Prajwal Ghimire

King's College Hospital NHS Foundation Trust · Department of Neurosurgery

BACKGROUND Patient-reported outcome measures (PROMs) play an important role in the evaluation of health outcomes, quality of life, and satisfaction, and have been successfully utilized in many areas of clinical medicine and surgical practice. The prevalence of PROMs in neurosurgery is not known. OBJECTIVE To review the PROMs that have been utilized...

Background Patient-reported experience measures (PREMs) are a unique measure of experience of patients which can help address the quality of care of the patients.Objective Our aim of the study is to collect quality of care outcomes with our newly navigated transcranial magnetic stimulation patient-reported experience measure (nTMS-PREMs) questionna...

Background Lesions within the primary motor cortex (M1) and the corticospinal tract (CST) represent a significant surgical challenge with a delicate functional trade-off that should be integrated in the overall patient-centered treatment plan. Methods Patients with lesions within the M1 and CST with preoperative cortical and subcortical mapping (na...

Penfield's motor homunculus describes a caricaturised yet useful representation of the map of various body parts on the pre-central cortex. We propose a supplemental map of the clinically represented areas of human body in pre-central cortex and a novel subcortical corticospinal tract map. We believe this knowledge is essential for safe surgery in...

Objectives: We aim to demonstrate intraoperative recording of cerebellar to cortical pathways that have not been previously recorded in humans, though imaged. Methods: We report two cases with intraoperative neurophysiological mapping of cerebello-cortical tracts. Direct electrical stimulation of subcortical cerebellum along with recordings of c...

Subependymal Giant Cell Astrocytoma (SEGA) is a common diagnosis in patients with Tuberous Sclerosis. Although surgical treatment is often required, resection may entail a significant risk for cognitive function given the anatomical relation with critical structures such as the fornices and subgenual area. Therefore, target subtotal resections usin...

Objectives The study aims to review therapeutic strategies in the management of craniospinal tumours in pregnant patients and the factors that may influence the management along with their influence on maternal & foetal outcomes. Materials and Methods A retrospective single-centre cohort study was performed at a tertiary neurosurgical referral c...

A Proposal for Supplemental Cortical and novel Subcortical Maps to the Motor Homunculus

Hemangiopericytoma (HPC) of the trigeminal nerve is extremely rare. We present a case of a large cystic HPC of the mandibular division of the trigeminal nerve, only the third case described in the literature, with both intradural and extradural components. We describe the surgical approach, assisted by neurophysiological techniques of mapping and m...

Background: The role played by the non-dominant parietal lobe in motor cognition, attention and spatial awareness networks has potentiated the use of awake surgery. When this is not feasible, asleep monitoring and mapping techniques should be used to achieve an onco-functional balance. Objective: This study aims to assess the feasibility of a dual-...

Background: The role played by the non-dominant parietal lobe in motor cognition, attention and spatial awareness networks has potentiated the use of awake surgery. When this is not feasible, asleep monitoring and mapping techniques should be used to achieve an onco-functional balance. Objective: This study aims to assess the feasibility of a du...

Background: Intraoperative neuromonitoring of motor functions experienced a dramatical revolution in the last years thanks to significant advances in anesthesiology procedures and both preoperative and intraoperative mapping techniques. Asleep, awake, and combined intraoperative mapping techniques were responsible for an improvement in the functio...

Aim • To assess the possibility of a dual strip method to obtain direct cortical stimulation for continuous real-time cortical monitoring and subcortical mapping of motor and visual pathways simultaneously Methods • Prospective single-centre study • Parietal lobe lesions resected with dual subdural strip electrodes for cortical subcortical mapping...

Persistent primitive olfactory artery (PPOA) is a rare variant of the proximal anterior cerebral artery 1,2. It is proposed to be more prone to aneurysms due to its sharp hairpin-like turn. Embryologically, the PPOA is the rostral division of the primitive internal carotid artery.

Background Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise di!erences in...

Alpha-fetoprotein (AFP) in the cerebrospinal spinal fluid (CSF) have been reported as a tumour marker for some intracranial tumours with yolk sac elements, and teratoma 1.

Intracranial yolk sac tumours usually are located commonly in the pineal gland, suprasellar and posterior third ventricular region 1,2. Primary YST has also been reported in the spinal cord 3.

