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Background: Biomarkers of systemic inflammation (BMSIs), including haemogram cell counts (CC, e.g., absolute neutrophil count) and cell count-ratios (CCR, e.g., the neutrophil-lymphocyte ratio, etc.), have been found to have prognostic significance in many solid-organ cancers. Aims: In this three-part study, we first examined if the CCs and CCRs were altered in patients with glioblastoma (GBM) when compared with healthy controls. Second, we evaluated for any correlation between the BMSIs and patient- and tumour-related factors. Third, we evaluated the influence of the CCs and CCRs on survival. Methods: This was a retrospective analysis of patients who underwent surgery/biopsy for a newly diagnosed brain tumour that was subsequently confirmed to be GBM (Cases). Controls were healthy individuals who underwent pre-employment screening blood tests. Statistical Methods: Parametric tests were used to compare normally distributed continuous variables, whereas non-normally distributed variables were compared using non-parametric tests. Thresholds for the BMSIs were determined using X-tile analysis. Cox regression using the proportional hazards model was used for survival analyses around the determined thresholds. Results: All CCs and CCRs were altered in Cases compared with Controls. Presentation with raised intracranial pressure, altered sensorium, poor performance status, loss of ATRX, and lack of p53 overexpression was associated with an inflammatory phenotype of changes in the BMSIs. The inflammatory phenotype of changes was associated with poor survival. Conclusions: A significant inflammatory response was found in patients with GBM and correlated with clinical features, the molecular profile of the tumour and poor survival.

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Phenytoin is a commonly used antiepileptic drug for various types of seizure disorders except for absent seizures. Long-term dose-dependent neurological side effects of phenytoin therapy include cerebellar atrophy, cerebral atrophy, and brain stem atrophy. Skull hyperostosis, gum hypertrophy, and megaloblastic anemia are other known effects of long-term therapy. We present four cases depicting clinical and neuroimaging findings of phenytoin-induced toxicity.

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Background: Stroke is a common neurological condition, and post-stroke seizures are known to occur. Early seizures may suggest the severity of insult and may have an effect on the outcome. There are conflicting results on the frequency of early seizures, and studies from India are scarce. Aim: To study the frequency and predictors of early seizures following the first acute stroke, both arterial and venous stroke, as well as to assess their effect on clinical outcome. Patients and Methods: This is a hospital-based, prospective, observational study conducted among 279 eligible consecutive patients admitted in the Neurology department with first acute stroke, including venous stroke. The demographic data, clinical history, risk factors, examination, and all other relevant investigations are done. Early seizures occurring within 7 days of the acute stroke are identified and correlated to various risk factors. Results: Out of the 279 patients enrolled in the study, ischemic stroke (IS) (62.4%) was the most common stroke subtype, followed by hemorrhagic stroke (HS) (20.4%), cerebral sinus venous thrombosis (CSVT) (15.8%), and IS with hemorrhagic transformation (ISH) (1.8%). Thirty-three patients (11.8%) had early seizures, among them CSVT 18 (40.9%) had the highest frequency followed by ISH 1 (20%), HS 5 (8.7%), and IS 9 (5.2%). Conclusions: The frequency of early onset post-stroke seizures is 11.8%, with most of them occurring within 24 hours. Venous stroke, large lesion, cortical location, supratentorial location, hypercoaguable states, and hyperhomocysteinemia are independent predictors. Duration of hospital stay is increased in patients with early seizures, however, they did not influence the in-hospital mortality.

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Background: Bibliometric analyses allow detecting citation trends within a field, including assessments of the most cited journals, countries, institutions, topics, types of study, and authors. Objective: The aim of this study was to perform a bibliometric analysis of the 100 most cited papers within infectious meningitis research. Materials and Methods: The 100 most cited publications and their data were retrieved from Scopus and Web of Science during 2019. Results: The New England Journal of Medicine had the greatest number of articles (27) and citations (12,266) in the top 100. Articles were mainly published after the late 1980s. Bacteria were the most discussed agents (72 articles and 26,362 citations), but Cryptococcus sp represented the most-discussed single agent (16 articles and 6,617 citations). Primary research represented 70 articles and 25,754 citations. Among them, the most discussed topic was Clinical Features and Diagnosis/Outcomes (22 articles and 8,325 citations). Among the 27 secondary research articles, the most common type of study was Narrative Review (18 articles and 5,685 citations). The United States was the country with the greatest number of articles (56) and citations (21,388). Centers for Disease Control and Prevention (CDC) and Yale University had the greatest number of articles (six each), being CDC the most cited (3,559). Conclusions: The most cited articles within meningitis research are primary research studies, more frequently published in high IF journals and by North American institutions. Bacterial meningitis comprises the majority of publications. The articles were mainly published after the AIDS pandemic and after the implementation of the main vaccines for meningitis.

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Background and Aims: Insular gliomas remain one of most challenging locations for aggressive resection. We report our experience and strategies we employed to avoid complications in immediate post-operative period of surgical resection of insular gliomas. Methods: Retrospective analysis of data collected in 61 consecutive patients who underwent surgical resection of insular gliomas between May 2013 and May 2016 was done. Primary outcome measures were neurological deficits and death in the immediate post-operative period to three months follow-up. Results: The average age of the study population was 42.57 ± 10.98 years with 41 (67.2%) men. Glioma was on the right side in 35 (57.3%) patients. Surgery for recurrent glioma was performed in three (4.9%) patients. The average MIB index of the entire group was 10.1 ± 13.9. While 23 (37.7%) patients underwent the TO approach, 38 (62.3%) underwent TS approach. In the immediate post-operative period, significantly higher number of patients under TS approach had post-surgical complications (8.6% vs 34.2%; P = 0.032). The surgical approaches did not differ significantly for outcome, mortality and complications at three month post-operatively (0.0% vs 10.5%; P = 0.287). However, a trend for lower complications at three months was observed with TO approach. Conclusion: We report that morbidity and mortality in immediate post-operative period can be reduced by: a) pre-surgical assessment of confinement of glioma in respect to lenticulo-striate arteries, b) Intra-operative use of functional-MRI, DTI tractography and ICG angiography, c) Application of Berger-Sinai classification to localize the glioma, d) selecting either TS or TO approach based on Berger-Sinai classification.

