Programme - Abstracts Book

WNWC-2020 Abstracts - Flipbook version:
(For other versions please see below)

The Abstract Book (Proceedings of the World Neurosurgery Webinar Conference 2020):

Abstract 1 [Poster]

Xanthogranuloma in the suprasellar region: a case report

Mechergui H, Kermani N, Jemel N, Slimen A, Abdelrahmen K, Kallel J

Neurosurgical department, National Institute of Neurology of Tunis

Contact: haifaamechergui@gmail.com; Tunisia

Conflict of interests: none

Objective: Xanthogranuloma, also known as cholesterol granuloma, is extremely rare. It represents approximately 1.9% of tumours in the sellar and parasellar region with 83 cases recognised in the literature. The preoperative diagnosis is difficult due to the lack of clinical and radiological specificities. Through this work, we report the third case of xanthogranuloma in the sellar region described in Tunisia.

Method: We report the case of 29-year-old girl who was followed up since 2012 for delayed puberty. The patient presented with a 1-year history of decreased visual acuity on the right side. On ophthalmological examination her visual acuity was rated 1/10 with right optic atrophy. Biochemical studies revealed ante-pituitary insufficiency. The MRI demonstrated a sellar and suprasellar lesion with solid and cystic components associated with calcification evoking in the first instance a craniopharyngioma. She underwent a total resection of the tumour by a pterional approach.

Result: The anatomopathological examination concluded the lesion to be an intrasellar Xanthogranuloma.

Conclusion: Sellar xanthogranuloma is a rare entity that is difficult to diagnose preoperatively due to its similarities with other cystic lesions of the sellar region, especially craniopharyngioma. The treatment is essentially surgical. A few rare cases of recurrence after complete excision have been described. Xanthogranulomas of the sellar region are reported to be predominantly located in the sella turcica, but should be included in the differential diagnosis even in cases of suprasellar mass lesions.

Key words: xanthogranuloma, suprasellar region, craniopharyngioma, cholesterol granuloma

Abstract 2 [Oral]

Surgical Treatment of Brainstem Cavernous Angiomas

Andrés Cervio, Maximiliano Nuñez, Sebastián Giovannini, Rubén Mormandi, Jorge Salvat

FLENI- Hospital del Cruce

Contact: acervio@fleni.org.ar; Argentina

Conflict of interests: none

Objective: Brainstem cavernomas (BC) are low flow vascular malformations detected incidentally or after bleeding and subsequent neurological deficit. Surgical resection continues to be the treatment of choice. However, cavernoma proximity to vital adjacent structures makes this surgery truly challenging. Recently, a variety of safe entry zones (SEZ) minimising risk of neurological damage during brainstem access have been described. We present a series of 21 patients with BC treated using these approaches

Method: Retrospective study of a series of adult patients (over 18 years of age) who after experiencing an episode of bleeding due to a BC, were operated on at our institution.

Result: Medical records from 21 patients who underwent surgery for BC between 2001 and 2019 were analysed retrospectively. Average patient age was 40 years and follow-up duration was 41 months. The most frequent symptom was sudden headache associated with CNS haemorrhage (66%), and the most frequent neurological sign was hemiparesis (53%). Most BCs were located in the pons (47%) Both telovelo-tonsillar and retrosigmoid approaches were used, most often through SEZs in the suprafacial triangle of the floor of the fourth ventricle, and in the peri-trigeminal area. Thirty-eight percent of patients were operated after the first episode of bleeding and 57% after the second. Gross total resection was achieved in 95% of cases. Finally, long-term follow-up showed neurological improvement in 71.4% of patients, stable outcome in 23.8% and worsening of symptoms in 4.7%.

Conclusion: At present, treatment of choice for BC continues to be surgical resection in well selected patients. Lesions causing minimal symptoms or without signs of pial-ependymal involvement may be followed conservatively with clinical and imaging surveillance. Detailed anatomical knowledge of the brainstem together with intraoperative neurological monitoring help to decrease postoperative deficits.

Key words: brainstem cavernomas, surgery, safe entry zone.

Abstract 3 [Oral]

Blood blister like aneurysm: general considerations and management

Leonidas Quintana

Cathedra of Neurosurgery, Valparaiso University School of Medicine, Chile

Contact: leonquin@gmail.com; Chile

Conflict of interests: none

Objective: Twenty-one cases of blood-blister like aneurysms (BBLA) are presented, 2% of 1,071 ruptured aneurysms treated in the last 23 years at Carlos Van Buren Hospital, Chile. Their aetiopathogenesis, topography, clinic and treatments are described.

Method: Aetiopathogenesis: 1-Acquired injury of the arterial wall as systemic hypertension with lipohyalinosis. and atherosclerosis with atheromatous ulcer. 2 - Hemodynamic stress of cerebral blood flow on areas with structural collagen dysfunction. Frequency 1- 2% of intracranial aneurysms. Location: 1-upper wall of the internal carotid, 2-segment M1 of middle cerebral a., 3-segment A1 of the anterior 

cerebral a., 4-segment V4 of the vertebral a.. Clinical picture: Posterior circulation: SAH of the posterior fossa. Anterior circulation: SAH related to dorsal ICA, parasellar HSA, frontal intracerebral haemorrhage. Treatment: Surgery and endovascular treatments. Surgery is limited to the expansion of a subadventicial arterial dissection with SAH. The surgical techniques used are: Aneurysm clipping, "Trapping" (with or without high-flow bypass) , Wrapping with muscle tissue or silk material and Arteriorraphy .

Result: Fourteen aneurysms of anterior circulation and 7 of posterior circulation were treated; in clinical WFNS II scale: 4 cases, in WFNS III :11 cases, in WFNS IV: 6 cases; Endovascular treatment was used in 9 cases, direct clipping in 8 cases, Trapping in 3 cases, Wrapping in 1 case. Good results were obtained (mRankin scale 1 and 2 ) in 11 cases. Bad results (mRankin scale 3 to 6) in 10 cases. (47.6%).

Conclusion: The treatment of BBLA is associated with a high rate of morbidity and mortality, due to a very high risk of intraoperative rupture of the aneurysm due to the fragility of the wall of the aneurysm and main artery, and high probability of losing the permeability of the main artery, inadvertently or as a consequence of the planned treatment.

Key words: blood blister like aneurysm, subarachnoid haemorrhage, intracranial arterial dissection

Abstract 4 [Flash]

Intracranial pressure monitoring (ICP) monitoring in traumatic brain injury adult and paediatric patients – Clinical significance

Karuppanan Bagathsingh, Krishnamoorthy Selvamuthukumaran

Meenakshi Mission Hospital and Research Centre, Madurai, India

Contact: kbagathsingh@yahoo.com; India

Conflict of interests: none

Objective: Every year we operated around 200 patients out of admitted 700 head injury patients. It is always difficult to decide in a group of patients whether to manage conservatively or, to operate. ICP monitoring is a very useful tool in this subset of patients. We want to report our experience of 25 patients during the period of 1 year.

Method: Twenty-five cases of ICP monitoring was done over a period of 18 months. The admission GCS was 3-7, 8-12,13-15. These patients have the CT scan findings contusions, 1. frontal, 2. temporal and 3. Parietal, cerebral oedema. Usually these patients are decided to monitor ICP in the interval of 0-6 hours after the admission. 

Most of the patients are inserted Codman ICP catheter in the operating theatre (OT); now we are inserting the catheter in the Neuro ICU through right frontal craniostomy under local anaesthesia. The follow-up CT are done on 48 -72 hours after the catheter placement. The ICP monitor is attached to the sensor after calibration and every hour we recorded the ICP measurement in the case sheet. We didn’t experience any procedure related complications in the operation theatre or neuro icu.

Result: Out of the 25 cases, 3 cases were taken up for the definitive craniotomy after ICP reading more than 20 mmhg. One case was expired due to sudden rise of ICP to 40 mmhg over a duration of 1 hour. All other patients are managed conservatively with minor procedure related morbidity . All these patients the ICP monitor is very useful tool to manage conservatively. We want to stress two patients of clinical significance.

Conclusion: ICP monitoring is very useful in the management of TBI. Now there is wide application of ICP monitoring in the neurosurgical field, TBI is the important and proved ICP monitor is very useful in managing the patients. There are various kinds of ICP monitoring; we use intra-parencymal pressure monitoring. From our data we want to conclude that in the clinical background of TBI, ICP monitoring is useful tool for the management of the patient.

Key words: paediatric trauma, ICP, clinical significance

Abstract 5 [Flash]

Haemorrhagic parasagittal meningioma

Joni Wahyuhadi, Rahadian Indarto Susilo, Irwan Barlian Immadoel Haq, Shaleh Drehem

Academic General Hospital Dr. Soetomo

Contact: shalehdrehem@hotmail.com; Indonesia

Conflict of interests: none

Objective: Meningiomas are one of the most commonly found intracranial tumours. Meningiomas are tumours that are often found and counted for 20-30% of primary intracranial tumours. The most frequent localisation of meningiomas is in parasagittal, lateral convexity, sphenoid wing, anterior fossa close to the olfactory nerve, sella region, and posterior fossa around the foramen magnum. Meningiomas with intra-tumoural bleeding are very rare and the pathophysiology is still not well known. The incidence of bleeding in meningiomas ranges between 0.5-2.4% with 28-50% mortality in the last third decade.

Method: A 38-year-old female suffered with a gradual decrease in consciousness since 2 days ago, headache (+) since 1 year ago and getting worse, weakness in left half of limbs since 1 year ago, decreased vision since January 2019. There’s no abnormalities for defecation and urination.

Result: The signs of increasing intracranial pressure are progressive. Headache complaints are also obtained. CT scan with contrast results showed a contrast enhancing lesion on parieto-occipital dextra impressing extra axial tumours with base in medial one third of superior sagittal sinus with peripheral oedema surrounding and accompanied by intratumoural haemorrhage.

Conclusion: In this case tumour resection craniotomy and osteoplasty were chosen to eliminate the symptoms of neurological deficit from the brain tumour itself.

Key words: meningioma parasagittal, intra-tumoural bleeding, craniotomy tumour resection, cranioplasty

Abstract 6 [Oral]

Lesioning for Tremor in the DBS era

Srinivas Dwarakanath

NIMHANS

Contact: dwarakaneuro@yahoo.com; India

Conflict of interests: none

Objective: Surgical management of tremor has evolved over the years with Deep Brain Stimulation (DBS) gradually supplanting lesioning as the mainstay in treatment. In this article, the largest of its kind from our country, we present our experience in the use of lesioning in the management of patients with multi-etiological tremors. These include not only common indications like Parkinson disease and essential tremor but also rare causes such as Pantothenate kinase-associated neurodegeneration (PKAN), multiple sclerosis (MS) and Wilson disease.

Method: Patients with medically refractory tremor who underwent surgery were included in the analysis. A comprehensive clinical and radiological evaluation was performed which was repeated 3 months post-operatively and at successive visits. Video documentation of was obtained at all visits.

Result: A total of 46 patients with an average age 37.7 years (range 21–65 years) underwent stereotactic thalamotomy/subthalamotomy at our institute between 2008 and 2019, for the treatment of medically refractory tremor of varying aetiologies. The mean preoperative duration of symptoms was 11 years (range 10 months to 34 years). The median time to onset of improvement was 2 months (range 1 week to 8 months). Analysing the improvement on the modified FTM scale, in part 1 the scores improved from 21.7 to 3.5, the part II subset improved from an average of 9.2 to 4.2 while the part III subset improved from an average of 14.1 to 4.6 postoperatively. This implied an excellent response in tremor while the other 2 components had a very good response.

Conclusion: In this study we have for the first time objectively analysed the tremor improvement with a modified FTM scale and have produced excellent results. We have also shown that tremor of various aetiologies respond extremely well to lesioning surgery. While DBS continues to remain the treatment of choice in various types of bilateral tremor, lesioning is very successful in a carefully selected cohort of patients. We are of the opinion that in predominantly unilateral tremor or when the patient cannot afford DBS especially in a country like ours, lesioning surgery is an important tool in the armamentarium of the functional neurosurgeon.

Key words: lesioning, Tremor, DBS, thalamotomy

Abstract 7 [Flash]

Association of May-Thurner syndrome in spine clinic

Rahul Srinivasan, Krishnakumar

Medical Trust Hospital

Contact: rahulmulund@gmail.com; India

Conflict of interests: none

Objective: May-Thurner is characterised by thrombosis of iliofemoral venous system, due to overlying Iliac artery compressing the Iliac vein. This is usually due to local vascular anatomical problem which predisposes to deep venous thrombosis (DVT) , termed as Classical MTS which was published in 1957 by May and Thurner. This remained a vascular phenomena for quite a few years until invention of CT and MRI. Of late there have been reports stating compression of vein due to degeneration of Lumbar spine mainly located to L5-S1 area. There can be plethora of aetiology from a simple osteophyte to complex sponylolisthesis. We at our institute report 2 examples each pertaining to vascular and lumbar spine aetiology and review of literature.

