Hydrocephalus is one of the commonest complications of tuberculous meningitis (TBM) occurring in up to 85% of children with the disease. It is more severe in children than in adults. It could be either of the communicating type or the obstructive type with the former being more frequently seen. The Vellore grading system for clinical grading of patients with TBM and hydrocephalus with grade I being the best grade and grade IV being the worst grade has been validated by several authors. The management of hydrocephalus can include medical therapy with dehydrating agents and steroids for patients in good grades and those with communicating hydrocephalus. However, surgery is required for patients with obstructive hydrocephalus and those in poor grades. Surgery can involve either a ventriculo-peritoneal shunt or endoscopic third ventriculostomy (ETV). Complications of shunt surgery in patients with TBM and hydrocephalus are high with frequent shunt obstructions and shunt infections requiring repeated revisions. ETV has variable success in these patients and is generally not advisable in patients in the acute stages of the disease. Mortality on long-term follow up has been reported to vary from 10.5% to 57.1% in those with altered sensorium prior to surgery and 0 to 12.5% in patients with normal sensorium. Surgery for patients in Vellore grade IV is usually associated with a poor outcome and high mortality and therefore, its utility in these patients is debatable

The trigeminocardiac reflex (TCR) is defined as the sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, apnea, or gastric hyper-motility during stimulation of any of the sensory branches of the trigeminal nerve. The proposed mechanism for the development of TCR is-the sensory nerve endings of the trigeminal nerve send neuronal signals via the Gasserian ganglion to the sensory nucleus of the trigeminal nerve, forming the afferent pathway of the reflex arc. It has been demonstrated that the TCR may occur with mechanical stimulation of all the branches of the trigeminal nerve anywhere along its course (central or peripheral). The reaction subsides with cessation of the stimulus. But, some patients may develop severe bradycardia, asystole, and arterial hypotension which require intervention. The risk factors already known to increase the incidence of TCR include: Hypercapnia; hypoxemia; light general anesthesia; age (more pronounced in children); the nature of the provoking stimulus (stimulus strength and duration); and drugs: Potent narcotic agents (sufentanil and alfentanil); beta-blockers; and calcium channel blockers. Because of the lack of full understanding of the TCR physiology, the current treatment options for patients with TCR include: (i) risk factor identification and modification; (ii) prophylactic measures; and (iii) administration of vagolytic agents or sympathomimetics.

The nonregenerative capability of the injured adult brain has been challenged in recent years and neural plasticity has been observed experimentally in both global and focal brain ischemia in animal models. Whether neuro-genesis increases in response to brain lesions or stem cells can be used for transplantation are the potential questions to be answered. Functional recovery may occur in a small or a localized brain injury using rehabilitation measures, but for large ischemic strokes, the restoration may require new synaptic connections within and away from the damaged tissue. In an infarcted area, the ischemic core may not respond to any pharmacological or rehabilitative intervention. For these reasons, the prospects of repairing the neuron system, using cell transplantation seems promising and may offer a unique approach for brain repair and restoration of function. On going animal and human trials have greatly helped us to burgeon our hopes on this method of restorative therapy after stroke. The ultimate aim of any therapeutic strategy is the maximum restoration possible and eventual complete normalcy of function.

Background: Vasoactive drug alprostadil improves microcirculation and can be effective in treating disorders of peripheral nerves. Vascular endothelial growth factor (VEGF) has been shown to have protective action in cerebral ischemia, disorders of spinal cord, and also peripheral nerves. However, the mechanism of action of VEGF in peripheral nerve injuries is uncertain. Objectives: To study the effect of application of alprostadil on the pathological and functional repair of crush nerve injuries and also the expression of VEGF. Materials and Methods: Rat sciatic nerves were crushed by pincers to establish the model of crush injury. All of the 400 sprague dawley (SD) rats were randomly divided into: Control; saline; saline + VEGF-antibody; alprostadil; and alprostadil + VEGF antibody groups. The SPSS 11.5 software was used for statistical analysis. The expression of VEGF in dorsal root ganglia (DRGs), following crush injury to sciatic nerves, was studied by reverse transcribed-polymerase chain reaction (RT-PCR), immunohistochemistry, electromicroscope, and electrophysiology. The effects of alprostadil on expression of VEGF, repair of neural pathology, and recovery of neural function were also evaluated. Results: We found that VEGF messenger ribonucleic acid (mRNA) was significantly increased in alprostadil and alprostadil + VEGF-antibody groups, compared to the saline and saline + VEGF antibody groups. The number of VEGF-positive neurons was significantly increased in the alprostadil group, compared to the saline, saline + VEGF antibody, and alprostadil + VEGF antibody groups. Besides, addition of this drug also caused less pathological changes in DRGs, better improvement of nerve conduction velocities of sciatic nerves, and more increase of toe spaces of right hind limbs of rats. Conclusions: The vasoactive agent alprostadil may reduce the pathological lesion of peripheral nerves and improve the rehabilitation of the neural function, which may relate to upregulation of the expression of VEGF, following crush injury to the peripheral nerves.

