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   Table of Contents - Current issue
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January-March 2020
Volume 15 | Issue 1
Page Nos. 1-249

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EDITORIALS  

Minimal access or optimal access: What to target? p. 1
Ahmed Ansari
DOI:10.4103/ajns.AJNS_361_19  
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Ethical dilemma in glioma surgery; How to opt for the holy grail? p. 2
Seyed Amir Hossein Javadi, Zahid Hossein Khan
DOI:10.4103/ajns.AJNS_363_19  
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REVIEW ARTICLES Top

Comparative outcome analysis of enterprise and neuroform stent-assisted coiling of cerebral aneurysms: A review of the literature p. 4
Ram Kumar Goyal, Yoko Kato, Tsukasa Kawase, Kentaro Suzuki, Yashuhiro Yamada, Saurabh Sharma, Sneha Chitra Balasubramanian, Riki Tanaka, Kyosuke Miyatani, Kojima Daijiro
DOI:10.4103/ajns.AJNS_284_19  
Introduction: One of the popular treatment strategies for complex cerebral aneurysms with wide necks or low dome-to-neck ratios is stent-assisted coiling. The most widely used intracranial stents for stent-assisted coiling are Neuroform (NF) and Enterprise (EP) stents. The purposes of this study are to review the recent literature of the past 5 years to compare outcomes between the EP and NF stent-assist coiling systems so as to comment on the safety, efficacy, complications, and recurrence rate of stent-assisted coiling in general. Methods: PubMed was used to search for all published literature of NF or EP stent-assisted coiling of unruptured cerebral aneurysms from January 2014 to August 2019 with the search terms of “Enterprise stent-assisted coiling,” “Neuroform stent,” and “Neuroform vs. Enterprise stent.” Results: Twenty two publications met the inclusion criteria which encompass 1764 patients and 1873 aneurysms. Out of these 1873 aneurysms, 1007 aneurysms were treated with EP stent and 866 aneurysms were treated with NF stent. The overall outcome was low rates of thromboembolic complications (4.37%) and intracranial hemorrhage (1.13%), low permanent morbidity (1.70%) and mortality (0.40%), and lower rate of recanalization (11%). Data analysis shows an overall higher rate of complication and recurrence of aneurysm and lower overall rate of aneurysmal occlusion in the patients where EP stent was used in comparison to NF stent. However, this difference was not statistically significant. Conclusions: The review of two stent-assisted coiling devices using EP and NF stents including 1873 aneurysms in 1764 patients revealed that overall, it is safe and effective with comparable outcomes.
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Combined therapy potential of apocynin and tert-butylhydroquinone as a therapeutic agent to prevent secondary progression to traumatic brain injury p. 10
Rovie Hikari Parastan, Michael Christopher, Yesyurun Sekundus Torrys, Tjokorda Gde Bagus Mahadewa
DOI:10.4103/ajns.AJNS_231_19  
Traumatic brain injury is caused by physical collision (primary injury). It changes the brain's biochemistry and disturbs the normal brain function such as memory loss and consciousness disturbance (secondary injury). The severity can be measured with the Glasgow Coma Scale. The secondary injury will cause oxidative stress that leads to the nervous cells death, so treatment is needed before it gets worse. Primary injury results in excess of reactive oxidative stress (ROS) which is known from NADPH oxidase 2 (Nox2). Excessive ROS is deadly to the nerve cells. Excessive ROS will activate nuclear factor erythroid 2-like 2 (Nrf2). Nrf2 will bind to antioxidant response elements, to protect multi organs against ROS, including this brain injury. However, this does not last long, so it requires handling excess ROS. Apocynin can inhibit the activation of Nox2, and reduce the neuron injuries in the hippocampus. It also protects the tissues from oxidative stress. While Nrf2 can be activated by tert-butylhydroquinone, to protect cells. The combination may reduce the secondary brain injury, improve the neurologic recovery, cognitive function, and reduce the secondary cortical lesion.
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Preservation of the lenticulostriate arteries during insular glioma resection p. 16
Michael George Zaki Ghali
DOI:10.4103/ajns.AJNS_146_18  
Insular gliomas represent 25% and 10% of low- and high-grade gliomas, respectively. Their resection proves challenging due to the intimate involvement of eloquent parenchyma and the lenticulostriate arteries (LSAs), limiting facility of achieving maximal safe resection. The majority of postoperative deficits following insular glioma resection is attributed to compromise of the LSAs. It is contemporaneously critical and challenging to preserve these vessels, given they are numerous and small, with an intraparenchymal course hidden from direct visualization during the operative intervention. A lesser degree of medially directed displacement of the LSAs predicts tumoral encasement of these vessels, which portends a decreased likelihood for achieving a gross total resection and increased probability of postoperative morbidity. Preservation of these vessels thus requires knowledge of their location during the entirety of the insular glioma resection and is facilitated by pre- and intra-operative imaging. Intraoperative real-time tracking, however, may prove rather challenging, especially with transcortical access. Conventional catheter digital subtraction angiography, computed tomographic angiography, magnetic resonance imaging and angiography, and three-dimensional ultrasound powered Doppler have proven effective modalities in assessing lenticulostriate position, and their use facilitates a greater extent of resection while minimizing the attendant morbidity consequent to LSA injury.
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ORIGINAL ARTICLES Top

Endoscopic endonasal transsphenoidal approach for resection of tuberculum sella and planum sphenoidale meningiomas: A snapshot of our institutional experience p. 22
Md Al Amin Salek, Md Hasnain Faisal, Md Abdul Hye Manik, Ahmed-Ul-Mursalin Choudhury, Rukun Uddin Chowdhury, Md Aminul Islam
DOI:10.4103/ajns.AJNS_85_19  
Introduction: Meningiomas of the tuberculum sellae and planum sphenoidale represent a subgroup of anterior skull base tumors that comprise approximately 5%–10% of all intracranial meningiomas. Most of the patients report with failing vision, so early surgical decompression either transcranial and/or endonasal approach is recommended. The endonasal route allows for direct coagulation of the tumor meningeal supply and extensive resection of dural attachments, and importantly, provides an inferior to superior access to the infrachiasmatic region that facilitates complete tumor removal without encountering the optic nerve. This article describes our institutional experience for the endonasal resection of tuberculum sellae and planum sphenoidale meningiomas. Materials and Methods: We retrospectively analyzed eight cases of tuberculum sellae and planum sphenoidale meningiomas who selectively underwent endoscopic endonasal transsphenoidal resection between 2015 and 2018. All patients had ophthalmological, endocrinological, and radiological evaluation both preoperatively and postoperatively. Results: Among the study group, we found age range 22–68 years, male:female 1:2. Among the radiological findings, there were five cases of tuberculum sellae meningioma, while three cases were of planum sphenoidale meningioma. In tumor resection status, we found gross total resection in six cases and debulking in two cases. Postoperative analysis of visual outcome revealed improvement in four cases, constant in three cases, and worsening in one case. We also found the post of nasal complications in four cases, cerebrospinal fluid leak in two cases and transient diabetes insipidus in one case. Conclusion: In this study, we highlighted our experience of a very small group of patients with anterior fossa meningioma specific to tuberculum sella and planum sphenoidale origin.
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Intraoperative use of microscope-integrated flow 800 – A valuable tool in surgical management of anterior communicating artery aneurysm: Our institutional experience p. 26
Vaibhav S Chavan, Yashuhiro Yamada, Kadam Chandratej, Devareddy Gowtham, Stanzani Riccardo, Shukurov Firuz, Kato Yoko
DOI:10.4103/ajns.AJNS_342_19  
Background: Flow 800 is microscope-integrated analytical visualization tool which analyses the indocyanine green (ICG) video sequence and converts it into an intensity diagram. This allows an objective evaluation of the result rather than subjective assessment of ICG fluorescence. The anatomy of anterior communicating artery region is complex because of multiple vessels and perforators in small space; hence, there is a need of objective assessment tool which can give precise idea about vascular compromise. Flow 800 can serve as a valuable tool in this complex surgery. Objective: The objective of this study was to evaluate the utility of microscope-integrated fluorescent ICG videoangiography (Flow 800) in A-com aneurysm surgery. Materials and Methods: We used Flow 800 in ten consecutive patients of A-com aneurysm surgery from July 2019 to October 2019. We studied patient characteristics, intraoperative observation of ICG and Flow 800, and corresponding changes made in the operative decisions. Results: The use of Flow 800 helped in intraoperative decision of four out of ten patients of A-com aneurysm. In two patients, incomplete clipping was confirmed with Flow 800 and the second clip was applied. In the third patient, perforator compromise was found hence needed clip readjustment, whereas in the fourth patient, ICG was inconclusive and Flow 800 confirmed complete clipping of aneurysm. Conclusion: Flow 800 is a conclusive reproducible and objective tool for early detection of vascular compromise of multiple vessels and perforators in A-com aneurysm surgery. It gives a better idea of vasculature, especially where ICG is ambiguous or inconclusive.
