Molecular Basis of Cerebral Vasospasm: What Can We Learn from Transcriptome and Temporal Gene Expression Profiling in Intracranial Aneurysm?

Cerebral vasospasm (CV) is a significant complication following aneurysmal subarachnoid hemorrhage (aSAH), and lacks a comprehensive molecular understanding. Given the temporal trajectory of intracranial aneurysm (IA) formation, its rupture, and development of CV, altered gene expression might be a molecular substrate that runs through these clinical events, influencing both disease inception and progression. Utilizing RNA-Seq, we analyzed tissue samples from ruptured IAs with and without vasospasm to identify the dysregulated genes. In addition, temporal gene expression analysis was conducted. We identified seven dysregulated genes in patients with ruptured IA with vasospasm when compared with those without vasospasm. We found 192 common genes when the samples of each clinical subset of patients with IA, that is, unruptured aneurysm, ruptured aneurysm without vasospasm, and ruptured aneurysm with vasospasm, were compared with control samples. Among these common genes, TNFSF13B, PLAUR, OSM, and LAMB3 displayed temporal expression (progressive increase) with the pathological progression of disease that is formation of aneurysm, its rupture, and consequently the development of vasospasm. We validated the temporal gene expression pattern of OSM at both the transcript and protein levels and OSM emerges as a crucial gene implicated in the pathological progression of disease. In addition, RSAD2 and ATP1A2 appear to be pivotal genes for CV development. To the best of our knowledge, this is the first study to compare the transcriptome of aneurysmal tissue samples of aSAH patients with and without CV. The findings collectively provide new insights on the molecular basis of IA and CV and new leads for translational research.

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.

Suprasellar masquerader: Chordoid glioma.

BACKGROUND: Chordoid glioma is a rare well-circumscribed glial neoplasm arising in adults and predominantly affects females. Tanycytes of the third ventricle have been proposed as the cell of origin owing to its location. It is characterized by chordoid features with myxoid and inflammatory stroma and recurrent PRKCA p.D463H missense mutation. CASE REPORT: We present two cases (30-year-old female and 45-year-old male) with similar complaints of behavioral change and headache. Midline suprasellar homogeneously enhancing mass was seen on contrast-enhanced magnetic resonance imaging. Histopathology and immunohistochemistry was characteristic of chordoid glioma with cords and clusters of epithelioid cells arranged in a solid pattern. There were variable amounts of myxoid stroma and lymphoplasmacytic infiltrate. No mitosis, necrosis, or brain invasion was noted. The cells expressed strong diffuse positivity for glial fibrillary acid protein (GFAP) and weak nuclear thyroid transcription factor (TTF-1). Epithelial membrane antigen (EMA)and brachyury were negative. Subsequently, the lady underwent gross total excision and died soon after the operation. The male patient received radiotherapy and is currently doing well after 6 months of follow-up. CONCLUSION: The rare occurrence as well as the radiological and morphological overlaps in chordoid gliomas make them a true masquerader. Combination of GFAP and TTF-1 in the immunohistochemical panel can be useful in differential diagnosis. Mainstay of treatment is complete surgical excision, with adjuvant radiotherapy becoming increasingly important.

Analysis of distribution and localization of proteins of the reelin signalling pathway in mesial temporal lobe epilepsy.

