Background: The aim of the study was to retrospectively evaluate the outcome of medical management of postoperative discitis (POD). Materials and Methods: A total of 31 patients treated for POD were included in the study. Clinical, radiological, and laboratory data of all patients were collected and evaluated. All patients were treated initially with bed rest and antibiotic therapy after radiological diagnosis. Surgical management was undertaken after failure of 4 weeks of conservative management. All cases were followed clinically with laboratory and radiological investigations. Results: Five cases failed to respond to medical management and were treated surgically with debridement and transpedicular fixation. All patients showed clinical recovery till the last follow-up. Conclusion: Early diagnosis and proper management are the keys to successful outcome of postoperative spndylodiscitis. Surgical debridement and fusion are required when conservative treatment fails.

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Since it was first introduced, a variety of modification techniques to block the impar ganglion appear such as transsacrococcygeal ligament technique, sacrococcygeal transdiscal approach, paramedian approach, and a two-needle technique using fluoroscopy or computed tomography scan. For therapeutic purposes, a combination of steroid and local anesthetic, neurolysis agents such as alcohol, phenol, cryolesioning, and heat lesioning using radiofrequency thermocoagulation could be used. Here, we reported a successful outcome in treating chronic perineal pain in a 65-year-old patient using combination of neurolysis agent which was alcohol 96% and radiofrequency thermocoagulation.

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Background and Objectives: Stabbing the head is a rare event. It may occur following an assault or self-inflicted injury. We intend to report our experience with four such cases and review narratively the relevant literature. A treatment algorithm will be delivered. Materials and Methods: We have reviewed four of our cases; three were stabbed to the orbit and one to the head. Results: Enucleation was performed in one case. Vision could be preserved in the other two and brain abscess developed in the other cases due to a retained piece of knife. We made a comparison between our cases and those limited reports in the literature to reach an algorithm. Conclusion: The temporal region and the orbit are the targets mostly attacked in the craniofacial stabs. Since knives have a sharp and thin edge, they may break when penetrating the skull. The damage to the brain tissue and the retained piece of knife may be missed easily by overlooking the small injury to the scalp. The suggested algorithm would be a contrast-enhanced computed tomography scan of the skull and brain and a kind of brain vascular study are necessary, considering the location of the knife in the skull and brain passing the area with crowded vasculature. The best treatment protocol is surgery accompanied by antibiotic therapy.

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Complex intracranial aneurysms (CIAs) rank high among the most technically demanding neurosurgical pathologies. Microsurgery and clip ligation can be challenging in CIAs as circumferential visualization of the aneurysm, parent vessels, branches, perforators, and other neurovascular structures is important to prevent residual aneurysms or strokes from vessel or perforator occlusion. Decompression of the aneurysm sac is often required for CIAs. We reviewed the literature and PubMed advanced search showed 13 results of adenosine-induced flow arrest to facilitate intracranial complex aneurysm clip ligation which included three independent case reports and ten cases in a case series from 1999 to May 2016. Few case series have described the use of adenosine in intracranial aneurysm surgery. Satisfactory aneurysm decompression was achieved in all cases, and all aneurysms were clipped successfully. We recommend that adenosine cardiac arrest is a relatively novel method for decompression of intracranial aneurysms to facilitate clip application. With appropriate safety precautions, it is a reasonable alternative method when temporary clipping of proximal vessels is not desirable or not possible.

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Hypomagnesemia is postulated as one of the important determinants of outcome following traumatic brain injury (TBI) through its effect on secondary injuries to neurons. Aims and Objective: The aim of this study was to determine the relationship between serum magnesium level and neurological outcome in patients admitted with severe head injury. Materials and Methods: In this prospective study, patients admitted with severe TBI were recruited and dichotomized into low serum magnesium group and normal serum magnesium group based on the initial serum magnesium level. Data were collected regarding age, sex, and Glasgow Coma Scale at admission. Neurological outcome of the patients in these groups was assessed using Glasgow Outcome Scale at 6 months. Results: Seventy-two patients (male = 50, female = 22) with a mean (±standard deviation) age of 42.5 (±12.7) years were studied. Forty-two (58%) patients had low serum magnesium level (<1.3 mEq/L) at admissions. At 6-month follow-up, 81% of patients with poor neurological outcome had low serum magnesium as compared to 19% of patients with good outcome (P = 0.01). Hypomagnesemia was associated with poor neurological outcome (odds ratio = 2.1, P = 0.04, 95% confidence interval = 1.0–8.8) on regression analysis. Conclusion: Hypomagnesemia appears to be an independent prognostic marker in patients with severe TBI.

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The meningo-orbital band (MOB) is a dural fold which runs along the lateral border of the superior orbital fissure and contains few small dural veins and the orbitomeningeal artery. MOB detachment is relatively easy to understand step-wise procedure, provides a wider exposure, and better orientation thus facilitating relatively easy approach to paraclinoid and cavernous sinus region. The present microsurgical technique helps to preserve the true cavernous membrane and thereby providing almost bloodless dissection of the cavernous sinus. The same technique can be used to uncover the anterior clinoid process laterally, posteriorly, superiorly, and also in the inferolateral region thereby decreasing the risk and time of clinoidectomy.

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Orbital encephalocele is a rare catastrophic complication of orbital roof fractures. Early diagnosis of this posttraumatic orbital encephalocele is very crucial because this condition if untreated leads to rapid loss of vision. Whenever displaced orbital roof fracture is identified in a head injury patient, an orbital encephalocele should be suspected. Although magnetic resonance imaging is the investigation of choice, computed tomography of orbit with thin axial and coronal sequences often gives the diagnosis. Frontobasal approach is the most commonly used surgical approach. Supra-transorbital approach is a minimally invasive alternative. Good results with regard to the orbital symptoms can be expected.

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Intracranial calcifications are not uncommon and are mostly seen with intracerebral hematomas, tuberculomas, and brain tumors. These lesions may be intra- or extra-axial and occasionally pose challenge in the diagnosis. We report a case of multiple intracranial extra-axial calcifications with congenital skull anomaly and multiple meningiomas. Authors could not find similar case reported in the literature and present their findings and discuss relevant literature.

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Background: Acute subdural hematoma (aSDH) is a major cause of admission at Neurosurgical Emergency Department. Nevertheless, concerns regarding surgical indication in patients with multiple comorbidities, poor neurological status, antithrombotic therapy, and older age still persist. Therefore, a correct recognition of predictive outcome factors at hospital discharge is crucial to an appropriate neurosurgical treatment. Methods: Eighty-nine medical records of consecutive patients with age ≥18 years old who were submitted to aSDH evacuation between January 2008 and May 2012 were reviewed. Demographic characteristics, neurological status on admission, anticoagulant or antiplatelet therapy, and outcome on discharge were collected. Patients with insufficient data concerning these variables were excluded from the study. Results: Sixty-nine patients were included; 52% were male; 74% were older than 65 years; 41% were under oral antithrombotic therapy (OAT); at admission, 54% presented with Glasgow coma scale (GCS) ≤8; 23% were submitted to a craniectomy instead of a craniotomy; 26% of the patients died, 32% were dependent, and 42% were independent on discharge. Crude analysis revealed craniectomy, A/A pupils, GCS ≤8 at admission statistically significant related with the worst outcome (P < 0.05). In the adjusted evaluation only A/A pupils (P = 0.04) was associated to poor outcome (spontaneous etiology P = 0.052). Considering daily living independency at hospital discharge, either male gender (P = 0.044) and A/A pupils (P = 0.030) were related to the worst outcome. No effect of age in outcome was observed. Conclusions: Male gender and A/A pupils are associated with lower probability of achieving independency living at hospital discharge. A/A pupils, low GCS at admission, spontaneous etiology, and craniectomy were associated with the worst outcome. Age and OAT were not predictive factors in this series. Caution should be taken when considering these factors in the surgical decision.

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Isolated fourth ventricle syndrome is an uncommon entity due to obstruction of both inlet and outflow foramina. The resulting mass effect from the progressively expanding fourth ventricle may cause symptoms from both cerebellar and brainstem compression. Although a variety of treatment modalities have been advocated for this condition, an in-depth description of placement of a fourth ventriculopleural (VPL) shunt from a single-stage prone approach has not yet been published in the literature. We describe here a case of successful placement of a fourth VPL shunt in a 22-year-old female with a history of a prior posterior fossa pilocytic astrocytoma resection who presented with symptomatic isolated fourth ventricular hydrocephalus

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Background: Factors affecting functional outcome after decompressive craniectomy (DC) performed for traumatic brain injury (TBI) remain poorly understood. Methods: We conducted a retrospective study of all patients who underwent primary DC for TBI at our hospital between 2010 and 2014. Multivariate regression analyses were used to determine the predictors of functional outcome and overall survival. Results: A total of 98 patients with severe (n = 81, 82.6%) or moderate (n = 17, 17.4%) TBI underwent primary DC and were included in this study. The 30-day and overall mortality rates were 15.3% and 25.5%, respectively. At a median follow-up of 90 (interquartile range (IQR): 38–180) days, median Karnofsky Performance Status (KPS) and Glasgow outcome scale-extended (GOSE) scores were 50 (IQR: 20–70) and 5 (IQR: 3–7), respectively. Young age and severe TBI were predictors of mortality. Glasgow coma scale (GCS) score on discharge was a strong predictor of KPS and GOSE scores. Conclusion: Primary DC afforded an acceptable functional outcome (GOSE score ≥5) in 45.9% of patients. Young age and lower GCS at presentation were associated with worse survival. GCS score on discharge was a strong predictor of functional outcome.

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Melanotic schwannomas (MS) are rare variants of schwannomas the occurrence of which is described in case reports only. They usually arise from posterior spinal nerve roots and less commonly from other cells of neural crest origin. Although they are relatively benign tumors in young, aggressive behavior is reported. They occur as isolated tumors or as part of a syndrome named Carney complex. We try to describe the pathology, diagnosis, management, and prognosis of MSs in two different cases: one cervical intramedullary with no recurrence on 5-year follow-up and the other one extramedullary in lumbar region with early recurrence and aggressive course. A brief review of literature is done.

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Background: The role of the electrophysiologic studies in peripheral nerves and muscles of lower limbs (including paraspinal muscles) in prolapsed lumbar intervertebral discs has been studied with equivocal results. Pre- and post-operative electrodiagnostic studies have not been compared much. Aims and Objectives: To study the role of the electrophysiologic studies in prolapsed lumbar/lumbosacral intervertebral discs for finding the association between clinical findings and electrophysiological changes and to compare the electrophysiologic studies pre- and post-operatively. Materials and Methods: The study was conducted from July 2014 to June 2016 on fifty patients who were admitted in the department of neurological surgery with lumbar disc prolapse and all these patients were subjected to surgery. Both pre- and post-operative (from 1 to 6 months after surgery) electrophysiological studies were conducted and compared. Results: As per the electromyographic (EMG) abnormalities, the most common levels of intervertebral disc prolapse were L4–L5 and L5–S1 accounting for 32% of cases each followed by L5–S1 level which was seen in 28% of patients with L2–L3, L3–L4, and L4–L5 prolapsed intervertebral disc (PIVD) and L3–L4 and L4–L5 PIVD were seen in 4% of cases each. Of the 50 patients, EMG findings correlated with operative findings in 37 (74%) patients, however operative findings did not correlate with EMG findings in 13 (26%) patients. Conclusion: In compressive lesions of nerve roots (due to disc prolapsed), the EMG method has a high degree of accuracy in determining not only the presence of such lesions but also their exact location. EMG is accurate when correlated with the operative findings.

