Decompressive craniectomy in children: indications and outcome from a tertiary centre.

INTRODUCTION: The role of decompressive craniectomy (DC) is as a rescue therapy for the treatment of intracranial hypertension. The indications for the DC are variable. METHODS: The clinical details, imaging, operative findings and follow-up data of children less than or equal to 18 years of age were reviewed for more information on the children who underwent DC in the last 5 years. RESULTS: During the study period, a total of 128 children underwent DC. The trauma cases were 66, and the non-trauma cases were 62. The common indication for DC was pure acute subdural hematoma 33 (50%), followed by contusion 10 (15%) in the trauma group, and in non-trauma, arterial infarction in 20 (32%) and cerebral venous thrombosis in 17 (27%). Hemicraniectomy was done in 114 (89%), and bifrontal craniectomy was done in 7 (5.4%) cases. The median duration follow-up was 7 months in non-trauma and 6 months in trauma. GCS was less than 8, the motor score was less than 3, and pupillary asymmetry, hypotension and basal cistern effacement were factors related to an unfavourable outcome in the non-trauma group. In regression analysis, only a motor score of less than three was associated with the non-trauma group. Age less than 10 years, GCS less than 8, motor score less than three and preoperative infarction were the predictive factors in univariate analysis, and only GCS less than 8 was the predictive factor for unfavourable factors in regression analysis in the trauma group. CONCLUSION: The DC is performed as a lifesaving procedure. The unfavourable outcome is slightly higher in non-trauma cases compared to trauma cases. However, the mortality rate is high in trauma cases.

Prospective Study to Evaluate the Role of Dual Point Contrast-enhanced Magnetic Resonance Imaging in Differentiation of Brain Tumoral from Nontumoral Tissue: A Magnetic Resonance/PET Study.

Background and Purpose: Follow-up imaging of gliomas is crucial to look for residual or recurrence and to differentiate them from nontumoral tissue. Positron emission tomography (PET)-magnetic resonance imaging (MRI) is the problem-solving tool in such cases. We investigated the role of dual point contrast (DPC)-enhanced MRI to discriminate tumoral from the nontumoral tissue compared to PET-MRI taken as the gold standard. Materials and Methods: The institutional ethics committee approved the study, and consent was obtained from all the patients included in the study. We prospectively did immediate and 75-min delayed contrast MRI in glioma cases who came for follow-up as a part of PET-MRI study in our institute. Subtracted images were obtained using immediate and 75-min delayed contrast images. Color-coded subtracted images were compared with PET-MRI images. 75-min delayed contrast MRI and diffusion-weighted imaging (DWI) images with Gray Scale inversion were compared with PET attenuation-corrected images. Results: We included 23 PET MRI cases done with different radiotracers in our study. Overall, we found PET-DPC correlation in (20/20 ~ 100%) cases of enhancing tumors. In two cases (DOPA and fluorodeoxyglucose), since they were nonenhancing low-grade gliomas and the other one was melanoma with intrinsic T1 hyperintensity and the DPC technique could not be used. DWI-PET correlated in 17/19 (~89.4%) cases, and perfusion-weighted imaging (PWI)-PET dynamic susceptibility contrast (DSC)/ASL correlated in 14/18 (~77.7%) cases after cases with hemorrhage were excluded. Conclusion: DPC MRI showed a good correlation with PET MRI in discriminating tumoral from the nontumoral tissue. DPC MRI can act as a potential alternative to PET MRI in peripheral hospitals where PET is not available. However, the DPC technique is limited in low-grade nonenhancing gliomas.

Surgical outcomes of trigonal intraventricular meningiomas: a single-centre study.

