Neurosurgery training in Nepal: then and now.

Introduction: Neurosurgery training lacks uniformity across the world. Differences in the methods of training adopted during the training period is one of the major problems encountered in the field of neurosurgery all over the world. Moreover, neurosurgery is not "one neurosurgery"; in other words, it is not a unified whole. Material and methods: In this study, we attempt to evaluate the present conditions of neurosurgery training in Nepal by exploring different institutions providing the training. Results: Due to various factors and challenges, the neurosurgery training provided in Nepal varies in different institutions. Many travel abroad for training due to a lack of sufficient seats in training institutions. Discussion and conclusions: Despite the challenges, the future is bright for neurosurgery training in Nepal. With continued investment in education and training, and the adoption of new technologies and techniques, it is likely that the field of neurosurgery will continue to thrive and make a positive impact on the health and well-being of the Nepali population.

A rare presentation of extra-axial supratentorial ependymoma with subdural hematoma mimicking a parasagittal meningioma.

Introduction: Primary extra-axial ependymomas, though rare, the majority of such lesions are identified as WHO grade III ependymomas. These ependymomas may mimick a meningioma on radiological investigations which can be confirmed by histopathology. Research Question: We show in this case report a rare presentation of extra-axial supratentorial ependymoma with concomitant subdural hematoma mimicking a parasagittal meningioma. Material and Methods: A 59 years lady with no known comorbidities presented with weakness of right half of body and decreased speech for 2 days. She was aphasic. Contrast MRI brain revealed an extra-axial dural-based homogenously enhancing lesion in the left anterior 1/3rd parasagittal area with left frontotemporoparietal chronic subdural hematoma. With a provisional diagnosis of meningioma, the patient was subjected to bifrontal open-book craniotomy with gross total excision of lesion with periosteal graft duraplasty and acrylic cranioplasty. Left sided frontotemporal subacute SDH with thin greenish yellow membrane was present. In post operative period, patient quickly became E4V5M6 with power of 4/5 in the right half of body which was same as compared to the preoperative period. Results: The biopsy of the mass, however, revealed features suggestive of extra-axial supratentorial ependymoma (WHO Grade III). Immunohistochemistry supported the diagnosis of supratentorial ependymoma, NOS. The patient was then referred for further chemoradiation. Discussion and Conclusion: We report the first case of extra-axial supratentorial ependymoma mimicking a parasagittal meningioma occurring with adjacent subdural hematoma. Clinical and imaging background along with a complete pathological examination with immunohistochemical study is essential to confirm the diagnosis of rare brain tumours.

Systematic use of point of care ultrasound in neurosurgical intensive care unit: a practical approach.

Background: Point of care ultrasound (POCUS) is a cost-effective, non-invasive procedure with high diagnostic reliability and therapeutic utilities. For various reasons, it is not being used routinely in neurosurgical intensive care unit (ICU). We have introduced a systematic use of POCUS in critically ill patients in our neurosurgical ICU. We have studied the various indications and benefit of using this technique. Methods: This is a prospective, single center cohort observational study done in patients who were admitted in a tertiary neurosurgical ICU over 1 year (17th September 2020 to 16th September 2021). POCUS was used daily as per a standardized format for multiple purposes. A formal training to the operator was provided and standardized method of evaluation and intervention was used. Outcome was studied to understand the impact of the POCUS and difficulties encountered during its use. Results: POCUS was used in 240 patients, including all patients for primary and secondary surveys, 192 patients (80%) for optic nerve sheath diameter (ONSD) measurement, 14 myelomeningoceles for trans-fontanelle ultrasound study, 16 post operative cases of aneurysm clipping for transcranial Doppler (TCD) study, 86 patients for deep vein thrombosis (DVT) screening, 17 for evaluation of ventriculo-peritoneal (VP) shunt functionality, 30 for transcranial defect ultrasound, 45 for chest ultrasound, 4 for evaluation of hemodynamic shock and 67 patients who had difficult cannualtion or while insertion of central venous catheter placement. POCUS was also used for difficult cannulation, central catheter placement and e-FAST scan. Significant findings were reported 129 times, which led to immediate change in management in 62 patients (25.83%) as compared to 16 patients in whom significant findings were not reported using POCUS, but management was changed using other radiological modalities (P<0.01). There was initial lag in adopting the technique, however with practice, the team developed confidence. As a result, the accuracy and time taken to perform the procedure was reduced significantly. Conclusions: Routine systematic use of POCUS can be beneficial not only for the rapid diagnosis and prompt management of patients, but also helpful in monitoring and performing various procedures in neurosurgical ICU. Though not all modalities mentioned in standardized format was used in all patients, use of this format has helped improved training and maintain proper use of POCUS in our ICU.

