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Background:Pituitary masses are common lesions accounting for about 15–20% of all brain tumours. Oozing blood is an annoyance in microscopic sublabial trans-sphenoidal approach for these masses. There have been many ways of reducing the ooze, having their own pros and cons. Objective:To find out the efficacy and safety of clonidine in reducing blood loss in pituitary adenoma surgery through a randomized masked trial. Methods:It was a prospective randomized controlled trial done. Total 50 patients of pituitary adenomas were randomized into two groups. Group A (25 patients) was given 200 μg clonidine orally, while Group B (25 patients) was given placebo. Surgeon, anaesthesiologist and patient were blinded for the trial. Sublabial trans-septal trans-sphenoidal approach to sella and excision of mass was performed in each patient. Patients were studied for pre-, intra- and post-operative blood pressure and heart rate, pre- and post-operative imaging findings, intra-operative blood loss, bleeding grading by surgeon, surgeon’s satisfaction about condition of specific part and quality of surgical field, operative time and extent of resection. Results:Blood loss during the surgery, operative time and bleeding grading by the surgeon were found significantly less in the clonidine group, while quality of surgical field, condition of the specific part and extent of resection were found significantly better in the clonidine group (pvalue <.05). There was no untoward adverse effect of the drug in the test group. Conclusion:Clonidine is a safe and effective drug to reduce bleeding in trans-sphenoidal microscopic pituitary adenoma surgeries. [ABSTRACT FROM PUBLISHER]

Background and Objectives: Atlantoaxial dislocation (AAD) poses a complex surgical challenge. Surgical approaches vary for reducible and irreducible cases. Challenges persist in reducing the atlantodental interval, especially in cases with oblique or vertical C1-C2 joints. The Rocker instrument (MJ Surgical), a less-explored technique, seeks to simplify instrumentation, reduce complexity, and enhance translation and retroflection reduction of AAD., Methods: This prospective observational study was conducted from January 2022 to July 2023 at a tertiary neurosurgical center. Inclusion criteria covered all age groups with AAD, with or without basilar invagination. Exclusions included medically unstable patients and severe osteoporotic spine conditions. Preoperative assessments included dynamic X-rays, magnetic resonance imaging, and computed tomography scans. The Rocker technique was used, and patients were followed up for 6 to 12 months., Results: Fifty-five patients (30 males, 25 females) underwent surgery. The mean age was 40.41 ± 15.01 years. Successful Rocker technique application was observed in 53 cases. Functional outcomes, assessed using Modified Ranawat grading, showed improvement postoperatively. Radiological outcomes revealed a significant reduction in the anterior atlantodental interval (7.21 ± 0.94 to 2.98 ± 0.78). Basilar invagination was reduced in all cases, whenever present. The technique exhibited versatility, applicability in various joint orientations, and cost-effectiveness., Conclusion: The Rocker technique is a safe and effective alternative for managing both reducible and irreducible AADs, with or without basilar invagination. It simplifies the reduction process, offering advantages over established techniques. Further trials, especially in rotational deformities, are warranted for validation., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Objective: The authors sought to analyze the residual connections formed by the temporal stem as a cause for seizure recurrence following endoscopic vertical interhemispheric hemispherotomy and to review and compare lateral approach (perisylvian) with vertical approach surgical techniques to highlight the anatomical factors responsible for residual connections., Methods: This study was a retrospective analysis of patients who underwent endoscopic hemispherotomy for drug-resistant epilepsy. Postoperative MR images were analyzed. Specific attention was given to anatomical 3D-acquired thin-section T1 images to assess the extent of disconnection, which was confirmed with a diffusion tensor imaging sequence. Cadaver brain dissection was done to analyze the anatomical factors responsible for persistent connections., Results: Of 39 patients who underwent surgery, 80% (31/39) were seizure free (follow-up of 23.61 ± 8.25 months) following the first surgery. Thirty patients underwent postoperative MRI studies, which revealed persistent connections in 14 patients (11 temporal stem only; 3 temporal stem + amygdala + splenium). Eight of these 14 patients had persistent seizures. In 4 of these 8 patients, investigations revealed good concordance with the affected hemisphere, and repeat endoscopic disconnection of the residual connection was performed. Two of the 8 patients were lost to follow-up, and 2 had bihemispheric seizure onset. The 4 patients who underwent repeat endoscopic disconnection had seizure-free outcomes following the second surgery, increasing the good outcome total among all patients to 90% (35/39). Cadaveric brain dissection analysis revealed the anatomical factors responsible for the persistence of residual connections., Conclusions: In endoscopic vertical approach interhemispheric hemispherotomy (and also vertical approach parasagittal hemispherotomy) the temporal stem, which lies deep and parallel to the plane of disconnection, is prone to be missed, which might lead to persistent or recurrent seizures. The recognition of this limitation can lead to improved seizure outcome. The amygdala and splenium are areas less commonly prone to be missed during surgery.

