Rationale Behind the Use of Double-Layer Polypropylene Patch (G-patch) Dural Substitute During Decompressive Craniectomy as an Adhesion Preventive Material for Subsequent Cranioplasty with Special Reference to Flap Elevation Time.

OBJECTIVE: Dural substitutes are used in decompressive craniectomy (DC) to prevent adhesions during subsequent cranioplasty. Current literature attributes them to reduced blood loss and reduction in operative time of cranioplasty. The use of double-layer substitute has rarely been documented. We studied the use of double-layer G-patch as a dural substitute in DC and evaluated its outcome during subsequent cranioplasty with special focus on flap elevation time and blood loss during cranioplasty. METHODS: We performed emergency frontotemporoparietal decompressive craniectomy using a double layer of G-patch as dural substitute. Subsequent cranioplasty was done in these 35 patients. The development of adhesion formation between the tissue layers, amount of blood loss, and flap elevation time were recorded. RESULTS: During the cranioplasty, a clear and smooth plane of dissection was found between the 2 layers of G-patch in all cases. Average flap elevation time was 21.8 minutes, and average time taken for cranioplasty was 124.12 minutes. Average blood loss was 83 mL. None of the patients required re-exploration for infection of bone flap or postoperative bleed. CONCLUSIONS: While evaluating the use of dural substitute during DC as an adhesion preventive material for subsequent cranioplasty, flap elevation time and blood loss should be taken into account rather than operative time. Double-layer G-patch during DC facilitates subsequent cranioplasty by preventing adhesions between the layers, resulting in easier dissection and reduced blood loss.

Single Parietal Burr-hole Craniostomy with Irrigation and Drainage for Unilateral Chronic Subdural Hematoma in Young Adults <40 Years: A Rationale behind the Procedure.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. It is mostly a disease of elderly population with very little data about the young patients. There is also the debate regarding treatment strategies. We decided to determine the overall efficacy of the single burr-hole craniostomy (SBHC) for unilateral CSDH in young adults <40 years. SUBJECTS AND METHODS: We performed a retrospective study of young patients undergoing SBHC for unilateral CSDH between January 2013 and June 2016 at our institution. Medical records were assessed based on patient characteristics in the form of sex of the patient, etiology, presenting symptoms, comorbidities, and signs including Glasgow Coma Scale, computed tomography (CT) brain findings (site and thickness of SDH with midline shift), and intraoperative presence of chronic/subacute component. RESULTS: Mean age of the patient was 33.69 years (range 18-40 years), mean thickness of SDH was 15.47 mm, and mean midline shift was 11.26 mm. 61.54% patients were male, trauma being the most common etiology (92.31%) with most common presenting complaint being headache (90.38% patients). 69.23% patients presented within 1 day of onset of symptoms. On CT scan, most of the patients were having SDH thickness between 11 and 20 mm (67.31%) with midline shift of 6-10 mm (53.85%). Right-sided SDH was present in 53.85%. Intraoperatively, 63.46% patients had subacute SDH whereas 34.61% had chronic component. There were total 2 recurrences (3.85%). CONCLUSIONS: Young adults who present with unilateral CSDH usually have a history of trauma. They have shorter duration of symptoms and present mainly with the features of raised intracranial pressure such as headache and vomiting. SBHC with irrigation and drainage has excellent result for unilateral CSDH in young adults compared to other methods of drainage and should be considered treatment of choice unless contraindicated.

Government Medical College Trivandrum - Fifty years of Neurosurgery in Kerala state.

The Department of Neurosurgery founded in the Trivandrum Medical College, Kerala, the first teaching hospital in Kerala state, is celebrating its 50th anniversary. The history of Neurosurgery in this Institute is synonymous with the history of Neurosurgery in the state as this was the first medical college to start a Neurosurgery department within the state.The students after undergoing their rigorous training in the department, went on to establish advanced neurosurgical centres throughout Kerala and in several other parts of the country. This article traces the illustrious history of the Department of Neurosurgery, Trivandrum Medical College and also of the eminent faculty members and residents, who helped in advancing the standards of Neurosurgery in the region as well as the rest of India. The Department of Neurosurgery was founded in the Trivandrum Medical College, Kerala, the first teaching hospital in Kerala state, in the year 1951, and is celebrating its 50th anniversary. The history of Neurosurgery in this Institute is synonymous with the history of Neurosurgery in the state as this was the first medical college to start a Neurosurgery department within the state.The students after undergoing their rigorous training in the department, went on to establish advanced neurosurgical centres throughout Kerala and in several other parts of the country. This article traces the illustrious history of the Department of Neurosurgery, Trivandrum Medical College and also of the eminent faculty members and residents, who helped in advancing the standards of Neurosurgery in the region as well as the rest of India.

Conservative Treatment of Chronic Subdural Hematoma in HIV-Associated Thrombocytopenia with Tranexamic Acid.

