bluuebunny/crossref_metadata_2025 huggingface dataset:
SRS for Cavernous Malformations
Authors: Gavin Cormac G , Radatz Matthias W R
Published: August 2023

The optimal management of cavernous malformations (CMs) remains controversial. Over the past decade, stereotactic radiosurgery (SRS) has gained wider acceptance in the management of CMs, especially in those with deep location, eloquence, and where surgery is of high risk. Unlike arteriovenous malformations (AVMs), there is no imaging surrogate endpoint to confirm CM obliteration. Clinical response to SRS can only be gauged by a reduction in long-term CM hemorrhage rates. There is concern that the long-term benefits of SRS and the reduced rehemorrhage rate after a latency period of 2 years may only be a reflection of natural history. Of further concern is the development of adverse radiation effects (AREs), which were significant in the early experimental studies. The lessons learnt from that era have led to the progressive development of well-defined, lower marginal dose treatment protocols that have reported less toxicity (5%–7%) and consequently reduced morbidity. Currently, there is at least Class II, Level B evidence for use of SRS in solitary CMs with previous symptomatic hemorrhage in eloquent areas with high surgical risk. Recent prospective cohort studies observing untreated brainstem and thalamic CMs report significantly higher hemorrhage rates and neurological sequelae than the rates reported from contemporary pooled large natural history meta-analyses. Furthermore, this strengthens our recommendation for early proactive SRS in symptomatic deep-seated CMs due to the higher morbidity associated with observation and microsurgery. The key to successful outcomes for any surgical intervention is patient selection. We hope that our precis on contemporary SRS techniques in the management of CMs will assist this process.
Role of Stereotactic Radiosurgery in Skull Base Paragangliomas – A Narrative Review
Authors: Garg Kanwaljeet , Singh Manmohan
Published: August 2023

Skull base paragangliomas, also known as glomus tumors, are grouped as glomus jugulare or glomus tympanicum. Paragangliomas are rare tumors, with an estimated incidence of 1 case per million persons. They occur more commonly in females and are more common in the fifth or sixth decade of life. Management of these tumors traditionally involved surgical excision. However, surgical excision can result in high complication rates, particularly cranial nerve palsies. Stereotactic radiosurgery has been shown to yield tumor control rates of more than 90%. A recent meta-analysis reported improvement in neurological status in 48.7% of cases, while it stabilized in 39.3% of patients. Transient deficits such as headache, nausea, vomiting, and hemifacial spasm developed following SRS in 5.8% of patients, while 2.1% of patients developed permanent deficits. There is no difference in the rate of tumor control between different radiosurgery techniques. Dose-fractionated SRS can be used for large tumors to decrease the risk of radiation-induced complications.
Volume Fractionation Stereotactic Radiosurgery for Large Volume Intracranial Arteriovenous Malformations
Authors: Garg Kanwaljeet , Singh Manmohan
Published: August 2023

Arteriovenous malformations (AVMs) are common intracranial vascular anomalies. Common treatment modalities used to manage AVMs are surgical excision, embolization, and stereotactic radiosurgery (SRS). Large AVMs are defined as AVMs larger than 10 cm3 and pose a therapeutic challenge with high rates of treatment-related morbidity and mortality. Single-stage SRS is a good option for small AVMs but carries high risks of radiation-induced complications in large AVMs. Volume-staged SRS (VS-SRS) is a newer strategy used in large AVMs that allows one to deliver an optimal radiation dose to the AVMs while reducing the risk of radiation damage to the normal brain. It involves the division of AVM into multiple small sectors which are irradiated at different time intervals with high radiation doses. Good obliteration rates with less risk of radiation-induced complications have been described in the literature with VS-SRS.
Radiological Parameters for Gamma Knife Radiosurgery
Authors: Ahuja Chirag K. , Vyas Sameer , Jani Parth , Singh Paramjeet , Mohindra Sandeep , Kumar Narendra , Tripathi Manjul
Published: August 2023

Accurate lesion targeting is the essence of stereotactic radiosurgery. With the currently available imaging modalities, scanning has become quick and robust providing a high degree of spatial resolution resulting in optimal contrast between normal and abnormal tissues. Magnetic resonance imaging (MRI) forms the backbone of Leksell radiosurgery. It produces images with excellent soft tissue details highlighting the target and surrounding “at-risk” structures conspicuously. However, one must be aware of the MRI distortions that may arise during treatment. Computed tomography (CT) has quick acquisition times giving excellent bony information but inferior soft tissue details. To avail benefits of both these modalities and overcome their individual fallacies and shortcomings, they are often co-registered/fused for stereotactic guidance. Vascular lesions like an arteriovenous malformation (AVM) are best planned with cerebral digital subtraction angiography (DSA) in conjunction with MRI. In specific cases, specialized imaging methods like magnetic resonance (MR) spectroscopy, positron emission tomography (PET), magneto-encephalography (MEG), etc., may be added to the treatment planning for stereotactic radiosurgery (SRS).
Adaptive Staged-Dose Gamma Knife Radiosurgery for the Treatment of Large Brain Metastases
Authors: Crisà Francesco M , Leocata Filippo , Arienti Virginia M , Picano Marco , Berta Luca , Brambilla Maria G , Mainardi Hae S , Monti Angelo F , Cenzato Marco , Palazzi Mauro , La Camera Alessandro
Published: August 2023

Background:

Brain metastases are the most common brain tumors, being one of the most frequent neurological complications of systemic cancer and an important cause of morbidity and mortality. Stereotactic radiosurgery is efficacious and safe in the treatment of brain metastases, with good local control rates and low adverse effects rate. Large brain metastases present some issues in balancing local control and treatment-related toxicity.

