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Background The use of the classic 2-ends anchoring technique is common in end-to side (ES) microvascular anastomosis. The literature on the toe-first (TF) technique is limited. In the current study we present the successful outcomes with the TF technique in ES anastomoses in rat femoral vessels model. Methods ES microvascular anastomosis with the tf technique was performed in the femoral vessels of 10 Sprague Dawley rats. Two-throw reef knot interrupted sutures were used in all cases. Individual parameters during the procedure were recorded for analysis. The immediate and delayed (cut open technique after 2 weeks) patencies were confirmed. An illustrative case showing the use of this technique in superficial temporal artery to middle cerebral artery bypass in a pediatric moyamoya disease case is included. Results The average suturing time was 40.14 ± 5.30 minutes, the procedures were completed with an average of 14.57 ± 1.90 sutures. The average time per suture was 2.78 ± 0.43 minutes. The immediate patency was 100% (10 of 10 cases). Two rats died of unknown cause in the observation period. The delayed patency was 100% in the remaining 8 cases (average observation: 29.6 days). Conclusions The TF interrupted suture technique of ES microvascular anastomosis with 2-throw reef knots is feasible with excellent immediate and delayed patency rates. The distinct advantages of the TF are the continuous visualization of the recipient lumen during anastomoses, avoiding back-wall bites, and the ability to correct any discrepancy in the recipient–donor lumens during the procedure.

Background and Introduction: Intraoperative neuromonitoring for eloquent cortical lesions is irreplaceable in present-day neurosurgery. Objective: We report a novel technique of combining awake craniotomy with direct cortical stimulation of the motor cortex using the NIM© nerve monitoring system. Technique: A 17-year-old boy presenting with focal motor seizures, diagnosed with left perirolandinc cavernoma, underwent awake craniotomy and complete excision under direct cortical stimulation with NIM monopolar stimulator electrode to locate the motor cortex. Result: The patient developed transient weakness of handgrip during surgery, which improved by the same day evening. At 3 months follow-up, he could perform all the activities with his dominant right hand. Conclusion: Cortical stimulation using a nerve monitoring system is a useful technique in case of nonavailability of standard evoked potential monitoring system for motor cortex mapping.

Background The use of a 3-throw knot for anastomosis by microvascular neurosurgeons is the usual standard. There is an inherent belief that the third throw adds extra security to the knot; however, the third throw can make the knot heavy and unbalanced and can exert undue extra pressure on the opposing walls of the small-caliber intracranial vessels. This study evaluated the feasibility and efficiency of 2-throw reef knot interrupted sutures for an end-to-side microvascular anastomosis. Methods A prospective observational study of end-to-side anastomosis using a femoral artery–to–vein model was performed in 30 Sprague–Dawley rats. All anastomoses were done using 2-throw reef knot interrupted sutures. Ten procedures each were done by the heel-first, toe-first, and classic 2-ends techniques. Individual parameters were recorded for analysis. The delayed patency was confirmed by reexploration after a mean duration of 19.82 ± 8.12 days. Results The overall patency rates were 100% in the immediate period and 96.43% (27 of 28) in the delayed period. The average clamping time, average suturing time, and the average time per suture were 65.48 ± 16.93 minutes, 40.94 ± 11.22 minutes, and 3.18 ± 1.10 minutes, respectively. Two rats died in the postoperative period. Conclusions The end-to-side microvascular anastomosis with 2-throw reef knots is feasible, with excellent immediate and delayed patency rates.

In macrosurgery creating a knot with at least three throws is an established practice. The potential disadvantages of this practice in microsurgery include the following: the direction of the cut ends interfere with the suture line, unbalanced nature of knot disturbs the apposition of delicate vessel ends and the excessive knot weight. A reef knot with only 2 throws may thus be a better alternative. We have described our technique of end to end anastomosis with 2-throw reef knots in a rat femoral artery model using one way up method. Judging from the surgical outcome the practice of two throw reef knot seems feasible and appealing.

Gangliogliomas (GGs) are rare tumors of the central nervous system occurring in the young population (8.5-25 years). GGs are one of the most common cause of epilepsy associated with CNS tumors and significant proportion of them is refractory to antiepileptic medications. Multifocal gangliogliomas are very rare and only few handful cases are reported. A rare case of multiple spinal ganglioglioma has also been reported in the literature. We present a case of an adolescent girl who presented with multiple episodes of seizures. She was initially evaluated and diagnosed with multiple tuberculomas. She was managed with antiepileptics and antitubercular medications. Her seizure frequency had decreased; but despite prolonged and complete course of anti-tubercular treatment, the lesions were not subsiding in size. Antitubercular medications were restarted and subsequent scan showed progression in the size of the lesions; and hence biopsy was done from the largest lesion. Histopathology was suggestive of GG. Ganglioglioma can be multifocal and can mimic other lesions like tuberculosis, radiologically. Surgical excision of the lesion provides the best treatment option. It is still under consideration whether to remove all of the lesions or only ones with considerable size. She had another episode of seizure and is now planned for surgical excision of the other lesion.

