Background: Stroke is a heterogeneous disorder comprising of clinical subtypes and many risk factors, also alluded to as cerebrovascular disorders (CVDs). Increase in the global burden of stroke in developed and developing countries has been alarming. To galvanize the efforts towards the prevention and treatment, there is a need for robust data on the burden of stroke. Objective: The aim of this study was to estimate the burden of stroke, a systematic review of community-based studies was conducted. Material and Methods: Systematic search of PubMed and Google Scholar for studies from January 1960 to December 2018 was done. The articles were screened and the data was retrieved and sorted into incidence, prevalence and mortality rates. Meta-analysis was done on Medcalc statistical software version 19.2.6. Results: Prevalence rate of stroke for total population inclusive of urban and rural population, varied from 44.54 to 150/100000.For the urban population prevalence rate was 45 to 487/100000 and 55 to 388.4/100000 for rural population. The incidence rate varied from 33 to 123/100000 in the urban population and in the rural population it was estimated to be 123.57/100000. The 30 days case fatality rate of stroke varied from 41.08% to 42.06% in urban population and 18% to 46.3%.in the rural population. Conclusions: Systematic review and meta-analysis reveal that the stroke burden in India is quite high.

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Context: Autologous bone is the most commonly used flap in cranioplasty to repair the defect; however, synthetic materials are available. Poly methyl methacrylate (PMMA) is an effective polymer owing to its thermoplastic and radiolucent properties comparable to bone strength. Three-dimensional (3D) printing combined with computer-assisted design (CAD) is a simple, low-cost method to print molds that ensure surgical success. Materials and Methods: A total of 114 patients underwent cranioplasty (July 2015–April 2018), and 25 of them using 3D printed template molds due to unavailability of autologous bone. The clinical features, patient demographics, and surgical parameters were analyzed. The visual analog score for cosmesis (VASC) and Odom's score was obtained pre and post-op. Results: The mean age of the patients is 38.4 ± 14.6 years (Range, 9–66). The primary pathology for undergoing craniectomy is stroke (n = 13; 52%), traumatic brain injury (10; 40%) and tumor (2; 8%). The reason for nonavailability of flap was infection (n = 14;56%), flap resorption (4;16%), and trauma or tumor (7;28%). The mean time for manufacturing the 3D printed template is 13.2 ± 2.1 h. On follow-up, median Odom's score is excellent in 52% of cases, good in 40%, and fair in 8%. The mean VASC score on follow up is 8.2 ± 1.3. Three patients developed minor postoperative complications. Conclusion: This is the first study from a single tertiary care center in India to systematically evaluate the outcomes in 3D cranioplasty using CAD and 3D printing technology. This method would be optimal especially in developing countries since PMMA is cost effective and also gives an ideal cosmetic effect.

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Background and Purpose: Epilepsy during pregnancy is a therapeutic challenge. Since the 1990s, the number of licensed antiepileptic drugs has substantially increased, but safety data on managing epilepsy during conception, pregnancy, and postpartum period use of newer generation antiepileptic drugs and birth defects are limited. We analyzed efficacy and safety of levetiracetam during pregnancy in northeast Indian women with active epilepsy (WWAE) which is being presented here. Design: Hospital based retrospective study. Patients and Methods: A retrospective analysis was conducted based on clinical records at a tertiary care teaching hospital and referral center in Northeast India between June 2008 through June 2018 without any personal identifying information. The Obstetric data from pregnancy register was supplemented with detailed neurologic data retrieved from medical records. Results: Of 103 women with active epilepsy, 47 (45.6%) received levetiracetam as monotherapy and 56 (54.4%) as polytherapy. During pregnancy, the seizure frequency was unchanged, or the change was better in the majority (61.1%) of the patients. With one twin pregnancy, there were 96 live births, 5 spontaneous abortions, 2 induced abortions, 1 stillbirth. However, the rate of small for gestational age was higher in WWAE, Apgar score at 5 min was lower in infants of WWAE, and the need for care in the neonatal ward and neonatal intensive care was higher. Seven of 103 exposed pregnancies had a major congenital malformation (6.79%), all 7 were exposed to other antiepileptic drugs. Generalized epilepsy accounted for 57.2%. Conclusion: Pregnancy course is uncomplicated and neonatal outcome is good in the majority of women with active epilepsy with proper antenatal and neurologic care. Levetiracetam taken in monotherapy can be considered as safer alternative for women with epilepsy of childbearing age. Long-term follow-up of neuropsychological and cognitive development of the children of WWAE is still needed.

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Background: The study of seizure patterns in electroencephalography (EEG) requires several years of intensive training. In addition, inadequate training and human error may lead to misinterpretation and incorrect diagnosis. Artificial intelligence (AI)-based automated seizure detection systems hold an exciting potential to create paradigms for proper diagnosis and interpretation. AI holds the promise to transform healthcare into a system where machines and humans can work together to provide an accurate, timely diagnosis, and treatment to the patients. Objective: This article presents a brief overview of research on the use of AI systems for pattern recognition in EEG for clinical diagnosis. Material and Methods: The article begins with the need for understanding nonstationary signals such as EEG and simplifying their complexity for accurate pattern recognition in medical diagnosis. It also explains the core concepts of AI, machine learning (ML), and deep learning (DL) methods. Results and Conclusions: In this present context of epilepsy diagnosis, AI may work in two ways; first by creating visual representations (e.g., color-coded paradigms), which allow persons with limited training to make a diagnosis. The second is by directly explaining a complete automated analysis, which of course requires more complex paradigms than the previous one. We also clarify that AI is not about replacing doctors and strongly emphasize the need for domain knowledge in building robust AI models that can work in real-time scenarios rendering good detection accuracy in a minimum amount of time.