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Glioblastoma multiforme (GBM) has the highest rate of vascular proliferation among solid tumors. Angiogenesis is the central feature of rapid tumor growth in GBM and therefore remains an appealing therapeutic target in the treatment of these highly malignant tumors. Antiangiogenic therapy is emerging as an important adjuvant treatment. Multiple antiangiogenic agents targeting various sites in vascular endothelial growth factor (VEGF) and integrin pathways have been tested in clinical trials of newly diagnosed and recurrent GBMs. These include bevacizumab, enzastaurin, aflibercept, cediranib, and cilengitide. In this review, we discuss the current status and challenges facing clinical application of antiangiogenic treatment including anti-VEGF therapy and integrin pathway agents' therapy in glioblastoma. Here, we highlight a strong biologic rationale for this strategy, also focusing on integrin pathways. PubMed-indexed clinical trials published in English on antiangiogenic treatment of glioblastomas in the past 5 years were reviewed. The results of the current clinical trials of these agents are presented.

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Cervical spine chance fracture (flexion-distraction) is a rare type of fracture, and the surgical management remains a dilemma to the neurosurgeons as there is a paucity of evidence accordingly. We herein report a traumatic chance fracture of C7 fractures and its surgical management. A 33-year-old male was transferred to our center after being hit as pedestrian and was diagnosed to have a chance fracture of C7 and bilateral C7 root injury. He underwent open reduction of the deformity by posterior-only fixation of C5 and C6 with a lateral mass screw and T1 and T2 with pedicular screws. The neurological examination improved postoperatively, and the patients were neurologically intact after 6 months of treatment. Traumatic cervical spine chance fracture is extremely rare and can be managed surgically through posterior fixation and open reduction of the deformity. The best choice of treatment is limited by the paucity of the evidence and should be individualized.

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Noncompressive myelopathy of lower dorsal spine secondary to trauma is a rare event. We report a case of delayed paraplegia in a patient with a history of road traffic accident. The X-ray of dorsolumbar spine did not show any abnormality. Magnetic resonance imaging of dorsolumbar spine was performed which showed the presence of central T2-weighted hyperintensities from D10–D11 to D12–L1 level. No associated bony injury was documented, and the integrity of the spinal canal was maintained. The patient was managed conservatively with bed rest, and steroids were given. However, the patient did not show any signs of improvement after 1 month of follow-up.

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Ruptured vertebral artery (VA) dissecting aneurysm carries high risk of rerupture and mortality if not treated immediately. Dissecting aneurysm of the VA involving the posteroinferior cerebellar artery (PICA) origin is difficult to treat by surgical and endovascular route. With the availability of flow diversion device for reconstructive procedure, endovascular treatment has now become easy to treat difficult aneurysm while maintaining the patency of the PICA. However, instead of using flow diverter (FD) in our case, we successfully treated dissecting VA aneurysm involving the PICA origin with retrograde stent placement from distal right VA to the left PICA to maintain the patency of PICA and occlusion of dissecting aneurysm of VA with detachable coils instead of performing surgical bypass and FD placement.

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Introduction: Surgical oculomotor nerve palsy(ONP), defined by ptosis, ophthalmoplegia, diplopia and pupillary dilatation, is associated with intracranial aneurysms, especially posterior communicating artery (PcomA) aneurysms. Treatment of PcomA aneurysms include endovascular coiling and surgical clipping. This study retrospectively compared the recovery of ONP in patients who underwent endovascular coiling or surgical clipping. Methods: A retrospective review of patients with PcomA aneurysms who presented with ONP between 1998 and 2012 in the National Neuroscience Institute, Singapore, was performed. Inclusion criteria included adult patients of age above 21 who have radiologically confirmed PcomA aneurysms with presentation of ipsilateral ONP. The aneurysms may be unruptured or ruptured with WFNS grade 2 subarachnoid hemorrhage (SAH) or better. Only patients with completely surgically or endovascularly obliterated PcomA aneurysms with regular follow-up are included. Results: A total of 22 patients were recruited. They were treated by either endovascular coiling or surgical clipping. The two groups of patients were demographically comparable, with 11 patients in each arm. 13 (59%) patients had unruptured aneurysms and 9 (41%) had WFNS grade 2 or better SAH. 13 (59%) patients presented with complete ONP and 9 (41%) had partial ONP. 64% of patients who underwent surgical clipping had resolution of ONP completely, compared to 18% of endovascularly coiling (P = 0.03) at 1-month follow-up. Conclusion: Compared to endovascular coiling, surgically clipped PcomA aneurysms are associated with a faster rate of full recovery of ONP.

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Aim: The medial temporal lobe (MTL) is a highly complex neuroanatomical structure of tremendous neurosurgical importance. It is a common site for epilepsy, vascular lesions, and tumors. Owing to the critical location behind the sphenoid wing, it is more prone for traumatic contusion often with surgical implications. Hence, its microneurosurgical anatomy needs to be evaluated in detail. Materials and Methods: Twelve formalin-fixed human cadaveric brains from North-west Indian population were dissected under neurosurgical microscope and various dimensions of the MTL and their distance from important neurovascular structures were measured. Results: The MTL consists of important neural structures such as parahippocampal gyrus, uncus, hippocampus, temporal horn, and choroidal fissure. The average distance of tentorium from the uncus was 1.96 mm. The temporal horn and the inferior choroidal point were located from the anterior temporal pole at 22.9 mm and 30.9 mm, respectively. Important vessels that are intimately related to the MTL were anterior choroidal artery (AchA), posterior communicating artery, the P1 segment of posterior cerebral artery, and the M1 segment of middle cerebral artery. Conclusion: Complex anatomic and cytostructural organization makes the MTL unique. In this study, along with the descriptive anatomy, morphometric measurements of various structures were performed. The uncus and its relation to other neurovascular structures is well described in literature, but its exact distance from them as determined in this study is particularly helpful in guiding the surgeons while approaching in this area. Knowledge of the distance of the temporal horn from various surfaces is important while opening the temporal horn to avoid unnecessary damage to nearby structures.

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Carcinosarcomas are tumors comprising part adenocarcinoma and part sarcoma; the presence of carcinosarcoma in the head-and-neck region is very rare. These tumors are typically highly aggressive (G3) and arise most frequently from the salivary gland. Here, we present a case report on a brain metastasis as the primary manifestation of a carcinosarcoma. Magnetic resonance imaging showed a tumor of the pineal region with infiltration of the brainstem and the corpus. The staging following the histopathological diagnosis revealed the origin of the tumor in the left parotid gland. We present an overview of the significance of published treatment strategies in carcinosarcoma.

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Methotrexate (MTX) is a common antimetabolite agent that is widely used today in treating leukemia, lymphoma, and osteosarcoma. Its use has been associated with leukoencephalopathy causing seizures, paralysis, and even coma. To achieve the best possible outcome, it is important to be able to make a prompt diagnosis. Studies reported restricted diffusion on diffusion-weighted imaging (DWI) which is a reliable early sign of acute MTX-induced leukoencephalopathy. However, we report here the first case of MTX-induced leukoencephalopathy without typical restricted diffusion on DWI and the utility magnetic resonance spectroscopy to support this diagnosis in the difficult case such as the one being presented here.

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Introduction: Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped off dural membrane and predominantly consists of venous blood in infants. The study aims to assess the outcome of pediatric EDH using King's Outcome Scale for Childhood Head Injury (KOSCHI). Materials and Methods: A total of 72 patients' files were reviewed retrospectively with a diagnosis of EDH from January 2012 to December 2014. Predesigned proforma was filled using data from patient records. In addition, KOSCHI was calculated using recent telephone interviews. Results: Among 72 patients, 65.3% were male and 34.7% were female. Overall, road traffic accident was the most common cause (52.8%) followed by fall, assault, and sports injury. The most common symptom was more than two episodes of vomiting which was present in 51.4% of patients followed by loss of consciousness in 37.5%, ENT bleed in 33.3%, headache in 16.7%, and fits in 11.1% of patients. The median follow-up of our patients was 19 (6–40) months. Most of our patients made good recovery with 76.4% of our patients scoring 5b on KOSCHI. Conclusion: EDH is not uncommon among children with head injury. It should be suspected in every child with posttraumatic skull fracture or scalp hematoma. Prompt surgical intervention can give good long-term outcome.

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Background: Pituitary apoplexy is a life-threatening event with unspecific clinical background and no standardized treatment. Materials and Methods: The authors retrospectively analyzed seventeen patients affected by pituitary adenoma apoplexy and treated in a 10-year period. Thirteen patients underwent surgery through transsphenoidal route while four patients have been treated conservatively. Results: The endoscopic surgical procedure showed a better result in term of complete removal of the tumor while in the “conservative” group less frequent evidence of hormones' deficiency has been registered. Once a residual lesions was observed a strict radiological follow-up is mandatory. Conclusions: According to dedicated literature and pre- and post-operative evidence of personal series, the authors try to provide an algorithm that could help in the standardization of the diagnostic and therapeutic pathways in patients with pituitary adenoma apoplexy.

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Background: Spinal cord injury (SCI) causes sensory, motor function and consists of a large proportion of patients that referred to trauma centers. Riluzole blocks the sodium channels and has possible supportive effects on the central nervous system. The aim of this study was to investigate the effect of riluzole on sensory and motor improvement and pain level in patients with acute SCI. Materials and Methods: In this clinical trial, sixty patients with acute SCI with A to C Frankel grade selected and randomly divided into two groups (each group included thirty patients). The two groups carefully matched in terms of age, sex, and Frankel class. Case group, in addition to conventional treatment, received riluzole and was evaluated after 6-week, 3-month, and 6-month periods in terms of sensory and motor status and compared with control group. Results: There were sixty patients divided into case and control groups. In the 6-week follow-up period and 3-month follow-up period, there was no significant difference between the two groups based on sensory and motor function (P = 0.053). In 6-month follow-up period, the difference was significant in case group (P = 0.001). Conclusion: The compressions between two groups demonstrated a significant difference in sensory and motor improvement and reduce pain level in patients with SCI.

