Background: For a favorable outcome, patients admitted to critical care units require continuous monitoring and swift decision-making ability regarding management. One of the biggest challenges in neurocritical care units is the identification and management of autonomic dysfunction and in the worst-case scenario, autonomic storms. Objective: Most of the literature available focuses mainly on autonomic storms following traumatic brain injury. However, due to the myriad neurological presentations in a critical care setting, it is particularly important for physicians and intensivists to suspect and manage autonomic dysfunction in various neurological scenarios. Methods: Understanding the mechanism of paroxysmal sympathetic hyperactivity (PSH) is essential for early recognition and treatment. PSH-AM is an assessment measurement scale to diagnose and assess the severity of PSH in traumatic brain injury. However, this is not yet standardized across all neurological settings. Conclusion: We present a comprehensive report on understanding the mechanism of autonomic storms across various neurological disorders and outline the management.

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Background: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment. One of the most devastating complications is complex regional pain syndrome. Objectivities: The aim of this study was to systematically analyze available evidence about complex regional pain syndrome after carpal tunnel syndrome surgery (CTSS), its risks, associated factors, and treatments. Material and Methods: Research conducted from 1962 through December 31, 2018, in the following databases: PubMed, Web of Science, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. The quality assessment of the methodology followed the definitions by the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. The GRADE system (Grades of Recommendation, Assessment, Development, and Evaluation) was applied to evaluate the efficacy of the stellate ganglion block, one of the most cited and recurrent treatments. Results: Of the 246 studies retrieved, 44 articles were included. Concerning patients' gender, we identified a ratio of 5 females: 3 males. The mean age for women was 57.79, a standard deviation of 14.96, and for men 60.75, a standard deviation of 9.4. Considering the total of primary publications of CTSS outcomes, the accumulated incidence reached the maximum of 0.15 CRPS after CTSS patients/CTSS patients. The known risk factors for CRPS after CTSS: female gender, from the fifth decade of life, tourniquet time, immobilization and surgery on dominant hand. Conclusion: CRPS affects 2-5% of people undergoing CTSS. Its diagnosis is still a challenge and its risk factors are unclear, although it seems more likely to affect women, in the dominant hand. The most used treatments include physiotherapy and stellate ganglion block. Most patients show improvement of symptoms within one year. Further clinical trials comparing treatment modalities are required.

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Melioidosis is gram-negative bacterial infection endemic in parts of Australia and Asia with significant morbidity and mortality. It is acquired in wet rainy seasons through occupational and recreational activities. Although central nervous system (CNS) involvement is seen in less than 10%, it can have severe sequelae. MRI (magnetic resonance imaging) findings in reported cases have shown predominant brain stem and frontoparietal involvement. We present three pediatric cases of neuromelioidosis in which corticospinal tract involvement was a characteristic finding.

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Subacute sclerosing panencephalitis (SSPE), an insidiously progressive slow viral infection of the central nervous system caused by the mutated measles virus, is invariably fatal. Various medications have been tried unsuccessfully till date with rare remissions. A case of 21-year woman with adult-onset SSPE who improved after treatment is reported. She had seizures, psychosis, and extrapyramidal symptoms and was on multiple anti-seizure medications without response. She was given a trial of levamisole with gradual escalation and achieved complete clinical remission by 21 months. This case demonstrates the curative potential of levamisole in adult-onset SSPE. A review of previous treatments attempted in cases who underwent remission of SSPE is also presented.

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Background: The data regarding patients eligible for endovascular thrombectomy (EVT), especially in the developing world is lacking. Objective: To determine the proportion of patients with acute ischemic stroke (AIS) who are eligible for EVT in the 0-24-h time window. Materials and Methods: We performed a retrospective cohort study using prospectively collected AIS data between July 2017 and September 2019. Demographic, clinical, and management information were analyzed. EVT eligibility was explored using the following criteria: National Institutes of Health Stroke Scale (NIHSS) score ≥6, presence of anterior circulation large-vessel occlusion (ACLVO), Alberta stroke program early Computerized Tomography score (ASPECTS) ≥6, baseline modified Rankin Scale (mRS) score 0–2, and within 24 h of time last seen well (TLSW). EVT-eligible patients were further evaluated for in-hospital course and outcomes. Results: In the study period of 27 months, there were 221 patients with AIS who presented within 24 h. The mean age of the patients was 54.4 (16.0) years and 66.1% (146) were males. A majority (61.5% [136/221]) arrived within 6 h of TLSW. Of these, 81.6% (111/136) presented in the time window for thrombolysis (0–4.5 h). The patients with NIHSS ≥6 and ACLVO constituted 41.2% (91/221) of the patients. AIS eligible for EVT constituted 19.5% (43/221) of the patients. Conclusion: In our study, the proportion of AIS eligible for endovascular thrombectomy was comparable to the developed world. These data predict a large potential for the late-window EVT in India.

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Prof B Ramamurthi was a pioneer of Indian neurosurgery and a major force in the development of Indian neuroscience. Founding the Madras Institute of Neurology and later the A Lakshmipathi Neurosurgical Centre (ALNC), both at Madras (or Chennai as it is now called), he developed centres of excellence in his career that spanned over five decades. During this period of time he made Madras, a destination for neurosurgery and neuroscience. Along with his colleagues a large number of publications were produced which influenced the world. Notable among his contributions were those in Stereotaxy for movement disorders, epilepsy, pain and psychiatric illness. He also had notable contributions in brain tumours especially acoustic neurinomas and pituitary tumours. His papers on the low incidence of aneurysms is still quoted widely. Head injuries formed a major part of the neurosurgical work and major contributions were made in that field too. As a developing country with socio-economic issues, infections of the nervous system were seen commonly. His publications on tuberculomas of the brain are noteworthy. He was intrigued by the neurophysiological basis of consciousness. He writings on the subject reflect his attempt to bring together ancient eastern thoughts and concepts of consciousness and life and western science. In the later part of his career he spoke on ethics in and the changing milieu of neurosurgery. While contributions to spinal surgery were not seen in the first half of his career, he along with his colleagues from ALNC published original articles on spinal surgery especially tumours and OPLL. Prof B Ramamurthi, has not only influenced, taught and mentored, during his lifetime, a great many neuroscientists, but he also continues to do so through his publications which continue to be relevant in todays world. A glimpse into his contributions show us how without the technology of today a lot was achieved - and we need to see that, to inspire us to achieve more and to strive for greater heights.

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Background: Brainstem gliomas (BSG) constitutes very small proportion in adults brain tumors with pons as most common location. There is significant paucity in literature for adult diffuse intrinsic pontine gliomas (DIPG). Objective: In this study, we attempt to review the outcomes of DIPG in single institute. Methods: We performed a retrospective chart review of adult DIPG from last 8 years (2010-2018) in a tertiary institute. DIPG was defined as expansile lesions involving more than 50% of the greatest diameter in the pons. Results: We found a total 46 patients with the diagnosis of adult BSG. Based on the definition, 23 patients with adult DIPG qualified to be included in the study. The median age was 32 years (IQR: 22-41), with a sex ratio of 16/7 (M/F). Cranial palsies were found in 17 (73%) patients. The median duration of symptoms was 6 months. On magnetic resonance imaging (MRI), contrast enhancement was found in seven (30%) patients. Biopsy was done in five patients. Median follow up was 11 months (IQR: 7-15). Median overall survival (OS) was 15 months (95%, CI 8.3-21.6). Fourteen patients had succumbed to death at the latest follow-up, and seven patients were alive. Median OS for the patients with age less than 40 years and more than 40 years was 7 and 22 months, respectively (p = 0.016). Rest of the variables did not effect OS significantly. Conclusion: Adult DIPG's significantly differs from pediatric counterparts in clinical characteristics, as well as OS. Age was the only factor which was significantly associated with survival in our study. Long-term studies with molecular profiling may help in further characterizing these lesions.

