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October-December 2021
Volume 16 | Issue 4
Page Nos. 669-908

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SYSTEMATIC REVIEW ARTICLE  

Anterior approach to the cervical spine: Elegance lies in its simplicity Highly accessed article p. 669
Kirit Arumalla, Hanish Bansal, Jigarsingh Jadeja, Aman Batish, Harsh Deora, Manjul Tripathi, Sandeep Mohindra, Sanjay Behari
DOI:10.4103/ajns.AJNS_313_20  
Introduction: Since the landmark publication by Smith and Robinson, approaches to the cervical spine anteriorly have undergone many modifications and even additions. Nevertheless, at its core, the anterior approach remains an elegant and efficient approach to deal with majority of cervical spine pathologies including the degenerative cervical spine. Methodology: For this review, we searched for all major cases series and randomized control trials of anterior cervical approaches using the PubMed databases. Articles having the details of clinical variables and outcomes were tabulated and analyzed. Results: A total of 9 case series for transoral, 7 case series for transmanubrial, 19 case series for anterior cervical discectomy and fusion (ACDF), 6 studies for ACDF versus posterior cervical foraminotomy, 37 case series for ACDF versus arthroplasty, and 7 studies for ACDF versus anterior cervical corpectomy and fusion have been included. The majority of the case series suggested that the anterior cervical procedures have good clinical outcomes. The upper cervical spine approached by the transoral route had good outcomes in ventral compressive pathologies, with morbidity of cerebrospinal fluid leak in 7% of patients. The midcervical spine approached by ACDF had better clinical outcomes equivalent to the majority of modifications even in multiple-level pathologies. The transsternal approach had provided greater access and stability to the cervicothoracic junction with minimal morbidity. Conclusion: The anterior cervical approach can address the majority of cervical pathologies. They provide adequate corridor from craniovertebral junction to T4 with minimal morbidity, thus providing a good clinical outcome.
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ORIGINAL ARTICLES Top

Performing awake surgeries in times of COVID-19 – A Singapore experience Highly accessed article p. 685
Swati Jain, Will Loh, Hui-Minn Chan, Calvin Lam, Tseng Tsai Yeo, Lwin Sein, Vincent Nga, Kejia Teo
DOI:10.4103/ajns.AJNS_61_21  
Introduction: It has been 17 years since the severe acute respiratory syndrome outbreak and Singapore is facing yet another daunting pandemic – the novel coronavirus (COVID-19). To date, there are 57,607 cases and 27 casualties. This deadly pandemic requires significant changes especially in the field of awake surgeries for intra-axial tumors that routinely involve long clinic consults, significant interactions between patient and multiple other team members pre, intra, and postoperatively. Materials and Methods: A retrospective review of all awake cases done during the COVID-19 pandemic from February to June 2020 was done. In this article, we outline the rigorous measures adopted during the COVID-19 pandemic that has allowed us to proceed with awake surgeries and intraoperative mapping at our institution. Results and Discussion: We have divided the protocol into various phases of care of patients planned for an awake craniotomy. Preoperatively, teleconsults have been used where possible thereby limiting multiple hospital visits and interaction. Intraoperatively, safety nets have been established during asleep-awake-asleep phases of awake craniotomy for all the team members. Postoperatively, early discharge and teleconsult are being employed for rehabilitation and follow-ups. Conclusions: Multiple studies have shown that with intraoperative mapping, we can improve neurological outcomes. As the future of the pandemic remains unknown, the authors believe that surgical treatment should not be delayed for intracranial tumors. Awake craniotomies and intraoperative mapping can be safely carried out by adopting the described protocols with combination of multiple checkpoints and usage of telecommunication.
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Minimally invasive surgery for traumatic high-grade lateral spondylolisthesis of L1 with multiple spinal fractures: Closed reduction and internal fixation using percutaneous pedicle screws Highly accessed article p. 692
Takeshi Sasagawa
DOI:10.4103/ajns.AJNS_63_21  
Background: Traumatic high grade lateral spondylolisthesis at the thoracolumbar junction is an extremely severe injury caused by high-energy trauma, commonly resulting in polytrauma. The treatment of this pathology is challenging, and even death following surgery has been reported. Therefore, it is necessary to focus on making surgical invasion minimal. Methods: A 53-year-old female fell from a height and presented with severe back pain and complete paralysis below L1. Computed tomography (CT) showed a Grade 4 traumatic lateral spondylolisthesis and severe comminution of L1, and mild compression fractures at T9 and L3. Results: First, we performed posterior surgery on the day of the injury to reduce the fracture and stabilize the spinal column using percutaneous pedicle screws (PPS). Twelve days later we resected the L1 vertebral body and inserted a cage with an iliac bone graft using an anterior approach. The estimated blood loss from posterior and anterior surgeries was 320ml and 200ml, respectively. Bony fusion was achieved as seen on CT at the 1-year follow-up. Conclusion: A 2-stage combined posterior-anterior approach using PPS can be performed less invasively, enabling adequate reduction, internal fixation, and anterior reconstruction for patients with high grade traumatic lateral spondylolisthesis without spinal shortening or facet interlocking.
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Surgical management of spinal tuberculosis – A retrospective observational study from a Tertiary Care Center in Karnataka Highly accessed article p. 695
Rakshith Srinivasa, Sunil Valentine Furtado, Kirthana Ubrangala Kunikullaya, Sangeeta Biradar, Dravya Jayakumar, Eilene Basu
DOI:10.4103/ajns.AJNS_78_21  
Context: Tuberculosis (TB) is a common infectious disorder in developing countries. A significant load of patients with extrapulmonary TB are diagnosed in our institute, mostly involving the spine. Aim: We aimed to present our experience in the surgical management of spinal TB. Setting and Design: This was a retrospective observational study. Materials and Methods: Seventy patients (year 2016–2018) who underwent surgical management with minimum of 1-year follow-up (17 patients lost during follow-up) were graded as per the American Spinal Injury Association (ASIA) grading system for neurological deficits. All were surgically treated with laminectomy and epidural abscess drainage/transpedicular debridement of granulation with/without spinal stabilization. Thoracic and lumbar cases were managed by posterior approach; among them, 12 patients who had no significant cord compression and good ASIA grade with facet involvement (requiring fusion) underwent minimally invasive pedicle screw fixation. Cervical cases were managed mostly by anterior approach. All patients received Anti-tubercular treatment (ATT) post operatively as per protocol postoperatively, following which magnetic resonance imaging (MRI) spine was done. Statistical Analysis: Data were analyzed using SPSS software version 18.0 (SPSS Inc. Released in 2009. PASW Statistics for Windows, version 18.0. Chicago, IL, USA: SPSS Inc.). The continuous variables were analyzed using descriptive statistics using mean and standard deviation. Results: The average age was 42.5 years. The most common location was thoracic (28 patients), followed by lumbar (20 patients), cervical (16 patients), and thoracolumbar (6 patients). Twenty patients had epidural abscess with cord compression. All patients who presented within 4 weeks of onset of symptoms showed a statistically significant improvement postsurgery. Sixteen patients with epidural abscess had good neurological recovery immediately after surgery (ASIA B to ASIA D/E). Four patients with epidural abscess with late presentation remained ASIA A after surgery. All patients had good fusion rates (follow-up X-ray) at 1 year. After ATT course completion, all patients had complete eradication of disease (MRI spine). Conclusion: Surgical treatment for spinal TB, if performed early (within 4 weeks) with good decompression, results in satisfactory clinical outcome with early improvement in the neurological deficits. Posterior approach to the spine with decompression and fixation gives good results, and minimally invasive procedures further help lessen muscle dissection, less pain, and early mobilization.
