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July-September 2019
Volume 14 | Issue 3
Page Nos. 619-1055

Online since Friday, August 2, 2019

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EDITORIAL  

Key hole craniotomy: When, where, and how to apply? p. 619
A Amirjamshidi
DOI:10.4103/ajns.AJNS_99_19  
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REVIEW ARTICLES Top

Potential neuroendoscopic complications: An anesthesiologist's perspective p. 621
Rudrashish Haldar, Sukhminder Jit Singh Bajwa
DOI:10.4103/ajns.AJNS_37_17  
Endoscopic techniques are being used extensively used in the current times for the diagnosis and treatment of numerous intracranial pathologies. Although the morbidity associated with these procedures is lower as compared to other conventional surgical modalities, neuroendoscopic techniques have its own fair share of distinct complications such as bleeding, cerebrospinal fluid leakage, and subdural hematoma. However, certain specific complication fall within the purview of the attending anesthesiologist who should remain vigilant, anticipating these problems to occur and should be well equipped to deal with such contingencies. This review attempts to sensitize the anesthesiologists regarding the well-known as well as rare complications of intracranial neuroendoscopic procedures and to familiarize them with their diverse presentations, preventive strategies, and management protocols.
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The role of transcranial doppler in traumatic brain injury: A systemic review and meta-analysis p. 626
Nida Fatima, Ashfaq Shuaib, Talat Saeed Chughtai, Ali Ayyad, Maher Saqqur
DOI:10.4103/ajns.AJNS_42_19  
To evaluate whether transcranial Doppler (TCD) monitoring plays a role as a prognostic indicator, by being both a diagnostic as well as a monitoring tool for increased intracranial pressure and cerebral vasospasm (VSP), in traumatic brain injury (TBI). Electronic databases and gray literature (unpublished articles) were searched under different MeSH terms from 1990 to the present. Randomized control trials, case–control studies, and prospective cohort studies on TCD in TBI (>18 years old). Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS) and Extended GCOS and mortality. Data were extracted to Review Manager Software. Twenty-five articles that met the inclusion criteria were retrieved and analyzed. Ultimately, five studies were included in our meta-analysis, which revealed that patients with TBI with abnormal TCD (mean flow velocity [MFV] >120 cm/sec or MFV <35 cm/sec and Pulsatility Index >1.2) have a >3-fold higher likelihood of having poor clinical outcome in comparison to patients with TBI and normal TCD monitoring (odds ratio [OR]: 3.87; 95% confidence interval [CI]: 2.97–5.04; P < 0.00001). Subgroup analysis revealed that abnormal TCD has a 9-fold higher likelihood of mortality (OR: 9.96; 95% CI: 4.41–22.47; P < 0.00001). Further, subgroup analysis based on TCD findings revealed that the presence of hypoperfusion on TCD (middle cerebral artery [MCA] <35 cm/s) is associated with a three-fold higher likelihood of having poor functional outcome (OR: 3.72; 95% CI: 1.97–7.0; P < 0.0001). The presence of VSP (MCA >120 cm/s) is associated with three-fold higher likelihood of poor functional outcome (OR: 3.64; 95% CI: 1.55–8.52; P = 0.003). TCD is an evolving diagnostic tool that might play a role in determining the prognosis of patients with TBI. Further prospective study is needed to prove the role of TCD in TBI.
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Home-based rehabilitation programs: Promising field to maximize function of patients with traumatic spinal cord injury Highly accessed article p. 634
Mojtaba Rezaei, Amirsina Sharifi, Alexander Richard Vaccaro, Vafa Rahimi-Movaghar
DOI:10.4103/ajns.AJNS_86_17  
Background: Traumatic spinal cord injury (TSCI) has profound effects on the patient's health condition and function. However current treatment strategies fail in terms of cure. Thus, rehabilitative management has become the main gadget to promote patients' residual function. The most challenging aspect of rehabilitation is high costs of inpatient rehabilitation programs and poor continuity of care while patients are transferred to home. In this regard, numerous home based rehabilitation programs have been introduced. Objectives: This review is an attempt to better introduce and classify different aspects of home care programs for patients with TSCI all around the world. Methods: A literature search was conducted in the PubMed, Medline, and Google Scholar database. Studies that addressed rehabilitative programs for patients with TSCI in their home or home-like facilities were reviewed. Reference lists from retrieved articles were also reviewed. Results: Home based rehabilitation can be categorized in five different but naturally relevant fields: home aids/modification, home nursing and family help, social support, home based primary care (multidisciplinary physician groups), and novel models/methods (e.g. “transitional rehabilitation” or telemedicine). Conclusion: Since most investigators in TSCI home based rehabilitation have only introduced their findings, there are no comparative studies available. Thus future studies should be dedicated to clinical trials evaluating clinical efficacy of different strategies. A comprehensive integrated strategy with consideration to financial and other limitations should be applied to each specific area.
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Delayed ischemic neurologic deficit after aneurysmal subarachnoid hemorrhage p. 641
Vitor Nagai Yamaki, Daniel Dutra Cavalcanti, Eberval Gadelha Figueiredo
DOI:10.4103/ajns.AJNS_15_19  
Delayed ischemic neurologic deficit (DIND) is the main preventable cause of poor outcomes in aneurysmal subarachnoid hemorrhage (SAH) patients. Of 50% of survivors from a SAH, approximately 30% of patients will present clinical vasospasm (VS). The cornerstone of the DIND management comprises prevention and early identification. Several diagnostic methods have been proposed differing in efficacy, invasiveness, and costs. Serial neurological examination is the most reliable method to detect a new neurological deficit. On the other hand, comatose patients require advanced monitoring methods which identify changes in the microcirculatory environment, brain autoregulation, and spreading depolarization. Multimodality monitoring with continuous electroencephalography, microdialysis, and intracranial pressure monitoring represents altogether the current state-of-art technology for the intensive care of SAH patients. Moreover, advances in genetic biomarkers to predict clinical VS have shown consistent accuracy which may in the near future allow the early prediction of DIND through a simple blood test. Several clinical trials have tested drugs with theoretical effects on DIND prevention or treatment. Nevertheless, nimodipine remains the Holy Grail in the prevention of clinical VS. Among rescue therapies, the endovascular treatment through intra-arterial vasodilator (verapamil or nicardipine) infusion is the most employed method for DIND reversal; however, there is no good quality evidence comparing results of intra-arterial infusion of vasodilators versus balloon angioplasty. Although we have addressed the most refined technology in the management of SAH and DIND, the clinical experience and strict follow-up in neurointensive care will be determinant for favorable long-term outcomes.
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Current updates on idiopathic normal pressure hydrocephalus p. 648
Boon Seng Liew, Kiyoshi Takagi, Yoko Kato, Shyam Duvuru, Sengottuvel Thanapal, Balamurugan Mangaleswaran
DOI:10.4103/ajns.AJNS_14_19  
Idiopathic normal pressure hydrocephalus (iNPH) is one of the neurodegenerative diseases which can be treated surgically with favorable outcome. The gait disturbance, cognitive, and urinary symptoms are known as the clinical triad of iNPH. In this review, we have addressed the comorbidities, differential diagnoses, clinical presentations, and pathology of iNPH. We have also summarized the imaging studies and clinical procedures used for the diagnosis of iNPH. The treatment modality, outcomes, and prognosis were also discussed.
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Current concepts in intradiscal percutaneous minimally invasive procedures for chronic low back pain Highly accessed article p. 657
Ioannis Gelalis, Ioannis Gkiatas, Antonios Spiliotis, Dimitrios Papadopoulos, Emilios Pakos, Marios Vekris, Anastasios Korompilias
DOI:10.4103/ajns.AJNS_119_17  
Study Design: A systemic review of thermal annular procedures (TAPs) and percutaneous disk decompression procedures (PDDPs) for the treatment of discogenic chronic low back pain (CLBP) was conducted. Objective: The objective of this review is to evaluate and to compare the effectiveness of TAPs and PDDPs in treating discogenic CLBP and to assess the frequency of complications associated with those procedures. Materials and Methods: English-language journal articles were identified through computerized searches of the PubMed database and bibliographies of identified articles and review papers. Articles were selected for inclusion if percutaneous minimally invasive procedures were the treatment options for patients with CLBP and if follow-up outcome data included evaluations of back pain severity, functional improvement, and/or incidence of complications. For this review, 27 studies were included. Results: Intradiscal electrothermal therapy (IDET) procedure in properly selected patients may eliminate or delay the need for surgical intervention for an extended period, whereas few adverse effects have been reported. In contrast to IDET, there is far less literature on the effectiveness of radiofrequency annuloplasty and intradiscal biacuplasty procedures. Nucleoplasty is a potentially effective treatment option for patients with contained disc herniation, while the procedure is well tolerated. Increased success rates have been found for percutaneous laser disc decompression and automated percutaneous lumbar discectomy in strictly selected patients. Conclusions: These procedures can be effective and may obviate the need for surgery completely. Further prospective randomized sham-controlled trials with higher quality of evidence are necessary to confirm the efficacy of these procedures.
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Superficial temporal artery: Middle cerebral artery bypass, our series of 20 cases, surgical technique and indications with illustrative cases p. 670
Abderrahmane Cheikh, Yamada Yasuhiro, Sudhakar Kasinathan, Tsukasa Kawase, Teranishi Takao, Yoko Kato
DOI:10.4103/ajns.AJNS_220_18  
The first extracranial-intracranial (EC-IC) bypass surgery was performed by professor Yasargil in 1967 since then this procedure has been widely used in vascular neurosurgery and sometimes, in tumors excision when a vascular sacrifice is necessary. In this article, we will illustrate the surgical technique of the superficial temporal artery-middle cerebral artery (STA-MCA) bypass with two cases; a 59-year-old male and 64-year-old female who presented with an occlusion of the MCA. The male presented also with a posterior communicating artery-IC aneurysm which was clipped in the same sitting. We also studied in this paper a series of 20 patients operated in Banbuntane Hotokukai Hospital, Fujita Health University, for which a low-flow STA-MCA anastomosis was done for steno-occlusive disease or moyamoya disease. In Banbuntane Hotokukai Hospital, Fujita Health University, 20 patients were operated since 2015, 12 patients were male. Five patients presented with moyamoya disease, while 15 patients presented with vascular steno-occlusive disease. The steno-occlusion was found in internal carotid artery in nine patients. The patients were divided into two categories (steno-occlusive disease and moyamoya). STA-MCA bypass is now one of the basic techniques to master in vascular neurosurgery. It requires to perform the anastomosis correctly within the permissible time. The goal is to have a long-term patency for the anastomosed vessel.
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Tumors of the orbit: Case report and review of surgical corridors and current options p. 678
Satish Kannan, Mitsuhiro Hasegawa, Yasuhiro Yamada, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_51_19  
Tumors that involve the orbit can be classified into two major groups: primary tumors of the orbit and tumors that extend into the orbit from other sites. The most frequent primary orbital lesions in adults include cavernous hemangiomas, lymphoid tumors, and meningiomas. The most common tumors that extend into the orbit are meningiomas, followed by sinonasal carcinomas. In this article, we report a case of intraconal orbital lesion operated at our center and a review of the surgical approaches to the orbit.
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Review of avoidance of complications in cerebral aneurysm surgery: The Fujita experience p. 686
Ahmed Ansari, Sai Kalyan, Treepob Sae-Ngow, Yasuhiro Yamada, Riki Tanaka, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_131_17  
Avoidance of complications during cerebral aneurysm surgery marks the future outcome in the patient. Various modalities such as adequate opening of the Sylvian fissure, motor-evoked potential, endoscope-assisted microsurgery, indocyanine green dye, and dual image video angiography are available to reduce these complications during surgery, either by prevention of injury to the small perforators or the parent artery. We present our experience at the Fujita Health University Banbuntane Hospital, Japan, of the cerebral aneurysm surgery along with the use of these modalities in our patients from September 2014 to December 2016 along with a brief review of the various techniques for avoidance of complications.
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ORIGINAL RESEARCH ARTICLE Top

Functional outcomes of 300 carpal tunnel release: 1.5 cm longitudinal mini-incision Highly accessed article p. 693
Keykhosro Mardanpour, Mahtab Rahbar, Sourena Mardanpour
DOI:10.4103/ajns.AJNS_31_17  
Objective: There is an opportunity for median nerve decompression by open surgery in carpal tunnel syndrome which is the most common surgical procedure in neurosurgical practice. The aim of this study is to evaluate the long-term outcomes of carpal tunnel release with 1.5 cm longitudinal mini-incision technique with regarding the effectiveness and safety. Methods: For this prospective study, 300 hands for 188 patients with advanced carpal tunnel syndrome who had indication for neurolysis underwent carpal tunnel release through a 1.5 cm longitudinal mini-incision between March 2011 and 2015. There were 132 (70%) females and 56 (30%) males with a mean age of 40 ± 29.5 years (ranging from 24 to 73) and female to male: About 2.56.178 operations were performed for the right hand and 122 for the left hand. Preoperatively, all patients were evaluated with clinical examination and nerve conduction studies. The clinical effects of the patients assessed with the Global Symptom Score (GSS) and Visual Analog Patient Satisfaction Scale. Results: The mean follow-up period was 18.6 ± 9.3 months (12–30 months). Postoperatively, 2% (six hands) complained of residual mild pain with tenderness of scar and only 1% (three hands) complained of median nerve damage (neuropraxy) with tingling and numbness but was temporary which improved after 1 week. Five patients (seven hands) loosed strength of their wrists, but muscle force of abductor pollicis brevis reinforced after 1 month. There is no evidence of local infection, stiffness, loss of some wrist strength, or recurrence of the disorder. Postoperative GSS scoring obviously improved than preoperative (P < 0.002). There is no patient who underwent reoperation. The mean time recovery appeared almost 2 weeks. Conclusion: 1.5 cm longitudinal mini-incision method in carpal tunnel syndrome decompression showed satisfactory pain relief, wound healing, and nontender scar with good functional outcomes. The technique was performed safely without major complication.
