Reverse Y stenting in the management of vertebrobasilar junction fenestrated aneurysm: A novel technique.

Fenestrated aneurysm at vertebrobasilar junction (VBJ) is very rare and can occur due to non-fusion of longitudinal neural axis forming basilar artery in the early stage of embryonic life. Due to defects in tunica media and weakness in its wall, these fenestrations are more likely to develop an aneurysm. Various treatment strategies are required for the management of these types of aneurysms including simple coiling, stent-assisted coiling, balloon remodeling technique, and more recently kissing flow diverters. Herein, we report the case of ruptured fenestrated VBJ aneurysm which was managed successfully with novel reverse Y stenting with coiling.

Intraventricular Pilocytic Astrocytoma: A Single Centre Experience.

Background: Intraventricular pilocytic astrocytomas are a rare occurrence, accounting for approximately 4% -15.6% of all pilocytic astrocytomas .The aim of the study was to describe the radiology, surgical management and outcome in 15 patients with histopathologically proven intraventricular pilocytic astrocytoma(IVPA). Objective: To study the clinical presentation radiology and operative challenges in rare intra ventricular pilocytic astrocytomas. Materials and Methods: Between January 2010 and August 2018, 15 patients with histopathologically proven IVPA were identified. The radiological images were obtained from PACS. Patient and surgical details were obtained from the computerized discharge summary, OT records and operative notes, whereas follow up was obtained from the record section. Results: Headache with progressive loss of vision was the most common presentation. Duration of symptoms varied from 4 months to 2 years (mean 9. 88 months). Except one patient, all patients with preoperative CT scan revealed calcifications in the lesion, with extensive calcification in 3 patients. All the tumors were predominantly hypointense on T1WI and iso to hyperintense on T2WI. Lesion in all patients showed heterogenous contrast enhancement on post gadolinium images. Mean blood loss in the series was 1969 ml (range 250 ml- 4500 ml).There was one death in this series due to meningitis and septic shock. Conclusion: IVPAs are rare tumors and are difficult to diagnose in the preoperative period based on the radiologic profile alone. These tumors can be extremely vascular with potential for massive blood loss. These tumors can be associated with extensive calcification and the calcified tumors have less bleeding as expected.

Choroid Plexus Carcinoma with Hyaline Globules: An Uncommon Histological Finding.

Background: Choroid plexus carcinoma (CPC) is a predominately pediatric CNS tumor with a variety of histologic features, with hyaline globules only reported once previously. Case report: A two-year-old male child presented with headaches, vomiting, and lower limb weakness. Radiological examination revealed a right temporoparietal intra-axial tumor. On histology, it showed features of CPC containing multiple eosinophilic intracytoplasmic and extracellular hyaline globular structures, which were PAS-positive, diastase resistant, and immunoreactive for alpha-fetoprotein (AFP). Conclusion: CPC can occasionally show AFP immune-positive hyaline globules.

A novel prefabricated patient-specific titanium cranioplasty: reconsideration from a traditional approach.

OBJECTIVE: Patient-specific implants (PSI) for cranioplasty are expensive, and cost remains the limiting factor in low- to middle-income countries. The authors describe a novel, reproducible and cost-effective method of designing prefabricated titanium PSI cranioplasty. METHODS: Ten patients from June 2018 to December 2020 were included in this retrospective study. A three-dimensional stereolithography model was made on a custom-built 3D printer with variable layer heights to produce efficient and accurate details. A certain amount of defect in the temporal region was left uncovered to avoid complications related to temporalis muscle dissection. The stereolithography model with a cranial defect was reconstructed with modelling wax. The wax model was scanned with a blue light visible scanner. The digital data was transferred to the milling machine (Jayon Surgical®, Kerala, India), where a 1-mm-thick sheet of titanium was milled according to the specifications. RFCC scoring system was used for assessing cosmetic outcome. RESULTS: The mean duration of the surgery was 56.50 min, SD = 14.916 min (range 45-75 min). In 9/10 patients, the RFCC score was 4 points. No other complications were found at a minimum follow-up of 18 months in all patients. The cost per patient was approximately 30,000 INR or 400 US dollars. The average time required for us to get the PSI ready for surgery was about 15 days. CONCLUSION: The authors demonstrate a novel, cost-effective and reproducible method of PSI using titanium for cranioplasty.

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.

