Innovations in craniovertebral junction training: harnessing the power of mixed reality and head-mounted displays.

OBJECTIVE: The objective of this study was to analyze the potential and convenience of using mixed reality as a teaching tool for craniovertebral junction (CVJ) anomaly pathoanatomy. METHODS: CT and CT angiography images of 2 patients with CVJ anomalies were used to construct mixed reality models in the HoloMedicine application on the HoloLens 2 headset, resulting in four viewing stations. Twenty-two participants were randomly allocated into two groups, with each participant rotating through all stations for 90 seconds, each in a different order based on their group. At every station, objective questions evaluating the understanding of CVJ pathoanatomy were answered. At the end, subjective opinion on the user experience of mixed reality was provided using a 5-point Likert scale. The objective performance of the two viewing modes was compared, and a correlation between performance and participant experience was sought. Subjective feedback was compiled and correlated with experience. RESULTS: In both groups, there was a significant improvement in median (interquartile range [IQR]) objective performance with mixed reality compared with DICOM: 1) group A: case 1, median 6 (IQR 6-7) versus 5 (IQR 3-6), p = 0.009; case 2, median 6 (IQR 6-7) versus 5 (IQR 3-6), p = 0.02; 2) group B: case 1, median 6 (IQR 5-7) versus 4 (IQR 2-5), p = 0.04; case 2, median 6 (IQR 6-7) versus 5 (IQR 3-7), p = 0.03. There was significantly higher improvement in less experienced participants in both groups for both cases: 1) group A: case 1, r = -0.8665, p = 0.0005; case 2, r = -0.8002, p = 0.03; 2) group B: case 1, r = -0.6977, p = 0.01; case 2, r = -0.7417, p = 0.009. Subjectively, mixed reality was easy to use, with less disorientation due to the visible background, and it was believed to be a useful teaching tool. CONCLUSIONS: Mixed reality is an effective teaching tool for CVJ pathoanatomy, particularly for young neurosurgeons and trainees. The versatility of mixed reality and the intuitiveness of the user experience offer many potential applications, including training, intraoperative guidance, patient counseling, and individualized medicine; consequently, mixed reality has the potential to transform neurosurgery.

Efficacy of antimicrobial medicated ventricular catheters: a network meta-analysis with trial sequential analysis.

There is paucity of evidence regarding relative performance of antibiotic-medicated (AM), silver-medicated (SM) and non-medicated (NM) ventricular catheters in controlling infection rate. We aim to quantitatively synthesize the current evidence after addition of the three-armed British Antibiotic and Silver Impregnated Catheters for ventriculoperitoneal Shunts (BASICS) trial, understand the need for further evidence using trial sequential analysis (TSA) and incorporate the indirect evidence using network meta-analysis (NMA). Randomized controlled trials (RCTs) comparing AM, SM and NM ventriculoperitoneal shunt (VPS) or external ventricular drain (EVD) were included. Antibiotic-medicated VPS show a significantly lower infection rate as compared to non-medicated VPS (RR 0.44; 95% CI: 0.27-0.73; p = 0.001), however, TSA reveals need for further evidence. SM including both EVD as well as VPS were found to be inferior to AM while no significant difference was found in comparison to the NM catheters. In NMA for VPS, the AM were found to be significantly better than SM (RR 0.41, 95% CI: 0.22-0.75) as well as NM (RR 0.42; 95% CI: 0.25-0.71) with a SUCRA of 99.8% and a mean rank of 1. However, antibiotic medicated shunts did not show a statistically significant association with reoperation rate (RR 0.99; 95% CI:0.81-1.20; p = 0.9) with no further need for evidence as per TSA.

Interval assessment using task- and procedure-based simulations: an attempt to supplement neurosurgical residency curriculum.

