Search

Objective: Ossified ligamentum flavum (OLF) of the spine is a rare cause of compressive myelopathy. OLF is prevalent in Asian countries. Surgery is the only treatment option for symptomatic patients. The recovery after surgery depends upon multiple clinical and radiological factors and varies significantly. We report our series of surgically managed thoracic OLF and the factors predicting poor outcomes., Methods: A retrospective study was conducted including 52 patients who underwent surgery for thoracic OLF. The pre-operative clinical status, radiology findings, intraoperative observations and complications were analyzed with post-op clinical outcomes. The mean follow-up period was 24 months (range 12-72)., Results: There were 35 males and 17 females with a mean age of 49.5 years (range: 30-75). The mean duration of symptoms was 13 months (range: 1 month to 5 years). The mean modified Japanese Orthopedic Association (mJOA) score was 5.8 preoperatively, 5.5 postoperatively and improved to 7.5 at the last follow-up. A good recovery rate (>50 %) was found in 18 patients, poor recovery (<50 %) in 24 patients, seven remained unchanged and three patients had worsened. In univariate analysis, the statistically significant factors for the recovery rate were the number of OLF levels, CT axial classification (tuberous type), associated OALL and cervical OPLL, T2W cord signal changes, ossification of dura mater, dural tear, and CSF leak. Dural tear and the number of OLF levels were the most predictive factors for the poor outcome on multivariate analysis., Conclusion: Predictors of poor surgical outcomes are the extent of OLF involved and dural tear. The patient improves with rehabilitation despite the immediate postoperative deterioration., Competing Interests: Declaration of Competing Interest None., (Copyright © 2025 Elsevier B.V. All rights reserved.)

Objective: To analyse patients with recurrent atlanto-axial dislocation and give a criterion of an ideal patient who can benefit from redo surgery., Methods: This retrospective study was conducted in a tertiary care center, which included 20 patients who failed atlanto-axial surgery from January 2013 to June December 2021. They were evaluated using X-ray, computed tomography, and magnetic resonance imaging examinations, and their clinical data were accessed from the hospital's medical records department and the picture archiving and communication system. They were given a trial of traction to look for clinical and/or radiological improvement. Those showing clinical and/or radiological improvement underwent redo fixation. The operative steps involved removing joint capsules, denuding articular cartilage and joint preparation followed by reduction of basilar invagination by the combination of spacer and/or bone graft and putting screws in C1/Occiput and C2. A strut graft was placed between Occiput/C1 and C2., Results: The mean change in modified Japanese Orthopaedic Association Scores and Nurick grade following the first surgery was statistically significant (1.00 ± 0.73, P value 0.002 and -0.15 ± 0.27, P value 0.046, respectively). On similar paths, the mean change in modified Japanese Orthopaedic Association Scores and Nurick grade following the second surgery was also statistically significant (4.25 ± 0.32, P value < 0.001 and -1.2 ± 0.11, P value < 0.001, respectively). Improper usage of constructs (31.57%), inadequate/no joint preparation (42.10%/57.90%), and poor choice of graft (100%) were the leading causes of failure of index surgery., Conclusions: The best candidates who can benefit after redo surgery are the ones who exhibit either clinical and/or radiological improvement on the trial of traction, as the pathological C1-C2 joints are either not fused or have undergone pseudoarthrosis. Those patients who do not exhibit significant clinical or radiological improvement post-trial of traction should not be offered subsequent surgical intervention., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Diffuse intrinsic pontine glioma (DIPG) in children comprises 80% of brainstem gliomas. In 2021, 5th edition of WHO CNS tumor classification defined H3K27M altered diffuse midline gliomas (DMGs) which replaced this entity. Lesion location precludes resection and the only current option available is radiotherapy. Patient age, duration of symptoms, histone subtype mutation etc. may helpl in prognostication but the disease remains incurable with a median overall survival of 9-12 months., Method: This is a prospective observational study from a tertiary health care center in a low to middle-income country. We included patients with DIPG (radiological and/or histopathological H3K27M altered) from June 2018 to April 2023. Clinical, radiological, histology, and molecular features were reviewed and prognostic factors for 3 months, 6 months, and overall survival was analysed for all patients., Results: We included 92 pediatric patients. The median age of our study population was 8.5 years. Median LPS was 80. Cranial nerve palsy was the most common presenting complaint. Hydrocephalus requiring CSF diversion was present in 38 patients (41.3%). Lesion biopsy was performed in 36 patients (39.1%) and exophytic component decompression was done in 11 patients (11.9%). Seven patients were lost to follow-up. Adjuvant therapy was received by 51 patients (51/85, 60%). Radiotherapy was the only significant prognostic indicator of 3 months, 6 months, and overall survival (HR: 0.39). The presence of necrosis on histopathology was also an indicator of poor prognosis (HR: 2.38). There were 7 long-term survivors in our study but we did not find any significant survival prognostic indicator amongst this group., Conclusion: Conventional adjuvant therapy has not proven of much benefit. With the advancement in molecular understanding of the entity, there is an upsurge in the development of targeted therapy but with no promising results so far. In this study, we have attempted to explore the prognostic factors and unique challenges we face in a resource-limited setting against this disease., Competing Interests: Declarations. Conflict of interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Informed consent: Informed consent was taken from all the patients included in the current study. Competing interests: The authors declare no competing interests. Ethics approval: Institute Ethics Committee approval was taken before the commencement of the study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Chiari malformations, characterized by the herniation of cerebellar tonsils through the foramen magnum, are complex neurosurgical conditions that pose significant diagnostic and therapeutic challenges. 1 Traditional interventions, such as foramen magnum decompression, have been the mainstay of treatment but are not universally effective, especially in cases with underlying atlantoaxial instability. However, recent studies highlight the importance of atlantoaxial instability in their pathogenesis, shifting the therapeutic focus towards atlantoaxial fixation. 