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.

Intraoperative Navigated Three-Dimensional Ultrasound Guidance Improves Resection in Gliomas Compared with Standard Two-Dimensional Ultrasound-Results from a Comparative Cohort Study.

OBJECTIVE: Intraoperative ultrasound is a promising tool for intraoperative tumor resection control. Navigated three-dimensional US (n3DUS) has many benefits over standard two-dimensional US (2DUS). METHODS: Two cohorts (2DUS and n3DUS) of patients with histologically confirmed adult diffuse gliomas undergoing US-guided resection control were compared. The primary outcomes assessed were extent of resection and morbidity. Multivariate analysis was performed to account for tumor characteristics (delineation and eloquence) and surgeon experience, which could confound the results. RESULTS: n3DUS was used more often (n = 252) than 2DUS (n = 86). Tumor delineation was similar in 2DUS and n3DUS cohorts, although the n3DUS cohort included more nonenhancing, histologically lower grade (2-3) gliomas and had more gliomas located in eloquent regions; also, n3DUS was more often used by senior surgeons. Gross total resection (GTR) rates were 47%, and major morbidity was 9.5%. On multivariate analysis, after controlling for all other variables between the 2 groups, patients with well-delineated tumors, patients with prior treatment, and patients who underwent n3DUS were more likely to have GTR (adjusted odds ratios 3.0, 1.8, and 2.2, respectively), whereas patients with tumors in eloquent locations were half as likely (adjusted odds ratio 0.5) to have GTR. Eloquent located tumors were likely to be associated with higher neurological morbidity, although major morbidity was not significantly different. CONCLUSIONS: Good delineation, noneloquent location, and use of n3DUS was associated with a higher probability of GTR in glioma surgery. Surgeons' experience did not influence the extent of resection. Morbidity was predominantly associated with eloquent location, independent of all other factors.

Partial hypoglossal-facial neurorrhaphy: a surgical technique.

This is a video demonstration of hemihypoglossal-facial neurorrhaphy. Any irreversible facial palsy more than House-Brackmann grade II is aesthetically problematic. Also, the functional and psychological impact associated with a higher grade of facial palsy is even worse. In this video, the procedure is demonstrated in a female patient with irreversible grade VI facial palsy and corneal opacity due to exposure keratitis 1 year following surgical excision of cerebellopontine angle (CPA) schwannoma. Postoperative outcomes are shown in another patient who underwent a similar procedure for establishing outcomes. The nasolabial fold and eye closure symmetry can be achieved with minimal or no hypoglossal morbidity. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID2290.

Effect of Position Specific Physiotherapy Training on performance of Indian football players: A Randomized Control Trial.

This study evaluated the effect of Position-Specific Physiotherapy Training on Agility, Speed endurance, and Balance in Indian Football Players. Around 70 football players were approached of which 48 gave consent to participate, and further 30 players sufficing inclusion criteria were recruited. They were divided into three groups, Forwards (Group A, n = 10), Defenders (Group B, n = 10), and Control (Group C, n = 10), according to their On-field Position. These participants underwent Position Specific Physiotherapy Training for 4 weeks. Significant improvement was noted in the Agility of Group A (p ≤ 0.001) and Group B (p ≤ 0.001) as compared to Group C (p = 0.071). Speed Endurance improved for Group A (p ≤0.001) and Group B (p ≤ 0.001) as compared to Group C (p = 0.111). Fatigue Index of Group A (p ≤ 0.001) and Group B (p ≤ 0.001) improved significantly as compared to Group C (p = 0.383). The Balance of Group A (p = 0.0063) and Group B (p = 0.0019) improved significantly as compared to Group C (p = 0.0632). Position-Specific Physiotherapy Training was found to be effective in improving Agility, Speed endurance, and Balance ability of the Indian Football Players.

Gamma Knife Radiosurgery for Large Vestibular Schwannoma More Than 10 cm 3 : A Single-Center Indian Study.