Embryonal tumours with multilayered rosettes (ETMR) are rare small round blue cell tumour of the central nervous system and are one of the most aggressive brain tumours usually encountered in children and are WHO grade 4 tumours.

Infants have a relatively large head size as compared to their body mass, weak neck muscles, large subarachnoid space, relatively flat skull base and pliable, thin skull. The infant's brain is relatively soft due to higher water content, lack of myelinated axons and immature glial cells. These factors make infants more prone to shearing injuries. A...

To the Editor: We read with great enthusiasm the article published by Khalafallah et al.1 The authors address an utmost point of importance in contemporary glioma surgery: an operational definition for supratotal resection (SpTR) in glioblastoma (GBM). We believe this is a potential landmark article on this subject because it paves the way toward...

Objectives: The study aims to evaluate therapeutic strategies in the management of craniospinal tumours in pregnant patients and the factors that influence the management along with their influence on maternal & foetal outcomes. Materials and Methods: A retrospective single-centre cohort study was performed at a tertiary neurosurgical referral ce...

Intraoperative neuromonitoring of motor functions experienced a dramatical revolution in the last years due to significant advances in anaesthesiology procedures and both preoperative and intraoperative mapping techniques. Asleep, awake and combined intraoperative mapping techniques were responsible for an improvement in the functional outcomes in...

We propose a supplemental map to Penfield motor homunculus in the pre-central cortex and a novel subcortical map of the cortico-spinal tract that are accurate and essential for safe surgery in patients with eloquent brain lesions.

The identification of the visual pathway during surgery for tumors in visual areas is challenging. We present our experience in visual pathway mapping and monitoring, describing the role of direct mapping of the optic radiations and different techniques of VEPs monitoring, employing both Scalp Recording (SR) and the use of strip electrode positione...

Introduction Chronic Subdural Hematoma (CSDH) is a neurological condition characterized as a hematoma in the subdural space with a period >3 weeks that primarily affects the elderly. Glucocorticoid, especially dexamethasone, either alone or combined with surgery, has been used to manage CSDH. We aimed to perform an updated systematic review and met...

We enthusiastically read the historical vignette on neurosurgical spinal oncology and its current modern-day practices by Shao et al published recently. 1 We agree with the authors that the numerous developments in spinal neuro-oncological surgery and microsurgery are enhancing the current practice of maximal safe resection and have optimized patie...

Background: There are many questions that remain unanswered regarding outcomes following cranioplasty including the timing of cranioplasty following craniectomy as well as the material used. Objective: To establish and evaluate 30-d outcomes for all cranial reconstruction procedures in the United Kingdom (UK) and Ireland through a prospective mu...

Letter: We enthusiastically read the recent historical review on endoscopic spinal discectomy published by Yong Ahn.1 The author provides a concise and evidence-based review of the use of endoscope in spinal procedures, and explains the progression from intradiscal to epidural procedures and the new range of applications beyond disc-centered pathol...

To the Editor: Keeble et al from our institution recently reported on the reliability and feasibility of combining electromagnetic (EM) neuronavigation systems and intraoperative neuromonitoring (IONM). Strategies to minimize the electrical interference from the EM navigation system to allow accurate recording of intra- operative somatosensory evok...

In this review, we summarise the current knowledge regarding the Superior Longitudinal Fasciculus(SLF) I and II. These fibres represent a longitudinal association tract between the parietal and frontal lobes of the brain. We highlight the anatomical representation of the SLF I and II in the primate and in the human brain. The fibres of the SLF I e...

Objective: The study analyzes the monitoring and subcortical mapping techniques for intra-axial visual eloquent tumors and their impact in the visual outcome. Design: It is a single-center prospective study from 2018- 2020. Subjects: Patients with intra-axial visual eloquent tumors(n=34) were included in the study. Methods: Single-center prospec...

Objectives: The study aims to evaluate craniospinal tumours in pregnant patients and the therapeutic strategies that influence maternal and foetal outcomes along with the challenges faced in management Design: A retrospective single-centre cohort study was performed at a tertiary neurosurgical referral centre. Subjects: Pregnant patients referre...

