteen (54.3%) cases had recurrence during follow- up period. Six (17.1%) cases recurrence at 1-year time, five (14.3%) cases at 3-year time, three (8.6%) at 5-yr time, four (11.4%) cases at 10- year time. Seventeen (48.6%) cases received radiotherapy, and 13 cases underwent re-exploration and excision of the tumor. Univariate ordinal logistic regression showed that the extent of resection was associated with 1-year, 3-year and 5-year recurrence. Multivariate ordinal logistic regression showed that only extent of resection (STR) was associated with both early and late recurrence.

CONCLUSIONS

The extent of resection is the main predictor of early and delayed recurrence. Upfront radiation therapy has superior tumor control in skull base location.

Management of Rehabilitation needs of "Unknown" Traumatic Brain Injury Survivors: A Medical and Psychiatric Social Work Perspective

Traumatic brain injuries [TBI] caused by road traffic accidents [RTA] are a serious health problem for people of all countries across the globe. RTA will be a leading cause of mortality, morbidity, disabilities and creating many rehabilitation needs. Hence, this, article highlights the clinical concerns, burden, challenges, role of medical and psychiatric social worker, rehabilitation strategies and practical guidelines needed for successful rehabilitation of the unknown and abandoned TBI survivors.

Intracranial Dural-based Convexity Chondroma

Intracranial chondromas arising from the convexity with dural attachments are extremely rare tumors with scarce reports in the literature. They have atypical radiological findings that can often preclude the preoperative diagnosis. Complete resection is treatment with a good prognosis.

Decompressive craniotomy: an international survey of practice

BACKGROUND

Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide.

METHOD

A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019.

RESULTS

We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC.

CONCLUSION

Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial.

Neurosurgical Randomized Trials in Low- and Middle-Income Countries

BACKGROUND

The setting of a randomized trial can determine whether its findings are generalizable and can therefore apply to different settings. The contribution of low- and middle-income countries (LMICs) to neurosurgical randomized trials has not been systematically described before.

OBJECTIVE

To perform a systematic analysis of design characteristics and methodology, funding source, and interventions studied between trials led by and/or conducted in high-income countries (HICs) vs LMICs.

METHODS

From January 2003 to July 2016, English-language trials with >5 patients assessing any one neurosurgical procedure against another procedure, nonsurgical treatment, or no treatment were retrieved from MEDLINE, Scopus, and Cochrane Library. Income classification for each country was assessed using the World Bank Atlas method.

RESULTS

A total of 73.3% of the 397 studies that met inclusion criteria were led by HICs, whereas 26.7% were led by LMICs. Of the 106 LMIC-led studies, 71 were led by China. If China is excluded, only 8.8% were led by LMICs. HIC-led trials enrolled a median of 92 patients vs a median of 65 patients in LMIC-led trials. HIC-led trials enrolled from 7.6 sites vs 1.8 sites in LMIC-led studies. Over half of LMIC-led trials were institutionally funded (54.7%). The majority of both HIC- and LMIC-led trials evaluated spinal neurosurgery, 68% and 71.7%, respectively.

CONCLUSION

We have established that there is a substantial disparity between HICs and LMICs in the number of published neurosurgical trials. A concerted effort to invest in research capacity building in LMICs is an essential step towards ensuring context- and resource-specific high-quality evidence is generated.

Orbitofrontal Extradural Hematoma: Unusual Cause of Proptosis

INTRODUCTION

Frontal extradural hematoma (EDH) extending into orbit is an uncommon entity. Clinical presentation can be subacutely progressive proptosis following head injury.

CASE PRESENTATION

We present a case of frontal EDH with orbital extension which had delayed progressive proptosis. The patient improved clinically after surgical evacuation of EDH.

CONCLUSION

It is important to look for orbital roof fractures, orbital hematoma in cases of head injury. Such cases should be treated surgically at the earliest.

Unusual Complication of a Neglected Growing Skull Fracture

INTRODUCTION

The growing skull fracture (GSF) is a rare complication seen after head injury in infants and young children. It occurs due to a wide skull defect with underlying dural defect and changes in pressure gradients within skull cavity. Neglected cases may develop progressive neurological deficits and complications after second head trauma. Case Discussion: We present a 14-year-old child who developed sudden-onset, diffuse, soft, fluctuant, circumferential swelling of the head after a road traffic accident. He had sustained a head injury at the age of 3-months leading to an asymptomatic soft swelling over the skull which was left untreated. Present CT scan of the brain showed a bony defect with ragged edges and cerebrospinal fluid (CSF) collection in subgaleal space circumferentially. He underwent exploration, duroplasty, and cranioplasty and had a good outcome.

CONCLUSION

Neglected GSF can rupture and cause diffuse subgaleal CSF collection. It should be managed with dural repair and cranioplasty.

Transcranial approach for pituitary adenomas - An evaluation of surgical approaches over two decades and factors influencing peri-operative morbidity

PURPOSE

Transcranial surgery(TCS) for pituitary adenoma(PA) is mostly reserved for lesions with widespread extensions. We sought to analyse the intraoperative challenges, morbidity and the factors associated with morbidity of transcranial approaches, in a large series from a tertiary neurosurgical institute.