INTRODUCTION: Granule cell dispersion (GCD) is pathognomonic of hippocampal sclerosis seen in the mesial temporal lobe epilepsy (MTLE). Current animal studies indicate deficiency of Reelin is associated with abnormal granule cell migration leading to GCD. The present study aimed to evaluate complete Reelin signalling pathway to assess whether Reelin deficiency is related to MTLE. MATERIALS AND METHODS: Hippocampal sclerosis was confirmed by H and E stain. To explore the amount and cellular location of the Reelin cascade molecules, the hippocampal tissues from MTLE surgery and controls (n = 15 each) were studied using Immuno-histochemistry (IHC). Additionally, confocal imaging was used to validate the IHC findings by co-localization of different proteins. Quantification of IHC images was performed using histo-score and confocal images by Image J software. RESULTS: Immune expression of active Reelin was significantly reduced in patients. Reelin receptors were deranged, apolipoprotein E receptor 2 was increased while very low-density lipoprotein receptor was reduced. Disabled-1, a downstream molecule was significantly reduced in MTLE. Its ultimate target, cofilin was thus disinhibited and expressed more in MTLE. Reelin cleaving protease, matrix metalloprotease-9 (MMP-9) and MMP-9 inhibitor, tissue inhibitor of matrix protease-1, showed reduced expression in extracellular matrix. Semi-quantification of immunohistochemistry was done using Histo (H) score. H score of Reelin in diseased patients was 15 against 125 for control patients. These results were validated by confocal fluorescence microscopy. CONCLUSIONS: Reelin signalling cascade was deranged in chronic MTLE. Pharmacological manipulation of Reelin cascade can be done at various levels and it may provide novel treatment options for MTLE.

Comparison of Intraoperative Low-Dose Ketodex and Fentanyl Infusion for Postoperative Analgesia In Spine Surgery: A Prospective Randomized Double-Blind Study.

STUDY DESIGN: Prospective randomized double-blind study. PURPOSE: To assess the analgesic effects of the combination of a low-dose ketamine and dexmedetomidine (ketodex) infusion and compare it with that of fentanyl for postoperative analgesia after spine surgeries. OVERVIEW OF LITERATURE: Adequate pain management following spine surgeries is crucial. Approximately 57% of patients experience inadequate pain control in the first 24 hours following elective spine surgery, which is attributable to the extensive soft tissue and muscle damage. METHODS: The study included 60 patients graded American Society of Anesthesiologists I and II and scheduled for thoracolumbar spine surgery involving >3 vertebral levels. The patients were divided into two groups: group KD (ketodex) and group F (fentanyl). The primary objective was to compare the postoperative analgesic requirements among the groups. The secondary objectives included a comparison of the intraoperative anesthetic requirements, postoperative pain scores, hemodynamic parameters, side effects of the study drugs, and the duration of post-anesthesia care unit stay of both the groups. RESULTS: Ketodex use prolonged the mean time to first rescue analgesia (22.00±2.30 hours vs. 11.69±3.02 hours, p <0.001) and reduced the requirement of rescue analgesics in the first 24 hours postoperatively compared to fentanyl use (70.00±8.16 µg vs. 113.31±36.65 µg, p =0.03). The intraoperative requirement of desflurane was comparable between the groups (p >0.05). The postoperative pain scores were significantly lower in the group KD than in group F at most timepoints (p <0.05). Patients in group KD had a shorter post-anesthesia care unit stay than group F did (p <0.001). CONCLUSIONS: Low-dose ketodex could be a safe substitute for fentanyl infusion when employed as an anesthetic adjuvant for patients undergoing thoracolumbar spine surgeries involving >3 vertebral levels to achieve prolonged analgesia without any opioidrelated side effects.

Dysregulated Genes and Signaling Pathways in the Formation and Rupture of Intracranial Aneurysm.

Intracranial aneurysm (IA) has the potential to rupture. Despite scientific advances, we are still not in a position to screen patients for IA and identify those at risk of rupture. It is critical to comprehend the molecular basis of disease to facilitate the development of novel diagnostic strategies. We used transcriptomics to identify the dysregulated genes and understand their role in the disease biology. In particular, RNA-Seq was performed in tissue samples of controls, unruptured IA, and ruptured IA. Dysregulated genes (DGs) were identified and analyzed to understand the functional aspects of molecules. Subsequently, candidate genes were validated at both transcript and protein level. There were 314 DGs in patients with unruptured IA when compared to control samples. Out of these, SPARC and OSM were validated as candidate molecules in unruptured IA. PI3K-AKT signaling pathway was found to be an important pathway for the formation of IA. Similarly, 301 DGs were identified in the samples of ruptured IA when compared with unruptured IAs. CTSL was found to be a key candidate molecule which along with Hippo signaling pathway may be involved in the rupture of IA. We conclude that activation of PI3K-AKT signaling pathway by OSM along with up-regulation of SPARC is important for the formation of IA. Further, regulation of Hippo pathway through PI3K-AKT signaling results in the down-regulation of YAP1 gene. This along with up-regulation of CTSL leads to further weakening of aneurysm wall and its subsequent rupture.

