Mini Temporal Craniotomy Using Anatomical Surface Landmarks for Temporal Lobe Epilepsy: Technical Note and Clinical Outcomes.

Background: Patients with temporal lobe epilepsy are subjected to standard temporal lobectomy wherever indicated. This is performed using a reverse question mark flap and a standard frontotemporal craniotomy. We describe the technique of minitemporal craniotomy (3 × 3cms) for temporal lobe epilepsy (TLE) and analyze the clinical outcomes of patients operated using this approach. Objectives: To describe the technique of minitemporal craniotomy for TLE without navigation guidance and to analyze the clinical outcomes of patients operated using this approach. Materials and Method: This was a retrospective analysis of all consecutive TLE cases operated at our institute from 2014 to 2019, via minitemporal craniotomy, using surface landmarks only without navigation guidance. The surgical technique, indications for surgery, and their clinical outcomes were analyzed. Results: A total number of 48 patients underwent surgery for TLE. There were no complications except three patients who had transient hemiparesis. The average duration of hospital stay was 4 days following surgery. Out of 28 patients with mesial temporal sclerosis, 22 (82%) had international league against epilepsy, Class I seizure outcome, 4 (12.5%) had Class II outcome and 2 (5.5%) had Class III outcome. 9 patients with dysembryoplastic neurectodermal tumor (DNET), 4 gangliogliomas, 2 neurocystecercosis (NCC), all had Class I outcome. Out of the five patients with MTS and associated anterior temporal focal cortical dysplasia (FCD), four (80%) had a Class I outcome, whereas one (20%) had Class II outcome. Conclusion: Utilizing surface anatomical landmarks, minitemporal craniotomy can be performed in even peripheral centers without neuronavigation, with good cosmesis, seizure outcomes.

Primary spinal cord glioblastoma multiforme: a single-center experience.

INTRODUCTION: Primary spinal glioblastoma (GBM) are very rare tumors of the spinal cord, with dismal prognosis and their exact management is controversial. We attempt to formulate treatment guidelines for these extremely rare tumors based on our institutional experience and a comprehensive review of the literature. MATERIALS AND METHODS: In this retrospective study from 2008 to 2020, all the patients diagnosed with primary spinal GBM who underwent surgery at our institution were included. Clinical data were retrieved from case files, outpatient records and telephonic follow-up. Data on postoperative chemoradiation was noted in all the patients. The final diagnosis of spinal GBM was confirmed as per the histopathology reports. Patients who could not be followed up and those with prior history of cranial GBM were excluded from the study. RESULTS: Nine patients were followed up and a median survival of 11 months was noted. Chemotherapy with TMZ and radiotherapy to the whole craniospinal axis significantly improved survival in these patients. The extent of surgical resection was not shown to be significant. Intracranial metastasis was the leading cause of mortality in such patients. Three patients developed documented intracranial metastasis during the course of the disease. CONCLUSIONS: Low threshold must be kept in mind in diagnosing patients with high-grade spinal cord intramedullary tumors in view of the rapidly progressing nature of the disease. In case of positive histopathological diagnosis of spinal GBM, the whole craniospinal axis should be imaged and any cranial metastasis which was originally missed during initial workup could be given appropriate radiotherapy.

En-bloc Resection of A Giant Solid Hemangioblastoma of The Vermis.

