The management strategies for arteriovenous malformations (AVMs) continue to evolve, spurred by advancing technology and improved understanding of the natural history of these lesions. In general, intervention is reserved for Spetzler-Martin Grade I-III lesions or for those with certain high-risk features. Grade IV-V AVMs, in contrast, are usually managed conservatively. Although multimodality therapy incorporating endovascular and/or radiosurgical techniques is increasingly common, microsurgical removal remains the definitive form of treatment.

High-grade gliomas are relatively frequent in adults, and consist of the most malignant kind of primary brain tumor. Being resistant to standard treatment modalities such as surgery, radiation, and chemotherapy, it is fatal within 1 to 2 years of onset of symptoms. Although several gene therapy systems proved to be efficient in controlling or eradicating these tumors in animal models, the clinical studies performed so far were not equally successful. Most clinical studies showed that methodologies that increase tumor infection/transduction and, consequently confer more permanent activity against the tumor, will lead to enhanced therapeutic results. Due to the promising practical clinical benefits that can be expected for the near future, an exposition to the practicing neurosurgeon about the basic issues in genetic therapy of gliomas seems convenient. Among the main topics, we shall discuss anti-tumoral mechanisms of various genes that can be transfected, the advantages and drawbacks of the different vectors utilized, the possibilities of tumor targeting by modifications in the native tropism of virus vectors, as well as the different physical methods for vector delivery to the tumors. Along with the exposition we will also review of the history of the genetic therapy for gliomas, with special focus on the main problems found during the advancement of scientific discoveries in this area. A general analysis is also made of the present state of this promising therapeutic modality, with reference to the problems that still must be solved and the new paradigms for future research in this area.

Advances in telecommunication which started with telephone lines, FAX, integrated service digital network (ISDN) lines and now internet have provided an unprecedented opportunity for transfer of knowledge and sharing of information. The information can be used for overlapping applications in patient care, teaching and research. In medicine there is increasing utilization of telemedicine; radiology and pathology being regarded as mature specialties and emergency medicine as maturing specialties compared to other evolving specialties which include psychiatry, dermatology, cardiology and ophthalmology. Of the emergencies, status epilepticus and stroke have high potential for improving patient management. Administration of tPA was more frequent when carried out under telemedicine guidance. Telemedicine has great potential for medical education. The principles of education are in congruence with those of telemedicine and can be closely integrated in the existing medical education system. Our experience of telemedicine as a medical education tool is based on video conferencing with SCB Medical College, Cuttack. We had 30 sessions during 2001 to 2004 in which 2-3 cases were discussed in each session. The patients' details, radiological and neurophysiological findings could be successfully transmitted. These conferences improved the knowledge of participants, provided an opportunity for a second opinion as well as modified the treatment decisions in some cases. The advances in telemedicine should be utilized more extensively in neurology, especially in emergency management, epilepsy and stroke patients as well, as it may have a role in neurophysiology and movement disorders.

BACKGROUND: While erectile dysfunction is frequent among people with disorders of the spinal cord, the role of various clinical neurophysiological tests in assessment is not clear. AIMS: To study the role of clinical neurophysiological investigations in assessing erectile dysfunction among men with spinal cord disorders. SETTING: National Institute of Mental Health and Neurosciences, India. DESIGN: Survey. MATERIALS AND METHODS: Subjects with a score of 21 or less on the International Index of Erectile Function-5 were classified as with erectile dysfunction and with a score of more than 21 as without erectile dysfunction. Clinical neurophysiological studies done were Sympathetic Skin Response from limbs, posterior tibial sensory evoked potential, pudendal sensory potential and bulbocavernous reflex. STATISTICAL ANALYSES: Chi-square test. RESULTS: Among 40 subjects 26 had erectile dysfunction. The frequency of abnormalities in clinical neurophysiological studies were: pudendal sensory evoked potentials - 16, posterior tibial sensory evoked potentials - 26, bulbocavernous reflex - 5, sympathetic skin response from sole - 24 and, sympathetic skin response from palm - 18. Significant associations were noted between erectile dysfunction and abnormal pudendal sensory evoked potentials (P=0.0479), and absent sympathetic skin response from palm (P=0.0279) and sole (P<0.001). There was no correlation between erectile dysfunction and posterior tibial sensory evoked potentials (P=0.133) or bulbocavernous reflex (P=0.418). Sympathetic skin response from sole was most sensitive (80.8%) and had best positive (87.5%) and negative predictive (68.8%) values. The specificity of these three tests was 78.6%. CONCLUSIONS: Sympathetic skin response from the sole of the foot was the most sensitive and specific clinical neurophysiological test for erectile dysfunction in spinal cord disorders.

