Intraventricular Tumors: Surgical Considerations in Lateral and Third Ventricular Tumors.

Management of lateral and third ventricular tumors has been a challenge for neurosurgeons. Advances in imaging and pathology have helped in a better understanding of the treatment options. Technical refinement of microsurgical technique and addition of endoscopy has enabled more radical excision of tumors, when indicated, and added more safety.A proper understanding of the pathology at various ages and treatment options is continuously evolving. Many pediatric tumors are amenable to conservative surgical methods with effective complementary treatments. However, radical surgery is required in many adults as the main treatment and for many benign tumors. Various intraventricular lesions encountered and their surgical management is reviewed here for their efficacy, safety, and outcome, encompassing changes in our practice over the last 20 years.

Natural history of post-operative non-functioning pituitary adenomas - a single centre cohort analysis.

PURPOSE: To study behaviour of endonasally operated non-functioning pituitary adenomas (NFPA) and propose a cost-effective stratified follow-up regimen. METHODS: A single centre retrospective cohort analysis from June 2009 till December 2019. All endonasally operated pituitary adenomas were identified with sub-analysis of the NFPA's. Patients of all age groups with radiological follow-up more than 30 months were included. Patients with any kind of cranial intervention performed < within 30 months of surgery were excluded. The post-operative MRI for this cohort was evaluated until either any intervention was performed or until the last follow-up. The maximal tumour diameter in any plane (mm) was measured from the MRI scans. The annual growth rate and the statistical relationship between age, sex, IHC, Ki-67, resection %, residual tumour was calculated. RESULTS: Out of 610 pituitary adenomas identified in the dataset, 116 patients met the inclusion criteria. Follow-up period ranged from 30 to 142 months (mean 78.5 months). A strong relationship existed between predicting tumour progression with first post-operative residue size (p = .001). A statistically significant relationship was found to be present between tumour growth and a residue of less than 10 mm diameter and 11-20 mm in diameter (Log rank p value .0216). On average, each patient with a residue < 5mm had MRI scans costing 976 £. CONCLUSION: Based on statistical analysis and internal validation of the growth rate of the residue, we have proposed MRI follow-up scans. These recommendations have the potential to save more than 300 £per patient towards MRI costs and can lay down a marker for defining time interval of serial scans for post-operative NFPA's.

Accelerated Canine Retraction by Using Mini Implant With Low-Intensity Laser Therapy.

Background The continuous increase in demand for reduced treatment times has led researchers to think in terms of "accelerated orthodontics." Generally, the duration for fixed orthodontic treatment is around two to three years. Prolonged use of braces leads to external root resorption, a high risk of caries, and decreased patient compliance. Therefore, finding an optimal supplementary approach to achieve faster tooth movement is still considered a subject of interest. Low-intensity laser therapy (LILT) is one of the non-invasive surgical techniques in the field of accelerated orthodontics. Low-level laser therapy (LLLT) has demonstrated faster healing, less bleeding, and biostimulation and anti-inflammatory effects. According to all studies, it accelerates tooth movement, thereby reducing braces treatment time. It is simple, safe, and minimally invasive. Despite these pieces of evidence, studies have shown variable findings in low-level laser therapy. This study evaluates the effect of LLLT on accelerated orthodontics in comparison with conventional canine retraction. An aluminum gallium arsenide-type diode laser with a wavelength of 940 nm has been used in this study. Methodology This study was conducted using the split-mouth method, which included 20 patients with permanent dentition who required first premolar extractions. A miniscrew implant was placed on both the right and left sides for maximum anchorage. Irradiation doses were applied on days 0, 3, 7, and 14 of the first month. Subsequently, irradiations were given every 15 days until the canine's retraction was complete in the test group. Results The study results three months after the canine retraction in the test and control groups (M1) were 0.81 ± 0.03 mm/month and 0.74 ± 0.04 mm/month, respectively, indicating a significantly higher rate of canine retraction in the test group than in the control group (P < 0.0001). The average increase in the amount of tooth movement at three months was 40.1% and 36.3% in the test and control groups, respectively. However, the average increase in the amount of movement of teeth following canine retraction was 100% in the test group and 68.2% in the control group. There were significant variations in the pain score between Day 1 and Day 3 (P = 0.003) in the test group; however, there was no analytic variation in the pain score between Day 1 and Day 30 in the test group (P = 0.18). The pain score between Day 3 and Day 30 was significantly lower. Conclusions It was concluded that the rate of canine retraction increases when it is combined with LILT-assisted accelerated orthodontics in comparison to conventional canine retraction. Although LLLT does not provide immediate pain relief, it relieves the sensation of pain after 24-72 hours. LILT is an innovative, non-invasive technique that allows rapid orthodontic tooth movement. The rate of canine retraction increases when it is combined with LILT-assisted accelerated orthodontics in comparison to conventional canine retraction using mini-implants.

