Altered expression of activating transcription factor 3 in the hippocampus of patients with mesial temporal lobe epilepsy-hippocampal sclerosis (MTLE-HS)

Aim of the study: Activating Transforming factor 3 (ATF3) is a stress induced gene and closely associated with neuro-inflammation while Transforming growth Factor Beta (TGFβ) signalling is also reported to be involved in neuro-inflammation and hyper-excitability associated with drug resistant epilepsy. Animal model studies indicate the involvement of ATF3 and TGFβ receptors to promote epileptogenesis. Human studies also show that TGFβ signalling is activated in MTLE-HS. However, lack of studies on ATF3 and TGFβRI expression in MTLE-HS patients exists. We hypothesize that ATF3 and TGFβRI might be expressed in hippocampi of patients with MTLE-HS and playing role in epileptogenesis. Materials & methods: Protein expression of ATF3 and TGFβRI was performed by western blotting. Localisation of ATF3 was performed by immunohistochemistry and immunoflorescence. Results: Protein expression of ATF3 and TGFβRI was significantly up-regulated in hippocampi of patients as compared to controls. Also ATF3 IR was significantly expressed in hippocampi of patients and ATF3 was expressed predominantly in cytoplasm as compared to nucleus. No correlation was found between ATF3 expression and epilepsy duration and seizure frequency. Conclusions: ATF3 and TGFβRI are both important players in neuro-inflammation and might potentiate epileptogenesis in these patients.

MYCN immunohistochemistry as surrogate marker for MYCN-amplified spinal ependymomas

MYCN (master regulator of cell cycle entry and proliferative metabolism) gene amplification defines a molecular subgroup of spinal cord ependymomas that show high-grade morphology and aggressive behavior. Demonstration of MYCN amplification by DNA methylation or fluorescence-in situ hybridization (FISH) is required for diagnosis. We aimed to (i) assess prevalence and clinicopathological features of MYCN-amplified spinal ependymomas and (ii) evaluate utility of immunohistochemistry (IHC) for MYCN protein as a surrogate for molecular testing. A combined retrospective-prospective study spanning 8 years was designed during which all spinal cord ependymomas with adequate tissue were subjected to MYCN FISH and MYCN IHC. Among 77 spinal cord ependymomas included, MYCN amplification was identified in 4 samples from 3 patients (3/74, 4%) including two (1st and 2nd recurrences) from the same patient. All patients were adults (median age at diagnosis of 32 years) including two females and one male. The index tumors were located in thoracic (n = 2) and lumbar (n = 1) spinal cord. One of the female patients had neurofibromatosis type 2 (NF2). All four tumors showed anaplastic histology. Diffuse expression of MYCN protein was seen in all four MYCN-amplified samples but in none of the non-amplified cases, thus showing 100% concordance with FISH results. On follow-up, the NF2 patient developed widespread spinal dissemination while another developed recurrence proximal to the site of previous excision. To conclude, MYCN-amplified spinal ependymomas are rare tumors, accounting for ~ 4% of spinal cord ependymomas. Within the limitation of small sample size, MYCN IHC showed excellent concordance with MYCN gene amplification.

Multiple spinal extradural arachnoid cysts presenting as compressive myelopathy in a teenager: case report and literature review with special emphasis on postoperative spine deformity in the current minimally invasive era

INTRODUCTION

Multiple synchronous spinal extradural arachnoid cysts are extremely rare in children and can lead to cord compression and disability. Multiple spinal extradural arachnoid cysts (SEDACs) in children with immature and growing spine need to be studied separately from multiple SEDACs in adults with mature and fully grown spine because of multiple surgical limitations in children (blood loss, surgery duration, long-term spinal stability after long segment exposure, etc.).

MATERIAL AND METHODS

We planned a non-systematic literature review of similar cases described in literature to analyse the pattern of presentation, management, and outcome of this surgically curable disease.

RESULTS

A total of 28 cases of paediatric multiple SEDACs in the age range of 5 months to 17 years and mean age of 11.54 years were analysed. Exposure was achieved by laminectomy in 9, laminoplastic laminotomy in 13, laminectomy in first surgery followed by laminoplasty in second surgery (re-exploration) in 1, hemilaminectomy in 2, and technique "not reported" in 3 children. Complete/near-complete recovery was seen in 27 (96.42%) children. Postoperative spine deformity was reported in 7 (25%) children and was progressive in 2 children during serial follow-up.

CONCLUSIONS

Symptomatic multiple synchronous SEDACs in children is a rare surgically curable condition. Sincere attempt to find out a dural defect in all cysts is a very important step in multiple SEDAC surgery. Total cyst wall excision with closure of all dural defects is the gold standard treatment for symptomatic cases. Laminoplasty is preferred for excision of multiple SEDACs in children to prevent postoperative spine deformity during long-term follow-up. Long serial follow-up for postoperative spine deformity is necessary.

The role of susceptibility-weighted imaging & contrast-enhanced MRI in the diagnosis of primary CNS vasculitis: a large case series

Primary CNS Vasculitis (PCNSV) is a rare, diverse, and polymorphic CNS blood vessel inflammatory condition. Due to its rarity, clinical variability, heterogeneous imaging results, and lack of definitive laboratory markers, PCNSV diagnosis is challenging. This retrospective cohort analysis identified patients with histological diagnosis of PCNSV. Demographic data, clinical presentation, neuroimaging studies, and histopathologic findings were recorded. We enrolled 56 patients with a positive biopsy of CNS vasculitis. Most patients had cerebral hemisphere or brainstem symptoms. Most brain MRI lesions were bilateral, diffuse discrete to confluent white matter lesions. Frontal lobe lesions predominated, followed by inferior cerebellar lesions. Susceptibility-weighted imaging (SWI) hemorrhages in 96.4% (54/56) of patients, either solitary microhemorrhages or a combination of micro and macrohemorrhages. Contrast-enhanced T1-WIs revealed parenchymal enhancement in 96.3% (52/54 patients). The most prevalent pattern of enhancement observed was dot-linear (87%), followed by nodular (61.1%), perivascular (25.9%), and patchy (16.7%). Venulitis was found in 19 of 20 individuals in cerebral DSA. Hemorrhages in SWI and dot-linear enhancement pattern should be incorporated as MINOR diagnostic criteria to diagnose PCNSV accurately within an appropriate clinical context. Microhemorrhages in SWI and venulitis in DSA, should be regarded as a potential marker for PCNSV.

Cold atmospheric plasma (CAP) treatment increased reactive oxygen and nitrogen species (RONS) levels in tumor samples obtained from patients with low-grade glioma

Low-grade gliomas (LGGs) are a heterogeneous group of tumors with an average 10-year survival rate of 40%-55%. Current treatment options include chemotherapy, radiotherapy, and gross total resection (GTR) of the tumor. The extent of resection (EOR) plays an important role in improving surgical outcomes. However, the major obstacle in treating low-grade gliomas is their diffused nature and the presence of residual cancer cells at the tumor margins post resection. Cold Atmospheric Plasma (CAP) has shown to be effective in targeted killing of tumor cells in various glioma cell lines without affecting non-tumor cells through Reactive Oxygen and Nitrogen Species (RONS). However, no study on the effectiveness of CAP has been carried out in LGG tissues till date. In this study, we applied helium-based CAP on tumor tissues resected from LGG patients. Our results show that CAP is effective in promoting RONS accumulation in LGG tissues when CAP jet parameters are set at 4 kV voltage, 5 min treatment time and 3 lpm gas flow rate. We also observed that CAP jet is more effective in thinner slice preparations of tumor as compared to thick tumor samples. Our results indicate that CAP could prove to be an effective adjunct therapy in glioma surgery to target residual cancer cells to improve surgical outcome of patients with low-grade glioma.

