Rathke's Cleft Cyst and Craniopharyngioma: A Continuum of the Same Spectrum? Insights from an Interesting Case and Previous Literature.

Rathke's Cleft Cysts (RCCs) and Craniopharyngiomas (CPs) may represent disease entities on the same etio-pathological spectrum. We report the case of a 36-year-old female presenting with vision loss and menstrual irregularities, imaging shows a predominantly cystic lesion in the sellar region with suprasellar extension. She underwent a microscopic transnasal resection of the lesion. She later presented with recurrent symptoms and increased residual lesion size on imaging, a transcranial excision of the lesion was performed. Histopathology from the initial operative specimen revealed RCC with squamous metaplasia which was BRAF negative, while the specimen from the second surgery revealed BRAF positive papillary stratified squamous architecture suggestive of Papillary CP. This case adds to the evidence that both RCCs and papillary CPs may be the spectrum of the same disease. Further, papillary CPs may be an evolution from the RCCs.

Neuropsychological Rehabilitation for Epilepsy in India: Looking Beyond the Basics.

BACKGROUND: Neuropsychological Rehabilitation (NR) helps manage cognitive deficits in epilepsy. As internationally developed programs have limited applicability to resource-limited countries, we developed a program to bridge this gap. This 6-week caregiver-assisted, culturally suitable program has components of (1) psychoeducation, (2) compensatory training, and, (3) cognitive retraining and is called EMPOWER (Indigenized Home Based Attention and Memory Rehabilitation Program for Adult Patients with Drug Refractory Epilepsy). Its efficacy needs to be determined. METHODS: We carried out an open-label parallel randomized controlled trial. Adults aged 18-45 years with Drug Refractory Epilepsy (DRE), fluency in Hindi and or English, with impaired attention or memory (n = 28) were randomized to Intervention Group (IG) and Control Group (CG). The primary outcomes were objective memory (Auditory Verbal Learning Test), patient and caregiver reported everyday memory difficulties (Everyday Memory Questionnaire-Revised), number of memory aids in use, depression (Hamilton Depression Rating Scale), anxiety (Hamilton Anxiety Rating Scale) and quality of life (Quality of Life in Epilepsy-31). Intention to treat was carried out for group analysis. In the absence of norms necessary for computing Reliable Change Indices (RCIs), a cut-off of +1.0 Standard Deviation (SD) was utilized to identify clinically meaningful changes in the individual analysis of objective memory. A cut-off of 11.8 points was used for quality of life. Feedback and program evaluation responses were noted. RESULTS: The majority of the sample comprised DRE patients with temporal lobe epilepsy who had undergone epilepsy surgery. Group analysis indicated improved learning (p = 0.013), immediate recall (p = 0.001), delayed recall (p < 0.001), long-term retention (p = 0.031), patient-reported everyday memory (p < 0.001), caregiver-reported everyday memory (p < 0.001), anxiety (p = 0.039) and total quality of life (p < 0.001). Individual analysis showed improvement in 50 %, 64 %, 71 %, 57 %, and 64 % of patients on learning, immediate recall, delayed recall, long-term retention, and total quality of life respectively. Despite improvements, themes indicative of a lack of awareness and understanding of cognitive deficits were identified. Overall, the program was rated favorably by patients and caregivers alike. CONCLUSION: NR shows promise for patients with DRE, however larger studies are warranted. The role of cognition in epilepsy needs to be introduced at the time of diagnosis to help lay the foundation for education and acceptance.

Topical Vancomycin for Prevention of Surgical Site Infection in Cranial Surgeries: Results of an Updated Systematic Review, Meta-Analysis and Meta-Regression.

