Hump on head: Rare case of bi-frontal fibrous dysplasia.

Background: FD is relatively rare in the craniofacial region, accounting for only 20% of all cases. Currently, two general subtypes of FD are recognized: monostotic and polyostotic. The monostotic form is more frequent, accounting for 75% to 80% of fibrous dysplasia cases. Case Description: An 18-year-old male presented with the complaint of bony-hard swelling over the forehead for 8 years. Radiology showed an expansile osseous lesion involving frontal bones. The patient underwent bi-frontal craniectomy with gross total resection of tumour mass with titanium mesh cranioplasty. His postoperative period was uneventful and was discharged on the seventh postoperative day. Conclusion: The cases of monostotic skull fibrous dysplasia should be treated by resection of the affected bone and cranioplasty. However, a more conservative re-contouring may be carried out in cases with multifocal involvement or when the excision is considered risky due to proximity to the major venous sinuses.

Supraorbital vs pterional keyhole for anterior circulation aneurysms: A systematic review and meta-analysis.

Background: The supraorbital approach is a modification of the traditional pterional approach, and it offers the benefits of a shorter skin incision and a smaller craniotomy than the pterional approach. The purpose of this systemic review study was to compare the two surgical approaches for raptured and unruptured anterior cerebral circulation aneurysms. Methods: We searched PubMed, EMBASE, Cochrane Library, SCOPUS, and MEDLINE, up to August 2021, for published studies on the supraorbital vs pterional keyhole approach for anterior cerebral circulation aneurysms, and reviewers performed a brief qualitative descriptive analysis of both approaches. Results: Fourteen eligible studies were included in this systemic review. Results indicated that the supraorbital approach for anterior cerebral circulation aneurysms had fewer ischemic events compared to pterional approach. However, no significant difference between both groups in terms of complications such as intraoperative aneurysm rupture, brain hematoma, and postoperative infections for ruptured aneurysms. Conclusion: The meta-analysis suggests that the supraorbital method for clipping anterior cerebral circulation aneurysms might be a viable alternative to the traditional pterional method as the supraorbital group had decreased ischemic events compared to the pterional group, however, the associated difficulties in utilizing this approach among ruptured aneurysms with cerebral oedema and midline shifts further needs to be understood.

Giant Tarlov Cyst presenting as pelvic mass: Often doing less is better.

Background: Tarlov cysts are sacral perineural cysts arising between the peri and endoneurium of the posterior spinal nerve root at the Dorsal Root Ganglion and have a global prevalence rate of 4.27%. These are primarily asymptomatic (only 1% with symptoms) and typically arise in females between the ages of 50-60. Patients' symptoms include radicular pain, sensory dysesthesias, urinary and/or bowel symptoms, and sexual dysfunction. Non-surgical management with lumbar cerebrospinal fluid drainage and computerized tomography-guided cyst aspiration typically provide only months of improvement before recurring. Surgical treatment includes a laminectomy, cyst, and/or nerve root decompression with fenestration of the cyst and/ or imbrication. Early surgery for large cysts provides the longest symptom-free periods. Case Description: A 30-year-old male presented with a very large magnetic resonance-documented Tarlov cyst (Nabors Type 2) arising from bilateral S2 nerve root sheaths with marked pelvic extension. Although he was initially treated with a S1, S2 laminectomy, closure of the dural defect, and excision/marsupialization of the cyst, he later required placement of a thecoperitoneal shunt (TP shunt). Conclusion: A 30-year-old male with large Nabors Type 2 Tarlov cyst arising from both S2 nerve root sheaths required a S1-S2 laminectomy, dural closure/marsupialization, and imbrication of the cyst, eventually followed by placement of a TP shunt.

'White Cord Syndrome': A Rare Catastrophic Complication Following Anterior Cervical Discectomy and Fusion.

