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   Table of Contents - Current issue
January-June 2022
Volume 10 | Issue 1
Page Nos. 1-62

Online since Thursday, September 22, 2022

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Robotics in cerebrovascular and endovascular neurosurgery: Current applications and prospective for the future p. 1
Jaspreet Singh Dil
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Microsurgery for anterior communicating artery aneurysms: One size does not fit all p. 3
Adesh Shrivastava, Suresh Nair, Rakesh Mishra
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Indocyanine green fluorescence video angiography – An indispensable tool for avoiding vascular complications during microsurgical clipping of ruptured intracranial aneurysms and improving surgical outcome: A preliminary study p. 9
Ashish Acharya, Sarvpreet Grewal
Background: The surgical complications in aneurysmal microsurgical clipping are attributable primarily to vascular compromise and retraction injury. The vascular complications almost 50% of these. ICG-VA gives us intraoperative real-time high definition functional imaging of the cerebrovascular tree, thereby allowing immediate quality assessment and control of aneurysm obliteration and parent vessel optimisation. Here we report our preliminary data of an ongoing series of patient study. Objective: This study aims at evaluating the role of ICG VA in avoiding vascular complications during microsurgical clipping of ruptured intracranial aneurysms and ascertaining normative data for ICG dye administration. Materials and Methods: The study aimed at determining the utility of microscope incorporated (Leica M530 OHX microscope) ICG VA in ruptured aneurysm surgery. We used ICG-VA in 17 patients of ruptured aneurysm with WFNS grade 1 and 2 as an adjunct to surgery. We studied multiple patient characteristics, intraoperative ICG peak flow and washout time of dye, and changes made in the operative decisions, and outcome of the surgeries. Results: ICG-VA helped in intraoperative decision making for 5 out of 17 patients. In one patient, inadequate clipping with residual neck was confirmed with ICG-VA and the clip was adjusted. In three patient's perforator/additional vessel compromise was found hence needed clip readjustment, whereas in two patients ICG-VA demonstrated residual filling of large neck sac and 2nd clip was applied in tandem. Conclusion: ICG VA is a conclusively simple adjunctive tool for the early detection and prevention of vascular compromise of multiple vessels and perforators during ruptured aneurysm surgery.
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Judicious use of temporary clipping on atheromatous vessels and avoidance of its complications in aneurysm surgery: A single-centre experience p. 14
Ganesh Kumar Manoharan, Rjvv Prasad, S Senthil Kumar
Introduction: Since the invention of aneurysm clipping surgery, temporary clipping of proximal vessels has been an integral part of the surgery. Temporary clipping provides adequate control of the proximal vessel and allows the surgeon to clip the aneurysm more confidently. Whereas, its complications are numerous, and one has to be very conscious in applying temporary clips, especially over the atheromatous vessels. Methods: A cross-sectional observational study was conducted on 50 cases of intracranial aneurysms operated at the study centre, wherein temporary clipping is used, and atheromatous proximal vessels were seen and noted. intraoperatively. Post-operative complications in these cases were noted. Results: The atheromatous proximal vessel as identified intraoperatively was seen in 60% of the cases. The mean age of the study population was 55.86 years. About 32% of the study population were male. The average body mass index of the study population was 24.5. 72% of the study group were hypertensive and 44% were diabetic. About 48% of patients presented with the World Federation of Neurosurgical Societies Grade 2. About 88% of the aneurysms were in the anterior circulation, with a mean size of <7 mm, and mean neck size was 4.8 mm. The average frequency of usage of temporary in each case was 3.08 times, and the longest clip used was for 8 min. The complications encountered in post-operative period were multiple lacunar infarcts (12%), massive infarcts along the parent vessel (4%) and vasospasm (16%). Conclusion: Temporary clips are notorious for causing thromboembolism and strokes when applied on atheromatous vessels. One must be careful while applying it and try to use other methods like adenosine in facilitating aneurysm clipping.
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Cardiac standstill and neurosurgery: A much-needed collaboration for complicated vascular procedures p. 17
Rachna Wadhwa, Daljit Singh
Complex intracranial aneurysm (ICA), large arteriovenous malformations and skull base tumours require absolute clean operative field and can be a battle of nerve testing at time due to torrential bleed. As such, there are various ways to reduce blood loss; however, maintaining cerebral perfusion during bleeding is a challenge. Currently, adenosine, hypothermia with cardiopulmonary bypass and rapid ventricular pacing (RVP) are options adopted at various places. Which one to choose may be a difficult preposition as there are several factors in its determinacy. This systematic review conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines evaluated 52 full-text articles for 2000–2022. A search of PubMed was done with keywords adenosine OR, hypothermia, OR RVP, OR cardiac stand still and ICA [All Fields]. Case reports and only abstracts were excluded. After exclusions, 26 articles were analysed. The relevant information for each modality has been tabulated. Adenosine produces short asystole as compared to RVP. Adenosine can be repeated if need arises. For hypothermia and RVP, one would need a good set-up with intense monitoring and complex logistics. There can be many complex situations where neurosurgeons may still need any of the above methods to choose for variable reasons or indications. Choosing any of the above methods is largely guided by individual set-ups; however, the use of adenosine seems to be simple and easy.
