Background: The use of minimally invasive endoscopic surgery is fast emerging in many subspecialties of neurosurgery as an effective alternative to the open procedures. Objective: The author describe a novel technique of using an endoscope for performing a corpus callosotomy and hemispherotomy. A description of endoscopic disconnection for a hypothalamic hamartoma (HH) and a review of the literature is also presented. Materials and Methods: Thirty four patients underwent endoscopic procedures between January 2010 and March 2015. These included endoscopic-assisted inter-hemispheric trans-callosal hemispherotomy (EH; n = 11), endoscopic-assisted corpus callosotomy with anterior/posterior commissurotomy (CCWC; n = 16), and endoscopic disconnection for HH (n = 7). EH and CCWC were performed with the use of a small craniotomy (4 cm × 3 cm). The surgeries were performed using a rigid high-definition endoscope, bayonetted self-irrigating bipolar forceps, and other standard endoscopic instruments along with the guidance of intra-operative magnetic resonance imaging and neuronavigation. HH disconnection was performed using endoscopic neuronavigation through a burr hole. Results: Hemispherotomy: Sequelae of middle cerebral artery infarct (5), Rasmussen's syndrome (3), and hemimegalencephaly (3). Outcome: Class I Engel (9) and class II (2), mean follow-up of 8.4 months, range: 3-18 months. Mean blood loss: 85 cc, mean operating time: 210 min. CCWC: All had a diagnosis of Lennox-Gastaut syndrome (LGS), with etiologies of hypoxic insult (10), lissencephaly (2), bilateral band heterotropia (2), microgyria and pachygyria (2). Mean follow-up: 18 ± 4.7 (16-27 months). Drop attacks stopped in all the patients. Seizure frequency and duration decreased >90% (11) and >50% (5). HH: Type II (2), Type III (2), Type IV (3). 5 had IA outcome. Conclusion: The article emphasizes the role of endoscopic procedures for epilepsy surgery and provides a review of literature. This experience may subserve to coin the term "endoscopic epilepsy surgery" for a fast emerging subspeciality in the field of epilepsy surgery.

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Dengue is associated with many neurological dysfunctions. Up to 4% of dengue patients may develop neuromuscular complications. Muscle involvement can manifest with myalgias, myositis, rhabdomyolysis and hypokalemic paralysis. Diffuse myalgia is the most characteristic neurological symptom of dengue fever. Dengue-associated myositis can be of varying severity ranging from self-limiting muscle involvement to severe dengue myositis. Dengue-associated hypokalemic paralysis often has a rapidly evolving course; benign nature; excellent response to potassium; and, often leads to diagnostic confusion with other dengue-associated neuromuscular disorders. Rhabdomyolysis is the most severe form of muscle involvement and may be life-threatening. Guillain-Barrι syndrome is another frequent neuromuscular dengue-associated complication. Dengue-associated Guillain-Barrι syndrome responds very well to intravenous immunoglobulins. Predominant spinal gray matter involvement has been reported in a patient presenting with areflexic paraparesis. Mononeuropathies often manifest with paralysis of the diaphragm due to phrenic nerve dysfunction. Brachial plexopathy, in the form of neuralgic amyotrophy, has been described much more frequently than lumbo-sacral plexopathy. Early recognition of these neuromuscular complications is needed for successful treatment and to prevent further disabilities.

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Background: Nutritional status and adiposity have not been studied to a significant extent in subarachnoid hemorrhage (SAH). The aim of this study was to determine the trends in anthropometric indices and assess their impact on patients with SAH. Methods: We prospectively studied in 56 patients with SAH, the triceps skinfold thickness (TSF), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), and other factors, and their relationship to clinical vasospasm and mortality. Results: The median MAC decreased significantly from 29.3 cm (interquartile range [IQR] 28-31 cm) at admission to 27 cm (IQR 26-29 cm) at 1-week (P < 0.001). The median TSF decreased significantly from 34 mm (IQR 30-40 mm) at admission to 30 mm (IQR 25-35 mm) at 1-week (P < 0.001). MAMC values did not show a significant change over a week. The patients who developed clinical vasospasm had significantly higher median admission TSF of 40 mm (IQR 35-45 mm), compared to the median admission TSF of 35 mm (IQR 30-40 mm) among those who did not develop vasospasm (P = 0.03). MAMC values did not differ significantly in relation to vasospasm. Patients who expired by 3 months had significantly greater fall in median MAMC values at 1-week (7.7% [IQR 5.2-11.5%]), compared to the fall in median MAMC values at 1-week among those who were alive at 3 months (2.6% [IQR 2.1-6.6%]) [P = 0.03]. However, the fall in TSF values did not differ significantly in relation to mortality. In multivariate analysis, only the admission TSF, Hunt and Hess and Fisher grades had a significant association with vasospasm. This association was independent of other prognostic factors and of each other. Conclusion: Excessive adiposity of patients, measured as an increased TSF value, is significantly associated with clinical vasospasm independent of other prognostic factors, while fall in MAMC, indicating somatic protein catabolism, has some impact on mortality.

