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Coverpage
November-December 2018
Volume 66 | Issue 6
Page Nos. 1539-1876

Online since Wednesday, November 28, 2018

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NI FEATURE: THE FIRST IMPRESSION - COMMENTARY  

The cover page Highly accessed article p. 1539

DOI:10.4103/0028-3886.246290  
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NI FEATURE: TIMELESS REVERBERATIONS - COMMENTARY Top

My journey in the field of neurosurgery and its changing trends p. 1540
Sushil Kumar
DOI:10.4103/0028-3886.246232  
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NI FEATURE: JOURNEY THROUGH THE EONS - COMMENTARY Top

Professor B. Ramamurthi (1922-2003): Personal reminiscences p. 1543
Prakash N Tandon
DOI:10.4103/0028-3886.246297  
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Tuberculous meningitis: Challenges in diagnosis and management: Lessons learnt from Prof. Dastur's article published in 1970 p. 1550
Manish Modi, Manoj Kumar Goyal, Anumiti Jain, Suhalika Singhal Sawhney, Kusum Sharma, Sameer Vyas, Chirag Kamal Ahuja
DOI:10.4103/0028-3886.246224  
It has been approximately five decades since Dastur et al., published their seminal work on pathology of tuberculous meningitis (TBM). Though most of their findings find relevance in today's era, there is an important difference; these findings can now be replicated during life using modern day technology. In this article, we review the seminal words of Professor Dastur and colleagues, analyse their findings, interpret how these revolutionized our understanding of TBM and highlight their relevance in today's era. We also discuss challenges in the management of TBM, which we continue to face today and the various options required to overcome these challenges.
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GUEST COMMENTARY Top

Generational tensions are a distraction from addressing the burnout crisis in Neurosurgery p. 1572
Alejandro M Spiotta, Sunil Patel
DOI:10.4103/0028-3886.246283  
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Basic principles of mathematical growth modeling applied to high-grade gliomas: A brief clinical review for clinicians p. 1575
Ana Karina Cisneros-Sanchez, Eduardo Flores-Alvarez, Guillermo Melendez-Mier, Ernesto Roldan-Valadez
DOI:10.4103/0028-3886.246238  
The battle against cancer has intensified in the last decade. New experimental techniques and theoretical models have been been proposed to understand the behavior, growth, and evolution of different types of brain tumors. Unfortunately, for glioblastoma multiforme (GBM), except for methylation of the O6-methylguanine-DNA methyltransferase (MGMT) promoter that has some benefit in the local control of tumors using alkylating agents such as temozolomide, to date personalized treatments do not exist. In this article, we present a comprehensive review of different aspects intertwined in the mathematical growth modeling applied to high-grade gliomas. We briefly cover the following fundamental aspects related to the conventional imaging in GBM: defining the tumor regions in GBM, segmentation of the tumor regions using magnetic resonance imaging (MRI) of the brain, response assessment using the neuro-oncology response criteria versus the Macdonald criteria, availability of software for the segmentation of MRI of the brain, mathematical modeling applied to tumor growth, principles of mathematical modeling, factors involved in tumor growth models, mathematical modeling based on imaging data, most common equations used in high-grade glioma growth modeling, integration of mathematical growth models in computer simulators, tumor growth modeling as a part of brain's complex system, and challenges in mathematical growth modeling. We conclude by saying that it is the combination of biomedical imaging and mathematical modeling that allows the assembling of clinically relevant models of tumor growth and treatment response; the most appropriate model will depend on the premise and findings of each experiment.
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Immunotherapy in autoimmune encephalitis - A need for “presumptive” diagnosis and treatment Highly accessed article p. 1584
Sunil Pradhan, Animesh Das, Vinita Elizabeth Mani
DOI:10.4103/0028-3886.246277  
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NI FEATURE: THE EDITORIAL DEBATE I-- PROS AND CONS Top

Status epilepticus related to pregnancy p. 1590
Sangeeta Ravat, Karan Desai, Mansi Shah
DOI:10.4103/0028-3886.246226  
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Status epilepticus in pregnancy: Most rare and most challenging p. 1593
Gagandeep Singh
DOI:10.4103/0028-3886.246227  
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NI FEATURE: THE EDITORIAL DEBATE II-- PROS AND CONS Top

Focal cortical dysplasias: A histopathologically diverse group of developmental lesions with unique clinicopathological and molecular/genetic aberrations p. 1595
Sandeep Mittal
DOI:10.4103/0028-3886.246231  
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Moving the clock on comprehensive post-surgical outcome assessment in specific etiological categories of epilepsy p. 1598
Garima Shukla
DOI:10.4103/0028-3886.246222  
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Focal cortical dysplasia p. 1601
Varindera P Singh
DOI:10.4103/0028-3886.246237  
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NI FEATURE: THE EDITORIAL DEBATE III-- PROS AND CONS Top

Diffusion tensor imaging: An overview p. 1603
Sikander Shaikh, Anjani Kumar, Abhishek Bansal
DOI:10.4103/0028-3886.246233  
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Use of quantitative diffusion tensor imaging as a diagnostic tool for intracranial lesions p. 1612
Aditya Vedantam
DOI:10.4103/0028-3886.246221  
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NI FEATURE: THE EDITORIAL DEBATE IV-- PROS AND CONS Top

Microsurgery of giant intracranial aneurysms: Current status p. 1614
Basant K Misra, Abhijit Warade
DOI:10.4103/0028-3886.246223  
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The ‘hybrid’ vascular neurosurgeon: The need of the hour p. 1617
Veer Singh Mehta
DOI:10.4103/0028-3886.246299  
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REVIEW ARTICLE Top

Focus on neuro-Behçet's disease: A review p. 1619
Paola Caruso, Rita Moretti
DOI:10.4103/0028-3886.246252  
Behçet's disease (BD) is a multisystemic vasculitis disorder of almost unknown etiology, which involves small and large vessels and affects both veins and arteries. BD is characterized by recurrent oral aphthae (the main and most recurrent symptoms), genital ulcers, variable skin lesions, arthritis, uveitis, and thrombophlebitis. Other reported symptoms concern the involvement of the gastrointestinal and the central nervous system. Neuro-Behçet's disease (NBD) is one of the main causes of long-term morbidity and mortality, making its prompt recognition and treatment fundamental to attaining a better outcome. As pointed out by Kalra et al., there are definite consensus statements for BD, but less data are available for NBD. A multidisciplinary team of rheumatologists, dermatologists, ophthalmologists, neurologists, cardiovascular surgeons, and gastroenterologists, often led by rheumatologists, participate in the management of patients with BD and NBD.
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ORIGINAL ARTICLES Top

