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   Table of Contents - Current issue
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July-September 2021
Volume 16 | Issue 3
Page Nos. 445-668

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GUEST EDITORIAL  

Optimal surgical resection of intracranial epidermoid tumor: A tailored approach Highly accessed article p. 445
SA Javadi, Zahid Hussain Khan
DOI:10.4103/ajns.AJNS_12_21  
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REVIEW ARTICLES Top

Extra-axial cerebello-pontine angle medulloblastoma in an infant: A rare case report with review of literature Highly accessed article p. 447
Santosh Prabhu, Sidharth Agarwal, Sujata Prabhu, Akash Prabhu
DOI:10.4103/ajns.AJNS_79_21  
Medulloblastoma is a fairly common neoplastic growth seen majorly in children, presenting as an intra-axial midline mass arising from the cerebellar vermis. However, its presentation as an extra-axial mass in the cerebellopontine angle (CPA) is extremely rare, such that, only 39 cases have been reported in the world literature till 2016. Only one case has ever been reported of an extra-axial CPA medulloblastoma in an infant; who was aged 1 year. We present a case report of an 8-month-old infant, with an extra-axial CPA medulloblastoma and discuss its management strategy.
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Pediatric central nervous system cancers in the democratic People's Republic of Korea Highly accessed article p. 452
Sunwoo Park, Sandra Moon, David S Hong, Kee B Park
DOI:10.4103/ajns.AJNS_76_21  
Purpose: Central nervous system (CNS) cancers rank as the most frequent solid tumors and the leading cause of cancer-related deaths in children and adolescents. There is less information available about pediatric brain and CNS tumors in low-income and middle-income countries, suggesting a lack of surgical accessibility or limited capacity to treat these conditions. In this study, we chose to study the epidemiology of CNS cancers in the Democratic People's Republic of Korea (DPRK). Methods: We extracted the prevalence, incidence, deaths, and disability-adjusted life years (DALYs) associated with CNS cancers in individuals under the age of 20 from the 2017 Global Burden of Disease study from the Institute for Health Metrics and Evaluation. DALYs, which signify the number of healthy life years lost due to ill health, disability, or early death. Economic impact was calculated from DALYs. Conclusions: Given the large burden of brain and CNS cancers among all pediatric cancers in the DPRK, scaling up and strengthening surgical services for children is an essential component to improving care of pediatric CNS cancers in the DPRK. Childhood cancers are time sensitive, and early diagnosis and treatment are vital in ensuring improved survival for the vulnerable pediatric cancer patient population. As surgical treatment can often prolong lives and even prevent premature deaths from these cancers, further analysis of current surgical capacity can inform the path to meeting these critical pediatric surgical needs.
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COVID-19-associated acute disseminated encephalomyelitis: A systematic review Highly accessed article p. 457
Kiran Sunil Mahapure, Anagha Sudhakar Prabhune, Aradhana Vijaysinh Chouvhan
DOI:10.4103/ajns.AJNS_406_20  
Objective: The objective of this study was to provide an overview of acute disseminating encephalomyelitis, a potential and serious complication of COVID-19. Methods: Three primary databases were used, PubMed, LitCovid, and WHO. The final review articles reported acute disseminated encephalomyelitis (ADEM) in COVID-19-positive patients and were full-text, peer-reviewed articles. Articles which did not have patient data such as in vitro studies and articles with unclear inference were excluded. Results: Out of 21 cases of ADEM, the diagnosis of severe acute respiratory syndrome-coronavirus 2 was confirmed in 18 and suspected in 3. Among the neurological symptoms, altered consciousness was most common (7/21), followed by anosmia (3), paraplegia (3/21), brain stem involvement (3/21), sphincter involvement (2/21), and quadriplegia (1/21). Raised inflammatory markers were most commonly seen in 9/17. Central nervous system imaging was abnormal in 19 cases and unavailable in 2 cases. Fifteen patients were treated with corticosteroids, 11 patients received intravenous immunoglobulin, while 3 patients received convalescent plasma. Two patients needed surgical intervention. Complications included seizures (1), acute kidney injury and septicemic shock (1), raised intracranial pressure (1), and supraventricular tachycardia secondary to hydroxychloroquine (1). One patient recovered completely and one had good recovery with mild deficits. Thirteen patients had incomplete recovery with residual neurological deficit while three patients died as the consequence of the disease. Conclusion: The physicians and neurosurgeons should be diligent while treating the COVID-19 patients with neurological manifestations and include ADEM as a differential diagnosis and stress on early diagnosis and treatment to reduce mortality and achieve satisfactory clinical outcome.
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Fourth ventricular epidermoid cyst – Case series, systematic review and analysis Highly accessed article p. 470
Sanjeev Kumar, Debabrata Sahana, Lavlesh Rathore, Rajiv Kumar Sahu, Amit Jain, Praveen Borde, Manish Tawari, Satya Narayan Madhariya
DOI:10.4103/ajns.AJNS_539_20  
Background: Epidermoid cysts are extra-axial, pearly white avascular lesions mostly found in the cerebellopontine region. They are slow-growing and mostly become symptomatic when they attain significant size. They do occur at other anatomical locations, but fourth ventricle is a rare location. Three representative cases with their outcomes are described here. Methods: The systematic review was done with adherence to predefined criteria. The studied variables were age, gender, duration of symptoms (DOS), clinical features, hydrocephalus (HCP), extent of resection, postoperative complications, outcome, follow–up, and recurrence. Statistical analysis was done to identify predictive factors for outcome. Results: Final analysis included 58 studies containing 131 patients. The most common clinical feature was cerebellar dysfunction (93%). The most common cranial nerve involved was the abducens nerve (n = 37, 28.46%). Preoperative HCP was present in nearly a third (35%) of patients. The outcomes were not different with age (P = 0.23), gender (P = 0.74), DOS (P = 0.09), and HCP (P = 0.50). Improved outcomes were associated with total resections (P = 0.001), absence of preoperative cranial nerve dysfunctions (P = 0.004), and presentation with features of raised intracranial pressure (P = 0.005). Longer DOS (mean 76.74 months) was associated with significantly increased cranial nerve nuclei involvement (P = 0.03). Aseptic meningitis was reported in 14.5% of cases. Recurrences were infrequently reported (n = 9). Conclusions: Although the fourth ventricular epidermoid lesions are difficult to detect in an innocuous stage, when found, they should be extirpated early and totally, as a longer DOS leads to cranial nerve dysfunctions and suboptimal outcomes.
