Quantitative analysis of the trajectory of simulated basilar apex aneurysms through the internal carotid artery to assess the need for an orbitozygomatic approach.

BACKGROUND: The aim of this study was to identify the correlation between the location of the internal carotid artery (ICA) and the need for an orbitozygomatic approach (OZA) when approaching a basilar apex (BX) aneurysm. MATERIALS AND METHODS: By imaging the virtual trajectory to access the basilar artery (BA) through the ICA, the correlations among the height of the BX, the height and lateral breadth of the bifurcation of the ICA, and the need for removal of the orbital rim or zygomatic arch were investigated using three-dimensional computed tomography angiography (3DCTA) data of approximately 80 random samples not limited to BX aneurysms. Furthermore, the utility of 3D simulation to determine the need for the OZA was verified using data from five patients with BX aneurysms. RESULTS: The height of the bifurcation of the ICA was inversely correlated and the height of the BX was positively correlated with the need for the OZA (both p < 0.017). Among patients undergoing surgery, clipping was successfully performed without the OZA in two patients in whom the distance from the simulated skull point on the extended line from the BX through the bifurcation of the ICA was more than 4 cm from the zygoma and orbital rim. CONCLUSIONS: It is necessary to determine the spatial relationship between the basilar artery and the ICA to decide whether the OZA is needed for surgery. Correlations of the height of the ICA and BX with the need for the OZA were not very strong individually, though they were significant. Therefore, simulation using 3DCTA appears to be important for planning the surgical approach for the treatment of BX aneurysms.

Intraoperative electrocorticography-guided resection of the epileptogenic zone in an unusual porencephalic cyst: case report and literature review.

Introduction: Porencephalic cysts resulting from perinatal artery infarctions typically manifest as large cysts accompanied by pre-existing neurological deficits. A small porencephalic cyst without any neurological deficit is a rare cause of medically refractory epilepsy. Case presentation: A 23-year-old female presented with a history of medically refractory epilepsy secondary to a small right parieto-temporal porencephalic cyst. Despite optimal anti-seizure medications, seizures persisted. Surgical intervention was planned, and intraoperative electrocorticography (ioECoG) was used to delineate the epileptogenic zone (EZ), which was found to be two gyri posterior to the cyst. Discussion: Very focal ischaemia resulting in a small porencephalic cyst from perinatal artery infarction exhibits a distinct organization of the EZ involving wider area posteriorly indicating involvement of arterial territory distal to the cyst. This contrasts with the typical perilesional EZ observed in other lesional epilepsy causes. Conclusion: Our findings emphasize the need to consider aetiology during interpretation of ioECoG to better define the electrophysiological border between the normal and epileptogenic brain, aiding in achieving a better surgical outcome.

A case of intradural lumbar disc herniation.

Key Clinical Message: MRI remains the best tool in the diagnosis of this disease entity however preoperative diagnosis remains a difficult task. A high degree of suspicion is raised when intraoperative findings and preoperative image description become incompatible. Abstract: Lumbar disc herniation into the dural space is a rare phenomenon of lumbar disc degeneration with an unclear remaining pathogenesis. Intraoperative ultrasonography and histopathological examination of resected specimen help in the diagnosis of intradural disc herniation. Prompt surgery is recommended due to the high incidence of cauda equina syndrome.

Orbital Apex Syndrome caused by invasive aspergillosis in patient with post-Covid-19 infection - A case report.

