Neurosurgery is one of the most technically demanding medical professions that warrants a high level of expertise. In the present context of competitive medical practice, high societal expectations regarding quality of patient care and medicolegal and financial constraints, there are fewer opportunities for a trainee to achieve competency in standard neurosurgical, microsurgical, and operative techniques. Practice on simulation models like cadavers has been a trend since antiquity; however, recent development of newer models with their strategic modifications has given simulation education a new dimension. It has allowed trainees to acquire and improve surgical skills and knowledge in specifically fabricated and controlled settings with no risk to real patients. Simulation also offers the opportunity for deliberate practice and repetition unlimited number of times so that psychomotor skills can be automated. There is ever-growing evidence showing the positive impact of simulation on resident training in various areas of health care. Advances in computer technology and imaging, development of sophisticated virtual reality simulators with haptic feedback and the recent addition of three-dimensional printing technology, have opened a wide arena for the development of high-fidelity patient-specific models to complement current neurosurgical training. Simulation training in neurosurgery in India is still elementary since its inception at the All India Institute of Medical Sciences, New Delhi. A structured modular training program has been developed which is yet to be implemented at a multi-institutional level. Stringent efforts are needed to establish a uniform resident training curriculum where simulators can be used to complement current neurosurgical training.

Prediction of prognosis in comatose patients surviving a cardiac arrest is still one of the intractable problems in critical care neurology because of lack of fool-proof ways to assess the outcome. Of all these measures, somatosensory-evoked potential (SSEP) has been perhaps the most evaluated and heavily relied-upon tool over the past several decades for assessing coma. Recent studies have given rise to concerns regarding the “absoluteness” of SSEP signals for the prognostic evaluation of coma. In this critical review, we searched the literature to focus on studies conducted so far on the prognostic evaluation of postanoxic coma using SSEPs. All those studies published on the use of SSEP as a prognostication tool in postanoxic coma were reviewed. A narrative review was created that included the strengths as well as limitations of the use of SSEP in postanoxic coma. The use of SSEP in coma has been universal for the purpose of prognostication. However, it has its own advantages as well as limitations. The limitations include challenges in performing and getting SSEP signals during coma as well as the challenges involved in reading and interpreting the signals. The recent usage of therapeutic hypothermia has become another factor that often interferes with the SSEP recording. Finally, based on these study results, some recommendations are generated for the effective use of SSEPs in comatose patients for further prognostication. We advocate that SSEP should be an integral component for the assessment of postanoxic comatose patients due to its several advantages over other assessment tools. However, SSEP recordings should follow certain standards. One should be aware that its interpretation may be biased by several factors. The bias created by the concept of “self-fulfilling hypothesis” should always be borne in mind before discontinuation of life support systems in terminal patients.

Background: Myasthenia gravis (MG) is an autoimmune disorder with a chronic fluctuating course. Quality of life (QoL) is affected by physical restrictions due to disease-related symptoms and effects of long-term treatment. Purpose: The purpose of this study was to assess QoL in a cohort of MG with stable disease course on optimal therapy. Materials and Methods: MG-QoL-15 was applied prospectively to 50 subjects of MG from India. Results: Mean MG-QoL-15 was 10.34 (standard deviation: 9.4; range: 0–32). Mean MG-QoL-15 scores for subjects with Myasthenia Gravis Foundation of America (MGFA) grades I, II, and III/IV were 3.54, 9.4, and 15.94, respectively. QoL scores correlated significantly with the MGFA grade. Age, gender, thymectomized status, thymoma, and steroid therapy did not affect QoL scores. All patients with MGFA grade I scored “0” or “1” in almost all items of MG-QoL-15. Seven and 11 patients with MGFA grades III/IV reported a significant affection (scores “3” or “4”) due to “trouble using my eyes” and “plan around MG,” respectively; and five subjects were “frustrated by MG.” None of the subjects, irrespective of their MGFA grade, reported significant difficulty in getting around public spaces due to MG, or had “trouble in performing personal grooming.” One subject each reported significant “trouble driving due to MG” or felt that “MG limits ability to enjoy hobbies and fun activities.” Conclusion: This is the first study from India to assess QoL in MG using MG-QoL-15. Increased disease severity was reflected in worse QoL. MG-QoL-15 is a simple, quick, and user-friendly tool. Longitudinal changes in the QoL scores may be required to determine its utility in the Indian context.

