First reported case of hydrocephalus in jointly diagnosed bacterial meningitis and a colloid cyst: how Ockham's razor became Hickam's dictum.

We report the first case in the literature of acute hydrocephalus due to a simultaneous diagnosis of bacterial (not asceptic) meningitis and a colloid cyst. Diagnosing disease is the cornerstone skill of a medical practitioner. Both education and experience allow for sharpening of this skill throughout years of medical practice. Disease is fraught with nuances and inconsistencies which can render an accurate diagnosis a difficult task. Medical practitioners can be guilty of cognitive biases such as Ockham's razor. We present the case of a patient with an initial diagnosis of obstructive hydrocephalus secondary to a colloid cyst. However, pneumococcal meningitis blunted Ockham's razor in favour of Hickam's dictum.

Spinal paraganglioma presenting with raised intracranial pressure: a note on the diagnosis and post-operative management.

BACKGROUND: Spinal paragangliomas are tumors of neuroendocrine origin that present with symptoms of mass effect or neurosecretion but rarely involve the central nervous system. Raised intracranial pressure and papilledema are therefore unusual presentations of a spinal paraganglioma. METHODS: We review the case of a 54-year-old man who presented with headache and visual disturbance. Fundoscopy confirmed papilledema with normal intracranial imaging. Neuraxis imaging revealed a lumbar intradural extramedullary tumor and pathological analysis confirmed a WHO Grade I spinal paraganglioma. The tumor was resected and post operatively his vison improved with resolution of optic disc swelling. CONCLUSIONS: Raised intracranial pressure and papilledema are unusual clinical manifestations of spinal tumors and imaging the entire neuraxis can be valuable.

A Review on Computer Aided Diagnosis of Acute Brain Stroke.

Amongst the most common causes of death globally, stroke is one of top three affecting over 100 million people worldwide annually. There are two classes of stroke, namely ischemic stroke (due to impairment of blood supply, accounting for ~70% of all strokes) and hemorrhagic stroke (due to bleeding), both of which can result, if untreated, in permanently damaged brain tissue. The discovery that the affected brain tissue (i.e., 'ischemic penumbra') can be salvaged from permanent damage and the bourgeoning growth in computer aided diagnosis has led to major advances in stroke management. Abiding to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, we have surveyed a total of 177 research papers published between 2010 and 2021 to highlight the current status and challenges faced by computer aided diagnosis (CAD), machine learning (ML) and deep learning (DL) based techniques for CT and MRI as prime modalities for stroke detection and lesion region segmentation. This work concludes by showcasing the current requirement of this domain, the preferred modality, and prospective research areas.

Neurogenic pulmonary oedema complicating traumatic posterior fossa extradural haematoma: Case report and review.

INTRODUCTION: Pulmonary oedema is accumulation of fluid in the lung air spaces and interstitia. Neurogenic pulmonary oedema (NPE) is a potentially life-threatening condition which has been noted in head injury, subarachnoid haemorrhage (SAH), intracerebral haemorrhage (ICH) and others. Timely management is crucial to achieve good outcome; however, no specific guidelines have been defined. METHODS: A 33-year female involved in a motor vehicular accident had a GCS of 14/15 and CT scan showed a moderate-sized unilateral posterior fossa extradural haematoma (PFEDH). She had sudden deterioration in her haemodynamic status with drop in sensorium 2 hours after admission. There was a copious amount of frothy secretions noted on intubation and she was diagnosed as having NPE. RESULTS: Sub-occiptial craneictomy (SOC) with haematoma evacuation was performed and was managed with PEEP mechanical ventilation post-operatively. Excellent outcome was obtained and was discharged with a GOS of 5. CONCLUSIONS: NPE is a poorly understood and uncommon complication of acute CNS injury and should be considered in any patient with acute respiratory distress in the setting of CNS injury. Reduction in ICP and supportive mechanical ventilation form the mainstay of management. Diagnosis of NPE remains challenging and more reliable diagnostic criteria need to be defined to identify such cases with greater frequency.

Intrapleural Migration of Ventriculoperitoneal Shunt due to Negative Intrathoracic Pressure.

