Botulinum toxins are, as a group, among the most potent neuromuscular toxins known, yet they are clinically useful in the management of conditions associated with muscular and glandular over-activity. Botulinum toxins act by preventing release of acetylcholine into the neuromuscular junction. While botulinum toxin type A is commonly available, different manufacturers produce specific products, which are not directly interchangeable and should not be considered as generically equivalent formulations. Type B is also available in the market. Each formulation of botulinum toxin is unique with distinct dosing, efficacy and safety profiles for each use to which it is applied. Botulinum toxin type A is the treatment of choice based on its depth of evidence in dystonias and most other conditions. Botulinum toxin type A is established as useful in the management of spasticity, tremors, headache prophylaxis and several other neurological conditions. Active research is underway to determine the parameters for which the type B toxin can be used in these conditions, as covered in this review. Botulinum toxin use has spread to several fields of medicine.

Non-functioning pituitary adenomas most commonly present secondary to mass effect and are classified according to their size and immunohistochemical staining. Local intrasellar mass effect may cause varying degrees of hypopituitarism. With extrasellar growth, neurological signs and symptoms develop. Appropriate therapy for these tumors requires close interaction across multiple disciplines. Trans-sphenoidal surgery offers safe and effective treatment in the overwhelming majority of patients with relatively low risk of new neurological and endocrinologic deficits. The multidisciplinary management of non-functioning adenomas, their diagnosis and therapeutic outcomes, is discussed.

Background: A significant proportion of human immunodeficiency virus (HIV) seropositive subjects may have subclinical asymptomatic involvement of the central and peripheral nervous system. Aims: To detect subclinical neurological involvement in asymptomatic HIV seropositive individuals by clinical, mini mental state examination (MMSE) and various electrophysiological tests. Material and Methods: MMSE, EEG, nerve conduction (NC), and multimodality-evoked potential studies were evaluated in 20 asymptomatic HIV seropositive subjects. Results: The majority of the subjects were young (mean age: 29.5 ± 8.9 yrs) and female (85%). The mean MMSE score was 25.8 ± 2.3, which was marginally less than that of matched controls (26.3 ± 2.4). Four subjects had a score of less than 23 suggesting subclinical cognitive impairment. EEG (n=19) was mildly abnormal in 8 cases: low alpha index (n=4), excess of fast background activity (n=3) and intermittent bursts of slow waves along with sometimes sharp waves (n=4). Motor NC studies (n=20) revealed a decreased mean nerve conduction velocity (NCV) compared to controls in the right median (P<0.05) and CP (P<0.001) nerves. Sensory NC studies revealed a decreased mean NCV in both the median (P<0.001) and sural (P<0.001) nerves compared with controls. Brainstem auditory evoked potential (BAEP) studies showed the involvement of the peripheral auditory pathway (23.5%). The somatosensory evoked potential (SSEP) study detected a delay of N20 latency in two. Only 3 subjects came for follow-up after 6 months. Conclusion: Asymptomatic HIV seropositive subjects may have subclinical central and peripheral nervous system involvement. Long-term follow-up studies are essential for better understanding of the significance of these changes.

Background: Thrombolysis is an expensive medical intervention for ischemic stroke and hence there is a need to study the feasibility of thrombolysis in rural India. Aims: To asses the feasibility and limitations of providing thrombolytic therapy to acute ischemic stroke patients in a rural Indian set-up. Material and Methods: The first 64 consecutive patients registered under the Acute Stroke Registry in a university referral hospital with a rural catchment area were studied as per a detailed protocol and questionnaire. Results: Of the 64 patients 44 were ischemic strokes, and 20 were hemorrhagic. Thirteen (29.55%) patients with ischemic stroke reached a center with CT scan facility within 3 hours, of whom only 7 (15.91%) were eligible to receive thrombolytic therapy as per the existing clinical and radiological criteria, but none received the therapy. Of the remaining 31 (70.45%) who arrived late, 11 (25%) had no clinical and radiological contraindications for thrombolysis, except the time factor. All the patients belonged to a low socioeconomic status and a rural background. Conclusion: Though a large proportion of ischemic stroke patients were eligible to receive thrombolytic therapy, the majority could not reach a center with adequate facilities within the recommended time window. More alarmingly, even for those patients who reached within the time window, no significant attempt was made to initiate thrombolysis. These data call not only for attention to improve existing patient transport facilities, but also for improving the awareness of efficacy and therapeutic window of thrombolysis in stroke, among the public as well as primary care doctors.

