Publications by authors named "Bhagavatula Indira Devi"

91 Publications

Letter to the Editor. Colloid cysts in children.

J Neurosurg Pediatr 2021 Sep 17. Epub 2021 Sep 17.

1National Institute of Mental Health and Neurosciences, Bangalore, India.

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http://dx.doi.org/10.3171/2021.5.PEDS21267DOI Listing
September 2021

Intracranial high-grade glioma with malignant progression of spinal intramedullary metastasis: an atypical presentation with review of literature.

Br J Neurosurg 2021 Aug 16:1-7. Epub 2021 Aug 16.

National Institute of Mental Health and Neuro Sciences, NIMHANS, Bengaluru, Karnataka, India.

Purpose: High-grade gliomas (grade 3 and grade 4) are known to be highly locally invasive and distant metastasis though known, rarely manifest clinically due to poor survival. Recently, due to increasing survival in view of early diagnosis at relatively young age, more cases of extra neural symptomatic metastasis are being diagnosed and treated. Among these, symptomatic spinal metastasis is even more rare. Dissemination of GBM to the spinal compartment, albeit uncommon, has an even poorer outcome, with most patients dying within 2-3 months after diagnosis of metastatic disease.

Materials And Methods: Here, we present a rare case report of a 25-year-old female with transformed/histologically progressed tumour in cranial region along with ultra-rapid progression of the spinal disease following metastasis. Proper consent of the patient relatives was taken prior to production of material as patient had expired by the time of writing of this paper. We also present an extensive review of spinal metastasis secondary to intracranial high-grade gliomas starting from 1950. We conducted a thorough and exhaustive systematic search and review of the indexed databases available in PUBMED, COCHRANE and GOOGLE SCHOLAR with key words 'spinal metastasis of glioma', 'spinal metastasis', 'glioma progression', 'secondary glioma', multicentric glioma', 'secondary spinal metastasis' and formulated a comprehensive table of the studies that met the set standards. The studies that included (a) Number of cases, (b) Age and sex of patients, (c) operated primary or non-operated primary with spinal metastasis, (d) time period from the index cranial surgery, (e) outcome after diagnosis of spine metastasis and (f) histopathology of both cranial and spinal tumour either following surgery or autopsy have been elucidated herewith. We searched the databases with no particular time period. Out of 42 case reports and series, 28 studies were selected for our publication as they met the standards set, starting from 1950 to 2020.

Results: In this case, the primary histopathological diagnosis post cranial tumour removal was Grade-3 anaplastic astrocytoma, whereas Spinal autopsy report done 16 months after the primary diagnosis showed Grade-4 GBM suggestive of secondary transformation (Secondary GBM), it showed same genome of IDH mutation and ATRX loss, neoplastic fibrillary and gemistocytic astrocytes with de-differentiation, foamy histiocytes as seen in primary lesion suggestive of progression and metachronicity rather than multicentricity or synchronicity. What is more peculiar and rare in our case is that the spinal disease was very malignant and it progressed in course of just two days to involve the whole spine.Key pointsMalignant ultra-rapid progression of spinal metastasis.Thorough review of literatureMetachronicity of spinal metastasisImportance of the studyThis study presents a very atypical case of malignant progression of spinal metastasis documented with successive MRI radiology scans in a span of mere two days.It is different from other studies in the sense such malignant progression in a span of few days has never been documented with radiographs.This manuscript also provides an exhaustive review of literature and draws comparisons among the same.This study compares→ Time period to diagnosis of spinal metastasis following primary diagnosis, Outcome from diagnosis of spine metastasis, age along with other variables like histopathology of spinal metastasis if available, Treatment underwent, site of metastasis among different studies.
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http://dx.doi.org/10.1080/02688697.2021.1961682DOI Listing
August 2021

Complex Chiari Malformation: Proposal of a New Set of Diagnostic Criteria and Outcomes After fusion Surgery.

World Neurosurg 2021 Jul 31. Epub 2021 Jul 31.

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India.

Background: The proposal of C1-C2 fusion as a better treatment option compared with foramen magnum decompression (FMD) for the treatment of Chiari 1 malformations has led to controversy. Although FMD is a time-tested treatment option, a group of patients exists who will benefit from C1-C2 fusion. We have proposed an objective system for defining complex Chiari malformations and studied the outcomes of fusion with decompression versus decompression alone for these patients.

Methods: A total of 26 patients with complex Chiari malformations were identified using our criteria (any 4 of 7 clinicoradiological parameters). Of the 26 patients, 13 had undergone C1-C2 fusion with FMD and 13 had undergone FMD alone. They had also undergone pre- and postoperative clinicoradiological evaluations, and the outcomes were assessed using the Chicago Chiari outcome score.

Results: Of the 13 patients in the fusion group, 12 (92.3%) showed improvement compared with only 6 of 13 patients (46.2%) in the nonfusion group using the Chicago Chiari outcome score, a statistically significant difference (P = 0.036, χ test). The mean hospital length of stay was longer for the fusion group (6.15 ± 1.46 days) than for the nonfusion group (4.38 ± 2.22 days; P = 0.02).

Conclusions: We have proposed a novel set of criteria for defining complex Chiari malformations. Fusion with decompression provided better outcomes than decompression alone.
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http://dx.doi.org/10.1016/j.wneu.2021.07.115DOI Listing
July 2021

Altered MicroRNA Expression in Intracranial Aneurysmal Tissues: Possible Role in TGF-β Signaling Pathway.

Cell Mol Neurobiol 2021 Jun 29. Epub 2021 Jun 29.

Department of Pathology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, 560069, India.