Objective:

Demonstrating adaptive staged-dose Gamma Knife radiosurgery (ASD-GKRS) being a safe and effective treatment for large brain metastases.

Materials and Methods:

We retrospectively analyzed our series of patients treated with two-stage Gamma Knife radiosurgery for large brain metastases in [BLINDED], between February 2018 and May 2020.

Results:

Forty patients with large brain metastases underwent adaptive staged-dose Gamma Knife radiosurgery, with median prescription dose of 12 Gy and a median interval between stages of 30 days. At three-month follow-up, the survival rate was 75.0% with a local control rate of 100%. At six-month follow-up, the survival rate was 75.0% with a local control rate of 96.7%. The mean volume reduction was 21.81 cm3 (16.76–26.86; 95% CI). The difference between baseline volume and six-month follow-up volume was statistically significant.

Conclusions:

Adaptive staged-dose Gamma Knife radiosurgery is a safe, non-invasive and effective treatment for brain metastases, with a low rate of side effects. Large prospective trials are needed to strengthen data obtained about the effectiveness and safety of this technique in managing large brain metastases.
Adverse Radiation Effects Following Gamma Knife Radiosurgery
Authors: Kedia Shweta , Santhoor Hemanth , Singh Manmohan
Published: August 2023

Gamma Knife Radiosurgery (GKRS) is now an established standard of treatment for the small-sized arteriovenous malformations (AVMs), meningiomas, schwannomas, metastasis, and other benign diseases. With an exponential rise in the indications for GKRS, we have witnessed an increase in the adverse radiation effects (ARE) following GKRS. The common AREs and associated risk factors following GKRS have been described for pathologies including vestibular schwannomas, arteriovenous malformations, meningiomas, and metastases based on the authors' experience, and a simplified management protocol has been provided for radiation-induced changes based on clinical and radiologic parameters. The dose, volume, location, and repeat stereotactic radiosurgery (SRS) are implied as the risk factors for ARE. Clinically symptomatic AREs require oral steroids for weeks to alleviate symptoms. In refractory cases, bevacizumab and surgical resection can be offered as a treatment modality. Appropriate dose planning strategy and hypofractionation for larger lesions help in mitigating the AREs.
History and Evolution of Radiosurgery in India
Authors: Deora Harsh , Tripathi Manjul , Singh Varindera Paul
Published: August 2023

Stereotactic radiosurgery (SRS) has been well received by the neurosurgical community since its introduction in India. Knowledgeable radiosurgeons and visionary neurosurgeons have contributed to its success. At present, we have five functional and busy gamma knife centers, one proton radiosurgery center, and seven CyberKnife centers in India. However, there is a need for more such centers and formal training facilities, especially in the unorganized private sector. Radiosurgery has expanded its horizon from its initial indications of vascular and benign disorders to functional ailments and metastasis. Here, we take a look at the seminal points in its development in India along with the centers of excellence that contributed to the same. While we have tried to cover all the facets of its development, it is natural to miss some undocumented events not available in public domain. Nonetheless, the future of radiosurgery seems promising in India with the assurance of minimally invasive, safe, and effective treatment delivery.
Role of Stereotactic Radiosurgery for Cavernous Sinus Hemangiomas - An Individual Patient Data-Based Meta-Analysis
Authors: Mishra Sandeep , Kumar Akshay Ganesh , Garg Kanwaljeet , Phalak Manoj , Tripathi Manjul , Agrawal Deepak , Singh Manmohan , Kale Shashank Sharad
Published: August 2023

Context:

Cavernous sinus haemangiomas (CSHs) are rare vascular malformations arising from the micro-circulation of the cavernous sinus. The current treatment options are micro-surgical excision of CSH, stereotactic radiosurgery (SRS), and fractionated radiation therapy (FRT).

Aims:

We conducted a meta-analysis assessing the effect and complications of SRS in CSH and compared the pooled results after surgical excision of CSH. The aim of the study is to provide valuable insight into the role of SRS in the treatment of CSHs.

Materials and Methods:

The literature search revealed a total of 21 articles with 199 patients who met our inclusion criteria, and these were analyzed for this study.

Results:

There were 138 (69.3%) female and 61 (30.7%) male patients. The mean age at the time of radiosurgery was 48.4 ± 14.9 years. The mean tumor volume at the time of SRS was 17.4 cm3 (range 0.3–138 cm3). Fifty (25%) patients had undergone surgery before SRS, whereas 149 (75%) patients received standalone SRS. A total of 186 (93.5%) patients were treated by gamma knife radiosurgery (GKRS), whereas 13 got treated by Cyberknife. The mean tumor volume in CK-F, GKRS, and GKRS-F groups was 36.6 ± 26.3, 15.4 ± 18.4, and 86.0 ± 19.5 cm3, respectively. The mean marginal dose was 21.8 ± 2.9 Gy, 14.0 ± 1.9 Gy, and 25 ± 0.0 Gy in CK-F, GKRS, and GKRS-F groups, respectively. The mean marginal dose of SRS was 14.6 ± 2.9 Gy. The mean follow-up period after SRS was 35.8 ± 31.6 months. Significant clinical improvement was seen in 106 patients out of 116 (91.4%) after SRS with remarkable shrinkage, 22 patients out of 27 (81.5%) with minimal shrinkage, and nine patients out of 13 (69.2%) with stationary tumor shrinkage. The sixth cranial nerve (CN6) was the most commonly involved nerve in 73 patients (36.7%). 30/65 (89%) experienced an improvement in the abducent nerve function following SRS. 115/120 (95.8%) patients primary treated with SRS experienced clinical improvement, whereas the rest of the five patients remained clinically stable.

