Pituitary tumour

 Upto 15% of brain tumours occur in the cellar and parasellar region, commonest of which is pituitary tumour. Normal size of pituitary is less than 15 mm and its weight is less than 1gram. it is attached to the infundibulum or pituitary stalk. Pituitary gland is housed in the Sella Turcica or pituitary fossa of the body of the sphenoid bone. The pituitary fossa is delineated anteriorly by the tubercular sella & schismatic sulcus and posterior by the dorsal sella & posterior clinoid process. Diaphragma sella is a fold of dura mater which forms the roof of the pituitary fossa. It has a central opening for pituitary stalk or infundibulam. Just beneath the sella turcica, inside the body of the sphenoid there are sphenoid sinuses which are paired cavities separated by a septum.

The distance between intracavernous parts of two carotid arteries are about 12 mm to 14 mm. 

Optic chiasm lies just above the pituitary gland (8-13 mm) , in the sucus chiasmaticus in 5%, over diaphragm sella in 12% and in 79% over the dorm sella ( post-fixed location of optic chiasm). 

The symptoms and signs of pituitary tumours vary according to the size and type of tumour. Visual symptoms occur due to compression of the optic chiasm. Visual field defects are very common. Bitemporal hemianopia is very common in pituitary tumours. Headache is also very common. Endocrine symptoms are very common. Prolactinomas are the most common pituitary tumours and account for up to 40% of such lesions. The is history of milk production ( galactorrhoea) in females. There is history of amenorrhoea. The endocrinopathy produced in women is the galactorrhea- amenorrhoea syndrome ( Forbes-Albright syndrome). The various menstrual disorders are amenorrhea, oligomenorrhoea & irregular periods. About 30% of women complain of galactorrhea. There is also associated infertility. 

The normal level of serum Prolactin is less than 25 ng/ml. Elevation of the fasting prolactin above 150 ng/ml is strongly suggestive of a prolactinoma.

Hormonal assay of the hormones is part of the detailed work up of the pituitary tumours. Most of the functioning pituitary tumours are associated with decreased thyroid function, increased growth hormone level, increased serum cortisol level, derranged FSH and LH. 

Ophthalmolocal examination is part of the investigation for diagnosis and prognosis of treatment of pituitary tumours. Visual field, visual acuity and funds examination must be done in all patients with pituitary tumours. Most of the time patients and sometimes doctors are not aware about the extent of visual defects in the patient. There may be mono-ocular visual loss before the surgery and it is noticed only after surgery. So, preoperative visual field chart ( bitemporal hemianopia) and visual acuity ( like finger counting upto 1 meter distance) are very much necessary.

CT scan of the brain show shows a lesion in the cellar region. MRI brain with contrast demonstrates the extent of the lesion, location of optic chiasm, any enhancement of the tumour inside pituitary, size of the pituitary tumor (micro adenoma or macro adenoma). MRI brain also shows the location of the carotid arteries in relation to the tumour. Pituitary tumour of size more than 10mm is known as pituitary macroadenoma. If tumour size is less than 10 mm, it is known as pituitary micro adenoma. Sometimes , haemorrhage occurs in pituitary tumor which is known as pituitary apoplexy. 

Drugs available for treatment are: bromocriptine, pergolide, cabergoline, quinagolide ( CV 205-502 ). Bromocriptine is an ergot alkaloid and dopamine agonist. The usual dose of Bromocriptine is 2.5 mg three times a day, which can be increased.

Surgery is done either through transcranial route or through transsphenoid route. If sphenoid bone is pneumatized and tumour is located in the mideline and without any para seller extension, the transnasal trans-sphenoidal surgery is the ideal mode of surgical intervention. After surgery, if any part of the tumour could not be excised, then Gamma knife radiosurgery is also an option to treat it.

Growth hormone secreting pituitary tumours present gigantism in children and acromegaly in adults. Hypertension, coronary artery disease, valvular heart disease, are common in these patients.

