Microsurgical Anatomy of Middle Cerebral Artery in Northwest Indian Population: A Cadaveric Brain Dissection Study.

BACKGROUND: Microsurgical anatomy of the Middle Cerebral Artery (MCA) of the Northwest Indian population has not been described to date. A study of cadaveric brains will add to the existing knowledge of brain vessels. OBJECTIVE: To study and compare the microsurgical anatomy of MCA in Northwest Indian Population with that of the available literature. METHODS AND MATERIAL: 15 Formalin Fixed Cadaveric brains, that is 30 vessels from its origin from Internal Cerebral Artery to M5 segment with respect to diameter, length and branching pattern were studied under high magnification (operating microscope) and the data compared with literature. RESULTS: The main trunk of MCA was 16±3 mm long with no significant differences between both sides. Its outer diameter was 3±0.1 mm. Among the early branches 58% were destined to the temporal lobe. Distance between the origin of the early branch from MCA origin was 4±2mm on the right side and 4.5±2.5 mm on the left side. The most consistent perforating branch group was the intermediate group. The pattern of branching of the main trunk was bifurcation (73%), single trunk (10%) and trifurcation (10%). Within the bifurcation group, inferior trunk dominance was seen in 50%. Amongst the cortical branches diameter of the angular artery was largest and the temporo-polar was smallest. No significant difference in the data as compared to literature. CONCLUSIONS: The knowledge of anatomy of MCA and its variations are important for neurosurgical residents' training and neurosurgeons dealing with MCA aneurysm management or bypass surgeries.

Microsurgical Anatomy of Medial Temporal Lobe in North-West Indian Population: Cadaveric Brain Dissection.

AIM: The medial temporal lobe (MTL) is a highly complex neuroanatomical structure of tremendous neurosurgical importance. It is a common site for epilepsy, vascular lesions, and tumors. Owing to the critical location behind the sphenoid wing, it is more prone for traumatic contusion often with surgical implications. Hence, its microneurosurgical anatomy needs to be evaluated in detail. MATERIALS AND METHODS: Twelve formalin-fixed human cadaveric brains from North-west Indian population were dissected under neurosurgical microscope and various dimensions of the MTL and their distance from important neurovascular structures were measured. RESULTS: The MTL consists of important neural structures such as parahippocampal gyrus, uncus, hippocampus, temporal horn, and choroidal fissure. The average distance of tentorium from the uncus was 1.96 mm. The temporal horn and the inferior choroidal point were located from the anterior temporal pole at 22.9 mm and 30.9 mm, respectively. Important vessels that are intimately related to the MTL were anterior choroidal artery (AchA), posterior communicating artery, the P1 segment of posterior cerebral artery, and the M1 segment of middle cerebral artery. CONCLUSION: Complex anatomic and cytostructural organization makes the MTL unique. In this study, along with the descriptive anatomy, morphometric measurements of various structures were performed. The uncus and its relation to other neurovascular structures is well described in literature, but its exact distance from them as determined in this study is particularly helpful in guiding the surgeons while approaching in this area. Knowledge of the distance of the temporal horn from various surfaces is important while opening the temporal horn to avoid unnecessary damage to nearby structures.

Long-term outcome in surviving patients after clipping of intracranial aneurysms.

OBJECTIVE: The quality of life and functional outcome may be significantly impaired in patients of aneurysmal subarachnoid hemorrhage. The purpose of the present study was to assess the status of patients undergoing surgical clipping of intracranial aneurysms in a long-term follow-up and to identify factors affecting outcome. METHODS: 494 patients who underwent clipping of their intracranial aneurysms with a minimum follow-up of 1 year after their discharge were studied. Preoperative factors such as age, Hunt and Hess grade, Fisher grade, time interval between ictus and surgery, and site of aneurysm were recorded. The long-term status was assessed using Glasgow Outcome Scale (GOS), Modified Rankin Scale (MRS), Barthel index (BI), and Mini-Mental State Examination (MMSE). RESULTS: Site of aneurysm and ictus-surgery interval did not have any effect on any parameter at long-term follow-up. Majority of patients who were discharged continued to improve as measured by GOS, Modified Rankin Scale, and Barthel index. However a significant proportion of patients had impaired MMSE at long-term follow-up. Multivariate analysis showed a significant effect of age on MMSE and also a positive correlation between number of aneurysms and GOS. CONCLUSIONS: Most patients who survived and were discharged continued to improve in the postoperative period even though the immediate postoperative outcome was not favorable in many. However, a substantial subset had impaired cognitive function.

