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October-December 2020
Volume 15 | Issue 4
Page Nos. 799-1103

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EDITORIAL  

Explaining the cerebral aneurysm's shape and timing of rupture – Unlocking the mystique using theoretical physics Highly accessed article p. 799
Ahmed Ansari, Yoko Kato
DOI:10.4103/ajns.AJNS_297_20  
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REVIEW ARTICLES Top

Current role of laser interstitial thermal therapy in the treatment of intracranial tumors Highly accessed article p. 800
Farhan A Mirza, Rida Mitha, Muhammad Shahzad Shamim
DOI:10.4103/ajns.AJNS_185_20  
Laser interstitial thermal therapy (LITT) is gaining popularity in the treatment of both primary and secondary intracranial tumors. The goal of LITT is to deliver thermal energy in a predictable, controlled, and minimally invasive fashion. It can be particularly valuable in patients with recurrent tumors who, due to previous radiation or surgery, may have a potentially higher risk of wound breakdown or infection with repeat craniotomy. Deep-seated lesions that are often inaccessible through open approaches (thalamus, hypothalamus, mesial basal temporal lobe, brainstem) may also be suitable targets. The experience and data published thus far on this modality is limited but growing. This review highlights the use of LITT as a primary treatment method in a variety of intracranial tumors, as well as its application as an adjunct to established surgical techniques.
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Management of mild brain trauma in the elderly: Literature review Highly accessed article p. 809
Federica Marrone, Luca Zavatto, Mario Allevi, Hambra Di Vitantonio, Daniele Francesco Millimaggi, Soheila Raysi Dehcordi, Alessandro Ricci, Graziano Taddei
DOI:10.4103/ajns.AJNS_205_20  
Purpose: The world population is aging. As direct consequence, geriatric trauma is increasing both in absolute number and in the proportion of annual admissions causing a challenge for the health-care system worldwide. The aim of this review is to delineate the specific and practice rules for the management of mild brain trauma in the elderly. Methods: Systematic review of the last 15 years literature on mild traumatic brain injury (nTBI) in elderly patients. Results: A total of 68 articles met all eligibility criteria and were selected for the systematic review. We collected 29% high-quality studies and 71% low-quality studies. Conclusion: Clinical advices for a comprehensive management are provided. Current outcome data from mTBIs in the elderly show a condition that cannot be sustained in the future by families, society, and health-care systems. There is a strong need for more research on geriatric mild brain trauma addressed to prevent falls, to reduce the impact of polypharmacy, and to define specific management strategies.
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Stent-assisted coiling of unruptured intracranial aneurysms with wide neck p. 821
Filippos Papadopoulos, Constantine Nikolaos Antonopoulos, George Geroulakos
DOI:10.4103/ajns.AJNS_57_20  
Objective: Morbidity and mortality in patients experiencing the rupture of intracranial aneurysm ruptures are high. We conducted a systematic review and meta-analysis to investigate the role of stent-assisted coiling (SAC) for unruptured intracranial aneurysms (UIAs) with wide neck. Materials and Methods: The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled proportions with 95% confidence intervals (CIs) of ten outcomes of interest were calculated. Results: We finally reviewed 13 studies, including 976 patients. The technical success of the method was 98.43% (95% CI: 95.62–99.95). Early outcomes included total periprocedural obliteration with a rate of 50.20% (95% CI: 36.09–64.30) and periprocedural rupture with zero rate. During the follow-up period, ranging from 6 months to 2 years, the total postprocedural obliteration rate was 63.83% (95% CI: 45.80–80.18) and the overall late rupture rate was 0.41% (95% CI: 0.00–2.38). The pooled in-stent stenosis rate was calculated at 1.24% (95% CI: 0.02–3.63). We also estimated a pooled rate of 0.02% (95% CI: 0.00–0.51) and 4.33% (95% CI: 2.03–7.23) for total mortality and overall neurological complications, respectively. A pooled rate of 3.94% (95% CI: 1.48–7.33) was found for stroke. Finally, the recanalization rate was recorded at 7.07% (95% CI: 4.35–10.26). Conclusions: SAC of UIAs with wide neck seems to be a safe and acceptable alternative to surgical clipping. Although early results concerning total periprocedural obliteration may be modest, follow-up outcomes may be indicative of adequate occlusion of treated UIAs.
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Women in Neurosurgery (WIN): Barriers to progress, world WIN directory and the way forward Highly accessed article p. 828
Sneha Chitra Balasubramanian, Dhivya Palanisamy, Souad Bakhti, Najia El Abbadi, Nelci Zanon Collange, Claire Karekezi, Boon Seng Liew, Yoko Kato
DOI:10.4103/ajns.AJNS_108_20  
Women in Neurosurgery (WIN) have come a long way and are making inroads in every neurosurgical subspecialty. There has been a worldwide increase in the number of female neurosurgeons both in the training and practice. Although this is a welcome trend, gender equality at work in terms of opportunities, promotions, and pay scales are yet to be attained. This is more apparent in the developing and underdeveloped nations. Barriers for a female neurosurgeon exist in every phase before entering residency, during training, and at workplace. In the neurosurgical specialty, only a few women are in chief academic and leadership positions, and this situation needs to improve. WIN should be motivated to pursue fellowships, sub-specialty training, research, and academic activities. Furthermore, men should come forward to mentor women, only then the gender debates will disappear and true excellence in neurosurgery can be attained. This article reviews the issues that are relevant in the present era focusing on the barriers faced by female neurosurgeons in the developing and underdeveloped countries and the possible solutions to achieve gender equality in neurosurgery. The authors also present the data from the World WIN Directory collected as a part of Asian Congress of Neurological Surgeons-WINS project 2019. These numbers are expected to grow as the WIN progress and add value to the neurosurgical community at large.
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Endoscopic microvascular decompression for hemifacial spasm p. 833
Maruf Matmusaev, R Senthil Kumar, Yasuhiro Yamada, Tetsuya Nagatani, Tsukasa Kawase, Riki Tanaka, Miyatani Kyosuke, Yoko Kato
DOI:10.4103/ajns.AJNS_152_20  
Introduction and Objective: Hemifacial spasm (HFS) is a condition, characterized by painless, involuntary unilateral tonic or clonic contractions of the facial muscles innervated by the ipsilateral facial nerve. HFS starts with contractions in the orbicularis oculi muscle with subsequent eyelid closure and/or eyebrow elevation, but may spread to involve muscles of the frontalis, platysma, and orbicularis oris muscles. Microvascular decompression (MVD) is reliable and accepted surgical treatment for HFS. MVD is the standard surgical technique now for HFS treatment with long-term success rates. Materials and Methods: We performed fully endoscopic MVD technique for 1 patient with HFS (a 83-year-old female) at our institution. HFS was diagnosed based on the clinical history and presentation, a neurologic examination, and additional imaging findings. Respectively, the durations of HFS were 3 years, respectively. The patient had been previously treated with repeated botulinum toxin injections. Preoperative evaluation was done with magnetic resonance imaging; three-dimensional computed tomography fusion images examinations had identified the anterior inferior cerebellar artery (AICA) as the offending vessel in this patient. Results: The patient with HFS was treated by fully endoscopic MVD technique. The AICA, which had been identified as the offending vessel by preoperative magnetic resonance imaging, was successfully decompressed. No surgery-related complications occurred and had excellent outcomes with the complete resolution of HFS immediately after the operation. Conclusions: Endoscopic surgery can provide a more panoramic surgical view than conventional microscopic surgery. Fully endoscopic MVD is both safe and effective in the treatment of HFS. This method minimizes the risks of brain retraction and extensive dissection often required for microscopic exposure. Endoscopic MVD is safe and has advantage over microscope in terms of visualization of structure, identification of neurovascular conflict, but it has a learning curve and technically challenging.
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ORIGINAL ARTICLES Top

Modified transclavicular-transmanubrial approach to cervicothoracic spine: Revisiting and Renovating the Path – Lessons learned p. 839
TS Vasan, Raghavendra M Rao
DOI:10.4103/ajns.AJNS_178_20  
Introduction: A thorough knowledge of the vital structures adds to the safety in approaching the cervicothoracic spine junction. The best described method to reach the spine is via viscero-neurovascular space. We present our experience of 10 cases operated at our institute using the modified transclavicular transmanubrial approach to the cervicothoracic spine pathology.As we gained experience we have used various corridors to the operating field and used a new space to approach the lower cervicothoracic junction spine. Methods: Between February 2011 to August 2015, 10 patients with disease in upper thoracic vertebral body were admitted and evaluated clinically and radiologically. Neurological status in all cases was graded according to Frankel grading system.Patients were followed up with Histopathological reports and treated accordingly. Results: All patients(except metastasis) improved by 1 or 2 grade in post op period. Metastasis patients remained in same grade. Conclusion: Anterior approach with its modifications are the better suited biomechanically for exploring the pathology of cervicothoracic spine,its decompression and stabilization. Also it preserves the stability of shoulder girdle with good neurological and cosmetic outcome.
