Surgical Management of Large (≥3 cm) Trigeminal Schwannomas: Functional Outcomes and Approach Selection in Multicompartmental Schwannomas.

Introduction Trigeminal schwannoma surgery has shown a remarkable improvement in functional recovery and tumor resection. In the era of radiosurgery, these outcomes need to be characterized for tumors which are outside the realm of being treated with radiosurgery. We present a series of trigeminal schwannomas larger than 3 cm, surgical approaches used, and outcomes with an emphasis on functional recovery in a high-volume center with radiosurgery facilities. Method All consecutive cases of trigeminal schwannoma from January 2012 to May 2021 which were more than 3 cm in size and underwent microsurgery were included in this series. The surgical approach, neurological outcomes, and extent of resection were defined objectively with pre/postoperative magnetic resonance imaging. Results A total of 83 such cases (>3 cm) were found, with cranial nerve symptoms (5th most common) being the commonest. Twenty three percent cases had blindness due to secondary optic atrophy and eighteen percent had long tract motor symptoms signifying the tumor burden in our series. Radiological gross total excision was achieved in 75.9% cases. Conclusion Large-volume schwannomas present with cranial nerve involvement and may need extensive skull base approaches. Functional outcomes need to be prioritized and can be achieved albeit with lesser gross resection rates. Hearing and facial preservation in addition to relief of trigeminal symptoms should be the goal of resection with minimal additional morbidity.

Deep brain stimulation in pediatric dystonia: calls for therapeutic realism over nihilism.

PURPOSE: Pediatric dystonia (PD) has a significant negative impact on the growth and development of the child. This study was done retrospectively to analyze functional outcomes in pediatric patients with dystonia who underwent deep brain stimulation. METHODS: In this retrospective analytical study, all the patients of age less than 18 years undergoing deep brain stimulation (DBS) for dystonia between 2012 and 2020 in a single center were analyzed and their functional outcomes were measured by the Burke-Fahn-Marsden-dystonia-rating-scale (BFMDRS). RESULTS: A total of 10 pediatric patients were included with a mean age of onset, duration of disease, and age at surgery being 5.75 years, 7.36 years, and 13.11 years, respectively, with a mean follow-up of 23.22 months. The mean pre-DBS motor score was 75.44 ± 23.53 which improved significantly at 6-month and 12-month follow-up to 57.27 (p value 0.004) and 50.38 (p value < 0.001), respectively. Limbs sub-scores improved significantly at both the scheduled intervals. There was a significant improvement in disability at 1-year follow-up with significant improvement in feeding, dressing, and walking components. There was a 27.34% and 36.64% improvement in dystonia with a 17.37% and 28.86% reduction in disability at 6 months and 12 months, respectively. There was a positive correlation between the absolute reduction of the motor score and improvement in disability of the patients at 6 months (rho = 0.865, p value 0.003). CONCLUSIONS: DBS in PD has an enormous role in reducing disease burden and achieving a sustainable therapeutic goal.

Pertinence of Streptococcus anginosus group in intracerebral abscesses in the era of extended antibiotic resistance.

AIMS: • To study the incidence of Streptococcus anginosus group (SAG) in pyogenic or community acquired intra cerebral abscess. • To understand the risk factors for the same. • To analyze the specific radiological features and clinical outcome after surgery and antibiotic therapy. METHODS: This is a retrospective observational study of case series over a period of one year. Patients diagnosed with intracerebral abscess were included in the study. Pus collected from were received in the laboratory and processed according to the standard protocols. Data regarding the clinical findings and demographics were collected from medical records. FINDINGS: A total of 202 samples were studied. 103 were found to be pyogenic. SAG were isolated from 21 samples (20.38%) and all the isolates were sensitive to Penicillin. Age of the patients ranged from 18months to 68years. Male preponderance was noted with male to female ratio of 4:1. Otogenic infections were the most common predisposing factors and focus of infection could not be ascertained in 5 patients. All patients were treated with surgical intervention and antibiotics (Vancomycin, Amikacin and Metronidazole) for 6 weeks and recovery was remarkable. One patient succumbed to the illness. CONCLUSION: SAG can be an aggressive pathogen with propensity for abscess formation. Chronic Suppurative Otitis Media (CSOM) is still a major cause of intracerebral abscess in developing country like India which is a benign and curable disease and should not be neglected. Injudicious use of antibiotics and negligence regarding the dose and duration of therapy from both patients and health care providers is the major cause for common infections to become more difficult to treat and succumbing to complications.

Delayed Vasospasm in Endoscopic Transsphenoidal Pituitary Surgery: Two Case Reports and Reviews.

