Supraorbital vs pterional keyhole for anterior circulation aneurysms: A systematic review and meta-analysis

Background

The supraorbital approach is a modification of the traditional pterional approach, and it offers the benefits of a shorter skin incision and a smaller craniotomy than the pterional approach. The purpose of this systemic review study was to compare the two surgical approaches for raptured and unruptured anterior cerebral circulation aneurysms.

Methods

We searched PubMed, EMBASE, Cochrane Library, SCOPUS, and MEDLINE, up to August 2021, for published studies on the supraorbital vs pterional keyhole approach for anterior cerebral circulation aneurysms, and reviewers performed a brief qualitative descriptive analysis of both approaches.

Results

Fourteen eligible studies were included in this systemic review. Results indicated that the supraorbital approach for anterior cerebral circulation aneurysms had fewer ischemic events compared to pterional approach. However, no significant difference between both groups in terms of complications such as intraoperative aneurysm rupture, brain hematoma, and postoperative infections for ruptured aneurysms.

Conclusion

The meta-analysis suggests that the supraorbital method for clipping anterior cerebral circulation aneurysms might be a viable alternative to the traditional pterional method as the supraorbital group had decreased ischemic events compared to the pterional group, however, the associated difficulties in utilizing this approach among ruptured aneurysms with cerebral oedema and midline shifts further needs to be understood.

Giant Tarlov Cyst presenting as pelvic mass: Often doing less is better

Background

Tarlov cysts are sacral perineural cysts arising between the peri and endoneurium of the posterior spinal nerve root at the Dorsal Root Ganglion and have a global prevalence rate of 4.27%. These are primarily asymptomatic (only 1% with symptoms) and typically arise in females between the ages of 50-60. Patients' symptoms include radicular pain, sensory dysesthesias, urinary and/or bowel symptoms, and sexual dysfunction. Non-surgical management with lumbar cerebrospinal fluid drainage and computerized tomography-guided cyst aspiration typically provide only months of improvement before recurring. Surgical treatment includes a laminectomy, cyst, and/or nerve root decompression with fenestration of the cyst and/ or imbrication. Early surgery for large cysts provides the longest symptom-free periods.

Case Description

A 30-year-old male presented with a very large magnetic resonance-documented Tarlov cyst (Nabors Type 2) arising from bilateral S2 nerve root sheaths with marked pelvic extension. Although he was initially treated with a S1, S2 laminectomy, closure of the dural defect, and excision/marsupialization of the cyst, he later required placement of a thecoperitoneal shunt (TP shunt).

Conclusion

A 30-year-old male with large Nabors Type 2 Tarlov cyst arising from both S2 nerve root sheaths required a S1-S2 laminectomy, dural closure/marsupialization, and imbrication of the cyst, eventually followed by placement of a TP shunt.

Real-world application, challenges and implication of artificial intelligence in healthcare: an essay

This essay examines the state of Artificial Intelligence (AI) based technology applications in healthcare and the impact they have on the industry. This study comprised a detailed review of the literature and analyzed real-world examples of AI applications in healthcare. The findings show that major hospitals use AI-based technology to enhance knowledge and skills of their healthcare professionals for patient diagnosis and treatment. AI systems have also been shown to improve the efficiency and management of hospitals´ nursing and managerial functions. Healthcare providers are positively accepting AI in multiple arenas. However, its applications offer both the utopian (new opportunities) as well as the dystopian (challenges). Unlike pessimists, AI should not be seen a potential source of "Digital Dictatorship" in future of 22^nd century. To provide a balanced view on the potential and challenges of AI in healthcare, we discuss these details. It is evident that AI and related technologies are rapidly evolving and will allow care providers to create new value for patients and improve their operational efficiency. Effective AI applications will require planning and strategies that transform both the care service and the operations in order to reap the benefits.

'White Cord Syndrome': A Rare Catastrophic Complication Following Anterior Cervical Discectomy and Fusion

Background

'White-cord syndrome' is an extremely rare entity following decompression of cervical cord in which post-operative reperfusion injury results in worsening of patient's neurology and MRI reveals signal changes in spinal cord in absence of cord compression. We wish to report a case of 'white-cord syndrome' following a 'routine' ACDF.

