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October-December 2019
Volume 14 | Issue 4
Page Nos. 1057-1311

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EDITORIAL  

From the realms of the depths of neurosurgery p. 1057
Ahmed Ansari
DOI:10.4103/ajns.AJNS_89_19  
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REVIEW ARTICLES Top

Flow diversion for the treatment of petrous internal carotid artery aneurysms Highly accessed article p. 1058
Michael George Zaki Ghali, Mandy Binning
DOI:10.4103/ajns.AJNS_119_18  
Petrous internal carotid artery (ICA) aneurysms are rare and pose a unique management dilemma. They are most commonly fusiform. They are difficult to treat surgically and typically not amenable to selective aneurysmal obliteration. The advent of flow diverters, such as the Pipeline endovascular device, has offered a new approach to these historically challenging lesions. The unique utility of flow diversion in treatment of petrous ICA aneurysms is reviewed and discussed.
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Posteroinferior cerebellar artery aneurysms: Influence of angioanatomy on the safety of flow diversion treatment p. 1063
Michael George Zaki Ghali, Yi Jonathan Zhang, Peter Kan, Gavin W Britz
DOI:10.4103/ajns.AJNS_120_18  
Several anatomical variables critically influence therapeutic strategies for posteroinferior cerebellar artery (PICA) aneurysms and, specifically, the safety of flow diversion for these lesions. We review the microsurgical anatomy of the PICA, discussing and detailing these considerations in the treatment of aneurysms of this vessel from a theoretical perspective and in light of our previously published clinical results.
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Occurrence of trigger finger following carpal tunnel release p. 1068
Masatoshi Yunoki, Ryoji Imoto, Nobuhiko Kawai, Atsushi Matsumoto, Koji Hirashita, Kimihiro Yoshino
DOI:10.4103/ajns.AJNS_149_19  
Surgical treatment of carpal tunnel syndrome (CTS) was recently started in our department, and we noticed that the development of trigger finger (TF), with which neurosurgeons are generally unfamiliar, is not rare after such treatment. We summarized the clinical and pathogenetic aspects of TF and retrospectively analyzed the medical records of all 39 patients who underwent CTR in our department to investigate the occurrence of TF. In 39 patients with CTS, 46 surgical interventions were performed in our department. All surgical procedures were carried out by open release of the transverse carpal ligament under local anesthesia infiltration, but the distal forearm fascia was not released. The mean postoperative follow-up period was 21.1 ± 16.8 months. TF after CTR occurred in nine hands of eight patients (9 of 46 hands, 19.6%). The mean interval between CTR and TF onset was 5.3 ± 2.8 months. TF after surgical treatment of CTS is not rare; therefore, surgeons who treat CTS should understand the clinical features of TF and carefully assess affected patients, particulary at presentation and within 6 months postoperatively.
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Expert consensus on the management of brain arteriovenous malformations Highly accessed article p. 1074
Yoko Kato, Van He Dong, Feres Chaddad, Katsumi Takizawa, Tsuyoshi Izumo, Hitoshi Fukuda, Takayuki Hara, Kenichiro Kikuta, Yasunobu Nakai, Toshiki Endo, Hiroki Kurita, Bin Xu, Vladimír Beneš, Raftopoulos Christian, Giacomo Pavesi, Mojgan Hodaie, Rajan Kumar Sharma, Harshal Agarwal, Krishna Mohan, Boon Seng Liew
DOI:10.4103/ajns.AJNS_234_19  
Brain arteriovenous malformations (bAVMs) are complex, heterogeneous, and uncommon intracranial lesions. They can be treated by one or a combination of the following treatment modalities, namely embolization, radiosurgery, or microsurgical resection. In Spetzler-Martin Grade 4 and 5 arteriovenous malformations (AVMs), conservative management may be the best option. A group of experts in the management of AVMs of different disciplines gathered in January 2019 in Hanoi to compile the “Expert Consensus on the Management of Brain Arteriovenous Malformations”.
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ORIGINAL ARTICLES Top

Do asians have higher carotid bifurcation? A computed tomographic angiogram study of the common carotid artery bifurcation and external carotid artery branching patterns p. 1082
Ekkapot Jitpun, Yodkhwan Wattanasen, Wuttipong Tirakotai
DOI:10.4103/ajns.AJNS_162_19  
Introduction: Carotid endarterectomy is a major treatment modality for high-grade carotid stenosis. Preoperative identification of the level of the carotid bifurcation and its branching pattern is important in planning for adequate exposure and cross-clamping to achieve hemostasis during the procedure. Most of the previous studies on carotid arteries were performed in cadavers. Methods: We studied levels of carotid bifurcation compared relatively with the level of the vertebral body and ipsilateral angle of the mandible and its branching pattern using computed tomographic angiogram (CTA) carotid with multiplanar reconstruction and three-dimensional imaging in 100 CTA studies. Results: Most of the carotid bifurcations were located at the level of C3–C4 vertebral body and 12% were considered to be high bifurcation. Carotid bifurcations were located below the angle of the mandible in 83.5%. The superior thyroid, facial, and lingual arteries arose from separate branches of external carotid arteries in 67.7% of samples. Facial arteries arose in common trunk with lingual arteries in 29.2%, much more common than previous cadaveric studies. The lingual arteries arose with superior thyroid arteries in 2%, while occipital arteries had high variations in their branching patterns. Conclusions: CTA is an effective and reliable modality for preoperative evaluation of the carotid system in patients undergoing carotid endarterectomy and other carotid procedures. Higher percentage of high carotid bifurcation was found in our study, concordant with other Asian cadaveric studies. We assumed that carotid bifurcation of Asian tends to be located slightly higher than those of the Caucasian population.
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Outcomes of the endoscopic transsphenoidal surgery for resection of pituitary adenomas utilizing extracapsular dissection technique with a cotton swab p. 1089
Janissardhar Skulsampaopol, Ake Hansasuta
DOI:10.4103/ajns.AJNS_169_19  
Purpose: The purpose of this study was to determine the effectiveness and safety of a cotton swab for extracapsular dissection in endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma (PA). Materials and Methods: A retrospective review of patients undergoing ETSS for PA from 2014 to 2017 was undertaken. Only patients with extracapsular dissection by cotton swab with the intent to completely remove the tumor were included. Assessment of the prospectively recorded clinical, laboratory, and radiographic presentation as well as the intra- and postoperative data was carried out. Factors influencing the extent of resection were analyzed. Results: Of the 222 patients, one hundred cases met the inclusion criteria. The cohort consisted of 81 nonfunctioning and 19 functioning PAs. Fifty patients presented with visual disturbance and 34 patients had prior surgical treatment. The majority of PAs was macroadenoma (97%) with 73% modified Hardy Stage C and 38% Knosp Grade 4. Intraoperative cerebrospinal fluid (CSF) leakage was the most frequently noted complication (78%). Meningitis occurred in three cases and repeat ETSS for CSF leakage repair was necessary in three patients. No death or vascular injury was observed. At 12 months after ETSS, magnetic resonance imaging scan confirmed 43% complete tumor resection. Previous surgery and Knosp Grade 4 were the strong factors for incomplete PA removal by multivariate logistic regression analysis. For functioning PAs, thirteen patients (68.42%) achieved biochemical remission. Conclusion: Cotton swab for extracapsular dissection proved its clinical effectiveness and safety. In spite of the technique, negative predictors for complete PA resection were parasellar extension and previous surgery.