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Although radiosurgery-induced transformation of vestibular schwannoma (VS) into malignant peripheral nerve sheath tumor (MPNST) is being widely discussed, little attention is paid to the spontaneous transition of these tumors. Although the pathogenesis of this phenomenon remains uncertain, growing number of reported cases might call to notice them. We present a case of a 29-year-old woman who suffered right-sided hearing loss which remained untreated for 4.5 years. Magnetic resonance imaging revealed a right cerebellopontine tumor and the patient underwent tumor removal through retrosigmoid approach. Pathologically, the tumor was benign acoustic schwannoma with increased Ki-67 8%–10%. The tumor relapsed only 6 months later and was removed again-this time it was malignant peripheral nerve sheath tumor MPNST. The patient was treated with stereotactic radiotherapy, but despite that tumor growth was observed again and she underwent the third operation. Later on, tumor progression was noted with multiple intraaxial metastases and patient died 17 months after the diagnosis of MPNST had been confirmed. This is a seventh documented case of spontaneous transformation of VS into MPNST, which is clinically important for recording.

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Introduction: Low backache (LBA) is highly prevalent in osteoporotic patients and affects their quality of life. Overall, osteoporosis incidence is greater in females than in males, and osteoporotic fractures typically occur with only modest or moderate trauma. Aims and Objectives: To evaluate osteoporosis as a cause of LBA in patients attending a neurosurgical outpatient department and to study various risk factors associated with it. Materials and Methods: The study entitled “Osteoporosis presenting as LBA: an entity not uncommon to be missed” was a 2-year hospital-based study conducted from August 2014 to July 2016 in a prospective manner and included 100 patients of osteoporosis with LBA. Analysis of records included their chief complaints, signs and symptoms, diagnostic investigations performed, treatment modalities they underwent, and further recommended management carried on them. Results: Out of total 100 patients evaluated, 33 (33%) were male and 67 (67%) were female; the age of patients was in the range of 35–70 years (mean 56.54 ± 91). The number of patients with a significant medical or surgical history was 31 (31%). The history of drug intake such as thyroxine, steroids, and antiepileptics was present in a total of 11 patients out of which 10 were female and one was male. Regarding lifestyle characteristics of studied patients, a total number of 72 (72%) were having sedentary habits with 15 (45.5%) males and 57 (85.1) females, the total number of moderate workers was 19 (27.3) males and 10 (14.9%) females, and heavy workers were 9 (9%) with 9 (27.3) males and 0 (0%) female. Conclusion: LBA is highly prevalent in osteoporotic patients especially in women. The incidence of osteoporosis and LBA increased with low body mass index, increasing age, and duration of menopause. The various risk factors for osteoporosis include smoking, history of medical diseases such as diabetes mellitus, history of hysterectomy, and history of antiepileptic, thyroxine, and steroid intake.

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Purpose: A high packing density (PD) (i.e., coil volume per aneurysm volume) helps prevent recanalization after endosaccular embolization of cerebral aneurysms. We hypothesized that the use of soft coils may be useful to raise PD and retrospectively investigated the correlation between the ED coil volume rate (i.e., volume ratio of all placed coils) and PD in patients treated with endosaccular embolization using this coil. Methods: Excluding aneurysms treated with a stent, 292 aneurysms treated using ED coils were included in this study. The 292 aneurysms and aneurysms with ≥30%, ≥40%, and ≥50% ED coil volume rates (202, 168, and 129 aneurysms, respectively) underwent linear regression analysis of the following seven factors' influence on PD:ED ratio, aneurysm volume, neck width, height, maximum diameter, dome-to-neck ratio, and aspect ratio. Results: Independent factors of a high PD were high ED ratio and small neck width on analyses of aneurysms with an ED ratio of ≥40% and ≥50%. Only neck width was an independent factor on analyses of all 292 aneurysms and aneurysms with ED ratio of ≥30%. Conclusion: The use of ED coils in high volume rate correlated with a high PD and may contribute to prevent recanalization in small aneurysms.

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Subdural hematoma (SDH) following labor epidural analgesia is a rare neurological complication. SDH is a late complication of this procedure; it is caused by a leak of cerebrospinal fluid that may damage the vascular structures of the brain. Persistent headache in the days after labor epidural analgesia is a nonspecific clinical symptom caused by hematoma. Preexisting vascular malformations can be a concomitant cause of headache. Clinical cases have been reported even after epidural anesthesia. The differential diagnosis includes unspecified headache, sinusitis headache, drug-induced headache, cortical vein thrombosis, fistula of the dura mater, and bacterial, viral, and aseptic meningitis.

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Background: Traumatic brain injury (TBI) is the leading cause of deaths worldwide. The morbidity and mortality due to TBI are related to both primary as well as secondary insults. The patients who survive from the primary insults, some may still have long-term disabilities. Most of these outcomes are related to the high incidence of prehospital secondary brain insults. Knowledge of these variables and timely management of the disease at the prehospital level can significantly improve the outcome and decrease the mortality. Aims: The present study is aimed to evaluate the current status of prehospital care, prehospital factors, epidemiological characteristics, and outcome of TBI patients at a Level 1 trauma center. Material and Methods: It is a prospective observational study of 830 cases of TBI, done from November 15, 2015, to March 15, 2016, in the Department of Neurosurgery, Institute of Traumatology, SMS Medical College, Jaipur, Rajasthan, India. Results: Analysis of data revealed that the incidence of TBI in males is four times higher than females. Most patients are in the age group of 21–30 years (30.24%) followed by 31–40 years (18.55%). Road traffic injury (69.52%) is the most common mode of injury in the age group of 21–30 years followed by injury due to fall (22.77%) which mostly affects the age group of 0–10 years (72.64%) and 61–70 years (38.6%). Analysis of different factors revealed that age is significantly correlated with the outcome having P = 0.016. Glasgow Coma Scale, saturation of peripheral oxygen, systolic blood pressure at admission are also significantly correlated with the outcome having P < 0.001, P < 0.001, and P < 0.001, respectively. Conclusion: It is evident from the study that the factors which affect the outcome of a TBI are influenced by prehospital care, and thus prehospital management of the TBIs can definitely improve the outcomes.

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Echinococcosis, also called hydatid disease, is a parasitic disease that passes from animals to humans. Literature reports suggest very rare cases of cerebral hydatid cysts. Brain involvement with hydatid disease occurs in 1%–2% of all Echinococcus infections. In this report, we aim to emphasize the presentation of such an isolated primary cerebral hydatid cyst, discuss its radiological features, Emergency department management, inpatient medical management, referral to neurosurgery, consequent operative procedures, postoperative care, and outcome.

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Introduction: Computed tomography (CT)-guided biopsy of spine is currently a valuable diagnostic tool and effective technique for diagnosing and planning a proper therapeutic strategy for certain spinal lesions. The reported diagnostic accuracy of core biopsy ranges from 77% to 97%. Materials and Methods: We included all patients with spinal lesions suspicious of metastasis on magnetic resonance imaging, who presented between May 2012 and April 2014 and underwent CT-guided biopsy in our study. A total of thirty patients with spinal lesions were evaluated. Results: Majority presented in the seventh decade of their life (average age = 53.93; age range = 10–72 years). Male:female ratio was 1.5:1. Pain was the most common presenting symptom (100%). Lumbar spine was the most common site of lesion followed by dorsal spine. Biopsy is the gold standard in histopathological evaluation of spinal lesions. Metastatic lesion was diagnosed in 12 (40%) cases, plasmacytoma in 12 (40%) cases, non-Hodgkin's lymphoma in 2 (6.66%) cases, small round cell tumor in 1 (3.33%) case, nonspecific chronic inflammation in two patients, and necrosis with no viable cells in one patient. The most common malignancy to metastasize to spine was adenocarcinoma. The most common primary tumor of spine was plasmacytoma - multiple myeloma. Conclusion: CCT-guided biopsy is a safe procedure, and no procedure-related complication was seen in any patient.

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Sinus histiocytosis with massive lymphadenopathy, or Rosai–Dorfman disease (RDD), was first described in 1969 as a reactive condition of unknown etiology that is characterized by a proliferation of histiocytes exhibiting emperipolesis of both lymphocytes and plasma cells. It usually presents with painless cervical lymphadenopathy either with or without extranodal manifestations. Intracranial involvement of this disease is extremely rare. Intracranial RDD occurs in <5% of all patients with extranodal disease. Here, we report a case of RDD with isolated intracranial involvement. A 67-year-old male presented with a long-standing headache, retro-ocular pain, and progressive visual loss of the left eye. Magnetic resonance imaging showed features of optic nerve meningioma. The histopathology revealed sheets of histiocytes displaying emperipolesis. These histiocytes were S100 positive; however, a CD1a and epithelial membrane antigen were negative.

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Herein, we describe a fatal case of central nervous system (CNS) pseudallescheriasis following near-drowning. A 13-year-old boy, who had been successfully resuscitated after near-drowning, presented with a transient episode of mental confusion during a hospital stay after recovering from severe aspiration pneumonia and respiratory failure. A magnetic resonance imaging (MRI) scan of the brain showed a small brain abscess in the left basal ganglia and ventriculitis in the left lateral ventricle. The brain abscess and ventriculitis did not respond to 4 weeks of antibiotic treatment and appeared even worse on a follow-up MRI. A diagnosis of CNS pseudallescheriasis was only possible with invasive stereotactic biopsy and aspiration of the abscess that showed the presence of hyphae and Scedosporium apiospermum. CNS pseudallescheriasis did not respond to multiple combinations of antifungal agents, including amphotericin B, isoconazole, itraconazole, and voriconazole. Two ventricular drainages and insertion of Ommaya reservoirs with intraventricular injection of voriconazole were insufficient to halt the infection. The patient passed away from sudden septic shock 2 months after identification of the brain abscess and ventriculitis. The patient's diagnosis was delayed because multiple examinations of the cerebrospinal fluid did not show positive cultures and could only be obtained from the aspirates of stereotactic biopsy. Physicians should be aware of CNS pseudallescheriasis associated with near-drowning because of the difficulty of diagnosis and the high mortality rate (70%) owing to poor responses to currently available antifungal agents.

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Background: The incidence of aneurysmal subarachnoid hemorrhage (SAH) reported in the literature has been very variable. Many authors have proposed a geographical variation in incidence, but others have dismissed this as being due to insufficient pickup rate. In India also, these arguments abound. Our aim was to find out if geographical variations exist in the incidence of aneurysmal SAH and whether the incidence of aneurysmal SAH was truly less in India as compared to the literature. Materials and Methods: The data from 182 consecutive cases of SAH admitted to this institution between March 1999 and July 2003 were used for this study. Results: There were 84 females and 98 males in this study. More than half of the patients were hypertensive. Four-vessel angiogram was done in 113 patients, of whom sixty-nine were normal. Of the patients with hypertension, 92% had angiogram done and was normal in 65% of cases. Conclusions: This study from a large general hospital in South India shows that the incidence of aneurysmal rupture as a cause of SAH is much less in India and probably in the Indian subcontinent in comparison with the western literature thus demonstrating geographical variations in the incidence of aneurysmal SAH. It is concluded that aneurysms as a cause of SAH are still less in India and that we are not missing anything. This study is intended to help target scarce, expensive resources toward more common pathologies.