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Delayed presentation in chiari malformation Highly accessed article p. 701
Muhammad Rafay, Farhan Gulzar, Hassan Masood Jafri, Salman Sharif
DOI:10.4103/ajns.AJNS_120_21  
Introduction: Chiari malformations are a group of clinicopathological entities with a variety of clinical presentations, different pathophysiology, and variable outcomes. It has a typical set of clinical presentation. In this study is to observe the different clinical presentations of the patients with Chiari malformation in our population. As the time of initial presentation is delayed that might change the sign and symptoms with which patient initially presents. Materials and Methods: This was a cross-sectional observational study with prospectively collected data of 46 patients with Chiari malformation. The duration of the study is from 2017 to 2020. Patient's data will be compiled and analyzed through Statistical Package for Social Sciences (SPSS) Version 25. Qualitative variables are presented as frequencies and percentages. Quantitative variables are presented as mean ± standard deviation. Effect modifiers are controlled through stratification. The Chi-square test is used for finding association between categorical variables. P ≤ 0.05 is considered as statistically significant. Results: According to our data 36% of our patients presented with motor weakness which is followed by sensory deficit, however in previous literature headache was the commonest clinical presentation. Conclusion: Clinical presentation in our population differs from other studies and the reason behind this is the delayed presentation of the patient and lack of awareness of disease and ultimately it will alter the outcome of disease and treatment.
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Evaluation of pediatric hydrocephalus: Clinical, surgical, and outcome perspective in a tertiary center p. 706
Rahul Singh, Ravi Shankar Prasad, Ramit Chandra Singh, Adarsh Trivedi, Kulwant Singh Bhaikhel, Anurag Sahu
DOI:10.4103/ajns.AJNS_132_21  
Context: Pediatric hydrocephalus (PH) results in significant clinical and psychosocial morbidity in pediatric population. Aims: The aims of the study are to evaluate clinical, surgical, and outcome perspective of PH patients of age <12 years. Settings and Design: This is a retrospective cohort study. Materials and Methods: This study includes 117 pediatric patients (age ≤12 years) of hydrocephalus due to various etiology admitted in our department between September 2018 and December 2020. Demographic profile, etiology, clinical presentation, management, complications and postoperative outcome characteristics were evaluated. Survival analysis was done with respect to etiology and age group. Statistical Analysis Used: P < 0.05 was considered statistically significant. Unpaired t-test and Chi-square test were used. Kaplan–Meier curve plotting and survival analysis were also done. Results: Male-to-female ratio was 1.3:1. Most frequent etiology of PH was postinfectious (35%). Posterior fossa pilocytic astrocytoma (34.2%) was the most common neoplastic etiology. Surgical procedure performed for PH was ventriculoperitoneal shunting (n = 103), Ommaya reservoir (n = 2) placement, and endoscopic third ventriculostomy (ETV) (n = 8). Mortality was significantly (P = 0.0139) more in patients of neoplastic etiology. Cognitive deficits and delayed developmental milestones were significantly (P < 0.05) more in congenital hydrocephalus etiology. There was a nonsignificant difference in survival between age groups (P = 0.1971). However, a significant survival difference was evident (P = 0.0098) for etiology. Conclusions: Disease-specific mortality is main cause of mortality in PH. Neoplastic etiology PH has poor survival when compared to others. Life-long routine controls are required to avoid future possible complications and enhance better rehabilitation of the child.
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Adult coagulase-negative staphylococcal meningitis in Qatar: Clinical characteristics and therapeutic outcomes p. 714
Fahmi Yousef Khan
DOI:10.4103/ajns.AJNS_144_21  
Background and Objectives: Coagulase-negative staphylococci (CoNS) have emerged as a major pathogen in nosocomial meningitis. This study was designed to describe the clinical profile, laboratory parameters, treatment, and outcomes of CoNS meningitis in patients admitted to Hamad General Hospital, Qatar. Materials and Methods: This retrospective hospital-based study described the patients with CoNS meningitis from 2009 to 2013. Results: Twelve patients were recruited for the study, of which there were 10 (83.3%) males and 2 (16.7%) females with a median age of 39 years (interquartile range [IQR]: 29–46 years). Fever was the most common presenting symptom being present in all patients, followed by mental alterations 7 (58.3%). All CoNS meningitis cases in this study were nosocomially acquired after neurosurgery and in most cases after external ventricular drain (EVD) insertion. The median time between the procedure and acquisition of infection was 13 days (IQR: 10–15.7 days). The isolated species include 8 (66.7%) Staphylococcus epidermidis, 2 (16.7%) Staphylococcus capitis, and 2 (16.7%) Staphylococcus haemolyticus. All CoNS isolates were sensitive to vancomycin while 75% of them were oxacillin resistance. In the eight patients with EVDs, the infected EVDs were removed, while all patients received empirical antibiotics involving mainly vancomycin and ceftriaxone that were modified upon receipt of culture results. All patients were cured, and no mortality was reported. Conclusions: CoNS meningitis is a recognized complication related to the introduction of neurosurgical devices. Because of its nonspecific clinical presentation, treating physicians should have a high suspicion index. If CoNS meningitis is highly suspected, vancomycin is the empirical treatment of choice while awaiting results of sensitivity.
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The effects of temperature and prothrombotic conditions on cerebral venous sinus thrombosis frequency: An institutional experience p. 719
Fatima Mustansir, Maha Inam, Aneela Darbar
DOI:10.4103/ajns.AJNS_21_21  
Objectives: The pathogenesis of cerebral venous sinus thrombosis (CVST) is complex and involves the interplay of underlying provocative factors. Upon observing a higher frequency of CVST cases presenting to our hospital in summer, we hypothesized that CVST may be influenced by variations in climate. Materials and Methods: A retrospective review of all patients who were diagnosed with CVST at a tertiary care hospital in Pakistan between January 2010 and December 2019 was conducted. After dividing patients into groups based on the type of risk, the frequency of CVST in these groups between four seasons (spring, summer, fall, and winter) was compared. Results: A total of 256 patients diagnosed with CVST were included, of which 129 were female and 127 were male. The mean age was 41.7 ± 15.2 years. Of the total patients, 91.4% had some sort of risk factor, either systemic (162 patients) or local (72 patients), while 22 patients did not have any identifiable risk factor. The number of patients with more than one known risk factor was 93 (36.3%). Of the total number of patients, 96 (37.5%) patients had hyperhomocysteinemia, followed by 85 patients (33.2%) with a prothrombotic risk factor other than hyperhomocysteinemia and 44 (17.2%) patients with central nervous system infections. The most commonly affected sinuses were a combination of the transverse sinus and sigmoid sinus (21%), There was a statistically significant seasonal variation in CVST cases among all patients (P = 0.03) and in the systemic risk factor group (P = 0.05), with the highest number of cases occurring in the summer season. Conclusions: CVST may be influenced by seasonal changes in atmospheric temperatures and humidity, especially in patients with underlying prothrombotic risk factors.
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Long-term clinicoradiological outcomes of cervical fusion with polyether ether ketone versus cervical disc arthroplasty in a double-blinded randomized control trial p. 725
Vijay Kumar Gupta, Neeraj Basantani, Ajay Sebastian Carvalho, Ekata Gupta
DOI:10.4103/ajns.AJNS_345_20  
Introduction: In this double-blinded randomized controlled trial, we compare the long-term clinicoradiological effects of anterior cervical discectomy and fusion with polyether ether ketone implant (ACDF with PEEK) versus artificial cervical disc (cervical disc arthroplasty [CDA]) in patients with single and bilevel cervical degenerative disc disease (CDDD). Aims: We aimed to compare the pain scores, cervical kinematics, and radiological outcomes in patients undergoing CDA and ACDF for single and bilevel CDDD over 5 years. Settings and Design: This study was carried out from 2010 to 2019 in the Neurosurgery Department of a Tertiary Care Hospital attached to a Medical College in India. Subjects and Methods: We enrolled 30 patients in each group. Clinical and radiological assessments were carried out for all patients over a period of 5 years. Statistical Analysis Used: Wilcoxon Signed-rank test, Mann–Whitney U-test, and Fischer's exact test were used for comparing the preoperative and follow-uP values. R software version 3.6.0 was used for statistical analysis. Results: A significant improvement in the cervical range of motion, sagittal range of motion (ROM), and functional spinal unit (FSU) was observed in the CDA group at final follow-up, while the PEEK group reported a significant decrease in the ROM and FSU and the difference between the two groups was also found to be statistically significant. Conclusions: When assessed over 5 years following surgery, we found CDA to be superior with respect to ROM, FSU, overall cervical alignment, and maintenance of disc height when compared to ACDF with PEEK implant.