Case Description

A 39-year-old woman with paresthesias and spastic quadriparesis was found to have C5-C6 PIVD on MRI. ACDF was performed at C5-C6, after which worsening of quadriparesis was noted, for which intravenous high-dose steroids were started. An urgent MRI was done, which revealed findings of white-cord syndrome, without compression on underlying cord. With conservative management, her ASIA grade improved from C to D and the features of white-cord syndrome disappeared on follow-up imaging.

Conclusion

It is important for surgeons and patients to be aware of this rare but potentially catastrophic entity as this needs to be discussed while taking consent for surgery.

Basal Cisternostomy in Head Injury: More Questions than Answers

Background

Cisternostomy has recently been reintroduced in the setting of severe TBI as an adjuvant surgical technique for decreasing brain edema and refractory intracranial hypertension. However, there is not much clarity regarding its role in head injury.

Objective

Study the effect of cisternostomy on intracranial pressure, morbidity, and mortality in head-injured patients.

Material and Methods

We conducted a single-center quasi-experimental study between November 2018 and November 2020. All candidates for decompressive hemicraniectomy (DHC) were divided into two groups: DHC-BC (undergoing basal cisternostomy with DHC) and DHC (undergoing DHC alone). We compared the impact of surgery on decreasing ICP and clinical outcomes in both groups.

Results

During the study duration, we admitted 659 head-injury patients. Forty patients were included in the study (9 in the DHC-BC group and 31 in the DHC group). Both the groups were comparable in terms of baseline clinical characteristics such as age, gender, preoperative GCS, head injury severity, radiological features, and opening ICP. Patients in both groups had a decline in ICP following surgery. The mean closing pressure in the DHC-BC group (11.3 ± 5.9) was significantly higher than that in the DHC group (5.3 ± 3.5) (P = 0.003). The mean drop in ICP in the DHC-BC group was 14.4 ± 11.5 while that in the DHC group was 18.9 ± 12.4 (P = 0.359). The average total number of hours of ICP >20 mm Hg and intracranial hypertension index were higher for the DHC-BC group. The average number of days of stay in the ICU and hospital were lower for the DHC-BC group (7.0 ± 6.1 and 15.0 ± 20.2, respectively) compared to the DHC group (10.6 ± 9.3 and 19.3 ± 13.9, respectively). The 30-day mortality rate was higher for the DHC-BC group (66.6%) than the DHC group (32.2%). The mean GCS at discharge was better in the DHC-BC group (11.7 ± 2.9) compared to 10.5 ± 3.7 in the DHC group, while 11.1% of patients in the DHC-BC group had a favorable outcome (1-month GOS-E) compared to 9.7% patients in the DHC group.

Conclusions

Our preliminary single-center study failed to show a clear benefit of adding basal cisternostomy to decompressive hemicraniectomy in patients with head injuries.

P-688 Combination of letrozole and clomiphene citrate versus letrozole alone for ovulation induction in women with polycystic ovary syndrome - a randomized controlled trial

Study question

Does clinical pregnancy rate improve using combination of letrozole and clomiphene versus letrozole alone for ovulation induction in infertile women with PCOS

Summary answer

The present study showed that combination drugs had no added advantage over Letrozole alone in terms of ovulation induction.

What is known already

Letrozole can offer a benefit over CC for ovulation induction because it doesn’t block estrogen receptors in both central and peripheral target tissues, therefore normal central feedback mechanisms remain intact. As letrozole and CC have different mechanisms of action, the combination of these medications can achieve an improved ovulatory rate over letrozole alone.

We aimed to test the hypothesis of whether combined therapy of letrozole and CC is effective and superior to the use of letrozole alone to achieve pregnancy in women with PCOS.

Study design, size, duration

Prospective Randomized Controlled Trial conducted from July 2019 to December 2020 at tertiary care centre in Uttarakhand

According to studies done earlier (49), it was observed that proportion of positive outcome in letrozole and clomiphene citrate combined therapy was assumed to be 0.7700 and for letrozole therapy alone was 0.4400. With significance level of 0.05 and power 90% a sample size of 42 in each group to detect assumed 0.33 difference between the two groups.

