Decision making plays a substantial role in our daily activities. The entire mechanism of perceiving, thinking and actively deciding is primarily controlled by neurology circuits. Recent studies in genetics, sociology and behavioural sciences has proven that environmental factors tend to influence our decisions indirectly by altering the neurological mechanisms.

Background: Craniopharyngiomas are benign tumor of skull base which often follows an aggressive clinical course. Adamantinomatous subtype are frequently observe in age group 5-15 years. Currently, treatment strategy has relied exclusively on surgery and radiotherapy. Materials and Methods: All pediatric Craniopharyngiomas operated at National Neurosurgical Referral Center, Bir hospital from Nov 2021 to Dec 2023 were included in this study. Results: A total of 17 patients underwent surgical excision of craniopharyngioma. The male to female ratio was 4.6:1. The mean age of the patients was 10.88 ± 4.18 (Range 2 to 16 years). The most common presenting symptoms were headache (64.7%) followed by visual disturbances.12 patients exhibited preoperative hypothalamic pituitary axis dysfunction including central hypothyroidism (35.6%), central diabetes insipidus (29%), growth hormone deficiency (35.6%), adrenocortical insufficiency (23.5%). The Gross total resection was achieved in 6 patients (45%) while subtotal resection was done in remaining 11 patients (55%). Modified Rankin scale score (mRS) on discharge was favorable outcome (mRS 0,1,2,3) in 75% and unfavorable outcome (mRS 4,5) in 19%. There was one mortality. The overall rate of postoperative Diabetes insipidus (DI) was 35.3 % (6/17), visual deterioration (6%), meningitis (11.7%) behavioral disturbances (6%). On 6 month follow up MRI, recurrence was noted in 5 cases, 3(50%) in cases with gross total resection and 2(18.2%) in subtotal resection with adjuvant radiotherapy group. Conclusion: We conclude that Surgical excision of pediatric craniopharyngioma caries a substantial risk of postoperative hypothalamic pituitary dysfunction which significantly impair the quality of life and functional recovery of these patients. A high index suspicion of hypothalamic involvement by tumor and its preservation can improvise patient functional outcome. Postoperative radiotherapy is advised in patient with subtotal resection to improve recurrence free survival.

Posterior reversible encephalopathy syndrome (PRES) is also called Reversible posterior leukoencephalopathy syndrome (RPLS). PRES typically manifests as parieto-occipital vasogenic edema, but radiologic investigations show a much wider range of involvement. Large studies have shown extension of the imaging findings in atypical areas and in atypical pattern. Also PRES has large number of etiological factors. Given its wide range of triggers, such as hypertension, renal failure, eclampsia, autoimmune illness, and cytotoxic treatments, prompt identification is crucial to enable prompt treatment of underlying causes and avoid irreparable damage or complications. Therefore, being aware of abnormal imaging patterns is essential for timely and efficient treatment and this article aims to review the imaging features of classical PRES and its variants.

Introduction: Supratentorial intraventricular tumors are rare central nervous system neoplasms located deep within the ventricular system. Their proximity to eloquent neural pathways and critical vascular structures makes surgical management technically challenging. Data from low and middle income regions remain limited. This study evaluates the clinical features, histopathological patterns, surgical approaches, and outcomes of patients treated at a tertiary neurosurgical center in Nepal. Material and Method: A retrospective observational study was conducted including 27 consecutive patients who underwent surgical resection of supratentorial intraventricular tumors between September 2020 and August 2025. Demographic, clinical, radiological, histopathological, operative, and postoperative data were collected and analyzed. Statistical analysis included descriptive statistics, chi-square testing, logistic regression modeling, and calculation of confidence intervals. Institutional Review Committee approval was obtained prior to study initiation. Results: The mean age was 24.9 ± 13.2 years, with a male predominance of 21 (77.8%). Headache was the most common presenting symptom, occurring in 14 (51.9%) patients. Colloid cyst was the most frequent histopathological diagnosis, identified in 7 (25.9%) patients, followed by subependymal giant cell astrocytoma in 5 (18.5%) and choroid plexus tumors in 5 (18.5%). The transcortical-transventricular approach was most frequently utilized in 14 (51.8%) cases. Postoperative hydrocephalus requiring cerebrospinal fluid diversion occurred in 5 (18.5%) patients. Overall mortality was observed in 3 (11.1%) patients. No statistically significant association was found between tumor type or surgical approach and postoperative complications. Conclusion: Microsurgical resection remains the cornerstone of management for supratentorial intraventricular tumors in resource-limited settings. Although acceptable surgical outcomes can be achieved, postoperative hydrocephalus continues to be a significant challenge. Larger prospective multicenter studies are needed to optimize surgical strategies and improve patient outcomes.

Neurosurgical residency training is uniquely demanding, requiring mastery of technical skills, advanced cognitive decision-making, and emotional resilience. Contemporary training faces additional pressures from duty-hour regulations, rapid technological advancement, subspecialization, and increasing emphasis on trainee well-being. This perspective reviews the evolution of neurosurgical training from classical apprenticeship models to modern, competency-based paradigms incorporating simulation, structured feedback, mentorship, and global collaboration. We provide a vision for a residency that balances surgical skill acquisition with reflective practice, professional identity formation, and resilience, aiming to produce neurosurgeons who are technically proficient, intellectually mature, and sustainable in the long term.

