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Benchmarking ethics oversight is a process of aligning comparing and evaluating the strengths and room for improvement of ethical review and approval process across different institutions or the country. The World Health Organization tool for benchmarking ethics oversight is designed to help countries assess and improve their systems for ethically overseeing health-related research involving human participants. It identifies gaps in legal frameworks, committee structures, resources, accountability and transparency while promoting best practices and policy alignment. Nepal has made progress through the research regulations body like the Nepal Health Research Council , but challenges such as inconsistent implementation, oversight of the implementation and resource limitations remain. The tool offers an opportunity to strengthen Nepal’s health research governance and regulation but it must be adapted to fit local contexts, emphasizing accountability, transparency, capacity-building, and improved communication.

Abstract Background Cranial nerve palsy (CNP) is a common complication of traumatic brain injury (TBI). Despite a high incidence of TBI in Nepal (382 per 100,000), literature on the specific management and outcome of CNP is lacking. This study aimed to examine the outcomes of TBI patients involving single versus multiple CNP. Methods A retrospective chart review of 170 consecutive TBI patients admitted to the tertiary neurosurgical center in Nepal between April 2020 and April 2022 was conducted. Demographic, clinical, and etiological characteristics; imaging findings; and management strategies were recorded, compared, and analyzed using descriptive statistics. The Glasgow Outcome Scale Extended (GOSE) was used to measure the outcomes in two groups of patients (single and multiple CNP) at 3 months. Results Out of 250 eligible patients, 80 were excluded and CNP was noted in 29 (17.1%) of the remaining 170. The median age was 34.9 years, and falls (60.6%) were the most common cause of trauma. TBI severity was categorized based on GCS: mild (82.4%), moderate (15.9%), and severe (1.8%). Cranial nerve involvement was seen in 29 (17.05%) patients: single cranial nerve involvement in 26 (89.65%) and multiple nerve involvement in 3 (10.34%). The most common isolated cranial nerve involved was the oculomotor nerve (37.9%). CT findings revealed a maximum of skull fractures with no significant association between CNP and CT findings. Conclusions CNP is a common consequence of TBI with the most common etiology being falls followed by RTA. Single CNP was more common than multiple CNP with no significant difference in the outcome in the 3-month GOSE score. Further research is needed to determine the burden of traumatic CNP and establish specific management guidelines for different types of CNP.

Introduction: Timely institution of pre-hospital therapies aimed at damage control and the appropriately timed decision of transfer to higher centers for definitive neurosurgical management are crucial in determining the outcome of patients following traumatic brain injury. This study aimed to evaluate the factors determining pre-hospital care and delay in patients with traumatic brain injury. Methods: This was a descriptive cross-sectional study conducted in a tertiary care center after obtaining ethical approval from the Institutional Review Board (approval number 392 (6-11) E2). All patients with traumatic brain injury who presented to the emergency department from 1 July, 2018 to 15 June, 2019 were enrolled. Data related to patient demographics, the primary cause of the incident, grading of traumatic brain injury on admission, pre-hospital care, and variables that cause pre-hospital delay were collected. Results: In this study of 144 patients with traumatic brain injury, we found that 70 (48.61%) experienced transfer delays exceeding one hour. There were 71 (49.31%) patients aged 15-44 years, and 100 (69.44%) were males , with falls being the primary cause of 119 (82.64%). Most patients had mild traumatic brain injury 80 (55.56%). Out of 144, 20 (13.89%) received prehospital care, and 28 (19.44%) underwent a computed tomography scan of the head before arrival. Conclusions: Our study highlights the challenges in pre-hospital care and delays in reaching for neurosurgical care in patients with traumatic brain injury. Falls, road accidents, and physical assaults were the leading causes.

