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Byline: K. Arun, Poornima. Nambiar, Santhosh. Kannath, Sapna. Sreedharan, Sajith. Sukumaran, Sankara. Sarma, P. Sylaja Background and Purpose: Limited data is available regarding the prevalence of aortic plaques in cryptogenic [...]

Background: Due to effective treatment of middle ear infections there is a change in etiologies causing lateral sinus thrombosis (LST) and outcome. There is a paucity of literature describing homogenous group of patients with nonseptic LST (NS-LST). Objective: To describe the clinical profile, risk factors, outcome of patients of NS-LST seen at a single center from South India. Methods and Materials: Prospective, observational study of 100 patients of NS-LST patients, diagnosed by magnetic resonance imaging (MRI) seen at the stroke unit. Results: During 2 years, 100 patients of NS-LST (isolated: combined: 27:73) (male: female: 44:56), mean age: 31.45 ± 11.13 years, were seen. Subacute presentation (74%) with headache, seizures, focal deficits, and features of raised intracranial pressure were presenting features. Hyperhomocysteinemia (61%), anemia (57%), postpartum state (41%), OCP use (37%), and low VitB12 (32%) were commonly seen risk factors. Imaging with MRI compared withcomputerized tomography (CT) had better diagnostic sensitivity (100% vs. 67%), detection of parenchymal (81% vs. 67%)/hemorrhagic (79% vs. 74%) lesions, and cortical vein thrombosis (31% vs. 15.46%). Treatment with anticoagulation and supportive therapy resulted in good outcome (mRS (0-2)) at 3 months in 81%. There were four deaths, all during admission (one - isolated, three - combined) and 11 patients underwent decompressive surgery. Patients with low GCS level of sensoriumat admission, hemiparesis, combined LST, cerebellar involvement, and decompressive craniectomy had a poor outcome. Conclusion: This single-center large cohort study of NS-LST patients brings out the clinical features, risk factors (peculiar to developing countries), and the superiority of MRI in the diagnosis. Majority of patients have good outcome, with low mortality with 10% requiring decompressive surgery. [ABSTRACT FROM AUTHOR]

Background: Studies on insular gliomas (IGs) generally focus on the oncological endpoints with a relative scarcity of literature focusing on the seizure outcomes. Objectives: To study the predictors of long-term postoperative seizure control in IG and propose a novel risk scoring system. Methods: Histopathologically proven, newly diagnosed adult IGs (>18 years) operated over a 10-year period were studied for postoperative seizure control as per International League Against Epilepsy (ILAE) grades at 6 weeks and at last follow-up (minimum of 6 months, median 27 months). Logistic regression analysis was performed and regression coefficients with nearest integers were used to build a risk prediction model. Receiver operator curve (ROC) analysis determined the predictive accuracy of this model. Results: The 6-week postoperative seizure freedom dropped to 41% at the last follow-up. The seizure-free group lived longer (100.69 months, 95% CI = 84.3-116.99 (60%)) than those with persistent postoperative seizures (27.92 months, 95% CI = 14.99-40.86). Statistically significant predictors (preoperative seizure control status, extent of resection, tumor extension to temporal lobe, and lack of postoperative adjuvant therapy) were used to compute a risk score, the score ranging from 0 to 9. A score of four most optimally distinguished the risk of postoperative seizures with an area under the ROC of 91.4% (95% CI: 84.1%, 98.7%, P < 0.001). Conclusion: In our experience, around 60% of patients obtained seizure freedom after surgery, which reduces over time. Control of seizures paralleled survival outcomes. Our proposed scoring system may help tailor management strategies for these patients. [ABSTRACT FROM AUTHOR]

Byline: K. Arun, Chinmay. Nagesh, C. Kesavadas, Sapna. Sreedharan, P. Sylaja Sir, High-resolution magnetic resonance (MR) vessel wall imaging (VWI) is an emerging technique which allows direct visualization of the [...]