Aim: This study addresses the role of neuroimaging in addition to the available clinical criteria for Creutzfeldt–Jakob disease (CJD) and its impact on its diagnosis in the absence of cerebrospinal fluid (CSF) biomarkers and tissue-based approaches. Methods: From a tertiary referral center in the city of Trivandrum, Kerala, South India, patients with rapidly progressive dementia (RPD) who fulfilled the World Health Organization (WHO) 1998 diagnostic criteria for CJD were included in this study. Their electrophysiological-clinical-radiological data were retrospectively studied and the results were analyzed. The other biomarkers of CJD were not assessed in the study. Results: Of the 96 patients with RPD, 41 patients were diagnosed as having a 'probable' and 'possible' CJD using the WHO 1998 diagnostic criteria between 2000 and 2013. While 92% patients satisfied the University of California, San Francisco (UCSF) 2007 and European magnetic resonance imaging (MRI)-CJD consortium criteria (2009), only 73% satisfied the MRI components of these criteria in addition to the more stringent, proposed UCSF MRI criteria (2011). The latter required the presence of diffusion weighted imaging abnormalities more than fluid attenuation inversion recovery abnormalities in the cortical and subcortical regions for the establishment of diagnosis on MRI of 'definite' (53.7%) and 'probable' CJD (19.5%). Conclusions: Significant heterogeneity exists in the presentation of CJD with only 48.8% patients simultaneously satisfying the MRI and electrophysiological criteria, suggesting that the diagnosis is impacted by these components in any of the currently prevalent criteria. With 27% of the cohort not meeting the radiological criteria, CSF and molecular biomarker assays may be reserved for MRI negative patients with suspected CJD and in atypical presentations.

Background: Cognitive symptoms are common in advanced Parkinson's disease (PD). However, assessment of cognitive impairment is difficult in PD because of accompanying motor symptoms and the coexistence of nonmotor symptoms. Specific subdomains affected in the disease are not reflected in the conventional scales used for assessing cognition. Objectives: This study was aimed at looking at the spectrum of cognitive impairment in the various phenotypes and stages of PD and the correlation of cognitive impairment with motor and nonmotor symptoms of PD. Patients and Methods: Fifty PD patients fulfilling the UK PD Society Brain Bank's criteria were selected after obtaining explicit consent. Patients were assessed clinically and by using various scales like Scales for Outcomes in PD-Cognition (SCOPA-COG), mini-mental state examination, and Beck's Depression Inventory and Scoring. Results: The mean age was 58 years, 82% of the patients were male, and the mean modified Hoehn and Yahr staging was 2. The most commonly affected domains were memory and executive functioning. Cognitive impairment was more in those with late-onset disease, more advanced stage of disease, and in the postural instability and gait disorder (PIGD) subgroup. The cognitive function deteriorated with increasing age and duration of the illness. Significant correlation with cognitive impairment was obtained for the manifestations of increased motor disability, presence of coexistent psychotic symptoms and depression. Conclusions: Cognitive impairment was common among PD patients, and it was more prevalent with increasing duration of the disease, in older patients, in late-onset disease, and in the PIGD subgroup. Increasing motor disability and associated psychotic symptoms as well as depression significantly increased the cognitive impairment.