2 Research shows that atlantoaxial fixation can effectively address the underlying instability, leading to better symptomatic relief and neurological outcomes compared to traditional decompression methods. 3 , 4-17 The findings from these studies consistently demonstrate that atlantoaxial instability is a critical factor in the development of Chiari malformations. Atlantoaxial fixation not only resolves the mechanical instability but also leads to significant symptomatic relief and improved neurological outcomes. Comparative analysis indicates superior efficacy of atlantoaxial fixation over traditional decompression techniques, especially in patients with concurrent basilar invagination and syringomyelia. This surgical Video 1 illustrates a case of a 20-year-old male patient with tonsillar herniation, syringomyelia, atlantooccipital assimilation, atlantoaxial instability, basilar invagination and dorsolumbar scoliosis, who was successfully managed with cervical fixation using a bilateral C1 lateral mass and C2 transpedicular screw construct. This surgery was able to achieve clinical and radiologic improvement without the need for a foramen magnum decompression. The patient consented to the procedure and to the publication of his images., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective  Intracranial meningiomas constitute a third of all brain tumors and are among the most common indications for neurosurgical procedures performed worldwide. Most meningiomas present with an indolent, longstanding history. However, the data on outcomes of emergency surgeries for meningioma is limited. This study aims to present our experience of urgent surgical intervention in patients with meningiomas presenting acutely. We also analyze the factors influencing early neurological outcomes and complications. Materials and Methods  All nonelective meningioma surgeries done on an emergency basis between January 2015 and December 2019 were retrospectively reviewed. Patients' demography, clinical, and radiological details were recorded for analysis. The surgical procedure, complications, and follow-up outcomes were also included for statistical comparison. Results  Forty-four patients qualified for the study with a mean age of 49.4 ± 13.4 years. The average presenting Glasgow Coma Scale (GCS) was 13; 47.7% of cases presented with altered sensorium. The most common lesion location was convexity (25, 56.8%), and the mean tumor volume was 74.1 ± 36.5 mL. Gross peritumor edema with mass effect was seen in 16 patients (36.4%). The mean Karnofsky Performance Status at 3 months' follow-up was 89.3 ± 18.2. Patient age and tumor size did not affect outcomes. The presenting GCS of < 15 (odds ratio [OR] 8.8, confidence interval [CI] 0.95-80.72, p 0.03) and the occurrence of postoperative complications (OR 25.71, CI 2.65-249.2, p 0.001) were associated with unfavorable outcomes. Although not statistically significant, a poor tumor grade was also associated with worse clinical outcomes ( p 0.20). Conclusion  Emergency meningioma surgery has comparable outcomes and complication rates with routine elective procedures. Grade II/III meningiomas are more likely to present with acute neurological deterioration and carry a relatively worse prognosis. Poor presenting GCS and postoperative complications are the most critical factors associated with poor patient outcomes in our study., Competing Interests: Conflict of Interest None declared., (Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Introduction: Diffuse midline glioma (DMG) is a relatively new entity which was introduced in the fourth edition of the WHO classification of CNS tumours in 2016 and later underwent revision in 2021. It is an infiltrative glioma arising from midline structures, viz., thalamus, spine, and brainstem. Current literature on DMG is based majorly on brainstem lesions, and DMGs arising elsewhere remain unexplored. In our study, we have discussed our experience with thalamic DMGs., Methodology: This is a retrospective observational study of all patients with histopathologically proven DMG H3K27M altered, arising in the thalamus from 2018 to 2022. Clinical, neuroimaging, and pathology were re-reviewed, and prognostic factors for 3 months, 6 months, and overall survival (OS) were analyzed for all patients., Results: There were 89 patients- 64 adults and 25 pediatric patients with thalamic DMG. The median age at presentation was 24 years. Raised ICP followed by limb weakness were the most common presenting complaints. Stereotactic biopsy was performed in 64 (71.9 %) patients and surgical decompression in 25 (28.1 %) patients. CSF diversion was required in 53 (59.6 %) patients. Median survival was 8 months in adults and 7 months in pediatric (p-value: 0.51). Raised ICP and TP53 mutation were prognostic factors in pediatric population. Radiotherapy with or without chemotherapy improved survival (p-value- <0.01)., Conclusion: Thalamic DMGs have a poor prognosis which is comparable to brainstem DMGs. Radiotherapy improves survival in these patients. However, the disease remains an enigma and further work delving into its molecular characterization should be encouraged., Competing Interests: Competing interest All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: The objective was to study the effectiveness and diagnostic outcome of frame-based stereotactic brain biopsy (STB) done for contrast non-enhancing lesions using indirect evidence of target selection observed in a plain computed tomography (CT) scan of the head., Methods: Data of patients with contrast non-enhancing brain lesions who underwent STB are collected retrospectively from NIMHANS Bangalore, hospital neurosurgery database from January 2021 to March 2023. Those cases subjected to plain CT scans after fixing the stereotactic frame to the head were included in the study. A final histopathological report analysis of these cases was done to assess the diagnostic accuracy., Results: A total of 27 such cases were biopsied. The mean age of subjects was 44.04 ± 17.812 years. Most subjects were in the age group 31-40 years (29.6%). About 55.6% were male and 44.4% were female. The most common site of biopsy was the frontal lobe. The most common indirect evidence on CT was perilesional edema at 33.3% and periventricular location at 33.3%, followed by intralesional calcification at 11.1%. Our diagnostic accuracy was 92.59%. The asymptomatic hemorrhage rate was 2%, and an increase in perilesional edema was seen in 2% of cases., Conclusion: Indirect targeting is a safe and intuitive method for biopsy of contrast non-enhancing lesions. Due consideration is to be given to various findings visible in non-contrast CT scans of the head as indirect evidence of target selection while performing frame-based STB of contrast