Occipital encephalocele: a retrospective analysis and assessment of post-surgical neurodevelopmental outcome.

BACKGROUND: Encephalocele represent a group of disorders which is characterised by extracranial herniation of the leptomeninges, brain, and CSF through a structural defect in the cranium. They are usually associated with other intracranial anomalies which may impact the neurological development. AIM: This study aimed to assess the predictors of neurological development of patients undergone surgical excision of occipital encephalocele. METHODS: All patients with occipital encephaloceles operated over the last decade (2012-2022). The sac size, presence of hydrocephalous, and associated anomalies were noted. The biopsy of these patients were reviewed and categorised as those which contains mature neural tissue and those without. The neurological outcomes were assessed by social, language, cognitive, and motor milestone and has been stratified into no delay, mild (1 of 4), moderate (2 or 3 of 4), and severe development delay (4 of 4). RESULTS: Total of 35 patients were included with median age of 10 months (IQR = 5-20 months). Fifteen (42.9%) patients had sac size of ≥ 5 cm, and 23 (65.7%) patients had mature neural tissues on biopsy. The median follow-up period was 6.4 years (IQR = 4.38-10.65) years. Seventeen (49.6%) patients had moderate to severe developmental delay. The sac size of ≥ 5 cm (AOR = 33.5; 95%CI = 3.35-334.8) (p = 0.003) and presence of mature neural content in the sac (AOR = 13.32; 95%CI = 1.1-160.36) (p = 0.041) were associated with significant neurodevelopmental delay. CONCLUSION: The presence of a large sac of ≥ 5 cm and the presence of mature neural tissues on histopathological specimen of patients with encephalocele point towards the possibility of poor neurological development.

Anterior clinoidectomy in low lying internal carotid artery-posterior communicating artery aneurysm.

BACKGROUND: At times, a regulation internal carotid artery-posterior communicating artery junction (ICA-P-Comm) aneurysm becomes a surgical hurdle owing to its close proximity to the anterior clinoid process, an immovable ICA and a concealed dominant P-Comm artery arising from the aneurysm neck. METHOD: A 70 year old patient with a low lying ICA-P-Comm aneurysm underwent a "tailored" intradural clinoidectomy for aneurysm clipping. CONCLUSION: A tailored anterior clinoidectomy to expose "just enough" allows a proximal ICA control in a suitable area, mobility of an atherosclerotic ICA and exposes the P-Comm artery origin which are essential in safe clipping of these aneurysms.

Trans-temporal trans-choroidal resection of thalamic and thalamopeduncular tumors: how I do it.

BACKGROUND:  Surgical resection is the cornerstone of treatment for low-grade tumors, albeit total excision is beneficial. As the thalamus is surrounded by vital neurovascular system, lesions here present a surgical challenge. METHOD: This article aims to demonstrate the trans-temporal, trans-choroidal fissure approach's effective surgical therapy on patients with thalamic lesions. With this approach, we were able to remove the tumor completely in three patients and almost completely in six more. Here we discuss a few technical details and potential hazards of the procedure with an operative video. CONCLUSION: This approach  provides excellent access to the deep areas of brain.

Insular glioblastoma: surgical challenges, survival outcomes and prognostic factors.

BACKGROUND: Insular gliomas are unique, challenging and evoke a lot of interest amongst neurosurgeons. Publications on insular glioma generally focus on the surgical intricacies and extent of resection pertaining to the low-grade gliomas. Insular glioblastomas (iGBM) have not been analysed separately before. METHODS: Histologically proven WHO grade IV gliomas involving the insula over a 9-year period were studied. Their clinical presentation, radiological features, surgical findings and survival outcomes were assessed. Statistical methods were used to determine the favourable predictors of survival. RESULTS: Out of 27 patients (M:F = 2.9:1), 18 (66%) patients had a tumour extension beyond the insula, 10 (37%) of whom had basal ganglia involvement. Total, near total and subtotal excisions were performed in 7 (26%), 9 (33%) and 11 (40.7%) patients, respectively. Twenty-three patients had glioblastoma, while four had gliosarcoma. IDH mutation was negative in six of the seven patients where it was done. Median overall survival was 5 months. Multivariate analysis showed that a female gender (p = 0.013), seizures in the preoperative period (p = 0.048) and completion of adjuvant therapy (p = 0.003) were associated with a longer survival. CONCLUSION: Insular glioblastomas have a poor prognosis. Insular location and certain tumour characteristics often limit the extent of resection of iGBMs. Moreover, postoperative complications sometimes negate the advantages of a radical resection. A female gender, presentation with seizures and completion of adjuvant chemoradiotherapy appear to be good prognostic factors.