Context: A definite diagnosis and characterization of intracranial mass lesions, based on structural Magnetic Resonance Imaging (MRI) alone may be difficult. In such cases Proton Magnetic Resonance Spectroscopy (1H-MRS) along with other non-invasive techniques represents an advance in the specificity of brain lesion diagnosis.1 Aims: The primary aim of this study was to evaluate the extent of the utility of 1H-MRS in adult brain tumors and their differentiation from similar-appearing space-occupying lesions. Material and Methods: MRS studies were performed on 1.5 Tesla whole body MR system using standard imaging head coil. Sixty patients (aged 30-65 years), including 35 males (31-65 years) and 25 females (30-65 years) were studied, along with 25 age-matched healthy volunteers (30-64 years). The Student ‘t’ test was used to statistically analyze the spectroscopic data for significant difference in the metabolite ratios of the lesions from normal brain tissue. Results: The Cho/Cr ratio was significantly raised in low and high-grade glioma and meningioma patients (1.85±0.36, 3.50±1.00 and 6.65±2.83 respectively) (mean±standard deviation), as compared with the control group (1.16±0.18); and NAA/Cr and NAA/Cho ratios were found to be lower than normal values in our study (P<0.01). However, in the non-neoplastic lesions, the Cho/Cr ratios were not statistically significant. The tubercular lesions revealed an average Cho/Cr ratio of 1.24±0.18, while it was 1.14±0.07 for infarcts. Conclusions: MR Spectroscopy was useful to arrive at a more definitive diagnosis in doubtful intracranial space-occupying lesions with similar morphological imaging patterns.

Background: The purpose of cranioplasty is not only cosmetic repair but also neurological improvement. The effect of cranioplasty on the cerebral hemodynamics flow has not been investigated by ultrasonographic techniques. Aims: To investigate changes of cerebral hemodynamics after cranioplasty in patients with cranial defect using transcranial Doppler sonography (TCDS). Setting: The Departments of Neurosurgery and Radiology of a university hospital. Design: A prospective clinical study. Material and Methods: We prospectively examined the cerebral hemodynamics with TCDS pre- and postoperatively in 18 patients with cranial defect who underwent cranioplasty. All postoperative studies were done between the 7th and 15th day after cranioplasty. The anterior cerebral artery was examined through the transtemporal and transorbital windows, the middle cerebral artery through the transtemporal window, and the posterior cerebral artery through the transforaminal window. Bilaterally, the peak systolic, end diastolic and mean blood flow velocities of these arteries were measured. Statistical Analysis: Wilcoxon matched-pairs signed-ranks test. Results: Before cranioplasty all the velocities ipsilateral to the cranial defect were significantly low, while in the contralateral side they were near normal. Ipsilateral low cerebral blood flows increased and reached normal levels (P<0.05) after cranioplasty. During the follow-up, neurological improvement was observed. Conclusion: Cranioplasty is carried out not only for preserving normal appearances and physical barrier but also for neurological improvement. This should be explained by the normalization of cerebral hemodynamics.

