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Introduction: - Accurate detection, segmentation, and volumetric analysis of brain lesions are essential in neuro-oncology. Artificial intelligence (AI)-based models have improved the efficiency of these processes. This study evaluated an AI-based module for detecting and segmenting brain metastases, comparing it with manual detection and segmentation., Methods: - MRIs from 51 patients treated with Gamma Knife radiosurgery for brain metastases were analyzed. Manual lesion identification and contouring on Leksell Gamma Plan at the time of treatment served as the gold standard. The same MRIs were processed through an AI-based module (Brainlab Smart Brush), and lesion detection and volumes were compared. Discrepancies were analyzed to identify possible sources of error., Results: - Among 51 patients, 359 brain metastases were identified. The AI module achieved a sensitivity of 79.2% and a positive predictive value of 95.6%, compared to a 93.3% sensitivity for manual detection. However, for lesions > 0.1 cc, the AI's sensitivity rose to 97.5%, surpassing manual detection at 93%. Volumetric agreement between AI and manual segmentations was high (Spearman's ρ = 0.997, p < 0.001). Most lesions missed by the AI (53.8%) were near anatomical structures that complicated detection., Conclusions: - The AI module demonstrated higher sensitivity than manual detection for metastases larger than 0.1 cc, with robust volumetric accuracy. However, human expertise remains critical for detecting smaller lesions, especially near complex anatomical areas. AI offers significant potential to enhance neuro-oncology practice by improving the efficiency and accuracy of lesion management., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background/objectives: To determine the impact of stereotactic radiosurgery on outcomes of metastatic breast cancer with intracranial metastases., Methods: We systematically searched the PubMed and EMBASE databases for studies published between 1 January 1990 and 1 August 2024. Primary research articles evaluating the outcomes of stereotactic radiosurgery on intracranial metastases from breast cancer were included. Adverse events were defined as leptomeningeal disease, radiation necrosis, seizure, and headache. The pooled estimate was calculated using the DerSimonian and Laird approach., Results: Sixteen studies encompassing 1228 patients met the inclusion criteria. Our analysis revealed a median survival duration of 13.1 ± 3.8 months and a pooled 1-year overall survival rate of 53.1% after SRS treatment. There was a 29% local recurrence rate at 1 year and a 35% overall distant recurrence rate. In addition, our analysis found a relatively low rate of acute adverse events at 15.5%., Conclusions: SRS demonstrates promising efficacy and safety in managing intracranial metastases from breast cancer, with a favorable toxicity profile.

Purpose: The differentiation between adverse radiation effects (ARE) and tumor recurrence or progression (TRP) is a major decision-making point in the follow-up of patients with brain tumors. The advent of immunotherapy, targeted therapy and radiosurgery has made this distinction difficult to achieve in several clinical situations. Contrast clearance analysis (CCA) is a useful technique that can inform clinical decisions but has so far only been histologically validated in the context of high-grade gliomas., Methods: This is a series of 7 patients, treated between 2018 and 2023, for various brain pathologies including brain metastasis, atypical meningioma, and high-grade glioma. MRI with contrast clearance analysis was used to inform clinical decisions and patients underwent surgical resection as indicated. The histopathology findings were compared with the CCA findings in all cases., Results: All seven patients had been treated with gamma knife radiosurgery and were followed up with periodic MR imaging. All patients underwent CCA when the necessity to distinguish tumor recurrence from radiation necrosis arose, and subsequently underwent surgery as indicated. Concordance of CCA findings with histological findings was found in all cases (100%)., Conclusions: Based on prior studies on GBM and the surgical findings in our series, delayed contrast extravasation MRI findings correlate well with histopathology across a wide spectrum of brain tumor pathologies. CCA can provide a quick diagnosis and have a direct impact on patients' treatment and outcomes., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Surveys generate valuable data in epidemiologic and qualitative clinical research. The quality of a survey depends on its design, the number of responses it receives, and the reporting of the results. In this study, we aimed to assess the quality of surveys in neurosurgery., Methods: Neurosurgical surveys published between 2000 and 2020 (inclusive) were identified from PubMed. Various datapoints regarding the surveys were collated. The number of citations received by the papers was determined from Google Scholar. A 6-dimensional quality assessment tool was applied to the surveys. Parameters from this tool were combined with the number of responses received to create the survey quality score (SQS)., Results: A total of 618 surveys were included for analysis. The target sample size correlated with the number of responses received. The response rate correlated positively with the target sample size and the number of reminders sent and negatively with the number of questions in the survey. The median number of authors on neurosurgery survey papers was 6. The number of authors correlated with the SQS and the number of citations received by published survey papers. The median normalized SQS for neurosurgical surveys was 65%. The nSQS independently predicted the citations received per year by surveys., Conclusions: The modifiable factors that correlated with improvements in survey design were optimizing the number of questions, maximizing the target sample size, and incorporating reminders in the survey design. Increasing the number of contributing authors led to improvements in survey quality. The SQS was validated and correlated well with the citations received by surveys., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Medicine has begun adapting to new information-sharing paradigms in the hyper-connected social media era. In this milieu, the role of journal websites in the dissemination of clinical and research information needs to be reevaluated., Objective: We sought to explore whether reader engagement with neurosurgical journal websites, reflected by the number of article views and downloads, correlated with the eventual number of citations received by the articles., Methods: The websites of all Medline indexed neurosurgical journals were screened to identify those that provided information regarding the number of abstract and full text views and downloads. Articles published in these journals between July 2010 and June 2011 were included in this analysis. Various article attributes were identified and the number of citations per article was obtained from Google Scholar. The impact factors of the selected journals for the year 2010 were obtained from the Journal Citation Reports., Results: Twenty-two journals that had published 2527 articles were finally included in this analysis. The number of abstract views, full-text views, and downloads all correlated strongly with the journal impact factors in 2010 as well as the eventual citations per article. The number of article downloads independently predicted the citations per article on multivariate analysis. Neurology India had significantly higher article views and downloads but lower citations per article than the other journals., Conclusions: Readers were found to engage significantly with neurosurgical journal websites and therefore, open access to articles would lead to increased visibility of articles, resulting in higher citation rates., (Copyright © 2024 Copyright: © 2024 Neurology India, Neurological Society of India.)