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Clinicopathological correlation of glioma patients with respect to immunohistochemistry markers: A prospective study of 115 patients in a Tertiary Care Hospital in North India p. 732
Gitanshu Dahuja, Ashok Gupta, Arpita Jindal, Gaurav Jain, Santosh Sharma, Arvind Kumar
DOI:10.4103/ajns.AJNS_377_20  
Background: With the incorporation of molecular subtyping in glioma patients in 2016 WHO classification, there is a need to understand the immunohistochemistry (IHC) marker expression in various glioma patients and to clinically correlate with various subgroups. Objective: Aim of the study was to assess IHC marker expression profile in glioma patients and to clinically correlate them in various subgroups. Materials and Methods: The prospective study included 115 glioma patients. IHC markers (isocitrate dehydrogenase [IDH] 1, ATRX, P53, Ki-67 antibody) were done in all patients. Patients received treatment as per the grade of tumor. The patients were followed in 3 monthly intervals, for a period of 12 months. SPSS software version 20.0 was used for statistical analysis. Tables were prepared in Microsoft Excel sheet. Kaplan–Meier method was used for survival analysis. Results: There were 11 Grade 1, 33 Grade 2, 26 Grade 3, and 45 glioblastoma multiforme (GBM) patients out of which 10 patients were secondary GBM cases. IDH1 mutation is frequent in Grade 2 and Grade 3 tumors of both astrocytic and oligodendroglia tumors. Its mutation is also common in secondary GBM patients. ATRX mutation is specific to astrocytic lineage, Grade 2, Grade 3, and secondary GBM patients. Conclusion: Molecular nature of DA and AA cases can be accurately confirmed by combined IDH1 and ATRX IHC thereby avoiding costly investigations such as fluorescence in situ hybridization. In astrocytic tumors, p53 can act as a surrogate marker. IDH-mutant glioma patients have better prognoses than IDH wild gliomas.
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Functional outcome of surgically treated patients of ossified posterior longitudinal ligament of cervical and dorsal spine in Indian population – A single center retrospective analysis of 40 patients p. 738
Sudhir K Srivastava, Manojkumar Basavareddy Gaddikeri, Sunil Bhosale, Aditya Raj, Atif Naseem, Nandan Marathe
DOI:10.4103/ajns.AJNS_477_20  
Aims: The aim of the study was to retrospectively evaluate the neurological outcome in operated patients of ossified posterior longitudinal ligament (OPLL) of cervical and/or dorsal spine using modified Japanese orthopedic association (mJOA) score and find out the factors affecting the outcome. Settings and Design: The study design was a retrospective study. Materials and Methods: Forty operated patients of cervical and/or dorsal spine OPLL were included in the study. Neurological examination was conducted and analyzed using mJOA score pre- and postoperatively at 1, 6, and 12 months. Improvement in the mJOA score based on age, sex, type of OPLL, duration of symptoms, type of surgical procedure, and radiological parameters were calculated, analyzed, and compared with previous records of the patient. Results: Significant improvement in mJOA scores with mean preoperative being 12.27 ± 1.95 with 1-year postoperative 13.85 ± 2.02 (P < 0.0001) noted. There is a significant difference in mean mJOA scores in posterior approach with instrumentation (P < 0.0001) as compared with laminoplasty group (P < 0.005). Patients with occupancy ratio <60% had better results (P < 0.0001) as compared to those with occupancy ratio of >60% (P = 0.003). Patients with duration of symptoms >1 year had poorer results compared to those of <1 year duration. Mean ossification kyphosis angle was 19.4° ± 5.73°. Conclusion: OPLL is a progressive disease which causes severe neurological deficit if left untreated. OPLL in a young patient with short duration of symptoms, low occupancy ratio, and low ossification kyphosis had better chances of neurological recovery. Type of OPLL and sex of patient do not affect the recovery. OPLL managed early and surgically has better results irrespective of anterior or posterior approach with significant improvement in mJOA score. Decompression with fusion has better results than decompression alone.
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Comparative analysis of long-term outcome of anterior reconstruction in thoracic tuberculosis by direct anterior approach versus posterior approach p. 745
Sudhir K Srivastava, Manojkumar Gaddikeri, Aditya Raj, Sunil Bhosle, Atif Naseem, Ankit Amin, Harsh Agrawal
DOI:10.4103/ajns.AJNS_519_20  
Study Design: Retrospective study. Aim: To retrospectively evaluate and compare the long-term outcome of anterior vertebral body reconstruction in tuberculosis (TB) of the dorsal spine by direct anterior-versus-posterior approach. Materials and Methods: A total of 127 patients operated by posterior approach, 118 by anterior for TB-thoracic spine with at least 1-year follow-up were included and retrospectively analyzed. Patients were assessed clinically, radiologically and data regarding age, sex, levels involved, surgical approach, operative time, blood loss, neurological recovery using Frankel grade, pre- and post-operative kyphosis, % correction of kyphosis, time for fusion, fusion grading using Bridwell criteria, % loss of correction, mobilization time and complications if any were collected, analyzed, compared in anterior-v/s-posterior approaches. Results: The mean age in anterior-approach was 36.03 and 39.83 years in posterior. Mean operative time in anterior-approach was 6.11 and 5 h in posterior. Mean blood loss of 1.6 L in anterior approach and 1.11 L in posterior. Mean preoperative kyphosis angle in posterior-approach was 34.803°and 11.286° (P < 0.001) at 3 months postopandtotal correction of 67.216%. Mean preoperative kyphosis angle in anterior-approach was 41.154° and 9.498° at 3 months postopandtotal correction of 77.467% (P < 0.001). Mean loss of correction at 1 year was 4.186°in posterior-approach and 6.184°in anterior. The mean time for fusion was 4.69 months in anterior-approach while 6.34 months in posterior as per Bridwell criteria. Meantime for mobilization in posterior-approach was 1.18 and 2.51 weeks in anterior. Significant improvement in neurology was seen in patients operated by either approach, slightly better in anterior. Complications were more in posterior-approach. Conclusions: Anterior-approach allows for thorough debridement, neural decompression, better anterior column reconstruction, and deformity correction under direct vision than posterior. Direct cord visualization while correcting kyphosis reduces the chances of neurological complications significantly. Both approaches have unique advantages and limitations. Though the posterior approach is easy to master, results shown by the anterior cannot be overseen. To conclude, better functional outcome and significantly better kyphosis correction are seen with anterior-approach, which are strong pointers favoring it.
