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Coverpage
May-June 2019
Volume 67 | Issue 3
Page Nos. 631-962

Online since Tuesday, July 23, 2019

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NI FEATURE: THE FIRST IMPRESSION - COMMENTARY  

The cover page Highly accessed article p. 631

DOI:10.4103/0028-3886.263265  PMID:31347518
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EDITORIAL Top

Discovering what I never knew, I never knew… Highly accessed article p. 632
Sanjay Behari
DOI:10.4103/0028-3886.263259  PMID:31347519
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NI FEATURE: TIMELESS REVERBERATIONS - COMMENTARY Top

The saga of the 'Chhabra' shunt Highly accessed article p. 635
Devendra K Chhabra
DOI:10.4103/0028-3886.263258  PMID:31347520
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NI FEATURE: JOURNEY THROUGH THE EONS - COMMENTARY Top

Cranial trepanation in ancient India p. 639
D Raja Reddy, T Satyamurthy
DOI:10.4103/0028-3886.263227  PMID:31347521
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Autopsy study of a case of skeletal fluorosis (1977) p. 643
Madakasira Bheemarao Pranesh, G Arjundas, S Kalyanaraman, R Sarasa Bharati
DOI:10.4103/0028-3886.263254  PMID:31347522
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NI FEATURE: THE EDITORIAL DEBATE I-- PROS AND CONS Top

Redefining neurology care at outpatient services of tertiary hospitals: Case for paradigm shift from tertiary to peripheral centers p. 648
M Gourie-Devi
DOI:10.4103/0028-3886.263257  PMID:31347523
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Service delivery in Neurology: Jack of all trades? p. 650
Madhu Nagappa, Sanjib Sinha
DOI:10.4103/0028-3886.263226  PMID:31347524
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NI FEATURE: THE EDITORIAL DEBATE II-- PROS AND CONS Top

Hyperbaric oxygen therapy in ischemic stroke management: Standardized consensus-based therapeutic protocol p. 653
Guru Dutta Satyarthee
DOI:10.4103/0028-3886.263205  PMID:31347525
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Hyperbaric oxygen therapy in neurological diseases p. 655
Faiz M H Ahmad, Charulata S Sankhla
DOI:10.4103/0028-3886.263204  PMID:31347526
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NI FEATURE: THE EDITORIAL DEBATE III-- PROS AND CONS Top

Restless leg syndrome in patients with liver cirrhosis: Waiting for the shoe to drop p. 657
Smriti Bose, Saiju Jacob
DOI:10.4103/0028-3886.263218  PMID:31347527
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Identifying risk factors for restless leg syndrome p. 660
Ashwin Kumar Panda, Sanjay Pandey
DOI:10.4103/0028-3886.263223  PMID:31347528
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NI FEATURE: THE EDITORIAL DEBATE IV-- PROS AND CONS Top

Chiari I malformation: Surgical considerations p. 662
Aaron Mohanty
DOI:10.4103/0028-3886.263222  PMID:31347529
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Cerebrospinal fluid studies in Chiari I malformation: Do we go with the flow? p. 664
Deepak Agrawal
DOI:10.4103/0028-3886.263256  PMID:31347530
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NI FEATURE: THE EDITORIAL DEBATE V-- PROS AND CONS Top

Flow diverters: Hope and hype p. 665
Paritosh Pandey, Ullas V Acharya
DOI:10.4103/0028-3886.263263  PMID:31347531
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Treatment of a complex intracranial aneurysm with a flow diverter p. 667
Vikas Gupta
DOI:10.4103/0028-3886.263266  PMID:31347532
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GUEST COMMENTARY Top

Approach to non-compressive back pain p. 671
Latika Gupta, Abhishek Zanwar, Durga Prasanna Misra, Vikas Agarwal
DOI:10.4103/0028-3886.263183  PMID:31347533
Back pain is the most common manifestation among rheumatologic conditions, with an 80% lifetime risk of development in each individual. Most patients have no specific identifiable etiology. Low back pain has always been an important public health problem, having a significant impact on the working class of the population. Hence, it is pertinent for the physician to be aware of the various causes of back pain and identify promptly the various red flags and poor prognostic markers. Lamentably, widespread access to technology and fear of litigation in this era of evidence based medicine has made us slaves of medical imagery in the context of back pain. It is crucial to recognize the teachings of ancient medicine, where keen observation, a detailed history-taking and a meticulous examination were the mainstay of good decision-making. Its precise management can help in obviating debility, preventing the work absenteeism, and consequently, decreasing health-care expenses.
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Brachial plexus injury and resting-state fMRI: Need for consensus p. 679
Divesh Thaploo, Dhananjaya I Bhat, Madhav V Kulkarni, Bhagavatula Indira Devi
DOI:10.4103/0028-3886.263178  PMID:31347534
Objective: The purpose of the study is to conduct the systematic review of literature available on resting-state functional MRI (fMRI) and brachial plexus injury. Methods: We reviewed all the literature that are available on PubMed; keywords used were resting state, brachial plexus injury, and functional imaging. The reference papers listed were also reviewed. The research items were restricted to publications in English. Some papers have also incorporated studies such as task-based fMRI and transcranial magnetic stimulation (TMS), but only resting-state studies were included for this review. Results: A total of 13 papers were identified, and only 10 were reviewed based on the criteria. The reviewed papers were further categorized on the basis of whether or not any surgical intervention was done. Seven papers have surgical management such as contralateral cervical 7 (CC7) neurotisation or intercostal nerve (ICN) musculocutaneous nerve (MCN) neurotisation. Conclusion: There is conclusive evidence showing that there is cortical reorganisation following brachial plexus injury in both birth and traumatic cases. The changes are restricted to some of the resting-state networks only (default mode network, sensorimotor network, in particular). However, no study till date has focused on a far more longitudinal approach at studying these changes. It will be interesting to see the exact time and effect of these changes.
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Cellular changes in the nervous system when exposed to gravitational variation p. 684
Vivek Mann, Alamelu Sundaresan, Maitreyi Chaganti
DOI:10.4103/0028-3886.263169  PMID:31347535
This review discusses the past and recent findings on how changes in gravity affect cellular and subcellular parameters of the human nervous system and the implementation of cell and tissue models of nervous tissue on space biology. In order to prepare for long duration space exploration, a focus on space life sciences research is critical. Such research not only improves our knowledge of the basic biological processes but also elucidates the mechanisms and treatment of various earthly medical conditions. However, the study of living organisms in space poses many challenges that may be negligible or nonexistent in ground-based research. In recent years, with an increase in the number of spaceflights, extended periods of stay of astronauts on the International Space station and the imminent possibility of future long term deep space exploration missions, there is a great deal of attention focused on the effects induced by altered gravitation on the human body, and in particular, on bone, skeletal muscle, immunity and brain function. The aim of this review is to collate, encapsulate and examine the effects of altered gravity on neuronal cell structure and function that have been established from data obtained during experiments performed in real microgravity and simulated microgravity like conditions.
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REVIEW ARTICLE Top

