Stereotactic radiosurgery (SRS) has proven to be an effective strategy in the management of intracranial arteriovenous malformations (AVMs) in children and adults over the past three decades. Its application has resulted in lowering the morbidity and mortality associated with treatment of deep-seated AVMs. SRS has been used as a primary modality of therapy as well as in conjunction with embolization and microsurgery in the management of AVMs. The obliteration rate after SRS has been reported to range from 35% to 92%. Smaller AVMs receiving higher marginal doses have obliteration rates of 70% and more. The median follow-up reported in most series is approximately 36–40 months. The median time to obliteration has been reported to be approximately 24–36 months in most series. Radiation-induced neurological complications have been reported in less than 10% of patients, with a 1.5%–6% risk of developing a new permanent neurological deficit. The bleeding rate during the latency to obliteration has been reported to be approximately 5%. This review describes the experience reported in literature with respect to the indications, dosage, factors affecting obliteration rate of AVMs, and complications after SRS.

Unruptured intracranial aneurysms (UIAs) present a unique challenge due to the lack of a clear understanding of their natural history and outcome. As the treatment of UIAs is aimed at preventing the possibility of rupture, the immediate risk of treatment must be weighed against the risk of rupture in the future. As such, no specific guidelines exist for a large proportion of UIAs, and treatment is currently individualized. It is also of paramount importance that the physicians be aware of the recent advances in the therapy of UIAs. The present article focuses on the recent advances in the understanding of UIAs.

Background: Triptans, which activate 5-hydroxytryptamine (5-HT)-1B/1D receptors in cerebral arteries, are very effective in aborting attacks of migraine. Although activation of 5-HT-1B/1D receptors diminishes the secretion of noradrenaline from cardiac sympathetic nerves, some studies report that they may cause chest discomfort, myocardial infarction and arrhythmias due to coronary vasospasm. The effect of zolmitriptan on cardiac autonomic modulation has not been evaluated in migraineurs. Subjects and Methods: Ten patients with migraine (nine women, mean age 33 ± 4 years) were crossover randomized to 2.5 mg zolmitriptan or identical placebo at least 5 days apart. Both time domain parameters (the mean R-R interval, the standard deviation of RR interval [SDNN], and the root mean square of successive R-R interval differences) and frequency domain parameters (low frequency [LF], high frequency [HF], and LF/HF ratio) of heart rate variability (HRV) were obtained during supine position, controlled respiration and handgrip exercise before and 2 h after zolmitriptan or placebo administration. Results: Baseline HRV parameters were similar for each occasion. Single dose zolmitriptan administration did not affect both time and frequency domain HRV parameters compared with the placebo. Conclusions: A single dose, 2.5 mg oral zolmitriptan administration did not change sympathetic and parasympathetic reactivity and sympathovagal balance in migraineurs.

Context: Multiple sclerosis (MS) has a spectrum of heterogeneity, as seen in western and eastern hemispheres, in the clinical features, topography of involvement and differences in natural history. Aim: To study the clinical spectrum, imaging, and electrophysiological as well as cerebrospinal fluid (CSF) characteristics and correlate them with outcome. Settings and Design: Retrospective analysis of MS patients during a period of 20 years. Subjects and Methods: Cases were selected according to recent McDonald's criteria (2010), They were managed in the Department of Neurology, Christian Medical College, Vellore. Statistical Analysis Used: Chi-square and Fisher's exact tests were used for categorical variables. Multiple binary logistic regressions were done to assess significance. Kaplan–Meier curves were drawn to estimate the time to irreversible disability. Results: A total of 157 patients with female preponderance (55%) were included. The inter quartile range duration of follow-up was 9.1 (8.2, 11) years for 114 patients, who were included for final outcome analysis. Relapsing remitting MS (RRMS) (54.1%) was the most common type of MS seen. RRMS had a significantly better outcome (odds ratio: 0.12, 95% confidence interval: 0.02–0.57, P = 0.008) compared to progressive form of MS (primary progressive, secondary progressive). The Expanded Disability Status Scale score of patients at presentation and at final follow-up was 4.4 ± 1.31 and 4.1 ± 2.31, respectively. During the first presentation, polysymptomatic manifestations like motor and sphincteric involvement, incomplete recovery from the first attack; and, during the disease course, bowel, bladder, cerebellar and pyramidal affliction, predicted a worse outcome. Conclusion: A high incidence of optico-spinal presentation, predominance of RRMS and a low yield on cerebrospinal fluid (CSF) studies are the major findings of our study. A notable feature was the analysis of prognostic markers of disability.