non-enhancing lesions. This method will also be helpful in resource-limited centers, especially in low-income countries., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Background: Diffuse intrinsic pontine gliomas are aggressive tumors that carry a poor prognosis with a 2-year survival rate of <10%. The imaging appearance is often pathognomonic, and surgical biopsy is not mandatory to initiate treatment in children. Studies of biopsy samples provide insight into the disease's molecular pathobiology and open prospects for targeted therapy. This study was conducted to determine the diagnostic yield and safety of stereotactic biopsies., Methods: This is a prospective observational study from a single tertiary health care center. All patients with clinical and radiological features diagnostic of diffuse intrinsic pontine gliomas (DIPGs) who underwent biopsy from July 2018 to June 2023 were included. Biopsies were performed using either stereotactic frame-based, frameless, or endoscopic techniques., Results: A total of 165 patients with DIPGs were evaluated in the study period. The option of biopsy with its associated risks and benefits was offered to all patients. A total of 76 biopsies were performed in 74 patients (40 children and 34 adults, including 2 repeat biopsies). The median age was 15 years. Diffuse midline gliomas, H3K27M altered, was the most common histopathological diagnosis (85% pediatric and 55.9% adults). The diagnostic efficacy of the procedure was 94.7%. The complication rate was 10.8%, with no permanent neurological deficits due to surgery. There was no procedure-related mortality., Conclusions: Establishing the safety of the procedure could be an important step toward popularizing the concept, which might offer a better understanding of the disease. Brainstem eloquence and a lack of direct benefit to patients are the primary obstacles to brainstem biopsy., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Neurocutaneous melanocytosis (NCM) is a rare, sporadic neuroectodermal dysplasia characterized by the presence of large or multiple congenital cutaneous nevi and melanocytic deposits in the central nervous system. Hitherto, unreported we describe a case of NCM with optic neuropathy and spinal cord melanoma from India. A 20 year-old-lady had headache and vomiting for 3 months followed by consecutive profound painless visual impairment. Visual acuity was counting of fingers at 1 m distance in both eyes with normal fundus. There were no symptoms of spinal cord involvement. Clinical examination showed multiple small to large melanocytic nevi over the face and body. Muscle power was normal. Tendon reflexes were exaggerated. Visual evoked potential showed bilateral prolonged P100 latency (Right eye - 144 msec; Left eye - 151 msec). Brain MRI revealed leptomeningeal enhancement of brainstem, cerebellum, oculomotor and facial-abducent nerve complex without optic nerve involvement. MRI spine showed extensive dorsal thoracic cord epidural lesion extending along the entire thoracic cord segment with dorsal cord compression. Positron Emission Tomography (PET) imaging showed Fludeoxyglucose F18 (FDG) avidity along D1-D12 levels of spinal cord. Biopsy from the cord lesion was suggestive of meningeal melanoma. Here we document a rare case of late onset NCM with intracranial meningeal infiltration and asymptomatic large epidural lesion of spinal cord, expanding its phenotypic spectrum. Optic neuropathy in NCM has not been reported earlier. Periodic screening of brain and spine is recommended for early prognostication and lesion identification in NCM., Competing Interests: none, (© 2024 The Authors.)

Background: Good visualization is a prerequisite for performing microvascular anastomosis. The most commonly used dye, methylene blue, has several limitations: it is washed off quickly and stains all the vessel layers. The objective of our study is to use 2 new novel dyes for improving visualization., Methods: After ethical committee approval, 2 Dyes (2% cresyl violet, 1% eosin) were studied in 3 groups, 20 rats in each group and 5 rats in the combined group. End-to-side anastomosis was performed in the classic fashion in 45 rats. After venotomy, the dye was applied to the raw surface of the vessels and subsequently, anastomosis was performed. The improvement in visualization was judged by 3 blinded experts and nonexperts in 4 groups on a scale of 1-10. Scores were statistically analyzed. After 2 weeks, animals were re-explored to check the delayed patency, and segments were harvested for histopathologic analysis., Results: The immediate and delayed patency rates were 100% (45/45) and 97% (33/34), respectively. In statistical analysis, the combined group (P = 0.005)was judged statistically significant because of the contrast in color. All the layers were stained by both dyes, staining lasted until the end of the surgery. Visibility of the cut ends was better in cresyl violet. All histopathologic findings suggested normal changes at the anastomotic site., Conclusions: This study showed that the use of these 2 dyes was not only feasible but highly efficacious. Even though all the layers were stained by both the dyes, the visibility of the cut ends was better. In both dyes, staining lasted until the end of surgery. To the best of our knowledge, this is the first study that has used these 2 novel dyes to improve visualization in microvascular anastomosis in an experimental setting., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Machine learning analyses within the realm of oral cancer outcomes are relatively underexplored compared to other cancer types. This study aimed to assess the performance of machine learning algorithms in identifying oral cancer patients, utilizing microRNA expression data. In this study, we implemented this approach using a panel of oral cancer-associated microRNAs sourced from standard incisional biopsy specimens to identify cases of oral squamous cell carcinomas (OSCC). For the model development process, we used a dataset comprising 30 OSCC and 30 histologically normal epithelium (HNE) cases. We initially trained a logistic regression prediction model using 70 percent of the dataset, while reserving the remaining 30 percent for testing. Subsequently, the model underwent hyperparameter tuning resulting in enhanced performance metrics. The hyperparameter-tuned model exhibited high accuracy (0.894) and ROC AUC (0.898) in predicting OSCC. Testing the model on cases of potentially malignant disorders (OPMDs) revealed that leukoplakia with mild dysplasia was predicted as having a high risk of progressing to OSCC, emphasizing machine learning's advantage over histopathology in detecting early molecular changes. These findings underscore the necessity for further refinement, incorporating a broader set of variables to enhance the model's predictive capabilities in assessing the risk of oral potentially malignant disorders.