INTRODUCTION: Hemangioblastomas (HMB) are extensively vascularized and benign neoplasms that are diagnosed predominantly in adults. The solid type of HMB is technically challenging to operate. The piecemeal resection of the tumor has been shown to have devastating intraoperative complications. Therefore, en-bloc tumor resection was shown to be the safest procedure to reduce the risk of intraoperative bleeding and facilitate the removal of large solid tumors. Unfortunately, most of these tumours are also not amenable for embolization, as they are fed by multiple pial vessels. However, the large arterial feeders may be embolized. OBJECTIVE: This video abstract presents a case of en-bloc resection of a giant solid type of Vermian HMB. SURGICAL TECHNIQUE: A 38-year-old male patient presented with headache and vomiting for 1 year, imbalance during walking for 6 months, and hoarseness of voice for 2 months. He underwent a CSF diversion procedure in another hospital and was referred to our center for definitive surgery. Contrast-enhanced MRI showed a large heterogeneously enhancing solid lesion of size 46 × 33 × 40 mm3 with central necrotic area in the posterior fossa with perilesional edema and several large flow voids on T2-MR sequence. Preoperative embolization was performed; however, there was no significant reduction in the vascularity of the lesion. The patient underwent a wide midline suboccipital craniotomy with C1 laminectomy and gross total en-bloc resection of HMB. RESULTS: The patient had an uneventful recovery in the postoperative period. CONCLUSIONS: The safest approach in the resection of giant solid HMB involves proper preoperative planning and understanding the vascular pattern of the lesion, wide exposure, circumferential dissection, and the en-bloc delivery of the tumor.

Endoscopic Hemispherotomy for Nonatrophic Rasmussen's Encephalopathy.

BACKGROUND: Hemispheric disconnection represents a challenging and major epilepsy surgical procedure. This procedure in experienced hands offers excellent results in terms of seizure outcomes, especially for hemispheric pathologies such as Rasmussen's encephalitis, hemispheric dysplasias, hemimegalencephaly. The technique of hemispherotomy has witnessed various modifications over the years, beginning from anatomical hemispherectomy to the current era of minimally invasive functional hemispheric disconnections. OBJECTIVE: This study aimed to describe the technique of performing endoscopic vertical hemispherotomy using interhemispheric corridor developed by the senior author. MATERIALS AND METHODS: A 12-year-old girl with seizure onset at the age of 10 years presented with an aura of fear and nausea followed by tonic deviation of eyes to the right and blinking with speech arrest. There were tonic-clonic movements of the right-sided limbs along with ictal spitting and occasional deviation of the angle of mouth to the right. The patient had loss of awareness for the event along with postictal confusion lasting few minutes. RESULTS: Video electroencephalography (VEEG) revealed left parietocentral and left temporal localization. Serial magnetic resonance imaging (MRI) brain over 3 years revealed progressive left hemispheric changes suggestive of Rasmussen's encephalitis. The patient underwent left-sided endoscopic hemispherotomy. At 2 years follow-up, the patient is seizure-free (ILAE [International League Against Epilepsy] Class 1). CONCLUSION: Endoscopic hemispherotomy using the interhemispheric approach is an elegant, minimally invasive, reproducible, safe, and efficacious technique.

Microscissor DREZotomy for post brachial plexus avulsion neuralgia: A single center experience.

INTRODUCTION: Brachial neuralgia is a dreaded sequelae which substantially impairs the quality of life in patients with brachial plexus avulsion (BPA) injuries. Dorsal Root Entry Zone (DREZ) lesioning of the cervical spinal cord is the most utilized procedure for alleviating this painful condition. In this study, we share a single center experience of surgically managing post BPA neuropathic pain. The efficacy, results and complications of the modified technique of DREZ, called the Microscissor DREZotomy (MDZ) are discussed along with the review of relevant literature. METHODS: This retrospective analysis included all the patients undergoing MDZ for post BPA brachialgia over 5 years period (2012-2018) at our institution. The pain was quantified using the Numeric rating Scale (NRS) between 0 and 10 scale and was graded as 'Excellent' in patients with more than 75% pain relief, 'Good' with 50-75% relief, 'Fair' between 25% and 50% and 'Poor' if less than 25%. RESULTS: A total of 56 patients underwent MDZ and a mean follow up of 32 months (range 18-69 months) available for 47 patients. Thirty three patients (70.4%) judged pain relief as Excellent, Five (10.6%) as Good, 3 (7%) as Fair and 6 (12%) having poor pain relief. Overall, in 38 (81%) patients long term analgesic effect (> 50%) was noted and 3 (7%) patients had more than 25% pain relief, making up an overall 41 (87%) of patients with some relief from pain. CONCLUSION: MDZ is a safe, efficacious technique with good long term pain relief and quality of life. This technique entails utilization of routine surgical instruments and can be performed with ease even in resource limited settings.

