A Single Standard Polyvinyl Chloride 3D Skull Model to Create the Polymethyl Methacrylate Cranioplasty Flap: A Novel and Low-Cost Technique.

BACKGROUND: Although, cranioplasty is a commonly performed neurosurgical procedure worldwide, the cost of available cranioplasty implants is a major issue in a low-income country like India. The aims of this study were to introduce a novel and low-cost technique using a single standard three-dimensional (3D) skull model to guide the polymethyl methacrylate (PMMA) cranioplasty flap production and to evaluate the functional and cosmetic outcomes. METHODS: We retrospectively evaluated 47 cases of PMMA cranioplasty in the period from February 2019 to June 2022. A single standard 3D skull model was used to make the PMMA cranioplasty flaps. The overall cost of this PMMA implant was compared with that of other available cranioplasty implants. The functional and cosmetic outcomes were evaluated postoperatively. RESULTS: The mean age of our patients was 37.17 ± 13.83 years and the age range was 17 to 63 years. The primary cause of surgery was trauma in the majority of cases (n = 31, 65.96%). The mean operative time was 78.55 ± 19.82 minutes. The cosmetic results were very satisfying in 46 of 47 (97.87%) patients and moderately satisfying in 1 (2.12%) patient. Overall, there were three (6.38%) complications. CONCLUSION: Our technique provides excellent functional and cosmetic outcomes. The overall surgical cost of these PMMA implants was lower than that of the other available cranioplasty implants. This technique is currently the most cost-effective option for cranioplasty.

Supratentorial Intracerebral Hematoma as a Rare Complication of Posterior Fossa Surgery in Prone Position: A Case Report with Review of Literature.

Supratentorial intracerebral hematoma is a rare complication after posterior fossa tumor surgery in prone positioning. Although rare, its occurrence may cause significant impact on survival of the patient. We had described this rare complication and their possible pathophysiology in this report. A 52-year-old male with fourth ventricle epidermoid tumor with noncommunicative hydrocephalus was presented to us in drowsy condition in emergency department. Right-sided medium pressure ventriculoperitoneal surgery was performed in emergency. After shunt surgery patient become conscious and oriented. Total excision of tumor was done via suboccipital craniotomy in prone positioning after preanesthesia fitness. Patient extubated from anesthesia and was conscious but after 2 hours patient condition deteriorated. Patient was intubated again and taken on ventilatory support. Postoperative plain computed tomography brain showed total excision of tumor with left temporal lobe hematoma. Patient was managed conservatively and his condition improved in 3 weeks' periods. Supratentorial intracerebral hematoma after posterior fossa surgery in prone positioning is a rare complication. Despite the rarity of this complication, it is still challenging as it may lead to significant morbidity and mortality.

Updates in the Management of Recurrent Glioblastoma Multiforme.

BACKGROUND: Glioblastoma is the most aggressive and diffusely infiltrative primary brain tumor. Recurrence is almost universal even after all primary standard treatments. This article aims to review the literature and update the standard treatment strategies for patients with recurrent glioblastoma. METHODS: A systematic search was performed with the phrase "recurrent glioblastoma and management" as a search term in PubMed central, Medline, and Embase databases to identify all the articles published on the subject till December 2020. The review included peer-reviewed original articles, clinical trials, review articles, and keywords in title and abstract. RESULTS: Out of 513 articles searched, 73 were included in this review after screening for eligibility. On analyzing the data, most of the studies report a median overall survival (OS) of 5.9 to 11.4 months after re-surgery and 4.7 to 7.6 months without re-surgery. Re-irradiation with stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) result in a median OS of 10.2 months (range: 7.0-12 months) and 9.8 months (ranged: 7.5-11.0 months), respectively. Radiation necrosis was found in 16.6% (range: 0-24.4%) after SRS. Chemotherapeutic agents like nitrosourea (carmustine), bevacizumab, and temozolomide (TMZ) rechallenge result in a median OS in the range of 5.1 to 7.5, 6.5 to 9.2, and 5.1-13.0 months and six months progression free survival (PFS-6) in the range of 13 to 17.5%, 25 to 42.6%, and 23 to 58.3%, respectively. Use of epithelial growth factor receptor (EGFR) inhibitors results in a median OS in the range of 2.0 to 3.0 months and PFS-6 in 13%. CONCLUSION: Although recurrent glioblastoma remains a fatal disease with universal mortality, the literature suggests that a subset of patients may benefit from maximal treatment efforts.

Surgical, Clinical, and Radiological Outcomes Analysis of Craniovertebral Junction Anomalies Cases: An Institutional Experience.

