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April-June 2020
Volume 15 | Issue 2
Page Nos. 251-467

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REVIEW ARTICLES  

Aspiration thrombectomy for posterior circulation stroke: A systematic review and meta-analysis Highly accessed article p. 251
Kevin Sheng, Marcus Tong
DOI:10.4103/ajns.AJNS_151_19  
Purpose: This study aims to analyze the efficacy of aspiration thrombectomy for large vessel occlusion of the posterior circulation, with an emphasis on comparison with stent retriever thrombectomy. Methods: A systematic review and meta-analysis were performed to analyze the outcomes of aspiration thrombectomy for acute posterior circulation stroke. For those studies that included data for both aspiration and stent-retriever thrombectomy, we additionally performed a second meta-analysis comparing their outcomes against each other. Results: A total of 17 articles were included. For the primary outcomes, the weighted pooled rate of mortality was 26.71% (95% confidence interval [CI] 19.35%–34.71%), modified Ranking Score (mRS) 0–2 at 3 months was 36.71 (95% CI 32.02%–41.52%), and successful recanalization 89.26% (95% CI 83.12%–94.31%). Primary stent retriever thrombectomy was inferior to primary aspiration thrombectomy for the outcomes of successful recanalization (odds ratio [OR] 0.57, 95% CI 0.36–0.91, P = 0.018), complete recanalization (OR 0.65, 95% CI 0.42–0.1.00, P = 0.048), procedure time (mean difference 28.17, 95% CI 9.47–46.87), and rate of embolization to new territory (OR 5.01, 95% CI 1.20–20.87, P = 0.027). No significant difference was seen for other outcomes. Further subgroup analysis suggests that for the outcome of recanalization, this may be dependent on the availability of second-line stent retriever thrombectomy. Limitations: The included studies were observational in nature. There was unresolved heterogeneity in some of the outcomes. Conclusions: There was no statistically significant difference seen for the primary outcomes of mortality and favorable outcome (mRS score 0–2) at 3 months. While superior rates of successful recanalization, complete recanalization, faster procedural time, and improved safety profile for primary aspiration thrombectomy were seen compared to primary stent retriever thrombectomy, this did not translate into superior clinical outcomes.
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Pediatric cerebellar pilomyxoid astrocytoma: Clinical and radiological findings in three cases Highly accessed article p. 262
Ghassen Gader, Ghassen Belkahla, Nadhir Karmani, Khalil Saadaoui, Mouna Rkhami, Jalel Kallel, Ihsèn Zammel, Mohamed Badri
DOI:10.4103/ajns.AJNS_268_19  
Pilomyxoid astrocytomas (PMA) is a particular form of glial tumors distinct from pilocytic astrocytomas (PA). On the last 2016 WHO classification for CNS tumours, no definite grade assignment was proposed for these lesions. They may be more aggressive with a different clinical course compared to PA due to their greater propensity for local recurrence and cerebrospinal dissemination. Most cases arise from the hypothalamic region. Only few studies reported cerebellar localization of the lesion. We report 3 pediatric cases treated for pediatric PMA of the posterior fossa. Clinical, radiological, and prognostic features were reviewed. The age of our patients was between 1 and 9 years old. Signs of intracranial hypertension were found in all patients. One of them presented an increased head circumference and the 2 others had a cerebellar syndrome. Brain CT-scan and MRI displayed a large wellcircumscribed intra-axial solid and cystic posterior fossa tumor. Total surgical resection was performed for all tumors. After a 2 years follow up, no signs of recurrence were noticed. In the literature, PMA been reported with overwhelming majority in children aged between 2 months and 4 years. Despite of many pathological similarities with PAs, PMAs have some specific features in histology, leading to their identification as independent type of glioma. Radiological differential diagnosis between PMAs and Pas can be made using arterial spin labeling imaging, which shows low perfusion parameters in PAs. Clinical and radiological follow up are mandatory do to different natural history and higher rates of local recurrence of this tumor compared to PA. Prognosis is favorable when complete surgical exeresis is possible.
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The ethical dilemma in the surgical management of low grade gliomas according to the variable availability of resources and surgeon experience Highly accessed article p. 266
Marshall Norman Lahiff, Michael George Zaki Ghali
DOI:10.4103/ajns.AJNS_296_19  
Low grade gliomas (LGGs) affect young individuals in the prime of life. Management may alternatively include biopsy and observation or surgical resection. Recent evidence strongly favors maximal and supramaximal resection of LGGs in optimizing survival metrics. Awake craniotomy with cortical mapping and electrical stimulation along with other preoperative and intraoperative surgical adjuncts, including intraoperative magnetic resonance and diffusion tensor imaging, facilitates maximization of resection and eschews precipitating neurological deficits. Intraoperative imaging permits additional resection of identified residual to be completed within the same surgical session, improving extent of resection and consequently progression free and overall survival. These resources are available in only a few centers throughout the United States, raising an ethical dilemma as to where patients harboring LGGs should most appropriately be treated.
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Surgical approaches to basilar apex aneurysms: An illustrative review Highly accessed article p. 272
Jiangbo Li, Amir Azarhomayoun, Mohsen Nouri, Ittichai Sakarunchai, Yasuhiro Yamada, Kei Yamashiro, Yoko Kato
DOI:10.4103/ajns.AJNS_76_16  
Surgical management of basilar apex aneurysms remains one of the most challenging areas in neurovascular surgery. Technical demands of treating these aneurysms have inspired several generations of neurosurgeons to push the limitations of technical achievement. Advances in neuroanesthesia, cerebral protection paradigms, and critical care management have enhanced surgical outcomes of these lesions. Several approaches have been described to reach these lesions from anterolateral or lateral corridors. Each surgical approach has its own advantages and limitations and should be chosen for each patient according to the aneurysm's position, projection, parent arteries, and perforators. In this review, we will discuss pros and cons of the common approaches to these aneurysms with description of the important steps of each surgical procedure.
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ORIGINAL ARTICLES Top

The keyhole approach in anterior circulation aneurysm – Current indication and limitation with review of literature Highly accessed article p. 278
Lavlesh Rathore, Yashiro Yamada, Tsukasa Kawase, Yoko Kato, Satya Bhusan Senapati
DOI:10.4103/ajns.AJNS_25_19  
Introduction: The keyhole approach has been an emerging technique for cerebral aneurysm surgery in the past two decades. The preoperative simulation and tailored-made approach for each patient make feasible to clip many cerebral aneurysms via keyhole approach. In our study, we reviewed the previous experiences of the keyhole approach, related specifically for anterior circulation aneurysm. Material and Methods: The comprehensive literature review was performed on PubMed, Google Scholar, ScienceDirect, and various neurosurgery and neurology journals. Then, each manuscript's reference list was reviewed for the potential relevant article. The data of total 17 articles, which met our inclusion criteria included for the final review. Results: It was found that the anterior communicating artery, middle cerebral artery, and internal carotid- posterior communicating aneurysms were the most common locations treated by keyhole approach. The size of an aneurysm was <10 mm in most of the studies. Many studies treated multiple aneurysms by single keyhole approach. Conclusion: The keyhole approach has shown benefit in term of satisfactory aneurysmal occlusion rate, short operative time, less blood loss, short hospital stay, and good overall surgical outcome.