Status epilepticus related to pregnancy: Devising a protocol for use in the intensive care unit p. 1629
Keni Ravish Rajiv, Ramshekhar N Menon, Sajith Sukumaran, Ajith Cherian, Sanjeev V Thomas, Muralidharan Nair, Ashalatha Radhakrishnan
DOI:10.4103/0028-3886.246279  
Background: Status epilepticus (SE) related to pregnancy is rare and carries a significant risk to both the mother and the fetus. Objectives: We conducted this study to devise a protocol for the management of SE related to pregnancy in a cohort of female patients admitted with SE during pregnancy. Materials and Methods: All women who developed SE related to pregnancy (gestation, labor, and puerperium) between January 2000 and December 2016 were included. Data was collected using a structured proforma. Results: There were 17 women who had SE related to pregnancy, of whom 10 had refractory SE. The various causes of refractory SE were eclampsia (N = 2), posterior reversible encephalopathy syndrome (PRES) due to various causes other than eclampsia (N = 3), cortical venous thrombosis (CVT) [N = 3], subarachnoid hemorrhage (SAH) [N = 1], and N-methyl-D-aspartate (NMDA) receptor antibody-mediated encephalitis (N = 1). Six out of 10 women with refractory SE (60%) and five out of 10 fetuses (50%) had a good outcome. Conclusion: There is a dearth of literature with regards to SE related to pregnancy and little or no guidelines exist for its management. Awareness about the diverse etiologies other than eclampsia is important. A protocol-based approach to the diagnosis and management of SE is necessary to ensure best outcomes.
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Immune-mediated neurological manifestations of dengue virus- a study of clinico-investigational variability, predictors of neuraxial involvement, and outcome with the role of immunomodulation Highly accessed article p. 1634
Bharat Bhushan, Vijay Sardana, Dilip Maheshwari, Piyush Ojha, Sankalp Mohan, Parag Moon, Sumit Kamble, Nishtha Jain, Sunil K Sharma
DOI:10.4103/0028-3886.246273  
Introduction: Our aim was to study dengue-related immune-mediated neurological complications (IMNC) during the recent epidemic. Materials and Methods: This was a cross-sectional observational study of 79 IMNC cases from 1627 laboratory confirmed dengue cases from January 2015 to January 2016 and their follow-up for 3 months. According to the World Health Organization, cases were categorized into those having dengue fever (DF), and those having a severe syndrome that includes dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Laboratory as well as clinicoradiological data, the predictors of outcome, and the role of immunomodulation in determining the final result were analyzed. Results: Out of the 1627 confirmed dengue cases, 14.6% developed neurological complications and only 4.86% cases had IMNC. Among the IMNC seen, the majority of the patients had the onset of their manifestations in the subacute (7–30 days) latency period; however, there was no mortality seen. We found Miller Fisher syndrome (MFS), limbic encephalitis, and immune-mediated cerebellar demyelination (IMCD) as the new findings in the IMNC spectrum. Patients with DF were more prone to developing brachial plexus neuritis and polyneuritis cranialis, whereas those patients with a severe syndrome were more commonly associated with Guillain–Barre syndrome (GBS). Significant (P < 0.001) predictors of central nervous system involvement were anemia, an elevated hematocrit, and the presence of DSS, whereas patients with a higher mean body temperature, DF, and elevated hematocrit were more prone to developing peripheral nervous system manifestations. The platelets counts and the hemoglobin levels had a negative correlation whereas the hematocrit value, the mean body temperature, and the alanine aminotransferase levels had a moderately significant positive correlation for the development of IMNC. The immunomodulatory therapy (IMT), if initiated after fever abatement led to a significant clinically favorable outcome at 3 months, especially in patients with GBS, polyneuritis cranialis, and brachial plexus neuritis. Conclusion: The spectrum of IMNC is vast and may include MFS, limbic encephalitis and IMCD. Early initiation of IMT, in the presence of significant predictors, may reduce the IMNC-related morbidity.
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A new scoring system and norms for, and the performance of cognitively-unimpaired older adults on the cube copying test p. 1644
Robert Mathew, Neelima Renjith, PS Mathuranath
DOI:10.4103/0028-3886.246242  
Background: Cube copying test is often used as screening test for dementia. However, there is a paucity of an effectively scoring system, and very little is known about how healthy older adults perform on this test. In this study, we present a modified scoring system for the wire-cube copying, evaluate the performance of cognitively unimpaired elderly individuals, and generate norms on community-dwelling older adults. Materials and Methods: The task consisted of copying a three-dimensional printed cube (i.e., wire-cube) of size 2.5 cm3. The scoring system devised by Maeshma et al. was modified and used. The target population consisted of cognitively normal individuals aged ≥65 years living in a predefined geographical area. Results: In this study, there were 511 participants (62% females) aged 69 ± 7.2 years. Of the 295 figures available, 51 were rejected. Among the candidates with acceptable cubes, 182 (74.5%) had ≥9 years of education. Of the 51 rejected cubes, 37 (72.5%) participants had <9 years of education. Education was found to be significantly correlated with composite score (P < 0.001) whereas age and sex had no correlation. The total score as well as subgroup scores of the cubes were correlating well with Mini-mental state examination (MMSE) as well as Addenbrooke's Cognitive Examination (ACE) composite scores (P < 0.0001). Conclusion: Good correlation was found between composite scores and subscores with most of the ACE parameters. The test can be used as a rapid screening test for dementia in view of its good correlation with ACE composite scores and subscores; it also has the advantage of being independent of culture and language.
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Genetic analysis of the glucocerebrosidase gene in South Indian patients with Parkinson's disease p. 1649
Ravi Yadav, Saketh Kapoor, Mayank Madhukar, Rajini M Naduthota, Arun Kumar, Pramod Kumar Pal
DOI:10.4103/0028-3886.246249  
Background: Mutations in the glucocerebrosidase (GBA) gene have been associated with Parkinson's disease (PD). Several variants in the gene have been identified as risk factors for the development of PD, but there is difference in the prevalence of this mutation in various ethnic groups and countries. There is no published study related to this field on the Indian population. Aims and Objectives: The aim of the study was to investigate the frequency of mutations in the GBA gene in Indian patients with PD. Materials and Methods: To perform the mutation analysis of the GBA gene, we amplified its entire coding region, spanning 11 exons and intron/exon junctions in three fragments, with a set of three primer pairs using the long polymerase chain reaction enzyme mix from Fermentas, Canada. Results: We screened a total of 100 PD patients for mutations in the GBA gene. The sequence analysis identified the following five variants in this gene: IVS1 + 191G > C, IVS4 + 47G > A (rs. 2075569), IVS6 − 86A > G (rs. 114099990), IVS9 + 141A > G (rs. 28373017), and IVS10 + 3G > A. Of these, two variants IVS1 + 191G > C and IVS10 + 3G > A are novel, and the remaining three are known variants reported in the Single Nucleotide Polymorphism database (dbSNP). All the known variants were detected in homozygous as well as in heterozygous states. Both novel variants were identified in only one patient in a heterozygous state. Conclusion: GBA mutation may not be so common in Indian patients with PD as compared to the other ethnic populations. These findings need to be confirmed in larger studies.