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Effect of anesthetic agents on cognitive function and peripheral inflammatory biomarkers in young patients undergoing surgery for spine disorders p. 1095
Asish Kumar Sahoo, Nidhi Panda, Pranshuta Sabharwal, Ankur Luthra, Mukilan Balu, Rajeev Chauhan, Hemant Bhagat
DOI:10.4103/ajns.AJNS_173_19  
Background: Exposure to anesthesia has been postulated to affect the cognitive function by inciting central nervous system inflammation. Hence, we planned to compare the psychometrical effects of anesthetic agents propofol, desflurane, or sevoflurane on postoperative cognitive function and also measure the change in concentration of serum S-100β, interleukin (IL)-6, and tumor necrosis factor (TNF)-α to look for the contribution of systemic inflammation. Methods: This was a prospective, double-blind, randomized controlled trial. Intuitional ethical committee approval and consent from patients were obtained. We enrolled 66 patients, allocated into three equal groups to receive either sevoflurane (n = 22), desflurane (n = 22), or propofol (n = 22). Standard anesthesia protocol was followed titrated to a bispectral index of 40–60. Patients with preoperative mini-mental state examination ≤23 were excluded. Each patient was assessed thrice with battery of cognitive tests in preoperative period (baseline), after 72 h (early postoperative cognitive dysfunction [POCD]), after 3 months (delayed POCD) of surgery. Serum levels of IL-6, TNF-α, and S-100β were measured preoperatively and 72 h after surgery. Results: Mean scores of various psychometric tests improved slightly in early postoperative period which was not statistically significant (P > 0.5). In delayed postoperative period, there was significant improvement in scores as compared to baseline (P < 0.5) in all the groups. There was nonsignificant change in the levels of biomarkers S-100β, TNF-α, and IL-6 between baseline and postoperative period in all the groups. Conclusion: In young patients, there is no effect of anesthesia on postoperative cognitive functions. There is no association of inflammatory markers with respect to the patient's cognitive status.
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Histopathological profile of brain tumors: A 12-year retrospective study from Madinah, Saudi Arabia p. 1106
Albasri Abdulkader Mohammed, Almuhamdi Nawal Hamdan, Alqaidi Sara Homoud
DOI:10.4103/ajns.AJNS_185_19  
Objectives: The objective of this study is to characterize the histopathological types and basic demographic parameters of brain tumors in the Madinah region of Saudi Arabia and to analyze and compare the findings with previously published literature. Materials and Methods: This retrospective study was conducted in the Department of Pathology, King Fahad Hospital, Madinah, Saudi Arabia, and comprised cases of brain tumors during 12 years (from January 2006 to December 2017). Basic demographic data, tumor site, and histopathological patterns were obtained from the medical records and further analyzed and graded according to the World Health Organization (WHO) 2007 classification. Results: A total of 227 brain tumors in 122 (53.7%) males and 105 (46.3%) female patients were recorded. Pediatric and adult patients accounted for 10.6% and 89.4% of the cases, respectively. The predominant age group affected was between 40 and 49 years (23.5%). The most common histopathological diagnosis in the present study was meningioma (30.8%), followed by astrocytic tumors (29.1%), metastatic tumors (7.7%), and embryonal tumors (6.6%). The meningothelial meningioma was the most common type of meningioma (48.5%). The majority of astrocytic tumors (52%) fell under the WHO Grade IV. Conclusion: This retrospective study established a baseline profile of brain tumors based primarily on the histopathological experience at a tertiary care hospital in the Madinah, Saudi Arabia, and provides an initiating platform to workup for future population targeted studies on brain tumors.
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Endoscopic surgery for thalamic hemorrhage with intraventricular hemorrhage: Effects of combining evacuation of a thalamic hematoma to external ventricular drainage p. 1112
Yu Shimizu, Katsuhiro Tsuchiya, Hironori Fujisawa
DOI:10.4103/ajns.AJNS_197_19  
Objectives: Intraventricular hemorrhage (IVH) caused by thalamic hemorrhage leads to hydrocephalus, increased intracranial pressure, and reduced levels of consciousness. The aim of this study was to investigate the efficacy and compare the results of endoscopic surgery for the evacuation of a thalamic and intraventricular hematoma against those of external ventricular drainage (EVD) surgery. Materials and Methods: From January 2010 to December 2018, 68 patients with IVH caused by thalamic hemorrhage were treated in our department. Our study was approved by the Institutional Ethics Committee. The included patients were randomly divided into an EVD group and an endoscopic surgery group. The outcome was measured after 3 months using a 30-day mortality rate, pneumonia onset rate, ventriculoperitoneal (VP) shunt dependency rate, and Glasgow Outcome Scale (GOS) score. Results: Thirty-eight of the 68 patients were randomly assigned to the endoscopic surgery group and 30 were assigned to the EVD group. Patients treated with endoscopic surgery had significantly less drainage dependency on day 30 (P = 0.00014 < 0.00005) in comparison to those treated with EVD. The difference in the functional outcomes between the two groups of patients was mainly dependent on the onset of pneumonia and the consciousness level at the time of admission. The onset rate of aspiration-related pneumonia until day 30 was 11% in the endoscopic surgery group and 45% in the EVD group. The VP shunt rates were 27.8% in the endoscopic surgery group and 60% in the EVD group. The endoscopic surgery group had a significantly lower VP shunt rate compared with the EVD group. Intracerebral hemorrhage evacuation late was found to be associated with shunt-dependent rate and hospitalization. Conclusions: Endoscopic surgery was found to be associated with a lower GOS score and lower onset rates for shunt-dependent hydrocephalus and aspiration-related pneumonia in comparison to EVD. High evacuation rate was associated with lower shunt-dependent rate and short hospitalization.
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X-ray and computed tomography scan-based morphometric analysis of skull baselines in Indian population p. 1116
Nandan Amrit Marathe, Aditya A Dahapute, Jigar Rajesh Desai, Kiran P Dhole, Shubhanshu Bhaladhare, Swapneel Shah
DOI:10.4103/ajns.AJNS_201_19  
Introduction: The study aims at providing an overview of morphometric measurements of the skull baselines in normal Indian population and compares these dimensions with those of other races and ethnicities. This study will help in defining “normal” baseline values for Indian population. It will also compare dimensions as measured on X-ray and computed tomography (CT) scan to assess the reliability of X-ray as a diagnostic modality for the assessment of the skull baselines in Indian population. Materials and Methods: Retrospective study with a sample size of 116 patients and duration of 30 months. Results: The mean value for distance between dens tip and Chamberlain line on CT was 0.498 mm and on X-ray was 0.528 mm and for the distance between dens tip and McGregor line on CT was 0.213 mm and on X-ray was 0.228 mm. The mean distance between the dens tip and McRae line was 4.67 1.69 mm on CT scan and 4.7 1.76 mm on X-ray. Conclusion: There was not a single patient in whom the dens tip crossed the McRae line. Any protrusion of the dens tip beyond the foramen magnum is abnormal. Hence, the McRae line is easiest to understand and remember. Furthermore, the Chamberlain and McGregor lines rely on identifying the hard palate, which may not be included in routine X-ray, CT, and magnetic resonance imaging studies depend on the field of view. Hence, we recommend the use of McRae line for screening purposes while evaluating pathologies of the craniovertebral junction. X-ray is a reliable diagnostic technique for assessing morphometry of the skull baselines in an emergency or rural setting if facility for CT scan is not available.
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A novel technique for stent-assisted coil embolization of intracranial aneurysms: The wireless trans-cell approach p. 1122
Tomotaka Ohshima, Reo Kawaguchi, Ryuya Maejima, Naoki Matsuo, Shigeru Miyachi
DOI:10.4103/ajns.AJNS_163_19  
Background: When inserting coils under stent deployment, a jailed microcatheter technique is typically applied as a first line approach. However, the trans cell approach might be required to achieve satisfactory complete occlusion. The trans cell approach occasionally ends in failure because the catheter cannot safely follow a proceeding guidewire into the aneurysm. Here, we report the new wireless trans cell approach (WTA), which allows feasible and safe catheter navigation through the stent strut into the aneurysm, without a proceeding guidewire. Methods: A straight tip microcatheter was used, and the tip was shaped as a very small bend of approximately 45°. The side aspect of the catheter tip exhibited a right angled edge, while the front aspect showed a round curve in the advancing direction. We compared the 45° microcatheter with a straight tip microcatheter using a silicon vascular model and then applied the WTA in a case of an unruptured basilar apex aneurysm. Results: Catheter navigation through the stent strut was smoother with the WTA than the conventional wire assisted approach. Our case of a basilar apex aneurysm was successfully treated with the dual catheter technique, which involved a jailed catheter and navigation using the WTA. After stent deployment from the right posterior cerebral artery to the basilar artery through the 45° microcatheter, the WTA was applied using the same catheter. No stress was detected during catheter navigation through the stent strut into the aneurysm. Conclusions: The WTA is associated with smoother catheter navigation compared with the conventional wire assisted approach in cases of a terminal type aneurysm.
