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

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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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Manish Kumar Kasliwal and Ashish Suri

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Aanchal Kakkar, Mehar C. Sharma, Nishant Goyal, Chitra Sarkar, Vaishali Suri, Ajay Garg, Shashank S. Kale and Ashish Suri

Meningeal fibromas are rare intracranial tumors that mimic meningiomas radiologically as well as histologically. The authors report 2 cases of meningeal fibroma with detailed clinical, radiological, histopathological, and immunohistochemical features, and discuss the differential diagnosis of this entity. Knowledge of this rare tumor is essential for pathologists to be able distinguish it from more common meningeal tumors, especially in younger patients. This knowledge is also essential for neurosurgeons, as incomplete resection may lead to tumor recurrence, and such patients require close follow-up.

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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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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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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.