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   Table of Contents - Current issue
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April-June 2019
Volume 14 | Issue 2
Page Nos. 343-617

Online since Friday, April 26, 2019

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REVIEW ARTICLES  

Spinal cord stimulation in pregnant patients: Current perspectives of indications, complications, and results in pain control: A systematic review Highly accessed article p. 343
Bruno Camporeze, Renata Simm, Marcos Vinícius Calfat Maldaun, Paulo Henrique Pires de Aguiar
DOI:10.4103/ajns.AJNS_7_18  PMID:31143246
Spinal cord stimulation (SCS) has been described as a valuable neuromodulator procedure in the management of chronic medically untreated neuropathic pain. Although the use of this technique has been published in many papers, a question still remains regarding its applicability in pregnant patients. The goal of this paper is to discuss the risks, complications, and results as well as the prognosis of SCS in pregnant patients. We performed a systematic review from 1967 to 2018 using the databases MEDLINE, LILACS, SciELO, PubMed, and BIREME, utilizing language as selection criteria. Eighteen studies that met our criteria were found and tabulated. SCS is a reversible and adjustable surgical procedure, which results in patients that demonstrated a significant effect in the reduction of pain intensity in pregnant patients. The etiologies most frequent were complex regional pain and failed back pain syndromes, which together represented 94% of analyzed cases. The technical complications most frequent were lead migration (3%, n = 1). Regarding the risks, the authors did not show significative factors among the categorical variables that can suggest a teratogenicity, while the maternal risks have been associated to the consequences of technical complications due to, among other factors, improvement of abdominal pressure during pregnancy and delivery. Finally, although there are not significative cohorts of pregnant patients, the procedure is still an effective surgical approach of neuropathic pain associated to lower rates of complications and significative improvement in the quality of life of patients during pregnancy.
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Diffuse low-grade glioma – Changing concepts in diagnosis and management: A review Highly accessed article p. 356
Rashid Jooma, Muhammad Waqas, Inamullah Khan
DOI:10.4103/ajns.AJNS_24_18  PMID:31143247
Though diffuse low-grade gliomas (dLGGs) represent only 15% of gliomas, they have been receiving increasing attention in the past decade. Significant advances in knowledge of the natural history and clinical diversity have been documented, and an improved pathological classification of gliomas that integrates histological features with molecular markers has been issued by the WHO. Advances in the radiological assessment of dLGG, particularly new magnetic resonance imaging scanning sequences, allow improved diagnostic and prognostic information. The management paradigms are evolving from “wait and watch” of the past to more active interventional therapy to obviate the risk of malignant transformation. New surgical technologies allow more aggressive surgical resections with a reduction of morbidity. Many reports suggest the association of gross total resection with longer overall survival and progression-free survival in addition to better seizure control. The literature also shows the use of chemotherapeutics and radiation therapy as important adjuncts to surgery. The goals of management have has been increasing survival with increasing stress on quality of life. Our review highlights the recent advances in the molecular diagnosis and management of dLGG with trends toward multidisciplinary and multimodality management of dLGG with an aim to surgically resect the primary disease, followed by chemoradiation in cases of progressive or recurrent disease.
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Simulation training methods in neurological surgery Highly accessed article p. 364
Louise Makarem Oliveira, Eberval Gadelha Figueiredo
DOI:10.4103/ajns.AJNS_269_18  PMID:31143248
Simulation training plays a paramount role in medicine, especially when it comes to mastering surgical skills. By simulating, students gain not only confidence, but expertise, learning to apply theory in a safe environment. As the technological arsenal improved, virtual reality and physical simulators have developed and are now an important part of the Neurosurgery training curriculum. Based on deliberate practice in a controlled space, simulation allows psychomotor skills augment without putting neither patients nor students at risk. When compared to the master-apprentice ongoing model of teaching, simutation becomes even more appealing as it is time-efficient, shortening the learning curve and ultimately leading to error reduction, which is reflected by diminished health care costs in the long run. In this chapter we will discuss the current state of neurosurgery simulation, highlight the potential benefits of this approach, assessing specific training methods and making considerations towards the future of neurosurgical simulation.
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The role of decompressive craniectomy in traumatic brain injury: A systematic review and meta-analysis Highly accessed article p. 371
Nida Fatima, Ghaya Al Rumaihi, Ashfaq Shuaib, Maher Saqqur
DOI:10.4103/ajns.AJNS_289_18  PMID:31143249
The objective is to evaluate the efficacy of early decompressive craniectomy (DC) versus standard medical management ± late DC in improving clinical outcome in patients with traumatic brain injury (TBI). Electronic databases and gray literature (unpublished articles) were searched under different MeSH terms from 1990 to present. Randomized control trials, case–control studies, and prospective cohort studies on DC in moderate and severe TBI. Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS) and extended GCOS, and mortality. Data were extracted to Review Manager software. A total of 45 articles and abstracts that met the inclusion criteria were retrieved and analyzed. Ultimately, seven studies were included in our meta-analysis, which revealed that patients who had early DC had no statistically significant likelihood of having a favorable outcome at 6 months than those who had a standard medical care alone or with late DC (OR of favorable clinical outcome at 6 months: 1.00; 95% confidence interval (CI): 0.75–1.34; P = 0.99). The relative risk (RR) of mortality in early DC versus the standard medical care ± late DC at discharge or 6 months is 0.62; 95% CI: 0.40–0.94; P = 0.03. Subgroup analysis based on RR of mortality shows that the rate of mortality is reduced significantly in the early DC group as compared to the late DC. RR of Mortality is 0.43; 95% CI: 0.26–0.71; P = 0.0009. However, good clinical outcome is the same. Early DC saves lives in patients with TBI. However, further clinical trials are required to prove if early DC improve clinical outcome and to define the best early time frame in performing early DC in TBI population.
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Hypertonic solutions in traumatic brain injury: A systematic review and meta-analysis Highly accessed article p. 382
Nida Fatima, Ali Ayyad, Ashfaq Shuaib, Maher Saqqur
DOI:10.4103/ajns.AJNS_8_19  PMID:31143250
This study aims to evaluate the efficacy of hypertonic saline versus crystalloids (normal Saline/lactated Ringers) in improving clinical outcome in patients with traumatic brain injury (TBI). Electronic databases and grey literature (unpublished articles) were searched under different MeSH terms from 1990 to present. Randomized control trials, case–control studies and prospective cohort studies on decompressive craniectomy in TBI (>18-year-old). Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS), Extended GCOS, and mortality. Data were extracted to Review Manager Software. A total of 115 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 who had hypertonic saline had no statistically significant likelihood of having a good outcome at discharge or 6 months than those who had crystalloid (odds ratio [OR]: 0.01; 95% confidence interval (CI): 0.03–0.05; P = 0.65). The relative risk (RR) of mortality in hypertonic saline versus the crystalloid at discharge or 6-month is RR: 0.80; 95% CI: 0.64–0.99; P = 0.04. The subgroup analysis showed that the group who had hypertonic solution significantly decreases the number of interventions versus the crystalloid group OR: 0.53; 95% CI: 0.48–0.59; P < 0.00001 and also reduces the length of intensive care unit stay (OR: 0.46; 95% CI: 0.21–1.01; P = 0.05). Hypertonic saline decreases the financial burden, but neither impacts the clinical outcome nor reduces the mortality. However, further clinical trials are required to prove if hypertonic saline has any role in improving the clinical and neurological status of patients with TBI versus the normal saline/lactated Ringers.
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ORIGINAL ARTICLES Top

Impact of comorbidities on outcome following revision of recurrent single-level lumbar disc prolapse between revision microdiscectomy and posterior lumbar interbody fusion: A single-institutional analysis p. 392
Chiazor U Onyia, Sajesh K Menon
DOI:10.4103/ajns.AJNS_299_18  PMID:31143251
Objectives: Reports exist in the literature on the relationship between comorbid conditions and recurrence of lumbar disc herniation. Meanwhile, documented evidence abound on microdiscectomy and posterior lumbar interbody fusion (PLIF) as techniques of managing recurrent disc prolapse. Some surgeons would choose to perform PLIF instead of microdiscectomy for a first time re-herniation, because of the possibility of higher chances of further recurrence as well as increased likelihood of spinal instability following treatment with microdiscectomy. In this study, the authors sought to determine whether PLIF is better than microdiscectomy for first-time recurrent single-level lumbar disc prolapse and to compare the impact of comorbidities on outcome following revision. Patients and Methods: This was retrospective review of surgical treatment of patients with recurrent single-level disc prolapse with either microdiscectomy or PLIF at a tertiary health institution in India. Results: A total of 26 patients were evaluated. There was no statistically significant correlation between the presence of comorbidity and outcome in terms of improvement of pain (P > 0.05 at 95% degree of confidence; Spearman's ρ =0.239). Patients who had PLIF were neither more nor less likely to have a better outcome compared to those who had microdiscectomy, though this finding was not statistically significant (odds ratio = 0.263; P = 0.284). Conclusion: There was no significant relationship between the presence of comorbidity and outcome following revision. Microdiscectomy did not prove to be a better option than PLIF for surgical management of recurrent single-level disc prolapse. A quality randomized controlled study would help to validate these findings.
