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Objectives Extracranial to intracranial (EC-IC) bypass is an important part of the armamentarium of a neurosurgeon in managing different vascular and neoplastic pathologies. Here, we report our initial experiences of EC-IC bypasses as experiences in the ‘learning curve’, including preparation and training of the surgeon, getting cases, patient selection, imaging, operative skills and microtechniques, complications, follow-up, and outcome. Lessons learned from the ‘learning curve experiences’ can be very useful for young vascular neurosurgeons who are going to start EC-IC bypass or have already started to perform and find themselves in the learning curve. Methods From July 2009 to September 2018, 100 EC-IC bypasses were performed. We looked back to these cases of EC-IC bypass as our initial or ‘learning curve’ experiences. The recorded data of patient management (EC-IC bypass patient) were reviewed retrogradely. Our preparation for EC-IC bypass was described briefly. Case selection, indications, preparation of the patient for operation, techniques and technical experiences, preoperative difficulties and challenges, postoperative follow-up, complications, patency status of the bypass, and ultimate results were reviewed and studied. Result A total of 100 bypasses were performed in 83 patients, of which 43 were male and 40 were female. The age range was from 04 to 72 years old (average 32 years old). Eleven patients were lost to follow-up postoperatively after 3 months and they were not even available for telephone follow-up. The follow-up period ranged from 3 to 120 months (average of18.4 months). Eight bypasses were high flow bypasses, whereas the number of low flow STA-MCA bypasses was 92. Indication of bypass were (in 83 cases):1. Arterial stenosis/occlusion/dissection causing cerebral ischemia (middle cerebral artery [MCA] stenosis/occlusion-05, MCA dissection-04, internal carotid artery [ICA] occlusion-19); 2. Intracranial aneurysm-30; 3. Moya-Moya disease-21; and 4. Direct carotid cavernous fistula [CCF]-04. Common clinical presentation was hemiparesis & dysphasia in ischemic group with history of transient ischemic attack (H/O TIA) (including Moya Moya disease). Features of subarachnoid hemorrhage (SAH) were the presenting symptoms in intracranial aneurysm group. The average ischemic time, due to clamping of recipient artery, was 28 minutes (range: 20–60 minutes). There was no clamp-related infarction. Two anastomoses were found thrombosed intraoperatively.One preoperatively ambulant patient deteriorated neurologically in the postoperative period. She developed hemiplegia but improved later. Here, the cause seemed to be hyperperfusion. Headache resolved in all cases. TIA and seizures were also gone postoperatively. Ophthalmoplegia recovered in all cases in which it was present, except in one CCF, in which abducent nerve palsy persisted. Complete unilateral total blindness developed in one patient postoperatively (due to ophthalmic artery occlusion), where high flow bypass with ICA occlusion were performed. Red eye and proptosis were cured in CCF cases. Motor and sensory dysphasia improved in all cases in which it was present, except for one case in which preoperative global aphasia converted to sensory aphasia in the postoperative period. Three patients died in the postoperative period. The rest of the patients improved postoperatively. All patients were ambulant with static neurostatus and without new stroke/TIA until the last follow-up. All bypasses were patent until the last follow-up. Conclusion The initial experiences of 100 cases of EC-IC bypass revealed even in inexperienced hand mortality and morbidity in properly indicated cases were low and result were impressive according to the pathological group and aim of bypass. Lessons learned from these experiences can be very helpful for new and beginner bypass neurosurgeons

Background: Optic nerve sheath fenestration (ONSF) is commonly used in idiopathic intracranial hypertension (IIH) with visual deterioration and visual improvement is observed post operatively in these patients. Objective: Retrospective evaluation of MRI observations in IIH patients who underwent optic nerve sheath fenestration (ONSF) with postoperative visual improvement. Materials and method: Optic nerve sheath fenestration (ONSF) was done in twenty four (24) patients with IIH having severe visual impairment. Post operatively all patients improved in their visual functions. The recorded pre operative MRI (of brain and orbit) of patients were reviewed and evaluated retrospectively. Results: Total number of MRI studied was 24. Male female ratio was 1:11. Posterior globe flattening was found in all 24 (100%) cases. Other findings were horizontal tortuosity of optic nerve (92%), optic nerve head protrusion (87.5%), optic nerve sheath distension (87%), and vertical buckling (62.5%). Ventricular size was normal in 92% cases and slit ventricle was found only in 8% cases. On magnetic resonance venogram (MRV) one sided transverse sinus abnormality was found in 25% cases. There was empty sella in 79% cases, more marked in three cases. Conclusion: The MRI findings in IIH patients with positive post ONSF result are of variable degree and prevalence except posterior globe flattening which was found in all cases. Delta Med Col J. Jul 2020 8(1): 21-27