Background: Surgical site infection (SSI) rates (1-9%) remain high despite the widespread adoption of infection control bundles. Topical vancomycin has emerged as an effective strategy to reduce the rate of SSI in patients undergoing spinal surgery including instrumentation. However, its use and efficiency in cranial neurosurgery is not well established. The aim of this study is to study the efficacy of topical vancomycin in cranial neurosurgery. Methods: A systematic search was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data regarding type of surgery, use of implants, the dose of vancomycin, technique of administration in each study, outcomes, rate of SSI, and the interval between surgery and SSI; possible complications related to antibiotic use were collected. Results: A total of 12 studies were included in the qualitative analysis with 3,446 patients. SSI developed in 1.6% of the patients in the vancomycin group as compared to 5.28% in the control group. The pooled risk ratio was 0.24 with 95% CI: 0.12-0.51 (P-value: <0.00001). The difference between the subgroups was significant (P-value: < 0.00001). The number needed to treat (NNT) was 27.2. The studies showed low heterogeneity with an I2 of 24%. Meta-regression analysis showed that the number of patients in a study, duration of follow-up, and year of publication did not contribute significantly to effect size. Conclusion: The limited systemic absorption of vancomycin and broad-spectrum led to its widespread applicability in the prevention of SSI in all types of cranial neurosurgery. Cases with implantable pulse generators, cranioplasty, and cerebrospinal fluid (CSF) diversion procedures have all demonstrated their unequivocal effectiveness.

Cortico-limbic disruption, material-specificity, and deficits in cognitive-affective theory of mind.

The Theory of Mind deficit due to cognitive-affective disintegration is a poorly understood cognitive consequence of cortical and subcortical disruption in right temporal lobe epilepsy. Following Marr's trilevel approach, we used the material-specific processing model to understand the Theory of Mind deficit in drug-resistant epilepsy (N = 30). We examined pre- and post-surgery changes in first-order (somatic-affective, non-verbal component) and second-order Theory of Mind (cognitive-verbal component) in three groups formed using: (i) seizure side (right versus left), (ii) right temporal epilepsy (right temporal lobe epilepsy versus non-right temporal lobe epilepsy), and (iii) right temporal lobe epilepsy with amygdalohippocampectomy (right temporal lobe epilepsy versus left temporal lobe epilepsy amygdalohippocampectomy versus non-amygdalohippocampectomy). We observed a marked deficit in the first-order Theory of Mind in the right temporal lobe amygdalohippocampectomy group; we mapped this deficit to decline in the non-verbal component of Theory of Mind (somatic-affective component). Preliminary results support using a material-specific processing model to understand the Theory of Mind deficits in right temporal lobe epilepsy amygdalohippocampectomy. Malleability of verbal processing in presence of deterioration of non-verbal processing might have clinical relevance for post-surgery recovery in right temporal lobe epilepsy amygdalohippocampectomy. Documenting the material-specific nature of deficits (verbal versus non-verbal) in non-western, linguistically, and socioeconomically diverse country enables us to understand the problem of heterogeneity in post-surgery cognitive consequences in the right amygdalohippocampectomy.

Long-Term Functional Outcome Following Left Hemispherotomy in Adults and Pediatric Participants with Fmri Analysis.

Background and Objective: Hemispherotomy surgery in adults is shrouded in doubts regarding the functional outcome. The age at surgery alone should not be the deciding factor for surgery. Language paradigms were used in functional magnetic resonance imaging (fMRI) to confirm the role played by the age at the onset of seizures to predict the postoperative functional outcome. The objective of the study was to formulate an optimal strategy for patient selection for the left-sided hemispherotomy in adults, based on functional outcome analysis. Materials and Methods: A retrospective analysis of 20 participants (age at surgery 1-26 years) who underwent left hemispherotomy (over a 5-year period) was conducted. The language and motor functional assessments of 18 participants (13 pediatric and five adult participants; attrition of participants- two) were recorded at presentation and during follow-up visits. After approval was obtained from the Institutional Ethics Committee, 13 cooperative participants (eight pediatric and five adult participants) underwent language fMRI. Motor fMRI with both active and passive paradigms was done in 16 participants. Results: All 18 participants with a mean follow-up of 24 months had class I seizure-free outcome. Of these 18, five were adults (mean age = 21 years, range: 18-22 years) and 13 were in the pediatric age group (mean age = 8 years, range: 2-15 years). Postoperatively, four adults retained both verbal fluency and language comprehension at a mean follow-up period of 38 months (range: 24-48 months). Their pre- and post-op language fMRI showed word generation and regional activations for semantic comprehension in the right hemisphere. The motor area activations were seen in the right hemisphere in two and in the left hemisphere in two participants. Among the pediatric participants, four (group I [n = 4/13]) who had good language outcome showed activations in the right hemisphere. In two participants (group II [n = 2/13]) who deteriorated postoperatively, the activations were in the left hemisphere. Five participants (group III [n = 5/13]) who retained the telegraphic language postoperatively had bilateral activations of semantic comprehension areas in fMRI. All 13 pediatric participants had motor area activations seen in the left hemisphere, similar to controls. Conclusion: Left hemispherotomy can be advised to adults with comparably good postoperative language and motor outcome as in the pediatric age group, provided the weakness is acquired perinatally or below the age of 7 years. The fMRI is a valuable tool to aid in patient selection.