Objective: This article aims to discuss the surgical nuances and major adjustments necessary in unlocking the frontotemporal dural fold (FTDF) and extradural anterior clinoidectomy (EDAC) in actual cases, allowing translation from the cadaveric to a clinical scenario. Materials and Methods: We retrospectively reviewed the technical details of 17 procedures over 8 years, where both the initial steps (FTDF unlocking and EDAC) were performed. Lesions involving or extending to the anterolateral skull base, like the suprasellar cistern, optico‑carotid cistern, interpeduncular cistern, petrous apex, and cavernous sinus, were included. The clinical data of the patients were retrieved retrospectively from the hospital information system (HIS) and in‑patient records. This study was approved as a multicenter individual project with IEC No: 2020‑342‑IP‑EXP‑34. Results: An illustrated note of the common steps and outcome of the 17 procedures of unlocking the FTDF and EDAC done is presented. The technique provided adequate exposure in performing aneurysmal clipping (posterior communicating artery [P. com], basilar top, and superior hypophyseal artery [SHA] aneurysm), giant pituitary adenoma (Wilson Hardy grade 4E, n = 2), fifth nerve schwannoma (n = 4), right Meckel’s cave melanoma, cavernous hemangioma (n = 4), petroclival meningioma (n = 2), and clival chordoma. Temporary and permanent cranial nerve palsy as a procedure‑related complication was seen in 11.8% (n = 2) each. Complete excision was achieved in 13 (n = 13/14) patients with tumors. Conclusion: FTDF unlocking and EDAC are elegant procedures providing reasonable access to the anterolateral skull base for myriad pathologies. Brain bulge, cavernous sinus bleeding, and losing the plane of dural duplication were significant challenges in switching from cadaveric to a clinical scenario. [ABSTRACT FROM AUTHOR]

Byline: Saraf. Umesh, K. Arun, Sapna. Sreedharan, P. Rajalakshmi, P. Sylaja Sir, Moyamoya disease (MMD) is a rare chronic cerebrovascular disorder characterized by progressive bilateral occlusion of the supraclinoid internal [...]

Background: In patients with acute ischemic stroke with large vessel occlusion, various angiographic features are important in patient selection and predicting outcome. Objective: We evaluated angiographic features like collaterals, clot burden score, angiographic recanalization, number of passes, and intracranial atherosclerotic disease (ICAD) with the functional outcome at 90 days. Materials and Methods: This was a retrospective analysis of prospectively collected data of 163 patients with acute ischemic stroke with large vessel occlusion who underwent mechanical thrombectomy within 24 hours of symptom onset. Angiographic data were reviewed blinded to clinical data. The outcome was defined as modified Rankin scale (mRS) at 90 days (good outcome mRS ≤2) Results: The median age of patients was 60 years and 34.4% were females. The median National Institutes of Health Stroke Scale (NIHSS) and Alberta Stroke Programme Early CT Score (ASPECTS) at admission were 17 and 6, respectively. On bivariate analysis, ASPECTS was >6, clot burden score was ≥7, recanalization of TICI was ≥2b, absence of ICAD, showed a positive correlation with the good outcome at 90 days (P-values of 0.003, 0.0001, and 0.03, respectively). Multiple attempts of device passes were associated with poor recanalization (P = 0.001) and it was seen more in ICAD patients. On multivariate analysis, independent predictors of poor outcome were clot burden score <7 (P = 0.043) and TICI score <2b (P = 0.048). Out of 41 patients (26%) with ICAD, 29 had a poor outcome at 90 days. Conclusion: Lower clot burden and less degree of recanalization were associated with poor outcome in acute ischemic stroke due to Large vessel occlusion (LVO). The presence of ICAD also predicted poor outcome. [ABSTRACT FROM AUTHOR]

Background: Maximal safe resection remains the most desired goal of insular glioma surgery. Intraoperative surgical adjuncts provide better tumor visualization and real-time "safety" data but remain limited due to a high cost and limited availability.Objective: To highlight the importance of anatomical landmarks in insular glioma resection and avoidance of vascular complications. We also propose to objectify the onco-functional balance in insular glioma surgery.Methods: Forty-six insular gliomas operated upon by a single surgeon between January 2015 and February 2020 were reviewed, focusing on the operative technique and clinical outcomes. A novel composite postoperative outcome index (CPOI) was designed, comprising the extent of resection and permanent postoperative deficits, and utilized to assess the surgical outcomes.Results: Gross-total, near-total, and subtotal resections were achieved in 10.9%, 52.1% (n = 24), and 36.9% (n = 17) patients, respectively. The median overall survival (OS) was 20 months (95% CI = 9.56-30.43). CPOI was optimal in 38 patients (82.6%). A well-defined tumor margin (P = 0.01) and surgeon's experience (P = 0.04) were significantly associated with an optimal CPOI. Out of seven (15.2%) patients who developed permanent neurological deficits, three (6.5%) patients had severe disability. Favorable prognostic factors of survival included younger age (<40 years) (P = 0.002), tumors with only frontal lobe extension (P = 0.011), tumors with caudate head involvement (P = 0.04), and non-glioblastoma histology (P = 0.006).Conclusion: Tumor margin and increasing surgeon experience are critical to an optimal postoperative outcome. Respecting the basi-sulcal plane is key to lenticulostriate artery preservation. Caudate head involvement is a new favorable prognostic factor in insular gliomas. [ABSTRACT FROM AUTHOR]

