NeuroSurgery

REVIEW ARTICLES
	Human tail: A benign condition hidden out of social stigma and shame in young adult – A case report and review	p. 1
	Pramod Janardan Giri, Vaibhav Sharadrao Chavan DOI:10.4103/ajns.AJNS_209_17   A human tail is a rare congenital anomaly which mostly presents immediately after birth or in early childhood. Here, we are presenting a case of 17-year-old male who presented with 18-cm long tail, which was hidden till this age because of social stigma and shame. This is longest human tail reported of our knowledge. This patient presented to us because he started having difficulty, pain while sitting, and discomfort in daily activities because of long tail. We suspect there are far more cases of human tails in developing world which are hidden because of lack of knowledge, illiteracy, social stigma, and shame. This patient had no neurological deficit and had no bowel/bladder involvement. The radiological investigation was suggestive of spina bifida at L5and S3–S4 levels (site of attachment of the tail), and tip of the coccyx had bony spur directed posteriorly. Intraoperatively, no connection was found between tail and neural tissue. Human tail is associated with occult spinal lesions in 50% of cases, hence careful neurological and radiological investigations are warranted before surgical exploration.
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	Convection-enhanced drug delivery for glioblastoma: A systematic review focused on methodological differences in the use of the convection-enhanced delivery method	p. 5
	Bo Halle, Kristian Mongelard, Frantz Rom Poulsen DOI:10.4103/ajns.AJNS_302_17   Glioblastoma (GBM) is a leading cause of brain cancer-related death. The blood–brain barrier (BBB) prevents the transport of most systemic delivered molecules to the brain. This constitutes a major problem in the therapy of brain tumors. In the last decade, numerous different drug-delivery approaches have been developed to overcome the BBB. The objective of this study is to provide an overview of the methodological aspects used in all preclinical and clinical studies published from 2011 to 2016 where convection-enhanced delivery (CED) was used for drug delivery in the treatment of GBM. A systematic review of English articles published in the past 5 years was undertaken using PubMed and Embase. The search terms (brain tumor [MeSH Terms]) AND (CED OR convection enhanced delivery) were used in PubMed and a similar search was carried out in Embase using their "multi-field search." All studies using CED on an intracranial GBM model were included. The search resulted in 151 hits after duplicates were removed. In total, 30 studies were included in the review. Of these, two publications studied the technical aspects of the CED method. Furthermore, only one study was a clinical study. The research field is focused on preclinical drug development trials and less emphasis is placed on the CED technique itself. However, it is important that future studies focus on establishing optimal protocols for the use of CED in rodents as well as for big brain models to be able to use the CED method in patients with GBM.
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	Timing of surgery and surgical strategies in symptomatic brainstem cavernomas: Review of the literature	p. 15
	Niranjana Rajagopal, Tsukasa Kawase, Ameen Abdul Mohammad, Liew Boon Seng, Yasuhiro Yamada, Yoko Kato DOI:10.4103/ajns.AJNS_158_18   Brainstem cavernomas (BSCs) are angiographically occult, benign low flow vascular malformations that pose a significant surgical challenge due to their eloquent location. The present study includes an extensive review of the literature and three illustrative cases of BSC with emphasis on the timing of surgery: surgical approaches, usage of intraoperative monitoring, and complication avoidance. A systematic search was performed using the PubMed database was from January 1, 1999, to June 2018. The relevant articles were reviewed with particular attention to hemorrhage rates, timing of surgery, indications for surgery, surgical approaches, and outcome. Along with this, a retrospective analysis of three cases of symptomatic BSC, who were operated for the same, during the year 2018 in our institute was conducted. All the three patients presented with at least 1 episode of hemorrhage before surgery. Of these, one patient was operated immediately due to altered sensorium whereas the other two were operated after at least 4 weeks of the hemorrhagic episode. The patients who were operated in the subacute phase of bleed were seen to have liquefaction of hematoma, thus providing a good surgical demarcation and thereby reduced surgery-related trauma to the surrounding eloquent structures. Two patients improved neurologically during the immediate postoperative period, whereas one had transient worsening of neurological deficits during the immediate postoperative period in the form of additional cranial nerve palsies which completely improved on follow-up after 2 months. Radical resection is recommended in all patients with symptomatic BSCs. Surgery should be considered after the first or the second episode of hemorrhage as multiple rebleeds can cause exacerbation of deficits and sometimes mortality as well. Considering surgical timing, anywhere between 4 and 6 weeks or the subacute phase of the hemorrhage is considered appropriate. The aims of surgical intervention must be to improve preoperative function, minimize surgical morbidity and to reduce hemorrhagic rates. In spite of the significant surgical morbidity associated with BSCs, appropriate patient selection, meticulous surgical planning with adjuncts such as intraoperative monitoring and neuronavigation will go a long way in avoidance of major postoperative complications.
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	Prognostic factors influencing outcome in unruptured anterior communicating artery aneurysm after microsurgical clipping	p. 28
	Sudhakar Kasinathan, Yashiro Yamada, Abderrahmane Cheikh, Takao Teranishi, Tsukasa Kawase, Yako Kato DOI:10.4103/ajns.AJNS_198_18   Anterior communicating artery (A.com.A) aneurysm projection is an important factor in determining the outcome of aneurysm clipping. The objective of this study was to analyze the outcome of A.com.A aneurysm projection and prognostic factors influencing it and comparing them with Glasgow outcome scale. A retrospective analysis of 47 patients from hospital records who have got admitted in the Banbuntanke Hotokokai Hospital, Nagoya, Japan, from 2014 to 2017, with unruptured A.com.A aneurysm and subsequently operated in the hospital. Demographic factors such as age, sex, and associated with other aneurysms and the morphological characteristics such as aneurysm size, projection, and height were analyzed with postoperative complications and Glasgow outcome scale. Totally 47 cases have been operated in which 26 (55.3%) are female and 21 (44.6%) are male, and the median age is 68 years, 7 (14.89%) patients had middle cerebral artery aneurysm along with A.com.A aneurysm and 1 had internal carotid artery-posterior communicating artery junction aneurysm. Four (8.5%) had chronic subdural hematoma and 1 (2.12%) had epilepsy, 1 (2.12%) case got reoperated, and 1 (2.12%) had hydrocephalus. Moreover, the overall complication rate is 14.89%. For six patients, motor-evoked potential monitoring was used. Forty-six patients had Glasgow outcome scale of 5 and 1 patient had Glasgow outcome scale of 4. There was no mortality in this study. Mean size of the aneurysm was 6.68 mm and the range was 2–25 mm. Mean height was 4.14 mm, 26 (56.52%) A.com.A aneurysm were anteriorly projecting, 9 (19.56%) were superiorly projecting, 8 (17.32%) were inferiorly projecting, and 3 (6.38%) were posteriorly projecting. Morphological parameters such as size, height, and projection were not only highly associated with A.com.A aneurysm rupture and also complications due to clipping of aneurysm.
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ORIGINAL ARTICLES
	Endoscopic third ventriculostomy in noncommunicating hydrocephalus: Report on a short series of 53 children	p. 35
	Arif Sarmast, Nayil Khursheed, Altaf Ramzan, Feroz Shaheen, Abrar Wani, Sarbjit Singh, Zulfikar Ali, Bashir Dar DOI:10.4103/ajns.AJNS_187_16   Introduction: Endoscopoic third ventriculostomy (ETV) is currently considered the best alternative to cerebrospinal fluid (CSF) shunt systems in the treatment of obstructive hydrocephalus. The aim of ETV is to communicate the third ventricle with the interpendicular cistern and create CSF flow which bypasses an obstruction to the circulation of the CSF. Aims and Objectives: The purpose of this study was to elucidate the indications, efficacy, safety and outcome Of ETV pediatric patients of noncommunicating hydrocephalus. Material and Methods: This study is a 3 year prospective study from June 2012 to May 2015. Records were kept for age, gender, etilogical factors, symptoms, signs, previous use of shunt or external ventricular device, imaging findings, and surgical complications (intraoperative and postoperative). Only those patients with age between 6months and 18 years with symptoms of intracranial hypertension and radiographic evidence of noncommunicating hydrocephalus were included in the study. Results: A total of 53 patients were studied, out of these 29 were boys and 24 were girls. The mean age of the patients was 6.6 years. Overall a total of 50 successful ETVs were done in 53 patients. The success rate is estimated to be 94%. There was no mortality. The average postoperative hospital stay was 4 days. The followup ranged from 6 to 16 months (mean, 12 months). Conclusion: ETV in children is a safe, simple and effective treatment and a logical alternative to shunting procedure for patients of noncommunicating hydrocephalus.
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	Clinicopathological characteristics of meningiomas: Experience from a tertiary care hospital in the Kashmir Valley	p. 41
	Basharat Mubeen, Rumana Makhdoomi, Khursheed Nayil, Danish Rafiq, Altaf Kirmani, Othman Salim, Farhat Mustafa, Aifa Aimen, Sumat Khursheed, Shazia Bashir, Saba Shafi, Altaf Ramzan DOI:10.4103/ajns.AJNS_228_16   Background: Meningiomas comprise 15%–20% of all primary intracranial tumors. They are generally benign tumors, and most patients are cured after surgery and remain free of recurrence. However, some tumors behave in an aggressive manner, and patients develop local recurrence or metastasis. Overall prognosis is good. Patients and Methods: This is an 11-year retrospective study conducted in the Departments of Pathology and Neurosurgery at Sheri-I-Kashmir Institute of Medical Sciences, Kashmir, India. Besides the demographic profile, the parameters analyzed were location of tumor on imaging, histopathological subtype, and grade of tumor according to the 2007 WHO classification and recurrence at follow-up. Results: A total of 254 patients were included in our study, of which 205 (80.7%) were brain meningiomas and 49 (19.3%) were spinal, with an overall female: male ratio of 2:1. Female: male ratio was more in spinal meningiomas, 15.3:1. Most of our patients were in the 4–6th decade of life with a mean age of 48 years (range: 5–73 years). Meningothelial meningioma was the most common histological type. Of ten patients who showed recurrence, seven cases showed only recurrence, but no progression to higher grade and three cases showed recurrence with progression by one WHO-grade. We also noticed that recurrence was higher in Simpson Grades II and III. Conclusion: Meningiomas are common in females and most of the meningiomas do well after surgery. The recurrence rate was 3.93% in our study and Simpson grade of tumor excision and histopathological grade contribute significantly to the recurrence of the tumor.
