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Background The coronavirus 2019 (COVID-19) pandemic has changed the practice of neurosurgery. Significant resources have been dedicated to the disease. The pandemic in the Indian subcontinent, compared with the rest of the world, is relatively delayed. The neurosurgical practice cannot remain unaffected by hugely disruptive measures such as a lockdown. The inevitable increase in COVID infections with the gradual relaxation of lockdown continues to pose a risk for health care providers. Therefore, it is imperative to evaluate whether the pandemic has had a discernible effect on health care providers, especially in terms of practice modifications in private establishments and publicly funded hospitals, the emotional impact on the surgeon, and the influence of social media on the psyche of the surgeon. Methods An online questionnaire-based survey was prepared, with questions related to the COVID-specific themes of precautions taken in outpatient services and operating theaters, the influence of social media, the economic loss incurred, and the perceptible impact of telemedicine and webinars. The links to the survey were mailed to neurosurgeons in private and public practice countrywide. The responses were anonymized to ensure free and unbiased answers to the survey questions. Results A total of 176 responses were received from across the Indian subcontinent. The median age of respondents was 39 years (range, 32–70 years) and the postresidency experience was 7 years (range, 0–34 years). Respondents were an equitable mix of public and private practitioners. Of respondents, 46% were practicing restricted outpatient services, more in public institutions (P = 0.22) which also had a higher incidence of tele-outpatient services (26% vs. 17%). Wearing surgical masks, N95 masks, and gloves were the most commonly practiced precautionary measures in outpatient services (>60%). Although private practitioners were continuing elective cases (40%), public institutes were more cautious, with only emergency patients being operated on (29%). The greatest fear among all practitioners was passing the infection to their family (75%). Social media were helpful for brainstorming queries and updating practice modifications, but some surgeons admitted to receiving threats on social media platforms (37.5%). Depression and economic losses were palpable for approximately 30% neurosurgeons. Conclusions The survey highlights the perception of neurosurgeons toward the pandemic and the difference in public–private practice. Suspension of elective procedures, severe curtailment of regular outpatient appointments, drastic modifications of the normal outpatient department/operating room practices, and apprehensions related to inadequacy of safety provided by personal protective equipment use and financial losses of private establishments were some of the visible themes in our survey results. Although telemedicine has not been as widely adopted as expected, online education has been favorably received.

Traumatic brain injury (TBI) is a multifaceted condition that causes mortality and disability worldwide. Limited data are available on the factors associated with the decision for the withdrawal of life-sustaining treatment (WLST) for patients with TBI. In the present study, we aimed to determine the risk factors and attitudes affecting neurosurgeons when deciding on WLST for patients with TBI using a multicenter survey.An online questionnaire was applied worldwide and shared using social media platforms and electronic mail to ∼5000 neurosurgeons. The social media group "Neurosurgery Cocktail" was used to post a link to the questionnaire. In addition, randomly chosen neurosurgery clinics around the world were sent the survey via electronic mail.Of the participants, 17.22% had decided on WLST after TBI for26 patients. Neurosurgeons with more WLST decisions were older, had had more clinical experience and intensive care unit (ICU) training, and were better prepared to involve the family members of TBI patients in their decision-making compared with those with fewer WLST decisions. The respondents stated that the patient's family, ICU consultants, and themselves played the most influential role in the WLST decisions, with the hospital administration, social workers, spiritual caregivers, and nurses having lesser roles. The current and presenting Glasgow coma scale scores, pupillary response, advanced patient age, candidates for a vegetative state, and impaired neurological function were significant factors associated with the WLST decision.To the best of our knowledge, the present study is the first to evaluate neurosurgeons concerning their opinions and behaviors regarding WLST decisions after TBI. Increased patient age, Glasgow coma scale score, pupillary response, the presence of comorbidities, candidacy for a vegetative state, and impaired neurological function were the main factors contributing to the decision for WLST. We also found that the family, ICU consultants, and the attending neurosurgeon had the most effective roles in the decisions regarding WLST.

