Clinical, microbiological profile and treatment response to intraventricular antibiotics in the Management of Post-Neurosurgical Meningitis: A single center experience.

Introduction Post-Neurosurgical Meningitis (PNM) is a serious medical condition with high mortality and morbidity caused by organisms like Staphylococcus aureus and Gram-negative organisms like Acinetobacter baumannii. Optimum concentration of antibiotics in the cerebrospinal fluid (CSF) to treat these infections are difficult to achieve. Intraventricular antibiotic administration bypasses the blood-brain barrier and can achieve high CSF concentration without causing systemic toxicity. Methods Retrospective review of all patient records were done to identify patients who developed post-neurosurgical meningitis and received intraventricular antibiotic therapy during the period of July 2017 to December 2022. Demographic and clinical data along with type of antibiotic, route, dose and duration of administration was collected. CSF parameters before and after intraventricular antibiotic administration were collected and analyzed. Results 26 patients with post-neurosurgical meningitis received intraventricular antibiotic therapy. Intracranial tumors were the most common underlying pathology followed by aneurysms. 17/26 patients had received vancomycin and 9/26 patients had received colistin. External ventricular drain was used in 17/26 cases and Ommaya reservoir was used in 9/26 cases. 6 cases showed growth of organism in CSF before starting intraventricular antibiotics, 1 case remained culture positive despite treatment. 3/26 patients died despite treatment. There were significant changes in the CSF parameters after intraventricular antibiotic therapy. Conclusion Intraventricular administration of antibiotic provides an alternative therapeutic option in the management of patients who are not responding or poorly responding to systemic antibiotics.

An Observational Comparative Study to Evaluate the Use of Image-Guided Surgery in the Management and Outcome of Supratentorial Intracranial Space-Occupying Lesions.

Objectives: The objective of this article is to study the effect of neuronavigation on the outcome of surgery for supratentorial tumors, such as the extent of resection, size of craniotomy, and overall morbidity and mortality by comparing with conventional excision. Methods: A total of 50 patients undergoing intracranial surgery for supratentorial space-occupying lesions from 2020 to 2022 were included in the study. One intervention group consisted of patients undergoing surgical resection of supratentorial tumors utilizing image guidance versus the control group, which consisted of patients undergoing surgical excision of supratentorial tumor excision without image guidance. Parameters used to compare the outcome were the extent of resection of the lesions, craniotomy size, and overall morbidity and mortality. Results and Conclusion: There was no significant reduction in craniotomy size or prolongation of operative duration with the use of neuronavigation. There was no significant difference in postoperative hospital stay between the two groups. Neuronavigation-assisted cases did not show any significant reduction in the occurrence of postoperative neurological deficits or any reduction of overall morbidity and mortality.

Corpus Callosal Hematoma by a Trivial Trauma Causing Concussion with "Blood at the Center" Radiological Sign.

Hematoma of corpus callosum is a very rare phenomenon and is caused by severe trauma to head. Most common traumatic injury to corpus callosum is seen in diffuse axonal injury in form of small hemorrhagic foci and associated prolonged unconsciousness. Trivial trauma causing well defined corpus callosal hematoma in absence of coagulation defects or neurological deficits in conscious patient has not been reported in the literature. We present such a unique case and the review the corpus callosal hematoma due to trauma.

Correlation Between Aneurysm Dome Direction and Patient Outcomes Following Surgery for Ruptured Anterior Communicating Artery Aneurysms.