Cerebral atrophy in people who consume alcohol

 Chronic alcohol consumption causes brain shrinkage, by reducing both grey and white matter volume. Even low-to-moderate consumption of alcohol is associated with brain atrophy. (http://pubmed.ncbi.nih.gov). Direct toxicity is the cause as Ethanol damages brain cells and interferes with the creation of new neurons, especially in the hippocampus which handles memory. In Alcohol related brain damage (ARBD) memory and thinking abilities worsen over time. ( http://www.alzheimers.or.uk). Alcohol related dementia is a type of dementia due to alcoholism. Any level of alcohol consumption increases risk of dementia ( University of Oxford, ox.ac.uk)

There is no safe limit. In my clinical experience, I have observed that CT scan or MRI of the brain of an alcoholic person show features of cerebral atrophy. The CT or MRI of 40 year old alcoholic person resembles the brain of a 70 year old with radiological features of cerebral atrophy.

HYDROCEPHALUS

Brain consists of neurons and neuroglia. Apart from neural components there are blood vessels and fluid known as cerebrospinal spinal fluid (CSF). CSF is present in the subarachnoid space ( space between Arachnoid & Pia mater) and inside the ventricles. 

In hydrocephalus, there is excess accumulation of CSF. As cranial capacity is limited, so accumulation of CSF causes increase in intracranial pressure (ICP). The excess of CSF can either be due to excess production of due to obstruction of the flow leading to diminished absorption.

There is a condition in which there is excess production, i.e., Choroid Plexus Papilloma or Choroid Plexus Carcinoma. This tumor arises from choroid plexus which contributes almost 80% of daily CSF formation ( remaining CSF is formed by Ependymal lining of ventricles & brain parenchyma). As this condition involves neoplastic growth of choroid plexus, there is hydrocephalus. So, there is communicating hydrocephalus, i.e., there is ventriculomegaly despite of no ventricular obstruction. This tumour is more common in younger age group. Choroid plexus papilloma has reported in newborns and infants. There is disproportionate enlargement of ventricles despite of a small intraventricular tumor.

About 0.33 mL / min is the CSF formation rate ( about 20 mL/hour & 500 mL /day). CSF circulation occurs & it gets absorbed by brain parenchyma, choroid plexus, arachnoid villi& granulations in dural venous sinuses. Total CSF in adult brain at one time is approximately 150 mL of which 25 mL is contained inside ventricle.

hydrocephalus can be congenital or acquired. The congenital hydrocephalus is usually seen in new borns and infants. The commonest cause is congenital aqueduct stenosis. As the cranial sutures are not fused in children so enlargement of ventricle causes enlargement of the head. So, hydrocephalus in new borns presents with macro crania. There is bulging of the anterior fontanelle. It is easy to recognise. 

The acquired hydrocephalus may be due to secondary to infections, trauma, neoplasms, etc. The meningitis or encephalitis in children may present with hydrocephalus.

CT scan or MRI of the brain can diagnose this condition. It can differentiate both obstructive and communicating hydrocephalus. In obstructive hydrocephalus all ventricle or both lateral and third ventricle are enlarged. Obstruction of aqueduct is very common in tubercular infections of brain as there is vasculitis & increased granulation tissue in peri-mesencephalic cistern. Aqueduct of Sylvius is about 18 mm in length & less than 5 mm in width,  and it is a narrow duct which connects third & four ventricle, 

MRI brain can detect hydrocephalus and any other associated congenital abnormality like Chiari Maformation, Dandy Walker Malformation, Schizeccephaly, Porencephalic cyst, corpus callosal agenesis, etc. 

In conditions where hydrocephalus is due to infections or neoplasms, the MRI brain with contrast is useful.

On CT scan of brain, the increase in hydrostatic pressure is reflected as hypo density around the ventricle that is known as Periventricular lucency (PVL). The frontal horns of lateral ventricles are enlarged, third ventricle becomes globular ( 3rd ventricle is normally seen as slit like in axial images of brain CT). The temporal horns are usually not more than than 2 to 3mm or may not be seen on routine brain CT with 1 cm slices, but in hydrocephalus it is increased in size.

The conservative treatment includes Tablet Acetazolamide ( Diamox) 250 mg three times a day in an adult of 60 kg weight. It is carbonic anhydrase inhibitor & reduces CSF formation.

Surgical treatment involves Endoscopic Third Ventriculostomy (ETV), and Ventriculoperitoneal shunt( VP shunt) surgery.

