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OBJECTIVE The aims of this study were to characterize syringomyelia in patients with lipomyelomeningocele (LMMC) and investigate the association between the presence of a syrinx and patient neurological deficits. METHODS Patients with LMMC who had been admitted between 2007 and 2020 were included in the study. Syringomyelia on magnetic resonance imaging (MRI) was classified into three groups: true syrinx, early syrinx, and presyrinx. The correlation of clinical deficits (at birth, new onset, and progressive) and type of lipoma with the presence and type of syrinx was studied. RESULTS Among a total of 140 patients, the median age was 2.5 (IQR 1.3–9) years. Neurological deficits were present at birth in 75 (53.6%) patients, but 67 (47.9%) had new-onset deficits or progression of their birth deficits. The most common type of spinal lipoma was the transitional type (75.7%). Thirty-nine (27.9%) patients had a syrinx (37 with a true syrinx, 2 with an early syrinx), and 25 (17.9%) patients had a presyrinx. There was no significant correlation between the presence of a syrinx and patient neurological deficits. However, patients with a syrinx that was not adjacent to the lipoma (≥ 1 vertebral level away) had a higher incidence of deficits at birth (p = 0.045), whereas those with a syrinx spanning ≥ 5 vertebral levels had a higher incidence of progressive neurological deficits (p = 0.04). Six (75%) of 8 patients in whom serial MRI had shown syrinx progression had clinical worsening. CONCLUSIONS Syrinx location with respect to the spinal lipoma, syrinx length, and progressive syringomyelia may have clinical significance in patients with LMMC.

We aimed to study the literature on chronic granulomatous invasive fungal sinusitis to elucidate the changing trends in the management of the disease.Using specific keywords, we searched the PubMed, PubMed Central, and Scopus databases over the past 50 years, which yielded 938 articles in the English language.Scrutiny of 147 relevant articles revealed 15 homogenous case series (255 cases of histologically proven chronic granulomatous fungal sinusitis alone) and 8 heterogeneous case series (patients with other types of fungal sinusitis included), which were analyzed in detail (all with5 cases each).The disease typically affected middle-aged adults with immunocompetence. Most reports were from Sudan, India, and Saudi Arabia. A slowly progressive orbital, cheek, or palatal mass with proptosis (88.2%) or sinonasal symptoms (39.2%) was typical. Ethmoid (57.2%) and maxillary (51.4%) sinuses were chiefly affected with intracranial extension in 35.1%.Chronic granulomatous fungal sinusitis should be diagnosed on the basis of well-defined histopathologic features. A combination of endoscopic sinus surgery and azole therapy usually yields good outcomes.

Background Differences in presentation and outcomes in children and adults with spinal dermoid tumors have not been documented. Surgical outcomes for dermoid tumors in different spinal cord planes have also not been studied. Methods Retrospective review of 59 consecutive patients who underwent surgery for intraspinal dermoid tumors at a single institution. Tumors were categorized as purely extramedullary (n = 15), purely intramedullary (n = 28) or intramedullary-extramedullary (n = 16) based on intraoperative and imaging findings. Results The cohort was composed of 45 children and 14 adults. The presence of a dermal sinus and prior history of meningitis was significantly associated with childhood presentation (P = 0.001 and P = 0.013, respectively). Most adults had purely intramedullary tumors (n = 12, 85.7%) as compared to children (35.6%, P = 0.001). Gross total resection (GTR) was achieved in 33.3% and 41.7% of children and adults, respectively (P = 1.000). Factors associated with GTR on logistic regression analysis included short segment (≤3 levels) dermoid cysts (P = 0.037) and absence of an intramedullary component (P = 0.027). Forty-seven patients were followed up over a mean period of 72.9 ± 8.3 months. Preoperative motor deficits were more likely to improve in children than in adults (P = 0.005). Recurrences were seen in 14.9% of cases (all with intramedullary tumors) at a median interval of 58 months (range: 40–166 months) after surgery, with no differences in recurrence-free survival between children and adults (P = 0.936). Conclusions Presentation of dermoid cysts is distinctively different in children and adults. GTR is a challenge for intramedullary and large tumors. Recurrences may manifest several years after surgery, mandating life-long surveillance.

Background The presence of perilesional edema among patients with parenchymal neurocysticercosis (pNCC) of various lesion subtypes has not been correlated with results of serum enzyme-linked immunotransfer blot (EITB) for cysticercal antibodies. Methods In total, 521 patients with pNCC were classified into solitary cysticercus granuloma (SCG), multiple lesions, at least one of which was an enhancing granuloma (GMNCC), solitary calcified cysticercal lesion (SCC) and multiple calcified cysticercal lesions (CMNCC). The proportion of EITB positivity among each lesion subtype and its association with perilesional edema were determined. Results There were significantly higher positive EITB results in patients with GMNCC (90/111, 81.1%) compared with other lesion types. Perilesional edema was associated with positive EITB in patients with CMNCC. On univariate analysis, perilesional edema and GMNCC were associated with EITB positivity. On multivariate analysis, only GMNCC (OR 7.5; 95% CI 3.5 to 16.2) was significantly associated with EITB positivity. Conclusions In patients with pNCC, the presence of perilesional edema is associated with a higher probability of a positive EITB result in patients with CMNCC, suggesting a synchronicity in the mechanisms associated with formation of perilesional edema and the antibody response in this subtype. In patients with enhancing granulomas, edema is not an independent predictor of a positive EITB, suggesting that the enhancement itself is associated with a strong antibody response.