OBJECTIVE: The longer learning curve and smaller margin of error make nontraditional, or "out of operating room" simulation training, essential in neurosurgery. In this study, the authors propose an evaluation system for residents combining both task-based and procedure-based exercises and also present the perception of residents regarding its utility. METHODS: Residents were evaluated using a combination of task-based and virtual reality (VR)-based exercises. The results were analyzed in terms of the seniority of the residents as well as their laboratory credits. Questionnaire-based feedback was sought from the residents regarding the utility of this evaluation system incorporating the VR-based exercises. RESULTS: A total of 35 residents were included in this study and were divided into 3 groups according to seniority. There were 11 residents in groups 1 and 3 and 13 residents in group 2. On the overall assessment of microsuturing skills including both 4-0 and 10-0 microsuturing, the suturing skills of groups 2 and 3 were observed to be better than those of group 1 (p = 0.0014). Additionally, it was found that microsuturing scores improved significantly with the increasing laboratory credits (R2 = 0.72, p < 0.001), and this was found to be the most significant for group 1 residents (R2 = 0.85, p < 0.001). Group 3 residents performed significantly better than the other two groups in both straight (p = 0.02) and diagonal (p = 0.042) ring transfer tasks, but there was no significant difference between group 1 and group 2 residents (p = 0.35). Endoscopic evaluation points were also found to be positively correlated with previous laboratory training (p = 0.002); however, for the individual seniority groups, the correlation failed to reach statistical significance. The 3 seniority groups performed similarly in the cranial and spinal VR modules. Group 3 residents showed significant disagreement with the utility of the VR platform for improving surgical dexterity (p = 0.027) and improving the understanding of surgical procedures (p = 0.034). Similarly, there was greater disagreement for VR-based evaluation to identify target areas of improvement among the senior residents (groups 2 and 3), but it did not reach statistical significance (p = 0.194). CONCLUSIONS: The combination of task- and procedure-based assessment of trainees using physical and VR simulation models can supplement the existing neurosurgery curriculum. The currently available VR-based simulations are useful in the early years of training, but they need significant improvement to offer beneficial learning opportunities to senior trainees.

Role of CDKN2A deletion in grade 2/3 IDH-mutant astrocytomas: need for selective approach in resource-constrained settings.

OBJECTIVE: The authors aimed to assess the frequency of homozygous CDKN2A deletion in isocitrate dehydrogenase (IDH)-mutant diffuse astrocytomas (grade 2/3) and to narrow down the clinicopathological indications in which the CDKN2A fluorescence in situ hybridization (FISH) assay is cost-effective in resource-constrained settings. METHODS: IDH-mutant astrocytomas were analyzed for ATRX, p53, MIB1-LI, and p16 expression using immunohistochemistry. The FISH assay was used to evaluate CDKN2A deletion and 1p/19q codeletion. Survival outcomes were assessed according to the different molecular markers. RESULTS: A total of 150 adult patients with IDH-mutant grade 2 (n = 95) and grade 3 (n = 55) astrocytomas (145 primary and 5 recurrent) were analyzed. Using a cutoff value of 30% for defining significant homozygous CDKN2A deletion, none of the grade 2 and 10.9% (6/55) of grade 3 astrocytomas showed this deletion (4 primary and 2 recurrent grade 3 tumors) and were reclassified as grade 4. This mutation was more frequent in recurrent (40%, 2/5) than primary (2.76%, 4/145) gliomas. Half (3/6, 50%) of the CDKN2A-deleted cases demonstrated poor outcomes; 2 of these cases experienced recurrence at 12 and 36 months after surgery, and 1 died at 5 months. The majority of CDKN2A-deleted cases showed marked cellularity (100%), pleomorphism (100%), brisk mitosis (83.3%), and tumor giant cell formation (83.4%). None of the cases with retained p16 expression harbored this deletion. Both overall survival (p = 0.039) and progression-free survival (p = 0.0045) were found to be worse in cases with p16 loss. Selectively performing CDKN2A FISH only in high-risk cases with histomorphological features of anaplasia, p16 loss, or recurrent tumors achieved a sensitivity and negative predictive value of 100%. This approach would have resulted in saving 41.1% of the original expenditure ($6900 US per 150 samples) and 27.6 person-minutes per sample without compromising the identification of deleted cases. CONCLUSIONS: Homozygous CDKN2A deletion is conspicuously absent in grade 2 and rare in primary grade 3 IDH-mutant astrocytomas. The authors propose that restricting use of the FISH assay to cases showing histomorphological features of anaplasia, p16 loss, or recurrent tumors will help this platform to be utilized in the most cost-effective manner in resource-constrained settings.

Challenges and prospects of neurosurgical teleconsultations in a developing country: a reality check.