Background: Cerebral vasospasm (CVS) due to injuries to arteries of the circle of willies has been reported in transsphenoidal pituitary surgeries. However, the incidence of delayed vasospasm following endoscopic transsphenoidal surgery is rare. Materials and Methods: Total 569 pituitary adenomas were operated on by endoscopic transsphenoidal approach from January 2016 to February 2020. We retrospectively described two cases of vasospasm following pituitary surgery from our institution. Objective: To describe two cases of delayed cerebral vasospasm following endoscopic transsphenoidal surgery and review previous literature. Results: Out of two patients, the Glasgow outcome score (GOS) of one patient was favorable and the other was unfavorable. Conclusion: CVS is rare after transsphenoidal pituitary surgery, which makes its predictability difficult. The clinician should maintain a high index of suspicion in patients with suprasellar extension of the tumor and postoperative hematoma in the tumor bed. Similarly, care should be taken in patients with a subarachnoid hemorrhage in basal cistern, intraoperative arachnoid breach, and postoperative meningitis.

Paediatric chronic subdural haematoma: what are the predisposing factors and outcomes in management of these cases?

INTRODUCTION: Chronic subdural hematoma (cSDH) is a disease of the elderly population. Incidence in paediatric population is relatively uncommon. Child abuse, birth trauma, coagulopathy and shunt surgeries represent major causes. Major impact of the disease on life of patient due to recurrence and repeat surgical procedure is significant, not to mention the burden on health care system. MATERIAL AND METHODS: We retrospectively reviewed our institute data for chronic sub-dural cases for the past 10 years (2008-2018) and collected data on the demography, clinical features, metabolic workup, mode of treatment, recurrence rates, predisposing factors, laterality, hematoma characteristics and factors associated with recurrence in all cases with less than or equal to 18 years of age. RESULTS: A total of 30 such cases were found in a period of 10 years (2008-2018). The mean patient age was 7.3 years (range 2 months-17 years), with 20 males (66.67%) and 10 females (33.33%). Raised intracranial pressure (n = 9) was the commonest presenting symptom in 30% of cases followed by seizures in 26.67% (n = 8). The previous shunt was the commonest predisposing factor seen in 43.33% (n = 13). cSDHs were unilateral in 56.67% cases (n = 17) and bilateral in 43.33% (n = 13). Burr hole craniostomy was done in 27 cases (90%), and conservative management was done in three cases (10%). Follow up was available for 27 cases (90%) with a mean follow up duration of 24 months. Recurrence rate was 30% (n = 9). Shunt surgery contributed to 77% of bilateral disease (p = 0.009). Child abuse was not reported in our series. CONCLUSION: Presence of paediatric cSDH is alarming, and the physician should be alerted to look for underlying cause and rule out child abuse. Detailed metabolic, skeletal workup is required. Treatment of primary pathology should be the goal as CSF diversion is not the solution to all problems, but can definitely be the cause of all the problems.

Syndromic Craniosynostosis: Objective and Parent-Reported Outcome Measurements after Cranio-Facial Remodelling Surgeries.

INTRODUCTION: Syndromic craniosynostosis (SC) is a rare entity compared to the non-syndromic variant. Treatment involves a multidisciplinary approach towards a multitude of problems. Early intervention is known to be better for optimum results. We reviewed outcomes of children with SC who underwent reconstructive cranio-facial surgery. MATERIALS AND METHODS: A retrospective study was conducted using data from hospital case files and the picture archival communication system. Objective data like the cephalic index (CI), both preoperatively and post-operatively, were compared. Subjective data for the cosmesis outcome - "Sloan and Whitaker outcome class" - following surgery were assessed. Also, parent-reported outcome measurement (PROM) was performed with various parameters to assess quality of life (QOL). RESULTS: We had 21 operated cases of SC, with 19 needing cranio-facial remodelling. The male to female ratio was 11:10. Crouzon's syndrome was the most common syndromic association followed by Apert's syndrome. Nineteen patients underwent cranio-facial remodelling surgeries and 2 underwent the ventriculo-peritoneal shunt only - for raised intracranial pressure (ICP). Nine patients underwent cranial remodelling with fronto-orbital advancements, and 3 of these patients also received le-fort's type 3 osteotomy and advancement later. Ten patients underwent fronto-orbital advancement with parieto-occipital barrel-stave osteotomies. OUTCOMES: Improvement in the CI was maximum at the 6-month follow-up. Six (37.5%) cases had Sloan class 1 outcome, 9 (56.25%) had class 2 outcomes, and 1 patient had a class 6 outcome. Whitaker cosmesis outcomes - 14 out of 16 cases (87.5%) had Category 1 outcomes. PROM was assessed. All parents reported at least a moderate improvement in cosmesis following surgery. Out of 15 cases, 10 (66%) reported significant improvement, while 4 (26.6%) cases reported moderate improvement with respect to eye and visual problems. Four parents reported snoring as a significant problem even after surgery. Most parents felt that the children were doing well, attending regular school, and social well-being was normal and had an overall good QOL. CONCLUSIONS: SC cases may have a multitude of other problems like raised ICP, ophthalmological problems, poor intelligence, and cognition apart from cosmetic concerns. PROMs revealed good outcomes in terms of cosmesis, cognition, and ophthalmological and oral cavity-related problems. Significant improvement in overall QOL was seen in most patients following cranio-facial remodelling surgery.

