The issue of stroke in young in India has long been of interest to neurologists in the country. The age group for stroke in young has been variable between different studies but perhaps should be restricted to 15-49 years as this age group tends to have a unique set of causes and risk factors. There is no evidence indicating higher incidence of stroke in young in India than in other countries. Age-specific incidence rates from recent population-based studies from India are comparable to the western populations. Though the traditional risk factors of stroke play a significant role in young age group also, the presence of high number of cryptogenic strokes, cardioembolic and venous strokes makes diagnostic evaluation in this age group more challenging. This review aims at defining the age group for stroke in young, focuses on incidence of stroke in young on the basis of different population-based studies and details the risk factors and diagnostic approach of different stroke subtypes in young.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic, proximal and distal, asymmetrical or symmetrical, motor and sensory demyelinating polyneuropathy with a progressive course for at least 2 months. The accurate diagnosis is crucial as CIDP is amenable to treatment. Recent advances have provided new strategies and options for management of this syndrome. In this article, we review the clinical and diagnostic features as well as discuss recent insights and treatment strategies along with our experience in the management of patients with CIDP.

Medical management remains unsatisfactory in about a third of patients with epilepsy and some of them are candidates for resective epilepsy surgery. Structural and functional neuroimaging plays an important role in the identification of the precise cortical region responsible for seizures and is very crucial for a good surgical outcome. Furthermore, identification of eloquent cortical areas near the region to be resected is essential to avoid postoperative neurologic deficit. The magnetic resonance imaging (MRI) protocol for epilepsy can be individually tailored depending on the seizure semiology and possibly electroencephalography. New MRI techniques demonstrate the structure of the brain in fine detail, help in understanding the underlying pathology, and demonstrate functional activity of the brain with high spatial and temporal resolution. Metabolic imaging techniques, such as positron emission tomography (PET) and single photon emission tomography (SPECT) visualize metabolic alterations of the brain in the ictal and interictal states. In MR-negative epilepsy patients, these techniques may have localizing value. The proper use and interpretation of the findings provided by these new technologies is crucial. In this review article, we discuss various conventional and advanced MRI techniques, interpretation of various findings, and the role of functional imaging modalities, such as functional MRI, PET, and SPECT in the localization of epileptogenic substrate as well as for understanding the pathophysiology, propagation, and neurochemical correlates of epilepsy.

Background: Hydrocephalus results from inadequate passage of cerebrospinal fluid (CSF) from its point of production within the cerebral ventricles to its point of absorption into systemic circulation. Aims: The objective of this study was to investigate the disorders of CSF absorption by arachnoid villi during the different phases of hydrocephalus. Materials and Methods: Silicone oil was injected into the fourth ventricle of 15 canines as an experimental group. Saline solution (0.9% NaCl) was injected in another nine canines as a control group. In order to block CSF transport through the cribriform plate, an external ethmoidectomy was performed in five dogs from experimental group and three dogs from control group at three days (acute stage), two weeks (sub-acute stage), and 12 weeks (chronic stage) respectively. Tritiated water was injected into the canines' cortical subarachnoid space and blood levels were measured at intervals of 1h, 4h, 8h, 16h and 48h respectively. Time-concentration curve of tritiated water was drafted. The area under the curve (AUC) was calculated for variance analysis and t-testing. Results: In the chronic group, the tritiated water concentration rose slowly to a peak at 16h. It was significantly lower than other groups at 1h, 4h, 8h and 16h, but was higher than other groups at 48h. Analysis of the AUC showed significant differences among all the groups (P<0.01). There were no significant differences in the AUC between control groups, the acute group, and the sub-acute group (P>0.05); however, the AUC of the chronic group was significantly lower than other groups (P<0.05). Conclusions: The CSF absorption ability of arachnoid villi is significantly damaged in a long-term state of hydrocephalus.