OBJECTIVE: The adoption of telemedicine became a necessity during the COVID-19 pandemic because patients found commuting to be difficult owing to travel restrictions. Initially, audio-based teleconsultations were provided. Later, on the basis of the feedback of patients and caregivers, the authors started to provide video-based teleconsultations via WhatsApp. The authors subsequently surveyed the patients and caregivers to determine their satisfaction levels with telemedicine services. METHODS: An anonymized telephone survey of patients who had participated in teleconsultation was conducted with a structured questionnaire. The responses were analyzed and their correlations with the perceived benefits and limitations of audio and video teleconsultation were determined. RESULTS: Three hundred respondents were included in the first round of surveys, of whom 250 (83.3%) consented to video teleconsultation. Among the respondents who participated in both audio and video teleconsultations (n = 250), paired analysis showed that video teleconsultation was perceived as better in terms of providing easier access to healthcare services (p < 0.001), saving time (p < 0.001), and satisfaction with the way patient needs were conveyed to healthcare providers (p = 0.023), as well as in terms of adequacy of addressing healthcare needs (p < 0.001) and consequently providing a higher rate of overall satisfaction (p < 0.001). For both audio and video teleconsultation, overall patient satisfaction was significantly related to only previous exposure to WhatsApp. However, for video consultation, longer call duration (p = 0.023) was an important independent factor. Video teleconsultation was preferable to face-to-face consultation irrespective of educational status, but higher education was associated with preference for video teleconsultation. CONCLUSIONS: Both audio and video teleconsultation are viable cost-effective surrogates for in-person physical neurosurgical consultation. Although audio teleconsultation is more user-friendly and is not restricted by educational status, video teleconsultation trumps the former owing to a more efficient and satisfactory doctor-to-patient interface.

Spontaneous external rupture of hydrocephalus after fontanelle closure: a case report and review of literature.

We report a 2-year-old child with congenital hydrocephalus who presented with a frontal meningocoele due to ventriculo-subgaleal fistula secondary to hydrocephalus (internal rupture), which gradually ruptured spontaneously through the skin. This case is unique given its association with occipital encephalocele and is only the second case to present with external rupture beyond the age of 1 year. Further, the ventricles have ruptured through the skull, after the closure of anterior fontanelle, into the subgaleal space. It challenges the present understanding that external rupture occurs only through an open anterior fontanelle.

Impact of different visualization devices on accuracy, efficiency, and dexterity in neurosurgery: a laboratory investigation.

OBJECTIVE: Extracorporeal telescopes (exoscopes) have been the latest addition to the neurosurgeons' armamentarium, acting as a bridge between operating microscopes and endoscopes. However, to the authors' knowledge there are no published preclinical laboratory studies of the accuracy, efficiency, and dexterity of neurosurgical training for the use of 2D or 3D exoscopes compared with microscopes. METHODS: In a controlled experimental setup, 22 participating neurosurgery residents performed simple (2D) and complex (3D) motor tasks with three visualization tools in alternating sequence: a 2D exoscope, 3D exoscope, and microscope, using a block randomization model based on the neurosurgeons' prior training experience (novice, intermediate, and senior: n = 6, 12, and 4, respectively). Performance scores (PS; including error and efficiency scores) and dexterity scores (DS) were calculated to objectify the accuracy, efficiency, and finesse of task performance. Repeated measures ANOVA analysis was used to compare the PS, DS, and cumulative scores (CS) of candidates using the three visualization aids. Bland-Altman plots and intraclass correlation coefficients were generated to quantify intraobserver and interobserver agreement for DS. Subgroup analysis was performed to assess the impact of participants' prior training. A postexercise survey was conducted to assess the comfort level (on a 10-point analog scale) of the participants while using each visualization tool for performing the suturing task. RESULTS: PS, DS, and CS were significantly impacted by the visualization tool utilized for 2D motor tasks (p < 0.001 for each), with the microscope faring better than the 2D exoscope (p = 0.04) or 3D exoscope (p = 0.008). The PS for the 3D object transfer task was significantly influenced by the visualization aid used (p = 0.007), with the microscope and 3D exoscope faring better than the 2D exoscope (p = 0.04 for both). The visualization instrument used significantly affected the DS and CS for the suturing task (p < 0.001 for both), with the microscope again scoring better than the 2D exoscope (p < 0.001) or 3D exoscope (p = 0.005). The impact of the visualization aid was more apparent in participants with a shorter duration of residency (novice, p = 0.03; intermediate, p = 0.0004). Participants also felt the greatest operational comfort while working with a microscope, 3D exoscope, and 2D exoscope, in that order (p < 0.0001). CONCLUSIONS: Compared with 3D and 2D exoscopes, an operating microscope provides better dexterity and performance and a greater operational comfort level for neurosurgeons while they are performing 2D or 3D motor tasks. For performing complex 3D motor tasks, 3D exoscopes offer selective advantages in dexterity, performance, and operational comfort level over 2D exoscopes. The relative impact of visualization aids on surgical proficiency gradually weakens as the participants' residency duration increases.

