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   Table of Contents - Current issue
Coverpage
July-August 2019
Volume 67 | Issue 4
Page Nos. 963-1183

Online since Tuesday, September 10, 2019

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NI FEATURE: THE FIRST IMPRESSION - COMMENTARY  

The Cover Page Highly accessed article p. 963

DOI:10.4103/0028-3886.266281  PMID:31512614
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EDITORIAL Top

We Stand on the Shoulders of Our Teachers … So that We Can See Further … Highly accessed article p. 964
P Sarat Chandra
DOI:10.4103/0028-3886.266286  PMID:31512615
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NI FEATURE: JOURNEY THROUGH THE EONS - COMMENTARY Top

Navigating Neurosurgery into an Optimal Future p. 966
PN Tandon
DOI:10.4103/0028-3886.266271  PMID:31512616
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REVIEW ARTICLES Top

Deep Brain Stimulation in Parkinson's Disease Highly accessed article p. 968
Naveed Malek
DOI:10.4103/0028-3886.266268  PMID:31512617
Deep brain stimulation (DBS) has become an established therapeutic tool for treating patients with Parkinson's disease (PD) who have troublesome motor fluctuations and dyskinesias refractory to best medical therapy. In addition to its proven efficacy in patients with late PD, the EARLYSTIM trial not only demonstrated the efficacy of DBS in patients with early motor complications but also showed that it did not lose its therapeutic efficacy as the years passed by. However, like all other therapies for PD, DBS is not offered to patients either as a cure for this disease nor is it expected to stop the progression of the neurodegenerative process underlying PD; these important issues need to be highlighted to patients who are considering this therapy. This article aims to provide an introduction to residents or trainees starting a career in movement disorders of the technical aspects of this therapy and the evidence base for its use. For the latter objective, PUBMED was searched from 1946 to 2017 combining the search terms “deep brain stimulation” and “Parkinson's disease” looking for studies demonstrating the efficacy of this therapy in PD. Inclusion criteria included studies that involved more than 20 patients with a physician confirmed diagnosis of PD and a follow-up of greater than or equal to at least 12 months. The findings from those studies on motor symptoms, medication requirements, quality of life, and independence in activities of daily living in PD patients are summarized and presented in tabulated form in this paper at the end.
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Eye Signs in Pituitary Disorders p. 979
Yan Chen, Zhihong Liu, Zhihui Lin, Xiaozhe Shi
DOI:10.4103/0028-3886.266265  PMID:31512618
The eye is a vital sense organ and plays a vital role in conveying the underlying physical and mental state of wellbeing of an individual. A comprehensive examination of the eye is often required in patients presenting with systemic complaints. Many endocrine disorders have characteristic manifestations pertaining to the eye, the classical being the exophthalmos in thyrotoxicosis. However, a cursory eye evaluation may lead to the identification of early features that can help in the diagnosis of other endocrine disorders. This is more common in cases of pituitary mass lesions, who often present with the functional hormonal alterations rather than the visual symptoms. The definitive therapy during the late stages of the disease leads to persisting visual disabilities and affects the quality of life. Hence, the endocrinologists and ophthalmologists need to be aware of various ophthalmic features in the pituitary disorders. In this review, we highlight the eye signs in pituitary disorders, along with a brief description of uncommon ocular-pituitary syndromes.
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The Benefits and Risks of Statin Therapy in Ischemic Stroke: A Review of the Literature Highly accessed article p. 983
Wang Zhao, Zhi-Jie Xiao, Shui-Ping Zhao
DOI:10.4103/0028-3886.266274  PMID:31512619
Statins are effective cholesterol-lowering drugs for reducing the risks of mortality and morbidity of cardiovascular diseases. Increasing evidence has shown that statin use is associated with a significant beneficial effect in patients with ischemic stroke. Both pre-stroke and post-stroke statin use has been found to be beneficial in ischemic stroke. Furthermore, good adherence is associated with a better clinical outcome, and statin withdrawal is associated with a poor functional outcome in patients with ischemic stroke. High-intensity statin therapy is advocated for the treatment of ischemic stroke. However, there are concerns regarding the adverse effects associated with statin use in ischemic stroke such as intracranial hemorrhage. In this review, we summarize the beneficial effect of statin use in ischemic stroke and discuss the potential risks associated with statin therapy.
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META ANALYSIS - ORIGINAL ARTICLE Top