Reelin Signaling Pathway and Mesial Temporal Lobe Epilepsy: A Causative Link.

Introduction: Mesial temporal lobe epilepsy (MTLE) is the most frequent form of partial epilepsy. Granule cell dispersion, resulting from aberrant neuronal migration in the hippocampus, is pathognomonic of MTLE. Reelin, a secreted neurodevelopmental glycoprotein has a crucial role in controlling the radial migration of neurons. Several animal studies have implicated Reelin in the MTLE pathogenesis Mesial temporal lobe epilepsy (MTLE) is the most frequent form of partial epilepsy. Granule cell dispersion, resulting from aberrant neuronal migration in the hippocampus, is pathognomonic of MTLE. Reelin, a secreted neurodevelopmental glycoprotein has a crucial role in controlling the radial migration of neurons. Several animal studies have implicated Reelin in the MTLE pathogenesis. Methods: The aim of this study was to investigate the Reelin signalling pathway in the MTLE patients. Therefore, we studied each step in the Reelin signalling pathway for the gene and protein expressions, in the hippocampal tissue obtained from patients undergoing surgery for MTLE and compared it with age matched normal autopsy cases. Results: We found statistically significant decrease (P<0.001) in the Reelin mRNA expression in MTLE patients. Among the two reelin receptors, apolipoprotein E receptor 2 (ApoER2) was significantly increased whereas very low density lipoprotein receptor (VLDLR) was decreased among the patients. Disabled 1 (Dab1), the downstream target of reelin, was found to be decreased. Dab1 in turn inhibits Cofilin, which is responsible for cytoskeletal reorganization, thus limiting aberrant neuronal migration. Statistically significant over expression of Cofilin protein was found in the patient group. Matrix metalloproteinase 9 (MMP-9) and tissue inhibitor of metalloproteases-1 (TIMP-1), both of which are involved in processing of Reelin, were down regulated in 70-85% of cases. Conclusion: The whole pathway was found to be deranged in MTLE. These results indicate that Reelin signalling pathway is disturbed at various points in the MTLE patients and might be involved in the pathogenesis & progression of MTLE. Our results extend the existing information regarding the components of the Reelin pathway and further, establish a link between pathway disturbance and MTLE.

SDH-B, INSM1, and GATA3 expression in cauda equina neuroendocrine tumors: report on 21 cases from a North indian tertiary care center.

Primary neuroendocrine tumors (NETs) of the central nervous system are rare, primarily seen in the cauda equina region, known as cauda equina NETs. This study was carried out to evaluate the morphological and immunohistochemical characteristics of cauda equina NETs. All cases of histologically proven NETs that originated within the spinal cord from 2010 to 2021 were retrieved from the surgical pathology electronic database. For each case, the clinical presentation, site, radiological features, functional status, and preoperative diagnosis were recorded. Immunohistochemical stains for GFAP, synaptophysin, chromogranin A, cytokeratin 8/18, INSM1, Ki-67, GATA3, and SDH-B were performed for every case using an automated immunostainer. GATA3 immunohistochemistry was repeated manually. A retrospective probe of records revealed 21 cases of NETs having a mean age of 44 years and slight male dominance (M:F ratio: 1.2:1). Cauda equina was the most prevalent site of involvement (19, 90.5%). The most typical presentation was lower backache and weakness of bilateral lower limbs. The histopathological features were similar to NETs seen at other sites. Reactivity for at least one neuroendocrine marker was seen in all cases while GFAP was negative. Cytokeratin 8/18 was expressed in the majority (88.9%) of cases. INSM1 and GATA3 expression was seen in 20 (95.2%) and 3 (14.3%) cases, respectively. All cases retained SDH-B cytoplasmic staining. Higher Ki-67 index (≥3%) was associated with a higher risk of recurrence. Cauda equina NETs rarely express GATA3 and are unlikely to be associated with SDH mutations. Recurrent cases may be negative for synaptophysin, chromogranin, and cytokeratin; thus, INSM1 immunohistochemistry is helpful.

