Comparison of propofol and desflurane for postoperative neurocognitive function in patients with aneurysmal subarachnoid hemorrhage: A prospective randomized trial.

Background: Following aneurysmal subarachnoid hemorrhage, 40-50% of survivors experience cognitive dysfunction, which affects their quality of life. Anesthetic agents play a pivotal role in aneurysm surgeries. However, substantial evidence regarding their effects on neurocognitive function is lacking. This study evaluated the effects of propofol and desflurane on postoperative neurocognitive function and serum S-100B levels. Methods: One hundred patients were equally randomized to receive either propofol (Group P) or desflurane (Group D). Cognitive function was assessed using the Montreal Cognitive Assessment scale at three different time points: Preoperatively, at the time of discharge, and one month after surgery. Perioperative serum levels of S-100B were also measured. Results: The preoperative mean cognitive score in Group P was 21.64 + 4.46 and in Group D was 21.66 + 4.07 (P = 0.79). At discharge, a significant decrease in cognitive scores was observed compared to preoperative scores (Group P- 20.91 + 3.94, P = 0.03 and Group D-19.28 + 4.22, P = 0.00); however, scores were comparable between the two groups (P = 0.09). One month following surgery, mean cognitive scores were 22.63 + 3.57 in Group P and 20.74 + 3.89 in Group D, and the difference was significant (P = 0.04). Higher memory and orientation scores were observed in Group P than in Group D at one month (P < 0.05) in the subgroup analysis. Both groups had similar serum S-100B levels. Conclusion: The mean cognitive scores one month after surgery improved significantly with propofol compared with desflurane, but without clinical significance. Individual domain analysis demonstrated that orientation and memory scores were better preserved with propofol.

Sex differences in cognitive function among people with HIV-1 clade C infection in Northern India.

Human immunodeficiency virus-1 (HIV-1) clade C is the most prevalent form of HIV-1 comprising nearly 46% of global infections and is the dominant subtype in India. Despite its predominance, the impact of HIV-1 clade C infection on cognitive function has been understudied in comparison with other subtypes, notably clade B, which is primarily found in Europe and North America. Few studies have assessed cognitive impairment in antiretroviral therapy (ART) naïve men and women with HIV-1 clade C infection. In this study conducted in Northern India, differences in neuropsychological functioning were compared between 109 participants (70 men, 39 women) with untreated HIV-1 clade C infection and 110 demographically matched healthy controls (74 men, 36 women). A comprehensive neuropsychological battery was used to examine depression, self-assessment of functioning, and cognitive performance in six domains of functioning. Group differences were assessed by HIV-1 status and sex, controlling for age and education. Results indicated that cognitive deficits were substantially greater among male participants with HIV-1 clade C compared to male controls in all domains of cognitive functioning; in contrast, women with HIV-1 clade C had only minor deficits compared to healthy female participants. In addition, a larger proportion of men with HIV-1 clade C exhibited high levels of depression than women with HIV-1 clade C. These findings suggest that untreated HIV-1 clade C infection in men can have debilitating effects on neuropsychological function and depression, and stress the importance of facilitating rapid access to treatment to reduce the impact of HIV-1 infection.

Morphology of intra tumoral cystic vestibular schwannoma and their response to gammaknife radiosurgery.

BACKGROUND: Cystic vestibular schwannoma (CVS) traditionally considered as poor responder to gammaknife radiosurgery (GKRS). Their longterm radiobiological behavior is less known. Here we discuss 38 cases with intra tumoral cyst CVS primarily treated with GKRS. Tumor morphology was assessed to understand their response to GKRS. METHODS: Total 38 patients(21 male and 17 female with median age of 41.7 years) of CVS treated with GKRS were retrospectively analysed. Tumors were divided as predominantly (greater than50% of total tumor volume) cystic or solid. They were subclassified as type 1 (predominantly cystic CVS, single cyst), type 2 (predominantly solid CVS, single cysts), type 3 (multicystic CVS). The entire cyst was incorporated for radiosurgery. The results were compared with volume matched control of 58 solid tumors(SVS). RESULT: The median tumor volume of CVS was 5.8 cc. The median tumor volume reduction was 44.5 % at a median follow-up of 68.5 months (30-110 months). Median tumor volume reduction was 68.5 %, 34.0%, 11.0.%, 30.5% at a median follow up of 52.5months, 66 months, 78.6 months, 96.5 months for type 1 CVS, type 2 CVS, type 3 CVS and SVS respectively. One patient with multicystic CVS showed increased tumor volume and expired after 9 months of surgery.The tumor volume reduction in type 1CVS was statistically significant as compared to type 3 CVS and SVS. However the tumor volume reduction among other groups did not differ significantly. CONCLUSION: Intra tumoral cystic components respond better to gammaknife radiosurgery in CVS. Tumor with single cyst respond better than multicystic vestibular schwannoma.

