Dorsal bony spur in pediatric split cord malformations: eight-year experience from a tertiary care hospital.

INTRODUCTION: Dorsal spurs in Type I split cord malformations (SCM-I) are infrequent findings. The pathogenesis of the same is debatable. The objective of this study is to analyze our experience with SCM-I patients having dorsal bony spurs. METHODOLOGY: Retrospective analysis of SCM patients operated from 2010 to 2017 was performed. Their demographic profile, clinic-radiological features, operative findings, and outcome following surgery were recorded. RESULTS: Twenty-four cases of Type I SCM harboring dorsal bony spurs were identified with mean age of 4.96 years. The commonest split site was lumbar, documented in 62.5%. Scoliosis was observed in 58.3%. Pre-operative neurological deficits were seen in 66.6% cases with asymmetric weakness of limbs seen in 16.6%. There was no new neurological deficit observed post-operatively. CONCLUSIONS: This is the largest series of dorsal spurs occurring in SCM, reported in literature so far. Meticulous pre-operative evaluation and imaging are important to identify dorsal spurs for appropriate management and good clinical outcome. Differentiating dorsal spur from ventral spur is important as it has a bearing on surgical approach.

Effect of topical and intraventricular antibiotics used during ventriculoperitoneal shunt insertion on the rate of shunt infection-a meta-analysis.

INTRODUCTION: The ventriculoperitoneal shunt is one of the most commonly performed neurosurgical procedures. One of the avoidable complications of shunt surgery is shunt infection. This PRISMA-compliant meta-analysis analysed the effectiveness of topical and/or intraventricular antibiotics in preventing shunt infections in patients undergoing shunt surgery. METHODS: Four databases were searched from inception to 30th June 2021. Only original articles comparing the rate of shunt infection with and without antibiotics were included. Random-effects meta-analysis was used to compare the effect of the use of antibiotics in preventing infection and subgroup analysis for finding differences in various antibiotics. RESULTS: The rate of shunt infection was 2.24% (53 out of 2362) in the topical antibiotic group in comparison to 5.24% (145 out of 2764) in the control group (p = 0.008). Subgroup analysis revealed that there is no significant difference between the antibiotics used. CONCLUSIONS: Our meta-analysis found that the risk of shunt infection is significantly reduced with the use of topical and intraventricular antibiotics without any serious adverse effect. No side effects of topical or intraventricular antibiotics were reported in the included studies. Further prospective studies are required to establish the safety and optimal dosage of topical antibiotics for them to be used routinely in neurosurgical practice. They can be used in patients at high risk of developing shunt infections till such studies are available.

Effectiveness of preoperative facial nerve diffusion tensor imaging tractography for preservation of facial nerve function in surgery for large vestibular schwannomas: Results of a prospective randomized study.

BACKGROUND: The goal of surgery in case of a large vestibular schwannoma is complete excision of tumor and preservation of facial nerve function. The identification and preservation of facial nerve is very difficult during surgery, particularly in case of large tumors. This prospective randomized study was conducted to find out the effectiveness of preoperative facial nerve diffusion tensor imaging tractography (DTI) to predict location of the nerve and preservation of facial nerve function in surgery for large vestibular schwannomas. MATERIALS AND METHODS: In this prospective randomized study, we recruited 100 patients with a large vestibular schwannoma(> 3cm). After initial scrutiny, 94 patients were randomized based on a computer generated chart. In group I, preoperative DTI was done and the operating surgeon was informed about the position of facial nerve preoperatively. In group II, DTI was not done. The facial nerve preservation rates and clinical outcome at follow up was compared between the two groups. RESULTS: Out of 94 patients, there were 47 patients in group I (DTI group) and 47 patients in group II (Non DTI group). In DTI group, 40 patients were left for comparison after the exclusion criteria was applied. Preoperative DTI predicted that the facial nerve position was concordant with its intraoperative position in 39 patients (97.5% concordance). Facial nerve preservation rates were statistically significant in group I (DTI group) (P value = 0.002). CONCLUSION: The study establishes the role of preoperative DTI tractography for better facial nerve preservation in surgery for large vestibular schwannomas (>3 cm).

Insights into molecular therapy of glioma: current challenges and next generation blueprint.