Background : Cerebral vasospasm is a major cause of morbidity and mortality after subarachnoid hemorrhage (SAH). It usually occurs about 3-9 days after SAH. The pathogenesis involves the release of endogenous spasmogens. Though various treatment modalities are available, none are really effective. Aims and Objectives : The aim of the study was to develop an effective animal model for the study of SAH and vasospasm as well as to study the efficacy of vasodilators, namely nitroglycerine and papaverine, on SAH-induced vasospasm using magnetic resonance angiography. Materials and Methods : Fifteen Wistar albino rats, weighing around 150-200 gm were used for the study. Five rats served as controls of SAH-induced vasospasm, while five rats each were used to study the efficacy of intracisternal injection of papaverine or nitroglycerine. Results : Rats demonstrate vasospasm in a manner similar to humans. The maximal vasospasm is seen in the basilar artery. Statistical analysis demonstrates an improvement in vasospasm after instillation of intracisternal papaverine at the end of 2 hours in basilar and left internal cerebral artery. However, nitroglycerine does not produce any significant amelioration of vasospasm. Thus, it can be deduced that the pathogenesis of the vasospasm is more due to the action of cGMPase enzyme rather than inhibition of nitric oxide (NO) synthetase by the spasmogens. The present study is the first study in the English literature to compare the effects of single bolus doses of nitroglycerine and papaverine using magnetic resonance angiography. Conclusion : Rats can be used to create an effective model for SAH-induced vasospasm as the pattern resembles human SAH. Papaverine is an effective drug for ameliorating SAH-induced vasospasm. Short-acting NO donors are not as effective in ameliorating vasospasm.

Context : Both tacrolimus (FK506) and nerve growth factor (NGF) enhance peripheral nerve regeneration, and in vitro experimental results demonstrate that the combination of FK506 and NGF increased neurite outgrowth compared with either treatment alone. Aim : To determine if the combination of FK506 and NGF benefits peripheral nerve regeneration compared with either treatment alone in vivo. Settings and Design : Rat sciatic nerves were cut off to form a 10 mm defect and repaired with the nerve conduits. All of the 32 Wistar rats were randomly divided into 4 groups: Group A: RGD peptide modification of poly{(lactic acid)-co-[(glycolic acid)-alt-(L-lysine)]} (PRGD)/FK506/NGF; Group B: PRGD/FK506; Group C: PRGD/NGF; and Group D: autologous nerves. Materials and Methods : At 3 months after surgery, the regenerated rat sciatic nerve was evaluated by electrophysiology, calf triceps wet weight recovery rate, and histologic assessment. Statistical Analysis Used : The SPSS 10.0 software (Bizinsight, Beijing China) was used for statistical analysis. Results : The compound muscle action potentials (CMAPs) of groups A and D were significantly stronger than those of groups B and C. The calf triceps wet weight recovery rate of groups A and D were higher than those of groups B and C. The regenerated nerves of groups A and D were more mature than those of groups B and C. There was no significant difference between groups A and D. Conclusions : PRGD/FK506/NGF sustained-release nerve conduits are more effective in regenerating nerves than both PRGD/FK506 sustained-release nerve conduits and PRGD/NGF sustained-release nerve conduits. The effect is as good as that of an autograft.

Background : Cerebral venous sinus thrombosis (CVST) is one of the common causes of stroke in young people. Mortality in CVST, in addition to progressive thrombosis, is related to elevated intracranial pressure causing transtentorial herniation. The role of decompressive surgery in CVST is not well established. Aims : We report our experience with decompressive surgery in CVST and review the literature. Settings and Design : This is a retrospective study carried out in the Stroke Unit of a multispeciality tertiary care hospital in south India. Materials and Methods : The medical records of patients admitted with the diagnosis of CVST between December 2003 and July 2009 were reviewed. The clinical presentation, etiology, medical management, indications for surgery and outcomes were assessed for patients undergoing decompressive surgery. The sensorium was assessed using the Glasgow Coma Scale (GCS), while the outcome was assessed using the modified Rankin scale (mRS). Descriptive statistics were used as appropriate. Results : One hundred and six patients were admitted with the diagnosis of CVST during the study period. Eleven patients (10%) underwent decompressive surgical procedure. Indications for surgery included a low GCS at admission with large infarct on the computed tomography scan, mass effect and midline shift, clinical and radiological signs of transtentorial herniation, deterioration in the sensorium in spite of anti-edema measures and postthrombolysis hematoma. Eight patients (73%) had a good outcome while three patients (27%) died. Of the patients who died, two had a low GCS and bilaterally nonreactive pupils before the surgery while one had thrombosis of the deep venous system. Conclusion : Decompressive surgery for patients with large cerebral venous infarcts is a life-saving procedure. Patients with CVST who develop clinical and radiological features of transtentorial herniation either at presentation or during the course of medical management may benefit from decompressive surgery.