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Background: Idiopathic intracranial hypertension (IIH) is well-described entity in literature. However, large studies on clinical and radiological profile are still very few from the Indian subcontinent. Aims: To analyze the clinical and radiological profile of IIH and correlation of various clinical and radiological parameters with papilledema and CSF opening pressure. Setting and Design: Hospital-based observational, descriptive study. Materials and Methods: This study analyzed 122 patients admitted in the department of Neurology (from January 2014 to December 2018) for detailed history, clinical examination, and neuroimaging. CSF manometry and routine CSF analysis were done. All participants met the modified Dandy criteria. Patients with secondary causes of raised ICP and primary ocular pathology were excluded. Statistical Analysis Used: Descriptive statistics and Chi-square test. Results: Among 122 cases 86 (70.49%) were females. The mean age was 33 years. 62 (50.82%) cases were obese. Headache was the most common symptom (114/122; 93.44%). Bilateral papilledema was noted in 114 (93.44%) cases. Higher grades of papilledema had a correlation with higher CSF opening pressure. Empty sella was the most common radiological finding (100/122; 81.97%). All radiological findings except empty sella had a correlation with higher CSF opening pressure. Conclusion: IIH typically affects obese females of childbearing age group. However, it is not uncommon in the nonobese and male sex. Obesity may not be a dominant risk factor for the development of IIH in the Indian subcontinent. Cases with normal BMI and male sex with clinical features of raised intracranial pressure and normal neuroimaging should also be evaluated for IIH. Cases with refractory headache and empty sella on MRI should be evaluated for IIH.

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Background and Introduction: Minimally invasive spine surgery (MISS) is a set of techniques and procedures that reduces the local tissue injury while achieving the same results through traditional open surgery. The techniques for the treatment of lumbar disc herniation and degenerative canal stenosis have evolved from tubular discectomy to endoscopic discectomy. This helps in preserving spine function. Good clinical outcomes have been reported with the use of an endoscope for degenerative lumbar disc disease. Objective: In this video abstract, we present a case lumbar foraminal stenosis in an elderly man that was treated successfully using unilateral biportal endoscopic spine surgery. (UBESS). Surgical Technique: A 70-year-old man presented with progressive neurogenic claudication and left L4 numbness and paresthesias. His claudication distance was 200 m. His MRI Lumbosacral spine showed severe left L4-5 foraminal stenosis due to a disc prolapse. The patient underwent a left-sided unilateral biportal endoscopic transforaminal decompression and discectomy at L4-5 successfully. Postoperative period was uneventful and the patient had significant relief in his symptoms. Postoperative MRI Lumbosacral spine showed no muscle damage with adequate decompression at left L4-5 level. Results: The patient had an uneventful recovery. Conclusion: Biportal percutaneous transforaminal endoscopic discectomy/decompression is an ideal alternative to the uniportal endoscopic and minimal invasive microsurgery for foraminal and paracentral disc herniations and lateral recess and foraminal stenosis.

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Background: Patients with temporal lobe epilepsy are subjected to standard temporal lobectomy wherever indicated. This is performed using a reverse question mark flap and a standard frontotemporal craniotomy. We describe the technique of minitemporal craniotomy (3 × 3cms) for temporal lobe epilepsy (TLE) and analyze the clinical outcomes of patients operated using this approach. Objectives: To describe the technique of minitemporal craniotomy for TLE without navigation guidance and to analyze the clinical outcomes of patients operated using this approach. Materials and Method: This was a retrospective analysis of all consecutive TLE cases operated at our institute from 2014 to 2019, via minitemporal craniotomy, using surface landmarks only without navigation guidance. The surgical technique, indications for surgery, and their clinical outcomes were analyzed. Results: A total number of 48 patients underwent surgery for TLE. There were no complications except three patients who had transient hemiparesis. The average duration of hospital stay was 4 days following surgery. Out of 28 patients with mesial temporal sclerosis, 22 (82%) had international league against epilepsy, Class I seizure outcome, 4 (12.5%) had Class II outcome and 2 (5.5%) had Class III outcome. 9 patients with dysembryoplastic neurectodermal tumor (DNET), 4 gangliogliomas, 2 neurocystecercosis (NCC), all had Class I outcome. Out of the five patients with MTS and associated anterior temporal focal cortical dysplasia (FCD), four (80%) had a Class I outcome, whereas one (20%) had Class II outcome. Conclusion: Utilizing surface anatomical landmarks, minitemporal craniotomy can be performed in even peripheral centers without neuronavigation, with good cosmesis, seizure outcomes.

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Aim and Objectives: We aimed to find the prevalence of bovine aortic arch in stroke and non-stroke patients and to study the relationship between bovine aortic arch and the occurrence of stroke. Materials and Methods: One hundred patients with and without stroke underwent computed tomography (CT) angiography of the thoracic aorta and its arch. Fifty diffusion-weighted magnetic resonance imaging (MRI)-confirmed anterior circulation stroke patients who had undergone digital subtraction angiography (DSA) afterward formed the case group. As controls, another 50 patients who had thoracic CT angiograms for disease other than stroke during this time period were randomly selected. Demographics and prevalence of bovine arch were compared between cases and controls. In the case group, demographics and prevalence of bovine arch variants and their relationship to stroke were studied. Results: Prevalence of bovine aortic arch variant in anterior circulation stroke was 22%, compared to 6% in non-stroke patients (P = 0.043). The bovine aortic arch was associated with the younger onset of stroke occurrence (P = 0.046). In the bovine arch group, the proportion of left-sided strokes (P = 0.022) and bilateral strokes (P < 0.00001) was significantly higher. As compared to type A (P = 0.140), type B bovine aortic arch had a better association (P = 0.092). Conclusions: Bovine aortic arch is a risk factor for young-onset anterior circulation stroke. Bilateral and left-sided infarcts were more common. Endovascular procedures are difficult to perform through conventional routes, so brachioradial access is preferred.

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Background: The literature regarding the utility of cerebrospinal fluid (CSF) procalcitonin (PCT) in the diagnosis of post-craniotomy bacterial meningitis and differentiating it from aseptic meningitis is sparse. Materials and Methods: CSF total WBC count, sugar, protein, and PCT were measured in febrile patients with suspected post-craniotomy meningitis during the first 30 days following an intradural cranial procedure for non-trauma indications. Patients were diagnosed as postoperative bacterial meningitis if CSF culture was positive (PBM, n = 28) or postoperative aseptic meningitis if CSF culture was sterile and there was no evidence of systemic infection (PAM, n = 31). CSF cytochemical parameters and PCT values were compared between the groups. Normal values of CSF PCT were obtained from 14 patients with noninfectious indications with hydrocephalus. Results: There was no significant difference in CSF total WBC count, sugar, and protein levels between PAM and PBM groups. The median PCT level in CSF in the normal group was 0.03 ng/mL (interquartile range [IQR] 0.02–0.07 ng/mL). CSF PCT in the PBM group (median 0.37 ng/mL, IQR 0.2–1.4 ng/mL) was significantly higher than normal values as well as PAM group (median 0.12 ng/mL, IQR 0.07–0.26 ng/mL (P = 0.0004). The area under the receiver operating characteristic (ROC) curve for CSF PCT was 0.767. A cutoff value of 0.12 ng/mL yielded a sensitivity of 85.7% (95% CI: 67.3% to 96%), specificity of 51.6% (95% CI: 33% to 69.9%), positive predictive value of 61.5% (95% CI: 51.9% to 70.3%), and negative predictive value of 80% (95% CI: 60.3.8% to 91.3%). Conclusions: CSF PCT assay in patients who are febrile during the first 30 days post-non-trauma neurosurgical procedures has a role in the early diagnosis of bacterial meningitis.

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Background: Stroke is a neurological deficit due to vascular disorders. Microglia are the first line of defense against brain injury. Anti-inflammatory cytokines activate M2 microglia, which upregulate CD206. EGCG is abundant in green tea, which has an anti-inflammatory effect. Objective: To know the effect of green tea with its active compound EGCG on CD206 expression. Settings and Design: True experimental trial design. Material and Methods: Rattus Novergicus were divided into six groups: a negative control group (Sham), a positive control group (P0), MCAO mice given 10 mg/kg BW EGCG (P1), 20 mg/kg BW EGCG (P2), 30 mg/kg BW EGCG (P3), and 30 mg/kg BW standardized green tea extract (P4). CD206 expression was measured using immunohistochemistry and scored according to the Allred scoring guidelines. Statistical Analysis Used: Descriptive test, Levine test, Kolmogorov–Smirnoff test, Independent sample t test, Pearson correlation test Results: We discovered that there is a significant difference in CD206 expression between the Sham and P0 groups (P < 0.05). In addition, there are significant differences in expression between the sham group and the other two groups (P1 and P2) (P < 0.05). Furthermore, when we compared the P0 group with each treatment group, we found that CD206 expression between P0–P2, P0–P3, P0–P4 are significantly different. There is a significant correlation between green tea with its active compound EGCG and CD206 expression enhancement. The correlation is positive. Conclusions: Green tea with EGCG active compound increases CD206 expression as an M2 marker in the Rattus norvegicus with MCAO model.