Sir, Spinal drop metastasis is common sequelae in high-grade like glioblastoma. In 2019, he presented with progressive spastic paraparesis and MRI dorsal spine revealed a contrast enhancing dorsally exophytic intramedullary mass lesion at D8D9 vertebral body level [Figure 1]c and [Figure 1]d. In literatureso far three cases have been reported on symptomatic spinal intramedullary metastasis (SIM) from low grade oilgodendroglioma.[[1]] We report an unusual case of a low-grade ODG, developed symptomatic intramedullary spinal cord metastasis after years. [Extracted from the article]

Background and Introduction: Clipping an aneurysm on an elongated and tented V4 segment near the origin of the posterior inferior cerebellar artery (high-riding VA-PICA junction aneurysm) can be challenging.Objective: We demonstrate the microsurgical clipping technique of such an aneurysm using a modified retromastoid approach (MRMA) and glossopharyngeal-cochlear triangle (GCT).Surgical Technique: A 50-year-old female with a ruptured high-riding left VA-PICA junction aneurysm underwent an MRMA. Using segmental vessel isolation with proximal and distal temporary clips, this aneurysm was occluded through the GCT by applying a tandem clipping technique while preserving the PICA.Results: The procedure was uneventful. Apart from transient ataxia, she recovered completely and maintains a good status at follow-up.Conclusion: In high-riding VA-PICA junction aneurysms, a conventional far lateral approach may create awkward viewing and working angles. An MRMA with a horizontal trajectory through the GCT may be a more appropriate strategy. [ABSTRACT FROM AUTHOR]

Background and Introduction: Unlocking of the frontotemporal dural fold (FTDF) and extradural removal of the anterior clinoid process (EACP) are challenging but mandatory skills for micro-neurosurgeons. Despite the presence of an extensive body of literature on this subject, the translation of this cadaveric and 3D simulation to a real patient turns out to be a very demanding and difficult task.Objective: This video is aimed to address the surgical nuances and major adjustments necessary in the unlocking of the FTDF and extradural ACP removal in an actual case for an early-career neurosurgeon.Surgical Technique: A 40-year lady presented with features of acromegaly with radiological evidence of significant component of the tumor in the right cavernous sinus along with sellar suprasellar component. To achieve a good hormonal control, a complete tumor excision was required, which was achieved with FTDF and EACP removal. The cavernous sinus was approached through the Parkinson's triangle.Results: The patient had uneventful recovery and good hormonal control at the 3-month follow-up.Conclusion: FTDF unlocking and EACP are elegant procedures and need to be learned by all neurosurgeons. This article will provide excellent teaching material for young neurosurgeons. [ABSTRACT FROM AUTHOR]

Background and Introduction: Spinal dural arteriovenous fistula (SDAVF) is a rare but curable condition. Microsurgery is a highly effective and readily affordable treatment modality.Objective: We present a surgical video of SDAVF to demonstrate the operative nuances involved.Surgical Technique: A 53-year-old wheelchair-bound man with spastic paraparesis for 1.5 years was found to have a SDAVF at L1/2 level with a single fistula point. During surgery, a L1-L2 laminectomy and durotomy revealed a dilated vein accompanying the nerve root exiting L1/2 foramen that showed early filling on indocyanine green (ICG) video angiography. This vein was occluded, and a segment of this vein was removed during surgery, which led to resumption of normal spinal cord perfusion.Results: The patient showed gradual recovery of lower limb motor power and improved to assisted ambulation after 3 months.Conclusions: Surgery is a simple, effective, and cost-effective treatment option in SDAVF. [ABSTRACT FROM AUTHOR]

Cushing's disease is rare in the paediatric age group. The disease manifestations are similar to that seen in adults. Most of the management protocols have, therefore, been adopted from experience in adults and the therapeutic strategies employed in the latter group. Management of paediatric Cushing's disease poses significant challenges with regard to achieving an optimal growth, a proper body composition, an adequate bone health and reproductive capability as well as a good quality of life. This article reviews the special clinical, biochemical, radiological, surgical, and adjunctive therapeutic considerations in paediatric Cushing's disease. [ABSTRACT FROM AUTHOR]

