Acute presentation of giant sporadic vestibular schwannoma with massive hemorrhage: A critical review with a case illustration.

Introduction: Hemorrhage in vestibular schwannoma (VS) is a rare but potentially devastating complication, owing to the proximity to the brainstem and small space in the posterior fossa. Research question: it is a challenge to manage such patients, coming in emergency in comatose state and whether early intervention can reverse the consequence or not. Material and methods: A 42-year-old male presented in emergency room (ER) with sudden onset of severe headache followed by loss of consciousness, with GCS- 3 (E1V1M1) and mid-dilated fixed pupil. Computer tomography (CT scan) head revealed a large hematoma in the right cerebellopontine angle (CP) with hydrocephalus, requiring urgent CSF diversion (External Ventricular Drain) in the ER. Subsequently microsurgical excision of the tumor was done after few days, once patient has shown improvement in GCS. Histopathology confirmed it as hemorrhagic VS. Post-operatively, he had right HB (House- Brackemann) grade IV facial weakness which could not be appreciated in preoperative phase. He gradually recovered well and was able to walk without support at the time of discharge. Result: At 4 months follow up, facial weakness slightly improved to HB grade III, and patient was doing his daily activity without difficulty. Follow-up magnetic resonance imaging (MRI) imaging showed a small residue near internal acoustic meatus (IAM). Discussion and conclusion: Hemorrhage in VS is associated with increased morbidity and mortality; and few times, urgent intervention can save life despite of comatose state of the patient.

The Effect of Environmental Noise on Consonant Perception in Individual With Normal Hearing: A Prospective Observational Study.

This study was done to identify the effect that environmental noises have on consonant perception of individuals with normal hearing sensitivity. The objectives were to find out the effect of white noise and environmental noises on consonant identification and to find the effect of noises on consonant features. Adult with normal hearing in both ears whose mother tongue was Odia were included. Initially the participants underwent pure tone audiometry, speech audiometry, immittance audiometry to confirm their normal hearing, good speech identification scores and normal middle ear function. For consonant identification test, the presentation level was 40 dB sensation level with reference to speech recognition threshold for all subjects. Consonant identification test was carried out in white noise and real environmental noises (traffic noise, classroom noise, park noise, restaurant noise) at 0 dB signal to noise ratio (SNR) and at + 5 dB (SNR). The results showed that at + 5 dB SNR condition all subjects were able to get 80% and above consonant identification (CI) scores irrespective of type of noise used for stimulus while at 0 dB SNR, the mean scores ranged from 75.5% (restaurant noise) to 84% (traffic noise). At + 5 dB SNR only in restaurant noise the CI scores were low as compared to those in white noise. At 0 dB SNR, the scores were low for both the test conditions of park noise and that of restaurant noise. Different types of noisy environments can affect consonant perception which can affect speech intelligibility.

Outcomes of Hearing Aid and Cochlear Implantation in Case of Congenital Non-Syndromic Bilateral Severe to Profound Sensorineural Hearing Loss: An Observational Study.

This study was done to measure the outcomes of hearing aid (HA) and cochlear implantation (CI) in case of congenital non syndromic severe to profound sensorineural hearing loss (SNHL) by using aided audiometry (AA), categories of auditory perception (CAP) score and speech intelligibility rating (SIR) scale. The objectives were to find out the effective management options available for bilateral severe to profound SNHL, to study the impact of age of CI on language development and to study the outcome of HA and CI. Patients with congenital severe to profound SNHL were included in the study. Initially the case history of the participants was taken then they underwent audiological tests to confirm hearing loss. To assess the outcomes of HA and CI, they were initially fitted with high gain digital behind the ear HA, then underwent auditory verbal therapy for twelve months, after that AA, CAP and SIR test done to measure the outcomes of HA and similar hierarchy followed for CI. The results showed that with HA, the benefit is very limited whereas with CI the benefit is significant. The average SIR score of HA and CI are 1 and 3.16 and average CAP score are 0.83 and 7.8 respectively. The study shows that the CI is one of the most effective management options available for severe to profound SNHL and found that early intervention followed by early detection of hearing loss helps in achieving better speech and language skills.

Pleomorphic Adenoma of the Orbital Ectopic Lacrimal Gland: An Extremely Rare Occurrence with Review of Literature.