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ORIGINAL ARTICLES Top

Analysis of 93 brain abscess cases to review the effect of intervention to determine the feasibility of the management protocol: A tertiary care perspective p. 483
Sambuddha Dhar, Barnava Pal
DOI:10.4103/ajns.AJNS_467_20  
Context: Brain abscess is a suppurative process within the brain parenchyma, which remains a challenge for clinicians. Surgical excision or aspiration combined with prolonged antibiotics (usually 4–8 weeks) or only conservative management remains the treatment of choice. Aims: The purpose of this study is to analyze the epidemiology of brain abscess and to determine the potential factors leading to better outcomes. Settings and Design: This was a retrospective analysis of 93 patients undergoing various treatment options for brain abscess in a tertiary care center. Materials and Methods: Their preoperative status, etiology, and microbiological and clinical outcomes were analyzed. Statistical Analysis Used: Statistical analysis was done by Chi-square, one-way analysis of variance, and post hoc Newman–Keuls multiple comparison test wherever applicable using SPSS software. Results: Among 93 brain abscess cases, only 21 cases had a diameter <2.5 cm. Among them, conservative treatment was done for 38% of patients (8/21), aspiration for 47.6% (10/21) of patients, and excision for only 3 (14.2%) of cases. About 37.5% (3/8) persons among these conservatively managed patients had recurrence. None of the patients of <2.5 cm abscess having surgical management had recurrence or any new neurological deficits postsurgery during the 6-month follow-up. Conclusions: There was a significantly high recurrence among the nonsurgically treated patients with lesions <2.5 cm and there was no recurrence or neurological deficit after aspiration among these patients. Probably, aspiration has better results among these patients contrary to previous recommendations of antibiotic therapy alone.
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Central nervous system tuberculoma in the corpus callosum mimicking a butterfly glioma: literature review of radiological findings and our experience p. 488
Claudia Scudieri, Fotios Kalfas
DOI:10.4103/ajns.AJNS_482_20  
Context: Central nervous system (CNS) tuberculoma is the most common form of intracranial parenchymal tuberculosis (TB) which accounts for approximately 40% of misdiagnosed brain lesions mimicking intracranial tumors. The most common sites are the cerebral hemispheres, basal ganglia, cerebellum, and brainstem. Materials and Methods: Radiological findings of corpus callosum tuberculomas have been described and set in relation with the available literature. Results: Corpus callosum tuberculomas are extremely rare, with only five cases reported in the current literature. Even though isolated CNS tuberculoma of the corpus callosum without systemic TB in immunocompetent patients occurs rarely, as in our case, it should be considered in the differential diagnosis of solitary corpus callosum lesions. Conclusions: Careful evaluation of the neuroradiological images with adequate clinicoradiological correlation allows for accurate diagnosis and ensures the proper and timely care.
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Risk factors associated with post-therapeutic outcome for medulloblastoma: An experience from Indonesia p. 494
David Tandian, Alphadenti Harlyjoy, Setyo Widi Nugroho, Syaiful Ichwan
DOI:10.4103/ajns.AJNS_490_20  
Context: The prognosis of medulloblastoma is better in patients who underwent complete treatment consisting of surgery, radiotherapy, and chemotherapy. However, the realization of such multidiscipline management is quite challenging in developing countries, including Indonesia. Until now, no study on the management of medulloblastoma has ever been conducted in Indonesia. Aims: The authors aimed to study the characteristics, management, and mortality outcome of medulloblastoma patients in Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia. Subjects and Methods: This study was based on medical record and registry of 44 medulloblastoma patients who underwent tumor removal in Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia, between 2011 and 2018. Statistical Analysis Used: Cox regression analysis was utilized to determine the relationship between patients' demography, tumor characteristics, and treatment, with mortality. Results: The incidence of mortality was 84.1% and median months' survival time (95% confidence interval [CI]) was 13 (8.67–17.32). Gross total removal (GTR) was performed in 43.2% of all tumor removal surgery. Only 50% of all patients completed radiotherapy, and 6.8% concluded multimodalities treatment (surgery, radiotherapy, and chemotherapy). Significant statistical association between age, gender, and extent of resection with mortality was identified (HR [95% CI] for age: 0.44 [0.22–0.88], gender: 0.001 [0.000–0.27; REF: female], and biopsy: 31.52 [1.09–910.56; REF: GTR]). Conclusions: The survival rate of medulloblastoma in Indonesia is inferior to that previously reported in other studies. There is no unusual characteristic contributing to neoteric risk factor. The authors surmise that insufficient multidisciplinary management for the disease, consisting of suboptimal tumor resection, the absence of risk stratification, and incomplete postsurgical treatment (radiotherapy and chemotherapy) resulted in such outcome.
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Prediction of outcome based on trauma and injury severity score, IMPACT and CRASH prognostic models in moderate-to-severe traumatic brain injury in the elderly p. 500
Dhoni Ganesh Siva Rama Krishna Moorthy, Krishnappa Rajesh, Sarathy Manju Priya, Thaminaina Abhinov, Kalavagunta Jyothiswarapillai Devendra Prasad
DOI:10.4103/ajns.AJNS_512_20  
Objectives: This study aimed to evaluate the trauma and injury severity score (TRISS), IMPACT (international mission for prognosis and analysis of clinical trials), and CRASH (corticosteroid randomization after significant head injury) prognostic models for prediction of outcome after moderate-to-severe traumatic brain injury (TBI) in the elderly following road traffic accident. Design: This was a prospective observational study. Materials and Methods: This was a prospective observational study on 104 elderly trauma patients who were admitted to tertiary care hospital, over a consecutive period of 18 months from December 2016 to May 2018. On the day of admission, data were collected from each patient to compute the TRISS, IMPACT, and CRASH and outcome evaluation was prospectively done at discharge, 14th day, and 6-month follow-up. Results: This study included 104 TBI patients with a mean age of 66.75 years and with a mortality rate of 32% and 45%, respectively, at discharge and at the end of 6 months. The predictive accuracies of the TRISS, CRASH (computed tomography), and IMPACT (core, extended, laboratory) were calculated using receiver operator characteristic (ROC) curves for the prediction of mortality. Best cutoff point for predicting mortality in elderly TBI patients using TRISS system was a score of ≤88 (sensitivity 94%, specificity of 80%, and area under ROC curve 0.95), similarly cutoff point under the CRASH at 14 days was score of >35 (100%, 80%, 0.958); for CRASH at 6 months, best cutoff point was at >84 (88%, 88%, 0.959); for IMPACT (core), it was >38 (88%, 93%, 0.976); for IMPACT (extended), it was >27 (91%, 89%, 0.968); and for IMPACT (lab), it was >41 (82%, 100%, 0.954). There were statistical differences among TRISS, CRASH (at 14 days and 6 months), and IMPACT (core, extended, lab) in terms of area under the ROC curve (P < 0.0001). Conclusion: IMPACT (core, extended) models were the strongest predictors of mortality in moderate-to-severe TBI when compared with the TRISS, CRASH, and IMPACT (lab) models.