Trigonal meningiomas are rare intraventricular tumours that present a surgical challenge. There is no consensus on the optimal surgical approach to these lesions, though the transtemporal and transparietal approaches are most frequently employed. We aimed to examine the approach-related morbidity and surgical nuances in treating trigonal meningiomas. This retrospective review assimilated data from 64 trigonal meningiomas operated over 15 years. Details of clinicoradiological presentation, surgical approach and intraoperative impression, pathology and incidence of various postoperative deficits were recorded. In our study, Trigonal meningiomas most frequently presented with headache and visual deterioration. The median volume of tumours was 63.6cc. Thirty-one meningiomas each (48.4%) were WHO Grade 1 and WHO Grade 2, while 2 were WHO Grade 3. The most frequent approach employed was transtemporal (38 patients, 59.4%), followed by transparietal (22 patients, 34.4%). After surgery features of raised ICP and altered mental status resolved in all patients, while contralateral limb weakness resolved in 80%, aphasia in 60%, seizures in 70%, and vision loss in 46.2%. Eighteen patients (28.13%) developed transient postoperative neurological deficits, with one patient (1.5%) developing permanent morbidity. Surgery for IVMs results in rapid improvement of neurological status, though visual outcomes are poorer in patients with low vision prior to surgery, longer duration of complaints and optic atrophy. The new postoperative deficits in some patients tend to improve on follow up. Transtemporal and transparietal approaches may be employed, based on multiple factors like tumour extension, loculation of temporal horn, size of lesion with no significant difference in their safety profile.

Predictors of Remission of Acromegaly following Surgical Treatment in Growth Hormone-Secreting Pituitary Adenoma.

Background and Objective Surgery is the treatment of choice for growth hormone (GH)-secreting pituitary adenoma. The remission of random GH depends on various factors. We aimed to evaluate the predictors related to remission of random GH following surgical treatment. Methods We collected the data retrospectively from the chart review from a single unit of neurosurgery. The diagnostic criteria for remission were a random GH < 1 ng/mL or nadir GH < 0.4 ng/mL after an oral glucose tolerance test. Results Data from a total of 110 (females 62 [56.4%]) patients were available for follow-up and were analyzed. The mean age was 36.5 years (14-69 years). Vision impairments were seen in 39 (35.5%) patients. The mean duration of symptoms before surgery was 34 months. The mean volume of the tumor was 7.2 mL (0.44-109.8 mL). Knosp grade 3 and 4 tumors were seen in 41.5% of cases. The mean preoperative random GH level was 68.9 ng/mL. Transsphenoidal surgery was done in 107 (97.3%) cases. The gross total resection could be done in 36 (32.7%) cases. At 3 months, 25 (26%) patients had a biochemical remission. In univariable analysis, lower Knosp grade, preoperative GH level < 40 ng/mL, gross total resection, and male gender were associated with remission at 3 months. In regression analysis, preoperative GH and male gender were related to remission at 3 months. Conclusion The preoperative GH level < 40 ng/mL is associated with higher chances of remission after surgery for GH-secreting pituitary adenoma.

Safety and Efficacy of Biopsy in Patients with Diffuse Intrinsic Pontine Gliomas.

BACKGROUND: Diffuse intrinsic pontine gliomas are aggressive tumors that carry a poor prognosis with a 2-year survival rate of <10%. The imaging appearance is often pathognomonic, and surgical biopsy is not mandatory to initiate treatment in children. Studies of biopsy samples provide insight into the disease's molecular pathobiology and open prospects for targeted therapy. This study was conducted to determine the diagnostic yield and safety of stereotactic biopsies. METHODS: This is a prospective observational study from a single tertiary health care center. All patients with clinical and radiological features diagnostic of diffuse intrinsic pontine gliomas (DIPGs) who underwent biopsy from July 2018 to June 2023 were included. Biopsies were performed using either stereotactic frame-based, frameless, or endoscopic techniques. RESULTS: A total of 165 patients with DIPGs were evaluated in the study period. The option of biopsy with its associated risks and benefits was offered to all patients. A total of 76 biopsies were performed in 74 patients (40 children and 34 adults, including 2 repeat biopsies). The median age was 15 years. Diffuse midline gliomas, H3K27M altered, was the most common histopathological diagnosis (85% pediatric and 55.9% adults). The diagnostic efficacy of the procedure was 94.7%. The complication rate was 10.8%, with no permanent neurological deficits due to surgery. There was no procedure-related mortality. CONCLUSIONS: Establishing the safety of the procedure could be an important step toward popularizing the concept, which might offer a better understanding of the disease. Brainstem eloquence and a lack of direct benefit to patients are the primary obstacles to brainstem biopsy.