Method: We present case report, which include 2 patients with MTS. By various investigation we could differentiate the MTS into vascular and Lumbar degeneration related MTS. We also investigated them in detail to exclude routine DVT risk factors.

Result: Case 1 demonstrated a vascular phenomena, but was reviewed in the spinal out-patients clinic in view of the history of long standing low back pain for which she was put on traction. Case 2 demonstrated ventral osteophyte of L5 compressing the left iliac spine; he too presented to spine clinic with long standing back for which MRI scan was obtained. He later had left limb swelling and typical vascular claudication.

Conclusion: May-Thurner though caused by venous thrombosis of iliofemoral system can be caused by compression of Iliac artery as well as lumbar spine degeneration, It can commonly present to spine clinic with back pain which usually due to degeneration or as a sequelae to prolonged traction which might provoke deep vein thrombosis in already anatomically distorted vein

Key words: May-Thurner syndrome(MTS), deep vein thrombosis (DVT)

Abstract 8 [Oral]

Systematic review of Robotic Assisted Spinal Surgery: A hope to perform safe spinal surgery During COVID-19 and any other infective outbreaks

Noor ul Huda Maria, Qurrat ul Ain Siddiq

PINS/CPSP/HMS

Contact: drnoorneuro@gmail.com; Pakistan

Conflict of interests: none

Objective: To evaluate the role of robotic assisted spinal surgery during infective pandemics such as COVID-19

Method: Following the PRISMA guidelines a review of 18 articles on robotics in spine surgery was performed a thorough search was conducted on PubMed, Cureus and Researchgate and relevant data considering the learning curve, the duration of robotic assisted procedures, efficacy in terms of precision and accuracy according to the specified spinal procedures, the caveats and nuances of procedures, radiation exposure, feasibility of remote supervision, risk of infection transmission, cost effectiveness and reasons for robotic failure were sought for

Result: Out of the 18 studies, 11 evaluated precision and accuracy of spinal procedures and declared them lengthy yet precise. Five studies considered failures and complications and concluded again lengthy but with less failure and complications. Ten studies studied the radiation exposure hazard in terms of usage of fluoroscopy, the overall times range and indicated better risk profile. Ten studies examined the learning curve and concluded that it is same as that for MIS and is directly proportion to the experience of the surgeon. A surgeon who has previous experience of MIS will learn the robotic assisted surgeries in a shorter period of times. All studied the duration of procedures and 12 were convinced that it is longer or at the most equal, 2 said not much difference and 2 said that it shortens the procedure. 5 evaluated the cost effectiveness, since the equipment is still under developmental phases so despite our future expectations and goals of having the procedure as a cost effective one, we are by far lacking adequate experience to deem it one. 5 studies evaluated the risk of infection transmission and 1 was for specifically COVID-19 and they were all convinced that the risk of transmission of infection both airborne and blood borne is much lower, mainly due a reduced exposure between patient and health personnel which can both be adequately protected against infection.

Conclusion: Robotic assisted spine surgery can be a safe way to perform surgery during COVID-19 and any other infective outbreak condition

Key words: COVID-19, pandemic, robotic spine surgery, spine surgery, infections, safe surgery

Abstract 9 [Oral]

Open vs endoscopic assisted surgery for craniosynostosis in terms of blood loss, Infection risk and hospital stay: a study from a low-to-middle-income country (LMIC)

Noor ul Huda Maria

PINS/CPSP/HMS

Contact: drnoorneuro@gmail.com; Pakistan

Conflict of interests: none

Objective: To compare open vs endoscopic assisted surgery fro craniosynostosis in terms of blood loss, infection risk and hospital stay

Method: We studied 14 patients with age range 4-months to 11-months, both gender, non-syndromic craniosynostosis. Seven underwent classical open surgery while the other 7 endoscopic assisted surgery.

Result: For endoscopic assisted surgeries compared with open surgeries operating time was shorter (2 hrs 50 minutes vs 6 hours 15 minutes, P = 0.001), estimated blood loss was lower (87 mL vs 305 mL, P = 0.001), lower blood transfusion (90.6 mL vs 226.9 mL), shorter hospital stays (4 days vs 8 days, P = 0.001) however infection risk was 3% in both groups.

Conclusion: We conclude that endoscopic assisted approach for craniosynostosis is better than conventional open surgery in terms of blood loss, need of transfusion, operative duration and post-op hospital stay. However, in LMIC, endoscopic assisted surgical option is not widespread and it is being done sparsely

Key words: craniosynostosis, endoscopic, open surgery

Abstract 10 [Oral]

Body weight as factor for post-operative COVID-19 Infection Risk in pediatric patients

Noor ul Huda Maria

PINS/CPSP/HMS

Contact: drnoorneuro@gmail.com; Pakistan

Conflict of interests: none

Objective: To evaluate the link between body weight of paediatric patients between 1-year to 8-years of age and incidence of acquiring COVID-19 infection post-operatively

Method: The study was conducted from 15 March 2020 until 15 September 2020. A total number of 78 patients of both genders were enrolled. The age range was between 1-year to 8-years. Most of them were operated for paediatric intracranial tumours. Patients were stratified according to weight into below average, average and above average according to their age group standard weights.

Result: The mean pre-operative admission time was 4 days and, the mean post-operative time was 6 days. Mostly the patients were admitted for intracranial brain tumours: 57% cerebellar tumours, 18% craniopharyngiomas , 21% ventriculo-peritoneal (VP) shunt and 4% had surgery for tethered cord. All children were free of any other co-morbidity and no family member had history of COVID-19 infection. A total 16% children were above average and 24% were below average weight. Patients were kept for the shortest possible pre-operative and post-operative period and complete precautions against COVID-19 were taken. Patients were asked to follow-up initially for stitch removal and then after 2 weeks later. Other followup schedules differed according to diagnosis and state. All patients were told about the likely symptoms for COVID-19 infection and were asked to report in case they come positive. Only 9 patients (11%) patients were turned positive for COVID-19 with one turning positive pre-operatively. The surgery was postponed for 1-week only and, he was successfully operated after a week. The other 9 were tested positive for COVID-19 after being operated. Two patients had become positive on 2nd and 3rd postoperative day (POD)respectively. Three patient turned positive on 4th POD while 1 turned positive on 7th POD. Out of these n=9, 55.5% (n=5) belonged to below average weight while 22.2% (n=) were over weight. However , there was not much difference in the recovery time from COVID-19 and all of them recovered without any surgery related complications as well.

Conclusion: From this study we strongly suspect that preoperative body weight does pose risk to postoperative incidence of COVID-19 infection. We suggest further studies on this topic as well however we did not find any difference in recovery and complications

Key words: COVID-19

Abstract 11 [Oral]

Comparison of surgical versus Intradiscal Ozone treatment of sciatica due to lumbar disc herniation: Can It be an ideal option to Consider during COVID-19 pandemic?

Noor ul Huda Maria

PINS/CPSP/HMS

Contact: drnoorneuro@gmail.com; Pakistan

Conflict of interests: none

Objective: To compare the outcome of surgical versus ozone treatment of sciatica due to lumbar disc herniation in patients without severe myelopathy and cauda equina syndrome as well as to evaluate this management option as a safe option during COVID-19 pandemic

Method: The study was conducted over 1 year from January 2017 to January 2018. A total number of 72 patients were enrolled and divided equally into two groups based on those who underwent surgical treatment and those who were treated with ozone 

nucleolysis. Outcome was assessed using VAS ( Visual Analogue Scale) and a VAS <2 was considered satisfactory. Cases with severe myelopathy, cauda equina syndrome and calcified disc were excluded. During the COVID-19 pandemic we recovered data regarding any transmission risk between patients and the health personnel.

Result: n=36 (50%) patients treated with ozone nucleolysis method and n=36 (50%) treated with surgical method (hemi-laminectomy and discectomy). The mean age, height, weight, duration of disease, VAS score before and after treatment of the ozone nucleolysis group was 42.13±2.85 years,176.77±2.0 cm, 70.50±3.15 kg, 8.88±3.09 weeks, 41.11±2.20 mm and 14.16±6.77 mm respectively. Satisfactory outcome was observed as n=24 (66.7%) and n=13 (36.1%) for ozone nucleolysis and surgical group respectively. This difference was statistically significant (p=0.009).

Conclusion: Ozone nucleolysis treatment of sciatica due to lumbar disc herniation is a better option as compared with surgical treatment in cases of disc herniation without myelopathic signs and symptoms especially in early course of disease. This therapy is especially useful for patients who are at high risk for surgery.

Key words: COVID-19, Ozone nucleolysis

Abstract 12 [Flash]

Comparison of surgical clipping vs endovascular coiling for posterior projecting anterior communicating artery aneurysms

Noor ul Huda Maria

PINS/CPSP/HMS

Contact: drnoorneuro@gmail.com; Pakistan

Conflict of interests: none

Objective: To compare surgical clipping with endovascular coiling for posterior projecting anterior communicating artery aneurysm in terms of per-operative technical feasibility and possible complications such as rupture, peri-operative complications and postoperative mortality and morbidity

Method: The study was conducted at Punjab Institute of Neurosciences. Total 6 cases were studied, 3 of them

(n=3, 50%) were operated by surgical clipping and 3 (n=3.50%) underwent endovascular

coiling. Average age was 52 years; 90% had hypertension; 80% were smokers. All presented through emergency with subarachnoid haemorrhage. Two of the patients in each surgical and endovascular group presented at ER with Hunt and Hess grade 3 (n=2,33.3%) the others were at Hunt and Hess grade 2 (n=4,66.6%). The average time from haemorrhage to surgery and coiling was 25 days. Outcome assessed using modified Rankin score and a score of 2 was considered satisfactory.

Result: In the surgically treated-arm, 2 patients had mRS of 2 while the third patient had 4. In the endovascular coiling group 1 had mRS of 1, one patient had mRS2 and third patient had mRS of 3. Despite the very small sample size the outcome in terms of mRS indicated slightly better results for patients undergoing coiling

Conclusion: Endovascular coiling is better in the treatment of posteriorly projecting anterior communicating artery aneurysm.

Key words: aneurysm, endovascular surgery

Abstract 13 [Oral]

The era of web-based education during pandemic: do we need to listen to the call of the void to take the leap of faith?

Noor ul Huda Maria

PINS/CPSP/HMS

Contact: drnoorneuro@gmail.com; Pakistan

Conflict of interests: none

Objective: To evaluate the efficacy of web based neurosurgery education during pandemic and to consider integration of this teaching methodology as a part of postgraduate integration even after pandemic

Method: We conducted an online survey with the neurosurgery trainees and junior consultants regarding their views on how the new online educational activities have been successful in teaching. A total 237 responses from 57% trainees and 43% junior consultant neurosurgeons were received from 80 different countries.

Result: All respondents (100%) agreed that learning from daily ward experience alone, book alone and web based learning alone is not sufficient. Sixty-five point-five percent (65.5%) reported satisfaction with web-based and all (100%) agreement that ward based learning should be combined with textbook reading and web-based learning program. Eighty-four point-six percent (84.6%) of the respondents agreed that web based learning should be continued as a part of neurosurgical training even after the pandemic is over. Seventy-six-point-nine percent (76.9%) agreed that web-based learning should be integrated as a part of future neurosurgical training. Fifty-three-point-eight (53.8%) agreed that they do not have stress during web-based training program as compared to their traditional learning program. Thirty-eight-point-five percent (38.5%) agreed that they remain more attentive during web based training as compared to ward rounds and class. On a scale of 1-5, 38.5% gave grade 5 to web-based learning, 30.6% gave 4. Sixty-nine-point-two percent (69.2%) agreed that web-based learning cause them to learn more per duration spent during web-based learning program as compared to the number of hours spent with the conventional learning method

Conclusion: Web-based teaching is an effective method of teaching and should be integrated in the residency curriculum

Key words: web-based learning, web-based teaching, pandemic

Abstract 14 [Oral]

The effects of COVID-19 on Hypothalamus: is it another Face of SARS-CoV-2 that may potentially control the level of COVID-19 severity?

Noor ul huda Maria

PINS/CPSP/HMS

Contact: drnoorneuro@gmail.com; Pakistan

Conflict of interests: none

Objective: To evaluate the infliction of hypothalamus in COVID-19 Infection

Method: Twenty-seven (27) patients of COVID-19 were interviewed regarding symptoms referring to hypothalamus .Their charts were also studied

Result: In a short study, we detected at least 27 patients who suffered from “unquenchable thirst” and “ravenous appetite”. 7 of them were diabetic including 2 who were insulin dependent. Most of them did not develop severe COVID-19 . Polydipsia and polyphagia raise suspicion of hypothalamic infliction, since 

hypothalamus has centres of thirst, hunger and satiety. The interplay between stimulation and inhibition leads to the normal hunger and thirst sensations. We further noted that 21 of them had other signs and symptoms related with peripheral nerves. They all suffered from dysosmia and dysgeusia as well. If we put all of these symptoms together and correlate it with the viral entry through the nose, it is quite simple to explain that SAS-CoV-2 affects the olfactory nerve and from there finds its way to the hypothalamus.

