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Coverpage
May-June 2018
Volume 66 | Issue 3
Page Nos. 603-901

Online since Tuesday, May 15, 2018

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NI FEATURE - COMMENTARY: THE FIRST IMPRESSION  

The cover page Highly accessed article p. 603

DOI:10.4103/0028-3886.232300  PMID:29766908
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NI FEATURE - COMMENTARY: TIMELESS REVERBERATIONS Top

Backward glance o'er travel'd roads p. 604
K Rajasekharan Nair
DOI:10.4103/0028-3886.232301  PMID:29766909
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NI FEATURE: JOURNEY THROUGH THE EONS - COMMENTARY Top

Founders of Indian Neurosciences: Professor Krishna Prasad Bhargava(5th October 1925- 16th August 1991) p. 610
Prakash N Tandon, Balram Bhargava
DOI:10.4103/0028-3886.232314  PMID:29766910
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Evolution of concepts in the management of craniopharyngiomas: Lessons learnt from Prof. S.N. Bhagwati's article published in 1993 p. 613
Harjinder S Bhatoe
DOI:10.4103/0028-3886.232302  PMID:29766911
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GUEST COMMENTARY Top

Widening the circle of service: The gift of academic neurosurgery p. 637
Vedantam Rajshekhar
DOI:10.4103/0028-3886.232297  PMID:29766912
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Telemedicine and neurosciences p. 642
Krishnan Ganapathy
DOI:10.4103/0028-3886.232346  PMID:29766913
It is well documented that there is an acute shortage of neurologists and neurosurgeons in India and globally. Despite all efforts, it will be impossible to make available neurospecialists in all suburban and rural areas. Simultaneously, there has been an exponential increase in the growth and development of Information and Communication Technology (ICT). Plummeting costs and unbelievable sophistication in the availability of user-friendly mobile video conferencing devices is making distance meaningless. Geography has become History! Worldwide, the ultraconservative health care industry, in particular, the medical community, has been uniformly slow to adopt and embrace the use of ICT to extend their clinical reach. In the last decade, however, specialists in all branches of neurosciences are slowly accepting the inevitable that telemedicine must and will have to be incorporated into the core of the healthcare delivery system. This literature review summarizes the current use of telemedicine in different subspecialties of neurosciences. The author defines the growth and development of clinical telemedicine in India with special reference to Neurosciences and attempts to show the stellar role telemedicine has to play in enhancing the services provided by doctors. As clinicians regularly using technology, it should not be difficult for us to convince our patients that today a virtual remote consult and management can indeed effectively substitute for a physical face-to-face encounter.
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Training residents and fellows in the procedure of diagnostic cervicocerebral angiography: Techniques to avoid complications p. 652
Xianli Lv, Wei Li, Youxiang Li
DOI:10.4103/0028-3886.232292  PMID:29766914
We examine the problems arising when training residents/fellows (RFs) initiate the learning of diagnostic cervicocerebral angiography (DCCA) and describe the steps on how to facilitate the learning process while avoiding complications. The risk of permanent neurological deficit as a result of DCCA ranges from 0.3–0.5%. Factors that correlated with complications include the following: the history of cerebral infarction, infusion of a large amount of contrast medium, a prolonged fluoroscopic time (>80 min) and the efficiency of training received. These findings suggest that the neurological morbidity depends largely upon the technique of catheterization of the patient. In order to reduce the complications arising from the lack of training, a personalised mentorship with a careful supervision of trainees is necessary. To ensure a good patient outcome, a decreased procedural time, awareness of complications at every step of the procedure and their avoidance, as well as the provision of good quality images is necessary. A mentorship program with a close supervision of the RFs is also one of the prerequisites for obtaining a good result.
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NI FEATURE: THE EDITORIAL DEBATE I-- PROS AND CONS Top

Parent vessel occlusion and revascularization: A dying art? p. 657
Paritosh Pandey
DOI:10.4103/0028-3886.232315  PMID:29766915
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What is the current role of bypass surgery in the management of cerebral aneurysms? p. 661
Laligam N Sekhar, Chun-Yu Cheng, Harley Brito Da Silva, Zeeshan Qazi
DOI:10.4103/0028-3886.232316  PMID:29766916
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NI FEATURE: THE EDITORIAL DEBATE II-- PROS AND CONS Top

High time we focus on sleep in amyotrophic lateral sclerosis! p. 664
Garima Shukla, Anupama Gupta
DOI:10.4103/0028-3886.232309  PMID:29766917
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Sleep in amyotrophic lateral sclerosis p. 666
Prahlad K Sethi, Nitin K Sethi
DOI:10.4103/0028-3886.232305  PMID:29766918
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NI FEATURE: THE EDITORIAL DEBATE III-- PROS AND CONS Top

Relapsing-remitting multiple sclerosis: Blood-brain barrier permeability and intravascular leakage measurement by dynamic contrast-enhanced MRI and the extended Tofts linear model p. 667
Basant K Puri
DOI:10.4103/0028-3886.232317  PMID:29766919
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Dynamic contrast-enhanced MRI perfusion in multiple sclerosis: Is this the way to go? p. 669
Neetu Soni, Sunil Kumar
DOI:10.4103/0028-3886.232318  PMID:29766920
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Quantification of blood brain barrier using DCE MRI in multiple sclerosis - Technical issues and its possible role in routine clinical practice p. 671
Rakesh K Gupta
DOI:10.4103/0028-3886.232323  PMID:29766921
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NI FEATURE: THE EDITORIAL DEBATE IV-- PROS AND CONS Top

Carpal tunnel syndrome: The precipitating risk factors p. 673
Gopal Krishnan, Dhananjaya I Bhat, B Indira Devi
DOI:10.4103/0028-3886.232319  PMID:29766922
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Carpal tunnel syndrome: The lessons learnt and the points often overlooked in its management p. 674
Ketan Desai
DOI:10.4103/0028-3886.232320  PMID:29766923
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NI FEATURE: THE EDITORIAL DEBATE V-- PROS AND CONS Top