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Endoscopic transcortical transventricular management of cystic craniopharyngioma: Outcome analysis of 32 cases at a tertiary care center p. 846
Somil Jaiswal, Manish Jaiswal, Pooja Jaiswal, Ankur Bajaj, Chhitij Srivastava, Anil Chandra, Bal Krishna Ojha, Janu Vikas, Awadhesh Yadav
DOI:10.4103/ajns.AJNS_252_20  
Background: Microsurgical resection has been considered the gold standard treatment of craniopharyngioma, but lately, it has found less favor due to its morbidity and is being replaced by minimally invasive cyst drainage procedures. We present our experience of transventricular endoscopy and cyst drainage along with its technique and have analyzed its results. Materials and Methods: Clinical and radiological data of all cystic craniopharyngioma patients treated by transventricular endoscopic cyst drainage and Ommaya placement were retrieved and analyzed Results: Thirty-two patients underwent endoscopic cyst drainage during the study period. All patients had immediate clinical and radiological improvement. No significant complications were seen. All patients underwent adjuvant radiotherapy and six patients (18.7%) showed recurrence. Three patients died in the follow-up period. Conclusions: Endoscopic transcortical transventricular cyst drainage with Ommaya reservoir along with adjuvant radiotherapy is a simple, safe, and effective treatment modality.
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Clinico-radiological outcome of single-level and hybrid total disc replacement with spineart Baguera®-C for cervical myeloradiculopathy: Minimum 2-year follow-up study in Indian population p. 856
Jeevan Kumar Sharma, Tarush Rustagi, Nandan Marathe, Abhinandan Reddy Mallepally, Rajat Mahajan, Harvinder Singh Chhabra, Kalidutta Das
DOI:10.4103/ajns.AJNS_288_20  
Context: Cervical radiculopathy and myelopathy is one of the most frequent ailments encountered by spine surgeon. Motion-preserving surgeries in cervical spine is a standard of care due to its certain advantages such as biomechanical anatomical conformity, reduced chances of adjacent segment degeneration, and revision surgeries. While there is abundant data from some centers, data from developing countries are still limited. Aims: The aim was to study the clinico-radiological outcome of single-level and hybrid total disc replacement (TDR) with Spineart Baguera®-C cervical prosthesis for cervical myeloradiculopathy. Settings and Design: Retrospective study. Materials and Methods: Retrospective analysis of the 29 consecutive patient undergoing single level TDR and hybrid fixation (i.e., TDR with anterior cervical discectomy and fusion) with Spineart Baguera®-C cervical prosthesis for myeloradiculopathy from January 1, 2014 to December 31, 2017, was done. Radiological features and outcome were studied from data collected on Insta-picture archiving and communication system. Statistical Analysis Used: SAS 9.4 was used for all computations. Results on continuous measurements were presented as mean and standard deviation (min-max) and results on categorical measurements were presented as numbers (n) and percentages. Results: Twenty-nine patients were included in the study. The mean age was 43.31 ± 9.04 years with 14 males and 15 females. The most common level of TDR was C5-C6 (72.41%). The mean follow-up duration was 3.14 years ± 1.13 years (2–5 years). The mean hospital stay was 4.93 ± 2.12 days. The mean neck disability index (NDI) at admission was 27.24 ± 7.66 which decreased to 6.41 ± 4.29 at final follow-up. Conclusions: Two-year data on treatment with Spineart Baguera®-C cervical prosthesis shows significantly improved NDI, visual analog scale (arm) with maintenance of movement of the prosthesis.
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High-flow bypass with radial artery graft for cavernous carotid aneurysms: A case series p. 863
Riki Tanaka, Boon Seng Liew, Kento Sasaki, Kyosuke Miyatani, Tsukasa Kawase, Yasuhiro Yamada, Yoko Kato, Akihiko Horiguchi
DOI:10.4103/ajns.AJNS_289_20  
Background: The incidence of cavernous carotid aneurysms (CCAs) of intracranial aneurysms is low. Majority of cases presented as incidental findings with benign natural progression. The most common presenting symptoms are multiple cranial neuropathies among symptomatic patients. The treatment modalities for symptomatic patients include direct surgical clipping, endovascular coil embolization, or placement of flow diverter, or indirect procedures such as occlusion of parent artery with and without revascularization techniques. The advancement in the microsurgical treatments and endovascular devices have enable a high success rate in the treatment of patients with CCAs with low morbidity and mortality rates. Objective: To study the surgical outcomes of patients with cavernous aneurysm who underwent high-flow bypass between 2015 and 2020 in our institution. Materials and Methods: A total of six patients in a single institution presented with CCAs who were treated with high-flow bypass surgery were included in this case-series. A single-case illustration was presented focusing on the details of surgical case management of CCA. The intraoperative middle cerebral artery (MCA) pressure monitoring during bypass surgery was also described. Results: All five female patients and one male patient who were diagnosed with cavernous carotid aneurysms were studied. The mean age was 68.8 years old (range: 24-84 years old) and the mean size of the aneurysm was 19.6mm (range: 9.7 – 30mm). There were successfully treated with high flow bypasses using radial artery graft without any neurological sequelae. Conclusion: The surgical treatments of cavernous carotid aneurysms should be limited to experienced neurosurgeons in view of significant risk of morbidity and mortality. Endovascular procedures may be the main stay of treatments. The success shown in this case series with parent artery occlusion and bypass surgery may provide an safe alternative to the endovascular treatment.
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Intradural versus extradural location of paraclinoid aneurysms: Preoperative red flag markers p. 870
Anuj Arun Bhide, Yashuhiro Yamada, Yoko Kato, Nidhisha Sadhwani, Tsukasa Kawase, Riki Tanaka, Kyosuke Miyatani, Daijiro Kojima
DOI:10.4103/ajns.AJNS_305_20  
Background: Exact preoperative confirmation of the distal dural ring and intradural location of a paraclinoid internal carotid aneurysm has been an age old dilemma. This study was aimed at identifying anatomical landmarks in cases of paraclinoid aneurysms, which were relatively consistent, and would help in predicting the possibility of an extradural inaccessible location of these aneurysms for surgical clipping. Methods: Ninety surgically managed unruptured paraclinoid aneurysms were retrospectively analyzed with preoperative computerized tomography. Axial relation of the aneurysm neck to the ophthalmic artery (OA), optic strut (OS), and anterior clinoid process (ACP) in terms of vertical distance and the direction of projection were analyzed and tabulated for all 90 cases. Intradural and extradural (inaccessible) aneurysms were compared. Results: Seven out of the 8 inaccessible necks were medially directed and 1 was ventrally placed (P = 0.053). The OA level when compared to the neck had a positive correlation with inaccessible aneurysms for clipping (P = 0.002) The OS location above the level of the neck had significant correlation with inaccessibility of clipping and extradural location (P < 0.001). The tip of the ACP had no statistical significance with inaccessibility (P = 0.351). Conclusions: Medially projecting aneurysms with necks below the level of the OS and origin of the OA should be managed with a high index of suspicion and an alternate method of treatment should be sought. The relation of the neck to the ACP does not seem to have significant statistical bearing with decision making.
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Racial disparities in the incidence and survival of spinal meningioma p. 877
Mahmoud Dibas, Ahmad Mamoun Rajab, Mohammad J Atiah, Saadi Aljundi, Sherief Ghozy, Kevin Phan, Nazmus Saquib
DOI:10.4103/ajns.AJNS_306_20  
Objective: Race is a significant prognostic factor in various cancers, including the breast. Its prognostic association with spinal meningioma has not been established, although the incidence of spinal meningioma varies by race. In this retrospective cohort study, we aimed to investigate the association of race with the incidence and survival of spinal meningioma among a large population sample. Materials and Methods: A comprehensive search was done in the surveillance, epidemiology, and end results database between 2000 and 2016 to identify patients with spinal meningioma. Overall and race-specific incidence were calculated. The effect of race on overall survival among these patients was determined with Kaplan–Meier curve and Cox proportional hazard models. Results: Of 3502 spinal meningioma patients, 82.6% were Caucasian, 7.7% were African-American, 8.8% were Asian/Pacific Islander and 0.7% were American Indian/Alaska Native. The overall age-adjusted incidence was 0.239/100,000; it was highest among Caucasian (0.249) and lowest among American Indian/Alaska Native patients (0.137). There was a race effect in overall survival in the unadjusted analysis with the worst overall survival reported for Caucasian patients, and the best reported for American Indian/Alaska Native patients. However, this relationship was insignificant in the adjusted analysis. Conclusions: Race was not significantly associated with overall survival among these patients. Future studies should use spinal-meningioma-specific survival as outcome to see whether there is a racial difference in survival.