Chaotic lipomas are an extremely rare variant of spinal lipomas. This entity was first defined in 2009 by Pang and colleagues. Not much has been written about this variant. Its characteristic is the haphazard distribution of DREZ (Dorsal root entry zone), nerve roots and placode-lipoma interface. Thus complete/near-total excision of this lesion is quite difficult. We describe a case of chaotic spinal lipoma and elucidate the challenges faced in the management of this entity and review the literature. We performed a thorough systematic review with the keyword 'chaotic', 'Lipomyelomeningocele', 'Complex Lipomyelomeningocele', 'LMMC', 'Lumbar lipoma', 'spinal lipoma' in the google scholar and PUBMED data system for indexed literature on the above topic with no particular time frame. The studies quoted range earliest from 1970 till currently. Additional potential relevant articles were further retrieved through a manual search of references from original reports. Out of 42 studies, a total of 21 publications were selected which could have encountered a chaotic variant, but due to the term introduced only recently in 2009, may have been described differently. Studies encompassing true lipomeningomyelocele were excluded from our review. What we found out? Chaotic lipoma may not be a new entity. The scarce description in literature may be in part due to non-introduction and unclear description of this term earlier. The management of this variant is particularly challenging with basic principles remaining the same. Meticulous near-total excision and placode-lipoma construct are the major obstacles.

Background: Glioblastoma (GBM) is the most frequently diagnosed malignant brain tumor in adults. GBM is usually lethal within 24 months of diagnosis, despite aggressive multimodality treatment. Although it has been established that cancer-related inflammation is associated with worse outcomes, the role of eosinophils, basophils, atopy, and allergy in glioma biology is only gradually being delineated. In this study, we aimed to examine if eosinophil-based and basophil-based indices were altered in patients with GBM compared with healthy controls. We also aimed to study if there was any correlation between these indices and patient-related and tumor-related factors and survival., Methods: This study was a retrospective analysis of prospectively maintained databases. Data pertaining to patient-related and tumor-related factors, hemograms, and survival data were obtained from the electronic medical records of selected patients. Correlations between eosinophil-based and basophil-based indices and these factors were studied, as was the association with overall survival., Results: All the indices were altered in patients with GBM compared with normal healthy controls. The absolute eosinophil count was higher and the neutrophils/eosinophils ratio was lower in the better prognosis groups: those with better performance status; those without features of increased intracranial pressure or altered sensorium at presentation; those with ATRX-retained tumors that did not overexpress p53; and in the long-term survivors. The total lymphocyte count/basophils ratio and the absolute eosinophil count both independently predicted survival in a multivariate analysis., Conclusions: The absolute eosinophil count was consistently higher in the better prognosis groups and is likely to be incorporated into prognostic models for GBM., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The post-bypass stroke risk factors and long-term outcomes of moyamoya patients are not well documented. Therefore, the authors studied 30-day stroke risks and patients' long-term physical, functional, and social well-being., Methods: This was a single-institution combined moyamoya disease (MMD) database interrogation and questionnaire study. From 1991 to 2014, 1250 revascularization procedures (1118 direct bypasses, 132 indirect bypasses) were performed in 769 patients. Completed questionnaires were received from and available for analysis on 391 patients, and 6-month follow-up data were available for 96.4% (741/769) of the patients., Results: The patients consisted of 548 females and 221 males, with a mean age of 32 years (range 1-69 years). Three hundred fifty-eight bypasses were performed in 205 pediatric patients (73% direct bypasses), and 892 revascularizations were performed in 564 adults (96% direct bypasses). Fifty-two patients (6.8%) developed major strokes with a worsening modified Rankin Scale (mRS) score within 30 days postoperatively. The 30-day major stroke risk was 5.3% (41/769) and 2.6% (12/467) after the first and second bypasses, respectively. Logistic regression analysis revealed that older age, modified MRI (mMRI) score, and hemodynamic reserve (HDR) score are clearly associated with higher postoperative stroke risks. Over a mean follow-up of 7.3 years (range 0.5-26 years), the long-term stroke risk among 741 patients was 0.6% per patient-year; 75% of these patients had excellent outcomes (mRS score 0-1). The long-term outcome questionnaire study showed that 84% (234/277) of patients reported resolution or improvement in their preoperative headache, 83% (325/391) remained employed or in school, and 87% (303/348) were self-caring., Conclusions: In this large, single-center surgical series, most of the adult and pediatric patients had direct revascularization, with a 4.2% per-bypass-procedure (6.8% per patient) 30-day major stroke risk and a 0.6% per-patient-year long-term stroke risk. The authors identified various risk factors that are highly correlated with postoperative morbidity (age, mMRI score, and HDR score) and are involved in ongoing work to develop the predictive modeling for future patient selection and treatment.