Background: 'White-cord syndrome' is an extremely rare entity following decompression of cervical cord in which post-operative reperfusion injury results in worsening of patient's neurology and MRI reveals signal changes in spinal cord in absence of cord compression. We wish to report a case of 'white-cord syndrome' following a 'routine' ACDF. Case Description: A 39-year-old woman with paresthesias and spastic quadriparesis was found to have C5-C6 PIVD on MRI. ACDF was performed at C5-C6, after which worsening of quadriparesis was noted, for which intravenous high-dose steroids were started. An urgent MRI was done, which revealed findings of white-cord syndrome, without compression on underlying cord. With conservative management, her ASIA grade improved from C to D and the features of white-cord syndrome disappeared on follow-up imaging. Conclusion: It is important for surgeons and patients to be aware of this rare but potentially catastrophic entity as this needs to be discussed while taking consent for surgery.

Real-world application, challenges and implication of artificial intelligence in healthcare: an essay.

This essay examines the state of Artificial Intelligence (AI) based technology applications in healthcare and the impact they have on the industry. This study comprised a detailed review of the literature and analyzed real-world examples of AI applications in healthcare. The findings show that major hospitals use AI-based technology to enhance knowledge and skills of their healthcare professionals for patient diagnosis and treatment. AI systems have also been shown to improve the efficiency and management of hospitals´ nursing and managerial functions. Healthcare providers are positively accepting AI in multiple arenas. However, its applications offer both the utopian (new opportunities) as well as the dystopian (challenges). Unlike pessimists, AI should not be seen a potential source of "Digital Dictatorship" in future of 22nd century. To provide a balanced view on the potential and challenges of AI in healthcare, we discuss these details. It is evident that AI and related technologies are rapidly evolving and will allow care providers to create new value for patients and improve their operational efficiency. Effective AI applications will require planning and strategies that transform both the care service and the operations in order to reap the benefits.

Neuroplasticity in Depression: A Narrative Review with Evidence-Based Insights.

Major Depressive Disorder (MDD) is one of the leading causes of disability worldwide. The current pharmacological treatment options for MDD, which rely on the mono-amine hypothesis, has their limitations with respect to treatment non-response, partial response etc. This propels for a search for a novel neurobiological understanding of MDD that can lead to novel treatment options. A literature search strategy was thus employed using relevant keywords pertaining to the topic in PubMed, Embase and Google Scholar. Systematic reviews and meta-analyses, narrative reviews and clinical trials were reviewed to incorporate the most robust evidence-based literature available. A total of 37 publications were narrowed down based upon the topic. Alterations in brain neuroplasticity, as evidenced by changes in neurotrophic factors and from neuroimaging, has been found to be a strong patho-mechanism for MDD. This link has been exploited to stimulate psychopharmacological research to treat MDD.

Basal Cisternostomy in Head Injury: More Questions than Answers.

Background: Cisternostomy has recently been reintroduced in the setting of severe TBI as an adjuvant surgical technique for decreasing brain edema and refractory intracranial hypertension. However, there is not much clarity regarding its role in head injury. Objective: Study the effect of cisternostomy on intracranial pressure, morbidity, and mortality in head-injured patients. Material and Methods: We conducted a single-center quasi-experimental study between November 2018 and November 2020. All candidates for decompressive hemicraniectomy (DHC) were divided into two groups: DHC-BC (undergoing basal cisternostomy with DHC) and DHC (undergoing DHC alone). We compared the impact of surgery on decreasing ICP and clinical outcomes in both groups. Results: During the study duration, we admitted 659 head-injury patients. Forty patients were included in the study (9 in the DHC-BC group and 31 in the DHC group). Both the groups were comparable in terms of baseline clinical characteristics such as age, gender, preoperative GCS, head injury severity, radiological features, and opening ICP. Patients in both groups had a decline in ICP following surgery. The mean closing pressure in the DHC-BC group (11.3 ± 5.9) was significantly higher than that in the DHC group (5.3 ± 3.5) (P = 0.003). The mean drop in ICP in the DHC-BC group was 14.4 ± 11.5 while that in the DHC group was 18.9 ± 12.4 (P = 0.359). The average total number of hours of ICP >20 mm Hg and intracranial hypertension index were higher for the DHC-BC group. The average number of days of stay in the ICU and hospital were lower for the DHC-BC group (7.0 ± 6.1 and 15.0 ± 20.2, respectively) compared to the DHC group (10.6 ± 9.3 and 19.3 ± 13.9, respectively). The 30-day mortality rate was higher for the DHC-BC group (66.6%) than the DHC group (32.2%). The mean GCS at discharge was better in the DHC-BC group (11.7 ± 2.9) compared to 10.5 ± 3.7 in the DHC group, while 11.1% of patients in the DHC-BC group had a favorable outcome (1-month GOS-E) compared to 9.7% patients in the DHC group. Conclusions: Our preliminary single-center study failed to show a clear benefit of adding basal cisternostomy to decompressive hemicraniectomy in patients with head injuries.