The literature regarding the utility of cerebrospinal fluid (CSF) procalcitonin (PCT) in the diagnosis of post-craniotomy bacterial meningitis and differentiating it from aseptic meningitis is sparse.CSF total WBC count, sugar, protein, and PCT were measured in febrile patients with suspected post-craniotomy meningitis during the first 30 days following an intradural cranial procedure for non-trauma indications. Patients were diagnosed as postoperative bacterial meningitis if CSF culture was positive (PBM, n = 28) or postoperative aseptic meningitis if CSF culture was sterile and there was no evidence of systemic infection (PAM, n = 31). CSF cytochemical parameters and PCT values were compared between the groups. Normal values of CSF PCT were obtained from 14 patients with noninfectious indications with hydrocephalus.There was no significant difference in CSF total WBC count, sugar, and protein levels between PAM and PBM groups. The median PCT level in CSF in the normal group was 0.03 ng/mL (interquartile range [IQR] 0.02-0.07 ng/mL). CSF PCT in the PBM group (median 0.37 ng/mL, IQR 0.2-1.4 ng/mL) was significantly higher than normal values as well as PAM group (median 0.12 ng/mL, IQR 0.07-0.26 ng/mL (P = 0.0004). The area under the receiver operating characteristic (ROC) curve for CSF PCT was 0.767. A cutoff value of 0.12 ng/mL yielded a sensitivity of 85.7% (95% CI: 67.3% to 96%), specificity of 51.6% (95% CI: 33% to 69.9%), positive predictive value of 61.5% (95% CI: 51.9% to 70.3%), and negative predictive value of 80% (95% CI: 60.3.8% to 91.3%).CSF PCT assay in patients who are febrile during the first 30 days post-non-trauma neurosurgical procedures has a role in the early diagnosis of bacterial meningitis.

To determine the functional outcomes and risk factors for outcomes following surgery for lipomyelomeningocele (LMMC). Data from 109 children with LMMC who underwent surgery from January 2008 to December 2017 were retrospectively studied to evaluate functional outcomes and possible risk factors for early- (at discharge from hospital or within 1 month of surgery) and long-term outcomes after surgery. There were 53 boys and 56 girls with median age of 36 months (IQR 12-90 months; range, 4 months to 18 years) at surgery. At presentation, neurological function was normal (asymptomatic group) in 28 (25.7%) children while there was neurological dysfunction (symptomatic group) in 81 (74.3%). Near total or radical excision of lipoma was done in 71 (65.1%) children. Six (5.8%) children had deterioration of neurological function in the post-operative period with recovery of function in three of them. There were no statistically significant risk factors for early outcomes. At a mean follow-up of 62.5 months (IQR 35–82 months; range, 12–146 months), 21 (27.6%) of the 76 symptomatic group children (including 59.3% with incomplete bladder dysfunction) showed improvement, 52 (68.4%) remained the same, while 3 (4%) deteriorated. In 31 children (symptomatic group) who developed symptoms after 1 year of age, early surgery after development of symptoms was associated with better chances of recovery (p = 0.0008). In the asymptomatic group, 23 (88.5%) had normal neurological function at mean follow-up of 57.5 months (IQR 30–77 months; range, 12–141 months) and 3 (11.5%) had neurological deterioration. The mean time to late deterioration (re-tethering) from surgery was 51.3 months (IQR 24–75 months; range, 24–84 months). Presence of syrinx on initial MRI (p = 0.008) and partial resection of the lipoma (p = 0.02) were independent risk factors for delayed deterioration. Radical resection of LMMC probably helps in preserving neurological function in > 90% of children at long-term follow-up. Fifty-five percent of children > 2 years of age with incomplete bladder dysfunction regained normal function following surgery. In children who develop symptoms after birth, early surgical intervention can reverse the neurological deficits.

Background We document the results of a protocol to reduce the incidence of cerebrospinal fluid (CSF) leak and other wound complications in patients undergoing tethered cord surgery (TCS). Methods Data from all patients undergoing TCS between January 2009 and April 2019 were reviewed retrospectively. Diagnosis (high risk or low risk; based on the presence of fascial and dural defects at surgery), type of graft used for dural or fascial repair, and CSF leak and other wound complications in the postoperative period were noted. All patients were nursed in the prone position with elevation of the foot end of the bed (Trendelenburg position) for at least 5 days after surgery with a subfascial drain in place. Results Of a total of 350 patients (191 high risk; 159 low risk), CSF leak from the wound was noted in 16 (4.5%). All but 4 of these patients were managed with wound suturing with or without insertion of a subcutaneous drain with continued nursing in the prone and Trendelenburg position. Two patients had meningitis and 3 patients had wound infection. Multivariate analysis revealed that the use of synthetic grafts (P Conclusion Postoperative prone nursing with Trendelenburg position minimizes the incidence of CSF leak and other wound complications.

Shunt infection is the most significant morbidity associated with shunt surgery. Based on the existing literature for the prevention and management of shunt infection, region and resource-specific recommendations are needed.In February 2020, a Guidelines Development Group (GDG) was created by the Indian Society of Paediatric Neurosurgery (IndSPN) to formulate guidelines on shunt infections, which would be relevant to our country and LMIC in general. An initial email survey identified existing practices among the membership of the IndSPN, and eight broad issues pertaining to shunt infection were identified. Next, members of the GDG performed a systematic review of the literature on the prevention and management of shunt infection. Then, through a series of virtual meetings of the GDG over 1 year, evidence from the literature was presented to all the members and consensus was built on different aspects of shunt infection. Finally, the guidelines document was drafted and circulated among the GDG for final approval. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to grade the evidence and strength of recommendation.The guidelines are divided into eight sections. Level I and Level II evidence was available for only five recommendations and led to a moderate level of recommendations. Most of the available evidence was at Level III and below, and hence the level of recommendation was low or very low. A consensus method was used to provide recommendations for several issues.Although most of the recommendations for the prevention and management of shunt infections are based on a low level of evidence, we believe that this document will provide a useful reference to neurosurgeons not only in India but also in other low and middle income countries. These guidelines need to be updated as and when new evidence emerges.