The molecular mechanisms behind the rupture of intracranial aneurysms remain obscure. MiRNAs are key regulators of a wide array of biological processes altering protein synthesis by binding to target mRNAs. However, variations in miRNA levels in ruptured aneurysmal wall have not been completely examined. We hypothesized that altered miRNA signature in aneurysmal tissues could potentially provide insight into aneurysm pathophysiology. Using a high-throughput miRNA microarray screening approach, we compared the miRNA expression pattern in aneurysm tissues obtained during surgery from patients with aneurysmal subarachnoid hemorrhage (aSAH) with control tissues (GEO accession number GSE161870). We found that the expression of 70 miRNAs was altered. Expressions of the top 10 miRNA were validated, by qRT-PCR and results were correlated with clinical characteristics of aSAH patients. The level of 10 miRNAs (miR-24-3p, miR-26b-5p, miR-27b-3p, miR-125b-5p, miR-143-3p, miR-145-5p, miR-193a-3p, miR-199a-5p, miR-365a-3p/365b-3p, and miR-497-5p) was significantly decreased in patients compared to controls. Expression of miR-125b-5p, miR-143-3p and miR-199a-5p was significantly decreased in patients with poor prognosis and vasospasm. The target genes of few miRNAs were enriched in Transforming growth factor-beta (TGF-β) and Mitogen-activated protein kinases (MAPK) pathways. We found significant negative correlation between the miRNA and mRNA expression (TGF-β1, TGF-β2, SMAD family member 2 (SMAD2), SMAD family member 4 (SMAD4), MAPK1 and MAPK3) in aneurysm tissues. We suggest that miR-26b, miR-199a, miR-497and miR-365, could target multiple genes in TGF-β and MAPK signaling cascades to influence inflammatory processes, extracellular matrix and vascular smooth muscle cell degradation and apoptosis, and ultimately cause vessel wall degradation and rupture.
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http://dx.doi.org/10.1007/s10571-021-01121-3DOI Listing
June 2021

Development of a Prognostic Model to Predict Mortality after Traumatic Brain Injury in Intensive Care Setting in a Developing Country.

J Neurosci Rural Pract 2021 Apr 1;12(2):368-375. Epub 2021 Apr 1.

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India.

 We aimed to develop a prognostic model for the prediction of in-hospital mortality in patients with traumatic brain injury (TBI) admitted to the neurosurgery intensive care unit (ICU) of our institute.  The clinical and computed tomography scan data of consecutive patients admitted after a diagnosis TBI in ICU were reviewed. Construction of the model was done by using all the variables of Corticosteroid Randomization after Significant Head Injury and International Mission on Prognosis and Analysis of Clinical Trials in TBI models. The endpoint was in-hospital mortality.  A total of 243 patients with TBI were admitted to ICU during the study period. The in-hospital mortality was 15.3%. On multivariate analysis, the Glasgow coma scale (GCS) at admission, hypoxia, hypotension, and obliteration of the third ventricle/basal cisterns were significantly associated with mortality. Patients with hypoxia had eight times, with hypotensions 22 times, and with obliteration of the third ventricle/basal cisterns three times more chance of death. The TBI score was developed as a sum of individual points assigned as follows: GCS score 3 to 4 (+2 points), 5 to 12 (+1), hypoxia (+1), hypotension (+1), and obliteration third ventricle/basal cistern (+1). The mortality was 0% for a score of "0" and 85% for a score of "4."  The outcome of patients treated in ICU was based on common admission variables. A simple clinical grading score allows risk stratification of patients with TBI admitted in ICU.
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http://dx.doi.org/10.1055/s-0041-1726623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064853PMC
April 2021

Management Options for Suprasellar Cystic Craniopharyngioma: Endoscopic Transventricular Approach and Microsurgical Approach.

J Neurosci Rural Pract 2021 Apr 1;12(2):343-349. Epub 2021 Apr 1.

Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

 The treatment of cystic craniopharyngioma in children is varied. The treatment ranges from radical excision to direct radiotherapy. As the morbidity of excision is high, more conservative approaches are used. Transventricular endoscopy is a minimally invasive treatment for cystic craniopharyngiomas. The objective of this study is to compare the outcome of microscopic versus endoscopic transventricular approach for cystic craniopharyngioma.  This is a retrospective study of series of children managed with microscopic excision and endoscopic transventricular approach for suprasellar cystic craniopharyngiomas. Operative details, visual outcome, endocrinological outcome, tumor-related cyst recurrence rate, and complication were compared between microscopic and endoscopic groups.  A total of 28 children underwent microscopic excision and 14 children underwent endoscopic procedure. The anesthesia time was significantly lower with endoscopic as compared to microscopic group ( = 0.0001) as well as blood loss during surgery ( = 0.0001). Hospital stay after surgery was shorter in endoscopic group. Incidence of diabetes insipidus was more in microscopic group (25%) compared to endoscopic group (7.14%). Visual outcome was almost same with approaches. Requirement of hormone replacement was more in microscopic group than in endoscopic group ( = 0.006). Incidence of cyst recurrence was more in microscopic (39.3%) compared to endoscopic group (7.7%).  Endoscopic transventricular approach is a safe alternative for initial treatment of suprasellar cystic craniopharyngioma in children.
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http://dx.doi.org/10.1055/s-0041-1722839DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064855PMC
April 2021

Disseminated Craniospinal Myxopapillary Ependymoma Treated with Biopsy and Adjuvant Radiation Therapy: A Case Report and Review of Literature.

Neurol India 2021 Mar-Apr;69(2):500-504

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India.

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http://dx.doi.org/10.4103/0028-3886.314566DOI Listing
June 2021

Predictors of Quality of Life at 3 Months after Treatment for Aneurysmal Subarachnoid Hemorrhage.

Neurol India 2021 Mar-Apr;69(2):336-341

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India.

Background: Patients with aneurysmal subarachnoid hemorrhage (SAH) have a low quality of life (QOL) despite diagnostic and therapeutic advancements. Less than half of the survivors can return to their previous jobs and have difficulty in being a functional part of society. Our study aimed to understand the overall outcome and QOL of these patients and to identify the predictive factors determining the same.

Methods: The clinical and radiological data were recorded at presentation, subsequent intervals at the hospital, and during discharge. Patients were interviewed telephonically or in the clinic subsequently at 3 months after treatment with following outcome assessment tools: Modified Rankin Scale (mRS), Barthel Index (BI), QOL after Brain Injury Overall Scale (QOLIBRI-OS), and Short Form 36 (SF 36) QOL scale.

Results: Out of the total patients (n = 143), 124 patients survived, of which 106 patients could be interviewed. The mRS, QOLIBRI-OS, BI, and SF36 had a good correlation with each other. Only 4.7% had moderate to severe disability on the mRS scale, and 2.8% had severe disability according to the Barthel index. Nearly one-third of patients had deteriorated QOL. The mental health domain was worst affected. The major determinant of QOL was GCS at presentation (mean P value 0.01), a course in the ward (0.0001), GCS at discharge (0.001).

