Free-access open-source e-learning in comprehensive neurosurgery skills training.

BACKGROUND: Since the end of last century, technology has taken a front seat in dispersion of medical education. Advancements of technology in neurosurgery and traditional training methods are now being challenged by legal and ethical concerns of patient safety, resident work-hour restriction and cost of operating-room time. To supplement the existing neurosurgery education pattern, various e-learning platforms are introduced as structured, interactive learning system. MATERIALS AND METHODS: This study focuses on the concept, formulation, development and impact of web based learning platforms dedicated to neurosurgery discipline to disseminate education, supplement surgical knowledge and improve skills of neurosurgeons. 'Neurosurgery Education and Training School (NETS), e-learning platform' has integration of web-based technologies like 'Content Management System' for organizing the education material and 'Learning Management System' for updating neurosurgeons. NETS discussion forum networks neurosurgeons, neuroscientists and neuro-technologists across the globe facilitating collaborative translational research. RESULTS: Multi-authored neurosurgical e-learning material supplements the deficiencies of regular time-bound education. Interactive open-source, global, free-access e-learning platform of NETS has around 1) 425 visitors/month from 73 countries; ratio of new visitors to returning visitors 42.3; 57.7 (2); 64,380 views from 190 subscribers for surgical videos, 3-D animation, graphics based training modules (3); average 402 views per post. CONCLUSION: The e-Learning platforms provide updated educational content that make them "quick, surf, find and extract" resources. e-Learning tools like web-based education, social interactive platform and question-answer forum will save unnecessary expenditure of time and travel of neurosurgeons seeking knowledge. The need for free access platforms is more pronounced for the neurosurgeons and patients in developing nations.

Suprasellar dermoid cyst associated with colloid cyst of the third ventricle: Disordered embryogenesis or a mere coincidence?

Intracranial dermoid cyst and colloid cysts of the third ventricle are rare benign congenital lesions of early adulthood. Both lesions are thought to be congenital in origin however association is rare. Only one case of this association has been reported. We report a 22-year-old male with suprasellar dermoid cyst and colloid cyst of the third ventricle presenting simultaneously. Embryogenesis of this association has been discussed.

Predictive factors for early symptomatic recurrence in pilocytic astrocytoma: does angiogenesis have a role to play?

We studied predictive factors with respect to angiogenesis and proliferative indices for early symptomatic recurrences in patients with pilocytic astrocytoma (PA). One hundred and eighteen patients who underwent surgery for PA were divided into non-recurrent and early symptomatic recurrence groups to analyze clinicoradiological and immunohistopathological (n=33) parameters. Patients with non-recurrent tumors presented with symptoms for a mean duration of 10.2 ± 9.1 months while those with recurrent tumors presented slightly earlier (6.9 ± 4.5 months). Common tumor locations were the cerebellum (38.1%), optic chiasm (27.9%), supratentorial region (19.4%) and brainstem (9.3%). Recurrent tumors were mostly located in the cerebellum (44%) and brainstem (33%). Strong contrast enhancement was noted in 70 (59.3%) tumors, while 48 (40.7%) showed poor contrast. Resection was complete in 53% of patients while near total excision was achieved for the remaining patients. Cellularity and pleomorphism were similar in both groups. Extensive endothelial proliferation was observed in 18.1% of patients while the remainder showed a focal pattern. Diffuse vascular endothelial growth factor (VEGF) expression was observed in 36.3% of patients while 63.6% showed mild-to-moderate focal expression. Endothelial proliferation and VEGF expression were more pronounced in patients with non-recurrent tumors, but this was not statistically significant. MIB-I labeling indices were similar (1-5%) for both groups. Symptomatic recurrences were common in infratentorial PAs. Radiology, histopathology and proliferative indices did not offer any prognostic information. Angiogenesis markers such as endothelial proliferation and VEFG expression did not predict early symptomatic recurrence. Diffuse VEGF expression and endothelial proliferation were observed in tumors that showed strong contrast enhancement.

A comparative study to assess the effect of amikacin sulfate bladder wash on catheter-associated urinary tract infection in neurosurgical patients.

BACKGROUND: The indwelling urinary catheter is an essential part of modern medical care. Unfortunately, when poorly managed, the indwelling catheter may present a hazard to the very patients it is designed to protect. Catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection in hospitals and nursing homes. AIMS AND OBJECTIVES: The primary objective was to study the effect of amikacin sulfate bladder wash on CAUTI in neurosurgical patients. The other objectives were to study the various organisms causing CAUTI and their antibiotic sensitivity and resistance pattern. MATERIALS AND METHODS: This was a prospective randomized controlled study performed on 60 patients who met the inclusion criteria at the neurosurgical intensive care of the All India Institute of Medical Sciences between June and December 2006. The patients were randomized into two groups - one was the trial group which received amikacin bladder wash, while the other was the control group that did not receive any bladder wash. RESULTS: Forty percent of the subjects in the control group developed CAUTI, while none of the subjects in study group developed CAUTI. (Fisher's exact test, P value < 0.001) Pseudomonas aeruginosa (51%) was the commonest pathogen. CONCLUSIONS: Amikacin sulfate bladder wash was effective in preventing CAUTI. It can thus decrease the antibiotic usage thereby preventing the emergence of antibiotic resistance.