2H-Pyran-2-one-Functionalized Diketopyrrolopyrrole Dye: Design, Synthesis, and Explosives Sensor.

In this work, a 2H-pyran-2-one-functionalized diketopyrrolopyrrole (DPP) (coded as receptor 1) was designed, synthesized, and fully characterized by various spectroscopic methods. The physical properties of molecular architecture 1 were studied employing theoretical calculations. Receptor 1 was elegantly scrutinized for the sensing of explosive nitroaromatic compounds (NACs). Receptor 1 exhibited detection of nitro explosives, i.e., picric acid (PA), 2,4-dinitrophenol (DNP), and nitrophenol (NP), via the fluorescence quenching mechanism. The Stern-Volmer equation was employed to evaluate the effectiveness of the quenching process. It was found that 1 exhibited a detection limit of about 7.58 × 10-5, 8.35 × 10-5, and 9.05 × 10-5 M toward PA, DNP, and NP, respectively. The influence of interfering metal ions and anions on PA detection was investigated thoroughly. Furthermore, receptor 1-based low-cost fluorescent thin-layer chromatography (TLC) plates were developed for the recognition of PA.

Intracranial Myxoid Mesenchymal Tumour with EWSR1-ATF1 Fusion Sans Myxoid Stroma - Report of A Newer Entity with Brief Review of Literature.

Intracranial myxoid mesenchymal tumors (IMMTs) are a relatively new group of tumors, first described in 2017. We report this rare variant in a 27-year-old female which was initially suspected to be a high-grade glial neoplasm. Next-generation sequencing confirmed the presence of fusion between the FET and cAMP response element-binding (CREB) family of genes. This fusion is diagnostic of IMMT, with only 19 such cases reported so far. The authors would like to highlight the need for genomic sequencing for the diagnosis of this tumor, its propensity to recur locally, and its relatively better prognosis as compared to high-grade gliomas.

Intratumoral and Peritumoral Brain Abscess Concomitant with Glioblastoma: Report of Two Cases with Review of Literature.

Intracranial abscess coexistent with a high grade glioma, without prior surgical intervention, is an unusual occurrence. This paper presents two such cases with Nocardia farcinica abscess surrounding the glioblastoma in an immunocompromised individual and Enterococcus faecium abscess within the glioblastoma in an immunocompetent patient. Adjuvant therapy was tapered as per each patient's clinical response. Till date, only eight cases of coexistent high-grade glioma and brain abscess have been reported in literature. This report stands distinct in highlighting the need to radiologically evaluate each foci of a multicentric cranial lesion on its own merit.

An overview of biodegradable packaging in food industry.

For many years, conventional plastics are manufactured and used for packaging applications in different sectors. As the food industries are increasing, the demand for packaging material is also increasing. Plastics have transformed the food industry to higher levels; however, conventional petroleum-based plastics are non-degradable which has created severe ecological problems to the environment like a threat to aquatic life and degrading air quality. Biodegradable polymers or biopolymers emerged as an alternative approach for many industrial applications to control the risk caused by non-biodegradable plastic. According to the type of starting material, they have been categorized as polymers extracted from biomass, synthesized from monomers, and produced from microorganisms. The quality of biopolymers depends on the physical, mechanical, thermal, and barrier properties. The present review highlights the characteristics of various biopolymers and their blends, comparison of properties between non-biodegradable and biopolymers, the market potential for food packaging applications. The review also emphasizes different commercial forms like films, trays, bags, coatings, and foamed products for application as modified atmosphere packaging, active packaging, and edible packaging. Different issues affecting market growth like harmful products formed during production and consumer perception have also been discussed. Information on biopolymers is widely scattered over many sources, this article aims to provide an overview of biodegradable polymer packages for food applications.

Spinal Nerve Root Extradural Melanocytoma Progressing to Malignant Melanoma: A Case Report with Review of Literature.

Melanocytomas are rare benign pigmented tumors arising from the leptomeninges with a very remote chance of progressing to malignant melanoma. They have a predilection for occurring in the posterior fossa or in the intradural extramedullary region of the cervical spine. We report the first case of malignant transformation of a nerve root (extradural) melanocytoma wherein immunotherapy has been added for its treatment. Only four such cases of malignant transformation of central nervous system melanocytoma have been reported in the literature. Definite diagnosis in such cases is based on immunohistochemistry evaluation. Surgical resection with adjuvant radiotherapy and immunotherapy is the recommended treatment.

