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Coverpage
January-February 2018
Volume 66 | Issue 1
Page Nos. 1-294

Online since Thursday, January 11, 2018

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NI FEATURE - COMMENTARY: THE FIRST IMPRESSION  

The cover page Highly accessed article p. 1

DOI:10.4103/0028-3886.222810  PMID:29322946
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NI FEATURE - COMMENTARY: TIMELESS REVERBERATIONS Top

Neurosurgery as it was Highly accessed article p. 2
RN Roy
DOI:10.4103/0028-3886.222819  PMID:29322947
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NI FEATURE: PRESIDENTIAL ORATION - COMMENTARY Top

Changing trends in surgery for suprasellar lesions p. 4
Bhawani Shanker Sharma, Dattaraj Paramanand Sawarkar
DOI:10.4103/0028-3886.222822  PMID:29322948
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NI FEATURE: JOURNEY THROUGH THE EONS - COMMENTARY Top

Evolution of concepts in the management of vestibular schwannomas: Lessons learnt from Prof B Ramamurthi's article published in 1970 p. 9
Sunil Kumar Gupta, Manjul Tripathi
DOI:10.4103/0028-3886.222846  PMID:29322949
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GUEST COMMENTARY Top

A medical-legal perspective on overlapping surgery p. 20
Alan M Scarrow
DOI:10.4103/0028-3886.222813  PMID:29322950
In the U.S., there has recently been increased scrutiny on the appropriateness of surgeons performing overlapping cases and the potential for adverse consequences. This article describes the current literature on overlapping surgery and the ethics that guide behavior by performing a review of the PUBMED literature on overlapping surgery and analysis. Although the literature on overlapping surgery supports it as a safe practice, some public opinion runs contrary to the data, which is driving changes in policy. Surgeons should become familiar with the overlapping surgery policy in the hospital(s) in which they practice and be mindful of the potential consequences of performing overlapping surgeries.
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Cerebrospinal fluid shunts – How they work: The basics Highly accessed article p. 24
Sandip Chatterjee, L Harischandra
DOI:10.4103/0028-3886.222820  PMID:29322951
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NI FEATURE: THE EDITORIAL DEBATE I-- PROS AND CONS Top

Current status of dystonias including Meige's syndrome p. 36
Madhuri Behari
DOI:10.4103/0028-3886.222827  PMID:29322952
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Botulinum toxin in patients with Meige's syndrome p. 38
Nirosen Vijiaratnam, Tissa Wijeratne
DOI:10.4103/0028-3886.222831  PMID:29322953
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NI FEATURE: THE EDITORIAL DEBATE II-- PROS AND CONS Top

Management of intracranial arterial dissection p. 40
Girish Rajpal, Vikas Naik
DOI:10.4103/0028-3886.222834  PMID:29322954
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Endovascular management of vertebral artery dissecting aneurysms p. 43
Vipul Gupta, Rajsrinivas Parthasarathy
DOI:10.4103/0028-3886.222833  PMID:29322955
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Dissecting aneurysms of the vertebrobasilar system with non-traumatic subarachnoid haemorrhage: Therapeutic considerations p. 46
Eike Immo Piechowiak, Jan Gralla
DOI:10.4103/0028-3886.222824  PMID:29322956
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NI FEATURE: THE EDITORIAL DEBATE III-- PROS AND CONS Top

Is intraoperative lumbar subarachnoid drainage necessary for endoscopic endonasal pituitary surgery? p. 49
Kiyoshi Saito
DOI:10.4103/0028-3886.222829  PMID:29322957
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The case for using lumbar drainage intraoperatively to help curb the number of iatrogenic CSF leaks p. 51
Manuel Cunha e Sá
DOI:10.4103/0028-3886.222842  PMID:29322958
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NI FEATURE: THE EDITORIAL DEBATE IV-- PROS AND CONS Top

Neurological manifestations of renal disease p. 53
Nitesh N Rao, Rajiv Juneja
DOI:10.4103/0028-3886.222825  PMID:29322959
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Neurology of renal disorders p. 55
Manas Ranjan Patel, Amit Gupta
DOI:10.4103/0028-3886.222828  PMID:29322960
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REVIEW ARTICLE Top

Perioperative strokes following combined coronary artery bypass grafting and carotid endarterectomy: A nationwide perspective p. 57
Reshmi Udesh, Hannah Cheng, Amol Mehta, Parthasarathy D Thirumala
DOI:10.4103/0028-3886.222849  PMID:29322961
Background: To assess the risk of perioperative stroke on in-hospital morbidity and mortality following combined coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA). Materials and Methods: Data from the National Inpatient Sample (NIS) database for all patients who underwent CABG with CEA were identified using ICD-9 codes. Combined procedures were identified as CEA and CABG procedures that happened on the same day. Various preoperative and perioperative risk factors and their association with in-hospital mortality and morbidity were studied. Results: A total of 8457 patients underwent combined CABG and CEA from 1999 to 2011. The average age of the patient population was 69.98 years. A total of 6.17% (n = 521) of the patients developed perioperative strokes following combined CABG and CEA. An in-hospital mortality of 4.96% and morbidity of 66.35% was observed in the patient cohort. Patients with perioperative strokes showed a mortality of 19% and a morbidity of 89.34%. Other notable risk factors for in-hospital mortality and morbidity were heart failure, paralysis, renal failure, coagulopathy, weight loss and fluid and electrolyte disturbances, and postoperative myocardial infarction. Conclusion: A strong association was found to exist between perioperative stroke and in-hospital mortality and morbidity after combined CABG and CEA. CEA procedures are thought to mitigate the high stroke rate of 3-5% post-CABG, but our study found that combined procedures exhibit a similar stroke risk undercutting their effectiveness. Further investigative studies on combined CABG+CEA are needed to assess risk-stratification for better patient selection and examine other preventative strategies to minimize the risk of ischemic strokes.
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ORIGINAL ARTICLES Top

