The Call for Neuroendoscopy Cadaveric Workshops in Lower-Middle Income Countries.

OBJECTIVE: This study aims to assess the impact of the workshops organized during Neuroendocon 23 on the perspective and confidence of neurosurgeons toward endoscopy in a lower-middle income country. METHODS: Neuroendocon 23 had cranial and spinal endoscopy cadaveric workshops with 30 delegates each. A pre and postworkshop survey was disseminated among the delegates, and statistical analysis was performed with SPSS (version 26) using P < 0.05. RESULTS: A total of 24 delegates (40%) consented to participate in the study, with only 1 female respondent (4.17%). After the cranial endoscopy workshop, there was an increase in the level of confidence of delegates in cranial endoscopic approaches (P < 0.001). Similarly, after the spine endoscopy workshop, the respondents had increased confidence in managing spine conditions with the endoscopic approach (P = 0.040), to the extent that they preferred the endoscopic over the microsurgical technique (P < 0.001). All respondents (n = 24, 100%) believed that endoscopy should be promoted in lower-middle income countries and integrated into residency curricula. CONCLUSIONS: Cranial and spinal endoscopy cadaveric workshops could be the first step in stimulating the interest of neurosurgeons in endoscopy.

Feasibility of awake endoscopic third ventriculostomy in selected patients of obstructive hydrocephalus.

BACKGROUND: Endoscopic third ventriculostomy (ETV) is usually performed under general anesthesia (GA) with proper head immobilization. However a few patients with hydrocephalus (HCP) may not be suitable for GA. Once the surgeon is familiar with endoscopic ventricular anatomy and gains adequate surgical experience with the procedure, ETV can be attempted under local anesthesia (LA) in selected patients. Here we discuss our experience of treating 32 patients of HCP with ETV under LA. METHODS: 32 symptomatic HCP patients with in the age range of 13 and 65 years, conscious, alert, cooperative and at high risk for GA owing to deranged liver or renal function, associated co-morbidities, pregnancy were considered for ETV under scalp block. All patients were evaluated for any discomfort during the surgical intervention. RESULT: All procedures were completed under LA. Four patients needed additional sedation prior to the scalp block to alleviate their apprehension. Four patients complained of bilateral orbital pain. In three it coincided with irrigation of fluid lower than body temperature. One patient had pain while touching the dorsum sella and needed analgesic supplement. All of them improved and none required additional CSF diversion within the average follow up of 9.5 months. CONCLUSION: ETV can be performed under local anesthesia in conscious, alert and cooperative patients in experienced hands. Unnecessary stimulation of the painful structures should be avoided and fluid for irrigation should be at body temperature. This ensures patient comfort and safety of the procedure.

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.

Single-entry two-stage rotational outside-in technique for simultaneous ventriculostomy and pineal region biopsy using traditional ventricular endoscope: technical note and comparative review.

BACKGROUND: Many methods are reported for simultaneous endoscopic 3rd ventriculostomy and posterior 3rd ventricular biopsy with their pros and cons. We describe a novel single-entry two-stage rotational outside-in technique using the common 6° ventriculoscope and contrast this with others. TECHNIQUE: Using a single burr hole, at the line extended from aqueduct through the larger foramen of Monro in parasagittal imaging, the ventricular endoscope is first inserted with 6° angled view anteroinferior, the tip of endoscope sheath just beyond the anterior part of the foramen, and ventriculostomy performed using flexible catheter's beveled cut end and balloon in a curvilinear trajectory using peripheral visualization. Keeping camera in the same orientation, it is then rotated 180° having 6° angled view postero-inferior, endoscope sheath traversing the posterior part of the foramen close to the posterior 3rd ventricular target, and biopsy obtained with rigid forceps. This technique overcomes some of the limitations of other methods by exploiting the flexible catheters and the rotational advantage of the 6° angle of the traditional ventriculoscope. CONCLUSION: Our single burr hole two-stage rotational technique for simultaneous third ventriculostomy and posterior third ventricular biopsy seems to be an excellent alternative to other methods which can be used with both traditional 6° and greater angled ventriculoscopes without any significant deterrent.

Effectiveness of dietary diabetes insipidus bundle on the severity of postoperative fluid imbalance in pituitary region tumours: A randomized controlled trial.

