Single-entry two-stage rotational outside-in technique for simultaneous ventriculostomy and pineal region biopsy using traditional ventricular endoscope: technical note and comparative review.

BACKGROUND: Many methods are reported for simultaneous endoscopic 3rd ventriculostomy and posterior 3rd ventricular biopsy with their pros and cons. We describe a novel single-entry two-stage rotational outside-in technique using the common 6° ventriculoscope and contrast this with others. TECHNIQUE: Using a single burr hole, at the line extended from aqueduct through the larger foramen of Monro in parasagittal imaging, the ventricular endoscope is first inserted with 6° angled view anteroinferior, the tip of endoscope sheath just beyond the anterior part of the foramen, and ventriculostomy performed using flexible catheter's beveled cut end and balloon in a curvilinear trajectory using peripheral visualization. Keeping camera in the same orientation, it is then rotated 180° having 6° angled view postero-inferior, endoscope sheath traversing the posterior part of the foramen close to the posterior 3rd ventricular target, and biopsy obtained with rigid forceps. This technique overcomes some of the limitations of other methods by exploiting the flexible catheters and the rotational advantage of the 6° angle of the traditional ventriculoscope. CONCLUSION: Our single burr hole two-stage rotational technique for simultaneous third ventriculostomy and posterior third ventricular biopsy seems to be an excellent alternative to other methods which can be used with both traditional 6° and greater angled ventriculoscopes without any significant deterrent.

Displaced odontoid synchondrosis fracture with C1-2 dysjunction in an 18-month-old child: challenges and solutions.

BACKGROUND: Odontoid synchondral fractures in very young children with displacement/angulation are highly unstable and require surgical intervention. Soft and small bones with poor pull-out strengths make instrumentation and manipulation difficult. CASE REPORT: We report an 18-month-old child with such a fracture where minimal traction made C1-2 dysjunction apparent with neurological worsening. The C1-2 facets were fixed with a short plate and facetal screws. The child had a good outcome. CONCLUSION: Traction should be applied cautiously to avoid distraction injuries. Careful intraoperative manipulation should be planned to avoid any pull outs/fractures while realigning the spine and fixing it.

A child with recurrent otitis media due to Bacteroides thetaiotaomicron.

Brain abscess remains a life-threatening condition. Here, we are reporting a case of brain abscess due to Bacteroides thetaiotaomicron in a previously known case of recurrent otitis media. A 15 years old boy with a history of recurrent otitis media presented with the complaints of right otalgia, headache and fever. Computed Tomography (CT) brain and neck revealed fluid filled right middle ear cavity with bony destruction along the inner cortex of right temporal bone. The abscess was drained and culture showed growth of Bacteroides thetaiotaomicron. This report illustrates the importance of MALDI-TOF MS in the species level identification of anaerobes thereby facilitating the selection of appropriate and prompt adjuvant antibiotic therapy. This timely identification thus led to a favourable outcome in an era of increasing antimicrobial resistance.

Laser-Cut Stent-Assisted Coiling of Wide-Necked Giant Cavernous ICA Aneurysm: Inviting a Catastrophe.

Management of wide-necked aneurysms in cavernous ICA has significantly evolved in the endovascular era, with flow diverters and stent-assisted coiling being an effective modality. It is vital to select the type of stent according to the arterial anatomy, hemodynamics, and device characteristics. We report a catastrophic complication of laser-cut stent used for SAC of cavernous ICA aneurysm performed at another center 5 years back, presenting with regrowth and massive life-threatening epistaxis managed successfully. In tortuous angulated anatomy, laser-cut stents are difficult to place, poorly visible, and the device opening is uncertain. Unlike braided stents, laser-cut stents do not provide flow diversion effect, stent migration, and buckling phenomena are more likely to occur with laser-cut stents. We intend to discuss the technical fallacies behind using laser-cut stents in such case scenarios and the optimal treatment approach for such cases with an attitude to learn from such complications.

Radiological Parameters for Gamma Knife Radiosurgery.

