Valsalva maneuver is associated with diverse physiological changes. These changes are used in various diagnostic and therapeutic clinical settings. Valsalva maneuver is also employed during various phases of neurosurgical procedures to achieve specific targets and confirm intraoperative findings. In this article, we attempt to describe the various clinical applications of the Valsalva maneuver within the realms of clinical neurosurgery. The associated complications of this act have also been discussed.

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Tropical ataxic neuropathy, which is prevalent in the tropics causes significant disability as well as increased mortality and remains an enigmatic disease with no effective treatment or cure, even a century after its identification. The syndrome, first described in Jamaica in 1897 and christened as tropical ataxic neuropathy in 1959, is a constellation of bilateral optic atrophy, bilateral sensory neural deafness, predominant posterior column involvement and pyramidal tract myelopathy, with ataxic polyneuropathy. The exact etiopathogenesis remains unresolved, and several factors have been proposed including malnutrition, vitamin B deficiencies, malabsorption, poor protein consumption, chronic cyanide, and nitrile toxicity, with a strong geospatial endemic prevalence in areas of cassava cultivation. In this review, we summarize the history, epidemiology, clinical features, and controversies regarding the pathogenesis and differential diagnosis of the disease and identify the potential areas for further research concerning this debilitating disorder that is common in the tropics. Its multifactorial etiopathogenesis provides potential opportunities for research and international collaboration to identify novel avenues for treatment.

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The services of clinical psychology (neuro) were established in 1969 under the tutelage of Dr. Surya Gupta. The unit has now established itself as a core group in the Neurosciences Centre, providing services to various other departments. The research and clinical services in Clinical Neuropsychology have substantially expanded since 2005. Research initiatives are underway toward better and more sophisticated systems of assessment and neuropsychological rehabilitation, aimed at facilitating patient care and in providing value-added services for the patients and their families.

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Background: Craniovertebral junction (CVJ) abnormalities, such as atlantoaxial dislocation (AAD) with or without basilar invagination (BI), with or without associated Chiari malformation (CM), may cause a high cervical myelopathy. Occasionally, mechanical factors such as inadequate canal decompression, torticollis, and/or scoliosis may lead to lack of improvement following the primary surgery. Furthermore, implant-related factors, requiring implant revision/removal, or the presence of surgical site infections may cause the patient to undergo resurgery. Aims: This study was aimed at highlighting the underlying etiopathogenesis of resurgery following the primary surgery undertaken in CVJ abnormalities. Setting and Design: This was a retrospective study from a tertiary care referral institute focusing on 414 operated cases of CVJ anomalies. Materials and Methods: The data of 55 patients who underwent resurgery included their clinicoradiological assessment and operative records. The inclusion criteria included failed primary procedure, repeat procedure for construct failure, infection at the surgical site, or wound dehiscence. Pure CM patients without bony anomalies were excluded from the study. Results: A total of 137 procedures were performed in 55/414 (13%) patients. Causes of resurgery could be divided into ventral [redo or denovo transoral decompression (TOD) or wound-related complications, n = 33, 40.2%] and dorsal causes (implant-related factors/wound infections, n = 49, 59.8%). De novo TOD was done in persisting myelopathy following posterior fusion (PF) with C1-2 distraction (n = 15,18.3%,). Redo TOD was done for residual anterior bony compression [n = 8, 9.6%, OR 0.61; [CI = 0.20-1.86]. Causes for oral wound reexplorations (n = 10, 12.2%) included velopharyngeal insufficiency, wound resuturing, oral bleeding, and cerebrospinal fluid (CSF) leak. Dorsal causes included: (A) Implant factors (n = 27, 32.7%) and (B) neck wound reexplorations (n = 22, 26.8%). Presence of subaxial spine scoliosis, torticollis, and asymmetric joints increased the incidence of reexploration. Occipitocervical fusion rather than C1-2 fusion was more prone towards construct loosening. Conclusions: Patients undergoing distraction with PF may require transoral surgery due to persisting myelopathy, especially in the presence of torticollis, scoliosis, and symmetrical joints. Single stage TOD+PF increases the chances of implant infection due to tissue contamination, bacteremia, or transfacetal migration of microbes. Chronic/recurrent sinus is usually a harbinger of deeper infection and can be cured with implant removal.