Supratentorial ependymomas (STEs) are an aggressive group of ependymomas, topographically distinct from their posterior fossa and spinal counterparts. Zinc finger translocation associated (ZFTA) fusion-positive cases have been reported to account for the majority of STEs, although data on its association with poorer outcomes are inconsistent.We assessed the prevalence of the ZFTA fusion by reverse-transcription polymerase chain reaction and fluorescence in situ hybridization in a cohort of 61 patients (68 samples) with STE. Our primary outcome was to determine the role of the ZFTA fusion on progression-free and overall survival of patients with STE. Our secondary objectives were to assess the impact of ZFTA fusion on nuclear factor (NF)-kB pathway signaling via surrogate markers of this pathway, namely COX-2, CCND1, and L1 cell adhesion molecule.ZFTA fusion was noted in 21.3% of STEs in our cohort. The presence of this rearrangement did not significantly impact the progression-free or overall survival of patients with STEs and was not associated with upregulation of markers of the NF-kB pathway. Only gross total resection was significantly associated with better progression-free survival.In contradiction to previous reports from across the world, the ZFTA fusion is far less prevalent among our population. It does not appear to drive NF-kB signaling or significantly affect outcomes. Gross total resection must be attempted in all cases of STE and adjuvant radiation and/or chemotherapy employed when gross total resection is not achieved.

PURPOSE To characterize the temporal profile of pre-operative deterioration in children with lipomyelomeningocele (LMMC) including those with congenital deficits and identify risk factors for clinical worsening. METHODS Records of 87 children who underwent surgery for LMMC were retrospectively reviewed to study the temporal profile of pre-operative deterioration, defined by the onset of new neurological dysfunction or progression of a pre-existing deficit. Preoperative magnetic resonance imaging (MRI) studies were examined to identify radiological features associated with deterioration. In children with extra-spinal placodes, the angle subtended by the terminal placode with the cord at the level of the laminar-fascial defect ("J sign") was assessed. RESULTS Pre-operative deterioration in function was seen in 37 children (43%), occurring at a median age of 36 months and was more frequent in children without congenital deficits (54% versus 27%; p = 0.016). On Cox regression analysis, extra-spinal location of the placode (p = 0.003) and presence of a congenital deficit (p = 0.009) were positively and negatively associated with deterioration respectively. On Kaplan-Meier analysis, the median deterioration-free survival time was 72 months and was positively associated with presence of congenital deficit (p = 0.026) and negatively associated with presence of an extra-spinal placode (p

We aimed to study whether the increased use of cell phone in south Asia over the past two decades has impacted presentation of patients with vestibular schwannoma (VS). In this observational cohort study, data on cell phone use and severity of hearing loss and tumor size was collected using a questionnaire through a patient interview (n = 62) in consecutive patients with VS managed between 2017 and 2020. Association between cell phone use and severity of hearing loss and tumor size were studied and compared with our data published earlier when telephone use was not widely prevalent. 71% of the 62 patients (aged between 15 and 81 years) had large or giant VS. Pure tone audiometry showed moderately severe or profound hearing loss in77.4%. Sixty (96.7%) patients used cell phones. 50% of patients complained of difficulty in using their cell phone because of hearing loss. Compared to the earlier era, a higher proportion consulted an ENT surgeon first for hearing loss (59.7% vs 26%; p = 0.0005) and had small or medium sized tumors (29% vs 8%; p = 0.008) with a smaller mean tumor size (3.3 vs 3.9 cm; p = 0.03). Increased cell phone use has led to earlier diagnosis of VS and smaller tumours in recent years when compared to an earlier era. However, the vast majority of patients continue to present with severe to profound hearing loss and large tumors.

PURPOSE The purpose of this study is to document the prevalence of MR findings suggestive of idiopathic intracranial hypertension (IIH) in patients undergoing endoscopic repair of spontaneous CSF rhinorrhea (SCSFR). METHODS In a retrospective study, MR images of 117 consecutive patients who had undergone endoscopic repair of SCSFR were evaluated for features suggestive of IIH (empty sella, widened optic nerve sheath, tortuous optic nerve, flattened posterior globe, and enlarged Meckel's cave). Pituitary height was used to diagnose partial and complete empty sella. MR images were independently evaluated by two of the authors without knowledge of the clinical findings. Consensus method was used to resolve differences between the two evaluators. RESULTS Empty or partially empty sella was diagnosed in the MR of 105 (89.7%) patients. In 38/105 (36.2%) patients with empty/partial empty sella, no additional MR findings were present. In 43/105 (41%) patients, one or more of the MR features with high specificity for diagnosis of IIH (flattened posterior globe and enlarged Meckel's cave) were seen. In the other 24 (22.9%) additional MR findings, less specific for IIH (widened optic nerve sheath, tortuous optic nerve) were noted. Papilledema was seen in 11 of 60 (18.3%) patients who underwent funduscopic examination. All patients with papilledema had empty/partial empty sella, and 9/11 (81.8%) had an additional MR finding suggestive of IIH. CONCLUSION The majority of patients with SCSFR have MR imaging features of IIH. These imaging features should be a major component of previously published modified diagnostic criteria for IIH in patients with SCSFR.

