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Introduction Glioblastoma multiforme (GBM) is a devastating form of cancer with a poor prognosis despite available treatments. Managing recurrent GBM remains challenging and lacks guidelines. This study aims to provide practice patterns for managing recurrent GBMs in India.

Background: The supra-cerebellar infratentorial approach to pineal region tumours is versatile and safe corridor to lesions located below the deep veins. Monitoring of the extra-ocular muscle pathways using the evoked compound muscle action potential can lead to safer resections. Technical note: To describe the use of electrooculography and a three handed retractor less method for pineal region tumour surgeries. Material and methods: Intraoperative electrooculography uses recording done from two channels (horizontal and vertical)by inserting disposable subdermal needle electrodes along the periorbital area. The oculomotor nerve is being monitored as it exits the midbrain. Retractor-less three-handed-technique allows for minimal handling of the cerebellum while maximizing the operative corridor. Result: The oculomotor nerve was stimulated post resection and correspondingly led to improved symptoms post-operatively. Discussion and conclusion: We demonstrate a method for the intraoperative monitoring of the continuity of the oculomotor tracts and a three handed retractor-less method of resection of pineal region tumours. The placement of electrodes and area of stimulation need sound knowledge of anatomy of the region. Haemostasis at every step is absolutely essential to be able to visualize in the narrow corridor.

Background: Lumbar discectomy is performed for symptomatic lumbar disc herniation and is one of the most widely performed spinal surgical procedures worldwide in a variety of ways. This survey aimed at providing an overview/perspective of different practice patterns and the impact of lumbar discectomy on axial back pain with or without sciatica. Methods: An online survey was performed using the application “Google Forms.” The link to the questionnaire was distributed to neurosurgeons through personal E-mail and social media platforms. Results: We received 333 responses. The largest percentage of responses across five continents was from Asia (66.97%, n = 223). The mean age of the respondents was 40.08 ± 10.5 years. A total of 66 respondents (20%) had a spine practice of 7%–90%, and 28 respondents had a spine practice of 90%–100% (8.4%). The number of respondents who practiced microscopic discectomy using a tubular retractor (n = 143 respondents, 42.9%) was nearly equal to the number of respondents who practiced open discectomy (n = 142 respondents, 42.6%). An almost equal proportion of respondents believed discectomy does not help in relieving axial back pain. Only 20.4% (n = 68) of respondents recommend bed rest for a longer duration postoperatively. Conclusions: Our survey revealed that only 22.2% of spine surgeons recommended discectomy in patients with radiological disc herniation with axial back pain alone and preferred a minimally invasive method of discectomy. Almost half of them believed discectomy to be ineffective for axial low back pain and only a few recommended prolonged bed rest postoperatively.

Abstract The medical-patient relationship is facing pollution of information all over the internet, for physician and patients is becoming tougher to keep updated with the highest quality of information. During the last 20 years multiple evaluation tools have been developed trying to find the best tool to assess high-quality information, to date DISCERN tool represents the most widely spread. Information can be found on the surface internet and in the deep web, constituting the biggest chunk of the internet, informing and controlling the quality of information is a formidable task. PubMed and Google Scholar are the most important tools for a physician to find information, although multiple others are available; awareness must be raised over improving current strategies for data mining high-quality information for the patients and the healthcare community.

Chronic subdural hematoma (cSDH) is one of the most studied clinical entities in the neurosurgical literature. Management of cSDH is complicated by its propensity to recurrence. Various factors for the development of recurrence of cSDH have been described in various clinical, epidemiological, and observational studies, yet the evidence available is limited. A systematic review and meta-analysis as per PRISMA guidelines to identify clinical and radiological factors which can predict the development of recurrence in cSDH. A total of 14 studies were included for the systematic review and meta-analysis after a comprehensive search of the online databases. Eight studies were of high methodological quality. Age, use of anticoagulants, obesity, seizure, and liver disease were found to be statistically significant clinical risk factors for the development of recurrence in cSDH. Among the radiological parameters, the internal structure of the hematoma and the width of the hematoma was found to be significant risk factor predicting the development of recurrence. Age >75 years, use of anticoagulation therapy, liver disease, and obesity were significant risk factors for cSDH recurrence. Pneumocephalus, internal architecture of hematoma, bilateral cSDH, the width of hematoma, and the presence of bilateral cSDH are important radiological parameters of the development of recurrent cSDH