Transradial approach in neurointervention: Part-II: Diagnostic and therapeutic intervention.

Recent studies and meta-analysis have shown the safety, feasibility, and success of the transradial approach in diagnostic and therapeutic neurointervention. This second part of the review focuses on the technical aspects of diagnostic and therapeutic neurointervention after the radial sheath has been placed.

Expressional Study of Permeability Glycoprotein and Multidrug Resistance Protein 1 in Drug-resistant Mesial Temporal Lobe Epilepsy.

Introduction: About 30% of patients with epilepsy do not respond to anti-epileptic drugs, leading to refractory seizures. The pathogenesis of drug-resistance in mesial temporal lobe epilepsy (MTLE) is not completely understood. Increased activity of drug-efflux transporters might be involved, resulting in subclinical concentrations of the drug at the target site. The major drug-efflux transporters are permeability glycoprotein (P-gp) and multidrug-resistance associated protein-1 (MRP-1). The major drawback so far is the expressional analysis of transporters in equal numbers of drug-resistant epileptic tissue and age-matched non-epileptic tissue. Methods: We have studied P-gp and MRP-1 drug-efflux transporters in the sclerotic hippocampal tissues resected from the epilepsy surgery patients (n=15) and compared their expression profile with the tissues resected from non-epileptic autopsy cases (n=15). Results: Statistically significant over expression of both P-gp (P<0.0001) and MRP-1 (P=0.01) at gene and protein levels were found in the MTLE cases. The fold change of P-gp was more pronounced than MRP-1. Immunohistochemistry of the patient group showed increased immunoreactivity of P-gp at blood-brain barrier and increased reactivity of MRP-1 in the parenchyma. The results were confirmed by confocal immunofluorescence microscopy. Conclusion: Our results suggested that P-gp in association with MRP-1 might be responsible for the multi-drug resistance in epilepsy. P-gp and MRP-1 could be important determinants of bio availability and tissue distribution of anti-epileptic drugs in the brain which can pharmacologically inhibited to achieve optimal drug penetration to target site.

Advanced multiparametric MRI-based scoring for isocitrate dehydrogenase mutation prediction of gliomas.

Purpose: To propose an advanced multiparametric magnetic resonance imaging (MRI)-based scoring system and evaluate its diagnostic accuracy with respect to the isocitrate dehydrogenase (IDH) mutation status of gliomas. Material and methods: This prospective observational study included 50 consecutive patients with suspected gliomas, enrolled for pre-operative MRI. The exclusion criteria were previous surgery, biopsy, or chemo/radiotherapy and contraindications to the gadolinium-based contrasts or MRI acquisition. A standardized brain-MRI protocol using a 3-Tesla machine and 16-channel head coil consisted of pre-contrast axial-T2WI, FLAIR, DTI, 3D-ASL perfusion, SWI, 3D-T1WI, and post-contrast axial-DSC perfusion followed by 3D-T1WI and MR spectroscopy. ROIs were drawn from the tumoral centre, periphery, and peritumoral oedema (3 ROIs for each) followed by normalization using the ROIs over the contralateral normal white matter. The cut-off values for the statistically significant (p <0.05) continuous variables were derived by drawing receiver operating characteristic (ROC) curves. A 7-point "glioma-score" was derived from the 3 categorical (T2/FLAIR-mismatch, contrast enhancement, and intratumoral susceptibility signals) and 4 continuous ROI-based variables (ADC, FA, ASL-CBF, and DSC-CBV). Results: The predictability of IDH mutant status using the multiparametric advanced MRI-based glioma score was statistically significant (sensitivity = 69.23%, specificity = 95.65%, PPV = 94.74%, NPV = 73.33%). A glioma score of more than 4.5 out of 7 predicted the IDH-mutation status with higher specificity and sensitivity compared to each of the individual imaging variables. Conclusions: The advanced multiparametric MRI-based glioma score can predict the IDH-mutation status with high statistical significance.