BACKGROUND Acta Neurochirurgica, (ANCH) and World Neurosurgery (WN), are two journals of significant importance in the neurosurgical community and have been associated with international federations. Of note is that these journals carry a similar impact factor. The difference is the years they have been active (ANCH starting publications in 1973 and WN in 2010). This allows for a unique opportunity to delve deep into comparative, scientometric parameters, to understand the evolution of neurosurgical research. METHODS A title specific search of the Web of Science database using the keywords ‘ACTA NEUROCHIRURGICA’, ‘Acta’ and ‘Neurochirurgica’; ‘World Neurosurgery’; ‘World’ and ‘Neurosurgery’ was done and arranged according to number of citations. Title of the articles, authors, corresponding authors, country of origin, journal of publication, year of publication, citation count and the journal impact factor were assessed. RESULTS The average citation for ANCH was 170.1 citations, majority being original articles (83/100). The articles of WN, garnered nearly 70.48 citations, averaging 8.3 citations per publication. Most corresponding authors in Acta originated from Germany with Neuro-oncology, followed by Neurotrauma and Vascular as subjects. In contrast the United States of America followed by China were the most common countries of origin for WN with ‘Endoscopy’ and ‘Skull-base’ being the topics achieving high impact. CONCLUSIONS Neurotrauma and consensus guidelines have been shown to have maximal citations for ANCH while Endoscopy and Skull-base lesions garnered the most for WN. Author subspecialisation and increased collaboration across specialities with more articles on refinement of technique and outcome have emerged as recent trends.

Background While multisession dose fractionated Gamma Knife radiosurgery (DFGKS) is common, its use has never been described for jugular paragangliomas (JP), which are notoriously difficult to treat. Objective To define efficacy, safety, and complication profile of DFGKS in 2 or 3 consecutive sessions for the treatment of a cohort of 10 cases of JP. Methods Between 2012 and 2017, 10 patients with JP were treated with DFGKS in 2 or 3 sessions, because it was not safe to treat the lesion in a single session because of the large volume or proximity to organs at risk. The small to medium-sized JP are treated with 16–22 Gy radiation, but the large-volume JP were treated with 23–25 Gy radiation dose. The Leksell G frame was kept in situ during the whole procedure. The tumor volumes on pretreatment and posttreatment imaging were compared, using the Leksell Gamma Plan treatment plan software to assess tumor progression. The patients were regularly evaluated for their clinical outcome with radiologic correlation. Results The mean radiologic follow-up was 39 months (range, 12–78 months). The mean marginal dose for 3 fractions and 2 fractions was 7.64 Gy at 50% and 11.2 Gy at 50%, respectively. The mean tumor size was 29.9 cm3 (range, 9.95–47.63 cm3) at treatment and 21.9 cm3 (range, 8.83–37.5 cm3) at follow-up (suggestive of 26.7% reduction). Tumor control was achieved in all patients (100%). Of 110 potential neurologic problems (signs/symptoms) evaluated (11 in each patient), 56 (50.9%) were present preoperatively. Of them, 27 (48.2%) improved and 29 (51.8%) stabilized after treatment. There were 2 new-onset neurologic problems (of 110, 1.8%) attributable to treatment (new-onset headache and spinal accessory paresis). No patient had any permanent neurologic deterioration. Conclusions DFGKS for large-volume JP leads to acceptable progression-free survival, tumor control rate, and symptomatic improvement. It may be preferred to surgery or fractionated radiotherapy given its better safety, efficacy, and complication profile.