Participants/materials, setting, methods

68 patients randomised in two group. Group I received combination of Letrozole (2.5mg) and clomiphene citrate (50 mg) once daily for 5 days (day 3-7 of cycle). Group II received Letrozole 2.5mg once daily for 5 days (day 3-7 of cycle) for 4 cycles. After induction follicular monitoring done and HCG given when dominant follicle size > =18mm with ET > =8mm followed by timed intercourse.

Main results and the role of chance

No statistically significant difference seen between the two groups in baseline characterstics. Comparing the pregnancy rate, 9.3% in Group 1 (n = 3) & 6.3% in Group 2 (n = 2) became pregnant after first cycle of ovulation induction (OVI), after 2nd cycle, 7.1% in Group 1 (n = 2) & 13.8% in Group 2 (n = 4) became pregnant. 11.5 % in Group 1 (n = 3) & 8.0 % in Group 2 (n = 2) became pregnant after cycle 3 and 21.7% in Group 1 (n = 5) & 8.7% in Group 2 (n = 2) became pregnant after 4th cycle of OVI. Though the pregnancy rate was statistically not significant in all the cycle (p <  0.615,0.413,0.671,0.218 respectively). The median number of cycles required for conception in Group 1 was 3 and that of group 2 was 2.

Limitations, reasons for caution

Small sample size

Larger multicentric randomised controlled trials required

Wider implications of the findings

Pregnancy rate was higher when ovulation induction was done using combination of clomiphene and letrozole but difference was not statistically significant.

Mean number of cycles required for conception similar in both groups.

Trial registration number

CTRI no: CTRI/2020/06/025688

Endovascular management of iatrogenic vertebro-vertebral fistula: Black Swan event in C2 pedicle screw

Background:

Vertebro-vertebral fistulas (VVF) are rare. Anatomically, they consist of an arteriovenous fistula, a direct pathological communication between vertebral veins (including the epidural vertebral venous plexus) and extradural vertebral artery. The various etiologies include trauma, iatrogenic, or spontaneous (e.g., NF-1 or Ehlers Danlos Syndrome). The clinical presentation may include acute/delayed onset of radiculopathy and/or myelopathy. They may further be characterized by the delayed onset hearing loss to tinnitus and/or the sensation of water in the ear.

Case Description:

We report successful endovascular management for iatrogenic VVF in a 37-year-old female who was diagnosed with an odontoid fracture (Anderson type IIC). She underwent a posterior C1 lateral masses to C2 pedicle/laminar screw fixation. An intraoperative vertebro-vertebral fistulas (VVF) was recognized during the procedure and it was managed successfully with percutaneous transarterial endovascular coiling.

Conclusion:

Iatrogenic VVF should immediately be suspected when the implant trajectory goes slightly off track during a C1-2 fixation. Immediate postoperative DSA and MRI are advisable, irrespective of whether the patient is symptomatic. These lesions are best managed with endovascular coiling with or without detachable balloons.

Cervical osteoma in hereditary multiple exostoses

Osteoid osteoma is a benign bony pathology. It presents either as a solitary lesion or as multiple lesions with a genetic predisposition. Reported more often in teenagers with thrice more common incidence among boys than in girls, it has a predilection for long bones of lower limbs. Less commonly arising from iliac crest or ribs; it is seen to be further rare to have originated from vertebrae or tarsal/carpal bones. Cranial osteomas are detected either incidentally on imaging or present as a bony hard swelling arising from the skull. Spinal intracanal osteomas are extremely rare to encounter in clinical practice. Cervical intracanal lesion in a case of hereditary multiple exostoses (HME) presenting with myelopathy is further rare. Less than thirty such cases have been reported so far. We present here a rare case of HME in a 16-year-old boy with compressive myelopathy secondary to intracanal cervical osteoma at C4 Lamina and spinous process. He had a phenotypical expression of hereditary multiple osteomas with a strong family history of inheritance of trait among first-degree male relatives favoring genetic transmission of disease with variable penetrance. All reported cases, to date, are discussed in a tabulated form.

Surgical Outcome of Large Solid Posterior Fossa Hemangioblastoma without Preoperative Embolization

BACKGROUND

 Large solid hemangioblastoma in the posterior fossa has an abundant blood supply as an arteriovenous malformation. The presence of adjacent vital neurovascular structures makes them vulnerable and difficult to operate. Complete surgical resection is always a challenge to the neurosurgeon.