Background: Hirayama disease (HD) is a cervical compressive myelopathy. Anterior cervical discectomy and fusion (ACDF) is identified as the best surgical approach. We evaluated surgical outcomes and factors influencing ACDF in HD., Methods: Between 2015 and 2019, 126 patients with HD underwent ACDF. Contrast magnetic resonance imaging of the cervical spine in full flexion was performed. Clinical examination and preoperative/postoperative assessment of hand function using Fugl-Meyer assessment, Jebsen-Taylor hand function test, and handheld dynamometry were performed at 3-monthly intervals for 1 year. Surgical outcomes were assessed as per the Odom criteria and Hirayama outcome questionnaire., Results: Age at onset and duration of illness were 12-31 years (mean, 18 ± 2.7) and 1-96 months (32.7 ± 24.4), respectively. All patients had progressive weakness and wasting of the affected limb. Cord atrophy was seen in 97.1%, with epidural detachment and engorgement of the posterior epidural venous plexus in all. All patients underwent ACDF. Of these patients, 54% had an excellent/good outcome and 39% had a satisfactory outcome as per the Odom scale at last follow-up (mean, 44.9 ± 16.5 months) after surgery. Handheld dynamometry showed improvement from preoperative values to 1 year follow-up. Duration of illness and age at onset had a negative correlation and the preoperative Fugl-Meyer score had a positive correlation with improvement., Conclusions: ACDF resulted in remarkable improvement or stabilization in neurologic deficits in many patients with HD. Because motor disability ensues over time, early surgical intervention during the progressive phase is advocated., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Netnography is a special kind of qualitative social media research. It applies ethnographic techniques to comprehend social interaction in settings of modern digital communications. This article aims to highlight the key contributors and knowledge structure of this research domain. Utilizing bibliographic data of 722 articles retrieved from the Scopus database, researchers used performance analysis to have insights into the most prolific authors, institutions, countries and journals. Keywords co-occurrence analysis was done to map the knowledge structure. The thematic map tool was used to recognize basic themes, motor themes, niche themes, and emerging themes in order to suggest future research directions. The results indicate that, in terms of research publications, the most productive nation is the United Kingdom. The most lucrative organization has been acknowledged as Griffith University. The most influential author is stated to be Mkono M. The most resourceful source is Journal of Business Research. In addition, three significant knowledge clusters important to study utilizing netnography were identified as a result of co-occurrence of keywords analysis namely, consumer behaviour, co-creation in online brand communities and authenticity. Further, niche and emerging themes include-sustainable tourism, customer engagement and sharing economy. When taken as a whole, this review is a useful tool for quickly understanding the most recent research findings and potential directions for further investigation. An assessment of the state of netnography in business and management research has not been systematically investigated. Hence, the present study aims to thorough a grasp of the state-of-the-art in Netnography research field over the past decades along with the future research directions. Studying the state of the art in the field adds to academic knowledge and provides updated information on the procedure., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Knot configuration is an important but relatively neglected topic in microvascular anastomosis literature., Objective: To study the differences between end-to-end microvascular anastomosis performed with two-throw reef knots as compared to traditional three-throw knots in a rat femoral artery model at the histological level., Material and Methods: Sprague Dawley rats underwent end-to-end microvascular anastomosis of the right femoral artery (one-way-up method). The rats were divided into two groups: two-throw reef knots versus traditional three-throw knots. The patency was checked by the standard empty refill method. After 2 weeks, the rats underwent re-exploration. An anastomotic segment was sent for histological analysis. Histological alterations including luminal patency and changes in Tunica intima, Tunica media, and Tunica adventitia were compared between the two groups., Results: Twenty-nine rats were operated on by the senior author (17 by three-throw and 12 by two-throw reef knots). In the two-throw reef knot group versus the traditional three-throw knot group, the immediate patency rates were 100% versus 82.4%, and the delayed patency rates were 90.9% versus 62.5%, respectively. The histopathological patency rates were concordant with delayed patency rates. Subintimal proliferation and fibrosis were comparable in both groups. Adventitial granulomas were noted in all, irrespective of the knotting technique. Tunica media preservation rates for the two-throw reef knot versus the traditional three-throw knot group were 63.6% versus 0%. Five rats were operated by the beginner in the field, all by two-throw reef knots (to assess the safety of this new method in the hands of a beginner)., Conclusion: Microvascular anastomosis performed with two-throw reef knots appears not only feasible but better in terms of anastomosis patency. Histological superiority in terms of Tunica media preservation further validates the technique., Competing Interests: None

Traumatic brain injury (TBI) causes significant neurological deficits and long-term degenerative changes. Primary injury in TBI entails distinct neuroanatomical zones, i.e., contusion (Ct) and pericontusion (PC). Their dynamic expansion could contribute to unpredictable neurological deterioration in patients. Molecular characterization of these zones compared with away from contusion (AC) zone is invaluable for TBI management. Using proteomics-based approach, we were able to distinguish Ct, PC and AC zones in human TBI brains. Ct was associated with structural changes (blood-brain barrier (BBB) disruption, neuroinflammation, axonal injury, demyelination and ferroptosis), while PC was associated with initial events of secondary injury (glutamate excitotoxicity, glial activation, accumulation of cytoskeleton proteins, oxidative stress, endocytosis) and AC displayed mitochondrial dysfunction that could contribute to secondary injury events and trigger long-term degenerative changes. Phosphoproteome analysis in these zones revealed that certain differentially phosphorylated proteins synergistically contribute to the injury events along with the differentially expressed proteins. Non-synaptic mitochondria (ns-mito) was associated with relatively more differentially expressed proteins (DEPs) compared to synaptosomes (Syn), while the latter displayed increased protein oxidation including tryptophan (Trp) oxidation. Proteomic analysis of immunocaptured complex I (CI) from Syn revealed increased Trp oxidation in Ct > PC > AC (vs. control). Oxidized W272 in the ND1 subunit of CI, revealed local conformational changes in ND1 and the neighboring subunits, as indicated by molecular dynamics simulation (MDS). Taken together, neuroanatomical zones in TBI show distinct protein profile and protein oxidation representing different primary and secondary injury events with potential implications for TBI pathology and neurological status of the patients., (© 2023 International Society for Neurochemistry.)