Accurate lesion targeting is the essence of stereotactic radiosurgery. With the currently available imaging modalities, scanning has become quick and robust providing a high degree of spatial resolution resulting in optimal contrast between normal and abnormal tissues. Magnetic resonance imaging (MRI) forms the backbone of Leksell radiosurgery. It produces images with excellent soft tissue details highlighting the target and surrounding "at-risk" structures conspicuously. However, one must be aware of the MRI distortions that may arise during treatment. Computed tomography (CT) has quick acquisition times giving excellent bony information but inferior soft tissue details. To avail benefits of both these modalities and overcome their individual fallacies and shortcomings, they are often co-registered/fused for stereotactic guidance. Vascular lesions like an arteriovenous malformation (AVM) are best planned with cerebral digital subtraction angiography (DSA) in conjunction with MRI. In specific cases, specialized imaging methods like magnetic resonance (MR) spectroscopy, positron emission tomography (PET), magneto-encephalography (MEG), etc., may be added to the treatment planning for stereotactic radiosurgery (SRS).

Decompressive Hemi Craniectomy in Malignant Middle Cerebral Artery Infarction: Adding Years of Quality Life or Mere Existence?

Background: In spite of advancements in treatment options for MCA infarct, there is a definite role of decompressive hemicraniectomy. When compared with best medical management, it decreases mortality and improves functional outcome. But does surgery improve quality of life in terms of independence, cognition or it merely leads to increased survival? Objective: Outcome of 43 consecutive patients of MMCAI who underwent DHC was studied. Materials and Methods: Functional outcome was evaluated based on mRS and GOS in addition to survival advantage. The patient's proficiency in performing ADL was evaluated. MMSE and MOCA were performed to evaluate the neuropsychological outcome. Results: In-hospital mortality was 18.6%, and by 3 months, 67.5% of patients survived. During follow-up, nearly 60% of patients showed improvement in functional outcome when evaluated based on mRS and GOS. No patient could reach to the level of independent existence. Only eight patients could perform MMSE and five had good score (>24). All were young and had a right-sided lesion. None of the patients could perform well in MOCA. Conclusion: DHC improves survival and functional outcome. Cognition remains poor in the majority of the patients. These patients, though survive the stroke, remain dependent on care givers.

Development, Validation, and Impact of Patient Information Booklet for Gamma Knife Radiosurgery.

Background: The inadequate awareness in the general population is a primary concern for the management of various neurosurgical ailments treated with gamma knife radiosurgery (GKRS). Objective: Our study aimed to assess the written patient information by focusing on readability, recall, communication, compliance, and patient satisfaction. Methodology: The senior author formulated disease-specific patient information booklets. The booklets comprised two segments: general information about GKRS and disease-specific information. The common themes for discussion were "What is your disease?", "What is gamma knife radiosurgery?", "What are the alternatives to gamma knife radiosurgery," "The benefits of gamma knife radiosurgery," "About gamma knife radiosurgery," "Recovering from gamma knife radiosurgery," "Follow up," "What are the risks," and "Contact." The booklet was emailed after the first consultation to 102 patients. Patients' socioeconomic status and comprehensibility were assessed on validated scoring. Post-GKRS, we emailed a custom-made Google feedback survey of 10 leading questions about the role of patient information booklet in educating and decision-making process. We tried to assess if the booklet helped the patient understand the disease and treatment options. Results: In total, 94% of patients read it thoroughly and understood it to their satisfaction. They also shared and discussed the information booklet with their family members and relatives (92%). Furthermore, 96% of patients found the disease-specific information informative. For 83% of patients, the information brochure cleared the doubts regarding the GKRS completely. For 66% of patients, their expectations met the reality. In addition, 94% of patients still recommended giving the booklet to the patients. All high, upper- and middle-class responders were happy and content with the patient information booklet. In contrast, 18 (90%) of the lower middle class and 2 (66.7%) of the lower class considered the information useful to the patients. Also, 90% patients found the language of the patient information booklet comprehensible and not too technical to understand. Conclusions: An essential component of disease management is to relieve the anxiety and confusion in the patient's mind and help one choose a treatment modality among the available options. A patient-centric booklet helps impart knowledge, clears doubts, and provides an opportunity to discuss options with family members.

Hypo-fractionated Gamma Knife Radiosurgery for Intra-cranial Pathologies: A Single-Center Prospective Analysis of Feasibility, Safety, Efficacy, and Complication Profile.