Conclusion: We strongly suspect SARS-CoV-2 affects the hypothalamus

Key words: COVID-19, hypothalamus

Abstract 15 [Poster]

Paediatric epidural hematoma spontaneous resolution: a case report and literature review

Gabriela Ferreira Kalkmann, Nicollas Nunes Rabelo, Carlos Umberto Pereira

Federal University of Paraná; UniAtenas University Center; Sergipe Emergence Hospital

Contact: gabykalk@gmail.com; Brazil

Conflict of interests: none

Objective: Report a case of epidural hematoma (EH) with spontaneous resolution in a child, with good results.

Method: Paediatric male, 11 months-old, victim of a fall from a height of two metres. At hospital care, irritability, constant crying, swelling in the left parietal region, with a score of 13, on the Glasgow Coma Scale modified for children. He underwent cranial computed tomography (CT) that revealed a left parietal fracture, subgaleal haematoma, left parietal EH and left parietal intraparenchymal haematoma. After 14 hours, he showed improvement in his neurological status. The new skull CT scan did not show epidural hematoma. He was discharged in good general condition, with no evident neurological deficit for his age.

Result: Epidural haematoma (EH) after its formation, it is uncommon to have a conservative resolution in less than 24 hours. Being considered as spontaneous resolution when it occurs less than 72 hours after the traumatic event. The extracranial space does not present any resistance in relation to the existing intracranial physiological pressures, therefore, from the diastatic fracture line, unilateral conduction of blood volume will occur, reducing the intracranial amount of the lesion and increasing the subgaleal haematoma. EH with a clinical course of spontaneous resolution, will present the same symptoms associated with all types of epidural collections. The clinical presentation can be through loss of consciousness and vomiting. The diagnosis can be made using a simple skull radiograph, in which diastatic fracture will be seen in 81% of cases. Since this entity presents spontaneous resolution, the treatment is strictly conservative, often due to the delay in performing the surgical treatment.Conclusion: EH can be subjected to conservative treatment in selected patients and accompanied by intense neurological surveillance associated with neuroimaging, due to the increase in the volume of blood collection and worsening of the patient's neurological status. Spontaneous resolution is possible, especially in young children who have a diastatic fracture associated with haematoma. In our case, due to technical problems, the surgery was delayed and haematoma resorption occurred. The size of the haematoma and the neurological status of the patient are important characteristics during the treatment decision.

Key words: Conservative treatment, haematoma epidural neuroimaging.

Abstract 16 [Flash]

A single centre review of endoscopic third ventriculostomy (ETV) success rate

Vinodh Vayara Perumall, Nishanthi Apparow, Pulivendhan Sellamuthu

Department of Neurosurgery, Sabah Women & Children Hospital, Sabah, Malaysia

Contact: vinodh_uk@hotmail.com; Malaysia

Conflict of interests: none

Objective: -To evaluate various etiologies, surgical indications and patient outcome in relation to ETV.

  • To review ETV failure and shunt dependency.
  • End point:

To determine if the ETV success score can help determine the best candidates for this procedure in our local cohort as the original ETV success score only had predictive value of less than 60%.

Method: Location: Patients admitted & treated with features of hydrocephalus requiring cerebrospinal fluid diversion at the Department of Neurosurgery of the Sabah Women & Children Hospital in Sabah, Malaysia. Period : 1st April, 2017 – 31st March, 2020. Patient grouping and analysis: i. Types of underlying pathology; ii. Age (new born up to age 12 years old; iii. ETV for CSF diversion; iv. associated post surgical ventriculo-peritoneal shunt (VPS) dependency at 1 year.

Result: -Out of the total 43 patients, 15 showed failure requiring VPS by 1 year.

- ETV success score (ETVSS) of 70-90 showed high favourability among our patients. Reliability of ETVSS is proven.

- Overall success rate of ETV in our cohort is 65.1% which is better and comparable to published data on predictive value of ETVSS of 53-59%.

- Outcome of the procedure is highly dependent on the aetiology and age.

- Favourable outcome are seen in those of: Congenital cases especially in aqueduct stenosis (75.6%), tumours causing obstruction (65.1%)

- Poor outcome are seen in those of: infection (22.2% failure), children lower than the age of 1 (63.2% failure)

Conclusion: ETV done with the correct indication & technique becomes a valuable asset in reducing the requirement of VPS. ETVSS proves to be crucial in aiding decision making

Key words: endoscopic third ventriculostomy(ETV), ETV success score, ventriculo-peritoneal shunt dependency, hydrocephalus, CSF diversion

Abstract 17 [Poster]

Intra-operative monitoring for spinal tumour surgeries

Vinodh Vayara Perumall, Nishanthi Apparow, Pulivendhan Sellamuthu

Department of Neurosurgery, Sabah Brain & Spine Centre, Hospital Queen Elizabeth 2, Kota Kinabalu, Sabah, Malaysia

Contact: vinodh_uk@hotmail.com; Malaysia

Conflict of interests: none

Objective: • Intra-operative monitoring (IOM) is used as an adjunct to reduce post-operative morbidity secondary to spinal cord or nerve injury.

• It is important to determine the requirement of IOM in various types of spinal tumours namely Extradural extramedullary (EDEM), Intradural extramedullary (IDEM) and Intradural intramedullary (IDIM).

• The post surgical morbidity among patients operated with or without IOM needs to be analysed.

• Final aim: If IOM can be proven not essential for all types of surgeries; its usage can be minimised to reduce patient’s financial burden as IOM is expensive.

Method: All patients treated with spinal tumours from April 2015 - March 2019 at the Department of Neurosurgery, Sabah Brain & Spine Centre, Hospital Queen Elizabeth 2, Sabah, Malaysia were included. Patients were grouped and analysed according to the: i. location; ii. usage of IOM; iii. associated post-surgical morbidity. Due to our department’s financial constraint IOM is only used for IDIM tumours if the patient is able to self-fund the rental or purchase of IOM.

Result: Fiofty-six (56) patients were included with 33 primary spinal tumours, 17 metastatic tumours and 6 post infective tuberculous lesions.

- 36 patients presented with IDEM tumours, 12 with EDEM tumours and 8 with IDIM tumours.

- Out of the 8 patients with IDIM tumours, only 6 patients used IOM due to financial constraint.

- All patients with IOM usage had better Glasgow Outcome Score (GOS) compared to patients operated without IOM for IDIM lesions.

- IOM usage also showed improvement ASIA score at 6 months’ post-surgery.

- As for the IDEM and ED group of patients, all had good GOS without the usage of IOM.

Conclusion: An excellent knowledge of surgical anatomy and expert surgical skills are adequate for good outcome among EDEM and IDEM tumour patients.

- IOM is not essential for all types of spinal tumour surgeries and should be highly selective for IDIM tumours if financial burden is an issue.

Key words: Intra-operative monitoring, spinal tumours, ASIA score, intramedullary tumours, surgical morbidity

Abstract 18 [Oral]

Hippocampal RNA expression gene sets and biological pathways with prognostic value for seizure outcome following anterior temporal lobectomy with amygdalohippocampectomy

Albert Alan, Ryan Sprissler, Michael Hammer, Willard S Kasoff, Martin E Weinand

University of Arizona College of Medicine-Tucson

Contact: albertalan144@email.arizona.edu; USA

Conflict of interests: none

Objective: Approximately 1% of the U. S. population suffers from epilepsy. Among these patients, 30% are defined as medically intractable and thus potential candidates for epilepsy surgery, most commonly amygdalohippocampectomy (AH) with or without anterior temporal lobectomy (ATL) in temporal lobe epilepsy (TLE). Approximately 65% of patients treated with AH will be seizure-free. Therefore, there is need to improve prognostic value of selection criteria for AH surgical candidates. Thus, we pursue an approach known as neurosurgical genomics, where the identification of RNA-Seg biomarkers will establish gene expression profiles in patients with different seizure outcomes.

Method: Whole transcriptome analyses were performed to test the hypothesis that hippocampal tissue RNA expression differs between patients rendered seizure-free (SF) and non-seizure-free (NSF) to establish predictive prognostic biomarkers. A total of 14 patients (mean age: 33.1 years, range 16-56 years; 10 males, 4 females) with intractable TLE have undergone AH/ATL with 1-year minimum follow-up dichotomized into SF and NSF. Logistic regression analysis of Next Generation Sequencing reveals sufficient statistical power for hippocampal RNA expression data.

Result: Comprehensive analysis of hippocampal RNA expression revealed an upregulation in biological pathways consisting of glucuronidation, reproduction, and activation of matrix metalloproteinases prognostic for SF group. Likewise, an upregulation in biological pathways encompassing the innate and adaptive immune system prognostic for NSF group.

Conclusion: Hippocampal tissue RNA expression is expected to enhance selection of TLE surgery candidates by establishing predictive prognostic biomarkers for successful outcome from operative AH/ATL. This research seeks to improve our understanding of pathophysiological TLE over-activation of the innate and adaptive immune system. This increases the transcription of pro- inflammatory genes perpetuating hippocampal neuroinflammation by damaging endothelial cell tight junctions breaching the blood-brain barrier to transcellular leukocyte diapedesis influencing epileptogenicity and seizure onset.

Key words: medically intractable epilepsy, precision medicine, neuroinflammation, blood brain barrier permeability, neurogenetics, neurosurgery

Abstract 19 [Oral]

Impact of intra-operative ultrasound on outcomes in patients undergoing seizure surgery for focal cortical dysplasia

Albert A Sufianov, Keith Simfukwe, Salavat V Mirkhaidarov, Iurii A Iakimov, Olga NSadykova, Rinat A Sufianov, Galina, Sufianova, Vadim V Mochalov, Stefan Z Stefanov, Olga M Klimenko, Kevin Akeret, Niklaus Krayenbühl, Luciano Mastronardi, Luis A Borba

1)I.M. Sechenov First Moscow State Medical University, Moscow, Russia

2)Federal Centre of Neurosurgery of the Ministry of Health of the Russian Federation

Contact: keithsimfukwe@gmail.com; Russia

Conflict of interests: none

Objective: Approximately 50-60% of patients with focal cortical dysplasia (FCD) attain seizure freedom after epilepsy surgery. The main prognostic hallmark of a seizure-freedom outcome is attaining gross total resection (GTr) of the offending lesion of which in this case, FCD. Archiving GTr is often challenging due to the fact that normal and dysplastic brain tissue in frequent scenarios are indistinguishable. Additionally, during course of surgery, brain-lesion shifting might occur which in turn render technical challenges for the neurosurgeon. Intra-operative ultrasound (iUS) is a real-time, cost and user friendly tool that can be used to circumvent the earlier described challenges. Here we describe our single centre experience use of iUS postoperative outcomes in 24 patients. Additionally we explore and showcase literature in which iUS was successfully used and subsequently postoperative seizure freedom .

Method: Literature was extrapolated by utilising eLibrary, PubMed, and ClinicalKey. Parameters of individual patient data on demographics, baseline clinical (including seizure) characteristics, procedure-related factors, and outcomes, including new or persistent neurological deficits and final Engel score were documented and analysed. We also conducted a prospective & retrospective analysis of patients who were surgically treated for FCD in our institution.

Result: In total, 46 patients (inclusive of our patients) were included in this study (25 male; 21 female; mean age 18.0 years), among whom 32 (69.6%) had a seizure outcome of Engel I.This rate was superior to the 59.7% reported from a previously published meta-analysis of 15 studies encompassing 469 patients. Of the 27(58.7%) patients with preoperative neurological deficits, 4 had their deficits completely resolved, while 3 showed marked improvement. No deficits developed among the 19 patients (41.3%) with no pre-operative deficits. Statistically-significant predictors of Engel class I were FCD (p = <0.05) and clear intra-operative visualization of FCD with iUS (p = <0.05).

Conclusion: Based on our experience and data supplemented in literature, intra-operative ultrasound appears to be a safe, inexpensive and effective tool to achieve intra-operative FCD imaging during epilepsy surgery, a necessity for attaining GTr of epileptogenic tissue. Employing iUS during FCD resection surgery leads to achieving better post-operative seizer free outcomes in more than 3/4 of patients.

Key words: epilepsy,ultrasound, Engel

Abstract 20 [Oral]

The Incidence of spina bifida in Pakistan: The need to consider food fortification strategy

Noor ul Huda Maria

PINS,CPSP,HMS

Contact: drnoorneuro@gmail.com; Pakistan

Conflict of interests: none

Objective: To know the incidence of spina bifida in Pakistan in order to assess the gravity of situation and propose food fortification in order to decrease risk

Method: Based on institution based registered data from the leading hospitals with neurosurgical facilities and literature review. 230 registered cases of affected infants were studied, 80 adults were studied occult defects, and 10 studies were reviewed.

