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Background: Despite a recent surge in keyhole approaches to aneurysm clipping, only few studies have compared these approaches, and none have laid any foundation or roadmap for surgeons newly venturing into these procedures. Objectives: To report a single surgeon's experience of multiple keyhole approaches to these aneurysms, and to highlight the case selection algorithm, technical nuances, and surgical results. Material and Methods: Twenty-four patients (25 aneurysms) underwent aneurysm clipping using either a mini-pterional approach (MPA), lateral supraorbital approach (LSO), or a supraorbital keyhole approach (SOKHA). Intraoperative premature rupture, adequacy of clipping, and immediate postoperative and long-term functional outcomes were recorded. Results: All but five patients presented with ruptured aneurysms (Hunt and Hess grade 1 in 12 patients, grade 2 in 5 patients, and grade 3 in 2 patients). The anterior communicating artery (A-Comm; n = 14, 56%) was most frequently involved with aneurysms. The MPA was most frequently employed (n = 11, 45.8%), followed by the LSO (n = 9, 37.5%) and the SOKHA (n = 4, 16.7%). An intraoperative rupture (total n = 5, 20.8%) was most frequently seen in the SOKHA group (50%) and the only case of inadequate aneurysm clipping resulted from inadequate clipping ergonomics during the SOKHA for A-Comm aneurysm. Major complications occurred in the supraorbital approaches (one each in the LSO and SOKHA). Irrespective of the approach used, the long-term outcomes were excellent. Conclusion: In properly selected patients, keyhole approaches--particularly the MPA and the LSO--can provide excellent surgical outcomes. The learning curve in the SOKHA is steeper. A pragmatic case selection algorithm is proposed. Keywords: Aneurysm, interhemispheric keyhole, mini craniotomy, mini-pterional approach, subarachnoid hemorrhage, supraorbital approach, Author(s): Kuntal K. Das (corresponding author) [1]; Anant Mehrotra [1]; Awadhesh K. Jaiswal [1]; Vipin Sahu [1]; Preetham Dange [1]; Priyadarshi Dikshit [1]; Sanjeev Pattankar [1]; Pawan K. Verma [1]; [...]

This study replicates Ahn, Khandelwal, and Wei’s (2011) model of intermediary trade. The study produces two main results. First, the authors are able to reproduce empirical evidence for AKW’s three main predictions for Chinese exports. This is impressive because much of the data for their replication are independently sourced. However, when the authors subject their model to additional tests, they find that the evidence is not robust. Using more recently available data to test AKW′s first prediction, the authors estimate coefficients that are wrong-signed and significant. When they re-analyze the evidence supporting the second and third predictions, they find that the full sample results mask significant heterogeneity across Chinese regions. In many cases, key coefficients are insignificant. In a few cases, they are wrong-signed and significant. Finally, using multiple versions of a key variable measuring the number of required import documents by country, the authors discover that the results are not robust across versions.

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]

The rosette-forming glioneuronal tumor (RGNT) is an uncommon entity and carries a special character because of its mixed glial and neuronal composition in the histomorphological appearance. These lesions have a benign character and carry a good outcome if undergoes gross total resection. Over the past 15 years, there have been a significant change in their nomenclature depending upon the location to histological composition. Herein, we report an interesting case of a 26-year-old lady who was diagnosed to have the lesion at the septum pellucidum with significant symptoms in the form of headache and seizure episodes. A gross total resection was achieved and she made an uneventful recovery. We discuss the literature on the incidence, location, and histological characteristics of the RGNT in various age groups. [ABSTRACT FROM AUTHOR]

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]