Conclusion: Though fewer of the patients had a severe disability, a majority of them had deterioration in QOL.
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http://dx.doi.org/10.4103/0028-3886.314581DOI Listing
June 2021

Neurotrauma clinicians' perspectives on the contextual challenges associated with long-term follow-up following traumatic brain injury in low-income and middle-income countries: a qualitative study protocol.

BMJ Open 2021 03 4;11(3):e041442. Epub 2021 Mar 4.

NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.

Introduction: Traumatic brain injury (TBI) is a global public health concern; however, low/middle-income countries (LMICs) face the greatest burden. The WHO recognises the significant differences between patient outcomes following injuries in high-income countries versus those in LMICs. Outcome data are not reliably recorded in LMICs and despite improved injury surveillance data, data on disability and long-term functional outcomes remain poorly recorded. Therefore, the full picture of outcome post-TBI in LMICs is largely unknown.

Methods And Analysis: This is a cross-sectional pragmatic qualitative study using individual semistructured interviews with clinicians who have experience of neurotrauma in LMICs. The aim of this study is to understand the contextual challenges associated with long-term follow-up of patients following TBI in LMICs. For the purpose of the study, we define 'long-term' as any data collected following discharge from hospital. We aim to conduct individual semistructured interviews with 24-48 neurosurgeons, beginning February 2020. Interviews will be recorded and transcribed verbatim. A reflexive thematic analysis will be conducted supported by NVivo software.

Ethics And Dissemination: The University of Cambridge Psychology Research Ethics Committee approved this study in February 2020. Ethical issues within this study include consent, confidentiality and anonymity, and data protection. Participants will provide informed consent and their contributions will be kept confidential. Participants will be free to withdraw at any time without penalty; however, their interview data can only be withdrawn up to 1 week after data collection. Findings generated from the study will be shared with relevant stakeholders such as the World Federation of Neurosurgical Societies and disseminated in conference presentations and journal publications.
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http://dx.doi.org/10.1136/bmjopen-2020-041442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934765PMC
March 2021

DREZotomy in the management of post brachial plexus root avulsion neuropathic pain: fMRI correlates for pain relief.

Br J Neurosurg 2021 Jan 19:1-10. Epub 2021 Jan 19.

Department of NeuroImaging and Interventional Radiology (NIIR), NIMHANS, Bengaluru, Karnataka, India.

Background: Deafferentiation pain following brachial plexus root avulsion has been documented to be severe enough to affect activities of daily living in patients. Microsurgical DREZotomy is known to alleviate the symptoms by decreasing the afferent signals transmitted from the spinal cord to sensory cortex.

Objectives: To document and analyse the effectiveness of DREZotomy and to evaluate the role of 'sensory cortex' in the cause and relief of dysesthetic pain, using fMRI.

Materials And Methods: This was a prospective study conducted between 2010 and 2016 and included all patients who underwent DREZotomy for dysesthetic pain following traumatic brachial plexus injury (TBPI). Patients were evaluated both preoperatively and postoperatively with Visual Analogue Scale(VAS), Hospital Anxiety and Depression score (HADS) and SF36 questionnaire and effectiveness of surgery was assessed. Functional magnetic resonance imaging (fMRI) of the brain in resting state was performed before and after surgery and was also compared with controls. Patients underwent standard microsurgical DREZotomy from C5 to D1. Postoperative assessment was done at 6 weeks and 6 months following surgery.

Results: Our series had 18 patients aged between 22 and 63 years. RTA was the most common cause of injury. There was significant decrease in pain at 6 months follow up compared to pre-operative values as assessed by VAS, HADS, SF36 questionnaire. fMRI analysis revealed cluster activations in the sensory, motor cortex and in the right cingulate gyrus in the preoperative group which was higher than in normal controls. In the postoperative group, the size of the resting state activation was significantly reduced.

Conclusion: DREZotomy is an effective procedure for TBPI patients. We hypothesize that these fMRI findings reflect the cortical reorganization that occurs not only after injury but also following successful surgery which explains the cause and relief of dyesthetic pain.
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http://dx.doi.org/10.1080/02688697.2021.1872769DOI Listing
January 2021

Trapped fourth ventricle-treatment options and the role of open posterior fenestration in the surgical management.

Acta Neurochir (Wien) 2020 10 26;162(10):2441-2449. Epub 2020 Apr 26.

Department of Neurosurgery, II Floor, Faculty Block, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru, India.

Background: Trapped fourth ventricle (TFV) is a rare and difficult to treat condition. Most patients have a past inciting event (infection, IVH, trauma) and history of prior CSF diversion. The symptoms are due to the mass effect on brainstem and cerebellum. Rarely, TFV can also be associated with syrinx formation due to a dissociated craniospinal CSF flow near the fourth ventricle outlets. We present our experience and outcomes of open posterior fenestration in 11 cases, along with an overview of the surgical management of TFV.

Methods: Between 2011 and 2018, 11 patients of TFV were operated by the posterior approach fenestration of the fourth ventricle outlets and arachnoid dissection. The clinical and radiological findings of the patients were retrieved from the hospital database. The surgical technique is described in detail. The patients' neurological status and imaging findings in the follow-up were recorded and compared.

Results: The average age of the patients was 23.55 years. The most common presenting symptoms were headache (9/11) and gait imbalance (7), with TB meningitis being the commonest etiology. Ten patients had a history of prior CSF diversion with two presenting with shunt malfunction. Mean follow-up duration was 33.33 months. The improvement in neurological status was observed in 9/11 patients, 2 remained status quo. On follow-up imaging, 8/11 (72.72%) patients had a decrease in the size of TFV while syrinx improved in 3/5 (60%).

Conclusion: Multiple surgical approaches have been described for TFV. Endoscopic fourth ventriculostomy with aqueductoplasty is gaining popularity in the past two decades. However, an open posterior fenestration of the midline fourth ventricle outlet (magendieplasty) along with sharp arachnoid dissection (adhesiolysis) along the cerebello-medullary cisterns and paracervical gutters is relatively simple and provides physiological fourth ventricular CSF outflow. This is especially useful in TFV with syrinx as the craniospinal CSF circulation is established.
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http://dx.doi.org/10.1007/s00701-020-04352-3DOI Listing
October 2020

Circulating MicroRNAs as Potential Molecular Biomarkers for Intracranial Aneurysmal Rupture.

