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   Table of Contents - Current issue
Coverpage
November-December 2019
Volume 67 | Issue 6
Page Nos. 1401-1576

Online since Friday, December 20, 2019

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NI FEATURE: THE FIRST IMPRESSION - COMMENTARY  

The Cover Page p. 1401

DOI:10.4103/0028-3886.273620  PMID:31857522
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EDITORIAL Top

Spinal Tuberculosis: Still a Great Mimic Highly accessed article p. 1402
Ravindra Kumar Garg, Hardeep Singh Malhotra, Neeraj Kumar
DOI:10.4103/0028-3886.273618  PMID:31857523
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GUEST COMMENTARY Top

The Unbearable Suffering Followed by Ineffable Relief of a Good Doctor: Tuberculosis as a Malady, Still Rules the Roost p. 1405
P Sarat Chandra
DOI:10.4103/0028-3886.273619  PMID:31857524
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REVIEW ARTICLES Top

An Institutional Review of Tuberculosis Spine Mimics on MR Imaging: Cases of Mistaken Identity p. 1408
Sunitha Palasamudram Kumaran, Pushpa Bhari Thippeswamy, Bhavana Nagabhushan Reddy, Sankar Neelakantan, Sanjaya Viswamitra
DOI:10.4103/0028-3886.273630  PMID:31857525
Although MRI has a spectrum of findings which help in the diagnosis of tuberculosis (TB) spine, a broad spectrum of spine pathologies resemble Pott's spine on MRI and are often missed due to inadequate clinical details. As a result, patients are often subject to unnecessary biopsy. A blinded radiologist may misdiagnose such mimic cases as TB. Our aim is to enable the reader to learn the main criteria that differentiate spine TB from other spine etiologies that mimic TB. A retrospective search was done and authors collected only MRI spine reports that showed a differential diagnosis or diagnosis of TB spine from the computer-based data records of the institution over a four-year period. This revealed 306 cases of TB spine out of which 78 cases with an alternate diagnosis that resembled TB spine were included. We describe a single institute review of 78 such cases that resemble and mimic Pott's spine on MRI. The cases being: (n = 15) pyogenic spondylitis, (n = 1) brucellar spondylodiscitis, (n = 12) rheumatoid arthritis, (n = 12) metastases, (n = 8) lymphoma, (n = 5) post-trauma fractures, (n = 10) degenerative disc disease, (n = 2) Baastrup's disease, (n = 9) osteoporotic fracture, (n = 3) spinal neuropathic arthritis, and (n = 1) case of Rosai–Dorfman disease. The clinical and radiological findings of all these cases were correlated with lab findings and histopathology wherever necessary. Appropriate recognition of these entities that resemble and mimic TB spine on MRI is important for optimal patient care. This paper exposes radiologists to a variety of spine pathologies for which biopsy is not indicated, and highlights key imaging findings of these entities to facilitate greater diagnostic accuracy in clinical practice.
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Peripheral Nerve Injuries: Electrophysiology for the Neurosurgeon p. 1419
Nitish Kamble, Dhaval Shukla, Dhananjay Bhat
DOI:10.4103/0028-3886.273626  PMID:31857526
Peripheral nerve injuries are a heterogeneous and distinct group of disorders that are secondary to various causes commonly including motor vehicle accidents, falls, industrial accidents, household accidents, and penetrating trauma. The earliest classification of nerve injuries was given by Seddon and Sunderland, which holds true till date and is commonly used. Neuropraxia, axonotmesis, and neurotmesis are the three main types of nerve injuries. The electrophysiological studies including nerve conduction studies (NCS) and electromyography (EMG) play a key role and are now considered an extension of the clinical examination in patients with peripheral nerve injuries. The electrophysiological results should be interpreted in the light of clinical examination. These studies help in localizing the site of lesion, determine the type and severity of lesion, and help in prognosticating. In neuropraxia, the compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) are elicitable on stimulating the nerve distal to the site of the lesion but demonstrate conduction block on proximal stimulation. The electrodiagnostic findings in axonotmesis and neurotmesis are similar. After few days of injury, Wallerian degeneration sets in with failure to record CMAP and SNAP. Intraoperative technique involves recording from the peripheral nerves during the intraoperative period and has proved useful in the surgical management of nerve injuries and helps in identifying the injured nerve, to determine whether the nerve is in continuity and in localizing the site of lesion. Intraoperative monitoring also helps in identifying the nerve close to an ongoing surgery so that surgical damage to the nerve can be prevented.
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META ANALYSIS Top

