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Changes in cerebral perfusion hormone profile and cerebrospinal fluid flow across the third ventriculostomy after endoscopic third ventriculostomy in patients with aqueductal stenosis: a prospective study

Clinical article

Anil Kumar Garg, Ashish Suri, Bhavani S. Sharma, Shamin A. Shamim, and Chander S. Bal

Object

The object of the present study was 3-fold: 1) to study regional cerebral perfusion before and after endoscopic third ventriculostomy (ETV) in patients with obstructive hydrocephalus by using 99mTc ethyl cysteinate dimer SPECT: 2) to study any correlation between clinically successful third ventriculostomy and CSF flow across the third ventriculostomy; and 3) to determine any changes in hormone profile following ETV.

Methods

The authors prospectively studied 15 patients with aqueductal stenosis who underwent ETV during the last 2 years. All the patients underwent pre- and postoperative MR imaging, brain 99mTc ethyl cysteinate dimer SPECT, and hormone profile studies.

Results

Eight patients were infants. The mean follow-up duration was 17.6 months. Thirteen patients (86.7%) exhibited clinical improvement after surgery. In all patients with clinical improvement the studies documented CSF flow through the ventriculostomy site. Clinical progress could be correlated with SPECT changes in 14 cases (93.3%). In the 13 clinically successful cases, 12 were substantiated by improvement on SPECT scans, whereas in the 2 failed cases, SPECT images revealed no improvement of perfusion defects. Hormone analysis conducted in 14 patients revealed hyperprolactinemia in 8, low triiodothyronine values in 2 patients, and hypocortisolemia in 1, which was reversed after ETV.

Conclusions

Clinical improvement is not well correlated with a decrease in ventricular size following ETV. Brain SPECT is a valuable tool for the follow-up of patients with hydrocephalus after ETV, particularly in cases in which MR imaging findings are not clear. There are subtle hormonal changes in patients with hydrocephalus that may improve following ETV.

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Challenges and prospects of neurosurgical teleconsultations in a developing country: a reality check

Narendra Kumar, Varidh Katiyar, Kokkula Praneeth, Ravi Sharma, Priya Narwal, Amol Raheja, Vivek Tandon, Shashwat Mishra, Kanwaljeet Garg, Ashish Suri, P. Sarat Chandra, and Shashank S. Kale

OBJECTIVE

The adoption of telemedicine became a necessity during the COVID-19 pandemic because patients found commuting to be difficult owing to travel restrictions. Initially, audio-based teleconsultations were provided. Later, on the basis of the feedback of patients and caregivers, the authors started to provide video-based teleconsultations via WhatsApp. The authors subsequently surveyed the patients and caregivers to determine their satisfaction levels with telemedicine services.

METHODS

An anonymized telephone survey of patients who had participated in teleconsultation was conducted with a structured questionnaire. The responses were analyzed and their correlations with the perceived benefits and limitations of audio and video teleconsultation were determined.

RESULTS

Three hundred respondents were included in the first round of surveys, of whom 250 (83.3%) consented to video teleconsultation. Among the respondents who participated in both audio and video teleconsultations (n = 250), paired analysis showed that video teleconsultation was perceived as better in terms of providing easier access to healthcare services (p < 0.001), saving time (p < 0.001), and satisfaction with the way patient needs were conveyed to healthcare providers (p = 0.023), as well as in terms of adequacy of addressing healthcare needs (p < 0.001) and consequently providing a higher rate of overall satisfaction (p < 0.001). For both audio and video teleconsultation, overall patient satisfaction was significantly related to only previous exposure to WhatsApp. However, for video consultation, longer call duration (p = 0.023) was an important independent factor. Video teleconsultation was preferable to face-to-face consultation irrespective of educational status, but higher education was associated with preference for video teleconsultation.