Introduction: Surgical clipping is the most definite treatment for intracranial aneurysms. Its aim is to achieve complete aneurysmal occlusion without compromising the lumen of a parent vessel or perforators, and with minimal brain tissue trauma. Objective: To evaluate the role of endoscopic controlled keyhole approach in clipping of anterior circulation aneurysms. Materials and Methods: In this retrospective study, all consecutive patients undergoing endoscopic controlled clipping via the keyhole approach by the senior author during the last 1 year were included. The cases in which a microscope was used at any stage of surgery were excluded. Results: Fourteen patients with anterior circulation aneurysms underwent clipping via the endoscopic keyhole approach (supraorbital and mini-pterional). Seven patients had anterior communicating (ACom) artery aneurysms, four had middle cerebral artery (MCA) bifurcation aneurysms, two had internal carotid artery bifurcation aneurysms, and one had a posterior communicating artery aneurysm. Ten patients presented with subarachnoid hemorrhage (Hunt and Hess grade I in 6 and grade II in 4 patients), whereas the remaining four were incidentally detected. The pre-clipping dissection as well as the clipping were successfully performed endoscopically in all patients. The post-clipping inspection revealed inclusion of a perforator within the clip blades in 2 patients (ACom and MCA bifurcation) that required clip readjustment. There was no residual neck/incompletely clipped aneurysm detected on post-clipping inspection. There was no morbidity directly attributable to the use of keyhole approach or the endoscope. Conclusion: Endoscopic keyhole approach for intracranial aneurysms combines the advantages of both keyhole approach and endoscopy. Endoscopic visualization can help to reduce chances of an incompletely clipped aneurysms/residual neck and the risk of parent vessel/perforator occlusion. However, the use of an endoscope in narrow corridors with space constraints has a learning curve that can be overcome by practicing on cadavers and initially performing several simple endoscopic procedures.

Objective: This study was designed to investigate the risk factors of, and the strategy for early diagnosis of cerebral venous sinus occlusion (CVSO) secondary to traumatic brain injury. Materials and Methods: The clinical data of 240 consecutive patients were analyzed retrospectively. The clinical symptoms were observed and imaging was carried out. The risk factors of CVSO were evaluated with logistic regression analysis. Early diagnosis of CVSO was established based on the clinical and imaging features. Results: Forty patients were diagnosed to be having CVSO according to the findings of computerized tomographic venogram (CTV) and magnetic resonance venogram (MRV). They were classified into three sub-types (thrombosis occlusion type, compression type, and mixed type). A skull fracture crossing the sinus (odds ratio [OR] =8.026; 95% confidence interval [CI]: 3.107–20.734) and an epidural hematoma crossing the sinus (OR = 3.062; 95% CI: 1.355–6.921) were risk factors associated with CVSO, and the former played a more significant role. The female gender (OR = 0.306; 95% CI: 1.715–61.943) was the risk factor for the thrombosis occlusion type of CVSO. An epidural hematoma crossing the sinus (OR = 5.653; 95% CI: 1.767–18.084) was the risk factor of the compression type of CVSO. The past medical history of deep vein thrombosis (DVT) (OR = 11.276; 95% CI: 1.315–96.664) combined with a skull fracture and epidural hematoma crossing the sinus were risk factors for the mixed type of CVSO. Conclusions: Paying close attention to the past medical history of DVT, skull fracture, and the imaging finding of an epidural hematoma that crosses the sinus are necessary for the early diagnosis of CVSO. CTV and MRV help in making an early diagnosis of CVSO.

Objective: Trigeminal neuralgia (TN) is a condition that has been studied over decades and whose pathogenesis has still not been well defined. Various open and minimally invasive procedures are in vogue for the treatment of intractable TN. All these procedures have their complications and recurrence rates. Percutaneous retrogasserian glycerol rhizotomy (PRGR) is one of the minimally invasive procedures that have been popular for quite a long time. Material and Methods: This paper is a prospective study analyzing the results of 93 patients with refractory TN who were treated with PRGR. Results: There was an immediate pain relief in 96.8% of patients and long-term pain relief in 89.4% of patients, with a mean follow-up duration of 18.8 months. Recurrence of pain was seen in 10.4% of patients. Conclusions: The PRGR is a simple, safe, cost-effective procedure without any need for expensive equipment and with a good outcome that is compared to the other relatively more expensive open and minimally invasive procedures.

