Institute and personal experience (over 25 years) of basilar invagination was reviewed. The database of the department included 3300 patients with craniovertebral junction pathology from the year 1951 till date. Patients with basilar invagination were categorized into two groups based on the presence (Group A) or absence (Group B) of clinical and radiological evidence of instability of the craniovertebral junction. Standard radiological parameters described by Chamberlain were used to assess the instability of the craniovertebral junction. The pathogenesis and clinical features in patients with Group A basilar invagination appeared to be related to mechanical instability, whereas it appeared to be secondary to embryonic dysgenesis in patients with Group B basilar invagination. Treatment by facetal distraction and direct lateral mass fixation can result in restoration of craniovertebral and cervical alignment in patients with Group A basilar invagination. Such a treatment can circumvent the need for transoral or posterior fossa decompression surgery. Foramen magnum bone decompression appears to be a rational surgical treatment for patients having Group B basilar invagination. The division of patients with basilar invagination on the basis of presence or absence of instability provides insight into the pathogenesis of the anomaly and a basis for rational surgical treatment.

Background: There is no universally accepted staging system for primary brain tumors wherein prognostication is mainly based on complex composite indices . Aim: To develop a simple, pragmatic, and widely applicable grouping/staging system for gliomas, the most common primary brain tumor. Materials and Methods: An expert neurooncology panel with representation from radiation oncology, neurosurgery, pathology, radiology, and medical oncology had several rounds of discussion on issues pertinent to brain tumor staging. The trade off was between the accuracy of prognostic categorization and a pragmatic, widely applicable approach. Results and Recommendations: The Tumor-Node-Metastasis staging was considered irrelevant for gliomas that seldom metastasize to lymphatics or outside the neuraxis. Instead, a 4-point staging/grouping system is proposed, using histological grade as the main prognostic variable and at least one stage migration based on other unfavorable features such as tumor location (brainstem); age (<5 years for all grades, >50 years for high-grade, and >40 years for low-grade gliomas); poor neurological performance status (NPS 2-4); multicentricity and/or gliomatosis; and adverse biological parameters (proliferative index, angiogenesis markers, apoptotic index, cytogenetic abnormalities, and molecular markers). Conclusion: In absence of a grouping/staging system for primary brain tumors, prognostification is mostly based on complex composite indices. The proposed clinicopathobiological grouping/staging system for gliomas is a simple, pragmatic, and user-friendly tool with a potential to fulfill the objectives of staging classification.

Recent evidence suggests that the risk of stroke in first few months after transient ischemic attack is higher than that was previously realized. There are clinical and imaging predictors which help in risk stratifying the patients to identify the high risk group who need immediate hospitalization and urgent evaluation. Recent advances in neuroimaging have revolutionized the evaluation of these patients. Further research is required in the deciding on the optimal treatment of these patients in the acute phase.

Background: The changing trends in the management of vestibular schwannoma (VS) in our practice over the last two decades as well as the current status are presented here. Materials and Methods: The observations are based on the experience of 559 consecutive cases of VS operated by the first author between 1987 and 2008, 438 of which were operated by microsurgery and 139 by gamma knife radiosurgery (GKR) (18 of which were previously operated by the authors). A detailed analysis of microsurgically managed patients in two different periods (100 consecutive patients each before 1993 and 2008) were compared to see the changing trend and document current results. Results and Discussion: In the initial experience (1990s), the emphasis in microsurgery was preserving life, total excision of tumor and preservation of function in that order. In the 21 ^st century, the emphasis in microsurgery has been all about functional preservation. In 100 consecutive cases of VS (excluding neurofibromatosis-2) that were treated microsurgically between 2005-08, there were four small tumors (<2 cm), 14 medium-sized tumors (2-3 cm) and 82 large tumors (≥3 cm). The total excision rate was 83%. The facial nerve anatomical preservation rate was 96% and function was Grade III House-Brackmann (HB) or better in 87%. Both the total excision rate and facial function of Grade II HB or better were 100% in cases with tumor size less than three cm. Functional hearing preservation was achieved in ten cases. There was no operative mortality. Conclusion: Total excision of VS, though aimed at, is no more pursued at the cost of facial function. Moreover, microsurgery, radiosurgery and observation are all valid options in the management of VS and choosing the correct modality helps in achieving optimal outcome.

