Background: COVID-19 pandemic has affected the world globally causing widespread repercussions on individuals' physical, mental and emotional well-being. In such times, sleep is likely to be affected. Objective: The aim of this study was to present the available literature on sleep and also the foresight as to the future national strategy to mitigate the effects of this pandemic. Materials and Methods: An extensive literature search on PubMed, Google Scholar, Epistemonikos database (https://www.epistemonikos.org), PsycINFO for available literature on the prevalence of sleep problem on COVID-19 was done. Cross-citation search was also conducted to increase relevance of the review. The key words used were- (((((((((((insomnia)) OR (sleep)) OR (sleepiness)) OR (“sleep quality”)) OR (OSA)) OR (“obstructive sleep apnoea”)) OR (“obstructive sleep apnea”)) OR ((“sleep problem”)) AND “covid-19” OR covid19* OR “COVID-19” OR “2019-nCoV” OR cv19* OR “cv-19” OR “cv 19” OR “n-cov” OR ncov* OR “sars-cov-2” OR “sars-cov2” OR “2019-ncov” OR “SARS-Coronavirus-2” OR “SARS-Coronavirus2” OR (wuhan* AND (virus OR viruses OR viral)) OR (covid* AND (virus OR viruses OR viral)) OR “covid-19-related” OR “SARS-CoV-2-related” OR “SARS-CoV2-related” OR “2019-nCoV-related” OR “cv-19-related” OR “n-cov-related”). Inclusion criteria consisted of articles in English, published from Jan 2020 till 19 Apr 2020. Two reviewers independently screened each research study for inclusion and eligibility. Results and Conclusion: Sleep is affected during COVID-19 pandemic in patients, their families, health-care workers and their families, population in isolation, and quarantine and as such in public. Limited literature exists with subjective data and no objective criteria were found to study sleep in COVID-19 pandemic. OSA was found to be a frequent baseline characteristic of COVID-19 patients. A need to follow guidelines is of paramount importance and strategies to better sleep in the population needs to be addressed.

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Phantom limb pain is a form of chronic neuropathic pain by which 50–80% of the amputees feel the pain that is not adequately controlled by analgesics. When pain management through pharmacological treatment alone is unsuccessful, surgical treatment options are proven to be effective. We report a case of 61-year-old man who sought consultation with phantom limb pain after his motor vehicular accident and below elbow amputation three years before the consultation. His pain was not relieved by analgesics alone and opted for spinal cord stimulation. Chronic Dual Channel dorsal column stimulation was done using Medtronic Prime Advance SCS System. He was in good pain relief and his VAS decreased from (8/10) to (2/10) but since the last six months follow-up he is complaining of pain again (4/10) for which he is taking analgesics too.

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Introduction: Most patients presenting with acute vertigo are believed to suffer from acute, self-limited, presumed viral or post-viral vestibular neuritis (VN). But 25% of such cases can be “Pseudo VN”, and are due to central causes, most often stroke. The aim of the present research was to study the sensitivity and specificity of Head Impulse, Nystagmus, Skew deviation (HINTS) battery for diagnosis of stroke in patients with acute-onset first episode of spontaneous vertigo. Materials and Methods: Seventy-five patients who visited outpatient department or admitted between August 2014 and April 2016 with acute-onset first episode of spontaneous vertigo were included. Each patient was subjected to bedside oculomotor tests and HINTS. All patients underwent magnetic resonance imaging (MRI) of the brain. Stroke was diagnosed by MRI brain. If initial MRI brain was normal and still clinical signs favor stroke, repeat MRI brain-diffusion-weighted imaging study was done at 72 h after symptom onset to confirm the diagnosis. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy and Youden's Index were used to quantify the diagnostic efficiency of HINTS at presentation against final MRI. Results: Patients presented with acute-onset first episode of spontaneous vertigo, HINTS battery was found to be more sensitive than the initial MRI of the brain done in first 24 h in diagnosing stroke (97.1 % Vs 82.9%). The specificity of the initial MRI of the brain and HINTS battery was 100.0 % and 80.0% respectively. Conclusions: The HINTS battery was more sensitive than the initial MRI of the brain in diagnosing stroke in first 24 h in patients presented with acute-onset first episode of spontaneous vertigo.

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The overexpression of the amyloid precursor protein (APP) gene, encoded on chromosome 21, has been associated in Down syndrome (DS) with the development of early-onset Alzheimer's disease (EOAD). The increase in APP levels leads to an overproduction of amyloid-β (Aβ) peptide that accumulates in the brain. In response to this deposition, microglial cells are active and generate cascade events that include release cytokines and chemokine. The prolonged activation microglial cells induce neuronal loss, production of reactive oxygen species, neuron death, neuroinflammation, and consequently the development of Alzheimer's disease (AD). The intrinsically deficient immune systems in people with DS result in abnormalities in cytokine levels, which possibly contribute to the development of neurodegenerative disorders such as AD. Knowledge about the biomarkers involved in the process of neurodegeneration and neuroinflamation is important for understanding the mechanisms involved in the incidence and the precocity of AD in individuals with DS.