Need of Integrating Sonoscopy in Undergraduate Medical Education in Developing Countries.

Early exposure to technical knowledge improves dexterity and encourages ingenuity. We see the role of ultrasound as a "sonoscope". Use of sonoscope improves anatomical understanding and improves virtual image interpretation (mind's eye). Early sonoscope use does not interfere with learning physical examination rather it improves one's sensitivity as one sees what lies underneath one's hand. Sonoscope is being used by various medical specialities not only to make diagnosis, but also to monitor and guide interventions. Medical schools worldwide have realised the need and relevance of sonoscope in medical curriculum and hence this needs to be integrated in undergraduate medical education in developing countries. Keywords: Medical education; point of care ultrasound (POCUS); sonoscope.

COVID-19 and the Role of Neurosurgeons in Nepal.

BACKGROUND: Despite the panic and chaos that coronavirus disease 2019 (COVID-19) has generated in over 200 countries, the role of neurosurgeons has never been more relevant and challenging. The health system in Nepal was never geared to face an onslaught of an infectious disease. METHODS: At Kathmandu Medical College Teaching Hospital, we designated a separate complex for housing COVID-19 suspects to prevent the unaffected from getting exposed. In a few hospitals, existing neurosurgical and medical intensive care units have been converted to isolation intensive care units. A separate roster of doctors, nurses, and allied staff has been drafted to care for these patients to avoid contamination and allow effective quarantine of the staff involved in care. RESULTS: At the directive of the government, all neurosurgical centers postponed routine cases and some have closed their outpatient departments because of the lack of protective gear. All neurosurgical centers have seen drastic reductions in cases. CONCLUSIONS: In these challenging times, we neurosurgeons, who are naturally primed and trained to respond and take on challenges in difficult situations, have the ideal opportunity to shine and make a true difference during this pandemic and beyond and be "5-star doctors."

Pure Acute-on-Chronic Subdural Hematoma Due to Ruptured Posterior Communicating Artery Aneurysm: Unsuspecting Entity.

BACKGROUND: Even though rarely reported as a cause of pure subdural hematoma (SDH), aneurysmal rupture should be suspected in patients with spontaneous SDH without coagulopathy. CASE DESCRIPTION: We report a case of acute-on-chronic SDH in a 55-year-old lady with cerebral herniation due to a ruptured posterior communicating artery aneurysm. She was managed with single-stage SDH evacuation along with clipping of the aneurysm. CONCLUSIONS: Computed tomography angiography of the head is advisable in patients with spontaneous SDH without coagulopathy. Pure SDH as compared with SDH associated with subacute hemorrhage, intraventricular hemorrhage, or intracerebral hemorrhage due to aneurysmal rupture has a good outcome.

Endoscopic Endonasal Transsphenoidal Approach to Pituitary Adenoma: A Multi-disciplinary Approach.

