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April-June 2021
Volume 16 | Issue 2
Page Nos. 237-444

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REVIEW ARTICLE  

Optimal use of temporary clip application during aneurysm surgery – In search of the holy grail p. 237
Sanjeev Kumar, Debabrata Sahana, Girish Menon
DOI:10.4103/ajns.AJNS_465_20  
Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were “Temporary Clip,” “Temporary Clipping,” “Cerebral Aneurysm,” and “Aneurysm.” Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use.
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ORIGINAL ARTICLES Top

Correlation of intraoperative neurophysiological parameters and outcomes in patients with intramedullary tumors p. 243
Leonardo Gilmone Ruschel, Afonso Aragão, Matheus Fernandes de Oliveira, Jerônimo Buzetti Milano, Mauricio Coelho Neto, Ricardo Ramina
DOI:10.4103/ajns.AJNS_234_20  
Introduction: Intramedullary spinal cord tumors (IMSCT) account for about 2%–4% of all central nervous system tumors. Surgical resection is the main treatment step, but might cause damage to functional tissues. Intraoperative neuromonitoring (IONM) is an adopted measure to decrease surgical complications. Below, we describe the results of IMSCT submitted to surgery under IONM at a tertiary institution. Methods: The sample consisted of consecutive patients with IMSCT admitted to the Neurological Institute of Curitiba from January 2007 to November 2016. A total of 47 patients were surgically treated. Twenty-three were male (48.9%) and 24 were female (51.1%). The mean age was 42.77 years. The mean follow-up time was 42.7 months. Results: Neurological status improved in 29 patients (62%), stable in 6 (13%), and worse in 12 (25%). Patients who presented with motor symptoms at initial diagnosis had a worse outcome compared to patients with sensory impairment and pain (P = 0.026). Patients with a change in electromyography had worse neurological outcomes compared to patients who did not show changes in monitoring (P = 0.017). Discussion and Conclusion: No prospective randomized high evidence study has been performed to date to compare clinical evolution after surgery with or without monitoring. In our sample, surgical resection was well succeeded mainly in oligosymptomatic patients with low preoperative McCormick classification and no worsening of IONM during surgery. We believe that microsurgical resection of IMSCT with simultaneous IONM is the gold standard treatment and achieved with good results.
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Algorithm of traumatic brain injury in pregnancy (Perspective on neurosurgery) p. 249
Ditto Darlan, Galan Budi Prasetya, Arif Ismail, Aditya Pradana, Joandre Fauza, Ahmad Data Dariansyah, Gigih Aditya Wardana, Tedy Apriawan, Abdul Hafid Bajamal
DOI:10.4103/ajns.AJNS_243_20  
Background: The maternal deaths due to obstetrical cases declined, but the maternal deaths that caused by nonobstetrical cases still increase. The study reported that traumatic cases in pregnancy are the highest causes of mortality in pregnancy (nonobstetrical cases) in the United States. Another study reported that 1 in 12 pregnant women that experienced traumatic accident and as many as 9.1% of the trauma cases were caused by traumatic brain injury (TBI). The female sex hormone has an important role that regulates the hemodynamic condition. Anatomical and physiological changes during pregnancy make the examination, diagnosis, and treatment of TBI different from non-pregnant cases. Therefore, it is very important to lead the algorithm for each institution based on their own resources. Case Series: A 37-year-old woman with a history of loss of consciousness after traffic accident. She rode a motorbike then hit the car. She was referred at 18 weeks' gestation. Glasgow Coma Scale (GCS) E1V1M4, isochoric of the pupil, reactive to the light reflex, and right-sided hemiparesis. The non-contrast head computed tomography (CT) scan revealed subdural hematoma (SDH) in the left frontal-temporal-parietal region, SDH of the tentorial region, burst lobe intracerebral hemorrhage, and cerebral edema. There was not a fetal distress condition. The next case, a 31 years old woman, in 26 weeks gestation, had a history of unconscious after motorcycle accident then she fell from the height down to the field about 3 m. GCS E1V1M3, isochoric of the pupil, but the pupil reflex decreased. Noncontrast CT scan revealed multiple contusion, subarachnoid hemorrhage, and cerebral edema. She had a good fetal condition. Discussion: We proposed the algorithm of TBI in pregnancy that we already used in our hospital. The main principle of the initial management must be resuscitating the mother and that also the maternal resuscitation. The primary and secondary survey is always prominent of the initial treatment. Conclusion: The clinical decision depends on the condition of the fetal, the surgical lesion of the intracranial, and also the resources of the neonatal intensive care unit in our hospital.
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Frameless free-hand navigation-guided biopsy for brain tumors: A simpler method with an endoscope holder p. 258
Takeshi Miyazaki, Mizuki Kambara, Yuta Fujiwara, Fumio Nakagawa, Tsutomu Yoshikane, Yasuhiko Akiyama
DOI:10.4103/ajns.AJNS_25_21  
Context/Aims: Given the limitations of current navigation-guided brain biopsy methods, we aimed to introduce a novel method and validate its safety and accuracy. Setting and Design: This was a retrospective study of twenty consecutive patients who underwent brain biopsy at Shimane University Hospital, Japan. Subjects and Methods: Clinical records of 13 and 7 patients who underwent brain biopsy with the novel frameless free-hand navigation-guided biopsy (FFNB) method or a framed computed tomography-guided stereotactic biopsy (CTGB) method, respectively, were retrospectively reviewed. We compared age, sex, tumor location, histological diagnosis, maximum size of the tumor (target), depth from target to cortical surface on the same slice of CT or magnetic resonance imaging, operative position, anesthesia method, setup time for biopsy, incision-to-closure time, trial times for puncture, success rate, and complications in the two groups. Statistical Analysis: Fisher's exact test and the Wilcoxon rank-sum test were performed. Results: Clinical characteristics and lesion size did not differ significantly between the FFNB and CTGB groups. The depth of the target lesion was significantly greater in the CTGB group (P < 0.05). All FFNB and CTGB procedures reached and obtained the target tissue. The number of punctures and the average incision-to-closure time did not differ between the FFNB and CTGB groups. However, the preoperative setup time was significantly shorter using FFNB (P = 0.0003). No complications were observed in either group. Conclusions: FFNB was comparable with CTGB in terms of safety, accuracy, and operative duration. The preoperative setup time was shorter using FFNB. Therefore, FFNB is a feasible method for brain tumor biopsy.
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Predictors of outcome following interventions for ruptured intracranial aneurysms in an emerging health institution in West Bengal: A 6-year experience p. 264
Enoch Ogbonnaya Uche, Mesi Matthew, Sujeet Meher, Laxmi Tripathy, Wilfred Mezue, Harsh Jain, Sunandan Basu, Mark Chikani, Ephraim Onyia, Izuchukwu Iloabachie
DOI:10.4103/ajns.AJNS_275_20  
Background: Microsurgical clipping and endovascular coiling have remained over the past half-century, the main options for definitive treatment of ruptured intracranial aneurysms. However, recent advances in endovascular techniques have broadened their application stimulating much debate regarding the usefulness of microsurgical options. For locations with limited capacity or evolving endovascular service, however, microsurgical treatment offers not only cost-effective and durable options but also oftentimes the only option available for most patients. Materials and Methods: This was a single institution questionnaire-based retrospective study from West Bengal India. It was performed on patients with aneurysmal rupture managed from June 2010 to October 2016. Data analysis was performed with SPSS for Windows, version 21. Results: One hundred and ten patients were studied. The mean age was 50.8 years (standard deviation [SD] ±13.5) for females and 50.2 (SD ± 12.4) for males (P = 0.8112, t-test). Ninety (81.8%) patients received microsurgical clipping. Microsurgical options such as wrapping, bypass, and excision were performed for 9 (8.2%) patients. Coiling was performed for 11 (10%) patients. ACOM was the most common site for ruptured aneurysm. Ictus-intervention interval (χ2 = 10.034, P = 0.007) and multiple surgical procedures (χ2 = 8.9341, P = 0.003) were the significant outcome determinants. Overall, 72.7% of those treated had a good outcome (Glasgow Outcome Score of 4 and 5). The good outcome was higher among microsurgery groups (73.7%) compared to the coiling group (63.6%) but this difference did not achieve statistical significance (χ2 = 0.46 P = 0.4976). Conclusion: Microsurgical options achieved good outcomes in the management of ruptured aneurysms in our series. Their availability makes them first-line options for low-income settings.