Background Anterior communicating (Acom) artery aneurysms are the most common type of intracranial aneurysms. Despite the enormous advancements in the field of endovascular surgery for intracranial aneurysms, open surgical clipping of aneurysms remains the most durable management of Acom aneurysms. There have been various studies based on the clinical-radiological profile and outcome of open clipping for intracranial aneurysms, but the correlation of the direction of the aneurysm with the surgical outcome remains incompletely defined. Aim To analyze the correlation between the direction of the aneurysm dome and patient outcomes after surgery for ruptured Acom artery aneurysms. Materials and methods  CT angiography of the brain was done in all patients pre-operatively as part of the standard treatment protocol. Retrospective data was collected from an inter-departmental computerized database, which included the patient's details, history, investigations, a course in the hospital from admission to discharge, and an operative note by the surgeon. Prospective data was collected from patients with ruptured Acom artery aneurysms. We analyzed the relationship between the direction of the dome of the Acom aneurysm and preoperative, intraoperative, and postoperative variables. Results Of the 48 patients who underwent surgery for ruptured aneurysms, 34 (70.8%) were female and 14 (29.2%) were male. Among the 27 cases with anteriorly projecting aneurysms, 11 (40.7%) experienced postoperative complications. Of the five cases with posteriorly projecting aneurysms, two (40%) experienced postoperative complications. One-third of cases of the inferior dome direction and 10% of cases of the superior direction of the dome of aneurysm were also found to have postoperative complications. However, using the chi-square test, the association between postoperative complications and the direction of the aneurysm was determined to be statistically non-significant (p-value = 0.93). Conclusion The findings of our investigation indicate that aneurysms with superior projection exhibit the lowest likelihood of experiencing intraoperative rupture. However, it was seen that the outcome was influenced by dome projection throughout the three-month follow-up. The findings of our study indicate that aneurysms with a superior orientation exhibit the least likelihood of experiencing intraoperative rupture.

Giant anterior communicating artery aneurysm with intrasellar extension.

Introduction: Aneurysms extending into the sella are uncommon with only a few cases reported till date. Most of these arise from either the supraclinoidal or infraclinoidal segments of the internal carotid artery. Research question: Can Anterior communication artery aneurysm present with hypopituitarism due to compression of pituitary gland? Materials & methods: Case report and literature review. Results: We discuss this rare presentation in a middle-aged patient its surgical management and the follow-up course with a review of available literature. Discussion & conclusion: Anterior communicating artery aneurysms extending into the sella are extremely uncommon with only 4 cases reported in literature. They are usually giant aneurysms which are partially thrombosed with presenting with predominantly with mass effect in this case visual impairment and hypofunction of the pituitary.

Bilateral Central Retinal Vein Occlusion in Recurrent Frontal Lobe Tumor.

Systemic malignancy can induce hypercoagulation and can cause retinal vein occlusion (RVO). Although RVO has been reported in association with breast, renal, lung, prostate, and ovarian malignancies, it has not been reported in brain tumors. We are reporting a case of bilateral central retinal vein occlusion (CRVO) associated with recurrent frontal lobe gliosarcoma. The association was established after ruling out all other systemic causes that can produce bilateral CRVO. The importance of this case report lies in the fact that, while evaluating bilateral CRVO cases, these rare associations should also be kept in mind.

Rare Case of Hemorrhagic Atypical Choroid Plexus Papilloma of Fourth Ventricle in Adult: A Diagnostic Dilemma.

Choroid plexus papillomas are highly vascular tumors, and such tumors causing subarachnoid hemorrhage have been reported in literature. Similarly, few articles have reported atypical fourth ventricular choroid plexus tumors in adults. However, such an atypical tumor presenting with grossly hemorrhagic transformation without any acute symptoms could not be found in the literature.

Oral Midodrine as an Adjunct in Rapid Weaning of Intravenous Vasopressor Support in Spinal Cord Injury.

Background Majority of acute cervical spinal cord injury end up requiring long-term stay in intensive care unit (ICU). During the initial few days after spinal cord injury, most patients are hemodynamically unstable requiring intravenous vasopressors. However, many studies have noted that long-term intravenous vasopressors remain the main reason for prolongation of ICU stay. In this series, we report the effect of using oral midodrine in reducing the amount and duration of intravenous vasopressors in patients with acute cervical spinal cord injury. Materials and Methods Five adult patients with cervical spinal cord injury after initial evaluation and surgical stabilization are assessed for the need for intravenous vasopressors. If patients continue to need intravenous vasopressors for more than 24 hours, they were started on oral midodrine. Its effect on weaning of intravenous vasopressors was assessed. Results Patients with systemic and intracranial injury were excluded from the study. Midodrine helped in weaning of intravenous vasopressors in the first 24 to 48 hours and helped in complete weaning of intravenous vasopressors. The rate of reduction was between 0.5 and 2.0 µg/min. Conclusion Oral midodrine does have an effect in reduction of intravenous vasopressors for patients needing prolonged support after cervical spine injury. The real extent of this effect needs to be studied with collaboration of multiple centers dealing with spinal injuries. The approach seems to be a viable alternative to rapidly wean intravenous vasopressors and reduce duration of ICU stay.