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Background: Deep location as well as relation to major vascular structures and eloquent brain areas make insular glioma resection challenging. Transsylvian and transopercular approaches have been described for resection of these tumors. Objective: We illustrate the anatomical relations of a dominant hemisphere insular glioma and present the video demonstrating the step-wise resection of the same via frontal transopercular approach. Surgical Procedure: A 27-year-old lady with dominant hemisphere insular glioma underwent awake surgery through a transopercular approach with cortical and subcortical mapping using direct electrical stimulation for resection of the same. Result: Gross total resection of left insular glioma was achieved without any fresh postoperative deficits. Conclusion: Awake transopercular approach with intraoperative motor, language, and neuropsychological monitoring helps achieve maximum safe resection of insular glioma in the dominant cerebral hemisphere.

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Background: The surgical skill practice in neurosurgery is being compromised in the recent past owing to the duty time constraint, patient safety concerns, and medico-legal issues. Surgical practice outside the operating room is essential to enhance a resident's operative skills and to gain confidence. Objective: To discuss the experience of establishing an 'in-house neurosurgery skills laboratory' and various training sessions conducted with cadaveric and non-cadaveric simulation modules. Methods: A skills laboratory was set up in the existing resident teaching hall with nine workstations. Each station has been equipped with an operating table, surgeon's chair, basic microscope, endoscope, high-speed drill system, and a suction machine. Vascular anastomosis, high-speed drilling, and basic neuroendoscopy were planned on low-cost non-cadaveric modules. Craniotomy and various surgical approaches were designed on cadaveric modules obtained from the anatomy department. Result: A total of 18 residents in divided groups during their initial three semesters had participated in the non-cadaveric simulation courses. Twenty-six residents had participated and 12 sessions were conducted on the cadaveric modules. Three workshops were conducted and 20 residents and faculty members from five other institutions had participated in the cadaveric hands-on training session. Conclusion: A well-equipped skills laboratory provides an opportunity for the residents to acquire operative expertise in a similar atmosphere to that of the operating theater. A structured program comprising various operative practice sessions should be incorporated into the resident training program.

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Background: Therapeutic plasma exchange (TPE) is indicated in the acute presentation of neuromyelitis optica spectrum disorders (NMOSD) as category II indication as per American Society for Apheresis guidelines 2016. Aim: To assess the efficacy of TPE in symptomatic patients of NMOSD not responding to high dose intravenous steroids. Patients and Methods: We retrospectively reviewed the record of TPE procedures in NMOSD patients over a period of 3 years (2013–2016). TPEs were done on Cobe® spectra (Terumo BCT, Lakewood Co., USA) using 5% human serum albumin or fresh frozen plasma as replacement fluid. Clinical improvement was recorded post-procedure and adverse reactions if any was noted. Results: We performed TPE in 11 clinically diagnosed patients of NMOSD. Three (27%) patients had only visual symptoms, five (46%) had both visual as well as muscular symptoms, whereas three (27%) patients presented with only muscular symptoms. Out of seven tested, three patients were aquaporin-4-immunoglobulin-G-positive (AQP4-IgG positive). Visual symptoms improved from no vision pre-TPE therapy to finger counting or 6/24 post-therapy.The muscle power of the limbs improved by grade one to grade two post-therapy. Adverse events were observed in 8% (5/62) of the procedures; allergic reactions to replacement fluid as the most common event (n = 3) followed by hypotension (n = 2). Follow-up was available in 81% (9/11) patients. Two patients died at 3 and 12 months of follow-up. One patient had relapsed and underwent a second TPE cycle. Conclusion: The addition of TPE as a part of therapy is effective and safe in acute exacerbations of NMOSD.

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Background and Objective: Aluminum chloride (AlCl3) can impair spatial memory recovery. We investigated the protective effect of L-arginine, a precursor of nitric oxide (NO), on memory retrieval in an Alzheimer's animal model induced by AlCl3 at intra-hippocampal CA1 using a seeking behavior practice. Materials and Methods: Wistar rats were deeply anesthetized and cannulated at CA1 (AP: -3.8 mm, L: ±2.2 mm, V: 3 mm), and received once AlCl3 (1–200 μg/rat, intra-CA1), on day of cannulation under stereotaxic device. After a week of recovery, they experienced the novelty task with a three-stage paradigm and injected L-arginine (0.05–25 μg/rat) intra-CA1, pretesting. L-NAME, the neuronal NO synthase inhibitor was administered before L-arginine effective doses in the test stage. Also, a reference group exclusively received beta-amyloid 2 μg/rat. Control group solely received saline. Finally, after euthanasia of rat, the hippocampal sample was collected on ice and evaluated by immunohistochemical marking and specific staining. Results: AlCl3 caused novelty-seeking behavior without meaningful change in animal locomotor activity. βA (2 μg/rat, intra-CA1) affected the rat's grooming, causing it to stop further in the new side. Pretest injection of L-arginine restored behavior in AlCl3-treated rats; however, this effect was stopped by L-NAME pretreatment, indicating NO involvement. CA1 did not show necrotic change due to AlCl3 exposure; however, neurofibrillary tangles were accumulated in the region. Conclusions: Prophylaxis with L-arginine probably due to NO has a protective role against the dangerous effect of AlCl3 on the function of neurons in the cortical hippocampus.

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We report a case of a 9-year-old boy with glioblastoma with a past history of colon cancer. Germline bi-allelic DNA-mismatch repair deficiency was diagnosed by a lack of immunohistochemical staining for PMS2 in the tumor and normal tissue. Family history was lacking. Sequencing confirmed compound heterozygous PMS2 mutations. A second hit in the DNA-polymerase-ε gene led to complete DNA-replication repair deficiency. This contributed to an ultra-hypermutated phenotype. Temozolomide was excluded from the treatment. PD-1 immunotherapy at recurrence contributed to extending post-relapse survival up to 11 months. Challenges included managing initial immune “flare” related to “pseudo-progression” and access to drug. Family screening diagnosed the sibling with Lynch syndrome. This is the first report of a child with a brain tumor treated with immunotherapy from India. Our report supports the routine inclusion of immunohistochemistry for mismatch repair proteins in the evaluation of pediatric high-grade glioma as this may directly impact the clinical care of these children and families.

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Background: Across literary fiction, allusions to medical ailments are common. However, in the bibliography of Stephen King, neurological disorders appear to be present disproportionately. Objective: The objective of this study is to describe the epidemiology of neurologic disorders depicted in the writings of Stephen King. Methods: This study presents data from Stephen King's 60 published novels. The frequency, prevalence, lethality, and mortality of each neurological diagnosis found in the characters that appear in the novels are reported. Results: Forty-eight novels portrayed at least one character with a neurological diagnosis, and in total, 150 characters exhibited a neurological condition. The overall prevalence was 111.2 per 1,000 characters. Their median age was 20 years (range 76), and 61.7% were males. Headache was the most common symptom (35.3%), followed by stroke symptoms in 28.7%. Prevalence was 24.5, 17.8 for headache and epilepsy, respectively. Lethality was 28.7%. The overall mortality rate was 31.9. Conclusions: The epidemiology described in Stephen King's novels parallels that of the real world. The depiction of neurological disorders found in his novels showcases the elevated contribution of neurological disorders to the global burden of the disease, an important message for the readers of his fiction and interest to all neurologists.

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Melioidosis is an emerging tropical disease. Central nervous system (CNS) melioidosis may present as a brain abscess or encephalomyelitis mimics tuberculosis. Early diagnosis and management decreases mortality as well as morbidity. This case of brain abscess and encephalomyelitis in a young man with no known comorbidities was a diagnostic challenge. The surgery helped in debulking as well as isolating the causative organism. Appropriate antibiotic therapy for melioidosis was lifesaving and prevented further complications.

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Background: Wide-neck intracranial aneurysms need additional devices like balloons or stent for management. Balloon-assisted coiling has evolved both with interventionalist experience and device modifications. Objective: We discussed our experience, evolution, and complications with this novel technique. Materials and Methods: Data of 2014–2019 was retrospectively reviewed for type of balloon used along with complications in intracranial aneurysm coiling. Two hundred five aneurysms were detected in 188 patients, of which balloon-assisted coiling was planned for 198 aneurysms. Both single and double-lumen balloons were used. Aneurysms were divided into bifurcation and sidewall aneurysms. The complications were compared between bifurcation and sidewall aneurysms, and between single and double lumen balloons. Results: Balloon-assisted coiling was planned for 198 aneurysms but successfully done for 195 (98.5%) cases. Single-lumen balloons were used in 56 aneurysms (28.3%), and double-lumen balloons were used in 142 cases (71.7%). Procedural thromboembolism within parent vessel was seen in 28 cases (14.1%); however symptomatic were encountered in 5 cases (2.5%). Intraprocedural rupture of the aneurysmal sac was seen in 9 cases (4.5%). The procedure-related mortality in our series was 1.6% (3/188 patients), and morbidity was 4.3% (8/188 patients). The complications among bifurcation and sidewall aneurysms compared between single- and double-lumen balloons showed a greater number of symptomatic thromboembolic complications in sidewall aneurysms with the use of single lumen balloons. Conclusions: There are significant symptomatic thromboembolic complications in sidewall aneurysms with the use of single-lumen balloons which decreased as interventionalist experience evolved and better hardware developed.

