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Background: In spite of advancements in treatment options for MCA infarct, there is a definite role of decompressive hemicraniectomy. When compared with best medical management, it decreases mortality and improves functional outcome. But does surgery improve quality of life in terms of independence, cognition or it merely leads to increased survival? Objective: Outcome of 43 consecutive patients of MMCAI who underwent DHC was studied. Materials and Methods: Functional outcome was evaluated based on mRS and GOS in addition to survival advantage. The patient’s proficiency in performing ADL was evaluated. MMSE and MOCA were performed to evaluate the neuropsychological outcome. Results: In‑hospital mortality was 18.6%, and by 3 months, 67.5% of patients survived. During follow‑up, nearly 60% of patients showed improvement in functional outcome when evaluated based on mRS and GOS. No patient could reach to the level of independent existence. Only eight patients could perform MMSE and five had good score (>24). All were young and had a right‑sided lesion. None of the patients could perform well in MOCA. Conclusion: DHC improves survival and functional outcome. Cognition remains poor in the majority of the patients. These patients, though survive the stroke, remain dependent on care givers. [ABSTRACT FROM AUTHOR]

Background: Management strategies for petroclival menigiomas remain controversial.Objectives: We share our experience in management of large and giant true petroclival meniongiomas with special emphasis on patient reported quality of life parameters.Methods: This is a single center study of 47 patients between 2008 and 2018. All patients were checked for tumor specific parameters, clinical parameters, extent of surgical excision, and outcome, as assessed by Karnofsky performance score (KPS), Glasgow outcome score, clinical status, and by SF-36 questionnaire.Results: 32/47 patients' data were assessed. Symptoms included headache (62.5%), involvement of 5th nerve (47%), facial nerve (40.6%), lower cranial nerves (37.5%), cerebellar signs (84%), and long tract signs in (50%) of patients. The mean preoperative KPS was 83.75+/-6.59. Surgical approaches included retromastoid suboccipital craniotomy (50%), Kawase's approach (31.25%), and others in 18.25% patients. 40.625% (n = 13) had a gross total excision, near total resection (NTR) was achieved in 53.125% (n = 17), and 6.25% (n = 2) had a subtotal excision (STE). In 13 patients who had gross total resection (GTR), there were 12 (70.5%) new neurological deficits, while among the 19 patients with NTR, only 5 (29.5%) new neurological deficits were seen. No new onset neurological deficit was seen in patients with STE of tumor. Patient assessed QoL parameters were worse in patients with GTR and best in patients with NTR/STE + GKRS.Conclusion: In patients of large/giant petroclival meningiomas, NTE/STE with adjuvant GKRS provided better preservation of quality of life. [ABSTRACT FROM AUTHOR]

Background: Extraskeletal mesenchymal chondrosarcoma (MCS) of the central nervous system (CNS) is extremely rare. Herein, we present the clinicopathological features of five CNS extraskeletal MCS.Material and Methods: Over the past 10 years, five cases of CNS MCS have been retrieved from in the archives of histopathology department. All biopsies were stained with vimentin, S-100, CD99, desmin, GFAP, INI1, WT1, STAT6, and EMA.Results: There were four males and one female patient in the age group of 1.5-35 years. The clinical and radiological impression was meningioma in three cases, glomus jugulare and primitive neuroectodermal tumor in one case each. All showed classic biphasic morphology, areas of undifferentiated small blue round cells sharply demarcated from the island of cartilage. Three patients experienced multiple recurrences and died subsequently.Conclusion: Extraskeletal MCS of CNS is rare and favors children and young adults. They show aggressive behavior and tend to recur despite surgery and radiotherapy. [ABSTRACT FROM AUTHOR]