BACKGROUND AND OBJECTIVE: Myasthenic crisis is a life-threatening complication of myasthenia gravis (MG) and when treated aggressively is associated with good outcome. MATERIALS AND METHODS: Retrospective study of case records of patients with episodes of myasthenic crisis. RESULTS: Twenty-one (22%) of the 95 patients with MG (9 with thymoma), experienced 23 episodes of myasthenic crisis, 3 (33%) in patients with thymoma. The crisis episodes occurred within 2 years of disease onset in 11 (52%) patients. Infection was the most common primary precipitant of the crisis occurring in 65%. The median duration of the crisis episode was 11 days (7-39 days), and the median neurological intensive care unit stay was 15 days (range 9-47 days). Fifteen (65%) episodes were treated with small volume plasma exchange (PE) and 8 (35%) episodes received intravenous immunoglobulin (IVIg). The time taken for disease stabilization, the median number of days for extubation, was 8 days (range 7-12) in the PE group and 10 days (range 7-39) in the IVIg group. Disease stabilization could not be achieved in one patient in the IVIg group. Ventilator-associated pneumonia (VAP) was the commonest complication, seen in 30%. Two (8%) of the 23 episodes of crisis were fatal, one resulting from VAP and septicemia, and the other due to crisis itself. All the 19 patients who survived to discharge had complete resolution of admission symptoms. CONCLUSIONS: In patients with myasthenic crisis, both therapeutic options, PE and IVIg, are equally effective in disease stabilization. To achieve good outcomes all efforts should be directed at decreasing the duration of intubation and also aggressively treating the associated medical complications.

AIMS: To report management results of vestibular schwannomas (VS) treated surgically in our institute, with particular reference to completeness of tumor excision, facial nerve and hearing preservation and complications of surgery. STUDY DESIGN AND SETTINGS: Retrospective study of 259 patients treated during the years 1988 to 2002. MATERIALS AND METHODS: The facial nerve function and hearing assessment was done according to House-Brackmann [HB] grading and pure tone audiometry (PTA) respectively. All patients were operated by retro-mastoid sub-occipital approach. RESULTS: Most patients had large tumors and had no useful hearing (90%), had disabling cerebellar ataxia (88%) and presented with features of raised intra-cranial pressure (45%). Large sized tumors were in 41.3% and giant sized tumors were in 56% cases. Complete tumor excision was carried out in 96.5% and anatomical preservation of facial nerve was achieved in 79.2% cases. Hearing preservation was achieved in 8 patients. Cerebrospinal fluid leak with or without meningitis and transient lower cranial nerve paresis were common complications. The mortality was 6%. CONCLUSIONS: With experience, complete tumor excision with good facial nerve preservation can be achieved in large tumors. Hearing preservation is difficult in bigger tumors. Prevention and control of infection was a major concern.

CONTEXT: Careful evaluation of pharmacotherapy, seizure control and quality of life (QOL) are helpful in improving epilepsy care but such data are relatively meager from developing countries. AIMS: To audit pharmacotherapy, seizure control and QOL in persons with epilepsy and to identify factors associated with impaired QOL. SETTINGS AND DESIGN AND MATERIALS AND METHODS: The study was carried out using a cross-sectional design in the setting of a tertiary care epilepsy center in India. Persons with epilepsy with >12 months follow-up at this Center and aged >16 years were eligible for enrollment. Persons with other disabilities or pregnancy were excluded. Subjects were interviewed with a standard questionnaire and an adapted version of Quality of Life in Epilepsy - 31 (QOLIE-31). Data pertaining to treatment at the time of referral to this center was extracted from medical records. STATISTICAL ANALYSIS USED: Chi-square test, analysis of variance and multiple regression analysis were carried out for statistical significance. RESULTS: One hundred and twelve patients with epilepsy (59 males, mean age 31.2±10.7 years) were included. Forty-seven (42%) persons had Generalized Epilepsy (GE) and 65 persons (58%) had Localization-Related Epilepsy (LRE). At entry 24 persons (21.4%) were not on treatment and 59 persons (64.8%) had frequent seizures. At last follow-up 64 persons (57.1%) were seizure-free, 83 persons (74.1%) were on monotherapy and 29 were (25.9%) on polytherapy. Cost of drug at entry was INR 2276 (monotherapy) and INR 3629 (polytherapy) (45 INR = 1 USD). At the time of last follow-up, it was 1898 and 4929 respectively. QOLIE-31 Total Score (TQOL) ranged from 22.6 to 94.4 (mean 68.0 ± 15.8). Multiple regression analysis showed significant correlation between low TQOL score and polytherapy (P=0.002) and occurrence of one or more seizures per month (P=0.001). CONCLUSIONS: Frequent seizures and polytherapy are associated with lower QOL in persons with epilepsy.