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Cavernous sinus hemangioma (CSH) are notoriously difficult to excise because of their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures. Radiosurgery offers an alternative treatment modality in cases of small and medium-sized CSH. However, no reports are available in the world literature detailing gamma knife radiosurgery (GKRS) in large (3–4 cm) and giant (>4 cm) CSH. Two patients with giant CSH (Tumor volume was 72.2 and 99.8 cm³, respectively) were treated with frame-based fractionated GKRS (5 Gy × 5 #). The treatment was done with Leksell Perfexion with frame in situ and interfraction interval of 24 h. The tumor was engulfing the optic apparatus, and chiasma could not be separated delineated. The patients were followed at 3 months interval with clinic–radiologic evaluation. Following GKRS, both patients showed remarkable clinical improvement in presenting complaints of headache and visual deterioration. Sixth nerve paresis recovered completely in case no. 1. Significant reduction in tumor volumes (85.1 and 75.6% respectively) was noticed in both the patients at 6 months follow-up radiology. Transient alopecia was noted in case 1 at 3 months follow-up that completely resolved by the 6 months. There was no complication till the last follow-up of 9 months. We report the first account of five fraction frame-based hypo fractionated GKRS for giant CSH. At an interval as short as 3 months, giant CSH shows remarkable clinical improvement. Primary hypofractionated GKRS may be considered an alternative effective modality in these difficult lesions with a favorable safety profile.

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Background: Surgical revascularization is the mainstay of treatment in symptomatic patients of moyamoya disease (MMD). Objective: The present study analyzed the postoperative angio-architecture in pediatric and adult patients of moyamoya disease. Material and Methods: Patients with MMD, both ischemic and hemorrhagic, were subjected to surgery. A superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was attempted in all. It was augmented by an encephalo-duro-myo-synangiosis), this was labelled as the combined surgical group. In patients where a direct bypass was not possible encephalo-duro-arterio-myo-synangiosis (EDAMS) was performed and these patients were put in the indirect surgery group. In the postoperative period, MRA was performed in all patients to look for (a) graft patency, (b) regression of moyamoya vessels, and (c) degree of surgical neovascularization (as quantified on adapted Matsushima and Inaba grading system). Results: Eighty-two patients underwent 131 surgical revascularization procedures. A combined surgery (STA-MCA bypass and EDAMS) was performed in 100 hemispheres and indirect surgery (EDAMS) on 31 sides. In children less than 5 years of age, STA-MCA anastomosis was possible in more than 50% of patients. Clinical improvement was seen in 85.4% of patients. Postoperative MRA demonstrated a patent bypass graft in 97% of cases. Regression of moyamoya vessels was seen in half of the cases and good surgical revascularization (type A and B) was seen in more than 80% of hemispheres in the combined surgery and indirect surgery group. Conclusions: Revascularization procedures led to a regression of moyamoya collaterals, appearance of surgical neo angiogenesis, and a graft patency rate of 97%. Surgical group with combined revascularization had a trend towards better collateral development.

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The incidence of cerebral aneurysms is rare in children, and it has to be definitively ruled out in all cases of intracranial bleed even if there is associated history of trauma. We report a case of 11-month-old girl who presented with intracranial bleed after a history of minor trauma whose diagnosis of an intracranial aneurysm was initially missed which later led to a rebleed. It was managed emergently with endovascular coiling and the patient showed incredible recovery in the post-operative period.

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Background: The role of viral infections in multiple sclerosis (MS) pathogenesis is unclear. Objective: Certain neurotropic viruses previously linked with MS among white population were studied including Epstein–Barr virus, human herpesvirus-6 (HHV-6) and MS-associated retrovirus (MSRV). Material and Methods: Sixty-two MS patients (37 had a recent clinical relapse) and 65 controls with other neurological disorders were included. Blood and cerebrospinal fluid (CSF) samples were obtained and processed with the primary objective of determining whether there was intrathecal multiplication of viruses under study (EBV, HHV6 A and B and human endogenous retrovirus) or a breach in blood–brain barrier associated with viral presence in both peripheral blood and CSF. Results: Evidence of breach in blood–brain barrier was seen in 86.5% of patients as evidenced by abnormal CSF/serum albumin index and or MRI. EBV nuclear antigen (EBNA1 IgG) was seen in 89% of MS patients and 58% controls (P = <0.001). However, HHV6 IgG was similar in both groups (85% versus 81%; P = 0.45). In affinity immunoblotting reaction intrathecal IgG synthesis against EBNA1 antigen was demonstrable in 26% (16/62) of patients and none against HHV6. A subset of patients showed significant elevation in mean copy number of plasma EBV DNA during relapse and there was a trend for the same among patients harboring HHV-6B. No evidence of isolated intrathecal viral presence or multiplication was seen. Conclusions: The results of our study suggest that viruses studied namely EBV and HHV6 have a role in triggering relapses through a peripheral mechanism, rather than a direct role through intrathecal multiplication.