Conclusion:

Radiosurgery SRS is a safe and effective option in patients with CSHs and resulted in more than 50% decrease in tumor volume in 72.4% of the patients.
Magnetization Transfer Contrast – Is it Sensitive Enough to Differentiate Demyelination from Axonal Loss?
Authors: Chaganti Joga , Woodford Hannah , Taylor Michael , Chaganti Sai Sivananda , MacDonald Alexandra Louise , Garrick Raymond
Published: August 2023

Background and Objective:

Magnetization transfer contrast imaging (MTC) exploits the principle of exchange of energy between the bound and free protons and was shown to be pathologically informative. There is, however, controversy as to whether it correlates with axonal loss (AL), demyelination (DM), or both. This study addresses the pathophysiological process that underlies the white matter injury using the metric derivative of MTC, magnetization transfer ratio (MTR), and defines the role of MTR in identifying the different stages of inflammation, that is, edema, DM, and AL, using optic nerve as the model.

Materials and Methods:

One hundred and forty-two patients with a single, unilateral episode of optic neuritis (ON) were included in the study. Patients were divided into three groups – those with AL, those with DM, and those who were clinically optic neurites but without any electrophysiological changes suggestive of either AL or DM. MTR and electrophysiological studies were performed in the post-acute stage of ON and the results were compared to those obtained from the unaffected optic nerve.

Results:

MTR was significantly reduced in the optic nerves of both DM and AL groups when compared to that in normal optic nerves (P < 0.001). The difference in MTR between the AL and DM groups did not reach statistical significance. Patient group with acute ON did not show any change in the MTR values compared to the normal controls.

Conclusions:

MTR is a sensitive technique to identify neuronal injury, whether it is DM or AL. It, however, cannot differentiate these two pathological processes. MTR is not sensitive to identify acute ON.
Primary Intracranial Germ Cell Tumors
Authors: Sahay Ayushi , Epari Sridhar , Chinnaswamy Girish , Chatterjee Abhishek , Goda Jayant Sastri , Patil Vijay , Moyiadi Aliasgar , Shetty Prakash , Singh Vikas , Sahu Arpita , Choudhary Amit , Janu Amit , Gupta Tejpal
Published: August 2023

Background and Objective:

Primary intracranial germ cell tumors (ICGCTs) are rare and are histologically classified as germinomas and non-germinomatous with distinctive prognostic and therapeutic implications. ICGCTs, essentially due to the inherent difficulty of surgical access, pose different challenges and management connotations than their extracranial counterparts. This is a retrospective analysis of histologically verified ICGCTs, which was undertaken to evaluate various clinicopathological features and their implications on patient management.

Materials and Methods:

Eighty-eight histologically diagnosed cases (over 14 years) of ICGCT at our institute formed the study cohort and were classified into germinoma and non-germinomatous germ cell tumors (NGGCTs). Additionally, germinomas were further subdivided on the basis of 1) tumor marker (TM) levels, as germinoma with normal TM, mildly elevated TM, and markedly elevated TM and 2) radiology features, as germinomas with typical radiology and atypical radiological features.

Results:

ICGCT with age ≤6 years (P = 0.049), elevated TM (P = 0.047), and NGGCT histology (P < 0.001) showed significantly worse outcomes. Furthermore, germinomas with markedly elevated TM and certain atypical radiological features showed prognosis akin to NGGCT.

Conclusions:

Analysis of our largest single cancer center Indian patient cohort of ICGCT shows that inclusion of age ≤6 years, raised TM, and certain radiological features may assist clinicians in overcoming the limitations of surgical sampling, with better prognostication of histologically diagnosed germinomas.
fMRI Analysis of Dissociative Convulsions
Authors: Garg Harshit , Sharan Pratap , Kumaran Senthil S , Bhargava Rachna , Patra Bichitra N , Tripathi Manjari
Published: August 2023

Background and Objectives:

Dissociative convulsions represent complex biopsychosocial etiopathogenesis and have semiological similarities with epilepsy, which leads to delays in definitive diagnosis as well as treatment. We explored the neurobiological underpinnings of dissociative convulsions using a functional magnetic resonance imaging (fMRI) design targeting cognitive, affective, and resting state characteristics in our subjects.

Materials and Methods:

Seventeen female patients with dissociative convulsions without any co-morbid psychiatric or neurological illness and 17 matched healthy controls underwent standardized task-based (affective and cognitive) and resting state fMRI. Blood oxygen level-dependent (BOLD) activation results were compared across the groups, and correlation with the severity of dissociation was measured.

