Women in India are greatly discriminated against if they happen to have epilepsy. Engagements are often cancelled. The parents of epileptic girls have to give heavy dowry at the time of marriage, even if the boy is handicapped. As a result, many girls do not disclose their problem before marriage. They take the medicine secretly. Epilepsy may sometimes produce problems during pregnancy and delivery, otherwise epileptic women on anti epileptic drugs, can lead a normal married, professional and social life. The stigma of epilepsy should be done away with, as we enter the 21st century.

Current philosophy of treatment of brain abscess includes aspiration, appropriate antibiotics, treatment of sequelae and eradication of the primary source. Early clinical suspicion and diagnosis with CT is crucial. Small abscesses (<3 cm) in cerebritis or capsular stage located deep in clinically stable, poor surgical risk patients with diagnosis firmly supported by CT, may be treated with medical treatment only. Biweekly CT scan must be done to monitor the treatment response. CT or ultrasound guided aspiration should be performed in the event of clinical deterioration, failure of reduction in size or enlargement of abscesses. Encapsulated abscess (>3 cm), presence of significant neurological deficit or mass effect, doubt in the diagnosis and presumed resistant organisms are best treated with aspiration. Excision is required in large superficial abscesses resistant to multiple aspirations, post-traumatic abscess with a foreign body or fistula and multiloculated abscess of nocardial or actinomycotic aetiology. Results are directly related to the sensorium at the time of presentation. Stereotactic aspiration of all the loculi of multiloculated abscess in single or staged aspiration, and more completed drainage and lavage with endoscopic stereotactic evacuation may cut down indications of excision of brain abscess in future. It is concluded that, with diagnostic and technical advancements, a trend of adequate drainage of brain abscess via minimally invasive surgery is emerging. Confirmation of diagnosis and monitoring of treatment response with magnetic resonance spectroscopy may allow greater number of patients in future to be managed with medical treatment only.

Blood flow velocities in the basal cerebral arteries were evaluated in 41 patients with supratentorial arteriovenous malformation (AVM), using a transcranial doppler 64-B instrument. The AVM was surgically excised in 20 patients and embolised in 21 patients. Blood flow velocities in feeding basal cerebral arteries were found markedly decreased in both the groups, at 24 hours after intervention. On follow up study at 3 months, blood flow velocity in feeding cerebral artery was found to be increased in 47 percent of patients who were embolised, but remained normal in all the patients who underwent surgery.

Analysis of 893 patients of ischaemic stroke in the stroke registry of Nizam's institute of Medical Sciences, Hyderabad is presented. 16% of them had lacunar infarction. The mean age at presentation was 56.9 years and male to female ratio was 3.5:1. The common risk factors included hypertension(62%),diabetes(38%) and smoking(28%). Six percent had an underlying cardiac source of embolism and none had significant (>50%) extracranial carotid atherosclerosis. In 22% of patients, no obvious risk factors could be identified. The frequency of risk factors was similar in patients with lacunar and non- lacunar infarctions. However, patients with lacunar infarction had higher frequency of diabetes and absence of significant (>50%) extracranial carotid artery disease. Pure motor hemiparesis was the presenting syndrome in 45% patients. Ataxic hemiparesis and sensorimotor stroke accounted for 18% each and dysarthria-clumsy hand syndrome for 14%. This study suggests that the frequency, risk factors and clinical profile of lacunar infarction in our stroke registry is similar to most of the western stroke registries.

The study was carried out to determine the safe site of entry and the appropriate trajectory of the screw implantation in the lateral masses of atlas (Cl) and axis (C2) during their fixation using the plate and screw technique. Fifty dried specimens of atlas and axis vertebrae were studied. Various dimensions of the lateral masses were quantitatively measured, laying stress on their relationship with the vertebral artery foramen. As the vertebral artery foramen was present entirely in the transverse process in all specimens, screw implantation in the facet of atlas was relatively safe. Best direction of screw implantation in the facet of atlas was observed to be 15 degrees medial to sagittal plane and 15 degrees superior to axial plane. It should be implanted from the middle of the posterior surface of facet. Vertebral artery foramen formed a deep groove in the undersurface of a majority of superior facets of axis. In 15% facets, vertebral artery foramen occupied the entire undersurface of the superior facet. Safe angle for screw implantation in the facet of axis through its pedicle was seen to be 40 degrees medial to sagittal plane and 20 degrees superior to axial plane. Safe site of screw entry in the axis was superior and medial third of the posterior surface of the pedicle. Quality of cancellous bone in the lateral masses in the proposed trajectory of screw in Cl and C2 was good, providing an excellent purchase of the screw.

