Background: Large and giant aneurysms still remain a therapeutic challenge both surgically and endovascularly. Objective: The authors report their clinical experience and follow-up results using Neuroform stent, as an adjunct in the treatment of large and giant aneurysms. Materials and Methods: A total of 71 consecutive patients with 72 large or giant intracranial aneurysms were treated with the Neuroform stent-assisted coiling. Both sequential technique and parallel technique were used. In all cases, embolization was completed by packing the aneurysm sac with a variety of commercially available coils. The technical feasibility of the procedure, procedure-related complications, angiographic results, clinical outcome, and follow-up angiography were evaluated. Results: In all the patients, the Neuroform stent system was delivered and deployed accurately, and occlusion was achieved. Immediate angiography demonstrated complete occlusion of the aneurysm in 59.7% of the patients, neck remnant in 26.4%, and incomplete occlusion in 13.9%. Procedure-related complication, morbidity, and mortality were 15.3, 4.2, and 1.4%, respectively. Favorable clinical outcome (modified Rankin Scale score 0-2) was observed in 83.3% of the patients (average follow-up time: 37.1 months). None of the treated aneurysm had rebleeding. Angiography follow-up was obtained in 81.7% (58/71 patients; 59/72 aneurysms; average follow-up time, 43.2 months). The overall recanalization rate was 28.8%. No delayed coil or stent migration was found. In-stent stenosis occurred as a delayed complication in one patient. Conclusions: The Neuroform stent-assisted coiling for large and giant intracranial aneurysms is safe and feasible with comparable incidences of morbidity and mortality.

Background: Optic chiasmatic-hypothalamic gliomas are sellar-suprasellar lesions with variable radiological features. The advocated treatment is mainly primary radiotherapy without a histological diagnosis. However, in developing countries, like India infective granulomas (tuberculomas) in the suprasellar region radiologically can mimic optic chiasmatic-hypothalamic gliomas. Hence primary radiotherapy without histological confirmation may have deleterious consequences. Aim: The aim of the paper was to analyze the sensitivity and specificity of magnetic resonance imaging (MRI) in these lesions and to analyze the feasibility of primary radiotherapy. Patients and Methods: The magnetic resonance imaging (MRI) characteristics of 24 patients with either histologically proven optic chiasmatic "pilocytic astrocytoma" or radiologically suspected optic chiasmatic-hypothalamic gliomas were analyzed. They were grouped into three groups on the basis of radiological features and treated with a suspected diagnosis. The final diagnosis was correlated with preoperative diagnosis, and the feasibility of managing these lesions without a histopathological confirmation is discussed. Results: The three radiological groups were: Group-1 solid tumors with or without microcysts in 9 patients (histology: 8 pilocystic astrocytomas and 1 tuberculoma); Group-2 mixed tumors with solid and cystic components in 9 patients (histology: 7 pilocytic astrocytomas and 2 craniopharyngiomas); Group-3 ring enhancing lesions in 6 patients (all the 6 patients initially received antituberculous treatment, in 3 patients the lesion resolved and in the remaining 3 patients the lesion was subjected to biopsy as it did not resolve, the biopsy was suggestive of pilocytic astrocytoma). Thus, MRI was shown to have a sensitivity of 83.33% and a specificity of 50% for diagnosing optic chiasmatic-hypothalamic gliomas. Conclusions: Various lesions like craniopharyngiomas, tuberculomas can mimic optic chiasmatic-hypothalamic gliomas radiologically, and it is not possible to diagnose them with certainty on the basis of radiological findings alone. Biopsy and tissue diagnosis should always be sought before instituting radiotherapy or chemotherapy for optic chiasmatic-hypothalamic gliomas.

