Gamma Knife Stereotactic Radiosurgery for Giant Intracranial Tumors - A Series of 70 Patients.

Background and Objective: Surgery remains the primary option in large intracranial tumors, but significant number of patients may not be amenable for surgery. We explored the role of stereotactic radiosurgery as an alternative to external beam radiation therapy (EBRT) in such patients. Our study objective was to assess the clinicoradiological outcomes of large intracranial tumors (volume ≥20 cm3) managed with gamma knife radiosurgery (GKRS). Materials and Methods: This was a single-center, retrospective study conducted from January 2012 to December 2019. Patients with intracranial tumor volume ≥20 cm3 who received GKRS and had a minimum of 12 months of follow-up were included. Clinical, radiological, and radiosurgical details and clinicoradiological outcomes of the patients were obtained and analyzed. Results: Seventy patients who had a pre-GKRS tumor volume ≥20 cm3 with >12 months of follow-up were included. The mean age of the patients was 41.9 ± 13.6 (range 11-75) years. Majority (97.1%) received GKRS in a single fraction. Mean pretreatment target volume was 31.9 ± 15.1 cm3. At a mean follow-up of 34.2 ± 17.1 months, tumor control was achieved in 91.4% (n = 64) of the patients. Adverse radiation effects were observed in 11 (15.7%) patients, but were symptomatic in only one (1.4%) patient. Conclusion: The present series defines "large intracranial lesions" for GKRS and demonstrates excellent radiological and clinical outcomes in these patients. GKRS may be considered as the primary option in such large intracranial lesions in which surgery carries significant risk based on patient-related factors.

Suicide hangings during pre-Covid-19 and Covid-19 - Myths debunked for the lower-middle-income group countries.

The psyche about the adverse effects of the Covid-19 pandemic has got fixed to a level of conviction that committing suicide is directly linked to coronavirus infection. The statistics of suicidal hangings for the pre-Covid-19 and the Covid-19 periods were compared in the Indian capital. The data analysis of the autopsy records showed the absence of temporal association between the incidence rates of suicides between these two periods. The study concludes that there was no net increase in suicide rates in the study population of this lower-middle-income group country during the Covid-19 pandemic.

Correction of pediatric cervical kyphosis with standalone posterior approach-a single-center experience of seven cases.

PURPOSE: To study clinical and radiological outcomes of pediatric cervical kyphosis correction with a standalone posterior cervical approach. Cervical spine kyphotic deformity in pediatric age group is a distinct entity and the management is challenging. Pediatric cervical kyphosis is less often encountered, and literature is sparse with only few case series. Management algorithms are devised keeping the flexibility of the deformity at the core of decision making. Circumferential fusion is mostly recommended for non-flexible (rigid) kyphosis. METHODS: Authors present a single center retrospective analysis of cases of pediatric cervical kyphosis managed by a standalone posterior approach. Pre- and post-operative clinical and radiological parameters were recorded and analyzed. Changes in neurological status, kyphosis correction and bony fusion were assessed. Surgical and implant related complications were noted. RESULTS: Seven cases (6 male, 1 female) were included. Mean age was 13.9±2.9 years, ranging from 8-17 years. Etiology was traumatic in 2 cases, developmental in 2, and syndromic, Hirayama disease and post-laminectomy in 1 case each. Mean kyphosis correction was 36.80±19.30 (87%±21%) with a mean pre-operative kyphosis angle of 37.80±15.30 and mean immediate post-operative kyphosis angle of 3.70±8.70. Mean hospital stay duration was 10±6 days. Median follow-up duration was 36 months. Myelopathy improved in 5 cases at last follow-up. Six cases demonstrated bony fusion at a mean follow-up of 8.4±1.5 months. CONCLUSION: Significant immediate correction in pediatric cervical kyphosis may be achieved with a standalone posterior approach with proper planning and technique in selected cases. Inserting pedicle screws at strategic locations of implant construct offer better corrections and pull-out strength and maintain long-term stability resulting in higher arthrodesis rates. Larger studies with longer follow up are needed to further ascertain the role of standalone posterior cervical approaches in pediatric cervical kyphosis.