Abstract Background Hospital-based cancer registries can provide information on the magnitude and distribution of cancers in a given hospital. Hospital-based brain tumor registry data, focusing on glioma, from a tertiary care rural neurological center is lacking in the scientific literature. This data can be useful in understanding the need for research and funding required for these specific brain tumors. Data of patients operated for glioma, at our institute, was collected between January 2004 and December 2015. Patients’ clinical details and histopathological diagnosis were recorded. Data were analyzed and compared with that of previously published literature, and inferences were drawn on patterns of reporting and epidemiology. Results A total of 1450 cases of glioma, with a mean age of 39.3 (± 17.36 SD) years with males (66.6%) comprising more population as compared to females. Majority of patients 70.8% (n = 1027) belong to the economically active age group of country (18–60 years). Majority of cases (41.4%) were glioblastoma with the next common tumor (22.8%) being diffuse astrocytoma (n = 331) followed by pilocytic astrocytoma (6.2%) and oligodendroglioma (4.5%) in that order. While our data followed similar trends with other Indian data the average age of glioma was a decade younger to what is quoted earlier in Indian and international studies. Conclusion This data for glioma gives a glimpse of the prevalence of this tumor in a primarily rural population and highlights the need for a National Brain Tumor Registry with the need for the development of evidence-based policymaking and enhanced research into this particular ailment.

Background: Seizures due to posterior fossa lesions is an uncommon phenomenon. In this study, a systemic literature review was done to (i) study the incidence of seizures in posterior fossa lesions, (ii) determine factors associated with high risk for seizures, and (iii) ascertain the role of prophylactic antiepileptic drugs (AEDs) in such cases. Methods: Systemic literature review was done, for the MeSH terms “posterior cranial fossa” AND “seizures” AND “anticonvulsants.” All original research articles, case reports, and systematic reviews pertaining to seizures or the use of anticonvulsants in posterior fossa lesions were considered for inclusion. Results: A total of 79 cases of posterior fossa lesions, identified from 8 studies, were included for analysis. The incidence of seizures in posterior fossa lesions ranged from 1.8% to 5% in various studies. The highest incidence for seizures was reported with medulloblastoma, cerebellar hemorrhage, and during microvascular decompression for cases of neurovascular conflict. The most significant risk factor for seizures in the postoperative period was the use of ventricular shunt or ventriculostomy. AEDs were administered symptomatically after the occurrence of seizures in 78 cases except for the use of prophylactic AEDs in a single case of posterior cranial fossa lipoma. Conclusion: Seizures in association with posterior fossa lesions are rare and associated with a poor prognosis. Clinical detection can often be difficult and electroencephalogram helps in early diagnosis and treatment. Further studies are needed to confirm the role of prophylactic AEDs in high-risk cases.

Oxidative stress is a silent participant in all chronic progressive pathology and degenerative disorders. Neurodegeneration and cognitive impairment are caused by increased imbalanced oxidative stress and down-regulated natural anti-oxidant combat mechanisms. Cancer is the end result of cell malfunction and the activation of tumour-specific genes, which are regulated by specific geneomolecular pathways. Acute stroke is the pathology of oxidative stress and a decrease in the body's combating defence mechanisms. Oxidative stress, which results from an imbalance between oxidative and antioxidative activities in cells, has been linked to the aetiology of a number of chronic degenerative diseases, including cancer and stroke. The harmful effects of ROS and their role in lesion progression after cancer and ischaemic stroke are undeniable; however, the therapeutic usefulness of anti-oxidants in this scenario remains debatable. In this review, we have summarised the potent molecular mechanisms which play a vital role through activation of various pathways and associated advanced targeted therapeutics to combat cancer and stroke like chronic pathologies.

Abstract Intracerebral hemorrhage is hemorrhage occurring in the brain that can occur because of immediate trauma or structural disease process. The age-standardized mortality rate is decreasing worldwide especially in the past 20 years, but the number of cases and incidence along with number of disability-adjusted life-years and deaths keeps rising. Despite having half the incidence as ischemic stroke, intracerebral hemorrhage (traumatic or spontaneous) causes more morbidity and mortality than ischemic stroke and yet an established strategy for treatment on the lines of reperfusion therapy is a far-fetched dream. A selective review of all relevant articles covering recent treatment options and guidelines along with major emphasis of the surgical aspect and pathophysiology has been done. Complete literature review and differences between management of traumatic and spontaneous hemorrhage were sought and discussed. A pathophysiological basis of management should be followed for both these different yet similar pathologies. Understanding the etiology reveals a somewhat clearer picture regarding treatment of this highly unfortunate and devastating disease. Current interest is focused on the surgical management of the disease with the pathophysiology often been forgotten.