Endovascular management of iatrogenic vertebro-vertebral fistula: Black Swan event in C2 pedicle screw.

Background: Vertebro-vertebral fistulas (VVF) are rare. Anatomically, they consist of an arteriovenous fistula, a direct pathological communication between vertebral veins (including the epidural vertebral venous plexus) and extradural vertebral artery. The various etiologies include trauma, iatrogenic, or spontaneous (e.g., NF-1 or Ehlers Danlos Syndrome). The clinical presentation may include acute/delayed onset of radiculopathy and/or myelopathy. They may further be characterized by the delayed onset hearing loss to tinnitus and/or the sensation of water in the ear. Case Description: We report successful endovascular management for iatrogenic VVF in a 37-year-old female who was diagnosed with an odontoid fracture (Anderson type IIC). She underwent a posterior C1 lateral masses to C2 pedicle/laminar screw fixation. An intraoperative vertebro-vertebral fistulas (VVF) was recognized during the procedure and it was managed successfully with percutaneous transarterial endovascular coiling. Conclusion: Iatrogenic VVF should immediately be suspected when the implant trajectory goes slightly off track during a C1-2 fixation. Immediate postoperative DSA and MRI are advisable, irrespective of whether the patient is symptomatic. These lesions are best managed with endovascular coiling with or without detachable balloons.

Surgical Outcome of Large Solid Posterior Fossa Hemangioblastoma without Preoperative Embolization.

BACKGROUND: Large solid hemangioblastoma in the posterior fossa has an abundant blood supply as an arteriovenous malformation. The presence of adjacent vital neurovascular structures makes them vulnerable and difficult to operate. Complete surgical resection is always a challenge to the neurosurgeon. MATERIAL AND METHOD: We share the surgical difficulties and outcome in this case series of large solid hemangioblastomas without preoperative embolization as an adjunct. This study included five patients (three men and two women, with a mean age of 42.2 years). Preoperative embolization was attempted in one patient but was unsuccessful. All the patients have headache (100%) and ataxia (100%) as an initial symptom. A ventriculoperitoneal shunt was inserted in one case before definite surgery due to obstructive hydrocephalus. The surgical outcome was measured using the Karnofsky Performance Status (KPS) score. RESULT: The tumor was excised completely in all the cases. No intra- and postoperative morbidity occurred in four patients; one patient developed transient lower cranial nerve palsy. Mean blood loss was 235 mL, and no intraoperative blood transfusion was needed in any case. The mean follow-up period was 14.2 months. The mean KPS score at last follow-up was 80.One patient had a KPS score of 60. CONCLUSION: Our treatment strategy is of circumferential dissection followed by en bloc excision, which is the optimal treatment of large solid hemangioblastoma. The use of adjuncts as color duplex sonography and indocyanine green video angiography may help complete tumor excision with a lesser risk of complication. Preoperative embolization may not be needed to resect large solid posterior fossa hemangioblastoma, including those at the cerebellopontine angle location.

Getting Neurosurgery Services Back on Its Feet: "Learning to Live" with COVID-19.