Trans-Oesophageal Migration of Pulled-Out Locking Screw (Zero-Profile Implant System) and its Retrieval Using Suction Catheter: A Technical Note.

Background: Intraoperative trans-esophageal migration of pulled-out screws, especially while using the zero-profile implant system, has been rarely reported in the literature. Objective: In this technical note, we are describing a simple technique to retrieve a trans-esophageally migrated pulled-out screw using a suction catheter. Material and Methods: A 32-year-old female presented with spastic quadriparesis. She underwent C5-C6 anterior cervical discectomy and fusion (ACDF). Nine months following the surgery, X-ray cervical spine showed implant loosening and failure of fusion across the instrumented disc space. However, during revision surgery, the loosened screw could not be located visually in the initial attempts, though it could be felt by probing the prevertebral space with the index finger. Intraoperative X-rays showed that the screw migrated curiously in the cranial direction as the surgical field was probed further manually. The screw was then finally retrieved using Magill's forceps assisted by video laryngoscopy assisted by intermittent negative pressure application via a blunt-tipped suction catheter. Results: She was discharged home on a Philadelphia collar, and at 1 year of follow-up, she was completely asymptomatic. Conclusion: Perforation of the aerodigestive tract by a displaced cervical spine implant is an uncommon complication. Manipulation during surgery may cause the implants embedded into the wall of the aerodigestive tract to become dislodged and then migrate into the pharyngeal lumen. In resource-constrained situations or when intraoperative endoscopy is not available, a trial of screw retrieval using a suction catheter may be attempted.

Endoscopic Total Corpus Callosotomy and Pan Commissurotomy for Lennox-Gastaut Syndrome.

Background: Corpus callosotomy (CC) is a major disconnection procedure that functionally isolates the cerebral hemispheres, thereby interrupting the spread of epileptic activity from one hemisphere to the other. It is extremely useful in children suffering from non-localized drug refractory epilepsy, especially drop attacks. The technique has evolved from microscopic to minimally invasive endoscopic surgery. The extent of callosotomy also varies based on the institutional practices ranging from anterior 1/3rd to total corpus callosotomies (TCC). The performance of TCC in conjunction with anterior, posterior, and hippocampal commissurotomies was described for the first time by the senior author from our institution. Objective: To describe the technique of performing endoscopic total corpus callosotomy, and pan commissurotomy using the interhemispheric corridor. Methods: A seven-year-old right-handed male child with seizure onset at the age of six months presented with three types of semiologies consisting of myoclonic jerks, frequent head drops and tonic posturing involving right upper and lower limbs with secondary generalization. Results: Video electroencephalography (VEEG) revealed diffuse slowing of the background, and slow spike and wave pattern. Generalized paroxysmal fast activity (GPFA) was noted in the VEEG, suggestive of LGS. MRI brain revealed bilateral parieto-occipital gliosis and gross brain atrophy. Ictal SPECT localized to left temporo-occipital area, while magnetoencephalography revealed bilateral temporal localization. Patient underwent TCC with pancommissurotomy. The patient was seizure-free (ILAE Class 3) at one-year follow up with no drop attacks, and significant reduction noted in other seizure types. Conclusion: Endoscopic corpus callosotomy and pan commissurotomy using the interhemispheric corridor is an elegant and minimally invasive technique best suited for appropriately selected children with refractory epilepsy.