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Objective: This study aims to evaluate the effects of transforaminal epidural steroid injection (TFESI) on neuropathic pain (NP) in patients with chronic unilateral radiculopathy due to lumbar disc herniation (LDH). Patients and Methods: Between September 2018 and April 2019, a total of 61 patients who were diagnosed with unilateral/unilevel radiculopathy due to LDH and were scheduled for single-level TFESI were included in this study. The Numeric Rating Scale (NRS), modified Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), and NP-Douleur Neuropathique 4 Questionnaire (DN4) were used before the procedure and at 1 hour, 3 weeks, and 3 months after the procedure. Results: There was a significant decrease in the NRS and significant improvement in the ODI, BDI, and DN4 scores in all patients at all postprocedural timepoints (P < 0.05). The number of patients with NP decreased from 35 (60.3%) at baseline to 23 (41.2%) at 3 months (P = 0.001). The NRS scores were similar at 3 weeks and 3 months between the patients with and without NP (P > 0.05). The ODI scores were significantly higher at 3 months in the patients with NP than those without NP (P = 0.013). The BDI scores at baseline, 3 weeks, and 3 months were significantly higher in the patients with NP than those without NP (P < 0.001, P = 0.016, and P = 0.016, respectively). Conclusion: Our study results suggest that TFESI is an effective and safe method to decrease not only nociceptive but also NP component in patients with chronic radiculopathy due to LDH. Clinicians should keep in mind that NP is a risk factor that adversely affects the TFESI success and patients should be evaluated before the procedure.

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Background: Risk for the development of coronary heart disease and diabetes is found to be more among people with epilepsy especially when on treatment. Redox imbalance contributes to this risk especially in India as it is the diabetic capital of the world with higher prevalence of inflammation. Objectives: The aim of this study was to evaluate atherogenic risk factors; dyslipidemia, oxidative stress, and systemic inflammation among young Indian adults with epilepsy on treatment with Phenytoin. Material and Methods: Three groups of age and gender-matched young subjects were recruited. Group 1-Healthy control subjects, Group 2- Newly diagnosed epileptic young adults with recent epileptic seizures, Group 3- Epileptic adults on treatment with Phenytoin for more than 6 months were recruited. Results: Dyslipidemia was found among the newly diagnosed epileptic subjects in comparison to healthy subjects. The LDL-cholesterol further increased, and HDL-cholesterol further decreased in the third group treated with Phenytoin. Body mass index of these treated epileptic subjects was more in comparison to healthy control. Low-grade inflammation as assessed by hsCRP and oxidative stress were significantly higher among the newly diagnosed epileptic subjects when compared to the healthy controls which further increased on treatment with phenytoin. We found dyslipidemia, oxidative stress, and low-grade inflammation among newly diagnosed epileptic subjects which further increased on treatment with Phenytoin for more than 6 months. Conclusion: From this study, we conclude that dyslipidemia, oxidative stress and low-grade inflammation are identified among the newly diagnosed young adult Indian epileptic patients. Phenytoin treatment further augmented these complications.

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Background: Posterolateral decompression and debridement in patients with TB spine led to defect in the anterior column which makes the spinal column unstable, thus making anterior column reconstruction an important step in surgical management. Objective: Through the study, authors sought to answer the following questions: 1) What are the differences in clinical outcomes between patients with TB spine undergoing anterior column reconstruction using titanium mesh cage versus PEEK cage? 2) What are the differences in radiological outcomes between these two groups of patients? Methods: This is a retrospective comparative study including patients with TB spine undergoing surgical management. The included subjects were divided into groups A and B depending on the implantation of PEEK or titanium mesh cage respectively for anterior column reconstruction. Outcome criteria analyzed included clinical criteria like VAS and ODI scores, radiological criteria like kyphosis correction, loss of kyphosis at follow-up, cage subsidence, and bony fusion on a 2D CT scan. Results: The study population included 14 patients in Group A and 15 patients in Group B. Improvement in VAS and ODI scores was comparable between groups. There was no significant difference in radiological outcome measures between the two groups, however, two patients from group B showed implant-related complications needing revision. All patients showed good bony fusion at the final follow-up. Conclusion: PEEK and titanium cages have comparable clinico-radiological outcomes for anterior column reconstruction in patients with active TB spine. Its advantages for being radiolucent and its ease of use may make it a choice of implant.

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Background: Hemispheric disconnection represents a challenging and major epilepsy surgical procedure. This procedure in experienced hands offers excellent results in terms of seizure outcomes, especially for hemispheric pathologies such as Rasmussen's encephalitis, hemispheric dysplasias, hemimegalencephaly. The technique of hemispherotomy has witnessed various modifications over the years, beginning from anatomical hemispherectomy to the current era of minimally invasive functional hemispheric disconnections. Objective: This study aimed to describe the technique of performing endoscopic vertical hemispherotomy using interhemispheric corridor developed by the senior author. Materials and Methods: A 12-year-old girl with seizure onset at the age of 10 years presented with an aura of fear and nausea followed by tonic deviation of eyes to the right and blinking with speech arrest. There were tonic–clonic movements of the right-sided limbs along with ictal spitting and occasional deviation of the angle of mouth to the right. The patient had loss of awareness for the event along with postictal confusion lasting few minutes. Results: Video electroencephalography (VEEG) revealed left parietocentral and left temporal localization. Serial magnetic resonance imaging (MRI) brain over 3 years revealed progressive left hemispheric changes suggestive of Rasmussen's encephalitis. The patient underwent left-sided endoscopic hemispherotomy. At 2 years follow-up, the patient is seizure-free (ILAE [International League Against Epilepsy] Class 1). Conclusion: Endoscopic hemispherotomy using the interhemispheric approach is an elegant, minimally invasive, reproducible, safe, and efficacious technique.

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Rasmussen's encephalopathy (RE) is an uncommon neurological disease of inflammatory origin which is characterized by intractable focal epilepsy, progressive limb weakness, and cognitive deterioration. RE presenting as movement disorder like hemidystonia or hemichorea is a rare occurrence. The duration of prodromal stage of RE is usually in weeks or months. Prolonged prodromal stage like in years is rarely reported. Magnetic resonance imaging (MRI) is a good biomarker in RE and it also suggests the sequential progression of disease. Here we report two cases of RE, one presenting with hemidystonia and other case with unusually prolonged prodromal stage duration of 7 years. In spite of severe hemi-atrophy of brain in second case response to immunomodulators was dramatic.

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A 43-year-old man presented with ataxia and stiffness of lower limbs for approximately last 10 years. The clinical examination revealed bilateral parkinsonism The magnetic resonance imaging of the brain and spine showed no structural abnormality to explain his symptoms. However, the dopamine transporter scan showed abnormal tracer uptake in both basal ganglia, suggestive of degenerative parkinsonism. The next generation sequencing of spastic paraparesis gene panel revealed probably pathogenic novel mutation in the SPG7 gene. Though the exact mechanism of parkinsonism in SPG 7 mutation is unclear, mitochondrial dysfunction and oxidative stress seem to play a key role. SPG7 mutation should be considered as a cause of early onset degenerative parkinsonism when no alternative explanation can be found.