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	Role of diffusion and perfusion magnetic resonance imaging in predicting the histopathological grade of gliomas - A prospective study	p. 47
	Yawar Shoaib, Khursheed Nayil, Rumana Makhdoomi, Abraq Asma, Altaf Ramzan, Feroze Shaheen, Abrar Wani DOI:10.4103/ajns.AJNS_191_16   Context: Gliomas are the most common brain tumors. In addition to conventional magnetic resonance imaging (MRI) techniques, a variety of new techniques offers more than the anatomic information. The new MRI techniques include perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI). Aims: The aim of this study is to assess the sensitivity, specificity, predictive value, and accuracy of diffusion- and perfusion-weighted MRI in the preoperative grading of gliomas. Setting/Design: The study was conducted in the Department of Neurosurgery, Pathology, and Radiodiagnosis, Sher-e-Kashmir Institute of Medical Sciences, Kashmir, India, which is the only tertiary care neurosurgical center in the state. It was a prospective study. Patients and Methods:Thirty-one consecutive patients with gliomas were included in the study. All the patients were evaluated by a standard conventional contrast-enhanced study on Siemens 1.5 Tesla MRI. In addition to the standard MRI, diffusion- and perfusion-weighted MRI were also performed. The histopathological grading of the tumor was done as per the WHO classification of 2007. The sensitivity, specificity, predictive value, and accuracy of diffusion- and perfusion-weighted MRI in determining tumor grade were calculated. Comparison was done between PWI, DWI findings, and WHO histopathological grading. Analysis Method: The statistical analysis was done using the Statistical Package for the Social Sciences, and receiver operating characteristic curves were used to estimate sensitivity, specificity, and accuracy. Results: The overall sensitivity of PWI (with regional cerebral blood volume cutoff of 1.7) in the preoperative assessment of high-grade gliomas was 82.6% and specificity was 75%, the positive predictive value (PPV) was 90.48%, and the negative predictive value (NPV) was 60%. The overall accuracy was 80.65%. In case of DWI, the sensitivity was 69.57% and the specificity was 75%, and the PPV and NPVs were 88.8% and 46.15%, respectively. The overall accuracy was 71%. Conclusion: Our results clearly show higher accuracy of diffusion- and perfusion-weighted MRI in assessment of glioma grade as compared to conventional MRI. This information can prove very useful for the operating neurosurgeon in preoperative assessment and surgical planning. Postoperatively, the neuropathologist can also benefit from such information.
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	Long term outcome in survivors of decompressive craniectomy following severe traumatic brain injury	p. 52
	Ashutosh Kaushal, Ashish Bindra, Abhyuday Kumar, Keshav Goyal, Niraj Kumar, Girija Prasad Rath, Deepak Gupta DOI:10.4103/ajns.AJNS_147_17   Background: Decompressive craniectomy (DC) is done for the management of intracranial hypertension due to severe traumatic brain injury (sTBI). Despite DC, a number of patients die and others suffer from severe neurological disability. We conducted this observational study to assess functional outcome as measured by Glasgow outcome scale-extended (GOSE) in survivors of DC. The correlation between various factors at admission and hospital with functional outcome was also obtained. Materials and Methods: Patients (15–65 years) posted for cranioplasty following DC due to sTBI were prospectively enrolled. Demographic profile, clinical data, and GOSE were noted at the time of admission for cranioplasty from the patient or nearest relative or both. Retrospective data noted from hospital records included admission Marshalls grading, Glasgow coma score (GCS), motor response, mean arterial pressure (MAP), and timing of DC at the time of initial admission following sTBI. Results: A total of 85 patients (71 males and 14 females) were enrolled over a period of 2 years. The mean age of the patients was 33.42 ± 12.70 years. The median GCS at the time of admission due to head injury, at the time of discharge, and at the time of cranioplasty was 8 (interquartile range [IQR] 3–15), 10 (IQR 4–15), and 15 (IQR 7–15), respectively. Thirty-one patients (36%) had good functional outcome (GOSE 5–8) and 54 patients (64%) had poor functional outcome (GOSE 1–4). On univariate analysis tracheostomy (P = 0.00), duration of hospital stay (P = 0.002), MAP at admission (P = 0.01), and GCS at discharge (P = 0.01) correlated with outcome [Table 1]. On multivariate analysis MAP at admission (odds ratio [OR] [95% confidence interval {CI}]; 0.07 [0.01–0.40] and tracheostomy (OR [95% CI]; 15 [1.45–162.9]) were found to be the independent predictors of functional outcome. Conclusion: Significant disability is seen among the survivors of DC. Tracheostomy and MAP at admission were found to be independently associated with the patient outcome.{Table 1}
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	Posterior transpedicular screw fixation of subaxial vertebrae: Accuracy rates and safety of mini-laminotomy technique	p. 58
	Erhan Celikoglu, Ali Borekci, Ali Fatih Ramazanoglu, Dilber Aycicek Cecen, Abdullah Karakoc, Pinar Kuru Bektasoglu DOI:10.4103/ajns.AJNS_178_17   Background and Aim: Posterior cervical transpedicular screw fixation has the strongest resistance to pullout forces compared with other posterior fixation systems. Here, we present a case on the use of this technique combined with a mini-laminotomy technique, which serves as a guide for accurate insertion of posterior cervical transpedicular screws. Materials and Methods: We retrospectively analyzed data from 40 patients who underwent this procedure in our clinic between January 2014 and March 2017. Results: The study population comprised 27 males (67.5%) and 13 females (32.5%) aged 15–80 years (median, 51.5 years). Surgical indications included trauma (n = 18, 45%), degenerative disease (n = 19, 47.5%), spinal infection (n = 2, 5%), and basilar invagination due to systemic rheumatoid disease (n = 1, 2.5%). In the 18 trauma patients, 14 short-segment (1–2 levels) and 4 long-segment (≥3 levels) posterior cervical instrumentation and fusion procedures were performed. The mini-laminotomy technique was used in all patients to insert, direct, and achieve exact screw fixation in the pedicles. Pedicle perforations were classified as medial or lateral and were also graded. Among the 227 cervical pedicle fixations performed, 48 were at the C3 level, 49 at C4, 60 at C5, 50 at C6, and 20 at C7. Axial computed tomography scan measurements showed that 205 of 227 (90.3%, Grade 0 and 1) screws were accurately placed, whereas 22 (9.69%, Grade 2 and 3) were misplaced. However, no additional neurological injury due to misplacement was observed. Conclusion: As negligible complications were observed when performed by experienced surgeons, the mini-laminotomy technique can be safely used for posterior transpedicular screw fixation in the subaxial vertebrae for single-staged fusion.
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	Endoscopic approach to putaminal bleed	p. 63
	Daisuke Suyama, Brajesh Kumar, Saiko Watanabe, Riki Tanaka, Yasuhiro Yamada, Tsukasa Kawase, Yoko Kato DOI:10.4103/ajns.AJNS_215_17   Objective: To highlight the basic points of brain endoscopic procedure for Putaminal Bleed to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons. Method: Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery. Conclusion: Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.
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	Endoscopic approach to subcortical (Lobar) hemorrhage	p. 67
	Daisuke Suyama, Brajesh Kumar, Saiko Watanabe, Riki Tanaka, Yasuhiro Yamada, Tsukasa Kawase, Yoko Kato DOI:10.4103/ajns.AJNS_216_17   Objective: To highlight the basic points of brain endoscopic procedure for Subcortical (Lobar) Hemorrhage to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons. Method:Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery. Conclusion: Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.
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	Endoscopic approach to cerebellar and large putaminal bleed	p. 72
	Daisuke Suyama, Brajesh Kumar, Saiko Watanabe, Riki Tanaka, Yasuhiro Yamada, Tsukasa Kawase, Yoko Kato DOI:10.4103/ajns.AJNS_217_17   Objective: To highlight the basic points of brain endoscopic procedure for Cerebellar and Large Putaminal Hemorrhage to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons. Method: Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery. Conclusion: Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.
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	Endoscopic approach to thalamic and intraventricular hemorrhage	p. 77
	Daisuke Suyama, Brajesh Kumar, Saiko Watanabe, Riki Tanaka, Yasuhiro Yamada, Tsukasa Kawase, Yoko Kato DOI:10.4103/ajns.AJNS_218_17   Objective: To highlight the basic points of brain endoscopic procedure for Thalamic and Intraventricular Hemorrhage to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons. Method: Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery. Conclusion: Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.
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	Lateral semi-sitting position: A novel method of patient's head positioning in suboccipital retrosigmoid approaches	p. 82
	Vernon Velho, Harish Naik, Anuj Bhide, Laxmikant Bhople, Prashant Gade DOI:10.4103/ajns.AJNS_203_17   Background: The most common methods of positioning patients for suboccipital approaches are the lateral, lateral oblique, sitting, semisitting, supine with the head turn, and park bench. The literature on the positioning of patients for these approaches does not mention the use of lateral semisitting position. This position allows utilization of the benefits of both semisitting and lateral position without causing any additional morbidity to the patient. Aims: The aim of the present study is to highlight the advantages of the lateral semisitting position while operating various cerebellopontine angle (CPA) and posterior fossa lesions. Materials and Methods: The position involved placing the patient in a lateral position with torso flexed to 45° and head tilted toward opposite shoulder by 20°. The most common approach taken was retrosigmoid suboccipital craniotomy. Results: The advantages of lateral semisitting position were early decompression of cisterna magna, and the surgical field remained relatively clear, due to gravity-assisted drainage of blood and irrigating fluid. We could perform all the surgeries without the use of any retractors. The position allowed better delineation of surrounding structures resulting in achieving correct dissection plane and also permitted early caudal to cranial dissection of tumor capsule, thereby increasing chances of facial nerve preservation. Importantly, there is less engorgement of the cerebellum as the venous outflow is promoted. We have not experienced any increased rate of complications, such as venous air embolism, tension pneumocephalus with this lateral semisitting position. Conclusions: Lateral semisitting position is a relatively safe modification, which combines the benefits of semisitting and lateral position, and avoids the disadvantages of sitting position in operating CPA tumors. This position can provide quick and better exposure of the CPA without any significant complications.
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	Speech and language dysfunctions in patients with cerebrocortical disorders admitted in a neurosurgical unit	p. 87
	Ushasree Bobba, Ashok Munivenkatappa, Amit Agrawal DOI:10.4103/ajns.AJNS_240_17   Introduction: Speech and language abnormality among brain injury patients are common, especially during the acute stage. The details of same from Andhra Pradesh (AP) state are limited. The present study provides details of speech and language abnormality among brain damage patients, from a tertiary care hospital AP. Materials and Methods: This study was conducted at tertiary care hospital, Nellore, AP. Patients with acute brain damage due to traumatic brain injury (TBI), cerebrovascular accident (CVA), and postoperative cases of brain tumors were selected for the study. Detail of speech and language disturbances was accessed using Western Aphasia Battery. All patients were right-handed and Telugu was their first language. Results: There were totally 38 patients, of them 28 had TBI, 8 patients were postoperative cases of brain tumor, and 2 cases were of CVA. The mean age was 45.6 years. A total of 22 patients were literate. TBI patients with left cerebral hemisphere damage manifested with anomic, conduction, transcortical sensory, global, and Wernicke's aphasia. Four patients of postoperative brain tumor manifested with anomic and transcortical sensory aphasia had left-sided brain damage and mild dysarthria had right-sided brain damage patient. CVA patients had anomic aphasia and subcortical aphasia having right and left cerebral hemisphere damage, respectively. Conclusions: This study reports that acute brain damage due to various causes manifest with speech and language abnormality, especially when the left cerebral hemisphere is involved.
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	Magnetic resonance imaging-guided stereotactic biopsy: A review of 83 cases with outcomes	p. 90
	Ali Akay, Mete Rüksen, Sertaç Islekel DOI:10.4103/ajns.AJNS_81_17   Background: The purpose of this study was to determine the relationship between the radiological and histopathological distribution of the cerebral lesions diagnosed with stereotactic biopsy (STB) procedure and its outcomes. Materials and Methods: In the current study, a retrospective analysis of 83 patients that underwent the STB in our clinic from January 2011 to December 2015 was made. T1-weighted contrast-enhanced cranial magnetic resonance imaging examinations were performed on patients on whom Leksell stereotactic frame system was installed. The histopathological and the radiological data derived from the STB procedure were classified. Results: In terms of localization, glial tumor (56.6%) was the most common lesion in all regions, except for the multifocal lesions. Contrary to the common knowledge, lymphoma (14.4%) was found to be the most common lesion among multifocal lesions. The success of obtaining positive STB samples in the current series was 95.2% and the complication rate was 3.6%. Conclusion: Had a routine computed tomography scan been performed on each patient in this series, the number of clinically insignificant small intracerebral hematomas would have probably been higher. Nevertheless, the rate of the STB sampling accuracy and the complication rate were similar to those reported in the relevant literature.