Comparative Analysis of Hemispherotomy in Adults versus Children- A Prospective Observational Series

BACKGROUND

Hemispherotomy (HS) is an effective treatment for unilateral hemispheric onset epilepsy. There are few publications for HS in adults, and there is no series comparing adults and pediatric patients of HS.

OBJECTIVE

To compare the hemispherotomies done in adult patients with pediatric ones in terms of efficacy and safety.

METHODS

Data was prospectively collected for HS patients (up to 18 years and more) from Aug 2014 to Aug 2018. Comparison between the groups was made for seizure onset, duration of epilepsy, frequency of seizures, number of drugs, intraoperative blood loss, postoperative seizure control, postoperative stay, postoperative motor functions, and preoperative and postoperative intelligence quotient. Follow-up was one year.

RESULTS

A total of 61 pediatric and 11 adults underwent HS. The seizure onset was earlier in children, and the duration of epilepsy was longer in adults. The frequency of seizures per day was more in children being 14.62 ± 26.34 in children, and 7.71 ± 5.21 per day in adults (P - 0.49). The mean number of drugs was similar in the preoperative and postoperative periods in both. Class I seizure outcome was similar in both the groups being 85.24% in children and 90.9% in adults (P - 0.56). Blood loss, postoperative stay, was similar in both the groups. No patient had a new permanent motor deficit. Power worsened transiently in 1 pediatric patient and in 4 adult patients. The visual word reading and object naming improved in both the groups (no intergroup difference), and IQ remained the same in both groups. One adult patient had meningitis, and another had hydrocephalus requiring shunt placement.

CONCLUSION

Hemispherotomy is a safe and effective procedure in adults as in children in appropriately selected patients.

RNA Sequencing of Intraoperative Peritumoral Tissues Reveals Potential Pathways Involved in Glioma-Related Seizures

Tumor-induced changes in the peritumoral neocortex play a crucial role in generation of seizures. This study aimed to investigate the molecular mechanisms potentially involved in peritumoral epilepsy in low-grade gliomas (LGGs). Intraoperative peritumoral brain tissues resected from LGG patients with seizures (pGRS) or without seizures (pGNS) were used for RNA sequencing (RNA-seq). Comparative transcriptomics was performed to identify differentially expressed genes (DEGs) in pGRS compared to pGNS using deseq2 and edgeR packages (R). Gene set enrichment analysis (GSEA) using Gene Ontology terms and Kyoto Encyclopedia of Genes & Genomes (KEGG) pathways was performed using the clusterProfiler package (R). The expression of key genes was validated at the transcript and protein levels in the peritumoral region using real-time PCR and immunohistochemistry, respectively. A total of 1073 DEGs were identified in pGRS compared to pGNS, of which 559 genes were upregulated and 514 genes were downregulated (log2 fold-change ≥ 2, padj < 0.001). The DEGs in pGRS were highly enriched in the "Glutamatergic Synapse" and "Spliceosome" pathways, with increased expression of GRIN2A (NR2A), GRIN2B (NR2B), GRIA1 (GLUR1), GRIA3 (GLUR3), GRM5, CACNA1C, CACNA1A, and ITPR2. Moreover, increased immunoreactivity was observed for NR2A, NR2B, and GLUR1 proteins in the peritumoral tissues of GRS. These findings suggest that altered glutamatergic signaling and perturbed Ca2+ homeostasis may be potential causes of peritumoral epilepsy in gliomas. This explorative study identifies important genes/pathways that merit further characterization for their potential involvement in glioma-related seizures.

Technique of Distraction, Compression, Extension, Reduction to Reduce and Realign Old Displaced Odontoid Fracture From Posterior Approach: A Novel Technique

Objective: Chronic ‘displaced’ displaced type II fractures, though uncommon, are difficult to manage. They usually require a transoral procedure followed by a posterior instrumented fusion. We describe here, a new method to reduce the fractured displaced odontoid using a posterior cervical approach only.Methods: Prospective and observational, n = 14 had a ‘displaced and irreducible’ old fracture dens causing cord compression (type I, 1; type II, 13). They underwent a novel technique to reduce the fracture. The C1 arch was first drilled and removed. The C1 lateral masses on both sides were then drilled completely and a spacer was placed between the occiput and C2 facet. Following this, an intraoperative reducing maneuver was performed, utilizing the spacer as a fulcrum, and then achieving complete reduction and realignment.Results: All patients improved clinically (mean Nurick preoperative score: 4.07 ± 0.8; the postoperative score was 1.3 ± 0.4). The mean correction in effective canal diameter was 74.3% ± 9.5% and the mean correction in actual canal diameter was 77% ± 8.7%. Solid bone fusion was demonstrated in 12 patients with at least 1-year follow-up (follow-up range, 12–35 months; mean, 21.8 ± 9.8 months).Conclusion: The new described modification of distraction, compression extension, and reduction seems to be effective for ‘displaced’ chronic fracture dens with cord compression. It avoids additional transoral surgery in these patients.

Complications of Decompressive Craniectomy: A Case-Based Review

Background Decompressive craniectomy (DC) is a frequently performed procedure to treat intracranial hypertension following traumatic brain injury (TBI) and stroke. DC is a salvage procedure that reduces mortality at the expense of severe disability and compromises the quality of life. The procedure is not without serious complications.

Methods We describe the complications following DC and its management in a case-based review in this article.

Results Complications after DC are classified as early or late complications based on the time of occurrence. Early complication includes hemorrhage, external cerebral herniation, wound complications, CSF leak/fistula, and seizures/epilepsy. Contusion expansion, new contralateral epidural, and subdural hematoma in the immediate postoperative period mandate surgical intervention. It is necessary to repeat non-contrast CT head at 24 hours and 48 hours following DC. Late complication includes subdural hygroma, hydrocephalus, syndrome of the trephined, bone resorption, and falls on the unprotected cranium. An early cranioplasty is an effective strategy to mitigate most of the late complications.

Conclusions DC can be associated with a number of complications. One should be aware of the possible complications, and timely intervention is required.

Correlation of age at seizure onset with GABAA receptor subunit and chloride Co-transporter configuration in Focal cortical dysplasia (FCD)

Focal cortical dysplasia (FCD) represents a group of malformations of cortical development, which are speculated to be related to early developmental defects in the cerebral cortex. According to dysmature cerebral development hypothesis of FCD altered GABAA receptor function is known to contribute to abnormal neuronal network. Here, we studied the possible association between age at seizure onset in FCD with the subunit configuration of GABAA receptors in resected brain specimens obtained from patients with FCD. We observed a significantly higher ratio of α4/α1 subunit-containing GABAA receptors in patients with early onset (EO) FCD as compared to those with late onset (LO) FCD as is seen during the course of development where α4-containing GABAA receptors expression is high as compared to α1-containing GABAA receptors expression. Likewise, the influx to efflux chloride co-transporter expression of NKCC1/KCC2 was also increased in patients with EO FCD as seen during brain development. In addition, we observed that the ratio of GABA/Glutamate neurotransmitters was lower in patients with EO FCD as compared to that in patients with LO FCD. Our findings suggest altered configuration of GABAA receptors in FCD which could be contributing to aberrant depolarizing GABAergic activity. In particular, we observed a correlation of age at seizure onset in FCD with subunit configuration of GABAA receptors, levels of NKCC1/KCC2 and the ratio of GABA/Glutamate neurotransmitters such that the patients with EO FCD exhibited a more critically modulated GABAergic network.