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Moya Moya disease is an important cause for childhood strokes and morbidity. An early diagnosis and treatment can prevent strokes and disability. Here we report the case of an eight-year-old boy who had transient episodes of headache and hemiparesis secondary to Moya Moya disease. He was misdiagnosed as hemiplegic migraine, seizure disorder, paroxysmal non-kinesigenic dyskinesia and dissociative disorder during the past three years. The diagnosis was significantly delayed as an important clinical cue was overlooked. A detailed history showed that symptoms were precipitated on eating spicy food. This clinical pointer prompted evaluation for Moya Moya disease. MRI and MR angiogram confirmed Moya Moya disease.

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Context: Dual task performance affects obstacle crossing ability in older adults. Previous studies suggest that cognitive dual tasking can lead to changes in obstacle crossing performance in older adults, but there is a lack of evidence to support changes in obstacle crossing performance due to the influence of motor dual tasking. Aims: To investigate the interaction of cognitive and motor tasks, on obstacle crossing performance, in healthy young and older adults. Settings and Design: This is a cross sectional comparative study, conducted at Mae Fah Luang University, Thailand. Methods and Material: Sixty-four participants performed an obstacle crossing task under three conditions during a 4-meter walk test. These included walking at their normal speed with an obstacle in the middle of the walkway, followed by 2 further order-randomized walking conditions comprising a cognitive and a motor dual tasking walking condition. The spatio-temporal gait variables and obstacle crossing kinematic variables were measured using a Kinect three-camera system. Statistical Analysis Used: The means for each variable, and for each condition, were analyzed using a mixed model analysis of variance (ANOVA) with walking conditions as covariant factors. Results: A significant main interaction effect was found in gait speed (P < 0.001), step length (P = 0.046) and cadence (P = 0.011), but there was only a significant between-group difference in step length during obstacle crossing, while performing a cognitive dual task (P = 0.008) and a motor dual task (P < 0.001). Conclusions: Older adults adopted a conservative strategy, and walked with a shorter step length, when stepping over an obstacle while performing a dual task.

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Background: Decompressive craniectomy (DC) is a rescue operation performed for reduction of intracranial pressure due to progressive brain swelling, mandating the need for cranioplasty. Objective: To describe expansile craniotomy (EC) as a noninferior technique that may be effectively utilized in situations requiring standard DC. Materials and Methods: A decision to perform DC or EC was taken by consecutively allocation to either of the procedures. The bone flap was divided into three pieces, which were tied loosely to each other and to the skull using silk threads. The primary outcome included functional assessment using Glasgow outcome scale (GOS) score at 1 year. Results and Conclusions: Total 67 patients were included in the analyses, of which, 31 underwent EC and 36 underwent DC. Both the cohorts were matched in terms of baseline determinants for age, Glasgow coma scale, and Rotterdam score at admission. There was no significant difference in GOS scores and the extent of volume expansion obtained by EC as compared to DC. Complication rates though less in EC group did not differ significantly between the groups. EC appears to be the safe and effective alternative to DC in the management of brain swelling due to TBI with a potential to obviate the need of cranioplasty.

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Background: Martin Gruber anastomosis is a common anomaly in forearm between median and ulnar nerve. It may lead to technical pitfall or misinterpretation of nerve conduction studies of these nerves. Objective: The aim of this studywasto determine the prevalence of Martin-Gruber Anastomosis (MGA) in healthy Raigarh subjects by electrophysiological evaluation. Subjects and Methods: A cross-sectional study was conducted in both forearms of 140 healthy subjects. Electrophysiological studies were performed to measure compound muscle action potentials of abductor pollicis brevis, abductor digiti minimi and first dorsal interosseous muscles when stimulated from distal (wrist) and proximal (elbow) site. Descriptive and analytic statistics were performed using SPSS software. Results: MGA was found in 44 (15.71%) out of the 280 forearms in 30 (21.4%) out of 140 subjects. It was present in 14 males and 16 females. Most frequent type of MGA was of Type II in both genders. The MGA was found bilaterally in 14 subjects. In unilateral cases 8 subjects had MGA in right forearm and 8 subjects had MGA in left forearm. Conclusions: The high prevalence of MGA in the Raigarh population suggest that the orthopedics and neurosurgeons should also take in account this anatomic anomaly while analyzing median and ulnar nerve conduction studies or needle electromyography.

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Background: Clinicians in neurological practice, particularly surgeons, encounter more deaths than most other specialists. Objective: This communication reviews the literature on “good death” and extrapolates the observations and inferences to neurological practice. Changes in approaches to “good death” in the COVID-19 era (coronavirus disease 2019) are also discussed. Materials and Methods: The author, over a 40-year period, has come across 2,500 deaths in a government, trust, and corporate hospital in Chennai, India. Retrospectively, the author questions if, in spite of his conservatism and obsession with quality of life, he should have taken proactive measures to also ensure a good quality of death. Results and Conclusion: In the background of the lessons learned in a metro, across various socioeconomic groups and with varied access to technology, the author concludes that ensuring “good death” should also fall within the domain of neurologic practice.

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Background: Proper diagnosis is the first and most critical step for effective identification and treatment of myopathy and dystrophy disorders. Although various histochemical and biochemical studies have paved the way for efficient testing of these disorders, they are insufficient for accurate diagnosis. To overcome this, the diagnostic procedure has now shifted more toward the “genetic first approach,” with the remarkable role played by various genetic and molecular techniques. Objective: In developing countries, successful diagnosis of such disorders is affected by the shortage of hospitals, poor lab setup, limited diagnostic methods, and unavailability of technical expertise. As a major population living in developing countries faces such inadequate healthcare facilities, there has always been a need for identifying effective diagnostic techniques that could identify genetic alterations more prone in such regions. Materials and Methods: This article reviews studies done in the last few years that primarily use nonsequencing-based molecular diagnosis methods to identify myopathy- and dystrophy-specific gene alterations and thus could equally hold potential for screening key genetic alterations reported in certain regions in developing countries. Further, this review deals with new emerging sequencing and next-generation sequencing (NGS)-based approach and their potential in providing an adequate diagnosis. Conclusions: This study promotes nonsequencing-based molecular methods to be an effective method for early-stage diagnosis and management of myopathies and dystrophies in developing countries and suggests the high importance of emerging NGS methods in proper diagnosis and identifying new players in neuromuscular disorders.

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Background and Introduction: Apersistent primitive trigeminal artery (PPTA) is an embryonic vessel that connects the cavernous part of the internal carotid artery with the posterior circulation. Though many are incidental, it is associated with conditions such as trigeminal neuralgia (TN). Objective: In this video, we present a case of TN due to neurovascular conflict with associate PPTA. The close association of PPTA with trigeminal nerve results in increased incidence of TN. Surgical view and technique of surgery are described in the video. Surgical Technique: A 55-year-old male presented with medically refractory TN with imaging suggestive of neurovascular conflict. During surgery, the superior cerebellar artery was visibly causing compression of nerve and on inspection, the PPTA was in close association with the trigeminal nerve near the entry to Meckel's cave. Microvascular decompression was done using Teflon to separate the nerve from both SCA and PPTA. Conclusion: TN with PPTA is rare, and surgery and its nuances have rarely been described. This video shows the operative findings as well as describes the surgical technique.