High-Entropy Alloys for Solid Hydrogen Storage: Potentials and Prospects.

Hydrogen storage is one of the most significant research areas for exploiting hydrogen energy economy. To store hydrogen with a high gravimetric/volumetric density, gaseous hydrogen storage systems require a very high-pressure compressed gas cylinder which is quite unsafe and the storage in the liquid form needs cryogenic containers to be maintained at roughly 20 K under ambient pressure because hydrogen has a very low critical temperature of 33 K. However, hydrogen can be stored in solid materials with higher concentration of hydrogen compared to the gaseous and liquid hydrogen storage systems. It is therefore, worthwhile to look into the experimental and theoretical research on prospective hydrogen storage materials. The hydride-forming alloys and intermetallic compounds are found to be the most important families of hydrogen storage materials. Multicomponent alloys consisting of five or more principal elements, also known as high-entropy alloys appear to have potential for the development as hydrogen storage materials. Hydride-forming elements like Ti, Zr, V, Nb, Hf, Ta, La, Ce, Ni, and others have been shown to have hydrogen storage properties and the ability to produce single-phase high-entropy intermetallics. Here, attempts will be made to present a short review on utilization of multicomponent high-entropy alloys as solid hydrogen storage materials. Furthermore, we will also present some of our work on the synthesis, structural-microstructural characterization and hydrogen storage properties of Ti-Zr-V-Cr-Ni equi-atomic hydride-forming high-entropy alloys. From the preliminary investigation, the maximum storage capacity in this system was observed to be 1.78 wt%, which is comparable to other hydrogen storage materials. The prospects of high-entropy-based alloys for hydrogen storage will be discussed.

Crouzon's Syndrome with a Dominant Sinus Pericranii Draining Transverse Sinus: Report of a Rare Association and Review of Literature.

INTRODUCTION: Crouzon's syndrome and sinus pericranii (SP) are rare entities. Only few cases having both the features are reported. SP most commonly drains in relation to superior sagittal sinus and their communication to major posterior dural sinuses is rare. CASE REPORT: We report a rare case of Crouzon's syndrome with SP at a suboccipital location with termination of left transverse sinus into the SP draining further through the extracranial suboccipital and extravertebral cervical venous plexi into external jugular veins. Distal transverse sinus and sigmoid sinus on the left side were absent. CONCLUSION: Crouzon's syndrome with SP is an extremely rare entity. SP with communication to major posterior dural venous sinuses is also rare and mostly associated with multi-suture craniosynostosis. Management depends on the volume of venous blood they are draining. Most of them are dominant type and their occlusion is not feasible. Preoperative diagnosis of a dominant SP is essential for proper surgical planning as it needs to be preserved mandatorily to prevent cerebral venous infarction.

Effect of External Ventricular Drain Tunnel Length on Cerebrospinal Fluid Infection Rates-A Bayesian Network Meta-Analysis.

BACKGROUND: External ventricular drain (EVD)-associated cerebrospinal fluid infection (EACI) remains a major complication associated with EVD. Length of EVD tunnel, an overlooked but modifiable factor, can be associated with increased risk of EACI. The aim of this study is to find the tunnel length associated with least chances of EACI by performing a network meta-analysis. METHODS: A comprehensive search of different databases was performed to retrieve studies that studied the rates of EACI with different EVD tunnel lengths and a Bayesian network meta-analysis was performed. RESULTS: Six studies met the inclusion criteria and were included in the network meta-analysis. With 0 cm tunnel length as reference, the odds ratio (OR) for developing EACI was minimum for tunnel length 5-10 cm (OR, 0.027). It was followed by tunnel length of 5 cm (OR, 0.060) and 10 cm (OR, 0.075). The surface under the cumulative ranking curve plot showed that the probability of the tunnel length 5-10 cm (ranked first), 5 cm (ranked second), and 10 cm (ranked third) for being the best EVD tunnel length was found to be 86%, 64%, and 61%, respectively. CONCLUSIONS: The length for which an EVD is tunneled may have an impact on the rate of EACI. Our network meta-analyses showed that the tunnel length of 5-10 cm was associated with the lowest rates of EACI, with 86% probability of being the best EVD tunnel length. The probability of a patient with 5-10 cm EVD length developing EACI was 2.7% compared with zero tunnel length.