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Epilepsy surgery for focal cortical dysplasia: Seizure and quality of life (QOLIE-89) outcomes p. 1655
Jitender Chaturvedi, Malla Bhaskara Rao, A Arivazhagan, Sanjib Sinha, Anita Mahadevan, M Ravindranadh Chowdary, K Raghavendra, AS Shreedhara, Nupur Pruthi, Jitender Saini, Rose Dawn Bharath, Jamuna Rajeswaran, P Satishchandra
DOI:10.4103/0028-3886.246263  
Aim: Surgery for drug resistant epilepsy (DRE) with focal cortical dysplasia (FCD) often requires multiple non-invasive as well as invasive pre-surgical evaluations and innovative surgical strategies. There is limited data regarding surgical management of people with FCD as the underlying substrate for DRE among the low and middle-income countries (LAMIC) including India. Methodology: The presurgical evaluation, surgical strategy and outcome of 52 people who underwent resective surgery for DRE with FCD between January 2008 and December 2016 were analyzed. The 2011 classification proposed by Blumcke et al., was used for histo-pathological categorization. The Engel classification was used for defining the seizure outcome. The surgical outcome was correlated with the preoperative clinical presentation, video encephalogram (VEEG) recording, magnetic resonance imaging (MRI), invasive monitoring, surgical findings as well as histopathology and the quality of life in epilepsy (QOLIE)- 89 scores. Results: Fifty-two patients underwent resective surgery for FCD (mean age at onset of seizure: 7.94 ± 6.23 years; duration of seizures prior to surgery: 12.95 ± 9.56 years; and, age at surgery: 20.88 ± 12.51 years). The following regional distribution was found; temporal-24 (language-13), frontal-15 (motor cortex- 5), parietal-5 (sensory cortex-4), occipital-1 and multilobar-7. Forty-seven percent of the cases had FCD in the right hemisphere and 53% had FCD in the left hemisphere. Invasive monitoring was performed for identification of the epileptogenic zone (EZ) as well as eloquent cortex in 7 cases and an intra-operative electro-corticography (ECoG) was used in 32 cases. Histopathology revealed the following distribution; FCD IA-4, IB- 1, IC-5, IIA-8, IIB-18, IIIA-13, IIIB -1, IIIC-1 and IIID-1. After a median follow up of 3.7 years after surgery, 84% of patients had Engel's Ia outcome. QOLIE-89 scores improved from 38.33 ± 4.7 (31.14-49.03) before surgery to 75.21 ± 8.44 (56.49-90.49) after surgery (P < 0.001). The younger age of the patient (<20 years) at surgery (P = 0.013), a lower pre-operative score (<9) on seizure severity scale (P = 0.012), focal discharges without propagation on ictal VEEG (P < 0.001), absence of acute post-operative seizures (P < 0.001) and Type II FCD (P = 0.045) were the significant predictors for a favorable seizure outcome. Conclusion: Surgical management of people with DRE and FCD is possible in countries with limited resources. Meticulous pre-surgical evaluation to localize the epileptogenic zone and complete resection of the focus and lesion can lead to the cure or control of epilepsy; and, improvement in the quality of life was observed along with seizure-free outcome.
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Application of diffusion tensor imaging in brain lesions: A comparative study of neoplastic and non-neoplastic brain lesions p. 1667
Neetu Soni, Karthika Srindharan, Sunil Kumar, Kamlesh Singh Bhaisora, Jayantee Kalita, Anant Mehrotra, Prabhakar Mishra
DOI:10.4103/0028-3886.246270  
Purpose: To evaluate the role of diffusion tensor imaging (DTI) in the differentiation of neoplastic and non-neoplastic brain lesions, on the basis of DTI parameters, fractional anisotropy (FA) and mean diffusivity (MD) from the lesion (L) and the perilesional edema (PE). Material and Methods: Patients with newly diagnosed 25 neoplastic [10 high grade gliomas (HGG), 11 metastases, 4 low grade glioma (LGG)] and 25 non-neoplastic [13 tuberculomas and 12 neurocysticercosis (NCC)] brain lesions underwent an MRI, including the DTI sequences. Fractional anisotropy from the lesion (FAL) and mean diffusivity from the lesion (MDL), as well as fractional anisotropy from the perilesional edema (FAPE), and mean diffusivity from the perilesional edema (MDPE) were calculated and quantified using region of interest (ROI) based assessment on DTI derived FA and MD parametric maps. The mean values of FAL, FAPE, MDL and MDPE from the two groups were compared by the independent sample t-test. Results: In the non-neoplastic group, perilesional edema showed a significantly higher (P = 0.015) MD compared to the neoplastic group. Perilesional FA and lesional FA and MD showed no such statistically significant difference. On further subgroup analysis, MDPE was higher in metastases compared to HGG (P < 0.001), reflecting an increase in the vasogenic edema. Perilesional FA was higher in HGG compared to metastases and tuberculomas (P < 0.001) reflecting tumour infiltration in addition to vasogenic edema. FAL was higher in tuberculomas compared to metastases (P < 0.001), pointing to a more microstructural destruction in metastases. Conclusion: Quantitative DTI parameters, FA and MD, from the lesion and from the area of perilesional edema are helpful in the evaluation and differentiation of brain lesions.
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Does adjunctive corticosteroid and aspirin therapy improve the outcome of tuberculous meningitis? p. 1672
Usha Kant Misra, Jayantee Kalita, Betai Sagar, Sanjeev Kumar Bhoi
DOI:10.4103/0028-3886.246278  
Background: Stroke is common in tuberculous meningitis (TBM), and aspirin has been shown to reduce mortality. A combination of aspirin and corticosteroid may be more useful in this condition. Aim: To evaluate the effect of aspirin and corticosteroid adjunctive therapy alone or in combination in determining the outcome of TBM. Materials and Methods: One hundred and fifty-three patients with TBM were evaluated from a prospectively maintained registry. The diagnosis of TBM was based on the clinical, magnetic resonance imaging (MRI)/computed tomography (CT), and cerebrospinal fluid criteria. The baseline clinical, laboratory, and radiological findings were noted. All patients received the standard 4-drug antituberculous (rifampicin, isoniazid, pyrazinamide, and ethambutol) treatment. Group I patients received in addition, aspirin, in the dose of 150 mg daily; group II patients received aspirin 150 mg plus prednisolone 40 mg daily; and, group III patients received none of these adjunctive therapies. The outcome at 3 months was defined in terms of death or functional disability. Results: Group I had 44, group II had 50, and group III had 41 patients. The baseline characteristics of all these patients were similar, except in group II, where patients had more severe meningitis and focal deficits compared to the patients in group I and III. At 3 months, 32 (23%) patients died; 8 (18.2%) in group I, 9 (18%) in group II, and 14 (34.1%) in group III. There was insignificant survival benefit in group II (hazard ratio [HR], 1.55; 95% confidence interval (CI), 0.96–26.49; P = 0.07). The three-month functional outcome and side effects were not significantly different in the three groups. Conclusion: Aspirin with corticosteroid adjunctive treatment seems to be beneficial in reducing mortality in TBM.
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COMMENTARY Top