Decompressive Hemi Craniectomy in Malignant Middle Cerebral Artery Infarction: Adding Years of Quality Life or Mere Existence?

Background: In spite of advancements in treatment options for MCA infarct, there is a definite role of decompressive hemicraniectomy. When compared with best medical management, it decreases mortality and improves functional outcome. But does surgery improve quality of life in terms of independence, cognition or it merely leads to increased survival? Objective: Outcome of 43 consecutive patients of MMCAI who underwent DHC was studied. Materials and Methods: Functional outcome was evaluated based on mRS and GOS in addition to survival advantage. The patient's proficiency in performing ADL was evaluated. MMSE and MOCA were performed to evaluate the neuropsychological outcome. Results: In-hospital mortality was 18.6%, and by 3 months, 67.5% of patients survived. During follow-up, nearly 60% of patients showed improvement in functional outcome when evaluated based on mRS and GOS. No patient could reach to the level of independent existence. Only eight patients could perform MMSE and five had good score (>24). All were young and had a right-sided lesion. None of the patients could perform well in MOCA. Conclusion: DHC improves survival and functional outcome. Cognition remains poor in the majority of the patients. These patients, though survive the stroke, remain dependent on care givers.

Simple CaroTID-VasC score to predict one-year risk of stroke in symptomatic carotid stenosis patients.

BACKGROUND: A subset of extracranial symptomatic carotid stenosis (ESCS) patients may fare well on current optimal medical therapy (OMT), and surgery may be avoided in these patients. Therefore, we aimed to develop and validate a stroke risk prediction model to stratify the risk among ESCS patients. METHODS: Adult ESCS patients who denied revascularization procedures were enrolled prospectively and prescribed OMT. Patients were followed-up for twelve months after assessing the clinical, imaging, and hemodynamics-based risk predictors at baseline. Cox regression analysis was performed on predictors which were significant in univariate analysis. Beta coefficients of significant predictors in Cox regression were used to generate a numeric score. The model was internally validated using bootstrapping. RESULTS: A total of 20 (20.2%) out of 99 patients had event recurrence during the follow-up. Transient ischemic attack index event (P = 0.014), diabetes mellitus (P = 0.018), contralateral significant stenosis (P = 0.007), echolucent plaque (P = 0.011), and impaired vasomotor reactivity (P = 0.006) were significant predictors in Cox regression analysis. A points score (0-6) was derived from regression coefficients of the significant predictors. The area under ROC was 0.884 for the developed model and 0.832 for the bootstrapped model. Youden's index divided the score into low-risk (2.2%) and high-risk (35.8%) groups, and the difference in risk was significant (P < 0.001). CONCLUSIONS: Most ESCS patients benefited from OMT, and the CaroTID-VasC score was effective in stratifying patients for risk of endpoint occurrence. The developed model may help identify high-risk subgroups of ESCS patients and assist the decision-making of carotid interventions.

Magnetic Resonance Tractography and Intraoperative Direct Electrical Stimulation in Eloquent Area Glioma Surgery for 102 Cases: A Tertiary Care Center Experience From Northwest India.