Introduction Gamma Knife radiosurgery (GKRS) is an effective treatment for benign vestibular schwannomas (VSs). The established cutoffs have recently been challenged, as recent literature expanded the horizon of GKRS to larger tumors. Even though microsurgery remains the primary option for large VS, GKRS can provide reasonable tumor control and is more likely to avoid cranial neuropathies associated with open surgery. Methods We analyzed patients with VS with volume exceeding 10 cm 3 who underwent GKRS at our center from January 2006 to December 2016. Clinicoradiological and radiosurgical data were collected from medical records for statistical analysis. Follow-up was performed every 6 months with a clinical assessment along with magnetic resonance imaging (MRI) of the brain and audiometric evaluation in patients with serviceable hearing. Results The study included 34 patients (18 males and 16 females) with an average age of 45.5 years. The mean tumor volume was 10.9 cm 3 (standard deviation [SD], ± 0.83), with a median tumor dose of 12 Gy (interquartile range, 11.5-12) and a mean follow-up of 34.7 months (SD, ± 23.8). Tumor response was graded as regression in 50%, stable in 44.1%, and increase or GKRS failure in 2 cases (5.8%). Treatment failure was noted in five cases (14.7%), requiring microsurgical excision and a ventriculoperitoneal shunt post-GKRS. The tumor control rate for the cohort is 85.3%, with a facial preservation rate of 96% (24/25) and hearing loss in all (5/5), while three patients developed new-onset hypoesthesia. We noted that gait ataxia and involvement of cranial nerve V or VII at initial presentation were associated with GKRS failure in univariate analysis. Conclusion Microsurgery should remain the first-choice treatment option for large VSs. GKRS is a viable alternative with good tumor control and improved or stabilized cranial neuropathies with a low complication rate.

Pattern of use of intraoperative ultrasound in surgery for brain tumors influences outcomes in glial tumors.

BACKGROUND: Intraoperative ultrasound (iUS) imaging has emerged as a promising adjunct in glioma surgery with both, 2-dimensional (2D) as well as navigated 3-dimensional (n3D), modes increasingly being used. METHODS: We analyzed our decade-long experience of 1075 brain tumor (807, 75% gliomas) cases operated using iUS. A retrospective chart and electronic records review was performed. The primary aim was to understand the patterns of use of iUS mode and its purpose of application (as a localizing tool or as a resection control modality) as well as to evaluate its impact on the extent of resection. RESULTS: The use of iUS increased over time, especially with the introduction of n3DUS though 2DUS remained the more commonly used mode (63%) overall during this period. For biopsies (156 cases), both 2D, as well as n3D iUS, were used as a localizing tool only. Lesion localization was the major purpose for use of iUS even for tumor resections (61%). Resection control was performed more often for gliomas (46.5% compared to 16.5% in non-glial tumors). n3DUS was the preferred modality as a resection control tool irrespective of histological class. GTR (gross total resection) was achieved in 53.1% cases overall, while in glial and non-glial tumors it was 44.7% and 80.7%, respectively. GTR was higher when iUS was used as a resection control modality. The US and MR defined EOR (extent of resection) showed substantial agreement (κ = 0.678) with high diagnostic accuracy of 84% for glial tumors. In glial tumors, iUS was used more often in eloquent tumors and GTR rates were slightly higher than when iUS was not used. CONCLUSION: iUS is a versatile tool and is a useful surgical adjunct for glioma surgeons. Besides its proven benefit as a localizing tool, when used as a tool for resection control it improves the resection rates. n3DUS may offer benefits over 2DUS as a resection control modality, though the evidence is still evolving.

Cranial and Spinal Malignant Peripheral Nerve Sheath Tumor: A Pathological Enigma.

Objective Malignant peripheral nerve sheath tumor (MPNST) arises from nerve sheaths, mostly seen in peripheral nerves but rare in craniospinal nerves. The information available in the literature to build up treatment strategy and improve clinical outcomes is scarce. We are reviewing cases from our institute, with emphasis on radiological features for early differentiation from its benign variants. Methods We analyzed pathologically diagnosed cases retrospectively from January 2007 to December 2018 at our institute. Clinicoradiological details and treatment parameters were collected from medical records for evaluation. Each case was contacted telephonically for final clinical follow-up at the time of writing the manuscript. Results A total of seven cases of MPNST were diagnosed in the last 10 years. It included four intracranial and three spinal cases. The mean age for the cohort was 34.3 years, with five females. We could achieve gross total resection (GTR) and subtotal resection in four (57.1%) and two (28.6%) cases, respectively. We could achieve an overall survival of 57.1% in the average follow-up of 28.2 months (range: 8-84 months). Conclusion MPNST is a rare tumor with a bad prognosis. Radical surgical resection is the mainstay of the treatment, but it is not always possible to achieve it because of the inaccessible location and large size of lesions. Preoperative diagnosis is challenging; however, few radiological findings may give a clue toward it. As a disease entity overall, it has a poor outcome with a high rate of fatality.