CONCLUSIONS

Both audio and video teleconsultation are viable cost-effective surrogates for in-person physical neurosurgical consultation. Although audio teleconsultation is more user-friendly and is not restricted by educational status, video teleconsultation trumps the former owing to a more efficient and satisfactory doctor-to-patient interface.

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Outcome following postneurosurgical Acinetobacter meningitis: an institutional experience of 72 cases

Ravi Sharma, Revanth Goda, Sachin Anil Borkar, Varidh Katiyar, Samagra Agarwal, Amandeep Kumar, Sarita Mohapatra, Arti Kapil, Ashish Suri, and Shashank S. Kale

OBJECTIVE

The authors aimed to evaluate the antimicrobial susceptibility pattern of Acinetobacter isolates responsible for nosocomial meningitis/ventriculitis in the neurosurgical ICU. The authors also sought to identify the risk factors for mortality following Acinetobacter meningitis/ventriculitis.

METHODS

This was a retrospective study of 72 patients admitted to the neurosurgical ICU between January 2014 and December 2018 with clinical and microbiological diagnosis of nosocomial postneurosurgical Acinetobacter baumanii meningitis/ventriculitis. Electronic medical data on clinical characteristics, underlying pathology, CSF cytology, antibiotic susceptibilities, and mortality were recorded. To evaluate the outcome following nosocomial postneurosurgical Acinetobacter meningitis/ventriculitis, patients were followed up until discharge or death in the hospital. Kaplan-Meier survival analysis and multivariable Cox proportional hazards models were used to compute factors affecting survival.

RESULTS

The study population was divided into two groups depending on the final outcome of whether the patient died or survived. Forty-three patients (59.7%) were included in the survivor group and 29 patients (40.3%) were included in the nonsurvivor group. Total in-hospital mortality due to Acinetobacter meningitis/ventriculitis was 40.3% (29 cases), with a 14-day mortality of 15.3% and a 30-day mortality of 25%. The 43 (59.7%) patients who survived had a mean length of hospital stay of 44 ± 4 days with a median Glasgow Outcome Scale–Extended score at discharge of 6. On univariate analysis, age > 40 years (p = 0.078), admission Glasgow Coma Scale (GCS) score ≤ 8 (p = 0.003), presence of septic shock (p = 0.011), presence of external ventricular drain (EVD) (p = 0.03), CSF white blood cell (WBC) count > 200 cells/mm3 (p = 0.084), and comorbidities (diabetes, p = 0.036; hypertension, p = 0.01) were associated with poor outcome. Carbapenem resistance was not a risk factor for mortality. According to a multivariable Cox proportional hazards model, age cutoff of 40 years (p = 0.016, HR 3.21), GCS score cutoff of 8 (p = 0.006, HR 0.29), CSF WBC count > 200 cells/mm3 (p = 0.01, HR 2.76), presence of EVD (p = 0.001, HR 5.42), and comorbidities (p = 0.017, HR 2.8) were found to be significant risk factors for mortality.

CONCLUSIONS

This study is the largest case series reported to date of postneurosurgical Acinetobacter meningitis/ventriculitis. In-hospital mortality due to Acinetobacter meningitis/ventriculitis was high. Age older than 40 years, GCS score less than 8, presence of EVD, raised CSF WBC count, and presence of comorbidities were risk factors for mortality.

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Preparedness and guidelines for neurosurgery in the COVID-19 era: Indian perspective from a tertiary care referral hospital

Amol Raheja, Nitish Agarwal, Sarita Mohapatra, Vivek Tandon, Sachin Anil Borkar, P. Sarat Chandra, Shashank S. Kale, and Ashish Suri

