bluuebunny/crossref_metadata_2025 huggingface dataset:
Craniovertebral Junction Anomalies
Authors: Garg Kanwaljeet , Tandon Vivek , Kumar Rajinder , Chandra P Sarat , Kale Shashank S , Sharma Bhawani Shankar , Mahapatra Ashok K
Published: August 2023

Background:

Vertebral artery dissection (VAD) is a treatable cause of vertebrobasilar ischemic stroke and can be spontaneous or more commonly traumatic. Craniovertebral junction (CVJ) anomalies are a rare and often overlooked cause of VAD.

Objective:

The objective of this study was to study cases where CVJ anomaly presented as posterior circulation infarct and to conduct a relevant literature review.

Materials and Methods:

The medical records of seven patients who were managed for posterior circulation infarct associated with CVJ anomaly at our center from January 2009 through August 2013 were reviewed. PubMed and MEDLINE databases were also searched for similar cases, and the published case reports/series were reviewed.

Results:

Seven patients met our inclusion criteria and were included in the study. The mean age was 17.4 years (range: 10–35 years). All the patients were males. The most common symptoms were headache, vomiting, and gait ataxia. Slurring of speech was seen in one patient. One patient had repeated episodes of gait ataxia with left-sided weakness with complete recovery in between the episodes. One patient presented in unconscious state. Four patients complained of vertigo. The median duration of symptoms was 7 days (range: 3 days–12 months).

Conclusions:

CVJ anomalies can present as posterior circulation infarct. One must evaluate all patients with posterior circulation stroke, especially young patients, for possible CVJ anomalies. Dynamic lateral cervical spine X-ray is an important tool to diagnose AAD. CVJ anomalies represent a treatable cause of VAD.
Single-Stage Posterior Only Approach for Unilateral Atlantoaxial Spondyloptosis with type-II odontoid Fracture in Pediatric Patients
Authors: Varshney Gaurav , Kumar Amandeep , Doddamani Ramesh S , Meena Rajesh , Sawarkar Dattaraj P , Verma Satish , Singh Pankaj Kumar , Gupta Deepak , Satyarthee Gurudutta , Chandra P Sarat , Kale Shashank Sharad
Published: August 2023

Objective:

When there is a complete slippage of facet joints of C1 over C2 such that there is no contact between the articulating surfaces of C1 and C2, the condition is known as atlantoaxial spondyloptosis (AAS). AAS represents an extremely rare manifestation of atlantoaxial instability. This study was performed to highlight the presentation, radiological features, and management of unilateral AAS in pediatric patients.

Material and Methods:

We retrospectively identified four pediatric patients with AAS from our hospital records in the last 6 years (2014–2019).

Results:

Among the four patients with unilateral AAS, three were posttraumic and one was diagnosed with craniovertebral junction tuberculosis (CVJ TB). All the patients had a varying degree of spastic quadriparesis on presentation. One patient with CVJ TB presented with neck tilt. All patients with traumatic unilateral AAS were associated with an odontoid fracture. These patients underwent C1-C2 fixation with complete reduction of spondyloptosis using the techniques of joint manipulation and joint remodeling with a posterior only approach. Complete reduction of AAS in patients with trauma was also associated with the realignment of the odontoid fracture. All patients improved neurologically after surgery and achieved excellent correction of the deformity on a follow-up imaging.

Conclusion:

Pediatric unilateral AAS is an extremely rare phenomenon. A single-stage posterior approach with C1-C2 fixation is a feasible technique for the treatment of this seemingly difficult to correct deformity in pediatric patients and the clinical outcomes are excellent.
AIIMS Cervical Myelopathy Score – A New Comprehensive and Objective Patient-Reported Modification of mJOA
Authors: Garg Kanwaljeet , Vij Vaibhav , Mishra Shashwat , Vibha Deepti , Singh Manmohan , Chandra P Sarat , Kale Shashank S
Published: August 2023

Background:

Several scoring systems have been developed for assessment of patients with compressive cervical myelopathy. However, all of these have some shortcomings. We proposed a new modification of the modified Japanese Orthopedic Association (mJOA) score—the AIIMS cervical myelopathy score (ACMS).

Objective:

The aim of this study was to compare the ACMS with mJOA score and Nurick score.

Methods:

We prospectively studied patients with cervical compressive myelopathy. The new ACMS, mJOA, Nurick proposed by Benzel, and Nurick scores were recorded preoperatively and at three months postoperatively in patients.

Results:

Sixty-two patients completed the 3-month follow-up and were included in the final analysis. The mean preoperative and postoperative Nurick, mJOA, and ACMS scores were 3.3 and 3.0, 12.3 and 13.8, and 15.1 and 17.7, respectively. High correlation (Pearson'sr> 0.8, 95% CI: 0.94 to 0.97,P< 0.005) was observed between ACMS and mJOA scores for all the individual components of both scales, both in pre- and postoperative assessments. A negative correlation was observed between the occupational ability scores ACMS and the Nurick scale (r= −0.76, 95% CI: −0.83 to − 0.68). No correlation was found with cord/canal ratio on magnetic resonance imaging (MRI) with any of the three scoring systems (preoperative, postoperative, or recovery rates).

Conclusions:

The ACMS score showed a good correlation with the mJOA score for evaluation of functional disability in the setting of cervical myelopathy. The patients could themselves report the scores using the ACMS scoring chart. The occupational component of the ACMS also correlated well with the Nurick score.
Correlation Between Obliquity of Exiting Nerve Root on Lateral Sagittal MRI Images and Degenerative Spondylolisthesis
Authors: Katikar Dattaprasanna B
Published: August 2023

Background:

MRI has become the investigation of choice for patients of low back pain with radiculopathy. However, MRI does not consistently detect spondylolisthesis. In far lateral sagittalT2 MRI images, exiting nerve roots are seen descending vertically. We observed that the obliquity of these descending nerve roots may be related to spondylolisthesis.