Background and objective There is a paucity of information regarding the concordance of traditional metrics across publicly searchable databases and about the correlation between alternative and traditional metrics for neurosurgical authors. In this study, we aimed to assess the congruence between traditional metrics reported across Google Scholar (GS), Scopus (Sc), and ResearchGate (RG). We also aimed to establish the mathematical correlation between traditional metrics and alternative metrics provided by ResearchGate. Methods Author names listed on papers published in the Journal of Neurosurgery (JNS) in 2019 were collated. Traditional metrics [number of publications (NP), number of citations (NC), and author H-indices (AHi)] and alternative metrics (RG score, Research Interest score, etc. from RG and the GS i10-index) were also collected from publicly searchable author profiles. The concordance between the traditional metrics across the three databases was assessed using the intraclass correlation coefficient and Bland-Altman (BA) plots. The mathematical relation between the traditional and alternative metrics was analyzed. Results The AHi showed excellent agreement across the three databases studied. The level of agreement for NP and NC was good at lower median counts. At higher median counts, we found an increase in disagreement, especially for NP. The RG score, number of followers on RG, and Research Interest score independently predicted NC and AHi with a reasonable degree of accuracy. Conclusions A composite author-level matrix with AHi, RG score, Research Interest score, and the number of RG followers could be used to generate an "Impact Matrix" to describe the scholarly and real-world impact of a clinician's work., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Kalvapudi et al.)

Background: Medial sphenoid wing meningiomas constitute 15%-20% of all intracranial meningiomas. These lesions have a propensity to encase the vessels of the circle of Willis and the surrounding cranial nerves. Thus, radical excision is a difficult proposition., Objectives: In this paper, we analyzed our series of sphenoid wing meningiomas. We describe our surgical strategy, which was based on zone-wise dissection of the tumor. We describe the complications and outcomes of surgery., Materials and Methods: This case series is a retrospective analysis of a single surgeon series of medial sphenoid wing meningiomas operated over a 13-year period. Clinical, radiographic, and outcome variables were studied. The surgical videos were analyzed in detail. The meningioma and its extensions were divided into several zones and a zone-wise strategy for tumor excision was evolved., Results: Twenty-four patients with medial sphenoid wing meningiomas were operated. In 14 patients, Simpson grade 3 excision could be achieved; 5 patients had Simpson grade 4 and 1 patient, grade 5 excision. Four (of 24 patients, 16.7%) had vessel injuries., Conclusions: Medial sphenoid wing meningiomas are difficult lesions to excise radically. Close follow-up of residual lesions (especially if attached to the basal dura) is warranted. Additional modalities of treatment like radiosurgery may be required in case of any progression and for higher-grade lesions., Competing Interests: None

Introduction: Takotsubo (Japanese fishing pot for trapping octopus) cardiomyopathy is a rare phenomenon of acute coronary syndrome presenting usually with the presence of transient apical ballooning of the left ventricle in the absence of obstructive coronary artery disease. It is mainly seen in women of older age secondary to emotional, physical, or psychological stress. In age less than 18 years, it is mainly seen in adolescents suffering from psychiatric disorders and substance abuse. In children, it is rarely described., Case Presentation: We present here a peculiar case of a 12-year-old child with neurogenic pulmonary oedema and takotsubo cardiomyopathy syndrome after surgery for recurrent medulloblastoma. Also, management challenges are discussed., Discussion/conclusion: Takotsubo cardiomyopathy is not just a classical or inverted type but indeed a spectrum. It can be seen in any case, be it a child or adult secondary to handling or injury to the ponto-medullary junction, rostral pons, or dorsolateral medulla. The density and distribution of beta-adrenergic receptors may be different in children and adults which needs further research. Prognosis is usually excellent across all ages., (© 2022 S. Karger AG, Basel.)

Background: The incidence of retractions has been increasing steadily, in direct proportion to the volume of scientific literature. Retraction of published articles depends on the visibility of journals and on postpublication scrutiny of published articles by peers. The possibility thus exists that not all compromised ("retractable") articles are detected and retracted from the less-visible journals. The proportion of "retractable" articles and its converse, the proportion of published articles in each journal that are likely to be "true" (PTP), have not been estimated hitherto., Methods: Three journal sets were created: pure neurosurgery journals (NS-P), the neurosurgery component of multidisciplinary journals (NS-MD), and high-impact clinical journals (HICJs). We described a new metric (the retraction gap [RGap]), defined as the proportion of retractable articles in journals that have not been retracted. We computed the expected number of retractable articles, RGap, and PTP for each journal, and compared these metrics across groups., Results: Fifty-three NS-P journals, 10 NS-MD journals, and 63 HICJs were included in the analysis. The estimated number of retractable articles was 31 times the actual number of retractions in NS-P journals, 6 times higher in the NS-MD journals, and 26 times higher for the HICJs. The RGap was 96.7% for the NS-P group, 83.5% for the NS-MD group, and 96.2% for the HICJs. The PTP was 99.3% in the NS-P group, 99.2% in the NS-MD group, and 98.6% in the HICJs., Conclusions: Neurosurgery as a discipline had a higher RGap but also a higher PTP than the other 2 groups., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Biomarkers of systemic inflammation (BMSIs), including haemogram cell counts (CC, e.g., absolute neutrophil count) and cell count-ratios (CCR, e.g., the neutrophil-lymphocyte ratio, etc.), have been found to have prognostic significance in many solid-organ cancers., Aims: In this three-part study, we first examined if the CCs and CCRs were altered in patients with glioblastoma (GBM) when compared with healthy controls. Second, we evaluated for any correlation between the BMSIs and patient- and tumour-related factors. Third, we evaluated the influence of the CCs and CCRs on survival., Methods: This was a retrospective analysis of patients who underwent surgery/biopsy for a newly diagnosed brain tumour that was subsequently confirmed to be GBM (Cases). Controls were healthy individuals who underwent pre-employment screening blood tests., Statistical Methods: Parametric tests were used to compare normally distributed continuous variables, whereas non-normally distributed variables were compared using non-parametric tests. Thresholds for the BMSIs were determined using X-tile analysis. Cox regression using the proportional hazards model was used for survival analyses around the determined thresholds., Results: All CCs and CCRs were altered in Cases compared with Controls. Presentation with raised intracranial pressure, altered sensorium, poor performance status, loss of ATRX, and lack of p53 overexpression was associated with an inflammatory phenotype of changes in the BMSIs. The inflammatory phenotype of changes was associated with poor survival., Conclusions: A significant inflammatory response was found in patients with GBM and correlated with clinical features, the molecular profile of the tumour and poor survival., Competing Interests: None