Background: Decompressive craniectomy (DC) with duroplasty is the gold standard for refractory intracranial hypertension despite paucity of randomized controlled trials. There are several morbidities associated with DC of which the persistence of bony defect is of paramount importance. Studies have shown that many of the morbidities associated with DC get reversed following replacement of the bone flap. Aim: To design a novel technique for control of refractory intracranial pressure (ICP), as well as to study its safety and efficacy compared to the conventional DC technique. Material and Methods: We conducted a prospective, comparative, observational pilot study comparing four-quadrant osteoplastic decompressive craniotomy (FoQOsD) with conventional DC. The demographic features, postoperative variables such as operating time, number of days of intensive care unit (ICU) stay and survival, as well as radiographic variables such as change in the midline shift (MLS) and expansion of the compressed brain were analyzed using relevant statistical tests. Results: Twenty patients were selected and grouped into two groups of 10 patients each. The male: female ratio in the two groups were 8:2 and 7:3, respectively, and the mean age at presentation was 42.7 ± 1.45 years in the FoQOsD group and 43.6 ± 1.32 years in the DC group. Both the groups were comparable in relation to the duration of surgery, duration of ICU stay, and survival (P > 0.05). There was significant brain expansion and reversal of MLS (P < 0.001) in the FoQOsD group, factors which were comparable to that in the DC group. Conclusions: FoQOsD may be as effective as conventional DC in managing intracranial hypertension. This procedure mainly avoids a revision cranioplasty. A prospective randomized controlled trial with a large sample size may be initiated for obtaining more accurate data.

Background: Surface electromyography (EMG) is a noninvasive, accurate method to measure electrical activity produced in muscles. Aim: To assess the improvement of spasticity after decompressive surgery for compressive myelopathy using surface EMG. Setting and Design: Neurophysiology laboratory of a tertiary care center. Before-after trial. Both EMG and Modified Modified Ashworth Scale (MMAS) were utilized. Materials and Methods: Thirty-one nonconsecutive patients (28 males; age 25–72 years) with compressive cervical myelopathy and spasticity (MMAS score ≥1) were recruited. Patients with lower motor neuron findings, Nurick grade 5, and those with joint deformities, contractures, or thrombophlebitis of the upper limbs were excluded. EMG activity was measured from the pronator teres and biceps brachii for 31 age-related controls (25 males) as well as for the patients both pre- and post-operatively. Statistical Analysis: Student's t-test for comparison of continuous variables and Pearson correlation co-efficient for assessing the significance of associations. Results: EMG recording done 1-week postoperatively showed a reduction in baseline activity in the pronators and supinators by 21% and 36%, respectively. There was a decrease in co-activation of the pronators during active supination by almost 62% and of the supinators during active pronation by around 33% (P < 0.05). On passive movement, there was a decrease in co-activation of the pronators during supination by approximately 23%, and the supinators during pronation by 35% (P < 0.05). EMG activity was significantly reduced in the pronators during supination in all patients, including those in whom the MMAS scores remained the same postoperatively. Conclusion: Surface EMG is an objective tool to detect improvement in spasticity following decompressive surgery for compressive cervical myelopathy even in those patients who showed no improvement on the MMAS.

Introduction: Camptocormia is seen with Parkinson's disease (PD), segmental or generalized dystonia, extensor myopathies, anterior horn cell disorders, and muscle disorders. In severe selected cases of PD with camptocormia and dystonic camptocormia, deep brain stimulation (DBS) has been tried with variable success. In this paper, the first case report of its kind from India, we report a case of dystonic camptocormia who underwent DBS and review the available literature. Methods: A 42-year-old male, presented with dystonia of 5-year duration, that initially started with cervical dystonia and later progressed to severe disturbance of posture causing involuntary truncal flexion induced by standing or sitting. The camptocormia was completely relieved when sitting on a chair or lying down on the bed. Routine blood testing was normal. The workup for secondary dystonia including slit lamp examination for Kayser-Fleischer ring and serum copper studies did not reveal any abnormality. Magnetic resonance imaging of the brain was unremarkable. The electromyogram of the lumbar and thoracic paraspinal muscles was also normal. Results: The patient was initially treated with multiple drugs and Botulinum A toxin which were ineffective. He underwent bilateral globus pallidus interna (GPi) DBS Over a period of 2 weeks; there was a mild reduction in the dystonia of the trunk and neck. The maximum improvement in dystonia, approximately 30% over baseline, was noted at 2 weeks postsurgery and over a further long-term follow-up, the improvement was 50% as determined by the sub-item (trunk) assessment of the Burke-Fahn-Marsden (BFM) dystonia score. Cervical dystonia improved by >90% in sub-item (neck) assessment of BFM scale. Conclusions: In this report, we have shown the efficacy of GPi DBS in the treatment of drug refractory dystonia associated camptocormia. Although only reported for PD associated camptocormia, evaluation for truncal extensor myopathy is mandatory in these cases also to achieve a good outcome.