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Objective: In this prospective study conducted over 2 years, 300 nonconsecutive cases of autosomal recessive limb girdle muscular dystrophies (AR-LGMD) were characterized, based on phenotypic features, biochemical findings, electrophysiological studies, muscle immunohistochemistry (IHC), and western blot (WB) analysis. Methods: Muscle biopsy was performed in 280 index cases. 226 biopsies were subjected for IHC, and, 176 of these for WB analysis. Results: A total of 246 patients were finally analyzed. This figure included 20 affected siblings. LGMD2B was the most common form and comprised of 33.3% (n = 82) of the entire cohort. This was followed by alpha-dystroglycanopathies with 61 (24.79%) patients (LGMD2I in 15, 2K in 10 and combined deficiency of both in the remaining). LGMD 2C-F was present in 35 (14.23%) cases and LGMD2A in 22 (10.2%) cases, and were identified by routine WB, densitometry method and autocatalytic assay. LGMD2G was present in 8 patients (3.25%), and LGMD2H and 2J in 2 cases each, respectively. Conclusions: For the first time, we have identified patients with LGMD2G, 2H, 2I, and 2K by the WB technique. These may be the common forms of autosomal recessive (AR)-LGMD's among Indian patients and need identification for prognostication and appropriate counseling. Although not a nationwide study, our data is sufficient to provide information about the relative proportions of various LGMD2 subtypes in India. Diagnosing LGMD2 based on classical clinical features, IHC and WB is fairly sensitive and specific; however, further genetic studies are required to confirm the diagnosis.

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We report a case where intraventricular migration of silicone oil occurred into the third ventricle, mimicking the presence of a colloid cyst. To the best of our knowledge, this is the first case reported where intraventricular silicone oil (SiO) presented at the foramen of Monro, resembling the radiological appearance of a colloid cyst. The systemic dissemination of silicone oil is a very rare complication of intravitreal SiO administration that is used for providing a mechanical tamponade that maintains the retinal attachment following repair of a retinal detachment. The imaging findings that are characteristic of the presence of intraventricular silicone oil are its usual dissemination in a nondependent location and the accompaniment of changes in its location based on changes in the patient's position.

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The department of neurosurgery at All India Institute of Medical Sciences (AIIMS) started its humble beginning in 1965. With the untiring and selfless hard work of Prof. P N Tandon and Prof. A K Banerji, the department progressed over time to become a center of excellence in the subcontinent. To establish a neurosciences center at AIIMS was an uphill task, which was accomplished with great efforts. The department has established itself as one of the highest centers of learning in the country with its vast infrastructure and diversity in all fields of neurosurgery. AIIMS, New Delhi was established by an act of the parliament in 1956. It was started with a grant from the Government of New Zealand under the "Colombo Plan." It was the vision of Rajkumari Amrita Kaur, the first Health Minister of India, that led to the establishment of a medical institute of international repute in India. AIIMS, New Delhi is an autonomous institute and is governed by the AIIMS Act, 1956. The department of neurosurgery at AIIMS was started in March 1965 with Prof. P.N. Tandon as the Head of the Department. Prof. A.K. Banerji joined him a few months later. The Department celebrated its golden jubilee in the year 2015, and has tremendously grown in stature from its humble beginnings to being a center of excellence with world-wide recognition.