Perioperative Stroke in Carotid Artery Stenting as a Surrogate Marker and Predictor for 30-day Postprocedural Mortality – A Pooled Analysis of 156,000 Patients with Carotid Artery Disease p. 1423
Ahmed M Altibi, Eyad E Saca, Harbir Dhillon, Parthasarathy D Thirumala
DOI:10.4103/0028-3886.273642  PMID:31857527
Background: Carotid artery stenosis (CAS) is being recognized as an effective alternative for carotid endarterectomy (CEA). CAS is especially preferred over CEA in high-risk surgical patients with severe carotid stenosis. However, CAS carries an increased risk of stroke and transient ischemic attack (TIA). Objective: To assess the association between periprocedural stroke/TIA and 30-day mortality in carotid stenosis patients undergoing CAS. Methods: We searched PubMed, Embase, and World Science for relevant publications. Studies reporting on perioperative neurologic status (stroke/TIA) and 30-day mortality in patients undergoing CAS were included. Sensitivity, specificity, pooled odds ratio (OR), and relative risk (RR) of perioperative stroke in predicting 30-day mortality following CAS were calculated. Results: 146 studies with 156,854 patients were included in the meta-analysis. The mean patient age was 70.7 years, and 57.6% were males. Only 26.5% of the CAS cohort were symptomatic and 15.2% had bilateral carotid disease. The incidence of perioperative TIA and stroke were 2.4 and 2.7 per 100 CAS procedure, respectively. Around 11.8% of stroke-events were fatal. The pooled OR of 30-day mortality after perioperative stroke was 24.58 (95% CI, 19.92–30.32) and the pooled RR was 21.65 (95% CI, 17.87–26.22). Perioperative stroke had a sensitivity of 42.0% (95% CI 37.8–46.4%) and specificity of 97.0% (95% CI 96.7–97.3%) in predicting 30-day mortality. Conclusions: Perioperative stroke drastically increases the risk of 30-day mortality. The occurrence of perioperative stroke exhibited high specificity but modest sensitivity in predicting 30-day mortality following CAS. This highlights the importance of neurophysiologic monitoring to detect intraoperative cerebral ischemia and perform timely interventions.
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COMMENTARY Top

Carotid Artery Stenting in Occlusive Carotid Artery Disease: An Appraisal p. 1429
Suyash Singh, Kamlesh Singh Bhaisora, Kuntal Kanti Das
DOI:10.4103/0028-3886.273616  PMID:31857528
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ORIGINAL ARTICLE Top

Brain Metastases from Ovarian Carcinoma: An Evaluation of Prognostic Factors and Treatment p. 1431
Anton Wohl, Gil Kimchi, Jacob Korach, Tamar Perri, Leor Zach, Zion Zibly, Ran Harel, Uzi Nissim, Roberto Spiegelmann, Dvora Nass, Zvi R Cohen
DOI:10.4103/0028-3886.273627  PMID:31857529
Aims and Objectives: To review a series of patients with brain metastases from ovarian cancer at a single institution. To describe treatment modalities, their outcomes and to determine prognostic factors. Patients and Methods: Between January 1995 and December 2014, 25 patients with ovarian cancer brain metastases were treated at The Sheba Medical Center. The medical records were retrospectively reviewed to collect demographic, clinical, and imaging data as well as the information on the treatment modalities used and their outcomes. Results: Mean patient age at the time of brain metastasis diagnosis was 62.7 years. The median interval between the diagnosis of primary cancer and brain metastasis was 42.3 months. Neurologic deficits, headache, and seizure were the most common symptoms. The brain was the only site of metastasis in 20% of the patients. Active ovarian cancer at the time of diagnosis of brain metastasis was observed in half of the patients with systemic disease. Multiple brain metastases were observed in 25% of the patients. We treated 11 patients with surgery plus radiation therapy protocols in various orders: surgery followed by complementary whole-brain radiation therapy (WBRT), surgery followed by stereotactic radiosurgery (SRS), and surgery followed by WBRT and then by adjuvant SRS. Five patients underwent surgery alone and nine patients were treated with radiation alone (WBRT, SRS, or both). Univariate analysis for predictors of survival demonstrated that age above 62.7 years at the time of central nervous system involvement was a significant risk factor and leptomeningeal disease was a poor prognostic factor in reference to supra-tentorial lesions. Multivariate analysis for predictors of survival, however, showed that multiple brain lesions (>4) were a poor prognostic factor, and multivariate analysis of the time to progression revealed that combined treatments of surgery and radiation resulted in longer median periods of progression-free survival than each modality alone. Conclusion: We conclude that the only significant predictors of survival or progression-free survival in our cohort were the number of brain metastases and the treatment modality.
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COMMENTARY Top

Commentary on Brain Metastasis from Ovarian Carcinoma: Evaluation of Prognostic Factors and Treatment p. 1437
Aliasgar Moiyadi, Salman Shaikh
DOI:10.4103/0028-3886.273610  PMID:31857530
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The Predictive Value of Conventional Magnetic Resonance Imaging Sequences on Operative Findings and Histopathology of Intracranial Meningiomas: A Prospective Study p. 1439
Madhivanan Karthigeyan, Sivashanmugam Dhandapani, Pravin Salunke, Paramjeet Singh, Bishan D Radotra, Sunil Kumar Gupta
DOI:10.4103/0028-3886.273632  PMID:31857531
Background: Previous studies have tried to relate magnetic resonance (MR) characteristics of meningiomas with its intraoperative features and histopathology with varying results. This is a prospective study to assess the independent predictive value of conventional MR signals [T1, T2, and fluid attenuated inversion recovery (FLAIR)] in relation to consistency, vascularity, operative plane, Simpson excision, and histopathology of intracranial meningiomas in a multivariate model. Materials and Methods: Seventy patients underwent T1, T2, FLAIR, postcontrast sequences followed by excision of their meningiomas. Tumor signal intensity in various sequences was studied in relation to the above-mentioned variables. Multivariate analysis to find their independent association was performed. Results: T1 images showed no correlation with any of the variables. FLAIR hypointensity and inhomogeneous enhancement had significant association with tumor hardness. FLAIR hypointense tumors were associated with low vascularity. FLAIR hypointensity, skull base location, and recurrence were significantly related to the subpial or mixed operative plane. The meningioma–brain interface on T2 sequence was significantly related to the operative plane. Only skull base location had significant impact on the extent of excision. T2 and FLAIR hypointensity had significant association with fibroblastic or psammomatous meningiomas. On multivariate analysis, FLAIR hypointensity and skull base location had a significant independent relationship with suboptimal operative plane, while skull base location had association with the extent of excision. Among MRI sequences, FLAIR hypointensity showed high specificity (94%) in predicting the suboptimal operative plane. Conclusions: FLAIR hypointensity of meningiomas appears to have a significant independent association with the suboptimal operative plane with high specificity.
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COMMENTARY Top

