Paraclinoid aneurysms, arising from the internal carotid artery between the proximal dural ring and the posterior communicating artery, pose significant microsurgical challenges due to their proximity to critical neurovascular structures. Despite advances in endovascular techniques, surgical clipping offers definitive exclusion with lower recurrence. This study evaluates surgical outcomes and operative nuances in clipping paraclinoid aneurysms over a 12-year period. A retrospective review was conducted of 116 patients with paraclinoid aneurysms who underwent surgical clipping at a tertiary centre between 2011 and 2023. Data on demographics, clinical presentation, aneurysm morphology, surgical strategy, and outcomes were analysed. The outcome was assessed using the modified Rankin Scale (mRS), with a favourable outcome defined as mRS 0–2. A p-value < 0.05 was considered significant. Informed consent was obtained from all the patients. Among 116 patients median age at presentation was 48 (38.25–59.75) years, 80.2

Spetzler–Martin (SM) grade III arteriovenous malformations lie at the borderline between low- and high-risk lesions, so their ideal management strategy is still debated. We aim to examine functional, angiographic and seizure outcomes after modern microsurgical treatment of SM grade III arteriovenous malformations (AVMs) and to assess prognostic factors within Lawton sub-groups. We retrospectively reviewed 45 consecutive SM grade III AVMs resected between January 2014 and December 2023. Demographics, nidus morphology, use of pre-operative embolization, surgical obliteration, complications, modified Rankin Scale (mRS) and modified Engel seizure class were recorded at discharge, 6 months and 1 year. Multivariate logistic regression identified predictors of unfavourable outcome (mRS > 2). Mean age was 26 years. 64

The study aims to assess a novel “direct C2 pedicle screw” (C2-DPS) insertion technique in mitigating vertebral artery (VA) injury in the case of high-riding vertebral artery (HRVA) and its application in a wider craniovertebral junction (CVJ) anomaly spectrum, including assimilated C1, C2C3 fusion, and persistent first cervical intersegmental artery (PFCIA). A retrospective analysis of consecutively operated cases of bony-CVJ anomaly with HRVA, from 2022 to 2025, was done. Patients who underwent posterior fixation by techniques other than C1 lateral mass and C2 direct pedicle screw insertion were excluded. Radiological workup included dynamic CT-CVJ, vertebral-angiograms, and MRI. The primary objectives were to assess the safety and screw profile of the C2-DPS technique, with secondary objectives focusing on clinical and radiological outcomes. A p-value < 0.05 was considered statistically significant. Thirteen patients with HRVA on twenty-three sides (n = 23/88.4

Postoperative vision loss following spine surgery is a rare and devastating complication with variable incidence. Various risk factors have been identified in the literature. A 16-year-old male presented with neck pain, spastic quadriparesis, and tingling paraesthesia in the left upper limb for the past 3 years. Radiological workup was suggestive of atlantoaxial dislocation with occipitalization of the posterior arch of the atlas (C1). The patient was prone to a horseshoe headrest and underwent occipito-C2-C3 fixation by removing the posterior rim of foramen magnum. Postoperatively, the patient complained of loss of vision in the right eye. Ophthalmology evaluation revealed a loss of perception of light in the right eye due to central retinal artery occlusion. An injectable steroid was started, but there was no improvement in vision in the involved eye. Proper head positioning and avoidance of intraoperative hypotension are modifiable factors to avoid such devastating complications.