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Histopathological pattern and outcome of posterior fossa tumors in children and adults – A 20-year experience p. 285
Abdul Rashid Bhat, Muhammed Afzal Wani, Altaf Rehman Kirmani
DOI:10.4103/ajns.AJNS_120_19  
Context: The postoperative quality and span of life in posterior fossa tumors (PFTs) is complicated by the residual disease, progression, recurrence, disabilities, and mortality. Aims: The aim of this study is to analyze the link between histopathological type of tumor and outcome in an ethnic Himalayan population of India. Settings and Design: The histopathological records of 410 out of 589 patients were compared with their clinical outcome up to the 1st postoperative year in a single center which amounts to regional epidemiological value of PFTs. Materials and Methods: In this observational study, retrospectively postoperative records of 589 PFTs from November 1990 to December 2010 (20 years) were retrieved, scrutinized, and observed. The postoperative records of 410 patients with proved histopathological examination results were included. Statistical Analysis Used: The statistical law of variance was applied wherever necessary. Results: About 63.2% of 410 operated PTFs were males while females predominated in meningiomas and pineoblastomas. About 31.7% of PFTs were children (below 18 years.). About 54.1% of the cases were histologically malignant. The residual tumors comprised 40.2%, and symptoms of disease progression occurred in 10.9%. The tumor recurrence occurred in 14.3% while 6.0% of the patients developed severe disability. The overall mortality was 11.4% up to the 1st postoperative year, with 18.9% in malignant patients. The first 1-year event-free survival (EFS) for all the patients was 66.0%. While the patients with malignancies had the first 1-year EFS of 47.7%, the histologically benign group had 87.7%. Conclusion: The first 1-year postoperative EFS of histologically benign and some malignant PFTs both in children and adults such as pilocytic astrocytomas, ependymomas, and pineoblastomas was much better (87.7%) than other malignant PTFs.
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Comparative study of minimally invasive lumbar decompression versus decompressive laminectomy with posterolateral transpedicular fixation for the treatment of degenerative lumbar canal stenosis p. 293
Ahmed Reda Aldahshory, Hazem Mashaly, Shafik Tahseen El Molla, Ibrahim Abdelmohsen Ismaiel, Khaled Saoud
DOI:10.4103/ajns.AJNS_132_20  
Background: The classic laminectomy for spinal decompression was the treatment of choice of the degenerative lumbar canal stenosis (LCS). Many surgeons prefer to add instrumented lumbar fusion to avoid future instability after the removal of posterior elements. Adding fusion is associated with more bleeding and longer periods of hospitalization. Minimally invasive lumbar decompression (MILD) has been advocated for successful decompression with less bleeding loss and shorter hospitalization. Aim of the Work: To evaluate and compare the clinical outcomes of two different treatment modalities for degenerative LCS: the classic laminectomy with posterolateral transpedicular screw fixation and the MILD. Patients and Methods: Fifty patients with degenerative LCS were randomized from two institutions: Ain Shams University Hospital and Arab Contractors Medical Center, who underwent surgeries for degenerative LCS between 2016 and 2018 with 1-year follow-up. The study compared two cohorts: Group A – 25 patients underwent classic lumbar laminectomy with posterolateral transpedicular fixation, and Group B – 25 patients underwent MILD. Results: There were no statistically significant differences between both treatment modalities in the VAS for leg pain and back pain, the patient satisfaction index, and the Oswestry disability index after 1 year. The fusion operations were associated with higher estimates of blood loss, longer hospital stay, and more financial costs. Conclusion: MILD has the same satisfactory results as classic laminectomy with posterolateral fixation for the treatment of degenerative LCS with less bleeding loss and shorter hospitalization. Since the results are comparable, MILD is suggested in low-income countries as Egypt for economic reasons.
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Endoscopic third ventriculostomy for hydrocephalus in infants: A single-center experience p. 302
Krishna Govind Lodha, Gaurav Jaiswal, Tarun Kumar Gupta, Vibhushankar Parashar, Yogendra Singh
DOI:10.4103/ajns.AJNS_17_20  
Introduction: Hydrocephalus remains one of the more common pathologies managed in pediatric neurosurgery. Endoscopic third ventriculostomy (ETV) has become the procedure of choice for the treatment of hydrocephalus due to aqueductal stenosis with high success rate. It has an advantage over ventriculoperitoneal (VP) shunting, as it enables patients to remain device free. Objective: The purpose of this study is to assess the role of ETV in the treatment of hydrocephalus in children under 1 year of age, including preterm low birth weight infants. Materials and Methods: A prospective study of 30 infants undergoing ETV in our institution between January 2014 and December 2018 was carried out. There were 25 cases of congenital hydrocephalus with aqueductal stenosis, two cases of Dandy–Walker cyst, two cases of cerebellopontine angle arachnoid cyst, and one case of posttubercular meningitis. ETV success score was calculated preoperatively to evaluate the percentage of success of ETV. Results: The overall success rate was 76.66% (23), with highest success rate of 84% in aqueductal stenosis. The mean age was 6.75 months (range: 1.5–12 months). Five infants were born preterm, four of them required a permanent VP shunt. There were two cases of intraoperative bleeding, four cases of cerebrospinal fluid leak from the wound, and one case of meningitis. Conclusion: ETV can be considered a safe and effective modality for the initial treatment of hydrocephalus in full-term normal birth weight infants, while the success of ETV in preterm low birth weight infants need further study of maturity at birth and birth weight as the determinant factors for the success of ETV in this special group.
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Safety and efficacy of a direct aspiration first-pass technique with large-bore catheters for acute ischemic stroke in vietnam: Experience of a single center p. 306
Vu Dang Luu, Le Hoang Kien, Tran Anh Tuan, Nguyen Quang Anh, Nguyen Tat Thien, Nguyen Thu Trang, Dao Viet Phuong, Mai Duy Ton, Pham Minh Thong, Le Chi Cong, Vu Van Trieu, Nguyen Tien Manh, Tran Cuong
DOI:10.4103/ajns.AJNS_263_19  
Purpose: The purpose of this study was to evaluate the safety and efficacy of mechanical thrombectomy with a direct aspiration first-pass technique (ADAPT) using large-bore catheters in patients with acute ischemic stroke due to large vessel occlusion (LVO) in a hospital in Vietnam. Methods: This was a retrospective review of patients with acute ischemic stroke due to LVO who were diagnosed and underwent mechanical thrombectomy using ADAPT with large-bore catheters at Bach Mai Hospital from January 2017 to June 2018. Results: Seventy-three patients (47.9% female; age: 61.29 ± 14.49 years) met study criteria. The average procedure duration was 45.09 ± 38.26 min. Successful recanalization post-ADAPT (thrombolysis in cerebral infarction 2b-3) was achieved in 72.6% (53/73) of patients. Good functional outcome (Modified Rankin Scale 0–2) at 3 months was achieved in 50.7% (37/73), with poor functional outcome in 24.7% (18/73). The 90-day mortality rate was 24.7% (18/73). The hemorrhagic transformation rate was 31.6%, in which 19.2% were symptomatic. Vessel perforation occurred in 5.5% (4/73) of patients but in all cases was associated with the guidewire and not the reperfusion catheter. Vessel dissection occurred in 1.4% (1/73) and vasospasm in 5.5% (4/73) of patients. Conclusion: Mechanical thrombectomy using ADAPT with large-bore catheters for acute ischemic stroke due to LVO is a method that yielded good results in recanalization and clinical recovery in a Vietnamese patient population.