AIM: To test the effectiveness of nurse-led dietary diabetes insipidus (DI) bundle on the severity of postoperative fluid imbalance in pituitary region tumours. DESIGN: Blinded randomized controlled trial. METHODS: Patients aged 18-65 operated for sellar-suprasellar tumours in an Indian tertiary care centre were enrolled through total enumeration sampling and underwent randomization with allocation concealment during Sep 2018-Feb 2019. Pre-operative DI, postoperative ventilation, renal failure or decompensated diabetes mellitus were excluded. Patients in the intervention group received a nurse-led DI bundle (validated by three Delphi rounds) with four dietary components: intake of only water during thirst and avoidance of the following-added salt, high-protein foods and caffeinated drinks. Treating clinicians and the investigator assessing outcome were blinded about enrolment. Urine output, serum sodium, vasopressin requirement and hospital stay were assessed as primary outcomes. The outcome measures were monitored daily till the 6th postoperative day. Analyses were performed on 'intention-to-treat' basis, irrespective of compliance. Independent t-test and Chi-square test were used. RESULTS: Of the initial 63 patients, 50 fulfilling criteria were randomized to two groups and assessed over six days yielding 150 patient-days per group. There were no significant baseline differences between groups. The mean daily urine output was significantly lower in the DI bundle group than in control, both overall and among endonasal operated pituitary adenomas [3000.09(462.7) vs. 4095.71(896.4)ml & 2987.14(419.5) vs. 4064.73(1051)ml], with the greatest difference on the second postoperative day. Though hypernatraemia in controls became most prominent during days 2-3 and resolved in a week, it was significantly lower in the intervention group (12.7% vs. 30.7% overall, 11.4% vs. 29.4% endonasal adenomas). The need for vasopressin analogues and hospital stay were also significantly lower with DI bundle (p < 0.001). CONCLUSION: This is probably the first ever report of dietary DI bundle among operated pituitary patients, which seem to flatten the DI trend with significant benefits in polyuria, hypernatraemia, vasopressin requirement and hospital stay. TRIAL REGISTRATION: CTRI/2018/07/015127 of ICMR. IMPACT: The nurse-led dietary DI bundle has effectively reduced the severity of DI among operated pituitary patients with significant benefits in polyuria, hypernatraemia, vasopressin requirement and hospital stay. Its implementation is simple and easy to carry out, especially in resource-constrained institutions, where continuous monitoring and repeated serum sodium estimation are difficult.

Differential independent impact of the intraoperative use of navigation and angled endoscopes on the surgical outcome of endonasal endoscopy for pituitary tumors: a prospective study.

Despite widespread popularity of navigation and angled endoscopes in endonasal endoscopy, there are hardly few studies on their efficacy with the extent of resection or retreatment. This is probably the first study to assess the independent impact of these adjuncts among pituitary tumors. Patients with pituitary tumors undergoing endonasal endoscopy were prospectively studied for their demographics, clinico-radiological features, intraoperative use of navigation, and angled endoscopes, in relation to gross total resection (GTR), near total resection (NTR), endocrine remission, and retreatment. Pertinent statistical analyses were performed. Among a total of 139 patients, navigation and angled endoscopes could be used in 54 and 48 patients, respectively, depending upon their availability rather than chosen as per the case. There was no significant difference in baseline characteristics in relation to their use. The surgeon's perception of immediate benefit was noted among 51.9% while using navigation. The use of angled endoscopes towards the end of resection could help with additional tumor removal in 62.5% of patients. Overall, the use of navigation resulted in a significantly higher GTR (80.8% vs. 59.7%, OR 2.83, p = 0.01), a higher GTR/NTR (86.5% vs. 70.8%, OR 2.65, p = 0.04), and a lower retreatment rate (7.7% vs. 20.8%, OR 3.15, p = 0.05) than the others. In functioning tumors with cavernous sinus invasion, navigation had significantly increased remission rates (69.2% vs. 0%, p = 0.03). The use of angled endoscopes yielded a significantly higher GTR/NTR (91.7% vs. 70.6%, p = 0.04) and a lower retreatment rate (0% vs. 15.7%, p = 0.05) among only non-functioning adenomas. In multivariate analyses, the use of neuronavigation had a significant association with both GTR and retreatment rates (p values 0.005 and 0.02 respectively), independent of other confounding factors. The elective intraoperative use of navigation has a significant independent impact on the extent of resection and retreatment overall. While navigation results in better remission rates among functioning tumors with cavernous sinus invasion, angled endoscopy has a significant association with surgical outcomes in non-functioning tumors.

Endonasal endoscopic versus microscopic transsphenoidal surgery in pituitary tumors among the young: A comparative study & meta-analysis.

PURPOSE: The transsphenoidal approach presents unique challenges in young, with scanty literature. This study compares the outcome of pituitary tumors among young in our center between endoscopic(EES) and microscopic(MTS) transsphenoidal surgery, with a meta-analysis. METHODS: Patients within 20 years were studied for their surgical approach to a favorable outcome of endocrine remission (ER) (functioning) or Gross/Near-Total resection (nonfunctioning), besides the need for retreatment. Relevant studies were pooled and analyzed according to PRISMA guidelines. RESULTS: Out of 64 young patients with pituitary tumors, 48 underwent transsphenoidal surgery using MTS(33) or EES(15). Of these, 21, 14, 5, and 8 had Cushing's, somatotropinomas, prolactinomas, and non-secreting tumors, respectively. Mean symptom duration was 28months, with weight gain(50 %) and visual complaints(29 %) most prevalent. Hypogonadism(21 %) was the most frequent endocrinopathy. The mean tumor volume was 3.8 cm3. Over mean follow-up of 4.4years, favorable outcome was significantly higher after EES than MTS(78.6 % vs. 46.7 %)(odds ratio 4.18, p = 0.05). EES's better outcome was homogeneous across subgroups of age and tumor type, with no significant subgroup difference. Symptom duration was significantly higher among those who required retreatment(p = 0.05), while ER had a non-significant association with tumor volume(p = 0.07). Overall, 40 %, 27 %, 17 %, and 8% were on hydrocortisone, thyroxine, sex hormone, and desmopressin, respectively, at follow-up with no significant difference between EES and MTS. In pooled analysis of literature, both favorable outcome(74 % vs. 48 %,p = 0.02) and retreatment rate(8% vs. 37 %,p = 0.004) were significantly better with EES than MTS. CONCLUSION: Among young patients with pituitary tumors, the favorable outcome and retreatment rates are better with endonasal endoscopy and associated with symptom duration and tumor volume.