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Endoscopic third ventriculostomy in children with failed ventriculoperitoneal shunt p. 399
Bijan Heshmati, Zohreh Habibi, Mehdi Golpayegani, Farhad Salari, Mousarreza Anbarlouei, Farideh Nejat
DOI:10.4103/ajns.AJNS_93_18  PMID:31143252
Context: Endoscopic third ventriculostomy (ETV) is an accepted procedure for the treatment of obstructive hydrocephalus. The role of endoscopic treatment in the management of shunt malfunction was not extensively evaluated. The aim of this study is to evaluate the success rate of ETV in pediatric patients formerly treated by ventriculoperitoneal (V-P) shunt implantation. Materials and Methods: Thirty-three patients with their first shunt failure and obstructive hydrocephalus in brain imaging between 2008 and 2014 were enrolled in this study. Results: The most common causes of hydrocephalus in these patients were aqueductal stenosis and myelomeningocele with or without associated shunt infection. Of these 33 cases, 20 ETV procedures were successful, and 13 cases needed shunt revision after ETV failure. There was no serious complication during ETV procedures. The follow-up period of patients with successful ETV was 6–50 months (mean 18 months). The time interval between ETV and new shunting subsequent to ETV failure was 24.4 days (10–95). Conclusions: ETV can be considered as an alternative treatment paradigm in patients with previous shunt or new shunt failure with an acceptable success rate of 6o%, although long-term follow-up is needed for these patients.
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Predictive factors for seizures accompanying intracranial meningiomas p. 403
Moamen Mohamed Morsy, Waleed Fawzy El-Saadany, Wael Mohamed Moussa, Ahmed Elsayed Sultan
DOI:10.4103/ajns.AJNS_152_18  PMID:31143253
Objective: Seizures represent a common manifestation of intracranial meningiomas. Their predictive factors before and after excision merit studying. Materials and Methods: Patients having intracranial meningioma were prospectively studied. There were two groups; Group “A” with seizures and Group “B” with no preoperative epilepsy. Results: This study included 40 patients. Their ages ranged from 40 to 60 years old, and female-to-male ratio was 2.3:1 in both groups. In Group A, partial seizures were the most common pattern (60%). Manifestations other than fits included headache in most patients (97.5%), symptoms of increased intracranial pressure were found in 50% in Group A and 20% in Group B patients, peritumoral edema was present in 14 (70%) patients of Group A, compared to 6 (25%) patients of Group “B.” There was a statistically significant relation between peritumoral edema and presentation with fits (P < 0.1). Complication after surgery included nonsurgical hematoma in three patients and contusion in 7 patients. Following surgery for Group “A”, 8 (40%) patients had good seizure control. While, in Group “B” 3 (15%), patients developed new-onset seizures. Good seizure control in 7 (53%) patients with frontal, frontotemporal tumors than in other locations. In addition, better control was obtained in left sided, small tumors, and no peritumoral edema. Postoperative complication was significantly associated with new-onset epilepsy and poor seizure control (P < 0.05). Neither tumor size nor location had a significant relation to either pre or postoperative epilepsy. Conclusion: Predictive factors for epilepsy accompanying intracranial meningioma included males, elderly patients and patients with small lesions, frontal and left-sided locations but were statistically insignificant predictors. Peritumoral edema and postoperative complications are the most significant predictors.
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Compound elevated skull fracture presented as a new variety of fracture with inimitable entity: Single institution experience of 10 cases p. 410
Ashok Kumar, Vivek Kumar Kankane, Gaurav Jaiswal, Pavan Kumar, Tarun Kumar Gupta
DOI:10.4103/ajns.AJNS_153_18  PMID:31143254
Background: Compound elevated Skull fracture (CESF) is a rare variety of fracture with rare presentation in comparison to other type of skull fracture. The mechanical force being applied is tangential causing high impact over skull as comparison to structure underlying the cranium. Objective: Aims of this study are bring attentiveness and management to deal this rare type of fracture and its outcomes. Materials and Methods: In this study, we demonstrated 10 cases of CESF in adult patients from January 2014 to January 2018 in the Department of Neurosurgery at RNT Medical College and M. B. Hospital, Udaipur, Rajasthan, India. Recorded documents were prospectively studied for age of distribution, sex, mode of injury, mechanism of injury, clinical profile, radiological investigations, neurosurgical management, and outcome asses by Glasgow outcome scale. Results: Totally 10 patients had CESF. Six are males and four are females. Male to female ratio was 3:2. Their age range was 20–45 years. The most common mode of injury was Road traffic accident in 60%. Wound exploration, cleaning, debridement, and reduction of fracture segment was done in eight cases, frontal bone craniotomy with evacuation of pneumocephalus done one case, frontal bone craniotomy, and extradural hematoma evacuation was done in one case. The postoperative course was uneventful, and outcome was good (GOS 5) in 8 (80%) cases. Conclusion: In compound elevated fracture, early recognition and immediate surgical intervention should be done to avoid related morbidity and mortality. Any delay in surgery may lead to a high possibility of wound infection and poor outcome.
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Outcome analysis of surgical clipping for incidental internal carotid posterior communicating and anterior choroidal artery aneurysms p. 415
Ameen Abdul Mohammad, Yamada Yasuhiro, Liew Boon Seng, Niranjana Rajagopal, Kato Yoko
DOI:10.4103/ajns.AJNS_155_18  PMID:31143255
Introduction: Surgical outcome and ischemic complications of Internal carotid Posterior Communicating (IC PC) and anterior choroidal aneurysms have been questionable due to frequent occlusion of the anterior choroid artery and also due to low incidence of true anterior choroid artery aneurysms. The present series describes the postoperative outcome after clipping of such aneurysms at a single centre. Methods: A retrospective analysis of 73 cases with IC PC and Anterior choroidal aneurysms performed at a Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Aichi, Japan from 2014 to 2018 have been studied and emphasis is made on the demography and ischemic complications. Results: A total of 73 patients with IC PC and anterior choroidal aneurysms were studied, out of which 57 patient had a true IC PC aneurysm, 14 patients had aneurysms involving the anterior choroidal artery and only 2 patients had aneurysms which involved both the IC PC and the anterior choroidal arteries. None of the patients had a permanent Anterior Choroidal Artery syndrome, whereas only 2 out of the 73 patients had postoperative complications in the form of transient hemiparesis. Conclusion: Ischemic complications following surgical clipping of IC PC and anterior choroidal aneurysms can be minimised by meticulous micro dissection to identify the anterior choroidal artery thus preserving the patency of the same.
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Small aneurysms should be clipped? p. 422
Gustavo Noleto, Nícollas Nunes Rabelo, Leonardo Abaurre, Hugo Sterman Neto, Mario Siqueira, Manoel J Teixeira, Eberval Gadelha Figueiredo
DOI:10.4103/ajns.AJNS_161_18  PMID:31143256
Background: Cerebral aneurysm prevalence may vary from 0.4% to 10%. The decision to treat or not incidental aneurysms remains controversial, especially when the lesions are small (<5 mm). Many recent publications are demonstrating that these lesions often bleed. Methods: We reviewed admitted patients with angiographic studies submitted to intracranial aneurysm surgical treatment from April 2012 to July 2013 in the Neurosurgery Department of São Paulo Medical School University (15 months), to define the rate and risk of bleeding. In addition, we proceeded literature review with collected 357 papers (past 5 years) which were selected 50 that were focused on our research. Clinical patients' status at the time of discharge was evaluated with the modified Rankin scale. Results: A series of 118 cases of surgically clipped aneurysms was analyzed: 73.7% woman; Ruptured (61 cases, 51%); middle cerebral artery (51 cases, 43%) was the more common aneurysm. Small size (<5 mm) was 25 cases (21%); that 2 died (16%), 3 (25%) with severe disability,restricted to bed and dependent on nursing care; blood pressure was the main risk factors (56%); and an aneurysm <2 mm (100%) was ruptured. Conclusion: The number of small aneurysms in our series was significant (25 cases, 21%), and its rate of bleeding was high (25 cases, 48%), resulting in death and disability in a significant number of cases. Our tendency is for surgical treatment when it is associated with risk factors.
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Trends in primary brain tumors: A 5-year retrospective histologically confirmed study in Tabriz, Iran, 2011–2016 p. 427
Firooz Salehpour, Farhad Mirzaei, Ali Meshkini, Sina Parsay, Sana Salehi, Mohammad Mahdi Bagheri Asl
DOI:10.4103/ajns.AJNS_212_18  PMID:31143257
Introduction: Tumors are the second-most common cause of death after cardiovascular diseases. Due to the high prevalence and mortality rate, brain tumors are of great importance and makeup about 5% of all tumors. Different types of brain tumors have their special pattern based on age, sex, complaints on admission, radiological signs and sometimes, their family history and seem these patterns are changing according to the geographic region over time. In this study, we evaluate the incidence of brain tumors in the northwest of Iran. Materials and Methods: All patients with brain tumor diagnosis that were hospitalized between April 2011 and March 2016 evaluated. Exclusion criteria were considered as secondary tumors of the central nervous system (CNS) (metastases) and duplicate records for the recurrent disease of the same patient. Data collected from their documents and analyzed with SPSS version 16. Results: In the present study, male to female (M: F) ratio is 1:1. 92.5% of tumors are primary in which meningiomas (22%) and glioblastoma multiforme (GBM) (19.6%) are the most common types. The rarest tumor types are neurocytoma (0.3%) and chondroid chordoma (0.3%). GBM is the most common tumor in the male population and meningiomas are most common in females. Medulloblastoma and meningioma with a median age of 11 and 58 years, respectively, were known as the most common primary CNS malignancy of the youngest and oldest age of study group. Conclusion: The obtained data from this study revealed that age and sex are associated with the tumor types, which is consistent with the previous results. Brain tumors involvement pattern is changing in male patients somehow there is a tendency of involving more aggressive and malignant tumor types in male individuals could be seen.