The predictors of hyperglycemia and its effects on neurological outcome in the patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping: A prospective observational study.

Background: Following intracranial aneurysm rupture, 70-90% of patients have hyperglycemia as a stressful response. Uncontrolled hyperglycemia is deleterious if not controlled well. The objectives of the study were to assess the prevalence, risk factors of hyperglycemia, and its effect on outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients who underwent aneurysmal clipping. Methods: Following intracranial aneurysm rupture, 70-90% of patients have hyperglycemia as a stressful response. Uncontrolled hyperglycemia is deleterious if not controlled well. The objectives of the study were to assess the prevalence, risk factors of hyperglycemia, and its effect on outcome in aSAH patients who underwent aneurysmal clipping. Results: At admission, the prevalence of hyperglycemia and severe hyperglycemia was 31.8% and 6.8%, respectively. Perioperative hyperglycemia and severe hyperglycemia were seen in 75.7% and 27%, respectively. History of diabetes mellitus (DM), higher admission random blood sugar, and higher admission mean blood pressure were predictors of perioperative hyperglycemia (P- 0.046, 0.00, and 0.004, respectively) and severe hyperglycemia (P- 0.048, 0.00, and 0.031). In addition, female sex, prolonged duration of anesthesia, and surgery were also found to be the predictors of hyperglycemia (P- 0.025, 0.07, and 0.012). Increased ventilator, intensive care unit, and hospital days were associated with perioperative hyperglycemia and severe hyperglycemia, respectively (P ≤ 0.006/0.00, P ≤ 0.007/0.00, and P ≤ 0.038/0.00). Poor Glasgow Outcome Score at 1 and 3 months after discharge was associated with admission and perioperative hyperglycemia ([P ≤ 0.000/0.000 and P ≤ 0.000/0.000], respectively). However, no association was seen between mortality and hyperglycemia or severe hyperglycemia. Conclusion: A higher prevalence of hyperglycemia is present in aSAH patients. A higher incidence of perioperative hyperglycemia is associated with poor neurological outcomes. Hence, the identification of risk factors and meticulous perioperative control of hyperglycemia will help in preventing poor neurological outcomes.

Setting up a Neurosurgical Skills Laboratory and Designing Simulation Courses to Augment Resident Training Program.

Background: The surgical skill practice in neurosurgery is being compromised in the recent past owing to the duty time constraint, patient safety concerns, and medico-legal issues. Surgical practice outside the operating room is essential to enhance a resident's operative skills and to gain confidence. Objective: To discuss the experience of establishing an 'in-house neurosurgery skills laboratory' and various training sessions conducted with cadaveric and non-cadaveric simulation modules. Methods: A skills laboratory was set up in the existing resident teaching hall with nine workstations. Each station has been equipped with an operating table, surgeon's chair, basic microscope, endoscope, high-speed drill system, and a suction machine. Vascular anastomosis, high-speed drilling, and basic neuroendoscopy were planned on low-cost non-cadaveric modules. Craniotomy and various surgical approaches were designed on cadaveric modules obtained from the anatomy department. Result: A total of 18 residents in divided groups during their initial three semesters had participated in the non-cadaveric simulation courses. Twenty-six residents had participated and 12 sessions were conducted on the cadaveric modules. Three workshops were conducted and 20 residents and faculty members from five other institutions had participated in the cadaveric hands-on training session. Conclusion: A well-equipped skills laboratory provides an opportunity for the residents to acquire operative expertise in a similar atmosphere to that of the operating theater. A structured program comprising various operative practice sessions should be incorporated into the resident training program.

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.

Paradoxical Brain Herniation after Cranioplasty: Secondary Sunken Flap Syndrome.