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Functional outcome of right-sided thoracotomy for tuberculosis of the dorsal spine p. 311
Sudhir Srivastava, Nandan Marathe, Sunil Bhosale, Aditya Raj, Kiran Dhole, Harsh Agarwal
DOI:10.4103/ajns.AJNS_311_19  
Introduction: In pathologies of the spine involving dorsal vertebrae, it is a routine practice to go for left-sided thoracotomy. It is so because in this approach, we encounter the aorta before reaching the concerned dorsal vertebra which is easy to handle as compared to the inferior vena cava on the right-sided approach. This is because the aorta is a structure with thick muscular wall. However, there are conditions which demand right-sided thoracotomy for better outcome such as idiopathic scoliosis and dorsal spine tuberculosis (TB). The selection of side of thoracotomy should be done on case-to-case basis. Study Design: This was a prospective study of 10-year duration. Purpose: The purpose of the study was to analyze whether it is more rational to do thoracotomy from the right side than left for dorsal spine TB. Materials and Methods: The study was performed on 102 dorsal Koch patients with neurological deficit who required surgical decompression. Magnetic resonance imaging of those patients was analyzed. Seventy-two patients had predominant right-sided lesion. Left and central types of predominant results were in 19 and 11 patients, respectively. Among these 102 patients, 82 were operated with right-sided thoracotomy, whereas 20 were operated for left-sided thoracotomy. Preoperative and postoperative kyphosis angle (K angle), average surgical time, mean blood loss, and visual analog scale (VAS) score were calculated. The SPSS 17 software was used for the statistical analysis. Results: Right thoracic approach turned out to be better approach than left in dorsal Koch spine. The average surgical time and mean blood loss were less in the right thoracotomy than left. Postoperative K angle and VAS were improved in the right thoracic approach as compared to left. Conclusion: Tubercular debris in the dorsal spine predominantly is on the right side, and right thoracotomy gives better results as there is better decompression of lesion.
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Ten years' experiences in the treatment of nonaneurysmal subarachnoid hemorrhage: A retrospective analysis of outcome parameters in a single-center study p. 315
Mohammed Alhoobi, Fatma Abu-Qadous, Mohsin Khan, Ahmed Shaaban, Nissar Shaikh, Firas Hammadi, Raed Abu-Jarir, Walid Albanna, Ghaya Alrumaihi, Sirajelddin Belkhair, Arun R Babu, Ali Ayyad
DOI:10.4103/ajns.AJNS_315_19  
Objectives: Subarachnoid hemorrhage (SAH) with negative angiographic findings has a heterogeneous nature with variations in clinical course and outcome as compared to the aneurysmal SAH. It makes up to 15% of the spontaneous SAH and is characterized by milder clinical presentation. The purpose of this study was the analyses of risk factors, clinical observations, radiologic characteristics, and outcome in patients with nonaneurysmal SAH (NA-SAH). Patients and Methods: In a retrospective design, 77 consecutive patients with NA-SAH were recruited from May 2008, to October 2018. All patients underwent conventional cerebral angiography. We stratified patients into two groups based on the distribution of blood on their CT scan into perimesencephalic (PM) and non-PM (NPM) SAH. We performed the Outcome using Glasgow Coma Scale (GCS) and modified Rankin scale (favorable mRS 0–2 vs. unfavorable mRS 3–6). Data were analyzed using IBM® SPSS® Statistics V22.0. Results: The mean age at presentation was 48.5 ± 8.4 years with male predominance (71.4%). About 76.7% of the patients had headache and vomiting, most of the patients (75.3%) presented with GCS 15 at initial clinical presentation (61.03%) had NPM versus (38.96%) with PM characters in computed tomography scans. Fourteen (17.9%) patients developed hydrocephalus and 12 (15.3%) needed external ventricular drain placement, while none of the patients needed permanent shunt placement. However, all patients had a favorable clinical and functional outcome at discharge and at late follow-up (up to 3 months). Conclusions: NA-SAH does not affect the short- and long-term prognosis. In our results, the pattern of bleeding affects the initial presentation, clinical course, and complications. The clinical and functional outcomes in the majority of our patients were comparable in both groups with good prognosis. Hypertension, smoking, and elevated venous pressure, such as a history of deep venous thrombosis and asthma might be considered as a risk factor.
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Morphometric analysis of the corpus callosum using cadaveric brain: An anatomical study p. 322
Apurba Patra, Rajan Kumar Singla, Priti Chaudhary, Vishal Malhotra
DOI:10.4103/ajns.AJNS_328_19  
Purpose: The present study was conducted to measure the longitudinal and vertical lengths of the brain hemisphere, longitudinal length of the corpus callosum (CC), and distances of CC from the frontal and occipital poles, in order to define its topographic location within the brain hemispheres. Materials and Methods: Fifty formalin-fixed human brains were dissected in the midsagittal plane. The parameters measured were as follows: (i) straight distance between frontal and occipital pole (AB); (ii) vertical distance (height) between the upper and lower surface of the brain hemisphere (CD); (iii) frontal pole to anterior-most point of CC (EG); (iv) occipital pole to posterior-most point of CC (ZO); (v) anterior-most point to posterior-most point of CC (EZ); and (v) anterior edge of genu to the upper end of lamina terminalis (EF). Results: The mean value of AB, CD, EG, ZO, EZ, and EF was 15.47 ± 0.94 cm, 9.48 ± 0.83 cm, 3.31 ± 0.29 cm, 5.65 ± 0.54 cm, 6.96 ± 0.55 cm, and 2.1 ± 0.39 cm, respectively. AB had the strongest positive correlation with ZO (0.79), whereas CD (height) had it with EZ (0.59). Both AB and CD had a strong positive correlation with EZ. The ratios EZ/AB = 0.45 (P = 0.001) and EZ/CD = 0.73 (P = 0.003) illustrated a steady and significant proportions, present in all the brains studied. Although the mean values of all the parameters were greater in males than in females, only two parameters (ZO and EZ) showed statistically significant (P < 0.05) gender differences. Conclusion: The precise anatomical knowledge regarding the morphometry of CC will provide baseline data for the diagnosis and progression of disease affecting it.
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Golden wires and rectangle: A cost-effective treatment for tuberculosis of the thoracic spine p. 328
Sudhir Srivastava, Nandan Marathe, Sunil Bhosale, Shaligram Purohit, Aditya Raj, Ankit Amin, Chetan Shende, Sai Gautham Balasubramanian
DOI:10.4103/ajns.AJNS_335_19  
Study Design: This was a retrospective study. Purpose: The purpose of this study was to compare the functional outcome and cost of surgery for tuberculosis (TB) of the thoracic spine between two commonly used fixation modalities “pedicular screws and rods” and “Hartshill loop rectangle and sublaminar wires.” Overview of Literature: TB is a common ailment in Asia. Surgical indications have remained almost unchanged since the middle-path regimen was advocated by Tuli. Pedicle screws and Hartshill loop rectangle with sublaminar wires are the two common fixation techniques used. Materials and Methods: This retrospective observational study was performed at a single tertiary center. Patients were divided into two groups depending on the method of fixation (pedicle screw rod/Hartshill loop rectangle and sublaminar wires). All patients were evaluated preoperatively by X-rays and magnetic resonance imaging. Patients were assessed clinically by preoperative and postoperative neurology and Visual Analog Scale score and radiologically assessed by the K angle. These variables were separately compared in both the groups. Results: The functional outcomes of Hartshill loop rectangle and sublaminar wire fixation and that of pedicular screw fixation were comparable. Hartshill loop rectangle and sublaminar wire fixation was found to be more cost-effective. Conclusion: Hartshill loop rectangle and sublaminar wire fixation gets purchase over the posterior column structures alone when compared to pedicle screws which have a 3-column hold. However, when combined with meticulous neural decompression and skillful preparation of osteogenic bed with autologous strut grafting and additional onlay grafting, it gives overall adequate stabilization of the column with functional outcome comparable to pedicular screw and rod fixation with additional benefit of cost-effectiveness. Although Hartshill loop rectangle and sublaminar wire fixation is less commonly used now, it has a special place in the management of TB, especially in a resource-poor setting like some countries of Asia.