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ORIGINAL ARTICLES Top

Initial experience with diffusion-weighted imaging to predict the tumor consistency and surgical success in solid growth hormone producing pituitary macroadenomas p. 698
Maysam Alimohamadi, Reza Sanjari, Mohamad Shirani, Fariba Alikhani, Abbas Amirjamshidi
DOI:10.4103/ajns.AJNS_56_16  
Background: Tumor consistency is an important factor impeding transsphenoidal resection of some pituitary macroadenomas. Preoperative prediction of the tumor consistency may help neurosurgeons in preparing the patients for other therapeutic options after a subtotally resected growth hormone (GH)-producing macroadenoma. We present the preliminary results of our study about the application of the preoperative diffusion-weighted (DW) magnetic resonance imaging (MRI) to predict the consistency and resection rate of GH-producing pituitary macroadenomas. Materials and Methods: Sixteen primary patients with solid GH-producing pituitary macroadenomas were enrolled. Hormonal assays as well as standard and DW-MRI were obtained before surgery. All the patients were operated via an endoscopic transsphenoidal approach. The intraoperative tumor consistencies (suctionable versus nonsuctionable) were documented. The samples were stained for measurement of the collagen content (low, moderate, and high). Postoperative hormonal study and MRI were performed after 8 weeks to evaluate the resection ratio and the hormonal remission. Results: On DW images, the tumor diffusion was enhanced (free) in four, moderate in ten, and restricted in two patients. The tumor was suctionable in 14 cases; gross total resection and hormonal remission were achieved in 12/14 of these. All the 14 suctionable tumors had moderate to enhanced diffusion on DW imaging (DWI). The two patients with a nonsuctionable fibrous tumor had a restricted diffusion in DWI. These were the only ones to have high collagen content in the histopathologic study. Conclusion: DWI could help identify the fibrous nonsuctionable GH-producing adenomas from the others.
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Morphometric evaluation of craniocervical junction by magnetic resonance imaging method Highly accessed article p. 702
Mukadder Sunar, Samet Kapakin
DOI:10.4103/ajns.AJNS_293_17  
Purpose: Morphometric evaluation of the craniocervical region using magnetic resonance imaging method in humans and determination of the reference values that could be used in various clinics were the aims of this study. Materials and Methods: In our study, 306 (95 males and 211 females) individuals who met the necessary criteria for anatomical structure were included and taken measurements afterward. Sagittal T1- and T2-weighted images were determined as a section thickness of 3 mm, an interval of 10 mm, a matrix of 352 × 224, a field of view of 170–240 mm, and a number of excitations of 4. Measurements of anatomical structures in the craniocervical region were taken via these images. Results: Statistically significant differences were found among the findings of male and female individuals such as height of dens axis, anteroposterior distance of the dens axis (APDDA), anterosuperior distance of the dens axis (ASDDA), sagittal diameter of the foramen magnum (SDFM), total cervical vertebra length (TCVL), distance of spatium retropharyngeum, Pavlov ratio, and the ratio between sagittal diameter of canalis vertebralis (SDCV) to the APDDA. Dens axis height showed a positive correlation with ASDDA and TCVL, and a negative correlation was found between the APDDA and the spatium retropharyngeum. Conclusion: Age- and sex-related changes in the measurements of anatomical regions reveal that an increase and a decrease in the various parameters reveal that these are the normal changes presumably determined by the functional and physical demands varying on the columna vertebralis.
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Comparison between 1 g and 2 g of intrawound vancomycin powder application for prophylaxis in posterior instrumented thoracic or lumbosacral spine surgery: A preliminary report p. 710
Sombat Kunakornsawat, Sirichai Sirikajohnirun, Chaiwat Piyaskulkaew, Pritsanai Pruttikul, Piyabuth Kittithamvongs, Warongporn Pongpinyopap, Tinnakorn Pluemvitayaporn
DOI:10.4103/ajns.AJNS_294_17  
Background: Surgical site infection (SSI) after instrumented spinal surgery is one of the most serious complications in spite of the routine use of prophylactic intravenous (IV) antibiotics. Many studies have suggested that intrawound vancomycin powder, applied during the intraoperative period, may decrease the incidence of SSI after surgery. However, the appropriate dose of vancomycin has not yet been reported. Purpose: The purpose of the study is to compare between the use of 1 g and 2 g intrawound vancomycin powder and to find out which of these two groups can reduce the rate of deep wound infection in posterior instrumented thoracic or lumbosacral spine surgery. Materials and Methods: The preliminary study was conducted from July 2013 to July 2015 at Lerdsin Hospital. A total of 400 patients were enrolled in the study, and their individual demographics were recorded. All patients underwent posterior instrumented thoracic or lumbosacral spine surgery. Of these, 131 patients received IV cefazolin and 2 g of vancomycin powder intrawound application, 134 patients received 1 g of intrawound vancomycin powder in addition to IV cefazolin, and 135 patients were given only IV cefazolin and were assigned as the control group. Results: One hundred and thirty-one patients were treated with posterior instrumented thoracic or lumbosacral fusions using IV cefazolin and adjuvant 2 g of intrawound vancomycin powder. Five patients in this group developed deep infections (3.8%). One hundred and thirty-four patients were treated with posterior instrumented thoracic or lumbosacral fusions using IV cefazolin and adjuvant 1 g of intrawound vancomycin powder. Of these, four patients developed deep infections (2.98%). One hundred and thirty-five patients in the control group were treated with posterior instrumented thoracic or lumbosacral using only IV cefazolin as prophylaxis. Of these, four patients developed deep infections (2.96%). Coagulase-negative staphylococcus was the most common isolated organism. There were no adverse clinical outcomes or wound complications due to local application of vancomycin powder. Conclusion: The preliminary result could not state the relation of intrawound vancomycin powder to the deep infection; further study with adequate sample size is required.
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Intraoperative micro-measurement in neurosurgical microsurgery: A technical note p. 715
Masaki Matsumoto, Tohru Mizutani, Tatsuya Sugiyama
DOI:10.4103/ajns.AJNS_315_17  
Objective: In neurosurgical microsurgery, understanding the accurate size of microstructures is essential to perform operation safely and less invasively. We here describe a simple method of measuring the size of microvessels using a digital image as a microscale. Materials and Methods: The digital image was made as a microscale on the computer. We measured the size of intracranial microstructures using the microscale. Results: We accurately measured the size of the vertebral artery perforator of 1 mm or less using the adjusted microscale on the computer. Conclusions: The development of a microscale is easy and renders the measurement of microstructures, sized 1 mm or less, feasible, and accurate.
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Management strategies of cranial encephaloceles: A neurosurgical challenge Highly accessed article p. 718
Vernon Velho, Harish Naik, Pravin Survashe, Sachin Guthe, Anuj Bhide, Laxmikant Bhople, Amrita Guha
DOI:10.4103/ajns.AJNS_139_17  
Background: Encephalocele is defined as herniation of cranial contents beyond the normal confines of the skull through a defect in the calvarium either along the midline or at the base of skull. These anomalies should be repaired in the first few months of life to prevent neurological deficits and facial disfigurement. The aim of the surgery is water tight dural closure at the level of internal defect, closure of skull defect, and reconstruction of external bony deformity. Materials and Methods: Fifty-four cases of encephalocoeles were studied in our hospital over a 6-year period from 2010 to 2016. Computed tomography (CT) and magnetic resonance imaging (MRI) brain were performed to delineate the bony defect and associated anomalies. Reconstruction of the bony defect was done using autologous calvarial bone graft, Osteopore polycaprolactone (PCL) bone scaffold filler and titanium mesh. Results: In our study, 54 patients (34 boys and 20 girls) whose age varied between 2 months and 14 years were evaluated. Frontoethmoidal (44.5%) and occipital encephaloceles (25.9%) were the most frequently seen varieties. Repair of the dural defect either primarily or using pericranium was done in all cases. Closure of the bony defect was done using autologous calvarial bone graft in 12 (22.22%) patients. Titanium mesh was used in eight and Osteopore PCL bone scaffold filler in four children. Cranioplasty was not done in remaining thirty children because of the small bone defect. Overall, 80% had no postoperative problem and were discharged between 7 and 10 days of surgery. Cerebrospinal fluid leak was the most frequent postoperative complication, noted in five patients. Re-exploration with repair was done in one and remaining four were managed conservatively. Overall, cosmetic results were acceptably good, with parents judging the cosmetic outcome as good to excellent in 70%, satisfactory in 18%, and poor in 3% at the last follow-up. Conclusion: Our study demonstrated that encephaloceles are associated with complex deformities and pose a technical challenge to the neurosurgeon. A multidisciplinary approach is necessary to manage these cases. MRI brain and three dimensional CT aids in evaluating the deformity better and surgical correction should be performed as soon as possible to prevent a further neurological deficit. Repair of dural defect and reconstruction of the skull defect results in a good long-term outcome. We present our experience on 54 cases of cranial encephaloceles managed surgically over a period of only 6 years which is one of the largest series reported from Asia.
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Recurrence rate of chronic subdural hematoma after evacuating it by two large burr holes, irrigation, and subgaleal low-pressure suction drainage p. 725
Mohamed Abdel Rahman Abdelfatah
DOI:10.4103/ajns.AJNS_321_17  
Background: There are no current standard operative steps for chronic subdural hematoma (CSDH). The aim of this study was to detect the recurrence rate after drainage of a unilateral diffuse CSDH by combining certain operative steps. Materials and Methods: This is a descriptive, retrospective cohort study that included 47 consecutive adult patients who underwent evacuation of a unilateral diffuse CSDH by two large burr holes (≥2 cm in diameter) and irrigation of the subdural space by warm saline, followed by placement of a subgaleal Redivac drain under low-pressure suction in our university hospital from August 2012 to August 2016. There were 29 men and 18 women with a mean age of 69.1 years. Results: All the operations were uneventful. All the patients had adequate drainage of their subdural hematomas, and all patients were discharged alert and oriented. No incidence of recurrence within 12 months after surgery. Conclusion: This study demonstrated that surgical management of a unilateral diffuse CSDH in adult patients by two large burr holes, irrigation, and a subgaleal Redivac low-pressure suction drainage was effective and associated with no recurrence.
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Surgical management of unruptured cerebral aneurysms in the elderly: An institution experience p. 730
Abderrahmane Cheikh, Sudhakar Kasinathan, Yamada Yasuhiro, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_233_18  
Background and Purpose: The elderly population is increasing in the world, especially in developed countries. The gain in life expectancy is remarkable in Japan, consequently incidence of aneurysms increases in this population. The purpose of this study is to evaluate the surgical treatment and outcome of patients aged more than 75 years treated for unruptured intracranial aneurysms. Patients and Methods: We conducted a retrospective study for unruptured cerebral aneurysms operated between September 2014 and August 31, 2018, in Fujita Health University, Banbuntane Hotokukai Hospital, for people aged more than 75 years. A demographic study was done. We also studied aneurysm location, aneurysm size, outcome, duration of stay, and complications. Results: About 61 patients aged more than 75 years were operated in 4 years, comprising 12 males and 45 females. The mean age was 79.32 ± 3.29 years. Mean size of the aneurysm was 6.22 ± 3.28. Aneurysm location (P = 0.0037), associated risk factors (P = 0.006), and association of hypertension and diabetes (P = 0.0362) influence outcome. Length of stay is directly correlated with outcome (P = 0.009). Conclusions: Elder patients with hypertension and diabetes or associated risk factors having a posterior circulation aneurysm have a poor diagnosis.
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Factors predicting outcomes in surgically treated pediatric traumatic brain injury p. 737
Sean Wei Yi Lee, Yang Ming, Swati Jain, Shu Ying Chee, Kejia Teo, Ning Chou, Sein Lwin, Tseng Tsai Yeo, Vincent Diong Weng Nga
DOI:10.4103/ajns.AJNS_2_19  
Introduction: Traumatic brain injury (TBI) is a common presentation to the pediatric emergency department. Understanding factors that predict outcomes will be useful in clinical decision-making and prognostication. The objective of this study was to identify important clinical parameters predictive of outcomes in pediatric TBI patients who underwent surgery. Materials and Methods: This retrospective study included 43 pediatric TBI patients who underwent surgery from January 2011 to January 2017. Clinical parameters, including presenting signs and symptoms, mechanism of injury, intracranial pressure (ICP), need for inotropes, and computed tomography findings were collected. Outcomes were assessed using the Glasgow outcome score (GOS) based on the latest follow-up. Outcomes were divided into favorable (GOS 4–5) and unfavorable (GOS 1–3). Results: Surgery was performed in 43 patients. The mean age was 9.6 ± 4.9. The mean follow-up period was 31 weeks. Thirty (70%) patients had favorable outcome and 13 (30%) had unfavorable outcome. On univariate analysis, mechanism of injury, vomiting, Glasgow coma scale score, pupil size and reactivity, hypotension, inotropic use, need for blood transfusion, and raised ICP (all P < 0.005) were significantly associated with outcomes. On step-wise logistic regression, only raised ICP (odds ratio [OR] = 35.6, P = 0.008) and hypotension (OR = 26.1, P = 0.01) were found to be statistically significant. Conclusion: The present study suggests that the majority of pediatric TBI patients who required neurosurgical intervention have favorable outcomes. Closer attention should be paid to raised ICP and hypotension as they were strong predictors of unfavorable outcomes. These findings also help manage expectations of patients' family and clinicians.
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Combined transpedicular-transarticular approach for ventrally located thoracic intradural meningiomas p. 744
Ahmed Mohammed Balaha, Ebrahim Ahmed Shamhoot
DOI:10.4103/ajns.AJNS_57_19  
Background: The ventrally located intradural meningiomas in the thoracic spine are still considered a challenge for all spine surgeons. Many surgical approaches were developed to excise the lesion without violating the neural structures. They differ in their invasiveness, safety, and efficacy. One of these approaches is the postero-lateral combined transpedicular-transarticular approach (TPA-TAA). Patients and Methods: From January 2016 to December 2018, all patients with ventrally located thoracic meningiomas were operated on using the combined TPA-TAA. We evaluated all the patients preoperatively, immediate postoperative, and 6 months later. Clinical and functional outcomes were assessed using the muscle strength grade and the Nurick grading system. Magnetic resonance imaging was obtained for all patients postoperative and at 6 months later. Results: After 6 months, all patients experienced clinical and functional improvement. The mean muscle strength grade rose from 3.8 preoperatively to 4.8 after 6 months. According to the Nurick grading system, the mean preoperative grade was 4.4 and dropped to 1.8 after 6 months. Minor transient complications such as superficial wound infection and the cerebrospinal fluid leak were observed in 1 patient for each. Gross total tumor excision was achieved in all patients. No cases of tumor recurrence were noted during the follow-up period. Conclusions: This combined TPA-TAA is considered a safe and effective approach in excising ventrally located intradural thoracic meningiomas with minimal postoperative morbidities.