Aim: This experimental biomechanical study was performed to determine the effects of multilevel anterior cervical discectomy and excision of posterior longitudinal ligament (PLL) to stabilize the cervical spine using an in vitro animal model. Materials and Methods: Fifty fresh cadaveric C3-C6 sheep spine specimens were divided into five experimental groups: Group A was the control group; Group B, one-level discectomy; Group C, two- level discectomy, Group D, three-level discectomy, and Group E, three-level discectomy and excision of PLL, respectively. The specimens were subjected to non-destructive loads cycled from zero to five Newton-meter for flexion, extension, right and left lateral bending, and axial rotation on an electrohydraulic test machine. Load displacement curves were obtained via collected data using strain gauges. The values were obtained for all five groups, statistical differences were determined respectively (P < 0.05, ANOVA). Results: One- level discectomy was less stable than the control group, two-level discectomy was less stable than one-level discectomy and three-level discectomy was less stable than two-level discectomy, respectively (P < 0.05). Excision of PLL did not seem to affect stability (P > 0.05). Conclusion: Our data suggested that cervical discectomy decreases stability of sheep spine pieces.

Context : Video-assisted thoracic surgery (VATS) has been proposed as a less invasive technique for treatment of myasthenia gravis. Materials and Methods : A total of 31 patients underwent a right-sided VATS to remove all anterior mediastinal fat and thymic tissue during a 4-year period in our institution. None of the patients had associated thymoma. Results : All procedures were performed successfully with no conversion to sternotomy. The mean operating time was 190 minutes. The median intubation time and assisted ventilation were 24 and 18 hours, respectively. The median ICU and hospital stays were 3 and 7 days, respectively. The median time for post-operative chest drainage was 48 hours. There was no perioperative mortality. Eight significant complications occurred. One patient had atelectasis, 1 patient had aspiration pneumonia, and 3 patients had postoperative myasthenic crisis and required prolonged mechanical ventilation. Other complications were granuloma of the vocal cord, right recurrent laryngeal nerve palsy, and temporary brachial plexus injury due to poor intraoperative positioning. The mean length of follow-up was 20 months (range: 3-42 months). Overall, 27 patients (87%) had improved clinically and 11 patients (35%) had complete remission. The resulting scars were cosmetically acceptable for all patients. Conclusion : VATS provides an effective alternative approach to thymectomy and has several advantages over open techniques. VATS causes minimal postoperative complications, shortens hospital stay, and gives better cosmetic results.

Background : While the clinical and immunocytochemical features of sarcoglycanopathies have been reported from India, genetic aspects have not been studied. There is large variation in the sarcoglycan mutations among the studied populations. Aim : To study the spectrum of mutations in sarcoglycan genes (SG). Materials and Methods : Patients fulfilling Bushby's criteria for limb girdle muscular dystrophy were prospectively analyzed. Patients gave their medical history and underwent a clinical examination, serum creatine kinase estimation, electrophysiology, muscle biopsy with immunostaining for alpha, beta, gamma, and delta subunits and mutational analysis using denaturing high pressure liquid chromatography and direct sequencing. Results : Mutations in SG accounted for 26.4% of the cohort of limb girdle muscular dystrophy. The mean age of these 18 patients was 22.5 years. Generally, proximal weakness affected the flexor and adductor compartments of the lower and upper limbs. The clinical profile of various mutations was indistinguishable from each other. Gamma SG mutations were most common, seen in 8 patients, followed by delta SG mutation in 5 patients and alpha mutation in 4 patients, while only 1 patient had mutation in the beta sarcoglycan gene. The most prevalent mutation in the gamma SG gene was 525del T. This is of interest as the mutation has been known to exist only in specific populations. Conclusion : This study, the first mutational analysis of Indian patients with sarcoglycanopathies suggests gamma SG mutations were the most common and the most prevalent mutation in the gamma SG gene was 525del T.

