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January-March 2021
Volume 16 | Issue 1
Page Nos. 1-235

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RESEARCH ARTICLE  

The impact of surgery on the survival of patients with recurrent glioblastoma Highly accessed article p. 1
Oumar Sacko, Alexandra Benouaich-Amiel, Pierre Brandicourt, Mahamadou Niaré, Saloua Charni, Clarissa Cavandoli, David Brauge, Isabelle Catalaa, Adam Brenner, Elizabeth Cohen-Jonathan Moyal, Franck-Emmanuel Roux
DOI:10.4103/ajns.AJNS_180_20  
Objective: The purpose of this study was to investigate the possible benefit of repeat surgery on overall survival for patients with recurrent glioblastoma multiforme (GBM). Methods: We performed a retrospective analysis of data from patients who presented with recurrent GBM over a 5-year period (n = 157), comparing baseline characteristics and survival for patients who had at least 1 new tumor resection followed by chemotherapy (reoperation group, n = 59) and those who received medical treatment only (no-reoperation group, n = 98) for recurrence. Results: The baseline characteristics of the two groups differed in terms of WHO performance status (better in the reoperation group), mean age (60 years in the reoperation group vs. 65 years in the no-reoperation group), mean interval to recurrence (3 months later in the reoperation group than in the no-reoperation group) and more gross total resections in the reoperation group. Nevertheless, the patients in the reoperation group had a higher rate [32.8%] of sensorimotor deficits than those of the no-reoperation group [14.2]. There was no significant difference in sex; tumor localization, side, or extent; MGMT status; MIB-1 labeling index; or Karnofsky Performance Status [KPS] score. After adjustment for age, the WHO performance status, interval of recurrence, and extent of resection at the first operation, multivariate analysis showed that median survival was significantly better in the reoperation group than in the no-reoperation group (22.9 vs. 14.61 months, P < 0.05). After a total of 69 repeat operations in 59 patients (10 had 2 repeat surgeries), we noted 13 temporary and 20 permanent adverse postoperative events, yielding a permanent complication rate of 28.99% (20/69). There was also a statistically significant (P = 0.029, Student's t-test) decrease in the mean KPS score after reoperation (mean preoperative KPS score of 89.34 vs. mean postoperative score of 84.91). Conclusion: Our retrospective study suggests that repeat surgery may be beneficial for patients with GBM recurrence who have good functional status (WHO performance status 0 and 1), although the potential benefits must be weighed against the risk of permanent complications, which occurred in almost 30% of the patients who underwent repeat resection in this series.
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NARRATIVE REVIEW ARTICLE Top

Are thinking machines breaking new frontiers in neuro-oncology? A narrative review on the emerging role of machine learning in neuro-oncological practice p. 8
Mustafa Mushtaq Hussain, Ainsia Shabbir, Saqib Kamran Bakhshi, Muhammad Shahzad Shamim
DOI:10.4103/ajns.AJNS_265_20  
Medical science in general and oncology in particular are dynamic, rapidly evolving subjects. Brain and spine tumors, whether primary or secondary, constitute a significant number of cases in any oncological practice. With the rapid influx of data in all aspects of neuro-oncological care, it is almost impossible for practicing clinicians to remain abreast with the current trends, or to synthesize the available data for it to be maximally beneficial for their patients. Machine-learning (ML) tools are fast gaining acceptance as an alternative to conventional reliance on online data. ML uses artificial intelligence to provide a computer algorithm-based information to clinicians. Different ML models have been proposed in the literature with a variable degree of precision and database requirements. ML can potentially solve the aforementioned problems for practicing clinicians by not just extracting and analyzing useful data, by minimizing or eliminating certain potential areas of human error, by creating patient-specific treatment plans, and also by predicting outcomes with reasonable accuracy. Current information on ML in neuro-oncology is scattered, and this literature review is an attempt to consolidate it and provide recent updates.
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REVIEW ARTICLES Top

Role of temozolomide regimen on survival outcomes in molecularly stratified WHO Grade II gliomas: A systematic review Highly accessed article p. 14
Arash Ghaffari-Rafi, Shadeh Ghaffari-Rafi, Jose Leon-Rojas
DOI:10.4103/ajns.AJNS_186_20  
Objective/Introduction: Although a critical chemotherapeutic, temozolomide's optimal regimen for 2016 World Health Organization (WHO) Grade II gliomas remains elusive, hence there is utility in not only cataloging survival outcomes of Grade II glioma subtypes against the background of temozolomide regimens, but also quantifying differences in progression-free survival (PFS) and overall survival (OS). Materials and Methods: A systematic review of MEDLINE, Embase, and Cochrane Central Register of Controlled Trails was conducted by using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis and the Cochrane Handbook of Systemic Reviews of Interventions. Results: Each molecular subtype of WHO Grade II glioma had a different temozolomide regimen identified as optimal in prolonging PFS and OS. For PFS, with temozolomide, the 25th, 50th, and 75th percentiles, were as follows (in months), respectively–A-wt II: 6.90, 12.95, and 19.95; A-mt II: 34.45, 36.01, and 39.60; OD II: 37.90, 46.00, and 55.03 (P = 0.016). For OS, the first quartile (25%), median (50%), third quartile (75%), were respectively identified (in months–A-wt II: 21.6 (median; n = 1); A-mt II: 60.6, 85.2, and 109.8; OD II: 86.1, 96.2, and 106.3 (P = 0.37). Conclusion: For each tumor molecular subtype, a different temozolomide regimen was identified as optimal for prolonging PFS and OS. Furthermore, regardless of temozolomide regimen, A-wt II had a significantly shorter PFS than A-mt II and OD-II. Overall, the data can provide useful prognostic insight to patients when making critical treatment decisions. Moreover, by cataloging and assessing survival outcomes per temozolomide regimen, such may facilitate future clinical trial design.
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A systematic review on the impact of the COVID-19 pandemic on neurosurgical practice and Indian Perspective p. 24
Saravanan Sadhasivam, Rajnish Kumar Arora, Rajasekhar Rekapalli, Jitender Chaturvedi, Nishant Goyal, Pranshu Bhargava, Radhey Shyam Mittal
DOI:10.4103/ajns.AJNS_379_20  
Objective: The study objective was to systematically review the impact of the current pandemic on neurosurgical practice and to find out a safe way of practicing neurosurgery amid the highly infectious patients with COVID-19. Materials and Methods: A review of the PubMed and EMBASE databases was performed. The literature was systematically searched using keywords such as “COVID-19” and “Neurosurgery.” Results: Among the 425 records, 128 articles were found to be eligible for analysis. These articles described the perspectives of the neurosurgical departments during the pandemic, departmental models, and organizational schemes for triaging emergent and nonemergent neurosurgical cases for the optimal utilization of limited resources, and solutions to continue academic and research activities. Triaging systems help us to optimally utilize the limited resources available. Guidelines have been developed for safe neurosurgical practice and for the continuation of clinical and academic activities during this pandemic by various national and international neurosurgical societies. Key changes in the telemedicine regulatory guidelines would help us to continue to provide neurosurgical care. Videoconferences, online education programs, and webinars could help us to overcome the disadvantages brought upon the neurosurgical education by the social-distancing norms. Conclusion: In an unprecedented time like this, no single algorithm is going to clear the ethical dilemma faced by us. Individual patient triage is a way for maintaining our ethical practice and at the same time, for efficiently utilizing the limited resources. As the pandemic progresses, new guidelines and protocols will continue to evolve for better neurosurgical practice.