MATERIAL AND METHOD

 We share the surgical difficulties and outcome in this case series of large solid hemangioblastomas without preoperative embolization as an adjunct. This study included five patients (three men and two women, with a mean age of 42.2 years). Preoperative embolization was attempted in one patient but was unsuccessful. All the patients have headache (100%) and ataxia (100%) as an initial symptom. A ventriculoperitoneal shunt was inserted in one case before definite surgery due to obstructive hydrocephalus. The surgical outcome was measured using the Karnofsky Performance Status (KPS) score.

RESULT

 The tumor was excised completely in all the cases. No intra- and postoperative morbidity occurred in four patients; one patient developed transient lower cranial nerve palsy. Mean blood loss was 235 mL, and no intraoperative blood transfusion was needed in any case. The mean follow-up period was 14.2 months. The mean KPS score at last follow-up was 80.One patient had a KPS score of 60.

CONCLUSION

 Our treatment strategy is of circumferential dissection followed by en bloc excision, which is the optimal treatment of large solid hemangioblastoma. The use of adjuncts as color duplex sonography and indocyanine green video angiography may help complete tumor excision with a lesser risk of complication. Preoperative embolization may not be needed to resect large solid posterior fossa hemangioblastoma, including those at the cerebellopontine angle location.

Getting Neurosurgery Services Back on Its Feet: "Learning to Live" with COVID-19

Background:

Cancellation/postponement of ”non-emergent” surgeries during coronavirus disease of 2019 (COVID-19) pandemic has created a huge backlog of patients waiting for surgery and has put them at risk of disease progression. We share our institute's policy and our department's attempt to resume ”non-emergent” surgeries.

Materials and Methods:

We collected details of all patients operated under department of neurosurgery since the onset of COVID-19 pandemic in India and categorized them into ”lockdown” and ”unlock” groups for comparison. COVID-19 tests done in these patients were also analyzed. We also compared our surgical volume with the number of COVID-19 cases in the state.

Results:

One hundred and forty-eight patients (97 males, 51 females) with mean age of 37.8 years (range-2 months-82 years) underwent surgery in our department during the study period. The operative volume per week increased by 37% during the ”unlock” period as compared to ”lockdown” period. The proportion of elective/”non-emergent” surgeries increased from 11.3% during ”lockdown” to 34.7% during the ”unlock” period (P = 0.0037). During ”lockdown” period, number of surgeries declined steadily as the number of COVID-19 cases rose in the state (rs(8) = −0.914, P = 0.000). Whereas there was a trend toward increased number of cases done per week despite increase in the number of cases in the state during the “unlock” period. During the ”unlocking” process, in-patient department admissions and surgeries performed per month increased (P = 0.0000) and this increase was uniform across all specialties. COVID-19 test was done (preoperatively or postoperatively) for all surgeries during ”unlock” period compared to 12 (22.6%) surgeries during ”lockdown” period. Three neurosurgery patients who underwent surgery during the ”unlock” period tested positive for COVID-19.

Conclusions:

Our experience shows that proper evidence-based protocols, setting up of adequate COVID-19 testing facilities and provision of ample personal protective equipments are instrumental in re-starting “nonemergent” surgeries.

Effects of Health Promotion Model-Based Visual Learning Module on Self-Efficacy and Health Promotion Behavior of Stroke Survivors: A Nonrandomized Controlled Trial

Background and Objectives  Globally, stroke is one of the major causes of disability and mortality among adults and old age people. The present study aims to evaluate the effects of the health promotion model-based visual learning module (HPM-VLM) on self-efficacy and behavioral modifications among stroke survivors.

Methods  This nonrandomized controlled trial was conducted on 70 stroke survivors (intervention group, n = 35, and control group, n = 35). The intervention group was subjected to two sessions of the HPM-VLM and the control group received routine instructions. Data were collected through face-to-face structured interview, and observation using a self-structured self-efficacy questionnaire and health promotion behavior questionnaire. Data were analyzed using descriptive (frequency and percentage) and inferential (Chi-square, independent t -test, mixed model, and ANCOVA) values by IBM Statistical Package for Social Sciences (SPSS; version 23) software.

Results  Eventually, follow-up could have been completed for 66 participants (intervention group, n = 34, and control group, n = 32). HPM-VLM is found to be effective in the promotion of self-efficacy (19.2 ± 1.6 vs. 16.12 ± 2.5; p = 001) and health promotion behavior of stroke survivors in most of the domains ( p < 0.01).