Background: Intramedullary ependymom a is a rare primary tumor in the pediatric population. The World Health Organization (WHO) grade II pediatric intramedullary ependymoma (PIME) is the most common in frequency, though it is a less discussed pathological grade. This study aims at sharing the clinical experience and management outcome of WHO grade II PIME from a tertiary care center. Materials and Methods: The clinico radiological details of all histologically proven, newly diagnosed primary PIME that underwent management were collected. Recurrent lesions and other spinal cord tumors were excluded. Details of surgical intervention and follow up visits were reviewed from the record keeping system. The surgical nuances and outcome predictors in the form of functional grade were analyzed. The statistical data were calculated by using the appropriate statistical tests. Results: The mean age of the study population was 16.3 ± 4.0 years. The male to female ratio was 2:1. The pain was noticed in 14 patients (14/18 [77.8%]), and four (22.2%) patients were ambulant at the time of admission. Overall, 15 (83.3%) patients underwent total excision, and subtotal excision was achieved in three patients. The median follow up period was 31.0 months, and the range was 2-126 months. After surgical decompression of tumor, there was a significant improvement in the modified McCormick's grade, when median score was compared between preoperative period and the last follow up visits (4 [2.8-4] vs. 2 [2-3], P = 0.001). There was one case of surgical mortality, with two symptomatic recurrences after surgical resection. Conclusions: The progression free survival (PFS) and overall survival (OS) depend on early excision at better functional status. Age, gender, and vertical extension of tumor have a debatable impact on the overall outcome in PIME. [ABSTRACT FROM AUTHOR]

Although computers are universal in the classroom, nearly 20 million children in the United States do not have computers in their homes. Surprisingly, only a few previous studies explore the role of home computers in the educational process. Home computers might be very useful for completing school assignments, but they might also represent a distraction for teenagers. We use several identification strategies and panel data from the two main U.S. data sets that include recent information on computer ownership among children--the 2000-2003 Current Population Survey (CPS) Computer and Internet Use Supplements matched to the CPS basic monthly files and the National Longitudinal Survey of Youth 1997 (NLSY97)--to explore the causal relationship between computer ownership and high school graduation and other educational outcomes. Teenagers who have access to home computers are 6-8 percentage points&apos; more likely to graduate from high school than teenagers who do not have home computers after controlling for individual, parental, and family characteristics. We generally find evidence of positive relationships between home computers and educational outcomes using several identification strategies, including controlling for typically unobservable home environment and extracurricular activities in the NLSY97, fixed effects models, instrumental variables, and including future computer ownership and falsification tests. Home computers may increase high school graduation by reducing nonproductive activities, such as truancy and crime, among children in addition to making it easier to complete school assignments. (JEL I2), I. INTRODUCTION The federal government has made the provision of computer and Internet access to schoolchildren a top priority. Spending on the E-rate program, which provides discounts to schools and [...]

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]

Idiopathic trigeminal neuralgia (TN) due to an embedded arteriovenous malformation (AVM) on the trigeminal root entry zone (REZ) is rare but a potentially challenging condition to manage. Herein, we report such a case with an additional unruptured aneurysm on the feeding artery and highlight the role of a multimodality approach to their management. A 50-year-old female presented with drug-resistant right-sided trigeminal neuralgia for one year. The magnetic resonance imaging (MRI) suggested a possibility of AVM, the angiographic study showed an AVM nidus with feeders from the right anterior inferior cerebellar artery (AICA) and a dilated right intrinsic pontine artery, the latter showing a flow-related aneurysm towards its brainstem end. The flow-related aneurysm, as well as the dilated intrinsic pontine artery feeder, was embolized at first. During surgery, the AVM was found embedded inside the root entry zone. Parts of the AVM and its draining vein were partially coagulated followed by microvascular decompression of the AICA loop as well as a feeder emanating from it following which the patient recovered completely. She subsequently received gamma knife surgery (GKS) for the residual AVM and remained asymptomatic after 3.5 years of GKS. AVM-related TN are rare, and the additional presence of a feeding artery aneurysm increases the management complexity. Endovascular management of the aneurysm followed by microvascular decompression (MVD) and tailored AVM coagulation represent a prompt and effective means of pain control. Subsequent GKS is necessary to obliterate the AVM nidus. [ABSTRACT FROM AUTHOR]

