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.

Extra-Axial Cerebellopontine Angle Medulloblastoma in an Infant.

Medulloblastoma is a common tumor of the posterior fossa, representing 20-25% of all pediatric neoplasms. It commonly occurs in the midline (cerebellar vermis) and rarely at the cerebellopontine angle. Most of them are intra-axial, and an extra-axial location of this tumor is very rare. Extra-axial cerebellopontine angle medulloblastoma is extremely uncommon and has never been reported in an infant. We report an extra-axial cerebellopontine angle medulloblastoma in a 1-year-old child.

Disappearance of the Hemorrhagic Component of the Frontal Contusion Possibly due to Redistribution of the Hematoma within the Subarachnoid Space: A Case Report.

Posttraumatic hemorrhagic contusions are a common sequel of traumatic brain injuries. They occur in around 8% of all traumatic brain injuries. Spontaneous resolution of acute subdural and acute extradural hematomas, although rare, is a recognized entity, but spontaneous resolution of the hemorrhagic component of a contusion within 24 h has not been reported in the literature. We present a patient in whom the hemorrhagic component of her contusion resolved spontaneously over a period of 24 h after injury. The rarity of this case prompted us to this study.

Establishing a deceased donor program in north Indian region: lessons learnt.

INTRODUCTION: Living-related donors are the source of almost all organ transplants in India. However, these donations fall far short of current needs, and there remains a huge disparity between demand and supply of organs. In the last five yr, a consistent increase in deceased donor transplant activity has been observed in some southern Indian states. This report describes our experience of establishing a new deceased donor program in the state of Uttar Pradesh in north India. METHODS: We describe our experience on counseling families of all brain-dead patients admitted to our center from October 2013 to September 2014 and data on retrieving and transplanting organs. RESULTS: A total of 99 brain-dead patients were identified, of which 67 were medically eligible as donors. Fourteen patients developed cardiac arrest before the counseling could begin. Only eight families agreed for multi-organ donation. CONCLUSION: Lack of consensus among the family members, mistrust of the medical system, fear of mutilation of the body, and delay in the funeral were identified as the main reasons behind negative consent. Conversely, mass media campaign, proper ICU care of brain-dead patients, rapport with the family and streamlining all medico legal processes were associated with positive consent.

Giant Interfrontal Encephalocele in an Infant: A Rare Entity.

Interfrontal encephalocele is one of the rare varieties of anterior encephalocele, and a giant interfrontal encephalocele is extremely rare. The authors could find only one case report of giant interfrontal encephalocele in the literature. Anterior encephaloceles are more prevalent in South-East Asia and some northern parts of India. Giant encephalocele poses a great challenge to neurosurgeons and neuroanesthetists during surgery, as these infants usually have a low birth weight and a large sac, thus making the infant prone to hypothermia and blood loss among other risks. We encountered a patient with a giant interfrontal encephalocele aged 1 month. The rarity of this case prompted us to this report.

Tumor necrosis factor-α and interleukin-1ß gene polymorphisms and risk of brain abscess in North Indian population.

OBJECTIVE: Brain abscess develops in response to a parenchymal infection with pyogenic bacteria. Tumor necrosis factor-α (TNF-α) and interleukin-1ß (IL-1ß) are the most crucial pro-inflammatory cytokines with both beneficial and destructive properties for the central nervous system. The present study evaluated the association of specific alleles/genotypes of TNF-α and IL-1ß with brain abscess. MATERIAL AND METHODS: A total of 90 brain abscess patients and 100 healthy controls were included in the study. Predisposing factors were identified in 56 (62.2%) patients with brain abscess. TNF-α (-308 G>A) and IL-1ß (-511 CA) and C allele in IL-1ß (-511 CA) and IL-1ß (-511 C

A randomized study of ventriculoperitoneal shunt versus endoscopic third ventriculostomy for the management of tubercular meningitis with hydrocephalus.

