Dhananjaya Ishwara Bhat

Reproduced with permission from Hutchinson et al . Decompressive craniectomy versus craniotomy for acute subdural hematoma. New Engl J Med 2023; 388 :2219–29. https://doi.org/10.1056/nejmoa2214172. © 2023 Massachusetts Medical Society. Background: Traumatic acute subdural haematomas often require surgical evacuation via craniotomy or decompressive craniectomy. Decompressive craniectomy may prevent intracranial hypertension; however, it is unclear whether it is associated with better outcomes. Objective: Multicentre, pragmatic, parallel-group randomised trial to compare the clinical and cost-effectiveness of decompressive craniectomy versus craniotomy for evacuation of acute subdural haematomas. Design: International, multicentre, pragmatic, parallel-group randomised trial with additional observational arm. Setting: Hospitals with neurosurgical services in the UK and internationally. Participants: Patients aged ≥ 16 years, with a diagnosis of acute subdural haematomas on a computed tomography scan that required evacuation with a large bone flap either by craniotomy or decompressive craniectomy according to the opinion of the admitting neurosurgeon. Interventions: The enrolled patients underwent acute subdural haematoma evacuation in the operating room under general anaesthesia. A large bone flap ipsilateral to the haematoma was raised, the dura opened and the haematoma evacuated. Other haematomas, such as contusions, were evacuated at the discretion of the surgeon. If clinically appropriate randomisation occurred, the bone flap was either replaced (craniotomy) or not replaced (decompressive craniectomy). Patients who could not be randomised were followed up in the observational arm. Main outcome measures: Primary outcome measure was the extended Glasgow Outcome Scale assessed 12 months post injury. An economic evaluation (based on UK participants) was undertaken to estimate the cost-effectiveness of craniotomy compared to decompressive craniectomy. Results: Four hundred and fifty patients were randomised: 228 to craniotomy and 222 to craniectomy – with the common odds ratio for the differences across the Glasgow Outcome Scale scores of 0.85 [95% confidence interval (0.6 to 1.18; p = 0.324)]. The results were similar at 6 months. At 12 months, death occurred in 30.2% of the craniotomy group versus 32.2% of the decompressive craniectomy group, vegetative state occurred in 2.3% versus 2.8%, and good recovery occurred in 25.6% and 19.9%, respectively. In the observed cohort, those who had a decompressive craniectomy had significantly worse outcomes at 6 and 12 months, but their baseline characteristics were different. Limitations: Clinicians were not blinded to the trial groups. Decompressive craniectomy was performed in 8.8% of patients allocated to the craniotomy group, and 5.4% of patients allocated to the decompressive craniectomy group underwent craniotomy. Intraoperative non-adherence with allocation did not influence the primary analysis, which was based on the intention-to-treat principle. Conclusions: Among patients undergoing evacuation of acute subdural haematomas, the outcomes were similar in both groups. Additional surgery was required in a higher proportion of patients in the craniotomy group, but more wound complications occurred in the decompressive craniectomy group. Future work: Long-term outcomes of patients following decompressive craniectomy, timing and impact of cranial reconstruction on a patient’s rehabilitation. Trial registration: This trial is registered as ISRCTN87370545. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/35/57) and is published in full in Health Technology Assessment ; Vol. 30, No. 66. See the NIHR Funding and Awards website for further award information.