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	A middle path in the surgical management of glomus jugulare: Lessons learnt from a short series	p. 96
	Balaji Sanjeev Pai, Pratham Raghunath Bysani, Nagarjun Maulyavantham Nagaraj DOI:10.4103/ajns.AJNS_232_17   Introduction: Glomus jugulare are rare vascular tumors arising from the jugular bulb with intra- and extra-cranial extensions. Although considered benign, these tumors are locally invasive with involvement of critical neurovascular structures causing significant morbidity. Due to their highly vascular nature, they pose a challenge for surgeons. Settings and Design: This is a retrospective analysis of a short series of glomus jugulare managed in a tertiary state-run referral center. Subjects and Methods: Three patients (two females, one male) of ages ranging from 32 to 55 years were evaluated for glomus jugulare and surgically managed. In the first case, total petrosectomy after transposing the facial nerve, cerebellopontine angle exploration, neck dissection and infratemporal fossa approach including removal of the internal jugular vein were done. Case 2 and Case 3 were managed with subtotal resection. Radiotherapy (RT) for residual tumor was given in Case 2. Results: Case 1 had secondary hemorrhage on 8th postoperative day to which she succumbed on postoperative day 18. Case 2 and Case 3 have been comfortable with no fresh deficits after 36- and 6-month follow-up, respectively. Apart from this, the authors also enumerate the various "lessons" learnt from this series. Conclusion: Planned subtotal resection followed by RT or stereotactic radiosurgery for the residual tumor yields a better outcome with lower morbidity and mortality.
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	Enterococcal meningitis/ventriculitis: A tertiary care experience	p. 102
	Iffat Khanum, Sana Anwar, Aisha Farooque DOI:10.4103/ajns.AJNS_260_17   Context: Enterococcal meningitis is very rare among bacterial meningitis and has variable clinical outcomes. Aims: The purpose of the current study is to evaluate clinical features, therapeutic options with susceptibility profile, and outcomes of enterococcal meningitis in a tertiary care hospital. Settings and Design: We retrospectively reviewed medical records of all patients with enterococcal meningitis over the periods of 4 years. Subjects and Methods: The clinical and laboratory data of all patients with enterococcal meningitis were evaluated between 2013 and 2016. Results: Six cases of enterococcal meningitis were found (three infant and three adults). All patients developed meningitis after neurosurgical procedures, and majority of patients (four out of six) had central nervous system (CNS) devices in situ at the time of development of meningitis. The causative organism isolated from cerebrospinal fluid (CSF) culture of all patients was Enterococcus species only. All Enterococcus spp. were resistant to ampicillin, Amoxicillin-clavulanate, and oxytetracycline and two isolates were also resistant to vancomycin. Four patients with vancomycin-sensitive Enterococcus spp. were treated with vancomycin alone for mean periods of 18 days (14–21 days). One patient with vancomycin-resistant Enterococcus(VRE) meningitis was treated with linezolid alone, and another one requires combination with rifampicin to achieve microbiological clearance of CSF. CNS devices were removed in all patients. No mortality was reported in current case series. Conclusions: Enterococcal meningitis is very uncommon, mostly associated with neurosurgical intervention. Early treatment is associated with favorable outcomes. Removal of CNS devices is recommended to achieve a clinical cure.
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	The relation between cord signal and clinical outcome after anterior cervical discectomy in patients with degenerative cervical disc herniation	p. 106
	Ali Rabee Kamel Hamdan DOI:10.4103/ajns.AJNS_262_17   Introduction: Cervical spondylotic myelopathy is a cervical cord compressive lesion that occurs as a result of the normal degenerative process which may cause magnetic resonance imaging (MRI) cord intensity changes that may worsen the clinical outcome even after successful anterior cervical decompression. Objective: To assess the relation between MRI T2 Weighted images (T2 WI) hyperintense cord signal and clinical outcome after anterior cervical discectomy in patients with degenerative cervical disc herniation. Materials and Methods: This is a retrospective observational study that was conducted on twenty-five patients with degenerative cervical disc prolapse associated with MRI T2WI hyperintense cord signal, at the Department of Neurosurgery, Qena University Hospital, South Valley University from August 2014 to December 2016. A complete clinical and radiological evaluation of the patients was done. Anterior cervical discectomy and fusion was done for all patients. Patients were clinically assessed preoperatively and postoperatively at 3, 6, and 12 months using Modified Japanese Orthopedic Association (MJOA) score. Radiographic assessment was done by preoperative and postoperative T2WI MRI. The statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software (version 22.0). Results: There were 25 patients included in the study; 16 (64%) females and 9 (36%) males. The mean age was 46.89 ± 7.52 standard deviation (SD) years with range from 26 to 64 years, 3 (12%) patients had worsened in the form of postoperative motor power deterioration, and 14 (56%) patients has no improvement and remain as preoperative condition. The remaining 8 (32%) patients had a reported postoperative improvement of symptoms and signs according to MJOA score. The mean follow-up period (in months) was 11 ± 2.34 (SD). Conclusion: The presence of T2W hyperintense signal on preoperative MRI predicts a poor surgical outcome in patients with cervical disc prolapse. The regression of T2W ISI postoperatively correlates with better functional outcomes.
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	Microvascular decompression in patients aged 30 years or younger	p. 111
	Prasanna Karki, Masayuki Yamagami, Koji Takasaki, Manoj Bohara, Hiroshi Hosoyama, Tomoko Hanada, Fumiyuki Yamasaki, Ryosuke Hanaya, Kazunori Arita DOI:10.4103/ajns.AJNS_266_17   Objective: The aim of this study was to identify the etiology of hemifacial spasm (HFS) and trigeminal neuralgia (TN) in patients aged 30 years or younger and to examine the efficacy of microvascular decompression (MVD). Patients and Methods: Between 1996 and 2012, 228 HFS and 190 TN patients underwent MVD at Atsuchi Neurosurgical Hospital. Of these, 7 patients were 30 years of age or younger at the time of treatment (HFS: n = 6, TN: n = 1). Assessments were based on their medical history and on magnetic resonance imaging, magnetic resonance angiography, surgical, and follow-up findings. Results: The age of the 6 HFS patients ranged from 23 to 30 years (mean 27.8 ± 1.8 [standard deviation] years) at the time of surgery; the earliest symptom onset was in an 11-year-old boy. We noted vascular variations in 5 patients, a duplicate posterior inferior cerebellar artery in 2 patients, a short basilar artery in 1 patient, and an aberrant arterial course in 2 patients. At the latest follow-up, 1–69 months after MVD, 5 of the HFS patients were asymptomatic and the 6th had mild residual symptoms. A 23-year-old TN female underwent straightening of the trigeminal nerve by separation of a thickened arachnoid membrane from the nerve and dislocation of a small branch of the superior cerebellar artery from the distal end of the root exit zone. While she continued to experience occasional facial pain 48 months after the operation, she required no medication because surgery yielded significant pain amelioration. Conclusion: Although the pathogenesis of early-onset HFS and TN remains unclear, our findings suggest that vascular variations may be related to the etiology of vascular compression symptoms in patients with HFS or TN. MVD was useful for the treatment of neurovascular compression symptoms in young patients.
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	Markers of fibrinolysis in Indian patients with isolated head trauma	p. 118
	Meera Sikka, Ruchika Sodhi, Mrinalini Kotru, Gurubachan Singh DOI:10.4103/ajns.AJNS_278_17   Context: Head injury causes disseminated intravascular coagulation as the most severe complication which is associated with high mortality. Elevated levels of markers of fibrinolysis such as D-dimer and fibrinopeptide A (FPA) have been correlated with poor outcome in these patients. Aim: The study aimed to correlate the levels of plasma fibrinogen, D-dimer, and FPA with outcome in patients with isolated head trauma. Settings and Design:This cross-sectional descriptive study was conducted in the Departments of Pathology and Neurosurgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, on 100 patients admitted within 12 h of isolated head trauma. Subjects and Methods: Plasma fibrinogen, D-dimer, and FPA were measured in 100 patients admitted within 12 h of isolated head trauma. While plasma fibrinogen and D-dimer were estimated in all patients, FPA was measured in 45 patients. Statistical Analysis: SPSS (20.2) software was used for mean, standard deviation, and median values of the quantitative parameters, and for all qualitative parameters, their frequencies were obtained. P < 0.05 was considered significant. Results: Elevated D-dimer (>250 ng/ml) and FPA (>3 ng/ml) were observed in 64% and 91.1% patients, respectively. Both D-dimer and FPA were elevated in 66.6% of patients. Disseminated intravascular coagulation (DIC) score, calculated using standard criteria, was ≥5 in 28% of patients indicating overt DIC. Hypofibrinogenemia was observed in 48% of patients. D-dimer, FPA, and DIC score was significantly (P < 0.001) higher and plasma fibrinogen significantly (P < 0.001) lower in nonsurvivors as compared to survivors. Elevated D-dimer and FPA and low fibrinogen levels were seen in patients irrespective of severity of injury. Conclusions: Elevated D-dimer and FPA were frequently observed in patients with isolated head trauma. As these markers rise soon after injury and indicate poor outcome, their measurement will help identify patients who will benefit with additional therapy, thus reducing morbidity and mortality.
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	Variation of ventricular size after surgical treatment of chronic subdural hematoma	p. 122
	Abad Cherif El Asri, Mohammed Benzagmout, Khalid Chakour, Mohamed Faiz Chaoui, Jawad Laaguili, Miloudi Gazzaz, Hassan Baallal, Brahim El Mostarchid DOI:10.4103/ajns.AJNS_298_17   Background: Surgical removal is the treatment of choice for chronic subdural hematoma (CSDH). Despite clinical improvement after surgery, computed tomography (CT) scan control often showed residual collection, which may discuss the possibility of failed surgery. The aim of this study is the assessment of ventricular size before and after surgery and to study its relation with residual hematoma. Methods: In this prospective study (2013-2016), 63 patients who had burr-hole drainage of CSDH were sequentially allocated to either two groups; Group 1 with CT scan control under the 3rd day of surgery and Group 2 with delayed CT scan control (from 4th to 7th day). Linear measure of ventricular size was assessed by Evans' index. We reviewed and analyzed the data between both groups. Results: There were 33 patients in Group 1 and 30 patients in Group 2. Preoperatively, the average thickness of hematoma was 20.5 mm in Group 1 versus 19.9 mm in Group 2 (P = 0.67); the mean midline shift was 8.5 mm in each group; Evans' index was 26.7% in Group 1 and 27% in Group 2 (P = 0.7). Postoperatively, the mean thickness of the residual hematoma was 7.7 mm in Group 1 and 8.4 mm in Group 2 (P = 0.57); the mean midline shift was 3.3 mm in Group 1 and 1.9 mm in Group 2 (P = 0.08); Evan's index was 28.5% in Group 1 and 32.1% in Group 2 (P = 0.002). Conclusion: The adoption of Evans' index, for assessing the variation of ventricular size after surgery, by neurosurgeons appears to be a good and simple method for evaluation and following the success of surgical removal of CSDH, despite the observation of some residual collection in early CT scan control.