Background : Autonomic dysfunction is a common and important complication in Guillain-Barre syndrome (GBS) and may be the cause of significant morbidity or death. Objectives : To show the possible autonomic involvement in patients with GBS. Materials and Methods : The sympathetic skin response (SSR) and the parameters of heart rate variability gathered from a 24-h electrocardiogram recording were studied in 14 patients with GBS [13 with acute inflammatory demyelinating polyneuropathy (AIDP) and one with acute motor axonal neuropathy (AMAN)]. Results : In two of the patients, SSR couldn't be elicited. In the rest of the patients, amplitude of SSR was found to be decreased when compared with the control subjects. In the time domain analysis of the 24-h electrocardiogram, SDNN (the standard deviation of all R-R intervals), SDANN (the standard deviation of the averages of R-R intervals during all 5-min periods that constitute the 24-h day), SDNN index (mean of the standard deviations of all R-R intervals for all 5-min segments of the 24-h recording); in the frequency domain analysis HF(high frequency), LF(low frequency), VLF (very low frequency) and total power were found decreased in patients when compared with the control subjects. When the mean values with standard deviations of controls were compared with the patients' values one by one, the pregnant patient with AMAN had increased heart rate variability parameters. The remaining 13 patients had decreased values. Conclusions : These findings reflect an involvement of both the parasympathetic and sympathetic systems in GBS. Our results suggest that SSR and heart rate variability parameters may be used for early detection of any autonomic dysfunction in patients with GBS.

Background : Despite the increasing use of recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke, uncertainty persists about the short- and long-term outcome of the thrombolysed patients. Objective : To identify predictors of major neurological improvement at 24 h after intravenous rt-PA administration in patients of acute ischemic stroke and their relationship with outcome at 12 months. Materials and Methods : We analyzed the data of the patients with acute ischemic stroke treated as per the National Institute of Neurological Disorders and Stroke (NINDS) criteria with intravenous rt-PA between January 2000 and June 2009 at a tertiary care center in south India. Major neurological improvement was defined by an 8-point improvement in National Institute of Health Stroke Scale (NIHSS) score or an NIHSS score of 0 or 1 at 24 h. Good outcome was defined as a 12-month modified Rankin Scale (mRS) of 0 to 1. Results : Of the 72 patients with acute ischemic stroke treated with intravenous rt-PA, 23 (32%) patients had major neurological improvement at 24 h. Age <60 years (OR 1.9, 95% CI 1.7 to3.2), admission glucose levels <8 mmol/L (OR 3.87, 95% CI 1.9 to 9.2) and mild to moderate baseline stroke severity (NIHSS median score 10+ 6) were associated with major neurological improvement after adjusting for co variables. Major neurological improvement at 24 h was an independent predictor of good outcome (mRS=1) at 12 months (OR 13.9, 95% CI 6.84 to 40.2). Conclusions : Age <60 years, glucose levels <8 mmol/L and mild to moderate stroke severity (NIHSS median score 10±6) was associated with major neurological improvement after intravenous rt-PA. Major neurological improvement at 24 h after the administration of intravenous thrombolysis independently predicted good outcome at 12 months.