Etiologies of simultaneous cerebral infarcts in multiple arterial territories: A simple literature-based pooled analysis p. 692
Tauseef Akhtar, Shima Shahjouei, Ramin Zand
DOI:10.4103/0028-3886.263244  PMID:31347536
Introduction: Acute multiple infarcts in multiple cerebral circulations are thought to suggest the presence of cardioembolic sources. However, several studies have shown other etiologies for simultaneous cerebral infarcts in multiple arterial territories. Methods: We conducted a systematic review of the literature using PubMed, Scopus, Embase, Clinicaltrial.gov, WHO International Clinical Trials Registry Platform (ICTRP), and Cochrane library. Studies reporting multiple acute strokes in more than one arterial territory based on diffusion-weighted imaging (DWI) findings were reviewed and included. Studies were excluded if they had limited inclusion criteria, performed limited subgroup analysis, did not use diffusion weighted imaging (DWI), and were not published in English. Results: Out of 15056 stroke patients from 21 studies included in this study, 1914 (13%) patients had acute multiple infarcts in multiple cerebral circulations. One hundred and ninety-nine patients were excluded as their workup and diagnosis were not reported. Out of 1715 patients, 472 (27.6%) patients had an undetermined etiology. Cardioembolism was the most common cause of stroke in multiple arterial territories [37.2%, 95% confidence interval (CI): 36–40%] followed by large artery atherosclerosis including aortic arch atheroma (25.7%, 95% CI: 21–25%). Hematological disorders were found to be the cause of cerebral infarcts in 36 (2.1%, 95% CI: 2–4%) patients. Other etiologies for stroke in multiple arterial territories were small vessel pathologies and intracranial small vessel atherosclerosis (1.8%), inflammatory disorders such as vasculitis and infection (0.2%), and iatrogenic causes (0.1%). Conclusion: Acute multiple infarcts in multiple cerebral circulations occur among 13% of stroke patients. Although cardioembolism is the most common cause, there are several other etiologies that require a different workup and secondary prevention strategy.
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COMMENTARY Top

Importance of etiology-based workup and diagnosis in acute multiple infarcts in multiple cerebral circulations p. 696
Man Mohan Mehndiratta, Abhijit Das
DOI:10.4103/0028-3886.263225  PMID:31347537
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REVIEW ARTICLE Top

The role of mifepristone in the management of meningiomas: A systematic review of literature p. 698
Ravi Sharma, Kanwaljeet Garg, Varidh Katiyar, Vivek Tandon, Deepak Agarwal, Manmohan Singh, Sarat P Chandra, Ashish Suri, Shashank S Kale, Ashok K Mahapatra
DOI:10.4103/0028-3886.263232  PMID:31347538
Background: Surgery is challenging in patients with multiple or recurrent meningiomas. With the discovery of progesterone receptors (PR) on meningioma cells, there is an increased interest in the hormonal treatment using mifepristone, a PR blocker. Materials and Methods: A systematic review of clinical studies evaluating the efficacy and side effects of mifepristone in recurrent, unresectable, or multiple meningiomas was done. The primary outcome of this review was to study the efficacy in terms of tumor regression and clinical symptoms. Secondarily, we also reviewed the frequency and severity of different side effects reported by various studies. Results: A total of 7 studies, including one Phase III randomized controlled trial, were found relevant to the topic. Though a few studies showed some response in terms of clinical improvement and tumor size reduction, the response was either minimal or temporary. The only subset showing a good response was the “diffuse meningiomatosis” group. None of the studies evaluated the relation of the PR isoform with mifepristone responsiveness. However, long-term mifepristone administration was well tolerated in most of the patients. Conclusions: Use of mifepristone as a hormonal agent for meningiomas has produced mixed results. We propose that the possible mechanisms of action of mifepristone on meningioma cells must be studied in further detail by in-vitro studies. This may help in the identification of a mifepristone responsive subset of meningioma. This must be followed up with appropriately designed clinical studies with detailed baseline evaluation and standardized clinical and radiological follow-up.
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COMMENTARY Top

Antiprogesterone therapy in recurrent meningiomas: A disappointing end to four decades of research? p. 706
Shireen R Chacko, Ari G Chacko
DOI:10.4103/0028-3886.263217  PMID:31347539
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ORIGINAL ARTICLES Top

Outpatient burden of neurological disorders: A prospective evaluation of 1500 patients p. 708
Raghunandan Nadig, Uday S Namapally, Gosala Raja K Sarma, Thomas Mathew
DOI:10.4103/0028-3886.263249  PMID:31347540
Introduction: Neurologists spend a significant amount of time in providing out-patient services. No comprehensive studies are there from India which have looked into the real burden of these common disorders in the out-patient population. This study was done to get a clear data on the burden of these disorders. Objectives: The aim of this study was to determine the incidence of various neurological disorders in the out-patient department services. Methods: The study was conducted in a tertiary care medical center. Clinical data of 1500 consecutive out-patients who attended the out-patient services were collected over a period of 2 months from December 2014 to January 2015. All patients were evaluated by a resident trainee and a senior consultant. Necessary investigations were done wherever applicable. The most probable clinical diagnosis was made after a detailed history and a thorough neurological evaluation. Age, sex, and the diagnosis were recorded and entered in an Excel sheet. Appropriate statistical methods were used for descriptive analysis. Results: Out of the 1500 patients, 766 were male and 734 were female. The most common complaints with which patients came to the outpatient services were headaches (28.6%), muscular and radicular pains (24.7%), seizures (12.7%) and hemiparesis/monoparesis (11.9%). Movement disorders, neuropathies, and nerve palsies were also present in a significant number of patients. Conclusion: The most common neurological disorders in the outpatient services are headache, neck pain, backache, fibromyalgia, stroke, epilepsy, and neuropathies. Newly joined residents should be well trained to efficiently manage these common outpatient disorders.
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The spectrum of deletions and duplications in the dystrophin (DMD) gene in a cohort of patients with Duchenne muscular dystrophy in Sri Lanka p. 714
Nilam Thakur, Gayan Abeysekera, Jithangi Wanigasinghe, Vajira H W Dissanayake
DOI:10.4103/0028-3886.263235  PMID:31347541
Background: Duchenne muscular dystrophy (DMD), which affects 1 in 3500 newborn males, is the most common fatal neurodegenerative disorder in children. Deletions and duplications in the DMD gene are the most common underlying etiological factors. Materials and Methods: Fifty consecutive children with DMD were screened for deletions and duplications in the DMD gene using Multiple Ligation-binding Probe Amplification (MLPA). Results: Forty (80%) children had deletions and 4 (8%) had duplications. Single exon involvement was seen in 8 (16%), two exon involvement was seen in 3 (6%), three exon involvement was seen in 6 (12%) children, and four exon involvement in 1 (2%) child. More than four exon involvement were seen in 26 (52%) children. The most common deletion was the deletion spanning from exon 45 to exon 52, which was seen in 6 (12%) children. The next common exon deletion was single exon 45 deletion seen in 4 (8%) children. The most frequent mutant region fell within exons 45 to 55 (52%) followed by within exons 21 to 44 (26%) and exons 1 to 20 (26%). The least common region fell within exons 56 to 79 (4%). Conclusion: The deletion/duplication pattern seen in this cohort of children with DMD was similar to that reported among other global populations.
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COMMENTARY Top

Duchenne muscular dystrophy: Still an incurable disease p. 717
Harneet Arora
DOI:10.4103/0028-3886.263203  PMID:31347542
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ORIGINAL ARTICLES Top