Impact of frailty on surgery for glioblastoma: a critical evaluation of patient outcomes and caregivers' perceptions in a developing country.

OBJECTIVE: The authors aimed to evaluate the impact of age and frailty on the surgical outcomes of patients with glioblastoma (GBM) and to assess caregivers' perceptions regarding postdischarge care and challenges faced in the developing country of India. METHODS: This was a retrospective study of patients with histopathologically proven GBM from 2009 to 2018. Data regarding the clinical and radiological characteristics as well as surgical outcomes were collected from the institute's electronic database. Taking Indian demographics into account, the authors used the cutoff age of 60 years to define patients as elderly. Frailty was estimated using the 11-point modified frailty index (mFI-11). Patients were divided into three groups: robust, with an mFI score of 0; moderately frail, with an mFI score of 1 or 2; and severely frail, with an mFI score ≥ 3. A questionnaire-based survey was done to assess caregivers' perceptions about postdischarge care. RESULTS: Of the 276 patients, there were 93 (33.7%) elderly patients and 183 (66.3%) young or middle-aged patients. The proportion of severely frail patients was significantly more in the elderly group (38.7%) than in the young or middle-aged group (28.4%) (p < 0.001). The authors performed univariate and multivariate analysis of associations of different short-term outcomes with age, sex, frailty, and Charlson Comorbidity Index. On the multivariate analysis, only frailty was found to be a significant predictor for in-hospital mortality, postoperative complications, and length of hospital and ICU stay (p < 0.001). On Cox regression analysis, the severely frail group was found to have a significantly lower overall survival rate compared with the moderately frail (p = 0.001) and robust groups (p < 0.001). With the increase in frailty, there was a concomitant increase in the requirement for readmissions (p = 0.003), postdischarge specialist care (p = 0.001), and help from extrafamilial sources (p < 0.001). Greater dissatisfaction with psychosocial and financial support among the caregivers of severely frail patients was seen as they found themselves ill-equipped to provide postdischarge care at home (p < 0.001). CONCLUSIONS: Frailty is a better predictor of poorer surgical outcomes than chronological age in terms of duration of hospital and ICU stay, postoperative complications, and in-hospital mortality. It also adds to the psychosocial and financial burdens of the caregivers, making postdischarge care challenging.

Perceptions of Indian neurosurgeons about medicolegal issues and malpractice suits.

OBJECTIVE: Despite the rising trend of medicolegal challenges in India, there is an absolute dearth of literature from India on this issue. The authors conducted a survey, to their knowledge a first of its kind, to assess the perceptions of Indian neurosurgeons about the medicolegal challenges faced in everyday practice. METHODS: An anonymous online survey performed using Google Forms was widely circulated among neurosurgeons practicing in India via email and social media platforms. The questionnaire consisted of 38 questions covering the various aspects of medicolegal issues involved in neurosurgery practice. RESULTS: A total of 221 survey responses were received, out of which 214 responses were included in the final analysis, barring 7 responders who had no work experience in India. The respondents were categorized according to their working arrangements and work experience. Out of all of the respondents, 20 (9.3%) had ≥ 1 malpractice suits filed against them. More than 90% of the respondents believed that malpractice suits are on the rise in India. Almost half of the respondents believed the advent of teleconsultation is further compounding the risk of malpractice suits, and 66.4% of respondents felt that they were inadequately trained during residency to deal with medicolegal issues. Most respondents (88.8%) felt that neurosurgeons working in the government sector had lesser chances of facing litigations in comparison to those working in the private sector. The practice of obtaining video proof of consent was more commonly reported by respondents working in freelancing and private settings (45.1%) and those with multiple affiliations (61.3%) compared to respondents practicing in government settings (22.8%) (p < 0.001). Neurosurgeons working in the private sector were more likely to alter management and refer sick patients to higher-volume treatment centers to avoid malpractice suits than their government counterparts (p = 0.043 and 0.006, respectively). The practices pertaining to legal preparedness were also found to be significantly higher among the respondents from the private sector (p < 0.001). CONCLUSIONS: This survey highlights the apprehensions of neurosurgeons in India with regard to rising malpractice suits and the subsequent increase of defensive neurosurgical practices, especially in the private sector. A stronger legal framework for providing for quick redress of patient complaints, while deterring frivolous malpractice suits, can go a long way to allay these fears. There is a dire need for systematic training of neurosurgeons regarding legal preparedness, which should begin during residency.