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Results of a preventive rebleeding protocol in patients with ruptured cerebral aneurysm: A retrospective cohort study p. 748
Pichayen Duangthongphon, Bunika Souwong, Waranon Munkong, Amnat Kitkhuandee
DOI:10.4103/ajns.AJNS_32_19  
Objective: In 2015, a protocol to prevent rebleeding was implemented to improve the outcome of patients with ruptured intracranial aneurysm. We performed a single-center retrospective analysis to compare the outcomes of pre/post using protocol. Methodology: Over a 3-year period, 208 patients with ruptured cerebral aneurysm were treated at our institution. The protocol for preventing rebleeding was initiated in 2015. We compared the two cohorts between the group of patients before initiating the protocol (n = 104) and after initiating the protocol (n = 104). We analyzed the protocol for preventing rebleeding which consisted of absolute bed rest, adequate pain control, avoiding stimuli (R), keeping euvolemia (E), preoperative systolic blood pressure <160 mmHg and within 140–180 mmHg after definite treatment (S), a short course (<72 h) of intravenous transaminic acid, and aneurysm treatment as early as possible (T). Outcomes are presented as in-hospital rebleeding, delayed cerebral ischemia (DCI), and proportion of unfavorable outcomes (score of 4–6 on a modified Rankin scale at 6 and 12 months). Results: Postprotocol, there was a reduction in the incidence of in-hospital rebleeding from 6.7% to 2.8% (P = 0.20, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.10–1.63) and in the proportion of patients who presented with good WFNS grades (1–3) with unfavorable clinical outcomes at 12 months from 27.0% to 12.8% (P = 0.03, OR = 0.40, 95% CI = 0.17–0.95). The DCI experienced a significant reduction from 44.2% to 7.7% (P < 0.001, OR = 0.10, 95% CI = 0.04–0.23), and their 180-day mortality rate in good WFNS grades patients decreased from 16.3% to 8.8% (hazard ratio 0.80, 95% CI = 0.28–2.28). Conclusion: Ruptured cerebral aneurysm patients benefit from this protocol due to its ability to reduce the incidence of DCI and reduce unfavorable outcome on good WFNS grade patients.
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Pituitary prolactinoma with amyloid deposits: Surgery or dopamine agonists? Review of previous reports and new recommendations for management p. 754
Santosh Prabhu, Sujata Prabhu
DOI:10.4103/ajns.AJNS_127_19  
Background: Pituitary adenomas, macro and micro, are a common occurrence in most neurosurgical centers. Prolactinomas are the most common pituitary tumors and are often treated nowadays with dopamine agonists such as cabergoline, with good results. Aims and Objectives: To suggest new therapeutic guidelines for treating Prolactinomas with Amyloid deposits on preoperative detection of Amyloid deposition in Pituitary tumors, based on MRI characteristics. Materials and Methods: We report a case of a pituitary prolactinoma with amyloid deposits in a 45-year-old male who underwent a transsphenoidal excision of the adenoma. Although on magnetic resonance imaging scans, no amyloid was reported, at histopathology, spherical amyloid within the pituitary tumor was found in abundance. The patient underwent surgery without any trial of cabergoline due to rapid deterioration of vision. Conclusion: Prolactinomas with amyloid deposits are known not to respond to dopamine agonists (cabergoline) by a reduction in size and may ,in fact increase in volume. Therefore, we recommend that in prolactinomas not responding to medical therapy, deposition of amyloid has to be considered as a cause for failure of medical therapy and surgery and then has to be offered pronto.
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A novel technique for microcatheter additional shaping during intracranial aneurysmal coil embolization: Microcatheter shaping cast p. 759
Tomotaka Ohshima, Reo Kawaguchi, Ryuya Maejima, Naoki Matsuo, Shigeru Miyachi
DOI:10.4103/ajns.AJNS_130_19  
Background: When a shaping mandrel is inserted into the tip of a preshaped microcatheter, the existing curve becomes uncertain because the tip is straightened by the inner mandrel. Therefore, we developed a way to perform microcatheter shaping by means of an external cast, which we named “microcatheter shaping cast.” Techniques: A shaping mandrel attached to a microcatheter was used and coiled 4–5 times around a metallic introducer, which was attached using a microguidewire. Then, a stent-like handmade cast was prepared. After the microcatheter tip was inserted into the cast, it was manually bent according to the aneurysmal shape and size. The tip and cast were heated with a hot air gun. We evaluated the relationship between degrees of bending and heating time to achieve appropriate right-angled shaping memory. Conclusions: The presented microcatheter shaping method should be more useful than conventional internal shaping, especially in cases that require an additional microcatheter shaping or reshaping during aneurysmal coil embolization.
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The use of osirix for surgical planning using cranial measures and region of interest tools: Technical note p. 762
Renan Maximilian Lovato, Joao Luiz Vitorino Araujo, Aline Lariessy Campos Paiva, Francisco Spessatto Pesente, Cumhur Kaan Yaltirik, Mehmet Volkan Harput, José Carlos Esteves Veiga
DOI:10.4103/ajns.AJNS_63_19  
Background: During the surgery for intrinsic brain lesions, it is important to plan the proper site of the craniotomy and to identify the relations with the gyri and superficial veins. This might be a challenge, especially in small subcortical lesions and when there is a distortion of the cortical anatomy. Materials and Methods: Using the free computer software Osirix, we have created a 3-dimensional reconstruction of the head and cerebral showing the gyri and superficial veins. With the aid of some tools, it is possible to create a colored image of the lesion and also to calculate the distance between the areas of interest and some easily identifiable structure, making it easier to plan the site of the craniotomy identify the topography of the lesion. Results: The reconstructions were compared to the intraoperative view. We found this technique to be useful to help identify the gyri and cortical veins and use them to find the lesions. The use of a region of interest to show better the lesion under the cortical surface and in the three-dimensional reconstruction of the head was also helpful. Conclusions: This is a low-cost and easy technique that can be quickly learned and performed before every surgery. It helps the surgeon to plan a safe craniotomy and lesionectomy.
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Supraorbital craniotomy for large anterior skull base meningiomas: A technical note p. 767
Kiran Khanapure, Krishna Chaitanya Joshi, Aniruddha T Jagannatha, Parichay J Perikal, Syed Aezaz Quryshi, Umesh Srikantha, Ravi Gopal Verma, Alankar S Hegde
DOI:10.4103/ajns.AJNS_40_19  
Background: Supraorbital craniotomy (SOC) has brought a paradigm shift in approaching anterior skull base lesions. With better understanding of relevant anatomy, the indications are being stretched from highly selected, small-to-moderate-sized tumors to large and complex anterior skull base lesions. Objective: We share our experience and discuss the nuances of surgery for large anterior skull base meningiomas using the SOC. Methods: This is a single institute study using prospectively collected retrospective data from seven cases of large anterior skull base meningiomas (>3 cm) using the SOC. We reviewed the indications, safety, and procedural complications in these cases. Results: Simpson's Grade 2 excision was achieved in all these seven cases, with faster postoperative recovery. Follow-up clinical outcome and cosmesis were satisfactory. Conclusion: SOC is a safe alternative for the standard skull base approaches in treating large anterior skull base meningiomas. The SOC can be effectively used to treat selected large anterior skull base meningiomas.
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Use of our protocol of multimodality tools to aid in the safe microsurgical clipping of unruptured anterior circulation aneurysms p. 773
Satish Kannan, Yasuhiro Yamada, Kyosuke Miyatani, Takao Teranishi, Arun Reddy Marathi, Krishna Mohan, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_65_19  
Objectives: The aim of this study is to analyze the effectiveness of our protocol of the use of multimodality tools, namely indocyanine green-dual image video angiography, neuroendoscope, neuromonitoring with motor-evoked potential, micro-Doppler in the microsurgical clipping of unruptured anterior circulation aneurysms, operated at our institute from January 2016 to December 2018. Materials and Methods: We performed a retrospective analysis of all cases of unruptured anterior circulation aneurysms, operated at Fujita Health University Banbuntane-Hotokukai Hospital, Japan, from January 2016 to December 2018. We assessed outcome at immediate postoperative, at discharge, and at 3 months follow-up by defining permanent morbidity as drop in Modified Rankin Scale (MRS) by 1 at 3 months follow-up and transient morbidity as temporary deficit that improved at discharge or follow-up. Postoperative events, namely seizures, infection that did not affect/change. Preoperative MRS and discharge timing were excluded. We concluded poor outcome as MRS ≥3 and good outcome as MRS <3 (0–2). All patients had a minimum of 3 months follow-up before outcome conclusion. Results: In 2016, a total of 98 cases were operated with no mortality or permanent morbidity (i.e., change in preoperative MRS), only transient morbidity was seen in (two cases) 2.04%. In 2017, a total of 119 cases were operated with no mortality or morbidity. In 2018, a total of 130 cases were operated with no mortality or permanent morbidity, only transient morbidity 0.7%. Summarizing from January 2016 to December 2018, a total of 347 cases of anterior circulation aneurysms were operated. Mostly, in the female sex (73.3%), the most common was middle cerebral artery aneurysm (39.1%). The mean size was 5.3 mm with no mortality or permanent morbidity with only transient morbidity in 0.9%. No poor outcome (MRS ≥3) was seen in our series. Conclusion: In our center for most unruptured anterior circulation aneurysms, microsurgical clipping is the treatment of choice. We believe our protocol of the intra-operative usage of multimodality tools have aided in the safe microsurgical clipping and have consistently resulted in good operative outcomes. Hence, we recommend and continue to use our Fujita-Bantane Protocol in all cases of micro-surgical clipping of aneurysms to consistently achieve good operative outcomes.
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To determine the surgical outcome of anterior cervical corpectomy and fusion without fixation for ossification of posterior longitudinal ligament Highly accessed article p. 780
Syed Muneeb Younus, Muhammad Imran, Ateeq Ahmed Khan, Saqib Basar, Daniya Sheikh
DOI:10.4103/ajns.AJNS_54_17  
Aims: The purpose of our study is to evaluate the surgical outcome in patients undergoing anterior cervical corpectomy without fixation with plates and screws for the treatment of ossification of posterior longitudinal ligament (OPLL). Subjects and Methods: The type of study was case series and was conducted from January 2015 to December 2015 for 1-year duration at the Department of Neurosurgery at a Tertiary Care hospital in Karachi, Pakistan. A total of n = 20 patients (16 men and 4 women; mean age of 57.45 ± 6.4 years [range: 45–68 years]) were included after thorough clinical history and physical examination. Neurological evaluation was done using the Japanese Orthopedic Association (JOA) scoring system. The pre- and post-operative JOA scores were used to calculate recovery rate (RR) of the patients. Radiographic assessment was done using various modalities such as X-ray, computed tomography scan, and magnetic resonance imaging. Surgical outcome and complications were studied and the data were analyzed using SPSS 21. Results: After the uniform follow-up period of 12 months, mean JOA scores improved from 9.1 ± 1.37 preoperatively to 14.3 ± 1.69 postoperatively and mean RR was 67.01 ± 15.5%. All the patients showed successful osseous fusion while one patient did not. Two patients developed cerebrospinal fluid leakage, one patient developed recurrent laryngeal nerve palsy, and one expired due to iatrogenic neurological deterioration. Conclusion: Anterior cervical corpectomy without fi xation with plates and screws is an effective surgical procedure for the treatment of OPLL (for up to three cervical levels of OPLL). It gives good neurological recovery with fewer postoperative complications.
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Efficacy of computed tomography perfusion – Alberta stroke program early computed tomography score for identifying patients with anterior circulation acute ischemic stroke that would benefit from endovascular treatment p. 785
Dittapong Songsaeng, Thewaporn Khamduang, Thipthara Tarathipayakul, Chulaluck Boonma, Timo Krings
DOI:10.4103/ajns.AJNS_237_18  
Background: The identification of criteria that improves the selection of ischemic stroke patients most suitable for mechanical thrombectomy (MT) will improve clinical outcomes. The aim of this study was to identify the computed tomography (CT) imaging parameter that best predicts patients who will benefit from endovascular treatment among patients with anterior circulation ischemic stroke. Materials and Methods: This retrospective study was conducted in patients with acute middle cerebral artery (MCA) stroke with/without internal carotid artery occlusion who underwent successful MT at Siriraj Hospital from November 2009 to October 2016. Evaluated parameters were compared between those with and without a favorable outcome. Results: Forty-four consecutive patients with acute MCA occlusion were included, and 61.4% had unfavorable clinical outcome. Regarding CT perfusion – Alberta stroke program early CT score (CTP-ASPECTS) at the 50% cut point, patients with favorable outcome had higher Cerebral blood volume-ASPECTS (CBV-ASPECTS) and mean transit time-ASPECTS (MTT-ASPECTS) than those with unfavorable outcome. For CTP-ASPECTS at the 75% cut point, patients with favorable outcome had higher CBV-ASPECTS, cerebral blood flow-ASPECTS, and MTT-ASPECTS than those with unfavorable outcome. Conclusions: CTP-ASPECTS at the 50% and 75% cut points of abnormality could not predict the clinical outcome of anterior ischemic stroke after thrombectomy. Of the ASPECTS evaluated in this study, MTT-ASPECTS at the 75% cut point was the most predictive parameter. Older age was associated with unfavorable outcome after thrombectomy.