Evaluation of Dural Parameters at C1 Level in Patients with Chiari 1 Malformation Following Foramen Magnum and C1 Posterior Arch Removal: Introduction of a Novel Concept to Decompress without Affecting Stability

Background

Chiari 1 malformation has crowding at craniovertebral junction (CVJ), treated by Foramen magnum decompression (FMD) but is associated with high failure rates, which is explained by recently introduced concept of central instability. So, we propose a new concept of relieving this crowding without affecting stability.

Objective

To derive a threshold for coring out of internal surface of C1 posterior arch instead of complete laminectomy accompanying FMD.

Methods and Material

We prospectively included nine patients with a mean age of 25.33 ± 7.97 years, diagnosed with ACM-1 without AAD, who were operated with FMD and lax duraplasty and C1 laminectomy. The preoperative dural diameter and area covered under the dura at the level of C1 were measured and compared with the postoperative state. Results were analyzed to derive a cut-off threshold which could be drilled from the inner aspect of C1 arch.

Results

The postoperative AP diameter of the dura increased statistically significantly from pre-op; however, the AP extension was less than the preoperative diameter with posterior arch included. Likewise, the area spanned by the dura increased statistically significantly from pre-op but was less than the cumulative area of dura with C1 arch included in pre-op. Analyzing all, a mean cut-off of 50.58% was achieved.

Conclusion

The authors suggest FMD with partial coring (~50%) of the inner part of arch of C1, instead of full-thickness laminectomy with a wider length of coring as the target, and this will serve the purpose intended, without increasing mobility.

Management of Pediatric and Adolescent Traumatic Thoracolumbar Spondyloptosis

BACKGROUND

Complete subluxation of >100% of one vertebral body with respect to the adjacent vertebra is defined as spondyloptosis. It is the severest form of injury caused by high-energy trauma. Pediatric patients with a traumatic spine injury, particularly spondyloptosis are surgically demanding as reduction and achieving realignment of the spinal column requires diligent planning and execution.

OBJECTIVE

To enlighten readers about this rare but severest form of thoracolumbar spine injury and its management.

METHODS

Retrospective analysis of patients treated here with spondyloptosis between 2008 and 2016 was done.

RESULTS

Seven children, ranging from 9 to 18 years (mean years) age were included in the study. Five patients had spondyloptosis at thoracolumbar junction and one each in the lumbar and thoracic spine. All patients underwent single-stage posterior surgical reduction and fixation except one patient who refused surgery. Intraoperatively, cord transection was seen in five patients while dura was intact in one patient. The mean follow-up period was 17 months (1-36 months) during which one patient expired due to complications arising from bedsores. All patients remained American Spinal Injury Association (ASIA) A neurologically.

CONCLUSIONS

Traumatic spondyloptosis is a challenging proposition to treat and the aim of surgery is to stabilize the spine. Rehabilitation remains the most crucial but the neglected part and dearth of proper rehabilitation centers inflict high mortality and morbidity in developing countries.

O-Arm Assisted Anterior Odontoid Screw Fixation in Type II and Rostral Type III Odontoid Fractures: Single Center Surgical Series of 50 Patients

BACKGROUND

Accuracy of screw placement is one of the important factors necessary for adequate union in odontoid fractures with malposition rates as high as 27.2% with standard techniques.

OBJECTIVE

To evaluate efficacy of intraoperative O-arm assistance in improving accuracy of anterior odontoid screw placement and clinco-radiological outcome in type II and III odontoid fractures.

MATERIAL AND METHODS

In this retrospective study, surgery consisted of anterior odontoid screw fixation under intraoperative O-arm assistance over 5 years. Demographical, clinical, radiological, operative details and postoperative events were retrieved from hospital database and evaluated for fusion and surgical outcome.

RESULTS

50 patients (Mean age 34.6 years, SD 14.10, range: 7-70 years; 44 males and 6 females) with Type II and Type III odontoid fracture underwent O-arm assisted anterior screw placement. The mean interval between injury and surgery was 12 days (range 1-65 days). Mean operating time was 132.2 min ± SD 33.56 with average blood loss of 93 ml. ±SD 61.46. With our technique, accurate screw placement was achieved in 100% patients. At the mean follow-up of 26.4 month (SD13.75), overall acceptable fusion rate was 97.8% with non-union in 2.2% patients. Morbidity occurred in two patients; one patient developed fixation failure while other patient had nonunion which was managed with posterior C1-C2 arthrodesis. We had surgical mortality in one patient due to SAH. So overall our procedure was successful in 94% patients and among patients whose follow-up was available, acceptable fusion rates of 97.8% were achieved.

CONCLUSION

We conclude that use of intraoperative three-dimensional imaging using O-arm for anterior odontoid screw fixation improves accuracy and leads to improved radiological and clinical outcomes. It further enables us to extend the indications of odontoid screw fixation to selected complex Type II and rostral Type III odontoid fractures.

Long-Term Functional Outcome Following Left Hemispherotomy in Adults and Pediatric Participants with Fmri Analysis

Background and Objective

Hemispherotomy surgery in adults is shrouded in doubts regarding the functional outcome. The age at surgery alone should not be the deciding factor for surgery. Language paradigms were used in functional magnetic resonance imaging (fMRI) to confirm the role played by the age at the onset of seizures to predict the postoperative functional outcome. The objective of the study was to formulate an optimal strategy for patient selection for the left-sided hemispherotomy in adults, based on functional outcome analysis.

Materials and Methods

A retrospective analysis of 20 participants (age at surgery 1-26 years) who underwent left hemispherotomy (over a 5-year period) was conducted. The language and motor functional assessments of 18 participants (13 pediatric and five adult participants; attrition of participants- two) were recorded at presentation and during follow-up visits. After approval was obtained from the Institutional Ethics Committee, 13 cooperative participants (eight pediatric and five adult participants) underwent language fMRI. Motor fMRI with both active and passive paradigms was done in 16 participants.

Results

All 18 participants with a mean follow-up of 24 months had class I seizure-free outcome. Of these 18, five were adults (mean age = 21 years, range: 18-22 years) and 13 were in the pediatric age group (mean age = 8 years, range: 2-15 years). Postoperatively, four adults retained both verbal fluency and language comprehension at a mean follow-up period of 38 months (range: 24-48 months). Their pre- and post-op language fMRI showed word generation and regional activations for semantic comprehension in the right hemisphere. The motor area activations were seen in the right hemisphere in two and in the left hemisphere in two participants. Among the pediatric participants, four (group I [n = 4/13]) who had good language outcome showed activations in the right hemisphere. In two participants (group II [n = 2/13]) who deteriorated postoperatively, the activations were in the left hemisphere. Five participants (group III [n = 5/13]) who retained the telegraphic language postoperatively had bilateral activations of semantic comprehension areas in fMRI. All 13 pediatric participants had motor area activations seen in the left hemisphere, similar to controls.

Conclusion

Left hemispherotomy can be advised to adults with comparably good postoperative language and motor outcome as in the pediatric age group, provided the weakness is acquired perinatally or below the age of 7 years. The fMRI is a valuable tool to aid in patient selection.

Progressive multifocal leukoencephalopathy in a patient with systemic lupus erythematosus and autoimmune hepatitis

Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating central nervous system illness encountered in the setting of immunosuppressive conditions like human immunodeficiency virus / acquired immunodeficiency syndrome, autoimmune diseases and hematologic malignancies. We had a 54-year-old woman with systemic lupus erythematosus and coexisting autoimmune hepatitis who presented with progressive cognitive decline, right hemiparesis and ataxia who was found to have PML. She had severe CD4 lymphopenia. She was managed with low-dose prednisolone and plasma exchange after which she showed significant clinical improvement. This case highlights the diagnostic and therapeutic challenges encountered in managing a case of PML in the setting of autoimmune conditions with profound lymphopenia.

