Telemedicine in Follow-up after Spine Surgery: Need of the Hour.

Purpose There is an acute shortage of neurosurgeons and spine surgeons especially in rural areas of low- and middle-income countries including India. Patients of spine surgery need to travel long distances for follow-up at tertiary care hospitals. This study was done to evaluate role and success rate of telemedicine in follow-up after spine surgery based on patients' diagnosis and demographic features and to identify barriers to successful telemedicine consultations. Materials and Methods All patients undergoing spine surgeries including craniovertebral junction (CVJ) surgeries from January 2021 to June 2022 were included in the study. Success rate of telemedicine was calculated using a simple formula: Success rate of telemedicine = successful telemedicine consultations / total number of telemedicine consultation × 100. Success rate was evaluated with respect to demographic features and underlying disease-related factors. Results Eighty-four patients formed the study group in which a total of 181 video teleconsultations were done. Overall success rate of telemedicine was 82.87%. Higher socioeconomic and educational statuses were related to higher success rates of tele-consultations ( p < 0.05). Difficulty in assessing neurological condition using video call in follow-up cases of CVJ and issues related to Internet communication network leading to inability to video call and share image/videos were major causes of failures. Conclusion Telemedicine may prove an effective option for following up patients undergoing spine surgeries except CVJ, which is likely to improve further with improvements in Internet connectivity.

Setting Up a Department of Neurosurgery in a Government Hospital in an LMIC: Jodhpur, India.

BACKGROUND: The number of government institutes offering affordable super specialty and tertiary healthcare in India has traditionally not been able to keep pace with the growth in population, most of whom are too poor to be able to afford private healthcare services. To meet this mandate, 6 new institutes built on the template of the premier institute of the country-the All India Institute of Medical Sciences, New Delhi-were founded and began operations in 2012. Using the progress of our department as an example, the aim of this report is to outline the principles that were followed to set up the department of neurosurgery. METHODS: The Department of Neurosurgery at All India Institute of Medical Sciences, Jodhpur, began providing services in August 2017. Data related to the inception and development of the department were collected. RESULTS: The department has grown during the past 5 years from 400 outpatients and 79 inpatients in 2017 to 11,144 outpatients and 1624 inpatients in 2022. Only 59 surgeries were performed in 2017 compared with 597 routine and 311 emergency procedures performed in 2022. Currently, the department has 7 faculty members performing all forms of complex skull base, craniovertebral junction, vascular, endovascular, epilepsy, and functional surgeries. A total of 134 studies have been reported in national and international journals, and 8 patents have been granted. CONCLUSIONS: We report the unique experiences of one department that could be useful as a template and as guidelines for the establishment process of a new department.

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.

Simulation of surgery for supratentorial gliomas in virtual reality using a 3D volume rendering technique: a poor man's neuronavigation.

OBJECTIVE: Different techniques of performing image-guided neurosurgery exist, namely, neuronavigation systems, intraoperative ultrasound, and intraoperative MRI, each with its limitations. Except for ultrasound, other methods are expensive. Three-dimensional virtual reconstruction and surgical simulation using 3D volume rendering (VR) is an economical and excellent technique for preoperative surgical planning and image-guided neurosurgery. In this article, the authors discuss several nuances of the 3D VR technique that have not yet been described. METHODS: The authors included 6 patients with supratentorial gliomas who underwent surgery between January 2019 and March 2021. Preoperative clinical data, including patient demographics, preoperative planning details (done using the VR technique), and intraoperative details, including relevant photos and videos, were collected. RadiAnt software was used for generating virtual 3D images using the VR technique on a computer running Microsoft Windows. RESULTS: The 3D VR technique assists in glioma surgery with a preoperative simulation of the skin incision and craniotomy, virtual cortical surface marking and navigation for deep-seated gliomas, preoperative visualization of morbid cortical surface and venous anatomy in surfacing gliomas, identifying the intervenous surgical corridor in both surfacing and deep-seated gliomas, and pre- and postoperative virtual 3D images highlighting the exact spatial geometric residual tumor location and extent of resection for low-grade gliomas (LGGs). CONCLUSIONS: Image-guided neurosurgery with the 3D VR technique using RadiAnt software is an economical, easy-to-learn, and user-friendly method of simulating glioma surgery, especially in resource-constrained countries where expensive neuronavigation systems are not readily available. Apart from cortical sulci/gyri anatomy, FLAIR sequences are ideal for the 3D visualization of nonenhancing diffuse LGGs using the VR technique. In addition to cortical vessels (especially veins), contrast MRI sequences are perfect for the 3D visualization of contrast-enhancing high-grade gliomas.