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Vestibular schwannoma surgery is a challenging operative procedure. Intricate anatomy of vital neurovascular structures demands a meticulous planning and execution. The cerebellopontine angle is an unforgiving area of skull bases surgery which can have grave implications on patient outcome even after a successful tumor removal. As more and more tumors are being detected at early stage, functional preservation of seventh and eighth nerve complex is increasingly being demanded. The key to any minimally invasive approach is to minimize the collateral damage while ensuring complete tumor removal. Binocular microscopy is the workhorse for illumination and dissection via retrosigmoid approach. However, as instrumentation has improved, endoscopic dissections are increasingly being performed. The following video presents the step-by-step nuances for an endoscope-assisted microsurgery for small vestibular schwannomas with stress on endoscopic drilling of the meatal wall to deliver out intracanacular tumor while preserving the labrynthine structures.

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Myxomas are the most common cardiac tumors and present clinically with cardiac manifestations, systemic constitutional symptoms, and embolic events. Posterior circulation involvement occurs in approximately 20 percent of cerebral ischemic events.The endovascular technique is an established life-saving therapy for eligible patients upto 24 hours from symptom onset. However, the role of endovascular management in embolic atrial myxoma remains unknown with no international consensus guidelines for the management of stroke in such patient population. Here, we present a case report of an embolic posterior circulation stroke in a young female treated with mechanical thrombectomy at 23 hours from symptom onset. To the best of our knowledge, this is the first thrombectomy case in posterior circulation with embolism from myxoma. Further workup confirmed an atrial myxoma which was resected. We also review the previous cases with mechanical thrombectomy done in such cases.

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Idiopathic trigeminal neuralgia (TN) due to an embedded arteriovenous malformation (AVM) on the trigeminal root entry zone (REZ) is rare but a potentially challenging condition to manage. Herein, we report such a case with an additional unruptured aneurysm on the feeding artery and highlight the role of a multimodality approach to their management. A 50-year-old female presented with drug-resistant right-sided trigeminal neuralgia for one year. The magnetic resonance imaging (MRI) suggested a possibility of AVM, the angiographic study showed an AVM nidus with feeders from the right anterior inferior cerebellar artery (AICA) and a dilated right intrinsic pontine artery, the latter showing a flow-related aneurysm towards its brainstem end. The flow-related aneurysm, as well as the dilated intrinsic pontine artery feeder, was embolized at first. During surgery, the AVM was found embedded inside the root entry zone. Parts of the AVM and its draining vein were partially coagulated followed by microvascular decompression of the AICA loop as well as a feeder emanating from it following which the patient recovered completely. She subsequently received gamma knife surgery (GKS) for the residual AVM and remained asymptomatic after 3.5 years of GKS. AVM-related TN are rare, and the additional presence of a feeding artery aneurysm increases the management complexity. Endovascular management of the aneurysm followed by microvascular decompression (MVD) and tailored AVM coagulation represent a prompt and effective means of pain control. Subsequent GKS is necessary to obliterate the AVM nidus.

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Aim: Endoscopic trans-nasal surgery has evolved a long way from the days of narrow corridors with high rates of cerebrospinal fluid (CSF) leak to the present state of HD optics with better tissue differentiation, extended approaches, and use of vascularized flaps for defect closure. Trans-nasal approach is an established technique for pituitary tumors practiced worldwide. However, trans-nasal endoscopic excision of suprasellar meningiomas provides a tougher challenge in terms of instrument manipulation, tumor excision with good visual outcome, and a robust defect closure to prevent CSF leaks. Materials and Methods: Out of 83 cases of midline anterior cranial fossa meningiomas operated over 14 years, our experience in 12 cases of suprasellar meningiomas for radical resection via the trans-nasal endoscopic route is discussed. Results: Amongst these, six were excised via primary extended endoscopic trans-sphenoidal surgery, four cases had a residual lesion or recurrence after primary transcranial surgery, and two cases involved a combined transcranial and extended endoscopic approach. Visual improvement along with resolution of headache was seen in all patients postoperatively. None of the patients had CSF leak requiring further repair. Syndrome of inappropriate antidiuretic hormone was found in one patient, which was transient and easily corrected. Conclusion: Trans-nasal endoscopic surgery for suprasellar meningiomas is an effective technique that provides results of tumor excision comparable to the transcranial approach in suitable cases. Visual outcome was found to be superior, and rates of CSF leak were remarkably reduced with vascularized flap. However, each case must be assessed individually and lateral extension beyond the optic canals with internal carotid artery encasement must be considered before planning surgery.