Use of Intraoperative Imaging to Preserve C1-C2 Mobility in Complex Atlas-Hangman Fractures.

Background: Combination fractures of the C1-C2 complex especially atlas and hangman are relatively uncommon and management usually compromises C1-C2 mobility. Objective: To evaluate the treatment of combined C1- hangman's fracture with and without intraoperative O- arm based navigation system, and its outcome in terms of preserving C1-C2 mobility. Methods: This was a case series of patients with combined C1 and hangman's fracture, managed at a tertiary care hospital during February 2009 to December 2016. Neurological function assessed with American Spine Injury Association (ASIA) impairment scale. Radiological fusion of the operated segment assessed with computed tomographic scan, criteria used for successful fusion included formation of callus across the fracture. Preservation of rotational motion between C1 and C2 was assessed by cervical flexion rotation (CFR) test. Results: We included 10 patients (male/female: 9/1; mean 47.7 ± 17.5 years) in our study. Operative intervention was performed in 9 patients. We used intraoperative computed tomogram (CT) scan with navigation in 5 patients. The mean follow-up period was 28.7 months (range 6 to 70 months). Neurological recovery occurred in all 4 patients with preoperative neurological deficits. Radiological fusion occurred in all cases. Rotation at C1-2 was preserved in all 5 cases operated under O-arm guidance and in one patient with type 1 fracture who was managed conservatively. Conclusions: The goals in treating these complex fractures are to achieve early maximum stability and preserving maximum range of motion. These are often competing phenomena, which can be achieved by using intra operative CT scan and navigation system.

Enhancing Safety in Epilepsy Surgery (EASINESS): Study Protocol for a Retrospective, Multicenter, Open Registry.

Introduction: Optimizing patient safety and quality improvement is increasingly important in surgery. Benchmarks and clinical quality registries are being developed to assess the best achievable results for several surgical procedures and reduce unwarranted variation between different centers. However, there is no clinical database from international centers for establishing standardized reference values of patients undergoing surgery for mesial temporal lobe epilepsy. Design: The Enhancing Safety in Epilepsy Surgery (EASINESS) study is a retrospectively conducted, multicenter, open registry. All patients undergoing mesial temporal lobe epilepsy surgery in participating centers between January 2015 and December 2019 are included in this study. The patient characteristics, preoperative diagnostic tools, surgical data, postoperative complications, and long-term seizure outcomes are recorded. Outcomes: The collected data will be used for establishing standardized reference values ("benchmarks") for this type of surgical procedure. The primary endpoints include seizure outcomes according to the International League Against Epilepsy (ILAE) classification and defined postoperative complications. Discussion: The EASINESS will define robust and standardized outcome references after amygdalohippocampectomy for temporal lobe epilepsy. After the successful definition of benchmarks from an international cohort of renowned centers, these data will serve as reference values for the evaluation of novel surgical techniques and comparisons among centers for future clinical trials. Clinical trial registration: This study is indexed at clinicaltrials.gov (NT 04952298).

Atypical Symptoms of Cervical Spondylosis: Is Anterior Cervical Discectomy and Fusion Useful? - An Institutional Experience.