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Rapid spontaneous resolution of the acute subdural hematoma: Case series and review of literature p. 33
Lavlesh Rathore, Debabrata Sahana, Sanjeev Kumar, Rajiv K Sahu, Amit K Jain, Manish Tawari, Pravin R Borde
DOI:10.4103/ajns.AJNS_380_20  
Background: Traumatic acute subdural hematoma (ASDH) is an oft encountered entity in neurosurgery. While resolution of such thick SDHs usually takes time, certain cases of rapid spontaneous resolution have also been reported. This article attempts to review the pathophysiology, clinical and radiological features of such cases, as well as provide an insight into decision making for their management. Methods: Electronic literature search was done to look for similar cases of spontaneous rapid resolution of ASDH. Five of authors cases have been described. Their clinical and radiological features along with those of cases from literature search were tabulated and analyzed. Results: A total of 44 relevant cases were included for analyses. Of these, 39 cases were from 33 articles found in existing literature and 5 cases were from author's collection. The M:F ratio was 25:19 with a mean age was 41.84(SD-4.094) years. Twenty -six patients showed “Rapid” neurological improvement (</= 24 hours) while “gradual” neurological improvement (>24 hours) occurred in 10 patients. The mean hematoma resolution time on CT scan was 13.78 hours (SD 16.46) ranging from 1- 72 hours. Twenty-nine patients showed redistribution of hematoma, most commonly to tentorium and falx cerebelli. CT scan findings were classified into 5 types as per the nature of hypodensity around hematoma. The geometric mean time to resolution of hematoma was least for type 2 (7.27 hours) and type 1(7.52 hours) patients. Conclusion: Selected patients of ASDH with rapid neurological improvement and specific CT findings may show spontaneous resolution of ASDH. Multicentric studies with larger study population may provide better insight into the nature and outcomes of such entities.
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A giant nondural-based lumbosacral clear cell meningioma mimicking schwannoma: A case report and review of the literature p. 44
Surendra Kumar Gupta, Nitish Nayak, Charandeep Singh Gandhoke, Rakesh Kumar Gupta, Anil Kumar Sharma, Prashant Singh, Raghvendra Sharma, Lokesh S Nehete
DOI:10.4103/ajns.AJNS_385_20  
Spinal clear cell meningiomas (CCMs) are rare and dural-based lesion usually affecting the younger population. We report the rare case of giant nondural-based spinal CCM mimicking schwannoma and review the literature. A literature search was performed at PubMed and Embase until January 1, 2020. A total of 19 cases of nondural-based spinal CCM was reported. The following relevant data were extracted: authors, publication year, patient and tumor characteristics, treatment, and outcome. The mean age of the presentation was 20.58 years. Twelve (63.16%) were female and seven patients (36.84%) were male. The most common location was lumbosacral region 15 (79%). Fifteen (79%) tumors had cranio-caudal dimension ≤2 vertebral level, and only four (21%) tumors had dimension ≥2 vertebral level. Gross total resection (GTR) was performed in 18 (95%) patients and subtotal resection (STR) in 1 patient. Recurrences were reported in five (26.14%) patients. Four of them showed recurrences within 6 months; earliest at 2.3 months in the patient had undergone STR. Our patient is 19-year-old male diagnosed with a lumbosacral intradural lesion. Craniocaudal dimension is ≥2 vertebral level shows the foraminal extension and vertebral scalloping. GTR is performed. Intraoperatively, the tumor has foraminal extension and shows attachment with right S1S2 nerve root. No dural attachment is found. Six-month follow-up magnetic resonance image shows no evidence of disease. Nondural-based spinal CCMs are extremely rare and should be kept as a differential diagnosis in young patients with giant intradural tumor, and whose radiological features suggesting of schwannoma. It affects young patients and usually involves more than one vertebral level. The chances of recurrences and metastasis are always high even after GTR; hence, close follow-up of the entire neuraxis is warranted.
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ORIGINAL ARTICLES Top

Castigating intraoperative bleeding: Tranexamic acid, a new ally p. 51
Krashan Hanada, Alhasan Ahmad, Hammadeen Shadi, Alnajada Wajdi, Saraireh Haitham, Khresat Wesam, Arabiyat Lamees, Malabeh Qamar, Alqroom Rami
DOI:10.4103/ajns.AJNS_339_20  
Introduction: The field of instrumented spinal procedures is associated with substantial blood volume losses, which is one of the major hazards we encounter; this would lead to a greater need for blood products transfusions. The frequent use of these products can have negative consequences due to body fluid shifting, and donor-host rejection. Thus, it has become mandatory to establish strategies to maintain blood volume and minimize losses. Several strategies have been approved to control the disproportionate blood loss. Objective: This study aims to assess the effectiveness of tranexamic acid in reducing intraoperative bleeding during our spine instrumented surgeries, while addressing complications associated. Methods: In this retrospective analysis was steered of 153- consecutive patients treated in the neurosurgical- spine unit of King Hussein hospital, King Hussein Medical Center (KHMC), between April 2017 to January 2020, patients who underwent instrumented surgery for different spinal pathologies at our institute were reviewed. Results: During the analysis period, 153-patients who underwent interbody fusion, were allocated into two groups. The mean instrumented segments were 2.8 level (range 1-5 levels). The demographical data of patients of both groups analyzed. The mean span of operating time was (212.74 ± 41.85 min) for group I, while for the control group mean length was (208.09min ±42.03). Study showed that the mean drop in the hemoglobin concentration postoperatively was statistically significant comparing the two groups. Analysis of blood volume in suction container showed that group I had: 470 ml ±153.06 ml; while in control group volume was: 1560 ml ± 567.59 ml, which showed significant difference (p = 0.002). Comparing the drainage volumes at 12 hours postoperatively displayed no statistically significant differences (p = 0.69) concerning the two groups. Minor adverse effects allied with the tranexamic acid administration. Conclusions: In summary, perioperative bleeding deemed one of the most important threat for patients. Tranexamic acid is proved excellent in controlling perioperative bleeding, harboring few contraindications. Future large studies are still needed to elaborate on unanswered issues.
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Safety and effectiveness of a modified ASAP technique during mechanical thrombectomy for acute ischemic stroke: Initial clinical experience p. 56
Tomotaka Ohshima, Reo Kawaaguchi, Naoki Matsuo, Shigeru Miyachi
DOI:10.4103/ajns.AJNS_503_20  
Objectives: For patients with acute ischemic stroke, various endovascular approaches have been reported with high recanalization rates and good clinical outcomes. However, the best technique for the first attempt at mechanical thrombectomy remains a matter of debate. In this study, we evaluated the efficacy of a modified version of a stent-retrieving into an aspiration catheter with a proximal balloon (ASAP) technique. Materials and Methods: Modification 1: After stent deployment, the microcatheter was not removed immediately. Modification 2: After the withdrawal of the stent retriever into an aspirator and its removal from the entire system, we focused on the drainage of fluid into a pump. The aspirator was withdrawn slowly until the fluid appeared to be draining continuously into the pump. Before the removal of the aspirator, we performed angiography through the aspirator. We carried out a retrospective analysis of 30 consecutive patients with acute ischemic stroke caused by occlusion of the anterior circulation who were treated with the modified ASAP technique at our institution. Results: A thrombolysis in cerebral infarction score of 2B or 3 was achieved in 29/30 patients (96.7%). The average number of passes was 1.2 ± 0.5. The mean time from puncture to recanalization was 17.6 ± 6.84 min. Twenty-three (76.7%) patients achieved a modified Rankin Scale score of 0–2 at 3 months after the procedure. Conclusions: We found that the modified ASAP technique yielded fast recanalization, minimal complications, and good clinical outcomes of mechanical thrombectomy in this case series.