Extradural spinal nerve root hemangioblastoma is a rare entity with very few cases reported in the literature. A comprehensive picture of the treatments and outcomes of the same is thus not available. A systematic search was done according to PRISMA guidelines. Search criteria included terms: spinal extradural hemangioblastoma, extradural hemangioblastoma, and spinal root hemangioblastoma. The parameters considered were treatment, motor, and sensory outcome, association with von-Hippel-Lindau (VHL) syndrome. Twenty-two studies (19 full text articles) were available for the review. A total of 39 cases of extradural spinal nerve root hemangioblastoma have been reported. These cases had a median age of 44 years with male predominance (2:1) and up to 48% occur in the thoracic level, similar to our case. Thirty-six percent of patients were associated with VHL syndrome. Surgical resection was the primary modality of treatment with embolization used in selected cases (20%). They had mean follow-up of 23 (±11) months. The prognosis was better than the intradural counterpart with no motor deficit and sensory deficit in only 9%. Preoperative identification of the extradural nature of this pathology and complete excision at the first surgery offers excellent outcomes compared to intradural lesion. Targeted embolization may be used in cases anticipated with high blood loss.

Any and all advances made by medical science cannot solve the problem of road traffic injuries (RTIs) in school-going children, especially if the only concerned people are those of the medical fraternity. Children are a vulnerable part of the traveling population and thus have been persistent due to the callous nature of the citizens and policy makers toward road safety and injury prevention. In our multicultural and multilingual country, there is a need for multistakeholder initiative with a countrywide presence if we are to stem the rise of mortality and morbidity due to these accidents. The first question we need to ask is how to prevent road traffic accidents and improve the condition of our roads. Pediatric RTIs are eternal problem of industrial revolution with complications and effects that may affect individual and society with increase in the number of motorized communications. Dedicated capacity building is urgently need who should be able to provide the necessary care to the injured children at the road crash spot as well as should be informed where to take the injured child and whom to contact in the dedicated injury care center while transporting the victims of situations.

Introduction: The presence of concomitant skull base defects resulting in spontaneous CSF rhinorrhea is an extremely rare entity with only 7 such cases reported to date. All of these cases whether done endoscopically/transcranially initially needed transmastoid or transcranial repair later apart from one report where both defects were repair simultaneously. We report the first case repaired simultaneously via a single craniotomy. Identification of such defects pre-operatively and intra-operatively are very important to prevent recurrence and associated morbidities. Case report: We present a case report of a 38-year-old patient with a double skull base defect who presented with spontaneous CSF rhinorrhea. Since the two defects were not in the same coronal plane and thus difficult to approach simultaneously via endoscopy hence a transcranial approach using neuro-navigation to repair both defects was undertaken. Also, a complete review of literature of all cases of double skull base defects showed that simultaneous access of both defects is essential to prevent re-surgery and hence a single craniotomy was used to repair both these defects. Conclusion: Any case presenting with spontaneous CSF rhinorrhea should undergo repair immediately after a thorough investigation of the site of the leak. This is a benign condition which if treated early can lead to a very satisfying resolution of symptoms. Preoperative identification of all defects can prevent re-surgery and simultaneous repair should be the goal at all times.

Background Thermal injuries in a patient undergoing magnetic resonance imaging (MRI) are rare; more so, when the patient in question is being operated upon. We attempt to elucidate the various factors that may predispose to such an unfortunate circumstance, through a series of four cases. Materials and Methods We conducted a retrospective review of our experience with intraoperative MRI and found four cases of burns attributed to MRI. Factors leading to possible injury were examined after other causes were ruled out. Results Collection of moisture between the leads and the patient's skin was the most common factor for the burns. There were no instances of closed loop formation or injury due to direct contact of cables to the skin. Conclusion Awareness of the causative factor can lead to prevention. Proper education of all concerned personnel involved in the conduction of the intraoperative MRI is paramount to prevention of the same.