Objective:

Aim of this study is to evaluate the correlation between obliquity of exiting nerve root on MRI and lumbar instability on dynamic radiographs.

Methods and Material:

We retrospectively studied 248 patients who underwent discectomy or laminectomy and stabilization for degenerative lumbar disease at our institute from January 2017 to February 2020. For objectively measuring the obliquity of the exiting nerve root, we described an angle between the vertebra and exiting nerve root on far lateral T2 MRI images. We measured the exiting root angle and studied its correlation with degenerative spondylolisthesis on dynamic X-rays.

Results:

Out of 108 patients having spondylolisthesis, 106 (98.15%) had an angle of obliquity of the exiting nerve root as >105° and only two (1.85%) had an angleof <105°. Among 140 patients without spondylolisthesis, 137 (97. 86%) had an angle of obliquity of <105°and only three (2.14%) had an angle of >105°. Statistical parameters for our test of “angle of obliquity for the exiting nerve root in spondylolisthesis”are as follows: sensitivity of the test- 98.14%, specificity of the test- 97.85%.

Conclusion:

Obliquity of the exiting nerve root is a very easy to detect. It has avery high sensitivity and very high specificity for detecting spondylolisthesis on supine MRI.
Comparison of Different Tidal Volumes for Ventilation in Patients with an Acute Traumatic Cervical Spine Injury
Authors: Sengupta Deep , Bindra Ashish , Kapoor Indu , Mathur Purva , Gupta Deepak , Khan Maroof A
Published: August 2023

Background:

There is scant literature comparing high tidal volume ventilation (HTV) over low tidal volume (LTV) ventilation in acute traumatic cervical spinal cord injury (CSCI).

Objective:

The aim of this prospective randomized controlled parallel-group, single-blinded study was to compare the effect of two different tidal volumes (12–15 mL/kg and 6–8 mL/kg) in CSCI on days to achieve ventilator-free breathing (VFB), PaO2/FIO2 ratio, the incidence of complications, requirement of vasopressor drugs, total duration of hospital stay, and mortality.

Materials and Methods:

We enrolled patients with acute high traumatic CSCI admitted to the neurotrauma intensive care unit within 24 h of injury, requiring mechanical ventilation. Participants were randomized to receive either HTV, 12–15 mL/kg (group H) or LTV, 6–8 mL/kg (group L) tidal volume ventilation.

Results and Conclusions:

A total of 56 patients, 28 in each group were analyzed. Patient demographics and injury severity were comparable between the groups. VFB was achieved in 23 and 19 patients in groups H and L, respectively. The median number of days required to achieve VFB was 3 (2, 56) and 8 (2, 50) days, P = 0.33; PaO2: FIO2 ratio was 364.0 ± 64 and 321.0 ± 67.0, P = 0.01; the incidence of atelectasis was 25% and 46%, P = 0.16, respectively, in group H and group L. The hemodynamic parameters and the vasopressor requirement were comparable in both groups. There was no barotrauma. The duration of hospital stay (P = 0.2) and mortality (P = 0.2) was comparable in both groups. There was no significant difference in days to achieve ventilator-free breathing with HTV (12–15 mL/kg) ventilation compared to LTV (6–8 mL/kg) ventilation in acute CSCI. The PaO2:FiO2 ratio was higher with the use of 12–15 mL/kg. No difference in mortality and duration of hospital stay was seen in either group.
Reporting a Case of Cervical Vertebral Body Primary Malignant Melanoma—A Rare Entity
Authors: Kumar G Krishna , Chigurupalli Chandrasekhar , Balasubramaniam Anandh , Rajesh BJ , Chavali Pooja
Published: August 2023

Melanomas of vertebral body are usually metastatic lesions. Isolated vertebral body melanomas are rare may be due to unknown primary. Only threesuch cases havebeen reported in literature. We are reporting a 30-year-old female presented with progressive quadriparesis and bladder involvement. On evaluation, an extradural lesion at the C4-5 level with the destruction of C4 vertebral body and anterior in the prevertebral space seen with areas of blooming. The patient underwent surgery and biopsy was suggestive of melanoma. On further evaluation, we could find any other lesion in the body. The lesion can be either metastatic with unknown primary or primarily arising from vertebrae. Primary vertebral body melanomas are rare, surgical decompressions followed by immunotherapy may prolong the survival in this patients.
The Future of Minimally Invasive Spine Surgery
Authors: Heo Dong Hwa , Ha Yoon , Yi Seung , Chung Hungtae
Published: August 2023

Minimally invasive spine surgery (MISS) is an important option for spinal operations, with advantages including rapid recovery and preservation of normal structures. As the number of geriatric patients is increasing, the role of MISS might expand in the future. MISS techniques and approaches continue to be developed, and recent trends in MISS development include the refinement of surgical approaches and techniques, as well as systems related to newly developed techniques, rather than spinal implants. Among the various techniques for MISS, endoscopic spine surgery, including uniportal and biportal endoscopic approaches, is the focus of vigorous research efforts that may lead to further expansion of the indications of endoscopic spine surgery. Endoscopic spine surgery will be an important part of spine surgery. Lateral lumbar interbody fusion and endoscopic lumbar interbody fusion may play meaningful roles in the MISS fusion area. Robotics and augmented reality are also likely to be important technological modalities in spine surgery in the future.
Intraoperative Neuromonitoring for Spinal Surgery in a Pregnant Patient
Authors: Tyagi Mayank , Bir Megha , Sharma Akanksha , Singh Pankaj K , Bindra Ashish , Chandra P Sarat
Published: August 2023