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Borrelia burgdorferi can affect the nervous system in various ways, which can generate significant confusion and dilemma regarding diagnosis. From India, a country until recently known to be a nonendemic zone for Lyme disease, several cases and one study of Lyme neuroborreliosis have been published. The aim of this study was to describe a young woman with bilateral facial nerve palsy as the presenting manifestation of Lyme neuroborreliosis. We herein report a case of a lactating woman with acute onset progressive ascending flaccid tetraparesis that was preceded by a misdiagnosed bilateral facial nerve palsy. She was finally diagnosed to be a case of acute Lyme neuroborreliosis, which responded favorably to intravenous and orally administered antibiotics. The possibility of Lyme neuroborreliosis should be considered more often from now on because in the last year four cases with the kindred clinical syndrome have been described from a so-called “nonendemic zone.”

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Brachioradial pruritus (BRP) is an enigmatic condition often encountered by dermatologists and passed off as a benign itch. It is an “idiopathic” pruritus, presenting as severe itching on the radial aspect of the elbow. The physical examination may be unremarkable except for mild pruritic lesions. Hence, the patient is treated with local applications of sunscreens, anti-inflammatory agents, anti-histamines and steroids, most of which prove to be ineffective. Dermatomal localization of localization of pruritis has suggested cervical myeloradiculopathy as a novel aetiology and this has been elucidated in recent studies. Here we report a young man, who presented with brachioradial pruritus and was diagnosed to have a C6-7 intramedullary cervical cord lesion.

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Cervical disc arthroplasty (CDA) is a newer alternative to the traditional fusion, in patients with prolapsed cervical disc in the younger eligible patient aiming to provide mobility similar to the native disc and by some ways preventing the adjacent segment disease. The rising popularity of its early success has seen emergence of a number of products in the market. In a country where cost remains an important constraint for the patients, local design products are available to cater to these lesser privileged patients. The present complication is an acute dissociation of components from such a product wherein the implant was retrieved and fusion was done. The patient was subsequently discharged uneventfully.

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Anaplastic ependymoma in the pineal region is rare. Here, we present a rare case of anaplastic ependymoma of the pineal region on a 42-year-old woman who came to our hospital with headache associated with blurring of vision since one month. MRI brain showed a contrast enhancing mass lesion measuring 30 × 30 × 35 mm in the pineal region with obstructive hydrocephalus. Initially, the ventriculoperitoneal (VP) shunt was done, followed by total tumor excision by the infratentorial supracerebellar approach. Histopathological and immunohistochemistry examinations of the tumor showed the features of anaplastic ependymoma (WHO Grade III). Patient made uneventful recovery and underwent radiotherapy. Only 12 cases of pineal ependymoma have been reported so far, of which only three have been anaplastic ependymoma.

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Formal brainstem reflex testing remains one of the most important procedures in identification and evaluation of patients who meet clinical criteria for brainstem death. Early identification of such patients is critical since willing donors may contribute to the organ donation process. During the first two waves of the coronavirus disease of 2019 (COVID-19) pandemic, organ transplantation from brainstem dead donors has declined significantly due to several reasons, including perceived increased risk of virus transmission to both physicians as well as patients as well as lack of awareness regarding donor workup in the context of the COVID-19 pandemic.

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Background: The age of onset of seizure, seizure types, frequency of seizure, structural abnormalities in the brain, and antiepileptic medication (polytherapy) causes increased incidence of anxiety and depression in intractable epilepsy patients. Aim: To compare the anxiety and depression levels in intractable epileptic patients with structural abnormalities [malformations of cortical development (MCD) and incomplete hippocampal inversion (IHI)] and without structural abnormalities. Materials and Methods: Participants were selected from (239 males and 171 females) intractable epilepsy patients. They were grouped into four groups; Group 1: 51 nonepileptic age-matched controls, Group 2: 41 intractable epilepsy patients without any brain abnormality, Group 3: 17 intractable epilepsy patients with MCD, and Group 4: 30 intractable epilepsy patients with isolated IHI. Neuropsychiatric tools used were Multiphasic Personality Questionnaire and Weschlers Adult Intelligence Scale to assess anxiety, depression, and intelligence. Groups were classified using 1.5T conventional magnetic resonance imaging and hippocampal volumetric studies. Group comparison design was used. Results: Demographic variables of intractable epilepsy, including seizure types, the frequency of seizure, the age of seizure onset, and antiepileptic drug therapies, did not show significant association between the groups using Chi-square P value. Analysis of variance showed significant anxiety and depression in epileptic patients than the control group (P < 0.01). Post hoc analysis using Tukey's B test showed significant difference in anxiety and depression scores between group value. In group 3 and 4, anxiety scores were significantly different but not depression scores. Conclusion: The present study concludes high prevalence of anxiety and depression in intractable seizure. Anxiety is observed predominantly when there is IHI along with depression. We emphasize the need to identify IHI in intractable epilepsy and assess anxiety and depression to treat them effectively.

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Background: Hirayama disease (HD) is a motor neuron disease and occasionally is associated with lower limb hyper-reflexia. Corticospinal tract dysfunction can be evaluated by diffusion tensor imaging (DTI), but there is paucity of study in HD. Objective: We report corticospinal tract functions using DTI in the patients with HD and correlate with clinical findings. Materials and Methods: The patients with HD diagnosed on the basis of clinical and electromyography findings were included. Their age, duration of illness, side of initial involvement, and progression were noted. Presence of lower limb hyper-reflexia, and cervical spine magnetic resonance imaging (MRI) findings were noted. Cranial MRI was done and DTI findings at internal capsule, cerebral peduncle, pons, and pyramid were noted. Results: In total, 10 patients with HD and 5 matched controls were evaluated. The apparent diffusion coefficient (7.03 ± 0.27 vs 6.83 ± 0.36), fractional anisotropy (0.79 ± 0.04 vs 0.82 ± 0.05), axial diffusivity (5.08 ± 0.08 vs 5.04 ± 0.07), and radial diffusivity (3.79 ± 0.05 vs 3.76 ± 0.05) between HD patients and controls were not different in internal capsule. These values were also not significantly different in cerebral peduncle, pons, and pyramid. These values were also not significantly different between the severe and less severely affected sides. The fractional anisotropy did not correlate with lower limb hyper-reflexia (P = 1.00) and spinal cord atrophy (P = 0.60). Conclusion: DTI study in HD patients did not reveal corticospinal tract involvement in brain.