Altered Spontaneous Glutamatergic and GABAergic Activity in the Peritumoral Cortex of Low-Grade Gliomas Presenting With History of Seizures.

The peritumoral regions of WHO grade II gliomas, like astrocytoma and oligodendroglioma, have been reported to show epileptiform activities. An imbalance of glutamatergic and GABAergic mechanisms is primarily responsible for the generation of epileptiform activities. Here we have compared the electrophysiological properties of pyramidal neurons in intraoperative peritumoral specimens obtained from glioma patients with (GS) and without (GN) a history of seizures at presentation. Histology and immunohistochemistry were performed to assess the infiltration of proliferating cells at the peritumoral tissues. Whole-cell patch clamp technique was performed to measure the spontaneous glutamatergic and GABAergic activity onto pyramidal neurons in the peritumoral samples of GS (n = 11) and GN (n = 15) patients. The cytoarchitecture of the peritumoral tissues was devoid of Ki67 immuno-positive cells. We observed a higher frequency of spontaneous glutamatergic and GABAergic activities onto pyramidal neurons of the peritumoral samples of GS patients. Our findings suggest that, in spite of similar histopathological features, the pyramidal neurons in the peritumoral samples of GS and GN patients showed differences in spontaneous excitatory and inhibitory synaptic neurotransmission. An alteration in postsynaptic currents may contribute to the spontaneous epileptiform activity in GS patients.

Altered hippocampal kynurenine pathway metabolism contributes to hyperexcitability in human mesial temporal lobe epilepsy-hippocampal sclerosis.

BACKGROUND AND PURPOSE: Glutamate receptor-mediated enhanced excitatory neurotransmission is typically associated with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). Kynurenic acid and quinolinic acid are two important tryptophan-kynurenine pathway metabolites that modulate glutamate receptor activity. This study was designed to test the hypothesis that alteration in metabolism of tryptophan-kynurenine pathway metabolites in the hippocampus of patients with MTLE-HS contributes to abnormal glutamatergic transmission. EXPERIMENTAL APPROACH: Levels of tryptophan-kynurenine pathway metabolites were determined using HPLC and LC-MS/MS in hippocampal samples from patients with MTLE-HS, compared with autopsy and non-seizure control samples. mRNA and protein expressions of tryptophan-kynurenine pathway enzymes were determined by qPCR and Western blot. Spontaneous glutamatergic activities were recorded from pyramidal neurons in the presence of kynurenine and kynurenic acid, using whole-cell patch clamp. KEY RESULTS: Levels of kynurenic acid were reduced and quinolinic acid levels were raised in hippocampal samples from MTLE-HS patients, whereas kynurenine levels remained unaltered, compared with levels in non-seizure controls. Spontaneous glutamatergic activity in MTLE-HS hippocampal samples was higher than that in non-seizure controls. Treatment with kynurenine inhibited glutamatergic activity in non-seizure control samples but not in MTLE-HS samples. However, exogenously applied kynurenic acid inhibited glutamatergic activity in both non-seizure control and MTLE-HS hippocampal samples. Also, levels of kynurenine aminotransferase II and its cofactor pyridoxal phosphate were reduced in MTLE-HS samples. CONCLUSION AND IMPLICATIONS: Our findings indicate that altered metabolism of tryptophan-kynurenine pathway metabolites in hippocampus could contribute to hyperglutamatergic tone in patients with MTLE-HS.

Is surgery effective for treating hypothalamic hamartoma causing isolated central precocious puberty? A systematic review.

