Neurosurgical Disorders Research Articles

Transient olfactory hallucinations after insular glioma surgery: a case report

Introduction and importance: There are various types of hallucinations reported in the literature (auditory, visual, tactile, gustatory, or olfactory), and most of them are related to psychiatric (schizophrenia) disorders. Olfactory hallucinations related to neurosurgical disorders are uncommon. The authors present a case of a patient with a left insular glioma who developed transient olfactory hallucinations after microsurgical resection of the tumor. Our Objective is to share a rare case of postoperative complication—olfactory hallucination following insular glioma surgery—which can potentially raise awareness among practicing neurosurgeons. Case presentation: A 32-year-old male patient underwent left insular glioma resection at our institution in 2024. He developed transient olfactory hallucinations after microsurgical resection of the tumor, which resolved within a month postoperatively. Clinical discussion: Insular gliomas often grow to a considerable size before becoming symptomatic in many patients. The insular region is regarded as one of the brain’s most sophisticated areas, with lesions manifesting in a wide range of symptoms and syndromes including olfactory hallucinations. Conclusion: Olfactory hallucinations following left insular glioma resection can potentially raise awareness among practicing neurosurgeons regarding this rare postoperative complication. These types of postoperative complications may resolve in a short period if no serious vascular injury has been encountered.

De novo variants disrupt an LDB1-regulated transcriptional network in congenital ventriculomegaly.

Congenital hydrocephalus (CH), characterized by cerebral ventriculomegaly (CV), is among the most common and least understood pediatric neurosurgical disorders. We have identified in the largest-assembled CV cohort (>2,697 parent-proband trios) an exome-wide significant enrichment of protein-altering de novo variants (DNVs) in LDB1 (p = 1.11 x 10-15). Eight unrelated patients with ventriculomegaly, developmental delay, and dysmorphic features harbored loss-of-function DNVs that truncate LDB1's carboxy-terminal LIM interaction domain, which regulates assembly of LIM homeodomain-containing transcriptional modulators. Integrative multiomic analyses suggest LDB1 is a key transcriptional regulator in ventricular neuroprogenitors through it's binding to LIM-homeodomain proteins, including SMARCC1 and ARID1B. Indeed, LIM-homeodomain-containing genes carry a disproportionate burden of protein-damaging DNVs in our cohort, with SMARCC1 (p = 5.83 x 10-9) and ARID1B (p = 1.80 x 10-17) surpassing exome-wide significance thresholds. These data identify LBD1 as a novel neurodevelopmental disorder gene and suggest an LDB1-regulated transcriptional program is essential for human brain morphogenesis.

Challenges and Progress in Neurosurgery: A Comprehensive Assessment of the Landscape in Nepal.

A large portion of the global population lacks access to essential surgical care, despite surgical conditions contributing significantly to the overall burden of disease worldwide. This burden is heaviest in developing countries like Nepal, where disparities in access to surgery for neurosurgical disorders stem from health system failures including an inadequate neurosurgical workforce, lack of requisite neurosurgical equipment, and challenges in perioperative care. By bibliometric analysis of neurosurgery-related publications in Nepal through PubMed search using the search terms "Neurosurg* AND Nepal", we have found a total of 528 articles with a notable increase in the number of such publications from 14 to 25 between 2015 and 2016, with over 300 published in 2021, 2022, and 2023. Nepal has also seen a drastic increase in neurosurgeon density from 0.166 per 100,000 population in 2016 to 0.377 per 100,000 population in 2023 compared to 0.780in China, 0.274in India, 0.130in Bhutan, and 0.092per 100,000 population in Bangladesh in 2023. This study underscores the pressing need for enhanced neurosurgical capacity and improved health equity in Nepal.

Tobacco Use and Trigeminal Neuralgia: Clinical Features and Outcome After Microvascular Decompression.

