Insular glioblastoma: surgical challenges, survival outcomes and prognostic factors

BACKGROUND

Insular gliomas are unique, challenging and evoke a lot of interest amongst neurosurgeons. Publications on insular glioma generally focus on the surgical intricacies and extent of resection pertaining to the low-grade gliomas. Insular glioblastomas (iGBM) have not been analysed separately before.

METHODS

Histologically proven WHO grade IV gliomas involving the insula over a 9-year period were studied. Their clinical presentation, radiological features, surgical findings and survival outcomes were assessed. Statistical methods were used to determine the favourable predictors of survival.

RESULTS

Out of 27 patients (M:F = 2.9:1), 18 (66%) patients had a tumour extension beyond the insula, 10 (37%) of whom had basal ganglia involvement. Total, near total and subtotal excisions were performed in 7 (26%), 9 (33%) and 11 (40.7%) patients, respectively. Twenty-three patients had glioblastoma, while four had gliosarcoma. IDH mutation was negative in six of the seven patients where it was done. Median overall survival was 5 months. Multivariate analysis showed that a female gender (p = 0.013), seizures in the preoperative period (p = 0.048) and completion of adjuvant therapy (p = 0.003) were associated with a longer survival.

CONCLUSION

Insular glioblastomas have a poor prognosis. Insular location and certain tumour characteristics often limit the extent of resection of iGBMs. Moreover, postoperative complications sometimes negate the advantages of a radical resection. A female gender, presentation with seizures and completion of adjuvant chemoradiotherapy appear to be good prognostic factors.

An Analysis of Temporal Trend of Incidence of Post-Resection Cerebrospinal Fluid Diversion in Pediatric Posterior Fossa Tumor Patients and the Predictive Factors

Objective

We aim to find the temporal trend of incidence of post-resection cerebrospinal fluid (CSF) diversion (ventriculoperitoneal [VP] shunt/endoscopic third ventriculostomy [ETV]) in pediatric posterior fossa tumor (pPFT) patients with no pre-resection CSF diversion and the possible clinical predictors.

Methods

We reviewed 108 operated children (age ≤16 years) with PFTs, from 2012 to 2020, at a tertiary care center. Patients with preoperative CSF diversion (n = 42), lesions within cerebellopontine cistern (n = 8), and those lost to follow-up (n = 4) were excluded. Life table, Kaplan-Meier curve, univariate and multivariate analyses were used to determine CSF-diversion-free survival and independent predictive factors, with significance defined as P < 0.05.

Results

The median (IQR) age was 9 (7) years (M: F: 2.5:1). Mean (±SD) duration of follow-up was 32.43 ± 21.3 months. 38.9% of patients (n = 42) needed post-resection CSF diversion. Of these, 64.3% (n = 27) were done in early (≤ 30 days), 23.8% (n = 10) in intermediate (>30 days to ≤6 months), and 11.9% (n = 5) in late (≥6 months) postoperative period (P-value < 0.001). Preoperative papilledema (HR: -5.8, 95%CI: 1.7-5.8), periventricular lucency (PVL) (HR: 6.2, 95%CI: 2.3-16.6), and wound complication (HR: 3.8, 95%CI: 1.7-8.3) were found on univariate analysis as significant risk factors for early post-resection CSF diversion. On multivariate analysis, PVL on preoperative imaging (HR: -4.2, 95%CI: 1.2-14.7, P = 0.02) was identified as an independent predictor. Preoperative ventriculomegaly, raised intracranial pressure and intraoperative visualization of CSF egress from the aqueduct were not found to be significant factors.

Conclusion

Significantly high incidence of post-resection CSF diversion in pPFTs occurs in early (≤30 days) postoperative period, with preoperative papilledema, PVL, and wound complication being its significant predictive factors. Postoperative inflammation, causing edema and adhesion formation can be one of the important factors for post-resection hydrocephalus in pPFTs.

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

Objectives

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

Materials and Methods

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

Results

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

Conclusion

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

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

Background

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

Objective

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

Methods and Material

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

Results

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

Conclusions

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

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

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

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

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

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Balancing the Extent of Resection and Ischemic Complications in Insular Glioma Surgery: Technical Nuances and Proposal of a Novel Composite Postoperative Outcome Index

BACKGROUND

Maximal safe resection remains the most desired goal of insular glioma surgery. Intraoperative surgical adjuncts provide better tumor visualization and real-time "safety" data but remain limited due to a high cost and limited availability.