BACKGROUND: The excellent visualization and minimally invasive approach employed in endoscopic endonasal procedures has now revolutionized the pituitary surgery, replacing the transnasal microscopic technique worldwide. However, it involves major shift in hand-eye co-ordination from static 3 dimensional images of microscope to 2 dimensional endoscopic images hence demands training and inter-disciplinary approach. Here we present our experiences in learning and developing a safe endonasal transsphenoidal endoscopic approach to resect pituitary adenomas. METHODS: This prospective study was jointly conducted in the departments of ENT and Neurologicals surgery Kathmandu Medical College, Nepal, from September 2014 to August 2016. The endoscopic approach to the sphenoid sinus was performed by an Otolaryngologist and ablative surgery by Neurosurgeon. The ease of procedure, intra operative challenges, surgical cure, post-operative cerebro spinal fluid (CSF) leaks and postoperative complaints were analyzed. RESULTS: Sixteen consecutive patients with pituitary adenoma (macro adenoma=13, micro adenoma =3) were analyzed. There were three intraoperative CSF leak, managed successfully. Two patients developed transient diabetes insipidus and surgical cure rate was 90%. No case had to be switched over to traditional microscopic route due to technical failure. There was no mortality. CONCLUSIONS: The endoscopic endonasal transsphenoidal approach to pituitary tumors is a safe and minimally invasive procedure, which can be employed safely in any of our centers in Nepal, equipped with endoscopic sinus surgery and endoscopically trained ENT and Neurosurgeons. A multi disciplinary approach provides good access, greater tumor excision and excellent postoperative follow up.

Cost Effective Use of Free-to-Use Apps in Neurosurgery (FAN) in Developing Countries: From Clinical Decision Making to Educational Courses, Strengthening Health Care Delivery.

INTRODUCTION AND OBJECTIVE: Financial limitations and the scarcity of technological knowledge are a major hurdle to good communication platforms, data storage, and dissemination of medical knowledge in developing countries. Out of necessity we used free-to-use apps in our practice. We studied the applicability and cost effective aspect of a systematic use of these apps in neurosurgery. MATERIALS AND METHODS: We designed the Free-to-use apps in neurosurgery (FAN) module in 4 phases at Kathmandu Medical College Teaching Hospital over the last 3 years. We used free apps like Viber, Dropbox, Skype, and VLC media player on 3G and Wi-Fi network. Users were trained in ethics and measures to ensure confidentiality and privacy of patient-related data. Endpoints studied were feasibility, reliability, cost effectiveness, and overall satisfaction of the users. RESULTS: In the FAN module, the Viber app was used to send pictures of digital images via smartphones within 30 minutes, enabling quick decisions by the consultants. Dropbox not only helped store images but also helped quick verification of discharge summaries as early as 15 minutes increasing overall efficiency. With Skype, consultants could be contacted even when they were abroad, and with the use of FAN they remain updated of their patients. By the use of Skype and VLC media player, 2 operative live workshops from abroad were transmitted live with good visual and audio reception, allowing question-and-answer sessions with the faculties. User satisfaction was more than 90%. CONCLUSIONS: The FAN module helped in quick reliable decision making, allowing for instantaneous communication and storing data and exchange of knowledge across countries.

Electrospun TiC/C nano-felt surface-decorated with Pt nanoparticles as highly efficient and cost-effective counter electrode for dye-sensitized solar cells.

Electrospun nano-felt consisting of overlaid TiC/C composite nanofibers was surface-decorated with Pt nanoparticles (Pt NPs) for use as highly efficient and cost-effective counter electrode (CE) in dye-sensitized solar cells (DSSCs). In the nanofibers, the self-generated TiC crystallites (~70 wt%) with sizes of ~20 nm were randomly embedded in carbon (~30 wt%). Upon surface-decoration, most Pt NPs were distributed on TiC crystallites, leading to substantial enhancement in the electrocatalytic activity/efficiency of Pt due to the strong interaction between Pt and TiC as well as the resulting synergetic effect on electrocatalysis. Electrochemical measurements indicated that the TiC/C-Pt CE exhibited low charge transfer resistance (Rct), large capacitance (C), and fast reaction rate towards the reduction of I3(-) ions, and the prototype DSSC exhibited a performance comparable to that with conventional Pt CE in terms of short circuit current density (Jsc), open circuit voltage (Voc), fill factor (FF), and energy conversion efficiency (η).