What Happens after Therapy? Quality of Life and Neurocognitive Functions of Children with Malignant Posterior Fossa Tumors after Adjuvant Therapy.

PURPOSE: The health-related quality of life (HRQoL) is an important endpoint in modern clinical practice with improved survival of pediatric posterior fossa malignant brain tumors (PFMBTs). We evaluated the effect of environmental and psychosocial milieu on QoL and cognitive functioning (CF) of Indian children with PFMBT. METHODS: In a cross-sectional study, 47 children <18 years of age with medulloblastoma or anaplastic ependymoma were evaluated ≥6 months after completion of adjuvant therapy. All clinical and socioeconomic details, educational status of child and family members, socioeconomic status, environmental factors affecting QoL were documented. Children underwent HRQoL evaluation using Pediatric quality of life Inventory (PedsQL) questionnaire and neuropsychological evaluation. RESULTS: The median age of the cohort at presentation was 7 years (1-18) and median duration of evaluation after adjuvant therapy was 16 months. In 47 families, 72.34% had low monthly income and 76.6% of mothers took formal education. QoL scores were above median values. Parents reported scores highlighted that Lansky performance score (P = 0.001) and maternal education (P = 0.043) significantly influenced the cognitive component of QoL. Twenty-seven children had below-average IQ. Young age at presentation (P = 0.020), maternal education (P = 0.032), high socioeconomic status (P = 0.001) influenced the IQ score. Even though the majority of children (57.44%) had below-average IQ, they had a score of more than 50 on the cognitive functioning scale. A total of 72.5% of the eligible children in our cohort went back to school following therapy, though often with a delay of one academic year. CONCLUSIONS: Overall cognitive functioning scores of these children are good, but they are not representative of actual neurocognitive tasks based performance or IQ scores. Children should remain under regular follow-up with a neurocognitive assessment and psychological counseling at regular intervals.

Removal of Perirolandic Cavernoma with Direct Cortical Stimulation and Neuronavigation with DTI.

BACKGROUND AND INTRODUCTION: Intraoperative neuromonitoring for eloquent cortical lesions is irreplaceable in present-day neurosurgery. OBJECTIVE: We report a novel technique of combining awake craniotomy with direct cortical stimulation of the motor cortex using the NIM© nerve monitoring system. TECHNIQUE: A 17-year-old boy presenting with focal motor seizures, diagnosed with left perirolandinc cavernoma, underwent awake craniotomy and complete excision under direct cortical stimulation with NIM monopolar stimulator electrode to locate the motor cortex. RESULT: The patient developed transient weakness of handgrip during surgery, which improved by the same day evening. At 3 months follow-up, he could perform all the activities with his dominant right hand. CONCLUSION: Cortical stimulation using a nerve monitoring system is a useful technique in case of nonavailability of standard evoked potential monitoring system for motor cortex mapping.

Navigated ultrasound-based image guidance during resection of gliomas: practical utility in intraoperative decision-making and outcomes.