Background: Gliomas represent a diverse range of clinical presentation, histological differentiation, and response to therapy. Altered cell proliferation and cell death signals in gliomas are of great interest to elucidate the key molecules involved and to find effective treatment modalities. By considering the role of different proteases in correlation with differential poly (ADP-ribose) polymerase (PARP) fragmentation we have studied the pattern of cell death in human glioma tissues. Materials and Methods: In our study, five different human glioma biopsies were collected and analyzed for the PARP cleavage pattern by using western immunoblotting. Samples were also analyzed for pro-caspase 3, calpain I (µ) and II (m), granzyme-B and apoptosis-inducing factor (AIF). Parallel sections of histologically confirmed astrocytoma and glioblastoma multiforme (GBM) were used for immunohistochemical analysis of cleaved caspase-3, granzyme B, AIF and cyclo-oxygenase -2 (cox-2). Results: We found PARP fragmentation, along with usual ~ 89 kDa and ~ 24 kDa fragments, into other fragments of different molecular weights. Caspase mediated cell death may lead to appearance of larger ~ 89 kDa fragment and smaller ~ 24 kDa fragment indicating existence of apoptosis in the tumors. However, other fragments corresponding to ~ 64 kDa, ~ 54 kDa, and ~ 40 kDa were observed concomitantly in all glial tumor tissues. Conclusions: These results may indicate, not only apoptosis and necrosis, but there occurs the co-existence of intermediate cell death pathways in human glial tumors.

Background: Cavernomas are rare in the brainstem and account for 18-35% of central nervous cavernomas and can cause recurrent hemorrhages, devastating neurological deficits and mortality. Objectives: To summarize the experience of microsurgical treatment of brainstem cavernomas and to investigate curative effect of microsurgical treatment of brainstem cavernomas. Materials and Methods: A retrospective analysis clinical data of 37 patients with brainstem cavernomas seen between 2003 and 2007. The analysis included age distribution, hemorrhage rates, clinical presentation, location of the lesions, and preoperative and postoperative Karnofsky Performance Scale (KPS) scores. The surgical indications, the timing of surgery and the surgical techniques were also assessed. Results: All the 37 patients received microsurgical resections, there was no surgery-related mortality. Histopathological examination confirmed the diagnosis of cavernoma. Postoperatively, 20 patients had functional improvement, 15 patients had no change in the neurological status, and two patients deteriorated. Early surgery was associated with better outcomes. Mean followed up period was 21.5 months (range 6-36 months). During the follow-up 20 patients had resumed activities of daily living (KPS scores of 90-100), 10 patients were able to self-care with some efforts (KPS scores of 70-80), five patients needed considerable assistance (KPS score of 50-60) and two patients suffered hemiparesis (KPS scores of 40). None of the patient had recurrent hemorrhage. Conclusions: Brainstem cavernomas can safely be resected. Successful resection of brainstem cavernomas can be achived by optimal surgical approaches, feasible entry zone and meticulous microsurgical techniques. The goal of surgical intervention should be the total resection of the lesion without any deteriorative in the neurological deficits.

Background: Brainstem gliomas are highly heterogeneous tumors both in their clinical manifestation and in their pathology. Despite significant advances in the surgery for brainstem gliomas many aspects of this pathology are still unclear Objective: To evaluate the clinical, radiological and surgical outcome of 40 focal 'intrinsic' brainstem gliomas and propose a surgical strategy-oriented classification. Materials and Methods: A total of 40 focal 'intrinsic' ("expanding variety") tumors have been operated over a period of 8.5-years (January 1998-June 2007). Our criteria included patients with (1) well-defined gadolinium enhancing tumor; (2) relatively long duration of symptoms (> six months) and (3) good neurological functional status and independent for all activities of daily living. The cutoff size of 2 cm was not rigidly adhered to. Results: The 'intrinsic' brainstem tumors were classified into three types: Expanding, diffuse infiltrative and pure ventral varieties. Only patients with expanding variety of brainstem gliomas were subjected to surgery, mean age 19.2 years (range 4-55 years) and male to female ration mean: 3:2). The tumor location included pons (n=19), midbrain (n=13) and medulla (n=8). Surgical approaches included midline suboccipital (n=28), retromastoid (n=7), subtemporal (n=3) and supracerebellar-infratentorial (n=2). Thirty-two cases with 'diffuse infiltrative' and 'pure ventral' variety were given radiotherapy only. Histology pathology revealed pilocytic variety (n=10), Grade II (n=17) and Grade III (n=13). There was one death in the surgical series (due to aspiration). Complications included meningitis (n=2), wound infection (n=1), chest infection (n=5) and transient mutism (n=1). Follow-up ranged from 3-68 months. Overall, 36 improved /remained same and three worsened in their clinical status at the time of discharge. Conclusion: The surgical management of intrinsic brainstem tumors presents a surgical challenge; radical excision yielded a good outcome in the majority of cases. The authors propose a classification system for 'intrinsic' brainstem tumors for defining surgical strategy.