Outcome following postneurosurgical Acinetobacter meningitis: an institutional experience of 72 cases.

OBJECTIVE: The authors aimed to evaluate the antimicrobial susceptibility pattern of Acinetobacter isolates responsible for nosocomial meningitis/ventriculitis in the neurosurgical ICU. The authors also sought to identify the risk factors for mortality following Acinetobacter meningitis/ventriculitis. METHODS: This was a retrospective study of 72 patients admitted to the neurosurgical ICU between January 2014 and December 2018 with clinical and microbiological diagnosis of nosocomial postneurosurgical Acinetobacter baumanii meningitis/ventriculitis. Electronic medical data on clinical characteristics, underlying pathology, CSF cytology, antibiotic susceptibilities, and mortality were recorded. To evaluate the outcome following nosocomial postneurosurgical Acinetobacter meningitis/ventriculitis, patients were followed up until discharge or death in the hospital. Kaplan-Meier survival analysis and multivariable Cox proportional hazards models were used to compute factors affecting survival. RESULTS: The study population was divided into two groups depending on the final outcome of whether the patient died or survived. Forty-three patients (59.7%) were included in the survivor group and 29 patients (40.3%) were included in the nonsurvivor group. Total in-hospital mortality due to Acinetobacter meningitis/ventriculitis was 40.3% (29 cases), with a 14-day mortality of 15.3% and a 30-day mortality of 25%. The 43 (59.7%) patients who survived had a mean length of hospital stay of 44 ± 4 days with a median Glasgow Outcome Scale-Extended score at discharge of 6. On univariate analysis, age > 40 years (p = 0.078), admission Glasgow Coma Scale (GCS) score ≤ 8 (p = 0.003), presence of septic shock (p = 0.011), presence of external ventricular drain (EVD) (p = 0.03), CSF white blood cell (WBC) count > 200 cells/mm3 (p = 0.084), and comorbidities (diabetes, p = 0.036; hypertension, p = 0.01) were associated with poor outcome. Carbapenem resistance was not a risk factor for mortality. According to a multivariable Cox proportional hazards model, age cutoff of 40 years (p = 0.016, HR 3.21), GCS score cutoff of 8 (p = 0.006, HR 0.29), CSF WBC count > 200 cells/mm3 (p = 0.01, HR 2.76), presence of EVD (p = 0.001, HR 5.42), and comorbidities (p = 0.017, HR 2.8) were found to be significant risk factors for mortality. CONCLUSIONS: This study is the largest case series reported to date of postneurosurgical Acinetobacter meningitis/ventriculitis. In-hospital mortality due to Acinetobacter meningitis/ventriculitis was high. Age older than 40 years, GCS score less than 8, presence of EVD, raised CSF WBC count, and presence of comorbidities were risk factors for mortality.

Outcomes in morbidly obese adolescent patients undergoing laparoscopic sleeve gastrectomy in the Indian subcontinent: A retrospective review.