Seed inhabiting bacterial endophytes of maize promote seedling establishment and provide protection against fungal disease.

Bacteria from different crops and plant varieties have been shown to possess enormous growth promotional attributes. The study aimed to investigate the role of the endophytic microbiome of seeds of corn in improving the growth of seedlings of two different varieties of maize crops (K-25 and baby corn). Furthermore, the study also assessed the role of these bacteria in the protection of seedlings from fungal pathogens. Total twenty-three endophytic bacterial strains were isolated from maize seeds and identified using 16S rDNA sequencing. Most of the isolates had the ability to synthesize auxin (70 %) and solubilize phosphate (74 %), while all the isolates showed nitrogen fixation ability. Some isolates also showed antagonistic activity against phytopathogenic fungi including Rhizoctonia solani and Fusarium sp. suggesting their biocontrol potential. The presence of different lipopeptide genes including bacillomycin D, fengycin, iturin A and surfactin was confirmed in some of the isolates. We observed that treating seeds with an antibiotic compromised the seedlings' growth; however, re-inoculation with endophytic isolates (ZM1/Lysinibacillus sp. and ZM2/Paenibacillus dendritiformis) restored the growth of the seedlings in terms of improved root and shoot development in comparison to non-inoculated controls. The colonization of inoculated bacteria on the root surface was visualized using fluorescent microscopy. Seedling protection assay showed that treated seeds (with ZMW8/ Bacillus velezensis) were protected from fungal infestation (Fusarium verticillioides) even after 12 days of inoculation in comparison to the uninoculated control. The study concludes that indigenous seed-associated bacteria of maize play a major role during seed germination, seedling formation and protect them from phytopathogens.

Management of Myelopathy due to Anterior Soft-Tissue Compression in Vertebral Hemangioma.

OBJECTIVE: Vertebral hemangiomas are benign but highly vascular lesions and are one of the most common lesions of the vertebral column. Anterior soft-tissue compression of spinal cord due to vertebral body hemangioma is challenging to manage. Our objective was to assess long-term clinical and radiologic effects of direct transpedicular absolute alcohol embolization, laminectomy, and short-segment instrumented fusion on resolution of extraosseous epidural soft tissue and improvement in myelopathy in cases of vertebral hemangioma causing anterior soft-tissue compression. MATERIALS AND METHODS: This was a retrospective analysis that included patients with single-level vertebral hemangioma with anterior intraspinal soft-tissue growth causing spinal cord compression and clinical features of myelopathy between June 2007 and June 2019 at authors' institute. Transpedicular vertebral body injection of absolute alcohol, laminectomy, and pedicle screw rod instrumentation was performed in all patients. Clinicoradiologic outcomes of surgery were noted. We proposed a grading system for the extent of anterior extraosseous epidural soft-tissue compression. RESULTS: In total, 14 patients were included in study. Their mean age was 28.4 ± 14.4 years. Mean follow-up duration was 67.5 ± 36.2 months. All patients had preoperative radiologic grade 4 compression. Postoperative radiologic grading improved to grade 1 in 4 (28.6%), grade 2 in 8 (57.1%), and grade 3 in 2 (14.3%). All the patients improved neurologically after surgery. Eleven patients improved to American Spinal Injury Association (ASIA) grade E, 2 improved to ASIA D, and 1 improved to ASIA C at the last follow-up visit. CONCLUSIONS: Vertebral hemangiomas with anterior extraosseous epidural extension causing spinal canal compromise and myelopathy can be managed with direct transpedicular ethanol embolization, laminectomy, and short-segment instrumented fusion with resolution of the extraosseous soft tissue and improvement in myelopathy. The procedure is relatively simple, cost effective, and has a good outcome.