Perioperative Management of Pediatric Brain Tumors: A Retrospective Analysis

BACKGROUND

Brain tumors are the second most common malignancy in childhood and the surgical excision remains the cornerstone of management. The objective of this study was to analyze the factors associated with the length of intensive care unit (ICU) and hospital stay, and postoperative outcome in such children.

MATERIALS AND METHODS

Three years of data were collected, retrospectively, by detailed review of medical records pertaining to pre-anesthetic evaluation and perioperative course of children less than 16 years of age who underwent excision of intracranial tumors.

RESULTS

One hundred sixty-eight medical records were analyzed. One third of the children were found to have developed various intraoperative adverse events; the most common were hemodynamic changes following brainstem handling and brain swelling. 58% of children required postoperative mechanical ventilation. 82.7% of patients had favorable neurologic outcome which was comparable between the two tumor locations (supratentorial vs infratentorial). On multivariate analysis, re-exploration surgery and electrolyte disturbances, such as serum sodium, were found to be the independent risk factors affecting hospital stay. The amount of intraoperative blood loss and postoperative pulmonary complications (POPCs) were independent risk factors affecting the neurologic outcome.

CONCLUSIONS

Adverse events are fairly common after excision of brain tumors in children. Intraoperative complications did not affect the ICU stay or neurological outcome; however, the postoperative complications increased length of ICU and hospital stays. POPC was the single most important factor responsible for poor neurologic outcome and was more so in children who underwent infratentorial surgery, prolonged mechanical ventilation, and who had a lower cranial nerve palsy.

Endoscopic Total Corpus Callosotomy and Pan Commissurotomy for Lennox-Gastaut Syndrome

BACKGROUND

Corpus callosotomy (CC) is a major disconnection procedure that functionally isolates the cerebral hemispheres, thereby interrupting the spread of epileptic activity from one hemisphere to the other. It is extremely useful in children suffering from non-localized drug refractory epilepsy, especially drop attacks. The technique has evolved from microscopic to minimally invasive endoscopic surgery. The extent of callosotomy also varies based on the institutional practices ranging from anterior 1/3^rd to total corpus callosotomies (TCC). The performance of TCC in conjunction with anterior, posterior, and hippocampal commissurotomies was described for the first time by the senior author from our institution.

OBJECTIVE

To describe the technique of performing endoscopic total corpus callosotomy, and pan commissurotomy using the interhemispheric corridor.

METHODS

A seven-year-old right-handed male child with seizure onset at the age of six months presented with three types of semiologies consisting of myoclonic jerks, frequent head drops and tonic posturing involving right upper and lower limbs with secondary generalization.

RESULTS

Video electroencephalography (VEEG) revealed diffuse slowing of the background, and slow spike and wave pattern. Generalized paroxysmal fast activity (GPFA) was noted in the VEEG, suggestive of LGS. MRI brain revealed bilateral parieto-occipital gliosis and gross brain atrophy. Ictal SPECT localized to left temporo-occipital area, while magnetoencephalography revealed bilateral temporal localization. Patient underwent TCC with pancommissurotomy. The patient was seizure-free (ILAE Class 3) at one-year follow up with no drop attacks, and significant reduction noted in other seizure types.

CONCLUSION

Endoscopic corpus callosotomy and pan commissurotomy using the interhemispheric corridor is an elegant and minimally invasive technique best suited for appropriately selected children with refractory epilepsy.

Trans-Sylvian Resection of Giant Left Insular Glioma: Operative Technique and Nuances

Background

Insular glioma was considered a nonsurgical entity due to resection-associated morbidities. The advancement in neurosurgical techniques and adjuncts used in the last two decades made the resection of insular gliomas simpler for neurosurgeons with the maximum extent of resection and acceptable morbidity rates. The complex anatomy of this region remains a challenge for neurosurgeons and requires expertise. The key factors to achieve complete resection in the insular region are the thorough knowledge of surgical anatomy and meticulous microsurgical techniques. Intraoperative adjuncts such as image guidance along with cortical and subcortical mapping assist in excellent outcomes.

Objective

In this study, we describe the operative technique and application of trans-Sylvian approach to do the compartmental dissection done by the senior author, along with challenges faced, with the hope to highlight the efficacy of the approach to achieve maximal resection of this entity without compromising patient's safety.

Materials and Methods

A 32-year-old right-handed gentleman presented with episodes of excessive salivation, tingling sensation on the right side of the body along with nausea that lasted for 15-20 s for the last 8 months and one episode of speech arrest without any loss of consciousness and motor or sensory deficit. CEMRI of the brain was suggestive of left insular glioma. The patient underwent left pterional craniotomy, and gross total resection of the tumor was done using compartmental dissection.

Results

At follow-up after 1 month, the patient is seizure-free without any speech difficulty and motor or sensory deficit.

Conclusion

Compartmental dissection of insular glioma is a safe and efficacious technique to achieve gross total resection of the tumor in this complex region without morbidity.

Determination of Availability of Safety Margin for Placement of C3-C6 Pedicle Screw on CT Angiography

BACKGROUND

Cervical pedicle screws (CPS) in the subaxial cervical spine (C3-C6) are faced with high incidence of perforating the lateral pedicular cortex endangering the vertebral artery (VA). The present study analyzes the pedicle width (PW) from C3 to C6 and defines the relation of VA with regard to pedicle and transverse foramen (TF) to determine the safety margin in cases of lateral pedicular breach.

METHODS

Computed tomography angiograms of 500 patients were retrospectively studied to identify the pedicle width (PW), VA area, TF area, and the lateral pedicle to vertebral artery distance (LPVA). Occupancy ratio (OR; the percentage area of transverse foramen occupied by VA) and safety margin (SM; permissible displacement of VA in TF), along with LPVA were considered to be protective parameters against VA injury if lateral pedicle breach happens.

RESULTS

PW was 4.7 mm at C3, 4.83 mm at C4, 5.26 mm at C5 and 5.41 mm at C6. Mean LPVA at different levels was between 0.97 mm and 1.15 mm, OR was around 20% at all levels, and mean SM was between 2.34 mm and 2.92 at various levels. Sex differences were statistically significant for PW but not for LPVA, SM, or OR.

CONCLUSIONS

This study gives us an idea about the various parameters in placement of cervical pedicle screw in subaxial cervical spine and the probable reasons there are few vertebral artery injuries despite high incidence of cervical pedicle breach. LPVA, safety margin, and OR may explain why even very significant CPS misplacement does not lead to vascular injury or neurologic deficit.