Background Internal Carotid Artery (ICA) bifurcation aneurysms are relatively an uncommon entity. These aneurysm contributes less than 5% of the total intracranial aneurysms in the available literature. They are noticed in relatively younger population and their surgical management poses challenges due to close relation to the terminal branches and perforators in the adjoining area. The present retrospective observational study aims to describe the clinical and radiological nuances in the management of ICA bifurcation aneurysms. Methodology: All the operated cases of aneurysmal subarachnoid hemorrhage (SAH) managed between January 2017 to December 2023 were included. The clinico-radiological scan, including their three-dimensional computerized tomography (3-D CT) of cerebral angiogram was recorded. The intraoperative details of these patients were collected from the neurosurgery operative records. The patients' follow up details were obtained either by the outpatient department or by telephone. Results A total of 33 patients were analysed with a mean age of 44.9 ± 16.5 yrs years. Sudden severe headache and vomiting were the most common presentation. The superomedial orientation 14 (42.4%) was the most common projection of the aneurysm fundus. 27 patients (81.8%) have good outcome (mRS:0–2), six patient (18.2%) had bad outcome (mRS:3–6) and there was no procedure related mortality in this study. The mean follow-up duration was 24.5 ± 4.5 months (range: 8 months to 82 months). Conclusions ICA bifurcation aneurysm are challenging subset of intracranial aneurysms and it requires a detailed neuroanatomical knowledge and 3-dimensional orientation of the ICA anatomy before successful clipping of these aneurysms.

Purpose: To assess the accuracy of freehand cervical C1 C2 screws placement by knock and drill (K and D) technique in craniovertebral anomalous bony anatomy. Materials and Methods: From January 2017 to December 2022, 682 consecutive C1 C2 screws in 215 patients with craniovertebral junction (CVJ) anomalies were enrolled. All patients underwent posterior fixation with K and D technique without any fluoroscopic guidance. The patient's demographic details, clinical details, radiological details, major intraoperative events, and postoperative complications were noted. The screws malposition grades and direction on CT images in the axial and sagittal plane were defined as new per proposed “SGPGI accuracy criteria.” All patients had a clinical evaluation at 3-month follow-up. Results: Total 682 C1, C2 screws were placed in 215 patients for CVJ anomalies using K and D technique. The accuracy of screws placement by freehand technique was 84.46% (576/682). So with technique explained the rate of malplacement in simple (16.35%) and complex (15.19%) groups were almost comparable and comparison difference was not significant (P = 0.7005). Conclusion: The freehand technique, as described, is effective in cases of anomalous bony anatomy, and it is mandatory in complex CVJ anomalies. The accuracy of screw placement and VA injury is comparable with major studies. This technique is supposedly cost-effective and less hazardous to both health-care workers and patients.

Background: The ruptured anterior communicating artery aneurysm is the most frequent intra-cranial aneurysm treated at any neurosurgical department. These aneurysms arise from either the A1-A2-Acom artery junction or Acom artery. The surgical outcome depends on the age of the patient, time duration between ictus and surgery, and Hunt and Hess grade at admission. In this article, we intend to analyze the surgical outcome based on our proposed classification with our overall experience of Acom aneurysm. Methods: A retrospective review of our surgical database with 250 patients of ruptured Acom was done, and the location, morphology, and direction of aneurysm, along with other clinical parameters including the demographic profile, radiological findings, and intra-operative details, were studied. We classified the Acom based on both site of origin and morphology (Type I, junctional on the dominant side; Type II, fusiform with an ill-defined neck and branching pattern; Type III, saccular true Acom A) and secondarily as described in the literature on the basis of the direction of fundus (Type A–E). The clinical parameters were compared among the above groups using Fischer-exact and one-way analysis of variance test. Results: A total of 250 patients (M: F =113:137) were included (mean age 52.1 ± 11.5 standard deviation years). 55.2% patients had left A1 dominance. Type I Acom A was commonly found on the left dominant circulation (P = 0.00). The difference in aspect ratio of Type I (2.0 ± 0.8) and Type II (1.8 ± 0.52) aneurysms was insignificant (P = 0.28). However, a significant difference in post-operative vasospasm among different types of aneurysms was found (P < 0.05). The Type I Acom A were anteriorly directed, while Type II and III were posteriorly directed (P = 0.001). The mean follow-up of the study was 44.4 ± 25.7 months, with age (P = 0.007) and Hunt and Hess grade (P = 0.001) at admission correlating with surgical outcome. Conclusion: Classifying the Acom A pre-operatively based on site and morphology, location, and direction of fundus helps in surgical planning and prognosis. The junctional ‘Type IA aneurysms’ are most common and possess a high intra-operative rupture rate. The anteriorly directed aneurysms have a better prognosis, and visual complaints are usually associated with anterior-inferiorly directed aneurysms.