Video Section-Operative Nuances: Step by Step - Donning and Doffing in Neurosurgical Operating Room.

BACKGROUND AND INTRODUCTION: Donning and doffing of personal protective equipments (PPE) has become relevant especially during COVID-19 pandemic and neurosurgeons operating upon COVID-19 positive or suspect patients should be aware of proper technique of donning and doffing of PPE.[1] Surgeries involving direct exposure of anterior nasal spaces/paranasal sinuses carry significantly more risk of infection and it may be prudent to use PPE while operating all such cases.[2]. OBJECTIVE: In this video, we present our extensive protocol of donning and doffing of PPE which we have devised for our operating room. TECHNIQUE: Donning consists of wearing of the PPE in a proper sequence so as to afford maximal protection from viral infection while conducting the surgical procedure. Various components of PPE and procedure of donning is shown followed by doffing, the sequential and safe removal of the PPE. RESULTS: A meticulous method of donning and doffing PPE for neurosurgeons handling COVID-19 positive / suspect cases has been shown . CONCLUSION: Proper sequence of donning and doffing of PPE gear is of crucial importance during the COVID pandemic to prevent infection to the health care workers while handling COVID-19 positive/suspect cases and this video demonstrates the protocol we use at our institute.

Endoscopic Management of Fourth Ventricle Neurocysticercosis: Description of the New Technique in a Case Series of 5 Cases and Review of the Literature.

BACKGROUND: Around 7%-33% of cases of neurocysticercosis (NCC) have intraventricular involvement, and the fourth ventricle is the most frequent site. Medical management and various surgical approaches have been described for treating this disease. The objective of this study was to describe technical modification for endoscopic fourth ventricular NCC removal in a series of 5 cases. METHODS: In this study (January 1, 2016, to December 31, 2017), all cases of fourth ventricular NCC which were treated with a special technique (endoscopic transcortical transforaminal transaqueductal approach) using a rigid endoscope system and 6-French infant feeding tube (IFT) were included in the study. The IFT was passed through the main channel, the cyst was engaged at the tip by applying gentle suction with a 20 cm3 syringe, and the cyst was removed along with the whole endoscopic assembly. Patient's clinical, radiologic, and follow-up data were retrieved from the department database records. RESULTS: Five patients (3 men, 2 women; mean age, 20 years; range, 11-27 years) were enrolled. All patients had features of raised intracranial pressure. Two patients also had drop attacks, and one presented with altered sensorium and one had upgaze palsy. Duration of symptoms ranged from 3 months to 3 years. All patients had isolated fourth ventricular NCC with obstructive hydrocephalus. Complete removal of the neurocysticercal cyst could be performed in all patients without any injury to the periaqueductal region or fornix. There was no intraoperative rupture of the neurocysticercal cyst. On follow-up (range, 12-28 months; mean, 19.4 months), all patients had relief of symptoms and imaging showed no cyst and hydrocephalus. CONCLUSIONS: We conclude that our endoscopic approach is safe, simple, cost-effective, and allows minimally invasive removal of the fourth ventricle cyst and treatment of hydrocephalus without any morbidity.

Traumatic Posterior Fossa Extradural Hematoma: Experience at Level I Trauma Center.