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Objective: The present study is to investigate the pre- and post-operative magnetic resonance imaging of pituitary tissues following transsphenoidal resection of pituitary macroadenomas, as well as its clinical significance. Materials and Methods: The medical records of 108 consecutive pituitary macroadenoma patients admitted at Fuzhou 900^th Hospital between September 2012 and September 2014 were retrospectively reviewed. Siemens 3. 0T magnetic resonance scanner was used to perform pre- and postoperative MRI scanning, including plain scan and contrast-enhanced scan of SE sequential T1WI and T2WI in sagittal, coronal and axial views. PACS medical imaging system was used to measure the diameter of pituitary adenoma, as well as the volumes of the adenoma and pituitary tissue. Hematoxylin-eosin staining and immunohistochemical staining were also performed. Results: Higher height of pituitary adenoma results in lower rate of posterior pituitary bright spot (PPBS) on MR T1-weighted imaging. Preoperative MR signal intensity of PPBS was negatively related to diabetes insipidus (DI). Normal pituitary tissues were likely to be above the pituitary adenomas in growth hormone-secreting adenoma patients, while mostly located aside in gonadotropin-secreting adenoma patients. Morphological restitution of postoperative pituitary tissues was better in lateral displacement than that in superior or superolateral patterns on pre-operative MR images. Positive rate of PPBS on preoperative MRI is negatively related to adenoma height, and the signal intensity of PPBS is inversely related to postoperative DI. Conclusions: The relative locations of pituitary tissues and adenoma tissues may be associated with the adenoma type and may affect the postoperative remodeling of residual pituitary tissues.

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Background: Pain is a common and distressing symptom of Parkinson's disease (PD). The relation of pain, its predictors, and its impact on quality of life (QoL) in PD has not been studied in Indian PD patients. Objective: To assess the predictors of pain and investigate its impact on QoL among Indian PD patients. Methodology: We conducted a cross-sectional study on 100 PD patients. The cases were diagnosed according to the UK brain bank criteria. Unified PD Rating Scale (UPDRS) parts III, V, and VI were employed to assess the severity of the disease. King's Parkinson Disease Pain Scale (KPPS) and PD questionnaire-8 (PDQ-8) were used to evaluate pain and QoL, respectively. Results: Prevalence of different pain types in patients with PD was 70%, mainly including musculoskeletal (53%), fluctuation-related (35%), and nocturnal pain (27%). Subjects with pain developed PD symptoms at a younger age and had a longer duration of the disease. A positive correlation was found between KPPS scores and UPDRS parts III and V, while a negative correlation was observed with UPDRS part VI. Pain in PD subjects had a significant impact on the QoL. Conclusions: Most of the PD patients suffered some form of pain with significant correlations with motor disability and poor QoL. Predictors of pain severity among PD patients included a longer disease duration, younger age of disease onset, and a higher levodopa equivalent daily dose (LEDD).

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Background: Giant intracranial aneurysms (GIAs) are treacherous lesions and in spite of the many advances, endovascular therapy (EVT) of GIAs is challenging. Objective: A retrospective analysis of our results with microsurgery of GIAs is presented to examine the role of microsurgery in the current trend of EVT. Materials and Methods: Between 1996 and 2019, 134 patients with 147 GIAs had microsurgery by the senior author in a single institute. The medical and imaging records for all the patients were reviewed. The patient outcome was determined by modified Rankin scale (mRS); ≤3 was considered as a good outcome. Statistical analysis was done using the SPSS program and odds ratios and their 95% confidence intervals were computed; a probability value of < 0.05 was considered significant. Results: There were 123 aneurysms (83.7%) in the anterior circulation and 24 aneurysms (16.3%) in the posterior circulation. Overall 103 out of 134 (76.8%) patients had a good outcome postoperatively. Good preoperative mRS score (≤3) had an overall good prognosis in the postoperative period and was statistically significant (P = 0.000, odds ratio: 0.036, 95% CI: 0.008–0.171). Presence of subarachnoid hemorrhage (SAH) was also statistically significant for good outcome (P = 0.04, odds ratio: 2.898, 95% CI: 1.051–7.991), but age was not a significant prognostic factor. Mortality within 30 days of treatment was 4.47%. Conclusion: GIAs need treatment because of their dismal natural history. Results of microsurgical treatment by a single surgeon of the large current series compare well with the results of EVT and justifies pursuing microsurgery for GIAs.

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Background: Screw diameters are currently available based on the literature available for the Western population. No data are available in such a large number of patients for the Indian population. Objective: The aim of this study was to define the average pedicle size available and to determine the angulation for placement of screws for C2 pedicle in the Indian population. We also try to determine the pedicle screw diameter which can be used universally in most Indian patients, considering the pedicle dimensions. Material and Methods: Retrospective morphometric analysis of CT scans of 247 patients (152 M, 95 F) was done to calculate the C2 pedicle width (PW), pedicle height (PH), pedicle length (PL), pedicle transverse angle (PTA) and the craniocaudal angulation (CCA) of the C2 pedicle. Results: Mean PW in females was 5.3 mm and in males it was 5.9 mm. This difference was statistically significant. The mean PH in the study population was 8.9 mm, while the mean PL was 29.7 mm. The mean PTA was 40.0 degrees and the CCA was 28.4 degrees. Conclusion: This is a morphometric analysis of the C2 pedicle which provides information for the surgeons to determine the safe site of entry and trajectory for the screw implantation. We conclude that a screw diameter of 2.7 mm can be safely implanted in a vast majority of the patient population.

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Background: Neurogenic stress cardiomyopathy (NSC), also known as stress-induced cardiomyopathy (SIC), is a significant complication of aneurysmal subarachnoid hemorrhage and an important contributor to morbidity mortality. Objective: This prospective observational study assessed whether the high sensitive troponin T (hsTnT) and N-terminal pro-B-type natriuretic peptide (NTproBNP) helps in the prediction of NSC after SAH. Methods: The consecutive patients with aSAH without any cardiac history were included prospectively over 12 months. Neurological assessment for the grade of SAH (Hunt & Hess and WFNS grade), electrocardiogram, and echocardiography done at admission. The serial measurements of serum hsTnT and NTproBNP for consecutive 7 days done. The NSC is defined as transient hypokinesia of the ventricular wall on echocardiography. Results: The study included 69 patients, and 7 (10.1%) were diagnosed with NSC. The NSC had a positive correlation with Hunt and Hess grade (P = 0.010), and the serum levels of hsTnT and NTproBNP were higher in patients with NSC in comparison to without NSC over all 7 days. The peak levels of hsTnT and NTproBNP were significantly higher in patients with cardiomyopathy (P = 0.000 and 0.032, respectively). The best cut-off level of peak hsTnT was 0.032 pg/dl to predict cardiomyopathy with sensitivity and specificity of 100% and 80%, respectively, and NTproBNP was 430.6 ng/dL with sensitivity and specificity of 86% and 73%, respectively. Conclusion: The peak levels of hsTnT and NTproBNP with abnormal ECG and echocardiography at admission help identify NSC in the early phase of aSAH.