Background: Guillain-Barrι syndrome (GBS) is an acute neurological illness affecting the peripheral nervous system causing significant morbidity. The syndrome has been classified electrophysiologically into demyelinating and axonal forms. The clinical features of the axonal variant (acute motor axonal neuropathy-AMAN) are not well characterized, particularly in the Indian context. Objective: To assess the incidence, clinical presentation and disease course of patients with AMAN. Materials and Methods: This is an observational study done at a tertiary referral center in South India. The study period extended from January 2006 to July 2007. All patients with a clinical diagnosis of GBS and satisfying the electrophysiological criteria for AMAN were included. Results: There were 12 cases of AMAN out of a total of 84 cases of GBS. All AMAN patients showed a characteristic pattern of hand weakness predominant weakness of finger extensors with relatively normal power in finger flexors, wrist flexors and extensors. Proximal limb weakness was mild and was present in 85% cases. One patient had cranial nerve palsy and one had hyperreflexia. None of the patients progressed to respiratory failure. Conclusion: AMAN is a distinct subgroup in GBS showing certain distinguishing features, the most notable being predominant weakness of finger extensors.

Background: Elevated cerebrospinal fluid (CSF) total protein (TP) concentration (mainly due to a dysfunctional blood-CSF barrier (B-CSFB)) with normal cell count is a hallmark for the diagnosis of Guillain-Barrι syndrome (GBS). Aims: This work presents the evaluation of B-CSFB dysfunction with respect to the course, severity, and clinical features of GBS. Materials and Methods: A sample of CSF was collected on admission from 68 patients of both genders (15 children and 53 adults) diagnosed with GBS. A follow-up CSF sample was obtained approximately 15 days after admission. TP concentration was determined in the CSF and 7.5% polycrylamide gel electrophoresis was employed for serum and CSF protein fractioning. A low percentage of prealbumin fraction was considered a test of impaired B-CSFB. Results: Elevated TP concentration and lower prealbumin were observed in almost 70% of the patients on admission, but this percentage was lower (52.4%) during the first week from onset of symptoms. Both variables were directly associated with the time of evolution of the disease and also with a greater clinical severity. Follow-up CSF studies showed higher CSF TP and lower prealbumin percentages, while deceased patients did not display this response pattern in the follow-up CSF. Conclusions: B-CSFB dysfunction was present in only half of the patients with GBS during the first week from onset and it was directly associated with progression and clinical severity; nevertheless, a low B-CSFB dysfunction response during follow-up was associated with a lethal outcome, suggesting it could also serve a 'protective' effect during regeneration.

Background: Baclofen, a GABA-agonist, is currently available as an immediate release (IR) formulation for relieving neurogenic spasticity in a variety of disorders. Baclofen IR requires to be administered three times a day which inadvertently increases the chances of medication noncompliance among patients and is also associated with side effects such as drowsiness and muscle weakness. Aim: To overcome the shortcomings of baclofen IR, two modified formulations, baclofen sustained release (SR) and gastric retentive system (GRS), have been proposed to be equivalent in efficacy to baclofen IR with the administration of a single daily dose. Materials and Methods: Ninety patients with chronic neurogenic muscular spasticity were enrolled requiring 10-20 mg of baclofen IR every eight hours. The patients were randomized to two treatment arms: SR (n = 46) or GRS (n = 44) at the same once-daily dose for four weeks. Efficacy was measured by Ashworth score for muscle tone, spasm score, reflex score, 30-item functional independence score, and patient's diary score for three most affected activities of daily life. Results: The mean Ashworth score changed significantly (P = 0.00) for patients in the SR group from 3.03-2.69 (-0.35) and 3.07-2.70 (-0.37) for patients in the GRS group. There was no significant difference (P = 0.87) between baseline-adjusted Ashworth score reductions on SR (-0.35) and GRS (-0.37). Similar results were obtained for spasm, reflex, and functional independence scores. The mean baseline-adjusted patient-diary scores did not differ significantly between 8 am, 12 pm, 4 pm, and 8 pm (P = 0.96), either on SR (-5.3 to -6.1) or GRS (-7.3 to -8.1), indicating a uniform effect round-the-day on both. Further, sedation scores (mean ± SEM) decreased significantly (P < 0.05) on both SR (10.36 ± 1.37 to 6.18 ± 0.92) and GRS (8.14 ± 1.57 to 5.33 ± 1.11), suggesting better toleration. Conclusion: Once-daily baclofen SR and GRS are efficacious, convenient, and better-tolerated alternatives to baclofen IR in patients with neurogenic spasticity.