Background : The attention of pediatric specialists has been continuously attracted to the problem of cerebral palsy (CP) and the formation of behavioral and motor skills in the initial years of life in these patients. This work aimed at studying the specifics of intra- and interhemispheric connections in the motor domain in children with CP as well as their dynamics in the process of rehabilitation using hand/finger synkineses and and lateral profile as markers. Materials and Methods : A total of 215 children aged 4-7 years were recruited after obtaining their parents' consent, including 95 patients with the most prevalent forms of CP (spastic diplegia, hemiparetic form) who underwent complex treatment in a neuropsychological sanatorium and 120 healthy children from a kindergarten. Data were analyzed using nonparametric methods and the chi-square test with the help of the statistical program SPSS v.14. Results : Changes in the scores and types of synkinesis after rehabilitation indicated that in spastic diplegia the assumed symmetric brain defects were associated with uniform restoration of interhemispheric connections and less disturbance of intrahemispheric connections. In hemiplegia, on the contrary, misbalance in intrahemispheric connections prevailed and compensation was noticed only in left-hemispheric pathology. The magnitude, type, and improvement of hand synkineses in the course of treatment depended on the lateral phenotype. Conclusion : Hand/finger synkineses in CP children change with rehabilitation. The methods used in the study can be recommended for application in the system of medico-biological and psycho-pedagogical monitoring of children with CP.

Background and Purpose : Mitoxantrone is an approved disease modifying agent for treatment of multiple sclerosis (MS). The aim of the study was to assess its efficacy and safety in Indian MS patients. Materials and Methods : A total of 23 patients with clinically definite MS (Poser criteria) were enrolled in an open label study. Of which, 21 satisfied the McDonald's criteria for MS and two satisfied the diagnostic criteria of neuromyelitis optica (NMO). The numbers of relapses and expanded disability status scale (EDSS) score were used as primary and secondary outcome measures. The patients were monitored for the adverse effects. Results : In 17 (15 MS and two NMO) patients who completed one year of therapy, there was significant difference in the mean annual relapse rates [before 0.879±0.58; on mitoxantrone 0.091±0.17, (P=0.003)]. Of the 17 patients, ten (MS 9 and NMO 1) completed therapy for two years. Annual relapse rates [before (1.024±0.59), on therapy (0.155±0.21), (P=0.0054)] and EDSS score [before start of therapy 5.3, at the end of therapy 2.4, (P=0.001)] showed significant benefit in the ten patients who completed two years therapy. This benefit persisted during the mean follow-up period of two and a half years after completion of therapy. The adverse events noted in the entire cohort were leucopenia in four patients and asymptomatic reversible decrease in cardiac ejection fraction in one patient. Leucopenia was severe in two patients requiring discontinuation of the therapy and mitoxantrone was also discontinued in the patient with cardiotoxicity. Conclusions : Mitoxantrone, as an initial therapy, decreases clinical exacerbations and disability progression, and has a reasonable safety profile in Indian patients with MS and NMO.

Objective : To investigate the outcomes of magnetic resonance imaging (MRI)-based thrombolysis using recombinant tissue plasminogen activator (rt-PA) in patients with acute middle cerebral artery (MCA) occlusion in 3-6 hours. Materials and Methods : MRI-selected patients (n=15) with acute ischemic stroke in MCA divided into two groups (#≤ 3h and 3-6 h) were treated with intravenous rt-PA. MR was performed before rt-PA, at 24 hours, 7 days, and 14 days after stroke. Recanalization was assessed 24 h after thrombolysis, and clinical status was evaluated before rt-PA treatment, 6 hours, 24 hours, 7 days, and 14 days after thrombolysis by the National Institutes of Health Stroke Scale (NIHSS). Modified rankin scale (MRS) was used to assess clinical outcome at 30 and 90 days after thrombolysis. Results : There was no significant between ≤ 3 h and 3-6 h group in length of hospital stay, recanalization, MRS, and favorable outcome at 90 days. Recanalization within 24 hours occurred in 9 (60%), and nonrecanalization in 6 (40%). One patient in recanalization group and three in nonrecanalization group had an asymptomatic intracranial hemorrhage (ICH) within 24 h after thrombolysis (P =0.235). Recanalization with thrombolysis was associated with a better outcome regardless of the time point of rt-PA treatment. Comparison with nonrecanalization group, recanalization was also associated with a lower NIHSS score at 14 days (P =0.003), a lower TIMI grade at 7 days (P < 0.001), and a shorter length of hospital stay (P =0.018). Conclusion : Our study suggested that MR-based thrombolysis using rt-PA was safe and reliable in patients with acute MCA occlusion in 3-6 hours.