BACKGROUND: Cancellation/postponement of "non-emergent" surgeries during coronavirus disease of 2019 (COVID-19) pandemic has created a huge backlog of patients waiting for surgery and has put them at risk of disease progression. We share our institute's policy and our department's attempt to resume "non-emergent" surgeries. MATERIALS AND METHODS: We collected details of all patients operated under department of neurosurgery since the onset of COVID-19 pandemic in India and categorized them into "lockdown" and "unlock" groups for comparison. COVID-19 tests done in these patients were also analyzed. We also compared our surgical volume with the number of COVID-19 cases in the state. RESULTS: One hundred and forty-eight patients (97 males, 51 females) with mean age of 37.8 years (range-2 months-82 years) underwent surgery in our department during the study period. The operative volume per week increased by 37% during the "unlock" period as compared to "lockdown" period. The proportion of elective/"non-emergent" surgeries increased from 11.3% during "lockdown" to 34.7% during the "unlock" period (P = 0.0037). During "lockdown" period, number of surgeries declined steadily as the number of COVID-19 cases rose in the state (rs(8) = -0.914, P = 0.000). Whereas there was a trend toward increased number of cases done per week despite increase in the number of cases in the state during the "unlock" period. During the "unlocking" process, in-patient department admissions and surgeries performed per month increased (P = 0.0000) and this increase was uniform across all specialties. COVID-19 test was done (preoperatively or postoperatively) for all surgeries during "unlock" period compared to 12 (22.6%) surgeries during "lockdown" period. Three neurosurgery patients who underwent surgery during the "unlock" period tested positive for COVID-19. CONCLUSIONS: Our experience shows that proper evidence-based protocols, setting up of adequate COVID-19 testing facilities and provision of ample personal protective equipments are instrumental in re-starting "nonemergent" surgeries.

A Systematic Review on the Impact of the COVID-19 Pandemic on Neurosurgical Practice and Indian Perspective.

OBJECTIVE: The study objective was to systematically review the impact of the current pandemic on neurosurgical practice and to find out a safe way of practicing neurosurgery amid the highly infectious patients with COVID-19. MATERIALS AND METHODS: A review of the PubMed and EMBASE databases was performed. The literature was systematically searched using keywords such as "COVID-19" and "Neurosurgery." RESULTS: Among the 425 records, 128 articles were found to be eligible for analysis. These articles described the perspectives of the neurosurgical departments during the pandemic, departmental models, and organizational schemes for triaging emergent and nonemergent neurosurgical cases for the optimal utilization of limited resources, and solutions to continue academic and research activities. Triaging systems help us to optimally utilize the limited resources available. Guidelines have been developed for safe neurosurgical practice and for the continuation of clinical and academic activities during this pandemic by various national and international neurosurgical societies. Key changes in the telemedicine regulatory guidelines would help us to continue to provide neurosurgical care. Videoconferences, online education programs, and webinars could help us to overcome the disadvantages brought upon the neurosurgical education by the social-distancing norms. CONCLUSION: In an unprecedented time like this, no single algorithm is going to clear the ethical dilemma faced by us. Individual patient triage is a way for maintaining our ethical practice and at the same time, for efficiently utilizing the limited resources. As the pandemic progresses, new guidelines and protocols will continue to evolve for better neurosurgical practice.

Effects of Health Promotion Model-Based Visual Learning Module on Self-Efficacy and Health Promotion Behavior of Stroke Survivors: A Nonrandomized Controlled Trial.

Background and Objectives Globally, stroke is one of the major causes of disability and mortality among adults and old age people. The present study aims to evaluate the effects of the health promotion model-based visual learning module (HPM-VLM) on self-efficacy and behavioral modifications among stroke survivors. Methods This nonrandomized controlled trial was conducted on 70 stroke survivors (intervention group, n = 35, and control group, n = 35). The intervention group was subjected to two sessions of the HPM-VLM and the control group received routine instructions. Data were collected through face-to-face structured interview, and observation using a self-structured self-efficacy questionnaire and health promotion behavior questionnaire. Data were analyzed using descriptive (frequency and percentage) and inferential (Chi-square, independent t -test, mixed model, and ANCOVA) values by IBM Statistical Package for Social Sciences (SPSS; version 23) software. Results Eventually, follow-up could have been completed for 66 participants (intervention group, n = 34, and control group, n = 32). HPM-VLM is found to be effective in the promotion of self-efficacy (19.2 ± 1.6 vs. 16.12 ± 2.5; p = 001) and health promotion behavior of stroke survivors in most of the domains ( p < 0.01). Conclusion HPM-VLM is an effective interventional tool for the promotion of self-efficacy and health promotion behavior of stroke survivors.