METHODS

We retrospectively evaluated 137 patients who underwent TCS for PA in our institute. The details of their clinical features, imaging, operative and peri-operative events and complications were collected and analysed. The factors associated with morbidity were evaluated.

RESULTS

The mean age of the cohort was 40.86 ± 13.35 years. 21 (15.3%) patients developed significant post-operative hematoma, out of which 7 patients (5.1%) required re-exploration. Post-operative diabetes insipidus was noted in 45 patients (32.84%), while SIADH was noted in 10 patients (7.35%). Other complications were cranial nerve palsy in 14 patients (10.2%), visual deterioration in 7 patients (5.1%). Neither tumour characteristics nor the choice of approach was associated with occurrence of post op hematoma. SIADH was significantly associated with patients with tumours involving cavernous sinus (p = 0.019) and subfrontal extension (p = 0.031). Patients with post-operative hematoma had significantly higher incidence of post-op DI (57.1% vs 28.7%; p = 0.021), while similar correlation was not noticed with SIADH (4.7 vs 7.8%).

CONCLUSION

TCS plays a distinct, albeit a small role in surgical management of pituitary adenoma. Tumour related or approach related factors are not significantly associated with the incidence of hematoma. Post-operative hematoma significantly influences the incidence of DI. A proper and judicious selection of approach and meticulous surgical technique should result in a reduction in associated morbidity and mortality.

Hinge/floating craniotomy as an alternative technique for cerebral decompression: a scoping review

Hinge craniotomy (HC) is a technique that allows for a degree of decompression whilst retaining the bone flap in situ, in a 'floating' or 'hinged' fashion. This provides expansion potential for ensuing cerebral oedema whilst obviating the need for cranioplasty in the future. The exact indications, technique and outcomes of this procedure have yet to be determined, but it is likely that HC provides an alternative technique to decompressive craniectomy (DC) in certain contexts. The primary objective was to collate and describe the current evidence base for HC, including perioperative parameters, functional outcomes and complications. The secondary objective was to identify current nomenclature, operative technique and operative decision-making. A scoping review was performed in accordance with the PRISMA-ScR Checklist. Fifteen studies totalling 283 patients (mean age 45.1 and M:F 199:46) were included. There were 12 different terms for HC. The survival rate of the cohort was 74.6% (n = 211). Nine patients (3.2%) required subsequent formal DC. Six studies compared HC to DC following traumatic brain injury (TBI) and stroke, finding at least equivalent control of intracranial pressure (ICP). These studies also reported reduced rates of complications, including infection, in HC compared to DC. We have described the current evidence base of HC. There is no evidence of substantially worse outcomes compared to DC, although no randomised trials were identified. Eventually, a randomised trial will be useful to determine if HC should be offered as first-line treatment when indicated.

Multiple-site neural tube defects: embryogenesis with complete review of existing literature

OBJECTIVE

Multiple-site neural tube defects (MNTDs) are very uncommon, with the predominant number of cases being reported in developing countries. The classic theory of neural tube closure fails to explain the occurrence of these defects. Multisite closure theory, first proposed in 1995, explains most of the occurrences with a few modifications specific to a few defects. In this paper, the authors endeavor to explain all the defects, along with their genetic and embryological bases, and to review the available literature and discuss their own experience in the management of these complex cases.

METHODS

The authors retrospectively reviewed the data of all the patients treated surgically for MNTDs over that past 14 years. All possible demographic data, clinical details, and radiological imaging data were reviewed. In addition, surgical parameters, complications, and status at follow-up of more than 12 months were evaluated. All previously reported cases of MNTD were analyzed, and comparisons with the present series were made.

RESULTS

A total of 3 major series (including the present one) on MNTDs have been from India. A total of 57 such cases (including those of the present series) have been reported in the available literature. While previous series reported a higher incidence of spinal defects, the present series had a higher rate of cephalic defects (55%). Among the reported cases, insertion of a ventriculoperitoneal shunt was necessary in 12 (26%), and only 4 patients were operated on in 2 stages. Neurological status at presentation dictated outcome.

CONCLUSIONS

MNTDs are extremely rare, and their embryogenesis is different from that of single neural tube defects. Simultaneous repair of 2 or even 3 defects is possible in a single-stage surgery. The requirement of a shunt is uncommon, and complications following surgery are rare. Folic acid supplementation may reduce the incidence of defects.

Endoscopic intervention for intraventricular neurocysticercal cyst: Challenges and outcome analysis from a single institute experience

OBJECTIVE

Endoscopic intervention is presently proposed as standard approach for the treatment of Intraventricular neurocysticercal cyst (IVNCC) as it helps to retrieve the cyst as well as CSF diversion. We present our series of 61 patients with IVNCC managed by endoscopic intervention and analyze the outcome.

METHOD

A retrospective analysis of 61 patients with IVNCC managed between 1998-2019 at our institute was performed. We reviewed the clinical details of consecutive patients, management, and outcome.