Background : Delayed cerebral ischemia from cerebral arterial vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) is associated with significant morbidity and mortality. Early recognition of the cerebral arterial vasospasm and institution of appropriate treatment can reduce the consequences. Aim : We investigated the association of transcranial Doppler (TCD) and Xe-CT with the characteristics of symptomatic vasospasm secondary to aneurysmal subarachnoid hemorrhage (SAH) in patients who underwent euvolemic treatment without sedation. Materials and Methods : Data collected prospectively in patients with aSAH admitted to a neurocritical care unit in a regional hospital were retrospectively analyzed. Out of the 98 consecutive patients with aSAH, 30 patients underwent paired Xe-CT (not sedated) and TCD studies. Correlation between cortical cerebral blood flow (CBF) and mean blood flow velocity in middle cerebral artery (MCA) territories was analyzed. The lowest cortical regional CBF and MCA velocity were compared between patients with and without symptomatic vasospasm. Results : Symptomatic vasospasm occurred in 12 patients. No correlation was found between CBF and mean blood flow velocity of the MCA territory. The differences between MCA velocity and lowest cortical CBF in patients with symptomatic vasospasm were significantly different from patients without symptoms. Conclusion : TCD does not help to predict regional CBF in the MCA territory in patients with aSAH on euvolemic treatment.

Background : The operative approaches for colloid cyst excision are varied with open microsurgical excision still being considered as the "gold standard". Endoscopic removal of these cysts is gaining in popularity. Aims : To document the efficacy and safety of the endoscope for colloid cyst excision. Materials and Methods : Retrospective study of all the patients who underwent endoscopic colloid cyst excision between January 2000 and March 2009. Patient records, radiological images and operative notes were assessed. Follow-up data including clinical and radiological details were retrieved. Results : Fifty-nine cases underwent endoscopic surgery during the study period. Gross total excision of cyst (with small residual nubbin) could be achieved in 46 (78%) patients. Others patients underwent: near-total excision (seven); partial excision (five); and cyst aspiration (one). A two-port technique for achieving excision was used in 18 patients. There was one death due to fulminant meningitis. No patients had recurrence, follow-up till 99 months. Two patients required ventriculo peritonealshunt for persistent hydrocephalus. Conclusions : Endoscopic excision is a safe and effective, minimally invasive method for colloid cyst removal. Even a subtotal excision of these slow-growing cysts may be acceptable when experience with the endoscope is limited.

Background : Non-functioning pituitary adenomas (NFPA) are characterized by the lack of clinical syndrome as compared to functioning adenomas (FA) but not all functioning adenomas have clinical effects. Their exact incidence varies in different series. Materials and Methods : This study was undertaken to analyze the hormonal profile of NFPA at the immunohistochemical level in the Indian population and to see if any differences exist from the earlier studies. Their biological aggressiveness was also studied by MIB-1 labeling index (MIB-! LI) and Epidermal Growth Factor Receptor (EGFR) expression. These parameters along with their clinical behavior were correlated with radiological features of invasiveness and size. Results : Of the 151 pituitary adenomas diagnosed during a period of one and half years, 77 (51%) were NFPA with a male predominance. There was increase in the incidence of NFPA with increase in age. Immunopositivity for various hormones was observed in 64 (83%) cases, either singly or in various combinations. On the basis of immunohistochemistry, NFPA were classified into three subtypes; gonadotroph adenomas, silent adenomas, and null cell adenomas. Gonadotroph adenomas were the commonest subtype. In general, NFPA showed low MIB-1LI but invasive NFPA had LI on the higher side, however, this difference was not significant. We observed EGFR positivity in two cases only; therefore the tumorigenesis mechanism may be different in NFPA. Conclusion : Although non-functional at the clinical level immunohistochemistry showed reactivity for various hormones. If a battery of immunostains including seven hormones is studied, a significant number of cases are shifted to the functional group.