Result: Incidence of NTDs was found to be 7-8/1000 live births and 35% of them are spina bifida. The incidence of spina bifida occulta has been found to be 25%. 97% were lumbosacral. Female : male ratio was 1.2:1.0.44.5% had overt hydrocephalus on presentation. 85% survived 1-year and 71% survived 2 years. Not much data on long term survival was found. A post operative wound infection rate of 14.2% was found. 24.1% suffered from CSF leak. 2.1% had history of an affected sibling. 23.7% parents with an affected child and 45.3% of those with an already affected pregnancy were cousins so it was because of consanguineous marriage

Conclusion: The incidence of spina bifida is high in Pakistan which is a country amongst those who do not fortify food. It is time to raise awareness and highlight the need to fortify food, arranging awareness campaigns, providing antenatal and prenatal care and proper counselling for future pregnancies. There is a need to address the culture of consanguineous marriages as well

Key words: NTDs, Spina Bifida, folate

Abstract 21 [Oral]

Metabolism related genes profile as a prognostic biomarker source in primary Glioblastoma

Martin Colom, Julia Eva, Moya Trillo, Elena, Dorado Capote, Francisco Javier, Fuentes Fayos, Antonio Carlos, Solivera Vela, Juan

1. Neurosurgery department of Queen Sofia University Hospital, 14004 Córdoba, Spain.

2. Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), 14004 Cordoba, Spain.

3. Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain.

4. Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14004 Cordoba, Spain.

5. CIBER Physiopathology of Obesity and Nutrition (CIBERobn), 14004 Cordoba, Spain.

Contact: julia_mc92@hotmail.com; Bulgaria

Conflict of interests: none

Objective: Glioblastoma multiforme is the most common primary malignant brain tumour and the most devastating CNS tumour. Notwithstanding currently treatment strategies mean survival rate is estimated in 15 months after diagnosis. Due to the ineffectiveness of current treatments, it is necessary to find new tools that allow a better approach of this tumour types. In this sense, mutations on the Isocitrate dehydrogenase (IDH) gene, a key enzyme for the metabolism, have been demonstrated to be able to discriminate tumours based on their prognosis. However, there are still many unknown aspects of this mutation/tumour-prognostic relationship. Thus, the aim of this study is to determine the prognostic value of metabolism-related gene fingerprint for primary Glioblastoma depending on the presence of the IDH mutation type.

Method: In this retrospective study, 28 patients diagnosed with primary glioblastoma between 2016 and 2019 were selected. Intra-operative samples were obtained to isolate DNA and mRNA. Consecutively, IDH1 mutation were measured using a High-fidelity Taq-poymerase and 39 metabolism-related genes were studied by qPCR microfluidic array. Finally, univariant Kaplan-Meier study (according to Long-Rank and Breslow) and Cox regression were performed.

Result: Clinical data showed 19,6 months mean survival rate with a median follow-up of 19±2.14 months after diagnosis. The median age at diagnosis was 59±9 years, incidence was higher in females (56%) than males (46%) being 86% of lobar lesions. Moreover, total or subtotal surgical resection was carried out successfully in 94% of patients. Regarding molecular analysis, IDH1 mutation was found only in one sample, which had the longer survival rate (32 months). Furthermore, levels of ETNK1/GCK/GLS/GLUL/IGF1/PC and SHMT1 genes demonstrated a statistically significant (p<0.05) survival impact.

Conclusion: Taken together, our results demonstrate that genes involved in the metabolism of glucose, glutamine, GABA, adaptation mechanisms, cell proliferation and treatment resistance showed a significant relation with mean survival having a prognostic relevance in these patients.

Key words: metabolism, IDH, glioblastoma, gene

Abstract 22 [Flash]

Hallermann-Streiff Syndrome, congenital myth.

Oyeleye Egunjobi

Sacred Heart Hospital

Contact: leyemmanuel@yahoo.com; Nigeria

Conflict of interests: none

Objective: Hallermann-Streiff syndrome (HSS) is an absolutely rare condition that has a constellation of dysmorphic features which generally include abnormal development of the skull, face, hairs, skin, teeth, bones and eyes. These are genetic abnormalities that may be inherited in an autosomal dominant or recessive manner

Method: This is a case of a still born baby delivered in a secondary health care facility. The pregnancy history was significantly eventful events with Intra-uterine fetal death coupled with maternal complications. Physical examination of the baby revealed: fresh still born, frontal bossing of the skull, brachycephaly, beaked shape nose from lateral view, micrognathia, natal teeth, short webbed neck, dysmorphic chest, asymmetric nipple and abnormal thoracoabdominal orientation.

Result: In Hallermann-Streiff syndrome (oculo-mandibulo-facial syndrome), the exact cause is not known, there have been studies at the molecular level which revealed gene mutations. More so, defect of elastin and abnormal glycoprotein metabolism has been reported. Majority of the features seen in the index case are in keeping with another publication revealing that HSS is characterized by seven main signs; dyscephaly with bird-face and hypoplasia of the mandible, proportioned dwarfism, dental anomalies (absent, malformed or irregularly set teeth), hypotrichosis (particularly the scalp, the eyelashes and eyebrows), cutaneous atrophy (usually affecting the skin scalp, face and nose), bilateral micro-ophthalmia, and spontaneous resorption of the congenital cataract. Low resources in this case was a significant factor in assessing structural congenital intracranial comorbidities. There have been reports about HSS with agenesis of corpus callosum, the presence of non-decussating fibre bundles of Probst medial to the bodies of lateral ventricles and classical appearance of lateral ventricle.

Conclusion: This report is the first of its kind in our locality and aims to emphasise the pan-systemic (especially cerebro-facial)

complications of congenital anomaly stemming from late ante-natal care.

Key words: Hallermann-Streiff syndrome

Abstract 23 [Oral]

Assessment of the prognostic value of Helsinki computer tomography score in severe traumatic brain injury patients at Kenyatta National Hospital (KNH)

Mangar Dave, Musau Mmedck, Odhiambo A, Mwangi G

University of Nairobi

Contact: davemangar@gmail.com; Kenya

Conflict of interests: none

Objective: The broad objective was to investigate the prognostic value of the Helsinki Computer tomography (CT) score on the outcome of severe traumatic brain injury (TBI) patients at KNH at 6 weeks post-admission. Our specific objectives were to establish the baseline GCS, physiological parameters, demographic characteristics and presenting extra cranial injuries among patients admitted at the KNH after sustaining severe TBI, to evaluate the predictive value of the Helsinki CT score and the correlation between the admission Helsinki CT score and the clinical parameters on the outcome of severe TBI patients at 6 weeks post-admission.

Method: This was a prospective observational study conducted on severe TBI patients admitted at the Critical care Unit/ Intensive Care Unit after initial assessment and resuscitation at the Accident and Emergency department at KNH. This study included all patients with age above 18 years, severe traumatic brain injury patients with GCS <8 and who had informed consent availed from relatives/ guardians. This study excluded all patients without a CT scan done, non resuscitated patients and those with mortality before 24 hours of admission. Sample size – The minimum study sample population using the Fishers' formula was calculated at n=36 patients.

Data Collection tools and Methods – Consecutive sampling was used for recruitment of study population. At the point of presentation, the investigator interviewed the guardian to obtain the history of clinical presentation, physically examined the patient and recorded both the clinical parameters and radiological imaging findings using the study proforma. At follow up the investigator recorded the Glasgow outcome scale score at two weeks and six weeks. SPSS 23.0 was used to process the available information.

Study variables – The independent variable included demographic, clinical parameters and the Helsinki CT score. Patient characteristics were summarised using the clinical parameters of age, GCS, pupillary reactivity, blood pressure, blood glucose level and extra cranial injuries, and presented as means or proportioned for continuous and categorical variables respectively. The Glasgow outcome score (GOS) was dichotomised as unfavourable (grade I – III) and favourable (IV and V). Association of GOS with extra cranial injuries, blood pressure, blood glucose level, pupillary reactivity, GCS and the initial Helsinki score were done. Logistic regression analysis was used to determine the independent predictors of outcome. Receiver-operator characteristic (ROC) curve was drawn for sensitivity and specificity and AUC values were calculated. Confidence interval was calculated at 95% for sensitivity and specificity to determine the level of precision. All statistical tests were conducted at a 5% level of significance.

Result: Results - There was a higher male preponderance at 90% (n=38). Mean age for patients with severe TBI was 33 years old with an overall mortality of 64.3%. RTA was the commonest mode of injury at 64% followed by assault at 26% and falls at 10%. Patients with non reactive pupil had mortality of 67% while slow reacting pupil had 

63%. Patients with systolic BP > 90 mmHg comprised 95% of the study population with a resultant mortality at 67.5%. The most common random blood glucose level was < 10 mmol/l at 80% with a mortality of 58.8%. Patients with GCS of 3-4 had the highest mortality of 100% while GCS of 7-8 lowest mortality of 60.9%. GCS of 3-4 had no favourable outcome at 6 weeks while GCS 7-8 had favourable outcome in 30.4%. The Helsinki CT score of 4 had mortality of 33.3% while Helsinki score of 11 had mortality of 100%. Patients with contusions and intracerebral haematomas had mortality of 80% while in acute subdural haematoma and extradural haematoma the mortality were 53.8% and 44.4% respectively. In correlation analysis the Helsinki CT score was significantly associated with GOS at 6 weeks(p=0.004) and death (p=0.009). Age was significantly correlated with 6 weeks GOS (p=0.03) and mortality(p=0.02). Systolic BP was only associated with mortality at p value of 0.043. The other clinical parameters did not show any statistical significance with both 6 weeks GOS and mortality. The specificity, sensitivity and accuracy for Helsinki CT score for mortality were 88.9%, 53.3% and 71% respectively; and for an unfavourable outcome, these values were 81.8%, 55.6% and 69% respectively. After performing logistic regression analysis for the predictors of outcome, the odds ratio for the Helsinki CT score to predict mortality was 9.1(95% CI 1.9-44) and unfavourable outcome at 5.6(95% CI 1.2-27.4).

Conclusion: Severe traumatic brain injury is a frequent source of mortality and acquired persistent disability among young individuals. It affects more than just the injured person and robs the person of his income per year to sustain a family. The patients often require neuro-intensive care which is expensive in developing countries and burdens the health care resources. A significant proportion of patients (35.7%) were still dependent for care at 6 weeks post-injury.

The age of patient, the systolic blood pressure on admission and the initial Helsinki CT score are significant predictors of outcome(p < 0.05). The Helsinki CT score correlates well with the clinical parameters at predicting outcome. Hence, a change to new computer tomography scoring system may be warranted and the Helsinki CT score can be used as a predictor of outcome in the African subcontinent.

Key words: Helsinki computer tomography score, traumatic brain injury, prognostic value, neurotrauma, Glasgow Coma Score

Abstract 24 [Flash]

Anterior spinal cord fissuring: a predictor of spontaneous resolution of syrinx?

Kartik Manoj Multani, Boyina Jagadishwar Rajesh, Krishna Kumar, Anjani Kumar

Yashoda Hospital, Secunderabad

Contact: kartik.multani@gmail.com; India

Conflict of interests: none

Objective: Syringomyelic affliction of spinal cord is usually seen in association with variety of cranio-vertebral junction anomalies i.e. Chiari malformations, basilar invagination/impression, atlanto-axial instability etc. The natural history is not very clearly understood and a majority of patient present with slowly progressive neurological deficit followed by sudden rapid deterioration. At present, there is a general consensus to offer surgical decompression in all patients diagnosed with Chiari I malformation with Syrinx irrespective of their symptoms in order to prevent delayed neurological worsening. Few authors have reported spontaneous resolution of syrinx with persistent tonsillar herniation without operative treatment. We report one such patient and propose anterior spinal cord fissuring as a plausible cause of spontaneous drainage of syrinx. We also propose an idea to keep such patients with anterior spinal cord fissure seen in index scans to be followed up conservatively closely instead of upfront Chiari decompression

Method: Case report : A 21-year-old female with history of birth asphyxia had an episode of generalised tonic clonic seizure during sleep at the age of 12 years. She was evaluated with non-contrast computed tomography (NCCT) scan of brain in 2010 which showed area of hypodensities in left temporal lobe which were suggestive of ischaemic damage and patient was managed conservatively with anti-epileptics. In 2011 Patient had similar episode of seizures for which she underwent Magnetic resonance imaging (MRI) brain which showed gliosis in left temporal lobe and bilateral occipital poles along with an incidental finding of tonsillar herniation with no evidence of syrinx and a diagnosis of seizure disorder with Chiari I malformation was made (Figure 1). Patient had similar episodes infrequently for three consecutive years and had multiple changes of anti-epileptic medication regime by a neurologist followed which she was one-year seizure free.