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Incidence and risk factors for venous thromboembolism following craniotomy for intracranial tumors: A cohort study p. 31
Anukoon Kaewborisutsakul, Thara Tunthanathip, Pakorn Yuwakosol, Srirat Inkate, Sutthiporn Pattharachayakul
DOI:10.4103/ajns.AJNS_351_19  
Context: Venous thromboembolism (VTE) is a devastating complication of intracranial tumor surgery. The present study helps identify patients at the greatest risk of developing VTE. Aims: The aim of the study was to evaluate the incidence of and risk factors for VTE following craniotomy for intracranial tumors. Setting and Designs: This was a retrospective cohort study. Methods: Data from the institutional database (between January 2017 and December 2018) were reviewed. Consecutive patients with intracranial tumors who underwent craniotomy were included. Statistical Analysis Used: Patient characteristics were reported as descriptive data, and factors associated with VTE development were analyzed by the Cox regression model. Results: The study identified 177 patients. The incidence of VTE was 10.2% (deep-vein thrombosis [DVT], 8.5%; pulmonary embolism [PE] 1.7%; and simultaneous DVT and PE, 1.7%). In univariate analysis, VTE development was associated with diabetes mellitus (DM), operative duration of >420 min, blood transfusion, and new-onset postoperative motor deficits. DM and new-onset postoperative motor deficits were statistically significant factors in multivariable analysis, with hazard ratios of 4.52 (95% confidence interval [CI] = 1.38–14.82) and 3.46 (95% CI = 1.17–10.23), respectively. Conclusions: Postcraniotomy VTE was detected in 10.2% of patients with intracranial tumors. Risk factors for VTE included DM and new-onset postoperative motor deficits. Hence, intracranial tumor patients with these risk factors are the most likely to require VTE prophylaxis with an anticoagulant.
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Morphometry of the C2 pedicle and lamina in thai patients p. 39
Pakorn Yuwakosol, Thakul Oearsakul, Thara Tunthanathip
DOI:10.4103/ajns.AJNS_312_19  
Background: Traumatic upper cervical spine leads to instability and neurological deficit. At present, C2 (axis) pedicle or lamina screws for fixation are popular because further external immobilization is not needed. However, these techniques demand experience inserting the screws and carry the risk of vertebral artery or spinal cord injury. In some patients, the C2 screws cannot be inserted because of limited C2 size. Objective: To determine the width, length, height, and angle in the C2 pedicle and lamina in the Thai population. Materials and Methods: Patient data were collected from the Picture Archiving and Communication System at the Faculty of Medicine, Prince of Songkla University from January 2016 to December 2017. The C2 parameters, i.e., width, length, height, and angle of the pedicle and lamina were recorded. Results: The CT C-spine scans of 270 patients were enrolled. The mean Thai C2 pedicle dimensions were width 5.51 mm, length 23.78 mm, angle 39.04°, and height 8.64 mm. The mean C2 lamina dimensions were width 5.88 mm, length 32.17 mm, angle 49.46°, and height 12.27 mm. Twenty-four patients from the 270 patients (8.8%) had a pedicle width <3.5 mm but all patients had a lamina width ≥3.5 mm. Conclusion: In the Thai samples, 8.8% had a C2 pedicle width <3.5 mm which would not allow insertion of screws; however, they could be replaced with lamina screws since the lamina width was ≥3.5 mm. In this study, all of the patients who could not be inserted pedicle can be replaced with lamina screws inserted.
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Freehand insertion of external ventricular drainage catheter: Evaluation of accuracy in a single center p. 45
Keng Siang Lee, John Jiong Yang Zhang, Nagarjun Bolem, May Lian Leong, Chun Peng Goh, Rashidul Hassan, Al Amin Maa Salek, Asher Paul Tan Sein Lwin, Kejia Teo, Ning Chou, Vincent Nga, Tseng Tsai Yeo
DOI:10.4103/ajns.AJNS_292_19  
Introduction: External ventricular drain (EVD) placement is the gold standard for managing acute hydrocephalus. Freehand EVD, using surface anatomical landmarks, is performed for ventricular cannulation due to its simplicity and efficiency. This study evaluates accuracy and reason(s) for misplacements as few studies have analyzed the accuracy of freehand EVD insertion. Patients and Methods: Preoperative and postoperative computed tomography scans of patients who underwent EVD insertion in 2014 were retrospectively reviewed. Diagnosis, Evans ratio, midline shift, position of burr hole, length of the catheter, and procedural complications were tabulated. The procedures were classified as satisfactory (catheter tip in the frontal horn ipsilateral lateral ventricle) and unsatisfactory. Unsatisfactory cases were further analyzed in relation to position of burr hole from midline and length of the catheter. Results: Seventy-seven EVD placements in seventy patients were evaluated. The mean age of the patients was 57.5 years. About 83.1% were satisfactory placements and 11.7% were unsatisfactory in the contralateral ventricle, corpus callosum, and interhemispheric fissure. Nearly 5.2% were in extraventricular locations. Almost 2.6% EVD placements were complicated by hemorrhage and 1 catheter was reinserted. Suboptimal placements were significantly associated with longer intracranial catheter length. The mean length was 66.54 ± 10.1 mm in unsatisfactory placements compared to 58.32 ± 4.85 mm in satisfactory placements. Between the two groups, no significant difference was observed in Evans ratio, midline shift, surgeon's experience, distance of burr hole from midline, and coronal suture. Conclusion: Freehand EVD insertion is safe and accurate. In small number of cases, unsatisfactory placement is related to longer catheter length.
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Postoperative venous thromboembolism in extramedullary spinal tumors p. 51
Anukoon Kaewborisutsakul, Thara Tunthanathip, Pakorn Yuwakosol, Srirat Inkate, Sutthiporn Pattharachayakul
DOI:10.4103/ajns.AJNS_279_19  
Context: Venous thromboembolism (VTE), including deep-vein thrombosis (DVT) and pulmonary embolism (PE), is the fatal complication following spine surgery and the appropriate perioperative prophylaxis is still debated. Aims: The aim of this study is to evaluate the incidence of along with risk factors for postoperative VTE in surgically treated extramedullary spinal tumor patients. Setting and Designs: The study design involves single institute and retrospective cohort study. Subjects and Methods: The cohort database was reviewed between the periods of January 2014 and June 2019. Patients undergoing surgery for spine tumor, extradural tumor, and intradural extramedullary were consecutively collected. Statistical Analysis Used: The incidence of VTE and clinical factors reported to be associated with VTE were identified, and then analyzed with an appropriate Cox regression model. Results: The study identified 103 extramedullary spinal tumor patients. Three patients (2.9%) were diagnosed with a proximal leg DVT, while symptomatic PE did not identify. Risk factors associated with DVT occurrence were as follows: operative time ≥8 h (Hazard ratio [HR] 13.98,P= 0.03) and plasma transfusion (HR 16.38,P= 0.02), whereas plasma transfusion was the only significant factor, after multivariate analysis (HR 11.77,P= 0.05). Conclusions: Patients who underwent surgery for extramedullary spinal tumors showed a 2.9% incidence of DVT. The highest rate of DVT was found in patients who received plasma transfusion. More attention should be paid on perioperative associated factors for intensive prevention coupled with early screening in this group.
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Analysis of surgical cases of tarsal tunnel syndrome in our department: Case series and literature review p. 59
Masatoshi Yunoki
DOI:10.4103/ajns.AJNS_257_19  
Background: Tarsal tunnel syndrome (TTS) is an entrapment neuropathy in which the tibial nerve is compressed within the tarsal tunnel and causes sensory disturbance in the sole of the foot. In this manuscript, we summarized our early surgical cases of TTS. Materials and Methods: Six feet in five patients with TTS were treated surgically. The patients were aged 31–70 years (mean 53.1 years), and all of them complained of pain or dysesthesia of the sole of the foot sparing the heel. Magnetic resonance imaging (MRI) and nerve conduction test were performed preoperatively. In surgery, flexor retinaculum was dissected (tarsal tunnel opening [TTO]), the posterior tibial nerve was freed from the arteriovenous complex (neurovascular decompression [NVD]), and fascia of the abductor hallucis muscle was excised to decompress the medial and lateral plantar nerve (releasing fascial of abductor hallucis muscle [RFAH]). Results: Preoperative MRI confirmed that all seven cases were idiopathic TTS. Moreover, NCD demonstrated delayed sensory conduction velocity but not delayed distal motor latency. Surgical decompression was beneficial in 5 feet. The recurrence of symptoms was found in one case within 1 postoperative month. Conclusion: Surgical treatment for idiopathic TTS with TTO, NVD, and RFAH was generally good. However, symptoms recurred in one instance. Some methods to prevent adhesion and granulation in the reconstructed tarsal tunnel should be considered.
