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Manish Kumar Kasliwal and Ashish Suri

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Ashish Suri, Rohit Kumar Goel, Faiz Uddin Ahmad, Ananth Kesav Vellimana, Bhawani Shankar Sharma and Ashok Kumar Mahapatra

Object

Neurocysticercosis (NCC) is the most common parasitic infestation of the central nervous system worldwide. In patients presenting with acute hydrocephalus due to intraventricular NCC, surgery is the only option. Still, there is no consensus regarding the optimal surgical strategy, although neuroendoscopic excision is a promising method. However, the literature regarding the use of this modality in fourth ventricular NCC is scarce. The authors describe a series of patients with fourth ventricular NCC treated endoscopically.

Methods

The clinical records of 13 patients with fourth ventricular NCC who had presented with hydrocephalus were retrospectively analyzed. A fourth ventricular cyst was completely excised in all patients by using a transventricular, transaqueductal “scope-in-scope” endoscopic technique. Twelve endoscopic third ventriculostomies and 1 septostomy had been performed.

Results

Shunt placement was avoided in all patients. There were minimal peri- and postoperative complications. The mean duration of follow-up was 22.3 months (range 3–41 months). All patients had an improved clinical outcome. Follow-up neuroimaging revealed no residual lesion and a decreased ventricle size in all patients.

Conclusions

The present series of patients with fourth ventricular NCC is the largest in the existing English-language medical literature. Endoscopic fourth ventricular cysticercal cyst excision along with internal cerebrospinal fluid diversion via endoscopic third ventriculostomy is an effective alternative to open microneurosurgical procedures and avoids shunt placement and its related complications.

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Ashish Suri, Karanjit Singh Narang, Bhawani Shankar Sharma and Ashok Kumar Mahapatra

Object

The purpose of this paper was to study the visual outcome after surgery in patients with suprasellar tumors who experienced preoperative blindness in 1 or both eyes.

Methods

All patients with suprasellar tumors and no perception of light in 1 or both eyes and who underwent surgery between May 2002 and May 2006 were included in this retrospective study. Outcome was analyzed at discharge from the hospital and at follow-up. There were a total of 79 patients (51 males and 28 females, age range 5–70 years). There were 37 cases of pituitary adenomas, 19 craniopharyngiomas, 18 meningiomas, and 5 other tumors. Preoperatively 61 patients had uniocular blindness and 18 patients had binocular blindness. Of all 158 eyes, 97 (61.4%) were blind at admission and these eyes were analyzed. Sixty-three patients (79.7%) presented with headache and 14 (17.7%) with hypothalamic symptoms. Nearly one fourth (24%) of patients with a pituitary adenoma had a history of apoplexy. The duration of visual decline ranged from 3 days to 7 years, and the duration of blindness ranged from 1 day to 3 years. Patients underwent either transcranial or transsphenoidal tumor decompression.

Results

At discharge from the hospital visual improvement was exhibited in 23 (29%) of 79 patients and 27 (27.8%) of 97 eyes. Improvement to serviceable vision occurred in 7 (8.9%) of 79 patients and in 8 (8.2%) of 97 eyes with pre-operative blindness. After surgery, visual improvement was noted in 15 (24.6%) of 61 patients with uniocular blindness and 8 (44.4%) of 18 patients with binocular blindness. However, serviceable vision was restored in 5 (8.2%) of 61 patients with uniocular and 2 (11.1%) of 18 patients with binocular blindness. Bivariate analysis revealed male sex, shorter duration of blindness, presence of apoplexy, sellar tumor extension, soft tumor consistency, operative evidence of hemorrhage in tumor, and tumor histopathology (pituitary adenoma) to have significant impact on the outcome. Multivariate analysis revealed duration of blindness for > 12 weeks, apoplexy, and sellar extension to have a significant impact on visual outcome.

Conclusions

The present study is the largest in the existing medical literature to evaluate the factors affecting visual outcome after surgery of suprasellar tumors with preoperative blindness.

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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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Ashish Goyal, Anil K. Singh, Daljit Singh, Vikas Gupta, Medha Tatke, Sanjiv Sinha and Sushil Kumar

✓ The authors present an unusual case of intramedullary arachnoid cyst diagnosed in a patient after the lesion was resected. A wide decompressive surgery was performed and the lesion removed. Histopathological findings were consistent with the diagnosis of arachnoid cyst. Postoperatively the patient exhibited marked improvement in neurological status. To the best of the authors' knowledge, there is no case report of intramedullary arachnoid cyst reported in the literature. With the advent of newer neuroimaging modalities such as magnetic resonance imaging the number of cases of intramedullary arachnoid cysts encountered in the future may increase.

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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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Christoph J. Griessenauer, Christopher S. Ogilvy, Nimer Adeeb, Adam A. Dmytriw, Paul M. Foreman, Hussain Shallwani, Nicola Limbucci, Salvatore Mangiafico, Ashish Kumar, Caterina Michelozzi, Timo Krings, Vitor Mendes Pereira, Charles C. Matouk, Mark R. Harrigan, Hakeem J. Shakir, Adnan H. Siddiqui, Elad I. Levy, Leonardo Renieri, Thomas R. Marotta, Christophe Cognard and Ajith J. Thomas

OBJECTIVE

Flow diversion for posterior circulation aneurysms performed using the Pipeline embolization device (PED) constitutes an increasingly common off-label use for otherwise untreatable aneurysms. The safety and efficacy of this treatment modality has not been assessed in a multicenter study.

METHODS

A retrospective review of prospectively maintained databases at 8 academic institutions was performed for the years 2009 to 2016 to identify patients with posterior circulation aneurysms treated with PED placement.

RESULTS

A total of 129 consecutive patients underwent 129 procedures to treat 131 aneurysms; 29 dissecting, 53 fusiform, and 49 saccular lesions were included. At a median follow-up of 11 months, complete and near-complete occlusion was recorded in 78.1%. Dissecting aneurysms had the highest occlusion rate and fusiform the lowest. Major complications were most frequent in fusiform aneurysms, whereas minor complications occurred most commonly in saccular aneurysms. In patients with saccular aneurysms, clopidogrel responders had a lower complication rate than did clopidogrel nonresponders. The majority of dissecting aneurysms were treated in the immediate or acute phase following subarachnoid hemorrhage, a circumstance that contributed to the highest mortality rate in those aneurysms.

CONCLUSIONS

In the largest series to date, fusiform aneurysms were found to have the lowest occlusion rate and the highest frequency of major complications. Dissecting aneurysms, frequently treated in the setting of subarachnoid hemorrhage, occluded most often and had a low complication rate. Saccular aneurysms were associated with predominantly minor complications, particularly in clopidogrel nonresponders.