Results:

Patients with dissociative convulsions had lower activation in the left cingulate gyrus, left paracentral lobule, right middle and inferior frontal gyrus, right caudate nucleus, and right thalamus. There was increased resting state functional connectivity (FC) between the left posterior superior temporal gyrus and left superior parietal lobule; left amygdala and Default Mode Network (DMN) of right lateral parietal cortex; right supramarginal gyrus and left cuneus in the patient group. Patients also had decreased FC between the anterior cingulate cortex (ACC) and left thalamus; ACC and right central opercular cortex; DMN of PCC, posterior cingulate gyrus, and right middle temporal lobe.

Conclusions:

Patients with dissociative convulsions have significant deficits in the areas associated with the processing of emotional, cognitive, memory, and sensory-motor functions. There is a significant correlation between dissociative severity and the functioning of areas involving the processing of emotions, cognition, and memory.
Role of Nerve Conduction Studies in Hansen's Disease
Authors: Chaudhary Sarvesh K , Kalita Jayantee , Misra Usha K
Published: August 2023

Background and Objective:

To report the role of nerve conduction study (NCS) in diagnosis, monitoring, and prognosis of Hansen's disease (HD).

Materials and Methods:

In a hospital-based prospecive observational study, the patients with HD as per World Health Organization (WHO) criteria were included; muscle wasting power, reflexes, and sensations were recorded. Motor NCS of median, ulnar, and peroneal nerves and sensory NCS of ulnar, median, and sural nerves were recorded. Disability was graded using WHO grading scale. The outcome was assessed after 6 months using modified Rankin scale.

Results:

In the present study, 38 patients with a median age of 40 (15–80) years and five females were included. The diagnosis was tuberculoid in seven, borderline tuberculoid in 23, borderline lepromatous in two, and borderline in six patients. The disability was grade 1 and 2 in 19 patients each. Out of 480 nerves studied, NCS was normal in 139 sensory (57.4%) and 160 (67.2%) motor nerves. NCSs were axonal in seven sensory and eight motor nerves, demyelinating in three nerves, and mixed in one in seven patients who had lepra reaction. NCS findings did not correlate with disability (p = 1.0) or outcome (0.304) and provided additional information in 11 nerves (seven patients). Peripheral nerves were enlarged in 79. NCSs were normal in 32 (29.90%) in thickened nerves.

Conclusion:

In HD, NCS abnormalities correlated with respective sensory or motor abnormality but related with neither disability nor the outcome.
Preventing Postoperative Apoplexy in Giant Pituitary Adenomas using Combined Trans-Sphenoidal and Cranial Surgery
Authors: Baldia Manish , Rajshekhar Vedantam
Published: August 2023

Background:

Combined surgery consisting of endoscopic trans-sphenoidal surgery (ETSS) and transcranial (TC) surgery for giant pituitary adenomas (GPAs) has been recommended to prevent lethal postoperative apoplexy. Based on our experience, we attempt to rationalize the indications for such surgery.

Materials and Methods:

We report the magnetic resonance (MR) characteristics of the tumor and the outcomes in patients with GPAs who underwent ETSS only and combined surgery. Total tumor volume (TTV), tumor extension volume (TEV), and suprasellar extension of tumor (SET) were calculated based on the lines drawn on MR images and compared between those who underwent ETSS only and those who underwent combined surgery.

Results:

Of 80 patients with GPAs, eight (10%) underwent combined surgery (seven in the same sitting and one had staged surgery). All eight patients (100%) who underwent combined surgery had tumors with multilobulations, extensions, and encasement of the vessels in the circle of Willis (COW). Of 72 patients who underwent ETSS alone, 21 (29.1%) had a multilobulated tumor, 26 (36.2%) tumors had anterior/lateral extensions, and 12 (16.6%) had encasement of the COW. The mean TTV, TEV, and SET for the combined surgery group were significantly higher than those in the ETSS group. None of the patients who underwent combined surgery suffered postoperative residual tumor apoplexy.

Conclusion:

Patients with GPAs in whom there are significant lateral intradural or subfrontal tumor extensions should be considered for combined surgery at the same sitting to avoid devastating postoperative apoplexy in the residual tumor, which can occur when ETSS alone is performed.
Magnetic Resonance Imaging Brain Findings in Chikungunya Virus (CHIKV) Infection with Neurological Complication during Epidemic Outbreak
Authors: Sethi Kanika Sekhri , Aryan Abhay Kumar , Ganeshan Prem Kumar
Published: August 2023

Background and Objective:

The Chikungunya virus is an alphavirus RNA of the family Togaviridae transmitted by the Aedes mosquito. We aim to report magnetic resonance imaging (MRI) brain findings for neurological complications at our institute during epidemic outbreak.

Materials and Methods:

A total of 43 seropositive cases of Chikungunya infection underwent MRI brain.

Results:

Out of 43 patients, 27 (63%) had discrete and confluent supra-tentorial T2-weighted (T2W) and fluid-attenuated inversion recovery (FLAIR) hyper-intense white matter foci. A total of 14 patients (33%) showed multiple foci/areas of diffusion restriction, and four of these patients had infra-tentorial T2 & FLAIR hyper-intense foci with restricted diffusion. In three pediatric age group patients including two neonates, the pattern of involvement was diffuse white matter changes with restricted diffusion. In 30% cases, MRI was normal.

