Diagnostic utility of intraoperative squash smear cytology of Intra-cranial lesions in a resource limited setup of central India

Introduction

Intraoperative squash smear cytology is a useful diagnostic tool in case of CNS lesions. In resource poor countries where frozen section is unavailable, cytology is the mainstay method in giving a rapid intraoperative diagnosis which helps Surgeons regarding the extent of excision. The current study aims to assess the feasibility and accuracy of intraoperative squash cytology in evaluation of CNS tumors. Definitive diagnosis is confirmed by histopathological examination.

Materials and methods

This retrospective observational study was carried out at Department of Neuropathology. All patients diagnosed with space occupying lesion (SOL) in CNS were enrolled in the study. Intra-operative cytological diagnosis was compared to histopathological diagnosis. WHO classification of CNS tumors 2021 was used to classify tumors.

Results

Total seventy patients with intracranial SOLs were enrolled in this study who were operated for the same and their specimens were examined. Two samples were found to be inadequate and not included in final analysis. Mean age was 38.8 ± 17.85 (SD). Male-female ratio was 1.5:1 with 41 (60.3%) males and 27 (39.7%) females. 58 had neoplastic and rest 10 had non-neoplastic lesions. Complete concordance was achieved in 61 cases (Diagnostic Accuracy-88.2%). 3 (4.4%) cases showed partial concordance and 4 (5.9%) were discordant. For detection of malignant lesions through squash smear cytology overall Sensitivity was 73.9%, Specificity-97.8%, Positive Predictive Value-94.4% and Negative Predictive Value-88%.

Conclusions

Squash smear cytology is a simple, rapid and cost-effective method relying solely on the expertise of pathologist. High diagnostic accuracy can be achieved with squash cytology by taking clinical and radiological findings into consideration.

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.

Indian Neurosurgeons at the Forefront: A Comprehensive Exploration of their Pioneering Contributions to Neuroendoscopy

This article delves into the profound impact of Indian neurosurgeons on the expansive canvas of neuroendoscopy. By scrutinizing their trailblazing research, innovations, new surgical techniques, and relentless dedication to education and training, we aim to unravel the intricacies of their influence on a global scale. The review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, conducts a comprehensive analysis of the literature related to neuroendoscopy contributed by Indian neurosurgeons. The exploration covers a spectrum of achievements, ranging from pioneering research and innovations to complication avoidance, neuroendoscopic training, and global recognition. Despite challenges, Indian neurosurgeons continue to lead the way in shaping the future of neuroendoscopy, ensuring better patient outcomes and improved quality of life. Many Indian neurosurgeons have contributed significantly to the development of neuroendoscopy in India. Prof. YR Yadav's contributions stand significant in the form of research articles and publications on almost all subjects on neuroendoscopy, the textbook on neuroendoscopy, popularizing neuroendoscopy by starting the first university-certified neuroendoscopy fellowship training program in India, describing many innovative techniques/first report of endoscopic techniques and conducting regular endoscopic workshops in his institutions and other major cities of India.

Seventh Cervical Nerve (C7) Transection for Spastic Arm Paralysis After Cerebral Injury

BACKGROUND

Spastic limb paralysis because of cerebral injury can cause long-term disability. Its treatment varies from conservative to operative; however, the optimum treatment is yet to be found.

OBJECTIVE

To test the hypothesis that patients with spastic arm paralysis who receive C7 nerve transection to their paralyzed side might have reduction in spasticity, pain, and improvement in arm function.

METHODS

Four patients with spastic hemiparesis that had ceased to improve after 1 year of rehabilitation, having pain and poor function, were included. All 4 patients underwent C7 nerve transection plus rehabilitation. The outcome was assessed at 1, 3, and 6 months by the Fugl-Meyer upper extremity scale for motor recovery, by the Modified Ashworth Scale score for spasticity, and by the visual analogue score for pain. Functional use of the limb was also assessed by performance of activities such as dressing, tying shoe laces, wringing a towel, and operating a mobile phone.

RESULTS

At the end of 6 months, there was a significant improvement in mean Fugl Meyer score, reduction in Modified Ashworth score, and Visual Analogue scale for pain. At the beginning of the study, none of the patients could perform any day-to-day activities; however, at the end of 6 months, 3/4 of the patients could perform at least 1 activity.

CONCLUSION

C7 neurectomy leads to improved motor function, reduction of spasticity and pain, and improvement in function in patients with spastic arm paralysis because of cerebral injury.

A Novel Brain Retractor for Endoscopic Evacuation of Chronic Subdural Hematoma

Background

Endoscopic chronic subdural hematoma (CSDH) evacuation is a safe and effective alternative to the conventional burr hole technique. Although a rigid endoscope has the advantage of good visualization, there are risks of brain damage due to limited space to accommodate the scope and frequent lens soiling.

Objective

This technical note describes a novel brain retractor to overcome the limitations of rigid endoscopy.

Methods

The novel brain retractor (by senior author) was made by dividing a silicon tube longitudinally into two halves, and tapered for easy introduction in the operative cavity. Sutures were placed at the outer end of the retractor to prevent migration and to assist in angulation.

