Enhancing microsurgical skills in neurosurgery residents of low-income countries: A comprehensive guide.

Background: The main objectives of this paper are to outline the essential tools, instruments, and equipment needed to set up a functional microsurgery laboratory that is affordable for low-income hospitals and to identify cost-effective alternatives for acquiring microsurgical equipment, such as refurbished or donated instruments, collaborating with medical device manufacturers for discounted rates, or exploring local suppliers. Methods: Step-by-step instructions were provided on setting up the microsurgery laboratory, including recommendations for the layout, ergonomic considerations, lighting, and sterilization processes while ensuring cost-effectiveness, as well as comprehensive training protocols and a curriculum specifically tailored to enhance microsurgical skills in neurosurgery residents. Results: We explored cost-effective options for obtaining microsurgery simulators and utilizing open-source or low-cost virtual training platforms. We also included guidelines for regular equipment maintenance, instrument sterilization, and establishing protocols for infection control to ensure a safe and hygienic learning environment. To foster collaboration between low-income hospitals and external organizations or institutions that can provide support, resources, or mentorship, this paper shows strategies for networking, knowledge exchange, and establishing partnerships to enhance microsurgical training opportunities further. We evaluated the impact and effectiveness of the low-cost microsurgery laboratory by assessing the impact and effectiveness of the established microsurgery laboratory in improving the microsurgical skills of neurosurgery residents. About microsutures and microanastomosis, after three weeks of training, residents showed improvement in "surgical time" for ten separate simple stitches (30.06 vs. 8.65 min) and ten continuous single stitches (19.84 vs. 6.51 min). Similarly, there was an increase in the "good quality" of the stitches and the suture pattern from 36.36% to 63.63%. Conclusion: By achieving these objectives, this guide aims to empower low-income hospitals and neurosurgery residents with the necessary resources and knowledge to establish and operate an affordable microsurgery laboratory, ultimately enhancing the quality of microsurgical training and patient care in low-income countries.

Combined Exoscopic- and Endoscopic-Assisted Resection of an Interpeduncular and Middle Fossa Epidermoid Cyst via a Transcavernous Approach: Technical Note.

OBJECTIVE: The endoscope and exoscope are gaining momentum as alternative visualization tools in the neurosurgical field, trying to overcome the limitations of an operative microscope and support minimally invasive approaches. However, few case series are available in the literature regarding their use in skull base surgery, especially in combined assisted resection, and their usefulness still needs to be proved. METHODS: An illustrative case to present the feasibility and minimally invasive advantages of a combined exoscopic- and endoscopic-assisted resection is reported. RESULTS: A 22-year-old man presented with a history of seizures and dizziness. Brain imaging showed a lesion involving the anteromedial middle fossa invading the interpeduncular cistern and impinging the brainstem, suggestive of an epidermoid cyst. A combined exoscopic- and endoscopic-assisted resection through a pterional transcavernous approach was planned and performed. No neurologic deficit occurred after the surgery, providing further evidence about the usefulness and safety of this hybrid technique. CONCLUSIONS: Combined exoscopic and endoscopic resection is also feasible and safe in complex skull base surgery. Moreover, this technique seems to be effective for minimizing the surgical invasiveness in skull base lesions.

Lumbar dermoid cysts: 3 illustrative cases and a total review of the literature of the last two decades / Quistes dermoides lumbares: 3 casos ilustrativos y revisión completa de la literatura en las últimas 2 décadas

Spinal dermoid cysts are relatively infrequent tumors generally associated with a benign course. Here we describe three cases and analyzed the 109 cases of lumbar dermal cysts described in the literature in the last 20 years. We report a pediatric patient with a dermoid cyst posterior to a lumbar surgery for myelomeningocele repair with bad evolution; and two adult patients with the affection of the motor and autonomic function with good surgical outcomes. In approximately half of the reviewed cases, it was reported at least one complication. In fact, two cases had a fatal outcome. We discuss relevant characteristics of these lesions and those aspects probably associated with complications and bad outcomes (AU)

Los quistes dermoides espinales son tumores relativamente infrecuentes, generalmente asociados con un curso benigno. Aquí describimos 3 casos y analizamos los 109 casos de quistes dermoides lumbares descritos en la literatura en los últimos 20 años. Nosotros reportamos un paciente pediátrico quien presentó un quiste dermoide secundario a una cirugía de reparación de mielomeningocele con mala evolución; y 2 pacientes adultos con decremento de la fuerza en las extremidades y afección autonómica con buenos resultados posquirúrgicos. En la revisión de la literatura es destacable que en aproximadamente la mitad de los casos se informó al menos una complicación. Incluso, se reportaron 2 defunciones. Se discuten aquí las características relevantes de estas lesiones y aquellos aspectos probablemente asociados con complicaciones y mala evolució (AU)

Lumbar dermoid cysts: 3 illustrative cases and a total review of the literature of the last two decades.