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Strategies to offer uninterrupted neurosurgical care at a tertiary center in Makka amid COVID-19 pandemic p. 271
Mohammed A Azab
DOI:10.4103/ajns.AJNS_324_20  
Background: Globally, there is a shooting pandemic that affected many healthcare systems. Healthcare facilities had to set up logistics to avoid being drained while facing a catastrophic health problem. There are currently no available vaccines or perfect therapies and also no certified immunity against that disease. Therefore, it is probable that healthcare systems will face it for an exceptionally long period. That will have a grave effect on the strategy of daily practice of different specialties' services at healthcare centers. Impossible decisions in usual workdays are now forcibly adopted for the sake of patients, care providers, and health resources. Methods: We try in a simple way to share tertiary center expertise in managing neurosurgical cases amid a dreadful healthcare crisis. Healthcare workers' safety and patient safety were typical priorities for neurosurgical service at King Abdullah Medical City. We expose the lines of management, triaging cases, the methods of handling confirmed and suspected neurosurgical patients, and strategies for discharging and following up patients. We identified hospital admission and discharge records starting from March 2020 till July to track the neurosurgical case burden and the state of service offered and the rate of infection among healthcare workers who participated in surgeries. Results: At the peak time of the COVID-19 pandemic in Makka starting from March till July, we have admitted 250 neurosurgical patients. About 210 (84%) of them did surgeries according to the triaging protocol described in the article. About 155 (62%) of those who did surgeries were urgent and the rest were borderline or semi-urgent. About 10 (4%) were severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive and three of them died due to acute respiratory distress syndrome. Only two mortality cases were reported due to a neurological complication and not related to SARS-CoV-2 infection. The rest of the cases (98%) were discharged for follow-up without grave complications after they were offered the service. No neurosurgeons or anesthesia staff involved in offering the service were infected with SARS-CoV-2. Successful uninterrupted neurosurgical care was available for patients during that health crisis without any healthcare worker being infected. Conclusion: Following the suggested strategies, any center can provide the healthcare service amid any pandemic happening now or in the future without dismantling the normal health system, especially for life-saving cases in a critical specialty as neurosurgery.
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Primary spinal extradural extraosseous primitive neuroectodermal tumor/Ewing's sarcoma: A critical analysis and review p. 276
Akshay Shrirang Patil, Prasheelkumar Premnarayan Gupta, Sandeep Wasudeorao Iratwar
DOI:10.4103/ajns.AJNS_340_20  
Primary spinal extradural Ewing's sarcoma/primitive neuroectodermal tumor (PNET) is rare malignant tumor of childhood and early adulthood. The World Health Organization classifies PNET as an undifferentiated round cell tumor arising from primitive neuroepithelial cell. It can be central or peripheral PNET depending on site of presentation. Usually, the presenting symptoms are chronic back pain and myelopathy. Overall prognosis and survival are dismal in spite of total surgical resection and adjuvant therapy. Because of the rarity and malignant behavior, definite management of spinal PNET has never been described. After review of medical record at Acharaya Vinoba Bhave Rural Hospital, Sawangi, India, we identified four patients of spinal PNET and were included in our study. Age at diagnosis ranging from 15 to 26 years old with mean age of 20 years old. All four cases were epidural in location, two of which were of Askin type tumor with spinal cord compression. Rural population with low literacy and financial constraints were the key reasons of late presentations at our hospital. Counseling and proper education regarding the disease are a must for early case detection and early treatment of those living in rural areas and suffers from financial constraints. Due to rarity of the disease and its poor prognosis, a well-organized multicentric controlled trial is required to formulate a standard guidelines in the management of this disease.
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Peripheral neurectomy for trigeminal neuralgia: A report of seventeen cases and review of the literature p. 281
Mohamed Ragab Nagy, Bokhary Mahmoud
DOI:10.4103/ajns.AJNS_361_20  
Background: Surgical intervention for trigeminal neuralgia (TN) is indicated if there is a failure of the medical treatment. Peripheral neurectomy is one of the oldest surgical procedures for TN. Objective: The aim is to evaluate the clinical outcome and the recurrence rate following peripheral neurectomy for the management of TN. Patients and Methods: This was a retrospective cohort study of 17 patients with classical TN treated by peripheral neurectomy. The visual analogue scale (VAS) was used for pain assessment preoperatively and during the follow-up period. The outcome of surgery was graded as a marked, moderate, or mild improvement. Kaplan–Meier analysis was used for the time to recurrence to predict the probability of recurrence at any given time following the procedure. Results: The mean pain-free interval was 29.3 ± 16.3 months. At 2 and 5 years of the follow-up period, the mean VAS improved significantly (P < 0.001 and P = 0.042 respectively). Thirteen patients had marked improvement of pain. There was recurrence of pain in 4 patients (23.5%). By Kaplan–Meier analysis, the survival rate without recurrence at 2, 3, 4, and 5 years following the procedure were 92.9%, 79.6%, 59.7%, and 29.8%, respectively. The mean preoperative Hospital Anxiety and Depression Scale-Anxiety and Depression scores significantly improved on the last follow-up visit following the procedure (P < 0.001 for both). Conclusion: Peripheral neurectomy provides short to medium-term good pain control for patients with TN. The preoperative severity of pain, anxiety, and depression levels improved markedly after the procedure.
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Outcome of decompressive craniectomy for traumatic brain injury: An institutional-based analysis from Nepal p. 288
Damber Bikram Shah, Prakash Paudel, Sumit Joshi, Prasanna Karki, Gopal Raman Sharma
DOI:10.4103/ajns.AJNS_392_20  
Objective: Decompressive craniectomy (DC) is one of the commonly used treatment modalities for refractory intracranial hypertension after traumatic brain injury. The objective of this study is to assess the functional outcome following DC in closed traumatic brain injury based on Glasgow Outcome Scale (GOS). Materials and Methods: This is a retrospective study conducted at Nepal Mediciti Hospital, Nepal, from September 2017 to October 2019. Data of the patients who had undergone DC for closed traumatic brain injury were reviewed from medical record files. Patients who had DC for nontraumatic causes were excluded from the study. Functional outcome was assessed using GOS at 3 months of follow-up. Results: Of the 52 decompressive craniectomies, 46 were included in the study. The majority was male (71.7%). The mean age and the mean Glasgow Coma Scale (GCS) score at presentation were 41.87 (standard deviation [SD] ± 15.29) and 7.59 (SD ± 2.97), respectively. The most common mode of injury was road traffic accident (76.1%). 60.9% had GCS score ≤8 while 39.1% had >8 GCS on admission. 34.8% had both the pupils reactive while 58.7% were anisocoric. Majority had Marshall IV and above grade of injury (67.4%). Sixteen (34.8%) had inhospital mortality. Favorable outcome was seen in 39.1%. GCS score >8 at presentation (72.2%, P < 0.001), bilaterally intact pupillary reflexes (75%, P < 0.001), Marshall grade injury ≤3 on computed tomography scan (90%, P < 0.001), and age <50 years (50%, P = 0.039) were significantly associated with favorable outcome. Procedure-related complications were seen in 36.9%. Conclusion: Favorable outcome was seen in 39.1%. Age <50 years, higher GCS score at presentation (>8), intact pupillary reflexes, and lower Marshall grade injuries were associated with favorable outcome. We recommend a larger prospective study to assess the long-term functional outcome after DC using extended GOS.