Dr. Vijay Kumar Kak, Emeritus Senior Professor and former Head of the Department of Neurosurgery at PGI, Chandigarh, left the earthly abode in the early hours of August 15, 2024. He was born in Saharanpur, Uttar Pradesh, and grew up in Allahabad, Kanpur, and Roorke. He was a distinguished alumnus of Agra Medical College and was a recipient of the Chancellor's medal in MBBS for having won multiple gold medals and distinctions and for being first in all the three professionals. After completing MS surgery in Agra, he trained in Belfast, Ireland, United Kingdom, for neurosurgery and obtained FRCS (Edinburgh) and FRCS (England). He joined PGIMER, Chandigarh, as an Assistant Professor of Neurosurgery. He was Professor and Head of Department of Neurosurgery till he retired in 1998. Following this, he was Director of Health Services and Director Principal of Chandigarh Medical College. He was also an honorary neurosurgeon to the armed forces. He was also the President of Neurological Society of India (NSI) and the Indian Society for Pediatric Neurosurgery (INDSPN). He was a Dr. B. C. Roy awardee. Prof. Kak was a legend in his own lifetime. Dr. Kak was a distinguished neurosurgeon, a revered educator, and a pioneering figure in the field of neurotrauma. His contributions to neurosurgery have left an indelible mark on the medical community, and his dedication to advancing the field has inspired countless students and colleagues. He quite a task master, always coaxing his residents to achieve the best. He inspired his team of colleagues, residents, and paramedical staff to excel. Under his tutelage, one learned that neurosurgery is a way of life, not just a superspecialty. Additionally, one learned to have courage in the face of adversity. He spoke his mind and was transparent in all his actions. His leadership at PGI, Chandigarh, was instrumental in establishing the institution as a center of excellence in neurosurgery. He taught his team not only to excel in medicine but also to be good human beings. With him, one learned the importance of communicating with the patient and their family, of informing the outcome of the surgery, and the value of documentation and publishing research. He had conducted original experimental work on cerebral ischemia, and many of his publications were included in textbooks. Throughout his illustrious career, Dr. Kak was known for his exceptional surgical skills, compassionate patient care, and unwavering commitment to medical education, research, and publications. Dr. Kak's legacy will continue to live on through the many lives he touched—both patients and the many residents he trained and mentored, as well as through the advances he championed in neurotrauma care. He will be deeply missed by his family, friends, colleagues, and the entire medical fraternity. Our thoughts and prayers are with his loved ones during this difficult time. Article published online: 31 December 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

