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Coverpage
January-February 2017
Volume 65 | Issue 1
Page Nos. 1-234

Online since Thursday, January 12, 2017

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NI FEATURE - COMMENTARY: THE FIRST IMPRESSION  

The cover page Highly accessed article p. 1

DOI:10.4103/0028-3886.198172  
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NI FEATURE - COMMENTARY: TIMELESS REVERBERATIONS Top

Clinicopathological conference: A strong educational tool Highly accessed article p. 2
Ashru K Banerjee
DOI:10.4103/0028-3886.198173  
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NI FEATURE: JOURNEY THROUGH THE EONS - COMMENTARY Top

Two patriarchs of Indian Neurosciences: Professor Baldev Singh and Professor Jacob Chandy p. 5
Prakash N Tandon
DOI:10.4103/0028-3886.198174  
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An early description of monomelic amyotrophy: An excerpt from the diaries of Dr. Charles I Smith (1830–1880) in Bangalore, Southern India p. 11
Sanjeev Jain
DOI:10.4103/0028-3886.198220  
An early description of paralysis confined to an upper limb can be found in the casebook of Dr. Charles I Smith, who was a doctor in Bangalore in the 19th century. The historical and clinical aspects, as well as the current importance of this entity are described briefly.
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NI FEATURE: I. THE EDITORIAL DEBATE-- PROS AND CONS Top

The death wish and motor neuron disease! The chameleons and new research optimism p. 14
Ashok Panagariya, Parul Dubey, Bhawna Sharma
DOI:10.4103/0028-3886.198179  
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Death wish in patients with amyotrophic lateral sclerosis p. 16
Sudesh Prabhakar
DOI:10.4103/0028-3886.198178  
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NI FEATURE: II. THE EDITORIAL DEBATE-- PROS AND CONS Top

Sonothrombolysis in acute large vessel ischemic stroke p. 18
Amit Herwadkar
DOI:10.4103/0028-3886.198176  
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Sonothrombolysis: An effective adjunct to intravenous tissue plasminogen activator therapy in acute ischemic stroke p. 20
Shigeru Miyachi
DOI:10.4103/0028-3886.198180  
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REVIEW ARTICLES Top

Association between endothelial nitric oxide synthase gene polymorphisms and risk of ischemic stroke: A meta-analysis p. 22
Amit Kumar, Shubham Misra, Pradeep Kumar, Kameshwar Prasad, Awadh K Pandit, Kamalesh Chakravarty, Prachi Kathuria, Arti Gulati
DOI:10.4103/0028-3886.198170  
Previously published studies that have examined whether the three polymorphisms, G894T, T786C, and 4b/a in the endothelial nitric oxide synthase (eNOS) gene, are associated with ischemic stroke (IS) have reported conflicting results. Thus, we performed a meta-analysis to examine the potential association between these three single nucleotide polymorphisms (SNPs) of the eNOS gene and IS risk. A literature search was carried out for eligible candidate gene studies published before August 05, 2015 in the PubMed, Embase, and Google Scholar databases. The following combinations of main keywords were used in our study: ('endothelial nitric oxide synthase') or ('eNOS') and ('G894T, 4b/a, and T786C') and ('polymorphism') or ('polymorphisms') and ('Ischemic Stroke' or 'IS') and ('Cerebral Infarction' or 'CI') and ('genetic polymorphism' or 'single nucleotide polymorphisms' or 'SNP'). Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by using fixed or random effects model. Meta-regression analysis was used to investigate the potential sources of heterogeneity. Begg's funnel plots were used to explore the publication bias, and heterogeneity was assessed by I2 test. Twenty seven case-control studies involving 6733 cases and 7305 controls were analyzed in our meta-analysis. Significant association was observed for G894T (OR = 1.17; 95% CI: 1.08 to 1.28; P< 0.001) and 4b/a (OR = 1.25; 95% CI: 1.13 to 1.39; P < 0.001) whereas a non-significant association was observed for T786C (OR = 1.11; 95% CI: 0.98 to 1.26; P =0.109) eNOS gene polymorphisms and IS. Our meta-analysis establishes that the G894T and 4b/a polymorphisms of eNOS gene are significantly associated with the risk of IS. However, a non-significant association was found between T786C polymorphism of the eNOS gene and IS risk. Further prospective large epidemiological studies need to be done to confirm these findings.
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A systematic review of pipeline embolization device for giant intracranial aneurysms p. 35
Xianli Lv, Huijian Ge, Hongwei He, Chuhan Jiang, Youxiang Li
DOI:10.4103/0028-3886.198200  
The experience with respect to the treatment of giant intracranial aneurysms with flow-diversion devices is limited. The aim of the present systematic review was to evaluate the effect of the pipeline embolization device (PED) on giant intracranial aneurysms. Eligible related articles were identified by searching the PubMed, Web of Science, Springer, ScienceDirect, and OVID databases using “giant aneurysm” and “pipeline” as the search items. The date of the last search was November 20, 2015. This systematic review adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In a total of 9 eligible studies with 200 patients and 215 aneurysms, 40 (18.6%) giant (aneurysm diameter >25mm) intracranial aneurysms treated with PED were analyzed. During a 6 to 34 month follow-up, complete occlusion was achieved in 23 (57.5%) cases. Seven patients (17.5%) developed intracranial hemorrhage, 5 developed ischemic attack (12.5%), and 13 (32.5%) developed a mass effect after PED treatment. The complication rate was 77.8% in PED for giant vertebrobasilar artery aneurysms. The cumulative mortality rate for giant paraclinoid carotid artery and middle cerebral artery aneurysms was 13.3% and increased up to 50% for giant vertebrobasilar artery aneurysms. The complete obliteration rate of PED for giant intracranial aneurysms was approximately 60%. Mass effect is the most mechanism of complications. Complication and mortality rates associated with PED for giant vertebrobasilar artery aneurysms are still extremely high.
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Intensive care unit models: Do you want them to be open or closed? A critical review p. 39
Debashish Chowdhury, Ashish K Duggal
DOI:10.4103/0028-3886.198205  
Intensive care is a specialized branch of medicine dealing with the diagnosis, management, and follow up of critically ill or critically injured patients. It requires input from other branches of medicine on various issues. A critical care specialist has expertise in managing such patients round the clock. Based on his freedom to take decisions in the intensive care unit (ICU), different types of ICUs – open, closed, or semi-closed – have been defined. There is no doubt that all critical patients should be evaluated by an intensivist. Therefore, it is argued that a closed ICU model would be the ideal model. However, this may not always be feasible and other models may be more useful in resource-limited countries. In this review, we compare the different formats of ICU functioning and their suitability in different hospitals.
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ORIGINAL ARTICLES Top