Background: Cranio-spinal axis teratomas are rare. This subset is interesting because symptoms can be varied, depending on the location. Histopathology is diagnostic; most of the lesions are benign. Rarely, malignancy develops in any of the somatic components. Aims: To study the demographic, clinico-morphological and follow-up data of central nervous system (CNS) teratomas. Materials and Methods: Cases diagnosed as mature or immature teratomas in the CNS over a 20-year period were included in the study. Clinico-radiological, demographic and follow-up data of these cases were analyzed. Results: A total of 14 tumors were diagnosed as teratomas. Of these, 11 were mature cystic teratomas; and 1 case each, of teratoma with malignant transformation, terato-carcinoma and mixed germ cell tumor (immature teratoma with germinoma). Six of the 14 cases were intracranial and 8 were spinal. Presenting features varied according to the location. Radiologically, contrast enhancement with predominantly solid component was suggestive of malignancy or an aggressive tumor. Morphologically, a variety of tissue derivatives were seen in the cases. Excision was curative or provided symptomatic relief in most cases; terato-carcinoma and mixed germ cell tumor patients needed adjuvant radiotherapy. Conclusion: CNS teratomas are rare. Morphology and location decide outcome.

Background: Venous bleeding induced by intercavernous sinus injury during sellar dural opening is a challenging intraoperative complication and is difficult to treat in transsphenoidal surgery. To date, few studies concerning the management of intercavernous sinus bleeding have been reported. Aims: Our aim was to assess the clinical outcomes of a new hemostasis technique utilizing nonpenetrating titanium clips for management of intercavernous sinus bleeding. Materials and Methods: From January 2007 to July 2008, 242 pituitary tumors were operated using a transnasal transsphenoidal approach. A new technique involving a specially devised clip applier and titanium clips was used to control venous bleeding in 13 (5.4%) patients who exhibited a prominent intercavernous sinus. All patients were evaluated clinically and radiologically at 9 to 24 months, and postoperative magnetic resonance imaging (MRI) was performed at 3 to 18 months. Results: No operation was interrupted or aborted due to ineffective bleeding control, and there was no delayed bleeding noted as a complication. No complications related to the use of the device occurred. Imaging studies revealed no evidence of significant clip artifact. Conclusions: Our surgical experience has revealed that this new hemostasis technique can be a safe, rapid and effective method for control of intercavernous sinus bleeding during sellar dural opening in transsphenoidal surgery. However, a further prospective study to evaluate this method more fully is planned.

Background: Duchenne muscular dystrophy (DMD) is a common X-linked recessive neuromuscular disorder, affecting 1 in 3,500 live male births. About 65% of cases are caused by deletions; ~5% to 8%, by duplication; and the remaining, by point mutations of the dystrophin gene. The frequency of complex rearrangements (double-deletion and non-contiguous duplications) is reported to be 4%. Aim: In this study, we examined the usefulness of multiplex ligation-dependent probe amplification (MLPA) for screening of deletion and duplication mutations in a group of DMD/ BMD (Becker muscular dystrophy) patients from India. Patients and Methods: We analyzed 180 patients referred from all over India, by both multiplex PCR technique (22 exons) and MLPA (all 79 exons). Results and Conclusion: By multiplex PCR, deletions were detected in 90 (50%) patients. MLPA studies in these cases detected 3 additional deletions, 16 (8.9%) duplications and 2 point mutations. MLPA is useful to verify absence of deletions/ duplications in all 79 exons. This sets the stage to look for point mutations using RNA- or DNA-based tests because of the availability of the drug PTC124. Also, the extent of the deletions and duplications could be more accurately defined by MLPA. The delineation of the precise extent of deletion helps in deciding whether exon-skipping technique would be useful as therapy.

Background: Dementias produce deficits in perfusion, in part, reflecting decreased metabolic needs. Single photon emission computed tomography (SPECT) studies have reported characteristic anterior-to-posterior perfusion gradients that permit distinction between the various forms of dementia. Aim: We undertook this study to evaluate the role of visual analysis of SPECT perfusion patterns for the differential diagnosis of types of degenerative dementia. Materials and Methods: Tc-99m ethylcysteinate dimer (ECD) was used with a dual-head scanner to generate perfusion images of the brain in 136 patients referred from the dementia clinic. Diagnosis was made by the nuclear physician unaware of clinical diagnosis. Results: Sensitivity, specificity, positive predictive value and negative predictive value of perfusion studies for Alzheimer's dementia were 93.42%, 95.12%, 97.26%, and 88.63%, respectively, and for frontotemporal dementia were 96.29%, 98%, 96.29%, and 98.88%, respectively. Conclusions: Tc-99m ECD brain perfusion SPECT is useful in the differential diagnosis of dementia with particular reference to AD as well as FTD.