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Common understanding of dementia is mostly based on the Alzheimer's disease model. However, in subcortical vascular dementia (SVaD), several other cognitive and behavioral dysfunctions predominate over what is commonly noticed in Alzheimer's disease. There are inconsistencies in literature regarding the profile of cognitive impairments in vascular dementia. Objective: In the current study, different cognitive functions pertaining to different lobes of the brain along with neuropsychiatric symptoms we explored in a holistic manner. Materials and Methods: A sample of 12 patients diagnosed with SVaD without any comorbidity were recruited for the study. All the patients underwent magnetic resonance imaging (MRI) scanning and different standardized neuropsychological tests were administered. Results: Patients reported various neuropsychiatric symptoms with varied severity, mostly falling in moderate range, reflecting organic personality change. Most of the cognitive functions pertaining to different lobes of the brain were impaired with parietal lobe being intact mostly. Comparison of MRI findings and neuropsychological findings revealed that there is involvement of cortical functions with the impairment in subcortical structure. Conclusion: These findings emphasis need to look beyond clinical diagnosis and MRI findings for better rehabilitation of the patients by including cognitive dysfunction as well as emotional disturbances prominent in SVaD which might me quite distressing for caretakers.

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Background: Abducens nerve palsy associated with subarachnoid hemorrhage (SAH) has rarely been reported. Its frequency, mechanism of palsy, association with aneurysmal location, and clinical course are poorly described. The purpose of our study was to evaluate patients with abducens nerve palsy caused by SAH occurring from ruptured vertebral artery (VA) dissecting aneurysm and to find aneurysmal location using initial computed tomography (CT) and its association with clinically detected cranial nerve palsy. Methods: Fourteen patients of SAH due to ruptured VA dissecting aneurysm were treated at our hospital from January 2011 to May 2015. The clinical courses and CT findings were reviewed retrospectively. Results: Abducens nerve palsy was observed in 77.8% of cases after excluding patients with decreased levels of consciousness. Clots within the prepontine cistern were significantly thicker in cases of VA dissecting aneurysm than in case of supratentorial aneurysm (P = 0.002). Conclusion: The findings of our study indicated that ruptured VA dissecting aneurysms, even in cases of angio-negative SAH, are likely to present with abducens nerve palsy.

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Context: Neuroendoscopic surgeries need specialized equipments, unavailable in neurosurgical departments of majority of public healthcare institutions of India. Aims: Neuroendoscopic treatment of hydrocephalus in the setting of minimal resources using utilization of available resources, inter-departmental co-ordination and indigenous innovations. Methods: Study was carried out at a public sector institute of India with scarce resources. Senior author (DKJ) used indigenously designed stainless steel working sheath along with equipments of 'awake endoscopic intubation system' of department of neuroanesthesia and 18 cm, 4 mm, 0° rigid telescope for neuroendoscopic surgeries for various intraventricular pathologies. Results: Thirty-four neuroendoscopic surgeries in 32 patients were done over last 3 years. There were 18 males and 14 females with average age of 23 years. It included hydrocephalus due to tubercular meningitis (n = 19), neurocysticercosis (NCC) (n = 4), intra-ventricular (n = 2) and para-ventricular (n = 2) space occupying lesions, aqueduct stenosis with (n = 2) or without (n = 1) shunt malfunction and one case each of pyogenic meningitis and right cerebellar infarction. Endoscopic third ventriculostomy (ETV) (n = 28), septostomy (n = 6), removals of cystic lesions (n = 3) and biopsies of intraventricular lesions (n = 2) were done in a total of 34 neuroendoscopic surgeries. Overall there were four failures of ETVs, which were managed by ventriculo-peritoneal shunts. Two mortalities in the study group were unrelated to the surgical procedures. Conclusion: Indigenous innovations and interdisciplinary co-ordination are the way ahead to tackle resource scarcity in public sector healthcare institutions of India in the scenario of plenty of neuroendoscopic trainings opportunities for young neurosurgeons and paucity of equipments required.

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Introduction: Laminectomy is the workhorse of spinal cord tumor surgery. This procedure is not without the debilitating sequelae of postoperative pain and delayed kyphosis. Hemilaminectomy is an alternate option to laminectomy which offers the advantage of preserving the posterior supporting structures of the spine on the contralateral side. In this study, we analyze the outcome of hemilaminectomy clinically with improvement in pain scores and Nurick's grade as well as radiologically by assessing for the development of delayed kyphosis. We also discuss the technique and operative nuances of hemilaminectomy in intradural extramedullary tumors of the spinal cord. Materials and Methods: All patients with intradural spinal cord tumors were included in the study. All patients underwent unilateral hemilaminectomy (UHL) depending on the laterality of the tumor on the preoperative magnetic resonance imaging. Preoperative neurologic status was assessed with Nurick's grade for tumors involving the cervicothoracic region tumors, and visual analog scale scores were recorded for tumors of Thoracic, Lumbar and Lumbosacral regions. The postoperative outcomes were assessed by improvement in respective scales on follow-up. The occurrence of delayed spinal deformity was assessed by follow-up X-rays. Any complications whether intraoperative or postoperative were recorded. Results: There were a total of 34 cases of intradural extramedullary tumors in this study. Patient population consisted of 11 males and 23 females. Total excision was achieved in 31 patients. In three patients, we were unable to achieve complete removal through UHL. In these patients the procedure was converted to total laminectomy. They were excluded from analysis. The distribution of the tumors was in cervical, cervicothoracic, thoracic, lumbar, and lumbosacral region. All patients presented with pain or varying degrees or neurologic deficits. Sixteen patients underwent UHL from the right side, while 18 from the left. There were no intraoperative complications. The neurological status and pain scores of all patients improved postoperatively at 3 and 6 months of follow-up. There was no radiological evidence of kyphosis of the involved segment. Conclusion: With a small learning curve, UHL is a good corridor for the removal of intradural extramedullary spinal cord tumors. This approach offers the advantage of less postoperative pain and no postoperative deformity.

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Aim: We have evaluated the anatomic measurements on sellar area of patients who were radiologically diagnosed with empty sella to determine the relation between the amount of pressure on the adenohypophysis and hormonal imbalances. Materials and Methods: Sixty-one cases were diagnosed with empty sella and had hormone tests and hypophysis magnetic resonance (MR). The cases were categorized into two groups – patients with hypophyseal hormone anomaly and patients without hormone anomaly. We have measured interclinoid distance, anteroposterior distance from the anterior diaphragm sella to the pituitary stalk, depth of the sella turcica, craniocaudal distance of the optic chiasm from the diaphragm sella, the heights of the right and left adenohypophysis, subcutaneous fat thickness measured orthogonal to the coronal suture and posteriorly at the level of C2–C3 for two groups on hypophysis and cranial MR imaging MRI. Results: Twenty-five hormone-positive cases (40.9%) (hormone test were abnormal) and 36 hormone-negative cases (59.1%) (hormone tests were normal) were included in the study. The most common hormone abnormality was thyroid-stimulating hormone, T3 and T4 deficiency in 12 cases (48%) and increase in prolactin level in 7 cases (28%). Right adenohypophysis height was 1.54 ± 0.840 mm for the 1^st group, and 1.96 ± 0.83 mm for the 2^nd group. The left adenohypophysis height was 1.66 ± 0.80 mm for the 1^st group, and 1.94 ± 0.94 mm for the 2^nd group. It was found out that the thickness at right and left side in the hormone-positive group diminished significantly. Conclusion: Adenohypophysis height and distance between stalk and optic nerve were good determiner for hormone defect.

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Objective: To evaluate the effectiveness of dural venous sinus sacrifice as a treatment of aggressive type cranial dural arteriovenous fistulas (dAVFs) in terms of both clinical outcome and angiographic outcome. Materials and Methods: One hundred and twenty-eight patients with 163 aggressive type cranial dAVFs who were treated with dural sinus sacrifice were retrospectively reviewed. Clinical and angiographic outcomes were analyzed. Procedural complications were also recorded. Only 103 patients (80.5%) who had been following up for at least 90 days were analyzed for clinical outcome. Results: There were 53 males and 75 females with age ranging from 20 years to 93 years (mean age 55.44 years). The overall angiographic cure rate of dural venous sinus sacrifice as a part of the treatment of aggressive dAVFs was 81.6%. Considering clinical outcome (average duration of follow-up was 2 years and 6 months), 75 patients (72.8%) had clinical improvement and 21 (20.4%) were clinically stable. Worsening of the presenting symptoms was observed in 7 patients (6.8%). Procedural complications were found in 5 patients (3.9%). Conclusion: Dural venous sinus sacrifice is a safe and effective treatment strategy with high angiographic cure rate, good clinical outcome, and low incidence of procedural-related complication.

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Background: In the era of evidence-based health care, protocol of intervention in traumatic brain injury (TBI) cases help decide more easily and safely about patients and prevent unnecessary transfer of patients to other centers. Objectives: The objective of this study is to provide protocol-based intervention and evaluate the epidemiological, clinical characteristics of TBI cases. Methods: This prospective study was conducted on 704 patients who were suspected of TBI at the Department of Neurosurgery, Narayana Medical College and Hospital, followed by protocol-based intervention assessed and reassessed repeatedly. Results: Overall, TBI involved 569 (80.82%) adults in the productive age groups (21–60 years); among males 81.47%. Among males, highest (23.15%) cases were in the age group of 31–40 years while in females, majority (27.04%) was among 41–50 years. Road traffic accidents were the most common (54.12%) mechanism of injury followed by fall (21.31%) and two-wheelers (15.20%). More than half sustained mild TBI (51.42%) while 26.28% moderate TBI and 22.30% severe TBI; among males, severe TBI victims 102 (18.82%) were in the productive age group. Loss of consciousness was almost a universal and significant observation (95.45%); vomiting was next common finding (76.42%). Bleeding from the ear-nose-throat (ENT) region was more in males (33.58%) than females (20.75%). Glasgow coma scale was significantly related with loss of consciousness (91.08%), vomiting (63.06%), and ENT bleeding (44.59%) in severe, moderate, and mild injuries. Conclusion: A rational clinical acumen with judicious use of diagnostic protocol leads to better management of TBI without unnecessary imaging and thus reduce total health-care costs.

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Objective and Background: Data on intraoperative neurophysiological monitoring (IOM) during surgery of spinal dural arteriovenous fistulas (SDAVFs) are lacking. The purpose of this study was to evaluate the role of IOM during microsurgery for SDAVFs. Materials and Methods: From March 2007 to March 2013, 12 patients had microsurgery with IOM for SDAVFs. The IOM included somatosensory-evoked potentials, motor-evoked potentials (MEPs), and – in selected cases – D-Waves. All patients were evaluated at admission and at follow-up (6, 12, and 24 months) with Aminoff–Logue Disability Scale for Gait-Aminoff–Logue Disability Scale (G-ALS) and Micturition-Aminoff–Logue Disability Scale (M-ALS). Statistical Analysis Used: Logistic regression was used for detecting the clinical risk factors influencing neurological functions after the treatment. Results: During surgery, we registered the absence of significant modifications of evoked potentials in nine cases (75%), while improvement of MEPs occurred in three cases (25%). No false-negative case was registered, and IOM predicted the absence of new postoperative neurological deficit in all patients. At 24-month follow-up, nine patients improved their overall neurological status, while three patients remained stable. At univariate analysis, Aminoff–Logue Disability Scales for Gait and Micturition (G + M-ALS) score at 24-month follow-up was directly associated with the duration of symptom before the surgery (P = 0.024), preoperative G-ALS (P = 0.02), M-ALS (P = 0.022), and G + M-ALS scores (P = 0.045), and improvement of IOM after occlusion of the fistula (P = 0.025). Conclusions: In our series, no significant worsening of evoked potentials occurred and subsequently the surgical strategy was not changed by IOM. However, no false-negative case was registered, and IOM predicted the absence of new postoperative neurological deficit in all patients. Patients with improvement of IOM parameters after occlusion of the fistula had greater chances of postsurgical improvement at the univariate analysis.