With the rapid advancement of health delivery, there has been a renewed interest in conducting research among healthcare professionals in Nepal. However, concern is there regarding availability of funds and mechanisms of awarding. The purpose of this scoping review is to map the available evidence regarding the evolution and current status of health research funding in Nepal and to highlight gaps and areas for future research. We searched three databases for empirical papers and several gray literature. Our search, conducted between March and April 2024 yielded 76 documents of which 30 that met the selection criteria were included in the scoping review. Almost all studies identified lack of funding as a deterrent to research. We found a paucity of research focusing on the role of researchers in funding decision-making. Our findings revealed that there are 12 national and four international organizations providing funds for research. University Grant Commission is the largest funder from Nepal whereas the Research Council of Norway is the biggest international funder. There were certain barriers and facilitators for obtaining funds identified by this scoping review. Further efforts are needed to increase the amount and availability of funds in Nepal to enable high-quality research.

Background: Brain tumour is a common problem in paediatric age group and posterior fossa is the commonest location. Treatment of these tumours is difficult due to a confined space and potential involvement of brainstem. The aim of this study is to analyse the clinical features, radiological findings, pathological diagnosis, surgical management, postoperative complications and outcome in 3 months in paediatric patients with posterior fossa tumours. Method: Retrospective chart review of 24 patients treated in the Department of Neurosurgery, TUTH, between 2019 April – 2023 April was done. The variables included were age, sex, clinical features, radiological findings, histopathological diagnosis, management and postoperative complications. Results: Twenty-four patients (30%) out of 80 childhood tumors were located in posterior fossa. The most common presenting symptoms was headache in 83.3% and vomiting in 75%. The most common location of tumour was the fourth ventricle in 66.7% while most common tumour histology was Type IV medulloblastoma in 45%. The commonest mode of treatment in 90% of cases was Ventriculoperitoneal (VP) shunting followed by surgical excision of tumour. Conclusion: Posterior fossa tumours are common tumour occurring in children. Majority of the patients presented with features of raised intracranial pressure and gait ataxia. Fourth ventricle and cerebellar vermis are the most common location. Most common histology types are medulloblastoma followed by pilocytic astrocytoma and ependymoma. Management involves addressing acute hydrocephalus followed by definitive surgery. Keywords: Medulloblastoma, Paediatrics, Posterior fossa, Surgery, Ventriculoperitoneal shunt

Introduction: The majority of trauma-related deaths occur in low- and middle-income countries; however, limited data exists in these settings related to injury types and severity. The prevalence of trauma similar to our setting was less estimated. This study aimed to find the prevalence of traumatic injury among patients presented to the department of emergency medicine of a tertiary care centre. Methods: This is a descriptive cross-sectional study conducted among patients presented to the Department of Emergency Medicine from 15 September 2021 to 14 September 2022. Ethical approval was taken from the Institutional Review Committee. World Health Organization trauma minimum data set, injury mechanism, types and patient disposition data were collected and injury severity scores were calculated. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 47,825 patients, 1,524 (3.19%) (3.03-3.34, 95% Confidence Interval) patients presented with a traumatic injury. A total of 967 (63.45%) were males and had a median age of 30 years (Interquartile range: 25). Most injuries were caused by falls 650 (42.65%), followed by road traffic accidents 411 (26.97%). A majority had minor Injury Severity Scores 1280 (83.99%). Conclusions: The prevalence of traumatic injury among patients presenting to emergency was found to be lower than other studies done in similar settings.

