Postoperative Herpes Viral Infections in Neurosurgery - An Experience and Arguments for and against the Plausible Hypotheses.

BACKGROUND: The literature contains several reports of herpes recrudescence after neurosurgery. We analyze our experience by vindicating or refuting the existing plausible hypotheses. MATERIAL AND METHODS: This is a retrospective review of all neurosurgical cases that developed postoperative herpes infection between January 2016 and June 2020. RESULTS: Six patients developed herpes infection after vestibular schwannoma (VS) surgery. Other neurosurgical cases did not develop herpes infection. There were five females and one male, with a mean age of 44.1 years. Four out of six patients developed delayed facial palsy (DFP) and did not improve after antiviral treatment. Postoperative herpes infections were 0.2% among all operated patients, 3.07% among all cerebellopontine (CP) angle surgeries, and 5.6% among VS surgeries. CONCLUSIONS: To date, none of the plausible hypotheses satisfactorily addresses all aspects of viral recrudescence. The etiology may be multi-factorial, and in all cases of unexplained clinical deterioration, herpes infection needs consideration in the differential diagnosis.

Internal Acoustic Meatus Localization During Anterior Petrosectomy: A Novel Technique.

OBJECTIVE: Anterior petrosectomy demands localization of the internal auditory canal (IAC) for safe bone drilling and maximum exposure. Various techniques have been described in the literature, each with shortcomings. We propose a new technique to localize the internal acoustic meatus (IAM) using more consistent anatomical landmarks. METHODS: The study was done in three phases. In phase-I (radiological), computed tomography scan heads of fifty patients (100 sides) were analyzed. Arcuate eminence-Greater Superficial Petrosal Nerve bifurcation angle(Garcia-Ibanez technique), Arcuate eminence-IAC angle(Fisch technique) and a new angle formed between foramen ovale (FO) and foramen spinosum (FS) line, and FS and IAM line (FO-FS-IAM angle) was measured. The mean, standard deviation, and variance were calculated. In phase-II (cadaveric), the FO-FS-IAM angle was measured on five (10 sides) dry skulls. In phase-III (clinical), the IAM was localized using the FO-FS-IAM angle in 13 patients. RESULTS: The mean angle between arcuate eminence and Greater Superficial Petrosal Nerve (Garcia-Ibanez technique) was 126.20 ± 11.63°(range 106-156) with a variance of 135.20. The mean bifurcation angle was 63 ± 5.81°(range 53-78). By the Fisch technique, the mean arcuate-IAM angle was 73.5 ± 11.70°(range 51-105) with a variance of 137.18. By our technique, the mean FO-FS-IAM angle was 94.72 ± 5.89°(range 84-108). The variance was 34.73. The mean FO-FS-IAM angle on dry skulls was identical (95 ± 1.97°) to our radiological measurements. This angle was reproduced reliably in clinical cases for localizing the IAM during anterior petrosectomy. CONCLUSIONS: The FO-FS-IAM angle variance was much lower than the analogous angles measured by Garcia-Ibanez and Fisch techniques, making it a more reliable and effective tool for localizing the IAM.

Extra-axial Endoscopic Third Ventriculostomy: A Novel Treatment for Managing Hydrocephalus Due to Vertebrobasilar Dolichoectasia.

BACKGROUND: Vertebrobasilar dolichoectasia, a rare vascular anomaly, rarely presents with hydrocephalus. The traditional treatment for hydrocephalus is a ventriculoperitoneal shunt. Conventional endoscopic third ventriculostomy can avoid shunt-related complications but is considered risky due to the presence of the dolichoectatic vessel. A subfrontal extra-axial fenestration of the lamina terminalis can circumvent this anatomic constraint and establish cerebrospinal fluid communication between the third ventricle and subarachnoid space. METHODS: We performed an extra-axial endoscopic third ventriculostomy to manage hydrocephalus due to vertebrobasilar dolichoectasia in a 26-year-old male. The clinical description, surgical technique, outcome, and rationale are described. RESULTS: The patient had symptomatic improvement in his headaches and vision. There was also improvement in the postoperative ventricular indices: Evans index-19% reduction, frontal occipital horn ratio-14.1% reduction, and third ventricle index-39.5% reduction. A cine-phase magnetic resonance image showed cerebrospinal fluid flow void through the lamina terminalis fenestration, suggesting patency. CONCLUSIONS: Extra-axial endoscopic third ventriculostomy may be a suitable treatment alternative to circumvent anatomic constraints produced by vertebrobasilar dolichoectasia in performing conventional endoscopic third ventriculostomy.