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Traumatic cerebellar hematoma: A tertiary care experience of 23 conservatively managed cases p. 882
Rahul Singh, Nityanand Pandey, Ramit Chandra Singh
DOI:10.4103/ajns.AJNS_309_20  
Context: Traumatic cerebellar hematomas are rare in comparison to nontraumatic cerebellar hematomas. Aims: The aim of this study is to evaluate the prognostic factors and outcome determining factors with regard to conservatively managed isolated traumatic cerebellar hematoma. Settings and Design: Retrospective cohort study. Materials and Methods: A retrospective study of 23 patients of conservatively managed isolated posterior fossa hematoma, admitted between August 2018 and May 2020, was conducted in the Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi. Each of the patients was evaluated in terms of age, sex, mode of injury, clinical presentation, comorbidity, the severity of injury, best motor response, Glasgow Coma Scale (GCS) at admission, computed tomography findings, and Glasgow Outcome Scale at discharge/death. Statistical Analysis: Chi-square test and unpaired t-test were used. P < 0.05 was deemed statistically significant. Results: Mean volume of posterior fossa contusion was 8.9 ml. The cerebellar hemispheric (60.9%) location of hematoma was more common. Age at presentation (P = 0.0086), best motor response (P < 0.0001), severity of injury (P = 0.0002), GCS at admission (P < 0.0001), effacement of basal cistern (P < 0.0001), fourth ventricular compression and intraventricular hemorrhage (P = 0.0008), presence of hydrocephalus (P = 0.0142), subarachnoid hemorrhage (P = 0.0008), and volume of posterior fossa contusion (P = 0.0002) were significantly associated with outcome of posterior fossa contusion. Conclusion: Traumatic cerebellar hematoma is rare. Conservatively managed cerebellar hematoma patients must be monitored closely for neurological and radiological status. Patients who show deterioration in neurological or radiological status require surgical intervention.
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Getting more out of follow-up three-dimensional time-of-flight magnetic resonance angiography in endovascularly treated intracranial aneurysms p. 889
Rajendra Vishnu Phadke, Vivek Singh, Madan Mohan Balaguruswamy, Alok Udiya, Gurucharan Sunnari Shetty, Surya Nandan Prasad, Somit Mittal, Gaurav Chauhan, Vedita Dhull, Zafar Neyaz
DOI:10.4103/ajns.AJNS_374_20  
Background: We retrospectively re-evaluated follow-up three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) in patients with aneurysms treated with coiling at our Institute. Aims: To document the type and frequency of postcoiling residue patterns as seen on follow-up MRA and to document their evolution with time where a further follow-up MRA was available. To assess the implications of the location of the aneurysm on residue and recurrence. Subjects and Methods: 3D TOF MRA for 104 aneurysms were evaluated for residue size and residue pattern. Mainly, three residue patterns were identified. The aneurysms were allocated to different groups depending on the location. Multiple MRA studies were available in subgroup 1* and subgroup 2* where the residue growth or reduction and pattern change was noted and residue growth rates were calculated. Results: Collectively 54 (51.92%) aneurysms showed occlusion (pattern 1 and 1A), 31 (29.81%) showed neck residue (pattern 2A, 2B and 2C) and 19 (18.27%) showed recurrence (pattern 3A, 3B and 3C, residue size >3 mm) at the last follow-up MRA. Type 2A/3A patterns were more common. In terms of residue and recurrence, the distally located aneurysms (Group 3) appeared to do well. For those showing growing residue/recurrence, the average growth rate was calculated at 0.094 mm/month and 0.15 mm/month, respectively, for subgroup 1* and subgroup 2*, although the difference was not statistically significant. With longer follow-up the persisting and growing residues from both the subgroups, not warranting early re-treatment, showed a low growth rate at approximately 0.05 mm/month. Conclusions: TOF MRA helps in identifying different residue patterns in coiled aneurysms. Serial follow-up MRA appears useful in showing the pattern and size changes in the residual aneurysm. Although more work is required in this regard, calculation of aneurysm/residue growth rate may be useful in prognostication and in scheduling further follow-up or retreatment. The risk factor related to the location of the aneurysm warrants further study.
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Avoiding complications in endoscopic trans-sphenoidal surgery for pituitary adenoma: A beginner's perspective p. 899
Pawan Goyal, Aditya Gupta, Sanjeev Srivastava, Shilpi Modi
DOI:10.4103/ajns.AJNS_121_20  
Introduction: We aimed to analyze the difficulties and complications experienced while as a beginner in endoscopic transnasal transsphenoidal approach for pituitary adenomas. Materials and Methods: We retrospectively analyzed 83 cases done from June 2016 to August 2019. Navigation-guided endoscopic transnasal transsphenoidal approach was used in all the cases. Results: Gross total tumor removal was achieved in 55 (66.26%) patients. We found that gross total resection rate was inversely proportional to Knosp grading, and the extent of resection was found to have a statistically significant correlation with grade of tumor (P < 0.05). Surgery-related complications were present in 33 of our patients. Nasal complications occurred in six patients: three epistaxis (3.6%) and two hyposmia (2.4%) and one case of septal hematoma (1.2%). Postoperative cerebrospinal fluid leak occurred in six (7.2%) cases, two (2.4%) cases had sinusitis, while two (2.4%) cases had meningitis. There was a very rare case of subarachnoid hemorrhage and one case had sellar hematoma. Endocrinologic complications occurred in 15 (18.07%) patients: anterior pituitary deficiency in five (6.02%) patients, transient diabetes insipidus (DI) in nine (10.84%) patients, and permanent DI in one (1.2%) patient. There was no vascular injury or mortality noted in our study. Conclusion: Endoscopic approach is an effective modality for pituitary surgery; with patience, learning lessons from your own mistakes and by adopting right technique, learning curve can be flattened significantly.
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A cadaveric anatomical study on anterior communicating artery aneurysm surgery by extended endoscopic endonasal approach p. 908
Anil Kumar Sharma, Dhyanesh Kumar Sharma
DOI:10.4103/ajns.AJNS_160_20  
Background: The use of minimally invasive approaches in the management of cerebral aneurysms continues to evolve and a purely endoscopic endonasal approach (EEA) for cerebral aneurysm has its own advantages. The purpose of the present study is to perform a detailed anatomical dissection study to test the usefulness of the extended EEAs for selected anterior communicating artery (ACoA) aneurysm. Materials and Methods: Nine human cadaveric heads were used for this study, and all dissections were performed through the endonasal corridor. Endoscopic endonasal surgical dissections were carried out, and surgery was simulated in all specimens to reach the ACoA region. The ACoA complex, its neural and osseous relations, degree of vascular exposure, and the ability to perform clip placement were observed and analyzed. Results: The transplanum and transtuberculum approaches exposed the A1 and A2 segments of the anterior cerebral artery and the ACoA in all specimens. This route allowed clip ligation of the distal A1 branches, ACoA and proximal A2 branches to the level of the pericallosal segment. Proximal and distal control was most readily achievable at the level of the ACoA complex. Conclusion: The present cadaveric study on nine specimens with bilateral dissection has demonstrated that the endonasal transplanum transtuberculum approach to the ACoA region provides excellent visualization of the vasculature. When selected prudently, such lesions may be favorable targets for an extended endoscopic endonasal (EEA) in comparison to transcranial approaches that may provide a suboptimal exposure.
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Preoperative localization of the carotid bifurcation for cervical carotid exposure using the mastoid-hyoid line p. 913
Somkiat Wongsuriyanan, Kitiporn Sriamornrattanakul
DOI:10.4103/ajns.AJNS_285_20  
Background and Importance: The location of the carotid bifurcation (CB) is highly variable, which makes precise exposure of the cervical carotid artery difficult, especially in transverse incisions. The method for preoperative localization of the CB is not well established. We used the distance from the mastoid-hyoid (M-H) line to the CB, measured preoperatively with computed tomography angiography, to localize the location of the transverse skin incision. We describe and evaluate the accuracy of a method for preoperative localization of the CB for cervical carotid exposure. Methods: The researchers retrospectively evaluated 16 patients with aneurysms arising from the internal carotid artery (ICA) who had received cervical carotid exposure using the localization method of incision and were retrospectively evaluated from February 2018 to November 2019. The method of measurement and localization of the skin incision are described, and two illustrative cases are demonstrated. Results: Saccular aneurysms of the ophthalmic (C2) segment and communicating (C1) segment of the ICA were found in 8 and 8 patients, respectively. Nine patients had left-sided exposure, and 7 patients had right-sided exposure. The mean distance from the M-H line to the CB was 2.1 cm (range 0.5–3.5 cm). The accuracy of this method was 93.8%. No paralysis of the depressor anguli oris or the depressor labii inferioris was found postoperatively. Conclusion: The distance from the M-H line to the CB can be used to estimate transverse skin incisions for cervical carotid exposure.
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Role of combined vertebroplasty and spinal decompression in the management of aggressive vertebral hemangiomas p. 919
Ebrahim Ahmed Shamhoot, Ahmed Mohammed Balaha, Ahmed Atef Ganna
DOI:10.4103/ajns.AJNS_291_20  
Background: There are different surgical modalities designed to manage aggressive vertebral hemangioma (VH) that causes neurological symptoms. The selection of the best approach is still controversial. It is crucial to safely achieve neurological recovery with the elimination of the risk of recurrence. The combined use of surgical decompression and vertebroplasty is one of the surgical modalities that are used to manage these cases. Patients and Methods: From January 2012 to January 2019, nine patients with aggressive VH were retrospectively included in the study. All of them were operated upon using combined surgical decompression and vertebroplasty. We evaluated all the patients preoperatively, immediate postoperative, 1 month, and 12 months later. Clinical and radiological outcomes were assessed. Results: Affected spinal levels were dorsal in six cases and lumbar in three cases. There was no postoperative worsening of the preoperative neurological status. For the cases presented with sciatica, the mean VAS score has dropped from 8.33 preoperatively to 2.67 postoperatively. One month later, all of them are free from the radicular pain. For the cases presented with myelopathy, they regain their motor power in both lower limbs over a period of 4 weeks with a mean Nurick grade of 1.17. The postoperative radiological studies revealed near total occlusion of the VH with the maintenance of the vertebral body height. No clinical or radiological signs of spinal instability or recurrence are observed over the period of follow-up. Conclusions: The combined use of surgical decompression and vertebroplasty is considered a safe and effective modality in the management of aggressive VHs.
