Surgical Management of Extradural Tumors at the Craniovertebral Junction - Insights from a Tertiary Care Center.

BACKGROUND: Craniovertebral junction (CVJ) tumors are challenging due to their unique anatomical location. This study aimed to evaluate the complexities in dealing with such precarious CVJ extradural lesions over the decade. METHODS: Twenty-seven patients of extradural CVJ tumors operated between 2009 and 2018 were included. The demographic details, neurological status, surgical approach, extent of resection, type of fixation, complications, and outcome at final follow-up were recorded for each patient. RESULTS: The mean age of the patients was 39.5 ± 20 years. Most (17/27) of the patients had involvement of a single level. Clivus was the most common (9/17) involved region followed by atlas (7/17) vertebrae. Majority of the patients (13/27) were operated through the posterior-only approach. About 15 patients (55.5%) had instability or extensive lesions that necessitated posterior fixation. None of the patients underwent anterior fixation. Gross and near total excision were achieved in 10 patients (37%) and 3 patients (11%) respectively while 14 patients underwent subtotal excision of tumor. On histopathological analysis, clival chordoma (8/27) was found to be the most common pathology followed by giant cell tumor (6/27), plasmacytoma (4/27), and multiple myeloma (2/27). Most patients (13 out of 27) had the same neurological status after the surgery. Six patients (22%) improved post-operatively with decreased weakness and spasticity. Thirteen (48%) patients underwent adjuvant radiotherapy. CONCLUSIONS: This retrospective study provides valuable insights into managing extradural CVJ tumors and highlights the importance of individualized approaches for optimal outcome.

An assessment of the variation in the practice of lumbar discectomy and its role in axial back pain.

Background: Lumbar discectomy is performed for symptomatic lumbar disc herniation and is one of the most widely performed spinal surgical procedures worldwide in a variety of ways. This survey aimed at providing an overview/perspective of different practice patterns and the impact of lumbar discectomy on axial back pain with or without sciatica. Methods: An online survey was performed using the application "Google Forms." The link to the questionnaire was distributed to neurosurgeons through personal E-mail and social media platforms. Results: We received 333 responses. The largest percentage of responses across five continents was from Asia (66.97%, n = 223). The mean age of the respondents was 40.08 ± 10.5 years. A total of 66 respondents (20%) had a spine practice of 7%-90%, and 28 respondents had a spine practice of 90%-100% (8.4%). The number of respondents who practiced microscopic discectomy using a tubular retractor (n = 143 respondents, 42.9%) was nearly equal to the number of respondents who practiced open discectomy (n = 142 respondents, 42.6%). An almost equal proportion of respondents believed discectomy does not help in relieving axial back pain. Only 20.4% (n = 68) of respondents recommend bed rest for a longer duration postoperatively. Conclusions: Our survey revealed that only 22.2% of spine surgeons recommended discectomy in patients with radiological disc herniation with axial back pain alone and preferred a minimally invasive method of discectomy. Almost half of them believed discectomy to be ineffective for axial low back pain and only a few recommended prolonged bed rest postoperatively.

Intracranial myeloid sarcoma as the first presentation of acute myeloid leukemia and literature review.

INTRODUCTION: Intracranial myeloid sarcoma is a rare extramedullary presentation of acute myeloid leukemia (AML). It can involve the meninges and ependyma presenting as extra-axial mass lesion. Rarely, it can also invade the brain parenchyma. It is commonly seen in children. It is usually misdiagnosed due to its close resemblance to other intracranial tumors (meningioma, metastasis, Ewing's sarcomas, and lymphoma). These are underdiagnosed if they precede the diagnosis of leukemia. CASE REPORT: A 7-year-old boy with isolated intracranial myeloid sarcoma who presented with raised intracranial pressure (ICP) which was successfully managed by surgical excision. CONCLUSION: Isolated intracranial myeloid sarcoma is a rare presentation of AML. Leukemia can be diagnosed early during the postoperative period and can be started on therapy timely. These patients requires regular follow-ups (clinical, laboratory and radiological) to detect relapses early.

Use of Assessment Tools in Cervical Spondylotic Myelopathy-Results of An Anonymized Survey Among Indian Spine Surgeons.