Developing Standard MRI Quantification for Predicting Meningioma—A Need of Time p. 1446
Vivek Singh, Suryanandan Prasad
DOI:10.4103/0028-3886.273611  PMID:31857532
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Various Strategies of Transsphenoidal Pseudocapsule-Based Extracapsular Resection in Noninvasive Functional Pituitary Adenomas and their Effectiveness and Safety p. 1448
Qing-Xin Li, Wei-Hong Wang, Xian-Xiang Wang
DOI:10.4103/0028-3886.273628  PMID:31857533
Introduction: Increasing attention has been paid to the pseudocapsule-based extracapsular resection in transsphenoidal surgery for pituitary adenomas. Prior reports focused more on Cushing disease or nonfunctional pituitary adenomas. In this study we present systematic research, especially concerning all kinds of noninvasive functional pituitary adenomas (NIFPAs) adopting various strategies of extracapsular resection, in order to evaluate the effectiveness and safety of these surgical methods for NIFPAs. Materials and Methods: From October 2008 to November 2014, 116 patients suffering from NIFPAs underwent pseudocapsule-based extracapsular resection (ER) with different surgical strategies; that is, by a microscope or endoscope via the endonasal transsphenoidal approach. During the same period, 90 patients suffering NIFPAs also underwent traditional transsphenoidal intracapsular resection (IR). In different postoperative periods, we re-examined the endocrine series and recorded the complications. Enhanced magnetic resonance imaging examination was also performed three months later. Results: In the ER and IR group, the tumors were completely removed in 97 (83.7%) and 62 (68.9%) cases, whereas the endocrine disorders were remitted in 89 (76.7%) and 53 (58.9%) cases, respectively. Statistical analyses to compare the overall complete resection rates and the overall endocrine remission rates in both groups showed significant differences (P = 0.028 and 0.006, respectively). Intraoperative rhinorrhea occurred in 26.7% patients of the ER group and 13.3% of the IR group, showing a significant difference (P = 0.019). Transient diabetes insipidus occurred in 73.3% patients of the ER group and 63.3% of the IR group, with no difference between groups (P = 0.126). There was no case with intracranial hematoma or pituitary crisis in both the groups. Conclusion: With our various surgical strategies of ER, the patients can achieve content imaging resection, high and sustained endocrine remission, which are effective and safe for NIFPAs.
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COMMENTARY Top

Extracapsular Resection of Noninvasive Functional Pituitary Adenomas p. 1456
Chandrashekhar Deopujari, Aniruddha Bhagwat
DOI:10.4103/0028-3886.273656  PMID:31857534
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What Happens to Swallowing Muscles after Stroke?: A Prospective Randomized Controlled Electrophysiological Study p. 1459
Ebru Karaca Umay, Volkan Yilmaz, Ibrahim Gundogdu, Erhan Ozturk, Eda Gurcay, Ozgur Karaahmet, Guleser Saylam, Tijen Ceylan, Aytul Cakci
DOI:10.4103/0028-3886.273645  PMID:31857535
Background: Stroke is the most frequent reason of neurological dysphagia Electrophysiological studies can be used to evaluate oral, pharyngeal and initial phase of esophageal phase. Aims: This study aims to noninvasively evaluate mastication, mimic, and tongue muscles of stroke patients, which play an important role in the oral phase of swallowing process and compare them with healthy individuals. Setting and Design: This study was conducted at the Physical Medicine and Rehabilitation Clinic of our hospital between January 2014 and December 2016. Materials and Methods: Fifty-one patients who were admitted to our clinic with stroke and 51 healthy individuals were evaluated for the study. Demographic features of individuals were recorded. The swallowing intervals and motor action potentials (MAPs) of trigeminal, facial and hypoglossal nerves were measured. After four weeks of treatment schedule, patients were re-evaluated. Statistical Analysis: The Wilcoxon Signed Rank test, the Mann–Whitney U test and Fisher exact test were used in this study. Results: The all swallowing intervals were found prolonged compared to the healthy controls (P < 0.05). The MAPs of the masseter, orbicularis oculi, and intrinsic tongue muscles were significantly lower in patient group (P < 0.05). After treatment, we found significant improvement for all parameters in patient group, but the swallowing intervals were still significantly prolonged, and MAPs of these muscles were still lower (P < 0.05). Conclusion: Although swallowing is examined as different phases, the process is complicated and should be evaluated totally. In post-stroke dysphagia, oral phase of swallowing process is as important as phayngeal phase and perioral, mastication, and tongue muscles are influenced even in an early period as a month.
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COMMENTARY Top