Quantitative assessment of brainstem distortion in vestibular schwannoma and its implication in occurrence of hydrocephalus.

PURPOSE: Anatomical distortion directly affects the clinical status of patients with vestibular schwannomas (VSs). It may vary for a given tumor size due to variability in posterior fossa anatomy. We aimed to quantitatively assess brainstem distortion (BSD) and review its role in occurrence of hydrocephalus associated with VSs. METHODS: Sixty-six patients with small (<3 cm, n= 8; 12.1%); large (3-4 cm; n= 26; 39.4%) and giant (>4 cm; n= 32; 48.5%) VSs were included. Cystic VSs were excluded. Tumor size, tumor-extent, linear displacement (LD; distance between line bisecting pons (line 1) and posterior fossa midline (line 2)) and angular distortion (AD; angle subtended between lines 1 and 2) in axial-T2-MRI section through pons, and their effect on hydrocephalus were assessed. RESULTS: Significant BSD occurred in a younger age (p value = .004/.003), larger-sized tumor (p value = .001/.002), hydrocephalus (p value = .001/.001), trigeminal (V) nerve palsy (p value = .004/.003) and long tract signs (p value = .001/.034). Tumors crossing midline had significant association with hydrocephalus (p value = .003). LD increased progressively even for 4-5 cm-sized tumors while AD stabilized. Receiver operating characteristic (ROC) curve revealed that diagnostic accuracy of LD (area under the ROC curve (AUROC): 78.9% (95% CI: 67.2%, 90.5%, p < .001)), AD (AUROC:77.6% (95% CI:65.8%, 89.5%, p < .001)) and LD × AD (AUROC:80.3% (95% CI: 69.2%, 91.2%, p < .001)) for predicting occurrence of hydrocephalus was better than tumor size (AUROC: 66.7% (95% CI: 53.5%, 79.9%, p < .05). Cut-off values of LD and AD for predicting occurrence of hydrocephalus were 6.25 mm and 14.6°, respectively. Hydrocephalus was significantly more when both LD was greater than  6.25 mm and AD was greater than 14.5° (p value = .034). The role of LD and AD in influencing hydrocephalus was greater than categorization based on tumor size (Spearman's correlation coefficient: 0.535 and 0.248, respectively). Hydrocephalus occurred at a lesser cut-off value of LD and AD when compared to long tract signs. CONCLUSIONS: LD and AD values in VSs have a significantly greater influence in the development of hydrocephalus compared to tumor size, and may aid, more reliably, in the prediction of hydrocephalus.

Constipation in degenerative cervico-thoracic spine myelopathy: a simple co-existence or a complex inter-relationship?

PURPOSE: Identify factors affecting constipation and post surgical improvement in patients of myelopathy. METHODS: Sixty-four patients with myelopathy due to extradural spine pathologies (47 cervical; 17 thoracic spine, male:female-5.4:1 with mean age 46.16) underwent evaluation including Bristol stool scale (BSS), PFT and uroflowmetry. All cases were evaluated by gastroenterologist to rule out any intrinsic bowel disease. Chi-square test, Kruskal-Wallis/Mann-Whitney U test and Wilcoxon signed rank test were employed to ascertain statistical significance. RESULTS: The presence of constipation was associated with male sex (p = 0.01), degree of constipation with duration bladder symptoms (p = 0.008) and numbness (p = 0.04). The improvement in BSS after surgery (p = 0.006) was associated with local pain (p = 0.02), duration of weakness (p = 0.04) and overall symptoms (p = 0.01), also with pulmonary function tests (p = 0.002) and pre-operative Nurick's grade (p = 0.01). CONCLUSION: Constipation is a myelopathic symptom as it is relieved by cord decompression and the gender, PFT and the duration of symptoms play an important role in defining constipation and expected improvement in these patients.