Decompressive craniectomy is a life-saving procedure done for innumerable etiologies. Though, not a technically demanding procedure, it has its own complications. Among many, sinking flap syndrome or syndrome of the trephined or paradoxical herniation of brain is frequently underestimated. It results from the pressure difference between the atmospheric pressure and the intracranial pressure causing the brain to shift inward at the craniectomy site. This can present with either nonspecific symptoms leading to delay in diagnosis or acute neurological deterioration, memory disturbances, weakness, confusion, lethargy, and sometimes death if not treated. Cranioplasty is a time validated procedure used to treat paradoxical brain herniation with good and early neurological recovery. We, here in, are going to describe a case report in which the paradoxical herniation occurred after cranioplasty which has not been described in literature.

Goal-directed Fluid Therapy Versus Conventional Fluid Therapy During Craniotomy and Clipping of Cerebral Aneurysm: A Prospective Randomized Controlled Trial.

BACKGROUND: Fluid imbalance is common after aneurysmal subarachnoid hemorrhage and negatively impacts clinical outcomes. We compared intraoperative goal-directed fluid therapy (GDFT) using left ventricular outflow tract velocity time integral (LVOT-VTI) measured by transesophageal echocardiography with central venous pressure (CVP)-guided fluid therapy during aneurysm clipping in aneurysmal subarachnoid hemorrhage patients. METHODS: Fifty adults scheduled for urgent craniotomy for aneurysm clipping were randomly allocated to 2 groups: group G (n=25) received GDFT guided by LVOT-VTI and group C (n=25) received CVP-guided fluid management. The primary outcome was intraoperative mean arterial pressure (MAP). Secondary outcomes included volume of fluid administered and several other intraoperative and postoperative variables, including neurological outcome at hospital discharge and at 30 and 90 days. RESULTS: There was no difference in MAP between the 2 groups despite patients in group G receiving lower volumes of fluid compared with patients in group C (2503.6±534.3 vs. 3732.8±676.5 mL, respectively; P <0.0001). Heart rate and diastolic blood pressure were also comparable between groups, whereas systolic blood pressure was higher in group G than in group C at several intraoperative time points. Other intraoperative variables, including blood loss, urine output, and lactate levels were not different between the 2 groups. Postoperative variables, including creatinine, duration of postoperative mechanical ventilation, length of intensive care unit and hospital stay, and incidence of acute kidney injury, pneumonitis, and vasospasm were also comparable between groups. There was no difference in neurological outcome at hospital discharge (modified Rankin scale) and at 30 and 90 days (Extended Glasgow Outcome Scale) between the 2 groups. CONCLUSION: Compared with CVP-guided fluid therapy, transesophageal echocardiography-guided GDFT maintains MAP with lower volumes of intravenous fluid in patients undergoing clipping of intracranial aneurysms with no adverse impact on postoperative complications.

Pineal parenchymal tumor of intermediate differentiation: a systematic review and contemporary management of 389 cases reported during the last two decades.

Pineal parenchymal tumor of intermediate differentiation (PPTID) is a WHO grade II and III tumor arising from pineal parenchymal cells. PPTID is a rare tumor accounting for less than 1% of all primary central nervous system neoplasms. Therefore, reports describing the clinical characteristics and biological features of PPTID are lacking. Moreover, the therapeutic strategy remains controversial. The current study aimed to evaluate treatment results and problems of contemporary therapeutic modalities of PPTID based on its features compared with other pineal parenchymal tumors. A comprehensive systematic literature review of 69 articles was performed, including articles on PPTID (389 patients) and similar tumors. Patient demographics, disease presentation, imaging characteristics, biological features, and current therapeutic options and their results were reviewed. We found that histopathological findings based on current WHO classification are well associated with survival; however, identifying and treating aggressive PPTID cases with uncommon features could be problematic. A molecular and genetic approach may help improve diagnostic accuracy. Therapeutic strategy, especially for grade III and aforementioned uncommon and aggressive tumors, remains controversial. A combination therapy involving maximum tumor resection, chemotherapy, and radiotherapy could be the first line of treatment. However, although challenging, a large prospective study would be required to identify ways to improve the clinical results of PPTID treatment.