Results

The novel retractor along with endoscopic assistance was used in 362 CSDH procedures. Endoscopy combined with this retractor provided additional help in complete removal of hematoma in organized/solid clots, septa, bridging vessels, and rapid expansion of brain in 83, 23, 21, and 24 patients, respectively (n = 151, 44%). Although there were three deaths (due to poor preoperative status), and two recurrences, there were no retractor-induced complications.

Conclusions

The novel brain retractor assists endoscope in proper visualization of complete hematoma cavity by gentle and dynamic brain retraction, helps in thorough irrigation of hematoma cavity, protects the brain, and prevents lens soiling. It allows easy insertion of the endoscope and instruments using bimanual technique even in patients with a small width of hematoma cavity.

Epilepsy-Related Injuries in Children: An Institution-Based Study

BACKGROUND

Epilepsy carries a lifetime risk of seizure-related accidents. The risk varies according to the socioeconomic profile of a place. Sufficient data is lacking for epilepsy-related accidents in the pediatric population.

OBJECTIVE

We aimed to identify the proportion of pediatric epileptic patients who met with accidents and their associated factors.

METHODS

A prospective study was done. Patients of less than 18 years with epilepsy of more than 1-year duration were included and were given a questionnaire modified for the pediatric population. The demography of accidents during seizures and drugs taken were recorded.

RESULTS

135 epileptic children were included. 70.4% of patients suffered seizure-related accidents ranging from 1-10 accidents in their epilepsy duration. Falls (83.15%) were the most common, 25.26% of them required hospitalization. Accidents due to missing of drug dosage were observed in 23% patients.

CONCLUSION

Seizure-related accidents are common in the pediatric population, and may lead to major accidents. Better epilepsy management with extra care for high-risk epilepsy patients may decrease their incidents.

Cadaveric study to assess the feasibility of S1 neurectomy and contralateral S1 transfer for spastic hemiparesis

Purpose

Acquired brain injury causing spasticity, pain and loss of function is a major cause of disability and lower quality of life. Sacral 1 (S1) neurectomy claims promising outcomes in spastic hemiparesis. This cadaveric study was conducted to study the surgical anatomy, surgical approach and feasibility of S1 neurectomy and contralateral S1 (cS1) transfer.

Methods

This study was conducted over a period of 10 months and 10 cadavers (age 18-60 years, 7 male and 3 female) were included in the study. 2 cadavers underwent endoscopic S1 neurectomy and 8 cadavers underwent open S1 neurectomy. Mean S1 root length and diameter were recorded using Schirmer tear strips and Vernier calliper. Feasibility of transfer was also assessed by measuring the length of donor nerve and distance between distal ends to proximal end of recipient nerve.

Results

Mean thickness of right S1 root was 4.02 ± 1.5 mm and left S1 was 3.89 ± 1.18 mm. Mean length of right S1 root was 24.9 ± 4.56 mm and left S1 was 23.6 ± 2.86 mm. Endoscopically dissected length of S1 was much less as compared to open technique.

Conclusion

S1 neurectomy is simple procedure to reduce spasticity in lower limb without any permanent deficit. It can be done by open as well as with endoscopic approach while for contralateral S1 transfer open approach need to be used.

Rotational Occipital Scalp Flap for Occipital Pressure Ulcer

Occipital pressure ulcers and wound gaping may occur in unconscious and malnourished patients. Most of the time, a large defect requires wound coverage by scalp flaps. This video describes a rotational occipital scalp flap for occipital pressure ulcer and wound gaping in a patient of operated midline posterior fossa mass & ventriculoperitoneal shunt. The defect measured 2.25 × 2.5 cm with exposed inion. The wound was included in an imaginary triangle, and the horizontal and vertical incision lengths were about four times the base of the triangle. The flap was based on the left occipital artery and raised in an avascular plane above the periosteum. The wound margins were freshened and undermined. The flap was rotated to bring it over the defect, and suturing was done in the standard manner. The flap had good healing, and the patient continued to be under care for his cerebellar medulloblastoma.

Mini Temporal Craniotomy Using Anatomical Surface Landmarks for Temporal Lobe Epilepsy: Technical Note and Clinical Outcomes

BACKGROUND

Patients with temporal lobe epilepsy are subjected to standard temporal lobectomy wherever indicated. This is performed using a reverse question mark flap and a standard frontotemporal craniotomy. We describe the technique of minitemporal craniotomy (3 × 3cms) for temporal lobe epilepsy (TLE) and analyze the clinical outcomes of patients operated using this approach.

OBJECTIVES

To describe the technique of minitemporal craniotomy for TLE without navigation guidance and to analyze the clinical outcomes of patients operated using this approach.

MATERIALS AND METHOD

This was a retrospective analysis of all consecutive TLE cases operated at our institute from 2014 to 2019, via minitemporal craniotomy, using surface landmarks only without navigation guidance. The surgical technique, indications for surgery, and their clinical outcomes were analyzed.