Management of brain-stem hemangioblastomas: Surgical skill versus technological advancements p. 676
Christopher P Deibert, Faiz Ahmad
DOI:10.4103/0028-3886.232322  PMID:29766924
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Management of brain-stem hemangioblastomas: A bird's-eye view p. 678
Abhay K Varma
DOI:10.4103/0028-3886.232321  PMID:29766925
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REVIEW ARTICLES Top

New daily persistent headache: An evolving entity Highly accessed article p. 679
Ravi Uniyal, Vimal Kumar Paliwal, Sucharita Anand, Paurush Ambesh
DOI:10.4103/0028-3886.232291  PMID:29766926
New daily persistent headache (NDPH) is characterized by an abrupt onset of headache that becomes a daily entity, is unremitting and continuous from the onset, and lasts for more than 3 months. Dr Walter Vanast first described NDPH in the year 1986. Originally, it was proposed as a chronic daily headache but it was placed under “other primary headaches” in the International Classification of Headache Disorder Second Edition (ICHD 2nd edition). However, with evolving literature and better understanding of its clinical characteristics, it was classified as a “chronic daily headache” in the ICHD 3rd edition beta. There are still many knowledge-gaps regarding the underlying cause, pathophysiology, natural history and treatment of NDPH. This review tries to revisit the entity and discusses the current status of understanding regarding NDPH.
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Microvascular decompression versus stereotactic radiosurgery as primary treatment modality for trigeminal neuralgia: A systematic review and meta-analysis of prospective comparative trials p. 688
Ravi Sharma, Manoj Phalak, Varidh Katiyar, Sachin Borkar, Shashank S Kale, Ashok K Mahapatra
DOI:10.4103/0028-3886.232342  PMID:29766927
Objective: The current opinion among neurosurgeons regarding the selection between microvascular decompression (MVD) and gamma knife radiosurgery for trigeminal neuralgia is not based on clear evidence. In this meta-analysis, we have attempted to synthesize the findings of the prospective trials comparing the efficacy and complications of the two procedures as primary treatment modality for medically refractory trigeminal neuralgia. Materials and Methods: The authors performed a systematic review of PubMed for manuscripts comparing the efficacy or complications of MVD and stereotactic radiosurgery for medically refractory trigeminal neuralgia. The data of the identified studies was pooled and a meta-analysis was done. Results: Five prospective studies fulfilling the eligibility criteria were identified. The mean age of the patients subjected to gamma knife therapy (GKT) was more than those who underwent MVD. The initial success rate in the pooled data with MVD was 96% (95% confidence interval [C.I.] 93.3%–98.6%) as compared to GKT which was 71.8% (95% C.I. 64.9%–78.7%) with the ratio of 1.309 (95% C.I. 1.217–1.409; P= <0.001). This superiority was sustained till the last follow up available in all the studies. Out of the complications common to both procedures, MVD had a lower rate of facial numbness, with a risk ratio of 0.481 (95% C.I. 0.297–0.778); and dysesthetic pain, with a risk ratio of 0.470 (95% C.I. 0.172–1.286). Conclusions: MVD seems to be more efficacious than GKT as a first line treatment for trigeminal neuralgia immediately as well as on a long term basis. However, the dilemma regarding the choice of treatment to be adopted still remains for special subgroups of patients, like the elderly patients and those in whom no vascular compression has been found during surgery. Further studies are needed for elucidating the unequivocal treatment plan under these circumstances.
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Parent artery sacrifice for ruptured aneurysms in acute and chronic phases: A systematic review p. 695
Xianli Lv, Wei Li, Huijian Ge, Hengwei Jin, Hongwei He, Chuhan Jiang, Youxiang Li
DOI:10.4103/0028-3886.232310  PMID:29766928
Background: Experience with respect to parent vessel sacrifice (PVS) for unclippable/uncoilable ruptured aneurysms is limited. Objective: The aim of the present systematic review was to evaluate the risk of PVS for unclippable/uncoilable ruptured aneurysms. Materials and Methods: The PUBMED and SCIENCEDIRECT databases were searched using “parent vessel occlusion OR parent artery occlusion” AND “acute subarachnoid hemorrhage” till December 27, 2015, and 1 journal was searched from November 1995 to April 2016 for relevant results. Results: Out of a total of 19 eligible studies, 104 patients with 104 ruptured aneurysms were treated by PVS with or without bypass surgery. Unfavorable outcome [modified Rankin Score (mRS) 4–6] was reported in 14 (13.4%) acute phase patients, with a 9.6% mortality rate. Thirty (28.8%) patients developed ischemic complications and 3 (2.9%) developed bleeding complications. The complication rate was higher for PVS in the acute phase (38.0% vs. 12.0%; P= 0.015). The unfavorable clinical outcome was found to be significant in acute phase versus chronic phase (17.7% vs. 0%; P= 0.024). The risk of morbidity associated with distal vessel [posterior cerebral artery (PCA) + superior cerebellar artery (SCA) + posterior inferior cerebellar artery (PICA)] sacrifice was not lower than that associated with major vessel [internal carotid artery (ICA) + basilar artery (BA) + vertebral artery (VA)] sacrifice (P = 0.961). Conclusion: Complication and unfavorable outcome rates associated with PVS for acutely ruptured aneurysms are high. The risk of distal vessel sacrifice was not lower than major vessel sacrifice in the acute phase.
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ORIGINAL ARTICLES Top