Transcriptomic profiling of high- and low-spiking regions reveals novel epileptogenic mechanisms in focal cortical dysplasia type II patients

Focal cortical dysplasia (FCD) is a malformation of the cerebral cortex with poorly-defined epileptogenic zones (EZs), and poor surgical outcome in FCD is associated with inaccurate localization of the EZ. Hence, identifying novel epileptogenic markers to aid in the localization of EZ in patients with FCD is very much needed. High-throughput gene expression studies of FCD samples have the potential to uncover molecular changes underlying the epileptogenic process and identify novel markers for delineating the EZ. For this purpose, we, for the first time performed RNA sequencing of surgically resected paired tissue samples obtained from electrocorticographically graded high (MAX) and low spiking (MIN) regions of FCD type II patients and autopsy controls. We identified significant changes in the MAX samples of the FCD type II patients when compared to non-epileptic controls, but not in the case of MIN samples. We found significant enrichment for myelination, oligodendrocyte development and differentiation, neuronal and axon ensheathment, phospholipid metabolism, cell adhesion and cytoskeleton, semaphorins, and ion channels in the MAX region. Through the integration of both MAX vs non-epileptic control and MAX vs MIN RNA sequencing (RNA Seq) data, PLP1, PLLP, UGT8, KLK6, SOX10, MOG, MAG, MOBP, ANLN, ERMN, SPP1, CLDN11, TNC, GPR37, SLC12A2, ABCA2, ABCA8, ASPA, P2RX7, CERS2, MAP4K4, TF, CTGF, Semaphorins, Opalin, FGFs, CALB2, and TNC were identified as potential key regulators of multiple pathways related to FCD type II pathology. We have identified novel epileptogenic marker elements that may contribute to epileptogenicity in patients with FCD and could be possible markers for the localization of EZ.

Anterior Odontoid Screw Fixation for Pediatric and Adolescent Odontoid Fractures: Single-Center Experience Over a Decade

OBJECTIVE

Management of pediatric odontoid fractures is tricky and controversial. This study will enrich world literature with intricacies of anterior odontoid screw (OS) fixation in the pediatric population learned over the last decade.

METHODS

In this retrospective study, all patients with pediatric odontoid fracture who underwent anterior odontoid screw fixation from January 2010 to December 2019 were included and evaluated for surgical outcome.

RESULTS

Thirteen patients were included in this study (mean age, 15 years; range, 6-18 years; male/female, 11:2; type II, 10; type IIA, 1; type III, 2). Common causes of injury were motor vehicle accidents (61.5%) followed by fall from height (38.5%) and all were acute fractures (2-30 days). Five patients had neurologic deficits. Accurate placement of screw was achieved in 92.3% of patients, including all 9 patients who used intraoperative O-arm. K wire migration during bicortical drilling resulted in neurovascular injury, with 1 mortality (7.7%). The remaining 12 patients were available for follow-up (mean, 36 months; range, 20-72 months) and all had preservation of neck movements. Successful OS fixation was achieved in 84.6% of patients, including 1 patient (7.7%) who had a fibrous union. One patient (8.3%) had nonunion because of migration of the screw head in the C2 body.

CONCLUSIONS

Anterior odontoid screw fixation in the pediatric population provides good functional outcomes with instant fixation by direct osteosynthesis. However, the surgeon should be meticulous in the surgical approach and should achieve a lag effect. The surgeon should stop after engaging the outer cortex of the odontoid peg with K wire to avoid cranial migration. Intraoperative O-arm guidance is useful.

Comparison of Peripheral Neurectomy vs. Medical Treatment for Migraine: A Randomized Controlled Trial

Background

Migraine is a common form of primary neurologic headache. Many patients are chronic migraineurs and suffer from a significant disability and adverse effects of drugs. There are various surgical options available to treat migraines, including peripheral neurectomies.

Objective

To study the surgical and functional outcomes of migraine surgeries using peripheral neurectomies and compare them with conservatively treated patients.

Materials and Methods

Migraine patients who had a unilateral onset pain were given local bupivacaine block at the suspected trigger site, and those who were relieved were given the option for surgery. In the operative group, the peripheral nerve of the trigger site was lysed under local anesthesia. The conservative group was continued with the standard treatment. Evaluations with a baseline and 6 months visual analog score (VAS), migraine headache index (MHI), migraine disability assessment test (MIDAS), and pain self-efficacy questionnaire (PSEQ) scores were done.

Results

A total of 26 patients got benefitted with the local bupivacaine block, out of which 13 underwent surgery. At baseline, the VAS, MHI, MIDAS, and PSEQ scores were similar in both the groups. The operative group had significant (P < 0.001) improvement in all these parameters 6 months after the surgery. All patients of the operative group got free from prophylactic migraine treatment; however, 11 out of 13 patients still needed occasional  use of analgesics. There was one complication of transient temporal numbness.

Conclusion

Migraine surgery using peripheral neurectomies was more effective than chronic drug treatment in appropriately selected patients.

Management of Myelopathy due to Anterior Soft-Tissue Compression in Vertebral Hemangioma

OBJECTIVE

Vertebral hemangiomas are benign but highly vascular lesions and are one of the most common lesions of the vertebral column. Anterior soft-tissue compression of spinal cord due to vertebral body hemangioma is challenging to manage. Our objective was to assess long-term clinical and radiologic effects of direct transpedicular absolute alcohol embolization, laminectomy, and short-segment instrumented fusion on resolution of extraosseous epidural soft tissue and improvement in myelopathy in cases of vertebral hemangioma causing anterior soft-tissue compression.

MATERIALS AND METHODS

This was a retrospective analysis that included patients with single-level vertebral hemangioma with anterior intraspinal soft-tissue growth causing spinal cord compression and clinical features of myelopathy between June 2007 and June 2019 at authors' institute. Transpedicular vertebral body injection of absolute alcohol, laminectomy, and pedicle screw rod instrumentation was performed in all patients. Clinicoradiologic outcomes of surgery were noted. We proposed a grading system for the extent of anterior extraosseous epidural soft-tissue compression.

RESULTS

In total, 14 patients were included in study. Their mean age was 28.4 ± 14.4 years. Mean follow-up duration was 67.5 ± 36.2 months. All patients had preoperative radiologic grade 4 compression. Postoperative radiologic grading improved to grade 1 in 4 (28.6%), grade 2 in 8 (57.1%), and grade 3 in 2 (14.3%). All the patients improved neurologically after surgery. Eleven patients improved to American Spinal Injury Association (ASIA) grade E, 2 improved to ASIA D, and 1 improved to ASIA C at the last follow-up visit.

CONCLUSIONS

Vertebral hemangiomas with anterior extraosseous epidural extension causing spinal canal compromise and myelopathy can be managed with direct transpedicular ethanol embolization, laminectomy, and short-segment instrumented fusion with resolution of the extraosseous soft tissue and improvement in myelopathy. The procedure is relatively simple, cost effective, and has a good outcome.

Increased levels of α4-containing GABAA receptors in focal cortical dysplasia: A possible cause of benzodiazepine resistance

Benzodiazepines are the first choice of anti-epileptic drugs used to treat seizures. However, it has been seen that their efficacy decreases with time leading to drug insensitivity, plausibly caused by an alteration in the expression of the benzodiazepine biding site on GABA_A receptors. This study was designed to investigate if the differential expression of GABA_A receptor subunits α1/α4/γ2/δ across the postsynaptic sites could contribute to benzodiazepine resistance in patients with focal cortical dysplasia (FCD), the most common cause of drug resistant epilepsy in pediatric population. Differential gene and cellular expression of GABA_A receptor subunits α1, α4, γ2 and δ were evaluated and validated using qPCR and immunohistochemistry. Whole cell patch clamp studies were performed on pyramidal neurons of resected cortical FCD samples to measure the spontaneous GABA_A receptor activity. Upregulation of α4-and γ2-subunits containing GABA_A receptors were observed at both mRNA and protein level. α1-and δ-subunits containing GABA_A receptors did not show any significant changes. Flumazenil treatment did not affect the kinetics of GABAergic events in FCD; however, it significantly reduced the frequency and amplitude of spontaneous GABAergic activity in non-seizure control samples. Our results demonstrate the enhanced expression of α4-containing GABA_A receptors and GABAergic activity in pyramidal neurons which in turn may contribute to benzodiazepine resistance in FCD patients.