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Effect of preoperative modic change in the outcome of patients with low back pain following posterior spinal fusion or laminectomy p. 432
Mohammad Reza Shahmohammadi, Sima Behrouzian
DOI:10.4103/ajns.AJNS_41_18  PMID:31143258
Background: Modic changes (MC), visible on magnetic resonance imaging (MRI) are associated with chronic low back pain (LBP). It is reported that different MC types could affect the surgical outcome in patients with LBP. Objective: In this study, we evaluated the effect of MC Type I and II on patients with LBP and degenerative disc disease following posterior spinal fusion (PSF) or laminectomy. Materials and Methods: We evaluated the outcome of 162 patients with LBP and MC Type I and II who underwent laminectomy (n = 72) or PSF (n = 90). Preoperative MRI was used to define MC types. Visual analog scale (VAS) was used to evaluate the pain intensity before and 3 months after surgery. Results: Patients had MC Type I in 46.3% and Type II in 53.7%. Pain VAS significantly decreased following surgery (7.93 ± 1.27–5.98 ± 1.57, P < 0.001). There was no difference between MC Type I and II in pain VAS before (P = 0.51) and after treatment (P = 0.51). Among MC Type I, PSF compared to laminectomy had significantly more improvement in pain VAS (P = 0.01), but the changes in modic Type II were similar between groups (P = 0.89). Conclusion: Surgical treatment in patients with LBP with MC accompanies with significant improvement in pain. PSF seems better treatment in patients with MC Type I.
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The role of temporal lobectomy as a part of surgical resuscitation in patients with severe traumatic brain injury p. 436
AK Hakan, Iskender Samet Daltaban, Sevilay Vural
DOI:10.4103/ajns.AJNS_240_18  PMID:31143259
Background: Traumatic brain injuries (TBIs) are serious morbidity and mortality risk for especially in the young population. Primary and secondary injury mechanisms may cause cerebral edema and intracranial hypertension. The target point of the TBI treatment is lowering the intracranial pressure medically or surgically if indicated. Methods: The files of the patients with severe brain injury admitted between January 2015 and December 2017 were reviewed retrospectively. Patients who underwent decompression surgery due to severe brain injury ([The Glasgow Coma Scale [GCS] score] <8) and additional temporal lobectomy were included in the study group. Results: Ten patients were included in the study during the 3 years. All the patients were suffering from blunt severe TBI. Traumatic etiology was vehicle traffic accident in six cases, nonvehicle traffic accident in two cases, and falling from height in two cases. All the cases suffered from blunt trauma. The admission GCS of the patients was 4–7 (mean = 5.5). Right-sided decompression surgery and lobectomy were performed for seven patients and left-sided in three cases. The postoperational survival was 60%. All the survivors were functionally independent with mild cognitive disturbances. Conclusion: Temporal lobectomy might be added to the surgery to apply all the interventions available in combat with progressively increasing intracerebral pressure as a part of surgical resuscitation.
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Solving the riddle of “Idiopathic” in idiopathic intracranial hypertension and normal pressure hydrocephalus: An imaging study of the possible mechanisms – Monro–Kellie 3.0 p. 440
Sandhya Mangalore, Srinivasa Rakshith, Rangashetty Srinivasa
DOI:10.4103/ajns.AJNS_252_18  PMID:31143260
Background: Idiopathic intracranial hypertension (IIH) and normal pressure hydrocephalus (NPH) represent a cluster of typical clinical and imaging findings, with no evident etiological cause noted. In this study, we have proposed a model for IIH and NPH called Monroe–Kellie 3.0 (MK 3.0). IIH and NPH may be entities which represent opposite sides of the same coin with venous system and cerebrospinal fluid (CSF) as core drivers for both these entities. Materials and Methods: IIH and NPH volume data were collected, voxel-based morphometry analysis was performed without normalization, and the distribution of the individual volumes of gray matter, white matter, and CSF was statistically analyzed. Visual morphometry analyses of segmented data were performed, and the findings in routine magnetic resonance imaging (MRI) were noted to build a model for IIH and NPH. Results: In IIH and NPH when the volumes were compared with controls, the distribution was similar. Furthermore, the morphometric changes noted in the MRI and segmented volume data were analyzed and the results were suggestive of changes in elastic property of brain causing a remodeling of brain shape and resulting in minor brain shift in the skull vault, and the resulting passive displacement of CSF which has been termed as MK 3.0. Conclusion: This model helps to put the clinical and imaging findings and complications of treatment in single perspective.
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Analysis of the surgical technique and outcome of the thoracic and lumbar intradural spinal tumor excision using minimally invasive tubular retractor system p. 453
Binoy Damodar Thavara, Geo Senil Kidangan, Bijukrishnan Rajagopalawarrier
DOI:10.4103/ajns.AJNS_254_18  PMID:31143261
Background: Conventionally, intradural spinal tumor excision requires longer skin incision, bilateral subperiosteal muscle stripping, and total laminectomy, thereby decreasing the stability of the spine and increasing the morbidity. Minimally invasive surgery (MIS) for intradural spinal tumor excision preserves the posterior supporting structures of the spine in the midline and on the contralateral side and decreases morbidity and achieves the resection of the tumor. Aims: The aim is to analyze the surgical technique and outcome of the thoracic and lumbar intradural spinal tumor excision using minimally invasive tubular retractor system. Patients and Methods: A retrospective study was conducted in patients admitted with thoracic and lumbar intradural spinal tumors who had undergone tumor excision using minimally invasive tubular retractor system and satisfied the inclusion and exclusion criteria. Intradural tumors involving one or two vertebral levels were included in the study. Intramedullary spinal tumor, intradural tumor extending into intervertebral foramen, and intradural tumor involving more than two vertebral levels were excluded from the study. The study included the data of the 13 patients, who were operated between January 2017 and October 2018. The age and sex of the patients were noted. Gadolinium-enhanced magnetic resonance imaging scan and X-ray of the spine were taken in all the patients. The pre- and postoperative data analyzed include pain using visual analog scale (VAS), power using Medical Research Council (MRC) grading, myelopathy using Nurick's grade, sensory changes, and bowel and bladder symptoms. The steps involved in the surgical technique, extent of resection, intraoperative blood loss, duration of surgery, postoperative complications, duration of stay after the surgery, and postoperative X-ray were analyzed. Results: Out of 13 patients, one case of dorsally placed meningioma was converted to open laminectomy and excision due to nonvisualization of the spinal cord and increased bleeding from the tumor. Hence, data of the remaining 12 patients were analyzed. The histopathology of these cases was meningioma (6), schwannoma (5), and neurenteric cyst (1). There were 5 men and 7 women with age group of 27–70 years (mean: 48 years). There were 8 thoracic and 4 lumbar tumors. The duration of symptoms was 2 days to 72 months (mean: 35 months). Eight cases were predominantly occupying on the right side and 4 cases on the left side within the spinal canal. The skin incision length was 25 mm to 35 mm (mean: 28 mm). We used tubular retractors with diameter ranging from 22 mm to 30 mm (mean: 24 mm). Expandable retractors were used in 9 cases (75%) and nonexpandable in 3 cases (25%). Tubular retractor of company Jayon (India) was used in 5 cases and PITKAR (India) in 7 cases. We have not found any significant difference in the usage of both the systems. The tumor size (craniocaudal) was ranging from 9.5 mm to 38 mm (mean: 19 mm). Intraoperative blood loss was 75–200 ml (mean: 115 ml). Gross total resection was achieved in 8 cases and near-total resection in 4 cases. Dura was sutured primarily in all the cases. The dural closure was done with continuous sutures in 6 (50%) cases and interrupted in 6 (50%) cases. Polypropylene suture was used in 10 cases and polyglactin suture in 2 cases of dural closure. The authors found it easy to suture the dura using 7-0 polypropylene. Fibrin sealant was used in 9 (75%) cases. The duration of the surgery was ranging from 160 min to 390 min (mean: 260 min). Cerebrospinal fluid leak and pseudomeningocele were noted in one case. One patient developed suture site infection. VAS for pain, sensory symptoms, Nurick's grade for myelopathy, and MRC grading for power were improved in all the affected patients. Out of two patients with constipation, one patient improved and the other developed incontinence, which was recovered on follow-up after 2 weeks. Out of the 4 patients with urinary symptoms, 3 were improved. Another patient of preoperative normal micturition developed urinary retention due to exacerbation of benign prostatic hypertrophy. Postoperative X-ray showed preserved spinous process and facet joints in all cases. The duration of the hospital stay was ranging from 2 days to 11 days (mean: 6 days). Conclusion: Anteriorly or laterally placed intradural spinal tumors confined to the spinal canal can be excised safely and effectively using tubular retractor system, with adding the advantages of the MIS surgery. When in doubt, always convert the MIS to open surgery to avoid injury to vital structures.