We report the strategy of anesthesia and intraoperative neurophysiological monitoring (IONM) in a 29-year-old, 22 weeks pregnant patient posted for surgery for aggressive vertebral body hemangioma. We used propofol and fentanyl-based anesthesia for IONM. Motor-evoked potentials (MEP) and somatosensory-evoked potentials (SSEP) were used to monitor the neural tracts during surgery. Fetal heart rate monitoring was done preoperatively and postoperatively. Train of 8, 75 μs duration pulse, 250–500 Hz stimulus was used for MEP and 30 mA, 200–400 μs, 3–5 Hz was used for SSEP. No new motor or somatosensory deficits appeared. Our findings suggest that IONM can be safely done in pregnant women.
Investigation of Sexual Function in Men with Spinal Cord Injury in a Rehabilitation Hospital in Turkey
Authors: Koyuncu Engin , Taşoğlu Özlem , Özgirgin Neşe
Published: August 2023

Background:

Sexual function is one of the most important functions for males with spinal cord (SC) injuries, and there are wide ranges and conflicting results about sexual dysfunction and the frequency of education of these patients.

Objectives:

The aim of our retrospective study is to evaluate sexual function and to determine the level of sexual education provided by medical professionals in males with SC injury.

Patients and Methods:

Eighty-one inpatient males with SC injury were included in the study. “International Index of Erectile Function” and “International Spinal Cord Injury Male Sexual Function Basic Data Set” were used to evaluate sexual function.

Results:

The median age of the patients was 31 years old (range 20–63), and the median disease duration was 190 days (range 30–5475). Of 81 patients, 55.6% had C1-T10, 33.3% had T11-L2, and 11.1% had L3 and lower injury. Of the patients, 90.1% were never informed about the impact of SC injury on sexual function. The rates of normal psychogenic and reflex erection were 16 and 18.5%, respectively. Erectile dysfunction was severe in 66.7% and moderate in 16% of patients. Only 4.9% of patients had normal ejaculation and 7.4% had normal orgasmic function. Sexual desire was very high or high in 49.4% and moderate in 32.1%. Overall, sexual satisfaction was high or moderate in only 6.2% of patients.

Conclusion:

Sexual education rates of male SC injured persons are very low. Although most of the patients have normal sexual desire, erection, ejaculation, orgasmic function, and sexual satisfaction are severely damaged.
Combined Effect of Virtual Reality Training (VRT) and Conventional Therapy on Sitting Balance in Patients with Spinal Cord Injury (SCI)
Authors: Nair Manasa S , Kulkarni Vivek N , Shyam Ashok K
Published: August 2023

Background:

Post spinal cord injury (SCI), sitting balance is considered a prerequisite for the effective performance of activities of daily living. Virtual Reality Training (VRT) may provide an interactive medium of rehabilitation, preventing a reduction in active participation of the patients while allowing for the training of sitting balance.

Aim:

The aim of this study was to evaluate the effect of the addition of VRT to conventional therapy in improving sitting balance in persons with SCI.

Subjects and Methods:

This was a single blinded randomized control trial conducted on 21 subjects with SCI (level of injury: D10 or below). They were randomly allocated into two groups; both groups received their routine exercise program. In addition, the intervention group, that is, Group B (n = 11) received 30 min of VRT in the seated position using Xbox-Kinect, while the conventional therapy group, that is, Group A (n = 10) received 30 min of additional conventional therapy to equalize the duration of the intervention (3 days/week, 4 weeks). The modified functional reach test and T-shirt test were measured at the beginning and at the end of 4 weeks.

Results:

MFRT changes for forward (Group A: 1.7 ± 1.09 cm; Group B: 4.83 ± 2.95 cm), right lateral (Group A: 2.43 ± 2.81 cm, Group B: 5.08 ± 1.85 cm), left lateral (Group A: 3.05 ± 4.65 cm, Group B: 6.19 ± 1.51 cm) were statistically significant for Group B (P < 0.05). No significant difference was observed between the two groups for T-shirt test (P > 0.05).

Conclusion:

VRT can be used as a part of a comprehensive rehabilitation program to improve sitting balance post-SCI.
Distinct Spinal Dysraphisms Arising from Each Hemicord of Type I Split Cord Malformation - A Rare Coexistence
Authors: Rathore Lavlesh , Sahana Debabrata , Kumar Sanjeev , Sahu Rajiv
Published: August 2023

In this report, we describe a 6-month-old child having Type I split cord malformation (SCM), associated with meningomyelocele of one hemicord and lipomeningomyelocele of other hemicord at the same level along with Type II Chiari malformation. The classical embryological theories on split cord malformation and neurulation defect do not clearly explain such a complex entity at one level. The new research on the genetic association of posterior neuropore defect opens a new horizon of research on such genesis.
Laminectomy with Rib Shears
Authors: R Rai Survendra Kumar , Dandapat Saswat K , Jadhav Dikpal , Jadhav Neha , Shah Abhidha , Rangnekar Ranjit D
Published: August 2023

Introduction:

Laminectomy/laminoplasty either free or vascularized pedicle flap is currently performed with a variety of expensive instruments. Use of Tudor Edwards rib shears to perform above procedure is described.