Assessment of 1p/19q status by fluorescence in situ hybridization assay: A comparative study in oligodendroglial, mixed oligoastrocytic and astrocytic tumors.

BACKGROUND: Due to overlapping histomorphological features, difference in clinical behavior and treatment response, establishing potential molecular markers to facilitate diagnosis of various genetic subtypes of diffuse gliomas is essential. AIM: To analyze 1p/19q status in diffuse gliomas and correlate it with epidermal growth factor receptor (EGFR) and p53 protein expression. MATERIALS AND METHODS: 1p/19q status in 43 cases was evaluated by fluorescence in situ hybridization assay. Glial fibrillary acidic protein (GFAP), EGFR and p53 were assessed by immunohistochemistry. RESULTS: Glial fibrillary acidic protein immunopositivity was observed in oligodendrogliomas within minigemistocytes and gliofibrillary oligodendrocytes as perinuclear homogenous blobs. It also highlighted the intermingled reactive astrocytes. Astrocytomas and the astrocytic component of oligoastrocytomas showed a diffuse fibrillary type of staining. 1p and/or 19q loss was seen in 65% (13/20) of oligodendrogliomas and 66.6% (5/9) of mixed oligoastrocytomas. There was one case each of pediatric oligodendroglioma and mixed oligoastrocytoma, none of which showed 1p/19q loss. None of the astrocytomas including two pediatric cases showed this alteration (P < 0.05). p53 was expressed in 57.1% of astrocytomas (8/14), 33% of mixed oligoastrocytomas (3/9) and 10% of oligodendrogliomas (2/20). Majority of oligodendrogliomas (85%; 17/20) and oligodendroglial areas in mixed oligoastrocytomas (77.7%; 7/9) showed a membranous lace-like immunopositivity with EGFR. In contrast, all astrocytomas (Grade II and III) were EGFR negative. CONCLUSION: Loss of 1p/19q is strongly associated with oligodendroglial phenotype, while astrocytic tumors are more likely to show p53 over-expression. p53 expression and 1p/19q status appear to be mutually exclusive.

Post- traumatic compound elevated fracture of skull simulating a formal craniotomy.

Fracture of the cranial bones following trauma is common. The fracture most commonly encountered in clinical practice is an undisplaced linear fracture of a skull bone or a depressed skull fracture. Compound elevated skull fracture, unlike depressed skull fracture is an extremely rare variety of post-traumatic cranial injury, seldom seen in modern clinical practice. Authors report one such rare case of compound elevated skull fracture, simulating a formal frontoparietal craniotomy, in a 20-year-old male patient following a railway accident. The mechanism of its production as well as the management of such injury is discussed.

Spinal intramedullary tuberculosis: a series of 15 cases.

OBJECTIVES: Spinal intramedullary tuberculosis is a rare disease. This study aims to acquaint readers with its clinicoradiological features and emphasizes the importance of early treatment in intramedullary spinal tuberculosis. MATERIALS AND METHODS: Retrospective analysis was conducted from 1985 to 2006 over a period of 21 years and data were retrieved from patient records at our institute (single centre study). Clinicoradiological and pathological data were reviewed along with final outcome at discharge and analyzed. RESULTS: Fifteen patients were analyzed. Mean age of presentation was 31 years (range: 18-45 years), with average duration at presentation being 11 months (2-24 months). Common locations: dorsal region: 7 cases, cervical: 5 cases, cervicodorsal: 2 cases and dorsolumbar region: 1 case. Sensori-motor involvement was noted in fourteen patients. Bowel and bladder involvement was seen in ten patients while one patient had respiratory distress. Only 40% of patients had secondary involvement of spine while the rest of the cases were having primary spinal intramedullary tuberculosis. Three patients had previous history of tubercular meningitis, while one patient had old pulmonary tuberculosis. There were one case each of cervical node involvement and intracranial granuloma. Twelve patients underwent surgery while others were conservatively managed, all patients received antitubercular therapy for 18 months. Nine of the twelve operated patients showed improvement in motor power, while two of the conservatively managed patients improved. Patients presenting late had a poorer outcome. CONCLUSION: Spinal intramedullary tuberculosis is a non-malignant, treatable lesion giving a good outcome on management. Surgically managed patients showed a better outcome.

Frontal mucocele presenting with forehead subcutaneous mass: an unusual presentation.

Frontal mucocele usually presents with visual complaints like diplopia, diminution of vision, visual field defect, ptosis, orbital swelling, retro-orbital pain, displacement of eye-globe and proptosis. Very rarely it can present as a subcutaneous swelling. To the best of the authors' knowledge, only two cases of frontal mucocele presenting with a forehead mass have been reported in the western literature. Authors report an unusual case of frontal mucocele in a 53-year- old female who presented with painless slowly progressive subcutaneous swelling of five-year duration on the forehead. The case is discussed and the pertinent literature is reviewed.