RESULTS

There were 61 patients with 34 males and 27 females. The mean age was 25 years. Fourth ventricular location is the most common (n = 34) followed by third ventricle(n = 14) and lateral ventricle (n = 13). Cyst retrieval could be done in 43 cases, while the cyst could not be retrieved in 18 cases due to intraventricular bleed, CSF turbidity, adhesion of cyst wall etc. Along with cyst retrieval, some patients underwent Endoscopic Third ventriculostomy, septostomy, foraminotomy for internal CSF diversion. Seven patients had a preoperative VP shunt surgery. The median follow-up was 12 months. Preoperative shunt (CI:1.33-62, P = 0.02) was associated with failure of cyst retrieval in univariate analysis as well as in multivariate regression analysis (CI: 0.02-0.94, P = 0.04). Two patients underwent shunt surgery at follow-up period due to the failure of endoscopic CSF diversion.

CONCLUSION

Endoscopic management of IVNCC is a safe and effective management option, avoiding an indwelling shunt system. Endoscopic third ventriculostomy should be considered for patients with IVNCC and hydrocephalus.

The Evolution of NIMHANS Neurotrauma Care

Neurotrauma services in NIMHANS, Bangalore, have been evolving since its inception in 1958. At present, it is a major referral center for Karnataka and surrounding districts of the southern states. It has many firsts to its credit, from having a separate building to having dedicated trauma teams to manage the service 24/7. It has made rapid strides in healthcare delivery based on data-driven evidence, improvisation with Lean sigma approach, and contribution through research and publications. This center has won best Neurotrauma center award in 2010.

Bilateral anomalous origin of ophthalmic artery from middle meningeal artery and coincidence of bilateral carotid artery aneurysm: Case report and literature review

Ophthalmic artery (OA) is known for anomalous origin and aberrant course probably attributable to its complex embryology. Anomalous origin of OA can be associated with intracranial aneurysm. Anomalous origins have been reported from middle meningeal artery (MMA), cavernous carotid, posterior communicating, anterior cerebral and basilar artery. Even though bilateral anomalous origin of OA from MMA is a rare finding, to the author's best knowledge, association of above condition with bilateral internal carotid artery aneurysms has not been described in the literature. We present a case of such anomalous bilateral OA originating from MMA and associated with bilateral internal carotid artery aneurysms. We have also reviewed the pertinent literature regarding anomalous OA origin.

Use of animal models in peripheral nerve surgery and research

Animal models are widely used in research of peripheral nerve injury and regeneration, since there are only minor differences in the anatomy of peripheral nerves and the physiology of nerve regeneration between the humans and animals. Animal models, especially rodents, are widely used for this purpose. This narrative review provides a brief overview of the role of animal models in peripheral nerve surgery and research.

Precipitating hydrophobic injectable liquid embolization of intracranial vascular shunts: initial experience and technical note

Precipitating hydrophobic injectable liquid is a new liquid embolic agent used mainly for intracranial neurointervention. The agent is ready to use (no shaking is required), since iodine, the radiopaque material, is covalently bonded into the compound. Additionally, due to the absence of tantalum, minimal artifacts are seen on postprocedure follow-up CT scans, and the agent penetrates into vessels smaller than 10 µm. The authors report their initial experience with the use of this agent in neurovascular intervention.

The Correlation of Endothelial Nitric Oxide Synthase (eNOS) Polymorphism and Other Risk Factors with Aneurysmal Subarachnoid Hemorrhage: A Case-Control Study

Objective

Endothelial nitric oxide synthase gene (eNOS) polymorphism is an association with cerebral aneurysm formation, rupture, and vasospasm and plays a role in the a functional outcome.

Patients and Methods

The aim of the study was to evaluate the role of eNOS gene polymorphism and further assess the predictors of outcome in the aneurysmal subarachnoid hemorrhage (aSAH). A prospective case-control study was conducted from 2009 to 2012 among those who presented with aSAH. A serum sample was collected from aSAH patients along with age and sex-matched healthy controls. The frequency of polymorphism of eNOS gene and other factors (demographic and aneurysmal) were correlated with functional outcome at six month of follow-up.

Results

100 patients with aSAH and 100 healthy controls were enrolled in the cohort. The mean age of the patient group was 51.61 years and control group was 45.81 years with a male:female ratio of 1:1.38 and 1:1.08 for patients and controls, respectively. Among all eNOS polymorphisms, 4BB (65%) 24-VNTR, TT (71%) of T-786C, and GG (71%) of G947T were the most common and frequency was similar in the control group. The occurrences of hypertension, smoking, diabetes were 32%, 37%, and 7% respectively in the patient group. Maximum patients were in WFNS grade 1 (53%) followed by 23% grade 2 and only 10% in grade 4. Fisher grade 3 (57%) was the most common followed by Fisher grade 4 (28%). Most aneurysms (97%) were in anterior circulation. 83% of the aneurysms were clipped and 10% underwent coiling. Size-wise most of the aneurysms were in the middle group (6-9 mm) followed by bigger group (>10 mm) (37%); only 6% aneurysms were in the small aneurysm (<6 mm) group. 33% of the patients had evidence of vasospasm. TT of G894T polymorphism (60%) had the highest incidence of vasospasm. Univariate analysis showed smoking (OR: 3.19, CI: 1.19-8.84, P = 0.01), 4AA (OR: 12.15, CI: 1.13-624.9, P = 0.03) variety of 24-VNTR polymorphism, CC (OR: 15.39, CI: 1.60-762.8, P = 0.01) variety of T786C polymorphism, Fisher grade 4 (OR: 3.43, CI: 1.24-9.68, P = 0.01), WFNS grade (poor vs. good) (OR: 3.42, CI: 1.17-10.12, P = 0.02), vasospasm (OR: 3.84, CI: 1.42-10.75, P = 0.006), intraoperative rupture (OR: 4.77, CI: 1.55-15.27, P = 0.004) were significantly related with unfavorable outcome at 6 months follow-up. In regression analysis, smoking (CI: 0.06-0.69, P = 0.01), Fisher grade 4 (CI: 0.09-1.00, P = 0.05), and intraoperative rupture (CI: 0.05-0.89, P = 0.03) were correlated with an unfavorable outcome at 6 months follow-up.