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The utility of cervical spine bracing as a postoperative adjunct to single-level anterior cervical spine surgery p. 461
Ian Caplan, Saurabh Sinha, James Schuster, Matthew Piazza, Gregory Glauser, Benjamin Osiemo, Scott McClintock, William C Welch, Nikhil Sharma, Ali Ozturk, Neil Rainer Malhotra
DOI:10.4103/ajns.AJNS_236_18  PMID:31143262
Background Context: Use of cervical bracing/collar subsequent to anterior cervical spine discectomy and fusion (ACDF) is variable. Outcomes data regarding bracing after ACDF are limited. Purpose: The purpose of the study is to study the impact of bracing on short-term outcomes related to safety, quality of care, and direct costs in single-level ACDF. Study Design/Setting: This retrospective cohort analysis of all consecutive patients (n = 578) undergoing single-level ACDF with or without bracing from 2013 to 2017 was undertaken. Methods: Patient demographics and comorbidities were analyzed. Tests of independence (Chi-square, Fisher's exact, and Cochran–Mantel–Haenszel test), Mann–Whitney–Wilcoxon tests, and logistic regressions were used to assess differences in length of stay (LOS), discharge disposition (home, assisted rehabilitation facility-assisted rehabilitation facility, or skilled nursing facility), quality-adjusted life year (QALY), surgical site infection (SSI), direct cost, readmission within 30 days, and emergency room (ER) visits within 30 days. Results: Among the study population, 511 were braced and 67 were not braced. There was no difference in graft type (P = 1.00) or comorbidities (P = 0.06–0.73) such as obesity (P = 0.504), smoking (0.103), chronic obstructive pulmonary disease hypertension (P = 0.543), coronary artery disease (P = 0.442), congestive heart failure (P = 0.207), and problem list number (P = 0.661). LOS was extended for the unbraced group (median 34.00 + 112.15 vs. 77.00 + 209.31 h, P < 0.001). There was no difference in readmission (P = 1.000), ER visits (P = 1.000), SSI (P = 1.000), QALY gain (P = 0.437), and direct costs (P = 0.732). Conclusions: Bracing following single-level cervical fixation does not alter short-term postoperative course or reduce the risk for early adverse outcomes in a significant manner. The absence of bracing is associated with increased LOS, but cost analyses show no difference in direct costs between the two treatment approaches. Further evaluation of long-term outcomes and fusion rates will be necessary before definitive recommendations regarding bracing utility following single-level ACDF.
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The role of combined posterior and anterolateral retroperitoneal approach in the treatment of posttraumatic burst lumbar fractures p. 467
Ebrahim Ahmed Shamhoot, Ahmed Rizk Elkholy
DOI:10.4103/ajns.AJNS_262_18  PMID:31143263
Context: Combined posterior and anterolateral retroperitoneal approach is very important for the treatment of unstable burst lumber fractures with retropulsed fragments. Aims: The aim of the study is to evaluate the role of combined posterior and anterolateral retroperitoneal approach in the treatment of unstable burst lumber fractures. Settings and Design: This is a retrospective clinical case series study. Patients and Methods: This study was conducted on 41 patients with unstable lumber burst fractures with retropulsed fragment. Frankel scale score and Denis pain score were used to evaluate the functional outcome. All patients were surgically treated using combined posterior and anterolateral retroperitoneal approach. They were followed for 1 year postoperatively. Statistical Analysis: Using SPSS version 21, data were presented as mean ± standard deviation, and percentage and paired sample and Wilcoxon signed-rank tests were used for data analysis. Results: the functional state of all patients improved after surgery. According to the Frankel and Denis pain scores, there was a significant improvement in patients' scores postoperatively compared to preoperative ones (P = 0.001). Visceral manifestations were present in 16 cases (36.6%) with complete improvement postoperatively except two cases. There is a significant improvement as regards pre- and postoperative regional kyphotic angle (9.12 ± 10.03) and vertebral body height (3.14 ± 0.37). Unintended durotomy occurred in six cases treated by stitching using absorbable sutures and fat graft. Wound infection was present in two cases treated by antibiotics and daily dressing. A solid fusion was achieved in all cases. Conclusions: Combined posterior and anterolateral retroperitoneal approach is feasible and effective in surgical exposure and treatment of unstable burst lumber fractures with retropulsed fragments.
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Continuous lumbar drainage for the prevention and management of perioperative cerebrospinal fluid leakage p. 473
Mohamed Hussein, Mostafa Abdellatif
DOI:10.4103/ajns.AJNS_265_18  PMID:31143264
Background: Cerebrospinal fluid (CSF) leak is an unfortunate, yet well-recognized complication of skull base fractures, skull base surgeries, and variety of spinal procedures. Continuous lumbar drainage (CLD) of leaking CSF has shown a high success rate with minimal morbidities in handling CSF leak in these patients. Therefore, we conducted this study to illustrate the efficacy of CLD as a prophylactic and therapeutic method for CSF leakage with the assessment of clinical outcome and early postoperative sequel. Materials and Methods: In the period from January to December 2017, patients with traumatic or postoperative CSF leak and those susceptible for postoperative CSF leak as skull base and spinal intradural surgeries at the Neurosurgery Department, Fayoum University, were included in our study. Results: A total of 20 eligible patients were included in the study. All patients showed successful cessation of CSF leakage at different durations of CLD. Fifteen patients showed excellent results; four showed good results; and one showed fair results. Besides a minimal pneumocephalus, headache was the most common presenting complication in our population, which occurred to all patients. Six patients had vomiting beside headache, whereas two patients experienced vomiting and nausea in addition to headache. There were neither mortalities nor life-threatening complications noted; however, a superficial wound infection occurred in a single case. Conclusion: CLD is a simple, safe, and efficient method in the management of CSF leakage at operative sites, CSF rhinorrhea, and CSF otorrhea of various etiologies.
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Outcome analysis of posterolateral decompression and spinal stabilization for tuberculous spine p. 479
Siddartha Reddy Musali, Prakash Rao Gollapudi, Srikrishnaaditya Manne, Nagarjuna Butkuri, Thatikonda Satish Kumar, Vamshi Krishna Kotha
DOI:10.4103/ajns.AJNS_274_18  PMID:31143265
Aim: This is a prospective study to analyze the clinical, radiological, and functional outcomes of posterolateral decompression and spinal stabilization with pedicle screws and rods done for the thoracolumbar tuberculous spine. Materials and Methods: This study was conducted at Gandhi Medical College and Hospital from September 2016 to September 2017 on 30 patients who underwent posterolateral decompression and spinal stabilization using pedicle screw and rod fixation for active spinal tuberculosis. Pain, erythrocyte sedimentation rate (ESR), kyphotic angle correction, and Frankel's grading were taken to study the clinical, radiological, and functional outcome at the end of 1 year. Other parameters taken into consideration were the duration of stay and level of involvement; antituberculous therapy was given to all the patients for 16–18 months until the signs of radiological healing were evident. Results: This study comprised of 30 patients with a mean age of presentation of 39.835 ± 14.75 and M: F ratio of 1:1. The mean duration of stay is 10.67 ± 4.06, and the most common level of involvement is D6–D11. Kyphotic angle was corrected by a mean of 19.08 ± 5.44 at the end of 1 year (P < 0.001). Visual analog score improved from a median of 8 preoperatively to 2 at follow-up (P < 0.001). ESR improved from a mean of 37.08 ± 12.64 mm/h preoperatively to 19.83 ± 13.68 mm/h at follow-up (P = 0.01). There was an improvement in Frankel's grading in most of the patients at the end of 12 months. Radiological healing was evident in the form of the reappearance of trabeculae formation and bony fusion at the end of 12 months. Conclusion: Posterolateral approach is a good method for decompression and spinal stabilization because of significant kyphotic correction, improvement in pain, good neurological recovery, less duration of stay, and less morbidity.
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Bespoke gelfoam wafers: A practical and inexpensive alternative to oxycel for hemostasis during neurosurgery p. 483
Santosh Prabhu, Sujata Prabhu
DOI:10.4103/ajns.AJNS_275_18  PMID:31143266
Background: Since the beginning of neurosurgery, intraoperative parenchymal bleeding has been a major problem. Achievement of hemostasis is the endpoint of any cranial or spinal neurosurgical exercise and is mandatory to avoid postoperative hematomas which mar the ultimate outcome of the surgery. Several biosurgical agents are used to achieve this goal. Agents such as oxidized cellulose, gelatin foam, fibrillar collagen, fibrin sealants, and antifibrinolytic agents are used, each having a different mechanism of action. Materials and Methods: The authors describe a simple technique for substituting oxidized regenerated cellulose (Surgicel) for lining the surgical cavities after excising brain lesions, with customized gelfoam wafers fashioned on the surgical trolley. This has been used in over 8000 cases with excellent hemostatic results over the last 25 years. No complications are noted with use of these wafers. Results: In a randomized trial done by us, similar hemostatic effect was found between oxycel and the gelfoam wafers described by us with satisfactory outcomes of surgeries. No previous use of such custom-fashioned wafers has been described for neurosurgical hemostasis in the literature.
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Hydrocephalus after gamma knife radiosurgery for schwannoma p. 487
Yu Shimizu, Tadao Miyamori, Jun Yamano
DOI:10.4103/ajns.AJNS_278_18  PMID:31143267
Objective: Gamma Knife radiosurgery (GKRS) has been established as an effective and safe treatment for intracranial Schwannoma. However, communicating hydrocephalus can occur after GKRS. The risk factors of this disorder are not yet fully understood. The objective of the study was to assess potential risk factors for hydrocephalus after GKRS. Methods: We retrospectively reviewed the medical radiosurgical records of 92 patients who underwent GKRS to treat intracranial Schwannoma and developed communicating hydrocephalus. The following parameters were analyzed as potential risk factors for hydrocephalus after GKRS: age, sex, target volume, irradiation dose, prior tumor resection, treatment technique, tumor enhancement pattern, and protein level of cerebrospinal fluid (CSF) after GKRS. Results: Of the 92 patients, eight of them developed communicating hydrocephalus. Target volume and tumor enhancement pattern, and protein level of CSF ware associated with the development of hydrocephalus. Conclusion: In particular, patients with intracranial Schwannomas with large tumor size, ring enhancement patterns, and high protein level of CSF should be carefully observed.