Poststroke Dysphagia- Does Electrophysiology Help in Evaluation and Monitoring? p. 1467
Soumya Sundaram, PN Sylaja
DOI:10.4103/0028-3886.273612  PMID:31857536
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Differential DNA Methylation Patterns in Patients with Epilepsy due to Malformations of Cortical Development: A Pilot Study p. 1469
Kuntal Sen, Rupali Gadkari, Rajkumar Agarwal, Senthil Sundaram
DOI:10.4103/0028-3886.273638  PMID:31857537
Objective: To study the DNA methylation profiles in brain tissue of patients with refractory epilepsy due to malformations of cortical development (MCDs). Materials and Methods: Clinical, neuroimaging, and pathology characteristics were defined for 13 patients who underwent resective surgery for epilepsy. Methylation analysis was performed using Illumina® 450k Methylation Microarray. Data analysis was completed, and pathway identification was done using the R/Bioconductor package. Results: Genes associated with Ephrin–Reelin pathway, potassium channels, and glutathione metabolism were differentially methylated in the MCD group when compared with patients who had no evidence of MCD. Conclusions: Our preliminary data reveal that epigenetic pathways may have a role in the pathobiogenesis of MCDs.
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COMMENTARY Top

Epigenetic Regulation of mTOR Pathway in Malformations of Cortical Development p. 1472
Krishan Kumar, Jyotirmoy Banerjee, Manjari Tripathi, P Sarat Chandra, Aparna B Dixit
DOI:10.4103/0028-3886.273613  PMID:31857538
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An Institutional Retrospective Study of Coil Loop Herniation and its Management p. 1474
Ishu Bishnoi, Tomotaka Ohshima, Kojiro Ishikawa, Taiki Yamamoto, Shunsaku Goto, Yoko Kato
DOI:10.4103/0028-3886.273637  PMID:31857539
Introduction: Endovascular coiling is a method of aneurysm embolization. Sometimes coil loops herniate in the lumen after deployment of the coil. It is usually seen in wide-necked aneurysms. It can cause migration of the coil and thromboembolic complications. There are different methods such as the use of a balloon, stent, and coil retriever to treat coil loop herniation. There are very few case series on coil loop herniation management. Most series are about the use of a stent/balloon for reposition. We are going to describe simple, novel techniques to treat coil loop herniation. Materials and Methods: In the last five years, 13 aneurysms out of 325 coiled aneurysms had coil loop herniation. We used three different techniques in these patients according to our selection criteria. The first technique was loop trap with another coil, the second was balloon and coil-plasty to trap, and the third was rescue stent and flow control. Results: The first, second, and third techniques were successfully used in five, five and three patients, respectively. There was a complete reposition of herniated coil and thus embolization of aneurysm in all cases. All patients recovered completely without any thromboembolic complications. Conclusions: We recommend the use of these techniques according to the proper selection criteria.
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COMMENTARY Top

Commentary on An Institutional Retrospective Study of Coil Loop Herniation and Its Management p. 1480
Gaurav Goel, Anshu Mahajan
DOI:10.4103/0028-3886.273614  PMID:31857540
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A Comparison of Intracerebral Transplantation of RMNE6 Cells and MSCs on Ischemic Stroke Models p. 1482
Yun Wu, Li-Wang Yang, Xiao-Yan Zhai, Jian-Chun Liu
DOI:10.4103/0028-3886.273641  PMID:31857541
Background: Cell therapy using stem cells is promising for stroke patients; however, stem cell therapy faces many problems. RMNE6 cells, a new stem cell line, are superior to other stem cell lines. Mesenchymal stem cells (MSCs) appear to be a promising candidate for stroke patients. In the current study, we determined the therapeutic effects of RMNE6 cells on a middle cerebral artery occlusion (MCAO) model of rats and identified the differences between RMNE6 cells and MSCs with respect to therapeutic effects. Material and Methods: RMNE6 and Enhanced green fluorescent protein (EGFP)-labeled MSCs were transplanted into the ischemic brains of MCAO rats. The behavior of rats was examined using the rotarod test with neuroradiologic assessment using magnetic resonance imaging (MRI). Four weeks after cell transplantation, the rats were investigated by immunofluorescence staining to explore the fates of the graft cells. Result: After transplantation, RMNE6 cells and MSCs survived and migrated toward the injured area without differentiation. There was tumorigenesis in the brains transplanted with RMNE6 cells. Cell transplantation had no effects on the size of the ischemic volume. The behavior of the model animals showed no significant improvement. Conclusion: MSCs are still the preferred cells for cell replacement in stroke therapy, while RMNE6 cells need to be modified.
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COMMENTARY Top