Conclusion

The eNOS gene polymorphism, smoking, clinical grade (WFNS), Fisher grade, intraoperative rupture, and vasospasm play a role in functional outcome after the treatment of cerebral aneurysms.

Response of Syrinx Associated with Chiari I Malformation to Posterior Fossa Decompression with or without Duraplasty and Correlation with Functional Outcome: A Prospective Study of 22 Patients

Background

The aim of the study is to correlate the surgical outcome with radiological changes in patients with Chiari I malformation (CMI) with syrinx. We also compared long-term functional and radiographic outcome in CM1 patients treated with posterior fossa decompression (PFD) with or without duroplasty.

Patients and Methods

From December 2013 to October 2015, 22 patients who underwent surgery with the diagnosis of CMI and syrinx were included in the study. Measurements were performed on preoperative and postoperative magnetic resonance (MR) scans using the same software. All patients underwent PFD with or without duroplasty. Clinical results were evaluated on the basis of the Chicago Chiari Outcome Scale (CCOS). We assessed the degree of resolution of syrinx and outcome of Chiari decompression with PFD versus PFD with duroplasty. Mean duration of follow-up was 12.4 ± 5.37 months (range: 6-24 months).

Results

Out of 19 patients in whom syrinx diameter decreased on postoperative MR imaging, 17 (89.5%) improved based on CCOS and 2 (10.5%) were unchanged while out of three patients in whom syrinx worsened, 2 (66.7%) improved and 1 (33.3%) was unchanged (P = 0.37). The cord diameter was found to have decreased in 12 patients and of these 11 (91.7%) improved. The cord diameter increased in 10 patients, but 8 (80%) improved (P = 0.57). The mean changes in syrinx, cord, and syrinx/cord ratio were studied in both groups with and without duroplasty, were not statistically significant. In this study, radiological parameters failed to predict functional outcome.

Conclusions

The outcome does not correlate with change in any of the syrinx-related factors. Surgical decompression with or without duroplasty does not have a statistically significant relationship in the degree of syrinx resolution. Surgical decompression without duroplasty provides the benefits of surgical decompression while avoiding the complications of intradural techniques.

Intracranial Germ Cell Tumors: Spectrum of Disease in an Indian Cohort and Management Strategies

Background:

Germ cell tumors (GCTs) represent approximately 3% of primary pediatric brain tumors in the West, whereas in Asia, they constitute between 8% and 15% of pediatric brain tumors.

Methods:

We retrospectively studied all patients with intracranial GCT managed at our institute from January 1998 to December 2013. The clinical data and radiological data were analyzed.

Results:

Forty-eight patients with intracranial GCT including 36 males and 16 females formed the cohort. The proportion of GCT in our study was 0.29%. The mean age was 16.5 ± 2.5 years. Germinomas constituted 56.3% and nongerminomatous GCTs constituted 43.7% of all the tumors. The most common location was posterior third ventricle (58.3%) followed by suprasellar (22.9%). Histopathological diagnosis was obtained in almost all patients (96%). Surgical procedures included tumor decompression (71.7%), stereotactic biopsy (13%), and endoscopic third ventriculostomy and biopsy (15%). Patient's age, location of the tumor, and histology did not influence the survival. Women with GCTs had poorer survival when compared to men.

Conclusions:

The present study documented a lower hospital-based incidence of GCT in Indian cohort. A multidisciplinary approach including surgical strategy based on location, appropriate radiation planning, and chemotherapy is needed for effective treatment and improved outcomes.

H3K27M, IDH1, and ATRX expression in pediatric GBM and their clinical and prognostic significance

PURPOSE

Pediatric glioblastoma (pGBM) tumors have been identified as an entity distinct and different from the adult variety of GBM not only with respect to pathogenesis, genetics, and molecular alterations but also in clinical outcomes and overall survival. This study aims to evaluate the immunohistochemical profile of molecular markers in pediatric GBM and correlate them with clinical features and prognosis.

MATERIALS AND METHODS

We retrospectively analyzed 29 pGBMs (age range 3 to 18 years), operated at our institute between 2009 and 2014, and evaluated their clinical and histopathological features along with the immunohistochemical expression of clinically relevant molecular markers: H3K27M, p53, ATRX, and IDH1 (R132H), and correlated their expression with clinical features. We further assessed the prognostic value of these markers in our cohort of patients.