Guillain–Barre syndrome in North Indian children: Clinical and serial electrophysiological features p. 724
Sandeep Yadav, Puneet Jain, Suvasini Sharma, Virendra Kumar, Satinder Aneja
DOI:10.4103/0028-3886.263191  PMID:31347543
Background: Guillain–Barre syndrome (GBS) is a common acquired polyneuropathy in children. Aim: To describe the clinical and serial electrophysiological features along with short-term outcomes of children with GBS in north India. Setting and Design: This was a prospective study conducted at a tertiary care pediatric hospital in north India. Materials and Methods: Consecutive children, aged 2 to 18 years, with GBS, presenting within 4-weeks of onset of weakness, diagnosed on clinical and/or electrophysiological grounds, were enrolled. The enrolled children underwent a detailed clinical-assessment followed by nerve conduction studies. Repeat nerve conduction studies were performed after 2-weeks of the first study to determine changes in the electrophysiological subtype. The patients were followed up for 3 months. Results: Thirty-six children were studied. The mean age at presentation was 5.1 years [standard deviation (SD): 2.1]. The mean medical research council (MRC)-sum-score at admission was 24.1 (SD: 10.4). Thirty-three children (91%) had loss of ambulation, 24 (66%) had cranial nerve involvement, and 6 (16.6%) required ventilation. At presentation, 20 had acute motor axonal neuropathy (AMAN), 13 had acute inflammatory demyelinating polyneuropathy (AIDP), 2 had in-excitable nerves, and 1 had normal findings. Four children, initially diagnosed as AIDP, had AMAN with reversible conduction failure on the repeat study. The final classification was AMAN in 25 (69.4%; 95% confidence interval (CI), 51.9–83.7%) and AIDP in 9 children (25%; 95% CI, 12.1–42.2%). Only one patient was nonambulatory at a 3-month follow-up (n = 32). The Erasmus GBS outcome score was 2 in 2 (5.6%), 3 in 5 (13.9%), 4 in 26 (72.2%), and 5 in 3 (8.3%) patients. Conclusions: The serial electrophysiological studies were helpful in establishing the final correct diagnosis.
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Hyperbaric oxygen therapy in patients with hypoxic ischemic encephalopathy p. 728
Ravi Sankaran, Kurupath Radhakrishnan, KR Sundaram
DOI:10.4103/0028-3886.263236  PMID:31347544
Background and Aim: To assess the efficacy of hyperbaric oxygen therapy (HBOT) in patients with hypoxic ischemic encephalopathy (HIE). Design: Non-randomized case-control observational study. Setting: Tertiary level neurorehabilitation unit. Population: Twenty-five patients with HIE seen between 1 to 12 months after the injury and having a coma recovery scale-revised (CRS-R) score less than 7 at entry were recruited. Methods: Out of the patients who received HBOT, 20 received 20 sessions of HBOT at two absolute atmosphere pressure (ATA), and two received 60 sessions at 2 ATA over three different treatment intervals. We compared the outcomes between cases (who received HBOT) and controls (who did not receive HBOT).Cases and controls were allocated to three groups based on the time interval after injury following which they were recruited to the study: 1–3 months (9 cases and 16 controls), 4–8 months (9 cases and 9 controls) and 9–12 months (8 cases and 3 controls). Outcome Measures: CRS-R, Karnofsky performance scale, and change in disorder of consciousness (DOC) at admission and discharge were assessed. Results: We observed a significant difference in CRS-R favoring the HBOT group at time intervals of 1–3 and 4–8 months. More patients in the HBOT group improved in DOC than the control group. Conclusions: HBOT given in the first nine months post-HIE can result in a better recovery and functional outcome.
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Liver disease severity is poorly related to the presence of restless leg syndrome in patients with cirrhosis p. 732
Vijay Kumar Halkurike-Jayadevappa, Amit Goel, Vimal Kumar Paliwal, Praveer Rai, Rakesh Aggarwal
DOI:10.4103/0028-3886.263171  PMID:31347545
Context: Restless leg syndrome (RLS) has been reported to be common in patients with cirrhosis. The relation of RLS with severity of liver disease is, however, unclear. Aim: We studied the association between occurrence of RLS and severity of cirrhosis. Setting and Design: Single centre, prospective, observational study. Materials and Methods: Adult patients with cirrhosis and relatively stable clinical condition and no associated neurological condition were prospectively studied. Severity of liver disease was graded as Child-Turcotte-Pugh (CTP) class A, B or C; using Model for End-Stage Liver Disease (MELD) score; and as a binary variable (compensated or decompensated disease). Each subject underwent an initial screening for RLS, followed by a re-evaluation by an independent neurologist to confirm the diagnosis, using the International RLS Diagnostic Criteria. In patients with RLS, its severity was assessed using a validated Hindi translation of the International RLS severity (IRLS) scoring system. Statistical Analysis Used: Data for categorical variables were expressed as proportions and compared using chi-squared test, and those for numerical variables were expressed as median and range, and compared using Wilcoxon rank sum test. Results: Among the 356 patients with cirrhosis studied (median [range] age: 48 [18-83] years; 241 [67.7%] male; CTP A/163, B/172, C/21; MELD 11 [6-41]; decompensated 51.7%), 36 (10.1%) had RLS. RLS severity was mild (1), moderate (15), severe (19) or very severe (1). Compared to those without RLS, patient with RLS had a lower MELD score (9 [6-25] versus 11 [6-41], P = 0.04), and a comparable distribution of CTP classes and frequency of decompensated liver disease. The prevalence and severity of RLS were not different between those with compensated and those with decompensated cirrhosis. Conclusion: In the Indian population, RLS is common in patients with cirrhosis. Its occurrence did not show any increase with the severity of liver disease.
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Posttraumatic movement disorders: A clinical and imaging profile of 30 patients p. 738
Netravathi Manjunath, Ketan Jhunjhunwala, Bhagvatulla Indira Devi, Pramod Kumar Pal
DOI:10.4103/0028-3886.263212  PMID:31347546
Background: Posttraumatic movement disorders (PTMDs) are frequently associated with severe head injury. There are very few studies on the clinical phenomenology and radiological correlation of PTMD. Aims: To study the clinical phenomenology of patients with PTMD and correlate it with the site of lesion on brain imaging. Materials and Methods: This was a prospective study of patients with suspected PTMD. All of these patients underwent neurological evaluation to characterize the phenomenology and imaging, such as computed tomography/magnetic resonance imaging (CT/MRI), to localize the site of lesion. Results: The age of the patients was 32.6 ± 16.4 years and the age at onset was 29.1 ± 16.0 years. Right upper limb was the initial body part affected in 36.7% patients. Tremor (alone or with dystonia) was the most common movement disorder (MD; 44.7%) followed by parkinsonism (17.2%), dystonia (13.8%), dystonia plus (dystonia associated with choreoathetosis: 10.3%), mixed MD (more than one MD: 10.3%), and myoclonus (3.4%). MRI was performed in 23 patients and the rest seven patients underwent CT brain. Normal MRI was observed in one patient with parkinsonism. Isolated, discrete lesions were found in six (27.3%) patients. Basal ganglia was the most common site of involvement (66.7%) followed by thalamus (16.7%) and brainstem (16.7%). Diffuse white matter involvement was the most common radiological lesion in patients with tremor. Conclusions: Our study describes the clinical phenomenology of patients with PTMDs and its radiological correlation. Tremor (alone or in combination with dystonia) was the most common MD observed and diffuse white matter lesions without affection of the basal ganglia was the most common site of lesion.
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Clinicoradiological study of adult Chiari malformation type 1 patients with emphasis on cerebrospinal fluid peak flow velocity at foramen magnum level p. 744
Abhishek Kumar, Samarendra Nath Ghosh, Shahid Iftekar Sadique
DOI:10.4103/0028-3886.263214  PMID:31347547
Introduction: The aim of this study was to determine the peak cerebrospinal fluid (CSF) flow velocity at the foramen magnum level in adult patients with Chiari type 1 malformation (CM1) and to determine the changes in velocity after posterior fossa decompression. An attempt was also made to determine whether or not CSF flow velocity can be a significant predictor in patients who need surgical intervention. Materials and Methods: A prospective longitudinal study was conducted in 32 symptomatic patients of CM1 treated with craniocervical decompression. Only adult patients with age ≥18 years and tonsillar herniation ≥5 mm were included in this study. Clinical and radiological assessment of patients with reference to their CSF flow characteristics was done both preoperatively and after suboccipital decompression. Results: Out of the 32 patients, 30 patients underwent a suboccipital decompression and two patients were treated with a venriculoperitoneal shunt procedure due to gross hydrocephalus. The preoperative mean tonsillar herniation was 10.4 ± 4.64 mm that reduced to 7.35 ± 3.10 mm in the follow up period. Postoperatively, there was also a substantial decrease in the peak CSF velocity at the foramen magnum along with reduction in the extent and size of the syrinx. These changes in CSF velocity correlated with a more normal appearing foramen magnum and an improvement in symptoms. Conclusion: Although the selection criteria for surgery are based mainly on the degree of tonsillar ectopia and presenting symptoms, the degree of CSF flow obstruction rather than the degree of tonsillar herniation can better select patients who are most responsive to surgery. An improved CSF velocity profile following surgery in such patients is a useful guide to anticipate a symptomatic improvement.
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A clinicopathologic study of surgically resected metastatic lesions of brain: A single institutional experience p. 749
Lavanya Sangati, Rajesh Alugolu, Suchanda Bhattacharjee, M Vijaya Saradhi, BP Sahu, Megha S Uppin, G Sadashivudu, Monica M Irukulla
DOI:10.4103/0028-3886.263251  PMID:31347548