Background: It has been reported that R2* is a sensitive marker for iron deposition. The aim of this study was to quantitatively assess iron deposition in Parkinson's disease (PD) using changes of R2* in enhanced T2 star-weighted angiography (ESWAN) and to discuss the value of ESWAN for PD. Methods: Fifty-four primary PD patients and twenty-eight healthy individuals were examined by ESWAN in the 3·0 T magnetic resonance imaging system. The R2* values were measured from the deep gray nuclei (including the substantia nigra [SN], red nuclei, globus pallidus, putamina, caudate nuclei, and thalami). The unified PD rating scale (UPDRS) III assessment, the nonmotor symptoms scale (NMSS), and the mini mental state examination (MMSE) were used to rate all the patients. Results: The comparison of the R* values between the deep gray nuclei on the same side of the PD patients and the control group revealed significant differences in the SN and red nuclei (P < 0.05). There was a significant difference between Hoehn and Yahr (HY) 1 and HY2-4 patients in terms of the values of the SN. There was a slight correlation between the R* values of the SN of the PD patients (HY >1) and the UPDRS III ratings. No correlation between the R* signal values in the PD patients and the NMSS and MMSE scales was found. Conclusion: Iron concentrations in the regions of interest may represent the severity of the PD motor symptoms, and whether they are related to the nonmotor symptoms remains a question for further investigation. ESWAN offers special advantages in determining iron depositions in the brain and in enabling a sensitive diagnosis of PD, although further study is necessary.

Background: Recanalization therapies have been increasingly applied in clinical practice, which might change the outcomes of patients with large middle cerebral artery (MCA) infarction. The purpose of this study was to study the clinical course, prognostic factors, and long-term outcomes of patients with an acute large MCA infarction. Methods: Patients with an acute large MCA infarction who were treated between January, 2011 – March, 2014 were studied. The demographics and vascular risk factors were compared between patients with and without clinical outcomes of interest, favorable outcome and death. Results: From a total of 1538 patients, 200 patients with large MCA infarction were included. The mean age was 67 years. The mean National Institute of Health Stroke Scale score was 20. The mean time from onset to the hospital was 289 min. Intravenous recombinant-tissue-plasminogen activator (rtPA) was given in 50 patients (25%). The mean follow-up time was 13 months. 51 patients (51/191, 27%) had a favorable outcome (modified Rankin Scale 0–2) at the final follow-up. 81 patients (81/191, 42%) died. A younger age, less severe stroke, rtPA treatment, and large-artery atherosclerosis stroke subtype were related to a favorable outcome. Older age and presence of coronary artery disease were associated with death and rtPA treatment was inversely related to death. Conclusions: Prognosis of patients with a large MCA infarction is still poor. Favorable outcomes were found in only a fourth of the total patients, and a high mortality rate was still present. Intravenous rtPA treatment seemed to be related to a favorable outcome.

Background: Transforaminal lumbar interbody fusion (TLIF) has emerged as one of the common procedures performed by spine surgeons. Back pain and radiculopathy due to degenerative disc disease, spondylolisthesis, or deformity are the usual indications. Minimally invasive surgery (MIS) techniques have proven to be effective in TLIF as they are associated with less blood loss, fewer wound complications and infections, faster recovery, and decreased hospital costs. The novel technique described in this study helps to achieve a circumferential lumbar fusion using a unilateral posterior approach, via a muscle-dilating exposure, thereby minimizing the approach-related morbidity. Objectives: An overview of the minimally invasive TLIF (MIS-TLIF) procedures including indications, techniques, and clinical experience along with a review of the medical literature is hereby presented. Methods: All patients who underwent MIS-TLIF for various indications at our institution from 2009 to 2014 were retrospectively reviewed. All patients in this series had low back pain as their predominant symptom, with varying degrees of radicular pain and neurologic symptoms. The data collected retrospectively for analysis were age, gender, previous diagnoses, revision diagnosis, duration of symptoms, levels of fusion, operating time, intraoperative blood loss, clinical and radiographic results after surgery, and complications. Back and leg pain quantified by visual analog scale scores preoperatively, postoperatively, and at the last follow-up were assessed for clinical outcomes. Conclusions: Our clinical experience along with a review of the medical literature indicates that TLIF can be effectively and safely performed in a minimally invasive fashion for a wide variety of indications.