Robotic thermocoagulative hemispherotomy: concept, feasibility, outcomes, and safety of a new "bloodless" technique

OBJECTIVE

The authors present a new "bloodless" technique for minimally invasive robotic thermocoagulative hemispherotomy (ROTCH). Such a method is being described in the literature for the first time.

METHODS

A robotic system was used to plan five sets of different trajectories: anterior disconnection, middle disconnection, posterior disconnection, corpus callosotomy, and temporal stem and amygdalar disconnection. A special technique, called the "X" technique, allowed planar disconnection. Registration was performed with surface landmarks (n = 5) and bone fiducials (n = 1). Coregistration with O-arm images was performed one or two times to confirm the trajectories (once for middle disconnection, and once for disconnection of the temporal stem and amygdala or body of the corpus callosum). Impedance measured before ablation allowed for minor adjustments. Radiofrequency ablation was performed at 75°C-80°C for 60 seconds. Surgical procedures were performed with multiple twist drills. After removal of the electrode, glue was used to prevent CSF leak, and a single stitch was applied. Follow-up CT and MRI were immediately performed.

RESULTS

The pathologies included Rasmussen's encephalitis (n = 2), hemispheric cortical dysplasia (n = 2), posttraumatic encephalomalacia (n = 1), and perinatal insult (n = 1). The mean ± SD (range) age was 6.7 ± 3.6 years (5 months to 10.2 years), and the right side was affected in 4 patients. The mean ± SD seizure frequency was 7.4 ± 5.6 seizures per day (1 patient had epilepsia partialis continua). The mean ± SD number of trajectories was 15.3 ± 2.5, and the mean ± SD number of lesions was 108 ± 25.8. The mean ± SD maximum numbers of trajectories and lesions required for middle disconnection were 7.1 ± 1.7 and 57.5 ± 18.4, respectively. All but 1 patient had class 1 outcomes according to the International League Against Epilepsy Outcome Scale at a mean ± SD (range) follow-up of 13.5 ± 1.6 (12-16) months; the remaining patient had a class 2 outcome. The estimated blood loss was < 5 ml for all patients. Complications included repeat surgery (after 2 weeks) for a "skip" area (n = 1) and a small temporal hematoma (n = 1), which resolved.

CONCLUSIONS

ROTCH seems to be a safe, feasible, and bloodless procedure, with a very low morbidity rate and promising outcomes.

Integrated Genome-Wide DNA Methylation and RNAseq Analysis of Hippocampal Specimens Identifies Potential Candidate Genes and Aberrant Signalling Pathways in Patients with Hippocampal Sclerosis

Background and Aims

DNA methylation and demethylation play a crucial role in the regulation of gene expression, though their interplay during pathogenesis of hippocampal scelerosis (HS) remains elusive. The present study was designed to investigate the DNA methylation regulated changes in expression of HS patients.

Methods

We performed integrative analysis of genome-wide CpG-DNA methylation profiling and RNA sequencing to profile global changes in promoter methylation and gene expression in HS patients. Real time PCR was performed to validate the findings of methylation and RNA sequencing.

Results

A total of 16040 sites showed altered DNA methylation in all the CpG islands. Of these, 3185 sites were in the promoter regions, of which 66 genes showed an inverse correlation between methylation and expression. These genes are largely related to pathways predicted to participate in axon guidance by semaphorins, MAPK, ionotropic glutamate receptor pathway, notch signaling, regulatory activities related to TFAP2A and immune response, with the most distinct ones included TFAP2A, NRP1, SEMA3B, CACNG2, MAP3K11, and ADAM17.

Conclusion

We performed integrated analysis of genomic methylation signature and differential gene expression patterns of hippocampal tissues resected from patients with HS for the first time. Collectively, our findings implicate DNA methylation as a critical regulator of the pathogenic mechanisms of epileptogenesis associated with HS.

The development and efficacy of a mobile phone application to improve medication adherence for persons with epilepsy in limited resource settings: A preliminary study

OBJECTIVE

Persons with epilepsy (PWE), especially those with limited education backgrounds from developing countries, are challenged by complicated medication regimens, debilitating seizures, and stigmatization in their daily life. Consequently, it is difficult for physicians to ensure medication adherence. This study validates a novel mobile application which was hypothesized to increase medication adherence and self-management skills in PWE. Created by medical professionals, the application included behavioral and educational components and was built to be easy-to-understand for those of socio-economically disadvantaged backgrounds.

METHODS

This was a parallel, two-armed randomized controlled trial in which a total of 96 participants were enrolled from a Neurology Outpatient Department into a control standard care group and a mobile application group that used the smartphone application (app) in addition to the standard medical treatment. The app was intuitive and easy to understand for those coming from a socio-economically disadvantaged background. Medication adherence and self-efficacy were assessed with the Morisky Green and Levine Scale (MGLS) and the Epilepsy Self Efficacy Scale (ESES). Patients were reassessed 12 weeks later. Change in seizure frequency following administration of the application was a secondary outcome.

RESULTS

In an intent-to-treat analysis, the mobile application interventional group showed over a 60% increase in the proportion of medication adherence (P < 0.0001). The mean self-efficacy score for the mobile application group was increased from 269.5 to 289.75 (P < 0.0001). The control group showed no statistically significant increases in either the proportion adherent or mean self-efficacy scores.

SIGNIFICANCE

This study demonstrated the statistically significant performance of a mobile application in improving medication adherence and self-management skills in Indian persons with epilepsy.

Evolution to Pedicle Reformation Technique in Surgical Management of Hangman's Fracture

BACKGROUND

Opinions vary regarding optimal treatment of unstable hangman's fractures. Recent technological advances have allowed short segment, motion preserving fixation, even in complex cases. The aim of the study was to demonstrate C1-C2 motion-preserving short-segment fusion in hangman's fracture and the evolution of technique from pedicle realignment to pedicle reformation in complex fractures with resorbed/destroyed C2 pedicles.

METHODS

This was a retrospective study. Patients operated by a single surgeon at a tertiary level center from 2012 to 2018 were included. The type of fracture, operating time, and blood loss was recorded. Neurologic deficits were recorded using the American Spinal Injury Association scale with regular clinicoradiologic follow-up.

RESULTS

Nine patients (8 male), with a mean age of 36 ± 16.9 years were included. In the initial 7 patients, C2 pedicle screw, C3-C4 lateral mass screw, and rod fixation was done. The last 2 patients were complex neglected injuries, with 1 having severe angulation and displacement and the other having spondyloptosis with C2 body placed anterior to C4 body. In both these patients, direct C2 body screw were placed and pedicle reconstruction was done. Mean follow up was 41.4 ± 29.8 months. All 5 patients with preoperative neurologic deficits had improvement in power. C1-C2 joint motion was preserved in all. All patients had bony fusion.

CONCLUSIONS

Preservation of motion at the C1-C2 joint should be the goal in all surgically managed hangman's fracture patients. The technique of C2 pedicle reconstruction can be utilized for the same in old neglected hangman's fractures.