Twenty five patients with post operative ischaemic deficits, following clipping of intracranial aneurysms, were studied. Hypertensive-hypervolaemic-haemodilution (triple H) therapy was given to all patients using colloids and crystalloids. CVP was used to monitor the fluid therapy. Dopamine was needed in 22 patients to elevate the systemic blood pressure. Vasospasm was confirmed in 20 patients with transcranial doppler studies (TCD). 20 (80%) patients survived, 10 (40%) with good outcome, 7 (28%) with fair, 2 (8%) with poor outcome and 1 (4%) with vegetative state. There were 5 (20%) deaths, 4 of which occurred due to infarct. All these patients had poor Hunt and Hess grade at admission, high Fisher grade haemorrhages in the initial CT scan and/or required prolonged temporary clipping at surgery. One death occurred due to central venous line induced septicaemia. The duration of 'triple H therapy' amongst the survivors varied from 2-7 days with an average of 4.6 days. The complications of 'triple H therapy' included hypokalaemia (3 patients), haemorrhagic infarct (1 patient) and septicaemia (1 patient). It is concluded that 'triple H therapy' is useful in treating vasospasm induced ischaemic deficits. It worsens brain oedema in presence of acute infarcts and hence is contraindicated in such patients. A further study involving a larger number of patients with strict haemodynamic and ICP monitoring is suggested to determine the usefulness of individual components of 'triple H therapy'.

Sixty cases of spinal tuberculosis with neurological deficit treated with 'middle path regimen' were analysed and therapeutic response was correlated with the magnetic resonance imaging (MRI) observations. Tuberculous lesions were found to be more extensive than seen on plain X-ray in 60% of the cases. MRI showed the involvement of one or both pedicles in nearly 90% of the cases, in addition to the vertebral body lesion as seen in the X-rays. The patients showing predominantly extradural collection of fluid with relatively preserved cord size, and MRI evidence of myelitis/oedema, improved neurologically with treatment. The myelomalacia of cord was found to be a poor prognostic sign for neural recovery. The magnitude of thinning of cord did not always correlate with severity of neural deficit, however, thinning of cord in association with myelomalacia carried a bad prognosis. The complete neural recovery is not expected in patients with syrinx formation proximal or distal to the diseased spine, either with antitubercular drugs or after mechanical decompression. MRI changes in dura-subarachnoid complex suggesting arachnoiditis generally correlated with poor neural recovery. MRI provided a reliable guide to the level and extent of surgical decompression, and prognostication of the outcome of therapeutic measures.

Balloon test occlusion of internal carotid artery has been frequently used in preoperative evaluation of patients with carotid aneurysms, fistulas and skull based neoplasms in whom arterial sacrifice is planned or considered as a possible part of therapy. We present our experience of the test in 28 patients. The test was positive in four and negative in twenty four patients. The results are compared with cross-compression angiography and the outcome following internal carotid artery sacrifice. There were no complications related to the test and the results accurately predicted the tolerance to occlusion of artery. We found the test safe, simple to perform and reliable to preoperatively detect patients at risk of ischaemic stroke following surgical ligation or endovascular occlusion of internal carotid artery.

Epidemic dropsy, which results from the accidental ingestion of mustard oil adulterated with argemone oil, has been associated with certain neurologic symptoms. The occurrence of objective neurologic involvement has, however, precluded this illness. We report two cases, who were victims of epidemic dropsy in the recent outbreak in India and showed objective neurologic deficit in the form of brachial neuritis.

Primary angiitis of CNS(PACNS) or granulomatous angiitis of CNS is a rare inflammatory disease of small blood vessels mostly confined to the CNS. The clinical and pathological features of 3 autopsied cases are described. Clinically all the three PACNS patients were young males, age ranging from 19 to 31 years. All presented with varied neurological manifestations. There was no evidence of systemic disease in any of the cases. The ESR was normal and CSF analysis showed chronic meningitic pattern. The cerebral angiogram in one case was normal and the CT scan done in another case showed multiple intracerebral haematoma due to vasculitis. Brain biopsy was not done. Diagnosis was made at post-mortem examination. Histology showed characteristic but variable degree of granulomatous and non-granulomatous angiitis of small vessels. Venulitis with parenchymal haemorrhages was the predominant feature and in one case phlebitis with thrombosis was noted. Since the disease responds to steroids and immunosuppressive therapy, establishing antemortem diagnosis is important. In view of the association of angiitis of CNS with bacteria and viral infections, their role in the evolution of the disease needs to be investigated.

Two patients with isolated schizencephaly, a very rare congenital anomaly of the brain, who presented with epilepsy are presented. According to imaging morphology, there are two types of schizencephaly, 'open lip' and 'minimally open lip'. These two cases emphasize that while MRI is superior to CT in the diagnosis of congenital brain anomalies, schizencephaly can be diagnosed by its characteristic CT features.

