There are close to one and half million women with epilepsy (WWE) in reproductive age group in India. WWE have several unique gender-specific problems in the biological and social domains. Women experience more social stigma from epilepsy and have more difficulty with education and employment. They have more difficulty to get married and sustain successful family life. Reproductive hormones like estrogen and progesterone have opposing effect on seizure threshold. WWE have increased risk of infertility. About 10% of their babies may have major congenital malformations. Most of the adverse biological outcomes for WWE are related to adverse effects of antiepileptic drugs (AEDs). Traditional AEDs like phenobarbitone and sodium valproate are probably associated with increased risk of fetal malformations or other adverse fetal outcomes. Polytherapy and use of high dose of any AED is associated with higher risk fetal complications. It is very important that all WWE have a preconception evaluation done by a neurologist, when the need to continue AEDs or possibility of reducing AED load could be assessed. All WWE need to take folic acid 5 mg daily during preconception period and pregnancy. They should undergo a detailed screening for fetal malformations between 12 and 18 weeks of pregnancy. The neurologist, gynecologist, imageologist and pediatrician need to work as a team while managing pregnancy in WWE. It is important to reassure WWE and their relatives that pregnancy is safe in WWE and their children are healthy in more than 90% instances.

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Lipomatous meningiomas are an uncommon subtype of meningiomas. In the present report, the clinical characteristics, neuroimaing and pathological features of 5 patients (4 males, 1 female; age range, 17-45 years; mean age, 35.2 years) with lipomatous meningioma were analyzed. The neuro-pathological reevaluation of lipomatous meningioma involved assessment of histological features proposed by the current WHO classification. The presence or absence of high whorls, fascicles, solid growth, glial invasion, necrosis and nuclear pleomorphism was assessed. The most common presenting symptom was seizures. Location of tumor was frontal (3 cases), parietal (1 case) and fronto-temporal (1 case). All cases showed radiological features of conventional meningioma. Complete excision of tumor along with involved dura was performed in all the patients. Three tumors were meningothelial and 2 were transitional. Tumoral lipid content was variable from 10% to 30%. In addition, there were microcystic features (2 cases) and psammoma bodies (1 case). No recurrence was noted in any of our cases till the last follow-up. Lipomatous meningioma represents a rare distinctive type of meningioma, with a good prognosis with complete removal.

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Spontaneous pneumorrhachis, non-traumatic, non-iatrogenic air within the spinal canal, is a very rare occurrence. We report a case of spontaneous pneumorrhachis, multiple air pockets in the epidural space, with vacuum discs and spndylolisthesis. Probably this is the first report of such case.

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Clinical symptoms and radiologic characteristics of gliomatosis cerebri (GC) are non-specific and the condition may be confused with other central nervous system diseases. We report three patients with GC; all the three patients had involvement of more than three lobes and the deep white matter, as well as bilateral involvement. Differentiation of GC from other neurologic diseases involving diffuse white matter may be difficult. However, the diagnosis can be based on the combination of radiologic and histopathologic features.

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Access to deep-seated brain lesions with traditional fixed and rigid brain retractors can be difficult without causing significant trauma to the surrounding brain. Tubular retractors offer an advantage of low retracting pressure. We developed a new inexpensive and simple tubular retractor which requires very small cortisectomy. The new tubular retractor was made up of silicone with inner diameter of 15, 18 and 23 mm and outer diameter of 17, 20 and 25 mm, respectively. This tube (1 mm thick) was cut in longitudinal direction. It was folded to make a small-diameter tube so that it could be introduced through a small cortisectomy. Margins of cortisectomy were gently and slowly retracted by Killian nasal speculum. Folded retractor, held by tissue forceps, was introduced inside the opened Killian nasal speculum. Tissue forceps and nasal speculum were removed leaving tubular retractor in place, which comes back to its normal tubular configuration after release. Surgery was performed using rigid Karl Storz 0° telescope (30 cm long and 4 mm in diameter) or microscope. Near-total removals of intracerebral hematomas, 37 hypertensive and 3 traumatic, was done using this retractor without any complication.