Background: We report our experience with the far lateral approach (FLA) and its modifications in the surgical resection of tumors of craniocervical junction (CCJ). Materials and Methodology: We retrospectively reviewed data of 36 patients with CCJ lesions who underwent surgical excision. Data are presented as frequency/percentages. Tumor locations were classified by anatomical relation around the CCJ (on axial plane). For anterior and laterally placed tumors, we preferred the FLA and its modification. A postoperative complication was defined as a new neurological deficit without subsequent recovery. The perioperative mortality was defined as death within 30 days of surgery. Results: The mean age of the study population was 48.8 years (5–64 years) with 15 women. Simpson's Scale Grade 2 resection was achieved in 18 out of 19 patients with meningiomas. Overall, transient complications were observed in eight patients (22%); none of the patients developed postoperative cerebrospinal fluid fistula. The permanent morbidity rate was 5.6%. One patient died on the 6^th postoperative day. The mean follow-up period was 4.1 years (range, 3 months–12 years). Tumor recurrence was observed in two patients who were advised radiotherapy. Twenty patients (96%) were independent for activities of daily living. Conclusion: The FLA is a versatile approach and is useful for a variety of lesions located ventrolateral to the brainstem and upper cervical cord. It allows adequate exposure with minimal retraction. Most of the foramen magnum meningiomas can be excised either without or with only partial resection of the condyle. The transjugular process approach to the jugular foramen (JF) is effective for JF tumors without the necessity of facial nerve transposition.

Background: Medial sphenoid wing meningiomas are medially located tumors on the sphenoid wing with attachment over the anterior clinoid process. They represent a distinct entity. These medial sphenoid wing meningiomas present a more difficult problem for the neurosurgeons because in a majority of cases, they involve the anterior visual pathways and arteries of the anterior circulation and may invade the cavernous sinus (CS). Higher morbidity, mortality and recurrence rates have been observed in these tumors compared with meningiomas in other locations. The rate of recurrence for medial sphenoid wing meningiomas is reported as being one of the highest amongst intracranial meningiomas. Material and Methods: The authors retrospectively analyzed 78 consecutive patients with the diagnosis of medial sphenoid wing meningioma who were operated in our department from January 2008 to December 2012. Results: These patients, having a meningioma of the medial sphenoid ridge, were divided into two types depending on the involvement of CS. Diplopia, internal carotid artery encasement, and postoperative visual deterioration were more common in Type 2 tumors. Similarly, extent of resection and postoperative morbidity were greater in Type 2 patients. Conclusions: CS invasion confers an added risk to the surgical morbidity and outcomes. However, with proper surgical techniques, optimum outcomes can be achieved and overall surgical results at our center are found to be comparable to that of the current literature.

Introduction: Giant vestibular schwannomas (VSs; ≥4 cm in size) are considered a separate entity owing to their surgical difficulty and increased morbidity. We studied the clinical presentation and surgical outcomes in a large series of giant VS patients. We also present the surgical nuances, which we believe can improve surgical outcomes. Materials and Methods: The clinical profiles, radiology, surgical results, and complications of 179 consecutive patients with a unilateral giant VS were reviewed. The study population was classified into two groups: Group A (4–4.9 cm, 124 [69.3%] patients) and Group B (≥5 cm, 55 [30.7%] patients). Results: The mean tumor size in Group A was 4.3 ± 0.2 cm (range, 4–4.8 cm), and in Group B, it was 5.3 ± 0.4 (range, 5–6.7 cm). Patients in Group B were younger, with a mean age at presentation of 34.8 ± 12.3 years versus 41.8 ± 13.1 years in Group A (P < 0.05). There was no difference in the clinical presentation except for papilledema (81.8% vs. 66.9%) and VI cranial nerve (CN) dysfunction (9.1% vs. 2.4%; P< 0.05), which was higher in Group B. There was no difference in the rate of total excision (86.2% vs. 85.4%), anatomical and physiological facial nerve preservation rates between the two groups (approximately 2/3 and 1/3, respectively), and the facial function at discharge. The incidence of postoperative morbidity was not statistically different between the two groups, except for the occurrence of postoperative cerebrospinal fluid (CSF) rhinorrhea, which was greater in Group B (10.9% vs. 2.4%). There were two mortalities in each group (overall, 4/179; 2.2%; P= 0.58). Conclusions: Patients with ≥5cm VSs were younger, with a higher incidence of papilledema and lateral rectus paresis. However, when compared with tumors ≥4 cm in size, there was no difference in the extent of excision, facial nerve preservation, and postoperative complications (except CSF rhinorrhea) or mortality. Thus, further subclassification of giant VSs does not seem to be necessary.