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A 54-year-old woman presented with a 1-month history of pain and numbness in both feet. She had taken metronidazole for over 4 years previously to treat vaginitis. On nerve conduction studies (NCS), neither the sural nor right superficial peroneal nerve (SPN) was evoked, nor did the left SPN have small amplitude, suggesting axonal peripheral polyneuropathy with sensory fiber involvement. When she restarted metronidazole, she immediately complained of recurrent paresthesia of the feet. We performed three electromyography (EMG) studies and followed the patient for 6 months.

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Congenital mobile atlantoaxial dislocation with cervicomedullary astrocytoma has never been described. We present a case of a 7-year-old male child who presented to us with gradually progressive spastic quadriparesis following a fall from table. His lateral radiograph and magnetic resonance images showed mobile atlantoaxial dislocation with intramedullary heterogeneously enhancing cervicomedullary mass. The patient underwent suboccipital craniectomy with C1–4 laminectomy. Tumor was pinkish grey, tenacious with ill-defined plane and cyst at poles. C1–C2 fusion was done using C1 lateral mass and C2 pars screw and rod system with onlay bone graft. Histopathology revealed pilocytic astrocytoma. At the time of discharge, the patient showed improvement in spasticity. Postoperative lateral radiograph showed reduced atlantoaxial dislocation with stable construct.

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Hyponatremia in the neurocritical care patients is commonly encountered in the setting of either syndrome of inappropriate ADH secretion or cerebral salt wasting. However, differentiation of SIADH and CSW is paramount in view of their divergent treatment strategies.

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Introduction: Endoscopic third ventriculostomy is a safe alternative to ventriculo-peritoneal shunt for certain cases of obstructive hydrocephalus. It has the advantage of not leaving a permanent foreign body in-situ, besides preventing over-drainage and reducing chances of infection. A thorough knowledge of endoscopic anatomy of ventricles is a must for performing various endoscopic procedures. Objective: The aim of this study was to demonstrate the endoscopic anatomy of ventricles for educational purpose. Procedure: ETV is done using a zero-degree LOTTA endoscope. Right Kocher's point is usually chosen as entry site into ventricle. The scope is negotiated into third ventricle through foramen of Monro. The premammillary membrane is perforated and dilated, thereby communicating the third ventricle to the chiasmatic, interpeduncular and prepontine cisterns. The video was recorded on Karl Storz recording system. It was edited using Imovie software. Photographs labeling was done using Windows PowerPoint 2018. Conclusion: Endoscopic anatomy knowledge allows a neurosurgeon to perform ETV safely.

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Background: Perls Prussian blue stain (PPB) for hemosiderin, a marker of vascular injury is often employed as an adjunct in the diagnosis of vasculitic neuropathies. However, inflammation/vascular injury is also seen in leprosy, immune mediated, paraproteinemic, diabetic neuropathies, etc. The frequency of detection of hemosiderin in these neuropathies and its utility in diagnosis of vasculitis has not been explored. Objective: We evaluated 208 peripheral nerve biopsies for hemosiderin deposits by PPB stain in vasculitis (78) and compared with inflammatory/immune neuropathies [leprous neuritis-32, chronic inflammatory demyelinating polyneuropathy (CIDP)-15, paraproteinemic neuropathies (POEMS)-12, diabetic neuropathy-37] and nonimmune neuropathies [Charcot-Marie-Tooth (CMT) disease-15, vitamin B12 deficiency-7, and ischemic neuropathy in aged-12)]. Results: Hemosiderin deposits were most frequent in vasculitis (48.72%) [59.2% in systemic; 43.1% in nonsystemic vasculitides] and enhanced the sensitivity of diagnosis in “probable” vasculitis (34.48%) that lacked transmural inflammation. Hemosiderin was also detected in infectious/immune-mediated neuropathies (leprous neuritis-56%, POEMS-33.3%, diabetes-18.9%) but absent in CMT, B12 deficiency, and ischemic neuropathy. Hemosiderin deposits involved epineurium in vasculitis, compared to endoneurial/perineurial location in leprosy and perineurial in POEMS and diabetic neuropathy. The sensitivity of detection was high in vasculitic neuropathy (49.35%) compared to other inflammatory neuropathies (22.3%) (P < 0.05) with high specificity (77.69% [positive predictive value (PPV)-56.71%; negative predictive value (NPV)-71.6%]. The specificity increased to 89% if leprous neuropathy was excluded, with PPV-77.5% while NPV dropped to 68.5%. Conclusion: These findings suggest that PPB stain for detection of hemosiderin is a useful adjunct in diagnosis of vasculitic neuropathy with high specificity but low sensitivity.

