Does New WHO 2022 Nomenclature of Pituitary Neuroendocrine Tumors Offer an Extra Edge to the Neurosurgeons for Its Management? A Narrative Review.

The new World Health Organization nomenclature of pituitary tumors was introduced in the year 2022 after much deliberation. This nomenclature clearly demarcates the anterior lobe (adenohypophyseal), posterior lobe (neurohypophyseal), and hypothalamic tumors. There is also focus on other tumors arising in the sellar region. The nomenclature has also advocated the routine use of immunohistochemistry in describing the pituitary transcription factors that plays a fundamental role in distinguishing the cell lineage of these tumors. However, the nomenclature is complex in understanding due to inclusion of pathological correlates like transcription factors, hormones, biomarkers, and various controversies that have emerged regarding the renaming of pituitary adenomas (PA) as PiTNETs ("Pituitary Neuroendocrine tumors") because majority of the adenomas are benign and have rare metastatic behavior while classifying them as PiTNETs will create unnecessary misinterpretation of these as aggressive tumors that will lead to apprehension among the patients. The new classification gives deeper insight into the histological picture of the various pituitary tumors but other than contributing to the follow-up strategy and postsurgery management, this classification does not add anything new that could be advantageous for the neurosurgeons in clinical practice and decision making, especially in deciding the plan of action for surgery. Hence, there is need of a more comprehensive, integrated, neuroradiological-based classification with more emphasis on the invasiveness of these tumors that would assist the neurosurgeons in planning the treatment strategy and managing patients of pituitary tumors.

A Framework to Diagnose Autism Spectrum Disorder Using Morphological Connectivity of sMRI and XGBoost.

In this study, we automated the diagnostic procedure of autism spectrum disorder (ASD) with the help of anatomical alterations found in structural magnetic resonance imaging (sMRI) data of the ASD brain and machine learning tools. Initially, the sMRI data was preprocessed using the FreeSurfer toolbox. Further, the brain regions were segmented into 148 regions of interest using the Destrieux atlas. Features such as volume, thickness, surface area, and mean curvature were extracted for each brain region, and the morphological connectivity was computed using Pearson correlation. These morphological connections were fed to XGBoost for feature reduction and to build the diagnostic model. The results showed an average accuracy of 94.16% for the top 18 features. The frontal and limbic regions contributed more features to the classification model. Our proposed method is thus effective for the classification of ASD and can also be useful for the screening of other similar neurological disorders.

A prospective, randomized, controlled study comparing two surgical procedures of decompressive craniectomy in patients with traumatic brain injury: Dural closure without dural closure.

Decompressive craniectomy (DC) is used to treat severe traumatic brain injury [TBI]. The present study compared dural open and closed surgical procedures for DC and their relationship with Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (E) (GOS-E) scores and survival in prospective randomized controlled TBI patients. Patients aged 10-65 (36.97 ± 13.23) with DC were hospitalized in the neurotrauma unit of King George's Medical University, Lucknow, India. The patients were randomized into test; with dural closure (n = 60) and control without dural closure (OD) (n = 60) groups. After decompressive craniectomy, patients were monitored daily until hospital discharge or death and for three months. GSC/E leakage, infection, and functional status were also assessed. Age (p = 0.795), sex (p = 0.104), mode of injury (p = 0.195), GCS score (p = 0.40, p = 0.469), Rotterdam score (p = 0.731), and preoperative midline shift (MLS) (p = 0.378) did not vary between the OD and CD groups. Neither technique affected the mortality, motor score, or pupil response (p > 0.05). After one and three months, GOS extension was associated with open and closed dural procedures (p = 0.089). Intracranial pressure, brain bulge, GCS score, and MLS were not associated with theoperative method(p > 0.05). The open dural group had a significantly shorter procedure time than the closed dural group (P = 0.026). Both groups showed no significant difference (p > 0.05) between CSF leak and post-traumatic hydrocephalus. Dural opensurgery for a compressed craniectomy is shorter and not associated with significant surgical consequences compared to close dural close surgery.