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	Follow-up bibliometric analysis of neurosurgical publications from Pakistan and institutional comparison with other countries using h-index and i-10 index	p. 126
	Muhammad Waqas, Usman Tariq Siddiqui, Muhammad Shahzad Shamim DOI:10.4103/ajns.AJNS_286_17   Aim: The aim of the study was to analyze the neurosurgical research output of Pakistan and compare it with that of developed countries. Methodology: We conducted a bibliometric analysis of publically available databases for all neurosurgical publications from Pakistan. All indexed peer-reviewed publications from January 2009 to December 2014 where at least one author was affiliated with any neurosurgical departments in Pakistan and research was conducted in Pakistan were selected. Manual and electronic search was done using MeSH terms to search for articles from Pakistan. Articles were then categorized according to design, subspecialty, region, and year. Results: Our search identified 121 articles during the defined study period (mean = 20.16 ± 5.2 papers/year). A relatively constant increase was noticed for the last 6 years, i.e., 2009–2014. From the total 121 references, 100 (82.4%) publications were from one city, and on subanalysis, 80 (66.1%) were from a single institution. Three primary authors cumulatively contributed to 76 (62.8%) of these publications. Almost two-thirds (n = 76, 62.8%) of these publications were published in either regional or international journals while only 37.2% (n= 45) were published in local nonneurosurgery-specific journals. Only one study in the 6-year study period was with Level I evidence (meta-analysis). Conclusion: Neurosurgery research in Pakistan has shown modest improvement in terms of quality and quantity. Collaboration between various centers and channelizing different resources to create national data registries along with basic science laboratories is much needed.
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	Management and surgical approaches of brainstem cavernous malformations: Our experience and literature review	p. 131
	Delia Cannizzaro, Giovanni Sabatino, Cristina Mancarella, Martina Revay, Marco Rossi, Guido Pecchioli, Andrea Cardia, Giulio Maira, Vincenzo D'Angelo, Maurizio Fornari DOI:10.4103/ajns.AJNS_290_17   Introduction: Brainstem cavernous malformations (BSCMs) are clusters of dilated sinusoidal channels. Clinical presentation is characterized by focal neurological deficits and/or hemorrhage. The goal of this study is to analyze surgical indications and approaches in a series of patients with BSCM and review pertinent literature and suggest prognostic factors related to the anatomical, clinical, and surgical data collected. Methods: We retrospectively reviewed the clinical data of 55 patients with BSCM, treated at three centers, from January 2006 to March 2016. We collected anagraphic data, pre and postoperative neurological status, pre and postradiological images, surgical procedures, and follow-up results. We summarized the anatomical, clinical, and surgical aspects of the lesions and identified two large groups based on the chosen approach: lateral and medial. Clinical and radiological results were then compared. Results: The series comprised 55 patients. Hemorrhagic onset was observed in all patients. Suboccipital, retrosigmoid, anterior, subtentorial, subtemporal, transvermian, telovelar, far lateral and trans, and infratentorial approaches were performed. Neurological status improved postoperatively in 34 cases at last follow-up. Five patients showed clinical neurological worsening. Total resection was achieved in 46 cases and, during a mean follow-up of 63.4 months, no recurrence or re-bleeding occurred in those patients. The mean follow-up was 63.9 months. The mean modified Rankin Scale at final follow-up was used to analyze the results and draw our conclusions. Conclusions: A reasonable surgical approach, selection, and gentle handling of the surrounding structures are required to prevent impairment of neurologic function and avoid partial resection.
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	Effect of sub-axial cervical lateral mass screw fixation on functional outcome in patients with cervical spondylotic myelopathy	p. 140
	Ali Rabee Kamel Hamdan, Radwan Nouby Mahmoud, Momen Mohammed Al Mamoun, Eslam El Sayed El Khateeb DOI:10.4103/ajns.AJNS_303_17   Background: The role of laminectomy alone as an etiology of postoperative cervical instability is well known. Cervical sagittal malalignment of the spine has been linked to unfavorable functional outcome, so the effect of restoration of sagittal spinal alignment on functional outcomes and treatment effectiveness has recently gained attention. Objective: This is a prospective observational study aims to observe the possible relation between cervical sagittal alignment and functional outcomes following sub-axial cervical lateral mass screw fixation in patients with cervical spondylotic myelopathy. Patients and Methods: Thirty patients were included in this study all suffering from cervical spondylotic mylopathy (CSM) who underwent cervical laminectomy and screw-rod fixation and followed up over 6 months. Functional outcome accessed using Nurick myelopathy score and neck disability index (NDI)?. We also used the Cobb angle method (C2–C7) as a parameter for radiographic assessment of the cervical sagittal alignment which was measured preoperatively and postoperatively on lateral neutral views of cervical X-ray. Results: All the patients underwent cervical laminectomy and fixation in a range of 3–5 levels. Two intraoperative facet fractures and four facet joint violations were observed. All the patients were followed-up for at least 6 months. There were significant improvements of the motor power (88.5%), Nurick score (90%), and NDI (90%) postoperatively. The mean preoperative Cobb angle for all patients was −8.51° ± 14.07° standard deviation (SD) which changed to −10.29 ± 12.43 SD at the end of follow-up. Conclusion: Combing posterior decompression with lateral mass screw– rod in patients with CSM was effective in improving or at least maintaining cervical alignment with the good functional outcome.
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	Modified inside-outside occipito-cervical plate system: Preliminary results	p. 148
	Sukru Caglar, Erhan Turkoglu, Hayri Kertmen, Bora Gurer, Huseyin Bozkurt, Rafet Ozay, Sahin Hanalioglu, Efkan Colpan DOI:10.4103/ajns.AJNS_305_17   Context: Internal rigid fixation provides immediate stability of the occipito-cervical (OC) junction for treatment of instability; however, in current practice, the optimal OC junction stabilization method is debatable. Aims: The aim of this study to test the safety and efficacy of a newly designed modified inside-outside occipito-cervical (MIOOC) plate system for the treatment of instability. Settings and Design: This was a feasibility study of MIOCC plate system. Subjects and Methods: Five male and four female patients with OC instability were treated using MIOOC plate system. Stabilization rate, safety, and efficacy were evaluated radiologically and clinically. Results:Mean age of the patients was 35 ± 11 (range: 22–58) years. Etiology of OC instability included trauma, neoplasm, congenital abnormalities, and iatrogenic. The fusion levels ranged from occiput-C3 to occiput-C6. Mean follow-up duration was 22 ± 10 (range: 6–46) months. There were neither complication nor was there any need for plate revision or screw pullout. Mortality occurred in one patient due to primary malignancy at 6 months; otherwise, no morbidity was observed. During the follow-up, no recurrent subluxation or newly developed instability at adjacent levels occurred. All patients showed a satisfactory union at the most recent follow-up examination. Conclusions:These preliminary results suggest that the MIOCC plate system is a useful and safe method for providing immediate internal stability of the OC junction. Using a multi-piece plate design in this plate system provided easy implantation and a better interface between plate and OC bones. Further, clinical studies and long-term results are needed to determine the reliability of the MIOOC plate system.
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	Nonvestibular schwannoma tumors in the cerebellopontine angle: A single-surgeon experience	p. 154
	Vivek Kumar Kankane, Anshu Chandrakant Warade, Basant Kumar Misra DOI:10.4103/ajns.AJNS_335_17   Background: The most common cerebellopontine angle (CPA) tumor is a vestibular schwannoma. Schwannomas account for 8.5% of all intracranial tumors and more than 90% of the tumors originate from the eighth cranial nerve, but one in five CPA tumors are not vestibular schwannoma. These tumors may have different manifestations and require different management strategies. Methods: We report 224 consecutive NVCPAT operated in the Department of Neurosurgery, P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, by the senior author between 2001 and 2014 and discuss the different approaches and outcomes in NVCPAT. Results: The age range was 20–60 years and there were 129 females and 95 male patients. The clinical material consisted of 81 cases of meningioma (36.1%), 44 cases of epidermoid (19.64%), 34 cases of trigeminal schwannoma (15.17%), 26 cases of jugular foramen schwannoma (11.60%), and 39 cases of other tumors (17.41%). In nonvestibular schwannoma (NVS), symptoms and signs from cranial nerve VIII are less frequent and other cranial nerves and cerebellar symptoms and signs predominate. Conclusion: Symptoms and signs are different in NVCPAT from those found in patients with vestibular schwannoma. Hearing loss is not the predominant symptoms. Cerebellar signs and trigeminal dysfunction are more common. The most common approach used in the current series was retrosigmoid craniotomy. Gamma knife radiosurgery was a useful adjunct in a subset of these patients.
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	Posttraumatic isolated intraventricular hemorrhage a rare entity: Case series	p. 162
	Karla Ravi, Musali Siddartha Reddy, Prakash Rao Gollapudi, Imran Mohammed, Srikrishnaditya Manne, Hemant Kumar Beniwal DOI:10.4103/ajns.AJNS_171_18   Background: Traumatic Intraventricular hemorrhage is commonly associated with other lesions like intracerebral contusions, subdural hemorrhage and subarachnoid hemorrhage. Isolated post- traumatic intraventricular hemorrhage is uncommon. It is mostly seen in the pediatric population and rarely seen in adults. Aims: To analyze the Demographics, mode of Injuries and outcome in injuries causing isolated post traumatic intraventricular hemorrhage which is a rare entity. Materials and Methods: This is a Retrospective analytic study of six cases, conducted at our Hospital in a span of eight years [2010-2018]. Results: Mean age of presentation is 36 years and all were males. The most common clinical presentation included loss of consciousness followed by vomiting and ENT bleed. Four cases presented with severe head injury and two with mild head injury as per Glasgow coma scale score. Mode of injury was acceleration and deceleration in all the cases. NCCT and CT Angiogram brain were done in all the cases which revealed isolated intraventricular hemorrhage without any vascular or tumoral pathology. All the patients were managed conservatively. Conclusion: The outcome was equivocal (3 patients had a bad outcome and 3 good outcomes) in our study.
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	The importance of measuring mamillopontine distance as a diagnostic criterion of hydrocephalus degrees	p. 166
	Gayrat Maratovich Kariev, Ulugbek Maksudovich Asadullaev, Temur Anvarovich Duschanov, Shavkat Orzikulovich Rasulov, Dilshod Muhammad Valievich Mamadaliev, Dilshod Nayimovich Khodjimetov DOI:10.4103/ajns.AJNS_79_18   Objectives: The occurrence of obstructive hydrocephalus (ObH) as sequelae of deep midline brain tumors (third and lateral ventricles, thalamic, pineal region, brainstem, and fourth ventricle) can be estimated up to 90% of cases. We believe that the mamillopontine distance (MPD) – the distance between the lower surface of the mammillary body and the upper surface of the pons in the sagittal images – can be a suffi ciently reliable alternative to the Evans' index (EI) for the diagnosis of ObH. Patients and Methods: The results of mamillopontine distance (MPD), Evans' index (EI), and angle of corpus callosum (ACC) measurement of 43 patients with non-communicative hydrocephalus were analyzed compared with results of 30 people without brain pathology. Results: Findings revealed that MPD is a strong and reliable alternative to the EI. MPD showed high specificity and sensitivity in the diagnosis of occlusive hydrocephalus. Moreover, from those findings, we have proposed classification of the degree of hydrocephalus severity, depending on the MPD. Conclusion: MPD one of the more accurate and powerful method for defining presence of hydrocephalus in-patient even in early stage of occlusion. It has high specificity and sensitivity and capable classify hydrocephalus into grades according to severity.