Factors Influencing Long-Term Outcomes of Single-Session Gamma Knife Radiosurgery in Large-Volume Meningiomas >10 cc.

INTRODUCTION: Meningiomas are the most common primary intracranial tumour. Gamma knife radiosurgery (GKRS) is a frequently employed non-invasive method of treatment, with good remission rates and low morbidity in literature. However, the role of GKRS in the management of "large" meningiomas is unclear, with reported outcomes that vary by centre. We aimed to assess the factors that influence long-term outcomes following GKRS in meningiomas >10 cc in volume. METHODS: A retrospectively analysed all patients with meningiomas exceeding 10 cc in volume who underwent GKRS between January 2006 and December 2021 at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. Demographic, clinical, radiological, and follow-up data were acquired, and factors associated with progression following GKRS were assessed. RESULTS: The cohort comprised 76 patients 29 males (38.2%) and 47 females (61.8%) with a mean age of 46.3 ± 11.02 years. Thirty-nine patients had been previously operated (51.3%). Meningiomas were most frequently located in the parasagittal region (26 tumours, 34.2%) and sphenopetroclival region (23 tumours, 30.3%), with mean lesion volume of 12.55 ± 5.22 cc, ranging 10.3 cc-25 cc. The mean dose administered to the tumour margin was 12.5 Gy ± 1.2 Gy (range 6-15 Gy). The median duration of clinical follow-up was 48 months, over which period radiological progression occurred in 14 cases (20%), with unchanged tumour volume in 20 cases (28.6%) and reduction in size of the tumour in 36 cases (51.4%). Progression-free survival after GKRS was 72% at 5 years, was significantly poorer among meningiomas with tumour volume >14 cc (log-rank test p = 0.045), tumours presenting with limb motor deficits (log-rank test p = 0.012), and tumours that underwent prior Simpson grade 3 or 4 excision (log-rank test p = 0.032). CONCLUSIONS: Meningiomas >10 cc in volume appear to display a high rate of progression and subsequent need for surgery following GKRS. Primary surgical resection, when not contraindicated, may be considered with GKRS serving an adjuvant role, especially in tumours exceeding 14 cc in volume, and presenting with limb motor deficits. Long-term clinical and radiological follow-up is essential following GKRS as the response of large meningiomas may be unpredictable.

Surgical Outcome of Torcula Herophili Meningioma: An Institutional Experience.

INTRODUCTION: Resection of meningiomas (THMs) at the torcular Herophili poses challenges to surgeons due to complex regional anatomy. The current study aims to evaluate factors affecting the extent of resections, progression-free survival, and the role of radiation. METHODS: We did a retrospective study of all the THM patients treated at our institute between May 1987 and June 2022. The demographic data, signs and symptoms, surgical notes, postoperative details, and radiotherapy were gathered retrospectively. Survival analysis was done with Kaplan-Meier tests along with predictors of the extent of resection as well as recurrence. RESULTS: A total of 39 patients qualified to be included in the study, with 10 male patients (male:female 1:2.9) and an average age of 50.8 years. The average follow-up duration was 75.9 months. Simpson's grade 2 excision was achieved in 19 (48.7%) patients, followed by Simpson's grade 3 excision in 17 patients (43.6%). Progression-free survival in subtotal resection was 60 months, and 100 months in gross total resection. Statistically, the extent of the resection was determined by the involvement of sinuses/torcula and the number of quadrants involved around torcula. A total of 16 patients received radiosurgery for the residual or small reccurrence of the lesion. Follow-up revealed reccurrence in 5 cases. CONCLUSIONS: Torcular meningiomas are relatively uncommon, described in few reports, and represent a therapeutic dilemma. Though some experts recommend complete removal of tumor and reconstruction of the sinus, others suggest maximum safe resection, followed by radiosurgery. The present study reflects reasonable control of the residual lesion with radiosurgery after maximum safe resection.