Background Ventriculoperitoneal (VP) shunt is still a mainstay of treatment in centers for infants with aqueductal stenosis which is the most common cause of congenital obstructive hydrocephalus. Shunt migration remains a common complication. Delayed distal shunt tip migration into the thoracic cavity due to negative intrathoracic pressure is a rare occurrence. Case Presentation Authors report a 1-year-old infant presenting with drowsy sensorium, increasing head circumference, and bulging anterior fontanelle. Magnetic resonance imaging of the brain revealed significant obstructive hydrocephalus with periventricular seepage. A large expansile diverticulum of the suprapineal recess extending infratentorially compressing the dorsal midbrain and cerebellum inferiorly. The child underwent an emergency right-side VP shunt (medium pressure) in view of clinical symptoms of raised intracranial pressure. A right iliac fossa infraumbilical transverse incision was taken for placing the abdominal end. Visual confirmation of bowel was done after opening the peritoneum by two operating surgeons prior to inserting the distal catheter. Postoperative course was uneventful. The child presented 3 months later with acute dyspnea and diminished breath sounds on the right hemithorax. Neurologically, the child was active, feeding well, and anterior fontanelle was lax. A chest roentgenogram and computed tomogram (CT) of the thorax revealed complete shunt migration into the pleural space with significant pleural effusion on the right side. The distal shunt system on CT appeared to enter the pleural space below the 8th rib, probably indicating that there was subcostal tunneling of the shunt below the 8th rib space during the first surgery which was inconspicuous and subsequently over a span of 3 months due to sucking effect of negative intrathoracic pressure the shunt gradually migrated into the pleural cavity which led to the effusion. An emergency VP shunt revision was performed. The distal end below the chamber was retunneled subcutaneously into a new incision in the left paraumbilical region. Postoperative chest and abdomen roentgenograms showed resolving effusion and accurate shunt placement. The child required elective ventilation temporarily to tide over the underlying lung collapse and an intercostal tube drainage for the cerebrospinal fluid (CSF) hydrothorax for 2 days to aid in quicker weaning. The child was discharged on the 5th postoperative day. Discussion Intrapleural migration of VP shunts has been contemplated to be due to trauma during surgery, migration across foramen of Bochdalek or Morgagni, and negative intrathoracic pressure. Taub and Lavyne have classified thoracic complications of VP shunt as thoracic trauma during shunt tunneling, supradiaphragmatic migration of shunt or transdiaphragmatic migration of shunt, and pleural effusion complicated by CSF ascites. Transdiaphragmatic migration is commonly seen in pediatric population and supradiaphragmatic migration can be seen in any age group. We believe our case to be a type of supradiaphragmatic migration of the shunt which has occurred slowly over a span of time due to the negative intrathoracic pressure. The idea behind this clinical case image is to edify neurosurgeons, pediatricians, and intensivists to remain wary of such a complication.

Brown Tumor of the Dorsal Spine With Hemorrhage Causing Acute Neurological Deterioration: A Rare Presentation of Secondary Hyperparathyroidism.

Brown tumor due to secondary hyperparathyroidism in chronic kidney disease is a well-established entity. Brown tumor of the spine with hemorrhage causing acute neurological deficit is a rare entity. A 35-year-old gentleman, with chronic kidney disease (CKD) on dialysis, presented with acute paraplegia and loss of lower limb sensation and bowel and bladder control. Imaging revealed a T8 vertebral body expansile lytic lesion with collapse, exaggerated kyphosis, and cord compression. He underwent an emergency decompressive laminectomy and transpedicular corpectomy of T8, with posterior stabilization. Histopathology revealed lobular clusters of osteoclast-like multinucleated giant cells with background of which was possibly the reason for acute neurological deterioration in this case. Brown tumors of the spine can mimic lytic lesions of the spine like myeloma and metastasis. Suspicion must be raised given in the setting of CKD and hyperparathyroidism. They can present with hemorrhage and acute neurological deficit, which warrants urgent surgical intervention for optimal outcomes.

Correlation of pre-operative and post-operative retinal nerve fibre layer thickness with visual outcome following decompression of pituitary macroadenoma.