Sleep disorders in amyotrophic lateral sclerosis: A questionnaire-based study from India p. 700
Samhita Panda, Mandaville Gourie-Devi, Ankkita Sharma
DOI:10.4103/0028-3886.232327  PMID:29766929
Background: Amyotrophic lateral sclerosis (ALS) is a relatively rare neurological disorder affecting upper and lower motor neurons in the brain and spinal cord with survival for 3-5 years and rarely beyond 10 years. Sleep disturbances in ALS are underreported and undertreated and there is no related data from India. This study aimed to assess the frequency of sleep disorders in patients of ALS and their determinants. Methods: Patients with definite and probable ALS as per the El Escorial criteria were recruited from May 2014 to April 2016. Functional impairment, presence of sleep specific abnormalities and anxiety and depression were assessed using standardized questionnaires. Results: Forty patients with ALS (23 male; 17 female) with their median age at presentation being 58.5 years (range 44-75 years) and the median duration of illness being 18 months (range: 4-120 months) were includedin the study. Half of the patients had poor sleep quality, which was significantly worse across all components of Pittsburgh Sleep Quality Index (PSQI) compared to controls. Sleep disorders were observed in 70%, insomnia in 65%, sleep disordered breathing/hypoventilation in 52.5% and restless legs syndrome in 5% patients. Night time awakenings attributable to symptoms associated with ALS were noted in 85%, and anxiety and depression in 57.5% patients. Excessive daytime somnolence emerged as an independent predictor for the presence of sleep disorders in ALS patients on multivariate logistic regression [P = 0.043, odd's ratio (OR) 1.435; 95% confidence interval[CI] (1.011-2.036)]. Conclusion: This is the first study from India providing insight into the presence of sleep disorders in ALS. About half of the patients of ALS had a poor sleep quality and two-thirds suffered from sleep disturbances.
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Measurement of the permeability, perfusion, and histogram characteristics in relapsing-remitting multiple sclerosis using dynamic contrast-enhanced MRI with extended Tofts linear model p. 709
Ping Yin, Hua Xiong, Yi Liu, Shambhu K Sah, Chun Zeng, Jingjie Wang, Yongmei Li, Nan Hong
DOI:10.4103/0028-3886.232324  PMID:29766930
Objective: To investigate the application value of using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with extended Tofts linear model for relapsing-remitting multiple sclerosis (RRMS) and its correlation with expanded disability status scale (EDSS) scores and disease duration. Materials and Methods: Thirty patients with multiple sclerosis (MS) underwent conventional magnetic resonance imaging (MRI) and DCE-MRI with a 3.0 Tesla MR scanner. An extended Tofts linear model was used to quantitatively measure MR imaging biomarkers. The histogram parameters and correlation among imaging biomarkers, EDSS scores, and disease duration were also analyzed. Results: The MR imaging biomarkers volume transfer constant (Ktrans), volume of the extravascular extracellular space per unit volume of tissue (Ve), fractional plasma volume (Vp), cerebral blood flow (CBF), and cerebral blood volume (CBV) of contrast-enhancing (CE) lesions were significantly higher (P < 0.05) than those of nonenhancing (NE) lesions and normal-appearing white matter (NAWM) regions. The skewness of Ve value in CE lesions was more close to normal distribution. There was no significant correlation among the biomarkers with the EDSS scores and disease duration (P > 0.05). Conclusions: Our study demonstrates that the DCE-MRI with the extended Tofts linear model can measure the permeability and perfusion characteristic in MS lesions and in NAWM regions. The Ktrans, Ve, Vp, CBF, and CBV of CE lesions were significantly higher than that of NE lesions. The skewness of Ve value in CE lesions was more close to normal distribution, indicating that the histogram can be helpful to distinguish the pathology of MS lesions.
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In vitro differentiation of neural cells from human adipose tissue derived stromal cells p. 716
Shruti D Dave, Chetan N Patel, Aruna V Vanikar, Hargovind L Trivedi
DOI:10.4103/0028-3886.232326  PMID:29766931
Background: Stem cells, including neural stem cells (NSCs), are endowed with self-renewal capability and hence hold great opportunity for the institution of replacement/protective therapy. We propose a method for in vitro generation of stromal cells from human adipose tissue and their differentiation into neural cells. Materials and Methods: Ten grams of donor adipose tissue was surgically resected from the abdominal wall of the human donor after the participants' informed consents. The resected adipose tissue was minced and incubated for 1 hour in the presence of an enzyme (collagenase-type I) at 370C followed by its centrifugation. After centrifugation, the supernatant and pellets were separated and cultured in a medium for proliferation at 370C with 5% CO2 for 9-10 days in separate tissue culture dishes for generation of mesenchymal stromal cells (MSC). At the end of the culture, MSC were harvested and analyzed. The harvested MSC were subjected for further culture for their differentiation into neural cells for 5-7 days using differentiation medium mainly comprising of neurobasal medium. At the end of the procedure, culture cells were isolated and studied for expression of transcriptional factor proteins: orthodenticle homolog-2 (OTX-2), beta-III-tubulin (β3-Tubulin), glial-fibrillary acid protein (GFAP) and synaptophysin-β2. Results: In total, 50 neural cells-lines were generated. In vitro generated MSC differentiated neural cells' mean quantum was 5.4 ± 6.9 ml with the mean cell count being, 5.27 ± 2.65 × 103/μl. All of them showed the presence of OTX-2, β3-Tubulin, GFAP, synaptophysin-β2. Conclusion: Neural cells can be differentiated in vitro from MSC safely and effectively. In vitro generated neural cells represent a potential therapy for recovery from spinal cord injuries and neurodegenerative disease.
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Prognostic value of cerebrospinal fluid lactate in meningitis in postoperative neurosurgical patients p. 722
AS Sumanth Kumar, Barada Prasad Sahu, Ashish Kumar