Abstract Objective: We summarise our experience and challenges faced with the non-navigated intraoperative ultrasound in cranial neuro-oncological surgery at a tertiary neurosurgical centre in UK. Design: It is a retrospective single-centre cohort study for a period of 2 years between Dec 2017-Dec 2019. Subjects: Adult patients(n=90) referred t...

Abstract Objective: The study aims to propose a supplemental map of the clinically represented areas of human body in pre-central cortex and a novel subcortical corticospinal tract map that are accurate and essential for safe surgery in patients with eloquent brain lesions. Design: It is a 5-year single-centre retrospective cohort study between 2...

Abstract Objective: To describe the endoscopic management of a septum pellucidum cavernoma. Design A case study of a 16-year female who presented with a septal haematoma whose repeat imaging demonstrated an underlying lesion most in keeping with a cavernoma. Methods All the patient data including imaging were collected from hospital records. The...

Objectives Ecchordosis physaliphora (EP) is a benign notochord lesion of the clivus arising from the same cell line as chordoma, its malignant counterpart. Although usually asymptomatic, it can cause spontaneous cerebrospinal fluid (CSF) rhinorrhea. Benign notochordal cell tumor (BNCT) is considered another indolent, benign variant of chordoma. Alt...

Letter to Editor: We write to you with an example of a scenario regarding the use of pre-operative imaging and intraoperative techniques for mapping in insular glioma surgery and its relation to improved surgical outcome in the current context.

Short lasting unilateral neuralgiform headache attacks can present with either conjunctival injection and tearing (SUNCT) or with cranial autonomic symptoms (SUNA) are rare headache syndromes that belong to a larger group of headaches known as trigeminal autonomic cephalgia and can present very similarly to trigeminal neuralgia. Clinical presenta...

Introduction: Penfield’s motor homunculus describes a caricaturised yet useful representation of the map of various body parts on the pre-central cortex. We propose a supplemental map of the clinically represented areas of human body in pre-central cortex and a novel subcortical corticospinal tract map that are accurate and essential for safe surge...

Introduction Inter-dural juxta-facet spinal cysts occur rarely. They form as part of the degenerative spinal disease process and can be misdiagnosed as synovial cysts or ganglion cysts. We report the case of a thoracic inter-dural juxta-facet spinal cyst causing acute compressive thoracic myelopathy. Methods The data was collected retrospectively...

The COVID-19 pandemic has challenged the delivery of care worldwide, with many outpatient clinics changing from face-to-face to telephone consultations [1]. This is particularly challenging in neuro-oncology, where often complex interventions need to be discussed and where communication can be compromised due to tumour-related language/cognitive de...

Introduction: Questionnaire based assessment is a simple, scientific tool to collect responses from individuals and standardised questionnaires can be used to assess health care quality of a health care institution. The aim of this study was to assess health service quality of a private hospital on the basis of questionnaire-based data collected fr...

After publication of our article [1] the authors have notified us that one of the names has been incorrectly spelled.

Suprasellar dermoid cysts are rare (<0.5% of all intracranial tumours), benign, slow-growing cystic lesions that can produce serious complications if they rupture such as chemical meningitis, cerebral infarction, hydrocephalus, vasospasm; they typically present in first 3 decades of life. The aetiology of rupture can be traumatic or spontaneous. Th...

Clival tumours are rare, comprising 1% of all intracranial neoplasms. The differential diagnosis for a clival lesion includes chordoma (40%), meningioma, chondrosarcoma, astrocytoma, craniopharyngioma, germ cell tumour, non-Hodgkin’s lymphoma, melanoma, metastatic carcinoma, and rarely pituitary adenoma. These tumours can behave as chordoma mimics...

Oral presentation

Background: Traumatic brain injury is a leading cause of death and disability worldwide. The nitric oxide synthase inhibitor Ronopterin was shown to improve clinical outcome by enhancing neuroprotection in a phase IIa trial. Methods/design: The NOSTRA phase III trial (Ronopterin in traumatic brain injury) is a multi-centre, prospective, randomis...

Gangliogliomas are relatively uncommon accounting for less than 1 percent of intracranial neoplasms. We report a case of endoscopic complete resection of a paraventricular ganglioglioma through the tumour cyst in an 18 years female: Recurrence-free and symptom-free at 24 months follow up.