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Aims and Objectives: To study clinical profile and outcome in Pediatric Guillain Barre Syndrome (GBS). Materials and Methods: Retrospective study of 30 patients (age 1 month to 12 years) admitted with GBS enrolled over a period of 2 years (August 2016-July 2018) from Department of Pediatrics of tertiary centre. Results: Mean age was 5.4 years (21 males; 9 females). Most common presenting complaints- symmetrical lower limb weakness (26 cases; 86.67% cases), respiratory complaints (6 cases; 20% cases), quadriparesis (4 cases; 13.33% cases) and facial palsy (2 cases; 6.67%). Antecedent illnesses- gastrointestinal (6 cases) and respiratory (3 cases). Two patients had varicella (in preceding one week) and one had mumps (one month prior to presentation). MRI-spine done in 12 patients; of whom 9 had features of GBS (thickening and contrast enhancement of the intrathecal and cauda equina nerve roots on T1 weighted MRI). Nerve conduction studies done in 16 patients, of which Acute Motor Axonal Neuropathy was seen in 10 cases. Intravenous immunoglobulin was given to 27 patients while 3 received methylprednisolone in addition. 90% patients receiving IVIG showed improvement. Sixteen patients were admitted to the intensive care unit and 7 required mechanical ventilation. Average hospital stay was 13 days. Two patients had recurrent episodes. Common complications included- pneumonia (6 cases; 2 aspiration and 4 ventilator associated) and autonomic disturbances (6 cases). Two patients died due to autonomic disturbances and presence of autonomic disturbances predicted higher mortality (P = 0.034). Conclusions: Gastrointestinal illness was common antecedent illness for GBS. Symmetrical lower limb weakness was commonest complaint. Pneumonia and autonomic disturbances were commonest complications. Presence of autonomic disturbances predicted higher mortality.

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Background: Low- and middle-income countries (LMICs) bear the majority of the neurosurgical burden of diseases but lack the resources to meet these needs. Objective: As we increase access to neurosurgical care in LMICs, we must understand patient attitudes toward neurosurgery. Methods and Material: PubMed, LILACS, and African Journals Online databases were searched systematically from inception to January 4, 2020, for studies on neurosurgical patient perceptions in LMICs. The articles found were blindly reviewed with Rayyan by two authors. The two authors resolved conflicts between themselves, and when this was not possible, a third reviewer was consulted. All the articles included were then appraised, and the results were summarized. Results: Six of the 1,175 articles met the inclusion criteria. The studies were set in Brazil, Ethiopia, India, Nigeria, South Korea, and Sub-Saharan Africa. Four of the studies (50%) were phenomenological studies, and the other two were grounded theory and narrative. The studies identified patient attitudes toward neurosurgical practitioners, diseases, and interventions. Ethiopian and Nigerian patients believed cranial diseases to be otherworldly and resorted to traditional medicine or spiritual healing first, whereas Brazilian patients were more comfortable with cranial diseases and even more so if they had had a previous craniotomy. The Indian paper was a recount of a neurosurgeon's experience as a spine patient. Conclusions: There are few studies on neurosurgery patient perception in LMICs. LMIC neurosurgeons should be encouraged to study their patient beliefs concerning neurosurgical diseases and interventions, as this can explain health-seeking behaviors.

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Objective: The aim of the present work was to propose and implement deep neural network (DNN)-based handheld diagnosis system for more accurate diagnosis and severity assessment of individuals with autism spectrum disorder (ASD). Methods: Initially, the learning of the proposed system for ASD diagnosis was performed by implementing DNN algorithms such as a convolutional neural network (CNN) and long short-term memory (LSTM), and multilayer perceptron (MLP) with DSM-V based acquired dataset. The performance of the DNN algorithms was analyzed based on parameters viz. accuracy, loss, mean squared error (MSE), precision, recall, and area under the curve (AUC) during the training and validation process. Later, the optimum DNN algorithm, among the tested algorithms, was implemented on handheld diagnosis system (HDS) and the performance of HDS was analyzed. The stability of proposed DNN-based HDS was validated with the dataset group of 20 ASD and 20 typically developed (TD) individuals. Results: It was observed during comparative analysis that LSTM resulted better in ASD diagnosis as compared to other artificial intelligence (AI) algorithms such as CNN and MLP since LSTM showed stabilized results achieving maximum accuracy in less consumption of epochs with minimum MSE and loss. Further, the LSTM based proposed HDS for ASD achieved optimum results with 100% accuracy in reference to DSM-V, which was validated statistically using a group of ASD and TD individuals. Conclusion: The use of advanced AI algorithms could play an important role in the diagnosis of ASD in today's era. Since the proposed LSTM based HDS for ASD and determination of its severity provided accurate results with maximum accuracy with reference to DSM-V criteria, the proposed HDS could be the best alternative to the manual diagnosis system for diagnosis of ASD.

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Background: Measurement of two-point discrimination (2-PD) is used in clinical practice to evaluate the severity of nerve injuries, neuropathy, and recovery of patients following nerve repair. Commercially available 2-PD testing devices are costly and therefore not available everywhere. Methods and Material: We made an economical indigenous 2-PD testing device from off-the-shelf components and tested its efficacy in volunteers. Statistical Analysis: The data were analyzed using Minitab Statistical Software Version 17.0 and Kappa statistics were used in the assessment of agreement between two devices. Results: A total of 30 (23 men, 7 women) subjects were included in the study. There was good agreement between the measurements of static 2-PD with the two different test devices: from fair (Kappa = 0.408, P = 0.018) to strong (Kappa = 0.618–0.795, P = 0.000). Conclusions: This device is simple to make, very economical, and obtains accurate 2-PD measurements.