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Efficacy of thrombus density on noninvasive computed tomography neuroimaging for predicting thrombus pathology and patient outcome after mechanical thrombectomy in acute ischemic stroke Highly accessed article p. 795
Dittapong Songsaeng, Tharathorn Kaeowirun, Ittichai Sakarunchai, Pornsuk Cheunsuchon, Jaruwan Weankhanan, Anek Suwanbundit, Timo Krings
DOI:10.4103/ajns.AJNS_238_18  
Background and Purpose: The aim of this study was to investigate the efficacy of thrombus density on noninvasive computed tomography (CT) neuroimaging for predicting thrombus pathology and patient outcome after mechanical thrombectomy in acute ischemic stroke. Materials and Methods: This retrospective chart and imaging review included patients that were treated by mechanical thrombectomy at Siriraj Hospital according to the American Heart Association/American Stroke Association guidelines for the early management of patients with acute ischemic stroke from March 2010 to February 2015 study period. Preintervention noncontrast CT (NCCT), CT angiography (CTA), and/or contrast-enhanced CT (CECT) images were interpreted using CT densitometry. Pathology results were classified as white, red, or mixed thrombi. The result of treatment was evaluated by the modified Rankin Scale at 90 days after treatment. Results: From 97 included patients – 97 NCCT images, 48 CTA images, 48 CECT images, and 54 pathologic results of cerebral thrombi were included in the final analysis. Mean clot Hounsfield unit values on NCCT, CTA, and CECT were significantly different between red and white thrombus (P = 0.001 on NCCT, P = 0.03 on CTA, and P = 0.001 on CECT), and between red and mixed thrombus (P = 0.043 on NCCT and P = 0.002 on CTA). However, no significant difference was observed between white thrombus and mixed thrombus (P = 0.09 on NCCT, P = 1.00 on CTA, and P = 0.054 on CECT). There was no significant correlation between type of cerebral thrombus or clot density and the result of treatment. Conclusion: Thrombus density on CT was found to be a significant predictor of thrombus pathology; however, no significant association was observed between thrombus type or clot density and patient outcome after mechanical thrombectomy.
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Reliability of ABC/2 method in measuring of infarct volume in magnetic resonance diffusion-weighted image p. 801
Thiparom Sananmuang, Thanya Dejsiripongsa, Jesada Keandoungchun, Mungkorn Apirakkan
DOI:10.4103/ajns.AJNS_68_19  
Aims: Manual planimetry is the current method defining infarct volume on magnetic resonance (MR) diffusion-weighted image. ABC/2 method is an ellipsoid geometric formula with advantage estimation of intraparenchymal hemorrhage volume. Our study aimed to find the reliability and reproducibility of ABC/2 method compared to manual planimetric segmentation method. Settings and Design: This was a cross-sectional analytical study with retrospective and prospective data collection. Subjects and Methods: A total of 109 patients with acute ischemic stroke and underwent MR images at Ramathibodi Hospital were retrospectively reviewed. Relationship between manual planimetric segmentation and ABC/2 methods (nonadjusted ABC/2 method and adjusted ABC*/2 method) was determined using Wilcoxon signed-rank test, linear regression analysis, and Bland–Altman plot. Subgroup analysis by location, onset, shape, and size of infarct volume was performed. Interobserver reliability was established using intraclass correlation coefficient and Bland–Altman plot. Statistical Analysis Used: Wilcoxon signed-rank test, linear regression analysis, and Bland–Altman plot were used for statistical analysis. Results: Infarct volume measured with nonadjusted ABC/2 method (23.56, 48.81, 4.25, 0.11, 318.94) (mean, standard deviation, median, minimum, maximum) and adjusted ABC*/2 method (13.37, 28.3, 2.08, 0.06, 170.10) was smaller than manual planimetric method (28.50, 58.64, 5.56, 0.27, 335.49) (P < 0.001). Linear regression's slope confirmed underestimation of volume infarct. In round-to-ellipsoid shape and white matter group, the differences found between nonadjusted ABC/2 and manual planimetric methods are not statistically significant. Conclusions: ABC/2 method is a simple, rapid, and reproducible method with an excellent positive correlation of both adjusted and nonadjusted ABC/2 methods to manual planimetric segmentation method but tendency to underestimated infarct volume. High interobserver reliability and good agreement between two observers have been established. The utilization of nonadjusted ABC/2 method should be used with caution due to its tendency to underestimate the infarct volume.
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What it is to be a woman neurosurgeon in India: A survey p. 808
Dhivya Palanisamy, Suchanda Battacharjee
DOI:10.4103/ajns.AJNS_142_19  
Background: Around the world, measures are being undertaken to increase the number of women in the field of neurosurgery, by improving their working conditions and developing a supportive system. This survey was conducted to assess the status of women neurosurgeons in India. Aims and Objectives: To assess the barriers, supportive system and professional/personal satisfaction of Indian women neurosurgeons. Materials and Methods: A survey questionnaire containing 19 questions was designed. The number of women neurosurgeons in India was found to be 73 as of September 2017. An anonymous Google survey was undertaken by sending the survey questionnaire through email to 69 female neurosurgeons in the month of September 2017, and the email ids of 4 neurosurgeons were not available. 55 out of 69 replied to the survey questionnaire (79.7%) in a time period of 4 weeks. Results were collected and analyzed. Results: Our survey showed that 34.54% of Indian women neurosurgeons were being residents and 65.45% being younger than 40 years of age. Majority of them (92.72%) joined neurosurgery with passion and only 30.9% had a medical professional who kindled the interest in neurosurgery. 72.68% were discouraged before joining into neurosurgical residency. 74.4% reported to receive good to excellent support from the parent department. Only 40% had another female colleague in the department and they received good to excellent support from the female colleagues. Though 74.5% received good support from male colleagues the excellent support remained low. 40% reported to face discrimination by gender. 74.5% are married and 96.4% reported to receive good to excellent support from the family members. 80% face difficulty in balancing career and personal life. 70.9% have satisfaction in professional life and 69% lead a satisfactory personal life. 67.3% of female neurosurgeons felt that formation of an exclusive women neurosurgeons' forum would benefit them. Conclusion: In India there is a positive trend in female physicians taking up neurosurgery. The present residency program in our country is supportive to women in majority. However active measures should be taken to encourage female physicians to take up neurosurgery, reduce the existing gender discrimination and improve the supportive system especially during pregnancy and child rearing.
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Surgical outcomes in depressed skull fractures: An institutional experience p. 815
Srikrishnaditya Manne, Siddartha Reddy Musali, Prakash Rao Gollapudi, Pratap Kumar Nandigama, Imran Mohammed, Nagarjuna Butkuri, Asma
DOI:10.4103/ajns.AJNS_111_19  
Aims: The aim is to study the various factors associated with depressed skull fractures (DSFs) and their relationship with outcomes in patients who underwent surgery. Settings and Design: This was a cross-sectional study in a hospital setting. Patients and Methods: One hundred and fifty patients who underwent surgeries over a period of 6 years at our institute for DSFs were followed up and outcomes were analyzed. Patients having other medical- or trauma-related surgical morbidities were excluded. All age groups were studied. Statistical Analysis Used: The statistical analysis was performed using Chi-square test. Results: There was a significant relationship between the mode of injury, Glasgow coma scale (GCS) score at admission and discharge, and underlying brain injuries with the outcomes. The variables such as pneumocephalus, dural tears, type of fracture and site of the fracture, and age and sex distribution of the patient were not statistically influencing the outcomes. Conclusions: Patients who underwent surgery for DSFs, with good GCS at admission and discharge, with no underlying brain injury, and who did not sustain injuries in a road traffic accident had better outcomes.
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Management and outcome analysis of conus and filum ependymoma: A tertiary center study p. 821
Manoharan Dwark Sudhan, Guru Dutta Satyarthee, Leve Joseph, Mehar Chand Sharma, Aanchal Kakkar, Bhawani Shankar Sharma
DOI:10.4103/ajns.AJNS_326_16  
Background: Spinal ependymomas constitute approximately 2%–8% of primary adult central nervous system tumors. Authors analyzed demographic, clinical, radiological, surgical, and histopathological factors which correlated with the postoperative neurological outcome of patients who underwent surgery for conus and filum ependymoma (CFE). Materials and Methods: A retrospective analysis of 31 patients regarding clinical feature, imaging study, surgical management, and McCormick grading system for assessing functional neurological status was carried out, who underwent surgical management for CFE between January 2009 and April 2014. Final neurological outcome at follow-up period was correlated with various factors in search to find out probable prognostic factors affecting final neurological outcome following surgical management. Results: The myxopapillary ependymoma was observed in 55% of cases (n = 17), while 39% cases (n = 12) had Grade II ependymoma and rest 6% (n = 2) cases had anaplastic ependymomas. The mean age was 30 years (range 7–60 years) with male to female ratio of 1:0.82. Patients predominantly presented with pain (80.65%); mean duration of symptoms was 28.61 months. Only, the preoperative McCormick grade was found to be the statistically significant prognostic factor (P = 0.045), affecting neurological outcome however, the age, sex, duration of symptoms, location of the tumor, extent of the tumor, extradural spread, degree of surgical excision, vascularity of tumor, and histopathological World Health Organization grades were not found to be significant prognostic factors in the current study. Conclusion: The preoperative McCormick score was found to be the only statistically significant factor predicting the functional and neurological outcome after surgery, so surgical treatment should be offered early in the course of the disease to provide chance of preservation and good neurological recovery.
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The description of urodynamic study for bladder dysfunction in compressive myelo- or radiculo-pathy: A prospective study in an institutional setup Highly accessed article p. 828
Nayil Khursheed, Bilal Pahalwan, Humam Nisar, Altaf Ramzan, Saleem Wani, Abrar Wani, Sarbjit Singh, Rouf Khawaja, Arif Hamid, Hussain Arif, Baldev Singh
DOI:10.4103/ajns.AJNS_173_16  
Purpose: To study the significance of filling cystometry with pressure flow studies and bladder electromyography (EMG) in assessment and management of neurogenic bladder with myelopathies and evaluated neurological recovery in the follow-up period. Methods: The study was a 3-year prospective urodynamic study in 63 patients, with traumatic and nontraumatic myelopathy. Bladder management was advised based on the cystometric findings. Neurological recovery and mode of bladder management were evaluated during follow-up after a minimum of 6 months. Results: Mean age was 44.6 years (range 10–80 years). Thoracolumbar area was most commonly involved. Cystometry revealed overactive detrusor in 46 patients, (17 had detrusor sphincter dyssynergia [DSD], 29 without DSD) and areflexic/underactive detrusor in 9 patients. Postvoid residual (>15% of voided urine) was significant in 27 patients. Neurological recovery was seen in 60.3%, whereas 22.2% showed no improvement (partial improvement in 4.8%) and 12.6% had normal bladder function both initially and at follow-up. Correlation between neurological recovery and bladder management was found to be insignificant (P > 0.05) using spearman's correlation coefficient. Conclusion: Filling cystometry with pressure flow studies and EMG study is valuable for the assessment and management of neurogenic bladder in patients with myelopathy. In neurogenic bladder management and follow-up, pressure flow studies help to prevent complications and upper urinary tract complications.
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Prevalence and antibiotic resistance profile of cerebrospinal fluid pathogens from neurosurgical patients from level 1 trauma center in India p. 834
Aishwarya Govindaswamy, Vijeta Bajpai, Parul Singh, Ayush Lohiya, Muruganantham Ayyanar, Deepak Kumar Gupta, Ashish Bindra, Gyaninder Pal Singh, Purva Mathur
DOI:10.4103/ajns.AJNS_268_18  
Introduction: The purpose of this study was to investigate the prevalence of Postoperative central nervous system infections (PCNSIs) and antibiotic resistance profiles of causative organisms in trauma patients following neuroinvasive procedures. Materials and Methods: This was a retrospective study conducted over a period of 4 years (2013–2017). All in-patients admitted under a neurotrauma unit meeting the inclusion criteria of PCNSIs were included in the study. Surgical site infections (SSIs) were defined according to the Centers for Disease Control and Prevention 2018 (CDC) criteria. We retrospectively examined the demographic characteristics, type of neurosurgery performed, laboratory data, causative organisms, and antimicrobial susceptibility testing results of patients who had positive cerebrospinal fluid cultures following craniotomy between January 2013 and December 2017. Results: Of total 2500 patients operated during the study, 961 patients were screened for PCNSIs. The estimated prevalence (95% confidence interval) of PCNSIs which is a type of organ/space SSI was 7.2% (6.3–8.3). Males were predominantly affected (85.0%). The mean age (standard deviation) of patients was 31.9 (16.5) years. Of all the cultures sent for microbiological examination, 18.6% were positive. The proportion of Gram-negative bacteria causing PCNSIs was 91.6%. Multidrug-resistant (MDR) Acinetobacter baumannii (41%) was the most common organism isolated. Among Gram-positive bacteria, the most common organism was Staphylococcus aureus (5.5%). All the Gram-positive isolates were susceptible to vancomycin, teicoplanin, and linezolid. Conclusion: There is a high burden of PCNSI caused by MDR Acinetobacter baumannii can pose a major clinical challenge with only few antimicrobials left in the pipeline.
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Initial experience of ORBEYE™ surgical microscope for carotid endarterectomy Highly accessed article p. 839
Tsuyoshi Izumo, Kenta Ujifuku, Shiro Baba, Yoichi Morofuji, Nobutaka Horie, Takayuki Matsuo
DOI:10.4103/ajns.AJNS_242_18  
Background: Carotid endarterectomy (CEA) is widely performed under operative microscopes. They provide magnified and stereoscopic vision of operative field suitable for precise maneuver. However, the microscope has some shortcomings, which are a narrow field-of-view, shallow depth-of-field, and the operator's fatigue due to fixed gaze posture through eyepieces. To overcome them, we introduced ORBEYE™ Surgical Microscope, which was 4K ultra high-definition three-dimensional (3D) system. We present our initial experience of the system for CEA and discuss its usefulness compared with the operating microscopes. Methods: A 66-year-old male presented to our department for the treatment of the left internal carotid artery severe stenosis. He underwent CEA using the ORBEYE™ Surgical Microscope. Results: The surgery was successfully completed only under the system without complication. The microscope was set over the operative field. Its wide field-of-view, deep depth of field, and smooth digital zooming allowed minimal repositioning of the microscope. The system provided high quality stereoscopic image of the surgical site, which enables us to perform precise surgery. The 55-inch 4K 3D monitor remarkably contributed to a reduction of the surgeons' fatigue. Conclusions: The ORBEYE™ Surgical Microscope, incorporating 4K 3D video technology, has overcome shortcomings of the operative microscope. This system is highly feasible for CEA and has the certain possibility for other neurovascular surgeries.