An insight into death wish among patients with amyotrophic lateral sclerosis in India using “Wish-to-Die Questionnaire” Highly accessed article p. 46
Mandaville Gourie-Devi, Reema Gupta, Vibha Sharma, Vibhor Pardasani, Siddharth Maheshwari
DOI:10.4103/0028-3886.198177  
Aims: In amyotrophic lateral sclerosis (ALS), death wish is expressed in a varying proportion of patients in different countries. In this first study from India, influence of belief system of religion/spirituality and attitude towards death, widely prevalent in the country, in decision making, was evaluated. Material and Methods: Twenty ALS patients were assessed using 'Wish-to-Die Questionnaire' (WDQ) developed to reflect seven domains, namely religion/spirituality, belief in karma, meaning of life, hope, family support, financial support and death wish. Functional impairment, depression, hopelessness and suicidal ideation were assessed by ALS Functional Rating Scale, Beck's Depression Inventory, Beck Hopelessness Scale and The Scale of Suicidal Ideation, respectively. Results: On WDQ, all the 20 patients had belief in religion/spirituality, had hope and family support. Nineteen patients (95%) believed in karma, 16 (80%) still found life meaningful and 15 (75%) had financial support. Six patients (30%) had mild to moderate depression; hopelessness was present in 6 (30%) and suicidal ideation was present in one (5%). The 5 (25%) patients who expressed death wish did not significantly differ from others in 6 domains (religion/spirituality, belief in karma, meaning of life, hope, family support, financial support) of WDQ. The main reason in 3 patients who expressed death wish was lack of financial support. The fourth patient could not find meaning of life after the onset of illness, and the fifth wished to end his life since he had satisfactorily fulfilled all his responsibilities. Conclusion: Smaller proportion of patients of ALS expressed death wish in India compared to the Western countries. This may be attributed to belief in religion/spirituality and karma, having meaning of life and family support. As this is the first report from India, useful information may be obtained if similar studies are done on a larger sample.
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Sonothrombolysis for acute ischemic stroke - Break on through to the other side p. 52
Sanjith Aaron, Sunithi Mani, AT Prabhakar, P Suresh Babu, Sanjeev Kumar, Rohith Ninan Benjamin, Ajith Sivadasan, Karthik Muthusamy, Anil Kumar B Patil, Vivek Mathew, Mathew Alexander
DOI:10.4103/0028-3886.198213  
Background: Intravenous (IV) tissue plasminogen activator (tPA) infusion combined with transcranial low-frequency ultrasound waves targeted on the occluded arterial segment (sonothrombolysis) can increase recanalization in large artery-acute ischemic stroke (LA-AIS). Aims: To evaluate the benefits of sonothrombolysis in LA-AIS. Settings and Designs: An open-labeled observational study done in a quaternary care teaching hospital. Methodology: Patients with LA-AIS within the window period (<4.5 h) with no contraindications for IV-recombinant tPA were sonothrombolysed. Recanalization was monitored and graded using the transcranial Doppler thrombolysis in brain ischemia (TIBI) flow criteria and also by time of flight magnetic resonance angiography using a modified thrombolysis in myocardial infarction score. Parenchymal changes were assessed using computed tomography (CT) or diffusion-weighted imaging-Alberta Stroke Programme Early CT Score. National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were used to assess the outcome. Results: Eighteen patients underwent sonothrombolysis and the mean onset to needle time was 138 min (range 65–256). TIBI residual flow grade of ≥2 was seen in 15 of 18 patients (83%). Immediate dramatic improvement (NIHSS score ≤3 points or improvement by ≥10 points) was seen in 6 of 18 patients (30%) and in 9 of 18 patients (50%) within the next 24 h. Two patients (one with TIBI 0, another with re-occlusion) underwent mechanical thrombectomy post-sonothrombolysis. Symptomatic hemorrhage occurred in 5.5% of the patients. At 6 months, 2 of 18 patients (11%) died and 10 of 16 patients (63%) achieved mRS ≤2. Conclusions: Sonothrombolysis appears to be a safe way to augment the effect of tPA without increasing the door to needle time with the added advantage of observing flow through the occluded artery in real time.
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Robotic thymectomy for myasthenia gravis with or without thymoma–surgical and neurological outcomes p. 58
Arvind Kumar, Vinay Goyal, Belal B Asaf, Anjan Trikha, Jayashree Sood, CL Vijay
DOI:10.4103/0028-3886.198211  