In 2017, she again had an episode of GTCS and she was referred to neurosurgery OPD. MRI showed similar cranial findings as was seen in 2011 scan with cervical cord syrinx at C2, C3 level (Figure 2). Till date patient showed no high cervical cord or posterior fossa symptoms. Considering Chiari I malformation with a large syrinx, patient was advised Posterior Fossa Decompression with duraplasty but Patient was not willing and was lost to follow up.

She returned to our OPD after one year with willingness to undergo surgery in 2018. Till now, patient was asymptomatic for syrinx/Chiari malformation since her index visit. An MRI cervical spine was ordered as a routine preoperative imaging protocol. To our surprise MRI showed persistent Tonsillar herniation as seen in 2017 but no syrinx in cervical cord. (Figure 3). We retrospectively reviewed all the radiological investigations and found a fissure in substance of spinal cord anterior to syrinx which was connecting it to subarachnoid space in 2017 MRI study (Figure 4). During the course of her treatment she remained asymptomatic for cervical disease.

Result: Spontaneous resolution of syrinx with persistent tonsillar herniation in patients with Chiari malformation is very rare. Less than 10 such cases have been reported in literature till date. Role of abnormal CSF flow is very well established in development of syrinx but due to variable natural history of the disease, the correct pathogenesis and predictive factor for spontaneous resolution of syrinx is not clearly established. This uncertainty challenges the present recommended surgical treatment of syrinx in all the patients.

Conclusion: With our report, we propose spinal cord fissure as a predictive factor for spontaneous resolution of syrinx and recommend to keep such patients who are asymptomatic under follow up and not to consider surgery irrespective of the size of syrinx. Further studies including documentation of flow across such fissure with CSF flow study (CINE-MRI) is needed to support this evidence. Also, reduction of syrinx can result in increased space at craniospinal junction which can promote progression of tonsillar herniation and thus, we recommend to keep such patients in close regular clinicoradiological follow up to detect early worsening signs of tonsillar herniation even after complete resolution of syrinx.

Key words: spontaneous resolution of syrinx, syringomyelia, Chiari malformation, conservative management of Chiari with syrinx, anterior spinal cord fissuring

Abstract 25 [Oral]

Utility and pitfalls of high field 3 Tesla intraoperative MRI in neurosurgery: A single centre experience of 100 cases

Kartik Manoj Multani, Anandh Balasubramaniam, Boyina Jagadishwar Rajesh, M. Maila Sharath Kumar, Nitin Manohara, Anjani Kumar

Department of Neurosurgery, Yashoda Hospitals, Secunderabad

Contact: kartik.multani@gmail.com; India

Conflict of interests: none

Objective: In India, several centres are using iMRI system. Ours’ is the first centre to acquire high field 3 Tesla iMRI system. The aim of this paper is to share our one year experience with the implementation of 3T iMRI in neurosurgical procedures and to evaluate its use to improve our surgical outcomes in neuro oncological conditions.

Method: Prospective observational study conducted from August 2017 to July 2018 at Yashoda Hospital, Secunderabad. All patient undergoing 3T iMRI guided resection of ICSOLs were included in the study.

All iMRI were conducted using a 3 Tesla machine (MAGNETOM SKYRA, Siemens medical system, Erlangen, Germany). At our centre, the magnet is located in the room adjacent to neurosurgery operating room (OR) i.e. “NEAR BY OT TYPE”. Before the start of procedure, the patient is positioned on MRI compatible head pins (DORO LUECENT®) attached to sliding patient board on operating table (MAQUET MAGNUS OR TABLE SYSTEM™). All skin to skin contact surfaces is covered with cotton rolls. Navigation system is placed and virtual position of patient inside gantry is anticipated using Bore gauze which mimics MRI gantry size ([Figure 1A1a). ]. MRI staff is informed 30 minutes prior to expected arrival for intraoperative imaging. Routine imaging is withheld, and floor of MRI suite and corridor along with MRI surface is sterilized using Disinfectant (BACILLOCID®, Ramen & Weil). When the need for Intra-operative imaging is felt, the surgery is suspended and all the ferromagnetic instruments are removed from patient’s body and surgical site is packed with antibiotic incise drape (IOBAN-TM) after filling the surgical cavity with saline. Patient is wrapped in a sterile plastic drape and checked with a metal detector for any accidentally left metal instruments on patient’s body. The MRI machine has a detachable trolley which is wheeled in and docked to operating table. An iMRI checklist is filled by team of neuroanesthetists before transfer of patient to ensure patient, personnel and equipment safety

After checklist patient is transferred to iMRI trolley and shifted to MRI room through a dedicated sterile corridor. Once in the imaging suite, patient is connected to MRI compatible ventilator and monitors using compatible ECG electrodes and oximeters ([Figure 1B1b). ]. A team of dedicated neuroanesthetists and neurosurgeons observe the patient throughout and strict asepsis is maintained. The acquired images are analysed by experienced neuroradiologists and neurosurgeons for any residual tumour and complications like bleeding, infarcts etc. ([Figures 2, and 3)].

Following The following variables were recorded:; preoperative imaging diagnosis, presence or absence of residue in Intra-operative imaging, whether or not iMRI modified our surgical decision, complications and mishaps attributed to iMRI, time required to shift and time required for image acquisition.

The resection status based on iMRI was divided into three 3 categories. Patient with no residue in iMRI were classified as “primary gross total resection (GTR)”, patients with residues seen in iMRI and surgery was continued with GTR confirmed in post-operative post-operative scan were classified as “Secondary GTR”, patients with residue seen but decision of aborting the surgery or partial resection of residue was taken were classified as “Subtotal resection (STR)”, and the total number of primary and secondary GTR was termed as “Total GTR”

The data was recorded using a spreadsheet software (EXCEL, Microsoft, Redmond, USA) and was analysed statistically.

Result: A total of 100 patients with various intracranial SOLs were included in the study. Primary GTR was achieved in 44% (44/100) and residue was detected in 56% (56/100), secondary GTR was achieved in 37% (37/100) and decision of discontinuing surgery was taken in 19% (19/100), due to presence of tumour remnant in eloquent cortex or adjacent to major vascular structures. ([Graph 1)].

Out of 100 cases, the most common surgical indications were intra-axial SOLs (42%) and pituitary macroadenomas (30%) followed by other extra-axial lesions. iMRI was able to detect residues in 59.52% (25/42) intra-axial SOL, 60.00% (18/30) pituitary adenomas, 45.45% (5/11) meningioma,71.42% (5/7) CPA mass lesions, 50% (1/2) craniopharyngioma and 33.33% (2/6) intraventricular SOLs. ([Tables 1 & and 2)].

iMRI also helped us to improve our extent of resection (to achieve secondary GTR) in 76% (19/25) detected residues in patients with intra-axial SOLs, 55.55% (10/18) pituitary adenoma residues, 60% (3/5) meningioma residues, 60% (3/5) CPA residues, 100% (2/2) residues of intraventricular SOL. ([Table 3)].

We also noted and analysed the mishaps occurred during imaging and complications in the early postoperative period. Coil induced and contact Radiofrequency burns were seen in 3 cases (3%)(1) , circuit disconnection and transient rise in ETCO2 occurred in 1 patient (1%) and minor easily resolvable technical issues like problems in docking the MRI trolley and sliding the patient on MRI trolley was recorded in total 18 patients (18%). Post-operative infections were seen in 2% which was comparable to our infection rate in non-iMRI guided surgeries.

The mean time required for shifting and image acquisition in first 20 cases was 85.6 minutes which was reduced to 37.4 minutes in next 80 cases due to multiple repetitions and adoption to the shifting process and reduction in number of MRI sequences to identify residual tumour.

Conclusion: Setting up and effective utilisation of any new surgical adjunct has its own challenges. iMRI success depends on multi-departmental efforts, good communication between group persons involved and sincere team work. The team of neuroanesthetists and technical staff plays a pivotal role for successful and safe image acquisition. Our experience shows that it takes multiple iteration of the shifting process, along- with initial training session and mock drill, proper education of neurosurgical technicians and nursing staff, meticulous data collection and auditing to analyse and smoothen the work flow. Institution protocols and checklists should be prepared to reduce any untoward events.

Limitations of our work include not describing the efficacy of iMRI in various grades of gliomas separately and not comparing it with the control conventional resection group along with no analysis of long term surgical outcome, overall survival and progression free survival rates of the patient which needs further attention.

So, to conclude, 3TiMRI is a valid and state of the art technology which can help us achieve better extent of safe resections, and in turn can improve prognosis in patients with intracranial SOLs.

Key words: intra-operative MRI, adjuncts in neuro-oncology, maximising resections of glioma

Abstract 26 [Poster]

Cervical medullary compression by brown tumour

Anasse Mejdoubi, Mohamed Khoulali, Nabil Raouzi, Noureddine Oulali, Fayçal Moufid

Neurosurgery service, University hospital center Med VI

P-box 60050, Oujda, Morocco

Contact: anasse.mejdoubi@gmail.com; Morocco

Conflict of interests: none

Objective: The brown tumour or fibrocystic osteitis is a benign bone lesion resulting in an abnormality of bone metabolism integrating in the context of hyperparathyroidism. The spine is an exceptional location and can be complicated by spinal compression.

Method: We report a case of cervical brown tumour revealed by a medullary compression table

Result: This is a patient aged 65 years, followed for chronic inflammatory rheumatism seronegative, who consults for heaviness of the four members evolving since a year of progressive worsening. The examination objectified an asymmetric tetraparesis. Medullary MRI showed a lesional process of C4-C5-C6 vertebrae with intracanalar extension and spinal cord compression. Biologically, hypercalcaemia at 120mg/l with hyperparathyroidism. The patient underwent decompression surgery with a double anterior and posterior approach associated with a parathyroidectomy. The postoperative course was marked by the recovery of the neurological deficit and the normalisation of the calcaemia.

Conclusion: Spinal brown tumours with spinal cord compression are extremely rare, requiring decompression surgery and spinal stabilisation.

Key words: brown tumour, hyperparathyroidism, cervical medullary compression, decompression surgery.

Abstract 27 [Poster]

Intradural spinal tumours : about six cases

Anasse Mejdoubi, Mohamed Khoulali, Nabil Raouzi, Noureddine Oulali, Fayçal Moufid

Neurosurgery service, University hospital center Med VI

P-box 60050, Oujda, Morocco

Contact: anasse.mejdoubi@gmail.com; Morocco

Conflict of interests: none

Objective: Intradural spinal tumours are rare tumours whose evolution is slow and the clinical symptomatology varied and not very specific. Intradural tumours account for less than 10% of spinal tumours. There is a distinction between extramedullary and intramedullary tumours. MRI is the test of choice for diagnosis. The treatment is based on surgical excision

Method: We report a series of six cases collected over a two-year period in the neurosurgery department at Oujda University Hospital.

Result: The average age of our patients was 44 (27 years - 67 years). There is a female predominance: four women and two men. The symptomatology was dominated by discrete and progressive neurological deficits with genito-sphincteric disorders. All our patients benefited from a spinal MRI. The lesions were intradural extramedullary in five cases, intradural intramedullary in one case. The level of lesions was predominant at the thoracolumbar hinge. All our patients have undergone surgical treatment. The excision was total in 5 cases, subtotal in the case of the intramedullary tumour. The anatomopathological study was in favour of a neuroma in 3 cases, a meningioma in one case, an ependymal cyst in 1 case and an intramedullary oligodendroglioma in 1 case. In the case of medullary oligodendroglioma, a complement by radiotherapy has been indicated.Conclusion: Intradural spinal tumours are rare with an annual incidence of 0.74 per 100,000 population. Extramedullary tumours represent 90%, intramedullary tumours 10%. These tumours are most often revealed by spinal pain, which may be associated with motor and / or sensory deficit of progressive or sub-acute onset and with vesicosphincteric disorders. Magnetic resonance imaging is the key examination in the assessment of these lesions. Meningiomas and neuromas are the most common extramedullary intradural tumours, they are usually benign and their treatment is mainly surgical with often complete excision. Medullary tumours, very rare, are mainly represented by astrocytomas and ependymomas whose excision is more difficult but remains the only possible treatment.

Key words: intradural spinal tumours, MRI, surgical excision

Abstract 28 [Poster]

Endoscopic treatment of pituitary macroadenoma in CHU Oujda

Anasse Mejdoubi, Mohamed Khoulali, Nabil Raouzi, Noureddine Oulali, Fayçal Moufid

Neurosurgery service, University Hospital Center Med VI, P-box 60050, Oujda, Morocco

Contact: anasse.mejdoubi@gmail.com; Morocco

Conflict of interests: none

Objective: The endoscopic endonasal surgery of the pituitary gland represents the gold stand in the management of pituitary adenomas. It is characterised by its minimally invasive character and benefits from the contribution of endoscopy

Method: The objective of our work is to report our experience in the management of pituitary macroadenomas and to highlight our results. Through a retrospective study of a series of thirty (30) cases operated at the neurosurgery department at Oujda by endoscopic endonasal transsphenoidal over a period of three years

Result: In our series, there is a female predominance: sixty seven (67) % of women. The average age of our patients was forty two (42) years old. Clinical symptomatology was dominated by neurological signs and visual disturbances. A hormonal biological assessment was performed in all patients including all anterior pituitary hormones

Pituitary adenoma was no-secreting in fifty three (53) % of cases. All of our patients benefited from the pituitary MRI and nasosinus CT. We obtained in our series the following result: twenty (20) % of microadenomas and eighty (80) % of macroadenomas. All of our patients were operated on by endoscopic endonasal transsphenoidal. The excision was considered: - total in 76.1% of cases - subtotal in 14.3% of cases - partial in 9.6% of cases related to the fibrous or haemorrhagic nature of the tumour. The postoperative complications in our series were marked by the occurrence of cerebrospinal rhinorrhoea in 9.52% of cases, meningitis in 4.76% of cases and diabetes insipidus in 9.52% of cases.