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Subaxial cervical spine injuries: Outcomes after anterior corpectomy and instrumentation p. 843
Ankit Madan, Manoj Thakur, Sachin Sud, Vaibhav Jain, Rudra Pratap Singh Thakur, Virender Negi
DOI:10.4103/ajns.AJNS_331_17  
Study Design: This is prospective study. Purpose: The purpose of this study is to assess the functional, neurological, and radiological outcomes of the patients of subaxial cervical spine injuries treated by anterior corpectomy and stabilization with anterior cervical locking plate and cage filled with bone. Overview of the Literature: The principles in the treatment of unstable cervical spine injuries are reduction and stabilization of the injured segment, maintenance of cervical lordosis and decompression where indicated and ranges from nonoperative to combined anterior and posterior surgical fusion. There is, however, debate on the indications for anterior, posterior, or combined surgery. Materials and Methods: The present study of 99 patients includes prospective patients of subaxial cervical spine injuries between February 2014 and February 2016 admitted and operated to Indira Gandhi Medical College, Shimla. Bony fusion, neurological recovery, Neck Disability Index and complication were studied in all patients. The mean follow-up period was 27 months (range 12–42 months). Results: Of the 99 procedures, 77 (77.8%) involved a single vertebral level, 19 (19.2%) involved two levels, and 3 (3%) involved three levels corpectomy. The mean Neck Disability Index was 7.57 ± 5.42. Definitive Bridwell Grade 1 fusion was seen in 64.6% of the cases. No deterioration of neurological symptoms was seen. Dysphagia was the most common complication in 79 (79.8%) patients. One patient had minimal screw back out. Conclusions: Anterior cervical corpectomy and stabilization with cage filled with bone and cervical reflex locking plate are good method for subaxial cervical spine injuries with good fusion rates and probably procedure of choice for posttraumatic multiple disc prolapse with reduced hazards of multiple grafts.
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The efficacy of posterior cervical laminectomy for multilevel degenerative cervical spondylotic myelopathy in long term period p. 848
Neilakuo Kire, Sanyam Jain, Zahir Abbas Merchant, Vishal Kundnani
DOI:10.4103/ajns.AJNS_49_19  
Study Design: This was a retrospective analysis. Background: Surgical decompression is the gold standard for preventing the progression of neurological deficit in degenerative multilevel cervical spondylotic myelopathy (CSM). The efficacy of posterior laminectomy in the surgical management of CSM has been described in the past, but long-term follow-up data are scanty. Objective: The aim of this study is to assess the long-term clinical-radiological outcomes following posterior cervical decompressive laminectomy in multilevel degenerative CSM. Materials and Methods: A retrospective analysis of 110 patients with degenerative multilevel CSM who underwent posterior cervical laminectomy alone in a single hospital by a single surgeon from 2009 to 2013 with minimum 5-year follow-up. Pre- and post-operative clinical parameters (visual analog scale [VAS], Nurick and modified Japanese orthopedic association [mJOA]), radiological parameter (Sagittal cervical Cobb's Angle), perioperative complications (time, blood loss, and hospital stay), postoperative complications (infection, C5 palsy, and neurological worsening) were evaluated. Results: Totally 110 patients (males – 68 and females – 42) with age varying from 46 to 80 (mean-57) years, and the mean duration of illness was 3 months were evaluated. Mean clinical parameters are VAS (preoperative = 5 ± 1.31, postoperative = 1.49 ± 0.687), Nurick grading (preoperative = 3.23 ± 71, postoperative = 1.924 ± 0.75), and mJOA (preoperative = 6.32 ± 0.87, postoperative = 9.89 ± 1.37). The mean blood loss was 93.95 ± 19.18 ml, and the mean time taken for surgery was 83.65 ± 10.18 min. About 13% (n = 15) patients developed cervical kyphosis and 29% (n = 32) developed changes in cervical spine alignment and 10% (n = 11) developed worsening of neurology at final follow-up. Two patients developed a superficial infection which was managed with antibiotics. Three patients developed C5 palsy which recovered with due time. Conclusions: With the proper selection of patients, posterior cervical laminectomy is effective in offering a clinical improvement to patients with degenerative multilevel CSM with a low incidence of clinically significant radiological deterioration.
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Local cerebral hemodynamics after superficial temporal artery-middle cerebral artery bypass in patients with symptomatic carotid occlusions p. 853
Anna Shulgina, Vasily Lukshin, Dmitry Usachev, Elena Shevchenko
DOI:10.4103/ajns.AJNS_78_19  
Context: Physiological insights into blood flow alterations in cortical vessels after superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery are important for the prognosis of bypass sustainability and hemodynamic patency. Aims: This study aims to assess the impact of STA-MCA bypass on local hemodynamics for patients with symptomatic carotid occlusions and Moyamoya disease. Settings and Design: This article presents a prospective nonrandomized study of intraoperative blood flow measurements in cortical branches of MCA and donor vessel before and after cerebral revascularization. Materials and Methods: Evaluation of local hemodynamic parameters was established for 112 patients with symptomatic carotid occlusive disease and cerebrovascular insufficiency during STA-MCA bypass surgery. We used intraoperative Doppler ultrasonography (89 patients – 72%), flowmetry (56 cases – 50%), and in 33 cases both methods. For physical justification of observed facts, we performed computational simulation with OpenFOAM CFD framework using Navier-Stokes nonstationary hemodynamic model. Statistical Analysis Used: All calculations were performed with IBM SPSS Statistics version 10.0 software. We used parametric (Z-test and Student's t-test) and nonparametric models (Wilcoxon, Mann–Whitney). For categorical values, we used Fisher's exact test. Results: Local cerebral hemodynamics after revascularization surgery significantly depended on initial perfusion deficit and the ability of bypass to reverse the blood flow in proximal parts of cortical artery (86 cases, 77%). Mechanism of cortical blood flow alteration was related to donor vessel cut flow value and potential consumption threshold of acceptor artery. Conclusions: Knowledge of hemodynamic principles of flow redistribution after STA-MCA bypass is important to improve bypass stainability and leads to better revascularization results.
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Combined endovascular and microsurgical hybrid management of cerebral aneurysms: The preliminary fujita experience p. 863
Riki Tanaka, Ahmed Ansari, Yoko Kato, Yasuhiro Yamada, T Kawase, Sai Kalyan
DOI:10.4103/ajns.AJNS_133_17  
Introduction: A subgroup of complex aneurysms demands multimodal treatment by microscopic and endovascular means. Partial obliteration or remnant postprocedure demands to go further to the other modality. Materials and Methods: All patients between July 2016 and January 2017 who had to undergo multimodality measures for complete obliteration of the aneurysms were included in the study. The patients who had either undergone clipping or coiling for their aneurysms, but with incomplete obliteration of the aneurysm, were also included in the study. Results: Between July 2016 and January 2017, a total of three patients had to undergo coiling after clipping of the aneurysm for complete obliteration. Two patients had to go for clipping following coiling. All five patients had complete obliteration of the aneurysm sac. Conclusion: Both microscopic and endovascular means are complementary measures instead of competing procedures. It is important to realize the technical difficulties when surgical therapy follows initial endovascular treatment. Similarly, coiling a previously clipped aneurysm can be difficult, if the clip obscures normal working projections.
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Microsurgical treatment of paraclinoid aneurysms by extradural anterior clinoidectomy: The fujita experience p. 868
Yasuhiro Yamada, Ahmed Ansari, Treepob Sae-Ngow, Riki Tanaka, Tsukasa Kawase, Sai Kalyan, Yoko Kato
DOI:10.4103/ajns.AJNS_130_17  
Introduction: Paraclinoid aneurysms pose technical difficulty in their approach, mainly because of their close proximity to neurovascular structures, deeper location, and a smaller corridor. Extradural anterior clinoidectomy is a highly beneficial technique in such cases, making more space to deal with these aneurysms. We describe our method of performing extradural anterior clinoidectomy in such patients. Materials and Methods: A total of 33 cases of paraclinoid internal carotid artery aneurysms presenting to Fujita Health University Banbuntane Hospital, Japan, were included. Females comprised the majority with 32 cases; the mean age was 54.8 years (range: 35–74 years). The mean size of the paraclinoid aneurysm was 5.3 mm (range: 3–12 mm). Results: Nine paraclinoid aneurysms were found projecting dorsally, 7 laterally, and 17 medially (Kazuhiko Kyoshim et al's. classification). An immediate complete occlusion rate of 100% was present. Visual disturbance was found in 6.2% of our patients. One of our patients developed permanent loss of vision. Conclusion: Extradural anterior clinoidectomy enables a better exposure to paraclinoid aneurysms. Precise anatomical knowledge along with microsurgical tactics is required to prevent and manage potential complications to achieve good outcomes.
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Double-balloon trapping for coil embolization of ruptured internal carotid artery aneurysm: A novel technique p. 873
Ahmed Ansari, Tomotaka Ohshima, Shunsaku Goto, Taiki Yamamoto, Kojiro Ishikawa, Yoko Kato
DOI:10.4103/ajns.AJNS_134_17  
Introduction: Endovascular treatment of complex ruptured aneurysms in the internal carotid (IC) artery is extremely challenging. Navigation of double-balloon catheters becomes all the more difficult in tortuous vessels. Patients and Methods: A 57-year-old female with more than three times previously ruptured left IC artery aneurysm with subarachnoid hemorrhage had a left IC small aneurysm with a neck of 3.2 mm. Proximal and distal balloons were inflated in left IC artery in respect to the aneurysm, to prevent further rupture during navigation of the microcatheter and first coil. Discussion: The technique uses two balloons placed proximal and distal to the ruptured aneurysm, to reduce further bleeding, just as the application of temporary clips, followed by inertion of coils rapidly to obliterate the aneurysm. Conclusion: It is a novel technique of double-balloon trapping of proximal and distal segment of IC artery with aneurysm coiling technique as an alternative to balloon-assisted coiling and stent-assisted coiling in patients with ruptured aneurysm.
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CASE REPORTS Top

A rare case of drug-induced liver injury caused by levetiracetam Highly accessed article p. 878
Tomohiro Kawaguchi, Teiji Tominaga
DOI:10.4103/ajns.AJNS_246_17  
Levetiracetam (LEV) is one of the newest antiepileptic drugs available on the market and is frequently used in neurosurgical patients requiring antiepileptic assistance. LEV is mainly excreted by the kidney with minimal hepatic metabolism, so it is considered to have a low liver toxicity. Drug-induced liver injury (DILI) associated with LEV administration is extremely rare, with only eight reported cases. In this report, we describe the case of a 44-year-old man who was admitted because of generalized convulsion, and LEV administration at a dose of 3000 mg/day was started following a diagnosis of status epilepticus. Laboratory values before LEV administration were as follows: alanine aminotransferase (ALT), 17 IU/L; aspartate transaminase (AST), 41 IU/L; and total bilirubin, 0.59 mg/dL. Viral serology tests for hepatitis B and hepatitis C yielded negative results. Several hours after LEV administration, the patient developed high-grade fever and his liver enzyme levels were found to be elevated. LEV administration was stopped immediately; the peak laboratory values were as follows: ALT, 1,192 IU/L; AST, 3,150 IU/L; and total bilirubin, 2.02 mg/dL. After conservative treatment, the patient's laboratory values were normalized. A drug-induced lymphocyte stimulation test (DLST) was performed and showed a positive response, indicating that the administration of LEV was responsible for DILI in this patient. Clearly, LEV can provoke DILI despite its low liver metabolism profile. Therefore, readministration of the drug should be avoided in such cases. An in vitro examination, such as a DLST, can be useful for ensuring a definitive diagnosis of DILI.
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Adult achondroplasia patient with extensive long segment severe C1 to C6 segment spinal canal stenosis: Unique presentation p. 883
Guru Dutta Satyarthee, Kanwaljit Grag
DOI:10.4103/ajns.AJNS_273_17  
Achondroplasia represents the common variety of skeletal dysplasia causing short-limb dwarfism. It may be associated with congenial craniovertebral junction anomaly, including atlantoaxial dislocation, Os odointoideum or basilar invagination or acquired as a result of the previous foramen magnum region surgery. However, long segment cervical compression from the first cervical vertebra region to sixth cervical region, such extensive compression producing myelopathy is not reported, and current case represents first case in the western literature. He was managed surgically with a good outcome. Perioperative management along with brief review of pertinent literature along with the management of such case is discussed in brief. Anesthetic management of such patient with coexisting extensive cervical compression presents unique challenges in view of the multisystem involvement along with preexisting anatomical and physiological constraints.
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Exploring a tumor spectrum in a patient with familial angiolipomatosis Highly accessed article p. 886
Shradha Maheshwari, Eham Lalit Arora
DOI:10.4103/ajns.AJNS_295_17  
Angiolipomas are uncommon spinal tumors which differ from their cutaneous counterparts in having larger caliber vascular stroma. Although slow growing, they can cause rapid spinal cord compression and sudden-onset sensorimotor symptoms due to vascular engorgement, hemorrhage, or thrombosis. The goal of surgery is spinal decompression, and favorable outcome is the rule. We report a patient with spinal angiolipoma, vertebral hemangioma along with subcutaneous lipomas and angiolipomas, exhibiting the entire histopathological spectrum of these related soft-tissue tumors. Analysis of his family tree revealed a hereditary predilection. Familial angiolipomatosis is an uncommon genetic condition which has not been reported to occur with spinal angiolipomas thus far.