OBJECTIVE: This study aims at generating knowledge to understand the conditions in which either of the two procedures (endoscopic third ventriculostomy (ETV) and shunt) are better options and to develop good practice guidelines for the treatment of tubercular meningitis (TBM) hydrocephalus. METHODS: This study was conducted on 48 patients in pediatric age group (less than or equal to 18 years) of TBM hydrocephalus. The patients were randomized to one of the cerebrospinal fluid diversion procedures (ETV or shunt). The two procedures were compared for their outcome, both radiologically and clinically. RESULTS: Twenty-four cases underwent shunt, out of which 13 (68%) cases were successful. Twelve (70.3%) cases belonged to grade 3, while one case was of grade 1. In ETV group, 10 (42%) cases had a successful outcome, out of which 7 (38.8%) cases were in grade 3, while 1 case each belonged to grades 1, 2, and 4. Incidence of ETV failure was more in younger age group, i.e., <2 years (n = 7), while no such correlation with age was found in shunt cases. CONCLUSION: Though with the present study it looks like that the relative risk of ETV failure is higher than that for shunt, but the risk becomes progressively lower with time. Therefore, if patients survive the early high-risk period, they could experience a long-term survival advantage devoid of life-long shunt-related complications. Though for definitive comparison, a long-term study is needed.

Is basal cisternostomy in traumatic brain injury a need of hour or white elephant - A randomized trial to answer.

Background: Basal cisternostomy (BC) recently emerged as an adjuvant/alternative procedure to decompressive craniectomy (DC) in traumatic brain injuries (TBIs) with its potential to effectively reduce both intracranial pressure (ICP) and brain edema. However, its role in TBI is not yet established in the true sense and with clarity. The objective of the present study was to evaluate the effect of adjuvant BC on ICP, mortality, and clinicoradiological outcome. Methods: A single-center randomized control trial was conducted. Fifty patients were assigned to each DC-group and DC+BC-group. Randomization was done using the sealed envelope method. Both groups were followed in the postoperative period to compare the impact of surgery on ICP, radiological changes, and clinical outcome (mortality, days on ventilator/in intensive care unit (ICU), and Glasgow outcome scale-extended (GOS-E) at 12 weeks). Results: Both groups were comparable in terms of preoperative clinicoradiological characteristics. On postoperative days 1, 2, and 3, mean ICP was significantly low in the DC+BC-group (P < 0.0001). The decline in ICP in the DC+BC-group was significant in both moderate and severe TBI patients. In comparison, DC+BC-group has a shorter duration of mechanical ventilation/ICU stay and significantly better GOS-E score at 12 weeks (P < 0.0001*). The mortality rate was less in the DC+BC-group (48%) as compared to the DC-group (64%). Among radiological features, mean midline shift and mean outward brain herniation were significantly less in the DC+BC group. Bone-flap replacement was possible in ten patients of DC+BC-group at the time of primary surgery. Conclusion: Results of our study indicated that BC is beneficial in reducing both ICP and brain edema, which translates into favorable clinicoradiological outcomes.

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.

COVID-19 associated mucormycosis: Staging and management recommendations (Report of a multi-disciplinary expert committee).

Even before the onslaught of COVID-19 pandemic could settle, the unprecedented rise in cases with COVID-19 associated mucormycosis pushed the medical health to the fringe. Hyperglycaemia and corticosteroids appear to be the most consistent associations leading to the commonest manifestation of mucormycosis, Rhino-Orbito-Cerebral Mucormycosis. To address challenges right from categorisation and staging of the disease to the management of relentless progression, a multi-disciplinary expert committee was formed to handle the task in an evidence-based format to enforce best practices. The report of the committee on one hand attempts to succinctly present the currently available evidence while at the other also attempts to bridge the evidence-deficient gaps with the specialty-specific virtuosity of experts.

Intraoperative ventriculo-stomographic evaluation of endoscopic cerebrospinal fluid diversion and flow restoration procedures.