Conclusions:

Detection of focal or confluent white matter hyper-intense foci with restricted diffusion on MRI in patients presenting with fever and neurological symptoms has potential to conclude the diagnosis of Chikungunya encephalitis, especially in epidemic settings.
The Journey and Progress of the Department of Neurosurgery at the University College of Medical Sciences and Guru Teg Bahadur Hospital
Authors: Sarma Pragyan
Published: August 2023

Background:

Guru Teg Bahadur Hospital (GTBH) associated with the University College of Medical Sciences (UCMS) is one of the largest hospitals associated with a medical college in the National Capital of Delhi, India. The Department of Neurosurgery was initially established here in 1997, but since its inception, has made rapid strides in terms of infrastructure and quality of patient care.

Objective:

The main objective of this article is to depict the history and path of progress of the Neurosurgery Department, from its inception to its present status, along with the inherent and existing challenges in running the department.

Materials and Methods:

A retrospective analysis from the time the department was established to its present status was done. The improvement of infrastructure, increase in patient inflow over the years, the number of procedures related to different subspecialties, and existing challenges along with the scope of further improvement were analyzed.

Results:

There has been a significant upgradation of infrastructure more so in the last 5 years. Both indoor and outdoor patient attendance has increased over the years along with steady significant growth of the number of elective and emergency procedures. However, despite the progress, significant challenges hampering optimal patient care still remain to be overcome.

Conclusion:

The department right now is providing satisfactory patient care with absolutely no financial burden to the patients. Neurosurgery academic residency has recently resumed, and a wide range of neurosurgical conditions are being successfully treated. If the existing challenges are addressed in a timely manner, the coming years hold a bright future for the department.
Cross-Cultural Teachings from Cremation Practices
Authors: Gupta Deepak K , Mazzeo Anna T
Published: August 2023

Atmaram bone (C2 axis vertebra) is usually handed over to the family of the deceased on the next day after cremation during the "Asthi sanchaya " commemoration. "Asthi visarajan" involves the practice of immersing the bones and ashes of the deceased in the Holy Ganges river as per Hindu beliefs. Atmaram bone, which usually does not burn during cremation, is handed over to the family of the departed (asthi sanchaya) after cremation which is then immersed in the holy Ganges river (asthi visarajan). Atma means soul, Ram means Lord and Atmaram combined means the one who is Lord of his own soul.” Worshiping of Lord Shiva (while living) and Asthi sanchaya-Asthi visarajan (of the departed) are two religious venerations in Hinduism. Atmaram bone was handed over to me for immersion in the holy Ganges on November 6, 2020, after conducting the asthi sanchaya of my mother during the coronavirus disease 2019 (COVID-19) pandemic. Atmaram bone looked like a Shivalinga statue to most who looked at it, whereas it resembled the image of the axis vertebrae (C2 vertebra) to me when I saw it that sacred day. Atmaram bone, the Shivalinga, and the C2 axis vertebra are among the most precious and sacred objects that humans can handle as relatives, as devotees, and as neurosurgeons, respectively. Asclepius, possibly a skilled war surgeon/neurosurgeon, was worshipped at Asclepieia. Trephination surgery in neurosurgery and religion are intertwined historically. Though there is no published literature, neurosurgeons in various parts of the world do offer religious prayers prior to major neurosurgical operations. In line with the religious veneration of worshipping Shiva Ling or immersion of bones of the departed soul in the Holy Ganges river, we believe it is the sacred responsibility of the operating neurosurgeon to perform surgery in complex craniovertebral junction. As neurosurgeons, we cannot ignore the axis in the living, the odontoid fracture in the injured, and the Atmaram in the deceased.
When Task is Huge but Time is Short! An Interesting Case of Stroke Thrombolysis
Authors: Chakraborty Debabrata , Maiti Suvadip , Dey Sadanand , Bhaumik Sanjay
Published: August 2023

A 64-year-old gentleman, diabetic, and smoker attended the emergency room (ER) with acute stroke. He had expressive aphasia with right upper limb weakness. His blood pressure was extremely high, and he presented in the final half an hour of the permissible window period for thrombolysis. Bringing down his blood pressure to make him eligible for the procedure within the available time was a real challenge for us. Fortunately, we succeeded in our attempt and he gradually improved. Truly, the maximum blood pressure allowable in his case to make him still eligible for thrombolysis was not clear to us. He had an explainable intracranial arterial stenosis and was probably auto-regulating during his acute presentation. Hence, we could have been more lenient in bringing down his blood pressure and thrombolyzed him earlier. A modified guideline will help us to handle these special situations more confidently and allow more patients to get the benefit of thrombolysis.
Volume of Aneurysmal Subarachnoid Hematoma Measured Quantitatively by 3D Slicer to Predict Symptomatic Cerebral Vasospasm
Authors: Yanming Huang , Xiaoyan Lai , Celin Guan , Xiaolong Qi , Huihua Li , Xin Lin , Shuanglin Que
Published: August 2023

Background and Objectives:

Aneurysmal subarachnoid hemorrhage is strongly associated with symptomatic cerebral vasospasm. This study aims to investigate whether a quantitative measure of aneurysmal subarachnoid hematoma by 3D Slicer is more valuable for vasospasm risk prediction compared with modified Fisher scale and the new scale by Eagles.