Previous studies investigating the effect of exchange rate changes on a country's exports have found little evidence that exchange rates matter. This "Exchange Rate Disconnect Puzzle" may stem from the fact that studies have mostly focused on aggregate data. Using HS-6 digit product-level data for Chinese exports, we analyze the effect of real exchange rate (RER) as well as the volatility of RER of the Chinese RMB. By decomposing China's exports into its "extensive" and "intensive margins," we find that RER volatility significantly impacts Chinese exports via both the margins. RER volatility increases the uncertainty and deters new firms from entering the market. As less firms operate, the export share of the existing firms increase. The overall effect of this volatility is slightly positive. We find that these effects are dominant for the minor trading partners of China compared to its major trading partners. We find weak evidence that RER depreciation affects China's exports via the extensive margin. [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]

We analyse discrepancy in the trade data between China and New Zealand, where what China reports as its exports to New Zealand and what New Zealand reports as its imports from China reached an alarming level of US$2.5 billion in 2014. We investigate the roles that export-tax and import-tariff avoidance play in explaining this discrepancy. We find strong evidence of export-tax avoidance for China's exports to New Zealand that explains 11–27% of the missing exports, equivalent to 3.9–8.8% of true export value. We find only weak evidence of import-tariff avoidance in either direction. [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]

Introduction: With improvements in overall and progression-free survival in gliomas, current focus in neurosurgical oncology has largely shifted to the issue of quality of life (QOL) after treatment. There are not too many prospective studies evaluating QOL in these patients. We prospectively analyzed the health related quality of life (HRQOL) using the short form (SF) 36 questionnaire among patients harbouring a supratentorial glioma who underwent surgery at a tertiary care center in India.Methods: HRQOL was evaluated prospectively in 103 patients, between May 2016 and November 2017, at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow. Score improvements were evaluated in terms of the smallest difference that a patient perceived to be clinically beneficial. The responsiveness of scores was assessed as minimum clinically important difference (MCID), effect size (ES) and relative efficiency. Cronbach's alpha co-efficient was used to assess the reliability of the result obtained.Results: The mean pre-operative score was the highest in the mental health domain (50.21±21.45) and significantly lower in patients with raised intracranial pressure (ICP), pre-operative deficits, a poor Karnofsky performance scale (KPS) score, in large tumors (>4cm) located in an eloquent location and in deep-seated tumors. A significant improvement was noted across all domains except the physical role (P-value 0.20). Overall, the general health domain was most responsive to change with the largest t-value (6.56) and 55.7% patients achieved their target MCID in general health (GH) domain. Among all the factors studied, only a low baseline SF-36 score was significantly associated with a change in QOL after surgery.Conclusion: Most parameters of HRQOL improved following surgery. Only small-to-moderate improvements occured in the early follow-up period. Large improving trends were noted on a long-term basis, irrespective of the histo-pathological grade. Similar improvements were also noted in patients who subsequently underwent re-surgery despite the development of post-operative complications or new deficits. Also, a low baseline QOL score heralded a poor survival. [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical topics including a comparison of transforaminal endoscopic discectomy and microdiscectomy, the effect of lordotic correction on C5 palsy after cervical laminectomy and fusion, and mechanical thrombectomy following intravenous alteplase after stroke.

Primitive neuroectodermal tumors (PNET) are highly malignant, yet relatively uncommon neoplasms of the central nervous system. Although a host of different parts of the nervous system can be affected, intramedullary location of PNET is extremely rare. Most reports on intramedullary PNET have reported central PNET (cPNET); peripheral PNET (pPNET) affecting intramedullary spinal location is extremely rare. Till now, seven such cases of intramedullary pPNET have been described in medical literature in English. Here, we report an 11-year-old boy with cervicomedullary junction intramedullary pPNET who presented with intratumoral bleed, wherein the clinical presentation and radiological features gave us no clue preoperatively about the underlying diagnosis. In this report, we additionally review certain salient aspects of this dreaded disease in light of the existing evidence. [ABSTRACT FROM AUTHOR]