Pediatric Cervical Spine Injuries.

Objective Pediatric cervical spine injuries are rare and account for 1 to 2% of all pediatric spine injuries. There is a paucity of data on pediatric cervical spine injuries in developing countries like India. The purpose of this study is to review and analyze our 5 years of experience with pediatric cervical spine injuries. Methods All the available medical records over the 5 years were reviewed retrospectively. The data was analyzed to know the epidemiology, mechanism of injury, injury patterns, management, and outcome. The patients were divided into two groups: 0 to 9 years and 10 to 18 years. Results Seventy-five eligible records were included in our study. The incidence of cervical spine injuries was significantly lower in younger children than the older ones ( p < 0.042). The most common mechanism of injury was fall from height: 33 (44%) patients followed by road traffic accidents: 27 (36%) patients. The involvement of the upper cervical spine was significantly higher in younger children ( p < 0.001). Fractures with subluxation were the most common pattern of injury, observed in 35 (47%) patients. However, fractures with subluxation were uncommon in younger children compared with older children ( p < 0.04). Spinal cord injury without radiographic abnormality (SCIWORA) was observed in 42% of younger children compared with 8% of older children ( p < 0.02). Thirty (40%) patients were managed surgically; anterior cervical corpectomy with fusion was the most commonly performed procedure in 19 (63%) patients. The overall mortality was 20%. Conclusion The results of our study revealed predominant involvement of the upper cervical spine in children younger than 10 years of age. SCIWORA was documented in both the age groups with a significantly higher incidence in younger children. The instrumentation and fusion techniques in children are safe; however, developing pediatric spine needs special considerations.

Dynamic change in cortisol levels associated with severity, progression, and survival of patients with traumatic brain injury.

BACKGROUND: Cortisol levels are elevated in severe traumatic brain injury (TBI) and gradually decrease during patient recovery. Thus, dynamic changes in cortisol levels may serve as a prognostic biomarker of TBI. AIM: This study aimed to examine the relationship between serum cortisol levels and outcomes in TBI patients. METHODS: In this prospective case-cohort study, 238 patients with TBI were enrolled. Demographic, clinical, and radiological data were recorded within the first 24 h of hospitalization. Serum cortisol levels were measured using chemiluminescence assay (Immunoassay i1000). The association between cortisol levels and outcome (Glasgow Outcome Scale score) was evaluated at discharge from the hospital and after six months of follow-up. RESULTS: The mean age of the patients was 35.03 ± 17.68 years and the male: female ratio was 4.3:1. At the time of admission(day-1), cortisol levels in the TBI patients were significantly higher than those on day-7 (9.81 ± 4.20 µg/dl versus 23.41 ± 11.83 µg/dl; p<0.001). There was a significant relationship between cortisol levels and Glasgow Coma Scale (GCS) (p = 0.018). Moderate head injury (GCS;9-12) was observed in 108(45.4 %) patients and 130(54.6 %) patients with severe head injury (GCS;3-8) at presentation. CGS was significantly associated with the survival of patients with TBI; alive(n = 143) vs. dead (n = 77); p < 0.001. At 6 months follow-up of patients (n = 184), the findings revealed that the Glasgow Outcome Scale (GOS) and GCS score were significantly associated(p = 0.018). One-way ANOVA showed a significant difference in cortisol levels on day-1, day-7 and six months of sampling (p < 0.0001). Based on the GOS E score, the cortisol levels in the unfavorable and favorable groups significantly differed from those in the GOSE groups (p = 0.05). Similarly, cortisol levels were significantly associated with survival in patients with TBI (p = 0.04). With increasing cortisol levels, the GOSE score was poor and at > 50 µg/dl, no patient has survived. CONCLUSIONS: Day 1 and 7 cortisol, correlated with the outcomes at 6 months, had predictive value post-TBI.