OBJECTIVE: Surgery of eloquent area gliomas is challenging and requires monitoring of the nearby white fiber tracts. In the present study, we analyzed 102 patients with eloquent region gliomas and discussed the concept of intraoperative dynamic white fiber tract navigation and monitoring. METHODS: A total of 102 patients with an eloquent area glioma (52 insular, 29 motor area, 21 temporoparietal) were evaluated. The position of the white fiber tracts (corticospinal tract [or motor fiber; CST], inferior fronto-occipital fasciculus [ventral language fiber; IFOF], superior longitudinal fasciculus [SLF], and arcuate fasciculus [dorsal language fiber; AF) was recorded. Awake mapping of the cortical and subcortical eloquent structures was performed for all 102 patients. The suction stimulator was coregistered and used as a dynamic stimulator navigator. RESULTS: Of the 102 patients, 60 were men and 42 were women, with an average age of 39.8 years. Most of the white fiber tracts were normal (CST, 31.3%; IFOF, 39.2%; SLF/AF, 40.19%) or displaced (CST, 59.8%; IFOF, 47.05%; AF/SLF, 44.11%). A few were disrupted (CST, 8.8%; IFOF, 13.7%; SLF/AF, 15.7%). The extent of tumor resection was 82.8%, 86.5%, and 94% for those with insular glioma, motor area glioma, and temporoparietal glioma, respectively. Of the 102 patients, 18 had developed transient speech and language disturbances with improvement, and 14 had developed motor deficits, of whom, all except for 2, had shown gradual improvement. When the dynamic suction stimulator navigator was used, the extent of resection was 96.5%, without any added deficits. CONCLUSIONS: The use of intraoperative neuronavigation and neurophysiological assessment can help achieve maximal tumor resection of eloquent area gliomas. Use of the integrated suction stimulator navigator provided dynamic navigation and mapping of the peritumoral eloquent fibers.

Neuropsychological Differences between the Unilateral and Bilateral Tinnitus Participants with Normal Hearing.

INTRODUCTION: This paper attempts to describe the neuropsychological differences between subgroups of tinnitus with normal hearing. METHODS: The study compared 150 normal-hearing participants with and without tinnitus in the 18-55 age-group. The participants completed nine neuropsychological tests, namely, Rey's auditory verbal learning test (RAVLT), Rey complex figure test (RCFT), digit vigilance test (DVT), Verbal N-back test (N Back), controlled oral word association test (COWA), animal names test (ANT), digit symbol substitution test (DSST), Wechsler digit span test (DST), and Stroop test. RESULTS: Poor verbal memory was demonstrated by a unilateral tinnitus group (p = 0.0001) for the total RAVLT score, immediate score, delayed recall, hits, and omissions). Significant deficits were observed in working memory functioning by the unilateral and bilateral tinnitus participants (p < 0.001) for one-back and two-back hit and error scores). In addition, there was a significant impairment in the auditory attention of single-sided tinnitus participants (p < 0.03, 0.02). Selective attention was affected in bilateral tinnitus participants (p < 0.05). DISCUSSION/CONCLUSION: Tinnitus, whether unilateral or bilateral, has an effect on working memory. The RAVLT and DST results, on the other hand, demonstrated that unilateral tinnitus suffers from significant deficits in auditory memory and attention, whereas bilateral tinnitus suffers from selective attention issues. When treating individuals with unilateral and bilateral tinnitus, these findings must be addressed.

Surgical Outcome Analysis of Large and Giant Petroclival Meningiomas with Special Reference to Quality of Life Issues.

Background: Management strategies for petroclival menigiomas remain controversial. Objectives: We share our experience in management of large and giant true petroclival meniongiomas with special emphasis on patient reported quality of life parameters. Methods: This is a single center study of 47 patients between 2008 and 2018. All patients were checked for tumor specific parameters, clinical parameters, extent of surgical excision, and outcome, as assessed by Karnofsky performance score (KPS), Glasgow outcome score, clinical status, and by SF-36 questionnaire. Results: 32/47 patients' data were assessed. Symptoms included headache (62.5%), involvement of 5th nerve (47%), facial nerve (40.6%), lower cranial nerves (37.5%), cerebellar signs (84%), and long tract signs in (50%) of patients. The mean preoperative KPS was 83.75+/-6.59. Surgical approaches included retromastoid suboccipital craniotomy (50%), Kawase's approach (31.25%), and others in 18.25% patients. 40.625% (n = 13) had a gross total excision, near total resection (NTR) was achieved in 53.125% (n = 17), and 6.25% (n = 2) had a subtotal excision (STE). In 13 patients who had gross total resection (GTR), there were 12 (70.5%) new neurological deficits, while among the 19 patients with NTR, only 5 (29.5%) new neurological deficits were seen. No new onset neurological deficit was seen in patients with STE of tumor. Patient assessed QoL parameters were worse in patients with GTR and best in patients with NTR/STE + GKRS. Conclusion: In patients of large/giant petroclival meningiomas, NTE/STE with adjuvant GKRS provided better preservation of quality of life.