RESULTS

A total number of 48 patients underwent surgery for TLE. There were no complications except three patients who had transient hemiparesis. The average duration of hospital stay was 4 days following surgery. Out of 28 patients with mesial temporal sclerosis, 22 (82%) had international league against epilepsy, Class I seizure outcome, 4 (12.5%) had Class II outcome and 2 (5.5%) had Class III outcome. 9 patients with dysembryoplastic neurectodermal tumor (DNET), 4 gangliogliomas, 2 neurocystecercosis (NCC), all had Class I outcome. Out of the five patients with MTS and associated anterior temporal focal cortical dysplasia (FCD), four (80%) had a Class I outcome, whereas one (20%) had Class II outcome.

CONCLUSION

Utilizing surface anatomical landmarks, minitemporal craniotomy can be performed in even peripheral centers without neuronavigation, with good cosmesis, seizure outcomes.

History of Endoscopic Spine Surgery in India

Endoscopic spine surgeries provide distinct advantages and is therefore a viable alternative to open or microscopic techniques. Indian surgeons have shown their expertise from craniovertebral junction to lumbosacral spine with these techniques. Many novel approaches like endoscopic transcervical, partial corpectomy, and others have been designed, and many technological innovations for these surgeries have been made. With different training programs attracting both native and international surgeons, the future of endoscopic spine surgery is bright.

Lumboperitoneal Shunts - Patient Selection, Technique, and Complication Avoidance: An Experience of 426 Cases

Background

Lumboperitoneal shunt is a known procedure for communicating hydrocephalus. Being an extracranial procedure, it can also be utilized in normal-sized ventricles.

Objective

To report our experience of lumboperitoneal shunt done with a minimal follow-up of 12 months with an emphasis on patient selection, technique, and complication avoidance.

Methods

This was a retrospective analysis of patients who underwent LP shunt during October 2014-October 2019 at the authors' institute. Inclusion criteria were patients with communicating hydrocephalus due to tubercular meningitis, normal pressure hydrocephalus, idiopathic intracranial hypertension, and postoperative refractory cerebrospinal fluid leaks. Data were collected for demographics, Glasgow coma scale and Glasgow outcome scale, vision, gait, memory, urinary incontinence, failed attempts, and complications.

Results

A total of 426 patients underwent the LP shunt procedure. The commonest indication was tubercular meningitis followed by idiopathic intracranial hypertension and normal pressure hydrocephalus. Age ranged from 16 to 72 years. There were 255 male and 171 female patients. The mean follow-up was 41 ± 8 months. Overall, 301 patients (70.6%) had neurological improvement. Shunt-related complications occurred in 112 (26.29%) patients, of which shunt block was the commonest. Other complications were infection in 17 (3.9%) patients and extrusion in four (0.9%) patients. Transient postural headache was seen in 46 (10.7%) patients, which gradually improved.

Conclusion

Lumboperitoneal shunt was found to be a safe and effective treatment in appropriately selected communicating hydrocephalus patients. A meticulous technique reduces the complication rate.

Endoscopic Third Ventriculostomy - A Review

BACKGROUND

Endoscopic third ventriculostomy (ETV) has become a proven modality for treating obstructive and selected cases of communicating hydrocephalus.

OBJECTIVE

This review aims to summarize the indications, preoperative workup, surgical technique, results, postoperative care, complications, advantages, and limitations of an ETV.

MATERIALS AND METHODS

A thorough review of PubMed and Google Scholar was performed. This review is based on the relevant articles and authors' experience.

RESULTS

ETV is indicated in obstructive hydrocephalus and selected cases of communicating hydrocephalus. Studying preoperative imaging is critical, and a detailed assessment of interthalamic adhesions, the thickness of floor, arteries or membranes below the third ventricle floor, and prepontine cistern width is essential. Blunt perforation in a thin floor, while bipolar cautery at low settings and water jet dissection are preferred in a thick floor. The appearance of stoma pulsations and intraoperative ventriculostomography reassure stoma and basal cistern patency. The intraoperative decision for shunt, external ventricular drainage, or Ommaya reservoir can be taken. Magnetic resonance ventriculography and cine phase-contrast magnetic resonance imaging can determine stoma patency. Good postoperative care with repeated cerebrospinal fluid drainage enhances outcomes in selected cases. Though the complications mostly occur in an early postoperative phase, delayed lethal ones may happen. Watching live surgeries, assisting expert surgeons, and practicing on cadavers and models can shorten the learning curve.

CONCLUSION

ETV is an excellent technique for managing obstructive and selected cases of communicating hydrocephalus. Good case selection, methodical technique, and proper training under experts are vital.