RESULTS

The median overall survival (OS) of the cohort was 6.00 ± 0.882 months. The mean overall survival was 7.571 ± 1.118 months which was lower than in most studies. Preoperative Karnofsky Performance Score (KPS), extent of surgical resection, and adjuvant radiotherapy were found to be the clinical factors strongly influencing median survival (p < 0.05). Loss of ATRX expression was predominantly noted in hemispheric tumors (84%), while p53 staining was maximum in thalamic tumors (8 out of 9 cases). H3K27M mutant protein expression was noted in 8/9 thalamic tumors and 5/7 tumors in the brain stem-cerebellar-peduncular region. Patients with tumors showing H3K27M immunopositivity had the worst prognosis with a mean OS of 5 months ± 0.832 months, as against patients with H3K27M-immunonegative tumors, which was 10.143 ± 1.866 months(p = 0.006). Other markers like p53, ATRX, and IDH1 did not influence the prognosis in this patient cohort. ATRX loss of expression was associated with a better OS, with a trend to significance, and such an association has not been reported earlier.

CONCLUSIONS

Ours is one among the few studies from India describing the clinical parameters and evaluating the key immunohistochemical markers in pGBM and deriving their prognostic significance. The study reiterates the poor prognostic significance of H3K27M immunopositivity.

Predictive validity of disability rating scale in determining functional outcome in patients with severe traumatic brain injury

BACKGROUND

Most patients with severe traumatic brain injury (TBI) are discharged when they have still not recovered completely. Many such patients are not available for follow up.

AIMS

We conducted this study to determine whether the condition at discharge from acute care setting, as assessed with disability rating scale (DRS), correlates with functional outcome at follow up.

SETTINGS AND DESIGN

This study was conducted at a Neurosurgical intensive care unit (ICU) of a tertiary care referral center. This was a prospective observational study.

MATERIALS AND METHODS

Patients admitted to ICU with a diagnosis of severe TBI were enrolled for the study. On the day of discharge, all patients underwent DRS assessment. A final assessment was performed using Glasgow outcome scale extended (GOSE) at 6 months after discharge from the hospital.

STATISTICAL ANALYSIS

The correlation between the DRS scores at the time of discharge with DRS scores and GOSE categories at 6 months after discharge was determined using Spearman's rho correlation coefficient.

RESULTS

A total of 88 patients were recruited for the study. The correlation coefficient of DRS at discharge for DRS at 6 months was 0.536 and for GOSE was -0.553. The area under the curve of DRS score at discharge for predicting unfavorable outcome and mortality at 6 months was 0.770 and 0.820, respectively.

CONCLUSION

The predictive validity of DRS is fair to good in determining GOSE at follow-up. Pending availability of a more accurate outcome assessment tool, DRS at discharge can be used as a surrogate outcome for GOSE at follow up.

Pediatric thoracolumbar spinal injuries: The etiology and clinical spectrum of an uncommon entity in childhood

BACKGROUND

Pediatric thoracolumbar (TL) spinal injuries are uncommon entities with an incidence of 5-34% of all pediatric spinal injuries. There is a scarcity of studies done on the pediatric population in the developing countries like India. This study aims to review our experience with TL spine injuries in children over a 12-year period.

MATERIALS AND METHODS

We retrospectively reviewed the epidemiology, risk factors, mechanisms, patterns of injury and management of pediatric TL injuries in our population.

RESULTS

There were 90 children with TL spine injuries comprising 2% of all the spine injuries treated in our institute. The mean age was 15.9 ± 3.2 years (range: 2-18 years) with a male predominance (3:1). The most common mode of injury was fall from height. 64/90 (71.1%) children sustained injury due to fall from height, 18/90 (20%) children sustained injury following motor vehicle accident and rest of the children sustained injury due to the fall of a heavy object over the neck. Most of the patients (27.8%) sustained Grade A injury. Lumbar spine was the most common spinal level injured (53.3%), and fractures were the most common type of injury (93.3%). Surgical fixation was performed in 18/90 (20%) children. Follow-up was available for 21 children of which 13 (62%) were ambulant at follow-up.

CONCLUSION

TL injuries are rare and are most common in children older than 10 years and mainly involve the lumbar region. When indicated, surgical fusion of the involved vertebrae is safe and effective.

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement

BACKGROUND

Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach.

METHODS

The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries.

RESULTS

The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval.

CONCLUSIONS

In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Atypical presentation of extraspinal neurofibroma presenting with acute-onset monoparesis and Horner's syndrome: Case report and review of literature

The clinical presentation of spinal or extraspinal neurofibroma is radiculopathy or myelopathy, pain, and motor weakness. Extraspinal neurofibroma presenting with acute-onset monoparesis and Horner's syndrome is very rare. We report the case of a 55-year-old female who presented with acute-onset monoparesis of the left upper limb along with left-side drooping of the eyelid. Imaging revealed C6–D2 extraspinal solitary mass lesion lateral to spinous process with bleed without intraspinal component. The patient underwent an anterior cervical approach and excision of the tumor. Final biopsy report was a neurofibroma. At 3-year follow-up, she recovered from motor weakness, and Horner's syndrome subsided. Extraspinal neurofibroma can present with acute bleed, and surgical outcome is superior in early intervention.