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Background : Thyroid antibodies (Thy-Abs) are frequently detected in various autoimmune disorders in coexistence with other systemic autoantibodies. In association with an encephalopathy, they are often taken as evidence of Hashimoto's encephalitis (HE). However, the presence of Thy-Abs in a cohort of limbic encephalitis (LE) patients and their association with anti-neuronal autoimmunity has not been explored. Patients and Methods : We investigated thyroid and anti-neuronal antibodies in the sera of 24 LE patients without identified tumors by cell-based assay and radioimmunoassay and evaluated their clinical features. Results : There was a female predominance in Thy-Ab-positive LE patients. Five of the eight Thy-Ab-positive patients and six of the 16 Thy-Ab-negative patients had antibodies to voltage-gated potassium channel (VGKC), N-methyl-D-aspartate receptor (NMDAR) or undefined surface antigens on cultured hippocampal neurons. There were trends towards fewer VGKC antibodies (1/8 vs. 5/16, P = 0.159) and more NMDAR antibodies (2/8 vs. 1/16, P = 0.095) among the Thy-Ab-positive LE patients; antibodies to undefined surface antigens were only identified in Thy-Ab-positive patients (2/8 vs. 0/16, P = 0.018). There were no distinguishing clinical features between Thy-Ab-positive patients with and without neuronal antibodies. However, patients with anti-neuronal antibodies showed a better treatment response. Conclusion : Thy-Abs can be found in a high proportion of patients with non-paraneoplastic LE, often in association with antibodies to specific or as yet undefined neuronal surface antigens. These results suggest that acute idiopathic encephalitis patients with Thy-Abs should be closely monitored for ion-channel antibodies and it should not be assumed that they have HE.

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Neurological manifestation of metronidazole toxicity include neuropathy and encephalopathy. We report a 67-year-old man with progressive painful paresthesias involving all the four limbs of 3 weeks' duration before admission. He had been treated with metronidazole and cephalosporin for 10 weeks for a hepatic abscess. Five weeks after the symptom onset, he complained of dysarthria and limb ataxia. Magnetic resonance imaging revealed signal abnormalities in the splenium of the corpus callosum and bilateral dentate nuclei. A few hours after brain imaging, the patient exhibited excessive diaphoresis and fluctuation in blood pressure, which resolved within several hours after discontinuation of metronidazole. Whereas his speech returned to near normal within approximately 1 week, a burning sensation was not completely relieved, even 6 months after discharge.

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The most frequent neurologic manifestations of hepatitis C virus infection include peripheral neuropathy axonal type and central nervous system (CNS) vasculitis. Affected patients usually have cryoglobulinemia and other signs of vasculitis. Demyelinating lesions, both central and peripheral are rarely described. We present a case of simultaneous peripheral nervous system and CNS demyelination that comes in relapsing episodes, with negative cryoglobulins.

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Of the intracranial epidermoids, interhemispheric epidermoids are extremely rare and only about 19 cases have been reported. This is a retrospective study of 15 patients with interhemispheric epidermoids surgically treated over a 13-year period. The age at the time of presentation varied between 17 and 45 years and there were 9 males. The presenting feature was seizures (focal with secondary generalization) in 12 patients, hemiparesis in 5 and features of raised intracranial pressure in 3. On computerized tomography scan the lesions were hypodense in the interhemispheric region. On magnetic resonance imaging, the lesions were located in the interhemispheric region with heterogenous signal intensities. Restricted diffusion was evident on diffusion-weighted images and apparent diffusion co-efficient images. All the lesions were predominantly located in the anterior interhemispheric region, with either basal or parietal extension along the interhemispheric fissure. Eleven patients underwent frontal or fronto-parietal craniotomies, 3 underwent bifrontal craniotomies and 1 patient underwent supra-orbital craniotomy and endoscopic procedure. Total excision could be achieved in 11 patients; near-total, in 3; and partial excision, in 1 patient. Follow-up was available in 10 patients. Three patients had recurrence of lesion at 5½, 8 and 10 years, respectively.

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Phenytoin can produce significant dose-related toxicity because of its zero order pharmacokinetics and is an important issue in pediatric emergency medicine. It is important to differentiate phenytoin toxicity manifesting with symptoms like fever, vomiting, seizures, ataxia masquerading as acute meningo-encephalitic illness, more so at centers where facilities to measure serum phenytoin levels are not available. Here we describe two children with phenytoin toxicity, presenting to the emergency department with features suggestive of acute meningo-encephalitis.