Chronic subdural hematomas (CSDHs) and its management comprise a majority work in a neurosurgical specialty. The effectiveness of surgery is beyond doubt and sometimes even lifesaving in severe cases. However, the straightforward surgery is sometimes complicated by the associated comorbidities of the patient. Comorbidities in the form of coagulopathies secondary to chronic liver diseases, drugs (warfarin, ecosprin, clopidogrel), thrombocytopenia secondary to systemic illness are always a challenge to deal with in patients with CSDH. The authors encountered a patient with thrombocytopenia secondary to systemic HIV infection who presented with CSDH. Her coagulation profile was severe enough to preclude surgery. She was managed conservatively with tranexamic acid and responded well. The authors present the challenges they faced in the course of successful management of this patient.

Rare sequelae following ventriculoatrial shunt: Case report and review of literature.

Ventriculoatrial shunt (VA) is one of the oldest solutions for hydrocephalus. However over subsequent years various complication of VA shunt such as obstructions, malposition, shunt infections, cardiac complications such as endocarditis, traumatic perforation, heart failure, tricuspid regurgitation, intraatrial thrombus, and pulmonary hypertension are reported. Hence, VA shunt procedure has fallen into disrepute. Still VA shunt may be a good option in selected patients with hostile peritoneum. Newer placement strategies and monitoring methods have been put forward to reduce complication following VA shunt. In this case report, we share a rare case of endocarditis with tricuspid regurgitation following a migrated retained calcified shunt tube in the right ventricle of heart 30 years after of VA shunt that was successfully managed.

Can the angle between optic nerves indicate whether optic chiasm is prefixed, normofixed or postfixed? An anatomical study with radiologic and neurosurgical implications.

PURPOSE: The objective of this study was to measure the angle (Interneural angle, INA) between intracranial segments of optic nerves (ISON), and to look for any relation between it and the relative anteroposterior location (RAPL) of the optic chiasm (OC)-viz. prefixed, normofixed and postfixed. METHODS: The sample comprised of 100 autopsy specimens from South Indian population. INA was measured using software-aided processing of digital photographs. Length of the ISON was measured on each side using Vernier calipers. RAPL of the OC was noted during dissection. These were analysed with statistical methods. RESULTS: RAPL of OC was found to be prefixed in 24 %, normofixed in 65 % and postfixed in 11 %. The INA had an overall mean of 69.9° (SD 9.29°). ANOVA confirmed statistically significant difference in INA among different groups; the corresponding mean value for the group was as follows: 79.61° (prefixed), 68.10° (normofixed) and 59.48° (postfixed). ROC curve was plotted for the use of various 'cut off' values of INA to 'diagnose' prefixed OC; an INA ≥71.4° was seen to diagnostically correlate with prefixed OC with 83.3 % sensitivity and 75 % specificity. CONCLUSIONS: The INA is wider when OC is prefixed, intermediate when normofixed and narrowed when postfixed. This observation throws light on the possibility of using INA as a marker of RAPL of OC. As INA can be measured in axial MRI sections, it can be used in differentiation of the cases with prefixed OC from others during pre-operative work up for pituitary surgeries and to identify individuals 'at risk' during subfrontal approach for pituitary lesions.

Four-quadrant osteoplastic decompressive craniotomy: A novel technique for refractory intracranial hypertension - A pilot study.

BACKGROUND: Decompressive craniectomy (DC) with duroplasty is the gold standard for refractory intracranial hypertension despite paucity of randomized controlled trials. There are several morbidities associated with DC of which the persistence of bony defect is of paramount importance. Studies have shown that many of the morbidities associated with DC get reversed following replacement of the bone flap. AIM: To design a novel technique for control of refractory intracranial pressure (ICP), as well as to study its safety and efficacy compared to the conventional DC technique. MATERIAL AND METHODS: We conducted a prospective, comparative, observational pilot study comparing four-quadrant osteoplastic decompressive craniotomy (FoQOsD) with conventional DC. The demographic features, postoperative variables such as operating time, number of days of intensive care unit (ICU) stay and survival, as well as radiographic variables such as change in the midline shift (MLS) and expansion of the compressed brain were analyzed using relevant statistical tests. RESULTS: Twenty patients were selected and grouped into two groups of 10 patients each. The male: female ratio in the two groups were 8:2 and 7:3, respectively, and the mean age at presentation was 42.7 ± 1.45 years in the FoQOsD group and 43.6 ± 1.32 years in the DC group. Both the groups were comparable in relation to the duration of surgery, duration of ICU stay, and survival (P > 0.05). There was significant brain expansion and reversal of MLS (P < 0.001) in the FoQOsD group, factors which were comparable to that in the DC group. CONCLUSIONS: FoQOsD may be as effective as conventional DC in managing intracranial hypertension. This procedure mainly avoids a revision cranioplasty. A prospective randomized controlled trial with a large sample size may be initiated for obtaining more accurate data.