Mol Diagn Ther 2020 06;24(3):351-364

Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bengaluru, 560029, India.

Introduction: Diagnosis of the rupture of an intracranial aneurysm (IA) relies on sophisticated neuro-imaging studies, and molecular biomarkers to identify an IA or predict its rupture are still unavailable.

Objective: Our objective was to determine the plasma microRNA (miRNA) expression profile in patients with ruptured IA presenting as aneurysmal subarachnoid hemorrhage (aSAH) and identify potential biomarkers of aneurysmal rupture.

Methods: Plasma miRNA profiling was carried out using quantitative real-time polymerase chain reaction (qRT-PCR) in 20 patients with aSAH and 20 age- and sex-matched healthy controls. Eight differentially expressed miRNAs were validated by qPCR in a larger cohort of 88 patients with aSAH and 110 healthy controls. A receiver operating characteristic (ROC) curve was constructed to evaluate the overall performance of the miRNA-based assay. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis was used to determine the potential pathway of miRNA-target genes.

Results: The miRNA profiles were clearly distinct in patients compared with controls. Validation studies showed that three upregulated miRNAs (miR-15a-5p, miR-34a-5p, miR-374a-5p) and five downregulated miRNAs (miR-146a-5p, miR-376c-3p, miR-18b-5p, miR-24-3p, miR-27b-3p) could distinguish patients with aSAH from healthy controls with high predicted probability (0.865 and 0.995, respectively). Further, the expression levels of the eight candidate miRNAs were significantly dysregulated only in aSAH cases and not in patients with SAH due to other causes. Plasma miR-146a-5p and miR-27b-3p were associated with clinical outcomes in patients with aSAH. Functional analysis of the eight differentially expressed miRNA showed that the target genes involved in signaling pathways were related to inflammation.

Conclusions: Our study determined the plasma miRNA signature of ruptured IAs and identified eight candidate miRNAs that could be useful biomarkers for this condition. We hypothesize that these differentially expressed miRNAs may play pivotal roles in IA pathology.
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http://dx.doi.org/10.1007/s40291-020-00465-8DOI Listing
June 2020

Estrogen receptor alpha gene variant, PvuII (rs2234693), as a potential pharmacogenetic biomarker for aneurysmal subarachnoid hemorrhage in postmenopausal women.

Pharmacogenomics J 2020 10 4;20(5):655-663. Epub 2020 Feb 4.

Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bengaluru, 560029, India.

Aneurysmal subarachnoid hemorrhage (aSAH) occurs more often in postmenopausal women than in men. Estrogen plays an important role in vascular homeostasis. Our aim was to elucidate whether a drop in circulating estradiol in conjunction with variants of estrogen receptor genes have a role in female gender susceptibility to aSAH. A total of 709 subjects were enrolled (349 aSAH patients, 360 controls) and genotyped for rs2234693 or PvuII (intron 1, T>C) in the ESR1 gene and rs4986938 or AluI (exon 8, 1730G>A) of ESR2 gene by PCR-RFLP. Serum estradiol was estimated by ELISA. Estrogen receptor gene expression was studied by qRT-PCR. Logistic regression analysis indicated a significant recessive effect of the T allele of PvuII on aSAH in females, and this association remained statistically significant even after adjusting for confounders (OR 1.702, CI 95% 1.062, 2.726, P value = 0.027). ESR1 gene expression was significantly reduced (P value = 0.0089) in subjects carrying PvuII T allele. In postmenopausal women with TT genotype and low serum estradiol, the odds for developing aSAH were found to be 3.5-fold increase compared with premenopausal women (CI 95% 1.424-8.828, P value = 0.0074). However, this variant showed no significant association with aSAH in men. No significant difference was found in genotype and allelic distribution of AluI polymorphism in ESR2 gene, between patients and controls. We propose that the PvuII T allele could be a potential pharmacogenetic marker for strategizing personal medicine for preventing aSAH in postmenopausal women with low circulating estradiol. Further larger studies in other population are warranted.
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http://dx.doi.org/10.1038/s41397-020-0155-4DOI Listing
October 2020

Persistent Trigeminal Artery: Neuroanatomic and Clinical Relevance.

World Neurosurg 2020 Feb 15;134:e214-e223. Epub 2019 Oct 15.

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.

Introduction: Persistent trigeminal artery (PTA) is the most common remnant of primitive circulation communicating the developing carotid and vertebrobasilar junction. Although discovered incidentally, an altered hemodynamic may lead to an increased association of aneurysms, vascular malformations, and stroke. Neurosurgeons should be aware of the presence and significance of PTA when interpreting imaging and planning interventions.

Methods: We retrospectively reviewed all magnetic resonance angiography and cerebral digital subtraction angiography performed between 2012 and 2017 for the presence of PTA. The radiologic and anatomic details were noted and analyzed along with the clinical profiles. We categorized the radiologic findings with respect to the available classification systems. A review of the available literature was done comparing our results.

Results: We found 33 cases of incidentally detected PTA. The average age of the patients was 45.42 years. The lateral surface of the proximal cavernous internal carotid artery was the most common origin (n = 23). Only 3 cases had a medial/transsellar course. Most cases were Saltzman/Weon type I (19/33). Intracranial aneurysms were associated with 6 patients (18.18%). Trigeminal neuralgia (TN) was a presenting feature in 5 patients. None had a direct neurovascular conflict at the root entry zone.

Conclusions: Our study is one of the largest to describe the incidence of PTA. We emphasized the importance of PTA to the neurosurgeons; increased association of aneurysms, as a route for intervention in occlusive disease of the posterior fossa; risk of injury and bleeding during transsphenoidal surgery; and the association with TN. However, we found that only PTA variants are likely to be associated with TN because of their cisternal course causing NV conflict.
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http://dx.doi.org/10.1016/j.wneu.2019.10.025DOI Listing
February 2020

Central Neurocytoma Presenting with Bleed and Obstructive Hydrocephalus: A Rare Presentation.

Asian J Neurosurg 2019 Jul-Sep;14(3):919-921

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Central neurocytomas (CNs) occur typically in the lateral ventricle, adjacent to the septum pellucidum and foramen of Monro. The clinical presentation varies and many are incidentally detected. Incidence of spontaneous hemorrhage at presentation is rare. We hereby report a case of the intraventricular lesion with bleed which was operated on an emergency basis as it caused obstructive hydrocephalus and the patient was in altered sensorium. The exact cause of hemorrhage in CNs is not known, and the previously discussed explanations are discussed.
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http://dx.doi.org/10.4103/ajns.AJNS_84_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703028PMC
September 2019

Predictors of outcome of subdural empyema in children.

