Neurosurgical Outcomes, Protocols, and Resource Management During Lockdown: Early Institutional Experience from One of the World's Largest COVID 19 Hotspots

BACKGROUND

As the COVID-19 pandemic surpasses 1 year, it is prudent to reflect on the challenges faced and the management strategies employed to tackle this overwhelming health care crisis. We undertook this study to validate our institutional protocols, which were formulated to cater to the change in volume and pattern of neurosurgical cases during the raging pandemic.

METHODS

All admitted patients scheduled to undergo major neurosurgical intervention during the lockdown period (15 March 2020 to 15 September 2020) were included in the study. The data involving surgery outcomes, disease pattern, anesthesia techniques, patient demographics, as well as COVID-19 status, were analyzed and compared with similar retrospective data of neurosurgical patients operated during the same time period in the previous year (15 March 2019 to 15 September 2019).

RESULTS

Barring significant increase in surgery for stroke (P = 0.008) and hydrocephalus (P <0.001), the overall case load of neurosurgery during the study period in 2020 was 42.75% of that in 2019 (P < 0.001), attributable to a significant reduction in elective spine surgeries (P < 0.001). However, no significant difference was observed in the overall incidence of emergency and essential surgeries undertaken during the 2 time periods (P = 0.482). There was an increased incidence in the use of monitored anesthesia care techniques during emergency and essential neurosurgical procedures by the anesthesia team in 2020 (P < 0.001). COVID-19 patients had overall poor outcomes (P = 0.003), with significant increase in mortality among those subjected to general anesthesia vis-a-vis monitored anesthesia care (P = 0.014).

CONCLUSIONS

Despite a significant decrease in neurosurgical workload during the COVID-19 lockdown period in 2020, the volume of emergency and essential surgeries did not change much compared with the previous year. Surgery in COVID-19 patients is best avoided, unless critical, as the outcome in these patients is not favorable. The employment of monitored anesthesia care techniques like awake craniotomy and regional anesthesia facilitate a better outcome in the ongoing COVID-19 era.

MRI features in dengue encephalitis: A case series in South Indian tertiary care hospital

Dengue virus, a RNA virus of family Flaviviradae is considered non-neurotropic. Increasing studies and case reports reveal neurological manifestations of dengue virus. In our case series, we have evaluated magnetic resonance imaging (MRI) findings of 3 patients with dengue fever diagnosed by positive dengue NS1 antigen with neurological symptoms, which revealed nonspecific imaging features of dengue encephalitis in two cases and dengue meningoencephalitis in one case. Autopsy findings are also correlated in 2 patients who succumbed to their disease. This case series underlines the consideration of dengue encephalitis in patients of dengue fever with neurological symptoms and relevant imaging findings.

Blooming of Gonyaulax polygramma along the southeastern Arabian Sea: Influence of upwelling dynamics and anthropogenic activities

The influence of upwelling on the phytoplankton community was examined during the upwelling-relaxation period in the southeastern Arabian Sea. Elevated upwelling intensity during the summer monsoon season of 2016 resulted in the re-suspension of harmful dinoflagellates into the surface water. Further, the surplus of phosphorus (P) inputs into the coastal waters from estuarine runoff during the upwelling-relaxation period induced blooming of Gonyaulax polygramma (4.9 × 10⁶ cells L^-1). Results from canonical correspondence analysis revealed that elevated upwelling intensity, P and salinity during the year 2016 likely triggered the bloom of G. polygramma in the study region. HABs like G. polygramma threaten fish stocks such as sardines which have a vital role in the ecosystem. Studies on phytoplankton communities and nutrient dynamics in upwelling systems would be useful in predicting the incidence/toxic effects of harmful algal blooms as these regions have a high potential for fisheries.

