Tuberculous meningitis is a serious infection caused by Mycobacterium tuberculosis. Early diagnosis is the key to success of treatment. Neuroimaging plays a crucial role in the early and accurate diagnosis of tuberculous meningitis and its disabling complications. Magnetic resonance imaging is considered superior to computed tomography. Neuroimaging characteristics include leptomeningeal and basal cisternal enhancement, hydrocephalus, periventricular infarcts, and tuberculoma. Partially treated pyogenic meningitis, cryptococcal meningitis, viral encephalitis, carcinomatous, and lymphomatous meningitis may have many similar neuroimaging characteristics, and differentiation from tuberculous meningitis at times on the basis of neuroimaging characteristics becomes difficult.

Background: Global developmental delay, lack of speech, and severe epilepsy are the characteristic hallmarks of Angelman syndrome (AS). The purpose of this study was to explore the utility of brain magnetic resonance imaging (MRI) as an ancillary tool for the diagnosis of AS. Material and Methods: Brain MRI images of nine laboratory-confirmed patients with AS from a neurorehabilitation center in Rio de Janeiro were reviewed. Each MRI was assessed by a set of two experienced neuroradiologists following a predefined protocol. Results: The main neuroimaging findings revealed in our study were: Thinning of the corpus callosum in five patients; enlargement of lateral ventricles in four patients; and, cerebral atrophy with frontal and temporal predominance in one patient. All patients presented with an increased signal intensity in T2-weighted images and fluid-attenuated inversion recovery (FLAIR) sequences. Conclusion: The lack of specific changes in the brain MRI of children with AS observed in this case series rendered brain MRI a less helpful complementary test. Thus, a definitive diagnosis of AS could only be established on molecular biology that was undertaken based on the clinical suspicion of AS.

Background: Intractable epilepsy is defined as the occurrence of seizures that cannot be controlled with medical treatment. The discovery of epilepsy biomarkers is increasingly attracting more attention from both clinical physicians as well as neuroscientists. Increased levels of soluble and/or cellular galectin-3 (Gal-3) have been associated with various diseases. However, the effects of Gal-3 in epilepsy are still unknown. In this study, we evaluated the association of higher interictal serum Gal-3 protein levels in patients diagnosed with intractable epilepsy. Patients and Methods: A group of 38 patients with intractable epilepsy and 26 healthy age-matched control subjects were included in this study. A commercially available electrochemiluminescence immunoassay (ECLIA) kit was used to determine serum Gal-3 protein levels. Results: Our results indicated that serum Gal-3 protein level in the patient group was 6.67 ± 0.34 ng/ml, and in the age-matched control group was 5.40 ± 0.34 ng/ml. The difference between the two groups was found to be statistically significant (P = 0.003). Conclusion: This study found a detectable elevation in serum Gal-3 concentration in patients with focal epilepsy. Given its secretory nature and detectable levels in the serum, Gal-3 could be a potential biomarker for intractable epilepsy.

Aims and Objectives: An assessment of the sensitivity and specificity of magnetic resonance (MR) imaging measurements of midbrain, pons, middle cerebellar peduncles (MCPs), and superior cerebellar peduncles (SCPs) and MR Parkinsonism Index (MRPI) in differentiating progressive supranuclear palsy (PSP) from Parkinson's disease (PD) and controls was performed. The correlation of these MR imaging measurements with the duration and severity of disease in the Indian patients using the PSP rating scale (PSPRS) was also performed. Materials and Methods: Twenty-six consecutive patients were enrolled in this study, satisfying the diagnostic criteria by the National Institute for Neurological Disorders and Stroke, and the Society for PSP (NINDS-SPSP), along with 13 PD and 30 control patients. All PSP patients were assessed using the PSP rating scale and staging system. Radiologists were blinded to the clinical diagnoses. MRPI was calculated by multiplying the pons area/midbrain area ratio by MCP width/SCP width ratio. The midbrain/pons area (M/P) ratio was measured as the ratio of midbrain area to pons area. Results: Mean MRPI in PSP patients (23.48 ± 9.61) was significantly higher than that in PD patients (9.07 ± 2.23) and controls (9.45 ± 1.87). In this study, MRPI was 100% sensitive, specific, and accurate in differentiating PSP from PD and was 96.3% sensitive, 100% specific, and 98.21% accurate in differentiating PSP from controls. No correlation was found between the duration of disease, PSP rating scale, PSP staging system, and MRPI in the present study. MRPI was only marginally superior to the M/P ratio in differentiating between PSP and PD patients on an individual basis. No overlapping values were observed in the PSP and PD patients. Conclusion: Magnetic Resonance Parkinsonism Index is more sensitive, specific, and accurate in differentiating PSP from PD in the early stages on an individual basis.