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Evaluation of lumbar spine bracing as a postoperative adjunct to single-level posterior lumbar spine surgery p. 333
Saurabh Sinha, Ian Caplan, James Schuster, Matthew Piazza, Gregory Glauser, Nikhil Sharma, William Charles Welch, Benjamin Osiemo, Scott Mcclintock, Ali Kemal Ozturk, Neil Rainer Malhotra
DOI:10.4103/ajns.AJNS_35_20  
Background: Clinical practice in postoperative bracing after posterior single-level lumbar spine fusion (PLF) is inconsistent between providers. This study seeks to assess the effect of bracing on short-term outcomes related to safety, quality of care, and direct costs. Methods: Retrospective cohort analyses of consecutive patients undergoing single-level PLF with or without bracing at a three-hospital urban academic medical center (2013–2017) were undertaken (n = 906). Patient demographics and comorbidities were analyzed. Test of independence, Mann–Whitney–Wilcoxon test, and logistic regression were used to assess differences in length of stay (LOS), discharge disposition/need for postacute care, quality-adjusted life year (QALY), surgical site infection (SSI), hospital cost, total cost, readmission within 30 days, and emergency room (ER) visits within 30 days. Results: Among the study population, 863 patients were braced and 43 were not braced. No difference was seen between the two groups in short-term outcomes from surgery including LOS (P = 0.836), discharge disposition (P = 0.226), readmission (P = 1.000), ER visits (P = 0.281), SSI (P = 1.000), and QALY gain (P = 0.319). However, the braced group incurred a significantly higher direct hospital cost (median increase of 41.43%, P < 0.001) compared to the unbraced cohort (bracing cost excluded). There was no difference in graft type (P = 0.145) or comorbidities (P = 0.20–1.00) such as obesity (P = 1.000), smoking (P = 1.000), chronic obstructive pulmonary disease (P = 1.000), hypertension (P = 0.805), coronary artery disease (P = 1.000), congestive heart failure (P = 1.000), and total number of comorbidities (P = 0.228). Conclusion: Short-term data suggest that removal of bracing from the postoperative regimen for PLF will not result in increased adverse outcomes but will reduce cost.
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Intraoperative use of endoscope, a valuable, adjunctive tool for the surgical management of anterior communicating artery aneurysm surgery: Our institutional experience p. 338
Vaibhav S Chavan, Yashuhiro Yamada, Chandratej Kadam, Gowtham Devareddy, Riccardo Stanzani, Firuz Shukurov, Kato Yoko
DOI:10.4103/ajns.AJNS_359_19  
Background: Anterior communicating (A-com) artery region is very complex; perforators are not always visualized on the microscope. The neuroendoscope with its higher magnification, better observation, and additional illumination can provide us information that may not be available with the microscope in aneurysm surgery. Objective: The objective was to study the use of endoscope in surgical management of A-com aneurysm surgery and its advantages, whether and how it changes operative management.Materials and Methods: We studied 25 serial cases of A-com aneurysm at Bantane Hospital, Fujita University, Japan, from November 2018 to October 2019. Once aneurysm was exposed, we did preclipping indocyanine green (ICG) study and examination with endoscope. After clipping, we again did ICG and endoscopic assessment. Preclipping and postclipping endoscopic information was used and necessary changes were made in the operative decisions. Whether endoscope gives any additional information over microscope and ICG which led to change in the operative decision was assessed. Results: In six out of 25 A-com aneurysm patients, the use of endoscope has given additional information over microscope, and ICG leading to change in the operative plans such as readjustment of the clip/application of the second clip or release of perforator compromise. Conclusion: Simultaneous endoscopic and microscopic guidance can reveal important information hidden from the microscope. Thus, this method increases the safety and durability of the A-com aneurismal clipping.
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Hearing outcomes after microvascular decompression for hemifacial spasm: An institutional experience p. 344
Ambuj Kumar, Ahmed Ansari, Yasuhiro Yamada, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_362_19  
Introduction: Hearing loss following microvascular decompression (MVD) for hemifacial spasm is one of the most dreaded complications. Several factors such as stretching of VIII cranial nerve, vasospasm of labyrinthine artery, and acoustic trauma due to drill noise may be considered in its causation. We evaluated the incidence and severity of hearing loss following MVD in hemifacial spasm and the factors which might be responsible for this complication. Methods: A retrospective analysis of 30 patients operated for hemifacial spasm between January 1, 2014, and December 31, 2018, with at least 3 months of follow-up were included in the study. Retromastoid craniotomy was made, and Teflon was placed between involved vessel and VII nerve. Results: Freedom from hemifacial spasm was noted in 27 of 30 patients. Moderate spasm persisted in one patient, which was controlled with medications. The recurrence was noted in 3 patients at 6 months follow-up. Postoperatively, hearing loss was found in one female patient. The offending vessel was both anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA) loop, which was transpositioned during surgery, and the patient was spasm free postoperatively. Conclusion: The incidence of hearing loss following MVD can be minimized using proper surgical techniques and various intraoperative adjuncts such as brainstem auditory evoked responses monitoring, use of endoscope, and indocyanine green or dual-image video angiography.
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Two-staged approach for giant hypervascular meningioma resection p. 349
Ahmed Ansari, Sadaf Riyaz
DOI:10.4103/ajns.AJNS_364_19  
Introduction: Giant meningiomas represent very uncommon and challenging tumors. Surgical morbidity is high due to the difficult and complex approaches to devascularize these hypervascular lesions. In the present series, we demonstrate a two-staged approach for surgical resection of giant hypervascular meningiomas. Patients and Methods: Four such patients having giant hypervascular meningiomas between July 2017 and June 2019 were taken in the present study. There were two falco-tentorial, one anterior and middle parasagittal and falcine meningioma, and one sphenoid wing with convexity meningioma. Results: In the first stage, only the hypervascular bone was removed, and the dura was coagulated and excised. In the definitive stage, usually undertaken 5–8 days following the first surgery, the meningioma was excised, leading to Simpson's Grade 2 excision in two and Grade 3 excision in the remaining two patients. There was one mortality of a previously operated malignant meningioma (histopathologically proven), owing to a cardiac event in the patient, while the other three were discharged without any new neurologic deficit. Conclusion: Two-staged approach for giant meningiomas represents a safe and effective surgical management, tolerable for the patient and more comfortable for the neurosurgeon.
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Radiologic–Histopathologic correlation of adult spinal tumors: A retrospective study p. 354
Murad Asilturk, Anas Abdallah, Erhan Özden Sofuoglu
DOI:10.4103/ajns.AJNS_366_19  
Aim: Preoperatively performed magnetic resonance images (MRIs) are essential before treating spinal tumors surgically. This study aims to investigate the compatibility of MRI preliminary diagnosis and proven histopathologic diagnosis of consecutively operated 96 spinal tumors. Material and Methods: Medical records were retrospectively reviewed for all spinal tumors operated at our institute during a period of 6 years. One hundred and ten spinal tumors were detected. Fourteen tumors were excluded because they were not met our study criteria. Results: Ninety-six cases of spinal tumors were detected in 46 female and 50 male patients. The mean age was 49.3 ± 22.7 years. The most common symptom was radicular pain (88.6%). Histopathologic diagnoses were metastasis (n = 26), meningioma (n = 16), schwannoma (n = 15), ependymoma (n = 9), astrocytoma (n = 6), chronic nonspecific granulomatous infection (n = 4), lymphoma (n = 3), lipoma (n = 3), epidural tuberculosis abscess (Pott's disease) (n = 3), and other pathologies in 11 cases. Cervical spine was the less spinal region affected with metastases (P < 0.05). Thoracic spine was the most affected spinal region from meningioma (P < 0.05). Preoperatively, preliminary diagnosis on MRIs was proven with histopathologic examinations in 22 metastasis, 14 meningioma, 11 schwannoma, and all epidermoid cyst and lipoma cases. Despite the fact that MRI cannot diagnose all cases of spinal tumors, MRIs had a high accurate rate to diagnose the most common spinal neoplasms (69.8%). Conclusions: Metastases rarely occurred in cervical spine, whereas meningiomas were most likely to occur in thoracic spine. MRIs can help diagnose metastases and spinal benign lesions, whereas they failed to distinguish astrocytomas and lymphomas. Further prospective studies with large size are needed to support our results.