Background: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy caused by median nerve compression at the wrist. It results in loss of considerable man days and the effectiveness the various treatment modalities are still debated. Aim: To study the efficacy of gabapentin in patients with CTS. The study aim is to investigate the efficacy of gabapentin in patients with CTS patients who were refractory to the other conservative measures or unwilling for the surgical procedure. Materials and Methods: Forty one patients diagnosed as idiopathic CTS were included in the study. Patients were assessed with symptom severity scale (SSS) and functional status scale (FSS) scores of Boston Carpal Tunnel Questionnaire (BCTQ) before and at 1, 3, and 6 months of the treatment. Response to therapy was determined by using SSS and FSS scores of BCTQ. Results: The median dosage of gabapentin was 1800 mg/daily. Side effects were mild and transient. There was a statistically significant difference in both symptom SSS and FSS scores between before and after treatment in patient groups at the end of six months (P < 0.001). According to grading the changes in subscales of BCTQ, of 41 patients, 34.1 and 29.3 had a ≥ 40% decrease in SSS and FSS, respectively. Conclusion: Gabapentin was found to be partially effective and safe in symptomatic treatment of CTS patients.

Background: Pain management is an important component in the postoperative period following discectomy. Aims: We hypothesized that mesalamine considering its better safety profile, is likely to be a better choice, if it would be as effective as ibuprofen in controlling post-discectomy pain. Settings and Design: A double-blind randomized controlled trial was performed on patients who underwent lumbar discectomy surgery. Materials and Methods: Of the 58 patients who had lumbar discectomy, 27 patients were randomized to oral ibuprofen 500 mg and 31 patients to mesalamine 400 mg, three times a day for nine days following surgery. There was no placebo group. Severity of pain was assessed by using 10- cm visual analogue scale (VAS), once before operation and for nine days after. Statistical Analysis: Mean ± SD pain scores were compared between groups and the statistical difference was estimated by Student's test using SPSS (Version 13). We also calculated the power of each t-test. Repeated measure ANOVA was performed for measuring the effect of time. Results: The age range of the patients was 35 to 60 years (mean: 42.2 years). Mean ± SD preoperative pain scores for ibuprofen or mesalamine-treated groups were 7.852 ± 2.441 and 7.806 ± 2.892, respectively. At the end of day 9, mean ± SD of pain score was 2.704 ± 2.284 and 2.717 ± 2.273 for ibuprofen and mesalamine-treated groups respectively. Both drugs significantly reduced postoperative pain and there was no statistically significant difference between the two groups.Conclusions: Since both drugs showed almost equal analgesic effect, considering its safety profile mesalamine, seems to be the preferred choice to alleviate post-discectomy surgery pain.

Use of mechanical devices in acute ischemic stroke has shown promise not only in recanalization rates but also with better clinical outcome and also extension of the window period to 8 hours. This is the first reported series of use of mechanical devices in India. We report five patients with acute stroke in whom mechanical devices (Penumbra System, Alameda, California) were used for thrombolysis. All the treated vessels (100%) were successfully re-canalized, Trials In Myocardial Infarction (TIMI) score of 3. At 90-day follow-up, of the 5 patients treated, 2 had modified Rankin score (mRS) of < 2. This small series shows the safety and efficacy of the Penumbra System in the thrombolysis of large vessel occlusive disease.

Basilar artery thrombosis has high morbidity and mortality. Though intra-arterial thrombolytics have proven efficacy in the treatment of acute basilar artery occlusion, the elevation of procoagulant factors in the blood after intra-arterial thrombolysis could result in subsequent thrombus formation and clinical deterioration. Glycoprotein IIb/IIIa inhibitors have been shown to reduce this elevation in procoagulants. We present a pilot study of three cases of acute basilar artery occlusion treated with a combination of intra-arterial thrombolytics and Gp IIb/IIIa inhibitor with remarkable clinical recovery seen in all the patients.

Background: In the postoperative period of posterior spinal surgery, surgeons usually encounter a wide spectrum of complications, including retained surgical sponge, gossypiboma. Materials and Methods: Retrospective review of case records of eight patients diagnosed with gossypiboma with emphasis on computed tomography (CT) and magnetic resonance imaging (MRI) findings. Results: All the eight patients presented with low back pain and/or symptoms of infection, such as draining from the incision site, fever, and tenderness. The diagnosis was confirmed by the imaging findings on MRI with gadolinium enhancement. Conclusion: Retained paravertebral surgical sponges are seldom reported due to medicolegal implications. Awareness of this complication among neurosurgeons and radiologists is essential to avoid unnecessary morbidity.

