A High-Fidelity Agar-Based Phantom for Ultrasonography-Guided Brain Biopsy Simulation: A Novel Training Prototype with Visual Feedback.

OBJECTIVE: A novel agar-based phantom was developed and assessed for ultrasonography (USG)-guided brain biopsy training. The phantom provides visual cues combined with sonologic cues, allowing multimodal training. Impact of multimodal training is evaluated through pretraining and posttraining trials. METHODS: Twenty-five participants were divided based on experience with USG-based procedures into familiar (≥3 procedures performed in the past) (n = 14) and unfamiliar (<3 procedures performed) (n = 11). Agar phantoms with an opaque top and transparent middle layer were constructed in transparent glass bowls, each having 12 embedded targets. Participants underwent 2 supervised trials of USG-guided biopsy with aluminum foil covering the glass bowls, eliminating visual cues. Between 2 trials, participants underwent unsupervised self-training on a phantom without foil cover, providing visual cues. Performance was measured through insonation efficiency (EfI), biopsy efficiency (EfB), efficiency score (Ef), error score (Er), and performance score (PS). Scores were compared between and within the 2 groups before and after training. Impact of the self-training session on subjective comfort levels with the procedure was assessed through feedback forms. RESULTS: Familiars had better pretraining EfB, Ef, Er, and PS (P < 0.001) compared with unfamiliars. After training, both performed similarly on all metrics. After training, familiars improved only in EfI (P = 0.001), with the unfamiliars showing significance in all metrics except EfI. CONCLUSIONS: Simulation and phantom-based models can never supplant training through supervised skill application in vivo but our model supplements training by enabling technical skill acquisition, especially for beginners in USG-guided brain biopsy.

Frailty and Neutrophil Lymphocyte Ratio as Predictors of Mortality in Patients with Catheter-Associated Urinary Tract Infections or Central Line-Associated Bloodstream Infections in the Neurosurgical Intensive Care Unit: Insights from a Retrospective Study in a Developing Country.

OBJECTIVE: We aim to evaluate the role of frailty and inflammatory markers in predicting the short-term outcomes after catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI). METHODS: Data regarding the patients' characteristics, isolates on CAUTI and CLABSI, antibiotic susceptibility, frailty (11-point Modified Frailty Index), and inflammatory markers were retrospectively collected. Their impact on the short-term outcomes was assessed using regression modeling response. RESULTS: One hundred and one patients with CAUTI (n = 71) and CLABSI (n = 30) between January 2018 and December 2019 were included in this study. The pooled incidence rates for CAUTI were 5.50 and for CLABSI 3.58 episodes/1000 catheter-days. We observed 74.7% drug resistance in our CAUTI isolates and 93.3% in CLABSI. In the multivariate analysis, frailty (P = 0.006), neutrophil/lymphocyte ratio (NLR) (P = 0.007) and the presence of sepsis (P = 0.029) were found to be significant predictors of in-hospital mortality in CAUTI. In patients with CLABSI, frailty (P = 0.029) and NLR (P = 0.029) were found significant and along with sepsis (P = 0.069) resulted in a regression model with good accuracy in predicting mortality. The receiver operating characteristic curve showed that 11-point Modified Frailty Index and NLR as well as the regression model significantly predicted mortality with an area under the curve of 86.1%, 81.4%, and 95.4%, respectively, in CAUTI, and 70.9%, 77.8%, and 95.2%, respectively, in CLABSI.

Efficacy of antimicrobial medicated ventricular catheters: a network meta-analysis with trial sequential analysis.

There is paucity of evidence regarding relative performance of antibiotic-medicated (AM), silver-medicated (SM) and non-medicated (NM) ventricular catheters in controlling infection rate. We aim to quantitatively synthesize the current evidence after addition of the three-armed British Antibiotic and Silver Impregnated Catheters for ventriculoperitoneal Shunts (BASICS) trial, understand the need for further evidence using trial sequential analysis (TSA) and incorporate the indirect evidence using network meta-analysis (NMA). Randomized controlled trials (RCTs) comparing AM, SM and NM ventriculoperitoneal shunt (VPS) or external ventricular drain (EVD) were included. Antibiotic-medicated VPS show a significantly lower infection rate as compared to non-medicated VPS (RR 0.44; 95% CI: 0.27-0.73; p = 0.001), however, TSA reveals need for further evidence. SM including both EVD as well as VPS were found to be inferior to AM while no significant difference was found in comparison to the NM catheters. In NMA for VPS, the AM were found to be significantly better than SM (RR 0.41, 95% CI: 0.22-0.75) as well as NM (RR 0.42; 95% CI: 0.25-0.71) with a SUCRA of 99.8% and a mean rank of 1. However, antibiotic medicated shunts did not show a statistically significant association with reoperation rate (RR 0.99; 95% CI:0.81-1.20; p = 0.9) with no further need for evidence as per TSA.