Background: Benign Nerve sheath tumors (NST) comprise almost one-third of primary spinal tumours. The majority are sporadic. They have low rates of recurrence but an occasional recurrence may need re-surgery. The present study was designed to identify the variables that can predict the risk of their recurrence., Methods: A retrospective chart review was done including all the histologically proven benign spinal NSTs operated between 2001 and 2019 in our institute. Demographic, operative and postoperative follow-up data were recorded. Recurrence was defined as local reappearance after definite surgical excision or symptomatic increase in size of a residual tumour on follow-up imaging studies. Statistical analysis was done to determine the significant variables associated with local recurrence., Results: 457 patients with a median age of 38 years operated for 459 NSTs qualified for the study. The most frequent location of occurrence of tumours was found to be Low Cervical level (C3-C7 levels). Majority of Schwannoma were located intradurally while Neurofibroma were dumb-bell shaped and extradural. Most of the tumours had solid consistency. Post operatively, 7.7% patients developed complications. 7.8% tumours developed local recurrence after median period of 12 months. The patients developing recurrence were younger compared to nonrecurring tumors. On univariate analysis, male gender, Low cervical and Cervicothoracic junction location were associated with higher recurrence. On multivariate analysis, location at Cervicothoracic junction reached significance., Conclusion: Overall recurrence risk among all NST was 7.8% with a median progression free survival of 36 months. The location of tumour at cervicothoracic location was the significant risk factors for recurrence of tumour in our study., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: A narrow working space, small diameters, and the tendency to collapse with clamps make cerebral microvascular anastomosis challenging. A retraction suture (RS) is a novel technique to keep the recipient vessel lumen open during the bypass., Objective: To provide a step-by-step overview of RS for end-to-side (ES) microvascular anastomosis on rat femoral vessels and successful use for superficial temporal artery to middle cerebral artery (STA-MCA) bypass in Moyamoya disease patients., Methods: A prospective experimental study with approval from the Institutional Animal Ethics Committee. Femoral vessels ES anastomoses were performed on Sprague Daley rats. The rat model used 3 types of RS (adventitial, luminal, and flap RSs). An ES-interrupted anastomosis was done. The rats were observed for an average period of 16.18 ± 5.65 days; the patency was assessed by reexploration. The immediate patency on the STA-MCA bypasses was confirmed with intraoperative indocyanine green angiography and micro-Doppler; delayed patency with magnetic resonance imaging and digital subtraction angiography after 3-6 months., Results: In the rat model, 45 anastomoses were performed, 15 each using the 3 subtypes. The immediate patency was 100%. Delayed patency was 42/43 (97.67%), and 2 rats died during observation. In the clinical series, 59 STA-MCA bypasses were done in 44 patients (average age, 18.14 ± 11.09 years) using RS. The follow-up imaging was available for 41/59 patients. Both immediate patency and delayed patency (41/41 at 6 months) were 100%., Conclusion: The RS allows continuous visualization of the vessel lumen, reduces the handling of intimal edges, and avoids incorporating the back wall in sutures, thus improving anastomosis patency., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction:  Vestibular dysfunction is a debilitating disorder frequently encountered in neurological and otological settings. The vestibular system is a complex network between peripheral and central mechanisms. This innate complexity of the vestibular system necessitates objective test procedures for evidence-based diagnostic formulations and intervention. Objective tests aid in the evaluation of both peripheral and central vestibular pathologies. Establishing and availability of comprehensive normative data for these objective tests is crucial for clinicians and researchers alike., Materials and Methods: This is a prospective study involving 120 participants (both males and females) aged between 18 and 55 years. All participants were right-handed individuals and had no significant medical history. On pre-set protocols, cVEMP (cervical vestibular evoked myogenic potential), oVEMP (ocular vestibular evoked myogenic potential), vHIT (video head impulse test), and VNG (videonystagmography) were done., Results: While all participants (n=120) underwent cVEMP, oVEMP, vHIT, saccade, smooth pursuit, and optokinetic tests, only 109 participants consented to the caloric test. Each test's mean, standard deviation, median, quartile, and third quartiles have been recorded. A right-left comparison yielded no significant difference on cVEMP, oVEMP, caloric test, smooth pursuit, and optokinetic test. However, few vHIT and saccade parameters did reveal significant differences., Discussion: This study presents comprehensive normative data for cVEMP, oVEMP, vHIT, caloric test on VNG, and oculomotor tests (smooth pursuit, saccade, optokinetic) on VNG. The test results were in concordance with previously published data. The significant difference between the right and left sides in vHIT may be because of the monocular goggles used for the testing., Conclusion: This study brings out the normative data for various vestibular tests on individuals aged between 18-55 years. This information could aid both clinicians and researchers working in the field of vestibular science., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Narayana Swamy et al.)