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Landscape, presentation, and characteristics of brain gliomas in Zimbabwe p. 294
Luxwell Jokonya, Aaron Musara, Ignatius Esene, Tariro Lavender Mduluza-Jokonya, Rudo Makunike-Mutasa, Sally Rothemeyer, Kazadi Kaluile Ntenge Kalangu, Takafira Mduluza, Thajasvarie Naicker
DOI:10.4103/ajns.AJNS_404_20  
Introduction: Gliomas are tumors of the supporting cells of the central nervous system. They have great heterogeneity in their clinical and pathological features as well as prognosis. There is paucity of glioma epidemiology data in Zimbabwe. We carried out a study to determine the landscape, presentation, and characteristics of brain gliomas in Zimbabwe. Materials and Methods: A prospective cross-sectional study was conducted in Zimbabwe over a 2 years period to determine descriptive epidemiological data with regards to demographic distribution, presentation, and tumor characteristics. Consecutive patients from across the country with brain gliomas were recruited in the study. Results: A total of 112 brain tumors were diagnosed histologically. Of these 43.8% (n = 49) were gliomas and hence recruited in the study. The mean age of study participants was 40.3 years (standard deviation = 23.1 years), range 3–83 years. Male to female ratio (M:F) was 1:1. The study population consisted of 14% caucasians (n = 7), 83.7% black (n = 41), and 2% (n = 1) were of mixed race. Eighty-six percent (n = 42) of participants were from urban areas. The most common presenting complaint was headache in 87.8% (n = 43). The majority (61.2%) presented with a Karnofsky score ≥70%. Astrocytomas were the most common gliomas constituting 57.1% (n = 28), followed by ependymomas and oligodendrogliomas being 8.1% (n = 4) each. There was no statistical difference in the hemisphere of the brain involved (P = 0.475). Eight percent of the population were HIV positive (n = 4). Age above 60 years has an adjusted odds ratio of 13 for presenting with high-grade tumors. Conclusion: There is a disproportionately high number of gliomas among Caucasians, urban dwellers, and those gainfully employed. The prevalence of HIV in glioma patients is less than that of the general population.
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Benchmarking of neurosurgery training in Pakistan p. 300
Noor-Ul-Ain Ali, Syed Maroof Ali, Salman Sharif, Faridah Amin
DOI:10.4103/ajns.AJNS_426_20  
Introduction: Neurosurgery is a challenging field of surgery. A neurosurgeon has to be trained with the finest skills, knowledge, and competencies necessary to provide high-quality patient care. Maintaining postgraduate training standards is a challenge in Pakistan due to low budget allocation to the health sector. This study aims to assess the difference in parameters among different institutes in different sectors and provinces offering neurosurgery training in Pakistan. Methods: A nationwide survey was conducted by the Neurosurgery Department at Liaquat National Hospital Karachi, from November 2019 to February 2020. Data were collected through a questionnaire from neurosurgery trainees from all over the country. The questionnaire was divided into the following sections: Sociodemographics and infrastructure of training site, clinical skills training and exposure, knowledge-based education, and workload. The data were kept confidential and institutional names were not inquired or disclosed. Results: The response rate was 85.3% (151/177), with more males (80%) than females. The total number of trainees was higher in government than private institutions (P < 0.005). The frequency (P = 0.030) and number of trainees (P < 0.005) inducted per cycle was more among government institutions. Participation in international conferences was higher among trainees in private sector (P = 0.006). The frequency of clinics was significantly higher in private institutions (P < 0.005), though the number of patients seen per clinic was lower than in government sector (P < 0.005). At a provincial level, there was a significant difference in gender distribution (P = 0.020), total number of trainees (P < 0.005), number of residents per induction (P < 0.005), frequency of mortality and morbidity meetings (P < 0.005), morning meetings (P < 0.005), number of calls per week (P < 0.005), number of workshops attended (P < 0.005), exposure to radiation (P = 0.003), frequency of outpatient departments (OPDs) attended per week (P = 0.002), and number of patients seen per OPD (P 0.02). Conclusion: This study reported variability in the quality of neurosurgery training programs within public and private sector with even greater differences between the four provinces of Pakistan. We recommend continuous assessments and re-accreditation of these training programs through subject experts and health-care educationists to improve the quality of training programs; hence the quality of service and patient care.
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MR venography in gamma knife radiosurgery for parasagittal meningiomas: A technical note with the rationale of venous protection and a review of literature p. 307
Sushanta Kumar Sahoo, Chirag Kamal Ahuja, Sivashanmugam Dhandapani, Renu Madan, Parsee Tomar, Sushil Kumar, Manjeet Kaur
DOI:10.4103/ajns.AJNS_436_20  
Postradiosurgery symptomatic brain edema may be seen with parasagittal meningioma owing to its proximity to major venous sinuses and cortical veins. Venous preservation radiosurgery planning is less described. Here, we discuss a new method of tumor volume contouring on postcontrast magnetic resonance venogram (CEMRV) images safely excluding the adjacent cortical veins and sinuses. Six cases of parasagittal meningiomas where Gamma Knife radiosurgery was planned on CEMRV sequence were studied in detail. A double-contrast injection method was used to obtain CEMRV images. The differential contrast enhancement showed the displaced and compressed sinuses and cortical veins in the vicinity of meningioma. Tumor was contoured on both contrast magnetic resonance imaging (CEMRI) and MRV image for comparative analysis. 15 Gy at 50% marginal isodose was prescribed and quantitative assessment showed reduced exposure to the adjacent veins and sinuses on the MRV plan as compared to the CEMRI plan. All patients remain asymptomatic at a mean follow-up of 34.2 months. Postcontrast MRV is a simple sequence and can delineate the adjacent venous structures in parasagittal meningiomas. Tumor contouring directly on this sequence guides the surgeon to prescribe adequate radiation dose while sparing cortical veins and sinuses in radiosurgery planning.
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Postdischarge 24/7 hotline service for neurology and neurosurgery patients and 1-year impact on readmission rates, unplanned emergency department visits, and patient satisfaction p. 312
Shafqat Bibi, Rida Mitha, Kiran Bano, Farida Datoo, Nadia Karim, Muhammad Shahzad Shamim
DOI:10.4103/ajns.AJNS_479_20  
Objective: Telephone triage is a system in which trained nurses use standardized protocols to evaluate symptoms over the phone and determine the appropriate course of action. Materials and Methods: We implemented a protocol for systematic follow up phone calls and telephonic triage to families of neurology and neurosurgery patients after discharge, primarily to improve care transition and to assess its impact on the ratio of visits in the emergency department, readmissions, and overall satisfaction of patients and families. The intervention comprised the implementation of nurse led telephone triage and postdischarge follow up phone calls. After implementing hotline services in mind and brain service line, a retrospective cohort study was conducted to evaluate the impact of hotline services on patient readmissions, emergency department visits, and overall satisfaction rate. We collected data of readmission rate and emergency visits of discharge patients in three periods a prehotline period, immediate posthotline period, and late posthotline period to make comparison. Patients discharged home from the neurology and neurosurgery services from January 2017 to September 2019 were provided with hotline number to call in case of any issue or query. These patients also received postdischarge follow up calls from hotline nurses. We initiated the hotline in October 2017. Results: On analysis, we found a 25% decline in readmission rate in the immediate period of hotline followed by a further decline to 37.2% in the late period as compared to the prehotline period. Among discharge patients visiting the emergency department, we found a decline of 18.5% in the immediate posthotline period which further declined to 77.7% in the later phase as compared to the prehotline period. Conclusion: A standardized telephone system and pathway can be an effective way to improve nurse–patient communication which can further improve health outcomes for many patients.