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	Surgical training for the management of intraoperative aneurysm rupture using a three-dimensional artificial model	p. 172
	Kosuke Kumagai, Kentaro Mori, Satoru Takeuchi, Kojiro Wada DOI:10.4103/ajns.AJNS_197_18   Background: Intraoperative aneurysm rupture (IAR) is one of the most dreaded complications of microsurgical cerebral aneurysm clipping. The surgical result is directly affected by whether an operator can control IAR. However, the development of endovascular treatment has decreased the probability of exposure to this situation for neurosurgical residents. Therefore, neurovascular surgeons must develop the skills and mental attitude to deal with IAR through off-the-job training, without conducting actual operations. Materials and Methods: We have developed a tabletop training system using three-dimensional artificial modeling that can be used for daily clinical practice. Results and Conclusions: Our model is useful for training because of its low cost, reusability, and ease of preparation and practice.
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	Venture in 101 cranial punctures: A comparative study between frame-based versus frameless biopsy of 101 intracranial space occupying lesion	p. 175
	Suresh Bishokarma, Pratyush Shrestha, Sagar Koirala, Manita Raut, Dinesh Nath Gongal DOI:10.4103/ajns.AJNS_137_18   Background: Presumptive diagnosis based solely on the clinical picture and imaging is not sufficient to provide appropriate treatment with certainty and hence histopathological confirmation of intracranial space occupying lesion (ICSOL) is essential. Needle biopsy via stereotactic frame-based or frameless neuronavigation technique is efficient procedure. The objective of this study is to compare their accuracy and efficacy and safety. Methods:This is a retrospective comparative study conducted among 101 biopsies of ICSOL. Patients data were retrieved from medical record. Data were analyzed in SPSS ver. 20. P value of <0.05 was considered significant. Results:Out of 101 patients, Frame-based stereotactic biopsy was done among 55 patients (54.4%) while 46 patients (45.6%) underwent frameless stealth neuronavigation guided biopsy. Male to female ration was 2.1:1. Age ranged from 5 to 82 years. 54.5% (55 patients) have deeper location of tumor while 45.5% (46 patients) have lobar location of tumor. Frontal (16.8%) and Thalamic (13.8%) were the common site. Mean size of tumor was 3.09±0.85cms. There was statistically significant difference in operative duration among study groups. Overall Diagnostic yield was 89.1%. Glioma was the most common (50.5%) diagnosis. Glioblastoma WHO Grade IV was 37.6% followed by lymphoma (12.8%). Conclusion: Needle biopsy via stereotactic frame-based or neuronavigation frameless technique is a safe and efficient procedure having high diagnostic yield. Reasons for negative biopsy could be missed target or retrieval of gliotic tissue.
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	Clinical, functional, and radiologic outcome of single- and double-level transforaminal lumbar interbody fusion in patients with low-grade spondylolisthesis	p. 181
	Keyvan Eghbal, Babak Pourabbas, Hamid Reza Abdollahpour, Reza Mousavi DOI:10.4103/ajns.AJNS_156_18   Objective: The main objective is to determine the functional, clinical, and radiological outcome of patients with low-grade spondylolisthesis undergoing single- or double-level transforaminal lumbar interbody fusion (TLIF). Materials and Methods: This quasi-interventional study was conducted during a 2-year period from 2016 to 2018 in Shiraz, Southern Iran. We included all the adult (≥18 years) patients with low-grade spondylolisthesis (Meyerding Grade I and II) who underwent single- or double-level TLIF in our center. The spinopelvic parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), and segmental LL (SLL) were measured. The pain intensity and disability were measured utilizing the visual analog scale (VAS) for back and leg pain and Oswestry Disability Index (ODI), respectively, after 1 year. Results: Overall, we included a total number of 50 patients with mean age of 54.1 ± 10.48 years. After the surgery, the PI (P = 0.432), PT (P = 0.782), and SS (P = 0.466) were not found to be statistically changed from the baseline. However, we found that single- or double-level TLIF was associated with increased LL (P < 0.001) and SLL (P < 0.001). Regarding the clinical outcome measures, both back (P = 0.001) and leg (P < 0.001) VAS improved after the surgery significantly. In addition, we found that improved leg VAS was positively correlated with improved ODI (r = 0. 634; P < 0.001). Conclusion: Single- or double-level TLIF is associated with increased global and SLL along with improved leg and back pain and disability in patients with low-grade spondylolisthesis. Interestingly, improved leg pain is correlated to improved disability in these patients.
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	The retrosigmoid approach: Workhorse for petroclival meningioma surgery	p. 188
	Neha Singh, Deepak Kumar Singh, Faran Ahmad, Rakesh Kumar DOI:10.4103/ajns.AJNS_192_18   Background: Petroclival meningiomas (PCMs) are technically challenging lesions. We retrospectively analyzed our experience with retrosigmoid approach between 2009 and 2015 in 17 patients with PCM to evaluate changes in management strategy. In this study, we evaluated the possible risk factors and challenges for unfavorable clinical outcomes with retrosigmoid approach. Materials and Methods: A total of nine patients (53%) of PCM were treated through the retrosigmoid approach in Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow. The patients received postoperative neurological and radiological follow-up. The primary difficulty in complete resection and outcomes including postoperative neurological deficits were evaluated, and all potential risk factors were assessed. Results: The mean follow-up time was 24 months. The maximum diameter of the tumors ranged from 2.0 cm to 6.8 cm (mean, 3.8 cm). Gross total resection (Simpson Grade II) was achieved in 6 (66%) patients, subtotal resection (Simpson Grade III) in 3 (33%). Two patients (22%) had new neurological deficits or worsening of preexisting deficits. No patient died after surgery. Within the follow-up period, there was no radiographic recurrence in patients with Simpson Grade II excision. Postoperative radiosurgery was administered to three patients who had residual tumors, and no further progression was found in them. Conclusions: Tumor characteristics played a critical role in identifying postoperative functional status. The retrosigmoid approach is suitable for treatment of majority of PCMs. It offers Simpson Grade II excision if the main part of the tumor is located in the posterior fossa in the cerebellopontine angle and the lower clivus, and only a minor part of the tumor extends to middle fossa or the posterior wall of the cavernous sinus. With incising tentorium or suprameatal extensension middle fossa extension can also be removed. Overall retrosigmoid approach provides a low degree of surgical difficulty and a low complication rate.
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	Endoscope-assisted microneurosurgery for neurovascular compression syndromes: Basic principles, methodology, and technical notes	p. 193
	Sabino Luzzi, Mattia Del Maestro, Donatella Trovarelli, Danilo De Paulis, Soheila Raysi Dechordi, Hambra Di Vitantonio, Valerio Di Norcia, Daniele Francesco Millimaggi, Alessandro Ricci, Renato Juan Galzio DOI:10.4103/ajns.AJNS_279_17   Background: Microscopic microvascular decompression (MVD) has a low but not negligible failure rate due to some missed conflicts, especially in case of multiple offending vessels. The reported study is aimed to assess the principles, methodology, technical notes, and effectiveness of the endoscope-assisted (EA) MVD for neurovascular compression syndromes (NVCS) in the posterior fossa. Materials and Methods: A series of 43 patients suffering from an NVCS and undergone to an EA MVD were retrospectively reviewed. Syndromes were trigeminal neuralgia in 25 cases, hemifacial spasm in nine cases, positional vertigo in six cases, glossopharyngeal neuralgia in two cases, and spasmodic torticollis in one case. In all cases, a 0°–30° specially designed endoscope was inserted into the surgical field to find/treat those conflicts missed by the microscopic exploration. Each procedure was judged in terms of the effectiveness of the adjunct of the endoscope according to a three types classification system: Type I – improvement in the visualization of the nerve's root entry/exit zone; Type II – endoscopic detection of one or more conflicts involving the ventral aspects of the nerve and missed by the microscope; Type III – endoscope-controlled release of the neurovascular conflict otherwise difficult to treat under the only microscopic view. Results: A total of 55 conflicts were found and treated. Twenty-eight procedures were classified as Type I, nine as Type II, and six as Type III. All the patients had a full recovery from their symptoms. Conclusions: In selected cases, EA MVD offers some advantages in the detection and treatment of neurovascular conflicts in the posterior fossa.
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	Prevalence of postconcussion syndrome after mild traumatic brain injury in young adults from a single neurosurgical center in east coast of Malaysia	p. 201
	Buveinthiran Balakrishnan, Razman Mohd Rus, Kin Hup Chan, Arvind Gerard Martin, Mohamed Saufi Awang DOI:10.4103/ajns.AJNS_49_18   Context: Postconcussion syndrome (PCS) is a set of symptoms occurred after a mild traumatic brain injury (MTBI). Aims: This study aims to determine the prevalence of PCS in a young adult population from a single Neurological Centre in Malaysia's East Coast and to evaluate the factors associated with PCS in MTBI patients. Settings and Design: This was a cross-sectional study conducted in a Neurological Centre at Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia, from January 2016 to December 2016. Subjects and Methods: A total of 209 patients; 133 males and 76 females, in the age range of 16–84 years, were randomly recruited for this study. All the selected patients were subjected to the checklist for diagnosis of PCS as per International Statistical Classification of Diseases and Related Health Problems 10th edition classification at a 2-week interval. Statistical Analysis Used: Descriptive statistic and Multivariable Logistic Regression Model were used for frequency and percentage analyses of categorical variables, using SPSS version 23.0. Results: Only 20 patients were identified with PCS. There were more female (70%) patients with PCS than the male (30%) patients. The prevalence of PCS for 2 weeks, 3 and 6 months since injuries were 9.6%, 8.1%, and 8.1% respectively. Majority (80%) of the patients were found to have PCS due to road traffic accidents, while the remaining were attributed to assault (15%), and falls (5%). Among the sample population, 25% were smokers, while 10% of them had either skull fracture or premorbidity. Conclusion: Less than 10% of patients with MTBI had PCS after 6 months' following trauma. None of the variables tested were significant factors for the development of PCS symptoms.
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	Carotid endarterectomy: The need for In vivo optical spectroscopy in the decision-making on intraoperative shunt usage – A technical note	p. 206
	Arun Balaji, Niranjana Rajagopal, Yasuhiro Yamada, Takao Teranishi, Tsukasa Kawase, Yoko Kato DOI:10.4103/ajns.AJNS_223_18   Background: Carotid endarterectomy (CEA) is the surgical excision of the atherosclerotic plaque in patients with severe carotid artery stenosis. It is a common surgical technique required by neurosurgeons that should be mastered. In this article, we provide an outline of the technique and multimodality adjuncts involved in performing an effective CEA with a better surgical outcome. Materials and Methods: We have operated a total of 14 patients in our institute from 2015 to 2018. The male to female ratio is 13:1. Four (28.5%) patients were symptomatic and 10 (71.5%) were asymptomatic; with an average percentage of carotid stenosis being 81.2% in symptomatic and 76.6% in asymptomatic patients. Two patients have undergone bilateral CEA. Intraoperative monitoring was done with continuous in vivo optical spectroscopy (INVOS). Furui's double balloon shunt system was used to maintain blood flow from common carotid artery to the internal carotid artery, thus preventing cerebral ischemia in selected cases with significantly lateralized cerebral oximetry (CO) recordings. Results: Of the 14 patients with 16 CEA procedures, continuous INVOS monitoring was used in 12 CEA procedures. Of the 12 cases, only 5 (41.6%) needed a shunt. Furui's shunt was not used in 7 (58.3%) CEA procedures, where there were no changes in the intraoperative CO and these patients had an uneventful postoperative period. INVOS monitoring not only reduced the use of routine intraoperative shunt but also reduced the total surgical time and thus aided in preventing neurological complications. Conclusion: CEA should be strongly considered for symptomatic patients with >70% of carotid stenosis and in patients with 50%–69% stenosis if no other etiological basis for the ischemic symptoms can be identified. Continuous INVOS monitoring is mandatory for the decision of the use of intraoperative shunt, which reduces the perioperative morbidity and mortality significantly.