PURPOSE: This prospective study was designed for intra-operative demonstration of cerebrospinal fluid (CSF) flow in ventricles and cisternal spaces before and after neuroendoscopic procedure. The aim of this study was to evaluate site of obstruction of CSF flow and subsequent stomal or aqueductal patency after endoscopic third ventriculostomy (ETV) or aqueductoplasty in patients with hydrocephalus of diverse aetiology. METHOD: Seventeen patients with hydrocephalus due to diverse aetiology underwent ETV (n = 15) and aqueductoplasty (n = 2) or cysto-ventrticulostomy (n = 1) or transaqueductal removal of neurocysticercus cyst (NCC) (n = 1). Intra-operatively, radio-opaque contrast agent (iohexol) instillation into the third ventricle was used for qualitative evaluation of obstruction and post-procedure CSF flow across the stoma into cisternal spaces. RESULT: 11 male and 6 female patients ranging from 3 to 50 years of age were included in the study. Post-procedure intra-operative ventriculo-stomography (IOVSG) showed free flow of dye across the endoscopic stoma (n = 13) or aqueduct (n = 2) into cisternal spaces. Diagnosis of fourth ventricular NCC was made in one patient with panventriculomegaly. In two patients of tuberculous meningitis hydrocephalus, poor flow of contrast in the prepontine area and basal cisterns was seen on IOVSG. They were subjected to ventriculoperitoneal shunt insertion in the same sitting. Cine MRI confirmed the patency of stoma or aqueduct in follow-up period in all patients with successful endoscopic procedure. CONCLUSION: IOVSG is a simple and safe technique that helps in confirming the adequacy of endoscopic procedure during surgery and thereby facilitates intra-operative decision about further management.

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.

Combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic decompression of a giant pituitary adenoma: case report.

OBJECTIVE: This is the first report of the simultaneous combined use of trans-sphenoidal and trans-ventricular-endoscopic route for decompression of a giant pituitary adenoma. METHOD: A 38 year old man presented to us with symptoms of raised intracranial pressure along with visual and hypothalamic disturbances. The CT scan revealed destruction of the sella by a large (5 x 3.5 x 2.5 cm) well defined enhancing mass in the sella and suprasellar region extending laterally up to the cavernous sinuses and both carotid arteries and superiorly into the lumen of the 3rd ventricle producing obstructive hydrocephalus. On T2WI of the non-contrast MRI scan the mass was iso-intense to grey matter suggesting the possibility of a firm nature of the adenoma. The tumour was first approached by the standard trans-sphenoidal route and as predicted from the pre-operative MRI, the tumour was found to be firm and not amenable to suction. After decompression of the intra-sellar part of the tumour, the intracranial pressure was raised in an attempt to make the remainder of the tumour descend into the sella but without success. The suprasellar part of the tumour was then simultaneously addressed via a trans-ventricular-endoscopic route but the firm tumour did not yield to endoscopic instruments viz. biopsy forceps, angiographic catheter and electrosurgical probes. It was then gently pushed down towards the sella and decompressed piecemeal by using trans-sphenoidal instruments. The sellar cavity was reconstructed using fat, fascia lata graft and a piece of septal bone. RESULTS: Post-operatively, the patient showed a remarkable improvement of his symptoms of raised intracranial pressure, hypothalamic dysfunction and visual disturbances. Follow-up imaging at 2 months and 1 year, did not show any residual or recurrent tumour. CONCLUSIONS: This novel technique of the combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic approach is a viable option for patients with giant fibrous pituitary adenoma when the tumour is not yielding to the trans-sphenoidal route alone.

Endoscopic Management of Intraventricular Neurocysticercosis.