A thirty year old female presented with sudden onset of severe headache, papilloedema and altered sensorium. Computerised tomography (CT) scan showed a hyperdense vermian mass in the posterior fossa. Operative findings and histological examination revealed spontaneous bleed into the epidermoid cyst. Difficulty in the preoperative diagnosis and uncommon presentation of the intracranial epidermoid cyst prompted us to report this case.

Vertebral artery (VA) aneurysms are rare. We present our experience with three cases of VA aneurysms. Two aneurysms were located close to the origin of basilar artery while the third patient had a giant posterior inferior cerebellar artery aneurysm. These aneurysms were operated by the far lateral inferior suboccipital approach with good results.

The authors report a rare complication of C1-C2 rotary subluxation in two children following posterior stabilization for congenital atlantoaxial dislocation (AAD). A patient, with mobile AAD, underwent Brook's C1-C2 fusion while the other, with fixed AAD, underwent transoral decompression followed by Jain's occipitocervical fusion. A pre-existing ligamentous laxity associated with an asymmetrical wire tightening or slippage of the wires due to rotation of the neck in the former, and the drilling of the C1-C2 lateral joints during the transoral procedure in the latter, could have contributed to the rotary subluxation. Both patients presented with persistent torticollis due to fusion in an asymmetrical position with dislocated facet joints. Rotary C1-C2 subluxation, when coexisting with anterior dislocation, has the potential to cause severe and occasionally fatal cord compression. Well defined criteria to diagnose this entity by conventional radiology exist, however, due to the overlap of anatomy, the condition is often overlooked. In the present study, three dimensional reconstruction images using helical computerized tomography were very useful in delineating the subluxation and in planning its surgical reduction and arthrodesis.

Human brucellosis, more specifically neurobrucellosis, is a less commonly reported disease in India; although, animal brucellosis and seroprevalence in specific areas is well reported. We are reporting 4 cases of neurobrucellosis presenting as meningoencephalitis. Diagnosis was confirmed by serological test and agglutination titre was > 1:320 in all the patients. All these patients had close contact with animals and history of raw milk ingestion was present in 3 cases. The aim of presenting these cases is to create awareness among physicians while treating meningitis in persons, engaged in occupations related to brucellosis or having a history of ingestion of raw milk or milk product.

An important feature of malignant transformation of tumours is the loss of cholesterol feedback inhibition mechanism (cholesterol-feedback lesion) that regulates mevalonate pathway recognized to play a crucial role in cellular growth, death and differentiation. Recently, it was shown that Receptor-C(k)-dependent signalling regulates genes involved in maintaining cellular cholesterol homeostasis through a transcription factor sterol response element binding protein (SREBP) having affinity for sterol regulatory element (SRE) present in the promoter region of these genes. The present study revealed that CNS tumours exhibit overexpression of Receptor-C(k) gene product which was accompanied by their inability to express SREBP gene product and this phenomenon has the inherent capacity to initiate the cholesterol feedback lesion in these tumours. Based upon these and our earlier studies, we propose for the first time that this loss of cholesterol feedback control may be responsible for the initiation of these tumours.

A case of cerebellar medulloblastoma in a 65 year old male is reported. Cerebellar medulloblastoma is classically seen during childhood, and less than 25% of these tumours are found in adults below 40 years of age. Rarely, cases are reported above the age of 40 years. So far only three cases have been reported in patients aged above 64 years and none of these case reports are from India.

Fulminant cerebral infarction secondary to arterial thrombosis in adults with nephrotic syndrome is rare. We report a 42 year old male with fulminant right anterior cerebral and middle cerebral artery infarction. Minimal change disease of the kidney was documented by renal biopsy. The possible pathogenesis is discussed and pertinent literature reviewed.

A case of spinal extradural abscess following local steroid injection for back ache, in a 26 years old male is described. The abscess presented as a swelling externally. MRI localised the lesion to L2-S1 segments. Mechanism of such an infection has been discussed.

Peduncular hallucinations are formed visual images often associated with sleep disturbance and are caused by lesions in the midbrain, pons and diencephalon. In present case report, a four year child, who was operated for midline posterior fossa medulloblastoma developed peduncular hallucinations on 3rd post operative day. Traction trauma or the compression of mid brain was thought to be the most possible cause of hallucinations.

A histopathologically proven case of cerebral toxoplasmosis in a young HIV positive patient has been presented. The clinical problems in management are highlighted.

Neurological manifestations of skeletal fluorosis have been attributed to compressive radiculomyelopathy. Experimental fluorosis has shown evidence of myopathic changes. Data on human muscle pathology is very scanty. This study included 22 patients with established osteofluorosis. 16 of them showed only EMG changes of neurogenic muscle disease. Histochemistry and histopathology of muscle biopsies showed features of muscle atrophy, evidenced by 'type I' atrophy and 'type I' grouping. No myopathic changes were observed. It may be concluded that the primary changes are related to the nerve, with muscle being affected secondarily. There was no evidence of any primary muscle pathology due to fluorosis.