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The main purpose of this review was to expound upon the mechanism of action of Levetiracetam (LEV) as an antiepileptic, neuroprotective, and hyperalgesic drug. LEV is a second-generation anti-epileptic drug (AED) that is approved for clinical use as monotherapy and may also be used for adjunctive treatment of patients with seizures. Several researchers have recommended LEV as a treatment option in different diseases causing neuronal damage, and recently, LEV has been used as an antihyperalgesic drug. LEV exhibits favorable characteristics, including a low potential for interaction, a short elimination half-life, and has neither active metabolites nor major negative effects on cognition. This has generated many new research avenues for the utilization of this drug. However, the precise mechanism of action of LEV has not been fully elucidated. In this review, a search was conducted on PubMed, ProQuest, EBSCO, and the Science Citation index for studies evaluating the effects of LEV as an antiepileptic, neuroprotective, and hyperalgesic drug. A total of 32 studies related to the use of LEV suggested different mechanisms of action, such as binding to the synaptic vesicle glycoprotein 2A (SV2A) protein, inhibition of Ca2+ N-type channels, and its presence as a neuromodulator. These studies concluded that the pharmacodynamics of LEV should be viewed as a single pathway, and should not be based on specific molecular targets that depend on the physiological or pathological conditions prevalent at that time.

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Objectives: To discuss the clinical and neuroradiological profile of pediatric patients with acute disseminated encephalomyelitis (ADEM). Design: Prospective observational study Settings: Children with clinico-radiological diagnosis of ADEM admitted in the pediatric ward of the Institute of Child Health between July 2009 to Sepetember 2014 were included. Materials and Methods: Clinical and neuroradiological parameters of children suffering from ADEM were noted. Results: A total of 36 children were included in the study, among whom approximately 50% had a history of either a preceding viral infection or the administration of a vaccination; and, 92% of them presented with some form of neurological deficits. Encephalopathy was present in 92% children at the time of admission. Seizures were present in 42% of children. The cerebrospinal fluid (CSF) study was non-contributory and magnetic resonance imaging (MRI) was diagnostic in most of the cases. The lesions were usually asymmetrically placed. All of them were treated with steroids and had a good prognosis, with complete neurological recovery in 75% of the children. Conclusion: Although it is perceived as a rare disease, ADEM is fairly common in the pediatric population, Most often, it is misdiagnosed as a meningoencephalitis. An early neuroradiological identification of the demyelinating lesions and treatment with steroid therapy leads to an excellent outcome.

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Background: Diagnosis of myasthenia gravis is difficult, especially when the disease is restricted to ocular muscles. It is a well-known observation that myasthenic ptosis improves with cold and based on this, the ice pack test has been used as a tool in its differential diagnosis. The aim of the study is to investigate the diagnostic value of ice pack test as a preliminary test in the differential diagnosis of myasthenia and to find out the percentage of positivity and negativity of the ice pack test. Materials and Methods: The study included patients seeking treatment for ptosis in a tertiary care center in Kerala. All patients were subjected to the ice pack test. Evaluation of patients was made by recording the marginal reflex distance (MRD). MRD was recorded before and after the application of ice pack, and an improvement of more than 2 mm was considered positive. Patients were divided into two groups: (1) those who had ptosis and features suggestive of myasthenia; and, (2) those who had ptosis but no features of myasthenia. Patients of both groups were subjected to relevant investigations and the diagnosis of myasthenia was established. Results: Ice cold test was positive in 48 (96%) patients and negative in two patients of the myasthenia group. In the control group, 6 (12%) patients had a false positive ice cold test and in the remaining 44 patients (88%), ice cold test was negative. Conclusion: Ice pack test has a high specificity and sensitivity in the differential diagnosis of myasthenic ptosis.

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Objective: To study the visual outcome after surgery for pituitary adenomas with visual deficits. Materials and Methods: All patients with pituitary adenoma, who presented from 2003-2014 in a tertiary care institute, were included in the study. Surgical outcome was measured in terms of difference in visual acuity, visual fields and optic fundus parameters documented before surgery, immediate post-operatively and at the third, and twelfth months following surgery. Results: At the initial presentation, visual involvement was seen in 87.2% patients. One year after surgery, 93.2% patients having abnormal vision had improvement in visual acuity and visual fields; whereas visual parameters were static in 5.2%. Visual deterioration occurred only in 1.3% patients. Moreover, five-percent of those who did not even have perception of light at presentation experienced significant improvement in vision after surgery. The shorter the duration of visual symptoms, the more was the percentage of patients having faster recovery in the early postoperative period. Conclusion: Post-operative visual outcome was directly proportional to the pre-operative visual acuity. Though the visual outcome was good in the long run irrespective of the duration of symptoms, the speed of recovery was proportional to the duration of visual deficits. However, presence of long-standing visual symptoms should not deter us to subject the patient to surgery. Even patients who are completely visually impaired for years should be subjected to surgery as early as feasible.