Background: Clinical presentations, management strategies and outcomes of patients with brain arteriovenous malformations (bAVMs) are complex due to variable natural history and uncertainty in the optimal treatment modality. Data are scarce regarding patients with bAVMs from developing countries either due to low incidence or a low detection rate. The objective of this study is to describe the clinical characteristics, management strategies, and outcomes of patients with bAVMs treated microsurgically in a university hospital from Nepal. Methods: The clinical records of patients confirmed to have bAVMs and microsurgically excised between July 2015 and March 2022 were retrospectively reviewed. Data on demographic and clinical characteristics, morphometric characteristics of bAVMs on imaging, management strategies, and the 6-month outcomes were abstracted and analyzed. Results: Out of 43 bAVMs diagnosed, 23 were microsurgically excised during the study period. The mean age of the patients was 28 (7–57) years. Eighteen patients (78.2%) presented with hemorrhage whereas 5 (17.4%) had seizures. Eight (34.8&) patients had bAVMs on the motor cortex (6 on the right side and 2 on the left side). Only one patient had infratentorial bAVM. Seventeen (73.9%) out of 23 were in Spetzler-Martin grade II and III before surgery. One patient had flow-related two arterial aneurysms. A single-stage surgery was performed with angiographic confirmation of obliteration in all patients. The favorable outcome (mRS 0–2) was achieved in 22 (95.6%) patients. One patient died. Conclusion: The overall number of subjects diagnosed with bAVMs in our hospital is markedly lower than cerebral aneurysms. The resource limitation in the diagnosis due to the limited availability of computed tomography (CT), magnetic resonance imaging and angiography is the most likely cause of low detection. With an individualized and careful selection strategy, surgical results are excellent even in this low-volume setting.

Intracranial aneurysms are sometimes associated with other vascular anomalies in extracranial location. Coarctation of aorta, a congenital vascular lesion can be associated with intracranial aneurysms. In patients with coarctation, evaluation of intracranial vasculature is essential. We encountered a 12-year kid with subarachnoid hemorrhage. On further evaluation, she had anterior communicating artery aneurysm. On further evaluation for secondary causes of aneurysm, she had coarctation of aorta. She was surgically managed successfully by clipping of the aneurysm.

Introduction: The establishment of local neurosurgery training programs in Nepal has proven critical for the expansion of the discipline across the country. This paper aims to describe the evolution, current status, challenges, and future directions of academic neurosurgery in Nepal. Research question: What is the current status and international standing of academic neurosurgery in Nepal? Material and methods: Information related to growth and development in Nepal was obtained from universities and regulatory bodies in Nepal. Variables described are the current number of neurosurgeons, the number of neurosurgical centers and centers with accreditation for training, the description of existing training models, the number of graduates, and the contribution of Nepalese neurosurgeons to world literature. Results: Formal neurosurgical training started in Nepal in 1999. Of 67 hospitals with neurosurgical facilities, 10 (14.9%) are accredited. Three training models (MCh, NBMS, and FCPS) currently exist. Of 116 neurosurgeons currently practicing in the country, 47 (40.5%) are homegrown. The contribution of the Nepalese neurosurgical community to the world includes the training of the first two Maldivian neurosurgeons and an increasing presence in world neurosurgical literature. Conclusions: Although comparable to other countries with similar economies, Nepal still faces some challenges to the sustainability and further developments of Neurosurgery. Continued concerted efforts will help Nepalese neurosurgeons achieve the goal of securing self-reliance in neurosurgical education.

Background: There are limited studies pertaining to management of encephalocele in Nepal. So the present study seems justifiable to bridge the gap in the literature on encephalocele from Nepal on its clinical profile and early outcome. This study aims to characterize the clinical profile, management and outcome of largest series of encephalocele at tertiary care center in Nepal. Materials and Methods: A retrospective analysis of encephalocele, managed surgically at two tertiary care centers between 2015 and 2020, was performed. Results: Total of 25 cases was surgically managed in the present study. The median age of study population was 2.5 months. There were 11 male and 14 female with male to female ratio of 1:1.26. Occipital encephalocele was the most common variant. Lump in the head (n=11) was the commonest clinical presentation followed by hyperteliorism (n=10). One patient presented with cleft lip and one had CSF discharge in a case of occipital encephalocele. Bony defect was the common radiological findings. Excision and repair was the most common mode of surgery leading to good outcome. Mortality rate was 4% with morbidity of 20%. Conclusion: Early surgical excision and tight dural closure with repair of bony defect is the standard treatment with relatively good outcome.