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Clinicoradiological profile and outcome of microsurgical clipping of ruptured anterior circulation aneurysms: A single-institute experience p. 316
Shivender Sobti, Jagminder Singh, Saurabh Sharma, Hanish Bansal, Ashwani Kumar Chaudhary
DOI:10.4103/ajns.AJNS_483_20  
Introduction: Prevalence of intracranial aneurysms is estimated to be from 1% to 5% of population, most of them are small and located in the anterior circulation. The real danger is when an aneurysm ruptures, leading to a subarachnoid hemorrhage (SAH). SAH is a catastrophic event with a mortality rate of 25% to 50%. Permanent disability occurs in nearly 50% of the survivors. Fifteen percent of patients expire before reaching the hospital and 25% die within 24 h. The purpose of our study is to report the clinicoradiological data and outcome of microsurgical clipping of ruptured anterior circulation aneurysms in our center. Materials and Methods: This study included ruptured anterior circulation aneurysms admitted to tertiary care hospital in northern India from January 2018 to June 2020. The final outcome of patients was analyzed with Glasgow Outcome Score (GOS) at the time of discharge from the hospital. Results: A total of 53 patients with ruptured anterior circulation aneurysm underwent microsurgical clipping comprising 25 (47.2%) males and 28 (52.8%) females. The mean neck size of all aneurysms was 3.43 ± 1.66 mm. The mean hospital stay was longer in patients having preoperative intraventricular hemorrhage (IVH) (35.96 ± 27.27 days) and postoperative complications (43.36 ± 29.76 days) compared to patients who did not have IVH (21.10 ± 15.47 days) and postoperative complications (18 ± 6.54 days). P value was ≤0.05. Patients with preoperative hydrocephalus had GOS 3.44 ± 1.20 at discharge compared to nonhydrocephalus who had GOS 4.32 ± 1.07 (P = 0.009). Patients with Intracerebral Hemorrhage (ICH) and non-ICH had GOS 3.31 ± 1.38 and 4.28 ± 1.01, respectively (P = 0.009). Conclusion: Poor outcome at the time of discharge after the surgical treatment of anterior circulation aneurysms was associated with poor world federation of neurological surgeons grade on admission, presence of IVH, hydrocephalus, intracerebral hemorrhage, and postoperative cerebral infarcts.
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Conventional carotid endarterectomy with shunt versus eversion carotid endarterectomy without shunt does the technique influence the outcome in symptomatic critical carotid stenosis p. 321
Vineeth Kumar, Sreekumar Ramachandran, PN Sylaja, Shivanesan Pitchai
DOI:10.4103/ajns.AJNS_486_20  
Introduction: Carotid endarterectomy (CEA) is a surgical procedure done to prevent future embolic stroke in patients with internal carotid artery (ICA) stenosis. Conventional CEA (c-CEA) and eversion CEA (e-CEA) are two surgical techniques used for the above. As carotid shunt is rarely used in e-CEA, a certain amount of cerebral ischemia occurs in patients who were already having carotid stenosis. In this study, we have evaluated the outcome of two surgical techniques in severe carotid stenosis and impact of carotid shunting on the postoperative outcome. Materials and Methods: In this single-center prospective nonrandomized trial, a total of 62 patients who underwent CEA (c-CEA, n = 31; e-CEA, n = 31) for symptomatic ipsilateral ICA stenosis ≥50% between January 2018 and December 2019 were included. Results: A total of 62 patients who underwent CEA (c-CEA, n = 31; e-CEA, n = 31) for symptomatic ipsilateral ICA stenosis ≥50% were included in the study. There was no major stroke or stroke related death in both the study groups. One patient in e-CEA had carotid occlusion and minor stroke. There was no statistically significant difference in minor stroke (e-CEA [3.2%], c-CEA [3.2%], P = 1), transient ischemic attack (e-CEA [3.2%], c-CEA n = 0, P = 0.3), postoperative MI (e-CEA (3.2%), c-CEA (3.2%), P = 1), hematoma (e-CEA [3.2%], c-CEA n = 0, P = 0.3), and re-exploration (e-CEA [3.2%], c-CEA n = 0, P = 0.3). The incidence of cranial nerve (CN) dysfunction was significantly higher in eversion group as compared to c-CEA (e-CEA n = 6 [19.4%], c-CEA n = 1, [3.2%] P = 0.045). Conclusion: Our study showed that the early outcomes of both c-CEA and e-CEA techniques are comparable. The routine insertion of carotid shunt even though decreases the cerebral ischemic time, it does not offer any additional advantage of decreasing perioperative stroke. The choice of the CEA technique depends on the experience and familiarity of the individual surgeon as both the techniques have their own advantages and disadvantages.
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Analysis of giant intraventricular and extraventricular epidermoids, defining risk factors for recurrence, an institutional experience p. 326
Vikas Chandra Jha, Adesh Shrivastava, Neeraj Jha, Sudhanshu Rewatkar, Saraj Kumar Singh
DOI:10.4103/ajns.AJNS_488_20  
Background: Multicompartmental intraventricular epidermoids behave differently from multicompartmental extraventricular lesions and localized lesions during its management. Few studies are available which have analyzed risk factors separately in these groups of cases for recurrence of these lesions and time to recur. Materials and Methods: In this retrospective observational study, 72 cases of intracranial epidermoid were treated over a span of 7 years. Cases were categorized into three groups. Group 1 comprised 15% (11/72) of cases with intraventricular multicompartmental, Group 2 with 22% (16/72) extraventricular giant tumors with multicompartmental involvement and size >4.5 cm, and Group 3 comprised 63% (45/72) of patients with lesions <4.5 cm and localized. Data pertaining to demography, clinical and radiological features, surgery performed, postoperative complication, histology, and follow-up were obtained from medical records available in the institute. Results: The average duration to treat was 1.86 ± 0.52 (standard deviation [SD]) years, with headache as a major complaint in all the groups. Combined endoscope-assisted microsurgery was performed in 38.8% (28/72), microsurgery in 54.1% (39/72), and endoscopic excision in 6.9% (5/72) of cases. Tumor calcification was found in 23.6% (17/72) and preoperative capsular enhancement was seen in 19.4% (14/72) which persisted in 79% (11/14) of cases postoperatively on subsequent follow-up suggesting recurrence. On stepwise logistic regression analysis, preoperative capsular enhancement was a strong predictor of recurrence of tumor (P = 0.001). The average follow-up was 46 ± 14.92 (SD) months in Group 1, 52.34 ± 11.45 (SD) months in Group 2, and 63.36 ± 18.42 (SD) months in Group 3. Conclusion: Although the intracranial epidermoid is known to recur after long interval, tumor with specific characteristics can recur in short span of 5–6 years. Tumor characteristics such as preoperative capsular enhancement, multicompartmental distribution in vertebrobasilar territory, large size, and presence of calcification are strong predictors for recurrence. Performing endoscope-assisted microsurgery can decrease the postoperative morbidities but does not reduce the recurrence risk.