Etiologic spectrum and prognosis in noncompressive acute transverse myelopathies: An experience of 80 patients at a tertiary care facility p. 65
Shuchit Pandey, Ravindra K Garg, Hardeep S Malhotra, Amita Jain, Kiran P Malhotra, Neeraj Kumar, Rajesh Verma, Praveen K Sharma
DOI:10.4103/0028-3886.222877  PMID:29322962
Introduction: We evaluated the spectrum of acquired demyelinating and inflammatory disorders in patients presenting with an acute transverse myelopathy. We also studied differences between an acute idiopathic transverse myelitis and myelitis resulting from other etiologies. Materials and Methods: Eighty consecutive patients with acute transverse myelopathy were included. At inclusion, clinical profile, serum and cerebrospinal fluid parameters, brain and spinal cord magnetic resonance imaging, and visual evoked potentials were obtained. All patients were given methylprednisolone therapy. Patients were followed up for 6 months. Outcome was assessed using modified Barthel index. A modified Barthel index score of ≤12 indicated a poor prognosis. Results: Majority (n = 49; 61.25%) of patients had idiopathic acute transverse myelitis. Eleven cases had neuromyelitis optica spectrum disorders (8 had anti-aquaporin antibody positivity). Multiple sclerosis was diagnosed in 7 cases. Eight cases had infectious or parainfectious myelitis. Longitudinally extensive transverse myelitis was noted in 66 (82.5%) patients. Seventeen patients had abnormalities in the brain. Majority of patients improved following methylprednisolone therapy. On univariate analysis, delay in administering methylprednisolone therapy, poor modified Barthel index at discharge, and extensive cord involvement were associated with severe residual disability. On multivariate analysis, delayed initiation of methylprednisolone was identified as a poor prognostic factor. Conclusion: A variety of inflammatory, infective, demyelinating, and autoimmune disorders present with acute transverse myelopathy. Early institution of methylprednisolone reduces the disability in these patients.
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Botulinum toxin in Meige's syndrome: A video-based case series Highly accessed article p. 71
Sanjay Pandey, Soumya Sharma
DOI:10.4103/0028-3886.222872  PMID:29322963
Context: Despite being the most common cause of cranial dystonia, Meige's syndrome remains a rare clinical entity. Characterized by blepharospasm and orofacial dystonia, patients suffering from Meige's syndrome benefit from the injection of botulinum toxin (BTX). Aims: As the majority of the studies tend to discuss Meige's syndrome with blepharospasm patients, there is a paucity of case-based studies dealing exclusively with this syndrome. Hence, we intended to characterize and define the evolution of this syndrome and objectively determine the response of the patients suffering from this entity to BTX therapy. Materials and Methods: Eight patients with Meige's syndrome who had never been injected with BTX in the past were evaluated at our movement disorder clinic using a structured questionnaire. Videotaping of abnormal movements was done for 5 minutes before the BTX injection and at a 1-month follow-up. All patients received electromyography-guided injection of BTX and the dosage was decided using clinical evaluation. Their demography, clinical features, and treatment response to BTX were analyzed using the “Burke–Fahn–Marsden dystonia rating scale” (BFMDRS) before injection and at a 1-month follow-up. Results: The peak age of symptom onset was 46.4 years with a male: female ratio of 1:1. The average duration of symptoms was 6.43 years. Majority of the patients (6/8) manifested their disease with blepharospasm, including five patients who had clonic blepharospasm. Lingual dystonia (6/8) and pharyngeal involvement (4/8) were commonly noted. Sensory tricks were present in all, with placement of the fingers over eyelids being the commonest trick (7/8). The average BTX dose administered was 51.58 units, and the peak onset of relief was noted at 8.62 days after the injection. The duration of the effect lasted for 82.5 days on an average. Only one patient reported mild weakness of the muscles of mastication following BTX injection. The average BFMDRS improved from the preprocedural score of 25.06 to 13.12 following the BTX injection. Conclusions: In this series exclusively dealing with Meige's syndrome patients, tongue involvement was found to be very common (6/8, 75%), and the response to the first dose of BTX treatment was found to be excellent without the occurrence of any major side effects.
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Natural history of a cohort of Duchenne muscular dystrophy children seen between 1998 and 2014: An observational study from South India p. 77
Ravinder-Jeet Singh, Mahadevappa Manjunath, Veeramani Preethish-Kumar, Kiran Polavarapu, Seena Vengalil, Priya T Thomas, Kandavel Thennarasu, Narayanappa Gayathri, Deepha Sekar, Saraswati Nashi, Atchayaram Nalini
DOI:10.4103/0028-3886.222881  PMID:29322964
Background: Duchenne muscular dystrophy (DMD) is the most common muscular dystrophy. There are no large studies describing its natural course from India. Materials and Methods: Immunohistochemically/genetically confirmed DMD patients diagnosed between 1998 and 2014 were ambispectively included. The main aim was to study the natural course of motor milestones, i.e., age at onset of wheelchair status, bedbound state, and age at death, which were considered as primary outcome measures. We also correlated the DMD genotype with the motor milestones and other phenotypic features. Results: A total of 500 DMD patients were included and 275 participated in the study. The mean age at symptom onset was 3.7 ± 1.9 years, mean age at presentation was 8.1 ± 2.5 years, and mean duration of illness was 4.4 ± 2.6 years. On following them over 15 years, 155 (56.4%) had attained at least one of the primary outcome measures. Wheelchair status was attained in 124 (45.1%) [mean age: 10.4 ± 1.6 years] and bedbound state in 24 (8.7%; mean age: 11.8 ± 2.2 years) patients. Seven patients (2.6%) died during the follow-up period (mean age: 15.2 ± 2.4 years). There was no significant impact of the genotypic or phenotypic features on the primary outcome. Conclusion: The pattern of major motor milestones (primary outcome measures) in this large cohort is comparable with that of the Western population despite variability in medical care. The genotypic pattern was also similar to other large studies, which suggests that DMD is a more homogeneous disorder with limited ethnic variability in its geno-phenotypic expression.
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Endovascular strategies for management of intradural vertebral artery dissecting aneurysms Highly accessed article p. 83
Swati D Chinchure, Vijay Jaykrishnan, BP Krishna Prasad
DOI:10.4103/0028-3886.222811  PMID:29322965