Traumatic brain injury (TBI) is one of the biggest challenges faced by neurosurgeons globally. The Global Burden of Disease Study 2019 showed a 11.1% increase in the age-adjusted incidence rate of TBI (from 499 per 100,000 in 1990 to 554 per 100,000 in 2019) and a 22.4% increase in age-adjusted prevalence (from 818 per 100,000 in 1990 to 1,002 per 100,000 in 2019) in India.[1] This contrasts starkly with a 5.5% decrease in incidence and a 0% change in the prevalence of TBI at the global scale. Road traffic accidents account for the major proportion of head injuries.[2] A World Bank 2021 report showed that India accounts for almost 10% of global crash-related deaths, despite having only 1% of the world's vehicles.[3] For comparison, the United States saw 2.21 million accidents in 2018 resulting in 27,461 deaths, while India saw 480,652 accidents in 2018 (one-fifth of the number in the United States) resulting in 150,785 deaths (>5 times the number in the United States). More than half of these crash deaths affect pedestrians, bicyclists, and motorcyclists and greater than 66% occur in rural areas. The lack of access to trauma care, particularly neurotrauma care, is a major obstacle to prevention of these road traffic deaths. Other factors that contribute include the poor availability of ambulance and transport services, the absence of prehospital care, and, perhaps, most significantly, the lack of adequate health care resources for low-income households. Low-income households reported twice the number of deaths postcrash compared to high-income households.[3] The glaring issue is the dearth of facilities available for low-income patients and the overburdened state of the existing facilities. As the World Bank report points out, there is an urgent need to improve the accessibility and inclusivity of health infrastructure and coverage as well as improve postcrash emergency care. The WHO Global Status Report on Road Safety 2023 also highlights the disproportionately high number of fatalities in lower middle-income countries.[4] The highest number of fatalities occurred in the South East Asian region (330,222 deaths or 28% of the global burden). Only 35 countries have legislation mandating five core areas of safety equipment and India is one of them. India is also one of the 166 countries with specific legislation on drink driving, even though it does not meet the WHO best practice legislation of a blood alcohol concentration (BAC) limit of ≤0.05 g/dL for general driving population. India is also one of the 54 countries that meets the WHO best practice legislation for helmet use. Out of five WHO best practice laws, India meets two—related to helmet use and seat-belt use. There is no law related to speed limit and India does not meet the WHO criteria for drink driving or child-restraint system use. The mere presence of a law requiring a helmet for riding motorbikes does not ensure that such a practice is widely adopted. Studies show only 22 to 51% prevalence of helmet use among riders.[5] [6] [7] Helmets reduce the risk of brain injury by up to 74%.[4] The Motor Vehicle Act of India requires all riders of a motorbike who are older than 4 years to wear “protective gear” under Section 129. Section 138 of the Central Motor Vehicles Rule requires the provision of two helmets to buyers of two-wheelers. The low utilization rate of helmets despite the existence of these laws requires urgent steps to rectify the situation. One of the reasons that riders may choose not to wear a helmet is that they are just not convinced of the fact that a helmet is necessary and would confer significant protection against head injury. Another reason is the lack of stringent punishment for not wearing a helmet. In a few states, the fine for not wearing a helmet is only Rs. 500 and in Uttarakhand and Gujarat, the fines were lowered from Rs. 1,000 to Rs. 500. Only in Maharashtra, Bihar, Haryana, Tripura, and Assam is it possible to have your driver's license canceled if you are not wearing a helmet. Stringent punishment as well as regular checks by the traffic police may help ensure a higher helmet utilization rate, apart from community-wide awareness programs. Even the presence of such laws and regular enforcement may be insufficient until the riders themselves believe in the safety provided by helmets. The improper use of helmets by riders such as the use of half-helmets or the incorrect strapping of a helmet go on to prove that the riders are only willing to wear these helmets to avoid fines, rather than to protect their brains. Helmetless riders are not the only safety concern on Indian roads. Poor road quality, innumerable potholes, and lack of lane sense are some of the other contributors to frequent road traffic accidents. Two-wheelers, four-wheelers, trucks, and buses occupy the same lanes and drive at different speeds. Many cities lack a proper footpath infrastructure, jeopardizing the safety of pedestrians. There is an urgent need for the government to focus on improving road safety and infrastructure with a primary focus on preventing road traffic accidents. A multitude of measures have been instituted to combat the problem of neurotrauma over the last decade. A review by Veerappan et al described efforts made at the national and local level to address the burden of neurotrauma.[8] Programs to improve helmet use have been conducted at the regional level by Andhra Medical College in 2019. The Neurotrauma Society of India (NTSI), Neurological Society of India (NSI), Indian Head Injury Foundation, and SaveLIFE Foundation have developed educational videos encouraging the use of helmets among the public. As pointed out in a study conducted at National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, almost one-third of trauma patients present to the hospital more than 24 hours posttrauma, highlighting the necessity of both quicker hospital transfers and better...

Blast-induced traumatic brain injury (TBI) poses a significant threat to individuals exposed to explosive events. We hypothesized that blast-induced neurotrauma is an oxidative stress to brain and hence prolidase (PD) enzyme, which is an antioxidant is recommended; its serum levels are better markers of degree of injury in the acute phase for TBI in a rat blast injury model. Results revealed that PD enzyme activity in the hippocampus showed a slight increase across high, medium, and low blast pressures, but remained lower than the sham group. However, serum PD enzyme activity levels were significantly higher in the blast-exposed groups compared to the sham group. Tau protein levels were significantly elevated in the blast-exposed groups. Longitudinal analysis demonstrated a decline in hippocampal PD activity over time, while tau protein levels progressively increased, suggesting a shift from initial oxidative stress to neurodegeneration. These findings suggest that blast injury triggers oxidative stress and subsequent neurodegenerative processes. The correlation with tau protein levels further supports the involvement of oxidative stress in neurodegeneration. In conclusion, this study provides insights into the underlying pathophysiological mechanisms of blast-induced TBI and highlights the potential utility of PD enzyme activity as a diagnostic marker. Work discussed in this article was presented in the award paper category at NTSI conference Jaipur August 2023. ^* National Institute for Health and Care Research Collaborators, NIHR, Cambridge, UK Article published online: 29 April 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