Stem Cell Therapy for Ischemic Stroke Injury: A Current Status p. 1491
Pius Padayatti
DOI:10.4103/0028-3886.273617  PMID:31857542
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Loss of SMARCB1/INI1 Immunoexpression in Chordoid Meningiomas p. 1492
Prit B Malgulwar, Aanchal Kakkar, Mehar C Sharma, Ranajoy Ghosh, Pankaj Pathak, Chitra Sarkar, Vaishali Suri, Manmohan Singh, Shashank S Kale, Mohammed Faruq
DOI:10.4103/0028-3886.273647  PMID:31857543
Background: Chordoid meningiomas have an aggressive clinical course characterized by frequent recurrences. Recent whole-genome sequencing studies demonstrated Chr22 loss in chordoid meningiomas not accounted for by NF2 mutations. SMARCB1/INI1 is a candidate gene on Chr22, which has not been analyzed extensively in meningiomas. AKT1 mutation has been recently identified to be a driver of meningiomagenesis. Materials and Methods: Cases of chordoid meningioma were retrieved along with meningiomas of other subtypes for comparison. INI1 immunohistochemistry was performed. SMARCB1 and AKT1 were analyzed by sequencing. Results: Sixteen chordoid meningiomas were identified (1.1% of all meningiomas). Six cases (37.5%) showed loss of INI1 immunoexpression. All other meningioma subtypes (n = 16) retained INI1 immunoexpression. AKT1 E17K mutation was identified in one case (16.7%). Notably, SMARCB1 mutations were not identified in any of the chordoid meningiomas analyzed, including those showing INI1 loss immunohistochemically. Conclusion: This is the first study to demonstrate loss of SMARCB1/INI1 immunoexpression in chordoid meningiomas, adding to the tumors with INI1 loss. However, in absence of INI1 mutation, mechanisms for INI1 loss require further evaluation. Identification of AKT1 mutation opens up new avenues for targeted therapy in patients with such aggressive tumors.
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Loss of INI1 Expression-Understanding the Molecular Basis of Chordoid Meningiomas p. 1498
Meenakshi Tiwari, Ajit K Saxena, Lokendra K Sharma
DOI:10.4103/0028-3886.273615  PMID:31857544
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The Prevalence of Physiological Anisocoria and its Clinical Significance - A Neurosurgical Perspective p. 1500
Anjali Sarah George, Ananth P Abraham, Shalini Nair, Mathew Joseph
DOI:10.4103/0028-3886.273623  PMID:31857545
Aim: We aimed to estimate the prevalence of physiological anisocoria and also evaluate the accuracy of clinical assessment of anisocoria employed in routine bedside examination. Materials and Methods: A total of 708 voluntary subjects between the ages of 20–69 years who had no history of ophthalmologic or neurological disease other than refractive error were included in the study. In a closed room with uniform ambient lighting, the subjects' pupils were examined clinically and the presence or absence of anisocoria was recorded. This was followed by photography of the subjects' pupils using a digital camera secured on a tripod at a fixed distance from the subject's face. A difference in pupillary size of 0.4 mm or more was considered anisocoria. Results: Of the 708 subjects, 361 (51%) were males. The average pupillary diameter of the subjects was 4.99 mm. Ninety-seven (13.7%) had measured anisocoria on photography. Ninety-seven subjects (13.7%) also had anisocoria on clinical examination, however, only 45 of them had measured anisocoria. The clinical measurement of anisocoria, therefore, showed a specificity of 0.91 and a sensitivity of 0.46. With a prevalence of anisocoria of 13.7%, the positive predictive value was 0.46, and the negative predictive value was 0.91. Conclusions: The prevalence of physiological anisocoria was 13.7%, which is less than what has previously been reported. The sensitivity of clinical examination in detecting early anisocoria is poor. Patients at risk of developing uncal herniation may, therefore, benefit from routine bedside pupillary assessment with a portable device such as a pupillometer.
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NEUROPATHOLOGY DISCUSSION Top

“Slow and Steady” Infiltrates the Brain: An Autopsy Report of Lymphomatosis Cerebri p. 1504
Kirti Gupta, Vivek Gupta, Bishan D Radotra, Manoj K Tewari
DOI:10.4103/0028-3886.273648  PMID:31857546
Primary central nervous system lymphomas (PCNSL) usually present as single or multiple lesions with mass effect involving the cerebral hemispheres or basal ganglia. An extremely rare pattern of involvement termed “Lymphomatosis cerebri” (LC) presents as diffuse, non-enhancing infiltrative lesions without mass effect. We describe the clinical, radiological, and autopsy findings of one such rare example with a patient presenting with a short history of fever, memory loss, and progressive cognitive decline. Because of subtle yet rapidly progressive clinical symptoms and overlapping neuroimaging features, the diagnosis of LC is challenging with wide ranging differential diagnoses. The dilemma in diagnosing such lesions can lead to delay in diagnosis and institution of appropriate management. Thus, knowledge about its imaging and morphological features is very critical for correct categorization and to avoid potential misdiagnosis of this often-missed disease.
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NI FEATURE: TECHNOLOGY INNOVATIONS Top