Background Vascular loop compression remains the most accepted theory for trigeminal neuralgia (TN). Apart from the normal adjoining vascular loops, certain unusual vascular loops incriminated in TN such as vertebrobasilar dolichoectasia and pure venous compressions do not truly fit into the traditional classification. Moreover, vascular diseases such as cavernoma and aneurysms causing TN are considered as secondary TNs. There is a lack of unified classification for TN with underlying vascular offenders, otherwise amenable to microvascular decompression. Methods We classified vascular offenders in TN (n = 53) into the usual offenders such as superior cerebellar artery or anterior inferior cerebellar artery loop with (n = 4) or without (n = 34) superior petrosal vein loop (n = 38, group I). The unusual vascular offenders (n = 15, group II) comprised unusual arterial loops (n = 4, IIa), pure venous compressions (n = 8, IIb) and vascular diseases (n = 3, IIc). The clinical symptoms, pain severity scores, and surgical outcomes were compared. Results A right-sided preference and male predominance typified the unusual group. The incidence of atypical pain and sensory impairment was higher in group II. Group II also showed a less favorable immediate pain outcome, particularly the patients in group IIb. Group IIb also showed a higher incidence of postoperative hemorrhagic complications. However, long-term outcomes did not differ significantly. Conclusions Unusual vascular offenders in TN do constitute a significant population. They differ from the usual group with respect to the type of pain, gender, and side of involvement and tend to have more complications with similar pain outcomes after microvascular decompression.

Background Proatlas segmentation anomalies represent a rare subset of congenital craniovertebral junction anomalies. In this condition, the structures originating from the proatlas, such as the clivus, occipital condyles, foramen magnum rim, and odontoid tip, may demonstrate congenital anomalies, usually without any spinal instability. Elongated clivus, as a result of nonsegmentation of the odontoid tip from the rest of the proatlas, has been reported before to cause ventral spinal cord compression. We report such a case with certain unreported other associations and explore the pathoembryology and management options of such complex anomalies. Case Description An 8-year old girl presented with a 2-year history of progressive spastic quadriparesis. On neuroimaging, the anterior arch of the atlas was deficient, the odontoid process was foreshortened, and the clivus was elongated, encroaching into the spinal canal leading to ventral spinal cord compression. Additionally, there was rotatory posterior dislocation of the occipital condyles onto the posterior atlantal arch and vertebral artery anomaly. This patient underwent transoral decompression followed by occipitocervical fusion using rods and screws with satisfactory results. Conclusions Proatlas anomalies are rare, varied, and often subtle enough to go unrecognized. Knowledge of the embryology and its aberrations is necessary to understand these anomalies. Our case describes a rare form of bony anomalies pertaining to the fate of the proatlas with accompanying atlanto-occipital dislocation.

Background Poor sanitation, poor hygiene, and archaic cooking practices have led to neurocysticercosis (NCC) being endemic in India. Apart from a cortical location that leads to seizures, intraventricular NCC can present with hydrocephalus and sudden deterioration in sensorium. Consequently, endoscopic excision plays an important role in its treatment because a dilated ventricle offers a minimally invasive and less traumatic route to the pathology. Methods All endoscopically excised intraventricular NCC cases operated were retrospectively analyzed from 2014 to 2017, discussing surgical nuances and postoperative outcome. Results Twelve such cases were found (mean age, 21.9 ± 8.36 years; 9 men and 3 women). The mean follow-up period was 21.17 ± 13.96 months (range, 2–40 months). The most common site was the aqueduct and fourth ventricle. Conclusions An endoscopic approach is a feasible and safe tool for treating this disease. Technical nuances such as entry point and trajectory of endoscope need to be kept in mind while operating.

Objective The aim of this article is examine the issue of ambidexterity under the neurosurgical lens and demonstrate its need, its validity, and its advantages to neurosurgery as a whole. Methods Inspiration can be derived from extraordinary circumstances that shaped ordinary people into legends. There have been instances in history where highly skilled professionals relying on hand motor skills had the misfortune of having to relearn their skill set with the other, less dominant hand. Results We as neurosurgeons have always been ahead of the curve. It is only natural for us to understand the need and advantages of using both our hands with equal dexterity. Whether ambidexterity is an inherited trait or one that can be taught and, if practiced, mastered has been controversial. Conclusion These remarkable individuals from history demonstrate that if one is willing to practice without ego and one has the right motivation, one can use both hands with equal dexterity.