Role of Decompressive Craniectomy in the Management of Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke more often affecting women and younger individuals. Blockage of the venous outflow rapidly causes edema and space-occupying venous infarctions and it seems intuitive that decompressive craniectomy (DC) can effectively reduce intracranial pressure just like it works for malignant middle cerebral artery infarcts and traumatic brain injury. But because of the relative rarity of this type of stroke, strong evidence from randomized controlled trials that DC is a life-saving procedure is not available unlike in the latter two conditions. There is a possibility that other forms of interventions like endovascular recanalization, thrombectomy, thrombolysis, and anticoagulation, which cannot be used in established middle cerebral artery infarcts and TBI, can reverse the ongoing pathology of increasing edema in CVST. Such interventions, although presently unproven, could theoretically obviate the need for DC when used in early stages. However, in the absence of such evidence, we recommend that DC be considered early as a life-saving measure whenever there are large hemorrhagic infarcts, expanding edema, radiological, and clinical features of impending herniation. This review gives an overview of the etiology and risk factors of CVST in different patient populations and examines the effectiveness of DC and other forms of interventions.

Iatrogenic peripheral nerve injuries

Iatrogenic peripheral nerve injury is a considerable social and economic concern and the majority of cases are preventable. Complications should be referred to, and dealt with promptly by experienced surgeons, to ensure the best chances for an optimal functional recovery. Their prevention should be emphasized. Their management should include ensuring an early diagnosis, administering an appropriate treatment with rehabilitation, rendering psychological support and providing control of pain. We will address the aetiology, predisposing factors, diagnostic approaches, and management strategies to reduce the incidence of iatrogenic peripheral nerve injuries.

Surgical Management and Outcome of a Bilateral Thalamic Pilocytic Astrocytoma: Case Report and Review of the Literature

The incidence of bilateral thalamic glioma in children is not reported in the literature. The majority of cases comprise either diffuse astrocytoma, anaplastic astrocytoma, or glioblastoma. Partial surgical resection or biopsy followed by adjuvant therapy is the usual treatment for bilateral thalamic gliomas. Prognosis is dependent on tumor grade and extent of tumor spread to surrounding critical structures. We present a rare case of bilateral thalamic pilocytic astrocytoma. Endoscopic biopsy, septostomy, and placement of a ventriculoperitoneal shunt was done followed by radiotherapy. The 36-month follow-up demonstrated radiological control of the tumor.

Complications of Decompressive Craniectomy

Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.

Preoperative functional magnetic resonance imaging in patients undergoing surgery for tumors around left (dominant) inferior frontal gyrus region

Background:

Preoperative functional magnetic resonance imaging (fMRI) helps to preserve neurological function and ensure maximal tumor tissue excision. We studied the lateralization and localization of speech centers in select cases of tumors around the left (dominant) inferior frontal gyrus (IFG).

Methods:

Twenty-three right-handed patients, harboring tumors involving the left (dominant) IFG or causing mass effect or edema extending onto the left IFG, were recruited over 17 months. Preoperatively, all patients underwent language and speech assessment followed by MRI and fMRI with paradigm (picture naming). Normative data for language fMRI was taken from the institute's imaging data bank.

Results:

The study included 23 patients [mean age: 38.9 (±11.9) years; M: F = 16:7; 9 – normal speech, 14 – abnormal speech]. Group analysis of controls showed significant activation in the region of interest (ROI) – left Brodmann's areas (BAs) 44,45. Group analysis of patients with normal speech showed no activation in the left BAs 44,45; however, activation was noted in the immediate adjacent areas, left BAs 13,47 and contralateral prefrontal cortex. Group analysis of patients with impaired speech showed no activation in BAs 44,45 or in the immediate adjacent areas.

Conclusions:

Neuroplasticity in the brain may enable functional language areas to shift to adjoining or distant regions in the brain when the primary areas are involved by intrinsic tumors. This phenomenon is more likely in slow-growing compared to fast-growing tumors. Preoperative language fMRI may help us in identifying and protecting these areas during surgery.

Pilocytic astrocytoma with spontaneous malignant transformation with intracranial and skeletal dissemination: case report and review of the literature

Pilocytic astrocytoma is a benign low-grade tumor with a favorable prognosis. We present a 47-year-old- lady with a posterior fossa pilocytic astrocytoma who underwent surgical decompression. She developed multiple early local recurrences Along with malignant transformation of the cranial lesion she developed skeletal dissemination within a very short time frame. There were no features or family history of neurofibromatosis 1. She did not receive radiotherapy or chemotherapy prior to the recurrences.

Intracranial Cryptococcoma-Clinicopathologic Correlation and Surgical Outcome: A Single-Institution Experience

OBJECTIVE

To describe clinical characteristics of patients with intracranial cryptococcoma, clinicopathologic findings, and outcomes after surgery.

MATERIALS AND METHODS

Clinical data were collected from hospital case records, and pathologic confirmation was done by a neuropathologist. Clinical details, imaging features, and treatment modalities were evaluated and correlated with outcomes based on regular follow-up.