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Clinical and morphological characteristics of ruptured small (<5 mm) posterior communicating artery aneurysms p. 335
Aoto Shibata, Tomoya Kamide, Shunsuke Ikeda, Shinichiro Yoshikawa, Eisuke Tsukagoshi, Azusa Yonezawa, Ririko Takeda, Yuichiro Kikkawa, Shinya Kohyama, Hiroki Kurita
DOI:10.4103/ajns.AJNS_495_20  
Context: Small intracranial aneurysms (IAs) are considered to have a low risk of rupture; however, in clinical practice, we often encounter patients with subarachnoid hemorrhage (SAH) due to rupture of small IAs. Aims: This study aims to clarify the clinical and morphological characteristics of ruptured small IA, focusing on posterior communicating artery (PCoA) aneurysms as a prone site. Settings and Design: We retrospectively reviewed 102 consecutive patients with SAH due to ruptured PCoA aneurysm who underwent microsurgical or endovascular aneurysm repair between April 2013 and March 2018. Subjects and Methods: All PCoA aneurysms were diagnosed using three-dimensional rotation angiography or three-dimensional computed tomography angiography. Information regarding the following clinical characteristics was collected: age, sex, past medical history, current smoking, antithrombotic therapy, multiplicity, hydrocephalus, intracerebral hemorrhage, intraventricular hemorrhage, and World Federation of Neurosurgical Societies (WFNS) Grade on admission. Statistical Analysis Used: We analyzed factors of ruptured small IA, focusing on PCoA aneurysms using univariate and multivariate regression analyses. Results: Univariate and multivariate analyses revealed that low aspect ratio (AR) (odds ratio [OR] = 0.33, P = 0.01) and nonfetal type of PCoA (OR = 0.31, P = 0.02) might be independent characteristics of ruptured small PCoA aneurysms. However, age, sex, past medical history, WFNS grade, and treatment outcome were not different between the small and nonsmall PCoA aneurysms. The aneurysm size was not associated to the selection of treatment, proportion of complications, and treatment outcome. Conclusions: In cases of ruptured PCoA aneurysms, low AR and nonfetal type of PCoA might be associated with rupture of small aneurysms.
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Getting Neurosurgery Services Back on Its Feet: “Learning to Live” with COVID-19 p. 340
Nishant Goyal, Kanav Gupta, Jitender Chaturvedi, Srikant Kumar Swain, Akhil Tomy
DOI:10.4103/ajns.AJNS_497_20  
Background: Cancellation/postponement of ”non-emergent” surgeries during coronavirus disease of 2019 (COVID-19) pandemic has created a huge backlog of patients waiting for surgery and has put them at risk of disease progression. We share our institute's policy and our department's attempt to resume ”non-emergent” surgeries. Materials and Methods: We collected details of all patients operated under department of neurosurgery since the onset of COVID-19 pandemic in India and categorized them into ”lockdown” and ”unlock” groups for comparison. COVID-19 tests done in these patients were also analyzed. We also compared our surgical volume with the number of COVID-19 cases in the state. Results: One hundred and forty-eight patients (97 males, 51 females) with mean age of 37.8 years (range-2 months-82 years) underwent surgery in our department during the study period. The operative volume per week increased by 37% during the ”unlock” period as compared to ”lockdown” period. The proportion of elective/”non-emergent” surgeries increased from 11.3% during ”lockdown” to 34.7% during the ”unlock” period (P = 0.0037). During ”lockdown” period, number of surgeries declined steadily as the number of COVID-19 cases rose in the state (rs(8) = −0.914, P = 0.000). Whereas there was a trend toward increased number of cases done per week despite increase in the number of cases in the state during the “unlock” period. During the ”unlocking” process, in-patient department admissions and surgeries performed per month increased (P = 0.0000) and this increase was uniform across all specialties. COVID-19 test was done (preoperatively or postoperatively) for all surgeries during ”unlock” period compared to 12 (22.6%) surgeries during ”lockdown” period. Three neurosurgery patients who underwent surgery during the ”unlock” period tested positive for COVID-19. Conclusions: Our experience shows that proper evidence-based protocols, setting up of adequate COVID-19 testing facilities and provision of ample personal protective equipments are instrumental in re-starting “nonemergent” surgeries.
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Morphology and morphometry of human paracentral lobule: An anatomical study with its application in neurosurgery p. 349
Apurba Patra, Harsimarjit Kaur, Priti Chaudhary, Adil Asghar, Anjali Singal
DOI:10.4103/ajns.AJNS_505_20  
Background: The human paracentral lobule (PCL) is the medial continuation of the precentral and postcentral gyri. It has important functional area related to the lower limb and perineum. Its visible surface that corresponds to magnetic resonance imaging scout images varies in morphology, so it requires exact data. Studies related to such data are rare. With such a facile, we studied the morphology and morphometry of PCL. Materials and Methods: Fifty formalin-fixed adult human brains dissected in the midsagittal plane were used in this study. First, the morphological types of PCL and its boundary were determined, followed by morphometry of its extrasulcal surface using digital vernier calipers. Measurements were done along the anteroposterior axis (length) and vertical axis (height). In addition to that, the extent of motor and sensory area into PCL was also measured. Results: Three distinct morphological types of PCL were found: continuous (2%), partially segmented (91%), and completely segmented type (7%). In completely segmented type, a short transitional lobulolimbic gyrus was also found in three cases. The mean extrasulcal surface of the left PCL was significantly larger, both in males (left 10.67 cm2 vs. right 8.80 cm2) and in females (left 8.80 cm2 vs. right 6.99 cm2). Irrespective of gender and sidedness, motor area was significantly larger than the sensory area. Conclusion: Reported data will be useful in diagnosis and treatment of diseases affecting the human PCL. Variations in the distribution of sensorimotor cortex over PCL may help further assessment of hemispheric lateralization and the location of central sulcus as a reliable indicator of cytoarchitectonic borders.
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Retrospective study and outcome predictor after microsurgical resection of cerebral arteriovenous malformations in Nepal p. 355
Prasanna Karki, Gopal Raman Sharma, Sumit Joshi, Prakash Paudel, Damber Bikram Shah
DOI:10.4103/ajns.AJNS_509_20  
Objective: The purpose of this study is to assess demographic, clinical, and morphological characteristics of patients with brain arteriovenous malformations (bAVMs). The relation of outcome using modified Ranklin Scale (mRS) at time of discharge, early and last follow ups with respect to various factors. Materials and Methods: Demographic data, arteriovenous malformation characteristics, and treatment outcomes were evaluated in 43 bAVMs treated with microsurgery between 2009 and 2019. For this series, 43 patients were retrospectively reviewed. A subgroup analysis for Spetzler-Martin grades (SMG) I/II, III, IV/V and III–V were performed. The mRS was used to assess functional outcomes. Results: Overall, mean age at diagnosis was 33 years (standard deviation = 19). Transient deficit, mRS deterioration and impaired functional outcome occurred less frequently in SMG I–II patients compared with Grade III–V patients combined (29% vs. 32% respectively, P = 0.00). All patients with SMG Grade I, Supplemented SMG Grade 2, 3, 4 and 6 had a mRS score of 2 or less at the last follow-up. Age was the only significant predictor of overall outcome after bAVM surgery on Chi-square test (P = 0.046), i.e: all patients <20 years had mRS score of 2 or less on last follow-up. Unfavorable outcome (mRS score of 3 or more than 3) level increased with higher grades in SMG on long term follow-up. Conclusion: The results of our case series of bAVM with SMG Grade I and Suplemented Grade 2, 3, 4 and even higher grade i.e., 6 can have excellent overall outcome after microsurgical resection. Association of factors which increases the grading system of bAVM like eloquence, deep venous drainage and increasing sizes did not correlate with the predicted unfavorable outcomes, whereas age of patients was a predictor of overall outcome. Although the small sample size of this study is a limitation, age of patient plays important role on the overall outcome.
