Transcranial electrical stimulation (TES) uses direct or alternating current to non-invasively stimulate the brain. Neuronal activity in the brain is modulated by the electrical field according to the polarity of the current being applied. TES includes transcranial direct current stimulation (tDCS), transcranial random noise stimulation, and transcranial alternating current stimulation (tACS). tDCS and tACS are the two non-invasive brain stimulation techniques that have been used alone or in combination with other rehabilitative therapies for the improvement of motor control in hemiparesis. Increasing research in these methods is being carried out to improvise on the existing technology because they have proven to exhibit a lasting effect, thereby contributing to brain plasticity and motor re-learning. Artificial stimulation of the lesioned or non-lesioned hemisphere induces participation of its cells when a movement is being performed. The devices are portable, stimulation is easy to deliver, and they are not known to cause any major side effects which are the foremost reasons for their trials in stroke rehabilitation. Recent research is focused on maximizing the outcome of stroke rehabilitation by combining them with other modalities. This review focuses on stimulation protocols, parameters, and the results obtained by these techniques and their combinations.

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Background: Fluid management during intracranial surgery is an important concern. The type of fluid used can have biochemical and metabolic effects during intraoperative management. However, it is yet to be known whether biochemical and metabolic effects have an influence on the clinical outcome of a patient. Objective: A prospective evaluation of the effects of normal saline (NS), Ringer's lactate (RL), and a combination of NS and RL on the biochemical, metabolic, and clinical outcomes in patients undergoing intracranial tumor surgery was carried out. Materials and Methods: Ninety patients undergoing elective intracranial tumor surgery were randomized to receive NS, RL, or a combination of NS and RL. The biochemical and metabolic parameters were studied at different time points in the intraoperative and postoperative period. The hemodynamic parameters, brain relaxation score at the time of bone flap elevation, postoperative complications, and the duration of hospital stay were the clinical outcome variables of our study. Results: The use of NS was associated with hyperchloremic metabolic acidosis and ionic hypocalcemia. RL caused significant hyponatremia and increase in serum lactate levels. The combination of NS and RL has least influence on biochemical and metabolic parameters. The effects of three fluids were similar on the hemodynamics, brain relaxation score, as well as on postoperative complications and the duration of postoperative hospital stay. Conclusion: There are variable effects of NS, RL, or its combination on the biochemical and metabolic parameters in patients undergoing intracranial tumor surgery. However, the clinical outcome of the patients remains similar.

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The Achanta Lakshmipathi Neurosurgical Center (ALNC) and Post Graduate Institute of Neurological Surgery is a private teaching neurosurgical institution located in the VHS (Voluntary Health Services) Hospital Chennai. It has been a leader and trendsetter among the private academic neurosurgical training institutions, and because of its unique legacy, has influenced the progress of Neurosurgery in India. The center was the second neurosurgical Institute to be created by Prof. B Ramamurthi and has trained neurosurgeons in the unique ALNC school of Neurosurgery. The Institute has grown to become a centre of excellence in microsurgery, and spinal surgery and has become a training centre for neurosurgery since 1985. The unique humanitarian aspects of the Voluntary Health Services Hospital helped in bringing the best of Neurosurgery to all strata of society. Forty years after its inception, the ALNC continues its delivery of excellence in clinical neurosurgery and academics.

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Background: Pineal gland tumors range from the well-differentiated “pineocytoma” [World Health Organization (WHO) grade I], which have a very good prognosis, to the aggressive and poorly differentiated “pineoblastoma” (WHO grade IV) with “pineal parenchymal tumor of intermediate differentiation” (PPTID; WHO grades II and III) occupying intermediary differentiation and prognosis. Papillary tumor of the pineal region (PTPR; WHO grades II and III) is a distinct entity with propensity for recurrence and spinal dissemination. However, the diagnostic criteria to differentiate these entities, especially between WHO grades II and III of both PPTID and PTPR, remain nebulous. Objective: To evaluate the relative frequency of the individual entities and histomorphological (including the proliferation indices) features across the spectrum of pineal parenchymal tumors (PPTs) [including PTPRs] along their course. Design: All cases of PPTs were retrieved, reviewed, and graded based on the histological criteria defined in the literature. Results: PPTID, more commonly seen in young adults, was the most common subtype of PPT. This was followed by pineoblastoma which was more commonly seen in children. Clinical progression was seen in both grades II and III of PPTID; however, it was more commonly seen in cases with a MIB1 labeling index of >10%. PTPRs (both grades II and III) showed an aggressive histological transformation and also intraparenchymal metastasis. Conclusion: PPTIDs are the most common adult primary PPTs and have the potential to progress and disseminate in both grades II and III. Both grades of PTPRs have a metastatic potential. These findings suggest the need for postoperative adjuvant therapy in both grades of PPTID and PTPR.