Background Endoscopic third ventriculostomy (ETV) has been established as a viable treatment option for obstructive hydrocephalus of children over 6 weeks of age. ETV in pediatric groups may be unsuccessful due to the failure of absorption of cerebrospinal fluid (CSF) or reclosure of ventriculostomy stoma or due to infection. The exact cause is still debatable. Some issues like failure to eliminate the second membrane during the procedure or formation of the new arachnoid membrane at the stoma are still not clear. This study aims to assess the surgical failure of ETV and its predisposing factors. Methods Thirty-four pediatric patients with hydrocephalus were analyzed retrospectively. The patients’ age limit was between 2.5 months and 14 years. This is a retrospective study of 34 patients in a single private hospital between June 2012 and January 2018. Patients having hydrocephalus in pediatric groups more than 6 weeks of age were included in the study. Results The mean age of all patients was 51.25 ± 53.90 months and the mean follow-up period was 50.47 ± 20.84 months. Of 34 surgeries, the success rate was 79% and the failure rate was 21%. Within 2 years, the success rate was 68.42% and above 2 years’ success rate was 93.33%. In this series, 7 cases of ETV were re-explored and found ventriculostomy stoma closure in 3 cases, the presence of the second membrane in re-exploration 2 cases, and presence of inflammatory arachnoid membrane in re-exploration 2 cases. The use of dexamethasone around the stoma in inflammatory stoma was useful, having no recurrence. In one patient of the second membrane probably due to absorption failure in communicating hydrocephalus re-exploration was failed and was managed successfully with VP shunt. Conclusions Predisposing factors causing ETV failure are ventriculostomy stoma closure by new arachnoid granulation tissues, remnants of the second membrane inside the stoma, CSF absorption failure, infection/high protein in CSF and inappropriate patient selection.

Arteriovenous malformations (AVMs) are tangled lesions that may digress the blood flow particularly the high flow ones and microsurgical resection is challenging. The natural history of AVM is not completely understood and its management is controversial. Microsurgical resection of cerebral arteriovenous malformation is a challenging procedure, particularly for high-flow type. Embolization, microsurgery, or radiotherapy are treatment options. Preoperative planning to control the feeders, arachnoid dissection around the AVM for identification and control of all arterial feeders around the AVM surfaces, lastly control of draining vein is the principal of microsurgery. The goal of surgery is to remove the AVM completely to eliminate the risk of bleeding avoiding neurological deterioration. In this paper, we reviewed a case of high-flow cerebral AVM in recurrent bleeding with successful microsurgical resection.The patient in this case report significantly improved his neurological condition and demonstrated a good quality of life during long-term follow-up. The results of this study showed that the microsurgical removal of AVMs represents an efficient treatment with good clinical outcomes. In the future, more investigations of the factors that lead to AVM rupture are required for the advancement of effective medical procedures.