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Superior effectiveness of a newly developed nonadherent polyurethane-coated surgical patty for hemostasis p. 507
Yohei Otsuka, Terushige Toyooka, Satoru Takeuchi, Arata Tomiyama, Satoshi Tomura, Kojiro Wada
DOI:10.4103/ajns.AJNS_446_20  
Background: Cotton patty is usually used to aspirate blood and cerebrospinal fluid to maintain a dry field. However, the cotton patty easily adheres to the vessels by capillary action, especially in combination with hemostat. Therefore, re-bleeding may be induced by removal of the cotton patty stuck to the vessel despite initial control of the bleeding. Methods: We have developed a new cotton patty (Non-Stina X®, Hakujuji, Co., Ltd., Tokyo, Japan) which does not adhere to the vessels. The newly developed cotton patty is made of 100% cotton, with only the contact surface coated with polyurethane film which prevents capillary action. The coated side includes many holes to allow aspiration from both sides. Results: The characteristics of four different surgical patties including our new patty which are available for surgical use in Japan were investigated. Transverse sections of four different surgical patties were investigated by light microscopy (magnification ×150). Our new cotton patty did not show any fluffing on the polyurethane-coated surface. However, other surgical patties showed some fluffing on their surfaces. The friction coefficients of four different surgical patties were investigated. Our new cotton patty had the lowest of the four neurosurgical patties. We confirmed the nonadherent characteristic using with hemostats of gelatinous sponge or fibrin glue-soaked oxidized cellulose cotton during hemostasis in neurosurgical procedures. The polyurethane-coated cotton patty could be removed easily from the hemostats without re-bleeding. Conclusions: The newly developed polyurethane-coated cotton patty is more effective for bleeding control from vessels with several types of hemostat due to the nonadherent characteristics.
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Is only anterior stabilization enough in three-column injury of subaxial cervical spine? – A long-term retrospective analysis of 78 patients p. 512
Sudhir K Srivastava, Manojkumar Gaddikeri, Aditya Raj, Sunil Bhosale, Nandan Marathe, Atif Naseem
DOI:10.4103/ajns.AJNS_518_20  
Study Design: This was a retrospective study. Purpose: The purpose was to retrospectively evaluate long-term outcome of anterior stabilization in three-column injury of the subaxial cervical spine. Overview of Literature: Literature shows varied results regarding the approach to be chosen. Most studies prefer a combined approach since biomechanically forms more stable construct. The isolated posterior approach is preferred by many as it is easy to reduce and fix three-column injuries. There are very few studies which show the isolated anterior approach to be better than the other two. Materials and Methods: Seventy-eight patients of three-column injury operated by anterior approach with follow-up of atleast 2 years were included and retrospectively analyzed. Clinical data included age, sex, time to surgery, methods of reduction, postoperative mobilization, and neurological evaluation using the ASIA scale. Radiological data included pre- and postreduction X-ray, computed tomography, and magnetic resonance imaging (MRI). X-rays taken post-operatively at 1,3, 6 months, 1yr and 2yrs.Variables like fracture type (AO Classification), overall alignment, localized kyphosis, time for fusion and grade of fusion mass were noted. Results: Of 78 patients, 61 had bifacetal dislocation and 17 unifacetal. The most common site was C5-6, followed by C3-4 and C6-7. The mean patient age was 35.98 years with 60 males and 18 females. The mean time to surgery was 4.4 days. Forty dislocations were reduced by closed method and 38 by open anterior approach. Fifty-six percent of patients had traumatic disc injury on MRI. All are managed by single-level anterior cervical discectomy and fusion with iliac crest autograft for fusion. The mean preoperative lordosis: 4.44° (range −13.4° to 25°) and mean postoperative lordosis: 28.57° (P < 0.0001) mean loss of alignment: 2.59° by 2 years, 100% fusion with mean time – 22.82 weeks, neurological recovery in 34.6% with atleast one grade improvement in ASIA scale. No neurological worsening or need for revision surgery was observed. Conclusion: The goal of surgery in cervical injury is bony stabilization and fusion using a least morbid approach and one with good long-term outcome. Above study concludes that only anterior stabilization after reduction of three-column injury would suffice with good long-term outcome, thereby obviating need for global fusion.
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Seizure outcome after lesionectomy with or without concomitant anteromedial temporal lobectomy for low-grade gliomas of the medial temporal lobe p. 518
Vandan Raiyani, Suyash Singh, Jayesh Sardhara, Anant Mehrotra, Vinita Mani, Vimal K Paliwal, Lily Pal, Ashutosh Kumar, Priyadarshi Dikshit, Ved Prakash Maurya, Pawan K Verma, Sanjay Behari
DOI:10.4103/ajns.AJNS_496_20  
Background: Mesial temporal lobe epilepsy attributed to low-grade glioma is known for intractable seizures and choice of surgery range from lesionectomy (Lo) to lesionectomy with anteromesial temporal resection (L0 + AMTR) is still debatable. We intend to analyze the seizure outcome after lesionectomy alone or with AMTR. Subjects and Methods: Retrospective analyses of patients operated for medial low-grade temporal lobe tumors with seizures were included in the study. Preoperative records include video-electroencephalographic, magnetic resonance imaging (epilepsy protocol), and neuropsychological evaluation for language, memory, and dominance were assessed. Two groups (Lo [Group I] and Lo + AMTR [Group II]) were assessed after surgery by the international league against epilepsy (ILAE) seizure outcome scale. Results: A total of 39 patients underwent Lo (n = 20) and Lo + AMTR (n = 19) with a mean age of 26.92 ± 12.96 months, and mean duration of seizures was 36.87 46.76 months. A total of 23 patients had long-term intractable seizures for >1 year despite >2 drugs(Group I [n = 10], Group II [n = 13]); remaining 16 had frequent seizures of <1-year duration. In the postoperative period, on a mean follow-up of 49.72 ± 34.10 months, the ILAE outcome scale shown a significant difference (P = 0.05) in seizure outcome between two groups. Four (40%) patients out of 10 having refractory seizures in Group I and 8 (80%) from the Group II out of 10 patients could achieved ILAE Class 1 outcome after surgery. Histopathology analysis includes low-grade astrocytoma (n = 29) and in two patients there were associated CA1 neuronal loss in hippocampus, one patient had mesial temporal sclerosis from Group II attributed to its intractability in seizures. Conclusion: For the mesial temporal low-grade glioma presenting with seizures, the seizure outcome by lesionectomy with AMTR is superior than lesionectomy only.