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Initial results of management for acute ischemic stroke due to large vessel occlusion by a direct aspiration first pass technique at a Vietnamese hospital Highly accessed article p. 65
Le Van Phuoc, Nguyen Huynh Nhat Tuan, Le Van Khoa, Nguyen Van Tien Bao, Pham Dang Tu, Duong Dinh Hoan, Pham Thi Ngoc Thao, Nguyen Van Khoi
DOI:10.4103/ajns.AJNS_258_19  
Background: The development of novel revascularization devices has improved procedural and clinical outcomes in acute ischemic stroke (AIS). A direct aspiration first pass technique (ADAPT) has been introduced as a rapid simple method for achieving good recanalization and clinical outcomes using large bore aspiration catheters in the treatment of AIS due to large vessel occlusion (LVO). Objectives: The aim of this study was to assess the safety and efficacy of ADAPT in the treatment of AIS due to LVO in the Vietnamese patient population. Materials and Methods: A retrospective analysis of a hospital database was conducted on all patients undergoing stroke therapy with the ADAPT technique at the institution from January 2017 to December 2017. Efficacy and safety were evaluated by the variables: revascularization rates (thrombolysis in cerebral infarction [TICI] score), time to revascularization, procedural complications, and clinical outcomes (modified Rankin scale [mRS] score) at the 90-day follow-up visit. Results: From the database review, 37 AIS patients treated with ADAPT were identified. The mean NIHSS score at presentation was 17.3 and improved to 8.9 at discharged. The average time arterial puncture to revascularization was 32.5 min. TICI 2b/3 revascularization was achieved in 30/37 (81.1%) patients, good clinical outcomes were achieved (mRS 0–2) in 21/37 (56.7%) patients, and mortality rate was 6/37 (16.2%) during follow-up. Conclusions: ADAPT utilizing large bore aspiration catheters appears to be a fast, simple, safe, and effective method for the management of AIS in the Vietnamese patient population.
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Intramedullary metastasis to the cervical spinal cord from malignant pleural mesothelioma: Review of the literature and case reports p. 70
Fotios Kalfas, Claudia Scudieri
DOI:10.4103/ajns.AJNS_234_18  
Context: Malignant mesothelioma is an aggressive tumor; median survival of patients following diagnosis is 12 months. Aims: Pleural malignant mesothelioma tends to spread along preexisting tissue planes and has the rare ability to spread along the nerve root into the spinal cord. In our case, there is an evidence of exceptional direct hematogenous spread to the spinal cord by the spinal branch of the intercostal arteries or the veins of Batson's plexus. Settings and Design: The authors report a case of intramedullary hematogenous metastasis to the cervical spinal cord from malignant mesothelioma, with a review of the literature. Materials and Methods: A 68-year-old male was admitted to our department because of a slowly progressive mild weakness of both low extremities, more pronounced on the left side. The patient has been treated for a malignant mesothelioma with left thoracotomy and subsequently underwent radiotherapy. Magnetic resonance imaging of the cervical-thoracic spine revealed a contrast-enhancing intramedullary expansive lesion of the left half of the spinal cord at the C6–C7 level. Results: The patient underwent surgical treatment through a C6–C7 laminectomy. Through a median posterior spinal cord incision, an intramedullary grayish lesion was completely removed. The paraparesis progressively improved and 20 days after surgery, the patient had regained normal lower extremity function. Conclusions: Malignant mesothelioma can spread to the spinal canal by the direct extension through the intervertebral foramina, by hematogenous spread to the spinal meninges, and by perineural growth along a single nerve root. The cleavage plane of the tissue may determine whether a successful gross total resection can be achieved with a good outcome for the patient.
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Minimally invasive spine (MIS) surgery in traumatic thoracolumbar fractures: A single-center experience p. 76
Mohamed Naufel Ansar, Syed Maroof Hashmi, Francesca Colombo
DOI:10.4103/ajns.AJNS_236_19  
Objective: Traumatic thoracolumbar fractures are common, and surgical fixation is a well-established treatment option, with the aim to achieve spinal stability and preserve neurological function. Pedicle screw fixation using a minimally invasive spine (MIS) surgical approach has emerged as an alternative approach for the treatment of thoracolumbar fractures. The aim of this study is to collect data regarding epidemiology, management, and outcomes of patients treated with MIS pedicle screw fixation for traumatic thoracolumbar fractures in our neurosurgical department. Materials and Methods: This was a retrospective cohort study including all patients who underwent MIS fixation from March 2013 to March 2017. Results: A total of 125 patients were included, 61 males and 64 females; the mean age was 59 years. The majority of injuries were from falls. In 48 cases, the fracture involved a thoracic vertebra and in 77 cases a lumbar vertebra. More than 10% of the patients presented with a neurological deficit on admission and 75% of those showed postoperative improvement in their neurology. The average length of hospital stay was 14 days. MIS fixation achieved a satisfactory regional sagittal angle (RSA) postoperatively in all patients. The vast majority of patients had no or mild postoperative pain and achieved a good functional outcome. Conclusions: MIS fixation is a safe surgical option with comparable outcomes to open surgery and a potential reduction in perioperative morbidity. MIS surgery achieves a rapid and significant improvement in pain score, functional outcome, Frankel Grade, and RSA. We expect that MIS fixation will become the predominant technique in the management of traumatic thoracolumbar fractures.
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Ventriculoperitoneal shunt complication in pediatric hydrocephalus: Risk factor analysis from a single institution in Nepal p. 83
Prakash Paudel, Prakash Bista, Durga Prasad Pahari, Gopal Raman Sharma
DOI:10.4103/ajns.AJNS_216_19  
Objective: Ventriculoperitoneal (VP) shunt surgery is one of the commonly performed neurosurgical procedures. Complications due to shunt failure are associated with high morbidity and mortality. We report an analysis of risk factors for shunt failure in pediatric patients from a single institution in Nepal. Materials and Methods: A retrospective analytical study with prospective data was designed. All children younger than 15 years, with first time VP shunting, at a tertiary government hospital in Kathmandu during 2014-2017 were followed up. Association of independent variables with the primary outcome variable (complication of VP shunt) was analyzed using Chi-square test. Bivariate logistic regression was performed to identify unadjusted odds ratio (OR) with 95% confidence interval (CI). Multivariate logistic regression model was designed to calculate adjusted OR with 95% CI. Results: Of 120 patients, more than half (55.8%) of the patients were male. Mean age was 62.97 months. Maximum duration of follow-up was 30 months. Most common cause of hydrocephalus was congenital aqueductal stenosis (40.8%) followed by tumors (29.2%). Overall shunt complication was found in 26.7% (95% CI 19.0%–35.5%). Shunt infection was seen in 5% while malfunction without infection was found in 21.7%. Bivariate logistic regression showed duration of surgery more than 1 h (OR 2.67, 95% CI 1.11–6.42, P = 0.028) compared to 1 h or less, experienced surgeon (OR 0.37, 95% CI 0.16–0.89, P = 0.026) compared to residents, and emergency surgery (OR 3.97, 95% CI 1.69–9.29, P = 0.001) compared to elective surgery as significant risk factors, while emergency surgery was the only significant variable for shunt failure on multivariate regression analysis (OR 3.3, 95% CI 1.16–9.35, P = 0.025). Conclusion: Longer duration of surgery, less experience of the surgeon, and the priority of the case (emergency) were independent risk factors for shunt complications.