INTRODUCTION AND IMPORTANCE: Orbital Apex Syndrome (OAS) are characterized by multiple symptoms, such as impaired eye movement, periorbital pain, and visual disturbance. AS symptoms may be caused by inflammation, infection, neoplasm, or a vascular lesion, potentially involving a variety of nerves, such as the optic, oculomotor, trochlear or abducens, or the ophthalmic branch of the trigeminal nerve. However, OAS caused by invasive aspergillosis in post-COVID patient is a very rare phenomenon. CASE PRESENTATION: A 43-year-old male with a history of diabetes mellitus and hypertension who had recently recovered from a COVID-19 infection developed blurred vision on the left eye field, followed by impaired vision on left eye field for 2 months then retro-orbital pain for a further 3 months. The blurring of vision and headache developed soon after recovering from COVID-19 and was progressive in left eye field. He denied any symptoms of diplopia, scalp tenderness, weight loss, or jaw claudication. The patient was treated with IV methylprednisolone for 3 days with as diagnosis of optic neuritis, followed by a course of oral corticosteroid therapy (prednisolone, starting at 60 mg for 2 days and then tapered for 1 month), which produced transient relief of symptoms that recurred when prednisone was discontinued. Then repeat MRI was perform with no evidence of lesion; treated again in a line of optic neuritis and symptoms relief transiently. After reoccurrence of symptoms repeat MRI was perform which showed a heterogeneously enhancing intermediate signal intensity lesion in the left orbital apex. The lesion was encasing and compressing the left optic nerve, without abnormal signal intensity or contrast enhancement within the left optic nerve either proximal or distal to the lesion. The lesion was contiguous with focal asymmetric enhancement in the left cavernous sinus. No inflammatory changes were seen in the orbital fat. CLINICAL DISCUSSION: OAS due to invasive fungal infection is uncommon and most often caused by Mucorales spp., or Aspergillus, particularly in those with immunocompromising conditions or uncontrolled diabetes mellitus. In OAS due to Aspergillosis urgent treatment is necessary to avoid complications such as complete vision loss and cavernous sinus thrombosis. CONCLUSION: OASs, represent a heterogenous group of disorders that results from a number of etiologies. OAS in a background of COVID-19 pandemic can be due to invasive Aspergillus infection as in our patient without any systemic illness and lead to miss diagnosis and delay in proper treatment.

Intra thecal baclofen pump as an ad hoc measure for a case of severe tardive dystonia refractory to multiple lesioning.

Tardive dystonia is an infrequent ailment in patient reliant with chronic antipsychotic medication. The front-line envoy in the treatment of this illness is set into motion with oral agents including baclofen, benzodiazepines, and other antispasmodics. Regardless of an extensive therapy, the patients are not able to control of their spasticity/ dystonia. The authors reported a case of severe tardive dystonia treated with baclofen therapy in a patient frigid to medical therapy and multiple lesioning. Case Report: A 31-year-old female, diagnosed as a case of depressive illness and being managed with neuroleptic medications, who went onto develop tardive dystonia progressively worsening over a 4-year duration. After a comprehensive and meticulous evaluation of her neurological and psychological stratum, globus pallidus interna lesioning was reputed as the best course of action. As intended, staged lesioning was executed bilaterally with a trivial resolution eventually succumbing into recurrence, compelling a repeat lesioning. It was inaptly discouraging to see her crippled with the plight. Determined, not to give upon her, a way out with a baclofen therapy was proposed. A test dose with a 100 mcg of baclofen with an increment up to 150 mcg over a 3-day period demonstrated a promising prospect. On that account, the insertion of the baclofen pump was performed with an outstanding aftermath in her neurological endeavor. Clinical Discussion: Tardive dystonia is believed to be caused by striatal dopamine receptor super-sensitivity persuaded by the dopamine-antagonizing action of antipsychotic drugs. The first line of treatment being oral agents including oral baclofen, benzodiazepines, and antispasmodics. If the patient suffers from an early-onset primary generalized dystonia, then treatment with deep brain stimulation of the globus pallidus interna is the approved and preferred treatment approach. Recurrence of the symptoms despite of multiple lesioning can be overcome by intrathecal baclofen pump infusion as stated by many research. It is not uncommon to face complications in such a procedure, but the benefits outreach the risk, which makes it a choice of treatment. Conclusion: The use of a continuous intrathecal baclofen pump for cases with tardive dystonia refractory to conventional therapy, it has been approved as one of the safest and capable procedures.

Unusual case of spontaneous bilateral basal ganglia bleed.