Translation and Validation of Penn Acoustic Neuroma Quality of Life Scale for Hindi-Speaking Population.

Background: The Penn Acoustic Neuroma Quality-of-life Scale (PANQOL) was specifically developed for assessing the quality of life (QOL) in patients with vestibular schwannoma (VS). Its utility has been established in many populations, but it has not been validated for use in India. Objective: The objective of this study was to translate PANQOL into Hindi and validate it for use in India. Materials and Methods: PANQOL was translated into Hindi by using the standardized procedure. Its conceptual equivalence was established by administering. For validation, PANQOL-Hindi and SF-36 were administered to 78 patients aged above 18 years and recently diagnosed to have VS. Test-retest reliability was established by readministering PANQOL-Hindi on 15 patients after 2 weeks. Results: Internal consistency was good for the composite scale (α = 0.87). The Cronbach's alpha for all domains except facial dysfunction was in an acceptable range. Intercorrelations between various domains showed that anxiety and energy were strongly correlated. All domains except pain had a strong correlation with the total PANQOL score. The intraclass correlation coefficient test indicated high test-retest reliability for the composite scale (ICC = 0.97; 95% CI, 0.93-0.99). Test-retest reliability for various domains was also good. The construct validity of PANQOL was assessed by correlating its specific domains with SF-36 domains. The meaningful correlations between domains of PANQOL and SF-36 indicated good construct validity. Conclusions: PANQOL-Hindi has been adequately translated and has satisfactory psychometric properties.

Yoga as a Preventive Intervention for Cardiovascular Diseases and Associated Comorbidities: Open-Label Single Arm Study.

Aim: Common Yoga Protocol (CYP) is a standardized yoga protocol authored by experts from all over the world under the aegis of the Ministry of AYUSH, Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa Rigpa and Homeopathy (AYUSH). The potential of CYP can be determined as a cost-effective lifestyle modification to prevent the risk of developing cardiovascular diseases (CVD). Methods: In this prospective trial, we compared the effect of CYP at baseline and after 1 month. A total of 374 yoga-naïve participants performed CYP under the supervision of experienced trainers. Physiological [body mass index (BMI), blood pressure, percent oxygen saturation], biochemical (fasting blood glucose and lipid profile), and neurocognitive parameters were measured before and after the intervention. Results: At day 30 of yoga practice, serum levels of low-density lipoprotein (LDL), total cholesterol (TC), and high-density lipoprotein (HDL) were found significantly improved as compared to the baseline levels observed at the time of enrollment. Similarly, the lipid profile was also obtained from experienced trainers and found to be significantly different from those of yoga-naïve volunteers. When the intervention was compared between the healthy yoga-naïve participants with yoga-naïve participants suffering from medical issues, it was found that cholesterol profile improved significantly in the healthy-naive group as compared to the diseased group (hypertension, diabetes, underwent surgery, and CVD). Conclusion: These results highlight the need for further research to better understand the effects of yoga on the primary prevention of CVD.

Impact of Hearing Loss on Cognitive Abilities in Subjects with Tinnitus.

Background: This study aimed to delineate the underlying pathophysiology of tinnitus between normal hearing and hearing loss subjects. Objective: The study aimed to characterize the neuropsychological aspects of two types of groups with tinnitus having variable hearing thresholds. Materials and Methods: The study sample comprises 75 subjects in a group with tinnitus and normal hearing, and 100 subjects in the tinnitus and hearing loss group. Subjects were matched to their respective controls for age, gender, and education levels. Subjects underwent verbal learning and memory tasks, visual learning, memory, listening attention, sustained visual attention, work memory, category control, phonemic mastery, response inhibition, and data processing velocity. Results and Conclusions: Subjects having hearing loss with bilateral tinnitus showed significantly reduced performance on total learning capacity (P = 0.02) and recognition (P = 0.05) (Rey's auditory verbal learning test), auditory attention tasks, digit forward span test (DFST) (P = 0.03), digit span test score (P = 0.01), and working memory (P = 0.02) (digit backward span test). For response inhibition tasks and Stroop interference (P = 0.03), subjects with normal hearing with bilateral tinnitus displayed lower performance. This study proves a relationship between poor working memory, auditory memory, total learning capacity, and recognition due to hearing impairment in bilateral Tinnitus subjects. The study has substantial implications for effective assessment and treatment recommendations in hearing loss with bilateral tinnitus subjects.