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Introduction: We present a retrospective study of distal anterior cerebral artery (DACA) aneurysms operated at our institute. Material and methods: From 1988 to 2013, a total of 132 DACA aneurysms were managed surgically. The retrospective data of these patients was collected and analysed. Results: They comprised 6.2% of all 2137 aneurysms operated during the same period. The mean age at presentation was 48.3 years (range: 24–77 years) and the male: female ratio was 1:2. The notable symptom in 114 (86.4%) patients was headache, in 94 (71.2%) was loss of consciousness, in 25 (18.9%) was seizures, and in 17 (12.9%) was limb weakness. There were 99 (75%) patients in World Federation of Neurosurgical Societies (WFNS) grade <3 at admission. On plain computed tomography (CT) scan, intracerebral hemorrhage was seen in 49 (37.1%) and intraventricular hemorrhage in 23 (17.4%) patients. The most common site of aneurysm was the pericallosal (A3 segment) artery noted in 65 (49.2%) patients. Multiple aneurysms were observed in 16 (12.1%) cases. The mean timing of surgery from the first ictus was 17.8 days. The delay was due to a late referral, poor general condition, recurrent bleeding, and worse WFNS grade at presentation. Aneurysms were operated through the following approaches: parasaggital craniotomy in 61 (46.2%), bifrontal craniotomy in 64 (48.5%), and frontotemporal craniotomy in 7 (5.3%). Aneurysms could be successfully clipped in 93.2% of the cases. Postoperative mortality was 8 (6%). The follow-up data was available for 83 (62.9%) patients. The mean duration of follow-up was 15.1 months (1–70 months), with more than 41 (31%) patients having a follow-up of more than 6 months. A favorable outcome (good recovery or moderate disability) was seen in 71 (85.5%) cases. Conclusions: A meticulous attention to the surgical technique provides gratifying results in DACA aneurysms even in patients who present initially in a compromised clinical status.

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Background: Through this cross-sectional study, we examined the demographic parameters, comorbidities, and antiepileptic drug (AED) utilization in patients with epilepsy. Materials and Methods: We collected data of 973 adult patients with epilepsy and analysed AED utilization according to the epilepsy type, age group and gender. Results: The study included 973 patients (males, 61.3%) with a mean age of 35.6 years. Only 3.6% patients were not educated whereas 45.3% patients were employed. Only 1.2% patients had a history of brain injury. The mean frequency of seizures during the previous 6 months was 24.0 ± 49.1 whereas the mean duration of epilepsy was 5.8 ± 5.8 years. Electroencephalogram was the most common (59.7%) investigation performed. A total of 109 (11.2%) patients had comorbid medical illness, with hypertension being observed in 3.3% patients. Levetiracetam was used in 583 (59.9%) patients whereas valproate, clobazam, and phenytoin were used in 16.3%, 14.8%, and 13.6% patients, respectively. Effectiveness and safety/tolerability profile were the two most important considerations for selecting the AED. A total of 924 (95%) patients had seizure control with the current therapy during the previous 6 months whereas the mean seizure-free interval was 7.1 ± 4.1 months. Levetiracetam was used in 34.9%, 45.7%, and 61.1% patients and valproate in 15.2%, 10.9%, and 4.6% patients in the age group of 18–30, 31–50 and 51–75 years, respectively. Levetiracetam was used in 57.7% and 63.4% whereas valproate was used in 19% and 12.2% male and female patients, respectively. The adverse event rate was only 0.1%. Conclusion: Epilepsy is common in adult patients. Hypertension is the most common comorbidity. Levetiracetam is the most commonly used AED across all studied age groups and both genders. Control of epilepsy with current treatment is satisfactory with no major adverse events.