Computed tomography predictors of adult spinal cord injury without radiographic abnormality.

Objective: Elasticity of the skeletal system in children and degenerative changes in adults are responsible for SCIWORA. The purpose of this study was to determine those degenerative changes on CT scan that predispose adults to SCIWORA, their correlation with MRI findings, clinical presentation and recovery. Materials and Methods: This prospective study was conducted over a period of 1.5 years and 30 patients were enrolled. Apart from the demographic profile, mode of injury, clinical symptoms, ASIA at admission, X-ray, CT and MRI findings were noted. All patients were managed conservatively and were followed up after 3 months. NCCT and MRI findings were correlated with each other, with clinical presentation and with recovery. Recovery was defined as any improvement in ASIA class. Statistical Analysis: Data was collected and organized. For normally distributed data parametric test and for others non-parametric test was used. Kendall tau rank correlation coefficient was used to measure the ordinal association between two measured quantities. Results: 28 (93.3%) patients were males and 2 (6.7%) were females. Patients with osteoporosis and/or osteophytes (n = 16) had a higher incidence of development of cord edema or non-haemorrhagic contusion (n = 15) (P = 0.028) while patients with canal stenosis and/or ligamentous calcification (n = 14) had a higher incidence of development of haemorrhagic contusion (n = 12) (P = 0.04). Patients with canal stenosis and/or ligament calcification showed significantly less recovery (n = 3) when compared with patients of osteophytes and/or osteoporosis (n = 6) (P = 0.04). Disc abnormality was seen in 1 patient only. 9 patients showed recovery and maximum recovery was seen in ASIA D (n = 4) class while no patient recovered in ASIA A class. Conclusion: Osteoporosis, osteophytes, canal stenosis and ligament calcification are the factors that predispose adults to SCIWORA. The final outcome seems to be poorer in cases of canal stenosis when compared with osteophytes and osteoporosis. NCCT findings can be used as an adjunct to MRI to predict clinical presentation, severity and recovery in adult SCIWORA.

Effect of tranexamic acid on blood loss, coagulation profile, and quality of surgical field in intracranial meningioma resection: A prospective randomized, double-blind, placebo-controlled study.

BACKGROUND: Resection of intracranial meningioma has been associated with significant blood loss. Providing a clear surgical field and maintaining hemodynamic stability are the major goals of anesthesia during meningioma surgery. Tranexamic acid has been used to reduce blood loss in various neurosurgical settings with limited evidence in literature. A randomized, double-blind, and placebo-controlled trial was conducted to evaluate the efficacy of tranexamic acid on blood loss, coagulation profile, and quality of surgical field during resection of intracranial meningioma. METHODS: Thirty patients aged 18-65 years undergoing elective meningioma resection surgery were given either tranexamic acid or placebo (0.9% saline), tranexamic acid at a loading dose of 20 mg/kg, and infusion of 1 mg/kg/h during surgery. The intraoperative blood loss, coagulation profile, and the surgical field using Likert scale were assessed. RESULTS: The patients in tranexamic group had significantly decreased intraoperative blood loss compared to the placebo group (616.42 ± 393.42 ml vs. 1150.02 ± 416.1 ml) (P = 0.02). The quality of the surgical field was better in the tranexamic group (median score 4 vs. 2 on Likert Scale) (P < 0.001). Patients in tranexamic group had an improved coagulation profile and decreased blood transfusion requirement (p=0.016). The blood collected in closed suction drain in 24 h postsurgery was less in the tranexamic acid group compared to placebo group (84.7 ± 50.4 ml vs. 127.6 ± 62.2 ml) (P = 0.047). CONCLUSION: Tranexamic acid bolus followed by infusion reduces perioperative blood loss by 46.43% and blood transfusion requirement with improved surgical field and coagulation profile in patients undergoing intracranial meningioma resection surgery.