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Remote surgery using a neuroendovascular intervention support robot equipped with a sensing function: Experimental verification p. 363
Shigeru Miyachi, Yoshitaka Nagano, Reo Kawaguchi, Tomotaka Ohshima, Hiroki Tadauchi
DOI:10.4103/ajns.AJNS_77_21  
Purpose: Expectations for remote surgery in endovascular treatments are increasing. We conducted the world's first remote catheter surgery experiment using an endovascular treatment-supported robot. We considered the results, examined the issues, and suggested countermeasures for practical use. Methods: The slave robot in the angiography room is an original machine that enables sensing feedback by using an originally developed insertion force-measuring device, which detects the pressure stress on the vessel wall and alerts the operator using an audible scale. The master side was set in a separate room. They were connected via HTTP communication using local area network system. The surgeon operated by looking at a personal computer monitor that shared an angiography monitor. The slave robot catheterized and inserted a coil for an aneurysm in the silicon blood vessel model in the angiography room. Results: Our robot responded to the surgeon's operations promptly and to the joystick's swift movements quite accurately. The surgeon could control the stress to the model vessels using various actions, because the operator could hear the sound from the insertion force. However, the robot required a time gradient to reach a stable advanced speed at the time of the initial movement, and experienced a slight time lag. Conclusion: Our remote operation appeared to be sufficiently feasible to perform the surgery safely. This system seems extremely promising for preventing viral infection and radiation exposure to medical staff. It will also enable medical professionals to operate in remote areas and create a ubiquitous medical environment.
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CASE REPORTS Top

Surgical management of multi-level cervical spine synovial chondromatosis p. 367
Farhan Arshad Mirza, Raul Alberto Vasquez
DOI:10.4103/ajns.AJNS_157_20  
Cervical synovial chondromatosis is a benign condition which most commonly affects the knee joint. The involvement of the spinal column is rare, with only a few reports in the literature describing surgical treatment for compressive spinal lesions. Given the rarity of this condition, the best treatment methodology is yet to be established. We describe the case of a 38-year-old female who presented with progressively worsening myeloradicular symptoms localizing to the cervical spinal cord. Imaging revealed a multilevel osseous and epidural lesion involving the subaxial cervical spine. A computed tomography-guided biopsy was performed to obtain a diagnosis to aid further treatment planning. Subsequently, surgical decompression and stabilization were performed after which the patient made an excellent recovery. She continues to do well at 2 years follow-up. Cervical synovial chondromatosis is a rare condition which can present with pain, radiculopathy, and/or myelopathy. Surgical treatment should focus on complete resection, decompression, and stabilization with arthrodesis and fusion to prevent recurrence. We propose that the lack of motion provided by stabilization and fusion after gross total resection prevents disease recurrence.
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Spontaneous resolution of postoperative giant frontal pseudomeningocele Highly accessed article p. 372
Duc Duy Tri Tran, Thi Phuong Hoai Dinh, Quoc Bao Nguyen, Dang Thi Mai, Van Tri Truong
DOI:10.4103/ajns.AJNS_18_21  
Cranial pseudomeningoceles are abnormal extradural collections of cerebrospinal fluid. Postoperative giant cranial pseudomeningoceles have been rarely reported in the literature and have no specific treatment guidelines. The optimal management strategy for this condition differs among authors, varying from conservative approach to surgical intervention. A spontaneous resolution of postoperative giant frontal pseudomeningocele is reported. A 41-year-old female presented a pseudomeningocele 3 weeks after a right frontal meningioma surgical resection. The pseudomeningocele progressed during the first 1.5-month postoperatively despite percutaneous aspiration and compressive bandage, it then shrank spontaneously and was completely resolved at the 15th month since the surgery. Nonoperative treatment with a close follow-up could be a good option for asymptomatic giant pseudomeningoceles, resulting in a spontaneous resolution.
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Clinical improvement of patients with endovascular treatment in the traumatic carotid-cavernous fistula p. 376
Galih Indra Permana, Nur Setiawan Suroto, Asra Al Fauzi
DOI:10.4103/ajns.AJNS_246_20  
A carotid-cavernous sinus fistula (CCF) is a clinical condition when there is an abnormal communication between the internal carotid artery, external carotid artery (ECA), or any of their branches to the cavernous sinus. Traumatic CCF (TCCF) is the most common type of all CCFs. This study aims to find clinical improvement of traumatic carotid-cavernous fistulas (TCCF) after endovascular treatment. We predict the degree of clinical recovery in an attempt to make the treatment of TCCF safe and effective. This study reported a series of 28 patients with TCCFs undergoing coiling and ballooning in a period of 3 years, i.e., from December 2014 to December 2017. This is a novel case report about CCF in our country, Indonesia, especially in Surabaya. We performed clinical, angiographical, and radiological assessments before and at regular time periods after the procedure until 6 months. All patients had a partial and complete occlusion of the fistula. Angiographic occlusion of fistula, visualization of the ophthalmic artery, and disappearance of bruit predicted a good clinical outcome. All patients made a recovery at different times, depending on the degree of fistulas and treatment. Improvement in clinical symptoms had a direct correlation with the degree of occlusion. Treatment was divided into coiling and ballooning depending on patient's condition and angiographic examination. Trans femoral cerebral angiography is still very important diagnostic tool in the diagnosis and treatment of TCCFs.
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Endotracheal tube obstruction experienced during an anterior cervical discectomy and fusion p. 381
Masahiro Aoyama, Masahito Hara, Ryuya Maejima, Tomoko Kinoshita, Hiroko Aoyama, Shuji Kurokawa, Atsushi Hashimoto, Hiroshi Ito, Yuko Sato, Yoshihiro Fujiwara, Shigeru Miyachi
DOI:10.4103/ajns.AJNS_258_20  
During anterior cervical discectomy and fusion (ACDF), endotracheal tube difficulties are anticipated at the operative level but are unexpected elsewhere in the airway. We report the case of a 66-year-old woman who underwent C4/C5 ACDF to treat adjacent segment disease following a previous anterior cervical fixation surgery. Shortly after her lower jaw was elevated and the fusion cage was inserted, a rise in airway pressure was observed, indicating impaired breathing. Subsequent examination revealed a bent endotracheal tube in the oral cavity as the cause of the respiratory impairment. During anterior cervical surgery, elevating the lower jaw can cause the tongue root to press against the endotracheal tube. Reinforced endotracheal tubes, with a spiral-wound wire in the inner wall, would effectively prevent this issue. In the unlikely event of impaired breathing during such an operation, the oral cavity should be inspected for confirmation of an open airway.