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Endoscopic third ventriculostomy: Role of image guidance in reducing the complications p. 926
Muhammad Samir Irfan Wasi, Salman Sharif, Yousuf Shaikh
DOI:10.4103/ajns.AJNS_161_20  
Introduction: Endoscopic third ventriculostomy (ETV) is performed by neurosurgeons around the world for the management of hydrocephalus. ETV has been associated with multiple complications, the most significant being iatrogenic injury to the fornix. We aim to establish the fact that the use of image guidance while planning a trajectory can reduce the incidence of complications as it significantly alters the usual approach for ETV, i.e., the coronal burr hole can be useful for young neurosurgeons to overcome the learning curve associated with the procedure. Materials and Methods: This is a prospective, observational study conducted at Liaquat National Hospital. In this study, 43 patients were included who underwent ETV for hydrocephalus. Complications were divided into three major groups: arterial hemorrhage, venous hemorrhage, and injury to neural structures (fornix, hypothalamus, and oculomotor nerve). The data were compared with studies showing the complications of ETV with and without usage of image guidance. Results: Among the 43 patients who underwent ETV with image guidance, only two patients (4.65%) had iatrogenic fornix contusions. Neither of them developed memory impairment. None of the patients (0%) encountered other major iatrogenic complications, including injury to the mammillary body, basilar artery, or oculomotor nerve. Conclusion: The use of image guidance can reduce trajectory-related complications, including hemorrhage and iatrogenic injuries to the fornix. This study showed that the altered trajectory was beneficial in avoiding major neurological structures while introducing an endoscope through the cortex into the ventricular system.
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Anterior communicating artery aneurysm clipping: Experience at a tertiary care center with respect to intraoperative rupture p. 931
Ramit Chandra Singh, Ravi Shankar Prasad, Rahul Singh
DOI:10.4103/ajns.AJNS_308_20  
Context: The incidence of anterior communicating artery (Acomm) aneurysm is high and it is associated with high risk of rupture. Aims: The aim is to evaluate various factors (size, wall morphology, and fundus direction) associated with intraoperative rupture (IOR) of Acomm aneurysm. Settings and Design: Retrospective cohort study. Subjects and Methods: Our study includes 25 operated patients diagnosed to have ruptured Acomm aneurysm in the Department of Neurosurgery of Institute of Medical Sciences, Banaras Hindu University, Varanasi, India, between January 2016 and July 2020. Our study included all patients with ruptured Acomm aneurysm who received clipping as method of treatment. Statistical Analysis: Chi-square test was used for analysis. Values with P < 0.05 were considered statistically significant. Statistical tests were done using GraphPad Prism version 8.3.0 software. Results: None of the patients with <4 mm, 6 patients of >4–10 mm, and 2 patients of >10 mm aneurysm size experienced IOR. IOR was seen in 2 patients with smooth wall and 6 in irregular aneurysm wall. All patients with posterior, 1 patient with inferior, 2 patients with anterior, and 1 patient with superior directing aneurysm experienced IOR. Patients with bilaterally clipped A1 experienced no IOR, while in unilaterally clipped aneurysm only 2 patients experienced IOR. Glasgow outcome score was better in patients with no IOR. Conclusion: The factors associated with high risk of IOR are: Aneurysm size >4 mm, multilobulated or irregular aneurysm wall, posteriorly and inferiorly directed aneurysms. Patients in whom Both A1 was temporarily clipped, experienced no IOR and better outcome.
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Endoscopic third ventriculostomy in failed ventriculoperitoneal shunt in pediatric population p. 937
Ajay Choudhary, Shivender Sobti, Sourabh Zambre, Suryanarayanan Bhaskar
DOI:10.4103/ajns.AJNS_117_20  
Introduction: Ventriculoperitoneal (VP) shunt malfunction is common in pediatric age group patients. There is a high complication rate and revision rate of VP shunt. Endoscopic third ventriculostomy (ETV) can alleviate these complications and can act as an effective alternative for the treatment of hydrocephalus in this age group of patients. Materials and Methods: The authors retrospectively reviewed the management and outcome of 36 failed VP shunts in pediatric patients for the treatment of hydrocephalus. The surgeries were performed between November 2010 and January 2016 in a tertiary care hospital. The minimal follow-up period was 3 months. We divided the patients into the following age groups: <1 year (eight infants), 1–10 years (18 children), and 10–18 years (10 children). The success of the procedure was determined by age, sex, type of hydrocephalus, and the number of shunt revisions and malfunction before ETV. Children with different age (P = 0.839) and sex group did not show any significant data (P = 0.798). Children with communicating hydrocephalus had a success rate of 52.9% (17 patients), and children with noncommunicating hydrocephalus had a success rate of 84.2% (19 patients). The success rate in children with only one shunt malfunction was 57.1% (21 patients), whereas in 15 children with two or more shunt malfunctions, the success rate of ETV was 86.7%. Conclusions: The authors conclude that ETV is an effective alternative for the treatment of hydrocephalus in children. Age does not present a contraindication for ETV in failed VP shunt.
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Comparison of preoperative hypertonic saline versus mannitol for intraoperative brain relaxation and early postoperative outcome among patients with cerebral low-grade glioma: A prospective study p. 941
Farhad Etezadi, Mahsa Babaie, Amirhossein Larijani, Mehdi Ketabchi, Mojtaba Mojtahedzadeh, Ali Jalali, Maysam Alimohamadi
DOI:10.4103/ajns.AJNS_224_20  
Introduction: Hypertonic saline (HS) has an important role in the treatment of raised intracranial pressure after traumatic brain injury. This study evaluates the efficacy and safety of HS and its impact on the postoperative course of patients undergoing craniotomy for low-grade gliomas. Materials and Methods: Sixty patients with supratentorial low-grade glioma were enrolled. All patients were anesthetized and operated with the same team and protocol. They successively received either HS or mannitol just before surgery. The amount of brain edema was classified according to the dural tension score (I–III) just after craniotomy and before dural opening. Other intraoperative measurements (such as urine output, need, and dosage of other diuretic agents) and postoperative findings (intensive care unit [ICU] and hospital stay, corticosteroid demand, and confusion period) were also assessed. Pre- and postoperative serum S100B levels were documented in both groups. Results: The dural tension score was not significantly different among the two groups: severe tension in six and five patients in the mannitol and HS groups, respectively. HS group had a significantly lower amount of diuresis (609 vs. 725 ml) during surgery. Patients in the HS group had shorter ICU stay (16.3 vs. 27.9 h) and shorter duration of corticosteroid therapy after surgery (3.4 vs. 5.2 days). Conclusion: HS infusion just before the onset of craniotomy is at least as effective as mannitol in controlling intraoperative brain edema in patients with supratentorial glioma. Improved early postoperative course and lower degrees of S100B rise after craniotomy seen in the HS group needs to be explained in more detailed studies.
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Free mucosal graft for reconstruction after nonfunctional pituitary adenoma surgery p. 946
Carlos Perez-Lopez, Alexis Junnior Palpan, Álvaro Zamarrón, Carolina Alfonso, Álvaro De Arriba, Javier Giner, Alberto Isla
DOI:10.4103/ajns.AJNS_37_20  
Background: In the search for an effective closure without nasosinusal morbidity, we have studied the efficacy of free mucosal graft as a reconstructive technique of the sellar floor after the resection of nonfunctioning pituitary adenomas (NFPA). Methods: In 100 endonasal endoscopic surgeries, we analyzed the personal history, radiological and intraoperative aspects that could have an impact on the risk of postoperative cerebrospinal fluid (CSF) leak. They were divided into three groups: no mucosa flap/graft, mucosal free graft, and nasoseptal pedicled flap. Results: The characteristics of the patients and adenomas were the same in all three groups. Intraoperative CSF leak was observed in 1/13 cases of the group without graft/flap (7%), in 16/50 of the free mucosal graft (32%) and 12/37 (32%) of pedicle flap. The proportion of cases in which other means of reconstruction were used in addition (fat, collagen matrix, and sealant) was similar in the different groups. No CSF leaks were observed, except for a doubtful one in the free mucosal graft group, which resolved spontaneously within 24 h, without receiving any type of treatment. Conclusions: The middle turbinate free mucosal graft can be of great value in endonasal surgery: It achieves a hermetic closure in cases of low-flow CSF leaks, it can be useful as a rescue for cases where nasoseptal mucosa is not available to perform a pedicled nasoseptal flap, minimizes the nasosinusal complications of the pedicled flap by leaving a smaller surface area of the nasal cavity devoid of the mucosa, and achieves greater nasosinusal functionality because proper reepithelialization occurs in the area.