Awake focussed craniotomy for oedematous/large brain lesions

Aim: Awake craniotomy has been proven to be safe and effective. It has generally been used for non-edematous conditions. If done in edematous states, large craniotomies are advised. Here, we report the combined use of techniques of awake anaesthesia and focussed craniotomy for dealing with large/edematous brain lesions. Materials and Methods: This was a prospective single-centre study from May to October 2019. Included were adult cooperative patients presenting with edematous brain lesions. A completely awake cycle was used using ring scalp block, Dexmedetomidine loading, and maintenance infusion, and use of Midazolam and Fentanyl. The dural flap was lifted limited to the lesion, and sometimes in stages to tackle the bulging brain. Data was collected for resection volume, pain scores using visual analogue scale (VAS) during the surgery, seizures, complications, new deficits, blood loss, duration of surgery, ICU, and postoperative hospital stay. Results: Fifteen patients underwent the procedure. Pathologies were high-grade gliomas (7), low-grade gliomas (3), tuberculoma (2), metastasis (1), ependymoma (1), and meningioma (1). Fourteen patients underwent total, and one underwent subtotal excision. Brain bulge could be handled with the staged opening of the dura and intratumoral decompression. No patient required postoperative ventilatory support. Intraoperative pain scores ranged from 2-3. The duration of surgery ranged from 60-280min. Blood loss ranged from 75-300ml. Postoperative stay varied from 3-20 days. There were two intraoperative seizures (managed), two CSF leaks, and two infections. Two patients developed transitory motor deficits. Conclusion: Awake focussed craniotomy was found safe and effective for large/edematous brain lesions in appropriately selected patients.

Endoscopic-Assisted C2 Transverse Process Mass Excision

Background and Introduction

C2 transverse process exostoses are rare lesions. Due to critical structures surrounding them, their excision is challenging. There are sparse reports of anterior retropharyngeal approach (ARPA) for high-cervical transverse process mass and none for endoscopic ARPA approach.

Objective

A step-by-step technical report with its video is presented.

Surgical Technique

A 14-year-old girl presented with chronic right-sided neck pain. The computed tomography scan revealed a 6.5 cm³ mass in the right transverse process extending into the lateral mass of the C2 vertebra. The mass was anterior and in direct contact with the vertebral artery. She underwent a minimally invasive endoscopic ARPA.

Results

The mass could be excised along with its cartilaginous cap without any complications. The patient's symptoms resolved completely. The biopsy came out as osteochondroma.

Conclusion

Endoscopic ARPA is a minimally invasive option for high-cervical tumors and was found safe and effective for C2 transverse process osteochondroma.

Endoscopic Anterior Cervical Discectomy (Disc Preserving)

Background and Introduction

Endoscopic anterior cervical approach has several advantages compared to conventional anterior cervical discectomy and fusion (ACDF).

Objective

This video demonstrates a step-by-step procedure for endoscopic anterior cervical discectomy.

Procedure

The patient is placed supine with the neck extended. A standard anterior cervical approach using about 3 cm skin incision is made and under "Easy Go" (Karl Storz, Tuttlingen, Germany) endoscopic vision, the uncinate process and uncus are drilled. Only a small portion of the normal disc, posterior longitudinal ligament (PLL), and compressing disc is removed. The closure is done in a standard manner.

Results

In 240 patients, the average postoperative reduction in disc height, operating time, and blood loss were 1.1 ± 0.2 mm, 110 ± 17 min, and 30 ± 11 mL, respectively. The average postoperative VAS score and Nurick grading improved significantly. There were no permanent complications or any mortality.

Conclusion

Endoscopic technique is an effective and safe alternative to ACDF after attaining the learning curve.

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.

Endoscope-controlled Access to Thalamic Tumors using Tubular Brain Retractor: An Alternative Approach to Microscopic Excision

BACKGROUND

 Surgery for thalamic lesions has been considered challenging due to their deep-seated location. Endoscopic excision of deep-seated brain tumors using tubular retractor has been shown to be safe and effective in prior studies; however, there are limited reports regarding its use for thalamic tumors. We present our experience of endoscope-controlled resection of thalamic tumors using a tubular retractor.

MATERIAL AND METHODS

 This was a prospective observational case series done at a tertiary center specialized for endoscopic neurosurgery during the period from 2010 to 2019. Surgeries were performed under the endoscopic control using a silicon tubular retractor. Lesions were approached transcortically or trans-sulcally. Data were collected for the extent of resection, amount of blood loss, operative time, need for conversion to microscopy, and complications.

RESULTS

 Twenty-one patients of thalamic masses of 14- to 60-year age underwent the surgeries. Pathologies ranged from grade I to IV gliomas. Gross total and near-total resection could be done in 42.85% of cases for each group. The average blood loss and operative time were164.04 ± 83.63 mL and 157.14 ± 28.70 minutes, respectively. Complications included a small brain contusion, two transient hemipareses, and one transient speech deficit.

CONCLUSION

 Endoscopic excision of thalamic tumors using a tubular retractor was found to be a safe and effective alternative to microscopic resection.