Not Available Bang. J Neurosurgery 2020; 10(1): 130-134

Objectives. Optic nerve sheath fenestration (ONSF) is commonly used in idiopathic intracranial hypertension (IIH). Here we will present our experiences of ONSF in 26 patients with special attention to indications, surgical techniques and results Methods. The recorded data of patient management (with the result) who underwent ONSF were reviewed and studied retrospectively. Results. The total number of patients who underwent ONSF was 26. The male-female ratio was 1:12. Indications of ONSF were: 1. Idiopathic Intracranial Hypertension (IIH)-23 cases; 2. Cerebral Venous Sinus Thrombosis (CVST)-02 cases; 3. CNS Tuberculosis-01case. All patient underwent bilateral ONSF with post-operative continues lumbar CSF drain for 04 days. After fenestration gush of CSF came out with force in all-first operated eyes whereas 13-second operated eyes showed very little CSF flow after fenestration. Vision improved in different grades in all cases at discharge except in three cases. Preoperatively, visual acuity was either PL&PR or hand movement in 40 eyes where 04 eyes were preoperatively total blind (no PL&PR). Visual acuity improved in 48 eyes (92.3% eyes) where the patient can do his/her daily life activities including self-care. Improvement in IIH is 100% (23 cases i.e-46 eyes) whereas 01 case out of 02 cases in CVST. Though vision was improved dramatically fundal appearances changes very slowly and very less frequently returned to normal appearance. Conclusion. Due to the delicate and technically demanding nature of the surgery, safety is a major concern of the ONSF. Our experience showed ONSF is a technically safe operation with very good results where indicated.

Atlanto-occipital non-segmentation failure of segmentation between the fourth occipital sclerotome and the first cervical sclerotome results in atlanto-occipital non-segmentation/ assimilation, also known as occipitalization of the atlas.1The incidence of occipitalisation has been reported to be between 0.08% to 3% of the general population, affecting males and females equally.2 A cartilaginous cleft and an open synchondrosis between the osseous posterior arches of the atlas is a normal finding in children up to four years of age; therefore, a true defect in the posterior arch was diagnosed only in patients who were more than four years old.3 Atlanto-occipital fusion reduces the foramen magnum dimension leading to neurological complications due to compression of spinal cord.4 The slow development of the fibrosis was the source of gradual spinal-cord compression with increasing symptoms.5 Fusion of atlanto-occipital joints can also result in restricted neck movement.6 Basilar invagination is an abnormality at the craniocervical junction (CVJ) either congenital or degenerative, where the odontoid tip is inside the foramen magnum with or without neurological symptoms.7

Background: Disc herniation of the thoracic spine is a rare lesion that is believed to occur in 1 in 1000 to 1 in 1,000,000 patients each year. Endoscopic-assisted thoracic disc microdiscectomy is a safe and effective surgical removal technique for intervertebral herniated thoracic discs. Case Presentation: A 48-year-old female was presented with progressive weakness in both lower limbs for three months, incapacity to void urine for 2 weeks. She had back pain and neck pain for 5 years. Clinically, she was diagnosed with paraplegia at stage D6/7 as a case of dorsal disc prolapse. After doing unilateral transpedicular microscopic discectomy she recovered over 4 weeks and her muscle strength was 4/5 in the lower limbs, and she was able to walk. Conclusion: Thoracic disc herniations are relatively uncommon compared with lumbar and cervical disc pathologies. Although it has posed significant problems for spinal surgeons, the adoption of minimally invasive thoracic disc resection procedures may result in decreased operating time, reduced blood loss, and faster patient recovery.

We report a case of a patient with pituitary tumor with psychiatric disorder, which posed a significant diagnostic dilemma and management challenge for the treating teams of neurosurgery, endocrinology and psychiatry. A more comprehensive endocrine work-up of atypical presentations can be considered in some cases. The criteria for determining when endocrine work should be considered should be investigated further. Bang. J Neurosurgery 2019; 9(1): 75-77

The progress in the understanding of central nervous system (CNS) and skull base infections, is tremendous and it is more so in the case of fungal infections of CNS and skull base, especially cavernous sinus (CS) fungal infection. Available diagnostic tools and appropriate management protocol are continuously changing towards the better management of the fungal infection of CS. CS fungal lesions usually spread from surrounding the paranasal sinuses (PNS) and from the orbit. So understanding the pathology and pathologenesis is vital in the management of such dangerous infections. Management of CS fungal infection is not straightforward and rather complicated due to the underlying immunodeficiency in most of the patients. Treatment is mainly surgical with antifungal drug therapy. For ease of discussion in this chapter, brief anatomy of CS, etiopathogenesis of CS fungal infection, clinical presentation, radiological findings, and management with some special condition/complications of CS fungal infection including prevention will be discussed briefly.