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Redefining the evolution of spinal discal cyst under percutaneous endoscopy: Report of two cases p. 890
Heun Sung Kim, Nitin Adsul, Ankur Kapoor, Shiblee Siddiqui, Il-Tae Jang, Seong-Hoon Oh
DOI:10.4103/ajns.AJNS_27_18  
Discal cyst has been recognized as a distinct cause of back pain and radiculopathy. The clinical features are similar to other pathologies as disc prolapse and stenosis. Various treatment modalities have been described, ranging from nerve blocks to surgical excision. There are scarce reports on the endoscopic appearance of discal cysts. The present paper based on two cases operated by transforaminal and interlaminar endoscopy at our institute demonstrates the explicit intraoperative view and different pathological components of discal cysts.
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Primary neuroendocrine tumor of the lumbar spine: Rare tumor mimicking nerve sheath tumor of the spine p. 894
Sanjay Kumar, Vikas Maheshwari, Aishik Mukherjee, Deep Kumar Raman
DOI:10.4103/ajns.AJNS_276_18  
Neuroendocrine tumors (Carcinoid tumors) generally arise from enterochromaffin cells of gut and bronchi. Primary carcinoid tumors of spine are extremely rare and have been described in sacrum and coccyx. Primary carcinoid tumors involving the spinal cord are still rarer, and review of literature revealed only two cases reported. Our patient a 39-year-old male had diagnosed as a case of nerve sheath tumor (intradural extramedullary) at LV4 region on neuroimaging. However, postoperatively, the tumor turned out to be a rare primary spinal carcinoid tumor on histopathological examination and immunohistochemical staining. Work up to rule out any other site in the body was negative. To the best of our knowledge, this is the first case of primary carcinoid tumor of the lumbar spine.
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A rare chronic presentation of schwannoma with hemorrhage p. 897
Sarang Gotecha, Prashant Punia, Anil Patil, Ashish Chugh, Megha Kotecha, Vybhav Raghu, Ali Mubashshir, Chhabra Shobhit, Dushyant Kashyap
DOI:10.4103/ajns.AJNS_277_18  
Spinal schwannomas are slow-growing benign tumors arising from the nerves. In the spinal cord, they arise most commonly from cervical and lumbar levels. They are mostly intradural extramedullary (IDEM) accounting for 30% of intradural tumors showing a female preponderance. They are seen occurring between 25 and 50 years of age. Most of these cases show acute presentation as hemorrhage within the tumor with weakness. This is a rare presentation by itself reported by only 12 cases world over. It is even rarer to see them show chronic presentation. We are reporting one such case of a 61-year-old female who presented to us with chronic low backache for 3 years with radicular symptoms in the bilateral lower limbs following a fall on her back. Magnetic resonance imaging was done which showed a well-defined IDEM lesion from L3 to L5 vertebral level which was isointense on T1 and hyperintense on T2 with a peripheral rim and short inversion time inversion-recovery showed fluid-fluid level within. Gradient-recalled echo showed blooming with no suppression on fat-sat and no diffusion restriction. A computed tomography angiography was done which ruled out vascular malformation. Intraoperatively, a large feeding vessel with a tumor was visualized after laminectomy was done for the corresponding levels. Postoperatively, the patient showed a significant decrease in radicular symptoms and was discharged after 2 weeks with an uneventful postoperative period. HPE of the lesion showed sheets of fascicles of elongated spindle cells arranged in loose myxoid matrix with hyperchromatic nuclei and scanty hemorrhage and lymphocytic infiltrates suggestive of schwannoma with myxoid degeneration. Immunohistochemistry also confirmed a diagnosis of schwannoma. From this case, it is seen that the diagnosis of a spinal schwnnoma showing delayed presentation with atypical imaging findings is a challenge and must needs a high index of suspicion and appropriate surgical planning.
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A rare case of supratentorial cavernous angioma associated with arterialized developmental venous anomaly p. 901
Matteo Martinoni, Eugenio Pozzati, Nicola Acciarri, Antonella Bacci, Andrea Cuoci, Carmelo Sturiale, Carlo Bortolotti
DOI:10.4103/ajns.AJNS_128_18  
The association of cavernous malformations and developmental venous anomalies (DVA) is well known, but the presence of arterial fistulous connection with the main venous collector has been reported in the literature only once. We report the unusual case of a hemorrhagic cavernous angioma associated with DVA characterized by a fine arterial supply to the main venous collector. During surgery, after the excision of the cavernous angioma, few small arterial feeders were found entering the main channel of the venous developmental anomaly. The presence of an arterial fistulous connection with the main venous collector of a DVA may be a possible mechanism involved in a higher bleeding potential of cavernous angioma.
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Primary intracranial squamous cell carcinoma arising in dermoid cyst p. 904
Muhammad Yousuf Shaikh, Salman Sharif, Muhammad Rafay
DOI:10.4103/ajns.AJNS_200_18  
Primary intracranial squamous cell carcinoma represents a rare entity. However, few cases have been reported in the literature so far. We report the case of a 32-year-old male who presented with a history of severe headache and vertigo for 3 weeks. Magnetic resonance imaging brain with contrast was done that showed a lesion measuring 5 cm × 4.8 cm in the left cerebellum near the midline which was hyperintense on T2 and hypointense on T1. It also showed ring-like heterogeneous contrast enhancement causing midline shift as well as pressure over the brainstem causing severe obstructive hydrocephalus. After emergency ventriculoperitoneal shunt placement, the patient subsequently underwent left paramedian suboccipital craniotomy and excision of space-occupying lesion. Intraoperatively, a well-demarcated capsule was identified. The entire lesion consisting of areas of calcification and hair particles was removed except the part of capsule which was adherent to the brainstem. Histopathology of the lesion showed infiltrating malignant neoplasm exhibiting papillary architecture with thick fibrovascular cores lined by stratified squamous cells. In order to rule out the possibility of metastases, systemic workup was done which yielded negative results.
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Gangliocytic paraganglioma of dorsolumbar spine: A rare tumor at rare site p. 907
Vaishali Baburao Nagose, Varsha Ashok Jadhav
DOI:10.4103/ajns.AJNS_80_19  
Spinal paragangliomas are rare benign tumors. The gangliocytic paragangliomas (GP) of spine are even rarer. The GPs are almost exclusively seen in duodenum. In spine, the usual site of affection is cauda equina region. The involvement of other spinal levels is far less often and includes thoracic and cervical region. We report this case of GP involving the conus medullaris region and reaching up to the upper part of cauda equina. The prognosis of spinal GP is excellent after total excision, as it is classified under WHO Grade I tumor. The patient made a full recovery after tumor removal. Clinical, radiological, and pathological characteristics of this rare tumor are discussed here along with.
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Intracranial chondroma of the falx cerebri: A rare case report with review of literature p. 911
Rati Agrawal, Arun Saroha
DOI:10.4103/ajns.AJNS_82_19  
Intracranial chondromas are extremely rare, benign slow-growing cartilaginous tumors mostly originating from embryonic rests at sphenoethmoidal region and sometimes can originate from the falx, convexity dura, the tentorium, the choroid plexus, or the brain parenchyma. In this article, we present a 22-year-old woman with a chondroma of dural origin. The clinical, radiological, and histopathological findings along with the operative findings and postoperative course are described as well as the pertinent literature regarding intracranial chondromas is reviewed.
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Onyx embolization of distal middle cerebral artery aneurysm in a patient with nontraumatic subdural hematoma p. 915
Nida Fatima, Ghanem Al Sulaiti, Ghaya Al Rumaihi
DOI:10.4103/ajns.AJNS_58_19  
Distal cortical middle cerebral artery (MCA) aneurysm is a rare entity. Despite the challenging procedure, the role of endovascular treatment is emerging due to its safety and efficacy in obliterating the microaneurysm. We report a 25-year-old male, who presented with a history of dizziness and headache for almost 2 weeks. Computed tomography scan showed a right front parietal subdural hematoma (SDH). We could not identify any underlying defining etiology of SDH neither head injury nor coagulopathy disorder. Therefore, diagnostic cerebral angiogram was performed, which showed a microaneurysm in the distal right MCA cortical branch. Hence, complete obliteration of this microaneurysm was performed using Onyx for endovascular embolization. Therefore, this case report demonstrates the efficacy of this modality in the treatment of microaneurysms with SDH.
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Central neurocytoma presenting with bleed and obstructive hydrocephalus: A rare presentation p. 919
Mustafa Iqbalahmed Chandshah, Nishanth Sadashiva, Subhas Konar, Bhagavatula Indira Devi
DOI:10.4103/ajns.AJNS_84_19  
Central neurocytomas (CNs) occur typically in the lateral ventricle, adjacent to the septum pellucidum and foramen of Monro. The clinical presentation varies and many are incidentally detected. Incidence of spontaneous hemorrhage at presentation is rare. We hereby report a case of the intraventricular lesion with bleed which was operated on an emergency basis as it caused obstructive hydrocephalus and the patient was in altered sensorium. The exact cause of hemorrhage in CNs is not known, and the previously discussed explanations are discussed.
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Intracranial malignant nerve sheath tumor in the middle cranial fossa: A rare case report with review of literature p. 922
Amey Prakash Patankar, Jwalit Hasmukhlal Sheth
DOI:10.4103/ajns.AJNS_59_19  
Intracranial malignant nerve sheath tumors rarely arise in the central nervous system. They usually arise from the cranial nerves, though rare cases of intraparenchymal lesions have also been reported. We report a case of malignant nerve sheath tumor located in the right middle cranial fossa. Preoperatively, the lesion resembled a meningioma arising from the petrous temporal bone. The lesion was completely excised. Postoperatively, the patient developed righted-sided complete facial nerve palsy. Histopathology and immunohistochemistry revealed the lesion to be a malignant nerve sheath tumor. The development of postoperative facial nerve palsy was puzzling but could be explained if we consider the possibility of the lesion arising from the facial nerve near the geniculate ganglion. Intracranial malignant nerve sheath tumor centered over the geniculate ganglion and projecting into the middle cranial fossa is uncommon, and to the best of our knowledge, only one such case has been previously reported. We review the relevant literature, discuss the management and add to the previously reported cases of this rare condition.
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Surgical significance of infra-optic course of A1 segment of anterior cerebral artery: Report of two cases p. 927
HS Nandish, Srinivasalu Selvapandian, Siddhartha Ghosh
DOI:10.4103/ajns.AJNS_34_19  
Anatomic variations of the anterior cerebral artery-anterior communicating artery complex (ACA-AComA) are common. An infra-optic course of the A1-ACA is extremely rare, and recognition of this variant is very important in planning surgery for ACA-AComA complex aneurysms. We present two cases of spontaneous subarachnoid hemorrhage due to ruptured AComA aneurysms with unilateral infra-optic course of the A1-ACA. In both the cases, the preoperative catheter angiography revealed low bifurcation with a horizontal course of internal carotid artery. In our first case, the finding was rather unexpected; however, in our second case, we could anticipate an infra-optic course of A1-ACA. Preoperative recognition of this anomaly helps in achieving proximal vascular control with ease and confidence. It also enhances surgical safety of aneurysm clipping, by avoiding unnecessary dissection elsewhere. This emphasizes the importance of careful preoperative angiographic evaluation. In the presence of this anomaly, one should always search for other associated vascular anomalies.
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Contralateral transcondylar fossa approach with bilateral V3 segment exposure for clipping of vertebral artery aneurysm which deviates across midline: A case report and review article p. 930
Kitiporn Sriamornrattanakul, Nasaeng Akharathammachote, Somkiat Wongsuriyanan, Atithep Mongkolratnan
DOI:10.4103/ajns.AJNS_90_19  
This article reports a patient with unruptured right vertebral artery aneurysm which deviates across the midline to the left side. The contralateral (left) transcondylar fossa approach with bilateral V3 exposure is used for aneurysm clipping. The literature related to this technique is also reviewed.
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Patent persistent fibrous tract in a patient with disconnected lumboperitoneal shunt p. 935
Rajan Kumar Sharma, Kiyoshi Takagi, Yasuhiro Yamada, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_91_19  
Disconnection of proximal or distal catheter is seen more frequently in the complication of the lumboperitoneal (LP) shunt. A connective tissue sheath that forms around the peritoneal catheter of silicone shunt tubing is a normal biological response to foreign material. The literature did not establish whether the disconnected LP shunt can allow passage of cerebrospinal fluid (CSF) through the disconnected portion. However, proof of the passage of CSF through these sheaths has been reported in only one published study to date. We present a case of a young patient with disconnected LP shunt who reported patent persistent fibrous tract around the tube shunt. In conclusion, asymptomatic patients with shunt disconnection should be evaluated with shuntography for patency of fibrous sheath before removal of the shunt to avoid the possible complications.
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Collision occurrence of meningioma and astrocytoma: A case report and literature review p. 938
Van Tri Truong, Duc Duy Tri Tran, Cong Thuan Dang
DOI:10.4103/ajns.AJNS_97_19  
A case of collision tumors occurring between two distinct primary brain tumors is reported. A 61-year-old female without history of radiotherapy or phakomatosis presented with progressive ly increasing headache and left hemiparesis. Investigation revealed a meningioma and a Grade II astrocytoma in the right frontal lobe. Simultaneous development of a meningioma and a low-grade glioma at adjacent sites is extremely rare. This is the third case reported in the literature. Some hypotheses are proposed to explain this phenomenon but most likely represent a coincidental event.
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Penetrating injury of the eye causing bilateral visual loss: An eye opener! p. 943
Mukesh Kumar Singh, Harsh Deora, Manjul Tripathi, Sandeep Mohindra, Aman Batish
DOI:10.4103/ajns.AJNS_64_19  
Penetrating orbitocranial injuries are often serious and life-threatening trauma. A thorough knowledge of the mechanism of injury, direction of the projectile object, low index of suspicion, appropriate radiological investigations, medical management, and timely surgical intervention are necessary for the prevention of any serious complication. The penetrating objects are usually lodged at the site of entry with very less chances of intracranial migration. Authors here describe their experience in the management of such an injury with a discussion of pitfalls in surgical treatment.