Conclusion  HPM-VLM is an effective interventional tool for the promotion of self-efficacy and health promotion behavior of stroke survivors.

Coma recovery scale: Key clinical tool ignored enough in disorders of consciousness

Background:

Disorders of consciousness (DoC) includes coma, vegetative state (VS), minimally conscious state (MCS), and emergence from the MCS. Aneurysmal rupture with high-grade SAH, traumatic brain injury, and neoplastic brain lesions are some of the frequent pathologies leading to DoC. The diagnostic errors among these DoC are as high as ranging from 25% to 45%, with a probable error in the conclusion of patients’ state, treatment choice, end-of-life decision-making, and prognosis. Some studies also reported that 37–43% of patients were misdiagnosed in VS while demonstrating signs of awareness. Despite its wide acceptance, Coma Recovery Scale-Revised (CRS-r) remained underused or inappropriately utilized, which may lead to substandard or unprofessional patient care. Literature is rare on the knowledge of CRS-r among physicians published from India and across the globe. Therefore, we carried out the present study to ascertain physicians’ knowledge on CRS-r and raise awareness about its justifiable clinical utilization. We also explored the factors associated with this perceived level of experience among participants and recommend frequent physicians’ training for care of patients with DoC.

Methods:

An institution-based cross-sectional online survey was conducted from June 8 to July 7, 2020, among Ninety-six physicians recruited using a convenient sampling technique. Twenty-item, validated, reliable, and a pilot-tested questionnaire was used to assess the knowledge regarding CRS-r and collect socio-demographic variables. The analysis was performed using the Statistical Package for the Social Sciences version 23. Bivariate and multivariate logistic regression analyses were employed to assess the association of participants’ socio-demographic variables and their parent department of work with the knowledge. P < 0.05 was considered statistically significant in the multivariate analysis.

Results:

A total of Ninety-six participants were included in the analysis, and only 33.3% of them were found to have adequate knowledge of CRS-r. Multivariate analysis revealed that age (adjusted odds ratio [AOR] = 31.66; 95% CI: 6.25–160.36), gender (AOR = 44.16; 95% CI: 7.43–268.23), and parent department of working (AOR = 0.148; 95% CI: 0.06–0.39) were significantly associated with the knowledge.

Conclusion:

Knowledge of the physicians on CRS-r is found to be exceptionally low. It has a strong tendency to adversely affect patients’ optimal care with disorders of consciousness (DoC). Therefore, it is crucial to expand physicians’ knowledge and awareness regarding CRS-r to adequately screen patients with DoC.

A Systematic Review on the Impact of the COVID-19 Pandemic on Neurosurgical Practice and Indian Perspective

OBJECTIVE

The study objective was to systematically review the impact of the current pandemic on neurosurgical practice and to find out a safe way of practicing neurosurgery amid the highly infectious patients with COVID-19.

MATERIALS AND METHODS

A review of the PubMed and EMBASE databases was performed. The literature was systematically searched using keywords such as "COVID-19" and "Neurosurgery."

RESULTS

Among the 425 records, 128 articles were found to be eligible for analysis. These articles described the perspectives of the neurosurgical departments during the pandemic, departmental models, and organizational schemes for triaging emergent and nonemergent neurosurgical cases for the optimal utilization of limited resources, and solutions to continue academic and research activities. Triaging systems help us to optimally utilize the limited resources available. Guidelines have been developed for safe neurosurgical practice and for the continuation of clinical and academic activities during this pandemic by various national and international neurosurgical societies. Key changes in the telemedicine regulatory guidelines would help us to continue to provide neurosurgical care. Videoconferences, online education programs, and webinars could help us to overcome the disadvantages brought upon the neurosurgical education by the social-distancing norms.

CONCLUSION

In an unprecedented time like this, no single algorithm is going to clear the ethical dilemma faced by us. Individual patient triage is a way for maintaining our ethical practice and at the same time, for efficiently utilizing the limited resources. As the pandemic progresses, new guidelines and protocols will continue to evolve for better neurosurgical practice.