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Visual outcomes after surgery for paraclinoid aneurysms: A fujita experience p. 363
Raja K Kutty, Ambuj Kumar, Yasuhiro Yamada, Tsukosa Kawase, Riki Tanaka, Kyosuke Miyatani, Saeko Higashiguchi, Vigneswar Ravishankar, Katsumi Takizawa, Yoko Kato
DOI:10.4103/ajns.AJNS_39_20  
Introduction: The surgical strategies for clipping of paraclinoid aneurysms are diverse. These aneurysms are unique in their location, as they closely abut the anterior clinoid process (ACP) and the optic nerve. The ultimate goal of clipping encompasses the exposure of neck of the aneurysm which is seldom complete without the manipulation of optic nerve and the ACP. This manipulation may result in disturbances of vision postoperatively. We analyze our results of visual outcomes in the surgery for paraclinoid aneurysms in this retrospective study. Materials and Methods: All patients with paraclinoid aneurysms who underwent surgery from June 2014 to June 2019 were included in the study. Surgical procedure was uniform in all patients which included anterior clinoidectomy and clipping of aneurysms as per the Bantane protocol. Glasgow Outcome Scale as well as vision was assessed at discharge and at 1 month and 6 months. Results: There were 77 cases of paraclinoid aneurysms operated during the abovementioned period. All patients had no symptoms related to vision preoperatively. Visual deterioration was noted in two patients. All patients were discharged with a good outcome on the Glasgow Outcome Scale. Conclusion: Paraclinoid aneurysm has a good outcome when treated with surgery. The visual deterioration following surgery can be minimized with extradural anterior clinoidectomy and careful handling of the vessels and nerve.
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Demystifying white matter injury in the unconscious patients with diffusion tensor imaging p. 370
Sneha Chitra Balasubramanian, Srikanth Talluri, Tsukasa Kawase, Yashuhiro Yamada, Kazuhiro Murayama, Riki Tanaka, Kyosuke Miyatani, Daijiro Kojima, Yoko Kato
DOI:10.4103/ajns.AJNS_55_20  
Background: Diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) provide a noninvasive window to study the neural connectivity and reconstruct the tracts. Detection of white matter injury (WMI) by DTT is a recent application being used in stroke, diffuse axonal injury, and neurodegenerative disorders. Fiber tracking in patients with brain hemorrhage can detect loss of fibers and anatomical disruption of the tracts, which can be useful in the prognostication of patient outcome. Materials and Methods: DTI and fiber tracking was done in four patients admitted at Fujita Health University Banbuntane Hospital, Japan, with decreased consciousness following brain hemorrhage (3 patients with aneurysmal subarachnoid hemorrhage and one patient with bifrontal hemorrhage), and WMI was analyzed. We also reviewed the literature on tractography in patients with brain hemorrhage and its correlation with consciousness. Results: We found significant frontal WMI in the form of thinning and anatomical disruption in all four cases. The frontal white matter tracts form an important component of the limbic system and ascending reticular activating system and frontal WMI correlated with the poor conscious level and cognitive dysfunction. Structural damage to the fiber tracts demonstrated as thinning, reduction in the volume or absence on tractography with corresponding reduction in the mean fractional anisotropy values in the frontal white matter of the affected side. Conclusion: DTI can be useful as a critical tool for revealing the anatomical basis for the cognitive dysfunction and unconsciousness and can be possibly used to prognosticate patient recovery. Early detection of WMI by DTI can also help in tailored rehabilitation. The authors believe that DTT could have a crucial role in the future for detecting structural changes which lead to cognitive dysfunction and further studies are needed to arrive at a specific protocol for detecting WMI.
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The satisfactory surgical outcome of posterior fossa brain tumors in children at civil hospital, karachi p. 377
Jahanzeb Kakar, Junaid Ashraf, Atiq Ahmed Khan, Muhammad Imran, Muhammad Asim Rehmani, Shiraz Ahmed Ghori, Mohammad Faaiq Ali
DOI:10.4103/ajns.AJNS_56_19  
Introduction: Posterior fossa brain tumor is the most devastating forms of human illness, primarily because of the limited space within the posterior fossa, the potential involvement of vital brain stem nuclei, and the mass effect causes obstructive hydrocephalus. Posterior fossa tumors are more common in children than adults. The Objective of the Study: To find out the satisfactory surgical outcome of posterior fossa brain tumors in children at Civil hospital, Karachi. Materials and Methods and Duration of Study Setting: This prospective observational, case series study was conducted from February 2015 to February 2105 in the Department of neurosurgery, Dow University of Health Sciences, Civil Hospital, Karachi, Karachi. Postoperative patients with the diagnosis of posterior fossa tumor were enrolled in the study. Detailed history, physical examination, anthropometrics, and biochemical measurements were recorded. Magnetic resonance imaging was done to determine the satisfactory surgical outcome. Patients were followed up at the third postoperative month to determine the satisfactory surgical outcome. Results: Seventy-one patients fulfilling the inclusion criteria, the mean ± standard deviation age of the study population was 6.63 ± 3.181 years. 29 (40.8%) were <7 years of age and 42 (59.2%) were of age 7 years and above. 50 (70.4%) were males and 21 (29.6%) were females. 49 (69%) patients presented with vomiting. 34 (47.9%) presented with seizures. (40.8%) had papilledema. (25.4%) presented with hemiparesis. 8 (11.3%) had meningismus. On analysis of the frequency of outcome variables (80.3%) achieved the satisfactory surgical outcome. Conclusions: There has been no major study to determine satisfactory surgical outcome in postoperative patients with posterior fossa brain tumor in our population. The study was to provide local data in our population and compare it to the international data. This may help in proper patient management. Majority of the patients had satisfactory surgical outcome. The absence of papilledema, hemiparesis, and meningismus had more chances of satisfactory surgical outcome.
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CASE REPORTS Top

Middle meningeal artery embolization following burr hole in chronic subdural hematoma p. 382
Abrar Arham, Nadya Zaragita
DOI:10.4103/ajns.AJNS_15_20  
Chronic subdural hematoma (CSDH) is a condition in which blood accumulates within the subdural space and may cause neurologic deficits. CSDH patients with neurologic deficits usually will undergo surgery, but reoccurrence is common. Middle meningeal artery (MMA) embolization has been proposed as one of the CSDH treatment options, either being used as a single treatment for the neurologically stable patients or certain conditions that may not allow patients to undergo surgery, or as a perioperative treatment. The authors reported a CSDH case with neurologic deficits who was on antiplatelet treatment that underwent both burr hole and MMA embolization for curation and prevention of rebleeding. The result showed near-complete blood resorption and no neurologic deficits.