Endoscopic clipping of an anterior communicating artery aneurysm.

BACKGROUND: Anterior communicating artery aneurysms are most prone to rupture. Surgically, they are conventionally being managed by a pterional approach. Some neurosurgeons prefer a supraorbital keyhole approach in select cases. Fully endoscopic clipping of such aneurysms is seldom described. METHOD: We clipped an antero-inferiorly directed anterior communicating artery aneurysm endoscopically via a supraorbital keyhole approach. The intraoperative aneurysmal rupture was also managed endoscopically. The patient made an excellent postoperative recovery without any neurological deficits. CONCLUSION: Select cases of anterior communicating artery aneurysms can be clipped endoscopically using standard instruments and adhering to the basic principles of aneurysm clipping.

Extra-axial endoscopic third ventriculostomy: preliminary experience with a technique to circumvent conventional endoscopic third ventriculostomy complications.

OBJECTIVE: Endoscopic third ventriculostomy (ETV) is mostly safe but may have serious complications. Most of the complications are inherent to the procedure's intra-axial nature. This study aimed to explore an alternative route to overcome inherent issues with conventional ETV. The authors performed supraorbital, subfrontal extra-axial ETV (EAETV) via the lamina terminalis. METHODS: This prospective study began in October 2021 and included patients with obstructive triventricular hydrocephalus with a Glasgow Coma Scale score of 8 or more and a minimum follow-up of 3 months. Patients with multiloculated hydrocephalus and those younger than 1 year of age were excluded. The preoperative parameters etiology, symptoms, Evans' Index, frontal occipital horn ratio (FOHR), and third ventricle index were recorded. The surgical procedure is described. Postoperative evaluation included clinical (modified Rankin Scale [mRS]) and radiological assessment with CT and cine phase-contrast MRI. Preoperative and postoperative parameters were compared statistically. RESULTS: Ten patients were included in this study. Six patients had acute hydrocephalus, and 4 had chronic hydrocephalus. After EAETV, all patients showed clinical improvement. An mRS score of 0 or 1 was achieved in 9 patients, but the mRS score remained at 4 in a patient with tectal tuberculoma. There was a significant reduction in Evans' Index, FOHR, and third ventricle index after EAETV (p < 0.05). The mean percent reduction in Evans' Index was 20.80% ± 13.89%, the mean percent reduction in FOHR was 20.79% ± 12.98%, and the mean percent reduction in the third ventricle index was 37.45% ± 14.74%. CSF flow voids were seen in all cases. The results of CSF flow quantification parameters were as follows: mean peak velocity 3.82 ± 0.93 cm/sec, mean average velocity 0.10 ± 0.05 cm/sec, mean average flow rate 46.60 ± 28.58 µL/sec, mean forward volume 39.90 ± 23.29 µL, mean reverse volume 34.10 ± 15.98 µL, mean overall flow amplitude 74.00 ± 27.61 µL, and mean stroke volume 37.00 ± 13.80 µL. One patient developed a minor frontal lobe contusion. The frontal air sinus was breached in 5 patients, but none had CSF rhinorrhea. Transient supraorbital hypesthesia was seen in 3 patients. No patient had electrolyte disturbance or change in thirst or fluid intake habits. CONCLUSIONS: EAETV is a feasible, safe, and effective surgical alternative to conventional ETV.

COVID-19 Pandemic Lockdown: A Cloud with a Silver Lining for the Road Traffic Accidents Pandemic.