Lateral Ventricle Atypical Teratoid/Rhabdoid Tumor (AT/RT): Case Report and Review of Literature.

A 4-year-old male child presented with features of raised intracranial pressure due to tumor in the left lateral ventricle with shunt blockage. Ventriculoperitoneal shunt was done earlier (one month ago). Craniotomy and gross total excision of the tumor was achieved. Histopathological examination was suggestive of Atypical Teratoid/Rhabdoid tumor. Patient relatives were not compliant with the advice for adjuvant therapy and patient expired after three months of definitive surgery due to aggressive course of the disease. To the best of our knowledge only six cases of AT/RT of the lateral ventricle in pediatric population has been described in literature. The tumor may mimic radiologically with benign pathology and can have an aggressive course with poor outcome. Differential diagnosis of AT/RT must be kept in cases of lateral ventricle tumor in pediatric population.

Neurosurgery training in India during the COVID-19 pandemic: straight from the horse's mouth.

OBJECTIVE: The COVID-19 pandemic has forced medical professionals throughout the world to adapt to the changing medical scenario. The objective of this survey was to assess the change in neurosurgical training in India following the COVID-19 pandemic. METHODS: Between May 7, 2020, and May 16, 2020, a validated questionnaire was circulated among neurosurgical residents across India by social media, regarding changes in the department's functioning, patient interaction, surgical exposure, changes in academics, and fears and apprehensions associated with the pandemic. The responses were kept anonymous and were analyzed for changes during the COVID-19 pandemic compared to before the pandemic. RESULTS: A total of 118 residents from 29 neurosurgical training programs across 17 states/union territories of the country gave their responses to the survey questionnaire. The survey revealed that the surgical exposure of neurosurgical residents has drastically reduced since the onset of the COVID-19 pandemic, from an average of 39.86 surgeries performed/assisted per month (median 30) to 12.31 per month (median 10), representing a decrease of 67.50%. The number of academic sessions has fallen from a median of 5 per week to 2 per week. The survey uncovered the lack of universal guidelines and homogeneity regarding preoperative COVID-19 testing. The survey also reveals reluctance toward detailed patient examinations since the COVID-19 outbreak. The majority of respondents felt that the COVID-19 pandemic will hamper their operative and clinical skills. Fear of rescheduling or deferring of licensing examinations was significantly higher among those closest to the examination (p = 0.002). CONCLUSIONS: The adverse impact of the pandemic on neurosurgical training needs to be addressed. While ensuring the safety of the residents, institutes and neurosurgical societies/bodies must take it upon themselves to ensure that their residents continue to learn and develop neurosurgical skills during these difficult times.

Perceptions of Indian neurosurgeons about medicolegal issues and malpractice suits.

OBJECTIVE: Despite the rising trend of medicolegal challenges in India, there is an absolute dearth of literature from India on this issue. The authors conducted a survey, to their knowledge a first of its kind, to assess the perceptions of Indian neurosurgeons about the medicolegal challenges faced in everyday practice. METHODS: An anonymous online survey performed using Google Forms was widely circulated among neurosurgeons practicing in India via email and social media platforms. The questionnaire consisted of 38 questions covering the various aspects of medicolegal issues involved in neurosurgery practice. RESULTS: A total of 221 survey responses were received, out of which 214 responses were included in the final analysis, barring 7 responders who had no work experience in India. The respondents were categorized according to their working arrangements and work experience. Out of all of the respondents, 20 (9.3%) had ≥ 1 malpractice suits filed against them. More than 90% of the respondents believed that malpractice suits are on the rise in India. Almost half of the respondents believed the advent of teleconsultation is further compounding the risk of malpractice suits, and 66.4% of respondents felt that they were inadequately trained during residency to deal with medicolegal issues. Most respondents (88.8%) felt that neurosurgeons working in the government sector had lesser chances of facing litigations in comparison to those working in the private sector. The practice of obtaining video proof of consent was more commonly reported by respondents working in freelancing and private settings (45.1%) and those with multiple affiliations (61.3%) compared to respondents practicing in government settings (22.8%) (p < 0.001). Neurosurgeons working in the private sector were more likely to alter management and refer sick patients to higher-volume treatment centers to avoid malpractice suits than their government counterparts (p = 0.043 and 0.006, respectively). The practices pertaining to legal preparedness were also found to be significantly higher among the respondents from the private sector (p < 0.001). CONCLUSIONS: This survey highlights the apprehensions of neurosurgeons in India with regard to rising malpractice suits and the subsequent increase of defensive neurosurgical practices, especially in the private sector. A stronger legal framework for providing for quick redress of patient complaints, while deterring frivolous malpractice suits, can go a long way to allay these fears. There is a dire need for systematic training of neurosurgeons regarding legal preparedness, which should begin during residency.