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Background: Pediatric central nervous system (CNS) tumors have a different histological spectrum as compared to adults with the infantile group having even more varied and distinct histological profiles. Intra-operative diagnosis is especially important as it guides the neurosurgeon to tailor an approach which is best suited for a particular case. The aim of the study was to evaluate the diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value of frozen section (FS) and squash cytology and to find out the degree of correlation (kappa value) between the two procedures. Materials and Methods: A prospective study was conducted on 55 pediatric patients with clinicoradiologically diagnosed CNS lesions for a period of 2.5 years. Intra-operative squash smears and FS were made and stained with hematoxylin and eosin stain. Diagnosis made subsequently on paraffin embedded sections was taken as the gold standard. Results: Although the specificity (90%) and positive predictive value (96%) were comparable between the two procedures, sensitivity (91.4%) and negative predictive value (75%) of FS was more as compared to squash cytology. Both the diagnostic modalities showed substantial agreement (k = 0.728). Conclusion: Even though the histological spectrum of pediatric CNS tumors is more varied than adults, FS gives a reasonable intra-operative diagnosis and better results when compared to squash alone.

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Background and Aims: Biotin-thiamine-responsive basal ganglia disease (BTBGD) is an autosomal recessive disorder due to mutations in the SLC19A3-gene, typically seen in early childhood. Materials and Methods: We report a 49-year-old lady presenting with rapidly progressive cognitive impairment, seizures, hypersomnolence, ataxia, and generalized dystonia of 3 weeks duration. The magnetic resonance imaging (MRI) of the brain revealed T2-hyperintensities in the basal ganglia, thalamus, cortical, subcortical regions with striatal necrosis suggestive of BTBGD that was confirmed by genetic analysis. She was treated with thiamine and biotin following which there was significant clinical and MRI improvement. Conclusions: BTBGD requires a high index of suspicion in any patient presenting with unexplained rapidly progressive dementia. High doses of biotin and thiamine are the mainstay of the treatment to achieve a favorable outcome.

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Background: Craniopharyngiomas are associated with long-term morbidity in the form of hormone deficiencies, visual deficits, and hypothalamic obesity. Objective: To study the long-term outcomes, including cure rates, endocrine dysfunction, visual dysfunction, hypothalamic obesity, and mortality in pediatric-onset craniopharyngiomas. Methods: A retrospective data analysis of pediatric (onset <18 years) craniopharyngioma diagnosed between 2003 and 2018. Data were collected from electronic hospital records, case files, and direct patient interviews. Results: The mean age at presentation was 10.4 ± 4.5 years (n = 62). The median duration of symptoms at diagnosis was 6 months (3–13 months). At presentation, central diabetes insipidus was present in four (6.5%), central hypothyroidism in 27 (43.5%), secondary adrenal insufficiency in 20 (32%) and delayed puberty in 15 (24%) patients. Hypothalamus was involved in 59/60 patients (98%). At last visit, 22.6% were obese in comparison to 4.6% at presentation, and anterior pituitary deficiency was present in 90% of the patients. Sixty-one percent patients (n = 62) had delayed puberty and 67% (n = 53) had short-stature. Out of 35 short children, nine (14%) children who received growth hormone had significant increase in height SD score (−3.8 (1.4) at start vs. −2.9 (1.2) at last follow-up; P = 0.008). Tumor progression was significantly less in the group that received RT compared to those who did not (8% vs. 39%; P = 0.002). Conclusion: Childhood-onset craniopharyngioma results in significant morbidity. The prevalence of pituitary hormones deficiency, visual deficits, and obesity are high at long-term follow-up. Incomplete tumor removal is also frequent. Thus, long-term monitoring is necessary for the timely management of the morbidities associated with craniopharyngioma.

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Background: Management of neonatal seizures with available limited guidelines across different gestation can cause long-term neurological and cognitive impairment. Objectives: To compare utilization and observe the efficacy of anti-epileptic drugs in the treatment of neonatal seizures. The association of hypoxic-ischemic encephalopathy with NS and the etiology of HIE were also determined. Subjects and Methods: A retrospective cohort study was conducted at a tertiary care hospital for a period of one year. It was approved by IEC prior to initiation. Participants: Neonates admitted for seizure management and perinatal asphyxia with hypoxic-ischemic encephalopathy were included in the study. Both term and preterm 267 neonates from January 2014 to July 2018 were retrospectively analyzed. The drugs with the fastest seizure resolution, least recurrence, and readmission rates were considered efficient. Phenobarbitone, levetiracetam, and phenytoin were compared as they were commonly prescribed. Inpatient medical records and hospital databases served as sources of information. Results: Phenobarbitone was commonly utilized, followed by phenytoin and levetiracetam. The commonly prescribed combination was phenobarbitone (first-line agent) and phenytoin (second-line agent). Phenobarbitone immediately resolved seizures (97, 75.1%) and had the least cases of seizure recurrences (53, 41.1%) and readmissions (20, 15.5%), making it most efficient. The best second-line agent was phenytoin, with the least seizure recurrence (4, 8.51%), least readmissions (7, 14.8%), and fastest resolution (25, 53.1%). Levetiracetam was an efficient third-line agent. Hypoxic-ischemic encephalopathy was the most observed cause of neonatal seizures. Conclusion: Phenobarbitone was observed as the most utilized and efficient anti-epileptic drug, followed by phenytoin and levetiracetam. Owing to limitations in this study, there is an alarming need for standardized clinical trials to establish thorough guidelines.

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Background: Anterior clinoidectomy for aneurysm clipping is generally performed intradurally. Despite obvious advantages, accidental drill slippage or indirect damage from heat and bone dust remain major drawbacks. Objective: To demonstrate the surgical technique and utility of a combined extra- and intra-dural clinoidectomy in the clipping of dorsal wall paraclinoid internal carotid artery aneurysm. Material and Methods: A case of dorsal wall paraclinoid aneurysm which was stuck to the anterior clinoid process on preoperative angiogram is presented. The surgical technique is shown stepwise, and the intricacies of the technique are described. Results: The hybrid clinoidectomy allowed for proper delineation of the aneurysm, mobilization of the optic nerve and intracranial proximal control on the clinoidal segment by dint of “apparent” intracranial ICA lengthening. This allowed the aneurysm to be clipped successfully and the patient made an uneventful recovery. Conclusion: Hybrid clinoidectomy is a useful technique and must be learnt.

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Background: Post-stroke fatigue (PSF), a highly distressing symptom, could exert an influence on the quality of life of stroke survivors. A previous meta-analysis reported that PSF was associated with mood disturbances such as depressive symptoms and anxiety. However, the association between stroke characteristics (stroke type and location) and PSF remains unclear. Objective: We performed a meta-analysis to study the association between stroke characteristics and PSF. Material and Methods: We conducted a search of electronic databases (PubMed, Web of Science, Cochrane Library) from the inception of all databases up to July 9, 2019. The quality of eligible articles was evaluated. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were applied to represent the combined effect value of each study. Results: Eight eligible studies including a total of 1816 stoke patients were identified. Three studies discussed the association between stroke type and PSF, and five studies investigated the relationship between stroke location and PSF. The results demonstrated PSF had a strong correlation with stroke type (OR = 2.42, 95% CI = [1.27, 4.61], P = 0.007) but was not relevant to stroke location, indicating that PSF was a complex, heterogeneous syndrome and that stroke characteristics may play only a very small role in the risk of developing PSF. Conclusions: Our meta-analysis indicated that PSF was closely relevant to stroke type and had no significant relationship with stroke location. However, the findings should be interpreted cautiously. Thus, we suggest an updated meta-analysis on this subject when more comprehensive studies that explore the above issue are available.