Glioma accounts for the majority of human brain tumors. With prevailing treatment regimens, the patients have poor survival rates. In spite of current development in mainstream glioma therapy, a cure for glioma appears to be out of reach. The infiltrative nature of glioma and acquired resistance substancially restrict the therapeutic options. Better elucidation of the complicated pathobiology of glioma and proteogenomic characterization might eventually open novel avenues for the design of more sophisticated and effective combination regimens. This could be accomplished by individually tailoring progressive neuroimaging techniques, terminating DNA synthesis with prodrug-activating genes, silencing gliomagenesis genes (gene therapy), targeting miRNA oncogenic activity (miRNA-mRNA interaction), combining Hedgehog-Gli/Akt inhibitors with stem cell therapy, employing tumor lysates as antigen sources for efficient depletion of tumor-specific cancer stem cells by cytotoxic T lymphocytes (dendritic cell vaccination), adoptive transfer of chimeric antigen receptor-modified T cells, and combining immune checkpoint inhibitors with conventional therapeutic modalities. Thus, the present review captures the latest trends associated with the molecular mechanisms involved in glial tumorigenesis as well as the limitations of surgery, radiation and chemotherapy. In this article we also critically discuss the next generation molecular therapeutic strategies and their mechanisms for the successful treatment of glioma.

Decompressive craniectomy in traumatic brain injury: A single-center, multivariate analysis of 1,236 patients at a tertiary care hospital in India.

OBJECT: To evaluate the outcome of patients undergoing a decompressive craniectomy (DC) in traumatic brain injury (TBI) and the factors predicting outcome. MATERIALS AND METHODS: A total of 1,236 patients with TBI operated with a DC from January 2008 to December 2013 at a tertiary care hospital were included in the study. The data from the hospital computerized database was retrospectively analyzed and 324 (45%) patients were followed-up for a mean duration of 25.3 months (range 3-42 months) among the cohort of 720 alive patients. The institute's ethical committee clearance was obtained before the start of the study. RESULTS: There were 81% males with a median age [interquartile range (IQR)] of 32 (23-45) years. The mortality rate and median (IQR) Glasgow outcome score (GOS) at discharge in patients presenting with minor, moderate, and severe head injury were 18%, 5 (4-5); 28%, 4 (1-5); and 47.4%, 2 (1-4), respectively. An overall favorable outcome (GOS 4 and 5) at discharge was observed in 46.5% patients and in 39% patients who presented with severe TBI. Only 7.5% patients were in a persistent vegetative state (PVS), while 78% had an overall favorable outcome at the last follow-up of surviving patients (P < 0.001). On multivariate analysis, the factors predictive of a favorable GOS at discharge were: a younger age (odds ratio (OR) 1.03, confidence interval (CI) = 1.02-1.04; P < 0.001), no pupillary abnormalities at admission (OR 2.28, CI = 1.72-3.02; P < 0.001), absence of preoperative hypotension (OR 1.91, CI = 1.08-3.38; P = 0.02), an isolated TBI (OR 1.42, CI = 1.08-1.86; P = 0.01), absence of a preoperative infarct (OR 3.68, CI = 1.74-7.81; P = 0.001), presence of a minor head injury (OR 6.33, CI = 4.07-9.86; P < 0.001), performing a duraplasty (OR 1.86, CI = 1.20-2.87; P = 0.005) rather than a slit durotomy (OR 3.95, CI = 1.67-9.35; P = 0.002), and, avoidance of a contralateral DC (OR 3.58, CI = 1.90-6.73; P < 0.001). CONCLUSIONS: The severity of head injury, performing a duraplasty rather than a slit durotomy, avoidance of a contralateral DC, and the presence of preoperative hypotension, infarct, and/or pupillary asymmetry have the highest odds of predicting the short term GOS at the time of discharge, after a DC in patients with TBI. Although DC carries a high risk of mortality, the probability of the survivors having a favorable outcome is significantly more as compared to those who remain in a PVS.

Case of cervicodorsal tuberculosis involving seven contiguous vertebrae in a young child.

We present a rare case of a male child in middle childhood who presented to the emergency department with neck pain, neck deformity, low-grade fever, breathing difficulty and swallowing difficulty. The patient had a significant history of weight loss and loss of appetite. On examination, neurological deficits were observed, including mildly increased tone in bilateral lower limbs, reduced power in both lower limbs, exaggerated knee and ankle jerks, and upgoing plantar reflexes. Radiographs and MRI revealed a kyphotic deformity with apex at the T1 vertebra, lytic lesions in seven contiguous vertebrae and a large prevertebral abscess extending from C2 to T5. The patient underwent a posterior-only surgical approach with decompression, abscess drainage and stabilisation, resulting in successful cord decompression and correction of the kyphotic deformity. At 18 months follow-up, the patient is doing well with improvement to normal neurology and full return of a child to normal activities.

