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We want to highlight a simple technique for performing smaller craniotomies, using a marker computed tomography scan, which does not require any special equipment, training or cost and is not time-consuming. Pictorial description of two such cases have been provided.

Objective: The study objective was to systematically review the impact of the current pandemic on neurosurgical practice and to find out a safe way of practicing neurosurgery amid the highly infectious patients with COVID-19. Materials and Methods: A review of the PubMed and EMBASE databases was performed. The literature was systematically searched using keywords such as “COVID-19” and “Neurosurgery.” Results: Among the 425 records, 128 articles were found to be eligible for analysis. These articles described the perspectives of the neurosurgical departments during the pandemic, departmental models, and organizational schemes for triaging emergent and nonemergent neurosurgical cases for the optimal utilization of limited resources, and solutions to continue academic and research activities. Triaging systems help us to optimally utilize the limited resources available. Guidelines have been developed for safe neurosurgical practice and for the continuation of clinical and academic activities during this pandemic by various national and international neurosurgical societies. Key changes in the telemedicine regulatory guidelines would help us to continue to provide neurosurgical care. Videoconferences, online education programs, and webinars could help us to overcome the disadvantages brought upon the neurosurgical education by the social-distancing norms. Conclusion: In an unprecedented time like this, no single algorithm is going to clear the ethical dilemma faced by us. Individual patient triage is a way for maintaining our ethical practice and at the same time, for efficiently utilizing the limited resources. As the pandemic progresses, new guidelines and protocols will continue to evolve for better neurosurgical practice.

Introduction: Chiari malformation type I is a collection of hindbrain abnormalities, for which natural history of the disease process is not clear. The challenge is to identify which patients will benefit most from posterior fossa decompression. Objectives: To identify important surgical implications that most likely benefit patients with Chiari malformation type I by analyzing and reviewing various operative interventions in these patients with appropriate symptoms and then following their course. Subjects & Methods: Retrospective analysis of 74 operated Chiari malformation type I with syrinx adult patients was done. Results: No definite pattern of progression in natural history of disease was noted. Most of the patients who were symptomatically stable for months to years presented with recent rapid progression. The most common symptom was suboccipital pain. The most common finding was lower extremity weakness. On clinical presentation basis, patients were divided into three categories: foramen magnum compression syndrome, central cord syndrome, and cerebellar syndrome. Most patients in our study fall in first category. Foramen magnum decompression with atlas posterior arch removal and sometimes partial C2 laminectomy depending on extent of tonsillar descent as well as augmentation duraplasty was done in most patients. Improvement was seen in foramen magnum compression syndrome group more significantly. Conclusions: Individualized surgical techniques for breaking the barriers of cerebrospinal fluid (CSF) flow in Chiari malformation type I with syrinx to restore normal CSF dynamics across craniocervical junction provide the pragmatic solution. The trend is toward balance between optimum wide decompression as compared with long craniocaudal decompression and preserving normal integrity.

INTRODUCTION Vertebral Arterio-venous fistulas (VAVFs) are uncommon lesions that can arise spontaneously or secondarily to iatrogenic or mechanical trauma. Among spontaneous cases, it is most commonly found to be associated with Neurofibromatosis type 1 (NF1). EVIDENCE ACQUISITION We performed a systematic review of the literature to obtain information regarding demographics, clinical presentation, treatment modalities and outcome of VAVFs associated with NF1. A literature search was performed by using databases PubMed Central, Embase, Cochrane Library, and Ovid MEDLINE. Also, the grey area search was done using the "Google Scholar" search engine. On screening of the original full-text English language articles, a total of 48 cases were considered suitable for inclusion in this review. EVIDENCE ANALYSIS VAVFs in NF1 commonly present between 3rd and 6th decade of life affecting females 2.4 times more than males. Left-sided fistulae were more common than the right side and most seen in the upper V2 segment of the vertebral artery. Most VAVFs in NF 1 patients were treated with constructive (occlusion of fistula only) endovascular therapy (n =26) with a high success rate. Moreover, Pooled proportion of the outcome data have shown significant difference between the endovascular constructive and destructive procedure. CONCLUSIONS The spontaneous VAVF, commonly associated with NF-1, often requires treatment. Awareness of the coexistence between NF1 and VAVF is crucial to avoid diagnostic delays and unnecessary surgical intervention leading to disastrous outcomes. Endovascular treatment is the preferred treatment approach while open surgical treatment is required in some complex fistulae and failure of endovascular techniques.