Neurosurgery training in India during the COVID-19 pandemic: straight from the horse's mouth

OBJECTIVE

The COVID-19 pandemic has forced medical professionals throughout the world to adapt to the changing medical scenario. The objective of this survey was to assess the change in neurosurgical training in India following the COVID-19 pandemic.

METHODS

Between May 7, 2020, and May 16, 2020, a validated questionnaire was circulated among neurosurgical residents across India by social media, regarding changes in the department's functioning, patient interaction, surgical exposure, changes in academics, and fears and apprehensions associated with the pandemic. The responses were kept anonymous and were analyzed for changes during the COVID-19 pandemic compared to before the pandemic.

RESULTS

A total of 118 residents from 29 neurosurgical training programs across 17 states/union territories of the country gave their responses to the survey questionnaire. The survey revealed that the surgical exposure of neurosurgical residents has drastically reduced since the onset of the COVID-19 pandemic, from an average of 39.86 surgeries performed/assisted per month (median 30) to 12.31 per month (median 10), representing a decrease of 67.50%. The number of academic sessions has fallen from a median of 5 per week to 2 per week. The survey uncovered the lack of universal guidelines and homogeneity regarding preoperative COVID-19 testing. The survey also reveals reluctance toward detailed patient examinations since the COVID-19 outbreak. The majority of respondents felt that the COVID-19 pandemic will hamper their operative and clinical skills. Fear of rescheduling or deferring of licensing examinations was significantly higher among those closest to the examination (p = 0.002).

CONCLUSIONS

The adverse impact of the pandemic on neurosurgical training needs to be addressed. While ensuring the safety of the residents, institutes and neurosurgical societies/bodies must take it upon themselves to ensure that their residents continue to learn and develop neurosurgical skills during these difficult times.

"Locked up inside home" - Head injury patterns during coronavirus disease of 2019 pandemic

BACKGROUND

As citizens have been forced to stay home during coronavirus disease of 2019 (COVID-19) pandemic, the crisis created unique trends in the neurotrauma patterns with changes in mode, severity, and outcome of head injured patients.

METHODS

Details of neurotrauma admissions under the neurosurgery department at our institute since the onset of COVID-19 pandemic in the country were collected retrospectively and compared to the same period last year in terms of demographic profile, mode of injury, GCS at admission, severity of head injury, radiological diagnosis, management (surgical/conservative), and outcome. The patients were studied according to which phase of pandemic they were admitted in - "lockdown" period (March 25 to May 31, 2020) or "unlock" period (June 1 to September 15, 2020).

RESULTS

The number of head injuries decreased by 16.8% during the COVID-19 pandemic. Furthermore, during the lockdown period, the number of admissions was 2.7/week while it was 6.8/week during the "unlock" period. RTA was the mode of injury in 29.6% patients during the lockdown, while during the unlock period, it was 56.9% (P = 0.000). Mild and moderate head injuries decreased by 41% and severe head injuries increased by 156.25% during the COVID-19 pandemic (P = 0.000). The mortality among neurotrauma patients increased from 12.4% to 22.5% during the COVID-19 era (P = 0.009).

CONCLUSION

We observed a decline in the number of head injury admissions during the pandemic, especially during the lockdown. At the same time, there was increase in the severity of head injuries and associated injuries, resulting in significantly higher mortality in our patients during the ongoing COVID-19 pandemic.

Spinal extradural arachnoid cyst: Rare cases from Indian Institutes

Background:

Spinal extradural arachnoid cyst (SEDAC), accounting for approximately 1% of all spinal lesions, rarely causes compressive myelopathy. It is usually found at lower thoracic or upper lumbar levels in males in their forties to sixties. The standard surgical procedures include direct dural repair.

Case Description:

A 37-year-old male presented with myelopathy attributed to a type I meningeal cyst (SEDAC) that was successfully managed with a laminectomy, cyst excision, and direct dural sleeve repair. Similar cases reported in the literature were also reviewed.

Conclusion:

SEDACs, although rare, must be considered among the differential diagnoses for compressive myelopathy/neurogenic bladder.

Angio-invasive Cerebral Aspergillosis Resulting in Hemispheric Infarct in an Immunocompetent Man

BACKGROUND

Cerebral aspergillosis usually affects immunocompromised hosts and may rarely occur in immunocompetent individuals. Due to its angio-invasive nature, Aspergillus may cause various vascular complications, particularly mycotic aneurysms and infarcts.