Materials and Methods:

We performed a retrospective research of Digital Imaging and Communications in Medicine format (DICOM) in aneurysmal patients treated at our institution from 2019 to 2020. Association between vasospasm and hematoma volume by 3D Slicer was explored by univariate and multivariate analyses. Value of risk prediction was compared through area under the receiver operator characteristic curve (AUC) among the modified Fisher scale, the new scale by Eagles, and hematoma volume by 3D Slicer.

Results:

Hematoma volume by 3D Slicer had a significant relationship with vasospasm both by one-way analysis of variance (ANOVA; F = 19.37, P < 0.001) and a binary logistic regression analysis (odds ratio [OR] = 1.05, P = 0.016). Hematoma volume by 3D Slicer had a significantly higher AUC (0.708; 95% confidence interval [CI]: 0.618–0.798, P < 0.001) than the modified Fisher scale and the new scale by Eagles. The optimal diagnostic threshold for hematoma volume by 3D Slicer was 15.98 ml, and the sensitivity and specificity were 73.5% and 58.6%, respectively.

Conclusions:

Volume of aneurysmal subarachnoid hematoma measured quantitatively by 3D Slicer can improve the predictive value for symptomatic cerebral vasospasm.
Postoperative Third Nerve Palsy after Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenoma
Authors: Villamil Facundo , Caffaratti Guido , Ruella Mauro E , Giovannini Sebastian J M , Cervio Andres
Published: August 2023

Third nerve palsy is a rare complication of transsphenoidal surgery and has been merely mentioned in different studies, but there is not any rigorous analysis focusing on this particular complication. The purpose of this study is to analyze this complication after transsphenoidal surgery for a pituitary adenoma to better understand its pathophysiology and outcome. The authors retrospectively analyzed 3 cases of third nerve palsy selected from the 377 patients operated via a transsphenoidal route between 2012 and 2021 at FLENI, a private tertiary neurology and neurosurgical medical center located in Buenos Aires, Argentina. The three patients who presented this complication were operated on via an endoscopic approach. It was observed that an extension into the cavernous sinus (Knosp grade 4) and to the oculomotor cistern was present in the three patients. The deficit was apparent immediately after surgery in two patients. For these two patients, the supposed mechanism of ophthalmoplegia was an intraoperative nerve lesion. The other patient became symptomatic in the 48 h following the surgery. The mechanism implied in this case was intracavernous hemorrhagic suffusion. The latter patient completely recovered the third nerve deficit in the 3 months that followed, while the other two recovered after 6 months postoperative. Oculomotor nerve palsy after transsphenoidal surgery is a very rare complication and appears to be transient in most cases. The invasion of both the cavernous sinus and the oculomotor cistern seems to be a major factor in its physiopathology and should be preoperatively analyzed on magnetic resonance imaging (MRI); recognizing such extension should play an important role in the surgeon's operative considerations.
Acute Toxic Encephalopathy in Occupational Exposure with Polyvinyl Chloride (PVC) Fumes
Authors: Verma Rajesh , Chakraborty Rajarshi , Giri Prithvi
Published: August 2023

Background:

Toxic encephalopathy is a spectrum of central nervous system disorders caused by exposure to toxins, especially from occupational workplace. Polyvinylchloride (PVC) is a synthetic chemical polymer that is used widely in daily activities of living. PVC is produced by polymerization of monomer units of vinyl chloride. Its manufacturing requires multiple procedures and additives for heat and light stabilization involving heavy metals.

Objective:

In this novel case series, we present the diverse clinical presentation of 10 patients, working in plastic recycling factory having inhalational exposure to PVC fumes, manifesting as acute toxic encephalopathy.

Materials and Methods:

All the patients were screened for the causes of acute encephalopathy including heavy metals, methanol poisoning, and organotins along with arterial blood gas analysis, brain imaging, and electroencephalogram. Memory loss, confusion, vertigo, headache, and nausea were complained in all the patients while seizure occurred in three patients. Neurocognitive status was grossly impaired in all the patients. Metabolic acidosis in presence of hyponatremia and/or hypokalemia was observed in nine cases. Five of the patients were having evidence of white matter involvement in brain imaging. The screening for heavy metal, methanol, and organotin were negative. Hemodialysis was done in six patients. Recovery was good in everyone and the average discharge was by 10.8 days (range: 2–25 days). All the patients were symptom-free at 3-months follow-up.

Conclusion:

Early suspicion and aggressive management can have favorable outcome in PVC toxic encephalopathy. Occupational hazards due to PVC toxicity are increasing in the present industrial era but it is very less identified.
Cervical Discometry
Authors: Yu Long , Cui Xu , Bao Da
Published: August 2023

Background and Objectives:

Anterior cervical discectomy and fusion (ACDF), which is widely used in the treatment of cervical spondylosis, may cause complications such as adjacent segment degeneration (ASD). However, such studies on complications are limited, and quantitative evidence is still lacking. To evaluate the clinical value of cervical discometry combined with adjacent intraoperative intradiscal pressure in cervical vertebral surgery through clinical explorations.

Materials and Methods:

In this retrospective study, 100 patients who were treated with anterior decompression, reconstruction, and internal fixation, were enrolled. Among them, 50 patients received ACDF combined with perioperative pressure adjustment of the adjacent segments to ensure that the pressure difference was less than 5 mmHg. The other 50 patients who had only simple ACDF were considered as the control group. Patient information, radiographic changes, axial symptoms (AS), and the occurrence of ASD were recorded in the study.