Conclusion: Pituitary endoscopy has grown considerably over the past twenty years.

It has made great progress in the management of pituitary macroadenomas

Key words: pituitary adenomas, no-secreting adenoma, endoscopic endonasal surgery

Abstract 29 [Flash]

Rachischisis: a case report

Khalil Ayadi MD, Fatma Kolsi MD, Anis Hachicha MD, Omar Hattab MD, Brahim Kammoun MD, Mohamed Zaher Boudawara Professor of neurosurgery

Habib Bourgiba Hospital, Sfax, Tunisia

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Rachischisis consists of a failure in the closure of the posterior part of the neural tube, leaving the spinal cord exposed. It can be diagnosed during early pregnancy. Few cases can be seen at birth

Method: We report the case of a baby boy who was admitted in the department of Neurosurgery at the Habib Bourguiba University Hospital for rachischisis complicated with meningitis.

Result: A term baby boy was delivered by vaginal birth. The pregnancy was not monitored. Parents were not consanguineous. The baby had a spontaneous cry at birth. On inspection, there was a 16 X 6 cm red mass, located in the back of the boy, covered by a thin layer of skin. The baby was paraplegic. In the second day of life, liquid was flowing out of the lesion and the baby had fever. Meningitis was suspected and antibiotics were started. The lesion was covered with sterile dressing that was changed daily. MRI was performed showing that it was rachischisis. The baby died at day 15 of life

Conclusion: Rachischisis is a very complex birth defect. Babies have often other congenital defects associated. MRI contributes to the diagnosis. Mortality is very high.

Key words: rachischisis, meningitis, pregnancy

Abstract 30 [Poster]

Hydatic cyst of the posterior fossa: a case report

Khalil Ayadi, Fatma Kolsi, Ines Cherif, Anis Hachcicha, Brahim Kammoun, Mohamed Zaher Boudawara

Habib Bourguiba Hospital, Sfax, Tunisa

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Cerebral hydatic cysts are unusual. Infratentorial localisation is very rare.

Method: We report the case of a young boy who was operated in the Department of Neurosurgery at the Habib Bourguiba University Hospital for a hydatic cyst located in the posterior fossa.

Result: A 3-year-old boy was admitted for headache and walking disturbance. Neurological exam revealed a bilateral convergent strabismus associated with a static and kinetic cerebellar syndrome. CT scan showed a large cyst situated in the vermis associated with tri-ventricular hydrocephalus. The lesion was not enhanced with contrast agent. The boy underwent

surgery and the cyst was completely removed. The patient was symptom-free after surgery and treatment by albendazole was started. Pathology confirmed that the lesion was a hydatic cyst.

Conclusion: Cerebral localisation of hydatic cysts is rare. It usually affects children and is often revealed by increased intracranial pressure syndrome. Imaging is very helpful and pathology can confirm the diagnosis. Surgery is the treatment for this infectious disease.

Key words: hydatic cyst, cerebellum, CT scan, surgery

Abstract 31 [Poster]

Occipital meningoencephalocoele: two case reports

Khalil Ayadi MD, Fatma Kolsi MD, Anis Hachicha MD, Mansour Khrifech MD, Firas Jarraya MD, Mohamed Zaher Boudawara

Habib Bourguiba Hospital, Sfax, Tunisia

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Occipital meningoencephalocoele is a rare defect that is less and less seen nowadays

Method: We report the cases of two female babies who were treated at the department of Neurosurgery at the Habib Bourguiba University Hospital for occipital meningoencephalocoele.

Result: Both babies were delivered by caesarean section. In the two cases pregnancy was poorly monitored. They both had a spontaneous cry at birth. On examination, a large mass (12 X10 cm and 8 X 5 cm in size) protruding from the occipital area was found. On palpation, soft tissue was felt within the mass. One of the babies had a club

 foot and flexion deformity of the hip, the other one had no congenital defect. MRI revealed in both cases a large defect in the occipital bone with extra-axial fluid,

meninges, brain matter and ventricles entering the defect. A Reparative surgery was performed (one at the age of 18 days and the other at the age of 53 days). Postoperatively, both patients had uneventful recovery.

Conclusion: Occipital meningoencephalocoele is a very rare type of neural tube defect. Preoperative MRI provides useful information to assess prognosis and plan the surgical management. Morbidity and mortality rates are very high.

Key words: occipital, meningoencephalocoele, MRI

Abstract 32 [Poster]

Place of decompressive craniectomy in traumatic brain injury

Khalil Ayadi, Fatma Kolsi, Mansour Khrifech, Anis Hachicha, Brahim Kammoun, Mohamed Zaher Boudawara

Habib Bourguiba Hospital, Sfax, Tunisia

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: To study the epidemiological, clinical, radiological, biological, treatment and outcome of patients who underwent a decompressive craniectomy after severe traumatic brain injury.

To identify the variations in surgical technique of decompressive craniectomy and its clinical, radiological and manometric indications.

To assess the vital and functional prognosis after decompressive craniectomy and highlight the statistical correlation with the various parameters studied

Method: Retrospective study which lasted 8 and half years (January 2006 to 30 June 2014) and including 100 severe traumatic brain injury patients (mean age 38.72, sex -ratio 5.66). Accident public roads occupy a large part in the causation. We proposed to study the epidemiological, clinical, radiological, biological, treatment and outcome of patients who undergone a decompressive craniectomy after severe traumatic brain injury and the various indications and techniques decompressive craniectomy and finally highlight the factors correlated with the prognosis in double univariate and multivariate analysis.

Result: The final outcome was marked by 44% mortality. The 56 survivors were classified according to the Glasgow Coma Score (GOS): (GOS 5; 37, 71%), (GOS 4; 32.14%), (GOS 3; 19.64%) and (GOS 2; 12.5%). The prognostic study was made based on the survival and quality of life. Independent factors related to mortality were: age> 60, GCS <6, bilateral dilated and fixed pupils, the shift on the median line ≥10 mm and not opening the dura mater. Independent factors correlated with poor functional outcome (GOS 2.3) were: GCS <6, hypoxaemia (Sa O2 <90%), the shift on the median line ≥10 mm, not taking the mannitol 20% preoperatively, not opening the dura mater. Independent factors correlated with a good prognosis (survival) were: age between 21 and 40 and opening the dura mater with plasty. Independent factors correlated with a good functional outcome (GOS 4.5) were: taking the mannitol 20% preoperatively and the time of surgery ≤ 6 fortunes.

Conclusion: In cases of severe traumatic brain injury, one must not consider the refractory intracranial hypertension as an entity without any therapeutic option, for when medical treatment is exceeded. A decompressive craniectomy can bring interesting results if the indication is put on time for well-selected patients.

Key words: decompressive craniectomy, traumatic brain injury, Intracranial hypertension, acute subdural haematoma

Abstract 33 [Poster]

Melanocytoma mimicking a pituitary adenoma

Khalil Ayadi, Fatma Kolsi, Haitham Najar, Anis Hachcicha, Brahim Kammoun, Mohamed Zaher Boudawara

Habib Bourguiba Hospital, Sfax, Tunisia

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Melanocytoma is a rare tumour. It is one of the melanocytic tumours of the central nervous system developed from leptomeningeal melanocytes derived from the neural crest.

Method: We report a case of pituitary localisation melanocytoma in a patient treated in the neurosurgery department in the Habib Bourguiba HospitalResult: A 41-year-old patient was admitted in the Department of Neurosurgery in Habib Bourguiba university hospital for a progressive visual acuity decline over the past year associated with headache and vomiting over the past 10 days. The examination finds a decrease in visual acuity with a slight papillary pallor at the fundus examination. Cerebral MRI shows a voluminous expansive sellar and supra-sellar process, with a double cystic and fleshy component, a macro-adenoma was suspected. The diagnosis of craniopharyngioma was unlikely in the absence of calcification. The biological check-up shows low cortisol, hypothyroidism and slight hyperprolactinemia. The patient underwent surgery through a trans-sphenoidal approach. The peri-operative aspect of the tumour was blackish.Histological examination concluded that it was a melanocytoma.

Conclusion: Melanocytomas represent 0.1% of brain tumours. The location in the sella turcica is rare. The MRI shows a dense or hyper-intense iso signal in T1 and intense hypo in T2, and a homogeneous contrast recording. These tumours have specific histological and immunohistochemical characteristics. The clinical course of melanocytomas is sometimes marked by local recurrences. The malignant transformation of melanocytomas is exceptional. The treatment of melanocytomas of the central nervous system is based on complete surgical excision. Radiation therapy is reserved for recurrences and for intermediate grade melanocytoma. Key words: melanocytoma, pituitary adenoma

Abstract 34 [Flash]

Intracerebral hematoma: an unusual mode of revelation of acute lymphoblastic leukaemia: a case report and review of the literature

Khalil Ayadi, Fatma Kolsi, Anis Hachicha, Mohamed Znazen, Firas Jarraya, Mohamed Zaher Boudawara

Habib Bourguiba Hospital, Sfax, Tunisia

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Intracerebral haematoma accounts for 20% of the mortality of acute lymphoblastic leukemia (ALL). It is unusual for intracerebral haematoma to be the first manifestation of ALL.

Method: We report an unusual way of presenting an ALL in a patient treated in the Department of Neurosurgery in the Habib Bourguiba Hospital.

Result: A female infant, aged 1 year, with no particular medical history, was admitted for macro crania evolving for 2 months without history of fever or trauma. The examination objected a tense anterior fontanel, with facial dysmorphia. Biology showed hyperleukocytosis at 14400Elts/mm3, thrombocytopenia at 97000 and haemoglobin at 9.7 g/dl. Cerebral CT showed a collection under the right hemispheric dura that was enhanced with the contrast agent associated with a spontaneously hyperdense right temporal mass with osteolysis of the right temporal bone. Brain MRI concluded that there was a right hemispherical empyema with a right temporal intraparenchymal haematoma. During the operation, dura mater and the subdural space contained a thick fibrous tissue and in continuity with an intraparenchymal haematoma. Post-operatively, bi-cytopaenia with leukopenia at 1900 Elts/mm3 and severe anaemia at 5.3g/dl was observed. The patient died in the early postoperative period. Pathological examination was in favor of an acute T lymphoblastic leukaemia.

Conclusion: Acute Leukaemia should be suspected in case of hyperleukocytosis with intracerebral haematoma. A quick and accurate diagnosis will help to make the right therapeutic choice and improve prognosis.

Key words: acute lymphoblastic leukemia, Intracerebral haematoma

Abstract 35 [Flash]

Intramedullary tuberculoma: A case report and literature review

Khalil Ayadi, Fatma Kolsi, Anis Hachcihca, Ines Cherif, Firas Jarraya, Mohamed Zaher Boudawara

Habib Bourguiba Hospital, Sfax, Tunisa

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Intramedullary tuberculoma is a rare condition for which diagnostic and therapeutic management may be difficult. Clinical manifestation is that of slow spinal cord compression. If medical treatment is still indicated, surgical treatment is still being discussed.

Method: We report the case of a patient treated for an intramedullary tumour in our department in the Habib Bourguiba Hospital.

Result: A 21-year-old patient with a history of treated pulmonary tuberculosis, was admitted for progressive walking disturbances with sphincter disorders. Neurological examination found para paresis. There was no fever and no meningeal syndrome. Achilles reflexes were weak while patellar ones were abolished with a bilateral Babinski sign. There was a T8 sensory level with decreased tactile and painful sensitivity of the lower limbs, proprioceptive ataxia, a bladder globe with overflow urination and anal hypotonia. Biological exploration was normal. Medullary MRI showed an intradural nodular process with meningeal attachment the spinal cord developed at the T7 vertebrae. The process was in hypo signal in T2 weighted sequences, with an intense and homogeneous enhancement with contrast agent injection. Urgent T6 to T8 laminectomy was done. However, the spinal cord was not stretched intraoperatively and the dura mater appeared to be infiltrated by the tumour. Total excision was impossible due to the extremely important pseudo inflammatory reaction and the degree of adhesion of the process. The postoperative period was marked by clinical improvement. The diagnosis of intramedullary tuberculoma was confirmed by the pathological examination.