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Pituitary hormonal status after endoscopic endonasal transphenoidal removal of nonfunctioning pituitary adenoma: 5 years' experience in a single center p. 62
Pungjai Keandoungchun, Wuttipong Tirakotai, Ampai Phinthusophon, Yodkhwan Wattanasen, Patcharapim Masayaanon, Sudasawan Takathaweephon
DOI:10.4103/ajns.AJNS_386_20  
Background: This study focuses on hormonal disorder and medical complications postoperative endoscopic endonasal transsphenoidal approach of nonfunctioning adenoma at Prasat Neurological Institute, Bangkok, between January 2013 and December 2017. Methods and Material: Baseline characteristics, clinical complications, and hormonal status data were collected from the patients' medical records and analyzed using the descriptive statistics. Results: There were four surgeons who operated 126 cases, 17 of them were reoperation. The average age of the patients was 49 years old. The average length of stay was 13 days, and average operating time was 134 min. Visual field defect was the most common presenting symptom. Almost all the tumors were classified as pituitary macroadenoma which invaded one or two sellar walls. Total or near total tumor removal was the most extend of resection. There were 61 cases developed early diabetes insipidus (DI), but only 12 cases continue to long-term DI. Seven cases were meningitis. Three cases were death. Out of 83 patients who had preoperative intact hypothalamic-pituitary-adrenal (HPA) axis and hypothalamic pituitary thyroidal (HPT) axis, 2 and 3 of them developed postoperative impair HPA and HPT axis in that order. In addition, among 45 patients who had preoperative impair HPA and HPT axis, 6 of them achieved postoperative endocrinological normalization. Conclusion: In preoperative intact pituitary hormone patients, the total or near total tumor removal of non functioning pituitary adenoma may have hypopituitarism during early postoperative period but gradually returned to normal during 4-6 month postoperative period.
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Endoscopic anterior odontoid screw fixation for the odontoid fracture: A cadaveric pilot study p. 67
Shweta Kedia, Dattaraj Sawarkar, Rajeev Sharma, Nasim Mansoori, Sanjeevv Lalwani, Deepak Gupta, Rajinder Kumar, Shashank Sharad Kale
DOI:10.4103/ajns.AJNS_312_20  
Introduction: Anterior odontoid screw fixation technique for specific types of odontoid fracture has been proven to be an effective, yet challenging procedure because of threatened damage to the structures in the vicinity. There are few articles suggesting the role of percutaneous and endoscopic technique as an alternative approach to the standard microscopic way. This is the first cadaveric study using existing “EASY GO” endoscopic system-assisted odontoid screw placement. Study Design: This was a cadaveric study. Objective: The objective of the study is to use the endoscope as a safer minimally invasive approach than the standard microscopic anterior approach to odontoid. Methodology: This is a pilot study on 10 fresh-frozen formalin-fixed adult human cadavers. The cadaver was positioned in a way to simulate reduced odontoid fracture. Tubular dilators were used to dock at C2–3 disk space after identifying the landmarks through the microscopic method. The EASY GO endoscopic system was then introduced, and a handheld drill was used to mark the entry point and pass the K-wire through the planned trajectory. Results: No vascular or adjacent vital structures' injury was observed in any of the cadavers. The initial difficulty in attaining the alignment was overcome by the appropriate positioning of the scope. Conclusions: Endoscopic-assisted technique for odontoid screw fixation shall provide a minimally invasive, safe, and easy surgery.
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The dilemma of multifocality in insular tumors: Multicentricity versus metastasis p. 72
Kuntal Kanti Das, Amanjot Singh, Deepak Khatri, Jaskaran Singh Gosal, Kamlesh Bhaisora, Anant Mehrotra, Sudarsana Gogoi, Sanjay Behari
DOI:10.4103/ajns.AJNS_458_20  
Background and Purpose: Multifocality and metastasis from insular glioma are extremely rare. Pathological insights and elaboration of the clinical course of this condition will contribute to their better understanding. Materials and Methods: Among 123 consecutively operated insular gliomas, 5 patients (4.2%) presented with a multifocal tumor. The clinico-radiological, histo-molecular, and treatment outcomes were noted and compared with the unifocal insular glioma cohort. Results: Among the five patients, all were males and involved the right insular lobe. Three patients presented with synchronous tumors, while two patients developed metachronous multifocal tumors. The histology of the insular tumor was Grade I glioma in 1, Grade II astrocytoma with p53 mutation in 2, and anaplastic astrocytoma and glioblastoma in one patient each. Histological confirmation of the second lesion was performed in two patients, showing the same histology of the insular tumor. Interconnection between the tumors was apparent through cerebrospinal fluid pathways in four patients, while no such connection could be established in one patient. Barring the patient of Grade I glioma, the rest of the patients died within months of the diagnosis. Conclusion: Multifocal insular glioma is rare and probably represents a biologically more aggressive tumor. Insular glioma that touches the ventricle appears a common denominator for multifocality. True multicentricity is rare. The prognosis in insular glioma with multifocality is poor in non-Grade I gliomas.
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The management and outcomes of coronavirus disease 2019 infection in a series of neurosurgical patients p. 78
Farzin Farahbakhsh, Mohsen Rostami, Alireza Khoshnevisan, Negin Naderian, Mohammad Ghorbani, Michael G Fehlings, Vafa Rahimi-Movaghar
DOI:10.4103/ajns.AJNS_187_20  
Background: The coronavirus disease 2019 (COVID-19) pandemic has impacted neurosurgical practice worldwide. In Iran, hospitals have halted their routine activities, and most hospital beds have been assigned to COVID-19 patients. Here, we share our experience with 10 neurosurgical cases with confirmed COVID-19. Materials and Methods: From February 24, 2020 to April 20, 2020, we were able to obtain clinical data on ten neurosurgical patients with COVID-19 through a predefined electronic form. Results: Of the 10 patients with COVID-19 on neurosurgical units, eight underwent surgical interventions. The age of the patients ranged from 21 to 75 years and 70% were males. The diagnosis of COVID-19 was based on chest imaging findings and reverse transcriptase-polymerase chain reaction for coronavirus and an infectious disease specialist and a pulmonologist confirmed the diagnoses. In two cases, there was a significant decrease in O2 saturation intraoperatively. Three patients in this series died during the assessment period. One death was due to respiratory failure induced by the coronavirus infection. The cause of death in other two patients was cardiovascular failure not related to COVID-19. Conclusions: We hope we can provide a reference for future studies and help develop a clearer understanding of neurosurgical practice and outcomes in patients with COVID-19. In the time of COVID-19 pandemic when dealing with neurosurgical emergencies, a conservative approach is recommended. Using committed personal protective equipment, short-time operating procedures or minimally invasive surgery must be considered in the management of emergent patients. Resuming elective surgeries need defining measures needed to ensure patients and health-care providers' safety. Reorganizing the health-care system for telemonitoring released patients can lessen hospital visits.
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Experimental evaluation of the risk of distal embolization during endovascular clot retrieval using various techniques p. 84
Tomotaka Ohshima, Shigeru Miyachi
DOI:10.4103/ajns.AJNS_237_20  
Background: This study was conducted to evaluate various devices and techniques for endovascular thrombectomy that can reduce the risk of intraprocedural distal embolism in a preliminary in vitro setting with different types of thrombi. Materials and Methods: Endovascular clot retrieval was performed in a vascular model with collateral circulation. White and red thrombi were prepared using whole blood collected from a pig. A Direct Aspiration First Pass Technique (ADAPT), simple stentretrieving with and without proximal flow arrest by a guiding balloon (SR [B+] and SR [B±]), the AspirationRetriever Technique for Stroke (ARTS), and A stentretrieving into an Aspiration catheter with Proximal balloon (ASAP) were performed three times, respectively. The saline samples that were collected at the distal side during each procedure were examined using a particle counter. The particles were counted and categorized into three groups based on size (100 μm). Results: SR (B−) and SR (B+) could not achieve complete retrieval of the clot, especially using the white thrombus. ASAP was the only method that was able to retrieve the clots in all attempts. In both clot types, SR (B−), SR (B+), and ARTS, which involved a temporary flow restoration through stent deployment, demonstrated the migration of a greater number of particles measuring >100 μm in size than that shown by ADAPT and ASAP. Conclusions: ASAP was the safest method in terms of intraprocedural clot migration among the five methods evaluated in this study. Temporary flow restoration through stent deployment may affect the dangerous distal clot migration.