Quality of life after surgical clipping of ruptured aneurysms from a developing country: differential independent impact of grading scales & baseline factors.

BACKGROUND: Detailed Quality of Life(QOL) burden among patients with ruptured aneurysms has not been thoroughly studied, especially from developing countries. This is to evaluate the independent impact of factors influencing QOL following clipping. METHODS: Patients who underwent clipping for ruptured anterior circulation aneurysms were prospectively studied for demography, site of aneurysm, H&H, WFNS, and Fisher grades, with QOL, assessed as per WHOQOL-BREF(range 4-20 in 4 domains), and analyzed. RESULTS: A total of 275 patients underwent prospective assessment of WHOQOL-BREF at 3 months after surgery, with a median age of 48. The sites of ruptured aneurysms were anterior cerebral(139), followed by middle cerebral(MCA)(82) and internal carotid(54) arteries. In univariate analyses, H&H grade had a significant rank order correlation with physical and psychological QOL domains, while WFNS grade had no significant correlation with QOL domains. Age showed a significant correlation with the social domain. The location of the ruptured aneurysm had a significant association as well, with MCA aneurysms having better scores in the environmental domain of QOL. Multivariate analysis using the generalized linear model confirmed the independent impact of these factors on QOL. Amongst all the factors studied, the age had the strongest independent impact, followed by H&H grade, location, and Fisher grade in the order of magnitude ofWald χ2. CONCLUSIONS: Following surgical clipping of ruptured aneurysms, age has the most substantial independent impact on QOL, followed by H&H grade, while WFNS grade shows no significant correlation. MCA aneurysms have better QOL scores than the rest.

Outcomes in pituitary adenoma causing acromegaly following endoscopic endonasal transsphenoidal surgery.

Objectives: The objectives of the study were to study the analysis of outcomes after endoscopic endonasal transsphenoidal surgery (EETSS) in acromegaly in terms of surgical complications, clinical improvement, endocrinological remission, achievement of prognostically critical growth hormone (GH) level, and requirement of additional treatment. Materials and Methods: The study included 28 acromegaly patients, who underwent EETSS. A 2010 consensus criterion was used for defining remission. Assessment of prognostically critical GH level (random value <2.5 ng/ml), the extent of resection and additional treatment, was done at post-operative week (POW) 12. Results: All adenomas were macroadenomas; with a mean volume of 16.34 cm3 (range, 0.4-99 cm3). Most adenomas had high-grade extensions. Most common suprasellar, infrasellar, anterior, and posterior extension grades were 3 (n = 13), 1 (n = 16), 1 (n = 14), and 0 (n = 20), respectively. Knosp Grade 3 was common on both sides (right, n = 9 and left, n = 8). One patient had already been operated on with EETSS, 1.5 years back from current surgery. Sixteen patients were on hormonal support, preoperatively. Four patients died during follow-up. Post-operative common complications were diabetes insipidus (DI, n = 18), cerebrospinal fluid rhinorrhea (n = 10), surgical site hematoma (n = 3), meningitis (n = 3), hydrocephalus (n = 2), and syndrome of inappropriate antidiuretic hormone (n = 1). The mean hospital stay was 11.62 days and 12.17 months were the mean follow-up period. At 12 POW, no improvement was seen in body enlargement and visual complaints, but all other complaints improved significantly except perspiration. Adenomas were decreased in all extensions except posterior and mean adenoma volume was reduced from 16.34 cm3 to 2.92 cm3 after surgery. Sub-total resection (STR, n = 10), near-total resection (NTR, n = 7), gross-total resection (GTR, n = 5), and partial resection (PR, n = 2) were achieved. Endocrinological remission and prognostically critical GH levels were attained in 29.17% (n = 7) and 66.67% (n = 16), respectively. NTR, GTR, STR, and PR were associated with 57.14%, 40%, 10%, and 0% endocrinological remission, respectively. Additional treatment was required in a total of 17 patients, three in GTR, nine in STR, three in NTR, and two in PR. Ten were treated with Gamma Knife radiosurgery along with medical treatment and seven with medical treatment alone. Conclusion: A successful EETSS can reduce adenoma volume to achieve clinical improvement, endocrinologic remission, and prognostically critical GH level with some complications related to surgery. Pre-operative larger volume and higher extension grades affect these outcomes adversely.

