Speakers

Cranial Missile & gunshot Injuries
1108 13:10-13:20
Neuro-trauma & Intensive Care/303A
Craniocerebral missile injuries are a cause of serious concern to a military surgeon operating in battlefield conditions, as well as to his/her civilian counterpart in urban areas or rural hinterland. Successive wars all over the world have witnessed increasing lethality of the missiles, whether bullets or shrapnel, due to their increased accuracy, and higher velocity. Outcome in low velocity missile injuries, as well in those injuries with good Glasgow Coma score has been uniformly good. Injuries due to high velocity injuries on the other hand carry grave prognosis inspite of improved care at the forward echelons, better evacuation facilities and availability of neuroimaging. Neuroimaging and critical care facilities have brought a change in the approach to these injuries. Patients with these injuries can now be selected and operated upon with precision and with a brain-conserving attitude. A less aggressive approach (in comparison to what was being advocated till the seventies) is now a universally followed principle. Predictably, this has led to controversies about the exposure (craniotomy or craniectomy), extent of debridement, attitude towards retained intracranial fragments, and surgery of sequelae, like hydrocephalus, cerebrospinal fluid rhinorrhea, cerebral abscess, etc. Role of critical care and medical management (antibiotics, cerebral decongestants, anticonvulsants, etc) assumes equal importance with operative management. Patients with retained intracranial splinters need long-term follow-up to detect migration, suppurative complications, hydrocephalus, etc.

Preserving the Dandy's vein during Microvascular Decompression for Trigeminal Neuralgia
1110 08:00-08:10
Functional Neurosurgery & Epilepsy/304A
Petrosal (Dandy’s) vein section certainly improves the view of the entire segment of trigeminal nerve, and eases the dissection and displacement of the offending vascular loop pressing the nerve. Caudal retraction on the cerebellum as advocated can tear the connection between the vein and the superior petrosal sinus, and torrential venous bleed that may be annoying and time consuming to control. In both these situations, venous drainage of the cerebellar hemisphere is generally not compromised. However, in an uncertain number of patients, there may be venous infarction and cerebellar swelling in the early postoperative period, resulting in obtundation, brainstem compression, apnea and death. The exact incidence of such complication is uncertain, since many of the patients with trigeminal neuralgia are elderly with comorbidities, and an unfavorable outcome may be ascribed these factors. Yuanxuan et al (2020) reported no difference in venous complications among the patients who underwent venous sacrifice and those who did not However, should venous sacrifice be carried out ad libitum? Anichini et al (2016) published a case report and reviewed previous reported complications following sacrifice of superior petrosal vein. Zhong et al (2008) reported response to temporary occlusion of the superior petrosal vein while monitoring brainstem auditory evoked responses and trigeminal evoked responses and avoided sacrificing the vein in patient showing adverse response. They observed unfavorable response in five out of 53 patients (8.9%) who underwent temporary occlusion. In three of these five patients, the vein was sacrificed, with poor outcome and persistent neurological morbidity. They cautioned against such sectioning of the vein. Thus, while a dural arteriovenous fistula in the trigeminal root zone can be tackled by sectioning the vein, the superior petrosal vein complex should be treated with respect, and care must be taken to avoid its avulsion or sectioning. Microvascular decompression should be accomplished working around the veins, taking care not to avulse or divide the connection between the superior petrosal vein and superior petrosal sinus. 1. Yuanxuan Xia, Kim Timothy Y, Mashouf Leila A, et al. Absence of complications after sacrificing the superior petrosal vein during microvascular decompression. Operative Neurosurgery 2020; 18(3): 316-320. 2. Anichini Giulio, Iqbal Mazhar, Rafiq Nasir Muhammad, Ironside James W, Kamel Mahmoud. Sacrificing the superior petrosal vein during microvascular decompression. Is it safe? Learning the hard way. Case report and review of literature. Surg Neurol Intl 2016; 7(suppl 14): S415-S420. 3. Zhong Jun, Li Shi-Ting, Xu Shun-Qing, Wang Liang, Wang Xuhui. Management of petrosal vein during management of trigeminal neuralgia. Neurol Res 2008; 30: 697-700.