Intracranial hematomas and contusions are common entity after traumatic brain injury in children and young population. However, cerebral infarction after traumatic head injury is a rare entity with frequency ranging from 1.9 to 10.4%. We herein report a case of cerebral infarction in right anterior cerebral artery (ACA) and parts of middle cerebral artery (MCA) territory after moderate head injury in a 14-year-old boy, in whom computed tomographic (CT) scan of the brain was performed 3.5 hours after injury, which showed specks of pneumocephalus in sellar suprasellar region, and 12 hours after injury showed right ACA territory infarct and evolving infarct in right MCA territory. Bony injury included right orbital roof and right sphenoid wing linear undisplaced fractures. Possible mechanism for development of infarction is right internal carotid artery (ICA) dissection by fractured bone fragments and/or thrombosis. The patient developed hemiplegia on second day after trauma. Intracranial pressure (ICP) monitoring was done, which was suggestive of raised ICP. The patient underwent right fronto-temporo-parieto craniotomy and decompression (tissue sent for histopathologic analysis) and augmentative duraplasty with bone flap replacement on fifth day after trauma. Histopathology was suggestive of cerebral infarct with hemorrhage. The patient was improved at follow-up, 10 months after trauma after rehabilitation, and physiotherapy to modified Rankin scale (mRS) score 3. Hence delayed CT scan plays a vital role in detecting developing posttraumatic infarcts, and rigorous rehabilitation care is necessary for clinical improvement.

OBJECTIVEThe aim of this study was to report the etiology, clinical features, microbiology, surgical outcome, and predictors of outcome of spontaneous subdural empyema (SDE).METHODSThe authors conducted a retrospective study in a tertiary hospital. Children up to 18 years of age, with a diagnosis of SDE with infective etiology, were included in the present cohort. Patients with posttraumatic, postsurgery, and tubercular origin of SDE were excluded from the study. The Glasgow Outcome Scale was used for outcome assessment at the end of 3 months. For analysis purposes, the demographic data, clinical features, radiological data, microbiology, type of surgery, and complication data were categorized, and univariate and multivariable logistic regression analyses were performed to identify the factors associated with outcome.RESULTSNinety-eight children were included in the study and the mean age was 10.9 years. Otogenic origin (34.7%) was the most common source of infection, followed by meningitis (14.3%). The mean duration of symptoms was 12 days. Seventy-six children presented with Glasgow Coma Scale (GCS) score > 8 and the supratentorial location was the most common location. Almost 75% of the children underwent craniotomy or craniectomy and the rest had burr-hole evacuation. Beta-hemolytic Streptococcus (10%) was the most common organism isolated. Cerebral venous thrombosis (CVT; 10.2%) was the most frequent complication in this cohort. The other complications were infarction (6.1%), new-onset seizure (4.1%), and bone flap osteomyelitis (4.1%). Thirteen cases had a recurrence of pus collection, which was more common in the craniotomy group than in the burr-hole group. Age (p = 0.02), GCS score ≤ 8 (OR 8.15, p = 0.001), CVT (OR 15.17, p = 0.001), and presence of infarction (OR 7, p = 0.05) were strongly associated with unfavorable outcome. In multivariable logistic regression analysis, only GCS score ≤ 8 (p = 0.01), CVT (p = 0.02), and presence of infarction (p = 0.04) had a significant impact on unfavorable outcome.CONCLUSIONSPrompt diagnosis and immediate intervention is the goal of management of SDE, especially in children as a delay in diagnosis can result in unconsciousness and secondary complications such as CVT and infarction, which adversely affect outcome.

In side to side anastomosis and end to end (one way up) microvascular anastomosis, the back wall of the vessel is sutured first with inverted/buried knots. A common mistake made by surgeons during this step is the formation of a granny knot. In inverted suturing, cut ends of granny knot points inside the vessel lumen and interfere with the suture line. This additional Intraluminal thread may promote foreign body reaction and may act as a nidus for thrombus formation. Hence, this subtle mistake in knot formation may cause immediate and/or delayed anastomosis failure. The purpose of the study was to describe principles of inverted/buried reef knot formation. We describe in detail the methodology to form an inverted reef knot in microsurgery using paracords and a glove model.

In this study, design of experiments (DoE) was employed to develop a single injection method using a headspace gas chromatograph with flame ionization detector for resolution of residual solvents of United States Pharmacopeia (USP) listed classes 1 and 2, against current recommendation of independent injections. G43 column (6% cyanopropylphenyl and 94% dimethylpolysiloxane) and nitrogen were used as the stationary phase and carrier gas, respectively. Initial temperature, hold time, temperature ramp and carrier gas velocity were the critical method parameters. Resolution of 1,1,1-trichloroethane and tetrahydrofuan (THF); THF and chloroform; benzene and 1,2-dichloroethane (DCE), and 1,2-dimethoxyethane and DCE were selected as critical quality attributes. These were optimized by DoE that resulted in resolution of >1.34 among various solvents. The separation of all the solvents was achieved within total run time of 77 min. A better resolution of 2.66 was observed in the case of acetonitrile and methylene chloride; there was improved Signal/Noise ratio of 8.86 for 1,1,1-trichloroethane; tailing factor for pyridine was 1.00, and the method showed acceptable repeatability of peak areas (%RSDmax = 11.53) and retention times (%RSDmax = 0.45). Thus, while system suitability criteria and validation results very well met the USP requirements, the optimized method proposed in this study proved advantageous additionally in terms of single injection; short run time, and use of nitrogen as a carrier gas instead of costly helium in the USP method.