Hypertension is the most prevalent determinant condition embarking on the development of spontaneous intracerebral hemorrhage. Usually, the presentation is a unilateral hematoma. Spontaneous bilateral intracerebral hemorrhage is an outstandingly infrequent context, and not a lot of cases have been reported till date. Ensuing hypertension, trauma inflicted on the brain case is another common cause that out turn into the sequelae of bilateral intracerebral hemorrhage. Lately, a few cases of bilateral basal ganglia bleed have been revealed, as a repercussion of COVID-19 infection. Globally, <40 such cases have been reported. A 39-year-old man presented with complaints of acute onset of weakness of right half of the body. Additionally, facial deviation was noticed by his family members. He then sought medical help from a local healthcare center where CT scan of head was advised. Unexpectedly, the scan demonstrated bilateral intracerebral hemorrhage. He was then managed conservatively with oral medications and rehabilitation. The course of his hospital stay was uneventful and was eventually discharged after 9 days. He then presented to our institution for further evaluation. Thereupon, he had slurring of speech but was able to walk with minimal support. Simultaneous Bilateral Basal Ganglia Hemorrhage (SBBGH) is an exceptionally rare ailment. This genre of cerebrovascular accident embraces a comprehensive span of morbidity and mortality. In an acute setting, CT scan of head is the most relevant imaging modality. Nonetheless, MRI is the gold standard for definitive diagnosis and should be performed urgently to further typify and delineate the lesion.

Cerebral venous sinus thrombosis as a complication of COVID-19 infection - A case report.

INTRODUCTION AND IMPORTANCE: Severe acute respiratory distress syndrome coronavirus 2 is the causative agent of COVID-19 (Coronavirus 2019) infection. Although symptoms are usually associated with the respiratory system, its neurological involvement should not be underestimated. The most common cerebrovascular complication following the infection is ischemic stroke however, CVST (Cerebral Venous Sinus Thrombosis) has been reported. PRESENTATION OF CASE: We report a unique case of a young patient who had a history of headache and abnormal body movement immediately after COVID-19 infection. His brain Computed tomography scan and Magnetic Resonance Imaging (MRI) showed typical images of CVST. He was admitted and treated with Low Molecular weight heparin. DISCUSSION: CVST is a rare form of stroke which may have devastating complications. The diagnosis is clinically challenging due to its non-specific presentation like headache and altered sensorium alone. Inflammatory process and hypoxic state after the virus infection may favor the hypercoagulable state in CVST. Our patient did not have any other predisposing factor for a hypercoagulable state other than the COVID-19 infection.MRI and venography and computed tomographic venography are the preferred modalities. The Patient is generally treated with anticoagulation therapy. CONCLUSION: High index of suspicion of CVST is necessary when a patient presents with unexplained neurological manifestation following a recent COVID-19 infection to prevent from life-threatening complications. Furthermore, clinicians should not underestimate the multisystem involvement of COVID-19.

Cervical vagal schwannoma, a rare differential of a neck swelling: A case report.

Cervical vagal schwannoma is a rare clinical entity that requires a different clinical approach than other neck swellings. Magnetic resonance imaging is the preferred initial diagnostic test. Complications may arise due to vagal stimulation in unsuspecting open biopsies. Surgical excision with perioperative vagal monitoring is recommended for the treatment of vagal schwannomas.

Surgical Management among Patients with Spontaneous Supratentorial Intracerebral Haemorrhage Admitted in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Spontaneous intracerebral haemorrhage is the second most common form of stroke and the most deadly one. An understanding of changing trends in the epidemiology of intracerebral haemorrhage prevalence, its risk factors, current practice in management, case fatality, and long-term outcome is essential to measure the effectiveness of stroke prevention and various treatment efforts. The objective of this study was to find out the prevalence of surgical management among patients with spontaneous supratentorial intracerebral haemorrhage in a tertiary centre. Methods: A descriptive cross-sectional study was conducted in the Department of Neurosurgery from January 2017 to December 2019. Ethical approval was obtained from the Institutional Review Committee (Reference number: 06/2020/IRC-ANIAS). A convenience sampling method was used. Data of the patients were retrieved from online medical records. Point estimate and 95% Confidence Interval were calculated. Results: Among 221 patients with spontaneous supratentorial intracerebral haemorrhage, 115 (52.04%) (45.45-58.63, 95% Confidence Interval) underwent surgical management. In-hospital mortality was seen in 23 (20%) and survivors at 3 months were 78 (67.82%) patients. Conclusions: The prevalence of surgical management among spontaneous supratentorial intracerebral haemorrhages was higher than in other studies done in a similar setting. Keywords: intracerebral haemorrhage; mortality; surgical procedure.