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Local balloon-assisted navigation of a microcatheter into an aneurysm during intracranial aneurysmal coiling: A dunk shot technique p. 384
Tomotaka Ohshima, Reo Kawaguchi, Naoki Matsuo, Shigeru Miyachi
DOI:10.4103/ajns.AJNS_26_21  
Objectives: Various endovascular approaches have been reported for patients with intracranial aneurysms. However, the safety of navigating a microcatheter into the aneurysm remains debatable. In this study, we evaluated a novel method “dunk shot technique,” in which a proximal balloon and a local balloon are used for navigation of a microcatheter into an aneurysm under challenging situations. Materials and Methods: We have reported two cases of unruptured internal carotid artery–superior hypothalamic artery aneurysm. An 8-F balloon-attached catheter was used as the guiding catheter. A local balloon catheter for neck remodeling and a microcatheter for coil insertion were navigated around the aneurysmal neck region. When it seemed difficult to navigate a microcatheter into an aneurysm, both the guiding balloon and a local balloon catheter were used for assistance. After inflation of the guiding balloon, the local balloon was inflated partially to negotiate the tip of the microcatheter. Results: The uncontrollable tip of the microcatheter could be intentionally moved by the local balloon. Conclusions: We evaluated the effectiveness of the balloon-assisted technique for the navigation of a microcatheter in cases with challenging anatomy. A little bit of direct effect to the tip of the microcatheter by a local balloon could produce effective outcomes under the proximal flow arrest.
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A rare variant of meningioma: Case report and review of literature p. 387
Elizabeth Joseph, Rojin Abraham, Sujin Koshy, John K John
DOI:10.4103/ajns.AJNS_381_20  
Meningioma is a morphologically heterogeneous tumour arising from meningothelial cells that has been classified by the World Health Organization into 15 different histological types and graded into three types groups (Grade I, II, and III) based on the biological behavior. Metaplastic meningioma is a rare subtype of meningioma characterized by focal or widespread mesenchymal differentiation in the form of bone, cartilage, fat, or xanthomatous tissue elements. Xanthomatous meningioma is a subclass of metaplastic meningioma which is exceedingly rare. Only a few cases have been reported in the literature. Here, we report the case of a 44-year-old man, who presented with left sided weakness and was diagnosed as a case of xanthomatous meningioma.
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A case of nonapoplectic pituitary adenoma presenting with isolated oculomotor nerve palsy p. 391
Kunio Yokoyama, Naokado Ikeda, Akira Sugie, Makoto Yamada, Hidekazu Tanaka, Yutaka Ito, Masahiro Kawanishi
DOI:10.4103/ajns.AJNS_397_20  
We report a rare case of nonapoplectic pituitary adenoma that did not invade the cavernous sinus and was associated with isolated oculomotor nerve palsy. A 61-year-old male was admitted to our hospital due to diplopia that had gradually worsened from 6 months to presentation. He was diagnosed with right oculomotor nerve palsy, and brain magnetic resonance imaging (MRI) showed a mass lesion within the sella. The tumor was homogeneously enhanced on contrast-enhanced MRI. However, no findings suggestive of pituitary apoplexy were found. Brain computed tomography revealed the tumor to have eroded the right side of the posterior clinoid process by gradual expansion. Endoscopic transsphenoidal surgery was used for complete resection of the tumor. Intraoperative findings showed that the tumor did not invade the cavernous sinus. The histological diagnosis was pituitary adenoma, and symptom improvement was observed from the early postoperative stage onward. Surgical treatment is essential because oculomotor nerve palsy caused by the enlargement of pituitary adenoma is not expected to resolve if treated conservatively, unlike that caused by pituitary apoplexy.
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Spinal nerve root extradural melanocytoma progressing to malignant melanoma: A case report with review of literature p. 394
Salman T Shaikh, Gaurav S Gupta, Chandan B Mohanty, Chadrashekhar E Deopujari
DOI:10.4103/ajns.AJNS_416_20  
Melanocytomas are rare benign pigmented tumors arising from the leptomeninges with a very remote chance of progressing to malignant melanoma. They have a predilection for occurring in the posterior fossa or in the intradural extramedullary region of the cervical spine. We report the first case of malignant transformation of a nerve root (extradural) melanocytoma wherein immunotherapy has been added for its treatment. Only four such cases of malignant transformation of central nervous system melanocytoma have been reported in the literature. Definite diagnosis in such cases is based on immunohistochemistry evaluation. Surgical resection with adjuvant radiotherapy and immunotherapy is the recommended treatment.
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Recurrent papillary tumor of pineal region misdiagnosed as pineocytoma 9-years ago p. 398
Nirav Mehta, Gaurav Gupta, Salman Shaikh
DOI:10.4103/ajns.AJNS_439_20  
Primary tumors of the pineal gland occur infrequently with a preponderance of either parenchymal tumors or germ cells tumors. Papillary tumor of the pineal region is a rare neuroepithelial lesion that arises exclusively in the pineal region. They have been designated as either Grade II or Grade III lesions as per the 2016 WHO classification of central nervous system tumors. Clinically, they usually present with obstructive hydrocephalus and visual disturbance. On imaging, these tumors are solid-cystic, heterogeneously enhancing, and show T2 hyperintensity. Pathologically, they can closely resemble a Grade I pineocytoma and immunohistochemistry is essential to differentiate the two. No definite guidelines exist to confirm the ideal protocol of treatment. Evidence regarding the role of radiation after surgery is limited to case reports and series. Adjuvant therapy is usually recommended for tumors with subtotal excision, high proliferative/mitotic index, or proven metastasis. We describe a case of a 29-year-old male with a recurrent papillary tumor of the pineal region, 9 years after primary surgery where it was misdiagnosed as a pineocytoma. The tumor was effectively controlled with surgical excision, cerebrospinal fluid diversion, and adjuvant radiation for 8 years before showing two recurrences within a span of 6 months with a rising proliferation index.
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Pathological diversity in schwannomas of the orofacial region p. 402
Aadithya Basavaraj Urs, Priya Kumar, Jeyaseelan Augustine, Rewa Malhotra, Kiran Jot
DOI:10.4103/ajns.AJNS_470_20  
Schwannoma is a slow-growing, encapsulated benign tumor of the neuroectodermal origin arising from the perineural Schwann cells. This study aims to elucidate the clinicoradiographical and histopathological features of orofacial schwannomas through a case series of seven cases. The patients' aged ranged from 13 to 45 years, with a male predilection in the ratio of 5:2. One intraosseous case presented as a radiolucent lesion. All the cases exhibited Antoni A and Antoni B type of microscopic patterns in varying amounts. One case of ancient schwannoma showed degenerative features. The tumor cells showed diffuse positive immunohistochemical reaction for S-100 protein. Our study suggests that intraosseous schwannoma should be considered in the differential diagnosis of the intraosseous jaw lesions. Histopathologically, it is important to recognize the findings of ancient schwannoma and to avoid misdiagnosing it as a malignant lesion.
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Cortical blindness after cervical spine surgery in supine position – A rare case report and review of the literature p. 406
Raghav Dutt Mulukutla, Phani Krishna Karthik Yelamarthy, RamMohan Vadapalli
DOI:10.4103/ajns.AJNS_473_20  
We report the first case of perioperative visual loss due to cortical blindness after supine cervical spine surgery. A 46-year-old female presented with severe right-sided brachialgia of 1½ years' duration. Her magnetic resonance imaging (MRI) (cervical spine) showed severe right foraminal stenosis at C5–6. She underwent C5–6 anterior cervical discectomy and fusion. Nine hours after surgery, during a routine postoperative round, the patient complained of complete bilateral visual loss. The fundus examination and pupillary light reflex were normal. MRI of the brain showed the posterior cerebral artery infarct with hypoplasia of the left vertebral artery. She was transferred to the neurointensive care unit where antiplatelet treatment was started along with heparin. Her vision slowly began to improve, and at the end of 1 year, she had a reasonable visual acuity in both eyes. It is now standard practice in our institution to check patients' vision immediately after surgery.