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Value of brain computed tomographic angiography to predict post thrombectomy final infarct size and clinical outcome in acute ischemic stroke p. 1126
Mungkorn Apirakkan, Withawat Vuthiwong, Chai Kobkitsuksakul, Jesada Keandoungchun, Ekachat Chanthanaphak
DOI:10.4103/ajns.AJNS_242_19  
Aims: This study aims to analyze the predictor in preoperative brain computed tomographic angiography (CTA) for final infarct and outcome in postendovascular thrombectomy patient. Subjects and Methods: 52 patients were retrospectively reviewed. The Alberta Stroke Program Early Computed Tomography Score (ASPECTS) comparison between preoperative noncontrast computed tomography (NCCT) and 24-h NCCT as well as preoperative CTA source image (CTA-SI) and 24-h NCCT were performed. Factors associated with increased ASPECTS and clinical outcome were evaluated. Results: Preoperative NCCT ASPECTS = 24-h NCCT in 23%. Whereas, 46% showed preoperative CTA-SI ASPECTS = 24-h NCCT. Moreover, 40.4% showed 24-h NCCT ASPECTS > preoperative CTA-SI (increased ASPECTS). The two significant factors associated with increased ASPECTS are thrombolysis in cerebral infarct score 2b/3 (P = 0.02) and good collateral status (P = 0.02). Finally, good clinical outcome was associated with age <60 (P = 0.04), preoperative CTA-SI ASPECTS >5 (P = 0.01), good collaterals status (P = 0.02), and increased ASPECTS (P = 0.05). Conclusions: Preoperative brain CTA provided the necessary factors that are associated with good clinical outcomes, which are CTA-SI ASPECTS > 5, good collateral status, and increased ASPECTS.
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Morphometric and anatomic variations of foramen ovale in human skull and its clinical importance p. 1134
Kuppasad Gurushanthappa Prakash, Kundadukkam Saniya, Thittamaranahalli Muguregowda Honnegowda, Haradi Shambu Ramkishore, Amit Nautiyal
DOI:10.4103/ajns.AJNS_243_19  
Objective: There is a paucity of information regarding the specific anatomy and clinical significance of variations of foramen ovale (FO). The present study was undertaken to define this anatomy in more detail and to review the literature regarding these anatomic variations. Materials and Methods: A total of 124 adult human dry skulls were analyzed for the variations in appearance and number of FO being noted. The length and width of the FO of both sides were determined using digital vernier calipers and area (A) was also calculated and analyzed. Results: Of 82 adult skulls, the values for the right side was 7.64 ± 1.194 mm, 5.128 ± 0.827 mm, and 30.808 ± 7.545 mm2 and for the left side the values was 7.561 ± 1.123 mm, 5.244 ± 0.950 mm, and 31.310 ± 8.262 mm2, respectively, for the mean length, width, and area of the FO. The shape of foramen was typically ovale in most of the skulls (56.70%) with some bony variations such as spine, tubercles, bony bridge/bar, and confluence. Conclusion: Such variants in the FO could interfere with transcutaneous needle placement into the FO or distort anatomic relationships during approaches to the cranial base.
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Neurosurgical management of parasagittal and falcine meningiomas: Judicious modern optimization of the results in a 100-case study p. 1138
Fotios Kalfas, Claudia Scudieri
DOI:10.4103/ajns.AJNS_245_18  
Context: The management of parasagittal and falcine meningiomas centers around the relationship between the tumor and the venous anatomy of the superior sagittal sinus (SSS) and the bridging veins. Aims: The present study aims to address neurosurgical outcomes in a cohort of patients with parasagittal and falcine meningiomas >2.0 cm in the largest diameter, in which a neurosurgical/multidisciplinary treatment was considered. Settings and Design: The clinical outcomes of patients undergoing neurosurgical management for parasagittal and falcine meningiomas at the authors' institution over a 15-year period were analyzed. Analysis was limited to those tumors (primary, residual, or recurrences) >2.0 cm in the largest diameter. Subjects and Methods: The authors identified 100 patients with parasagittal/falcine meningiomas >2.0 cm in their largest diameter, who underwent neurosurgical treatment at their institution between 1999 and 2013. Statistical Analysis Used: Tumor control was assessed using Kaplan–Meier analysis, and specific attention was paid to the relationship between the tumor and the SSS and its impact on tumor control and outcome. Results: There was no difference in rates of tumor control in patients who received subtotal resection for a WHO Grade I tumor, followed by close observation, compared with those undergoing gross-total resection, primarily because no cases were observed in which the tumor remnant in the SSS demonstrated interval growth on serial imaging studies. Of patients in this series, 13% experienced at least one neurological, medical, surgical, or radiosurgical complication, and the mortality was 0%. Conclusions: These data provide a more judicious optimization of the expected outcome that can be obtained with treatment of these tumors, in which a combination of image guidance, advanced microsurgical techniques, and conformal radiation treatments is used.
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Pediatric brainstem gliomas: An institutional experience p. 1144
Altaf Ali Laghari, Mirza Zain Baig, Ehsan Bari, Aneela Darbar, Naureen Mushtaq, Umm E Hani Abdullah, Daniyal Aziz Khan
DOI:10.4103/ajns.AJNS_101_19  
Objective: The aim of this study was to analyze the clinical profiles and outcomes of pediatric brainstem gliomas treated at our institute. Methodology: We reviewed the files of 18 pediatric age group patients diagnosed with brainstem glioma at our institution. The following variables were recorded: age, sex, duration of symptoms, date of diagnosis, main clinical symptoms, Karnofsky performance status score, magnetic resonance imaging findings, histopathology findings, details of the treatment given, disease progression, and date of mortality/last follow-up. This data were then transferred to SPSS version 23 which was used for further analysis. Results: The mean age of our cohort was 8.6 years (range 3–15). There were 11 (61.1%) males and 7 (38.9%) females. There were 16 (88.9%) patients with diffuse intrinsic pontine gliomas (DIPGs), 1 (5.6%) patients with exophytic medullary gliomas, and 1 (5.6%) patient with midbrain/tectal glioma. Mean overall survival (OS) was 9.7 months. Mean progression-free survival (PFS) was 6.3 months. All patients with DIPG eventually passed away from their disease. Patients with DIPG who received radiotherapy had a longer OS and PFS than those who did not (9.8 and 6 months vs. 3.4 and 2.4 months). Diagnostic latency >1 month was found to have a statistically significant longer progression-free interval. Conclusion: DIPGs in the pediatric population have a poor prognosis. Radiotherapy serves to increase survival time but is not curative.
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Management of recurrent aneurysms after endovascular coiling: A Fujita experience p. 1151
Raja K Kutty, Ambuj Kumar, Yasuhiro Yamada, Riki Tanaka, Satish Kannan, Vigneshwar Ravisankar, Aaron Musara, Kyosuke Miyatani, Saeko Higashiguchi, Katsumi Takizawa, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_105_19  
Introduction: Microsurgical clipping and Endovascular coiling (EC) are both effective alternatives in the management of intracranial aneurysms. EC has been shown to be associated with the risk of recurrent aneurysm (RA) growth. Considering the minimally invasive nature of this procedure, the management of intracranial aneurysms has been skewed toward EC, especially in the developed world. In this scenario, there has been an upsurge of RAs after EC. Since the optimal management of these RAs has not been defined, they pose a unique challenge to the treating surgeons. Aims and Objectives: The aim of this study is to elucidate the optimal management of RAs after EC. Materials and Methods: Medical records of all patients who underwent surgery for RAs were reviewed from the period January 2014 to March 2019. The demographic and angiographic patterns of the patients and operative techniques and complications were studied. The outcome was dichotomized into good and bad depending on the Glasgow outcome scale (GOS). Results: There were four cases of RAs operated in our institution between the above-mentioned period. There were varied differences between the initial coiling and time to recurrences. All four patients were operated under neuromonitoring. Three underwent clipping and one patient underwent clipping with bypass. All four patients had good outcome with a GOS of 5/5. Conclusion: Operations for RAs constitute many technical challenges and require a lot of expertise. Such surgeries are recommended in high-volume centers, with sufficient experience in both clipping and cerebral bypass.
