Treatment Dilemma of Latrogenic Pseudoaneurysm of the Intracavernous Internal Carotid Artery in Young Girl Following Transnasal Transsphenoidal Surgery: A Case Report.

Epistaxis following transnasal transsphenoidal (TNTS) removal of pituitary adenoma can be massive and life-threatening. The intracranial source of bleeding is usually the intracavernous segment of the internal carotid artery (ICA) or adjacent branches. Injury to the cavernous ICA can lead to pseudoaneurysm (PA) or fistula formation. Management of PA is different from saccular aneurysms. A timely diagnosis and adequate management can restore vessel integrity and prevent associated morbidity. A young patient of growth hormone-secreting pituitary adenoma, who underwent microscopic TNTS excision of the tumour, presented with massive epistaxis. Pseudoaneurysm of the cavernous ICA was initially not seen on computed tomography angiography and was later diagnosed on digital subtraction angiography. The attempted management of PA with coils without stent could not stop aneurysm recurrence. The management of such complicated PAs is discussed, and a literature review is done regarding epistaxis in growth hormone secreting adenoma.

Posterior ischemic optic neuropathy with acute monocular vision loss following clipping of anterior communicating artery aneurysm. A case report and review of literature.

BACKGROUND: The acute postoperative monocular vision loss following anterior communicating artery aneurysm clipping secondary to posterior ischemic optic neuropathy (PION) a rare presentation. CASE DESCRIPTION: A 32-year old patient presented with a spontaneous holocranial thunderclap headache for 7 days, associated with vomiting. The SAH was diagnosed with a tiny saccular aneurysm arising from the anterior communicating artery. A left pterional craniotomy and clipping of aneurysm were done. On the 3rd postoperative day, he complained of left-sided complete blindness, and on the 5th postoperative day, his GCS dropped to E4V1M5 with right-sided hemiplegia. MRI brain showed normal optic apparatus with bilateral ACA and left MCA territory infarct. CONCLUSION: The PION must be kept in the differential diagnosis of post-clipping sudden visual deterioration, especially following anterior communicating artery aneurysm rupture.

Occipital transtentorial approach for pineal region lesions: Addressing the controversies in conventional teaching.

BACKGROUND: The occipital transtentorial (OT) approach is well-established approach for pineal region tumors and can be of choice for the lesions located around the suboccipital part of tentorium such as the quadrigeminal plate, posterior part of thalamus, tentorial surface of cerebellum, splenial region, posterior falx, and lesions around the tentorial incisura. However, it is not very much extensively used in the above-mentioned locations other than the pineal region. METHODS: Thirty-one patients of pineal region lesions were operated by OT approach, the role of conventional preoperative evaluation of the anatomy of the venous sinuses, deep venous system, and tentorial angle was investigated. RESULTS: A variety of lesions were operated using this approach achieving gross and near total resection in majority of the cases (76.6%), with acceptable postoperative mean modified Rankin scales (1.8). CONCLUSION: The OT is a preferable approach for pineal region lesions for patients of all ages and can be tailored for achieving high resectability rates irrespective of the status of the deep venous system and tentorial angle, with reasonable postoperative surgical outcome.

Dissection of C2 Guiding to C1 Lateral Mass and Facilitation of Screw Placement: Technical Note.

OBJECTIVE: Surgical intervention at the craniovertebral junction requires preoperative and intraoperative planning to get optimum postoperative results. Careful positioning minimizes the risk of iatrogenic injury and can also facilitate adequate surgical exposure. Tortuous venous channels that are usually encountered as the dissection proceeds may cause excessive bleeding before reaching the lateral mass (LM). However, both localization and placement may be made easier by altering the dissection technique and modifying the patient's position. Traditionally, the military tuck position is described for the dorsal approach to the craniovertebral junction. The objective of this study is to emphasize the role of arc or bow like position, a modification of prone position for adequate placement of C1 LM screw in these cases. METHODS: We operated on 68 patients with atlantoaxial dislocation in an arc or bow position from January 2013 to September 2018. In 58 patients, at least 1 C1 LM screw was placed. RESULTS: This position helped in easy and early recognition with easy trajectory for the C1 LM screw placement and less work force. CONCLUSIONS: Visual axis to the lateral mass of C1 in an arc/bow position with head elevation puts C1 LM more in the visual axis of the operator, which makes the trajectory straight without causing much angulation while inserting the screw. At the same time, the axis vertebra guides the surgeon to the C1 lateral mass with no handling of dura.

Intraoperative microsurgical anatomy of the anterior communicating artery complex harbouring an anterior cerebral territory aneurysm.