OBJECTIVE

To highlight the importance of anatomical landmarks in insular glioma resection and avoidance of vascular complications. We also propose to objectify the onco-functional balance in insular glioma surgery.

METHODS

Forty-six insular gliomas operated upon by a single surgeon between January 2015 and February 2020 were reviewed, focusing on the operative technique and clinical outcomes. A novel composite postoperative outcome index (CPOI) was designed, comprising the extent of resection and permanent postoperative deficits, and utilized to assess the surgical outcomes.

RESULTS

Gross-total, near-total, and subtotal resections were achieved in 10.9%, 52.1% (n = 24), and 36.9% (n = 17) patients, respectively. The median overall survival (OS) was 20 months (95% CI = 9.56-30.43). CPOI was optimal in 38 patients (82.6%). A well-defined tumor margin (P = 0.01) and surgeon's experience (P = 0.04) were significantly associated with an optimal CPOI. Out of seven (15.2%) patients who developed permanent neurological deficits, three (6.5%) patients had severe disability. Favorable prognostic factors of survival included younger age (<40 years) (P = 0.002), tumors with only frontal lobe extension (P = 0.011), tumors with caudate head involvement (P = 0.04), and non-glioblastoma histology (P = 0.006).

CONCLUSION

Tumor margin and increasing surgeon experience are critical to an optimal postoperative outcome. Respecting the basi-sulcal plane is key to lenticulostriate artery preservation. Caudate head involvement is a new favorable prognostic factor in insular gliomas.

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

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

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

BACKGROUND

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

Hybrid clinoidectomy is a useful technique and must be learnt.

Combined endovascular and surgical management of a case of Cobb syndrome

Cobb syndrome is a rare neurocutaneous disorder characterised by spinal and cutaneous vascular malformations in a metameric distribution. Managing such cases is a challenge for the interventionists and neurosurgeons as the results are often suboptimal. We describe a case of Cobb syndrome in a young male child who presented clinically with acute paraparesis and lower backache. On radiological workup, an intradural perimedullary complex spinal arteriovenous fistula was seen with presence of subarachnoid haemorrhage in the spinal canal and compressive myelopathy. There was a haemangioma in paraspinal muscles and a maculopapular cutaneous lesion in the lower back. He was treated with combined endovascular embolisation and surgical intervention and showed significant clinical improvement on follow-up.

Comparison of Recovery Profiles of Patients Undergoing Endoscopic Lumbar Discectomy under Desflurane, Propofol, or Sevoflurane Anesthesia: A Randomized, Prospective, Clinical, Comparative Study

Background  Agents like propofol, sevoflurane, and desflurane having rapid revival of psychomotor and cognitive functions translating into reliable anesthetic recovery are chosen for day care procedures. This prospective randomized comparative study was undertaken to compare the psychomotor and cognitive functions of patients undergoing discectomy under different anesthetic strategies.

Methods  Seventy-five adult American Society of Anesthesiologists grade I and II patients being operated for endoscopic lumbar discectomy under different anesthetic regimens were enrolled and were subjected to Trieger Dot Test (TDT), Digit Symbol Substitution Test (DSST), and Mini-Mental State Examination (MMSE) preoperatively at specified intervals postoperatively. There emergence and early recovery times, complications, and satisfaction levels were also noted.

Results  No difference was found in the postoperative TDT and DSST and MMSE scores among the groups at all the time points (15 minutes, 3 minutes, 1 hour, 2 hours, 3 hours, and 4 hours). TDT and DSST demonstrated a tendency to return to baseline by 2nd and 3rd hour postoperatively. Emergence and early recovery times were earlier in the inhalation groups ( p 0.005 and 0.007, respectively). Time required to attain a Modified Aldrete Score of 9, complications, and observed side effects were similar among the groups.

Conclusion  Patients in the three groups had similar impairments in their psychomotor and cognitive functions which recovered at comparable time periods postoperatively. Emergence and early recovery were, however, faster in the desflurane group.