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Sodium fluorescein in brain tumor surgery: Assessing relative fluorescence intensity at tumor margins p. 88
Ragavan Manoharan, Jonathon Parkinson
DOI:10.4103/ajns.AJNS_221_19  
Purpose: The use of intraoperative 5-aminolevulinic acid fluorescence has been shown to increase the extent of resection in high-grade glioma surgery. Sodium fluorescein is an alternate fluorescence agent with advantages of low cost, low adverse effect profile, and ability to visualize anatomical detail under the fluorescence filter. Sodium fluorescein-based fluorescence is not specific to tumor cells, and the significance of residual fluorescence at tumor margins has been questioned. In this article, the authors sought to correlate fluorescence intensity at tumor margins with the presence of residual contrast-enhancing tumor on magnetic resonance imaging (MRI). Methods: Eleven patients with a total of 12 lesions were enrolled in the study. Sodium fluorescein was administered at a dose of 5 mg/kg on induction of anesthesia. Relative intensity of fluorescence was extrapolated from intraoperative photographs through isolation of the green channel from the red/green/blue image, then graphically representing of pixel intensity through application of a thermal map. The correlation between areas of avid fluorescence at tumor cavity margins and the presence of residual contrast-enhancing tumor on postoperative MRI was evaluated. Results: All tumors demonstrated fluorescence. The presence of avid fluorescence at tumor cavity margins had a sensitivity of 66.7% and specificity of 75% for the presence of residual contrast-enhancing tumor on postoperative MRI. There were no adverse effects of fluorescein administration. Conclusion: Quantification of relative fluorescence intensity allows easy identification of areas that are high risk for residual contrast-enhancing tumor. Graphical representation of green pixel intensity requires validation through histopathological analysis but has the potential for real-time clinical application.
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Evaluation of the evan's and bicaudate index for rural population in central india using computed tomography p. 94
Atul Dhok, Prasheelkumar Gupta, Salman T Shaikh
DOI:10.4103/ajns.AJNS_223_19  
Introduction: Evans index (EI) and Bicaudate index (BCI) are practical markers of ventricular volume and are helpful radiological markers in the diagnosis of normal pressure hydrocephalus. Worldwide, variation exists in normative studies for both these indices. Most of the studies conducted for EI and BCI are based on the Western population data. No study has been performed on the rural population of Central India. The purpose of this study is to develop normative data on EI and BCI that can be extrapolated for future reference. Materials and Methods: This was a retrospective study conducted from December 2018 to May 2019 in MGIMS Hospital, Sevagram, Maharashtra, India, which is a rural hospital in Central India. All patients with either a head injury or neurological complaints although with normal computed tomography (CT) brain were included in the study. Patients with diagnosed neurological disorder, clinical features suggesting hydrocephalus, or intracranial pathology on CT brain were excluded from the study. Five hundred and eleven patients were selected for this study, and EI and BCI was calculated for them. Results: The mean value of EI and BCI in our study was 0.2707 and 0.1121, respectively. Both indices showed a statistically significant difference between males and females. The value of both indices increased with age. Conclusion: Although our study is in agreement with the cutoff value of EI to diagnose dilated lateral ventricles as 0.3 for age <70 years, cutoff value of EI for the older population should be reconsidered to 0.34.
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Transpalpebral approach for microsurgical removal of tuberculum sellae meningiomas p. 98
Revaz Semenovich Dzhindzhikhadze, Oleg Nikolaevich Dreval, Valeriy Aleksandrovich Lazarev, Andrey Victorovich Polyakov, Renat Leonidovich Kambiev, Elvira Igorevna Salyamova
DOI:10.4103/ajns.AJNS_186_19  
Background: The evolution of skull base approaches associated with individualization of surgical corridor and minimizing the collateral damage. Achieving the radical removal of tumor and preserving the neurological status of the patient is possible, both with the traditional approaches and keyhole approaches. Our work presents experience using the transpalpebral approach (TPA) for microsurgical removal of tuberculum sellae meningioma (TSM). Materials and Methods: A total of 15 patients with meningiomas underwent microsurgical removal of TSM through TPA. Ten patients were women and five were men. The standard preoperative diagnostic protocol includes magnetic resonance imaging with contrast enhancement, brain computed tomography for neuronavigation. We assess surgical complications, functional and cosmetic outcomes, and surgical parameters, including the time of surgery and intraoperative blood loss. Results: Visual impairment was finding in 100% patients, including slight decrease of vision (46,7%, seven patients), partial vision field loss (six patients, 40%), and serious visual impairment (two patients 13.3%). Visual improvement was noted in ten cases (66.7%), there was no improvement in four cases (26.7%), and one case (6.6%) had transient visual worsening for 4 days and slow improvement in 1 month. Headache disappeared in three patients (50%). There were no cases of cerebrospinal fluid leak. Transient frontal hypoesthesia was noted in all patients (100%) without permanent deficit. Transient palsy of the frontal muscle was noted in four patients for 4–6 months. Histological examination revealed WHO Grade I meningioma in 14 cases and in 1 case WHO Grade II meningioma. No deaths were identified in follow-up at 12 months. The average value of the Modified Rankin Scale was 1.4. The mean length of stay in hospital was 5. Conclusion: TPA is technically difficult and requires some experience to work in deep structures in a small surgical corridor. This technique can be good alternative to traditional fronto-lateral, supraorbital keyhole craniotomies, and endoscopic endonasal approaches.
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Reliability and interobserver variability of evans' index and disproportionately enlarged subarachnoid space hydrocephalus as diagnostic criteria for idiopathic normal pressure hydrocephalus p. 107
Kiyoshi Takagi, Ryota Watahiki, Toru Machida, Kenji Onouchi, Kazuyoshi Kato, Marie Oshima
DOI:10.4103/ajns.AJNS_354_19  
Background: The image diagnosis of idiopathic normal-pressure hydrocephalus (iNPH) is based on the ventriculomegaly, whose criterion is an Evans' Index (EI) >0.3. Recently, disproportionately enlarged subarachnoid space hydrocephalus (DESH) has been proposed as a morphological characteristic to iNPH. Several studies cast doubt on the reliability of these criteria in the diagnosis of iNPH. Furthermore, interobserver differences of these criteria have not yet been investigated. The objective of this study was to assess the diagnostic reliability and interobserver variability of EI and DESH. Materials and Methods: The preoperative magnetic resonance (MR) images of 84 definite iNPH patients were retrospectively evaluated by a neuroradiologist (NR) and physical therapist (PT). They independently assessed the EI and DESH. The MR images were evaluated preoperatively by a neurosurgeon (NS). The results were showed in mean (standard deviation). Results: The mean age was 78.4 (6.3) years (male:female = 49:35). The mean EI was 0.33 (0.04), 0.32 (0.04), and 0.31 (0.03) for NS, NR, and PT, respectively (P < 0.0001). The rate of accurate diagnosis of iNPH with EI >0.3 was 74%, 66%, and 61% for NS, NR, and PT, respectively, and there was a moderate level of agreement. By contrast, there was a substantial lower level of accuracy in assessment with DESH for all three evaluators as 50%, 44%, and 27% for NS, NR, and PT, respectively, again with a moderate level of agreement. However, the rates of patients fulfilling both EI >0.3 and DESH were remarkably lower than either of the two parameters individually at a mere 37%, 30%, and 16% for NS, NR, and PT, respectively, with a low level of agreement between the rates. Conclusion: This study suggests that DESH cannot be a diagnostic criterion for iNPH. If EI >0.3 and DESH were both necessary to diagnose iNPH, then more than 70% of patients would have been misdiagnosed and would have been deprived of the chance of treatment and its benefits. These results request a paradigm shift in the concepts of iNPH.
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Endovascular therapy for aneurysmal subarachnoid hemorrhage complicated by neurogenic pulmonary edema and takotsubo-like cardiomyopathy: A report of ten cases p. 113
Senshu Nonaka, Hidenori Oishi, Satoshi Tsutsumi, Hisato Ishii
DOI:10.4103/ajns.AJNS_331_19  
Objective: Patients sustaining aneurysmal subarachnoid hemorrhage (aSAH) can be further complicated by neurogenic pulmonary edema (NPE) and Takotsubo-like cardiomyopathy (TCM) with dismal outcomes. The present study aimed to validate the efficacy of endovascular therapy for patients with aSAH complicated by NPE and TCM. Materials and Methods: Patients who were diagnosed with aSAH complicated by NPE and TCM and treated by endovascular therapy were retrospectively evaluated. Results: In the past 5 years, a total of ten female patients with aSAH were also diagnosed with NPE and TCM. Six of the ten were cases with high-grade aSAH (Hunt and Hess Grades IV and V), whereas four were low-grade aSAH (Grades II and III). The locations of ruptured aneurysms were the internal carotid-posterior communicating artery junctional site in five patients, the anterior communicating artery in two, the vertebral artery in two, and the middle cerebral artery in one. These aneurysms were successfully embolized by endovascular therapy without any procedure-associated complications. The clinical outcome measure at 6 months after discharge on the Modified Rankin Scale was found to be 0 in four patients, 1 in two, 3 in one, and 5 in three. Conclusions: Endovascular therapy can be a feasible, alternative measure for the treatment of patients with high-grade aSAH who also have NPE and TCM.