Background In patients with enhancing brain parenchymal lesions, parenchymal neurocysticercosis (pNCC) is often difficult to distinguish from tuberculoma, necessitating biopsy or empirical therapy. Methods In a prospective study, peripheral blood monocytes were isolated from patients with definitive pNCC (n = 39) and brain tuberculomas (n = 20). Patients with tuberculomas were diagnosed by the presence of concurrent systemic tuberculosis (n = 7), pathological or bacteriological confirmation (n = 5), and resolution of typical brain lesions following a therapeutic trial of antituberculous therapy (n = 8). Expressions of 14 NCC-associated monocyte genes were determined by quantitative polymerase chain reaction and analyzed for diagnostic usefulness between the 2 groups. Results Expression of 7 genes (TAX1BP1, RAP1A, PLCG2, TOR3A, GBP1P1, LRRFIP2, and FEZ2) was significantly higher in pNCC patients than in tuberculoma patients, with TAX1BP1 and RAP1A expressions more than 22- and 5-fold higher in pNCC patients. TAX1BP1 had the highest sensitivity of 66.7% at a specificity of 100% in discriminating pNCC from tuberculoma. A combination of TAX1BP1 and RAP1A increased the sensitivity to 84.6%, and including GBP1P1 with TAX1BP1 and RAP1A further increased sensitivity to 87.2% while maintaining specificity of 100%. Conclusions Expression of a panel of genes in blood monocytes distinguishes pNCC from brain tuberculomas in patients with enhancing brain lesions.

Objective: To evaluate the safety and efficacy of long tunnelled external ventricular drains (LTEVD) as a temporizing measure in patients with ventriculitis/meningitis requiring cerebrospinal fluid (CSF) diversion in whom immediate shunt surgery is not feasible.Methods: A retrospective review of the records of 15 patients with ventriculitis/meningitis, in whom an LTEVD was inserted, was performed to evaluate its safety, new onset CSF infection and need for permanent CSF diversion.Results: 15 patients with ventriculitis/meningitis had 16 LTEVDs placed between May 2006 and December 2016. There were 10 males and 5 females, their mean age being 16.5 years (range, 8 months-50 years). The mean duration of CSF drainage was 15.6 days (range, 4 to 44 days). Of the 16 LTEVDs that were inserted, two (13.3% - one CSF infection and one wound infection) developed new infection after 44 and 17 days of continuous CSF drainage respectively. The LTEVDs were removed and permanent CSF diversion procedures were performed in 10 patients during the same admission and in one patient later. At a mean follow up of 11.6 months (range 2-40 months), 8 of the 11 patients who underwent a permanent CSF diversion procedure had no clinical features of meningitis/ventriculitis.Conclusion: LTEVDs are an effective method of temporary CSF diversion in patients requiring the same for more than 5 days. These drains have a low infection rate when placed up to four weeks making them a safe and efficacious adjunct in management of ventriculitis/meningitis associated hydrocephalus.

Objective This study was performed to review the literature and to present the most up-to-date information and recommendations on the indications, complications, and success rate of anterior surgical techniques for cervical spondylotic myelopathy (CSM). The commonly performed anterior surgical procedures are multiple-level anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion and its variants (skip corpectomy and hybrid surgery), and oblique corpectomy without fusion. Methods A comprehensive literature search and analysis were performed using MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and the Web of Science for peer-reviewed articles published in English during the last 10 years. Results Corpectomy is mandated for ventral compression of fewer than 3 vertebral segments where single-level disc and osteophyte excision is inadequate to decompress the cord. Endoscopic or oblique partial corpectomy improves the sagittal canal diameter by 67% and obviates the need for an additional bone graft procedure. Conclusion The indications of anterior surgery in patients with CSM include a straightened or kyphotic spine with a compression level lower than 3. With an appropriate choice of implants and meticulous surgical technique, surgical complications can be seen only rarely. Improvements after anterior surgery for CSM have been reported in 70% to 80% of patients.

To analyze factors associated with the development of early symptomatic hydrocephalus following posterior fossa tumor (PFT) surgery in children. In this retrospective study, data from 148 children (age

Objective We studied the accuracy of the radiologic diagnosis of lateral ventricular masses in children ( Methods In this retrospective study, data were collected from children with lateral ventricular masses managed in our unit between 2001 and 2016. There were 43 patients (26 boys and 17 girls; mean age, 12.1 years; range, 8 months to 20 years). Magnetic resonance imaging was available for 36 patients, whereas in 7 patients only a contrast-enhanced computed tomography scan was available. The images were read independently by 3 radiologists, who were blinded to the pathology. Two differential diagnoses were offered for each patient. The agreement between the 3 radiologists was calculated using the Fleiss κ statistic. Results The common pathologic diagnoses were subependymal giant cell astrocytoma (SEGA) (20.9%), low-grade astrocytoma (16.3%), high-grade astrocytoma (9.3%), choroid plexus papilloma (9.3%), and meningioma (9.3%). The sensitivity, specificity, and accuracy of the radiologic diagnoses were 62%, 96.7%, and 94.2%, respectively. Low-grade tumors such as low-grade gliomas, SEGAs, choroid plexus papillomas, and meningiomas were diagnosed with a high level of accuracy. High-grade gliomas, choroid plexus carcinomas, and other malignant neoplasms were difficult to diagnose on imaging. Cavernous angiomas were also difficult to diagnose. There was only fair agreement between the 3 radiologists (Fleiss κ = 0.24). Conclusions The pathologic spectrum of lateral ventricular tumors in children is wide, and identifying the pathology on imaging is difficult for malignant tumors. Benign tumors such as SEGAs, low-grade astrocytomas, and choroid plexus papillomas are relatively easier to diagnose. There is significant interobserver variability in the radiologic diagnosis of these tumors.