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Background: Multiple system atrophy parkinsonian type (MSA-P) patients with resistance to dopamine have highly limited treatment options. This calls for further study of spinal cord stimulation (SCS) as a potential nondopaminergic therapy to improve motor and speech functions of patients with dopamine-resistant parkinsonism. Case Presentation: A 58-year-old male with MSA-P had hypokinetic dysarthria, freezing of gait (FOG), and spinal disc herniation with refractory back pain. SCS was used to treat his refractory back pain. Serendipitously, after the surgery, the patient reported not only a reduction in pain but also rapid improvement of FOG and hypokinetic dysarthria. Conclusion: SCS has been found in some cases to improve FOG and hypokinetic dysarthria. It is necessary to further study the potential of and the mechanism behind SCS as a potential nondopaminergic therapy to improve motor and speech functions of patients with dopamine-resistant parkinsonism.

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Background: Prescription of orthoses and assistive devices that facilitate physical function is a major component of the rehabilitation process in spinal cord injury (SCI). Objective: To evaluate the long-term use of orthoses prescribed during inpatient rehabilitation in people with SCI and investigate the factors related to discarding the device. Materials and Methods: Medical records of 202 SCI patients who were included in an inpatient rehabilitation program of a tertiary research hospital were reviewed retrospectively. Patients' demographic data, neurological level of spinal cord injury functional state and use of assistive devices for ambulation (orthoses, walkers, etc.) at discharge were recorded. At follow-up, study participants were contacted by telephone and queried regarding the frequency and duration of use of orthoses; if the individual had discontinued using the orthoses, the reasons for discarding the device were sought. Results: The majority of the study participants (62.7%) had been prescribed a knee-ankle-foot orthosis during their inpatient stay. At follow-up, the regular use of orthoses was ongoing in 67.6% of the participants, and nonuse was determined in 32.4%. The most common cited reasons for discarding the device were difficulty in donning and doffing, functional improvement, and mechanical problems of the orthoses. Conclusions: A significant number of patients had discarded their orthoses at the long-term follow-up and the main reasons for discarding the devices were orthotic factors. Timely reevaluation of the patient and orthosis modification according to patients' needs is necessary to achieve long-term compliance.

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Background: Published trials and meta-analyses have suggested the role of surgery in select patients of hypertensive intracerebral hematoma. Objective: This study compares two methods of hematoma aspiration, craniotomy, and stereotactic aspiration. Methods and Material: We conducted retrospective analyses of patients who underwent surgery for capsule-ganglionic hematoma during Jan-2015–Dec-2019. Surgical, intensive-care parameters, and neurological outcomes were compared. Patients operated for Capsule-Ganglionic hypertensive hematomas, Glasgow Coma Scale (GCS) 5-12, hematoma volume ≥30 ml, no concomitant IVH, age <80 years were included. Results: A total of 173 patients were included (90 craniotomy and 83 stereotactic aspiration groups). Both groups were equivalent in preoperative parameters (P > 0.5). There were no significant differences in residual hematoma volumes, surgical site infections/Meningitis, and chances of re-bleed between the two groups (P > 0.05). The number of days on ventilation, ICU-stay, and hospital-stay were higher in craniotomy group (P < 0.001). Mean Modified Ranking Score (MRS) was lower (P 0.01) in the stereotactic aspiration group. A higher number of patients in the stereotactic aspiration group achieved good MRS (0-2) (P 0.02). Overall case-fatality rate was 38/173 (21.96%) (craniotomy - 24/90 (26.66%), stereotactic aspiration - 14/83 (16.86%), P 0.12). In left-side hematomas, mean MRS was not different between both methods, whereas it differed in the right-side hematomas. On step-wise logistic regression analysis, predicting parameters for the poor outcome (MRS 3-6) were GCS 5-8 (Odds Ratio (OR) 2.38), Left-side (OR 1.75), and craniotomy as a method of evacuation (OR 1.70). Conclusions: Stereotactic aspiration of the hematoma has the superior edge over craniotomy. Neurological and care parameters are significantly better with stereotactic aspiration. Its safety and surgical performance parallel craniotomy.

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Background: Pain is a common complaint in COVID-19 disease. Neurotrophic features of the COVID virus are reported. Neuropathic pain is seen during many viral infections and observed during the COVID-19 pandemic part of the clinical presentations. Objective: The aim of this is to evaluate neuroptic pain as presenting symptom in COVID-19 patients. Materials and Methods: In this cross-sectional descriptive study, adult patients (18 years and older) who applied to the COVID Outpatient Clinic completed the demographic data form and the neuropathic pain questionnaire. The patients were divided into positive and negative according to the PCR test results and the presence of neuropathic pain was compared. Results: In total, 440 participants included in the study. Among 301 who stated to had any complaints, 197 (65.4%) had pain. The intensity of their pain was 5.8 ± 2.4 (0 – no pain and 10 – the most severe pain of life). Neuropathic pain component was present in 29.2% of the patients. Among the first admissions, neuropathic pain component was observed significantly higher in those with positive PCR test (55.0%) than negative ones (23.8%), and the Odd's ratio was calculated as 3.911. Conclusions: COVID-19 virus is thought to have neuroinvasion and neurotropic effects. In this study, neuropathic pain specifically was evaluated in COVID-19 patients, and the frequency of neuropathic pain was significantly higher in PCR confirmed COVID-19 patients at the onset of the disease.

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We present a case of a 40-year-old man with rapid decline in cognition followed by Parkinsonism, apraxia and stimulus sensitive myoclonus within 9 months of onset. Magnetic Resonance imaging (MRI) showed periventricular confluent white matter changes with persistent diffusion restriction even after 9 months. Clinical exome sequencing showed colony stimulating factor 1 receptor (CSF1R) gene mutation. The phenotype, MRI and genotype are suggestive of adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP). This is the first case being reported from India. Differential diagnosis of young onset dementia is broad. Therefore, finding the exact etiology is challenging. Neuroimaging and genetic analysis greatly aid in the final diagnosis.

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Cerebrospinal fluid leakage is largely associated with spontaneous intracranial hypotension and iatrogenic events, such as complications associated with spinal tapping or durotomy. Intracranial hypotension causes a positional headache, neck stiffness, nausea, dizziness, or tinnitus. Although rare, intracranial hypotension can lead to serious complications, including subdural hematomas and cerebral infarction. Given its rarity, there is no consensus protocol for treating cerebrovascular complications after intracranial hypotension. We report two cases of intracranial hypotension with cerebrovascular complications, including acute cerebral infarction and cerebellar hemorrhage.

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Background: An increased incidence of systemic macrothrombotic phenomena such as strokes has been observed in moderate and severe COVID. However, strokes have also been increasingly observed in mild COVID, post COVID, or without obvious COVID illness. Objective: To share our experience with a specific stroke type noted during the COVID pandemic period. Materials and Methods: A single-center observational study was conducted in Western India from January to December 2020, and data regarding stroke patients admitted under Neurology services were noted. Clinical, laboratory, and radiological characteristics of strokes and subtypes were documented. Results: A total of 238 stroke patients were admitted in 2020, 76.5% during the COVID pandemic period. Among 153 ischemic strokes, 16.3% and 56.2% had large vessel occlusion (LVO) in pre-COVID and COVID pandemic period, respectively. Of all ischemic strokes, 20.9% (18 patients) and 12% (3 patients) had free floating thrombus (FFT) in the COVID versus pre-COVID period, respectively. Only 44.4% of all FFT patients could be proven SARS-CoV-2 RT-PCR positive while 50% were COVID suspect with surrogate markers of heightened inflammation at time of stroke. All patients were given anticoagulation and average mRS at discharge was 3.1 (range: 1–6) and 1.84 (range: 0–4) at 3-month follow-up in survivors. Conclusions: This study highlights the presence of FFT causing LVO as a new stroke subtype during the COVID-19 pandemic. With renewed and steeper spike in COVID-19 cases, especially new variants, the resurgence of this stroke subtype needs to be actively explored early in the course of illness to reduce morbidity and mortality.

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Background and Introduction: The interhemispheric transcallosal approach provides an elegant pathway to access the lesions of the third ventricle. However, every step of this approach is fraught with hazards which must be negotiated delicately. A comprehensive knowledge of surgical anatomy coupled with technical skill is necessary for optimum surgical results. Objective: This video aims to address the surgical nuances of the suprachoroidal transcallosal approach while accessing the lesions around the foramen of Monro in the anterior and middle part of the third ventricle. Surgical Technique: A 16-year-old boy presented with worsening headaches with episodes of speech arrest and blank stare for 6 years, which had become more frequent over the past 4–5 months. Radiology showed a subcentimeteric colloid cyst at the foramen of monro. A transcallosal corridor was used to reach the foramen of monro, and the suprachoroidal access was adopted to uncover the colloid cyst and excise it completely preserving the deep veins. Results: The patient had uneventful recovery and radiology showed complete excision of the cyst. Conclusion: Transcallosal approach, being minimally invasive, exploits the natural extra-axial corridor (interhemispheric) obviating the need for a cortical incision. The suprachoroidal approach mitigates the risks of thalamostriate vein injury, basal ganglia stroke, and hemiparesis.