Background: Surgical revascularization is the mainstay of treatment in symptomatic patients of moyamoya disease (MMD).Objective: The present study analyzed the postoperative angio-architecture in pediatric and adult patients of moyamoya disease.Material and Methods: Patients with MMD, both ischemic and hemorrhagic, were subjected to surgery. A superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was attempted in all. It was augmented by an encephalo-duro-myo-synangiosis), this was labelled as the combined surgical group. In patients where a direct bypass was not possible encephalo-duro-arterio-myo-synangiosis (EDAMS) was performed and these patients were put in the indirect surgery group. In the postoperative period, MRA was performed in all patients to look for (a) graft patency, (b) regression of moyamoya vessels, and (c) degree of surgical neovascularization (as quantified on adapted Matsushima and Inaba grading system).Results: Eighty-two patients underwent 131 surgical revascularization procedures. A combined surgery (STA-MCA bypass and EDAMS) was performed in 100 hemispheres and indirect surgery (EDAMS) on 31 sides. In children less than 5 years of age, STA-MCA anastomosis was possible in more than 50% of patients. Clinical improvement was seen in 85.4% of patients. Postoperative MRA demonstrated a patent bypass graft in 97% of cases. Regression of moyamoya vessels was seen in half of the cases and good surgical revascularization (type A and B) was seen in more than 80% of hemispheres in the combined surgery and indirect surgery group.Conclusions: Revascularization procedures led to a regression of moyamoya collaterals, appearance of surgical neo angiogenesis, and a graft patency rate of 97%. Surgical group with combined revascularization had a trend towards better collateral development. [ABSTRACT FROM AUTHOR]

Background: Anatomy of the temporal region is complex with controversy over the relationship of fascial planes with the upper division of the facial nerve.Objective: This study aimed to identify the safe surgical landmarks to preserve the frontotemporal branch of the facial nerve during surgery and define the safest approach for surgical procedures in this region.Material and Methods: The anatomical relationship of the frontal branch of the facial nerve, superficial temporal artery (STA), fascial planes, and fat pads was determined after dissection on 10 cadaveric heads, that is (20 sides) Dissection was performed layer by layer from skin to bone.Results: The temporoparietal fascia was made up of multiple (3-4) layers above the zygomatic arch and these layers were integrated with thin fibrous septa. The frontotemporal branch of the facial nerve (FTFN) was observed in a deeper part of temporoparietal fascia and superficial fat pad. The frontotemporal branch of the facial nerve (FTFN) crossed the zygomatic arch as two branches in 25%, as three branches in 65% and as four branches in 10% of specimens.Conclusions: Interfascial dissection between two layers of deep temporal fascia through the intermediate fat pad is superior to other approaches because of the lack of facial nerve branches in this plane. The Intermediate fat could be easily separated from deep layer of deep temporal fascia. [ABSTRACT FROM AUTHOR]

Background: The world is in the midst of the COVID crisis, which has forced the neurosurgical community to change its practices.Objective: To advocate the necessary adaptations in radio surgical practices to effectively manage the radio surgical patients, resource utilization, and protecting the healthcare provider during the COVID pandemic.Material and Methods: In addition to the literature review, pertinent recommendations are made in respect to the gamma knife radiosurgery (GKRS).Results: Every patient presenting to GKRS treatment should be considered as a potential asymptomatic COVID carrier. Patients should be categorized based on the priority (urgent, semi-urgent, or elective) on the basis of pathological and clinical status. The only urgent indication is a non-responding or enlarging cerebral metastasis. There is a high risk of aerosol dispersion during gamma radiation delivery in the gamma gantry.Conclusion: These recommendations should be used to minimize the chances of pathogenic exposure to the patient and caregivers both. [ABSTRACT FROM AUTHOR]

Introduction: Hyperosmotic agents are used to decrease intracranial pressure (ICP). We aim to compare the effect of euvolemic solutions of 3% hypertonic saline (HTS) and 20% mannitol on intraoperative brain relaxation in patients with clinical or radiological evidence of raised ICP undergoing surgery for supratentorial tumors.Materials and Methods: A.prospective double-blind study was conducted on 30 patients randomized into two equal groups. Each patient was administered 5 ml/kg of either 20% mannitol or 3% HTS over 15 minutes (min) after skin incision. Hemodynamic data, brain relaxation and serum electrolyte levels were recorded.Results: Intraoperative brain relaxation was comparable between the two groups. There was a statistically significant difference in the mean arterial pressures (MAPs) between the two groups after one minutes (min) with a greater degree of decrease in blood pressure recorded in the mannitol group (P = 0.041). MAP with mannitol was significantly lower than the preinduction value after 75 min of administration of drug (P = 0.003). Urine output was significantly higher in the mannitol group (P = 0.00). Administration of HTS was associated with a transient increase in serum sodium concentrations, which was statistically significant but returned to normal within 48 h (P < 0.001).Conclusions: Both mannitol and HTS provided adequate intraoperative brain relaxation. On the contrary, there was no statistically significant fall in blood pressure with HTS. Thus, we advocate the use of HTS over mannitol as it maintains better hemodynamic stability. [ABSTRACT FROM AUTHOR]