Background: Cervical spondylotic myelopathy (CSM) is the commonest cause of cervical myelopathy. It contributes to high morbidity and consequent economic burden for society. Many measurement tools have been devised to quantify the disease severity, assist in decision-making, and to evaluate the outcome of surgical intervention. Objective: Most of the assessment scales are used for research purposes only and rarely in clinical practice. The purpose of this survey was to check the awareness of spine surgeons about these assessment scales and their role in the management of patients with CSM. Methods: An online questionnaire using the application "Google Forms" made consisting of 10 questions regarding the experience of treating the CSM patients and their preference for various parameters in assessing these patients. Statistical analysis was done using the statistical programming language R. Results: One-hundred and sixty-three responses were analyzed. About 90% of the respondents were aware of the assessment tools and only 57% of them used any in management. Nurick's grade was the most well known among all groups. The commonest reason for surgeons not using any of these assessment scales despite being aware of these scales was their perception that it is very time-consuming to complete these assessment scales. Conclusion: Assessment scales have a role in the management and follow-up of CSM patients. While awareness regarding these tools is well spread, time constraint plays a major role in limiting its usage.

Suprameatal Extension of Retrosigmoid Approach in Microvascular Decompression for Trigeminal Neuralgia with Petrous Endostosis: Case Report and Literature Review.

Petrous endostosis or prominent suprameatal tubercle is a rare entity which may prevent adequate microscopic exposure of the trigeminal nerve root entry zone during microvascular decompression (MVD) for trigeminal neuralgia. We present a rare case of trigeminal neuralgia (TN) with petrous endostosis, which was managed adequately by partial removal of the prominent suprameatal tubercle to improve the obscured site of neurovascular conflict and enabled complete MVD. Through this manuscript, we additionally discuss the nuances involved in this extension of the standard retrosigmoid approach in light of the published literature. Petrous endostosis encountered during MVD for TN can impose an operative challenge. Suprameatal extension of the standard retrosigmoid approach improves exposure at the site of neurovascular conflict but requires utmost care and attention to avoid complications. We emphasize recognizing this anatomical variation in the preoperative period to predict an operative difficulty, ensure appropriate patient counselling, and avoiding surgical complications.

Effect of topical and intraventricular antibiotics used during ventriculoperitoneal shunt insertion on the rate of shunt infection-a meta-analysis.

INTRODUCTION: The ventriculoperitoneal shunt is one of the most commonly performed neurosurgical procedures. One of the avoidable complications of shunt surgery is shunt infection. This PRISMA-compliant meta-analysis analysed the effectiveness of topical and/or intraventricular antibiotics in preventing shunt infections in patients undergoing shunt surgery. METHODS: Four databases were searched from inception to 30th June 2021. Only original articles comparing the rate of shunt infection with and without antibiotics were included. Random-effects meta-analysis was used to compare the effect of the use of antibiotics in preventing infection and subgroup analysis for finding differences in various antibiotics. RESULTS: The rate of shunt infection was 2.24% (53 out of 2362) in the topical antibiotic group in comparison to 5.24% (145 out of 2764) in the control group (p = 0.008). Subgroup analysis revealed that there is no significant difference between the antibiotics used. CONCLUSIONS: Our meta-analysis found that the risk of shunt infection is significantly reduced with the use of topical and intraventricular antibiotics without any serious adverse effect. No side effects of topical or intraventricular antibiotics were reported in the included studies. Further prospective studies are required to establish the safety and optimal dosage of topical antibiotics for them to be used routinely in neurosurgical practice. They can be used in patients at high risk of developing shunt infections till such studies are available.

Lessons learned during covid-19 pandemic, a worldwide survey: evolution of global neurosurgical practice.

BACKGROUND: During the COVID-19 pandemic, a multitude of surveys have analyzed the impact virus spreading on the everyday medical practice, including neurosurgery. However, none have examined the perceptions of neurosurgeons towards the pandemic, their life changes, and the strategies they implemented to be able to deal with their patients in such a difficult time. METHODS: From April 2021 to May 2021 a modified Delphi method was used to construct, pilot, and refine the questionnaire focused on the evolution of global neurosurgical practice during the pandemic. This survey was distributed among 1000 neurosurgeons; the responses were then collected and critically analyzed. RESULTS: Outpatient department practices changed with a rapid rise in teleservices. 63.9% of respondents reported that they have changed their OT practices to emergency cases with occasional elective cases. 40.0% of respondents and 47.9% of their family members reported to have suffered from COVID-19. 56.2% of the respondents reported having felt depressed in the last 1 year. 40.9% of respondents reported having faced financial difficulties. 80.6% of the respondents found online webinars to be a good source of learning. 47.8% of respondents tried to improve their neurosurgical knowledge while 31.6% spent the extra time in research activities. CONLCUSIONS: Progressive increase in operative waiting lists, preferential use of telemedicine, reduction in tendency to complete stoppage of physical clinic services and drop in the use of PPE kits were evident. Respondents' age had an impact on how the clinical services and operative practices have evolved. Financial concerns overshadow mental health.