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Neurobrucellosis is a rare neurological complication of brucellosis. This report describes 19 patients of neurobrucellosis and they accounted for 8% of all cases of brucellosis admitted to Shiraz University Hospitals over a period of eight years. Headache, fever, fatigue, drowsiness and neck stiffness were the common clinical features. Cerebrospinal fluid (CSF) showed pleocytosis in 100%, elevated protein levels in 89% and low glucose level in 47% of the patients. All the patients improved with specific antibiotic treatment. Of the 19 patients, 10 (52.5%) patients received treatment for 8 to 28 weeks. Duration of antibiotic treatment was: 8-14 weeks in 8 (42%) patients; 24-28 weeks in 2 (10.5%) patients; 6 months in 7 (37%) patients; 12 months in 1 (5.3%) patient; and 18 months in 1 (5.3%) patient. Clinicians in endemic areas should consider the likelihood of neurobrucellosis in patients with unexplained neurological and psychiatric symptoms.

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An adverse drug reaction (ADR) is defined by the World Health Organization as a noxious, unintended, and undesired drug effect, when used for therapeutic purposes in humans. ADRs to anti-epileptic drugs (AEDs) significantly impact the quality of life of people with epilepsy and account for a little less than half of all recorded treatment failures with AEDs. Hence prevention and early recognition of ADRs constitute an important aspect of management of epilepsy. Recent developments have improved our ability to predict and hence potentially prevent the occurrence of some of the serious ADRs to AEDs. One example is the potential prediction of the risk of severe cutaneous hypersensitivity reactions including Stevens Johnson syndrome and toxic epidermal necrolysis by testing for expression of HLA B*1502 allele in people of Asian origin who are prescribed carbamazepine. The association between HLA B*1502 expression and carbamazepine skin reactions has been documented in India but the role of HLA testing in Indian populations needs to be clarified in larger studies across different ethnic groups within the country.

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Background : Community-based studies of epilepsy in India have reported variable prevalence rates, 5−10/1000 population. Reasons for this wide variation in the prevalence rates are uncertain. Most of the earlier studies had not done appropriate investigations to establish the possible etiology. Aim : To study the prevalence and etiological profile of active epilepsy in the rural population of Uttarakhand. Material and Methods : In this rural community-based study in the state of Uttarakhand, a door-to-door survey was conducted using validated questionnaire. All the suspected cases of epilepsy were examined by a neurologist to confirm the diagnosis of epilepsy and all the confirmed cases underwent contrast computed tomography (CT) scan and electroencephalography (EEG). Epilepsy and epilepsy syndromes were classified using the classifications proposed by the International League Against Epilepsy. Results : Of the 14,086 population studied, 141 cases of active epilepsy were detected giving a crude prevalence rate of 1%. After clinical evaluation and scanning, 35 (24.8%) were found to have seizure disorder active neurocysticercosis (NCC) and 14 (9.9%) had remote symptomatic seizures related to calcified granuloma. After excluding acute and remote symptomatic cases related to NCC, prevalence rate of epilepsy was 6.5/1000. Conclusion : The study suggests that the region-specific prevalence rates of epilepsy in India are partly dependent on the prevalence of NCC in the given community. To some extent, this may be responsible for variable rates of epilepsy prevalence reported from different regions of the country.

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Background : Aneurysms of the posterior cerebral artery (PCA) are a distinct rarity and present with some peculiar morphologic features and specific clinical findings. These aneurysms can be managed endovascularly with good results. Objective : To evaluate the clinical features and endovascular management of PCA aneurysms. Material and Methods : Between 2000 and 2008, we treated 24 patients (14 male and 10 female; mean age: 36 years) with PCA aneurysms. Clinical presentations, radiologic images, and endovascular management were reviewed. Results : There were 11 saccular aneurysms, including 4 giant or large aneurysms, and 13 dissecting aneurysms, including 11 giant or large aneurysms. Of the 24 patients, 13 presented with hemorrhage and 6 with neurologic deficits. Five patients presented with headaches without any neurologic deficits. Parent vessel occlusion was performed in 12 patients, selective coil embolization was performed in 11 patients, and 1 patient conservatively. Eighteen patients had a good recovery, 5 had a moderate disability (one with 1 visual deficit after the treatment) related to hemorrhage, vasospasm, or infarction before aneurysm trapping, and 1 patient died because of rebleeding. The conservatively treated patient made a good recovery. Conclusion : PCA aneurysms have specific clinical characteristics compared with aneurysms located elsewhere. Endovascular technique can achieve good outcomes despite the aneurysmal site and size.