Background/Aims: To compare the influence of stroke risk factors between different stroke types and age groups in Taiwan. Materials and Methods: During the study period, March 2007 to August 2008, 1,161 patients with acute ischemic stroke were admitted to the neurological ward. All the patients had risk factors work up and stroke subtype categorization. Results: The study cohort included 736 men and 425 women. Patients were grouped into three age groups: below 50 years (153, 13.2%); 50-75 years, (702, 60.5%) and above 75 years (306, 26.4%). Stroke subtypes included: (1) large-artery atherosclerosis (14.6%), cardioembolism (12%), small-artery occlusion (39.4%), stroke of other determined etiology (1.5%) and stroke of undetermined etiology (32.6%). Older patient group had higher frequency of hypertension and diabetes mellitus. Younger age group of patients had high frequency of obesity and elevated serum triglyceride levels. Smoking and alcohol consumption were strongly related to men, and heart disease and obesity were related to women. Conclusions: The influence of risk factors at different ages is different. Awareness of the stroke risk factors before stroke and treatment with appropriate therapies or life modifications may have a bearing on the outcomes.

Background and Objectives: Spontaneous vertebral artery dissection (sVAD) is a rare condition and can potentially cause a stroke, particularly in young to middle-aged people. Patients and Methods: The clinical manifestations, medical imaging characteristics, treatment, and prognosis of 16 patients with sVAD were analyzed. Results: None of the 16 patients had a history of head or neck trauma. The most common clinical manifestation was headache with symptoms of posterior-circulation ischemia (63%). Diagnosis of VAD was definitive in one patient at autopsy, and in the remaining it was established by magnetic resonance angiography, computer tomography angiography, or digital subtraction angiography. Treatment modalities included: thrombolysis with urokinase (1), antiplatelet therapy (6), and endovascular stenting (9). There was one death and the remaining 15 patients were followed up for 3-48 months and did not have recurrence of cerebral events. Conclusions: Rapid and accurate diagnosis of sVAD and proper treatment are crucial for good outcomes. This study shows that antiplatelet therapy and endovascular treatment are effective treatments for sVAD.

Ability to non-invasively map the hemodynamic changes occurring focally in areas of brain involved in various motor, sensory and cognitive functions by functional magnetic resonance imaging (fMRI) has revolutionized research in neuroscience in the last two decades. This technique has already gained clinical use especially in pre-surgical evaluation of epilepsy and neurosurgical planning of resection of mass lesions adjacent to eloquent cortex. In this review we attempt to illustrate basic principles and techniques of fMRI, its applications, practical points to consider while performing and evaluating clinical fMRI and its limitations.

Background: Surgical resection of brainstem lesions has a high risk of morbidity, because vital fasciculi in the brainstem can be damaged along the entry routes. Diffusion tensor imaging (DTI) is an in vivo method for mapping white matter fiber tracts in the brain. Objective: To summarize the experience of surgical treatment of brainstem lesions with the assistance of DTI and fiber tractography. Materials and Methods: A retrospective analysis clinical data of nine patients with brainstem lesions were investigated between July 2007 and September 2009. The analysis included age distribution, clinical presentation, pre- and postoperative modified Rankin score (mRS), and surgical approach. DTI and fiber tractography were used to reconstruct the corticospinal tracts and the medial lemnisci. Results: DTI and fiber tractography showed that most of the corticospinal tracts were compressed anteriorly or anterolaterally, except for one case (posteriorly). All the medial lemnisci were displaced posteriorly or posterolaterally. Individualized surgical approaches were designed according to the information provided by DTI and fiber tractography. Total resection was achieved in two patients with brainstem cavernomas and two patients with pilocytic astrocytoma. Partial resection was performed in the other patients. The neurological functional status was better than preoperative period in eight patients, one patient with medulla oblongata astrocytoma deteriorated. The preoperative average mRS score was 2.22 points. At the time of the last follow-up, the average postoperative score had improved by 0.56 to 1.66 points. Conclusions: DTI and fiber tractography can provide valuable information regarding the relationship between the principal fiber tracts and brainstem lesions, which is useful in neurosurgical planning.