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Background: The voltage-dependent calcium channel α1 subunit (CACNA1A) gene plays a major role in neuronal communication. Mutation in this gene results in altered Ca²⁺ ion influx that modify the neurotransmitter release resulting in the development of various neurological disorders like hemiplegic migraine with cortical spreading depression, epilepsy, episodic ataxia type 2, and spinocerebellar ataxia type 6. Objective: This review aimed in portraying the frequent mutations in CACNA1A gene causing hemiplegic migraine with cortical spreading depression, epilepsy, episodic ataxia type 2 and spinocerebellar ataxia type 6. Methodology: A systematic search has been adopted in various databases using the keywords “Calcium channel,” “migraine,” “epilepsy,” “episodic ataxia,” and “spinocerebellar ataxia” for writing this review that collectively focuses on mutations in the CACNA1A gene causing the common neurological diseases from 1975 to 2019. Conclusion: Every type of mutation has its own signature in gene functioning and understanding them might aid knowing more in disease progression.

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Background and Introduction: Clipping an aneurysm on an elongated and tented V4 segment near the origin of the posterior inferior cerebellar artery (high-riding VA-PICA junction aneurysm) can be challenging. Objective: We demonstrate the microsurgical clipping technique of such an aneurysm using a modified retromastoid approach (MRMA) and glossopharyngeal-cochlear triangle (GCT). Surgical Technique: A 50-year-old female with a ruptured high-riding left VA-PICA junction aneurysm underwent an MRMA. Using segmental vessel isolation with proximal and distal temporary clips, this aneurysm was occluded through the GCT by applying a tandem clipping technique while preserving the PICA. Results: The procedure was uneventful. Apart from transient ataxia, she recovered completely and maintains a good status at follow-up. Conclusion: In high-riding VA-PICA junction aneurysms, a conventional far lateral approach may create awkward viewing and working angles. An MRMA with a horizontal trajectory through the GCT may be a more appropriate strategy.

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Wall-eyed monocular internuclear ophthalmoplegia (WEMINO) is a rare variant of internuclear ophthalmoplegia (INO), consisting of unilateral INO and ipsilateral exotropia. This distinctive syndrome is probably associated with damage to the medial longitudinal fasciculus. However, WEMINO caused by a midbrain lesion has not been previously reported. We herein report a 50-year-old man presenting with WEMINO and vertical gaze dysfunction resulting from infarction of the midbrain tegmentum.

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Background: Gliomas are aggressive tumors with limited treatment options. Immunotherapy targets are under evaluation as new therapeutic targets in gliomas. Aims and Objectives: The aims of the study were to analyze expression of PDL1 in adult diffuse gliomas in World Health Organization grade II, III, and IV and to corelate its expression with demographic features, IDH-1, ATRX, and p-53 mutation status. Materials and Methods: This was a case series that included 30 cases of adult diffuse glioma. In all cases, a composite diagnosis including histologic type, grade, and molecular alterations was rendered. PDL1 testing was done by immunohistochemistry using PDL1 SP-263 antibody. Results: PDL1 expression was identified in 33.3% cases in tumor cells and in 6.67% cases in immune cells. All neoplasms with PDL1 expression were astrocytic tumors. PDL1 expression was significantly associated with IDH-1 immunonegative gliomas (P = 0.013). Conclusion: PDL1 is a novel therapeutic target in gliomas. The current study is an attempt to evaluate the expression of PDL1 over the varied spectrum of gliomas. Key Words:

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Intraparenchymal venous congestive changes secondary to carotico-cavernous fistula are not common. Isolated basal ganglia venous congestive changes in carotico-cavernous fistula have been rarely described. We report MRI findings of the unilateral basal ganglia hyperintensity, angiographic features including cortical venous reflux into a variant basal vein of Rosenthal, in a postpartum woman presenting with the left eye proptosis and the right upper limb weakness. We also describe the reversal of imaging findings and resolution of patients' symptoms after definitive treatment of the carotico-cavernous fistula by endovascular embolization

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Ictal fear is a common manifestation with seizures originating from temporal lobe, orbitofrontal region and cingulate cortex. Ictal smile has been described in association with seizures from hypothalamus, cingulate cortex, lateral and prefrontal cortex. Isolated fear or ictal smile has been reported in various published reports in the past in patients with cingulate epilepsy. We report an unusual semiology with ictal smiling along with fear and preserved sensorium during the event, in a four-year-old child; Our hypothesis was that the ictal origin, most likely from the right mesial frontal or cingulate cortex. The child underwent resective surgery after multimodality evaluation and has been seizure free for 6 years post-surgery.

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Hemorrhagic neuropathy is an extremely rare condition. This condition refers to bleed into or around a peripheral nerve, causing either an extra neural or an intraneural hematoma. When they do occur, it is usually due to iatrogenic/inherited coagulopathies or as a consequence of injections targeting nerves. We present a case of sciatic nerve palsy developed secondary to anticoagulant therapy (Warfarin). MRI imaging showed features of sciatic nerve hematoma following which warfarin was withdrawn. The patient showed symptomatic improvement and a follow up ultrasound of left thigh showed resolution of hematoma with normal sciatic nerve diameter. To the best of our knowledge there is limited available literature regarding nerve hematomas secondary to anticoagulation therapy. This complication should be promptly recognized and immediate steps should take place because of the favorable results of the early treatment.

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A 45-year-old man presented with acute onset ataxia for last 1 week. On examination he had signs of left-sided cerebellar involement. MRI brain revealed asymmetric altered signal intensities in bilateral cerebellar hemispheres suggesting demyelinating lesions. ELISA for Human Immune Deficiency virus-1 was positive. CSF JC virus DNA PCR was positive. A diagnosis of Progressive Multifocal Leukoencephalopathy (PML) was made on the basis of clinico-radiological picture and JC virus DNA PCR presence in CSF. PML is unknown and under diagnosed CNS infection seen in HIV patients mostly seen with advanced disease. We present an unusual case report where isolated cerebellar involvement occurred as the first AIDS defining event in the absence of appreciable immunodeficiency in a patient with previously undiagnosed HIV infection.

