Krause approach to pineal tumour with intraoperative oculomotor nerve monitoring.

Background: The supra-cerebellar infratentorial approach to pineal region tumours is versatile and safe corridor to lesions located below the deep veins. Monitoring of the extra-ocular muscle pathways using the evoked compound muscle action potential can lead to safer resections. Technical note: To describe the use of electrooculography and a three handed retractor less method for pineal region tumour surgeries. Material and methods: Intraoperative electrooculography uses recording done from two channels (horizontal and vertical)by inserting disposable subdermal needle electrodes along the periorbital area. The oculomotor nerve is being monitored as it exits the midbrain. Retractor-less three-handed-technique allows for minimal handling of the cerebellum while maximizing the operative corridor. Result: The oculomotor nerve was stimulated post resection and correspondingly led to improved symptoms post-operatively. Discussion and conclusion: We demonstrate a method for the intraoperative monitoring of the continuity of the oculomotor tracts and a three handed retractor-less method of resection of pineal region tumours. The placement of electrodes and area of stimulation need sound knowledge of anatomy of the region. Haemostasis at every step is absolutely essential to be able to visualize in the narrow corridor.

Validity of Glasgow outcome scale-extended (GOSE) mobile application for assessment of outcome in traumatic brain injury patients.

PURPOSE: To develop the Glasgow Outcome Scale-Extended (GOSE) mobile application and examine the validity of the application against GOSE scoring based on traditional interview method. METHODS: Concurrent validity was determined by comparing two independent raters' scoring for GOSE of 102 patients with traumatic brain injury, who had attended outpatient department of a tertiary neuro hospital. Agreement was assessed between the traditional interview-based pen and paper scoring and algorithm based mobile application scoring of GOSE. RESULTS: Agreement was tested using Cohen's kappa, and the analysis revealed near perfect agreement between two raters (0.89) (p < 0.01). CONCLUSION: The GOSE mobile application can measure GOSE Score similar to the traditional interview method. This application may help fasten the process of assessing outcome in TBI patients in clinical practice and in research.

The Use of Retraction Sutures in End-To-Side Microvascular Anastomosis-A Novel Technical Innovation in Experimental Rat Femoral Model with Successful Use in STA-MCA Bypass in Moyamoya Disease.

BACKGROUND: A narrow working space, small diameters, and the tendency to collapse with clamps make cerebral microvascular anastomosis challenging. A retraction suture (RS) is a novel technique to keep the recipient vessel lumen open during the bypass. OBJECTIVE: To provide a step-by-step overview of RS for end-to-side (ES) microvascular anastomosis on rat femoral vessels and successful use for superficial temporal artery to middle cerebral artery (STA-MCA) bypass in Moyamoya disease patients. METHODS: A prospective experimental study with approval from the Institutional Animal Ethics Committee. Femoral vessels ES anastomoses were performed on Sprague Daley rats. The rat model used 3 types of RS (adventitial, luminal, and flap RSs). An ES-interrupted anastomosis was done. The rats were observed for an average period of 16.18 ± 5.65 days; the patency was assessed by reexploration. The immediate patency on the STA-MCA bypasses was confirmed with intraoperative indocyanine green angiography and micro-Doppler; delayed patency with magnetic resonance imaging and digital subtraction angiography after 3-6 months. RESULTS: In the rat model, 45 anastomoses were performed, 15 each using the 3 subtypes. The immediate patency was 100%. Delayed patency was 42/43 (97.67%), and 2 rats died during observation. In the clinical series, 59 STA-MCA bypasses were done in 44 patients (average age, 18.14 ± 11.09 years) using RS. The follow-up imaging was available for 41/59 patients. Both immediate patency and delayed patency (41/41 at 6 months) were 100%. CONCLUSION: The RS allows continuous visualization of the vessel lumen, reduces the handling of intimal edges, and avoids incorporating the back wall in sutures, thus improving anastomosis patency.

Prediction of Surgical Outcome for Acute Traumatic Brain Injury in Older Adults.