CASE PRESENTATION

A 22-year-old immunocompetent male with diagnosed case of sino-cerebral aspergillosis was taking voriconazole for two months. His headache worsened and repeat imaging showed an increase in the size of the lesion. The patient was managed with right frontal craniotomy and surgical debridement, and voriconazole was continued. After ten days of uneventful post-operative course, the patient developed left-sided hemispheric infarct. The patient is doing well at nine months' follow-up, and he is off voriconazole for three months after the follow-up imaging showed complete resolution of disease.

CONCLUSION

Treatment of choice for cerebral aspergillosis is voriconazole. Surgical debridement may be a useful adjunct in patients not responding to voriconazole alone.

Basal Cisternostomy in Traumatic Brain Injury: An Idea whose Time has Come?

Traumatic brain injury is associated with high morbidity and mortality. Since the introduction of decompressive craniectomy more than a century ago, no major surgical advancement has been introduced in this field in spite of neurosurgery having seen a sea change in general. Basal cisternostomy, introduced recently, is said to have great promise. In this regard, neurosurgeons need to understand the theory behind the recently introduced basal cisternostomy and whether it holds any merit or not.

Impact of the COVID-19 Pandemic on Neurosurgical Practice in India: Results of an Anonymized National Survey

Background

The COVID-19 pandemic has created an unprecedented challenge for medical professionals throughout the world to tackle the rapidly changing scenario. The objective of this survey was to analyze the change in neurosurgical practice in India following the COVID-19 outbreak and assess its impact on practising neurosurgeons.

Materials and Methods

Between May 7^th and 23^rd, 2020, a validated questionnaire was circulated amongst practising neurosurgeons across the country by social media and e-mails, regarding changes in the patterns of patients seen, adaptations made in their practice, effect on surgeries performed, financial burden, and impact on their personal lives. The responses were kept anonymous and were analyzed for correlations between the changes observed and independent factors such as hospital affiliations, teaching professions, and neurosurgical experience.

Results

Our survey showed a drastic fall in the number of neurosurgical patients seen in the outpatient department (OPD) as well as the number of surgeries performed. A drop of 76.25% was seen in OPD patients (P = 0.000) and that of 70.59% in surgeries performed (P = 0.000). There was no uniformity among the neurosurgeons in the number of COVID-19 tests being done before elective/emergency surgery and in the use of protective gear while examining patients. Private practitioners were more affected financially as compared to those in the government sector. The pandemic has affected the research work of 53.23% of all respondents, with those in the teaching profession (70.96%) more affected than those in the non-teaching profession (24.67%).

Conclusions

Evidence-based policies, screening COVID-19 tests with better sensitivity, and better-quality personal protective equipment kits in adequate numbers are required to protect our medical professionals from COVID-19. Mental health issues among neurosurgeons may also be an issue, this being a high risk speciality and should be closely watched for.

Expression and interpretation of relative risk and odds ratio in biomedical research studies

Relative risk and odds ratio are commonly used in the biomedical research studies; however, expression and interpretation must be done very carefully. A risk ratio and an odds ratio are used in cohort studies but only odds ratio is used in case control studies. However, relative risk or risk ratio is found to be frequently used in the interventional biomedical research studies. The relative risk and odds ratio provide important information regarding the effect of a risk factor on the outcome of interest. The relative risk and odds ratio of 1 suggests that there is no difference between two groups. A value >1 suggests increase risk, while a value <1 suggest reduction of risk. If the confidence interval meets or includes value 1.00 (line of no difference) indicates there is no difference between the groups.

Surgery for Spinal Trauma: Early Days at a Young Institution in a Hilly State

Background Spinal trauma is associated with significant morbidity and affects the overall quality of life of the patient as well as their family. The aim of this study was to study the epidemiology, in-hospital outcome, and follow-up of patients undergoing surgery for spinal trauma.

Methods All patients who underwent surgery for spinal trauma at the Department of Neurosurgery between June 2016 and October 2019 were studied retrospectively. Data collected from patient record included demographic profile, mode of injury, level of injury, neurological status at admission, time from injury to operative intervention, hospital stay, neurological outcome at discharge, and follow-up. Postoperative computed tomography scans were done in all patients to check for adequacy of screw placement.