Neurosurg Focus 2019 08;47(2):E17

Objective: The aim of this study was to report the etiology, clinical features, microbiology, surgical outcome, and predictors of outcome of spontaneous subdural empyema (SDE).

Methods: The authors conducted a retrospective study in a tertiary hospital. Children up to 18 years of age, with a diagnosis of SDE with infective etiology, were included in the present cohort. Patients with posttraumatic, postsurgery, and tubercular origin of SDE were excluded from the study. The Glasgow Outcome Scale was used for outcome assessment at the end of 3 months. For analysis purposes, the demographic data, clinical features, radiological data, microbiology, type of surgery, and complication data were categorized, and univariate and multivariable logistic regression analyses were performed to identify the factors associated with outcome.

Results: Ninety-eight children were included in the study and the mean age was 10.9 years. Otogenic origin (34.7%) was the most common source of infection, followed by meningitis (14.3%). The mean duration of symptoms was 12 days. Seventy-six children presented with Glasgow Coma Scale (GCS) score > 8 and the supratentorial location was the most common location. Almost 75% of the children underwent craniotomy or craniectomy and the rest had burr-hole evacuation. Beta-hemolytic Streptococcus (10%) was the most common organism isolated. Cerebral venous thrombosis (CVT; 10.2%) was the most frequent complication in this cohort. The other complications were infarction (6.1%), new-onset seizure (4.1%), and bone flap osteomyelitis (4.1%). Thirteen cases had a recurrence of pus collection, which was more common in the craniotomy group than in the burr-hole group. Age (p = 0.02), GCS score ≤ 8 (OR 8.15, p = 0.001), CVT (OR 15.17, p = 0.001), and presence of infarction (OR 7, p = 0.05) were strongly associated with unfavorable outcome. In multivariable logistic regression analysis, only GCS score ≤ 8 (p = 0.01), CVT (p = 0.02), and presence of infarction (p = 0.04) had a significant impact on unfavorable outcome.

Conclusions: Prompt diagnosis and immediate intervention is the goal of management of SDE, especially in children as a delay in diagnosis can result in unconsciousness and secondary complications such as CVT and infarction, which adversely affect outcome.
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http://dx.doi.org/10.3171/2019.5.FOCUS19268DOI Listing
August 2019

Intracranial fungal granuloma: a single-institute study of 90 cases over 18 years.

Neurosurg Focus 2019 08;47(2):E14

Departments of1Neurosurgery.

Objective: Intracranial fungal granuloma (IFG) remains an uncommon entity. The authors report a single-institute study of 90 cases of IFG, which is the largest study until now.

Methods: In this retrospective study, all cases of IFG surgically treated in the years 2001-2018 were included. Data were obtained from the medical records and the pathology, microbiology, and radiology departments. All relevant clinical data, imaging characteristics, surgical procedure performed, perioperative findings, and follow-up data were recorded from the case files. Telephonic follow-up was also performed for a few patients to find out their current status.

Results: A total of 90 cases consisting of 64 males (71.1%) and 26 (28.9%) females were evaluated. The mean patient age was 40.2 years (range 1-79 years). Headache (54 patients) was the most common presenting complaint, followed by visual symptoms (35 patients), fever (21 patients), and others such as limb weakness (13 patients) or seizure (9 patients). Cranial nerve involvement was the most common sign (47 patients), followed by motor deficit (22 patients) and papilledema (7 patients). The mean duration of symptoms before presentation was 6.4 months (range 0.06-48 months). Thirty patients (33.3%) had predisposing factors like diabetes mellitus, tuberculosis, or other immunocompromised status. A pure intracranial location of the IFG was seen in 49 cases (54.4%), whereas rhinocerebral or paranasal sinus involvement was seen in 41 cases (45.6%). Open surgery, that is, craniotomy and decompression, was performed in 55 cases, endoscopic biopsy was done in 30 cases, and stereotactic biopsy was performed in 5 cases. Aspergilloma (43 patients) was the most common fungal mass, followed by zygomycosis (13 patients), chromomycosis (9 patients), cryptococcoma (7 patients), mucormycosis (5 patients), and candida infection (1 patient). In 12 cases, the exact fungal phenotype could not be identified. Follow-up was available for 69/90 patients (76.7%). The mean duration of the follow-up was 37.97 months (range 3-144 months). The mortality rate was 52.2% (36/69 patients) among the patients with available follow-up.

Conclusions: A high index of suspicion for IFG should exist for patients with an immunocompromised status and diabetic patients with rhinocerebral mass lesions. Early diagnosis, aggressive surgical decompression, and a course of promptly initiated antifungal therapy are associated with a better prognosis.
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http://dx.doi.org/10.3171/2019.5.FOCUS19252DOI Listing
August 2019

Brachial plexus injury and resting-state fMRI: Need for consensus.

Neurol India 2019 May-Jun;67(3):679-683

Department of Neurosurgery, National Institute of Mental Health and Neuroscience, Bangalore, Karnataka, India.

Objective: The purpose of the study is to conduct the systematic review of literature available on resting-state functional MRI (fMRI) and brachial plexus injury.

Methods: We reviewed all the literature that are available on PubMed; keywords used were resting state, brachial plexus injury, and functional imaging. The reference papers listed were also reviewed. The research items were restricted to publications in English. Some papers have also incorporated studies such as task-based fMRI and transcranial magnetic stimulation (TMS), but only resting-state studies were included for this review.

Results: A total of 13 papers were identified, and only 10 were reviewed based on the criteria. The reviewed papers were further categorized on the basis of whether or not any surgical intervention was done. Seven papers have surgical management such as contralateral cervical 7 (CC7) neurotisation or intercostal nerve (ICN) musculocutaneous nerve (MCN) neurotisation.