Functional status of cerebrospinal fluid (CSF) diversion procedure for hydrocephalus is difficult to assess on several occasions. We report the use of serial ultrasonographic measurement of optic nerve sheath diameter (ONSD) to assess the functional status of CSF diversion procedures in patients with hydrocephalus.In this prospective observational study, ultrasonographic ONSD measurement was performed preoperatively, on postoperative days 1, 3, and 7 (n = 51 at each time point) and at follow-up (n = 31) in patients undergoing ventriculoperitoneal shunt or endoscopic third ventriculostomy for hydrocephalus. Change in ONSD values during first week after CSF diversion procedure and at follow-up were correlated with ventriculoperitoneal shunt/ETV function.ONSD ≥5.5 mm strongly correlated with clinical and imaging features of raised ICP (P0.001). Mean ONSD progressively decreased in the postoperative period and was the lowest on postoperative day 7 (P0.001) with95% of patients having ONSD5.5 mm at that time point. At follow-up (median, 12 months; n = 31), ONSD had further reduced in 78.6% of patients. All 3 patients with shunt dysfunction had an increase in the ONSD value compared with that on postoperative day 7.ONSD measurement on postoperative day 7 after CSF diversion correlates well with early surgical outcome but decreases further in many patients at a follow-up of 12 months. Rise in postoperative day 7 ONSD at follow-up correlates with failure of the CSF diversion procedure.

The purpose of this study is to evaluate the role of spinal angiography and arterial embolization in avoiding spinal cord ischemia in patients undergoing CT-guided alcohol injection of aggressive vertebral hemangiomas. In this retrospective study, patients with vertebral hemangioma who underwent CT-guided direct alcohol injection between January 2007 and October 2018 were identified. Of 28 such patients, 26 had neurological deficits, and 2 had only back pain or radiculopathy. Direct alcohol injection without prior arterial embolization was done in 17 patients. Direct alcohol injection with prior arterial embolization was done in 11 patients. Clinical outcome was assessed immediately after the intervention and at follow-up. Three patients, who underwent alcohol injection without trans-arterial embolization, had worsening of neurological deficits in the post procedure period due to spinal cord ischemia. No complications related to spinal cord ischemia were noted in the embolization group. There was no significant difference in the outcomes between the two groups if the three patients with complications are excluded (p = 0.34). While CT-guided direct alcohol injection is effective in the management of symptomatic and aggressive vertebral hemangiomas, spinal angiography and trans-arterial embolization of the blood supply to the vertebral body hemangioma, prior to the direct transpedicular alcohol embolization of the lesion, improves the safety of the procedure.

This study documents the monitorability using different anesthesia regimes and accuracy of muscle motor evoked potentials (mMEPs) in children ≤2 years of age undergoing tethered cord surgery (TCS). Intraoperative mMEP monitoring was attempted in 100 consecutive children, ≤2 years of age, undergoing TCS. MEP monitoring was done under 4 different anesthetic regimes: (Total intravenous anesthesia (TIVA); balanced anesthesia with sevoflurane and ketamine; balanced anesthesia with isoflurane and ketamine; and balanced anesthesia with sevoflurane). Factors analyzed for their effect on monitorability were: age, neurological deficits, type of anesthesia, and the number of pulses used for stimulation. Baseline mMEPs were obtained in 87% children. Monitorability of mMEPs was similar in children ≤1 year and 1-2 years of age (85.7% and 87.5%). In multivariate analysis, anesthesia regime was the only significant factor predicting presence of baseline mMEPs. Children undergoing TIVA (p=0.02) or balanced anesthesia with a combination of propofol, sevoflurane, and ketamine (p=0.05) were most likely to have baseline mMEPs. mMEPs had a sensitivity of 97.4%, specificity of 96.4%, negative predictive value of 98.2% and accuracy of 96.8%. Baseline mMEPs were obtained in >85% of children ≤2 years of age including those who had motor deficits. TIVA and balanced anesthesia with sevoflurane and ketamine are ideal for mMEP monitoring. mMEPs have a high accuracy although, false positive and false negative results can occasionally be experienced.

This study documents the monitorability using different anesthesia regimes and accuracy of muscle motor evoked potentials (mMEPs) in children ≤2 years of age undergoing tethered cord surgery (TCS).Intraoperative mMEP monitoring was attempted in 100 consecutive children, ≤2 years of age, undergoing TCS. MEP monitoring was done under 4 different anesthetic regimes: (Total intravenous anesthesia (TIVA); balanced anesthesia with sevoflurane and ketamine; balanced anesthesia with isoflurane and ketamine; and balanced anesthesia with sevoflurane). Factors analyzed for their effect on monitorability were: age, neurological deficits, type of anesthesia, and the number of pulses used for stimulation.Baseline mMEPs were obtained in 87% children. Monitorability of mMEPs was similar in children ≤1 year and 1-2 years of age (85.7% and 87.5%). In multivariate analysis, anesthesia regime was the only significant factor predicting presence of baseline mMEPs. Children undergoing TIVA (p=0.02) or balanced anesthesia with a combination of propofol, sevoflurane, and ketamine (p=0.05) were most likely to have baseline mMEPs. mMEPs had a sensitivity of 97.4%, specificity of 96.4%, negative predictive value of 98.2% and accuracy of 96.8%.Baseline mMEPs were obtained in85% of children ≤2 years of age including those who had motor deficits. TIVA and balanced anesthesia with sevoflurane and ketamine are ideal for mMEP monitoring. mMEPs have a high accuracy although, false positive and false negative results can occasionally be experienced.