Background: An anaplastic large cell lymphoma (ALCL) involving the cervical spine and leading to quadriplegia is very rare. Case Description: A 48-year-old immunocompetent male presented with quadriplegia that warranted an anterior cervical corpectomy/fusion. He was previously being presumptively treated for cervical disease attributed to tuberculosis. The histopathology and immunohistochemistry revealed an ALCL that was anaplastic lymphoma kinase (ALK) negative. The patient had a favorable response to surgery followed by CHOEP (cyclophosphamide, doxorubicin, vincristine, etoposide, and prednisolone) chemotherapy. Conclusion: ALK-negative ALCL presenting with quadriplegia due to primary involvement of cervical spine is extremely rare, but must be diagnosed and appropriately managed.

Sinonasal teratocarcinosarcoma (SNTCS) is one of the rarest, aggressive malignant neoplasms of sinonasal tract, consisting of primitive neuroepithelial elements with various malignant epithelial and mesenchymal components. Previously described as teratoid carcinosarcoma, malignant teratoma, or blastoma, SNTCS constitutes less than 1% of all cancers and approximately 3% of all malignancies of head and neck region, which is mainly located in the nasal cavity and paranasal sinuses, although tumors occurring in other locations including the nasopharynx and oral cavity have been described. Here, we are presenting a 22-year-old patient with SNTCS involving the nasal cavity, nasopharynx, and all paranasal sinuses with bilateral orbital and intracranial extension treated with surgery followed by radiotherapy and chemotherapy.

Cavernous malformations (CMs) are vascular anomalies with dilated spaces called caverns. These spaces are lined by endothelial cells and collage and devoid of smooth muscle or intervening neural tissue, and filled with blood at various stages of stasis, thrombosis, organization, and calcification. Most CMs are relatively small in size but when they are large enough they can produce sing of mass effect and may simulate neoplastic, vascular, inflammatory pathology. Giant CM (size >6 cm) are very rare lesions and very few cases are reported in world literature. We are reporting such a rare case of a 16 year male. Our case is also unique in the sense that it is the largest reported CM in Indian population.

Central nervous system (CNS) tuberculosis commonly manifests as tubercular meningitis. CNS tuberculomas are more common intracranially and less frequently involve the spinal cord. Combination of intramedullary with intracranial tuberculomas is extremely rare. We report a case of concurrent occurrence of intramedullary tuberculoma with multiple intracranial tuberculomas in a young 16-year-old boy, who presented with two weeks history of paresthesias and weakness of the lower limbs and diminution of vision in left eye, who had been treated for pulmonary tuberculosis. Magnetic resonance imaging (MRI) spine showed a well-circumscribed lesion opposite L1, which was diagnosed as intramedullary tuberculoma. As for vision complaint, on cranial imaging, he was found to have multiple round contrast enhancing lesions, which were diagnosed as intracranial tuberculomas based on their typical MRI findings. He had complete recovery with conventional treatment of anti-tubercular therapy and steroids, without any surgical intervention. We suggest that MRI of the brain should be performed in all case of intramedullary spinal tuberculoma because of the possible presence of early asymptomatic/mild symptomatic intra-cranial tuberculomas.

Solitary fibrous tumor (SFT) is a rare neoplasm that is thought to be of mesenchymal origin. Occurrence of such a tumor in the orbit is rare, more so in its malignant form. Histopathologically, it can mimic several other tumors of the orbit and can be differentiated by CD34 positivity. We report a case of malignant transformation of an SFT of the orbit that recurred after 15 years. The differentiating histopathological features with special stress on the importance of CD34 positivity and principles of management are outlined. The need for long-term follow-up to detect recurrence and malignancy is stressed.

Chordoid glioma of the third ventricle was classified as a rare tumor by the World Health Organization in 2000. Approximately 55 cases have been reported so far in world literature. These tumors are usually slow growing presenting with features of raised ICP. Most tumors have low proliferative index and these tumors are immunohistochemically negative for P53. We are reporting a case of chordoid glioma of the third ventricle, with atypical features of high proliferative index and P53 positivity on immunohistochemistry.

Introduction Even in this modern era of neurosurgery, we could not achieve 0% mortality in operated aneurysmal subarachnoid hemorrhage (SAH) patients. An analysis of factors affecting outcome was never published in detail, and a recent update of guidelines for management of aneurysm SAH noted deficiency in knowledge about this issue. Objective The study aims to assess the effect of various factors on the outcome of operated aneurysmal SAH patients. Methods: The various factors regarding age, sex, associated chronic diseases, clinical condition of patients, surgery interval, and nature of aneurysm were correlated with outcomes of 345 operated aneurismal SAH patients. Statistical analysis was done by chi-square test and logistic regression. Results As per grade, patients' survival is 80.16% for fair grade and 21.65 % for poor grade, which was statistically significant (p 0.05). On comparing with Hunt and Hess (H-H) grade, all the above-mentioned variables showed significantly better survival in fair grade than in poor grade (p