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Petroclival meningioma: Management strategy and results in 21st century p. 89
Vivek Kumar Kankane, Basant Kumar Misra
DOI:10.4103/ajns.AJNS_357_20  
Background: Petroclival meningioma (PCM) is considered among the most difficult tumors to be treated by microneurosurgery because of its location and its relation to critical structures. The authors report on the outcome in a series of patients with PCM treated in the new millennium with a tailored approach of gross total excision or subtotal removal and adjuvant Gamma Knife Radiosurgery (GKR) depending on the particular case. Methods: Between 2001 and 2017, 72 consecutive PCMs were operated in a single center by the senior surgeon. Clinical presentation, operative approaches, intraoperative findings, complications, and imaging findings were retrospectively analyzed. Postoperative outcome, adjuvant Gamma knife, and follow-up findings were reviewed. Results: The average age was 47.95 years, and female-to-male ratio was 52:20. Cavernous sinus extension was present in 21 patients. The mean duration of follow-up was 66.65 months. Gross-total resection, near-total resection (NTR), and subtotal resection (STR) resection was achieved in 30, 24, and 18 (42.8%, 34.28%, and 25%) patients, respectively, with recurrences of 10%, 33%, and 50%, respectively. Twenty-two patients (18 STR and 4 NTR) had received postoperative GKR. Only four patients had recurrences following GKR. New cranial nerve deficits were more common in patients in whom a total resection was performed. There was no mortality. Conclusions: Gross total excision had the best recurrence free rate though with a higher morbidity. Upfront GKR is advisable in patients with residual tumor, if the preoperative temporal course had a rapid symptomatology, to reduce recurrence. Wait and watch for a small intracavernous residue and radiosurgery on growth is also a valid option as long as follow-up is not suspect. A flexible approach of individualizing the treatment protocol for a given patient goes a long way toward optimal outcome.
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Comparative study of subgaleal and subdural closed drain in surgically treated cases of chronic subdural hematoma p. 96
Jagminder Singh, Shivender Sobti, Ashwani Chaudhary, Vikram Chaudhary, Tarun Garg
DOI:10.4103/ajns.AJNS_101_20  
Background: Chronic subdural hematoma (CSDH) is seen most common in geriatric patients, and trauma is the most important reason for CSDH. Operative treatment of CSDH in symptomatic patients is yet the gold standard of therapy because it allows decompression of the subdural space and aids improvement in neurological status. Burr-hole craniostomy is the most common accepted treatment for CSDH. There is still controversy regarding which type of drain placement is best in the outcome: subdural or subgaleal drain. Aim: The aim of the study was to compare the outcome of subgaleal versus subdural drain in surgically treated patients of CSDH. Materials and Methods: Patients were assigned by simple random sampling in two groups. The study was conducted from February 2016 to July 2017. A total of 70 patients were enrolled into the study and were divided in two groups (Group 1 – Subgaleal drain; Group 2 – Subdural drain). Statistical analysis was done using Chi-square and t-test. Outcome was assessed at the end of hospital stay by modified Rankin scale. Postoperative computed tomography scan was done after 24 h of surgery. Results: This study concluded that both types of drains are equally effective for the treatment of CSDH. There is a statistically significant difference in the occurrence of seizure in both the groups as there was no seizure in subgaleal drain group compared to 5 (14.3%) patients who had seizures postoperatively in subdural drain group (P = 0.020). There was insignificant difference with respect to preoperative Glasgow Coma Scale/sex/preoperative hematoma volume/postoperative hematoma volume/preoperative midline shift. Conclusion: Subgaleal drain is safe and technically easy, as subgaleal drain has no direct contact with brain parenchyma, thus less chances of brain laceration, intracerebral hematoma formation, and seizures.
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Evaluation of cognitive functions in traumatic brain injury patients using mini mental state examination and clock drawing test p. 99
Anamika Singh, Raj Kumar, Naresh Pal Singh, Ramakant Yadav, Arushi Kumar
DOI:10.4103/ajns.AJNS_331_20  
Background: Traumatic brain injuries (TBIs) are the leading cause of morbidity, mortality, disability, and socioeconomic losses globally, but of more concern, in India and other developing countries. The Mini mental state examination (MMSE) and clock drawing test (CDT) are the two mostly adapted methods for cognitive impairment screening. Therefore, it is necessary to establish a robust evaluation system exclusively for post-TBI cognitive impairment. Materials and Methods: One hundred and thirty-four cases treated previously at the health facility for TBIs were evaluated for cognitive functions during the follow-up period ranging from 3 weeks to 6 months in the out-patient department. All cases underwent mini-mental score examination (MMSE) and CDT to assess their cognitive performances. The data were analyzed statistically using Chi-square and ANOVA tests of significance. Results: Statistically significant association (P < 0.001) between the cognitive status of patients on the basis of overall MMSE score and the site of brain injury was observed. It was noted that 76 (56.7%) of the cases had cognitive impairment (MMSE score <24) with majority 44 (32.8%) patients having frontal lobe injuries, followed by 14 (10.1%) having brain injuries in the temporal lobe. On the other hand, using CDT score, it was observed that 102 (76.1%) of the cases had cognitive impairment (CDT score <5) with the majority 49 (36.6%) cases having frontal lobe injury followed by 19 (14.2%) having brain injury in the parietal lobe. Conclusion: The CDT was able to access cognitive function disruption in those patients, in whom the mini-mental score examination was not able to assess the same, and this difference in detection capabilities of both the tests was statistically found significant.
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Proximal junctional kyphosis after pediatric angular kyphotic deformity correction: Are we missing something? p. 106
Abhinandan Reddy Mallepally, Rajat Mahajan, Nandan Marathe, Ankur Nanda, Tarush Rustagi, Harvinder Singh Chhabra
DOI:10.4103/ajns.AJNS_311_20  
Purpose: Corrective maneuvers in an angular kyphotic deformity have its own problems including early complications such as neurological deficit and late complications such as proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). This article discusses the probable mechanisms, leading to PJK in pediatric severe angular kyphotic deformities and preventive strategies for the same. We will also assess natural course of untreated PJK and its devastating consequences. Materials and Methods: Three patients, two 13-year males presented with progressive, painless thoracolumbar kyphoscoliotic deformity, with segmental kyphosis 100° and 140° and scoliosis of 33° and 78°, respectively, and one 14-year-old female presented with angular kyphotic deformity of 60° with apex at D11-12 level. Results: Posterior vertebral column resection with segmental deformity correction with good coronal and sagittal balance was done. In the follow-up, PJF was seen. Second surgery was done with the extension of instrumentation to D4 along with deformity correction in both the male patients. The female patient did not opt for a revision surgery, and we are following the natural history of this case. Conclusion: In severe thoracolumbar angular kyphotic deformities with normal or negative sagittal balance, it might be a safer option to select the sagittal stable vertebra as upper instrumented vertebra based on the C2 plumb line on the preoperative standing lateral radiographs. However, a study with a larger sample size is needed to validate our hypothesis.