Anaplastic Intraventricular Meningioma with Rhabdoid Features: An Unusual Tumor with Usual Clinical Presentation.

Meningiomas are tumors arising from leptomeninges. Malignant counterpart of them is known as anaplastic meningioma which are WHO grade III tumors. Intraventricular location of these tumors is rare and is clinic-radiologically challenging. Histopathology and immunohistochemistry are confirmatory. We present case of a 27-year-old girl, who presented with usual symptoms of intraventricular mass in emergency. After shunt surgery, clinical diagnosis of ependymoma was formed with differential of high-grade glioma. Squash tissue was difficult to crush displaying tight clusters of spindle cells with necrosis in background. Definitive histology revealed high grade spindle cell neoplasm disposed in sheets with brisk and atypical mitosis. Only focal whorling pattern was seen. Large cells with eccentric cytoplasm, reminiscent of rhabdoid cells were also seen. Immunohistochemistry was positive for vimentin and EMA, negative for GFAP. Final diagnosis of Anaplastic meningioma was dispatched. The histological pattern of the present case, young age of presentation and presence of Rhabdoid cells make it unusual. Though rare but intraventricular meningiomas must also be kept in clinical radiological differentials apart from the usual ependymoma at this location.

Elucidating the mechanisms of Temozolomide resistance in gliomas and the strategies to overcome the resistance.

Temozolomide (TMZ) is a first-choice alkylating agent inducted as a gold standard therapy for glioblastoma multiforme (GBM) and astrocytoma. A majority of patients do not respond to TMZ during the course of their treatment. Activation of DNA repair pathways is the principal mechanism for this phenomenon that detaches TMZ-induced O-6-methylguanine adducts and restores genomic integrity. Current understanding in the domain of oncology adds several other novel mechanisms of resistance such as the involvement of miRNAs, drug efflux transporters, gap junction's activity, the advent of glioma stem cells as well as upregulation of cell survival autophagy. This review describes a multifaceted account of different mechanisms responsible for the intrinsic and acquired TMZ-resistance. Here, we summarize different strategies that intensify the TMZ effect such as MGMT inhibition, development of novel imidazotetrazine analog, and combination therapy; with an aim to incorporate a successful treatment and increased overall survival in GBM patients.

Complications Encountered with ETV in Infants with Congenital Hydrocephalus.

BACKGROUND: Hydrocephalus is an abnormal excessive accumulation of cerebrospinal fluid (CSF) in the cavity and spaces of the brain. Endoscopic third ventriculostomy (ETV) has been an established treatment modality for congenital hydrocephalus. However, in very young infants, the results are challenging. In our study, we have evaluated whether ETV really offers an acceptable complication-free postoperative course. OBJECTIVE: To study the complication and mortality rate in infants having congenital hydrocephalus treated with ETV. MATERIALS AND METHODS: This is a single-center prospective study conducted at the Department of Neurosurgery, K. G. M. U, Lucknow, from January 2019 to February 2020. We studied 40 infants presenting with clinical and radiological features suggestive of congenital hydrocephalus. Follow-up was done at the first, third, and sixth months after discharge. RESULTS: Nineteen infants (47.5%) required a second CSF diversion procedure at 6 months of follow-up. The failure rate was significantly higher in infants less than 3 months of age (P value of 0.04). The ETV site bulge was the most frequent complication encountered in the postoperative period, occurring in 20% of the cases. Eventually, all these infants required a ventriculoperitoneal shunt; 15% developed clinical features consistent with the diagnosis of post-ETV meningitis. The ETV site CSF leak occurred in 10% of the patients. Subdural hygroma developed in 7.5% of the patients; 17.5% of the patients contributed to mortality with a mean time of expiry of 22 days post-procedure. All these deaths had multifactorial causes and could not be said as a complication or failure of ETV. CONCLUSION: We do not recommend ETV for infants less than 3 months because of a high failure rate. The ETV site bulge was the most reliable and earliest marker of failure and a second CSF diversion surgery should be immediately considered.