Context (Background): We report our experience with robotic thymectomy in patients with myasthenia gravis (MG)and provide data on the surgical results and neurologic outcomes, as per the Myasthenia Gravis Foundation of America (MGFA) recommendations for MG clinical research standards. Objective: The study aims at reporting the surgical and neurological outcomes of patients of Myasthenia gravis treated by robotic thymectomy. Materials and Methods: Prospective data was collected from 71 patients with myasthenia gravis (in the age range 15-67 years) with or without thymoma, who had completed a minimum follow up of one year. All patients were treated with robotic radical thymectomy. The clinical classification, status of preoperative and postoperative therapy, evaluation of post-interventional clinical status, and descriptions of morbidity/mortality were done as per the MGFA recommendations. Univariate and multivariate analysis was done to assess the factors associated with achievement of complete stable remission(CSR). Results: A total of 71 patients were included in this study. Twenty-one out of 71 patients (29.6%) with myasthenia gravis had thymoma. At the last follow up, 70 patients were alive. No evidence of tumour recurrence was found in patients with thymoma. The overall CSR rate was 38% with the median time to CSR of 17.5 months (range 11-48 months). The CSR rate for patient of MG with thymoma was 19 % (n=4/21). Factor found to be significantly predicting CSR were young age, lesser severity of MG and non-thymomatous histology. Conclusions: Robotic thymectomy is a technically feasible and safe operation with a low morbidity and short hospitalization. It is associated with good neurological long-term results in terms of both CSR and clinical improvement.
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Neurological manifestations of HIV-AIDS at a tertiary care institute in North Eastern India p. 64
Shri Ram Sharma, Masaraf Hussain, Hibu Habung
DOI:10.4103/0028-3886.198203  
Background: The nervous system is among the most frequent and serious targets of human immunodeficiency virus (HIV) infection. The infection usually occurs in patients with profound immunosuppression. In 10 - 20% of the patients, the presence of a neurological disease is the first manifestation of symptomatic HIV infection. Aims and Objective: Despite the wide prevalence of neurological manifestations in HIV, there is no study examining the clinical manifestations of this disease in the resource- limited communities from north-eastern parts of India. To characterize the neurological involvement in patients with HIV infection at a tertiary care institute in northeast India, we studied various neurological presentations of HIV. Setting and Design: This was a retrospective observational study done at a tertiary care institute in northeast India over a period of 6 years from August 2008 to September 2014. Material and Methods: A total of 91 HIV seropositive patients of both genders, aged >18 years, showing clinical evidence of central nervous system (CNS) involvement, and admitted in a tertiary care institute were included. Their clinical manifestations, laboratory investigations, and imaging were studied. Result: Tuberculous meningitis was the most common presentation as secondary CNS illness (43.9%), followed by cryptococcal meningitis (14.2%) and cerebrovascular accidents (5.49%). Furthermore, 6.59% had neurosyphilis, 6.59% had acquired immune deficiency syndrome (AIDS) - associated dementia, and peripheral neuropathy occurred in 16.4% of the patients. Headache was the most common neurological symptom seen in 25% of the patients. Seizures were noted in 25% of the pateints. CD4 was significantly low in most of the patients with progressive multifocal leukoencephalopathy, HIV associated encephalopathy (HAD) and cryptococcal meningitis compared with other neurological manifestations. CD4 counts in tuberculous meningitis and HAD were 110.3/μl and 95/μl, respectively. Conclusion: CNS tuberculosis was the most common secondary infection seen in HIV patients followed by cryptococcal meningitis. A high index of clinical suspicion of neurological involvement in HIV patients helps in the early diagnosis and early institution of specific treatment, which in turn decreases the morbidity and mortality considerably.
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The “11 O'clock Heel First” technique for microvascular end-to-side anastomosis p. 69
Ahmed Hegazy, Mohammad Fathy Adel, Foad Abd-Allah, Hiedar Al-Shamy, Ahmed Elbassiouny, Sameh Mahmoud Amin, A El. Samadoni, Adam Sandler, Arundhati Biswas
DOI:10.4103/0028-3886.198207  
Background: The heel of a microvascular end-to-side anastomosis is a common site for technical imperfections. We describe a simple technique to overcome this challenge. The aim of the technique is to insert all the sutures in an inside-to-outside manner at the heel area on the donor side of the anastomosis. This technique has first been tested in a laboratory setting and then was further elaborated in a clinical setting. Materials and Methods: One hundred and twenty adult albino Wistar rats of both genders were randomized into the following two groups: (A) Control, 48 rats, representing approximately 40% of the total sample, underwent the usual two anchoring stitch technique; (B) Study group, 72 rats, representing approximately 60% of the total sample, underwent the technique described. Patency was confirmed both clinically and by the use of fluorescein angiography. Rat weight, diameter of both the donor and recipient vessels, type of anastomosis (arterio–arterial or arterio–venous) and angiographic findings were used as variables. A P value of less than 0.05 was considered significant. Results: The proposed technique had increased patency rates as compared to the standard technique, which was statistically significant (P = 0.021). However, there was no difference between the patency rates of arterio-arterial and arterio-venous atastomoses. Conclusion: The proposed technique is useful for perfecting the heel area of a microvascular end-to-side anastomosis in both laboratory and clinical settings.
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COMMENTARY Top

