Qualification: 
MS, MCh, MBBS
suhasudayakumaran@aims.amrita.edu

Dr. Suhas Udayakumaran currently serves as Professor at the Department of Neurosurgery, Amrita School of Medicine, Kochi. 

QUALIFICATION : MS, MCh, MRCSed, Fellowship in Paediatric Neurosurgery

Publications

Publication Type: Journal Article

Year of Publication Title

2019

Suhas Udayakumaran, Arjun Krishnadas, and Pramod Subhash, “Why do metopic sutural synostoses angulate? The concept of nasion sutural complex and its implication on the management of hypotelorism-early results and proof of concept.”, Childs Nerv Syst, vol. 35, no. 6, pp. 907-912, 2019.[Abstract]


<b>OBJECT: </b>Angulation at the suture is a hallmark of metopic synostoses amongst all craniosynostoses. No other sutural synostoses demonstrate angulation at synostoses consistently. We look into the possible aetiology and the implication of the understanding in the treatment goals of trigonocephaly. We hypothesise that the nasal bone and nasofrontal suture viz. "nasion sutural complex" are involved in trigonocephaly along with the well-accepted role of metopic suture. We propose that it is the angulation at this junction which leads to trigonocephaly and its secondary features.
<b>MATERIALS AND METHODS: </b>The study included seven infants, who underwent correction for trigonocephaly at our paediatric craniofacial division at Amrita Institute of Medical Sciences and Research Centre, Kochi, India, between the period July 2015 to March 2018. The cohort included were infants with trigonocephaly who had CT head for diagnosis. We analysed the multidimensional CT (MDCT) of these infants and compared to an equal number of age-matched controls. The controls were infants with other forms of sutural synostosis with metopic uninvolved and normal infants where MDCT was done for other reasons. Sutural characteristic at the nasion and metopic suture recorded in comparison with an equal number of age-matched controls. We performed spring cranioplasty for three infants after metopic suturectomy, extending the release beyond the nasion sutural complex, placing springs to distract the suture. The infants who underwent spring cranioplasty were followed up for the aesthetic outcome. Remaining infants of the study underwent standard frontorbital correction for metopic craniosynostoses.

<b>RESULTS: </b>We could demonstrate a fusion of nasofrontal and nasal suture in all cases (n = 7) of trigonocephaly included in the study on MDCT and intraoperatively. We performed spring cranioplasty for three infants (n = 3/7), where we released the internasal suture. At 3&nbsp;months follow-up, along with correction of the angulation, the hypotelorism improved significantly. Other infants in the study (4/7) underwent classical frontorbital advancement.

<b>CONCLUSIONS: </b>Fusion of nasion sutural complex along with metopic sutures may explain the angulation in trigonocephaly. We propose that all minimally invasive techniques for correction of trigonocephaly and associated hypotelorism should consider this fact for an improved outcome

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2018

A. Pillai, Ratnathankom, A., Ramachandran, S. N., Suhas Udayakumaran, Pramod Subhash, and Arjun Krishnadas, “Expanding the Spectrum of Robotic Assistance in Cranial Neurosurgery.”, Oper Neurosurg (Hagerstown), 2018.[Abstract]


BACKGROUND: Robotic automation and haptic guidance have multiple applications in neurosurgery.

OBJECTIVE: To define the spectrum of cranial procedures potentially benefiting from robotic assistance in a university hospital neurosurgical practice setting.

METHODS: Procedures utilizing robotic assistance during a 24-mo period were retrospectively analyzed and classified as stereotactic or endoscopic based on the mode utilized in the ROSA system (Zimmer Biomet, Warsaw, Indiana). Machine log file data were retrospectively analyzed to compare registration accuracy using 3 different methods: (1) facial laser scanning, (2) bone fiduciary, or (3) skin fiduciary.

RESULTS: Two hundred seven cranial neurosurgical procedures utilizing robotic assistance were performed in a 24-mo period. One hundred forty-five procedures utilizing the stereotactic mode included 33% stereotactic biopsy, 31% Stereo-EEG electrode insertion, 20% cranial navigation, 7% stereotactic catheter placement, 6% craniofacial stereotactic wire placement, 2% deep brain stimulation lead placement, and 1% stereotactic radiofrequency ablation. Sixty-two procedures utilizing the haptic endoscope guidance mode consisted of 48% transnasal endoscopic, 29% ventriculoscopic, and 23% endoport tubular access. Statistically significant differences in registration accuracies were observed with 0.521 ± 0.135 mm (n = 132) for facial laser scanning, 1.026 ± 0.398 mm for bone fiduciary (n = 22), and 1.750 ± 0.967 mm for skin fiduciary (n = 30; ANOVA, P < .001).

