Extra-Axial Third Ventriculostomy Through Lamina Terminalis with Multiple Cisternostomies - Rescue Surgery for Patients with Failed Shunt Surgeries and Hydrocephalus.

Background and Aim: Contemporary management of hydrocephalus involves various modes of cerebrospinal fluid (CSF) diversion, including shunt surgery and endoscopic ventriculostomy. However, there are times when either of these procedures have either failed or are not feasible. Highly invasive procedures aimed at internal CSF have been described previously, which, with the aid of modern microsurgical techniques, can be attempted in cases with very limited options. Our aim was to study the utility of extra-axial third ventriculostomy via lamina terminalis fenestration with multiple cisternostomies in the treatment of failed hydrocephalus. Materials and Methods: Forty-five patients with hydrocephalus were operated for extra-axial trans-lamina terminalis third ventriculostomy with multiple cisternostomies from January 2017 to January 2019. A minimally invasive supraorbital craniotomy was performed with subfrontal fenestration of the lamina terminalis and trans-lamina terminalis fenestration of the floor of the third ventricle with multiple cisternostomies including the optico-carotid cistern and opening of the Liliequist membrane. Results: Tuberculous meningitis was the most common etiology in the series, and multiple shunt procedures and incompatible CSF profiles were the most common reasons that necessitated this alternate rescue procedure. At a mean follow-up of 6 months, no patient required a revision shunt surgery. There was one death due to cardiac failure with anasarca, unrelated to the procedure. Conclusions: Extra-axial trans-lamina terminalis ventriculostomy with cisternostomies can safely be performed using minimally invasive micro-neurosurgical techniques, adding to the armamentarium of neurosurgeons in the management of complex cases of hydrocephalus.

Solitary Dorsal Intramedullary Schwanomma ­ A Rare Lesion

Intramedullary schwanommas are rare, and most cases are reported in cervical region. Less than 20 dorsal intramedullary schwanommas have been reported till date in literature. This is due to their cell of origin, the Schwann cell, which is not normally found within the parenchyma of the brain and spinal cord; therefore it is not surprising that these lesions are rare. We report a rare solitary dorsal intramedullary schwanomma in a young adult patient who presented with paraplegia.

Intraoperative Ultrasound an Economical Tool for Neurosurgeons: A Single-Center Experience.

BACKGROUND: Over the past decade, the use of intraoperative image guidance in neurosurgery has gradually gained in importance. Apart from some sophisticated and very expensive techniques, intraoperative ultrasound (IOUS) is a simple and economical technique that allows the surgeon to localize deep-seated lesions under a real-time ultrasonic image display without dissection. The purpose of this study was to present our own preliminary experiences in various (n=1250) neurosurgical procedures carried out at our tertiary care centre in a developing country. MATERIALS AND METHODS: A Prospective study was carried out in our department of neurosurgery at Grant Medical College and Sir J J Group of hospitals from January 2010 to May 2019. IOUS was used during various elective neurosurgical procedures done during this period as given in table no below. A total of 1250 patients, 850 supratentorial lesion, 290 infratentorial lesion and 110 spinal lesion, were included in this study. All studies were performed using an ultrasound machine with variable 3.5~7.5 MHz sector transducers. The echogenicity and pathomorphology between IOUS and computed tomography/magnetic resonance imaging (CT/MRI) of various disease entities were compared. RESULTS: Intracranial structures could be well demonstrated by ultrasound once the skull was opened. Most of the intracranial lesions were hyperechoic, except those with a cystic component. IOUS was more sensitive in demonstrating non-enhanced solid lesions and lesions with a cystic component than was preoperative CT/MRI. The border between the tumor and healthy brain was better delineated on IOUS in all cases aiding in tumor resection. CONCLUSIONS: High-resolution real-time IOUS is a convenient and user-friendly method for identifying, localizing, and characterizing the pathological focus during an operation. Such information is very important and can enhance surgical results.

Management Strategies of Cranial Encephaloceles: A Neurosurgical Challenge.

BACKGROUND: Encephalocele is defined as herniation of cranial contents beyond the normal confines of the skull through a defect in the calvarium either along the midline or at the base of skull. These anomalies should be repaired in the first few months of life to prevent neurological deficits and facial disfigurement. The aim of the surgery is water tight dural closure at the level of internal defect, closure of skull defect, and reconstruction of external bony deformity. MATERIALS AND METHODS: Fifty-four cases of encephalocoeles were studied in our hospital over a 6-year period from 2010 to 2016. Computed tomography (CT) and magnetic resonance imaging (MRI) brain were performed to delineate the bony defect and associated anomalies. Reconstruction of the bony defect was done using autologous calvarial bone graft, Osteopore polycaprolactone (PCL) bone scaffold filler and titanium mesh. RESULTS: In our study, 54 patients (34 boys and 20 girls) whose age varied between 2 months and 14 years were evaluated. Frontoethmoidal (44.5%) and occipital encephaloceles (25.9%) were the most frequently seen varieties. Repair of the dural defect either primarily or using pericranium was done in all cases. Closure of the bony defect was done using autologous calvarial bone graft in 12 (22.22%) patients. Titanium mesh was used in eight and Osteopore PCL bone scaffold filler in four children. Cranioplasty was not done in remaining thirty children because of the small bone defect. Overall, 80% had no postoperative problem and were discharged between 7 and 10 days of surgery. Cerebrospinal fluid leak was the most frequent postoperative complication, noted in five patients. Re-exploration with repair was done in one and remaining four were managed conservatively. Overall, cosmetic results were acceptably good, with parents judging the cosmetic outcome as good to excellent in 70%, satisfactory in 18%, and poor in 3% at the last follow-up. CONCLUSION: Our study demonstrated that encephaloceles are associated with complex deformities and pose a technical challenge to the neurosurgeon. A multidisciplinary approach is necessary to manage these cases. MRI brain and three dimensional CT aids in evaluating the deformity better and surgical correction should be performed as soon as possible to prevent a further neurological deficit. Repair of dural defect and reconstruction of the skull defect results in a good long-term outcome. We present our experience on 54 cases of cranial encephaloceles managed surgically over a period of only 6 years which is one of the largest series reported from Asia.