To document the outcomes and quality of follow-up compliance after planned subtotal, near-total and gross-total resection (STR, NTR, and GTR) of vestibular schwannomas (VSs).This is a retrospective study of 294 consecutive patients, who underwent excision of a previously untreated VS, between 2005 and 2015. Outcomes including long-term tumor control, facial nerve outcomes, and compliance with follow-up advice were studied.The mean diameter of the tumors was 4.2 cm (±0.8 cm; range: 2.2-7.5 cm). Less than total excision was performed in 55 cases (18.7%), of which NTR was performed in 65% of the cases (n = 36) and STR in the remaining 35%. In the GTR group, 29.3% of patients had a good facial outcome (House and Brackmann [HB] grades 1-3) whereas 81.8% of patients undergoing NTR/STR had a good facial outcome. Follow-up was available in 94.5% of patients undergoing NTR/STR whereas only 69.5% of patients undergoing GTR could be followed up. Only 61.8% of the patients who had NTR/STR were compliant with our follow-up advice and were on either regular radiological surveillance or underwent stereotactic radiosurgery (SRS) as advised. In this group of patients, those with larger tumors and those who underwent a more extensive resection of their tumor were less likely to be compliant with follow-up advice (P = 0.043 and 0.007, respectively). Among patients who had GTR, nine patients (3.7%) were detected to have tumor recurrence at a mean interval of 5.5 years after surgery."Incomplete" microsurgical excision followed by SRS is an effective strategy that fulfills the twin objectives of preservation of function and long-term tumor control. Considering follow-up attrition due to various causes, upfront SRS at the first follow-up visit-even for a small residue-may be a prudent strategy in selected patients.

There is a significant knowledge gap and anxiety among health care workers (HCWs) including neurosurgeons regarding in-hospital disease transmission and use of personal protective equipment (PPE) during the ensuing COVID-19 pandemic.To assess present practice and perceptions among Indian neurosurgeons with respect to type of surgeries performed, PPE usage and SARS-CoV-2 testing.A 12-item questionnaire on surgeries performed in the 6 weeks prior to the survey date, PPE usage, and preoperative SARS-CoV-2 testing was circulated electronically to Indian neurosurgeons from May 12, 2020 to May 31, 2020 and their responses analyzed.Two hundred forty-four neurosurgeons (237 males) participated in the survey; of whom, 230 had performed surgeries during the pandemic period. In total, 84.3% of respondents were performing semiemergency or emergency procedures only. N95 masks were utilized by only 83% of the respondents (n = 230) while performing surgical procedures. Only 40.9% of the respondents were satisfied regarding adequacy of available PPE. Preoperative SARS-CoV2 testing as well as testing of all asymptomatic patients prior to admission into ward/intensive care unit was perceived to be beneficial in reducing transmission risk by more than 85% respondents. More than 90% respondents felt that HCWs including neurosurgeons were at risk of acquiring infection through an outpatient consultation from an asymptomatic individual.Access to and utilization of appropriate PPE was lacking among the one-fifth of neurosurgeons who participated in this survey. To gain the confidence of neurosurgeons, hospitals should address their concerns regarding PPE and testing of patients prior to surgery and admission to the hospital.

Sagittal alignment of the cervical spine might influence the development of radiological adjacent segment pathology (RASP) after central corpectomy (CC). Range of motion (ROM) of the adjacent segments is closely linked to the development of RASP. To investigate the ROM of the adjacent segments after CC, we developed a C2-T1 finite element (FE) model. The model with a lordotic sagittal alignment served as the baseline model. Models with straight and kyphotic alignment were generated using mesh morphing methods. Single-level corpectomy at C5 was done on these models. Segmental ROMs of intact and corpectomized spines were compared for physiologic flexion-extension loads. The flexion ROM decreased by an average of 13% with the change in sagittal alignment from lordosis to kyphosis; however, a consistent decrease was not observed in extension. After CC, the ROM increased by an average of 95% and 31% in the superior and inferior adjacent segments. With kyphotic change in the sagittal alignment, the postoperative increase in flexion ROM exhibited a decreasing trend, while this was not seen in extension. Kyphotic changes of the intact spine resulted in segmental stiffening, and after corpectomy, it resulted in inconsistent variations of segmental extension ROMs.

