Background Cranioplasty using synthetic materials for restoration of the exact shape of the skull has always remained a challenge until the development of 3D printing technology. However, the high-cost of available 3D printed implants limits their extensive use. Objectives To study the effectiveness of a low-cost, 3D-printed template for molding the polymethyl methacrylate (PMMA) (bone cement) in order to achieve exact contours of the skull specific to each patient. Materials and Methods 10 cranioplasties have been performed between July 2018 to December 2019 in a variety of craniotomy defects using bone cement flaps shaped using custom-made molds. The mold was 3D-printed and based on each patient’s CT images in digital imaging and communications in medicine (DICOM). Miniplates and screws were used to fix the flap. Postoperatively, clinical and radiological evaluation were done to assess patient satisfaction and accuracy of contour achieved. Results Patient satisfaction as well as accuracy of contouring, as seen on postoperative CT scans, were excellent. There were no notable complications on follow-up. Conclusion PMMA cranioplasty flap, contoured using a 3D-printed mold, is a very cost-effective alternative for restoration of skull contour for various craniotomy defects.Polymethyl methacrylate (PMMA) molded to form the exact shape of lost calvarium using 3D printed plastic templates is a smart and economical solution

Introduction: Alternate approaches such as ventriculoatrial (VA) or ventriculopleural (VPL) procedures still have a place in the surgical armamentarium for patients with recurrent ventriculoperitoneal (VP) shunt failures related to defective absorption, infections, or frequent malfunctions. Methods: We reviewed the literature and our experience with these techniques, and offered suggestions for safely performing these operations. Historical perspectives were also included to facilitate an improved understanding of the technical developments. Results: Our findings and the available medical literature suggest VA and VPL options are safe and effective alternatives for managing the complex patient with hydrocephalus. Potential issues and complications were discussed along the technical advances for a safer operation. Conclusion: The VA and VPL options should be considered for patients with recurrent VP shunt issues. They are safe and effective options for managing complex hydrocephalus patients.

Introduction One of the most seen neurosurgical complications is the ventriculoperitoneal (VP) shunt failure. The cause can be often due to peritoneal malabsorption of cerebrospinal fluid. The next safer alternative is to place a ventriculoatrial (VA) shunt. Various methods of access to the right atrium had been described. The percutaneous method of insertion of distal catheter using Seldinger technique is a safer alternative to open method. We describe the percutaneous insertion of distal catheter using Seldinger technique, modifications in the method, and specific tools required for the insertion. Clinical History The patient is a 22-year-old male who is a known case of tubercular meningitis with recurrent failure of VP shunt due to malabsorption at peritoneal end of catheter. During the last hospital visit, he presented with altered sensorium and computed tomography scan brain showed ventriculomegaly. He was planned for VA shunt placement. Surgical Technique The insertion of ventricular end of the catheter is similar to any other shunt placement. The internal jugular vein (IJV) was punctured using introducer needle and guide wire was placed in the IJV at the level of T6-T7 and the serial dilators passed on the guide wire for creating a track for passage of shunt catheter. The shunt catheter was passed over the guide wire to the desired vertebral level and distal shunt catheter is connected proximally to the shunt catheter in the neck. Conclusion The percutaneous insertion of distal catheter with serial dilators using Seldinger technique is a safe and effective method for VA shunt placement.

Introduction The role of frame-based stereotactic biopsy in brainstem lesions has been well established in literature. Transfrontal, transtentorial, and transcerebellar routes are used to access various targets within the brainstem. While the transfrontal approach is preferable in midbrain lesions, a transcerebellar approach via the middle cerebellar peduncle forms the shortest possible trajectory for pontine and medullary lesions. Objective Authors to describe the technical nuances of frame-based stereotactic biopsy of lower brainstem lesions to increase the procedural safety and efficacy. Materials and Methods Technical modifications in frame fixation were done to acheive the desired trajectory to the target. In adult cases biopsy was performed with patient awake during the procedure. Results Total of five patients underwent biopsy with the technical modifications. Three patients were adults and two were in pediatric age group. Their age ranged from 12 to 50 years. No complications were encountered. Two of the biopsies showed demyelination and the other three turned out to be low-grade glioma, pilocytic astrocytoma, and lymphoma, respectively. Conclusion Despite obvious inherent risks, the transcerebellar biopsy in semi-sitting position is a well-tolerated and effective method of obtaining a diagnostic tissue sample in brainstem lesions. We have noted that adoption of the technical modifications described in this article has aided in improving the safety and ease of the procedure.

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