BACKGROUND: The effects of age and hematocrit on transcranial Doppler (TCD) velocities have not been evaluated in a large patient group with recent ischemic stroke. AIM: This study assessed the effects of age and hematocrit on TCD measurements in patients with recent ischemic stroke compared to patients with non-vascular diseases. SETTINGS AND DESIGN: University Hospital, retrospective study. MATERIALS AND METHODS: TCD records and data files of 862 consecutive patients (mean age, 57±16 years) with various neurological diagnoses were reviewed retrospectively. The peak systolic, end diastolic and mean flow velocities (FV), systolic/diastolic ratios and pulsatility indices (PI) in the middle cerebral arteries were averaged and the effect of age and hematocrit values on these TCD values was studied. Independent samples t test, Pearson's coefficients of correlation, and linear regression test were used for statistical analysis. RESULTS: Among 862 patients, 413 were women (mean age, 53±17 years) and 449 were men (mean age, 60±13 years). Peak systolic and mean FV were higher and hematocrit concentration was lower in women compared to men (P<0.001). The relation of TCD velocities with age and hematocrit was more remarkable in the group of patients with non-vascular neurological disorders. PI values demonstrated a significant correlation to age (r=+0.47) (P<0.001), but did not change significantly with hematocrit level. CONCLUSIONS: It should be remembered that blood FV measured by TCD may be significantly affected by age and hematocrit level. However, there seems to be no significant association between TCD velocities and hematocrit in patients with a recent ischemic stroke.

AIMS AND OBJECTIVES: To study the clinical and laboratory features of patients admitted with vitamin B12 deficiency-related (B12def) neurological syndromes. SETTINGS AND DESIGN: A hospital-based retrospective and prospective study conducted at a referral teaching hospital. MATERIALS AND METHODS: Consecutive patients admitted with vitamin B12 deficiency-related neurological disorders during a three-year period from June 2000 to May 2003 were included. Data regarding clinical and laboratory features were obtained. Follow-up was done at least six months following treatment with parenteral vitamin B12. Chi-square test was used for statistical analysis. RESULTS: A total of 63 patients (52 males) with a mean age of 46.2 years were studied. The mean duration of symptoms at presentation was 10.3 months. Myeloneuropathy (54%) was the commonest neurological manifestation, followed by myeloneuropathy with cognitive dysfunction (34%), and peripheral neuropathy (9%). Neuropsychiatric manifestations and dementia were observed in 38% and 19% of patients respectively. All the patients had megaloblastic changes in the bone marrow smear. Eleven (17.5%) patients had both hemoglobin and the mean corpuscular volume (MCV) within the normal range. Follow-up after at least six months of therapy with parenteral B12 showed improvement in 54% patients. CONCLUSIONS: A high index of suspicion of B12def is required in patients presenting with myelopathy, cognitive decline, or neuropathy. A normal hemoglobin or MCV does not exclude B12def; therefore, other tests such as bone marrow smear and serum vitamin B12 assay are essential, as the condition is often reversible with treatment.

BACKGROUND: Cognitive dysfunctions such as dementia have emerged as a leading public health problem among the elderly. Its early detection is important for the management of patients, and for the educational support of other family members. Although cognitive dysfunction screening tests are available, they have not been widely utilized in community or primary care settings. AIM: To validate the PHC-cog (Public Health Center Cognitive Dysfunction Test) and to assess it as a simple and brief method for massive screening of cognitive dysfunctions in the primary care setting. MATERIALS AND METHODS: The study comprised 137 community-dwelling patients with dementia and 134 age, sex, and education-matched controls. The PHC-cog was made combining patients' and informants' questionnaires to improve performance. The PHC-cog patient's section briefly assessed the patient's cognition. RESULTS: The PHC-cog Patient's Section had a sensitivity and specificity of 0.75 and 0.92, respectively. The PHC-cog Informants' Section had a sensitivity and specificity of 0.79 and 0.83, respectively. The total method of administering the PHC-cog had a sensitivity and specificity of 0.96 and 0.82, and the two-stage method had a sensitivity and specificity of 0.92 and 0.76, respectively. CONCLUSIONS: The PHC-cog test is a simple, accurate and reliable, performance-based tool in the screening for cognitive dysfunction. The PHC-cog test is quick, and easy-to-use, and will hopefully become widely used in the cognitive screening of the aging population in the primary public medical institutions of Korea.