Background The novel coronavirus disease 2019 (COVID-19) pandemic has been at its peak for the past 8 months and has affected more than 215 countries around the world. India is now the second most-affected nation with more than 48,000,000 cases and 79,000 deaths. Despite this, and the fact that it is a lower-middle-income nation, the number of deaths is almost one third that of the United States and one half that of Brazil. However, there has been no experience published from non−COVID-19−designated hospitals, where the aim is to manage noninfected cases with neurosurgical ailments while keeping the number of infected cases to a minimum. Methods We analyzed the number of neurosurgical cases (nontrauma) done in the past 5 months (March−July 2020) in our institute, which is the largest neurosurgical center by volume in southern India, and compared the same to the concurrent 5 months in 2019 and 5 months preceding the pandemic. We also reviewed the total number of cases infected with COVID-19 managed during this time. Results We operated a total of 630 cases (nontrauma) in these 5 months and had 9 COVID-19 infected cases operated during this time. There was a 57% (P = 0.002) reduction in the number of cases operated as compared with the same 5 months in the preceding year. We employed a dual strategy of rapid antigen testing and surgery for cases needing emergency intervention and reverse transcriptase-polymerase chain reaction test for elective cases. The hospital was divided into 3 zones (red, orange, and green) depending on infectivity level with minimal interaction. Separate teams were designated for each zone, and thus we were able to effectively manage even infected cases despite the absence of pulmonology/medical specialists. Conclusions We present a patient management protocol for non−COVID-19−designated hospitals in high-volume centers with the constraints of a lower-middle-income nation and demonstrate its effectiveness. Strict zoning targeted testing and effective triage can help in management during the pandemic.

Background A histiocytosis is a group of immunoproliferative disorders of clonal cells. The management protocols are still evolving, with chemotherapy as the mainstay of treatment. Objective This study aims to evaluate the feasibility, safety, efficacy, and complication profile of stereotactic radiosurgery for intracranial histiocytosis. Methodology The authors reviewed PubMed, Scopus, Web of Science, and Embase for “radiosurgery” and “histiocytosis” in the English/Japanese language following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The patient profile, radiosurgical parameters (dose and isodose), target volume, and mode of radiosurgery (Gamma knife, LINAC radiosurgery, etc.) were collected. Its use as primary or adjuvant therapy, clinical and radiological outcome was also evaluated. Results We identified 7 studies (9 patients); mean age: 41.9 years (24–57 years). Six patients received Gamma-knife radiosurgery, whereas 3 received CyberKnife radiosurgery. The Langerhans cell histiocytosis variants were eosinophilic granuloma in 3, whereas 4 were not defined. Two cases had Rosai-Dorfman disease, and 2 different yet pathogenetically related histiocytic disorders. Four patients harbored lesions in the pituitary stalk and posterior pituitary, 2 patients in the petrous region, 1 patient had a pontine lesion, and 2 patients had multiple lesions. The dose delivered ranged from 8 to 28 Gy. A total of 18 lesions (9 patients) were followed for 81.67 patient-years: 7 (39%) disappeared, 8 (44.4%) showed radiological reduction, and 2 (11%) remained stable. One lesion (5%) showed an increase in size needed surgical excision. There were no adverse effects. Conclusion The role of stereotactic radiosurgery needs to be further evaluated as the current cohort with only 9 cases (2 are Rosai-Dorfman disease) is insufficient to make conclusions. It may be a viable alternative in localized disease, along with chemotherapy and targeted surgery.

Background Cannulation of lateral ventricles via a posterior approach is a common neurosurgical procedure. It is often believed that a single entry and fiducial point applies to all. No importance is given to skull shape variations, which can lead to wrong shunt positions and revisions. Objective A virtual-reality study was conducted to find the ideal entry point, ideal forehead fiducial point, and ideal angulation of the ventricular catheter and variations in these with changes in skull shapes. Methods Fifty human cadaveric skulls were used to measure anteroposterior (AP) diameter and width and to classify shape of skulls into 4 types. Hydrocephalus (100 cases) and normal magnetic resonance images (50 cases) were studied from a PACS (Picture Archiving and Communication System) database. An Osirix DICOM Viewer (3.9.4) was used to reconstruct the images and estimate the ideal, 90°, and midline shunt trajectory and correlate the same with AP/width ratios and skull shapes. Results Contrary to popular practice, the vertical distance from the inion for ideal trajectory placement was 4 cm in all shapes and ratio groups for hydrocephalus and nonhydrocephalus cases, respectively. As the AP/width ratio increases, the fiducial needs to be placed at a higher distance from the nasion and the distance of the entry point also increased from the inion. A rounder or more dolichocephalic skull dictates a 90° approach to be better, especially as the first pass. Conclusions No magical external entry point uniformly applicable for all cases exists. Hence, there is a need to classify skulls according to shapes/ratios and to use a tailored approach for a freehand pass to cannulate the ventricles.