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Factors influencing 1-year functional outcome after surgery in aneurysmal subarachnoid hemorrhage patients: A single-center series p. 525
I-sorn Phoominaonin, Somkiat Wongsuriyanan
DOI:10.4103/ajns.AJNS_13_21  
Objective: The objective of the study was to evaluate the outcome and related factors in patients with aneurysmal subarachnoid hemorrhage (aSAH). Materials and Methods: Clinical data of 221 patients who were diagnosed with spontaneous SAH due to ruptured intracranial aneurysm and surgically treated at Vajira Hospital between January 2013 and May 2016 were retrospectively reviewed. Patient and aneurysm characteristics, clinical status at presentation, treatment, and status at discharge and 1 year after discharge were recorded. Outcomes 1 year after surgery were assessed using the Glasgow Outcome Scale (GOS). Patients were divided into two groups according to the GOS score: the favorable outcome group (GOS scores 4 and 5) and unfavorable outcome group (GOS scores 1–3). Results: Among the 221 study patients, 158 were classified in the favorable outcome group and 63 in the unfavorable outcome group. Patient age, Hunt and Hess grade, aneurysm size, use of Vitamin C solution irrigation in the subarachnoid space, and GOS score 1 year after surgery significantly differed between the two groups. Conclusions: Numerous factors analyzed in this study were significantly associated with 1-year outcome in surgically treated aSAH patients, including subarachnoid Vitamin C irrigation. Further study of subarachnoid Vitamin C irrigation is warranted.
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Role of three-dimensional printing in neurosurgery: An institutional experience p. 531
Ankit Chaudhary, Sanjeev Chopra, Virendra Deo Sinha
DOI:10.4103/ajns.AJNS_475_20  
Background: Recent advancements in three-dimensional (3D) printing technology in the field of neurosurgery have given a newer modality of management for patients. In this article, we intend to share our institutional experience regarding the use of 3D printing in three modalities, namely, cranioplasty using customized 3D-printed molds of polymethylmethacrylate, 3D-printed model-assisted management of craniovertebral (CV) junction abnormalities, and 3D model-assisted management of brain tumors. Materials and Methods: A total of 55 patients were included in our study between March 2017 and December 2019 at S. M. S Medical College, Jaipur, India. 3D-printed models were prepared for cranioplasty in 30 cases, CV junction anomalies in 18 cases, and brain tumors in 7 cases. Preoperative and postoperative data were analyzed as per the diagnosis. Results: In cranioplasty, cranial contour and approximation of the margins were excellent and esthetic appearance improved in all patients. In CV junction anomalies, neck pain and myelopathy were improved in all patients, as analyzed using the visual analog scale and the Japanese Orthopedic Association Scale score, respectively. Our questionnaire survey revealed that 3D models for brain tumors were useful in understanding space interval and depth intraoperatively with added advantage of patient education. Conclusion: Rapid prototyping 3D-printing technologies provide a practical and anatomically accurate means to produce patient-specific and disease-specific models. These models allow for surgical planning, training, simulation, and devices for the assessment and treatment of neurosurgical disease. Expansion of this technology in neurosurgery will serve practitioners, trainees, and patients.
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Growing skull fractures; pathogenesis and surgical outcome p. 539
GD Singhal, Sanjeev Atri, Sudheer Suggala, Dinesh Jaluka, Shakti Singhal, AK Shrivastava
DOI:10.4103/ajns.AJNS_183_18  
Background: We performed a retrospective study of 67 patients and their data for radiological investigations by serial Xrays, computed tomography, magnetic resonance imaging, uniform surgical procedure of craniotomy. The results were analyzed to determine the natural course of the disease, anatomical changes at various intervals following trauma, and outcome of surgical procedure in terms of cranial reconstruction, seizures, and progress in neurological deficit. Results: Among 67 patients, 34 (50.74%) were male and 33 (49.26%) were female patients. About 86.67% of patients sustained the injury before the age of 3 years. Development of seizures in 28 patients (41.80%) is the most common symptom. In our study, 43.28% of patients (29 cases) had a combination of Type I and II of growing skull fracture. The dural defects confirmed in all cases were nearly twice (average 1.42) as large as the bone defects. All patients under the age of 3 years with diastatic skull fracture should be closely followed up and should be examined 2–3 months later to look for evidence of a growing skull fracture. Linear fractures and burst fractures in an infant with a scalp swelling must be corrected early to prevent a growing skull fracture. Conclusion: Early management can avoid difficult surgical dissection and progressive neurological sequelae seen with delayed intervention. Surgical correction results in the prevention of brain shift and increase in meningocerebral cicatrices. Meticulous surgery and vigilant postoperative care reduce the morbidity and mortality. In our opinion, the autologous material is the best choice because of its tissue compatibility, convenience, inexpensiveness, and rare rate of infection.
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Clinical and outcome analysis in head injury patients with fahr's disease p. 549
Rahul Singh, Anurag Sahu, Ramit Chandra Singh, Kulwant Singh Bhaikhel, Ravi Shankar Prasad
DOI:10.4103/ajns.AJNS_92_21  
Context: Fahr's disease (FD) is a rare neurodegenerative disorder. Head injury in patients with FD is an uncommon occurrence. Aim: The aim is to evaluate clinical and outcome characteristics in traumatic head injury patients with FD. Settings and Design: Retrospective cohort study. Materials and Methods: This retrospective cohort study includes 13 patients of FD presenting as head injury in neurosurgical emergency between September 2018 and February 2021. Each patient was evaluated in terms of demographic profile, Glasgow coma scale (GCS) at admission, severity of head injury, type of head injury, preexisting clinical features of FD, radiological findings, Glasgow outcome score (GOS), family history of FD, and biochemical abnormalities. Patients were also evaluated for dichotomized outcome (Good recovery: GOS 5–4 versus Poor recovery: GOS 1–3) and gender differences in FD presentation. Statistical Analysis Used: Fisher's exact test and unpaired t-test were used. P < 0.05 was considered statistically significant. Results: Neurological symptoms (69.2%), neuropsychiatric manifestations (46.1%) and extrapyramidal features (38.5%) were preexisting in these patients. Seizure (61.5%) was the most common neurological manifestation. Depression (23.1%) and anxiety disorder (15.4%) were common psychiatric disorders seen. Akathisia (23.1%) followed by tremor (15.4%) were predominant extrapyramidal presentations. On dichotomized outcome analysis, preexisting neurological, neuropsychiatric, and extrapyramidal manifestations due to FD were not associated significantly with outcome following head injury. GCS at admission, severity of head injury and pupillary changes were significantly associated with outcome (P < 0.05). Neuropsychiatric features (P = 0.0210) were significantly more in females suffering from FD. Conclusions: Neurological features in FD predominate over neuropsychiatric and extrapyramidal symptoms. FD does not affect outcome following head injury.