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Background: Fear of falling (FOF) is a serious problem in Idiopathic Parkinson's Disease (IPD) which increases mortality and affects Health Related Quality of Life (HRQoL). Objective: To evaluate the effect of FOF on HRQoL in IPD. Methods: 84 controls and 87 IPD patients were compared by means of Fall Efficacy Scale (FES), Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC Scale), Impact Of Events Scale-Revised (IES-R), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Parkinson Disease Specific Quality of Life Scale (PDQ-39). Then, patients were divided into two subgroups such as patients with FOF (Group 2a) and patients without FOF (Group 2b) by FES. Groups were compared in terms of BBS, ABC Scale, IES-R, BDI, BAI, PDQ-39. Independent factors affecting HRQoL were measured. Results: FOF was higher in IPD patients than controls. Female sex, previous falls, off periods, hallucinations, urge incontinence were significantly higher in Group 2a. However, RBD, dyskinesia, daytime somnolence and FOG were not different in IPD patients whether they have FOF or not. FOF was mostly correlated to disability level and disease severity. In addition, UPDRS and FOF were found to be independent factors affecting HRQoL in IPD. Conclusions: Clinicians should be aware that FOF can be detected in IPD patients, who are female, depressed or anxious, who had more severe disease with off periods, urge incontinence, hallucinations and previous falls. FOF should be questioned in every IPD patients because it is an independent factor which affects HRQoL of IPD patients.

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Background: A significant proportion of patients with cervical spondylosis can present with atypical symptoms like vertigo, tinnitus, nausea, vomiting, headache, blurred vison, palpitations and gastrointestinal (GI) discomfort. The role of ACDF in alleviating these atypical symptoms remains unexplored. Objective: The current study attempts to investigate the role of anterior cervical discectomy and fusion (ACDF) in alleviating atypical symptoms associated with cervical spondylosis. Materials and Methods: The patients with cervical spondylosis who underwent ACDF between January 2011 and December 2015 were contacted by phone. Data regarding the severity and frequency of atypical symptoms was collected by a structured questionnaire. Wilcoxon signed rank test was used to compare the severity and frequency of these symptoms before the surgery and at last follow up. Results: A total of 467 patients underwent ACDF for cervical spondylosis between January 2011 and December 2015, of which 358 patients were interviewed telephonically. 99 of 358 (27.65%) patients who met the eligibility criteria were included in the final analysis. The severity and frequency of vertigo, headache, nausea, vomiting and GI discomfort significantly improved at last follow-up (P < 0.001) compared to pre-operative period. Significant improvement in hypertension was also seen (P = 0.001). Improvements in severity and frequency of tinnitus (P = 0.083), palpitation (P = 0.317) and blurring of vision (P = 1.00) were not significant. Conclusions: ACDF might improve the atypical symptoms like vertigo, headache, nausea, vomiting and GI discomfort in patients with cervical spondylosis. Some patients also show improvement in hypertension following surgery.

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Background: The anatomical location of white matter hyperintense lesions in small vessel disease are apparently similar to those of borderzone infarction. The objective of this study is to find clinical and radiological points of differentiation between the two vascular disorders in a sample of Egyptian patients which might have an impact on primary and secondary prevention. Methods: Ischemic stroke patients with white matter lesions were categorized into two groups: small vessel disease and borderzone infarctions. NIHSS was done on admission. Risk factor profile was reported, and investigations done including: HbA1C, lipid profile, CRP, ECG, echocardiography, carotid duplex, brain MRI, MRA and MR perfusion study. Results: 46 patients completed the study, 29 with SVD and 17 with BZI. Smoking, hypertension and recurrent stroke were more common in borderzone infarctions, but only diabetes was significantly higher (p = 0.047). Limb shaking was more observed in borderzone infarctions (p = 0.049). Radiologically: lacunar pattern was observed more in small vessel disease, while rosary pattern was more in borderzone infarctions (p = 0.04). FLAIR symmetrical lesions and microbleeds were more significant in small vessel disease (p = <0.001; 0.048, respectively). Perfusion study time to peak denoted evidence of significant hypoperfusion in all regions of interest in borderzone infarctions. Conclusion: Limb shaking, retinal claudication or syncope, with MRI showing rosary pattern of white matter hyperintensity, few microbleeds and markedly impaired perfusion favor the diagnosis of borderzone infarctions. On the other hand, presence of lacunae, FLAIR showing symmetrical WMH and microbleeds with minimal or no perfusion deficit suggests the diagnosis of small vessel disease.

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Background: Non-convulsive status epileptics (NCSE) is a common neurological emergency necessitating rapid assessment and management, but is often underdiagnosed as it lacks specific electroencephalographic features. The diagnostic value of periodic lateralized epileptiform discharges (PLEDs) in NCSE is still unclear. Herein, we reported a case with NCSE manifesting as PLEDs and coma. Case Report: A 62-year-old man presented with epileptic seizures. Based on clinical and radiological profiles, he was diagnosed with frontal hemorrhage, coma, and NCSE. An electroencephalogram (EEG) revealed PLEDs. A combined antiepileptic regimen was initiated and, over a follow-up period of 2 months, a favorable outcome was achieved. Conclusion: EEG may help identify potential NCSE in comatose patients, and PLEDs can be an atypical manifestation of NCSE, which can be effectively treated with antiepileptic drugs. The emphasis in NCSE is on early identification and individualized therapeutic regimens.