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World Health Organization grade III supratentorial extraventricular ependymomas in adults: Case series and review of treatment modalities p. 1157
Fotios Kalfas, Claudia Scudieri
DOI:10.4103/ajns.AJNS_239_18  
Context: Supratentorial ependymomas and their anaplastic variants are relatively uncommon central nervous system neoplasms that afflict both adults and children. Aims: Discuss the clinical and pathological features of patients with anaplastic ependymomas involving an extraventricular supratentorial location and review modalities and options of treatment for those rare tumors. Settings and Design: Whereas the treatment algorithm in the pediatric population is well established, however, treatment in the adult population is less defined. Treatment options are exposed through the author's cases and review of the literature. Subjects and Methods: In our case series of two adult patients with supratentorial ependymomas World Health Organization (WHO) Grade III (anaplastic variant), patients presented in both cases in the emergency room after having a generalized tonic–clonic seizure at home the first case, and mild hemiparesis the second case. Results: Patients underwent surgical treatment, and a gross total resection was achieved in both cases. The histopathological examination revealed a diagnosis of anaplastic ependymoma (WHO Grade III). Both patients had additional radiotherapy, and in the first case, adjuvant platinum-based chemotherapy was administered due to leptomeningeal gliomatosis. Conclusion: In our experience, gross total resection was achieved in all patients with supratentorial extraventricular ependymomas WHO Grade III with additional radiotherapy and platinum-based chemotherapy. Patients require initial close serial imaging follow-up. The role of chemotherapy is still uncertain but may be necessary in younger patients and in tumors that behave more like the pediatric ependymomas.
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Experimental evaluation of stent clot retrieval using the confront clot scrambling method with an equitable automatic withdrawal machine p. 1165
Reo Kawaguchi, Tomotaka Ohshima, Yoshitaka Nagano, Shigeru Miyachi, Naoki Matsuo, Masakazu Takayasu
DOI:10.4103/ajns.AJNS_285_18  
Background: Stent clot retrievers can be used to perform mechanical thrombectomies to treat cases of acute major arterial occlusion. This approach is associated with faster recanalization and better outcomes than internal treatments. The function of the stent retrievers is based on a technique known as confront clot scrambling method (CCSM), which usually involves the insertion of two stent retrievers (one from each side) and the simultaneous withdrawal of the retrievers with an equal force. It was determined that a stent used to remove the sham clot possessed a stronger ability for clot retrieval. However, this method involves inherent manipulation bias, and the results may vary due to operator-specific factors. Thus, this approach can be difficult to teach, especially to beginners. Materials and Methods: We evaluated the accuracy of using an equitable automatic withdrawal machine for the CCSM on a model of a sham clot in the middle of a polyvinyl chloride tube. Results: This tool is expected to facilitate thorough and repeated training that is needed to learn the fine maneuvers against invisible vessels associated with actual endovascular clot retrieval, particularly for beginners.
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Does mesh cage subsidence have any effect on functional outcome in spinal tuberculosis? p. 1168
Tushar Narayan Rathod, Abhinav Dinesh Jogani, Nandan Marathe, Kalaivanan Masilamani, Chetan Vitthalrao Shende, Prashant Kamble
DOI:10.4103/ajns.AJNS_261_19  
Introduction: Occurrence of mesh cage subsidence in patients undergoing anterior column reconstruction following Tuberculosis spine is frequent radiological finding as bone quality of affected vertebrae is poor. This study aims at determining effect of mesh cage subsidence on functional outcome. Methods: Retrospective demographics of 30 patients of consecutive series in age range 4-60 year were collected with Clinical outcome evaluation using VAS, ODI and ASIA scale. 30 patient having Dorsolumbar tuberculosis with vertebral involvement ranging from 1-6 with mean vertebral level involvement of 2.71, underwent anterior column reconstruction through posterior only approach between 2011-15 were reviewed. Patients were followed at regular intervals of 6 weeks, 12 weeks, 6 months & thereafter on yearly basis. They were evaluated for interbody height loss with subsidence, fusion & segmental angle. Results: Clinical parameters i.e. VAS & ODI showed improvement in postoperative period which continued to remain same even after subsidence (P < 0.05). Subsidence was categorized as combined anterior + posterior < 5mm; 5 -10mm; >10mm. ODI at follow up was 8.5 ±4.62, 9 ± 2 and 9 ± 4.2 (P = 0.961) respectively & VAS score in above group was 1.3 ± 0.51, 1.5 ± 1.2 & 1.5 ± 0.7 (P = 0.975) respectively. Subsidence was age, spinal level nonspecific. Conclusion: Study indicates that though Cage subsidence occurs to varying severity due to weakened vertebral bodies, it did not have significant impact on functional outcome in terms of VAS, ODI or radiological evidence of fusion following reconstruction in Spinal tuberculosis.
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Trauma-induced coagulopathy: Incidence and outcome in patients with isolated traumatic brain injury in a level I trauma care center in India p. 1175
Poonam Rani, Nidhi Bidyut Panda, Amarjyoti Hazarika, Jasmina Ahluwalia, Rajesh Chhabra
DOI:10.4103/ajns.AJNS_126_19  
Context: Trauma-induced coagulopathy (TIC) is life-threatening in head injury patients, and there is a lack of Indian data on its incidence and outcome. Aims: In this study, incidence and outcome related to coagulopathy were assessed in patients with moderate-to-severe isolated traumatic brain injury (iTBI). Settings and Design: A prospective observational study carried out in patients admitted within 24 h of injury. Materials and Methods: One hundred patients with moderate-to-severe iTBI were included. Samples for coagulation tests (prothrombin time [PT], PT index [PTI], international normalization ratio [INR], activated partial thromboplastin time, and platelet count) were collected at 5 points of time for 72 h. TIC was diagnosed if any three readings were abnormal during this period. Patients were also followed up posthospital discharge using the Glasgow Outcome Score (GOS) at 1 and 3 months. Statistical Analysis: Data were analyzed using SPSS ver. 21. Logistic regression analysis was employed to determine individual coagulation test as best predictors for mortality. P < 0.05 was considered statistically significant. Results: The incidence of TIC was found to be 62%; it was 63.75% in severe head injury and 55% in moderate head injury patients. Deranged INR at the time of hospital admission (odds ratio [OR] 4.38) and PTI at 24 h (OR 3.913) are highly predictive of mortality. There was no significant difference in GOS score at 1 and 3 months. Conclusions: The incidence of TIC in our study was 62% among iTBI patients. It contributes to increased mortality at 1 and 3 months. However, the neurological outcome was not different in between the groups.