The aim of this review was to determine the role of surgery in treating hypothalamic hamartoma (HH) causing isolated central precocious puberty (CPP). Literature review was done according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Patients with isolated CPP due to HH, managed with surgical resection, were included. We found 33 studies, reporting 103 patients (76 pedunculated, 27 sessile). Patients were considered "cured" if the symptoms of PP had regressed and the hormone profile had normalized after surgery. Indications for surgery included hamartoma deemed surgically resectable (n-12), for the purpose of tissue diagnosis (n-3), partial response/failure of preoperative therapy (n-9), and unable to afford/to avoid long-term medical therapy (n-7). The extent of resection was total (TR) (n-39), near total/subtotal (NTR/STR) (n-20), partial (PR) (n-35), or unspecified (n-9). On follow-up (range: 3 months-16 years), 73.6% (56/76) of patients with pedunculated HH were cured, while 17.1% (13/76) had partial relief. Only 3/27 (11.1%) of patients with sessile HH were cured. All patients with a pedunculated hamartoma who underwent TR (n=36) improved, with 88.88% cured of the symptoms. Surgery had no effect in 17/23 (73.9%) patients with sessile HH who underwent PR. Psychological symptoms improved in 10/11 patients. There was no mortality. Permanent complications, in the form of 3rd nerve palsy, occurred in 3.7% (2/54) of the patients. To conclude, in the current era of availability of GnRH analogs, surgical resection in a subset of patients may be acceptable especially for small pedunculated hamartomas.

Case Report: Isolated Central Nervous System Melioidosis from a Non-Endemic Area.

Central nervous system (CNS) melioidosis is a rare neurological infectious disease which carries a high mortality. We describe a previously healthy middle-aged female, who presented to us with left-sided hemiparesis and was on antitubercular therapy from a previous presumed diagnosis of CNS tuberculoma. Non-characteristic imaging picture, multiple negative body fluid cultures, and positive Cerebrospinal fluid galactomannan led to a further delay in diagnosis. Gram stain of the tissue obtained from brain biopsy revealed Gram-negative rods in "safety pin" appearance. By picking up the colonies that appeared on blood agar and MacConkey agar, the identification of the clinical isolates was performed using VITEK® matrix (BioMérieux, Marcy-L'Etoile, France)-assisted laser desorption ionization time-of-flight mass spectrometry (VITEK MALDI TOF MS database version 3.2) which revealed Burkholderia pseudomallei. After the institution of appropriate treatment, she survived but with significant morbidity. A high index of suspicion should be kept for such previously healthy individuals belonging to non-endemic areas, where presentation is suspicious of an infective etiology, but not improving despite appropriate therapy. This may help in early recognition and institution of recommended treatment so that mortality can be avoided.

Vagal Nerve Stimulation in the Management of Epilepsy - Recent Concepts.

Epilepsy surgery currently offers the best treatment for patients with drug-refractory epilepsy (DRE). Resective surgery, in the presence of a well-localized epileptogenic focus, remains the best modality towards achieving seizure freedom. However, localization of the focus may not be possible in all the cases of DRE, despite comprehensive epilepsy workup. Neuromodulation techniques such as vagal nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS) may be a good alternative in these cases. This article intends to provide an overview of VNS in the management of DRE, including indications, comprehensive preoperative workup, exemplified by case illustrations and outcomes by reviewing the evidence available in the literature.

Vagal Nerve Stimulation for Drug Refractory Epilepsy.