Background: Traumatic injury of peripheral nerves is a worldwide problem and can result in significant disability. Management of peripheral nerve injuries (PNIs) requires accurate localization and the assessment of severity of the lesion. Aim: The purpose of this study is to analyze the data of patients with PNIs referred for electromyography to a tertiary care hospital. Materials and Methods: This is a retrospective study of clinical and electromyographic data of patients with PNIs seen over a period of eight-years (1999-2007) in a tertiary hospital. The data collected included: Demographic data, cause, type of lesion, anatomical location of the lesion, and the mechanism of lesion. Results: During the study period 938 patients were seen with nerve injuries and the distribution of nerve injuries was: PNIs: 1,165; brachial plexus lesions: 76; and lumbar plexus lesions: 7. The mean age was 31.8 years (range 2-81 years) and the male to female ratio was 2.4:1. The most frequent nerve injuries were ulnar nerve in the upper extremity and sciatic nerve in the lower extremity. The most common cause of nerve injury was motor vehicle accidents. Two-thirds of the PNIs were partial. Conclusion: This study can serve as a guide to determine the epidemiology and classification of traumatic peripheral and plexus injuries.

Background: Basilar apex aneurysms (BAA) are located in interpeduncular cistern surrounded by eloquent neurovascular structures. Surgical access is difficult due to narrow surgical corridors and requires traversing through a depth of 6-8 cm of subarachnoid space. Aim: Surgical management of BAAs clipped using frontotemporal craniotomy, orbitozygomatic osteotomy with combined subtemporal and transylvian (half and half) approach is discussed. Setting and Design: Tertiary care referral institute; prospective study. Materials and Methods: Five patients with BAA rupture causing subarachnoid hemorrhage presented in modified Hunt and Hess (Hand H) grades II (n=1), III (n=1) and IV (n=3), respectively. In 4 patients, the aneurysms were 0.8-1.2 cm in diameter, situated 7 mm-1 cm above dorsum sellae. Two of them had posteriorly projecting aneurysms. One patient had a giant, high BAA with a left parietooccipital arteriovenous malformation. Vasospasm of posterior cerebral/proximal basilar artery was seen in 2 patients. In one patient, internal carotid artery was mobilized by intradural anterior clinoid drilling with carotid collar division. Triple-H therapy was administered following surgery. Results: There was no intraoperative rupture or temporary clipping. Follow up angiography showed complete aneurysmal obliteration with preservation of posterior cerebral and superior cerebellar arteries. Follow up (mean: 8.7 ± 3.5 months) H and H grades were II (n=2) and III (n=3), respectively. The morbidity include caudate and thalamic region infarct, transient III ^rd nerve palsy and cerebrospinal fluid otorrhoea (n=1, respectively). Conclusions: This simple approach provides a wide surgical corridor from 5 mm below to greater than 1 cm above dorsum sellae with adequate proximal control of basilar artery. It is an option to endovascular embolization especially with large and giant, or wide-necked BAA, vertebrobasilar tortuosity, coil compaction or postcoiling re-rupture and an associated large haematoma.