Recurrent Papillary Tumor of Pineal Region Misdiagnosed as Pineocytoma 9-Years Ago.

Primary tumors of the pineal gland occur infrequently with a preponderance of either parenchymal tumors or germ cells tumors. Papillary tumor of the pineal region is a rare neuroepithelial lesion that arises exclusively in the pineal region. They have been designated as either Grade II or Grade III lesions as per the 2016 WHO classification of central nervous system tumors. Clinically, they usually present with obstructive hydrocephalus and visual disturbance. On imaging, these tumors are solid-cystic, heterogeneously enhancing, and show T2 hyperintensity. Pathologically, they can closely resemble a Grade I pineocytoma and immunohistochemistry is essential to differentiate the two. No definite guidelines exist to confirm the ideal protocol of treatment. Evidence regarding the role of radiation after surgery is limited to case reports and series. Adjuvant therapy is usually recommended for tumors with subtotal excision, high proliferative/mitotic index, or proven metastasis. We describe a case of a 29-year-old male with a recurrent papillary tumor of the pineal region, 9 years after primary surgery where it was misdiagnosed as a pineocytoma. The tumor was effectively controlled with surgical excision, cerebrospinal fluid diversion, and adjuvant radiation for 8 years before showing two recurrences within a span of 6 months with a rising proliferation index.

Transnasal Endoscopic Surgery for Suprasellar Meningiomas.

AIM: Endoscopic trans-nasal surgery has evolved a long way from the days of narrow corridors with high rates of cerebrospinal fluid (CSF) leak to the present state of HD optics with better tissue differentiation, extended approaches, and use of vascularized flaps for defect closure. Trans-nasal approach is an established technique for pituitary tumors practiced worldwide. However, trans-nasal endoscopic excision of suprasellar meningiomas provides a tougher challenge in terms of instrument manipulation, tumor excision with good visual outcome, and a robust defect closure to prevent CSF leaks. MATERIALS AND METHODS: Out of 83 cases of midline anterior cranial fossa meningiomas operated over 14 years, our experience in 12 cases of suprasellar meningiomas for radical resection via the trans-nasal endoscopic route is discussed. RESULTS: Amongst these, six were excised via primary extended endoscopic trans-sphenoidal surgery, four cases had a residual lesion or recurrence after primary transcranial surgery, and two cases involved a combined transcranial and extended endoscopic approach. Visual improvement along with resolution of headache was seen in all patients postoperatively. None of the patients had CSF leak requiring further repair. Syndrome of inappropriate antidiuretic hormone was found in one patient, which was transient and easily corrected. CONCLUSION: Trans-nasal endoscopic surgery for suprasellar meningiomas is an effective technique that provides results of tumor excision comparable to the transcranial approach in suitable cases. Visual outcome was found to be superior, and rates of CSF leak were remarkably reduced with vascularized flap. However, each case must be assessed individually and lateral extension beyond the optic canals with internal carotid artery encasement must be considered before planning surgery.

Neuroendoscopy in the Surgical Management of Lateral and Third Ventricular Tumors: Looking Beyond Microneurosurgery.

BACKGROUND: Intraventricular tumors pose a surgical challenge because of the difficulty in reaching their deep location through safe corridors and their adherence or proximity to vital neurovascular structures. Although microneurosurgery is the mainstay of surgical management, neuroendoscopy aided by adjuncts, namely, navigation and ultrasonic aspirators, has made a great contribution to improving surgical results. OBJECTIVE: This article reviews the experience of a neurosurgical unit with endoscopic procedures for intraventricular tumors. The current indications, benefits, and complications of neuroendoscopy are described. MATERIALS AND METHODS: This is a retrospective, observational study of lateral and third ventricular tumors tackled either purely with an endoscope or with its assistance over 19 years in a single unit at Bombay Hospital Institute of Medical Sciences, Mumbai. RESULTS: Of a total of 247 operated patients with intraventricular tumors, 85 cases operated using an endoscope were included. The majority of the patients had a tumor in the third ventricle (n = 62), whereas 23 patients had tumor in the lateral ventricle. The most common pathologies were colloid cyst and arachnoid cyst (n = 18). An endoscope was used for microsurgical assisted excision of tumors in 31 cases, biopsy in 24, cyst fenestration in 23, and pure endoscopic excision in seven cases. CONCLUSION: Microsurgery remains the gold standard for the removal of giant, vascular intraventricular tumors. However, endoscopic fenestration or excision of cysts and biopsy have become better alternatives in many cases. Endoscope-assisted microsurgery affords safety and helps in achieving a more complete excision.