Colloid Cyst Presenting as Head Injury

Colloid cysts are mucous- or hyaloid-filled lesions with an outer fibrous layer. These are rare developmental and nonneoplastic malformation. They may be found incidentally, while some cases may present with intermittent headache, rapid neurologic deterioration, drop attacks, and even sudden death. Early recognition of this disease may result in lesser mortality. Here, we present a 22-year-old male with a history of fall while driving his two-wheeler. A diagnosis of colloid cyst of the third ventricle with a head injury was made. Colloid cyst presenting with a head injury is exceedingly rare with only five case reports in the literature. This report may help to support surgical intervention in an asymptomatic patient, as the cyst can predispose head injury with serious consequences. It also stresses the importance of a high degree of suspicion when there is any well-defined radiological abnormality in the region of the third ventricle. A colloid cyst may easily be confused with intracranial hemorrhage due to hyperdensity in head trauma. It can be distinguished by the presence of an accompanying traumatic lesion. The cyst usually has well-defined round margins, and the morphologic appearance and density do not change on a follow-up computed tomography (CT) scan, whereas in hemorrhage the density usually regresses with clinical improvement on serial imaging.

Hypothalamic Hamartoma and Endocrinopathy: A Neurosurgeon's Perspective

Background

The management of hypothalamic hamartomas (HH) rests upon the type of presentation. These are rare congenital benign lesions presenting either with central precocious puberty (CPP), drug refractory epilepsy (DRE) or combination of both. We present here our experience in the management of these lesions from a neurosurgeon's perspective and review the pertinent literature.

Objective

To present a series of HH presenting with CPP and DRE managed in the neurosurgery department at our center with an emphasis on the associated endocrine abnormalities.

Materials and Methods

A prospective observational study over a period of five years included 16 patients of HH. All patients were evaluated with 3 Tesla Magnetic Resonance Imaging (MRI) brain, complete hormonal workup including gonadotrophins, testosterone (males) and estradiol (females), and video-electroencephalography (VEEG) as a part of epilepsy workup. All these patients were evaluated with postoperative hormonal workup and repeat MRI brain if repeat surgery was contemplated.

Results

Among the 16 patients of HH, there were 11 male and 6 female children. All the patients presented with DRE with four of these had associated CPP. All the patients underwent robotic-guided radiofrequency ablation (RFA), with 75% seizure freedom following 1^st RFA surgery. Three of the four patients with CPP achieved both clinical and biochemical normalization. One patient had just a marginal reduction in the serum gonadotrophins. One patient was reoperated twice and three underwent RFA thrice.

Conclusion

The management of HH should be individualized with DRE taking the precedence requiring early surgery. A multidisciplinary approach is therefore recommended for a successful outcome.

Recent Developments in Endoscopic Endonasal Approach for Pituitary Adenomas

Background

Endoscopic endonasal transsphenoidal approach has become the workhorse for pituitary adenomas. The residual rates and complications continue to present as challenges for the pituitary surgeons.

Objective

To review the recent developments in endoscopic pituitary surgeries for improving patient outcomes and safety rates.

Methodology

A search of the last ten years, on PubMed and Google Scholar was performed with the keywords "Pituitary and Neuroendoscopy". A total of 345 articles were found (44 review, 193 original). Relevant articles were chosen.

Results

Substantial improvement has taken place in the field of endoscopic pituitary surgery in the last decade. These include 3D printing, 3D endoscopes, 3D neuronavigation, multi-modal neuronavigation, ultra-high-definition endoscopes, optical fluorescence agents, intraoperative MRI, to name a few.

Conclusion

The technological advancements have increased the resection rates, improved patient outcomes, and helped in the training of younger surgeons. A higher cost remains a concern.

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.

Techniques for Differentiating Motor and Sensory Fascicles of a Peripheral Nerve—A Review

Differentiating motor and sensory fascicles before anastomosis is essential for achieving an excellent postoperative functional outcome for peripheral mixed nerves injuries. However, identifying them is not easy. There are several techniques to address this important issue. Each identifying technique has its own pros and cons; this narrative review highlights the salient features of each of these. Many of the newer techniques need to be tested in humans before they can be recommended for regular use; till then we have to rely mainly on per operative electrical stimulation of nerve to differentiate between sensory and motor fascicles to improve postoperative functional outcome.

Teaching Glasgow Coma Scale Assessment by Videos: A Prospective Interventional Study among Surgical Residents

Objective  Glasgow Coma Scale (GCS) assessment is vital for the management of various neurological, neurosurgical, and critical care disorders. Learning GCS scoring needs good training and practice. Due to limitation of teachers, the new entrants of the clinical team find it difficult to learn and use it correctly. Training through videos is being increasingly utilized in the medical field. This study aimed to evaluate the efficiency of video teaching of GCS scoring among general surgery residents. Materials and Methods  A prospective study was done utilizing the freely available video at glasgowcomascale.org. The participants (general surgery residents, 1st-3rd year) were asked to assess and record their responses related to GCS both before and after watching the video. A blinded neurosurgeon recorded the correct responses separately. Statistical Analysis  The difference between correct responses of the residents before and after watching the video was calculated using the "chi-square test." p -Value ≤ 0.05 was taken as significant. Results  There was a significant improvement in GCS scoring by residents after watching the videos ( p < 0.05). On estimating the responses separately, all the three responses (eye, verbal, and motor) improved significantly for 1st-year residents while only the motor response improved significantly for 2nd- and 3rd-year residents. The mode subjective improvement for the 1st-, 2nd-, and 3rd-year residents was 5, 4, and 3, respectively. Conclusion  Training GCS scoring through videos is an effective way of teaching the surgery residents with maximum benefit to the junior-most ones.