Objective: To study the course, relationships, branches and possible anomalies of the vertebral artery in the suboccipital region in adult Indian cadavers. Materials and Methods: Twenty-one suboccipital segment vertebral artery specimens from embalmed, Indian adult cadavers were dissected and studied. Dissection was performed using microsurgical instruments and was carried out from the skin up to the vertebral artery in layers. The course, relationships and the branches of the vertebral artery were studied and measurements were taken using Vernier calipers. The readings obtained were corroborated with the measurements derived from the digital images using a computer. Observations: All the vertebral arteries had a tortuous course and were covered with rich venous plexuses. None of the specimens had an anomalous course. The artery was divided into a vertical segment (Vv) between C2 and C1 vertebra and a horizontal segment (Vh) from the C1 transverse foramina to its dural entry. The mean diameter of the artery was 4.8mm. The shortest distance of Vv segment from the dural tube was 16.1mm, and the distance from the C2 ganglion was 7.2mm. The average length of the Vv segment was 15mm and the average length of the Vh segment was 35.6mm. The average of the shortest distance between the vertebral artery and the midline was 13.4mm. Conclusion: The vertebral artery has a tortuous course and is prone to accidental iatrogenic injury, which can result in devastating neurological sequelae depending on contralateral vertebral artery flow. A thorough anatomical knowledge of this segment is essential for the surgeon who intends to operate in this area.

Aims: The purpose of this study was to assess the clinical value of indocyanine green angiography (ICG) in intracranial aneurysm surgery by comparing the findings with postoperative angiographic results. Materials and Methods: One hundred and twenty patients with 148 intracranial aneurysms were included. ICG angiography was performed before and/or after the aneurysm clipping. A near-infrared excitation light illuminated the operation field, ICG was injected intravenously. The intravenous fluorescence was imaged with a video camera integrated into the microscope. Results: A total of 208 investigations of ICG angiography were performed. Aneurysm clipping was applied in 120 patients. Incomplete clipping was detected in four patients. Parent and/or branching artery stenosis was found in five patients. Delayed perfusion of ICG was detected in one patient. Postoperative digital subtraction angiography (DSA) was performed in 108 patients. The postoperative angiographic results were consistent with findings on intraoperative ICG angiograms in 100 patients (92.6%). In three cases, a mild stenosis was seen on DSA, which was not detected intraoperatively using ICG angiogram. In one patient, middle cerebral artery stenosis was found. Three patients had small residual aneurysms found by postoperative DSA. The remaining one developed a severe cerebral vasospasm. Conclusions: ICG angiography is a simple, reliable and cost-effective method. It provides real-time information in detecting the patency of parent, branching, perforating arteries and residual aneurysm. This technique may be a useful adjunct to improve the quality of intracranial aneurysm surgery.

Eight children with pyridoxine-dependent seizures (PDS) were seen over a period of 10 years. Of those children, 6 are on regular follow-up. Four of the children were seen in one family. All the patients presented with refractory seizures, mainly neonatal status epilepticus. Though PDS is a rare condition, it must be considered in all cases with refractory seizures, particularly in childrens younger than 3 years. When confirming a diagnosis, oral pyridoxine is as effective as intravenous pyridoxine.

Background: Intraoperative consultation for neurosurgical specimens can be difficult at times, despite the use of both frozen section and squash preparation. Various factors influence the diagnostic accuracy of these procedures. This study was conducted to evaluate reasons for discordant case results in neurosurgical intraoperative consultations and make a comparative analysis of these two commonly used methods to identify the possible pitfalls, errors, and limitations. Materials and Methods: All the neurosurgical cases received in the Department of Pathology for intraoperative consultation over a period of 3 years were studied retrospectively. The slides of frozen sections and squash preparation were retrieved and the diagnosis was compared with the final diagnosis given on paraffin-embedded sections. Results and Observations: A total of 6% of the cases were found to be discordant; these included angiomatous meningioma, Non-Hodgkins lymphoma, metastatic renal cell carcinoma, cerebellopontine angle fibrous meningioma, and craniopharyngioma. Highly vascular lesions, unavailability of squash preparation in a few cases and technical errors like thick smears, excessively crushed specimen, freezing, and cautery induced and crushing artifacts contributed to misdiagnosis. Conclusion: The discrepant cases need to be reviewed regularly by pathologists to familiarize themselves with the morphological changes and artifacts. The knowledge of possible errors could minimize misinterpretation and help in providing a more conclusive opinion to the operating surgeon.