Introduction The thecoperitoneal shunt is a modality of cerebrospinal fluid (CSF) diversion used to treat various clinical conditions such as idiopathic intracranial hypertension (IIH), normal pressure hydrocephalus (NPH), and CSF leaks. There is a wide variability in the data regarding the utility and complications associated with it. We thus reviewed the outcomes and complications of the shunt done in our setting. Methods The study is a retrospective review of all the thecoperitoneal shunts performed at NIMHANS (National Institute of Mental Health and Neurosciences) from January 2000 to December 2020. The demographic details, clinical profile, indications for the shunt, magnetic resonance imaging, follow-up and complications, and shunt revisions were collected and analyzed. Results Three-hundred twelve patients underwent shunt primarily at our institute. The mean follow-up of the patients was 5.2 years. The indications include pseudomeningocele in 31.4%, CSF leak from surgical site in 25.3%, IIH in 17.6%, and NPH in 7.3% patients.The shunt was more effective in pseudomeningocele in up to 95% and CSF leaks in 91% compared to 64‰ in IIH, though it is not significant (p > 0.05). The complication rate was 17% that included shunt block, wound CSF leak, infection, and subdural hygromas. The shunt malfunction was seen in 14.69% patients who underwent revision. Conclusion Thecoperitoneal shunt is a useful treatment option for various pathologies including IIH, NPH, and wound CSF leaks. They have good clinical outcomes and acceptable revision rates especially in conditions with slit ventricle. The complications such as low-pressure headache can be overcome by using adjuncts as programmable valve or antisiphon device.

Brain relaxation is an important requirement in intracranial neurosurgical procedures and optimal brain relaxation improves the operating conditions. Optic nerve sheath diameter (ONSD) is a non-invasive bedside surrogate marker of intracranial pressure (ICP) status. Elevated ICP is often associated with marked autonomic dysfunction. There is no standard measure to predict intraoperative brain condition non-invasively, considering both anatomical displacement and physiological effects due to raised ICP and brain oedema. This study was aimed to determine the usefulness of heart rate variability (HRV) parameters and ONSD preoperatively in predicting intraoperative brain relaxation in patients with supratentorial tumors undergoing surgery.This prospective observational study was conducted in a tertiary care centre. 58 patients with supratentorial brain tumors undergoing elective surgery were studied. Preoperative clinical presentation, computed tomography (CT) findings, ONSD and HRV parameters were assessed in determining intraoperative brain condition. Intraoperative hemodynamic parameters and brain relaxation score after craniotomy were studied. There was significant difference in CT grade, ONSD and HRV parameters in patients between lax and tight brain. A receiver operating curve was constructed to determine the cut off to predict intraoperative brain bulge. A CT grade more than 2, ONSD of greater than 0.63 cms and ratio of low frequency to high ratio (LF/HF) of more than 1.8 were good predictors of brain bulge. The changes in ONSD and HRV parameters, with the CT findings can be used as surrogate markers of increased ICP to help predict intraoperative brain condition.

Aim Giant pituitary adenomas are difficult to resect due to multicompartmental extension. We developed a new grading system for giant pituitary adenomas (GPAs) considering possible extension in superior, lateral, anterior, and posterior (SLAP) directions. We also related the degree of resection to the SLAP grading. Methods A review of case files and radiological images of patients with the GPAs defined as pituitary adenomas with a size of more than 4 cm in any dimension was done. The extent of the tumour was noted and scored as per the SLAP system. The maximum total score is 10 and represents a large tumour with maximum extensions in all directions. The subtotal resection (STR) was defined as a residual tumour volume of more than 10%. The association between individual and total score on the degree of resection was determined. Results A total of 103 cases of GPAs were analyzed. All patients had a suprasellar (S) extension. The lateral (L) extension was seen in 97.3% of cases. The anterior (A) extension was seen in 28 (27.2%) cases. The posterior (P) extension was seen in 45 (43.7%). Forty-eight (46.6%) had a total score of 5 or more. The STR was achieved in 64 (62.2%) cases. On regression analysis, a total score of ≥5 was associated with odds of 5.02 (1.69–14.93), p-value 0.004 for STR. Conclusion The SLAP grading is a comprehensive grading system that can be applied easily to the GPAs and gives a complete picture of the extension of the tumour.

High-grade gliomas (grade 3 and grade 4) are known to be highly locally invasive and distant metastasis though known, rarely manifest clinically due to poor survival. Recently, due to increasing su...