BACKGROUND: Very few studies have specifically addressed surgical treatment and outcome of patients with tumor-related temporal lobe epilepsy (TLE). AIM: To define the postoperative seizure outcome and the factors that influenced the outcome of patients with tumor-related TLE. MATERIALS AND METHODS: We selected patients whose surgical pathology revealed a temporal lobe neoplasm and who had completed > 1 year of postoperative follow-up. We reviewed the clinical, EEG, radiological and pathological data, and the seizure outcome of these patients and assessed the factors that influenced the outcome. RESULTS: Out of the 409 patients who underwent surgery for refractory TLE during the 8-year study period, there were 34 (8.3%) patients with temporal lobe neoplasms. The median age at surgery was 20 years and the median duration of epilepsy prior to surgery was 9.0 years. MRI revealed tumor in the mesial location in 21 (61.8%) patients. Interictal and ictal epileptiform EEG abnormalities were localized to the side of th lesion in the majority. Mesial temporal lobe structures were included in the resection, if they were involved by the tumor; otherwise, lesionectomy alone was performed. During a median follow-up of 4 years, 27 (79%) patients were completely seizure-free. The only factor that predicted long-term seizure-free outcome was being seizure-free during the first two postoperative years. CONCLUSIONS: Our results emphasize the fact that in patients with tumoral TLE, when the seizures are medically refractory, surgery offers potential for cure of epilepsy in the majority.

CONTEXT: Computed tomographic angiography (CTA) is widely applied in the evaluation of cerebral vessels. Contrast enhancement in cerebral CTA without care or test bolus is not always sufficient for high-quality images. AIMS: Evaluation of the possibilities of calculation of scan delay for cerebral CTA in case of subarachnoid hemorrhage (SAH), based on clinical data of a patient and to find out prognostic error of the model. SETTINGS AND DESIGN: Prospective study in Neurosurgery and Radiology departments. MATERIALS AND METHODS: Scan delay in 53 patients suffering an acute SAH was measured employing test bolus technique. Cerebral CTA was performed afterwards. STATISTICAL ANALYSIS USED: SPSS for Windows v.10.1 software package was applied for dispersion analysis, including one-sample Kolmogorov-Smirnov's test and Levene's Test of Equality of Error Variances. RESULTS: A statistical model for the prediction of scan delay in SAH was developed. Cerebral CTA scan delay was dependent upon age, neurological status and impact of the latter factors together (P<0.05). The determined mean square error of prognosis of scan delay of the developed model equals 3.3 sec. CONCLUSION: Using our proposed model it is possible to estimate an optimal delay time for CTA in most patients with SAH with a determined error.

BACKGROUND: Uptake of aluminum may disturb the learning and memory of humans or animals. Naloxone (NAL) has been shown to exert beneficial effects on memory deficits. AIMS: We investigated the effects of naloxone on aluminum-induced learning and memory impairment in rats. SETTINGS AND DESIGN: Aluminum-induced learning and memory impairment model was established by gavage of Aluminum chloride (600 mg/kg) for 3 months. Rats were divided into three groups viz. naloxone-treated rats (NAL 0.8 mg/kg, i.p. daily for 7 days), non-treated model rats and normal controls. MATERIALS AND METHODS: The Morris water maze test was performed to study spatial learning and memory. Long-term potentiation (LTP) of the Schaffer collateral-CA1 synapse was recorded. Aluminum and zinc contents in the hippocampus were assayed with atomic absorption spectrophotometry. STATISTICAL ANALYSIS: Parameters of the hidden and visible platform trials and data of LTP were analyzed using two-way repeated measures ANOVA. RESULTS: In the hidden platform trials, escape latencies of the NAL rats were significantly shorter than that of the non-treated rats (P=0.000, 95% confidential interval low bound 14.31, upper bound 22.68). In probe trails, the number of entries in the target area of the NAL rats (6.75±1.28 times/min) was more than that of non-treated model rats (4.56±2.16 times/min, P=0.004, 95% confidence interval low bound -3.65, upper bound -0.788). The magnitudes of LTP recorded in the CA1 pyramidal neurons of the NAL-treated rats were significantly augmented when compared to the non-treated model rats (P=0.005, 95% confidence interval low bound 0.16, upper bound 0.84). CONCLUSIONS: NAL could facilitate spatial learning and memory and enhance LTP in the CA1 region of the hippocampus in aluminum-induced learning and memory impairment in rats.