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Filum terminale arteriovenous fistula coexisting with a large L2–L3 disc sequestration and associated diffuse lumbar arachnoiditis p. 412
Prasert Iampreechakul, Ekkapot Jitpun, Korrapakc Wangtanaphat, Punjama Lertbutsayanukul, Sirirat Khunvutthidee, Somkiet Siriwimonmas
DOI:10.4103/ajns.AJNS_489_20  
The authors describe a case of filum terminale arteriovenous fistula (FTAVF) in association with a large L2–L3 disc sequestration and diffuse lumbar arachnoiditis. A 64-year-old male manifested with chronic back pain and gait difficulty. Magnetic resonance imaging (MRI) of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T9. There was a large disc sequestration came from L2–L3 disc herniation. In addition, thickening, clumping, and enhancement of the entire cauda equina were noted, probably representing arachnoiditis. MR angiography (MRA) and spinal angiography confirmed FTAVF at the level of L5. The patient underwent laminectomy with lysis adhesions and obliteration of the fistula. His postoperative course was uneventful. MRI and MRA of the thoracolumbar spine obtained 4 months after surgery revealed complete obliteration of the fistula and significant resolution of spinal cord congestion. Enhancement of the cauda equina roots was no longer visible. Interestingly, the significant resorption of the sequestrated disc was documented on MRI. The formation of the FTAVF in the present study may result from severe spinal canal stenosis caused by a large disc sequestration blocking the rostral venous drainage of the fistula, or chronic inflammation, and adhesions of the caudal nerve roots from lumbar arachnoiditis. It seems that FTAVF may be of acquired origin by this evidence.
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Mixed pial-dural arteriovenous malformation in the anterior cranial fossa mimicking dural arteriovenous fistula p. 418
Yoshinori Maki, Taro Komuro, Takeshi Satow, Ryota Ishibashi, Susumu Miyamoto
DOI:10.4103/ajns.AJNS_494_20  
Mixed pial-dural arteriovenous malformation (MpdAVM) and dural arteriovenous fistula (dAVF) are rare entities in the anterior cranial fossa (ACF). As dural-pial vascular anastomosis can exist near the cribriform plate, MpdAVM with a small nidus, which cannot be apparently identified, can be logically indistinguishable from dAVF in ACF. A 71-year-old man was referred for evaluation of possible intracranial vascular malformation. Cerebral angiography revealed an arteriovenous shunt in the ACF. The lesion was fed by the bilateral ethmoidal arteries and right orbitofrontal artery, draining through the bilateral cortical veins to the superior sagittal sinus. As a nidus was not detected, dAVF was suspected. Venous interruption was planned with direct surgery. Intraoperatively, an arterial aggregation was observed in the right frontal lobe. The arterial aggregation seemed to be connected to the interrupted drainer in the right ACF. The arterial aggregation was removed and pathologically diagnosed as arteriovenous malformation. Postoperatively, intracerebral hemorrhage was confirmed, and postoperative cerebral angiography confirmed the resolved arteriovenous shunt. The intracranial hemorrhage was possibly due to the timing gap between drainer interruption and removal of the nidus. MpdAVM with a small nidus in the ACF can mimic dAVF. Clinicians must be aware that an unremoved nidus of MpdAVM may postoperatively result in fatal intracranial hemorrhage.
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Filum terminale arteriovenous fistula with additional arterial supply by the posterior spinal artery: A report of two cases p. 423
Prasert Iampreechakul, Naruedol Yaisarn, Korrapakc Wangtanaphat, Punjama Lertbutsayanukul, Somkiet Siriwimonmas, Nawaporn Techataweewan
DOI:10.4103/ajns.AJNS_528_20  
Filum terminale arteriovenous fistulas (FTAVFs) are rare and usually supplied by the artery of the filum terminale, distal termination of the anterior spinal artery (ASA). These fistulas may also supply from the lateral sacral artery (LSA) arising from the internal iliac artery and/or middle sacral artery. Additional supply by the posterior spinal artery (PSA) has never been mentioned before. The authors describe two middle-aged men harboring FTAVFs manifested with progressive myelopathy and bowel/bladder dysfunction. The first fistula was supplied by the ASA with additional supply by the dilated PSA connecting with the ASA. Another fistula was supplied by the LSA and the PSA communicating with the ASA. The first case was successfully treated by endovascular treatment with N-butyl cyanoacrylate through the enlarged PSA, whereas the second case was surgically treated by direct obliteration of the fistula. Both patients had good neurological outcome.
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Temporalis muscle cysticercosis: Common parasite at uncommon location p. 431
Lomesh Wankhede, Sushanta Kumar Sahoo, Bharat Hosur
DOI:10.4103/ajns.AJNS_55_19  
Isolated involvement of the temporalis muscle by cysticercosis is uncommon. The clinical features may mimic other inflammatory conditions of maxilofacial region or that of temporal headache. We describe here a case of right temporalis muscle cysticercosis that was initially misdiagnosed as dental caries. She clinically improved with albendazole and steroid. The radiology done after 6 months of therapy showed a complete resolution of the intramuscular lesion. Although rare, cysticercosis should be kept as one differential in patients present with unilateral temporal headache in endemic areas. Intramuscular cysticercosis can be diagnosed on the basis of radiological findings and respond well to pharmacological therapy.
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Glioblastoma shortly after a normal conventional brain magnetic resonance imaging: A report of two cases and review of the literature p. 433
Tayfun Hakan, Erhan Çelikoglu
DOI:10.4103/ajns.AJNS_553_20  
Glioblastoma (GB) is the most common malignant tumor of the brain. Most of these tumors are primary or de novo GBs that manifest rapidly with initial presentations such as headache, new-onset epileptic seizure, focal neurological deficits, and altered mental status. The typical radiological features of GB include strong contrast enhancement, central necrosis, and edema with mass effect. Herein, we describe two cases of primary GB – two women aged 60 and 51 years who were diagnosed with GB 3.5 and 4 months, respectively, after their initial admission. These patients presented with right-sided headaches, and their neurological examination was within the normal limits. Their initial radiological investigations revealed no suspicious lesions, either on T1-weighted or T2-weighted magnetic resonance (MR) images. The 60-year-old patient was readmitted with persistent headache, and her T1-weighted MR images revealed a well-demarcated mass lesion in the right temporal lobe with strong contrast enhancement. Moreover, the T2-weighted MR images revealed closed sulci and swollen midline structures because of edema. The 51-year-old patient was readmitted with persistent headache, and her MR image revealed a mass lesion with heterogeneous contrast enhancement and necrosis on T1-weighted images and hyperintense areas with severe edema on T2-weighted images. The patients underwent craniotomy and gross total tumor resection. Notably, in both cases, the lesions were pathologically diagnosed as GB. Therefore, it should be borne in mind that only persistent headache could be a sentinel sign of GB before it becomes radiologically visible, thereby emphasizing the need for follow-up imaging studies at short intervals.
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COMMENTARY Top

Alexander Alexandrovich Potapov, MD, PhD, 1948–2021 p. 437
Yoko Kato
DOI:10.4103/1793-5482.317007  
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LETTER TO EDITOR Top

John Ching-Kwong Kwok (1951–2020): The renaissance man of Hong Kong neurosurgery p. 443
Peter Yat-Ming Woo, Safi Ur Rehman, Yung Chan, Alberto Chi-Ho Chu, Marco Cheuk -Lun Kwan, Alain Kai-Sing Wong, Hoi-Tung Wong, Kwong-Yau Chan
DOI:10.4103/ajns.AJNS_23_21  
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