Now a days, the  endoscopic treatment of hydrocephalus is an established technique of treating hydrocephalus. Previous works of Lespinase, Dandy, Mixter, Fay and Grant had contributed in the evolution of this concept. 
Lespinasse in 1910 was the first one to perform endoscopic choroid plexus fulgration for treating hydrocephalus.
Dandy described the open technique for third ventriculostomy for treatment of hydrocephalus.
In 1923, Mixter first  described percutaneous ventriculostomy, and Fay Grant published the visual record of endoscopic anatomy.
The aim of this surgery is to create a passage in the floor of the third ventricle and to allow the flow of CSF into the pre pontine cistern so that obstruction at the aqueduct can be avoided. The easiest example to explain is of obstructive hydrocephalus due to aqueductal stenosis. In this condition, patient presents with enlargement of the lateral ventricles and third ventricle. The obstruction at the aqueduct causes obstructive hydrocephalus and the cerebral sulci are effaced. So, an endoscope is introduced through the frontal horn of right lateral ventricle and advanced into the third ventricle through dilated Foramen of Monro. Floor of the third ventricle is visualized and an opening is made in the floor of the third ventricle allowing the CS flow to the pre-pontine cistern. 

How to use the knowledge of neuroscience for your own growth: Brain & Mind Growth Hacks

 The use of Prefrontal cortex (PFC) : The prefrontal cortex is the intelligent part of the brain. Never stop dreaming big. It will challenge your prefrontal cortex and it will search the way to find the solutions. It puts your intelligent part of brain on work. It can be done deliberately. Never restrain your dreams because of current situation. have a strong desire for some big goal, Visualise it, subconscious mind understands it so you can pursue it, enjoy the process. Manifestation can be practiced.

  Serotonin: A neurotransmitter which makes you happy. Increase your serotonin level.

  Endorphin is useful hormone. Its level can be increased. Exercise and adopting good lifestyle are easy way of increasing its level.

  Decrease serum cortisol level: avoid unnecessary stress. have good sleep.

   Decrease dopamine level: Avoid addiction forming bad habits.

   Avoid cerebral atrophy: consumption of alcohol and cigarette smoking increases cerebral atrophy. Avoid alcohol addiction and cigarette smoking.

 The most amazing phenomenon is neuroplasticity. The brain is an anatomical structure. Mind is physiological part. Thoughts, Mind, Conscious and subconscious mind are very interesting subjects.  Brain is made up of billion of brain cells (neurons) & trillions of connections (synapses).

Neurons consist of cell bodies (perikaryon), axon & dendrites. Dendrites (dendron means tree) are short,  branched & carry impulses toward the cell body. Axons are usually single and long. Nerve cells convey signals to one another at synapses by releasing chemicals or neurotransmitters.

Human Brain is Born Unfinished. It takes many years to transform from helpless newborn to become an independent person. New born child remains totally dependent on others for survival. Dolphins are born swimming, baby zebra can run within 45 minutes. Is it advantage or limitation? Baby animal brains are wired up for preprogrammed routine. Flexibility, capacity to adopt & ability to thrive in many different environments is possible with human brain because it is born remarkably unfinished.

       

Childhood pruning. The number of brain cells is same in children & adults. Secret lies in how these cells are connected.  At birth, a baby’s neurons are least connected & in first 2 years of life they begin connecting up extremely rapidly as they take in sensory information.In infant, 2 million new connections or synapses/second. By age 2, 100 trillion synapses (2X adult). then neural pruning, carving makes everyone unique.

      All experiences in our life shape the microscopic details of our brain & neural circuits. Because our experiences are unique, brain rewrites our own pattern of neural networks.

  Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively & is able to make a contribution to the community. The mental health moves up & down in response to the life circumstances, it is a state in which same person feels low, euthymic or excited depending upon situation. Not like normal or abnormal. Not like perfect or imperfect. Not like sane or insane.

Range of mental health

No one is perfect, no mental status is permanent, moves up & down with circumstances:

Happy, excited, elated, joyful, optimistic, fulfilment, gratitude

Low energy, feeling negative, disappointed, feeling lonely, sad

Feeling anxious, worried

Life skills

Self awareness, Empathy, Humor

Critical thinking, Decision making, leadership, Problem solving, Effective communication, Interpersonal relationship, Assertiveness

Resilience (Coping with stress and emotions, dealing effectively with challenges)

Ability for adaptive & positive behaviour to deal effectively with the demands & challenges of life (Psychosocial competency)

Value clarification (what is important to me), financial literacy

Habits (Basal ganglia & Prefrontal cortex)

Within 3 weeks a new habit is formed (or break old bad habit & get rid of it)