The quest to revascularize brain in ischemic stroke p. 73
Basant K Misra
DOI:10.4103/0028-3886.198183  
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ORIGINAL ARTICLE Top

Multimodal intraoperative neuromonitoring in scoliosis surgery: A two-year prospective analysis in a single centre p. 75
R Krishnakumar, N Srivatsa
DOI:10.4103/0028-3886.198189  
Aim: The present study is a prospective analysis of neuromonitoring [somatosensory evoked potentials (SSEP) and transcranial motor evoked potentials (TcMEP)] in consecutive scoliosis surgeries done at a tertiary care spine centre. Materials and Methods: Prospective analysis was performed on 52 consecutive patients undergoing scoliosis correction from 2013 to 2015. SSEPs were obtained by stimulating the median and tibial nerves with stimulus intensity level 20–25 mA. TcMEPs were recorded bilaterally from abductor pollicis brevis, biceps, and deltoid for the upper limb, and from tibialis anterior, quadriceps, gastrocnemius, and abductor hallucis for the lower limb. Stimulation was given in the form of a high voltage (300–400 V) stimulus. An “alert” was defined as reduction in the amplitude of at least 50% for SSEP and at least 65% for TcMEP compared to the baseline recordings and an increase in the latency by more than 10%. Results: The mean age of the patients was 14.6 years (7-33 years). Thirty-nine of the patients were females and 13 were males. Baseline values in neuromuscular scoliosis were low compared to adolescent idiopathic scoliosis (AIS). There were no false negative incidents. False positive cases were due to low blood pressure and malfunctioning of the leads. Conclusion: Use of upper limb leads could help in identifying malposition or malfunctioning of leads to eliminate false positive results. Combined multimodal intraoperative monitoring helps in increasing the safety in scoliosis corrective surgeries with a high sensitivity and specificity. Baseline values in neuromuscular scoliosis patients are possibly lower than idiopathic scoliosis patients. Intraoperative variations must be interpreted with caution.
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COMMENTARY Top

Multimodal intraoperative neuromonitoring during surgery for correction of spinal deformity: Standard of care or luxury? p. 80
Natarajan Muthukumar
DOI:10.4103/0028-3886.198221  
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ORIGINAL ARTICLE Top

Predictive validity of disability rating scale in determining functional outcome in patients with severe traumatic brain injury p. 83
Akhil Deepika, B Indira Devi, Dhaval Shukla
DOI:10.4103/0028-3886.198228  
Background: Most patients with severe traumatic brain injury (TBI) are discharged when they have still not recovered completely. Many such patients are not available for follow up. Aims: We conducted this study to determine whether the condition at discharge from acute care setting, as assessed with disability rating scale (DRS), correlates with functional outcome at follow up. Settings and Design: This study was conducted at a Neurosurgical intensive care unit (ICU) of a tertiary care referral center. This was a prospective observational study. Materials and Methods: Patients admitted to ICU with a diagnosis of severe TBI were enrolled for the study. On the day of discharge, all patients underwent DRS assessment. A final assessment was performed using Glasgow outcome scale extended (GOSE) at 6 months after discharge from the hospital. Statistical Analysis: The correlation between the DRS scores at the time of discharge with DRS scores and GOSE categories at 6 months after discharge was determined using Spearman's rho correlation coefficient. Results: A total of 88 patients were recruited for the study. The correlation coefficient of DRS at discharge for DRS at 6 months was 0.536 and for GOSE was −0.553. The area under the curve of DRS score at discharge for predicting unfavorable outcome and mortality at 6 months was 0.770 and 0.820, respectively. Conclusion: The predictive validity of DRS is fair to good in determining GOSE at follow-up. Pending availability of a more accurate outcome assessment tool, DRS at discharge can be used as a surrogate outcome for GOSE at follow up.
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COMMENTARY Top

Outcome prediction in traumatic brain injury: Is it a “Holy Grail?” p. 87
Sivashanmugam Dhandapani, Kanchan K Mukherjee
DOI:10.4103/0028-3886.198243  
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ORIGINAL ARTICLE Top