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Study of C677T methylene tetrahydrofolate reductase gene polymorphism as a risk factor for neural tube defects p. 554
Anjalika Goyal, Manjulata Kumawat, Minakshi Vashisth, Paramjit Singh Gill, Ishwar Sing, Dhara B Dhaulakhandi
DOI:10.4103/ajns.AJNS_372_20  
Introduction: Various genetic and environmental factors contribute to the development of neural tube defects (NTDs) which are a group of neurulation defects resulting from failure of closure of embryonic neural tube. Among genetic factors is polymorphism in methylene tetrahydrofolate reductase (MTHFR) gene, giving rise to a gene variant or mutant. However, in most studies directed at finding an association between MTHFR variants and NTD, there is no clear evidence of a cause-and-effect relationship. Materials and Methods: Forty diagnosed cases of NTDs and forty healthy individuals were investigated in a case–control study for presence of C677T MTHFR gene polymorphism. Serum folate and Vitamin B12 levels were estimated and MTHFR gene polymorphism was detected by polymerase chain reaction-restriction fragment length polymorphism. Results: It was found that 32 cases were homozygous with CC genotype and eight were heterozygous with CT genotype, whereas 35 controls had CC genotype and five had CT genotype. TT genotype was absent in both the groups. There was no statistically significant difference between both the groups. No evidence of association between MTHFR C677T polymorphism and NTDs was found. Conclusion: Although there was no evidence of association between MTHFR C677T polymorphism and NTDs, our study does not rule out the impact of MTHFR gene mutation on folate metabolism. The reason for absence of TT genotype and no association could be a small sample size. Larger, comprehensive, and well-designed multicentric but feasible studies involving proper subjects and appropriate and adequate controls from several hospitals may provide more meaningful data.
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The use of fusion images as a diagnostic and neurosurgical planning tool in microvascular decompression p. 562
Thomas Tommy, Ittichai Sakarunchai, Yasuhiro Yamada, Koichiro Yoshida, Tsukasa Kawase, Yoko Kato
DOI:10.4103/ajns.AJNS_413_20  
Preoperative assessment of surgery using high-quality images can help surgeons to achieve best result of treatment. With the advances in computer technology, interactive multimodality fusion images have been developed. The use of fusion images as a preoperative planning tool is described with its examples in illustrative cases of trigeminal neuralgia and hemifacial spasm microvascular decompression (MVD). Interactive computer graphics such as multimodality fusion method is a useful tool to preoperatively predict the need of bone exposure and configuration of blood vessels with its correlation to cranial nerves in MVD.
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CASE REPORTS Top

High-grade intraventricular astroblastoma in a young adult: A rare and controversial tumor to manage p. 567
Karuna Singh, Shipra Garg, Shilp Rani, Parvinder Sandhu
DOI:10.4103/ajns.AJNS_430_20  
Astroblastoma is a rare primary central nervous system tumor of controversial site of origin. They account for 0.45-2.8% of all primary neuroepithelial central nervous system. It has been reported in paediatric age group with bimodal age distribution affecting more females with male to female ratio being 1:11. Astroblastomas are controversial and challenging tumors in terms of diagnosis and therapeutics. Since it carries an unpredictable disease course it needs a regular follow up even for low grade tumor. Authors have tried various schedules of post op radiotherapy after maximum safe resection. Various chemotherapeutic drugs combination have also been tried without much success. We here report a 35 years old female patient who was diagnosed with high grade astroblastoma referred for post-operative radiotherapy after gross total resection. Since it is extremely rare tumor, its treatment still not well defined and also makes it difficult conduct studies to examine tumor characteristics.
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Isolated thoracic spine intramedullary metastasis from primary ovarian carcinoma: A rare case report p. 575
Kartik Manoj Multani, Rahul Srinivasan, Komal Tejwan, Boyina Jagadeshwar Rajesh
DOI:10.4103/ajns.AJNS_42_21  
Ovarian carcinoma is one among the most commonly diagnosed cancer in women. Most commonly it metastasizes within peritoneal cavity by transcoelomic spread; distant metastasis to central nervous system through hematogenous spread is rare, and intramedullary spread is even rarer. Till date, only six reports have identified isolated intramedullary metastasis to spinal cord in a patient who were considered disease free on follow-up after treatment of primary disease; of which only two were in dorsal spine. The average time for diagnosis of intramedullary metastasis after diagnosis of primary disease was 26 months in previous reports. All were on regular follow-up, and clinicians were misleaded by normal CA-125 levels, and patients were considered disease free. This report is third in world literature case of isolated intramedullary dorsal spinal cord metastasis in a patient of primary ovarian carcinoma who was on follow-up with normal CA-125 levels and was treated with myelotomy and gross total resection of lesion + adjuvant chemotherapy and oral steroids. With our experience, we recommend keeping magnetic resonance imaging neuraxis to be done in follow-up of patients treated for high-grade ovarian carcinoma so that early diagnosis and prompt management can be given to patients that can improve their quality of life.
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Dyke–davidoff–masson syndrome: A rare cause of acquired cerebral hemiatrophy p. 579
Deepak Bhol, Shyam Chandrasekar, Joseph John, Amit Kumar Satapathy
DOI:10.4103/ajns.AJNS_499_20  
Dyke–Davidoff–Masson syndrome is a rare disease of childhood which is clinically characterized by hemiparesis, refractory seizures, facial asymmetry, and mental retardation. The classical radiological findings are cerebral hemiatrophy, calvarial thickening, and hyperpneumatization of the frontal sinuses. Seizure refractory to medical management warrants surgical intervention with excellent outcome. Here, we are reporting two such cases who presented late and diagnosis was made on the basis of magnetic resonance imaging brain features. Both of our children responded to oral anticonvulsant and are on regular follow-up.
