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Background: Surgical site infection (SSI) rates (1-9%) remain high despite the widespread adoption of infection control bundles. Topical vancomycin has emerged as an effective strategy to reduce the rate of SSI in patients undergoing spinal surgery including instrumentation. However, its use and efficiency in cranial neurosurgery is not well established. The aim of this study is to study the efficacy of topical vancomycin in cranial neurosurgery. Methods: A systematic search was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data regarding type of surgery, use of implants, the dose of vancomycin, technique of administration in each study, outcomes, rate of SSI, and the interval between surgery and SSI; possible complications related to antibiotic use were collected. Results: A total of 12 studies were included in the qualitative analysis with 3,446 patients. SSI developed in 1.6% of the patients in the vancomycin group as compared to 5.28% in the control group. The pooled risk ratio was 0.24 with 95% CI: 0.12-0.51 (P-value: <0.00001). The difference between the subgroups was significant (P-value: < 0.00001). The number needed to treat (NNT) was 27.2. The studies showed low heterogeneity with an I2 of 24%. Meta-regression analysis showed that the number of patients in a study, duration of follow-up, and year of publication did not contribute significantly to effect size. Conclusion: The limited systemic absorption of vancomycin and broad-spectrum led to its widespread applicability in the prevention of SSI in all types of cranial neurosurgery. Cases with implantable pulse generators, cranioplasty, and cerebrospinal fluid (CSF) diversion procedures have all demonstrated their unequivocal effectiveness.

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Cervical schwannoma excision usually involves laminectomy and violation of the facet joints that necessitates the need for fusion with consequent loss of cervical mobility. The authors present the first video demonstration of an excision of the cervical schwannoma at the C1-2 level using minimally invasive spine tubular retractors, which allows direct access to the lesion and prevents the need for any bony removal. It also preserves the paraspinal muscles, which are important for spinal stability, especially at the C2 level. Special attention is given to incision planning and preoperative image analysis for preventing injury to critical neurovascular structures at this level.

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Background: Brainstem gliomas (BSG) constitutes very small proportion in adults brain tumors with pons as most common location. There is significant paucity in literature for adult diffuse intrinsic pontine gliomas (DIPG). Objective: In this study, we attempt to review the outcomes of DIPG in single institute. Methods: We performed a retrospective chart review of adult DIPG from last 8 years (2010-2018) in a tertiary institute. DIPG was defined as expansile lesions involving more than 50% of the greatest diameter in the pons. Results: We found a total 46 patients with the diagnosis of adult BSG. Based on the definition, 23 patients with adult DIPG qualified to be included in the study. The median age was 32 years (IQR: 22-41), with a sex ratio of 16/7 (M/F). Cranial palsies were found in 17 (73%) patients. The median duration of symptoms was 6 months. On magnetic resonance imaging (MRI), contrast enhancement was found in seven (30%) patients. Biopsy was done in five patients. Median follow up was 11 months (IQR: 7-15). Median overall survival (OS) was 15 months (95%, CI 8.3-21.6). Fourteen patients had succumbed to death at the latest follow-up, and seven patients were alive. Median OS for the patients with age less than 40 years and more than 40 years was 7 and 22 months, respectively (p = 0.016). Rest of the variables did not effect OS significantly. Conclusion: Adult DIPG's significantly differs from pediatric counterparts in clinical characteristics, as well as OS. Age was the only factor which was significantly associated with survival in our study. Long-term studies with molecular profiling may help in further characterizing these lesions.

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OBJECTIVE: Choroid plexus tumours (CPT) are rare intraventricular tumours representing less than 0.5 % of brain tumours. The tumour is commonly located in the supratentorial region, but the location varies depending on the age. We present our experience of managing these tumours in a tertiary hospital. METHODS: Retrospectively, we reviewed our operative database and recruited 80 cases of CPT who underwent surgical treatment in our institute from 1995 to 2018. We analysed the factors affecting the outcome and the perioperative complications of the choroid plexus tumour. RESULTS: A total of 80 choroid plexus tumours were recruited in our retrospective review, of which 44 were choroid plexus papilloma (CPP), 13 were atypical choroid plexus tumours (ACPP), 23 were choroid plexus carcinomas (CPC). The mean age was 16.75 (SD 16.71) in the overall cohort. Males were found to be predominant in all tumour groups (M/F: 46/34). Headache was the most common symptom (52.5 %). Hydrocephalus was seen in 53.8 % of cases. The median overall survival was 89.88 months. Gross total resection was achieved in 62.5 % cases (n = 50/80), and near-total resection in 27. 5 % cases (n = 22/80). The median overall survival was 89.88 months. The median overall survival for CPP, ACPP, CPC was 106.83, 37.37, 36.19 months, respectively. Median Event-free survival was 65.83 months. A Cox regression analysis of predictors of overall survival of atypical CPP and CPC was done, in which age, sex, location, size, the extent of the resection, and complications were considered. The extent of the resection (p = 0.01) and the size (p = 0.02) were related to overall survival CONCLUSION: CPT's are the rare intraventricular tumours, which requires aggressive resection strategies. The extent of resection offers survival benefit based on the histological grades.

