Dermoid cysts of the posterior fossa--morbid associations of a benign lesion.

Dermoid cysts of posterior fossa are uncommon benign lesions. They differ from other lesions found in the infra tentorial compartment by virtue of their associated conditions. Due to their association with dermal sinus tracts, intracranial infection is a potential threat following infection of the cyst. Due to their embryologic origin, these cysts may also be associated with other congenital anomalies. In this article we detail our eleven-year-experience with posterior fossa dermoid cysts in fifteen patients. Despite the morbid presentation with severe life-threatening complications, the overall outcome was excellent. Implications of the various associations are discussed.

Traumatic brain injury during COVID-19 pandemic-time-series analysis of a natural experiment.

OBJECTIVES: This study aims to find if the incidence and pattern of traumatic brain injury (TBI) changed during the COVID-19pandemic. We also aim to build an explanatory model for change in TBI incidence using Google community mobility and alcohol sales data. DESIGN: A retrospective time-series analysis. SETTING: Emergency department of a tertiary level hospital located in a metropolitan city of southern India. This centre is dedicated to neurological, neurosurgical and psychiatric care. PARTICIPANTS: Daily counts of TBI patients seen between 1 December 2019 and 3 January 2021 (400 days); n=8893. To compare the profile of TBI cases seen before and during the pandemic, a subset of these cases seen between 1 December 2019 and 31 July 2020 (244 days), n=5259, are studied in detail. RESULTS: An optimal changepoint is detected on 20 March 2020 following which the mean number of TBI cases seen every day has decreased and variance has increased (mean 1=29.4, variance 1=50.1; mean 2=19.5, variance 2=59.7, loglikelihood ratio test: χ2=130, df=1, p<0.001). Two principal components of community mobility, alcohol sales and weekday explain the change in the number of TBI cases (pseudo R2=58.1). A significant decrease in traffic accidents, falls, mild/moderate injuries and, an increase in assault and severe injuries is seen during the pandemic period. CONCLUSIONS: Decongestion of roads and regulation of alcohol sales can decrease TBI occurrence substantially. An increase in violent trauma during lockdown needs further research in the light of domestic violence. Acute care facilities for TBI should be maintained even during a strict lockdown as the proportion of severe TBI requiring admission increases.

Neurotrauma clinicians' perspectives on the contextual challenges associated with traumatic brain injury follow up in low-income and middle-income countries: A reflexive thematic analysis.

BACKGROUND: Traumatic brain injury (TBI) is a major global health issue, but low- and middle-income countries (LMICs) face the greatest burden. Significant differences in neurotrauma outcomes are recognised between LMICs and high-income countries. However, outcome data is not consistently nor reliably recorded in either setting, thus the true burden of TBI cannot be accurately quantified. OBJECTIVE: To explore the specific contextual challenges of, and possible solutions to improve, long-term follow-up following TBI in low-resource settings. METHODS: A cross-sectional, pragmatic qualitative study, that considered knowledge subjective and reality multiple (i.e. situated within the naturalistic paradigm). Data collection utilised semi-structured interviews, by videoconference and asynchronous e-mail. Data were analysed using Braun and Clarke's six-stage Reflexive Thematic Analysis. RESULTS: 18 neurosurgeons from 13 countries participated in this study, and data analysis gave rise to five themes: Clinical Context: What must we understand?; Perspectives and Definitions: What are we talking about?; Ownership and Beneficiaries: Why do we do it?; Lost to Follow-up: Who misses out and why?; Processes and Procedures: What do we do, or what might we do? CONCLUSION: The collection of long-term outcome data plays an imperative role in reducing the global burden of neurotrauma. Therefore, this was an exploratory study that examined the contextual challenges associated with long-term follow-up in LMICs. Where technology can contribute to improved neurotrauma surveillance and remote assessment, these must be implemented in a manner that improves patient outcomes, reduces clinical burden on physicians, and does not surpass the comprehension, capabilities, or financial means of the end user. Future research is recommended to investigate patient and family perspectives, the impact on clinical care teams, and the full economic implications of new technologies for follow-up.

Neurotrauma clinicians' perspectives on the contextual challenges associated with long-term follow-up following traumatic brain injury in low-income and middle-income countries: a qualitative study protocol.