Proximal or A1 segment anterior cerebral artery (ACA) aneurysms are rare aneurysms. They have certain unique properties when compared to all other intracranial aneurysms. They are smaller and prone to an early rupture. Thus, they need an aggressive intervention even when they are less than 7 mm in size. The technical difficulties that arise in their management are based on their location along the length and circumference of the ACA. Accordingly, they have been variously classified in literature. Their intimate relationship to the medial lenticulostriate perforators and the recurrent artery of Heubner is the prime factor in determining the surgical or endovascular strategy and outcome. These aneurysms are commonly associated with vascular anomalies, needing a thorough interpretation of preoperative angiograms. Though there are many series reporting the clinical features and management outcome of proximal ACA aneurysms, all are limited by a small sample size due to the rarity of the pathology. In this article, the pertinent literature related to the surgical nuances associated with dealing with A1 segment aneurysms is reviewed. The clinical presentation, associated anatomical characteristics, microsurgical management, role of endovascular therapy, and outcome are discussed.

Objectives: Stereotactic biopsy (STB) is a potential diagnostic tool considering its minimal invasiveness, high diagnostic yield, and minimal associated complications. Over the years, various frame-based instrument systems and frameless stereotactic biopsy systems have emerged to be employed in clinical use. With this study, we intend to get more by doing less in the form of STB for the patients of doubtful intracranial lesions treated over the past 5 years. We also want to highlight the technique of performing the procedure under scalp block, which can be used as a versatile tool in many clinical scenarios. Stereotactic biopsies may be planned even in rural district-level health facilities. One-time investment to procure instruments and avail existing imaging can lead to establishing definitive diagnoses in many doubtful cases. This will result in lesser cost and early establishment of treatment. Independent risk factors determining the outcome, such as deep-seated lesions, associated edema, and intraoperative hypertension, were studied. Establishing the diagnosis helped in prognosticating the disease, explaining the natural progression of symptoms, and starting adjuvant therapy. This tissue biopsy would also help secure samples for research and molecular analysis. Materials and Methods: Twenty patients underwent STBs at our institution between January 2018 and December 2022. We retrospectively analyzed patient characteristics, tumor pathology, surgical procedures, and outcomes, including the diagnostic value and surgery-related complications. These patients were followed up, and their progression-free and overall survival were analyzed. The need for adjuvant treatment was noted and analyzed. All procedures were performed using Cosman Roberts Wells® stereotactic frame. Pre-procedure magnetic resonance scans were performed at the time of admission. Contrast-enhanced computerized tomography (CT) scan after frame application was performed to identify targets and calculate the coordinates. A post-procedure CT scan was done to confirm the accessibility of the targeted lesion. Results: The most common location of the tumor was a deep-seated thalamic lesion. A definitive diagnosis was established in 19 patients (95%) at the first STB. The diagnoses were glioma in 55% of cases, primary central nervous system lymphoma, tuberculosis, and demyelinating disorders in 10% of each, and a metastatic brain tumor in 1 (5%). The post-operative complications were all transient except in one patient with deterioration of motor weakness. The follow-up was noted, and modes of adjuvant treatment needed in these patients were recorded. Conclusion: Stereotactic biopsy is a useful and effective method for achieving a definitive diagnosis and aiding in treating multifocal or small deep-seated lesions in or around eloquent regions.