Conclusion: There is conclusive evidence showing that there is cortical reorganisation following brachial plexus injury in both birth and traumatic cases. The changes are restricted to some of the resting-state networks only (default mode network, sensorimotor network, in particular). However, no study till date has focused on a far more longitudinal approach at studying these changes. It will be interesting to see the exact time and effect of these changes.
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http://dx.doi.org/10.4103/0028-3886.263178DOI Listing
February 2020

The vascular protective role of oestradiol: a focus on postmenopausal oestradiol deficiency and aneurysmal subarachnoid haemorrhage.

Biol Rev Camb Philos Soc 2019 12 1;94(6):1897-1917. Epub 2019 Jul 1.

Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bengaluru-560029, Karnataka, India.

The steroid hormone, oestradiol, has pleiotropic functions. The protective effects of oestradiol are attributed to its anti-inflammatory, antioxidant, anti-atherogenic, anti-apoptotic, vasodilatory activities and regulation of micro RNA. Oestradiol upregulates endothelial nitric oxide synthase gene expression and increases the production of nitric oxide, an important vasodilator. It suppresses the renin-angiotensin system and monitors haemodynamic stress. The hormone maintains the integrity of blood vessels by reducing oxidative stress while upregulating the expression of antioxidant enzymes and prevents vascular inflammation by regulating pro- and anti-inflammatory cytokines. Aneurysmal subarachnoid haemorrhage (aSAH) occurring as a consequence of the rupture of an intracranial aneurysm is a devastating cerebrovascular event, representing 5-7% of all strokes. Postmenopausal women are more susceptible to aSAH compared to men in the same age group. This gender disparity has been attributed to reduced levels of the vascular protective hormone oestradiol following menopause. This review is focused on the protective role of oestradiol on vasculature and how the drop in oestradiol levels after menopause dramatically increases the incidence of aSAH in women. During menopause, oestradiol deficiency may affect vascular integrity causing dysregulation of vascular homeostasis by affecting the renin-angiotensin-aldosterone system (RAAS) and inflammatory and apoptotic cascades, resulting in the weakening of the cerebral arterial wall and potentially to development of an aneurysm and its rupture. In view of the role of oestradiol in maintaining vascular integrity, treatments involving hormone replacement could be a promising approach in postmenopausal women who are at risk of developing or rupturing an intracranial aneurysm.
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http://dx.doi.org/10.1111/brv.12541DOI Listing
December 2019

Cosmetic Outcome of Cranioplasty After Decompressive Craniectomy-An Overlooked Aspect.

World Neurosurg 2019 Sep 13;129:e81-e86. Epub 2019 May 13.

NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom.

Background: Cranioplasty (CP) is an obligatory surgery after decompressive craniectomy (DC). The primary objective is to protect the brain from external injury and prevent syndrome of trephined. In a government hospital, such cases pose a significant burden to a trauma center. Because of this reason, cosmetic outcome is never taken into account for the CP. We present results of CP performed at our hospital.

Methods: This is a retrospective review of the cases of CP performed over the past 3 years at our hospital. The cosmetic outcome was divided into 3 grades: 1-good symmetrical, 2-irregularities, 2a-elevated and 2b depressed, and 3-bad cosmetic outcome requiring reoperation.

Results: A total of 133 patients with acute brain injury underwent CP during the study period. The outcome was good in 74 (55.6%) and bad, requiring reoperation, in 2 (1.5%) cases. Various types of the CP materials like autologous bone flap, titanium mesh, and customized titanium plates were used. Methods of fixation were threads or miniplates and screws. In univariate analysis, cerebral venous thrombosis as an indication for DC, use of autologous bone flap, and fixation with thread were associated with poor outcome. However, in multivariate analysis only the method of implant fixation was associated with poor outcome. It was found that if screws and plates are used for fixation of bone flap, the chances of bad outcome are reduced by 74.6%.

Conclusions: The cosmetic outcome is overlooked for CP. The bone flap fixation has to be rigid for a good outcome.
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http://dx.doi.org/10.1016/j.wneu.2019.05.027DOI Listing
September 2019

Ruptured intracranial dermoid cysts: A retrospective institutional review.

J Clin Neurosci 2019 Sep 11;67:172-177. Epub 2019 May 11.

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.

Intracranial dermoids (ID) are relatively uncommon. They are usually located in the midline or posterior fossa, and present in the first three decades of life. Rupture of IDs are a rare occurrence, and can present with diverse clinical features. They have a characteristic appearance on Computerized Tomography (CT) and Magnetic-Resonance-Imaging (MRI). Here we retrospectively review the clinical features, radiology, treatment and outcomes of ruptured IDs managed in our institute. We did a retrospective review of all the IDs from 2011 to 2017 that presented to us with rupture, or that were diagnosed to have ruptured based on imaging characteristics. Nine patients qualified for our study. The data of all 9 patients was analyzed retrospectively and their demographic details, clinical variations, and radiological features were studied and analyzed. Mode of management and outcome was assessed. Mean age of the patients was 32.1 years (SD 7.65) with male-female ratio of 7:2. Patients presented with either headache or seizures in the majority. Two patients had hydrocephalus requiring shunts. Despite their varied location and clinical features, all lesions showed similar and characteristic radiological features-namely, fat droplets in subarachnoid spaces, hypo-intensity on Susceptibility-Weighted-Imaging (SWI) with chemical shift artifact. Treatment of patients varied from medical management in 4, to cerebrospinal fluid (CSF) diversion in 2 and surgery for the lesion in 3 cases. Ruptured IDs present with a wide array of clinical features. Imaging characteristics are fairly distinct and consistent, which aids in diagnosis. Decision for mode of management has to be decided based on case-by-case basis.
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http://dx.doi.org/10.1016/j.jocn.2019.04.025DOI Listing
September 2019

Multiple Remote Sequential Supratentorial Epidural Hematomas-An Unusual and Rare Complication After Posterior Fossa Surgery.

World Neurosurg 2019 Aug 6;128:83-90. Epub 2019 May 6.

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.

Background: Postoperative hemorrhage is a serious complication of intracranial surgery. Epidural hematomas (EDHs) are one of the common forms of bleeding after surgery, with ≤12% of patients requiring re-exploration. However, distant or remote site EDHs have been rare, in particular, those in a supratentorial location after infratentorial surgery.