INTRODUCTION: Traumatic brain injury (TBI) is a global public health concern; however, low/middle-income countries (LMICs) face the greatest burden. The WHO recognises the significant differences between patient outcomes following injuries in high-income countries versus those in LMICs. Outcome data are not reliably recorded in LMICs and despite improved injury surveillance data, data on disability and long-term functional outcomes remain poorly recorded. Therefore, the full picture of outcome post-TBI in LMICs is largely unknown. METHODS AND ANALYSIS: This is a cross-sectional pragmatic qualitative study using individual semistructured interviews with clinicians who have experience of neurotrauma in LMICs. The aim of this study is to understand the contextual challenges associated with long-term follow-up of patients following TBI in LMICs. For the purpose of the study, we define 'long-term' as any data collected following discharge from hospital. We aim to conduct individual semistructured interviews with 24-48 neurosurgeons, beginning February 2020. Interviews will be recorded and transcribed verbatim. A reflexive thematic analysis will be conducted supported by NVivo software. ETHICS AND DISSEMINATION: The University of Cambridge Psychology Research Ethics Committee approved this study in February 2020. Ethical issues within this study include consent, confidentiality and anonymity, and data protection. Participants will provide informed consent and their contributions will be kept confidential. Participants will be free to withdraw at any time without penalty; however, their interview data can only be withdrawn up to 1 week after data collection. Findings generated from the study will be shared with relevant stakeholders such as the World Federation of Neurosurgical Societies and disseminated in conference presentations and journal publications.

Anesthetic management for foramen magnum decompression in a patient with Morquio syndrome: a case report.

Morquio syndrome is a hereditary mucopolysaccharide disorder presenting with an abnormality of the craniocervical junction from childhood. We describe an adult patient who presented with Morquio syndrome who had subglottic narrowing of the airway, restrictive pulmonary disease, and mild mitral regurgitation and trivial aortic regurgitation. The anesthetic management of this patient for atlantoaxial stabilization is presented.

Circulating MicroRNAs as Potential Molecular Biomarkers for Intracranial Aneurysmal Rupture.

INTRODUCTION: Diagnosis of the rupture of an intracranial aneurysm (IA) relies on sophisticated neuro-imaging studies, and molecular biomarkers to identify an IA or predict its rupture are still unavailable. OBJECTIVE: Our objective was to determine the plasma microRNA (miRNA) expression profile in patients with ruptured IA presenting as aneurysmal subarachnoid hemorrhage (aSAH) and identify potential biomarkers of aneurysmal rupture. METHODS: Plasma miRNA profiling was carried out using quantitative real-time polymerase chain reaction (qRT-PCR) in 20 patients with aSAH and 20 age- and sex-matched healthy controls. Eight differentially expressed miRNAs were validated by qPCR in a larger cohort of 88 patients with aSAH and 110 healthy controls. A receiver operating characteristic (ROC) curve was constructed to evaluate the overall performance of the miRNA-based assay. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis was used to determine the potential pathway of miRNA-target genes. RESULTS: The miRNA profiles were clearly distinct in patients compared with controls. Validation studies showed that three upregulated miRNAs (miR-15a-5p, miR-34a-5p, miR-374a-5p) and five downregulated miRNAs (miR-146a-5p, miR-376c-3p, miR-18b-5p, miR-24-3p, miR-27b-3p) could distinguish patients with aSAH from healthy controls with high predicted probability (0.865 and 0.995, respectively). Further, the expression levels of the eight candidate miRNAs were significantly dysregulated only in aSAH cases and not in patients with SAH due to other causes. Plasma miR-146a-5p and miR-27b-3p were associated with clinical outcomes in patients with aSAH. Functional analysis of the eight differentially expressed miRNA showed that the target genes involved in signaling pathways were related to inflammation. CONCLUSIONS: Our study determined the plasma miRNA signature of ruptured IAs and identified eight candidate miRNAs that could be useful biomarkers for this condition. We hypothesize that these differentially expressed miRNAs may play pivotal roles in IA pathology.

Three­time point view of mild brain injuries' structural alteration and their association with cognitive domains.

BACKGROUND: Mild traumatic brain injury (mTBI) accounts for 70­80% of total neurotrauma, majority among them manifest with cognitive deficits. Till date there are few/or no 3­time­point longitudinal studies that have evidenced brain volume changes. The current study has investigated volume changes at 3­time­points and their association with cognitive sequel. METHODS: Twenty­one mTBI patients with normal imaging and 15 GCS were recruited. Initially these patients were evaluated with magnetic resonance imaging (MRI) scan ≤36hours and neuropsychological test (NPT) during 2­3weeks after­injury. All the patients were available for follow­up for repeat MRI and NPT on 3­4 and 6­7months. The imaging and test scores were analyzed using repeated measures of analysis (P<0.05). The brain volumes were correlated with respective test­scores using partial­correlation. RESULTS: Left frontal lobe (P<0.029) and thalamus (P=0.049) showed significant increase in mean volume overtime, whereas corpus callosum (mid­anterior [P=0.011] and central [P=0.04]) and left cerebellum (P=0.043) showed significant decrease in mean volume overtime. Clinically cognitive scores improved with time. Eventual improvements in attention and memory scores were positively associated with increase in cingulate gyrus volume. CONCLUSIONS: The 3­time­point longitudinal study illustrates brain areas that changes with time and their association with improving cognitive scores. The study provides hint about the pattern of natural recovery.