OBJECTIVE: To evaluate the efficacy of anterior instrumentation in patients with subaxial and cervicodorsal spinal tuberculosis in reconstruction of the spine, providing pain relief, neurological recovery and prevention of deformity. MATERIALS AND METHODS: The records of 61 consecutive patients, of surgically treated spinal tuberculosis affecting C3 to D2 region, in our neuro and spinal surgery unit over a five-year period were retrospectively reviewed. Patients with involvement of the C3-C6 vertebrae underwent excision of the involved vertebrae and intervertebral discs followed by reconstruction with titanium implants by anterior approach. A transclavicular approach was used for patients with involvement of the C7-D2 vertebrae. A five-drug antituberculous regimen was administered for a period of one year. The follow-up ranged from 24 to 84 months (mean 38 months). Clinical and radiological assessment using flexion and extension radiographs was performed at 24 months for all cases. RESULTS: The neck pain score based on a visual analog scale (1-10) changed from a pre-operative average of 7 to 2 at follow-up after 4 months. Fifty-two patients (85%) had complete relief of pain while 16 patients who had Grade III to IV muscle strength regained complete power. The asymmetric wasting in patients with involvement of the cervicodorsal region did not recover completely. Flexion-extension radiographs at 24 months did not show any evidence of instability or nonunion. CONCLUSIONS: Anterior reconstruction using titanium plates and locking screws for stabilization of the subaxial and cervicodorsal region tuberculosis is a useful adjunct in preventing kyphotic deformity. A satisfactory segmental stability and fusion is achieved by this technique.

BACKGROUND: Meningitis, termed as foreign material collection in the subarachnoid space, leads to various meningeal, cerebral and spinal cord pathologies. Meningitis still remains a problematic disease with severe complications in spite of advanced medical technology. AIMS: In this study, we aimed to investigate the role of cisternal irrigation in the prevention of meningitis complications. SETTING AND STUDY DESIGN: Experimental study was done in the Social Security Hospital of Erzurum. Histopathological specimens were evaluated in the Pathology Department in the Ataturk University Research Hospital, Erzurum, Turkey. MATERIALS AND METHODS: This study was conducted on twelve lambs. Experimental meningitis was achieved with streptococcus pneumonia. Two animals were not treated. Ten animals were given CefotaximeR (4x1 g/day) for 20 days, and additionally half of these animals underwent cisternal irrigation. Then, all animals were sacrificed and brains were observed histopathologically. RESULTS: Massive purulent CSF formation, hemorrhagic cortical lesions, vascular congestion, leptomeningeal and cortical adhesions and brain edema were observed in the non-irrigated group, but these findings were observed slightly or absent in the irrigated group. CONCLUSION: Meningitis can affect all central neural tissues, consequently serious central nervous system lesions may develop. The irrigation procedure may decrease the percentage and severity of meningitis complications by way of the excretion of inflammed purulent collection from the subarachnoid spaces.

The study explored the genetic susceptibility and prevalence of epilepsy in twins. The data on epilepsy were retrieved from the health records of 199 pairs of twins. Proband concordance rate in monozygotic (MZ) twins was four times more than that in dizygotic (DZ) twins (0.67 vs. 0.17). Three of 15 (20%) affected twin kinships had epileptic first-degree relatives. These findings indicated significant underlying genetic susceptibility to epilepsy with the Holzinger's heritability estimate being 0.45. The prevalence of epilepsy was similar in MZ (45.45), DZ (45.11) twins, and their non-twin siblings (47.60). In the general population from various nationalities, the mean prevalence rate of epilepsy varied from 5 to 17 per 1000. The appreciably higher prevalence rate in twin kinships could be attributed to peculiar development factors associated with the twinning process or the intrauterine environment of mothers having tendencies to bear twins. Of the genetic markers, PTC locus seemed to be associated with the susceptibility to epilepsy. The allele frequency of non-tasters (t) seemed greater in epileptic twin kinships (0.71) than that in the general population (0.53). The frequency of non-tasters was similar in MZ and DZ twins and singletons: 27.3%, 26%, and 27.7% respectively. The PTC data on the general population was based on a sample of 278 individuals.