To determine the functional outcomes and risk factors for outcomes following surgery for lipomyelomeningocele (LMMC).Data from 109 children with LMMC who underwent surgery from January 2008 to December 2017 were retrospectively studied to evaluate functional outcomes and possible risk factors for early- (at discharge from hospital or within 1 month of surgery) and long-term outcomes after surgery.There were 53 boys and 56 girls with median age of 36 months (IQR 12-90 months; range, 4 months to 18 years) at surgery. At presentation, neurological function was normal (asymptomatic group) in 28 (25.7%) children while there was neurological dysfunction (symptomatic group) in 81 (74.3%). Near total or radical excision of lipoma was done in 71 (65.1%) children. Six (5.8%) children had deterioration of neurological function in the post-operative period with recovery of function in three of them. There were no statistically significant risk factors for early outcomes. At a mean follow-up of 62.5 months (IQR 35-82 months; range, 12-146 months), 21 (27.6%) of the 76 symptomatic group children (including 59.3% with incomplete bladder dysfunction) showed improvement, 52 (68.4%) remained the same, while 3 (4%) deteriorated. In 31 children (symptomatic group) who developed symptoms after 1 year of age, early surgery after development of symptoms was associated with better chances of recovery (p = 0.0008). In the asymptomatic group, 23 (88.5%) had normal neurological function at mean follow-up of 57.5 months (IQR 30-77 months; range, 12-141 months) and 3 (11.5%) had neurological deterioration. The mean time to late deterioration (re-tethering) from surgery was 51.3 months (IQR 24-75 months; range, 24-84 months). Presence of syrinx on initial MRI (p = 0.008) and partial resection of the lipoma (p = 0.02) were independent risk factors for delayed deterioration.Radical resection of LMMC probably helps in preserving neurological function in90% of children at long-term follow-up. Fifty-five percent of children2 years of age with incomplete bladder dysfunction regained normal function following surgery. In children who develop symptoms after birth, early surgical intervention can reverse the neurological deficits.

To study hormonal axis (HA) dysfunction pre-operatively and at three months after surgery in patients with large (3 cms) (Hardy's grade C) and giant (4 cms) nonfunctioning pituitary adenomas (NFPA).One hundred thirty nine patients operated between 2006 and 2017, with 3 months post-operative hormonal evaluation, were included in this retrospective study. HA damage was categorized as 0 to 3 based on number of axes (thyrotroph, corticotroph and gonadotroph) that were affected. Risk factors studied for HA dysfunction before and after surgery included duration of symptoms, size of tumor, diabetes mellitus, hypertension and extent of resection.Preoperatively 45 (32.3%) had no axis involvement, 34 (24.4%), 36 (25.8%) and 24 (17.2%) had one, two and three axes involvement respectively. Thyrotroph axis was affected in most patients. Tumor volume had significant correlation with preoperative pituitary dysfunction (P0.000). Post-operatively HA function remained same in 100 (72%), improved in only 7 (5%) and worsened in 32 (23%) of the patients. Of the 3 HA, corticotroph function worsened in most patients. None of the patients who had dysfunction in all three axes had improvement after surgery. No significant risk factors were associated with post-operative pituitary function outcomes. Persistent diabetes insipidus was noted in six (4.3%) patients.Pre-operatively anterior pituitary dysfunction is noted in nearly two-thirds of patients with large and giant NFA. Tumor volume15 cc had significant correlation with pre-operative panhypopituitarism. Post-operatively, pituitary function remains the same in nearly three quarters of the patients. No significant risk factors were found for post-operative hormonal outcomes.

Diagnosis of non-symptomatic epilepsy includes a history of two or more seizures and brain imaging to rule out structural changes like trauma, tumor, infection. Such analysis can be problematic. It is important to develop capabilities to help identify non-symptomatic epilepsy in order to better monitor and understand the condition. This understanding could lead to improved diagnostics and therapeutics. Serum mass peak profiling was performed using electrospray ionization mass spectrometry (ESI-MS). A comparison of sera mass peaks between epilepsy and control groups was performed via leave one [serum sample] out cross-validation (LOOCV). MS/MS peptide analysis was performed on serum mass peaks to compare epilepsy patient and control groups. LOOCV identified significant differences between the epilepsy patient group and control group (p = 10&minus, 22). This value became non-significant (p = 0.10) when the samples were randomly allocated between the groups and reanalyzed by LOOCV. LOOCV was thus able to distinguish a non-symptomatic epilepsy patient group from a control group based on physiological differences and underlying phenotype. MS/MS was able to identify potential peptide/protein changes involved in this epilepsy versus control comparison, with 70% of the top 100 proteins indicating overall neurologic function. Specifically, peptide/protein sera changes suggested neuro-inflammatory, seizure, ion-channel, synapse, and autoimmune pathways changing between epilepsy patients and controls.

Background: The COVID-19 infection outbreak has aroused increasing attention and affected thousands of people nationwide. The long incubation period, high infectious rate, varied manifestation, and absence of effective treatment make it difficult to manage the disease transmission. Objective: The intended goals are to encourage efficient management of neurological and neurosurgical patients, resource utilization, and protecting the healthcare provider during the COVID-19 epidemic. Herein, we present a consensus statement from various centers in India Methodology: In addition to the literature review, recommendations were included from neurologists and neurosurgeons from various centers in India. Results: Every patient presenting for treatment should be treated as a potential asymptomatic infected case. Patients should be categorized based upon the priority as acute (require immediate treatment/surgery within 24 h), sub-acute (requiring treatment within a maximum of 7–10 days), or chronic (requiring treatment within a month). Non-essential elective surgeries and outpatient clinics should be avoided after informing the patient(s). There is a high risk of aerosol dispersion during intubation and certain neurosurgical procedures particularly those involving drills and endoscopes. These procedures should be performed wearing full personal protective equipment. The workflow of the operating rooms should also be modified significantly. Minor modifications in personal and professional lifestyles and routine training to use the PPE will ensure efficient management of resources. Conclusion: These recommendations could be used to mitigate the risks and reduce exposure to other patients, public, and healthcare staff.