BACKGROUND: A significant proportion of patients with cervical spondylosis can present with atypical symptoms like vertigo, tinnitus, nausea, vomiting, headache, blurred vison, palpitations and gastrointestinal (GI) discomfort. The role of ACDF in alleviating these atypical symptoms remains unexplored. OBJECTIVE: The current study attempts to investigate the role of anterior cervical discectomy and fusion (ACDF) in alleviating atypical symptoms associated with cervical spondylosis. MATERIALS AND METHODS: The patients with cervical spondylosis who underwent ACDF between January 2011 and December 2015 were contacted by phone. Data regarding the severity and frequency of atypical symptoms was collected by a structured questionnaire. Wilcoxon signed rank test was used to compare the severity and frequency of these symptoms before the surgery and at last follow up. RESULTS: A total of 467 patients underwent ACDF for cervical spondylosis between January 2011 and December 2015, of which 358 patients were interviewed telephonically. 99 of 358 (27.65%) patients who met the eligibility criteria were included in the final analysis. The severity and frequency of vertigo, headache, nausea, vomiting and GI discomfort significantly improved at last follow-up (P < 0.001) compared to pre-operative period. Significant improvement in hypertension was also seen (P = 0.001). Improvements in severity and frequency of tinnitus (P = 0.083), palpitation (P = 0.317) and blurring of vision (P = 1.00) were not significant. CONCLUSIONS: ACDF might improve the atypical symptoms like vertigo, headache, nausea, vomiting and GI discomfort in patients with cervical spondylosis. Some patients also show improvement in hypertension following surgery.

Robotic Applications in Cranial Neurosurgery: Current and Future.

Robotics applied to cranial surgery is a fast-moving and fascinating field, which is transforming the practice of neurosurgery. With exponential increases in computing power, improvements in connectivity, artificial intelligence, and enhanced precision of accessing target structures, robots are likely to be incorporated into more areas of neurosurgery in the future-making procedures safer and more efficient. Overall, improved efficiency can offset upfront costs and potentially prove cost-effective. In this narrative review, we aim to translate a broad clinical experience into practical information for the incorporation of robotics into neurosurgical practice. We begin with procedures where robotics take the role of a stereotactic frame and guide instruments along a linear trajectory. Next, we discuss robotics in endoscopic surgery, where the robot functions similar to a surgical assistant by holding the endoscope and providing retraction, supplemental lighting, and correlation of the surgical field with navigation. Then, we look at early experience with endovascular robots, where robots carry out tasks of the primary surgeon while the surgeon directs these movements remotely. We briefly discuss a novel microsurgical robot that can perform many of the critical operative steps (with potential for fine motor augmentation) remotely. Finally, we highlight 2 innovative technologies that allow instruments to take nonlinear, predetermined paths to an intracranial destination and allow magnetic control of instruments for real-time adjustment of trajectories. We believe that robots will play an increasingly important role in the future of neurosurgery and aim to cover some of the aspects that this field holds for neurosurgical innovation.

Comparison of Peripheral Neurectomy vs. Medical Treatment for Migraine: A Randomized Controlled Trial.

BACKGROUND: Migraine is a common form of primary neurologic headache. Many patients are chronic migraineurs and suffer from a significant disability and adverse effects of drugs. There are various surgical options available to treat migraines, including peripheral neurectomies. OBJECTIVE: To study the surgical and functional outcomes of migraine surgeries using peripheral neurectomies and compare them with conservatively treated patients. MATERIALS AND METHODS: Migraine patients who had a unilateral onset pain were given local bupivacaine block at the suspected trigger site, and those who were relieved were given the option for surgery. In the operative group, the peripheral nerve of the trigger site was lysed under local anesthesia. The conservative group was continued with the standard treatment. Evaluations with a baseline and 6 months visual analog score (VAS), migraine headache index (MHI), migraine disability assessment test (MIDAS), and pain self-efficacy questionnaire (PSEQ) scores were done. RESULTS: A total of 26 patients got benefitted with the local bupivacaine block, out of which 13 underwent surgery. At baseline, the VAS, MHI, MIDAS, and PSEQ scores were similar in both the groups. The operative group had significant (P < 0.001) improvement in all these parameters 6 months after the surgery. All patients of the operative group got free from prophylactic migraine treatment; however, 11 out of 13 patients still needed occasional  use of analgesics. There was one complication of transient temporal numbness. CONCLUSION: Migraine surgery using peripheral neurectomies was more effective than chronic drug treatment in appropriately selected patients.

Predictive value of intraoperative D-wave and m-MEP neurophysiological monitoring in patients with preoperative motor deficits in immediate and late postoperative period.