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Background: Severe traumatic brain injury (TBI) is associated with disabling cognitive impairment. Currently available options to improve the cognitive function have been futile. However, recently, commonly used medicine for Parkinson's disease, amantadine, has been shown to assist in the improvement of cognitive function. Methodology: We conducted a single institution-based observational study in adult Indian population. Fifty consecutive patients with documented static or declining cognitive function at 2 months of severe TBI fulfilling the inclusion/exclusion criteria received amantadine 200 mg/day (100 mg twice a day) orally or through enteral feeding tube for the duration of 4 weeks. The functional assessment done with Full Outline of Unresponsiveness (FOUR) score, Disability Rating Scale (DRS), and Glasgow Outcome Scale (GOS) during 4 weeks of treatment and 2 weeks posttreatment was assessed. Results: The cognitive function improved progressively during the 4-week treatment interval as shown by significant improvement on FOUR score, DRS, and GOS. However, after discontinuation of the drug, the speed of recovery slowed down significantly, but the achieved recovery was not lost. Out of fifty, eight patients had convulsions as an adverse effect of amantadine, of which five patients required discontinuation of the drug with treatment for convulsions. Conclusions: This study indicates the safety and efficacy of amantadine in partial reversal of cognitive dysfunction in adults with severe TBI in adult Indian population.

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Pathogenesis of intracranial aneurysms is multi-factorial. Origin of aneurysm may be acquired or genetic, and there may be more than one aneurysm simultaneously, or there may be the formation of a new aneurysm after treatment of previous one. Collagen vascular disorders, neurofibromatosis, polycystic kidney disease, and so many other disorders are associated with multiple intracranial aneurysms. As Factor VII deficiency is also genetic in origin, there might be a correlation between deficiency of the same with multiple intracranial aneurysms. Only one such case is reported in the literature and we are reporting such a rare case having a similar association.

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Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy. This syndrome has various etiologies of which heterotopic ossification of the flexor retinaculum is a rare cause. Ankylosing spondylitis (AS) is a systemic, progressive inflammatory disease of unknown etiology that mainly affects the axial skeleton and rarely causes peripheral neurological symptoms. A 48-year-old woman presented with numbness and pain in her right hand. Ten years earlier, she was diagnosed with AS. Electrodiagnostic evaluation revealed severe median nerve compression at the right wrist. The patient underwent surgery for severe CTS. During the operation, the flexor retinaculum could not be incised due to marked stiffness. Ossification of the flexor retinaculum was seen, and the retinaculum was partially excised with an osteotome and Kerrison rongeur. The patient's complaints resolved almost totally after the operation. AS is a common systemic inflammatory disease that can produce heterotopic ossification of the flexor retinaculum. Preoperative wrist computed tomography should be obtained in patients with CTS and AS.

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Tumefactive multiple sclerosis (MS) is characterized by the presence of a single MS-plaque in the brain. It mimics tumors due to large size, mass effect, and enhancement patterns. Refractory intracranial hypertension due to tumefactive MS requiring decompressive craniectomy (DC) was reported in five cases. However, none of these cases were documented new lesions during the follow-up. We report a case of a 28-year-old female admitted with acute right hemiparesis, headache, and nausea. A brain magnetic resonance imaging (MRI) revealed a left parietal lobe lesion. Within 4 days, she became comatose. Computed tomography (CT) scan revealed the left uncal herniation. DC and resection of the lesion were carried out. Histopathology revealed active demyelinating disease. After 11 years of the first attack, she went to the emergency department due to headache and left hemiparesis. Head CT scan revealed a hypodense area in the right frontal lobe. Three months later, the patient was asymptomatic, and new MRI did not show new lesions.

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Introduction: Moyamoya disease is a steno-occlusive cerebrovascular disease of unknown etiology involving the terminal portion of the internal carotid artery and the proximal portions of the anterior and middle cerebral arteries with associated collateral vascular network. When the vascular pattern is associated with a particular condition (e.g., Type 1 neurofibromatosis, Down syndrome), it is defined as moyamoya syndrome (MMS) (or quasi-moyamoya). Among different indirect bypass techniques used to prevent ischemic injury by increasing collateral blood flow to hypoperfused areas of the cortex, multiple burr holes technique is an easy and diffuse indirect revascularization approach in the treatment of moyamoya. Discussion: While the effectiveness in patients with moyamoya disease was demonstrated, its role in MMS remains uncertain. In this study, we describe surgical and diagnostic implications in three pediatric cases of moyamoya sydrome unsuccessfully treated with multiple cranial burr hole technique. A critical review of the literature about the use of the surgical indirect revascularization techniques in pediatric patients was also reported.

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Giant cell tumors (GCTs) are rare, usually affecting the epiphyses in long bones of the extremities. GCTs may be locally aggressive with a high rate of local recurrence and exhibit the potential for distant metastasis. They seldom occur in the skull, where they preferentially affect the sphenoid and temporal bones. Several case reports with follow-up describe gross total resection of skull-base GCT to be curative. Radiation therapy, although controversial, is reserved for lesions that cannot be completely resected. Here, we describe the case of an 18-year-old female with GCT of sphenoid bone who underwent subtotal resection followed by adjuvant radiotherapy, although whose radiotherapy could not be completed because of her demise due to erythema multiforme associated with phenytoin and cranial radiation therapy syndrome.

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The absence of the internal carotid artery (ICA) is a rare congenital anomaly. Diagnosis of this entity is important because of its association with the cerebral aneurysm and also indicated during planned carotid or transsphenoidal surgery in thromboembolic disease and in the surveillance and detection of associated cerebral aneurysms. We report a case of congenital absence of unilateral ICA with associated cerebral aneurysm of the anterior cerebral artery.

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Background: Machine learning is a type of artificial intelligence which aims to improve machine with the ability of extracting knowledge from the environment. Glioblastoma multiforme (GBM) is one of the most common and aggressive primary malignant brain tumors in adults. Due to a low rate of survival in patients with these tumors, machine learning can help physicians for better decision-making. The aim of this paper is to develop a machine learning model for predicting the survival rate of patients with GBM based on clinical features and magnetic resonance imaging (MRI). Materials and Methods: The present investigation is an observational study conducted to predict the survival rate in patients with GBM in 12 months. Fifty-five patients who were registered in five Iranian Hospitals (Tehran) during 2012–2014 were selected in this study. Results: This study used Cox and C5.0 decision tree models based on clinical features and combined them with MRI. Accuracy, sensitivity, and specification parameters used to evaluate the models. The result of Cox and C5.0 for clinical feature was <32.73%, 22.5%, 45.83%>, <72.73%, 67.74%, 79.19%>, respectively; also, the result of Cox and C5.0 for both features was <60%, 48.58%, 75%>, <90.91%, 96.77%, 88.33%>, respectively. Conclusion: Using C5.0 decision tree model in both survival models including clinical features, both the imaging features and the clinical features as the covariates, shows additional predictive values and better results. The tumor width and Karnofsky performance status scores were determined as the most important parameters in the survival prediction of these types of patients.

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Introduction: Side-to-side anastomoses are a relatively newer and more difficult technique used in neurovascular surgery for complex aneurysms/lesions. In view of the complex surgical technique and the infrequent clinical opportunities to acquire skills relevant to this surgery, laboratory training assumes great importance. The authors studied the feasibility of establishing a training model for performing side-to-side anastomosis using rat femoral vessels and compared the immediate and delayed patency rates in this animal model. Materials and Methods: After Institutional Animal Ethics Committee clearance, 16 Sprague-Dawley rats were used in this prospective study between August 2013 and March 2015. Using the standard groin incision, the femoral vessels were dissected. After applying temporary clamps, opening of approximately 3–4 mm (at least double the diameter of the wider vessel) of length was made on the facing surfaces of both vessels. 10-0 nylon was used for anastomosis. The clamps were released, and the anastomoses patency confirmed. Leg movements following the anastomoses were studied. The animals were subsequently sacrificed to assess delayed patency. Results: The immediate patency rate was 87.5% (14/16). The delayed patency rate (mean follow-up 209 days) was 53.8% (7/13). Three rats died during the follow-up period. The mean clamp duration and suturing time was 57.25 and 41.50 min in the first eight cases and 57.50 and 36.75 min in the last eight experiments, respectively. Conclusion: This animal model was found to be extremely useful for training in the difficult art of side-to-side anastomoses. The need of the hour is to establish well-planned training programs in centers with animal research facilities and use such models. This will promote younger colleagues and trainees to take up and perfect this difficult art. The present work could be used as a baseline study in this direction.

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Giant pituitary adenomas (GPAs) are defined as pituitary lesions larger than 40 mm of diameter. Surgical resection remains the gold standard to decompress the optic apparatus, reduce lesion load, and preserve hormonal function. The endoscopic endonasal approach (EEA) has been increasingly used for the treatment of pituitary adenomas and skull base tumors due to the wide angle of view and exposure. Through the description of an exemplificative case of EEA resection of a nonsecreting GPA in the setting of a multimodal treatment, the authors discuss the advantages and disadvantages of this management strategy and provide a detailed review of the literature.

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An understanding of the microsurgical anatomy of posterior clinoid process (PCP) is extremely important to where the removal of PCP is required to access the interpeduncular and prepontine cisterns and upper basilar artery region to manage the aneurysms located in this region. In the present article, we describe our experience with a technique that is safe and provides ample space to look into these regions. The key to safe drilling is that the drilling of the posterior clinoid needs to be performed in a “touch and back” manner (rather than clockwise or counterclockwise motion) to break the cortex.

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Persistent primitive trigeminal artery (PPTA), a fetal carotid-basilar anastomosis, is the most common embryological vascular remnant persisting into adult age. However, reported cases associated with cerebral aneurysms are rare. A 33-year-old female presented with an extremely rare PPTA-basilar artery (PPTA-BA) aneurysm manifesting as subarachnoid hemorrhage. Computed tomography revealed subarachnoid bleeding in the prepontine cistern, and cerebral angiography disclosed a PPTA-BA aneurysm. The aneurysm was managed with stent-assisted coiling technique to achieve complete obliteration. The patient was discharged without neurological deficits 2 weeks later. At 6 months follow-up, the patient is doing well and has returned to her previous daily activities. PPTA-BA aneurysms usually present with cranial nerve palsy and sometimes with carotid-cavernous fistulae if they rupture. Their deep seating favors interventional management as a first option and this case illustrates the efficacy and safety of endovascular treatment. This case adds to the evidence that endovascular techniques are a safe and effective tool in managing aneurysms of the primitive trigeminal artery. Even in cases where the anastomosis itself is not preserved, the patient can be managed satisfactorily, provided that the patency of the basilar and the carotid artery are kept, like in our patient.