Hybrid Workshops During the COVID-19 Pandemic-Dawn of a New Era in Neurosurgical Learning Platforms.

BACKGROUND: During the COVID-19 pandemic, disruption of surgical hands-on training has hampered the skills acquisition by budding neurosurgeons. Online and virtual classrooms have not been able to substitute the hands-on experience and learning via direct interaction with senior colleagues. To overcome these challenges, we organized a hybrid workshop where simulation-based learning modules, and direct and virtual interaction with surgeons during live surgeries or didactic lectures were utilized to help delegates in understanding the nuances of neurosurgery. METHODS: A 3-day hybrid workshop was held in March 2021, which was attended by 133 delegates. A structured questionnaire was utilized to record their feedback. RESULTS: An overwhelming majority of the respondents (94.1%, n = 64) found hybrid conferences to be better than an online conference. Most of the respondents (88.3%, n = 60) rated the utility of direct face-to-face interaction to be more satisfying as compared with online interaction with faculty during a webinar. Again, many the respondents (86.8%, n = 59) believed that similar hybrid events will be the new normal given the current situation of COVID-19 pandemic. A large majority (88.2%, n = 60) of the respondents reported that they will prefer a hybrid event over an online conference. CONCLUSIONS: In this era of the COVID-19 pandemic, "hybrid" microneurosurgery workshops offer unique opportunities to enhance surgical skills acquisition by hands-on simulation-based learning and observing live surgical demonstrations, apart from 2-way interactions with experts under one roof. This may be a stepping stone for what lies ahead in the future of neurosurgical training.

Perinatal mental health in India: protocol for a validation and cohort study.

BACKGROUND: Common mental disorders (CMD) are among the largest contributors to global maternal morbidity and mortality. Although research on perinatal mental health in India has grown in recent years, important evidence gaps remain, especially regarding CMD. Our study aims to improve understanding of CMD among perinatal and non-perinatal women of reproductive age across two settings in India: Bangalore (Karnataka) and Tanda (Himachal Pradesh). METHODS: The study is embedded within the Maternal and Perinatal Health Research Collaboration India (MaatHRI). This mixed-methods observational study comprises three consecutive phases: (i) focus group discussions and individual interviews to explore women's knowledge and seek feedback on CMD screening tools; (ii) validation of CMD screening tools; and (iii) prospective cohort study to identify CMD incidence, prevalence and risk factors among perinatal and non-perinatal women. Results of the three phases will be analyzed using inductive thematic analysis, psychometric analysis and multivariable regression analysis, respectively. CONCLUSION: Improving understanding, detection and management of CMD among women is key to improving women's health and promoting gender equality. This study will provide evidence of CMD screening tools for perinatal and non-perinatal women in two diverse Indian settings, produce data on CMD prevalence, incidence and risk factors and enhance understanding of the specific contribution of the perinatal state to CMD.

Effect of statins on functional outcome and mortality following aneurysmal subarachnoid hemorrhage - Results of a meta-analysis, metaregression and trial sequential analysis.

OBJECTIVE: Cerebral vasospasm (CVS) and delayed ischemic neurological deficits (DIND) are a common cause of morbidity following aneurysmal subarachnoid hemorrhage (SAH). Statins have been shown to decrease CVS. The objective of this article was to ascertain the effect of statins on functional outcome and mortality following aneurysmal SAH by performing meta-analysis. METHODS: A comprehensive search of different databases was performed to retrieve randomized controlled trials. Meta-analysis with subgroup analysis and metaregression was done. Trial sequential analysis (TSA) was performed to determine if the cumulative sample size was appropriately powered for the obtained pooled effect values and to avoid random error. RESULTS: Twelve articles were selected for meta-analysis. Pooled OR for the change in favorable outcome, mortality, CVS, DIND and elevated transaminases was 1.07 (p = 0.55), 0.78 (p = 0.17), 0.58 (p = 0.0004), 0.54 (p = 0.0293) and 0.68 (p = 0.1774) respectively. Further, subgroup analysis and metaregression showed that the use of different statin or dose did not result in significant variation in results in the parameters studied. TSA showed that more trials and patients are required to reach to a definitive conclusion regarding any effect on statins on functional outcome and mortality as the current studies neither reached the level of confidence nor crossed the futility boundary. CONCLUSION: Use of statins in patients with aneurysmal SAH resulted in marginal but non-significant favorable impact on functional outcome and mortality. TSA showed that more studies are required to get conclusive evidence in this regard.