Background: Development of cerebral infarcts following clipping of ruptured intracranial aneurysm is one of the major determinants of functional outcome in patients with subarachnoid hemorrhage (SAH). The aim of this study is to evaluate the factors affecting development of postoperative infarcts, its incidence, pattern, and functional outcome.Material and Methods: This study includes 118 patients of spontaneous SAH because of ruptured anterior communicating artery aneurysm, who underwent clipping. Relevant points in history, preoperative and intraoperative findings, and postoperative outcome are evaluated.Results: 29 of 118 (24.5%) patients developed postoperative radiological infarcts. Approximately 37.9%, 17.2%, and 3.4% patients developed isolated infarcts, respectively, in anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) territory. About 20.7% patients developed infarcts in deep perforator territory. Nine of 29 (31.3%) patients developed multiple-vessel territory infarcts. Patients with poor preoperative neurologic status, prior history of seizure, and history of intraoperative rupture had higher chances of development of infarcts. Development of infarct was irrespective of temporary clipping (TC), duration of clipping, and elective versus rescue clipping. Development of infarcts adversely affected the outcome in significant proportions. Among patients with infarcts, unilateral ACA territory infarcts showed best prognosis, whereas all patients with multiple territory infarcts and PCA territory infarcts died. Age or sex of the patients did not affect the functional outcome. Timing of development of infarcts has no influence on functional recovery.Conclusion: Development of symptomatic infarct is the sole important predictor of functional outcome. A crowded neurovascular neighborhood and complex variations in local angioarchitecture make anterior communication (ACOM) territory predisposed to operative insults. Elective TC and aggressive management of cerebral vasospasm are recommended to prevent development of infarcts. [ABSTRACT FROM AUTHOR]

The Department of Neurosurgery started functioning at the Postgraduate Institute of Medical Education and Research, Chandigarh in 1962 with the joining of Dr. Gulati. The department provides neurosurgical services primarily to the people of Chandigarh, Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir as well as the neighbouring areas of Rajasthan, Uttar Pradesh and Uttarakhand. The infrastructure and subspecialties have been developed over the last 5 decades by the dedicated and tireless efforts of the faculty and residents. We attempt to chronicle the contributions of those who have served the department in the past. [ABSTRACT FROM AUTHOR]

Background: The fornix is the main efferent tract from the hippocampus and is an important component of the memory pathways. Variations in the anatomy of the fornix are not commonly encountered.Materials and Methods: The anatomy of the fornix was studied in 30 cadavers of normal adult healthy males who had died in road accidents. The full extent of the hippocampus was prosected up to the tail under the magnoscope.Results: In 10 of the 30 brains, the crura and the body of fornix were bilaterally broad and flat like a sheet, rather than the usual compact bundle, forming a cobra-like hood over the roof of the third ventricle. The maximum width was approximately 16 mm on the right side (mean: 11.7 mm) and 11 mm on the left (mean: 8.5mm).Conclusion: Knowledge of this variation will be useful during the transcallosal approach to third ventricle tumors, especially while going subchoroidal, because an unexpected lateral span of the fornix in the surgical corridor can result in inadvertent injury to it, leading to memory defects. [ABSTRACT FROM AUTHOR]

Background: Nutritional status and adiposity have not been studied to a significant extent in subarachnoid hemorrhage (SAH). The aim of this study was to determine the trends in anthropometric indices and assess their impact on patients with SAH. Methods: We prospectively studied in 56 patients with SAH, the triceps skinfold thickness (TSF), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), and other factors, and their relationship to clinical vasospasm and mortality. Results: The median MAC decreased significantly from 29.3 cm (interquartile range [IQR] 28-31 cm) at admission to 27 cm (IQR 26-29 cm) at 1-week (P < 0.001). The median TSF decreased significantly from 34 mm (IQR 30-40 mm) at admission to 30 mm (IQR 25-35 mm) at 1-week (P < 0.001). MAMC values did not show a significant change over a week. The patients who developed clinical vasospasm had significantly higher median admission TSF of 40 mm (IQR 35-45 mm), compared to the median admission TSF of 35 mm (IQR 30-40 mm) among those who did not develop vasospasm (P = 0.03). MAMC values did not differ significantly in relation to vasospasm. Patients who expired by 3 months had significantly greater fall in median MAMC values at 1-week (7.7% [IQR 5.2-11.5%]), compared to the fall in median MAMC values at 1-week among those who were alive at 3 months (2.6% [IQR 2.1-6.6%]) [P = 0.03]. However, the fall in TSF values did not differ significantly in relation to mortality. In multivariate analysis, only the admission TSF, Hunt and Hess and Fisher grades had a significant association with vasospasm. This association was independent of other prognostic factors and of each other. Conclusion: Excessive adiposity of patients, measured as an increased TSF value, is significantly associated with clinical vasospasm independent of other prognostic factors, while fall in MAMC, indicating somatic protein catabolism, has some impact on mortality. [ABSTRACT FROM AUTHOR]