Segmental polymethylmethacrylate-augmented fenestrated pedicle screw fixation for lumbar spondylolisthesis in patients with osteoporosis – A case series and review of literature p. 89
V V Ramesh Chandra, B C M Prasad, MA Jagadeesh, V Jayachandar, Sanjeev A Kumar, Ravi Kumar
DOI:10.4103/0028-3886.198229  
Background: Instrumentation in patients with osteoporosis is challenging. Bone cement-augmented fenestrated pedicle screw fixation is a new procedure for fixation in osteoporotic bone. Very few studies related to this procedure are published in literature. Aims: To evaluate the clinical and radiological outcome of polymethylmethacrylate (PMMA)-augmented fenestrated pedicle screw fixation in patients with spondylolisthesis having significant osteoporosis. Settings and Design: This was a prospective, observational, single centre study. Materials and Methods: All the patients with lumbar spondylolisthesis and osteoporosis with symptomatic neural compression, managed surgically with PMMA-augmented fenestrated pedicle screws, were included in the study. Patients were evaluated preoperatively and postoperatively by means of Oswestry disability index (ODI), visual analog score (VAS); and, radiologically by plain radiography and computed tomography. Statistical Analysis: Wilcoxon nonparametric test for paired samples with a level of significance of 0.05 was performed. Results: A total of 25 patients of spondylolisthesis with osteoporosis (average T score of −3.0) were included in the study. The average age at presentation was 56.5 years. Females predominated with a female:male ratio of 3.16:1.Most of the patients had spondylolisthesis at the L4/L5 level followed by the L5/SI level. All the patients underwent spinal fusion with instrumentation and bone cement (PMMA)-augmentation through fenestrated cannulated pedicle screws. Preoperative and postoperative functional assessment done with VAS and ODI showed statistically significant improvement. All the patients had an evidence of bone fusion at follow-up. Conclusion: Fenestrated pedicle screw fixation with bone cement-augmentation in patients with lumbar spondylolisthesis and osteoporosis provided effective and lasting screw purchase.
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COMMENTARY Top

Spinal surgery in patients with significant osteoporosis: The therapeutic advances and research perspectives p. 96
Sushil K Gupta, Rekha Singh
DOI:10.4103/0028-3886.198245  
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CASE REPORT Top

“I swear, I can't stop it!” – A case of severe Tourette's syndrome treated with deep brain stimulation of anteromedial globus pallidus interna p. 99
S Dwarakanath, A Hegde, J Ketan, P Chandrajit, R Yadav, K Keshav, S Sampath, PK Pal, Y C J Reddy
DOI:10.4103/0028-3886.198188  
Introduction: Tourette's syndrome (TS) is a complex neuropsychiatric disorder characterized by the presence of multiple motor and vocal tics. Here, we report the case of a young man with severe TS refractory to multiple medications who underwent deep brain stimulation (DBS), which was successful in substantially ameliorating his tics. To our knowledge, this is the first such report from India and South Asia. Case Report: An 18-year-old right-handed male patient was diagnosed with TS at the age of 10 years. He had facial and ocular tics. He was also hitting his fist against his chest and shouting obscenities. The manifestations would be present in every waking hour with a maximum tic free interval of 15–20 minutes. They would often result in self-injury or damage to objects. He would have frequent crying spells, anger outbursts, and death wishes. As tics became highly conspicuous and socially inappropriate, he dropped out of school and remained almost completely house-bound for the preceding year. On evaluation, he scored 96 (46 on tic-severity subscale and 50 on impairment subscale) of a maximum of 100 on the Yale Global Tic Severity Scale. (YGTSS). Management: After failure of multiple combinations of medicines, repetitive transcranial magnetic stimulation, and behavioural therapies, he successfully underwent DBS to bilateral anteromedial globus pallidus interna. Conclusion: Tic severity reduced substantially post-surgery, with the YGTSS score improving by more than 72%. These improvements were sustained on follow-up visits with the patient successfully returning to join college. To our knowledge, this is the first such report from India and South Asia.
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COMMENTARY Top

Neuromodulation in Tourette's syndrome p. 103
Milind Deogaonkar
DOI:10.4103/0028-3886.198271  
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CASE REPORT Top

Diagnostic dilemma—dengue or Japanese encephalitis? p. 105
Kalaimani Sivamani, Varun Dhir, Surjit Singh, Aman Sharma
DOI:10.4103/0028-3886.198194  
Dengue and Japanese encephalitis (JE) are arboviral diseases that are common in the tropical countries. JE virus is a classical neurotropic virus. The dengue virus, however, is usually not considered to be neurotropic, even though in recent years, reports of direct central nervous system involvement in dengue has been described. Here, we report a case wherein the patient had magnetic resonance imaging evidence of bilateral thalamic and brainstem involvement with positive serologies for both dengue and JE. We also discuss the diagnostic challenge in these cases.
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COMMENTARY Top

Dual infection with Japanese encephalitis and dengue fever: Issues with diagnosis p. 108
Ravindra K Garg, Hardeep S Malhotra, Amita Jain
DOI:10.4103/0028-3886.198210  
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CASE REPORT Top

Coexistent intracerebral metastatic melanoma and meningioma p. 110
Sweety V Shinde, Asha S Shenoy, Hemant V Savant, Srikant B Balasubramaniam
DOI:10.4103/0028-3886.198212  
Coexistence of multifocal neural crest tumors, namely meningioma, melanoma, and nerve sheath tumors, is termed as neurocristopathy. Neurofibromatosis is the commonest form of neurocristopathy. We report a rare case of frontal lobe metastatic melanoma coexistent with a parietal lobe meningioma, in the absence of any stigmata of neurofibromatosis.
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NI FEATURE: PATHOLOGY PANORAMA - ORIGINAL ARTICLE Top