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Can apparent diffusion coefficient predict the grade, genotype, or proliferation index of oligodendrogliomas p. 752
Laghari Altaf Ali, Khalid Muhammad Usman, Mubarak Fatima, Alvi Amna, Ali Tazeen Saeed, Shaikh Namra Qadeer, Shamim Muhammad Shahzad, Enam Syed Ather
DOI:10.4103/ajns.AJNS_520_20  
Background: Genetic subsets of oligodendrogliomas (OD) have distinct chromosomal and biophysical profiles. Pretherapeutic tumor grade and genotype analysis is a challenging aspect of management, with 1p/19q codeletion status and grade of oligodendroglioma among the most important considerations for clinical decision making. Methodology: Seventy-three patients with histopathological diagnosis of oligodendroglioma were selected, and their preoperative 1.5T magnetic resonance imaging (MRI) scans were reviewed through parameters including diffusion weighted image, susceptibility-weighted imaging, and apparent diffusion coefficient (ADC). These images were correlated with patients' histopathological and chromosomal testing. Tumor border irregularity, homogeneity, contrast enhancement, and other MRI characteristics were also studied. For analysis, descriptive statistics were generated, and normality was evaluated for ADC value, age, and Ki-67 tumor proliferation index. Objectives: The study aimed to determine the correlation of ADC with Ki-67, grade, and 1p/19q co-deletion in oligodendroglioma at a tertiary care hospital within a low-middle income country. Results: Ki-67 tumor proliferation index was high in 33 tumors. It was found to be statistically significant (P = 0.048) with respect to ADC, showing that 1p/19q co-deleted tumors have a difference in their Ki-67 index. Ki-67 also showed a significant relationship (P < 0.05) with grade of OD. However, there was no statistically significant relationship between 1p19q chromosomal co-deletion and ADC. Linear regression was carried out as the data set was continuous. Univariate analysis showed no significant result with all P values above 0.10. Conclusion: Mean ADC is a viable tool to predict Ki-67 and assist prognostic clinical decisions. However, mean ADC alone cannot predict 1p/19q codeletion and tumor grades in OD. Further supplementation with other radiological modalities may provide greater yield and positive results.
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Postoperative outcome of robot-assisted transforaminal lumbar interbody fusion: A pilot study p. 759
Sultan Alsalmi, Mohammad Alsofyani, Abdulgadir Bugdadi, Abdu Alkhairi, Johann Peltier, Michel Lefranc
DOI:10.4103/ajns.AJNS_558_20  
Introduction: Transforaminal lumbar interbody fusion (TLIF) surgery is well established for the treatment of discopathy, foraminal disc herniation, and recurrent disc herniation. At the Amiens university medical center, we have been using a robot-assisted technique for performing the TLIF. The purpose of this study is to evaluate the radiological and clinical outcome, specifically pain, of patients having undergone robot-assisted TLIF. Materials and Methods: We performed a retrospective analysis of prospectively collected data of patients having undergone minimally invasive (MI) robot-assisted TLIF between November 2014 and July 2018 in a French university medical center. In clinical consultations at 6 weeks, 12 months, and 24 months posttreatment, patients were assessed for back and leg pain (on a visual analog scale), breached screws, and sagittal parameters. Results: A total of 136 pedicle screws were inserted with robot guidance into 32 patients. Four of the patients required laminectomy before fusion. No pedicle breach occurred for 94% of the screws, and no joint violation was observed for 90%. Lordosis was improved in 78% of the cases. Conclusions: The robot provides valuable assistance during MI arthrodesis; it facilitates the surgical procedure by preplanning the trajectory, providing instantaneous navigation and tracking, and thus assure the accuracy of screw positioning.
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Patient satisfaction with implant removal after stabilization using percutaneous pedicle screws for traumatic thoracolumbar fracture p. 765
Takeshi Sasagawa, Yasutaka Takagi, Hiroyuki Hayashi, Kazuhiro Nanpo
DOI:10.4103/ajns.AJNS_559_20  
Context: There are no reports of patient satisfaction with implant removal after stabilization using percutaneous pedicle screws (PPS) for traumatic thoracolumbar fracture (TTF). Aims: The aim of this study was to investigate patient satisfaction with implant removal after stabilization using PPS for TTF. Settings and Design: A retrospective study. Subjects and Methods: The present study included data from 24 patients who underwent posterior stabilization using PPS for single-level TTF following implant removal. The degree of patient satisfaction was evaluated using a questionnaire. We investigated residuary back pain, using the numerical rating scale (NRS) and Oswestry disability index (ODI), and types of occupation. Patients were divided into groups of those with residuary back pain (Group P) and those without (Group N). We evaluated local kyphosis and disc degeneration after implant removal. We investigated whether residuary back pain or types of occupation affect patient satisfaction. Statistical Analysis Used: All statistical analyses were conducted using IBM SPSS statistics. Results: Patients were “extremely satisfied” in 13 cases (54%), “moderately satisfied” in eight cases (33%), and “neither” in three cases (13%). No patients answered “moderately dissatisfied” or “extremely dissatisfied.” The mean scores on the NRS and ODI in Group P were 1.8 ± 0.9 and 13.2 ± 9.3, respectively. Patient satisfaction, disc degeneration, and local kyphosis were not significantly different between Group P and Group N. Patient satisfaction was not significantly different between the hard and light workgroups. Conclusions: Patient satisfaction with implant removal was high regardless of whether persistent back pain existed and did not depend on the type of occupation.
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Efficacy of transcutaneous electrical nerve stimulation on salivary flow rates in normal healthy adults according to gender and age groups p. 770
C Ramesh, Sharad S Sawant, Deepak R Kolte, Barun Kumar, Kosuru Kranthi, Tejal R Patil, J Suresh Babu, C Swarnalatha, Abhishek Singh Nayyar
DOI:10.4103/ajns.AJNS_48_21  
Introduction: Salivary gland hypofunction might be associated with various local and systemic conditions and is managed with a plethora of therapeutic options with associated side effects. Transcutaneous electrical nerve stimulation (TENS) is one such option with no known systemic side effects for dealing with this crippling condition. The present study was planned with a similar intent of assessing impact of TENS on salivary flow rates in normal healthy adults according to gender and age groups. Materials and Methods: The present study was designed as a cross-sectional study on 130 healthy adults wherein unstimulated and stimulated saliva was collected for 5 min in graduated test tubes fitted with a funnel while mean salivary flow rates were calculated. The data were analyzed using SPSS version 17.0 (SPSS Inc., Chicago, IL, USA). Results: In the present study, differences between mean unstimulated and stimulated salivary flow rates with TENS were found to be statistically significant for both genders (P < 0.001). Furthermore, in relation to age groups included, maximum increase in salivary flow rate was seen in 20–29 years of age group, though significant results were seen in all three age groups included namely 20–29 years, 30–39 years, and 40–49 years (P < 0.001). Conclusions: Based on results from the present study, it could be concluded that TENS comes out to be a safer, nonpharmacological therapeutic option for treating patients with xerostomia.
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Risk factors associated with malignant transformation of astrocytoma: Competing risk regression analysis p. 777
Thara Tunthanathip, Surasak Sangkhathat, Kanet Kanjanapradit
DOI:10.4103/ajns.ajns_159_21  
Background: Malignant transformation (MT) of low-grade astrocytoma (LGA) triggers a poor prognosis in benign tumors. Currently, factors associated with MT of LGA have been inconclusive. The present study aims to explore the risk factors predicting LGA progressively differentiation to malignant astrocytoma. Materials and Methods: The study design was a retrospective cohort study of medical record reviews of patients with LGA. Using the Fire and Grey method, the competing risk regression analysis was performed to identify factors associated with MT, using both univariate and multivariable analyses. Hence, the survival curves of the cumulative incidence of MT of each covariate were constructed following the final model. Results: Ninety patients with LGA were included in the analysis, and MT was observed in 14.4% of cases in the present study. For MT, 53.8% of patients with MT transformed to glioblastoma, while 46.2% differentiated to anaplastic astrocytoma. Factors associated with MT included supratentorial tumor (subdistribution hazard ratio [SHR] 4.54, 95% CI 1.08–19.10), midline shift >1 cm (SHR 8.25, 95% CI 2.18–31.21), nontotal resection as follows: Subtotal resection (SHR 5.35, 95% CI 1.07–26.82), partial resection (SHR 10.90, 95% CI 3.13–37.90), and biopsy (SHR 11.10, 95% CI 2.88–42.52). Conclusion: MT in patients with LGA significantly changed the natural history of the disease to an unfavorable prognosis. Analysis of patients' clinical characteristics from the present study identified supratentorial LGA, a midline shift more than 1 cm, and extent of resection as risk factors associated with MT. The more extent of resection would significantly help to decrease tumor burden and MT. In addition, future molecular research efforts are warranted to explain the pathogenesis of MT.