Background : Intraoperative somatosensory evoked potential (SSEP) monitoring during cervical spine surgery is not a universally accepted standard of care. Our retrospective study evaluated the efficacy and cost-effectiveness of intraoperative SSEP in a single surgeon's practice. Materials and Methods : Intraoperative SSEP monitoring was performed on 210 consecutive patients who had cervical spine surgery: anterior cervical approach 140 and posterior approach 70. They were screened for degradation or loss of SSEP data. A cost analysis included annual medical costs for health and human services, durable goods and expendable commodities. Results : Temporary loss of the electrical wave during cauterization resolved upon discontinuation of the cautery. We had no loss of cortical wave with preservation of the popliteal potential. A drop in the amplitude of the cortical wave was observed in three patients. This drop was resolved after hemodynamic stabilization in the first patient, readjusting the bone graft in the second patient, and interrupting the surgery in the third patient. The additional cost for SSEP monitoring was $835 per case and the total cost of the surgery was $13,835 per case. By spending $31,546 per year on SSEP, our institution is saving a total cost ranging from $64,074 to $102,192 per patient injured per year. Conclusion : Intraoperative SSEP monitoring is a reliable and cost-effective method for preventing postoperative neurological deficit by the early detection of vascular or mechanical compromise, and the immediate alteration of the anesthetic or surgical technique.

Purpose : Choroid plexus tumors (CPT) are rare neoplasms that pose considerable treatment challenges. This study reviews a single institute's experience with 25 patients of CPT and attempts to contribute to the general body of knowledge on CPT. Materials and Methods : A retrospective analysis of the case records of 25 patients operated for CPT since January 1998 and having a minimum of 1 year follow-up. Results : The study group included 12 (48%) cases of choroid plexus papilloma (CPP), 09 (36%) cases of choroid plexus carcinoma (CPC) and 4 cases of atypical CPP. The mean age at presentation was 18.6 years (range, 6 months to 54 years; SD, 18.7) and a male preponderance was noted (17:8). Raised intracranial pressure was the commonest presenting symptom (72%). The tumors were distributed as follows: lateral ventricle (16; 64%), fourth ventricle (5; 20%), fourth ventricle with cerebellopontine angle extension (3; 12%), and third ventricle (1; 4%). A complete surgical excision was achieved in 11 cases of CPP and 8 cases of CPC. Operative complications include pneumocephalus (40%), focal deficits (36%), subdural effusion (32%), and persistent hydrocephalus requiring shunt (24%). All patients with CPP had a good outcome at the end of a mean follow-up of 5.4 years, whereas the median survival for patients with CPCs who underwent a subtotal resection with adjuvant therapy was 36 months. Conclusion : CPTs include a spectra ranging from CPP to CPC. Radiologic and histologic characterization of these tumors is difficult and newer immunohistochemical and genetic studies should be done to differentiate them from each other. Total excision offers a good prognosis and should be attempted for all forms of CPTs. CPPs carry a good prognosis, and adjuvant therapy is not indicated even after partial excision. CPCs and atypical CPCs carry a poor prognosis, and adjuvant therapy improves survival marginally after total excision. Spinal drop metastases are common for CPC and screening of the spine for possible metastasis should be part of the routine preoperative and postoperative investigation protocol.

Facioscapulohumeral dystrophy (FSHD) is an autosomal dominant muscular dystrophy. We retrospectively studied three families (two Indian, one Nepalese) with 12 affected members (male:female-7:5). Mean age at onset of weakness was 17.63 + 5.48 years. Patients were classified according to muscle groups affected (F-face, S-scapula, H-humeral, PG-pelvic girdle, P-peroneal, A-loss of independent ambulation): FSH-A (2), four FSH (4), SH (3), FSH-PG (2) and one: F (1). Progression of weakness was classified as F>S>P>PG in eight cases, S> F>P in one, static in three. Eleven patients had electromyographic findings suggestive of myopathy and one had features of neurogenic involvement. Molecular diagnosis was done by southern blotting using probe p13E-11 after digestion of genomic DNA with EcoRI and/or EcoRI/BlnI for twelve patients and three unaffected relatives. No EcoRI fragment smaller than 35 Kb was seen in unaffected subjects. Size of EcoRI fragment varied between 17 kb to 27 kb in affected subjects and was constant for affected members of the same family. Molecular diagnosis by southern blotting has helped to provide genetic counseling for the families.