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Cerebral sinus venous thrombosis is an uncommon complication of hypernatremic dehydration in neonates. Non-improvement in neurological status even after correction of hypernatremia should lead to suspicion of intracranial complications due to hypernatremia or its overtreatment. Slow correction of hypernatremia, calculated fluid administration, and anticoagulation improve outcome in neonates with CSVT.

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Background: Transient ischemic attack (TIA) is a super warning for cerebral infarction stroke, thus probe of sensitive biomarker for TIA diagnosis and prognosis can contribute to make an optimal intervention plan. Objective: This study was conducted to explore the value of ischemic modified albumin (IMA) and microRNA-12miR-126 on the diagnosis of posterior circulation TIA and the prediction of secondary cerebral infarction. Study Design: This study was conducted as a longitudinal prospective research. Methods: The levels of serum IMA and miR-126 at 3h, 6h and 12h after TIA onset were analyzed in 106 patients, then the predictive value of IMA and miR-126 for secondary cerebral infarction were tested. Results: A significant increase of serum IMA and a decrease of miR-126 were observed after TIA onset (P = 0.000),simultaneously a significant negative correlation was found between serum IMA for 3 h and miR-126 for 12 hr=-0.401, P = 0.000. Both IMA and miR-126 were significant associated with the secondary cerebral infarction. Conclusion: Early detection of IMA and miR-126 is of great value in diagnosing posterior circulation TIA and predicting the secondary cerebral infarction.

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Background: Information regarding the clinical presentation and outcome of Guillain-Barré Syndrome (GBS) in adults from Latin America is limited. Objective: To identify clinical characteristics and short-term outcome predictors in adult Mexican patients with GBS. Patients and Methods: We included adult patients with clinical and electrophysiological data with confirmed GBS, admitted to a tertiary hospital in Western Mexico, from January 2002 to February 2011. A good outcome at hospital discharge was considered if patients had a Hughes score of 0–2 and at 3 and 6 months, a Hughes score of 0–1. Results: A total of 115 patients were analyzed (68% men, mean age 44 years old, range 18–84). Previous infection occurred in 63% of cases. Descendent pattern of weakness was observed in 40 (35%) patients. GBS subtypes were: acute motor axonal neuropathy in 31%, acute inflammatory demyelinating polyneuropathy in 29%, sensory axonal neuropathy (AMSAN) in 18%, and equivocal in 22%. A total of 73 (63%) patients received induction therapy: 50 (68%) received plasmapheresis and 13 (18%) received intravenous immunoglobulin (IVIG). In-hospital mortality occurred in 14 (12%) patients. Early gait complaints and emergency room admission with mild Hughes score (0-2) were predictors for a good outcome at hospital discharge (P < 0.05); meanwhile, age >75 years; dysarthria and higher Hughes score were associated with a poor outcome(P < 0.05). Conclusions: Axonal pattern, motor involvement, and the descendent pattern of presentation were the main clinical GBS findings in our cohort. Higher Hughes scale scores at hospital admission were a strong predictor for a bad outcome at hospital discharge and short-term follow-up, independently of treatment type or in-hospital management. GBS in Mexico still carries considerable mortality.

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Context: A host of microRNAs have been reported to suppress tumor growth, invasion, and metastasis and play roles in neurodegeneration disorders. Moreover, microRNA changes are found in the peripheral blood, cerebrospinal fluid (CSF), and brain tissues of central nervous system diseases, including glioma, Alzheimer's disease (AD), Parkinson's disease (PD), multiple sclerosis, and depression. Compared with other body fluids, CSF can reflect the brain pathological processes more accurately. Aims: To understand whether microRNA expression may be misregulated in patients with PD, and further discover potential diagnostic biomarkers and promising therapeutic targets for PD. Materials and Methods: Here, through real-time reverse-transcription polymerase chain reaction (RT-PCR), we compared CSF microRNA from 15 PD patients, 11 AD patients, and 16 controls with other neurologic disorders, such as encephalitis and Guillain–Barre syndrome. Results: Finally, we identified hsa-miR-626 changes in the CSF of PD patients. The mean expression level of hsa-miR-626 was significantly reduced in the CSF of PD patients compared with AD patients and controls. Conclusions: Our approach provides a preliminary research for identifying biomarkers in the CSF that could be used for the detection, diagnosis, and monitoring of PD.

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Background: As the world faces a new viral pandemic, which has spread very rapidly, initial response from most countries was to suspend nonemergent health services so that available resources can be diverted to handle the large numbers of patients with COVID-19 infection. Many societies issued guidelines to suspend or postpone nonemergent surgeries. Methods: We reviewed the emerging evidence regarding the impact of COVID-19 infection in neurosurgery and the postponement of elective surgeries. Results and Observations: COVID-19 infection poses serious threat in hospitals in the form of cross-infection, hospital staff falling sick, with potential risk to overwhelm or paralyze the healthcare. In addition, we have come to realize the significant perioperative morbidity and mortality secondary to active COVID-19 infection. All these strongly favor suspension of elective neurosurgical services. However, these have to be weighed against the fallout due to prolonged postponement of neurosurgical treatment for conditions, which can progress and cause neurological deterioration. Conclusion: This article discusses the contemporary published literature regarding the perioperative risk of COVID-19 infection, impact of postponed surgeries, challenges, risk assessment and guidelines for elective neurosurgery at this point of time.