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Background: E-learning platforms, especially the online neurosurgical video sharing sites, are playing a key role in the dissemination of knowledge related to the essential steps of operative neurosurgery. Aim: A national survey was undertaken to assess the utility of neurosurgical operative videos exhibited on the online video-sharing sites. Materials and Methods: Resident trainees in neurosurgery, as well as junior and senior consultant neurosurgeons practicing in India were provided, on the Google platform, a questionnaire consisting of nine multiple-choice questions and a space for remarks. 520 people were contacted using e mail and/or whattsapp modalities, out which 98 responses were considered valid. Results: Majority (n = 87, 88.8%) of the responders voted that internet videos have helped them in improving their surgical skills. There was no statistically significant difference between people working in rural and urban areas in this regard (P = 0.517). Both senior and junior neurosurgeons were utilizing these online videos for enhancing their surgical skills, and there was no statistically significant difference regarding the perception of the usefulness of these online video channels between the two groups (P = 0.660). However, the response rate to the questionnaires sent was only 18.84%. Conclusions: Online video-sharing platforms are useful, especially in a country like India with diverse neurosurgical infrastructure. The need for the development and maintenance of a dedicated, high-quality, structured video bank through collaboration and cooperation of high volume centers and institutes of repute in India is strongly advocated.

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Background: Gamma knife stereotactic radiosurgery is, compared with surgical treatment, a less invasive treatment option for patients with trigeminal neuralgia (TN). Aim: In this report, we analyzed the effect and safety of gamma knife radiosurgery performed in patients with TN. Materials and Methods: We retrospectively reviewed patients who underwent gamma knife radiosurgery for TN between June 2014 and January 2017. All patients were treated with Leksell Gamma Knife Model C (Elekta, Stockholm, Sweden) with a prescription dose of 40 Gy with a 50% isodose line. The follow-up of the patients was performed 1 week after the procedure and after every 3 months. The pain score of the patients was recorded using the visual analog scale (VAS). Complications were also reviewed. Statistical Analysis: Statistical analysis was performed using the Statistical Package for the Social Sciences software for Windows, version 23.0. Results: Twenty-four patients (10 males, 14 females) were included in the study. The median age of the patients was 62.5 years (range, 34–91 years). The pre-gamma knife median VAS was 10 (range, 5–10), and the median VAS was 1 (range, 0–10) during the last follow-up. The pain decreased in 16 (76%) patients. Two patients (9%) had treatment-related complications. One patient developed hypoesthesia along the dermatome of the maxillary branch of the fifth cranial nerve and another patient developed facial paresis, which recovered after the usage of steroids for 3 months. Conclusion: Gamma knife radiosurgery is an effective and safe treatment for patients with TN with an acceptable pain control rate.

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Background: Frontal assessment battery (FAB) was devised as a specific study design to assess frontal lobe dysfunction. Since Parkinson's disease (PD) is often associated with cognitive and other higher mental function complications, FAB test has been carried out by a number of workers to assess the integrity of the frontal lobe. On the other hand, the other frequently conducted test, performed in order to evaluate the mental status, is the Mini Mental State examination of Folstein (MMSE), but its reliability has been questioned in PD, since it does not assess the functions of the frontal lobe alone. Material and Methods: The present study was undertaken in order to assess the suitability of application of the FAB test in Indian patients and to perform its comparative analysis with the MMSE scale. Results and Conclusions: It was observed that the FAB test correlated with the age and the level of education of the patient. The results also correlated with that of the MMSE study, in spite of the fact that the latter is not considered to be a test which can assess exclusively the status of the frontal lobe. To the best of our knowledge, this is first study undertaken in India in this regard.