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Fremantle back awareness questionnaire in chronic low back pain (Frebaq-I): Translation and validation in the Indian Population p. 113
Parnandi Bhaskar Rao, Mantu Jain, Apurba Barman, Sumit Bansal, Rabi Narayan Sahu, Neha Singh
DOI:10.4103/ajns.AJNS_359_20  
Background: The Fremantle Back Awareness Questionnaire (FreBAQ) has been found to possess adequate psychometric properties in low back pain (LBP) patients worldwide. The aim of this study was to translate the questionnaire into a classical Indian language (Odiya) and validate in the Indian population (FreBAQ-I). Materials and Methods: The English edition of the FreBAQ was transformed into Indian classical language (Odiya). One hundred adult patients with chronic LBP were recruited for psychometric evaluation using Rasch analysis. Demographic parameters, clinical characteristics like pain, Oswestry Disability Index, and Beck's depression inventory were assessed along with responses to the study questionnaire. Results: The FreBAQ-I correlated well with intensity of pain (r = −0.19, P = 0.04), duration of the LBP (r = 0.35, P < 0.001), depression score (r = 0.25, P = 0.012), but not statitistically with disability (r = 0.06, P = 0.49). The fit statistics was neither excessively positive nor negative, and the average agreeability measure of the study participants progressed as presumed across the different categories. Internal consistency of the FreBAQ-I version was found to be good with a person reliability of 0.54 and Cronbach's alpha of 0.91. Conclusions: Patients with greater disturbed body perception are addressed adequately by the questionnaire. All nine items are essential and adequate, which makes the survey complete, although item 2 was found to be endorsed more often. Overall, the FreBAQ-I has suitable psychometric properties in Indian populations with chronic LBP.
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Lifesaving decompressive craniectomy for high intracranial pressure attributed to deep-seated meningioma: Emergency management p. 119
Irwan Barlian Immadoel Haq, Fajar Herbowo Niantiarno, Muhammad Reza Arifianto, Alhusain Nagm, Rahadian Indarto Susilo, Joni Wahyuhadi, Takeo Goto, Kenji Ohata
DOI:10.4103/ajns.AJNS_179_20  
Objects: As the most common intracranial extra-axial tumor among adults who tend to grow slowly with minimal clinical manifestation, the patients with meningioma could also fall in neurological emergency and even life-threatening status due to high intracranial pressure (ICP). In those circumstances, decompressive craniectomy (DC) without definitive tumor resection might offer an alternative treatment to alleviate acute increasing of ICP. The current report defines criteria for the indications of lifesaving DC for high ICP caused by deep-seated meningioma as an emergency management. Patients and Methods: This study collected the candidates from 2012 to 2018 at Dr. Soetomo General Hospital, Surabaya, Indonesia. The sample included all meningioma patients who came to our ER who fulfilled the clinical (life-threatening decrease in Glasgow Coma Scale [GCS]) and radiography (deep-seated meningioma, midline shift in brain computed tomography [CT] >0.5 cm, and diameter of tumor >4 cm or tumor that involves the temporal lobe) criteria for emergency DC as a lifesaving procedure. GCS, midline shift, tumor diameter, and volume based on CT were evaluated before DC. Immediate postoperative GCS, time to tumor resection, and Glasgow Outcome Scale (GOS) were also assessed postoperation. Results: The study enrolled 14 patients, with an average preoperative GCS being 9.29 ± 1.38, whereas the mean midline shift was 15.84 ± 7.02 mm. The average of number of tumor's diameter and volume was 5.59 ± 1.44 cm and 66.76 ± 49.44 cc, respectively. Postoperation, the average time interval between DC and definitive tumor resection surgery was 5.07 ± 3.12 days. The average immediate of GCS postoperation was 10.07 ± 2.97, and the average GOS was 3.93 ± 1.27. Conclusion: When emergency tumor resection could not be performed due to some limitation, as in developing countries, DC without tumor resection possibly offers lifesaving procedure in order to alleviate acute increasing ICP before the definitive surgical procedure is carried out. DC might also prevent a higher risk of morbidity and postoperative complications caused by peritumoral brain edema.
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Effect of perioperative fluids on serum osmolality and serum sodium in patients undergoing transcranial excision of craniopharyngioma: A prospective randomized controlled trial p. 126
Pranshuta Sabharwal, Nidhi Panda, Neeru Sahni, Ashish Kumar Sahoo, Ankur Luthra, Rajeev Chauhan, Hemant Bhagat, Pinaki Dutta
DOI:10.4103/ajns.AJNS_324_19  
Background: Electrolyte imbalance and acute diabetes insipidus (DI) are the most common complications in patients undergoing craniopharyngioma excision. Data are sparse regarding the choice of fluid in these patients. We compared the effects of balanced salt solution and 0.45% saline infused perioperatively on serum osmolality and serum sodium levels in these patients. Methodology: A prospective randomized double-blinded study was conducted in 30 patients undergoing transcranial excision of craniopharyngioma. The patients received either balanced salt solution or 0.45% sodium chloride solution perioperatively till they were allowed orally. Serum and urine osmolality, serum and urine sodium, urine specific gravity, and total dose of desmopressin required to treat DI were measured in the perioperative period. Results: Demographic data were comparable. We observed that there was significantly higher serum osmolality in the intraoperative period at 2nd h (P = 0.04), 3rd h (P = 0.01), at end of the surgery (P = 0.034) and on postoperative day 0 (POD 0) with P = 0.03 in patients receiving balanced salt solution. We also observed that the difference in serum sodium levels were significantly higher in patients receiving balanced salt solution as compared to those receiving 0.45% sodium chloride solution intraoperatively, at 3rd h (P = 0.02) and at the end of surgery (P = 0.04) although the values were comparable in both the groups as measured on POD 0, 1 and 2. Conclusion: 0.45% sodium chloride solution has better effect on serum osmolality than balanced salt solution in patients undergoing transcranial resection of craniopharyngioma.
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CASE REPORTS Top

Penetrating injury of superior sagittal sinus p. 132
Abrar Arham, Nadya Zaragita
DOI:10.4103/ajns.AJNS_320_20  
Penetrating injury of superior sagittal sinus (SSS) is very rare yet serious which can lead to morbidity and mortality. Complications such as bleeding, thrombosis, and infection are possible and should be anticipated. We report a case of 3-year-old boy with penetrating injury caused by a nail at the middle third of SSS. The patient underwent the surgery for extraction and sinus repair and antibiotic treatment during the hospital stay. He was neurologically intact and recovered completely. Comprehensive treatment of both surgical and medical management is important in achieving the best possible outcome.
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A novel combined transorbital transnasal endoscopic approach for reconstruction of posttraumatic complex anterior cranial fossa defect p. 136
Ashwin Gajendran Vedhapoodi, Anbazhagan Periyasamy, Devanand Senthilkumar
DOI:10.4103/ajns.AJNS_363_20  
The transorbital neuroendoscopic surgery (TONES), endoscopic transnasal skull base procedures, and the concept of multiportal minimal access neurosurgery are novel, rapidly evolving approaches in the management of complex skull base lesions. A 27-year-old male presented with a history of road traffic accident with nasal bleed, cerebrospinal fluid (CSF) rhinorrhea, and left eye deformity. There was left upper eyelid ecchymosis, orbital dystopia, left pupil was dilated, and fixed with no extraocular movements. The computed tomography scan showed basifrontal contusion and complex comminuted anterior cranial fossa (ACF) fracture involving left cribriform plate and left orbital roof with fracture fragment impinging on the superior rectus muscle with suspicious orbital CSF leak. There was no improvement with conservative management. Hence, a novel combined TONES, transnasal endoscopic multiportal surgery was undertaken for the removal of fracture fragments and multi-layered closure of the complex ACF defect. The patient had a complete resolution of orbital dystopia and visual loss with no evidence of CSF leak postoperatively.