Study objective: To learn how to avoid injury to the carotid artery during recurrent pituitary surgery. Design: Through transsphenoidal endonasal approach the steps of surgery with avoidance of complications were described in the video particularly the use of Minidoppler was to localise the carotids. Setting: Comfort Nursing Home, a private hospital in Dhaka, Bangladesh. Subject/Audience: Neurosurgeons/Residents. Intervention: Demonstration of transsphenoidal endonasal approach for recurrent pituitary tumor and use of Minidoppler to avoid carotid artery injury. Results: Avoidance of complications like intraoperative accidental injury to carotids where symptomatic tumor is small and inter carotid distance is less. Taking this into account, we created this video to demonstrate the important steps specifically to use Minidoppler to avoid a devastation like carotid artery injury. Conclusion: The steps of recurrent pituitary surgery through endonasal approach is well established. To evaluate the details of anatomical structures specifically the inter carotid distance prior to surgery will prevent the unwanted complications in recurrent pituitary surgery and with high resolution monitoring and use of Minidoppler, carotid arteries can be localised.

Background Penetrating nonmissile injuries to the head are far less common than missile penetrating injuries. Here we describe our experience in managing 17 cases of nonmissile injury to the head, likely the largest such series reported to date. We also highlight the surgical steps and techniques used to remove in situ objects (including weapons) in the penetrating wounds that have not been described previously. Methods We conducted a retrospective study of cases of nonmissile, low-velocity penetrating injuries of the head managed in our department. The recorded data of patients with penetrating head injuries were studied for the cause of the injury, type of object, type and extent of penetration, Glasgow Coma Scale score on admission, other clinical issues, evaluation and assessment, interval from penetration to operation, surgical steps and notes, difficulty during the operation, major and minor complications, follow-up, and ultimate outcome. Results Our 17 cases included 6 cases of accidental penetration and 11 cases of penetration as the result of violence. Weapons and other foreign objects causing injury included a teta (a pointed metal weapon with a wooden handle and a barb near the tip, used for hunting and fishing) in 4 cases, a dao (a sharp metal cutting instrument with a wooden handle used for cutting vegetables, fish, meat, bamboo, wood, etc.) in 3 cases, a bamboo stick in 3 cases, a metal rod in 2 cases, a knife in 2 cases, a sharp stone in 1 case, a metal steam chamber cover in 1 case, and a long peg in 1 case. GCS on admission was between 13 and 15 in 15 cases. Only 1 patient exhibited limb weakness. Four patients with an orbitocranial penetrating injury had 1-sided vision loss; 2 of these patients had orbital evisceration, and 1 of these patients died. In 14 patients, the foreign object was in situ at presentation and was removed surgically. Computed tomography scan and plain X-ray of the head were obtained in all patients. Postoperatively, 2 patients (11.7%) needed support in the intensive care unit but died early after surgery. One patient developed late osteomyelitis. The remaining patients were doing well at the most recent follow-up. Conclusions The presenting picture of nonmissile penetrating injury to head may be daunting, but these cases can be managed with very good results with proper (clinical and radiologic) evaluation and simple neurosurgical techniques.

Extensive and elaborative discussion of TB involving the cerebrum, deep structures of the brain, and cerebellum is beyond the scope of this chapter of the book. Every day the sciences are progressing in the knowing of TB of CNS. Available diagnostic tools and appropriate management protocol are continuously changing. In the management of cerebral and cerebellar TB, paradigm shifted toward the conservative drug therapy though surgery has its own definite role in the management of many cases, and sometimes it is lifesaving. Drug-resistant TB and cerebral and cerebellar TB in immunocompromised or immunosuppressed patients are very specially problematic with increased frequency of occurrence. For ease of discussion in this chapter, TB of cerebral hemisphere and deep structures of the brain (i.e., basal ganglia and parts of diencephalon) will be discussed together, and cerebellar TB will be discussed in the later part of the chapter. In this chapter all important aspects of cerebral and cerebellar TB including surgical aspects are discussed briefly.