DOI:10.4103/0028-3886.232330  PMID:29766932
Objective: To evaluate the prognostic usefulness of cerebrospinal fluid (CSF) lactate in postoperative bacterial meningitis (POBM) and to establish the optimal CSF lactate cut-off values in our population to identify POBM in neurosurgical patients. Patients and Methods: A prospective study of postoperative neurosurgical patients with presumed and established bacterial meningitis in the Department of Neurosurgery, NIMS, Hyderabad, India, from September 2012 to December 2014. The diagnostic and prognostic values of CSF lactate have been evaluated and compared with other well-established CSF markers. All the patients who have undergone intradural cranial surgery with features of meningism have been included. Results: The study included 37 patients. The CSF value of the first lumbar puncture (LP) was taken to evaluate the diagnostic value of CSF lactate. Twenty three corresponded to Group A, and 14 to Group B. The mean CSF lactate in Group A was 5.94 ± 2.36, and in Group B 4.60 ± 2.31. Subsequent LPs were performed and CSF analyzed to evaluate the prognostic value of CSF lactate. The CSF markers like neutrophil count (P = 0.003), CSF/blood glucose ratio (P = 0.012), CSF lactate (P = 0.024), lymphocyte count (P = 0.046), leukocyte count (P = 0.047) have shown their prognostic value in a descending order. CSF markers like the presence of red blood cells (P = 0.540) and proteins (P = 0.757) did not show prognostic significance. The decline in CSF lactate (content and concentration) after initiation of antibiotics correlated with subsidence of fever (P = 0.0001), decrease in neck rigidity (P = 0.022) and improvement in sensorium. They were also correlated improvement in CSF/blood glucose ratio and CSF white blood cell counts. Conclusions: In our study, CSF lactate was noted to have a dependable prognostic value in POBM. As routine CSF markers can be ambiguous in POBM, CSF lactate can be considered a better alternative for both establishing the diagnosis and prognostication.
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Corticospinal tract changes in acute brainstem ischemic stroke patients: A diffusion kurtosis imaging study p. 726
Huiyou Chen, Liang Jiang, Hong Zhang, Ying-Dong Zhang, Wen Geng, Yuan Feng, Qian Chen, Yu-Chen Chen, Xindao Yin
DOI:10.4103/0028-3886.232281  PMID:29766933
Purpose: The present study aimed to investigate the corticospinal tract (CST) changes in patients with brainstem ischemic stroke by using the diffusion kurtosis imaging (DKI) approach.. Materials and Methods: Twenty-one patients with brainstem stroke and 21 group-matched healthy controls underwent brain DKI with 3.0 T magnetic resonance imaging (MRI). The DKI was obtained by using three b values of 0, 1,000, 2,000 s/mm2 with 15 diffusion directions. Regions of interest (ROIs) were placed at four levels: the pons, posterior limb of the internal capsule (PLIC), corona radiata, and precentral gyrus. The DKI parameters, including fractional anisotropy (FA), mean diffusivity (MD), and mean kurtosis (MK) values, in these regions were measured from the contralateral to the ipsilateral side of patients and both the left and right sides of healthy controls at all the four selected levels. Results: The ipsilateral side of the ischemic lesion showed a decrease in FA and MD and an increase in MK when compared with the contralateral normal region at all the four selected levels with statistically differences (P < 0.05). At these four selected levels, there were no differences between the left and right sides in healthy controls with MD, FA, and MK (P > 0.05). The MD values of the contralateral side of the ischemic lesion in patients at the four selected levels were significantly higher than those in the corresponding side of the healthy controls (P < 0.05). Compared to the healthy controls, there was a decrease at the posterior limb of the internal capsule (PLIC) in FA of the contralateral side of the ischemic lesion in stroke patients (P < 0.05). However, no significant differences were observed for MK values between the groups (P > 0.05). Conclusion: The current results suggest that the DKI technique could identify the early microstructural changes along the motor pathway and that these changes were not limited to the ipsilateral side of the ischemic lesion; in fact, the contralateral changes also occurred, especially at the PLIC.
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Spectrum of metastatic neoplasms of the brain: A clinicopathological study in a tertiary care cancer centre p. 733
Smrita Singh, Usha Amirtham, Chennagiri S Premalata, Kuntegowdanahalli C Lakshmaiah, Lokesh Viswanath, Rekha V Kumar
DOI:10.4103/0028-3886.232333  PMID:29766934
Background: While brain metastases (BM) are the most common causes of neurologic disorders in patients with known systemic malignancies, they can often be the initial manifestations of an undetected primary elsewhere. BM are major causes of morbidity and mortality in cancer patients. Aims: We describe a mixed population (data from both retrospective and prospective collection) having a BM from a solid tumor. We report the percentage distribution of the most frequent types of BM, confirming the data published in the literature. This paper may play a role in presenting the Southeast Asian reality compared with the Western countries. Setting: A tertiary-care cancer centre. Materials and Methods: Data for 4 years were retrieved from the records of the Department of Pathology of our institute. Hematolymphoid and meningeal tumors were excluded. Hematoxylin and eosin (H and E) stained slides were reviewed, and in cases with an unknown primary, immunohistochemistry (IHC) was advised. The panel of markers was chosen based on the histomorphology on H and E sections. IHC was done in cases with an unknown primary where paraffin blocks were available. Results: Lung cancer was found to be the most common primary malignancy (n = 30; 48.4%) followed by breast cancer (n = 13; 21%), colorectal cancer (n = 6; 9.6%), and skin cancer (melanoma) [n = 3; 4.8%]. Conclusion: The incidence of BM from lung and breast cancer was similar to that seen in the Western studies. However, BM from colorectal cancer and melanoma show a higher and lower incidence, respectively, in comparison with the Western literature.
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COMMENTARY Top