Results A total of 70 patients (45 males, 25 females) with a mean age of 36 years (range: 16–65 years) were operated for spinal injuries at our department during the study period. Fall was the most common mode of injury (77.1%), followed by road traffic accident (28.5%). Most common site of injury was lumbar spine (38.6%), followed by dorsal (32.9%) and cervical (28.5%). Out of the total, 27.1% of our patients were American Spinal Injury Association (ASIA) grade A at presentation whereas 18.6% were ASIA E. Remaining 54.3% patients had incomplete injuries (ASIA B, C, and D). Burst fracture was the most common morphology of injury (60%), followed by translational injuries (30%). Mean duration between injury and operative intervention was 20.8 days. The mean duration of hospital stay was 21.4 days (range: 8–90 days). Six patients expired during hospitalization. All these six cases had cervical spinal injury. One patient of dorsal spine injury with a complete neurological injury expired 6 months after discharge from the hospital (cause unknown). Nine of our cases showed neurological improvement on follow-up and in rest of the patients, neurological status remained same as preoperative status.

Conclusion Neurological status at admission (ASIA grade) and level of injury remain the most important predictor of the outcome. Spinal injury patients must be managed with a holistic and multidisciplinary approach. Rehabilitation is important for helping these patients in leading a productive life.

Mirror meningioma at foramen magnum: Enigma in management of a very rare case

Background:

We report a very rare case of bilateral foramen magnum mirror meningioma and discuss difficulties in managing the surgical challenge. To the best of our knowledge, mirror foramen magnum meningioma (FMM) has been reported only once in literature. FMMs are rare and also a great challenge for neurosurgeons due to the complex anatomy of this area. The purpose of this article is to illustrate the rare occurrence of bilateral meningioma in the foramen magnum and the difficulties in managing the surgical challenge.

Case Description:

A case of a 45-year-old female presented with neck pain, paresthesia in all four limbs, and difficulty in walking for 1 year duration. Magnetic resonance imaging revealed well-defined lobulated dural based mass lesion at foramen magnum on both sides. The left vertebral artery (VA) was encased within the lesion while the right VA was seen abutting it. Tumor was resected gross totally on the right side. However, during the resection of the medial part of the left side tumor, it was found to be adhered to the VA. Since the mass was adherent to the left VA, subtotal resection was done.

Conclusion:

There is no single best surgical approach for FMMs and the optimal approach should be defined according to the localization and the extent of the tumor to minimize the extent of resultant morbidity. Although complete excision of the tumor is the aim of surgery, it is safer to leave portions of tumor that is adherent to critical structures which can be managed by Gamma Knife radiosurgery.

Metastatic Intracranial Adenoid Cystic Carcinoma with Unknown Primary: Case Report and Review of Literature

Adenoid cystic carcinoma (ACC) is an epithelial malignancy comprising approximately 8–10% of all salivary gland tumors. Intracranial ACC without a known primary is an extremely rare pathobiological event. Only 13 cases have been reported in available literature. We report a case of a rare intracranial ACC in a 35-year-old gentleman presenting with features of raised intracranial pressure. Patient had a lesion in the right parieto-occipital lobe and underwent gross total decompression. There was no evidence of any primary after a thorough systemic evaluation. In the postoperative period, he showed a good clinical improvement and was recurrence free at follow-up of 18 months. We also discuss and review the existing relevant literature.

Retrobulbar Lymphangioma: A Rare Case Report

We report a case of biopsy-proven retrobulbar lymphangioma in a 14-year-old girl. She presented with chief complaints of swelling in the left eye for 2 months. The patient underwent imaging evaluation and it was diagnosed as cavernous hemangioma, radiologically. However, later on, the patient underwent surgery, and the specimen was sent for histopathology which revealed it to be a lymphangioma.

Giant Occipitocervical Encephalocele

Encephaloceles are cranial defects in which sac contains herniating brain, which is often gliotic. Congenitally, this defect may extend into posterior elements of cervical vertebrae and leads to occipitocervical encephalocele. When the size of this sac is larger than head size, they are termed as giant. Very young age and associated congenital anomalies in these patients pose significant challenges in diagnostic, anesthetic, and surgical techniques. We share a case of giant occipitocervical encephalocele managed at our institute and discuss about its management issues with review of literature.

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.