Materials and Methods:

Tudor Edwards rib shear was used to cut lamina in 18 cases for a variety of spinal lesions. Depending upon the size of lesion, laminectomy/laminoplasty was required for 2 to 8 levels. Vascularized pedicle laminoplasty or free flap laminoplasty was done with Tudor Edwards rib shears. Ligamentum flavum and interspinous and supraspinous ligaments were preserved in cases of vascularized pedicled laminoplasty, which was carried out in 12 cases. Free flap laminoplasty was carried out in 6 cases.

Results:

In all our cases, laminectomy was successfully achieved with rib shears without any injury to the dura or its underlying structures. It was possible to perform vascularized pedicle laminoplasty or free flap laminoplasty in all cases. Laminectomy was easier to perform in the cervical region and dorsal region, while it was difficult in the lumbar region due to the wider, thick lamina and its angulation, especially in adults.

Conclusion:

Laminectomy/laminoplasty with Tudor Edwards rib shears is quick, safe, and easy. Beveled cut edges with minimal bony loss prevents sinking of laminoplasty, thereby facilitates lamina fixation. This is an alternative method of performing laminectomy/laminoplasty, especially for those not having accessibility to expensive equipment.
A Novel Brain Retractor for Endoscopic Evacuation of Chronic Subdural Hematoma
Authors: Yadav Yad R , Bajaj Jitin , Ratre Shailendra , Yadav Nishtha , Parihar Vijay
Published: August 2023

Background:

Endoscopic chronic subdural hematoma (CSDH) evacuation is a safe and effective alternative to the conventional burr hole technique. Although a rigid endoscope has the advantage of good visualization, there are risks of brain damage due to limited space to accommodate the scope and frequent lens soiling.

Objective:

This technical note describes a novel brain retractor to overcome the limitations of rigid endoscopy.

Methods:

The novel brain retractor (by senior author) was made by dividing a silicon tube longitudinally into two halves, and tapered for easy introduction in the operative cavity. Sutures were placed at the outer end of the retractor to prevent migration and to assist in angulation.

Results:

The novel retractor along with endoscopic assistance was used in 362 CSDH procedures. Endoscopy combined with this retractor provided additional help in complete removal of hematoma in organized/solid clots, septa, bridging vessels, and rapid expansion of brain in 83, 23, 21, and 24 patients, respectively (n = 151, 44%). Although there were three deaths (due to poor preoperative status), and two recurrences, there were no retractor-induced complications.

Conclusions:

The novel brain retractor assists endoscope in proper visualization of complete hematoma cavity by gentle and dynamic brain retraction, helps in thorough irrigation of hematoma cavity, protects the brain, and prevents lens soiling. It allows easy insertion of the endoscope and instruments using bimanual technique even in patients with a small width of hematoma cavity.
A Case of Parinaud Syndrome in a Patient with Parkinson's Disease
Authors: Dubey Souvik , Ghosh Ritwik , Ray Biman Kanti , Gutiérrez-Ortiz Consuelo , Benito-León Julián
Published: August 2023

Background:

Parinaud syndrome is a dorsal mid-brain syndrome characterized by upgaze paralysis, convergence retraction nystagmus, and pupillary light-near dissociation. Infarctions or hemorrhages involving the mid-brain are the most frequent causes in older adults.

Objective:

To report a novel case of a patient who presented with classical parkinsonian signs and Parinaud syndrome.

Material and Methods:

Patient data were obtained from medical records from the Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India.

Results:

A 62-year-old previously healthy man presented with motor and non-motor symptoms of Parkinson's disease (PD) for the past 6 years. The neurological examination revealed an asymmetric resting tremor of the upper limbs with rigidity, bradykinesia, hypophonia, hypomimia, decreased blinking, and micrographia. The neuro-ophthalmological examination showed Parinaud syndrome. He was treated with levodopa-carbidopa and trihexyphenidyl. After 6 months and 1 year of follow-up, his neurological condition was re-assessed; motor symptoms improved substantially, but Parinaud syndrome persisted.

Conclusions:

Parinaud syndrome can be a potential manifestation of PD. A detailed neuro-ophthamological examination should be carried out even in patients having a diagnosis of classic PD in whom eye-movement abnormalities are distinctly infrequent.
Craniospinal MRI Findings in Neuromelioidosis
Authors: Naik Suprava , Bhoi Sanjeev Kumar , Jha Menka , Kumar Mukesh
Published: August 2023

Background:

Melioidosis is a bacterial infection caused by Burkholderia pseudomallei that is endemic in Southeast Asia, northern Australia, and Africa. Neurological involvement is rare and reported in 3–5% of total cases.

Objective:

The purpose of this study was to report a series of cases of melioidosis with neurological involvement and a brief review of the literature.

Materials and Methods:

We collected the data from six melioidosis patients having neurological involvement. Clinical, biochemical, and imaging findings were analyzed.

Result:

All patients in our study were adults (age range 27 to 73 years). The presenting symptoms were fever of varying duration (range 15 days to 2 months). Altered sensorium was noted in five patients. Four cases had brain abscess, one had meningitis, and one had a spinal epidural abscess. All cases of brain abscesses were T2 hyperintense with an irregular wall showing central diffusion restriction and irregular peripheral enhancement. The trigeminal nucleus was involved in one patient, but there was no enhancement of the trigeminal nerve. Extension along the white matter tract was noted in two patients. Magnetic resonance (MR) spectroscopy done in two patients showed increased lipid/lactate and choline peak in both of them.