Epilepsy surgery in COVID times-a unique conundrum

The COVID-19 pandemic has forced hospitals to prioritize admissions. Epilepsy surgeries have been postponed at most centers. As the pandemic continues with no definite end in sight in the near future, the question arises until when such patients should be denied appropriate treatment. A 12-year-old child with left-sided Rasmussen's encephalitis with drug refractory epilepsy (DRE) presented at the height of the pandemic, with worsening of seizure frequency from 4-5/day to 20/day, with new-onset epilepsia partialis continua. She demonstrated features of progressive cognitive decline. The pros and cons of operating during the pandemic were discussed with the parents by a multidisciplinary team. She underwent endoscopic left hemispherotomy. Postoperatively she became seizure free but developed hospital-acquired mild COVID infection for which she was treated accordingly. Chosen cases of severe DRE, as the one illustrated above, who are deemed to benefit from surgery by a multidisciplinary team of physicians, should be re-categorized into the most severe class of patients and scheduled for surgery as soon as possible. The risk benefit ratio of the seizures being mitigated by surgery on one hand and possibility of acquiring COVID infection during hospital stay has to be balanced and a decision made accordingly.

EPEN-38. EZH2 INHIBITORY PROTEIN (EZHIP/Cxorf67) EXPRESSION IS HIGHLY CONCORDANT WITH H3K27me3 LOSS AND IS A PROMISING SURROGATE MARKER FOR POSTERIOR FOSSA TYPE A EPENDYMOMAS

BACKGROUND

Gene expression and DNA methylation have identified 2 distinct clinicopathological subgroups among the WHO Grade II/III posterior fossa (PF) ependymomas (EPN), of which the PF-A molecular subgroup associates with poor outcome.

OBJECTIVE

To analyse the utility of immunohistochemistry for H3K27me3, Tenascin C, EZHIP (Cxorf67), EZH2 and fluorescence-in-situ-hybridisation for chromosome 1q21 locus gain in the prognostic stratification of PF-EPNs.

METHODS

All PF Grade II/III tumors were retrieved (2009–2019). Immunohistochemistry for H3K27me3, H3K27M-mutation-specific antibody, EZH2, EZHIP, Tenascin-C and fluorescence in-situ hybridisation for 1q21 locus was performed and compared with outcome.

RESULTS

71 PF-EPNs were included. H3K27me3 loss (PF-A) was seen in 65% (46/71) of cases, of which majority were positive for EZHIP (73%, 24/33) and Tenascin C (65%, 28/43). Minority showed chromosome 1q gain (19%, 8/42). An EZHIP negative PF-A tumor was immunopositive for H3K27M-mutant staining, while all others were negative. PF-A EPNs occurred at a median age of 4.5 years (range 1–53), were predominantly grade III (Grade III:II – 1.6:1), and 50% (10/20) of patients on follow-up experienced tumor progression. EPNs with retained H3K27me3 (PF-B) did not show EZHIP expression (0/20) or 1q gain; however, tenascin C expression was seen in 47% (8/25) of them. They occurred predominantly in adults, showed Grade II preponderance and only 2/11 patients on follow-up experienced progression. EZH2 expression did not correlate with H3K27me3 loss but positively correlated with EZHIP expression (p=0.015).

CONCLUSION

H3K27me3 is a reliable surrogate for prognostic classification of PF-EPNs. EZHIP expression is highly concordant with H3K27me3 loss and is a valuable adjunct.

EZH2 inhibitory protein (EZHIP/Cxorf67) expression correlates strongly with H3K27me3 loss in posterior fossa ependymomas and is mutually exclusive with H3K27M mutations

The PFA molecular subgroup of posterior fossa ependymomas (PF-EPNs) shows poor outcome. H3K27me3 (me3) loss by immunohistochemistry (IHC) is a surrogate marker for PFA wherein its loss is attributed to overexpression of Cxorf67/EZH2 inhibitory protein (EZHIP), C17orf96, and ATRX loss. We aimed to subgroup PF-EPNs using me3 IHC and study correlations of the molecular subgroups with other histone related proteins, 1q gain, Tenascin C and outcome. IHC for me3, acetyl-H3K27, H3K27M, ATRX, EZH2, EZHIP, C17orf96, Tenascin-C, and fluorescence in-situ hybridisation for chromosome 1q25 locus were performed on an ambispective PF-EPN cohort (2003-2019). H3K27M-mutant gliomas were included for comparison. Among 69 patients, PFA (me3 loss) constituted 64%. EZHIP overexpression and 1q gain were exclusive to PFA seen in 72% and 19%, respectively. Tenascin C was more frequently positive in PFA (p = 0.02). H3K27M expression and ATRX loss were noted in one case of PFA-EPN each. All H3K27M-mutant gliomas (n = 8) and PFA-EPN (n = 1) were EZHIP negative. C17orf96 and acetyl-H3K27 expression did not correlate with me3 loss. H3K27me3 is a robust surrogate for PF-EPN molecular subgrouping. EZHIP overexpression was exclusive to PFA EPNs and was characteristically absent in midline gliomas and the rare PFA harbouring H3K27M mutations representing mutually exclusive pathways leading to me3 loss.

GABAA Receptor-Mediated Epileptogenicity in Focal Cortical Dysplasia (FCD) Depends on Age at Epilepsy Onset

Enhanced spontaneous GABA_A receptor activity is associated with focal cortical dysplasia (FCD), a developmental malformation of the cerebral cortex. Clinical manifestations in FCD vary with age at epilepsy onset with a more favorable prognosis in patients with late-onset (LO) compared to that in cases with early-onset (EO). This study was designed to test the hypothesis in FCD that spontaneous GABA_A receptor-mediated epileptogenicity depends on the age at epilepsy onset and varies between patients with early and late-onset age in FCD. To this end, brain specimens were obtained from the maximal spiking region (MAX) and minimal spiking region (MIN) of the epileptic foci of EO (n = 14, mean age = 10.6 ± 2.9 years) and LO (n = 10, mean age = 27 ± 5.6 years) patients undergoing electrocorticography (ECoG) guided surgery. The whole-cell patch-clamp technique was used to record spontaneous GABAergic currents from normal-looking pyramidal neurons in slice preparations of resected brain samples. We detected higher frequency and amplitude of GABAergic events in MAX samples compared to MIN samples of LO patients, while they were comparable in MIN and MAX samples of EO patients. Further GABAergic activity in the MIN and MAX samples of EO patients was higher than the MIN samples of LO patients. This suggests that in LO patients, GABA_A receptor-mediated epileptogenicity is confined only to the high spiking areas, but in EO patients, it affects low spiking regions as well.

Video Section-Operative Nuances: Step by Step - Single Stage Clipping of Ruptured Middle Cerebral Artery and Unruptured Basilar Top Aneurysm

Background and Introduction

Presence of multiple aneurysms, especially a combination of anterior and posterior circulation aneurysm in the same patient, is rare. Surgical clipping of both the aneurysms in the same sitting, although ideal, may be surgically challenging and requires a good preoperative planning.

Objective

In this video abstract, we present a case of a ruptured middle cerebral artery (MCA) aneurysm with a simultaneous occurrence of an unruptured basilar top aneurysm.

Surgical Technique

A 45-year-old female presented with modified Hunt and Hess grade II subarachnoid hemorrhage (SAH). CT scan showed diffuse SAH with a dense bleed in the left sylvian cistern and mild hydrocephalus. Angiography showed a left MCA aneurysm (34 mm size) with a bleb and also an un-ruptured basilar bifurcation/right posterior cerebral artery aneurysm (20 mm). The patient underwent a left frontotemporal craniotomy, zygomatic osteotomy, and clipping of both aneurysms. No temporary clips were applied. The extended craniotomy allowed the surgeon to reach to the base of the aneurysm.

Results

The patient had an uneventful recovery.

Conclusions

Simultaneous occurrence of both anterior and posterior circulation aneurysms are rare, but maybe tackled surgically with proper planning.

