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.

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.

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.

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.

mTOR pathway activation in focal cortical dysplasia.

BACKGROUND: Focal cortical dysplasia (FCD) is a localized cortical malformation and considerable morphological overlap exists between FCD IIB and neurological lesions associated with Tuberous sclerosis complex (TSC). Abnormal mTOR pathway secondary to somatic mTOR mutation and TSC gene mutation linked to PI3K/AKT/mTOR pathway have supported the hypothesis of common pathogenesis involved. Role of converging pathway, viz. Wnt/ß-Catenin and mTOR is unknown in FCD. We aimed to analyse FCD IIB for TSC1/TSC2 mutations, immunoreactivity of hamartin, tuberin, mTOR and Wnt signalling cascades, and stem cell markers. MATERIALS AND METHODS: Sixteen FCD IIB cases were retrieved along with 16 FCD IIA cases for comparison. Immunohistochemistry was performed for tuberin, hamartin, mTOR pathway markers, markers of stem cell phenotype, and Wnt pathway markers. Mutation analysis for TSC1 and TSC2 was performed by sequencing in 9 FCD cases. RESULTS: All FCD cases showed preserved hamartin and tuberin immunoreactivity. Aberrant immunoreactivity of phospho-P70S6 kinase, S6 ribosomal, phospho-S6 ribosomal and Stat3 was noted in FCD IIB, with variable phospho-4E-BP1 (45%) and absent phospho-Stat3 expression. Immunoreactivity for phospho-P70S6 kinase (100%), S6 ribosomal protein (100%) and Stat3 (100%) was noted in FCD IIA, but not for phospho-S6 ribosomal, phospho-4E-BP1 and phospho-Stat3. c-Myc immunoreactivity was noted in all FCD cases. Nestin (81%) and Sox 2 (88%) stained balloon cells in FCD IIB (44%), while in FCD IIA cases were negative. All FCD cases were immunopositive for Wnt, but were negative for ß-Catenin and cyclin-D1. TSC mutations were detected in two cases of FCD IIB. CONCLUSION: Abnormal mTOR pathway activation exists in FCD IIB and IIA, however, shows differential immunoreactivity profile, indicating varying degrees of dysregulation. Labelling of neuronal stem cell markers in balloon cells suggests they are phenotypically immature. TSC1/2 mutation play role in the pathogenesis of FCD. Deep targeted sequencing is preferred diagnostic technique since conventional sanger sequencing often fails to detect low-allele frequency variants involved in mTOR/TSC pathway genes, commonly found in FCD.

Surgical Outcome in Spinal Operation in Patients Aged 70 Years and Above.

INTRODUCTION: The world is seeing a growth of the aging population and the number of surgical treatments in this age group which is also true for spinal conditions. The greatest increase in spinal fusion surgery has been observed in patients aged 65 years and above. Only a few works of literature were available on the issue, especially in India. MATERIALS AND METHODS: An observational study in which 70 patients aged 70 years and above who underwent spinal surgery for degenerative and traumatic spinal injury, from January 2013 to July 2017 in the neurosurgery department of a single institute, were reviewed. Around 53 patients were assessed for disability/functional outcome and their health-related quality of life (HRQOL) using the Oswestry disability index (ODI) and RAND 36-item health survey 1.0 scoring method (SF-36) comparing the preoperative and postoperative status. RESULT: The mean age was 74.19 years (range 70-91 years). Laminectomy-19 (27.14%) was the most common surgical procedure performed. Overall there were nine (12.85%) major complications with mortality of five (7.14%) patients. There was a significant reduction of crippled patients (14-9, P = 0.009) in the ODI score. SF-36: There was significant improvement in degenerative patient (P = 0.000 to P = 0.012). In traumatic patient, only pain had significant improvement (P = 0.045). CONCLUSION: This study showed that the age of the patient should not be the limiting factor for the surgical management of a patient with a degenerative or a traumatic spinal condition.

Primary spinal atypical teratoid/rhabdoid tumour presenting with hematomyelia and subarachnoid haemorrhage-a case report.

Atypical teratoid/rhabdoid tumours (AT/RTs) are highly aggressive and uncommon malignant tumours of the central nervous system (CNS) affecting children younger than 3 years of age. Primary spinal cord involvement is an extremely rare presentation. AT/RTs show necrosis and haemorrhages on histopathology frequently. However, spinal atypical teratoid/rhabdoid tumour (AT/RT) with hematomyelia and spinal subarachnoid haemorrhage (SAH), as seen in our case, has never been reported in the literature in the paediatric age group. We report a case of primary spinal AT/RT in a 3-year-old male child presenting acutely with hematomyelia and spinal SAH and try to elucidate its pathophysiological basis.

Need of Immediate Drug Reduction after Epilepsy Surgery - A Prospective Observational Study.

BACKGROUND: Patients undergoing epilepsy surgery are on polytherapy. Drug tapering is usually done after 1 year in adults and after 6 months in children. Sometimes, drugs have to be altered during the perioperative period, which is more commonly seen in hemispherotomy (HS) patients. The present study was done to compare perioperative drug alterations between HS and temporal (TL) lobectomy patients. MATERIALS AND METHODS: Prospective analysis of postoperative HS and TL patients was done. Primary outcomes were drug number, dosage changes, and seizure outcome. Secondary outcome studied was a change in intelligence quotient (IQ) in the two groups. RESULTS: At total of 71 patients were included. Perioperative drug stopping (clobazam - CLB) was needed in 3/38 patients in the HS group, due to sedation. Dosage was reduced in 23/38 (60.52%) in HS group, and in 2/33 (6%) in TL group P < 0.001. The most common drug was CLB, with reduction in 21/27 (77.77%) patients, with a mean reduction of 41.21 ± 4.01%. Two patients required drug substitution in the HS group. About 64/71 (90.1%) patients achieved Class I outcome at a 1-year postoperative time point (TL - 90.9%, HS - 89.47%). There was no change in IQ in any of the groups. CONCLUSION: Perioperative drug alteration is often needed in the HS patients as compared to TL patients. Benzodiazepines have to be reduced to maintain alertness in the HS patients. The increased sedation postoperatively can be due to decreased cortical drive over the reticular activating system, gamma-aminobutyric acid (GABA) receptor denervation hypersensitivity, or increased activity of drugs over the remaining active hemisphere.