Use of viber app: a fast, easy and cost effective method of communication in neurosurgery.

OBJECTIVE: Neurosurgeons often have to rely on judgments of junior staffs to decide on patients whom they cannot attend immediately. Viber is a free to use application for image transfer on Internet. We evaluated the use of viber in neurosurgical scenario, to show it is cheap, fast, accessible, reliable and feasible. MATERIALS AND METHODS: We conducted a prospective study from March 2013 to July 2013. Residents were taught to take sharp pictures and upload them immediately using viber on Internet. Primary endpoints were discordance between opinion of residents and consultants on viber images and subsequent actual image evaluation and time delay in decision-making. Discordance was considered significant if it changed management decision. RESULTS: During the study period, 120 (mean age: 42 years, 58% males) patients were enrolled. Wi-Fi is freely available in the institute and thus no costs were involved. Decision could be made on images received on viber at an average of 20 min. There was discordance in 56.7% cases between residents' reports and images on viber, which was significant in 88.2% cases. However in 5% cases decision changed after actual images were reviewed. Of all imaging modalities, computed tomography angiographic images were associated with statistically significant discordance (P <0.05). CONCLUSION: This study suggests that the use of viber app in neurosurgery can be an easy fast reliable and almost free mode of communicating images enabling a quick decision. However this cost-effective method should be used with caution particularly with imaging modalities, which require processing and review on console.

Nickel incorporated carbon nanotube/nanofiber composites as counter electrodes for dye-sensitized solar cells.

A nickel incorporated carbon nanotube/nanofiber composite (Ni-CNT-CNF) was used as a low cost alternative to Pt as counter electrode (CE) for dye-sensitized solar cells (DSCs). Measurements based on energy dispersive X-rays spectroscopy (EDX) showed that the majority of the composite CE was carbon at 88.49 wt%, while the amount of Ni nanoparticles was about 11.51 wt%. Measurements based on electrochemical impedance spectroscopy (EIS) showed that the charge transfer resistance (R(ct)) of the Ni-CNT-CNF composite electrode was 0.71 Ω cm(2), much lower than that of the Pt electrode (1.81 Ω cm(2)). Such a low value of R(ct) indicated that the Ni-CNT-CNF composite carried a higher catalytic activity than the traditional Pt CE. By mixing with CNTs and Ni nanoparticles, series resistance (R(s)) of the Ni-CNT-CNF electrode was measured as 5.96 Ω cm(2), which was close to the R(s) of 5.77 Ω cm(2) of the Pt electrode, despite the significant difference in their thicknesses: ∼22 µm for Ni-CNT-CNF composite, while ∼40 nm for Pt film. This indicated that use of a thick layer (tens of microns) of Ni-CNT-CNF counter electrode does not add a significant amount of resistance to the total series resistance (R(s-tot)) in DSCs. The DSCs based on the Ni-CNT-CNF composite CEs yielded an efficiency of 7.96% with a short circuit current density (J(sc)) of 15.83 mA cm(-2), open circuit voltage (V(oc)) of 0.80 V, and fill factor (FF) of 0.63, which was comparable to the device based on Pt, that exhibited an efficiency of 8.32% with J(sc) of 15.01 mA cm(-2), V(oc) of 0.83, and FF of 0.67.

Intraoperative pulse and blood pressure recordings of neurosurgeons: a pilot study of cardiovascular performance.