Objective The aim of this study was to evaluate the clinical and radiological outcomes analysis of craniovertebral junction (CVJ) anomalies cases. Materials and Methods Retrospective analysis of 43 CVJ anomalies cases, which were surgically managed at Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Uttar Pradesh, India, from period between June 2015 and June 2019. They were analyzed for age, sex, clinical characteristics, radiological diagnosis, and treatment given. Patient's clinical and radiological status was assessed pre- and postoperatively during time of discharge and at 6 months of follow-up. For clinical assessment we used visual analogue scale (VAS) and Nurick grading system. Radiological assessment was done by atlantodental interval (ADI), craniobasal angle, and craniometric lines. Overall outcomes were depicted as favorable, stabilized, and mortality at 6 to 18 months (mean 12.69 ± 3.77) of follow-up. Results The age range of our cases was 7 to 71 years (mean 29.93 ± 17.39). Male-to-female ratio was 2.91:1. Majority of the cases were presented with neck pain ( n = 38; 88.37%), motor weakness ( n = 35; 81.40%), and sensory deficits ( n = 25; 58.14%). Congenital atlantoaxial dislocation ( n = 31; 72.09) was the most common CVJ anomaly. Clinically, there were significant improvements in VAS ( p = 0.001) and Nurick grade ( p = 0.007) postoperatively. Radiologically, ADI ( p = 0.003) had decreased, clivus canal angle ( p = 0.005) become less acute, and odontoid process ( p = 0.003 for McRae's line) goes downwards in postoperative period. Bony fusion was achieved in 41 (95.35%) cases. Out of 43, 73% cases had favorable outcomes, 21% were stabilized, and mortality was seen in 2.33% cases at 6 months (mean ± standard deviation = 12.69 ± 3.77) of follow-up. Conclusion Proper preoperative evaluation and selection of individualized surgical technique was the key for excellent clinical and radiological outcomes with minimal complications.

Prognostic Role of Catecholamine in Moderate-to-Severe Traumatic Brain Injury: A Prospective Observational Cohort Study.

Objective Traumatic brain injury leads to the activation of sympathetic nervous system and elevation in serum catecholamine levels. The aim of this study was to determine whether catecholamine level obtained within 24 hours of traumatic brain injury provides a reliable prognostic marker for outcome. Materials and Methods This study was a prospective observational cohort study on 36 moderate-to-severe traumatic brain injury. Plasma epinephrine (E), norepinephrine (NE), and dopamine (DA) levels were measured by using computed tomography enzyme-linked immunosorbent assay test and compared with Glasgow coma scale (GCS) that was obtained concurrently. Neurological outcome was determined by GCS at day 7 of treatment and by Glasgow outcome scale at mean follow-up of 9.73 ± 2.26 months. Results Patients with GCS 3 to 4 had markedly increase in baseline mean E (771.5 ± 126.0), NE (2,225.0 ± 215.4), and DA (590.2 ± 38.8) levels as compared with control, while patients with better GCS (11-12) had mildly elevated levels. Patients with GCS 5 to 10 had intermediate values. Cases with markedly elevated baseline E, NE, and DA level were either died or remained in poor GCS (3 or 4) at day 7 of treatment and remained in persistent vegetative state at mean follow-up of 9.73 ± 2.26 months. Cases with only mildly elevated E, NE, and DA level were improved to better GCS on treatment and had good recovery on follow-up. Conclusion These data indicate that a markedly elevated catecholamine level was an excellent endogenous and readily quantifiable marker that appears to reflect the extent of brain injury and predict the likelihood of recovery.

Recurrent glioblastoma in elderly: Options and decision for the treatment.

Background: Glioblastoma (GBM) is the most common primary malignant brain tumor in adult. Its incidence increases with age and nearly half of the all newly diagnosed GBM cases are older than 65 years. Management of GBM in elderly is challenging and recurrence poses further challenge. This article aims to review the literature, evaluate the various options, and to decide the treatment plan in elderly cases with GBM recurrence. Methods: A systemic search was performed with the phrase "recurrent GBM (rGBM) in elderly and management" as a search term in PubMed central, Medline, and Embase databases to identify all the articles published on the subject till February 2022. The review included peer-reviewed original articles, review articles, clinical trials, and keywords in title and abstract. Results: Out of 473 articles searched, 15 studies followed our inclusion criteria and were included in this review. In 15 studies, ten were original and five were review articles. The minimum age group included in these studies was ≥65 years. Out of 15 studies, eight studies had described the role of resurgery, four chemotherapy, three resurgery and/or chemotherapy, and only one study on role of reradiotherapy in patients with rGBM. Out of eight studies described the role of resurgery, six have mentioned improved survival and two have no survival advantage of resurgery in cases of rGBM. Conclusion: Resurgery is the main treatment option in selected elderly rGBM cases in good performance status. In patients with poor performance status, chemotherapy has better post progression survival than best supportive care.

Comparative Outcome Analysis of Endoscopic Third Ventriculostomy and Ventriculoperitoneal Shunt Surgery in Pediatric Hydrocephalus: An Experience of a Tertiary Care Center.