Background: Neuro-oncology is a relatively young subspecialty of neurosurgery. 2018 was the 10 th year since the founding of the Indian Society of Neuro-oncology., Objective: To assess patterns in neuro-oncology practice in India., Methods: This was an online survey covering various domains of neuro-oncology such as demographics and practice setting, protocols for the medical management of patients with brain tumors, protocols for surgery and the perioperative period (including antibiotic prophylaxis, dural closure techniques, etc.), technological adjuncts used for brain/spine tumors (including intraoperative neurologic monitoring-IONM), and management protocols for certain specific clinical scenarios., Results: The response rate was 13%. Although 37% of the respondents' institutions could be considered as having reasonable surgical volumes (>1 procedure/day), only about half of these had high volumes of malignant brain tumor surgery. A wide variation was seen in medical management, perioperative protocols, use of adjuncts and intraoperative technologies, and paradigms for specific clinical scenarios., Conclusions: There is a need to standardize the protocols in neuro-oncology. This could be achieved by strengthening the formal training process in surgical neuro-oncology., Competing Interests: None

Background: Some patients with glioblastoma multiforme (GBM) survive 3-5 years (or longer) after diagnosis. The goal of this study was to identify differences between the long-term survivors (LTS) and those who had a shorter overall survival (non-LTS groups)., Methods: This study was a retrospective analysis of prospectively maintained surgical databases. All patients who underwent safe maximal resection for GBM were included. Demographic, clinical, radiologic, and pathologic data were obtained from electronic medical records. Values of the biomarkers of systemic inflammation were computed from the preoperative hemogram reports. Patients with an overall survival (OS) ≥36 months were defined as the LTS group and were compared with the non-LTS groups (OS<36 months)., Results: Patients in the LTS group were younger, had a better baseline performance status, and were more likely to have undergone near- or gross-total resection. LTS was associated with lower Ki67 labeling, MGMT methylation, IDH mutation, and lack of p53 overexpression. Several novel findings were generated by this study. A longer pretreatment duration of symptoms was associated with a longer OS. Higher pretreatment levels of the absolute neutrophil count, neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio, derived neutrophil-lymphocyte ratio and systemic index of inflammation, and lower levels of the absolute eosinophil count and eosinophil-lymphocyte ratio all correlated with a shorter OS., Conclusions: Several differences were identified between the LTS and non-LTS groups. These differences will likely be incorporated into future prognostic models. They may also aid in differentiation between recurrent disease and treatment-related changes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: As the volume of scientific publications increases, the rate of retraction of published papers is also likely to increase. In the present study, we report the characteristics of retracted papers from clinical neurosurgery and allied clinical and basic science specialties., Methods: Retracted papers were identified using two separate search strategies on PubMed. Attributes of the retracted papers were collected from PubMed and the Retraction Watch database. The reasons for retraction were analyzed. The factors that correlated with time to retraction were identified. Detailed citation analysis for the retracted papers was performed. The retraction rates for neurosurgery journals were computed., Results: A total of 191 retractions were identified; 55% pertained to clinical neurosurgery. The most common reasons for retraction were plagiarism, duplication, and compromised peer review. The countries associated with the highest number of retractions were China, USA, and Japan. The full text of the retraction notice was not available for 11% of the papers. A median of 50% of all citations received by the papers occurred after retraction. The factors that correlated with a longer time to retraction included basic science category, the number of collaborating departments, and the H-index of the journal. The overall rate of retractions in neurosurgery journals was 0.037%., Conclusions: The retraction notice needs to be freely available on all search engines. Plagiarism checks and reference checks prior to publication of papers (to ensure no retracted papers have been cited) must be mandatory. Mandatory data deposition would help overcome issues with data and results.

Introduction Retraction of published papers has a far-reaching impact on the scientific world, especially if the retracted papers were published in high-impact journals. Although it has been noted that the retraction rates of journals correlated with their citation metrics, no conclusive data were available for most clinical specialties. In this study, we determined the retraction rate for anesthesia and two comparison groups (neurosurgery and high impact clinical journals). We then studied the correlation of the retraction rate with citation metrics. Methods We generated a list of all anesthesia journals that were indexed in the National Library of Medicine database. We obtained the number of papers published in each journal as well as the number of papers retracted from each. We also collated the Impact Factor® and H-index of each journal. The same methodology was followed for neurosurgery and high impact clinical journals. We then studied the correlations between the retraction rate and citation metrics of each journal. Results The retraction index was 2.59 for anesthesiology, 0.66 for neurosurgery and 0.75 for the high-impact clinical journals group. The retraction rate did not correlate with the citation metrics. However, the number of papers published in each journal and the absolute number of retractions showed a positive correlation with the citation metrics. The H-index showed stronger correlations with these parameters than the Impact factor. Conclusions The number of retractions increased in proportion to both the number of papers published in a journal and the citation metrics of that journal., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Nagella et al.)