Chronic kidney disease causes a myriad of changes in the normal physiology of the body. Inflammation, atherosclerosis, vascular calcification, the effect of uremic toxins, cerebral blood flow dysautoregulation, dialysis techniques, vascular access, prothrombotic tendency, and anticoagulation are just some of the changes which form a part of the cascade. Stroke is intimately associated with this disease process and it is difficult to manage both simultaneously. In this review, we have narrated to outline the pathophysiological cascade behind each of the two disease processes that how they interact with each other. In this review we have focused on possible therapeutic options exist to manage both with special emphasis on antiplatelets, miRNA, and pre and probiotics. This review exist all the possible pathological pathways and therapeutic targets in such dual cascade that will be very useful for the clinicians while dealing in this complex interplay.

Abstract While sudden hearing loss after stereotactic radiosurgery has been demonstrated in some cases a recent article by Linge et al. and have demonstrated the need for further discussion on this topic. We attempt to delineate the fact that the type of dosing regimen or technology used will not affect the hearing or radio-graphical control outcomes and thus should not be a consideration while administering treatment. Also we discuss the role of location of the lesion and vascularity and potential new therapies for this unexpected outcome after radiosurgery.

Objective This study was performed to review the literature and to present the most up-to-date information and recommendations on the indications, complications, and success rate of anterior surgical techniques for cervical spondylotic myelopathy (CSM). The commonly performed anterior surgical procedures are multiple-level anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion and its variants (skip corpectomy and hybrid surgery), and oblique corpectomy without fusion. Methods A comprehensive literature search and analysis were performed using MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and the Web of Science for peer-reviewed articles published in English during the last 10 years. Results Corpectomy is mandated for ventral compression of fewer than 3 vertebral segments where single-level disc and osteophyte excision is inadequate to decompress the cord. Endoscopic or oblique partial corpectomy improves the sagittal canal diameter by 67% and obviates the need for an additional bone graft procedure. Conclusion The indications of anterior surgery in patients with CSM include a straightened or kyphotic spine with a compression level lower than 3. With an appropriate choice of implants and meticulous surgical technique, surgical complications can be seen only rarely. Improvements after anterior surgery for CSM have been reported in 70% to 80% of patients.

Chiari I malformation is characterized by the downward displacement of cerebellar tonsils through the foramen magnum. While discussing the treatment options for Chiari I malformation, the points of focus include: (1) Has the well-established procedure of posterior fossa decompression become outdated and has been replaced by posterior C1–2 stabilization in every case? (2) In case posterior stabilization is required, should a C1–2 stabilization, rather than an occipitocervical fusion, be the only procedure recommended? The review of literature revealed that when there is bony instability like atlantoaxial dislocation (AAD), occipito-atlanto-axial facet joint asymmetry or basilar invagination (BI) associated with Chiari I malformation, one should address the anterior bony compression as well as perform stabilization. This takes care of the compromised canal at the foramen magnum and re-establishes the cerebrospinal fluid flow along the craniospinal axis; and also provides treatment for CVJ instability. In the cases with a pure Chiari I malformation without AAD or BI and with completely symmetrical C1–2 joints, however, posterior fossa decompression with or without duroplasty is sufficient to bring about neurological improvement. The latter subset of cases with pure Chiari I malformation have, thus, shown significant (>70%) rates of neurological improvement with posterior fossa decompression alone. A C1–2 posterior stabilization is a more stable construct due to the strong bony purchase provided by the C1–2 lateral masses and the short lever arm of the construct. However, in the cases with significant bleeding from paravertebral venous plexus; a very high BI, condylar hypoplasia and occipitalized atlas; gross C1–2 rotation or vertical C1–2 joints with unilateral C1 or C2 facet hypoplasia, as well as the presence of subaxial scoliosis; maldevelopment of the lateral masses and facet joints (as in very young patients); or, the artery lying just posterior to the C1–2 facet joint capsule (being endangered by the C1–2 stabilization procedure), it may be safer to perform an occipitocervical rather than a C1–2 fusion.