An attempt was made to quantitatively analyze the alpha activity in the awake relaxed state of Amyotrophic Lateral Sclerosis (ALS) patients and was compared with normals. ALS patients showed significantly low amplitude with a corresponding alpha band (8-13 Hz) power reduction, in both hemispheres though the change was more prominent in the left hemisphere. A review of the literature revealed no studies done on alpha oscillations in ALS patients; hence the results may have important implications for the interpretation of resting state brain activities.

We describe a child with pathologically proven Hallervorden Spatz disease. He presented with extrapyramidal symptoms and characteristic "eye-of-the-tiger" sign on magnetic resonance imaging. He was given the possible benefit if any of deep brain stimulation with no much improvement. Pathological examination of the brain showed iron deposition in bilateral globus pallidi, spongiform change and neuron axonal degeneration (spheroids).

A 26-year-old man was admitted with complaints of worsening of vision for one month. Investigations revealed a large sellar and parasellar tumor mass invading into both the cavernous sinuses. The tumor invaded the clivus and both petrous apices. It was radically but partially resected through a transsphenoidal approach. Following surgery, the patient showed symptomatic improvement. The residual tumor was treated by radiation treatment. The case is discussed and the literature on the subject is briefly reviewed.

Topiramate, a new anticonvulsant, is also used for the prophylaxis of migraine and cluster headache. A serious but not often discussed side effect of the drug is the development of acute myopia and acute angle-closure glaucoma in the early stage of therapy that subsides rapidly with prompt discontinuation. One such case is reported here and the relevant literature in this regard is also reviewed.

A 40-year-old male presented with a single generalized tonic-clonic seizure. MRI revealed an enhancing, dural-based, left lateral sphenoid wing lesion suggestive of a meningioma. At microsurgical excision, the lesion was firm and relatively avascular. The histopathological report revealed S-100 positive histiocytic proliferation with lymphophagocytosis (emperipolesis) characteristic of the Rosai-Dorfman disease. The case and its management are discussed.

Benign gliomas of the brain show decreased uptake of 18F fluorodeoxyglucose (FDG) on positron emission tomography (PET). Malignant transformation is usually manifested by an increase of 18FDG uptake. A 45-year-old female has been followed up since 1987 by means of 18FDG-PET for a right hemispheric World Health Organization Grade II oligoastrocytoma. In 1996, increased epileptic activity was accompanied by increased 18FDG uptake within the temporal part of the tumor. After surgery, the epileptic seizures diminished. Histological examination of the resected tumor showed no change in the pathology when compared with the first biopsy. Localized temporal increase of 18FDG uptake was not associated with malignant progression. The decrease of seizure frequency might shed light on a putative connection of hyperglycolysis and epileptic discharges.

Paget's disease of skull usually causes neurological complications such as basilar invagination, cranial neuropathies, etc. Occurrence of extradural hematoma in association with Paget's disease of skull is rare. A 48 year old man presented with headache and right upper limb weakness, two days after a fall from scooter. CT Scan of brain showed a large extradural hematoma at the vertex with the cranial vault showing features of Paget's disease. At surgery, no skull fracture or injury to the superior sagittal sinus was evident. There was diffuse oozing from the inner table of the skull, which showed features of Paget's disease. The extradural hematoma was evacuated and the patient made good recovery.He deteriorated a few hours after surgery. Follow up CT Scan showed diffuse brain swelling with minimal recollection of hematoma. Re-exploration showed a small recollection which was evacuated and the part of the oozing diseased skull was excised. The patient recovered completely. This is the first reported case of vertex extradural hematoma in association with the Paget's disease of skull. The unusual features are the absence of skull fracture and injury to the superior sagittal sinus. The increased vascularity of the skull due to Paget's disease has caused the hematoma by diffuse oozing from the inner table.

A case of Morgagni Stewart Morel syndrome with progressive depression in frontal bone, headache, transient monoparesis, obesity; imbalance, neuro psychiatric symptoms and recurrent disc prolapse with absent right radial pulse is discussed. This syndrome was first mentioned 235 years back, but till now exact pathology is not known. Balance assessment using dynamic posturography was done, which revealed abnormal vestibular function. To our knowledge this is the first case examined for Dynamic Posturography.