Tobacco use is known to affect incidence and postoperative outcome for several neurosurgical disorders, but its relationship to trigeminal neuralgia (TN) is not known. We sought to identify unique population characteristics that correlate with tobacco use in a cohort of patients with TN who underwent microvascular decompression (MVD), including effect on long-term postoperative outcome. Data about 171 patients with classic TN treated with MVD were obtained from a prospectively maintained registry. Patients were classified as smokers or nonsmokers based on the use of tobacco within the 6 months before surgery. Analysis of clinical characteristics and postoperative outcome was performed. Compared with nonsmokers with TN, MVD patients using tobacco were significantly younger (53 vs 62 years, P < .01) and less likely to report pain in a single distribution of the trigeminal nerve (36% vs 65%, P < .01). There was no difference between smokers and nonsmokers in the presence of some degree of continuous pain, severity of neurovascular compression, sex, race, obesity, pain duration before presentation, immediate postoperative outcome, length of stay, or postoperative complication profile. Among 128 patients followed for at least 6 months, smokers were significantly less likely to be pain-free off medications at the last follow-up (36% vs 57%, P < .05). In patients undergoing MVD for TN, smoking is associated with younger age of TN onset, more widespread facial pain, and worse long-term postoperative outcome after MVD. These features suggest that TN in smokers may represent a more severe disease form compared with TN in nonsmokers with different responses to treatment.

Factors associated with radiographic progression and neurologic decline in patients with isolated traumatic subarachnoid hemorrhage

BackgroundComplicated mild traumatic brain injury (cmTBI) is a common neurosurgical disorder that consumes a significant amount of healthcare resources without a clearly established benefit. Best practices for the management of cmTBI regarding triage, hospital admission, and the necessity for repeat imaging are controversial. Our objective is to describe the rate of radiographic progression and neurologic decline for isolated traumatic subarachnoid hemorrhage (itSAH) patients admitted to the hospital. We hypothesized that only a minority of itSAH patients suffer radiographic progression and that radiographic progression is not necessarily associated with neurologic decline.MethodsDatabase queries and direct patient chart reviews were used to gather patient data. T-tests and Fisher’s exact tests were performed.ResultsA total of 340 patients with cmTBI associated with itSAH were included for analysis. The radiographic progression rate was 5.6%. There was no statistically significant association between age, gender, GCS at presentation, anticoagulation status, and risk of radiographic progression. However, subgroup analysis on anticoagulated patients did show those on warfarin had a statistically significant risk of radiographic progression (p = 0.003). No patient developed neurologic decline, irrespective of whether they developed radiographic progression.ConclusionSecondary triaging, hospital admission, ICU stay, and repeat HCT might not be necessary for awake, GCS 13–15 patients with itSAH without any other significant injuries. In the case of anticoagulant use, but not necessarily antiplatelet use, the medication should be reversed, and admission should be considered.

Spina bifida transition care in India: strengths amidst challenges.

In India, adult neurosurgeons are required to care for children regularly because the concept of dedicated pediatric specialty care is not yet entirely established in the subcontinent. Likewise, pediatric neurosurgeons do not exclusively offer their services to the young, but they also provide care to adult patients with neurosurgical disorders. This creates a medical system where the transition between specialties is not often a formal and recognized aspect of neurosurgical care because most neurosurgeons provide care for patients of all ages. Additionally, there are very few teams geared toward caring for conditions in children that merit lifelong medical support, with spina bifida (SB) being one of them. Since there are no focused or structured pediatric programs on a large scale, developing a multidisciplinary clinic for adults becomes challenging. A pragmatic approach using technology-based education, supported by an organized system or a coordinator, may be a new strategy. A new system utilizing telemedicine and smartphones for established patients maybe an alternative option for SB children in India. During virtual video conferences, an established patient may benefit from multispecialty care and education toward a smooth transition that avoids significant issues with time, transportation, or financial constraints. Achieving a seamless transition among allied specialists from the pediatric to adult systems is a utopia. The current system in the subcontinent may be improved, with an opportunity to develop smooth transition care between coordinated specialists (who simultaneously treat children and adults). Learning from various global SB management styles, the Indian transition situation may offer another model in the near future.