The COVID-19 pandemic has severely impacted healthcare systems globally. The need of the hour is the development of effective strategies for protecting the lives of healthcare providers (HCPs) and judicious triage for optimal utilization of human and hospital resources. During this pandemic, neurosurgery, like other specialties, must transform, innovate, and adopt new guidelines and safety protocols for reducing the risk of cross-infection of HCPs without compromising patient care. In this article, the authors discuss the current neurosurgical practice guidelines at a high-volume tertiary care referral hospital in India and compare them with international guidelines and global consensus for neurosurgery practice in the COVID-19 era. Additionally, the authors highlight some of the modifications incorporated into their clinical practice, including those for stratification of neurosurgical cases, patient triaging based on COVID-19 testing, optimal manpower management, infrastructure reorganization, evolving modules for resident training, and innovations in operating guidelines. The authors recommend the use of their blueprint for stratification of neurosurgical cases, including their protocol for algorithmic patient triage and management and their template for manpower allocation to COVID-19 duty, as a replicable model for efficient healthcare delivery.

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Letter to the Editor: Joining the masters: the Dolenc-Kawase approach

Eberval Gadelha Figueiredo, Manoel J. Teixeira, Robert F. Spetzler, and Mark C. Preul

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Letter to the Editor: Neurosurgery skills training laboratories and curriculum: a supplement to Halstedian practice

Ashish Suri and Manjul Tripathi

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Dose-dependent facilitation of peripheral nerve regeneration by bone marrow–derived mononuclear cells: a randomized controlled study

Laboratory investigation

Amol Raheja, Vaishali Suri, Ashish Suri, Chitra Sarkar, Arti Srivastava, Sujata Mohanty, Krishan G. Jain, Meher C. Sharma, Hruda N. Mallick, Pradeep K. Yadav, Mani Kalaivani, and Ravindra M. Pandey

Object

Bone marrow–derived stem cells enhance the rate of regeneration of neuronal cells leading to clinical improvement in nerve injury, spinal cord injury, and brain infarction. Recent experiments in the local application of bone marrow–derived mononuclear cells (BM-MNCs) in models of sciatic nerve transection in rats have suggested their beneficial role in nerve regeneration, although the effects of variable doses of stem cells on peripheral nerve regeneration have never been specifically evaluated in the literature. In this paper, the authors evaluated the dose-dependent role of BM-MNCs in peripheral nerve regeneration in a model of sciatic nerve transection in rats.

Methods

The right sciatic nerve of 60 adult female Wistar rats (randomized into 2 test groups and 1 control group, 20 rats in each group) underwent transection under an operating microscope. The cut ends of the nerve were approximated using 2 epineural microsutures. The gap was filled with low-dose (5 million BM-MNCs/100 μl phosphate-buffered saline [PBS]) rat BM-MNCs in one group, high-dose (10 million BM-MNCs/100 μl PBS) rat BM-MNCs in another group, and only PBS in the control group, and the approximated nerve ends were sealed using fibrin glue. Histological assessment was performed after 30 days by using semiquantitative and morphometric analyses and was done to assess axonal regeneration, percentage of myelinated fibers, axonal diameter, fiber diameter, and myelin thickness at distal-most sites (10 mm from site of repair), intermediate distal sites (5 mm distal to the repair site), and site of repair.

Results

The recovery of nerve cell architecture after nerve anastomosis was far better in the high-dose BM-MNC group than in the low-dose BM-MNC and control groups, and it was most evident (p < 0.02 in the majority of the parameters [3 of 4]) at the distal-most site. Overall, the improvement in myelin thickness was most significant with incremental dosage of BM-MNCs, and was evident at the repair, intermediate distal, and distal-most sites (p = 0.001).

Conclusions

This study emphasizes the role of BM-MNCs, which can be isolated easily from bone marrow aspirates, in peripheral nerve injury and highlights their dose-dependent facilitation of nerve regeneration.

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Neurosurgery residency match for international medical graduates in the United States

Anudeep Yekula, Sattwik Sreeram, Sanjay Dhawan, Mayur Sharma, Carolina Sandoval-Garcia, Jared D. Huling, Ashish Suri, Kumar Belani, Michael C. Park, Bob S. Carter, and Clark C. Chen

OBJECTIVE

Training of international medical graduates (IMGs) offers opportunities for the US neurosurgery community to engage the global talent pool and impact national and international healthcare. Here, the authors analyzed the time trend of IMGs matching into US neurosurgery programs and identified potential opportunities for enhancing IMG engagement.