Spinal dermoid cysts are relatively infrequent tumors generally associated with a benign course. Here we describe three cases and analyzed the 109 cases of lumbar dermal cysts described in the literature in the last 20 years. We report a pediatric patient with a dermoid cyst posterior to a lumbar surgery for myelomeningocele repair with bad evolution; and two adult patients with the affection of the motor and autonomic function with good surgical outcomes. In approximately half of the reviewed cases, it was reported at least one complication. In fact, two cases had a fatal outcome. We discuss relevant characteristics of these lesions and those aspects probably associated with complications and bad outcomes.

Management and outcomes following emergency surgery for traumatic brain injury - A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study).

INTRODUCTION: Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. METHODS AND ANALYSIS: The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. ETHICS AND DISSEMINATION: This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.

Cisternostomy: A Timely Intervention in Moderate to Severe Traumatic Brain Injuries: Rationale, Indications, and Prospects.

Traumatic brain injury (TBI) represents a major public health concern worldwide, with no significant change in its epidemiology over the last 30 years. After TBI, the primary injury induces irreversible brain damage, which is untreatable. The subsequent secondary injury plays a critical role in the clinical prognosis because without effective treatment it will provide additional tissue damage. The resulting scenario is the rise in intracranial pressure (ICP) with the development of progressive neurological deficits. Current optimal management is based on a progressive, target-driven approach combining both medical and surgical treatment strategies among which is decompressive hemicraniectomy. With the advent of technology, research in the glymphatic pathways, and advances in microscopic surgery, a novel surgical technique-the cisternostomy-has emerged that holds promise in managing rising ICP in TBI-affected patients. In this article we describe the rationale for cisternostomy, an emerging microneurosurgical approach for the management of moderate to severe TBI.

Cerebral Venous Thrombosis at High Altitude: A Retrospective Cohort of Twenty-one Consecutive Patients.

Background  Cerebral venous thrombosis (CVT) is a rare cerebrovascular disorder, comprising <1% of all strokes. The incidence of CVT is higher in females but a small number of cases suggest that men have a higher risk for CVT in high elevation. The aim of this retrospective cohort study is to investigate this gender-related relationship and to describe the baseline characteristics and treatment outcomes of patients who suffered CVT at high altitude in eastern Nepal. Methods  We conducted a retrospective analysis of 21 consecutive patients with CVT at a tertiary care center in Nepal from July 2017 to January 2018. Clinical data, radiologic characteristics, therapeutic strategies, and outcomes were analyzed. The Glasgow Outcome Scale (GOS) at discharge was reported for each patient.  Result The study cohort comprised 21 patients (76% males) with a mean of 56 years. Medical comorbidities included hypertension (76%) and diabetes mellitus (57%). All patients received low-molecular-weight heparin therapy (LMWH). Eight patients (38%) underwent decompressive craniectomy while the remaining 13 (62%) were treated with medical therapy alone. The GOS at discharge was 5 in 57%, 2-4 in 33%, and 1 in 10%. Conclusion  In our series, men were found to have a higher risk for CVT at high altitude. The reversal in the gender ratio could be related to elevation, but could also be confounded by alcoholism. Increasingly sophisticated imaging techniques, such as computed tomography venography (CTV) and magnetic resonance venography (MRV), have facilitated the diagnosis of CVT. LMWH is a safe and easily accessible treatment option, especially in developing countries. Further studies are needed to assess the incidence and prevalence of CVT in the developing world, to establish the gender-related trends.

Case Report: Levetiracetam causing acute liver failure complicating post-operative management in a neurosurgical patient.

Background: Herein we report a rare case of acute liver failure due to levetiracetam, which has been considered to have an excellent safety profile with minimal hepatic side effects. Case presentation: A 55-year-old male patient presenting with sudden onset dizziness, slurring of speech and headache was operated for posterior fossa cerebellar hematoma. His post-surgical period was complicated by development of icterus with elevation of liver enzymes. After ruling out common inciting factors, it was decided to stop levetiracetam which was given prophylactically for preventing seizures owing to presence of external ventricular drain. From the next day patient had dramatic improvement in liver functions and sensorium. Conclusions: We would like to highlight this side effect that is potentially life threatening, though rare, of levetiracetam, which is very commonly used in today's practice and fast superseding all other time-tested antiepileptics.

Technique of Posterior Clinoidectomy and Its Applications.