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CASE REPORTS
	Burden of dengue-related neurosurgical emergencies during an epidemic: A tertiary care experience	p. 211
	Raja Krishnan Kutty, Sunilkumar Balakrishnan Sreemathyamma, Jyothish Laila Sivanandapanicker, Vijay Mundhe, Kapil Chhabra, Anilkumar Peethambaran DOI:10.4103/ajns.AJNS_318_17   Dengue is one of the most common flavivirus infections which can manifest from common flu-like fever to fatal hemorrhagic complication. Epidemics of dengue return every year with peaks during the rainfall claiming substantial number of lives in the tropical and subtropical regions of the world. We present manifestations of dengue in patients who underwent neurosurgery in a tertiary referral center during such an epidemic. There were total four patients referred for neurosurgical intervention as sequelae to dengue coagulopathy. Among them, three had intracranial bleeds and one had spinal cord hematoma along with intracranial hemorrhages. This small series includes the youngest reported case of dengue coagulopathy with intracranial bleed and only the second case of spontaneous intraspinal hematoma sequelae to dengue hemorrhagic fever. The situations where patients contract dengue in a setting of neurosurgical intervention are grave. The margin of safety in the presence of dengue coagulopathy is narrow. The surgeon has to outweigh benefit against risk of surgery in each individual.
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	Cerebrospinal fluid leakage at the lumbar spine: A unique cause of delayed neurologic deterioration in a traumatic acute subdural hematoma patient	p. 219
	Keita Mayanagi, Masashi Nakatsukasa, Joji Inamasu DOI:10.4103/ajns.AJNS_185_17   We present a rare case of traumatic acute subdural hematoma (SDH) in which intracranial hypotension (IC) secondary to cerebrospinal fluid (CSF) leakage at the lumbar spine caused delayed neurological deterioration. A 70-year-old male sustained a head injury after ground-level fall and was brought to our institution. A brain computed tomography (CT) showed a thin acute SDH with mild brain shift, and conservative management was initiated. He exhibited neurological deterioration on the 9th hospital day, however, and a brain CT showed a change in CT density and marked an increase in hematoma volume and brain shift. It was thought that conversion from acute to subacute SDH was associated with the deterioration, and emergency hematoma evacuation was performed. Despite the surgery, neither clinical nor radiographical improvement occurred. The lack of improvement pointed to the presence of underlying IC, and a CT myelography revealed the dural sleeve of the right L2 nerve root as the source of the CSF leakage. An epidural blood patch therapy was performed on the 12th hospital day to seal the CSF leakage. The postprocedural course was uneventful, and the patient was discharged free of symptoms on the 20th hospital day. Spinal CSF leakage should be considered as a cause of delayed neurological deterioration in patients with traumatic acute SDH which exhibits conversion to subacute SDH.
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	Papillary ependymoma of the spinal cord: A case report with summary of prior published cases	p. 223
	Priyanka Maity Chaudhuri, Debashis Chakrabarty, Shubhamitra Chaudhuri, Uttara Chatterjee DOI:10.4103/ajns.AJNS_250_17   Papillary ependymoma is a rare variant of ependymoma. It has been included in Grade II tumors of updated 2016 WHO classification of central nervous system tumors. Only a handful of cases of spinal papillary ependymomas have been reported so far. The differential diagnoses include choroid plexus papilloma, papillary meningioma, metastatic carcinoma, and papillary tumor of the pineal region. Here, we take the opportunity of reporting a rare case of spinal papillary ependymoma along with its squash cytological features and a summary of prior published cases.
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	Large intradiploic growing skull fracture of the posterior fossa with syringomyelia	p. 227
	Harish Naik, Vernon Velho, Anuj Bhide, Amrita Guha DOI:10.4103/ajns.AJNS_275_17   Growing skull fracture (GSF), also known as leptomeningeal cyst, is a rare but significant complication of pediatric head injury. It is mainly seen in infancy and childhood. GSFs of the posterior fossa are uncommon, and intradiploic location in the posterior fossa is extremely rare. Only a few cases of pediatric GSF of the posterior fossa and intradiploic location have been reported in the literature. We report a case of a 15-year-old boy who had large intradiploic GSF of the posterior fossa, associated with cervical syringomyelia. The lesion developed progressively over a period of 5 years following a documented occipital linear fracture. This case of a GSF developing from a known occipital linear fracture demonstrates that a GSF may reach a considerable size, and although uncommon, intradiploic development and occipital localization of a GSF are possible. Syringomyelia associated with posterior fossa GSF is very unusual which makes this case even more unique.
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	Skull vault plasmacytoma mimicking parasagittal meningioma: "Mini-brain appearance"	p. 231
	Satyashiva Munjal, Amit Srivastava, Sunila Jain, Veer Singh Mehta DOI:10.4103/ajns.AJNS_219_17   Plasmacytomas occur as lesions in soft tissue or bone. Skull vault plasmacytomas are rare lesions comprising 0.7% of all plasmacytomas. Workup for myeloma must be done in such cases to rule out multiple myeloma. Here, we report a case of a 63-year-old female who presented to us with a large skull vault swelling which appeared to mimic a parasagittal meningioma on imaging. Histopathological imaging revealed it to be a plasmacytoma. A retrospective review of the radiology revealed the characteristic "mini-brain appearance" in our case. Literature on the subject is also reviewed.
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	Intracranial hemorrhage caused by bacterial meningitis: Case report and review of the literature	p. 234
	Atsushi Matsumoto, Shogo Mino, Tadashi Nishiyama DOI:10.4103/ajns.AJNS_239_17   Hemorrhagic stroke is an extremely rare complication in bacterial meningitis. Therefore, the incidence and prognosis have not been fully clarified. In this case report, we describe a case of intracranial hemorrhage caused by bacterial meningitis, which originated from paranasal sinusitis. A man visited the hospital due to fever, nonproductive cough, and oppressive pain of cheek. He was diagnosed with purulent sinusitis and received antibiotics. However, he suddenly developed a severe headache and came to our department. Computed tomography scan revealed right subcortical hematoma. We performed hematoma evacuation, but headache and fever did not cease. From the analysis of the cerebrospinal fluid, he was diagnosed with cerebral hemorrhage caused by meningitis and treated with broad-spectrum antibiotics. Through this treatment, his condition rapidly improved. Hemorrhagic stroke is a rare complication of bacterial meningitis, but if this condition develops, then, there is a high risk of mortality and morbidity.
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	Elevated skull fractures - Too rare to care for, yet too common to ignore	p. 237
	Viraat Harsh, Vanya Vohra, Prashant Kumar, Jayendra Kumar, Chandra Bhushan Sahay, Anil Kumar DOI:10.4103/ajns.AJNS_242_17   Elevated skull fractures form a rare subset of compound skull fractures owing to the paucity of cases studied and reported. In this article, we present 17 cases of elevated skull fracture in a mixed population of adult and pediatric age groups which were operated over a period of 5 years (2012–2017) at our institute. We have discussed the mode of injury, clinical presentation, clinicoradiological findings, and treatment options highlighting the appropriate management strategies opted. Although elevated fractures are rare; issuing definite treatment protocol can reduce the morbidity and mortality of the patients.
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	Progressive multifocal leukoencephalopathy diagnosed by brain biopsy, not by the DNA test for JC Virus	p. 240
	Seung-yoon Lee, Hak-cheol Ko, Sang-il Kim, Youn Soo Lee, Byung-chul Son DOI:10.4103/ajns.AJNS_243_17   Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by a lytic infection of oligodendrocytes due to the presence of JC polyomavirus (JCV). The disease occurs mostly in immunocompromised patients and is associated with a high mortality rate. The diagnosis of PML is based on a polymerase chain reaction (PCR) assay for JC viral DNA in cerebrospinal fluid (CSF). However, case reports of the diagnosis of PML established with brain biopsy despite negative JCV CSF PCR analysis when clinical and neuroimaging features are suggestive of PML have been published. A 44-year-old male with a 6-year history of acquired immunodeficiency syndrome developed mental confusion and memory impairment despite 3 months of highly active antiretroviral therapy. Magnetic resonance imaging revealed multiple subcortical white matter lesions in bilateral hemispheres and subcortical nuclei including the thalamus and basal ganglia. JCV DNA was not detected in CSF study, but a brain biopsy showed a high JCV DNA titer. The diagnosis of PML was established with brain biopsy. An early brain biopsy may be important in the diagnosis of PML in patients with clinical manifestations and neuroimaging findings if JCV DNA is undetectable in the CSF PCR.
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	Acute paraplegia revealing a hemorrhagic cauda equina paraganglioma	p. 245
	Khalil Ghedira, Nidhal Matar, Sofiene Bouali, Alia Zehani, Hafedh Jemel DOI:10.4103/ajns.AJNS_206_17   Cauda equina paragangliomas are rare neuroendocrine benign and slow-growing tumors. Acute paraplegia, occurring because of sudden intratumoral hemorrhage, represents an extremely rare clinical picture of this disease. We report the case of a 64-year-old male presenting with a 5-day acute lower back pain, sciatica, and leg weakness. Spinal imaging showed an intradural mass of the cauda equina region and an emergent surgical treatment was achieved. The lesion was removed "en bloc," and subarachnoid blood was noticed during surgery. The postoperative course was uneventful, with complete regression of pain and progressive motor recovery. The histological study revealed typical microscopic and immunohistochemical features of paragangliomas.
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	How to treat repeated subdural hematomas after lumbar puncture?	p. 249
	Edvin Zekaj, Christian Saleh, Marina Minichiello, Paolo Perazzo, Domenico Servello DOI:10.4103/ajns.AJNS_263_17   Serious complications following spinal anesthesia (SA) are rare. However, surgeons and neurologist need to be aware that postsurgery headache refractory to conservative treatment or change in headache's characteristics could be due to serious intracranial complications such as a subdural hematoma. Any delay in diagnosis and treatment can be fatal. We report and discuss a case of a patient who suffered repeated subdural bleeds following SA.
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	Phosphaturic mesenchymal tumors involving skull bones: Report of two rare cases	p. 253
	Toshi Mishra, Maria Alina Desouza, Keyuri Patel, Girish A Mazumdar DOI:10.4103/ajns.AJNS_176_17   Phosphaturic mesenchymal tumor (PMT) is a rare tumor causing oncogenic osteomalacia (OO). Most such tumors occur in soft tissue and bones of extremities and appendicular skeleton. Intracranial location and involvement of temporal–occipital bone is extremely rare. We report two unusual cases: The first was intracranial, involving the temporal bone, while the other was a skull base tumor arising from the occipital–temporal bone. Both of them presented with paraneoplastic syndrome of OO, resembled a meningioma radiologically, and underwent gross total resection of tumor. Histologically, both of them were diagnosed as PMT, mixed connective tissue variant.
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	The "negative" impact of a subgaleal drain: Post-cranioplasty negative pressure subgaleal drain-induced ascending transtentorial herniation	p. 256
	Peter Y. M. Woo, Wilson H. Y. Lo, Hoi-Tung Wong, Kwong-Yau Chan DOI:10.4103/ajns.AJNS_285_17   One commonly practiced procedural step to reduce the risk of postoperative hematoma accumulation when performing cranioplasties is to place a closed negative-pressure subgaleal drain. We present a patient with sinking skin flap syndrome that underwent such a procedure and subsequently experienced immediate postoperative ascending transtentorial herniation and intracranial hemorrhage remote from the surgical site. On determining that the subgaleal drain was the responsible cause, it was immediate removed, and the patient had neurological recovery. Fewer than 30 cases of life-threatening subgaleal drain-related complications have been documented, and this is the first reported case of ascending herniation occurring after cranioplasty. This report illustrates the potential risks of subgaleal drainage, the importance of early recognition of this rare phenomenon and that intervention can be potentially life-saving.