Management of multiloculated hydrocephalus in children with emphasis on role of CT ventriculography.

OBJECTIVE: The authors performed a retrospective review of children diagnosed with multiloculated hydrocephalus (MLH) in our institute. The goal was to analyze the different diagnostic and therapeutic modalities used with special emphasis on CT ventriculography (CTV). METHODS: Male and female patients below the age of 18 years diagnosed with MLH were included. Cases of uniloculated hydrocephalus like entrapped temporal horn or isolated fourth ventricle were excluded. We used iohexol for CTV and gadodiamide for MR ventriculography. Neuroendoscopic procedures performed were endoscopic fenestration, endoscopic third ventriculostomy (ETV), endoscopic septostomy, endoscopic aqueductoplasty, or a combination of the above. The cohort was divided into two groups (endoscopic or shunt) based on initial surgical intervention. RESULTS: A total of 52 patients were included, with 43 boys and 9 girls. The average age of presentation was 7.7 months. The most common predisposing factor for MLH was neonatal meningitis seen in 30 patients. Mean duration of follow-up was 39 months. CTV was used in 26 patients and MR ventriculography in three patients. In one patient, the diagnosis of MLH was ruled out after ventriculography. Patients who underwent ETV only had the best outcome with 71.4% success rate. At the end of follow-up, 14 patients (27%) were shunt independent. CONCLUSIONS: The present study indicates that CTV helps to accurately define the anatomy of the ventricles and determine the site of physiological CSF obstruction. This helps in therapeutic planning and in avoiding misdiagnoses. Further, neuroendoscopy has the potential to lead to shunt independence in some patients.

Cranial and ventricular size following shunting or endoscopic third ventriculostomy (ETV) in infants with aqueductal stenosis: further insights from the International Infant Hydrocephalus Study (IIHS).

PURPOSE: The craniometrics of head circumference (HC) and ventricular size are part of the clinical assessment of infants with hydrocephalus and are often utilized in conjunction with other clinical and radiological parameters to determine the success of treatment. We aimed to assess the effect of endoscopic third ventriculostomy (ETV) and shunting on craniometric measurements during the follow-up of a cohort of infants with symptomatic triventricular hydrocephalus secondary to aqueductal stenosis. METHODS: We performed a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicenter study of infants (< 24 months old) with hydrocephalus from aqueductal stenosis who were treated with either an ETV or shunt. During various stages of a 5-year follow-up period, the following craniometrics were measured: HC, HC centile, HC z-score, and frontal-occipital horn ratio (FOR). Data were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and sex. RESULTS: Of 158 enrolled patients, 115 underwent an ETV, while 43 received a shunt. Both procedures led to improvements in the mean HC centile position and z-score, a trend which continued until the 5-year assessment point. A similar trend was noted for FOR which was measured at 12 months and 3 years following initial treatment. Although the values were consistently higher for ETV compared with shunt, the differences in HC value, centile, and z-score were not significant. ETV was associated with a significantly higher FOR compared with shunting at 12 months (0.52 vs 0.44; p = 0.002) and 3 years (0.46 vs 0.38; p = 0.03) of follow-up. CONCLUSION: ETV and shunting led to improvements in HC centile, z-score, and FOR measurements during long-term follow-up of infants with hydrocephalus secondary to aqueductal stenosis. Head size did not significantly differ between the treatment groups during follow-up, however ventricle size was greater in those undergoing ETV when measured at 1 and 3 years following treatment.

Endoscopic Transcortical Transventricular Management of Cystic Craniopharyngioma: Outcome Analysis of 32 Cases at a Tertiary Care Center.