Only three cases of pleomorphic adenomas (PAs) of ectopic lacrimal gland mass in deep orbital location have been reported in the literature. This report describes a case of PA of the ectopic lacrimal gland situated deep in the orbit leading to proptosis, which was managed successfully by supraorbital orbitotomy via eyebrow incision. A 60-year-old female presented with complaints of gradually progressive, painless proptosis of the right eye. Imaging revealed a well-defined circumscribed mass lesion in the right orbit located predominantly in the postero-superior aspect of the globe. The patient underwent complete excision through supraorbital orbitotomy approach, using eyebrow incision. There was no clinical evidence of recurrence at eight months follow up. In orbit, PAs of the ectopic lacrimal gland are extremely rare, and the success of the treatment depends on the removal of the tumor with its capsule.

Synergies and prospects for early resolution of the neutrino mass ordering.

The measurement of neutrino mass ordering (MO) is a fundamental element for the understanding of leptonic flavour sector of the Standard Model of Particle Physics. Its determination relies on the precise measurement of [Formula: see text] and [Formula: see text] using either neutrino vacuum oscillations, such as the ones studied by medium baseline reactor experiments, or matter effect modified oscillations such as those manifesting in long-baseline neutrino beams (LB[Formula: see text]B) or atmospheric neutrino experiments. Despite existing MO indication today, a fully resolved MO measurement ([Formula: see text]) is most likely to await for the next generation of neutrino experiments: JUNO, whose stand-alone sensitivity is [Formula: see text], or LB[Formula: see text]B experiments (DUNE and Hyper-Kamiokande). Upcoming atmospheric neutrino experiments are also expected to provide precious information. In this work, we study the possible context for the earliest full MO resolution. A firm resolution is possible even before 2028, exploiting mainly vacuum oscillation, upon the combination of JUNO and the current generation of LB[Formula: see text]B experiments (NOvA and T2K). This opportunity is possible thanks to a powerful synergy boosting the overall sensitivity where the sub-percent precision of [Formula: see text] by LB[Formula: see text]B experiments is found to be the leading order term for the MO earliest discovery. We also found that the comparison between matter and vacuum driven oscillation results enables unique discovery potential for physics beyond the Standard Model.

Surgical Outcome of Large Solid Posterior Fossa Hemangioblastoma without Preoperative Embolization.

BACKGROUND: Large solid hemangioblastoma in the posterior fossa has an abundant blood supply as an arteriovenous malformation. The presence of adjacent vital neurovascular structures makes them vulnerable and difficult to operate. Complete surgical resection is always a challenge to the neurosurgeon. MATERIAL AND METHOD: We share the surgical difficulties and outcome in this case series of large solid hemangioblastomas without preoperative embolization as an adjunct. This study included five patients (three men and two women, with a mean age of 42.2 years). Preoperative embolization was attempted in one patient but was unsuccessful. All the patients have headache (100%) and ataxia (100%) as an initial symptom. A ventriculoperitoneal shunt was inserted in one case before definite surgery due to obstructive hydrocephalus. The surgical outcome was measured using the Karnofsky Performance Status (KPS) score. RESULT: The tumor was excised completely in all the cases. No intra- and postoperative morbidity occurred in four patients; one patient developed transient lower cranial nerve palsy. Mean blood loss was 235 mL, and no intraoperative blood transfusion was needed in any case. The mean follow-up period was 14.2 months. The mean KPS score at last follow-up was 80.One patient had a KPS score of 60. CONCLUSION: Our treatment strategy is of circumferential dissection followed by en bloc excision, which is the optimal treatment of large solid hemangioblastoma. The use of adjuncts as color duplex sonography and indocyanine green video angiography may help complete tumor excision with a lesser risk of complication. Preoperative embolization may not be needed to resect large solid posterior fossa hemangioblastoma, including those at the cerebellopontine angle location.

Syndromic Craniosynostosis: Objective and Parent-Reported Outcome Measurements after Cranio-Facial Remodelling Surgeries.