Management Dilemma in A Rare Case of Bilateral Temporo-Insular Glioma.

Multicentric gliomas are uncommon pathological entities, although well described in the literature. The aim of this study was to highlight the management issues in a rare case of multicentric glioma occurring in a bilateral temporo-insular region. A 35-year-old farmer with no comorbid illness presented with a history of progressively increasing holocranial headaches, intermittent episodes of vomiting, and memory disturbances from the last 3 months. Radiological findings were suggestive of multicentric glioma involving bilateral temporo-insular regions. Patient underwent tumor decompression first on the left side followed by the right side. Postoperative course was uneventful. Management of multicentric gliomas is challenging.

Enlarging cervical vertebral pneumatocyst - A case report.

Intraosseous pneumatocyst refers to gas-filled cystic lesions inside bone. Vertebral pneumatocysts are rare and most have been described to remain static over time. We report a rare case of an enlarging spinal pneumatocyst. A 58-year-old male patient with cervical ossified posterior longitudinal ligament with two cervical vertebral pneumatocysts (C4 and C5). The C5 cyst (9.91 × 5.9 × 4.3 mm) was larger than the C4. MRI was suggestive of compression at C4-5 and C5-6 level. Repeat imaging done eight months later showed an increase in the size of the C5 pneumatocyst (12.41 × 7.6 × 6.3 mm). In view of the enlarging pneumatocyst, patient underwent C5 corpectomy. Histopathological examination of the cyst wall revealed fibro-collagenous tissue with histiocytes and foreign body giant cells confirming the benign nature of the disease. This case highlights the importance of radiological follow up of a pneumatocyst.

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

Background Neurological patients who are ventilator-dependent occupy scarce beds in the hospitals for prolonged periods of time. Most, if not all, can be discharged on home mechanical ventilation (HMV). However, due to lack of insurance and state support, it remains prohibitively expensive for the vast majority of those who require it most. Materials and Methods The authors discuss three patients admitted in the Department of Neurosurgery between January and August 2019, who were discharged on HMV after remaining on ventilator support for prolonged period in the hospital. Each patient was discharged with two units (one as standby) of AgVa home ventilator (AgVa Healthcare; New Delhi, India), one Ambu-bag, one pulse oximeter, and one backup power supply unit capable of supplying power to ventilator for a minimum of 24 hours. All the equipment were given free-of-cost through donations by hospital staffs and other donors. All patients were followed up telephonically from their homes and the incidence of complications, ventilator malfunction, and additional cost of HMV on the families were ascertained. Observation and Results Of the three patients, two were male and one female. Age ranged from 12 to 17 years. The duration of in-hospital ventilator support prior to discharge on HMV varied from 1 to 5 years. There was no insurance cover available for any of the patients with all expenses being "out of pocket." The equipment cost Indian Rupees (INR) 115,700 (USD 1,615: two units of AgVa home ventilator costing INR 100,000 [USD 1,396], one Ambu-bag costing INR 1,100 [USD 15], one pulse oximeter costing INR 1,600 [USD 22], and one backup power supply unit costing INR 13,000 [USD 182]). Discharge on HMV was planned on specific request from patients' families and informed consent was taken from all. All patients had tracheostomies. Mode of HMV was pressure support ventilation in all. Telephonic follow-up ranged from 1 to 7 months. The cost of disposables was INR 100 per month (USD 0.7) for all the patients. No complications occurred in any patient. There was no incidence of ventilator-associated pneumonia (VAP) or ventilator malfunction. Conclusions Availability of cost-effective indigenous ventilator like AgVa home has made HMV possible, even for poor patients with neurological diseases, and has the potential to improve quality of life, decrease VAP rates, and free up scarce ventilator beds in hospitals. Longer-term follow-up in larger number of patients will improve the data on safety and feasibility in developing countries like India.