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Being a neurosurgeon is a protracted, time-consuming, and labor-intensive occupation. It presupposes excellent, continuing physical and mental competence, and a passion to always do better than the best. During the last two decades, the exponential deployment of operative technology has resulted in a radical transformation, making a neurosurgeon trained four decades ago, run the risk of being outdated. Expectations from patients have reached an all time high level. Socioeconomic and medicolegal aspects cannot be brushed aside. It is universally accepted that in spite of increasing longevity in the educated upper middle class, the process of ageing per se continues relentlessly. When is enough enough? Is there a risk that a “senior, experienced” neurosurgeon may even become a liability to his patients some day? Should there be a mandatory time point at which a neurosurgeon should necessarily stop operating. The author reviews the published literature and opines that after the age of 65 years, all seniors should agree to their operating privileges being formally reviewed regularly every 2 years.

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Objective: Bilateral subthalamic nucleus deep brain stimulation (STN DBS) improves motor complications and quality of life (QOL) in patients with Parkinson's disease (PD). However, it does not delay or prevent the occurrence of dementia. The deleterious effects of dementia on QOL and activities of daily living (ADL) underscore the importance of identifying predictors of dementia-free survival in PD patients considered for STN DBS. Aims and Methods: The baseline clinical and neuropsychological data and the occurrence of dementia recorded during the longitudinal follow-up of a cohort of patients with PD with at least 2 years follow-up after bilateral STN DBS, were reviewed. Results: One hundred and sixteen patients operated between 1999 to 2014 satisfied the inclusion criteria. Their mean age was 56.5 (±10) years and the mean duration of PD at surgery was 11.2 (±4.2) years. During the 542 person–years of follow-up, 30 patients developed dementia. The mean dementia-free survival after surgery was 8.7 [95% confidence interval (CI): 7.8–9.6] years. In univariate analysis, the baseline factors of older age, longer disease duration, past history of depression or psychosis, freezing of gait in OFF phase, worse ADL scores in ON phase, lower levodopa response of the Unified Parkinson's Disease Rating Scale (UPDRS) III axial sub-scores, and poor performances in the Addenbrooke's Cognitive Examination and Wisconsin Card Sorting Test (WCST) were associated with a shorter dementia-free survival. Among these, only freezing of gait and poor performance in WCST were independent predictors. Conclusion: Presence of freezing of gait in the drug OFF state and executive dysfunction predict the occurrence of earlier dementia in PD patients who otherwise qualify for bilateral STN DBS.

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Background: Although acute cholecystitis after stroke is rare, an immediate diagnosis and treatment is required. Material and Methods: In the past five years, we observed six patients with acute cholecystitis during the initial hospitalization for stroke. Results: Three patients had cardiac embolism, two had subarachnoid hemorrhage, and one had intra-cerebral hemorrhage. Four had calculous cholecystitis and two had acalculous cholecystitis. One of the patients with acalculous cholecystitis had hemorrhagic cholecystitis. The most commonly presented symptom was fever (50%), whereas only one patient (17%) had abdominal pain. Three patients (50%) were completely asymptomatic. Conclusions: Acute cholecystitis and stroke are closely associated, and anti-thromboembolic drugs may cause hemorrhagic cholecystitis. Stroke patients tend to have atherosclerotic risk factors resulting in ischemic injury of the gallbladder. Furthermore, severe hemiparesis, a fasting state, dehydration, or bacteremia, which are occasionally exhibited by stroke patients, are known risk factors for acalculous cholecystitis. Stroke patients, especially patients with aphasia and consciousness disturbance, require immediate abdominal examination, if acute cholecystitis is suspected.