Intracranial pressure following surgery of an unruptured intracranial aneurysm—a model for normal intracranial pressure in humans

ObjectiveOptimizing the treatment of several neurosurgical and neurological disorders relies on knowledge of the intracranial pressure (ICP). However, exploration of normal ICP and intracranial pressure pulse wave amplitude (PWA) values in healthy individuals poses ethical challenges, and thus the current documentation remains scarce. This study explores ICP and PWA values for healthy adults without intracranial pathology expected to influence ICP.MethodsAdult patients (age > 18 years) undergoing surgery for an unruptured intracranial aneurysm without any other neurological co-morbidities were included. Patients had a telemetric ICP sensor inserted, and ICP was measured in four different positions: supine, lateral recumbent, standing upright, and 45-degree sitting, at day 1, 14, 30, and 90 following the surgery.ResultsICP in each position did not change with time after surgery. Median ICP was 6.7 mmHg and median PWA 2.1 mmHg in the supine position, while in the upright standing position median ICP was − 3.4 mmHg and median PWA was 1.9 mmHg. After standardization of the measurements from the transducer site to the external acoustic meatus, the median ICPmidbrain was 8.3 mmHg in the supine position and 1.2 mmHg in the upright standing position.ConclusionOur study provides insights into normal ICP dynamics in healthy adults following a uncomplicated surgery for an unruptured aneurysm. These results suggest a slightly wider normal reference range for invasive intracranial pressure than previously suggested, and present the first normal values for PWA in different positions. Further studies are, however, essential to enhance our understanding of normal ICP.Trial registration The study was preregistered at www.clinicaltrials.gov (NCT03594136) (11 July 2018)

Can Artificial Intelligence Mitigate Missed Diagnoses by Generating Differential Diagnoses for Neurosurgeons?

Neurosurgery emphasizes the criticality of accurate differential diagnoses, with diagnostic delays posing significant health and economic challenges. As large language models (LLMs) emerge as transformative tools in healthcare, this study seeks to elucidate their role in assisting neurosurgeons with the differential diagnosis process, especially during preliminary consultations. This study employed three chat-based LLMs, ChatGPT (versions 3.5 and 4.0), Perplexity AI, and Bard AI, to evaluate their diagnostic accuracy. Each LLM was prompted using clinical vignettes, and their responses were recorded to generate differential diagnoses for 20 common and uncommon neurosurgical disorders. Disease-specific prompts were crafted using Dynamed, a clinical reference tool. The accuracy of the LLMs was determined based on their ability to identify the target disease within their top differential diagnoses correctly. For the initial differential, ChatGPT 3.5 achieved an accuracy of 52.63%, while ChatGPT 4.0 performed slightly better at 53.68%. Perplexity AI and Bard AI demonstrated 40.00% and 29.47% accuracy, respectively. As the number of considered differentials increased from two to five, ChatGPT 3.5 reached its peak accuracy of 77.89% for the top five differentials. Bard AI and Perplexity AI had varied performances, with Bard AI improving in the top five differentials at 62.11%. On a disease-specific note, the LLMs excelled in diagnosing conditions like epilepsy and cervical spine stenosis but faced challenges with more complex diseases such as Moyamoya disease and ALS. LLMs showcase the potential to enhance diagnostic accuracy and decrease the incidence of missed diagnoses in neurosurgery.

Causal associations of COVID‐19 on neurosurgical diseases risk: a Mendelian randomization study

Many researchers have explored the potential association between one neurosurgical disease and coronavirus disease 2019 (COVID-19), but few systematically analyzed the association and causality between COVID-19 and various neurosurgical diseases. A Mendelian randomization analysis was conducted to evaluate the causal association between COVID-19 (including critically ill COVID‐19, hospitalized COVID‐19, and respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection) and 30 neurosurgical diseases within European populations. The consequences of inverse variance weighted models suggest that genetic susceptibility of critically ill COVID-19 may increase the risk of cerebral infarction (odds ratio [OR] = 1.02; p‐value = 0.006), genetic susceptibility of SARS-CoV-2 infection may increase the risk of stroke (OR = 1.02; p‐value = 0.047), and conversely, genetic susceptibility of hospitalized COVID-19 may reduce the risk of pituitary adenoma and craniopharyngioma (OR = 0.90; p‐value = 0.032). In addition, evidences revealed potential associations between genetic susceptibility of COVID-19 and spinal stenosis (OR = 1.03; p‐value = 0.028), diffuse brain injury (OR = 1.21; p‐value = 0.040) and focal brain injury (OR = 1.12; p‐value = 0.040). By testing for heterogeneity and pleiotropy, the above causal conclusions are robust. In summary, our analysis shows that COVID-19 has an independent and powerful causal influence on multiple neurosurgical disorders.