Introduction: One of the most common tumors of the brain are metastatic lesions. They can present as cancer of unknown primary (CUP) and require careful determination of the site of origin of the primary. Histopathologic and immunohistochemical analysis helps to determine the primary site. Aim: To study the clinicopathological features of metastatic tumors of the brain. Materials and Methods: All cases of surgically resected brain metastasis (solid tumor metastasis) from January 2013 to April 2015 were included in the study. The clinical details including age, gender, clinical features, and location were taken from medical records. The histopathology slides were retrieved and reviewed along with clinical and imaging findings from medical records. Immunohistochemistry was performed wherever necessary. Results: Out of 1662 resected brain lesions during the study period, 69 accounted for central nervous system metastasis, of which 36 were brain metastasis and 33 were isolated spinal cord metastasis. In the 36 brain metastasis cases, 19 were cases with an unknown primary. Carcinoma lung (47.2%) was found to be the most common primary malignancy. Immunohistochemistry with cytokeratin (CK)7, CK20, and thyroid transcription factor (TTF) 1 as a primary panel in metastatic tumors is highly recommended. Conclusion: Metastatic tumors accounted for 4.1% of intracranial lesions. Histopathologic pattern and immunohistochemistry aid in the accurate diagnosis of the original site of malignancy.
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Brain metastasis: Momentum towards understanding the molecular milieu p. 755
Srinivas Chilukuri, Rakesh Jalali
DOI:10.4103/0028-3886.263255  PMID:31347549
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The predictors of recovery from diabetes mellitus following neurosurgical treatment of acromegaly: A prospective study over a decade p. 757
Pinaki Dutta, Abhishek Hajela, Prakamya Gupta, Ashutosh Rai, Naresh Sachdeva, Kanchan K Mukherjee, Ashis Pathak, Sivashanmugam Dhandapani
DOI:10.4103/0028-3886.263242  PMID:31347550
Objective: The natural history of glucose intolerance (GI) in patients with acromegaly undergoing surgical treatment has not been fully understood. This study was aimed to unravel the prevalence and predictors of recovery from GI in these patients in a prospective multivariate model. Materials and Methods: Patients with acromegaly treated between 2007 and 2016 were prospectively studied with respect to demographics, clinicoradiological features, comorbidities, and hormonal investigations before surgery and at regular follow-up. The independent predictors of recovery from diabetes were analyzed. Results: There were a total of 151 patients with active acromegaly included in the study. The median baseline growth hormone (GH) and insulin-like growth factor (IGF)-1 levels were 25 and 811 ng/mL, respectively. Diabetes mellitus (DM) and pre-diabetes were noted in 93 (61.6%) and 20 (13.2%) patients, respectively. Following surgical treatment, the median HbA1c decreased significantly from 6.4% to 5.5% (P < 0.001), with 46.8% having complete recovery from DM or pre-diabetes. This glycemic recovery had significant association with both biochemical (P = 0.001) and radiological remission (P = 0.01). The recovery from DM had a greater association with post-operative IGF-1 than GH, especially among those with discordant GH and IGF-1 levels (60% in normal IGF-1 and high GH vs. 20% in high IGF-1 and normal GH). Post-operative IGF-1 had a significant impact on recovery from DM (P = 0.01) independent of age, body mass index, duration of DM, and pre-operative HbA1c. Conclusion: Nearly half of the patients with acromegaly with DM or pre-diabetes had glycemic recovery, influenced by biochemical and radiologic remission. Post-operative IGF-1 appears to be the strongest independent determinant of recovery from DM.
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Presurgical simulation for neuroendoscopic procedures: Virtual study of the integrity of neurological pathways using diffusion tensor imaging tractography p. 763
Sergio Garcia-Garcia, Sofia Kakaizada, Laura Oleaga, Arnau Benet, Jordina Rincon-Toroella, José Juan González-Sánchez
DOI:10.4103/0028-3886.263199  PMID:31347551
Background: White matter (WM) transgression is an unexplored concept in neuroendoscopy. Diffusion tensor image (DTI) tractography could be implemented as a planning and postoperative evaluation tool in functional disconnection procedures (FDPs), which are, currently, the subject of technological innovations. We intend to prove the usefulness of this planning method focused on the assessment of WM injury that is suitable for planning FDPs. Methods: Ten cranial magnetic resonance studies (20 sides) without pathological findings were processed. Fascicles were defined by two regions of interest (ROIs) using the fiber assignment method by the continuous tracking approach. Using three-dimensional (3D) simulation and DTI tractography, we created an 8-mm virtual endoscope and an uninjured inferior fronto-occipital fasciculus (IFOF) from two ROIs. The injured tract was generated using a third ROI built from the 3D model of the intersection of the oriented trajectory of the endoscope with the fascicle. Data and images were quantitatively and qualitatively analyzed. Results: The average percentage of the injured fibers was 32.0% (range: 12.4%–70%). The average intersected volume was 1.1 cm3 (range: 0.3–2.3 cm3). Qualitative analysis showed the inferior medial quadrant of the inferior fronto-occipital fasciculus (IFOF) as the most frequently injured region. No hemispherical asymmetry was found (P > 0.5). Conclusion: DTI tractography is a useful surgical planning tool that could be implemented in several endoscopic procedures. Together with a functional atlas, the presented technique provides a noninvasive method to assess the potential sequelae and thus to optimize the surgical route. The suggested method could be implemented to analyze pathological WM fascicles and to assess the surgical results of FDP such as hemispherotomy or amygdalohippocampectomy. More studies are needed to overcome the limitations of the tractography based information and to develop more anatomically and functionally reliable planning systems.
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Presurgical simulation for neuroendoscopic procedures to virtually study the integrity of neurological pathways using diffusion tensor imaging tractography p. 770
Chandrashekhar Deopujari, Salman Shaikh
DOI:10.4103/0028-3886.263200  PMID:31347552
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Ultrasound-measured optic nerve sheath diameter correlates well with cerebrospinal fluid pressure p. 772
Salil Gupta, Aditya Pachisia
DOI:10.4103/0028-3886.263231  PMID:31347553
Background: Intracranial pressure (ICP) can be raised in many neurological conditions and must be treated early to prevent poor clinical outcomes. To detect the rising ICP, it is important to measure it repeatedly using a tool that is noninvasive, safe, accurate, and portable with minimal inter- and intraobserver variability. The aim of our study was to correlate cerebrospinal fluid (CSF) pressure with ultrasound (US)-measured optic nerve sheath diameter (ONSD) and find out a measurement which correlates best with CSF pressure of >20 cm of water. Materials and Methods: All patients in whom lumbar puncture (LP) was indicated and CSF pressure could be measured using manometer were included in the study. Ocular US was used to measure the ONSD. Results: A hundred patients were included in the study out of which 81% were males. The mean age was 60.5 years (±15.6) with a range of 26–90 years. Significant positive correlation was found between the ONSD and CSF pressure. Correlation coefficient (r) was 0.715 (P < 0.001). Receiver's operating characteristic curve was used to find out the ONSD value correlating with a CSF pressure of >20 cm of water. An ONSD >0.63 cm had a sensitivity of 77.3% [95% confidence interval (CI) 54.6–92.1] and specificity of 92.3% (95% CI 84.0–97.1) in predicting a CSF pressure of >20 cm of water (likelihood ratio [LR] + 10.05, LR − 0.25). Conclusion: There is a positive correlation of US-measured ONSD and LP-measured CSF pressure. ONSD of >0.63 cm suggests a CSF pressure of >20 cm of water.
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How is neurosurgical residency in India? Results of an anonymized national survey of residents Highly accessed article p. 777
Kanwaljeet Garg, Harsh Deora, Shashwat Mishra, Manjul Tripathi, Nishanth Sadashiva, P Sarat Chandra, Shashank S Kale
DOI:10.4103/0028-3886.263264  PMID:31347554
Aim: To evaluate whether the residency training programs in India are meeting the expectations and aspirations of the present-day trainees. Introduction: Residents in training today are the neurosurgeons of tomorrow. Significant resources are dedicated to their training and education. Neurosurgical residency in India—when compared to the rest of the world—is relatively new. However, the structure of the Indian neurosurgical training programs has remained relatively unchanged since they were first introduced. In contrast, the treatment paradigms for neurosurgical conditions have changed rapidly in recent years, as new subspecialties have gained prominence. Methods: An online questionnaire based survey was prepared considering the common themes of neurosurgery residency. The links to the survey were mailed to residents in training all over the country. Results were evaluated after a minimum of 100 responses was collected. The responses were anonymized to ensure free and frank answers to the survey questions. Results: A total of 104 responses were received from all the major post-graduate training institutes of the country. The period of joining residency ranged from July 2010 to August 2018. Respondents generally agreed on the need for work hour regulations, the importance of history taking and clinical examination and the significance of imaging interpretation as major training goals. The residents were desirous of more hands-on opportunities during operative teaching. Deficiencies were recognized in the exposure to various upcoming subspecialties such as endovascular therapy, radiosurgery, epilepsy surgery, etc. The residents were generally satisfied with the pattern of examination system and showed a clear preference for electronic resources for reading and knowledge acquisition. Conclusion: The survey highlights the perception of the residents towards the training programs that they are enrolled into. Several lacunae and potential areas of improvement are brought to our attention, which have been necessitated by the recent advancements in technology affecting the neurosurgical treatment paradigms. The training programs need to keep pace with the aspirations and hopes of the residents so that the training experience is mutually fruitful for the trainees and educators. This is important to ensure that the present-day residents can step into their future roles with confidence and preparedness.
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NI FEATURE: PATHOLOGY PANORAMA - COMMENTARY Top