An understanding of the microsurgical anatomy of posterior clinoid process (PCP) is extremely important to where the removal of PCP is required to access the interpeduncular and prepontine cisterns and upper basilar artery region to manage the aneurysms located in this region. In the present article, we describe our experience with a technique that is safe and provides ample space to look into these regions. The key to safe drilling is that the drilling of the posterior clinoid needs to be performed in a "touch and back" manner (rather than clockwise or counterclockwise motion) to break the cortex.

The Orbitomeningeal Band as a Way to Bloodless Transcavernous Dissection and Anterior Clinoidectomy.

The meningo-orbital band (MOB) is a dural fold which runs along the lateral border of the superior orbital fissure and contains few small dural veins and the orbitomeningeal artery. MOB detachment is relatively easy to understand step-wise procedure, provides a wider exposure, and better orientation thus facilitating relatively easy approach to paraclinoid and cavernous sinus region. The present microsurgical technique helps to preserve the true cavernous membrane and thereby providing almost bloodless dissection of the cavernous sinus. The same technique can be used to uncover the anterior clinoid process laterally, posteriorly, superiorly, and also in the inferolateral region thereby decreasing the risk and time of clinoidectomy.

Current Perspectives in the Surgical Treatment of Severe Traumatic Brain Injury.

BACKGROUND: The available surgical options to control increased intracranial pressure and to limit secondary brain damage in the setting of severe traumatic brain injury (TBI) include decompressive craniectomy, cisternostomy, and other methods to divert cerebrospinal fluid (CSF) such as placement of an external ventricular drain. METHODS: We discuss the rationale and the limitations of these surgical techniques based on preclinical and clinical evidence. A detailed description of the differences between ventricular CSF drainage and cisternal drainage is added based on recent hypotheses on TBI physiopathology and CSF circulation. RESULTS: Cisternostomy seems a more physiological approach to the treatment of brain swelling, with the potential of effectively controlling intracranial pressure and reducing the effects of secondary brain damage. CONCLUSIONS: Further clinical studies need to be performed to validate the efficacy of this emerging surgical procedure for severe TBI.

Posttraumatic Cervicovertebral Junction Acute Subdural Hematoma and Cisterna Magna Subarachnoid Hemorrhage Presenting with Progressive Hydrocephalus.

Herein, we discuss a rare case of posttraumatic cervicovertebral junction subdural hematoma and associated cisterna magna subarachnoid hemorrhage. Due to progression in the hydrocephalus, he has undergone midline suboccipital craniectomy and evacuation of the hematoma. The patient made an uneventful recovery.

Medical and surgical management of acute spinal injury during pregnancy: A case series in a third-world country.

BACKGROUND: There is scant literature describing the management of acute spinal injury in pregnant patients. Here, we report our experience with five cases of pregnant patients including three females who suffered acute traumatic spinal cord injuries (SCIs). METHODS: This retrospective study evaluated five pregnant women presenting with traumatic spinal injuries over a 16-month period. All were assessed using the International Standards for Neurological Classification of Spinal Cord Injury Patients and the American Spine Injury Association Impairment Scale (AIS). RESULTS: Three patients sustained SCIs: two cervical spine (C4 AIS-A and C5 AIS-B) and one thoracolumbar junction fracture dislocation (T11 AIS-A). Two patients required surgical stabilization during pregnancy, with one undergoing surgery after delivery. All three patients subsequently delivered healthy newborns. The remaining two patients without neurologic deficits at admission were treated conservatively; one had a healthy child, whereas the other patient aborted the baby due to the initial trauma. CONCLUSIONS: Our study demonstrates that the same surgical principals may be applied to pregnant women as to routine patients with SCIs. Further studies with greater patient data should be performed to better develop significant guidelines for the management of pregnant patients with spinal injuries.

Introducing the concept of "CSF-shift edema" in traumatic brain injury.

Brain edema after severe traumatic brain injury (TBI) plays an important role in the outcome and survival of injured patients. It is also one of the main targets in the therapeutic approach in the current clinical practice. To date, the pathophysiology of traumatic brain swelling is complex and, being that it is thought to be mainly cytotoxic and vasogenic in origin, not yet entirely understood. However, based on new understandings of the hydrodynamic aspects of cerebrospinal fluid (CSF), an additional mechanism of brain swelling can be considered. An increase in pressure into the subarachnoid space, secondary to traumatic subarachnoid hemorrhage, would result in a rapid shift of CSF from the cisterns, through the paravascular spaces, into the brain, resulting in an increase of brain water content. This mechanism of brain swelling would be termed as "CSF-shift edema." This "CSF-shift," promoted by a pressure gradient, leads to increased pressure inside the paravascular spaces and the interstitium of the brain, disturbing the functions of the paravascular system, with implications of secondary brain injury. Cisternostomy, an emerging surgical treatment, would reverse the direction of the CSF-shift, allowing for a decrease in brain swelling. In addition, this technique would reduce the pressure in the paravascular spaces and interstitium, leading to a recovery of the functionality of the paravascular system.