Angio-invasive Cerebral Aspergillosis Resulting in Hemispheric Infarct in an Immunocompetent Man.

BACKGROUND: Cerebral aspergillosis usually affects immunocompromised hosts and may rarely occur in immunocompetent individuals. Due to its angio-invasive nature, Aspergillus may cause various vascular complications, particularly mycotic aneurysms and infarcts. CASE PRESENTATION: A 22-year-old immunocompetent male with diagnosed case of sino-cerebral aspergillosis was taking voriconazole for two months. His headache worsened and repeat imaging showed an increase in the size of the lesion. The patient was managed with right frontal craniotomy and surgical debridement, and voriconazole was continued. After ten days of uneventful post-operative course, the patient developed left-sided hemispheric infarct. The patient is doing well at nine months' follow-up, and he is off voriconazole for three months after the follow-up imaging showed complete resolution of disease. CONCLUSION: Treatment of choice for cerebral aspergillosis is voriconazole. Surgical debridement may be a useful adjunct in patients not responding to voriconazole alone.

Impact of the COVID-19 Pandemic on Neurosurgical Practice in India: Results of an Anonymized National Survey.

BACKGROUND: The COVID-19 pandemic has created an unprecedented challenge for medical professionals throughout the world to tackle the rapidly changing scenario. The objective of this survey was to analyze the change in neurosurgical practice in India following the COVID-19 outbreak and assess its impact on practising neurosurgeons. MATERIALS AND METHODS: Between May 7th and 23rd, 2020, a validated questionnaire was circulated amongst practising neurosurgeons across the country by social media and e-mails, regarding changes in the patterns of patients seen, adaptations made in their practice, effect on surgeries performed, financial burden, and impact on their personal lives. The responses were kept anonymous and were analyzed for correlations between the changes observed and independent factors such as hospital affiliations, teaching professions, and neurosurgical experience. RESULTS: Our survey showed a drastic fall in the number of neurosurgical patients seen in the outpatient department (OPD) as well as the number of surgeries performed. A drop of 76.25% was seen in OPD patients (P = 0.000) and that of 70.59% in surgeries performed (P = 0.000). There was no uniformity among the neurosurgeons in the number of COVID-19 tests being done before elective/emergency surgery and in the use of protective gear while examining patients. Private practitioners were more affected financially as compared to those in the government sector. The pandemic has affected the research work of 53.23% of all respondents, with those in the teaching profession (70.96%) more affected than those in the non-teaching profession (24.67%). CONCLUSIONS: Evidence-based policies, screening COVID-19 tests with better sensitivity, and better-quality personal protective equipment kits in adequate numbers are required to protect our medical professionals from COVID-19. Mental health issues among neurosurgeons may also be an issue, this being a high risk speciality and should be closely watched for.

Spinal Intradural Extramedullary Ependymoma with Intracranial Metastasis and Leptomeningeal Spread: A Case Report and Comprehensive Review of Literature.

Dorsolumbar intradural extramedullary ependymoma is a rare entity. Spinal metastases in patients with intracranial ependymoma are well described, but it is extremely rare for a spinal ependymoma to metastasize to brain. We describe a case of aggressive dorsolumbar intradural extramedullary ependymoma mimicking arachnoid cyst radiologically, which developed intracranial metastasis.

Management of Choroid Plexus Tumors in Infants and Young Children Up to 4 Years of Age: An Institutional Experience.