Background: Increasing patient age is strongly associated with a rising incidence of traumatic brain injury (TBI) and a higher mortality and morbidity rates. Objective: This study aimed to identify the predictors of mortality after craniotomy for TBI in elderly patients. Material and Methods: Data of all patients aged ≥65 years who underwent craniotomy for acute TBI, over a period from January 2015 to October 2019, were retrospectively reviewed. The standard clinical and imaging variables for TBI were recorded. The medical comorbidities, indication for surgery, and intraoperative complications were also recorded. The outcome of interest was survival at 6 months after surgery. Results and Conclusions: A total of 206 patients were available for analysis. The age of patients ranged from 65 to 80 years. The most frequent surgical procedure performed was craniotomy and evacuation of supratentorial subdural hematoma with or without evacuation of the traumatic parenchymal lesion. The in-hospital mortality was 46 out of 206 (22.3%), and 6 months mortality was 116 out of 206 (56.3%). Among the survivors at 6 months, good recovery was seen in 70.5%, moderate disability in 19.8%, and severe disability in 8.6% patients. Only 1.2% patients survived in a vegetative state at 6 months. The odds of death are nearly three times more for patients with dilated and nonreactive pupillary reaction. The odds of death are less by 72% for a unit increase in motor score. In older adults, the main determinants of survival after surgery for TBI are pupillary reaction and motor score.

Intraventricular Craniopharyngiomas-Overcoming Their Relative Inaccessibility: Institutional Experience With a Review of Literature.

Introduction: Craniopharyngiomas constitute 2-4% of intracranial neoplasms. Intraventricular craniopharyngiomas (IVCrs) are the rarely encountered varieties of these lesions. Objective: The objective of the study was to study the special features in clinical presentation, imaging, management, and surgical outcome of IVCrs. Materials and Methods: This retrospective analysis included the combined experience from two tertiary care institutions. Medical records of histopathologically proven cases of IVCrs from January 1994 to June 2021 were assessed, and images were analyzed based on the criteria by Migliore et al. for inclusion of solely intraventricular lesion with the third ventricular ependyma demarcating it from the suprasellar cistern. Results: Among the 25 patients included (mean age: 35.4 years), the most common presentation included headache (n = 21, 84%), vomiting and other features of raised ICP (n = 18, 72%), visual complaints (n = 12, 48%), and endocrinopathies (n = 11, 44%). Fifteen had predominantly cystic tumors, two were purely solid, and eight were of mixed consistency. Primary open microsurgical procedures were performed in 18 (72%) patients, of which four (16%) were endoscope-assisted. Seven (28%) underwent a purely endoscopic procedure. One underwent a staged surgery with endoscopic cyst fenestration and intracystic interferon (IFN)-alpha therapy, followed by microsurgical excision. Complete excision was achieved in 10 patients, near-total in nine, and partial excision in six. Four patients underwent a ventriculoperitoneal shunt (one before the definitive procedure). At a median follow-up of 36 months (range:11-147 months), five patients developed a recurrence, and one had a stable small residue. This patient and two others with small cystic recurrences were observed. One patient was managed with radiotherapy alone. Another underwent re-surgery after a trial of radiotherapy, and the last patient developed a local recurrence, which was managed with radiotherapy; he then later developed an intraparenchymal recurrence, which was operated. Conclusion: Purely IVCrs present with raised intracranial pressure, and visual disturbances are less common. Their deep-seated location and limited surgical field-of-view makes minimally invasive endoscopic-assisted surgery most suitable for their excision. The thin-walled cystic lesions may be occasionally adherent to the ependymal wall in close vicinity to the thalamus-hypothalamus complex, making complete excision difficult. Their responsiveness to radiotherapy, often leads to a gratifying long-term outcome.

Surgical outcomes of Supra- Infra Tentorial Extradural Hematoma (SIEDH): A retrospective study from a single institution.