In this systematic review, we detailed the current understanding and controversies on venous thromboembolism as the sequel following traumatic brain injury (TBI). The review was conducted on the literature survey to find the thromboembolic morbidities in TBI patients. This review presented the thromboembolic sequel of patients with TBI by a comprehensive focused assembly of research publications by searching various resources. A search strategy with specific inclusion criteria was performed in PubMed, Cochrane, Web of Science, and the WHO Global Health Library. TBI is related with the incremental presence of spectrum of thromboembolic disorders from primary and secondary injuries by the significant increases in the concentrations of the initiating factors of the coagulation cascade. The incidences of thromboembolism vary on factors like the severity of TBI, methods of prophylaxis used or the processes to diagnose embolic involvement. The most effective time for the initiation of antithrombotic therapy chemoprophylaxis should be initiated after 24 h or after 72 h in patients with brain trauma is still a controversial issue. Patients with brain injury are at increased risk for thromboembolism for which prophylaxis and timely management are highly recommended, and this should be available in all levels of care.

Subarachnoid hemorrhage (SAH) is a neurological emergency occurring frequently and has significant morbidity and mortality. Etiological classification divides it into traumatic and nontraumatic or spontaneous. Even though it has been referred that these are almost the same pathology, there is a slight difference between them regarding several aspects, such as epidemiological, pathophysiological, clinical, and diagnostic approach and treatment. These differences deserve detailed understanding to help physicians treat this disease more efficiently. We reviewed all available literature regarding these two types of SAH and tried to elicit differences between them with respect to etiology and treatment. The differences were made keeping in mind the utility of the same to a general physician so that rapid and informed decisions can be made at that level. Pathophysiological differentiation of these two diseases is of paramount importance, and etiological diagnosis determines prognosis. Knowledge of the same is essential and lifesaving.

(1) Objective—Intraoperative Magnetic Resonance Imaging (IOMRI) guided surgery has revolutionized neurosurgery and has especially impacted the field of Neuro-Oncology, with randomized controlled trails demonstrating improved resection, fewer postoperative deficits and enhanced survival rates. Bibliometric analysis allows for analysing chronological trends and measuring the impact and directions of research in a particular field. To the authors’ knowledge, this is the first Bibliometric analysis conducted on IOMRI. (2) Methods—a title specific search of the Web of Science database was executed using the keywords ‘intraoperative MRI’, ‘intraoperative magnetic resonance imaging’, and “IOMRI’ on 23rd April 2021. Results—663 articles met the inclusion criteria and were included in the final analysis. In addition, the 100 most cited were analysed as well. Among these 100 articles, 76 were original research papers, while 14 others were review articles. Amongst all the authors, Ganslandt contributed the maximum number of articles, with USA being the largest single source of these articles, followed by Germany. Interestingly, a shift of trends from “Image guided surgery’ and ‘accuracy’ in the early 2000s to ‘extent of resection’, ‘impact’, and ‘survival’ in the later years was noted. (3) Conclusions—IOMRI has now become an integral part of neurosurgery, especially in neuro-oncology. Focus has now shifted from implementation to refinement of technique in the form of functional and oncological outcomes. Therefore, future research in this direction is imperative and will be of more impact that in any other sub-field related to IOMRI.

Background: Chronic renal failure in neurosurgical patients is not uncommon especially in the setting of hemorrhagic stroke. However, unfamiliarity with the syndrome of increased ICP during dialysis in these cases can lead a novice into the Bermuda Triangle. neurosurgeons prognosticating a patient with an ICH are often left in a state of ambiguity when the baseline blood reports reveal a deranged kidney function profile. To compound matters, Dialysis Disequilibrium syndrome presents with symptoms of raised intracranial pressure like nausea, headache, and vomiting and may even fatal in such cases. Case description: We describe a 64 yr old gentleman with right basal ganglia bleed who also had chronic kidney failure at presentation. An ICP monitor was placed in this case and dialysis was carried out along with anti-edema measures such as Mannitol with input-output and serum electrolyte monitoring. The ICP monitor showed a sudden rise in ICP during the dialysis sessions and this was reproducible over 3 such sessions. Eventually, further such sessions were stopped and the patient was managed with osmotic diuretics, antiepileptics. The eventual CT scan also did not show any sign of increased hematoma or mass effect thus pointing to a different mechanism of increase of the same. Conclusion: Too often neurosurgeons are faced with cases that may demand knowledge of a disease that may affect the neurological outcome. Avoiding high urea gradients during the procedure, minimizing the dialysis dose and isolated ultrafiltration may be the ideal approach.