Brain metastasis and their management: A current perspective p. 739
Kuntal Kanti Das, Sushila Jaiswal
DOI:10.4103/0028-3886.232312  PMID:29766935
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ORIGINAL ARTICLES Top

Risk factors, symptom severity and functional status among patients with carpel tunnel syndrome p. 743
F Sharief, J Kanmani, S Kumar
DOI:10.4103/0028-3886.232351  PMID:29766936
Background: Carpal tunnel syndrome refers to a constellation of symptoms resulting from compression of the median nerve at the wrist. The characteristic symptoms include pain and numbness in the hands. Aim: To identify the risk factors responsible for carpal tunnel syndrome, to identify the symptom severity as well as functional status of patients with carpal tunnel syndrome, and to determine the relationship between symptom severity and functional status among patients with carpal tunnel syndrome. Settings and Design: A non-experimental descriptive study was conducted. Materials and Methods: A semi-structured questionnaire was administered to assess the risk factors. Standardized questionnaires included the symptom severity scale (SSS) and functional status scale (FSS). Results: The risk factors assessed were the female gender (64%), premorbidities (75%), diabetes mellitus (53%), hypertension (25%), dyslipidemia (24%), osteoarthritis (8%), and impaired thyroid functions (10%). Fifty-one patients were overweight and 8 were obese. There was an association between symptom severity and presence of any of the premorbidities (χ2 = 5.80; P < 0.05). There was also an association between symptom severity and diabetes mellitus (χ2 = 13.62; P < 0.05). A positive correlation was also noted between the symptom severity and the functional status of patients with carpal tunnel syndrome (r = 0.705; P = 0.00). Conclusions: Prompt recognition, timely management, and avoidance of risk factors responsible for the manifestations of carpal tunnel syndrome have practical implications in the treatment of carpal tunnel syndrome.
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Enhanced resection of primary high-grade gliomas using a combination of intraoperative magnetic resonance imaging and intraoperative fluorescence (5-aminolevulinic acid): A single-centre experience p. 747
Vikas Sharma, Rishabh Kedia, Karanjit S Narang, Ajaya N Jha
DOI:10.4103/0028-3886.232334  PMID:29766937
Background: The extent of resection (EOR) of a tumor is a proven prognostic factor in patients undergoing surgery for suspected high grade glioma. A few recent publications have shown the importance of intraoperative magnetic resonance imaging (iMRI) with 5-aminolevulinic acid (5-ALA) fluorescence-guidance in order to maximally increase the EOR. Aim: The objective of our study was to calculate the effect on survival of patients with high grade gliomas of resection using both iMRI and 5-ALA fluorescence-guidance as intraoperative adjuncts. Methods: Thirty-seven patients with gadolinum-enhancing high gliomas on preoperative MRI undergoing surgical excision were included in a prospective study. Surgeries began under white-light conditions. Intermittently, a blue light filter was switched on to search for remaining tumor tissue not visible to the naked eye. When gross total resection (GTR) was thought to have been achieved, iMRI was done to check for any contrast-enhancing part left behind. Surgery was concluded or resumed based on the iMRI findings. Histopathological examination of the tumor tissue was done. All patients underwent immediate postoperative MRI at the end of the surgery to calculate the EOR. Results: Our results showed that out of the total of 37 patients, 17 patients died during the follow up period and 11 patients were still alive. The mean survival was 587.1 days and median survival was 491 days with a range of 342 to 943 days. When we compared these figures with the average survival in patients with a high grade glioma, i.e., 9 to 14 months, it showed that both the above mentioned modalities were very helpful in increasing the EOR, and in turn, the overall survival. Conclusions: The use of iMRI as well as fluorescence-guidance are appropriate methods to improve the extent of resection in surgery of contrast-enhancing gliomas. Best results can be achieved by the complementary use of both modalities.
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COMMENTARY Top

Surgery for high-grade gliomas using intraoperative MRI and fluorescence p. 753
Masazumi Fujii
DOI:10.4103/0028-3886.232313  PMID:29766938
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CASE REPORTS Top

Minimally invasive options for surgical management of adjacent segment disease of the lumbar spine p. 755
Mazda K Turel, Mena G Kerolus, Brian T David, Richard G Fessler
DOI:10.4103/0028-3886.232335  PMID:29766939
Background: The incidence of adjacent segment disease (ASD) after lumbar spine surgery is a condition that has become increasingly common as the rate of lumbar spine surgery continues to rise. Minimally invasive techniques continue to be refined and offer an opportunity to treat ASD with minimal tissue disruption, lower blood loss, a shorter hospital stay, and decreased morbidity. The aim of this report is to describe the various minimally invasive options for ASD with a comprehensive review of the existing literature. Materials and Methods: A retrospective chart review of patients undergoing minimally invasive spine surgery (MIS) for ASD of the lumbar spine was conducted. Four basic techniques and their modifications were identified to address ASD. Illustrative cases, surgical techniques, and post-surgical outcomes are described. Results: Four MIS techniques were identified as common surgical methods to correct ASD. (1) Non-instrumented discectomy, foraminotomy, or decompression, (2) anterior lumbar interbody fusion (ALIF), (3) transforaminal lumbar interbody fusion (TLIF), and (4) lateral lumbar interbody fusion (LLIF) were found to be MIS techniques that address ASD. ALIF and LLIF provide indirect decompression of the neural foramina, while TLIF provides direct decompression. The addition and removal of screws and rods can be combined with any of these techniques. Conclusions: MIS techniques provide decompression of the neural elements, stabilization, and, potentially, fusion for patients with ASD. These illustrated cases and the review of MIS surgical techniques can provide a comprehensive framework for addressing ASD.
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Melanotic intracranial epidermoid: Case report and description of a new subtype p. 763
Krishnamurthy Sridhar, Mukul Vij
DOI:10.4103/0028-3886.232336  PMID:29766940
Intracranial epidermoids are generally seen as hypodense nonenhancing lesions on computed tomography scans; and, as T1 hypointense and T2 hyperintense lesions on magnetic resonance imaging (MRI). Unusual radiological findings have been reported earlier. The authors present the case of a 54-year old male patient who had prior intracranial surgery. On MRI, there was a thick peripheral mantle of diffusion restriction with a central core of brilliant T1 hyperintensity and very black T2 hypointensity. The peripheral mantle showing diffusion restriction was heterogeneously T1 hypointense and T2 hyperintense. At surgery, there was a typical pearly white epidermoid peripherally with a greenish-brown centre. Pathology showed abundant extracellular melanin which was also found in the basal layer. The authors present the first case of a melanin pigmented intracranial epidermoid in literature, describing a new histological subtype.
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NI FEATURE: PATHOLOGY PANORAMA - ORIGINAL ARTICLE Top