BACKGROUND: Presence of preoperative motor deficits in patients poses a distinct challenge in monitoring the integrity of corticospinal tracts during spinal surgeries. The inconsistency of the motor-evoked potentials is such patients, limits its clinical utility. D-wave is a robust but less utilized technique for corticospinal tract monitoring. The comparative clinical value of these two techniques has not been evaluated in the patients with preoperative deficits. OBJECTIVES: The objective of the study was to compare the predictive utility of myogenic Motor Evoked Potentials (m-MEP) and D-wave in terms of recordability and their sensitivity and specificity in predicting transient and permanent new motor deficits. MATERIALS AND METHODS: Thirty-one patients with preoperative motor deficit scheduled to undergo spinal surgery were included in the study. Intraoperative m-MEP and D-wave changes were identified and correlated with postoperative neurology in the immediate postoperative period and at the time of discharge. RESULTS: The mean preoperative motor power of the patient pool in left and right lower limb was 2.97 ± 1.56 and 3.32 ± 1.49, respectively. The recordability of m-MEPs and D-wave was observed to be 79.4% and 100%, respectively. The m-MEP predicted the motor deterioration in immediate postoperative period with 100% sensitivity and 80% specificity, while D-wave had 14% sensitivity and 100% specificity. At the time of discharge, m-MEPs' specificity reduced to 61%, while D-wave demonstrated 100% specificity. CONCLUSIONS: D-wave has a better recordability than m-MEPs in neurologically compromised patients. D-wave predicts development of long-term deficits with 100% specificity, while m-MEPs have a high sensitivity for transient neurological deficit. A combination of D-wave and m-MEP is recommended for monitoring the integrity of the corticospinal tract in patients with preoperative motor deficits.

Comparative contribution of magnetoencephalography (MEG) and single-photon emission computed tomography (SPECT) in pre-operative localization for epilepsy surgery: A prospective blinded study.

PURPOSE: The aim of this study was to compare the diagnostic value and accuracy of ictal SPECT and inter-ictal magnetoencephalography (MEG) in localizing the site for surgery in persons with drug resistant epilepsy. METHOD: This was a prospective observational study. Patients expected to undergo epilepsy surgery were enrolled consecutively and the localization results from different imaging modalities were discussed in an epilepsy surgery meet. Odds ratio of good outcome (Engel I) were calculated in patients who underwent surgery in concordance with MEG and SPECT findings. Post-surgical seizure freedom lasting at least 36 months or more was considered the gold standard for determining the diagnostic output of SPECT and MEG. RESULTS: MEG and SPECT were performed in 101 and 57 patients respectively. In 45 patients SPECT could not be done due to delay in injection or technical factors. The accuracy of MEG and SPECT in localizing the epileptogenic zone was found to be 74.26 % and 78.57 % respectively. The diagnostic odds ratio for Engel I surgical outcome was reported as 2.43 and 5.0 for MEG and SPECT respectively. The diagnostic odds ratio for MEG in whom SPECT was non-informative was found to be 6.57 [95 % CI 1.1, 39.24], although it was not significantly associated with good surgical outcome. MEG was useful in indicating sites for SEEG implantation. CONCLUSION: SPECT was found to be non-informative for most patients, but reported better diagnostic output than MEG. MEG may be a useful alternative for patients in whom SPECT cannot be done or was non-localizing.

Trans-Sylvian Resection of Giant Left Insular Glioma: Operative Technique and Nuances.