Results:

The degree of lordosis (D values) at postoperative of all cases were positive. The D value of the two groups of patients immediately after the operation and at the last follow-up were significantly higher than that before the operation (P < 0.05). The incidence of AS was significantly lower in the experimental group than that in the control group (P < 0.05). Besides, there were only 10 patients in the experimental group during the five-year follow-up period, which was significantly lower than the 19 patients in the control group (P < 0.05).

Conclusions:

The intraoperative intervertebral disc pressure measurement could effectively monitor the vertebral body distraction strength and reduce the incidence of postoperative AS and ASD.
Diagnostic Cerebral Angiography Through Distal Transradial Access
Authors: Bhatia Vikas , Kesha Meghashyam , Kumar Ajay , Prabhakar Anuj , Chauhan Rajeev , Singh Apinderpreet
Published: August 2023

Background and Objective:

Over the last few years, there has been considerable interest in the neurointervention community to use transradial approach for diagnostic and therapeutic neurointerventions. Distal radial approach has been postulated as an effective technique with reduced risk of hand ischemia. Our objective was to assess the safety and feasibility of distal transradial access (DTRA) to perform diagnostic cerebral angiography.

Materials and Methods:

A retrospective evaluation of 25 patients who were taken for DTRA through the anatomical snuff box from December 2021 to March 2022 was done.

Results:

Twenty-five diagnostic cerebral angiographies were attempted with DTRA in 25 patients (age, 23–70 years; mean age, 45.4 years; 10 (40%) females). The right distal radial artery mean diameter was 2.09 mm. The procedure was successful in 21 (84%) procedures. Failure was seen in four cases, with three being converted to the proximal transradial approach without any need for redraping and one was converted to the transfemoral approach. The reason for access conversion was a severe spasm in three cases and dissection in one case. Selective catheterization of the cranial vessels through a distal transradial approach was achieved in 92 (96.8%) of 95 vessels. No significant access site complications were seen in the study cohort.

Conclusion:

DTRA is a promising approach for diagnostic cerebral angiography. Interventionists should get accustomed to this approach by overcoming the initial learning curve.
Rivastigmine for Cognitive Impairment in Multiple Sclerosis
Authors: Gotur Amrita J , Prasad Kameshwar , Bhatia Rohit , Srivastava Achal K , Tripathi Manjari , Goyal Vinay , Pandit Awadh K , Vibha Deepti , Rajan Roopa , Padma Srivastava MV
Published: August 2023

Background and Objective:

Nearly 40–65% patients with MS develop cognitive impairment during the disease. There is no treatment clearly effective in improving the cognitive deficits. To evaluate the efficacy and safety of Rivastigmine in cognitively impaired MS patients.

Materials and Methods:

This was a parallel group randomized open label study with blinded end-point assessment. The patient allocation to treatment and control arm was done by telephonic contact with an independent statistician who used a computer to generate a random sequence of allocation using permuted block randomization (varying block size of 4 and 6) in 1:1 ratio. The outcome assessor was blinded to this allocation. A total of 60 patients were in included in the study (30 in each arm). Primary outcome was improvement in memory functions (using logical memory subset of Wechsler Memory Scale III, India) assessed after 12 weeks. Secondary outcomes included fatigue, depression, and safety.

Results:

In modified intention to treat analysis (N = 22), treatment arm showed statistically significant improvement in memory function with mean difference of 7.56 [95% CI (0.67,14.46), p 0.032] as compared to control arm. There was no statistically significant difference in outcomes such as fatigue and depression. Vomiting was the most common side effect. No major adverse events were observed in either group.

Conclusion:

Rivastigmine is safe and effective in improving memory functions in cognitively impaired MS patients. However, our study has a small sample size and tested only a single domain. Larger studies with a validated single comprehensive neuropsychological test are needed.
Modified Nasoseptal Flap Technique to Prevent the Recurrence of Rathke's Cleft Cyst
Authors: Joshua Shejoy P. , Sundar Shyam S. , Viswam Vineeth , Panikar Dilip
Published: August 2023

Background:

Rathke's cleft cysts (RCCs) are benign epithelial lesions arising from the Rathke's pouch remnants that fail to regress during embryogenesis. Some RCCs become symptomatic and require treatment. Cyst fenestration and drainage of its contents is the preferred procedure to treat symptomatic cases but carries a risk of recurrence. We propose the use of a novel modified nasoseptal flap technique to partially line the cyst wall to avoid recurrence.

Methods:

This was a prospective, observational study that included all RCC patients admitted to the Department of Neurosurgery, Aster Medcity, from April 2015 to May 2018. The modified nasoseptal flap technique was performed in all patients. They underwent preoperative and postoperative ophthalmological, endocrine, endoscopic, and MRI evaluations to look for recurrence.

Results:

Ten patients underwent the modified nasoseptal flap technique. The median follow-up was 36 months. Postoperatively, all patients were relieved from headaches. Moreover, their visual fields and pituitary functions normalized. None of the patients developed recurrence of RCC on follow-up brain MRI. On endoscopic examination, all patients had retained patency of the fenestra. The longest follow-up was 72 months.