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Detection and evaluation of intracranial aneurysms in the posterior fossa by multidetector computed tomography angiography – Comparison with digital subtraction angiography p. 491
Vivek Singh, S Vignesh, Zafar Neyaz, Rajendra Vishnu Phadke, Anant Mehrotra, Prabhakar Mishra
DOI:10.4103/ajns.AJNS_290_18  PMID:31143268
Introduction: Posterior fossa hemorrhages are not so frequent but as posterior cranial fossa space is narrow and has many vital structures, even a small amount of bleed can lead to compression of brain stem and serious consequences. Identification and planning management of cause of bleed requires angiogram. Digital subtraction angiography (DSA) being invasive modality but is gold standard, so noninvasive computed tomography angiography (CTA) is compared to detect cause of bleed in the posterior fossa in this study. Materials and Methods: From January 2017 to October 2018, all patients with posterior fossa bleed who underwent CTA and DSA for evaluation were compared regarding identification of aneurysm as cause of bleed. Results: A total of 49 patients were evaluated in this study during study duration, of which 26 (53%) were male and 23 (47%) were female. Out of 49 patients evaluated, 47 patients had aneurysms detected on DSA. Of 25 patients who underwent both procedures, 23 patients had aneurysms, and correct diagnosis was made with CTA in 24 out of 25 aneurysms. One aneurysm missed by CTA was close to bony structure. Discussion: With advancement of CTA technology, sensitivity of detecting intracranial aneurysms has increased to >96%. The overall sensitivity in detecting aneurysms is 96% with sensitivity in detecting aneurysms >4 mm being 100%. The sensitivity of CTA for smaller sized aneurysms is low which is attributed partially to lower spatial resolution of CT compared to DSA. Conclusion: CTA is a simple, fast, and noninvasive imaging modality that can be used to detect and characterize intracranial aneurysms in the posterior fossa.
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Treatment outcomes of cerebral aneurysms presenting with optic neuropathy: A retrospective case series p. 499
Koji Hirata, Yoshiro Ito, Wataro Tsuruta, Tomoji Takigawa, Aiki Marushima, Masayuki Sato, Mikito Hayakawa, Yasunobu Nakai, Noriyuki Kato, Kazuya Uemura, Kensuke Suzuki, Yuji Matsumaru, Akio Hyodo, Eiichi Ishikawa, Akira Matsumura
DOI:10.4103/ajns.AJNS_294_18  PMID:31143269
Background: Optic neuropathy due to an aneurysm is relatively rare, with only a few small case series on this topic, and no randomized trials having been published until now. As such, the functional prognosis and treatment for aneurysm-induced optic neuropathy remain controversial. Objective: We quantified optic nerve injuries using an objective index (the visual impairment score) and evaluated prognostic factors of postoperative visual function. Materials and Methods: Of 960 patients treated for an unruptured intracranial aneurysm, 18 (1.9%) patients had optic neuropathy. Visual acuity and visual field were assessed before surgery and 6 months' postoperatively. Cases were classified on the basis of treatment modality (coil embolization or flow alteration [FA]) and prognostic factors of the two treatment groups. Results: Of the 18 patients with an intracranial aneurysm and optic neuropathy, 12 (67%) were treated using coil embolization and 6 (33%) were FA. Visual function improved after surgery in 8 patients (44%), 5 (42%) in the coil embolization group, and 3 (50%) in the FA group. The visual function remained stable after surgery in 6 (33%) patients and worsened in 4 (22%). Patients with an aneurysms <15 mm in size had a favorable outcome (P = 0.05). Conclusions: Surgical treatment improved vision in 44% of cases, with no difference in the prognosis of coil embolization and FA and no effect of the duration of symptoms on outcomes. Further, the prognosis of visual function recovery was better for aneurysms <15 mm in diameter.
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Neural tube defects: A retrospective study of 69 cases p. 506
Ali Haydar Turhan, Semra Isik
DOI:10.4103/ajns.AJNS_300_18  PMID:31143270
Objective: Neural tube defects (NTDs) are congenital disorders that significantly increase the risk of death and disability in the 1st year of life. The aim of this study was to retrospectively evaluate the patients admitted to our neonatal intensive care unit because of NTD. Materials and Methods: We retrospectively examined the demographic features, familial risk factors, physical examination and radiological findings, and accompanying diseases of 69 patients with NTD. Results: Of the 69 patients hospitalized in a 5-year period, 38 were female and 31 were male. The median birth weight was 3150 g and the median delivery week was 38 weeks. Forty-nine of the patients (71%) had meningomyelocele, 11 patients (16%) had encephalocele, and nine patients (13%) had meningocele. Forty-five of the patients (65.2%) had Arnold–Chiari type 2 malformation. Twenty-five percent of the mothers had a history of periconceptional use of folic acid. The median time of making a diagnosis of NTD by prenatal ultrasonography was 20 (16–24) weeks. Thirty-nine of the patients (56.5%) had other organ disorders, some with multiple systemic disorders. Conclusion: The use of periconceptional folic acid in mothers and a decision for termination in selected cases may be effective in reducing the frequency of NTD.
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Bilateral chronic subdural hematoma presenting with pseudo-subarachnoid hemorrhage sign on computed tomography p. 510
Hiroshi Shima, Kazutaka Shirokane, Eiichi Baba, Atsushi Tsuchiya, Motohiro Nomura
DOI:10.4103/ajns.AJNS_11_19  PMID:31143271
Background: On rare occasions, cisterns are demonstrated as high-density areas on computed tomography (CT) and misdiagnosed with subarachnoid hemorrhage (SAH). This false-positive finding is called pseudo-SAH. Patients and Methods: From April 2014 to August 2018, a total of 161 patients with chronic subdural hematoma (CSDH) were treated in our hospital. For these cases, the existence of a pseudo-SAH sign on CT was retrospectively examined. Results: One patient with bilateral CSDH showed pseudo-SAH and a further examination to evaluate vascular abnormalities causing true SAH was necessary. In three patients, the Sylvian fissures were demonstrated as high-density areas due to an atherosclerotic middle cerebral artery; however, the condition was not misdiagnosed with SAH. Conclusion: In cases of CSDH, there is a possibility that CT demonstrates a pseudo-SAH sign. In such cases, close examinations to exclude true SAH are mandatory.
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Comparative study of single burr-hole craniostomy versus twist-drill craniostomy in patients with chronic subdural hematoma p. 513
Binoy Damodar Thavara, Geo Senil Kidangan, Bijukrishnan Rajagopalawarrier
DOI:10.4103/ajns.AJNS_37_19  PMID:31143272
Background: Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly. On accounting its risk-to-benefit ratio, there was always controversy regarding the management of the CSDH as to which procedure is superior. Aims: The aim is to compare the clinical and radiological outcomes in patients of CSDH who have undergone single burr-hole craniostomy (BHC) versus twist-drill craniostomy (TDC). Patients and Methods: A retrospective study was conducted in patients admitted with CSDH who had undergone single BHC or TDC between January 2014 and December 2016. Patients between 18 and 90 years of age were selected. Patients with CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, and mixed density were selected. CT scan findings of CSDH with hyperdense gravity-dependent fluid level were also selected. Patients with CT evidence of multiple septations were excluded from the study. Recurrent CSDH, bilateral CSDH, and CSDH with secondary acute bleed were also excluded. Diagnosis was done using noncontrast CT scan. The maximum thickness of the CSDH was measured in the axial film of CT scan. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline in axial CT film. The mass effect was determined by the effacement of the sulci, sylvian fissure obscuration, or compression of lateral ventricles. The decrease in the signs and symptoms in postoperative period was considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of the MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan. Patients with significant residue underwent reoperation. Results: There were 63 patients in BHC group and 46 patients in TDC group. The mean age in BHC and TDC groups was 61.39 ± 13.21 standard deviation (SD) and 73.36 ± 10.82 SD, respectively. There were 48 (76.19%) male and 15 (23.81%) female in BHC group. There were 32 (69.57%) male and 14 (30.43%) female in TDC group. In BHC group, 41.27% were on the right side and 58.73% on the left side. In TDC group, 50% were on the right side and 50% on the left side. In BHC group, 82.54% were in the frontotemporoparietal region, 9.52% in the frontoparietal region, 6.35% in the temporoparietal region and 1.58% in the parietooccipital region. In TDC group, 86.95% were in the frontotemporoparietal region, 8.69% in the frontoparietal region, 2.17% in the temporoparietal region, and 2.17% in the parietooccipital region. There was no significant difference in duration of symptoms and history of trauma in both the groups. The symptoms of the patients in BHC versus TDC include weakness of the limbs (44.44% vs. 73.91%), headache (50.79% vs. 32.60%), altered sensorium or decreased memory (44.44% vs. 54.4%), vomiting (19.04% vs. 6.52%), speech abnormalities (15.87% vs. 19.56%), urinary incontinence (25.39% vs. 15.21%), seizure (1.58% vs. 4.34%), and diplopia (4.76% vs. 0%). The mean preoperative Glasgow Coma Scale (GCS) score in BHC versus TDC was 13.44 ± 2.23 SD versus 12.47 ± 2.95 SD limb weakness was noted in 52.38% BHC group and 82.60% TDC group. There was significantly decreased GCS score in TDC group. The number of the patients with limb weakness on affected side was significantly more in TDC group. The mean maximum thickness of the CSDH (in millimeter) in axial CT scan was 17.22 ± 4.29 SD in BHC group and 22.21 ± 4.52 SD in TDC group. The number of patients with MLS was 59 (93.65%) in BHC group and 45 (97.82%) in TDC group. There was significant difference in thickness of CSDH in both the groups. However, there was no significant difference in MLS in both the groups. There was no significant difference in prothrombin time, International Normalized Ratio, and activated partial thromboplastin time values of both the groups. There was significant difference in platelet counts of both the groups. The mean duration of procedure (in minutes) in BHC versus TDC was 79.20 ± 26.76 SD versus 27.47 ± 4.80 SD. The duration of procedure was significantly more in BHC compared to TDC. In postoperative assessment, there was no significant difference in the GCS score, power improvement, power deterioration, clinical improvement, and improvement in CT scans of both the groups. Postoperative CSDH residue requiring reoperation was significantly more in TDC group against the BHC group (13.04% vs. 1.58%). There was no significant difference in the development of acute subdural hematoma (SDH) (4.76% vs. 8.6%), reoperation rate (6.35% vs. 17.39%), complications (9.52% vs. 15.21%), and death (4.76% vs. 10.87%) in BHC group vs. TDC group. There was no significant difference in the period of hospital stay (days) in BHC (8.90 ± 5.89 SD) and TDC groups (7 ± 4.24 SD). Conclusion: The duration of procedure was significantly more in BHC than in TDC. In postoperative outcome, there was no significant difference in the GCS score, motor power improvement, motor power deterioration, overall clinical improvement, and improvement in CT scans of both the groups. Postoperative residue requiring reoperation was significantly more in TDC group. There was no significant difference in the development acute SDH, reoperation rate, complications, death, and hospital stay in both the groups. Avoiding the complications of general anesthesia and giving the equal postoperative improvement and complications of BHC, the TDC is considered as an effective alternative to the BHC in the surgical management of CSDH.