Evaluating the Diagnostic Efficacy of 99mTc-Methionine Single-Photon Emission Computed Tomography-Computed Tomography: A Head-to-Head Comparison with 11C-Methionine Positron Emission Tomography-Magnetic Resonance Imaging in Glioma Patients.

Background: Amino acid positron emission tomography (PET) imaging plays a significant role in the diagnosis of gliomas and in differentiating tumor recurrence from necrosis. In this study, the authors evaluated the diagnostic efficacy of [99mTc]Tc-methionine single-photon emission computed tomography-computed tomography (SPECT-CT) in comparison with [11C]methionine PET-magnetic resonance imaging (MRI) in delineating tumors. Methods: Thirty-one (primary: 16 and postoperative: 15) patients of confirmed (either MRI or histopathological proven) glioma underwent both [99mTc]Tc-methionine SPECT-CT and [11C]methionine PET-MRI. A comparative analysis was performed between SPECT, PET, and MR images to calculate the concordance between the modalities and to evaluate the diagnostic efficacy of the [99mTc]Tc-methionine SPECT. Results: [99mTc]Tc-methionine SPECT showed comparable uptake in the tumor lesions in comparison to [11C]methionine PET. A significant and strong positive correlation was observed between the volume of tumor (Vt) in PET and Vt MR (p < 0.004). Likewise, a significant and strong positive correlation was found between Vt SPECT and Vt MR. [99mTc]-methionine has a sensitivity and specificity of 91% and 75%, respectively, compared with 82% and 100% for [11C]methionine in postoperative cases to differentiate the tumor recurrence from necrosis. The sensitivity and specificity of [99mTc]Tc-methionine was 92% and 100%, respectively, compared with 92% and 67% for [11C]methionine in primary tumors. Conclusion: [99mTc]Tc-methionine SPECT-CT is as equally good as [11C]methionine for diagnosing and differentiating it from necrosis especially in high-grade glioma.

Endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS) for paediatric hydrocephalus due to primary aqueductal stenosis.

PURPOSE: The purpose of this study was to compare outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in children with symptomatic triventricular hydrocephalus due to primary aqueductal stenosis. METHOD: This is a retrospective analytical study. Patients who underwent either ETV or VPS as the first procedure for hydrocephalus due to primary aqueductal stenosis were included in the study. RESULT: A total of 89 children were included in the study for analysis. The mean age was 8.4 years. Forty-four (49.4%) had their first surgery as ETV and 45 (50.6%) had their first surgery as VPS. Overall, 34 (38.2%) patients required a second surgery (either ETV or VPS) for persistent or recurrent hydrocephalus. The mean follow-up duration was 832.9 days. The overall complication rate was 13.5%. The mean timing of the second surgery after index surgery was 601.35 days. Factors associated with a second surgery were the presence of complications, high protein in cerebrospinal fluid, the relative change of frontal-occipital horn ratio (FOHR) and Evans' index. The survival of the first surgery was superior in ETV (751.55 days) compared to VPS (454.49 days), p = 0.013. The relative change of fronto-occipital horn index ratio (FOIR) was high in the VPS (mean 7.28%) group compared to the ETV (mean 4.40%), p = 0.001 group. CONCLUSION: Overall procedural survival was better after ETV than VPS for hydrocephalus due to aqueductal stenosis. VPS causes more reduction in linear indices of ventricles as compared to ETV, however, is not associated with the success or complication of the procedure.

Glioma arising in the setting of mismatch repair deficiency-rare or are we missing it?