Craniovertebral junction anomalies: When is resurgery required?

BACKGROUND: Craniovertebral junction (CVJ) abnormalities, such as atlantoaxial dislocation (AAD) with or without basilar invagination (BI), with or without associated Chiari malformation (CM), may cause a high cervical myelopathy. Occasionally, mechanical factors such as inadequate canal decompression, torticollis, and/or scoliosis may lead to lack of improvement following the primary surgery. Furthermore, implant-related factors, requiring implant revision/removal, or the presence of surgical site infections may cause the patient to undergo resurgery. AIMS: This study was aimed at highlighting the underlying etiopathogenesis of resurgery following the primary surgery undertaken in CVJ abnormalities. SETTING AND DESIGN: This was a retrospective study from a tertiary care referral institute focusing on 414 operated cases of CVJ anomalies. MATERIALS AND METHODS: The data of 55 patients who underwent resurgery included their clinicoradiological assessment and operative records. The inclusion criteria included failed primary procedure, repeat procedure for construct failure, infection at the surgical site, or wound dehiscence. Pure CM patients without bony anomalies were excluded from the study. RESULTS: A total of 137 procedures were performed in 55/414 (13%) patients. Causes of resurgery could be divided into ventral [redo or denovo transoral decompression (TOD) or wound-related complications, n = 33, 40.2%] and dorsal causes (implant-related factors/wound infections, n = 49, 59.8%). De novo TOD was done in persisting myelopathy following posterior fusion (PF) with C1-2 distraction (n = 15,18.3%,). Redo TOD was done for residual anterior bony compression [n = 8, 9.6%, OR 0.61; [CI = 0.20-1.86]. Causes for oral wound reexplorations (n = 10, 12.2%) included velopharyngeal insufficiency, wound resuturing, oral bleeding, and cerebrospinal fluid (CSF) leak. Dorsal causes included: (A) Implant factors (n = 27, 32.7%) and (B) neck wound reexplorations (n = 22, 26.8%). Presence of subaxial spine scoliosis, torticollis, and asymmetric joints increased the incidence of reexploration. Occipitocervical fusion rather than C1-2 fusion was more prone towards construct loosening. CONCLUSIONS: Patients undergoing distraction with PF may require transoral surgery due to persisting myelopathy, especially in the presence of torticollis, scoliosis, and symmetrical joints. Single stage TOD+PF increases the chances of implant infection due to tissue contamination, bacteremia, or transfacetal migration of microbes. Chronic/recurrent sinus is usually a harbinger of deeper infection and can be cured with implant removal.

Spinal neurenteric cysts: Associated developmental anomalies and rationale of surgical approaches.

BACKGROUND: Neurenteric cysts (NC) occur due to failure of separation of neurectoderm from endoderm at the 3rd week of embryogenesis. This study focuses on key clinico-radiological features of NCs, with emphasis on surgical nuances involved in resecting anteriorly placed NC, especially at the foramen magnum (FM). METHOD: Sixteen consecutive patients having a spinal NC were included. Their clinico-radiological status, surgical nuances and follow-up status were noted. RESULTS: The duration of spasticity/paraparesis/quadriparesis ranged from 15 days to 48 months. Twelve patients had an intradural extramedullary (IDEM; nine anterior and three anterolateral) cyst and four had an intramedullary (IM) cyst. Six of them had an anteriorly placed FM lesion (five IDEM and one IM). Amongst ten subaxial NCs, four were anterior, two antero-lateral and one postero-lateral; three were IM. Three patients had the characteristic stigmata of occult spinal dysraphism: two, a large mesenteric cyst, and one, a posterior mediastinal cyst. Excision was total in 13 patients. Subtotal excision of tumour capsule was performed for two recurrent cysts and an IM cyst. A far lateral approach was adopted for anteriorly placed FM lesions and posterior laminectomy for subaxial lesions. Histopathology revealed eight type A cysts, four type B cysts and four type C cysts. At follow-up (range, 8 months to 12 years; median, 60 ± 45.84 months), complete neurological recovery occurred in seven patients; six patients had persistent spasticity but only minor disability; two patients had difficulty in walking; and one patient with an anteriorly placed thoracic recurrent NC had sustained neurological deterioration. CONCLUSIONS: Surgical difficulties in addressing NCs are related to their anterior or IM location, presence of adhesions and inability to dissect the tumour capsule from the spinal cord due to fibrous or lipomatous connections. The associated developmental anomalies must be specifically sought and addressed.