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Background: Telomerase reverse transcriptase promoter (pTERT) mutation is a dominant altered telomere maintenance mechanism in primary glioblastomas (GBMs). Objective: The aim of this study was to correlate pTERT mutations with clinico-histological features and other molecular markers (p53 protein-expression, ATRX protein-expression, IDH mutations, EGFR gene amplification and MGMT methylation) in adult GBMs. Materials and Methods: Evaluated for histological patterns, p53 and ATRX protein expression by immunohistochemistry (IHC), IDH mutations by IHC followed by sequencing in IHC negative cases, EGFR gene amplification by fluorescence in situ hybridization, MGMT promoter methylation by methylation-specific PCR and pTERT mutation by sequencing. Results: A total of 155 adult supratentorial GBMs [age-range 20-80 years] formed study cohort. 15.6% were IDH1R132 mutated, none were IDH2R172 mutated and 27% were EGFR amplified. 43% were MGMT methylated and were more common with IDH-mutation (mIDH) than EGFR amplification. 90% of mIDH (but no EGFR amplified) cases showed ATRX-loss. 43.5% were pTERT mutated (C228T was the commonest type) and were mutually exclusive with ATRX-loss. 14% of mIDH and 42% of EGFR amplified cases showed pTERT mutation, the latter was more commonly pMGMT unmethylated (63.6%). Conclusions: 43.5% of the GBMs showed pTERT mutation (C228T was commonest; 72%). pTERT mutations were mutually exclusive with ATRX protein loss, more commonly associated with IDH wild type and EGFR amplified GBMs.

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Background and Introduction: Deep brain stimulation (DBS) has been increasingly used in the treatment of refractory epilepsy with remarkable safety. Experimental data demonstrated that electric current could modulate distinct brain circuits and decrease neuronal hypersynchronization seen in epileptic activity. The ability to carefully choose the most suitable anatomical target and precisely implant the lead is of extreme importance for satisfactory outcomes. Objective: This video aimed to explore the targeting of the three most relevant nuclei in the treatment of refractory epilepsy. Technique: Through a step-by-step approach, this video describes the surgical planning for DBS implantation in the anterior nucleus of the thalamus (ANT), the centromedian nucleus of the thalamus (CM), and the hippocampus (HIP). Conclusion: Each of the discussed targets has its own pearls and pitfalls that should be considered for an adequate lead placement. Accurate planning of the surgical procedure is essential for achieving optimal results.

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To study the efficacy and safety of intravenous thrombolysis for the older acute ischemic stroke patients, clinical data were prospectively analyzed from 168 patients with acute ischemic stroke including 42 older adult patients (ET group), 66 younger patients (NET group) treated with rt-PA, and 60 older adult patients treated without rt-PA (ENT group). Stroke severity was assessed with an NIHSS score at baseline, 1-day and 14-day after treatment. Functional outcomes were evaluated by the modified Rankin scale and a Barthel index. Adverse effects were observed during the treatment. The rate of “good” prognosis was higher in the ET group than that in the ENT group at 90 days post-stroke. In older patients with stroke, thrombolytic therapy was found to be of greater benefit to patients with lower NIHSS scores at baseline, or patients classified as posterior circulation infarction, than for patients with higher NIHSS scores or infarctions located in other brain regions. Thrombolytic therapy may exhibit long-term efficacy by improving the future quality of life for older stroke patients with fewer bleeding risk factors and lower baseline NIHSS scores.

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Aim: The aim of this case series is to report two cases of giant cavernomas treated at a tertiary level centre along with a literature review on the differences between giant cavernomas and normal sized cavernomas. Method: The first case was that of a 13-year-old male with habitual seizures since one year of age with normal examination findings. His imaging revealed a large parieto-occipital lesion which was excised microsurgically after a parieto-occipital craniotomy and a transcortical approach. The second case was a 26-year-old male who presented with generalised seizures and bilateral visual loss. Imaging was suggestive of a large left lateral ventricular lesion. A left fronto-temporo-parietal craniotomy was done followed by transventricular microsurgical excision. Histopathology of both cases were reported to be cavernomas. The first patient had transient hemiparesis post-operatively which improved within 24 hours. Eventually, both patients had an uneventful follow-up. Conclusion: Microsurgical excision remains the treatment of choice for giant cavernomas. In toto excision may be advocated depending upon the location of the cavernoma especially with respect to eloquence and venous anatomy.

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The Department of Neurosurgery at KEM Hospital, Seth G S Medical College, Mumbai, was founded by Dr H. M. Dastur in 1956. The department from its inception performed all diagnostic Neuro-Radiological procedures, angiography, ventriculography, pneumo-encephalography, and myelography. In 1976 transfemoral cerebral angiography was started by Dr S K Pandya. In 1978 he started performing interventional procedures. In 1980, Dr Anil Karapurkar went for training in Neuro-Intervention to Nancy, France, under Prof. Luc Picard. Thereafter all neurointerventions, cranial, and spinal, were performed routinely.