Background and Objectives: Neurinoma arising from other than nonvestibular cranial nerves is less prevalent. Here we present our experiences regarding the clinical profile, investigations, microneurosurgical management, and the outcome of nonvestibular cranial nerve neurinomas. Materials and Methods: From January 2005 to December 2011, the recorded documents of operated nonvestibular intracranial neurinomas were retrospectively studied for clinical profile, investigations, microneurosurgical management, complications, follow-up, and outcomes. Results: The average follow-up was 24.5 months. Total number of cases was 30, with age ranging from 9 to 60 years. Sixteen cases were males and 14 were females. Nonvestibular cranial nerve schwannomas most commonly originated from trigeminal nerve followed by glossopharyngeal+/vagus nerve. There were three abducent nerve schwannomas that are very rare. There was no trochlear nerve schwannoma. Two glossopharyngeal+/vagus nerve schwannomas extended into the neck through jugular foramen and one extended into the upper cervical spinal canal. Involved nerve dysfunction was a common clinical feature except in trigeminal neurinomas where facial pain was a common feature. Aiming for no new neurodeficit, total resection of the tumor was done in 24 cases, and near-total resection or gross total resection or subtotal resection was done in 6 cases. Preoperative symptoms improved or disappeared in 25 cases. New persistent deficit occurred in 3 cases. Two patients died postoperatively. There was no recurrence of tumor till the last follow-up. Conclusion: Nonvestibular schwannomas are far less common, but curable benign lesions. Surgical approach to the skull base and craniovertebral junction is a often complex and lengthy procedure associated with chances of significant morbidity. But early diagnosis, proper investigations, and evaluation, along with appropriate decision making and surgical planning with microsurgical techniques are the essential factors that can result in optimum outcome.

Aims and Objectives Even in the era of tremendous microneurosurgical and endoscopic development, the cavernous sinus (CS) is a challenging anatomical site for a neurosurgeon. Many transcranial and a few endoscopic cadaveric studies have been done to study the CS; probably none were undertaken to study its microsurgical and endoscopic anatomy side by side. In this cadaveric study we perform a side-by-side comparison of the microsurgical and endoscopic anatomy of the CS that can help neurosurgeons deal with CS lesions more efficiently. Materials and Method Sixteen fresh cadaveric heads were studied after dissection. Six heads were dissected for transcranial study and six for endoscopic study of CS. During the transcranial study, the supratentorial brain was removed in three heads and CS and related anatomical structures were dissected. In the remaining heads, the CS was studied by keeping the brains in situ. In four heads both transcranial and endoscopic study was done simultaneously. Following dissection, microsurgical and endoscopic anatomy of CS was studied. Result The CS and related anatomical structures were dissected sequentially in all cases (transcranially in 10 [6 + 4] heads; endoscopically in 10 [6 + 4] heads), and their relationship was studied. Conclusion Microscopic and endoscopic exposure of the CS is relatively easy in cadavers. But endoscopic or microsurgical exposure of the CS during surgery is more difficult requiring skill. With experience of the cadaveric study , the CS may be explored via transcranial microsurgery, endonasal endoscopy, or both simultaneously, according to the nature and extension of the pathology.

Schwannoma arising from high cervical spinal root are common among the spinal schwannomas.Here, we prospectively recorded the clinical features, radiological features, surgical approachesfindings,postoperative follow upultimate neurological outcome of high cervical spinal schwannomas and then we evaluated the records retrospectively.Here, schwannomas arising from C1, C2 and C3 spinal nerve roots were regarded as high cervical spinal schwannoma. All patients with high cervical spinal schwannomas that were consecutively operated micro-neurosurgically from 2006-2010 were included in the study. Postoperatively all patients were followed up regularly both clinically and neuro-radiologically (MRI of cervical spine).Average follow up was 31.5 months. The mean age of the series was 35.8 years (range 10-61 years). There were 8 male and 7 female patients. The mean duration of symptoms at the time of presentation was 32 months (range 06 months-5 years). Two schwannomas were completely extradural, seven were intradural and rest six were interdural or hourglass type (both extra and intradural) as identified during surgery. The standard midline posterior approach was used in all patients. A C2 hemilaminectomyor C2 laminectomy with or without cutting of posterior arch of atlas was used for most intradural and large interdural C2 schwannomas. Tumor removal was complete in all cases. Preservation of the nerve root fibers was not possible in 9 cases and was possible only in 3 cases. In two patients CSF leak developed after operation. One patient who had severe myelopathic features with bed sore failed toimprove and expired 5 months after operation. Rest of the patients showed postoperative improvement in their preoperative symptoms and returned to their normal life by the end of sixth month. There was no tumor recurrence in any patient till last follow up.Proper 3-D anatomical orientationphysiological knowledge, deep neuro-radiological observation,pathological appreciations and micro-neurosurgical skill and expertization can make the surgical management of these tumors ( in a surgically complex site) simple with gratifying result (i.e.neurological outcome) without extensive bone removal or soft tissue manipulation through a standard midline posterior approach.