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Infection with spinal instrumentation: A 20-year, single-institution experience with review of pathogenesis, diagnosis, prevention, and management Highly accessed article p. 1181
Fotios Kalfas, Paolo Severi, Claudia Scudieri
DOI:10.4103/ajns.AJNS_129_19  
Objective and Importance: Instrumentation has become an integral component in the management of various spinal pathologies. The rate of infection varies from 2% to 20% of all instrumented spinal procedures. Postoperative spinal implant infection places patients at risk for pseudo-arthrosis, correction loss, spondylodiscitis, and adverse neurological sequelae and increases health-care costs. Materials and Methods: We performed a cohort study of 1065 patients who underwent instrumented spinal procedures in our institution between 1995 and 2014. Fifty-one patients (4.79%) contracted postoperative spinal infection. Isolated bacterial species, infection severity, diagnosis/treatment timing, surgical/medical strategy treatment, and patient's medical background were evaluated to assess their relationship with management outcome. Results: Multiple risk factors for postoperative spinal infection were identified. Infections may be early or delayed. C-reactive protein and magnetic resonance imaging are important diagnostic tools. Prompt diagnosis and aggressive therapy (debridement and parenteral antibiotics) were responsible for implant preservation in 49 of 51 cases, whereas implant removal noted in two cases was attributed to delayed treatment and uncontrolled infection with implant loosening or late infection with spondylodesis. Infection in the setting of instrumentation is more difficult to diagnose and treat due to biofilm. Conclusion: Retention of the mechanically sound implants in early-onset infection permits fusion to occur, whereas delayed treatment and multiple comorbidities will most likely result in a lack of effectiveness in eradicating the infecting pathogens. An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight into the pathogenesis and management of infected spinal implants. It is important to accurately identify and treat postoperative spinal infections. The treatment is multimodal and prolonged.
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Endoscopic transsphenoidal approach in treatment of germinomas of the chiasmosellar region p. 1190
Maxim Alexandrovich Kutin, Dmitry Vladislavovich Fomichev, Alexey Nikolaevich Shkarubo, Ilia Valerievich Chernov, Oleg Ildarovich Sharipov, Dmitry Nikolaevich Andreev, Denilbek Beksultanovich Ismailov, Nikita Igorevich Mikhailov, Grigoriy Lvovich Kobyakov, Yuriy Yurievich Trunin, Ludmila Igorevna Astafyeva, Abdishukur Abdilatipovich Abdilatipov, Artem Andreevich Poddubsky, Pavel Lvovich Kalinin
DOI:10.4103/ajns.AJNS_156_19  
Introduction: Germinogenic central nervous system (CNS) tumors represent a heterogeneous group of tumors, constituting approximately 0.4% of all primary brain tumors. Removal of the tumor has no prognostic value. In “pure” primary germinomas of the CNS, the alpha-fetoprotein and human chorionic gonadotropin levels are within normal limits, and no specific biochemical tumor markers currently exist for this tumor type, making histological verification crucial for the choice of treatment tactics. When the tumor is located in the chiasmosellar region, one of the possible verification methods is endoscopic endonasal transsphenoidal biopsy. Objective: the main objective of the study is to demonstrate the feasibility and safety of endoscopic transsphenoidal approach for histological verification of primary germinomas of the CNS with chiasmosellar localization. Materials and Methods: The current study includes 13 patients with “pure” germinomas of the chiasmosellar region who underwent endoscopic endonasal surgical interventions with subsequent treatment according to the “Germinoma 2008” protocol. Results: The extent of surgical intervention ranged from biopsy (4) to partial (5) and total (4) removal of the tumor. In all cases, histological verification of the diagnosis was achieved and none of the patients presented with cerebrospinal fluid leaks and/or meningitis in the postoperative period, allowing to evaluate endoscopic intervention in our patient series as safe and effective. Two out of 13 patients were lost to follow-up. Conclusion: The endoscopic endonasal approach for histological verification and removal of chiasmosellar region germinomas is safe, and in some cases, less traumatic for the patient than transcranial and transventricular approaches.
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A case series of craniopharyngioma: Epidemiological study and management analysis at tertiary care center p. 1196
Venkata Satya Ramanbhavana, Kadali Satya Vara Prasad
DOI:10.4103/ajns.AJNS_67_19  
Introduction: Debate continues as to the optimal treatment for craniopharyngioma; radical surgical resection or partial resection followed by radiotherapy. Radical surgical resection may be complicated by intraoperative injury to surrounding structures and stormy postoperative hormonal problems. This study aims to examine the result of safe maximal surgical resection. Methodology: Retrospective study of all histopathologically proven craniopharyngiomas who had undergone surgical resection over an almost 4-year period was included. Data were collected reviewing demography, clinical presentation, hormonal dysfunction, extent of resection, and visual deterioration. Outcome was measured in terms of Glasgow Outcome Scale and recurrence. Results: Of 41 patients, 20(48.8%) were male and 21(51.2%) were female. Age of patients ranged from 1 to 59 years with a mean of 15.9 years. Thirty-seven patients (90%) had headache, 32 patients (78%) had visual disturbances, 23 patients (56%) had vomiting, and 10 patients (24%) had convulsions. Six patients (15%) had memory and sleep disorders and three patients of those >15 years (12.5%) had amenorrhea/sexual dysfunction. Patients who had surgery followed by radiotherapy had better prognosis, so also those aged 18 or less compared to older, males better than females and those without headache had better prognosis, though not statistically significant. Conclusions: Gross total excision if judiciously decided intraoperatively has a favorable outcome with acceptable morbidity. Patient has better prognosis who has surgery with radiotherapy.
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Anatomical and biomechanical study of the lumbar interspinous ligament p. 1203
Joe Iwanaga, Emily Simonds, Emre Yilmaz, Maia Schumacher, Mayank Patel, R Shane Tubbs
DOI:10.4103/ajns.AJNS_87_19  
Objective: The lumbar interspinous ligaments (ISLs) are thin and short fibers connecting adjacent spinous processes. However, their morphology is variably described and their biomechanics are not well understood. Therefore, the purpose of this study was to assess the anatomy and biomechanics of the lumbar ISL. Materials and Methods: Five fresh frozen cadaveric specimens were dissected posteriorly to reveal and study the lumbar ISL. Measurements of the ligaments included the anterior vertical height (length A), the posterior vertical height (length P), and the length (length H) at each lumbar level. Next, 17 lumbar vertebral levels from 6 cadaveric specimens were used for tensile strength testing. The ISLs were subjected to vertically controlled increasing manual tension. The force necessary to disrupt the ISL was recorded. Results: All the ISLs ran horizontally in an anterior–posterior direction with a slight curve. The average of length A, length P, and length H on the right sides was 9.82, 9.57, and 20.12 mm, respectively. The average of length A, length P, and length H on the left sides was 11.56, 12.01, and 21.42 mm, respectively. The mean tensile strength of the ISL was 162.33 (N) at L1/2, 85.67 (N) at L2/3, and 79 (N) at L3/4. There was a significant difference in the tensile force between L1/2 and L2/3 and L1/2 and L3/4 (P < 0.05). The ligaments became weaker with a descent along the lumbar levels. Conclusion: The results of this study might help surgeons understand pathology/trauma of the lumbar vertebral region.
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Clinico-radiological efficacy of posterior instrumentation, decompression, and transpedicular bone grafting in osteoporotic burst fracture associated with neurological deficit p. 1207
Gaurav Mehta, Ankit Patel, Sanyam Jain, Zahir Abbas Merchant, Vishal Kundnani
DOI:10.4103/ajns.AJNS_95_19  
Objective: The aim of this study is to evaluate clinico-radiological outcomes of posterior surgery (decompression + instrumentation + transpedicular bone graft) in osteoporotic burst fracture associated with neurological deficit [OFND]. Materials and Methods: Forty patients with neurological deficit due to delayed osteoporotic vertebral collapse managed by posterior surgery (decompression + instrumentation + transpedicular bone graft) with minimum 2 years follow-up were included in the study. Approval from the Institutional Review Board was taken. Demographic data (age, sex, mode of injury, and the severity of osteoporosis); clinical parameters (Visual Analog Score [VAS], Oswestry Disability Index [ODI], Frankel grade), radiological parameters (local kyphosis), and surgical variables (blood loss, surgery duration, and intraoperative events) were recorded. Neurological worsening/improvement, complications, and implant failures were noted. Results: Significant improvement was noted in VAS (preoperative 8.20 ± 0.65/postoperative 4.1 ± 0.64) and ODI (preoperative 76.54 ± 6.96/postoperative 30.5 ± 6.56). Complete neurological recovery was noted in 37 patients (Frankel Grade E), three patients remained nonambulatory (Frankel Grade C). Significant improvement was noted in local kyphosis angle (preoperative = 21.80 ± 2.70; postoperative 11.40 ± 1.80), with 10% loss of correction (2.5 ± 0.90) at final follow-up. Symptomatic implant failure was noted in two patients and proximal junctional failure in one patient requiring an extension of fixation. Conclusions: OFND can be managed with a single posterior-only surgery with significant improvement in neurology and functional scores of patients. Aggressive kyphosis correction is often not required and optimal correction of kyphosis is noticed due to prone-positioning alone. Transpedicular grafting is safe and simple alternative to cement augmentation or anterior surgery for collapsed vertebrae.