Infantile form of Niemann-Pick disease type C with demyelination: An uncommon feature p. 783
Karalanglin Tiewsoh, Kirti Gupta, Anmol Bhatia
DOI:10.4103/0028-3886.263230  PMID:31347555
Demyelination, neurofibrillary tangles, and axonal spheroids are neuropathological features rarely encountered in infantile form of Niemann-Pick disease type C compared to swollen neurons and neuronal loss which are more commonly seen. We describe clinico-pathological findings in an autopsy case of an infant who died of suspected inborn error of metabolism. At autopsy, storage cells of Niemann-Pick type were observed in plenty in spleen and lymph nodes, and sparsely in liver and brain. Preterminally, the child also developed fungal meningitis with minimal boderzone encephalitis. The neuropathological findings are unique and have been illustrated in detail.Congenital anomaly of the urogenital system was an incidental associated finding.
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NI FEATURE: THE QUEST - ORIGINAL ARTICLES Top

Guidelines versus ground lines: Tuberculosis of the central nervous system p. 787
Satish V Khadilkar, Nikhil D Kadam, Rahul V Kulkarni, Chandrashekhar M Meshram, Archana R Meshram, Bhagyadhan A Patel, Akash H Chheda
DOI:10.4103/0028-3886.263198  PMID:31347556
Aim: This questionnaire-based national survey is aimed at understanding the patterns of practice of various aspects of central nervous system (CNS) tuberculosis (TB) among neurologists. Settings and Design: Neurology department of a tertiary medical college. Materials and Methods: A questionnaire was sent through email to all practicing neurologists in India. The responses were analyzed. Statistical Analysis: Inferential statistics. Results: In all, 144 responses were received (out of the 853 questionnaires sent). The major discrepancies were in the primary antitubercular drug regimen (HRZE + HR), duration for tubercular meningitis (TBM) [12 months] and tuberculoma (12–18 months) to develop, follow-up (varied), linezolid use (varied), proportion of drug-resistant cases (<25%), and not taking histological aids (91%). The cerebrospinal fluid (CSF) TB polymerase chain reaction (PCR) utility (75%), not using CSF adenosine deaminase [ADA] (58%), the strategy to stop antitubercular drugs, and the use of steroids (77%) were according to guidelines. Conclusion: The present survey, for the first time, provides ground-level evidence of various aspects of CNS TB as practiced by neurologists in India. The major diversity was observed in therapeutics such as the choice of antitubercular drugs, its duration, linezolid use beyond the recommended duration, and knowledge of drug resistance. The monitoring aspects of CNS TB also showed variations. The investigational aspects of CNS TB such as using TB PCR, not using CSF ADA, and regular neuroimaging revealed a good clinical practice. Other CSF parameters require uniformity. This survey thus helps to identify areas of future work in CNS TB in India.
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Changing trends of presentation of central nervous system tuberculosis: Relative prevalence of cranial and spinal tuberculosis and drug resistance patterns p. 792
Vetrivel Muralidharan, Bijesh Ravindran Nair, Vedantam Rajshekhar
DOI:10.4103/0028-3886.263176  PMID:31347557
Objective: Inappropriate use of antituberculosis drugs and a poor compliance has led to an increase in the prevalence of resistant Mycobacterium tuberculosis. The aim of this study was to document the changing trends in clinical presentation and drug resistance in patients with tuberculosis (TB) of the brain and the spine. Materials and Methods: The authors retrospectively analyzed data from 243 patients admitted in a neurosurgical unit for surgical management of TB of the brain and spine from 2000 to 2013. To establish changes in trends, the patient population was arbitrarily divided into two groups based on their years of admission: 2000–2006 (Group A; n = 121) and 2007–2013 (Group B; n = 122). Results: In the second era (Group B), there were 14.5% more patients with TB spine [from 42/121 (34.7%) in Group A to 60/122 (49.2%) in Group B; P = 0.02] with a corresponding reduction in the proportion of patients with TB brain. The number of cerebrospinal fluid (CSF) diversion procedures remained the same in both the groups, but there was significant reduction in other surgical procedures for patients with TB brain in Group B (P = 0.0004). In patients with TB brain, the culture yield was 10/50 (20%) from tissue and 8/72 (11%) from CSF and there was no significant difference between the groups. In patients with TB spine, the culture yield was higher in Group B patients but was not statistically significant [7/35 (20%) in Group A versus 18/57 (31.6%) in Group B (P = 0.27)]. In Group A, nine patients with TB brain grew Mycobacterium tuberculosis in culture and none was resistant to first-line antituberculosis therapy (ATT), while in Group B, nine patients grew the bacilli and five had resistance to first-line ATT (P = 0.03). Among patients with a positive culture of resistant TB, all had received prior ATT (100% secondary resistance). None of the seven patients with TB spine in Group A with a positive culture had resistant organisms, but in Group B, 5 of 18 (27.8%) with a positive culture had resistant organisms (P = 0.27). Of these, five patients with TB spine with resistance, three of five (60%) patients had secondary resistance, and two of five (40%) patients had primary resistance. Overall, 10 of 27 (37%) patients with a positive culture had resistant organisms in Group B, while none of 16 patients in Group A with a positive culture had resistant organisms (P = 0.007). Conclusion: The most significant finding of our study is an alarming increase in the number of patients with TB brain and spine who have resistant disease (from 0% to 37%) with most of the resistance being secondary in nature. There was an increase in the number of in-patients with spinal TB relative to those with TB brain, though the cause for this is unclear.
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NI FEATURE: CENTS (CONCEPTS, ERGONOMICS, NUANCES, THERBLIGS, SHORTCOMINGS) - ORIGINAL ARTICLE Top