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Patterns of neurosurgical conditions at a major government hospital in Cambodia Highly accessed article p. 952
Miri Kim, Chung Bin Yoo, Owen Lee-Park, Sam Nang, Din Vuthy, Kee B Park, Iv Vycheth
DOI:10.4103/ajns.AJNS_213_20  
Background: Low- and middle-income countries (LMICs) have a growing and largely unaddressed neurosurgical burden. Cambodia has been an understudied country regarding the neurosurgical pathologies and case volume. Rapid infrastructure development with noncompliance of safety regulations has led to increased numbers of traumatic injuries. This study examines the neurosurgical caseload and pathologies of a single government institution implementing the first residency program in an effort to understand the neurosurgical needs of this population. Methods: This is a longitudinal descriptive study of all neurosurgical admissions at the Department of Neurosurgery at Preah Kossamak Hospital (PKH), a major government hospital, in Phnom Penh, Cambodia, between September 2013 and June 2018. Results: 5490 patients were admitted to PKH requiring neurosurgical evaluation and care. Most of these admissions were cranial injuries related to road traffic accidents primarily involving young men compared to women by approximately 4:1 ratio. Spinal pathologies were more evenly distributed in age and gender, with younger demographics more commonly presenting with traumatic injuries, while the older with degenerative conditions. Conclusions: Despite increased attention and efforts over the past decade, Cambodia's neurosurgical burden mirrors that of other LMICs, with trauma affecting most patients either on the road or at the workplace. Currently, Cambodia has 34 neurosurgeons to address the growing burden of a country of 15 million with an increasing life expectancy of 69 years of age, stressing the importance of better public health policies and urgency for building capacity for safe and affordable neurosurgical care.
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Surgical management of complex middle cerebral artery aneurysms: An institutional review p. 959
Anuj Arun Bhide, Yashuhiro Yamada, Yoko Kato, Tsukasa Kawase, Riki Tanaka, Kyosuke Miyatani, Daijiro Kojima, Ahmed Sayah
DOI:10.4103/ajns.AJNS_5_20  
Background: Complex middle cerebral artery (MCA) aneurysms are defined as large (≥10 mm) or giant (≥25 mm) aneurysms with M2 branches arising from the aneurysm rather than M1 segments and usually require some form of reconstruction of the bifurcation. Their management is difficult and surgery is preferred over endovascular modalities because of their peculiar angioarchitecture and association with critical branch points or perforators. Objectives: The study was aimed at analyzing surgically managed complex MCA aneurysms and discussing characteristics not favorable for endovascular management, surgical nuances and clipping strategies, patient outcomes, and newer diagnostic modalities which help improve management. Methods: Nine cases of surgically operated complex MCA aneurysms were identified from January 2017 to July 2019. The aneurysm characteristics, surgical nuances, clipping strategies, patient outcomes and points not favoring endovascular management were tabulated and analyzed. Results: The mean maximum aneurysm diameter was 13.4 mm and the mean fundus/neck ratio was 1.6. The average microscope time was 124 min, and the most common method was clip reconstruction. The average number of clips used was 2.7 and the mean follow-up was 13 months. All patients have good postoperative outcome (Modified Rankin Score 0-2). The complete occlusion rate was 88.9% with one intraoperative voluntary residual sac which was coated. Computational fluid dynamic study results done preoperatively correlated with intraoperative findings. Conclusions: MCA aneurysms pose a significant challenge for endovascular treatment because of various factors such as luminal thrombi, complex angio-architecture, precarious branch/perforator locations, broad necks, and fusiform characteristics. Surgical management in experienced hands can tackle all these problems with an armamentarium of clipping techniques and bypass procedures.
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Study of anterior commissure-posterior commissure distance among Nepalese cohort p. 966
Sambardhan Dabadi, Raju Raj Dhungel, Pragya Dhungel, Pritam Gurung, Resha Shrestha, Samir Acharya, Pravesh Rajbhandhari, Pranaya Shrestha, Basant Pant
DOI:10.4103/ajns.AJNS_232_20  
Introduction: The main aim of this study is to determine the anterior commissure-posterior commissure (AC-PC) distance in Nepalese cohort and has comparison of intercommissural distance of Nepalese cohort with some other races. Materials and Methods: The 47 patients, with mean age of 50 years, included in the study had undergone DBS or lesioning (Pallidotomy). Data were collected through the magnetic resonance imaging under DBS protocol and the manipulation, marking of AC and PC was done in Inomed Planning Software (IPS). Results: The data revealed average AC-PC distance of Nepalese cohort to be 24.86 ± 2.08 mm, ranging from 16 mm to 30 mm. The study among 29 males and 18 females illustrated male to have longer AC-PC as compared to female (25.38 mm male and 24.02 mm female). The results also confirmed age related changes in AC-PC distance which was linearly increasing with the age. Conclusion: Comparison of data from other studies revealed Nepalese cohort to have almost similar AC-PC distance with Asian population, while that was longer in Caucasian and shorter in Hispanic Population.
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The wakayama-immediate stroke life support course: Achieving successful training on the stroke emergency system without using mechanical medical training simulators p. 970
Koji Fujita, Ryo Yoshimura, Yoshiyuki Tanaka, Masayuki Kawabata, Akane Masumitsu, Sadao Kawasaki, Yoko Kato, Seiya Kato, Naoyuki Nakao
DOI:10.4103/ajns.AJNS_254_20  
Background: The Immediate Stroke Life Support (ISLS) course run in Wakayama (Wakayama-ISLS course) is an off-the-job training course for understanding the initial treatment of acute stroke. A total of 22 Wakayama-ISLS courses have been held in Wakayama Prefecture since 2008. To begin with, the case presentation was performed using human-like, mechanical manikins for simulation training. However, as the course progressed, we found the students paying great attention to the display monitor, and less to the patients' neurological status. Methods: From the fourth Wakayama-ISLS course onward, we conducted the group work with the facilitators pretending to be patients, i.e., without medical training manikins. Results: When the facilitators acted as patients, the students gained a more realistic and expressive perception of neurological symptoms. As a result, they expressed a high level of satisfaction with the course in the questionnaire sent immediately afterwards, regardless of their profession or prior experience. Moreover, as we did not need to transfer medical training simulators, we were able to carry out three ISLS courses at locations some distance from Wakayama city on a low-cost basis. This also enabled the regional medical staff in rural hospitals to participate in the courses easily. Conclusion: The Wakayama-ISLS course without medical training manikins is an entirely feasible off-the-job training course, which provides training on fast and excellent treatment of acute stroke problems based on clinical practice. The course has the potential to spread not only across Japan but throughout the world, including to developing countries, given the cost perspective.
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Endoscopic third ventriculostomy and simultaneous tumor biopsy in pineal region tumors using the “Single Burr Hole” technique: An analysis of 34 cases p. 976
Gagandeep Attri, Jaskaran Singh Gosal, Deepak Khatri, Kuntal Kanti Das, Kamlesh Singh Bhaisora, Anant Mehrotra, Jayesh Sardhara, Arun Kumar Srivastava, Sanjay Behari, Sushila Jaiswal, Awadhesh Kumar Jaiswal
DOI:10.4103/ajns.AJNS_194_20  
Background: Pineal region tumors often present with hydrocephalus. Endoscopic third ventriculostomy (ETV) and simultaneous tumor biopsy remain a minimally invasive procedure offering both diagnostic and therapeutic advantages in the management of these tumors. However, different operative techniques have been described in the literature. Aim: The aim is to study the ETV success rate, diagnostic rate of simultaneous tumor biopsy, complications, and follow-up of patients of pineal region tumors managed with ETV and simultaneous tumor biopsy using the single burr hole technique. Methods: The study was performed by retrospectively reviewing the records of patients of pineal region tumors managed by simultaneous ETV and tumor biopsy using a “single burr hole” technique from January 2012 to December 2019. Results: Thirty-four patients (22 males and 12 females) with a mean age of 28.7 years were analyzed. ETV was successful in relieving hydrocephalus in 29 (87.8%) patients. Three patients needed a ventriculoperitoneal shunt, and one required Ommaya reservoir placement for persistent hydrocephalus. Histological diagnosis was successfully established in 26 (78.8%) patients. There were two procedure-related mortalities. Two patients underwent craniotomy and tumor excision subsequently. Radiotherapy was given to 11 patients, and 9 patients were managed by observation alone. The mean follow-up of our study was 15.8 months. Conclusions: Simultaneous ETV and tumor biopsy using a single burr hole technique is a safe, minimally invasive procedure for the management of pineal region tumors.
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Intraoperative ultrasound an economical tool for neurosurgeons: A single-center experience p. 983
Vernon Velho, Hrushikesh Umakant Kharosekar, Laxmikant Bhople, Shilpa Domkundwar
DOI:10.4103/ajns.AJNS_332_20  
Background: Over the past decade, the use of intraoperative image guidance in neurosurgery has gradually gained in importance. Apart from some sophisticated and very expensive techniques, intraoperative ultrasound (IOUS) is a simple and economical technique that allows the surgeon to localize deep-seated lesions under a real-time ultrasonic image display without dissection. The purpose of this study was to present our own preliminary experiences in various (n=1250) neurosurgical procedures carried out at our tertiary care centre in a developing country. Materials and Methods: A Prospective study was carried out in our department of neurosurgery at Grant Medical College and Sir J J Group of hospitals from January 2010 to May 2019. IOUS was used during various elective neurosurgical procedures done during this period as given in table no below. A total of 1250 patients, 850 supratentorial lesion, 290 infratentorial lesion and 110 spinal lesion, were included in this study. All studies were performed using an ultrasound machine with variable 3.5~7.5 MHz sector transducers. The echogenicity and pathomorphology between IOUS and computed tomography/magnetic resonance imaging (CT/MRI) of various disease entities were compared. Results: Intracranial structures could be well demonstrated by ultrasound once the skull was opened. Most of the intracranial lesions were hyperechoic, except those with a cystic component. IOUS was more sensitive in demonstrating non-enhanced solid lesions and lesions with a cystic component than was preoperative CT/MRI. The border between the tumor and healthy brain was better delineated on IOUS in all cases aiding in tumor resection. Conclusions: High-resolution real-time IOUS is a convenient and user-friendly method for identifying, localizing, and characterizing the pathological focus during an operation. Such information is very important and can enhance surgical results.
