Abstract Stroke is marked by sudden symptoms leading to neurological function loss due to brain bleeding or impaired blood supply. Intracerebral hemorrhage (ICH) is the most common stroke subtype, involving bleeding in the brain parenchyma. A craniotomy is performed to evacuate the hematoma, reducing pressure and potentially restoring neurological functions such as consciousness, motor skills, and blood pressure. This study aims to compare preoperative and postoperative neurological deficits in ICH stroke patients who underwent craniotomy. An analytical observational study with a cross-sectional design was conducted using purposive sampling in patients diagnosed with ICH stroke who underwent craniotomy in a tertiary hospital. Data were analyzed using the McNemar and Wilcoxon tests. A p < 0.05 was considered statistically significant. Of the 162 patients with ICH stroke, most were male (56.8%) and aged 45 to 54 years (32.1%). Facial nerve paresis significantly improved after surgery (p = 0.006). All patients were seizure-free postoperatively. Motor function also showed significant improvement (p = 0.001). Blood pressure decreased significantly after surgery (p < 0.001) and Glasgow Coma Scale (GCS) scores improved (p = 0.005). There is a significant improvement in neurological deficits between the preoperative and postoperative stages in ICH stroke patients. Craniotomy significantly improves neurological outcomes, including facial nerve paresis, motor function, seizures, blood pressure control, and GCS scores in patients with ICH stroke.

Abstract The aim of this study is to identify and establish biochemical parameters that can predict shunt blockage or malfunction in patients undergoing ventriculoperitoneal (VP) shunt surgery for hydrocephalus by analyzing cerebrospinal fluid (CSF) obtained during surgery. This retrospective study was conducted among patients with hydrocephalus who underwent VP shunt surgery in the Departments of Neurosurgery at two medical institutions during the periods 2011 to 2014 and 2021 to 2024, respectively. CSF samples were collected during shunt surgery and analyzed. Individual biochemical parameters were studied to identify potential predictive factors for shunt blockage. Each patient was followed-up for a minimum of 6 months to assess shunt malfunction or blockage. Patients with shunt malfunction due to infection or malposition were excluded. A high CSF protein value (>100 mg/dL) was found to be statistically significant in predicting the possibility of shunt blockage during follow-up in patients undergoing VP shunt surgery. The CSF protein level was also inversely proportional to the symptom-free interval following VP shunt placement. The ability to predict shunt malfunction using CSF parameters prior to surgery may help a group of patients avoid unnecessary VP shunt-related complications and help surgeons in appropriate surgical planning and in explaining prognosis.

Abstract Craniosynostosis is a craniofacial developmental anomaly resulting from the premature fusion of single or multiple skull sutures. It can have a syndromic (approximately 25%) or non-syndromic association (approximately 75%). Premature fusion of sutures can lead to developmental delays and cosmetic abnormalities of the calvarium. Their management involves surgical removal of the fused suture lines. Surgical correction, however, can lead to several complications such as hematomas, dural tear, and cerebrospinal fluid (CSF) leaks, etc. We present an 8-month-old child who presented with clinical features of non-syndromic craniosynostosis. He underwent “Pi” stripping 3 months ago. On follow-up, he developed two symmetrical bilateral globular swellings over the coronal sutures, 2 months after the first surgery. The swellings gave the appearance of a “bull horn.” Imaging with a CT brain was suggestive of hydrocephalous. A low-pressure ventriculoperitoneal shunt was placed. The postoperative period was uneventful, with resolution of the swellings and improvement in the craniofacial cosmetic appearance.

Abstract The middle meningeal artery (MMA) supplies over two-thirds of the cranial dura mater, making its anatomical knowledge crucial for surgery. Rarely, the MMA may originate from the basilar artery. Typically, it arises between the superior cerebellar artery and anterior inferior cerebellar artery, following a course near the trigeminal nerve to reach the petrous branch of the MMA. An embryological origin involves anastomosis between persistent stapedial and trigeminal arteries. The image illustrates an unusual case of a patient with right MMA originating from the posterior circulation via the basilar artery.