Management of intramedullary tumors in children: analysis of 82 operated cases.

INTRODUCTION: Intramedullary tumors are rare and comprise only a small percentage of all central nervous system neoplasms. There has been much controversy with the surgical management of these tumors. This study presents detailed information regarding clinical presentation, histological findings, outcomes, functional assessment, and management of a series of patients with this diagnosis. METHODS: The authors reviewed 82 cases of up to 18 years of age operated between 2001 and 2010. The symptomatology, neurological and neuroradiological findings, operative details, perioperative and postoperative complications, histopathological data, and follow-up examinations were studied and analyzed. RESULTS: There were 57 (69.5 %) males and 25 (30.4 %) females. Overall, epidermoid (20.7 %) constituted the most common tumor followed by low-grade gliomas and ependymoma (19.5 % each). Near total resection for epidermoid and dermoid was possible in 82.3 % and 60 % cases, respectively. Ependymomas were more amenable for gross total excision (43.7 %) as compared to pilocytic astrocytomas (22.2 %); however, near total resection was possible in another 50 % and 66.6 % cases, respectively. At the last clinical evaluation on follow-up, 8 patients (14.2 %) had improved in their grades, 46 patients (82.1 %) remained unchanged, and 2 patients (3 %) worsened. CONCLUSION: Complete removal of the lesion is the primary goal. In our experience, we conclude that the strongest predicting factor of functional outcome was the preoperative neurological condition beyond the histological differentiation of the intramedullary tumors.

Effect of Goal-Directed Intraoperative Fluid Therapy on Duration of Hospital Stay and Postoperative Complications in Patients Undergoing Excision of Large Supratentorial Tumors.

Background: Optimal fluid management during neurosurgery is controversial. Evidences suggest that goal-directed fluid therapy (GDFT) can improve postoperative outcome. This study aimed to assess the intraoperative use of GDFT on the duration of hospital stay and postoperative complications in patients undergoing craniotomy for large supratentorial tumors. Materials and Methods: Forty patients of 18-65 years age undergoing large supratentorial tumor surgery were prospectively randomized into two groups. Control-group received fluid regimen based on routine hemodynamic monitoring, whereas patients belonging to GDFT group received fluid based on stroke volume variation (SVV)-guided therapy. A colloid bolus of 250 ml 6% hydroxyl ethyl starch was given, if the SVV was more than 12% in the GDFT group. Hemodynamic parameters, such as blood pressure and heart rate, and dynamic parameters, such as cardiac index, stroke volume index, and SVV, were recorded at different time intervals. Results: The total amount of fluid required was significantly lower in GDFT (P = 0.003) group as compared to the Control group. Intraoperative complications were significantly lower in GDFT group (P = 0.005), but the incidence of tight brain was significantly higher in the control group. The duration of hospital stay (P = 0.07) and incidence of postoperative complications (P = 0.32) were lower in GDFT group. Neurological outcomes at-discharge were similar in both the groups. Conclusions: This study did not show any benefit of GDFT over conventional intraoperative fluid therapy in terms of incidence of postoperative complications, hospital and ICU stay, and Glasgow outcome scores at-discharge in patients undergoing craniotomy for excision of large supratentorial tumors. However, the use of GDFT leads to better perioperative fluid management and brain relaxation scores. Clinical Trial Registry: CTRI/2016/10/007350.

Craniosynostosis associated with neural tube defects: is there a causal association?

The majority of primary craniosynostosis cases are sporadic. Very few articles in the literature have described cases of primary craniosynostosis associated with neural tube defects (NTDs). This co-occurrence has been seen by most authors as just a coincidence. The authors report a clinical series of 4 patients of primary craniosynostosis associated with NTDs treated at their center. Among these 4 cases, 2 had lumbosacral myelomeningocele, 1 frontoethmoidal encephalocele and 1 had occipital encephalocele. Although the co-occurrence of craniosynostosis and NTD is said to be rare, there seems to exist a justified underlying explanation for the same. The NTD causes a decrease in intracranial pressure due to egress of cerebrospinal fluid in the malformed sac that results in a deficient cerebral impulse for cranial growth that might stimulate premature sutural fusion. Thus, all patients with NTDs should be thoroughly evaluated for this association and for possible surgical management.