En-bloc Resection of A Giant Solid Hemangioblastoma of The Vermis.

INTRODUCTION: Hemangioblastomas (HMB) are extensively vascularized and benign neoplasms that are diagnosed predominantly in adults. The solid type of HMB is technically challenging to operate. The piecemeal resection of the tumor has been shown to have devastating intraoperative complications. Therefore, en-bloc tumor resection was shown to be the safest procedure to reduce the risk of intraoperative bleeding and facilitate the removal of large solid tumors. Unfortunately, most of these tumours are also not amenable for embolization, as they are fed by multiple pial vessels. However, the large arterial feeders may be embolized. OBJECTIVE: This video abstract presents a case of en-bloc resection of a giant solid type of Vermian HMB. SURGICAL TECHNIQUE: A 38-year-old male patient presented with headache and vomiting for 1 year, imbalance during walking for 6 months, and hoarseness of voice for 2 months. He underwent a CSF diversion procedure in another hospital and was referred to our center for definitive surgery. Contrast-enhanced MRI showed a large heterogeneously enhancing solid lesion of size 46 × 33 × 40 mm3 with central necrotic area in the posterior fossa with perilesional edema and several large flow voids on T2-MR sequence. Preoperative embolization was performed; however, there was no significant reduction in the vascularity of the lesion. The patient underwent a wide midline suboccipital craniotomy with C1 laminectomy and gross total en-bloc resection of HMB. RESULTS: The patient had an uneventful recovery in the postoperative period. CONCLUSIONS: The safest approach in the resection of giant solid HMB involves proper preoperative planning and understanding the vascular pattern of the lesion, wide exposure, circumferential dissection, and the en-bloc delivery of the tumor.

Impact of different visualization devices on accuracy, efficiency, and dexterity in neurosurgery: a laboratory investigation.

OBJECTIVE: Extracorporeal telescopes (exoscopes) have been the latest addition to the neurosurgeons' armamentarium, acting as a bridge between operating microscopes and endoscopes. However, to the authors' knowledge there are no published preclinical laboratory studies of the accuracy, efficiency, and dexterity of neurosurgical training for the use of 2D or 3D exoscopes compared with microscopes. METHODS: In a controlled experimental setup, 22 participating neurosurgery residents performed simple (2D) and complex (3D) motor tasks with three visualization tools in alternating sequence: a 2D exoscope, 3D exoscope, and microscope, using a block randomization model based on the neurosurgeons' prior training experience (novice, intermediate, and senior: n = 6, 12, and 4, respectively). Performance scores (PS; including error and efficiency scores) and dexterity scores (DS) were calculated to objectify the accuracy, efficiency, and finesse of task performance. Repeated measures ANOVA analysis was used to compare the PS, DS, and cumulative scores (CS) of candidates using the three visualization aids. Bland-Altman plots and intraclass correlation coefficients were generated to quantify intraobserver and interobserver agreement for DS. Subgroup analysis was performed to assess the impact of participants' prior training. A postexercise survey was conducted to assess the comfort level (on a 10-point analog scale) of the participants while using each visualization tool for performing the suturing task. RESULTS: PS, DS, and CS were significantly impacted by the visualization tool utilized for 2D motor tasks (p < 0.001 for each), with the microscope faring better than the 2D exoscope (p = 0.04) or 3D exoscope (p = 0.008). The PS for the 3D object transfer task was significantly influenced by the visualization aid used (p = 0.007), with the microscope and 3D exoscope faring better than the 2D exoscope (p = 0.04 for both). The visualization instrument used significantly affected the DS and CS for the suturing task (p < 0.001 for both), with the microscope again scoring better than the 2D exoscope (p < 0.001) or 3D exoscope (p = 0.005). The impact of the visualization aid was more apparent in participants with a shorter duration of residency (novice, p = 0.03; intermediate, p = 0.0004). Participants also felt the greatest operational comfort while working with a microscope, 3D exoscope, and 2D exoscope, in that order (p < 0.0001). CONCLUSIONS: Compared with 3D and 2D exoscopes, an operating microscope provides better dexterity and performance and a greater operational comfort level for neurosurgeons while they are performing 2D or 3D motor tasks. For performing complex 3D motor tasks, 3D exoscopes offer selective advantages in dexterity, performance, and operational comfort level over 2D exoscopes. The relative impact of visualization aids on surgical proficiency gradually weakens as the participants' residency duration increases.