Background: This prospective study analyzes the factors responsible for pre and postoperative persistent tinnitus following vestibular schwannoma (VS) surgery and discusses the possible etiopathogenetic mechanisms.Materials and Methods: Sixty-seven consecutive patients with unilateral VS operated via the retrosigmoid-suboccipital approach were included in the study. The Cochlear nerve, often unidentifiable from the tumor capsule, was resected during the surgery. Tinnitus Handicap Inventory (THI) score assessed the severity of pre and postoperative tinnitus.Result: Twenty-eight (41%) patients had preoperative tinnitus. Out of those 28 patients, 24(85%) had significantly improvement in postoperative THI score. In 15 of the 24 patients, tinnitus subsided completely. In 3 of the 28 (10%) patients, THI scores were unaltered, and in 1 of the 28 (3.5%) patients, THI scores worsened. In 39 (58.2%) patients without preoperative tinnitus, 4 (10%) developed a new-onset postoperative tinnitus. Patients with severe sensory neural hearing loss (SNHL) had significantly higher incidence of postoperative persistent tinnitus (PPT) (P = 0.00) compared to those with mild-to-moderate SNHL. Patients with profound SNHL, however, had a much lower incidence of PPT (P = 0.007; odds ratio = 0. 0.077; 95% CI: 0.009-0.637). Large (P = 0.07) and giant schwannomas (P = 0.03) VS had an increased risk of PPT. Patients with PPT further analyzed with brain stem auditory evoked response (BAER) showed normal contralateral waveform.Conclusion: Assessment of tinnitus is mandatory during the management of VS as there are high chances (nearly 46%) of PPT. Preoperative tinnitus, linked to the degree of SNHL (higher incidence in severe SNHL compared to mild-to-moderate/profound SNHL), is dependent on an intact cochlear nerve functioning. However, PPT is dependent on other mechanisms (brain stem/ipsilateral cochlear nuclei compression, and cortical reorganization) as it persists despite cochlear nerve resection. [ABSTRACT FROM AUTHOR]

Background: Progressive vision loss is a dismal sequelae of idiopathic intracranial hypertension (IIH) and secondary intracranial hypertension with cerebro-venous sinus thrombosis (CVST). The initial management revolves around weight loss, acetazolamide, steroids, and diuretics. A subset of unfortunate patients, refractory to medical therapy, need surgical intervention in the form of CSF diversion or optic nerve decompression (OND). The ONDd is an emerging alternative with encouraging early results.Aim: In our study, we share our experience of ONDd by endoscopic endonasal corridor, highlighting the technical nuances of procedure and discuss the indications of the same in the era of advanced technology.Materials and Methods: A retrospective, noncomparative review of the medical records of all the patients of IIH (ICHD-III criteria) with severe vision loss, refractory to medical treatment, and with established objective evidence of papilledema was done. All the patients were operated in our department by endoscopic endonasal sheath fenestration.Results: Nine patients (M:F 3:6) underwent endoscopic endonasal optic nerve decompression (2016-2019) approach for medically refractive IIH (n = 6) and CVST (n = 3). The mean age of population was 21.44 ± 5.14 years; 6 patients had improvement in headache and 6 had improvement in visual acuity. The visual acuity deteriorated in two patients (n = 1 IIH and n = 1 CVST with dural AVF). One patient needed postoperative lumbar drain for CSF leak, while none had meningitis.Conclusion: Endoscopic optic nerve sheath fenestration is minimally invasive and effective alternative with promising outcome in the management of medical refractory IIH or CVST. [ABSTRACT FROM AUTHOR]