Background: Diffusion tensor imaging (DTI) is a sensitive technique for studying cerebral white matter. Only a few studies have examined the association between changes in extratemporal integrity and cognition in temporal lobe epilepsy (TLE), especially in Chinese patients. Aim: We used DTI to characterize microstructural changes and investigate their associations with cognition in patients with temporal lobe epilepsy. Patients and Methods: We studied 27 adult patients with TLE and 21 healthy controls. A standardized neuropsychological evaluation and diffusion tensor imaging examination were conducted on each subject. Eight patients were excluded because T2-weighted magnetic resonance imaging (MRI) results showed visible lesions. Furthermore, we determined mean diffusivity (MD) and fractional anisotropy (FA) values in the different regions of interest - normal-appearing white matter (NAWM) in the frontal lobe white matter, the occipital lobe white matter, the corpus callosum, the internal capsules, the external capsules; and normal-appearing gray matter (NAGM) in the caudate nucleus head, the putamens and the thalami. These diffusion measurements were compared between the two groups, and we examined the correlations between DTI values and clinical characteristics. In addition, multiple linear regression analysis was used to study the association of DTI values with cognitive function. Results: Compared with normal controls, TLE patients demonstrated decreased FA in NAGM of both thalami and NAWM of the posterior limb of the left internal capsule (P<.01). In patients with temporal lobe epilepsy, right thalamus FA showed a tendency to correlate with age at seizure onset (ß=0.47, P=.045), and left thalamus MD showed a tendency to correlate with the duration of epilepsy (ß=0.54 P=.038). Patients with temporal lobe epilepsy showed significantly poorer performance on nearly all tasks concerning category fluency and other executive functions (P<.01). In patients with TLE, there was a positive correlation between category fluency scores and FA in the white matter of the left frontal lobe (ß=0.429, P=.041) and the right occipital lobe (ß=0.613, P=.001). Conclusions: Our results suggested that the thalamus might be a potentially important extratemporal structure involved in temporal lobe epilepsy. Moreover, a longer duration of epilepsy or an earlier age at onset may result in more abnormalities in the thalamus. Patients with temporal lobe epilepsy showed significantly poorer performance on nearly all tasks concerning category fluency and other executive functions. Our results showed that frontal lobe white matter contributed to category fluency impairment in patients with TLE, but other areas might also contribute to these impairments.

Background: Language area-related lesion is a serious issue in neurosurgery. Removing the lesion in the language area and at the same time preserving language functions is a great challenge. Aim: In this study, we aimed to screen functional magnetic resonance imaging (fMRI) based task types suitable for activation of Broca and Wernicke areas in Chinese population, characterize lesion properties of functional area of Chinese language in brain, and assess the potential of fMRI-guided neuronavigation in clinical applications. Materials and Methods: Blood oxygen level-dependent fMRI has been used to localize language area prior to operation. We carried out extensive fMRI analyses and conducted operation on patients with lesions in speech area. Results: fMRI tests revealed that the reciting task in Chinese can steadily activate the Broca area, and paragraph comprehension task in Chinese can effectively activate the Wernicke area. Cortical stimulation of patients when being awake during operation validated the sensitivity and accuracy of fMRI. The safe distance between language activation area and removal of the lesion in language area was determined to be about 10 mm. Further investigation suggested that navigation of fMRI combined with diffuse tensor imaging can decrease the incidence of postoperative dysfunction and increase the success rate for complete removal of lesion. Conclusion: Taken together, these findings may be helpful to clinical therapy for language area-related lesions.

Aims: The advent of three-dimensional (3D) rotational angiography (3D DSA) challenged the role of digital subtraction angiography (DSA) as a "gold standard" in the diagnosis of intracranial aneurysms. In this study, we report our experiences in diagnosing intracranial aneurysms by using 3D DSA with volume rendering (VR) technique, particularly focusing on its role in depicting additional aneurysms missed by 2D DSA. Materials and Methods: One hundred and thirty-eight consecutive patients with known or suspected aneurysms (54 men, 84 women; median age, 55 years; age range, 18-83 years) underwent both conventional DSA and 3D DSA with VR examination simultaneously. The images of 2D DSA or 3D DSA with VR were evaluated by two observers independently for the presence of aneurysms. Then additional aneurysms were decided and depicted. Results: 3D DSA with VR showed 146 aneurysms in 123 (89.1%) of 138 patients and no aneurysms in 15 patients. 2D DSA showed 115 aneurysms in 110 of 137 patients, with one aneurysm in 106 patients each, 2 in 3 patients each and 3 in 1 patient. After reaching a consensus, there were 31 additional aneurysms detected by 3D DSA with VR. 30 aneurysms were <3 mm in maximum diameter with 3 aneurysms ruptured. These additional aneurysms were located in internal carotid artery (ICA, n = 28, 90.32%), anterior cerebral artery (ACA, n = 3, 9.68%). No additional aneurysms were found in either middle cerebral artery (MCA) or vertebrobasilar and posterior cerebral artery (PCA) systems. Conclusions: 3D DSA, especially VR images, not only clearly reveals aneurysms and aneurysmal morphology, but also detects additional aneurysms missed by 2D DSA, especially small aneurysms less than 3 mm.