INTRODUCTION: There is a worldwide increase in the prevalence of obesity among the adolescent population in India from 16.3% in 2001 to 19.3% in 2010. Recent evidence suggests that bariatric surgery leads to resolution of comorbidities and associated long-term complications in adolescent patients with morbid obesity. AIM: The aim of this study is to determine the impact of bariatric surgery on the weight loss and comorbidities of morbidly obese adolescents. MATERIALS AND METHODS: A retrospective review of the data of 10 adolescent patients, who underwent Laparoscopic Sleeve Gastrectomy at our institute (tertiary care hospital), from July 2009 to July 2016 was carried out. RESULTS: Of the 10 patients, 4 patients had syndromic forms of obesity. The median age was 16.54 years. The median pre-operative weight and height were 112 kg and 154 cm, respectively, with a body mass index of 47.2 kg/m2. There was no intra-operative or post-operative complication except for suspected methylene blue toxicity in one patient which was treated conservatively. Median follow-up period was 1 year (0-5 years). The patients had an increase in excess weight loss (EWL) of 54.5% until the end of 1 year. There was a regain of weight between the 1st and 2nd year, followed by a sustained weight loss achieving 44.8% EWL at 3 years and 60% at the end of 5 years (only two patients followed up at 5 years). Similar results were found in syndromic patients. Among the four diabetic patients, three had complete resolution and one had improvement in diabetes status. Among the three patients with obstructive sleep apnoea, two patients had complete resolution, while one patient had improvement in symptoms. One patient with hypocortisolism improved after surgery with a decrease in the steroid requirement. Among the hypothyroid patients, one patient had a complete resolution, one patient had improvement in hypothyroid status while two patients had no change. CONCLUSION: Bariatric surgery is effective for morbidly obese adolescents, leading to significant resolutions of comorbid illness.

Microvascular decompression versus stereotactic radiosurgery as primary treatment modality for trigeminal neuralgia: A systematic review and meta-analysis of prospective comparative trials.

OBJECTIVE: The current opinion among neurosurgeons regarding the selection between microvascular decompression (MVD) and gamma knife radiosurgery for trigeminal neuralgia is not based on clear evidence. In this meta-analysis, we have attempted to synthesize the findings of the prospective trials comparing the efficacy and complications of the two procedures as primary treatment modality for medically refractory trigeminal neuralgia. MATERIALS AND METHODS: The authors performed a systematic review of PubMed for manuscripts comparing the efficacy or complications of MVD and stereotactic radiosurgery for medically refractory trigeminal neuralgia. The data of the identified studies was pooled and a meta-analysis was done. RESULTS: Five prospective studies fulfilling the eligibility criteria were identified. The mean age of the patients subjected to gamma knife therapy (GKT) was more than those who underwent MVD. The initial success rate in the pooled data with MVD was 96% (95% confidence interval [C.I.] 93.3%-98.6%) as compared to GKT which was 71.8% (95% C.I. 64.9%-78.7%) with the ratio of 1.309 (95% C.I. 1.217-1.409; P= <0.001). This superiority was sustained till the last follow up available in all the studies. Out of the complications common to both procedures, MVD had a lower rate of facial numbness, with a risk ratio of 0.481 (95% C.I. 0.297-0.778); and dysesthetic pain, with a risk ratio of 0.470 (95% C.I. 0.172-1.286). CONCLUSIONS: MVD seems to be more efficacious than GKT as a first line treatment for trigeminal neuralgia immediately as well as on a long term basis. However, the dilemma regarding the choice of treatment to be adopted still remains for special subgroups of patients, like the elderly patients and those in whom no vascular compression has been found during surgery. Further studies are needed for elucidating the unequivocal treatment plan under these circumstances.

Clinicoradiological Parameters and Biochemical and Molecular Alterations Predicting Remission and Recurrence After Surgical Treatment of Corticotroph Adenomas-Cushing Disease.