BACKGROUND: Microsurgical resection has been considered the gold standard treatment of craniopharyngioma, but lately, it has found less favor due to its morbidity and is being replaced by minimally invasive cyst drainage procedures. We present our experience of transventricular endoscopy and cyst drainage along with its technique and have analyzed its results. MATERIALS AND METHODS: Clinical and radiological data of all cystic craniopharyngioma patients treated by transventricular endoscopic cyst drainage and Ommaya placement were retrieved and analyzed. RESULTS: Thirty-two patients underwent endoscopic cyst drainage during the study period. All patients had immediate clinical and radiological improvement. No significant complications were seen. All patients underwent adjuvant radiotherapy and six patients (18.7%) showed recurrence. Three patients died in the follow-up period. CONCLUSIONS: Endoscopic transcortical transventricular cyst drainage with Ommaya reservoir along with adjuvant radiotherapy is a simple, safe, and effective treatment modality.

A Comparative Analysis Between Four-Quadrant Osteoplastic Decompressive Craniotomy versus Conventional Decompressive Craniectomy for Traumatic Brain Injury.

OBJECTIVE: Primary decompressive craniectomy (DC) is indicated to evacuate the hematoma and reduce intracranial pressure in traumatic brain injury (TBI). However, there are a myriad of complications because of absence of the bone flap. A novel technique, four-quadrant osteoplastic decompressive craniotomy (FoQOsD) retains the bone flap while achieving adequate cerebral decompression. METHODS: A single-center randomized controlled trial of 115 patients with TBI needing decompressive surgery was conducted. Of these patients, 59 underwent DC and 56 underwent FoQOsD. The primary outcome determined was functional status at 6 months using the Glasgow Outcome Scale-Extended. RESULTS: No significant differences were identified in baseline characteristics between both groups. Mean Glasgow Outcome Scale-Extended score was comparable at 6 months (4.28 in DC vs. 4.38 in FoQOsD; P = 0.856). Further, 22 of 58 patients in the DC group had died (38%) compared with 25 of 55 patients in the FoQOsD group (44.6%) (odds ratio [OR], 1.19; 95% confidence interval [CI], 0.6-2.36; P = 0.6) (1 patient lost to follow-up in each group). A favorable outcome was seen in 56.8% of patients in the DC group versus 54.4% of patients in the FoQOsD group (P = 0.74). Presence of intraventricular hemorrhage and subarachnoid hemorrhage (OR, 7.17; 95% CI, 1.364-37.7; P = 0.020), opposite side contusions (OR, 3.838; 95% CI, 1.614-9.131; P = 0.002) and anisocoria (OR, 3.235; 95% CI, 1.490-7.026; P = 0.003) preoperatively were individual factors that played a significant role in final outcome. CONCLUSIONS: FoQOsD is as efficacious as conventional DC with the added benefit of avoiding a second surgery. The procedure is associated with better cosmesis and fewer complications.

Traumatic Pediatric Extradural Hematoma: An Institutional Study of 228 Patients in Tertiary Care Center.

BACKGROUND: Extradural hematoma (EDH) is one of the most common causes of mortality and morbidity after traumatic brain injury in pediatric patients. Early surgical intervention in these patients produces excellent results. OBJECTIVE: We reviewed surgical experience at our center, examining and presenting symptomatology and outcome analysis. MATERIALS AND METHODS: A retrospective study of 228 pediatric patients of EDH from July 2007 to August 2017 was performed. Patients were evaluated in terms of demographic profile, clinical features, pupillary size and reaction, computed tomography findings, operative measures, and several other parameters. Neurological status was assessed using motor component (M) of Glasgow Coma Scale score. Best motor response was considered as a criterion to classify severity of traumatic brain injury and for the assessment of outcome. RESULTS: Most of the patients were in the age group of 13-18 years (n = 122, 53.5%). Majority of them were male (n = 182, 79.8%). The commonest mode of injury was fall from height (n = 116, 50.9%) followed by road traffic accident (n = 92, 40.4%). Most common site of hematoma was frontal region (n = 66, 28.9%) followed by parietal region (n = 54, 23.7%). The volume of hematoma was between 30 and 50 mL in majority of the patients (n = 186, 81.6%), and most of the patients had a motor responses of M5 (n = 88, 38.6%) and M6 (n = 108, 47.4%). The association between hematoma site and volume was not significant (χ2 = 5.910, p = 0.749), whereas statistically significant association was noted between volume of hematoma and motor response (χ2 = 93.468, p ≤ 0.001), volume and age (χ2 = 7.380, p ≤ 0.05), and volume to time between trauma and surgery (χ2 = 8.469, p ≤ 0.05). Maximum mortality was in patients of low motor (M1-M3) response and who were operated 24 h after injury. CONCLUSION: Mortality in patients of EDH can be significantly reduced with gratifying results if operated early. Best motor response at presentation, pupillary abnormalities, time between injury to surgery, and location of hematoma have been identified as the important factors determining outcome in patients of EDH.