Anterior Skull Base Meningioma: Surgical Approach and Complication Avoidance

Introduction  Endoscopic endonasal approach (EEA) and keyhole transcranial approaches (TCAs) are being increasingly used in anterior skull base meningioma (ASBM) surgery. Objective  We compare tumor resection rates and complication profiles of EEA and supraorbital keyhole approach (SOKHA) with conventional TCAs. Methods  Fifty-four patients with ASBM (olfactory groove meningioma [OGM], n  = 19 and planum sphenoidale/tuberculum sellae meningioma [PSM/TSM], n  = 35) operated at a single center over 7 years were retrospectively analyzed. Results  The overall rate of gross total resection (GTR) was higher in OGM (15/19, 78.9%) than PSM-TSM group (23/35, 65.7%, p  = 0.37). GTR rate with OGM was 90% and 75% with TCA and EEA. Death ( n  = 1) following medical complication (TCA) and cerebrospinal fluid leak requiring re-exploration ( n  = 2, one each in TCA and EEA) accounted for the major complications in OGM. For the PSM/TSM group, the GTR rates were 73.3% ( n  = 11/15), 53.8% ( n  = 7/13), and 71.4% ( n  = 5/7) with TCA, EEA, and SOKHA, respectively. Seven patients (20%) of PSM-TSM developed major postoperative complications including four deaths (one each in TCA and SOKHA, and two in EEA groups) and three visual deteriorations. Direct and indirect vascular complications were common in lesser invasive approaches to PSM-TSM especially if the tumor has encased intracranial arteries. Conclusion  No single approach is applicable to all ASBMs. TCA is still the best approach to obtain GTR but has tissue trauma-related problems. SOKHA may be a good alternative to TCA in selected PSM-TSMs, while EEA may be an alternate option in some OGMs. A meticulous patient selection is needed to derive reported results of EEA for PSM-TSM.

Sialic acid blockade in dendritic cells enhances CD8+ T cell responses by facilitating high-avidity interactions

Sialic acids are negatively charged carbohydrates that cap the glycans of glycoproteins and glycolipids. Sialic acids are involved in various biological processes including cell-cell adhesion and immune recognition. In dendritic cells (DCs), the major antigen-presenting cells of the immune system, sialic acids emerge as important regulators of maturation and interaction with other lymphocytes including T cells. Many aspects of how sialic acids regulate DC functions are not well understood and tools and model systems to address these are limited. Here, we have established cultures of murine bone marrow-derived DCs (BMDCs) that lack sialic acid expression using a sialic acid-blocking mimetic Ac53FaxNeu5Ac. Ac53FaxNeu5Ac treatment potentiated BMDC activation via toll-like receptor (TLR) stimulation without affecting differentiation and viability. Sialic acid blockade further increased the capacity of BMDCs to induce antigen-specific CD8+ T cell proliferation. Transcriptome-wide gene expression analysis revealed that sialic acid mimetic treatment of BMDCs induces differential expression of genes involved in T cell activation, cell-adhesion, and cell-cell interactions. Subsequent cell clustering assays and single cell avidity measurements demonstrated that BMDCs with reduced sialylation form higher avidity interactions with CD8+ T cells. This increased avidity was detectable in the absence of antigens, but was especially pronounced in antigen-dependent interactions. Together, our data show that sialic acid blockade in BMDCs ameliorates maturation and enhances both cognate T cell receptor-MHC-dependent and independent T cell interactions that allow for more robust CD8+ T cell responses.

Bacteriological profile, antibiotic susceptibility pattern and other factors related to neonatal meningitis: A cross-sectional hospital-based study from West Bengal

Background: Neonatal sepsis and meningitis is an important cause of neonatal mortality and morbidity especially in the developing countries. Bacteriological profile of meningitis and antibiotic sensitivity pattern may vary from one region to another. Aims and Objectives: We have planned this study to know the etiological agent of neonatal meningitis with its antibiotic sensitivity profile and to evaluate some other associated risk factors of meningitis. Materials and Methods: This observational, cross-sectional study was done for a period of 1 year in the SNCU and NICU of a district Medical College of West Bengal in neonates presented with clinical sepsis and meningitis. Sepsis screen, blood culture, cerebrospinal fluid (CSF) study, and culture sensitivity was done and recorded along with demographic data, clinical presentation, outcome, and other associated factors. Results: We found meningitis in 55 neonates out of 250 clinical sepsis. CSF culture was positive in 42 cases with Escherichia coli (30.9%), Klebsiella (26.1%), Staphylococcus aureus (16.6%), Acinetobacter (14.2%) and Coagulase negative Staphylococcus (CoNS 11.9%) as prevalent organism. E. coli and Klebsiella were mostly sensitive to Amikacin, Levofloxacin, and Colistin whereas less sensitive to Cefotaxime, Pipercilin-tazobactam or Meropenem and Acinetobacter showed good sensitivity only to Levofloxacin. Among the gram-positive organism, S. aureus and CoNS were only sensitive to Linezolid, Vancomycin, and Teicoplanin. Conclusion: This type of study should help to make a proper antibiotic policy for an institution so that the empirical first-line antibiotic can be started with good effect in cases of neonatal sepsis and meningitis before the arrival of culture sensitivity report.