Background Lesions within the corticospinal tract (CST) represent significant surgical challenge with a delicate functional trade-off that should be integrated in the overall patient-centred treatment plan. Methods Patients with lesions within the CST with preoperative cortical and subcortical mapping (nTMS and tractography), intraoperative mappin...

Rationale WHO Grade 3 meningiomas are a rare, malignant subtype of meningioma. Few controlled case series detailing its treatment and follow-up are to be found in the literature. Methods Retrospective cohort study of patients treated in a single neuro-oncology centre in the period between September 2008 and March 2019 with an initial diagnosis of...

Introduction Multiple surgeries for recurrent / progressive glioblastomas is a matter of debate within the neuro-oncology community reflecting the higher risk of complications and the limited adjuvant treatment options for patients who recurred after initial treatment. Therefore it is crucial to identify who may benefit of a more aggressive approac...

Background Supratentorial Metastatic Melanomas are common and increasingly treated with immunotherapy. While improving the outcome, the immunotherapy potentially increases the risks of the intracranial surgical procedures, particularly bleeding. However, scarce reports address this complications. Case Description A 52-year old male with a history...

Introduction Navigated Transcranial Magnetic Stimulation (nTMS) is a non-invasive adjunct used in surgical planning for lesions in eloquent brain. However, its patient tolerability and effect on their overall healthcare experience is still unknown. To our knowledge, there is no other literature available evaluating patient experience with nTMS. Me...

There are no established non-invasive methods for accurately assessing shunt patency. Invasive methods such as shunt tapping and radioisotope techniques are not without risk. A potential non-invasive method for assessing patency is a flow-sensitive magnetic resonance image (MRI) sequences. Studies dating back to the late 1980s evaluated the sensiti...

First case series of cortical and subcortical stimulation of the cortex and subcortical region leading to stimulation and contraction of intercostal muscles during intraoperative mapping and neuromonitoring for brain tumour resection.

XLIF- Our Experince at King's College Hospital

We read with great enthusiasm the review published by Hervey-Jumper and Berger on insular glioma surgery 3 (Hervey-Jumper SL, Berger MS: Insular glioma surgery: an evolution of thought and practice. J Neurosurg 130:9-16, January 2019). The authors provide a comprehensive historical review about the anatomical and functional aspects of insular gliom...

Case series and technical procedure for XLIF at King's College Hospital, London

Objectives: Navigated Transcranial Magnetic Stimulation (nTMS) for brain mapping is becoming increasingly frequent for pre-surgical non invasive brain mapping. No data about Patient Reported Outcome Measure is currently available about TMS, which can be associated with anxiety or discomfort. Therefore patient collaboration and understanding of TMS...

Single-Neuro-Oncology Surgical Centre (1 neurosurgical and 2 medical neuro-oncology units) retrospective cohort study of patients with more than one craniotomy for resection for intracranial Glioblastoma Multiforme (GBM).

Prospective Cohort Study and Technical Report. Patients with suspected metastatic lesions within the motor cortex considered not suitable for radiosurgery were included. Preoperative MRI for neuronavigation, navigated transcranial magnetic stimulation (nTMS), pre-operative DTI Tractography, intraoperative neuromonitoring and demographic/clinical va...

We present the surgical approach to this tumour, the commonly used blink reflex test and the identification of the motor branch of the trigeminal nerve and describe a previously poorly reported method of monitoring the function of the branches of the trigeminal nerve: mapping of the sensory roots through transcranial somatosensory cortex sensory ev...

We describe the case of a 65-year-old lady who presented with mutism and a right hemiparesis. Imaging showed a severe spontaneous tension pneumocephalus. The cause was diagnosed as Ecchordosis physali-phora (EP). EP is a rare cystic congenital hamartomatous benign notochordal tumor (BNCT) arising from an ectopic notochordal remnant. To the authors'...

Introduction: We report the first case series of cortical and subcortical stimulation of the cortex and subcortical region leading to stimulation and contraction of intercostal muscles during intraoperative mapping and neuromonitoring for brain tumour resection. Our findings define this previously under-studied region of the motor homunculus and i...

This study aimed at describing the first case of subcortical stimulation of the corticospinal tract leading to selective contraction of the intercostal muscles during surgery for removal of a tumour centred in the right central lobule/supplementary motor area. A 53-year-old male presented with partial motor seizures. Imaging demonstrated a low-grad...