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Background : Controlled studies on the effect of alcohol-based hand rub before and after each patient contact on surgical site infection (SSI) among neurosurgical patients are scarce. Aim : To evaluate the effect of alcohol-based hand rub before and after each patient contact on SSI after elective neurosurgical procedures. Setting and Design : Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala. An intervention study using a 'before-after' design. Material and Methods : Two 9-month study periods were compared; between these periods, an infection-control protocol incorporating an alcohol-based hand rub was implemented for a period of 3 months and continued thereafter. Consecutive patients who underwent neurosurgery between January and September 2006 (control group, before protocol) and between January and September 2007 (intervention group, after protocol) were included. Outcome measures included SSI rates, profile of microorganisms and patient survival. Statistical Analysis : SPSS statistics version 17.0. Results : A total of 1,899 operated cases were reviewed. The patients in the control and intervention groups were similar with regard to sex, age and type of neurosurgery. The surgical site infection rates were 22 (2.3%) out of 974 in the control group and 14 (1.5%) out of 925 in the intervention group (P = 0.2). Patient survival rates were 97.6% (control) and 98.3% (intervention). Post hoc power calculation for an alpha value equal to 0.05, the power obtained was 24.9%, showing inadequacy of sample size to get significant results. To achieve 80% power, the sample size required is about 4,800 each for the control and intervention groups. Conclusion : Use of alcohol-based hand rub before and after each patient contact in the neurosurgical intensive care unit did not show a significant reduction in SSI in the present study. This lack of difference between the two groups may be related to the inadequate sample size. The other possibility is that both the strategies are of equal efficacy for prevention of SSIs.

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Objective : To assess outcome of epilepsy surgery in children with medically refractory partial epilepsy evaluated with non-invasive protocol and to determine the predictors of outcome. Patients and Methods : Retrospective analysis of presurgical, surgical, and postsurgical data was performed in 87 children who had at least 1 year post surgery follow-up. Outcome was assessed according to Engel's outcome classification. Stepwise regression followed by logistic regression analysis was employed in data analysis. Results : Mean follow-up was 32 (12-58) months and 44 (50.6%) were males. The age of onset of epilepsy was below the age of 2 years in 24 (30.8%). Resective surgery was done in 78 children. The commonest surgery performed was a temporal resection (88.9%) in adolescents and an extra-temporal resection ( 60.6%) in children. The commonest pathology was hippocampal sclerosis (HS) in adolescents and developmental, tumoral lesions, and gliosis in children. At last follow-up, 50 (64.1%) were seizure free and Engel's favourable outcome was noted in 59 (75.6%). After stepwise regression analysis, variables found to be significant (P < 0.05) and predicting a favourable outcome were lesion on MRI, normal IQ, and partial seizures without secondary generalization. Bilateral spikes on interictal EEG and acute postoperative seizures were predictors of poor outcome. A regression model was developed; the sensitivity, specificity, accuracy, and area under ROC curve were 82%, 91%, 88.5%, and 0.97%, respectively. Conclusion : Favourable outcome after epilepsy surgery can be obtained in children with temporal lobe epilepsy with HS and lesion-related epilepsies in developing countries with limited resources, after evaluation with a non-invasive protocol.

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The authors developed a simple reproducible technique for aneurysm creation and adapted it to mimic intracranial dissection conditions using glue application as a pseudo-arachnoid type layer. Ten 1-2-month-old healthy domestic swine were employed under general anesthesia. A novel technique for bifurcation aneurysm creation was developed using two arteries and a vein. After aneurysm creation, diluted sulfuric acid was applied on the dome with a micropipette to increase aneurysm fragility in selected zones. The surgical field was then dried and contact glue was applied around the vascular complex in a circular manner so as to emulate arachnoidal connection fibers. Microsurgical dissection of the aneurysm and surrounding vessels was performed by delicately removing the adhesive substance. Diverse aneurysm clipping techniques, emergency rupture situations and vascular reconstruction procedures were trained. Twenty-two aneurysms were created at several vascular sites, one aneurysm dome ruptured during application of sulfuric acid, two aneurysm models were proved to be thrombosed, two aneurysms ruptured during the dissection and no intraoperative deaths occurred. All aneurysms were clipped in an acceptable manner. This bifurcation aneurysm model provides a novel training system to be used not only by neurosurgeons but also by neurovascular interventionists.