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CASE REPORTS Top

En plaque meningioma presenting as a cutaneous nodule p. 522
Sotirios Apostolakis, Aikaterini Karagianni, Ioannis Mylonakis, Konstantinos Vlachos, Lavrentios Roussos
DOI:10.4103/ajns.AJNS_273_18  PMID:31143273
Meningiomas are the most common central nervous system tumor and can be found anywhere in the neuraxis. In rare cases, they may extend beyond the cranial vault, while cases without evidence of intracranial mass existence have also been reported. Here, we report the case of a 64-year-old male patient with a history of craniectomy for parasagittal meningioma, who presented at the emergency department with onset of focal seizures. The patient underwent nonenhanced brain computed tomography scan which was indicative of recurrence of the mass. The patient was scheduled for craniotomy and excision of the mass. He also expressed his desire to have a scalp nodule removed concomitantly. Thickening of the meninges underlying the nodule was observed but without indication of a space-occupying lesion. Both histological examinations were suggestive of Grade II, atypical meningiomas. A case of a subcutaneous meningioma in a patient with a history of surgically excised parasagittal meningioma is presented. Radiologic evidence of dural proliferation underlying the mass was suggestive of an en plaque meningioma secondary to iatrogenic dissemination of tumor cells.
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Anterior release and anterior reconstruction for a neglected osteoporotic odontoid fracture p. 525
Sandeep Sonone, Aditya Anand Dahapute, Sai Gautham Balasubramanian, Rohan Gala, Nandan Marathe, Deepika Albert Pinto
DOI:10.4103/ajns.AJNS_42_18  PMID:31143274
A 70 years old lady presented to us with history of a fall 3 months prior. She had suffered a type 2 odontoid fracture with atlantoaxial dislocation, that was not reducible by traction. She had symptoms of neck pain with inability to hold the neck upright. The patient was subsequently planned for anterior release and reduction of odontoid fracture dislocation with posterior stabilization in the same sitting. The patient was treated with cervical skeletal traction and immobilized. However, she developed occipital sore during the period and was mobilized with brace after which she developed myelopathic symptoms and gait disturbance due to the collapse of fracture segment. The patient was planned for anterior release and fixation with contoured reconstruction plate fixing C1 lateral mass to the lateral mass on the right side and C1 lateral mass to C2 body on the left side primarily with distraction of the C1–C2 joint by autologous tricortical iliac bone graft. The posterior stabilization was planned after healing of the sore, and the patient was counseled for the same. However, the patient was lost on follow-up and returned at 3-month postoperative period with collapse of the graft, resubluxation of C1–C2 segment, and failure of anterior fixation. The standard modality of treatment for such cases includes an anterior release of contracted soft tissues and ligaments and posterior stabilization with fusion in a single setting. However, it is the posterior fixation that stabilizes the fracture and prevents it from redislocation. Anterior fixation as a stand-alone treatment in osteoporotic bone has high risks of failure due to severe posterior tensile stresses. This article describes the importance of posterior fixation in osteoporotic bone based on our experience.
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Phenytoin toxicity manifesting as acute psychosis: An uncommon side effect of a common drug p. 532
Mohit Agrawal, Sachin Anil Borkar, Shashank Sharad Kale
DOI:10.4103/ajns.AJNS_86_18  PMID:31143275
Antiepileptic drug-induced psychotic disorder represents an iatrogenic, adverse drug reaction. Phenytoin has rarely been shown to be a causative agent of acute psychosis in patients. We present such a rare case of short term use of phenytoin causing toxicity manifesting as acute psychosis and complete recovery following phenytoin withdrawal.
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Giant lumbar dumbbell extradural schwannoma in a child p. 535
Amit Agrawal, Venati Umamaheswara Reddy, Vissa Santhi, Yashawant Sandeep
DOI:10.4103/ajns.AJNS_132_18  PMID:31143276
Completely giant lumbar extradural spinal Schwannomas are a rare subgroup of spinal nerve sheath tumors in the pediatric age group. Single stage, single approach, complete, and safe surgical removal while preserving the spinal stability is the mainstay of treatment of giant lumbar extradural Schwannomas. In the present case, we report a case of a 9-year-old male child studying in 2nd standard presented with pain in both thighs and legs for 3 months. Magnetic resonance imaging lumbosacral spine showed lobulated dumbbell-shaped lesion extending from L4 superior endplate to inferior endplate of L5 in intraspinal space displacing the nerve roots. The patient underwent a posterior midline approach, L4 and L5 laminectomy and complete excision of the tumor. Histopathological confirmed the diagnosis of benign extradural dumbbell Schwannoma. Postoperatively, the child was showing gradual improvement in motor power, but his pain was significantly relieved.
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Hydrocephalus after deep brain stimulation for Parkinson's disease p. 538
Edvin Zekaj, Christian Saleh, Domenico Servello
DOI:10.4103/ajns.AJNS_136_18  PMID:31143277
A fearsome complication of deep brain stimulation (DBS) constitutes intracranial hemorrhage. Incidence rates vary between 0.5% and 5%, with 1.1% of cases resulting in permanent deficit or death. Intracranial hemorrhage can present asymptomatically or result in fatal outcome. A rare complication in this setting is acute hydrocephalus due to obstruction of the cerebrospinal fluid flow. This complication might have catastrophic consequences resulting in death in a few hours if not an external ventricular drainage promptly is placed. We report a patient with acute hydrocephalus due to intraventricular hemorrhage after the DBS procedure. Patients should be warned of this complication when informed consent is obtained.
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Solitary primary central nervous system plasmablastic lymphoma in a young immunocompetent female: Report on an extremely rare entity with review of literature p. 541
Iqbal Mohd, Sanjog Shankar Gajbhiye, Ritu Verma, Jayesh Sardhara
DOI:10.4103/ajns.AJNS_194_18  PMID:31143278
Primary central nervous system (CNS) plasmablastic lymphoma (PBL) in immunocompetent patients is an extremely rare disease, and only three cases had been reported till date. We present a case of a young female of age 21 years immunocompetent human immunodeficiency virus (HIV) and Epstein–Barr virus (EBV) negative, presented to us with left frontal lesion with weakness of the right upper and lower limbs for 9 months. Magnetic resonance images showed ring-enhancing lesions resembling a cavernoma or tuberculoma. Histopathological diagnosis was PBL. Surgical excision of tumor, followed by rapid recurrence with bleed in 3-month duration, was treated by adjuvant chemoradiotherapy. We report a young immunocompetent, HIV-negative, and EBV-negative female, with rapidly progressive primary CNS solitary PBL in the posterior frontal region, developed rapid recurrence of the tumor twice despite gross total excision.
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Mycotic aneurysm of intracavernous internal carotid artery presenting as cavernous sinus syndrome p. 547
Kumudini Sharma, Vikas Kanaujia, Rachna Agarwal, Vivek Singh, Priyadarshini Mishra
DOI:10.4103/ajns.AJNS_39_18  PMID:31143279
Mycotic intracranial aneurysms are infectious aneurysms accounting for 0.7%–6.5% of all intracranial aneurysms and are most commonly located in distal branches of the middle cerebral arteries, particularly at the bifurcation area. They are caused by weakening of the vessel wall secondary to infection of a segment of the artery that can be endovascular as in infective endocarditis or extravascular as in meningitis or cavernous sinus thrombophlebitis. The rare occurrence of the mycotic cavernous internal carotid artery aneurysm, its variable clinical picture and limited knowledge of its natural course is a challenge for both diagnosis and management.
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Spontaneous subdural hematoma of dorsal spine secondary to dengue fever: A rare case report with review of literature p. 550
Vikas Maheshwari, Sanjay Kumar, Arun Kumar, Ashok Kumar
DOI:10.4103/ajns.AJNS_228_18  PMID:31143280
A 54-year-old female patient had a sudden onset of febrile illness following which she developed low backache and sudden onset paraplegia with urinary retention. Her hemogram, biochemistry, and coagulation profile was within normal limits. Her dengue serology was positive for IgG antibodies but negative for NS1 Ag. Magnetic resonance imaging of dorsolumbar spine revealed extensive subdural bleed from D6–D12 with cord compression. She underwent emergency laminectomy D6–D12 along with complete evacuation of hematoma. There was complete recovery of sensations in the immediate postoperative period though her motor weakness showed only marginal improvement.