OBJECTIVE: To (i) correlate preoperative retinal nerve fibre layer (RNFL) thickness with visual parameters in patients with pituitary macroadenomas. (ii) study the predictive role of preoperative RNFL in visual outcome following surgery for pituitary macroadenomas (iii) correlate change in postoperative RNFL thickness (RNFLT) with visual outcome. METHODS: Preoperative and post-operative RNFL thickness of thirty-three consecutive patients operated for pituitary macro adenoma between June 2022 and May 2023 were measured using Optical Coherence Tomography (OCT) and compared with standard visual examination findings and Magnetic Resonance Imaging (MRI) measurements. RESULTS: A total of 66 eyes of 33 patients who underwent surgical excision of pituitary macro adenoma between June 2022 and May 2023 were studied. The mean age in years of the study group was 44.36 ± 13.77 and both sexes were equally represented (Male: Female = 16:17). RNFL thinning predominantly involved the temporal (51.21+/-15.19 µm) followed by nasal quadrants (62.67+/- 17.03 µm) and correlated well with the visual field (VF) deficit (p <0.001). Patients with severe disc pallor had extremely thin RNFL (less than 67 +/- 8.68 µm). Patients with moderate to severe visual acuity (VA) deficits had significantly thinner RNFLs (65.08±7.09) compared to patients with normal to mild impairment in vision. (83.185±1.2) (p<0.05). RNFL values were significantly thinner for patients with Wilson Grade C, D and E tumours (66.13 ±12.19 µm) compared to those in Grade A and B (77.67±22.12 µm). The mean preop RNFL of patients who showed post-operative improvement in vision was 87.025± 15.02 µm, of patients in whom vision remained static was 74.58 ±18.31 µm. The mean VA (Decimal) increased from a minimum of 0.60 at the pre-operative timepoint to a maximum of 0.68 at the post-operative timepoint. (Wilcoxon Test: V = 42.5, p = <0.001). The mean RNFLT (µm) increased from 77.14 µm at the pre-operative timepoint to 83.77 µm at the post-operative timepoint. (Wilcoxon Test: V = 218.0, p = <0.001). The mean change of RNFL in patients in whom vision improved was 3.6 µm and the mean change of RNFL in patients in whom vision remained static was 9.51 µm. Absence of postoperative visual improvement was noted despite postoperative RNFL thickness improvement in eyes which showed significant preoperative thinning of the nasal (<65 µm) and temporal (<52µm) quadrants. CONCLUSION: RNFL thinning corelates directly with visual acuity, visual field, and optic disc pallor. Patients with pituitary adenoma have preferential thinning of temporal and nasal quadrants. Visual outcome is better in patients with preserved RNFLT of values more than 82 +/- 5 µm. Reversal of RNFL thinning postoperatively need not necessarily correlate with visual improvement especially in patients who showed significant preoperative thinning of nasal and temporal quadrants.

Automatic identification of hypertension and assessment of its secondary effects using artificial intelligence: A systematic review (2013-2023).

Artificial Intelligence (AI) techniques are increasingly used in computer-aided diagnostic tools in medicine. These techniques can also help to identify Hypertension (HTN) in its early stage, as it is a global health issue. Automated HTN detection uses socio-demographic, clinical data, and physiological signals. Additionally, signs of secondary HTN can also be identified using various imaging modalities. This systematic review examines related work on automated HTN detection. We identify datasets, techniques, and classifiers used to develop AI models from clinical data, physiological signals, and fused data (a combination of both). Image-based models for assessing secondary HTN are also reviewed. The majority of the studies have primarily utilized single-modality approaches, such as biological signals (e.g., electrocardiography, photoplethysmography), and medical imaging (e.g., magnetic resonance angiography, ultrasound). Surprisingly, only a small portion of the studies (22 out of 122) utilized a multi-modal fusion approach combining data from different sources. Even fewer investigated integrating clinical data, physiological signals, and medical imaging to understand the intricate relationships between these factors. Future research directions are discussed that could build better healthcare systems for early HTN detection through more integrated modeling of multi-modal data sources.

Extraventricular Neurocytoma of the Posterior Fossa: A Case Report Written by ChatGPT.