Spontaneous extradural hematoma (EDH) is an uncommon form of intracranial hematoma and is caused by the adjacent sinus and otic infections, dural vascular malformations and disorders of blood coagulation. We report spontaneous EDH in a 54-year old women with chronic kidney disease (CKD) on intermittent hemodialysis. She was successfully managed by conservative treatment. The EDH in her was probably related to the coagulation abnormalities associated with CKD, hemodialysis or heparin use during the dialysis.

Coil migration is a severe complication in endovascular treatment. We report our experience of prompt surgical extraction of migrated coils via excised proximal A1 following endovascular embolization of intracranial aneurysms in two patients. Both patients had to undergo coiling or stent-assisted coiling for cerebral aneurysms, and while operating the coils protruded and migrated to the bifurcation of internal carotid artery and middle cerebral artery. Immediate craniotomy was performed after unsuccessful or unfeasible endovascular retrieval. The migrated coils were removed via excised proximal A1, and the patients recovered well without any neurological deficits. We suggest that this surgical procedure might be an alternative route in selected patients with good cross circulation in emergency. In addition, a rare occasion of coil migration after stent-assisted coiling is also described in one patient, which might have resulted from unsatisfactory wall apposition of the stent due to a curved vessel.

Penetrating cranial injury is a potentially life-threatening condition. The majority of war injuries are high-velocity penetrating cranial injuries; but in civilian cases, most penetrating cranial wounds are low-velocity type. We report an interesting case of transorbital penetrating cranial injury with a knife-sharpening stone made up of ceramic in a 28-year-old male. The pertinent literature is reviewed and management of such cases is discussed.

A rare complication of ventriculoperitoneal shunting (VPS) is bowel perforation by the peritoneal catheter of the shunt tube. Rarer still is the peroral extrusion of such a perforated shunt. A two-month-old infant with history of neonatal meningitis, presented with a large head, bulging fontanelle, and hydrocephalus. A VPS was inserted. The child was doing well till the age of eight months, when following vomiting, the peritoneal end of the shunt came out through the mouth. The shunt was removed and antibiotics started. At follow up after 12 months, the child was doing well. Peroral extrusion of the shunt tube needs prompt treatment, including removal of the extruded shunt tube, and attention to bowel perforation and possible cerebrospinal fluid infection. The reported patient is younger than the five cases reported earlier. Strategies in the management of this complication are reviewed. An individualized approach is essential for the successful treatment of this rare complication.

Carpal tunnel syndrome (CTS) is an entrapment neuropathy where the median nerve is compressed in the carpal canal. There are many variations of the distal branches of the median nerve at the wrist. Anatomical variations of this nerve have fundamental clinical importance to prevent injuries, especially during limited open or endoscopic surgical procedures. A case is presented of an anomalous course of the recurrent motor branch of the median nerve and high division of the third common digital nerve seen in a limited open carpal tunnel release.

Primary hyperparathyroidism (PHPT) is not an uncommon endocrine disorder. We describe a patient with PHPT who presented with progressive proximal limbs weakness and dystrophic changes of leg muscles. Serum calcium, alkaline phosphatase, and parathyroid hormone were elevated and serum phosphorus was low. Neck computerized tomography scan showed a parenchymatous tumor in the right lobe of the thyroid. The tumor presented as a 'cold nodule' in the dual-phase single-agent Tc-99m MIBI scan. The right lobectomy examination confirmed the diagnosis of an intrathyroidal parathyroid adenoma of the right gland.

We report a 28-year-old male who presented with severe vertigo, vomiting, diplopia, clumsiness of right extremities. Physical examination revealed low reading of blood pressure in the left upper limb and evidence of mild left upper limb ischemia. On neurological examination he had right cerebellar ataxia. Computed tomography and magnetic resonance imaging, revealed an acute right cerebellar infarction in the anterior inferior cerebellar artery territory. Doppler ultrasono­graphy revealed an aneurysm of the left subclavian artery. The patient was tested positive for serology of syphilis,

Syphilis is still a significant public health problem in developing countries. Although chorea is a very rare manifestation of neurosyphilis, it might be on occasions the initial symptom. This report presents a patients with neurosyphilis who had chorea as the initial presenting symptom.