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Introduction: With improvements in overall and progression-free survival in gliomas, current focus in neurosurgical oncology has largely shifted to the issue of quality of life (QOL) after treatment. There are not too many prospective studies evaluating QOL in these patients. We prospectively analyzed the health related quality of life (HRQOL) using the short form (SF) 36 questionnaire among patients harbouring a supratentorial glioma who underwent surgery at a tertiary care center in India. Methods: HRQOL was evaluated prospectively in 103 patients, between May 2016 and November 2017, at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow. Score improvements were evaluated in terms of the smallest difference that a patient perceived to be clinically beneficial. The responsiveness of scores was assessed as minimum clinically important difference (MCID), effect size (ES) and relative efficiency. Cronbach's alpha co-efficient was used to assess the reliability of the result obtained. Results: The mean pre-operative score was the highest in the mental health domain (50.21±21.45) and significantly lower in patients with raised intracranial pressure (ICP), pre-operative deficits, a poor Karnofsky performance scale (KPS) score, in large tumors (>4cm) located in an eloquent location and in deep-seated tumors. A significant improvement was noted across all domains except the physical role (P-value 0.20). Overall, the general health domain was most responsive to change with the largest t-value (6.56) and 55.7% patients achieved their target MCID in general health (GH) domain. Among all the factors studied, only a low baseline SF-36 score was significantly associated with a change in QOL after surgery. Conclusion: Most parameters of HRQOL improved following surgery. Only small-to-moderate improvements occured in the early follow-up period. Large improving trends were noted on a long-term basis, irrespective of the histo-pathological grade. Similar improvements were also noted in patients who subsequently underwent re-surgery despite the development of post-operative complications or new deficits. Also, a low baseline QOL score heralded a poor survival.

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Background: Remarkable advancements in the understanding of etiological risk factors and pathophysiology of cerebrovascular diseases have led to the refining of definitions and terminologies in stroke medicine periodically. We aim to analyze the utility and meaning of different eponyms in the stroke medicine literature during the last 20 years. Materials and Methods: A systematic search was performed in Google Scholar for the words “stroke,” “TIA,” “cerebrovascular accident (CVA),” “cerebrovascular insult,” “cerebrovascular event,” “cerebral ischemia,” and “cerebrovascular disease.” Each of the words were searched yearwise from 1996 to 2015, and the numbers of articles using these words were collected and analyzed. Results: “ Stroke” has been the most common terminology used in literature, which showed a progressive increase in its usage until 2010, after which its use drastically reduced. “Cerebrovascular events” and “cerebral ischemia” are the second most commonly used terminologies with variable definitions; there was a steep increase in the use of these words until 2012. Conclusions: The most imprecise term that continues to be used is “CVA”. The precisely defined entity like “cerebrovascular disease,” which is a group of diseases, continues to be used inappropriately. All the terms are not defined uniformly across the globe, whereas most continue to use the World Health Organisation definition of stroke, defined in the 1970s. It is essential to condemn the use of imprecise terminologies and promote the use of recently defined precise terms “stroke” and “transient ischemic attack (TIA)”. Unless the same terms with precise definitions are used in clinical practice or literature, the progress of stroke medicine will continue to be hampered.

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Objective: To study the prevalence and clinical characteristics of malformation of cortical development (MCD) and incomplete hippocampal inversion (IHI) in adults with intractable seizures. Materials and Methods: In this prospective study of 3220 epileptic patients in our epilepsy clinic between 2012 and 2014, 416 had intractable seizures. In all patients, a detailed clinical history, neurological examination, electroencephalography (EEG), computed tomography (CT) scan, magnetic resonance imaging (MRI) brain, and neuropsychological assessment was conducted to identify MCD and IHI. Results: Out of 416 patients with intractable seizures, MCD and IHI were confirmed in 85 patients (48 males, 37 females). MCD was observed in 46 (11.05%) patients and IHI were observed in 39 (9.37%) patients. Chi square test revealed no signi cant difference between the MCD and IHI groups across the patients in different age groups, gender, type of seizure, duration and onset of seizure, seizure frequency, clustering, status epilepticus, EEG, febrile seizures, and family history. Statistically significant differences (P < 0.05) were observed between the MCD and IHI groups for change in seizure semiology and in intelligence quotient (IQ) and memory quotient (MQ) scores obtained using Wechsler's adult intelligence scale III and Wechsler's memory scale. The IHI group showed higher IQ and MQ scores when compared to the MCD group. Furthermore, IHI occurred along with MCD in 6.52% (N = 3) of the population. Conclusion: MCD and IHI patients are often associated with intractable complex partial seizures. Intractable epilepsy patients with normal intelligence and normal MRI should be investigated with hippocampal volumetric studies to identify the presence of IHI. Isolated IHI can be considered as a form of MCD because it mimics the clinical features of MCDs.