BACKGROUND/OBJECTIVE:Visual impairment affects 55%-80% of medial sphenoid wing meningiomas (mSWMs) patients, making optic nerve decompression a critical surgical goal. Complete resection often leads to better visual outcomes. However, involvement of critical neurovascular structures increases postoperative morbidity and mortality, with vascular injury reported in 18%-20% of cases. This study aims to evaluate the relationship between the extent of resection (EOR), visual outcomes, and the incidence of vascular injury, seeking to identify the optimal surgical approach for mSWMs. METHODS:We retrospectively analyzed data from patients undergoing surgery for mSWM at our tertiary care center from January 2001 to December 2021. Inclusion criteria included histopathologically confirmed globoid mSWMs (N = 89). Patients with recurrent tumors (n = 14) or lost to follow-up (n = 9) were excluded. We classified patients into 2 groups based on EOR using Simpson's grade: Group 1 (good-resection,Simpson Grade-I/II,n = 51) and Group 2 (poor-resection,Simpson Grade III/IV, n = 15). RESULTS:Among 66 (=N) patients, visual impairment was the most common symptom (81.8%), followed by headaches (77.3%) and seizures (27%). T2-hyperintensity on magnetic resonance imaging [(OR:5.4, 95%CI:1.5-18.6) (P-value<0.01)] and cavernous sinus-extension [(OR:3.9, 95%CI:1.1-13.1) (p-value-0.02)] were independent significant predictors of poor resection. Visual status was preserved in 90.3% of Group-1 and 86.6% of Group-2, with no significant difference based on EOR. Vascular involvement was noted in 87.9%, higher than the vessel encasement (>1800) (57.6%, P = 0.04). Vessel injury occurred in 7.8% of Group-1 and 6.6% of Group-2, with no significant impact on EOR. CONCLUSIONS:Cavernous sinus-extension and T2-hyperintensity predict poor resection rates in mSWMs. While visual outcomes are not directly affected by EOR, long-term visual status may decline due to tumor recurrence and radiotherapy. Vascular injury incidence is not associated with EOR. Thus, the "maximal safe resection" of mSWMs involves a surgical strategy balancing targeted aggressive and conservative resection for maximal cytoreduction and functional preservation.

Incidental atlantoaxial dislocation (AAD) is an obscure and abstruse entity. The level of evidence and studies concerning the management strategy of incidental AAD have been rarely published. It demands a thorough evaluation of facet joint alignment and anticipation of progression of the disease to prevent sudden neurological deterioration by acute dislocation. The primary conditions commonly associated with incidental AAD are congenital craniovertebral junction anomalies, rheumatoid arthritis, syndromic AAD, os odontoideum, Chiari malformation, and painless torticollis. The most common pathology among these is congenital AAD. We aim to broadly review the management of incidental AAD while focusing on its diagnosis, management strategies, and various atlantoaxial fixation techniques. Age, disease progression, and degree of instability are the highly essential factors that impact the management strategy. Asymptomatic and fixed variety of AAD can be treated conservatively under strict precaution. All the patients with neurological symptoms or significant neck pain, with radiological confirmation of reducible AAD (overt C1/C2 instability), should undergo surgical stabilization, preferably by the posterior C1/C2 fixation technique. Posterior C1/C2 fusion is still the gold standard for the surgical treatment of incidental AAD.

Fibrous dysplasia (FD) of bone is a rare benign condition, sporadic or congenital, where normal cancellous bone is replaced with fibro-osseous tissue with immature osteogenesis. The term “craniofacial fibrous dysplasia” (CFD) is used when FD lesions are in contiguity with craniofacial skeleton. CFD is a rare sub-type of all FDs involving skull base, facial bones, and calvaria. The disease may involve either a single bone (monostotic) or multiple bones (polyostotic). It may be associated with café au lait skin macules and endocrinopathy in McCune–Albright syndrome, or myxoma in Mazabraud syndrome. In our experience of 39 cases, CFD were analyzed with a mean age of 22.85 (range 8–55 years). Clinical presentations include vision loss (n = 7) and sensorineural hearing loss (n = 2) and cosmetic deformities (n = 28). A majority of cases were mono-ostotic (n = 24) followed by polyostotic (n = 15) FD. The surgical approach included craniotomy (25.6%), decompression (23.1%), shaving of the hyperostotic bone (17.9%), or biopsy (10.3%). This was followed by cranioplasty (10.3%) or contouring (5.1%). In the median follow-up of 11-years, a majority of patients improved (n = 19); the most common complication was wound bulge (n = 3). In our chapter, we have briefly discussed the pathogenesis, syndromic associations, and management principles In CFD. Despite being mildly symptomatic, they rarely present with a critical, craniofacial cosmetic disfiguremen. The overt presentations often warrant surgical intervention. Radiotherapy and chemotherapy do not play any role in the management of FD, and the former may increase the risk for malignant degeneration. Maximum safe resection improves the short-term outcome but a staged approach is required for the majority of patients.