Introduction: Petroclival meningiomas are based on or arising from the petro-clival junction in upper two-thirds of clivus, medial to the fifth cranial nerve. This study focuses on the surgical experience in resecting large-giant tumors >3.5 in size predominantly utilizing middle fossa approaches.Material and Methods: 33 patients with a large or a giant petroclival meningioma (size >3.5 cm) were included. Clinical features, preoperative radiological details, operative findings, and postoperative clinical course at the follow-up visit were reviewed. Group A tumors (n = 17,51.5%) were sized 3.5cm-5cm, and Group B (n = 16,48.48%) tumors were of size >5 cm. Extent of resection was described as 'gross total' (no residual tumor), 'near total' (<10% residual tumor) and 'subtotal resection' (>10% residual tumor). Glasgow outcome scale (GOS) quantitatively scored postoperative neurological outcome (mean follow up: 35.77months; range 1-106 months).Results: 25 (75.8%) patients had tumour extension into both supratentorial and infratentorial compartments. Extension into Meckel's cave (n = 25,75.8%), cavernous sinus (n = 17,48.4%], sphenoid sinus (n = 12,38.7%] and suprasellar area [12,38.7%] was often seen. In 31 (93.9%) patients, the tumor crossed the midline in the premedullary, prepontine, and interpeduncular cisterns. In 20 (60.6%) patients, the tumour extended below and posterior to the internal auditory meatus (IAM), while in 13 (39.4%) patients, the tumor was located above and anterior to the IAM. Kawase's approach was the most commonly used approach in 16 (48.48%) patients and resulted in maximum tumor resection. Other approaches included half-and-half (trans-Sylvian with subtemporal) [n = 6, 18.18%]; frontotemporal craniotomy with orbitozygomatic osteotomy [n = 1, 3%] and retromastoid suboccipital craniectomy (RMSO) [n = 7, 21.21%]. In 2 (6.06%) patients, staged anterior petrosectomy with RMSO; and, in 1, staged presigmoid with half-and-half approach was used. Gross total excision was achieved in 12 (36.36%), near-total excision in 15 (45.45%) and subtotal excision in 6 (18.18%) patients. 20 (60.6%) patients had a good functional outcome; 6 patients succumbed due to meningitis, pneumonitis, perforator injury or a large tumor recurrence.Conclusions: Half-and-half approach was used in tumors with middle and posterior cranial fossae components often extending to the suprasellar region. Kawase's anterior petrosectomy was utilized in resecting tumors with predominant posterior fossa component (along with a small middle fossa component) that was crossing the midline anterior to the brain stem, and mainly situated superomedial to the IAM. Tumors confined to the posterior fossa, that extended laterally and below the IAM were resected utilizing the RMSO approach. Occasionally, a combination of these approaches was used. Middle fossa approaches help in significantly avoiding morbidity by an early devascularisation and decompression of the tumor. In tumors lacking a plane of cleavage, a thin rim of capsule of tumor may be left to avoid brain stem signs. [ABSTRACT FROM AUTHOR]

A simultaneous odontoid decompression and bilateral posterior atlanto-axial facetal distraction, C1-2 joint spacer/bone graft placement and stabilization may be performed utilizing the 'posterior-only' approach. This procedure may be performed utilizing a single posterior midline incision, a bilateral posterior approach to the C1-2 facet joints and a bilateral posterolateral approach to the odontoid process and C2 body. It may be carried out in situations where a C1-2 non-reduction/partial reduction using a 'posterior alone' procedure is anticipated due to the complex bony/soft tissue configuration anterior at the thecal sac existing at the cervicomedullary junction. In the four cases described in this report, the procedure led to a successful circumferential decompression at the level of foramen magnum along with posterior C1-2 facetal distraction and stabilization in various complex craniovertebral junction anomalies (atlantoaxial dislocation [AAD] and/or a high basilar invagination [BI] associated with a significantly retroverted dens, along with a rotatory component, due to grossly asymmetrical facet joints). This technique may also be utilized in those diseases that result in an anterior osteoligamentous mass at the CVJ associated with C1-2 instability. [ABSTRACT FROM AUTHOR]

Objective: Arterial spin labeling (ASL) magnetic resonance (MR) perfusion is a noninvasive and repeatable method for quantitatively measuring cerebral blood flow (CBF). This study aims to compare measurements of ASL-derived CBF with dynamic susceptibility contrast (DSC) MRI in the assessment of enhancing brain tumors (primary and metastatic), with an aim to use ASL as an alternative to DSC.Materials and Methods: Thirty patients with newly diagnosed brain tumors (16 meningiomas, 6 gliomas, 3 metastases, 2 cerebellopontine angle schwannoma, 1 central neurocytoma, and 2 low-grade gliomas) were examined using a 3T MR scanner. Values of CBF, regional cerebral blood flow (rCBF), and regional cerebral blood volume (rCBV) were determined in the tumor (T) as well as in the contralateral normal gray matter (GM) and white matter (WM). Tumor-to-GM or WM CBF, rCBF, and rCBV ratios were calculated to estimate normalized perfusion values (i.e., ASL normalized tumor blood flow [nTBF], DSC nTBF, and DSC normalized tumor blood volume [nTBV]) from the ASL and DSC techniques. ASL and DSC MRI derived perfusion parameters were compared using paired t-test and correlated using Pearson correlation coefficient.Results: Mean values for ASL nTBF and DSC nTBF using contralateral GM as the reference point were 2.98 ± 1.67and 2.91 ± 1.43, respectively. A very strong correlation coefficient was found between ASL nTBF and DSC nTBF with contralateral GM as the reference region (r = 0.903; R2= 0.813). Mean DSC nTBF and DSC nTBV also showed strong correlation (r = 0.83; R2= 0.701).Conclusion: Our study results suggested that measurement of CBF from ASL possesses the potential for a noninvasive assessment of blood flow in intracranial tumors as an alternate to DSC MRI, in those patients requiring multiple follow-up imaging and in patients with impaired renal functions. [ABSTRACT FROM AUTHOR]