Colloid cysts: Neuropsychological outcome, quality of life and long-term control after endoscopic gross total resection.

BACKGROUND: Endoscopy is increasingly being adopted for removing colloid cysts. However, the neuropsychological outcome and quality of life (QOL) have not been studied in detail. This study is to evaluate the efficacy of endoscopic excision on cognitive measures and QOL. METHODS: Patients with colloid cysts larger than 7 mm, undergoing endoscopy were prospectively studied concerning clinico-radiology, cognitive parameters (age and education adjusted), extent of resection and recurrence. A cross-sectional QOL assessment was additionally performed on endoscopic patients in comparison with cases who underwent microsurgery or standalone ventriculo-peritoneal (VP) shunt. RESULTS: A total of 22 endoscopic patients with a mean age of 34 years and a mean cyst diameter of 19 mm were studied. Gross total resection(GTR) could be achieved in all. Over a mean follow-up of 53.4 months, none had a recurrence, ventriculomegaly, or retreatment. Among neuropsychological parameters, digit span was the most affected before surgery. There was a broad-based improvement in the mean global cognitive score from 40.63(±10.4) at baseline to 50.25(±5.8) after endoscopy with maximum improvement in 'immediate recall.' The change in scores also had a significant inverse correlation with cyst size, with cysts larger than 18 mm, resulting in lower scores following endoscopy(R=-0.9, P=0.01). QOL was significantly influenced by visual and cognitive impairments and was better among endoscopic patients than similar microsurgery or VP shunt controls, with a significant difference in social and environmental domains(P=0.02). CONCLUSION: Endoscopy is effective in achieving GTR and long-term control, with neuropsychological improvement correlated with cyst size. This is probably the first report to show QOL is influenced by cognitive parameters and is better following endoscopy than after microsurgery or VP shunt.

Outcome Following Surgical Revascularization in Patients of Moyamoya Disease with Focus on Graft Patency and Angiographic Changes.

BACKGROUND: Surgical revascularization is the mainstay of treatment in symptomatic patients of moyamoya disease (MMD). OBJECTIVE: The present study analyzed the postoperative angio-architecture in pediatric and adult patients of moyamoya disease. MATERIAL AND METHODS: Patients with MMD, both ischemic and hemorrhagic, were subjected to surgery. A superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was attempted in all. It was augmented by an encephalo-duro-myo-synangiosis), this was labelled as the combined surgical group. In patients where a direct bypass was not possible encephalo-duro-arterio-myo-synangiosis (EDAMS) was performed and these patients were put in the indirect surgery group. In the postoperative period, MRA was performed in all patients to look for (a) graft patency, (b) regression of moyamoya vessels, and (c) degree of surgical neovascularization (as quantified on adapted Matsushima and Inaba grading system). RESULTS: Eighty-two patients underwent 131 surgical revascularization procedures. A combined surgery (STA-MCA bypass and EDAMS) was performed in 100 hemispheres and indirect surgery (EDAMS) on 31 sides. In children less than 5 years of age, STA-MCA anastomosis was possible in more than 50% of patients. Clinical improvement was seen in 85.4% of patients. Postoperative MRA demonstrated a patent bypass graft in 97% of cases. Regression of moyamoya vessels was seen in half of the cases and good surgical revascularization (type A and B) was seen in more than 80% of hemispheres in the combined surgery and indirect surgery group. CONCLUSIONS: Revascularization procedures led to a regression of moyamoya collaterals, appearance of surgical neo angiogenesis, and a graft patency rate of 97%. Surgical group with combined revascularization had a trend towards better collateral development.

Head injury care in a low- and middle-income country tertiary trauma center: epidemiology, systemic lacunae, and possible leads.