Development of a Unique Retractor for Performing Endoscopic Pituitary Surgery-EASYTRAC p. 1509
P Sarat Chandra, Kiran Deep Kaur
DOI:10.4103/0028-3886.273609  PMID:31857547
Background: A unique self-expanding retractor (EASYTRAC®) is described, which provides several advantages for endoscopic pituitary surgery-enhanced visualization, creating more space, reducing the mucosal damage, and enhancing the nasal quality of life (QoF). Presented here is the proof of concept. Methods: EASYTRAC® is made of an aircraft-grade, SS-titanium alloy to provide optimal opening strength with a low profile (0.5 mm thick). It has a nonreflective, smooth surface finish. Patented design and wire pulling method of the EASYTRAC® makes it easy to insert and deploy. EASYTRAC® is inserted through the submucosal tunnel using a small, unilateral mucocutaneous incision. Following this, the ring attached to the wire is pulled out to deploy the retractor. This provides expansion of the retractor leading to fracture of the septum to one side at the keel of the vomer. The rest of the surgery is performed in the standard manner using an endoscope. The retractor is a single-use, disposable instrument and available in three different sizes. Results: Five endoscopic endonasal surgeries have been performed using the EASYTRAC®(four pituitary adenomas, one craniopharyngioma). Deviated nasal septum (DNS) was present in two of the surgeries. All surgeries were approached through the right mucoseptal corridor, and presence of DNS did not reduce exposure (<10 minutes for exposure). No hardware problem was observed in any of the cases. Intraoperative cerebrospinal fluid (CSF) leak (n = 1) was managed with intraoperative, standard, triple-layer closure with glue and lumbar drain. Conclusion: Retractor seems to be safe, easy to use, and effective. The surgeon's capabilities are enhanced by the retractor's dynamicity, minimal fogging of scope, minimal trauma to the mucosa, and adequate space to allow the introduction of three instruments through a single nostril.
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KNOW YOUR VITAL STATISTICS Top

Statistical Significance versus Clinical Importance p. 1513
Kameshwar Prasad
DOI:10.4103/0028-3886.273608  PMID:31857548
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CASE REPORTS Top