Single centre experience of flow diverter treatment of complex intracranial aneurysms from South India: Intermediate and long-term outcomes p. 797
Santhosh K Kannath, Aneesh Mohimen, Kapilamoorthy T Raman, Mathew Abraham, Suresh Nair, Jayadevan E Rajan
DOI:10.4103/0028-3886.263195  PMID:31347558
Background and Purpose: To report the intermediate and long-term clinical and angiographic outcomes of the treatment of complex intracranial aneurysms with flow diverter (FD) stents. Setting: A tertiary care centre from south India. Materials and Methods: Patients treated with FD stents were retrospectively analyzed. The clinical demographics, technical success, angiographic, and long-term outcomes were recorded. Results: A total of 13 patients underwent FD treatment, in whom 11 procedures were successful. The cohort included large or giant intracranial aneurysms and recurrent aneurysms following conventional endovascular treatment. Major morbidity was observed in 1 patient, who developed basal ganglia bleed that needed evacuation. Minor complications were seen in 36% of patients without clinical sequelae. Significant obliteration of aneurysm was noted on 1 month computed tomography angiogram in >80% of the patients. Angiographic complete obliteration was noted in 89% of the patients at 6 months. Cranial nerve deficits were noted in 2 patients that improved on subsequent follow up. There was no mortality observed in this cohort. Conclusion: FD treatment of complex cerebral aneurysms was associated with favorable clinical and angiographic outcomes in the intermediate and long-term follow up. Minor complications were common, which needed to be effectively managed to prevent major catastrophic events. The steep learning curve influenced the technical success of the procedure.
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Neuro-navigation assisted pre-psoas minimally invasive oblique lumbar interbody fusion (MI-OLIF): New roads and impediments p. 803
Jayesh Sardhara, Suyash Singh, Anant Mehrotra, Kamlesh Singh Bhaisora, Kuntal Kanti Das, Arun Kumar Srivastava, Awadhesh K Jaiswal, Sanjay Behari
DOI:10.4103/0028-3886.263262  PMID:31347559
Introduction: Minimally invasive spine-oblique lumbar interbody fusion (MIS-OLIF) has emerged as a novel anterolateral, retroperitoneal, “pre-psoas” approach for lumbar interbody fusion for degenerative spinal instability, as well as for correction of deformity in patients without severe canal stenosis. In the last decade, the technique has gained popularity owing to several advantages like the minimal blood loss, minimal tissue dissection, preservation of posterior tension bands, better biomechanical strength, provision of mechanical stability to the lumbar spine, and a larger footprint of the implant, associated with it. It, thus, maximises load bearing on the cortical bone, and provides a better lordotic correction of the lumbar spine. The armamentarium is further boosted by the use of neuro-navigation and neuro-monitoring tools, thereby improving the surgical outcome. Material and Methods: The clinical indications of MIS-OLIF and various fixation methods [lateral lumbar fixation (LLF) and percutaneous posterior pedicle fixation (PPF)] are discussed. The summary of the 15 patients on whom the technique was utilized, are discussed. The patients' demographics, clinical history and neurological examination data, pre- operative Oswestry disability index (ODI) and visual analogue scale (VAS) score, intraoperative surgical details and postoperative follow up clinical as well as radiological data were assessed. Complications, readmissions, length of stay, estimated blood loss, surgical time and surgical outcome were also recorded. Results: 11 cases had grade 1 spondylolisthesis and 4 had grade 2 spondylolisthesis. One patient had both grade I and II spondylolisthesis at different levels. 13 patients had improvement in mechanical back pain and neurogenic claudication. Two patients had improvement in back pain but one-sided limb radiculopathy persisted, which was treated conservatively. The mean pre-operative ODI score was 35 ± 6.1, which improved to 14.6 ± 4.1 at follow-up (range of follow-up: 1 to 10 months; mean 5.7 ± 3.3 months]. The mean pre-operative VAS score was 7 ± 0.7, which improved to 3.3 ± 0.4 at follow-up. Conclusions: The MIS-OLIF technique at the L2–L5 levels has shown encouraging early surgical outcomes with a good fusion rate and rapid recovery. While utilizing the unfamiliar oblique trajectory, the use of navigation can guide the surgeon in real time and also help in reducing the radiation exposure.
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NI FEATURE: CITADELS SCULPTING FUTURE - COMMENTARY Top