CONCLUSION: The combination of accurate, automated stereotaxy with image and haptic guidance can be applied to a wide range of cranial neurosurgical procedures. The facial laser scanning method offered the best registration accuracy for the ROSA system based on our retrospective analysis.

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2018

Suhas Udayakumaran and Rathod, C. T., “Tailored Strategies to Manage Cerebrospinal Fluid Leaks or Pseudomeningocele After Surgery for Tethered Cord Syndrome.”, World Neurosurg, vol. 114, pp. e1049-e1056, 2018.[Abstract]


BACKGROUND: Cerebrospinal fluid (CSF) leaks are a dreaded complication after surgery for tethered cord and are associated with significant patient morbidity. Although many strategies for managing postoperative CSF leaks exist, this problem is still daunting, especially in very young patients. In this study, we compared different management techniques for CSF leaks or significant pseudomeningocele in patients with tethered cord syndrome (TCS).

METHODS: We analyzed a cohort of children who underwent surgery for TCS from January 2011 to March 2016 (n = 260) and postoperatively experienced either a CSF leak or significant pseudomeningocele. A subset of patients presented with CSF leak (n = 25). We analyzed patient age, sex, presentation, leak appearance, management, and outcome. The different techniques of management were compared for efficacy and morbidity.

RESULTS: The diseases associated with leak formation included lipomyelomeningocele (n = 16), myelocystocele (n = 4), and myelomeningocele (n = 5). Three children also had hydrocephalus. Management techniques included cystoperitoneal shunt (CPS) (n = 15), primary resuturing with local rotation flap of muscle (n = 3), external ventricular drain placement (n = 1), ventriculoperitoneal shunt (n = 3), external ventricular drainage (n = 1), and a combination of techniques (rotation flap with external drain; n = 1). Five patients who underwent primary wound revision experienced a leak and required a secondary intervention, but none of the patients who underwent CPS had any complications.

CONCLUSIONS: In carefully selected cases, CPS performed early after CSF leakage is highly successful with low morbidity. The primary closure can be attempted for low-pressure leaks without an associated pseudomeningocele.

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2017

Suhas Udayakumaran, Menon, S. K., Onyia, C. U., and Tahasildar, N., “Single-stage deformity correction in children with neurogenic kyphoscoliosis: nuances and a proposal for risk stratification.”, Neurosurg Focus, vol. 43, no. 4, p. E13, 2017.[Abstract]


<p>OBJECTIVE Neurogenic kyphoscoliosis in pediatric patients has varied causes and diverse management options. The most common management strategy is to stage the orthopedic and neurosurgical aspects of the correction at an interval of 3-6 months from each other. The aim of this study was to report the authors' experience with correction of deformity in children with associated neurological abnormalities requiring intervention as a single-stage surgical treatment. METHODS Of 591 pediatric patients with scoliosis treated at the Amrita Institute of Medical Sciences and Research Centre between January 2001 and January 2011, the authors identified all patients with neurogenic kyphoscoliosis who underwent deformity correction and a neurosurgical procedure in the same surgical session when they were younger than 15 years. Data regarding the demographic details, preoperative Cobb angle/kyphotic angle, surgical details, postoperative complications, cost of the procedure, and long-term neurological outcome were collected for each case and analyzed. Based on the results of this analysis, the authors propose a 2-category risk stratification system for the timing of deformity correction depending on the primary neurogenic etiology. RESULTS Ten cases involving patients with neurogenic kyphoscoliosis requiring both deformity correction and neurosurgical procedure met the criteria and were included in the analysis. All 10 patients were younger than 15 years; their mean age was 10.8 years. The average Cobb angle was 59.5°. Five patients underwent foramen magnum decompression, 5 patients underwent spinal cord detethering, and 1 patient had intraspinal intradural tumor excision. The mean estimated blood loss was 1177 ml (range 700-1550 ml), and the mean operative time was 4.4 hours (range 3-5.5 hours). There were no intraoperative complications. None of the patients had any new postoperative neurological deficits. The mean postoperative Cobb angle of the main thoracic curve was 12.6°. CONCLUSIONS Simultaneous deformity correction along with a definitive neurosurgical procedure in patients with neurogenic kyphoscoliosis can be performed without added morbidity and avoids both the added costs and the risk of complications associated with a second surgery. The risk stratification system proposed in this paper may serve as a guideline for case selection and help to optimize outcome.</p>

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2017

Suhas Udayakumaran, Onyia, C. U., and R Kumar, K., “Forgotten? Not Yet. Cardiogenic Brain Abscess in Children: A Case Series-Based Review.”, World Neurosurg, vol. 107, pp. 124-129, 2017.[Abstract]