Impact of the coronavirus disease 2019 pandemic on neurosurgical patients in Taif city, Saudi Arabia

ABSTRACT Background: During the coronavirus disease 2019 (COVID-19) pandemic, the healthcare systems were obligated to work at more than maximum capacity for time due to the high transmission rate and incidence of newly infected cases. During the pandemic, all priority was given to COVID-19 cases, as the pandemic stream may exceed the health-care system’s available resources, affecting many other patients, including those with neurosurgical disorders. Aim: This study was designed to assess how COVID-19 affected neurosurgical patients. Materials and Methods: A retrospective study included all patients who were admitted to the neurosurgical department at King Abdulaziz Specialist Hospital, King Faisal Medical Complex, and Al-Hada Armed Forces Hospital during the COVID-19 pandemic. The data were collected in 5 months (April–August 2022) from the records of accessible patients. Results: A total of 777 neurosurgical patients were included 474 (61%) patients were male and 303 (39%) were female. The mean age of the patients was 41.2 ± 13.9 years old. A total of 481 (61.9%) patients were admitted before the pandemic, and 120 (15.4%) were admitted during the lockdown, 176 (22.7%) were admitted after the lockdown. The patient’s length of stay ranged from 1 day to more than 1 year, where 307 (39.5%) stayed for 1 week, and only 87 (11.2%) stayed for more than 2 weeks. 338 (70.7%) cases were Priority 1A emergencies, 17.8% improved, 52 (6.7%) remained stationary, while 7 (0.9%) showed clinical deterioration, and 15 (1.9%) died. Conclusion: According to the results of this study, both the admission rate for cases and the clinical outcome for neurosurgical patients were adversely affected by the COVID-19 pandemic. Compared to nonurgent cases, urgently admitted cases showed greater improvement.

Global neurosurgery: the need of the hour for developing countries

Global neurosurgery is relatively a new sub-discipline of global surgery. It is an area of study, research, practice, and advocacy that focuses on enhancing health outcomes and promoting health equity for all individuals around the world who are afflicted by neurosurgical disorders or require neurosurgical care. Low- and middle-income countries (LMICs) around the world have not benefited from advances in neurosurgery; most have little or no neurosurgical capacity in their entire country. The need of the hour is that a global problem necessitates a global response with a common vision and objectives.

Spinal Stenosis with Sacral Osseous Deformity Mimicking Chronic Inflammatory Demyelinating Polyneuropathy

BACKGROUND: Differential diagnoses of neurosurgical spinal disorders and polyneuropathies have been recognized to cause clinical perplexity, occasionally misdiagnosing chronic inflammatory demyelinating polyneuropathy (CIDP). When nerve conduction studies and cerebrospinal fluid (CSF) analyses reinforce a certain clinical presentation, the importance of imaging studies, conservative treatment response, and interdisciplinary clinical approach should be highly emphasized. CASE PRESENTATION: We report a 51-year-old patient who presented with a 16-week history of neurogenic claudication and right-sided lower extremity monoparesis, with low back pain syndrome dating from 10 years ago. He was initially evaluated by a neurologist under the suspicion of CIDP, supported by nerve conduction studies and CSF analyses, without any subjective or objective improvements after systemic corticosteroid therapy. After performing magnetic resonance imaging (MRI) of the lumbosacral spine, he was referred to a neurosurgeon. Neurological examination revealed features of lower motor neuron lesion, consistent with the MRI findings of L4-L5 and L5-S1 stenosis with right-sided S1 vertebra osseous deformity, without any radiographic evidence of CIDP. The patient underwent surgery and improvements were noted early in the post-operative recovery phase and continuously throughout the regular monthly follow-ups, without any clinical features of CIDP. Histopathology results confirm sacral osseous deformity. No evidence of CIDP, osseous deformity residue, or recurrence was evident on the post-operative MRI control performed 11-month post-surgery. CONCLUSIONS: Degenerative spinal stenosis compromising spinal canal dimensions can mimic CIDP due to sharing multiple clinical similarities. That scenario is especially highlighted when age-related spinal degenerative disease is unexpected and seldom aggravated by spinal osseous lesions. Avoiding misdiagnosis and providing adequate treatment can pose a serious challenge for neurosurgeons and neurologists, demonstrating the importance of an interdisciplinary approach toward diverse spinal disorders.