Developmental Retrocerebellar Cysts: A New Classification for Neuroendoscopic Management and Systematic Review.

OBJECTIVE: Posterior fossa cystic malformations are diversely classified with considerable overlap without therapeutic relevance. These cysts posterior to the cerebellum, presenting in children younger than 5 years, are labeled developmental retrocerebellar cysts (DRCCs) under a new classification in relation to neuroendoscopy. METHODS: DRCC was categorized as type 0 for asymptomatic enlarged cistern magna and was not treated. Among symptomatic cases, cysts with a compressed fourth ventricle were labeled type 1, whereas cysts in continuity with the fourth ventricle were termed type 2. They were further categorized as subtype B if hydrocephalus was greater relative to the cyst, or otherwise as subtype A. The literature was reviewed according to PRISMA guidelines. RESULTS: There were 13 children aged 3-48 months. Type 1A DRCC was noted in 5 patients, with onset before 6 months, 4 of whom (80%) had intracranial hypertension. All underwent suboccipital endoscopic deroofing and cisternostomy (SEDC), a new technique. Type 1B DRCC was seen in 2 patients, with onset at 8-9 months, who underwent endoscopic third ventriculostomy (ETV) + endoscopic ventriculocystostomy (EVC). Type 2A DRCC was observed in 4 patients, with onset at 5-47 months, who underwent SEDC. Type 2B DRCC was noted in 2 patients, with onset 6-8 months, who underwent ETV. With a mean follow-up of 32 months, all showed clinicoradiologic improvement. The application of our classification to other studies showed ETV/EVC to be successful in only 67% of type 1A DRCC and 72% of type 2A DRCC, compared with 100% efficacy of SEDC in our series. CONCLUSIONS: This is probably the first ever endoscopic classification of pediatric posterior fossa cyts, elucidating pathophysiology, presentation, and treatment. Patients with type 1 DRCC present early because of extraneous compression. Among patients with type 2 DRCC, posterior fossa compliance determines the degree of hydrocephalus. The newly described SEDC seems more appropriate for types 1A and 2A DRCC. ETV is adequate in type 2B DRCC and effective with EVC in type 1B.

Operative nuances to safeguard anomalous vertebral artery without compromising the surgery for congenital atlantoaxial dislocation: untying a tough knot between vessel and bone.

OBJECT: Stabilization of the craniovertebral junction (CVJ) by using lateral masses requires extensive dissection. The vertebral artery (VA) is commonly anomalous in patients with congenital CVJ anomaly. Such a vessel is likely to be injured during dissection or screw placement. In this study the authors discuss the importance of preoperative evaluation and certain intraoperative steps that reduce the chances of injury to such vessels. METHODS: A 3D CT angiogram was obtained in 15 consecutive patients undergoing surgery for congenital atlantoaxial dislocation. The course of the VA and its relationship to the C1-2 facets was studied in these patients. The anomalous VA was exposed intraoperatively, facet surfaces were drilled in all, and the screws were placed according to the disposition of the vessel. RESULTS: A skeletal anomaly was found in all 10 patients who had an anomalous VA. Four types of variations were noted: 1) the first intersegmental artery in 5 patients (bilateral in 1); 2) fenestration of VA in 1 patient; 3) anomalous posterior inferior cerebellar artery crossing the C1-2 joint in 1 patient; and 4) medial loop of VA in 5 patients. The anomalous vessel was dissected and the facet surfaces were drilled in all. The C-1 lateral mass screw was placed under vision, taking care not to compromise the anomalous vessel, although occipital screws or sublaminar wires were used in the initial cases. A medial loop of the VA necessitated placement of transpedicular or C-2 lateral mass screws instead of pars interarticularis screws. The anomalous vessel was injured in none. CONCLUSIONS: Preoperative 3D CT angiography is a highly useful method of imaging the artery in patients with CVJ anomaly. It helps in identifying the anomalous VA or its branch and its relationship to the C1-2 facets. The normal side should be surgically treated and distracted first because this helps in opening the abnormal side, aiding in dissection. In the posterior approach the C-2 nerve root is always encountered before the anomalous vessel. The defined vascular anatomy helps in choosing the type of screw. The vessel should be mobilized so as to aid the drilling of facets and the placement of screws and spacers under vision, avoiding its injury (direct or indirect) or compression. With these steps, C1-2 (short segment) rigid fusion can be achieved despite the presence of anomalous VA.