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Background: Sporadic inclusion body myositis (s-IBM) is rare in India. Aim: The aim of this study was to diagnose s-IBM according to the European Neuromuscular Center (ENMC) IBM research diagnostic criteria 2011. Materials and Methods: A retrospective review of patient records diagnosed as s-IBM according to the above criteria during the period from January 2010 to May 2015 was done with an emphasis on pattern of muscle weakness.Serumcreatine kinase (CK) andelectromyography (EMG) were noted. Muscle biopsy was evaluated with basic panel of histochemical stains including Congo red stain. Immunohistochemistry (IHC) with ubiquitin was done in 10 biopsies. IHC for major histocompatibility complex-1 and electron microscopy studies were not performed. Results: The diagnosis of s-IBM constituted 5 clinicopathologically defined, 12 clinically defined, and 10 probable IBM in the study period. There was male predominance with median age at 51 and duration of disease varying from 1–5 years. All the patients presented with insidious onset of muscle weakness of quadriceps and/or forearm flexors. CK varied from 57–2939 IU/L. EMG was myopathic in 22, mixed in 2, and neuropathic in 3. Endomysial inflammation was seen in 23 (85.19%) and rimmed vacuoles in 24 (88.89%). Amyloid was demonstrated in only 5 (18.52%) and ubiquitin in 2 biopsies. Mitochondrial abnormalities were seen in 92.59% biopsies. Conclusions: Application of the ENMC IBM research diagnostic criteria allowed diagnosis of clinically-defined and probable IBM in the absence of all pathology criteria. Rimmed vacuoles in 88.89% of biopsies indicate presentation at a late stage. Use of ancillary techniques can improve diagnostic yield.

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Background: Neuro-oncology is a relatively young subspecialty of neurosurgery. 2018 was the 10^th year since the founding of the Indian Society of Neuro-oncology. Objective: To assess patterns in neuro-oncology practice in India. Methods: This was an online survey covering various domains of neuro-oncology such as demographics and practice setting, protocols for the medical management of patients with brain tumors, protocols for surgery and the perioperative period (including antibiotic prophylaxis, dural closure techniques, etc.), technological adjuncts used for brain/spine tumors (including intraoperative neurologic monitoring-IONM), and management protocols for certain specific clinical scenarios. Results: The response rate was 13%. Although 37% of the respondents' institutions could be considered as having reasonable surgical volumes (>1 procedure/day), only about half of these had high volumes of malignant brain tumor surgery. A wide variation was seen in medical management, perioperative protocols, use of adjuncts and intraoperative technologies, and paradigms for specific clinical scenarios. Conclusions: There is a need to standardize the protocols in neuro-oncology. This could be achieved by strengthening the formal training process in surgical neuro-oncology.

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Background and Purpose: Dental implantation is thought to be associated with enhancement of neuro-cortical sensorimotor activity which has been lost due to an edentulous state. Such changes are either feeble or absent after the placement of a conventional denture. In the present study, we test this hypothesis using blood oxygen level-dependent (BOLD) activity on functional MRI (fMRI) as a bio-surrogate. Materials and Methods: fMRI was performed in 12 consecutive edentulous subjects (mean age = 59.2 years) after the placement of a conventional complete denture (CD) and subsequently after intraoral dental implantation (IOD). The semi-quantitative data of the BOLD activity was compiled to depict the activation seen in both scenarios in six anatomical regions. Statistical analysis was done to evaluate the significance of enhancement in BOLD activity in these regions in patients having an IOD as compared to those having a CD. Results: The enhancement of BOLD activity on fMRI after placement of an IOD was much more significant as compared to that noted with CD. Using Wilcoxon's signed-rank test the nonparametric data showed a significant positive elevation in global and regional assigned mean ranks of BOLD activity. Conclusion: Intraoral implantation leads to a significant elevation in the BOLD activity of the sensorimotor cortex as compared to the placement of a conventional CD.

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Background: Non-contrast CT (NCCT) brain imaging biomarkers of hematoma expansion in intracerebral hemorrhage (ICH) has gained relevance in recent times. Though intra-hematoma hypodensities (IHH) can predict hematoma expansion and outcome, it is postulated to be time-dependent. Aim: To assess the differential prevalence of IHH in spontaneous ICH over time and assess its predictive valve in early hematoma expansion and functional outcome at 3 months. Material and Methods: Patients with ICH within 48 h of stroke onset were included. Baseline clinical and demographic data were collected. Baseline NCCT brain was analyzed for hematoma volume, characterization of IHH, with 24-hours follow-up NCCT hematoma volume calculated for identification of hematoma expansion. Poor functional outcome was defined as mRS ≥3. Results: Around 92 subjects were included in the study. IHH was found in 40%. Prevalence of IHH was higher in those with baseline NCCT performed within 3 h of symptom onset compared to those beyond 3 h (71% vs 29%, P = 0.002). The hematoma expansion was more common in patients with IHH compared to those without (54% vs 29%; P = 0.02). Multivariate analysis revealed the presence of IHH (rather than pattern or number) to be strongly associated with poor functional outcome at 3 months (OR 3.86; 95% CI: 1.11–13.42, P = 0.03). Conclusion: There is a decreasing prevalence of IHH as the time from symptom onset to NCCT increases. Nevertheless, its presence is significantly associated with hematoma expansion and predicted poor short-term functional outcomes in spontaneous ICH.