BACKGROUND: Insular glioma was considered a nonsurgical entity due to resection-associated morbidities. The advancement in neurosurgical techniques and adjuncts used in the last two decades made the resection of insular gliomas simpler for neurosurgeons with the maximum extent of resection and acceptable morbidity rates. The complex anatomy of this region remains a challenge for neurosurgeons and requires expertise. The key factors to achieve complete resection in the insular region are the thorough knowledge of surgical anatomy and meticulous microsurgical techniques. Intraoperative adjuncts such as image guidance along with cortical and subcortical mapping assist in excellent outcomes. OBJECTIVE: In this study, we describe the operative technique and application of trans-Sylvian approach to do the compartmental dissection done by the senior author, along with challenges faced, with the hope to highlight the efficacy of the approach to achieve maximal resection of this entity without compromising patient's safety. MATERIALS AND METHODS: A 32-year-old right-handed gentleman presented with episodes of excessive salivation, tingling sensation on the right side of the body along with nausea that lasted for 15-20 s for the last 8 months and one episode of speech arrest without any loss of consciousness and motor or sensory deficit. CEMRI of the brain was suggestive of left insular glioma. The patient underwent left pterional craniotomy, and gross total resection of the tumor was done using compartmental dissection. RESULTS: At follow-up after 1 month, the patient is seizure-free without any speech difficulty and motor or sensory deficit. CONCLUSION: Compartmental dissection of insular glioma is a safe and efficacious technique to achieve gross total resection of the tumor in this complex region without morbidity.

Cervical Split Cord Malformations: A Systematic Review.

Cervical split cord malformations are extremely rare with less than 75 cases reported in the literature worldwide. The widely different terminologies used to describe the same pathoanatomy make the documentation of all reported cases a difficult task. We conducted a systematic review of 71 cases documented over 38 reports from 1889 to 2016. The controversy regarding prophylactic surgery in asymptomatic individuals remains. We advocate prophylactic surgery in all asymptomatic individuals to preclude severe neurological deficit following trivial trauma in future. The results of surgery in asymptomatic individuals are excellent while those in symptomatic individuals are good as well.

Long-Term Outcome of Surgical Management in Symptomatic Pediatric Vertebral Hemangiomas Presenting With Myelopathy.

BACKGROUND: Vertebral hemangiomas are benign, highly vascular lesions of the vertebra, rarely seen in the pediatric age group. OBJECTIVE: To analyze the long-term (>3 yr) outcome of patients of pediatric vertebral hemangioma presenting with myelopathy and to describe our surgical strategy to treat such cases. METHODS: All patients up to 18 yr of age with a symptomatic vertebral hemangioma treated at our hospital from May 2003 to August 2016, with at least 3-yr follow-up were included. Functional clinical outcomes were measured using American Spinal Injury Association (ASIA) score. RESULTS: There were 7 male and 7 female patients. All hemangiomas were located in the thoracic spine with single-level involvement. Upper thoracic spine involvement was more common (12 cases: 85.71%) than lower thoracic spine involvement (2 cases: 14.29%). All patients had features of myelopathy. The mean age was 14.57 yr, ranging from 10 to 18 yr. The mean follow-up was 62.21 mo, ranging from 36 to 90 mo. All patients had improvement in motor strength of both lower limbs postoperatively. Local pain, which was present in 1 patient, resolved, and the bladder symptoms present in 5 patients also resolved. CONCLUSION: Our experience in treating symptomatic pediatric vertebral hemangiomas, along with the long-term follow-up data, suggests that good postoperative results can be achieved with minimal complications in carefully selected patients.

Evaluation of memory in persons with mesial temporal lobe sclerosis: A combined fMRI and VBM study.

Persons with drug refractory TLE have the option of being managed by surgery. They may develop memory impairment with specific etiology of mesial temporal sclerosis and anterior temporal lobe resection (ATLR). The study evaluated the semantic verbal memory outcomes in pre- and post-surgery temporal lobe epilepsy (TLE) patients using functional MRI and voxel morphometric methods. Twenty consecutive persons with drug-resistant epilepsy (DRE) and 20 healthy controls were recruited after obtaining the institute ethics approval. The fMRI scans were performed on a 1.5 T MR Scanner using standardized semantic verbal memory tasks using a native Hindi paradigm, before and after an anterior temporal lobectomy (in cases). A task-based functional connectivity (FC) was estimated using a conn toolbox. Data analysis was carried out using the statistical parametric imaging (SPM12) and CAT12 toolbox. Post-surgery TLE group showed increased robust FC in the right middle and posterior temporal regions as compared to pre-surgery session. A significant reduction in grey matter volume was observed in the left temporal lobe post-operatively as compared to presurgery and healthy control groups. In the post-surgery TLE group, neuropsychological scores were reduced in specific PGI domains such as visuospatial, working memory, and executive functioning. Our results may help in understanding of memory reorganization in TLE post-operatively.