Background: Clinical, radiological, postmortem and experimental studies are not enough for the definition of pathophysiological differences between rapid and slow-progressing cerebral venous system obstruction. Aims: An experimental study was conducted to set some physiopathological differences between rapid and slow occlusion of the superior sagittal sinus. Settings and Design: Eighteen dogs categorized into 3 groups were chosen as test subjects. The three groups were the rapid occlusion, slow occlusion and the control study groups and each group had six subjects. Material and Methods: Intracranial pressure values, histopathological findings, and the degree of cerebral edema formation, estimated by measuring the water content ratio of the brain and the angiographic results in the 2 different groups of subjects that underwent rapid and slow superior sagittal sinus obstruction were compared with that of the control subjects. Statistical Analysis: Statistical analysis was performed using GraphPad Prisma V.3 statistical software. Variables of the 3 groups were compared using non-parametric Kruskal Wallis ANOVA test and multiple comparisons were made using Dunn’s multiple test. The comparison of initial and terminal 1ntracranial pressure values obtained before and after the sinus occlusion, was made using the Wilcoxon test. A probabability value of less than 0,05 was regarded as significant. Results and Conclusions: Comparison of the water content ratio of the brain in the 3 groups, the difference between the initial and terminal intracranial pressure values of the rapid occlusion study group, and the difference between the terminal intracranial pressure values of the 3 groups was statistically significant (P<0,05). Dunn’s Multiple Comparison Test yielded significant differences in the water content ratio of the brain and in the intracranial pressure values between the rapid occlusion study group and the control group (P<0,05). Moreover, histopathological and radiological examination disclosed more prominent brain edema findings, and less apparent collateral venous flow in the rapid occlusion study group than in the slow occlusion one. To conclude, the clinical severity of sinus occlusion seems directly related to the quickness of the occlusion and the capacity of the collateral venous system.

Background: Tumor necrosis factor a TNF-alpha has a possible role in the pathogenesis of the Guillain-Barre’ syndrome (GBS). Aims: To study the effect of intravenous immunoglobulin (IVIg) on serum TNF-alpha concentrations in patients with GBS. Material and Methods: The effect of IVIg on TNF-alpha was evaluated in 36 patients with GBS. Serum TNF-alpha concentration was measured by enzyme-linked immunosorbent assay (ELISA). The sera of 22 (61%) patients with GBS showed elevated concentrations of TNF-alpha (35–182 pg/ml) and these sera were individually incubated in vitro with IVIg (0.25mg/ml) at 37°C for 24 hours. Results: The serum TNF-alpha concentrations in the 22 GBS patients with elevated levels showed a steady decline (60.34—19.78 pg/ml) following incubation with IVIg. These 22 patients also received IVIg therapy, and serum TNF-alpha concentrations showed a significant decline (65.5—9.75 pg/ml) at the end of the therapy. At the time of discharge from the hospital, there was a positive correlation between neurological recovery and decline in TNF-alpha concentrations in these 22 GBS patients. Conclusions: The results of this study indicate that elevated levels of TNF-alpha occur in a proportion of patients with GBS and in these patients elevated serum TNF-alpha levels decline with IVIg therapy.

A prospective study of 31 percutaneous vertebroplasty procedures (PVP) in 22 patients treated during January 2000 to December 2001 is presented. PVP was performed using polymethylmethacrylate (PMMA) to treat vertebral collapse due to osteoporosis and vertebral metastasis, to obtain analgesia and spinal stabilization. We analyze the efficacy and complications related to the procedure. PVP is a safe, effective and a daycare surgery. It can be performed under local anesthesia and has minimal and manageable complications.

Tropical Spastic Paraparesis (TSP) is an uncommon myeloneuropathy with an insular geographic distribution. In 1985, Human T-lymphotropic virus type I (HTLV-1) was reported to be a possible etiological factor.1 We did an epidemiological, clinical and virological study of 25 cases of TSP. They were predominantly young adult men, whose duration of illness ranged from 6 months to 15 years. Difficulty in walking, stiffness of legs and paraesthesia of legs were the main symptoms. None had tuberculosis, syphilis, malnutrition or lathyrism. Pyramidal signs of the lower limbs, upper limbs, posterior column involvement and spinothalamic tract dysfunction were the common signs. Laboratory findings and cerebrospinal fluid analysis were normal in most. Myelograms or MRI were normal in all. Only 1 case repeatedly tested positive for HTLV-1 antibodies. None of his relatives had clinical or virological evidence of TSP or HTLV-1 infection. Based on our study, we could not link HTLV-I infection to TSP in Indian cases. Virological testing for HTLV-I infection by polymerase chain reaction may be a better tool to reveal such an association. Our cases were similar to seronegative spinal spastic paralegia. A related new retrovirus or an altered immune response to HTLV-1 due to environmental or dietary factors are possibilities which require further exploration.