Cognitive Deficits in Euthymic Patients With Bipolar Disorder: State or Trait Marker?

Cognitive deficits have been demonstrated in people in the euthymic phase of bipolar disorder. This cross-sectional study compared euthymic bipolar disorder patients (n = 30) with never psychiatrically ill controls (n = 30) on a neuropsychological test battery containing tasks of executive function, the Wisconsin Card Sorting Test (WCST), attention and working memory, digits forward and backward, and speed of information processing digit symbol. Scores on the Mini-Mental State Examination (MMSE) and vocabulary test did not differ between the groups. The bipolar group was significantly impaired compared with controls on various indices of executive function on the WCST and on the digit tests. The impaired performance on the digit tests, but not the WCST, was significantly associated with medication status, notably prescribed benzodiazepines. There was no significant effect of severity or course of illness on performance. The findings support the hypothesis that impairments in executive function are present between illness episodes in bipolar disorder, and so they are not simply state markers.

Clinical profile of obsessive-compulsive disorder in children and adolescents: A multicentric study from India.

CONTEXT: Data from the Western countries suggest that obsessive-compulsive disorder (OCD) in children and adolescents is associated with male preponderance, comorbid neurodevelopmental disorders, and high family loading. However, data are limited from the developing countries with respect to the demographic and clinical characteristics of OCD in children and adolescents. AIMS: To study the demographic and clinical characteristics of children and adolescents (age ≤18 years) with OCD. SETTING AND DESIGN: This was a cross-sectional study, conducted in outpatient treatment setting, across six centers in India. MATERIALS AND METHODS: Participants were assessed using a semi-structured pro forma for sociodemographic information, clinical characteristics, the Children's Yale Brown Obsessive Compulsive Scale (CYBOCS), Structured Clinical Interview for Diagnostic and Statistical Manual, 5th Edition Research Version, Children's Depression Rating Scale, and Family Interview for Genetic Studies. RESULTS: The sample was largely male with a moderate illness severity. Nearly 75% of the sample had illness onset before the age of 14 years. Aggressive, contamination-related obsessions and washing, checking, and repeating compulsions were the most common symptoms. CYBOCS assessment revealed that >2/3rd of children and adolescents endorsed avoidance, pathological doubting, overvalued sense of responsibility, pervasive slowness, and indecisiveness. Family history and comorbidity rates were low. OC-related disorders were present in about 10% of the sample. CONCLUSIONS: This study suggests that the clinical characteristics of OCD in children and adolescents in developing countries differ on certain aspects as reported from developed countries.