Endoscopic Management of Chronic Subdural Hematoma

Background Twist drill evacuation, burr hole aspiration, mini-craniotomy, and craniotomy are some of the surgical methods to remove chronic subdural hematoma (CSDH). Endoscopic treatment was also recently found to be useful.

Methods We conducted a prospective study of 72 hematomas in 68 patients. Computed tomography was performed in all cases. Endoscopic surgery was performed in all CSDH patients.

Surgical procedure A 4-cm skin incision was performed at the most curved part of skull with the CSDH. A mini-craniotomy or enlarged burr hole was made. The inner and outer table of the burr hole margin was drilled to provide a straight trajectory to the hematoma cavity. An endoscope supported by a telescope holder was used. A modified silicone brain retractor was used in five patients. A subgaleal drain was left in all patients for 3 to 5 days.

Results There were 42 male and 26 female patients. The age ranged from 45 to 79 years (average: 69 years). All patients had a history of head trauma. Preoperative average Glasgow Coma Scale Score was 14. The procedure was effective in hematoma evacuation and a good visualization of the whole cavity in all patients. The endoscopic technique helped in complete hematoma removal in organized/solid clot, septations, and bridging vessels in 17, 2, and 2 cases, respectively. Duration of surgery ranged from 35 to 80 minutes. One death occurred. There was no recurrence, infection, fresh bleed, or injury to the brain or membrane.

Conclusion The endoscopic technique is an effective alternative technique for treating CSDH. Although the study has limitations because of the small number of patients with a short follow-up, the study indicated that thick and vascular membranes, septations, and organized and solid clots can be removed effectively using this technique.

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.

Neurotrauma Audit at Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh

Introduction For the prevention and better management of traumatic brain and spine injury patients, it is mandatory to understand the demographic and clinical profiles of cases of a particular region. This study was aimed at describing the epidemiology, pattern, and outcomes of head and spine injury patients at a tertiary care center in central India.

Materials and Methods All the patients with head and spine injury admitted to the Department of Neurosurgery between September 1, 2018, and August 31, 2019 were included in the study. Data of all these patients were collected from the medical record section and analyzed for age, sex, mode of injury, severity of injury, management, and outcomes.

Results During the study period, 932 patients with head injury and 241 patients with spine injury were admitted to our department. Around 65% of the patients in both head and spine injury categories fell in the age group of 26 to 55 years. Approximately 80% of all neurotrauma patients were male. The most common mode of injury was road traffic accident followed by fall from height. Mortality for severe head injury was 39% and that for ASIA A (American Spinal Injury Association grade A) cervical spine injury was 65%.

Conclusion Even after aggressive treatment strategies, morbidity and mortality are very high, and the ultimate outcome depends mainly on the clinical status immediately after trauma. The data from this study can be helpful in strategy-making for the prevention and management of head and spine injury patients, especially in the central Indian population.

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.

Need of Immediate Drug Reduction after Epilepsy Surgery - A Prospective Observational Study

Background

Patients undergoing epilepsy surgery are on polytherapy. Drug tapering is usually done after 1 year in adults and after 6 months in children. Sometimes, drugs have to be altered during the perioperative period, which is more commonly seen in hemispherotomy (HS) patients. The present study was done to compare perioperative drug alterations between HS and temporal (TL) lobectomy patients.

Materials and Methods

Prospective analysis of postoperative HS and TL patients was done. Primary outcomes were drug number, dosage changes, and seizure outcome. Secondary outcome studied was a change in intelligence quotient (IQ) in the two groups.

Results

At total of 71 patients were included. Perioperative drug stopping (clobazam - CLB) was needed in 3/38 patients in the HS group, due to sedation. Dosage was reduced in 23/38 (60.52%) in HS group, and in 2/33 (6%) in TL group P < 0.001. The most common drug was CLB, with reduction in 21/27 (77.77%) patients, with a mean reduction of 41.21 ± 4.01%. Two patients required drug substitution in the HS group. About 64/71 (90.1%) patients achieved Class I outcome at a 1-year postoperative time point (TL - 90.9%, HS - 89.47%). There was no change in IQ in any of the groups.

Conclusion

Perioperative drug alteration is often needed in the HS patients as compared to TL patients. Benzodiazepines have to be reduced to maintain alertness in the HS patients. The increased sedation postoperatively can be due to decreased cortical drive over the reticular activating system, gamma-aminobutyric acid (GABA) receptor denervation hypersensitivity, or increased activity of drugs over the remaining active hemisphere.

Drug Refractory Epilepsy - A Series of Lesions with Triple Pathology

The associations between gangliogliomas, dysembryoplastic neuroepithelial tumors (DNETs), and cortical dysplasias remain debatable. We report five cases of drug refractory epilepsy with temporal lobe lesions. On resection, histopathological examination showed distinctive areas of gangliogliomas and DNETs with cortical dysplasia. The coexistence of the above three lesions as distinct entities in a single lesion is virtually unknown. This points to the presence of a possible etiological relationship among them. Finally, we also delve into a plausible hypothesis for such a pathogenesis.