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Recurrence of previously clipped anterior communicating aneurysm: The surgical techniques and strategies: A case series p. 120
Rajan Kumar Sharma, Ahmed Asiri, Yasuhiro Yamada, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_107_19  
Background: Microsurgical aneurysm (MSA) clipping is considered as the standard therapy with the endovascular coiling. Microsurgical clipping is considered superior to endovascular in terms of the recurrence rate. The management of recurrent aneurysm following previous microsurgical clipping is challenging. The management of recurrent aneurysm following previous microsurgical clipping is challenging. This study aims to explore the management of recurrent aneurysm of the anterior communicating artery (ACoM). Materials and Methods: This is a case series of three elder women who had a recurrence of ACoM aneurysm after MSA clipping. All the three patients were operated with microsurgical clipping. We studied the preoperative images of the first surgery of all the patients. The detailed case-by-case analysis was performed based on preoperative, postoperative, and follow-up radiologic examinations and operative findings. Results: All three patients who had a recurrence after MSA clipping of ACoM aneurysm and were asymptomatic. At presentation, they were diagnosed at the postoperative imaging at follow-up. The earliest recurrence was 1 year while in one patient; the recurrence was detected 8 years after the initial MSA clipping. The cerebral aneurysms were posteriorly directed in the initial preoperative images in all the cases. Conclusion: This study revealed the recurrence as the residual neck or the enlargement of the aneurysm even after MSA in these cases of ACoM aneurysm. Even with the complete clipping, there can be recurrence at the clip site due to the change in hemodynamics over the time. We should follow-up the patients regularly even after microsurgical clipping.
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CASE REPORTS Top

Primary central nervous system lymphoma involving entire ventricular system p. 126
Hemant Kumar, Achal Sharma, Vinod Sharma, Shashi Singhvi
DOI:10.4103/ajns.AJNS_94_16  
Primary central nervous system lymphoma (PCNSL) is a rare tumor that accounts for <1%–4% of primary CNS tumor.[1] PCNSLs are class of non-Hodgkin's lymphomas which are primarily of diffuse large B-cell origin (90%), with remaining being T-cell lymphoma (10%). Author report a rare case of PCNSL presenting as an intracranial mass involving the entire ventricular system, in an immunocompetent 36-year-old male with severe headache, decreased vision, and unsteady gait. The diagnosis was obtained by histopathological and subsequent immunohistochemistry.
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Spinal metastasis from merkel cell carcinoma in an elderly male p. 128
Kalah Jockisch, Yazan Abdeen, Carlisle Alderink, Tony Flippin, Sugabramya Kuru, Hamid Shaaban
DOI:10.4103/ajns.AJNS_5_18  
Merkel cell carcinoma is a cutaneous neuroendocrine malignancy that has an aggressive nature. Classically, it affects the elderly Caucasian population with a predilection for the sun-exposed areas of the body. Pathogenesis has been linked to ultraviolet radiation, immunosuppression, and the Merkel cell polyomavirus. Definitive diagnosis entails histologic evaluation and immunohistochemical staining. With its generalized appearance and tendency for metastasis, a high index of suspicion must be utilized. In this case, we present the unique presentation of Merkel cell carcinoma as a rapidly enlarging lymph node with metastatic disease to the spinal column presenting as new-onset low back and radicular pain.
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Complex chiari malformation presenting with bulbar symptoms in an adult: Single-stage posterior fusion and foramen magnum decompression: A rare case report p. 132
Sneha Chitra Balasubramanian, Navas Nazumudeen Saphiya, Abu Madan, Shobha Sara Mathews, Ajith Rajappan Nair
DOI:10.4103/ajns.AJNS_344_19  
Complex Chiari malformation (CCM) is a spectrum of congenital bony and soft tissue abnormalities, which includes Chiari 1.5 malformation, medullary kinking, retroflexed odontoid, abnormal clival-cervical angle (CXA), occipitalization of the atlas, basilar invagination, syringomyelia, and scoliosis. CCM usually manifests in the pediatric age group and is a challenging entity to treat. It requires detailed evaluation of craniometric indices to decide the appropriate surgical management. Patients with maximum perpendicular distance of dens to the line from the basion to the inferoposterior part of the C2 body (pBC2 line) of more than 9 mm and CXA <125° require a posterior fixation and will benefit from a single-stage posterior fusion and foramen magnum decompression (FMD). We report a rare case of CCM manifesting in a 32-year-old male with brainstem compression and bulbar symptoms. We could realign the craniovertebral junction with only a C1-C2 fixation by a modified distraction, compression, extension, and reduction technique and also relieve the neural compression by FMD and tonsillar resection in a single surgery with a good outcome. The authors find it to be an effective alternative to avoid the occipital fixation.
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Extend of skipped multifocal noncontiguous spinal tuberculosis beyond imagination: A rare case report and literature review p. 136
Dhiraj Vithal Sonawane, Bipul Kumar Garg, Kishor Bapuji Jadhav
DOI:10.4103/ajns.AJNS_345_19  
Skipped multifocal extensive spinal tuberculosis involving the whole spine is very rare, which presents with atypical presentations and imaging features. So far, only five cases have been reported. Most of these patients have only two noncontiguous lesions. We are reporting a case of an 18-year-old boy with noncontiguous multifocal spinal tuberculosis involving cervical, thoracic, thoracolumbar, and lumbar segments. The patient was treated with antituberculous drug therapy and was operated for thoracolumbar spinal lesion. He made an excellent recovery. The possibility of tuberculosis is considered for any skip lesions involving the spine cautiously. Careful physical examination, trials of antitubercular therapy, and using the whole spine magnetic resonance imaging routinely also play an important role in the diagnosis and treatment of this disease. In patients with noncontiguous spinal involvement, there is a high percentage of requirement of surgical treatment due to fulminant behavior of the disease in these patients.
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Unique case of atypical central neurocytoma with craniospinal metastases and pituitary adenoma p. 140
Peter Soh, Bailey Manning, Ninh Doan
DOI:10.4103/ajns.AJNS_316_19  
Atypical central neurocytoma with extracranial metastases is a rare variant of benign central neurocytoma (CN). No definitive course of treatment exists for atypical CN. We report a unique case of atypical CN with concomitant pituitary macroadenoma and subsequent metastases to the spine. The patient received craniospinal radiation therapy. Close-follow up post tumor-resection may be advised to monitor for drop metastases. To the best of our knowledge, this is the only case reported of atypical CN with drop metastases to the spine concomitant with pathological-proven pituitary macroadenoma.
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Reversible thalamic dementia caused by venous hypertension of bilateral thalami resulting from multiple intracranial dural arteriovenous fistulas successfully obliterated by endovascular treatment using liquid embolic materials: A case report and literature review p. 144
Prasert Iampreechakul, Punjama Lertbutsayanukul, Yodkwhan Wattanasen, Thon Thiraworawong, Surasak Komonchan, Somkiet Siriwimonmas
DOI:10.4103/ajns.AJNS_317_19  
We describe a patient with multiple cranial dural arteriovenous fistulas (DAVFs) presenting with thalamic dementia. A 52-year-old man experienced progressive dementia and behavioral change for 1 month. Cranial computed tomography scan and magnetic resonance imaging (MRI) showed bilateral thalamic edema with subsequent hemorrhagic transformation. Cerebral angiography demonstrated multiple cranial DAVFs at the straight sinus and posterior part of the superior sagittal sinus. The symptomatic fistula was the straight sinus DAVF, Cognard Type II a + b, supplied by meningeal branches of the left superior cerebellar artery, the left ascending pharyngeal artery originating from the left occipital artery, and multiple tiny branches of the left occipital artery with retrograde venous drainage into the straight sinus and vein of Galen. In addition, there was probable thrombosis at the middle part of the straight sinus associated with anatomical variation of the dural venous sinuses at the torcular herophili. The patient underwent successfully endovascular treatments in a two-staged embolization using liquid embolic materials. The patient has gradually recovered and could get back to the activities of daily living at home within 2 months. Follow-up MRI of the brain at 6 months revealed nearly complete resolution of the bilateral thalamic congestion. Cerebral angiography, obtained 1 year after endovascular treatment, confirmed complete obliteration of both DAVFs. We also reviewed the literature of thalamic dementia caused by intracranial DAVFs.