Introduction: Decompressive Craniectomy (DC) is a common neurosurgical procedure performed to reduce the intractable intracranial pressure in various neurosurgical diseases (infarction, hemorrhage, traumatic brain injury). The main aim of the study was to describe the demographic, clinical and operative characteristics of patients who underwent DC for different conditions and to correlate the outcome with various preoperative and intraoperative factors in our center. Methods: This was a retrospective study of patients who underwent DC for various neurosurgical diseases from January 2019 to January 2021 in Tribhuvan University Teaching Hospital, Kathmandu, Nepal. The chart of the patients were retrieved from the medical records and additional information obtained via telephone. Results: A total of 55 patients were enrolled in the study with a mean age of 43.0 + 17.3 years and male:female ratio of 1.5:1. There were 20 (36.4%) patients who presented with trauma and 35 (63.6%) patients with non traumatic origin. Among them, 28 (51%) patients presented with GCS8 and 37 (67.3%) patients with unequal pupil. At the end of six months follow up, the favorable outcome was seen in 23 (41.8%) patients. The only factor significantly associated with favorable outcome was the preoperative pupillary status. Conclusion: In our cohort the preoperative pupillary status (bilateral equal and reactive pupil) was the variable significant for favourable outcome in patients undergoing DC.

Documented re-infection of COVID-19 is uncommon and doing a major spinal surgery in an elderly patient right after the recovery from the first event is itself a major undertaking. Re-infection after successful surgery points to the possibility of COVID-19 infection being a post-surgical complication. Here, we report a case of a 72-years-old elderly female who had presented to us with features of COVID-19 infection confirmed by reverse transcription polymerase chain reaction assay and unstable spinal fracture who underwent a pedicle screw fixation for the fracture of the third and fourth thoracic vertebrae after two consecutive negative serology assays. A month after discharge from the hospital, she presented with severe symptoms of COVID-19 again confirmed by two consecutive polymerase chain reaction assays. She was managed conservatively and was discharged without significant respiratory and neurological complications. We described this case in detail in addition to reviewing the pertinent literature.

Introduction Antiepileptic drug (AED) therapy has been used prophylactically in various centers in patients with chronic subdural hematoma (CSDH) after surgical evacuation, although the benefit is unclear. Materials and Methods In this randomized controlled trial, patients with CSDH undergoing burr hole drainage were enrolled into two groups—one which received prophylactic phenytoin and the other without the drug use. Their clinical presentation, imaging findings and postoperative complications were analyzed. Primary objective of the study was to assess the efficacy of phenytoin in the reduction of early postoperative seizure. Results A total of 54 patients were enrolled in the study and randomized into two groups. Twenty-seven patients were assigned into the phenytoin group while another 27 patients to the “no phenytoin” group. Analysis of all patients in the no phenytoin group and those in the phenytoin group with therapeutic serum phenytoin levels were done. The incidence of postoperative seizure was 5.7%; and all patients who had seizures were in the no phenytoin group. This, however, was not statistically significant (p = 0.262). Two out of 25 patients on phenytoin (8%) developed adverse drug reactions. Conclusion Incidence of postoperative seizure in patients undergoing burr hole drainage for CSDH was low. Routine prophylactic use of AED, did not reduce seizure in early postoperative period.

Introduction: Variation in Circle of Willis is a commonly encountered entity in patients undergoing computed tomography angiography, identification of which is crucial in the management of patients with vascular pathologies. The aim of the study was to find out the anatomical variations in the Circle of Willis in patients undergoing Computed Tomography cerebral angiography in a tertiary hospital in Nepal. Methods: This is a descriptive cross-sectional study involving 95 patients using convenient sampling techniques who were sent to the Department of Radiology and Imaging, Tribhuvan University Teaching hospital, for further evaluation of suspected vascular pathologies in the brain from April 2017 to September 2017. Ethical approval was taken from the Institutional Review Committee of the Institute of Medicine with reference number 326 (6-11-E). CT angiographic images of these patients were evaluated for the presence of variations in Circle of Willis, aneurysms, and other vascular pathologies. Data were analyzed using SPSS. Results: Among 95 subjects included in the study, the anatomical variations in the arteries of Circle of Willis was seen in 52 (54.7%) patients, hypoplastic posterior communicating artery being the most common variation 33 (34.7%). The aneurysm was seen in 22 (23.2%) of cases. Conclusions: CT Angiography is a commonly performed imaging modality for suspected cases of cerebral aneurysms and various other vascular pathologies. Multidetector computed tomography can effectively detect variations in arteries of Circle of Willis, recognition of which is crucial in operative management of vascular pathologies.