Basilar Invagination and Atlantoaxial Dislocation: Reduction, Deformity Correction and Realignment Using the DCER (Distraction, Compression, Extension, and Reduction) Technique With Customized Instrumentation and Implants

Objective

The technique of distraction, compression, extension, and reduction (DCER) is effective to reduce, realign, and relieve cranio-spinal compression through posterior only approach.

Methods

Study included all patients with atlantoaxial dislocation and basilar invagination (BI) with occipitalized C1 arch. Study techniques included Nurick grading, computed tomography scan to study atlanto-dental interval, BI, hyper-lordosis, and neck tilt. Sagittal inclination (SI), coronal inclination (CI), cranio-cervical tilt, presence of pseudo-joints, and anomalous vertebral artery were also noted. Patients underwent DCER with/without joint remodeling or extra-articular distraction (EAD) based on the SI being <100°, 100°–160°, or >160° respectively. In cases with pseudo-joints, joint remodeling was performed in type I and EAD in type II. Customized ‘bullet shaped’ PSC spacers (n=124) and prototype of the universal craniovertebral junction reducer (UCVJR, n=36) were useful.

Results

A total of 148 patients with average age 27.25±17.43 years, ranging from 3 to 71 years (87 males) were operated. Nurick’s grading improved from 3.14±1.872 to 1.22±1.17 (p<0.0001). Fifty-two percent of total joints (n=154/296 joints) were either type I (19%)/type II (33%) pseudo-j oints. All traditional indices such as Chamberlein line, McRae line, atlanto-dental interval, and Ranawat line improved (p<at least 0.001). BI, SI, and CI values correlated with type of pseudo-joints (p<0.0001). Side of neck tilt correlated with the type of pseudo-joint (p<0.0001). Cervical hyperlordosis improved significantly (p<0.0001).

Conclusion

Occipito-C2 pseudo-joints are important in determining the severity of BI. Asymmetrical pseudo-joint causes coronal/neck tilt. Type of pseudo-joint can strategize by DCER. Customized instruments and implants make technique safe, effective and easier.

Endoscope-assisted (with robotic guidance and using a hybrid technique) interhemispheric transcallosal hemispherotomy: a comparative study with open hemispherotomy to evaluate efficacy, complications, and outcome

OBJECTIVEEndoscope-assisted hemispherotomy (EH) has emerged as a good alternative option for hemispheric pathologies with drug-resistant epilepsy.METHODSThis was a prospective observational study. Parameters measured included primary outcome measures (frequency, severity of seizures) and secondary outcomes (cognition, behavior, and quality of life). Blood loss, operating time, complications, and hospital stay were also taken into account. A comparison was made between the open hemispherotomy (OH) and endoscopic techniques performed by the senior author.RESULTSOf 59 cases (42 males), 27 underwent OH (8 periinsular, the rest vertical) and 32 received EH. The mean age was 8.65 ± 5.41 years (EH: 8.6 ± 5.3 years; OH: 8.6 ± 5.7 years). Seizure frequency per day was 7 ± 5.9 (EH: 7.3 ± 4.6; OH: 15.0 ± 6.2). Duration of disease (years since first episode) was 3.92 ± 1.24 years (EH: 5.2 ± 4.3; OH: 5.8 ± 4.5 years). Number of antiepileptic drugs per patient was 3.9 ± 1.2 (EH: 4.2 ± 1.2; OH: 3.8 ± 0.98). Values for the foregoing variables are expressed as the mean ± SD. Pathologies included the following: postinfarct encephalomalacia in 19 (EH: 11); Rasmussen's syndrome in 14 (EH: 7); hemimegalencephaly in 12 (EH: 7); hemispheric cortical dysplasia in 7 (EH: 4); postencephalitis sequelae in 6 (EH: 2); and Sturge-Weber syndrome in 1 (EH: 1). The mean follow-up was 40.16 ± 17.3 months. Thirty-nine of 49 (79.6%) had favorable outcomes (International League Against Epilepsy class I and II): in EH the total was 19/23 (82.6%) and in OH it was 20/26 (76.9%). There was no difference in the primary outcome between EH and OH (p = 0.15). Significant improvement was seen in the behavioral/quality of life performance, but not in IQ scores in both EH and OH (p < 0.01, no intergroup difference). Blood loss (p = 0.02) and hospital stay (p = 0.049) were less in EH.CONCLUSIONSEH was as effective as the open procedure in terms of primary and secondary outcomes. It also resulted in less blood loss and a shorter postoperative hospital stay.

Early Syringomyelia in Tubercular Meningitis

Tubercular meningitis (TBM) can have various complications. Sometimes syringomyelia can also occur as a late complication of tubercular meningitis. Although syrinx formation in early stage of TBM is very rare. There are only four published case reports of syringomyelia in acute stage of TBM. Here we report a patient with tubercular meningitis who developed syringomyelia in early course of illness.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Endoscopic Vascular Decompression in Trigeminal Neuralgia

AIM

Microscope may fail to detect culprit vessel at the root entry zone or distally, especially when the suprameatal tubercle is prominent and when the compressing vessel is lying anteriorly to the trigeminal nerve without using significant brain retraction. Endoscopic techniques allow better visualization of the nerve and vascular conflict.