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

BACKGROUND

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

CASE REPORT

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

CONCLUSION

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

Added value of 3D-DRIVE and SWI Magnetic Resonance Imaging Sequences in Intraventricular Neurocysticercosis (IVNCC): An Institutional Experience from Northeast India

Background:

Prompt diagnosis and early treatment institution are important in intraventricular neurocysticercosis (IVNCC) as compared to the parenchymal or racemose form because it is associated with a poorer patient prognosis. Intraventricular neurocysticercosis is often missed on CT scan or conventional cranial magnetic resonance imaging because of similar density or signal intensity of cysticercus lesion with cerebrospinal fluid.Thestudy aims to evaluate the added value of 3D-DRIVE and SWI MRI sequences in isolated intraventricular cysticercosis with acute neurological presentation.

Methods and Materials:

This retrospective study was carried out on diagnosed 10 patients with isolated intraventricular neurocysticercosis (IVNCC) presented to a tertiary care hospital with an acute onset of symptoms or acute neurological deficit between June 2019 to May 2021. Relevant neurological examination, CSF analysis, a serological test of neurocysticercosis and MRI scan of the brain were performed.

Result:

Tenpatients of isolated intraventricular neurocysticercosis (3 males and 7 females) having 3 pediatric and 7 adults were included in this study sample.The common neurological complications of the isolated intraventricular neurocysticercosis in this study are observed as obstructive hydrocephalus in 8(80%) patients and ependymitis in 7(70%) patients. IVNCC with distinctly visualized scolex (visibility score 2) identified in 2(20%) patients in T2WI, 8 (80%) patients in 3D-DRIVE and 3(30%) patients in SWI sequences. The cyst wall of IVNCC was distinctly visualized (visibility score 2) in 1(10%) patient in T2WI, 8(80%) patients in 3D-DRIVE and 6(60%) patients in SWI sequence.

Conclusion:

Heavily T2-weighted steady-state and SWI sequences should be added to routine MRI sequences that helps to identify IVNCC and should be used in patients with unexplained hydrocephalus, especially in endemic regions of Neurocysticercosis.

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

Background

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

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

Results

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

Conclusion

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

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

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

Endoscopic Keyhole Approach for Intracranial Epidermoid

Objective  In contemporary neurosurgical practice, keyhole endoscopic approach has established its role in various neurosurgical pathologies. Intracranial epidermoid is an ideal pathology for endoscopic keyhole approach as epidermoid is well encapsulated, extra-axial, avascular, and easily suckable. The objective of this study is to share our experience of endoscopic keyhole approach for intracranial epidermoids at various locations as a new minimally invasive neurosurgical approach to deal with these lesions. Materials and Methods  We conducted a retrospective study on 26 patients who underwent keyhole pure endoscopic excision of intracranial epidermoid between July 2015 and December 2019. Patient's demographics, clinical features, radiological imaging, and postoperative complications were noted. Follow-up outcome of preoperative symptoms and postoperative complications were also analyzed. Results  The mean age of the study population was 30.5 years with a mean follow-up of 30 months. The common presenting features were headache, hearing loss, and trigeminal neuralgic pain. Gross total resection was achieved in 73.1% cases, while near total resection and subtotal resection were achieved in 19.2 and 7.7% cases, respectively. In the follow-up, maximal improvement was seen in trigeminal neuralgic pain (83%) and headache (66.7%). Major postoperative complications were facial nerve paresis, lower cranial nerve paresis, and transient facial hypoesthesia, most of which improved over time. None of the patients required resurgery till date. Statistical Analysis  Patients' data were analyzed using SPSS software version 23 (Statistical Package for Social Sciences, IBM, Chicago, United States). Conclusion  This study demonstrates that with careful patient selection, endoscopic keyhole excision of epidermoid is a good alternative to conventional microsurgical excision with comparable surgical and functional outcomes.