Pituitary dysfunction in survivors of spontaneous subarachnoid hemorrhage of anterior communicating artery and middle cerebral artery aneurysms: A comparative study.

BACKGROUND: The data on incidence of hypopituitarism after SAH are conflicting. Furthermore, it is still not known whether there is any difference in hormonal deficiencies between SAH due to anterior communicating artery (A-com) and middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS: This study includes both retrospective and prospective arms. The data collected included baseline demographic profile, clinical severity on admission to the hospital by the Hunt and Hess grading system and World Federation of Neurological Surgeons (WFNS) grading, radiological severity of bleed by the Fisher's classification, and treatment details. All the patients underwent detailed hormonal evaluation at baseline and 6 months in prospective group while at the end of 1 year in the retrospective group. Hormonal deficiencies between patients with A-com and MCA aneurysmal SAH were compared using appropriate statistical tests. RESULTS: Of 60 patients studied, 47 patients (A-com: 28 and MCA: 19) were in the retrospective group, while 13 patients (A-com-9, MCA-4) were in the prospective group. The baseline data were comparable between the two groups. At or after 6 months follow-up, 19 (31.6%) patients, 10 patients with A-com and 9 patients with MCA aneurysmal SAH, had some form of hormone deficiency. Furthermore, there was no difference in endocrine dysfunctions between the two groups. There was no correlation between the severity of hormonal deficiency and the clinical severity of SAH grade by Hunt and Hess and radiological grade of SAH by Fisher's grade. CONCLUSION: Hormonal deficiencies are not uncommon in patients with SAH. There is no difference in hormonal deficiencies and severity of hypopituitarism in patients with SAH due to A-com and MCA bleed.

Primary gliosarcoma--clinical experience from a regional cancer centre in north India.

AIMS: We intended to assess the clinicopathological features and treatment outcome in patients of primary gliosarcoma, a rare malignant brain tumour. MATERIALS AND METHODS: Medical records were reviewed and data collected on primary gliosarcoma over an 8-year period (2002-2009) from the departmental archives. Overall survival (OS) was analysed by Kaplan-Meier method. RESULTS: Seventeen patients met the study criterion (male:female = 9:8). Median age and performance status at presentation were 50 years and Karnofsky performance scale (KPS) 70, respectively. Symptoms of raised intracranial tension (in 100%) and motor impairment (in 64.7%) were commonly observed. Tumour location was frontal in four patients, temporal in three, parietal in three, thalamic in one, multilobed in five and multicentric in one. All patients underwent maximal safe surgery (total excision-10, near-total excision-2, subtotal excision and decompression-5). On histopathology, all tumours showed biphasic pattern, glial component positive for glial fibrillary acidic protein (GFAP) and mesenchymal component positive for vimentin and reticulin. Atypia, mitoses, necrosis and endothelial proliferation were identified in the glial component. Post-operative radiotherapy (median dose--60 Gy/30#/6 weeks) was used in 15 patients (88.2%). Concurrent and adjuvant chemotherapy with temozolomide (TMZ) were used in two patients depending upon affordability. After the completion of treatment, 35.3% patients were asymptomatic, 23.5% had symptomatic improvement, while 41.2% deteriorated. Salvage therapy for local recurrence was used in three patients (temporal lobectomy-1; total excision-1; TMZ+bevacizumab-1). At last follow-up (FU), eight patients were alive, seven patients dead and two patients lost to FU with symptom. Median overall survival in the evaluable patients (N = 15) was noted to be 8.27 months (6 month survival 60.76%). CONCLUSIONS: Primary gliosarcoma, a variant of glioblastoma poses clinical challenge because of rarity, poor prognosis and limited experience. In our centre, principle of therapy is akin to that of glioblastoma--surgery followed by radiation along with concurrent and adjuvant TMZ. However, chemotherapy is often cost-prohibitive in our setting as mirrored by limited use (17.6%). Median survival of only 8.27 months in our series is in concert with the existing survival result of primary gliosarcoma in world literature (6.25-11.5 months).

Intramedullary abscess in association with tumor at the conus medullaris. Report of two cases.

The authors report on two patients with intramedullary tumors complicated by abscess formation. Both patients experienced abrupt onset of neurological deterioration and poor surgical outcome. An intratumoral abscess developed in one, whereas the other had a tumor-associated syrinx in which an intramedullary abscess developed. Such a conversion of a syrinx into an abscess has not been reported earlier. It is septicemia that underlies all such catastrophic complications; therefore, rapid neurological deterioration should always be looked on with caution and investigated with contrast-enhanced magnetic resonance imaging. Despite poor neurological outcome in such patients, urgent surgical intervention is mandatory.