Objectives: An intracranial epidermoid tumor is relatively a rare tumor, accounting for approximately 0.1% of all intracranial space occupying lesions. These are also known as pearly tumor due to their pearl like appearance. In this series, the localization of the tumor, presenting age and symptoms, imaging criteria for diagnosis, surgical management strategy with completeness of excision and overall outcome were studied prospectively. Here, we report our short experience of intracranial epidermoid as a whole. Materials and Methods: Between January 2006 to December 2010, 23 cases of intracranial epidermoid were diagnosed preoperatively with almost certainty by computed tomography (CT) and magnetic resonance imaging (MRI) of brain in plain, contrast and other relevant studies. All of them underwent operation in Dhaka Medical College Hospital and in some Private Hospital in Dhaka, Bangladesh. All patients were followed-up routinely by clinical examination and neuroimaging. Average follow-up was 39 (range-71-11months) months. Patients of the series were prospectively studied. Results: Supratentorial epidermoids were 04 cases and infratemporal epidermoids were 19 cases. Clinical features and surgical strategy varies according to the location and extension of the tumors. Age range was 19-71 years (37.46 years). Common clinical features were headache, cerebellar features, seizure, vertigo, hearing impairment and features of raised intracranial pressure (ICP). Investigation was CT scan or/+ MRI of brain in all cases. Pre-operative complete excision was 20 cases, but post-operative images showed complete excision in 17 cases. Content of tumor was pearly white/white material in all cases except one, where content was putty material. Re-operation for residual/recurrent tumor was nil. Complications included pre-operative mortality one case, persisted sixth nerve palsy in one case, transient memory disturbance one case, and extra dural hematoma one case. One senior patient expired three months after the operation from spontaneous intracerebral hemorrhage. Rest of the patients were stable and symptom/s free till last follow-up. Conclusion: In the management of such tumors, one should keep in mind that an aggressive radical surgery carrying a high morbidity and mortality and a conservative subtotal tumor excision is associated with a higher rate of recurrence, but earlier diagnosis and complete excision or near total excision of this benign tumor can cure the patient with the expectation of normal life.

AIM Endonasal transsphenoidal approaches are getting rapidly popular in removing many midline skullbase lesions from crista galli to foramen magnum. For safe removal of these lesions, familiarity with endoscopic endonasal anatomy of circle of Willis is very important. Furthermore, for safe development of this approach in vascular neurosurgery in the near future, endoscopic endonasal exposure of circle of Willis is a fundamental step. The goals in this study were to dissect the circle of Willis completely through the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using fresh cadaveric specimens. MATERIAL AND METHODS After obtaining ethical clearance, 26 fresh cadaver heads were used without any preparation. Using a neuroendoscope, complete exposure of the circle of Willis was done endonasaly, and various observations including relation of circle of Willis was recorded. RESULTS Complete exposure of the circle of Willis was made through an endonasal approach in all cases without injuring surrounding structures. CONCLUSION Endoscopic endonasal extended transsphenoidal exposure of CW can make the surgeon more efficient in removing midline skullbase lesions with safe handling of different parts of circle of Willis and it may help in development of endonasal endoscopic vascular neurosurgery in the near future.