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Background: Small vessel disease (SVD) is the underlying anatomical substrate for both lacunar infarction and subcortical hemorrhage. Aim: To assess predictive factors of ischemic or hemorrhagic stroke in patients with cerebral SVD. Materials and Methods: Prospective hospital-based stroke registry (“The Sagrat Cor Hospital of Barcelona Stroke Registry”) in an acute-care teaching hospital in Barcelona, Spain. From 4597 acute stroke patients included in the stroke registry over a 24-year period, 440 cases of lacunar stroke and 210 of subcortical intracerebral hemorrhage were selected. Demographics, clinical characteristics, risk factors, and early outcome were compared. Predictors of lacuna versus subcortical hemorrhage were assessed by multivariate analyses. Results: In a logistic regression model based on demographics, risk factors, clinical features and outcome, dyslipidemia (odds ratio [OR] 2.06 (95% confidence interval (CI) 1.17-3.62) and diabetes (OR 1.97, 95% CI 1.19–3.26) were independent risk factors for lacunar infarction. Anticoagulation therapy (OR 0.05, 95% CI 0.01–0.28), sudden onset (OR 0.51, 95% CI 0.33–0.78), motor symptoms (OR 0.44, 95% CI 0.26–0.76), headache (OR 0.23, 95% CI 0.12–0.41), altered consciousness (OR 0.10, 95% CI 0.05–0.21), respiratory complications (OR 0.19, 95% CI 0.08–0.46), and in-hospital death (OR 0.08, 95% CI 0.02–0.36) were predictors of subcortical hemorrhage. Conclusion: Identification of differential clinical and prognostic profile between ischemic and hemorrhagic consequences of underlying cerebral SVD is useful for risk stratification in the current process pursuing precision medicine.

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The chromosome 22q11.2 region is highly susceptible to both microdeletions and microduplications that have been known to be responsible for multiple congenital anomaly disorders. We describe a patient of 22q11.2 duplication syndrome presenting with bilateral ptosis who has normal psychomotor development. Cranial magnetic resonance imaging and electromyography with repetitive nerve stimulation were normal. Chromosome microarray analysis was performed, and the patient was found to have a de novo 2.8 Mb duplication at 22q11.21. To our knowledge, bilateral ptosis and normal psychomotor development with 22q11.2 duplication syndrome has not been described. The 22q11.2 duplication syndrome should be considered in the differential diagnosis of ptosis. This case report contributes to an expanding clinical spectrum of patients with 22q11.2 duplication syndrome.

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Introduction: Verbal fluency test is a short psychometric test, which is sensitive to verbal ability and executive control impairment. We did not find studies that analyze verbal fluency in relation to the neurodevelopmental disorders in Spanish-speaking children with letters P-M. Our objective was to analyze the verbal fluency of Spanish-speaking children with neurodevelopmental disorders. Method: We carried out a retrospective cross-sectional study to analyze the performance of children who had undergone a neuropsychological assessment. Results: We included 164 patients. There were 55 (33.54%) patients with low intellectual performance (LIP), 19 (11.59%) patients with dyslexia , and 90 (54.88%) patients had an ADHD. Patients with LIP showed lower phonological fluency than patients with ADHD. As for semantic fluidity, differences were observed between patients with LIP and ADHD and also between LIP and dyslexia. The probability of having LIP was 9.6 times greater when somebody had a scale score lower than 7 in the PF task and it was 16.7 times greater when the scale score was lower than 7 in the SF task. Conclusions: There was a direct relationship between FSIQ and the performance in verbal fluency test, which is a brief and effective neuropsychological test in revealing deficits in executive functions, verbal abilities, and LIP.

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Background: Traumatic brain injury (TBI) leads to various sequelae that affect the day-to-day functioning of patients. However, there is a dearth of studies investigating these sequelae in complicated mild TBI and moderate TBI patients. Objective: The prime objective of the present study was to present the neurocognitive and affective profile of complicated mild and moderate TBI patients along with to compare the neurocognitive and affective sequelae in patients with complicated mild and moderate TBI. Materials and Methods: Twenty-two patients with complicated mild TBI and 17 patients with Moderate TBI, each with an intracranial lesion were recruited from level 1 trauma center in Varanasi. All patients were assessed with neurocognitive measures, Rivermead Post Concussive Symptoms Questionnaire, and Hospital Anxiety and Depression Scale. The patients' profiles were presented as clinical series using descriptive analysis. Further, comparison was done by using the Chi-square test and Fisher's exact test. Results: Findings revealed that complicated mild TBI patients reported significantly higher psychological distress and post head injury symptoms in comparison to patients with moderate TBI. Further, the complicated mild TBI and moderate TBI groups showed differences with respect to verbal fluency, mental speed, and flexibility tasks. Conclusions: Complicated mild TBI and moderate TBI groups have not differed significantly on most of the cognitive tasks. Furthermore, affective symptoms were found more prominent in complicated mild TBI group as compared to the moderate TBI group.