Histological spectrum of oligodendroglial tumors: Only a subset shows 1p/19q codeletion p. 113
Trupti Pai, Sridhar Epari, Sangeeta Desai, Amol Wadile, Tejpal Gupta, Jayant S Goda, Aliasgar Moiyadi, Prakash Shetty, Shubhada Kane, Rakesh Jalali
DOI:10.4103/0028-3886.198195  
Background: Canonical oligodendroglial tumors (ODGs) are characterized genetically by chromosomes 1p/19q codeletion. Aims: This study was essentially aimed at the detection of frequency of 1p/19q codeletion in the different histological spectrum of ODG tumors in a large cohort of Indian patients. Materials and Methods: All the ODG tumors evaluated for 1p/19q by fluorescence in-situ hybridization (FISH) during 2009–2015 were correlated with histology, immunohistochemical expression for p53 protein and clinical features. Results: A total of 676 cases included both pediatric (n = 18) and adult (n = 658) patients. Histologically, 346 pure ODGs [oligodendroglioma (OD) and anaplastic oligodendroglioma (AOD)] and 330 mixed ODGs [oligoastrocytomas (OA), anaplastic oligoastrocytomas (AOA) and glioblastoma with oligodendroglioma component (GBM-O)] were included. 1p/19q co-deletion was noted in 69% (60/87), 55.9% (145/259), 18.2% (18/99), 10.5% (18/172), and in 5.1% (3/59) cases of OD, AOD, OA, AOA, and GBM-O, respectively. In the pediatric age-group, 1p/19q codeletion was seen in 25% (2/8) of pure ODGs and in 10% (1/10) of mixed ODGs. In adults, it was observed in 60% (203/338) cases of pure ODGs and in 11.9% (38/320) cases of mixed ODGs. In adults, pure ODG histology (P = 0.00), frontal location (P = 0.004), calcification [in pure ODGs] (P = 0.03), and lack of p53 protein overexpression (P = 0.00) showed significant statistical correlation with 1p/19q codeletion. Conclusions: This study is unique in being one of the largest on ODGs for 1p/19q co-deletion including both pediatric and adult age groups of Indian patients. The results showed co-deletion in 60% of adult ODGs and 25% of pediatric pure ODGs. This reemphasizes the occurrence of 1p/19q codeletion, even though rare, in the pediatric age group.
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COMMENTARY Top

Histological spectrum of oligodendroglial tumors: Only a subset shows 1p/19q codeletion p. 121
Vani Santosh
DOI:10.4103/0028-3886.198196  
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NI FEATURE: THE QUEST - COMMENTARY Top

How to recognize and treat metabolic encephalopathy in Neurology intensive care unit Highly accessed article p. 123
Ivana I Berisavac, Dejana R Jovanović, Višnja V Padjen, Marko D Ercegovac, Predrag D J Stanarčević, Maja S Budimkić-Stefanović, Milan M Radović, Ljiljana G Beslać-Bumbaširević
DOI:10.4103/0028-3886.198192  
Metabolic encephalopathy (ME) represents a syndrome of temporary or permanent disturbance of brain functions that occurs in different diseases and varies in clinical presentation. It can be manifested in a range from very mild mental disorders to deep coma and death. Clinically, it is characterized by a variety of psychiatric and neurological symptoms and signs. The most common causes of ME are: hypoxia, ischemia, systemic diseases and toxic agents. ME is the most frequent in elderly people who have previously been exhausted by chronic illnesses and prolonged stay in bed. ME is a very common complication in patients treated in intensive care units. Treatment and prognosis of the disease are varied and depend on aetiology, as well as on the type and severity of clinical presentation. Mortality of patients with septic encephalopathy ranges from 16-65%, while the one-year survival of patients with encephalopathy and liver cirrhosis is less than 50%.
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NI FEATURE: CENTS (CONCEPTS, ERGONOMICS, NUANCES, THERBLIGS, SHORTCOMINGS) - ORIGINAL ARTICLE Top

A novel nasoseptal flap harvesting technique in revision expanded endoscopic transsphenoidal approaches p. 129
Edmond J Gandham, Rajan Sundaresan, Regi Thomas, Ari G Chacko
DOI:10.4103/0028-3886.198214  
Objectives: To describe the technique of harvesting the nasoseptal flap (NSF) in revision-expanded endoscopic approaches (EEA). Study Design: We retrospectively analyzed four cases of endoscopic skull base reconstruction (ESBR) following revision EEA done for pituitary adenoma recurrence. The presence of an intact mucoperiosteum between the nasal septum and the roof of the choana as judged on a preoperative endoscopic and radiological assessment was considered to be sufficient for the presence of a viable pedicle. By strategic placement of the incisions, the entire bilateral posterior nasal septal mucoperiosteum was raised in the NSF containing the remnant vascular pedicle. ESBR was performed with multilayer grafting of the dural defect, and the NSF was placed onto the bony margins of the defect. Results: All patients had successful skull base reconstruction with the NSF raised by this technique as none of them developed postoperative cerebrospinal fluid leak. Conclusion: Though the number of patients in this study is small, we would like to present the concept of harvesting the NSF in revision surgery, wherein neither measuring the surface area of the pedicle nor the acoustic Doppler assessment of the pedicle is required.
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NI FEATURE: CITADELS SCULPTING FUTURE - COMMENTARY Top