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Decrease of proliferative potential and vascular density of giant prolactinoma in patients treated with cabergoline p. 385
Ludmila Astaf’eva, Ludmila Shishkina, Pavel Kalinin, Boris Kadashev, Galina Melnichenko, Dariia Tserkovnay, Oleg Sharipov
DOI:10.4103/ajns.AJNS_16_20  
Introduction: Currently, cabergoline therapy is the main treatment for prolactinomas. The use of the drug in most cases leads to regression of the tumor, normalization of prolactin (PRL) levels, and restoration of gonadotropic function. The mechanism of its action in tumor cells “in vivo” tracked in dynamics in the same human tumor is of considerable interest. Materials and Methods: A 30-year-old male was admitted to N.N. Burdenko National Medical Research Center of Neurosurgery. An magnetic resonance imaging (MRI) revealed a giant pituitary adenoma. The level of PRL was more than 5000 mU/l (30-360) (serum dilution was not used to determine PRL). Transcranial microsurgical removal of the tumor was performed. He was treated by cabergoline after surgery. Endoscopic transsphenoidal approach was repeated with subtotal removal of the rest of the tumor. Morphological and immunohistochemical studies of the tumor were done. Results: A morphological study revealed PRL-positive tumor with a Ki-67 LI of 8% with a distinctive expression of D2R, CD31, and CD34 markers. Control MRI in 3 months after surgery revealed remnants of a tumor of endoinfrasellar localization, the tumor remainders were found in endoinfrasellar localization. The tumor retained pronounced immunopositivity to PRL and D2R and a decrease in the Ki-67 to 2% and in the expression of CD31 and CD34. Subsequent therapy with cabergoline resulted in persistent normoprolactinemia, restoration of androgenic function, and absence of tumor recurrence during the 10-year follow-up period. Conclusions: Cabergoline is an effective treatment for prolactinoma, which leads to tumor regression. One of its mechanisms is the reduction of the proliferative index and tumor angiogenesis.
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Traumatic partial posterior cord brachial plexus injury in a patient with aberrant innervation of the long head of the triceps by the axillary nerve: Implications in nerve transfer surgery p. 391
Suyash Singh, Kuntal Kanti Das, Harsh Deora, Awadhesh Kumar Jaiswal, Sanjay Behari
DOI:10.4103/ajns.AJNS_160_19  
Brachial plexus repair forms an unmet need in terms of posttraumatic rehabilitation, especially the young population, wherein the incidence of accidents is high. This leads to decrease in the number of functionally active years after the accident. We encountered an interesting case of posttraumatic posterior cord injury predominantly affecting the shoulder abduction beyond 15°. An electrodiagnostic study showed a complete lack of conduction within the axillary nerve with reduced conduction velocity in the radial nerve. We took the patient up for the long head of the triceps transfer to the anterior division of the axillary nerve transfer. Intraoperatively, we found that the long head branch was originating from the axillary nerve at the point of division. As it could not be used for neurotization, we transferred the medial head branch of the radial nerve to the axillary nerve. The patient started to show electroclinical improvement after 3 months of the surgery. A few similar cases have been published, as a cadaveric finding. We report this case to highlight the possibility and need for a high clinical suspicion and also to provide a possible treatment option, in such aberrant anatomy.
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Morphological change of cerebral aneurysm with possible pseudoaneurysm at A2/3 of the anterior cerebral artery on three-dimensional computed tomographic angiography p. 394
Atsushi Tsukiyama, Toshiki Nozaki, Shutaro Matsumoto, Toshimasa Uekusa, Atsushi Tsuchiya, Motohiro Nomura
DOI:10.4103/ajns.AJNS_23_20  
Intracranial pseudoaneurysm formation due to a ruptured nontraumatic aneurysm is rare. We describe a case of ruptured aneurysm, which showed morphological change on radiological examinations. An 83-year-old woman developed subarachnoid hemorrhage (SAH) with ventricular rupture and intracerebral hematoma in the corpus callosum. Contrast-enhanced computed tomography (CE-CT) demonstrated an aneurysm at the right A2/3 junction of the anterior cerebral artery. CE-CT repeated 17 h after the initial one showed shortening of the lesion on both three-dimensional and raw images. The aneurysm was surgically clipped. In cases of SAH with a hematoma or thick SAH, there is a possibility that a pseudoaneurysm will form at the tip of the true aneurysm in an adjacent thrombus or existence of intraluminal thrombus. The morphology may change during the period between initial radiological evaluation and the operation in these cases. We should be aware that the intraoperative findings or subsequent radiological findings might be different from those observed on preoperative radiological examinations.
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Expandable titanium cages in the emergent treatment of severe spinal deformity secondary to osteomyelitis: A series of three complex cases p. 397
Ryan Screven, Mohammad Hassan A Noureldine, Paul R Krafft, Puya Alikhani
DOI:10.4103/ajns.AJNS_28_20  
The literature lacks robust evidence on the benefits versus risks of instrumenting and fusing the spinal column in the setting of active osteomyelitis. We report three patients with vertebral osteomyelitis and subsequent severe and complex kyphotic deformities. Patients 1 and 2 had previous instrumentation that required revision because of hardware failure in the thoracic and thoracolumbar regions, respectively. Patient 3 developed a severe cervical kyphotic deformity at 2 months after being diagnosed and treated with antibiotics for osteomyelitis, necessitating emergent instrumentation and fusion. All the three patients are doing very well so far. Spinal instrumentation and fusion for correction of kyphotic deformity is sometimes necessary in the context of active osteomyelitis and should be done emergently and without hesitation when spinal cord injury from spinal instability is of concern.
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Surgical management of hirayama disease: A rare entity with unusual clinical features p. 405
Sudhir Kumar Srivastava, Nandan Marathe, Aditya Raj, Sunil Bhosale, Kiran Dhole
DOI:10.4103/ajns.AJNS_291_19  
Hirayama disease (HD) is a rare type of cervical myelopathy in young males due to neck flexion causing cervical cord atrophy and asymmetric flattening with preferential involvement of anterior horn cells of the spinal cord. This is due to forward displacement of the cord during neck flexion getting compressed between the posterior part of the vertebral body and the posterior dura. The spinal cord involvement occurs due to repeated flexion and extension motion of the neck leading to selective spinal cells injury and atrophy. Most cases report an asymmetric lower motor neuron type of weakness predominantly involving the forearm and hand muscles. We report here a case of HD in an 18-year-old male who presented to us with weakness and wasting in the right hand. The patient was progressively symptomatic over a period of 1 year before presentation. The etiology and the exact cause of HD largely remain debatable and rely on the understanding of few theories which have been put forward. The natural history of this disease reaches a plateau in terms of neurological involvement after 2–5 years and is considered a self-remitting disorder. The patient was initially managed with a cervical collar immobilization but symptoms were largely not improving which was attributed to poor brace compliance. The patient was then managed surgically with a posterior lateral mass instrumentation without fusion in a lordotic alignment at the levels of maximal dural shift anteriorly. The patient improved neurologically following the surgery and maintained the intact status at the last follow-up.
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Multiple lesions accompanied by postoperative spontaneous intracystic hemorrhage in a pediatric patient with pilocytic astrocytoma p. 409
Muhammad Arifin Parenrengi, Yunus Kuntawi Aji
DOI:10.4103/ajns.AJNS_308_19  
Pilocytic astrocytoma is the most common primary brain tumor in the pediatric population and has a classic imaging manifestation of a solitary, cyst-like mass with a strong contrast-enhancing mural nodule. Here, we report a case of multiple lesions in pilocytic astrocytoma in a pediatric patient accompanied by postoperative spontaneous intracystic hemorrhage. We describe the case of a 14-year-old female patient with a history of surgery for right cerebellar tumor 6 years ago. Computed tomography (CT) and magnetic resonance imaging showed cystic lesion with a mural nodule in the cerebellum and right retrothalamic area, suggesting a pilocytic astrocytoma. Emergency surgery was done. Pathology confirmed a pilocytic astrocytoma World Health Organization Grade 1. During postoperative course, clinical outcomes of the patient did not improve. Follow-up CT showed cystic remnant compressing the brain stem with spontaneous intracystic hemorrhage. The second surgery was done to evacuate the hemorrhage and to remove the cyst. Serial CT was made after the second surgery with no cyst growth nor hemorrhage present. Only three other pediatric multiple pilocytic astrocytomas have been reported previously, and there were only 11 publications about spontaneous intracystic hemorrhage in pediatric pilocytic astrocytoma. Our review of all previously reported cases found that the patients were predominantly male, and some had a history of neurofibromatosis type 1.