Intracranial peripheral primitive neuroectodermal tumor presenting as neurosurgical emergency: A report of two cases.

Ewing's sarcoma/peripheral primitive neuroectodermal tumor (ES/pPNET) belongs to the family of malignant small and blue round cell tumors. It usually occurs in children and young adults with 3/4th of the cases arising from bone and 1/4 from soft tissue. Here, we present two cases of intracranial ES/pPNET who presented with mass effect. Management consists of surgical excision followed by adjuvant chemotherapy. Intracranial ES/pPNETs are highly aggressive and rare malignancies, reported to comprise of 0.03% of all intracranial tumors. The most common genetic aberration associated with ES/pPNET is chromosomal translocation t (11,12) (q24;q12). Patients with intracranial ES/pPNETs may present in acute or delayed manner. The presenting symptoms and signs depend on the location of the tumor. Intracranial pPNET although slow growing, they are highly vascular and may present as neurosurgical emergencies due to mass effect. We have presented the acute presentation of this tumor and its management.

Aggressive vertebral hemangiomas in children.

BACKGROUND: Aggressive vertebral hemangiomas are rare tumors in children, usually occurring in the thoracic spine that can cause significant neurological morbidity. They are technically difficult to treat with significant risk of blood loss during surgery. METHODS: We describe a case of aggressive vertebral hemangioma managed in our institution. We performed a literature review of reported cases of aggressive vertebral hemangiomas in pediatric age group. We discuss the clinical presentation, diagnosis, and management of these lesions. RESULTS: We identified 23 cases of aggressive vertebral reported in children. Neurodeficit was the most common presentation, and the most common location was the thoracic spine. Surgery was the most common modality of treatment. All the patients reported in literature had improvement in their symptoms after treatment. CONCLUSION: Although technically challenging, aggressive vertebral hemangiomas have a good outcome after treatment. Treatment should be tailored to the individual patient. Further studies are needed to determine the optimum treatment strategy.

Circular Configuration of Torcular Herophili Presenting as Childhood Headache: 2D Computational Fluid Dynamic Analysis with a Proposed Mechanism.

This case report presents a rare anatomical variant of the torcular Herophili, characterized by a circular configuration and the absence of the left transverse sinus. A 12-year-old child presented with intermittent holocranial headaches, and imaging revealed the circular torcular Herophili along with mild ventricular enlargement. The straight sinus drained into the left side of the circular torcular Herophili. Following lumbar puncture and cerebrospinal fluid (CSF) drainage, the child experienced symptom improvement. During a 6-month follow-up, the patient remained asymptomatic, without further headaches or academic disruptions. Similar to a previously reported case, the circular torcular Herophili with unilateral absent transverse sinus may be associated with impaired CSF absorption due to altered blood flow through abnormal venous anatomy. We performed two-dimensional computational fluid dynamic analysis of simulated flow through a synthetic model and showed that this circular configuration is associated with venous stasis. The venous stasis in the sinus may impair CSF absorption through the arachnoid granulations causing hydrocephalus and explaining the headache. Close monitoring and follow-up are recommended for patients with this variant. Further investigation is needed to better understand the clinical implications and underlying mechanisms of such torcular Herophili variations.

Shunt Migration in Children: A Patient Level Systematic Review of Risk Factors and Outcome.

Ventriculoperitoneal shunt insertion is one of the most common pediatric neurosurgical procedures performed. Shunt migration is one of the infrequent complications of shunt insertion and often requires a change of the shunt system. The objective of the study is to systematically review the sites of shunt migration and factors associated with mortality in children. Comprehensive search and review of the literature were done according to the PRISMA guidelines. Citations were selected using the following inclusion criteria: 1. Shunt migration in ventriculoperitoneal shunts was the primary inclusion criteria, 2. Age of the study participants <18 years, and 3. Patient-level data available in the study. Exclusion criteria were 1. Age >18 years, 2. Patient-level data not available, 3. Full text of the article not available, and 4. Article not in the English language. Sites of migration and risk factors for mortality were assessed. In total, 111 studies out of 161 studies were included in the final analysis. The scrotum was the most common site of shunt migration (30.67%), followed by anal migration, migration into the bowel, chest wall/thoracic migration, and intracranial/subgaleal migration. Univariate analysis showed the presence of infection and site of migration to be significantly associated with mortality. Multivariate analysis showed the presence of infection and age at presentation to be significant predictors of mortality. This study highlights that presence of infection is a significant predictor of mortality in cases of shunt migration. Infection should be managed expeditiously for optimum management of shunt migration.