Objective: Endovascular treatment of vertebral intradural dissecting aneurysms is complex and requires different strategies for each case. The current study aims to classify these aneurysms for an easy selection of optimal strategies for endovascular therapy. Materials and Methods: This study is a retrospective evaluation of 10 patients harbouring a vertebral intradural dissecting aneurysm (including 6 female and 4 male patients). The clinical, procedural, and angiographic data were evaluated. Results: Nine patients presented with acute subarachnoid hemorrhage and 1 with acute-onset headache. The aneurysms were classified into two types, depending on the developmental state of the contralateral vertebral artery: Dominant (A) and hypoplastic (B). Type A (n = 7) group was further divided into three subtypes on the basis of location of the aneurysm in relation to the posterior inferior cerebellar artery (PICA): aneurysm proximal to the PICA, Type I (n = 3); involving the PICA, Type II (n = 2); and, distal to the PICA, Type III (n = 2). Internal trapping was done for 4 patients in this group, 2 patients with aneurysm involving the PICA underwent proximal occlusion and 1 patient underwent stent-assisted coiling since he refused to undergo vertebral artery sacrifice. B Type patients (n = 3) were treated with reconstructive endovascular management. No symptomatic complication was seen in the patients with trapping. Antiplatelet medication-related complication was seen in 2 patients who underwent stent-assisted coiling. Clinical outcome at the time of discharge was good [modified Rankin score (mRS) 0–2] in 8 and poor (mRs >2) in 2 patients. At follow-up visit, one patient had developed severe cognitive impairment but was independent in activities of daily living. Conclusion: The classification of vertebral artery aneurysms based on their location and on the status of the contralateral vertebral artery appears to be an effective method for the selection of safe and appropriate endovascular therapy.
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The influence of adjunctive caudal epidural steroid injection on the therapeutic effect of transforaminal epidural steroid injection p. 90
Atilla Kircelli, Tufan Cansever, Cem Yılmaz
DOI:10.4103/0028-3886.222850  PMID:29322966
Background: Epidural steroid injection is widely used to treat the short and long-term symptoms of low back and radicular pain. To the best of our knowledge, the influence of transforaminal epidural steroid injection (TFSI) combined with caudal epidural steroid injection (CESI) on pain intensity, patient satisfaction, and quality of life in lumbar radiculopathy has not been examined. Aim: To evaluate the short and long-term efficacy of TFSI, and TFSI combined with CESI (TFSI + CESI) in patients with lumbar radiculopathy. Materials and Methods: We retrospectively examined the records of 104 patients with lumbar radicular pain and L4/5 and/or L5/S1 intervertebral disc disease who underwent TFSI or TFSI + CESI. We compared the pain intensity using a Visual Numeric Scale (VNS), North American Spine Society (NASS) pain satisfaction index, and EuroQol five dimensions (EQ-5D) quality of life scores before intervention, and after 1, 6 and 12 months. Results: In the TFSI group, the mean pre-treatment VNS score was 9.2, which improved to 4.9 after 1 month and to 7.2 after 12 months. In the TFSI + CESI group, the mean pre-treatment VNS score was 9.4, which improved to 2.6 and 4.6 after 1 and 12 months, respectively. Improvement in the VNS scores was significantly higher in the TFSI + CESI group (P < 0.0001 for each). Mean EQ-5D quality of life index in the TFSI group improved from 0.59 in the pre-treatment phase to 0.76 after 12 months of intervention, while it improved from 0.62 in the pre-treatment phase to 0.84 at 12 months of intervention in the TFSI + CESI group. The EQ-5D scores were significantly better in the TFSI + CESI group at 1, 6, and 12 months after the procedure (P = 0.004, 0.036, and 0.042, for 1, 6, and 12 months, respectively). The NASS scores were significantly better in the TFSI + CESI group at 6 and 12 months after the intervention (P = 0.025 and 0.001 for 6 months and 12 months, respectively). Conclusion: In patients with lower lumbar radiculopathy, a combined TFSI + CESI technique offers superior short and long-term pain relief, quality of life, and long-term patient satisfaction, than when TFSI is performed alone.
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Alternative bibliometrics from the web of knowledge surpasses the impact factor in a 2-year ahead annual citation calculation: Linear mixed-design models' analysis of neuroscience journals p. 96
Araceli Diaz-Ruiz, Ulises Orbe-Arteaga, Camilo Rios, Ernesto Roldan-Valadez
DOI:10.4103/0028-3886.222880  PMID:29322967
Context: The decision about which journal to choose for the publication of research deserves further investigation. Aims: In this study, we evaluate the predictive ability of seven bibliometrics in the Web of Knowledge to calculate total cites over a 7-year period in neuroscience journals. Settings and Design: Coincidental bibliometrics appearing during 2007, 2008, 2009, 2010, and 2011, along with their corresponding cites in 2009, 2010, 2011, 2012, and 2013, were recorded from the journal citation reports (JCR) Science Edition. This was a retrospective study. Materials and Methods: This was a bibliographic research using data from the Web of Knowledge in the neuroscience category. Statistical Analysis Used: A linear-mixed effects design using random slopes and intercepts was performed on 275 journals in the neuroscience category. Results: We found that Eigenfactor score, cited half-life, immediacy index, and number of articles are significant predictors of 2-year-ahead total cites (P ≤ 0.010 for all variables). The impact factor, 5-year impact factor, and article influence score were not significant predictors; the global effect size was significant (R2= 0.999; P < 0.001) with a total variance of 99.9%. Conclusions: An integrative model using a set of several metrics could represent a new standard to assess the influence and importance of scientific journals, and may simultaneously help researchers to rank journals in their decision-making during the manuscript submission phase.
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Treatment strategies for traumatic cervico-cranial pseudoaneurysms: A single institution experience p. 105
Ming-Jun Cai, Guo-Zheng Xu, Ming Yang, Lian-Ting Ma, Xin-Jian Yang, Bao-Chang Shi, Jun Li, Li Pan
DOI:10.4103/0028-3886.222873  PMID:29322968
Aim: Limited clinical and angiographic data exists for patients with traumatic cervico-cerebral pseudoaneurysms. In this paper, we present our limited experience with various management strategies for traumatic cervico-cranial pseudoaneurysms. Materials and Methods: We retrospectively analyzed 37 consecutive cases of traumatic pseudoaneurysms involving the cervico-cranial or the cerebral arteries diagnosed at our center from September 2009 to December 2014. The demographic data, etiology, clinical presentation, lesion location, treatment modality, and follow-up outcomes of these patients were reviewed. Among these 37 patients, 5 patients were treated by surgery, while 29 patients were treated by the endovascular approach and 3 received conservative treatment. Results: During the study period, 42 pseudoaneurysms were identified in 37 patients with a history of head or neck injury. Five patients underwent surgical exploration of the lesion with an uneventful postoperative course. Twenty-nine patients were treated by endovascular interventions with various embolization materials including coils, stents, detachable balloons, liquid embolic agents, and a combination of these agents. The angiographic follow-up imaging demonstrated complete exclusion of the aneurysm from the circulation with the patient being free from any additional neurological deficits. Conclusion: Proper selection of an appropriate approach is essential to address the management of traumatic cervico-cerebral pseudoaneurysms. The treatment of traumatic cervico-cerebral pseudoaneurysms should be selected according to the location and the clinical features of the pseudoaneurysms. The endovascular treatment is a safe and effective modality and should be the first-line choice for treatment of traumatic pseudoaneurysms.
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COMMENTARY Top