Idiopathic inflammatory myopathies in adults: A comparative study of Bohan and Peter and European Neuromuscular Center 2004 criteria p. 767
Sundaram Challa, Saumya Jakati, Megha S Uppin, Meena A Kannan, Rajasekhar Liza, MK Murthy Jagarlapudi
DOI:10.4103/0028-3886.232296  PMID:29766941
Background: Bohan and Peter criteria are widely used for the diagnosis of idiopathic inflammatory myopathies (IIMs). Recently, European Neuromuscular Center (ENMC) formulated criteria to identify subgroups of IIMs. Aim: To compare the two diagnostic criteria in adult IIMs. Materials and Methods: This was a retrospective review of case records of histologically confirmed IIMs in adults between January 2014 and May 2015. Both the Bohan and Peter, and ENMC 2004 criteria were applied in the same group of patients to subgroup the IIMs. Muscle biopsy was evaluated in all the four domains: muscle fiber, inflammatory, connective tissue, and vascular, with the basic panel of histological stains. Sporadic inclusion body myositis (s-IBM) was diagnosed using ENMC IBM diagnostic research criteria 2011. Results: During the study period, 69 patients fulfilled the ENMC criteria for IIMs including 16 patients with s-IBM. The subgrouping as per the ENMC criteria (53) was: dermatomyositis (DM) in 30; polymyositis (PM) in 2; immune-mediated necrotizing myopathy (IMNM) in 9; and nonspecific myositis (NM) in 12 patients, whereas subgrouping by the Bohan and Peter criteria was DM in 9 and PM with and without connective tissue disease (CTD) in 26 patients only. There was underdiagnosis of DM, as perifascicular atrophy is not recognized as a diagnostic histological feature, and overdiagnosis of PM with and without CTD due to poor characterization of histological features in PM by the Bohan and Peter criteria. Conclusions: Systematic evaluation of muscle biopsy according to the ENMC criteria with basic panel of histochemical stains improved the diagnostic yield of IIM significantly when compared to the Bohan and Peter criteria.
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NI FEATURE: THE QUEST - COMMENTARY Top

Thalamus and Language: What do we know from vascular and degenerative pathologies p. 772
Rita Moretti, Paola Caruso, Elena Crisman, Silvia Gazzin
DOI:10.4103/0028-3886.232283  PMID:29766942
Language is a complex cognitive task that is essential in our daily life. For decades, researchers have tried to understand the different role of cortical and subcortical areas in cerebral language representations and language processing. Language-related cortical zones are richly interconnected with other cortical regions (particularly via myelinated fibre tracts), but they also participate in subcortical feedback loops within the basal ganglia (caudate nucleus and putamen) and thalamus. The most relevant thalamic functions are the control and adaptation of cortico-cortical connectivity and bandwidth for information exchange. Despite having the knowledge of thalamic and basal ganglionic involvement in linguistic operations, the specific functions of these subcortical structures remain rather controversial. The aim of this study is to better understand the role of thalamus in language network, exploring the functional configuration of basal network components. The language specificity of subcortical supporting activity and the associated clinical features in thalamic involvement are also highlighted.
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NI FEATURE: CENTS (CONCEPTS, ERGONOMICS, NUANCES, THERBLIGS, SHORTCOMINGS) - ORIGINAL ARTICLE Top

Brain-stem hemangioblastomas: The seemingly innocuous lesion in a perilous location p. 779
Jeena Joseph, Sanjay Behari, Shruti Gupta, Kamlesh Singh Bhaisora, Anish Gandhi, Arun Srivastava, Awadhesh K Jaiswal
DOI:10.4103/0028-3886.232294  PMID:29766943
Introduction: Hemangioblastomas [75% sporadic, 25% with Von Hippel Lindau (VHL) disease] are highly vascular, benign lesions. The surgical nuances, management, and complication avoidance in brain-stem hemangioblastomas (BHs) have been studied. Material and Methods: Over 18 years, 27(mean age: 29 years; range 15-60 years) consecutive cases of BH underwent microsurgical excision. All patients were assessed clinico-radiologically for neurological deficits and screened for VHL disease. Outcome of the patients was based on Karnofsky Performance Status scale (KPS). Results: 12 out of 19 (70.4%) patients with hydrocephalus underwent a cerebrospinal fluid (CSF) diversion procedure. Lower cranial nerve palsy was present in 10 (37%) patients and motor weakness in 13 (48%). The tumours [mean size 3.34 ± 1.06 cm, range: 1.4-5.5 cm; 11 solid, rest solid-cystic; 18 (66.7%) subpial and 9 (33.33%) intramedullary] were divided into four categories based on size: A: <2 cm (n = 5,18.5%); B: 2-3 cm (n = 10,37%); C: 3-4 cm (n = 6,22.2%); D: >4 cm (n = 6,22.2%). Their location was at posterior cervicomedullary junction (n = 12); pontomedullary junction (n = 7); pons (n = 3), medulla (n = 3) and ponto-mesencephalic region (n = 2). Multiple flow voids were seen in >50% patients with tumour >2 cm. 5 patients had syringomyelia; and, 8 had diffuse cervical cord expansion. Two patients with a large vascular tumour underwent preoperative embolization. Six patients had VHL disease; one underwent bilateral adrenalectomy for refractory hypertension; and, the another, nephrectomy for renal cell carcinoma. Twenty-six patients underwent a midline suboccipital craniectomy; and, 1 with a cerebellopontine angle tumour, a retromastoid craniectomy. 15 patients underwent total excision; 10 patients, near-total (<10% remaining) excision, and 2 patients, a subtotal (>10% remaining)) excision. Three patients (2 with VHL disease) expired due to exsanguinating hemorrhage, spreading venous thrombosis and aspiration pneumonitis, respectively. At follow-up visit (median: 25 ± interquartile range 2-56months), 17 patients had improved KPS, 4 remained in same status and 3 (recently operated, on tracheostomy) had worsened KPS. Conclusions: Significant improvement is achievable in neurological status in patients following successful extirpation of a brain-stem hemangioblastoma, despite a turbulent perioperative period. Leaving tumour capsule adherent to the brain-stem often helps in preserving brain-stem function. Postoperatively, the patients should be monitored for their respiratory and lower cranial nerve status to prevent aspiration pneumonitis.
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NI FEATURE: NORMATIVE DATA - ORIGINAL ARTICLE Top