Tiny/small & incremental changes lead to significant improvement

1% change everyday : walk for 10 minutes, 5 minute aerobics will be enjoyable, requires little effort. So, choose easiest change and repeat. Gradually it will become a habit & create a system

Improve eating habits: balanced diet, eat vegetables, less sugar/salt/oil, less junk food

Practice gratitude, practice appreciation

Maintain Sleep hygiene, Try to wake up early

Practice mindfulness 

Good mental health & subconscious mind

CREATE SYSTEM THROUGH SUBCONSCIOUS MIND 

Emotionally stable

Healthy relationship/connected with other people

Positive outlook, positive self perception

Sound & effective decisions 

Having good sleep

Mindfullness/at peace

Good self care

Feeling happy most of the time

Optimistic, hopeful

Sense of meaning/purpose

Resilient

Pre-frontal cortex

Logical mind 

Planning, decision making, reasoning

Genius of the brain

Put your prefrontal cortex on work ( I cannot afford/ how I can afford? I don’t know/ How I can be expert? )

Amygdala: Emotional control center of brain

Stress, anxiety, fear activate it, which increases cortisol level.

Resilience

        Success is not final, failure is not fatal

• There is no failure. You either win or learn.
• If you survive through  a tough situation, your brain becomes more resilient
• Bounce back, “Rise from the dust.” Recover from setbacks & learn from them
• Turn your failures into stepping stones for success

 You can build resilience

Resilience can be developed, 

Fail fast & learn faster, rapidly testing ideas, learn from mistakes, innovate, encourage mistakes & even celebrate

Helps to face stresses & challenges

Helps to adjust in adverse situations

Bullet proof mindset, act if nothing bothers you

You can outgrow your problems

Neuroplasticity

    Ability of brain to change, adapt & learn new skill  

Billion of neurons & synapses (neuronal connections) make functional networks which change through growth

Dynamic & ever evolving nature of brain

New experience creates new synaptic connections, it helps in personal growth. 

Rewire your brain, fortify your brain, you can consciously & intentionally create new neural connection & level up the mental strength by learning new skills, exposing yourself to new challenges

Brain hacks: Re-train your nervous system : start the day relaxed, meditation, prayer, exercise, watch sun rise, talk to friend or family, choose to slow down little, eat slowly, be relaxed, walk slowly, activates parasympathetic system, learn a new skill/language/musical instrument, non dominant hand exercise ( neurobics ), travel

Neuroplastic rewiring: brain repairs itself, it is core of neuro-rehabilitation concept & practice

  Happy hormones make us happy 

Dopamine

Serotonin

Endorphin

Oxytocin

Mindfulness

Recognise & appreciate things around you & connect to the present moment

Pause, Stillness, calm spend sometime without bothering for anything

Fixed mindset vs growth mindset

   Survive/Thrive 

Linear growth vs exponential growth (compounding)

Most people overestimate what they can achieve in a year and underestimate what they can achieve in 10 years.

“ Your life is a result of the choices you have made. If you don’t like your life, start making better choices ”Zig Ziglar

Intelligence is an overrated word. Everyone has a particular skill set which he or she acquires incidentally or intentionally. That person becomes extraordinary in that particular skill. More opportunities, rewards, encouragement, exposure, self belief, belief of others in that person further makes that person a super human. It can be done intentionally by practice, patience, perseverance, grit, motivation, etc. The subconscious mind can be altered. Books, coaching, training, guidance, exposure can help a person to develop good habits. 

Risk mitigation & management of neurosurgical complications

The common risk in neurosurgical procedure if occurrence of neurological deficit, bleeding during surgery, oedema due to retraction of the brain tissue, CSF leak, surgical site infection, inadequate decompression of the tumour, brain herniation, etc.

A proper preoperative surgical planning is an important step for risk mitigation.

So, risk mitigation starts with initial clinical work up of the patient. Identification of the co-morbid conditions like diabetes, hypertension, ischemic heart disease, hypothyroidism, endocrinopathy, is the priority of both anesthetist and neurosurgeon. Many co-morbid conditions are not even known to the patient. For example a patient with pituitary tumour may have visual deficits, hemianopia, hypothyroidism, diabetes insipidus of which patient may not be aware. Similarly, patients with brain metastasis may have systemic cancer which remains undetected. 

All exigencies must be considered by a neurosurgeon before operating. For example, during surgery of the spinal cord there is chance of CSF leak. So, dural repair with artificial dura and its reinforcement with fibrin glue must be considered prior to surgery.