INTRODUCTION: Bicompartmental Supra plus Infratentorial Extra Dural Hematoma (SIEDH) is an uncommon yet important category of Extradural Hematoma (EDH) straddling the transverse sinus. It requires quick decision making and proper surgical evacuation. METHODS: We did a retrospective chart review of all SIEDH cases from prospectively maintained operative database in our institute between 2011 & 2017. Clinical status at discharge and follow up were used to assess outcome. Ordinal regression analysis was used for analysis of factors predicting the outcome. We also describe the surgical procedure we follow at our high-volume trauma center for this unique entity. RESULTS: We had 61 operated cases of SIEDH in our series. The median age of the cohort was 30 years (IQR: 21.5-42). Road Traffic Accident was the most common mode of injury (67.2 %). Median pre-operative GCS was 12 (IQR: 9-12). The median volume of SIEDH was 50cc (IQR: 40-70). Mass effect on 4thventricle and brainstem was seen in 47 and 34 patients respectively. An associated fracture was seen in 54 patients. Sinus injury related bleed was noted intra-operatively in 57 % (N = 35). Follow up was available for 60 cases with a median of 130 days. On evaluating with ordinal regression analysis, we found that, the GCS at presentation, pupillary asymmetry, volume of SIEDH, infratentorial volume, blood loss and mass effect on 4thventricle were statistically significant factors affecting GCS at discharge. However, the GCS at presentation, infratentorial volume and blood loss were the only factors determining GOS at follow-up. CONCLUSION: SIEDH are uncommon yet important type of injury type which requires prompt attention and appropriate nuanced approach. Large SIEDH are commonly associated with sinus injury, and large volume blood loss may be anticipated. In addition, SIEDH may be associated with other traumatic brain injuries which may require surgical evacuation.

Symptomatic Post-Radiosurgery Intratumoral Hemorrhage in a Case of Vestibular Schwannoma: A Case Report and Review of the Literature.

Gamma knife radiosurgery (GKRS) is considered an established treatment for vestibular schwannoma (VS) in selected patients. Spontaneous intratumoral hemorrhage in VS after GKRS is very rare. In this report, we present a 63-year-old gentleman who had right-side severe sensorineural hearing loss on MRI showing a right cerebellopontine angle tumor (volume 4.96 cm3) with an internal acoustic meatus extension. He underwent GKRS with the prescription dose of 12 Gy to the 50% isodose line, covering 4.66 cm3 (i.e., 94%) of the tumor. Ten days later, he experienced a symptomatic intra-lesional hemorrhage with a mass effect over the brainstem. When symptoms did not resolve after an initial conservative approach, he underwent surgical decompression of the lesion. Postoperatively, the patient had facial palsy but was free of disabling vertigo and ataxia. At the 6-month follow-up, he was doing well without any other complaints. Although rare, an intralesional bleed can occur after GKRS in VS and should be suspected when new severe symptoms develop immediately after therapy.

Arterioenteric Fistulae Due to Pseudoaneurysms of the Right Common Iliac and Splanchnic Vessels Presenting as Upper GI Bleed.

Arterial pseudoaneurysms are relatively rare complications of the vascular system. Many cases may remain asymptomatic for a lifetime only to be discovered incidentally, whereas others may cause fatal hemorrhage. Majority of cases present with local compressive symptoms. Rarely, it has been implicated as an etiology for gastrointestinal (GI) bleed by eroding into an adjacent bowel, with splanchnic pseudoaneurysm being more commonly responsible as compared to peripheral ones. Although rare, they are an important consideration because of the high mortality rate. They require a high index of suspicion with prompt diagnosis and expedient treatment, either surgical or endovascular. In this study, we report a case series of a right iliacoduodenal and 2 splanchnic pseudoaneurysms presenting as upper GI bleeding. These 3 cases presented with occult source of hematemesis due to the formation of arterioenteric fistula. Also discussed are the diagnostic approach used and successful treatment methods, which included placing endoprosthesis in the aorta and common iliac artery and endovascular coiling for respective cases. To the best of our knowledge, such a case of common iliac pseudoaneurysm presenting with massive hematemesis due to fistulization into duodenum has never been reported previously.