The article presents the cases of three patients who were harboring multiple intracranial lesions and whose histopathology revealed a glioblastoma. These include a 50-year-old woman whose neurological examination showed a right-sided hemiparesis and sensory aphasia, a 30-year-old male who had a heterogenous solid-cystic lesion in the left frontal lobe with sub-falcine herniation and a midline shift, and a 50-year old female patient with an enhancing mass in the right frontal lobe.

Background: Traumatic cerebrospinal fluid (CSF) rhinorrhea is a serious and potentially fatal condition as it may lead to meningitis. As acetazolamide decreases CSF production and hence CSF pressure, it has been proposed that the medication may help in curing CSF rhinorrhea. There is no definitive evidence, however, that acetazolamide is actually beneficial in treating traumatic CSF rhinorrhea. The aim of this study was to determine if the administration of acetazolamide in patients of head trauma with CSF rhinorrhea was beneficial in decreasing the duration of CSF rhinorrhea. The acid-base and electrolyte changes caused by the drug were also studied. Materials and Methods: We conducted a single center randomized prospective study. Forty-four patients of head trauma with CSF rhinorrhea were divided into two groups, the experimental group (21 patients) was given acetazolamide; and, the control group (23 patients) did not receive the medication. The median duration of CSF leak in days, and the electrolyte changes observed on administration of the medication were recorded in both the groups. Results: Both the experimental and control groups were well matched in terms of age, sex, mechanism of injury, Glasgow Coma Scale (GCS) and the type of skull fracture. The median duration of CSF leak in the control group was of 4 days and in the study group, of 5 days. Acetazolamide caused significant metabolic acidosis and hypokalemia (as shown by decreased serum pH, serum bicarbonate and serum potassium levels) in the experimental group when compared to the control group. Conclusions: Acetazolamide did not influence the resolution of traumatic CSF rhinorrhea and instead lead to significant metabolic and electrolyte disturbances. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 29‑year old male patient met with an accident and had a brief loss of consciousness for which he was managed conservatively. He was found to have right eye proptosis and extensive chemosis with complete absence of right eyeball movement. He was diagnosed with middle meningeal arteriovenous fistula causing unilateral proptosis.

The article presents a case study of a 62-year-old female patient who was diagnosed with persistent trigeminal artery (PTA) aneurysm. Topics discussed include the hyperdense left cavernous sinus lesion revealed by computed tomography (CT), the confirmation of aneurysm by the subsequent diagnostic angiography, and the classification of PTA.

Background: Management of patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) is difficult and the protocols followed differ from center to center. Material and Methods: In this report, we present our experience with aneurysmal clipping in patients with poor-grade SAH. Patients with poor Hunt and Hess (H and H) grade (Grade IV and Grade V) were offered surgery after stabilization of their hemodynamic and metabolic parameters. The status was recorded as favorable (good recovery, mild to moderate disability but independent), unfavorable (severe disability, vegetative) and dead. Results: Out of a total of 1196 patients who underwent aneurysmal clipping, 165(13.8%) were in poor grade. Of the 165 patients, 99 (60%) were in H and H Grade IV and 66 (40%) were in Grade V. More than half of the patients (58%) were operated within 24 h of admission. There was an overall mortality of 50.9%. In the long term, of the survivors who were followed up, about 72% achieved a favorable outcome. Conclusions: With an aggressive approach aimed at early clipping, the chances of rebleed are reduced and vasospasm can be managed more aggressively. This protocol resulted in survival in a significant proportion of patients who would have otherwise died. In the long-term followup, the surviving patients showed significant improvement from the status at discharge. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which describes the case of a 45-year-old woman diagnosed with a ruptured anterior artery aneurysm and monocular blindness.