INTRODUCTION: Syndromic craniosynostosis (SC) is a rare entity compared to the non-syndromic variant. Treatment involves a multidisciplinary approach towards a multitude of problems. Early intervention is known to be better for optimum results. We reviewed outcomes of children with SC who underwent reconstructive cranio-facial surgery. MATERIALS AND METHODS: A retrospective study was conducted using data from hospital case files and the picture archival communication system. Objective data like the cephalic index (CI), both preoperatively and post-operatively, were compared. Subjective data for the cosmesis outcome - "Sloan and Whitaker outcome class" - following surgery were assessed. Also, parent-reported outcome measurement (PROM) was performed with various parameters to assess quality of life (QOL). RESULTS: We had 21 operated cases of SC, with 19 needing cranio-facial remodelling. The male to female ratio was 11:10. Crouzon's syndrome was the most common syndromic association followed by Apert's syndrome. Nineteen patients underwent cranio-facial remodelling surgeries and 2 underwent the ventriculo-peritoneal shunt only - for raised intracranial pressure (ICP). Nine patients underwent cranial remodelling with fronto-orbital advancements, and 3 of these patients also received le-fort's type 3 osteotomy and advancement later. Ten patients underwent fronto-orbital advancement with parieto-occipital barrel-stave osteotomies. OUTCOMES: Improvement in the CI was maximum at the 6-month follow-up. Six (37.5%) cases had Sloan class 1 outcome, 9 (56.25%) had class 2 outcomes, and 1 patient had a class 6 outcome. Whitaker cosmesis outcomes - 14 out of 16 cases (87.5%) had Category 1 outcomes. PROM was assessed. All parents reported at least a moderate improvement in cosmesis following surgery. Out of 15 cases, 10 (66%) reported significant improvement, while 4 (26.6%) cases reported moderate improvement with respect to eye and visual problems. Four parents reported snoring as a significant problem even after surgery. Most parents felt that the children were doing well, attending regular school, and social well-being was normal and had an overall good QOL. CONCLUSIONS: SC cases may have a multitude of other problems like raised ICP, ophthalmological problems, poor intelligence, and cognition apart from cosmetic concerns. PROMs revealed good outcomes in terms of cosmesis, cognition, and ophthalmological and oral cavity-related problems. Significant improvement in overall QOL was seen in most patients following cranio-facial remodelling surgery.

A Giant Nondural-Based Lumbosacral Clear Cell Meningioma Mimicking Schwannoma: A Case Report and Review of the Literature.

Spinal clear cell meningiomas (CCMs) are rare and dural-based lesion usually affecting the younger population. We report the rare case of giant nondural-based spinal CCM mimicking schwannoma and review the literature. A literature search was performed at PubMed and Embase until January 1, 2020. A total of 19 cases of nondural-based spinal CCM was reported. The following relevant data were extracted: authors, publication year, patient and tumor characteristics, treatment, and outcome. The mean age of the presentation was 20.58 years. Twelve (63.16%) were female and seven patients (36.84%) were male. The most common location was lumbosacral region 15 (79%). Fifteen (79%) tumors had cranio-caudal dimension ≤2 vertebral level, and only four (21%) tumors had dimension ≥2 vertebral level. Gross total resection (GTR) was performed in 18 (95%) patients and subtotal resection (STR) in 1 patient. Recurrences were reported in five (26.14%) patients. Four of them showed recurrences within 6 months; earliest at 2.3 months in the patient had undergone STR. Our patient is 19-year-old male diagnosed with a lumbosacral intradural lesion. Craniocaudal dimension is ≥2 vertebral level shows the foraminal extension and vertebral scalloping. GTR is performed. Intraoperatively, the tumor has foraminal extension and shows attachment with right S1S2 nerve root. No dural attachment is found. Six-month follow-up magnetic resonance image shows no evidence of disease. Nondural-based spinal CCMs are extremely rare and should be kept as a differential diagnosis in young patients with giant intradural tumor, and whose radiological features suggesting of schwannoma. It affects young patients and usually involves more than one vertebral level. The chances of recurrences and metastasis are always high even after GTR; hence, close follow-up of the entire neuraxis is warranted.

Effect of coronavirus disease 2019 pandemic on case volume, spectrum, and perioperative coronavirus disease 2019 incidence in neurosurgical patients: An experience at a tertiary care center in India.

BACKGROUND: The volume and spectrum of neurosurgical procedures being performed during the coronavirus disease 2019 (COVID-19) pandemic have significantly changed as compared to the pre-COVID-19 period. The objective of this study is to examine this change and draw useful conclusions. METHODS: We collected data retrospectively of all patients who attended outpatient clinics and who were operated at our institute under the department of neurosurgery from October 23, 2019, to August 23, 2020. These data were then divided into two groups (pre-COVID period and during the COVID pandemic) and compared. RESULTS: Out of the 388 surgeries performed, 284 surgeries were performed during the pre-COVID period, and 104 surgeries were performed during the COVID pandemic. During this ongoing COVID pandemic, the total number of surgeries performed by the department of neurosurgery decreased significantly by 63.38%, the proportion of routine surgeries performed decreased from 50.35% to 19.23% and the proportion of minor cases increased from 19.72% to 30.77%. The Outpatient Clinic Workflow decreased by 72.3% as compared to the pre-COVID period, and the perioperative COVID-19 reverse transcription-polymerase chain reaction positive incidence in our neurosurgical patients was 11.71%. CONCLUSION: This paper highlights the drastic reduction in the operative workflow and the outpatient clinic workflow during the ongoing corona pandemic which will have significant collateral damages in the long run. We will have to strike the right balance between providing our patients with the best medical treatment while limiting the spread of the COVID-19 infection.