Germline mutations in mismatch repair (MMR) genes (MLH1, MSH2, MSH6, PMS2) can be mono-allelic or biallelic, resulting in a Lynch syndrome (LS) or constitutional mismatch repair deficiency (CMMRD) syndrome respectively. Glioma arising in the setting of MMR deficiency is uncommon. We describe two pediatric patients with high-grade glioma (HGG) and associated MMR protein deficiency. On histomorphology both cases showed HGG with astrocytic morphology and prominent multinucleated tumor cells. On immunohistochemistry, the first case was negative for IDH1 p.R132H showed loss of ATRX and p53 positivity. The second case was positive for IDH1 p.R132H and p53, but showed retained expression of ATRX. The histomorphology in both cases and additionally IDH mutation with retained ATRX in the second case, prompted us to test for MMR protein deficiency which was carried out by immunohistochemistry (IHC). One case revealed an immunostaining pattern suggestive of CMMRD while the other was suggestive of LS. Both the cases showed good response to surgery and radio-chemotherapy in the follow-up available. Our cases highlight the importance of testing for MMR proteins by simple IHC, in the setting of appropriate clinical scenario, histopathological and immunohistochemical findings. The recognition of these tumors is extremely important to guide further treatment and prompt family screening.

Role of magnetoencephalography in predicting the epileptogenic zone and post-operative seizure outcome - A retrospective study.

PURPOSE: Study assessed the role of MSI in predicting the post-operative seizure outcome. METHODS: This retrospective study included patients who underwent MEG and epilepsy surgery and had a minimum 6 months of postoperative follow-up. Concordance of MEG cluster with post-surgical resection cavity was classified as follows Class I) Concordant and region-specific, Class II) Concordant and region non-specific, Class III) Concordant lateralization only and Class IV) Discordant lateralization. The relationship between MSI concordance and post-operative seizure outcome was assessed. RESULTS: A total of 183 patients (M: F = 109:74) were included. The mean age at onset of seizures: 8.0 ± 6.4 years. The dipoles were frequent in 123(67.2 %). The primary cluster orientation was regular in 59 (32.2 %) and mixed in 124 (67.8 %) patients. Concordance between MEG and resection cavity: Class I - 124 (67.8 %), class II- 30 (16.4 %), class III- 23 (12.6 %), and class IV- 6 (3.3 %). The post-surgically mean duration of follow-up was 19.52 ± 11.27 months. At 6-month follow-up period, 144 (78.7 %) patients had complete seizure freedom out of which 106 (73.6 %) had class I concordance. Concordance of MEG with resection cavity was associated with a good outcome at 6 months (p = 0.001), 1 year (p = 0.001), 2 years (p = 0.0005) and 5 years (p = 0.04). MEG cluster characteristics had no association with seizure outcome except the strength of the cluster and outcome at 3 years (p = 0.02) follow-up. CONCLUSION: The study supports that the complete resection of the MEG cluster had high chance of seizure-freedom and can be used as a complementary noninvasive presurgical evaluation tool.

Localisation of eloquent cortex using magnetoencephalography and its clinical implications.

OBJECTIVES: This study aimed to localise the eloquent cortex and measure evoked field (EF) parameters using magnetoencephalography in patients with epilepsy and tumours near the eloquent cortex. METHODS: A total of 41 patients (26 with drug-refractory epilepsy and 15 with tumours), with a mean age of 33 years, were recruited. Visual evoked field (VEF), auditory evoked field (AEF), sensory evoked field (SSEF), and motor-evoked field (MEF) latencies, amplitudes, and localisation were compared with those of a control population. Subgroup analyses were performed based on lobar involvement. Evoked Field parameters on the affected side were compared with those on the opposite side. The effect of distance from the lesion on nearby and distant evoked fields was evaluated. RESULTS: AEF and VEF amplitudes and latencies were reduced bilaterally (p < 0.05). Amplitude in the ipsilateral SSEF was reduced by 29.27% and 2.16% in the AEF group compared to the contralateral side (p = 0.02). In patients with temporal lobe lesions, the SSEF amplitude was reduced bilaterally (p < 0.02), and latency was prolonged compared with controls. The MEF amplitude was reduced and latency was prolonged in patients with frontal lobe lesions (p = 0.01). EF displacement was 32%, 57%, 21%, and 16% for AEF, MEF, VEF, and SSEF respectively. Patients in the epilepsy group had distant EF abnormalities. CONCLUSIONS: EF amplitude was reduced and latency was prolonged in the involved hemisphere. Distant EF amplitudes were more affected than latencies in epilepsy. Amplitude and distance from the lesion had negative correlation for all EF. EF changes indicated eloquent cortical displacement which may not be apparent on MRI.