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Familial colloid cysts of the third ventricle: Case report and literature review p. 414
Carlos Calderon, Ricardo Jose Fernandez-de Thomas, Orlando De Jesus
DOI:10.4103/ajns.AJNS_332_19  
Colloid cysts of the third ventricle are rare lesions. To our knowledge, only 23 familial cases of colloid cysts have been reported in the literature. The country of origin of the patients with familial cases had not been previously studied as a group. A 49-year-old female patient from Puerto Rico and her 21-year-old daughter underwent surgical resection for colloid cysts within a period of 5 years. The daughter presented with symptomatic hydrocephalus, while the mother only had mild chronic headaches. The occurrence of a colloid cyst in this family prompted us to perform a literature review and tabulate all the familial cases. This report presents the 24th case of a familial colloid cyst, and the fourth involving a mother and daughter. Australia is the country with the largest amount of reported cases. For smaller countries such as Sweden and Finland, two cases had been reported for each of them. Due to the unlikely probability of familial colloid cyst occurring at random, a genetic component is likely to be involved. The occurrence of several reports from patients from Australia, Finland, Sweden, and Puerto Rico where the population is smaller or more segregated may also suggest a genetic inheritance. Screening of first-degree-related subjects is recommended for families in which two or more members are affected. The presence of a colloid cyst in a twin mandates neuroimaging in the other twin, as there are five familial cases in twins reported in the literature.
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Fatal subarachnoid hemorrhage: A rare presentation of ruptured A2 dissecting aneurysm p. 418
Shigeomi Yokoya, Ayaka Ogata, Akihiko Hino, Sho Nishii, Yukihiro Goto, Hideki Oka, Naoto Shiomi
DOI:10.4103/ajns.AJNS_337_19  
Anterior cerebral artery dissection (ACAD), especially simultaneously presenting with subarachnoid hemorrhage (SAH) and cerebral infarction (CI), is rare. Only a few cases of severe SAH due to ACAD have been reported. Herein, we present an unusual case of severe SAH with simultaneous CI caused by ACAD. A 56-year-old male was brought to our hospital for severe disturbance of consciousness. Head computed tomography (CT) disclosed SAH with intracerebral hematoma. We suspected ruptured anterior communicating artery saccular aneurysm on CT angiography. Emergency craniotomy was performed to avoid cerebral herniation which confirmed the ruptured ACAD of right A2. The dissecting site was treated by wrapping with a Goretex sheet. ACAD of A2 may present with a severe hemorrhagic event.
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Organized chronic subdural hematoma treated with middle meningeal artery embolization and small craniotomy: Two case reports p. 421
Shigeomi Yokoya, Sho Nishii, Hidesato Takezawa, Tetsuya Katsumori, Yasufumi Takagi, Yukihiro Goto, Hideki Oka, Naoto Shiomi, Akihiko Hino
DOI:10.4103/ajns.AJNS_341_19  
The most preferred treatment for organized chronic subdural hematoma (OSDH) remains controversial. Although a large craniotomy has been reported to be necessary and effective for the treatment of an OSDH, a craniotomy is associated with postoperative hemorrhagic complications and recurrence. Although middle meningeal artery (MMA) embolization has been reported to be effective for a refractory chronic subdural hematoma (CSDH), its efficacy for an OSDH remains unclear. We report two cases of OSDH treated with MMA embolization followed by hematoma removal via a small craniotomy under local anesthesia with good progress. Case 1: A 71-year-old man underwent a single burr hole irrigation for a CSDH, which failed due to a solid hematoma. He underwent a small craniotomy under local anesthesia after an MMA embolization. During the craniotomy, a small hemorrhage from the hematoma and its outer membrane was observed. Postoperatively, the symptoms disappeared immediately, and the hematoma did not recur. Case 2: A 77-year-old man underwent a burr hole irrigation, but the hematoma was not evacuated because of an OSDH, and he remained in motor aphasia. After an MMA embolization, a craniotomy was performed under local anesthesia. Intraoperative hemorrhage was minimal, and after the craniotomy, his neurological symptoms improved without any recurrence. MMA embolization and hematoma removal with a small craniotomy could be a treatment option for an OSDH.
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Extrusion of anterior abdominal wall by a ventriculoperitoneal shunt - An uncommon complication: Case report and literature review p. 425
Amira Alolyani, Fatimah Al Dandan, Shaymaa Al-Umran, Ahmed Ammar
DOI:10.4103/ajns.AJNS_347_19  
Ventriculoperitoneal shunt (VP-shunt) is a commonly performed procedure for the management of hydrocephalus. Migration of the distal end of VP-shunt is one of the rarest complications. The authors report a case of an 11-year-old boy who presented with a spontaneous extrusion of the distal end of the VP-shunt through an intact abdominal wall. Literature was reviewed regarding the possible causes of such complication and the management approach in similar cases. The suggested phenomenon for this case could be attributed to the continuous hammer effect of the cerebrospinal fluid (CSF) pulsations on the abdominal wall. It is important to assess the future need for long-term CSF diversion, as in this case, the patient did not require reinsertion of a new shunt system because he was shunt independent.
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Acute coils migration causing significant m3 branch occlusion: A case report of rescue surgery with superficial temporal artery-middle cerebral artery bypass p. 428
Riccardo Stanzani, Yasuhiro Yamada, Tukasa Kawase, Gowtham Devareddy, Chandratej Kadam, Firuz Shukurov, Chavan Vaibhav, Yoko Kato
DOI:10.4103/ajns.AJNS_349_19  
We describe an uncommon case of acute coils migration with significant occlusion of M3 branch and our management of this complication. Ballon-assisted coil placement was performed for an unruptured intracavernous internal carotid artery aneurysm in a 62-year-old woman. After coil placement and balloon deflection, we observed coils migration with significant occlusion of M3 branch. After early clinical deterioration without other neurological symptoms, we decided to perform superficial temporal artery-middle cerebral artery (STA-MCA) bypass to ensure blood flow distal to the occlusion. The patient was discharged without neurological deficit. To the best of our knowledge, this is the first case report about STA-MCA bypass to treat acute coils migration. This technique could represent a successful rescue therapy in case of acute coils migration that cannot be retrieved by endovascular tools or in case where distal and deep location of migrated coils controindicate surgical removal.
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The histopathological findings of two nonbranching saccular cerebral aneurysms p. 431
Satoru Kida, Hiroshi Tenjin, Tsutomu Tokuyama, Osamu Saito
DOI:10.4103/ajns.AJNS_353_19  
Cerebral aneurysms arising from nonbranching sites are different from ordinary branching aneurysms in clinical course and histology. We pathologically examined two cases of saccular aneurysm occurring at nonbranching sites. One was a pseudoaneurysm arising at a branch of the right pericallosal artery. The other had an entirely hyalinized and thickened aneurysmal wall. Despite similar angiographical findings, our two cases had different pathological features as described above. Based on the pathological findings obtained from these cases, we believe that aneurysms in nonbranching sites are caused by injury to the internal elastic lamina. A ruptured aneurysm may be discovered as a blood blister-like aneurysm, whereas an unruptured one may develop into a “nonbranching true aneurysm.”