Pseudoaneurysms of the craniocervical region p. 115
Mathew Abraham
DOI:10.4103/0028-3886.222844  PMID:29322969
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ORIGINAL ARTICLE Top

Minimally invasive transforaminal lumbar interbody fusion using bone cement-augmented pedicle screws for lumbar spondylolisthesis in patients with osteoporosis. Case series and review of literature p. 118
Venkata Ramesh Chandra Vemula, Bodapati Chandramowliswara Prasad, MA Jagadeesh, Jayachandar Vuttarkar, Sanjeev Kumar Akula
DOI:10.4103/0028-3886.222826  PMID:29322970
Background: Instrumentation in patients with osteoporosis is challenging. Bone cement-augmented fenestrated pedicle screw fixation is a new procedure for fixation in the osteoporotic bone; and, applying minimally invasive techniques to the above is a challenging and novel concept. Aims: To evaluate the clinical and radiological outcome of minimally invasive spine surgery transforaminal lumbar interbody fusion (MIS-TLIF) in patients with spondylolisthesis and poor bone quality, performed with rigid instrumentation using bone cement [poly(methylmethacrylate)]-augmented fenestrated pedicle screws. Settings and Design: Prospective, observational, single-center study. Statistical Analysis Used: Wilcoxon nonparametric test for paired samples with a level of significance of 0.05. Methods: A clinical series of 25 patients with lumbar spondylolisthesis and osteoporosis who underwent minimally invasive TLIF with bone cement-augmented pedicle screws were included in the study. Clinical outcome and the function were assessed using the visual analog scale (VAS) score for pain and the Oswestry Disability Index (ODI). Perioperative, postoperative, and long-term complications were monitored with a mean follow-up of 18 months. Results: A total of 25 (20 female and 5 male) patients were included in the study with an average age of 61.05 years. The major symptom was low back pain with radiating pain to lower limbs. The average T-score was −3.0. All the patients were followed clinically and radiologically. There was a statistically significant improvement in the VAS scores and ODI scores postoperatively. No events of cement extravasation, radiological loosening, or pulling out of screws were observed. Conclusions: Fenestrated pedicle screw fixation with bone cement augmentation in patients with osteoporosis is a well-established alternative to increase the pullout strength of screws placed in the osteoporotic bone. Applying the concept of minimally invasive surgery to this procedure makes it a more complete solution for instrumentation in osteoporotic spine. Our series is the largest in literature on spondylolisthesis and confirms the feasibility and safety of this procedure in treating spondylolisthesis in the aging population.
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Osteoporotic lumbar spine - Principles of pedicle screw fixation and interbody fusion p. 126
J K B C Parthiban
DOI:10.4103/0028-3886.222835  PMID:29322971
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ORIGINAL ARTICLE Top

A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas p. 133
Gandham E Jonathan, Sauradeep Sarkar, Georgene Singh, Sunithi Mani, Regi Thomas, Ari George Chacko
DOI:10.4103/0028-3886.222823  PMID:29322972
Background: Intraoperative cerebrospinal fluid (CSF) leaks are a frequent cause of morbidity in patients undergoing transsphenoidal surgery. This prospective study was performed to examine the impact of intraoperative lumbar subarachnoid drainage (LSAD) on the incidence of this complication and on the extent of resection in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Materials and Methods: This prospective study was conducted in a single large academic medical center. All patients with pituitary adenomas who had not undergone prior transsphenoidal surgery were eligible for inclusion in the study. Patients were randomly assigned to undergo transsphenoidal surgery with intraoperative lumbar drain insertion (LSAD group) or no lumbar drain insertion (no LSAD group). An otolaryngologist independently determined the occurrence of an intraoperative CSF leak. Extent of tumor resection was determined by volumetric analysis of postoperative magnetic resonance images in patients with nonfunctional tumors or functional adenomas with a large suprasellar component. Results: Sixty patients were eligible for inclusion, of which 30 were assigned to the LSAD group and 30 to the no LSAD group. There were no statistically significant differences in patient demographics, tumor pathology, or radiology between the two groups. The LSAD catheter was successfully inserted in all patients in the LSAD group. Intraoperative CSF drainage significantly reduced the incidence of CSF leak from 46.7% in the no LSAD group to 3.3% in the LSAD group (P < 0.001). However, there were no statistically significant differences in the incidence of postoperative CSF rhinorrhea between the two groups. There were no major catheter-related complications. There was no statistically significant difference in the extent of resection between the two groups. Conclusions: Controlled intraoperative CSF drainage significantly reduces the incidence of intraoperative CSF leakage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas.
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CASE REPORT Top