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Endodermal cysts of the central nervous system: Review of the literature and a case report p. 989
Fotios Kalfas, Claudia Scudieri
DOI:10.4103/ajns.AJNS_322_19  
Context: Endodermal cysts are rare benign developmental cysts lined by mucin-secreting and/or ciliated, cuboidal, or columnar epithelium of probably endodermal origin. Aims: Endodermal cysts are rarely intracranial, frequently located in the posterior fossa. Supratentorial location is the most infrequent and only few cases are reported in the literature, included our case. Settings and Design: The authors report a case of intracranial supratentorial endodermal cyst with a review of the literature. Subjects and Methods: A 40-year-old woman was admitted to our department because of progressive gait disorder for 3 months due to right brachial and crural motor deficit associated to right crural sensory disorder (tactile hypesthesia) and right Babinski response at neurological examination due to an endodermal cyst located in the left frontoparietal convexity. Discussion: Total resection of endodermal cysts is recommended, despite their location and adhesion to the surrounding structures, due to its high risk of recurrence. Fenestration of the cystic content into the subarachnoid cistern may cause obstructive hydrocephalus or chemical meningism. Results: Although rare, surgeons should be aware that these lesions must be differentiated clinically, radiologically, and histologically from other supratentorial cystic lesions.
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CASE REPORTS Top

Solitary plasmacytoma with amyloid – An unusual dural-based lesion p. 997
Pooja Kamlesh Gajaria, Asha Sharad Shenoy, Jayashri Popat Chaudhari, Naina Atul Goel
DOI:10.4103/ajns.AJNS_184_20  
Solitary plasmacytoma of the dura without systemic involvement are extremely rare lesions, with <15 cases reported in the literature. Among these, ours is the second case to show the presence of amyloid. Fifty-year-old male had presented with headache, sudden onset right-sided weakness, and vomiting. Magnetic resonance imaging revealed an extra-axial mass in the left fronto-parietal region measuring 10 cm × 8.7 cm × 3.9 cm, suggestive of meningioma. The left fronto-parietal craniotomy was performed and multiple tissue bits aggregating to 10 cm × 8.5 cm × 2 cm along with thinned out membrane-like bit of calvarium was sent for pathologic examination. H and E stained sections showed sheets of plasmacytoid cells along with amyloid, which showed apple-green birefringence on Congo red staining. On immunohistochemistry, tumor cells were positive for CD38, CD138, showed kappa light chain restriction and were negative for CD45, CD34. Hence, it was diagnosed as a plasma cell neoplasm. Further work-up with whole-body positron-emission tomography scan revealed no systemic involvement. Dural-based lesions can mimic meningioma radiographically as well as intraoperatively. Histopathological examination unveils the diagnosis, to guide appropriate therapeutic regimens.
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High-grade diffuse large B-cell lymphoma of the dura with skull and scalp involvement with simultaneous sternum involvement p. 1003
Sevilay Vural, AK Hakan
DOI:10.4103/ajns.AJNS_246_19  
Diffuse large B-cell lymphoma (DBCL) is the largest subgroup of non-Hodgkin's lymphomas. Primary dural lymphoma, primary skull vault lymphoma, and primary sternum lymphoma are the rare lymphomas. We present the case of a 69-year-old patient with scalp, skull, and dura involvement that accompanying sternum involvement. It should be kept in mind that in the differential diagnosis of high-grade diffuse large B-cell lymphoma in patients presenting with a mass in the skull or sternum.
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Intraoperative transcranial embolization following decompressive craniectomy for a dural arteriovenous fistula presenting with acutely raised intracranial pressure p. 1006
Suresh Giragani, Ashok Reddy Kasireddy, Anandh Balasubramaniam, Vikas Agrawal, Swathi Muthyala
DOI:10.4103/ajns.AJNS_250_20  
We report the clinical details, imaging findings, and management of a 58-year-old female who presented with rapidly deteriorating neurological function and acute raise in intracranial pressure secondary to posterior fossa dural arteriovenous fistula (DAVF). In this report, we present the emergency management of the DAVF with single-stage combined surgical decompressive craniotomy and direct transcranial embolization.
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Management of metastatic spine and hip alveolar soft part sarcoma: Case report and review of literature p. 1011
Munjal Shah, Akshay Gadia, Abhay Nene, Priyank Patel
DOI:10.4103/ajns.AJNS_290_20  
Alveolar soft part sarcoma (ASPS) is a rare soft tissue tumor. Primary or metastatic involvement of the spine is unusual in ASPS. In most case, it is refractory to chemotherapy and radiation. Surgical resection is the most effective intervention. We report the case of a 38-year-old female having ASPS along with metastatic spine and hip involvement treated surgically as a single-stage operation, which is the first of its kind approach to our knowledge. We present the case of a 38-year-old female with simultaneous L4 pathological fracture with symptomatic lumbar canal stenosis without focal neurology and pathological fracture of neck of femur of left hip, secondary to metastatic ASPS. Since both conditions were contributing equally to her disability and demanded early intervention, they were treated simultaneously with intralesional excision of the tumor and posterior stabilization of the spine and left hip proximal femur resection and replaced it with proximal femur endoprosthesis as a single-stage operation. Postoperatively, she had significant relief of radiculopathy and left hip pain. She was mobilized out of bed on the postoperative day 1 and was discharged from hospital on the postoperative day 6. She was given chemotherapy drug sunitib postoperative. At her last follow-up, 20 months' postoperative, she was asymptomatic and was independent in terms of activities of daily living. Metastatic ASPS of the spine and hip is a rare clinical entity. Simultaneous surgical treatment of the spine and hip pathology is technically demanding. If the conditions demands, as in our case, both of them can be managed safely in a single-stage with good midterm outcome.
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Huge ventral cervicomedullary neurenteric cyst: A rare entity with good surgical outcome and appraisal p. 1016
Moududul Haque, Asifur Rahman, Nazmin Ahmed, Shamsul Alam
DOI:10.4103/ajns.AJNS_351_20  
Neurenteric cysts are rare congenital lesions of benign nature that can be encountered at any level of the neuraxis, starting from the cranium down to coccyx. Rewarding outcome can be achieved with early diagnosis and complete removal of these benign lesions. Here, we report a case of a huge neurenteric cyst in an 11-year-old boy at the ventral craniocervical junction, a rarely reported entity with literature review. In this article, we focus on the clinical presentation, pathogenesis, radiological findings, surgery, and surgical outcome of this benign lesion, as we succeeded to have gratifying result following surgery in our instance.
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A rare complication of pituitary adenoma surgery in a patient with multiple endocrine neoplasia 1 syndrome with two novel genetic mutations p. 1020
Neeraj Sharma, Suchanda Bhattacharjee, Beatrice Anne
DOI:10.4103/ajns.AJNS_100_20  
Pituitary adenoma surgeries are common in neurosurgical setup. Majority are tackled by a transsphenoidal route either by endoscopic or microscopic aid. Complications such as cerebrospinal fluid (CSF) leak, meningitis, diabetes insipidus, hematoma, and loss of vision are known, but midbrain infarct is rarely reported. We report and discuss the possible mechanism of this rare and unusual complication in transsphenoidal surgery. A 36-year-old nulliparous female with no comorbidities suffering from primary infertility presented with intermittent headache for 9 months with bitemporal vision disturbances for 3 months, pigmentation around the neck and nape, oligomenorrhea with an established diagnosis of plurihormonal secreting pituitary tumor (predominantly adrenocorticotropic hormone and prolactin), hyperparathyroidism, and diabetes. The whole symptom fitted into the diagnosis of multiple endocrine neoplasia 1 (MEN-1) syndrome. Molecular genetic testing was done with full gene sequencing analysis of MEN-1 gene using polymerase chain reaction. Furthermore, Sanger DNA sequencing was done, and two novel variations, namely IVS 9c.1364 + 99C>G and EXON 10 c.1813 C>T (p. L605 L), were detected. Radiology detected a microadenoma in the right lobe of the pituitary with mild deviation of the pituitary stalk on dynamic contrast-enhancing magnetic resonance imaging. Gross total excision of the tumor was done through transsphenoidal approach. The surgery was uneventful other than some blood-mixed CSF leak. Post excision, fat and tissue glue was packed. The patient did not wake up from anesthesia and had bilateral dilated pupil with no oculocephalic reflex. Investigations revealed bilateral thalamic and midbrain infarct. The patient subsequently expired. This case is reported in view of its unusual complication and to create awareness for such a fatal complication following transsphenoidal surgery for pituitary microadenoma and the importance of diligent approach to transsphenoidal surgery and to report novel genetic mutation of MEN-I gene.