Coma recovery scale: Key clinical tool ignored enough in disorders of consciousness.

BACKGROUND: Disorders of consciousness (DoC) includes coma, vegetative state (VS), minimally conscious state (MCS), and emergence from the MCS. Aneurysmal rupture with high-grade SAH, traumatic brain injury, and neoplastic brain lesions are some of the frequent pathologies leading to DoC. The diagnostic errors among these DoC are as high as ranging from 25% to 45%, with a probable error in the conclusion of patients' state, treatment choice, end-of-life decision-making, and prognosis. Some studies also reported that 37-43% of patients were misdiagnosed in VS while demonstrating signs of awareness. Despite its wide acceptance, Coma Recovery Scale-Revised (CRS-r) remained underused or inappropriately utilized, which may lead to substandard or unprofessional patient care. Literature is rare on the knowledge of CRS-r among physicians published from India and across the globe. Therefore, we carried out the present study to ascertain physicians' knowledge on CRS-r and raise awareness about its justifiable clinical utilization. We also explored the factors associated with this perceived level of experience among participants and recommend frequent physicians' training for care of patients with DoC. METHODS: An institution-based cross-sectional online survey was conducted from June 8 to July 7, 2020, among Ninety-six physicians recruited using a convenient sampling technique. Twenty-item, validated, reliable, and a pilot-tested questionnaire was used to assess the knowledge regarding CRS-r and collect socio-demographic variables. The analysis was performed using the Statistical Package for the Social Sciences version 23. Bivariate and multivariate logistic regression analyses were employed to assess the association of participants' socio-demographic variables and their parent department of work with the knowledge. P < 0.05 was considered statistically significant in the multivariate analysis. RESULTS: A total of Ninety-six participants were included in the analysis, and only 33.3% of them were found to have adequate knowledge of CRS-r. Multivariate analysis revealed that age (adjusted odds ratio [AOR] = 31.66; 95% CI: 6.25-160.36), gender (AOR = 44.16; 95% CI: 7.43-268.23), and parent department of working (AOR = 0.148; 95% CI: 0.06-0.39) were significantly associated with the knowledge. CONCLUSION: Knowledge of the physicians on CRS-r is found to be exceptionally low. It has a strong tendency to adversely affect patients' optimal care with disorders of consciousness (DoC). Therefore, it is crucial to expand physicians' knowledge and awareness regarding CRS-r to adequately screen patients with DoC.

Cervical Osteoma in Hereditary Multiple Exostoses.

Osteoid osteoma is a benign bony pathology. It presents either as a solitary lesion or as multiple lesions with a genetic predisposition. Reported more often in teenagers with thrice more common incidence among boys than in girls, it has a predilection for long bones of lower limbs. Less commonly arising from iliac crest or ribs; it is seen to be further rare to have originated from vertebrae or tarsal/carpal bones. Cranial osteomas are detected either incidentally on imaging or present as a bony hard swelling arising from the skull. Spinal intracanal osteomas are extremely rare to encounter in clinical practice. Cervical intracanal lesion in a case of hereditary multiple exostoses (HME) presenting with myelopathy is further rare. Less than thirty such cases have been reported so far. We present here a rare case of HME in a 16-year-old boy with compressive myelopathy secondary to intracanal cervical osteoma at C4 Lamina and spinous process. He had a phenotypical expression of hereditary multiple osteomas with a strong family history of inheritance of trait among first-degree male relatives favoring genetic transmission of disease with variable penetrance. All reported cases, to date, are discussed in a tabulated form.

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.