Objective: The horizontal fissure of the cerebellum, which is the largest and most prominent fissure, has received less interest from anatomists and neurosurgeons. Hence, the current study aims to provide comprehensive detail about the horizontal fissure and its anatomic and surgical relationship with deeper structures such as the dentate nucleus and middle cerebellar peduncle for the benefit of the neurosurgeon., Methods: Ten whole formalin-fixed human cadaveric cerebellar hemispheres were obtained from human cadavers donated to the institution. Different parameters of the horizontal fissure were studied, such as length, depth (medial end, lateral end, and middle), sulcal and gyral variations (superficial and deep), and its close relationship, especially at depth, with the dentate nucleus and middle cerebellar peduncle., Results: The total length of the horizontal fissure on the right and the left side was 64.3 ± 7.9 mm (range, 53-77 mm) and 65.6 ± 8.01 mm (range, 53-79 mm), respectively. The medial third of the horizontal fissure, with the fewest vessels, was the most suitable place to puncture or start the dissection of the horizontal fissure. The surface projection of the center of the posterior border of the dentate nucleus lies within 20-21 mm on either side of the posterior midline along the horizontal fissure and is only approximately 4 mm deep from the horizontal fissure., Conclusions: The anatomic measurements and relationships provided in this description of the horizontal fissure will serve as a tool for surgery selection and planning, as well as an aid to improve microneurosurgical techniques, with the final goal being better patient outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Chiari malformation type 1 has been traditionally treated with foramen magnum decompression and C1 arch excision with or without duroplasty depending on the surgeon's preference. Each of the various surgical modifications has its advantages and disadvantages., Methods: We describe a minimally invasive tubular retractor-based approach to achieve bony decompression in these cases. We have had good results comparable to the open approach., Conclusions: Strict orientation to the midline using soft tissue landmarks in between the muscles and bony landmarks in the deeper planes is important to achieve good surgical results. Operative time decreases with expertise and is comparable to the open technique. Minimal blood loss and decreased hospital stay and an excellent cosmetic scar make this procedure more appealing., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: In the recent coronavirus disease 2019 (COVID-19) pandemic, follow-up of patients with trigeminal neuralgia post radio-frequency ablation (RFA) of the Gasserian ganglion was restricted because of closure of pain clinic services (PCSs) at our institution, travel restrictions, and fear of contracting COVID-19 infection by hospital visit. Periodic follow-ups are a must in this group of patients. Because the access to pain medications and consultations remained restricted, we tried identifying the factors predisposing to these difficulties in patients., Methods: We had contacted patients telephonically, who underwent RFA at our institution in the past 5 years as the PCS had not re-started to follow up with in-person consultation. Demographics, socio-economic factors, clinical factors, literacy status, distance to the health care system, and current health status were noted. Collected data were analyzed descriptively, and correlations were calculated between the predictors for difficulty in follow-up to access the medications and consultations., Results: Out of 121 patients who underwent RFA in the past 5 years, 73 were accessible on phone. Of these, 42.46% (31/73) patients had difficulty in accessing either medications or consultation. The literacy status of the patient was the strongest predictor (0.044) with a negative correlation (-1.216). Difficulty in accessing PCS was associated with a poor health status (p-0.032) and higher pain scores (0.066)., Conclusion: Along with the clinical factors, we have to overlook other factors in predicting difficulty to access PCS in trigeminal neuralgia patients post the RFA status. Difficulty in access to pain medicines and/or consultations was associated with a poor health status and higher pain scores., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Saudi Journal of Anesthesia.)

The central vestibular compensation reduces vestibular symptoms and helps individuals improve balance affected by vestibular dysfunction. The video head impulse test provides an opportunity to study central vestibular compensation objectively. This study aims to methodically present existing information about the video head impulse test as a measure to evaluate central vestibular compensation in patients with unilateral vestibular dysfunction. Literature review comprised 12 research articles selected based on pre-set criteria and timeline (January 2010 to June 2020). The findings indicate that the appropriate video head impulse test measures to evaluate central vestibular compensation after the occurrence of temporary unilateral vestibular dysfunction are the improvement in vestibulo-ocular reflex gain. And, for permanent unilateral vestibular dysfunction are reduction in catch-up saccades percentage, velocity, amplitude, latency, and Perez and Rey score.