Conclusion:

Melioidosis can present as multiple micro-abscesses in the brain. Involvement of the trigeminal nucleus and extension along the corticospinal tract may raise the possibility of infection by B. pseudomallei. Meningitis and dural sinus thrombosis, although rare, can be presenting features.
Impulse Control Disorders with Short-term Use of Cabergoline in Macroprolactinomas
Authors: Sanjan Ganesh , Das Liza , Ahuja Chirag K , Dhandapani Sivashanmugam , Sachdeva Naresh , Grover Sandeep , Dutta Pinaki
Published: August 2023

Impulse control disorders (ICDs) are less-emphasized adverse effects of dopamine agonists. Evidence on prevalence and predictors of ICDs in patients with prolactinomas is limited and confined chiefly to cross-sectional studies. This was a prospective study performed to investigate ICDs in treatment-naïve patients with macroprolactinomas (n = 15) using cabergoline (Group I), compared to consecutive patients of nonfunctioning pituitary macroadenomas (n = 15) (Group II). Clinical, biochemical, radiological parameters and psychiatric comorbidities were evaluated at baseline. ICD was assessed by Minnesota impulsive disorder interview, modified hypersexuality and punding questionnaires, South Oaks gambling scale, kleptomania symptom assessment scale, Barratt impulsive scale (BIS), and internet addiction scores (IAS) at baseline and 12 weeks. Group I had a significantly lower mean age (28.5 vs. 42.2 years) with a female predominance (60%) compared to group II. Median tumor volume was lower in group I (4.92 vs. 14 cm3) despite significantly longer symptom duration (2.13 vs. 0.80 years) than in group II. Serum prolactin decreased by 86% (P = 0.006) and tumor volume decreased by 56% (P = 0.004) at 12 weeks in group I, with a mean weekly cabergoline dose of 0.40 ± 0.13 mg. There was no difference between both groups in hypersexuality, gambling, punding, and kleptomania symptom assessment scale scores at baseline and 12 weeks. Mean BIS showed a more remarkable change in group I (16.2% vs. 8.4%, P = 0.051), and 38.5% of patients transitioned from average to above-average IAS in group I. The current study found no increased risk of ICD with short-term use of cabergoline in patients with macroprolactinomas. The use of age-appropriate scores (such as IAS in younger individuals) may help diagnose subtle alterations in impulsivity.
A Novel Case of Primary Conus Medullaris Epithelioid Glioblastoma with Gliosarcomatous Differentiation
Authors: Malhotra Kiran P , Kaif Mohammad , Malhotra Hardeep Singh , Husain Nuzhat
Published: August 2023

Intramedullary location is seldom seen in spinal cord neoplasms. Ependymomas and astrocytomas comprise the vast majority of these intramedullary lesions. Primary spinal origin is rarely seen in gliosarcomas. No epithelioid glioblastomas have been reported in the spine. We describe the case of an 18-year-old male who presented with symptoms suggestive of a spinal mass lesion. Magnetic resonance imaging revealed a homogeneous intradural-intramedullary lesion involving the conus medullaris. Biopsy of the lesion showed a unique morphology comprising gliosarcoma and epithelioid glioblastoma differentiation, supported by relevant immunohistochemistry. The prognosis of such an entity is expected to be poor. However, the presence of mutant BRAF V600E, as seen in the current case, and the availability of targeted therapy against it are expected to improve the prognosis.
An Analysis of Temporal Trend of Incidence of Post-Resection Cerebrospinal Fluid Diversion in Pediatric Posterior Fossa Tumor Patients and the Predictive Factors
Authors: Kumar Ashutosh , Bhaisora Kamlesh Singh , Rangari Kamlesh , Mishra Prabhakar , Raiyani Vandan , Sardhara Jayesh , Maurya Ved Prakash , Verma Pawan Kumar , Das Kuntal Kanti , Mehrotra Anant , Srivastav Arun Kumar , Jaiswal Awadhesh , Kumar Raj , Behari Sanjay
Published: August 2023

Objective:

We aim to find the temporal trend of incidence of post-resection cerebrospinal fluid (CSF) diversion (ventriculoperitoneal [VP] shunt/endoscopic third ventriculostomy [ETV]) in pediatric posterior fossa tumor (pPFT) patients with no pre-resection CSF diversion and the possible clinical predictors.

Methods:

We reviewed 108 operated children (age ≤16 years) with PFTs, from 2012 to 2020, at a tertiary care center. Patients with preoperative CSF diversion (n = 42), lesions within cerebellopontine cistern (n = 8), and those lost to follow-up (n = 4) were excluded. Life table, Kaplan–Meier curve, univariate and multivariate analyses were used to determine CSF-diversion-free survival and independent predictive factors, with significance defined as P < 0.05.

Results:

The median (IQR) age was 9 (7) years (M: F: 2.5:1). Mean (±SD) duration of follow-up was 32.43 ± 21.3 months. 38.9% of patients (n = 42) needed post-resection CSF diversion. Of these, 64.3% (n = 27) were done in early (≤ 30 days), 23.8% (n = 10) in intermediate (>30 days to ≤6 months), and 11.9% (n = 5) in late (≥6 months) postoperative period (P-value < 0.001). Preoperative papilledema (HR: −5.8, 95%CI: 1.7–5.8), periventricular lucency (PVL) (HR: 6.2, 95%CI: 2.3–16.6), and wound complication (HR: 3.8, 95%CI: 1.7–8.3) were found on univariate analysis as significant risk factors for early post-resection CSF diversion. On multivariate analysis, PVL on preoperative imaging (HR: −4.2, 95%CI: 1.2–14.7, P = 0.02) was identified as an independent predictor. Preoperative ventriculomegaly, raised intracranial pressure and intraoperative visualization of CSF egress from the aqueduct were not found to be significant factors.