Traditional posterior approaches to the thoracic spine are done with either costo-transversectomy, lateral extracavitary approaches, or transpedicular approaches. The transpedicular approach is the only one that preserves the rib head. However, placing an expandable cage with this rib head intact poses special challenges because of the narrow corridor defined by the rib head and the spinal cord. Instead of removing the rib head, which requires pleural dissection and carries the risks of pleural injury, we disarticulate it and push it laterally during cage placement. This avoids pleural dissection and affords expandable cage placement through a transpedicular approach.

Background: Reversible posterior leukoencephalopathy syndrome (PRES) is a neurological disorder characterized by signs of posterior cerebral edema upon radiographic examination. Materials and Methods: We retrospectively analyzed the records of nine children with the diagnosis of PRES. Results: Of the nine patients, seven were receiving immunosuppressive therapy and two were acute hypertensive crisis associated with renal disease. Immunosupressive drugs were intrathecal methotrexate in two patients, cyclosporine in two patients, intrathecal cytarabine in one patient, cyclophasphamide in one patient, and intravenous immunoglobulin (IVIg) in another one patient. The most presenting symptoms were seizure, headache, and altered consciousness. Six patients had seizures. Altered consciousness was present in four patients. Headache and nausea or vomiting was present also in six patients. Visual abnormalities were noted in two patients. Magnetic resonance imaging (MRI) studies showed white-matter abnormalities suggestive of edema in the posterior regions of the cerebral hemispheres, but the changes often involved other cerebral areas, the brain stem, basal ganglia or the cerebellum. The patients were treated with antihypertensive medications, and immunosuppressive therapy was withdrawn. In all the patients, the clinical and radiological findings resolved morly completely. Conclusion: Reversible posterior leukoencephalopathy may develop in patients who have renal insufficiency or hypertension or who are immunosuppressed. This syndrome should be recognized immediately and trigger agents can be discontinued to prevent long-term sequelae.

Ischemic stroke following snake bite is rare. We report an 18-year male who developed right hemiplegia with expressive aphasia following a Russell's viper bite. T2-weighted magnetic resonance imaging revealed infarct in the left middle cerebral artery territory. The possible mechanisms for cerebral infarction in this scenario include disseminated intravascular coagulation, toxin induced vasculitis and endothelial damage.

Delayed encephalopathy following carbon monoxide poisoning is a serious complication. Here, we report a patient with delayed encephalopathy who suffered from cognitive disorders and urinary incontinence after a temporal normal period of 15 days after acute intoxication, and his cognitive function recovered gradually following donepezil hydrochloride treatment. Now, he can undertake slight farming work.

Spinal tuberculosis most commonly presents as a paradiscal lesion involving the disc space and adjacent vertebral bodies. Atypical forms of spinal tuberculosis have been described and are most often a result of posterior element involvement. The authors report a patient, who presented with complete posterior migration of an intact vertebral body, a complication of spinal tuberculosis that has not been reported till date. A 12-year-old girl with history of pulmonary tuberculosis presented with progressive paraparesis and back pain. Plain X-rays and MRI revealed that the L2 vertebral body had migrated posteriorly into the spinal canal, without significant movement of the posterior elements. The vertebral body was normal, with no erosion or bone loss. However, bilateral pedicle and facet joint involvement was seen. The neural elements were decompressed through an anterolateral retroperitoneal approach and the spine reconstructed. The authors present this rare manifestation of spinal tuberculosis and discuss the possible mechanisms of this presentation.

Choroid plexus papilloma (CPP) is a rare benign tumor of the central nervous system with a propensity for location within the lateral ventricle in children. We report a case of a 14-year-old girl who presented with transient facial paresis and ataxia. Her imaging showed a non-enhancing intra fourth ventricular mass, the histology of which was reported as CPP. The atypical clinical and radiological features in this case are discussed. Choroid plexus papillomas should be considered in the differential diagnosis of non-enhancing fourth ventricular masses.

This report presents a rare complication of ventriculoperitoneal shunt, delayed development of brain abscess and foreign body granuloma formation adjacent to the intraventricular catheter. Both the complications occurring in the same patient is unusual.

Bone wax is a well-known agent used to prevent bleeding from the bone that can be used in different surgical procedures. Bone wax is a safe agent, but it may rarely lead to significant foreign body reactions. In this report, we present a patient who developed bone wax-related disc space foreign body granuloma following L4 total laminectomy, extremely rare complication.