INTRODUCTION: Posterior fossa extradural hematoma (PFEDH) is rare among the traumatic brain injury and represent about 4-7% cases of all EDHs. This rare condition is rapidly fatal unless identified and intervened timely. Because of limited space in posterior fossa, comparatively small volume can cause clinical deterioration. Early diagnosis by cranial computed tomography and emergent evacuation is vital for a good outcome. MATERIALS AND METHODS: This study was conducted at Level I trauma center at All India Institute of Medical Sciences, New Delhi, India. Hospital medical records were reviewed from September 2007 to June 2015. There were 856 cases of acute EDHs and of these 69 cases had PFEDHs. Records of patients with PFEDHs were reviewed for the mode of injury, Glasgow Coma Scale (GCS) at admission, imaging, type of intervention, outcome, and follow-up. GCS was assessed at 6 months and 12 months follow-up. Pertinent literature is reviewed. RESULTS: Of these 69 patients, 51 were males and 18 females. The mean age of patients was 28.6 years (range 4-43 years). Forty-three patients had GCS 15 at admission, and only 4 of them had admission GCS <8. Mean EDH volume was 29.2 ml. Sixty-six patients were operated, three managed conservatively. Sixty-seven patients were discharged, of which, 56 (81.1%) had GCS 15. Two patients died. Most common associated injuries were long bone fractures (18, 26.1%) followed by blunt injury thorax (11, 15.9%). Mean follow-up duration was 69.2 months (range 6-94 months). At 6 months follow-up, 61 (88.4%) patients had good recovery (Glasgow Outcome Score [GOS] 5) and at 12 months, 62 (89.8%) had GOS 5. CONCLUSION: PFEDH are rare. They are usually associated with occipital bone fractures and may also have a supratentorial hematoma. It may be rapidly fatal due to the expansion of hematoma and compromise of the posterior cranial fossa space leading to brainstem compression, tonsillar herniation, and/or obstructive hydrocephalus. Early diagnosis and emergent evacuation lead to good outcome.

Mycosynthesis of bactericidal silver and polymorphic gold nanoparticles: physicochemical variation effects and mechanism.

AIM: Extracellular synthesis of silver and gold nanoparticles using aqueous cell-free filtrate (CFF) of endophytic Chaetomium globosum and characterization of its bioactive proteins. METHODS: Temperature and pH gradients were used to assess their effects on dimensions of NPs. NPs were tested in vivo for antibacterial activity. MALDI-TOF-MS/MS was used for characterization of CFF proteins. RESULTS: Fungal CFF fabricated nanoparticles of various shape under varied physicochemical conditions. Silver nanoparticles showed significantly (p ≤ 0.5) enhanced antibacterial activity against Staphylococcus aureus and Klebsiella pneumoniae compared with AgNO3. Two prominent CFF proteins showed homology with benzoate 4-monooxygenase cytochrome P450 and ubiquinol-cytochrome c reductase. CONCLUSION: The study achieved controlled mycosynthesis of NPs and explains the hitherto poorly known mechanism of reduction, stabilization and antibacterial activity of nanoparticles.

Fatal Superior Sagittal Sinus and Torcular Thrombosis After Vestibular Schwannoma Surgery: Report of a Rare Complication and Review of the Literature.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare condition with the potential to cause severe morbidity and mortality. CVST can also occur after vestibular schwannoma (VS) surgery with the thrombosis of transverse and sigmoid sinus. However, there is not a single report of superior sagittal sinus (SSS) thrombosis after VS surgery reported in the literature. CASE DESCRIPTION: A 45-year-old woman presented to our center with large left-sided solid cystic VS. On admission she was dehydrated, and after clinical stabilization, she underwent gross total excision of tumor through left retromastoid suboccipital craniotomy after cerebrospinal fluid drainage through an external ventricular drain. Surgery was uneventful, but postoperatively she had an episode of seizure. Immediate postoperative computed tomography (CT) brain scan was normal with good operative cavity. However, 24 hours later, she developed left-sided motor deficit, and a repeat CT scan showed right frontal parenchymal hemorrhage with intraventricular extension. On further evaluation, magnetic resonance venography showed entire SSS thrombosis, with patent bilateral transverse and sigmoid sinuses. She was not started on the anticoagulants in view of intracranial hemorrhage. Subsequently, she underwent right-sided decompressive craniectomy because there was progressive deterioration in her Glasgow Coma Scale, and she succumbed despite all efforts. Retrospectively, dehydration and intracranial hypotension could be likened to her sinus thrombosis. CONCLUSIONS: This case underscores the significance of adequate optimization of the patients prior to surgery, besides adequate operative skills to avoid this rare but serious complication of SSS and torcular thrombosis after VS surgery.