Background: Studies on insular gliomas (IGs) generally focus on the oncological endpoints with a relative scarcity of literature focusing on the seizure outcomes. Objectives: To study the predictors of long-term postoperative seizure control in IG and propose a novel risk scoring system. Methods: Histopathologically proven, newly diagnosed adult IGs (>18 years) operated over a 10-year period were studied for postoperative seizure control as per International League Against Epilepsy (ILAE) grades at 6 weeks and at last follow-up (minimum of 6 months, median 27 months). Logistic regression analysis was performed and regression coefficients with nearest integers were used to build a risk prediction model. Receiver operator curve (ROC) analysis determined the predictive accuracy of this model. Results: The 6-week postoperative seizure freedom dropped to 41% at the last follow-up. The seizure-free group lived longer (100.69 months, 95% CI = 84.3–116.99 (60%)) than those with persistent postoperative seizures (27.92 months, 95% CI = 14.99–40.86). Statistically significant predictors (preoperative seizure control status, extent of resection, tumor extension to temporal lobe, and lack of postoperative adjuvant therapy) were used to compute a risk score, the score ranging from 0 to 9. A score of four most optimally distinguished the risk of postoperative seizures with an area under the ROC of 91.4% (95% CI: 84.1%, 98.7%, P < 0.001). Conclusion: In our experience, around 60% of patients obtained seizure freedom after surgery, which reduces over time. Control of seizures paralleled survival outcomes. Our proposed scoring system may help tailor management strategies for these patients.

Objective: We aim to find the temporal trend of incidence of post-resection cerebrospinal fluid (CSF) diversion (ventriculoperitoneal [VP] shunt/endoscopic third ventriculostomy [ETV]) in pediatric posterior fossa tumor (pPFT) patients with no pre-resection CSF diversion and the possible clinical predictors. Methods: We reviewed 108 operated children (age ≤16 years) with PFTs, from 2012 to 2020, at a tertiary care center. Patients with preoperative CSF diversion (n = 42), lesions within cerebellopontine cistern (n = 8), and those lost to follow-up (n = 4) were excluded. Life table, Kaplan–Meier curve, univariate and multivariate analyses were used to determine CSF-diversion-free survival and independent predictive factors, with significance defined as P < 0.05. Results: The median (IQR) age was 9 (7) years (M: F: 2.5:1). Mean (±SD) duration of follow-up was 32.43 ± 21.3 months. 38.9% of patients (n = 42) needed post-resection CSF diversion. Of these, 64.3% (n = 27) were done in early (≤ 30 days), 23.8% (n = 10) in intermediate (>30 days to ≤6 months), and 11.9% (n = 5) in late (≥6 months) postoperative period (P-value < 0.001). Preoperative papilledema (HR: −5.8, 95%CI: 1.7–5.8), periventricular lucency (PVL) (HR: 6.2, 95%CI: 2.3–16.6), and wound complication (HR: 3.8, 95%CI: 1.7–8.3) were found on univariate analysis as significant risk factors for early post-resection CSF diversion. On multivariate analysis, PVL on preoperative imaging (HR: −4.2, 95%CI: 1.2–14.7, P = 0.02) was identified as an independent predictor. Preoperative ventriculomegaly, raised intracranial pressure and intraoperative visualization of CSF egress from the aqueduct were not found to be significant factors. Conclusion: Significantly high incidence of post-resection CSF diversion in pPFTs occurs in early (≤30 days) postoperative period, with preoperative papilledema, PVL, and wound complication being its significant predictive factors. Postoperative inflammation, causing edema and adhesion formation can be one of the important factors for post-resection hydrocephalus in pPFTs.