Tumor Occupancy Ratio-An Imaging Characteristic Prognosticating the Surgical Outcome of Benign Intradural Extramedullary Spinal Cord Tumors.

BACKGROUND: Intradural extramedullary (IDEM) spinal cord tumors are two thirds of all spinal tumors. We have prospectively analyzed the importance of the tumor occupancy ratio as a factor for predicting the course of the disease and in prognosticating the surgical outcome in patients with IDEM tumors. METHODS: We prospectively analyzed 44 consecutive cases of IDEM tumors, diagnosed as cervical, thoracic, and lumbar IDEM tumors (excluding conus/cauda equina lesion) by magnetic resonance imaging (MRI), that were operated on at our institution between 2014 and 2016. We measured the tumor occupancy ratio and noted the sagittal and axial location of the tumor in the preoperative MRI and performed the laminectomy and unilateral medial facetectomy. A primary outcome has been noted according to the gait disability score in the preoperative period and in the follow-up period of 1 year. In the statistical analysis, categorical variables were compared using a chi-square test, and an analysis of variance and student t tests were used for the continuous variables. P < .05 was considered statistically significant. RESULTS: The tumor occupancy ratio showed a significant association to the preoperative gait disability score (P < .001) and also predicted that the surgical outcome is much better in patients with tumors with a low tumor occupancy ratio than in patients with tumors with a high occupancy ratio (P < .001). No difference in the tumor occupancy ratio was noted in 2 different pathological tumors, and there was also no difference in the tumor occupancy ratio at different sagittal and axial locations of the tumor. CONCLUSION: Tumor occupancy ratio has shown a significant impact on the preoperative course and also predicts the surgical outcome in patients with IDEM tumors. Hence, it is an important imaging characteristic to prognosticate the outcome in IDEM tumors and should be noted in each case.

Institutional Experience of Microsurgical Management in Posterior Circulation Aneurysm.

INTRODUCTION: Posterior circulation aneurysm constitutes 15%-20% of all intracerebral aneurysms. With the advancement of endovascular techniques, the microsurgery for posterior circulation aneurysms has been pushed back a little. Even the International Subarachnoid Aneurysmal Trial gave support to the concepts of endovascular procedures, but microsurgical modality should not be discouraged. We present our institutional experience of microsurgical techniques on posterior circulation aneurysms. MATERIALS AND METHODS: We performed a retrospective analysis of 37 patients of posterior circulation aneurysm from 2015 to 2019, referred to Bantane Hospital, Japan. We included all posterior circulation aneurysms such as basilar tip, basilar trunk, and vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms, admitted and treated with clipping or bypass and trapping. We assessed the outcome as measured by modified Rankin Score (mRS), complications, and mortality. RESULTS: Out of 37 patients, 10 cases were a basilar tip, one case was the basilar trunk, and 26 cases were VA-PICA aneurysm. Intraoperatively, neuromonitoring, indocyanine green dye, dual-image videoangiography (DIVA), and neuro endoscope were used. Two patients of basilar tip aneurysm developed third cranial nerve paresis and six patients of VA-PICA aneurysm developed lower cranial nerve paresis which resolved spontaneously. All the patients were discharged with mRS of 0 or 1. No mortality was recorded in our study. CONCLUSION: Microsurgical clipping of posterior circulation aneurysm is safe in unruptured aneurysm with a very low risk of mortality and morbidity under experienced hands. All postoperative complications in our study were transient and resolved with time with no residual deficits. Preoperative simulation, intraoperative neuromonitoring, DIVA, and neuro endoscope help achieve complete obliteration of aneurysmal sac and avoid complications.

High-Flow Bypass with Radial Artery Graft for Cavernous Carotid Aneurysm.