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Microsurgical anatomy of middle cerebral artery in Northwest Indian Population: A cadaveric brain dissection study p. 785
Rakshith Srinivasa, Kedia Shwetha, Salunke Pravin, Saini Daisy, Basu Eilene, Suresh Narain Mathuriya, Krishnakutty Muthiraklayil Sareeshkumar
DOI:10.4103/ajns.ajns_189_21  
Background: Microsurgical anatomy of the Middle Cerebral Artery (MCA) of the Northwest Indian population has not been described to date. A study of cadaveric brains will add to the existing knowledge of brain vessels. Objective: To study and compare the microsurgical anatomy of MCA in Northwest Indian Population with that of the available literature. Methods and Material: 15 Formalin Fixed Cadaveric brains, that is 30 vessels from its origin from Internal Cerebral Artery to M5 segment with respect to diameter, length and branching pattern were studied under high magnification (operating microscope) and the data compared with literature. Results: The main trunk of MCA was 16±3 mm long with no significant differences between both sides. Its outer diameter was 3±0.1 mm. Among the early branches 58% were destined to the temporal lobe. Distance between the origin of the early branch from MCA origin was 4±2mm on the right side and 4.5±2.5 mm on the left side. The most consistent perforating branch group was the intermediate group. The pattern of branching of the main trunk was bifurcation (73%), single trunk (10%) and trifurcation (10%). Within the bifurcation group, inferior trunk dominance was seen in 50%. Amongst the cortical branches diameter of the angular artery was largest and the temporo-polar was smallest. No significant difference in the data as compared to literature. Conclusions: The knowledge of anatomy of MCA and its variations are important for neurosurgical residents' training and neurosurgeons dealing with MCA aneurysm management or bypass surgeries.
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Facial fractures: Independent prediction of neurosurgical intervention p. 792
Brandon Lucke-Wold, Kevin Pierre, Sina Aghili-Mehrizi, Gregory Joseph Anatol Murad
DOI:10.4103/ajns.AJNS_251_21  
Context: Over half of patients with facial fractures have associated traumatic brain injury (TBI). Based on force dynamic cadaveric studies, Lefort type 2 and 3 fractures are associated with severe injury. Correlation to neurosurgical intervention is not well characterized. Aims: This study characterizes fracture pattern types in patients requiring neurosurgical intervention and assesses whether this is different from those not requiring intervention. Settings and Design: Retrospective data were collected from the trauma registry from 2010 to 2019. Subjects and Methods: Patients over 18, with confirmed facial fracture, reported TBI, available neuroimaging, and hospital admission were included. Statistical Analysis Used: Retrospective Contingency Analysis with Fraction of Total Comparison was used with Chi-square analysis for demographic and injury characteristic data. Results: One thousand and one patients required no neurosurgical intervention and 171 required intervention. The intervention group had a significantly greater number of patients with Glasgow Coma Scale (GCS) <8 compared to the nonintervention group. Subset analysis revealed a twofold increase in Lefort type 2 fractures and notable increase in Lefort type 3 and panfacial fractures in the intervention group. Patients requiring craniectomy, craniotomy, or burr holes were much more likely to have Lefort type 2 or 3 fractures compared to those only requiring external ventricular drains or intracranial pressure monitoring. Subset analysis accounting for GCS supported these results. Conclusions: Lefort type 2 and type 3 fractures are significantly associated with requiring neurosurgical intervention. An improved algorithm for managing these patients has been proposed in the discussion. Ongoing work will focus on validating and refining the algorithm to improve patient care.
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Early exposure of the dorsal surface of M1 segment via the distal transsylvian approach for clipping of anteroinferior-projecting middle cerebral artery bifurcation aneurysms p. 797
Kitiporn Sriamornrattanakul, Nasaeng Akharathammachote, Somkiat Wongsuriyanan
DOI:10.4103/ajns.ajns_275_21  
Background: Middle cerebral artery bifurcation (MCAB) aneurysms are common intracranial aneurysms. Anteroinferior-projecting MCAB aneurysms, with the M1 segment usually embedded into the deep part of the Sylvian fissure, cause some surgical challenges. The distal transsylvian approach (DTSA) allows M1 exposure from the dorsal surface for proximal control in the early step. Therefore, this study aimed to demonstrate the efficacy and safety of DTSA for clipping anteroinferior-projecting MCAB aneurysms. Materials and Methods: Among 97 patients with MCA aneurysms, 13 with anteroinferior-projecting MCAB aneurysms who underwent aneurysm clipping via the DTSA between June 2018 and January 2021 were retrospectively evaluated for the aneurysm obliteration rate, surgical complications, and outcomes. Results: Ten patients (76.9%) had ruptured MCAB aneurysms and three (23.1%) had incidentally discovered unruptured MCAB aneurysms. Favorable outcome was achieved in 100% of patients with good grade. The complete aneurysm obliteration rate was 100% without intraoperative lenticulostriate artery injury. Twelve (92.3%) patients had early identified distal M1 segment for proximal control, and one (7.7%) patient had premature rupture of aneurysm that achieved favorable outcome at 3 months postoperatively. Difficult M1 exposure and premature rupture occurred in the patient with MCAB located above the Sylvian fissure line. Permanent postoperative neurological deficit was detected in one patient due to severe vasospasm. Conclusions: DTSA, which simplify the early exposure of the dorsal surface of distal M1, is safe and effective for clipping anteroinferior-projecting MCAB aneurysms without extensive Sylvian fissure dissection. High-positioned MCAB requires careful dissection of the aneurysm neck with consideration of tentative clipping preparation.
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Rolandic cortex morphology: Magnetic resonance imaging-based three-dimensional cerebral reconstruction study and intraoperative usefulness p. 805
Krishnapundha Bunyaratavej, Piyanat Wangsawatwong
DOI:10.4103/ajns.ajns_307_21  
Background: During brain surgery, the neurosurgeon must be able to identify and avoid injury to the Rolandic cortex. However, when only a small part of the cortex is exposed, it may be difficult to identify the Rolandic cortex with certainty. Despite various advanced methods to identify it, visual recognition remains an important backup for neurosurgeons. The aim of the study was to find any specific morphology pattern that may help to identify the Rolandic cortex intraoperatively. Materials and Methods: Magnetic resonance imaging of the brain from patients with various conditions was used to create the three-dimensional cerebral reconstruction images. A total of 216 patients with 371 intact hemispheres were included. Each image was inspected to note the morphology of the Rolandic cortex and the suprasylvian cortex. In addition, other two evaluators exclusively inspected the morphology of the suprasylvian cortex. Their observation results were compared to find the agreements. Results: A number of distinctive morphology patterns have been identified at the Rolandic cortex and the suprasylvian cortex including a genu, or a knob at the upper precentral gyrus (pre-CG), an angulation of the lower postcentral gyrus (post-CG), a strip for pars opercularis, a rectangle for the lower pre-CG, and a triangle for the lower post-CG. Combined total and partial agreement of the suprasylvian cortex morphology pattern ranged 60.4%–85.2%. Conclusion: The authors have demonstrated the distinctive morphology of the Rolandic cortex and the suprasylvian cortex. This information can provide visual guidance to identify the Rolandic cortex particularly during surgery with limited exposure.