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Pituitary tuberculoma masquerading as a pituitary adenoma: Interesting case report and review of literature p. 141
Blessy Balaji Prabha, Vijay Rangachari, Venugopal Subramaniam, Thottatil Viswanathan Gopan, Vidya Bhat Baliga
DOI:10.4103/ajns.AJNS_371_20  
We present a rare case of a pituitary tuberculoma masquerading as pituitary adenoma with pituitary apoplexy-like presentation in a 31-year-old female, who had symptoms suggestive of acute secondary adrenal insufficiency with secondary amenorrhea. After initial evaluation which was suggestive of pituitary adenoma, she underwent endoscopic transnasal pituitary tumor excision. Histopathology revealed features of pituitary tuberculoma. She was subsequently started on four drug anti-tubercular therapy and is on follow-up. Although uncommon, tuberculomas, especially in the pituitary gland, are known for behaving like pituitary adenomas, by impairment of pituitary hormonal function and by exerting pressure effects on surrounding vital intracranial structures. Diagnostic challenges, treatment modality, and literature review are presented in this case report. Pituitary tuberculoma even though a rare entity should be borne in mind as a differential diagnosis in a patient manifesting with pituitary apoplexy-like syndrome.
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Dorsal spinal epidural cavernous angioma; A case report p. 144
Girish Krishna Joshi, KN Krishna, Dilip Gopal Krishna, Ganesh K Murthy, Ajay Herur, Sundeep V Karnam
DOI:10.4103/ajns.AJNS_150_20  
Spinal cavernous angiomas are lesions formed by vessels lined by closely clustered endothelial cells. They are common in the vertebral body and less common in an intradural location. However, these are very rare in the extra-osseous and epidural region. Less than 100 cases have been reported. Here, we report a case of dorsal spinal extradural cavernous angioma in a 52-year-old man who presented with back pain and difficulty in walking. Magnetic resonance imaging brain showed D7–D8 (thoracic) extradural spinal lesion, enhancing homogeneously on contrast administration. He underwent D7–D8 hemilaminectomy and tumor decompression. The tumor was extradural, tightly adherent to the dura, and highly vascular. He recovered completely after surgical removal with no recurrence 2 years after removal. He was not administered adjuvant radiotherapy. In this article, we review the literature regarding clinical features, imaging findings, and outcome of spinal epidural cavernous angioma.
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Customized cost-effective polymethyl-methacrylate cranioplasty implant using three-dimensional printer p. 150
Sambardhan Dabadi, Raju Raj Dhungel, Upama Sharma, Dinuj Shrestha, Pritam Gurung, Resha Shrestha, Basant Pant
DOI:10.4103/ajns.AJNS_441_20  
There is no doubt that many synthetic materials used in cranioplasty have given good result regarding patient's calvarial shape. However, the use of these materials is costly to the patient and requires complex intraoperative process. There has been a long history regarding the use of acrylic bone cement called as polymethyl-methacrylate (PMMA) as an implant due to its desirable properties. Here, we present three cases of simple, cost effective manually sculpted calvarial defect using three-dimensional (3D) printer. Sharing the achievement and challenges, we want to focus that the 3D customized implant of PMMA can be used as bone substitute.
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Surgical management of pediatric cervical angular kyphosis with 540° approach and metacarpal plate: A case report and introduction of a novel technique p. 155
Mohammad Zarei, Mersad Moosavi, Nima Ostad Rahimi, Mohsen Rostami
DOI:10.4103/ajns.AJNS_195_20  
Surgical decompression, deformity correction, and instrumentation of the upper cervical spine are challenging problems in cervical kyphosis, especially in infants and pediatrics. According to patients' age, surgical exposure is difficult and selecting the appropriate instrument for rigid fixation is crucial. In this article, we present a case of 2 years old with cervical angular kyphosis, which was approached posteriorly at first. Through posterior approach, C3–C5 laminectomy with complete excision of spinous process was performed. Then, the patient's position was changed to supine and C3–C5 corpectomies were performed anteriorly with a longitudinal incision, and the thecal sac was decompressed. A titanium cage with appropriate size and graft was placed after possible deformity correction conducted with head traction and neck extension. Anterior fixation was performed with two, 2-mm T-shaped metacarpal plates with two screws in C2 and four screws in C6. The patient's position was changed to prone again, and posterior fixation was done with two metacarpal plates located on lateral masses. We showed that a novel technique in correction and fixation of cervical kyphosis in pediatric is using metacarpal plates while they are fixed to lateral masses.
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Recurrent meningeal melanocytoma of cervical spine: A rare case p. 159
Mihir Mohan Vaidya, Rahul Dnyandev Dhake, Rashmi Chintan Parikh, Manish Sitaram Sabnis, Josna Manish Sabnis
DOI:10.4103/ajns.AJNS_327_20  
Melanocytomas of the central nervous system are rare benign or intermediate grade localized melanocytic tumors. Despite its benign nature, it can follow a locally aggressive course with propensity to recur. We present the case of a 29 years old female who presented with a recurrent lesion in cervical spine and rapidly progressing quadriparesis. On examination, there was loss of power in right-sided extremities and reduction in sensations in left-sided extremities. Magnetic resonance imaging spine revealed a homogeneously enhancing intradural extramedullary dumbbell-shaped mass lesion at C4/5 level with extension through right C4 neural foramina to the extraforamina space, causing severe spinal cord compression. Intraoperatively, bluish-colored tumor was identified along with underlying hematoma. Gross total excision of the tumor was done. Tumor was received in the histopathology department in multiple black-colored fragments. Microscopically, a heavily pigmented tumor was seen with the sheets and nodules of polygonal cells with large nuclei and prominent nucleoli. Differentials considered were meningeal melanocytoma and malignant melanoma. On immunohistochemistry, the tumor cells showed diffuse positivity for HMB 45 and S100. Ki 67 index was around 1%. On radiological review, the tumor was fairly well circumscribed and did not infiltrate the adjacent tissues. There was no evidence of any lesions elsewhere in the body. Considering these features, the tumor was diagnosed with meningeal melanocytoma. Postoperatively, there was significant immediate improvement in quadriparesis and patient could walk with minimal support.
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Selection of an appropriate surgical method for the management of chronic subdural hematoma in a patient with poor physical status p. 164
Jin Eun, Jae-Geun Ahn
DOI:10.4103/ajns.AJNS_354_20  
Physical status is an important factor to consider when treating patients with chronic subdural hematomas. Surgical treatment of chronic subdural hematoma is mainly by burr hole trephination. However, operative methods must be selected after careful consideration of mortality, morbidity, and recurrence rates. In the case presented here, a chronic subdural hematoma was noted in a 65-year-old patient with several comorbidities; therefore, minimally invasive burr hole trephination was performed. After thrice repetition of the burr hole trephination procedure, a craniectomy for hematoma removal and middle meningeal artery embolization was finally conducted, followed by cranioplasty to treat a subsequent epidural hemorrhage. In the case discussed here, we review the options for the treatment of chronic subdural hematoma and evaluate the factors that should be considered in determining the appropriate surgical course. Despite poor patient physical status, minimally invasive operation may not always be the best option. If the patient is at high risk for recurrent subdural hematoma, craniotomy with hematoma removal may be a better choice.
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Endoscopic third ventriculostomy in the fourth ventricle outlet obstruction associated with chiari malformation Type I and syringomyelia: Case report p. 170
Sidi Salem-Memou, Tolba Amal, Sidi-Mohamed Salihy, Outouma Soumare, Boukhrissi Najat
DOI:10.4103/ajns.AJNS_67_20  
Hydrocephalus by the fourth ventricle outlet obstruction (FVOO) associated with a Chiari malformation type I and syringomyelia is a well-known entity but a rare situation in clinical practice. Although suboccipital craniectomy with the opening of the obstruction membrane appears to be the most physiological approach, by restoring the original pathway of cerebrospinal fluid flow, the endoscopic third ventriculostomy (ETV) represents an important minimally invasive alternative. We report the case of an adult patient with tetra ventricular hydrocephalus by FVOO associated with Chiari malformation and syringomyelia. The ETV alone completely resolved all symptoms, as well as neuroimaging abnormalities on the control magnetic resonance imaging. The ETV is a minimally invasive option for the treatment of hydrocephalus in patients with obstruction at the exit of the fourth ventricle, even in cases associated with Chiari malformation and syringomyelia.