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Background: The anaesthetic mandate for a combination of electrocorticography (ECoG) and subcortical motor evoked potential mapping (SCMEPM) substantially differs from that required for each of these monitors in isolation. There is no current consensus defining the anaesthetic management for intraoperative multimodal monitoring combining these two modalities. Case description: We report our experience of anaesthetising a drug resistant epileptic patient for craniotomy and resection of his frontal gliotic lesion. We propose a novel anaesthetic technique to cater to the multiple goals of this surgery like optimal neuromonitoring under adequate depth of anaesthesia. We used balanced anaesthesia technique. Continuous intravenous (IV) infusions of Inj. Dexmedetomidine of 1.5 mcg/kg/hour and Inj. Ketamine at 0.5mg/kg/hour were used to supplement inhalational anaesthetic titrated to a MAC up to 0.5. Neuromuscular blockade was avoided after the initial tracheal intubation dose. Conclusion: To the best of our knowledge, this is the first case reporting the safety and efficacy of balanced anaesthetic technique for concurrent ECoG and SCMEPM. Successful intraoperative ECoG and SCMEPM monitoring with absent intraoperative awareness confirmed the safety of our anaesthetic technique. Through this, a composite of patient safety, surgeon satisfaction and adequate intraoperative monitoring could be achieved.

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Background: Although the nonsurgical treatment for idiopathic intracranial hypertension (IIH) involves weight loss, diuretics, and steroids, surgical intervention is required if there is a worsening of symptoms or visual deterioration. Objective: To determine the efficacy and complications of transcranial optic nerve sheath fenestration (ONSF) using an ultrasonic aspirator as an adjunct in the treatment of refractory IIH. Material and Methods: This prospective study included all patients with medically refractory IIH with visual deterioration from November 2017 to June 2019. Pterional craniotomy was followed by extradural clinoidectomy and optic foramen bony decompression using an ultrasonic aspirator. All the cases were followed up for changes in visual acuity and field and surgical outcomes. Results: A total of 21 consecutive patients who underwent ONSF in the study period were included for analysis. Improvement in visual acuity was noted in 19/21 (90.47%) patients. Improvement in visual fields was noted in 17/21 (80.95%). Headache improved in 66.67% of patients. Improvement in the fundus picture was noted in 90.47%. Symptoms < 6 months showed better results compared to > 6 months symptom, although statistically nonsignificant (P = 0.2556). A 270-degree optic canal decompression was achieved in all the cases. Conclusion: Transcranial optic nerve sheath decompression with a bone ultrasonic aspirator is a safe and direct decompression of the optic nerve in malignant/refractory cases of IIH.

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Aim: The aim of this study was to assess the clinico-epidemiological profile, etiology, and imaging findings in neonatal stroke (NS). Materials and Methods: This was a retrospective, observational study on neonates presenting with stroke between August 2014 and July 2016 to a tertiary care hospital in eastern India. Results: In all, 43 neonates were analyzed, with a male-to-female ratio of 2.3:1. About 88% babies were born at term and the rest were preterm. In 37%, the etiology of stroke was related to hypoxic injury, 21% had sepsis, and 35% had idiopathic causes. Seizures were the most common mode of presentation (62%) followed by poor feeding, abnormal tone, recurrent apnea, encephalopathy, and hemiparesis. There was an almost equal prevalence of ischemic stroke (53%) and hemorrhagic stroke (HS). Middle cerebral artery territory was the primary site of involvement in arterial ischemic stroke, and intra ventricular hemorrhage was the most common presentation of HS. Conclusion: NS is an acute emergency with high morbidity and mortality. Magnetic resonance imaging helps in diagnosis and prognostication in the absence or paucity of focal neurological signs in neonates.

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Objective: Preliminary study of magnetic resonance (MR) diffusion kurtosis imaging (DKI) assessing the pathological glial fibrillary acidic protein (GFAP), TopoIIα, and O 6-methylguanine–DNA methyltransferase (MGMT) expression in astrocytomas. Materials and Methods: This study was approved by the local ethics committee, and informed consent was obtained from all participants. Sixty-six cases with pathologically proven astrocytomas were enrolled in this study; of which, 34 were high grade and remaining 32 were low grade. They patients underwent conventional MRI head scan, DKI scan, and enhanced scan under the same conditions. Fractional anisotropy (FA) and mean kurtosis (MK) calculated from DKI, as well as GFAP, TopoIIα, and MGMT expression level were compared prospectively between high and low-grade astrocytomas. Spearman rank correlation analysis was used for comparing values of DKI and GFAP, TopoIIα, and MGMT expression level in the two groups. Results: The MK values were significantly higher in high-grade astrocytomas than those in low-grade astrocytomas (P < 0.05); FA values demonstrated no significant difference between the two groups (P = 0.331). GFAP expression level was significantly lower in high-grade astrocytomas than in low-grade astrocytomas (P < 0.05). Topo-IIα expression level were significantly higher in high-grade astrocytomas than in low-grade astrocytomas (P < 0.05). There was no significant difference in MGMT expression level between the two groups (P = 0.679). MK values were negatively correlated with the expression of GFAP (r = -0.836; P = 0.03), however, they were positively correlated with the expression of Topo-IIα (r = 0.896; P = 0.01). FA values were not correlated with the expression of GFAP (r = 0.366; P = 0.05), Topo-IIα (r = −0.562; P = 0.05), and MGMT (r = −0.153; P = 0.10). Conclusion: MK, the DKI parameter values of astrocytomas, was significantly correlated to the expression of GFAP and TopoIIα. To a certain extent, applying DKI may provide the biological behavior of tumor cell differentiation, proliferation activity, invasion and metastasis, and can guide individual treatment.