Role of aspirin as an adjuvant therapy in tuberculous meningitis in adults: The time has come for a phase III randomized controlled trial p. 1678
Ravi Yadav
DOI:10.4103/0028-3886.246225  
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ORIGINAL ARTICLE Top

Pons ratio as a potential diagnostic biomarker for the detection of growth hormone deficiency in children p. 1680
Ozum Tuncyurek, Mehmet Turgut, Tolga Ünüvar, R Shane Tubbs, Yelda Özsunar
DOI:10.4103/0028-3886.246236  
Introduction: Pituitary insufficiency (PI) needs further research to optimize treatment. Growth hormone deficiency (GHD) is a subtype of PI. The purpose of the present study is to investigate the possible relationship between GHD and the anatomical position of the pons as revealed by magnetic resonance imaging (MRI) in the pediatric age group. In the current study, we developed a novel and simple index using MRI that could provide an alternative to other indexes in the classical literature. Patients and Methods: Brain MRI and clinical data of 48 children with suspected PI (22 females, 26 males; mean age 11.6 ± 2.2 years) were examined retrospectively. To estimate the location of the pons, the ratio of pons height over the axis between the dorsum sellae and the fourth ventricular hill in the sagittal plane (A) to the total height of the pons (B) was calculated (A/B). It was termed the pons ratio (PR). The PRs of children with or without a diagnosis of GHD were then compared statistically. Results: Fifteen children were diagnosed with GHD and treated with growth hormone (GH), whereas the remaining 33 were reported normal. The mean PRs of the children diagnosed with GHD and given GH treatment (0.31 ± 0.07, range: 0.18–0.42) differed significantly from those without PI (0.26 ± 0.06, range: 0.17–0.44; P = 0.018). Conclusion: There appears to be an association between GHD and decreased PR in children receiving GH treatment. Spatial measurements of posterior fossa in radiological examinations may provide additional information that is helpful in the diagnosis of suspected cases of GHD.
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COMMENTARY Top

Diagnosis of childhood growth hormone deficiency: Controversies, consensus and the need for new diagnostic tools p. 1685
Alpesh Goyal, Rajesh Khadgawat
DOI:10.4103/0028-3886.246229  
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ORIGINAL ARTICLE Top

Ring graft technique for microvascular decompression p. 1687
Ishu Bishnoi, Daljit Singh, Sheikhoo Bishnoi, Tushit Mewada, Deepashu Sachdeva, Amit Mittal, Shrinivas H Odugora
DOI:10.4103/0028-3886.246282  
Introduction: Various nerve compression syndromes, such as trigeminal neuralgia (TN), glossopharyngeal neuralgia (GN), and hemifacial spasm (HFS), are caused by compression of the concerned nerve by the adjacent vessel. Patients who do not respond to medical management are usually treated by “microvascular decompression (MVD) of the nerve.” Teflon patch graft is the most commonly used material for MVD. This graft has been used in various shapes like a patch, in the shredded form, or as a sling. This is done to prevent recurrence because of graft failure. We used a teflon ring graft to perform a successful MVD in 10 patients. Material and Methods: Out of 10 cases, 6 cases were of TN, 2 of HFS, 1 of GN, and 1 case was of cochleovestibular nerve compression syndrome (CNCS). After MVD, every patient underwent a follow up assessment for 5 years. Results: There was no major postoperative complication, except in the patient with CNCS who suffered from a temporary episode of facial palsy. All cases were symptom free at a follow-up duration of equal to or more than 5 years. Conclusion: Ring teflon graft may be used as an alternative as well as a safe method to perform MVD and has a good success rate.
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COMMENTARY Top

Ring graft technique: A unique modification for ensuring an effective microvascular decompression p. 1692
Likhith Alakandy
DOI:10.4103/0028-3886.246230  
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ORIGINAL ARTICLE Top