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Background: Epidural fibrosis is a major contributing factor to the onset of failed back syndrome. Many studies have attempted to prevent this physiological response. Interestingly, N-acetyl-cysteine (NAC) has been effective in some cases in the treatment of pulmonary fibrosis. Objective: The objective of this study was to determine whether local NAC is an effective way to prevent epidural fibrosis after laminectomy in rats. Materials and Methods: Twenty Wistar rats were used in this study. Animals were divided into two groups: NAC group and a control group. We performed two-level laminectomy (L4–L5) in these rats. Rats in the control group just had laminectomy, and in the other group, L4 and L5 laminectomy followed by local treatment with NAC. Four weeks later, the rats were killed, and the laminectomy level was subjected to histopathological examination to evaluate epidural fibrosis and fibroblast density. Results: Histopathological examination showed that after 4 weeks of surgery the NAC group had significantly less epidural fibrosis and fibroblasts compared with control group. Conclusion: Our findings indicate that NAC decreased spinal epidural fibrosis after laminectomy in rats.

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Despite growing popularity of endovascular techniques, certain subsets of patients with cerebrovascular compromise may benefit from bypass surgery. We present four cases in which pending ischemic lesion was prevented by (1) A3 resection and reanastomosis following falx meningioma removal, (2) rescue superficial temporal artery–middle cerebral artery (STA-MCA) bypass after pituitary adenoma surgery, (3) STA-MCA bypass for chronic internal carotid artery occlusion, and (4) external carotid artery-MCA bypass using radial artery grafting. Following the procedure, there were no further clinical or radiological deteriorations and long-term patency was confirmed in all four cases.

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Intracranial aneurysms may cause embolic stroke. Medical or surgical management is selected on an individual basis, as the optimal treatment strategy has not been established. A 79-year-old woman with a large cavernous carotid aneurysm suffered repeated embolic stroke after enlargement and partial thrombosis of the aneurysm, in spite of antiplatelet therapy. Coil embolization of the primitive trigeminal artery and ligation of the internal carotid artery (ICA) at the cervical portion followed by high-flow bypass from the cervical external carotid artery to the middle cerebral artery were performed. The aneurysm was thrombosed, and prevention of further stroke was achieved. Acute enlargement and thrombosis of large or giant cavernous carotid aneurysm may cause repeated embolic stroke, and requires emergent exclusion of the aneurysm from circulation by proximal ICA occlusion together with distal revascularization before devastating embolic stroke occurs.

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Hemifacial spasm (HFS) caused by a venous offender is rare, and its clinical course and optimal surgical strategy are unclear. A case of 57-year-old male who had an HFS caused by a venous offender is described in this report. Frontalis, orbicularis oculi, orbicularis oris, and mentalis muscles were involved while his platysma muscle showed no spasm. He was treated successfully with microvascular decompression using Teflon felt and 12 months outcome was excellent without any complications. Lateral spread response was not observed in the facial electromyography during the whole operation. Adequate visualization of the facial nerve root exit zone and meticulous exploration for offenders are necessary to avoid surgical failure and reoperation.

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Trans -sellar trans-sphenoidal encephalocele is an extremely rare entity. We present the case of an 18-month old boy who presented with a trans-sellar, trans-sphenoidal encephalocele associated with cleft lip, cleft palate and microphthalmia. This patient was treated successfully by a trans-cranial extra-dural route. In this paper, we discuss the clinico-radiological findings as well as various surgical options in managing these rare lesions and briefly review the literature.

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Introduction: This study describes a technique using gravity for guidance in stereotactic brain biopsy. This will be especially useful in hospitals where the stereotactic equipment is unavailable. Objectives: The aim of this study is to describe the technique, develop a formula to define its limits of accuracy, and report on its clinical application. Methods: Using the positioning laser grid lines on the computed tomography scanner, a small metallic marker is placed on the scalp at the intended biopsy site. The distance between the tumor and the inner table of the bone is measured. In the operating theater, the patient is positioned such that the tip and the bridge of the nose are aligned in a horizontal position. The patient's two eyebrows or the orbital canthi are aligned in a vertical line. Simultaneously, the posterior borders of the two pinnae are aligned vertically. Gravity is used to guide the biopsy needle through the marked burr hole into the target. Seven patients had biopsies. One was for targeting the craniopharyngioma cyst to place an Ommaya catheter. The fraction of error or error fraction (EF), E/a=x/a tan α - 1 was developed for verification of its limits of accuracy. Results: All the biopsies were diagnostic and the Ommaya catheter was correctly sited. The EFs at α = 5° were all predictive of the limits of accuracy of this technique. Conclusion: This is the first reported gravity-guided stereotactic brain surgery. The outcome in all the eight cases showed that it was within the limits of its accuracy. EF can be calculated to ensure accuracy. This technique is helpful if a commercial stereotactic system is not available.

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Background: Initial surgical management of the anterior foramen magnum lesions through the posterior approaches was fraught with unacceptable morbidity, mortality, and incomplete removal. The far-lateral approach provides excellent exposure and access to these lesions resulting in complete excision of these lesions with reduced frequency of unwanted complications. Materials and Methods: Eight patients with lesions anterior to the brainstem and upper cervical cord were surgically treated using the far-lateral transcondylar approach. Two of these patients had a meningioma while three patients had “white epidermoid.” One patient had a vertebral artery (VA) aneurysm while another was a rare case of lower brainstem compression by the VA and the last was a clival chordoma. The technical aspects of this surgical procedure are briefly illustrated in this article. Results: Total excision was achieved in five neoplastic cases while subtotal excision was done in one case. The VA aneurysm was satisfactorily clipped while in the brainstem compression patient, microvascular decompression was done. The VA aneurysm patient developed postoperative lower cranial nerve palsies. There were no fresh postoperative deficits in any of the other patients. One patient had an unexplained sudden cardiorespiratory arrest 18 h after the surgery and succumbed. One patient had cerebrospinal fluid (CSF) otorrhea which was satisfactorily managed by intrathecal CSF drainage. Conclusion: The far-lateral transcondylar approach provides excellent approach to lesions located anterior to the brainstem and upper cervical cord. Total excision of these benign lesions is safely possible through this approach.

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Objective: Craniopharyngioma is a benign tumor. However, sometimes, this tumor may recur repeatedly even after apparent total resection. This study investigated the requirements for ideal radical treatment, based on a discussion of the long-term clinical course and pathological findings in surgical patients. Methods: We performed 81 surgical procedures for 67 patients with craniopharyngioma between February 1990 and December 2015. We classified patients into Groups I–III according to emphasis of surgery in chronological order, so we investigated the tumor recurrence rate and the necessity for postoperative hormonal replacement. Results: Multiple comparison of results from the three groups found significant differences in recurrence rate between Groups I and II (P = 0.0111) and Groups I and III (P = 0.0056). Although there were no differences in recurrence rate between Groups II and III, mortality rate of Group III was lower than that of Group II. No significant difference was seen between any group in terms of hormonal replacement. Conclusions: These results strongly suggest that the radical resection used to treat patients in Group III should be given priority as the procedure for removing craniopharyngioma.

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Purpose: The purpose of this study is to collect the information on patients with intracranial aneurysm (IA) receiving endovascular management in Siriraj Hospital, Mahidol University, Thailand. Materials and Methods: We retrospectively reviewed data from patients with IA who underwent endovascular treatment from January 1997 through July 2013. We collected patients' demographic data including age, sex, clinical presentations, and aneurysmal profiles, as well as endovascular treatment technique, complications, angiographic results, and regrowth rate. Treatment results included success rate, clinical findings during follow-up, and regrowth rate. Results: We reviewed data from 497 patients with 636 aneurysms (female:male ratio, 1.9:1; age range, 15–90 years; mean age, 59.18 years) and 69% presented with rupture. One hundred and twenty patients with 127 aneurysms received endovascular treatment. The most common location for endovascular treatment was the posterior communicating artery (15.8%), and endovascular techniques were used most often for posterior circulation and paraclinoid aneurysms. The success rate was approximately 99.2% with a 16.5% regrowth rate and no rebleeding. Regrowth rate did not correlate with immediate postoperative angiographic findings. We encountered 23 complications (18.1%); most commonly, intra-procedural rupture (7/23). Good outcomes occurred in approximately 95.9% of the patients. Conclusions: The success rate for endovascular treatment was >90%. Regrowth rate and clinical outcomes were within standard limits. Posterior circulation and paraclinoid aneurysms were our main targets. We tended to use fewer devices and simpler techniques to secure ruptured IA; however, the regrowth rate was similar to that using device-assisted techniques in other studies. We found no significant factors affecting regrowth rate, including immediate posttreatment angiographic results.

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Idiopathic intracranial hypertension (IIH) is a disease of mainly unknown etiology. Latest theories as to the pathogenesis have postulated a final common pathway of cerebral venous hypertension secondary to venous outflow impairment leading to decreased cerebrospinal fluid absorption. We present the case of a 42-year-old female who was treated for several years for headache and for approximately 12 months for IIH until appropriate imaging showed a right-sided cervical dural arteriovenous fistula (AVF) at the level of C4. The patient's IIH symptoms resolved following surgical excision of the fistula. We suggest that the cranial venous outflow impairment secondary to the cervical AVF was responsible for intracranial hypertension and that complete investigation of IIH patients should include imaging of the neck vasculature.

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Iodinated contrast encephalopathy is known as one of the rare complications of cerebral angiography and neurovascular intervention. The mechanism and causes of contrast encephalopathy are not understood well. In this case, we experienced transient neurological deficit following coil embolization of unruptured aneurysms. A 67-year-old woman with two unruptured aneurysms of internal carotid artery underwent endovascular coil embolization. During the procedure, she presented transient hemiparesis and aphasia. After the treatment, she presented the symptom again, and computed tomography scan showed cortical edema and subarachnoid leakage of contrast agent. Magnetic resonance imaging excluded cerebral infarction. The neurological symptom resolved completely within 24 h after the treatment, and she was diagnosed as the contrast encephalopathy. In our case, we speculated that contrast encephalopathy has occurred subsequently to the transient cerebral ischemia. Iodinated contrast encephalopathy may have induced with neurovascular intervention following cerebral ischemia and increased use of contrast agent. We should consider iodinated contrast encephalopathy when a patient presents hemiparesis and aphasia such as that caused by acute stroke during neurovascular intervention.