ChatGPT (Chat Generative Pre-trained Transformer) is the latest artificial intelligence (AI) tool that has taken the internet by storm. A large language model-based AI tool, ChatGPT is used to generate natural prose-like answers learning from a large database of text. A lot is being written and spoken about the future of academic writing using this tool.We attempt to generate a short case report of a brain tumour labelled extraventriuclar neurocytoma (EVN) which is a rare tumour of the central nervous system. When posed with a set of questions on this uncommon topic, ChatGPT did well with relevant but not very specific answers. Validation of the information is an issue like with most machine learning solutions. This case report is an attempt to summarise EVN and its management. Q: Summarise extraventricular neurocytoma. ChatGPT: EVN is a rare and benign tumor that typically occurs in the brain. It often causes no symptoms, but as it grows, it can cause headaches, seizures, and changes in vision or balance. Surgery is usually curative, but there is a lack of studies to know the best treatment options. The prognosis is generally good with high rates of long-term survival and low rates of recurrence. Text italicised in the article is generated by ChatGPT.

Mini anterior interhemispheric approach for A3 segment distal anterior cerebral artery aneurysms.

INTRODUCTION: Aneurysms of the A3 segment of the distal anterior cerebral artery (DACA), in relation to the genu of the corpus callosum, are specific sub-group which pose unique surgical challenges due to their discrete anatomical location. We describe a mini-anterior interhemispheric approach which can be safely utilised to clip these aneurysms rather than the traditional bifrontal approach. METHODS: Retrospective analysis of the clinical and radiological data of ruptured DACA-A3 aneurysms operated between 2014 and 2021 at our institute. A curvilinear scalp incision within the hairline followed by raising small, unilateral, free frontal bone flap, avoiding the opening of frontal sinus. Superior sagittal sinus is displaced medially, inter-hemispheric dissection carried out with posterior trajectory and small callosotomy is performed. DACA is skeletonised, proximal control is established, and the A3 aneurysm is dissected and clipped. RESULT: Our cohort of 18 patients had a definite female preponderance (F:M::2:1) with mean age of 55.6 years. On admission three patients were categorized as WFNS Grade I, thirteen in Grade II, and two in Grade III for subarachnoid haemorrhage. All the patients had evidence of blood in the interhemispheric fissure; intraparenchymal haemorrhage was seen in seven, with intraventricular haemorrhage in six patients. Within the A3 segment six aneurysms were infragenu (inferior), eight were at the genu (anterior) and four were supragenu (superior). Two (11.1%) elderly patients succumbed post-surgery following ischemic infarcts and associated complications. At the time of follow-up at 3 months of the remaining sixteen (72.2%) patients, thirteen had a good outcome (mRS 0-3) and three (16.7%) had a poor outcome (mRS > 3). CONCLUSION: The mini anterior interhemispheric is an effective minimally invasive alternative for A3 segments aneurysms and helps to avoid the complications of the conventional bifrontal interhemispheric approach.

Medulloblastoma with Subcutaneous Spread: A Rare Entity.

Medulloblastoma is the most common malignant pediatric brain tumor. Histological subclassification and adjuvant therapy have improved prognostication and outcome. Extraneural metastasis remains a poor prognostic factor and subcutaneous seeding is rarely encountered and reported in the pediatric population. We report a 3-year-old child who rapidly presented with subcutaneous seeding a month following gross total resection of his tumor.

Neurosurgical emergencies during pregnancy - Management dilemmas.

Background: Neurosurgical emergencies in the obstetric setting pose considerable challenges. Decision-making involves deliberations on the gestational age, critical nature of the illness, timing of surgery, maternal positioning during neurosurgery, anesthesiologic strategies, monitoring of the pregnancy during surgery, and the mode of delivery. The present study discusses the management and ethical dilemmas encountered during the management of six obstetric patients with neurosurgical emergencies. Methods: A retrospective review of all neurosurgical operations performed between January 2016 and December 2022 were included in the study. Results: This study includes a series of six pregnant women who presented with neurosurgical emergencies, secondary to freshly diagnosed pathologies in the period 2016-2022. The mean maternal age was 31.33 years. Four of the six patients were in the third semester and two were in the second trimester. The underlying etiologies were as follows: spontaneous intracerebral hypertensive hemorrhage (1), obstructive hydrocephalus due to shunt malfunction (1), brain tumor (02), and compressive spinal cord myelopathy due to tumors (02). Three patients who were near term underwent lower cesarean section followed by emergency neurosurgical procedure in the same sitting. Two second trimester patients continued their pregnancy after the emergency neurosurgical operation. In one patient, in whom a brain tumor was diagnosed near term, underwent neurosurgery 1 week after successful cesarean section. All the six mothers and fetus recovered well, ex3cept two patients who have persisting residual deficits. Conclusion: Treatment of neurosurgical emergencies during pregnancy needs to be customized depending on the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. With careful planning, timely intervention, consultative decision making and it is possible to achieve the ultimate goal - which is to protect and safeguard the mother and preserve and deliver a viable fetus.