Extramedullary Hematopoiesis Presenting with Thoracic Spinal Cord Compression in a Young Adult with Thalassemia Major: A Case Report.

Background: Extramedullary hematopoiesis (EMH) refers to the production of blood cellular components at sites other than the bone marrow, namely liver, spleen, and lymph nodes. The common sites associated with this condition are the liver, spleen, and lymph nodes whereas the common conditions associated with it are myelofibrosis, myelodysplasia, thalassemia, sickle cell anemia, and polycythemia vera. Case Description: This report describes a young male with thalassemia major, who presented with symptomatic cord compression due to a thoracic intraspinal lesion. It was surgically excised and diagnosed as a case of EMH. The boy recovered fully and has been asymptomatic for six months now. Conclusion: The occurrence of EMH in the thoracic spine is uncommon, whereas symptomatic cord compression as a result of it is even more unusual. Magnetic resonance imaging (MRI) is the diagnostic imaging of choice and treatment options that can be offered are surgical decompression, radiotherapy, hydroxyurea, and transfusion of packed red blood cells (RBCs).

Giant extradural spinal schwannoma in a non-neurofibromatosis child-case report and review of literature.

Spinal schwannoma is a rare occurrence in non-neurofibromatosis (NF) pediatric patients, especially in the extradural space extending beyond two vertebral levels. Within this age group, the common extradural tumors are either soft tissue sarcomas or metastasis, often with vertebral bony involvement. Spinal schwannomas are usually benign, slowly progressive, well-defined, intradural extramedullary lesion showing homogenous contrast enhancement on imaging. Though its clinical presentation may be with marked neurological involvement, timely surgical excision usually leads to a quick recovery of the deficits in the young age.This case report describes a giant, spinal, benign schwannoma in a 6-year-old boy which was extradural in location. The lesion was resected completely, and since then, he has been asymptomatic, tumor-free for over 3 years.

Experience with Management of Intracranial Arachnoid Cysts.

OBJECTIVES: The aim of this study was to analyze the demographics, clinical presentation, and surgical outcome of intracranial arachnoid cysts and to review the surgical options. METHODS: This is a retrospective observational study of 56 cases of symptomatic arachnoid cysts among all age groups treated between 2004 and 2020 at the Bombay Hospital, Mumbai. Endoscopic fenestration, microsurgical cyst excision, and shunt insertion were the interventions performed. Clinical presentation, cyst reduction post-intervention, and complications were studied. The follow-up period varied from 1 month to 16 years. Statistical analysis was done for 43 patients with a minimum of 3 years' follow-up. RESULTS: In all, 75% of patients were <18 years of age. Of these, the majority were between the age of 1 and 10 years. There were 14 cases of temporal, 13 cases of retrocerebellar, 10 cases of quadrigeminal cistern, and 7 cases each of interhemispheric and suprasellar arachnoid cysts. The most common clinical presentation was headache and vomiting. Concomitant hydrocephalus was seen on imaging in 24 cases. Endoscopic fenestration of cyst was the most routinely performed procedure (35 cases). Four patients of endoscopic fenestration underwent a redo endoscopic procedure on follow-up. Post-operative reduction in cyst size was found to be significantly better after endoscopic fenestration (p < 0.05). CONCLUSION: Though the best available treatment for arachnoid cysts remains controversial, surgery has been found to be beneficial in symptomatic cases. Endoscopic fenestration is considered the first-line surgical option and it may be followed by shunt, if necessary. Shunts may be preferred in very young children where there is associated hydrocephalus/macrocephaly.

Scedosporium Apiospermum: Rare Cause of Brain Abscess in an Immunocompetent Patient.

Scedosporium apiospermum is a filamentous fungus causing a broad spectrum of clinical diseases especially in those who are immunocompromised. The common sites involved are lungs, skin, sinuses, eyes, bones, joints, and central nervous system (CNS). CNS is involved in invasive Scedosporiosis in the form of a cerebral abscess. An antecedent event of either near-drowning or history of some trauma is present in the majority of the cases where the patients' immune response remains intact. Prognosis is generally poor since the majority of the patients have coexistent medical morbidity. Surgical drainage followed by adjuvant antifungal, i.e., voriconazole therapy offers the best possible chance for survival in these patients. This case report discusses a rare event of brain abscess caused by S. apiospermum in an immunocompetent patient without any preceding precipitating factor.

Computed Tomography Evaluation of Craniovertebral Junction in Asymptomatic Central Rural Indian Population.