BACKGROUND: Vagal nerve stimulation (VNS) is a form of neuromodulation for patients with drug-refractory epilepsy (DRE), in whom extensive preoperative evaluation fails to localize the epileptogenic zone. VNS is often compared to Corpus callosotomy (CC) in terms of both indications and efficacy. However, VNS represents a less invasive and less morbid procedure compared to CC and is the preferred procedure in majority of patients with DRE. OBJECTIVE: The aim of this study was to present the surgical technique and nuances involved in the implantation of vagal nerve stimulator. PROCEDURE: A 16-year-old boy suffering from DRE, with bilateral seizure onset on evaluation, for 12 years, underwent left vagal nerve stimulator placement. The VNS device has a lead and a pulse generator, the lead has coils to be wrapped around the vagus nerve and the pulse generator is placed in a subcutaneous pocket in the infraclavicular region (demonstrated in the video). RESULTS: The patient is relieved of the disabling drop attacks along with improved cognitive functions at 1 year follow up. CONCLUSIONS: In carefully selected patients, VNS is a safe and effective procedure to alleviate seizures, in cases otherwise morbidly affected due to drug refractory epilepsy.

Robotic Guided Bilateral Anterior Cingulate Radiofrequency Ablation for Obsessive-Compulsive Disorder.

BACKGROUND: Bilateral anterior cingulotomy (BAC) constitutes the most commonly performed procedure for treatment of refractory OCD. Evolution of stereotactic procedures has rekindled the interest in the effective management of refractory psychiatric disorders, especially OCD with utmost safety and excellent outcomes. OBJECTIVE: The aim of this study was to demonstrate the technique of performing BAC under robotic guidance using radiofrequency ablation with an operative video. PROCEDURE: A 23-year-old gentleman diagnosed with symptoms of OCD for a duration of 8 years and was refractory to conventional therapy. The trajectories for BAC were planned on the robotic platform (ROSA, Zimmer-Biomet, Warsaw, Indiana, USA). The target point was selected on the anterior cingulate, approximately 2 cms posterior to the anterior most point of the frontal horn, 2-3 mm above the corpus callosum and 7 mm lateral to the midline. Pre coronal (1 cm anterior and 3 cms lateral to midline) holes of 2.5 mm diameter were made using pneumatic handheld drill. Radiofrequency (RF) thermocoagulation of the anterior cingulum was performed using an RF probe of 2.2 mm diameter and 4 mm uninsulated tip under robotic guidance after confirming the position with intraoperative O-arm imaging bilaterally. RESULTS: The surgery was uneventful and the patient had a significant improvement following surgery, with the Yale Brown Obsessive Compulsive Scale of 18 at 1 year follow-up compared to the preoperative score of 36. CONCLUSION: Robotic-guided BAC is a safe and effective technique for the treatment of drug-refractory OCD. Intraoperative O arm CT augments the precision of the lesions created.

Feasibility of Double Anterior Odontoid Screw: A CT-Based Morphometric Analysis of the Axis in Adult Indian Population.

BACKGROUND: The fractures of the odontoid process constitute 10% of all cervical spine injuries. Odontoid screw placement, although technically challenging, in indicated cases is the ideal treatment. Hence, a thorough knowledge of the odontoid dimensions is necessary prior to the surgical endeavor, more so for planning double odontoid screws. MATERIALS AND METHODS: A prospective morphometric analysis of retrospective data of 250 patients was acquired at our institute using Somatom Definition edge 128 slice 64-row detector Siemens CT scanner. The dimensions of the odontoid process were measured at the waist (narrowest portion), widest diameter both in anteroposterior and transverse diameters. The dimensions of the C2 vertebra were measured at the level of the superior and inferior endplate in both the planes. RESULTS: A total of 250 patients were evaluated with age ranging from 1 to 80 years. Males constituted 174 (69.6%) and 76 (30.4%) were females. The mean transverse diameter (TD) at the odontoid waist (narrowest diameter) was 8.66 mm. The mean TD at the widest point of odontoid was 9.68 mm. Mean anteroposterior (AP) diameter 2.5 mm away from the midline on the left side at the level of the waist was 9.51 mm and 2.5 mm on the right of midline was 9.01 mm. The mean AP diameter at the C2 base was 15.824 mm in males and 14.833 mm in females (P < 0.001). CONCLUSION: Double odontoid screw insertion is feasible in only 36% of Indians in the transverse plane, whereas 98.4% of the odontoids can accommodate double screws in the sagittal plane.