An institutional review of 10 cases of spinal hemangiopericytoma/solitary fibrous tumor.

BACKGROUND: Spinal hemangiopericytoma is very rare tumors with only a few case reports and one case series. We have treated ten patients between 2004 and 2017 and, thus, present a retrospective review of our patients with a focus on clinical presentation, radiological features, management, pathology, and outcome. MATERIALS AND METHODS: Histopathological data were reviewed in all the cases and clinical and follow-up details were collected from data available in our department. RESULTS: There were five males and five females, including one pediatric patient. The mean age of the patients was 34.7 years (Range 12-52 years). Dorsal, cervical, and lumbar spine involvement were found in five, four, and one patient, respectively. Intradural extramedullary tumor was the most common tumor and all patients presented motor weaknesses. Gross total resection of the tumor was done in seven patients and six patients received postoperative radiotherapy. Histopathology showed anaplastic tumor in two cases with high MIB-1 labelling index. Most patients were positive for CD34, vimentin, mic-2, and bcl-2. While the seven patients who underwent gross total resection improved significantly and were self-ambulatory in the follow-up period, two patients who underwent subtotal resection expired due to tumor metastasis. CONCLUSION: Spinal hemangiopericytoma is a very rare tumor. We present a series of cases treated at our institute for the same. Gross total resection is the goal and radiotherapy should be given in case of residual tumor or high-grade tumors. Prognosis is good after gross total excision and functional recovery can be expected in most patients.

Management of Pediatric Posterior Circulation Aneurysms-12-Year Single-Institution Experience.

BACKGROUND: Pediatric posterior circulation aneurysms are rare, complex, poorly understood lesions on which only limited literature is currently available. We report our 12-year experience of managing this condition to enhance knowledge of this rare entity. METHODS: Patients <18 years old with posterior circulation aneurysms managed at our institution from January 2005 to April 2017 were included. Demographic, clinical, radiologic and management details were retrieved from hospital records and characteristics of the aneurysms and treatment were analyzed. RESULTS: During this period, 20 pediatric patients (male-to-female ratio 15:6; mean age, 13.1 years) with posterior circulation aneurysms were treated. Most of the patients (75%) presented with subarachnoid hemorrhage. The most common location was the vertebrobasilar junction and vertebral artery (31.81%) followed by the basilar artery and the posterior cerebral artery (27.72% each). Dissecting (81.8%) and large (63.63%) aneurysms were the most common types noted. Of the15 patients with 22 aneurysms treated, 13 underwent endovascular management (parent vessel sacrifice in 8 aneurysms and parent vessel preservation in 5 aneurysms), 1 patient underwent surgery, and 1 patient received medical management for central nervous system tuberculosis. During follow-up, 1 patient had recurrence of aneurysm, and 1 patient died after discharge from the hospital. Overall good outcome was recorded in 90% of patients (Glasgow Outcome Scale score 4-5). CONCLUSIONS: Vertebrobasilar junction and vertebral artery was the most common location for posterior circulation aneurysms and most were dissecting aneurysms. Endovascular treatment was the mainstay of management. Overall good outcome was observed at long-term follow-up.

Randomized controlled study comparing the efficacy of rapid and slow withdrawal of antiepileptic drugs during long-term video-EEG monitoring.

OBJECTIVE: Antiepileptic drugs (AEDs) are routinely withdrawn during long-term video-electroencephalography (EEG) monitoring (LTM), to record sufficient number of seizures. The efficacy of rapid and slow AED taper has never been compared in a randomized control trial (RCT), which was the objective of this study. METHODS: In this open-label RCT, patients aged 2-80 years with drug-resistant epilepsy (DRE) were randomly assigned (1:1) to rapid and slow AED taper groups. Outcome assessor was blinded to the allocation arms. Daily AED dose reduction was 30% to 50% and 15% to <30% in the rapid and slow taper groups, respectively. The primary outcome was difference in mean duration of LTM between the rapid and slow AED taper groups. Secondary outcomes included diagnostic yield, secondary generalized tonic-clonic seizure (GTCS), 4- and 24- hour seizure clusters, status epilepticus, and need for midazolam rescue treatment. The study was registered with Clinical Trial Registry-India (CTRI/2016/08/007207). RESULTS: One hundred forty patients were randomly assigned to rapid (n = 70) or slow taper groups (n = 70), between June 13, 2016 and February 20, 2017. The difference in mean LTM duration between the rapid and slow taper groups was -1.8 days (95% confidence interval [CI] -2.9 to -0.8, P = .0006). Of the secondary outcome measures, time to first seizure (2.9 ± 1.7 and 4.6 ± 3.0 days in the rapid and slow taper groups respectively, P = .0002) and occurrence of 4-hour seizure clusters (11.9% and 2.9% in the rapid and slow taper groups, respectively, P = .04) were statistically significant. None of the other safety variables were different between the 2 groups. LTM diagnostic yield was 95.7% and 97.1%, in rapid and slow taper groups respectively (P = .46). SIGNIFICANCE: Rapid AED tapering has the advantage of significantly reducing LTM duration over slow tapering, without any serious adverse events.