Lateral Semi-sitting Position: A Novel Method of Patient's Head Positioning in Suboccipital Retrosigmoid Approaches.

BACKGROUND: The most common methods of positioning patients for suboccipital approaches are the lateral, lateral oblique, sitting, semisitting, supine with the head turn, and park bench. The literature on the positioning of patients for these approaches does not mention the use of lateral semisitting position. This position allows utilization of the benefits of both semisitting and lateral position without causing any additional morbidity to the patient. AIMS: The aim of the present study is to highlight the advantages of the lateral semisitting position while operating various cerebellopontine angle (CPA) and posterior fossa lesions. MATERIALS AND METHODS: The position involved placing the patient in a lateral position with torso flexed to 45° and head tilted toward opposite shoulder by 20°. The most common approach taken was retrosigmoid suboccipital craniotomy. RESULTS: The advantages of lateral semisitting position were early decompression of cisterna magna, and the surgical field remained relatively clear, due to gravity-assisted drainage of blood and irrigating fluid. We could perform all the surgeries without the use of any retractors. The position allowed better delineation of surrounding structures resulting in achieving correct dissection plane and also permitted early caudal to cranial dissection of tumor capsule, thereby increasing chances of facial nerve preservation. Importantly, there is less engorgement of the cerebellum as the venous outflow is promoted. We have not experienced any increased rate of complications, such as venous air embolism, tension pneumocephalus with this lateral semisitting position. CONCLUSIONS: Lateral semisitting position is a relatively safe modification, which combines the benefits of semisitting and lateral position, and avoids the disadvantages of sitting position in operating CPA tumors. This position can provide quick and better exposure of the CPA without any significant complications.

Unravelling Hitherto Unreported Masses Camouflaged as Pituitary Macro Adenomas.

BACKGROUND: Lesions of the pituitary gland and the juxtasellar region are quite frequently encountered in daily practise of a neurologist/neurosurgeon. While the differentials of sellar masses are quite large and form an extensive list and the management protocol varies in each case, the onus of properly categorizing and diagnosing the pituitary mass often falls on the reporting radiologist. We hereby present two such unusual masses in the sellar-suprasellar region which were masquerading as pituitary macro adenomas. MATERIALS AND METHODS: Two cases of sellar-suprasellar masses which were preoperatively diagnosed as pituitary macro-adenomas on radiological imaging proved out to be pituitary natural killer cell lymphoma and lepromatous abscess. RESULTS: The first one is a rare case of pituitary abscess seen in a lepromatous patient which is not yet reported in the literature. The second case is of primary pituitary natural killer cell lymphoma which is almost entirely unknown, with only two such cases being reported worldwide till date. CONCLUSION: It is important to realize that all enhancing pituitary lesions are not macro adenomas and it is necessary to have a high index of suspicion in such cases. The clinical implications of such an error and steps that can be taken to prevent misinterpretations of unusual sellar masses camouflaging as pituitary macro adenomas have been briefly outlined.

Laparoscopic versus open management of duodenal perforation: a comparative study at a District General Hospital.

INTRODUCTION: Duodenal perforation is one of the common pathologies in patients presenting in emergency with acute abdominal pain in an emergency ward and requires prompt surgery as life saving and curative intervention. The present study was conducted to determine whether the minimal access approach by laparoscopy was equally feasible as the open method. AIM: To compare laparoscopic vs. open management duodenal perforation in all aspects. INCLUSION CRITERIA: patients presenting to the emergency ward with acute pain in the abdomen with clinical signs of peritonitis and air under the diaphragm on X-ray abdomen standing were selected. Exclusion criteria were: patient age < 15 years and > 70 years, presentation > 2 days, shock with systolic blood pressure < 90 mm Hg which did not improve after hydration with 2000 ml of Ringer lactate solution, respiratory distress, history of cardiac disorder or respiratory disorders such as ischemic heart disease, arrhythmias, chronic obstructive pulmonary disease or asthma, bleeding and clotting disorders, pregnancy in females, previous upper abdominal surgery, and intra-operatively patients having perforation other than duodenal perforation. After excluding patients fitting the above criteria, two groups - test and control - were formed. RESULTS: We found that complications both early and late were significantly fewer in patients treated by laparoscopy. Thus laparoscopy was both feasible and had comparable mortality and leakage rate. CONCLUSIONS: Laparoscopic management of perforated duodenal ulcer is feasible, effective and decreases morbidity and overall treatment time and cost if performed in properly selected patients.