Venture of a Tertiary Care Neurosurgical Center in Course of COVID-19 Lockdown without RT-PCR.

"I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient." Obliged by the aforementioned oath, no medical practitioner shall sit in a moral judgment on any patient but will treat their illness to the best of their ability whatever the circumstances. A clear concord was yet to be authorized after the World Health Organization (WHO) declared the global pandemic of severe acute respiratory syndrome coronavirus 2infection. As a diagnostic modality, WHO recommended real-time reverse transcription-polymerase chain reaction (RT-PCR) as a reliable test; however, its availability in a deprived nation like ours became a major restraining factor. Despite an asset of having high specificity, RT-PCR for coronavirus disease 2019has its own liability of having low sensitivity. Henceforth, as time passed by, the validity of the rapid diagnostic tests was put into question. In later months, a few centers around our periphery started conducting RT-PCR, but the time taken to obtain the result was long-drawn-out process and the patient who needed urgent neurosurgical intervention at Annapurna Neurological Institute and Allied Sciences had to wait. We would like to share our expedition through peaks and valleys of managing 215 patients during the vicious circle of lockdown and global pandemic.

A case of postpartum chronic subdural hematoma.

Headache is a common presentation during postpartum period. Anesthesiologist, obstetrician, and neurosurgeon should be aware of the possibility of subdural hematoma in patient complaining of headache following spinal anesthesia.

A Case of Sellar/Suprasellar Neurocysticercosis Mimicking a Craniopharyngioma.

Neurocysticercosis (NCC) commonly presents with seizures in developing countries such as Nepal. It may also present with raised intracranial pressure due to obstructive hydrocephalus when cyst is located in the fourth ventricle or foramen of Monro. There are four main stages of NCC (1) Vesicular, (2) Colloidal vesicular, (3) Granular nodular, and (4) Nodular calcified. The colloidal vesicular stages can cause arachnoiditis and thus can cause hydrocephalus whereas obstructive hydrocephalus is usually caused by racemose type of NCC. This case was a suprasellar cyst mimicking craniopharyngioma, supported with clinical history of poor visual acuity, endocrine abnormality, suggested radiological findings by computed tomography scan, and magnetic resonance imaging. Suprasellar NCC was confirmed only by intraoperative findings and histopathology report.

A case report of multiple isolated intradural neurocysticercosis of the lumbo-sacral spine.

INTRODUCTION AND IMPORTANCE: Neurocysticercosis is the most common parasitic infection of the nervous system and it is mostly intracranial. Intradural intramedullary or extramedullary is the rarest involvement of intraspinal cysticercosis. Its isolated involvement is even rare, as it usually has intracranial association. We aim to report a rare case of isolated intraspinal neurocysticercosis and discuss the measures we can take for early management. Despite being an eradicable disease of public health importance, its prevalence is increasing widely in developed countries too. Therefore, we aim to discuss its pathogenesis, mode of spread, and preventive aspects as well. PRESENTATION OF CASE: A 40-year-old woman presented to our hospital with pain over the lower back region radiating to the right thigh. Magnetic Resonance Imaging (MRI) of her lumbosacral spine revealed a cystic lesion at the spinal level L5-S1. We confirmed the diagnosis via Histopathological examination (HPE) following surgery. DISCUSSION: Isolated intradural neurocysticercosis of the spine is extraordinarily rare involvement. It is caused by the larval stage of taenia solium. An MRI is the preferred imaging modality. Due to rarity and nonspecific clinic-radiological findings, diagnosis may often be missed. In our case, MRI revealed a cystic lesion at the L5-S1 level of the spine and multiple cystic lesions at the level were found intra-operatively. Its diagnosis is confirmed by HPE. Treatment can be medical or surgical according to the severity of the disease. CONCLUSION: Although rare, neurocysticercosis can cause irreversible neurological damage. Therefore, surgeons should consider it in the differential diagnosis of intraspinal lesions.

Early internal capsule infarction following globus pallidus internus lesioning for cervical dystonia.