Transventricular Endoscopic Approach for Cystic Craniopharyngioma: Case Series.

Background and Study Aims The treatment of craniopharyngioma is varied. The treatment ranges from radical excision to direct radiotherapy. As the morbidity of excision is high, more conservative approaches are used. Transventricular endoscopy is a minimally invasive treatment for cystic craniopharyngiomas. The objective of this study is to describe a personal experience with this method of treatment. Material and Methods This is a retrospective review of a series of patients managed with endoscopic catheter and reservoir placement for cystic craniopharyngiomas. Results Twenty-nine patients presented with clinical features of raised intracranial features. Imaging showed a predominantly cystic craniopharyngioma extending into the third ventricle with hydrocephalus. All patients underwent transcortical transventricular endoscopic biopsy, and catheter placement connected to a reservoir. There was no morbidity ascribed to the endoscopic procedure when fenestration and aspiration or fenestration and reservoir were placed. Twelve patients underwent radiotherapy. The median duration of follow-up was 18 months (3-72 months). Eight (27.5%) cases had recurrences. Five (17.2%) could be managed with only reaspiration, two (6.8%) required craniotomy and resection, and one (3.4%) could be managed only with ventriculoperitoneal shunt. Conclusion The neuroendoscopic fenestration, aspiration of cyst, and placement of catheter reservoir followed by radiation is an optional treatment for predominantly cystic craniopharyngiomas arising within or extending into the third ventricle causing hydrocephalus.

Endovascular Management of a Basilar Artery Pseudoaneurysm After Iatrogenic Injury During Endoscopic Third Ventriculostomy: Case Report.

Endoscopic third ventriculostomy (ETV) is a well-established neurosurgical procedure. However, it carries risks of intraoperative complications, among which major vascular injury is the most dangerous. Reportedly, prominent bleeding during ETV has been noted in <1% of cases. Herein, we describe a case of a 34-year-old woman with occlusive hydrocephalus caused by a quadrigeminal cistern arachnoid cyst, who developed a pseudoaneurysm after injury of the basilar artery apex during ETV. Complete obliteration of the pseudoaneurysm with endovascular balloon-assisted coiling was done on the first postoperative day, and the patient demonstrated gradual recovery, but approximately 4 weeks later, she suffered massive rebleeding, seemingly due to rupture of the weak pseudoaneurysm wall, which resulted in her death. Careful evaluation of sagittal T2-weighted magnetic resonance images before ETV may be invaluable for assessment of the basilar artery position in relation to the third ventricle floor. In addition, use of a blunt surgical instrument (instead of a sharp one or cautery) for fenestration may be safer for prevention of arterial injury. Finally, special care should be applied in cases with an opaque third ventricle floor and inability to visualize the basilar artery during ETV.

Impact of perioperative factors on short-term outcomes after emergency surgery for acute traumatic extradural hematoma - A retrospective cohort study.