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N-butyl cyanoacrylate transvenous arteriovenous malformation embolization with arterial balloon assistance: Defining parameters for a transvenous approach as a potential upfront treatment option in managing cerebral arteriovenous malformations p. 434
Catherine Higbie, Deepak Khatri, Barbara Ligas, Rafael Ortiz, David Langer
DOI:10.4103/ajns.AJNS_357_19  
Complete obliteration of arteriovenous malformations (AVMs) using a transvenous approach as the primary and stand-alone treatment modality has been increasingly considered as a useful endovascular approach in the treatment of AVMs. AVMs are typically treated with microsurgery, stereotactic radiosurgery, endovascular embolization, or some combination of the three methods. Preservation of the draining vein is a key requisite common to all treatment modalities. Transvenous embolization (TVE) is conventionally not recommended as a stand-alone treatment for the vast majority of AVMs and has been thought to be best indicated when traditional approaches are considered less safe and when specific evaluation criteria are met. We report a case of a 35-year-old asymptomatic male diagnosed with a small intracranial AVM adjacent to the right motor strip which was managed utilizing this approach. We employed endovascular embolization via a transvenous approach with arterial balloon assistance due to the small size of the nidus, eloquent location, en passage arterial supply proximal to the venous varix, and a single draining vein from the fistula. This case illustrates the selective indications and technical nuances of TVE approach in managing AVMs as a potential upfront treatment option. When patients harbor AVMs with specific angio-architectural findings as outlined, TVE utilizing Onyx or N-butyl cyanoacrylate can be safely performed as a primary treatment modality.
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Cervical epidural abscess due to Brucella treated with decompression and instrumentation: a case report and review of literature p. 440
Muhammad Mohsin Khan, R Arun Babu, Javeed Iqbal, Surya Narayan Batas, Ali Raza
DOI:10.4103/ajns.AJNS_358_19  
Brucella is caused by a Gram-negative bacillus and is a common disease in endemic areas where people are in close contact with animals and dairy products, but brucellar cervical epidural abscess is rare. We describe a rare case of a C5–6 brucellar epidural abscess in a veterinary doctor who was treated with decompression and instrumentation. We also review the cases of cervical brucellar epidural abscess treated with instrumentation in the literature.
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Spinal ewing's Sarcoma presenting as an epidural collection: A rare presentation of a rare entity p. 445
Sibhi Ganapathy, Venugopal Subramaniam, Vidya Baliga
DOI:10.4103/ajns.AJNS_371_19  
Rare entities are difficult to predict. They are considered last rightly, to expedite treatment and alleviate symptoms quickly. Rare presentations of rare diseases form a particularly difficult section of diagnoses that are not only impossible to predict but difficult to recognize, diagnose, and treat. Often the dilemma is to, investigate thoroughly saving time but financially burdening the patient and hospital, or, to investigate in gradual increments taking more time and effort, especially in rare cases where prolonged hospitalization and suffering occurs before the diagnosis is reached. This approach, however, wastes critically important time, which, especially in neurological compression, may often lead to irreversible deficits. This dilemma is admirably demonstrated in this case report of spinal Ewing's sarcoma. A young female presented to us with recurrent high cervical epidural collections presenting as compressive myelopathy. She underwent repeated decompressions, and the collection was misdiagnosed as tuberculosis, which was treated without empirical evidence, leading to significant irreversible disability. Finally, when she came to us, the histopathological assessment was done to reveal the diagnosis. Ewing's sarcomas, and indeed the whole gamut of small-round-cell malignancies, are great imitators. They are known to exist in the skull base mimicking schwannomas, chordomas, germinomas, pituitary adenomas, and even epidermoids and occasionally extend to the vertebral bodies and the cranio-vertebral Junction (CVJ) leading to instability and neurological compression. Here, they mimic vertebral tumors, discitis, infective abscesses, and even myeloma. Predictably, such an entity is diagnosed last, and diagnosed late, leading to bad consequences for the patient. Such was the fate of our patient. The report emphasizes the diagnostic dilemma and presents the need to use protocols for diagnosis and treatment, even in rare cases, to effect the best possible outcomes for patients. The use of a thorough diagnostic and management algorhythm prevents deeper and sinister disease processes from being missed.
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Diplopia presenting in a case of pineal metastasis of pulmonary sarcomatoid carcinoma refractory to treatment p. 449
Akiyama Mitsumasa, Nagahisa Shinya, Oeda Motoki, Kougame Hirotaka, Kumai Tadashi
DOI:10.4103/ajns.AJNS_60_20  
A 42-year-old male presented with diplopia, headache, and nausea. Magnetic resonance imaging (MRI) of the brain showed pineal tumor, and chest computed tomography (CT) demonstrated a lung tumor. Disorientation developed, with occurrence of hydrocephalus, and we performed neuroendoscopic surgery for biopsy of the pineal tumor and third ventriculostomy. The lung tumor was biopsied under bronchoscopic and CT guidance, and based on the pathological results, we diagnosed pineal metastasis of pulmonary sarcomatoid carcinoma (cT3N1M1b Stage IVA). Stereotactic radiotherapy for the metastatic pineal tumor and systemic chemotherapy (carboplatin + pemetrexed) were pursued, but hemorrhage of the tumor occurred, hydrocephalus worsened, and neoplastic meningitis was diagnosed by MRI. Therapy was switched to nivolumab, but without effect, and the patient succumbed. Even among lung tumors, sarcomatoid carcinoma is rare. There are also few reports of lung tumors metastasized to the pineal gland. Our case report of pineal tumor regarded as metastasis of pulmonary sarcomatoid carcinoma also includes a discussion of the literature.
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Acute spontaneous cervical spinal epidural haematoma a very rare presentation mimicking of carotid dissection during sleep p. 455
Mohammad Jaweed, D Ganesan, Mohammad Ajmal Yasin, Boon Seng Liew, Azmin Kass Bin Rosman
DOI:10.4103/ajns.AJNS_318_19  
Acute spontaneous spinal epidural hematoma without any identified etiology is a rare phenomenon and an uncommon cause of acute spinal cord compression. We report a case of acute spontaneous cervical spinal epidural hematoma, with sudden onset of acute neck pain and left-side body weakness during sleep which resembling of cervicle carotid dissection. The pain commenced suddenly, early in the morning while the patient was asleep. He had no previous history of any relevant medical disorder. Cervical Spine MRI revealed a cervical epidural haematoma at C3/C4, mainly on the left side, with spinal cord compression. Therefore, an emergent C3/C6 hemilaminectomy and evacuation of hematoma were carried out within 24 h of presentation. The patient's neck pain resolved after surgery and he was able to walk, though he required bladder catheterization on discharge after 1 week. He has nearly intact motor neurological examination in the second month of the operation.
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LITERATURE REVIEW Top

Parietal arteriovenous malformation mimicking carotid-cavernous fistula in context of sinus thrombosis: Bidirectional or unidirectional relationship? Literature review p. 458
Waseem Aziz, Mohammed Abdel Hady, Hadeel Awad Shihan
DOI:10.4103/ajns.AJNS_249_17  
Cortically located arteriovenous malformations (AVMs) constitute majority of brain AVMs. A common drainage is through respective cortical veins into superior sagittal or transverse sinuses. Through a case report and literature review, we discuss three issues: first, the anomalous drainage of a cortical AVM into an anterior orbital venous drainage system; second, the impact of this drainage on the clinical picture; and third, importantly, the bidirectional versus unidirectional relationship of AVM and old venous sinus thrombosis.
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LETTERS TO EDITOR Top

A second traumatic cervical spine injury: Lighting can strike twice p. 462
Prasad Krishnan
DOI:10.4103/ajns.AJNS_134_20  
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Surgeon experience of the surgical safety with kinevo 900 in vascular neurosurgery: The initial experience p. 464
Kazutaka Nakao, Binoy Damodar Thavara, Riki Tanaka, Yasuhiro Yamada, Girish Joshi, Kyosuke Miyatani, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_40_20  
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