OBJECTIVE: Intraoperative imaging is increasingly being used for resection control in diffuse gliomas, in which the extent of resection (EOR) is important. Intraoperative ultrasound (iUS) has emerged as a highly effective tool in this context. Navigated ultrasound (NUS) combines the benefits of real-time imaging with the benefits of navigation guidance. In this study, the authors investigated the use of NUS as an intraoperative adjunct for resection control in gliomas. METHODS: The authors retrospectively analyzed 210 glioma patients who underwent surgery using NUS at their center. The analysis included intraoperative decision-making, diagnostic accuracy, and operative outcomes, particularly EOR and related factors influencing this. RESULTS: US-defined gross-total resection (GTR) was achieved in 57.6% of patients. Intermediate resection control scans were evaluable in 115 instances. These prompted a change in the operative decision in 42.5% of cases (the majority being further resection of unanticipated residual tumor). Eventual MRI-defined GTR rates were similar (58.6%), although the concordance between US and MRI was 81% (170/210 cases). There were 21 false positives and 19 false negatives with NUS, resulting in a sensitivity of 78%, specificity of 83%, positive predictive value of 77%, and negative predictive value of 84%. A large proportion of patients (13/19 patients, 68%) with false-negative results eventually had near-total resections. Tumor resectability, delineation, enhancement pattern, eloquent location, and US image resolution significantly influenced the GTR rate, though only resectability and eloquent location were significant on multivariate analysis. CONCLUSIONS: NUS is a useful intraoperative adjunct for resection control in gliomas, detecting unanticipated tumor residues and positively influencing the course of the resection, eventually leading to higher resection rates. Nevertheless, resection is determined by the innate resectability of the tumor and its relationship to eloquent location, reinforcing the need to combine iUS with functional mapping techniques to optimize resections.

Real-Time 2D Ultrasound Guided Frameless Biopsy of a Multifocal Glioma: Improving Accuracy and Diagnostic Yield.

BACKGROUND AND INTRODUCTION: Intraoperative ultrasound imaging can be a multi-dimensional tool with various applications, including localization, resection control, and biopsy of brain tumors. OBJECTIVE: We demonstrate a frameless biopsy technique by using real-time 2D ultrasound (RT-2DUS) for localizing and guiding the biopsy of cranial tumors. TECHNIQUE: A 60-year-old male presented with progressive right hemiparesis, memory, and behavioral disturbances. MRI brain showed a multifocal lesion in the left temporal, parietal, and occipital lobes with extension into the splenium. He underwent left parietal mini-craniotomy with frameless RT-2DUS-guided biopsy. RESULT: Postoperative US scan showed a small biopsy site hematoma. Histopathology confirmed it to be IDH-negative primary glioblastoma. For multifocal glioma, the patient underwent adjuvant WBRT with concurrent and adjuvant temozolomide. CONCLUSION: RT-2DUS improves the sampling accuracy of the tumor by detecting the solid component of the lesion intraoperatively. In addition, the detection of operative site hematoma can be picked up immediately, avoiding post-procedure imaging.

The Yield of Repeat Angiography in Angiography-Negative Spontaneous Subarachnoid Hemorrhage.

Objective Despite the technological advancement in imaging, digital subtraction angiography (DSA) remains gold standard imaging modality for spontaneous subarachnoid hemorrhage (SAH). But even after DSA, around 15% of SAH remains elusive for the cause of the bleed. This is an institutional review to solve the mystery, "when is second DSA really indicated?" Methods In a retrospective review from January 2015 to December 2017, we evaluated cases of spontaneous SAH with initial negative DSA with repeat DSA after 6 weeks to rule out vascular abnormality. The spontaneous SAH was confirmed on noncontrast computed tomography (NCCT) and divided into two groups of perimesencephalic SAH (PM-SAH) or nonperimesencephalic SAH (nPM-SAH). The outcome was assessed by a modified Rankin's score (mRS) at 6 months postictus. Results During the study period, we had 119 cases of initial negative DSA and 98 cases (82.3%) underwent repeat DSA after 6 weeks interval. A total of 53 cases (54.1%) had PM-SAH and 45 cases (45.9%) had nPM-SAH. Repeat DSA after 6 weeks showed no vascular abnormality in 53 cases of PM-SAH and in 2 (4.4%) out of 45 cases of nPM-SAH. At 6 months postictus, all cases of PM-SAH and 93% of nPM-SAH had mRS of 0. Conclusion We recommend, a repeat DSA is definitely not required in PM-SAH, but it should be done for all cases of nPM-SAH, before labeling them as nonaneurysmal SAH. Although the overall outcome for nonaneurysmal spontaneous SAH is better than aneurysmal SAH, nPM-SAH has poorer eventual outcome compared to PM-SAH.

Navigated intraoperative ultrasonography for brain tumors: a pictorial essay on the technique, its utility, and its benefits in neuro-oncology.

