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Ajay Bakshi, Rana Patir, Asha Bakshi and Ajit Kumar Banerji

✓ The authors combined a monopolar electrode and a suction/irrigation channel with a 0°, 4-mm Hopkins rigid telescope into a single multifunctional unit. This three-in-one instrument is inserted through a lightweight 7.5-mm outer sheath, which is fixed separately. A fourth instrument (for example, a balloon catheter or a biopsy forceps) can be introduced and manipulated independently with the other hand.

All endoscopic procedures were performed with a trephine to create a 15-mm craniotomy. After opening the dura mater, ventricles were tapped with a brain needle, which was followed by the insertion of the rigid scope for visualization. The telescope was then withdrawn momentarily; the outer sheath was introduced into the ventricle and fixed over the area of interest. The definitive procedure was then performed with ease by using the multifunctional three-inone instrument in one hand and a fourth instrument in the other hand.

This novel neuroendoscopic system has been used in clinical testing at the Vidyasagar Institute of Mental Health and Neurosciences since May 1998. Thus far, 83 neuroendoscopic procedures have been successfully performed with the aid of this instrumentation system, which has proven to be safe, versatile, and cost-effective, allowing a greater degree of freedom for the neurosurgeon.

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Ajay Bakshi, Asha Bakshi and Ajit Kumar Banerji

Object

The aim of this study was to describe a new, minimally invasive technique for the endoscopic evacuation of intracerebral hematomas (ICHs) and the clinical and radiological outcomes in patients who underwent the procedure. The authors used a multifunctional three-in-one endoscopic instrument that combines a 0°, 4-mm rigid telescope, an irrigation cannula, and a cautery electrode.

Methods

In 13 patients a small keyhole craniotomy was made through noneloquent cortex to gain access to the hematoma. After opening the dura mater, a small cortical tunnel (~6 mm in diameter) was created using bipolar forceps and suction to enter into the clot. The three-in-one endoscope was then introduced to provide illumination and irrigation inside the cavity. The clot was safely aspirated under endoscopic vision and constant irrigation by performing microsurgical suction with the other hand. Hemostasis could be achieved using electrocautery and Surgicel. This technique eliminates the use of an endoscopic sheath, thus providing more maneuverability to the neurosurgeon. The brilliant illumination provided by the endoscope and the possibility of using electrocautery in the depths of the brain combined with the increased maneuverability make this technique valuable. Near-complete hematoma evacuation was achieved in 11 (85%) of 13 patients. There were four deaths (30%).

Conclusions

Safe and effective evacuation of large ICHs is possible by using the three-in-one endoscopic device. Appropriate indications for surgery in patients with large intracerebral hemorrhage must be developed.

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Ajay Bakshi, Omar Fisher, Taner Dagci, B. Timothy Himes, Itzhak Fischer and Anthony Lowman

Object. Spinal cord injury (SCI) is a complex pathological entity, the treatment of which requires a multipronged approach. One way to integrate different therapeutic strategies for SCI is to develop implantable scaffolds that can deliver therapies in a synergistic manner. Many investigators have developed implantable “bridges,” but an important property of such scaffolds—that is, mechanical compatibility with host tissues—has been neglected. In this study, the authors evaluated the results of implanting a mechanically matched hydrogel-based scaffold to treat SCI.

Methods. A nonbiodegradable hydrogel, poly(2-hydroxyethylmethacrylate) (PHEMA), was engineered using thermally initiated free radical solution polymerization. Two groups of 12 adult Sprague—Dawley rats underwent partial cervical hemisection injury followed by implantation of either PHEMA or PHEMA soaked in 1 µg of brain-derived neurotrophic factor (BDNF). Four rats from each group were killed 1, 2, or 4 weeks after induction of the injury. Immunofluorescence staining was performed to determine the presence of scarring, cellular inflammatory responses, gliosis, angiogenesis, and axonal growth in and around the implanted scaffolds.

Conclusions. The implanted PHEMA with 85% water content had a compressive modulus of 3 to 4 kPa, which matched the spinal cord. Implanted PHEMA elicited modest cellular inflammatory responses that disappeared by 4 weeks and minimal scarring was noted around the matrix. Considerable angiogenesis was observed in PHEMA, and PHEMA soaked in BDNF promoted axonal penetration into the gel. The authors conclude that mechanically engineered PHEMA is well accepted by host tissues and might be used as a platform for sustained drug delivery to promote axonal growth and functional recovery after SCI.

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Ajay Bakshi, Corey Hunter, Sharon Swanger, Angelo Lepore and Itzhak Fischer

Object. Stem cell therapy has been shown to have considerable therapeutic potential for spinal cord injuries (SCIs); however, most experiments in animals have been performed by injecting cells directly into the injured parenchyma. This invasive technique compromises the injured spinal cord, although it delivers cells into the hostile environment of the acutely injured cord. In this study, the authors tested the possibility of delivering stem cells to injured spinal cord by using three different minimally invasive techniques.

Methods. Bone marrow stromal cells (BMSCs) are clinically attractive because they have shown therapeutic potential in SCI and can be obtained in patients at the bedside, raising the possibility of autologous transplantation. In this study transgenically labeled cells were used for transplantation, facilitating posttransplantation tracking. Inbred Fisher-344 rats received partial cervical hemisection injury, and 2 × 106 BMSCs were intravenously, intraventricularly, or intrathecally transplanted 24 hours later via lumbar puncture (LP). The animals were killed 3, 10, or 14 days posttransplantation, and tissue samples were submitted to histochemical and immunofluorescence analyses. For additional comparison and validation, lineage restricted neural precursor (LRNP) cells obtained from E13.5 rat embryos were transplanted via LP, and these findings were also analyzed.

Conclusions. Both BMSCs and LRNP cells home toward injured spinal cord tissues. The use of LP and intraventricular routes allows more efficient delivery of cells to the injured cord compared with the intravenous route. Stem cells delivered via LP for treatment of SCI may potentially be applicable in humans after optimal protocols and safety profiles are established in further studies.