Background: Single-session stereotactic radiosurgery (SRS) is a proven and effective treatment modality for various benign, malignant, and functional intra-cranial pathologies. In certain situations, single-fraction SRS is limited because of lesion size and location. Hypo-fractionated gamma knife radiosurgery (hfGKRS) is an alternative approach for such unconventional indications. Objective: To evaluate the feasibility, efficacy, safety, and complication profile of hfGKRS with evaluation of different fractionation schemes and dosing patterns. Methodology: The authors prospectively evaluated 202 patients treated with frame-based hfGKRS over a 9-year period. GKRS was administered fractionated because of either a large volume (>14 cc) or an inability to spare neighboring organs at risk from permissible radiation in single-session GKRS. The inter-fraction interval was kept at 24 hours, and the dose calculation was performed with linear quadratic equations. Patients with more than 3 years of clinical and radiological follow-up were included in prospective analysis. At pre-decided follow-up criteria, treatment effects and side effects were documented on objective scales. Results: A total of 169/202 patients met inclusion criteria. 41% patients received treatment in three fractions, whereas 59% received two-fraction GKRS. Two patients of giant cavernous sinus hemangiomas were treated with 5 Gy in the five-fraction regimen. In patients with more than 3 years of follow-up, the obliteration rate was 88% for complex arteriovenous malformations (AVMs) treated with hfGKRS because of eloquent locations, whereas it was 62% for Spetzler-Martin grade 4-5 AVMs. For non-AVM pathologies (meningiomas, schwannomas, pituitary adenomas, paragangliomas, hypothalamic hamartomas, etc.), the 5-year progression free survival was 95%. Tumor failure was noted in 0.05% patient population. Radiation necrosis developed in 8.1% patients, and radiation-induced brain edema developed in 12% patients. It was resistant to treatment in 4% patients. No patient developed radiation-induced malignancy. Hypo-fractionation did not provide any hearing improvement in giant vestibular schwannomas. Conclusion: hfGKRS is a valuable standalone treatment option for candidates unsuitable for single-session GKRS. The dosing parameters need to be tailored as per the pathology and neighboring structures. It provides comparable results to single-session GKRS with an acceptable safety and complication profile.

Isolated cerebellar abscess by Norcardia asiatica: A case report with review of literature.

Human nocardiosis is primarily an opportunistic infection affecting immunocompromised patients, however, one-third of them are immunocompetent. CNS involvement is less commonly reported and associated with a grave prognosis. The majority of these patients are organ transplant recipients on immune suppressants. In the recent past, association of Nocardia asiatica with brain abscess has been reported in a few cases. We are reporting a case of isolated cerebellar abscess caused by N. asiatica in an immune-compromised adult with a review of relevant literature. A 53-year-old male presented with complaints of headache and vomiting for 14 days. There was no previous history of any comorbid illness. During presentation, he was having gait ataxia and radiology showed the right-sided cerebellar multiple lesions. Further hematological investigations revealed the patient to be HIV positive. The abscess was tapped and the pus culture showed Nocardia species. Antibiotics were started as per sensitivity and the patient did well at 3-month follow-up. Though rare, Nocardia should be kept as a differential in brain abscess patients. Owing to the different antimicrobial sensitivity patterns among Nocardia species, both appropriate speciation and susceptibility testing of uncommon species such as N. asiatica are required for their successful treatment.

Please spare my teeth! Dental procedures and trigeminal neuralgia.

BACKGROUND: The correct diagnosis of trigeminal neuralgia (TN) is still a far cry and the patients suffer from unnecessary dental procedures before getting the definite treatment. In this study, we evaluated, if the patients have undergone dental procedures for their misdiagnosed TN before receiving definite treatment for the same. METHODS: A total of 187 patients received GKRS for their TN (excluding secondary TN) in two institutes from 2010 to 2019. We did a retrospective analysis of these patients' primary complaints on a standard questionnaire. RESULTS: One hundred and seventeen of the 187 patients responded. About 55.5% of patients had a toothache and 65.8% did visit a dentist for the pain. About 41.8% of patients underwent one dental procedure; 18.8% suffered from worsening of the pain while 8.5% received some partial improvement. About 19.6% also underwent root canal treatment while 6.8% had a nerve block. Mean of 1.6 teeth was extracted per person. About 71% of patients were satisfied with their Gamma Knife radiosurgery for TN at a median follow-up of 49 months. CONCLUSION: There is a need for a better understanding of the disease among the dentists and the patients for the timely and correct treatment, without losing their teeth. The onus lies on neurosurgeons/neurologists disseminate knowledge regarding proper diagnosis and treatment modalities.