The vascular protective role of oestradiol: a focus on postmenopausal oestradiol deficiency and aneurysmal subarachnoid haemorrhage.

The steroid hormone, oestradiol, has pleiotropic functions. The protective effects of oestradiol are attributed to its anti-inflammatory, antioxidant, anti-atherogenic, anti-apoptotic, vasodilatory activities and regulation of micro RNA. Oestradiol upregulates endothelial nitric oxide synthase gene expression and increases the production of nitric oxide, an important vasodilator. It suppresses the renin-angiotensin system and monitors haemodynamic stress. The hormone maintains the integrity of blood vessels by reducing oxidative stress while upregulating the expression of antioxidant enzymes and prevents vascular inflammation by regulating pro- and anti-inflammatory cytokines. Aneurysmal subarachnoid haemorrhage (aSAH) occurring as a consequence of the rupture of an intracranial aneurysm is a devastating cerebrovascular event, representing 5-7% of all strokes. Postmenopausal women are more susceptible to aSAH compared to men in the same age group. This gender disparity has been attributed to reduced levels of the vascular protective hormone oestradiol following menopause. This review is focused on the protective role of oestradiol on vasculature and how the drop in oestradiol levels after menopause dramatically increases the incidence of aSAH in women. During menopause, oestradiol deficiency may affect vascular integrity causing dysregulation of vascular homeostasis by affecting the renin-angiotensin-aldosterone system (RAAS) and inflammatory and apoptotic cascades, resulting in the weakening of the cerebral arterial wall and potentially to development of an aneurysm and its rupture. In view of the role of oestradiol in maintaining vascular integrity, treatments involving hormone replacement could be a promising approach in postmenopausal women who are at risk of developing or rupturing an intracranial aneurysm.

Anaplastic Ependymoma With Ganglionic Differentiation: Report of a Rare Case and Implications in Diagnosis.

Ependymomas are glial neoplasms with rare cases exhibiting neuronal differentiation. We describe a case of spinal anaplastic ependymoma with ganglionic differentiation in a 28-year-old woman. The ganglionic component was labeled by synaptophysin, whereas the rest of the tumor showed features of an anaplastic ependymoma. Stem cell marker MELK was noted to stain both the neoplastic ependymal and ganglionic components, possibly suggesting a stem cell/progenitor origin for the tumor with subsequent divergent differentiation.

EEG Neurofeedback therapy: Can it attenuate brain changes in TBI?

BACKGROUND: Electroencephalogram Neurofeedback therapy (EEG-NFT) has several potential beneficial effects in terms of improving cognition and electrophysiological regulation among patients with brain injury. However, in vivo structural and functional changes remain less explored. OBJECTIVE: The aim of the present study is to explore EEG-NFT induced in vivo changes in traumatic brain injury (TBI) patients. METHOD: Two patients with mean age of 15 years with moderate head injury who had more than seven post concussion symptoms and poor cognitive performances (<5 percentile) were subjected to 20 sessions of EEG-NFT. The neuropsychological test scores, post concussion symptoms and MRI scan of the brain were recorded pre-post to EEG-NFT. RESULTS: During EEG-NFT the cognitive scores and concussion symptoms improved significantly (p < 0.05). The EEG-NFT has shown significant increase in cortical grey matter (GM) volumes (p < 0.0001) and fractional anisotropy (FA) of cortical white matter (WM) tracts (p < 0.0001, voxel max 60 and above). There was a significant decrease in global, local efficiency, cost and clustering coefficient of functional connectivity (Wilcoxon Sign Rank Test p < 0.05). Interestingly there was a significant increase in thalamo-cortical connection (increase FA value) after EEG-NFT. CONCLUSION: The EEG-NFT therapy has shown significant changes in structural and functional connectivity among young moderately injured TBI patients.

Pediatric spinal schwannomas: An institutional study.

OBJECTIVE: The objective was to analyze the demography, clinical presentation, and management of spinal intradural schwannomas in pediatric population. MATERIALS AND METHODS: This retrospective study includes 21 pediatric patients (under 18 years of age) who underwent surgery for spinal intradural schwannomas from January 1998 to April 2008. The medical records were reviewed retrospectively and the information regarding clinical presentation, tumor location, operative findings, and postoperative status and functional outcome were analyzed. RESULTS: A total of 21 patients (14 females and 7 males) were operated for spinal schwannomas. Six patients had associated neurofibromatosis (five were NF I and one was NF II) at presentation. The most common presenting symptom was progressive myelopathy (86%). The tumor location was either cervical or dorsal in 18 cases. All patients underwent surgery. Gross total excision was achieved in 20 cases. The median follow-up was 38 months. All the patients had neurological improvement in both power and bladder symptoms. CONCLUSION: Pediatric spinal neurofibromas/schwannomas are an uncommon but completely treatable group of tumors. Complete surgical excision gives excellent outcome.