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Telangiectatic osteosarcoma (TOS), an uncommon variant of osteosarcoma, involving skull bones is extremely rare. We present clinico-pathological, imageological and treatment outcome of a primary TOS of occipital bone in a 30-year-old woman and review the previously reported skull bone TOS. We suggest that TOS should be included in the differential diagnosis of destructive lytic lesions involving the skull bones. As radical surgical procedures are not applicable to skull bones, the outcome is poor even with adjuvant chemotherapy.

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Background : Neuroanesthesiologists are a highly biased group; so far the use of nitrous oxide in their patient population is concerned. We hypothesized that any adverse consequence with use of nitrous oxide should affect the patient so as to prolong his/her stay in the hospital. The primary aim of this preliminary trial was to evaluate if avoidance of nitrous oxide could decrease the duration of Intensive Care Unit (ICU) and hospital stay after elective surgery for supratentorial tumors. Patients and Methods : A total of 116 consecutive patients posted for elective craniotomy for various supratentorial tumors were enrolled between April 2008 and November 2009. Patients were randomly divided into Group I: Nitrous oxide - Isoflurane anesthesia (Nitrous oxide-based group) and Group II - Isoflurane anesthesia (Nitrous oxide-free group). Standard anesthesia protocol was followed for all the patients. Patients were assessed till discharge from hospital. Results : The median duration of ICU stay in the nitrous group and the nitrous-free group was 1 (1 - 11 days) day and 1 (1 - 3 days) day respectively (P = 0.67), whereas the mean duration of hospital stay in the nitrous group was 4 (2 - 16) days and the nitrous free group was 3 (2 - 9) days (P = 0.06). The postoperative complications in the two groups were comparable. Conclusion : From this preliminary study with a low statistical power, it appears that avoidance of nitrous oxide in one's practice may not affect the outcome in the neurosurgical patients. Further large systemic trials are needed to address this issue.

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Background : Primary spontaneous intracerebral hemorrhage (PSICH) is common in Asia and may have a genetic basis. Objective : To report the role of angiotensin-converting enzyme (ACE) and a ADDUCIN (ADD1) gene polymorphisms in patients with PSICH. Setting : Tertiary care teaching referral hospital. Patients and Methods : Study subjects included 104 patients with PSICH diagnosed by computed tomography (CT) brain scan and 198 controls. The vascular risk factors of stroke were noted. The location and size of the hematoma on CT scan were recorded. ACE (rs4646994) and a ADDUCIN (rs4961) gene polymorphisms were analyzed by polymerase chain reaction (PCR). The genotype and allele frequency were compared between patients and controls and within the PSICH group. Results : The median age of the PSICH group was 58 years, 17 (16.3%) patients were aged above 70 years and 40 (38%) were females. Ninety-three (91.2%) patients were hypertensive and 17 (16.5%) were diabetic. Hematoma was putaminal in 88 (84.5%), pontine in 5 (4.9%), cerebellar in 2 (1.9%), lobar in seven (6.8%) and multiple and primary intraventricular in one (1%) patient each. In the patients with PSICH, ACE DD genotype was present in 44 (42.8%) and ID in 40 (38.4%) whereas in controls these were 22 (11.1%) and 103 (52%) respectively. ADD1- WW genotype was found in two patients (1.9%), and GW in 44 patients (42.7%). In the controls these were found in nine (4.5%) and 65 (32.8%) respectively. DD genotype had 7.4 times higher risk of PSICH. ADD1 variant genotypes were not associated with increased risk but in association with ACE DD genotype resulted in significantly higher risk of PSICH. ACE and ADD1 variant genotypes were associated with nonlobar hematoma. Conclusion : ACE DD genotype in isolation or in combination with ADD1 GW genotype is associated with PSICH, especially nonlobar hematoma.