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Spontaneous regression of pineal region arachnoid cyst: A case report and review of literature p. 155
Ahmed Ammar, Abdulrazaq Abdulmohsen Alojan, Alaa Nabil Turkistani, Majd Mohammed Alrayes
DOI:10.4103/ajns.AJNS_289_19  
Arachnoid cyst is a rare benign cerebrospinal fluid-filled cyst that can develop anywhere in the brain along the arachnoid membrane and usually unaccompanied by the anomalous development of the brain structure. These cysts are usually located in the middle cranial fossa. However, they are also denoted in other regions. Arachnoid cysts are mostly asymptomatic and diagnosed incidentally. Spontaneous regression of arachnoid cysts in different anatomical regions of the brain has been reported in the literature. However, to the best of our knowledge, this is the first case reporting an unusual spontaneous regression of arachnoid cyst in the pineal region in a 3-year-old child presented to our hospital with hydrocephalus without alarming signs and was treated conservatively as the patient was stable, and the cyst showed spontaneous regression. A comprehensive review of the literature regarding spontaneous regression of arachnoid cysts has been collected and discussed in this article.
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Adult-onset seizure disorder secondary to schizencephaly p. 159
Abiodun Idowu Okunlola, Paul Olowoyo, Cecilia Kehinde Okunlola, Olakunle Fatai Babalola
DOI:10.4103/ajns.AJNS_293_19  
Schizencephaly is a very rare neurological disorder usually discovered during radiological evaluation of children and young adults with seizure disorders or neurodevelopmental anomalies. We present a 66-year-old patient with right-sided hemiatrophy and paresis presenting with an adult-onset seizure disorder. Her seizure was satisfactorily controlled with a single-therapy antiseizure drug. Congenital brain lesions should be part of the differential diagnoses in patients with epilepsy who have body asymmetry dated back to childhood.
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Primary diffuse large B-cell non-hodgkin's lymphoma of the thoracic spine presented initially as an epigastric pain Highly accessed article p. 162
Fakhr Fakhouri, Nihad Shoumal, Batoul Obeid, Ayman Alkhoder
DOI:10.4103/ajns.AJNS_300_19  
Non-Hodgkin's lymphoma (NHL) compromises the vast majority of lymphomas and predominantly takes on the form of B-cell lymphomas. More specifically, 30% of all newly diagnosed cases of NHL in the United States (US) are of diffuse large B-cell lymphoma (DLBCL) type, making it the most prevalent form of NHL in the US. Arising from either nodal or extra-nodal lymphatic tissue origin, DLBCL is an aggressive tumor which is fatal if left untreated. Primary central nervous system lymphoma is rare; however, when diagnosed, it presents as a DLBCL in 90% of patients. Herein, we present an elderly male complaining initially of acute epigastric pain but soon afterward developed acute spinal cord compressive symptoms; subsequently, it was found to be caused by a primary DLBCL diagnosed in the thoracic spinal cord. This case report presents a rare condition with unexpected initial presentation, and we attempt to illustrate the importance of early detection and treatment of DLBCL in attaining more favorable prognostic and survival rates among patients. Written consent was obtained from the patient after reading a written summary of the case report. This consent was checked and approved from the Scientific Board of the University of Aleppo.
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Surgical management of extraocular muscle cysticercosis causing optic foramen syndrome p. 165
Rajnish Kumar Patidar, Suryanarayanan Bhaskar, Jaskaran Singh Gosal, Mayank Garg, Deepak Kumar Jha, Poonam Elhence
DOI:10.4103/ajns.AJNS_280_19  
Extraocular muscle cysticercosis usually presents with proptosis and restriction of eyeball movements. However, it can cause vision loss by compression of the optic nerve at the optic foramen in infrequent circumstances. We report a rare case with an unusual manifestation of ptosis, proptosis, lateral rectus palsy, and acute vision loss in the right eye. Magnetic resonance imaging was suggestive of cysticercal cyst. Emergency optic nerve decompression with cyst excision was done. Treatment of choice for extraocular muscle cysticercosis presenting with restriction of eyeball movements is mainly medical, consisting of albendazole and steroids. However, as this lesion rarely causes vision loss, indications of surgical decompression of optic nerve are not well defined. We recommend that early surgical management should be done along with medical treatment in cases of vision loss caused by extraocular muscle cysticercosis.
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A case of adult orbital intraconal lymphangioma p. 168
Binoy Damodar Thavara, Bijukrishnan Rajagopalawarrier, Sunitha Balakrishnan, Geo Senil Kidangan
DOI:10.4103/ajns.AJNS_282_19  
Orbital lymphangioma is an intra-orbital, nonencapsulated, congenital vascular tumor with a propensity for recurrent hemorrhage. It is a common vascular tumor in children below 10 years of age. Adult orbital intraconal lymphangiomas are very rare. The authors present a case of 68-year-old male patient presented with left eye symptoms of decreased vision, proptosis, restricted eye movement, and diplopia. The symptoms started following a trauma to the left eye 6 months back. Contrast magnetic resonance imaging scan showed a contrast enhancing well-defined 2.2 cm × 1.8 cm × 1.8 cm fairly rounded, slightly lobulated intraconal tumor in the retrobulbar region inferior to optic nerve. Patient underwent the left fronto-temporo-orbito-zygomatic (FTOZ) craniotomy. The tumor was moderately vascular, firm in consistency with lobulated surface. Few foci of hemorrhages were seen. Near total excision of the tumor was done. Histopathology and immunohistochemistry confirmed the diagnosis of orbital lymphangioma. Although rare, intraconal orbital lymphangioma should be kept in the differential diagnosis of orbital tumors presenting in adult patients following a trauma. It can radiologically mimic other intraorbital tumors. It is a surgical challenge and FTOZ craniotomy provides direct access to the orbital intraconal compartment.
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Dermal sinus tract associated with type I and type II split cord malformation p. 172
Juan Esteban Munoz Montoya, Marcial Anaya Jara, María Paula Vargas Osorio, Fernando Rueda Franco
DOI:10.4103/ajns.AJNS_287_19  
The dermal sinus tract of the spine is associated with other occult spinal dysraphisms, such as the split cord malformation (diastematomyelia) in a 40% of the cases and embryologically is not clearly defined if the dermal sinus and split cord malformation have origin in gastrulation or late primary neurulation, but the most accepted theory of the dermal sinus tract consists in early incomplete disjunction, which explains the relation with other spinal dysraphisms. Here, we present two cases, with a dermal sinus tract of the spine associated with Type I and Type II split cord malformation.
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Anterior cranial fossa dural arteriovenous fistula with pial arterial supply p. 176
Akinari Yamano, Kazuhiro Nakamura, Daisuke Watanabe, Kuniyuki Onuma, Masayuki Sato, Yuji Matsumaru, Kiyoyuki Yanaka, Eiichi Ishikawa, Akira Matsumura
DOI:10.4103/ajns.AJNS_288_19  
Anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs) are mainly fed by the ethmoidal arteries and sometimes have pial arterial feeders. DAVFs with pial arterial supply in ACF are extremely rare because most of the reported cases of DAVFs with pial arterial supply are located at the transverse sigmoid sinus and tentorium. A 68-year-old male presented with dizziness. Angiography showed cortical venous reflex (CVR) through an ACF DAVF fed by both bilateral ethmoidal arteries and by the right orbitofrontal artery as a pial feeder. The ethmoidal feeders were disconnected by craniotomy. The pial arterial feeder from the anterior cerebral artery was not found during surgery, and disconnection of the draining vein was not performed. CVR showed a significant reduction after the surgery. After 2 years of follow-up, angiography revealed an increased shunt flow from the pial feeder. Endovascular treatment using n-butyl-2-cyanoacrylate was performed, resulting in the complete occlusion of the fistula. DAVFs with pial supply are reported to carry a high risk of perioperative complications because of the restriction of the venous outflow and retrograde thrombosis of the pial artery. Endovascular pial feeder occlusion after surgical dural arterial feeder disconnection might achieve a safe and effective outcome. With close follow-up, the recurrence of increased shunt flow may be an appropriate timing for additional treatment. This rare condition may offer a new insight into the mechanisms of pial feeder development.