OBJECTIVE: Endonasal endoscopic transsphenoidal surgery (TSS) and resection of pituitary adenomas are considered the gold standard treatment for Cushing disease (CD). Even with various recent advances in management, disease persistence and recurrence are common in these patients. The remission rate in the global population after surgery has been reported to vary widely from 64% to 93%. This study aims to determine the various clinical, biochemical, radiological, and histological factors that correlate with persistence and recurrence in patients with CD. This study also aims to understand the clinicopathological significance of EGFR-MAPK, NF-κB, and SHH pathway activation and to study the protein expression of activation markers of these pathways (i.e., c-Fos, c-Jun, GLI-1, pMEK, NR4A1, and p44) in functioning corticotroph pituitary adenomas. METHODS: From January 2009 to September 2022, the clinical data of 167 patients who underwent surgical treatment (n = 174 surgeries) for CD with a median follow-up of 8.1 years (range, 1-13.29 years) were ambispectively analyzed. The preoperative clinical, biochemical, and radiological features, operative findings, postoperative clinical and biochemical data, and histopathological and molecular profiles were retrieved from the electronic medical records. The patients were followed up to assess their remission status. RESULTS: Among the 174 surgeries performed, 140 were primary surgeries, 22 were revision surgeries, 24 surgeries were for pediatric patients, and 12 surgeries were for patients with Nelson syndrome. In the primary surgery cohort, 74.3% were female, and the average age was 28.73 ± 10.15 years. Of the primary surgery cohort, 75% of the patients experienced remission compared with 47.4% after revision surgery. The remission rate for the pediatric patients was 55.5%. The postoperative day 1 plasma cortisol (P < 0.001; area under the curve, 0.8894; range, 0.8087-0.9701) and adrenocorticotropic hormone (P < 0.001; area under the curve, 0.9; range, 0.7386-1) levels were seen to be strong independent predictors of remission in the primary surgery cohort. The remission rate after endoscopic TSS was greater than that after microscopic TSS in patients undergoing primary surgery (81.08% vs. 57.14%; P = 0.008). The presence of adenoma on histopathological examination (HPE) was also a strong predictor of disease remission (P = 0.020). On stratifying by surgical approach and HPE, microscopically operated patients without histopathological evidence of adenoma had significantly higher odds of nonremission (odds ratio, 38.1; 95% confidence interval, 4.2-348.3) compared with endoscopically operated patients with adenoma found on HPE. A lower immunoreactivity score for NR4A1 was found to correlate with higher remission rates (P = 0.074). However, none of the molecular markers studied (i.e., c-Fos, c-Jun, GLI-1, pMEK, and p44) showed a significant correlation with the preoperative cortisol values. CONCLUSIONS: The remission rate after primary surgery is higher than that after revision surgery and is lower for pediatric patients than for adults. The postoperative day 1 plasma cortisol and adrenocorticotropic hormone levels are strong independent predictors of remission in the primary surgery cohort. An endoscopic approach with histopathological evidence of adenoma is associated with a higher remission rate; thus, endoscopy should be the approach of choice for these patients with the goal of identification of an adenoma on HPE.

Re-Admissions of 'Unknown' Traumatic Brain Injury Patients - Inadequacy of Rehabilitative Services in a Developing Country.

BACKGROUND: In neurosurgical practice, continuous care after discharge and the ability to detect subtle indicators of clinical deterioration are mandatory to prevent the progression of a disease. The care of 'unknown' patients discharged to rehabilitation homes may not have this privilege, especially in resource-poor countries such as India. OBJECTIVE: We have attempted to study the causes and outcomes of re-admissions of 'unknown' patients with previous traumatic brain injury (TBI) to estimate the quality of nursing care in our rehabilitation centers. MATERIAL AND METHODS: The electronic hospital records of all consecutive 'unknown' TBI patients with unplanned re-admissions at our institute from January 2014 to December 2018 were retrospectively reviewed and analyzed for the factors determining the risk and outcomes of re-admission. RESULTS: Out of 245 patients sent to rehabilitation homes at discharge, 47 patients (19.18%) were re-admitted. A total of 33 patients (70%) were re-admitted between 1 month and 1 year. Out of these, 38 patients (80.9%) were re-admitted because of preventable causes. Fifteen patients (31.9%) died during the hospital stay. The rest of the 32 (68%) patients were discharged after the management of the concerned condition with an average hospital stay of 9 ± 11.1 days. The average Glasgow coma scale (GCS) at re-admission of the patients who died was 6 (range 3-11). Two patients were brought in the brain dead status, whereas 20 patients (42.6%) had a GCS of 5 or below at the time of re-admission. The risk of mortality among patients with non-preventable causes was 88.9% (8/9) compared to preventable causes 18.4% (7/38). However, preventable causes for re-admission are much more common, resulting in nearly a similar overall contribution to mortality. CONCLUSIONS: There is a high rate of mortality and morbidity in 'unknown' patients with TBI because of poor post-discharge care in developing countries. Because preventable causes are the major contributor to re-admissions, the re-admission rate is a good indicator of a lack of adequate rehabilitative services. The need for improving the post-discharge management of 'unknown' patients with TBI in resource-poor countries cannot be over-emphasized.