A 23-year-old male patient presented with intermittent cerebrospinal fluid (CSF) rhinorrhea for four years and right sensorineural hearing loss for two years. VP shunt in first stage surgery reduces the chances of postoperative CSF leak and allows the repair to heal, while the patient waits for the excision of the vestibular schwannoma as the second stage surgery. The chronically raised ICP due to vestibular schwannoma was probably compensated by herniation of the brain through the extensive skull base defects and intermittent CSF leak [Figure 1]a and [Figure 1]b. [Extracted from the article]

Context: Pterional or fronto-temporal craniotomy, developed by Prof. M. G. Yasargil, is among the most familiar skull base surgery techniques. The cranio-orbito zygomatic (COZ) approach evolved to address the significant limitations of the pterional exposure in excising some parasellar lesions. Although extremely versatile, the COZ technique involves extensive dissection of the cranio-facial soft tissue and reconstruction towards the end of the procedure. The zygomatic reshaping is a minor modification of the pterional approach, which enhances the exposure possible through the classical approach and often circumvents the need for an orbito-zygomatic osteotomy.Aims: To demonstrate the technique of reshaping of the zygomatic complex for an optimum surgical exposure and cosmetic results.Materials and Methods: Between April 2013 and December 2014, 8 patients with various middle and anterior skull base lesions were operated using this technique. These patients form the clinical material for this study. The clinical details, radiological images and follow-up data of these patients were collected for this clinical series.Results: No mortality or significant morbidity were noted in this series. The post-operative cosmetic results were also acceptable.Conclusions: A quick and easy modification of the classical pterional approach through zygomatic reshaping has the potential to provide a significantly enhanced surgical exposure for parasellar lesions. Using this approach, it might be possible to avoid an extensive orbito-zygomatic osteotomy in suitable lesions. [ABSTRACT FROM AUTHOR]

Background: Aneurysms of proximal (AI)-segment of anterior cerebral artery (ACA) constitute <1% of all intracranial aneurysms. Aim: Management dilemmas of A1-segment aneurysms were studied utilizing a new classification based upon their location on the longitudinal and circumferential axis of A1-segment. Setting and Design: Tertiary care referral center. Materials and Methods: This is a retrospective analysis of 14 patients (0.98%; mean age: 38.02 ± 15.74 years) with AI-segment aneurysms. The data collected included clinical features, computed tomography (CT) scan and CT-angiography (CTA)/digital subtraction angiography (DSA) findings, modified Hunt and Hess (H and H) grade, surgical steps and difficulties encountered. Results: The modified Hunt and Hess (H and H) grades in the 14 patients were: grade I in two, grade II in two, grade III in four, grade IV in five and grade V in 1. The mean ictus-admission duration was 5.07 ± 2.30 days (range: 1-10 days). Multiple aneurysms were two. Thirteen patients underwent clipping and one, wrapping. Bilateral lateral ventricle hemorrhage occurred in 8 (66%) patients and frontal intracerebral hematoma in 2 (16.66%) patients. In one patient, the aneurysm could only be detected following the third angiogram. AI-aneurysms were classified as proximal (n = 6), distal (n = 7), and mid-segment (n = 1); and, anterior (n = 2), posterior-inferior (n = 7) and posterior-superior (n = 5). Follow-up (range: 6 months-10 years, mean: 2.9 years) recovery (assessed using Modified Rankin's score or mRS) correlated with preoperative status. The preoperative H and H grade and follow-up mRS status were as follows: H and H I (n = 2): mRS 0 (asymptomatic, n = 2); H and H II (n = 2): mRS 1 (minor symptoms without disability, n = 2); H and H III (n = 4):mRS 1 (n = 2) and mRS 2 (slight disability but performing unassisted activities of daily living, n = 1); H and H IV (n = 5): mRS 3 (moderate disability, requiring help for daily living but unassisted walking, n = 2) and mRS 4 (moderately severe disability, requiring help for daily living and walking, n = 2). One patient each from H and H grade III, IV and V died (mRS 6) during treatment due to severe vasospasm, pneumonitis and septicemia. Conclusions: AI-segment aneurysms have unique properties: rupturing of small-sized aneurysms; multiplicity; undetectable on initial imaging; frontal lobar/intraventricular bleeding; origin from main trunk and not bifurcating points; neck obscuration by AI-trunk; close proximity to perforators; and, associated AI-segment and ACA anomalies. A new classification identifies surgical difficulties inherent in different sites of origin of A1-aneurysms. [ABSTRACT FROM AUTHOR]