Context: Effects of coronavirus disease 2019 (COVID-19) pandemic lockdown on road traffic accidents (RTAs) in Chhattisgarh, India. Background: Most neurosurgical emergencies are from brain and spine trauma. RTA is the leading cause of such injuries. While the nationwide lockdown was an extreme measure to control the COVID pandemic, it influenced the overall road traffic dynamics and neurotrauma. Objective: This study aims to assess the impact of the lockdown on neurotrauma. Methods and Materials: This retrospective study included all patients with brain and spine injuries who were admitted between January 17th and May 31st, 2020. The study population was divided into prelockdown (PL) and lockdown (L) groups. Results: Of the 668 patients, 436 were placed in the PL and 232 in the L group. The mean ages were 36.34 (SD = 17.96) and 35.98 (SD = 16.93), respectively. Male to female ratios were 82.3:17.7 in the PL group and 79.7:20.3 for the L group. RTA-related injuries were significantly lower during the lockdown period (n = 335 PL vs. 162 L [P = 0.048]). During the lockdown, there were more mild injuries (25.91% PL vs. 36.63% L) and less severe injuries (33.25% PL vs. 18.96% L [P = 0.0002]). Mortality was significantly less (P = 0.029) during the lockdown (n = 48 L vs. 124 PL). The proportion of RTA-related neurotrauma cases increased (33.33% L1, 57.14% L2, 73.13% L3, and 80.39% L4) with each phase of lockdown (L1-L4). Conclusions: During the lockdown period, the number of trauma cases had decreased, with a significant decrease in RTA-related admissions, along with their severity and mortality. The number of trauma cases and their severity increased gradually with each phase of lockdown.

Distinct Spinal Dysraphisms Arising from Each Hemicord of Type I Split Cord Malformation - A Rare Coexistence.

In this report, we describe a 6-month-old child having Type I split cord malformation (SCM), associated with meningomyelocele of one hemicord and lipomeningomyelocele of other hemicord at the same level along with Type II Chiari malformation. The classical embryological theories on split cord malformation and neurulation defect do not clearly explain such a complex entity at one level. The new research on the genetic association of posterior neuropore defect opens a new horizon of research on such genesis.

Preoperative Visual Impairment in Vestibular Schwannoma Patients: An Overlooked Entity of Developing World.

Objective Visual impairment in vestibular schwannomas is an underreported entity. The plethora of literature focuses primarily on facial and hearing preservation. This study aims to describe our experience and find the possible reasons for visual impairment. Materials and Methods This is a retrospective observational study. We evaluated 114 patients with vestibular schwannoma, operated during 2015 to 2020. Eight parameters were studied-age, gender, maximum tumor size, hydrocephalus, economic status, duration of symptoms, visual loss, and ease of access to the tertiary neurosurgical facility. JASP software (version 0.14.1, Amsterdam) was used for statistical analysis. Results A total of 42/114 (36.84%) patients had a varying degree of impairment. Patients with impaired vision had significantly larger tumors (4.31 vs. 4.12 cm, p = 0.02), longer duration of symptoms (19.14 vs. 16.45 months, p = 0.02), hydrocephalus ( p = 0.03), and were from remote areas ( p = 0.009). In stepwise logistic regression analysis, longer duration of symptoms and difficult access to neurosurgical facility stand out as decisive factors for visual impairment. The follow-up data were available for 35/42 (83.33%) cases of visual impairment. Vision improved in 14/35 (40%) of cases. Vision improved in a significantly higher number of patients when a preoperative ventriculoperitoneal shunt was placed ( p = 0.03). Conclusion The visual handicap occurs in a significant number of patients with vestibular schwannoma. Delayed arrival at the neurosurgical facility due to difficult access appears to be the primary factor leading to blindness. Strengthening our healthcare systems in rural areas would go a long way in the timely detection and prevention of blindness in such cases.

An experience with Goel-Harms C1-C2 fixation for type II odontoid fractures.