Role of concordance between ictal-subtracted SPECT and PET in predicting long-term outcomes after epilepsy surgery.

OBJECTIVE: F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) and ictally subtracted single photon emission tomography (iSPECT) are important for localizing the epileptogenic focus. The following study analyzes the role of inter-concordance between FDG-PET and iSPECT in predicting long-term outcomes after epilepsy surgery. METHODS: We prospectively evaluated (January 2003-January 2008) patients undergoing surgery for temporal or extratemporal drug refractory epilepsy (DRE) who had at least a 5 years follow up. Patients with MRI and video EEG (vEEG) concordance for the seizure focus underwent iSPECT and FDG-PET. Concordance of the iSPECT and FDG-PET with each other and with the substrate (defined by MRI and vEEG) for temporal and extra-temporal epilepsies was evaluated and correlated with outcomes. RESULTS: One hundred twenty-three patients (74 males) were included in the study (mean age at time of surgery: 18.9±10.41 years). The mean age of onset of seizures was 9.87±8.37 years. The most common semiology was complex partial (45%). When both FDG-PET and iSPECT were concordant with each other, this translated into a (class I Engel at 5 years) outcome of 62% for extra-temporal epilepsies (provided they were also concordant with the lesion, as defined by MRI and vEEG). This percentage was significant (p<0.01) compared with all other situations (both FDG-PET/iSPECT not concordant to MRI/vEEG, only PET or iSPECT concordant with MRI/vEEG). This correlation was not found for the temporal epilepsies, where the MRI and vEEG were the most important prognostic parameters. In both temporal and extratemporal epilepsies the concordance of the iSPECT/FDG-PET with the MRI/vEEG correlated with a better 5-year outcome (temporal: 70% vs 25%; extra-temporal: 62% vs 33%; p<0.05). SIGNIFICANCE: Concordance between non-invasive investigations iSPECT and FDG-PET is an important predictive factor for surgical outcomes in extra-temporal epilepsy.

Role of simvastatin in prevention of vasospasm and improving functional outcome after aneurysmal sub-arachnoid hemorrhage: a prospective, randomized, double-blind, placebo-controlled pilot trial.

BACKGROUND: Vasospasm plays a major role in the morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The preliminary studies suggest that statins protect against cerebral vasospasm. OBJECTIVE: The aim of the study was to determine the role of simvastatin in preventing clinical vasospasm and improving functional outcome in patients with aSAH. METHODS: All patients with aSAH admitted within 96 h of ictus were randomized to receive either Simvastatin or placebo - 80 mg/day for 14 days. Thirty eight patients were recruited in the study- 19 received Simvastatin and 19 placebo. All the patients underwent surgical clipping of the aneurysm. The primary outcome of the study was the development of clinical cerebral vasospasm. The secondary outcomes included Glasgow Outcome Score (GOS), Modified Rankin Scale (MRS) and Barthel Index Score (MBI) at follow-up at 1, 3 and 6 months. RESULTS: 16% of the patients in the simvastatin group had high Middle Cerebral Artery velocities (> 160 cm/sec) on transcranial Doppler on one or more than one day during the study duration as compared to 26% of the patients in the placebo group (p = 0.70). Neurological deterioration occurred in 26% and 42% of the patients in simvastatin group versus placebo group, respectively (p = 0.31). There was an improvement in the functional outcome in the simvastatin group at 1, 3 or 6 months in the follow-up; however, this difference was not statistically significant. CONCLUSIONS: There was benefit of simvastatin in terms of reduction in clinical vasospasm, mortality or improved functional outcome, however, this was not statistically significant.