Patients with a renal transplant are an ever-increasing demographic. Their life expectancy is also on the rise and thus malignancies or tumors in these cases are more frequent. These patients are often on immunosuppressive drugs that are known to cause changes in the microvasculature, especially of the deep white matter. However, benign dural-based lesions are a rarity in these cases with very few (5) ever being reported. Imaging findings in such cases are altered, which leads to an altered set of differential diagnosis.We present a case of a right parasagittal lesion in case of postrenal transplant with imaging findings suggestive of an inflammatory lesion. The lesion was excised and histopathology was that of a fibrous meningioma. Pathological basis of altered imaging is discussed and potential causes elaborated along with a thorough review of similar cases and their findings.Renal transplants and long-term survival are now a reality; calcineurin inhibitors are a staple for these cases. The drugs alter imaging findings and hence cases need to be carefully evaluated with a host of differential diagnosis. Knowledge of these changes is now necessary for these new spectra of cases.

Background Endoscopy is now a staple of any neurosurgical practice. The versatility of this approach and gratifying results has resulted in its increased popularity. The objective of this paper is to report our experience of managing various cerebellopontine angle (CPA) pathologies by endoscopic keyhole retromastoid suboccipital craniectomy (RMSO) approach. Methods A retrospective review of the medical records of patients operated in our department by endoscopic keyhole RMSO approach was done along with a collection of relevant patient particulars. Results Forty-four patients (24 men and 20 women) were operated via an endoscopic keyhole RMSO approach for various lesions in and around the CPA. The craniectomy was of 2.0–2.5 cm in size. An endoscope was used as the sole visualizing tool throughout the procedure in all cases. Primarily 2 kinds of pathologies were approached: neoplasms, mostly benign (n = 33), and vascular loops (n = 11). The extent of excision in 33 tumor cases was gross total (n = 20), near total (n = 12), and subtotal (n = 1). In cases of a vascular loop, microvascular decompression was performed. Anatomic facial nerve preservation was ensured in all cases of vascular loops and in 30 tumor cases. Postoperative complications included new-onset/worsening of facial nerve paresis (n = 12, 27.3%), 9 of which improved in follow-up, transient facial hypoesthesia (n = 2, 4.5%), transient abducens paresis (n = 4, 9%), transient lower cranial nerve paresis (n = 3, 6.8%), pseudomeningocele (n = 1, 2.3%), cerebrospinal fluid leak with meningitis (n = 1, 2.3%) and operative site hematoma (n = 1, 2.3%) which required evacuation. Conclusions Endoscopic keyhole RMSO approach is minimally invasive and yields an excellent outcome in the management of various CPA lesions.

Objective The primary training in any surgical practice starts with tissue handling and effective hemostasis. Neurosurgical procedures start with an incision in the scalp and require summative use of mechanical hemostats and bipolar coagulation to achieve hemostasis. Though Raney clips are the most popular and effective in maintaining hemostasis, their high cost and nonreusability become deterrents for routine use in resource-stricken environments. Methods We have compared stationery binder clips of different sizes with Raney clips on the parameters of effectiveness, availability, and cost. Binder clips were also used in intraoperative settings for scalp hemostasis. The comparative efficacy, additional usage of cautery, and need for sterilization are also discussed. Results We describe our experience with simple stationery metal binder clips in maintaining effective hemostasis in a cost-effective manner. The 25-mm size binder clip exerts same force as a Raney clip without any tissue injury. Practical application revealed effective scalp hemostasis up to blood pressure of 150 mm Hg. Conclusions Stationery binder clips are a cost-effective, ready-to-use alternative for standard Raney clips.