Objective: The presence of a glioma is associated with increasing mortality. In this study, nuclear magnetic resonance (NMR) based metabonomics has been applied to investigate the metabolic signatures of a glioma in plasma. The purpose of this study was to assess the diagnostic potential of this approach and gain novel insights into the metabolism of glioma and its systemic effects. Methods: Plasma samples were collected prospectively by centrifugation of blood samples from patients with a glioma (n = 70) or a control group (n = 70). NMR spectra of these plasma samples were analyzed using orthogonal partial least square discriminant analysis (OPLS-DA) to identify the potential biomarkers. Results: The OPLS-DA model showed a good differentiation between the glioma and the control groups. A total of 20 metabolites were identified, which are closely correlating with the presence of a glioma. Compared to the control group, patients with a glioma were associated with lower concentrations of isoleucine, leucine, valine, lactate, alanine, glycoprotein, glutamate, citrate, creatine, myo-inositol, choline, tyrosine, phenylalanine, 1-methylhistidine, α-glucose, β-glucose, and higher concentrations of very low density lipoprotein, low density lipoprotein (LDL), unsaturated lipid, and pyruvate. These 20 metabolites, which are involved in energy, fatty acid, and amino acid metabolism, may be associated with a human glioma. Conclusion: Our study is the first one to identify the plasma metabolites that have the potential to distinguish between patients with a glioma and healthy subjects. NMR-based metabonomics provides a good sensitivity and selectivity in differentiating the healthy control group from patients suffering form the disease. Plasma metabolic profiling may have a potential in diagnosing a glioma in the early phase and may help in enhancing our understanding of its underlying mechanisms.

Background: Growth hormone (GH) levels following oral glucose tolerance test (OGTT) at 12 weeks or later after surgery have been accepted as the most reliable parameter for defining remission and/or cure in patients with acromegaly. However, the role of random GH in predicting remission in the immediate postoperative period using modern criteria is not known. This study was undertaken to evaluate the role of random GH levels in first 5 postoperative days as an early predictive tool for long-term remission of patients with acromegaly following transsphenoidal pituitary surgery (TSS). Patients and Methods: Seventy-five consecutive acromegaly patients with at least three postoperative OGTT values at 3, 6, and 12 months of follow-up were included in the study. GH levels were measured just before surgery, in the immediate postoperative period, at 6 h and on day 1 to day 5 after surgery. Remission was defined as normal age-specific insulin-like growth factor-1 and either basal fasting GH <1 ng/ml or a nadir GH following OGTT <0 .4 ng/ml at 3 months of surgery. Results: Of the 75 patients with acromegaly who underwent TSS, long-term remission was achieved in 42 (56%) patients. GH values ≤1.55 ng/ml at 6 h of surgery showed the highest predictive power for long-term remission, with a sensitivity of 81.2% and a specificity of 83.3%. The duration of disease and tumor volume had no effect on the 6 h GH value-related prediction of cure. Conclusion: Early postoperative GH values may be used to predict long-term cure. A value of ≤1.5 ng/ml at 6 h following surgery may predict long-term cure in two-thirds of the patients with acromegaly who undergo TSS.