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Background and Aims: Extracranial vertebral artery aneurysms are a rare cause of embolic stroke; various surgical and endovascular treatment options are available. Methods: We report a 44-year-old man with a symptomatic proximal extracranial vertebral artery aneurysm of unclear etiology. The patient presented with brainstem infarction, and the diagnosis of primary extracranial vertebral artery aneurysm was made by computed tomography angiography (CTA). Results: This patient's aneurysm was definitively treated using an endovascular approach with placement of a covered stent in the right proximal vertebral artery. Conclusion: Although aneurysms of this location are traditionally repaired with open aneurysmectomy, we show that endovascular treatment can be a safe and effective alternative approach. In the case reported here, primary extracranial vertebral artery aneurysm presenting with embolic stroke was successfully treated with a covered stent. Complete exclusion of the aneurysm from blood circulation is advisable to achieve full resolution of the embolic source.

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Blepharoptosis (ptosis) is classified, based on etiology, into mechanical, cerebral, neurogenic, neuromuscular, myogenic, and due to miscellaneous causes. Primary myopathic diseases are rare causes of blepharoptosis and many patients with myogenic ptosis undergo a series of extensive investigations before a myopathy is being considered. In this study, we report four patients with different myopathic disorders who had blepharoptosis as a presenting symptom of their disease. Moreover, we highlight frequent diagnostic errors and difficulties in patients with myopathies who present blepharoptosis. Lack of clear cut aggravation of symptoms by fatigue and response to cholinesterase inhibitors treatment, the association of proximal, distal or extraocular muscle weakness, and positive family history or evidence of a multi systemic disorder should prompt evaluation of an underlying myopathy.

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We report about two young males who developed significant proximal weakness of all four limbs secondary to intracranial hypertension due to intracranial venous sinus thrombosis. Intracranial venous sinus thrombosis can manifest in a variety of ways which includes isolated intracranial hypertension, focal neurological symptoms or signs and acute or subacute encephalopathy. Various false localising signs have been reported to occur in patients with raised intracranial pressure including cranial nerve palsies and extensive radiculopathy. In a patient presenting with flaccid areflexic quadriparesis and papilledema, the possibility of a potentially reversible dysfunction of the cranial nerves and spinal nerve roots due to a marked rise in intracranial and intraspinal pressure must be recognised. Lumboperitoneal shunt to reduce the intraspinal pressure on the spinal nerve roots has been advocated to reverse the symptoms of extensive radiculopathy in such patients. Both of our patients showed remarkable improvement in symptoms and signs with medical treatment of CVT.

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Toxic encephalopathy is an important differential diagnosis in a child with encephalopathy and seizures. Subtle circumstantial evidence and apt neuroimaging features can significantly contribute to management, especially in a case of accidental exposure. 2, 4-D (ethyl ester) poisoning is a rare diagnosis, despite the common usage of this toxic compound as weedicide in northern India. The clinical similarity to the anticholinesterase poisoning, especially in the setting of agrochemical exposure is the main cause of under-diagnosis with usually fatal outcomes. We present an interesting case of accidental 2, 4-D (ethyl ester) poisoning in a child with typical neuroimaging features. A review of the literature regarding neuroimaging patterns of bilaterally symmetrical signal abnormalities involving basal ganglia in brain magnetic resonance imaging (MRI) from the point of view of clinical significance, is also discussed.

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Background: Anti α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis is a rare autoimmune encephalitis. They present with memory, confusion or behavioral changes. Objective: The aim of this study was to describe unusual clinical features in a patient with AMPAR-associated encephalitis. Case: A 42-year-old female presented to us with bulbar and gait disturbances of three weeks duration and behavioral changes for ten days. She was found to have memory impairment along with psychosis. She had left eye ptosis, restricted eye movements, sluggish deep tendon reflexes, and bilateral cerebellar signs. Her serum and CSF (cerebrospinal fluid) AMPAR2 antibodies were strongly positive; CT (computed tomography) chest showed evidence of Thymoma. She was treated with steroids with significant improvement initially but expired within 3 months of diagnosis. Conclusion: This is the first report of AMPAR associated encephalitis from India presenting with unique clinical features affecting both the CNS (central nervous system)––(psychosis, ataxia, cognition) and PNS––peripheral nervous system involvement (ptosis, restricted eye movements, bulbar disturbances).

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We report a 40-year-old male who presented with seizures due to hypocalcemia. Biochemical evaluation revealed the diagnosis of hypoparathyroidism. The symptom complex of dysmorphic facies and intellectual disability along with hypoparathyroidism led to a suspicion of 22q11.2 microdeletion syndrome (22q11.2DS), which was confirmed by multiplex ligation-dependent probe amplification (MLPA) analysis showing 22q11.2.21 microdeletion.

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