Chordoma is a rare and locally aggressive tumor that arises from the notochordal remnants and has an incidence of 0.1/100000 per year. It has a predilection for the axial skeleton and is the most common primary malignant tumor of sacrum. The mainstay of treatment is wide surgical excision but there is a risk of recurrence due to the infiltrating nature of the tumor. Here, we report a case of a 56-years male who complained of pain over his sacral region for the past two years along with episodic urinary symptoms, constipation, and weakness of both legs. Seven years after undergoing surgery and radiotherapy for his sacral chordoma, he was diagnosed with recurrent sacral chordoma and planned for reoperation. Subtotal excision of the chordoma was done which significantly alleviated his symptoms postoperatively. Timely intervention helps to improve the quality of life in patients with either primary or recurrent sacral chordomas.

ABSTRACTBackground: Brain abscess in pediatric population is serious life threatening problem. Many risk factors are associated with this entity like congenital heart disease, ear infection and immunocompromised state. Early diagnosis and treatment with minimal invasive procedure has good outcome. Materials and Methods: This is a hospital based cross-sectional study conducted at institute of Medicine (IOM), Tribhuvan University Teaching Hospital Kathmandu, Nepal over the period of 3 years between September 2014 to August 2017. Clinical profile, management and outcome were analyzed. Results: A total of 27 cases were taken for the surgical management in the present study. There were 18 male and 9 female with the male to female ratio of 2:1. Mean age of the study population was 7.08 years. Otogenic Abscess was the most common 37.03% (n=10) and the temporal lobe was the most common site (37.5%). Headache was the most common clinical presentation seen in 74.07 %. All the cases were initially managed with the burrhole and aspiration. Only 14.8 %( n=4) of cases subsequently required surgical excision of the abscess wall. Only18.5 %( n=5) of the cases required multiple session aspiration. Positive culture was seen in 25.9% (n=7). Pseudomonas aeruginosa and E.coli were the commonest organisms grown. Mortality rate was 3.7%.Conclusion: Modern advances in radio imaging and multidisciplinary team involvement has decreased the morbidity and mortality.Keywords: otogenic brain abscess; pediatric brain abscess; tubercular abscess.

Joubert syndrome (JS) isa rare autosomal recessive neuro developmental disorder involving cerebellar vermis and brainstem, marked by agenesis of cerebellar vermis, ataxia, hypotonia, oculomotor apraxia, neonatal breathing problems and mental retardation. Magnetic Resonance Imaging (MRI) reveals the characteristic Molar tooth sign of midbrain and Batwing appearance of rostral fourth ventricle.

Introduction: Computed tomography (CT) is the ‘gold standard’ for detecting subarachnoid hemorrhage (SAH) and digital subtraction angiography (DSA) for visualizing the vascular pathology. There is some correlation between the pattern (based on Fisher grading) and location of bleed on CT scan and eventual location of cerebral aneurysm(s). Our aim was to assess the correlation between distribution of hemorrhage on the initial CT scan and eventual site of the ruptured aneurysm at our institution. Methods: This retrospective review of prospectively collected data consisted of 50 patients with SAH over 8 months period. CT scan of patients performed within 72 hours after the ictus with suspected SAH were included in the study. Four neurosurgeons, who had at least three years of experience after being qualified, who were blind to the imaging studies, analyzed and scored independently the quantity and distribution of the hemorrhage on CT. Their prediction of the site of the ruptured aneurysm was recorded and this was correlated with the CT angiography (CTA) and/ or DSA findings. Results: Overall accuracy of prediction was 71.6 % (68.2-75%). Parenchymal cerebral hematoma was an excellent predictor for the site of a ruptured aneurysm but was present in only a few cases (16%). The next valid predictor was blood distribution on CT for ruptured anterior communicating artery (ACom) and middle cerebral artery (MCA) aneurysms (89.4% and 85% respectively). Pattern of blood on CT together with CTA/DSA findings was found to be reliable for identifying the ruptured aneurysm in patients with multiple aneurysms in all cases. Conclusion: The quantity and pattern of the blood on CT is a fairly reliable and quick tool for locating a ruptured MCA or ACom aneurysms. It is not, however, reliable for locating other ruptured aneurysms.