A Multicentric Study on the Clinical Profile, Serology, Neuroimaging and Treatment of Neurocysticercosis

Introduction: Neurocysticercosis (NCC) is the most common parasitic disease affecting the human brain, and the leading infectious cause of seizures/epilepsy in India. It is often a diagnostic challenge due to varying clinical and imaging presentations. Aim: To describe the clinical profile, serological testing, imaging features and treatment outcomes of NCC, in an Indian population. Materials and Methods: This prospective observational study with a case control design was carried out over a period from June 2015 to June 2019, at two Tertiary Care Hospitals in Mumbai and Bangalore. Seventy four (74) cases who had evidence of parenchymal/extra-parenchymal NCC lesions based on Contrast MRI Brain (1.5 Tesla), were included in the study. Fifty matched controls with Idiopathic epilepsy were also recruited in the study, so as to establish the sensitivity and specificity of the commonly used ELISA test (IgG antibody) for NCC. All patients with viable parenchymal NCC lesions were given standard cysticidal therapy (Albendazole), along with anti-epileptic drugs, as per clinician discretion. Disability at six months follow-up was assessed using the modified Rankin Scale (mRS). Pearson’s Chi-square test was used to compare dependent variables. The p-values <0.05 were accepted as statistically significant. Results: Of the 74 cases with NCC enrolled in the study, 81% (60) were males and the mean age of the population was 36.4 years. Total 91% cases (68) presented with seizures. Neuro-imaging revealed majority of lesions were vesicular (28%). Total 42% (31/74) had Solitary Cystisercal Granuloma (SCG), only 26% (19/74) cases and 8% (4/50) controls were positive for the IgG anti-cysticercal antibody by ELISA. This gave the antibody test a sensitivity of 26%, and a specificity of 92%. This translated into a Positive Predictive Value (PPV) of 83%, Negative Predictive Value (NPV) of 45%, and a positive likelihood ratio of 3.21. In patients who had single or multiple viable parenchymal NCC lesions (57/74), cysticidal therapy with Albendazole (under steroid cover) was safe and effective in 88% (50/57) cases. Conclusion: NCC commonly presents with seizures, and is best diagnosed with contrast MR imaging of the brain. The commercially available ELISA based antibody test do not add significantly in the management of this tropical infection. Cysticidal therapy is safe and effective in a majority of the patients, however treatment of extra-parenchymal NCC remains a challenge.

Experience with FRED junior flow diverter in treatment of cerebral aneurysms at or distal to the circle of Willis

This retrospective study was aimed at assessing our results of endovascular management using the FRED junior flow diverter in cerebral aneurysms at or distal to the circle of Willis. 12 patients with 15 small cerebral vessel aneurysms at or distal to the circle of Willis underwent endovascular treatment using the FRED junior flow diverter at two tertiary care centres in Mumbai, India. 12 of the 15 aneurysms were unruptured, one was treated in an acutely ruptured setting, while two, which had presented with SAH were initially treated with balloon assisted coiling and later treated in a staged manner with a flow diverter. Technical success was 100% in all 15 deployments. Deployments were made across angles ranging from 45° to 180°. There was no stroke/TIA/death in any of the cases, which were unruptured. The O'Kelly-Marotta (OKM) staging was used to analyze angiographic follow up (at least one post procedure angiogram) which was available in 8 patients (10 aneurysms). OKM D & C was seen in 80% of the aneurysms on follow up angiograms. The treatment of small vessel cerebral aneurysms at or distal to the Circle of Willis using a dedicated flow diverter (FRED Jr.) is both technically feasible and highly efficacious.

Endovascular Management of Vein of Galen Aneurysmal Malformations: A Retrospective Analysis over a 15-Year Period

OBJECTIVES

This retrospective study was aimed at assessing our results of endovascular management in vein of Galen aneurysmal malformation (VGAM).

MATERIALS AND METHODS

This is a retrospective study of 26 patients of VGAM who underwent endovascular treatment between 1998 and 2012. All patients underwent trans-arterial embolization. Of 26 patients, 23 were treated using n-butyl cyano acrylate (Glue), while 3 out of 26 patients were treated using the ethylene vinyl alcohol (EVOH) copolymer.

RESULTS

Ages of the treated patients ranged from 1 day to 18 years of age. Of the patients treated, 17 were males and 9 were females. Around 15 of the VGAMs were of the mural variety and 11 were choroidal in nature. A good outcome was seen in 22/26 (85%) of the patients. Complications were seen in total in 7/26 patients (26.92%) of which 3/26 (12%) has a fatal outcome.