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CASE REPORTS Top

Microsurgical clipping of distal basilar trunk aneurysm during adenosine-induced profound hypotension p. 1214
Narayanam Anantha Sai Kiran, Veldurti Ananta Kiran Kumar, Valluri Anil Kumar, Amit Agrawal
DOI:10.4103/ajns.AJNS_157_19  
A 46-year-old male presented with a history of sudden severe headache 1 week back, altered sensorium and right hemiparesis for 2 days. On examination, Glasgow Coma Scale (GCS) was E4V4M6 and the patient had right hemiparesis (power – 4/5). Computed tomography (CT) revealed diffuse subarachnoid hemorrhage (Fisher's Grade III). CT angiogram revealed distal basilar trunk aneurysm arising between the origin of the left posterior cerebral artery and superior cerebellar artery, ectatic dilatation of distal basilar trunk, and a left middle cerebral artery (MCA) bifurcation aneurysm. Basilar trunk aneurysm was approached through subtemporal route and aneurysm was clipped during adenosine-induced profound hypotension (AIPH) without application of temporary clip. Single bolus 6 mg of adenosine was given, and aneurysm was successfully clipped during AIPH (systolic <60 mmHg). There were no complications related to adenosine. Ectatic part of distal basilar trunk was wrapped with Teflon. The left MCA bifurcation aneurysm was clipped in the same session. At 3-month follow-up, the patient's sensorium was normal (GCS-E4V5M6) and the right hemiparesis improved (4+/5). Adenosine enhances the safety of clipping these aneurysms by providing transient cardiac arrest or profound hypotension. In developing countries, microsurgical clipping is a cost-effective treatment option for basilar artery aneurysms.
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The usefulness of straight chemotherapy for dermal exposed anaplastic lymphoma kinase fusion-positive anaplastic large-cell lymphoma with intracranial invasion p. 1218
Hiroyuki Abe, Taishi Nakamura, Masahiro Yoshitomi, Makiko Enaka, Kensuke Tateishi, Norio Shiba, Shoji Yamanaka, Tetsuya Yamamoto
DOI:10.4103/ajns.AJNS_158_19  
Anaplastic large-cell lymphoma (ALCL) is characterized as extranodal lymphoma and usually chemosensitive disease with overall survival rate of 70%–90%. Prognosis is roughly distinguished by the existence of anaplastic lymphoma kinase (ALK) fusion in tumor cells with higher frequencies observed in the pediatric population, and the outcome of ALK fusion-positive ALCL is relatively good when appropriate treatment is completed. Here, we report a case of dermal-exposed ALK fusion-positive ALCL with intracranial invasion. The patient received straight chemotherapy (ALCL99 protocol) without any plastic or resection surgery. The dermal dehiscence was rapidly healed with controllable local infection, and the tumor was regressed without relapse. Therefore, straight chemotherapy has clinical relevance and is a useful treatment strategy for ALK fusion-positive ALCL with dermal dehiscence.
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Cavernoma of the right lateral ventricle: A rare case report p. 1222
Uday Kiran Katari, Govindappagari Venkateswara Prasanna, Divya Tejaswi Gopidesi
DOI:10.4103/ajns.AJNS_161_19  
Intraventricular cavernoma (IVC) is a rare pathological entity constituting 2.5%–10.8% of cerebral cavernomas. The lateral ventricles are the most frequent site, followed by the third and fourth ventricles. IVCs usually attain a large size compared to parenchymal cavernomas and cause signs and symptoms mainly due to mass effect. IVCs lack specific clinical manifestations and radiological features. Microsurgical excision of IVCs is a safe and effective treatment option. We present a 71-year-old male patient with right lateral ventricle cavernous angioma. The patient underwent microsurgical resection of the vascular lesion with good neurological outcome.
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One-stage operation with ipsilateral two-piece craniotomies for a case of subarachnoid hemorrhage with multiple intracranial aneurysms p. 1226
Sho Tsunoda, Gakushi Yoshikawa, Osamu Ishikawa
DOI:10.4103/ajns.AJNS_165_19  
Subarachnoid hemorrhage (SAH) with multiple intracranial aneurysms is common, but the difficulties often arise in determining treatment strategy in the acute phase. We experienced a case of SAH with distal anterior cerebral artery aneurysm coexisting with middle cerebral artery and anterior communicating artery aneurysms, in which it was difficult to identify the precise rupture site preoperatively, and both pterional approach and interhemispheric approach were required in the acute phase of SAH. However, we could treat whole aneurysms in one stage and obtained an excellent outcome using our surgical procedure with ipsilateral frontotemporal and frontal parasagittal craniotomies through a single skin incision.
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Congenital spinal canal stenosis with ossification of the ligamentum flavum in an achondroplastic patient: A case report and literature review p. 1231
Kritsadakorn Kachonkittisak, Sombat Kunakornsawat, Tinnakorn Pluemvitayaporn, Chaiwat Piyaskulkaew, Pritsanai Pruttikul, Piyabuth Kittithamvongs
DOI:10.4103/ajns.AJNS_170_19  
Achondroplasia has an effect on intracartilaginous ossification during the development of the spine resulting in a narrow spinal canal. This abnormal anatomy could make an achondroplastic patient tend to have spinal canal stenosis. We reported a case of congenital spinal canal stenosis with achondroplasia combined with ossified ligamentum flavum (OLF) at the thoracolumbar and lumbar spine, which was treated by decompressive surgery. We reported a 52-year-old Thai male with achondroplasia presented with progressive myelopathy and neurogenic claudication due to spinal canal stenosis. Spinal canal stenosis was observed at T10/11 and L1–L5 and OLF at T10/11 through L5 varying in size. Laminectomy and removal of the OLF were performed at T11 and L1–L5. The patient's neurological symptom improved after the surgery. He could walk with a walker at the time of 6-month follow-up postoperatively. In this report, we describe a rare case of achondroplasia with OLF presenting with progressive myelopathy and claudication symptoms from multiple levels of spinal canal stenosis. Laminectomy, removal of the ossified ligament, and fusion with instrumentation resulted in the improvement of the patient's neurological symptoms and function.
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Overlapping stents with coil sandwich for ruptured blood-blister aneurysm in a patient with ipsilateral persistent primitive trigeminal artery: A case report and review of literature p. 1236
Ryosuke Maeoka, Ichiro Nakagawa, Hiroyuki Ohnishi, Hiroyuki Nakase
DOI:10.4103/ajns.AJNS_177_19  
Ruptured blood-blister aneurysms (RBBAs) of the intracranial internal carotid artery (ICA) are associated with high morbidity and mortality. RBBA has been treated with trapping with high-flow bypass avoiding manipulation of RBBA. In case of the presence of persistent primitive trigeminal artery (PPTA), it is necessary to preserve the antegrade blood flow of PPTA because avoiding ischemic complications. Here, we present a case of RBBA concomitant with ipsilateral PPTA successfully treated with multistaged overlapping braided stents maintaining PPTA flow. A 30-year-old woman suffered from headache and was diagnosed RBBA of the intracranial ICA concomitant with ipsilateral PPTA. A reconstructive endovascular treatment using low-profile visualized intraluminal support (LVIS) stent was performed. However, it has recurred, and RBBA has finally been occluded after overlapping LVIS stents with coil sandwich that is not yet reported in the literature. We report the first case of overlapping LVIS stents with coil sandwich for RBBA.