Above-The-Hairline Suboccipital Transverse Approach for the Treatment of Chiari I Malformation.

Chiari I malformation is a common pediatric neurosurgical disorder with an established treatment paradigm. Posterior fossa decompression and duraplasty (PFDD) is associated with symptom improvement but it carries postoperative risk, particularly cerebrospinal fluid (CSF) leak and wound complications. In addition, the cosmetic outcomes of PFDD have been overlooked in the literature. To describe a novel approach for PFDD in which the transverse surgical incision is completely hidden above the hairline and to report early outcomes in a prospective patient cohort. Clinical and cosmetic outcomes were recorded for 15 consecutive pediatric patients who underwent PFDD for Chiari I malformation via the above-the-hairline transverse suboccipital approach. The median clinical follow-up time was 6 months (range 1-12 months), and the majority of patients experienced significant improvement of their preoperative symptoms. Three patients (20%) experienced complications associated with surgery, which included injury to the greater occipital nerve, CSF hypotension and subfascial pseudomeningocele, and superficial wound dehiscence that resolved spontaneously with oral antibiotics. Zero patients (0%) returned to the operating room for persistent CSF leak, deep wound infection, or revision decompression. An excellent cosmetic outcome was achieved in 12 patients (80%). No patient had a poor cosmetic outcome. The above-the-hairline transverse suboccipital approach for PFDD in patients with Chiari I malformation offers favorable cosmetic outcomes and fascial closure while permitting adequate decompression.

An 8-year, single-centre experience of primary image-guided insertion of 'button' gastrostomy catheters: Technical and clinical results.

'Button' gastrostomy insertion is traditionally a two-step procedure with an initial longer gastrostomy tube inserted followed by placement of the shorter 'button' gastrostomy in 6 weeks when the track is mature. The aim of this study is to assess whether the placement of a Button gastrostomy de novo is a safe and effective method of radiologically inserted gastrostomy (RIG) insertion. Using our PictureArchive and Communication System (PACS) and electronic patient charts we identified all patients who underwent primary 'button' gastrostomy over an 8-year period with at least a 1-year follow-up period. We evaluated technical success rate, indications for insertion, major and minor complications, 30-day mortality and the number of exchanges performed. Overall, 482 patients underwent a primary button RIG insertion during this period with an overall success rate of 97.1%. Indications for RIG insertion included neurological and neurosurgical disorders 236 (48.9%), head and neck malignancy 182 (37.8%), oesophageal malignancy 27 (5.6%) and other indications in 37 (7.7%). The mean age was 59.55 years (range 18-88 years) with 290 men (60.2%) and 192 women (39.8%). Major complications were recorded in 0.8% and minor complications in 1.7%. A 30-day mortality of 1% was identified (five patients), mortality was directly related to the RIG insertion in one patient (0.2%). A total of 65 exchanges/replacements took place over this period of time, with 33 (50.1%) due to 'inadvertent removal'. Primary button RIG insertion is a procedure that has a high success rate and low morbidity and mortality. We believe it is a safe and effective alternative to deliver enteral nutrition.

Swedish trial on embolization of middle meningeal artery versus surgical evacuation in chronic subdural hematoma (SWEMMA)—a national 12-month multi-center randomized controlled superiority trial with parallel group assignment, open treatment allocation and blinded clinical outcome assessment