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Background: This study aimed to delineate the underlying pathophysiology of tinnitus between normal hearing and hearing loss subjects. Objective: The study aimed to characterize the neuropsychological aspects of two types of groups with tinnitus having variable hearing thresholds. Materials and Methods: The study sample comprises 75 subjects in a group with tinnitus and normal hearing, and 100 subjects in the tinnitus and hearing loss group. Subjects were matched to their respective controls for age, gender, and education levels. Subjects underwent verbal learning and memory tasks, visual learning, memory, listening attention, sustained visual attention, work memory, category control, phonemic mastery, response inhibition, and data processing velocity. Results and Conclusions: Subjects having hearing loss with bilateral tinnitus showed significantly reduced performance on total learning capacity (P = 0.02) and recognition (P = 0.05) (Rey's auditory verbal learning test), auditory attention tasks, digit forward span test (DFST) (P = 0.03), digit span test score (P = 0.01), and working memory (P = 0.02) (digit backward span test). For response inhibition tasks and Stroop interference (P = 0.03), subjects with normal hearing with bilateral tinnitus displayed lower performance. This study proves a relationship between poor working memory, auditory memory, total learning capacity, and recognition due to hearing impairment in bilateral Tinnitus subjects. The study has substantial implications for effective assessment and treatment recommendations in hearing loss with bilateral tinnitus subjects.

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Background: Schizencephaly is a rare congenital disorder of cerebral cortical development. Clinical features vary based on the areas and severity of cortical involvement. The most prominent manifestations being motor deficits, seizures, and cognitive impairment. MRI has been the diagnostic modality of choice. Till now, a handful of case reports associating schizencephaly with psychiatric manifestations have been reported. Methods: In this brief report, we review the available literature and present the summary of a 50-year-old gentleman who presented with paranoia, irritability, impulsive spending, emotional lability, and circumstantial speech with perseveration of themes. Results: MRI findings are suggestive of closed lip schizencephaly. Conclusion: This case helps us in understanding the neurodevelopmental model and functional neuroanatomy of psychiatric symptom dimensions.

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Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi. The diagnosis of scrub typhus relies on the patient's history of exposure, clinical manifestations, and results of serological tests. Our patient had a history of altered sensorium, inability to walk, and macular rashes predominantly distributed over the chest and bilateral upper limbs. Post serological testing, the patient was referred to the radiology department for MRI brain. Radiologically, MRI being a superior modality helps in the evaluation of lesions in depth, helping to simplify the diagnosis of meningitis, scrub typhus encephalitis, and other related conditions. Various findings have been described in scrub typhus encephalitis in MR brain imaging, and our case shows an unusual finding in brain imaging.

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Background: Electrophysiological investigations are now very common in clinical investigations. Event-related potential (ERP) is also common in most electrophysiological recording in which P₃₀₀ is considered as the best indicator of psychological status. P₃₀₀wave latency and amplitude are the best indicators of superior mental function status. Variability in P₃₀₀ has been demonstrated in diseases exhibiting cognitive abnormalities. Objective: The present study aimed to generate the normative data of P₃₀₀ wave latency and amplitude in healthy young adults of 18–25 years age group in healthy young adults. Material and Methods: Hundred healthy young adults age (18–25 years) were analyzed for P300 using auditory oddball paradigm [Octopus NCV/EMG/EP-4 Channel Machine (Model name- CMEMG 01)], after taking anthropometric measurements (height, weight, and BMI). Whole data were collected after taking the willing consent of participants recruited for the study, and approval of Institute's ethics committee was taken before the start of study. Normally, distributive data were presented in the form of mean, standard deviation, and Pearson correlation was used to see check the correlation using MS-excel 2007. Results: The mean P₃₀₀ latency and amplitude were 281.38 ± 33.39 ms and 4.53 ± 1.67μV, respectively, in healthy young adults with mean age 19.81 ± 1.80 years. With age the P300 latency was significantly positively correlated. Conclusions: This study results reflected normative data of P₃₀₀wave latency and amplitude in healthy young adults of 18–25 years age group.

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Background: New controversies have raised on brain death (BD) diagnosis when lesions are localized in the posterior fossa. Objective: The aim of this study was to discuss the particularities of BD diagnosis in patients with posterior fossa lesions. Materials and Methods: The author made a systematic review of literature on this topic. Results and Conclusions: A supratentorial brain lesion usually produces a rostrocaudal transtentorial brain herniation, resulting in forebrain and brainstem loss of function. In secondary brain lesions (i.e., cerebral hypoxia), the brainstem is also affected like the forebrain. Nevertheless, some cases complaining posterior fossa lesions (i.e., basilar artery thrombotic infarcts, or hemorrhages of the brainstem and/or cerebellum) may retain intracranial blood flow and EEG activity. In this article, I discuss that if a posterior fossa lesion does not produce an enormous increment of intracranial pressure, a complete intracranial circulatory arrest does not occur, explaining the preservation of EEG activity, evoked potentials, and autonomic function. I also addressed Jahi McMath, who was declared braindead, but ancillary tests, performed 9 months after initial brain insult, showed conservation of intracranial structures, EEG activity, and autonomic reactivity to “Mother Talks” stimulus, rejecting the diagnosis of BD. Jahi McMath's MRI study demonstrated a huge lesion in the pons. Some authors have argued that in patients with primary brainstem lesions it might be possible to find in some cases partial recovery of consciousness, even fulfilling clinical BD criteria. This was the case in Jahi McMath.

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Background: Endoscopic third ventriculostomy (ETV) is a procedure that involves devising an opening in the third ventricle floor, allowing cerebrospinal fluid to flow into the prepontine cistern and the subarachnoid space. Third ventricular floor bowing (TVFB) serves as an indicator of intraventricular obstruction in hydrocephalus and existence of pressure gradient across third ventricular floor, which is the prerequisite of a successful ETV. Objective: In this systematic review and meta-analysis, we aimed to synthesize the latest evidence on the TVFB as a marker for surgical success in patients undergoing ETV. Material and Methods: We performed a comprehensive search on topics that assesses the association of TVFB with the surgical success in patients undergoing ETV from several electronic databases. Results: There was a total of 568 subjects from six studies. TVFB was associated with 85% (81-88%) ETV success. TVFB was associated with OR 4.13 [2.59, 6.60], P < 0.001; I²: 6% for ETV success. Subgroup analysis on pediatric patients showed 86% (82-91%) success rate. In terms of value for ETV success compared to ETV Success Score (ETVSS), a high ETVSS does not significantly differ (P = 0.31) from TVFB and TVFB was associated with OR 3.14 [1.72, 5.73], P < 0.001; I²: 69% compared to intermediate/moderate ETVSS. Funnel plot analysis showed an asymmetrical funnel plot due to the presence of an outlier. Upon sensitivity analysis by removing the outlier, the OR was 3.62 [2.22, 5.89], P < 0.001; I²: 0% for successful surgery in TVFB. Conclusions: TVFB was associated with an increased rate of successful surgery in adults and children undergoing ETV.

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Background and Purpose: Leukoaraiosis is thought to be related to long-standing microvascular ischemia. The pathogenic mechanisms and hemodynamic changes could be different for periventricular and deep white matter leukoaraiosis. In this cross-sectional study, we examined whether the Pulsatility Index (PI) in Transcranial Doppler ultrasonography (TCD), which can give indirect information regarding downstream microvascular resistance and compliance, is different for leukoaraiosis in periventricular and deep locations. Correlation between presence of leukoaraiosis and PI was also studied since it was not studied in South-Asian patients before. Methods: Consecutive patients with suspected lacunar stroke or white-matter disease, undergoing MR brain imaging were included. Vascular imaging was done with CT or MR Angiography to rule out significant (>50%) stenosis. Fazeka's grading was done for severity of leukoaraiosis and mean PI in the middle cerebral artery (MCA) was obtained with trans-temporal TCD. Results: Ninety patients (Mean age 61 ± 10.9 years, 29% females) were available for final analysis. Age, hypertension, diabetes mellitus, CAD, and presence of leukoaraiosis were strongly associated with elevated mean PI in univariate analysis. In multivariate analysis, presence of leukoaraiosis was significantly associated with higher mean PI after adjusting for other variables. Mean PI strongly correlated with both periventricular (Spearman's correlation coefficient 0.56, P = 0.01) and deep white matter (Spearman's correlation coefficient 0.63, P = 0.01) leukoaraiosis. Conclusions: Our study confirms the correlation of Pulsatility Index with leukoaraiosis in South-Asian patients. Interestingly, changes in microvascular resistance appeared to be similar for both periventricular and deep white matter leukoaraiosis in spite of potential differences in etiopathogenesis.