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Endovascular rescue strategies for nonopening of pipeline device: Report of two cases p. 1240
Anshu Mahajan, Vinit Banga, Apratim Chatterjee, Gaurav Goel
DOI:10.4103/ajns.AJNS_191_19  
We report two cases of rescue strategies for nonopening of Pipeline flow-diverter device for the treatment of intracranial aneurysm. The first patient, a 65-year-old female, presented with complaints of headache for 3 months and was found to have giant supraclinoid internal carotid artery (ICA) (ophthalmic segment) aneurysm. We planned endovascular partial coiling and flow-diverter placement for the treatment of ICA aneurysm. During the progressive deployment of PED, there was nonopening of Pipeline embolization device (PED) at its proximal end. We tried multiple attempts to navigate Marksman microcatheter over the PED delivery microwire and Echelon microcatheter over the Traxcess microwire across the pinched site, but we were not able to achieve success. After that, we tried opposite transcranial approach across prominent anterior communicating artery with the Synchro and Transcend microguidewire which finally resulted in the opening of the device; however, there was acute extravasation of dye on check angiogram. Thus, our technical success turned into disaster. The second patient, a 55-year-old female, presented with complaint of seizures for 3 months due to mass effect of cavernous sinus aneurysm. Pipeline Flex flow-diverter placement was done across the aneurysm neck. During the progressive deployment of device, there was nonopening of the mid and proximal segment of Pipeline Flex which was successfully managed by intra-Navien deployment of device followed by simultaneous push of Marksman microcatheter and pull of Navien catheter. In our case series, two rescue strategies were applied to successfully open the proximal constricted portion of Pipeline Flex; however, technical success in one case resulted in unmanageable disasters. Thus, transcranial rescue strategy for opening the constricted Pipeline Flex device should be cautiously used in our endovascular practice.
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Atypical symptomatic bilateral spontaneous cavernous carotid aneurysm with systemic vessel wall pathology in young female: A rare case report p. 1245
Kyosuke Miyatani, Paresh Korde, Yasuhiro Yamada, Tsukasa Kawase, Katsumi Takizawa, Yoko Kato
DOI:10.4103/ajns.AJNS_210_19  
Bilateral cavernous carotid aneurysm (CCA) is a rare entity. Its association with connective tissue disorder makes the diagnosis and treatment of symptomatic patient an enigma. We present a case report of a 25-year-old female medical student presented to us with bilateral spontaneous atypically symptomatic CCA with incidentally diagnosed case of Ehlers–Danlos syndrome. Both surgical and endovascular options of treatment were weighed and were ultimately treated satisfactorily by high-flow bypass with carotid artery ligation with an insurance bypass.
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Traumatic atlantoaxial dislocation with an odontoid fracture: A rare and potentially fatal injury p. 1249
Khaled Zitouna, Hend Riahi, Nabil Ben Lassoued, Mohamed Amine Selmene, Maher Barsaoui, Ghassen Drissi
DOI:10.4103/ajns.AJNS_214_19  
Traumatic dislocation of the atlanto-axial joint in combination with an odontoid fracture remains a rare entity. Beaucause of its instability, it's alsoo a seriuous injury. A fatal outcome is feared especially in elderly. We report a case of 74-year-old man who presented with neck pain Confusion and spastic tetraparesia after a low energy trauma. Radiographs and computed tomography demonstrated a C1C2 dislocation with odontoid fracture. After an unsuccessful attempt at closed reduction with halo traction, a surgical stabilisation was performed using a posterior approach. Death was occured in early postoperative due to respiratory distress.
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Cardiovascular changes and lumbar spine surgery: A neglected entity p. 1253
Shalvi Mahajan, Adarsh Chandra Swami, Amit Kumar
DOI:10.4103/ajns.AJNS_224_19  
Cardiovascular changes following lumbar spine surgeries in the prone position have been less commonly described. Here, we report a case of an elderly male patient undergoing lumbar spine decompression and transforaminal interbody fusion who developed multiple but transient episodes of hypotension and bradycardia. Anesthesiologist should be vigilant while monitoring such patients and should use invasive blood pressure monitoring if possible, so as to detect transient cardiovascular episodes which may progress and results in a dreadful outcome.
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Medullary hemorrhage caused by foramen magnum dural arteriovenous fistula successfully obliterated using combination of endovascular and surgical treatments: A case report and literature review p. 1256
Prasert Iampreechakul, Anusak Liengudom, Punjama Lertbutsayanukul, Yodkhwan Wattanasen, Somkiet Siriwimonmas
DOI:10.4103/ajns.AJNS_259_19  
The authors describe an extremely rare case of foramen magnum dural arteriovenous fistula (DAVF), Cognard type V, presented with medullary hemorrhage caused by venous varix on the lateral medullary draining vein embedded into the medulla oblongata. Following mild myelopathy for 3 days, a 20-year-old male developed dyspnea, generalized seizures, loss of consciousness, and finally cardiac arrest. After successful resuscitation, computed tomography scan (CT) of the brain was obtained and showed acute medullary hemorrhage. Subsequent magnetic resonance imaging of the brain revealed diffuse venous congestion or edema of the medulla with multiple dilated flow voids surrounding the medulla, more prominent on the left side, with venous varix embedded into the left-sided of the lower medulla. He was sent to the emergency department of the local hospital and intubated promptly. A few minutes later, the patient had a cardiac arrest. Digital subtraction angiography (DSA) demonstrated DAVF of the foramen magnum supplied mainly by dural branches of bilateral hypertrophic posterior inferior cerebellar arteries (PICAs), slightly by the posterior meningeal branch of the left vertebral artery, and the jugular branch of the left ascending pharyngeal artery (APA) originating from the occipital artery. Transarterial embolization through the bilateral dural branches of the PICAs was successfully performed using N-butyl-2-cyanoacrylate (NBCA), resulting in complete obliteration. The patient had excellence recovery and lost to annual follow-up. Seven years later, he had a recurrent of the fistula presented with occipital headache. DSA with angiographic CT in three-dimensional reconstruction and maximum intensity projection reformatted images clearly demonstrated the exact location of the DAVFs at the posterior rim of the foramen magnum, mainly recruited by the hypertrophic jugular branch of the APA originating from the occipital artery. The fistula was successfully treated surgically following transarterial embolization through the jugular branch of the APA using NBCA. Follow-up DSA confirmed complete obliteration of the DAVF. The patient has remained clinically asymptomatic 2 years after the operation.
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Spontaneous closure of a cavernous sinus dural arteriovenous fistula with spinal perimedullary drainage (Cognard V) during attempted transvenous embolization p. 1268
Prasert Iampreechakul, Korrapakc Wangtanaphat, Punjama Lertbutsayanukul, Yodkhwan Wattanasen, Somkiet Siriwimonmas
DOI:10.4103/ajns.AJNS_277_19  
The authors describe a patient with spontaneous closure of a spontaneous cavernous sinus dural arteriovenous fistula (CSDAVF), Cognard type V, during transvenous attempt. A 39-year-old woman experienced mild proptosis, redness of the left eye, and diplopia. Four months later, she developed left retro-orbital pain and left-sided headache. Cerebral angiography revealed the left CSDAVF exclusively draining into the superior petrosal sinus with subsequent drainage into the veins surrounding the medulla oblongata, and finally into the perimedullary spinal veins, classified as Cognard type V. The feeders arise from the dural branches of both the left external and internal carotid arteries. Following 2 h period of attempted transvenous embolization, the fistula disappeared spontaneously. Follow-up angiography obtained 6 months later confirmed complete resolution of the CSDAVF. At 2-year follow-up, the patient has remained clinically asymptomatic. The mechanism of thrombosis in this fistula related to the endovascular procedure. We speculated that putting the wire tip in the draining vein may induce the spontaneous thrombosis in the venous side. In addition, precipitating factors may include small, low-flow fistula, and pre-existing thrombosis.