Cavernous carotid aneurysms can be managed by different surgical as well as endovascular methods. The aim of treatment is to exclude the aneurysm from circulation and maintain normal cerebral blood flow. We are reporting a case of incidentally detected CCA managed by high flow bypass with radial artery graft. We discuss the surgical technique and nuances of high flow bypass surgery.

Minimally Invasive Anterolateral Approach for C2 Neurofibroma in Elderly Patient.

Conventionally ventrally located spinal tumor is approached through anterior vertebrectomy which requires bony fixation and then immobilization for a couple of months. The alternative route to deal with such type of tumor is anterolaterally to avoid the surgical and nonsurgical complications. We are reporting a minimally invasive anterolateral approach for C2 neurofibroma in an 84-year-old patient. Postoperatively this patient did not require cervical brace and postoperative discomfort was minimal. It was observed that dumbbell-shaped cervical tumor with no intradural pathology and wide neural foramina could also be taken care through the anterolateral route which did not require bony fusion or immobilization, but the expertise of the surgeon is necessary for performing these types of minimally invasive procedure to achieve the best results.

Unusually Located Proximal Middle Cerebral Artery Saccular Aneurysm.

Middle cerebral aneurysms constitute almost one-third of all anterior circulation aneurysms. Most of the saccular aneurysms originate from the arterial branching sites, but origins other than at the branching site are extremely rare. In this article, we are describing a unique M1 segment middle cerebral artery aneurysm which is not related with any branching site. Our literature search suggests that atherosclerotic changes in the arterial wall and local hemodynamic forces play an important role in the development of these types of aneurysm. Surgical management is not so unique in this type of aneurysm, but due to atherosclerotic parent arterial wall and thin-walled aneurysm sac, a neurosurgeon should be more cautious.

Is Endoscopic Third Ventriculostomy a Feasible Option or Ventriculoperitoneal Shunt a Safer Bet for the Treatment of Posttraumatic Hydrocephalus? A Gap Time Model-based Algorithm.

BACKGROUND: Posttraumatic hydrocephalus (PTH) adds to the morbidity and mortality of traumatic brain injury (TBI) and there are insufficient clinical data to suggest usefulness of ventriculoperitoneal shunt (VPS) over endoscopic third ventriculostomy (ETV) in PTH or vice versa. OBJECTIVE: To evaluate the usefulness of VPS and ETV in the treatment of PTH and to establish the indications for their usage. MATERIALS AND METHODS: This was an ambispective study of 141 patients who developed PTH out of 2500 cases of TBI treated during the study duration (2012-2016). These patients were segregated into two groups depending on the primary procedure for PTH-ETV group and VPS group. The two groups were compared to analyze the differences in radiological and clinical outcome. RESULTS: 141 patients were included in the study and 175 procedures were performed in these patients. ETV group had 30 procedures and VPS had 145 procedures. In the ETV group, 37% of cases showed improvement v/s 73% cases in the VPS group. A statistically significant number of patients had improvement in presenting symptoms in the VPS group, as compared with the ETV group (P = 0.001). There was no significant difference in Glasgow coma scale (GCS) at discharge (P = 0.15) and Glasgow outcome score at 6 months of follow-up (P = 0.22) between the two groups. Poor GCS, previous cerebrospinal fluid infection, and postoperative meningitis were found to have significant effect on the failure-free period of the procedure. On comparing the probabilities of failure-free period of ETV v/s VPS, the chances of VPS failure are 61% lesser than ETV. CONCLUSIONS: VPS is an effective modality for the management of PTH and has a much lower failure rate as compared to ETV. However, ETV can be considered as a salvage procedure in difficult situations of recurrent shunt malfunction or infection.

Rapidly growing diffuse neurofibroma of the scalp with calvarial defect in a young woman: A rare entity.