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Background: Endothelial nitric oxide synthase (eNOS) is an enzymatic marker whose genetic polymorphism might predispose to acute ischemic stroke (AIS) via vascular endothelial dysfunction. It has a potential role in atherosclerosis, making it a plausible risk factor for stroke. Prior studies have failed to prove a conclusive relationship between eNOS polymorphism and AIS. Objective: The aim of this study is to find an association between the presence of eNOS polymorphism (Glu298Asp) and the risk of developing AIS. Materials and Methods: We recruited 307 subjects including 153 AIS cases and 154 healthy controls. The eNOS (Glu298Asp) polymorphism was identified in EDTA blood by PCR amplification of the target region followed by restriction enzyme digestion, and genotyping on Agarose gel. GG, GT and TT genotypes were obtained. Statistical analysis was done using SPSS software version 20. Results: A significant association was found between the presence of TT genotype and the risk of AIS (Odd's ratio (OR): 2.43, P-value = 0.038). There was no significant association between the TT genotype and the traditional stroke risk factors. However, the TT genotype was significantly associated with the presence of altered consciousness (OR: 5.27, 95% CI: 1.59–17.04, P-value = 0.003) and with the occurrence of seizures at presentation (OR: 7.98, 95% CI: 1.99–32.09, P-value = 0.007). Conclusions: There is a significant association between the presence of eNOSpolymorphism (Glu298Asp) and the risk of AIS, and the TT genotype may predispose to a more severe initial presentation of ischemic stroke.

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Introduction: Microsurgical embolectomy though is the oldest known recanalization technique is being dismissed in favor of the latest mechanical endovascular techniques for the management of acute large vessel occlusion. Aim and Objective: We aim to highlight the role of microsurgical embolectomy in the current era of pharmacological and mechanical (endovascular) thrombolysis. Methods: An outline of the microsurgical embolectomy technique is described along with its current indications, advantages, and disadvantages. Results: It carries higher complete (TICI 3) revascularization rates with lower risk of distal embolic events especially in cases with high clot burdens; but is more labor-intensive and has longer reperfusion time in comparison to endovascular methods along with the requirement of highly skilled neurovascular surgeons to perform it quickly. Conclusion: Microsurgical embolectomy is an important indispensable recanalization technique in the armamentarium of vascular neurosurgeons.

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Epilepsy is one of the most prevalent neurological disorders, accounting for over 13 million disability-adjusted life years (DALYs). Nearly 80% of people with epilepsy live in low- and middle-income countries (WHO, 2019). Rehabilitation of cognitive impairments through compensatory training in such patients encompasses a wide range of techniques. However, interventional studies exploring their efficacy remain scarce despite being recommended in various reviews. Further, cultural contexts and other related factors have often been overlooked. We aimed to appraise the existing evidence on internal and external compensatory strategies in patients with epilepsy and identify the gaps and pitfalls in the existing literature for applicability to low resource and literacy settings from a neuropsychological perspective.

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Background: Stereoelectroencephalography (SEEG) has become an integral part of epilepsy surgery, often used in the localization of the epileptogenic zone. It is an essential modality not only in the evaluation of nonlesional but also lesional drug refractory epilepsy, especially in the presence of anatomo-electro-clinical discordance. Objective: To describe our technique and the operative nuances involved in the performance of robotic SEEG placement. Methods: A 28-year lady with seizure onset at the age of 15 years presented with two types of seizures: one was associated with an aura of chest discomfort, palpitations along with oral and bilateral automatisms. There was associated speech and behavioral arrest along with ictal urinary incontinence. The other type has head turning to the right with secondary generalization lasting up to 1 min. Results: Multimodality investigations showed bilateral temporal origin of seizures. SEEG evaluation revealed left amygdala and anterior temporal neocortical (ATL) origin of seizures. The patient underwent left ATL and amygdalectomy. Histopathology revealed focal cortical dysplasia (FCD type Ib). The patient became seizure free (ILAE Class 1) at 1-year follow up. Conclusion: Robotic-guided SEEG is a safe and accurate method of evaluating complex MRI negative epilepsy.

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Background: Awake craniotomy encompasses surgical resection of focal zone of neurological impairment, using intraoperative functional zone mapping. The strength of the procedure is maximum retention of functionally significant zones to ensure better function and quality of life outcomes in patients. A clinical neuropsychologist plays a vital role in profiling the patient's cognitive and psychosocial functioning as well as increasing the efficacy of functional zone mapping procedures. Objective: Aim of this article is to summarize the literature on the role of clinical neuropsychologists in awake craniotomy and underscoring the need for establishing standardized operating procedures for neuropsychologists in awake craniotomy highlighting experiential anecdotes from a tertiary care facility. Materials and Methods: A review of articles that elucidate the role of clinical neuropsychologists was done and summarized to highlight the role of clinical neuropsychologists. An attempt was made to explain the implementation of this role in regular clinical practice at a tertiary care facility. Results: The role of a clinical neuropsychologist is highly crucial at pre-/during and postawake craniotomy, and has a significant bearing on the overall psychological outcome of the individual. The need for a standardized protocol to unify practice and increase the efficacy of the awake-craniotomy procedure is put forth. Recommendations for future directions in research to increase the scope of neuropsychologists in awake craniotomy have also been made.