Conclusion: Intramedullary tuberculoma is a rare condition. Treatment is essentially medical. Surgery should be reserved in case of rapid neurological deterioration or diagnostic doubt.

Key words: tuberculosis, paraparesis, MRI

Abstract 36 [Poster]

Transdural approach for upper lumbar disc herniation

Khalil Ayadi, Fatma Kolsi, Anis Hachicha, Mohamed Amine Hadj Taieb, Firas Jarraya, Mohamed Zaher

Habib Bourguiba Hospital, Sfax, Tunisia

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Upper lumbar disk herniation is not frequent. It represents 1 to 2% of all disc herniations. Surgical approaches are different from usual low lumbar disc herniations due to the difficulty in mobilising the nerve root.

Method: We report the case of a patient treated with a transdural approach for a lumbar disk herniation in our depatrment.

Result: We report a case of a 27-year-old man was admitted in the department of neurosurgery in the Habib Bourguiba teaching hospital for back pain and bilateral L3 radicular pain following a fall. The pain was not relived by analgesics. There was no motor nor sensitive deficit. MRI revealed a giant L1-L2 disk herniation. The patient underwent surgery. The herniated disc was extracted through a transdural approach. The patient developed a discrete motor deficit in the L5 trajectory (4/5). He was discharged one week after surgery. The motor deficit disappeared few weeks later thanks to physical rehabilitation.

Conclusion: Surgery of upper lumbar disc herniation represents a challenge to surgeons and requires a long learning curve to master.

Key words: lumbar disk herniation, transdural approach

Abstract 37 [Flash]

Association between breast cancer and glioblastoma, is it a coincidence?

Khalil Ayadi, Fatma Kolsi, Anis Hachicha, Haitham Najjar, Brahim Kammoun, Mohamed Zaher Boudawara

Habib Bourguiba Hospital, Sfax, Tunisia

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Breast cancer is the most common cancer in women. In many cases, it can be associated with another tumour. However, the association between

breast cancer and glioblastoma is rare and has been reported only in few

cases in the literature.

Method: We report the case of a woman with a history of breast cancer who was treated in our department for a glioblastoma.

Result: We report the case of a 37-year-old woman with a history of breast cancer. She had a TisN0M0 breast cancer in the right breast at the age of 22. Only surgery was performed and the patient was followed up in the oncology department. She was admitted to the department of neurosurgery in the Habib Bourguiba university hospital in Sfax, Tunisia, for an increased intracranial pressure syndrome. Physical examination did not reveal any neurological deficit. CT scan showed a left parietal lesion. MRI and a full body CT scan were performed. Surgery was performed. The patient was symptom-free after surgery and had no deficit.

Pathology revealed that the lesion was a glioblastoma. The patient was treated with radiation and chemotherapy.

Conclusion: Association between breast cancer and glioblastoma has been reported in few cases in the literature. Genetic mutations and hormones are the most implicated factors. Prognosis is not better than other patients with

glioblastoma.

Key words: breast cancer, glioblastoma, genetic mutations, radiation therapy

Abstract 38 [Poster]

Primary epidermoid cyst of the cauda equina

Ayadi Khalil, Fatma Kolsi, Anis Hachicha, Mohamed Znazen, Firas Jaraya, Mohamed Zaher Boudawara

Habib Bourguiba Hospital, Sfax, Tunisia

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Intraspinal epidermoid cyst is very rare. It represents 0.5 to 1% of all spinal tumours. The cauda equina is an uncommon location in such cases.

Method: We report the case of a patient who was treated in the department of neurosurgery in the Habib Bourguiba hospital for a primary epidermoid cyst located in the cauda equina.

Result: We report the case of a 44-year-old female. The patient has been suffering from chronic lumbar pain for two years. During the last two months, she reported a weakness of both lower limbs with a retention type sphincter malfunction. Neurological examination showed paraparesis with abolished deep tendon reflexes. Lumbar spine MRI showed a posterior intradural and extramedullary oval tumoural formation extending from L1 to L5. Surgery was performed and complete removal was not possible due tight adherences to the cauda equina nerve roots. Histological examination was in favour of an epidermoid cyst. The patient had a good recovery. She was symptom-free few weeks after surgery.

Conclusion: Epidermoid cyst of the cauda equina is a rare finding. Despite its location and surgery difficulties, the post-operative results are promoting.

Key words: cauda equina, epidermoid cyst

Abstract 39 [Poster]

Primary neuroectodermal tumour of the spine

Khalil Ayadi, Fatma Kolsi, Anis Hachicha, Mohamed Amine Hadj Taieb, Brahim Kammoun, Mohamed Zaher Boudawara

Habib Bourguiba Hospital, Sfax, Tunisia

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Primary neuroectodermal tumour is a malignant neural crest tumour. It usually develops in the brain in children and young adults. Secondary localisation in the spine is possible through the cerebrospinal fluid. However, a primary localisation is rare.

Method: We report the case of a young patient who was treated for a primary neuroectodermal tumour located in the lumbar spine, in the department of neurosurgery in the Habib Bourguiba Hospital in Sfax, Tunisia.

Result: The patient is a 33-year-old man. He had no previous medical history. He was complaining of lower back pain for 6 months. He was admitted to our department for sudden exacerbation of the pain with walking disturbances. There were no sphincter disfunction associated. Physical examination noted a flask paraplegia, with abolition of deep tendon reflexes and a L1 sensitive level. Spinal MRI revealed a single well-limited right posterior lesion at the level of L1-L2. The patient underwent urgent surgery and the lesion was completely removed. The patient improved after surgery and was symptom-free after physical therapy. Pathological exam was in favor of a Primary neuroectodermal tumour.

Conclusion: Primary neuroectodermal tumour is a malignant tumour that rarely develops in the spine. Prognosis remains poor despite progress in medical treatment.

Key words: neuroectodermal tumour, spine

Abstract 40 [Poster]

Sacral hydatidosis

Khalil Ayadi, Fatma Kolsi, Anis Hachicha, Ines Cherif, Firas Jarraya MD, Mohamed Zaher Boudawara

Habib Bourguiba Hospital, Sfax, Tunisia

Contact: khalilayadi@gmail.com; Tunisia

Conflict of interests: none

Objective: Hydatidosis is a parasitosis caused by the larva of the taenia Ecchinococcus Ganulosis. The bony localization of hydatidosis remains rare and is characterized by its clinical latency which delays diagnosis and favours the extension of the affection.

Method: We report the case of a patient who was treated for a sacral hydatid cyst in the department of neurosurgery in the Habib Bourguiba hospital, in Sfax, Tunisia.

Result: The patient is a 44-year-old man with no medical history. He was living in a rural area and was a shepherd. The patient was admitted for progressive back pain. He noted that he had sexual impotency for few weeks and no sphincter dysfunction. Clinical examination objected an isolated distal paraparesis. Lumbar MRI revealed multilocular cystic lesions in the sacrum with osteolysis. The patient underwent surgery. The removal of the cysts was challenging and could not be complete. The patient developed a distal motor deficit after surgery. Pathology was in favour of hydatidosis. Albendazole was admitted to the patient. With physical therapy the patient had partial mobility; however, sexual impotency did not improve.

Conclusion: Vertebral hydatidosis is a rare entity. It is characterised with its latency. Symptoms are not specific and spinal MRI is the key to diagnosis. Treatment depends on maximal cyst removal and on medical treatment. Prognosis is generally poor. Prevention is the best means of protection.

Key words: hydatidosis, vertebral, sacral

Abstract 41 [Oral]

Extrusion of distal shunt catheter: a report of three cases

Benjamin Mutiso, Nimrod Mwang'ombe

University of Nairobi

Contact: kasyokaben@gmail.com; Kenya

Conflict of interests: none

Objective: To describe three unusual shunt complications seen in a tertiary referral hospital in Kenya

Method: Three cases of distal catheter shunt complications are described here. This patients were seen in the neurosurgical unit in within a period of one year. Possible hypothesis of shunt extrusion are also explored. Ideal management of a patient with distal shunt catheter extrusion is discussed.

Result: Individual management outcomes for each patient are discussed in the article

Conclusion: Shunt extrusion is a rare distal catheter complications that if managed well has good outcomes

Key words: hydrocephalus, ventriculo-peritoneal shunt, distal catheter extrusion

Abstract 42 [Flash]

Maternal care of a quadriplegic patient

Noor ul Huda Maria, Qurrat ul Ain Siddiq

HS,PINS,CPSP

Contact: drnoorneuro@gmail.com; Pakistan

Conflict of interests: none

Objective: We want to share our experience with a quadriplegic patient who gave birth to a healthy baby at 37-weeks gestation spontaneously and without any immediate and delayed complications.

Method: Here we are sharing a case report and the literature review on the topic of spontaneous vaginal delivery in quadriplegic patients.

Result: It is case report from our hospital of a 28-year-old primigravida who acquired spinal cord injury at 36-week of pregnancy as fracture of C3 vertebra. She acquired the injury while she was waiting for her husband who was in a shop while sitting on the front seat of her car when a truck hit her parked car from behind. She was immediately rushed to the ER. Her motor power was 0/5 in all four limbs. She was admitted and the family was counselled. She had SLIC score of 6. The gynaecology and obstetric department was involved and evaluation of foetal well being was done. The patient was admitted and was kept under observation. After 1 week, patient’s attending mother noticed and felt contractions and the duty doctors was notified. Patient was fully dilated and the baby was delivered safely even without forceps assistance. The patient did not suffer from any postnatal complication as well. also performed literature review regarding the management of pregnant quadriplegic patients and any increased risk of pregnancy and birth related complications.

Conclusion: Normal delivery is possible in quadriplegic patients. In some studies, an increased risk of urological sepsis has been suggested. Some studies suggested use of forceps assistance but in our case, our patient had an uneventful normal delivery without forceps assistance and our patient did well during her postpartum period.

Key words: SVD, quadriplegia

Abstract 43 [Flash]

Anterior mini-temporal approach for tumours of the temporal lobe

Francisco Javier Dorado Capote, Julia Eva Martín Colom, Elena Moya Trillo, Antonia Garcia Iglesias, Alvaro Toledano Delgado, Juan Solivera Vela

UGC de Neurocirugía y Neurofisiología. Hospital Universitario Reina Sofía, Córdoba.

Contact: jdcapote@gmail.com; Spain

Conflict of interests: none

Objective: Minimally invasive procedures have demonstrated benefits compared to common techniques by diminishing comorbidities and showing better aesthetical results. Thus, the aim of this study is to analyse our results with temporal lobe resections through anterior mini-temporal approach.

Method: We carried out a retrospective observational analysis of anterior mini-temporal approach for temporal lobe resections performed in our hospital. Based on this criteria, seven cases were included. Grade of resection, size of craniotomy, survival time, complications, and hospitalisation rates were examined.

Result: Complete supramarginal resections were successfully performed in 100% of patients, verified by immediate post-operative magnetic resonance. Average size of craniotomies was 3cm, verified with post-operative CT-scan. After microscope resection, the endoscope was used in order to obtain a greater view of the resection cavity and surgical field, and evaluate the grade of resection. All patients had favourable outcomes, there were no complications after surgery or during hospitalisation. Any post-operative bleeding, infections or damage of the frontal branch of the facial nerve were reported. All patients had an early recovery, and average hospitalisation rate was three days.

Conclusion: This study demonstrated that anterior mini-temporal approach for temporal lobe resections is a safe technique. The comparison with common craniotomy revealed that this minimally invasive procedure had similar survival time, with the benefits of reduced operative time and stay time in the operation room, less risk of infections, lesser hospitalisation rates, diminished soft tissue manipulation, better aesthetical outcomes, less temporal muscle atrophy and less chewing pain.

Key words: mini-craniotomy, mini-temporal, endoscope, temporal and tumours

Abstract 44 [Oral]

Microvascular decompression for hemifacial spasm. Our experience and literatur review

Efdal Erdoğan, Yahya Cem Erbaş, Serhat Pusat, Ersin Erdoğan

Ufuk University Medical Faculty Department of Neorology, Ankara ,Turkey

Nörospine Center,Ankara,Turkey

University of Health Science, Sultan Abdulhamid Training and Resarch Hospital, Department of Neurosurgery, İstanbul, Turkey

Contact: pusatserhat@yahoo.com; Turkey

Conflict of interests: none

Objective: In this study, we examined the hemifacial spasm patients operated in our clinic with the literature.

Method: Hemifacial spasm is a disease that causes involuntary contraction of the facial muscles. It also causes social withdrawal because the disease is caused by unintentional contraction of muscles. Hemifacial spasm is a curative disease if treated properly. We presented 60 patients with follow-up from 78 patients who were operated between 2016-2020. The ages of the patients are between 23-71 (mean 45.89) and F/M 32/28. Hemifacial spasm was detected on the left side in 26 patients and on the right side in 34 patients. In 18 of these patients, aica, 18 in pica, 4 in vertebral + pica, 2 in basils, 2 in venous base, 2 in basilar torticollis, 2 in vertebral artery + aica, 4 in vertebral + pica. + aica, pica + aica in 4, and vertebral arterial pressure was detected in 4. Patients were operated in the lateral decubitus position. Permanent retractor had not been used in any patient. Vascular contact was sought in medulla region, 2-3 mm above the cranial nerves, where the facial nerve is jutted, 9,10,11. Intraoperative monitoring was not used in patients.