Background: Leptin, an adipocytokine functions via the leptin receptor, OB-Rb that contains an intact intracellular domain and activates the JAK/STAT signalling cascade. It stimulates growth, migration and invasion of cancer cells in vitro potentiating angiogenesis. Recently, the involvement of leptin in tumor progression is being explored. Gliomas exhibit poor prognosis, low survival rates demanding for novel therapeutic regimens resulting in discovery of many potential biomarkers and pharmaceutical targets. We analysed the potential role of leptin and OB-Rb in carcinogenesis of malignant gliomas. Methods: Sixty fresh tissue samples of diffuse gliomas were collected after tumor excision. Real time PCR, immunohistochemical (IHC) analysis and western blot analysis were carried out to assess the expression of leptin and its receptor. Results: The present study demonstrates the expression of leptin and LepR and their involvement in tumor progression. Of the 60 cases, 57 cases (95%) and 53 cases (88.3%) showed amplification for leptin and OB-Rb respectively. The expression of these proteins were measured semi-quantitatively and correlated with degree of malignancy (p<0.05). The bands were visualised on western blot. Conclusion: Leptin may be valued as a pharmaceutical target and anti-leptin compounds could be developed as drugs in mono- or combined therapies for these tumors., (Creative Commons Attribution License)

Objective: Arteriovenous malformations (AVMs) of the basal ganglia and thalamus are particularly difficult lesions to treat, accounting for 3%-13% of all AVMs in surgical series and 23%-44% of malformations in radiosurgery series. The goal of this study was to report the results of multimodal management of basal ganglia and thalamic AVMs and investigate the factors that influence radiographic cure and good clinical outcomes., Methods: This study was a retrospective analysis of a prospectively maintained database of all patients treated at the authors' institution. Clinical, radiological, follow-up, and outcome data were analyzed. Univariate and multivariate analyses were conducted to explore the influence of various factors on outcome., Results: The results and data analysis pertaining to 123 patients treated over 32 years are presented. In this cohort, radiographic cure was achieved in 50.9% of the patients. Seventy-five percent of patients had good clinical outcomes (stable or improved performance scores), whereas 25% worsened after treatment. Inclusion of surgery and radiosurgery independently predicted obliteration, whereas nidus diameter and volume predicted clinical outcomes. Nidus volume/diameter and inclusion of surgery predicted the optimal outcome, i.e., good clinical outcomes with lesion obliteration., Conclusions: Good outcomes are possible with multimodal treatment in these complex patients. Increasing size and, by extension, higher Spetzler-Martin grade are associated with worse outcomes. Inclusion of multiple modalities of treatment as indicated could improve the chances of radiographic cure and good outcomes.

Background: Fluorescence guided resections have been increasingly used for malignant gliomas. Despite the high reliability of the technique, there remain some practical limitations., Methods: We retrospectively reviewed our experience with 50 consecutive cases of 5-aminolevulinic acid (ALA)-guided resections. Clinico-radiological features and intraoperative variables (pattern and type of fluorescence) were recorded. In a subset (12 cases), we performed annotated biopsies to calculate the diagnostic accuracy of the technique. We recorded and analysed the patterns of excision and residual fluorescence and correlated this with postoperative magnetic resonance imaging (MRI)., Results: Majority of the tumours (92%) were resectable and predominantly enhancing. Though strong fluorescence was seen in most of them, there were 2 cases with a non-enhancing tumor which showed fluorescence. Visualized strong fluorescence had a very high predictive value (100%) for detecting the pathological tissue. However, it was not always possible to resect all the fluorescing tissue. Proximity to critical neuro-vascular structures was the commonest reason for failure to achieve a gross total excision (16 cases). Additionally, there were some cases (5 of 8) where the non-fluorescing residue was resected intraoperatively with the help of ultrasound. Despite the presence of residual fluorescence, overall radiological gross total resection was achieved in 66% cases., Conclusions: ALA guided resections are very useful in malignant gliomas, even if these lesions do not enhance signi cantly. Although ALA reliably depicts the tumour intraoperatively, it may not be possible to resect all this tissue completely. Additionally, non-fluorescing tumor may be completely missed out and may require additional imaging tools. Working within the limitations of the technique and using complementary modalities (ultrasound or brain mapping) may be ideal for achieving a radical resection of malignant gliomas., Competing Interests: There are no conflicts of interest

Objectives: For patients who develop brain metastases from solid tumors, age, KPS, primary tumor status and presence of extracranial metastases have been identified as prognostic factors. However, the factors that affect survival in patients who are deemed fit to undergo resection of brain metastases have not been clearly elucidated hitherto., Patients and Methods: This is a retrospective analysis of a prospectively maintained database. All patients who underwent resection of intracranial metastases from solid tumors were included. Various patient, disease and treatment related factors were analyzed to assess their impact on survival., Results: Overall, 124 patients had undergone surgery for brain metastases from various primary sites. The median age and pre-operative performance score were 53 years and 80 respectively. Synchronous metastases were resected in 17.7% of the patients. The postoperative morbidity and mortality rates were 17.7% and 2.4% respectively. Adjuvant whole brain radiation was received by 64 patients. At last follow-up, 8.1% of patients had fresh post-surgical neurologic deficits. The median progression free and overall survival were 6.91 was 8.56 months respectively., Conclusions: Surgical resection of for brain metastases should be considered in carefully selected patients. Gross total resection and receiving adjuvant whole brain RT significantly improves survival in these patients., (Copyright © 2018 Elsevier B.V. All rights reserved.)

OBJECTIVE Brainstem arteriovenous malformations (AVMs) are rare lesions that are difficult to diagnose and treat. They are often more aggressive in their behavior when compared with their supratentorial counterparts. The consequence of a brainstem hemorrhage is often devastating, and many patients are in poor neurological status at presentation. The authors examine the factors associated with angiographically confirmed cure and those affecting management outcomes for these complex lesions. METHODS This was a retrospective analysis of data gathered from the prospectively maintained Stanford AVM database. Lesions were grouped based on their location in the brainstem (medulla, pons, or midbrain) and the quadrant they occupied. Angiographic cure was dichotomized as completely obliterated or not, and functional outcome was dichotomized as either independent or not independent at last follow-up. RESULTS Over a 23-year period, 39 lesions were treated. Of these, 3 were located in the medulla, 14 in the pons, and 22 in the midbrain. At presentation, 92% of the patients had hemorrhage, and only 43.6% were functionally independent. Surgery resulted in the best radiographic cure rates, with a morbidity rate of 12.5%. In all, 53% of patients either improved or remained stable after surgery. Absence of residual nidus and female sex correlated with better outcomes. CONCLUSIONS Brainstem AVMs usually present with hemorrhage. Surgery offers the best chance of cure, either in isolation or in combination with other modalities as appropriate.