CONCLUSION

Endovascular embolization for VGAMs is highly efficacious and has helped create a population of VGAM survivors in this condition, which until only a few decades ago caused high mortality and morbidity.

Pattern of Emergent Head Computed Tomography Findings in a Tertiary Care Hospital during off Working Hours: Retrospective Analysis

Introduction:

Emergency head computed tomography (CT) is rising exponentially during off working hours due to evidence-based medicine, patient's expectation and desires, easy availability and apprehension of medico-legal cases, thereby raising health-care cost. There is huge gap in demand and supply of radiologist, especially during off working hours. There is need to know the pattern of emergency head findings.

Materials and Methods:

A retrospective analysis of all emergent noncontrast CT head during off working hours in the Department of Radiodiagnosis of a Tertiary Care Hospital, Mumbai, India, which were performed from June 2017 to May 2018. CT findings of 308 patients were analyzed.

Results:

About 63.6% of total head CT showed no significant abnormality. The most common abnormality was intracranial hemorrhage which was just 9.1% followed by acute infarct which was 6.2%. Extradural hemorrhage, subdural hemorrhage, and subarachnoid hemorrhage was only 1% each of total head CT findings. No significant abnormality was detected in 74.65%, 70.21%, 89.13%, 31.37%, 100%, and 69.09% in cases of head injury, seizure, giddiness/dizziness/syncope, cerebrovascular accident, transient ischemic attack, and altered sensorium, respectively.

Conclusion:

Pattern analysis of emergent head CT reveals that most of the emergent CT head shows no significant abnormality. There is a need for stringent guidelines for emergent head CT, training of emergency physician as well as CT technician for common findings to bridge the radiologist demand-supply gap for providing effective health care in peripheral hospitals.

A Study on the Clinical and Angiographic Spectrum of Spontaneous Extracranial Dissections in the Cerebral Vasculature

Aim:

To prospectively study the clinical profile, angiographic features, and functional outcomes, in consecutive cases of extracranial dissection seen at two tertiary stroke care centers in South India.

Materials and Methods:

In this observational study, spanning 4 years (December 12–December 16), a total of 442 patients presented with an acute ischemic stroke/transient ischemic attack (TIA) at our study centers. 14/546 (3.2%) of these patients had magnetic resonance angiography (MRA)/computed tomography angiography (CTA) evidence of extracranial dissections. All cases underwent detailed clinical evaluation on arrival, and data were recorded on a predesigned stroke pro forma. Contrast MRA was done on arrival in all cases as part of a standard stroke protocol, and CTA was done only if MRA was inconclusive. The pattern of the vessel involved and morphology of vessel dissection was analyzed as per a standard radiology protocol. All the cases were managed with short-term anticoagulation using low-molecular-weight heparin followed by oral anticoagulants for 3–6 months. All cases were followed up for 1–2 years and the functional outcomes were recorded using the modified Rankin Scale (mRS).

Results:

There were 11 males and 3 females in the study, and the mean age was 45.1 years (range = 27–65 years). Focal neurological symptoms occurred in all these patients (10 patients had a stroke, and 4 had TIA). Nearly 64.2% of these (9/14) were stroke in young (age <45 years). The internal carotid artery was the most common vessel involved in 85.7% (12/14) cases. Of the ten patients with completed stroke, a good functional outcome (mRS 1–2) was seen in 8/10 (80%). Digital subtraction angiography and revascularization procedures were needed only in a minority of cases 3/14 (21%).\

Conclusion:

This hospital-based study highlights the importance of suspecting arterial dissections in young strokes of unexplained etiology, and offering optimum anticoagulant therapy in the acute phase, to achieve good long-term outcomes.

Loricate ciliates as an indicator of eutrophication status in the estuarine and coastal waters

Owing to the environmental sensitivity of ciliate species, the monitoring and assessment of these communities can indicate the health of the aquatic environment. Sampling for loricate ciliates was carried out during different seasons at three different locations in the estuarine and coastal waters of Kochi, Southwest coast of India. The loricate ciliate community comprising of 27 species belonging to 10 genera revealed significant differences among the three sampling locations. The maximum numerical abundance and less species diversity of loricate ciliates were recorded at the estuarine locations whereas the minimum abundance and more species diversity were encountered in the coastal waters. Multivariate statistical analyses revealed that Tintinnopsis beroidea and Tintinnopsis uruguayensis were correlated positively with nutrients in the estuarine environment, which receives large amount of anthropogenic inputs. Thus, we propose that these two loricate ciliates may be considered as a potential bioindicator of eutrophication status in marine ecosystems.