Background Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt surgery (VPS) are used for the surgical management of pediatric hydrocephalus. There is controversy regarding the safety and efficacy of these procedures according to age, etiologies, and type of hydrocephalus. Objective The purpose of this study was to compare the outcomes and complications of ETV and VPS in pediatric hydrocephalus and to evaluate the better procedure. Material and Methods We retrospectively analyzed the pediatric hydrocephalus cases that were operated by ETV and VPS at our department from June 2016 to June 2019. Data were analyzed with respect to the etiology of hydrocephalus, age, and gender of the patients. We compared the outcomes (success and failure) depending on age at surgery, etiology, and type of hydrocephalus, complications at 12 months of follow-up. Fisher's exact test and chi-square test were applied to test the significance of difference. Results There were 195 pediatric hydrocephalus cases, which were operated by ETV ( n = 43; 22.05%) and VPS ( n = 152; 77.95%). The mean age of the cases was 53.63 ± 60.24 (ranged 0.5-204 months) in the ETV group and 53.44 ± 54.10 (ranged 0.3-210 months) in the VPS group. The male-to-female ratio was 1.41:1 in the ETV group and 1.21: 1 in the VPS group. Overall, ETV had successful outcomes in 30(69.77%) cases and VPS in 102(67.11%) cases at 12 months of follow-up. The complication rates were found in 7 (16.28%) cases in the ETV group and 38 (25.0%) cases in the VPS group. At initial 0.5 months of follow-up, ETV required revisions in 6 (13.95%) cases and VPS in 15 (9.87%) cases. Conclusion Although the success and failure of both the procedure vary according to the age at surgery, etiology and type of hydrocephalus, and complications, and failure rates on follow-up, there were no statistically significant differences between the two surgical groups in respect to these variables.

A simplified overview of the World Health Organization classification of central nervous system tumors 2021.

Background: Building on the 2016 updated fourth edition and the work of consortium to inform molecular and practical approach to CNS tumor taxonomy, the major dramatic change occurs in 2021 fifth edition by advancing the role of molecular diagnostics in CNS tumor classification. The present review summarizes the major general changes in the 2021 fifth edition classification and the specific changes in each taxonomic category. Methods: The review was designed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Articles published in PubMed Central, Medline, and Embase databases till now were all searched. Only nonexperimental and nonanimal clinical studies were included in the study. Articles written only in the English language were considered. Results: All IDH mutant diffuse astrocytic tumors are considered in a single type "astrocytoma IDH mutant" and then graded as CNS WHO Grades 2-4. Pediatric-type diffuse gliomas are now classified as separate entity. Anatomical site is also taken into consideration to classify ependymoma. The "Desmoplastic myxoid tumor of the pineal region, SMARCB1 mutant" and "Atypical neurofibromatous neoplasm of unknown biological potential" are new tumor type added to pineal and neurofibroma group, respectively. Mesenchymal tumor is now termed as only solitary fibrous tumor. Adamantinomatous and papillary subtype of craniopharyngioma are now classified as distinct tumor type. The new term "Pituitary neuroendocrine tumor" has been coined for pituitary adenoma. Conclusion: The WHO CNS-5 introduces a new knowledge into the classification with progressive manner by introducing newly recognizing entities, by obsoleting tumor type, and by adjusting the taxonomic structure.

Thoracolumbar fracture classification: evolution, merits, demerits, updates, and concept of stability.

Thoracolumbar fracture classification system is required to facilitate effective communication between spine surgeons, to guide treatment, and to help predict the prognosis. An ideal classification system should be simple, comprehensive, reliable, and reproducible with predictive outcomes. Unfortunately, most of the existing classifications have certain merits and demerits and they failed to fulfill the above criteria; some are oversimplified while others are too inclusive and complex for routine use. Given the scenario where none of the classifications is accepted worldwide, it is imperative to understand the evolution of thoracolumbar injury classification. The authors concisely review the subject from its inception in the year 1929 to the present day.

Endoscopic versus Microscopic Pituitary Adenoma Surgery: An Institutional Experience.

AIM: The aim of this study was to compare the efficacy of endoscopic versus microscopic excision of pituitary adenoma, and to evaluate the merits and demerits of each approach. MATERIALS AND METHODS: Prospective data were collected and patients were surgically treated for pituitary adenoma at SMS Hospital, Jaipur, Rajasthan, India. Patients consent was obtained. Age, sex, presenting symptoms, length of hospital stay, pre- and post-operative hormone status, extent of resections of tumors, and intra- and post-operative complication were noted. RESULTS: A total of thirty patients with pituitary adenoma were operated transsphenoidally. Seventeen patients were operated by endonasal endoscopic transsphenoidal surgery and 13 patients were operated by microscopic transsphenoidal surgery. In an endoscopic group, complete tumor excision was achieved in 11 (64.71%) patients, and in microscopic group, it was achieved in 6 (46.15%) patients. In endoscopic group, mean operative time was 111.29 ± 21.95 min (ranged 80-135 min), and in microscopic group, it was 134.38 ± 8.33 min (ranged 120-145 min). In endoscopic group, mean blood loss was 124.41 ± 39.64 ml (60-190 ml), and in microscopic group, it was 174.62 ± 37.99 (100-220 ml). Postoperative sinusitis was present in 1 (5.88%) patient in endoscopic group and in 2 (15.38%) patients in microscopic group. CONCLUSION: Endoscopic approach provides a wide surgical field and broad lateral vision making easier distinction of tumor tissues. Thus, there is less blood loss, greater extent of tumor removal and it had less operative time, less postoperative complication, and early discharge from the hospital.