BACKGROUND: Although hemodynamic changes in anesthetized patients remain well documented, no study has quantified the effect of operating stress on the neurosurgeon. OBJECTIVE: We present a study of intraoperative (IOP) pulse and blood pressure (BP) recordings obtained from neurosurgeons and compare them with rest and exercise values. METHODS: This prospective, single-blind comparative analysis used an ambulatory BP device to record IOP, rest and exercise BP, and pulse. The Student t test and chi test were used for statistical analysis. RESULTS: Five neurosurgeons performed 10 aneurysm clippings and 1 vestibular schwannoma excision. The average IOP pooled systolic, diastolic, and mean BPs and pulse rates were 140, 103, and 116 mm Hg and 94 bpm, respectively. Corresponding rest and exercise values were 116, 75, and 89 mm Hg and 76 bpm and 130, 99, and 109 mm Hg and 128 bpm, respectively. Average IOP mean and diastolic BPs were significantly elevated compared with rest readings (P = .032, P = .023). Episodes of severe IOP BP (systolic BP/diastolic BP > 180/110 mm Hg) accounted for 28% of all readings and were significantly increased over rest values (P < .001). The incidence of abnormal IOP BP (systolic BP/diastolic BP > 140/90 mm Hg) was also significantly greater than exercise and rest values (P < .001). CONCLUSION: Neurosurgery can induce a significant hemodynamic stress malresponse in the operating surgeon that appears to be greater than that induced by vigorous exercise. The correlation of this occupational hazard to long-term health and longevity remains to be studied.

Post-traumatic seizures-A prospective study from a tertiary level trauma center in a developing country.

RATIONALE: No large studies till date are available from India on post-traumatic seizures (PTS). METHODS: This is a prospective observational study of 520 patients with traumatic brain injury (TBI) (July 2007-2008). Patients admitted after 24h of injury, with Glasgow coma scale (GCS)

Surgical interventions in intracranial arteriovenous malformations: indications and outcome analysis in a changing scenario.

BACKGROUND: Intracranial arteriovenous malformations (AVM) are being increasingly managed by multimodality approach. This changing scenario encouraged us to study the present state of surgery in intracranial AVMs and the outcomes. MATERIALS AND METHODS: Of a total of 868 patients evaluated for suspected or known AVMs between January 2000 and July 2008, 790 had intracranial AVMs. The clinical characteristics and surgical outcomes of the 111 operated patients were analyzed. RESULTS: Of the 111 patients, 73 were males. Clinical features included: Headache (70%), loss of consciousness (48%) and seizures (32%). The commonest AVM grade was Spetzler-Martin (SM) grade II (41%), 7% had AVM > 6 cm and 78% had evidence of bleed. In total 143 surgeries were performed and 22% of patients required multiple interventions. The types of surgical interventions included elective excision of AVM in 23%, emergency surgery (either AVM excision or evacuation of hematoma) in 55%, surgery following radiosurgery/embolization in 5% and palliative non-definitive surgeries (e.g. shunt) in 15%. Post-operative angiography was done in 67% of patients. Obliteration rates for elective excision of AVM in Spetzler Martin Grade I, II, IIIa, IIIb and IV were 100%, 71%, 33%, 50% and 67% respectively (mean follow-up:31.6 months). Of 39 patients with residual AVMs, 33 received gamma knife and four underwent embolization. Outcome was modified Rankin scale (mRS) grade 1 in 34% of patients and the overall favorable outcome was 83% and there were six deaths. CONCLUSION: In our patients' cohort one in every eight patients required surgery. In intracranial AVMs, surgery still plays an important role. In developing countries like India it may be beneficial to electively excise Grade I and II AVMs if cost is a consideration.

Epidermoid cyst of anterior fontanelle with clear contents.

BACKGROUND: Epidermal inclusion cysts very rarely occur in the midline in the area of the anterior fontanelle. CASE DESCRIPTION: We report the second case of epidermal inclusion cysts in the midline in the area of the anterior fontanelle in world literature of a 7-month female infant who presented with a slow-growing soft mass located in the midline over the vertex of the head. CONCLUSION: These lesions with clear contents can have all the features of encephalocele on clinical examination, and imaging will show the exact location, but histopathology will confirm the diagnosis.