Diagnosing thoracic venous aneurysm: A contemporary imaging perspective

Thoracic venous aneurysms are a rare clinical entity and contrast-enhanced computed tomography has been the cornerstone of their diagnosis. We are reporting a rare case of isolated left brachiocephalic vein aneurysm, which was surgically managed, highlighting the role of dynamic contrast-enhanced magnetic resonance imaging as a definitive diagnostic modality in this patient.

MR fistulography with percutaneous instillation of aqueous jelly: A cost effective technique innovation

Background:

Perianal fistula is a commonly encountered condition in routine surgical practice. Accurate presurgical mapping of these tracts is vital to prevent recurrence. We have assessed the effectiveness of percutaneous instillation of aqueous jelly prior to magnetic resonance (MR) fistulography.

Aims and Objectives:

To study the role of percutaneous instillation of aqueous jelly in fistulous tracts prior to MR fistulography.

Materials and Methods:

All patients with active discharge, referred for MR fistulography between January 2014 and April 2016, were included in this study. Approximately 3–5 ml of sterile aqueous jelly was percutaneously instilled into the external openings prior to MR fistulography. Post MR fistulography, patients were monitored till surgery for pain, fever, or bleeding. The type of fistulae, location of internal openings, lateral ramifications, and presence of abscess were compared with per operative findings for diagnostic accuracy.

Results:

Sixty-four patients enrolled in our study had undergone preoperative MR fistulography with aqueous jelly instillation. MR fistulography revealed a total of 77 tracts and showed a sensitivity and specificity of 100% in delineation of type of tract. Forty-nine internal openings were identified with 94.2% sensitivity, 100% specificity, and 95.3% accuracy. 90.5% sensitivity, 100% specificity, and accuracy of 97% were observed in delineation of lateral ramifications. None of the patients reported pain, fever, or bleeding post procedure till surgery.

Conclusion:

Percutaneous instillation of aqueous jelly prior to MR fistulography is a safe, cost effective, and accurate technique to provide a comprehensive delineation of the complex anatomy of perianal fistulae.

A Comparative Study of Pituitary Volume Variations in MRI in Acute Onset of Psychiatric Conditions

INTRODUCTION

The growing belief that endocrine abnormalities may underlie many mental conditions has led to increased use of imaging and hormonal assays in patients attending to psychiatric OPDs. People who are in an acute phase of a psychiatric disorder show Hypothalamic Pituitary Adrenal (HPA) axis hyperactivity, but the precise underlying central mechanisms are unclear.

AIM

To assess the pituitary gland volume variations in patients presenting with new onset acute psychiatric illness in comparison with age and gender matched controls by using MRI.

MATERIALS AND METHODS

The study included 50 patients, with symptoms of acute psychiatric illness presenting within one month of onset of illness and 50 age and gender matched healthy controls. Both patients and controls were made to undergo MRI of the Brain. A 0.9 mm slices of entire brain were obtained by 3 dimensional T1 weighted sequence. Pituitary gland was traced in all sagittal slices. Anterior pituitary and posterior pituitary bright spot were measured separately in each slice. Volume of the pituitary (in cubic centimetre- cm³) was calculated by summing areas. Significance of variations in pituitary gland volumes was compared between the cases and controls using Analysis of Covariance (ANOVA).

RESULTS

There were significantly larger pituitary gland volumes in the cases than the controls, irrespective of psychiatric diagnosis (ANOVA, f=15.56; p=0.0002). Pituitary volumes in cases were 15.36% (0.73 cm³) higher than in controls.

CONCLUSION

There is a strong likelihood of HPA axis overactivity during initial phase of all mental disorders along with increased pituitary gland volumes. Further studies including hormonal assays and correlation with imaging are likely to provide further insight into neuroanatomical and pathological basis of psychiatric disorders.