Conclusion:

Significantly high incidence of post-resection CSF diversion in pPFTs occurs in early (≤30 days) postoperative period, with preoperative papilledema, PVL, and wound complication being its significant predictive factors. Postoperative inflammation, causing edema and adhesion formation can be one of the important factors for post-resection hydrocephalus in pPFTs.
Outcome of COVID-19–Associated Acute Stroke
Authors: Chaudhuri Jaydip Ray , Sharma Vijay K , Mridula K Rukmini , Anjanikumar Darapureddy , Bandaru Srinivasarao VCS
Published: August 2023

Background and Objective:

Coronavirus 2019 (COVID-19) infection is prevalent worldwide. COVID-19 infection can lead to various neurological disorders including acute stroke. We investigated the functional outcome and its determinants among our patients with acute stroke associated with COVID-19 infection in the present setup.

Materials and Methods:

This study is a prospective study in which we recruited acute stroke patients with COVID-19 positivity. Data on duration of COVID-19 symptoms and type of acute stroke were recorded. All patients underwent stroke subtype workup and measurement of D-dimer, C-reactive protein (CRP), lactate-dehydrogenase (LDH), procalcitonin, interleukin-6, and ferritin levels. Poor functional outcome was defined by modified Rankin score (mRS) ≥3 at 90 days.

Results:

During the study period, 610 patients were admitted for acute stroke, of whom 110 (18%) tested positive for COVID-19 infection. Majority (72.7%) were men with a mean age of 56.5 years and mean duration of COVID-19 symptoms for 6.9 days. Acute ischemic and hemorrhagic strokes were observed in 85.5% and 14.5% patients, respectively. Poor outcome was observed in 52.7%, including in-hospital mortality in 24.5% patients. COVID-19 symptoms ≤5 days (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.20–2.99), CRP positivity (OR: 1.97, 95% CI: 1.41–4.87), elevated levels of D-dimer (OR: 2.11, 95% CI: 1.51–5.61), interleukin-6 (OR: 1.92, 95% CI: 1.04–4.74), and serum ferritin (OR: 2.4, 95% CI: 1.02–6.07), and cycle threshold (Ct) value ≤25 (OR: 8.8, 95% CI: 6.52–12.21) were independent predictors of poor outcome.

Conclusion:

Poor outcomes were relatively higher among acute stroke patients with concomitant COVID-19 infection. In the present study, we established the independent predictors of poor outcome to be onset of COVID-19 symptoms (<5 days) and elevated levels of CRP, D-dimer, interleukin-6, ferritin, and Ct value ≤25 in acute stroke.
Hypophysitis – A Review of Fourteen Cases
Authors: Chatterjee Sudip , Chatterjee Sandip , Bhartiya Sankalp
Published: August 2023

Background:

Primary hypophysitis is a rare condition, usually diagnosed retrospectively after surgery for a suspected pituitary adenoma. Improved awareness of the condition and better imaging have resulted in more patients being diagnosed without surgery.

Objective:

A retrospective chart analysis study of hypophysitis from a single secondary endocrine and neurosurgical referral center in eastern India was conducted between 1999 and 2021 to assess the diagnostic and therapeutic challenges posed by these patients.

Methods and Material:

Fourteen patients presented to the center between 1999 and 2021. All patients had an MRI of the head with contrast and a full clinical workup. Twelve patients had headache, of whom one had progressive visual impairment. One patient had severe weakness, attributed later to hypoadrenalism and one had sixth nerve palsy.

Results:

Six patients had glucocorticoids as their primary treatment, four refused treatment, and one was on glucocorticoid replacement. One patient had decompressive surgery because of progressive visual loss, and two had surgery because of a presumptive diagnosis of pituitary adenoma. There was no difference between the patients who had glucocorticoids and those who did not.

Conclusions:

Our data suggest that it is possible to identify most patients with hypophysitis on clinical and radiological grounds. In the largest published series on this subject and in ours, glucocorticoid treatment did not alter the outcome.
Anesthetic Concerns during Gamma-Knife Radiosurgery
Authors: Tripathi Manjul , Chauhan Rajeev , Luthra Ankur , Sadashiva Nishanth , Deora Harsh , Batish Aman , Kaur Rupinder , Madan Renu , Mohindra Sandeep
Published: August 2023

Background:

Gamma-knife radiosurgery (GKRS) has emerged as one of the mainstream modalities in the treatment of many neurosurgical conditions. The indications for Gamma knife are ever-increasing and presently more than 1.2 million patients have been treated with Gamma knife worldwide.

Objective:

A neurosurgeon usually leads the team of radiation oncologists, medical physicists, nursing staff, and radiation technologists. Seldom, help from anesthetist colleagues is required in managing patients, who either require sedation or anesthesia.

Methods:

In this article, we try to elucidate anesthetic considerations in Gamma-knife treatment for different age groups. With the collective experience of authors involved in Gamma-Knife Radiosurgery of 2526 patients in 11 years with a frame-based technique, authors have tried to elucidate an effective and operational management strategy.

Results:

For pediatric patient (n = 76) population and mentally challenged adult patients (n = 12), GKRS merits special attention given its noninvasive nature but problems of frame fixation, imaging, and claustrophobia during radiation delivery become an issue. Even among adults, many patients have anxiety, fear, or claustrophobia, who require medications either to sedate or anesthetize during the procedure.