Abstract With the advent of intraoperative neuromonitoring (IONM), facial nerve (FN) preservation improved to nearly 85% in cerebellopontine tumor (CPA) surgeries. Various parameters, such as FN proximal and distal absolute electromyography (EMG) amplitude, stimulation threshold, proximal-to-distal amplitude ratio, and free-run EMG train time, have been used to predict outcomes but not consistently. Hence the aim of this study is to investigate the outcome of FN function in the immediate postoperative period versus the final outcome at 1-year postop and assess factors affecting it. A total of 87 consecutive patients of CPA tumor surgery were retrospectively analyzed between 2015 and 2023 to allow a minimum 12-month postoperative period. Tumor size, immediate postoperative House–Brackmann (HB) scale, and 1-year postoperative HB scale were analyzed. All patients with HB II and above were advised physical therapy. A statistical analysis was conducted to investigate any relationships with FN outcome. Eighty-seven patients underwent resection; 62% had vestibular schwannoma followed by nearly 9% each of meningioma, trigeminal schwannoma, and epidermoid. In addition, 80.5% were large tumors and did not have any statistical relation with outcome. FN continuity was preserved in all 100% patients. Furthermore, 32 (36.7%) had immediate postop facial paralysis. The severity of immediate postoperative paralysis had a statistically significant correlation with the final FN outcome (p = 0.006). Compliance with physical therapy improved the HB grade in 100.0% of the cases in a statistically significantly manner (p = 0.001). Use of IONM improves FN outcome by enabling anatomical continuity. FN function immediate postop can be used to predict long-term outcome. Counseling for continued physical therapy for at least 1-year postoperative period improves outcomes.

Abstract This article aims to summarize 22 years of pediatric experience using three generations of the Gamma Knife and show how technological advances in the machine have led to better safety, patient tolerance, and wide application.A retrospective review of Gamma Knife radiosurgery (GKRS) patients younger than 18 years, treated from 1999 to 2020, was conducted. Data points include primary pathology, age, lesion volume, radiation dose, fixation type, and single session versus hypofractionation. The Gamma Knife models used during this period were the Model 4C, Perfexion, and Icon, and we discuss the evolved planning and treatment delivery options.Fifty-five patients aged 2.8 to 18 years (49% between 15 and 18 years old) underwent 80 treatments: 55% of patients had tumors, and 45% had AVMs. A rigid frame was used for 49 patients; while six were secured with a thermoplastic mask, five patients had single session, with one having multiple treatments and one hypofractionation. In this group, six sessions were under general anesthesia and six with monitored anesthesia care. They presented mean deviation from the post-stereotactic registration baseline of 0.15 mm. The median dose was 20 Gy (8–28 Gy), and the median lesion volume was 1.066 cc (0.081–34.791 cc). No radiation-induced tumors have been detected in the follow-up so far.GKRS is a viable modality for pediatric patients needing intracranial radiation. A variety of tumors, as well as AVMs, can be treated. Some level of anesthesia/sedation is required for most patients. The advent of thermoplastic mask fixation has expanded the use of the Gamma Knife to younger patients.

Abstract Arteriovenous malformations (AVMs) present significant treatment challenges due to their hemorrhage risk and associated neurological deficits. Stereotactic radiosurgery (SRS) is a technique designed to obliterate AVMs while minimizing complications.This study aims to evaluate the obliteration rate and clinical outcomes of patients undergoing SRS using linear accelerators (LINAC) for the treatment of brain AVMs.This retrospective and prospective study included 56 consecutive patients who underwent SRS for AVMs between 2008 and 2021, with the study period till 2023. The mean patient age was 29.21 years (range: 8–67 years). Complete obliteration rates and clinical improvements were assessed, and statistical analysis was conducted using SPSS.The mean planning target volume was 11.39 cc (median: 7.74 cc) and the average modified AVM score was 1.79 (median: 1.56). The obliteration rate was 83.92%, with 7.1% of patients exhibiting residual AVM and 5.3% requiring surgical excision. Post-radiation hemorrhage occurred in 7.14% of cases.LINAC-based SRS proves to be a highly effective and safe treatment modality for small or surgically inaccessible brain AVMs.

