Background: Elderly patients with major ischemic strokes may remain severely disabled or dead. However, efficacy and safety of thrombolysis in this have not been fully explored. Materials and Methods: Data from the case records of patients aged >80 years with acute ischemic stroke with admission National Institute of Health Stroke Scale (NIHSS) score ≥10 admitted between April 2009 and May 2011 were retrieved. Outcomes in patients treated with thrombolysis and control subjects were compared. Primary outcome was 3-month modified Rankin Scale (mRS) score 0-2. Secondary outcomes were 3-month mRS score 0-3, mRS score 5-6, mortality, and improvement NIHHS score at discharge. Safety outcome was hemorrhagic transformation. Results: Study subjects included 22 patients treated with thrombolysis and 23 controls not treated with thrombolysis. Age, stroke severity, and proportion of identified major vessel occlusions were the variables for comparison between the two groups. More patients in the thrombolyzed group had mRS 0-2 outcome than in non-thrombolyzed group (18.2% vs. 0%; P = 0.049). Proportion of patients with mRS 0-3 outcome was also higher in thrombolyzed group than in non-thrombolyzed group (22.7% vs. 0%; P = 0.022). Patients in the thrombolyzed group had higher mortality, non-significant when compared to patients in the non-thrombolyzed group (18.2% vs. 8.7%; P = 0.414). However, lesser number of patients in the thrombolyzed group had mRS 5-6 outcome (35% vs. 65%; P = 0.075). Median improvement in NIHSS score at discharge also showed a more favorable trend in thrombolyzed group (10 vs. 2; P = 0.082). Rates of symptomatic and asymptomatic hemorrhagic transformations in thrombolyzed group were 4.5% and 27.3% respectively. Conclusion: For elderly patients with major ischemic strokes, thrombolysis offers a greater chance of functional independence.

Objective: To evaluate the unique clinical characteristics and management of lateral ventricular subependymomas (LVSs). Patients and Methods : The case records of 27 adult consecutive patients with LVS admitted between March 1996 and May 2011 were reviewed. The relevant clinical data (including patient age and sex, neuroimaging studies, surgical records and follow up) were collected through a chart review. Patient neurological status was recorded using the Karnofsky Performance Scale (KPS). Results: The gender distribution was 14:13 and the age from 33 to 66 years (median 45 years) at the time of operation. Headache and dizziness were the most common initial symptoms (17/27). Most of these tumours were located at the foramen of Monro (12/27). Magnetic resonance imaging (MRI) (21/27) showed well circumscribed tumours with cystic changes (21/27). The lesions were hypointense on T1-weighted images (19/21), hyperintense on T2-weighted images (21/21), and contrast enhancement was no or minimal (19/21). Gross total resection was performed in 23 patients. Five patients required a ventriculo-peritoneal shunt because of postoperative hydrocephalus. The follow-up period ranged from 6 to 188 months (mean 55.5 months). No recurrence was observed during the follow up. Conclusion: In this study LVSs had equal gender distribution. Tumours around the foramen of Monro were the candidates for aggressive treatment; surgery was the best curative treatment; postoperative hydrocephalus should be attended to.

Background: Thalamic tumors are rare intracranial tumors. The most common approaches to the thalamus have been directed through the ventricular system, which surrounds it. The transsylvian trans-insular approach to the lateral thalamus has been infrequently described probably because of the vulnerability of the internal capsule, which skirts this part of the thalamus. Aims: To describe the approach emphasizing its anatomical basis and also to evaluate its safety and efficacy. Settings and Design: Retrospective study conducted at a tertiary hospital. Materials and Methods: Patient population included all the patients who underwent surgery for the lesions in lateral thalamus using the transylvian trans-insular approach between 2005 and 2011. A trephine craniotomy was made, centered over posterior sylvian fissure and the surgical corridor was developed through the insular cortex. Results: During the study period 10 patients (7 tumors and inflammatory lesions and 3 hypertensive bleeds) were treated using this approach. One peri-operative mortality was noted. In patients with lesions other than hypertensive thalamic hemorrhage, there was no postoperative worsening of neurological deficit as comparative to preoperative deficits. Total excision/evacuation of the lesion could be accomplished in all the patients. Conclusions: The transylvian trans-insular approach is safe, effective, anatomical procedure, and can be performed at a peripheral center without the need for navigation and intra-operative monitoring.

Background: The data on incidence of hypopituitarism after SAH are conflicting. Furthermore, it is still not known whether there is any difference in hormonal deficiencies between SAH due to anterior communicating artery (A-com) and middle cerebral artery (MCA) aneurysms. Materials and Methods: This study includes both retrospective and prospective arms. The data collected included baseline demographic profile, clinical severity on admission to the hospital by the Hunt and Hess grading system and World Federation of Neurological Surgeons (WFNS) grading, radiological severity of bleed by the Fisher's classification, and treatment details. All the patients underwent detailed hormonal evaluation at baseline and 6 months in prospective group while at the end of 1 year in the retrospective group. Hormonal deficiencies between patients with A-com and MCA aneurysmal SAH were compared using appropriate statistical tests. Results: Of 60 patients studied, 47 patients (A-com: 28 and MCA: 19) were in the retrospective group, while 13 patients (A-com-9, MCA-4) were in the prospective group. The baseline data were comparable between the two groups. At or after 6 months follow-up, 19 (31.6%) patients, 10 patients with A-com and 9 patients with MCA aneurysmal SAH, had some form of hormone deficiency. Furthermore, there was no difference in endocrine dysfunctions between the two groups. There was no correlation between the severity of hormonal deficiency and the clinical severity of SAH grade by Hunt and Hess and radiological grade of SAH by Fisher's grade. Conclusion: Hormonal deficiencies are not uncommon in patients with SAH. There is no difference in hormonal deficiencies and severity of hypopituitarism in patients with SAH due to A-com and MCA bleed.