The purpose of the study was to identify children at our institute who possibly suffered abusive head trauma (AHT). A retrospective study of CT imaging of children between one month to three years of age between January 2013 and May 2021 was carried out at a dedicated neurocentre in Southern India. We identified 48 cases of possible AHT. The demographics, clinical features at presentation, imaging and fundus findings were analyzed. Imaging revealed subdural hemorrhage (SDH) in 42 and sub dural effusion (SDE) in 5 cases, one case had only hypoxia. The location of SDH was studied as was hypoxia underlying SDH, global hypoxia and ischemia. Cases of subarachnoid hemorrhage (SAH), parenchymal hematoma & intraventricular hemorrhage (IVH) were also noted. Skeletal survey, chest X-ray and CT spine were reviewed. AHT needs to be paid attention to in the Indian scenario. An extensive work up is required to substantiate the claim and to work on prevention & management of these cases subsequently.

Objective: The aim of this study was to study mechanism, risk factors, and prognosis of patients with vertebral artery dissection (VAD) from acute cervical spine trauma (CST)., Methods: A total of 149 consecutive patients were chosen from 2014 to 2019 from our institute data base, and their records were retrospectively studied. Morphology of fracture and subluxation were studied in detail with respect to the presence or absence of VAD., Results: Patients were divided in subsets of axial spine injury and subaxial spine injury. Subgroup and group analysis was performed and computerized tomography angiogram, MR angiogram and T1/T2 axial scans were studied to identify VAD, an incidence of 14.1% was found. Patients having infarcts in posterior circulation were also identified., Conclusion: There is a significant contribution of biomechanics of CST and evolution of VAD. This is an important consideration to prevent significant morbidity and mortality. Hence, a diagnostic algorithm which can be applied in any hospital setup is the need of the hour., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Craniovertebral Junction and Spine.)

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The proposal of C1-C2 fusion as a better treatment option compared with foramen magnum decompression (FMD) for the treatment of Chiari 1 malformations has led to controversy. Although FMD is a time-tested treatment option, a group of patients exists who will benefit from C1-C2 fusion. We have proposed an objective system for defining complex Chiari malformations and studied the outcomes of fusion with decompression versus decompression alone for these patients., Methods: A total of 26 patients with complex Chiari malformations were identified using our criteria (any 4 of 7 clinicoradiological parameters). Of the 26 patients, 13 had undergone C1-C2 fusion with FMD and 13 had undergone FMD alone. They had also undergone pre- and postoperative clinicoradiological evaluations, and the outcomes were assessed using the Chicago Chiari outcome score., Results: Of the 13 patients in the fusion group, 12 (92.3%) showed improvement compared with only 6 of 13 patients (46.2%) in the nonfusion group using the Chicago Chiari outcome score, a statistically significant difference (P = 0.036, χ 2 test). The mean hospital length of stay was longer for the fusion group (6.15 ± 1.46 days) than for the nonfusion group (4.38 ± 2.22 days; P = 0.02)., Conclusions: We have proposed a novel set of criteria for defining complex Chiari malformations. Fusion with decompression provided better outcomes than decompression alone., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Type II odontoid fractures are the commonest C2 fractures. The management of dens fractures remains controversial with various radiological and fracture morphological factors affecting the approach and outcomes., Methods: All cases of anterior odontoid screw fixation between 2010 and 2020 were retrospectively analyzed. Patients' clinical, radiological (type of fracture, orientation, displacement, and diastasis), operative (single vs. double screw) and follow-up records were documented. The postoperative imaging findings were classified into grades I (excellent), II (good), and III (poor) based on the anatomical alignment with the screw. Follow-up cervical computed tomography was reviewed for fracture union., Results: A total of 49 patients with a mean age of 37.3 ± 13.8 years were included in the study. The average time from injury to surgery was 23.1 ± 22.2 days. The bicortical screw purchase and superoposterior odontoid tip breach significantly affected the postoperative alignment (P = 0.035 each). Fracture union was noted in 41 (83.7%) patients. The horizontal fracture displacement ≥2.5 mm (P = 0.02) and poor postoperative fracture alignment (P < 0.001) resulted in worse fracture union rates. Transient dysphagia was the commonest complication (n = 12), whereas screw breakout (n = 2) and pullout (n = 2) were other hardware-related complications. One patient underwent re-exploration for screw readjustment and 2 underwent posterior instrumentation., Conclusions: Anterior odontoid screw fixation is technically straightforward, less morbid, and preserves biomechanical cervical mobility, when compared with the posterior instrumentation. With careful patient selection, meticulous surgical planning, and intraoperative image-guided screw insertion, good fracture union outcomes can be obtained. In the current study, we were able to achieve stable fracture union in 83.7% patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Atlantoaxial instability, although rarely reported in the literature, can be associated with cervical dystonia (CD) and may lead to compression of the cord at the craniovertebral junction. We present a case series of 4 patients of longstanding CD with neurologic complications. Treatment strategies and challenges are discussed., Methods: Retrospective analysis of 4 cases of longstanding CD with complications of myelopathy or radiculopathy., Results: The average age at onset of complications was 28 years (range, 17-37). The average duration of CD was 23.75 years. Narrowing of the craniovertebral junction was seen in 3 patients, of which 2 had os odontoideum, and 1 had rotational malalignment at the atlantoaxial joint. One patient had disc desiccation with bulge and intramedullary signal changes in the cord at C3-4 level. Medical treatment was not