BACKGROUND: Arachnoid cysts (ACs) are develop-mental anomalies formed by splitting the arachnoid mem-brane's layers. ACs contribute around 2% of all intracranial space-occupying lesions. ACs are more prevalent in children. Because of varied clinical presentation, there has been a constant need for clinicoradiologic risk stratifica-tion with a possible role in outcome prediction. The pre-sent study describes the management strategies and outcomes in symptomatic intracranial ACs.METHODS: All biopsy-proven symptomatic patients who -nderwent surgical management over last 15 years were included in this study (January 2008-December 2022), while those with non-conclusive biopsies were excluded. Patients presenting with acute deterioration were managed in the emergency department with or without cerebrospinal fluid diversion and decompression of the AC. The microsurgical or endoscopic approach was the preferred surgical modality. Postoperative clinicoradio-logic improvement was evaluated at 3 months follow-up visit.RESULTS: A total of 108 patients were analyzed in this retrospective observational study. The median age of the patients was 27.5 years (range, 1 to 76 years). Headache was the most typical clinical presentation. Supratentorial ACs (n = 59, 54.6%) were higher than the infratentorial ACs (n = 49, 45.4%). Forty-seven patients belonged to the pediatric age group (<18 years), and seizure was their presenting complaint. In this observational study, there was no statistical difference in operative duration between microsurgical technique versus endoscopic decompres-sion (P= 0.23).CONCLUSIONS: ACs are uncommon brain lesions having a broad spectrum of symptoms. The location and clinical presentation of ACs decide the preferred surgical approach. Individuals in high-risk groups must be treated on priority to achieve long-term relief of symptoms.

The rosette-forming glioneuronal tumor (RGNT) is an uncommon entity and carries a special character because of its mixed glial and neuronal composition in the histomorphological appearance. These lesions have a benign character and carry a good outcome if undergoes gross total resection. Over the past 15 years, there have been a significant change in their nomenclature depending upon the location to histological composition. Herein, we report an interesting case of a 26-year-old lady who was diagnosed to have the lesion at the septum pellucidum with significant symptoms in the form of headache and seizure episodes. A gross total resection was achieved and she made an uneventful recovery. We discuss the literature on the incidence, location, and histological characteristics of the RGNT in various age groups.

Background: Pediatric posterior fossa tumors (pPFTs) may present acutely with features of increased intracranial pressure that need urgent intervention or with stable symptoms requiring elective management. In this article, we have analyzed the outcomes of pPFTs managed under three arms: (1) emergency tumor resection (A), (2) elective tumor resection (B), and (3) pre-resection cerebrospinal spinal fluid (CSF) diversion followed by elective tumor resection (C). Materials and Methods: We retrospectively reviewed our database from July 2012 to March 2020 for pediatric patients (age <= 16 years) with PFTs. The patients were classified into three groups based on the timing and type of intervention. Their result was assessed as the primary (postoperative complications) and secondary outcomes (post-resection CSF diversion, CSF diversion failure, residual tumor, and survival). A P value < 0.05 was considered significant (SPSS version 22.0, IBM, New York). Results: A total of 154 patients (M:F = 2.42:1) were included with a mean age of 8.1 (SD +/- 4.2)-years (range 1-16). Group B (n = 72/46.8%) had a significantly higher number of patients as compared to the group A (n = 40/26%) and group C (n = 42/27.3%) (chi(2) test, P value = 0.02). The primary outcomes were comparable between group A and group B. A higher incidence of preoperative external ventricular drain insertion and post-resection CSF diversion failure was noted in group A as compared to group B (P value < 0.01). Group C had a significantly higher proportion of patients with residual tumor (n = 19/48.7%) as compared to group A (n = 11/29.7%, P value = 0.09) and group B (n = 20/ 29.4%,P value < 0.05). The post-resection CSF diversion failure rate was significantly higher in group C than in the other two groups (P value < 0.05). Conclusion: The pre-resection CSF diversion subgroup had a poorer outcome as compared to elective and emergency tumor resection. The outcomes of elective and emergency resection of pPFTs were comparable, except for the higher risk of shunt failure in the emergency cohort.