Gamma Knife Radiosurgical Pallidotomy for Dystonia: Not a Fallen Angel p. 1515
Manjul Tripathi, Srinivasan Sharan, Sahil Mehta, Harsh Deora, Nishant S Yagnick, Narendra Kumar, Chirag K Ahuja, Aman Batish, Jenil Gurnani
DOI:10.4103/0028-3886.273644  PMID:31857549
The authors report a case of successful management of right side hemidystonia with gamma knife radiosurgery. A 24-year-old male with a history of birth asphyxia subsequently developed worsening right-sided torsional hemidystonia which failed to respond to the medical management. MRI of the brain was unremarkable. Stereotactic gamma knife radiosurgery (GKRS) was performed to create a lesion in the left posteroventral globus pallidum. The patient gradually improved over a course of 18 months without any complication. He obtained 61% improvement in dystonia rating scale. Radiosurgical pallidotomy is often viewed with suspicion and functional neurosurgeons show reluctance in preferring it to stereotactic radio frequency lesioning or stimulation surgery. The authors would like to highlight the chances of not only control, but also cure of the disease with this cost-effective treatment modality.
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Tumefactive Demyelinating Lesions and Pregnancy p. 1519
Domenico Plantone, Carlo Piantadosi, Serena Ruggieri, Vincenzo Anelli, Tatiana Koudriavtseva
DOI:10.4103/0028-3886.273654  PMID:31857550
Until now, only one gestational tumefactive demyelinating lesion (TDL) has been described. Here we report two TDL cases occurring during and after the pregnancy. A 26-year-old 6-week pregnant woman developed a 3-cm left frontotemporoparietal subcortical TDL with inhomogeneous partial enhancement. Brain biopsy revealed a subacute demyelinating lesion with abundant macrophages and mild chronic perivascular inflammatory infiltrates. She also had femoralpopliteal deep vein thrombosis. During the 4-year follow-up, magnetic resonance imaging showed only residual biopsied TDL. The second case was a 41-year-woman affected by both multiple sclerosis (MS) and rheumatoid arthritis who developed a 2-cm right anterior corona radiata TDL with sporadic gadolinium-enhancing “annular spots” eight months after delivery. After steroid therapy at the 6-month radiological follow-up, this TDL was half-reduced. Five years earlier, at the beginning of her MS, she already had a 2-cm TDL with incomplete ring enhancement. These two described TDLs formed in prothrombotic conditions and were likely representative of thromboinflammation around and inside the small-medium veins.
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The Effects of Lee - Silverman Voice Treatment on Voice and Swallowing Functions in a Case with Bilateral Striopallidodentate Calcinosis p. 1522
Fatma Esen Aydinli, Aydan Baştuǧ Dumbak
DOI:10.4103/0028-3886.273625  PMID:31857551
Background: Bilateral striopallidodentate calcinosis (BSPDC) is a rare neurodegenerative disorder characterized by abnormal calcium accumulation in the basal ganglia, dentate nucleus, and semioval center. Speech, voice, and swallowing abnormalities can be associated with the disease. However, there are a limited number of studies regarding the speech and swallowing characteristics of this disease in the literature. Lee-Silverman voice therapy (LSVT-LOUD) is a structured speech therapy method that can be used to treat neurogenic conditions. Aims: The main purpose of this article was to document the effects of LSVT-LOUD on voice and swallowing functions in a case of BSPDC. Design: Case report. Methods: A comprehensive voice and swallowing evaluation, including objective methods, was conducted before therapy and at post-therapy follow-ups (FU) after 3 months and 6 months. Results: The voice and swallowing parameters were substantially improved at the 3-month FU; at the 6-month FU, the improvement in swallowing function was still preserved; however, the improvement in voice function had regressed. Conclusion: LSVT-LOUD may improve the voice and swallowing functions of patients with BSPDC. However, long-term retention of the effects of LSVT-LOUD should be investigated in future studies.
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A Singular Manifestation of Contrast-induced Encephalopathy Following Coronary Angiography p. 1525
Leila Riahi, Meriem Mediouni, Meriem Messelmani, Wafa Fehri
DOI:10.4103/0028-3886.273634  PMID:31857552
Contrast-induced encephalopathy is an uncommon complication of coronary angiography. The clinical presentation may be very puzzling, leading to an unnecessary and hazardous therapy. The prognosis is believed to be benign, with spontaneous resolution. We report a 71-year-old woman with a past medical history of hypertension, type two diabetes and no history of renal disease. She was admitted to our cardiology department with symptoms of recurrent angina. She had a history of unstable angina two years ago and had undergone a percutaneous coronary intervention without incident. Three hours after un-elective coronary angiography, she experienced a sudden, transitory deterioration in her consciousness's level with neurovegetative symptoms (high blood pressure, high temperature). The cerebral Computer Tomography scan ruled out any acute hemorrhagic or ischemic stroke. In less than 24 hours, she recovered spontaneously with a complete resolution of the neurological symptoms.
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Young Stroke: An Unusual Presentation of Arrhythmogenic Right Ventricular Dysplasia p. 1528
Jignesh M Parikh, Gaurav Ganeshwala, Navin Mathew, Anil Venkitachalam, Krishna Upas Natarajan
DOI:10.4103/0028-3886.273639  PMID:31857553
Arrhythmogenic right ventricular dysplasia (ARVD) is an underdiagnosed cardiomyopathy which commonly presents in young adults with ventricular tachycardia or sudden cardiac death. We report a case of ARVD presenting with features of acute ischemic cerebrovascular stroke. The suspicion of ARVD came only when the echocardiogram revealed dilatation and abnormal wall motion of the right ventricle in the presence of certain ECG findings consistent with ARVD. The diagnosis was later confirmed by cardiac MRI which is one of the most specific diagnostic tests for ARVD.
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A Severe Form of M - protein Negative Distal Acquired Demyelinating Symmetric Neuropathy p. 1532
Tien Lee Ong, Khean-Jin Goh, Nortina Shahrizaila, Kum-Thong Wong, Cheng-Yin Tan
DOI:10.4103/0028-3886.273621  PMID:31857554
Distal acquired demyelinating symmetric neuropathy (DADS) is a variant of chronic inflammatory demyelinating polyneuropathy (CIDP) characterized by symmetrical, distal, sensory or sensorimotor involvement. DADS with M-protein (DADS-M) is less responsive to immunotherapy compared to those without M-protein (DADS-I). We report a case of DADS-I with severe clinical presentation viz. early hand involvement with marked wasting, inexcitable peripheral nerves on neurophysiology and poor response to immunotherapy. Despite the unusual presentation, ancillary tests including cerebrospinal fluid analysis, nerve biopsy and nerve ultrasound were supportive of an inflammatory demyelinating polyneuropathy. This case demonstrated the heterogeneity of the disorder and expands the clinical spectrum of DADS neuropathy.
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Recurrent Guillain-Barré Syndrome – Case Series p. 1536
Ivana Basta, Ivo Bozovic, Ivana Berisavac, Olivera Stojiljkovic-Tamas, Sonja Lukic Rajic, Aleksandra Dominovic-Kovacevic, Aleksandar Stojanov, Gordana Djordjevic, Dejana Jovanovic, Stojan Peric
DOI:10.4103/0028-3886.273649  PMID:31857555
Recurrent Guillain-Barré syndrome (RGBS) episodes appear in up to 6% of Guillain-Barré syndrome (GBS) patients. The purpose of this study was to identify patients with previous episodes of GBS and to assess their clinical features in a large cohort of adult GBS patients. GBS patients hospitalized at tertiary centers in three Balkan countries were included in the study (n = 404). We identified 13 (3.2%) patients with recurrent GBS (RGBS). The male to female ratio was 3: 1. All RGBS patients had two episodes of the disease. The most common GBS subtype in both episodes of the disease was acute inflammatory demyelinating polyradiculoneuropathy (AIDP) (77%, first episode; 85%, second episode). Around 23% of patients presented with a different variant during the second GBS attack. Disability seems to be equally severe at both episodes (P > 0.05). Recurrent GBS was registered in 3% of our GBS patients. The majority of them were younger males. Different GBS subtypes were found to recur.
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BRIEF REPORT Top