Anterior Odontoid Screw Fixation for C2 Fractures: Surgical Nuances, Complications, and Factors Affecting Fracture Union.

OBJECTIVE: Type II odontoid fractures are the commonest C2 fractures. The management of dens fractures remains controversial with various radiological and fracture morphological factors affecting the approach and outcomes. METHODS: All cases of anterior odontoid screw fixation between 2010 and 2020 were retrospectively analyzed. Patients' clinical, radiological (type of fracture, orientation, displacement, and diastasis), operative (single vs. double screw) and follow-up records were documented. The postoperative imaging findings were classified into grades I (excellent), II (good), and III (poor) based on the anatomical alignment with the screw. Follow-up cervical computed tomography was reviewed for fracture union. RESULTS: A total of 49 patients with a mean age of 37.3 ± 13.8 years were included in the study. The average time from injury to surgery was 23.1 ± 22.2 days. The bicortical screw purchase and superoposterior odontoid tip breach significantly affected the postoperative alignment (P = 0.035 each). Fracture union was noted in 41 (83.7%) patients. The horizontal fracture displacement ≥2.5 mm (P = 0.02) and poor postoperative fracture alignment (P < 0.001) resulted in worse fracture union rates. Transient dysphagia was the commonest complication (n = 12), whereas screw breakout (n = 2) and pullout (n = 2) were other hardware-related complications. One patient underwent re-exploration for screw readjustment and 2 underwent posterior instrumentation. CONCLUSIONS: Anterior odontoid screw fixation is technically straightforward, less morbid, and preserves biomechanical cervical mobility, when compared with the posterior instrumentation. With careful patient selection, meticulous surgical planning, and intraoperative image-guided screw insertion, good fracture union outcomes can be obtained. In the current study, we were able to achieve stable fracture union in 83.7% patients.

Management of Neurosurgical Cases in a Tertiary Care Referral Hospital During the COVID-19 Pandemic: Lessons from a Middle-Income Country.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) pandemic has been at its peak for the past 8 months and has affected more than 215 countries around the world. India is now the second most-affected nation with more than 48,000,000 cases and 79,000 deaths. Despite this, and the fact that it is a lower-middle-income nation, the number of deaths is almost one third that of the United States and one half that of Brazil. However, there has been no experience published from non-COVID-19-designated hospitals, where the aim is to manage noninfected cases with neurosurgical ailments while keeping the number of infected cases to a minimum. METHODS: We analyzed the number of neurosurgical cases (nontrauma) done in the past 5 months (March-July 2020) in our institute, which is the largest neurosurgical center by volume in southern India, and compared the same to the concurrent 5 months in 2019 and 5 months preceding the pandemic. We also reviewed the total number of cases infected with COVID-19 managed during this time. RESULTS: We operated a total of 630 cases (nontrauma) in these 5 months and had 9 COVID-19 infected cases operated during this time. There was a 57% (P = 0.002) reduction in the number of cases operated as compared with the same 5 months in the preceding year. We employed a dual strategy of rapid antigen testing and surgery for cases needing emergency intervention and reverse transcriptase-polymerase chain reaction test for elective cases. The hospital was divided into 3 zones (red, orange, and green) depending on infectivity level with minimal interaction. Separate teams were designated for each zone, and thus we were able to effectively manage even infected cases despite the absence of pulmonology/medical specialists. CONCLUSIONS: We present a patient management protocol for non-COVID-19-designated hospitals in high-volume centers with the constraints of a lower-middle-income nation and demonstrate its effectiveness. Strict zoning targeted testing and effective triage can help in management during the pandemic.

Indian Society of Pediatric Neurosurgery Consensus Guidelines on Preventing and Managing Shunt Infection: Version 2020-21.