Conclusions:

The modified nasoseptal flap technique maintains patency and avoids recurrence of RCCs on long-term follow-up.
Alberta Stroke Program Early CT Score can Predict Severity of Spasticity and Functional Outcome in Ischemic Stroke Survivors
Authors: Krishnan Reshma K. V. , Sankaran Ravi
Published: August 2023

Background:

Post-stroke spasticity is common and an early predictor of the severity of spasticity can help track recovery trajectory helping to modify rehabilitation plans.

Objectives:

We explored the utility of the Alberta Stroke Program Early CT Score (ASPECTS) to predict functional motor capacity in patients after acute ischemic stroke.

Methods:

One hundred and one patients (mean age of 58.6 ± 7.6 years; M:F = 72: 29) with the first documented acute ischemic stroke were followed up for three to twelve months after the stroke. Cerebral lesions within the territory of the middle cerebral artery were evaluated using the ASPECTS. Spasticity was assessed using the Modified Ashworth Score (MAS) and walking with Timed Up and Go test (TUG). The associations between severity of spasticity and size/extent of infarct as derived from ASPECTS and between spasticity and functional walking in post-stroke survivors were analyzed.

Results:

Among the patients studied, 61.3% (n = 62) had infarct in the region of supply of the left middle cerebral artery (MCA) and 38.7% (n = 39) had infarct in the region supplied by the right MCA. Three percent (n = 3) had a low ASPECTS, 53.6% (n = 54) had an intermediate score and 44.4% (n = 44) had a high score. The majority of patients with no to mild spasticity had high ASPECTS. Worse spasticity was significantly associated with low ASPECTS (P = 0.001). High scores in Timed Up and Go test (TUG) were associated with low ASPECTS (P < 0.001). Patients with high ASPECTS had the propensity to have subcortical infarcts (P < 0.001) when compared to those with moderate ASPECTS, who had a mix of cortical and subcortical infarcts.

Conclusion:

ASPECTS at admission in patients with acute ischemic stroke is a good predictor of post-stroke spasticity and functional walking. Low ASPECTS is associated with higher spasticity and lower functional walking status on follow-up after stroke.
Assessment of Sleep Disturbances on Mental Health in Patients with Restless Legs Syndrome
Authors: Olgun Hülya , Yazar Tamer , Çakmak Berna B , Arıcı Yeliz K
Published: August 2023

Background and Objective:

In our study, we aimed to evaluate the sleep disturbances of patients diagnosed with restless legs syndrome (RLS) regarding their mental health according to the severity of the disease.

Materials and Methods:

The study included 166 patients diagnosed with RLS and 161 healthy controls in the same age interval as patients. Sleep disturbances of patients were defined with the “personal information form” (PIF) prepared by the researchers, while the mental health status of patients was defined with the “Brief Symptom Inventory” (BSI).

Results:

All RLS patients had an increase in BSI subscale points, with a positive correlation to disease severity, and subscale points were significantly higher than the control group (p < 0.05). Those with the “frequent waking” problem had higher BSI subscale points compared to those without the problem (p<0.01 or 0.001). Those with “waking with respiratory distress,” “daytime sleepiness,” “very early waking,” and “sleep disorder” problems had statistically significantly high BSI subscale points for all subscales, apart from hostility, compared to those without these problems (p<0.01 or 0.001).

Conclusion:

It is considered that assessment of sleep disturbances causing disrupted quality of life and mood disorders is beneficial for the treatment of patients with RLS. Our study data appears to be related to the result that sleep disturbances and mental health disruptions might be associated with the disease severity among RLS patients.
Is Asterion a Reliable Surgical Landmark for the Transverse and Sigmoid Sinus Junction in Indian Skulls?
Authors: Rohilla Swati , Singh Seema , Sudheer Arava Harisha Kusuma , Tamang Shradha , Rani Neerja , Gurjar Hitesh Kumar , Shariff Ahmadulla
Published: August 2023

Background:

Asterion is the junction of lambdoid, parietomastoid, and occipitomastoid sutures. In traditional anatomy teaching, it is believed that asterion sits over the transverse-sigmoid sinus junction (TSSJ). It is a significant surgical landmark for the placement of a burr hole in the retrosigmoid approach.

Objective:

The purpose of this study was to evaluate the asterion's accuracy as a TSSJ-specific external surgical landmark in the Indian population.

Materials and Methods:

16 human dried skulls were obtained from the Department of Anatomy, AIIMS, New Delhi. The point of TSSJ was taken between the two lips and just posterior to the entry of the superior petrosal sinus. Asterion internally was localized with the help of a geometrical divider. The x- horizontal/ anterior and y- vertically superior (+)/ inferior (-) distances were measured from asterion (internally) to the TSSJ by a digital vernier caliper.

Results:

The mean horizontal distance (x) of the left side asterion & TSSJ was 10.3±1.0mm whereas the vertical distance (y) ranged between +2 to -4.3 mm. The mean horizontal distance (x) of the right side asterion & TSSJ was 13.5±1.4mm whereas the vertical distance (y) ranged between +3 to -4.2 mm.

Conclusion:

Asterion is not a reliable landmark for TSSJ in Indian skulls. The TSSJ with respect to asterion was found on average 10mm and 13.5mm anterior on the left and right side respectively, and mostly inferior (average 4.2mm) in 75% of the skulls. The TSSJ was closer to the asterion on the left side in comparison with the right side. However, further studies with a larger sample size will be needed to evaluate the population-specific relation of asterion with the TSSJ.