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Papillary tumor of the pineal region (PTPR) is a rare tumor of the pineal region. Not much is known about the pathogenesis, prognosis, and treatment protocol of this uncommon entity. We present three cases of PTPR with follow-up from 8 months to 98 months. All patients presented with headache and visual disturbance. One patient also had amenorrhea. Radiology revealed an heterogeneously enhancing mass arising from the pineal region with associated hydrocephalus. Histopathologically, all cases showed the papillary architecture, strong pan cytokeratin and cytokeratin 18 positivity, and faint positivity for synaptophysin and neuron-specific enolase. All cases received postoperative radiotherapy. One case showed tumor recurrence after 7 years. Other two cases did not show any recurrence till the last follow-up.

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Background: Strokes caused by normal variants of the cerebral circulation can be difficult to diagnose, hence a high index of suspicion is needed. This case series discusses the clinical and radiological aspects of one such stroke caused by occlusion of the artery of Percheron (AOP). Materials and Methods: Computerized discharge summaries, outpatient records and imaging from picture archiving and communication system (PACS, GE), of patients with AOP infarction over a period of 12-years (2002-2014) were identified and their clinical and radiological features analyzed. Results: Of 3589 strokes (both ischemic and hemorrhagic), 17 (0.47%) were due to AOP infarction. Their mean age was 50 years (range: 31-72 years). Disorders of consciousness (94%) were the most common presenting symptoms followed by gaze (53%) and memory impairment (24%). At follow-up, 2/17 (12%) patients developed extrapyramidal features. All patients had bilateral paramedian thalamic infarcts on magnetic resonance imaging (MRI). Associated anterior thalamic (5/17; 30%) and mid brain (10/17; 59%) infarcts were also seen. CT scan done in 11/17 patients prior to the MRI picked up only 6/11 (55%) of these infarcts. The most common etiological factors detected using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria were cardio embolic (8/17; 47%) followed by small vessel occlusion (7/17; 41%). Mortality occurred in 2/17 (12%) patients. At 6 months, a modified Rankin score of 2 or less was seen in 8/17 (47%) patients. Conclusions: Artery of Percheron infarcts should be considered in the differential diagnosis of patients presenting with sudden alterations in consciousness. MRI should be the investigation of choice. An embolic etiology should be actively looked for.

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Background: This study was undertaken to find out if metabolic syndrome (MetS) in the elderly was associated with cognitive decline and also if this association was modified by the presence of inflammation. Materials and Methods: 100 patients more than 60 years of age were divided into 2 groups of 50 each and were age and sex matched. Group 1 and 2 had patients with and without MetS, respectively. The individual components of MetS were measured in each patient. Cognitive decline was measured by Modified Mini-Mental Score (3MS) of Teng. Inflammation was measured by high-sensitivity C-reactive protein (hs-CRP). Results: Fasting hyperglycemia was the most common component of MetS (60% of group 1). The mean serum hs-CRP in patients of group 1 was 6.56 ± 9.72 while that in the patients of group 2 was 1.95 ± 1.93. In the group-1, 36% (n = 18) patients were having a decreased 3MS, whereas in group-2, 22% (n = 11) were having a decreased 3MS. MetS was associated with an odd's ratio of 1.99 for developing cognitive decline. 3MS had a negative correlation with hs-CRP values. Regression analysis showed a significant association of hs-CRP and MetS with cognitive decline in the elderly population. Conclusion: Cognitive decline in the elderly is associated with the presence of inflammation and MetS. Hence, early identification of the high-risk groups may offer benefit by disease course modification and better caregiving.

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Neurosurgeons are often identified with traits such as arrogance and hubris. However, the true legacy of neurosurgeons is excellence. Harvey Cushing, the pioneering neurosurgeon of the United States, is largely responsible for this legacy of excellence. Eminent personalities have agreed that sincere and hard work is necessary to achieve excellence. Excellence in neurosurgery in the domains of surgical work and research will be discussed in the article. Excellence in surgical work should be measured comprehensively and over long follow-up periods using tools such as functional outcomes and quality of life instruments besides morbidity and mortality. For excellence in neurosurgical research, one can use the help of indices such as the h-index and i10 index. No single measure, whether for surgical excellence or excellence in research, however, incorporates a measure of qualities such as empathy, integrity and mentorship. These intangible qualities should be an integral part of the assessment of a neurosurgeon and his/her work. Cushing's attributes of meticulous record keeping, attention to detail, and maximal utilization of opportunities should guide us in our pursuit of excellence. In recent years, it has been suggested that excellence is not the result of an innate talent but can be aspired to by anyone willing to adopt a work ethic that involves several hours of "deliberate practice," feedback and passion. Neurosurgeons should continue to pursue the legacy of Cushing especially in present times when medical professionals are frequently depicted as being driven more by avarice than by Hippocratic principles.