Background: This study assesses the tract alterations observed before and after resection of solid posterior fossa tumors (PFTs) using diffusion tensor imaging (DTI) and white matter tractography (WMT). Materials and Methods: Pre- and post-surgical DTI and WMT data were acquired in eight patients undergoing surgical resections of PFT. A tensor deflection algorithm was used to reconstruct the tracts adjacent to the lesions. The tracts were evaluated regarding their spatial orientation and integrity. A software additionally assessed the luminosity and pixel values from specific regions of interest (ROIs) quantifying the magnitude of tract alterations. The individual neurological condition was additionally evaluated. Results: In eight tumors (metastases (4), neurinomas (2) and meningiomas (2), the preoperative WMT revealed different tract alterations, including deviation (all cases), deformation (7 cases), thinning (8 cases) and apparent tract interruption (4 cases). The ROI histograms from noncompromised tracts showed a tendency for value concentration and peak formation, while affected tracts showed different dispersion patterns. After tumor resection, the compromised white matter tracts showed a resolution (3 cases) or reduction (5 cases) of the deviation. Postoperatively, 7 cases of tract thinning and 3 cases with tract interruptions showed an improvement. The comparison between ROI histograms from preoperative and postoperative compromised tracts mostly revealed a postoperative accentuated reduction of the luminosity with a simultaneous increase of pixels and improved histogram definition (homogeneous values distribution). At this time (5 weeks post-surgery), several neurological functions had improved to different levels. Conclusions: Preoperative and postoperative tract alterations in patients with solid PFT can be accurately assessed with WMT. The magnitude of tract changes can be quantitatively analyzed by assessing color, signal brightness in compromised bundles.

Background: Pain-related studies have mainly been performed through traditional methods, which lack the rigorous analysis of anatomical locations. Functional magnetic resonance imaging (fMRI) is a noninvasive method detecting neural activity, and has the ability to precisely locate related activations in vivo. Moreover, few studies have used painful stimulation of changed intensity to investigate relevant functioning nuclei in the human brain. Aim: This study mainly focused on the pain-related activations induced by electrical stimulation with different intensities using fMRI. Furthermore, the electrophysiological characteristics of different pain-susceptible-neurons were analyzed to construct the pain modulatory network, which was corresponding to painful stimulus of changed intensity. Materials and Methods: Twelve volunteers underwent functional scanning receiving different electrical stimulation. The data were collected and analyzed to generate the corresponding functional activation maps and response time curves related to pain. Results: The common activations were mainly located in several specific regions, including the secondary somatosensory cortex (SII), insula, anterior cingulate cortex (ACC), thalamus, and other cerebral regions. Moreover, innocuous electrical stimulation primarily activated the lateral portions of SII and thalamus, as well as the posterior insula, anterior ACC, whereas noxious electrical stimulation primarily activated the medial portions of SII and thalamus, as well as the anterior insula, the posterior ACC, with larger extensions and greater intensities. Conclusion: Several specified cerebral regions displayed different response patterns during electrical stimulation by means of fMRI, which implied that the corresponding pain-susceptible-neurons might process specific aspects of pain. Elucidation of functions on pain-related regions will help to understand the delicate pain modulation of human brain.