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Effect of preoperative serum transthyretin levels on postoperative clinical results and morbidity in patients undergoing spinal surgery p. 811
Bora Gurer, Hayri Kertmen
DOI:10.4103/ajns.ajns_228_21  
Introduction: This study aims to investigate the effects of preoperative serum transthyretin (TTR) levels on surgical success, pain scores, and postoperative morbidity. Methods: Note that, in our clinic, 188 patients who were operated for spinal pathologies between June 2010 and January 2011 were included in this study. Blood samples were drawn from all patients on the morning of surgery, and then, serum TTR measurements were made. Demographic data of all patients were collected, and then their preoperative and postoperative neurological examinations, Karnofsky scores, Visual Analog Scale (VAS) scores, Oswestry disability index (ODI) scores, postoperative infection and wound healing status, hospital stay, and morbidity levels were recorded, and TTR levels were compared. Results: When preoperative TTR level of patients was low, their Karnofsky scores decreased, ODI scores increased, the early postoperative VAS and late postoperative VAS values increased, and the length of hospital stay was increased. Moreover, in patients with low TTR levels, postoperative Karnofsky scores were lower, postoperative ODI levels were higher, postoperative early and late VAS scores were higher, hospital stays were longer, peroperative complication rates were higher, wound infection rates were higher, the delay in wound site healing was higher, and the morbidity rate was higher. Conclusion: Consequently, preoperative low TTR levels have been reported to be an effective parameter that can be used to predict surgical results, wound infection and wound site healing status, perioperative complications, and morbidity in spinal surgery.
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Linear cephalometric analysis of pharynx at the level of epiglottis among snorers and nonsnorers: A cross-sectional study p. 817
Ravi Rathod, Vimal Joseph Devadoss, Baliram Jadav, Reshmi Leila Ninan, B Kanagasabapathy, AR Ramshad, J Suresh Babu, C Swarnalatha, Abhishek Singh Nayyar
DOI:10.4103/ajns.ajns_315_21  
Background and Aim: Snoring, which falls within the spectrum of sleep-related breathing disorders, is considered to be one of the common symptoms of airway obstruction. Lateral cephalometric analysis is an effective way of diagnosing airway obstruction by evaluating skeletal and soft-tissue abnormalities in patients with sleep-disordered breathing. The present study was planned to analyze the pharyngeal space among snorers and nonsnorers in retroglossal region and in the region of the hypopharynx at the level of epiglottis. Materials and Methods: The present cross-sectional study included a total of 60 individuals who were grouped into snorers and nonsnorers based on their answers for the study questionnaire related to snoring. Digital lateral cephalograms were taken for all maintaining the exposure parameters, whereas Digora software was used for measurements related to the soft-tissue parameters. The two significant soft-tissue parameters analyzed were the distance of epiglottis from the tip of the soft palate, the retroglossal length and the distance of posterior pharynx from the tip of the epiglottis, the pharyngeal space. Statistical Analysis Used: The statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) version 17.0 (SPSS Inc., Chicago, IL, USA), whereas paired t-test was used for inter-group analysis. P <0.05 was considered statistically significant. Results: The mean retroglossal length was found to be 25.52 mm among the snorers and 23.70 mm among the nonsnorers. In the case of pharyngeal space, a mean of 8.54 mm was recorded among the snorers, whereas among the nonsnorers, the respective mean value of 10.16 mm was observed. Conclusion: In the present study, pharyngeal space was found to be less at the level of the tip of epiglottis among the snorers compared to nonsnorers which can be attributed to be one of the significant reasons behind snoring and obstructive sleep apnea syndrome.
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TECHNICAL NOTE Top

Transfalcine approach for the resection of a bilateral falx meningioma: Technical nuances and review of literature p. 821
Sebastien Boissonneau, Nathan Beucler, Thomas Graillon, Kaissar Farah, Stephane Fuentes, Henry Dufour
DOI:10.4103/ajns.AJNS_476_20  
The tendency to reduce invasive surgeries is gaining more adepts, and the primary goal in meningioma surgery is the maximal safe resection. Falx meningioma is common location for intracranial meningioma, and according to their deep localization, falx meningioma represents a neurosurgical challenge. The objective of the study is to report the feasibility of a transfalcine nontumor dominant side approach for a bilateral falx meningioma. We report a technical note about the surgical approach of a 44-year-old female suffering from an evolutive meningioma of the middle third of the falx. According to the venous drainage anatomy, and the tumor conformation, a contralateral transfalcine approach was done. We described with details this surgical approach, and a reflection about transfalcine approach is proposed, which is a variant of the interhemispheric approach. It permits a good exposure of the medial surface of the contralateral hemisphere thanks to a falx incision. Moreover, a literature review is proposed about 278 articles with a special emphasis on transfalcine approach in meningioma surgery. We report an original minimal invasive approach for an intracranial meningioma, with a complete resection (Simpson I) without any technical complication. This contralateral transfalcine approach brings new technical nuances for the resection of falx or midline intracranial tumors.
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CASE REPORTS Top

Papillary tumor of Pineal Region in a 5-year-old male child: A rare entity p. 824
Kanika Gupta, Sumat Khursheed, Khursheed Nayil, Sumaira Khursheed, Rumana Makhdoomi
DOI:10.4103/ajns.AJNS_81_19  
Papillary tumor of the pineal region (PTPR) is a rare grade II to III pineal lesion. These tumors mostly occur in adults, only rarely in children, with six cases in children under the age of 16 years (10.2%) up to now. We report the case of a 5-year-old male child presenting with worsening headaches, abnormally enlarged head since birth and visual disturbances. Imaging reveals a mass in the region of the pineal gland. The third and lateral ventricles were enlarged. The patient underwent a gross-total surgical resection of pineal mass through a suboccipital supracerebellar approach and tissue sent for histopathological examination and an available immunohistochemical workup has been done which confirmed the diagnosis of papillary tumor pineal region. This case highlights the histopathological features, imaging along clinical presentation similar to those in the original description of this rare entity PTPR. More studies are required to determine the prognosis and standard treatment protocol of this rare entity.
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Symptomatic postsurgical lumbar pseudomeningocele treated by ultrasound-guided epidural blood patch application p. 827
Rohit Akshay Kavishwar, Ajoy Prasad Shetty, Balavenkata Subramanian, Shanmuganathan Rajasekaran
DOI:10.4103/ajns.AJNS_83_21  
Postsurgical pseudomeningoceles are extradural collections of cerebrospinal fluid (CSF) that results following an intraoperative dural breach. Although usually asymptomatic and self-subsiding, they may present with symptoms of postural headache, blurred vision, diplopia, photophobia, back pain, radiculopathy, and vomiting. Most of the cases recover with conservative measures such as bed rest, hydration, and pressure dressings. Symptomatic patients usually require surgical re-exploration and direct open repair of the durotomy. We report the case of a 48-year-old female who presented with lumbar pseudomeningocele following lumbar microdiscectomy treated by Ultrasound-guided (USG)-guided epidural blood patch application. She had globular swelling at the surgical site, postural headache, and left lower-limb radicular pain with normal neurology. Her magnetic resonance imaging (MRI) showed a left L4 laminar defect with pseudomeningocoele (measuring 5.5 cm × 4.2 cm × 4 cm) with intraspinal communication. USG was used to guide the aspiration of CSF from pseudomeningocele and to apply the epidural blood patch one level above and at the level of laminectomy. Postoperatively, she had marked improvement in her symptoms. At 1-year follow-up, she was completely symptom free and full resolution of pseudomeningocele was seen on 1-year follow-up MRI. This case is being reported to highlight the use of USG-guided epidural blood patch for the treatment of postoperative lumbar pseudomeningocele.
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Cocaine-induced massive ischemic stroke treated by decompressive craniectomy with favorable outcome p. 830
Hussein Algahtani, Bader Shirah, Mubarak Algahtany, Saeed Alqahtani, Nawal Abdelghaffar
DOI:10.4103/ajns.AJNS_104_21  
Cocaine abuse is a significant health hazard with multiple cardiac and neurological complications. Cocaine-induced ischemic stroke can have multiple underlying pathophysiological mechanisms, resulting in various complex neurological presentations. We describe a case of a young man who had a massive ischemic multi-territorial stroke who was managed successfully with decompressive craniectomy with a favorable outcome. Cocaine use should be routinely suspected in young patients presenting with ischemic stroke, and a urine toxicology screen should be part of the initial workup for such patients. Brain magnetic resonance imaging is an essential neuroimaging modality, which is very helpful in confirming the ischemic insult and planning management. Early diagnosis and treatment are crucial due to potential reversibility and reduction of the size of infarcted tissue. In addition, multidisciplinary care, including a vascular neurosurgeon, should be implicated.