Impact of frailty on surgery for glioblastoma: a critical evaluation of patient outcomes and caregivers' perceptions in a developing country.

OBJECTIVE: The authors aimed to evaluate the impact of age and frailty on the surgical outcomes of patients with glioblastoma (GBM) and to assess caregivers' perceptions regarding postdischarge care and challenges faced in the developing country of India. METHODS: This was a retrospective study of patients with histopathologically proven GBM from 2009 to 2018. Data regarding the clinical and radiological characteristics as well as surgical outcomes were collected from the institute's electronic database. Taking Indian demographics into account, the authors used the cutoff age of 60 years to define patients as elderly. Frailty was estimated using the 11-point modified frailty index (mFI-11). Patients were divided into three groups: robust, with an mFI score of 0; moderately frail, with an mFI score of 1 or 2; and severely frail, with an mFI score ≥ 3. A questionnaire-based survey was done to assess caregivers' perceptions about postdischarge care. RESULTS: Of the 276 patients, there were 93 (33.7%) elderly patients and 183 (66.3%) young or middle-aged patients. The proportion of severely frail patients was significantly more in the elderly group (38.7%) than in the young or middle-aged group (28.4%) (p < 0.001). The authors performed univariate and multivariate analysis of associations of different short-term outcomes with age, sex, frailty, and Charlson Comorbidity Index. On the multivariate analysis, only frailty was found to be a significant predictor for in-hospital mortality, postoperative complications, and length of hospital and ICU stay (p < 0.001). On Cox regression analysis, the severely frail group was found to have a significantly lower overall survival rate compared with the moderately frail (p = 0.001) and robust groups (p < 0.001). With the increase in frailty, there was a concomitant increase in the requirement for readmissions (p = 0.003), postdischarge specialist care (p = 0.001), and help from extrafamilial sources (p < 0.001). Greater dissatisfaction with psychosocial and financial support among the caregivers of severely frail patients was seen as they found themselves ill-equipped to provide postdischarge care at home (p < 0.001). CONCLUSIONS: Frailty is a better predictor of poorer surgical outcomes than chronological age in terms of duration of hospital and ICU stay, postoperative complications, and in-hospital mortality. It also adds to the psychosocial and financial burdens of the caregivers, making postdischarge care challenging.

Factors predicting loss of cervical lordosis following cervical laminoplasty: A critical review.

BACKGROUND: Laminoplasty is a method of posterior cervical decompression which indirectly decompresses the spinal column. Unfortunately, many patients undergoing laminoplasty develops postoperative loss of cervical lordosis (LCL) or kyphotic alignment of cervical spine even though they have sufficient preoperative lordosis which results in poor surgical outcome. OBJECTIVE: We would like to highlight the relationship between various radiological parameters of cervical alignment and postoperative LCL in patients undergoing laminoplasty. METHODS: We performed extensive literature search using PubMed, Google Scholar, and Web of Science for relevant articles that report factors affecting cervical alignment following laminoplasty. RESULTS: On reviewing the literature, patients with high T1 slope have more lordotic alignment of cervical spine preoperatively. They also have more chances of LCL following laminoplasty. C2-C7 sagittal vertical axis (SVA) has no role in predicting LCL following laminoplasty though patients with low T1 slope (≤20°) and high C2-C7 SVA (>22 mm) had correction of kyphotic deformity following laminoplasty. C2-C7 lordosis, Neck Tilt, cervical range of motion, and thoracic kyphosis has no predictive value for LCL. Lower value of T1 slope (T1S-CL) and CL/T1S has more incidence of developing LCL following laminoplasty. The role of C2-C3 disc angle has not yet been evaluated in patients undergoing laminoplasty. Dynamic extension reserve determines the contraction reserve of SPMLC and lower dynamic extension reserve is associated with higher chances of LCL following laminoplasty. CONCLUSIONS: Cervical lordotic alignment is important in maintaining cervical sagittal balance which ultimately is responsible for global spinal sagittal balance and horizontal gaze. Among various radiological parameters, T1 Slope has been reported to be the most important factor affecting cervical alignment following laminoplasty.

Is medulloblastoma associated with systemic immunomodulation? - A comparative analysis of preoperative inflammatory markers.