Introduction: Obstructive sleep apnoea (OSA), is characterized by loud snoring and excessive daytime sleepiness. Though the gold standard for diagnosis is overnight polysomnography (PSG), sleep questionnaires have also been used to diagnose this with good predictive value. Material and Methods: A pre-designed proforma with clinical details, symptom-specific questions for diagnosis of OSA, and Epworth Sleepiness Scale (ESS) was administered to 20 patients presenting to the Sleep Disorder Clinic of our hospital and to 40 age and sex-matched relatives (control group). The students ‘t-test’ and chi-square were used as the statistical tests. Results: There were 20 patients with a mean age of 41± 8 years, and 40 controls with a mean age of 41 ± 6 years (P=>0.05). Seven had family history of snoring in the study group and 3 in the control group (P=0.02). Four had met with road traffic accidents in the study group and none in the control group (P=0.001). The body mass index (BMI) was 29.9 (SD 4.4) in the study group and 24.5 (SD3.5) in the controls (P=0.001). The mean ESS was 13.3 ± 6 in the patients and 4.2+ 4 in the controls (P=0.001). A larger number of patients with OSA had hypertension: 5/20 vs. 3/40 (P=0.01). Conclusion: Patients with OSA had significantly higher BMI and ESS score, and were more likely to have hypertension and road traffic accidents. Increased awareness of this entity is essential.

Introduction: Electrocardiographic (ECG) changes are observed in patients with acute stroke and are related with the prognosis. Aims: To determine the frequency and significance of ECG changes in patients with acute ischemic stroke. Material and Methods: In a prospective hospital-based study 87 patients with cerebral infarction were observed for ECG changes during their stay in the hospital. All the patients had ischemic stroke for the first time. The ECG changes observed were compared with those of the control group consisting of 87 patients. Results: Of the 87 patients of the study group, 47.1% were females and 52.9% males. The mean age was 65.5 ± 11.9 (range 31–91 yrs). The control group consisted of 50.6% females and 49.4% males. The mean age was 64.5 ± 11.9 (range 31–87 yrs). The frequency of the ECG changes observed in patients with cerebral infarct was 62.1% while it was 29.9% in the control group (P<0.0001). ECG changes observed were mostly related to myocardial ischemia. The six-month mortality rate in the patients with ECG changes was 38.9% whereas it was 15.2% in those with normal ECG (P<0.05). Conclusions: The observations of this study suggest that cardiac evaluation in patients with acute ischemic stroke is of prognostic importance.

Thirty patients with low-grade (WHO Grade II) astrocytomas involving the insula, who had undergone stereotactic biopsy followed by radiotherapy, were followed up to evaluate the outcome with regard to control of seizures, memory and language function, Karnofsky Performance scale and regression in tumor volume. Patients were followed up for a mean of 27.8 months, during which time they showed improvement in all the factors that were studied. A statistically significant change was, however, seen only in the reduction in tumor size, probably due to the small sample size and the short duration of follow-up. Stereotactic biopsy followed by radiation therapy provides a good short-term outcome in patients with low-grade insular astrocytomas.

Between 1995 and 2000, 22 cases with low velocity missile injuries of the spine and spinal cord were treated in three service hospitals. All were adult males, with a mean age of 30.7 years. The wounds were caused by splinters in 18 (82%) and bullets in 4 (18%). Twelve patients received more than one splinter. The cervical and thoracic spines were most frequently involved. In 7 cases, there were injuries to other organs. There was extensive initial deficit (quadriplegia, paraplegia) in 18 (82%) cases, while 4 (18%) had partial deficits. The patients were evaluated by spine radiographs. Myelography was done in 4, CT myelography in 11 and MRI in 4 patients. Two patients had intramedullary hematoma without any skeletal injury, and were treated conservatively. Seventeen patients were treated operatively, and associated injuries of other organs received priority management. Surgery was in the form of debridement, exploration of the spinal cord, hemostasis, decompression and dural repair. Steroids and antibiotics were given routinely. Three patients (2 with cervical and 1 with thoracic spine injury) died preoperatively, and 1 (with dorsolumbar injury) died in the postoperative period due to multi-organ injury. Patients with complete injury remained completely paralyzed, while those with an incomplete injury showed improvement in their neurological grades. The initial neurological grade is the best prognostic indicator, and these injuries are often accompanied by multi-organ injuries. There was no instance of postoperative meningitis or CSF leak. These injuries should be explored for debridement and dural repair.