Prospective observational research on the clinical profile and outcome analysis among a cohort of patients sustaining traumatic cervical spine and cord injury in a peripheral tertiary spine care centre in Nepal.

Background: In developing nations like Nepal, spinal cord injury has multispectral consequences for both the patient and their family members. It has the tendency to cripple and handicap the patients, and burn out their caretakers, both physically and mentally. Furthermore, the centralization of health care with only a handful of dedicated rehabilitation centers throughout Nepal further places patients into disarray. This study was carried out as a pilot study to determine the modes of injury, age groups affected, clinical profiles and patterns of injury sustained, as well as the efficacy of managing a subset of patients, who have sustained cervical spine and cord injuries. Methods: This was a prospective cohort study comprising of 163 patients enrolled over a period of three years that were managed in the spine unit of College of Medical Sciences, Bharatpur, Nepal. Results: Road traffic accidents were implicated in 51% of these patients. 65% of them were in the age group of 30-39 years. Traumatic subluxation occurred in 73 patients with maximum involvement of the C4/5 region (28.76%). Good outcome was seen in patients with ASIA 'C' and 'D' with 55% of patients showed improvement from 'C' to 'D' and 95% of patients showed improvement from 'D' to 'E' at 1 year follow up. The overall mortality in the patients undergoing operative interventions was only 1.98%. Conclusions: The prevalence of cervical spine injuries in the outreach area is still significant. The outcome of managing these patients, even in the context of a resource limited setup in a spine unit outside the capital city of a developing nation, can be as equally as effective and efficient compared to the outcome from a well-equipped and dedicated spine unit elsewhere.

Case Report: Managing a giant, high-grade carotid body tumor in a resource-limited setting.

Herein we report the management of a giant, high-grade and vascular carotid body tumor in a young woman. She presented with slowly progressive neck swelling. Vascular imaging revealed a left-sided, high-grade giant carotid body tumor (> 8cm).  The tumor was completely excised by caudocranial subadventitial dissection. Histology of the tumor revealed a characteristic Zellballen pattern of the lesion, suggestive of a paraganglioma. The patient made an uneventful recovery. We also discuss newer insights regarding the management of such highly vascular lesions.

Intraoperative Anatomical and Hemodynamic Analysis of Intracerebral Arteriovenous Malformations by Semi-quantitative Color-coded Indocyanine Green Videoangiography.

OBJECTIVE AND BACKGROUND: To evaluate possible roles for indocyanine green (ICG)-based FLOW 800 software in surgical treatment of cerebral arteriovenous malformations (AVMs). METHODS: We perform ICG videoangiography several times for each step of AVM resection to elucidate feeders, drainers, and cerebral perfusion. RESULTS: Since 2010, 22 AVM surgeries in our department have been conducted using FLOW 800 intraoperatively. We demonstrated ICG angiograms, color-coded images, and semi-quantitative curves for AVMs. By reviewing all these modalities, we would define vascular structure of the AVM, proceed with resection, and finally recheck for any remnant. CONCLUSIONS: ICG FLOW 800 software helps the surgeon to recognize feeding and draining vessels of an AVM intraoperatively. Further studies to evaluate semi-quantitative acquired data regarding blood flow and tissue perfusion are warranted.

Newer insights to pathogenesis of traumatic brain injury.

Traumatic brain injury (TBI) is a silent epidemic and a global burden. However, when it comes to advancement in our quest to managing patients with head injuries, we seem to be making circles rather than moving forward. In this review paper, we focus on the current understandings in the pathogenesis of TBI that may aid us in providing newer avenues in management of the same.

Case Report: Orbital metastasis as the presenting feature of lung cancer.

Orbital metastasis from lung cancer as an initial presenting symptom is a rare entity, which may paradoxically delay the diagnosis and initiation of correct management, due to the confusion of it being primary orbital pathology. Herein we report a case of a 58 year old woman, who presented with painful orbital swelling along with diminution in her vision. The patient was initially thought to have a primary eye lesion; however chest X-ray was suggestive of a lung mass, which was confirmed by chest computed topography followed by ultrasound guided fine needle aspiration cytology. The patient was then referred to a cancer centre for further management. This case report aims to increase the knowledge about this metastasis as a probable cause of orbital symptoms in certain subsets of patients, so that correct therapeutic decisions may be made in the future.