Endoscopic MIS-TLIF with Destandau's system: leveraging endoscopy with conventional instruments.

This presentation showcases an endoscopic minimally invasive spine surgery (MISS) technique for lumbar interbody fusion. Significantly expanding the scope of Destandau's system within MISS, it serves as a pivotal link to unilateral biportal endoscopy (UBE) for endofusion. The method involves minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) using a 4-mm rigid endoscope through Destandau's system. With the widespread familiarity with Destandau's system and the absence of specialized instrument requirements, this approach is easily adoptable, particularly in resource-limited centers. The favorable clinical and radiological outcomes underscore the effectiveness of this technique, propelling the role of endoscopy in MISS, particularly in endofusion. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23216.

An institutional study on accuracy of freehand cervical C1 C2 screws placement by knock and drill technique in craniovertebral anomalous bony anatomy: An evaluation of more than 600 screws based on SGPGI screw accuracy criteria.

Purpose: To assess the accuracy of freehand cervical C1 C2 screws placement by knock and drill (K and D) technique in craniovertebral anomalous bony anatomy. Materials and Methods: From January 2017 to December 2022, 682 consecutive C1 C2 screws in 215 patients with craniovertebral junction (CVJ) anomalies were enrolled. All patients underwent posterior fixation with K and D technique without any fluoroscopic guidance. The patient's demographic details, clinical details, radiological details, major intraoperative events, and postoperative complications were noted. The screws malposition grades and direction on CT images in the axial and sagittal plane were defined as new per proposed "SGPGI accuracy criteria." All patients had a clinical evaluation at 3-month follow-up. Results: Total 682 C1, C2 screws were placed in 215 patients for CVJ anomalies using K and D technique. The accuracy of screws placement by freehand technique was 84.46% (576/682). So with technique explained the rate of malplacement in simple (16.35%) and complex (15.19%) groups were almost comparable and comparison difference was not significant (P = 0.7005). Conclusion: The freehand technique, as described, is effective in cases of anomalous bony anatomy, and it is mandatory in complex CVJ anomalies. The accuracy of screw placement and VA injury is comparable with major studies. This technique is supposedly cost-effective and less hazardous to both health-care workers and patients.

Stereotactic biopsy for brain lesions: Doing more with less.

Objectives: Stereotactic biopsy (STB) is a potential diagnostic tool considering its minimal invasiveness, high diagnostic yield, and minimal associated complications. Over the years, various frame-based instrument systems and frameless stereotactic biopsy systems have emerged to be employed in clinical use. With this study, we intend to get more by doing less in the form of STB for the patients of doubtful intracranial lesions treated over the past 5 years. We also want to highlight the technique of performing the procedure under scalp block, which can be used as a versatile tool in many clinical scenarios. Stereotactic biopsies may be planned even in rural district-level health facilities. One-time investment to procure instruments and avail existing imaging can lead to establishing definitive diagnoses in many doubtful cases. This will result in lesser cost and early establishment of treatment. Independent risk factors determining the outcome, such as deep-seated lesions, associated edema, and intraoperative hypertension, were studied. Establishing the diagnosis helped in prognosticating the disease, explaining the natural progression of symptoms, and starting adjuvant therapy. This tissue biopsy would also help secure samples for research and molecular analysis. Materials and Methods: Twenty patients underwent STBs at our institution between January 2018 and December 2022. We retrospectively analyzed patient characteristics, tumor pathology, surgical procedures, and outcomes, including the diagnostic value and surgery-related complications. These patients were followed up, and their progression-free and overall survival were analyzed. The need for adjuvant treatment was noted and analyzed. All procedures were performed using Cosman Roberts Wells® stereotactic frame. Pre-procedure magnetic resonance scans were performed at the time of admission. Contrast-enhanced computerized tomography (CT) scan after frame application was performed to identify targets and calculate the coordinates. A post-procedure CT scan was done to confirm the accessibility of the targeted lesion. Results: The most common location of the tumor was a deep-seated thalamic lesion. A definitive diagnosis was established in 19 patients (95%) at the first STB. The diagnoses were glioma in 55% of cases, primary central nervous system lymphoma, tuberculosis, and demyelinating disorders in 10% of each, and a metastatic brain tumor in 1 (5%). The post-operative complications were all transient except in one patient with deterioration of motor weakness. The follow-up was noted, and modes of adjuvant treatment needed in these patients were recorded. Conclusion: Stereotactic biopsy is a useful and effective method for achieving a definitive diagnosis and aiding in treating multifocal or small deep-seated lesions in or around eloquent regions.