Tubercular meningitis (TBM) can have various complications. Sometimes syringomyelia can also occur as a late complication of tubercular meningitis. Although syrinx formation in early stage of TBM is very rare. There are only four published case reports of syringomyelia in acute stage of TBM. Here we report a patient with tubercular meningitis who developed syringomyelia in early course of illness., (© Journal of the Association of Physicians of India 2011.)

Although endoscopic techniques have many advantages including improved visualization and magnification, they are also associated with limitations. The objective of this review is to discuss the practical aspects that can reduce complications after endoscopic procedures, and their management. The review is based on the personal experience of more than 2000 neuroendoscopic procedures performed by the senior author. Topic search was made on PubMed using Neuroendoscopy, complications and neuroendoscopy, complication avoidance and neuroendoscopy, endoscopic neurosurgery, and minimally invasive neurosurgery. Relevant articles were selected after analyzing abstracts and/or topics. Endoscopic procedures are also associated with limitations such as obstruction in instruments manipulation, steep learning curve, blind area, difficulty in visualization, disorientation, loss of stereoscopic image and others. Neuroendoscopy is distinct from microsurgery and the surgeon has to learn endoscopic skills in addition to microsurgical techniques. Difficulties in controlling bleeding, working in a limited area, higher complication rate during the initial learning curve and longer operative time are some of the limitations. Attending live workshops, practicing on models, and hands on cadaveric workshops can reduce the learning curve. Proper case selection, multidisciplinary team approach, watching operative video, visiting other departments, observing a skillful endoscopic surgeon, lab training, and simulators can improve results and shorten the learning curve. Limitations of this review are that the search is limited to the English literature and personal experience of a single surgeon that may create some bias. Although neuroendoscopic techniques are associated with improved results in some indications, they have many limitations. Neuroendoscopic skills need to be learned to improve results.

Introduction:  Several different surgical techniques have been used in the treatment of patients with symptomatic Arnold-Chiari malformation type 1 (ACM-1) with or without syrinx. Endoscope-assisted decompression of the posterior fossa has been found to be safe and effective. We report our initial experience of endoscopic management of ACM-I., Material and Methods:  This was a prospective study of 15 symptomatic patients. Pre- and postoperative clinical status and computed tomography and magnetic resonance imaging findings were recorded. Suboccipital bone of ∼ 3 cm distance from the foramen of magnum and posterior arch of atlas was removed. Partial splitting of the dura mater with preservation of the inner portion and the arachnoid membrane was performed. Any change in axial and sagittal length of the syrinx, tonsillar ascension, shape of the tonsil tip, appearance of cerebrospinal fluid posterior to the tonsil, and formation of the cisterna magna were recorded. Patients with atlantoaxial instability, tethered cord, associated myelomeningocele, hydrocephalus, or elevated intracranial pressure were excluded., Results:  Age of patients ranged from 26 to 48 years. There were nine female patients. There were six patients with ACM-I without and nine with ACM-I with syrinx. Average pre- and postoperative Karnofsky performance score was 78 and 93, respectively. Average operative time was 130 minutes (110-190 minutes), and blood loss was 30 mL (20-180 mL). Follow-up ranged from 9 to 21 months., Conclusion:  Although the study is limited by the small number of patients with a short follow-up, endoscopic decompression in selected patients of ACM-I with or without syrinx with dural splitting was a safe and effective alternative to microsurgical treatment., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Aim: Microscope may fail to detect culprit vessel at the root entry zone or distally, especially when the suprameatal tubercle is prominent and when the compressing vessel is lying anteriorly to the trigeminal nerve without using significant brain retraction. Endoscopic techniques allow better visualization of the nerve and vascular conflict., Material and Methods: A retrospective study of 178 patients of endoscopic vascular decompression without the use of microscope was done. The follow-up period ranged from 12 to 108 months (average 58 months)., Results: The age of the patients ranged from 32 to 75 years. Neuralgia was in the maxillary, mandibular and both (maxillary and mandibular) divisions in 89, 72 and 16 patients, respectively. Duration of the operation and hospital stay ranged from 85 to 160 minutes and 2 to 10 days (average 2.7 days), respectively. Offending vessels could be identified in 174 patients. The superior cerebellar artery, anterior inferior cerebellar artery, single vessel, double vessel conflicts and a vessel anterior to the nerve were seen in 136, 76, 133, 41 and 31 patients, respectively. The pain was relieved in 167 patients (93.8%). Temporary complications included trigeminal dysesthesias (3.9%), cerebrospinal fluid leak (2.8%), facial paresis (3.9%), decreased hearing (1.7%) and vertigo (3.3%). Permanent hearing loss, recurrence of pain and re-surgery was observed in 1, 7 and 3 patients, respectively., Conclusion: Endoscopic vascular decompression is a safe and effective technique for vascular decompression with advantages of better visualization of the entire course of the nerve and vascular conflict without brain retraction. It also helps in better detection of the completeness of surgery.