Cerebral abscess as a neurosurgical emergency in Eisenmenger syndrome: illustrative case.

BACKGROUND: Eisenmenger syndrome caused by severe pulmonary arterial hypertension in congenital heart disease can cause multisystemic involvement and is a risk factor for development of cerebral abscess. Cerebral abscess, if not detected and treated in a timely manner, can present as acute neurosurgical emergency. OBSERVATIONS: The authors reported a case of cerebral abscess in a patient with Eisenmenger syndrome. The patient presented with acute neurological deterioration with mass effect and cerebral infarcts and received emergency neurosurgical intervention. A further literature search was done to identify prior reported cases of cerebral abscess with Eisenmenger syndrome. LESSONS: Patients with Eisenmenger syndrome have compromised cardiorespiratory status, and decision for neurosurgical intervention should be given careful consideration. Multidisciplinary team management along with preoperative optimization of the patient should be used.

Contiguous-Level Unilateral Cervical Spine Facet Dislocation-A Report of a Less Discussed Subtype.

Unilateral facet dislocation of subaxial cervical spine trauma is characterized by dislocation of inferior facet of superior vertebra over the superior facet of inferior vertebra. The injury is due to high-velocity trauma and associated with instability of spinal column. Such unilateral facet dislocations occurring at multiple adjacent levels for some reason are not reported or studied frequently. We have reported two cases of multiple-level dislocation of unilateral facets managed in our hospital with a review of available literature. The injury occurs as one side of the motion segment translates and rotates around an intact facet on the contralateral side. The major mechanism of injury is distractive flexion injury with axial rotation component. The injury is associated with instability secondary to loss of the discoligamentous complex. In cases with multiple-level dislocations of unilateral cervical facets, there are multiple mechanisms associated with significant neurological injury and most of them succumb at the site of injury. Only three other cases are available in English language literature. The neurological outcome is invariably poor. Multiple-level facet dislocations of subaxial cervical spine are reported sparsely in literature. We suspect that due to high-velocity nature of these injuries, most of them succumb soon after injury and not often reported. This article reports two cases of contiguous-level unilateral facet dislocation of subaxial cervical spine with associated injuries and the outcomes with review of literature.

Customized and Cost-Effective 3D Printed Mold for Cranioplasty: India's First Single Center Experience.

CONTEXT: Autologous bone is the most commonly used flap in cranioplasty to repair the defect; however, synthetic materials are available. Poly methyl methacrylate (PMMA) is an effective polymer owing to its thermoplastic and radiolucent properties comparable to bone strength. Three-dimensional (3D) printing combined with computer-assisted design (CAD) is a simple, low-cost method to print molds that ensure surgical success. MATERIALS AND METHODS: A total of 114 patients underwent cranioplasty (July 2015-April 2018), and 25 of them using 3D printed template molds due to unavailability of autologous bone. The clinical features, patient demographics, and surgical parameters were analyzed. The visual analog score for cosmesis (VASC) and Odom's score was obtained pre and post-op. RESULTS: The mean age of the patients is 38.4 ± 14.6 years (Range, 9-66). The primary pathology for undergoing craniectomy is stroke (n = 13; 52%), traumatic brain injury (10; 40%) and tumor (2; 8%). The reason for nonavailability of flap was infection (n = 14;56%), flap resorption (4;16%), and trauma or tumor (7;28%). The mean time for manufacturing the 3D printed template is 13.2 ± 2.1 h. On follow-up, median Odom's score is excellent in 52% of cases, good in 40%, and fair in 8%. The mean VASC score on follow up is 8.2 ± 1.3. Three patients developed minor postoperative complications. CONCLUSION: This is the first study from a single tertiary care center in India to systematically evaluate the outcomes in 3D cranioplasty using CAD and 3D printing technology. This method would be optimal especially in developing countries since PMMA is cost effective and also gives an ideal cosmetic effect.