Chronic Respiratory Disease and Cognitive Impairment in Older Mexican Adults p. 1539
Sreenivas P Veeranki, Brian Downer, Daniel Jupiter, Yong-Fang Kuo, Mukaila Raji, William Calhoun, Rebeca Wong
DOI:10.4103/0028-3886.273646  PMID:31857556
Background: Cognitive impairment has emerged as an important concern in clinical practice in aging population. Several comorbid factors contribute to etiopathogenesis; one disease of interest is chronic respiratory disease. Aim: The aim of this study is to investigate the association of chronic respiratory disease with risk of cognitive impairment in older Mexicans. Materials and Methods: Data were obtained from 2782 Mexicans, aged ≥60 years, enrolled in waves I (2001) and III (2012) of the Mexican Health and Aging Study, a prospective cohort of nationally representative sample of older Mexicans. Participants' self-reported responses were used to categorize them into having respiratory disease or not. Study outcome included participants categorized into “cognitively impaired” or “cognitively normal” groups. Multivariable logistic regression models were used to investigate the relationship. Results: Overall, 16% of cohort participants reported cognitively impaired at Wave III. Compared with older Mexicans without chronic respiratory disease diagnosis, those diagnosed were not significantly associated with risk of cognitive impairment [adjusted odds ratio (OR): 0.94, 95% confidence interval (CI): 0.58–1.58]. Conclusion: Chronic respiratory disease is not significantly associated with risk of cognitive impairment in older Mexican adults.
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LETTERS TO EDITOR Top

A Rare Case of Intradural Extramedullary Ewing's Sarcoma in the Cervical Region p. 1543
Anshu C Warade, Ashish K Jha, Sanjeev Pattankar, Chitra Madiwale, Bharat Rekhi, Ketan Desai
DOI:10.4103/0028-3886.273622  PMID:31857557
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Intradural Invasion of Cervical Chordoma in a 34 Year Old Patient p. 1545
Huibing Ruan, Ratnesh N Mehra, Daehyun Park, Dean Chou
DOI:10.4103/0028-3886.273633  PMID:31857558
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Risk Homeostasis and Automation Bias in Neurosurgery p. 1549
George C Vilanilam, Gopikrishnan Rajasekar
DOI:10.4103/0028-3886.273643  PMID:31857559
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Do All Displaced Midline Ectodermal Cells Assimilate into Epidermoid Cysts? p. 1551
Sumedha Anjankar, SD Anjankar
DOI:10.4103/0028-3886.273624  PMID:31857560
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Short Segment C1 - C2 Fusion in a Case of Congenital C2 Spondylolysis Associated with Chiari Malformation p. 1553
Kokkula Praneeth, Pravin Salunke, Madhivanan Karthigeyan, Puneet Malik
DOI:10.4103/0028-3886.273635  PMID:31857561
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Neurophysiological Monitoring in Spinal Dural Arteriovenous Fistula Surgery at the Thoracic Spine: A Case Report p. 1556
Emine Taskiran, Rahşan Kemerdere, Orkhan Alizada, Murat Hancı
DOI:10.4103/0028-3886.273640  PMID:31857562
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Adrenoleukodystrophy: The Importance of Early MRI Findings and Serial Imaging p. 1559
Neeraj Jain, Rajendra Vishnu Phadke, Shubha Phadke, Aradhana Dwivedi
DOI:10.4103/0028-3886.273651  PMID:31857563
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Nonalcoholic Wernicke's Encephalopathy Followed by Neuromyelitis Optica Spectrum Disorders: A Case Report p. 1562
Dongdong Zhang, Xiaohui Yang, Zaihang Zhang, Wanyu Zhao, Peiyang Duan, Ganqin Du
DOI:10.4103/0028-3886.273629  PMID:31857564
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A Relapsing Chronic Inflammatory Demyelinating Polyneuropathy Preceding Type I Diabetes in a Young Male p. 1565
Mansour Malek, Souissi Wala, Kacem Wafa, Riahi Anis, Mrissa Ridha
DOI:10.4103/0028-3886.273652  PMID:31857565
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NEUROIMAGES Top

Late-onset Hemorrhagic Disease of a Newborn Mimicking an Atypical Teratoid/Rhabdoid Tumor p. 1566
Mahesh Kamate, Mayank Detroja, Virupaxi Hattiholi
DOI:10.4103/0028-3886.273655  PMID:31857566
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An Adult Presentation of Leigh's Disease-like with Brainstem Involvement p. 1568
Gaurav K Mittal, Sachin Sureshbabu, Sudhir Peter, Chindripu Sobhana, Amit Garg, Raghunath Babu, Laxmi Khanna
DOI:10.4103/0028-3886.273650  PMID:31857567
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Lingual Cysticercosis p. 1571
Tarun Nagpal
DOI:10.4103/0028-3886.273631  PMID:31857568
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Fahr's Syndrome in a Sporadic Case p. 1573
Valerio Brunetti, Michela Ada Noris Ferilli, Marco Luigetti
DOI:10.4103/0028-3886.273636  PMID:31857569
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BOOK FROM MY SHELF Top

“Who Moved My Cheese?” by Spencer Johnson p. 1575
Natarajan Muthukumar
DOI:10.4103/0028-3886.273653  
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Online since 20th March '04
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