Context: Traumatic brain injury (TBI) remains a major cause of morbidity and mortality worldwide. Largely, the prognosis is dependent on the nonmodifiable factors such as severity of the initial injury, Glasgow coma scale score, pupillary response, age, and presence of additional physiological derangements such as hypoxia or hypotension. However, secondary insults continue to take place after the initial injury and resuscitation. The study hypothesis in the present research article was that hypoglycemia is an independent outcome prognosticator in severe traumatic brain injury. The study aimed to assess the role of glucose monitoring in the brain parenchyma as an independent outcome prognosticator and also to study its association with plasma glucose levels. Aims: The aim of the study was to analyze the relationship of intracerebral glucose measured by intraparenchymal cerebral microdialysis (CMD), and also to study its relationship with blood glucose levels. We also evaluated the relationship of these values to the outcome of patients. Settings and Design: Prospective nonrandomized study conducted at a tertiary care trauma center in India. Subjects and Methods: Twenty-five patients with severe TBI, who underwent decompressive craniectomy, were prospectively monitored with CMD catheters. Twenty cases had unilateral catheters placed intraparenchymally (20 mm inside the brain parenchyma to accommodate 10 mm of the semipermeable catheter tip and another 10 mm of extra catheter length). Frontotemporal contusions were noted in 21 cases and an acute subdural hematoma (with/without associated contusions) were noted in 15 cases in the present series. Bilateral CMD catheters were placed during bifrontal decompressive craniectomies in five patients (two patients had peri-contusional catheters placement; these patients had bilateral frontal contusions); while, the remaining 3 patients had a contralateral catheter placement in the normal brain parenchyma [Table 1]. The position of the catheters was confirmed on postoperative computerized tomographic scan carried out in these subjects. However, bilateral catheter placement to compare the difference in cerebral biochemical values of glucose in the penumbric zone as well as the normal brain could not be done in all cases due to cost restraints. The relation between plasma glucose and CMD-measured interstitial brain glucose concentrations, as well as the temporal pattern of CMD glucose was studied for 3–5 days following a decompressive craniectomy using a CMD analyzer at the patient's bedside at 1 hourly intervals. Statistical Analysis Used: All data were tabulated in Microsoft Excel 2011 and analyzed using SPSS version 21. To calculate the correlation between plasma and CMD glucose, Pearson's correlation was used with a two-tailed test of significance. Student's t-test was used to calculate the difference in means between the two groups. Significance was assumed at P ≤ 0.05. Results: Fifteen patients (60%) had a good outcome in terms of the Glasgow Outcome Scale (GOS) at 3 months while the rest (10 patients) had a poor GOS at 3 months. There was a significant difference in the incidence of hyperglycemia (random blood sugar >10 mmol/L) between the two groups (P < 0.0001). The difference between the two groups while comparing episodes of hypoglycemia was also significant (P = 0.0026). The good outcome group had fewer episodes of brain hypoglycemia during the presence of systemic hypoglycemia (P = 0.0026). Neither the mean blood glucose values nor the mean cerebral glucose values predicted the outcome at 3 months. Conclusions: After decompressive craniectomy in severe TBI, there was a poor correlation between the plasma and CMD glucose concentration. A higher degree of variation was seen in the correlations for individual patients. Neither the mean blood glucose values nor the mean cerebral glucose values predicted the outcome at 3 months. The good outcome group had fewer episodes of both hyperglycemia and hypoglycemia.

Objective: To compare the value of MRI diffusion kurtosis imaging (DKI) and diffusion tensor imaging (DTI) in grading cerebral astrocytomas and to analyze the correlation of respective parameters with aquaporin-4 (AQP4) expression. Methods: Sixty patients with cerebral astrocytoma, including low-grade astrocytomas (LGA, n = 25) and high-grade astrocytomas (HGA, n = 35), were studied. The values of DKI parameters (mean kurtosis [MK], radial kurtosis [K_r], and axial kurtosis [K_a]) and DTI parameters (fractional anisotropy, mean diffusivity [MD]) corrected by contralateral normal-appearing white matter in the solid parts of the tumors and peritumoral edema were compared. Receiver operating characteristic curves were used to identify the best parameters. Spearman correlation analysis was conducted to assess the correlation of AQP4 expression with each parameter value. Results: MK, K_a, and K_rvalues were significantly higher whereas MD values were significantly lower in the solid parts of HGA, as compared to those of LGA. MK value in peritumoral edematous tissue was significantly higher in HGA as compared to that in LGA. K_a (0.889) had the largest area under the curve (AUC), followed by MK (0.840), K_r (0.750), and MD (0.764). The AUC of K_aand MK was significantly higher than that of MD. Optimal thresholds for MK, K_a, K_r, and MD for differentiating the two groups were 0.490, 0.525, 0.432, and 1.493, respectively. The AQP4 expression in the solid parts of the tumors was significantly higher in HGAs. MK, K_r, K_avalues positively correlated with the AQP4 expression, whereas MD showed a slight negative correlation with AQP4. Conclusion: Use of DKI improved grading of cerebral astrocytomas when compared with DTI. DKI parameters appeared to reflect the level of AQP4 expression in astrocytomas.