BACKGROUND: Shunt infection is the most significant morbidity associated with shunt surgery. Based on the existing literature for the prevention and management of shunt infection, region and resource-specific recommendations are needed. METHODS: In February 2020, a Guidelines Development Group (GDG) was created by the Indian Society of Paediatric Neurosurgery (IndSPN) to formulate guidelines on shunt infections, which would be relevant to our country and LMIC in general. An initial email survey identified existing practices among the membership of the IndSPN, and eight broad issues pertaining to shunt infection were identified. Next, members of the GDG performed a systematic review of the literature on the prevention and management of shunt infection. Then, through a series of virtual meetings of the GDG over 1 year, evidence from the literature was presented to all the members and consensus was built on different aspects of shunt infection. Finally, the guidelines document was drafted and circulated among the GDG for final approval. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to grade the evidence and strength of recommendation. RESULTS: The guidelines are divided into eight sections. Level I and Level II evidence was available for only five recommendations and led to a moderate level of recommendations. Most of the available evidence was at Level III and below, and hence the level of recommendation was low or very low. A consensus method was used to provide recommendations for several issues. CONCLUSIONS: Although most of the recommendations for the prevention and management of shunt infections are based on a low level of evidence, we believe that this document will provide a useful reference to neurosurgeons not only in India but also in other low and middle income countries. These guidelines need to be updated as and when new evidence emerges.

Effect of Gamma Knife Radiosurgery on Vestibular Schwannoma with Serviceable Hearing: A Single-Center Indian Study.

OBJECTIVE: Gamma Knife radiosurgery (GKRS) is an established treatment modality for vestibular schwannomas (VSs). The tumor control and hearing preservation rates suggest that GKRS is a good alternative treatment for small- and medium-size VS. Data are lacking from India regarding GKRS for VSs. Our aim was to find the hearing preservation and tumor control rates and the factors contributing to these. METHODS: In a retrospective 9-year study period, 87 patients had undergone GKRS for unilateral VS with Gardner-Robertson (GR) class I or II serviceable hearing. All 87 had been evaluated with magnetic resonance imaging and audiometry before GKRS and during follow-up to assess for the factors influencing tumor control and hearing preservation. RESULTS: Of the 87 patients, 77 with a minimum follow-up of 2 years and magnetic resonance imaging and audiometry evaluations available were included in the present study. The median follow-up period was 30 months. The tumor control rate and hearing preservation rate was 96.1% and 79.2%, respectively. Hearing preservation was not affected by the tumor volume. However, age >40 years, pre-GKRS pure tone average <30 decibels, speech discrimination score >85%, pre-GKRS Gardner-Robertson grade I hearing, mean cochlear dose <4 Gy, and pre-GKRS Ohata class of laterality C, D, E were significant on univariate analysis. The multivariate analysis revealed that age >40 years (P = 0.017), pre-GKRS pure tone average <30 decibels (P = 0.002), and Gardner-Robertson class I (P = 0.001) were significant factors. No patient developed cranial nerve dysfunction, hydrocephalus, or malignant degeneration. CONCLUSION: For most patients with small VSs, GKRS will be an effective alternative treatment to microsurgery with retained serviceable hearing and good tumor control.

Experience of pallidal deep brain stimulation in dystonia at a tertiary care centre in India: An initial experience.

INTRODUCTION: Dystonia is one of the most prevalent forms of movement disorders and is characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive, movements, postures, or both. Dystonia causes significant morbidity with an adverse impact on the quality of life. When dystonia is medically refractory, causing severe pain and impairment in activities of daily living, deep brain stimulation (DBS) of the globus pallidus interna (GPi) is a potential option to reduce disability. MATERIALS AND METHODS: This is a chart review of patients who underwent DBS for dystonia (from 2009 to 2015) at our tertiary referral centre. A total of ten patients (7 males, 3 females) underwent DBS for non-parkinsonian conditions. The patients were selected after failure of adequate medical management. All the patients had a severe disability with normal cognitive (Mini-Mental State Examination) and psychiatric profile. They also had to have a suitable GPi for DBS based on magnetic resonance imaging. RESULTS: The mean baseline Burke-Fahn-Marsden dystonia movement score of the 10 patients selected for surgery was 60.3 ± 27.3 (ranging from 19 to 104). On repeated-measures analysis of variance, there was significant difference in the different time points (pre-DBS, post-DBS at 3 months, 6 months, and 1 year) F (3, 5) = 7.68, P = 0.026. The data showed that there was a maximum improvement after 1 year of stimulation (pre-DBS vs. 3 months 12.9 ± 1.9 vs 8.8 ± 2.1, P = 0.01; pre-DBS vs. 6 months 12.9 ± 1.9 vs 7.4 ± 1.6, P = 0.04; pre-DBS vs. 1 year, 12.9 ± 1.9 vs. 7 ± 2.4. CONCLUSION: In medically refractory primary or secondary dystonia patients, bilateral GPi DBS can be considered as an option. Patients with disabling symptoms that significantly deteriorate activities of daily life may consider DBS before these symptoms become fixed.