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Background: Intraoperative trans-esophageal migration of pulled-out screws, especially while using the zero-profile implant system, has been rarely reported in the literature. Objective: In this technical note, we are describing a simple technique to retrieve a trans-esophageally migrated pulled-out screw using a suction catheter. Material and Methods: A 32-year-old female presented with spastic quadriparesis. She underwent C5-C6 anterior cervical discectomy and fusion (ACDF). Nine months following the surgery, X-ray cervical spine showed implant loosening and failure of fusion across the instrumented disc space. However, during revision surgery, the loosened screw could not be located visually in the initial attempts, though it could be felt by probing the prevertebral space with the index finger. Intraoperative X-rays showed that the screw migrated curiously in the cranial direction as the surgical field was probed further manually. The screw was then finally retrieved using Magill's forceps assisted by video laryngoscopy assisted by intermittent negative pressure application via a blunt-tipped suction catheter. Results: She was discharged home on a Philadelphia collar, and at 1 year of follow-up, she was completely asymptomatic. Conclusion: Perforation of the aerodigestive tract by a displaced cervical spine implant is an uncommon complication. Manipulation during surgery may cause the implants embedded into the wall of the aerodigestive tract to become dislodged and then migrate into the pharyngeal lumen. In resource-constrained situations or when intraoperative endoscopy is not available, a trial of screw retrieval using a suction catheter may be attempted.

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Introduction: Giant cell tumor of the tendon sheath (GCTTS) is commonly seen in the appendicular skeleton, and rarely arises from the axial skeleton. We describe a rare case of GCTTS in an adolescent in the upper cervical spine. Case Presentation: A previously healthy 16-year-old boy presented with a 6-month history of numbness of right upper extremity, and had experienced a neck pain 4 months ago. Spinal MRI demonstrated a small syrinx at C2 level and a well-circumscribed extradural mass with contrast enhancement extending from the posterior arch of C1 to C2. The extradural mass was totally resected, and the syrinx underwent clinical and imaging surveillance. Discussion: GCTTS should be considered in the differential diagnosis of the axial skeletal lesion although very rare. Gross-total resection is advocated in GCTTS of the upper cervical spine, and subtotal resection with meticulous lesion monitoring should be performed in unresectable cases.

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Background: The challenges associated with surgeries of cavernous sinus (CS) lesions have shifted the management trend towards upfront gamma knife radiosurgery (GKRS). Although GKRS is effective in arresting the progression of certain small residual/recurrent lesions, its efficacy in alleviating neurological deficits is less evident. Furthermore, GKRS without establishing the histopathological diagnosis, at times can be detrimental. Objective: We present our clinical experience to reemphasize the role of surgery for CS lesions in the current era of upfront GKRS. Materials and Methods: We reviewed our database of 32 patients with various CS lesions treated by surgery for progressive cranial nerve deficits. The follow-up data were analyzed for the extent of resection, and in particular for improvement in their symptoms. Results: The lesions were confirmed as hemangioma (CSH)-8, meningioma-8, trigeminal schwannoma-6, chordoma-3, residual pituitary with CS extension-3, fungal granuloma-3, and dysgerminoma-1. Symptoms improved in 23 (complete in 13) and remained at least static in six patients. Follow-up ranged from 4–36 months. Conclusions: The nature of pathology should determine the management modality in CS lesions. Excision of CS schwannomas and chordomas yields rapid clinical improvement and good long-term outcomes. Resection is preferred for large CSH and functioning pituitary tumors. Although the clinical improvement may be less dramatic, surgery debulks the meningiomas. Most importantly, surgery also establishes the histopathological diagnosis of CS lesions. Even with an easy alternative of upfront GKRS, resection has a definite role in the primary management of most CS pathologies.

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A 39-year-old female presented with complaints of occipital headaches, diplopia, numbness over left half of face and deviation of face to the right. On examination she had hypoesthesia over left half of face, associated with bilateral abductor and left facial palsy. Neuroradiology showed a well-defined lytic lesion involving the clivus and adjacent sphenoid sinus and sella. The patient underwent an endoscopic transnasal decompression of the clival lesion. Intraoperative squash preparation was reported to show tuberculous granulation, which was confirmed on postoperative histology. The patient was advised anti-tubercular therapy. At 12 months follow up neuroradiology showed a near total resolution of the clival lesion. The patient had completely recovered from her cranial nerve deficits. Tuberculous involvement of spheno-clival region is rare and the authors' literature search has yielded only three previous similar case reports. A surgical decompression followed by anti-tubercular therapy is the recommended approach for management of clival tuberculosis. The relevant literature on the subject is presented.

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Background: To date, it has been suggested that there may be many genetic, environmental, and vascular factors that affect hand preference. In previous studies evaluating the relationship between cerebral dominance and hand preference, carotid and vertebral artery (VA) Doppler ultrasonography (USG) was generally preferred; and these studies only measured VA diameters. Unlike other studies, we aimed to reevaluate the relationship between hand preference and cerebral vascular dominance by measuring VA and internal carotid artery (ICA) diameters. In addition, we used carotid and VA computed tomography (CT) angiography instead of Doppler USG. Methods and Material: A total of 345 participants were included in the study. The results of carotid and VA CT angiography taken during hospitalization were retrospectively evaluated by two radiologists, and the Edinburgh Hand Preference Questionnaire was applied to these patients. Results: In right-handed patients, the diameter of the left VA was significantly larger than the diameter of the right VA (p = 0.005). In left-handed patients, the diameter of the left ICA was larger than the diameter of the right ICA, but the difference was not statistically significant (p = 0.055). There was no significant difference between the diameter of the right and left ICA in right-handed patients (p = 0.771). Conclusions: In our study, we found a correlation between the dominant hemisphere VA diameter and hand preference. Using CT angiography, we were able to eliminate many challenges of ultrasonography that make radiological evaluation difficult, such as differences of opinion between radiologists, and technical and anatomical reasons.

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Pantothenate kinase-associated neurodegeneration (PKAN) is an autosomal-recessive disease characterized by iron accumulation in the brain due to PANK2 gene mutation. The typical “eye-of-the-tiger” sign is the characteristic manifestation of brain magnetic resonance imaging (MRI). We report a Chinese patient with atypical PKAN whose brain MRI scans displayed the typical “eye-of-the-tiger” sign in bilateral pallidum. Genetic analysis identified a compound heterozygous mutation (c. 629-2A > T, c. 1130T > C) for the PANK2 gene. These two mutations were further demonstrated in his parents and other relatives.

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Background: In recent years, among patients with chronic cerebral artery occlusion, recanalization can be achieved by an endovascular operation. However, complications and restenosis rates remain high. Objective: To evaluate the utility of high-resolution C-arm CT (Dyna micro-CT) for stent placement in patients with chronic cerebral artery occlusion. Methods and Materials: We retrospectively reviewed the clinical data of 27 patients with chronic cerebral artery occlusion who underwent mechanical recanalization and stent implantation. Images were reconstructed using conventional C-arm CT (Dyna CT) and Dyna micro-CT. Whether the stent was fully expanded and image quality was evaluated. Follow-up assessments included clinical and angiographic outcomes and complications. Results: Twenty-two patients successfully underwent stenting (22 stents; 14 cases: Neuroform EZ; eight cases: Enterprise); stenting failed in five patients. Compared to Dyna CT, Dyna micro-CT afforded improved visualization of the stent structure, providing significantly improved image quality (P < 0.05). In seven patients, the stent under-expanded and dilatation was performed; thereafter, stent malapposition improved. One patient experienced sudden headache 22 hours after the procedure; CT showed intraparenchymal hemorrhage. The remaining 21 patients did not have acute thrombosis or bleeding complications and were followed up by imaging for 3-6 months. In three patients, digital subtraction angiography showed mild in-stent stenosis. Conclusions: High-resolution C-arm CT can improve visualization of stent structures in chronic cerebral artery occlusion, making it easy to determine the extent of stent deployment and potentially reduce complications and stent restenosis.