Conclusion:

A major goal in treatment would be a painless frame fixation, avoid inadvertent movement during dose delivery, and a fully wake, painless, and smooth course after frame removal. The role of anesthesia is to ensure patient immobilization during image acquisition and radiation delivery while ensuring an awake, neurologically accessible patient at the end of the radiosurgery.
Gamma Knife Stereotactic Radiosurgery for Giant Intracranial Tumors – A Series of 70 Patients
Authors: Verma Satish Kumar , Agrawal Deepak , Santhoor Hemanth Amardeep , Singh Manmohan , Kale Shashank Sharad
Published: August 2023

Background and Objective:

Surgery remains the primary option in large intracranial tumors, but significant number of patients may not be amenable for surgery. We explored the role of stereotactic radiosurgery as an alternative to external beam radiation therapy (EBRT) in such patients. Our study objective was to assess the clinicoradiological outcomes of large intracranial tumors (volume ≥20 cm3) managed with gamma knife radiosurgery (GKRS).

Materials and Methods:

This was a single-center, retrospective study conducted from January 2012 to December 2019. Patients with intracranial tumor volume ≥20 cm3 who received GKRS and had a minimum of 12 months of follow-up were included. Clinical, radiological, and radiosurgical details and clinicoradiological outcomes of the patients were obtained and analyzed.

Results:

Seventy patients who had a pre-GKRS tumor volume ≥20 cm3 with >12 months of follow-up were included. The mean age of the patients was 41.9 ± 13.6 (range 11–75) years. Majority (97.1%) received GKRS in a single fraction. Mean pretreatment target volume was 31.9 ± 15.1 cm3. At a mean follow-up of 34.2 ± 17.1 months, tumor control was achieved in 91.4% (n = 64) of the patients. Adverse radiation effects were observed in 11 (15.7%) patients, but were symptomatic in only one (1.4%) patient.

Conclusion:

The present series defines “large intracranial lesions” for GKRS and demonstrates excellent radiological and clinical outcomes in these patients. GKRS may be considered as the primary option in such large intracranial lesions in which surgery carries significant risk based on patient-related factors.
Correlation Based on the WHO Grading with Tumor Control and Clinical Outcome Following Gamma Knife Radiosurgery in Meningiomas
Authors: Naik Vikas , Pahwa Bhavya , Singh Manmohan , Kale Shashank , Agrawal Deepak
Published: August 2023

Background and Aim:

The aim of this study was to study the effect of Gamma Knife (GK) on meningiomas based on the World Health Organization's (WHO) grading system in terms of tumor control and final clinical outcome.

Methodology:

This retrospective study included clinicoradiological and GK characteristics of patients who had undergone GK for meningiomas at our institute from April 1997 until December 2009.

Results:

Of 440 patients, 235 underwent secondary GK for residual/recurrent lesion and 205 received primary GK. Of the 137 patients whose biopsy slide could be reviewed, 111 patients had grade I, 16 had grade II, and 10 had grade III meningiomas. Good tumor control rates were seen in 96.3% of grade I meningioma patients, 62.5% of 16 grade II, and 10% of grade III meningioma patients at median follow-up of 40 months. Age, sex, Simpson's grade of excision, and increasing peripheral dose of GK did not affect the response to radiosurgery (P > 0.05). Multivariate analysis showed that high-grade tumor and radiotherapy prior to GK were important negative predictors for progression of tumor size after GK radiosurgery (GKRS) (P < 0.05). In patients with WHO grade I meningioma, radiation therapy prior to GKRS and repeat surgery were predictors for poorer outcome.

Conclusion:

In WHO grades II and III meningiomas, no factors affected tumor control except the histology itself.
The Role of Stereotactic Radiosurgery for Functioning and Nonfunctioning Pituitary Adenomas
Authors: Lehrer Eric J , Kowalchuk Roman O , Trifiletti Daniel M , Sheehan Jason P
Published: August 2023

Pituitary adenomas are benign brain tumors that comprise 10%–20% of all central nervous system neoplasms. In recent years, stereotactic radiosurgery (SRS) has emerged as a highly effective treatment option in the management of functioning and nonfunctioning adenomas. It is associated with tumor control rates frequently ranging from 80% to 90% in published reports. While permanent morbidity is uncommon, potential side effects include endocrine dysfunction, visual field deficits, and cranial nerve neuropathies. In patients where single fraction SRS would pose an unacceptable risk (e.g. large lesion size or close proximity to the optic apparatus), hypofractionated SRS delivered in 1–5 fractions is a potential treatment option; however, available data are limited. A comprehensive literature search of PubMed/MEDLINE, CINAHL, Embase, and the Cochrane Library was conducted to identify articles reporting on the use of SRS in functioning and nonfunctioning pituitary adenomas.
Role of Stereotactic Radiosurgery in Glial Tumors
Authors: Garg Kanwaljeet , Agrawal Deepak
Published: August 2023