Introduction: To evaluate the role of limited field radiation therapy in the management of high-grade gliomas and glioblastoma multiforme (GBM). Material and Methods: From July ’96 to January ’98, 50 newly diagnosed patients of high-grade gliomas (Grade III and IV) and glioblastoma multiforme who underwent surgery in the form of partial, sub-total or near-total excision as the primary treatment were enrolled in this study. The patients were randomized to receive two different postoperative external radiation protocols, Study Group A: Localized field external radiotherapy 50 Gy/25#/5 wks followed by Boost 10 Gy/5#/1 wk, Control Group B: Whole brain external radiotherapy 40 Gy/20#/4 wks followed by Boost 20 Gy/10#/2 wks by localized field. Results: 20/25 (80%) patients in the study group and 14/25 (56%) patients in the control group showed improvement in their Karnofsky Performance Status (KPS). Thus a significant difference in the performance status was noted in favor of limited field irradiation. No significant difference in the local response was seen between the two groups after radiotherapy. Six months progression-free survival of the study group was 44% as compared to 26% in the control group. Six months overall survival was 66.67% in the study group and 50.72% in the control group (P<0.01). Maximum recurrences were noticed within 2 cm of the original tumor margin in both the groups. Conclusions: Although local control and survival of the patient in both the groups were same, performance status definitely improved in patients treated with localized field irradiation only.

Non-verbal serial pattern learning in patients with mild brain injury was examined using a serial pattern-learning task introduced by Nissen and her colleagues. The task involves two types of pattern cycles: Simple and Complex. Each pattern cycle consists of eight acquisition trials followed by a final generation phase, i.e. the ninth trial. The subjects responded to the asterisks appearing in repetitions of a 10-element spatial sequence in each pattern cycle. Eighty subjects were taken, of which 40 subjects had mild head injury and 40 were uninjured. Prior research with this task has shown that individuals show intact performance on the indirect measure of pattern learning, but are impaired on the direct measure. The results of this study showed that mild brain injury does cause a marked disruption in the ability to learn and remember serial pattern information in both simple and complex patterns.

Chordoid meningioma is an uncommon histopathological variant of meningioma. We report 2 cases of chordoid meningioma occurring in adult patients.

Megalencephalic leukoencephalopathy with subcortical cysts (MLC) is a rare, recently described disease.1 This disorder, reported predominantly in infants and children, was originally described by van der Knaap as ‘leukoencephalopathy with swelling and a discrepantly mild clinical course’. The gene locus for this autosomal recessive disease has been assigned to chromosome 22qtel, and a gene has been identified, presently called MLC1.2,3 It is characterized clinically by a large head and mild neurological symptoms such as ataxia, spasticity and remarkably slow course of functional deterioration. The MRI features described include ‘swollen white matter’ with large symmetrical cystic changes in the cerebral hemispheres.1,2,4 The MRS findings in this disorder include mild to moderate decreases in the NAA to choline and choline to creatine ratios.5 We report a child with this disease and discuss the MRI and MRS features.

Baló’s Concentric sclerosis (BCS) is a rare demyelinating disease considered to be a variant of multiple sclerosis (MS). The typical magnetic resonance imaging (MRI) changes associated with BCS consist of concentric rings or onions’ cross-section on T1-weighted (T1W) images. Because MRI reveals pathological changes consistent with autopsy in the focus of BCS, it plays an important role in the before-death diagnosis of BCS. We report three cases of BCS diagnosed antemortem on the basis of the typical concentric rings pattern on MRI and on the basis of clinical findings and cerebrospinal fluid (CSF) examination. BCS often occurs in the prime of life, acutely or subacutely. Then come cerebral multifocal symptoms and signs. We find that BCS is not always an acute and irreversible pathological process as described in the past.