The current management of atlantoaxial dislocation emphasizes on C1-2 reduction and fusion. The fusion of C1-2, however, hampers the neck movements significantly. The author has designed and developed artificial C1-2 joints that can mimic the natural joints to some extent. The concept and nuances of the design has been described. The joints have been fixed in dry cadaveric bones to demonstrate the possible movements.

An ependymoma is an uncommon glial tumor, which arises from different parts of the neuroaxis. Considerable variation in presentation and survival in tumors in different locations after an optimum treatment indicates inherent molecular and genetic differences in tumorigenesis between them. A number of genetic aberrations have been identified to distinctly characterize different subgroups of ependymomas that include a posterior fossa tumor, a supratentorial tumor, and a pediatric tumor. These different groups have substantial genetic alterations, and also distinct demography, clinical characteristics, and prognosis. This article is intended to review the diverse molecular and genetic aberrations that may be helpful in prognostication and prediction of survival in patients suffering from an ependymoma.

Traumatic brachial plexus injuries are devastating injuries commonly affecting the young population and leading to significant socioeconomic losses to the society. The results of brachial plexus surgery have been severely disappointing in the past. However, several technological advancements and newer surgical techniques, especially the advent of distal nerve transfers over recent years, have led to a paradigm shift in the outcome of patients with these injuries. The best time window for surgery is the first 3 months after injury, and the next best time is the next 3 months. The timing is a crucial factor as the neuromuscular junctions degenerate in 20–24 months. The presence of spontaneous fibrillations in a muscle on electromyography is an indication of denervated yet vital muscle. The restoration of elbow flexion is a priority followed closely by restoration of shoulder abduction and stabilization. The various surgical strategies in brachial plexus injuries should be directed toward accomplishing this goal. The global avulsion injuries have a poor outcome because of very limited source of donors in such types of injury whereas the partial injuries have a remarkable outcome in a majority of cases. This article presents the reader with the guidelines and management algorithms of repair strategy and various surgical approaches utilized in the surgical treatment of brachial plexus injuries.

The Department of Neurological Sciences at Christian Medical College (CMC), Vellore was the first department to start neurosurgical and neurological services in India. Jacob Chandy started the department in 1949 against several odds. He started a formal training program in neurosurgery in 1958, for the first time in India, and went on to qualify several neurosurgeons, who in turn pioneered neurosurgical departments all over India. After 1970, K V Mathai and Jacob Abraham guided the department through some difficult times when there was a severe shortage of personnel and no faculty in the neurology section. Through their commitment and hard work, they continued not only the neurosurgery service but also looked after patients with neurological disorders. Mathew J Chandy, son of Jacob Chandy, joined them in 1980 and introduced micro-neurosurgery and several other neurosurgical techniques. Training of residents in micro-neurosurgery began in the early 1980s. The last quarter of a century has been a period of rapid progress for neurosurgery at CMC. There has been an exponential rise in the number of surgeries, number of residents and number of publications. Research has always been an integral part of the activities of the department and several high impact articles have been published by the faculty and residents. The neurosurgical faculty at CMC has also contributed significantly to organized neurosurgery in India and internationally, with five of them serving as President of the Neurological Society of India, a society which had Jacob Chandy as its founder President. With this heritage, the neurosurgery section at CMC, Vellore is likely to continue to provide high quality ethical neurosurgical care to patients from all over India and overseas.