BACKGROUND: We attempt to compare preoperative inflammatory markers among children with medulloblastoma and pilocytic astrocytoma and establish their diagnostic efficacy to distinguish these tumors. METHODS: Children (<18 years) with biopsy-proven medulloblastoma and pilocytic astrocytoma operated at our institute from January 2012 to January 2018 were enrolled in this study. The hematological parameters were compared between the two groups and with healthy controls. Children with a history of disease or medications that may confound these parameters were excluded from the study. Receiver operator characteristic curves were made to assess the diagnostic accuracy of markers found to be significant. RESULTS: Patients with medulloblastoma were found to have higher neutrophil-lymphocyte ratio (NLR), derived neutrophil-lymphocyte ratio (dNLR), platelet-lymphocyte ratio (PLR), and platelet counts compared with pilocytic astrocytoma. Absolute lymphocyte count (ALC) was significantly lower in medulloblastoma group as compared to healthy controls but not with pilocytic astrocytoma. NLR and dNLR demonstrated maximum diagnostic accuracy in distinguishing patients with medulloblastoma from healthy controls and pilocytic astrocytoma. Using a cutoff of 2.45 for NLR distinguishes medulloblastoma from healthy controls as well as pilocytic astrocytoma with a sensitivity of 75.5% and specificity of 66.7%. Similarly, dNLR cutoff of 1.47 distinguishes medulloblastoma from healthy controls with a sensitivity of 83% and specificity of 76% and a cutoff of 1.53 distinguishes medulloblastoma from pilocytic astrocytoma with a sensitivity of 81.1% and specificity of 81.8%. Combination of NLR and dNLR performed only marginally better than individual variables with area under the curve being 0.856 for medulloblastoma versus healthy controls and 0.86 for medulloblastoma versus pilocytic astrocytoma. CONCLUSION: NLR and dNLR can be used as a preoperative predictive marker in medulloblastoma. There is decreased ALC in patients with medulloblastoma contributing to raised NLR and dNLR suggestive of systemic immunosuppression.

Meta-Analysis with Trial Sequential Analysis on the Efficacy and Safety of Erythropoietin in Traumatic Brain Injury: A New Paradigm.

OBJECTIVE: Erythropoietin (EPO) has been shown to be beneficial in traumatic brain injury (TBI). We have attempted to quantitatively synthesize the findings of current randomized controlled trials (RCTs) in this meta-analysis and analyzed the need for further trials using trial sequential analysis (TSA). METHODS: A systematic search was performed in PubMed, the Cochrane Library databases, and Google Scholar for RCTs until December 2019 evaluating the role of EPO in patients with TBI. Seven RCTs were finally included in the quantitative analysis. TSA was done to evaluate the need for further studies. RESULTS: The pooled estimate demonstrated that EPO significantly reduced mortality at 6 months (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.43-0.97; P = 0.04) but not in hospital mortality (OR, 0.84; 95% CI, 0.31-2.32; P = 0.74). There was no significant difference in the rate of favorable outcomes with EPO (OR, 1.58; 95% CI, 0.84-2.99; P = 0.16). The rate of deep vein thrombosis (RD, -0.02; 95% CI, -0.06 to 0.02; P =0.41) was also not found to be significantly different in the 2 groups. TSA showed that the accrued information is insufficient to make any definitive conclusions. CONCLUSIONS: EPO seems to be beneficial in terms of reducing 6-month mortality, however, its effect on in-hospital mortality, neurologic outcomes, and risk of deep vein thrombosis fails to reach statistical significance. TSA suggests a need for large trials to evaluate the role of EPO in patients with TBI in a more systematic way.

Interplay of Dynamic Extension Reserve and T1 Slope in Determining the Loss of Cervical Lordosis Following Laminoplasty: A Novel Classification System.

BACKGROUND: Laminoplasty causes destruction of the posterior musculoligamentous complex, which may result in cervical kyphosis, or more commonly loss of cervical lordosis (LOCL). In this study, we evaluated the role of various preoperative radiologic parameters in predicting not only the LOCL/kyphosis but also the functional outcomes in the form of change in Oswestry Disability Index (ODI) score following laminoplasty. METHODS: Patients were evaluated both clinically and radiologically with dynamic cervical spine radiograph, noncontrast-enhanced computed tomography, and magnetic resonance imaging of the cervical spine preoperatively as well as at 1 year follow-up. RESULTS: One hundred twenty-one patients who underwent laminoplasty for cervical spondylotic myelopathy/ossified posterior longitudinal ligament from 2011 to 2018 at our center were included in final analysis. In multivariate analysis, preoperative Cobb angle (P = 0.001), T1 slope (TIS; P = 0.001), and dynamic extension reserve (P < 0.001) were found to have an independent effect on LOCL. The receiver operating characteristic curve using the regression model significantly predicted LOCL >10° with an area under the curve of 88.3% (P < 0.001). Similarly, preoperative T1S (P = 0.036) and SVA (P < 0.001) were found to be independent predictors of significant improvement in ODI after laminoplasty. The receiver operating characteristic curve using the regression model significantly predicted change in ODI with an area under the curve of 83.7% (P < 0.001). Based on these findings, classification and scoring systems with good accuracy have been proposed for prediction of LOCL and improvement in ODI. CONCLUSIONS: We have found that the chances of significant LOCL is determined by an interplay of preoperative Cobb angle, T1S, and dynamic extension reserve.