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A rare case of right trigeminal neuralgia due to dural arteriovenous fistula p. 174
Sagar Ghodasara, Rohit Balasubramanian, Santhosh Poyyamoli
DOI:10.4103/ajns.AJNS_93_20  
Trigeminal neuralgia (TGN) is often caused by a neurovascular conflict at the root entry zone of the fifth nerve. Dural arteriovenous fistula (DAVF) accounts for 3%–4% cases of TGN. We report a posttraumatic head injury patient, presenting with gait ataxia and right facial pain. Radiographic evidence with magnetic resonance imaging and digital subtraction angiography was suggestive of DAVF. Surgical clipping and obliteration of fistula alleviated the TGN.
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Glioblastoma occurring as second primary in a treated case of diffuse large B-Cell lymphoma p. 178
Pooja Kamlesh Gajaria, Asha Sharad Shenoy, Balaji Devrao Baste, Naina Atul Goel
DOI:10.4103/ajns.AJNS_230_20  
Glioblastoma as second primary malignancy (SPM) has been reported after prostate cancer, meningiomas, Hodgkin's lymphoma. We report an extremely rare case of glioblastoma as SPM, occurring after remission of diffuse large B-cell lymphoma (DLBCL). Fifty-year-old male presented with loss of consciousness followed by right-sided weakness. He was treated with chemotherapy for DLBCL of the cervical lymph nodes, 5 years back. Present scans revealed well-defined intra-axial lesion in the left parietal lobe, suggestive of central nervous system (CNS) involvement by lymphoma. Left parieto-occipital craniotomy was performed and microscopic examination revealed the tumor to be Glioblastoma, WHO Grade IV. The tumor cells were positive for glial fibrillary acid protein and negative for leucocyte common antigen. He was treated by radiotherapy and temozolomide. Pathologic examination is a must for CNS lesions. Had it not been for the biopsy, the patient would have been treated as a recurrence of CNS lymphoma by chemotherapy and would have probably succumbed.
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A rare case of a high-grade astroblastoma with 5-year follow-up p. 183
Lawrence D'Cruze, Sandhya Sundaram, Shruti Iyer, Krishnamurthy Ganesh
DOI:10.4103/ajns.AJNS_315_20  
Astroblastoma is a very rare glial tumor derived from astroblasts. It has been controversial in terms of its features and diagnosis. The objective of this report is to present the findings of the high-grade astroblastoma with a good prognosis in a 21-year-old female who presented to us with diplopia and headache. While imaging led to the foremost differentials of pleomorphic xanthoastrocytoma and Ganglioglioma which are low-grade neoplasms, the final diagnosis was established on microscopy and immunohistochemistry after excision. Treatment protocol included surgery with postoperative radiotherapy and chemotherapy. Due to controversial and limited literature, this tumor poses difficulties in diagnosis and management. This is a rare, successfully managed case of astroblastoma with a positive outcome 5 years after the diagnosis was established. In this case report, we review the steps of diagnosis, the differentials, the pathological and histological features, and the management of this rare entity.
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A rare case report of flexion teardrop cervical fracture with blunt vertebral artery injury leading to stroke p. 187
Sudhir Srivastava, Aditya Raj, Sunil Bhosale, Nandan Marathe, Manojkumar Gaddikeri
DOI:10.4103/ajns.AJNS_31_20  
Non penetrating trauma to vertebral artery is a known complication in craniovertebral trauma. They are mainly reported with facet dislocations or injuries involving the foramen transversarium. Such a type of injury is rarely seen with flexion injuries. We report such a case leading to cerebellar stroke in a young male presenting to us with hemiparesis. A 43-year-old male presented to us 1 month post trauma after a motor vehicular accident with complaint of weakness of right half of the body since the trauma. He suffered blunt trauma to head and neck and complained of a flail right upper limb since trauma and weakness of the right lower limb which had partly improved. He was conservatively managed elsewhere. Radiographic investigations revealed complete occlusion of the right vertebral injury above the level of 6th cervical vertebra and flexion teardrop fracture of 5th cervical vertebra. He was managed conservatively for the vertebral artery injury (VAI) and corpectomy of C5 vertebra with anterior cervical plating and fusion. Such a rare type of injury can present with unexplained neurodeficit which needs appropriate radiological investigations for diagnosis before ascribing the cause to cord trauma. Hence, all high velocity motor vehicular accidents with associated fractures and neurodeficit should be screened for blunt VAIs.
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Epithelioid sarcoma of lumbar spine: A rare mesenchymal tumor masquerading as infection p. 191
G Sudhir, S Vignesh Jayabalan, Amith Ram, Saikrishna Gadde, Karthik Kailash
DOI:10.4103/ajns.AJNS_190_20  
Epithelioid sarcoma of the spine has been rarely reported in the literature. Its diagnosis is challenging due to nonspecific findings. We report a case of 42-year-old gentleman with back pain. Magnetic resonance imaging (MRI) revealed lesion in the L4 vertebral body extending into the spinal canal with pre and paravertebral involvement. He underwent posterior spinal decompression and instrumentation with biopsy. Histopathological examination was nonspecific. Considering clinical and radiological features, antitubercular treatment was initiated. The patient developed acute onset weakness of both lower extremities 1 month post-surgery. Repeat MRI and positron emission tomography (PET) computed tomography revealed an increase in the extent of lesion which required revision decompression. Histopathological examination showed cells with epithelioid appearance, positive for Vimentin, and epitheloid membrane antigen in immunohistochemistry. Radiotherapy was planned but the patient expired due to multiorgan dysfunction. Epithelioid sarcomas are rare soft-tissue neoplasms with poor prognosis. They can mimic infection and a high degree of suspicion is required in these cases to diagnose and treat them early.
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Pharyngocutaneous fistula and horner's syndrome following loosening of locking screw of anterior cervical plating: A rare case report and management p. 196
Abhinav Jogani, Tushar Rathod, Nandan Marathe, Shubhranshu Mohanty, Chetan Shende
DOI:10.4103/ajns.AJNS_230_19  
We hereby present a rare case of pharyngocutaneous fistula associated with locking screw loosening causing internal cricopharynx perforation and Horner's syndrome following anterior cervical plating. A 27-year-old male patient had undergone anterior cervical plating at C5–C7 level due to gunshot injury to the neck, and 1 month postsurgery, he developed fistula in the neck showing discharge of consumed food contents. He presented to us 1 year postsurgery with the discharging fistula, left upper-limb weakness, and Horner's syndrome that developed after surgery. The previously unexplored right side was used to remove implant, and owing to solid union at corpectomy, no additional fixation was performed. Intraoperatively, pharyngeal wall dehiscence was observed. Attempt of removal of impinged screw was abandoned since it migrated into the esophagus. Serial abdomen radiographs revealed successive passage of screw through the gastrointestinal (GI) tract until it could not be visualized. As the patient showed reduced discharge, a GI surgeon gave a conservative trial with nasogastric intubation. Currently, fistula is showing minimal discharge with no food. Having knowledge of this possible rare outcome and awareness of various multidisciplinary approaches for management makes practicing spine surgeon equipped to handle such undesirable complications.