Result: Patients being postoperative were not reoperated. Facial paralysis has not occurred in any patient. Loss of partial hearing occurred in 3 patients. Wound monitored due to cos flow in 3 patients. Surgical cured were provided to all patients. None of these patients had mortality or morbidity.

Conclusion: Hemifacial spasm is a disease that can be treated with surgery

Key words: hemifacial, spasm, decompression

Abstract 45 [Poster]

Spindle cell oncocytomas of the pituitary gland

MECHERGUI Haifa, Dr BOUALI Sofien, Dr KERMANI Nadhir, JMAL Nesrine, Dr ABDELRAHMEN Khansa, Dr kALLEL Jalel

National institute of Neurology Tunis

Contact: haifaamechergui@gmail.com; Tunisia

Conflict of interests: none

Objective: Spindle cell oncocytoma is a rare tumour of the pituitary gland with a dual diagnostic and therapeutic problem. Given the non-specific nature of the presentation, the diagnosis is based solely on anatomopathology. It is likely that the quality of the surgical gesture will condition the prognosis, but this gesture is not without risks and no prognostic factor has been identified to date. The number of cases described is currently insufficient to conclude to a standardised management.

Method: Our case is about a years old man who present a headache and a rapidly new occurring diplopia. He presented with bitemporal hemianopsia

Result: The patient underwent trans-sphenoidal surgery with a good operative follow-up. A complete excision was made Anatomopathology concluded that it was a spindle cell oncocytoma of the adenohypophysis.

Conclusion: The evolution of these benign tumours, little described in the literature, is characterised by a tumour progression that can threaten the visual prognosis and require early surgery. In addition, they are hypervascularized tumours that cause preoperative difficulties and have a much higher risk of haemorrhage than adenomas, which limits the possibility of complete removal.

Key words: pituitary gland, oncocytoma

Abstract 46 [Poster]

Primary dural lymphoma: case report and review of the literature

Mechergui Haifa, Bouali Sofiene, Kermani Nadhir, Ben Atig Fatma

National Institut of Neurology Tunis, Tunisia

Contact: haifaamechergui@gmail.com; Tunisia

Conflict of interests: none

Objective: MALT lymphomas of the dura, are an uncommon form of CNS lymphoma, accounting for an even smaller proportion of dural masses. They are, however, the most common form of primary dural lymphoma. On imaging, they are difficult to diagnose pre-operatively as primary dural lymphomas share many similarities with meningiomas which are vastly more frequent.

Method: we report the case of a 51-years-old who present a chronic headache evolving since 2 years. The clinical exam show an exophthalmos grade II. The MRI shows a pachymeninges with fibrous appearance located at the level of the pericerebellar region and in the cavernous sinus extended to the orbital apex. The patient was operated. An excision of fibrous thickening has been carried out.

Result: Histological analysis led to the diagnosis of MALT type B lymphoma, localised to the dura mater.

Conclusion: Primary lymphoma arising in dura is exceedingly rare. Literature describe only 14 reports of similar entity. Primary lymphomas arising in dura appear to have a more favourable clinical course compared to PCNSL and may require a less aggressive treatment.

Key words: lymphoma, MRI

Abstract 47 [Oral]

Issues in craniovertebral and spinal instability

Atul Goel

Seth G S Medical College and K E M Hospital, Mumbai

Contact: atulgoel62@hotmail.com; India

Conflict of interests: none

Objective: The author will present his philosophy on the manipulation of articular facet joint in the management of a number of complex anomalies of craniovertebral junction and rest of spine. An alternative strategy of treatment of degenerative spine will be presented.

Method: The experience is with over 30 year experience with C1-2 fixation and about 10 years experience with cervical and lumbar spine where facetal distraction and fixation of the spinal segment was done. Wide removal of the articular cartilage, stuffing of bone graft with or without a metal spacer provides a wide ground for bone fusion and for stabilisation. Facetal distraction was done using specially designed ‘Goel’ facet spacers.

Result: Attempts at fixation of the joint, manipulation and distraction of the facets can result in restoration of the alignment of the craniovertebral junction and clinical recovery. Facetal distraction of the subaxial spine (cervical, thoracic, lumbar) provide remarkable stability to the spinal segment, restores the intervertebral and spinal canal dimensions and results in immediate clinical recovery. The procedure ultimately results in arthrodesis of the spinal segment. No manipulation or resection of any part of the disc, ligament or bone is required.

Conclusion: Reduction of the joint cavity space, listhesis of the facets, arthritis of the cartilage, and destruction of the facets are the primary causes of a wide range of pathological entities that involve the craniovertebral junction and the spine. Facet treatment is effective and relevant.

Key words: craniovertebral instability, spinal instability, atlantoaxial fixation, spinal fixation

Abstract 48 [Oral]

Limbic System – Anatomical and Surgical Correlates

Abhidha Shah, Neurosurgery, Sukhdeep Jhawar, Atul Goel

Seth G S Medical College and KEM Hopsital, Mumbai

Contact: abhidha@gmail.com; India

Conflict of interests: None

Objective: A fibre dissection technique was used to study the limbic system and Papez circuit in particular. The relationship of the various components of the limbic system to normal anatomical structures and their relevance to surgery was studied.

Method: Six previously frozen and formalin-fixed cadaveric human brains were used. The fibre dissection techniques described by Klingler were adopted. The primary dissection tools used were handmade, thin and wooden and curved metallic spatulas with tips of various sizes.

Result: All the connections of the limbic system have been anatomically demonstrated. The course, length and anatomical relations of the structures that make up Papez circuit is delineated. Papez circuit begins in the hippocampus, continues into the fornix to reach the mamillary body. From there the mamillothalamic tract continues to the anterior nucleus of the thalamus, which in turn connects to the cingulum by means of the anterior thalamic radiations. The cingulum courses around the corpus callosum to end in the entorrhinal cortex which then projects to the hippocampus. The whole circuit has been anatomically dissected in the hemisphere first and then reconstructed outside after removing its various components meticulously.

Conclusion: Dissection of the brain delineates the anatomical details of the circuit clearly and assists in providing a three dimensional perspective of the limbic system. Intricate knowledge of the anatomy of this part of the brain aids the neurosurgeon while performing epilepsy surgeries, pyschosurgery and while approaching various lateral ventricular and third ventricular tumours.

Key words: limbic system, paper circuit, surgery, limbic tumours, paralimbic tumours

Abstract 49 [Poster]

Amoebic cerebral abscess: a report of four cases with literature review

Krifa Elyes, Mechergui Haifa, Abdelrahmen Khansa, Jemel Nesrine, Bouali Sofien, Kallel Jalel

Department of Neurosurgery , National Institute of Neurology, Tunis

Contact: haifaamechergui@gmail.com; Tunisia

Conflict of interests: None

Objective: Cerebral amoebic abscess is a rare infection but fatal. Since its identification in 1965, few cases have been observed world-wide.

Method: The objectives of this study were to characterise the clinical, radiological, histological, prognostic and therapeutic aspects of this pathology with a review of the literature. We report four cases of cerebral amoebic abscess that were admitted to our department between 2010 and 2020

Result: Four men and one woman, aged 33, 43 ,44 and 56 respectively, were operated on. The diagnosis was confirmed by histological and serological examinations. No mortality was observed.

Conclusion: It is sporadic but it present a public health problem and usually has a poor prognosis.

Key words: amoebic abscess, cerebral abscess, MRI

Abstract 50 [Oral]

Vasopressin performance in chronic pain: study through systematic review

Laura Beatriz Martins, Gabriela Ferreira Kalkmann, Isabella Carla Barbosa Lima Angelo, Matheus Zago Soares dos Santos, Thania Gonzalez Rossi.

1. University Nove de Julho.

2. Federal University of Paraná.

3. Catholic University of Pernambuco.

Contact: laura.martins@uni9.edu.br; Brazil

Conflict of interests: none

Objective: To present a systematic review analysing the relationship between the role of vasopressin in chronic pain (CP).

Method: The systematic review was performed according to the guidelines contained in the Preferred Reporting Items for systematic reviews and meta-analyses (PRISMA). The data were extracted directly from the included papers full text. The search terms: “'chronic pain' AND (vasopressin * OR ADH OR V1 Receiver OR v2 receptor)” were used in the PubMed / MEDLINE, Scielo, Cochrane, Lilacs and TripDataBase databases on October 14, 2020, totaling 231 identified articles (PubMed / MEDLINE: 60; Scielo: 29; Cochrane: 4; Lilacs: 60; TripDataBase: 78). After removing duplicate studies, 195 articles were selected. The inclusion criteria were: studies in humans or animals with CP diagnosed by any criteria, in any age group, observational studies and case reports, originals published in any language. Studies published only as a summary, articles that prevented their full access, prior to 1990, publications only of protocol, as well as systematic or non-systematic reviews, were excluded. Three reviewers conducted the screening and removed studies that were not suitable based on the title and abstracts, making a total of 12 eligible. One study was excluded because it is not possible to have full access. Subsequently, four reviewers read the entire content of these articles and reached the consensus of 4 included studies. Studies that did not meet the eligibility criteria (inclusion and exclusion) were removed. Discrepancies at any stage were discussed between the authors until a consensus was reached.

Result: The frequencies of single nucleotide polymorphisms (SNPs) of the arginine vasopressin 1A receptor gene (AVPR1A) and one of its SNPs, rs10877969, is associated with pain. CP was not significantly associated with SNP rs10877969, however this polymorphism of the gene was associated with acute pain. The difference for this association may be due to differences between samples and their heterogeneity. The catastrophic pain and depressive symptoms are associated with rs10877969, suggesting a possible relationship between AVP and chronic pain through the limbic system. Hypersensitivity to vasoconstrictors is present in CP. A study carried out the application of intradermal doses of adrenergic agonists in rats with post-ischaemic CP (PICP), verifying that the models presented pain when submitted to these vasoconstrictors for several seconds, due to the abnormal and hypersensitised response to these substances. Nociceptive behaviours increased with the use of non-adrenergic vasoconstrictors, such as AVP, and suggests that hypersensitivity to sympathetic vasoconstriction and ischaemia are important mechanisms for pain and can be used for the development of future treatments.

Conclusion: The correlation between AVP and CP is not well understood by the studies. As limitations, difficulties were found in finding studies in the databases that evaluated this hormone in patients diagnosed with CP. However, it was possible to

 observe that there is a change in the serum concentration of AVP in the presence of CP that causes justifiable symptoms to its abnormal values, but it has not been clarified yet whether it is a consequent or causal link of CP. This change in AVP should be better studied to clarify its pathophysiological pathways that may be related to CP, enabling studies that improve existing treatments for CP patients.

Key words: chronic pain, V1 receptor, V2 receptor, vasopressin

Abstract 51 [Oral]

Role of neuroendoscopy (rigid and flexible) in management of hydrocephalus in children: our experience in last 2 years.

Shighakolli Ramesh, Konanki Ramesh, MA Jaleel

Kamineni Hospitals, Rainbow Hospitals

Contact: srameshns1@gmail.com; India

Conflict of interests: none

Objective: Hydrocephalus is significant burden in paediatric age group. Endoscopic third ventriculostomy (ETV) has become standard of care in management of hydrocephalus. Aim of this study is to analyse outcome in children and identify factors related to failure or success of endoscopic third ventriculostomy.

Method: This is a retrospective study done in patients who underwent endoscopic third ventriculostomy during 2017 to 2019 at Kamineni hospital, Rainbow children hospital Hyderabad, Telangana. During the study period around 52 Endoscopic third ventriculostomy were done. ETV was success full in 33 children (64%). Out of 52 patients 30 were male and 22 were female child. ETV was performed in various aetiologies. 18 patients were due to Aqueductal stenosis with obstructive hydrocephalus, 3 patients were in obstructive hydrocephalus due to space occupying lesions in and around 3rd and 4th ventricle, 18 patients in communicating hydrocephalus, 7 patients in dandy walker variant with hydrocephalus, 5 patients in preterm IVH and 1 patient in multi-septate hydrocephalus. Having flexible neuroendoscope in armamentarium helps is performing trans lamina terminalis third ventriculostomy (ETV-LT) in cases where floor is not suitable for standard third ventriculostomy. ETV LT was done in 2 cases. Aqueductoplasty was done in 5 cases adjuvant to standard third ventriculostomy. Subdural hygromas were seen in 4 cases. 1 child improved with conservative management with successful third ventriculostomy, 2 children required burr hole evacuation of sub dural hygroma, 1 children who was managed conservatively had arrested hydrocephalus.