Which factors predict the loss of cervical lordosis following cervical laminoplasty? A review of various indices and their clinical implications.

BACKGROUND: Many patients undergoing laminoplasty develop postoperative loss of cervical lordosis or kyphotic alignment of cervical spine despite sufficient preoperative lordosis. This results in poor surgical outcomes. METHODS: Here, we reviewed the relationship between multiple radiological parameters of cervical alignment that correlated with postoperative loss of cervical lordosis in patients undergoing laminoplasty. RESULTS: Patient with a high T1 slope (T1S) has more lordotic alignment of the cervical spine preoperatively and is at increased risk for the loss of cervical lordosis postlaminoplasty. Those with lower values of difference between T1S and Cobb's angle (T1S-CL) and CL-T1S ratio have higher risks of developing a loss of the cervical lordosis postoperatively. Alternatively, C2-C7 lordosis, neck tilt, cervical range of motion, and thoracic kyphosis had no role in predicting the postlaminoplasty kyphosis. CONCLUSION: Among various radiological parameters, the preoperative T1S is the most important factor in predicting the postoperative loss of the cervical lordosis/alignment following laminoplasty.

Outcome following postneurosurgical Acinetobacter meningitis: an institutional experience of 72 cases.

OBJECTIVE: The authors aimed to evaluate the antimicrobial susceptibility pattern of Acinetobacter isolates responsible for nosocomial meningitis/ventriculitis in the neurosurgical ICU. The authors also sought to identify the risk factors for mortality following Acinetobacter meningitis/ventriculitis. METHODS: This was a retrospective study of 72 patients admitted to the neurosurgical ICU between January 2014 and December 2018 with clinical and microbiological diagnosis of nosocomial postneurosurgical Acinetobacter baumanii meningitis/ventriculitis. Electronic medical data on clinical characteristics, underlying pathology, CSF cytology, antibiotic susceptibilities, and mortality were recorded. To evaluate the outcome following nosocomial postneurosurgical Acinetobacter meningitis/ventriculitis, patients were followed up until discharge or death in the hospital. Kaplan-Meier survival analysis and multivariable Cox proportional hazards models were used to compute factors affecting survival. RESULTS: The study population was divided into two groups depending on the final outcome of whether the patient died or survived. Forty-three patients (59.7%) were included in the survivor group and 29 patients (40.3%) were included in the nonsurvivor group. Total in-hospital mortality due to Acinetobacter meningitis/ventriculitis was 40.3% (29 cases), with a 14-day mortality of 15.3% and a 30-day mortality of 25%. The 43 (59.7%) patients who survived had a mean length of hospital stay of 44 ± 4 days with a median Glasgow Outcome Scale-Extended score at discharge of 6. On univariate analysis, age > 40 years (p = 0.078), admission Glasgow Coma Scale (GCS) score ≤ 8 (p = 0.003), presence of septic shock (p = 0.011), presence of external ventricular drain (EVD) (p = 0.03), CSF white blood cell (WBC) count > 200 cells/mm3 (p = 0.084), and comorbidities (diabetes, p = 0.036; hypertension, p = 0.01) were associated with poor outcome. Carbapenem resistance was not a risk factor for mortality. According to a multivariable Cox proportional hazards model, age cutoff of 40 years (p = 0.016, HR 3.21), GCS score cutoff of 8 (p = 0.006, HR 0.29), CSF WBC count > 200 cells/mm3 (p = 0.01, HR 2.76), presence of EVD (p = 0.001, HR 5.42), and comorbidities (p = 0.017, HR 2.8) were found to be significant risk factors for mortality. CONCLUSIONS: This study is the largest case series reported to date of postneurosurgical Acinetobacter meningitis/ventriculitis. In-hospital mortality due to Acinetobacter meningitis/ventriculitis was high. Age older than 40 years, GCS score less than 8, presence of EVD, raised CSF WBC count, and presence of comorbidities were risk factors for mortality.