Does lesioning surgery have a role in the management of multietiological tremor in the era of Deep Brain Stimulation?

INTRODUCTION: Surgical management of tremor has evolved over the years with Deep Brain Stimulation (DBS) gradually supplanting lesioning as the mainstay in treatment. In this article, the largest of its kind from our country, we present our experience in the use of lesioning in the management of patients with multietiological tremors. These include not only common indications like Parkinson disease and essential tremor but also rare causes such as Pantothenate kinase associated neurodegeneration (PKAN), multiple sclerosis (MS) and Wilson disease. MATERIALS AND METHODS: Patients with medically refractory tremor who underwent surgery were included in the analysis. A comprehensive clinical and radiological evaluation was performed which was repeated 3 months postoperatively and at successive visits. Video documentation of was obtained at all visits. RESULTS: A total of 21 patients (18 men, 3 women) with an average age 37.7 years (range 21-65 years) underwent stereotactic thalamotomy/subthalamotomy at our institute between 2008 and 2013, for the treatment of medically refractory tremor of varying etiologies. The mean preoperative duration of symptoms was 11 years (range 10 months to 34 years). The median time to onset of improvement was 2 months (range 1 week to 8 months). Analyzing the improvement on the modified FTM scale, in part 1 the scores improved from 21.7 to 1.5, the part II subset improved from an average of 9.2 to 3.2 while the part III subset improved from an average of 14.1 to 4.1 postoperatively. This implied an excellent response in tremor while the other 2 components had a very good response. DISCUSSION: In this study we have for the first time objectively analyzed the tremor improvement with a modified FTM scale and have produced excellent results. We have also shown that tremor of various etiologies respond extremely well to lesioning surgery. While DBS continues to remain the treatment of choice in various types of bilateral tremor, lesioning is very successful in a carefully selected cohort of patients. We are of the opinion that in predominantly unilateral tremor or when the patient cannot afford DBS especially in a country like ours, lesioning surgery is an important tool in the armamentarium of the functional neurosurgeon.

MRS findings in cerebral coenurosis due to Taenia multiceps.

Cerebral coenurosis due to Taenia multiceps is a rare infection with no case reports from India. A 55-year-old male patient had presented with progressive symptoms of hemiparesis of 1-year duration. Magnetic resonance imaging (MRI) with magnetic resonance spectroscopy (MRS) of the lesion was performed that showed a septated cystic lesion in left parieto-occipital lobe. Multivoxel MRS through the lesion was performed using repetition time of 1500 ms and time to echo of 144 ms at 3T MRI. MRS showed mildly elevated choline (Cho), depressed creatine (Cr), and N-acetyl aspartate (NAA), a large peak of lactate, pyruvate, and acetate peaks. To best of our knowledge, there has been no reported case of in vivo proton MRS finding ever reported. We present MRS findings in this operatively proven case of T. multiceps cyst of the brain.

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.

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.

Intracranial hemangioblastomas: an institutional experience.

BACKGROUND AND AIMS: We present our Institutional experience with intracranial hemangioblastomas. SETTINGS AND DESIGN: A retrospective study. MATERIALS AND METHODS: This study included all patients of intracranial hemangioblastomas admitted in our institution over a period of 11 years from January 1992 through June 2003. RESULTS: There were a total of 69 patients (45 males and 24 females). The average age at presentation was 34.5 years. The tumor was located in the cerebellar hemispheres, vermian and brainstem regions in 42 (60%) patients, 19 (28%) patients and 8 (12%) patients, respectively. Hydrocephalus was seen in 48 (69%) patients. Thirty-three patients underwent CSF diversion procedures prior to surgery on the tumor. All except one underwent definitive surgery. The mortality was 8 (11%). Sixty eight patients underwent surgery on the tumor. The follow-up ranged from 1 month to 11 years. Fifteen patients developed recurrent lesions. CONCLUSION: Lifelong surveillance is necessary in cases with hemangioblastomas to identify recurrences especially in those patients having VHL syndrome.