BACKGROUND: The vascular anatomy of the anterior communicating artery complex (ACAC), the most frequent site of occurrence of aneurysms, is complex and associated with many anatomical and morphological variations. AIMS: The aim of this study was to determine the anatomical variations of ACAC in the Indian population. SETTING AND DESIGN: This was an observational study. MATERIALS AND METHODS: Sixty-two patients of ACAC aneurysms were subjected to clipping, and intraoperative microsurgical details were analyzed. RESULTS: Twenty-two (35.48%) patients had anatomical and morphological variations that were more common on the right side. Right A1 was hypoplastic in 5 (8.06%), aplastic in 2 (3.22%), and tortuous in 1 (1.61%) patient. Left A1 was aplastic in 3 (4.83%), hypoplastic in 1 (1.61%) and prominent in 2 (3.22%) patients. One patient (1.61%) had a prominent left A2 segment and 2 (3.22%) had a prominent right A1 and A2 segment. Two patients (3.22%) had fenestration of the ACAC and 3 (4.83%) had the median artery of corpus callosum. The recurrent artery of Heubner was identified in only 44 (70.96%) patients, and in these patients, distinct anatomical variations were noted. Eleven patients were found to present with a parent vessel anomaly, having a total of 23 (mean, 2.09) perforators arising from ACAC, whereas those without a parent vessel anomaly had a total of 57 (mean, 1.11) perforators. This difference was statistically significant. CONCLUSION: The ACAC region is the area of highest anatomical and morphological variability. This variability is even more exhaustive when associated with aneurysmal formation. A sound anatomical knowledge of the perforators and their preservation during the surgical management of the ACAC is of paramount importance for ensuring a good clinical outcome of patients.

Association of GABAA Receptor Gene with Epilepsy Syndromes.

GABA has always been an inviting target in the etiology and treatment of epilepsy. The GABRA1, GABRG2, and GABRD genes provide instructions for making α1, ϒ2, and δ subunits of GABAA receptor protein respectively. GABAA is considered as one of the most important proteins and has found to play an important role in many neurological disorders. We explored the association of GABAA receptor gene mutation/SNPs in JME and LGS patients in Indian population. A total of 100 epilepsy syndrome patients (50 JME and 50 LGS) and 100 healthy control subjects were recruited and analyzed by AS-PCR and RFLP-PCR techniques. In our study, GABRA1 965 C > A mutation and 15 A > G polymorphism gene may play an important role in modulating the drug efficacy in LGS patients. The GABRA1 15 A > G polymorphism may also play an important role in the susceptibility of LGS and the inheritance of GG genotype of this polymorphism may provide an increased risk of development of LGS. The GABRG2 588 C > T polymorphism may decrease the duration of seizures in JME patients. The GABRD 659 G > A polymorphism may play an important role in the susceptibility of JME and LGS and this polymorphism may also increase the duration of postictal period in JME patients but may decrease the duration of seizure in LGS patients.

Neonatal Brain Tumors: A Review.

Brain tumors in neonatal age group is uncommon comparing with older children and adults. In older children brain tumors are commonly infratentorial, where as in neonates, they are supratentorial. Though extracranial tumors are commoner in neonates, brain tumors cause 5-20% deaths approximately. We are presenting a review on brain tumors in neonates.

Controversy about Management of Hydrocephalus - Shunt vs. Endoscopic Third Ventriculostomy.

The best management of hydrocephalus is still controversial in the twenty-first century. Shunt treatment for hydrocephalus is the most common procedure performed in neurosurgical practice and is associated with the highest complications rate. But during the last 2 decades, the treatment of hydrocephalus has improved with better shunt devices available today, increased facilities for investigations and newer approaches like endoscopic third ventriculostomy. The recent advances in development of better endoscopes have provided the patient and treating doctor with an option for an alternative surgery for treatment of hydrocephalus.

Postmyelotomy Closure of Spinal Cord-"Zip Lock Technique": An Initial Experience.

Proper closure of the pia matter is necessary to restore normal anatomy and prevent postoperative painful dysesthesia after excision of intramedullary spinal cord tumor. Two methods of closure of the pia have been described: welding technique and conventional suturing. Here, we report our initial experience with a new "pial press" or "zip lock" technique for pial closure, where pial layers are simply held together and plunged into each other with small microtooth forceps. Advantages of the technique over other techniques are it has less chance of suture-related complications or trauma to the posterior column and the simplicity of the technique.

Transanal protrusion of ventriculoperitoneal shunt via appendicular perforation: A rare case report.

Perforation of abdominal viscera and protrusion of the distal end of ventriculoperitoneal shunt (VPS) through natural orifice is well known but rare complication. We report a case of a transanal protrusion of distal end of VPS through appendix perforation without any symptomatology of prior appendicitis. To the best of our knowledge, no case of such kind has been reported in literature yet. The management plan of these patients should be looked in a different way because they may have underlying inflammation of the appendix and distal end of shunt removal should be done by proper surgical exploration followed by added appendicectomy.