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Idiopathic epidural lipomatosis associated with degenerative discopathy: Grand round presentation of unusual lumbar canal stenosis resolved by weight loss p. 180
Mohammad A Alsofyani, Vincent Haignere, Sultan Alsalmi, Olivier Gille, Jean-Marc Vital, Vincent Pointillart, Louis Boissi, Ibrahim Obeid
DOI:10.4103/ajns.AJNS_255_19  
Here, we report a case of idiopathic epidural lipomatosis presented with a clinical picture of lumbar canal stenosis with neurogenic claudication which resolved completely only by weight loss. A 53-year-old obese male with a body mass index of 36 without significant past medical history presented to the outpatient clinic with neurogenic claudication and bilateral sciatic radiculopathy. Initially, magnetic resonance imaging (MRI) showed epidural lipomatosis at the level of L5 vertebral body and L5–S1 intervertebral disc. A conservative treatment was decided with dietary regime program. After 6 months of follow-up, his bilateral sciatic radiculopathy disappeared, and updated MRI showed complete disappearance of epidural lipomatosis. Based on the Grand Round case and relevant literature, we present a case of an unusual epidural lipomatosis with mixed clinical picture of degenerative lumbar disease. This case report set out the importance of Borré classification for differentiating the mixed clinical complaint of degenerative discopathy and epidural lipomatosis.
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Simultaneous presence of juxtafacet cyst and ligamentum flavum hematoma p. 184
Hakan Ak, Sevilay Vural
DOI:10.4103/ajns.AJNS_271_19  
Juxtafacet cysts and ligamentum flavum hematoma have the potential to cause acute root or spinal cord compression despite their low incidences. Their simultaneous presence with acute nerve compression has not been reported. Herein, we present a case who reported with low back and leg pain to the emergency department.
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Spontaneous cerebral spinal fluid rhinorrhea with meningocele secondary to congenital foramen rotundum defect: A case report and review of literature p. 187
Kyle William Scott, Daryoush Tavanaiepour, Kourosh Tavanaiepour, Akaber Halawi, Dinesh Rao, Gazanfar Rahmathulla
DOI:10.4103/ajns.AJNS_228_19  
Spontaneous cerebrospinal fluid (CSF) rhinorrhea is a rare occurrence. We present a case of spontaneous CSF rhinorrhea in a 57-year-old patient secondary to a sphenoid osseous defect involving the foramen rotundum and maxillary nerve with an associated arachnoid cyst and meningocele compressing the maxillary nerve. The location of the defect made correction amenable to an open skull-based approach. To the best of our knowledge, this is the first reported case of a spontaneous meningocele herniating into the sphenoid osseous defect through the medial aspect of the foramen rotundum. Early detection of these defects, open or endoscopic approaches and definitive treatment by closing the defect can result in excellent outcomes.
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Cervicomedullary ependymoma with hemorrhage: A case report and review of literature p. 190
Raja K Kutty, Kazumi Ohmori, Yasuhiro Yamada, Yoko Kato
DOI:10.4103/ajns.AJNS_233_19  
Ependymoma is a rare tumor central nervous system that arises from the ependymal lining of the ventricles or the central canal of the spinal cord. They are of neuroectodermal in origin and constitute about 30%–86% of tumors arising in the spinal cord. The occurrence of these tumors in the cervicomedullary region is very rare. Sudden symptomatic neurologic presentations due to hemorrhage in cervicomedullary ependymoma is very rare and so far have never been reported. Mostly presenting as neurologic deficits involving limbs, these tumors pose a technical challenge in their removal. We present a patient who presented with sudden-onset dysesthesia of the upper and lower limbs. On imaging, he was found to have a cystic medullary tumor extending to the cervical region with hemorrhage. We discuss the epidemiology, surgical challenges, and outcome along with review of literature of these rare tumors located in this precarious location.
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Coexisting moyamoya syndrome and type 1 diabetes mellitus: A case report and review of the literature p. 194
Nagarjun Bolem, Vincent Diong Weng Nga, Ning Chou, Tseng Tsai Yeo, Jeremy Lin, Vijay K Sharma
DOI:10.4103/ajns.AJNS_218_19  
Moyamoya disease (MMD) is an incompletely understood malady that affects many age groups, primarily in a bimodal age distribution. We present a patient with the association of type 1 diabetes mellitus (type 1 DM) and MMD followed by a review of the existing literature. We found five papers that describe this association, in the form of one case report, one case series, and three retrospective reviews. Despite a poor understanding of the underlying pathophysiology, a clear association between autoimmune conditions and MMD appears to exist. Clinicians who manage such patients ought to be vigilant and have a high index of suspicion when young patients with type 1 DM present with new onset of neurological symptoms.
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Custom-made hydroxyapatite cranioplasty: Radiological and histological evidence of bone-biomaterial osteointegration in five patients p. 198
Zanotti Bruno, Nataloni Angelo, Spaggiari Riccardo, Zingaretti Nicola, Pizzolitto Stefano, Parodi Pier Camillo, Nicolosi Federico, Morselli Carlotta
DOI:10.4103/ajns.AJNS_208_19  
Custom-made cranial implants facilitate the surgical reconstruction of destructive pathologies of the skull or extensive demolitive skull surgery. Customized cranioplasty allows for an immediate restoration of the functional integrity of the cranial defect (restitutio ad integrum), with excellent functional and esthetic outcome and a quick, safe, and simple procedure. In this context, bioceramics like hydroxyapatite (HA) claim high biocompatibility and bone-binding capability. The osteoconductive properties of the HA have been reported in animal models and humans. The purpose of this study is to demonstrate with radiological and histological examination and how HA prosthesis may integrate after their implantation showing data related to five patients that needed primary HA cranial reconstruction with secondary removal after few years. The histological examination showed neo-formed lamellar/trabecular bone tissue fragments accompanied by the amorphous reticular tissue (HA prosthesis) revealing diffuse ossification sites in all included cases.
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Cervical, intradural extramedullary solitary fibrous tumor of the spinal cord: A case report and review of the literature p. 204
Gregory Glauser, Nikhil Sharma, Michael Kritikos, Neil Rainer Malhotra, Omar Choudhri
DOI:10.4103/ajns.AJNS_213_19  
Solitary fibrous tumors (SFTs) are rare, spindle cell neoplasms of the mesenchymal origin. Lesions localized to the spine are exceptionally uncommon, only described in the literature in case reports and small case series. While these lesions are typically benign, there are a few reports in which they recur or present as malignancies. The patient presented in the case herein was a 72-year-old male, who presented with a 1-year history of lower extremity weakness, pain, and numbness and was found to have a cervical, intradural extramedullary tumor. In addition to the case report, the authors perform a thorough review of all previously published cases of spinal SFT.
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Trans-nasal trans-sphenoidal endoscopic resection of spindle cell oncocytoma of adenohypophysis: The first case report in a child and a review of literature p. 210
Mohammad Samadian, Seyad Ali Mousavinejad, Shahrokh Khoshsirat, Mahmood Dehghan, Guive Sharifi, Kaveh Ebrahimzadeh, Omidvar Rezaei
DOI:10.4103/ajns.AJNS_166_19  
Spindle cell oncocytoma (SCO) is a rare tumor of adenohypophysis, arising from the sellar region. So far, about 35 cases of SCO in the sellar region have been reported. In this report, we present the first case of pediatric SCO and review the literature concerning the tumor origin, clinical presentations, radiological features, and treatment modalities. An 8-year-old male was referred to our clinic with progressive visual loss in the left eye and headache over the past 6 months. Cranial magnetic resonance imaging revealed a solid adenohypophysis mass with suprasellar extension, as well as compression and displacement of the optic chiasm. The patient underwent endoscopic trans-sphenoidal resection of the tumor. The tumor was diagnosed as SCO based on the histological study. He did not receive radiation therapy. The patient's condition remained stable, with no radiological recurrence in the past follow-up 2 years after the surgery.
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Isolated Infarction of the Splenium: A Rare Presentation of Mild Head Injury p. 214
Saravanan Sadashivam, Arun Kumar Natarajan
DOI:10.4103/ajns.AJNS_167_19  
Posttraumatic cerebral infarction (PTCI) is a devastating complication of traumatic brain injury. It is usually seen in patients with moderate-to-severe head injury with a reported incidence of 1.9%–10.4%. Brain shift associated with the traumatic intracranial space-occupying lesions with or without severe cerebral edema is the most common mechanism underlying the PTCI. Without associated direct vascular injury, isolated PTCI is very rare after mild head injury. Such cases of PTCI following mild head injury have been reported in children in whom they usually affect the gangliocapsular region supplied by the lenticulostriate arteries. Such infarcts in adults are extremely rare. Although the exact pathogenesis is not clear, vasospasm or shearing-associated intimal tear is proposed to be the cause for this infarct. Other common causes of cerebral infarction should be ruled out before making such a diagnosis. Unlike PTCI associated with a severe head injury, cerebral infarction following mild head injury is expected to have a better neurological outcome.