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	Facial nerve paralysis occurring 4 days following stereotactic radiosurgery for a vestibular schwannoma	p. 262
	Kevin Kwong-Hon Chow, Abdulrazag Ajlan, Allen Lin Ho, Gordon Li, Scott Gerard Soltys DOI:10.4103/ajns.AJNS_53_17   Stereotactic radiosurgery (SRS) is commonly used for the treatment of vestibular schwannomas given its high rate of tumor control and low rate of complications. Facial nerve palsy has been reported several months after treatment as a rare late complication of SRS. Here, we report a case of facial weakness occurring only 4 days after treatment and discuss potential etiology and management considerations.
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	Spontaneous carotid cavernous fistula in young female with anti-thrombin III deficiency	p. 266
	Ram Narayan, Mansoor Cherumkuzhiyil Abdulla DOI:10.4103/ajns.AJNS_252_17   A 27-year-old female patient presented with headache, vomiting, and visual disturbances who was evaluated and detected to have a direct carotid cavernous fistula (CCF). Secondary causes were ruled out, and she was treated with coil occlusion and glue injection. A month after almost complete clinical recovery, she developed deep vein thrombosis of left thigh. Subsequent work-up revealed antithrombin III (ATIII) deficiency in her. To the best of our knowledge, this is the first reported case of ATIII deficiency associated with CCF. This case shows the importance of working up for a primary etiology if any, to prevent further complications after surgery.
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	Unusual radiological presentation of intracranial dermoid cyst: A case series	p. 269
	Sunitha Palasamudram Kumaran, Rakshith Srinivasa, Nandita Ghosal DOI:10.4103/ajns.AJNS_304_17   Intracranial dermoids are rare congenital lesions of the brain that account for <1% of all intracranial tumors. Even though they are rare, typical computed tomography (CT) scan and magnetic resonance imaging (MRI) features along with location allow radiological diagnosis in the majority of patients. Radiologically, dermoid cysts typically appear as nonenhancing low-density masses on CT scan and are hyperintense on T1-weighted (T1-W) MRI sequences with variable signal on T2-W sequences. We describe two cases of dermoid with unusual imaging appearance with the presence of mural nodule in both the cases. The recognition of atypical radiological features can avoid diagnostic pitfalls and is clinically relevant for overall surgical management.
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	Glioma simultaneously present with adjacent meningioma: Case report and literature review	p. 272
	Satyashiva Munjal, Jitendra Kumar, Sunila Jain, Veer Singh Mehta DOI:10.4103/ajns.AJNS_308_17   A 51-year-old male patient presented to us with an episode of generalized tonic-clonic seizure. Magnetic resonance imaging revealed a dural-based contrast-enhancing lesion in the right temporal lobe and another heterogeneously contrast-enhancing intra-axial lesion in the right insula adjacent to it. Histopathology confirmed it as a meningioma adjacent to an anaplastic oligodendroglioma. This is only the second such case reported in literature. Literature on "adjacent site" gliomas and meningioma was also reviewed.
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	Aggressive primary pediatric intracranial malignant melanoma: Sphinx of the tissue diagnosis	p. 275
	Laxminadh Sivaraju, Nandita Ghosal, Anita Mahadevan, AS Uday Krishna, Shilpa Rao, Alangar S Hegde DOI:10.4103/ajns.AJNS_253_17   It is often intriguing to suspect and confirm the diagnosis of primary malignant melanoma (PMM) in the brain without any evidence of neurocutaneous melanosis. We report a 16-year-old male patient with malignant melanoma which intraoperatively was small sized, soft, fleshy, hemorrhagic in appearance resembling hematoma. Interestingly, the histopathology showed prominent papillary architecture with a differential diagnosis of papillary meningioma and ependymoma and perplexed the tissue diagnosis. This case is discussed in light of very uncommon occurrence of intracranial PMM in pediatric age group, enigmatic histological features, and aggressive nature of lesion with rapid progression despite complete excision following radiation therapy.
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	Bilateral cerebellopontine angle osteomas: Case report and review of the literature	p. 280
	Bahadir Muhammet Yilmaz, Emrah Egemen, Ayhan Tekiner, Özgür Öcal DOI:10.4103/ajns.AJNS_330_17   Osteomas and exostoses of cerebellopontine angle (CPA) are very rare, benign, and usually slow-growing lesions; few case reports have been published about these lesions in literature. The most common localizations of these temporal bone lesions are the mastoid cortex and the external acoustic canal. To our knowledge, only two cases of bilateral osteoma arising from both internal acoustic canals (IACs) have been reported. However, these tumors are usually asymptomatic and diagnose incidentally, and they can cause symptoms related to the 7th and 8thcranial nerve involvement. We report on a 75-year-old woman affected with bilateral osteoma of CPA and review the literature that 27 cases of IAC osteoma and exostoses have been reported.
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	Malignant peripheral nerve sheath tumor: Treat or not treat?	p. 283
	Muhamad Fairuz Bin Samsuddin, Mohamad Azhari Bin Omar DOI:10.4103/ajns.AJNS_332_17   Malignant peripheral nerve sheath tumors (MPNSTs) are uncommon, biologically aggressive soft tissue sarcomas of neural origin that poses tremendous challenges to effective therapy. MPNSTs are among the most challenging mesenchymal malignancies to treat with poor prognosis. They usually affect young and middle-aged adults, tend toward early metastasis, and often demonstrate resistance to chemotherapy. We present a case of a 23-year-old female who initially presented with the right temporal swelling for 1 month associated with constitutional symptom which progressively worsening. The right craniotomy and excision biopsy were done with histopathological examination results suggestive of MPNST. Thorax-abdominal-pelvic computed tomography and magnetic resonance imaging further revealed multiple metastatic lesions involving spine, retroperitoneal, pelvic, chest wall, and lungs. This case illustrates the typical presentation of MPNST with its known poorly outcome.
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	Spontaneous cervical epidural hematoma with stroke manifestations	p. 286
	Mohammadreza Emamhadi, Shervin Ghadarjani, Babak Alijani, Shahrokh Yousefzadeh-Chabok, Hamid Behzadnia, Amin Naseri, Sasan Andalib DOI:10.4103/ajns.AJNS_333_17   Spontaneous cervical epidural hematoma (SCEH), which is a rare disease, is manifested as by a sudden quadriplegia or paraplegia and other neurological deficits. SCEH can compress the spinal cord resulting in its clinical manifestations. The reported etiological risk factors are anticoagulants, coagulopathies, vascular malformations, infections, and herniated discs. Here, we report a 77-year-old woman with a presenting chief complaint of left hemiparesis and a history of hypertension. The medical drugs in use were aspirin and antihypertensives. The initiating presentations were hemiparesis, in favor of ischemic stroke, so the patient admitted to neurology ward and received anticoagulant therapy with the initial diagnosis of stroke. Although clinical manifestations and examinations are important in these patients due to mimicking stroke picture, imaging evaluation is paramount for a definite diagnosis, which in our case showed a SCEH, who was suspected to have an ischemic stroke during the initial assessment because its initial demonstration mimicked ischemic stroke. This patient underwent laminectomy after 3 days and showed a clinical recovery the day after. Her muscle strength improved gradually, and neurological symptoms were diminished after physiotherapy.
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	Giant encephalocoele: A rare case report and review of literature	p. 289
	Vikas Naik, Vinay Marulasiddappa, Mandya Appaji Gowda Naveen, S Balaji Pai, Pratham Bysani, SB Amreesh DOI:10.4103/ajns.AJNS_87_18   Giant encephalocoeles are rare entities with only one case series and few case reports reported in medical literature. Encephalocoeles, which reach a size larger than the head size, are be called Giant encephalocoeles. We report a case of a 6 month old child who had giant encephalocoele with delayed motor milestones in the form of inability to hold neck. Anesthetic implications include difficulty in securing air way due without undue pressure on the sac. She underwent VP shunt followed by excision of the encephalocele sac. Patient is doing well at 1 year of follow up. Preoperative neurological status and amount of brain tissue herniating into the sac are the most important factors determining the long term prognosis.
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	Spontaneous resolution of epidural hematoma: A rare case	p. 292
	Srikrishnaditya Manne, Siddartha Reddy Musali, Prakash Rao Gollapudi, Ravi Karla DOI:10.4103/ajns.AJNS_173_18   An epidural hematoma is a life-threatening condition which necessitates early surgical intervention. Conservative management is undertaken in smaller hematomas; rarely, a massive hematoma may show spontaneous resolution which can be picked up only by a repeat computed tomography before surgery. Here, we report one such case where we noted a surprisingly rapid resolution of an epidural hematoma, which was relatively a large clot and where the last minute call to have a repeated computed tomography scan changed the line of management altogether from a surgical one to conservative. The patient in this particular case is a 20-year-old male, with a history of fall from height. The initial scan showed a large epidural hematoma which requires surgical evacuation, whereas the subsequent scans showed near-complete resolution and hence was managed conservatively. Rare cases like these should always be kept in mind, and the importance of a repeat scan should never be disregarded.
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	Loss of contralateral upper limb motor evoked potential due to occlusion of the internal carotid artery in microsurgical clipping of basilar tip aneurysm	p. 295
	Liew Boon Seng, Yamada Yasuhiro, Niranjana Rajagopal, Ameen Abdul Mohammad, Teranishi Takao, Miyatani Kyosuke, Kawase Tsukasa, Yoko Kato DOI:10.4103/ajns.AJNS_157_18   The motor evoked potential (MEP) monitoring is routinely used as an adjunct in the microsurgical clipping of anterior circulation. We describe a case of unruptured basilar tip aneurysm treated with microsurgical clipping developed loss in MEP recording of the left abductor pollicis brevis (APB) following clipping of basilar tip aneurysm. A 58-year-old man was referred to the Fujita Health University Banbuntane-Hotokukai Hospital, Nagoya, Aichi, Japan, with incidental finding of unruptured 6.5 mm basilar tip saccular aneurysm. He underwent right anterior temporal approach of basilar tip aneurysm clipping. The internal carotid artery (ICA) was mobilized laterally to allow direct visualization of the neck of the basilar tip aneurysm. Following the application of temporary clip and subsequently permanent clip at the neck of the aneurysm, the MEP signal was lost in the left APB. The temporary clip was immediately removed. Dual-image videoangiography (DIVA) showed a filling defect in the right ICA and a branch of middle cerebral artery (MCA). The MEP was absent for about 23 minutes and the amplitude improved to only 75% of the baseline recording at 38 minutes till the end of the surgery. A repeat DIVA showed good flow within the right ICA and MCA. Glasgow coma score was 15/15 on postoperative day 1 and there was no gross motor or sensory deficit except right oculomotor nerve palsy with complete recovery at 6 months follow-up. This is the first reported ICA occlusion due to its mobilization in microsurgical clipping of basilar tip aneurysm. The use of neuromonitoring especially MEP is essential even in the posterior circulation aneurysm surgery especially when excessive manipulation of the ICA is unavoidable. When performing intraoperative angiography for aneurysm surgery, it is prudent to detect any filling defect within the surrounding vessels.