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Lesch–Nyhan syndrome is a rare neurometabolic condition characterized by progressive choreoathetosis, intellectual disability, and peculiar manifestations like self-mutilation. Occasional case reports in adults have suggested an association between Lesch–Nyhan syndrome and hypercoagulability; however, no such report of either a venous or arterial stroke in children with Lesch–Nyhan Syndrome exists in literature. We present a 3-year-old boy with global developmental delay, dystonic posturing, choreoathetoid movements, and self-mutilation involving fingers and lips. He had acute worsening of sensorium, recurrent seizures, and opisthotonous posturing. A diagnosis of Lesch–Nyhan Syndrome was confirmed by extremely low hypoxanthine-guanine phosphoribosyltransferase enzyme levels. In view of an acute neurological deterioration, magnetic resonance imaging brain and magnetic resonance venogram were done that showed sagittal and left transverse venous sinus thrombosis. This case is the first case report of cerebral venous sinus thrombosis in a child with Lesch–Nyhan Syndrome. It further strengthens the association between hypercoagulability and Lesch–Nyhan syndrome.

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Music is universal and is present in all cultures and capable of conveying emotions irrespective of verbal content. The present study was conducted to understand the impact of music on brain with real-time monitoring of EEG changes in patients with moderate-to-severe neuronal dysfunction. In this prospective study, adult patients who had brain trauma and unconscious were considered for the study. Two different music pieces were selected to give music experience. One is Revathi raga with Upanishads' stands. Another is Ragamalika, an instrumental music piece comprising various Carnatic ragas. For EEG recording, electrode montage was done according to international 10-20 system. After music experience, again EEG recording was done without music. Comparison of EEG activity during different musical pieces was not considered. A total of six adults were studied. During the time of music session, there was no change in the EEG at other channels, but at T6 electrode, EEG did not have the arc like fast theta. That fast theta was disappeared in T6 electrode and it was suppressed like a contralateral sided electrode. After the music session (post music session), the EEG is back to baseline, but the temporal arc like fast theta speed was decreased (2–4 seconds per page). In this case series, we observed that in one case, there was appearance of slow activity in EEG. However, there is a need for larger studies to confirm these findings.

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Cerebral phaeohyphomycosis is a rare but serious fungal infection of the central nervous system caused by dematiaceous septate fungi characterized by the presence of melanin-like pigment within the cell wall that is a pale brown to black. It is associated with poor prognosis despite aggressive treatment. We report a previously well 3-year boy with cerebral phaeohyphomycosis who had subacute meningoencephalitic presentation with refractory raised intracranial pressure and had fatal outcomes. The diagnosis was confirmed by histopathological examination of brain tissue obtained by brain biopsy.

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The anterior approach to cervical spine is a common surgical approach used in spinal surgeries, usually done under fluoroscopic guidance. However, in certain situations like in patients where the area of interest is lower cervical spine, it is not possible to visualize the area of interest with fluoroscopy. The use of intraoperative navigation is very helpful in these scenarios. However, intraoperative navigation is used very sparingly in the anterior approaches to cervical spine. This might be due to the lack of a proper place to fix the reference frame on the anterior aspect of cervical spine. We present our way of using intraoperative navigation during anterior approach to cervical spine.

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Background: Coronary artery disease (CAD) and ischemic stroke share the same risk factors. Objective: The aim of the study was to explore the prevalence and predictors of concomitant CAD in acute ischemic stroke patients. Methods: One hundred and five patients (64.3 ± 15.0 years, 61 male) presenting with acute ischemic stroke documented by neuroimaging were consecutively included. All patients were carefully evaluated to determine their cardiovascular disease risk scores. The patients who had been previously shown to have ≥50% stenosis in at least one of the major coronary arteries by coronary angiography were grouped as CAD patients. Results: Of the 105 stroke patients, 27 patients had documented concomitant CAD. The stroke patients with CAD had higher cardiovascular risk scores and troponin I levels and carotid plaques were more prevalent. ROC analysis determined cut-off values as ≥22% for Framingham Heart Study Risk Score, ≥0.05 ng/mL for Troponin I, and ≥0.80 mm for carotid artery intima-media thickness to predict concomitant CAD. During 6 months of follow-up, among the 78 stroke patients without documented CAD, 16 patients had experienced major cardiovascular events including myocardial infarction, recurrent stroke, or cardiovascular death. These patients had higher Framingham Heart Study Risk Score and high-sensitive C reactive protein levels. Conclusion: Our study suggests stroke patients with higher Framingham Heart Study Risk Score and troponin I levels and carotid plaques be further investigated for the presence of concomitant CAD.

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Context: Plain computed tomography (CT) of the brain is an important first-line investigation of choice in an acute neurologic setup. Unless clinically suspected concealed areas like the confluence of venous sinuses often go unnoticed. Diagnosing anemia, thrombosis, or polycythemia correlating the CT attenuation values might prove to be fruitful in early patient management where the mode of varied clinical presentations causes a clinical dilemma. Aims: 1) To determine the objective correlation between CT attenuation of the cerebral venous sinus and hemoglobin (Hb) as well as hematocrit (HCT) value and 2) to detect anemia from measuring venous sinus attenuation. Methods and Materials: An exploratory study design of 200 patients, who had plain CT of the head and Hb and HCT levels obtained within 24 h of the scan. Statistical Analysis Used: Two-tailed unpaired t-test was used to test the difference between two independent samples. Correlation and regression analyses were used to assess the correlation between two quantitative variables. Results: A significant correlation was observed between the Hb-Hounsfield unit (HU) and HCT-HU. The simple linear regression model revealed that HU (P value < 0.001) was significantly correlated with Hb and the regression model was, Hb = 2.1 + 0.2 × HU. Similarly, HU (P value < 0.001) was significantly correlated with HCT and regression model was HCT = 6.2 + 0.7 × HU. Conclusions: Objective attenuation values of dural sinuses on plain CT can be positively correlated with Hb and HCT values. Considering the cutoff of 35.5 HU, we were able to show the specificity of 100% for the detection of anemia.

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Background and Purpose: We present our experience in using the single Solitaire AB stent for small wide-neck bifurcation aneurysms (WNBAs). Materials and Methods: During 18 months, 20 small (the largest width <10 mm) WNBAs were treated with the single Solitaire AB stent-assisted coiling. The patients were 12 women and 8 men, with a mean age of 52 years (range: 36–66 years). The mean aneurysm size was 4.2 mm (2–9 mm) and mean neck size was 3.9 mm (2–9 mm). Results at follow-up were graded as complete occlusion, neck remnant, or residual aneurysm. Results: All 20 small WNBAs were adequately occluded after a single Solitaire AB stent placement. There were no procedural ruptures and no thromboembolic complications occurred. Two patients developed a transient neurological deficit. In 20 patients with angiographic follow-up at 6 months, 16 (80%) aneurysms remained adequately occluded. Clinical follow-up in the 20 patients revealed mRS 0–2 in all. Conclusions: Single Solitaire AB stent-assisted coil embolization for small WNBAs was safe and effective.