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Anesthetic management of intraoperative rupture of intracranial aneurysms p. 26
Harpreet Kaur, Harkomal Kaur
Intraoperative rupture of cerebral aneurysm is still the most commonly encountered fearsome complication that leads to subarachnoid hemorrhage and can be life threatening. Despite the advances in medical equipment and procedures, its incidence has not changed much in the past two decades. This article aims at reviewing the existing literature and describes the challenges faced by the diagnostician, surgeons, and anesthesiologists. It delineates the preoperative and perioperative factors that influence the rupture of cerebral aneurysm intraoperatively and further sketches the management of the same. A series of 129 articles related with the topic were searched from PubMed, Cochran, and Google databases to review the factors affecting the intraoperative rupture and its management. These factors were then collaborated and reported in this article to provide concise information on the topic that can direct the improvement in patient outcomes and management. This review concludes that thorough knowledge of the pathophysiology of intraoperative cerebral rupture and identifying the risk factors is the mainstay in better patient outcome. The management of this fearsome complication demands a synergistic approach from the surgeon, neuroradiologist, and the anesthesiologists.
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Distal anterior cerebral artery aneurysms: A brief review p. 35
Sumeet Narang, Jaspreet Singh Dil, A Raja
Distal anterior cerebral artery (DACA) aneurysms or pericallosal aneurysms are defined as aneurysms arising from any part of the A2 up to the A5 segments of the anterior cerebral arteries. They are relatively uncommon and have unique salient features that are pertinent to its accepted surgical management, hence requiring strong theoretical and conceptual knowledge. The objective of this study is to provide a comprehensive review and discussion on DACA aneurysms, from its nomenclature, anatomical characteristics and its impact on the pathophysiology, to the data on surgical management and outcome, and essential considerations required in the microneurosurgical approach, and to summarise the subject in a sequential and wholesome manner for a neurosurgeon at any stage of the career. Extensive review of available literature and surgical experiences published in indexed journals, was consolidated into concise text. DACA aneurysms represent about 6% of all intracranial aneurysms, and A3 aneurysms are the most common subtype. They have been identified at a mean age of 50 years, women more commonly affected, and found to be associated with other intracranial aneurysms. Patients present with subarachnoid haemorrhage in the distal interhemispheric fissure and pericallosal cisterns along with intracerebral and intraventricular haemorrhage in the vicinity of the frontal lobes, most commonly with Hunt and Hess Grade 2. The majority of such patients managed with surgical clipping had complete occlusion achieved in 67% and favourable outcome achieved in as many as 94%, versus a mortality rate of as high as 70% in conservatively managed cases, making surgical clipping through the interhemispheric approach is the preferred treatment modality. DACA is microsurgically interesting and challenging due to its peculiarities in anatomy. Microsurgical clipping of DACA aneurysms has been proven by literature, and tested by time, to be safe and have a favourable outcome, and hence must be taken up with clarity and vigour.
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Mirror Aneurysms of the Distal Posterior Infereior Cerebellar Artery (PICA): A Case Report and Review of Literature p. 41
Roopesh V R. Kumar, Venkatesan Sanjeevi, Arunkumar Karthikayan, Adhithyan Rajendran
Mirror aneurysms of the distal posterior inferior cerebellar arteries are extremely rare. We report a young female with bilateral aneurysms of the cortical segment of the posterior inferior cerebellar artery (PICA) with subarachnoid haemorrhage managed by microsurgical clipping of both the aneurysms in a single stage with excellent outcome. The management dilemmas and the risk factors of the mirror aneurysms of the distal PICA are also discussed.