Background: Neurosurgical task shifting and task sharing (TS/S), delegating clinical care to non-neurosurgeons, is ongoing in many hospital systems in which neurosurgeons are scarce. Although TS/S can increase access to treatment, it remains highly controversial. This survey investigated perceptions of neurosurgical TS/S to elucidate whether it is a permissible temporary solution to the global workforce deficit. Methods: The survey was distributed to a convenience sample of individuals providing neurosurgical care. A digital survey link was distributed through electronic mailing lists of continental neurosurgical societies and various collectives, conference announcements, and social media platforms (July 2018–January 2019). Data were analyzed by descriptive statistics and univariate regression of Likert Scale scores. Results: Survey respondents represented 105 of 194 World Health Organization member countries (54.1%; 391 respondents, 162 from high-income countries and 229 from low- and middle-income countries [LMICs]). The most agreed on statement was that task sharing is preferred to task shifting. There was broad consensus that both task shifting and task sharing should require competency-based evaluation, standardized training endorsed by governing organizations, and maintenance of certification. When perspectives were stratified by income class, LMICs were significantly more likely to agree that task shifting is professionally disruptive to traditional training, task sharing should be a priority where human resources are scarce, and to call for additional TS/S regulation, such as certification and formal consultation with a neurosurgeon (in person or electronic/telemedicine). Conclusions: Both LMIC and high-income countries agreed that task sharing should be prioritized over task shifting and that additional recommendations and regulations could enhance care. These data invite future discussions on policy and training programs. Key words: Global health, Global neurosurgery, LMIC, Neurotrauma, Task sharing, Task shifting, Workforce

Introduction: Eloquent location and difficult access make insular surgery challenging. Thus operative adjuncts like neuronavigation, intraoperative monitoring and awake surgery are now considered the standard of care for these lesions. However, these may not be possible in all cases and resource constraints may place limits to what could be achieved. There still remains a possibility of achieving reasonable results with good surgical technique and meticulous surgery. Case report: We report 2 cases of giant (>6 cm) left insular cavernoma, excised using pterional-transylvian-transinsular approach, in a resource constrained and emergency setting. Both the cases had a sudden presentation with one case presenting with sudden increase in hemiparesis while the other presented with headache resulting from bleed in the background of a history seizures for 6 months. While clearing the clot in the first case, the hemosiderin rim was removed while it was deliberately avoided in the second patient. While the first case developed neurological worsening after surgery, eventually improving at follow-up, the postoperative course was uneventful in the second patient. Postoperative scan revealed a complete cavernoma excision in both the patients. Conclusion: Operating outside ideal conditions is always challenging, but not impossible. Spontaneous hemorrhage in and around these lesions may also be a blessing in disguise during surgery. While we do not advocate this as the ideal methodology, emergent conditions and lack of gadgets often necessitate evasive action and push ourselves. A combination of sound anatomical knowledge and experience in operating in this area can allow their safe excision with considerable safety. Considering the global neurosurgical burden and paucity of skilled manpower and resources, an undertaking of such a nature might be helpful to other readers in similar conditions. Keywords: Cavernoma, Insula, Microneurosurgery, Neuromonitoring

Introduction: Cervical benign lesions present a unique opportunity to provide significant improvement in the quality of life of the patient along with the promise of a cure. Critical neurovascular structures are nearby and must be kept in mind along with the minimal bone loss to avoid postoperative instability. Ganglioneuroma of the cervical spine presents such a unique opportunity where complete excision often results in a cure. Case report: We report a case of 57 year old male with a dumbbell-shaped ganglioneuroma with an intra-dural extension which was operated via a C6–C7 hemilaminectomy and facet preserving inside-out technique under neuro-physiological monitoring and also report the all the previous such reported cases via a thorough literature search. With only 15 such cases previously reported, the traditional teaching of a rare intradural extension has now been reversed with majority of the cases having an intradural extension and dumbbell-shaped tumors. Conclusion: Although childhood in origin they present in adulthood due to their slow growth rate and multiplicity and recurrence are rare unless associated with familial syndromes. Knowledge of this rare pathology increases the index of suspicion and thus dictates the outcome of the case. Keywords: Ganglioneuroma, Dumbbell cervical tumors, Hemi-laminectomy, Primitive neuroectodermal tumors