BACKGROUND: Although head injury (HI) from low- and middle-income countries (LMIC) heavily contributes to the global disease burden, studies are disproportionately less from this part of the world. Knowing the different epidemiological characteristics from high-income nations can target appropriate prevention strategies. This study aims to provide a comprehensive overview of the clinico-epidemiological data of HI patients, focusing on the existing challenges with possible solutions from a developing nation's perspective. METHODS: This is a prospective, registry-based, observational study of HI in an Indian tertiary trauma-care center over 4 years. Various clinico-epidemiological parameters, risk factors, and imaging spectrum were analyzed in a multivariate model to identify the challenges faced by LMIC and discuss pragmatic solutions. RESULTS: The study included a large-volume cohort of 14,888 patients. Notably, half of these patients belonged to mild HI, despite most were referred (90.3%) cases. Only one-third (30.8%) had severe HI. Less than a third reached us within 6 h of injury. Road traffic accidents (RTA) accounted for most injuries (61.1%), especially in the young (70.9%). Higher age, males, RTA, helmet non-usage, drunken driving, systemic injuries, and specific imaging features had an independent association with injury severity. CONCLUSIONS: The study represents the much-needed, large-volume, epidemiological profile of HI from an LMIC, highlighting the suboptimal utilization of peripheral healthcare systems. Strengthening and integrating these facilities with the tertiary centers in a hub and enhanced spoke model, task sharing design, and efficient back-referrals promise effective neurotrauma care while avoiding overburden in the tertiary centers. Better implementation of road safety laws also has the potential to reduce the burden of HI.

Efficacy and safety of 177Lu-DOTMP in palliative treatment of symptomatic skeletal metastases: a prospective study.

AIMS: Bone-seeking radiopharmaceutical 177Lu-DOTMP with favorable pharmacokinetics in the preclinical studies has been evaluated for its role in reducing bone pain and improving quality of life (QOL) in patients with symptomatic skeletal metastases. METHOD: Patients with painful widespread skeletal metastases documented on 99mTc-MDP bone scintigraphy were intravenously administered 37 MBq/kg of 177Lu-DOTMP. Visual analogue score (VAS), analgesic score, European Cooperative Group of Oncology (ECOG) and the European Organization of Research and Treatment of Cancer QLQ-C30 of all the patients were assessed at baseline and posttherapy follow-up. Adverse effects were graded according to NCI-CTCAE V 5.0. RESULTS: Twenty-seven patients with painful widespread skeletal metastases (men 18; median age 61 years; range: 18-81) were studied for their responses as complete response, partial response, minimal response, no response and pain progression based on VAS and analgesic score. Overall response was seen in 77.8% of patients (complete, partial and minimal in 29.6, 33.3 and 14.8%, respectively) with significant improvement in median VAS and mean analgesic score at 2 months posttherapy from baseline (P < 0.001). The best response was seen in patients with breast cancer (100%) followed by prostate cancer (81%) and lung cancer (28%). Improvement in QOL was noted in 40% of patients, with change in ECOG score from 3.07 ± 0.67 at baseline to 2.6 ± 0.9 at 2 months posttherapy. Grade 2/3 anemia, grade 1/2 leukopenia and grade 1/3 thrombocytopenia were seen in 37, 11.1 and 18.5% patients respectively in the follow-up. CONCLUSION: 177Lu-DOTMP appears to be efficacious treatment for bone pain palliation with improvement in QOL though less effective in patients with lung cancer. The patients had transient mild-moderate hematotoxicity.

Clinical Outcome, Cognitive Function, and Quality of Life after Endoscopic Third Ventriculostomy versus Ventriculo-Peritoneal Shunt in Non-Tumor Hydrocephalus.

BACKGROUND: Endoscopic Third Ventriculostomy (ETV) is increasingly being accepted as the treatment of choice in place of Ventriculo-Peritoneal (VP) Shunt for hydrocephalus. However, their differences in cognitive and Quality of Life (QOL) scores have not been studied much in children. OBJECTIVE: To compare the outcome, cognitive function, and QOL between ETV and VP shunt. METHODS: Patients of non-tumor hydrocephalus treated with ETV or/and VP shunt underwent cognitive assessment (using modified child MMSE standardized as per the age group) and QOL (using PedsQL as per the age group in Physical, Emotional, Social, and School Functioning domains) in addition to the outcome of not requiring additional intervention. RESULTS: Out of 139 patients, there were 29 infants and 40 children upto 14 years. Among these children, ETV was the primary intervention in 45, VP shunt in 24, and could be studied for a mean follow-up of 1.7 years. Though ETV required lesser additional intervention than VP shunt (19.2% vs. 28.6%) in toddlers and older children, there was no overall significant difference. Subnormal cognitive scores were noted in 25%, 40%, and 50% after ETV, single shunt procedure, and multiple shunt procedures, respectively, with no statistically significant difference. Among the different domains of QOL, the child reported scores in the social domain were significantly better after ETV than VP shunt (475[+13] vs. 387[+43], P value 0.03), whereas most other scores were non-significantly better following ETV. CONCLUSION: Patients who underwent ETV show a trend for better clinical outcome, cognitive function, and QOL with significantly better child-reported QOL scores in the social domain.