In neurosurgery nothing is unexpected. All the steps are well planned. It is like standard operating procedure. It is like checklist of each neurosurgical procedure. 

Prevention and reduction of infection in surgery was possible by introduction of antiseptic principles described by Joseph Lister in 1867. So, the antisepsis must be maintained in operation theatre and also during any invasive procedure in any neurosurgical patient. The use of prophylactic antibiotic significantly reduces the risk of infection in a neurosurgical patient. Part preparation should be done properly and enough time to be given for part preparation. It is surgeon's responsibility to ensure that all staff involved in surgical procedure adheres to the set principles of antisepsis. 

The patients of intracranial brain lesions often present with seizures. Some patients with brain tumours do not present with seizures but are very much likely to develop epilepsy, especially patients with lesions in basifrontal region, at rectus gyrus after surgery. Meningiomas are also epileptogenic. In such patients prophylactic anti epileptic drug be started.

Some intracranial brain lesions have associated vasogenic oedema. So, in high grade gliomas or meningiomas, steroid ( Dexamethasone) to be started before neurosurgical procedure to avoid sudden increase in oedema and any chance of brain herniation.

Sometimes, during surgery, intraoperative Mannitol is given to reduce intracranial pressure. 

Blood loss is a risk during a neurosurgical procedure. So, to reduce blood loss during surgery head end elevation is done during surgery. It reduces intracranial procedure. Enough blood is arranged before surgery depending upon the procedure. 

All neurosurgical procedures are designed in such a manner that there should be minimal retraction of the brain. It reduces need for retraction of the brain and any possibility of post operative edema and subsequent brain schema or brain herniation. It is the basis principle of practising skull base surgical approaches.

Surgical approach to the lesion is always through non-eloquent area of the brain. So, there is immense significance of surface marking and pre-operative surgical planning. Most of the intraparenchymal frontal lobes lesions like frontal lobe gliomas are approached through right middle frontal gyrus just anterior to the coronal suture. Similarly, posteriorly placed intraparenchymal parietal lobe lesions are approached through right sided superior parietal lobe. It is very common practice that ventricular end of the ventriculo-peritonal surgery is introduced either through right middle frontal gyrus just anterior to the coronal suture or through the right superior parietal lobule. The endoscopic third ventriculostomy (ETV) is also done through right middle frontal gyrus by making a bur hole just anterior to the coronal suture in the mid pupillary line.

While planning excision of the cerebral convexity meningioma, the arrangement should be made for dural repair if it involves excision of the tumour along with involved dura.

Since microneurosurgery involves working through narrow surgical corridors a rigid head fixation is essential in order to maintain the desired head position and also even slight head movement may cause damage. So, either Mayfield's head-holder system or Sugita head-holder is used in such neurosurgical procedures. 

Operating surgical chair is to used by neurosurgeon to avoid fatigue and tremors during surgery for better control of cautery, microscope, endoscope, drill, etc.

Neurosurgeon should be the first person to reach the operation theatre and be the last person to leave the operation theatre (If best outcome is expected). never outsource the position of the patient on operation table, marking of the incision, corticectomy to the subordinate. If not sure from the beginning, it will definitely haunt him during the entire neurosurgical procedure. Only after extubation and seeing the expected neurological outcome immediately at the end of neurosurgery ensures homeostasis of any neurosurgical procedure. Only then neurosurgeon becomes sure that operation was done perfectly. It looks a very tough task to spend so much time in surgery and also spending much more time than any body else in your team, but it is true. It must be practised without any exception. It is for perfection. Nobody is perfect but in pursuit of perfection you achieve excellence. 

During spinal surgery bone nibbler is used . it should be used carefully as it may cause damage to the spinal cord. It should just nibble. Don't rotate or tear anything. Don't pull any structure unnecessarily. Use Kerrison ronguers of appropriate numbers, for nibbling small parts of the lamina.

All neurosurgeons are well versed with brain and spinal surgery. Only difference is the expertise in extent excision of the lesion without causing any complication or neurological deficit in a neurosurgical patient. So, risk mitigation is the most important task of neurosurgeon. 

Mastering Neurosurgery Operative Skills

The neurosurgery operative skill can be mastered by learning  basic steps which are common to almost all neurosurgical procedures.