History of Neurosurgery at Postgraduate Institute of Medical Education and Research, Chandigarh Highly accessed article p. 134
Sunil K Gupta, Kanchan K Mukherjee, Rajesh Chhabra, Manjul Tripathi
DOI:10.4103/0028-3886.198236  
The Department of Neurosurgery started functioning at the Postgraduate Institute of Medical Education and Research, Chandigarh in 1962 with the joining of Dr. Gulati. The department provides neurosurgical services primarily to the people of Chandigarh, Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir as well as the neighbouring areas of Rajasthan, Uttar Pradesh and Uttarakhand. The infrastructure and subspecialties have been developed over the last 5 decades by the dedicated and tireless efforts of the faculty and residents. We attempt to chronicle the contributions of those who have served the department in the past.
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NI FEATURE: THE FOURTH DIMENSION - COMMENTARY Top

A summary of some of the recently published, seminal papers in neuroscience p. 152
K Sridhar, Mazda K Turel, Manjul Tripathi, Ravi Yadav, Aastha Takkar, Kuntal K Das, Anant Mehrotra
DOI:10.4103/0028-3886.198276  
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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTERS TO EDITOR Top

Ipilimumab-induced hypophysitis and ileocolitis: Serial pituitary MRI findings p. 165
Dalveer Singh, Charlie Chia-Tsong Hsu, Gigi Nga Chi Kwan, Sandeep Bhuta
DOI:10.4103/0028-3886.198182  
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Dural venous sinus thrombosis following intravitreal bevacizumab p. 166
Sinchu C Maniangatt, Madhukar Trivedi, Sapna E Sreedharan, ER Jayadevan, PN Sylaja
DOI:10.4103/0028-3886.198223  
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Proximal ulnar artery thrombosis after cysticidal therapy: A rare complication of neurocysticercosis p. 167
Rudrarpan Chatterjee, Krishnarpan Chatterjee, Chetana Sen
DOI:10.4103/0028-3886.198199  
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Refractory status dystonicus in ataxia telangiectasia p. 169
Somdattaa Ray, Ravinder J S Sidhu, Ravi Yadav, Dwarakanath Srinivas, Pramod K Pal
DOI:10.4103/0028-3886.198206  
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Drug-induced Parkinsonism on the rise: Beware of levosulpiride and its combinations with proton pump inhibitors p. 173
Thomas Mathew, Uday S Nadimpally, Arvind D Prabhu, Raghunandan Nadig
DOI:10.4103/0028-3886.198175  
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LETTERS TO EDITOR Top