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Multiple cranial nerve involvement as a presentation of primary central nervous system lymphoma: A case-based review p. 835
Tanvi Modi, Mitusha Verma, Deepak Patkar
DOI:10.4103/ajns.AJNS_110_21  
Central nervous system (CNS) lymphoma is of two types: primary and secondary (more common). Primary CNS lymphoma usually presents as parenchymal lesions having characteristic imaging findings and may be associated with leptomeningeal involvement. Involvement of multiple cranial nerves as the initial manifestation of primary CNS lymphoma with the development of typical parenchymal lesions on follow-up is a rare entity. This nerve involvement is termed as neurolymphomatosis. We present the magnetic resonance imaging features of five patients presenting with neurolymphomatosis due to non-Hodgkin's lymphoma.
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A true mimicker to plasmacytoma clinically, radiologically, and pathologically – A rare case report p. 841
Shino P Ashly, Anu C Thomas, Sajeev S Vadakkedam
DOI:10.4103/ajns.AJNS_116_21  
Lympho plasmacytoma is distinct type of diffuse large B cell lymphoma predominantly seen in HIV-positive patients. The diagnosis of lympho plasmacytoma could be a challenge due to its overlapping characterizes with those of myeloma and lymphoma. We report a case of a 50-year-old man who initially presented with a painful solitary destructive lesion at the second lumbar vertebra. Clinico-pathological findings were consistent with a solitary plasmacytoma, and he was treated with definitive radiotherapy. Eight months after completing radiotherapy, he was found to have similar lesions at D4 vertebral body, multiple ribs, and pelvis. Subsequent biopsy confirmed lympho plasmacytoma. Because of its rarity and heterogeneous presentations, lympho plasmacytoma could easily be overlooked clinically and pathologically in immunocompetent patients. The diagnosis of lympho plasmacytoma should be considered when there is coexpression of myeloma and lymphoma immune markers.
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Purely suprasellar (Hypothalamic) atypical teratoid rhabdoid tumor presenting with diabetes insipidus and panhypopituitarism in an adult male: A case report and review of literature p. 846
Ahmed Shaaban, Amro Al Hajali, Orwa Elaiwy, Ahmed El Sotouhy, Issam Al-Bozom, Ali Ayyad
DOI:10.4103/ajns.AJNS_328_20  
Atypical teratoid rhabdoid tumor (ATRT) is a rare primary malignant tumor of the central nervous system. Little knowledge is available about natural history, behavior, prognosis, and best management guidelines of such tumor. Its occurrence in adults is very rare and more predominant in females. Locations in adults are mainly cerebral hemispheres, but recently, more cases are reported in sellar/suprasellar cisterns. We are reporting a case of purely suprasellar ATRT of a middle aged male who presented initially with diabetes insipidus (DI).
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Revisiting dandy–Walker malformation with associated neurofibromatosis p. 850
Shreykumar Pravinchandra Shah, Jaypalsinh Ashoksinh Gohil, Krishnakumar Kesavapisharady, Harihara Venkat Easwer
DOI:10.4103/ajns.AJNS_468_20  
This report describes a very rare Dandy–Walker malformation (DWM) associated with neurofibromatosis (NF) and bony defect over torcula emphasizing the role of meticulous follow-up for asymptomatic DWM. The clinical aspects of an adolescent patient with undiagnosed DWM who was asymptomatic until the age of 14 years are being discussed. Computed tomography and magnetic resonance imaging were revealed DWM. To our knowledge, this is the first report from India that describes a patient who has been diagnosed with DWM with associated NF with bony defect over torcula creating a management dilemma.
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Spinal intradural extramedullary capillary hemangioma with coexistent spinal edema and syringomyelia successfully treated by tumor removal and cervical laminoplasty p. 854
Motohiro Takayama, Yoshinori Maki
DOI:10.4103/ajns.AJNS_51_21  
Capillary hemangioma (CH) is usually found in pediatric patients and is located in soft tissue of the neck or head. As uncommon location of CH, spinal intradural extramedullary space has been reported; however, coexistent spinal edema or syringomyelia with spinal intradural extramedullary CH seems rare manifestations on preoperative magnetic resonance imaging. Laminectomy and tumor resection have been often performed for spinal intradural extramedullary CH. An 83-year-old man was referred to our hospital, complaining of nocturia and motor weakness of the lower extremities. Magnetic resonance imaging revealed a mass at the level of T1, which was homogeneously enhanced on gadolinium-enhanced T1-weighted images. The lesion was accompanied by spinal edema and syringomyelia. An intradural extramedullary tumor was first considered. We thought that the coexistent spinal edema and syringomyelia could have been caused by spinal stenosis. Preoperative angiography revealed that the mass was fed by the radicular artery of C5–C6. To improve the clinical symptoms of the patient, tumor removal and cervical laminoplasty were performed. The spinal edema and syringomyelia regressed postoperatively. The histopathological diagnosis was CH. This is the first reported case of cervical intradural extramedullary CH with spinal edema and syringomyelia successfully treated by cervical laminoplasty and tumor removal.
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Metastatic colon cancer in the pituitary: A case report with review of literature p. 872
Kishan Karia, Sally-Ann Price, Wai Cheong Soon, Yasir Arafat Chowdhury, Kyaw Zayar Thant, Ruchika Batra, Sara Meade, Niki Karavitaki, Georgios Tsermoulas
DOI:10.4103/ajns.AJNS_52_21  
We report a rare case of metastatic colonic adenocarcinoma to the pituitary gland in a 58-year-old who presented with visual decline and panhypopituitarism. He underwent urgent transsphenoidal endoscopic surgery with significant improvement of his vision, followed by adjuvant fractionated radiotherapy to the resection cavity. He made a satisfactory recovery, but regrettably died from COVID-19 9 weeks after completion of radiotherapy. A multidisciplinary approach is essential for optimal management of this condition due to its rarity and complexity.
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Neurocutaneous melanosis with hydrocephalus and dandy-walker variant p. 876
Mohammad Sarwar, Laxminarayan Tripathy, Harsh Jain, Sunandan Basu, Ashvini Sengupta
DOI:10.4103/ajns.AJNS_542_20  
Neurocutaneous melanosis (NCM) is one of the rare, congenital, noninheritable phakomatoses characterized by the presence of large and/or multiple congenital melanocytic cutaneous nevi associated with intracranial leptomeningeal melanocytosis. NCM usually presents before 2 years of age. So far 302 cases have been reported in literature. We report a case of NCM presenting with obstructive hydrocephalus and Dandy-Walker Variant in a young adult.
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Understanding of pathophysiology and optimal treatment for anterior circulation large vessel occlusion beyond 24 h from onset of stroke p. 881
Takashi Mizowaki, Atsushi Uyama, Atsushi Fujita, Jun Imura, Hiroyasu Shose, Hirotomo Tanaka, Yoshiyuki Takaishi, Takeshi Kondoh
DOI:10.4103/ajns.AJNS_554_20  
We report three cases in which endovascular treatment (EVT) was performed for anterior circulation large vessel occlusion (LVO) beyond 24 h from the onset of stroke. Case 1 experienced left hemispatial neglect and gait disorder due to right internal cerebral artery (ICA) occlusion and underlying atherosclerosis. After percutaneous transluminal angioplasty (PTA), revascularization with mild stenosis was achieved. Case 2 complained of reduced activity, motor aphasia, and right-sided hemiparesis due to left middle cerebral artery occlusion. After thrombectomy using a retrieval stent, revascularization with M1 stenosis and distal perfusion delay was observed, which improved after PTA. Case 3 arrived at our hospital 30 h after the onset of dysarthria and gait disturbance due to left ICA occlusion. Since the symptoms were mild, medical treatment was started; however, the patient's symptoms deteriorated 6 h later, and EVT was required. After thrombectomy using a retrieval stent, revascularization was achieved. LVO pathophysiology beyond 24 h of stroke onset varies and may require multimodal treatment. Preserving the pyramidal tract may lead to favorable outcomes, even in cases of anterior circulation LVO. EVT may be effective for anterior circulation LVO because, in some patients, infarct volume continues to increase >24 h after stroke onset.