Historical perspective on the Department of Neurosurgery at the Nizam's Institute of Medical Sciences p. 813
Suchanda Bhattacharjee, P Aneel Kumar, M Vijaya Saradhi, Manas Panigrahi, Anirudh K Purohit
DOI:10.4103/0028-3886.263211  PMID:31347560
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Intraoperative microsurgical anatomy of the anterior communicating artery complex harbouring an anterior cerebral territory aneurysm p. 823
Atul Agrawal, Anita Jagetia, Shaam Bodeliwala, Daljit Singh, Gautam Dutta, Ankit Shah
DOI:10.4103/0028-3886.263174  PMID:31347561
Background: The vascular anatomy of the anterior communicating artery complex (ACAC), the most frequent site of occurrence of aneurysms, is complex and associated with many anatomical and morphological variations. Aims: The aim of this study was to determine the anatomical variations of ACAC in the Indian population. Setting and Design: This was an observational study. Materials and Methods: Sixty-two patients of ACAC aneurysms were subjected to clipping, and intraoperative microsurgical details were analyzed. Results: Twenty-two (35.48%) patients had anatomical and morphological variations that were more common on the right side. Right A1 was hypoplastic in 5 (8.06%), aplastic in 2 (3.22%), and tortuous in 1 (1.61%) patient. Left A1 was aplastic in 3 (4.83%), hypoplastic in 1 (1.61%) and prominent in 2 (3.22%) patients. One patient (1.61%) had a prominent left A2 segment and 2 (3.22%) had a prominent right A1 and A2 segment. Two patients (3.22%) had fenestration of the ACAC and 3 (4.83%) had the median artery of corpus callosum. The recurrent artery of Heubner was identified in only 44 (70.96%) patients, and in these patients, distinct anatomical variations were noted. Eleven patients were found to present with a parent vessel anomaly, having a total of 23 (mean, 2.09) perforators arising from ACAC, whereas those without a parent vessel anomaly had a total of 57 (mean, 1.11) perforators. This difference was statistically significant. Conclusion: The ACAC region is the area of highest anatomical and morphological variability. This variability is even more exhaustive when associated with aneurysmal formation. A sound anatomical knowledge of the perforators and their preservation during the surgical management of the ACAC is of paramount importance for ensuring a good clinical outcome of patients.
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Multidelay arterial spin-labeled perfusion magnetic resonance imaging in healthy individuals: A single-center experience p. 829
Ying Hu, Qi Li, Li Chen, Fajin Lv
DOI:10.4103/0028-3886.263246  PMID:31347562
Purpose: To explore the optimal postlabeling delay (PLD) of arterial spin labeling (ASL) in different age groups and the correlation between cerebral blood flow (CBF) and age in adults. Materials and Methods: Eighty-four healthy adults (20-80 years) were divided into three groups (youth group, middle-aged group, elderly group) and underwent conventional MRI and three-dimensional arterial spin labeling (3D-ASL) perfusion scanning. Multi-phase PLDs (1025,1525, 2525, 3025ms) were used in each age group. Statistical parametric mapping (SPM) was used to analyze the data and to extract the CBF of predefined regions of interest (ROI) including whole brain gray matter, frontal lobe, parietal lobe, temporal lobe, occipital lobe and limbic lobe. Results: The CBF of shorter PLDs (1025,1525ms) were higher in the youth group, and the CBF were higher with longer PLDs (2525,3025ms) in the middle-aged and elderly group. In addition, the standard deviation of CBF was lower with longer PLD in all age groups. The CBF of all ROIs had negative correlation with age (r=-0.440, P < 0.001; -0.425, P < 0.001; -0.412, P < 0.001; -0.553, P < 0.001; -0.464, P < 0.001; -0.450, P < 0.001 for each ROIs respectively). The youth and middle-aged group, the youth and elderly group had statistically significant difference (P < 0.05); however, the middle-aged and elderly group had no difference (P > 0.05). Conclusion: The shorter PLD is suitable for the youth group and 1525 ms is the best PLD. The longer PLD is suitable for the middle-aged group and elderly group and 3025ms is the best PLD. Most brain regional CBF parameters decrease with age and gradually reach a plateau after middle age.
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Cerebral blood flow measurement with arterial spin labeling MRI: An underutilized technique p. 834
Namita Mohindra, Zafar Neyaz
DOI:10.4103/0028-3886.263224  PMID:31347563
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NI FEATURE: THE FOURTH DIMENSION - COMMENTARY Top

A summary of some of the recently published, seminal papers in neuroscience p. 837
Mazda K Turel, Manjul Tripathi, Ashish Aggarwal, Navneet Singla, Chirag K Ahuja, Aastha Takkar, Sahil Mehta, Kanwaljeet Garg, Ravi Yadav, Anant Mehrotra, Kuntal K Das
DOI:10.4103/0028-3886.263220  PMID:31347564
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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTERS TO EDITOR Top

Leptomeningeal metastases with subarachnoid hemorrhage mimicking primary angiitis of CNS p. 856
Boby V Maramattom, Ananth Ram, Prashant Narayanan, T Jithendra, Dilip Panikar
DOI:10.4103/0028-3886.263252  PMID:31347565
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Acute confusional state induced by diclofenac: Report and review of literature p. 858
Dhananjay Gupta, Mahendra Javali, Rangaiah Pradeep, Anish Mehta, Purushottam T Acharya, Rangasetty Srinivasa
DOI:10.4103/0028-3886.263243  PMID:31347566
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Respiratory arrest immediately after thrombolysis for posterior circulation stroke p. 861
Hiroshi Nawashiro
DOI:10.4103/0028-3886.263202  PMID:31347567
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Intra-operative, spontaneous subarachnoid hemorrhage during anterior temporal lobectomy for mesial temporal sclerosis: Video evidence and literature review p. 862
Ujwal Yeole, Bhaskara Rao Malla, A Arivazhagan, Abhinith Shashidhar, Harsh Deora, Ravindranadh Chowdary Mundalamuri, K Raghvendra, Rose Dawn Bharath, Sanjib Sinha
DOI:10.4103/0028-3886.263215  PMID:31347568
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Aluminum intoxication: A rare cause of myelopathy p. 866
Rajesh Verma, Soumik Sarkar
DOI:10.4103/0028-3886.263248  PMID:31347569
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Radiation-induced osteosarcoma of the calvarium in a patient of left frontal oligodendroglioma following surgery and radiotherapy p. 869
Radha K Verma, Sunita Ahlawat, Rana Patir, Rakesh K Gupta
DOI:10.4103/0028-3886.263209  PMID:31347570
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LETTERS TO EDITOR Top