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White epidermoid of the sylvian fissure masquerading as a dermoid cyst: An extremely rare occurrence p. 553
Jaskaran Gosal, Jeena Joseph, Deepak Khatri, Kuntal Kanti Das, Awadhesh Jaiswal, Aviral Gupta
DOI:10.4103/ajns.AJNS_241_18  PMID:31143281
We report the case of a 30-year-old female with a Sylvian fissure, white epidermoid which was radiologically looking like a dermoid cyst. The female presented with a headache with no neurological deficits. On radiology, the lesion was in Sylvian fissure, T1 hyperintense, T2 hypointense, and with minimal diffusion restriction medially. Hence a preoperative impression of dermoid cyst was made, a quite uncommon location. Intraoperatively, the classical pearly-white flaky appearance of epidermoid was seen which was confirmed histopathologically. White epidermoids appearing so because of high protein content are a rarity and are more likely to cause aseptic meningitis in the event of intraoperative spillage. Differentiating between a dermoid cyst and white epidermoid preoperatively and radiologically is difficult. Dermoids show diffusion restriction and are usually midline, whereas white epidermoids do not show diffusion restriction and are usually lateral. This is the first report of a white epidermoid in Sylvian fissure to the best of our knowledge.
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Surgical treatment of brainstem cavernous malformation with concomitant developmental venous anomaly p. 557
Vania Bozhidarova Georgieva, Emil Dimitrov Krastev
DOI:10.4103/ajns.AJNS_246_18  PMID:31143282
Surgical resection of brainstem cavernous malformations (BCMs) is a high-risk procedure and can be challenging to the neurosurgeon. Lateral surgical routes are becoming increasingly used to approach ventrolaterally brainstem cavernoma. Surgical approach decision depends on the location of the cavernoma in the brainstem and a possible association with brainstem developmental venous anomalies (DVAs). DVA can affect the formation and clinical course of cavernous malformation (CM). CMs related to DVAs tend to have more aggressive behavior than isolated CM. In cases of DVAs associated with hemorrhage, CMs are most often the site of bleeding rather than DVAs themselves. In this case report, we present a 24-year-old woman with a pontomedullary CM and associated dorsally located DVA. BCM was operated through a far lateral suboccipital craniotomy. Brainstem entry point was at inferior olive with extension to the pontomedullary sulcus. This approach should be preferred as a safe surgical exposure to the central and paramedian pontomedullary cavernoma, especially in the cases with associated intraparenchymal brainstem DVA. Such surgical exposure allows preservation of the concomitant brainstem DVA.
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Staged endovascular treatment of ruptured vertebral artery dissection involving the posterior inferior cerebellar artery p. 561
Yukihiro Yamao, Eiji Ogino, Sadaharu Torikoshi, Waro Taki, Masaki Nishimura
DOI:10.4103/ajns.AJNS_251_18  PMID:31143283
In the treatment of vertebral artery (VA) dissection involving the origin of the posterior inferior cerebellar artery (PICA), the prevention of rebleeding and the preservation of VA and PICA patency are challenging. We report a case with ruptured VA dissection involving the origin of the PICA. In the acute stage, the fusiform dilatation of the dissection was first treated by means of stent-assisted coil embolization. Dual-antiplatelet therapy was administered just before stent placement. Seven days after the first treatment, two additional stents without coils were added. Rebleeding did not occur, and the lesion was thrombosed successfully 4 days after the second treatment, with the preservation of VA and PICA patency. This staged therapy appears to be beneficial in preventing rebleeding and in preserving VA and PICA patency.
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Navigation for tubular decompression of the l5 nerve root ganglion after cement leakage via a wiltse approach p. 565
Sebastian Hartmann, Pujan Kavakebi, Anja Tschugg, Sara Lener, Anna Stocsits, Claudius Thomé
DOI:10.4103/ajns.AJNS_253_18  PMID:31143284
Osteoporotic vertebral fractures are a widespread problem in the elderly population. In experienced hands, treatment procedures are safe and can be done in a minimally invasive fashion. Nevertheless, in rare cases, severe complications may occur. We present a case report of cement leakage after vertebroplasty of L5 compressing the nerve root with neurological signs and radiculopathy. An 86-year-old female patient was introduced to our department with severe L5 nerve root radiculopathy and a foot flexion paresis after vertebroplasty of L5. Computed tomography (CT) of the lumbar spine revealed extraforaminal extravasation of cement around the nerve root causing significant compression. The patient underwent surgical revision using spinal navigation for skin incision, retractor placing, and verification of the cement extravasation. The cement plombage was removed, and the patient improved immediately. Sufficient decompression of the nerve root after cement leakage can be achieved using a spinal navigation setup in combination with intraoperative CT.
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Meningiomas with collagenous rosettes: A report of three cases p. 568
Mihir Mohan Vaidya, Asha Sharad Shenoy, Naina Atul Goel
DOI:10.4103/ajns.AJNS_256_18  PMID:31143285
Formation of rosettes is very rarely encountered in meningiomas. The 2016 WHO classification of central nervous system tumors mentions it as a rare pattern secondarily encountered in different variants. We report three cases of meningiomas forming collagenous rosettes. Case 1 was a 60-year-old male with a right frontoparietal mass lesion. Excisional biopsy showed features of atypical meningioma (WHO Grade II) with diffusely scattered collagenous rosettes. Case 2 was a 48-year-old male with right frontoparietal space-occupying lesion. Microscopy revealed a papillary variant of meningioma (WHO Grade III) with prominent diffusely scattered collagenous rosettes. Case 3 was a 75-year-old female with left parietal convexity tumor. Microscopy revealed a clear-cell meningioma (WHO Grade II) with cerebral invasion. Focal collagenous rosettes and fibrosclerotic whorls were noted. In all three cases, Masson's trichrome was used to confirm collagenous nature of the rosettes. All three tumors were positive for epithelial membrane antigen and vimentin.
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De novo aneurysm formation on internal carotid artery at origin of thick posterior communicating artery: 7 years after transient occlusion of contralateral internal carotid artery p. 571
Masato Takeda, Kazutaka Shirokane, Eiichi Baba, Atsushi Tsuchiya, Motohiro Nomura
DOI:10.4103/ajns.AJNS_261_18  PMID:31143286
The incidence of de novo intracranial aneurysm formation has been reported to be 0.84% per year. It is rare for de novo aneurysm formation to be observed on serial radiological examinations. A 64-year-old male with a history of right internal carotid artery (ICA) occlusion 7 years ago had subarachnoid hemorrhage (SAH) due to a ruptured left ICA aneurysm at the bifurcation of the posterior communicating artery (PComA). At the time of ICA occlusion, the left PComA was thick, about 3.0 mm in diameter, and no aneurysm was detected on radiological examinations. Thirty-eight months later, a small aneurysm was detected on the left ICA on magnetic resonance angiography (MRA). At the onset of SAH, the aneurysm was larger than that observed on the previous MRA. Left frontotemporal craniotomy was performed, and the aneurysm was clipped. A thick PComA might contribute to the development of an aneurysm at its origin due to hemodynamic stress. Persistent hemodynamic stress may cause enlargement of an aneurysm in 4 years and its subsequent rupture. In patient with a thick PComA, close observation is necessary to screen for de novo formation of a cerebral aneurysm.
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Cerebral phaeohyphomycosis with onychomycosis: Case report and review of literature p. 575
Ravishankar S Goel, Sachin Gupta, Vikram Dua, Ranjan Kumar
DOI:10.4103/ajns.AJNS_259_18  PMID:31143287
The term phaeohyphomycosis (PHM) means dark-pigmented fungal hyphae. Cerebral PHM (CPHM) with onychomycosis is extremely rare; very few have been reported so far. The authors report a case of CPHM with onychomycosis in a 37-year-old male from a rural background in Haryana, India, with involvement of the left frontal lobe. The mass was resected and biopsy was sent for histopathological examination. He was given antifungal drugs in the postoperative period. The patient responded very well to the treatment, and there were no signs of recurrence at the 6-month follow-up visit. The clinical features, imaging and histopathological investigations, and management of this rare entity are discussed, and the available literature is also reviewed.
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Giant calvarial cavernous hemangioma: A rare case report and review of literature p. 578
Govindappagari Venkateswara Prasanna, Uday Kiran Katari, Sathish Kumar Vandanapu, Malepeddi Sireesh Reddy, Hima Bindu Adusumilli
DOI:10.4103/ajns.AJNS_260_18  PMID:31143288
Primary intraosseous cavernous hemangiomas (PICHs) are benign vascular lesions that may occur in any part of the body. They account for 0.2% of all bone tumors and 10% of benign skull tumors. PICHs are usually seen in vertebral column and very rarely involve skull. We report a 36-year-old female patient with large right parietal cavernous hemangioma. The lesion had been excised completely with a good neurological outcome.
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Intraparenchymal pericatheter cyst after cerebrospinal fluid shunt: A rare complication with challenging diagnosis – Case presentation and review of the literature p. 581
Ploutarchos Karydakis, Ioannis Nikas, Dimitrios Panagopoulos, Maria Filippidou, George Sfakianos, Marios Themistocleous
DOI:10.4103/ajns.AJNS_288_18  PMID:31143289
An intraparenchymal pericatheter cyst is a rare complication of ventriculoperitoneal shunt, which is not well described yet. Due to its rarity, lack of characteristic symptoms and radiological features that often mimic brain tumors or abscesses, especially in head computed tomography without contrast can be easily misdiagnosed. We report the case of a 9-year-old girl who was admitted to a peripheral hospital due to severe headaches and vomiting. The child had a history of craniotomy and ventriculoperitoneal shunt for posterior fossa tumor, performed in our department, 4 years earlier. The patient underwent a brain magnetic resonance imaging (MRI) scan and transmitted to our hospital with the diagnosis of brain tumor. However, a closer look at the MRI established the diagnosis of intraparenchymal pericatheter cerebrospinal fluid cyst; hence, the patient underwent shunt revision and cyst drainage. We researched the literature and described 20 reported cases, discussing the pathophysiological mechanisms, the radiological features, and the optimal treatment of this interesting, yet a challenging complication.