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Morphological electrocardiological changes and arrhythmias are commonly encountered in patients with aneurysmal subarachnoid hemorrhage. These, if undetected and unaddressed, can cause cardiovascular ailments, postsurgical poor neurological outcomes and long term medical complications.

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Although most of the cases of atlanto-axial dislocation (AAD) and basilar invasion can be managed by posterior approaches in the recent times, anterior decompression with stabilization is required in selected patients who persist with irreducible AAD even after manipulation of the C1-C2 facet joint under general anesthesia. A single stage endoscopic trans-oral decompression and stabilization can be used in such patients. It has not been described so far to the best of authors' knowledge. This is indicated in irreducible AAD with the mandibular angle lying below the C2-C3 disc space. It is not a proper choice when the mandibular angle is above the C2-C3 disc space, there is involvement of the facet joint by trauma or any other pathologies, and if a posterior compression at the cervicomedullary junction persists. All patients should undergo pre-operative radiographs, computed tomography (CT) scan and magnetic resonance imaging with angiogram of the cranio-vertebral region. Utilizing this technique, an intra-operative satisfactory reduction of the dislocation with C1-C2 stabilization could be achieved in 3 patients, and 7 required an additional odontoid excision. Post- operative plain radiographs should be performed to assess for C1- C2 alignment and fusion at 3 and 12 months after surgery. All 10 patients of our series had an irreducible AAD and two had an additional basilar invasion. All patients improved from the pre-operative Ranawat grade 3A (n = 8) and 3B (n = 2) to post-operative grade 1 (n = 9) and 2 (n = 1) at a 3–12- month follow-up assessment. The average duration of the procedure and blood loss was 145 minutes and 75 ml, respectively. Endoscopic trans-oral single stage decompression and stabilization seems to be an effective and safe alternative in selected patients with AAD and basilar invasion.

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Brachial plexus neuropathies are uncommon and are rarely caused by a tumor. The clinical presentation of a brachial plexus neuropathy caused by a tumor depends on the degree of malignancy of the tumor and its localization. We report an illustrative case of a 27-year old female subject with a progressively increasing mass lesion causing brachial plexus compression, ipsilateral shoulder pain, C8 dermatomal paresthesia, and impairment of motor power. The patient underwent surgical resection of the mass and neurolysis of the nerves in the vicinity. Following the surgical procedure, the patient had improvement in the pain and paresthesia that he was suffering from. The histopathological diagnosis revealed a hibernoma, an extremely rare tumor described only once previously in this location. A systematic review of the literature was performed utilizing the PubMed database to access articles published before March 2018, using: A – the term 'hibernoma' in the title/abstract associated with the following MeSH terms: brachial plexus neuropathies OR brachial plexus neuropathy OR nerve compression syndrome, OR brachial plexus; B – the MeSH term 'brachial plexus' associated with the term 'non neural sheath nerve tumor' or 'peripheral non-neural sheath nerve tumor'. The origin of the hibernoma, as well as its metabolic influence, pathology, and treatment have been discussed.

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This article is the culmination of two axioms. The first is the authors' belief that the practice of medicine is, if anything, a social profession. The second is the glaring realization that conscience is the worst motivator. When we combine the two, we understand why a war needs to be waged for a stronger legislation making the wearing of helmets compulsory, and why doctors need to be at the forefront of this war.

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We present a case of posttraumatic cavernous carotid pseudo-aneurysm presenting with epistaxis, in which microsurgical treatment was the treatment of choice as endovascular treatment was perceived to be too risky because of a bone fragment impinging on the wall of the aneurysm. The patient was successfully managed by a high-flow, radial artery, external carotid artery-middle cerebral artery bypass and trapping of the internal carotid artery. The patient was discharged one week later without any further episode of hemorrhage.

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