Early restoration of flow to perfuse the salvageable brain tissue in acute ischemic stroke significantly reduces mortality and morbidity. Recanalization of large vessel occlusions has not been more than 10-20% with intravenous thrombolysis. Use of mechanical devices in acute ischemic stroke has shown promise in greater recanalization rates and hopefully will yield more optimal stroke outcomes. The results of the recent trials appear promising as the devices continue to evolve, become more operator friendly, and patient outcomes improve.

Background and Purpose: Intravenous tissue plasminogen activator (TPA) has limited efficacy in proximal large vessel occlusions. This study was to assess the safety and efficacy of mechanical thrombectomy with a retrievable Solitaire stent in acute large artery occlusions . Materials and Methods: This is a single center study enrolling patients treated with Solitaire-assisted thrombectomy between November 2010 and March 2011. Inclusion criteria were severe stroke of National Institutes of Health Stroke Scale (NIHSS) score ≥10, treatment initiation within 6 hours from onset, and an angiographically verified occlusion of proximal middle cerebral artery (MCA) or internal carotid artery (ICA). The primary outcome was recanalization defined as Thrombolysis in Cerebral Infarct (TICI) reperfusion grade 2b/3. Secondary outcomes were good functional outcome at 3 months (modified Rankin Scale [mRS] ≤2), early substantial neurological improvement (NIHSS score improvement ≥8 at 24 hours), and symptomatic hemorrhagic transformation (SHT). Results: Ten patients were consecutively enrolled: Age: 72.4 ΁ 5.7 years; female: 70%; baseline median NIHSS score: 19.5; and ICA occlusion in 50% and M1 portion of MCA occlusion in 50%. Six patients received intravenous TPA before intra-arterial treatment, and five patients were treated with adjuvant intra-arterial urokinase. Successful recanalization was achieved in 7 (70%) patients. Four (40%) patients had a good functional outcome at 3 months, and three (30%) patients had an early substantial neurological improvement. SHT occurred in two patients (20%), and 3-month mortality rate was 30%. There was no procedure-related complication. Conclusions: Mechanical thrombectomy with the Solitaire device can effectively recanalize proximal large vessel occlusions, and potentially improves clinical outcome.

Background: There is dismal rate of recanalization following intravenous thrombolysis of large vessel occlusive ischemic stroke. Trials on use of mechanical clot retrievers in acute ischemic stroke have used time from onset and clinical deficit at presentation as the main indications for intervention. Materials and Methods: Retrospective analysis of case records of acute stroke seen between May 2009 and October 2011 was done. It revealed 23 patients with acute ischemic stroke treated by mechanical thrombectomy using Penumbra system (PS). We used magnetic resonance (MR) imaging in correlation with clinical presentation to determine patients likely to benefit from recanalization and accordingly offered or at times deferred revascularization. A comparison of approach and outcomes was done with other relevant trials/reports. Results: Recanalization was achieved in all but one patient. Median modified Rankin Scale (mRS) score at 90 days was 2. Good clinical outcome (mRS ≤ 2) was achieved in 56.5% compared with 25% in Penumbra pivotal trial and 36% in multi Mechanical Embolus Removal in Cerebral Ischemia (multi MERCI) trial. All cause mortality was 13.04%. Symptomatic intracerebral hemorrhage (ICH) occurred in two patients (8.6%). Conclusion: Analysis of our results suggests that PS is safe and effective (91.3%) in recanalizing cerebral vessels without concomitant thrombolytics.

Intracranial pial arteriovenous fistulae (pAVFs), a direct shunt between a feeding artery and a venous channel with the absence of a true nidus characteristic of other types of arteriovenous malformations, are rare. We report a seven-year-old girl with an incidental intracranial pAVF. Following partial embolization with a combination of platinum coils and liquid embolic material, this lesion was surgically disconnected and a definitive cure was achieved. Based on the particular characteristics of this lesion-multiple, small arterial feeders, superficial location, and proximity to the non-eloquent cortex-we feel this vascular lesion represents a subset of pAVFs that may be most reasonably and safely treated by open surgery. While staged embolization has recently gained popularity as a treatment option, the additive risk of multiple embolizations as well as repeated exposure to ionizing radiation should not be understated, especially in the pediatric population. Furthermore, given the paucity of data on the long-term effectiveness of embolization, surgery remains an elegant and durable treatment option for pAVFs in carefully selected patients.

Remote brainstem hemorrhage is an extremely rare complication following supratentorial surgery. We describe here a 55-year-old patient with ruptured anterior communicating artery aneurysm, who underwent an uneventful clipping of the aneurysm, and had a lumbar drainage intra-operatively to facilitate brain relaxation. In the postoperative period, he developed pontomesencephalic hemorrhage, and had a fatal outcome. The potential causative factors are discussed, and the relevant literature reviewed. This is probably the first reported case of this complication in the literature.