Papillary tumors of the pineal region are recently described as rare mass lesions with limited literature available on their natural history and imaging features. Magnetic resonance imaging (MRI) including perfusion, diffusion, and spectroscopic features were described in an 18-year-old girl with papillary tumor of pineal region. A well-defined, T1 hyperintense and contrast-enhancing mass lesion was noted in pineal region with few cystic spaces within. Solid portion of lesion showed minimal diffusion restriction with average apparent diffusion coefficient of 0.812 Χ 10 ^-3 mm ² /s; on MR spectroscopy elevated myo-inositol peak with reduced N-acetylaspartate and elevated choline in the tumor. On perfusion study there was significantly high relative cerebral blood volume (rCBV) (6-9 times) and relative cerebral blood flow (rCBF). Our findings agree with previous descriptions of cystic areas with T1 hyperintense appearance of this tumor but very high level of tumor perfusion, diffusion restriction, and presence of myo-inositol peak are important imaging findings and may correlate with the recent reports of high tumor recurrence in these cases.

Wilson's disease (WD) has neuro-anatomical, pathophysiological and neurochemical basis for sleep disturbances. The aim of the study was objective evaluation of the frequency and nature of sleep abnormalities using polysomnography (PSG) in patients with WD. The study included 25 subjects with WD (males, 18; age , 24.4 ± 9.25 years) and 25 healthy controls (all males; age, 33.1 ± 9.7 years). After phenotypic assessment and magnetic resonance imaging (MRI), sleep-related questionnaires were administered, and PSG was performed. Patients had significantly reduced total sleep-time (P=.001), sleep-efficiency (P=.001), percentage of deep sleep (P=.01), and REM-sleep (P=.04) with prolonged sleep-onset latency (P=.05) and latency to stage 2 (P=.02). Subgroup analyses of patients based on demographic and clinical parameters were done. Men had significantly more bradycardia both during awake (P=.002) and sleep (P=.03) states. Younger patients (<20 years) had frequent tachycardia (P=.01), higher Periodic Limb Movement (PLM) Index (P=.01) and lesser REM% sleep (P=.05). Patients on de-coppering therapy had prolonged REM-sleep-onset latency (P=.03) and mixed apnea events (P=.04). The isolated limb movements were more in the severe form of disease (P=.05) and in patients taking anticonvulsants (P=.03). This study, the first of its kind in literature, revealed significant sleep disturbances in patients with Wilson's disease.

Human immunodeficiency virus (HIV) may affect any part of the neuraxis and may affect skeletal muscle in many ways, ranging from myofiber atrophy in the wasting syndrome to inflammatory muscle disease and a host of opportunistic infections involving muscle. We report here a case series of 4 zidovudine-naοve patients with proven HIV infection with myopathy. One was a case of HIV wasting syndrome, and the three others were diagnosed as HIV polymyositis. Muscle biopsy proved invaluable in the characterization of these cases

Tumors located within the third ventricle have some potential limitations during surgical approach. Generally speaking, it is impossible to reach the third ventricle without incision of any neural structure. We report a patient with choroid glioma in the anterior part of the third ventricle, and coincident cavum septum pellucidum (CSP) in whom we could remove the tumor gross totally without damaging any neurovascular structures. The tumor expanded the space between the rostrum of the corpus callosum and the column of the fornix and lifted up the floor of CSP. The transcavum-septum-pellucidum approach anterior to foramen of Monro was chosen to remove the anterior third ventricle tumor. We propose that the tumor had likely expanded within the above-mentioned space and elevated the floor of CSP thus increasing the anteroposterior diameter of the floor providing a feasible avenue to third ventricle making it feasible to pass through the enlarged space safely. Overall, cavum septum pellucidum provided a feasible route to approach the anterior third ventricle directly.

Traumatic retroclival hematomas are uncommon lesions usually associated with significant trauma. Majority of the reported hematomas are epidural; and in the pediatric population. Retroclival acute subdural hematomas (RSDH) are very rare, with only two previous cases reported in English literature. An 18-year-old man presented with headache and no deficits following an accident. Computer tomography (CT) scan and magnetic resonance imaging (MRI) showed an acute RSDH extending into the spinal subdural space. He developed bilateral sixth nerve palsies, with symptoms of raised intracranial pressure within the next 24 hours. He underwent evacuation of hematoma with a good outcome. Another 19-year-old man presented with neck pain following a fall from a moving bus. He had no neurological deficits. CT scan showed a RSDH extending across the craniovertebral junction. He was managed conservatively with good outcome.