Background: Aneurysms of proximal (Al)-segment of anterior cerebral artery (ACA) constitute <1% of all intracranial aneurysms. Aim: Management dilemmas of Al-segment aneurysms were studied utilizing a new classification based upon their location on the longitudinal and circumferential axis of Al-segment. Setting and Design: Tertiary care referral center . Materials and Methods: This is a retrospective analysis of 14 patients (0.98%; mean age: 38.02 ± 15.74 years) with Al-segment aneurysms. The data collected included clinical features, computed tomography (CT) scan and CT-angiography (CTA)/digital subtraction angiography (DSA) findings, modified Hunt and Hess (H and H) grade, surgical steps and difficulties encountered. Results: The modified Hunt and Hess (H and H) grades in the 14 patients were: grade I in two, grade II in two, grade III in four, grade IV in five and grade V in 1. The mean ictus-admission duration was 5.07 ± 2.30 days (range: 1-10 days). Multiple aneurysms were two. Thirteen patients underwent clipping and one, wrapping. Bilateral lateral ventricle hemorrhage occurred in 8 (66%) patients and frontal intracerebral hematoma in 2 (16.66%) patients. In one patient, the aneurysm could only be detected following the third angiogram. A1-aneurysms were classified as proximal (n = 6), distal (n = 7), and mid-segment (n = 1); and, anterior (n = 2), posterior-inferior (n = 7) and posterior-superior (n = 5). Follow-up (range: 6 months-10 years, mean: 2.9 years) recovery (assessed using Modified Rankin's score or mRS) correlated with preoperative status. The preoperative H and H grade and follow-up mRS status were as follows: H and H I (n = 2): mRS 0 (asymptomatic, n = 2); H and H II (n = 2): mRS 1 (minor symptoms without disability, n = 2); H and H III (n = 4):mRS l (n = 2) and mRS 2 (slight disability but performing unassisted activities of daily living, n = 1); H and H IV (n = 5): mRS 3 (moderate disability, requiring help for daily living but unassisted walking, n = 2) and mRS 4 (moderately severe disability, requiring help for daily living and walking, n = 2). One patient each from H and H grade III, IV and V died (mRS 6) during treatment due to severe vasospasm, pneumonitis and septicemia. Conclusions: A1-segment aneurysms have unique properties: rupturing of small-sized aneurysms; multiplicity; undetectable on initial imaging; frontal lobar/intraventricular bleeding; origin from main trunk and not bifurcating points; neck obscuration by Al-trunk; close proximity to perforators; and, associated Al-segment and ACA anomalies. A new classification identifies surgical difficulties inherent in different sites of origin of Al-aneurysms. [ABSTRACT FROM AUTHOR]

Surgical excision of rare, large-to-giant posterior third ventricular (PTV) meningiomas [including velum-interpositum meningiomas (VIM; postero-superior venous complex displacement; without falco-tentorial attachment) and falco-tentorial meningiomas (FTM; falco-tentorial attachment; displacing major veins antero-inferiorly)] is extremely challenging. To study the management nuances in the excision of large-to-giant PTV meningiomas. Tertiary care referral center. Four patients with large (> 3 cm; n = 2) and giant (>5 cm; n = 2) meningiomas (FTM = 2; VIM = 2, mean tumor size = 4.9 cm) underwent occipital transtentorial approach (OTT) for tumor excision. One also underwent a second-stage supracerebellar infratentorial (SCIT) approach. The side of approach was determined by lateral tumor extension and venous displacement (right = 3, left = 1). Near-total removal or subtotal excision (< 10% remaining) with radiotherapy was performed in 2 patients each, respectively. At follow-up (mean: 14.75 months), clinical improvement without tumor recurrence/re-growth was achieved. Extent of excision was determined by position of great vein of Galen; tumor attachment to falco-tentorium or major veins; its consistency; its lateral and inferior extent; and, presence of a good tumor-neuraxial arachnoidal plane. OTT is the preferable approach for large-to-giant meningiomas as it provides a wider corridor and better delineation of tumor-neurovascular arachnoidal interface. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the MR findings in clinically suspected cases of Hirayama disease. Materials and Methods: The pre and post contrast neutral and flexion position cervical MR images of eight patients of clinically suspected Hirayama disease were evaluated for the following findings: localized lower cervical cord atrophy, asymmetric cord flattening, abnormal cervical curvature, loss of attachment between the posterior dural sac and subjacent lamina, anterior shifting of the posterior wall of the cervical dural canal and enhancing epidural component with flow voids. The distribution of the above features in our patient population was noted and correlated with their clinical presentation and electromyography findings. Observations: Although lower cervical cord atrophy was noted in all eight cases of suspected Hirayama disease, the rest of the findings were variably distributed with asymmetric cord flattening, abnormal cervical curvature, anterior shifting of the posterior wall of the cervical dural canal and enhancing epidural component seen in six out of eight (75%) cases. An additional finding of thoracic extension of the enhancing epidural component was also noted in five out of eight cases. Conclusion: Dynamic post contrast MRI evaluation of cervicothoracic spine is an accurate method for the diagnosis of Hirayama disease. [ABSTRACT FROM AUTHOR]