BACKGROUND: Preoperative clinical and imaging findings predict neurological outcomes in patients with traumatic brain injury (TBI). Similarly, intraoperative factors such as blood loss and hypotension can also affect outcomes. However, there is not much data regarding the influence of perioperative variables on clinical outcomes in patients with extradural hematoma (EDH). This study aimed to understand the effect of perioperative factors on short-term neurological outcomes in patients operated for acute traumatic EDH. METHODS: After obtaining institutional ethical approval, we collected data retrospectively from records of patients who underwent emergency surgery for acute traumatic EDH over a two-year period. Data regarding age, gender, preoperative Glasgow coma scale (GCS) score, clinical and imaging findings, surgical and anesthetic details, blood loss and transfusion, duration of hospital stay, and GCS score at discharge were collected. Patients with discharge GCS score of 14-15 were considered to have favorable outcome and <14 as unfavorable outcome. Regression analysis was performed to examine the association between predictors and outcomes. Odds ratios (OR) and 95 % confidence intervals (CI) were calculated. RESULTS: Data of 501 patients were analyzed. Outcome was favorable in 343 (68.5 %) and unfavorable in 158 (31.5 %) patients. On multivariate logistic regression analysis (OR, 95 % CI, p value), age (1.03, 1.01-1.05, 0.01), preoperative GCS score (0.68, 0.61-0.76, <0.001), signs of basal skull fracture (1.9, 1.02-3.61, 0.043) and intraoperative blood loss (2.23, 1.2-4.16, 0.01) were independently associated with unfavorable outcome. Pneumonia, neurological deficits, inotrope use and duration of hospital stay was more in this group. CONCLUSIONS: Older age, poor pre-operative GCS score, signs of basal skull fracture, and intraoperative blood loss were associated with lower discharge GCS score, increased neurological deficits and longer hospital stay in patients operated for acute traumatic EDH.

Factors predicting recurrence in benign spinal nerve sheath tumors: A retrospective study of 457 patients from a single institution.

BACKGROUND: Benign Nerve sheath tumors (NST) comprise almost one-third of primary spinal tumours. The majority are sporadic. They have low rates of recurrence but an occasional recurrence may need re-surgery. The present study was designed to identify the variables that can predict the risk of their recurrence. METHODS: A retrospective chart review was done including all the histologically proven benign spinal NSTs operated between 2001 and 2019 in our institute. Demographic, operative and postoperative follow-up data were recorded. Recurrence was defined as local reappearance after definite surgical excision or symptomatic increase in size of a residual tumour on follow-up imaging studies. Statistical analysis was done to determine the significant variables associated with local recurrence. RESULTS: 457 patients with a median age of 38 years operated for 459 NSTs qualified for the study. The most frequent location of occurrence of tumours was found to be Low Cervical level (C3-C7 levels). Majority of Schwannoma were located intradurally while Neurofibroma were dumb-bell shaped and extradural. Most of the tumours had solid consistency. Post operatively, 7.7% patients developed complications. 7.8% tumours developed local recurrence after median period of 12 months. The patients developing recurrence were younger compared to nonrecurring tumors. On univariate analysis, male gender, Low cervical and Cervicothoracic junction location were associated with higher recurrence. On multivariate analysis, location at Cervicothoracic junction reached significance. CONCLUSION: Overall recurrence risk among all NST was 7.8% with a median progression free survival of 36 months. The location of tumour at cervicothoracic location was the significant risk factors for recurrence of tumour in our study.

Navigation guidance in neuroendoscopic management of complex hydrocephalus.

Patients with multiloculated hydrocephalus have multiple, separate abnormal CSF collections with no communication between them. Causes include complications of neonatal meningitis, germinal matrix hemorrhage in neonates, head trauma, and intracranial surgery. Endoscopic fenestration with shunt insertion is a safe and less invasive technique as the initial treatment. In this video, the authors demonstrate a few cases in which electromagnetic navigation was used with a stylet inserted through the operating endoscope to guide the surgeon. Modalities such as insertion of intraventricular contrast and fluorescein may be used as adjuvants, as demonstrated. The use of navigation helps to identify distorted anatomical landmarks and guides surgery. The video can be found here: https://stream.cadmore.media/r10.3171/2023.1.FOCVID22152.

Resting-State Functional MRI/PET Profile as a Potential Alternative to Tri-Modality EEG-MR/PET Imaging: An Exploratory Study in Drug-Refractory Epilepsy.