Imaging and interventions in idiopathic intracranial hypertension: A pictorial essay

Intracranial hypertension is a syndrome of elevated intracranial pressure that can be primary or secondary. The primary form, now termed idiopathic intracranial hypertension (IIH), was in the past a disease of exclusion and imaging played a limited role of excluding organic causes of raised intracranial pressure. However imaging markers have been described with patients with IIH at the orbit, sella and cerebral venous system. We wish to reiterate the characteristic imaging features of this poorly understood disease and also emphasise that stenting of the transverse sinus in select cases of IIH is an efficacious option.

Pressure injectors for radiologists: A review and what is new

Pressure Injectors are used routinely in diagnostic and interventional radiology. Advances in medical science and technology have made it is imperative for both diagnostic as well as interventional radiologists to have a thorough understanding of the various aspects of pressure injectors. Further, as many radiologists may not be fully conversant with injections into ports, central lines and PICCs, it is important to familiarize oneself with the same. It is also important to follow stringent operating protocols during the use of pressure injectors to prevent complications such as contrast extravastion, sepsis and air embolism. This article aims to update existing knowledge base in this respect.

Orbital apex osteodural fistula - An unusual surgical access

Dural arteriovenous fistulas (DAVFs) are fistulas connecting the branches of dural arteries to dural veins or a venous sinus. Osteodural fistulas are a rare subset of this group of diseases. We wish to report a rare case of an osteodural arteriovenous fistula at the foot of the superior ophthalmic vein (SOV), treatment of which required an unusual surgical approach via the orbit and SOV. Though access for endovascular treatment via the SOV for treatment of caroticocavernous fistulas is reported, the external approach is relatively infrequently performed, outside Europe and the Americas, with this being the first reported procedure from the Indian subcontinent. We wish to explain the steps of this unusual surgical access and highlight the salient precautions and pitfalls in the technique.

Cerebral and spinal vascular involvement in Hereditary Hemorrhagic Telengiectasia: Report of two cases

INTRODUCTION

We present two cases of Hereditary Hemmorhagic Telengiectasia (HHT), one pediatric and the other adult, with a view to highlight the myriad cerebral and spinal vascular manifestations of this disease. The syndrome and its various findings will be reviewed including the utility of angiography in assessing the various vascular abnormalities of the cerebral and spinal vasculature.

METHODS

A review of literature regarding various developmental abnormalities including brain and spinal cord arterio-venous malformations (AVMs), arterio-venous fistulae (AVFs), micro AVMs, micro-fistulae, aneurysms and cavernomas that occur in pediatric and adult population subsets of HHT. Both patients underwent thorough clinical and laboratory evaluation. The pediatric patient underwent a contrast enhanced computed tomography (CECT) of the chest; cerebral, Pulmonary & celiac angiography. The adult patient underwent cerebral and spinal angiography.

CONCLUSION

The spectrum of vascular malformations in Hereditary Hemorrhagic Telengiectasia (HHT) is varied.The incidence and manifestations of brain and spinal cord AVMs, AVFs, micro AVMs, micro-fistulae, aneurysms and cavernomas are different in the pediatric and adults affected by the disease. Cerebral and spinal angiography are necessary in characterising the various developmental vascular abnormalities in order to guide further management.

An evaluation of the modified Airway Management Device

We evaluated the modified Airway Management Device (AMDTM) in 60 spontaneously breathing anaesthetised patients. The insertion and removal of the device was very easy and atraumatic. The airway was secured on the first attempt in 41 patients (70%; 95% CI 57-80%). The most important problem was loss of airway, which occurred in 11 patients (19%; 11-30%) during maintenance of anaesthesia. The AMD was dislodged during maintenance in one patient. There was a loss of the airway in 12 patients (20%; 12-31%); in 10, it was maintained with simple airway manoeuvres or a laryngeal mask airway and tracheal intubation was required in two patients. Ten of these patients were male and two were female; the failure rate was 33% (12-31%) among the male patients and 6% (2-22%) among the female patients. The cuff volumes ranged from 4 ml to 80 ml and cuff pressures from 6 cm H2O to 92 cm H2O. Blood was seen on removal in three patients (6%; 2-16%) and nine patients (18%; 10-30%) experienced sore throat after removal of the device.