Background: Tardive dyskinesia is a debilitating hyperkinetic movement disorder characterized by repetitive involuntary movements involving the orofacial musculature. The disorder most commonly arises following exposure to dopamine receptor–blocking medications and reflects dysfunction within cortico-basal ganglia-thalamocortical motor circuits¹. Structural brain lesions may further destabilize motor network function and contribute to abnormal movement patterns. Cerebral arteriovenous malformations (AVMs) are congenital vascular anomalies that typically present with intracranial hemorrhage, seizures, headaches, or progressive neurological deficits². Movement disorders associated with AVMs are rare. Case Description: We report a case of severe refractory oro-buccal dyskinesia in a patient with a cerebral AVM and seizure disorder. Neuroimaging demonstrated a left posterior temporal arteriovenous malformation located near the temporoparietal junction. Despite withdrawal of the offending medication and trials of tetrabenazine and botulinum toxin injections, the dyskinesia persisted. The patient underwent microsurgical AVM excision, which resulted in angiographic cure and seizure control but did not resolve the abnormal movements. Because of persistent disabling dyskinesia, the patient subsequently underwent bilateral globus pallidus internus deep brain stimulation (GPi-DBS). Intraoperative microelectrode recordings confirmed appropriate pallidal neuronal activity. An implantable pulse generator was implanted during the same procedure and stimulation was activated immediately in the recovery period, resulting in rapid suppression of dyskinetic movements. Conclusion: This case highlights the complex interaction between structural cerebrovascular pathology and dysfunctional basal ganglia circuitry. Successful treatment required a staged neurosurgical strategy combining vascular and functional neurosurgery. Immediate activation of pallidal stimulation produced dramatic clinical improvement and demonstrates the therapeutic role of neuromodulation in refractory dyskinetic disorders.

Background: Anterior cervical discectomy and fusion (ACDF) is the most common surgical procedure of cervical spine, and its number has drastically increased in recent years due to advancement in technology and technique. Most of the time, it is safe and effective. However, unusual complications sometimes can cause devastating outcomes. The main aim of this report is to make surgeons aware of such complications and to prevent unexpected outcomes. Here we present two cases of unusual complications of ACDF. Case Reports: The first case was a 60-year-old female who was planned for ACDF at the level of C3-4-5-6. While dissecting the soft tissues and longus colli (LC) muscle on the right side of the anterior surface of the vertebral body, the vertebral artery (VA) was injured. Immediate endovascular intervention saved the patient's life. The second case was a 50-year-old female with morbid obesity and was planned for ACDF at C6-7. Because of a short and thick neck, retraction was difficult. Postoperatively she developed visual symptoms due to right Horner’s syndrome. Conclusion: Complications happen after surgery. However, every effort should be made to prevent them, especially those which can endanger the patient’s life. Careful preoperative evaluation of patient and radio-imaging often gives hints most of the time.

Background: Primary intracerebral hemorrhage (ICH) is a leading cause of stroke-related mortality in South Asia, yet data from western Nepal remain limited. This study describes the clinical profile, radiological characteristics, management strategies, and three-month outcomes of primary ICH patients at a tertiary care center in western Nepal. Material & Methods: This prospective analytical study was conducted at the Department of Neurosurgery, Nepalgunj Medical College and Teaching Hospital (NGMCTH), Kohalpur, Nepal. Sixty-three adult patients with confirmed primary ICH on non-contrast CT head were enrolled over three months using consecutive sampling and followed up for an additional three months. Clinical, demographic, and radiological data were collected at the time of admission. Neurological status was assessed using the Glasgow Coma Scale (GCS) at admission and at three months. Results: The median patient age was 62 ± 12.8 years, with male predominance (65.1%). Hypertension was the most common comorbidity (74.6%). \Approximately 74.6% presented with moderate-to-severe neurological compromise. Admission GCS was significantly associated with three-month neurological outcome. Conservative management was employed in 63.5% of patients, and 17.5% underwent surgical intervention. A notable 25.4% left against medical advice (LAMA). Conclusion: Primary ICH in western Nepal predominantly affects middle-aged hypertensive males. Admission GCS is the strongest predictor of short-term neurological outcome. The high LAMA rate reflects critical socioeconomic barriers that likely underestimate true ICH mortality. Strengthening community-level hypertension control, expanding financial protection for neurosurgical emergencies, and improving patient retention seem essential to improving outcomes in this region.

As a neurosurgeon practicing within the walls of a busy Nigerian tertiary hospital, I am witnessing a quiet but devastating shift in our nation’s epidemiological landscape. Where our wards were once dominated by trauma and infectious pathologies, we are now seeing an unprecedented surge in the incidence of brain tumors. This is no longer a peripheral concern; it is a burgeoning public health crisis that demands immediate attention from the global medical community and national stakeholders.

No abstract available.