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Choroid plexus papilloma of the fourth ventricle: A pediatric patient p. 585
Juan Esteban Munoz Montoya, Miguel Angel Maldonado Moran, Paula Santamaria Rodriguez, Sebastian Toro Lopez, Carlos Sayith Perez Cataño, Juan Carlos Luque Suarez
DOI:10.4103/ajns.AJNS_301_18  PMID:31143290
Choroid plexus papilloma is a low-frequency entity in both the adult and pediatric populations. Its clinical presentation is very variable as it depends on its location and length. We must always do the differential diagnosis between papilloma and other intraventricular pathologies. This article is about a case report of a pediatric patient with a Choroid plexus papilloma located in the fourth ventricle, a location that is atypical for the pediatric population.
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Diagnosis and treatment of early-stage glioblastoma p. 589
Makoto Hishii, Toshiharu Matsumoto, Hajime Arai
DOI:10.4103/ajns.AJNS_18_19  PMID:31143291
Early-stage glioblastoma has few identifiable findings; clinical significance of its early diagnosis and treatment remains unclear as no report has described treatment and long-term follow-up for early-stage glioblastoma. Here, we report a case of a 69-year-old woman with early-stage glioblastoma treated by microsurgical resection and chemoradiotherapy. Magnetic resonance imaging (MRI) revealed a small high-intensity lesion in the right temporal lobe on T2-weighted imaging. Contrast-enhanced T1-weighted MRI revealed ring enhancement. On magnetic resonance spectroscopy, the lesion demonstrated increased choline and reduced N-acetyl-aspartate levels compared with the normal brain. Positron emission tomography with 11C-methionine (MET) revealed 11C-methionine uptake in the lesion. Microsurgical resection was performed, and glioblastoma was pathologically diagnosed. The patient was treated with local radiotherapy and temozolomide chemotherapy postoperatively. Eight years postoperatively, the patient is surviving without tumor recurrence, but progressive cognitive impairment developed 6 years' postoperatively. Aggressive treatment of early-stage glioblastoma may improve its extremely poor prognosis. Conversely, cognitive impairment may become a significant medical and social problem when effective therapies for glioblastoma are developed.
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Intraorbital solitary fibrous tumor requiring preoperative embolization of feeding artery p. 593
Munehiro Demura, Yasuhiko Hayashi, Yasuo Sasagawa, Masanao Mohri, Masayuki Takahira, Mitsutoshi Nakada
DOI:10.4103/ajns.AJNS_30_19  PMID:31143292
Solitary fibrous tumors (SFTs) are derived from mesenchymal cells and commonly develop in thoracoabdominal organs; however, their occurrence in orbit is rare. The first-choice treatment is to surgically remove as much of the SFT as possible; however, if total removal is not achieved, the recurrence rate is high, resulting in poor prognosis. A 42-year-old man presented with painless right-sided proptosis and diplopia 4 years ago. Orbital computed tomography revealed a right extraconal mass medial to the optic nerve, measuring 25 mm. Magnetic resonance imaging demonstrated iso-signal intensity on T1- and T2-weighted imaging, including flow-void signals. During biopsy of the intraorbital mass, which was performed by ophthalmologists 3 years earlier, difficulty with hemostasis occurred due to massive hemorrhage from the mass. The mass grew to reach a maximal diameter of 33 mm, resulting in referral to the authors' department. Diagnostic cerebral angiography revealed a hypervascular orbital tumor with multiple feeding arteries. To control intraoperative bleeding, the patient underwent preoperative endovascular embolization. Subsequently, the tumor was completely removed using a combination of microsurgical craniotomy and endoscopic endonasal approach, without the occurrence of massive intraoperative hemorrhage from the tumor. Postoperatively, his clinical course was uneventful except for the remaining preoperative diplopia. The tumor was diagnosed histologically as SFT and has not recurred for 8 months since surgery. Preoperative intravascular embolization of branches of the ophthalmic artery can be performed safely, resulting in excellent control of intraoperative bleeding and facilitating complete removal of SFT without additional complications.
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Resolution of papilledema associated with chiari I malformation with ventriculoperitoneal shunting p. 598
Imran Jivraj, Grant Liu, Nikhil Sharma, Gregory Glauser, Michael Sean Grady, Neil Rainer Malhotra
DOI:10.4103/ajns.AJNS_33_19  PMID:31143293
Chiari malformation type 1 (CMI) usually presents with cervical pain and suboccipital headache, among other symptoms. Patients with CMI describe symptoms that are clearly correlated with CMI for an average of 3.1 years before diagnosis. We present a case of a patient with bilateral papilledema and CMI but with no long-standing CMI symptoms. She was initially diagnosed with a concussion but developed unremitting intense occipital headaches 4 days later which prompted an evaluation for an alternative diagnosis. Treatment of this case was ventriculoperitoneal shunting, which may serve as an alternative to posterior fossa decompression under certain circumstances.
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Dural arteriovenous fistula arising after intracranial surgery in posterior fossa of nondominant sinus: Two cases and literature review p. 602
Shohei Yokoyama, Ichiro Nakagawa, Masashi Kotsugi, Daisuke Wajima, Takeshi Wada, Kimihiko Kichikawa, Hiroyuki Nakase
DOI:10.4103/ajns.AJNS_5_19  PMID:31143294
The results of recent clinical and experimental studies suggest that the most important factor associated with the pathogenesis of dural arteriovenous fistula (AVF) is sinus thrombosis and subsequent venous or intrasinus hypertension. Here, we describe two patients who each developed a dural AVF after a posterior fossa craniotomy on the side of the nondominant or hypoplastic transverse (TS)-sigmoid (SS) sinuses. A 63-year-old female underwent surgical resection of a meningioma in the left cerebellopontine angle. Preoperative subtraction digital angiography (DSA) revealed a hypoplastic, ipsilateral left TS-SS and the sinus occlusion was revealed after surgery. Sixteen months later, she presented with a progressive left retroauricular, pulse-synchronous bruit. An AVF in the left TS-SS region was diagnosed by DSA and treated with transvenous coil embolization. The patient recovered without neurological deterioration. A 56-year-old female underwent surgical removal of an epidermoid tumor in the right cerebellopontine angle. Preoperative DSA revealed severe, ipsilateral right TS stenosis and the sinus occlusion was revealed after surgery. Two years later, she presented with the progressive right retroauricular, pulse-synchronous bruit, which was diagnosed by DSA as dural AVF in the right TS-SS region. She was treated with transvenous coil embolization and recovered without neurological deterioration. Sinus manipulation during intracranial surgery carries a potential risk of dural AVF development and this should be carefully considered, even when the ipsilateral TS-SS is nondominant or appears hypoplastic.
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CASE SERIES Top

Bone morphogenetic protein in the repair of cerebrospinal fluid leak after transsphenoidal surgery p. 607
Dejan Slavnic, Richard Floyd Cook, Matthew Bahoura, Gijong Paik, Doris WL Tong, Clifford M Houseman, Ryan J Barrett, Teck-Mun Soo
DOI:10.4103/ajns.AJNS_130_18  PMID:31143295
Background: Recurrent cerebrospinal fluid (CSF) leak carries significant morbidity. We sought to demonstrate that bone morphogenetic protein (BMP) use is effective and safe for the repair of recurrent CSF leak after a transsphenoidal pituitary tumor resection (TSPTR). Materials and Methods: We reviewed charts and radiographic data of consecutive patients who underwent BMP repair of recurrent CSF leak after TSPTR from January 2010 to June 2015 and who failed previous multilayer closure. We detailed the technique for constructing and placing a BMP-DuraGen patch for the repair. The primary variables include postoperative computed tomography/magnetic resonance imaging (CT/MRI) evidence of ectopic bone growth or inflammation, newly diagnosed systemic neoplasm within 1 year, and recurrent CSF leak. Secondary outcome is the length of stay after BMP repair. All patients were followed up radiographically and through phone interview. Results: Four patients underwent BMP repair of recurrent CSF leak after TSPTR. The average postoperative CT/MRI interval was 22 months. Postoperative CT/MRI revealed no ectopic bone formation or inflammatory changes around the site of BMP application. There was no recurrence of CSF leak or newly diagnosed neoplasm from both chart review and phone interview. Conclusions: We demonstrate that the use of BMP is a safe and an effective treatment in the repair of recurrent CSF leaks after TSPTR.
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LETTERS TO EDITOR Top

Single stage 360° correction of fixed cervical deformity with anterior and posterior ankyloses p. 612
Manish Kumar Kasliwal
DOI:10.4103/ajns.AJNS_2_18  PMID:31143296
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An audit of patients with intracranial hemorrhage admitted to the surgical intensive care unit of a tertiary hospital in Singapore p. 614
Daniel Yong En Lee, Shahla Siddiqui, Lynn Yeo, Jiexun Wang
DOI:10.4103/ajns.AJNS_229_18  PMID:31143297
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Carmustine wafer implantation at the era of standardized chemoradiation protocol p. 616
Alexandre Rou, Marc Zanello, Gilles Zah-Bi, Johan Pallud
DOI:10.4103/ajns.AJNS_297_18  PMID:31143298
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