MATERIAL AND METHODS

A retrospective study of 178 patients of endoscopic vascular decompression without the use of microscope was done. The follow-up period ranged from 12 to 108 months (average 58 months).

RESULTS

The age of the patients ranged from 32 to 75 years. Neuralgia was in the maxillary, mandibular and both (maxillary and mandibular) divisions in 89, 72 and 16 patients, respectively. Duration of the operation and hospital stay ranged from 85 to 160 minutes and 2 to 10 days (average 2.7 days), respectively. Offending vessels could be identified in 174 patients. The superior cerebellar artery, anterior inferior cerebellar artery, single vessel, double vessel conflicts and a vessel anterior to the nerve were seen in 136, 76, 133, 41 and 31 patients, respectively. The pain was relieved in 167 patients (93.8%). Temporary complications included trigeminal dysesthesias (3.9%), cerebrospinal fluid leak (2.8%), facial paresis (3.9%), decreased hearing (1.7%) and vertigo (3.3%). Permanent hearing loss, recurrence of pain and re-surgery was observed in 1, 7 and 3 patients, respectively.

CONCLUSION

Endoscopic vascular decompression is a safe and effective technique for vascular decompression with advantages of better visualization of the entire course of the nerve and vascular conflict without brain retraction. It also helps in better detection of the completeness of surgery.

Concurrent Intramedullary and Intracranial Tuberculomass

Tuberculosis of the central nervous system (CNS) is well known. CNS involvement can occur in the form of tubercular meningitis (TBM), tuberculous vasculitis, tuberculoma and rarely brain abscess. Tubercular granulomas generally solitary and occur in the brain but they may be multiple and involve other areas such as spinal cord, epidural space and subdural space also. Tuberculoma in the spinal cord is rare. Co-occurrence of intracerebral and intramedullary spinal tuberculoma is extremely rare in children with only few cases reported till date. We are reporting one such case in children and review of literature.

Deep brain stimulation for movement disorders: Surgical nuances

Parkinson's disease (PD) and dystonia are common indications for the deep brain stimulation (DBS) procedure. It is very important to be diligent about target localization and execution of the procedure. The single most important predictor of a good postoperative outcome is proper patient selection. The various steps of performing DBS include taking a preoperative non - stereotactic MRI, stereotactic frame fixation, fusion of MRI with stereotactic CT scan images, planning of the target and trajectory, lead placement at target through the planned trajectory, implantation of pulse generator/ battery and programming of the implanted device. Utmost care and precision are required to execute the procedure, which decide the final outcome of the surgical procedure.

Does surgery help in reducing stigma associated with drug refractory epilepsy in children?

INTRODUCTION

Epilepsy has several comorbidities and associated stigma. Stigma associated with epilepsy is well known and prevalent worldwide. Surgical treatment is an established treatment for drug refractory epilepsy. Following surgery in children, it is possible that the stigma may reduce, but such an effect has not been studied earlier.

MATERIALS AND METHODS

Analysis of prospectively collected data was performed for pediatric patients at a single tertiary center for treating epilepsy. Child stigma scale, as described by Austin et al., was used to evaluate stigma both pre- and postoperatively. Analysis was done using Paired t test.

RESULTS

In this study, following surgery, there was significant reduction of stigma (P<0.001). This was proportional to the reduction in seizures, though there were 9 (30%) patients, who due to persistent neurodisability did not have any reduction of stigma despite having good seizure outcome.

CONCLUSION

Surgery in drug-resistant epilepsy helps in reducing stigma. Seizure reduction is probably not the only factor responsible for a change in stigma outcome.

Whether Superficial Abdominal Reflex is Affected by Subcostal Transverse Abdominal Incisions? A Prospective, Observational Early Experience

Introduction:

Superficial abdominal reflex (SAR) is an important part of the neurologic assessment. It is normally present and may be present or absent in various physiological as well as pathological conditions. The presence of an abdominal incision creates a dilemma in the mind of the clinician for it affecting this reflex. As there is no literature on this, we decided to study the effect of abdominal incisions on SAR.

Materials and Methods:

It was a prospective, observational study. We evaluated the patients requiring transverse subcostal incision (range 3–12 cm) both preoperatively and postoperatively, for their abdominal reflexes. Patients with preoperative normal and symmetrical abdominal reflexes were included in the study. Postoperatively, we compared the change of SAR with the preoperative status and analyzed the data.

Results:

A total of 94 patients underwent surgeries, out of which 54 patients came under inclusion criteria, comprising 36 males and 18 females. Subcostal transverse abdominal incisions were made for surgeries including both gastrointestinal and ventriculoperitoneal shunts. SAR was found unaffected by the incisions in all patients.

Conclusions:

Although the study was small, subcostal transverse abdominal incisions were not found to affect SAR.