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Primary myoepithelial carcinoma of the clivus: A rare presentation p. 1024
Shilpi Modi, Deepa Goel, Pawan Goyal, Aditya Gupta
DOI:10.4103/ajns.AJNS_144_20  
Myoepithelial tumor (MET) of bone is an unusual tumor of uncertain differentiation and histogenesis. Although its presence in various bones has been reported sparsely, the presentation in clivus as primary myoepithelial carcinoma (MEC) has never been reported. They resemble their salivary gland counterparts morphologically and immunohistochemically, but harbor distinct molecular phenotype. At present, moderate nuclear atypia is the acceptable criteria to differentiate MEC from myoepithelioma. Because of their rarity, wide histopathological spectrum, and intraosseous location, MET of bone is easily confused with a variety of primary bone and cartilaginous tumors. Application of immunohistochemistry and, if required, molecular testing are required for making a correct diagnosis. In this article, we describe an extremely rare case of a primary MEC arising from the clivus, which owing to unusual location and immunohistochemical profile was diagnostically challenging.
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An unusual case of primary intracranial germinoma with diffuse subarachnoid spread masquerading as tuberculous meningitis p. 1027
Amit Kumar Sharma, Anita Jagetia, Arvind Kumar Srivastava, Ravindra Kumar Saran
DOI:10.4103/ajns.AJNS_174_20  
Central nervous system (CNS) germinomas often extend or disseminate into the ventricular and subarachnoid space. We present a case of primary CNS germinoma consisting mainly of meningeal dissemination, which is extremely unusual and must be kept in the differential diagnosis.
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Abrupt cessation of atrial fibrillation in a neurosurgical patient: Does positioning matter? p. 1031
Steve Joys, Shalvi Mahajan, Rajeev Chauhan, Sanjay Kumar
DOI:10.4103/ajns.AJNS_192_20  
Atrial fibrillation (AF) has been associated with cancer. However, the literature regarding the occurrence of AF in patients with brain tumors is limited. Neuroanatomic connections between the brain and the heart may affect heart rate and rhythm. We discuss a case of transient AF in a 64-year-old female who was operated for a right-sided sphenoid wing meningioma. The AF might have been related to the positioning of the head and neck of the patient, in whom the intracranial compliance was reduced due to the brain tumor.
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Transcranial stab injury with knife: A rare case with excellent outcome p. 1034
Rajveer Garg, Chetan Wadhwa, Rakesh Kaushal, Jagminder Singh
DOI:10.4103/ajns.AJNS_89_16  
Traumatic stab injury/wounds to the brain are rare type of injuries having fatal outcomes. In the present case report, we report a case of a 17-year-old male who presented to the accident and emergency department of our hospital with an alleged history of assault due to a vegetable cutting knife with the knife lying in the right temporal region. In these types of injuries, no attempt should be made to remove the weapon without adequate investigations and facilities as it can be fatal. While removing the weapon, care should be taken that there is no rocking or zigzag movement and the weapon should be retrieved back from the same trajectory. The underlying principles in these types of cases include thorough debridement of the wound with removal of dead tissue with no rocking movement while retrieving the weapon. The wound should be thoroughly closed to prevent postoperative cerebrospinal fluid leak.
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Osteoid osteoma of the body of the vertebrae causing painful scoliosis p. 1037
Mantu Jain, Sunil Doki, Amrit Gantaguru, Sudipta Mohakud, Shilpy Jha
DOI:10.4103/ajns.AJNS_228_20  
Osteoid osteoma (OO) affecting the spine is one of the common causes of painful scoliosis in the growing age group. The involvement is usually in the posterior elements involving the lumbar and cervical spine. We report a case of OO affecting the body of the thoracic vertebral body. A 15-year-old male presented with painful left thoracolumbar scoliosis. Computed tomography (CT) and magnetic resonance imaging (MRI) and MRI showed a lucent area with central dense focus (nidus) suggesting OO. Surgical excision was done under image intensifier and void filled with a mesh cage having bone graft reinforced posteriorly with pedicle screws. Postoperatively, the patient was relieved of his diffuse pain and CT scan revealed complete excision of the lesion. At the follow-up, the patient has an active, unconstrained life. OO in the spine presents as scoliosis which can be painful or painless. The diagnosis can be missed on a plain radiograph and complete radiographic evaluation includes a CT scan and MRI. Spinal management includes curettage or radiofrequency ablation. Recurrence is a known but rare complication.
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Spontaneous spinal osseous epidural arteriovenous fistula with long segments of prominent epidural venous drainage causing severe compressive thoracic myelopathy successfully treated with combined endovascular and surgical treatments: A case report and review of the literature p. 1041
Prasert Iampreechakul, Wuttipong Tirakotai, Punjama Lertbutsayanukul, Samasuk Thammachantha, Somkiet Siriwimonmas
DOI:10.4103/ajns.AJNS_353_20  
The authors describe an extremely rare case of spinal osseous epidural arteriovenous fistulas (SOEAVFs) with unique characteristic features. A 25-year-old man presented with progressive weakness and paresthesia of the lower extremities for 1 month. Magnetic resonance imaging of the thoracic spine showed an extradural dilated vascular flow void structure extending from T4 to T8 levels with abnormal hyperintense T2 signal from T6 to T8 levels. Magnetic resonance angiography and spinal angiography revealed unique features of SOEAVF supplied by multiple small arterial feeders of intercostal arteries converging into a dilated round venous sac corresponding to a bony defect of T7 lamina and spinous process. The venous drainage directly drained into prominent epidural venous plexus extending from the level of T4 to T8 without intradural venous drainage, causing severe compressive myelopathy. Transarterial embolization was performed using N-butyl cyanoacrylate through the main feeder. Subsequently, he successfully underwent laminectomy and total excision of the fistula and large epidural draining venous plexus. Histopathology confirmed spinal vascular malformations with evidence of previous embolization. He gradually improved until being ability to walk independently 3 months later. Follow-up spinal angiography confirmed complete resection of SOEAVF. The patient has remained clinically asymptomatic 5 years after operation.
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Subarachnoid hemorrhage and internal carotid artery dissection and occlusion following self-enucleation p. 1050
Hadi Joud, Mohammad Hassan A. Noureldine, Ivo Peto, Jay I Kumar, Jasmina Bajric, Siviero Agazzi
DOI:10.4103/ajns.AJNS_183_20  
Self-enucleation is an uncommon type of major self-injury, which may lead to severe neurological deficits and life-threatening complications, such as subarachnoid hemorrhage (SAH) and internal carotid artery (ICA) dissection and occlusion. Our patient is a 53-year-old man with a history of bipolar disorder and schizophrenia who presented with SAH, intraventricular hemorrhage, ICA dissection and occlusion, and right cerebral infarct following self-enucleation. Despite a Glasgow Coma Score of 6 on initial presentation, he improved with conservative management. He achieved a near-complete neurological recovery, with residual left lower extremity weakness and mild confusion. Self-enucleation is a major neurologic, ophthalmologic, and psychiatric emergency with a potential for serious neurological complications and contralateral visual loss. Yet, conservative management may lead to dramatic recovery.
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Spontaneous disappearance of an intracranial small unruptured aneurysm on magnetic resonance angiography: Report of two cases p. 1055
Yu Akimoto, Kiyoyuki Yanaka, Kuniyuki Onuma, Kazuhiro Nakamura, Nobuyuki Takahashi, Eiichi Ishikawa
DOI:10.4103/ajns.AJNS_281_20  
Spontaneous radiographic disappearance of cerebral aneurysms is often observed under special conditions such as giant aneurysms. However, spontaneous disappearance of an unruptured and nongiant intracranial saccular aneurysms is rare. We describe two cases of this rare vascular phenomenon. The first patient is a 64-year-old female diagnosed with a small unruptured aneurysm arising from the distal anterior cerebral artery. Spontaneous disappearance of the aneurysm on magnetic resonance angiography (MRA) was observed 5 years after the initial diagnosis. Continuous imaging surveillance also revealed spontaneous reappearance of the aneurysm 2 years later. The second patient is a 57-year-old female harboring a small unruptured saccular aneurysm arising from the M1–M2 bifurcation of the middle cerebral artery. The aneurysm showed spontaneous disappearance on MRA 13 years after the initial diagnosis. These cases provide a new insight into this natural dynamic process even in cases of a small unruptured intracranial saccular aneurysm.
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Acquired lumbosacral spinal dural arteriovenous fistula in association with degenerative lumbosacral disc herniation and spinal canal stenosis: Report of two cases and review of the literature p. 1059
Prasert Iampreechakul, Pongwat Polpong, Korrapakc Wangtanaphat, Punjama Lertbutsayanukul, Yodkhwan Wattanasen, Somkiet Siriwimonmas
DOI:10.4103/ajns.AJNS_318_20  
The authors describe two cases harboring lumbosacral spinal dural arteriovenous fistulas (SDAVFs) manifested with nonspecific initial symptoms, leading to misdiagnosis and unnecessary procedures. A curvilinear flow void in the lumbar region and thoracic cord congestion with subtle perimedullary flow voids were detected on magnetic resonance imaging (MRI) in both patients. Contrast-enhanced magnetic resonance angiography and spinal angiography confirmed the SDAVFs in the lower lumbar and sacral region. Both fistulas were located at the same level of disc herniation and spinal canal stenosis and supplied by branches of the internal iliac arteries (i.e., iliolumbar and lateral sacral arteries) with cranial drainage from the dilated vein of the filum terminale, corresponding to a curvilinear flow void, to the perimedullary veins. The first case was successfully treated with embolization. Another case had recanalization of the fistula 4 months after endovascular treatment and was successfully treated with surgical interruption of the fistula. Our two case reports may provide additional evidence supporting an acquired etiology of SDAVFs, probably secondary to lumbosacral disc herniation and spinal canal stenosis. The authors also reviewed literature about preexistent lumbosacral SDAVFs associated with disc herniation and spinal canal stenosis. From our review, the level of SDAVFs in most patients is correlated with the level of disc herniation, spondylolisthesis, and/or spinal stenosis.