<p><b>BACKGROUND: </b>Brain abscess is a significant cause of morbidity in patients with uncorrected or partially palliated congenital cyanotic heart disease (CCHD). Unfortunately, in the developing world, the majority of patients with CCHD remain either uncorrected or only partially palliated. Furthermore, a risk of this feared complication also exists even among those undergoing staged corrective operations in the interval in between operations. There have been no recent articles in the literature on the outcomes of surgical management of cardiogenic brain abscess in children. In this study, we aimed to describe the clinical and demographic profile of patients with cardiogenic cerebral abscess and to highlight the fact that uncorrected or palliated CCHD continue to be at risk for brain abscess.</p><p><b>METHODS: </b>This study was a retrospective analysis of 26 children (age <19 years) being managed for CCHD who were diagnosed with cerebral abscess managed surgically (26 of 39 of cases cerebral abscess in children), at Amrita Institute of Medical Sciences and Research Centre, Kochi, India between December 2000 and January 2014. Data collected retrospectively included demographic information, modes of presentation, diagnosis, location of abscess, details of the underlying heart disease, management of the cerebral abscess, and outcomes of management.</p><p><b>RESULTS: </b>The patient cohort comprised 26 patients (16 males and 10 females), with a mean age of 7.19 years (range, 1.5-19 years). Ten of the 26 patients (38%) required reaspiration after the initial surgery. On follow-up, all the patients had improved symptomatically and demonstrated no signs of cerebral abscess.</p><p><b>CONCLUSIONS: </b>Cardiogenic origin of cerebral abscess is the most common cause of cerebral abscess in children. Unresolved CCHD is a risk factor for the occurrence, persistence, and recurrence of cerebral abscess.</p>

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2017

Suhas Udayakumaran, Onyia, C. U., and Cherkil, S., “An Analysis of Outcome of Endoscopic Fenestration of Cavum Septum Pellucidum Cyst - More Grey than Black and White?”, Pediatr Neurosurg, vol. 52, no. 4, pp. 225-233, 2017.[Abstract]


<p><b>BACKGROUND: </b>Cavum septum pellucidum (CSP) and cavum vergae are actually fluid-filled, generally communicating midline cavities located between the third ventricle and corpus callosum. There have been various reports of their association with many behavioral and psychiatric disorders. Infrequently, they have been associated with an obstructive hydrocephalus-like picture. Although the structure and management of CSP has long been known, it has been an enigma as far as functional significance and management indications are concerned. The authors of this article try to analyze the significance of a persistent cavum and involvement of the same entity in varied presentations ranging from an incidental imaging finding to acute hydrocephalus, and propose a possible implication on the present surgical intervention paradigm.</p><p><b>PURPOSE: </b>To assess the surgical outcome of fenestration of a CSP cyst.</p><p><b>METHODS: </b>Retrospective analysis of 3 patients who underwent endoscopic fenestration for CSP with obstructive hydrocephalus between 2012 and 2014 was done, and data were analyzed for symptomatic clinical improvement in particular behavior.</p><p><b>RESULTS: </b>Pre- and postoperative brain MRI showed a significant decrease in the size of the cyst as well as the ventricles. There were no recurrences during follow-up. All of the patients improved.</p><p><b>CONCLUSIONS: </b>(1) Endoscopic fenestration of symptomatic CSP cysts is a safe treatment option. (2) Neurocognitive assessment is essential in the evaluation and outcome assessment of CSP.</p>

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2016

Suhas Udayakumaran and Onyia, C. U., “Customizable rigid head fixation for infants: technical note.”, Childs Nerv Syst, vol. 32, no. 1, pp. 159-61, 2016.[Abstract]


<p><b>INTRODUCTION: </b>The need and advantages of rigid fixation of the head in cranial surgeries are well documented (Berryhill et al., Otolaryngol Head Neck Surg 121:269-273, 1999). Head fixation for neurosurgical procedures in infants and in early years has been a challenge and is fraught with risk. Despite the fact that pediatric pins are designed, rigid head fixation involving direct application of pins to the head of infants and slightly older children is still generally not safe (Agrawal and Steinbok, Childs Nerv Syst 22:1473-1474, 2006). Yet, there are some surgeries in which some form of rigid fixation is required (Agrawal and Steinbok, Childs Nerv Syst 22:1473-1474, 2006). We describe a simple technique to achieve rigid fixation of the head in infants for neurosurgical procedures.</p><p><b>TECHNICAL NOTE: </b>This involves applying a head band made of Plaster of Paris (POP) around the head and then applying the fixation pins of the fixation frame directly on to the POP.</p><p><b>CONCLUSION: </b>We have used this technique of head fixation successfully for infants with no complications.</p>

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