Objective The study explores whether the epileptic networks associate with predetermined seizure onset zone (SOZ) identified from other modalities such as electroencephalogram/video electroencephalogram/structural MRI (EEG/VEEG/sMRI) and with the degree of resting-state functional MRI/positron emission tomography (RS-fMRI/PET) coupling. Here, we have analyzed the subgroup of patients who reported having a seizure on the day of scan as postictal cases and compared the findings with interictal cases (seizure-free interval). Methods We performed independent component analysis (ICA) on RS-fMRI and 20 ICA were hand-labeled as large scale, noise, downstream, and epilepsy networks (Epinets) based on their profile in spatial, time series, and power spectrum domains. We had a total of 43 cases, with 4 cases in the postictal group (100%). Of 39 cases, 14 cases did not yield any Epinet and 25 cases (61%) were analyzed for the final study. The analysis was done patient-wise and correlated with predetermined SOZ. Results The yield of finding Epinets on RS-fMRI is more during the postictal period than in the interictal period, although PET and RS-fMRI spatial, time series, and power spectral patterns were similar in both these subgroups. Overlaps between large-scale and downstream networks were noted, indicating that epilepsy propagation can involve large-scale cognition networks. Lateralization to SOZ was noted as blood oxygen level-dependent activation and correlated with sMRI/PET findings. Postoperative surgical failure cases showed residual Epinet profile. Conclusion RS-fMRI may be a viable option for trimodality imaging to obtain simultaneous physiological information at the functional network and metabolic level.

Contemporary Role of Stereotactic Radiosurgery for Psychiatric Disorders.

Psychiatric disorders are the hidden pandemic of the current century. Despite major advances in medical management, the options for treatment are still limited. Neurosurgical intervention is effective for certain refractory psychiatric illnesses and the options range from stimulation surgeries to precise disconnection procedures influencing the neuronal network. Literature regarding stereotactic radiosurgery (SRS) is now enriched with successful treatment of obsessive compulsive disorder, major depression disorder, and anorexia nervosa. These procedures by reducing compulsions, obsessions, depression, and anxiety, improve substantially the quality of life for patients with a good safety profile. It is a valid treatment alternative for a selected group of patients who otherwise have no therapeutic options for whom the neurosurgical intervention is the only hope. It is also cost effective and highly reproducible among specialists. These procedures are adjuvant to the medical and behavioural treatment of psychiatric disorders. In this study the Contemporary role of Stereotactic radiosurgery is reviewed starting with relevant history of psychosurgery followed by individual psychiatric disorders.

Anesthetic Concerns during Gamma-Knife Radiosurgery.

Background: Gamma-knife radiosurgery (GKRS) has emerged as one of the mainstream modalities in the treatment of many neurosurgical conditions. The indications for Gamma knife are ever-increasing and presently more than 1.2 million patients have been treated with Gamma knife worldwide. Objective: A neurosurgeon usually leads the team of radiation oncologists, medical physicists, nursing staff, and radiation technologists. Seldom, help from anesthetist colleagues is required in managing patients, who either require sedation or anesthesia. Methods: In this article, we try to elucidate anesthetic considerations in Gamma-knife treatment for different age groups. With the collective experience of authors involved in Gamma-Knife Radiosurgery of 2526 patients in 11 years with a frame-based technique, authors have tried to elucidate an effective and operational management strategy. Results: For pediatric patient (n = 76) population and mentally challenged adult patients (n = 12), GKRS merits special attention given its noninvasive nature but problems of frame fixation, imaging, and claustrophobia during radiation delivery become an issue. Even among adults, many patients have anxiety, fear, or claustrophobia, who require medications either to sedate or anesthetize during the procedure. Conclusion: A major goal in treatment would be a painless frame fixation, avoid inadvertent movement during dose delivery, and a fully wake, painless, and smooth course after frame removal. The role of anesthesia is to ensure patient immobilization during image acquisition and radiation delivery while ensuring an awake, neurologically accessible patient at the end of the radiosurgery.