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Primary spinal epidural extraosseous Ewing's Sarcoma with brachial plexus infiltration p. 1068
Sarbesh Tiwari, Taruna Yadav, Jaya Pamnani, Kartikeya Shukla, Meenakshi Rao, Jaskaran Singh Gosal, Pawan Garg, Pushpinder Singh Khera
DOI:10.4103/ajns.AJNS_138_20  
The Ewing's sarcoma family of tumors are aggressive malignant small round blue cell tumors of undifferentiated mesenchymal origin. Skeletal Ewing's sarcoma is a common entity that classically involves the diaphysis of the long bones, pelvis, ribs, and sacrum. Extraosseous Ewing's sarcoma (EES) is rare, most commonly presenting as a paravertebral mass lesion. Its manifestation as an anterior epidural mass lesion with extension along brachial plexus is an even rarer phenomenon. A 25-year-old male presented with neck stiffness and progressive weakness of the bilateral upper and lower limbs. Magnetic resonance imaging of the cervical spine revealed an anterior epidural mass lesion compressing the cervical cord and extending along the right brachial plexus, suggesting imaging differentials of EES and lymphoma. The patient underwent laminectomy with gross tumor resection, and histopathology confirmed a diagnosis of EES. EES should be kept in the differential diagnosis of anterior epidural mass lesions in young adults, specifically when the lesion shows extension along multiple neural foramina and nerve plexus.
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Ruptured mycotic cerebral aneurysm secondary to disseminated nocardiosis p. 1072
Masayuki Goto, Aiki Marushima, Kyoji Tsuda, Tomoji Takigawa, Wataro Tsuruta, Eiichi Ishikawa, Yuji Matsumaru, Akira Matsumura
DOI:10.4103/ajns.AJNS_283_20  
We report a case of a ruptured mycotic cerebral aneurysm caused by Nocardia infection. A 22-year-old immunocompromised woman with adult-onset Still's disease developed a subarachnoid hemorrhage (SAH). Digital subtraction angiography revealed a small aneurysm at the M2-3 bifurcation of the right middle cerebral artery. Cardiac ultrasonography showed vegetation at the posterior cardiac wall, suspecting infective endocarditis (IE). Gram-positive filamentous bacteria were observed in the necrotic tissue surrounding the aneurysm obtained during trapping surgery. Long-term blood culture showed that the cause of her cerebral mycotic aneurysm was nocardiosis. A mycotic ruptured cerebral aneurysm is an important cause of SAH in immunocompromised patients. Early diagnosis of IE, detection of gram-positive rods by Gram staining, and long-term culture to identify the bacteria is crucial in diagnosing nocardiosis.
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Modification of periosteal flap as management of cerebrospinal fluid leakage after frontal sinus fracture surgery in moderate traumatic brain injury patients p. 1076
Rifqi Aulia Destiansyah, Mustaqim Apriyansa Rahmadhan, Fajar Herbowo Niantiarno, Yusuf Yusuf, Shafhan Dustur, Galih Indra Permana, Fachriy Balafif, IGM Aswin Rahmadi Ranuh, Tedy Apriawan, Abdul Hafid Bajamal
DOI:10.4103/ajns.AJNS_206_19  
Main management for the frontal sinus fracture is using the pericranial flap. Pericranial flaps based on the supraorbital and supratrochlear vasculature have previously been used with significant success for the separation of intracranial and extracranial spaces after major trauma. Defect closure was modified due to lack of the frontal periosteum; the graft was made from the temporal side of periosteum to make primary periosteal flap longer. Defect closure could be optimum. Evaluation for 6 months showed a significant improvement without major complications. In this article, we propose a new modification technique as one of promising alternatives.
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Completely extradural spinal arteriovenous fistula (Abnormal direct connection between arteries and extradural venous plexus) with totally extradural venous drainage causing compressive cervical myelopathy p. 1081
Sumit Goyal, Ajit Kumar Sinha, Har Narayan Agarwal
DOI:10.4103/ajns.AJNS_260_20  
Spinal extradural arteriovenous fistulas are rare vascular lesion which are defined as abnormal direct connection between an artery or arteries and the extradural venous plexus within the spinal canal and/or intravertebral foramen. These lesions with exclusive extradural venous drainage are even rarer. Because of the limited cases the natural history, demography and treatment understanding of these are limited. Endovascular treatment remains the mainstay of treatment for these lesions. This case and its management are thus presented for its rarity.
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Complete resolution of a large hemorrhagic lumbar synovial cyst following spinal fusion alone p. 1085
Prasert Iampreechakul, Punjama Lertbutsayanukul, Samasuk Thammachantha
DOI:10.4103/ajns.AJNS_366_20  
The authors reported complete regression of a large hemorrhagic lumbar synovial cyst following posterior spinal fusion without direct cystic resection. A 64-year-old woman suffered from sudden onset of the left buttock pain radiating to the left leg after waking up in the morning following the previous history of a minor accident 2 months ago. Magnetic resonance imaging (MRI) of the lumbosacral spine showed a large extradural round mass originating from the left facet joint at the level of L3–L4. The mass was hyperintense on T1-weighted images and hypointense on T2-weighted images, probably compatible with hemorrhagic joint-related cyst. Surgical treatment was chosen for her because of persistent left radicular pain with no responding to medications. The patient underwent decompressive laminectomy, subtotal facetectomy, instrumented fusion, and only tissue biopsy due to severe adherence of the mass and dura. Histopathological examination was consistent with a hemorrhagic synovial cyst. The radicular pain completely disappeared after the surgery. Follow-up MRI of the lumbosacral spine obtained 6 months after the surgery demonstrated complete resolution of the hemorrhagic cyst. Complete resolution of hemorrhagic synovial cyst seems to correlate with subtotal facetectomy, probably resulting in leakage of cyst content and subsequent resorption of the cyst wall. In addition, hematoma within the synovial cyst may resolve spontaneously over time.
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A rare tumor of clivus masquerading as pituitary adenoma p. 1091
Swati Singh, Dipanker Singh Mankotia, Kepeemadam Balasubramanyam Shankar, Fouzia Siraj
DOI:10.4103/ajns.AJNS_188_20  
Giant cell tumors (GCT) are generally benign, commonly affecting young adults, with a slight preponderance in females. They are locally aggressive with a high rate of local recurrence. Most of them are found in the epiphysis of long bones, making the base of the skull a rare site. We report the case of a 35-year-old female, who presented with neurological symptoms of headache and diplopia. On magnetic resonance imaging, a space-occupying lesion was discovered in the clivus. Histopathology was diagnostic of a GCT. GCT arising from the clivus is extremely uncommon, with about 15 cases published in the literature. The present case highlights the rarity of this tumor and contributes to the existing literature with analysis and evaluation of the management strategies and prognosis.
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CASE REPORT AND LITERATURE REVIEW Top

“Fountain Sign,” a basic finding toward the diagnosis of partially thrombosed giant aneurysm: Describing a challenging case and literature review p. 1096
Alireza Tabibkhooei, Meysam Abolmaali, Feiz Ebrahimnia
DOI:10.4103/ajns.AJNS_352_20  
Although the occurrence of cerebral aneurysms in pediatric age group describes as rare, giant ones are more commonly be found than in adults. Insufficient epidemiological information, their association with other medical comorbidities, diagnostic pitfalls, complex surgical anatomy, and issues should be considered during surgery to make them difficult to diagnose and manage. We report a 6-year-old boy with presenting complaint of acute-onset headache without any other symptoms and a small area of intracerebral hemorrhage detected on initial computed tomography (CT) scan. Primary evaluations failed to result in a definite diagnosis, and delayed vascular studies suggested vascular malformation or an aneurysm as the causative factor of hemorrhage. Surgical exploration led to the diagnosis of a giant partially thrombosed aneurysm at the A2 segment of the left anterior cerebral artery and successful clipping. One of our findings on preoperative CT angiography, “fountain sign,” may be useful for the diagnosis of partially thrombosed aneurysms when active bleeding from the aneurysm has been ruled out. Fountain sign can be a useful finding in the diagnosis of partially thrombosed aneurysms. Vascular lesions should always be considered as the primary cause of intracranial hemorrhage in pediatrics despite negative initial studies. Therefore, close follow-up and using delayed and multimodality vascular evaluations are crucial for successful management.
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LETTER TO EDITOR Top

Management of trigeminal neuralgia during COVID-19 pandemic p. 1102
Siddharth Chavali, Girija Prasad Rath, Vanitha Rajagopalan, Arvind Chaturvedi
DOI:10.4103/ajns.AJNS_268_20  
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