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Ruptured tentorium originating masson tumor p. 200
Haydar Sekmen, Ihsan Doğan, Orkhan Mammadkhanli, Esra Erden, Hakan Tuna
DOI:10.4103/ajns.AJNS_249_20  
Intravascular papillary endothelial hyperplasia (IPEH) also known as Masson's tumor, is a benign, slow growing, vascular lesion which is seen very rarely and only a few cases have been reported intracranially in the literature. It has been reported at many sites, but the posterior fossa involvement is very rare. The preoperative diagnosis is very difficult, as there is no enough cases to achieve a clear understanding about the details of its radiological findings. Differential diagnosis have to be made especially from angiosarcoma and meningioma. It is curable by total surgical removal. In this article we presented the characteristic clinical, radiological, perioperative and pathological findings in a case of IPEH in an unusual location, origin and behavior. To best of our knowledge, we presented the first case of IPEH originating from tentorium.
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A case of sellar/suprasellar neurocysticercosis mimicking a craniopharyngioma p. 204
Sasa Shakya, Pritam Gurung, Dinuj Shrestha, Pravesh Rajbhandhari, Basant Pant
DOI:10.4103/ajns.AJNS_423_20  
Neurocysticercosis (NCC) commonly presents with seizures in developing countries such as Nepal. It may also present with raised intracranial pressure due to obstructive hydrocephalus when cyst is located in the fourth ventricle or foramen of Monro. There are four main stages of NCC (1) Vesicular, (2) Colloidal vesicular, (3) Granular nodular, and (4) Nodular calcified. The colloidal vesicular stages can cause arachnoiditis and thus can cause hydrocephalus whereas obstructive hydrocephalus is usually caused by racemose type of NCC. This case was a suprasellar cyst mimicking craniopharyngioma, supported with clinical history of poor visual acuity, endocrine abnormality, suggested radiological findings by computed tomography scan, and magnetic resonance imaging. Suprasellar NCC was confirmed only by intraoperative findings and histopathology report.
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Primary intraosseous xanthogranuloma in adult cervical spine: A case report of benign cause of lytic bone lesion p. 208
Sundus Ali, Adnan Qasim, Muhammad Rizwan Sarwar, Attah Ul Munam, Shahzad Shams
DOI:10.4103/ajns.AJNS_480_20  
Lytic lesions in adult spine are a common manifestation of aggressive disease such as primary bone tumor, metastasis, myeloma, or infectious pathology. Xanthoma arising in the spine with purely intraosseous component is an extremely rare occurrence with only six cases reported in the adult population, none in the cervical region. We report the first case of primary xanthoma of the cervical spine in a 50-year-old male solely confined to osseous compartment. The imaging mimics of lytic lesion with expansile mass in adult spine are reiterated.
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Impact of extracranial–Intracranial bypass on cognitive function in a patient with chronic cerebral ischemia p. 212
Toshiya Aono, Hideaki Ono, Tomohiro Inoue, Takeo Tanishima, Akira Tamura, Isamu Saito
DOI:10.4103/ajns.AJNS_485_20  
Extracranial–intracranial (EC-IC) arterial bypass surgery was developed to prevent subsequent stroke by improving hemodynamics distal to the occluded intracranial artery, but its utilization has been decreasing due to the development in medical treatment. However, EC-IC bypass surgery may be effective for arresting or reversing cognitive decline in patients with cerebral ischemia. A 69-year-old man with the left internal carotid artery occlusion that manifested as scattered cerebral infarction of the left hemisphere presented with dysarthria and transient right hemiparesis. Hemodynamic condition was impaired in the left side, and therefore, EC-IC bypass surgery was performed to prevent recurrence of cerebral infarction. Neuropsychological examination at 6 months after the surgery showed marked improvement as compared to the preoperative examination and there was no recurrence of stroke in the patient. EC-IC bypass may contribute to the improvement of cognitive function as well as the prevention of recurrence of cerebral infarction in patients with hemodynamic insufficiency, but there might be a threshold of hemodynamic impairment with respect to the reversibility of cognitive performance. Investigation of the target and timing can identify cases in which the cognitive function is improved by surgery.
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Resolution of idiopathic epidural lipomatosis after bariatric surgery: Case report and literature review p. 217
Mohammad A Alsofyani, Sultan Alsalmi, Haifaa Malaekah, Majed Alharthi, Anouar Bourghli, Ibrahim Obeid, Louis Boissière
DOI:10.4103/ajns.AJNS_294_20  
Spinal epidural lipomatosis (SEL) is traditionally a rare disorder defined as an abnormal accumulation of unencapsulated epidural fat. SEL can be classified into idiopathic and secondary. We report a 46-year-old obese male with idiopathic epidural lipomatosis with a clinical picture of bilateral L5 and S1 radiculopathy, with an L5 and S1 distribution. Magnetic resonance imaging (MRI) showed epidural lipomatosis at L4, L5, and S1. After 2-year of sleeve gastrectomy, his bilateral sciatic radiculopathy disappeared, and updated MRI showed complete resolution of epidural lipomatosis. We present a case of an unusual epidural lipomatosis, resolved completely by bariatric surgery. This case report set out the effect of metabolic surgery on the local and systemic metabolic process.
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“When the Benign Bleed” vestibular schwannomas with clinically significant intratumoral hemorrhage: A case series and review of the literature p. 221
Peter Yat-Ming Woo, Pak-Lun Lam, Yuki Hoi-Kei Ip, Timothy Siu-Ki Chan, Oliver Kwan-Shun Ng, Marco Cheuk-Lun Kwan, Hoi-Tung Wong, Alain Kai-Sing Wong, Kwong-Yau Chan
DOI:10.4103/ajns.AJNS_287_20  
Vestibular schwannomas (VSs) are slow-growing benign neoplasms commonly located at the cerebellopontine angle. Although clinically significant hemorrhagic VSs are rarely encountered with only 75 patients previously reported, they could be life threatening. We discuss the presentation and outcomes of three patients with hemorrhagic VS as well as review the literature for this phenomenon. Consecutive adult patients with a histologically proven diagnosis of VS over a 9-year period were retrospectively reviewed. Fifty adult patients were identified with three (6%) having clinically significant intratumoral hemorrhage. This was defined as patients having acute to subacute symptoms with frank radiological evidence of hemorrhage. The mean age of diagnosis was 62 ± 9 years and the male-to female ratio was 2:1. The mean duration of symptoms, namely headache, vertigo, and sensorineural hearing impairment, was 26 ± 4 days with one patient presenting with acute coma. Retrosigmoid craniotomy for tumor resection was performed for all patients. Histopathological examination revealed extensive areas of microhemorrhage with considerable macrophage infiltration. All three patients were discharged with no additional neurological deficit and good functional performance. Clinically significant hemorrhagic VSs are rare, and patients may present with acute to subacute (i.e., within a month) symptoms of hearing loss headache, facial, or trigeminal nerve palsy. Macrophage infiltration is frequently encountered in tumor specimens and reflects the pivotal role of chronic inflammation in their pathophysiology. Surgical resection can lead to good outcomes with timely intervention.
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COMMENTARY Top

Recurrent glioblastoma: Nuances and insights p. 228
Maysam Alimohamadi, Amirhossein Larijani
DOI:10.4103/ajns.AJNS_395_20  
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LETTER TO EDITOR Top

Simulation training for neurosurgical residents: Need versus reality in Indian Scenario p. 230
Rajnish Kumar Arora, Radhey Shyam Mittal, Rajasekar Rekhapalli, Saravanan Sadhasivam, Pranshu Bhragava, Chandrashekhar Eknath Deopujari, Mrinal Parkash Barua, Mukesh Singla, Brijendra Singh, Poonam Arora
DOI:10.4103/ajns.AJNS_463_20  
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