Intraoperative imaging has become one of the most important adjuncts in neurosurgery, especially in the surgical treatment of intra-axial tumors. Navigation and intraoperative magnetic resonance imaging have limitations, and intraoperative ultrasonography (IOUS) has emerged as a versatile and multifaceted alternative. With technological advances in ultrasound scanners and newer multifunctional probes, the potential of IOUS is increasingly being utilized in the resection of tumors. The addition of image guidance to IOUS has exponentially increased the power of this technique. Navigated ultrasonography (nUS) can now overcome many of the limitations of conventional standalone two-dimensional ultrasonography. In this pictorial essay, we outline our nUS technique (both two- and three-dimensional) for the resection of intra-axial tumors with illustrated examples highlighting the various steps and corresponding benefits of the technique.

Surgical outcomes in traumatic brain injuries with bilateral mass occupying lesions. Analysis of prognostic factors.

INTRODUCTION: Traumatic brain injury is a silent epidemic with major impacts on national productivity as it affects the economically productive age group. Bilateral injuries are usually severe with no clearly defined predictors of outcome as per current available literature. METHODS: We retrospectively assessed 102 consecutive cases of post traumatic intracranial mass lesions operated bilaterally, either simultaneously or sequentially, between January 2011 and April 2019. The primary and secondary end points of the study were to assess mortality and GCS at discharge respectively. RESULTS: The cohort included 102 patients. 91(89.2 %) were males, mean age was 40(±13.6) years. Median GCS at presentation was 9 with 47(46.07 %) having moderate head injury. EDH with contusion was seen in 38(37.3 %), SDH with contusion in 24(23.5 %) and 4 patients (3.9 %) had EDH, SDH and contusion. On univariate analysis, female gender(p = 0.001), poor GCS at presentation(p < 0.001), higher Rotterdam grade on initial CT scan(p < 0.001), need for blood transfusions(p = 0.026) and intraoperative hypotension(p = 0.007) were associated with significantly higher mortality. On multivariate analysis female gender(p = 0.034), poor GCS(p = 0.026) and worse Rotterdam score(p = 0.038) were associated with mortality. Among the subgroup of survivors, GCS at presentation(p < 0.001), Rotterdam grading(p = 0.003), time to surgery after trauma(p = 0.032), duration of hospital stay(<0.001), intraoperative brain bulge(p=.003) and craniotomy instead of craniectomy(p = 0.001) were associated with clinical outcome at discharge. CONCLUSION: Traumatic brain injuries with bilateral mass lesions requiring surgery have been rarely reported. In this study we have elucidated management strategies and have further studied the factors influencing mortality and clinical outcome. Careful considerations are required in decision making in such cases. Larger multicentric studies would throw more light on outcomes of this rare variety of traumatic brain injury.

Role of repeat CT in mild to moderate head injury: an institutional study.

OBJECTIVE: Patients with traumatic brain injury (TBI) often undergo repeat head CT scans to identify the possible progression of injury. The objective of this study is to evaluate the need for routine repeat head CT scans in patients with mild to moderate head injury and an initial positive abnormal CT scan. METHODS: This is a retrospective study of patients presenting to the emergency department from January 2016 to December 2017 with Glasgow Coma Scale (GCS) scores > 8 and an initial abnormal CT scan, who underwent repeat CT during their in-hospital medical management. Patients who underwent surgery after the first CT scan, had a GCS score < 9, or had a normal initial CT scan were excluded. Demographic, medical history, and physical examination details were collected, and CT scans were reviewed. Radiological deterioration, neurological deterioration, and/or the need for neurosurgical intervention were the primary outcome variables. RESULTS: A total of 1033 patients were included in this study. These patients underwent at least two CT scans on an inpatient basis. Of these 1033 patients, 54.1% had mild head injury and 45.9% had moderate head injury based on GCS score at admission. The most common diagnosis was contusion (43.8%), followed by extradural hematoma (28.8%) and subdural hematoma (26.6%). A total of 2636 CT scans were performed for 1033 patients, with a mean of 2.55 per patient. Of these, 25 (2.4%) had neurological deterioration, 90 (8.7%) had a progression of an existing lesion or appearance of a new lesion on repeat CT, and 101 (9.8%) required neurosurgical intervention. Seventy-five patients underwent surgery due to worsening of repeat CT without neurological deterioration, so the average number of repeat CT scans required to identify one such patient was 21.3. On multiple logistic regression, GCS score at admission (p = 0.024), abnormal international normalized ratio (INR; p < 0.001), midline shift (p = 0.005), effaced basal cisterns (p < 0.001), and multiple hemorrhagic lesions (p = 0.010) were associated with worsening of repeat CT, neurological deterioration, and/or need for neurosurgical intervention. CONCLUSIONS: The role of routine repeat head CT in medically managed patients with head injury is controversial. The authors have tried to study the various factors that are associated with neurological deterioration, radiological deterioration, and/or need for neurosurgical intervention. In this study the authors found lower GCS score at admission, abnormal INR, presence of midline shift, effaced basal cisterns, and multiple lesions on initial CT to be significantly associated with the above outcomes.