INTRODUCTION AND IMPORTANCE: Ischemia associated with lesioning for the treatment of cervical dystonia is a very rare phenomenon. We reported a case of early internal capsule infarction following GPi lesioning for cervical dystonia. CASE PRESENTATION: A 56-year-old man with one year history of progressive onset of cervical dystonia which was unresponsive to medical therapy. He was planned for bilateral globus pallidus internus pallidotomy. After completion of the procedure on one side and the successful completion of stimulation and test lesion on another side, the patient suddenly developed dysarthria and one sided weakness. Post-operative magnetic resonance imaging revealed acute infarction in the posterior end of the internal capsule. The patient was managed conservatively and underwent physiotherapy and rehabilitation care. He recovered gradually with modified ranking scale 3 on discharge. CLINICAL DISCUSSION: Globus pallidus internus lesioning or ablation is one of the surgical treatment for dystonia and movement disorder. Though considered as a safe technique, various risk are associated with the procedure. Ischemia is one of the associated risk but is a very rare phenomenon. Though the patient did not have any signs of pre-operative ischemia, the occlusion of one of the perforators to internal capsule during ablation may be the cause of intra-operative ischemia. CONCLUSION: Ischemia associated with lesioning in the treatment of cervical dystonia is a very rare phenomenon. Though, ischemia related with radiofrequency ablation is very rare and sporadic, one has to be very cautious during GPi pallidotomy to prevent occlusion of perforators to internal capsule.

Customized Cost-Effective Polymethyl-Methacrylate Cranioplasty Implant Using Three-Dimensional Printer.

There is no doubt that many synthetic materials used in cranioplasty have given good result regarding patient's calvarial shape. However, the use of these materials is costly to the patient and requires complex intraoperative process. There has been a long history regarding the use of acrylic bone cement called as polymethyl-methacrylate (PMMA) as an implant due to its desirable properties. Here, we present three cases of simple, cost effective manually sculpted calvarial defect using three-dimensional (3D) printer. Sharing the achievement and challenges, we want to focus that the 3D customized implant of PMMA can be used as bone substitute.

Ganglioglioma Arising from the Septum Pellucidum.

A 24-year-old gentleman presented to us with complaints of occasional headache for 2 years. Magnetic resonance imaging showed enhancing supra sellar mass with nonenhancing cystic components, extending superiorly up to the body of bilateral lateral ventricle, laterally displacing septum pellucidum, and compressing the third ventricle with obstructive hydrocephalus. Hormone profile depicted adrenocorticotropic hormone <5.00 pg/mL, growth hormone 1.32 ng/mL, insulin-like growth factor-1 <3.0 ng/mL. The patient underwent surgical resection. Histological finding was suggestive of ganglioglioma World Health Organization grade I. Customized immunohistochemistry panel was advised and revealed positive CD 56, NSE, and GFAP immunohistochemical stains. Gangliogliomas are less frequent neoplastic lesions confined to only a handful of case reports and studies. Accounting less than 2% of intracranial neoplasms, these lesions primarily affect those in the first 3 decades of their life. As ubiquitous it is in nature, we hereby present a case of ganglioglioma in a young adult male arising from septum pellucidum.

Study of Anterior Commissure-Posterior Commissure Distance among Nepalese Cohort.

INTRODUCTION: The main aim of this study is to determine the anterior commissure-posterior commissure (AC-PC) distance in Nepalese cohort and has comparison of intercommissural distance of Nepalese cohort with some other races. MATERIALS AND METHODS: The 47 patients, with mean age of 50 years, included in the study had undergone DBS or lesioning (Pallidotomy). Data were collected through the magnetic resonance imaging under DBS protocol and the manipulation, marking of AC and PC was done in Inomed Planning Software (IPS). RESULTS: The data revealed average AC-PC distance of Nepalese cohort to be 24.86 ± 2.08 mm, ranging from 16 mm to 30 mm. The study among 29 males and 18 females illustrated male to have longer AC-PC as compared to female (25.38 mm male and 24.02 mm female). The results also confirmed age related changes in AC-PC distance which was linearly increasing with the age. CONCLUSION: Comparison of data from other studies revealed Nepalese cohort to have almost similar AC-PC distance with Asian population, while that was longer in Caucasian and shorter in Hispanic Population.

Transient Augmentation of Intraoperative Motor Evoked Potentials During Middle Cerebral Artery Aneurysm Surgery.