Approximately 20% of all patients requiring mechanical ventilation suffer from neurological dysfunction. It is imperative in the ventilatory management of such patients to have a thorough understanding of the disease pathology that may require institution of mechanical ventilation as well as in realizing its effects on the injured brain. These patients have unique challenges pertaining to the assessment and securing of the airway, maintenance of mechanical ventilation, as well as weaning and extubation readiness. This manuscript aims to present the current evidence in ventilatory management of the important subset of patients with neuronal injury. The indications for ventilatory management include both neurological and neurosurgical causes.

Background: Hospital-based cancer registries (HBCRs) provide information on the magnitude and distribution of cancers in a given hospital. Hospital-based brain tumor registry (HBBTR) data on primary intracranial tumors from a tertiary care neurological center is presented. This is compared with related national and international data. Materials and Methods: Data of patients operated for brain tumors at the National Institute of Mental Health and Neurosciences, Bangalore, India, between January 2010 and December 2014 was collected. Patients' clinical details and histopathological diagnosis were recorded. Data was analyzed and compared with that of Tata Memorial Hospital (TMH), Mumbai, and the Central Brain Tumor Registry of the United States (CBTRUS). Results: A total of 4295 primary intracranial tumors in 1847 (43%) females and 2448 (57%) male patients were recorded. Pediatric and adult patients accounted for 16.2% and 83.8% of the cases, respectively. The maximum proportion of tumors was noted in the fourth decade. Among children, astrocytomas (25.1%), embryonal (20.6%), and ependymal tumors (14.8%) were the most frequently reported histology. In adults, meningiomas (23.2%), glioblastomas (15.5%), and nerve sheath tumors (12.7%) were common. Glioblastomas and all other tumors showed a male predilection whereas meningiomas presented more commonly in females. While our HBBTR followed similar trends as TMH data, marked difference was seen in the median age of some tumor subtypes when compared to CBTRUS. Conclusion: This HBBTR data gives a glimpse of the prevalence of varied primary intracranial tumors. Such data can be linked to other HBCRs and population-based cancer registries in India for improved research and policy-making decisions.

Although the conventional hematoxylin and eosin (H and E) staining is vital for the histological diagnosis of lesions, the role of immunohistochemistry (IHC) is undeniable in surgical pathology. Morphology, which looks more or less similar on H and E staining, can be further differentiated by merely doing IHC. This, in turn, not only helps in rendering a definitive diagnosis but also helps in the selection of appropriate therapy for the individual patient. Thus, IHC has become an integral part of the armamentarium of neuropathology.

Bangur Institute of Neurosciences is one of India's oldest teaching institutions in the field of neurosciences. It has contributed richly over four decades in training and research in Neurology and Neurosurgery. Situated in Kolkata, the City of Joy and the Cultural Capital of India, and run under the aegis of the Government of West Bengal's Ministry of Health and Family Welfare, it remains one of the highest-volume neurological and neurosurgical centers in the country. This is a humble attempt to illustrate the history of this Institute and to provide a vignette of the many illustrious neurologists and neurosurgeons who were intimately involved in the setting up practice of Clinical Neurosciences in Eastern India.