Sanjay Behari

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% were male. Pre operative embolization was employed in 44%, predominantly S2E0V1 lesions which correlated with eloquence (p = 0.005) and nidus size > 3 cm (p = 0.04). Gross-total resection was achieved in 9% (41/45). New neurological deficits occurred in 1% overall but were permanent in 7%. Favourable mRS (≤ 2) improved from 7% pre-operatively to 4% at one year. Engel I seizure freedom reached 3%. Only baseline mRS > 2 independently predicted unfavourable outcome (adjusted OR 20.0, 5% CI 3.7-108.2; p = 0.001). Modern microsurgery supported by selective embolization, neuro-monitoring and indocyanine-green video-angiography delivers high cure and low permanent morbidity for most SM-III AVMs. Functional prognosis depends chiefly on baseline status, underscoring the value of early referral.

Purpose 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). Methods 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. Results Thirteen patients with HRVA on twenty-three sides (n = 23/88.4%) were analyzed, with a mean age of 29.7 ± 13.5 years and a follow-up duration of 10.9 months (95%CI:5.8–16.0). the cohort has type-2 (n = 13/56.5%) and type-3(n = 10/43.5%) HRVAs with mean “a” and “e” parameters as 4.4(2.3) mm and 2.5(± 1.2) mm, respectively. 47.8% (n = 11) of the HRVAs had an anomalous course (PFCIA) and 77.8% (n = 14) were dominant/co-dominant. There was a significant improvement in Nurick’s grade (4.69 ± 1.0 vs. 3.0 ± 0.9), atlanto-dental interval (8.9 ± 3.0 mm vs. 2.7 ± 1.4 mm), and basilar-invagination [6.3 mm (95%CI4.4-8.3) vs. 0] postoperatively (p-value < 0.01). The medial and cranio-caudal angulations of C2-DPS were 20.4 ± 6.2 degrees (range 8.5-32.1 degrees) and 21.4degrees (95%CI:13.3–21.1). The effective screw length was 20.2 ± 2.6 mm. No incidence of implant failure or associated complications was noted. Conclusion The study demonstrates the effectiveness and safety of the C2-DPS technique in managing complex bony CVJ anomalies with PFCIA and HRVA. It provides a greater effective screw length and a robust construct in a wide spectrum of anomalous CVJ.

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.

Malignant tumors of sinonasal region are rare and affect less than 1 in 100,000 people per year. They are histologically diverse group and potentially pose significant management problems due to their proximity to the orbit and intracranial cavity. Although squamous cell carcinoma (SCC) is most common malignant tumor of paranasal cavity, tumors like adenocarcinoma, olfactory neuroblastoma, malignant melanoma, adenoid cystic carcinoma, sarcomas, haemoproliferative tumors, e.g. lymphoma may also occur. Retrospectively study was done in a tertiary care institute from January 2008 to December 2018 in India. Inclusion criteria—all biopsy proven PNS malignancy patients operated by endoscopic approach, irrespective of age and gender. Exclusion criteria- patients diagnosed with nasopharyngeal carcinoma, skin involvement, gross orbital involvement (muscle invasion), metastasis, operated by open approaches. 46 patients who underwent endoscopic tumor removal were reviewed. 36 (78.2%) were males and 10 (4.6%) females. Most common tumor in our study was adenoid cystic carcinoma. Recurrence was seen in 6 patients. Palliative therapy was given to all patients with recurrence. Management of malignant PNS tumor involving anterior skull base is multidisciplinary. R0 resection should be main goal in all malignant PNS malignancy. Tumors invading unresectable areas like cavernous sinus, brain parenchyma, carotids can be left in these places followed by palliation except in cases of squamous cell carcinoma. If R0 cannot be achieved surgically in SCC than patient should be considered inoperable and send for palliation. T1–T3 PNS malignant tumors can be managed by endoscopic approach followed by adjuvant therapy after a period of 6 weeks. Endoscopic excision should be converted to endoscopic assisted open approach in case of T4 tumors. We have tried to give a management protocol for management of malignant PNS tumors. Level of evidence: II.

Anatomical distortion directly affects the clinical status of patients with vestibular schwannomas (VSs). It may vary for a given tumor size due to variability in posterior fossa anatomy. We aimed ...

Orbit can be home for a spectrum of tumors with almost every orbital structure having the potential to harbor a neoplastic process. Surgical exposure and resection of orbital tumors can often be tricky due to the intricate anatomy of the region, with an additional complexity caused by a tumor related distortion. The clinical presentation depends on the primary structure involved and the location of the tumor within the orbit, and so does the scheme of management. Modern diagnostic imaging modalities offer a crucial pre-operative understanding of the precise location of the tumor within the orbit; it also helps in defining the nature of the tumor. Both these aspects are required for planning the appropriate surgical approach. Often, orbital tumors extend beyond the confines of the orbit requiring the tailoring of the surgical procedure, which may necessitate the involvement of a multidisciplinary team. The contemporary neurosurgical practice is also witnessing a progressive inclination towards minimally invasive endoscopic approaches, which have shown equally good if not better results in properly selected cases. Furthermore, early promising results with attempts at performing multisession stereotactic radiosurgery on orbital tumors has rekindled interest in this modality, in line with the management of intra-cranial tumors having a similar pathology. This article aims to recapitulate relevant surgical anatomy and to elucidate the current practice in the management of common orbital tumors encountered by neurosurgeons.

Background: Paraclinoid segment aneurysms arise from the internal carotid artery (ICA) between the distal dural ring and the origin of the posterior communicating (PComm) artery. Objective: This pictorial study presents videos showing clipping of paraclinoid segment aneurysms. Materials and Methods: The various subtypes of these aneurysms, the nuances in the technique of clinoidectomy, and methods of proximal control are presented. Results: Cavernous ICA is designated as C4, clinoidal segment (between the proximal and distal dural rings) as C5, and supraclinoid segment (between the distal dural ring up to the PComm artery as C6 segment. The techniques used for clipping various aneurysms are based upon their subtypes and location. In the first case, in a giant superior hypophyseal artery aneurysm directed toward the suprasellar region, an intradural clinoidectomy helped in accessing the neck of the aneurysm encroaching into the clinoidal segment of ICA. In the second case, concurrent bilateral “kissing” paraclinoid segment aneurysms were clipped using a unilateral approach. In the third case, clipping of a dissecting paraclinoid segment aneurysm is demonstrated. Conclusions: Surgery still represents the most definitive form of treatment. It may also be used to evacuate an intracerebral hematoma, with an extremely tortuous proximal vessel or in an aneurysm with complex anatomy, with blister aneurysms, or following aneurysm regrowth following a failed endovascular procedure. Assessing the three-dimensional anatomy of various segments of ICA is an important step.