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Aim: Glioblastoma (GBM) is one of the most aggressive neoplasms of the central nervous system with dismal survival. In recent years, different variants of GBM have been described in the literature. GBM with areas of neuroectodermal differentiation (GBM-PNET) is a relatively new entity in GBM. Presence of the neuroectodermal component increases the propensity of systemic dissemination as with other intracranial primitive neuroectodermal tumors (PNET). The optimal treatment for these patients remains a controversy, with authors reporting local radiotherapy to craniospinal irradiation and chemotherapy. We intend to analyze the pattern of care for GBM with neuroectodermal component. Materials and Methods: We retrieved data of four patients with GBM-PNET treated in our institute; data were also retrieved from published series to derive treatment and outcome results. Results: In this series, we report the outcome of a series of four patients of GBM-PNET treated with adjuvant radiotherapy and temozolomide. All but one patient underwent gross total resection of the tumor. Adjuvant hypofractionated radiation with concurrent and adjuvant temozolomide was used in all cases. The median follow-up was 12.9 months in the present series. One patient experienced local recurrence 18 months after the treatment. A review of published literature on GBM-PNET was done; studies with details of patient outcome were used for an independent analysis. Twenty-three patients were identified, and the pooled analysis revealed a median progression free and overall survival of 10 and 25, months respectively. Extent of surgery, local radiation vs. craniospinal irradiation, and age at presentation had no impact on the survival. Conclusion: GBM PNET is a new entity with only few cases reported so far. Clinical behavior and treatment outcome of these tumors are not different from conventional GBM. However, these patients are at higher risk of CSF dissemination. Hence, an individualized treatment approach is best suited.

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Background: Spinal cord injury (SCI) and its negative impact on the quality of life (QOL) is a significant public health concern in India. People with SCI suffer from serious health, economic, and social consequences in their lives. Often, care for SCI survivors is left to their immediate family members in India. Appropriate planning is needed for prevention, rehabilitation, health, and psychological care for SCI in the country. Purpose: This study assessed the overall QOL of SCI survivors and their satisfaction levels with specific domains and their importance of QOL. Materials and Methods: In this observational study, two instruments, Farrens and Power for QOL and Barthel Index for functional abilities, were administered to a convenience sample of participants drawn from Narayana Medical College, Nellore, in South India. Results: Statistically, SCI survivors were found moderately and very satisfied with their QOL. Their perception about importance of health, functioning, social, and economic subscale also did not differ statistically.

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Background: Reflected image processing is a unique brain function and its abnormalities result in problems of localizing, recognizing the images, and utilizing this information in everyday life. Objectives: The aim of this study was to characterize clinical and neuropsychological profiles and to identify the probable neural substrate for this phenomenon in major cognitive disorder. Materials and Methods: We conducted a prospective study from February 2015 to May 2017 in patients with Major Cognitive Disorder (MCD, DSM-5 criteria). All patients were tested for problems in reflected image processing using the detailed protocol after ethical approval of the institute and consent. They also underwent a detailed neuropsychological evaluation, biochemical tests and neuroimaging (structural, diffusion, and resting-state functional MRI) as per established protocol. Results: Of the 18 patients, 11 had mirror agnosia (MA), 5 had mirror image agnosia (MIA) and 2 had both. MRI of MA patients showed parietal atrophy and whereas diffuse pattern of atrophy was seen with MIA. In the MA group, the left superior longitudinal fasciculus showed significantly greater fractional anisotropy and the left angular gyrus showed increased functional connectivity with left anterior cingulate, left dorsolateral prefrontal and bilateral posterior cingulate regions. Conclusion: Mirror image processing defects were not related to the type of MCD, severity or pattern of neuropsychological dysfunction. There are structural and functional alterations in localized regions as well as both hemispheres. Therefore, it is more likely to be a network disorder, irrespective of the MCD type or severity.

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Background: There is a paucity of data on outcomes following four-level anterior cervical discectomy and fusions (ACDFs), especially the sagittal balance (SB) parameters. Objective: We aimed to review the long-term clinical and radiographic outcomes for 41 consecutive patients that underwent instrumented four-level ACDF. Materials and Methods: Records of 27 men and 14 women, aged 40–68 years, who underwent instrumented four-level ACDF and plating at C3–C7 (n = 37) or C4–T1 (n = 4) were retrospectively analyzed. Clinical outcomes that were assessed were the visual analog scale (VAS) for pain, neck disability index (NDI), Odom's criteria, improvement of symptoms, intraoperative and postoperative complications, SB, and need for revision surgery. Results: The mean follow-up was 65 ± 36.3 months. The mean VAS for arm and neck pain significantly improved from 7.7 ± 1.4 to 3.5 ± 1.7 (P < 0.001). The NDI score significantly improved from 31 ± 8.2 to 19.3 ± 8.1 (P < 0.001). Concerning Odom's criteria, the grades were excellent (14), good (17), fair (9), and poor (1). Concerning intraoperative and postoperative complications, 10 cases developed dysphagia, 3 cases developed temporary dysphonia, 2 cases developed a postoperative hematoma, 1 patient developed C5 palsy, 1 vertebral artery (VA) injury, and 1 case had superficial infection. The average length of stay (LOS) was 2.9 ± 3.7 days. Three patients needed another surgery (one adjacent segment and two posterior foraminotomies). Regarding the mean change in SB parameters, Cobb's angle (CA) (C2–C7) was 14° ± 8.3°, fusion angle (FA) was 10.9 ± 10.9°, cervical straight vertical alignment (cSVA) was 0.6 ± 0.5 cm, T1 slope was 2.3° ± 3.4°, and disc height (DH) was 1.3 ± 0.9 mm. Conclusion: Instrumented four-level ACDF is safe with a satisfactory outcome and supplementary posterior fusion was not required in any case.

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Background and Introduction: Unlocking of the frontotemporal dural fold (FTDF) and extradural removal of the anterior clinoid process (EACP) are challenging but mandatory skills for micro-neurosurgeons. Despite the presence of an extensive body of literature on this subject, the translation of this cadaveric and 3D simulation to a real patient turns out to be a very demanding and difficult task. Objective: This video is aimed to address the surgical nuances and major adjustments necessary in the unlocking of the FTDF and extradural ACP removal in an actual case for an early-career neurosurgeon. Surgical Technique: A 40-year lady presented with features of acromegaly with radiological evidence of significant component of the tumor in the right cavernous sinus along with sellar suprasellar component. To achieve a good hormonal control, a complete tumor excision was required, which was achieved with FTDF and EACP removal. The cavernous sinus was approached through the Parkinson's triangle. Results: The patient had uneventful recovery and good hormonal control at the 3-month follow-up. Conclusion: FTDF unlocking and EACP are elegant procedures and need to be learned by all neurosurgeons. This article will provide excellent teaching material for young neurosurgeons.

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