We present a case of a boy with juvenile myoclonic epilepsy (JME) who presented with features of non-convulsive status epilepticus (NCSE). This case highlights the fact that NCSE, even though not a common occurrence in JME, should be kept in mind when a patient with previous history of seizures presents with subtle changes in sensorium with no obvious cause.

An injury to the pharynx and esophagus is a known complication of anterior cervical spine surgery. Two cases of delayed pharyngo-esophageal perforation following anterior cervical spine surgery that resulted in fistula are presented. We postulate that graft displacement and dislodgement of implant with resulting esophageal erosion was responsible for this complication.

Traumatic aneurysm of the superficial temporal artery is an uncommon lesion. Two cases of post-traumatic superficial temporal artery aneurysm are presented.

Late postpartum eclampsia is an increasingly recognized entity. We describe a patient who developed postpartum eclampsia on the 6th day of delivery without any preceding pre-eclampsia. A high index of suspicion and close follow-up will help in the early detection of this condition. Awareness of this condition will also save the patient from unnecessary investigations. This may be all the more relevant in developing countries where eclampsia contributes to one-third of maternal mortality and the resources for patient investigation and management are limited.

A case of multiple giant congenital melanocytic naevi in whom central nervous system melanosis was detected at 6 weeks of age is described. The infant was asymptomatic, but presence of risk factors such as multiple naevi, giant naevi and naevi on scalp and posterior axial location prompted a magnetic resonance imaging study of the brain. To our knowledge, neurocutaneous melanosis at such a young age has not been reported in Indian literature.

Five children with Guillain-Barre syndrome (GBS), following a national oral polio vaccination campaign to eradicate disease, are reported. Clinical examination, CSF and electromyographic findings conformed to the classical description of GBS. Four of them received therapeutic dose of intravenous IgG. Two children succumbed to the disease. It was observed that the number of cases of GBS in children increased during the period of the oral polio vaccination (OPV) campaign in Turkey, suggesting a causal relationship.

Histological, immunohistochemical, and CT morphological features of medulloepithelioma, a rare embryonal tumor of primitive neuroepithelium, are described.

A case report of a pituitary tuberculoma, with magnetic resonance imaging (MRI) features is described. The patient was treated with anti-tuberculous chemotherapy, and a follow-up MRI after 6 months showed good response. The relevant literature is briefly reviewed.

This case report describes a rare, non-epileptic manifestation of neurocysticercosis where a 22-year-old male presented with acute onset right 3rd nerve palsy with left hemiplegia (Weber syndrome). Computerized tomography and magnetic resonance imaging revealed cysticercus granuloma. The patient improved and became asymptomatic with steroid treatment. Recognizing this clinical entity would avoid unnecessary antituberculous treatment and surgical intervention.

A 28-year-old man with a large Sylvian fissure cyst was treated by making a small pre-coronal burr hole, and subsequently, under a direct view its wall was fenestrated with a Cushing’s needle and the cyst fluid was tapped. The patient had complete neurological recovery. The follow-up was of 90 months.

This report describes a case of acute steroid-induced myopathy following a single dose of oral prednisolone. A 55-year-old man presented with an acute exacerbation of chronic obstructive pulmonary disease (COPD), which was treated with prednisolone 40 mg daily in addition to bronchodilators. He developed features of myopathy the next day. Serum CPK was moderately elevated and electromyogram (EMG) was suggestive of primary muscle disease. He was managed conservatively and improved 10 days after stopping prednisolone. Mechanisms of steroid-induced myopathy and relevant literature have been reviewed.

We present an unusual case of cerebrotendinous xanthomatosis in a female elderly patient with recurrent TM joint dislocation and oromandibular dyskinesia.