Challenges and Outcomes of COVID-19 Positive Neurosurgical Patients: An Institutional Experience With Emphasis on Modifications of Neurosurgical Practice.

INTRODUCTION: There has been a drastic reduction in the number of neurosurgeries performed during the COVID-19 pandemic due to a multitude of challenges prompting restructuring of neurosurgical services. The present study describes the challenges and outcomes of non-elective neurosurgical procedures done on COVID-19 positive patients along with the modifications in neurosurgical practice during the pandemic. METHODS: A retrospective study was done in the Department of Neurosurgery over a period of one year and three months. Demographic and clinical details including outcomes of the COVID-19 positive patients, who had undergone non-elective neurosurgical interventions, were collected. RESULTS: Ten patients (3.8%) were COVID-19 positive out of 262 neurosurgical interventions done. The age of the patients ranged from 5 days to 78 years with five males and five females. Out of the 10 patients, five were neurotrauma cases including one patient of head injury with craniovertebral junction injury. The patient with craniovertebral junction injury underwent foramen magnum decompression with C1 lateral mass-C2 pedicle screw on the right and C0-C2 pedicle screw and rod fixation on the left. The rest of the neurotrauma cases underwent craniotomy or burr-hole craniostomy followed by evacuation. Only one patient (10%) had postoperative 30-day mortality. The rest nine patients (90%) survived the post-operative 30-day mortality. The various modifications incorporated in the neurosurgical practice included categorizing the emergency room into various zones, a separate operating theatre for COVID-19 patients, limiting the number of operating members as well as minor modifications in the operating procedures. CONCLUSIONS: The postoperative surgical outcome is favorable in COVID-19 positive patients with modifications of the existing neurosurgical practices.

Microvascular Clipping of A1 Segment Aneurysms.

BACKGROUND: Aneurysms arising from the proximal segment (A1) of the anterior cerebral artery (ACA) are relatively rare. Because of their small size, abnormal location in relation to the parent artery and the risk of damage to the surrounding perforators, their surgical management is a big challenge. We present our experience with 7 patients of A1 segment aneurysms. SETTINGS AND DESIGN: Tertiary care referral center. MATERIALS AND METHODS: Seven patients who were diagnosed with A1 aneurysms between 2009 and 2017 were included. Preoperative evaluation included Non-Contrast Computed Tomography (NCCT) head and angiography (Digital Subtraction Angiography with/without CT-Angiography). The clinicoradiological condition of the patients was graded as per World Federation of Neurological Surgeons (WFNS), Fisher and Hunt and Hess (H and H) Grading systems. A retrospective review of clinical features, radiological descriptions, surgical treatment, and outcomes was done. RESULTS: All patients underwent microneurosurgical clipping. All aneurysms were saccular, ranging in size from 4 to 14 mm and neck size varied from 2 to10 mm. Most aneurysms 5 (71.4%) had a posterior direction. Anatomical variations were noticed in 3 (42.8%) patients. Posteroinferiorly directed aneurysms were difficult to clip. As per Glasgow Outcome scale (GOS), 6 (85.7%) patients had a good outcome, whereas 1 (14.2%) had poor outcome. As per the modified Rankin Scale (mRS) too, 6 (85.7%) had a favorable outcome. There were no deaths. CONCLUSION: A1 aneurysms are frequently associated with vascular anomalies and generally rupture when small. A1 aneurysms with a superior and anterior direction are relatively easy to clip whereas those directed postero-inferiorly are difficult. Close association with critical perforators also compounds the situation. Due to the rarity of A1 aneurysms, large series are few in literature.

Primary Neuroendocrine Tumor of the Lumbar Spine: Rare Tumor Mimicking Nerve Sheath Tumor of the Spine.

Neuroendocrine tumors (Carcinoid tumors) generally arise from enterochromaffin cells of gut and bronchi. Primary carcinoid tumors of spine are extremely rare and have been described in sacrum and coccyx. Primary carcinoid tumors involving the spinal cord are still rarer, and review of literature revealed only two cases reported. Our patient a 39-year-old male had diagnosed as a case of nerve sheath tumor (intradural extramedullary) at LV4 region on neuroimaging. However, postoperatively, the tumor turned out to be a rare primary spinal carcinoid tumor on histopathological examination and immunohistochemical staining. Work up to rule out any other site in the body was negative. To the best of our knowledge, this is the first case of primary carcinoid tumor of the lumbar spine.

Spastic quadriparesis due to pathological fracture of odontoid secondary to carcinoma prostate: A rare presentation.

Prostate carcinoma presenting as symptomatic metastases to atlantoaxial spine is extremely rare. Spastic quadriparesis due to pathological fracture of odontoid as the only initial manifestation without symptoms of primary malignancy is rarer still. We report a 64-year-old male who presented with progressive spastic quadriparesis along with urinary retention of 3 weeks duration. Computed tomography and magnetic resonance imaging cervical spine and craniovertebral junction showed type III pathological fracture of odontoid with anterior translation of C1 with spinal cord compression. Biopsy from an enlarged prostate showed adenocarcinoma of prostate. The patient was managed conservatively from neurological aspect as he refused for any surgical intervention.