Craniovertebral junction evaluation by computed tomography in asymptomatic individuals in the Indian population p. 797
Chinmaya Dash, Raghav Singla, Mohit Agarwal, Ambuj Kumar, Hitesh Kumar, Shashwat Mishra, Bhawani S Sharma
DOI:10.4103/0028-3886.232288  PMID:29766944
Background: The available literature on the anatomy and imaging of the craniovertebral junction (CVJ) focusses on the osteometric indices described for the detection of abnormal relationships between the components of CVJ. However, a knowledge of the normal osteometry of this region in the Indian population is critically important for the operating surgeon as it may influence the surgical technique as well as the choice, size and configurations of the implants. It is also important to determine whether critical differences exist between the osteometric data of Indians and the rest of the world for this part of the anatomy. Accordingly, the present study is an attempt to quantitate the osteometric indices for the anatomically normal CVJ in Indian subjects Materials and Methods: We retrospectively studied the imaging data of 49 consecutive adult patients (31 males, 18 females) who underwent a computed tomographic (CT) angiogram for suspected vascular conditions unrelated to the craniovertebral junction. Several parameters related to the atlanto-dental relationship, foramen magnum, atlas and axis vertebrae were recorded, including the dimensions of the commonly instrumented bony regions and also the indices related to the CVJ bony relationships. The data was also compared between the two genders, statistically through the Student's t-test using the statistical program “R”. Results: No patient had an atlanto dens interval >2.5 mm. The mean distance of the odontoid tip from the McRae line in this series was 5.11 mm and no patient had the odontoid tip above the McRae line. Female subjects had significantly smaller diameters of C1 lateral masses and odontoid screw trajectory length when compared to males. Additionally, in the Indian population, the length range of odontoid screw trajectory and the thickness of the narrowest part of the C2 pedicles was smaller with respect to similar data from other geographical regions. However, the rest of the parameters resembled the data from studies conducted on populations with other ethnicities. Conclusion: The osteometric parameters of the CVJ in the Indian population are largely similar to those described globally. However, there are some important differences too which can influence the design of surgical implants suited to the Indian population.
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NI FEATURE: TECHNOLOGICAL INNOVATIONS - COMMENTARY Top

Proposed solution for dorsal internal carotid artery aneurysms: Suggestion of a novel new clip design p. 804
Ashish Aggarwal, Manarshhjot Singh, Parveen Kalra
DOI:10.4103/0028-3886.232282  PMID:29766945
Dorsal internal carotid artery (ICA) aneurysms are notorious for their high morbidity and mortality. They have an extremely fragile wall and have a high chance of rupture and clip slippage during the intraoperative and postoperative period. Strategies proposed to mitigate these problems encompass including part of the normal ICA wall in addition to neck of aneurysm in clip blades, as well as the use of encircling materials (silicon, cellulose, Weck's clip) over a clip. The Achilles' heel of the problem is to take an appropriate thickness of the normal ICA in clip blades. Too less or too much of this can spell disaster. This is easier said than done during an actual surgical procedure. So, in this difficult situation, is there any better method of clipping? We propose a fenestrated clip in which the clip blades are placed just at the beginning of fenestration and at right angles to the clip. This occludes the aneurysm taking part of the normal ICA wall in the clip blades. The fenestration hugs the ICA and prevents clip slippage. This has been explained with appropriate figures in the two and three-dimensional format. There cannot be a single stop solution for a complex disease like dorsal ICA aneurysm. The present proposed design is an attempt to provide a better clipping chance in these difficult aneurysms. Future work on this design can prove its usefulness.
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NI FEATURE: CITADELS SCULPTING FUTURE - COMMENTARY Top

Department of Neurosurgery, Madurai Medical College and the development of neurosurgery in South Tamil Nadu p. 807
Subbiah Thiruppathy, Ramiah Manimaran, Gopalakrishnan M Niban, Natarajan Muthukumar
DOI:10.4103/0028-3886.232298  PMID:29766946
The development of neurosurgery in South Tamil Nadu can be traced to the Department of Neurosurgery, Madurai Medical College and Government Rajaji Hospital, Madurai, Tamil Nadu, India. The hospital was established in the year 1940 and Madurai Medical College was started in 1954. Prof. M. Natarajan founded this department in September, 1963. This department has a Neurosurgery Residency Program that is 50 years old. The establishment of this department and its growth to its present stature is documented here.
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NI FEATURE: THE FOURTH DIMENSION - COMMENTARY Top

A summary of some of the recently published, seminal papers in neurosciences p. 815
Mazda K Turel, Manjul Tripathi, Ravi Yadav, PR Srijithesh, Aastha Takkar, Sahil Mehta, Chirag K Ahuja, Anant Mehrotra, Kuntal K Das
DOI:10.4103/0028-3886.232306  PMID:29766947
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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTERS TO EDITOR Top

Methamphetamine-induced internal carotid artery vasospasm: A rapidly fatal stroke p. 826
Chen Fei Ng, Chia Yin Chong
DOI:10.4103/0028-3886.232337  PMID:29766948
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Inadvertent stent placement in the persistent hypoglossal artery: A case for caution p. 828
Shyam S Rao, Lakshmi Shankar, Kumar Rajamani
DOI:10.4103/0028-3886.232348  PMID:29766949
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False localizing oculomotor nerve palsy after endovascular coiling of a posterior communicating artery aneurysm p. 830
Boby V Maramattom, Vijay Jayakrishnan, Dilip Panikar, S Shyam Sundar
DOI:10.4103/0028-3886.232345  PMID:29766950
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Pigmented intramedullary spinal cord meningioma mimicking a nervous system infection: An unusual report and review of the literature p. 832
Shambu Kumar Sah, Xiaoqing Shi, Sanjeet Kumar Sah, Pranesh Kumar Yadav, Yongmei Li
DOI:10.4103/0028-3886.232293  PMID:29766951
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LETTERS TO EDITOR Top