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A severe case of brain myiasis: Treatment rationale and review of literature p. 582
Christian Curzi, Viola Bartoletti, Giuseppe Canova, Enrico Giordan
DOI:10.4103/ajns.AJNS_521_20  
Cerebral myiasis is a rare condition caused by a parasitic infestation of fly larvae feeding on the host's necrotic or living tissue. Only 16 cases of cerebral myiasis have been published. We presented the case of a 72-year-old man with a neglected infestation of an extensive ulcerative cancer of the scalp. A large cranial lesion, with exposed brain and dura mater and severe Sarcophaga carnaria maggot infestation, was evident. We gently removed the maggots and covered the defect with thick gauze and sodium hypochlorite solution dressing. We additionally present a review of the literature to highlight shared features and suggestions for care management. In all cases, there was an absence of fatal meningitis and encephalitis, which is surprising given the open skull erosion with prolonged cortical exposure and points to the protective effects of larvae wound infestation.
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Ghost aneurysm in atraumatic acute subdural hematoma: A sign of caution or a mere finding – A case report p. 587
Apratim Chatterjee, Gaurav Goel, Piyush Ojha, Anshu Mahajan, Anirban Deep Bannerjee
DOI:10.4103/ajns.AJNS_560_20  
Atraumatic subdural bleed often presents with diagnostic and management dilemma. This is a case of a 36-year male who presented with acute onset headache while at rest without any focal neurodeficit. Computed Tomographic Scan of brain revealed subdural hematoma. Cerebral Digital Subtraction Angiography showed a same sided focal dye extravasation which corresponded exactly to the inner margin of the subdural bleed. Though the patient opted out for surgical management this imaging and DSA finding correlated with the “Ghost Aneurysm” concept in acute atraumatic subdural bleeds and its early recognition is an important imaging marker for caution for hematoma expansion.
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Giant intraosseous meningioma associated with calvarial hyperostosis and subcutaneous invasion: Case reports and literature review p. 589
Keisuke Sasaki, Atsushi Saito, Yasuo Nishijima, Takashi Inoue, Shinsuke Suzuki, Masayuki Ezura, Hiroshi Uenohara, Teiji Tominaga
DOI:10.4103/ajns.AJNS_534_20  
Most meningiomas grow intracranially, and primary intraosseous meningioma is rarely reported. We present two rare surgical cases of giant intraosseous meningothelial meningioma. The first patient was a 35-year-old male with parietal skull deformity without neurological symptoms. Total resection was successful. The origin was the parasagittal intraosseous layer, and the superior sagittal sinus was partially opened. The second patient was a 20-year-old female with a slightly upward protrusion of the frontal skull without pain or neurological deficits. The lesion was totally resected, and the origin was the parasagittal intraosseous layer invading into the dura matter and subcutaneous layer. The clinical management of these cases presented a surgical challenge because of detachment and repair from venous sinuses. The current report provides surgical tips for such rare diseases and is a good reference for the future treatment of similar diseases.
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Rare consequence of pituitary apoplexy surgery: Artery of percheron infarction p. 595
Subhas Konar, Sadashiva Nishanth, B Indira Devi
DOI:10.4103/ajns.AJNS_491_20  
Management of pituitary apoplexy is multimodal. The surgical intervention followed by endocrinological management is the standard of care. Various vascular complications have been described in the literature after pituitary adenoma surgery. Artery of Percheron (AOP) infract is a rare finding. Few cases were reported in the English literature after the endoscopic approach for pituitary adenoma. We present a 55-year-old lady presented with sudden-onset headache followed by vision loss. She was evaluated with imaging and diagnosed pituitary adenoma with apoplexy. She underwent an endoscopic transnasal approach and decompression of the tumor. In the postoperative period, she developed bilateral ptosis with altered sensorium. Imaging showed infarction of bilateral paramedian thalamus and rostral midbrain, suggestive of AOP infarct. Gradually, the patient improved, and at 3 months of follow-up, she was conscious and obeying with partial improvement of ptosis.
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Coincidence of intracranial myoepithelioma and adrenocortical carcinoma in a young man p. 598
Lai-Fung Li, Ronnie Siu-Lun Ho, Anderson Chun-On Tsang
DOI:10.4103/ajns.AJNS_502_20  
Myoepithelial tumors are rare neoplasms that develop from myoepithelial cells in glandular structures and soft tissues. Primary intracranial myoepithelial neoplasms are even rarer with around ten cases reported. On the other hand, adrenocortical carcinoma (ACC) is also uncommon with an annual incidence of 0.7–2 per million and carries a poor prognosis. It is known to have an association with certain familial cancer syndromes. Even in sporadic cases, a significant portion of them had other malignancies before and after diagnosis of ACC. We reported a 34-year-old gentleman who was diagnosed to have ACC without known familial cancer syndrome. After that, he was also found to have right occipital myoepithelioma that was confirmed by excisional biopsy. There was no known association between these two pathologies. This is the first report of coincidence of ACC and intracranial myoepithelioma.
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Novel approach to medullary oblongata cavernous hemangioma p. 603
Nithish Korimerla, Anand Doshi, Prashant Khandelwal, Sudhir Sudumbrekar
DOI:10.4103/ajns.AJNS_362_20  
We report the case of a 31-year-old male patient who presented with complaints of left upper and lower limb weakness with giddiness, imbalance while walking, hiccups, nasal regurgitation, and history of difficulty in swallowing. He was evaluated and diagnosed to have a space-occupying lesion in the left medulla oblongata-cavernous hemangioma. He underwent suboccipital craniotomy and excision of the lesion. Postoperatively, he regained strength and balance. He is asymptomatic during follow-up.
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Primary cutaneous apocrine carcinoma of the scalp: A rare case report p. 606
Rohit Balasubramanian, Sheena Ali, A Manohar, Sangita S Mehta
DOI:10.4103/ajns.AJNS_452_20  
Primary cutaneous apocrine carcinoma of the scalp is a rare adnexal sweat gland neoplasm. It is most commonly observed over eyelids and ear canals and is often confused with dermoid and epidermoid cysts, lipomas, cutaneous metastatic lesions, or basal cell carcinomas. We describe a 66-year-old male who presented with a midline scalp lesion. He was treated surgically with a wide local excision.
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Transvenous embolization of cavernous sinus dural arteriovenous fistula through the angiographically occlusive superior ophthalmic vein p. 610
Shigeta Moriya, Shingo Maeda, Motoharu Hayakawa, Kiyonori Kuwahara
DOI:10.4103/ajns.AJNS_71_21  
Transvenous embolization (TVE) through the superior ophthalmic vein (SOV) is a useful approach for the treatment of cavernous sinus (CS) dural arteriovenous fistulae (DAVFs). This venous route is usually confirmed by angiography. Herein, we present a case of favorable embolization of the CS DAVF through the angiographically occlusive SOV. A 61-year-old man presented with progressive exophthalmos and hypertonia. The patient was diagnosed with a CS DAVF, and TVE was planned. The first approach through the inferior petrosal sinus was infeasible; therefore, we attempted to approach the fistula through the left facial vein. The microcatheter was easily advanced to the shunt point through the angiographically occlusive SOV. We performed coil embolization, and the CS DAVF was completely obstructed.