Malignant peripheral nerve sheath tumours may arise from any cranial or somatic nerve. The median survival with best therapy is 49 months. The present case reports a patient with an MPNST that exhibited an unusually indolent behaviour. Besides this, the patient developed a dural metastasis from the lesion and presented with a spontaneous extra-dural haematoma. This has not been reported hitherto in literature.

Introduction: The role of Vascular Endothelial Growth Factor (VEGF) in angiogenesis has been extensively studied in gliomas, such as astrocytoma and oligodendrogliomas, worldwide. However, there is limited information available with regard to the Indian population., Aim: To study, whether VEGF is expressed in the Indian population in a pattern similar to that in other population., Materials and Methods: In this prospective study approved by the Institute Ethics Committee for Human Studies at Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER) the patients operated for glioma in 2014 and 2015 (n = 60) were included. Tumours were graded as per the World Health Organization (WHO) grading system. VEGF expression in various grades was analysed using immunohistochemistry., Results: Of the 60 patients included in this study, 15 were Grade II- (diffuse astrocytomas - 12; oligodendrogliomas- 3), 15 were Grade III-(anaplastic astrocytomas- 2; anaplastic oligodendrogliomas - 13) and 30 were Grade IV-glioblastomas. For VEGF antibody staining, two patients (3.33%) showed negative results and 58 patients (96%) showed positive results. VEGF positivity was 100% in Grade II and III, while it was 93.3% (28/30) in Grade IV tumours (p=0.012)., Conclusion: The expression of VEGF was associated with the grade of tumour, which gradually increased from Grade II to Grade IV. We conclude that VEGF-regulated angiogenesis plays an important role in tumour progression of astrocytomas and oligodendrogliomas in the Indian population as observed worldwide.

Objective: Several studies have assessed clinical and radiologic outcomes after detethering of the cord for tethered cord syndrome (TCS). However, no data regarding the impact of detethering on the metabolism or electrophysiologic functioning of the cord are available. The aim of this study was to assess the changes in the cerebrospinal fluid (CSF) levels of markers of neuronal injury and alterations in the electrophysiologic functioning of the spinal cord after detethering., Methods: This prospective study included patients with congenital TCS. Patients underwent clinical assessment, magnetic resonance imaging, somatosensory evoked potentials (SSEP) study, and CSF biochemical analysis (to estimate lactate, glial fibrillary acidic protein, and S100B levels), before and 3 months after surgery. Clinical and radiologic outcomes were assessed. We studied changes in biochemical and electrophysiologic parameters before and after detethering as surrogate markers for the effects of this intervention., Results: Twenty-one patients were recruited over 2 years. Detethering led to clinical improvement in 75% of patients with motor deficits, 60% of patients with bladder symptoms, and 50% of patients with gait problems. At 3 months follow-up, 43% (median) of the preoperative vertical tethering was found to be corrected. There was significant reduction in CSF lactate, glial fibrillary acidic protein, and S100B levels as well as a significant decrease in the latencies of the SSEP waves 3 months after surgery., Conclusions: Surgical detethering led to a reduction in the CSF levels of the markers of anaerobic metabolism and neuronal injury. There was also a reduction in the latencies of the SSEP waves, indicating better electrophysiologic functioning of the cord., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Context: The highest cited papers published in a journal provide a snapshot of the clinical practice and research in that specialty and/or region., Aims: The aim of this study was to determine the highest cited papers published in Neurology India and analyze their attributes., Setting and Design: This study was a citation analysis of all papers published in Neurology India since online archiving commenced in 1993., Methods: All papers published in Neurology India between the years 1993-2014 were listed. The number of times each paper had been cited up till the time of performing this study was determined by performing a Google Scholar search. Published papers were then ranked on the basis of total times cited since publication and the annual citation rate. Statistical Techniques: Simple counts and percentages were used to report most results. The mean citations received by papers in various categories were compared using the Student's t-test or a one-way analysis of variance, as appropriate. All analyses were carried out on SAS University Edition (SAS/STAT®, SAS Institute Inc, NC, USA) and graphs were generated on MS Excel 2016., Results: The top papers on the total citations and annual citation rate rank lists pertained to basic neuroscience research. The highest cited paper overall had received 139 citations. About a quarter of the papers published had never been cited at all. The major themes represented were vascular diseases and infections., Conclusions: The highest cited papers reflect the diseases that are of major concern in India. Certain domains such as trauma, allied neurosciences, and basic neuroscience research were underrepresented.

Although cerebral abscesses caused by animal bites have been reported, they are extremely rare in infants and have not been described following monkey bite. A 55-day-old male infant presented with a multi-loculated Streptococcus oralis cerebral abscess following a monkey bite on the scalp. There was a clinical response to antibiotic therapy and repeated surgical aspiration followed by a ventriculoperitoneal shunt. This is the first report of a patient with a brain abscess following a monkey bite.