Cerebellar hemangioblastoma during pregnancy: Management options and review of literature.

BACKGROUND: Symptomatic cerebellar hemangioblastomas are extremely rare in pregnant women and the ideal management is not well established. In the present article, we aimed to report a case of large cerebellar hemangioblastoma complicated by pregnancy and managed successfully by surgical resection. In addition, we also discuss management options and review of the current literature pertaining to this pathology. CASE DESCRIPTION: A 22-year-old female presented with a history of headache and vomiting for 4 weeks. She was carrying 28 weeks of pregnancy. She had left cerebellar signs, gait ataxia, and bilateral six nerve paresis. Fundus examination revealed bilateral papilledema. She was diagnosed to have large cerebellar hemangioblastoma with mass effect and obstructive hydrocephalus. She underwent suboccipital craniotomy and excision of lesion in lateral position. She recovered well postoperatively and delivered a healthy baby in the full term. Imaging at10- month follow-up demonstrates no residual lesion or another hemangioblastoma. CONCLUSION: Early diagnosis and direct surgery for excision of hemangioblastoma is a good option during pregnancy while avoiding CSF diversion procedures. The symptomatic hemangioblastoma during pregnancy can be safely operated during early pregnancy.

Surgical Management and Outcomes of Aneurysms of Posterior Inferior Cerebellar Artery: Location-Based Approaches with Review of Literature.

Background Posterior inferior cerebellar artery (PICA) is a tortuous, variable, and uncommon site for aneurysms. Surgical management of PICA aneurysms involves careful selection of approach based on the location of the aneurysm and meticulous dissection of the neurovascular structures and perforators. Materials and Methods We did a retrospective review of all the PICA aneurysms operated at our institute in the past 10 years along with the site, presentation, and approach used for the same. Preoperative World Federation of Neurosurgical Society scores and follow-up modified Rankin scores (mRS) were also evaluated. During the same period, data for intervention cases of PICA aneurysm were also collected with follow-ups for a comparative analysis. Results A total of 20 patients with 21 PICA aneurysms were reviewed. All the reviewed cases presented with subarachnoid hemorrhage, and the most common location was the lateral medullary segment and vertebral artery (VA)-PICA junction. Midline approaches were used for distal PICA cases, with far-lateral approach reserved for anterior medullary/VA-PICA junction. No lower cranial nerve palsies were recorded at follow-up. Four cases needed cerebrospinal fluid diversion and two developed cerebellar infarcts. All cases were mRS 0 to 2 at follow-up. Conclusion Our series compares well with some of the larger surgical series of PICA aneurysms. This may be due to early referral patterns and early surgery (<24 hours) policy at our institution. Anatomical knowledge of PICA anatomy and sound perioperative management are keys to good outcomes in these cases.

Hemorrhage in long segment cervical schwannoma; case report and literature review.

BACKGROUND: Although hemorrhages associated with cervical and thoracic intraspinal schwannomas are typically localized to the subarachnoid hemorrhages (SAH) or subdural hemorrhages (SDH) compartments, rare intratumoral bleeds may also occur. METHODS: In the literature, we found and analyzed multiple factors for 13 cases (e.g., epidemiological, clinical, and pathological) of cervical schwannomas with intratumoral hemorrhages (ITH). We added the 14th case of a 35-year-old female with along segment cervical schwannoma with ITH who presented with acute quadriplegia and respiratory decompensation. RESULTS: These 14 patients averaged 51.77 years of age, 60% were male, and the tumor involved 2.83 segments. The incidence of SAH and ITH was noted in five cases each, while SDH's were very rare. The pathological characteristics were consistent with the diagnosis of cellular schwannomas with S-100 positivity. The clinical outcomes were good (100%) in all the cases, including the one presented (modified McCormick score III). CONCLUSION: Cervical schwannomas with ITH are rare, and the surgical outcomes in such patients are good-excellent (>90%). The histopathology is always of prime importance and decisive in establishing and confirming the etiology of such ITH.