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Background: Fragile X syndrome (FXS) is also a leading cause of intellectual disability along with Down's syndrome. It is caused by the expansion of CGG triplet repeat at 5' untranslated region of the fragile X mental retardation 1 (FMR1) gene. Since the prevalence rate is quite high in the general population, molecular diagnosis is important to establish the cause and the prenatal diagnosis. At present, there are a number of methods available with their own merits and demerits. Aim and Methods: Molecular screening of intellectually disabled patients and those with premature ovarian failure with combined triplet repeat primed polymerase chain reaction (TP-PCR) and methylation-specific polymerase chain reaction (MS-PCR) for establishing the diagnosis of FXS. Results: The specificity of the method has been validated with archived previously genotyped samples, facilitating the application of this method in the screening procedure. The combined TP-PCR and MS-PCR approach identified six (10%) of the intellectually disabled cases as full mutation positive, one (4%) of the premature ovarian failure cases as premutation positive, and one (out of two) of the prenatal samples as premutation positive. Conclusion: The present study concludes that a combined usage of TP-PCR and MS-PCR will be a useful alternative approach to diagnose patients suffering from fragile X syndrome.

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Organized neurosurgery in India started in 1951 with the formation of the Neurological Society of India (NSI). Essentially, this society was the first superspecialty group in medicine comprising of clinical neuroscientists of India. The character of the Society has changed over the years with the formation of the Indian Academy of Neurology as well as separate groups with multiple specialty doctors in Neurosurgery also starting their own societies. The present mandate of the organization is to promote educational opportunities for residents, young members, and practicing neurosurgeons.

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Objects: To clarify the effects of endovascular therapy (ET) for acute ischemic stroke (AIS) patients, we conducted an updated meta-analysis using data from randomized controlled trials (RCTs). Methods: We searched major electronic databases for RCTs comparing ET with intravenous thrombolysis (IVT) or other standard treatments for AIS patients. Eligible and high-quality RCTs were included in the meta-analysis. The overall estimates were demonstrated as an odds ratio (OR) with 95% confidence interval (CI) and P value. Results: Thirteen high-quality trials met the inclusion criteria and were analyzed. Patients treated by ET were more likely to have good functional outcomes (OR, 1.70; 95% CI, 1.32–2.19; P< 0.0001) and lower mortality rates (OR, 0.77; 95% CI, 0.60–0.98; P = 0.03) at 90 days than patients treated by IVT or standard treatment. There was no significant difference in the rate of symptomatic intracerebral hemorrhage [sICH] (OR, 1.18; 95% CI, 0.73–1.91; P = 0.50). Conclusions: ET is superior to both IVT and standard treatment in providing functional improvement and reducing the mortality rate at 90 days, while not increasing the risk of sICH for the treatment of AIS.

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Context: Microsurgery is considered to be the optimal treatment for brainstem cavernous malformations (BCMs); however, the high surgery-related morbidity requires further assessment of therapeutic protocols. Aims: The surgical experience and the optimal surgical strategy for the management of brainstem cavernous malformations is discussed. Materials and Methods: From September 2007 to August 2014, a total of 120 patients with BCMs underwent surgical treatment in our hospital. The clinical features and neurological outcome of these patients were retrospectively analysed, and our institutional surgical strategy was discussed. Results: The preoperative annual hemorrhage and rehemorrhage rates were 4.2% and 42.9%, respectively. Gross total resection was achieved in 116 patients (96.7%) and subtotal resection in 4 (3.3%). After a mean follow-up of 50.7 ± 26.5 months (range: 18–90 months), the neurological status showed improvement in 71 patients (67.0%) and remained stable in 24 (22.6%). The postoperative new-onset or worsened symptoms occurred in 53 cases. During the follow-up period, 58.5% of these symptoms improved and 32.1% remained stable. The mean modified Rankin score (mRS) score was 2.51 ± 0.90 preoperatively, 2.73 ± 0.83 postoperatively, and 1.71 ± 0.98 at the recent follow-up. The surgery-related mortality was 1.7% (n = 2), and two patients suffered from recurrence during the follow-up period. The preoperative mRS was considered to be an independent predictive factor of the neurological outcome (P = 0.003). Conclusions: Safe resection and a favourable outcome can be achieved via a standardized surgical strategy based on appropriate surgical indications, optimal selection of safe trajectories, and application of advanced supplementary techniques in the surgical treatment of BCMs.