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Hydatid cyst of dorsal spine masquerading as tubercular infection: A case report and review of literature p. 886
Gurudip Das, Saurav Narayan Nanda, Nabin Kumar Sahu, Doki Sunil Kumar, Bishnu Prasad Patro
DOI:10.4103/ajns.ajns_199_21  
Hydatid cyst disease of the spine is rare, and only a few are reported in the scientific literature. This infection is caused by the larvae of Echinococcus granulosus cestode. The presentation is usually late because the patient remains asymptomatic for a longer duration after the infection. The initial form of treatment is always surgical in a symptomatic patient for excision of the diseased tissue. A 35-year-old male presented in the outpatient department with a chief complaint of mid-back pain and intermittent history of fever following his back surgery for 4 years. The patient has taken presumptive treatment for tuberculosis before presenting it to us. Radiological investigations dictate the presence of hydatid cyst in the D4 vertebra. Intact cysts were excised with perioperative albendazole coverage. The patient was mobilized on postoperative day-1 with Taylor's brace, and the brace was continued for 6 weeks. The patient was followed up at regular intervals for 1 year, and no recurrence was found. Hydatid cyst disease in the spine is a rare disease but associated with high morbidity despite significant advances in diagnostic imaging techniques and surgical treatment. For a provisional diagnosis, magnetic resonance imaging is the investigation of choice. Surgical decompression is the main stray of treatment along with antihelminthic therapy. A close follow-up is required after the initial treatment to find the recurrence at the earliest.
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Pituitary apoplexy following severe diabetic ketoacidosis, with two uncommon complications of supraventricular tachycardia and acute limb ischemia, in a patient with neglected pituitary adenoma and undiagnosed diabetes mellitus: A rare clinical association p. 890
Sanjeev Pattankar, Phulrenu Chauhan, Farhad Kapadia, Milind Sankhe
DOI:10.4103/ajns.ajns_217_21  
Pituitary apoplexy (PA) is a clinical emergency arising from acute ischemia or hemorrhage of the pituitary gland. A small subset of pituitary adenomas present with an apoplectic crisis, with common symptoms being headache, nausea-vomiting, visual impairment, ophthalmoplegia, altered sensorium, and panhypopituitarism. Though diabetic ketoacidosis (DKA) is an established complication of uncontrolled diabetes mellitus, its association with PA is extremely rare. Likewise, supraventricular tachycardia (SVT) and Acute limb ischemia (ALI) have rare, reported association with DKA. We present one such case of rare associations seen in our clinical practice. A 20-year-old woman was brought to our emergency room with headache, breathlessness, and altered sensorium. Clinical and biochemical evaluation revealed SVT, DKA, and right lower limb ALI. On enquiry, the patient was found to be diagnosed with pituitary adenoma 2 years ago and lost to follow-up. PA was detected on neuroimaging and confirmed histopathologically. Possibility of PA presenting as DKA and its sequelae exists.
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Cerebrospinal fluid hypovolemia: A case report of a red herring p. 895
Brannan E ONeill, Nasser K Yaghi, Maryam N Shahin, Olabisi R Sanusi, Justin S Cetas, Aclan Dogan
DOI:10.4103/ajns.ajns_239_21  
Mild intracranial hypotension can lead to classically recognizable symptoms such as positional headaches, nausea, vomiting, and occasionally blurred vision. Less commonly, severe cerebrospinal fluid (CSF) hypovolemia can lead to a life-threatening condition that mimics intracranial hypertension, including transtentorial herniation and subsequent rapid neurologic decline. In this report we present a unique case of severe intracranial hypotension from a thoracic tumor resection that led to symptoms initially mistaken for intracranial hypertension, however ultimately correctly diagnosed as severe CSF hypovolemia that improved with dural repair. Additionally, we describe a rare angiography finding associated with CSF hypovolemia, kinking of the basilar artery. Here we report a 47-year-old female with neurofibromatosis Type 2 found to have a T3 intradural extramedullary tumor. She initially presented with urinary incontinence and gait/balance difficulty. She underwent thoracic laminectomies at T3 and T4 for the excision of the lesion. She was discharged on postoperative day 4. On postoperative day 9, she was noted to have nausea, vomiting, and decreased consciousness. Head computed tomography (CT) demonstrated acute downward herniation. She was transferred to our institution from a community facility obtunded and was intubated for airway protection. She was placed in the Trendelenburg position with immediate improvement, and declined every time her head was raised. Angiogram showed significant kinking of her basilar artery. A CT myelogram revealed a CSF leak from her recent thoracic surgery. She underwent exploration of her thoracic wound, and a ventral durotomy was repaired. Following this, she began to tolerate the head of bed elevations and recovered back to her neurologic baseline. A postoperative head CT angiography obtained before discharge showed improvement of her basilar kink. Mild intracranial hypotension is a common finding in patients who undergo procedures that enter the CSF space. Severe intracranial hypotension can easily be missed diagnosed as the signs on the exam are similar to patients with signs of intracranial hypertension. It is of paramount importance that the clinician recognizes brain sag, as the treatment algorithms are vastly different from that of intracranial hypertension leading to transtentorial herniation.
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Fibromuscular dysplasia: A rare case with multiple vascular beds involvement p. 899
Siew-Hong Yiek
DOI:10.4103/ajns.AJNS_269_21  
Fibromuscular dysplasia (FMD) is an idiopathic, non-inflammatory, and non-atherosclerotic vascular disease of small- to medium-sized arteries. It can be occurred in almost all arteries and most commonly involving cervicocranial and renal arteries. FMD is commonly present as renovascular hypertension and affecting most young ladies. However, this case demonstrates a casuistically rare form of multiple arterial beds involvement at different sites, i.e. vertebral, coronary, hepatic, and lumbar arteries, with the conjunction of both bilateral renal and cervicocranial arteries.
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Intracranial myopericytoma: A rare benign tumor at an extremely rare location p. 902
Ashish Kumar Shrivastav, Manish Garg, Hema Malini Aiyer, Gaurav Sharma, Prachi
DOI:10.4103/ajns.ajns_255_21  
A 50-year-old female with a history of seizures, headache, nausea, and vomiting. On imaging, parafalcine meningioma with mass effect features was rendered. She underwent right frontal tumor excision and craniotomy. Pathological examination showed a tumor composed of syncytial aggregates of round to plump fusiform cells forming whorls around prominent branching congested vessels. The tumorous cells expressed alpha-smooth muscle actin and heavy chain caldesmon and were negative for epithelial membrane antigen, protein S100, HMB45, CD34, calponin and desmin, thus providing the final diagnosis of intracranial myopericytoma. The rarity of this benign tumor at an extremely location, prompted this study. As preoperative radiological investigations are nonspecific in such cases, hence a detailed and comprehensive pathological examination is mandatory to come to a definitive diagnosis.
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Is “Vital” more appropriate than “Super” specialty in addressing emergency neurosurgery for head injury and stroke in rural India p. 907
Mohinish Bhatjiwale, Mrudul Bhatjiwale
DOI:10.4103/ajns.ajns_179_21  
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