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Bilateral putaminal haemorrhages – unearthing a myth, lessons learnt p. 44
Rajesh Parameshwaran Nair, Lakshman I Kongwad, Vinod Kumar, Ajay Hegde, Raghavendra Nayak, R Girish Menon
Primary multiple spontaneous intracerebral haemorrhages (MSICHs) are a cryptic entity that is very less understood since they are sparsely encountered in clinical practice. MSICH has been deciphered and defined as 'two discrete primary intracerebral haemorrhage occurring simultaneously or within 24 h since the first identified intracerebral haemorrhage. Primary MSICH is sporadic and has a reported incidence varying from 0.75% to 3% of all spontaneous intracerebral haemorrhage; however, the trigger for such bleeds is yet to be ascertained. We present our clinical experience with six cases of MSICHs. A retrospective analysis of data from the Medical Records Department of Kasturba Medical College, Manipal (KMC, Manipal), spanning from 2016 to 2017 and collecting the data of all the patients with the diagnosis of bilateral putaminal haemorrhages who have been treated/operated in KMC, Manipal. SPSS software was used to analyse the data and determines the correlation between the variables. Simultaneous bilateral basal ganglionic bleeds are rare but carry a grave prognosis. The exact pathophysiology is unknown but is probably related to long-standing hypertension. The treatment essentially involves primary prevention with strict control of hypertension and minimising the risk factors. SICH are very rare forms of intracranial bleeds and are often associated with high morbidity and mortality. Often seen in the basal ganglia or thalamus, the mechanism and predisposing factors still remain elusive. The varied clinical presentation and uncertainty in ideal treatment still leave a lot to subjective protocols of individual surgeons. The jury is still out in this matter.
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Syndromic association of spinal arteriovenous malformations: CLOVES syndrome p. 49
Mahesh Mahajan, Daljit Singh, Harkaran Singh Sahni, Sumit Bhandari, Dheeraj Vishwakarma
The study design was a case report of spinal cord arteriovenous malformation (SCAVM) with various associations. The objective of this study was to demonstrate the need to identify atypical clinical associations with spinal arteriovenous malformation and their staged management. A 19-year-old boy was diagnosed with SCAVM after paraplegia and bowel bladder disturbances. However, a complete diagnosis of SCAVM with its syndromic association helps to treat the patient in holistic way. The correct diagnosis of SCAVMs and their type is difficult. Complete diagnosis relies on radiological investigations as well as detailed examination. The early and complete diagnoses of SCAVMs are important because patients are likely to have better functional statuses after treatment if their pre-treatment deficits are relatively mild.
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Cerebral Hemispheric Infarct Following Ipsilateral IntraCerebral Haemhorrhage: Case Report and Review of Literature p. 53
Sumeet Narang, Jaspreet Singh Dil, A Raja, Sumeet Kaur Dil
The authors report the development of a cerebral hemispheric infarct in a patient who was diagnosed to have an intracerebral haematoma and neurologically worsened in the first 6 h. The occurrence of such a phenomenon is rare and scarcely reported. Possible explanations for the development of ischaemia in such a setting have been discussed based on existing literature.
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Delayed bleeding of femoral artery pseudoaneurysm: A rare complication of endovascular technique p. 56
Shankara Ram Choudhary, Bhanu Pratap Singh Chauhan, Sunita Chaudhary, Wajid Nazir, Daljit Singh
Femoral artery pseudoaneurysm is the most common complication of femoral artery access. Since the 1990s, the most common access site for intracranial endovascular interventions has been the femoral artery. The incidence of pseudoaneurysm has been documented around 0.2%–0.5% following diagnostic procedures and up to 8% following therapeutic interventions. This study aimed to assess the rationale of observation of pseudoaneurysm and the risk therein. A 52-year-old female presented with a subarachnoid haemorrhage and basilar artery aneurysm. Endovascular coiling was done using the standard technique on the right femoral artery percutaneous access. On post-operative day, she had swelling in the right groin region with bluish discolouration of the skin. Later on, a necrotic skin patch developed. On palpation, tenderness and pulsatile mass were present. Colour Doppler and computed tomography angiography were suggestive of pseudoaneurysm. On post-operative day 24th, the patient developed sudden onset of bleeding and haematoma expansion. The patient was taken for emergency surgery with primary repair of pseudoaneurysm with bilobed skin graft for closer of skin defect. Pseudoaneurysms at the puncture site can increase during observation, can bleed and may require curative repair.
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An intracerebral sporadic mixed cavernous angioma: An extremely rare entity with review of literature p. 60
Shirish Sahebrao Chandanwale, Ruchi Samir Randive, Rakesh Kumar Rashmi, Rajeshwari Ravishankar, Shraddha Ramadhar Yadav, Nirali Patel
Cerebral vascular malformations are non-neoplastic lesions resulting from focal anomalies in the development of cerebrospinal circulation. They tend to be asymptomatic, but in 40% of cases, they can be symptomatic; the four morphological types have been described in standard surgical pathology textbooks such as capillary, cavernous, venous and arteriovenous malformations. Mixed types are very rare and remain exceptional. Computed tomography (CT) and CT angiography lack sensitivity and specificity for accurate diagnosis. Magnetic resonance imaging is the choice of diagnostic modality. A conservative approach is observed in asymptomatic patients. Microsurgical resection is the only definitive treatment in symptomatic patients for supratentorial lesions. Due to the heterogeneity of this entity and ongoing debate about ontogenesis, diagnosis and management, we report the case of an 18-year-old boy who presented with a history of seizures for 3 years.
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