Background In the present study, we investigated the changes in cyst volume detected on interval computed tomography (CT) in patients undergoing radiation therapy (RT) for residual cystic craniopharyngioma after surgery. Methods We performed a retrospective analysis of CT scans performed halfway during the course of RT for residual cystic craniopharyngioma from January 2005 to January 2018 to assess the incidence of cyst expansion requiring additional intervention. The possible risk factors for cyst expansion during RT were also analyzed. Results A total of 33 patients (23 males) with a median age of 15 years (interquartile range 8–21 years) who had undergone surgical excision (n = 30) or aspiration (n = 3) of cystic craniopharyngiomas, followed by stereotactic (n = 25) or conformal (n = 8) RT were included. The extent of reduction in tumor volume after surgery was 66.5% ± 17.9% (range, 20.6%–88.9%). Of the 33 patients, 6 (18.2%) experienced a median increase in cyst volume of 11.1 mL (interquartile range, 9.1–12.1 mL; range, 6.3–40 mL) that was beyond the initial planned target volume (PTV) and necessitated additional intervention. Of the 6 patients in whom the cyst showed an increase in volume, 4 underwent cyst aspiration followed by repeat planning of RT and 2 underwent repeat planning of RT alone without additional surgical intervention. In 5 of these 6 patients, the increase in cyst volume was asymptomatic. Younger age (P = 0.002) and a larger residual cyst wall (P = 0.009) were risk factors for early cyst expansion. Conclusions Cyst expansion will occur in nearly one fifth of patients with cystic craniopharyngioma during the course of RT. As nearly all these expansions are asymptomatic, interval CT scans midway through RT are essential to avoid geographic miss of the tumor.

Neurocysticercosis is associated with epilepsy in pig-raising communities with poor sanitation. Current internationally recognized diagnostic guidelines for neurocysticercosis rely on brain imaging, a technology that is frequently not available or not accessible in areas endemic for neurocysticercosis. Minimally invasive and low-cost aids for diagnosing neurocysticercosis epilepsy could improve treatment of neurocysticercosis. The goal of this study was to test the extent to which patients with neurocysticercosis epilepsy, epilepsy of unknown etiology, idiopathic headaches and among different types of neurocysticercosis lesions could be distinguished from each other based on serum mass profiling. For this, we collected sera from patients with neurocysticercosis-associated epilepsy, epilepsy of unknown etiology, recovered neurocysticercosis, and idiopathic headaches then performed binary group comparisons among them using electrospray ionization mass spectrometry. A leave one [serum sample] out cross validation procedure was employed to analyze spectral data. Sera from neurocysticercosis patients was distinguished from epilepsy of unknown etiology patients with a p -value of 10 −28 . This distinction was lost when samples were randomized to either group ( p -value = 0.22). Similarly, binary comparisons of patients with neurocysticercosis who has different types of lesions showed that different forms of this disease were also distinguishable from one another. These results suggest neurocysticercosis epilepsy can be distinguished from epilepsy of unknown etiology based on biomolecular differences in sera detected by mass profiling.

Neurocysticercosis (NCC) is an infestation of the nervous system caused by encysted larvae of Taenia solium. NCC is an important acquired cause of epilepsy and other neurological manifestations especially in endemic areas. NCC in children has pleomorphic manifestations depending on the location, number, viability of the cysts, and host response. Even with advancing knowledge of the disease manifestations, many aspects related to diagnosis and treatment, particularly in children, still remain controversial and pose challenges to clinical practice. There is no gold standard test to diagnose NCC and the management recommendations are still emerging. This review provides an overview of diagnosis of NCC in children and its management with special focus on current challenges and future prospects.In developing countries, NCC is important not only because of its frequency but also because of high morbidity and mortality rates associated, especially in cases in which it progresses to increased intracranial pressure. Because of its pleomorphic presentation, NCC should be considered in the differential diagnosis of a number of neurological conditions. Treatment with cysticidal therapy leads to reduction in seizure frequency and a faster resolution of lesions.We have summarized the current approaches to diagnosis and treatment of NCC, recent advances in understanding the biology of NCC, and how one can take advantage of these new insights to formulate the next generation of clinical trials.

Though frontal lobe contusion is a major cause for morbidity and prolonged hospitalization following excision of anterior skull base meningiomas, there is only limited literature on this complication. This study aimed to find out the incidence of postoperative frontal lobe contusion, identify the risk factors for its development and its impact on early postoperative outcome.Data from 110 patients who underwent excision of anterior skull base meningiomas through a unilateral supraorbital craniotomy from 2001 to 2018 were retrospectively analyzed. The risk factors analyzed for development of postoperative contusion were tumor location, size, volume, peritumoral edema, tumor consistency, extent of resection, tumor grade and type of retraction used.Simpson grade II excision was achieved in ninety-two patients (83.6%). There was no frontal lobe contusion in eighty-two patients (74.5%). Frontal lobe contusion was noted in twenty-eight patients (25.5%), but was severe in only four patients (3.6%). On multivariate analysis, fixed retractor use (OR 11.56 [1.21-110.03]; P =0.03) and WHO grade II tumor (OR 3.29 [1.11-9.77]; P =0.03) were independently associated with postoperative frontal lobe contusion. Patients with higher contusion grade had significantly longer postoperative hospitalization (P =.02) and lower KPS score at discharge (P =.01).Unilateral supraorbital craniotomy and lateral subfrontal approach is an excellent procedure for excision of anterior skull base meningiomas with minimal postoperative complications related to frontal lobe retraction. Frontal lobe contusion should be avoided with the use of dynamic retraction, since postoperative contusion prolongs hospitalization and worsens the functional outcome at discharge.