BackgroundChronic subdural hematoma (cSDH) is one of the most common neurosurgical disorders and the incidence is rising. The routine treatment is neurosurgical hematoma evacuation, which is associated with recurrence rates up to 10–25%. In recent years, endovascular embolization of the middle meningeal artery (eMMA) has garnered much attention due to recurrence rates as low as < 5%. Several randomized controlled trials are planned or ongoing. In most of these trials, conventional neurosurgical treatment with or without adjunctive endovascular embolization is compared. The proposed trial aims to conduct a head-to-head comparison between neurosurgical and endovascular treatment as stand-alone treatments.MethodsThe trial is academically driven and funded within existing public healthcare systems and infrastructure. Patients with uni- or bilateral cSDH, presenting with mild-to moderate symptoms, and admitted to neurosurgery on clinical grounds will be offered participation. Subjects are randomized 1:1 between conventional neurosurgical treatment (control) and endovascular embolization of the middle meningeal artery (intervention). Primary endpoint is reoperation due to clinically and/or radiologically significant recurrence within 3 months. Secondary endpoints include safety, technical success rate, neurological disability, and quality of life.DiscussionThere are mounting retrospective data suggesting eMMA, as sole treatment or as an adjunctive to neurosurgery for cSDH, is safe and effective with a reoperation rate lower than neurosurgical hematoma evacuation alone. If randomized controlled trials confirm these findings, there is a potential for a paradigm shift in the treatment of cSDH where a minimally invasive procedure can replace open surgery in a large and oftentimes old and fragile patient cohort.Trial registrationClinicalTrials.gov, ClinicalTrials.gov Identifier NCT05267184. Registered March 4, 2022.

Practice and associated factors of Glasgow Coma Scale assessment among nurses working in adult intensive care units of federally administered hospitals in Addis Ababa, Ethiopia

Background &amp; Aim: The Glasgow Coma Scale is a helpful instrument for measuring patients’ level of consciousness with neurosurgical disorders. Literature showed a majority of nurses don’t believe the Glasgow Coma Scale assessment is their area of practice. This study aimed to examine the Glasgow Coma Scale assessment practice and associated factors among nurses working in adult intensive care units of federally administered hospitals&#x0D; Methods &amp; Materials: : Institutional-based cross-sectional study was conducted on conventionally selected 126 nurses working in adult intensive care units. Six clinical scenarios were used to assess practice, and those who correctly answered at least four scenario questions out of 6 practical scenario questions for the Glasgow Coma Scale assessment were considered good practice. Data was collected using a self-administered questionnaire. The Chi-square test was applied to examine the variables affecting Glasgow Coma Scale practice. Furthermore, the proportions of categorical variables’ replies were contrasted among the various groups.&#x0D; Result: With a response rate of 96.03%, 121 nurses participated in the study. (53.7%) was males. In this study, the overall good Glasgow Coma Scale assessment practice of intensive care units nurses was 47.1%. Lack of training (77.7%), job overload (73.6%), and insufficient knowledge and skills (61.2 %) are barriers for nurses to assess Glasgow Coma Scale.&#x0D; Conclusion: In this, only nearly half of the participants displayed good practice on the Glasgow Coma Scale. Sex and educational status were both found to be significant factors in nurses’ Glasgow Coma Scale assessment practice.

Management of Adult Chiari I Patients Based on CSF Flow Magnetic Resonance Imaging: Experience of Two Neurosurgical Centers.

Chiari malformation type 1 (CM1) is one of the most discussed neurosurgical disorders. No consensus exists how to manage adult CM1 patients. We aimed to evaluate all adult CM1 patients consecutively managed at our institutions and discuss our approach based on the phase-contrast (PC) magnetic resonance imaging (MRI). The medical charts of adult patients diagnosed with CM1 at two referral neurosurgical centers between 2010 and 2017 were reviewed. The patients were either managed conservatively or surgically. We evaluated the patients clinically with the Chicago Chiari Outcome Scale (CCOS). The radiologic diagnosis was based on both craniocervical and PC-MRI. Ninety adult CM1 patients were managed conservatively. Conservative treatment failed in 5 of these 90 patients. Seventy-two patients (including those 5 patients who did not benefit from conservative treatment) underwent posterior fossa decompression with duraplasty. Eighty-five patients (94.4%) from the conservative group and 61 patients (84.7%) from the surgical group were treated successfully. An aqueductal stroke volume (ASV) value of 12 µL was found as the cutoff value for surgical candidates. A strong positive correlation between the increase in ASV values and clinical improvement was observed. PC-MRI can help in the management and follow-up of adult CM1 patients. Conservative management is possible in selected symptomatic CM1 patients with a high ASV (ASV > 15 µL). Surgery should be considered in patients with an ASV ≤ 12 µL. CM1 patients with ASV ≤12 to >15 μL require close follow-up. Long-standing symptoms, severe sleep apnea, symptoms influencing functionality, and syrinx are factors that affected outcomes negatively.