α7 nicotinic receptors contributes to glutamatergic activity in the hippocampus of patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS)

Hyperglutamatergic activity in the hippocampus is a major feature of patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). Here we investigated whether tonic α7 nicotinic receptor (nAChR) activity could contribute to enhanced glutamatergic activity in the hippocampus of patients with MTLE-HS. Results showed that frequency and amplitude of glutamatergic events recorded from pyramidal neurons in the hippocampal samples obtained from patients with MTLE-HS were altered by α7 nAChR antagonist, methyllycaconitine, suggesting α7 nAChRs may influence hyperexcitability in MTLE-HS.

Management of C2 Body Giant Cell Tumor by Innovatively Fashioned Iliac Crest Graft and Modified Cervical Mesh Cage Used as Plate

BACKGROUND

Locally aggressive vertebral body tumors of the axis must be treated with wide local excision for best outcome. Reconstruction of the load-bearing vertebra needs to be done after tumor resection in such a manner so as to give stable, long-term fusion in this young population.

METHODS

We describe the management strategy of a 25-year-old acutely quadriplegic patient, with respiratory distress, with a C2 giant cell tumor. The use of a novel iliac crest graft modification used for C2 reconstruction along with a modified mesh cage used as an anterior plate has been reported.

RESULTS

The patient had a good outcome at 18 months' follow-up, with neurologic improvement and a solid fusion.

CONCLUSIONS

Iliac crest autograft is inexpensive and easy to harvest and can be considered as a C2 prosthesis, especially in a resource-constrained setting. Modified iliac crest graft can be used for load transmission from C1 lateral mass to C3 body, and the mesh cage can be modified according to need as a plate with good results in an emergency.

Cost-Effective Home Mechanical Ventilation in Neurosurgery Patients: Case Series of Three Patients

Background  Neurological patients who are ventilator-dependent occupy scarce beds in the hospitals for prolonged periods of time. Most, if not all, can be discharged on home mechanical ventilation (HMV). However, due to lack of insurance and state support, it remains prohibitively expensive for the vast majority of those who require it most.

Materials and Methods  The authors discuss three patients admitted in the Department of Neurosurgery between January and August 2019, who were discharged on HMV after remaining on ventilator support for prolonged period in the hospital. Each patient was discharged with two units (one as standby) of AgVa home ventilator (AgVa Healthcare; New Delhi, India), one Ambu-bag, one pulse oximeter, and one backup power supply unit capable of supplying power to ventilator for a minimum of 24 hours. All the equipment were given free-of-cost through donations by hospital staffs and other donors. All patients were followed up telephonically from their homes and the incidence of complications, ventilator malfunction, and additional cost of HMV on the families were ascertained.

Observation and Results  Of the three patients, two were male and one female. Age ranged from 12 to 17 years. The duration of in-hospital ventilator support prior to discharge on HMV varied from 1 to 5 years. There was no insurance cover available for any of the patients with all expenses being “out of pocket.” The equipment cost Indian Rupees (INR) 115,700 (USD 1,615: two units of AgVa home ventilator costing INR 100,000 [USD 1,396], one Ambu-bag costing INR 1,100 [USD 15], one pulse oximeter costing INR 1,600 [USD 22], and one backup power supply unit costing INR 13,000 [USD 182]). Discharge on HMV was planned on specific request from patients’ families and informed consent was taken from all. All patients had tracheostomies. Mode of HMV was pressure support ventilation in all. Telephonic follow-up ranged from 1 to 7 months. The cost of disposables was INR 100 per month (USD 0.7) for all the patients. No complications occurred in any patient. There was no incidence of ventilator-associated pneumonia (VAP) or ventilator malfunction.

Conclusions  Availability of cost-effective indigenous ventilator like AgVa home has made HMV possible, even for poor patients with neurological diseases, and has the potential to improve quality of life, decrease VAP rates, and free up scarce ventilator beds in hospitals. Longer-term follow-up in larger number of patients will improve the data on safety and feasibility in developing countries like India.

Left Temporal Lobectomy Using Functional MRI in a Math Genius: A Case Report

Standard treatment of drug-refractory epilepsy, due to left mesial temporal sclerosis, is anterior temporal lobectomy with amygdalohippocampectomy (ATL). This carries a risk of cognitive deficits, including comprehension, verbal memory, and visual memory. Preoperative language lateralization and localization is important to preserve these functions. Often Wada testing is used for these, but it carries risk due to its invasive nature. In addition, it can lateralize but not localize and may not be readily available. We hereby present a mathematics genius who underwent left ATL under the guidance of functional MRI and neuropsychological assessment alone, resulting in the preservation of all of his cognitive abilities even in the immediate postoperative period. A video demonstration of his calendar likeability is also shown.

Management of neglected complex hangman's fracture by reforming the C2 pedicle: new innovative technique of motion preservation at the C1-2 joint in 2 cases

Hangman's fracture, also known as traumatic spondylolisthesis of the axis, causes widening of the neural canal and thus a low rate of neurological deficits. This low rate is one of the reasons it is neglected and patients present with late neurological deficits. In an effort to preserve motion at the C1-2 joint, the authors devised a new technique of bilateral C2 pedicle reconstruction. They describe the first two cases in the literature of an old hangman's fracture with resorbed C2 pedicles due to chronic fracture, in which bilateral C2 pedicles were reconstructed. One of the two cases (case 2) is the first reported case of severe C2-3 spondyloptosis with C2 displaced up to the level of C4. Case 1 had a follow up of 21 months, while case 2 had a follow up of 12 months. Both patients experienced neurological improvement with evidence of fusion and artificial pedicle formation at last follow-up. Bilateral C2 pedicle reconstruction is a feasible technique that can be used with a good outcome in select patients.

Enhancing outcomes of endoscopic vertical approach hemispherotomy: understanding the role of "temporal stem" residual connections causing recurrence of seizures

OBJECTIVE

The authors sought to analyze the residual connections formed by the temporal stem as a cause for seizure recurrence following endoscopic vertical interhemispheric hemispherotomy and to review and compare lateral approach (perisylvian) with vertical approach surgical techniques to highlight the anatomical factors responsible for residual connections.

METHODS

This study was a retrospective analysis of patients who underwent endoscopic hemispherotomy for drug-resistant epilepsy. Postoperative MR images were analyzed. Specific attention was given to anatomical 3D-acquired thin-section T1 images to assess the extent of disconnection, which was confirmed with a diffusion tensor imaging sequence. Cadaver brain dissection was done to analyze the anatomical factors responsible for persistent connections.

RESULTS

Of 39 patients who underwent surgery, 80% (31/39) were seizure free (follow-up of 23.61 ± 8.25 months) following the first surgery. Thirty patients underwent postoperative MRI studies, which revealed persistent connections in 14 patients (11 temporal stem only; 3 temporal stem + amygdala + splenium). Eight of these 14 patients had persistent seizures. In 4 of these 8 patients, investigations revealed good concordance with the affected hemisphere, and repeat endoscopic disconnection of the residual connection was performed. Two of the 8 patients were lost to follow-up, and 2 had bihemispheric seizure onset. The 4 patients who underwent repeat endoscopic disconnection had seizure-free outcomes following the second surgery, increasing the good outcome total among all patients to 90% (35/39). Cadaveric brain dissection analysis revealed the anatomical factors responsible for the persistence of residual connections.

CONCLUSIONS

In endoscopic vertical approach interhemispheric hemispherotomy (and also vertical approach parasagittal hemispherotomy) the temporal stem, which lies deep and parallel to the plane of disconnection, is prone to be missed, which might lead to persistent or recurrent seizures. The recognition of this limitation can lead to improved seizure outcome. The amygdala and splenium are areas less commonly prone to be missed during surgery.