Background and objectives. Due to marked increase in violence, the world is facing problem of refugee population either as a source of refugee population or shelter provider. These refugee population is exposed to prolonged physical and emotional distress over years, may result into spectrum of neuropsychiatric disease conditions including traumatic brain injury (TBI). Although trauma is one of the major events faced by refugee population, the exact details of the injuries still not documented and there is paucity of published literature; further these injuries may be recorded as unspecified. Methods. The present article is intended to provide a theoretical overview of existing knowledge and gaps on trauma and injuries in the refugee population. Authors analysed all relevant articles available on PubMed and Medline using the keywords: “Refugee”, “Traumatic Brian Injury”, “Head Injury”. Results. There is a gap in knowledge for this particular demographic population. They suffer a wide range of physical and emotional to social traumatic events. The most common cause of head injury was assault; however, motor vehicle accidents were less prevalent, and there is an ongoing struggle for resources to fulfil basic needs leading to health care taking a backseat. There is high prevalence of post-traumatic stress disorder. Many of the refugees are settled in relative economically poorer countries which further add to the burden of a nation already besotted with internal requirements. There is a need for international collaboration to tackle unique problem. Conclusion. Authors recommend urgent need to handle the root causes responsible for the generation of refugee population and at the same time it is necessary to identify the epidemiology, patterns, management challenges and consequences of injuries and barriers to seek and provide care in refugee population.

Abstract Background Ventriculoperitoneal shunt malpositions are known complications which tend to increase the morbidity and recovery time of an elegant procedure. Distal malpositions into subcutaneous space due to improper closure or positioning can lead to shunt failure. Migration to the scrotum due to a patent processus vaginalis is, however, reported only in a handful of cases and, thus, needs to be highlighted and reported. Results We report a case of congenital hydrocephalus that underwent shunting at the age of 3 months and reported to be 9 months later with the shunt tube being felt in the scrotum. Repositioning along with herniotomy was performed. Conclusions A rare occurrence, scrotal migration, needs to recognized and reported. Potential preventive measures include truncation stiches and laproscopic assisted insertion.

Visual loss following spinal surgery is a potentially devastating and rare complication. Spinal surgery is the leading cause of POVL. Although the etiology of POVL is not clearly understood, multiple risk factors have been proposed. The horseshoe is no longer an appropriate device for prone spinal surgery and its use should not be supported. Awareness, evaluation and timely management of this rare devastating complication is crucial. It is advisable to inform high-risk patients that there is a small, unpredictable risk of perioperative visual loss. We discuss a case of 32 year old lady; who had experienced unexpected visual loss after elective spine surgery. Keywords: Visual loss, Spinal surgery, Ischemic optic neuropathy

While the Haberland syndrome was first reported in 1970, the anaesthetic management of this rare cohort of patients has not been described. With only 54 such cases reported, describing primarily the unilateral cutaneous, ocular, and neurologic malformations associated with this syndrome without focussing on the anaesthetic management. We describe the case of a 7 year old case of Harberland syndrome with special focus on the difficulties faced by us in mask ventilation, as well as intubation and the need for elective ventilation and planned extubation. We also discuss the precautions to be taken while undertaking such a case like preparations for emergency tracheostomy and possibility of re-intubation after extubation. A meticulous preoperative workup along with neurological and airway examination along with preparation for elective ventilation and tracheostomy is a prerequisite for the successful management of this case.

Basal cell carcinoma (BCC) is the most common skin cancer worldwide. The WHO has defined it as “a locally invasive, slowly spreading tumor which rarely metastasizes, arising in the epidermis or hair follicles and in which the peripheral cells usually simulate the basal cells of the epidermis.” Here we discuss the management of BCCs of central face with surgical excision and reconstruction with forehead flap as single modality treatment. Material and Methods. This is a retrospective review of 50 patients who underwent surgical excision of BCC involving the facial region followed by primary reconstruction using forehead flaps at a single institution. There were 20 males and 30 females, mean age of 59 years. Results. No recurrence at primary site was observed during the follow-up of 1–4 yrs. There was no ectropion or exposure sequela. However, epiphora was evident. Size of lesions ranged from 2 to 6 cm. Keloid formation was seen in 2 (4%) patients. Functional and cosmetic outcomes were satisfactory. Conclusion. For the face, the best reconstructive effort eventually fails in the face of tumor recurrence. The forehead flap represents one of the best methods for repair of extensive facial defects. Complete tumor extirpation, the primary event, is the key.