For promptly referral of a patient with acute ischemic stroke (AIS) for possible thrombolysis, general practitioners (GPs) need to equipped with the advanced knowledge of AIS treatment. We assessed the knowledge regarding treatment of AIS among GPs practicing in and around a quaternary care teaching hospital in south India. A total of 109 GPs who attend to medical emergencies were interviewed using a standard questionnaire. Of the 109 GPs interviewed, 54% felt that tissue plasminogen activator (tPA) can be used in the treating AIS, but only 24% had chosen tPA as the best treatment option and 22% opted for other agents like citicholine or edavarone. Only 17% were aware that tPA should be given within 3 h. and 35% felt that intra-arterial thrombolysis as a treatment option.. Only 30% felt the need for good sugar control and 37% wanted aggressive lowering of blood pressure. Majority of GPs are not clear about beneficial effects of thrombolysis and are not updated regarding BP and sugar control in the setting of AIS.

Autoimmune myasthenia gravis (MG) is a disorder of neuromuscular junction. Possible role of multiple genes in the development of the MG has been documented. This case-control study, studied the association of apolipoprotein E (Apo-E) alleles with MG. Anti-AChR antibody was measured using radio receptor immunoassay. Apo-E genotypes were analyzed in 120 MG patients and 120 healthy subjects. Comparison between patients with MG and controls showed no significant association with Apo-E allelic variants. However, a significant association of Apo-E4 allele with AChR-antibody positive patients was observed (P = 0.007). Also, among seropositive patients, a significant association was seen between female gender and Apo-E4 allele (P = 0.023). Our results suggest that the presence of Apo-E4 allele might influence seropositive status in patients with MG and seems an associated susceptible factor in female patients.

Aneurysms of the A1 segment of the anterior cerebral artery (ACA) are rare and challenging to treat. We evaluated our experience of endovascular treatment in 11 patients with A1 segment aneurysms of ACA. Seven aneurysms were treated with coiling; three were treated with stent-assisted coiling and one was treated with balloon-assited coiling. Endovascular treatments were technically successful and without complication. Follow-up examinations showed complete cure in all 11 patients.

Stiff limb syndrome (SLS) is a rare "focal" variant of stiff person syndrome which presents with rigidity and painful spasms of a distal limb, and abnormal fixed foot or hand postures. Anti-glutamic acid decarboxylase antibodies (GAD-Ab) are variably present in most cases. Most reported cases of SLS are unassociated with cancer. We describe a patient with SLS as a paraneoplastic manifestation of breast carcinoma, in whom GAD-Ab was present. The patient responded very well to oral diazepam, baclofen and steroids.This is the third reported case of SLS as a paraneoplastic accompaniment to cancer.

Demyelinating disorders of the central nervous system (CNS) in children pose diagnostic and prognostic difficulties in clinical practice. In this report, we describe our experience with inflammatory demyelinating disorders of CNS in six children, classified as per the proposed criteria by the Pediatric Multiple Sclersois Study Group. We emphasize the importance of appropriate diagnosis and follow-up to distinguish transient inflammatory demyelinating diseases from chronic inflammatory demyelinating diseases.

Cerebral involvement is rare in polyarteritis nodosa (PAN) and is mostly characterized by ischemic events and intracranial hemorrhages secondary to cerebral aneurysms is extremely rare. We report two patients of PAN with multiple intracranial aneurysms. One patient presented with intracerebral hemorrhage and in the other patient multiple intracranial aneurysms were incidental findings and were asymptomatic. Both our cases suggest that multiple intracranial aneurysms are not very uncommon in PAN and cerebral angiography should be considered while doing abdominal angiogram in these patients.