Endoscopic surgery of spontaneous basal ganglionic hemorrhage p. 1694
Shailendra Ratre, Nishtha Yadav, Vijay Singh Parihar, Amitesh Dubey, Yad Ram Yadav
DOI:10.4103/0028-3886.246288  
Introduction: Although there are controversies about the optimal management of spontaneous intracerebral hemorrhage (ICH), benefits of endoscopic procedures in ICH have been reported. This study is aimed to evaluate the result of 270 patients undergoing endoscopic treatment of ICH. Methods: This was a retrospective study from July 2008 to June 2017. All procedures were done with the endoscopic technique using a tubular retractor. Patients with the hematoma volume between 30 to 80 ml, with the Glasgow Coma Scale (GCS) between 5 to 14, and evidence of severe mass effect, were included in the study. Results: The average stay in the intensive care unit was 6 days (range 1–17 days). The median pre-operative midline shift of 8.3 mm was reduced to 2.7 mm after surgery. The average hematoma removal ratio, the duration of surgery, and the blood loss was 90%, 90 min, and 60 ml, respectively. There was improvement in the average pre-operative GCS from 9.4 to 11.3 at seventh post-operative day. The post-operative mortality rate was 10.7%. A good outcome was observed in 71% patients at 6 months after surgery. Larger the volume of hematoma, more the operative time, more the pre-operative midline shift, and poorer the GCS, significantly higher was the association with mortality. The patients with a better pre-operative GCS were associated with a better Glasgow Outcome Score. The follow-up period ranged from 7 to 115 months. Conclusion: Endoscopic surgery with the help of a tubular retractor was effective and safe. It allowed for a good visualization of the hematoma and the surrounding brain, and helped in proper hemostasis. The hematoma may also be removed with the help of the microscope and the tubular retractor, in case any difficulty during the endoscopic technique is encountered.
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COMMENTARY Top

Spontaneous intracerebral hemorrhage p. 1704
Chandrashekhar Deopujari, Salman Shaikh
DOI:10.4103/0028-3886.246300  
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ORIGINAL ARTICLE Top

Clinical observations on selective dorsal root ganglion pulsed radiofrequency lesioning combined with gabapentin in the treatment of postherpetic neuralgia p. 1706
Youqing Huang, Fang Luo, Xiaofeng He
DOI:10.4103/0028-3886.246245  
Background: This study investigated the clinical effects of selective dorsal root ganglion pulsed radiofrequency lesioning in combination with oral administration of gabapentin in the treatment of postherpetic neuralgia (PHN). Material and Methods: One hundred and sixteen consecutive cases of initially diagnosed patients with PHN were randomly divided into the control and the observation groups, with each group consisting of 58 patients. The control group was treated with oral gabapentin (2400 mg/d, tid), while the observation group received gabapentin and pulsed radiofrequency lesioing of the dorsal root ganglion. The clinical efficacy of both the regimens was compared after a follow up period of 6 months. Results: The observation group had a significantly lower score on the visual analog scale than the control group (P ≤ 0.05, with no significant complications occurring in both the groups) at a 1, 2, and 4 week posttreatment duration. The percentage of cluster of differentiation (CD) 4+ cells and the CD4+/CD8+ ratio increased gradually, while the percentage of CD8 + cells decreased in the observation group (P ≤ 0.05). No significant alterations were observed in the control group (P > 0.05). The observation group had significantly lower serum interleukin-6, C-reactive protein, and tumor necrosis factor-α levels than the control group (P < 0.05) at 1, 2, and 4 weeks after the treatment was instituted. The observation group also demonstrated a superior total effective rate and efficiency than the control group (P ≤ 0.05). Conclusion: Our study demonstrated that radiofrequency combined with gabapentin in the treatment of PHN has a good safety and efficacy profile. The effects of this treatment may be related to an increased T-cell immunity and an inhibited inflammatory response.
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COMMENTARY Top

Selective dorsal root ganglion pulsed radiofrequency lesioning combined with gabapentin in the treatment of postherpetic neuralgia: The unanswered questions p. 1711
Jason P Dauffenbach, Manish Singh Sharma
DOI:10.4103/0028-3886.246228  
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ORIGINAL ARTICLE Top

Neurological, neuropsychological, and functional outcome after good grade aneurysmal subarachnoid hemorrhage p. 1713
Subir Dey, J Keshav Kumar, Dhaval Shukla, Dhananjaya Bhat
DOI:10.4103/0028-3886.246243  
Background: There is a paucity of information about which impairments, cognitive or neurological, determine the functional outcome after aneurysmal subarachnoid hemorrhage (SAH). The present study aims to determine the relative contributions of each of the above impairments for determining the functional outcome after SAH. Materials and Methods: This is a prospective observational study including patients with aneurysmal SAH. Patients underwent assessment at 6 months after discharge for neurological deficits, cognitive impairment, and functional outcome using the National Institute of Health and Social Sciences (NIHSS) score, National Institute of Mental Health and Neurosciences (NIMHANS) Neuropsychology Test Battery, and Glasgow Outcome Scale – Extended (GOSE), respectively. The correlation of GOSE with NIHSS scores and neuropsychological test scores was done using Spearman's rho correlation coefficient. Result: Fifty-six patients underwent assessment using all the three tools, i.e., NIHSS, neuropsychological tests, and GOSE. Fifty-one healthy volunteers participated in the study for neurological examination and neuropsychological assessment. At 6 months, patients with SAH had significant cognitive impairment as compared to controls. The mean NIHSS score was 10.01 ± 9.04, indicating moderately severe impairment. The median GOSE at 6 months was 6 (range: 3–8) indicating the upper level of moderate disability. There was a significant correlation of NIHSS scores with GOSE, Spearman's rho −0.653 (<0.001). There was a significant correlation of neuropsychological test scores with GOSE and NIHSS. The Spearman's rho for NIHSS vs GOSE was within range for neuropsychological scores vs GOSE. Conclusion: Both the neurological deficits and cognitive impairment determine functional outcome after SAH at 6 months.
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COMMENTARY Top

Outcome assessment following aneurysmal subarachnoid hemorrhage – need for a comprehensive tool p. 1718
Girish Menon
DOI:10.4103/0028-3886.246220  
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CASE REPORT Top