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Interhemispheric approach to anterior communicating artery aneurysm: A case illustration p. 946
Satya Bhusan Senapati, Lavlesh Rathore, Yasuhiro Yamada, Yoko Kato
DOI:10.4103/ajns.AJNS_43_19  
There are two main types of approaches for anterior communicating artery (AcomA) aneurysms, namely pterional approach, and an interhemispheric (IH) approach. Pterional approach is the most common for anterior circulation aneurysms. However, this approach cannot be used without resection of gyrus rectus when aneurysm is located high within the IH fissure and directed posterosuperiorly, which is better handled with IH approach. In this article, we will describe the tricks of IH approach with a case illustration.
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Giant spinal intradural metastatic adenocarcinoma of unknown primary: A rare case report p. 949
Natarajan Meenakshisundaram, Balasubramanian Dhandapani
DOI:10.4103/ajns.AJNS_65_18  
Giant intradural metastases of nonneurogenic origin involving multiple segments represent an extremely rare manifestation of an unknown primary. The respective literature is very scarce. We present a 45-year-old female with complaints of low back pain for 4 years, involuntary urination for 2 years, and difficulty in using both lower limbs for 1 month. Examination revealed paraparesis with hypotonia. Imaging of lumbosacral spine revealed that expansile lytic destruction of vertebral bodies and posterior elements was noted from D8 to S2 vertebra and a large-sized patchy enhancing heterogeneous intradural extramedullary lesion was noted in D8–S2 level. Decompressive laminectomy from D11 to L4 vertebra and subtotal excision of the lesion were done. There was a marked improvement in the lower limb weakness and low back pain postoperatively. Histopathology revealed metastatic adenocarcinoma. Immunohistochemistry showed epithelial membrane antigen positivity. Accordingly, the aim of the surgery is strictly palliative. The majority of patients benefit with respect to neurological deficit/pain independent of the extent of resection. Thus, decompressive surgery is recommended to increase the quality of life. The occurrence of intradural spinal metastasis is rare. Only few cases of intra dural spinal metastasis involving multiple cord segments and osteolytic bony erosions have been documented. Hence this case is being presented here for its rarity and its uniqueness.
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Nocardia araoensis causing brain abscess p. 952
Shejoy Joshua, Rachana Babu, Anup Warrier, Dilip Panikar
DOI:10.4103/ajns.AJNS_66_19  
Nocardial brain abscess is a rare central nervous system infection with high morbidity and mortality. Most of the human infections, i.e., about 90%, are due to Nocardia asteroides group comprising N. asteroides complex, Nocardia farcinica, and Nocardia nova. Other species rarely cause human infections. Here, we report a case of left parieto-occipital abscess caused by a rare species, Nocardia araoensis, its diagnosis, treatment options, and review of literature. A 73-year-old male, known case of diabetes mellitus, on prolonged oral corticosteroid for autoimmune hemolytic anemia presented with a 1-month history of memory deficit and gait imbalance. On examination, he had a right inferior quadrantanopia and hemiparesis. Magnetic resonance imaging showed a multiloculated ring-enhancing lesion in the left parieto-occipital region. Navigation-assisted biopsy was done. The organism isolated was N. araoensis. He was treated successfully with prolonged course of antibiotics which resulted in complete clinical and radiological resolution. N. araoensis is a rare cause of brain abscess and needs to be suspected in immunocompromised individuals. Early diagnosis and prolonged treatment can result in complete clinical and radiological resolution.
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Unilateral fenestrated A1 segment of anterior cerebral artery multiple aneurysms: Case reports and literature review p. 957
Dilshod Mamadaliev, Yoko Kato, Sandeep Talari, Tushit Mewada, Yasuhiro Yamada, Yamashiro Kei, Tsukasa Kawase
DOI:10.4103/1793-5482.258113  
The fenestration of the cerebral arteries is infrequent anomaly mostly occurring in the posterior communicating artery, the vertebral artery, the basilar artery, and the middle cerebral artery.[1] We report a case of unilateral A1 fenestration associated saccular aneurysm, focusing on its features of surgical treatment.
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Apoplexy inside a giant medial sphenoid wing meningothelial (Grade I) meningioma: An extremely rare but a potentially dangerous complication p. 961
Sanjog Gajbhiye, Jaskaran Singh Gosal, Satyadeo Pandey, Kuntal Kanti Das
DOI:10.4103/ajns.AJNS_10_19  
Hemorrhage associated with meningiomas is extremely rare and most commonly occurs in convexity meningiomas of higher grade or the angioblastic variety. Moreover, bleeding associated with a meningioma usually occurs in the form of a subdural hematoma or subarachnoid hemorrhage. We report a case of giant left medial sphenoid wing meningioma with histopathological diagnosis of a meningothelial type with apoplexy. A 54-year-old female presented with clinical features suggestive of apoplexy. Her neuroimaging demonstrated a large left medial sphenoid wing meningioma with features suggestive of an intratumoral bleed with mass effect. Gross total excision of the tumor was done with the good postoperative outcome. The biopsy came out to be Grade I meningothelial meningioma. Apoplexy in meningiomas is extremely rare with a reported incidence of 0.5%–2.4%, especially in a nonconvexity meningioma with histopathological diagnosis of meningothelial variety. Early diagnosis and prompt surgical intervention are critical as meningiomas associated with apoplexy are associated with high morbidity.
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Delay posttraumatic paradoxical cerebrospinal fluid leak with recurrent meningitis p. 964
Guive Sharifi, Seyed Ali Mousavinejad, Hooman Bahrami-Motlagh, Ali Eftekharian, Mohammad Samadian, Kaveh Ebrahimzadeh, Omidvar Rezaei
DOI:10.4103/ajns.AJNS_95_18  
Cerebrospinal fluid (CSF) rhinorrhea complicates 2% of all head traumas, and 12%–30% of all basilar skull fractures. Posttraumatic CSF rhinorrhea usually occurs within the first 48 h, and majority of them occur in the first 3 months, whereas delayed CSF leak beyond 3 months is rare. On the other hand, CSF usually leaks through dural tearing associated with fracture of the anterior skull base. CSF leak through fractures of middle cranial fossa to the nose through the eustachian tube is very rare. We present a 52-year-old woman with delayed posttraumatic paradoxical CSF rhinorrhea and recurrent meningitis.
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Iatrogenic seizures during intraoperative transcranial motor-evoked potential monitoring p. 967
Suman Sokhal, Keshav Goyal, Navdeep Sokhal, Niraj Kumar, Shweta Kedia
DOI:10.4103/ajns.AJNS_96_18  
Intraoperative neurophysiological monitoring (IONM) is an important tool for early detection of inadvertent damage and guide intra-operative manipulation during complex neurosurgical procedures. However trans-cranial stimulation can evoke an iatrogenic seizure and it remains a real concern while using Tc-MEP. We report a case of intra-operative seizure during transcranial electrical stimulation for motor evoked potential monitoring in a patient without seizure disorder, who underwent surgery for thoracic intra-medullary tumor excision.
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Extracranial internal carotid artery aneurysm – Challenges in the management: A case report and review literature p. 970
Rajan Kumar Sharma, Ahmed Mohammed Asiri, Yasuhiro Yamada, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_292_18  
Extracranial internal carotid artery aneurysms (EICA) are rare. Incidence is <1% of all an arterial aneurysm. This aneurysm being rare but is important because it is associated with a high risk of neurological thromboembolic events, cranial nerve compression, and rupture. The causes of the EICA are congenital, trauma leading to the pseudoaneurysm, atherosclerosis, infections, and fibromuscular dysplasia. Here, we describe a case report of a 69-year-old female with progressive enlargement of the right neck mass accompanied by dyspnea on exertion. The patient had been diagnosed as right EICA and underwent the endovascular procedure as parent vessel occlusion 4 years ago. There was still enlargement of the size of the right neck mass and was causing troublesome to the patient. We performed selective embolization of the various feeders to the mass, but after this also, it was still enlarging. Three-dimensional reconstruction of the computed tomography scan showed fusiform dilatation of the right proximal EICA. We made the diagnosis of the thrombosed EICA and hence we planned to undergo surgical management. We performed removal of the intraluminal thrombus and ligation of the EICA. The size of the swelling decreased significantly.
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Thoracic dorsal dermal sinus with secondarily infected intramedullary dermoid cyst p. 975
Sriram Patwari, Bhavana Nagabhushana Reddy, Manoj Kumar Kapanigowda, Sujith Kamalakshi Ramesha, Harsha Chadaga
DOI:10.4103/ajns.AJNS_13_18  
Dorsal dermal sinus (DDS) is an uncommon type of occult spinal dysraphism most often located in the lumbar region. Patients present either due to secondary infection or compression of neural structures by an associated dermoid or epidermoid cyst. We report a rare case of 2-year-old child who presented with progressive paraparesis with magnetic resonance imaging of spine showing a thoracic DDS with an infected intramedullary dermoid cyst. Partial excision of the dermoid cyst and resection of the sinus opening was done with partial clinical improvement postsurgery.
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Trigeminal neuralgia secondary to vertebrobasilar dolichoectasia treated with cyberknife stereotactic radiosurgery p. 978
Vijay Bhaskar Lakshman, Mahalaxmi Aal, Pradeep Kumar Karumanchi, Ayesha Jaleel, Aarthi Pashupathy Iyer
DOI:10.4103/ajns.AJNS_53_18  
Trigeminal neuralgia caused by vertebrobasilar dolichoectasia is a rare condition. It is characterized by paroxysmal hemifacial pain which is lancinating in type mostly refractory to medical management. This is a report of trigeminal neuralgia secondary to vertebral dolicholectasia refractory to medical management treated with cyber knife stereotactic radiosurgery to the dose of 66 Gy in single fraction to the proximal nerve root. Pain relief was achieved immediately after the treatment and with a follow up period of 2 years, patient is pain free. Cyberknife assisted radiosurgery is relatively safe in delivering high ablative doses with precise conformality to small target regions like proximal nerve root entry of trigeminal nerve with no major toxicities and achieving early pain relief. It is an outpatient and non-invasive procedure. It can be used as a definite treatment modality for trigeminal neuralgia induced by vertebrobasilar dolichoectasia.
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Thoracic spinal intramedullary arachnoid cyst presented with myelopathy with marked postoperative improvement: A case report and review of literature p. 981
Ahmed Shaaban, Amrou Abdelrahman, Raed Abu Jarir, Issam Al-Bozom, Ali Raza
DOI:10.4103/ajns.AJNS_72_19  
Intramedullary spinal cord arachnoid cysts are rare. So, we present an interesting case of adult male presented with myelopathic symptoms and signs. Further investigations revealed a finding of thoracic intramedullary cystic lesion, found postoperatively to be an arachnoid cyst. Patient improved remarkably postoperative and during follow up period.
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A case study on aneurysmal bone cyst of T2 vertebral body in a 7-year-old girl: Anterior and posterior surgical approach for tumor resection and spinal reconstruction Highly accessed article p. 985
Mansour Parvaresh, Morteza Taheri, Alireza Azimi, Sadra Rohani
DOI:10.4103/ajns.AJNS_120_17  
Aneurysmal bone cyst (ABC) is defined as a benign lesion of bone containing blood-filled channels divided by soft-tissue septa and mostly diagnosed in children and adolescents. In the present study, the case of a 7-year-old girl with spastic paraparesia and left foot drop was investigated. Spinal imaging revealed a large lytic mass in the posterior elements of the T2 vertebral body, which resulted in the partial collapse of the T2 vertebral body, a T1 to T3 dislocation, and a spinal sagittal imbalance. The patient underwent a two-stage surgical procedure including an anterior T2 corpectomy, T1/T2 and T2/T3 discectomy, anterior instrumentation, posterior total tumor resection, and posterior fixation with laminar hooks. Postoperative imaging demonstrated cord decompression and good spinal alignment. Although a spinal ABC is a rare entity, it can occur in any segment of the spinal column and cause cord compression and spinal instability. Thus, proper treatment planning is crucial for total tumor resection to avoid tumor recurrence and correct spinal imbalance.
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Unusual complication of paraplegia following intracranial aneurysm clipping in a patient with undiagnosed coarctation of aorta p. 989
Shaik Afsar Pasha, Rajesh K Ghanta, Biju Govind
DOI:10.4103/ajns.AJNS_327_16  
We report a case of subarachnoid hemorrhage in a 38-year-old male, diagnosed to have the right middle cerebral artery aneurysm on computed tomography (CT) cerebral angiogram. He was a known hypertensive for 17 years and was on irregular treatment. Craniotomy and clipping of the aneurysm were done. Postoperatively, the patient had high blood pressure of 200/120 mmHg. Treatment of hypertension in the postoperative period resulted in paraplegia. CT angiogram of aorta revealed coarctation-postductal type. He underwent balloon dilatation for the coarctation of aorta followed by coarctopalsty and stenting with the improvement in motor power in both lower limbs.
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Good outcome in a patient with massive pontine hemorrhage Highly accessed article p. 992
Somkrit Sripontan
DOI:10.4103/ajns.AJNS_295_18  
Massive pontine hemorrhage with comatose condition has a poor prognosis and bad outcome despite adequate surgical treatment. However, this case report gives a different result. Providing adequate prophylactic treatment to prevent secondary brain injury resulted in a very good recovery at the 6-month follow-up. A 42-year-old man with a history of heavy smoking and poorly controlled blood pressure (BP) developed acute loss of consciousness. He was then brought to the emergency room (ER) in 30 min. At the ER, his Glasgow coma scale score was E1M2V1 and the BP was high. An emergency computed tomography (CT) scan of the brain showed massive hematoma in the pons with intraventricular extension. He was admitted to the intensive care unit with close monitoring of both vital signs and neurosigns. External ventricular drainage was inserted to control intracranial pressure and then removed in only 5 days after adequate control. The patient returned to a good recovery status in 6 months with a modified Rankin scale score of 2 and the CT brain scan showed a small cavity-like lesion at the hemorrhage area. Massive hemorrhage and low consciousness may not truly indicate a poor prognosis in patients with pontine hematoma. Medical and surgical treatments are still needed to control intracranial pressure for prophylaxis of secondary brain injury. Restoration of neuronal functions was achieved after resolution of the hematoma.