Case Description: We report an unusual complication of surgery for fourth ventricular outlet obstruction. A young male patient developed multiple sequential supratentorial EDHs after posterior fossa surgery. He required 2 re-explorations after the primary surgery for evacuation of the EDHs within 24 hours. In the available data, we found only 28 such reported cases previously. Only 2 additional cases have been reported to have sequential EDHs after surgery. Various theories have been postulated, ranging from sudden intracranial pressure decompression, pin site hematoma, and shunt site bleeding due to dural stripping. None has been proven to definitively explain the complication.

Conclusions: We wished to highlight this unusual complication of posterior fossa surgery, with an emphasis on rapid computed tomography scanning of the brain for patients in the early postoperative period with any neurological deterioration. Early radiological detection and timely intervention can be lifesaving.
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http://dx.doi.org/10.1016/j.wneu.2019.04.228DOI Listing
August 2019

Comparison of equiosmolar dose of hyperosmolar agents in reducing intracranial pressure-a randomized control study in pediatric traumatic brain injury.

Childs Nerv Syst 2019 06 16;35(6):999-1005. Epub 2019 Mar 16.

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.

Introduction: There are no comparative studies available for hyperosmolar therapy in children. The present study is a prospective open label randomized control trial to compare the effect of equiosmolar doses of mannitol and hypertonic saline in reducing intracranial pressure in children who sustained severe traumatic brain injury.

Methods: This is a prospective open-label randomized controlled trial. Thirty children aged less than or equal to 16 years with severe traumatic brain injury and raised intracranial pressure as measured by ventricular catheter insertion were enrolled. Sixteen children received 20% mannitol, and 14 children received 3% saline as 2.5 ml/kg bolus for episodes of intracranial pressure above cutoff value for age. The mean reduction in intracranial pressure and Glasgow outcome scale at 6 months after injury was measured.

Results: The mean reduction in intracranial pressure in mannitol group was 7.13 mmHg and in hypertonic saline group was 5.67 mmHg, and the difference was not statistically significant, p = 0.33. The incidence of death or survival in vegetative state was 23.07% in mannitol group and 16.66% in hypertonic saline group, and the difference was not statistically significant, p = 0.69.

Conclusion: Both mannitol and hypertonic saline were equally effective for treatment of raised intracranial pressure in children with severe traumatic brain injury.
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http://dx.doi.org/10.1007/s00381-019-04121-3DOI Listing
June 2019

Duplication of Ventral Dura as a Cause of Ventral Herniation of Spinal Cord-A Report of Two Cases and Review of the Literature.

World Neurosurg 2019 Jun 6;126:346-353. Epub 2019 Mar 6.

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.

Background: Idiopathic spinal cord herniation (ISCH) is a treatable spinal disease. It is rare and often misdiagnosed, causing a delay in management. The etiology is multifactorial, with one of the causes being duplication of the ventral dura. The spinal cord herniates within this defect and becomes strangulated, causing neurological deficits. We report the duplication of a ventral spinal cord as an important cause of ISCH in our review.

Case Description: We present 2 cases of ISCH with duplication of the dura, including their relevant clinical and imaging features. The patients underwent surgical reduction of the herniated spinal cord with enlargement of the defect and placement of a dural substitute ventral to the cord. We have also reported the outcomes of the 2 patients, with an emphasis on the factors predictive of poor outcomes (i.e., long-standing symptoms, a delay in intervention, poor neurological status at presentation, and a thinned out atrophic spinal cord found during surgery). We also reviewed the available data for duplication of the dura with ISCH.

Conclusions: Very few asymptomatic patients can be treated conservatively. The surgical outcomes have been favorable for symptomatic patients. Proper exposure, gentle manipulation while reducing the herniated spinal cord, enlargement of the defect, and the use of intraoperative monitoring will help limit the postoperative deficits. Duplication of the ventral dura is an important cause of ISCH. It prevents the formation of an anterior pseudomeningocele after surgery. Owing to the rarity of the disease and the lack of follow-up data with recurrence rates, it has not been possible to form clear guidelines for management.
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http://dx.doi.org/10.1016/j.wneu.2019.02.143DOI Listing
June 2019

Surgical management of traumatic extradural hematomas in children: an analysis of 201 patients at a tertiary neurosurgical center.

Childs Nerv Syst 2019 05 22;35(5):807-813. Epub 2019 Feb 22.

Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences(NIMHANS), Hosur Road, Bangalore, Karnataka, 560029, India.

Introduction: The effects of traumatic extradural hematoma (EDH) are potentially reversible if treated early. Pediatric EDH differs from its adult counterpart because of the differential elastic and adherence properties of skull bone and dura respectively. There is a paucity of literature regarding prognosis and factors predicting the outcome of pediatric EDH. In this study, we aimed to study the factors predicting outcome and prognosis of traumatic EDH in the pediatric age group.

Materials And Methods: We did a retrospective chart review of all pediatric EDH operated in our center between 2011 and 2017. Factors affecting prognosis were analyzed through univariate and multivariate analyses.

Results: Two hundred one patients qualified for the study. There were 159 boys and 42 girls with a sex ratio of 3.78:1. The most common modes of injury were road traffic accidents (n = 108, 53.3%) followed by falls from a height. The most common clinical presentation was vomiting (n = 168, 83.3%), followed by headache (n = 72, 35.8%). Pupillary asymmetry was present in 11.4% (n = 23) patients. The mean GCS at presentation was 12.71. The mean volume of EDH was 37.18 cc, with a mean maximum thickness of 23.19 mm. The most common location of the EDH was at temporoparietal region (n = 67, 33.3%). The median time of diagnosis from injury was 14.69 h (SD, 32.9 h). The mean GCS at discharge was 14.43 (SD ± 0.51). Sixteen patients were lost to follow; 185 patients were available for follow-up and were included in the outcome analysis. The mean GOS at follow-up was 4.9 (SD ± 0.368) with a median follow-up of 13.46 months. In our cohort, only one child died. Univariate and multivariate analyses revealed that pupillary asymmetry, pyramidal signs, low GCS at presentation, associated parenchymal injuries, and post-operative complications correlated negatively with outcome, whereas vomiting correlated positively with outcome.

Conclusion: Pediatric EDH differs from adults in complications as well as outcome. EDH in this pediatric cohort had a better outcome with very less mortality. Increased transportation facilities and the industrial revolution may have facilitated the shift of mode of injury from fall of height in the past to road traffic accidents in this study. A large study comparing the outcomes with pediatric and adult patients is warranted.
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http://dx.doi.org/10.1007/s00381-019-04088-1DOI Listing
May 2019

Neurotrauma Care Delivery in a Limited Resource Setting-Lessons Learned From Referral and Patient Flow in a Tertiary Care Center.