Autopsy in dengue encephalitis: An analysis of three cases p. 1721
Deepak Jois, Nikhil Moorchung, Salil Gupta, Deepti Mutreja, Sunita Patil
DOI:10.4103/0028-3886.246276  
Dengue viral infection with unusual presentations has been described in literature, but autopsy is rarely done and is only limited to some cases, based on the literature review. Here, we present the autopsy findings in three cases of dengue encephalitis. All the three patients clinically presented with signs of meningoencephalitis and were positive for dengue non-structural (NS) 1 antigen (Ag) in the serum and cerebrospinal fluid. The postmortem findings revealed cerebral edema, inflammation, hemorrhage, and microinfarcts in all the three cases with herniation of the brain in one case. Sub-massive hepatocellular necrosis was seen in one case. The renal findings included hemorrhage into the Bowman's capsule with red cell cast in two of three cases. The pulmonary findings included a diffuse destruction of the alveoli and hemorrhage into the alveolar spaces in all the three cases.
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NI FEATURE: PATHOLOGY PANORAMA - ORIGINAL ARTICLE Top

Molecular profile of tumors with oligodendroglial morphology: Clinical relevance p. 1726
Tulasi Geevar, Rekha Pai, Geeta Chacko, Karthik Malepathi, Bimal Patel, Jacob John, Ari G Chacko, Rajesh Balakrishnan, Subashini John
DOI:10.4103/0028-3886.246275  
Background: The plethora of biomarkers available for the diagnosis and prognostication of gliomas has refined the classification of gliomas. The new World Health Organization (WHO) 2016 classification integrates the phenotypic and genotyping features for a more robust diagnosis. Materials and Methods: Fifty gliomas with oligodendroglial morphology according to the WHO 2007 classification were analyzed for isocitrate dehydrogenase 1 and 2 (IDH1/2) mutations by polymerase chain reaction, 1p/19q status by fluorescent in situ hybridization (FISH), and IDH1 and X-linked alpha-thalassemia retardation (ATRX) expression by immunohistochemistry. Tumors were reclassified into oligodendrogliomas, astrocytomas, and glioblastomas (GBMs) according to the new “integrated” diagnostic approach. Results: 30% of previously diagnosed oligodendrogliomas and almost 90% of oligoastrocytomas were reclassified as astrocytomas. Twenty gliomas showed 1p/19q co-deletion, while 18 gliomas showed polysomy of chromosome 1/19. Polysomy of chromosome 1/19 was significantly associated with astrocytic tumors (P ≤ 0.001). Loss of ATRX expression was seen in 20 of 23 WHO grade II/III astrocytomas and 3 of 7 GBMs. All WHO grade II and III gliomas in our cohort showed IDH1/2 mutations. Moreover, 4 of 7 GBMs showed the wild-type IDH1/2 mutation, and 2 of 3 GBMs which showed IDH1/2 mutations were secondary GBMs. There was no significant difference in progression-free and overall survival between WHO grade II and III gliomas, possibly because all these tumors showed IDH1/2 mutations. In multivariate analysis, only the WHO grade (grade IV versus II and III combined) was significantly associated with increased risk of recurrence and death (P = 0.016 and 0.02). Conclusion: The new integrated diagnosis provides a more meaningful classification, removing the considerable subjectivity that existed previously.
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NI FEATURE: THE QUEST - COMMENTARY Top

Neurotoxicity of the antibiotics: A comprehensive study Highly accessed article p. 1732
Naghmeh Javanshir Rezaei, Amir Mohammad Bazzazi, Seyed Ahmad Naseri Alavi
DOI:10.4103/0028-3886.246258  
Antibiotics are among the most widely used medications in clinical settings. Seizures, encephalopathy, optic neuropathy, peripheral neuropathy, and exacerbation of myasthenia gravis are important examples of neurotoxic adverse events associated with the use of antibiotics. This article aims to review the most common and important neurotoxic adverse effects associated with various antibiotics routinely used in a clinical setting.
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NI FEATURE: CENTS (CONCEPTS, ERGONOMICS, NUANCES, THERBLIGS, SHORTCOMINGS) - ORIGINAL ARTICLE Top

Surgery for very large and giant intracranial aneurysms: Results and complications p. 1741
Qazi Zeeshan, Basavaraj V Ghodke, Gordana Juric-Sekhar, Jason K Barber, Louis J Kim, Laligam N Sekhar
DOI:10.4103/0028-3886.246291  
Background: Results of and the complications encountered during surgery for very large and giant intracranial aneurysms are illustrated. Objective: To analyze a consecutive series of patients with very large and giant aneurysms treated with microsurgery. Methods: This retrospective study included seventy six very large and giant aneurysms which were managed by clipping and bypass technique. Sixty two (82%) aneurysms were located in anterior circulation, and 14 (18%) aneurysms were located in posterior circulation. The bypasses performed included local bypasses, extra-intracranial bypasses, double bypasses and combination techniques of external carotid-internal carotid (EC-IC) bypass and local bypasses. Results: 73 patients with 76 aneurysms were treated over 13 years. There were 44 very large and 32 giant aneurysms. Twenty-four patients presented with subarachnoid hemorrhage [SAH] (32%) while forty nine patients with 52 aneurysms (68%) were unruptured. These 73 patients underwent 63 bypass procedures with aneurysm occlusion and 13 clipping procedures. Out of 62 anterior circulation aneurysms, bypass surgery was performed in 49 patients while 13 underwent clipping. In posterior circulation aneurysms, all patients were treated with bypass procedures with proximal occlusion or trapping. In the ruptured group, 16 (67%) patients had postoperative modified Rankin Scale (mRs) 0-2, six patients (25%) had mRs 3-5, and two patients (8.4%) died. In the unruptured group, 45 patients (87%) had mRs 0-2, 3 patients (6%) had mRs 3-5, and four patients (7.6%) died. Conclusions: In this large series of very large and giant aneurysms treated with microsurgical clipping and bypasses, excellent results were obtained in the long term, in regards to aneurysm occlusion, functional status, and graft patency. Our experience will be very useful to other neurosurgeons who treat these complex lesions
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NI FEATURE: CITADELS SCULPTING FUTURE - COMMENTARY Top

History of neurosurgery in the Armed Forces p. 1758
Harjinder S Bhatoe, MS Sridhar
DOI:10.4103/0028-3886.246298  
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NI FEATURE: TECHNOLOGICAL INNOVATIONS - COMMENTARY Top