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Background: Mannitol has been used intravenously for decreasing cerebral edema since decades. The study was performed to evaluate the effect of its irrigation on edema in live rats. Edema was induced by artificial brain injury. We hereby present our results on the same using live rats and confirm its beneficial effect on reducing edema when used as irrigation. Aims: The aim of this study is to evaluate the effect of mannitol irrigation in reducing cerebral edema in rat brain after induction of artificial trauma and to compare the results with standard normal saline irrigation using randomized controlled study. Settings and Design: This study was a prospective randomized controlled trial. Materials and Methods: A total of 20 fully grown Albino Wistar rats were subjected to artificial trauma after a burr hole and divided randomly into two groups of ten rats each. One group was subjected to mannitol irrigation after durotomy and the other was subjected to normal saline. Tissue biopsy was sent at the end of 1 h to check for the status of edema and was classified into three grades. Statistical Analysis Used: Comparison of proportions test. Results: Mannitol irrigation produced a statistically significant difference (P = 0.022) in the grade of edema at the end of 1 h as compared to normal saline. Conclusions: Mannitol irrigation can be used during neurosurgical procedures instead of normal saline to reduce postoperative brain edema.

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Prostate carcinoma rarely develops intracranial metastasis. In case it does, the dura is the most affacted area. In general, brain computed tomography (CT) findings mimic subdural hematoma making surgery challenge. We report the case of a 52-year-old male, presented as an emergency with a month history of headache, progressive temporospatial disorientation, mental confusion, and abrupt consciousness deterioration up to coma occurring few hours prior admission. An urgent brain CT scan showed a subdural collection in favor of a chronic subdural hematoma. The patient underwent surgery by standard burr hole, and surprisingly, peroperatively, there was a very bloody diffuse thickening of the dura without a real hematoma obliging to switch to a large fronto-temporoparietal craniotomy revealing a subdural mass that was completely removed. Histopathology disclosed a metastatic prostatic carcinoma confirming that such a subdural collection could behave as a great simulator. A contrast brain CT scan, is advisable, even in emergency, in selected case, with atypical images finding, especially if, a malignant disease is already known; the former could be of great help in the differential diagnosis and the best prompt management.

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Background: Head trauma is one of the most common mortality and morbidity causes in adolescent. Numerous studies have been conducted on changes in laboratory results and mortality and morbidity prognostic factors; however, the obtained results have been varied and controversial. The aim of this study is to evaluate changes in laboratory findings and arterial blood gas (ABG) analyses test at admission and investigation of the relation between these changes with outcomes in patients with traumatic brain injury. Materials and Methods: In this study, laboratory and metabolic variables were compared in patients with severe brain trauma and normal subjects. Laboratory and metabolic variables and ABG were measured on admission in patients with severe brain trauma and then compared with normal values. At last, the correlation between these variables with the prognosis in the patients was studied. Results: Of 93 studied patients, 82 were male and 11 were female with the mean age of 30.54 years. Among the studied variables, prothrombin time (PT), partial thromboplastin time, international normalized ratio (INR), creatinine (Cr), blood sugar, sodium (Na+), potassium, white blood cell, and blood urea nitrogen increased while hemoglobin and platelet decreased significantly. Regarding the ABG results, the difference in PaCO₂, HCO₃, and SO₂at values was significant; whereas there were no statistical significant difference between the discharged and expired patients. In contrast, PT, INR, Cr, and Na had significant difference comparing the discharged and expired patients. Conclusion: Laboratory variables do change in patients with severe brain trauma; these changes are influential on patient prognosis, especially in case of PT, INR, Cr, and Na.

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Although ventriculoperitoneal shunt (VPS) is the most common procedure performed by pediatric neurosurgeons, it is still associated with frustrating complications, most common of which are obstruction and infection. Traumatic occipital artery pseudoaneurysm is a very rare complication of VPS procedure. To the best of our knowledge, there is no similar case reported in the English language literature. A 12-month-old patient suffered posthemorrhagic hydrocephalus of prematurity, and multiple other complications due to extreme prematurity, including immature lung disease, retinopathy of prematurity, necrotizing enterocolitis, bowel perforation, short bowel syndrome resulting in total parenteral nutrition-dependence, and hydrocephalus which was treated by insertion of VPS. Four weeks after the shunt, a slowly enlarging pulsatile swelling distal to the valve under the catheter altering the shunt function was noted. The swelling was diagnosed as a pseudoaneurysm of the occipital artery and treated by excision of the aneurysm. The child developed isolated dilated fourth ventricle, which was treated by endoscopic fourth ventriculostomy. Traumatic occipital artery pseudoaneurysm as a result of tunneling of VPS catheter is a very rare complication of VPS. Clinical and radiological imaging is diagnostic of the aneurysm. Surgical repair should be considered in such cases. This case report is aimed to raise the awareness among physicians about this rare complication.

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Introduction: The basilar artery (BA) is formed by the fusion of right and left vertebral arteries and divides to form right and left posterior cerebral arteries. This study was done to provide a baseline database regarding length, mid-length diameter, level of origin, and level of termination of BA.Materials and Methods: Thirty-eight formalin-fixed brains were obtained from cadavers dissected for undergraduate studies. The external length and the average external diameter of BA were measured by a digital Vernier caliper. Variation in origin and termination of BA was noted using magnifying glass. Results: The length and diameter of the BA were 25.58 ± 3.57 mm and 3.05 ± 0.41 mm, respectively. The origin and termination of BA was normal in most cases. In two cases, the origin was above the pontomedullary junction, and in one case, it was below. In two cases, the termination was above the pontomesencephalic junction, and in one case, it was below. Conclusion: There was no gender predisposition in length and diameter of the basilar artery. The baseline data established in this study regarding length, diameter, level of origin and level of termination of basilar artery will help neurosurgeons and interventional radiologists to diagnose as well as plan and execute various vascular procedures such as shunting for the treatment of aneurysms and stenosis in the blood vessels of the posterior cranial fossa.

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Obtaining adequate working space is difficult for complete and safe resection of meningioma located in the middle third of the falx, because of the risk of damage to the bridging veins that flow into the superior sagittal sinus and the location near the eloquent area. Consequently, surgical resection of the meningioma in the middle third of the falx tends to result in neurological disorders caused by retraction of the brain and injury of the bridging vein. Two patients underwent tumor removal of the falx meningiomas located in the middle third of the falx through the occipital interhemispheric approach (OIA) in the lateral semiprone position with the affected side down. Tumor resection was achieved safely and less invasively. Both patients suffered numbness and motor weakness, but these neurological dysfunctions improved and clinical courses were uneventful. Postoperative computed tomography showed neither brain swelling nor contusion in both cases. The OIA can remove tumor in the middle third of the falx, because the approach avoids the bridging veins, and provides working space without excessive mechanical cerebral retraction.

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Background: Nonmissile anterior skull-base penetrating brain injuries (NASBPBIs) have specific characteristic features that are different from missile injuries. Our study presents our experiences on the characteristic features as well as management of NASBPBI. Materials and Methods: We retrospectively reviewed 22 consecutive patients with NASBPBI managed at our institute during a 13-year period. The mechanism of injury, clinical investigations, and complications were analyzed, with more emphasis on diagnostic and treatment regimen. Results: The 22 cases included in our study comprise of 20 males and 2 females. Majority (72.7%) of the patients were adults with a mean age of 27.5 years. The mechanisms of injury often include accidental fall, either onto a small-diameter sharp object (10 cases) or while carrying such an object in the hand (4 cases). The other common mechanisms were stabbing, accident, or during an altercation (8 cases). Clinical manifestations included periorbital hematoma (10 cases, 45.5%) and cerebrospinal fluid rhinorrhea or orbitorrhea (4 cases, 18.2%) as well as signs of embedded foreign object (8 cases, 36.4%). We performed emergency craniotomy in 21 cases and skin debridement in one case. Postoperative complications were abscess (1 case), epilepsy (1 case), and traumatic carotid-cavernous fistula (1 case). Conclusion: Nonmissile injuries are generally on the rise and therefore deserve more attention. We observed that clinical outcomes were excellent in 14 (Glasgow Outcome Scale [GOS] score of 5) and good in the remaining 8 patients (GOS of 4) during 6-month–10-year (mean 4.6 years) follow-ups.

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We present a case of a partially thrombosed giant aneurysm of the pericallosal artery that experienced a temporary worsening of perianeurysmal edema after clipping. A 66-year-old man presented with progressive weakness of the right leg. Imaging studies revealed a partially thrombosed giant aneurysm at the bifurcation of the left pericallosal artery with concomitant perianeurysmal edema. The aneurysm was thought responsible for the symptoms of the patient, and he agreed to undergo clipping surgery. The aneurysmal neck was clipped using two long aneurysm clips without dissecting the aneurysmal dome. The patient woke up from anesthesia with the right-sided hemiparesis, which progressed to hemiplegia by 12 h after surgery. Brain computed tomography revealed worsening of the perianeurysmal edema. Fortunately, his symptoms resolved completely by 2 weeks after surgery with conservative management. Perianeurysmal edema is frequently observed in patients with partially thrombosed giant aneurysms. Although worsening of perianeurysmal edema is a relatively common complication of endovascular procedures, its occurrence after clipping has rarely been reported. The worsening may have been induced by release of inflammatory cytokines from aneurysm wall, which was rendered ischemic due to obliteration of the vasa vasorum by the clips. Perianeurysmal edema may develop or worsen after clipping of a partially thrombosed giant aneurysm if the interface between the aneurysm and surrounding brain is not fully dissected.

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A case of delayed occurrence of C3 vertebra anterior subluxation diagnosed 10 days after surgery for epidural hematoma is herein described. A 56-year-old man underwent surgery for right epidural hematoma. No spinal fracture was identified on the cervical–spinal computed tomography (CT) on arrival. The patient developed neck pain after the craniotomy, and cervical magnetic resonance imaging 5 days postoperatively revealed a disruption of the C3–C4 posterior ligament complex. The patient was conservatively treated with immobilization. Cervical CT 10 days postoperatively revealed C3 vertebra anterior subluxation. Posterior fixation surgery was performed 21 days after admission, and the postoperative course was uneventful. This case suggests that awareness of delayed occurrence of cervical dislocation after traumatic intracranial hemorrhage should be increased among neurosurgeons.

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Atypical teratoid rhabdoid tumor (ATRT) is a rare, highly malignant tumor of the central nervous system, commonly affecting children below 3 years of age, with around 300 cases reported in the literature. Suprasellar area is a very rare location for such tumor in the pediatric population, with technical difficulties in complete excision. Third ventricular ATRT is very rare. Here, we report the case of a 2-year-old male child who presented with lethargy and vomiting. He had features of raised intracranial pressure with reduced vision in both eyes. Magnetic resonance imaging of the brain revealed a heterogeneously enhancing lobulated giant lesion in the suprasellar location, occupying the third ventricle and hypothalamus with encasement of both carotids. He underwent pericoronal parasagittal craniotomy, interhemispheric transcallosal interforniceal approach and gross total excision of the lesion. Postoperatively, the child had altered sensorium and diabetes insipidus, both of which recovered over a span of 10 days. Histopathological examination of the specimen was consistent with the diagnosis of World Health Organization Grade IV ATRT. In spite of all our efforts, he succumbed to his illness 5 months postoperatively.

