Unlocking in COVID Times: The Neurosurgical Way

The humankind is facing one of the worst nightmares in the form of the ongoing Corona crisis. The pandemic has spread all across the globe and we are struggling to deal with its might. All nations have made their own strategies to deal with this situation and mainly a phase of lockdown has been the savior in most countries, especially India, where it was enforced early and well in time. After a successful lockdown, there is a phase of unlocking, which is equally important. One should exercise caution in that this should be done gradually and phased, with all the precautions in place and without any complacency. Neurosurgeons are faced with a situation pertaining to those afflicted by posterior fossa lesions with hydrocephalus. They are treated with ventriculoperitoneal shunt, but sometimes they develop reverse tentorial herniation. This needs prompt evaluation and intervention and carries a poor prognosis if untreated. Another situation is where bifrontal contusions need decompressive surgery; some patients develop encephaloceles and extradural hematomas following successful surgery and complicate the prognosis. Both situations emerge due to sudden decompression, leading to quick changes in brain pressure and perfusion. The solution is slow and careful decompression, with all precautions in place despite the temptation of eureka moments. A similar response could be desirous over the course of our unlocking period. Hope this wisdom brings us good results in these Corona times.

Intracerebral hemorrhage with tentorial herniation: Conventional open surgery or emergency stereotactic craniopuncture aspiration surgery?

Background To observe the therapeutic effect of conventional decompressive craniectomy with hematoma evacuation and frame-based stereotactic minimally invasive surgery (MIS) for supratentorial intracranial hematoma with herniation. Methods One hundred forty-nine patients with hypertensive ICH complicated with tentorial herniation were reviewed and analyzed in the present study. The intracranial hematoma was evacuated by emergency surgery within 6 h after admission. According to the authorized representatives’ wishes and consent, 74 of the 149 patients were treated by conventional decompressive craniectomy followed by hematoma removal, defined as the CDC group, and the remaining 75 patients underwent frame-based stereotactic MIS for ICH evacuation, defined as the MIS group. The intervals between the admission to surgery, the duration of surgery, the amount of iatrogenic bleeding, the occurrence of postoperative rebleeding, and the recovery of neurological functions were compared between the two groups. All patients were followed up for 3 months. Secondary epilepsy, survival in a vegetative state, severe pulmonary complications, mortality, and activities of daily living (ADL) classification were also recorded and compared. Results The interval between admission and surgery, the duration of surgery, and intraoperative blood loss in the MIS group were significantly decreased compared to the CDC group. The mortality rate, the rate of rebleeding, prevalence of vegetative state, and severe pulmonary complications in the MIS group were remarkably decreased compared to the CDC group. In the MIS group, the survivors’ (ADL) grade also showed advantages. Conclusions In the surgical treatment of hypertensive ICH complicated with tentorial herniation, frame-based stereotactic MIS for ICH showed advantages compared to conventional open surgery.

Sunken Brain Syndrome

A 34-year old Chinese lady presented to the hospital in 2013 with acute left sided weakness and was found to have a right middle cerebral artery territory infarct requiring thrombolysis using intravenous alteplase. Her condition deterioriated post thrombolysis as it was complicated by right subdural hematoma, left parieto-occipital hematoma with mass effect and midline shift, for which she required urgent decompressive craniectomy and insertion of ventriculo-peritoneal (VP) shunt for hydrocephalus. Post-operatively she had severe physical and cognitive impairments. She was discharged home with a caregiver after an extensive period of inpatient rehabilitation. Repeated computed tomography (CT) brain between 2014 to 2016 revealed interval resolution of hematoma and stable hydrocephalus. (Figure 1). In late 2017 she was noted to have right gaze preference. Her Glasgow Coma Scale was 15 with no changes to her cognition or behavior. Blood pressure was 110/60 mmHg and pulse rate was 72/minute. Physical examination revealed concavity on the left temporalparietal region of the head. A repeat CT brain showed a concavity of the left craniectomy site suggestive of sunken brain syndrome (SBS) and progressive hydrocephalus from partial shunt blockage without trans-tentorial herniation (Figure 2). Prompt neurosurgical consult was sought and this was quickly followed with an acrylic cranioplasty and revision of VP shunt. She was reviewed post-operatively with resolution of right gaze preference.

Hydrocephalus in the Patient with Acoustic Neuroma

Hydrocephalus can occur in conjunction with large acoustic neuromas. Cerebral tentorial herniation and brainstem compression can be a complication of surgical excision. Three cases of hydrocephalus and acoustic neuroma are presented and therapeutic options are discussed. Ventriculoperitoneal shunting 1 to 2 weeks before translabyrinthine or suboccipital excision of acoustic neuroma is recommended.