Posterior quadrant disconnection for sub-hemispheric drug refractory epilepsy.

The posterior quadratic epilepsy (PQE) is a form of a multilobar epilepsy, involving the temporal-parietal and occipital lobes. Basically, epilepsies with localized networks to the posterior temporal, posterior parietal, and occipital lobes can benefit from this type of surgery. Gliosis due to perinatal insult and cortical dysplasis and angiomas in Sturge Weber syndrome involving the PQ have often been cited in the literature as the etiology for PQE. However, before considering surgery, it is important to localize the epileptogenic focus through a complete pre operative work up involving; EEG (Electro-Encephalo-Graphy), video EEG, single photon emission computed tomography (SPECT), positron emission tomography (PET), and magneto encephalography (MEG). Historically, these pathologies were dealt with multi-lobar resections, which were associated with high morbidity and mortality, owing to blood loss, especially in young children, hydrocephalus, and hemosiderosis. Based on the theory of networks involved in epileptogenesis, the concept of disconnection in epilepsy surgery was introduced. Delalande and colleagues, described the technique of hemispheric disconnection (functional hemispherectomy) for pathologies like: hemimegalencephaly, rasmussens encephalitis involving the entire hemisphere. The technique has evolved with time, moving towards minimally invasive endoscopic vertical hemispherotomy, described by Chandra and colleagues.[1],[2] The posterior quadrant disconnection (PQD) evolved as a tailored disconnection on similar lines as hemispherotomy, for managing refractory epilepsy arising from the posterior quadrant.[3] The technique and principles involved in the PQD surgery are similar to the those of peri-insular hemispherotomy and has been described in the literature by few authors.[3],[4],[5],[6] The technique of performing PQD will be described here in a step-wise fashion with illustrations supplemented by a surgical video.

Functional Cerebral Specialization and Decision Making in the Iowa Gambling Task: A Single-Case Study of Left-Hemispheric Atrophy and Hemispherotomy.

The Iowa Gambling Task (IGT) is a decision-making task that preferentially involves the right prefrontal cortex (PFC). However, the performance of the task is driven by two attributes: intertemporal (long vs. short-term) and frequency-based processing of rewards-punishments, and differs over the two phases of uncertainty (early trials) and risk (later trials). Although intertemporal decision making involves the right PFC, the extent of hemispheric specialization in attribute and phase-specific decision making is unknown. Therefore, the current study assessed decision making in a patient with a uni-hemispheric disease, who underwent hemispherotomy surgery, comparing pre-surgical IGT performance (3 days prior to surgery) with post-surgical performance (1 month, and 12 months post-surgery). The patient's pre- and post-surgical IGT performances were analyzed to examine changes in attribute and phase-specific decision making, including the widely reported deck B phenomenon. The results for the two attributes of deck selection at the pre- and post-surgical assessments suggested marked changes in the two IGT phases of risk and uncertainty. Pre-surgery, the patient made more intertemporally disadvantageous choices, and task-progression contributed to it; within 1 month of surgery, intertemporal disadvantageous deck choices were contingent on task progression, after 1 year, disadvantageous choices were independent of task progression. Intertemporal attribute alteration was unresponsive to uncertainty and risk phase. The effect of task progression on frequency attribute remained unchanged before and immediately after the surgery, and preference for infrequent decks was observed only after 1 year. Further, pre and post surgery alteration in frequency attribute was phase-specific: within 1 month of surgery, infrequent deck choices decreased in uncertainty and increased in risk, whereas the reverse was observed after 12 months. Deck B choice increase was in the uncertainty phase. Results are discussed in reference to valence-linked hemispheric specialization and its potential role in attribute and phase-specific IGT decision making.