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Alzheimer's disease (AD) is characterized by beta-amyloid plaques and neurofibrillary tangles that cause devastating cognitive and memory deficits. AD is known to be associated with neuronal death and synaptic loss. Thus, methods to retard the progression of the disease and to promote neuro-regeneration are vital for the prevention of advancement of AD. The recent trend is to decipher the molecular mechanisms of AD, and further aim at neuro-restorative mechanisms such as neuro-protection, neuro-modulation, and neuro-regeneration. In this review, we provide an overview of the recent studies describing various neuro-restorative strategies for AD and mainly focus on stem cell and neuro-modulation therapies. Furthermore, we briefly refer to the other neurorestorative treatments including medications, bioengineering, and gene therapies for AD. Although most of them remain in an experimental phase, neuro-restorative strategies may have the potential for clinical use in the management of this debilitative disease.

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Objective: There is significant variability in the biologic behavior of meningiomas, especially of atypical and anaplastic meningiomas, that cannot be accounted for by just histology and grade of excision. The aim of our study was to analyze deletions in regions 22q, 18p11, 1p32, and 14q32 in grade II and grade III meningiomas and their correlation with tumor grade and recurrence. Materials and Methods: A total of 59 samples from 50 cases of grade II and grade III meningiomas were analyzed with fluorescence in situ hybridization (FISH) technique with locus specific probes. The types of aberrations and deletions were analyzed and correlated with the tumor status. Results: There was a statistically significant increase in deletions in recurrences when compared to primary surgeries. The mean mitotic index was higher in patients with deletions. Patients with 18p deletions tended to be younger and had a significant association with sheeting. 22q deletions were associated with hypercellular tumors. 1p, 14q, and 1p14q codeletion had a significant association with mitosis ≥7. Conclusion: This is a first study from India analyzing all these four sites for deletions using the FISH technique. Recurrent tumors and tumors with tendency to recur have a higher frequency of deletions. The FISH study can be used to predict the behavior of meningiomas if significant association is found. Further studies in larger sets of patients along with their clinical correlation would help in categorizing patients who have a higher risk of recurrence and help in guiding their clinical management.

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A rare case of simultaneous occurrence of myasthenia gravis and situs inversus totalis is reported. The implications of the presence of these two entities on management are discussed

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Objective: To investigate the feasibility of tissue similarity map (TSM)-based relative cerebral blood volume (rCBV) assessment in evaluating the hemodynamic characteristics of gliomas and in differentiating high-grade gliomas from low-grade ones without concentration time curve (CTC). Materials and Methods: TSM-based rCBV (rCBV _TSM ) and conventional rCBV (rCBV _PWI ) maps were generated (n = 35). The differences in percentage and concordance correlation coefficient (CCC) of the rCBV _TSM and rCBV _PWI ratios were calculated. The Mann-Whitney test and the receiver operating characteristic (ROC) curve analysis were also performed to examine the relationships of rCBV ratios between high- and low-grade gliomas. The improvement factors of signal to noise ratio (SNR) of rCBV _TSM maps were also calculated. Results: The mean difference in percentage between rCBV _TSM and rCBV _PWI ratios was 4.29 ± 2.62%. The CCC of rCBV _TSM and rCBV _PWI ratios was 0.9974, with 95% confidence interval of 0.9948, 0.9987, which implied a high agreement between them. The Mann-Whitney test suggested that the rCBV _TSM and rCBV _PWI ratios of high-grade gliomas were significantly different from those of low-grade gliomas (P < 0.001). The improvement factors of SNR of the rCBV _TSM map were 1.31 ± 0.24 for glioma and 1.28 ± 0.24 for normal white matter. Conclusion: It is feasible to use rCBV _TSM in the evaluation of hemodynamic characteristics of gliomas and differentiation of high- and low-grade gliomas without CTC. Moreover, rCBV _TSM maps possess a higher SNR, which allows potentially more accurate diagnosis compared with the conventional ones.

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