Subdural Hematoma (SDH) or effusion following Ventriculoperitoneal (VP) shunt for hydrocephalous is not an unusual complication. However, we rarely come across organized chronic subdural hematoma (CSDH) following shunts. We present a case of organized CSDH in a four-year-old female child who presented with seizure three and half year after the VP Shunt placement for obstructive hydrocephalus due to aqueductal stenosis. The child was managed with craniotomy and evacuation of hematoma with membranectomy. We report this unusual case and review the relevent literature.

Introduction: CNS tumor requires intraoperative decision making regarding the extent of tumor removal. Clinical examination and imaging studies are not sufficient enough to predict the biological behavior of the tumors. Squash cytology is a quick method of evaluation of cytomorphologic features prepared from smear technique and provide the preliminary diagnosis and aid in intraoperative decision making by differentiating neoplastic from non neoplastic and benign from malignant lesions. The aim of this study is compare the diagnostic accuracy of squash cytology to that of histopathological examination. Methods: This study consists of 36 specimens from both brain and spine subjected to both squash cytology and histopathological evaluation. The squash preparation and histopathological finding were later compared and diagnostic accuracy calculated. Results: Gliomas are the most common tumor encountered and the accuracy of Squash cytology obtained was 71%. In meningioma, 100% diagnostic accuracy was obtained however, there was limitation in accurately predict the subgroup of tumor by squash cytology alone. Other neoplastic lesions included in this study were Schwannoma, Oligodendroglioma, Ependymoma, mixed tumors and others. Overall, the accuracy predicted by squash cytology is found to be 77.8 % in this study. Conclusion: Squash cytology is rapid and reliable method of tissue diagnosis that aid in intraoperative decision making regarding the extent of Central Nervous System tumor excision

Introduction: Traumatic brain injury(TBI) is a major cause of disability, death and economic burden to the society. Albumin is a major protein of human. Values fall as a component of metabolic response to injury or infection. Albumin being a negative phase reactant is consumed under states of stress such as TBI. Materials and Methods: This is a descriptive observational study conducted at the Department of Surgery, TUTH over a period of 1 year between 2014 and 2015. Albumin level at admission was correlated with severity of head injury, Glasgow Coma Scale at admission and duration of hospital stay. Results: Among 59 patients with isolated TBI patients from TUTH, 40(68%) were male and 19(32%) were female. 55% of head injuries occurred between the ages of 18-40 years. Out of total patients, fall was the major cause of head injury with 24 (41%) under this category. Nine (15%) had severe head injury; 22 (37%) had moderate and 28 (47.45%) patients had severe head injury at admission. Contusion 19 (28%) and subdural hematoma 17(26%) were the predominant computed tomography findings. Twenty four (40%) patients were managed conservatively, thirty five (60%) patients were operated. The average albumin level at admission for patients with mild, moderate and severe head injury were 41,46gm/dl, 33.76gm/dl, 31.1gm/dl respectively. There is a positive correlation between initial serum albumin and GCS at admission (p=0.01, R= 0.747). Conclusion: There is a positive correlation between initial serum albumin and GCS at admission. Further research on this topic at multiple centres is warranted.