Triple neural tube defect and the multisite closure theory for neural tube defects: is there an additional site? Case report.

Triple neural tube defects (NTDs) are rare; only 1 case exists in the available literature. There has been a divergent view on the etiogenesis of NTDs, and 2 main theories have been postulated: the more widely held orderly closure theory and the less accepted multisite closure theory. In this article the authors present 2 cases of patients with triple NTDs, and they examine the embryological basis of NTDs with special reference to the multisite closure theory. The patient in Case 1 had a 2-level myelomeningocele (MMC) along with an encephalocele; the patient in Case 2 had a 3-level MMC. To the authors' knowledge, this paper outlines only the second and third cases described in world literature of triple NTDs including the first case of a triple MMC. The embryogenesis of triple NTDs can be better explained by the multisite closure theory. However, it fails to adequately explain the triple MMC in Case 2, given that the closure has to proceed in an orderly manner. The authors thus propose an additional closure site to explain this.

Gamma Knife surgery for intracranial arteriovenous malformations in children: a retrospective study in 103 patients.

OBJECT: This retrospective study was designed to study the outcome in children with intracranial arteriovenous malformations (AVMs) treated with Gamma Knife surgery (GKS). METHODS: One hundred and forty-two children were treated with GKS at the authors' institution between April 1997 and March 2006; of these, 103 patients with a mean follow-up of 26.4 months (range 6-96 months) were included. The mean age at presentation was 13.9 years (range 3-18 years). Eighty-six (83%) patients presented with hemorrhage. In 57 children the AVMs were Spetzler-Martin Grade I or II, and in 46 the AVMs were Grades III, IV, or V. The mean volume of the AVMs was 2.4 ml (range 0.04-23.3 ml). The mean marginal dose administered was 24.4 Gy (range 15-27 Gy). Follow-up angiography was advised at 2 years after GKS and yearly thereafter. In patients with residual AVMs, follow-up angiography was advised yearly until 4 years after GKS. If residual AVM was present, even on a follow-up angiogram obtained 4 years postsurgery, the GKS was considered a failure. RESULTS: Complete obliteration of the AVM was documented in 34 (87%) of the 39 patients with complete angiographic follow-up. The 3- and 4-year actuarial rates of nidus obliteration were 66 and 86% respectively. Three patients (2.9%) experienced bleeding during the latency period, and symptomatic radiation-induced edema was noted in four patients (3.8%). A significantly higher incidence of radiation edema was noted in patients with AVM volumes greater than 3 ml and in patients with Spetzler-Martin Grade IV and V AVMs. CONCLUSIONS: Gamma Knife radiosurgery is an effective modality for the treatment of intracranial AVMs in children, yielding high obliteration rates and low complication rates.

Surgical results in patients with tuberculosis of the spine and severe lower-extremity motor deficits: a retrospective study of 48 patients.

OBJECT: Significant numbers of patients with spinal tuberculosis (TB), especially in developing countries, still present late after disease onset with severe neurological deficits. The authors conducted a study to assess the outcome in these patients. METHODS: Fifty-nine patients with spinal TB and severe motor deficits underwent surgery at the authors' center during the past 10 years. Data obtained in 48 patients with a minimum of 3 months of follow up (mean follow-up period 12.8 months) were analyzed. The disease in 34 patients was characterized by Frankel Grade A/B (Medical Research Council Grade 0/5) and in 14 patients by Frankel Grade C (unable to walk even with support) at admission. Thirty (88%) of the 34 patients with Frankel Grade A/B status and 13 (92.8%) of the 14 patients with Frankel Grade C status at admission experienced improvement to Frankel Grade D/E (walking with or without support) at the last follow-up examination 3 or more months after surgery. The degree of improvement exhibited by patients with a Frankel Grade A/B spinal cord injury was comparable to that shown by patients with Frankel Grade C status. Even patients with flaccid paraplegia, gross sensory deficit, prolonged weakness, spinal cord signal changes demonstrated on magnetic resonance imaging, and bladder involvement have experienced dramatic improvement in motor function since surgery. A significant number of the patients have shown remarkable improvement in other symptoms such as pain (91.6%), spasticity (88%), and bladder symptoms (88%). CONCLUSIONS: A significant proportion of patients with spinal TB and severe motor deficits experience remarkable improvement after surgical decompression and hence should undergo surgery even though they may be suffering from paraplegia of considerable duration.

Transarticular screw fixation using neuronavigation: Technique.

BACKGROUND: Transarticular screw placement needs highly accurate imaging. We assess the efficacy and accuracy of C1-C2 transarticular screw fixation using neuronavigation and also cast a technical note on the procedure. MATERIALS AND METHODS: This study included a total of nine patients who underwent transarticular screw fixation using the neuronavigation system. A total of 15 screws were placed. All patients underwent postoperative CT scan with 3-Dimensional (3-D) reconstruction to check for the accuracy of implantation. RESULTS: One patient had encroachment of the transverse foramen but there was no vertebral artery injury. There were no clinical complications or adverse sequelae. CONCLUSION: Neuronavigation is extremely helpful in C1-C2 transarticular screw fixation and gives excellent accuracy.