RESULTS

This case series included 5 cases of histology- and culture-proven intracranial cryptococcoma. Three patients (60%) were aged between the 3rd and 5th decades. Three cases were supratentorial in location, and 2 were in the posterior fossa. One patient presented with seizures. Three patients (60%) presented with fever. Three patients (60%) had papilledema, and 4 (80%) had signs of meningeal irritation. Four patients (80%) were immunocompetent. Only 1 patient was immunocompromised. All lesions were peripherally enhancing on computed tomography. Four of 5 patients underwent surgical decompression without any residue. Only 1 patient underwent stereotactic biopsy. All patients received antifungal therapy. One patient who was immunocompromised developed multiorgan failure and died after 2 months after surgery (20%). Of 5 cases, 4 (80%) had a good outcome with a mean follow-up of 5 years.

CONCLUSIONS

Cryptococcus gattii is a rarer species implicated in intracranial cryptococcoma that is seen along with the more common Cryptococcus neoformans. Early diagnosis and surgical decompression followed by intravenous amphotericin B therapy for at least 6 weeks and concomitant therapy with fluconazole for prolonged periods may reduce morbidity and mortality.

Fatal penetrating orbitocerebral injury by bicycle brake handle

Accidental penetrating head injuries are rare but significant cause of morbidity in children. We report a case of a nine-year-old who sustained a fatal trans-orbital penetrating injury following a fall from bicycle. The plastic sheath of the metal brake handle was lodged intracranially, injuring the brainstem. The CT scan features and autopsy findings are described.

Cortical plasticity after brachial plexus injury and repair: a resting-state functional MRI study

OBJECTIVE The authors aimed to understand the alterations of brain resting-state networks (RSNs) in patients with pan-brachial plexus injury (BPI) before and after surgery, which might provide insight into cortical plasticity after peripheral nerve injury and regeneration. METHODS Thirty-five patients with left pan-BPI before surgery, 30 patients after surgery, and 25 healthy controls underwent resting-state functional MRI (rs-fMRI). The 30 postoperative patients were subdivided into 2 groups: 14 patients with improvement in muscle power and 16 patients with no improvement in muscle power after surgery. RSNs were extracted using independent component analysis to evaluate connectivity at a significance level of p < 0.05 (familywise error corrected). RESULTS The patients with BPI had lower connectivity in their sensorimotor network (SMN) and salience network (SN) and greater connectivity in their default mode network (DMN) before surgery than the controls. Connectivity of the left supplementary motor cortex in the SMN and medial frontal gyrus and in the anterior cingulate cortex in the SN increased in patients whose muscle power had improved after surgery, whereas no significant changes were noted in the unimproved patients. There was a trend toward reduction in DMN connectivity in all the patients after surgery compared with that in the preoperative patients; however, this result was not statistically significant. CONCLUSIONS The results of this study highlight the fact that peripheral nerve injury, its management, and successful treatment cause dynamic changes within the brain's RSNs, which includes not only the obvious SMN but also the higher cognitive networks such as the SN and DMN, which indicates brain plasticity and compensatory mechanisms at work.

Cascade of Traumatic Brain Injury: A Correlational Study of Cognition, Postconcussion Symptoms, and Quality of Life

INTRODUCTION

Traumatic brain injury (TBI) constitutes a significant burden on health care resources in India. TBI is a dynamic process which involves damage to the brain thus leading to behavior cognitive and emotional consequences.

AIM

To study the cognitive profile, post-concussion symptoms (PCS), quality of life (QOL), and their correlation.

METHODS

A total of 60 patients with TBI were recruited and assessed for neuropsychological profile, PCS, and QOL, the correlation among the variables were analyzed.

RESULTS

The results suggest that TBI has series of consequences which is interrelated, and the study has implications for rehabilitation of TBI.

CONCLUSION

The study highlights the deficits of cognition, and its correlation with PCS and QOL, emphasizing integrated rehabilitation approach for patients with TBI.

Standardization of Tests of Attention and Inhibition

AIM

The aim of the study was to standardize tests of attention and inhibition for adults in the age range of 16-30 years, who had 1-10 years of formal education. The objectives were to develop normative data for the tests of attention and inhibition, to establish the reliability of the tests of attention and inhibition, and to establish the validity of the tests of attention and inhibition.

MATERIALS AND METHODS

The tests studied were figural visual scanning test (FVST), auditory target detection test (ATDT), stop signal test, and go/no-go (GNG) test. The four tests were given to a normal sample of 60 subjects (30 males and 30 females). Reliability of the tests was determined by retesting 20 individuals, (10 subjects from each group) from the sample after an interval of 1 month. The tests were given to a matched clinical sample of patients with unilateral focal lesions, and the results were compared to test discriminant validity. Means, standard deviations, t-test, correlations, and percentiles were used to analyze the data.

RESULTS AND CONCLUSION

Results indicated that FVST and ATDT were reliable and valid tests of attention and stop signal test and GNG test were reliable and valid measures of inhibition of motor processes.