AIM: To evaluate the technique and outcome of endoscopic management of intraventricular neurocysticercosis (NCC). MATERIAL AND METHODS: We retrospectively analysed the records of 30 consecutive patients of intraventricular (intra-third and fourth ventricle) NCC who underwent endoscopic management. The clinical profiles of the patients were evaluated which included age, symptoms and signs. Transcranial endoscopy was performed through a frontal burr hole using a Gaab Universal Endoscope system with rigid 0° and 30° telescope for endoscopic third ventriculostomy and removal of the cyst was described. The mean follow-up period was 22.6 months. RESULTS: In 86.67% (26/30) patients we are able to visualize/excise/decompress the cyst. We were able to successfully excise all the third ventricular cysts (16/16) and in 66.67% (8/12) of the fourth ventricular cysts. In 90% (27/30) patients we were able to successfully divert the CSF flow and achieve long-term shunt free period. CONCLUSION: We found that endoscopic cerebrospinal fluid (CSF) diversion in cases of intraventricular NCC is feasible and associated with high success rate. Endoscopic CSF diversion in NCC related hydrocephalus usually produces a long-term cure.

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.

Spinal cord abscess secondary to infected dorsal dermal sinus in an infant: uncommon presentation of a known entity.

Infection along the congenital dermal sinus tract is well known. However, congenital dorsal dermal sinus presenting with intramedullary abscess is quite rare. The sinus tract usually presents in the midline and acts as a portal of entry for infection that may manifest as meningitis, extradural or subdural abscess and may further involve the cord. Surgical drainage of pus and complete excision of the sinus tract is the standard treatment. Here we describe an infant with an infected congenital dorsal dermal sinus with atypical presentation as large paracentral abscess in the upper back. We further highlight the importance of recognising and treating these skin dimples even when clinically silent to avoid catastrophic complications.

Self inflicted stab with a knife: An unusual mode of penetrating brain injury.

Self-inflicted penetrating injuries have been very rarely described in the medical literature. We describe a middle-aged woman, who had driven a long knife inside her skull with the help of a brick. She had done this to get relief from chronic headache, which was troubling her for 10 years. Patient was hemodynamically stable and had Glassgow Coma scale score of 15. She was immediately operated to remove the knife and evacuate the acute subdural hematoma. Patient made a steady postoperative recovery. Psychiatric and neurological evaluation in the postoperative period revealed features of mixed anxiety and depressive disorder with migraine, for which she was started on treatment. Management of such cases needs a team approach with inputs from neurosurgeon, neurophysician and psychiatrist.

Endoscopic transoral surgery for craniovertebral junction anomalies. Technical note.

Craniovertebral junction (CVJ) anomalies continue to be challenging for neurosurgeons because of the complex anatomy of this region. To date, microsurgical decompression via a transoral route is the standard treatment for anteriorly located compressive lesions of the cervicomedullary junction (CMJ). The results obtained by minimizing surgical trauma are fewer complications, shorter hospital stays, and reduced overall psychological burden. Endoscopic surgery is becoming a leading modality in minimally invasive neurosurgical treatment. The authors performed surgery in 11 patients with irreducible osseous dislocations resulting from CVJ abnormality during a 2-year period. Anterior CMJ decompression was achieved in all patients by performing neuroendoscopically controlled transoral excision of bone and soft tissues. The surgical technique and results will be discussed. The use of the endoscope offers several advantages in cases requiring a transoral approach to the lower clivus and atlantoaxial region. The use of minimally invasive endoscopic techniques has the potential to reduce the need for a wider cranial base opening and to decrease postoperative complications.

Association of ICAM-1 (K469E) and MCP-1 -2518 A>G gene polymorphism with brain abscess.

Brain abscess develops in response to a parenchymal infection. Intercellular adhesion molecule-1 (ICAM-1) and monocyte chemoattractant protein-1 (MCP-1) play vital role in central nervous system (CNS) diseases. We studied ICAM-1 (K469E) and MCP-1 (-2518 A>G) polymorphisms among brain abscess patients. The genotypic distributions of ICAM-1 (K469E) and MCP-1 (-2518 A>G) were significantly different between patients and controls. Further, patient with predisposing factors, and also with culture result, we found significant association. The study revealed that the polymorphisms of these molecules lead to increased production, which appears to be a risk for the development of brain abscess.