Prediction of angular kyphosis after cervical laminoplasty using radiologic measurements.

Angular kyphosis is an important complication after cervical laminoplasty. Previous reports have suggested that T1 slope (T1s) and extension function (EF) have key roles in kyphosis, and no different radiologic measuments which affects postoperative kyphosis were seen between ossification of the posterior longitudinal ligament (OPLL) or cervical spondylotic myelopathy (CSM). We tried to find preoperative radiologic measurements predicting angular kyphosis after laminoplasty according to disease entities. We retrospectively analyzed 133 patients with OPLL or CSM who underwent expansive laminoplasty. Preoperative neutral and extension C2-7 cobb angle (CA), T1s, C2-7 sagittal vertical axis, and C2-7 slope angle (SA) were measured. EF of C2-7 CA and C2-7 SA was defined as extension CA/SA minus neutral CA/SA. Significant angular kyphosis was defined as LCL less than -10° after surgery. Mean loss of lordosis was -3.23, and 16.5% of patients showed significant kyphosis. Preoperative EF-CA, EF-SA, and T1s were found to be predictive for angular kyphosis by Pearson correlation analysis. The receiver operating characteristic (ROC) curve analysis showed that the area under the curve (AUC) of radiologic measurements could not reach 0.7. In patients with OPLL, the AUC of preoperative neutral CA was 0.716. However, in patients with CSM ROC curve analysis revealed that EF-CA and EF-SA could predict the significant angular kyphotic changes. Examining OPLL and CSM separately, preoperative radiologic measurements were found to influence postoperative cervical kyphosis, respectively. However, preoperative C2-7 neutral CA in OPLL patients and both EF-CA and EF-SA in CSM patients could predict significant angular kyphosis after cervical laminoplasty.

Trends in Neurosurgical Teleconsultation Services Across the Globe During COVID-19 Pandemic.

BACKGROUND: Global use of telemedicine has increased rapidly during the coronavirus disease 2019 (COVID-19) pandemic to bridge the gap in existing health care services. Intercontinental trends in neurosurgeons' perception and practices of telemedicine have been sparingly reported. METHODS: We conducted an online anonymized and validated survey using a structured questionnaire to gain insight into neurosurgeons' experience with telemedicine across various continents and rated its usefulness on a 5-point Likert scale. RESULTS: We received 286 responses across 5 continents. There was a trend to support a major paradigm shift favoring teleconsultations during the COVID-19 pandemic in respondents from North America (P = 0.06). Signed prescriptions were e-mailed along with video-based teleconsultations preferentially in Europe and North America. In comparison, audio- or text-based teleconsultations along with unsigned prescriptions were prevalent in Asia and Africa (P = 0.0005). Acceptability and perceived usefulness for telemedicine during the pandemic were similar across the globe, regardless of neurosurgeons' experience (mean satisfaction score 3.72 ± 1.09; P = 0.62). A majority of neurosurgeons from Asia and South America complained of difficulties during teleconsultations owing to lack of appropriate infrastructure, internet connectivity/prescription-related issues, and potential risk of litigation (P = 0.0005). Approximately 46% of neurosurgeons, predominantly from Europe and North America, thought that telemedicine could play a vital role in clinical practice even after the COVID-19 pandemic subsides (mean satisfaction score 3.26 ± 1.16; P = 0.007). CONCLUSIONS: Telemedicine in neurosurgery is a viable alternative to physical outpatient services during the COVID-19 pandemic and could potentially play a vital role after the pandemic.

Factors predicting loss of cervical lordosis following cervical laminoplasty: A critical review.