satisfactory, but botulinum toxin was partly useful in all. One patient had sequelae of myelopathy and did recover partially after deep brain stimulation. Of the 2 patients who underwent surgical fixation with a fusion of the spine, one improved, and the other had no improvement due to irreversible cord damage. The overall outcome was satisfactory only in 2 patients., Conclusions: Early-onset CD can lead to cord complications at a young age and at higher levels of the cervical spine and at the cervicovertebral junction. Comprehensive management by a multidisciplinary team is crucial to prevent complications early., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The cerebellum is one of the most primitive and complex parts of the human brain. The fiber microdissection technique can be extremely useful for neurosurgeons to understand the topographical organization of the cerebellum's important contents, such as the deep cerebellar nuclei and the cerebellar peduncles, and their relationship with the brain stem., Objective: To dissect the deep cerebellar nuclei and the cerebellar peduncles using the fiber microdissection technique., Methods: Under the operating microscope, 5 previously frozen, formalin-fixed human cerebellums and brain stems were dissected from the superior surface, and 5 were dissected from the inferior surface. Each stage of the process is described. The primary dissection tools were handmade, thin, wooden spatulas with tips of various sizes, toothpicks, and a fine regulated suction., Results: In 15 simplified dissection steps (6 for the superior surface and 9 for the inferior surface), the deep cerebellar nuclei (dentate, interpositus, and fastigial) and the cerebellar peduncles (inferior, middle, and superior) are delineated. Their anatomical relationships with each other and other neighboring structures are demonstrated., Conclusion: The anatomy of the deep cerebellar nuclei and the cerebellar peduncles are clearly defined and understood through the use of the fiber microdissection technique. These stepwise dissections will guide the neurosurgeon in acquiring a topographical understanding of these complex and deep structures of the cerebellum. This knowledge, along with radiological information, can help in planning the most appropriate surgical strategy for various lesions of the cerebellum., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Phaeohyphomycosis causes a wide spectrum of systemic manifestations and can affect even the immunocompetent hosts. Involvement of the central nervous system is rare. A 48-year-old farmer presented with chronic headache, fever, and impaired vision and hearing. Serial MRIs of the brain showed enhancing exudates in the basal cisterns, and lesions in the sella and perichiasmatic and cerebellopontine angle regions along with enhancement of the cranial nerves and leptomeninges. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis with elevated protein and decreased glucose on multiple occasions. Clinical, imaging, and CSF abnormalities persisted despite treatment with antitubercular drugs and steroids for 2 years. Biopsy of the dura mater at the cervicomedullary junction revealed necrotizing granulomatous lesions, neutrophilic abscesses, and giant cells containing slender, pauci-septate, pigmented fungal hyphae. Fungal culture showed growth of Fonsecaea pedrosoi , which is classically known to cause brain abscesses. Here, we report the diagnostic odyssey in a patient with chronic meningitis from a region endemic for tuberculosis and describe the challenges in establishing the accurate diagnosis. Lack of therapeutic response to an adequate trial of empirical antitubercular therapy warrants search for alternative causes, including fungal meningitis. We highlight the uncommon manifestation of F. pedrosoi with chronic meningitis as well as the protracted clinical course despite not receiving antifungal therapy.

We report here a case to illustrate the potential intraoperative multimodal monitoring options available for safe ligation of spinal dural arteriovenous fistula (DAVF). The success of microsurgical treatment depends on the correct identification of the arterial feeder and monitoring the functional integrity of the corticospinal tract., Competing Interests: Conflict of Interest: The authors have no conflicts of interest to declare., (© Copyright 2020 by Turkish Anaesthesiology and Intensive Care Society.)

Background: Trapped fourth ventricle (TFV) is a rare and difficult to treat condition. Most patients have a past inciting event (infection, IVH, trauma) and history of prior CSF diversion. The symptoms are due to the mass effect on brainstem and cerebellum. Rarely, TFV can also be associated with syrinx formation due to a dissociated craniospinal CSF flow near the fourth ventricle outlets. We present our experience and outcomes of open posterior fenestration in 11 cases, along with an overview of the surgical management of TFV., Methods: Between 2011 and 2018, 11 patients of TFV were operated by the posterior approach fenestration of the fourth ventricle outlets and arachnoid dissection. The clinical and radiological findings of the patients were retrieved from the hospital database. The surgical technique is described in detail. The patients' neurological status and imaging findings in the follow-up were recorded and compared., Results: The average age of the patients was 23.55 years. The most common presenting symptoms were headache (9/11) and gait imbalance (7), with TB meningitis being the commonest etiology. Ten patients had a history of prior CSF diversion with two presenting with shunt malfunction. Mean follow-up duration was 33.33 months. The improvement in neurological status was observed in 9/11 patients, 2 remained status quo. On follow-up imaging, 8/11 (72.72%) patients had a decrease in the size of TFV while syrinx improved in 3/5 (60%)., Conclusion: Multiple surgical approaches have been described for TFV. Endoscopic fourth ventriculostomy with aqueductoplasty is gaining popularity in the past two decades. However, an open posterior fenestration of the midline fourth ventricle outlet (magendieplasty) along with sharp arachnoid dissection (adhesiolysis) along the cerebello-medullary cisterns and paracervical gutters is relatively simple and provides physiological fourth ventricular CSF outflow. This is especially useful in TFV with syrinx as the craniospinal CSF circulation is established.