Objective: The authors analysed the outcome of intramedullary spinal cord tumour surgery, focusing on the preoperative & postoperative neurological status and influence of preoperative gait status on postoperative gait. Methods: Retrospective analysis of medical records of 53 intramedullary tumour patients, operated at our institute between Jan 2006 and July 2012 was done. Pre - and postoperative neurological status was determined. Preoperative MRI was done. Ambulatory status were evaluated using the modified McCormick Scale. All the patients were operated using standard microsurgical techniques. Extent of resection was quantified by direct visualization with microscope as: gross resection, subtotal resection, partial resection, and biopsy. Results: 73.5% of the patients were in 40-60 years of age group (age range, 5-81 years; mean age 41 years). Region most commonly affected was thoracic (40%). The preoperative McCormick grade was I in 20 (37.7%), II in 16 (30.1%), III in 7 (13.2%), IV in 9 (16.9%), and V in 1 (1.88%) patients. Gross resection was possible in 54.7% of cases. Gross resection rate was significantly higher in good preoperative gait (grade - I). Histologically 41.5% of the lesions were ependymomas. Overall postoperative neurological status improved in 16 (30.3%) of the patients, remained unchanged in 27 (50.9%) of cases, and deteriorated in 10 (18.8%) patients. Conclusions: Better final outcome of walking ability correlated with good preoperative gait. Higher Gross resection rate was found in cases at an early stage. We favor early and optimal resection of tumour to give least morbidity and better quality of life.

Introduction: Various studies have been carried out proposing the concept of knee spine syndrome measuring simultaneous changes in knee flexion and sacral inclination, but none regarding its management. Here in this study, we put forward the management and diagnostic algorithm for the knee and spine disease operated by the same surgeon. Materials and methods: This is a prospective study of 10 patients having knee spine syndrome operated by the same surgeon from January 2016 to January 2018. They were selected and treated as per the treatment protocol put forward and clino-radiological outcomes were evaluated with visual analog scale (VAS), oswestry disability index (ODI) scoring, and radiographs. Results: Age of the patients included in this study ranged from 55–80 years. In 6 patients, the spine was operated first and in others, knee replacement was done as an index procedure. Average pre-operative ODI score was 28.9 which decreased to 7.5 postoperatively at 2-year follow-up. VAS score decreased from 7.4 preoperatively to 1.5. Conclusion: Knee spine syndrome is one of those entities which need to be identified and treated as a whole and not as two different symptomatic diseases. According to our proposed algorithm, radicular symptoms (spinal pathology) should be treated first. In cases of predominant back pain which could be either due to loss of lumbar lordosis or precipitated by deformity caused by malalignment in osteoarthritis knee, knee replacement was considered first. Despite the proposed algorithm, the clinical acumen of the surgeon in determining the leading cause of morbidity may help prevent unnecessary further staged surgeries.

The growing skull fracture (GSF) occurs in younger age group as a sequel of trauma. The most common site of these lesions is parietal region. Here we are presenting a case of GSF of posterior fossa with cerebrospinal fluid (CSF) fistula. As per literature, we have not found a single case of GSF in the posterior fossa with CSF fistula. The aim of this presentation is discussing the unusual presentation of GSF and its management.

Gunshot wound (GSW) to the spine which was earlier common in the military population is now being increasingly noted in civilians due to easy availability of firearms of low velocity either licensed or illegal combined with an increased rate of violence in the society. Contributing to 13% to 17% of all spinal injuries, the management of complex injury to the spine produced by a GSW remains controversial. Surgery for spinal cord injuries resulting from low velocity GSWs is reserved for patients with progressive neurologic deterioration, persistent cerebrospinal fluid fistulae, and sometimes for incomplete spinal cord injuries. Surgery may also be indicated to relieve active neural compression from a bullet, bone, intervertebral disk, or a hematoma within the spinal canal. Spinal instability rarely results from a civilian GSW. Cauda equina injuries from low velocity GSWs have a better overall outcome after surgery. In general, the decision to perform surgery should be made on consideration of multiple patient factors that can vary over a period of time. Although there have been plenty of individual case reports regarding GSW to the spine, a thorough review of unique mechanical and biological factors that affect the final outcome has been lacking. We review the key concepts of pathogenesis and management of GSW to the spine and propose an algorithm to guide decision making in such cases.

Bilateral cerebellopontine angle (CPA) arachnoid cysts (ACs) are very rare: only one case is reported in literature. Pathogenesis of those cysts is unknown; they are thought to be congenital. The presenting symptoms of CPA AC are frequently nonspecific or otological. The management of ACs of the CPA is controversial. We are reporting two cases of bilateral CPA AC with their pathophysiology and review of literature.