BACKGROUND: Laminoplasty is a method of posterior cervical decompression which indirectly decompresses the spinal column. Unfortunately, many patients undergoing laminoplasty develops postoperative loss of cervical lordosis (LCL) or kyphotic alignment of cervical spine even though they have sufficient preoperative lordosis which results in poor surgical outcome. OBJECTIVE: We would like to highlight the relationship between various radiological parameters of cervical alignment and postoperative LCL in patients undergoing laminoplasty. METHODS: We performed extensive literature search using PubMed, Google Scholar, and Web of Science for relevant articles that report factors affecting cervical alignment following laminoplasty. RESULTS: On reviewing the literature, patients with high T1 slope have more lordotic alignment of cervical spine preoperatively. They also have more chances of LCL following laminoplasty. C2-C7 sagittal vertical axis (SVA) has no role in predicting LCL following laminoplasty though patients with low T1 slope (≤20°) and high C2-C7 SVA (>22 mm) had correction of kyphotic deformity following laminoplasty. C2-C7 lordosis, Neck Tilt, cervical range of motion, and thoracic kyphosis has no predictive value for LCL. Lower value of T1 slope (T1S-CL) and CL/T1S has more incidence of developing LCL following laminoplasty. The role of C2-C3 disc angle has not yet been evaluated in patients undergoing laminoplasty. Dynamic extension reserve determines the contraction reserve of SPMLC and lower dynamic extension reserve is associated with higher chances of LCL following laminoplasty. CONCLUSIONS: Cervical lordotic alignment is important in maintaining cervical sagittal balance which ultimately is responsible for global spinal sagittal balance and horizontal gaze. Among various radiological parameters, T1 Slope has been reported to be the most important factor affecting cervical alignment following laminoplasty.

Transcriptional regulation of HSPB1 by Friend leukemia integration-1 factor modulates radiation and temozolomide resistance in glioblastoma.

Glioblastoma (GBM) is the most common primary brain tumor and is invariably fatal. Heat shock proteins (HSPs) provide protein signatures/biomarkers for GBM that afford potential as targets for developing anti-GBM drugs. In GBM, elevated expression of hypoxia inducible factors under the influence of Ets family proteins significantly promotes the expression of HSPs. RNAseq analysis identified HSPB1 as a prominent upregulated HSP in GBM and in radiation resistant/temozolomide resistant (radio/TMZR) GBM. Here, we established friend leukemia integration 1 (Fli-1), a member of Ets family to be playing a transcriptional regulatory role on the HSPB1 gene. Fli-1 binds to nucleotide residues GGAA at binding sites 3, 6 and 7 in the 5-kb upstream region of HSPB1. Fli-1 has been linked to oncogenic transformation with upregulation in radio/TMZR GBM. Overexpression of Fli-1 in GBM promotes resistance, whereas Fli-1 knockdown in radio/TMZR GBM cells suppresses resistance. We identify the underlying molecular mechanisms of Fli-1-mediated regulation of HSPB1 that drive extracellular matrix remodeling and epithelial to mesenchymal transition in radio/TMZR GBM cells. This study uncovers Fli-1 as a potential therapeutic target for combating radiation and temozolomide resistance in GBM.

Remote site extradural haematoma.

Postoperative extradural haematoma is a well described and serious complication of intracranial procedures that usually occurs at the site of the operation. Remote site extradural haematoma (that occurring distant to the site of the craniotomy) is relatively rare and may occasionally cause significant neurological morbidity or even death. We report this rare complication in an 18-year-old male who underwent craniotomy for excision of recurrent left temporal ganglioglioma.

Transorbital penetrating cerebral injury with a ceramic stone: report of an interesting case.

Penetrating cranial injury is a potentially life-threatening condition. The majority of war injuries are high-velocity penetrating cranial injuries; but in civilian cases, most penetrating cranial wounds are low-velocity type. We report an interesting case of transorbital penetrating cranial injury with a knife-sharpening stone made up of ceramic in a 28-year-old male. The pertinent literature is reviewed and management of such cases is discussed.

Post- traumatic compound elevated fracture of skull simulating a formal craniotomy.

Fracture of the cranial bones following trauma is common. The fracture most commonly encountered in clinical practice is an undisplaced linear fracture of a skull bone or a depressed skull fracture. Compound elevated skull fracture, unlike depressed skull fracture is an extremely rare variety of post-traumatic cranial injury, seldom seen in modern clinical practice. Authors report one such rare case of compound elevated skull fracture, simulating a formal frontoparietal craniotomy, in a 20-year-old male patient following a railway accident. The mechanism of its production as well as the management of such injury is discussed.

Giant Sporadic Unilateral Vestibular Schwannoma in Child: Can It Get Bigger Than This?

Vestibular schwannomas (VSs) are rare in children and, when present, are usually part of neurofibromatosis 2 and bilateral. Sporadic unilateral VSs in the pediatric age group itself are rare in medical literature and giant sporadic unilateral pediatric VSs (>4 cm) are extremely rare. Herein, we describe the largest reported case of giant sporadic left-sided VS in a 10-year-old boy.