Clinicoradiologic Risk Stratification and Outcome Assessment in Symptomatic Intracranial Arachnoid Cyst Managed Over Fifteen Years.

BACKGROUND: Arachnoid cysts (ACs) are developmental anomalies formed by splitting the arachnoid membrane's layers. ACs contribute around 2% of all intracranial space-occupying lesions. ACs are more prevalent in children. Because of varied clinical presentation, there has been a constant need for clinicoradiologic risk stratification with a possible role in outcome prediction. The present study describes the management strategies and outcomes in symptomatic intracranial ACs. METHODS: All biopsy-proven symptomatic patients who underwent surgical management over last 15 years were included in this study (January 2008-December 2022), while those with non-conclusive biopsies were excluded. Patients presenting with acute deterioration were managed in the emergency department with or without cerebrospinal fluid diversion and decompression of the AC. The microsurgical or endoscopic approach was the preferred surgical modality. Postoperative clinicoradiologic improvement was evaluated at 3 months follow-up visit. RESULTS: A total of 108 patients were analyzed in this retrospective observational study. The median age of the patients was 27.5 years (range, 1 to 76 years). Headache was the most typical clinical presentation. Supratentorial ACs (n = 59, 54.6%) were higher than the infratentorial ACs (n = 49, 45.4%). Forty-seven patients belonged to the pediatric age group (<18 years), and seizure was their presenting complaint. In this observational study, there was no statistical difference in operative duration between microsurgical technique versus endoscopic decompression (P= 0.23). CONCLUSIONS: ACs are uncommon brain lesions having a broad spectrum of symptoms. The location and clinical presentation of ACs decide the preferred surgical approach. Individuals in high-risk groups must be treated on priority to achieve long-term relief of symptoms.

Hydrogen peroxide-scavenging enzymes impart tolerance to high temperature induced oxidative stress in sugarcane.

Seventy-one genotypes of sugarcane from diverse agro-climatic zones of India viz. peninsular, northwest, north-central and eastern zones, were screened for their tolerance to high temperature stress based on the damage to leaf biomass i.e. necrosis of leaf-tips and margins, and rolling of leaves. Nine selected genotypes showing variable response to heat injury were tested for activity pattern of isoforms of two H2O2-scavenging enzymes; ascorbate peroxidase (APX) and catalase (CAT), under high temperature induced oxidative stress. Changes in the activity of APX and CAT isozymes in leaves corresponded to the level of tolerance of genotypes towards heat injury which was substantiated by the highly negative correlation coefficients of heat injury levels of leaves vs. integrated density of APX and CAT isozyme bands. This indicated that the criteria of higher expression of CATs' andAPXs', the two major reactive oxygen species scavenging proteins in leaves may be used to screen large seedling populations and germplasm for high temperature tolerance.

Arterial Fencing: A Challenge During Complex Craniovertebral Junction Surgery.

A 32-year-old woman presented with chronically progressive spastic quadriparesis. Detailed clinicoradiological evaluation led to the diagnosis of irreducible atlantoaxial dislocation and basilar invagination, with associated "kissing" carotids and an anomalous right vertebral artery (VA). Both internal carotid arteries had an abnormally tortuous course, "kissing" retropharyngeally at the level of C1-C2. The right VA became intradural at the level of C2-C3, an extremely rare anomaly-C3 segmental artery. Despite the deformed joints and the possibility of injuring the anomalous right VA during C2-C3 instrumentation, a tailored posterior-only approach was used to circumvent the arterial fence created by both vascular anomalies. The patient underwent bilateral C1-C2 joint opening and left C1-C2 joint spacer placement, followed by bilateral occipito-C3-C4 fixation. This is possibly the first reported case of a complex craniovertebral junction anomaly associated with both kissing carotids and a C3 segmental VA.