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Background: Skills assessment forms an integral part of the exit examination in neurosurgical training programs. The established method of evaluating trainees for their clinical knowledge and surgical proficiency in the operating room is not feasible in the current time of SARS-COV19 pandemic. Objective: The feasibility of conducting such an assessment using case modules on an online meeting platform is discussed. Methods: Six candidates were evaluated on two consecutive days with two internal examiners located at the examination site and two external examiners situated at their own institutions elsewhere in the country. Clinical details, including images and videos of patients managed at our institute were recorded and provided to the candidates as case modules. Four sessions were conducted in the form of long and short cases, operative neurosurgery, neuroradiology, and neuropathology and a general viva-voce using “Zoom” (Zoom-Video-Communications, Inc. USA) platform. Feedback from the examinee and the examiners were obtained for any modification in the current format. Result: The online platform worked well without any interruption except for slight lag in the audio-visual system and occasional difficulty in using microphone and screen simultaneously. Trainees were able to interpret the clinical details and rated this format close to actual clinical evaluation. The examiners uniformly agreed that the online format for assessment was satisfactory and made some suggestions for improvement. Conclusion: Clinical and surgical skill evaluation is feasible using case modules and online meeting platforms. Use of original patient's data, images, videos demonstrating clinical signs, and operative procedures makes this assessment more objective.

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Background: Disability evaluation as per World Health Organization includes assessment of impairments, activity limitations, and participation restriction, which unfortunately is not assessed by the existing guidelines of disability in India. Aim: The aim of this study wasto comparea new study criterion with the existing guidelines for assessing cognitive disability for chronic neurological conditions. Methodology: A cross-sectional pilot study was conducted on 41 participants. They were assessed on an existing guideline (Gazette India 200,1 assessing physical domain and Intelligence Quotient[IQ]) and study criterion assessing three aspects of cognitive capacity: IQ, neurocognitive functioning, and QOL. Results: The existing guideline underestimated 84% of cases for disability. The average percentage of disability measured by the study criterion was 33.2% more as compared to existing guidelines with S.D of 26.6. Conclusion: Cognitive capacity assessment is an important element to be measured in chronic neurological disability certification. However, a large sample is required to make an affirmative claim for the same.

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Background: Mechanisms involved in the causation of sudden unexpected death in epilepsy (SUDEP) are not well understood. Ictal asystole has been identified as a cause of SUDEP in patients with temporal lobe epilepsy. Herein, we report a patient who developed cardiac arrest during the ictal period of frontal lobe epilepsy. Case Report: A 35-year-old man presented with a history of progressive nocturnal stiffness in the left lower extremity since 6 years and that of paroxysmal episodes of altered consciousness. In the last 2 years, he sustained epileptic seizures which presented as closed eyes, wheezy phlegm in the throat, facial pallor, moist cold skin, clenched fists, and limb stiffness; the episodes lasted 3–4 min. The seizures did not respond to antiepileptic therapy. Twenty four-hour electrocardiography monitoring showed transient atrial tachycardia, supraventricular premature beats, and cardiac arrest. Conclusion: Frontal lobe epilepsy may be a potential cause of SUDEP. Clinician should be aware of this condition.

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Primary central nervous system lymphoma (PCNSL) is a rare disease that can be confused with Wernicke encephalopathy (WE). We have reported here the case of a 31-year-old malnourished man who presented with headache, fever, vomiting, diarrhea, and confusion. His imaging and laboratory findings were indicative of WE. His condition improved after treatment with a high dose of vitamin B1 and intravenous administration of methylprednisolone. However, after continuing to take vitamin B1 for 2 weeks, his symptoms and neuroimaging findings worsened. Increased standardized uptake values of positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (¹⁸F-FDG-PET) and interleukin-10 (IL-10) in the cerebrospinal fluid led to the diagnosis of PCNSL. After treatment with methotrexate and calcium leucovorin, the symptoms and neuroimaging abnormalities disappeared at the 6-month follow-up examination. The possibility of PCNSL should be considered if the routine treatment for WE are ineffective. ¹⁸F-FDG PET and IL-10 may provide a new method for the early diagnosis of PCNSL.

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Choroid plexus papillomas (CPP) are commonly seen in the supratentorial compartment in children and only very rarely in the posterior fossa. CPP in the cerebello-pontine angle and cerebello-medullary fissure (CPA) in the pediatric age group are extremely rare with only seven previous cases reported in literature. The authors present the case of a 7-year-old girl who presented with neck tilt, imbalance, and headache. The MRI showed a lesion with a frond-like appearance in the CPA with heterogeneous enhancement. The tumor was excised radically using a cerebello-medullary fissure approach. The authors review and analyze the literature on this rare pediatric tumor, with specific attention to radiology and the surgical aspects.