Background: Low backache (LBA) is now increasing in younger population due to misdirected spinal kinetics secondary to improper posture, heavy load lifting and motorbike driving. Hence minimally invasive procedures are increasingly sought after. Among these, PLDD is currently popular and in use. We present our long term follow-up in the use of Nd:YAG laser for PLDD. Aim: To evaluate the efficacy of PLDD in treatment of contained herniation of lumbar discs & long term follow up results. Materials and Methods: Forty patients with contained lumbar disc herniation on MRI and who did not respond to 6 weeks conservative treatment were subjected to PLDD. L4-5 disc was treated in 31, L5-S1 in 12 and L1-2 and L3-4 in one each. Nd:YAG laser at 1064 nm was used for the procedure. Total laser energy of 1500-2000 Joules was delivered at the disc space depending upon the size. Results: There was immediate pain relief in 32/40 (80%). According to MacNab criteria good to fair response was seen in 37/40 (92%) and 3 patients (7.5%) responded poorly to this treatment. On follow up which ranged from 1 to 7 years, 34/40 (85%) had pain relief with no need for further treatment. Complications: Significant pain at local puncture site was experienced by 8 (20%), pain during lasing was experienced by one. One patient developed muscular spasm. Conclusion: Percutaneous laser disc decompression is a safe, relatively noninvasive and effective treatment modality for contained, nonsequestered, herniated lumbar disc disease in carefully selected patients. [ABSTRACT FROM AUTHOR]

The article presents a case study of five-year-old patient diagnosed with Chiari malformation Type one (CM1) and syringomyelia through spontaneous resolution. Topics discussed include surgical intervention for treating the disorders, the variance of tonsillar position with age and the need of revisiting the treatment strategy for asymptomatic Chiari patients.

Background: Congenital spondylolisthesis is characterized by dysplasia of the facet joint or congenital defect in the pars., Objective: Our study highlights the clinical and radiological profile, various treatment options, and outcomes in patients with pediatric congenital lumbar and lumbosacral spondylolisthesis., Methods: A retrospective analysis and follow-up of 22 patients were conducted presented with radiological diagnosis of congenital lumbar/lumbosacral spondylolisthesis (2018-2021)., Results: Twenty patients (91%) had L5-S1 listhesis and two patients (9%) had L4-L5 listhesis. Six (27.3%) patients had low-grade listhesis (grades 1-2), 16 (72.7%) had high-grade listhesis (grades 3-5). Seventeen (77.3%) had S1, three (13.6%) had L5, and two (9%) had both L4-L5 radiculopathy. All patients had neurogenic claudication. One had an associated spina bifida occulta. Six (27.3%) patients underwent two-level fixation, and 16 (72.7%) underwent three-level fixation. Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS TLIF) was done in two patients. Revision of at least one screw was done in three patients. After one year of follow-up, all the patients had 75-100% relief in radicular pain and neurogenic claudication. The Oswestry Disability Index (ODI) score in preop for all patients was 41-60% and postoperatively they showed an improvement in ODI score (0-20). The postoperative low back pain score on the Numeric Rating Scale was 0-1 for all patients., Conclusion: Congenital lumbar spondylolisthesis usually presents with high-grade listhesis. Management of such cases is a surgical challenge but posterior decompression resulted in relief of pain in all patients. However, in situ fixation without reduction is also effective in selective cases where attempts to reduce the listhesis result in a decline in intraoperative neuromonitoring parameters., (Copyright © 2024 Copyright: © 2024 Neurology India, Neurological Society of India.)

Competing Interests: None