“Hot-cross bun” and “inverse trident sign' in neurosarcoidosis: An important finding p. 175
Kadam Nagpal, Puneet Agarwal
DOI:10.4103/0028-3886.198227  
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Multiple Acyl CoA dehydrogenase deficiency: Uncommon yet treatable disorder p. 177
M Pooja, R Subasree, S Sumanth, M Veerendra Kumar, N Gayathri, S Rashmi
DOI:10.4103/0028-3886.198186  
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Guillain–Barré syndrome: A rare manifestation of Hansen's disease p. 179
Saumya H Mittal, KC Rakshith, ZK Misri, Shivanand Pai, Nisha Shenoy
DOI:10.4103/0028-3886.198191  
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Novel SCN8A mutation in a girl with refractory seizures and autistic features p. 180
Puneet Jain
DOI:10.4103/0028-3886.198198  
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Newly described additional sites of extrapontine myelinolysis along with typical pontine and extrapontine myelinolysis p. 181
Kamble Jayaprakash Harsha, K Parameswaran
DOI:10.4103/0028-3886.198197  
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Trunk proprioceptive neuromuscular facilitation influences pulmonary function and respiratory muscle strength in a patient with pontine bleed p. 183
Lavnika Dubey, Suruliraj Karthikbabu
DOI:10.4103/0028-3886.198193  
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Bartter's syndrome: A rare cause of seizures and quadriparesis p. 184
Rajesh Verma, Abdul Qavi, Sudhakar Pandey, Amrit A Bansod
DOI:10.4103/0028-3886.198190  
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Chronic encephalopathy with ataxia, myoclonus, and auditory neuropathy: A case of bismuth poisoning p. 186
Ramesh Siram, Ragasudha Botta, Chetan Kashikunte, Pramod K Pal, Ravi Yadav
DOI:10.4103/0028-3886.198185  
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An unusual cause of bilateral tongue wasting and weakness p. 188
Aastha Takkar, Aditya Choudhary, Manoj K Goyal, Manish Modi, Vivek Lal
DOI:10.4103/0028-3886.198235  
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Paroxysmal sympathetic hyperactivity after symptomatic hypoglycemia p. 189
Mohammad R Mohebbi, Pragya Punj, Premkumar N Chandrasekaran, Christopher R Newey
DOI:10.4103/0028-3886.198187  
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Reversal of angiographic findings of moyamoya syndrome after congenital cyanotic heart disease repair p. 190
Aniket C Pande, Praveen Kesav, Sapna E Sreedharan, PN Sylaja
DOI:10.4103/0028-3886.198202  
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Intracranial fibrous xanthoma mimicking a falcine meningioma p. 192
Zhiqin Lin, Zongze Li, Meng Zhao, Yongzhi Wang, Zhongli Jiang
DOI:10.4103/0028-3886.198204  
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Treatment challenges in neurogenic stress cardiomyopathy following aneurysmal subarachnoid hemorrhage p. 193
Kamble Jayaprakash Harsha
DOI:10.4103/0028-3886.198234  
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Unilateral moyamoya disease with co-existing arteriovenous malformation p. 195
Nishanth Sadashiva, Kannepalli N Rao, Sampath Somanna
DOI:10.4103/0028-3886.198230  
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A rare association of dysphagia and cervical compressive myelopathy in diffuse idiopathic skeletal hyperostosis p. 198
Rakesh Gupta, Harshad Patil
DOI:10.4103/0028-3886.198231  
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Recurrent meningitis with unusually delayed cerebrospinal fluid leak detected by magnetic resonance cisternography p. 201
Surjeet Kumar, Anju Aggarwal, Aashima Dabas, Ankur Roy
DOI:10.4103/0028-3886.198233  
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Extraventricular neurocytoma: An uncommon tumor in a young boy. A review of literature p. 202
Parimal Agrawal, Kirti Gupta, Harsimrat B S Sodhi
DOI:10.4103/0028-3886.198201  
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“Stroke by a pencil”: A friend turned fiend p. 206
Ashish Aggarwal, Darpan Gupta, SS Dhandapani
DOI:10.4103/0028-3886.198224  
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Unusual presentation of an intracranial hemangiopericytoma as a cystic intraparenchymal mass lesion closely mimicking a glioma p. 208
Zhiqin Lin, Yongzhi Wang, Meng Zhao, Zongze Li, Xiaolin Chen, Zhongli Jiang
DOI:10.4103/0028-3886.198222  
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A case of traumatic C2-3 listhesis without pars fracture: Insights from this possible variant of hangman's fracture p. 209
Madhivanan Karthigeyan, Vasundhara Rangan, Pravin Salunke
DOI:10.4103/0028-3886.198219  
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Surgical considerations for intramedullary conus medullaris metastatic tumors with origin from primary lung lesions: A review of the literature p. 211
Giorgio M Callovini, Andrea Bolognini, Marco Giordano, Roberto Gazzeri
DOI:10.4103/0028-3886.198218  
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Spinal dysraphism with tripedus: A child with three legs p. 214
Shaam Bodeliwala, Daljit Singh, Hukum Singh, Mohammad Iqbal, Atul Agarwal, Priyanka Khurana
DOI:10.4103/0028-3886.198209  
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Intradural sacral mature teratoma associated with a low-lying conus p. 216
Bekir Akgun, Sait Ozturk, Ozlem Ucer, Fatih S Erol
DOI:10.4103/0028-3886.198208  
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Incidentally detected bilateral petrous apex cephaloceles: CT and MRI features p. 217
Arzu Canan, Kamil Çıra, Özgür Özbilek, Koray Koç, Cihat Aksoy
DOI:10.4103/0028-3886.198215  
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NEUROIMAGES Top

Posterior reversible encephalopathy syndrome after high-dose cytarabine in acute myelogenous leukemia p. 220
Christopher R Newey, Premkumar N Chandrasekaran, Mohammad R Mohebbi
DOI:10.4103/0028-3886.198171  
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Unilateral lateral rectus cysticercosis presenting as Duane retraction syndrome type IIb p. 221
Pratibha Prasad, Prakash K Sinha, Deepika Joshi, Sandeep K Chaudhary
DOI:10.4103/0028-3886.198232  
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Choroid plexus involvement in Rosai–Dorfman disease p. 222
Bilal Battal, Salih Hamcan, Ugurcan Balyemez, Veysel Akgun
DOI:10.4103/0028-3886.198217  
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Type 1 neurofibromatosis with intracanalicular rib head dislocation p. 223
Venkata R C Vemula, Chandramouliswara P Bodapati, Krishna Mohan, Sudarshan Agarwal
DOI:10.4103/0028-3886.198226  
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Early-onset pure absence epilepsy with eyebrow myoclonia p. 224
Puneet Jain
DOI:10.4103/0028-3886.198184  
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Traumatic retropharyngeal pseudomeningocele following C5-C6 subluxation p. 226
Aslam Louati, Khaled Hadhri, Anis Tebourbi, Mondher Kooli
DOI:10.4103/0028-3886.198216  
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CORRESPONDENCE Top

“Going home the same day” – Is day care neurosurgery a measure of surgical skill and technical advancement? p. 228
George C Vilanilam, Vellore S Hari
DOI:10.4103/0028-3886.198168  
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Author's Reply: Resurgence of day care surgery in Neurosurgery p. 230
Mazda K Turel, Mark Bernstein
DOI:10.4103/0028-3886.198181  
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Concern and utilization of smart phone based telemedical health-care in allied neurological speciality: Real health–care model of future India p. 232
Guru Dutta Satyarthee
DOI:10.4103/0028-3886.198169  
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Author's Reply: Smartphone-based telemedical healthcare: The HP telestroke model p. 233
Sudhir Sharma, MV Padma
DOI:10.4103/0028-3886.198282  
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