Adult-onset leukodystrophy with homozygous AARS2 mutation located in the aminoacylation domain p. 871
Gunes A Uzun
DOI:10.4103/0028-3886.263237  PMID:31347571
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Primary generalized dystonia due to TOR1A ΔGAG mutation in an Indian family with intrafamilial clinical heterogeneity p. 872
Subhajit Giri, Arindam Biswas, Shyamal Kumar Das, Kunal Ray, Jharna Ray
DOI:10.4103/0028-3886.263172  PMID:31347572
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Thalamic abscess caused by a rare pathogen - streptococcus sanguinis - A report and a review on thalamic abscess p. 875
Ramesh Vengalathur Ganesan, Karthikeyan K Veerasamy, Madhulika Chittala, Chandramouli Balasubramanian
DOI:10.4103/0028-3886.263201  PMID:31347573
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Headache in a middle-aged man due to a rare mutation in the NOTCH 3 gene p. 879
Anil Gurung, Shakya Bhattacharjee, Azlisham M Nor
DOI:10.4103/0028-3886.263177  PMID:31347574
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Decerebrate rigidity with preservation of consciousness in pontine hemorrhage with complete neurologic recovery p. 881
Boby V Maramattom, Siddharth Bhattacharjee
DOI:10.4103/0028-3886.263170  PMID:31347575
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Two siblings with atypical pantothenate-kinase-associated neurodegeneration p. 883
Gunasekaran K, Sivakumar S, Thiruvarutchelvan K
DOI:10.4103/0028-3886.263173  PMID:31347576
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Kluver–Bucy syndrome in a girl with anti-NMDAR encephalitis p. 887
Vimlesh Soni, Indar K Sharawat, Ananthanarayanan Kasinathan, Lokesh Saini, Renu Suthar
DOI:10.4103/0028-3886.263181  PMID:31347577
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Reflex bradycardia due to traction on filum terminale during detethering of spinal cord p. 889
Siddharth Chavali, Konika Das, Suman Sokhal, Girija P Rath
DOI:10.4103/0028-3886.263184  PMID:31347578
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Tumoural transformation in Van der Knaap syndrome p. 890
Pankaj Gupta, Varsha Kumar, Rashim Kataria, Trilochan Srivastava, VR Sardana
DOI:10.4103/0028-3886.263185  PMID:31347579
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A quaint masquerader of breast cancer: Paraneoplastic cerebellar degeneration p. 892
Steffi Chacko, Rona Joseph, Anoop Thattungal Manoharan, Venugopal M
DOI:10.4103/0028-3886.263186  PMID:31347580
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Loose bodies of bilateral atlantoaxial joints: A rare occurrence p. 894
Madhivanan Karthigeyan, Pravin Salunke, Mandeep Singh Kataria, Kirti Gupta
DOI:10.4103/0028-3886.263187  PMID:31347581
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Primary spinal Rosai–Dorfman disease: Report of an unusual extradural pathology p. 896
Aditya Arun Atal, Sumit Thakar, Nandita Ghosal, Alangar Hegde
DOI:10.4103/0028-3886.263188  PMID:31347582
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Gitelman syndrome with Arnold–Chiari malformation for neurosurgery p. 898
Shilpa V Nagmoti, Manikandan Sethuraman, Ajay P Hrishi
DOI:10.4103/0028-3886.263189  PMID:31347583
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Pure intracranial, intraparenchymal presentation of a malignant peripheral nerve sheath tumour: A rare case p. 900
Ganesh Arumugam, Sudha Ram, P Bhaskar Naidu, Selvakumar Kumaravelu
DOI:10.4103/0028-3886.263190  PMID:31347584
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Pleuro-peritoneal (PLP) shunt in paediatric hydrocephalus: A report p. 903
Laxmi Narayan Tripathy, Indrajit Rana
DOI:10.4103/0028-3886.263192  PMID:31347585
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Capillary haemangioma of the spinal cord: Report of two cases and a review of literature p. 906
Deepika Gupta, Manveen Kaur, Debajyoti Chatterjee, Vipin Gupta
DOI:10.4103/0028-3886.263193  PMID:31347586
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Perfusion MRI may facilitate the diagnosis of a tumefactive demyelinating lesion p. 908
Suprava Naik, Sanjeev Kumar Bhoi, Vivek Agarwal, Sunil Kumar, Rajendra V Phadke
DOI:10.4103/0028-3886.263196  PMID:31347587
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Metastatic pituitary lymphoma: Report and literature review p. 911
Palak A Jaiswal, Prakash Nair, Priya M Jacob, Mathew Abraham, Jaypalsinh Gohil
DOI:10.4103/0028-3886.263197  PMID:31347588
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Spontaneous skull osteomyelitis with subgaleal abscess due to Kocuria rosea p. 915
Ranjit Devidas Rangnekar, Mohamed Amjad Jamaluddin, Kavita Raja, Mathew Abraham
DOI:10.4103/0028-3886.263238  PMID:31347589
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Pontine metastasis as an initial presentation of lung cancer p. 918
Waseem R Dar, Mohmad H Mir
DOI:10.4103/0028-3886.263179  PMID:31347590
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Multiple symmetric lipomatosis: A clinical marker of mitochondrial cytopathy p. 920
PR Sowmini, P Vijayashankar, S Gobinathan
DOI:10.4103/0028-3886.263182  PMID:31347591
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Surgical nuances to avoid blind areas in endoscopic surgery: A new surgical technique p. 923
Yad Ram Yadav
DOI:10.4103/0028-3886.263260  PMID:31347592
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NEUROIMAGES Top

Tumefactive cyst after stereotactic radiosurgery for cerebral arteriovenous malformation p. 926
Ronaldo Goncalves Pereira, Bruno Niemeyer, Clécia Ferreira, Thaís Ribeiro Gomes Coutinho Pereira, Emerson Gasparetto, Edson Marchiori
DOI:10.4103/0028-3886.263229  PMID:31347593
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V-shaped MRI change in the midbrain of a patient with artery of Percheron infarction p. 927
Yuya Kobayashi, Hiroyuki Yahikozawa, Shunichi Sato
DOI:10.4103/0028-3886.263240  PMID:31347594
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Pelvic osteochondroma causing meralgia paresthetica p. 928
Lucas V B Magalhães, Felipe R Massardi, Samuel A C Pereira
DOI:10.4103/0028-3886.263206  PMID:31347595
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Persistent encephalopathy in a patient with numerous neurocysticerci p. 929
Ravindra K Garg, Sudhakar Pandey, Imran Rizvi, Ravi Uniyal, Hardeep S Malhotra, Neeraj Kumar
DOI:10.4103/0028-3886.263228  PMID:31347596
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Acute corpus callosum infarct p. 930
Dinesh Chaudhari, Pushpendra N Renjen, Anoop S Arora
DOI:10.4103/0028-3886.263234  PMID:31347597
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A rare case of a giant tentorial bicompartmental cystic schwannoma unrelated to the cranial nerves p. 932
Ananth P Abraham, Sauradeep Sarkar, Pavithra Mannam, Geeta Chacko, Ari G Chacko
DOI:10.4103/0028-3886.263175  PMID:31347598
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Labrune syndrome: A rare cause of reversible hemiparesis p. 934
Madan Mohan Gupta, Anuj Prabhakar, Leve Joseph, Ajay Garg, Shailesh Gaikwad
DOI:10.4103/0028-3886.263194  PMID:31347599
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14- and 6-Hz positive bursts and N waves: Lesser known benign EEG variants in adolescents p. 936
Puneet Jain, Felippe Borlot, Nadine Morrison-Levy, Ayako Ochi, Robyn Whitney
DOI:10.4103/0028-3886.263233  PMID:31347600
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CORRESPONDENCE Top

Day care neurosurgery in India: Is it a possible reality or a far-fetched illusion? A neuroanesthesiologist's perspective p. 938
B Nisha, Karen R Lionel, P Unnikrishnan, Rangantha Praveen, Ajay P Hrishi
DOI:10.4103/0028-3886.263216  PMID:31347601
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Primary angiitis of the central nervous system (PACNS) – a rare and serious, but treatable entity p. 942
Saiju Jacob
DOI:10.4103/0028-3886.263180  PMID:31347602
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Cerebrospinal fluid dynamics study in clinical practice p. 944
Vengalathur G Ramesh
DOI:10.4103/0028-3886.263213  PMID:31347603
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Intracranial migrating bone dust p. 946
Sunil Pandya
DOI:10.4103/0028-3886.263221  PMID:31347604
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The temporal lobe “Paine like” point - angle, depth and haptics too! p. 947
George C Vilanilam, Palak Jaiswal, Nithin Raj, Mathew Abraham
DOI:10.4103/0028-3886.263207  PMID:31347605
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Artificial intelligence and up-to-date technology in the clinical neurosciences p. 949
Sunil K Pandya
DOI:10.4103/0028-3886.263253  PMID:31347606
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NI FEATURE - BOOKS FROM MY SHELF - COMMENTARY Top

Insomniac City. New York, Oliver, and me p. 952
Sunil Pandya
DOI:10.4103/0028-3886.263210  PMID:31347607
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BOOK REVIEWS Top

Scalpel mavericks Highly accessed article p. 957
Harsh Deora
DOI:10.4103/0028-3886.263208  
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Minimal invasive spine surgery – A ready reckoner p. 959
Umesh Srikantha, Akshay Hari
DOI:10.4103/0028-3886.263219  
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OBITUARY Top

Dr. Sunkara Balaparameswara Rao p. 961
Subba Rao Bhavaraju
DOI:10.4103/0028-3886.263261  PMID:31347608
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Online since 20th March '04
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