METHODS

The authors analyzed the National Resident Matching Program (NRMP) match results, NRMP program director (PD) surveys, and applicant surveys from 2013 to 2022. Regression methods were used to analyze time trends.

RESULTS

Between 2013 and 2022, the number of US neurosurgery residency positions increased by 17.6% (from 204 to 240). During this period, the percentage of IMGs matching into neurosurgery increased from 3.5% to 7%, translating into a 6.8% increase in the likelihood of a successful IMG match per year (95% CI 0.3%–13.8%, p = 0.042). The likelihoods of a successful match for US MDs and IMGs scoring > 260 on the USMLE Step 1 were > 90% and approximately 55%, respectively. In PD surveys, approximately 90% of PDs indicated that they seldom/never interview or rank IMGs. In terms of factors that influenced the PD decision for interviewing/ranking, IMGs are disadvantaged in several categories, including the ability to secure an audition elective/rotation, and proper letters of recommendation, as well as the influence of the culture on the preconceived perception of poor interpersonal skills.

CONCLUSIONS

The number of IMGs matching successfully in neurosurgery has increased marginally during the past decade. The authors outline the challenges that IMGs encounter in this process and suggest strategies for considerations of IMG training in NRMP-associated institutions.

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Quantitative analysis of the Kawase versus the modified Dolenc-Kawase approach for middle cranial fossa lesions with variable anteroposterior extension

Manjul Tripathi, Rama Chandra Deo, Ashish Suri, Vinkle Srivastav, Britty Baby, Subodh Kumar, Prem Kalra, Subhashis Banerjee, Sanjiva Prasad, Kolin Paul, Tara Sankar Roy, and Sanjeev Lalwani

OBJECT

The surgical corridor to the upper third of the clivus and ventral brainstem is hindered by critical neurovascular structures, such as the cavernous sinus, petrous apex, and tentorium. The traditional Kawase approach provides a 10 × 5–mm fenestration at the petrous apex of the temporal bone between the 5th cranial nerve and internal auditory canal. Due to interindividual variability, sometimes this area proves to be insufficient as a corridor to the posterior cranial fossa. The authors describe a modification to the technique of the extradural anterior petrosectomy consisting of additional transcavernous exploration and medial mobilization of the cisternal component of the trigeminal nerve. This approach is termed the modified Dolenc-Kawase (MDK) approach.

METHODS

The authors describe a volumetric analysis of temporal bones with 3D laser scanning of dry and drilled bones for respective triangles and rhomboid areas, and they compare the difference of exposure with traditional versus modified approaches on cadaver dissection. Twelve dry temporal bones were laser scanned, and mesh-based volumetric analysis was done followed by drilling of the Kawase triangle and MDK rhomboid. Five cadaveric heads were drilled on alternate sides with both approaches for evaluation of the area exposed, surgical freedom, and angle of approach.

RESULTS

The MDK approach provides an approximately 1.5 times larger area and 2.0 times greater volume of bone at the anterior petrous apex compared with the Kawase’s approach. Cadaver dissection objectified the technical feasibility of the MDK approach, providing nearly 1.5–2 times larger fenestration with improved view and angulation to the posterior cranial fossa. Practical application in 6 patients with different lesions proves clinical applicability of the MDK approach.

CONCLUSIONS

The larger fenestration at the petrous apex achieved with the MDK approach provides greater surgical freedom at the Dorello canal, gasserian ganglion, and prepontine area and better anteroposterior angulation than the traditional Kawase approach. Additional anterior clinoidectomy and transcavernous exposure helps in dealing with basilar artery aneurysms.

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Abstracts of the 2014 Annual Meeting of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves Orlando, Florida • March 5–8, 2014