World Neurosurg 2019 Mar 7;123:e588-e596. Epub 2018 Dec 7.

Medtronic Labs and Global Health, Fridley, Minnesota, USA.

Background: With the increasing population, motorization, and road traffic accidents, neurotrauma has been increasing in India. Inadequate triage and underusage of locally available resources at all healthcare levels has led to nonuniform neurotrauma care delivery. We present our experience at a tertiary care hospital. We evaluated the referral pattern of mild traumatic brain injury (mTBI) cases to enable adequate care to patients with moderate and severely injured TBI.

Methods: All patients with head injury (n = 3891) referred to the emergency department of our institution during a 4-month period were evaluated. The demographic characteristics, ambulance usage, and time management during in-hospital patient flow were evaluated using the Lean Six Sigma approach. We have also provided solutions for optimal usage of available resources.

Results: Patients with mTBI comprised 77% of head injury referrals. Of all the patients referred from peripheral hospitals, 48% had normal head computed tomography (CT) scan findings. The CT waiting and lead (arrival-to-discharge) times were 35 ± 44 minutes and 114 minutes, respectively. No clinical to radiological correlation was found between the head CT scan findings and a decision to refer a patient to our institute. Only 10% of the patients with abnormal head CT scans (41%) required neurosurgical intervention. The mean duration from CT imaging to the initiation of surgery was 192.7 ± 172.1 minutes.

Conclusions: Most of the patients with mTBI were referred to a tertiary care center, leading to secondary overtriage and overburdening of the existing resources at a specialized care hospital, possibly owing to ineffective triage at the primary and secondary healthcare centers. This would limit the adequate management of moderate to severe TBI cases in such a hospital.
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http://dx.doi.org/10.1016/j.wneu.2018.11.227DOI Listing
March 2019

The current status of decompressive craniectomy in traumatic brain injury.

Curr Trauma Rep 2018 Sep;4(4):326-332

Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK.

Purpose: This review describes the evidence base that has helped define the role of decompressive craniectomy (DC) in the management of patients with traumatic brain injury (TBI).

Recent Findings: The publication of two randomized trials (DECRA and RESCUEicp) has strengthened the evidence base. The DECRA trial showed that neuroprotective bifrontal DC for moderate intracranial hypertension is not helpful, whereas the RESCUEicp trial found that last-tier DC for severe and refractory intracranial hypertension can significantly reduce the mortality rate but is associated with a higher rate of disability. These findings have reopened the debate about 1) the indications for DC in various TBI subtypes, 2) alternative techniques (e.g. hinge craniotomy), 3) optimal time and material for cranial reconstruction, and 4) the role of shared decision-making in TBI care. Additionally, the role of primary DC when evacuating an acute subdural hematoma is currently undergoing evaluation in the context of the RESCUE-ASDH randomized trial.

Summary: This review provides an overview of the current evidence base, discusses its limitations and presents a global perspective on the role of DC, as there is growing recognition that attention should also focus on low- and middle-income countries due to their much greater TBI burden.
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http://dx.doi.org/10.1007/s40719-018-0147-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6244550PMC
September 2018

Autonomic Function in Insular Glioma: An Exploratory Study.

World Neurosurg 2018 Oct 20;118:e951-e955. Epub 2018 Jul 20.

Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India.

Introduction: Autonomic nervous system dysfunction is a known entity in strokes involving insula. It causes significant morbidity and mortality. No study to date has demonstrated autonomic nervous system dysfunction in patients with insular glioma. This is an exploratory study to identify the subclinical autonomic dysfunctions in insular glioma.

Methods: A total 50 patients with newly diagnosed insular glioma in the age group of 18-60 years were evaluated with heart rate variability (HRV). All the HRV parameters in patients with insular glioma were compared with normal healthy age- and sex-matched control patients.

Results: There was a significant difference (P < 0.05) in most of the HRV parameters between patients and control patients. Patients with left insular glioma showed significantly increased heart rate (P = 0.027), low-frequency normalized units (P = 0.048), and also increased low-frequency/high-frequency ratio (P = 0.015), which indicates sympathetic dominance. Patients with seizures had significantly lower values of total power (P = 0.042). No significant difference was found in terms of the extent and size of the tumor or histopathologic grades of gliomas.

Conclusions: Patients with insular gliomas have significant impairment of autonomic functions, with left insular glioma showing sympathetic dominance. Suppression of autonomic function is greater in those presenting with seizures.
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http://dx.doi.org/10.1016/j.wneu.2018.07.107DOI Listing
October 2018

Fulminant acanthamoebic meningoencephalitis in immunocompetent patients: an uncommon entity.

Br J Neurosurg 2018 Jul 23:1-4. Epub 2018 Jul 23.

a Department of Neurosurgery , National Institute of Mental Health and Neuro-Sciences , Bangalore , India.

We are reporting two patients of fatal and rapidly progressive amoebic encephalitis in immunocompetent host from poor socioeconomic status. Both these patient had acute neurological worsening preoperatively and did not respond to subsequent surgical decompression. Biopsy report confirmed acanthamoebic cerebral infection.
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http://dx.doi.org/10.1080/02688697.2018.1485873DOI Listing
July 2018

Unusual cause of high cervical myelopathy-C1 arch stenosis.

J Craniovertebr Junction Spine 2018 Jan-Mar;9(1):37-43

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Introduction: High cervical myelopathy can be rarely caused by the developmental anomalies of atlas. Patients with C1 arch stenosis can present in early childhood or later in life. In symptomatic patients, posterior decompression at atlas is mandatory. We report the first clinical series of 20 patients of C1 arch stenosis in the English literature.

Materials And Methods: This is retrospective case series having a cohort of 20 patients with congenital C1 arch stenosis.

Results: There were 12 pediatric (age <18 years) and 8 adult patients. Mean age was 22.85 years. Syndromic association was seen in four patients. Following decompressive surgery, these patients noticed a symptomatic improvement.

Conclusions: Isolated C1 arch stenosis is a surgically curable rare cause of high cervical myelopathy and responds well to surgery.
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http://dx.doi.org/10.4103/jcvjs.JCVJS_134_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5934963PMC
May 2018
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