Penetrating injury to the spine is the third most common cause of spinal injury. Injuries due to bullet, glass, nails and pencil injuries are well documented in literature. We report a rare case of delayed onset intramedullary abscess following thorn prick and have reviewed the literature for similar forms of injuries.

Objective: Spinal intramedullary tuberculoma (SIMT) is rare, accounting for 2/100,000 cases of tuberculosis and only 0.2% of all cases of central nervous system (CNS) tuberculosis. We share our experiences of 11 cases of this entity for improving diagnosis and conceptualize the management of this rare disease. Methods: The clinical profile, radiological data and management of 11 cases of SIMT which were managed either conservatively or by surgical intervention during last 27 years (1987-2014) were analysed. Results: Male:female ratio was 1.75:1. Five cases had associated pulmonary Koch’s. Most common site was thoracic cord. Two cases had concurrent multiple intracranial tuberculoma. Most common presentation was paraparesis. X-ray myelography was performed in two patients in the initial period of study suggesting intramedullary pathology. In the subsequent nine cases who had magnetic resonance imaging (MRI), seven showed typical ‘‘target sign’’ and conglomerate ring lesion. Out of 8 surgically managed patients, 6 cases improved rapidly and in 2 patients gradual improvement was seen in follow-up. Most common indication of surgical excision was rapid neurological deterioration followed by diagnosis in doubt. Histopathology confirmed tuberculous etiology of the intramedullary lesion in all. Clinical and radiological improvement was seen in all 3 conservatively managed patients in follow-up. Conclusion: MRI findings of SIMT were specific and proven histologically correct. Surgical intervention may be indicated if there is no response to chemotherapy, the diagnosis is in doubt, or there is a rapid deterioration in neurological function because surgical outcome is good in these circumstances.

Primary non-Hodgkin's lymphoma (NHL) of the cranium with extra- and intracranial extension without systemic or skeletal manifestation in a non-immunocompromised patient is extremely rare. These lesions are most of the time misdiagnosed because they mimic other conditions like meningioma. Here, we report a case presented with huge bulky scalp mass which on magnetic resonance imaging (MRI) brain showed involvement of scalp, cranial vault, meninges, and the brain parenchyma, mimicking a meningioma. After gross total resection, biopsy and CD marker study revealed primary non-Hodgkin's diffuse large B-cell lymphoma (DLBCL). Malignant NHL should be considered in differential diagnosis of bulky scalp mass lesion.

We came across a case of jugular foramen mass causing positional hoarseness on turning the head left and disappearing on returning the head to a straight position. Hoarseness of voice due to vagus nerve involvement is seen in jugular foramen mass but positional hoarseness has never been seen before. We report this rarest presentation and discuss the pathophysiology behind it.

Juvenile Xanthogranuloma (JXG) is a rare disorder of central nervous system. It rarely produces compressive myelopathy. On reviewing world literature, we could find only nine cases of this disease involving spine and of which only four cases were in adults' i.e., 18 years and above. We are presenting a case of Spinal JXG in an18-year-old male with thoracic compressive myelopathy presenting as short duration progressive paraparesis. Magnetic Resonance Imaging of Spine showed mass lesion in epidural space compressing cord from behind without any bony involvement at D7 to D10 vertebral segment. It was isointense on T1 and hyperintense on T2 with no contrast enhancement. D7 to D10 Laminectomy with complete excision of firm epidural mass was carried out. The histopathology with tumor markers confirmed the diagnosis of JXG. Post-operative neurological recovery in this patient was good. His power improved to grade 5/5 with decreased spasticity. Follow-up MRI at 3 months showed no residual tumor. This case appears to be the first in the series with entirely extradural component in adult thoracic spine.

Hemangioma accounts for 7% of total tumors of soft tissue in which 0.8% is intramuscular. Only 17% of the intramuscular hemangioma are posttraumatic at any site. There are only 23 case reports of temporalis muscle hemangioma and among these there is only one case report of posttraumatic hemangioma of the temporalis muscle in the available literature. Here we report a second case of posttraumatic temporalis muscle hemangioma in a 30-year-old female who presented with 4-year long history of progressive enlarging and painful swelling on the left temporal region following blunt injury in the same region. The mass was completely removed and histopathological examination showed cavernous hemangioma, so it should always be considered in the differential diagnosis of unexplained pain and swelling of muscle. Magnetic resonance imaging (MRI) is investigation of choice but computed tomography (CT) carotid angiography is superior choice with high flow type as it not only gives detail of a lesion but also shows arterial feeder and draining veins, which help in surgical planning as in our case.