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	Adult pilomyxoid astrocytoma with hemorrhage in an atypical location	p. 300
	Madhivanan Karthigeyan, Prankul Singhal, Pravin Salunke, Rakesh Kumar Vasishta DOI:10.4103/ajns.AJNS_164_18   Pilomyxoid astrocytomas (PMAs) are generally seen in young children and tend to occur in the hypothalamic–chiasmatic region. Their presence in other parts of the brain in the nonpediatric age group is uncommon. In addition, hemorrhage in such low-grade tumors is an occasional event. We describe a case of PMA that presented with spontaneous bleed in an atypical location (temporoparietal region) in an adult. A concise literature of the cases of PMA which were associated with bleed is also presented. Occasionally, low-grade tumors such as PMA may present with bleed. These benign looking neoplasms behave differently from the commonly occurring pilocytic astrocytomas (PAs) and should be considered as a differential. It is important to differentiate these from PA, as the management and prognosis differs.
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	Spinal intradural extramedullary bizarre parosteal osteochondromatous proliferation of bone (Nora's Lesion): First case report	p. 304
	Alkhayri Abdu, Bugdadi Abdulgadir, Alsalmi Sultan, Andre Arthur DOI:10.4103/ajns.AJNS_163_18   Bizarre parosteal proliferation of bone (Nora's lesion) is a known bony lesion that affects mainly hands and feet. In this article, we present the first case of spinal intradural extramedullary Nora's lesion along with the management. Radiologically, the tumor was initially diagnosed as a meningioma. However, histopathological analysis confirmed bizarre parosteal proliferation of bone. It was successfully managed by surgical resection followed by physical rehabilitation.
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	Optic tract edema: A rare entity in pituitary macroadenoma	p. 307
	Sanjay Kumar, Ashok Kumar, Maneet Singh Gill, Vikas Maheshwari DOI:10.4103/ajns.AJNS_178_18   Pituitary tumors are relatively common tumors accounting for almost 15% of all primary brain tumors. Pituitary macroadenomas cause mass effect on the optic apparatus causing a myriad of visual deficits. On imaging generally the anterior visual pathway is involved which may be compressed by the mass lesion. Edema in the posterior visual pathway, i.e., optic tracts on magnetic resonance imaging is a relatively common finding in craniopharyngiomas and other metastatic lesions in the pituitary region. Edema in the optic tracts in pituitary macradenomas is a very rare entity as reported by various authors in literature. We report a case of optic tract edema in a case of pituitary macroadenoma which caused rapid deterioration in the vision of the patient and improved after administration of steroids.
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	Meningitis for Streptococcus salivarius secondary to paradoxical cerebrospinal fluid rhinorrhea as a complication of retrosigmoid approach	p. 310
	María Paula Vargas Osorio, Juan Esteban Muñoz Montoya, Marco Luciano Charry Lopez, Luis Orlando Rojas Romero DOI:10.4103/ajns.AJNS_179_18   Rhinorrhea secondary to a retrosigmoid approach is rare, but when it manifests, it is due to a paradoxical cerebrospinal fluid (CSF) leak, as a result of the communication between the mastoid cells, middle ear, and eustachian tube, which finally ends on the release of CSF through the nasopharynx. Abnormal communications increases the risk of infections, not only at the surgical site but also through an ascending path. Magnetic resonance cisternography (MRC) with intrathecal gadolinium injection through a lumbar puncture not only allows an adequate diagnosis but also helps to establish management plans. Here, we present an eighty-three-year-old female patient, with a history of trigeminal neuralgia, who underwent retrosigmoid approach to perform trigeminal microvascular decompression. After intervention, the patient consulted for rhinorrhea, fever, and headache. Lumbar puncture was performed, resulting on the isolation of Streptococcus salivarius in CSF. Nuclear MRC with intrathecal gadolinium injection was performed, identifying a paradoxical CSF leak. Failure in medical management with conservative treatment ends in surgical reexploration, identifying a bone defect in mastoid cells, which was corrected.
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	Extensive pulmonary metastases 13 years after initial resection of intracranial meningioma	p. 314
	Samuel Rajadurai, Ziad Thotathil, Rakesh Biju, Fouzia Ziad, Zakier Hussain DOI:10.4103/ajns.AJNS_191_18   Background: Extracranial metastasis from intracranial meningioma is a very rare condition. A current literature review reveals that only few cases are documented with extensive pulmonary involvement >10 years after initial intracranial meningioma resection. Diagnosis of pulmonary meningioma is often confirmed by computed tomography chest-guided core biopsies. The prognosis of extensive metastatic pulmonary meningioma, however, is unknown and there is no gold standard treatment option. Case Description: We present a case of multiple pulmonary meningioma metastases developing 13 years after initial resection of left occipital parafalcine World Health Organization Grade I intracranial meningioma. Conclusion: There are no established guidelines for the optimal management or surveillance of extensive pulmonary metastatic meningioma. In patients with high-grade meningioma and multiple cannonball pulmonary lesions, metastatic meningioma should be considered as part of the differential diagnosis. Metastatic meningioma may occur even a decade after initial tumour resection.
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	Coexistent cerebral cavernous malformation and developmental venous anomaly: Does an aggressive natural history always call for surgical intervention?	p. 318
	Kuntal Kanti Das, Kamlesh Rangari, Suyash Singh, Kamlesh S Bhaisora, Awadhesh Kumar Jaiswal, Sanjay Behari DOI:10.4103/ajns.AJNS_196_18   Coexistence of cerebral cavernous malformations (CMs) and developmental venous anomaly (DVA) represents the most common form of mixed intracranial vascular malformations. Existing literature supports not only a possible causative role of DVA for de novo CMs but also a potentially detrimental effect on an associated CM, increasing the chances of hemorrhagic complications and growth in the latter. A 52-year-old gentleman presented to us with a 17-year long history of simple motor seizures on the left faciobrachial region. On magnetic resonance imaging (MRI) of the head, a 1.5 cm × 1.5 cm CM without any evidence of recent hemorrhage was identified in the left high frontal premotor area. There was a linear enhancement in the adjoining superior frontal sulcus on contrast MRI. On intra-arterial angiogram, this hyperintensity was confirmed to be a venous channel draining into the superior sagittal sinus. Thus, a diagnosis of cavernoma associated with a DVA was made. The patient was advised conservative treatment and he was doing well at follow-up. Unless diligently looked for, DVA associated with CM may be easily missed. The coexistence has pathophysiological and management implications. Despite the reported aggressive natural history, there is a scope for conservative treatment for these complex vascular malformations.
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	Contrecoup extradural hematoma without fracture: A case report and review of literature	p. 322
	Siddartha Reddy Musali, Srikrishnaditya Manne, Nagarjuna Butkuri, Prakash Rao Gollapudi, Thatikonda Satish Kumar DOI:10.4103/ajns.AJNS_283_18   Extradural hemorrhages are commonly seen in coup head injuries, rarely seen in contrecoup head injuries. Acute extradural hemorrhage in the coup head injuries associated with a fracture is common, but the incidence of acute contrecoup extradural hemorrhage not associated with the fracture is extremely rare. Only 21 cases have been reported previously. A 28-year-old male patient presented to the emergency department with complaints of sustaining injuries in a road traffic accident by fall from a two-wheeler. No history of loss of consciousness, vomiting, seizures, and ear/nose bleed. On examination, the patient was conscious and coherent with a Glasgow Coma Scale score of 15/15 and a laceration on the right frontotemporal region which was sutured. Contrast tomography of the brain revealed an extradural hemorrhage of 10 mm thickness in the left parieto-occipital region with soft tissue swelling in the right temporoparietal region, without any evident fractures in the calvarium. The patient was managed conservatively. Contrecoup extradural hematoma is a rare entity, and those without fracture are extremely rare. Early diagnosis, careful observation, and management lead to a good outcome.
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	Delayed pneumoventricle following endonasal cerebrospinal fluid rhinorrhea repair with thecoperitoneal shunt	p. 325
	Shyam Sundar Krishnan, Adarsh Manuel, Madabhushi Chakravarthy Vasudevan DOI:10.4103/ajns.AJNS_224_18   Pneumocephalus and pneumoventricle are well-documented in neurosurgical practice. Although both are common posttraumatic sequelae, iatrogenic causes are also well recognized. Iatrogenic causes may be seen after intracranial surgical procedures or cerebrospinal fluid (CSF) diversion procedures. Small amount of pneumoventricle postshunt procedure is usually a self-limiting condition. Rarely, the patient may develop tension pneumoventricle which requires emergency intervention. The occurrence of delayed tension pneumoventricle/pneumatocele following surgery for CSF rhinorrhea with CSF diversion procedures is very rare. We report one case of late presentation of delayed tension pneumoventricle with temporal pneumatocele in a patient who underwent transnasal endoscopic repair of CSF fistula followed by thecoperitoneal shunt. This condition is potentially lethal that requires prompt recognition and surgical treatment.
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	Subpial cervical subependymoma: Report of an unusual tumor with review of literature	p. 329
	Deepak Khatri, Kamlesh Singh Bhaisora, Jaskaran Singh Gosal, Kuntal Kanti Das, Arun Kumar Srivastava DOI:10.4103/ajns.AJNS_225_18   Subependymoma is rare benign neoplasm (World Health Organization Grade I) usually found in the 4th ventricle and lateral ventricles. They were first described by Boykin as a separate entity in 1954. Subependymoma constitutes only 1%–2% of spinal ependymal tumors. Majority of the spinal subependymoma is intramedullary, with a rare few reported in the extramedullary plane. Clinicoradiologically, subependymoma often mimic more frequent, aggressive tumors of the spine (astrocytoma and ependymoma) which makes them difficult to differentiate. In fact, the diagnosis of subependymoma comes as a histopathological surprise. Maximal safe resection holds the key to good postoperative outcome with a very limited role of adjuvant therapy. Complete excision of the tumor, though desirable, is not feasible in all cases. Owing to their rarity and lack of characteristic clinicoradiological features, there is limited information currently available regarding their preoperative diagnosis and "optimal" management strategy. In this case report, we are discussing a case of eccentric subpial cervical subependymoma discussing important differentiating radiological features, and surgical nuances with an attempt to define "optimal" management strategy.
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LETTERS TO EDITOR
	Dr. Hsiang-Lai Wen: Father of Hong Kong neurosurgery	p. 332
	Guru Dutta Satyarthee DOI:10.4103/ajns.AJNS_164_17
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	A piece of wire into the brain	p. 333
	Andreas Zigouris, Nikolaos Konsolakis, George Alexiou, Spyridon Voulgaris DOI:10.4103/ajns.AJNS_46_17
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	Obituary Shih Chun-Jen: Dedicated life for advancement of neurosurgical specialty	p. 334
	Guru Dutta Satyarthee DOI:10.4103/ajns.AJNS_190_17
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	Professor Jean Holowach-Thurston: Who along with spouse laid the foundation stone of modern pediatric neurology as superspeciality	p. 336
	Kanwaljit Garg, Guru Dutta Satyarthee DOI:10.4103/ajns.AJNS_265_17
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	Froin's syndrome mimicking Guillain–Barre syndrome in a patient with spinal epidural abscess	p. 338
	Luis Rafael Moscote-Salazar, Andrei F Joaquim, Gabriel Alcala-Cerra, Amit Agrawal, Willem Guillermo Calderon-Miranda DOI:10.4103/ajns.AJNS_11_17
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	Endoscopic third ventriculostomy in the management of obstructive hydrocephalus	p. 340
	Farideh Nejat DOI:10.4103/ajns.AJNS_51_17
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	Prof. Shokei Yamada: An international neurosurgeon, regarded as father figure for adult tethered cord syndrome management and dedicated life for the advancement of intracranial arteriovenous malformation surgery	p. 341
	Guru Dutta Satyarthee, Aman Jagdevan DOI:10.4103/ajns.AJNS_189_18
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