1. Starts with making Burr hole & craniotomy, corticectomy 

2. Suboccipital craniectomy

2. Laminectomy

4. Laminectomy, durotomy, myelotomy

For operating all supratentorial lesions, craniotomy is done. 

For operating midline posterior fossa or infra tentorial lesions, sub occipital craniotomy is performed.

For operating spinal lesions, laminectomy is very commonly performed. This is basic neurosurgical skill.

The surface marking and understanding of the applied neuroanatomy is important. Once you reach the brain surface after craniotomy and opening of the dura, all he cortical surface looks similar, i.e., clci, gyri, CSF in subarachnoid space, and cortical vessels. So, there is only one way of identifying intracranial cerebral structures, like frontal lobe, parietal lobe , temporal lobe or occipital lobe is by surface marking of the skull, before start of the surgery. Similar principle is applied for identifying motor strip, speech area, hearing area, visual area or any other eloquent area of cerebral cortex, is by surface marking. So, before draping of the surgical area, a marking is made over the scalp.

Majority of the neurosurgical procedures are done through non eloquent area of the brain, especially, right middle frontal gyrus or right superior parietal lobule.

Twist drill and ventriclostomy is a life saving procedure in patients of acute hydrocephalus.

In pyogenic meningitis with hydrocephalus, external ventricular drainage (EVD) is done. 

Vemtriculo-peritoneal shunt surgery (VP shunt) is very common neurosurgical procedure. This procedure must be mastered and it must be repeated many times. Everyone should be well versed with all complications associated with this procedure. 

Endoscopic third vetriculostomy (ETV) is another neurosurgical procedure for treatment of hydrocephalus. 

During surgery, lamina terminals is perforated to drain CSF.

So, if any neurosurgeon regularly practices these 5 procedures, namely twist drill, EVD, VP shunt, ETV, opening of laminate terminals, it means that he or she has perfected the art of CSF diversion procedure.

The management of head injury involves 5 neurosurgical procedures, 1. Depressed fracture, 2. Evacuation of Extradural hematoma, 3. Evacuation of acute subdural hematoma, 4. Evacuation of intracerebral hematoma, 5. Contusectomy. Surgery for depressed fracture is easy. If there is communited depressed fractures and there if lactation over the depressed fracture segment, a linear incision is made in the scalp and retracted. Bone fragments are removed. Sometimes a small bur hole is made just adjacent to the depressed segment, in order to elevate it. Sometimes, dural repair is also required. CT scan is the investigation of choice of managing head injury patients. For evacuation of extradural hematoma a preoperative planning is done to make a craniotomy just over the EDH. Dural hitches are applied in the dura and the incision is closed in layers. For acute subdural hematoma evacuation a very large frontoteporoparietal craniotomy is made along with duratomy to reduce the intracranial pressure. Acute subdural hematoma is very commonly associated with brain edema, so wide decompressive craniectomy is done. 

In cases of intraparenchymal hemorrhagic contusions associated with midline shift, craniotomy and contusectomy is done. Sometimes frontal or temporal lobectomy is done to reduce mortality. Management of head injury is challenging as it requires prompt neurosurgical decisions in emergency situations. Neurosurgeons may be the first responder during management of neurotrauma patients. It necessitates the availability of neurosurgeon round the clock, 24X7, all 365 days in a year. This situation makes a neurosurgeon indispensable. It is not only the surgical procedure which matters but it also involves management of emotional trauma of the patients and their relatives and managing medicolegal issues. 

The neurosurgical management includes long term follow up of the patient after surgery. A neurosurgeon is a team leader of a multidisciplinary team. 

If you develop a habit of accepting challenges, then you are destined to be good neurosurgeon. The majority of head injury patients are medico-legal cases (MLC) which requires you to attend the court cases where you will be summoned to attend the hearing as a witness. Sometimes it requires intense questioning by stakeholders which may unnerve you, but you have to maintain your composure and your disposition should be unbiased and without any prejudice. The frequent summons may disturb your routine clinical schedule but it is part & parcel of neurosurgical career. It should not deter you and you should continue your neurosurgical practice with enthusiasm & passion. Management of head injury in emergency situation is very challenging but very rewarding also. However, because of high incidence head injury, neurosurgeons are always in demand. 

Another field neurosurgery is very demanding that is Neuro-oncology. It requires very meticulous neurosurgical skill and good interdisciplinary team work.