Glial tumors are a relatively new indication for stereotactic radiosurgery (SRS). Traditionally, SRS has been considered to be an inadequate treatment for glial tumors as these are diffuse tumors, but SRS is a highly focused treatment. Tumor delineation can be challenging given the diffuse nature of the gliomas. It has been recommended to include the T2/fluid-attenuated inversion recovery (FLAIR) altered signal intensity areas in addition to the contrast enhancing part in the treatment plan of glioblastoma in order to increase the coverage. Some have recommended to include 5 mm margins to cover up for the diffusely infiltrative nature of the glioblastoma. The most common indication of SRS in patients with glioblastoma multiforme is tumor recurrence. SRS has also been used as a boost to the residual tumor or tumor bed after surgical excision before conventional radiotherapy. The addition of bevacizumab has been recently tried along with SRS in patients with recurrent glioblastoma to decrease radiation toxicity. Besides, SRS has also been used in patients with low-grade gliomas following recurrence. Brainstem gliomas, which are usually low-grade gliomas, are another indication for SRS. Outcomes following the use of SRS are comparable with external beam radiotherapy in brainstem gliomas, whereas the risks of radiation-induced complications is less. SRS has also been used in other glial tumors such as gangliogliomas and ependymomas.
Proton Radiosurgery
Authors: Rosa Alonso La , Wroe Andrew , Fellows Zachary , Kotecha Rupesh
Published: August 2023

Introduction:

Stereotactic radiosurgery (SRS) is highly conformal, high-dose radiation therapy delivered in 1–5 fractions, and is considered the standard of care for several central nervous system (CNS) indications. Particle therapies, such as protons, have physical and dosimetric advantageous properties compared to photons. However, proton SRS (PSRS) is not widely performed given the few particle therapy facilities, high-cost, and limited outcomes research as a sole modality and in comparative studies. The data available differs from each pathology. For AVMs, especially those with deep or eloquent locations, PSRS obliteration rates outcomes appear favorable and superior. For meningiomas, PSRS has been used for grade 1 alone, and for higher grades a PSRS boost has been considered. For vestibular schwannoma, PSRS seems to have favorable control rates with modest toxicity outcomes. For pituitary tumors, data shows excellent results with PSRS for functional and non-functioning adenomas. For brain metastasis, moderate doses of PSRS achieves high local control rates with low rates of radiation necrosis. For uveal melanoma, dedicated eyeline PSRS (4–5 fractions) are associated with very high tumor control and eye retention rates.

Conclusions:

PSRS is effective and safe for various intracranial pathologies. Limited data, usually retrospective and single institution series exist. There are numerous advantages of protons over photons, so it is important to understand limitations with further studies. Published clinical outcomes and widespread adoption of proton therapy will be key to unlocking the potential benefits of PSRS.
Radiobiology of Radiosurgery for Neurosurgeons
Authors: Tuleasca Constantin , Tripathi Manjul , Starnoni Daniele , Daniel Roy Thomas , Reyns Nicolas , Levivier Marc
Published: August 2023

Stereotactic radiosurgery (SRS) is a precise focusing of radiation to a targeted point or larger area of tissue. With advances in technology, the radiobiological understanding of this modality has trailed behind. Although found effective in both short- and long-term follow-up, there are ongoing evolution and controversial topics such as dosing pattern, dose per fraction in hypo-fractionnated regimens, inter-fraction interval, and so on. Radiobiology of radiosurgery is not a mere extension of conventional fractionation radiotherapy, but it demands further evaluation of the dose calculation on the linear linear-quadratic model, which has also its limits, biologically effective dose, and radiosensitivity of the normal and target tissue. Further research is undergoing to understand this somewhat controversial topic of radiosurgery better.
Hypo-fractionated Gamma Knife Radiosurgery for Intra-cranial Pathologies
Authors: Tripathi Manjul , Kumar Narendra , Sreenivasan Sanjeev A , Ahuja Chirag K , Jani Parth , Bhatta Rajkumar , Kaur Rupinder , Mohindra Sandeep , Chauhan Rajeev
Published: August 2023

Background:

Single-session stereotactic radiosurgery (SRS) is a proven and effective treatment modality for various benign, malignant, and functional intra-cranial pathologies. In certain situations, single-fraction SRS is limited because of lesion size and location. Hypo-fractionated gamma knife radiosurgery (hfGKRS) is an alternative approach for such unconventional indications.

Objective:

To evaluate the feasibility, efficacy, safety, and complication profile of hfGKRS with evaluation of different fractionation schemes and dosing patterns.

Methodology:

The authors prospectively evaluated 202 patients treated with frame-based hfGKRS over a 9-year period. GKRS was administered fractionated because of either a large volume (>14 cc) or an inability to spare neighboring organs at risk from permissible radiation in single-session GKRS. The inter-fraction interval was kept at 24 hours, and the dose calculation was performed with linear quadratic equations. Patients with more than 3 years of clinical and radiological follow-up were included in prospective analysis. At pre-decided follow-up criteria, treatment effects and side effects were documented on objective scales.

Results:

A total of 169/202 patients met inclusion criteria. 41% patients received treatment in three fractions, whereas 59% received two-fraction GKRS. Two patients of giant cavernous sinus hemangiomas were treated with 5 Gy in the five-fraction regimen. In patients with more than 3 years of follow-up, the obliteration rate was 88% for complex arteriovenous malformations (AVMs) treated with hfGKRS because of eloquent locations, whereas it was 62% for Spetzler–Martin grade 4-5 AVMs. For non-AVM pathologies (meningiomas, schwannomas, pituitary adenomas, paragangliomas, hypothalamic hamartomas, etc.), the 5-year progression free survival was 95%. Tumor failure was noted in 0.05% patient population. Radiation necrosis developed in 8.1% patients, and radiation-induced brain edema developed in 12% patients. It was resistant to treatment in 4% patients. No patient developed radiation-induced malignancy. Hypo-fractionation did not provide any hearing improvement in giant vestibular schwannomas.

Conclusion:

hfGKRS is a valuable standalone treatment option for candidates unsuitable for single-session GKRS. The dosing parameters need to be tailored as per the pathology and neighboring structures. It provides comparable results to single-session GKRS with an acceptable safety and complication profile.