Objectives Craniovertebral junction (CVJ) is a unique, mobile and complicated component of our spine which necessitates specific study pertaining to its structure as well as pathologies. This study aims to report the normative data detailing the CVJ anatomy among the rural population of Central India which would help us in understanding the joint dynamics. Materials and Methods A retrospective observational study was undertaken in the Department of Neurosurgery and Radiology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Maharashtra, from December 2018 to May 2019. A total of 255 head injury patients with a normal CT brain cervical spine were included in this study. Anterior and posterior atlantodental interval (AADI/PADI), clivus length (CL), foramen magnum diameter (FMD), Boogard's and basal angle (BOO & BA) were measured and analyzed. Statistical Analysis Statistical analysis was done using Microsoft Excel 2016. A web-based, open source application known as OpenEpi.com (version 3.01) was used for applying unpaired t -test. Results This study had a mean age of 42.9 years. The difference in mean value of AADI between male and female population was not found to be statistically significant, while in case of PADI, CL, FMD, BOO and BA, it was found to be significant ( p < 0.05). On comparison of cases with age ≤ 20 years and > 20 years, we found the difference in values of ADI, CL and FMD to be statistically significant ( p < 0.05). Conclusion Although there are some similarities, namely, AADI measurements as compared with other studies, there are differences in cutoff values of other parameters. Being a major draining reference center for rural population in India, this data can be extrapolated to a similar population for reference.

Evolution of Pituitary Surgery.

Pituitary tumors may well be the most common brain tumors with a mean incidence of 16.7%. Even small tumors become symptomatic when they arise from functioning cells and produce devastating effects on the body. The nonfunctioning tumors may become quite large before producing symptoms due to raised intracranial pressure or mass effect on the surrounding structures, most commonly, the optic apparatus. Many of them remain asymptomatic through life. Evolution of pituitary surgery is testimony to the advances in diagnostic and surgical techniques in neurosurgery and improved understanding of 360° of surgical skullbase anatomy as well as the need to provide not only immediate good postoperative results but also a long-lasting relief. Despite considerable advances in medical treatment as well as focussed radiation techniques, surgery remains the primary treatment in many of these tumors. Visual improvement, hormonal cure, avoidance of hypopituitarism, and neurological deficit remain immediate goals of surgery. Long-term cure or remission may require a multidisciplinary approach.

Customized Low-Cost Model for Hands-on Training in Intraoperative Ultrasound for Neurosurgeons: Our Experience and Review of Literature.

BACKGROUND: Practical ultrasound (US) training is essential to overcome operator dependence and optimize image acquisition. For intraoperative neurosurgical application, in addition to hand-eye coordination, ultrasound training should incorporate training for visuomotor and visuospatial skills, as well as 3-dimensional depth orientation. Our agar-based, low-cost model has been developed keeping these skill sets in mind. MATERIALS AND METHODS: We have described preparation of an agar-based, low-cost customizable model using commonly available echogenic objects as targets, which allows the clinician to perform various training tasks like depth insonation, target localization, and biopsy and resection cavity insonation. This low-cost model was implemented for internal training and validated at an international training course. RESULTS: The cost of the model was 4 USD, and its preparation time was <1 hour. It can be used for performing multiple US training tasks and provides realistic images and good tactile feedback. However, the model is perishable and artifacts are occasionally visible. Feedback survey results showed that >80% of participants felt the model was useful for US training. CONCLUSIONS: Our customizable low-cost US training model is an effective and efficient tool for US training with high acceptance by neurosurgeons. It faithfully mimics various intraoperative tasks and helps clinicians gain confidence to use intraoperative ultrasound as an adjunct during the procedures. This model can be used by individual surgeons/departments for ongoing training, as well as for larger training courses and workshops.

Navigated intraoperative ultrasonography for brain tumors: a pictorial essay on the technique, its utility, and its benefits in neuro-oncology.

Intraoperative imaging has become one of the most important adjuncts in neurosurgery, especially in the surgical treatment of intra-axial tumors. Navigation and intraoperative magnetic resonance imaging have limitations, and intraoperative ultrasonography (IOUS) has emerged as a versatile and multifaceted alternative. With technological advances in ultrasound scanners and newer multifunctional probes, the potential of IOUS is increasingly being utilized in the resection of tumors. The addition of image guidance to IOUS has exponentially increased the power of this technique. Navigated ultrasonography (nUS) can now overcome many of the limitations of conventional standalone two-dimensional ultrasonography. In this pictorial essay, we outline our nUS technique (both two- and three-dimensional) for the resection of intra-axial tumors with illustrated examples highlighting the various steps and corresponding benefits of the technique.