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Background: Genetic factors, including causal gene and modifier genes, contribute significantly in PD pathogenesis in an ethnicity-dependent manner. Dopamine Receptor 4 (DRD4), involved in dopamine metabolism is one such modifier locus for PD. Objective: To identify the potential association of DRD4 polymorphic variants with PD among Eastern Indians. Methods and Materials: PD-related DRD4 variants were genotyped among 291 PD patients and 265 ethnically matched controls from Eastern India. Results and Conclusion: Among the three DRD4 variants, only the 120 bp duplicated allele [P = 0.036; Odds ratio: 1.323; 95% CI: 1.014–1.725] and its homozygous genotype [P = 0.034; Odds ratio: 1.452; 95% CI: 1.025–2.057] were found as risk factors for overall PD and sporadic PD among Eastern Indians. However, no other disease-associated variant or haplotype was identified. Therefore, in conclusion, our study demonstrates that DRD4 plays a small role in PD pathogenesis among Eastern Indians.

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Background: Dopamine deficiency causes Parkinson's disease (PD), and on treatment, levodopa is the gold standard. Various drug-metabolizing enzymes and drug receptors are believed to be involved in prompting dyskinesias due to the extended usage of levodopa. Shreds of evidence in genomic studies have presented that ADORA2A receptor antagonism has beneficial outcomes to avoid these drug-induced side effects. Objective: The aim of this study was to study the polymorphisms of rs2298383, rs35060421, and rs5751876 in the ADORA2A in patients diagnosed as PD and describe their possible relationships with levodopa-induced dyskinesias (LID). Methods: One-hundred and seventy-two patients were recruited and separated as the study and the control group. DNA was achieved from peripheral venous blood, high resolution melting analysis, and reverse-transcriptase PCR was performed. Results: The allele differences among the groups were not statistically significant. Although it was not statistically significant, the rs35060421 allele was observed to repeat more frequently. However, we did not find an association between such polymorphisms of ADORA2A and LID. Conclusions: Although this result showed that a higher sample number might produce different results as possible, current results in the Turkish sample indicated that these alleles of ADORA2A might not be related to LID in patients.

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Context: Heart failure and acute ischemic stroke (AIS) are frequently associated, due to similar risk factors and intertwined pathophysiologic mechanisms, and both result in a high mortality rate. Aims: Our objective was to demonstrate that left ventricular systolic dysfunction (LVSD) is associated with AIS. Settings and Design: Prospective matched, case-control study on 110 patients with AIS. Methods and Material: The patients in the control group (CG) without history of AIS and the same inclusion criteria were matched for age, sex, and atrial fibrillation (AF) prevalence. Statistical Analysis Used: Fisher's exact test was used for statistical analysis. Results: LVSD of any degree was not statistically more or less frequent in AIS patients than in the CG. The same was true if only the patients with AF were considered (the prevalence of LVSD was not significantly different in patients with AIS and AF than in controls with AF). However, among the patients without AF the proportion of patients with normal systolic function was significantly higher in the controls than in the AIS group (P = 0.036). There was no significant difference regarding LVSD either between the patients with cardioembolic AIS and those with noncardioembolic AIS or between the AIS patients with AF and AIS patients without AF. Conclusions: Our study concluded that the prevalence of LVSD was the same in AIS patients and controls matched for age, sex, and AF prevalence, although the prevalence of LVSD was indeed higher in AIS patients without AF than in controls without AF.

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Background: COVID-19 causes a hypercoagulable state leading to thrombosis. Many of these thrombotic complications occur in those with severe disease and late in the disease course. COVID-19 has recently been associated with cerebral venous thrombosis (CVT). Objective: To study the onset of CVT in relation to COVID-19 and compare their characteristics and outcomes with non-COVID CVT patients admitted during the same period. Materials and Methods: This multicentric, retrospective study conducted between April 4 and October 15, 2020, included adult patients with CVT who were positive for the SARS-CoV-2 virus and compared them with CVT patients who were negative for the SARS-CoV-2 virus hospitalized during the same period. We studied their clinical profile, risk factors for CVT, and markers of COVID coagulopathy, imaging characteristics, and factors influencing their outcomes. Results: We included 18 COVID-19-infected patients and compared them with 43 non-COVID-19 CVT patients. Fourteen patients in the COVID-19 group presented with CVT without the other typical features of COVID-19. Thirteen patients had non-severe COVID-19 disease. Twelve patients had a good outcome (mRS ≤2). Mortality and disability outcomes were not significantly different between the two groups. Conclusion: Our study suggests a possible association between COVID-19 and CVT. CVT can be the presenting manifestation of an underlying COVID-19, occurring early in the course of COVID-19 and even in those with mild disease. Patients with worse GCS on admission, abnormal HRCT chest, severe COVID-19, and need for invasive ventilation had a poor outcome.

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Background and Introduction: Botulinum neurotoxin (BoNT) is a potent biological toxin extracted from Clostridium Botulinum bacteria. BoNT injection is mainly used for medical purposes; it is frequently used for cosmetic purposes as well. The hypothesis that frequent application of this treatment modality may also affect the central nervous system constitutes the subject of our study. Objective: We aimed to demonstrate the possible central effects of BoNT in hemifacial spasm patients. Methods and Materials: Diffusion tensor imaging was used for this study. Patients were divided into two groups, and the measured values for each determined bilateral neuroanatomic region were compared within the relevant group. Results: Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were found to be closer to the pathological values in the right motor cortex and in the left internal capsule areas of the patients who were injected with BoNT into the left side, in the left motor cortex area of the patients who were injected with BoNT into the right side. No significant changes were detected in other regions. Conclusion: Botulinum neurotoxin administration in patients with hemifacial spasms may cause some changes in the central nervous system as well as peripheral effects. In the case of similar studies supporting pathological changes, BoNT treatment modalities or appropriate indications may be reviewed, and regulation on excessive cosmetic use may be in question.

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Nasoethmoidal schwannomas are rare lesions and their presentation with intracranial extension is even rarer. Here, a patient presenting with rhinorrhea, epistaxis, and proptosis of left eye was diagnosed with giant nasoethmoidal schwannoma extending to frontal lobe and orbit, which was managed with bifrontal craniotomy with endoscopic transnasal gross total excision. This being predominantly a benign lesion has good prognosis if total excision is achieved.

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Background: Atrial fibrillation (AF) is the most commonly encountered cardiac dysrhythmia, and AF patients are five times more likely to have a risk of stroke. Although the effects of stroke on patients are quite severe, lately it has been recognized that AF is associated with the incidence of cognitive impairment and dementia. Objective: This study aims to analyze and determine the differences in two isoforms of amyloid beta (Aββ40 and 42) and malondialdehyde (MDA) serum levels in AF patients who experience and who do not experience cognitive impairment. Methods: An observational study with case-control design was carried out on 63 people with atrial fibrillation, consisting of 38 people with cognitive impairment and 25 people without cognitive impairment. Examination of MDA and the Aβ40 and Aβ42 levels was carried out by ELISA. The difference level of each variable in the two groups was tested by the Mann–Whitney and χ² tests, at P ≤ 0.05 significance level. Results: Lower mean levels of Aβ42 and higher mean levels of MDA were found in the group with cognitive impairment rather than in the group without cognitive impairment. Lower mean levels of Aβ40 were found in the group with cognitive impairment rather than in the group without cognitive impairment but this difference was not statistically significant. Conclusion: Significantly lower levels of Aβ42 and higher levels of MDA were found in the AF patients with cognitive impairment rather than in the AF patients without cognitive impairment.

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Background: Blood-brain barrier (BBB) is frequently disrupted in patients with diabetes mellitus (DM) and/or neurosyphilis (NS). Clinical cases reflect a trend that non-neurosyphilis (non-NS) patients with impaired glucose tolerance (IGT) are likely to develop NS and/or DM. Objective: To investigate whether IGT promotes BBB disruption in patients with non-NS. Methods and Material: A total of 21 subjects were enrolled, including six with IGT, nine with non-NS, and six with both IGT and non-NS. BBB permeability was evaluated by dynamic contrast-enhanced (DCE) MRI and the secretion of biomarkers from cerebrospinal fluid (CSF) were measured by colorimetric method, immune turbidimetric method, and enzyme-linked immunosorbent assay (ELISA) method. Results: The non-NS patients with IGT have higher BBB permeability at cortex superior frontal gyrus, white matter, and thalamus than non-NS patients without IGT or IGT patients without non-NS. The CSF-serum albumin-quotient (Qalb) levels and CSF secretion are highest in non-NS patients with IGT, including matrix metalloproteinase 9 (MMP9), soluble intercellular cell adhesion molecule-1 (sICAM-1), and soluble vascular cell adhesion molecule-1 (sVCAM-1). Conclusions: Significant correlations between CSF biomarkers and BBB permeability were found.

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