Improving the detection of ventricular shunt disruption using volume-rendered three-dimensional head computed tomography

Hydrocephalus is the most common neurosurgical disorder in children, and cerebrospinal fluid (CSF) diversion with shunt placement is the most commonly performed pediatric neurosurgical procedure. CT is frequently used to evaluate children with suspected CSF shunt malfunction to assess change in ventricular size. Moreover, careful review of the CT images is important to confirm the integrity of the imaged portions of the shunt system. Subtle shunt disruptions can be missed on multiplanar two-dimensional (2-D) CT images, especially when the disruption lies in the plane of imaging. The use of volume-rendered CT images enables radiologists to view the extracranial shunt tubing within the field of view as a three-dimensional (3-D) object. This allows for a rapid and intuitive method of assessing the integrity of the extracranial shunt tubing. The purpose of this pictorial essay is to discuss how volume-rendered CT images can be generated to evaluate CSF shunts in the pediatric population and to provide several examples of their utility in diagnosing shunt disruption. We also address the potential pitfalls of this technique and ways to avoid them.

Does modern research validate the ancient wisdom of gut flora and brain connection? A literature review of gut dysbiosis in neurological and neurosurgical disorders over the last decade.

The connection between gastrointestinal microbiota and the brain has been described in ancient medical texts and is now well established by research. It is a bidirectional communication which plays a critical role in regulating not only the gastrointestinal homeostasis but has also been linked to higher emotional and cognitive functions. Recent studies have sought to expand on this concept by providing concrete evidence of the influence of gut microbiome on a wide array of diseases and disorders of the central nervous system. This article reviews the most recent literature published on this subject, over the previous decade and aims to establish the role of a healthy gut microbiome and probiotics as an effective adjunct in health and management of diseases of the nervous system. A literature search on PubMed database was conducted using keywords including "gut brain-axis," "gut dysbiosis," "neuropsychiatric disorders," "neurodegenerative disorders," "probiotic," and "traumatic brain injury." The search was performed without any publication date restrictions. Both animal and human studies evaluating the role of gut dysbiosis on various neurological and neurosurgical diseases, published in peer-reviewed journals, were reviewed. Current studies do not provide conclusive evidence of a direct origin of CNS disorders from gut dysbiosis, but a possible modulatory role of gut microbiota in certain neurological disorders has been implicated. An understanding of this connection can aid in finding novel therapeutic strategies for the management of neurological disorders associated with memory dysfunctions and brain and spinal cord injuries.

Pattern and frequency of neurological and neurosurgical care of adult inpatients and outpatients at a tertiary referral hospital in Kenya.

ObjectiveTo describe the patterns and burden of neurological and neurosurgical disorders at a national tertiary level referral hospital in western Kenya.MethodsWe conducted a three-month period prevalence study. We recruited consecutive adult patients seeking neurological-neurosurgical care in both inpatient and outpatient settings at Moi Teaching and Referral Hospital.Results833 participants were included. The age range was between 19 year and 99 years (mean age = 45.3 years). The most common diagnoses among neurology inpatients were meningitis (12%), ischemic stroke (11.0%) and epilepsy/seizure (6.7%). Among neurology outpatients, epilepsy (35.1%) and ischemic stroke (18.8%) were the most common diagnoses. The most common neurosurgery inpatient diagnosis was hemorrhagic stroke (16.3%) and among outpatients, the most common diagnoses were traumatic brain injury (17.4%) and hemorrhagic stroke (16.3%). Overall, 471 (56.5%) patients underwent HIV testing, of which, 89 (18.9%) were HIV positive and 382 (81.1%) were HIV negative. Thirty-one inpatient deaths (male 58%), attributable to neurological and neurosurgical disorders, occurred during the study period. Meningitis was the most common cause of death.ConclusionsThe findings suggest that meningitis, stroke, epilepsy, and traumatic brain injury were the most common diagnosis. More resources and efforts should be directed towards prevention, diagnosis and management of these conditions in the region.