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Surgical nuances of intramedullary white epidermoid cyst in the conus medullaris: A rare entity p. 614
Varun Aggarwal, Amit Narang, Rahul Jain, Chandni Maheshwari, Divya Kavita
DOI:10.4103/ajns.AJNS_321_20  
Spinal epidermoid cysts (ECs) are benign slow-growing spinal tumors. The account for <1% of spinal tumors and are usually found intradural extramedullary. This report is regarding two rare cases of intramedullary white ECs present at the conus medullaris. In the first case, a 32-year-old male presented with a complaint of lower backache for 5 years, which progressively increased in intensity, radiating to the left leg. The patient had left lower limb weakness in the form of difficulty in walking. On examination, power of left knee and ankle was 4/5. Left extensor hallucis longus power was 3/5. Left Babinski sign was extensor. In the second case, a 42-year-old male, presented with a complaint of numbness over the left foot for 5–6 months. On examination, the power of the left ankle was 3/5, left extensor hallucis longus was 3/5. Both patients had EC in conus medullaris, which was hyperintense on T1-weighted magnetic resonance imaging and underwent laminectomy with the evacuation of the cyst with electrocoagulation of cyst epithelial lining. White ECs are extremely rare in the conus medullaris. Electrocoagulation of the cyst wall is like walking on a tight rope. Liberal electrocoagulation can lead to the neurological deficit but decreases the chances of recurrence. On the other hand, conservative electrocoagulation can lead to recurrence but decreases the chance of a new deficit. Recurrence should also lead to suspicion of atypical changes in the cyst wall, which may require adjuvant treatment such as radiotherapy and chemotherapy.
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Extra-axial desmoplastic medulloblastoma in adult cerebellopontine angle: Case report and noninvasive molecular subgrouping utilizing magnetic resonance imaging-based radiomics nomogram p. 618
Sundus Ali, Adnan Qasim, Shahzaib Tasdique, Muhammad Rizwan Sarwar, Shahzad Shams
DOI:10.4103/ajns.AJNS_525_20  
Cerebellopontine angle (CPA) is an atypical site for adult medulloblastoma (MB) with only 12 cases reported in pure extra-axial location. None was predicted on preoperative imaging while the most common misdiagnosis was petrous meningioma. We add the 13th case to this list, attempting to reiterate the radiological features for preoperative prediction of this rare pathology on conventional magnetic resonance imaging (MRI). Molecular subtyping also is not yet reported for adult extra-axial CPA MB. We propose the routine use of MRI-based nomograms, in atypical CPA extra-axial masses, for noninvasive prediction of molecular subgroup, especially in resource-limited setups that lack the facility of genetic profiling.
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A rare case of isolated intraventricular primary central nervous system lymphoma in an 85-year-old man p. 623
Gaurav Khanna, Sunita Ahlawat, Neeraj Garg, Rakesh Gupta, Rana Patir
DOI:10.4103/ajns.AJNS_551_20  
Primary CNS lymphoma (PCNSL) is rare malignant B cell lymphoid tumor of brain which predominantly occurs in supratentorial region in periventricular location. Majority of PCNSL are of DLBCL type and idiopathic in etiology. Here we are reporting a case of primary CNS lymphoma, DLBCL involving extremely uncommon intraventricular location. Central neurocytoma, subependymal giant cell astrocytoma, choroid plexus tumors and meningiomas are the common diagnosis at this site. Aim of reporting this case is to bring awareness of unusual intraventricular location of primary CNS lymphoma which should be kept in mind before considering gross total excision of lesion.
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Cranial and spinal oligodendrogliomatosis: A case report and review of the literature p. 626
Koral Erdogan, Orkhan Mammadkhanli, Ihsan Dogan, Cevriye Cansiz Ersoz, Aylin Heper Okcu, Mustafa Agahan Unlu
DOI:10.4103/ajns.AJNS_514_20  
Secondary leptomeningeal gliomatosis is a condition known as a result of invasion of the subarachnoid space or the ventricular system of primary intraparenchymal glioma. In this article, we present a 7-year-old boy presented with neck and back deformity and deterioration of gait. Cranial and spinal magnetic resonance imaging revealed lesions in the supratentorial and infratentorial areas, in the brainstem downward the spinal cord. Disseminated oligodendrogliomatosis is extremely rare and our case we present is the 24th in the literature.
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A rare combined trigeminal neuralgia with hemifacial spasm in a 78-year-old male patient p. 630
Donny Argie, Christopher Lauren, Elric Brahm Malelak
DOI:10.4103/ajns.AJNS_433_20  
This case reported a 78-year-old male patient presented with combined trigeminal neuralgia and hemifacial spasm, which is a rare finding and seldom addressed. Magnetic resonance imaging examination showed compression of right N.V by the right superior cerebellar artery (SCA) but did not prove any compression on the right N.VII. This patient is treated with microvascular decompression, and we found out compression of right N.V by right SCA and N.VII from the right anterior inferior cerebellar artery. Postoperatively, the symptoms were resolved with transient hypoesthesia and no recurrence after 1-year follow-up.
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Four hands surgery for intracerebral hemorrhage using orbeye: Educational values and ergonomic advantages – A technical note p. 634
Tomoaki Murakami, Shingo Toyota, Takuya Suematsu, Yuki Wada, Kanji Nakagawa, Takeshi Shimizu, Kanji Mori, Takuyu Taki
DOI:10.4103/ajns.AJNS_148_21  
We have developed a new educational approach to microsurgery in which a trainee and supervisor can cooperate with “4 hands” using the exoscope. We evaluated 4-hands surgery for intracranial hemorrhage (ICH) using the exoscope to validate the educational value and ergonomic advantages of this method. Thirty consecutive patients who underwent surgery for ICH using the exoscope between December 2018 and May 2020 were studied retrospectively. All operations were performed by a team comprising a supervisor (assistant) and a trainee (main operator). The assistant set the visual axis of the exoscope, and adjusted focus and magnification as a scopist. After setting the ORBEYE, the supervisor helped retract the brain and withdraw and irrigate the hematoma using suction tubes or brain retractors. Moreover, the trainee evacuated the hematoma with a suction tube and coagulated using bipolar forceps. Patient background and results of treatment were evaluated. Intraoperative postures of the operators were observed, and schemas compared with the use of a conventional microscope were developed. All microsurgical procedures were accomplished by a trainee with a supervisor using only the exoscope. During the surgery, the surgeons could work in a comfortable posture, and the supervisor and trainee could cooperate in microsurgical procedures using their four hands. The results of the present case series concerning evacuation of ICH were not inferior to those described in previous reports. To increase opportunities for education in microsurgery, 4-hands surgery for ICH using the exoscope appears feasible and safe and offered excellent educational value and ergonomic advantages.