Patient-specific interactive software module for virtual preoperative planning and visualization of pedicle screw entry point and trajectories in spine surgery p. 1766
Vetrivel Muralidharan, Ganesh Swaminathan, Devakumar Devadhas, Baylis V Joseph
DOI:10.4103/0028-3886.246281  
Background: Lumbar pedicle screw insertion involves a steep learning curve for novice spine surgeons and requires image guidance or navigation. Small volume centers may be handicapped by the lack of cost-effective user-friendly tools for preoperative planning, guidance, and decision making. Objective: We describe a patient-specific interactive software module, pedicle screw simulator (PSS), for virtual preoperative planning to determine the entry point and visualize the trajectories of pedicle screws. Materials and Methods: The PSS was coded in Python for use in an open source image processing software, 3D Slicer. Preoperative computed tomography (CT) data of each subject was loaded into this module. The entry-target (ET) mode calculates the ideal angle from the entry point through the widest section of the pedicle to the desired target in the vertebral body. The entry-angle (EA) mode projects the screw trajectory from the desired entry point at a desired angle. The performance of this software was tested using CT data from four subjects. Results: PSS provided a quantitative and qualitative feedback preoperatively to the surgeon about the entry point and trajectories of pedicle screws. It also enabled the surgeons to visualize and predict the pedicle breach with various trajectories. Conclusion: This interactive software module aids in understanding and correcting the orientation of each vertebra in three-dimensions, to identify the ideal entry points, angles of insertion and trajectories for pedicle screw insertion to suit the local anatomy.
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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - ORIGINAL ARTICLE Top

Gadoxetate disodium, a modern hepatospecific MRI contrast agent: Indirect signs for gadolinium deposition in the brain structures with signal intensity increase after intravenous application p. 1771
Michal Holesta, Jiri Weichet, Monika Grilli Wagnerova, Jiri Lukavsky, Hana Malikova
DOI:10.4103/0028-3886.246259  
Background: Gadolinium brain deposits after intravenous application of gadolinium-based contrast agents (GBCA) have been recently reported. Aim: We focused selectively on gadoxetate disodium, a hepatospecific linear GBCA. There are currently only a few studies in peer-reviewed literature focused selectively on gadoxetate disodium with conflicting results. Materials and Methods: Twenty patients (mean age 55.5 ± 14.0 years) after previous repeated administrations of gadoxetate disodium (mean 2.6 ± 1.5) for liver diagnostic process were included. All patients had normal renal and liver functions, an intact blood–brain barrier, and did not receive any other GBCA. They underwent 26 brain magnetic resonance imaging (MRI) with T1WI axial scans for signal intensity (SI) evaluation. The SI changes were measured in globus pallidus (GP), dentate nucleus (DN), pons (Po), and thalamus (Th) and SI ratios (DN/Po, GP/Po, GP/Th, Th/Po) were calculated. The control group consisted of 10 healthy volunteers (mean age 54.8 ± 12.1 years) with no prior GBCA applications. Statistical Analysis: Robust linear regression was used to test the effect of number of applications on the SI ratios. Results: The significant effect of number of gadoxetate previous applications on DN/Po SI ratio was found. On an average, the DN/Po ratio increased by 0.36 percentage points [P = 0.042, 95% CI (0.03, 0.69)]. Other SI ratios were not significantly affected. Conclusions: Repeated administrations of hepatospecific gadoxetate disodium leads to a statistically significant increase in the SI values in DN in patients with normal renal and liver functions, and with an intact blood–brain barrier, probably due to gadolinium deposition.
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NI FEATURE: THE FOURTH DIMENSION - COMMENTARY Top

A summary of some of the recently published, seminal papers in neuroscience p. 1776
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:10.4103/0028-3886.246289  
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LETTERS TO EDITOR Top

A case of Lemierre's syndrome with disturbed venous flow confirmed by conventional angiography p. 1793
Sung K Kim, Seongheon Kim, Jae-Won Jang
DOI:10.4103/0028-3886.246255  
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Case of hypomagnesemia with secondary hypocalcemia with a novel TRPM6 mutation p. 1795
Naresh Lal, Swati Bhardwaj, Saptharishi Lalgudi Ganesan, Rachna Sharma, Puneet Jain
DOI:10.4103/0028-3886.246240  
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Adult post-varicella small vessel vaculopathy mimicking hypertensive basal ganglia haemorrhage with coexisting infarcts p. 1800
Kamble J Harsha, K Parameswaran
DOI:10.4103/0028-3886.246293  
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Mitochondrial acetoacetyl-CoA thiolase enzyme deficiency in a 9-month old boy: Atypical urinary metabolic profile with a novel homozygous mutation in ACAT1 gene p. 1802
Soumya Sundaram, Muralidharan Nair, Sheela Namboodhiri, Ramshekhar N Menon
DOI:10.4103/0028-3886.246264  
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Morvan's syndrome: An underdiagnosed entity. A short review p. 1805
Ritu Shree, Manoj K Goyal, Vishnu Y Venugopalan, Manish Modi, Awadh K Pandit, Vivek Lal, BR Mittal
DOI:10.4103/0028-3886.246272  
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Resolution of primary ovarian insufficiency after corticosteroid administration in a myasthenia gravis patient: Report and minireview of the literature p. 1807
Xinxin Liu, Ran Li, Yun Jing
DOI:10.4103/0028-3886.246274  
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Celiac disease presenting as motor neuron disease Highly accessed article p. 1810
Jee Eun Lee, Dong Woo Ryu, Joong Seok Kim, Jae Young An
DOI:10.4103/0028-3886.246268  
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Targeted next generation sequencing reveals novel splice site mutations in COL6A3 gene in a patient with congenital muscular dystrophy p. 1812
Aneek Das Bhowmik, Karthik Tallapaka, Megha Uppin, Challa Sundaram, Ashwin Dala
DOI:10.4103/0028-3886.246266  
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Thalamic hypophonia and the neural control of phonation p. 1815
Appaswamy T Prabhakar, Atif I Shaikh, Ashish Vijayaraghavan, Gideon Rynjah
DOI:10.4103/0028-3886.246247  
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Epineurial ganglion cyst at the cubital tunnel: A rare cause of ulnar neuropathy p. 1817
G Lakshmi Prasad, Girish R Menon
DOI:10.4103/0028-3886.246248  
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Paroxysmal sympathetic hyperactivity due to fourth ventricular tumor resection resulting in cerebrovascular constriction syndrome p. 1821
Sonia Bansal, AR Prabhuraj, Dhaval Shukla, Hima Pendharkar
DOI:10.4103/0028-3886.246261  
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Glossopharyngeal vagal reflex: A matter of concern during neurosurgery p. 1822
Gaurav Singh Tomar, Rajeeb K Mishra, Arvind Chaturvedi
DOI:10.4103/0028-3886.246267  
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Atypical appearance of a premedullary cyst p. 1824
Madhivanan Karthigeyan, Pravin Salunke, Paramjeet Singh, Rekhapalli Rajasekhar, Sunil Kumar Gupta
DOI:10.4103/0028-3886.246269  
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Cavernous angioma of the cerebellopontine angle presenting as hemifacial spasm p. 1826
Lijiang Wang, Mingfang Jiang, Haibin Yin, Ming Huang, Lei Zhu, Xinchen Liang, Yanlan Deng, Shuzhen Hu, Xiang Zhang, Jie Liu
DOI:10.4103/0028-3886.246250  
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Unexplained encephalopathy with phenytoin toxicity – hyperammonemia, the underlying cause p. 1829
Sudhakar Pandey, Praveen K Sharma, Ravindra K Garg, Kedar Takalkar
DOI:10.4103/0028-3886.246257  
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Umbilical cerebrospinal fluid fistula: Report and a review p. 1831
Anand Kumar Jha, Saurav Kumar, Jayendra Kumar, CB Sahay, Anil Kumar
DOI:10.4103/0028-3886.246239  
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An easy mnemonic to remember anesthetic considerations during transsphenoidal surgeries p. 1833
Summit Dev Bloria, Pallavi Bloria
DOI:10.4103/0028-3886.246280  
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Phrenic nerve stimulation for diaphragmatic pacing in chronic ventilator-dependent patients p. 1834
Ratnadip Bose, Anirban D Banerjee, Vimalendu Brajesh, Karanjit S Narang, Sudhir Dubey, Varindera P Singh
DOI:10.4103/0028-3886.246256  
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An unusual postoperative complication in a thoracic spinal extradural arachnoid cyst p. 1837
Ravi Dadlani, Arun S Rao
DOI:10.4103/0028-3886.246241  
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Dorsal arachnoid web: A missed entity p. 1839
Priyamvadha Kovai, Paramveer Sabharwal, Anil K Singh
DOI:10.4103/0028-3886.246271  
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NEUROIMAGES Top