BACKGROUND: A diffuse neurofibroma, a variant of neurofibroma, most commonly occurs in young adults and involves the head and neck. In the absence of neurofibromatosis, associated calvarial defect with these swellings is rarely seen. CASE DESCRIPTION: An 18-year-old woman presented with a history of rapidly progressive painless large swelling over the bilateral parieto-occipital region of scalp. It was soft and boggy with brownish discoloration of overlying skin. Imaging study showed brilliantly enhancing diffuse lesion involving the bilateral parieto-occipital region of scalp and extending into the extradural region. She underwent excision of lesion. Postoperatively, she developed flap necrosis and it was allowed to heal with the secondary intention. The biopsy findings were consistent with neurofibroma. The patient is on regular follow-up, without any evidence of recurrence at 1 year. CONCLUSION: Rapidly growing solitary diffuse neurofibroma is rare in children and adolescents. Preoperative diagnosis may be difficult and surgical treatment needs to be individualized. These patients need regular follow-up for early detection of recurrence.

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.

Contralateral Anterior Interhemispheric Transparaterminal Gyrus Approach for Thalamopeduncular Pilocytic Astrocytoma in an Adult: Technical Report.

BACKGROUND: Thalamopeduncular gliomas arise at the junction of the thalamus and cerebral peduncle and constitute a subgroup of thalamic gliomas. These are surgically challenging lesions because of close proximity to important neural structures including corticospinal tracts (CSTs) and the thalamus. These tumors usually displace CSTs anterolaterally or extend to the lateral ventricular surface. Such tumors can be removed by either temporal or transventricular approaches. However, if CSTs cover the entire lateral surface of tumor and tumor does not extend to the ventricular surface, temporal and transventricular approaches cannot be used because the trajectories of both approaches would pass through normal eloquent structures (CSTs and thalamus), and consequently there would be a very high risk of postoperative neurologic deficits developing. CASE DESCRIPTION: A 50-year-old woman presented with contralateral hemiparesis. Radiologic evaluation revealed a right Thalamopeduncular glioma that displaced CSTs laterally and was covered by normal thalamus superiorly. Some CST fibers passed through the tumor. Because both lateral and superior surfaces were covered by eloquent structures, we used an anterior interhemispheric transparaterminal gyrus approach to access the tumor successfully and achieved subtotal excision. The patient had transient neurologic deterioration postoperatively that recovered to preoperative level within 2 weeks. CONCLUSIONS: The anterior interhemispheric transparaterminal gyrus approach has not been described previously for accessing brainstem lesions. This approach can be used to access tumors of the cerebral peduncle that displace CSTs laterally and are covered by normal thalamus superiorly. The anterior interhemispheric transparaterminal gyrus approach adds to the armamentarium of neurosurgeons for treatment of cerebral peduncular lesions.

Brahmarasayana protects against Ethyl methanesulfonate or Methyl methanesulfonate induced chromosomal aberrations in mouse bone marrow cells.

BACKGROUND: Ayurveda, the traditional Indian system of medicine has given great emphasis to the promotion of health. Rasayana is one of the eight branches of Ayurveda which refers to rejuvenant therapy. It has been reported that rasayanas have immuno-modulatory, antioxidant and antitumor functions, however, the genotoxic potential and modulation of DNA repair of many rasayanas have not been evaluated. METHODS: The present study assessed the role of Brahmarasayana (BR) on Ethyl methanesulfonate (EMS)-and Methyl methanesulfonate (MMS)-induced genotoxicity and DNA repair in in vivo mouse test system. The mice were orally fed with BR (5 g or 8 mg / day) for two months and 24 h later EMS or MMS was given intraperitoneally. The genotoxicity was analyzed by chromosomal aberrations, sperm count, and sperm abnormalities. RESULTS: The results have revealed that BR did not induce significant chromosomal aberrations when compared to that of the control animals (p >0.05). On the other hand, the frequencies of chromosomal aberrations induced by EMS (240 mg / kg body weight) or MMS (125 mg / kg body weight) were significantly higher (p<0.05) to that of the control group. The treatment of BR for 60 days and single dose of EMS or MMS on day 61, resulted in significant (p <0.05) reduction in the frequency of chromosomal aberrations in comparison to EMS or MMS treatment alone, indicating a protective effect of BR. Constitutive base excision repair capacity was also increased in BR treated animals. CONCLUSION: The effect of BR, as it relates to antioxidant activity was not evident in liver tissue however rasayana treatment was observed to increase constitutive DNA base excision repair and reduce clastogenicity. Whilst, the molecular mechanisms of such repair need further exploration, this is the first report to demonstrate these effects and provides further evidence for the role of brahmarasayana in the possible improvement of quality of life.