OBJECTIVE: To study clinical significance of augmentation of intraoperative motor evoked potentials (MEPs) during direct open surgery for middle cerebral artery (MCA) aneurysms. METHODS: Between 2009 and 2017, 134 MCA aneurysm surgeries were performed with intraoperative MEP monitoring. The frequency and cause of augmentation with >50% increase of MEP amplitude from baseline were studied. Factors associated with MEP augmentation were investigated. RESULTS: MEP augmentation was demonstrated in 9 patients. All 9 events were observed just after application of the temporary clip to the parent artery. The ratio of the maximum amplitude to baseline was 2.6 ± 1.1 at an mean of 2.4 ± 1.1 minutes after parent artery occlusion. Ten patients who did not show MEP augmentation after parent artery occlusion were compared with the patients showing MEP augmentation. The distance of the temporary clip point from the midline was smaller in patients with MEP augmentation compared with patients without MEP augmentation (P = 0.033). CONCLUSIONS: MEP augmentation was thought to be an early ischemic sign preceding a significant decrease in MEPs during MCA aneurysm surgery. Transient augmentation of MEPs was more frequently observed in cases with a temporary clip applied to the more proximal part of the MCA.

A simple bracing technique to correct kinking of arterial branches to avoid ischemic sequelae during neurovascular surgery.

BACKGROUND: During microscopic procedures for neurovascular disease, we sometimes encounter kinking of arterial branches resulting in ischemic sequelae. A simple and useful technique that involves inserting a small, ball-like prosthesis made of oxidized cellulose or shredded Teflon with fibrin glue that corrects the arterial branch kinking and avoids subsequent compromise is reported. METHODS: Between January and December 2014, three patients developed arterial kinking during microscopic procedures, including two in the caudal loop of the posterior inferior cerebellar artery during microvascular decompression for glossopharyngeal neuralgia and one in a branch of the middle cerebral artery (MCA) during clipping for an unruptured MCA aneurysm. Blood flow insufficiency was confirmed by microvascular Doppler ultrasonography (MDU) and indocyanine green (ICG) videoangiography. The prosthesis, which was made of shredded Teflon in two cases and oxidized cellulose in one case, was inserted into the crotch of the kinked arteries to correct the kinking of the arteries and restore the proper vascular shape and normal blood flow. RESULTS: The small, ball-shaped prosthesis corrected the kinked arteries and maintained the proper shape, which was confirmed by ICG videoangiography and MDU during the operation and three-dimensional computerized tomography angiography postoperatively. Postoperatively, the patients did not manifest any ischemic sequelae related to the kinked arteries. CONCLUSION: The insertion of prostheses with fibrin glue into the crotch of a kinked artery for repair is considered a simple and useful method for correcting a kinked artery that avoids ischemic sequelae.

Indocyanine Green (ICG) Videoangiography-Guided Dissection of the Sylvian Fissure on the Transsylvian Approach: Technical Note.

BACKGROUND: The transsylvian approach is a standard method of approach for anterior circulation aneurysms or paraclinoid tumors. Care must be taken, however, to avoid inadvertent obliteration of sylvian veins to prevent postoperative brain swelling and venous infarction. Sometimes, the superficial sylvian veins have complex connections or are not visible because of the thickness of the arachnoid membrane, especially in the case of subarachnoid hemorrhage (SAH). The present report describes a simple method to dynamically visualize the sylvian vein via indocyanine green (ICG) angiography for the purposes of appropriately wide dissection of the sylvian fissure. METHODS: Before dissection of the sylvian fissure and after opening the dura mater, a bolus of ICG is administered intravenously. ICG videoangiography is used for dynamic venography at 10 seconds after the depiction of branches of the middle cerebral artery. RESULTS: Clear documentation of the sylvian vein was obtained via ICG videoangiography, even in cases of SAH with ambiguous anatomical topography attributable to clot under the superficial arachnoid membrane. ICG was able to differentiate between the sylvian veins of the frontal and temporal lobes, which allowed wide dissection of the sylvian fissure while preserving the veins. CONCLUSIONS: ICG videoangiography is an easy and useful method for identifying the connections and tributaries of the superficial sylvian veins from a transsylvian approach. This method allows wide opening of the sylvian fissure while preserving the sylvian veins.