Hybrid Anterior Clinoidectomy in the Clipping of Paraclinoid Aneurysms: Technique, Utility and Case Illustration.

Background: Anterior clinoidectomy for aneurysm clipping is generally performed intradurally. Despite obvious advantages, accidental drill slippage or indirect damage from heat and bone dust remain major drawbacks. Objective: To demonstrate the surgical technique and utility of a combined extra- and intra-dural clinoidectomy in the clipping of dorsal wall paraclinoid internal carotid artery aneurysm. Material and Methods: A case of dorsal wall paraclinoid aneurysm which was stuck to the anterior clinoid process on preoperative angiogram is presented. The surgical technique is shown stepwise, and the intricacies of the technique are described. Results: The hybrid clinoidectomy allowed for proper delineation of the aneurysm, mobilization of the optic nerve and intracranial proximal control on the clinoidal segment by dint of "apparent" intracranial ICA lengthening. This allowed the aneurysm to be clipped successfully and the patient made an uneventful recovery. Conclusion: Hybrid clinoidectomy is a useful technique and must be learnt.

An Alternative Surgical Treatment of Giant Serpentine Aneurysm of the Middle Cerebral Artery: Resection and End-to-End Anastomosis.

Some giant intracranial aneurysms can develop serpentine morphology, secondary to a peculiar near-complete intra-aneurysmal thrombosis. The resulting complex angioarchitecture, along with atypical clinical presentations (i.e., mass effect, distal ischemia) seen, makes management of such aneurysms technically challenging. These aneurysms are not amenable to endovascular treatment, and hence the only remaining treatment option is a tailored microsurgical procedure (clipping/parent vessel occlusion or reconstruction/trapping/aneurysmorrhaphy) accompanied by a safety bypass (high-flow, low-flow, or in situ bypass, subject to dependence of distal circulation on proximal trunk with reference to aneurysm). The microsurgical procedure can be performed either in 1 or 2 stages (bypass followed by aneurysm treatment at a later date). Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass followed by aneurysm trapping/decompression is the most routinely performed microsurgical procedure for such aneurysms. The operative video illustrates an alternative surgical treatment of a giant serpentine aneurysm of the MCA: resection and end-to-end anastomosis. A 20-year-old man underwent microsurgery for a giant right MCA serpentine aneurysm. In view of the poor distal flow in the ipsilateral MCA territory, an STA-MCA bypass with aneurysm trapping/decompression was planned. Intraoperatively, the presence of a stretched and elongated ipsilateral MCA (secondary to aneurysm mass effect) plus the relatively narrow neck of the thrombosed aneurysm provided a rare opportunity to perform resection and end-to-end anastomosis (Video 1). Intraoperative and postoperative angiography confirmed the anastomosis patency. The patient's recovery was uneventful. This treatment can save operating time, eliminate donor artery-related morbidity, and offer a surgical alternative to the conventional strategy of STA-MCA bypass.

Role of Extradural Clinoidectomy and Trapping in Giant Superior Hypophyseal Artery Aneurysm.