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Background : There are no studies quantifying the nature of autonomic changes in absence epilepsy. Aims : We characterized the heart rate variability (HRV) during pre-interictal epileptiform discharges (IED), IED and post-IED states in absence epilepsy. Material and Methods : Electroencephalogram (EEG) records with generalized 3-Hz spike-wave discharges in 8 patients (M: F: 3 : 5; mean age: 13.0 ± 2.5 years) with absence epilepsy were identified and corresponding electrocardiogram (ECG) time series were obtained. The time domain HRV measures were applied to pre-IED, IED and post-IED simultaneous ECG tracing. Results : There was slight tachycardia during the IED phase (pre-IED: 90.15 ± 3.45 bpm, IED: 94.82 ± 4.63 bpm, P = 0.09) which returned to baseline during the post-IED phase (post-IED: 89.65 ± 3.78 bpm). There was significant decrease in the standard deviation of RR interval (pre-IED: 40.0 ± 4.15 ms, IED: 30.4 ± 4.19 ms, P = 0.032) and trend in reduction of triangular index (pre-IED: 0.05 ± 0.01, IED: 0.04 ± 0.004, P = 0.08) during the IED phase when compared to pre-IED phase. The percentage of RR intervals >50 ms was lower during the IED phase and achieved significance when compared to post-IED phase (IED: 10.08 ± 4.89, post-IED: 18.74 ± 6.17, P = 0.050). While mean HR and RR interval significantly correlated with the duration of IEDs, there was no significant correlation between its duration with change in HRV parameters between the groups. There was no significant difference in HRV parameters between patients with long (>10s) and short (<10s) duration of IED. Conclusions : Transient increase in heart rate during IED phase was noted in patients with absence epilepsy. Longer duration of IED seems to be linked with significant tachycardia. While most HRV parameters did not reach statistical significance, standard deviation of RR intervals and triangular index was noted to be decreased during the IED phase and returns to pre-IED levels after the episode.

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Neuroimaging findings in 1,2-dichloroethane (1,2-DCE) encephalopathy have seldom been reported. We present the comprehensive neuroimaging findings, conventional magnetic resonance imaging (MRI) combined with diffusion tensor imaging (DTI) and ¹ H-magnetic resonance spectroscopy ( ¹ H-MRS), in a case of 1,2-DCE encephalopathy. On day-4 the signal intensity of the lesions on diffusion-weighted imaging (DWI) was higher than that with T2-weighted imaging (T2WI); mean apparent diffusion coefficient (ADC) values for lesions were lower than control values. On day-20, the mean ADC value was increased gradually, whereas the mean fractional anisotropy (FA) of the lesions was significantly reduced. ¹ H-MRS showed reduced ratios of N-acetyl aspartate to creatinine (NAA/Cr) and NAA to choline (NAA/Cho) on day-20 as compared with the control values. Combining conventional MRI with DTI and MRS is valuable in the early diagnosis and prognosis of 1,2-DCE-induced encephalopathy.

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Transvenous embolization has become the treatment of choice for such lesions We evaluated Onxy for patients with cavernous dural arteriovenous fistulae (CDAVFs) who underwent transvenous embolization via different transvenous approaches. Case records of six patients with symptomatic CDAVFs, treated between October 2006 and November 2007 were reviewed. A total of seven transvenous procedures were performed in the six patients with CDAVFs. All the patients with CDAVFs of the cavernous sinus were symptom free following embolization. The approach via the internal jugular vein and the inferior petrosal sinus was possible in four of the six patients, with complete occlusion of the fistula. In the remaining two patients, the approach was via the facial vein. Transient bradyarrythmia without morbidity was the only complication in two patients.

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We report our preliminary clinical experience with microscope-integrated intraoperative indocyanine green (ICG) videoangiography in the treatment of arteriovenous malformations (AVMs). Nine patients underwent surgical procedures for AVMs. All patients had preoperative and early postoperative digital subtraction angiography (DSA). In all the procedures, ICG was injected intravenously during AVM occlusion and the removal of the nidus were directly analized into the microscope-integrated video, and they were compared with early postoperative angiography images. A total of 16 intraoperative ICG angiographies were performed. In all the patients the image quality was excellent, allowing intraoperative real-time evaluation of the completeness of the removal of the nidus. ICG videoangiography is easily performed during surgery for AVM and can confirm the completeness of the removal and may detect residual nidus, thus improving outcomes.

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A 42-year-old immunocompetent man presented with subacute onset unilateral headache and associated lower cranial nerve palsies. Cranial magnetic resonance imaging showed enhancing thickened tentorium cerebelli and subtentorial dura mater. Cerebrospinal fluid examination revealed lymphocytic pleocytosis and positive polymerase chain reaction assay of Aspergillus DNA. While on voriconazole treatment a progressive increase was noted in subtentorial pachymeningeal hypertrophy, which was excised because of critical compression of the medulla. The excision material showed extensive fibrosis, cellular infiltrates and no organisms. With combination therapy with anti-fungal agents and corticosteroids, pachymeningitis showed regression. We hypothesised that intact immune status and less burden of Aspergillus infection in this patient may have resulted in a chronic progressive hypertrophic pachymeningitis.

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