Susac syndrome is a clinical triad of branch retinal artery occlusions, sensorineural hearing loss, and encephalopathy. The characteristic central corpus callosum involvement in Susac syndrome is readily recognizable on conventional magnetic resonance imaging (MRI); however, the neurocognitive effect of these lesions is not well-understood. We present a case of Susac syndrome with typical MRI findings of central callosal lesions at diagnosis. The patient had a protracted clinical course and did not respond well to immunosuppression therapy. Follow-up brain single photon emission computed tomography with Tc-99m hexamethylpropyleneamine oxime revealed marked unilateral frontoparietal and temporal lobe hypoperfusion. Our case highlights the utility of functional neuroimaging to uncover the possible underlying white matter dysfunction, which is not otherwise detectable with conventional MRI techniques.

Brachial plexus injuries are devastating injuries that usually affect the younger population. The usual modes of injuries are roadside accidents, falls, and assaults. The affected individuals are crippled and may suffer from excruciating peripheral or central deafferentation pain for rest of their lives. The loss of functional capacity accounts for a significant number of man-hours lost at the workplace and consequent financial burden on the family. The results of brachial plexus reconstructive surgery have generally been unsatisfactory in the past. However, in recent decades, the efficacy of surgery has been proven beyond doubt, and there have been various published series in literature that have reported a good outcome after surgical management of these injuries. This has been made possible by the use of operating microscopes, better microsuture techniques for nerve graft and nerve or tendon transfer repair, and advanced perioperative electrophysiological techniques. The key to successful management lies in the proper clinical evaluation, supplemented with electrophysiology, preoperative imaging studies, and planning of surgical strategy. The partial injuries have a better outcome as compared with global palsies, and early referral should be emphasized. Selective combinations of nerve graft and transfers provide a moderate shoulder and elbow control. However, a multispecialty approach involving hand surgeons, plastic surgeons, and physiotherapists is required.

Aims: Vascular complications have the most serious consequences in patients with tuberculous meningitis (TBM). Although stroke is seen in approximately 20% of patients with TBM, the underlying vascular damage and infarction are much more extensive. This study has been undertaken to study the pathology at different levels of cerebral vessels and their resultant complications in TBM. Materials and Methods: Fifty-one postmortem TBM brains were examined over a period of 16 years (1997–2012). The vascular pathology was studied in detail. Changes in middle cerebral artery (MCA) and basilar artery (BA) and their branches at different levels were analyzed in all cases. Results: The age of the patients ranged from 3 months to 72 years. Infarcts were found in 37 cases, among which they were grossly visible in 27 cases. Macroscopic infarcts were more common in MCA territory whereas microscopic infarction was more in BA distribution—brainstem and cerebellum. Vascular involvement was almost universal, with smaller branches of both MCA (94%) and BA (100%) carrying the brunt of the disease, whereas the larger branches were variably involved. Infiltrative lesions were most common at all levels; necrotizing lesions were more common in smaller branches, whereas proliferative changes were seen more in larger branches. Conclusion: This study showed extensive damage of cerebral vessels in TBM, which was responsible for the presence of widespread infarctions. Microscopic infarctions in the brainstem and cerebellum were much more common than reported by radiological studies. Thus, more aggressive management of TBM is required to combat its vascular complications.

Vertigo is a common symptom in everyday clinical practice. The treatment depends on the specific etiology. Vertigo may be secondary to inner ear pathology, or any existing brainstem or cerebellar lesion but may also be psychogenic. Central vertigo is a consequence of a central nervous system lesion. It is often associated with a focal neurological deficit. Peripheral vertigo is secondary to dysfunction of the peripheral vestibular system and is usually characterized by an acute vertigo with loss of balance, sensation of spinning in the space or around self, and is exaggerated with changes of the head and body position; no other neurological deficit is present. Some medications may also cause vertigo. Depending on the cause of the vertigo, drugs with different mechanisms of action, physical therapy, psychotherapy, as well as surgery may be used to combat this disabling malady. Symptomatic treatment has a particularly important role, regardless of the etiology of vertigo. We reviewed the current medications recommended for patients with vertigo, their mechanisms of action and their most frequent side effects.

The Madras Medical College and its affiliated Government General Hospital, Chennai, are among the oldest medical institutions in India. The Madras Institute of Neurology (MIN) was the second neurosciences department to be started in India. The MIN has trained several batches of illustrious neurologists and neurosurgeons. This article briefly traces the history of the MIN, its important milestones, and its current developments.