Retinal nerve fiber layer thickness and its correlation with visual symptoms and radiological features in pituitary macroadenoma.

Objective: The aim of the study was to evaluate the association of the thickness of retinal nerve fiber layer (RNFL) with (i) visual symptoms and (ii) suprasellar extension defined by magnetic resonance imaging (MRI) in patients with pituitary macroadenoma. Materials and Methods: RNFL thickness of 50 consecutive patients operated for pituitary macroadenoma between July 2019 and April 2021 were compared with standard visual examination findings and MRI measurements such as optic chiasm height, distance between the optic chiasm and adenoma, suprasellar extension, and chiasmal lift. Results: The study group included 100 eyes of 50 patients operated for pituitary adenomas with suprasellar extension. RNFL thinning predominantly involved the nasal (84.26 ± 16.43 µm) and temporal quadrants (70.72 ± 14.80 µm) and correlated well with the visual field deficit (P < 0.001). Patients with moderate-to-severe deficit in visual acuity had a mean RNFL thickness <85 µm and patients with severe disc pallor had extremely thin RNFLs (<70 µm). Suprasellar extension defined as Wilsons Grade C, D, and E and Fujimotos Grades 3 and 4 were significantly associated with thin RNFLs <85 µm (P < 0.01). Chiasmal lift more than 1 cm and tumor chiasm distance of <0.5 mm were associated with thin RNFL (P < 0.002). Conclusion: RNFL thinning correlates directly with the severity of visual deficits in patients with pituitary adenoma. Wilsons Grade D and E, Fujimoto Grade 3 and 4, chiasmal lift more than 1 cm, and chiasm tumor distance <0.5 mm are strong predictors of RNFL thinning and poor vision. Pituitary macro adenoma and other suprasellar tumors need to be excluded in patients with preserved vision but having obvious RNFL thinning.

Spontaneous Intracerebral Hemorrhage in the Young: An Institutional Registry Analysis.

Background: Spontaneous intracerebral hemorrhage (SICH) accounts for about 10-15% of all strokes. Generally, it is a disease of the elderly; worldwide, the incidence of SICH in the young is showing an increasing trend, especially in India and the Asian continent. An attempt is also made to analyze the presence of factors, which may predict the risk of SICH among young hypertensives. Methods: A six-year retrospective review of patients aged below 50 years who presented with SICH was included in the study. Patients with bleeds secondary to an identifiable cause such as tumor, trauma, vascular malformations, and coagulopathy-induced bleeds were excluded from the study. The outcome was measured at 90 days using the modified ranking scale, and predictors of outcome (good outcome modified ranking score (mRS): 0-3; poor outcome mRS: 4-6) were analyzed. Results: SICH in the young accounted for 28.4% of all intracerebral hemorrhage (ICH) patients admitted during the study period (344/1210). The mean age of our male-dominant (78.5%) cohort was 42.9 ± 6.24 years, and the median Glasgow coma score (GCS) on presentation was 11 (IQR: 8-14). A prior history of hypertension (HTN) was obtained in 51.2% (176), and left ventricular hypertrophy (LVH) was documented in 237 (68.9%) patients. The basal ganglia was the most common location of the bleed (62.2%). At 90 days, 200 patients (58.1%) had good outcome and 144 (41.9%) had poor outcome with an overall mortality of 75 (21.8%). Independent predictors of poor outcome were poor GCS, larger volume, and high serum creatinine values. Conclusion: The incidence of SICH among the young accounts for nearly 30% of admitted ICH. Poor outcome and mortality are high with HTN being the single most important modifiable risk factor in the cohort.