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Background: Parkinson's disease (PD) is characterized by bradykinesia, tremor, rigidity, postural instability and cognitive deficits in attention, executive functions, learning and memory. Motor speed, measured using Finger Tapping Test (FTT), is an important indicator and predictor of cognitive and motor functions. Deficits in motor speed have significant impact on performance on other neuropsychological tests. Objective: This study aimed to understand and compare the cognitive profile of patients with and without deficits in motor speed as evaluated on the FTT. Method and Material: A detailed neuropsychological evaluation using the NIMHANS Neuropsychological Battery was carried out on 70 PD patients. The PD patients were divided into patients with (n = 46) and without (n = 24) motor speed deficits. The two groups were comparable with regard to age (P = 0.591), years of formal education (up to 10^th – 24.3, above 10^th – 75.7) duration of illness (P = 0.703) and age of onset (P = 0.721). Results: Across the various cognitive domains such as executive functions, verbal recognition, visuospatial functions, visual learning and memory, the group without deficits in motor speed performed significantly better in comparison to patients with motor symptoms. Conclusion: A short and simple test such as FTT may be helpful in predicting the range and severity of cognitive deficits across other cognitive domains in patients with PD. Future studies on larger cohort examining the intricate role and association of FTT and other motor functions such as dexterity may be helpful in understanding the nature and severity of other cognitive functions in this clinical population.

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Background: The human calvaria harbors a variety of pathology and majority of them are incidentally noticed as painless swelling. The aim of the present study is to describe the histopathological subtypes of calvarial lesions, their management and factors affecting their surgical outcome at a tertiary care referral center. Material and Methods: All patients who underwent excision of the calvarial lesions over the last 15 years (from January 2005 to July 2019) were included in this study. Patients having calvarial pathology of infective origin and recurrent lesions were excluded. Any patient with multiple calvarial lesions who have been operated more than one time for same histopathological diagnosis was counted as one patient. We studied Karnofsky Performance Status (KPS) scores and radiological changes at 3-month follow up. Results: Total 65 patients were recruited in this retrospective observational study. The median age of patients in the study was 29 years (range: 8 years to 68 years). Fibrous dysplasia 20 (30.7%) was the commonest lesion while metastatic thyroid carcinoma 3 (4.6%) was the most common malignant pathology. Complete excision was performed in 51 (78.5%) of patients while in 14 (21.5%) cases, subtotal or near total decompression were achieved. After three months of surgery, there was significant improvement in the KPS score (P < 0.00001). Duration of follow up ranges from 6 months to 5 years with 4 mortality in the study. Conclusions: Most of the calvarial tumors were benign and surgically addressable. The malignant lesions were scattered with diverse underlying pathology and required individualized holistic approach.

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Background: Neuroanesthesiology and neurocritical care are constantly evolving branches of clinical neuroscience, and patient management is often influenced by literature such as randomized controlled trials, systematic reviews, and meta-analyses. Many controversies still exist in the management of neurologically injured patients, and most research in this field does not translate into significant changes in clinical practice. Objective: This review aims to discuss studies of clinical importance published in preeminent journals over the time period 2017–2020, which may have the potential to influence our current management protocols. Methods: In this review, key articles have been selected to represent neuroemergencies where recent evidence may prompt changes in practice. In preparing this article, contents of prominent journals between 2017 and 2020 were reviewed, and relevant articles were also identified from abstraction services. Areas chosen for consideration are high-quality trials researching the management of pathologies such as epilepsy, traumatic brain injury and acute ischemic stroke, cortical venous sinus thrombosis, as well as hemorrhagic stroke. For each subject, a brief review of the article is followed by “take home” points. Conclusion: We have attempted to perform a review of some of the highest impact medical journals from 2017 till 2020 and have summarized articles with the potential to change clinical practices for readers so that management protocols for acute neuroemergencies to ensure good outcomes may be formulated.

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Background and Introduction: C2 transverse process exostoses are rare lesions. Due to critical structures surrounding them, their excision is challenging. There are sparse reports of anterior retropharyngeal approach (ARPA) for high-cervical transverse process mass and none for endoscopic ARPA approach. Objective: A step-by-step technical report with its video is presented. Surgical Technique: A 14-year-old girl presented with chronic right-sided neck pain. The computed tomography scan revealed a 6.5 cm³ mass in the right transverse process extending into the lateral mass of the C2 vertebra. The mass was anterior and in direct contact with the vertebral artery. She underwent a minimally invasive endoscopic ARPA. Results: The mass could be excised along with its cartilaginous cap without any complications. The patient's symptoms resolved completely. The biopsy came out as osteochondroma. Conclusion: Endoscopic ARPA is a minimally invasive option for high-cervical tumors and was found safe and effective for C2 transverse process osteochondroma.

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Background: Bilateral lambdoid and sagittal craniosynostosis (BLSS), also known as Mercedes Benz pattern craniosynostosis, is a rare form of craniosynostosis. The whole cranial vault remodeling gives the best result. Objective: To describe the role of endoscopic third ventriculostomy (ETV) and whole cranial vault remodeling for treatment of BLSS. Material and Methods: Surgical technique/procedure: A single-sitting three-step surgery was performed for a 7-month-old child who had BLSS and hydrocephalus. First ETV and anterior cranial vault remodeling were done in the supine position. The posterior cranial vault expansion was done in the prone position. Results and Conclusions: The ventricle volume reduced at follow-up and the frontal bossing also reduced. The whole cranial vault remodeling gives the best result for BLSS.

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