Alpha dystroglycanopathies are heterogeneous group of disorders both phenotypically and genetically. A subgroup of these patients has characteristic brain imaging findings. Four patients with typical imaging findings of alpha dystroglycanopathy are reported. Phenotypic features included: global developmental delay, contractures, hypotonia and oculomotor abnormalities in all. Other manifestations were consanguinity (3), seizures (3), macrocephaly (1), microcephaly (3), retinal changes (2) and hypogenitalism (2). Magnetic resonance imaging (MRI) of the brain revealed polymicrogyria, white matter changes, pontine hypoplasia, and subcortical cerebellar cysts in all the patients, ventriculomegaly, callosal abnormalities, and absent septum pellucidum in two and Dandy -Walker variant malformation in three. Magnetic resonace imaging of the first cousin of one the patient had the same characteristic imaging features. Brain imaging findings were almost identical despite heterogeneity in clinical presentation and histopathological features. Pattern recognition of MR imaging features may serve as a clue to the diagnosis of alpha dystroglycanopathy.

A case of spontaneous subarachnoid pleural fistula following rupture of a thoracic meningocele into the pleural cavity is described in this article. The patient had symptoms of low-pressure headache and difficulty in breathing. The fistulous opening was closed near the foramina by rotating a vascularized muscle flap. After showing initial improvement the patient had a recurrence of symptoms after 6 weeks, with a small leak at the closure site. A lumbar thecoperitoneal shunt led to permanent cure. In this article we discuss the course of the disease, the symptoms, the diagnostic methods, and the various treatment modalities for subarachnoid pleural fistula.

Craniopharyngiomas can present as suprasellar cystic lesion with varied imaging appearance. In magnetic resonance imaging using T1-weighted sequence, the cyst can show hypointense, isointense or hyper intense signals depending on the cyst content. We report a case where the T1 signal intensity of a craniopharyngioma changed over time. The hypointense lesion had become hyper intense in the follow-up scan after six months. Such change in signal intensity is described with Rathke's cleft cyst but has not been reported with craniopharyngioma. The possible reason for this change in signal intensity is discussed.

Papillary tumors of the pineal region (PTPR) are very rare. We describe the first report of a PTPR empirically managed with gamma knife radiosurgery. The patient was initially shunted and referred for empirical gamma knife radiosurgery. After initially showing some improvement, he had recurrence of tumor after 7 years. For recurrence he underwent a gross total resection and the biopsy established the diagnosis of PTPR. Further research needs to be done as to the efficacy of gamma knife surgery for PTPR. In addition, the role of stereotactic biopsy for eligible patients should be considered as the initial step to direct the treatment of choice.

Gangliogliomas are benign lesions that are predominantly temporal in location and present with chronic epilepsy. Intraventricular gangliogliomas are extremely rare and still rarer is intratumoral hemorrhage. Till date only 9 cases of lateral ventricular gangliogliomas have been reported. To the best of our knowledge only 1 case of intratumoral hemorrhage has been reported. We report a rare case of lateral ventricular ganglioglioma with intratumoral hemorrhage in a 27-year-old man.

The treatment options for symptomatic arachnoid cysts are shunting, open craniotomy, and endoscopic fenestration. Endoscopic fenestration of large arachnoid cyst is safe and effective. Postoperative subdural hematoma and intraparenchymal hemorrhage can be avoided by endoscopic fenestration. This technique has the additional advantage of identifying and treating ventricular abnormalities, such as foramen of Monro stenosis and cerebral aqueduct occlusion. This report describes endoscopic dual fenestration in a child with large multicompartmental intraventricular arachnoid cyst extending from foramen magnum to foramen of Monro. The child presented with difficulty to hold the neck in upright position, irritability, vomiting, and large head. Follow-up postoperative magnetic resonance imaging at 3 months showed a significant reduction in size of the cyst. Clinically, the patient showed a gradual improvement at 10 months follow-up. Probably this is the first report of this nature.