Background: Elevation of the neutrophil to lymphocyte ratio (NLR) has been shown to be an indicator of poor prognosis in many malignancies including recurrent glioblastoma multiforme., Objectives: This study was aimed at assessing if the NLR and other leukocyte counts and indices were deranged in treatment-naïve patients with primary brain tumors when compared with an age-matched healthy control group., Materials and Methods: This was a prospective comparative clinical observational study by design. A healthy control population was compared with treatment-naïve patients diagnosed with intra- and extraaxial brain tumors. Leukocyte counts (neutrophil, lymphocyte, monocyte, eosinophil, and basophil counts) as well as leukocyte ratios such as the NLR and the monocyte to lymphocyte ratio (MLR) were calculated. We also evaluated if the counts and indices were related to the tumor volume., Results: In all patients with tumors, the platelet and neutrophil counts were elevated when compared to the controls. In contrast, monocyte counts and the MLR were found to be decreased in patients with tumors when compared to the controls. The subset of patients with glioblastoma showed a significant increase in NLR when compared to the controls., Conclusions: Significant changes in the neutrophil, monocyte, and platelet counts as well as NLR and MLR were observed. Prospective longitudinal studies are required to determine the prognostic and therapeutic implications of these findings.

Context: Gliomas are irregular in shape unlike benign brain tumors like meningiomas or schwannomas. Simplifying assumptions about glioma geometry are therefore more likely to lead to wrong calculations of glioma volumes than for other tumors., Aims: We compared simple linear measurement.based techniques of measuring glioma volume with manual region of interest.based image segmentation and to assess concordance., Settings and Design: This study was a retrospective radiology archive-based study., Subjects and Methods: The volumes of gliomas were measured by two assessors using five different techniques - manual image segmentation and four linear measurement-based formulae, which included the formulae for the volume of a sphere, cylinder, ellipsoid and its simplification v = abc/2., Statistical Analysis Used: Intra-ssessor concordance was evaluated using mean vs. difference. (Bland-Altman) plots and raw agreement indices. Inter-rater agreement was assessed by calculating the intra-class correlation coefficient for each technique., Results: The best inter.rater concordance was for volume measured by manual segmentation. The tumor volumes measured using the formulae for volume of a sphere and cylinder had poor agreement with the planimetric volume and low inter.rater concordance. The formula for volume of an ellipsoid and its simplification had good agreement with the manual planimetric volume and had good inter.rater concordance. However, for larger tumors, the agreement with planimetric volume was poorer., Conclusions: Manual region of interest-based image segmentation is the standard technique for measuring glioma volumes. For routine clinical use, the simple formula v = abc/2 (or the formula for volume of an ellipsoid) could be used as alternatives.

Purpose: The posterior fossa contains structures that are vital to life. In this study, we aimed at establishing normal linear dimensions and volume data of the posterior fossa in a homogeneous south Indian population. We also evaluated the influence of large tumors on these parameters. We evaluated the accuracy of different techniques of measuring these dimensions and compared them with literature., Materials and Methods: Control and tumor MRIs were selected from an imaging database. Linear posterior fossa dimensions as well as volumes were measured using Image J and Fiji. The volume data were compared with similar data from literature. The effect of the presence of a tumor on posterior fossa volume was measured., Results: The posterior fossa volume was higher in men than in women, irrespective of whether the volume was estimated on axial, sagittal or coronal MR images. Despite the wide variation in the techniques used, there was no significant difference between the volumes reported in literature and the volumes calculated in the current series. The presence of large tumors did not affect linear dimensions or posterior fossa volumes. Among the techniques based on linear measurements that were assessed for concordance with manual segmentation, the technique using the formula for volume of an ellipsoid had the best agreement., Conclusions: Posterior fossa volume is higher in men than in women, Posterior fossa dimensions were not affected by the presence of large tumors. Manual segmentation remains the most accurate method to measure posterior fossa volume.

Objectives: This study aimed at determining the frequency of abnormal finger flexion, Hoffman's and extensor plantar (Babinski) response in healthy adults and to determine the sensitivity and specificity of these tests as markers of spinal cord compression in symptomatic patients., Methods: Patients attending the neurosurgery clinic with neck related complaints formed the case group. The control group consisted of consenting patient attenders and volunteers drawn from the students and faculty of our institute. All subjects underwent examination of the finger flexion, Hoffman's and plantar reflexes and an MRI as per standard protocol. The frequency of the reflexes in the control group, sensitivity and specificity of the reflexes to detect cord compression in the case group were computed., Results: The frequency of the reflexes in healthy controls were finger flexion - 1%, Hoffman's - 0.3% and Babinski sign - 0%. None of the controls with positive reflexes had any abnormality on MR imaging. A combination of the three reflexes had a sensitivity of 91.7%, specificity of 87.5%, PPV of 95.7% and NPV of 77.8% in detecting spinal cord compression., Conclusions: A combination of finger flexion, Hoffman's and plantar reflexes could be used effectively as a marker of spinal cord compression in symptomatic individuals. They cannot, however, be depended on as screening tests in asymptomatic individuals., (Copyright © 2015 Elsevier B.V. All rights reserved.)

A flipped classroom is a learner centered approach in which the learner is responsible to attend the class with basic understanding of the subject to fully participate and engage in discussions. The aim of this study was to evaluate students' perception of flipped classroom approach for neuroanatomy module and assess the impact on their performance and attitudes. The subject chosen to evaluate the flipped classroom model for first year medical students was clinical neuroanatomy. One hundred and thirty first year medical students participated in the study module. Students were divided into five groups and five case scenarios pertaining to various clinically relevant regions of the neuraxis, with varying anatomical complexity were generated. The pre- and post-tests were designed to specifically test the declared learning objectives of the session. The perception of the students regarding this model of teaching and learning was also evaluated. Eighty-six percent of students felt that the flipped classroom approach was better at fulfilling the stated learning objectives than the conventional didactic teaching, 92% felt that the work-sheet with questions provided prior to the class enabled a better understanding of the subject and 87% were of the opinion that the web sources with references kindled a greater interest to read as compared with didactic lectures. The paired t test showed highly significant differences between the pre and post-test scores. Student response to the flipped classroom structure was largely positive, indicating it to be an approach worth pursuing in future years.