Objective: Type II odontoid fractures need surgical stabilization for disabling neck pain and instability. Anterior odontoid screw fixation is a well-known technique. However, certain patients require posterior fixation. We present our surgical results and experiences with nine cases managed by the Goel-Harms technique. Materials and Methods: This is a retrospective review of nine patients operated on between January 2019 and December 2021 for Type II odontoid fractures with posterior fixation technique. Their clinical profile was collected from case files. The radiological data were retrieved from radiology archives. The indications for surgery were instability and refractory neck pain. The surgical decision for posterior fixation was guided by fracture morphology. Results: The mean age of presentation was 37.22 ± 9.85 years. Seven patients had Type II, and two had Type IIa odontoid fracture. All patients presented with unbearable neck pain. One patient had a quadriparesis. The fracture line was anterior-inferior sloping in six, posterior-inferior sloping in two, and transverse in one case. The anterior-posterior displacement of fracture ranged from 0 to 7 mm (mean 2.44 ± 2.18 mm). Partial transverse ligament tear without the Atlanto Axial Dislocation was present in three patients. The C1-C2 joint distraction was required in five cases. C1-C2 joint spacer was required in two cases. Following surgery, neck pain was relieved in all cases. Complete fracture alignment was achieved in eight patients. There were no postoperative complications. At the mean follow-up of 16.22 ± 9.61 months, there was no implant failure. Conclusions: Posterior C1-C2 fixation by the Goel-Harms technique is an excellent alternative to anterior fixation in selected cases.

Hearing Rehabilitation After Treatment of Sporadic Vestibular Schwannomas.

Background: Hearing preservation in vestibular schwannoma resection is a much-discussed topic in these times of functional preservation. Irrespective of the mode of treatment of large tumors, this becomes possible only in a lucky few. The overall burden of such deaf patients is on a rising trend, and therefore, it is high time neurosurgeons look into this often-neglected area of hearing rehabilitation. Objectives: In this review, the authors intend to provide a glimpse of available hearing rehabilitation modalities in the present era. Materials and Methods: : This review deals with both immediate and long-term hearing outcomes following both surgery and stereotactic radiosurgery for sporadic vestibular schwannoma and the need for hearing rehabilitation in these patients. Various databases, including PubMed, Medline/Medscape, Scopus, Cochrane, and Google Scholar were searched to find available literature on hearing rehabilitation after treatment of sporadic vestibular schwannoma. The searched MeSH terms were "Hearing", "Vestibular schwannoma", "Rehabilitation", and "Acoustic Neuroma", alone and in various combinations. Results: : The authors were surprised to find a paucity of literature. Even though neurosurgeons are at the forefront in managing vestibular schwannoma, they are not actively involved in hearing rehabilitation techniques possible for those who are rendered deaf following treatment. Conclusions: : The authors strongly believe that this review will be a wake-up call for neurosurgeons on a relatively untouched topic.

A Prospective Comparative Evaluation of Surgery and Conservative Treatment for Compound Depressed Skull Fractures.

OBJECTIVE: The Brain Trauma Foundation issued level III evidence guidelines for surgical management of compound depressed fractures. However, some patients undergo successful conservative treatment. This study compares these 2 treatment modalities. METHODS: This prospective study included 67 patients with compound depressed skull fractures with surgical indications and a minimum follow-up of 6 months. Depressed fractures in front of the hairline (operated on for cosmetic reasons) and associated with significant intracranial injuries were excluded. Those who gave consent for surgery were included in the surgical group, and those who denied were included in the conservative group. RESULTS: The surgical group had 38 patients and the conservative group had 29. Both groups were comparable in mean age, gender, Glasgow Coma Scale score, head injury severity, depth of fractures, and follow-up duration. Focal neurologic deficits were observed in 19 patients at presentation and were higher in the surgical group. Mean hospital stay was significantly shorter in the conservative group. Mean Glasgow Outcome Scale score at follow-up was statistically similar in both groups (P = 0.13). Focal neurologic deficits improved equally in both groups (P = 0.67). The severity of traumatic brain injury (P = 0.004) and the presence of focal neurologic deficits (P < 0.001) affected the neurologic outcomes. The age, gender, mode of treatment (surgery vs. conservative), surgical site infections, and seizures did not affect neurologic outcomes. The overall complication rates were similar among groups (P = 0.50). New-onset focal neurologic deficits, seizures, and infection rates were not significantly different among the groups (P = 0.98, P = 0.72, P = 0.69). CONCLUSIONS: Conservative management has equivalent neurologic outcomes and complications compared with surgical management.

Comparison of Craniotomy and Stereotactic Aspiration Plus Thrombolysis in Isolated Capsulo-Ganglionic Hematoma: A Retrospective Analyses.