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Intraoperative management of a patient for deep brain stimulation with severe dyskinesia and tremors: Ketamine to the rescue! p. 1275
Suman Sokhal, Keshav Goyal, Navdeep Sokhal, Niraj Kumar, Shweta Kedia
DOI:10.4103/ajns.AJNS_47_18  
The loss of dopaminergic neurons from the substantia nigra pars compacta characterizes the classical pathology of Parkinson's disease (PD). Deep brain stimulation (DBS) has become an increasingly common treatment for PD. Sometimes excessive tremors due to exacerbated PD hinder the surgery and may almost make it impossible. This is a case report highlights use of IV ketamine for intraoperative sedation of a patient with PD, with severe dyskinesia & tremors, posted for DBS. IV ketamine resulted in prompt abolition of tremors and dyskinesia, which were unresponsive to previous traditional sedative drugs.
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Spinal arteriovenous fistulas of the filum terminale: Case report and literature review p. 1277
Fayçal Lakhdar, Mohammed Benzagmout, Khalid Chakour, Mohammed El Faiz Chaoui
DOI:10.4103/ajns.AJNS_100_19  
Spiinal arteriovenous fistulae (AVF) are an uncommon cause of myelopathy that require a high degree of suspicion to diagnose. Treatment strategies have not yet been established. Only a few cases of AVFs of the filum terminale (FT) have been reported. In this review, we describe clinical presentation, imaging, and treatment options for this rare type of spinal AV shunt. A 43-year-old male patient presented with progressive low back pain and paraparesis with gradually worsening bilateral foot paresthesias and sphincter dysfunction. He underwent magnetic resonance imaging, which revealed a hypersignal in the thoracolumbar cord and angiography diagnosed a microfistula of the FT. Surgery was preferred over endovascular treatment and we realized an L5 laminectomy to open the dura mater and found a hypertrophic FT. After identifying the fistula which was closely related to cauda equina, and dissecting the root from the fistula, a permanent clip was placed on the proximal part of the arterialized vein. Surgery was uneventful, and 6 months postoperatively, the patient has fully recovered. FT AVFs although rare should be considered as a differential diagnosis of progressive paraparesis, and successful surgery through clipping relies on the angioarchitecture of the shunt and the clinical manifestations of the patient.
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Anterior temporal approach and clipping of a high-riding basilar tip aneurysm: Case report and review of the surgical technique p. 1283
Aaron Musara, Yasuhiro Yamada, Katsumi Takizawa, Liew Boon Seng, Tsukasa Kawase, Kyosuke Miyatani, Rikki Tanaka, Saeko Higashiguchi, Ambuj Kumar, Raja Krishnan Kutty, Vigneshwar Ravisankar, Yoko Kato, Takao Teranishi
DOI:10.4103/ajns.AJNS_121_19  
Basilar apex aneurysms constitute 5%–8% of all intracranial aneurysms. Microsurgical clipping of basilar tip aneurysms is still advocated for as it is safe, especially for unruptured basilar tip aneurysms which have a low risk of postoperative mortality or morbidity. Careful patient preparation is needed preoperatively because the risk of intraoperative rupture is significant. Good surgical techniques should be applied. The skill will need to be preserved as endovascular surgery becomes more popular.This is a case of basilar tip aneurysm managed by clipping through the anterior temporal approach, followed by a review of the literature.
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Spontaneous intracranial extradural hematoma secondary to hypofibrinogenemia: A rare case report p. 1288
Santosh Prabhu, Sidharth Agarwal, Sujata Prabhu
DOI:10.4103/ajns.AJNS_143_19  
Spontaneous extradural hematoma is a well-documented but fairly rare condition, which can be associated with conditions such as vascular malformations, sickle cell disease, metastasis to the skull, infectious diseases of the skull, coagulation disorders, and use of anticoagulants. Of these, very few cases are of life-threatening extradural hematomas in adults, where hypofibrinogenemia is the cause of bleed, without any history of trauma. In this report, we have discussed the management of such a patient.
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Primary pineal rhabdomyosarcoma: A rare case p. 1291
Mihir Mohan Vaidya, Asha Sharad Shenoy, Naina Atul Goel
DOI:10.4103/ajns.AJNS_53_19  
Primary pineal rhabdomyosarcoma (RMS) is extremely rare, and only three cases have been reported so far. Here, we report a case of 12-year-old male who presented with complaints of diplopia and diminution of vision since 15 days. He also had left-sided facial paresis. Magnetic resonance imaging brain revealed a space-occupying lesion in the region of pineal gland. The patient underwent midline suboccipital craniectomy with excision of tumor. Microscopic examination revealed a highly cellular tumor with areas showing small round cells admixed with cells having abundant eosinophilic cytoplasm resembling rhabdomyoblasts and multinucleated giant cells. Differential diagnoses of pineal anlage tumor and primary RMS were considered. The tumor cells were positive for desmin while being negative for synaptophysin and glial fibrillary acidic protein. Myogenin was used to confirm the diagnosis of RMS, which showed focal nuclear positivity. INI1 was retained. All the markers for germ cell tumors were negative.
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Coexisting vestibular schwannoma with fibrous dysplasia: A rare occurrence p. 1295
Vikas Sharma, Rishabh Kedia, Ishani Mohapatra, Anirban Deep Banerjee
DOI:10.4103/ajns.AJNS_73_19  
Coexisting vestibular schwannoma (VS) with fibrous dysplasia is extremely rare. Here, we represent the case of a 48-year-old female with coexisting VS and fibrous dysplasia of overlying occipital bone. After proper evaluation, the patient underwent surgery and microscopic total excision of the right cerebellopontine angle lesion was achieved. However, during surgery, bone work was extremely tedious and exposure to reach up to lesion was difficult. To the best of our knowledge, this is the first reported case of coexisting fibrous dysplasia of overlying bone and VS as histopathological diagnosis.
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Traumatic vertebral body second lumbar over third lumbar retrolisthesis in a child: Reporting the first case along with the review of relevant literature p. 1298
Singh Mathuria Kaushal-Deep, Abdul Rashid Bhat
DOI:10.4103/ajns.AJNS_93_19  
Traumatic retrolisthesis of the lumbar vertebrae is a rare entity in children. Only four such cases, two cases each of first lumbar–second lumbar (L1–L2) and L5-S1 retrolisthesis in children, have been reported so far in the English scientific literature. Here, we report a traumatic retrolisthesis of the L2 vertebra in an 8-year-old male child. He was injured when he lost control while playing, skidded, and fell into a 1-m deep drainage system hole. He presented with backache and urinary retention. His plain radiographs and noncontrast computed tomography of the lumbosacral spine revealed Meyerding Grade II retrolisthesis of the L2 vertebra over the third. The magnetic resonance imaging of the affected area revealed no significant canal narrowing, and there was no spinal cord compression or contusion. A urodynamic study was done which revealed a normal bladder function. The patient was given a trial of spontaneous urination by removing the Foley's catheter after 5 days of injury, and he passed urine normally. The patient was managed conservatively. He was discharged on day 7 with the advice of complete bed rest of 6 weeks and thoracolumbosacral orthoses. The patient has been in follow-up for the past 15 months, and his listhesis has completely resolved. The patient is ambulatory with no neurodeficit. This case is being presented in view of rarity. This is the first case report of L2 over L3 retrolisthesis in a child.
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A 5-year follow-up of intracranial arterial dolichoectasia: A case report and review of literature p. 1302
Lavlesh Rathore, Yashiro Yamada, Tsukasa Kawase, Yoko Kato, Satya Bhusan Senapati
DOI:10.4103/ajns.AJNS_282_18  
A patient with multiple dolichoectasia of the intracranial cerebral artery was followed sequentially with clinical and radiological progression of disease in the past 5 years. The patient was treated in multiple stages in the past 5 years with the endovascular and microsurgical clipping method. The maximum diameter of each major intracranial artery segment was recorded and compared in the follow-up year. The progression in size of the dolichoectatic segment was observed in spite of surgical intervention. In review diagnostic criteria, etiopathogenesis and treatment options have been discussed.
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Safety checklist for gamma knife radiosurgery p. 1308
Nishanth Sadashiva, Manjul Tripathi
DOI:10.4103/ajns.AJNS_237_19  
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