Facial nerve schwannomas: A case series with an analysis of imaging findings p. 139
Shambhu K Sah, You You Guo, Nirajan Mahaseth, Yanlin Chen, Silin Du, Yongmei Li
DOI:10.4103/0028-3886.222870  PMID:29322973
Facial nerve schwannomas (FNSs) are rare benign tumors arising from the Schwann cells of the sheath of the facial nerve. These tumors may arise anywhere along the course of the facial nerve. Owing to their rarity and nonspecific clinical and radiological presentations, the preoperative diagnosis of FNSs is exceedingly difficult. In this study, we present four cases of histopathologically proven extratemporal schwannomas and a solitary case of intratemporal schwannoma. The purpose of this study was mainly focused on analyzing the imaging findings of extratemporal and intratemporal schwannomas in an effort to better characterize these lesions preoperatively. An early diagnosis of FNSs is helpful for the management and rehabilitation of these cases.
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COMMENTARY Top

Facial schwannomas: Diagnosis and surgical perspectives p. 144
Narayan Jayashankar, Suresh Sankhla
DOI:10.4103/0028-3886.222821  PMID:29322974
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CASE REPORT Top

Atlantoaxial instability associated with pan cervical vertebral fusion: Report on management of 4 cases p. 147
Abhidha Shah, Amol Kaswa, Sonal Jain, Atul Goel
DOI:10.4103/0028-3886.222853  PMID:29322975
We report a series of four patients aged 4, 5, 14, and 27 years (1 male and 3 female patients) with severe shortening of the neck and torticollis since early childhood who presented with complaint of pain in the nape of neck as the primary symptom. All four patients had relatively well preserved neurological functions. One patient had vertical mobile and reducible atlantoaxial dislocation, and 3 patients had anteroposterior mobile and reducible dislocation. There was assimilation of atlas in 1 patient. The arch of atlas was bifid in 3 patients. Two patients underwent atlantoaxial fixation. Both the patients were relieved of neck pain after their surgery. The potential surgical difficulties due to the presence of severe shortening of neck height and marginal presenting symptoms favored conservative observation in the other 2 patients. Follow-up ranged from 6 to 84 months. All patients are functionally and socially active.
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COMMENTARY Top

“Fusing the appropriate” in complex craniovertebral junction anomalies p. 151
Pravin Salunke
DOI:10.4103/0028-3886.222858  PMID:29322976
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The chicken or the egg - Pancervical fusion with atlantoaxial dislocation p. 153
Sandip Chatterjee
DOI:10.4103/0028-3886.222809  PMID:29322977
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NI FEATURE: PATHOLOGY PANORAMA - ORIGINAL ARTICLE Top

Chromosomal aberrations in chordoid meningioma – An analysis p. 156
Harsha Sugur, Arun H Shastry, Nishant Sadashiva, Dwarakanath Srinivas, Vani Santosh, Sampath Somanna
DOI:10.4103/0028-3886.222808  PMID:29322978
Introduction: Chordoid meningiomas (CMs) are a rare subgroup of tumors, accounting for approximately 0.5% of all meningiomas. These tumors correspond to World Health Organization (WHO) Grade II lesions and behave aggressively, with an increased likelihood of recurrence. There are only two studies that have described the genetic alterations in CMs. While a majority of meningiomas are known to have deletion at many chromosomal loci such as 22q, 18p, 14q, and 1p, which are found to be associated with initiation, progression, and malignancy of these tumors, these have not yet been studied in CMs. Thus, our aim was to evaluate the status of these four chromosomal aberrations in CMs and correlate the findings with the clinical outcome of patients. Materials and Methods: A total of 15 cases of CM operated over a period of 12 years from 2001 to 2013 were analyzed. The archival paraffin blocks were retrieved and sections were subjected to locus-specific fluorescent in situ hybridization (FISH) using 22q12.2, 18p11.3, 14q32.2, and 1p32.3 probes. Immunohistochemistry (IHC) was done on all cases using MIB-1, vimentin, glial fibrillary acidic protein (GFAP), and epithelial membrane antigen (EMA) antibodies. Results: All cases had characteristic features of CM, and were positive for EMA and vimentin and negative for GFAP. The mean labeling index for MIB-1 was 2.7 ± 0.8%. Of the 15 cases, 5 cases showed recurrence with a median follow-up period of 28 months. Patients who underwent Simpson's grade I excision did not show any relapse of the tumor. Of the 5 recurrent cases, 4 had complete deletion of all four chromosomal loci. Among the 10 nonrecurrent cases, 9 (90%) showed either partial deletion or an intact status. Conclusions: This is the first study to evaluate the combined chromosomal status of 22q, 18p, 14q, and 1p in CMs. Our study shows that there was a higher propensity of recurrence in tumors, even with complete excision, with complete deletion in all four chromosomal loci.
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COMMENTARY Top

Meningiomas: A continuum of progress in risk-stratification p. 161
Geeta Chacko
DOI:10.4103/0028-3886.222841  PMID:29322979
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NI FEATURE: THE QUEST - COMMENTARY Top