Effect of Gamma Knife Radiosurgery on Vestibular Schwannoma with Serviceable Hearing: A Single-Center Indian Study.

OBJECTIVE: Gamma Knife radiosurgery (GKRS) is an established treatment modality for vestibular schwannomas (VSs). The tumor control and hearing preservation rates suggest that GKRS is a good alternative treatment for small- and medium-size VS. Data are lacking from India regarding GKRS for VSs. Our aim was to find the hearing preservation and tumor control rates and the factors contributing to these. METHODS: In a retrospective 9-year study period, 87 patients had undergone GKRS for unilateral VS with Gardner-Robertson (GR) class I or II serviceable hearing. All 87 had been evaluated with magnetic resonance imaging and audiometry before GKRS and during follow-up to assess for the factors influencing tumor control and hearing preservation. RESULTS: Of the 87 patients, 77 with a minimum follow-up of 2 years and magnetic resonance imaging and audiometry evaluations available were included in the present study. The median follow-up period was 30 months. The tumor control rate and hearing preservation rate was 96.1% and 79.2%, respectively. Hearing preservation was not affected by the tumor volume. However, age >40 years, pre-GKRS pure tone average <30 decibels, speech discrimination score >85%, pre-GKRS Gardner-Robertson grade I hearing, mean cochlear dose <4 Gy, and pre-GKRS Ohata class of laterality C, D, E were significant on univariate analysis. The multivariate analysis revealed that age >40 years (P = 0.017), pre-GKRS pure tone average <30 decibels (P = 0.002), and Gardner-Robertson class I (P = 0.001) were significant factors. No patient developed cranial nerve dysfunction, hydrocephalus, or malignant degeneration. CONCLUSION: For most patients with small VSs, GKRS will be an effective alternative treatment to microsurgery with retained serviceable hearing and good tumor control.

Physiotherapy practices in Intensive Care Units across Maharashtra.

PURPOSE: To find out the current physiotherapy practices in Intensive Care Unit (ICU) across Maharashtra. MATERIALS AND METHODS: Study design was exploratory cross-sectional survey. Questionnaires were sent to the physiotherapists working in hospitals across Maharashtra state, India. Four weeks for completion of questionnaire was given in an attempt to ensure good response rates. RESULT: Of 200, 73 questionnaires were received representing a 36% response rate. The study revealed that 76% of the respondents were bachelors qualified, 15% were masters in physiotherapy with only 4% specialized in cardio-respiratory physiotherapy; 82% had <5 years experience in ICU. Almost 19% had not at all attended any seminars/workshops related to ICU management while 61% attended up to three within last 2 years. The availability of a physiotherapist during the night was affirmed by 63%, 58% responded initiation of physiotherapy to be "always physician referred" and 39% mentioned "physiotherapist initiated." Almost 80% performed chest wall techniques, 86% positioning, 27% postural drainage, 5% manual hyperinflation, 12% application of nebulizer, and 56% bedsores management. Only 5% reported involvement in ventilator setting, 11% had their opinion sought before weaning from ventilator, 29% practiced noninvasive ventilation, 11% were involved in decision-making for extubation and 44% reported involvement in patient family education. CONCLUSION: The study showed that physiotherapists among the responding ICUs surveyed lack in experience and updated knowledge. Physician reference is necessary to initiate physiotherapy and there exists no established criteria for physiotherapy treatment in ICU. All physiotherapists were routinely involved in chest physiotherapy, mobilization, and positioning.