A rare cause of spinal extramedullary compression: An epidural bullet p. 1842
Sami Kouki, Miryiam Moussa
DOI:10.4103/0028-3886.246246  
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A probable cerebral angiitis after allogeneic bone marrow transplantation p. 1843
Hecheng Ren, Lin Ma, Mingsheng Yu, Ming Wei, Long Yin
DOI:10.4103/0028-3886.246260  
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The black pearl of the ocean: Kennedy disease p. 1845
Preet Mukesh Shah, Pradip Parikh, Vijay Dhakre
DOI:10.4103/0028-3886.246251  
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Pericallosal lipoma masquerading as venous thrombosis on magnetic resonance imaging p. 1846
Ravi K Jakkani, K Krishna Reddy, Sandeep Satyanarayan, A Suryanarayana, Kiran K Ramineni
DOI:10.4103/0028-3886.246253  
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Congenital bilateral perisylvian syndrome p. 1847
Chinky Chatur, Ankit Balani
DOI:10.4103/0028-3886.246254  
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Walker–Warburg syndrome p. 1849
Renu Suthar, Suresh K Angurana, Usha Singh, Paramjeet Singh
DOI:10.4103/0028-3886.246262  
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Calcified stylohyoid ligament: A rare presentation as a thick cord-like structure during anterior cervical discectomy and fusion p. 1850
Osmond C Wu, Abhijeet S Barath, Manish K Kasliwal
DOI:10.4103/0028-3886.246265  
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CORRESPONDENCE Top

Deployment of Telemedicine in Neurosciences: The good and the evil—A balanced approach p. 1852
Krishnan Ganapathy
DOI:10.4103/0028-3886.246295  
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Management of advanced Parkinson disease: Still a riddle p. 1853
Jayantee Kalita, Usha K Misra
DOI:10.4103/0028-3886.246294  
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Early post-stroke seizures: An unresolved question p. 1854
Ravinder-Jeet Singh
DOI:10.4103/0028-3886.246292  
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Cerebral interstitial fluid impairment syndrome p. 1855
Pier Paolo Panciani, Karol Migliorati, Marco Maria Fontanella
DOI:10.4103/0028-3886.246234  
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Dos and Don'ts of virtual reality-based simulators for cranial tumor surgery p. 1857
Anatoli Dimitrov, Ali Adnan Dolachee, Mohammed M AbdulAzeez, Samer S Hoz, Alexis Narvaez-Rojas, Guru Dutta Satyarthee, Luis Rafael Moscote-Salazar
DOI:10.4103/0028-3886.246244  
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Role of corrected-assisted-synchronized-periodic therapy in post-stroke rehabilitation: Additional facts p. 1859
Sunil Pradhan, Robin Bansal
DOI:10.4103/0028-3886.246296  
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NI FEATURE - BOOKS FROM MY SHELF - COMMENTARY Top

MacDonald Critchley: The citadel of the senses and other essays p. 1861
Sunil Pandya
DOI:10.4103/0028-3886.246287  
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BOOK REVIEW Top

M Gazi Yasargil. Father of Modern Neurosurgery p. 1865
Harjinder S Bhatoe
DOI:10.4103/0028-3886.246286  
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The skull of Alum Beg. The life and death of a rebel of 1857 p. 1868
Sunil Pandya
DOI:10.4103/0028-3886.246284  
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Self-assessment and review of neurosciences Highly accessed article p. 1870
Harsh Deora
DOI:10.4103/0028-3886.246285  
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OBITUARY Top

IN MEMORIAM: Thanjavur Santhanakrishna Kanaka (31st March 1932 – 14th Nov 2018) Highly accessed article p. 1872
Krishnan Ganapathy
DOI:10.4103/0028-3886.246235  
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Online since 20th March '04
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