Background: Published trials and meta-analyses have suggested the role of surgery in select patients of hypertensive intracerebral hematoma. Objective: This study compares two methods of hematoma aspiration, craniotomy, and stereotactic aspiration. Methods and Material: We conducted retrospective analyses of patients who underwent surgery for capsule-ganglionic hematoma during Jan-2015-Dec-2019. Surgical, intensive-care parameters, and neurological outcomes were compared. Patients operated for Capsule-Ganglionic hypertensive hematomas, Glasgow Coma Scale (GCS) 5-12, hematoma volume ≥30 ml, no concomitant IVH, age <80 years were included. Results: A total of 173 patients were included (90 craniotomy and 83 stereotactic aspiration groups). Both groups were equivalent in preoperative parameters (P > 0.5). There were no significant differences in residual hematoma volumes, surgical site infections/Meningitis, and chances of re-bleed between the two groups (P > 0.05). The number of days on ventilation, ICU-stay, and hospital-stay were higher in craniotomy group (P < 0.001). Mean Modified Ranking Score (MRS) was lower (P 0.01) in the stereotactic aspiration group. A higher number of patients in the stereotactic aspiration group achieved good MRS (0-2) (P 0.02). Overall case-fatality rate was 38/173 (21.96%) (craniotomy - 24/90 (26.66%), stereotactic aspiration - 14/83 (16.86%), P 0.12). In left-side hematomas, mean MRS was not different between both methods, whereas it differed in the right-side hematomas. On step-wise logistic regression analysis, predicting parameters for the poor outcome (MRS 3-6) were GCS 5-8 (Odds Ratio (OR) 2.38), Left-side (OR 1.75), and craniotomy as a method of evacuation (OR 1.70). Conclusions: Stereotactic aspiration of the hematoma has the superior edge over craniotomy. Neurological and care parameters are significantly better with stereotactic aspiration. Its safety and surgical performance parallel craniotomy.

Fourth Ventricular Epidermoid Cyst - Case Series, Systematic Review and Analysis.

BACKGROUND: Epidermoid cysts are extra-axial, pearly white avascular lesions mostly found in the cerebellopontine region. They are slow-growing and mostly become symptomatic when they attain significant size. They do occur at other anatomical locations, but fourth ventricle is a rare location. Three representative cases with their outcomes are described here. METHODS: The systematic review was done with adherence to predefined criteria. The studied variables were age, gender, duration of symptoms (DOS), clinical features, hydrocephalus (HCP), extent of resection, postoperative complications, outcome, follow-up, and recurrence. Statistical analysis was done to identify predictive factors for outcome. RESULTS: Final analysis included 58 studies containing 131 patients. The most common clinical feature was cerebellar dysfunction (93%). The most common cranial nerve involved was the abducens nerve (n = 37, 28.46%). Preoperative HCP was present in nearly a third (35%) of patients. The outcomes were not different with age (P = 0.23), gender (P = 0.74), DOS (P = 0.09), and HCP (P = 0.50). Improved outcomes were associated with total resections (P = 0.001), absence of preoperative cranial nerve dysfunctions (P = 0.004), and presentation with features of raised intracranial pressure (P = 0.005). Longer DOS (mean 76.74 months) was associated with significantly increased cranial nerve nuclei involvement (P = 0.03). Aseptic meningitis was reported in 14.5% of cases. Recurrences were infrequently reported (n = 9). CONCLUSIONS: Although the fourth ventricular epidermoid lesions are difficult to detect in an innocuous stage, when found, they should be extirpated early and totally, as a longer DOS leads to cranial nerve dysfunctions and suboptimal outcomes.

Rapid Spontaneous Resolution of the Acute Subdural Hematoma: Case Series and Review of Literature.