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Pleomorphic xanthoastrocytoma (PXA) is a benign glial tumor, the association of which with neurofibromatosis type I (NF-1) has been often reported in the literature. Although malignant conversion to glioblastoma may be seen in 5%–10% of PXA, the same has been reported only once in the presence of NF-1. We report, so far known to be only the second such case all over. A 25-year-old male, a known case of NF-1, underwent frontal craniotomy for a superficially located right frontal lesion, histology of which suggested PXA. Two years later, the lesion recurred and the subsequent surgery revealed malignant conversion to glioblastoma. After adjuvant radiotherapy, the patient now continues to do well and is free of disease after another 3 years of follow-up. We believe that if low levels of neurofibromin are seen in such cases with malignant conversion, subsequently increased neurofibromin levels may be responsible for better overall survival in these patients.

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Background: Postoperative pain and cerebrospinal fluid (CSF) leak are common known complications of spinal surgery, both having a synergistic effect on each other. Thus, both need to be dealt simultaneously. Double drug impregnated autologous coagulum patch (DDIAC) is a novel method which reduced both incidences of postoperative CSF leaks as well as pain. Methodology: Twenty-seven patients undergoing lumbar disc surgery without instrumentation were included and randomized into DDIAC and single drug impregnated autologous coagulum patch (SDIAC) group. The patients were assessed postoperatively with visual analog scale (VAS). Results: There were 21 males and 6 females in the study. Seventeen (63%) patients got randomized for DDIAC patch application and other 10 (37%) patients entered the control arm group (SDIAC) patch use. Preoperative VAS was 5 in both the groups. The average postoperative VAS was 3.01 in DDIAC arm and 4.29 in control arm. The average analgesic shot required in the DDIAC group was 0.41 in 24 h and SDIAC group was 4.1 in 24 h. In DDIAC group, none of these patients had CSF leak from the surgical wound till discharge from the hospital. In the SDIAC group, one (10%, n = 10) patient had CSF leak. Conclusions: DDIAC patch was effective in controlling pain in the postoperative period; however, few patients may require analgesic shots for pain management. SDIAC patch may control some pain in the immediate postoperative period; however, this was not sufficient for a longer postoperative period.

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A 60-year-old homemaker presenting with pedal edema and ascites was found to have a planum sphenoidale meningioma concurrently with nephrotic syndrome. On renal biopsy, the patient was found to have membranous glomerulonephritis. There was complete remission of nephropathy after excision of the meningioma. Nephrotic syndrome has been commonly found in association with malignancies and blood disorders but the association with a meningioma is extremely rare, and only one case has been previously reported as per our knowledge.

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Introduction: One of the underreported complications of clipping of unruptured aneurysm is chronic subdural hematoma/hygroma (CSDH). It can cause sudden deterioration and might need emergency evacuation. Recently, very few papers have studied its incidence and predisposing factors. We are reporting our institutional experience of it along with the study of its risk factors and possible pathogenesis. Methodology: Totally 91 postoperative patients of unruptured aneurysms were retrospectively analyzed. Totally 21 patients had CSDH who were operated. In rest seventy patients, there was no CSDH. Results: Male sex, old age, anticoagulant use, presence of pneumocephalus and dead space were significantly associated with occurrence of CSDH, whereas arachnoidoplasty significantly protected against it. There was no significant relation of CSDH with Gorei-san use. Conclusions: We recommend arachnoidoplasty should be carried out in all patients of clipping of unruptured aneurysm. Male patients or/and patients with dead space with pneumocephalus must be given extra attention like avoiding any dead space in postoperative period, doing arachnoidoplasty and regular follow up till 1^st year.

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The brain metastasis of angiosarcoma is very rare, and little is known about its clinical features or therapeutic strategy. A 74-year-old male was hospitalized for disturbance of consciousness. Radiological examination revealed multiple cerebral hematomas. Gadolinium contrast-enhanced magnetic resonance imaging showed no significant enhancement at any of the lesions. To detect a suspected metastatic brain tumor or abscess, a full-body scan was performed but revealed only a poorly enhanced mass in the removal cavity caused by thoracoplasty in the left upper chest. After admission, a cascade of expansion of those hematomas occurred in the right frontal, left parietal, and right temporal lobes, and each lesion thus had to be sequentially removed by craniotomies. The pathological diagnosis of the right frontal lesion was an abscess with hematoma. However, a malignant vascular tumor was highly suspected because of many CD31(+)/Ki-67(+) cells in the left parietal lesion. A mass in the scar caused by thoracoplasty was suspected to be the primary lesion, and brain metastasis of angiosarcoma was finally diagnosed. Whole-brain irradiation and systemic paclitaxel administration were performed, and a complete response for the brain lesions was obtained for 22 months; the patient then died of an intratracheal hemorrhage. This case represents the first report of multiple brain metastases from pyothorax-associated angiosarcoma accompanied by sequentially and gradually expanding hematomas, as well as the first case with the control of metastatic brain lesions for over 1 year after the onset of neurological symptoms. Control of the lesions could be achieved by their total removal with complete hemostasis, as well as additional radio- and chemotherapy.

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Oligodendrogliomas (ODGs) is a diffuse glial tumor that constitutes 4.2% of all brain tumors. Extraneural metastases, sometimes seen in glioblastoma multiforme, are extremely rare in ODG. In this report, we present a 63-year-old male patient who was diagnosed with Grade 3 ODG and had an intracranial mass resected in our clinic 4 years ago. The subject now presented with low back pain and was found to have widespread metastases. The prolongation of patient survival by current treatment regimens has revealed a growing number of ODG patients with metastases. We believe that back pain complaints in patients with ODG should be viewed as an indicator of metastasis.

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This technical note describes a direct puncture of the superior sagittal sinus (SSS) to treat a complex dural arteriovenous fistula (dAVF). A 40-year-old female was admitted having a history of increasing confusion. Computer tomography revealed enlargement of the right superior ophthalmic vein and magnetic resonance imaging demonstrated extensive bilateral hemispheric venous engorgement. Digital subtraction angiography (DSA) demonstrated a high flow dAVF involving the right transverse sinus. There was extensive cortical venous rerouting with venous sinus occlusion at the right transverse and sigmoid junction. Under general anesthesia, the sinus was exposed and catheterized. The angiography catheter was fed over the guide wire into the sinus. The remaining right sigmoid and transverse sinus were obliterated using a combination of microcoils and Onyx^®. She made a good postoperative recovery, and a repeat DSA at 30 days postoperatively showed evidence of the meningohypophyseal trunk but complete occlusion of the fistula. A check DSA 2 years later confirmed no evidence of a residual fistula. Our case demonstrates the potential use of the SSS as a novel conduit to treat distant targets.

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Extensive en plaque intradural extramedullary tuberculomas can occur as a paradoxical response to chemotherapy for intracranial tuberculomas. We report a case of 31-year-old male who presented with backache and progressive weakness and urgency of micturition. Magnetic resonance imaging dorsolumbar spine which showed an ill-defined T1 hypointense and T2 heterointense lesion noted posterior to the thoracic spinal cord, extending from C7 to D5 vertebral levels suggestive of en plaque meningioma. The patient underwent D1-D5 laminectomy, with subtotal debulking of the tumor. The histopathological examination of lesion was suggestive of granulomatous inflammation with multinucleated and Langhan type giant cells confirming the diagnosis of tuberculoma.

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Medulloblastoma is one of the common posterior fossa tumors in children. The natural history of this tumor in presymptomatic period is not well known. Widespread use of brain imaging has increased the detection of incidental brain tumors in totally asymptomatic persons. Here, we report a case of a 4-year-old boy with prenatal diagnosis of congenital brain abnormalities and neurofibromatosis type I. He underwent regular brain imaging to follow interhemispheric arachnoid cyst and ventriculomegaly that a posterior fossa tumor was discovered. The tumor size increased during time and became symptomatic after 28 months which was resected.

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An extremely rare case of chronic epidural empyema after cranioplasty is presented. It derives its extreme rareness from its association with calcification. This patient when presented to our department had a complaint of swelling with on and off discharging sinus for 2 months adjacent to old incision scar mark. The patient had a history of decompressive craniectomy and evacuation of acute subdural hematoma, in some other institution, 8 years back. Following that, the patient underwent cranioplasty with the exteriorized and preserved bone flap. In the meantime, he was asymptomatic. It is a unique interesting case of chronic epidural empyema with calcified walls after 8 years of long duration following cranioplasty.

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Chordoid meningioma is a rare variety of meningioma (0.5%–1%) with high rate of recurrence. They are grouped in WHO Grade II tumors. They are mainly distributed in the supratentorial location. There has been a single report of foramen magnum chordoid meningioma in a 3-year, 6-month-old child. Our patient, a 22-year-old female, admitted with progressive spastic quadriparesis with bowel and bladder involvement. She was operated with tumor resection done; postoperatively, patient showed dramatic improvement in the motor power as well as bowel and bladder function. Histopathology was suggestive of chordoid meningioma. She received 54 Gy of radiotherapy. She is doing well with no neurological deficits and no recurrence at 2-year follow-up.

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The persistent trigeminal artery is one of the presegmental arteries in the embryonic period; in some rare cases, it is associated with cerebral aneurysm but as a cause of subarachnoid hemorrhage (SAH) has not been described in the literature. We report a patient who presented a Fisher IV SAH associated with a ruptured intracranial aneurysm. The performed cerebral angiography demonstrated the presence of aneurysm in the anterior communicating artery associated to hypoplastic vertebral artery on the same side. We considered those finding coincidental. The coexistence of saccular aneurysm with anatomical variations in the intracranial vasculature is briefly discussed. It was managed by endovascular embolization. The patient returned to normal activities.

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First reported case of simultaneous occurrence of hemangiopericytomas(HCP) at multiple sites of craniospinal axis in a thirty four year male is presented. Patient presented with neck pain for 1 year, and one episode of simple partial seizure involving his left lower limb. He was diagnosed as having HCP in right middle one third parasagittal region, and C4,5 vertebral bodies. Another lesion was present in L5 vertebra, which was radiologically similar to the cervical lesion, but not biopsy proven. High index of suspicion, and low threshold for screening, for coexistence of spinal HCP, in patients harboring cranial HCP's and complaints of back pain.

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Deep brain stimulation (DBS) is a new alternative treatment for treatment-resistant major depression (MD) and obsessive-compulsive disorder (OCD). Various DBS targets were defined for MD and OCD. Nucleus accumbens (NAcc) comes out among the other targets in patients with MD and comorbid OCD when physiopathology and limited side effects are taken into account. We report a 27-year-old male with MD and OCD who was treated by bilateral NAcc-DBS. The aim of this study is to discuss NAcc as a DBS target in patients with MD and OCD and to report the first case of a psychiatric disorder treated with DBS in Turkey.

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