Subdural Hygroma Following Endoscopic Third Ventriculostomy: Understanding the Pathophysiology.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has overtaken the use of a ventriculoperitoneal shunt for the treatment of congenital hydrocephalus. Although ETV is relatively safe, several postoperative complications have been reported. One of the least described and understood complications is subdural hygroma following third ventriculostomy. METHODS: In this series, we retrospectively analyzed patients who were managed for postventriculostomy subdural hygroma and analyzed the possible factors responsible for this condition. RESULTS: A total of 248 patients who underwent ETV between 2014 and 2016 were included in this study. Twelve patients (4.8%) had developed subdural hygroma, including 6 patients with bilateral hygroma, 2 with contralateral hygroma, and 4 with ipsilateral subdural hygroma. Only 4 patients (1.6%) were symptomatic, with complains of pseudomeningocele, persistent vomiting, or headache. Significant mass effect was present in 2 patients with unilateral subdural hygroma, which improved after placement of a subduroperitoneal shunt. In 1 patient, the subdural hygroma decreased with persistent ventriculomegaly and improved after ventriculoperitoneal shunt implantation. One patient with posttraumatic hydrocephalus who had a bilateral subdural hygroma following ETV improved with conservative management. At a 12-month follow-up, all patients remained asymptomatic. CONCLUSIONS: Post-ETV subdural hygroma may result from poor absorption of cerebrospinal fluid (CSF) in the subarachnoid space, dysfunction of the stoma with persistence of the ventriculosubdural fistula, or altered CSF cytology, such as hemorrhage. Most of these patients remain asymptomatic and improve with time. Symptomatic patients should be properly evaluated for the cause of the formation of subdural hygroma, which will guide the appropriate interventions.

Clinico-Radiological Outcome Analysis in Craniovertebral Junction Diseases: An Institutional Experience of 38 Patients in a Tertiary Care Centre.

BACKGROUND: Craniovertebral junction diseases, although considered rare, are common in northern parts of India. This study was conducted to evaluate the clinico-radiologic and surgical outcome of patients with a minimum follow-up of 1 year. Our study also compared bony fusion among various techniques of posterior fusion. METHODS: This retrospective study was performed with 38 patients who met the inclusion criteria for analysis. These patients were contacted by telephone and letters, and their clinical examination and radiologic investigations were performed at a follow-up visit. The preoperative, postoperative, and follow-up clinical evaluations of the patients were done using the Nurick grading system. RESULTS: The age range was 4-60 years with an average of 20.5 years. There were 31 male and 7 female patients, with a male:female ratio of 4.43:1. There were 13 cases of fixed atlantoaxial dislocation (AAD), 17 cases of mobile AAD, 6 cases of traumatic AAD, and 2 cases of postinfective AAD. The majority of these patients (n = 29; 76.31%) had neck pain and cerebellovestibular disturbances (n = 27; 71.1%). Sphincter disturbances were observed in 9 patients. An increase in craniovertebral angle was observed in postoperative period in all patients. Initially, 84% of the patients had a poor Nurick grade; this was reduced to 28% after the surgical intervention. One hundred percent bony fusion was attained in patients who underwent rigid fixation technique, and 80% was attained using a semirigid fixation technique. CONCLUSIONS: The key to successful management of craniovertebral junction disease is individualized selection of judicious surgical intervention from various available techniques.

Craniofacial Trauma in Pediatric Patients Following Winnowing Blade Injury-review of Literature.

In developing countries, during the harvest season, winnower blade injuries occur very frequently in children and results in lifelong disability. Nine children were managed during 1 month, all resulting due to winnower blade induced craniofacial trauma. PubMed search for "fan blade injury" showed two case series and three case reports. In our study, 88% had compound depressed fracture; brain matter leak in 56%, cerebrospinal fluid (CSF) leak alone in 22%. 66.7% had injury involving the frontal bone. Two patients had eye injury with visual loss. Seven underwent debridement craniectomy, five augmentation duroplasty and three contusectomy. All had vegetable material, sand particles. Complications in 66.6% with two cases of CSF leak settled with lumbar drain, one case of CSF otorrohea, 22.2% of wound infection, 44.4% wound dehiscence requiring redebridement and suturing in five patients. Two patients had postoperative seizures, two patients had hemiparesis both improved. Two low Glasgow Coma Scale remained so on postoperative period. One case of subdural empyema needed debridement and duroplasty with glue. No mortality noted. These findings were consistent with previous reports. Follow-up at 1.5 months showed good functional recovery. Early surgery debridement, steps to minimize postoperative infections, identifying putative risk factors early in the management are the principles of a successful treatment regimen.