Giant paraclinoid internal carotid artery (ICA) aneurysms are surgically challenging, mainly owing to lack of adequate working space and distortion of the regional anatomy. Anterior clinoidectomy is a vital surgical technique in such cases, allowing optic nerve decompression and exposure of the proximal ICA outside the confines of the arachnoid. While clinoidectomy is generally conducted intradurally, some aneurysms, particularly unruptured and directed medially paraclinoid ICA aneurysms, can allow a completely extradural clinoidectomy. Extradural clinoidectomy avoids bone dust spillage and drill bit-related injury from prolonged intradural drilling times. An 18-year-old man with a giant left superior hypophyseal artery aneurysm presented with progressive headache and visual diminution. He had a very good cross-flow from the contralateral ICA and tolerated balloon test occlusion. The aneurysm was exposed after extradural clinoidectomy and optic nerve mobilization. It was a wide-necked aneurysm and involved the distal dural ring. Owing to intraoperative somatosensory evoked potential findings as well as our concern of inadequate neck occlusion in view of the distal dural ring involvement and a possible future aneurysm regrowth, we trapped the aneurysm. The patient made an uneventful recovery with improvement in vision and normal visual fields. This video demonstrates the feasibility and utility of extradural clinoidectomy in adequate exposure of giant paraclinoid aneurysms and the role of aneurysm trapping for definitive aneurysm obliteration when the distal dural ring is involved. Trapping, in contrast to direct clipping, avoids manipulation of the compressed optic nerves, which is necessary for an optimal environment for postoperative visual recovery.

Impact of Postoperative ABG Analysis and ICU Weaning Protocol in Surgical Outcome of Atlanto-Axial Dislocation: It's not the Towering Sail, but the Unseen Wind that Moves the Ship.

Background: The outcome in patients of atlanto-axial dislocation (AAD) depends on multiple factors like preoperative optimization, intraoperative distractio and cord manipulation. Certain unfocussed factors such as respiratory reserve and compensatory acclimatization to hypoxia warrant consideration. Aims: The purpose of this study is to find the association of postoperative arterial blood gas (ABG) analysis and respiratory reserve in patients of AAD with clinical outcome. Study Design: We retrospectively analyzed the available records of patients, operated for AAD, at our institute (n = 66), from January 2014 to November 2018. Materials and Methods: Preoperative pulmonary function test (PFT) and the postoperative ABG analysis was noted. Timing of extubation, duration of intensive care unit (ICU) stays, and clinical outcomes (Nurick grade) were noted from the inpatient record and the last outpatient follow up. An independent t-test and analysis of variance were used to find significance. Results: In total, 41% (n = 27) patients had body mass index of less than 18.5, and 50% (n = 33) had breath holding time of less than 20 minutes. There was improvement in mean Nurick grade from 3.17 ± 0.8 to 2.76 ± 0.7 in follow up. A trend suggesting that patients with poor preoperative PFT has more ICU duration and worse outcome. In patients with mild acid-base disorders, extubation was possible within 24 hours. Out of 26 patients with ICU duration less than 2 days, 23 patients had "good" outcome, whereas ten out of 40 patients with ICU duration of more than or equal to 2 days had "bad" outcome (P = 0.00). Conclusion: Patients having moderate to severe primary or mixed acid-base disorder have a probability of re-intubation or delayed extubation. A strong correlation was seen with the novel grading system (grade >6 had worse outcome).

The Spectrum of Invasive Fungal Sinusitis in COVID-19 Patients: Experience from a Tertiary Care Referral Center in Northern India.

This study aimed to determine the patient demographics, risk factors, which include comorbidities, medications used to treat COVID-19, and presenting symptoms and signs, and the management outcome of COVID-19-associated invasive fungal sinusitis. A retrospective, propensity score-matched, comparative study was conducted at a tertiary care center, involving 124 patients with invasive fungal sinusitis admitted between April 2021 and September 2021, suffering from or having a history of COVID-19 infection. Among the 124 patients, 87 were male, and 37 were female. A total of 72.6% of patients received steroids, while 73.4% received antibiotics, and 55.6% received oxygen during COVID-19 management. The most common comorbidities were diabetes mellitus (83.9%) and hypertension (30.6%). A total of 92.2% had mucor, 16.9% had aspergillus, 12.9% had both, and one patient had hyalohyphomycosis on fungal smear and culture. The comparative study showed the significant role of serum ferritin, glycemic control, steroid use, and duration in COVID-19-associated invasive fungal disease (p < 0.001). Headache and facial pain (68, 54.8%) were the most common symptoms. The most involved sinonasal site was the maxillary sinus (90, 72.6%). The overall survival rate at the three-month follow-up was 79.9%. COVID-19-related aggressive inflammatory response, uncontrolled glycemic level, and rampant use of steroids are the most important predisposing factors in developing COVID-19-associated invasive fungal sinusitis.