Context: Scientific publications are a reflection of the quality of the clinical and academic work being carried out in an institute. Training in the process of research and scientific writing are important components of the residency curriculum., Aims: The publication performance and research output of institutes training residents in neurology and neurosurgery were evaluated., Setting and Design: Internet-based study., Methods: This study was based on the data available on the websites of the Medical Council of India and the National Board of Examinations. The PubMed search interface was used to determine the publication output of institutes over the past 5 years (2010-2014). Google Scholar was used to determine the citation performance of each paper. The publication parameters were normalized to the number of faculty members in each institute as listed on the institutional web page. The normalized publication performance for an institute was computed by comparing the figures for that institute with the national average., Results: Institutes could be ranked on several criteria. There was a high degree of clustering of output from the top 5% of the institutes. About 13% of the neurology intake and 30.9% of neurosurgery intake over the past 5 years has been into the institutes that have not published a single paper during this period., Conclusions: This evaluation of the publication performance and research output of neurology and neurosurgery training institutes would serve as a baseline data for future evaluations and comparisons. The absence of any publication and research output from several training institutes is a matter of concern.

Background: The citation climate in neurosurgical literature is largely undefined., Objective: To study the patterns of citation of articles in neurosurgery as a scientific field and to evaluate the performance of neurosurgery journals vis-à-vis journals in other fields., Methods: References cited in articles published in neurosurgery journals during a specified time period were analyzed to determine the age of articles cited in neurosurgical literature. In the next analysis, articles published in neurosurgical journals were followed up for 13 years after publication. The postpublication citation patterns were analyzed to determine the time taken to reach the maximally cited state and the time when articles stopped being cited. The final part of the study dealt with the evolution of a new interfield citation metric, which was then compared with other standardized citation indexes., Results: The mean ± SD age of articles cited in neurosurgical literature was 11.6 ± 11.7 years (median, 8 years). Citations received by articles gradually increased to a peak (at 6.25 years after publication in neurosurgery) and then reached a steady state; articles were still cited well into the late postpublication period. Neurosurgical articles published in nonneurosurgical high-impact journals were cited more highly than those in neurosurgical journals, although they took approximately the same time to reach the maximally cited state (7.2 years). The most cited pure neurosurgery journal was Neurosurgery., Conclusion: The citation climate for neurosurgery was adequately described. The interfield citation metric was able to ensure cross-field comparability of journal performance., Abbreviations: G1, group 1G2, group 2G3, group 3G4, group 4IFCM, interfield citation metric.

Giant anterior communicating artery aneurysms are rare. Apatient presented with visual dysfunction, gait ataxia and urinary incontinence. MRI showed a giant suprasellar mass. At surgery, the lesion was identified as being an aneurysm arising from the anterior communicating artery. The difficulty in preoperative diagnosis and relevant literature are reviewed.

Congenital anomalies of the craniovertebral junction (CVJ) are complex developmental defects. We describe a patient with atlantoaxial dislocation (AAD) and short stature whose morphopathologydid not fit into any of the previously described syndromic constellations. The patient underwent a reduction of the AAD followed by fixation with C1-C2 transarticular screws. Although numerous syndromes have been linked to both dwarfism and craniovertebral junction anomalies, this patient did not fit into any of these patterns. It is possible that this may be one of the many as yet unrecognized patterns of congenital anomalies.

A case of left parietal calvarial actinomycotic osteomyelitis in a young woman is described. She had no predisposing illnesses. She had delivered a live child at term and presented in the puerperal period. No extracranial focus of infection was identified. She responded well to a combination of surgery and medical therapy and had an excellent outcome. The authors emphasise the importance of establishing a histopathological diagnosis since radiological signs are non-specific and unreliable., (2014 BMJ Publishing Group Ltd.)

Purpose: Primary intraosseous spinal malignant peripheral nerve sheath tumor (MPNST) is exceedingly rare. MPNST with multifocal origin has been described to occur in the extremities. Such a lesion has not been described to occur in the spine. We describe a case of multifocal spinal MPNST and to review the literature relevant to this rare entity and its management., Methods: A 40-year-old immunodeficient patient presented with rapidly progressive paraparesis and mid back ache., Results: Despite aggressive surgical decompression, he developed multiple metastases 3 months after surgery. However, he remained stable for 1 year without any adjuvant therapy. Presently, he has received palliative radiotherapy for spinal recurrence and cerebral metastasis., Conclusion: Multifocal spinal MPNST is a rare lesion. In this instance, the multifocality of the disease and its odd location could be attributed to the immunodeficiency state. The prolonged survival could be due to an improvement in his immune status due to HAART.

Schwannomas are common slow growing benign tumors. About 25-45% of all schwannomas arise in the head and neck region. Less than 4% of these tumors are found in sinonasal regions and usually affect nasal ethmoid. There are very few case reports of a schwannoma arising from the sphenoid sinus. We report a case of sphenoid sinus schwannoma treated by microscopic decompression and review the relevant literature.

Background: Various combinations of bony and soft tissue anomalies have been described at the craniovertebral junction (CVJ). These include posterior fossa dermoids (with or without dermal sinuses) associated with Klippel-Feil anomalies and dermoids (no previous reports of overlying dermal sinuses) associated with bony anomalies., Patients: Two patients with a combination of CVJ anomalies are described., Results: Both patients had a posterior fossa dermoid, dermal sinus, and occipitalized C1 arch. Furthermore, one patient had a complex bony CVJ anomaly, and the other had a Klippel-Feil anomaly in addition. The clinical presentation and management are elucidated., Conclusions: Patients who present with any one of these lesions need to be evaluated for the existence of other congenital anomalies. These are complex malformations to treat., (Georg Thieme Verlag KG Stuttgart · New York.)