Neurology of renal disorders p. 163
Pushpendra N Renjen, Dinesh Chaudhari, Gaurav Sagar, Sanjiv Jasuja
DOI:10.4103/0028-3886.222815  PMID:29322980
Chronic kidney disease (CKD) is a critical and rapidly growing global health problem. Neurological complications occur in almost all patients with severe CKD, potentially affecting all levels of the nervous system, from the central nervous system (CNS) through to the peripheral nervous system (PNS). Patients with CKD exhibit a high incidence of symptomatic and occult cerebrovascular diseases, associated tremendously high levels of inflammatory factors and homocysteine, as well as anemia, hypertension, and diabetes. As these risk factors overshadow aging and nonvascular factors, CKD patients represent a potential model of accelerated vascular cognitive impairment. In this article, the disease-related and treatment-related neurological complications of renal disorders will be reviewed.
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NI FEATURE: CENTS (CONCEPTS, ERGONOMICS, NUANCES, THERBLIGS, SHORTCOMINGS) - COMMENTARY Top

Expansile manubriotomy for ventral cervicothoracic junction disease p. 168
Sudhir Dubey, Amit Agrawal
DOI:10.4103/0028-3886.222851  PMID:29322981
Cervicothoracic junction can be approached anteriorly, anterolaterally, posterolaterally, and posteriorly. The anterior approaches in this region best address the ventral vertebral body disease but may cause significant morbidity. Twelve patients with their disease process located ventral to the spinal cord in the cervicothoracic junction underwent expansile manubriotomy and corpectomy. Eleven patients underwent fusion. One patient underwent an oblique corpectomy. All patients had their disease process from T1 to T3 vertebral levels. After dissection, the manubrium was cut open in the midline until the sternal notch. Further manubrial cut was extended laterally to just below the second rib. A self-retaining retractor was placed and opened. This gave an additional exposure of 10 cm from the midline towards the right side. It also opened the thoracic inlet. The superior mediastinum was dissected. Brachiocephalic vessels were looped down and a plane was made between the carotid artery laterally, and the trachea and esophagus medially. The prevertebral fascia was reached and opened to access the vertebral body. The procedure could be carried out successfully in all the patients. A patient with uncontrolled diabetes mellitus and end-stage renal disease with pyogenic epidural abscess succumbed to her illness after 3 weeks. Expansile manubriotomy is technically feasible, less invasive, and least morbid of all the anterior approaches for accessing the anteriorly located disease process above the T4 vertebral level.
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COMMENTARY Top

Expansile manubriotomy versus standard approach for accessing ventral cervicothoracic junction disease: Methods to improve the decision-making process p. 174
Manjunath Prasad, Nitin Mukerji
DOI:10.4103/0028-3886.222832  PMID:29322982
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NI FEATURE: NORMATIVE DATA - ORIGINAL ARTICLE Top

Auditory P300 event-related potential: Normative data in the Indian population p. 176
NA Uvais, S Haque Nizamie, Basudeb Das, Samir K Praharaj, Mohammad Zia Ul Haq Katshu
DOI:10.4103/0028-3886.222874  PMID:29322983
Objective: To generate the normative data of auditory P300 event-related potential for various age groups in the Indian population. Materials and Methods: Auditory P300 event-related potentials, using the oddball paradigm, of healthy control participants in studies carried out at our institute were included to generate normative data in the age range of 10–50 years. The amplitude and latency of P300 for Fz, Cz, and Pz were selected for analysis. Results: For P300 amplitude, overall multivariate analysis of variance (MANOVA) was significant [Pillai's Trace F (9/453) = 3.46, P < 0.001]. Follow-up ANOVA showed significant difference across age groups at Fz, Cz, and Pz. For P300 latency, there was a trend towards significance for overall MANOVA [Pillai's Trace F (9/453) = 1.68, P = 0.09]. Follow-up ANOVA showed a trend towards significant difference across age groups at Fz only. Conclusion: Our study generated a P300 amplitude and frequency normative database at Fz, Cz, and Pz, which will serve as a reference for future studies attempting to define P300 abnormalities in various psychiatric disorders in Indian population.
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NI FEATURE: TECHNOLOGICAL INNOVATIONS - COMMENTARY Top

A device for three-dimensional quantitative assessment and alignment of C1-2 vertebrae during posterior distraction and fusion technique for atlantoaxial dislocation and/or basilar invagination p. 181
PB Karthik, Jayesh Sardhara, Nachiketa Tiwari, Sanjay Behari
DOI:10.4103/0028-3886.222847  PMID:29322984
The most common type of congenital C1-2 dislocation is a combined type in which atlanto-axial dislocation (AAD) and basilar invagination (BI) are often associated with a rotational dislocation and coronal tilt. An optimal surgical treatment involves reduction of AAD and BI with simultaneous correction of the rotation and coronal tilt to achieve an optimal cervical canal decompression, sagittal and coronal realignment and bony fusion. The most acceptable technique to facilitate this correction is the C1-C2 distraction technique, which is accomplished by the manual joint manipulation. In this study, the authors describe an instrument that accomplishes distraction of the C12 joint space along with its quantitative assessment, permits the easy installation of a joint spacer without damage to the articular surfaces, brings about reduction of AAD and BI, while simultaneously also helping in the correction of the coexisting coronal tilt and rotational dislocation. This distractor not only achieves a multi-planar three-dimensional correction of the displacements at the C1-2 vertebral level, but may be used for the quantitative assessment of the correction and is compatible with the related surgical instruments of all standard companies utilized in this operative procedure.
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NI FEATURE: CITADELS SCULPTING FUTURE - COMMENTARY Top

PGIMER, Chandigarh: A temple of holistic Neurology Highly accessed article p. 188
Vivek Lal, Manoj K Goyal
DOI:10.4103/0028-3886.222812  PMID:29322985
History helps us to become better students, judge wisely, understand change, and most importantly, it tells us who we are. It helps us to understand what happened, why it happened and what its ramifications are. Winston Churchill once said: “Study history, study history. In history lie all the secrets of statecraft.” Here, we take this opportunity to pay our gratitude to our esteemed teachers who worked relentlessly for uplifting of the department of Neurology, PGIMER, Chandigarh; and, narrate chronicles of all those people who made this department reach the heights where it stands today.
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NI FEATURE: THE FOURTH DIMENSION - COMMENTARY Top