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“Contralateral dry eye in hemifacial spasm:” A new clinical sign p. 996
Jaskaran Singh Gosal, Kuntal Kanti Das, Deepak Khatri, Gagandeep Attri, Awadhesh Kumar Jaiswal
DOI:10.4103/ajns.AJNS_48_19  
Hemifacial spasm (HFS) is a benign condition characterized by unilateral, involuntary, paroxysmal clonic and tonic contractions of the facial muscles. This condition usually results from a focal demyelination at the root entry zone of the 7th cranial nerve secondary to a vascular loop compression, and hence, it responds to microvascular decompression (MVD) surgery, similar to trigeminal neuralgia. Herein, we report an interesting clinical finding of a contralateral dry eye in the case of HFS, which has not been described previously and discuss the possible underlying mechanisms. A 53-year-old man presented with a 6-month history of involuntary twitching movements of the left hemiface that persisted during sleep, consistent with the diagnosis of HFS. The patient's attempts to voluntarily control the troublesome involuntary left-sided eye blinking led to the development of dryness and reddening of the right eye. Corneal reflex, both direct and consensual, was intact bilaterally, and an ophthalmological examination ruled out the diagnosis of conjunctivitis. The patient underwent MVD of the facial nerve. To our surprise and validating our supposition, his contralateral conjunctival hyperemia and dry eye resolved within a day of surgery, along with complete resolution of the HFS. HFS can lead to the contralateral dry eye from the voluntary suppression of ocular blinking which resolves following MVD. We demonstrate this finding for the first time and believe its recognition may be of value in the patient management.
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Ossification of the cruciform ligament of atlas; a rare cause of cervical myelopathy: Case report and review of literature p. 999
Muhammad Waqas Saeed Baqai, Gohar Javed, Mirza Zain Baig
DOI:10.4103/ajns.AJNS_76_19  
We present a case of cervical myelopathy secondary to ossification of the cruciform ligament (also known as cruciate ligament). This is a rare phenomenon that, to the best of our knowledge, has only been reported 16 times previously in literature. We have added a review of literature after our case presentation. We hope that by doing so, we may aid clinicians reach early diagnosis so as to be able to better manage this rare disease.
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Microvascular revascularization for recurrent A1 anterior cerebral artery aneurysm postendovascular treatment: A case report and review of the literature p. 1004
Aaron Musara, Yasuhiro Yamada, Katsumi Takizawa, Kenichi Haraguchi, Tsukasa Kawase, Riki Tanaka, Kyosuke Miyatani, Takao Teranishi, Krishna Mohan, Yoko Kato
DOI:10.4103/ajns.AJNS_113_19  
The recurrence of aneurysms postcoil embolization is a common occurrence. Endovascular coiling has been noted to be more effective for small lesions rather than the giant aneurysms. A postembolization recurrent aneurysm is a difficult condition to manage. We present a case of a recurrent giant aneurysm of the anterior cerebral arteries (ACAs) first segment (A1). It was managed by superficial temporal artery to A3 segment of anterior cerebral artery bypass anastomotic revascularization plus distal A1- segment clipping. A literature review is presented for the management of giant A1 artery aneurysms.
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Precautions for using a filter protection device with a flow reversal method during carotid artery stenting: A case report on in-filter thrombus p. 1008
Tomotaka Ohshima, Shigeru Miyachi, Naoki Matsuo, Reo Kawaguchi, Masakazu Takayasu
DOI:10.4103/ajns.AJNS_296_18  
The combination of a flow reversal with two balloons and a filter protection device is one of the safest methods that can be used during carotid artery stenting (CAS). Although major adverse events did not occur under restrict protection, we experienced a case of in-filter thrombus during the procedure. A 68-year-old male presented with temporary right hemiparesis. The radiological examinations revealed 95% stenosis on the origin of the left internal carotid artery (ICA). The patient underwent left CAS of wherein a proximal common carotid artery balloon, an external carotid artery balloon, and a distal ICA filter, with continuous flow reversal to the femoral vein, were used. Although the reversal circulation was established, a massive newly developing thrombus was found in the proximal side of the filter. After an additional systemic heparinization, the thrombus disappeared. The procedure was performed without any complications. Physicians should be aware of the risk of developing intraprocedural thrombosis in a filter protection device. Because the filter protection device is designed for the antegrade flow, it may promote the development of thrombus against the retrograde flow. Thus, the filter protection device should be retrieved first under the flow reversal circumstance to avoid the distal migration of a clot around the filter device.
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Spontaneous resolution of brain abscess by rupture into middle ear p. 1011
Mohit Agrawal, Manoj Phalak, Smriti Panda, Shashank Sharad Kale
DOI:10.4103/ajns.AJNS_85_18  
Intracranial abscesses are uncommon, serious, and life-threatening infections, with mortality rate of about 15%. Surgical treatment is warranted for an abscess size more than 2.5 cm. We present an unusual case with spontaneous resolution of a large abscess through the middle ear without any surgical intervention.
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Horner's syndrome due to cervical sympathetic chain schwannoma: A rare presentation and review of literature p. 1013
Harshad Patil, Shrikant Rege
DOI:10.4103/ajns.AJNS_58_18  
Cervical sympathetic chain schwannoma (CSCS) is an extremely rare benign tumor, and it is a diagnostic challenge. We report a case of 45-year-old female who presented with a solitary right cervical swelling with clinical features of Horner's syndrome (HS). She was evaluated with computed tomography, magnetic resonance imaging, and angiography. Surgical excision of the lesion was performed, and the histological examination revealed the diagnosis of schwannoma. Herein, we review the presentation, imaging characteristics, and operative considerations of a patient with a large CSCS, presenting with HS.
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Correction of postlaminectomy cervical kyphosis in an operated case of cervical spine primitive neuroectodermal tumor p. 1017
Sudhir Srivastava, Nandan Marathe, Sunil Bhosale, Sai Gautham
DOI:10.4103/ajns.AJNS_52_19  
A 14-year-old boy presented with gradually worsening spastic quadriparesis and cervical kyphotic deformity as a consequence of laminectomy for tumor debulking and chemoradiotherapy done 2 years prior for cervical primitive neuroectodermal tumor. Problems to be addressed particularly to the case were a rigid kyphosis of 102.7°, poor soft-tissue coverage, internal gibbus compressing cord, perched facets, and superficial location of cord. The surgery was staged, in that the first anterior release was done with gradually increasing traction to correct the kyphosis progressively. Posterior instrumentation was done in the second stage. Finally, anterior reconstruction with tricortical iliac bone grafting was done. The patient regained full power with complete union at the end of 18 months. Irradiation of tumor along with laminectomy results in loss of posterior tension band which results in progressive kyphotic deformity in children. A staged plan of surgical interventions can help in postoperative correction of deformity with circumferential union and prevention of recurrence. This article describes successful treatment of a patient with postlaminectomy cervical kyphosis with 77° of correction achieved postoperatively and also highlights the importance of anterior and posterior reconstructions to achieve a stable vertebral column.
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Acute calcific discitis or symptomatic calcified schmorl's node of the upper thoracic spine in an adult: A case report and literature review p. 1021
Prasert Iampreechakul, Punjama Lertbutsayanukul, Narupat Suanprasert
DOI:10.4103/ajns.AJNS_119_19  
We describe a patient with acute calcific discitis following symptomatic Schmorl's node (SN) of upper thoracic spine. A 28-year-old female suffered from sudden severe pain in mid-thoracic, left scapular area, radiating to her chest. Plain radiography of the thoracic spine showed calcification in T3–4 intervertebral disc space. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the spine demonstrated calcification of the T3–T4 nucleus pulposus, migrating into the inferior of T3 vertebral body with reactive bone marrow edema. By conservative treatment with multidrug therapy, the pain subsided and disappeared in 3 months. Follow-up CT scan and MRI of the thoracic spine confirmed complete resolution of calcified SN and reactive bone marrow edema.
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Staged deep brain stimulation of ventral intermediate nucleus of the thalamus for suppression of essential tremors p. 1030
Riki Tanaka, Ahmed Ansari, Yasukazu Kajita, Yasuhiro Yamada, T Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_132_17  
Deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of the thalamus is a powerful surgical option in the treatment of essential tremors (ETs). However, its therapeutic efficacy depends on the tremor distribution. DBS is highly efficient in the relief of distal appendicular tremor but not other types of tremor. We report a case of staged DBS of ventral intermediate nucleus (VIM) of thalamus for the suppression of ETs.
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Cavernous malformation of a thoracic spinal nerve root: Case report and review of literature p. 1033
Juan C Vicenty, Ricardo J Fernandez-de Thomas, Samuel Estronza, Miguel A. Mayol-Del Valle, Emil A Pastrana
DOI:10.4103/ajns.AJNS_249_18  
Intradural extramedullary spinal cavernous malformations (CMs) remain the least common variant of these lesions and can originate from the inner surface of the dura mater, the pial surface of the spinal cord, and the blood vessels in the spinal nerves. Root-based-only extramedullary CMs are very rare in the thoracic region with only four cases reported. We present a case of 56-year-old male with 1-year progression of lower extremities weakness. Magnetic resonance imaging demonstrated a hyperintense lesion in the upper thoracic region. Surgical exploration revealed a CM with origin in the second thoracic nerve root with gross total resection. Histopathological examination confirmed a CM. The patient had complete recovery of neurological function at 3 months interval. Intradural extramedullary CM is extremely rare entity that must be considered in the differential diagnosis of intradural extramedullary lesions. Surgical resection is the treatment of choice to prevent further neurological damage.
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Acute hydrocephalus caused by cerebellar abscess in HIV-negative castleman's disease p. 1037
Angelo Rusconi, Alessandro Dario, Gianluca Agresta, Sergio Balbi
DOI:10.4103/ajns.AJNS_32_17  
Castleman's disease (CD) is a rare and indolent hematologic disorder characterized by solitary bulky adenopathy. Multiple nodal nonbulky localizations are described, while central nervous system involvement is rare. Immunodeficiency is associated with higher incidence of CD, and HIV serology should be performed at initial diagnosis. We report the case of a 64-year-old HIV-negative man affected by CD, presenting with acute hydrocephalus caused by a large cerebellar abscess.
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Efficacy and safety of a modified pigtail-shaped microguidewire during endovascular thrombectomy p. 1040
Fuminori Ato, Tomotaka Ohshima, Shigeru Miyachi, Naoki Matsuo, Reo Kawaguchi, Masakazu Takayasu
DOI:10.4103/ajns.AJNS_28_19  
A 75-year-old man presented with right-sided hemiplegia and was diagnosed with a left middle cerebral artery occlusion. He underwent endovascular thrombectomy, and a bulge was found. A modified pigtail-shaped microguidewire (MPMGW) proved useful for diagnosis because it allowed differentiation between the occluded artery and a saccular aneurysm as the etiology. When a clot was partially retrieved, a previously unidentified vessel dilatation appeared. The dilatation origin was unclear and could have resulted from either the occluded artery or an unruptured saccular aneurysm. We tried to navigate the MPMGW into the bulging area. The patient showed unusual body movement attributed to pain and the dilatation was diagnosed as an aneurysm. Subsequent 3-dimensional angiography revealed a recanalized artery and the aneurysm. With no subarachnoid hemorrhage or extravasation of the contrast medium. The hemiplegia dramatically improved. An MPMGW may be useful in acute thrombectomy where the target vessel cannot be visualized during the procedure.
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TECHNICAL NOTE Top

“Cable suturing technique” a dural obliteration method for the prevention of cerebellar herniation through a large occipital meningocele p. 1044
Abdulrazaq Abdulmohsen Alojan, Ibtihal Sadiq Alsaad, Fatimah Yousef Alghareeb, Wisam Mostafa Al-issawi, Ahmed Sabry Ammar
DOI:10.4103/ajns.AJNS_60_19  
The authors present a patient who had a large occipital meningocele, which was transformed into an encephalocele after primary closure due to a large skull defect. Thus, the technical importance of classifying patients with occipital meningocele with a large skull defect and a tight dural obliteration is crucial, not to leave a wide dead space with a potential risk of cerebellar herniation. Encephalocele and meningocele are embryological anomalies, which result in intracranial structures herniation due to inborn skull defect. Acquired encephalocele may develop through the same defect with normal cerebellar tissues; since the prognosis of occipital encephalocele may worsen as the size of herniation increases, the patient underwent a modified dural obliteration technique (Cable Suturing Technique) to adjust the size of the dura and to strengthen it to prevent the risk of future herniation followed by cranioplasty and the cerebellar herniation regressed significantly after the procedure.
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LETTERS TO EDITOR Top

Ipsilateral two spontaneous chronic calcified epidural hematoma Highly accessed article p. 1048
Sheikhoo Bishnoi, Ishu Bishnoi, Nisha Gahlawat, Vikram Saini
DOI:10.4103/ajns.AJNS_199_17  
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T. S. Kanaka: First asian woman neurosurgeon, who pioneered stereotactic, functional and cerebral electrode implant surgery and developed separate neurosurgical speciality in India Early 1970 p. 1050
Guru Dutta Satyarthee, Aman Jagdevan
DOI:10.4103/ajns.AJNS_287_18  
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A dry pineapple slice like lesion in the anterior skull base p. 1051
Harald De Cauwer, Anniek Eerdekens, Filip Stessels, Dieter Vanneste, Gert De Mulder
DOI:10.4103/ajns.AJNS_367_16  
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Primary intracranial dural-based ewing sarcoma/peripheral primitive neuroectodermal tumor with extracranial extension: An uncommon case p. 1052
Sumit Bansal, Rabi Narayan Sahu, Pritinanda Mishra, Saubhagya Kumar Jena
DOI:10.4103/ajns.AJNS_22_19  
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Near complete resolution of bilateral thalamic venous infarct in the absence of superficial venous sinus thrombosis Highly accessed article p. 1054
Sachin Sampat Baldawa, Sunil Hogade
DOI:10.4103/ajns.AJNS_62_17  
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