BACKGROUND: Traumatic acute subdural hematoma (ASDH) is an oft encountered entity in neurosurgery. While resolution of such thick SDHs usually takes time, certain cases of rapid spontaneous resolution have also been reported. This article attempts to review the pathophysiology, clinical and radiological features of such cases, as well as provide an insight into decision making for their management. METHODS: Electronic literature search was done to look for similar cases of spontaneous rapid resolution of ASDH. Five of authors cases have been described. Their clinical and radiological features along with those of cases from literature search were tabulated and analyzed. RESULTS: A total of 44 relevant cases were included for analyses. Of these, 39 cases were from 33 articles found in existing literature and 5 cases were from author's collection. The M:F ratio was 25:19 with a mean age was 41.84(SD-4.094) years. Twenty -six patients showed "Rapid" neurological improvement (24 hours) occurred in 10 patients. The mean hematoma resolution time on CT scan was 13.78 hours (SD 16.46) ranging from 1- 72 hours. Twenty-nine patients showed redistribution of hematoma, most commonly to tentorium and falx cerebelli. CT scan findings were classified into 5 types as per the nature of hypodensity around hematoma. The geometric mean time to resolution of hematoma was least for type 2 (7.27 hours) and type 1(7.52 hours) patients. CONCLUSION: Selected patients of ASDH with rapid neurological improvement and specific CT findings may show spontaneous resolution of ASDH. Multicentric studies with larger study population may provide better insight into the nature and outcomes of such entities.

Optimal Use of Temporary Clip Application during Aneurysm Surgery - In Search of the Holy Grail.

Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were "Temporary Clip," "Temporary Clipping," "Cerebral Aneurysm," and "Aneurysm." Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use.

Management Challenges and Outcomes of Traumatic Brain Injury due to Bear Maul in Tribal Areas of Chhattisgarh, India-Man versus Wild.

Objectives Neurosurgeons working in the vicinity of tribal areas face traumatic brain injury (TBI) cases due to bear maul which is on the rise in Chhattisgarh. Most of the literature is focused on the management of maxillofacial injuries. This study intends to describe the challenges in management and outcomes of TBI due to bear maul. Materials and Methods A retrospective review was conducted from May 2018 to April 2020. The patients without TBI were excluded. The variables studied were age, gender, timing and mode of conflict, Glasgow coma scale (GCS) at arrival, injury spectrum, hospital stay, the modified Rankin score (MRS), mini mental status examination (MMSE), and surgical site infections (SSI). Results Twenty-eight patients were eligible for analysis. The mean age of presentation was 40.67 ± 13.99 years. There were 23 males (82.15%). Most common time of attack was during dawn ( n = 11, 39.28%) followed by dusk ( n = 9, 32.14%) and day ( n = 8, 28.57%) time. Provoked conflicts were seen in 64.28%. The mean preoperative GCS was 11.07 ± 3.54 and hospital stay was 18.71 ± 9.51 days. Skull fractures were found in 24/28 (85.71%). The mean MRS was 1.67 ± 1.38 at a mean follow-up of 14.53 ± 6.59 months. Favorable outcome (MRS ≤ 2) was seen in 64.28% of patients. The mean MMSE score was 22.28 ± 5.36. Eight patients developed SSI (28.57%). Conclusion Outcomes of TBI due to bear maul depend on preoperative GCS. There are higher incidences of skull fractures and SSI. Humans need to avoid infiltration in wildlife territory to reduce the number of conflicts.

Endoscopic Anatomy of Lateral and Third Ventricles: A must Know for Performing Endoscopic Third Ventriculostomy.

INTRODUCTION: Endoscopic third ventriculostomy is a safe alternative to ventriculo-peritoneal shunt for certain cases of obstructive hydrocephalus. It has the advantage of not leaving a permanent foreign body in-situ, besides preventing over-drainage and reducing chances of infection. A thorough knowledge of endoscopic anatomy of ventricles is a must for performing various endoscopic procedures. OBJECTIVE: The aim of this study was to demonstrate the endoscopic anatomy of ventricles for educational purpose. PROCEDURE: ETV is done using a zero-degree LOTTA endoscope. Right Kocher's point is usually chosen as entry site into ventricle. The scope is negotiated into third ventricle through foramen of Monro. The premammillary membrane is perforated and dilated, thereby communicating the third ventricle to the chiasmatic, interpeduncular and prepontine cisterns. The video was recorded on Karl Storz recording system. It was edited using Imovie software. Photographs labeling was done using Windows PowerPoint 2018. CONCLUSION: Endoscopic anatomy knowledge allows a neurosurgeon to perform ETV safely.