A summary of some of the recently published, seminal papers in neurosciences p. 204
Mazda K Turel, Manjul Tripathi, Ravi Yadav, Srijitesh P R, Aastha Takkar, Sahil Mehta, Chirag K Ahuja, Anant Mehrotra, Kuntal K Das
DOI:10.4103/0028-3886.222845  PMID:29322986
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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - ORIGINAL ARTICLE Top

Complications related to sitting position during Pediatric Neurosurgery: An institutional experience and review of literature p. 217
Priyanka Gupta, Girija P Rath, Hemanshu Prabhakar, Parmod K Bithal
DOI:10.4103/0028-3886.222852  PMID:29322987
Background: Sitting position is preferred during posterior fossa surgeries as it provides better anatomical orientation and a clear surgical field. However, its use has been declining due to its propensity to cause life-threatening complications. This study was carried out to analyze the perioperative complications and postoperative course of children who underwent neurosurgery in sitting position. Materials and Methods: Medical records of 97 children (<18 years) who underwent neurosurgery in sitting position over a period of 12 years, were retrospectively analyzed. Data pertaining to the perioperative course such as demographics, hemodynamic changes, various complications, duration of intensive care unit (ICU) and hospital stay, and neurological status at discharge were recorded. Statistical analysis was done by chi-square and Mann–Whitney test, and a P value <0.05 was considered as significant. Results: The median age of these children was 12 (3–18) years. Hemodynamic instability was observed in 12 (12.3%) children. A total of 38 episodes of venous air embolism (VAE) were encountered in 21 (21.6%) children; nine experienced multiple episodes. VAE was associated with hypotension in five (23.8%) and desaturation in four (19.1%) children. Six children presented with postoperative tension pneumocephalus; three were managed with twist drill burr-hole evacuation. Brainstem handling was the most common indication (42.5%) for the requirement of elective postoperative ventilation. The duration of ICU and hospital stays were comparable among the children who experienced VAE and those who did not (P > 0.05). Neurological status at discharge was also comparable between these two groups (P = 0.83). Conclusions: This study observed a lesser incidence of VAE and associated complications. Tension pneumocephalus was managed successfully without any adverse outcome. Hence, it is believed that with meticulous anesthetic and surgical techniques, sitting position can safely be practiced in children undergoing neurosurgery.
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COMMENTARY Top

The sitting position for Neurosurgery: A bane or a boon p. 223
Shashi Srivastava
DOI:10.4103/0028-3886.222830  PMID:29322988
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LETTERS TO EDITOR Top

Association of hemolysis, elevated liver enzymes, low platelets syndrome with posterior reversible encephalopathy and intracranial hypotension p. 226
Zahide Yılmaz, Nuray Voyvoda, Pinar Bekdik Şirinocak, Hasan Terzi
DOI:10.4103/0028-3886.222856  PMID:29322989
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Carotid stump syndrome treated with endovascular coiling: A rare cause of stroke in young patients p. 228
Anshu Mahajan, Biplab Das, Gaurav Goel, Arun Garg, Harsh Sapra
DOI:10.4103/0028-3886.222861  PMID:29322990
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Sporadic spinocerebellar ataxia, type 5: First report from India p. 230
Rohan Mahale, Anish Mehta, Sridevi Hegde, Kiran Buddaraju, Mahendra Javali, Purushottam T Acharya, Rangasetty Srinivasa
DOI:10.4103/0028-3886.222857  PMID:29322991
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CARASIL, a rare genetic cause of stroke in the young p. 232
Navalli Devaraddi, G Jayalakshmi, Narayan R Mutalik
DOI:10.4103/0028-3886.222859  PMID:29322992
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Sertraline-induced reversible myopathy with rhabdomyolysis and trismus p. 235
Boby V Maramattom, Joe Thomas, Nanda Kachhare
DOI:10.4103/0028-3886.222860  PMID:29322993
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Ictal bradycardia: A missed etiology for intraoperative bradycardia p. 237
Unnikrishnan Prathapadas, Smita Vimala, Karen Ruby Lionel, Ajay Prasad Hrishi
DOI:10.4103/0028-3886.222862  PMID:29322994
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Familial amyloid polyneuropathy due to p.ALA140 SER mutation p. 238
Azize Esra Gürsoy, Gözde Yeşil, Selma Sonmez Ergun, Zeynep Tosuner
DOI:10.4103/0028-3886.222879  PMID:29322995
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Disseminated cysticercosis presenting as status epilepticus, rhabdomyolysis, and acute kidney injury: An unreported complication p. 241
Sanjay Vikrant, Balbir S Verma
DOI:10.4103/0028-3886.222855  PMID:29322996
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Lumber nerve root cavernous angioma p. 244
Shu-xin Sun, Ji Zhang, Ji-cheng Sun, Zhi-jie Chen, Xiang-heng Zhang, Zheng-he Chen, Jing-xiu Huang, Yu Jiang, Yong-gao Mou, Zhong-ping Chen, Ke Sai
DOI:10.4103/0028-3886.222867  PMID:29322997
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Primary sphenoid wing meningioma in contiguity with a glioblastoma p. 245
Salman T Shaikh, Mihir D Chawda, Chandan B Mohanty, Chandrashekhar E Deopujari
DOI:10.4103/0028-3886.222854  PMID:29322998
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Sacral Ewing's tumor: Use of neoadjuvant chemotherapy for preoperative cytoreduction of the tumor p. 249
Venkata Ramakrishna Tukkapuram, Satish Rudrappa, Vijay Kumar Shabadi, Dheeraj Masapu, Sunil Kumar
DOI:10.4103/0028-3886.222848  PMID:29322999
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Primary diffuse leptomeningeal gliomatosis: A coveted diagnosis we think of less p. 252
Raja K Kutty, B Sunilkumar, Anilkumar Peethambaran, Balachandran G Krishna Nair, Sourabh K Jain, Shailesh Kumar
DOI:10.4103/0028-3886.222869  PMID:29323000
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Dirofilariasis mimicking an osteoma p. 255
M Sreekumar, Jayashree Goethe, Roshith H Chekkattu
DOI:10.4103/0028-3886.222868  PMID:29323001
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Trans-third ventricular approach to basilar top aneurysm p. 256
Shunsuke Nomura, Hiroshi Ujiie, Kouichi Kato, Takashi Higa, Chie Shinohara, Mineo Kawasaki
DOI:10.4103/0028-3886.222866  PMID:29323002
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Primary lymphoma of the radial nerve presenting as nerve sheath tumor p. 258
Jayapalan Jayendrapalan, Vengalathur G Ramesh, Kavindapadi V Karthikeyan, Subburayan Devi
DOI:10.4103/0028-3886.222865  PMID:29323003
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Middle meningeal arteriovenous fistula causing unilateral proptosis p. 260
Rajeev P Kamble, Vivek Gupta, Sunil K Gupta, N Khandelwal
DOI:10.4103/0028-3886.222864  PMID:29323004
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NEUROIMAGES Top