Medial sphenoid wing meningiomas: Experience with microsurgical resection over 5 years and a review of literature.

BACKGROUND: Medial sphenoid wing meningiomas are medially located tumors on the sphenoid wing with attachment over the anterior clinoid process. They represent a distinct entity. These medial sphenoid wing meningiomas present a more difficult problem for the neurosurgeons because in a majority of cases, they involve the anterior visual pathways and arteries of the anterior circulation and may invade the cavernous sinus (CS). Higher morbidity, mortality and recurrence rates have been observed in these tumors compared with meningiomas in other locations. The rate of recurrence for medial sphenoid wing meningiomas is reported as being one of the highest amongst intracranial meningiomas. MATERIAL AND METHODS: The authors retrospectively analyzed 78 consecutive patients with the diagnosis of medial sphenoid wing meningioma who were operated in our department from January 2008 to December 2012. RESULTS: These patients, having a meningioma of the medial sphenoid ridge, were divided into two types depending on the involvement of CS. Diplopia, internal carotid artery encasement, and postoperative visual deterioration were more common in Type 2 tumors. Similarly, extent of resection and postoperative morbidity were greater in Type 2 patients. CONCLUSIONS: CS invasion confers an added risk to the surgical morbidity and outcomes. However, with proper surgical techniques, optimum outcomes can be achieved and overall surgical results at our center are found to be comparable to that of the current literature.

Giant calvarial cavernous hemangioma.

Though hemangiomas of the bone are quite common, calvarial (skull) cavernous hemangiomas are relatively rare pathologies. Calvarial hemangiomas are usually small and asymptomatic. However, they may occasionally grow in size to achieve large sizes and can present as a palpable swelling. We present a child with massive temporo-parieto-occipital calvarial cavernous hemangioma, who was managed with a multimodal approach with excellent cosmetic and neurologic outcome.

Orbital roof intradiploic meningioma in a 16-year-old girl.

Primary intraosseous or ectopic meningioma of the skull is a rare tumor accounting for about 1% of meningioma. Intradiploic meningioma is an extremely rare type of extraneuraxial meningiomas. Intradiploic meningioma of the orbit is extremely rare, and <8 such cases are reported till date in western literature occurring in the pediatric age group. Here the authors present a case of 16-year-old female, who presented with progressive proptosis, with normal vision and was managed successfully surgically. Clinical features, pathophysiology, and surgical management of this rare entity are discussed in the context of pertinent literature.

Giant intradiploic arachnoid cyst for 13 years.

A case of intradiploic arachnoid cyst is reported. The patient presented with a progressively enlarging swelling situated over left frontal region for approximately 13-years following blunt trauma to head. Magnetic resonance imaging showed an intradiploic fluid containing cyst having intensity like cerebrospinal fluid (CSF). He underwent craniotomy and successful surgical repair. Intraoperatively CSF cyst was located in the frontal pole with a large defect over inner table and large rent in the dura. It was lined with arachnoid membrane. Pertinent literature is reviewed in brief.

Giant choroid plexus papilloma of the lateral ventricle in fetus.

Choroid plexus papillomas (CPPs) are rare tumors having bimodal distribution. Pediatric CPPs are commonly present in supratentorial compartment and most commonly located in lateral ventricle and usually present at 16-18 months. Authors could find only one case report of fetal choroid plexus papilloma in the literature. In the present case, authors illustrate an unusual presentation of CPP with raised intracranial pressure (ICP) since birth, the need for proper preoperative planning, meticulous surgical technique, and intensive intra operative monitoring for normothermia, fluid-electrolyte balance, and blood replacement for achieving excellent results.