Two patients with giant dumbbell foramen magnum neurinomas are reported. The intradural component was located anterior to the cervicomedullary junction while the extradural and extraspinal portion of the tumor had grown large enough to present as a neck swelling. In both patients total surgical removal was achieved by a single-stage posterior midline approach. Both patients had complete neurological recovery. [ABSTRACT FROM AUTHOR]

We report a patient with an uncommon presentation in the form of massive bilateral calvarial hyperostosis with biparasagittal en plaque meningioma. The tumour was removed by bilateral fronto-parieto-occipital craniotomies. The patient was subjected to post operative radiotherapy to reduce the chances of recurrance. The management of such a case is a surgical challenge. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "Study of Trends in Anthropometric Nutritional Indices and the Impact of Adiposity Among Patients of Subarachnoid Hemorrhage" in a 2015 issue is presented.

The article focuses on endovascular management of most intracranial aneurysms caused by either compression of the brain parenchyma, brain stem or the cranial nerve. The treatment regimens to address this condition including use of stent-assisted coling and flow diverters, direct clipping of the aneurysm and skull base approach combined with anterior clinoidectomy. The surgical option for giant aneurysm of the middle cerebral artery and giant posterior circulation aneurysms is discussed.

The article presents a case of an 18-year-old girl presented with complaints of watery nasal discharge and was diagnosed with posterior fossa arachnoid cyst (AC) with isolated cerebrospinal fluid (CSF) rhinorrhea. Endoscopic sinus surgery for repair of CSF leak failed and bifrontal craniotomy and anterior cranial fossa repair with pericranial grafting, both intra and extradural was done. The computed tomography shows disappearance of pneumocephalus and pneumoventricle at six-month follow-up.

A letter to the editor is presented about the results of a study of gunshot wounds of the atlanto-axial region.

Background: Surgical excision of giant (>4 cm size) vestibular schwannomas (VS) with preservation of facial nerve (FN) function remains a challenge., Objective: Our surgical technique using an extra-arachnoid plane of dissection and limited meatal drilling is described with the goal of improving FN preservation., Methods: Surgical results with respect to FN preservation were analyzed for two groups of giant VS patients: Group A-operated between 2002 and 2009 using "standard" surgical technique, group B-operated between 2009 and 2016 using extra-arachnoidal dissection and limited meatal drilling. All patients had a minimum follow-up of 1 year., Results: Group a: Of the 115 patients, total excision was possible in 103 (89.5%), near-total in 7 (6%), and subtotal in 5 (4.3%) patients. At a >6-month follow-up, 68 (59.1%) patients had good FN function (House-Brackmann [H&B] grades 1-2), while 21 (18.3%) patients had poor function (H&B grade 3-5). Grade 6 involvement was seen in 26 (22.6%). Five patients had lower cranial nerve impairment necessitating tracheostomy., Group B: Of the 98 patients, total excision was achieved in 70 (71.4%) patients, near-total in 9 (9.2%), and subtotal in 19 (19.4%). Four patients had repeat surgery; 14 underwent gamma-knife radiosurgery. At >6-month follow-up, 78 (79.5%) patients had good FN function (H&B grades 1-2), while 20 (20.4%) had poor function (H&B grade 3-5)., Conclusions: With our 'modified' surgical technique of extra-arachnoidal dissection of VS throughout surgery and limited meatal drilling, an improved rate of functional FN preservation was observed., Competing Interests: None

Background: Traumatic cerebrospinal fluid (CSF) rhinorrhea is a serious and potentially fatal condition as it may lead to meningitis. As acetazolamide decreases CSF production and hence CSF pressure, it has been proposed that the medication may help in curing CSF rhinorrhea. There is no definitive evidence, however, that acetazolamide is actually beneficial in treating traumatic CSF rhinorrhea. The aim of this study was to determine if the administration of acetazolamide in patients of head trauma with CSF rhinorrhea was beneficial in decreasing the duration of CSF rhinorrhea. The acid-base and electrolyte changes caused by the drug were also studied., Materials and Methods: We conducted a single center randomized prospective study. Forty-four patients of head trauma with CSF rhinorrhea were divided into two groups, the experimental group (21 patients) was given acetazolamide; and, the control group (23 patients) did not receive the medication. The median duration of CSF leak in days, and the electrolyte changes observed on administration of the medication were recorded in both the groups., Results: Both the experimental and control groups were well matched in terms of age, sex, mechanism of injury, Glasgow Coma Scale (GCS) and the type of skull fracture. The median duration of CSF leak in the control group was of 4 days and in the study group, of 5 days. Acetazolamide caused significant metabolic acidosis and hypokalemia (as shown by decreased serum pH, serum bicarbonate and serum potassium levels) in the experimental group when compared to the control group., Conclusions: Acetazolamide did not influence the resolution of traumatic CSF rhinorrhea and instead lead to significant metabolic and electrolyte disturbances.