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Objectives: This study was conducted to investigate the associations between white matter lesions and language and memory dysfunctions in patients with magnetic resonance imaging (MRI)-negative temporal lobe epilepsy. Materials and Methods: This study included 26 patients with temporal lobe epilepsy, who did not have significant findings on conventional MRI scanning, and 17 healthy subjects as control. Diffusion tensor imaging data was obtained with a 3Tesla (T) MRI scanner. Neuropsychological scores of language and memory functions were measured. One-way analysis of variance was used to analyze abnormal fractional anisotropy and mean diffusivity values. Correlations were performed to evaluate the relationship between fractional anisotropy/mean diffusivity of each fiber tract and neuropsychological measures. Regression analysis was performed to determine the contribution of each fiber tract to cognitive performance. Results: Our data showed significantly decreased neuropsychological scores in the left and right temporal lobe epilepsy groups compared with control; it however, failed to show a statistical difference between the two groups. For the left temporal lobe epilepsy group, the mean diffusivity of the left parahippocampal and cingulate cortex, right arcuate fasciculus, and left fornix were significantly higher than control. Fractional anisotropy of the right fornix and mean diffusivity of the left uncinate fasciculus were significantly related to confrontational naming scores. There were significant correlations between the fractional anisotropy of the left fornix and verbal delayed memory scores and between the fractional anisotropy of the left fornix and nonverbal delayed memory scores. The mean diffusivity of left fractional anisotropy and the fractional anisotropy of the left uncinate fasciculus were significantly related to confrontational naming and verbal fluency scores, and seizure frequency was significantly related to nonverbal delayed memory scores. Conclusions: Language and memory function impairment was correlated with white matter structural integrity.

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Objectives: Variability exists with the use of neuro-navigation in the placement of Ommaya reservoir. In the setting of recent healthcare reforms in the United States that are focused on cost-containment strategies, we discuss from our experience at the Louisiana State University, Shreveport, if the use of high-cost stealth-guided navigation technique reduces malposition rates over free-hand placement. Patients and Methods: A retrospective cohort analyses on 146 patients that underwent placement of Ommaya reservoir between 1991 and 2014 using free-hand and neuro-navigated technique was performed. Primary endpoint was to evaluate the differences in rates of malposition across these two placement techniques. Results: The mean age of our cohort was 44.85 ± 15.05 years and 45% patients were female. We did not find any statistical differences for complications rates including infections (8.3% vs 9.2%; P = 1.000), hemorrhage (0.0% vs 3.1%; P = 0.551), and repositioning (6.3% vs 8.2%; P = 1.000) across patients that underwent placement of Ommaya reservoir using neuro-navigation and free hand technique. Conclusion: Although placement of Ommaya reservoir is a relatively easier technique as compared to other neurosurgical procedures, based on our experience and literature, we found lower rates of complications in patients who underwent placement via the stealth-guided neuro-navigational approach. Despite not having found any statistical difference in malposition rates between navigated and free-hand implantation of Ommaya reservoirs in our series, it is plausible that the number of technical complications in the neuronavigational group in the early years of acquisition could possibly be attributed to the learning curve, rather than their occuring purely by chance. Nevertheless, considering the increased cost of hospitalization associated with the use of navigational technology, future studies are recommended to weigh the cost-benefit ratio of preferring the neuro-navigational techniques for placement of Ommaya reservoir over the free-hand placement techniques.

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Aim: To correlate histopathological grading of meningiomas segregated into subgroups based on the MIB-1 labelling index (MIB-1 LI) with chromosomal loss of 14q using fluorescence in situ hybridization (FISH). Settings and Design: Retrospective study conducted in a tertiary hospital. Methods and Material: Forty-six cases from January to December 2011 were segregated into 5 categories based on the MIB-1 LI. Slides were reviewed to ascertain the grade. Immunohistochemical staining for MIB-1 was performed using a Ventana Benchmark XT autostainer. Commercially available FISH paraffin pretreatment kit and SpectrumOrange fluorophore labelled probe were used. The Statistical Package for the Social Sciences version 16.0 for Windows was used for statistical analysis. Results: There were 21 World Health Organisation (WHO) grade I, 24 grade II, and 1 grade III meningiomas. There was a statistically significant difference between the mean duration of symptoms, maximum dimension, and the MIB-1 LI of grade I and grade II meningiomas. 33.3% grade I cases showed 14q deletion, compared to 84% of grade II and III meningiomas. Histologically, hypercellularity, small cell formation, prominent nucleoli, and sheet-like growth were significantly associated with 14q deletion. All brain invasive meningiomas had 14q deletion. As MIB-1% increased, the prevalence of deletions was significantly higher. The mean MIB-1 of the 7 grade I meningiomas that had 14q deletions was 8.86 ± 1.95% when compared to 4.14 ± 1.35% for those without 14q deletions. Conclusions: A strong association existed between histologic grade, MIB-1 LI, and the presence of chromosome 14q deletion. Association of high MIB-1 LI with 14q deletions, even in meningiomas with a Grade I histology, defines a distinct subset of benign meningiomas.

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