Nasu–Hakola Disease p. 263
Bedia Samanci, Çağri Ulukan, Tuncay Gündüz, Murat Kürtüncü, Mefkure Eraksoy
DOI:10.4103/0028-3886.222875  PMID:29323005
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Spastic paraparesis with basal ganglia changes: Infantile neuroaxonal dystrophy p. 264
Ananthanarayanan Kasinathan, Chirag K Ahuja, Pratibha Singhi
DOI:10.4103/0028-3886.222887  PMID:29323006
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Triad of gloom in a girl child: Aicardi syndrome p. 265
Lokesh Saini, Parag Shankarao Dekate, VS V Prasad, Dandu Ravi Varma
DOI:10.4103/0028-3886.222876  PMID:29323007
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Multiple extraneural metastases from a benign intracranial meningioma p. 266
Yaxiong Li, Fengshi Fan, Hongwu Qi
DOI:10.4103/0028-3886.222888  PMID:29323008
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Reversible symptoms present in a patient with Balo's concentric sclerosis p. 268
Edyta Dziadkowiak, Mieszko Zagrajek, Anna Zimny, Bogusław Paradowski
DOI:10.4103/0028-3886.222885  PMID:29323009
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Revisiting a historical phenomenon: Myodil droplets in the subarachnoid space p. 269
Gulhan Ertan, Sila Ulus, Serdar Baki Albayrak, Aysenur Cila
DOI:10.4103/0028-3886.222843  PMID:29323010
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Multiple cranial nerve enhancement as a rare presentation of secondary brain lymphoma p. 270
Farrokh Seilanian-Toosi, Majid Shams, Reza Akhavan, Bita Abbasi
DOI:10.4103/0028-3886.222884  PMID:29323011
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CORRESPONDENCE Top

Senior citizenship in neurosurgery p. 273
Sunil Pandya
DOI:10.4103/0028-3886.222816  PMID:29323012
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The Indo-US Collaborative Stroke Registry and infrastructure development project p. 276
Dheeraj Khurana, Jeyaraj Pandian, PN Sylaja, Subhash Kaul, MV Padma Srivastava, Suruchi Thakur, Deepti Arora, Tijy Thankachan, Aneesh B Singhal
DOI:10.4103/0028-3886.222871  PMID:29323013
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India and its potential for neuroinformatics p. 278
Vishal Bharmauria
DOI:10.4103/0028-3886.222814  PMID:29323014
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Anesthetic considerations for intraoperative neurophysiological monitoring in patients undergoing scoliosis surgery p. 279
Naveen Naik, Tanvir Samra
DOI:10.4103/0028-3886.222863  PMID:29323015
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Magnesium: Hope for prehospital care in intracranial hemorrhage p. 280
Adrija Hajra, Dhrubajyoti Bandyopadhyay, Shyamal K Hajra
DOI:10.4103/0028-3886.222878  PMID:29323016
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Authors' Reply: Magnesium supplementation in intracerebral hematoma: The hope and the hype! p. 282
Mukesh K Bhaskar, Bal Krishna Ojha, Rajesh Verma
DOI:10.4103/0028-3886.222840  PMID:29323017
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Arterial spin labeling p. 283
Ankit Balani, Seung Hong Choi, Chinky Chatur, Eun Jeong Lee
DOI:10.4103/0028-3886.222882  PMID:29323018
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Authors' Reply: Arterial spin labeling: Clarifying the apparent contradiction p. 284
Sona A Pungavkar, Rishi Awasthi
DOI:10.4103/0028-3886.222839  PMID:29323019
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Author's Reply: Arterial spin labeling p. 285
Neetu Soni
DOI:10.4103/0028-3886.222836  PMID:29323020
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Subgaleoatrial or subgaleopleural shunt? p. 285
Suryanarayanan Bhaskar, Mayank Garg
DOI:10.4103/0028-3886.222883  PMID:29323021
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Authors' Reply: In defence of subgaleoatrial shunt! p. 286
Ananth P Abraham, Edmond Jonathan Gandham, Krishna Prabhu, Ari G Chacko
DOI:10.4103/0028-3886.222837  PMID:29323022
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Visual outcome following microscopic transsphenoidal surgery for pituitary adenomas: A few concerns p. 287
Mehmet Turgut
DOI:10.4103/0028-3886.222886  PMID:29323023
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Authors' Reply: How long can the optic nerve defy compression? p. 288
Ashutosh Rai, Pinaki Dutta, Sivashanmugam Dhandapani
DOI:10.4103/0028-3886.222838  PMID:29323024
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NI FEATURE - BOOKS FROM MY SHELF - COMMENTARY Top

Russel Brain: Some reflections on genius and other essays p. 290
Sunil Pandya
DOI:10.4103/0028-3886.222818  
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BOOK REVIEW Top

Past Presidents: 2000-2016: Neurological Society of India p. 294
S Kalyanaraman
DOI:10.4103/0028-3886.222817  
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Online since 20th March '04
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