Magnetic resonance imaging and magnetic resonance spectroscopy in varicella zoster necrotizing encephalitis p. 836
Remya Baburaj, Rajeswaran Rangasami, PS Rajakumar
DOI:10.4103/0028-3886.232343  PMID:29766952
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The mysterious case of bilateral sensory neural hearing loss (superficial siderosis) p. 839
Pushpendra N Renjen, Dinesh Chaudhari
DOI:10.4103/0028-3886.232339  PMID:29766953
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Necklace body myopathy: A rare entity p. 841
Aditya Choudhary, Saurabh Bansal, Louis Gaspar Balan, Manoj Goyal, Manish Modi
DOI:10.4103/0028-3886.232350  PMID:29766954
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Episodic ataxia in a child with senataxin mutation p. 842
S Sesh, Ashalatha Radhakrishnan
DOI:10.4103/0028-3886.232295  PMID:29766955
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Retracing the natural history of Dravet syndrome: Report and review of literature p. 844
Sachin Sureshbabu, Ivy Sebastian, Sudhir Peter, Chindripu Sobhana, Gaurav K Mittal
DOI:10.4103/0028-3886.232328  PMID:29766956
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A rare association of Gorlin–Goltz syndrome p. 847
Sunil Kumar, Ruthira Eshanth, Venkatraman Indiran, Kalaichezhian Mariappan, Prabakaran Maduraimuthu
DOI:10.4103/0028-3886.232340  PMID:29766957
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Peripheral primitive neuroectodermal tumor of cauda equina: A report and review of literature Highly accessed article p. 850
A Ajaya Kumar, Shaikhali Barodawala
DOI:10.4103/0028-3886.232344  PMID:29766958
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Trigeminal neuralgia caused by a venous angioma: The neuroimaging and surgical findings p. 852
Arslan Aydan, Ulus Sila, Berkman Z Mehmet, Karaarslan Ercan
DOI:10.4103/0028-3886.232338  PMID:29766959
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Primary spinal cord glioblastoma metastasizing to the cerebellum: A missed entity p. 854
Akarsh Jayachandran, Gandham E Jonathan, Bimal Patel, Krishna Prabhu
DOI:10.4103/0028-3886.232347  PMID:29766960
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Anaplastic astrocytoma and pituitary macroadenoma within the same patient: A rare case of intracranial collision tumor p. 857
Harish Naik, Velho Vernon, Prashant Gade, Laxmikant Bhople, Amrita Guha
DOI:10.4103/0028-3886.232341  PMID:29766961
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Giant cell tumor at the clivus: Not an area 51 p. 861
Ayusman Satapathy, Manjul Tripathi, Ravi B Chauhan, Jenil Gurnaani, Sandeep Mohindra
DOI:10.4103/0028-3886.232286  PMID:29766962
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Intracranial chondroma without meningeal attachment p. 865
Kadir Oktay, Umit Akin Dere, Murat Arslan, Sevcihan Kesen, Tufan Ciftci
DOI:10.4103/0028-3886.232290  PMID:29766963
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Calvarial intraosseous leiomyoma: Another consideration in children with suspected esosinophilic granuloma p. 866
Wenjian Zheng, Liangming Li, Shaohua Lin
DOI:10.4103/0028-3886.232331  PMID:29766964
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Hypersexuality following anterior communicating artery aneurysm rupture p. 868
Kush Dev Singh Jarial, Moushumi Purkayastha, Pinaki Dutta, Kanchan K Mukherjee, Anil Bhansali
DOI:10.4103/0028-3886.232289  PMID:29766965
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Primary cerebellar agenesis in a normal man p. 871
Shah Omair, Wani Arif, Bashir Muiez, Suhail Jan, Dar Musaib, Gojwari Tariq
DOI:10.4103/0028-3886.232287  PMID:29766966
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A novel cost-effective pillow for prevention of an occipital pressure sore p. 873
Jayesh Sardhara, Rachana Mishra
DOI:10.4103/0028-3886.232303  PMID:29766967
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NEUROIMAGES Top

Cortical hyperintensities: A rare magnetic resonance imaging finding in Wilson's disease p. 876
Rajesh Verma, Soumik Sarkar, Anirudda More
DOI:10.4103/0028-3886.232325  PMID:29766968
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Sieve-like basal ganglia: A rare MRI presentation of vascular parkinsonism p. 878
Sunil Pradhan, Robin Bansal
DOI:10.4103/0028-3886.232349  PMID:29766969
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Fetal meningocele manqué p. 879
MH Shabina Banu, Rajeswaran Rangasami, Indrani Suresh
DOI:10.4103/0028-3886.232299  PMID:29766970
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Persistent primitive trigeminal artery- a study of two cases p. 881
Musaib Ahmad Dar, Fahad Shafi, Jan Muhammad Suhail, Mohammad Arif Wani, Mohammad Yaqoob Wani, Naseer Ahmad Choh
DOI:10.4103/0028-3886.232285  PMID:29766971
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Eye in the brain p. 883
Manjul Tripathi, Nagesh Varshney, Aman Batish, Sandeep Mohindra
DOI:10.4103/0028-3886.232284  PMID:29766972
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Large serpentine aneurysm of the anterior cerebral artery p. 884
Amith S Kumar, Julie Sachdeva, Neeraj Balaini, Ritu Shree, Manoj K Goyal, Vivek Lal, Chirag Ahuja
DOI:10.4103/0028-3886.232329  PMID:29766973
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An unusual cause of combined cauda equina and conus medullaris syndrome p. 886
Suraj Sajeev, R Krishnakumar
DOI:10.4103/0028-3886.232280  PMID:29766974
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CORRESPONDENCE Top

Why do we need the humanities in medicine? p. 889
Sunil K Pandya
DOI:10.4103/0028-3886.232308  PMID:29766975
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Current trends in the management of intracranial aneurysms and how neurosurgical residency programs in India are falling behind in this revolution p. 892
Krishna Chaitanya Joshi
DOI:10.4103/0028-3886.232332  PMID:29766976
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Change in the natural profile of Duchenne muscular dystrophy with the judicious use of steroids p. 893
Sunil Pradhan, Ananya Das
DOI:10.4103/0028-3886.232304  PMID:29766977
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NI FEATURE - BOOKS FROM MY SHELF - COMMENTARY Top

Wilder Penfield. The second career with other essays and addresses. p. 896
Sunil Pandya
DOI:10.4103/0028-3886.232307  PMID:29766978
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BOOK REVIEW Top

The ASSI monographs p. 898
Sunil K Pandya
DOI:10.4103/0028-3886.232311  
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Online since 20th March '04
Published by Wolters Kluwer - Medknow