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Objective Despite the technological advancement in imaging, digital subtraction angiography (DSA) remains gold standard imaging modality for spontaneous subarachnoid hemorrhage (SAH). But even after DSA, around 15% of SAH remains elusive for the cause of the bleed. This is an institutional review to solve the mystery, "when is second DSA really indicated?" Methods In a retrospective review from January 2015 to December 2017, we evaluated cases of spontaneous SAH with initial negative DSA with repeat DSA after 6 weeks to rule out vascular abnormality. The spontaneous SAH was confirmed on noncontrast computed tomography (NCCT) and divided into two groups of perimesencephalic SAH (PM-SAH) or nonperimesencephalic SAH (nPM-SAH). The outcome was assessed by a modified Rankin's score (mRS) at 6 months postictus. Results During the study period, we had 119 cases of initial negative DSA and 98 cases (82.3%) underwent repeat DSA after 6 weeks interval. A total of 53 cases (54.1%) had PM-SAH and 45 cases (45.9%) had nPM-SAH. Repeat DSA after 6 weeks showed no vascular abnormality in 53 cases of PM-SAH and in 2 (4.4%) out of 45 cases of nPM-SAH. At 6 months postictus, all cases of PM-SAH and 93% of nPM-SAH had mRS of 0. Conclusion We recommend, a repeat DSA is definitely not required in PM-SAH, but it should be done for all cases of nPM-SAH, before labeling them as nonaneurysmal SAH. Although the overall outcome for nonaneurysmal spontaneous SAH is better than aneurysmal SAH, nPM-SAH has poorer eventual outcome compared to PM-SAH.

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OBJECTIVE: Patients with traumatic brain injury (TBI) often undergo repeat head CT scans to identify the possible progression of injury. The objective of this study is to evaluate the need for routine repeat head CT scans in patients with mild to moderate head injury and an initial positive abnormal CT scan. METHODS: This is a retrospective study of patients presenting to the emergency department from January 2016 to December 2017 with Glasgow Coma Scale (GCS) scores > 8 and an initial abnormal CT scan, who underwent repeat CT during their in-hospital medical management. Patients who underwent surgery after the first CT scan, had a GCS score < 9, or had a normal initial CT scan were excluded. Demographic, medical history, and physical examination details were collected, and CT scans were reviewed. Radiological deterioration, neurological deterioration, and/or the need for neurosurgical intervention were the primary outcome variables. RESULTS: A total of 1033 patients were included in this study. These patients underwent at least two CT scans on an inpatient basis. Of these 1033 patients, 54.1% had mild head injury and 45.9% had moderate head injury based on GCS score at admission. The most common diagnosis was contusion (43.8%), followed by extradural hematoma (28.8%) and subdural hematoma (26.6%). A total of 2636 CT scans were performed for 1033 patients, with a mean of 2.55 per patient. Of these, 25 (2.4%) had neurological deterioration, 90 (8.7%) had a progression of an existing lesion or appearance of a new lesion on repeat CT, and 101 (9.8%) required neurosurgical intervention. Seventy-five patients underwent surgery due to worsening of repeat CT without neurological deterioration, so the average number of repeat CT scans required to identify one such patient was 21.3. On multiple logistic regression, GCS score at admission (p = 0.024), abnormal international normalized ratio (INR; p < 0.001), midline shift (p = 0.005), effaced basal cisterns (p < 0.001), and multiple hemorrhagic lesions (p = 0.010) were associated with worsening of repeat CT, neurological deterioration, and/or need for neurosurgical intervention. CONCLUSIONS: The role of routine repeat head CT in medically managed patients with head injury is controversial. The authors have tried to study the various factors that are associated with neurological deterioration, radiological deterioration, and/or need for neurosurgical intervention. In this study the authors found lower GCS score at admission, abnormal INR, presence of midline shift, effaced basal cisterns, and multiple lesions on initial CT to be significantly associated with the above outcomes.

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