Abstract Epidermoid cysts (ECs) account for 0.2 to 1.8% of all intracranial tumors and are even rarer in the cavernous sinus. They are benign with a favorable prognosis following surgical resection, but rarely can undergo malignant transformation to squamous cell carcinoma (SCC). We hereby report the first case of SCC arising in an EC of the cavernous sinus. A 40-year-old woman presented with recurrent cyst in the left cavernous sinus. Thirteen years ago, she underwent a surgery for EC at the same site. Histopathology of the recent resection showed features of a primary SCC arising from the EC, fulfilling the Garcia criteria for malignant transformation. SCCs usually involve the brain as a manifestation of metastases from a primary located elsewhere in the body or as a result of direct local spread from a head and neck primary. Primary intracranial SCCs are rare and usually arise from malignant transformation of benign epithelial cysts. It may present itself at the initial clinical presentation or may develop following a variable lag period (3 months to 33 years) after resection of a previous benign cyst and has a dismal prognosis. Clinically, rapid deterioration, recurrence, or failure to recover following surgery for a benign cyst along with contrast-enhanced computed tomography or magnetic resonance imaging findings on the lesion should raise suspicion for malignant transformation.

Abstract Spinal lipomas are a group of spinal dysraphisms that most commonly present as closed spinal disorders associated with tethered cord syndrome. This is a pilot study spanning over 4.5 years, accounting for around 40 cases, aimed to conveniently study the demographic profile of the incidence, age, sex, clinical features, surgical outcome, complications, and follow-up of patients with conus lipomas. Also reviewed were the benefits and risks of prophylactic surgery as well as early versus late surgery.It is a prospective cohort study of review of the cases conducted over 4.5 years (between January 2019 and May 2023) at the Department of Neurosurgery, IMS and SUM Hospital, Bhubaneswar, Odisha, India, with a broad literature review done using search words “Conus” <AND/OR> “Spinal” <AND/OR> “Lipomas” spanning over academic articles indexed in PubMed, PubMed Central, NCBI, Embase, Scopus, and Google Scholar. A few home research articles written previously by a senior author of the current article were also cited. Data analysis was done using SPSS 22.0 for Windows for statistical computing.There was a 1.2:1 male-to-female ratio. The most common age group of the patients ranged between 1 and 5 years. The commonest symptom was swelling in the lower back, and the commonest neurological involvement was motor deficit with bladder dysfunction, subjectively. Most patients remained neurologically intact postoperatively. CSF collection and urinary retention were the most common post-op complications observed.Symptomatic conus lipoma patients underwent surgery readily, given the deficits. However, looking into all the neurological deficits babies can develop in the long run, our study proposes prophylactic and early surgeries in even asymptomatic babies. However large-scale randomized trials should be undertaken to review the claim and advise accordingly.

Abstract Surgical resection of lesions occupying the incisural space is challenging and requires deep knowledge of the complex neurovascular and skull base anatomy. This video illustrates a case of incisural meningioma that was surgically resected using the extreme lateral supracerebellar infratentorial (SCIT) approach. A 49-year-old woman presented with a history of left-sided numbness, gait instability, and left trochlear nerve palsy. Neuroimaging demonstrated a left incisural meningioma with brainstem compression. Surgical management was indicated using the extreme lateral SCIT. Postoperatively, the patient showed good recovery with residual left trochlear nerve palsy that improved on follow-up. The extreme lateral SCIT approach provided direct access to the incisual space with minimal cerebellar retraction and favorable outcomes.