Evaluation of Plasma Amyloid Peptides Aß1-40 and Aß1-42 as Diagnostic Biomarker of Alzheimer's Disease, its Association with Different Grades of Clinical Severity and 18F-Fluorodeoxyglucose Positron Emission Tomography Z score in the Indian Population: A Case-Control Study.

BACKGROUND: We estimated plasma amyloid-peptides levels (Aß1-42 and Aß1-40) as diagnostic biomarker of Alzheimer's disease (AD) and evaluated its association with clinical severity and 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) Z score of the different brain regions in the Indian population. PATIENTS AND METHODS: A case-control study was conducted. Diagnostic and statistical manual-IV, Dubois, and NIA-AA criteria were used for the diagnosis of AD. The plasma Aß1-42 and Aß1-40 concentration and 18F-FDG PET Z score were estimated for different brain regions. RESULTS: Forty-seven cognitive impairment patients (AD = 29, mild cognitive impairment = 18) and 33 age-matched controls were enrolled. Plasma Aß1-42 level was significantly higher in the AD group compared to controls (P = 0.046) and a cut-off >5.7 ng/mL has a specificity of 96.9%, sensitivity of 27.6%, positive predictive value 88.9%, and negative predictive value 60.4% for differentiating AD patients from controls. Significant correlation was seen between Aß1-40/Aß1-42 ratio and 18F-FDG PET Z score in the bilateral-parietal, temporal, frontal-association area, and posterior-cingulate areas. CONCLUSION: As a diagnostic biomarker of AD, plasma Aß1-42 level showed good specificity but low sensitivity in the Indian population.

COVID-19: changing patterns among neurosurgical patients from North India, efficacy of repeat testing, and inpatient prevalence.

OBJECTIVE: COVID-19 has affected surgical practice globally. Treating neurosurgical patients with the restrictions imposed by the pandemic is challenging in institutions with shared patient areas. The present study was performed to assess the changing patterns of neurosurgical cases, the efficacy of repeated testing before surgery, and the prevalence of COVID-19 in asymptomatic neurosurgical inpatients. METHODS: Cases of non-trauma-related neurosurgical patients treated at the Postgraduate Institute of Medical Education and Research (PGIMER) before and during the COVID-19 pandemic were reviewed. During the pandemic, all patients underwent a nasopharyngeal swab reverse transcription-polymerase chain reaction test to detect COVID-19 at admission. Patients who needed immediate intervention were surgically treated following a single COVID-19 test, while stable patients who initially tested negative for COVID-19 were subjected to repeated testing at least 5 days after the first test and within 48 hours prior to the planned surgery. The COVID-19 positivity rate was compared with the local period prevalence. The number of patients who tested positive at the second test, following a negative first test, was used to determine the probable number of people who could have become infected during the surgical procedure without second testing. RESULTS: Of the total 1769 non-trauma-related neurosurgical patients included in this study, a mean of 337.2 patients underwent surgery per month before COVID-19, while a mean of 184.2 patients (54.6% of pre-COVID-19 capacity) underwent surgery per month during the pandemic period, when COVID-19 cases were on the rise in India. There was a significant increase in the proportion of patients undergoing surgery for a ruptured aneurysm, stroke, hydrocephalus, and cerebellar tumors, while the number of patients seeking surgery for chronic benign diseases declined. At the first COVID-19 test, 4 patients (0.48%) tested were found to have the disease, a proportion 3.7 times greater than that found in the local community. An additional 5 patients tested positive at the time of the second COVID-19 test, resulting in an overall inpatient period prevalence of 1%, in contrast to a 0.2% national cumulative caseload. It is possible that COVID-19 was prevented in approximately 67.4 people every month by using double testing. CONCLUSIONS: COVID-19 has changed the pattern of neurosurgical procedures, with acute cases dominating the practice. Despite the fact that the pandemic has not yet reached its peak in India, COVID-19 has been detected 3.7 times more often in asymptomatic neurosurgical inpatients than in the local community, even with single testing. Double testing displays an incremental value by disclosing COVID-19 overall in 1 in 100 inpatients and thus averting its spread through neurosurgical services.