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Dysphagia in a young adult: Rare case of giant cervical osteophyte p. 218
Abhinandan Reddy Mallepally, Vikas Tandon, Harvinder Singh Chhabra
DOI:10.4103/ajns.AJNS_181_19  
Cervical osteophytes may be seen in diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, posttraumatic, postoperative, degenerative causes, cervical spondylosis, and infectious spondylitis. A cervical osteophyte is very rarely considered among the differentials for symptoms of dysphagia. C5–C6 as well as C6–C7 being a site of greater load-bearing and mobility, the propensity to form osteophytes is high, with a small osteophyte leading to local mass effect. A 42-year-old male patient presented with mild dyspnea and significant dysphagia since 8 months, accompanied by dysphonia, weight loss, and intermittent aspiration. Clinical examination including neurological examination was normal. A barium swallow showed that osteophytes were severely protruding and displacing the lower pharynx and the proximal esophagus anterosuperiorly. The patient underwent surgical removal of the osteophyte through Smith–Robinson approach. Complaints of dysphagia were significantly decreased in postoperative period. A thorough evaluation is necessary to rule out other causes of dysphagia. Surgical management of this uncommon condition might be considered after confirmation of the osteophyte to be the offending lesion as it has favorable clinical outcomes.
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Posterior cervical interbody fusion – Single-stage approach of anterior reconstruction and posterior stabilization: A case report and review of literature Highly accessed article p. 222
Sandeep Sonone, Aditya A Dahapute, Shubhanshu Mahendra Bhaladhare, Nandan Amrit Marathe, Sai Gautham Balasubramanian, Prakash Kieron George
DOI:10.4103/ajns.AJNS_189_19  
The success and popularity of the transforaminal approach in the lumbar spine have been made possible by the routine use of pedicle screws in the lumbar spine. Transforaminal approach in the cervical spine can give access to the disc and the vertebral body anteriorly and avoid an additional anterior approach in certain clinical situations. A case of cervical spine trauma was managed by this approach. Technical details and difficulties faced were analyzed in this article. Transforaminal approach in the lower cervical spine, though has a learning curve, seems to be a feasible technique along with the use of cervical pedicle screws. The safety and reproducibility of the approach need to be substantiated with a larger study. Further, this procedure can avoid additional anterior surgery in certain situations in the cervical spine.
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ATRT of lateral ventricle in a child: A rare tumor at a very rare location p. 225
Fayçal Lakhdar, Mohammed Benzagmout, Yasser Arkha, Khalid Chakour, Mohammed El Faiz Chaoui
DOI:10.4103/ajns.AJNS_128_19  
Atypical teratoid/rhabdoid tumors (AT/RTs) of infancy are highly malignant central nervous system neoplasms that are most commonly seen during the first 2 years of life with limited therapeutic options. To date, only two cases have been described in the lateral ventricle. A 4-year-old boy presented with a 4-month history of increased intracranial pressure. Cerebral magnetic resonance imaging (MRI) revealed a huge intraventricular tumor, occupying the entire temporal horn and the body of the left lateral ventricle. The boy was operated through a left temporal transventricular approach with gross total removal of the lesion. The histopathological diagnosis was an AT/RT. The infant underwent adjuvant chemotherapy and radiation therapy. The 1-year MRI of control showed a local recurrence of the tumor. Then after, Gamma Knife radiosurgery was performed because of the small volume and the deep location of the lesion. At the 3-month follow-up, the MRI showed a significant growth of the tumor volume, and the child was given additional adjuvant chemotherapy. Unfortunately, he died 9 months later. AT/RT of the lateral ventricle is a very rare tumor in children, associated with a poor prognosis in spite of multimodal treatment. Gamma knife surgery (GKS) was rarely reported as a treatment modality of AT/RT. The aim of this work is to discuss about the rarity of this tumor and the best treatment strategy to improve prognosis.
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Heel suturing on the donor vessel prior to arteriotomy for end-to-side cerebrovascular anastomoses p. 230
Somkiat Wongsuriyanan, Kitiporn Sriamornrattanakul
DOI:10.4103/ajns.AJNS_241_19  
Microvascular anastomosis is a common procedure in cerebrovascular surgery. End-to-side anastomoses were the most common procedure for extracranial-to-intracranial bypass. Many techniques were used to reduce clamping time of the recipient vessel. The authors innovated heel suturing on the donor vessel prior to arteriotomy (HSDA) technique from the previously described double sutures on the toe and heel of the donor vessel before arteriotomy technique for end-to-side anastomosis. Forty-three end-to-side anastomoses using the HSDA technique were collected from 32 patients.
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Dystopic Os odontoideum causing cervical myelopathy: A rare case report and review of literature p. 236
Aditya Raj, Sudhir Kumar Srivastava, Nandan Marathe, Sunil Bhosale, Shaligram Purohit
DOI:10.4103/ajns.AJNS_35_19  
Os odontoideum (OO) was first described by Giacomini in 1886 as separation of the odontoid process from the body of the axis. Instability can consequently occurs at this level due to the failure of the transverse atlantal ligament (TAL) and this atlantoaxial instability can be a cause of progressive neurological deficits. It is considered a rare anomaly of the odontoid process. It is a disease with controversial etiology, debatable incidence, and only a partly known natural history owing to the paucity of the literature on this topic. There are insufficient demographic data about the occurrence of the disease, and most of the management is dictated by the isolated case reports and few studies which have been carried out at handful of institutes. OO is classified into two types by Fielding et al. based on the anatomic location: orthotopic and dystopic. Orthotopic OO consists of an ossicle that moves with the anterior arch of the atlas, whereas the dystopic type presents as an ossicle near the basion or one that is fused with the clivus. In one magnetic resonance imaging (MRI) study of odontoid morphology, a 0.7% (1 case of 133 patients) incidence was reported. The spectrum of the clinical presentation varies from completely asymptomatic individuals to patients presenting with features of cervical myelopathy. Here, we present a case of 35-year-old-male with dystopic OO who presented to us with features of gradually progressing cervical myelopathy without any obvious history of neck trauma. On investigations, he was found to have atlantoaxial instability with wide atlanto-dens interval. He was treated with the posterior C1-C2 stabilization and reduction of atlantoaxial instability.
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TECHNICAL NOTE Top

Initial clinical experience of using a newly designed preshaped microguidewire in acute endovascular thrombectomy p. 241
Tomotaka Ohshima, Reo Kawaguchi, Ryuya Maejima, Naoto Yukiue, Naoki Matsuo, Shigeru Miyachi
DOI:10.4103/ajns.AJNS_365_19  
Mechanical thrombectomy has been widely used for the treatment of acute ischemic stroke. During this procedure, operators must navigate the microcatheter with a microguidewire (MGW) into vessels that cannot be visualized on fluoroscopy as rapidly as possible. In this study, we developed a modified pigtail-shaped MGW (MPMGW) for security and controllability. Moreover, the efficacy of the MPMGW for the treatment of acute ischemic stroke was assessed. The MPMGW was designed using 0.014 MGW. Because we created four MPMGWs during a clinical evaluation before the launch in the market, these wires were used in four consecutive patients with acute ischemic stroke in the single institution. The occluded arteries were the basilar artery (n = 1), middle cerebral arteries (M1 and M2, n = 2), and internal carotid artery (n = 1). All four procedures were conducted without any complications. The procedures included navigating the MGW and passing it through the clot. Complete recanalization was achieved in all cases. The average time between femoral artery puncture and recanalization was 15 min. The use of the preshaped MPMGW in acute thrombectomy was effective in terms of both security of procedure and reduction in recanalization time.
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LETTERS TO EDITOR Top

A rare case of Achromobacter species subdural empyema and brain abscess in an adult patient with hematologic malignancy p. 245
Aristedis Rovlias
DOI:10.4103/ajns.AJNS_373_19  
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Infraoptic course of anterior cerebral artery coexistence with double fenestration of proximal A2 segment of anterior cerebral artery with associated dysplastic anterior communicating artery aneurysm treated with stent-assisted coiling p. 247
Anshu Mahajan, Vinit Banga, Apratim Chatterjee, Gaurav Goel
DOI:10.4103/ajns.AJNS_193_19  
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