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Remote intramedullary hemorrhage in the thoracic spinal cord secondary to a perimedullary arteriovenous fistula of the distal end of conus medullaris mimicking filum terminale arteriovenous fistula p. 638
Prasert Iampreechakul, Anusak Liengudom, Punjama Lertbutsayanukul, Somkiet Siriwimonmas, Sirintara Pongpech
DOI:10.4103/ajns.ajns_185_21  
Perimedullary arteriovenous fistulas (PMAVFs) of the conus medullaris are rare and usually manifest with progressive myelopathy secondary to venous congestion resulting from retrograde arterialization of the draining vein into the spinal cord. We present a rare case of conus PMAVF presenting with remote intramedullary spinal cord hemorrhage in the thoracic cord. A 37-year-old woman was transferred to our institute due to sudden severe pain in the left lower leg and weakness of the lower extremities following progressive paresthesia of the lower extremities. Magnetic resonance imaging of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T6 with intramedullary hemorrhage at the level of T8–9 on the left side of the spinal cord. There were abnormal serpiginous intradural flow voids along the anterior surface of the spinal cord extending from the level of L2 to the lower cervical with venous varix at the level of T8–9, probably being the source of hemorrhage. Spinal angiography confirmed conus PMAVF at the distal end of the conus medullaris supplied by the sulco-commissural artery arising from the enlarged anterior spinal artery originating from the left T11 intercostal artery with cranial drainage through the dilated anterior spinal vein into the tortuous perimedullary veins up to the lower cervical level. The patient underwent successful endovascular treatment with N-butyl cyanoacrylate and had gradually improved until being ability to walk independently without residual pain of the left lower leg. We speculated that an increased venous flow into a varix may be considered an important risk factor of hemorrhage.
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TECHNICAL NOTE Top

A novel technique of microcatheter shaping using real image display for endovascular aneurysmal coil embolization p. 645
Tomotaka Ohshima, Yoshitaka Nagano, Shigeru Miyachi
DOI:10.4103/ajns.AJNS_90_21  
In coil embolization of intracranial aneurysms, guiding the microcatheter to an appropriate site in the aneurysm and stabilizing it there are important. In paraclinoid internal carotid aneurysms, complicated three-dimensional (3-D) shaping of the microcatheter tip is occasionally required. We devised a novel shaping method for microcatheters by using a real image display (RID). The usefulness of this technique was validated. We used a RID consisting of a couple of concave mirrors. A piece of patient-specific vascular model, which was made using a 3-D printer before the operation, was set inside the RID. We obtained a real 3-D image just above the RID. As a microcatheter and its shaping inner mandrel could be entered in the hologram of the vasculature, we could create the actual shape of the microcatheter. The shaped microcatheter could be navigated at the desired position in the aneurysm. Complete obliteration of the aneurysm was achieved without any trouble among 30 consecutive cases. We evaluated the effectiveness of the RID for making and navigating a microcatheter in cases with challenging anatomies. It was useful for favorable microcatheter shaping, as the RID could be entered inside the aneurysm models, unlike when tracing the outer surface of rigid 3-D models.
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Methylmethacrylate inter-facetal and inter-vertebral body spacers for cranio-vertebral junction and various spine surgeries: Technical note p. 648
Deepak Kumar Jha, Mayank Garg, Suryanarayanan Bhaskar, Jaskaran Singh Gosal, Kartikeya Shukla, Vinay Kumar Chugh, Pushpinder Khera, Pradeep Kumar Bhatia
DOI:10.4103/ajns.AJNS_443_20  
Study Design: Prospective. Purpose: Over past one and half decade, ready-to-use magnetic resonance imaging (MRI) compatible spinal implants have changed the clinical practice and economics of spinal surgery. These are beyond reach of majority of population of developing countries like India due to financial reasons and also availability in remote areas. There is a growing need for a MRI compatible cost-effective spinal implant of proven quality. The authors used bone cement spacers for the said purpose for various level spine surgeries. Overview of Literature: Methylmethacrylate, known as bone cement, was used extensively for spinal surgeries from craniovertebral junction to sacrum for augmentation and replacement of various spinal elements. Its biochemical and biomechanical properties were tested for safe clinical use and was a favored material for spinal surgeons. Materials and Methods: The authors made molds for making bone cement spacers for various spine levels with the help of silicone material. Results: Sixteen patients (12 males, 4 females with an average age of 31 years) of various spine level surgeries were done where bone cement spacers were used. It included patients of basilar invagination (n = 9), dorsal Pott's disease (n = 1), lumbar (n = 2), and lumbo-sacral spondylolisthesis (n = 1). Spacers could be used without any difficulties and postoperative day 1- and 3-months follow-up computed tomography scan of the patients revealed no change in the dimensions of the spacer and fusion at 3 months of operated levels. Conclusion: The authors feel that bone cement spacers may be an effective and low-cost alternative to the existing costly alternatives.
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INVITED COMMENTARY Top

Pineal tumors: A pathological challenge p. 655
Seyed Amir Hossein Javadi
DOI:10.4103/ajns.AJNS_106_21  
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OBITUARY Top

Tetsuo Kanno, PhD, 1940–2021 p. 656
Yoko Kato
DOI:10.4103/1793-5482.325955  
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LETTERS TO EDITOR Top

Isolated aqueductal blood clot in primary intraventricular hemorrhage leading to acute obstructive hydrocephalus in an adult p. 661
Anagha Sudhakar Prabhune, Ranjitsingh K Deshmukh
DOI:10.4103/ajns.AJNS_450_20  
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Historical vignette: Andreas vesalius and head injuries in royalty p. 663
Prasad Krishnan, Shubhrajit Nag
DOI:10.4103/ajns.AJNS_54_21  
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Letter to the editor regarding “lumbar interbody fusion: Techniques, pearls and pitfalls” p. 665
Santino Ottavio Tomasi, Peter A Winkler
DOI:10.4103/ajns.AJNS_82_21  
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Beyond the neuro-oncological outcome: A perspective of the seizure control after resection of the medial temporal lobe gliomas p. 667
Maysam Alimohamadi, Ahmad Pour-rashidi, Sanaz Ahmadi Karvigh
DOI:10.4103/ajns.AJNS_100_21  
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