BACKGROUND: Choroid plexus tumors (CPTs) are rare tumors characterized by papillary and intraventricular growth. The young age of presentation of such tumors, especially in infants, and the lack of consensus on adjuvant therapy in case of atypical choroid plexus papilloma (aCPP) and choroid plexus carcinoma (CPC) create dilemma for the management of such tumors. We discuss the presentation, management, complications, and outcome in 15 patients (children 4 years of age and younger) and review pertinent literature. METHODS: We retrospectively analyzed the case records of all patients with CPTs who were operated in our institute from January 2010 to March 2018. We found 15 patients in the age group of 0-4 years of age. The variables analyzed include age, sex, presentation, location, surgical approach, extent of resection, intraoperative blood loss, percentage of blood loss, blood transfused, histopathology, postoperative complications, and outcome. Images were obtained from picture archiving and communication system, and patient details and follow-up were obtained from discharge summary, operative notes, and hospital records. RESULTS: Ten patients had choroid plexus papilloma (CPP), 2 patients had aCPP, and 3 patients had CPC. The mean age was 15.2 months, whereas the median age was 8 months (range, 40 days-4 years). The mean blood loss was 329 mL, whereas the median blood loss was 175 mL. There were a total of 5 deaths, including 3 patients with CPC and 1 each with aCPP and CPP. CONCLUSIONS: CPTs are challenging tumors in infants and very young children because of the potential for massive blood loss. CPP is associated with lesser blood loss and favorable outcome compared with aCPP and CPC. Massive blood loss in CPC and aCPP can be life threatening as has been shown in our series. CPC has a rapid proliferation potential as shown in one of our cases. Attempts at decreasing vascularization of such tumors should be made by various methods, including preoperative embolization and neoadjuvant chemotherapy; however, a consensus on this is lacking.

Study of Incidence and Factors: Risk and Preventive, of Chronic Subdural Hematoma/hygroma in Clipped Patients of Unruptured Intracranial Aneurysms - An Institutional Experience.

INTRODUCTION: One of the underreported complications of clipping of unruptured aneurysm is chronic subdural hematoma/hygroma (CSDH). It can cause sudden deterioration and might need emergency evacuation. Recently, very few papers have studied its incidence and predisposing factors. We are reporting our institutional experience of it along with the study of its risk factors and possible pathogenesis. METHODOLOGY: Totally 91 postoperative patients of unruptured aneurysms were retrospectively analyzed. Totally 21 patients had CSDH who were operated. In rest seventy patients, there was no CSDH. RESULTS: Male sex, old age, anticoagulant use, presence of pneumocephalus and dead space were significantly associated with occurrence of CSDH, whereas arachnoidoplasty significantly protected against it. There was no significant relation of CSDH with Gorei-san use. CONCLUSIONS: We recommend arachnoidoplasty should be carried out in all patients of clipping of unruptured aneurysm. Male patients or/and patients with dead space with pneumocephalus must be given extra attention like avoiding any dead space in postoperative period, doing arachnoidoplasty and regular follow up till 1st year.

Craniovertebral junction evaluation by computed tomography in asymptomatic individuals in the Indian population.

BACKGROUND: The available literature on the anatomy and imaging of the craniovertebral junction (CVJ) focusses on the osteometric indices described for the detection of abnormal relationships between the components of CVJ. However, a knowledge of the normal osteometry of this region in the Indian population is critically important for the operating surgeon as it may influence the surgical technique as well as the choice, size and configurations of the implants. It is also important to determine whether critical differences exist between the osteometric data of Indians and the rest of the world for this part of the anatomy. Accordingly, the present study is an attempt to quantitate the osteometric indices for the anatomically normal CVJ in Indian subjects. MATERIALS AND METHODS: We retrospectively studied the imaging data of 49 consecutive adult patients (31 males, 18 females) who underwent a computed tomographic (CT) angiogram for suspected vascular conditions unrelated to the craniovertebral junction. Several parameters related to the atlanto-dental relationship, foramen magnum, atlas and axis vertebrae were recorded, including the dimensions of the commonly instrumented bony regions and also the indices related to the CVJ bony relationships. The data was also compared between the two genders, statistically through the Student's t-test using the statistical program "R". RESULTS: No patient had an atlanto dens interval >2.5 mm. The mean distance of the odontoid tip from the McRae line in this series was 5.11 mm and no patient had the odontoid tip above the McRae line. Female subjects had significantly smaller diameters of C1 lateral masses and odontoid screw trajectory length when compared to males. Additionally, in the Indian population, the length range of odontoid screw trajectory and the thickness of the narrowest part of the C2 pedicles was smaller with respect to similar data from other geographical regions. However, the rest of the parameters resembled the data from studies conducted on populations with other ethnicities. CONCLUSION: The osteometric parameters of the CVJ in the Indian population are largely similar to those described globally. However, there are some important differences too which can influence the design of surgical implants suited to the Indian population.