Post-traumatic cervical spondyloptosis: A rare entity with multiple management options

Post-traumatic cervical spondyloptosis is a rare condition associated with high energy injuries, and to our knowledge only case reports are available. There are no universally accepted treatment paradigms for these cases and management is individualised according to the case and surgeon preference. We retrospectively analysed our management and clinical outcomes of this condition. From January 2007 to August 2014 we treated eight patients with cervical spondyloptosis at our institute. Only two patients had no neurological deficits; all the remaining patients had partial cord injury. Seven were treated surgically with preoperative traction followed by anterior cervical discectomy and fusion with fixation in three patients, and combined anterior and posterior fusion and fixation in four. Depending on the presence of anterior compression by a disc an anterior first or posterior first approach was advocated. All four combined anterior and posterior fusion and fixation patients needed to be turned more than once (540°). There was no neurological deterioration in any of the patients, as they either improved or remained stable neurologically. Post-traumatic cervical spondyloptosis is a challenging entity to manage. Surgery can be done safely with good clinical and radiological outcome and needs to be tailored to the individual patient.

Peculiarities and Patterns of Cervical Spine Injuries in Children and Adolescents: A Retrospective Series of 84 Patients from a Single Institute

Cervical spine injuries occur infrequently in children but are associated with significant disability and mortality. A retrospective analysis was performed of 84 consecutive pediatric spine injuries treated at our institute from January 2002 to December 2011. The mean age was 14.7 years. There were 18 patients (21%) in group A (0-12 years) and 66 patients (79%) in group B (13-18 years). Overall, injury was more common in boys (ratio of 6:1). Trivial fall was the predominant cause in group A and fall from height in group B. There were 30 children (36%) with injuries of the upper cervical spine, 53 (63%) with injuries of the lower cervical spine and 1 patient (1%) with a combined injury of upper cervical spine and thoracic spine. Overall, 22% of the group A children and 67% of the group B patients had more severe injuries (Frankel grades A, B and C); 21% (18/84) were treated by surgical fusion. Where follow-up was available, 17 out of 22 children (77%) had good outcome (Frankel grade >C). In conclusion, mechanisms and patterns of injury in children are age related and the majority of the children had good outcome.

Remote multiple intracranial hemorrhage in multiple metastatic lung adenocarcinoma following decompression of posterior fossa lesion: Unknown cause

Cerebral metastasis can present with hemorrhage. However, multiple hemorrhages in metastatic lesions following surgical decompression of a single lesion are never reported. We report a case of cerebral metastasis from lung cancer that developed multiple hemorrhages in supratentorial metastatic lesions following surgical resection of an infratentorial lesion.

Complications of cranioplasty after decompressive craniectomy for traumatic brain injury

INTRODUCTION

Decompressive craniectomy (DC)--a potentially life-saving intervention following traumatic brain injury (TBI) with medically refractory brain swelling--once performed, surviving patients, more often than not, undergo a second procedure with cranioplasty (CP) in the future. This study analyzes complications following CP after DC, as the beneficial effects of the DC can't be extrapolated in long run over a population unless one adds into it the complications associated with the CP in the survivors of TBI.

MATERIALS AND METHODS

An observational study was performed retrospectively, with the review of case records. Demographic, clinical, and outcome data were collected, and complications were studied for any predictive parameters. A multivariate analysis was performed to identify factors that influenced these complications.

RESULTS

Data were collected for a total of 74 patients who underwent CP with a median age of 32, and a mean follow-up time of 2 years and 8 months. The mortality rate was 1.35% and overall complication rate 31%. The most significant factor determining complications were operating time more than 90 min Odds ratio (OR) 4.77 (1.61-14.20); timing of CP less than 3 months after craniectomy, OR 2.86 (1.48-8.11); age more than 20 years, OR 2.59 (1.20-6.53); and female gender, OR 1.91 (1.13-4.17).

CONCLUSIONS

Although considered as a straight-forward procedure, the risks associated with this elective procedure should be kept in mind by the surgeon so that the patients and families can be apprised judiciously. It should be ascertained that patient and/or family consents for the procedure after being appropriately informed about the benefits and risks associated with the procedure.

Central nervous system lymphoma: patterns of incidence in Indian population and effect of steroids on stereotactic biopsy yield

BACKGROUND

Epidemiology of primary central nervous system lymphoma (PCNSL) world-wide shows an increase in incidence linked to human immunodeficiency virus (HIV) pandemic.

MATERIALS AND METHODS

This retrospective review of case records analyzed the trends of hospital-based incidence of PCNSL over two decades (1991-2010), relation to immune status and effect of steroids on yield of stereotactic biopsy (STB).

RESULTS

A total of 76 cases of PCNSL were diagnosed over a period of two decades. Incidence of lymphomas amongst all biopsied lesions showed a gradual increase from 0.18% at the beginning of study period to 0.41% at the end of study period. Only 8.6% (3 of 35 tested) of the PCNSL patients were positive for HIV. The mean age of patients with HIV infection (31.3 ± 3.5 years) was significantly lower compared with those without HIV infection (44.7 ± 10.9 years) (P = 0.033). Diagnosis was obtained by open biopsy in 32 patients (42.1%) and STB in 44 patients (57.9%). Open biopsy yielded a histological confirmation of PCNSL in all cases. Among those who underwent STB, the incidence of negative biopsy with short duration of steroids (≤ 1 week) was 33.3% and increased to 57.1% with increasing duration of steroid treatment (>1 week).

CONCLUSIONS

This study documented an increase in hospital based incidence of PCNSL in our institute, independent of HIV association. Steroid intake administration for more than a week prior to biopsy adversely affected the yield of STB in PCNSL.