Role of Aspirin in Tuberculous Meningitis: A Systematic Review and Meta-analysis Highly accessed article p. 993
Imran Rizvi, Ravindra K Garg, Hardeep S Malhotra, Neeraj Kumar, Ravi Uniyal
DOI:10.4103/0028-3886.266232  PMID:31512620
Objectives: Aspirin is a drug that has been found to be useful in reducing the incidence of infarctions. This systemic is aimed at review evaluating the benefits of aspirin in the management of tuberculous meningitis. Methods: A systematic literature search was performed using PubMed, Cochrane Central Register of Controlled Trials, and SCOPUS for articles published on or before September 22, 2018. The meta-register of controlled trials and bibliography was also searched. Randomized controlled trials wherein aspirin was used were included in the systematic review. The data was extracted using a predetermined format. The risk ratio (RR) for dichotomous data was calculated and a random-effects model was used to combine the data. Death and occurrence of new infarctions were considered as primary outcomes. The quality of evidence was assessed using the GRADE approach. Results: Four trials including 546 patients were found eligible. The addition of aspirin to anti-tuberculosis drug regimens did not significantly reduce mortality [RR = 0.66 (0.42–1.02); low-quality evidence] but significantly reduced the risk of new infarctions [RR = 0.52 (0.29–0.92); moderate-quality evidence]. Aspirin did not differ from the placebo with regard to the adverse event outcome. Conclusion: Aspirin reduces the risk of new infarctions in patients with tuberculous meningitis but does not affect mortality (moderate-to-low level of evidence).
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COMMENTARY Top

Tuberculous Meningitis – Adjunctive Therapy: Corticosteroids, Aspirin, or Both p. 1003
J M K Murthy
DOI:10.4103/0028-3886.266280  PMID:31512621
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The Correlation of Endothelial Nitric Oxide Synthase (eNOS) Polymorphism and Other Risk Factors with Aneurysmal Subarachnoid Hemorrhage: A Case-Control Study p. 1006
Subhas K Konar, Shruthi Ramesh, Rita Christopher, A Prasanthi, Dhananjaya I Bhat, Dhaval Shukla, R Bharath, B Indira Devi
DOI:10.4103/0028-3886.266231  PMID:31512622
Objective: Endothelial nitric oxide synthase gene (eNOS) polymorphism is an association with cerebral aneurysm formation, rupture, and vasospasm and plays a role in the a functional outcome. Patients and Methods: The aim of the study was to evaluate the role of eNOS gene polymorphism and further assess the predictors of outcome in the aneurysmal subarachnoid hemorrhage (aSAH). A prospective case-control study was conducted from 2009 to 2012 among those who presented with aSAH. A serum sample was collected from aSAH patients along with age and sex-matched healthy controls. The frequency of polymorphism of eNOS gene and other factors (demographic and aneurysmal) were correlated with functional outcome at six month of follow-up. Results: 100 patients with aSAH and 100 healthy controls were enrolled in the cohort. The mean age of the patient group was 51.61 years and control group was 45.81 years with a male:female ratio of 1:1.38 and 1:1.08 for patients and controls, respectively. Among all eNOS polymorphisms, 4BB (65%) 24-VNTR, TT (71%) of T-786C, and GG (71%) of G947T were the most common and frequency was similar in the control group. The occurrences of hypertension, smoking, diabetes were 32%, 37%, and 7% respectively in the patient group. Maximum patients were in WFNS grade 1 (53%) followed by 23% grade 2 and only 10% in grade 4. Fisher grade 3 (57%) was the most common followed by Fisher grade 4 (28%). Most aneurysms (97%) were in anterior circulation. 83% of the aneurysms were clipped and 10% underwent coiling. Size-wise most of the aneurysms were in the middle group (6–9 mm) followed by bigger group (>10 mm) (37%); only 6% aneurysms were in the small aneurysm (<6 mm) group. 33% of the patients had evidence of vasospasm. TT of G894T polymorphism (60%) had the highest incidence of vasospasm. Univariate analysis showed smoking (OR: 3.19, CI: 1.19–8.84, P = 0.01), 4AA (OR: 12.15, CI: 1.13–624.9, P = 0.03) variety of 24-VNTR polymorphism, CC (OR: 15.39, CI: 1.60–762.8, P = 0.01) variety of T786C polymorphism, Fisher grade 4 (OR: 3.43, CI: 1.24–9.68, P = 0.01), WFNS grade (poor vs. good) (OR: 3.42, CI: 1.17–10.12, P = 0.02), vasospasm (OR: 3.84, CI: 1.42–10.75, P = 0.006), intraoperative rupture (OR: 4.77, CI: 1.55–15.27, P = 0.004) were significantly related with unfavorable outcome at 6 months follow-up. In regression analysis, smoking (CI: 0.06–0.69, P = 0.01), Fisher grade 4 (CI: 0.09–1.00, P = 0.05), and intraoperative rupture (CI: 0.05–0.89, P = 0.03) were correlated with an unfavorable outcome at 6 months follow-up. Conclusion: The eNOS gene polymorphism, smoking, clinical grade (WFNS), Fisher grade, intraoperative rupture, and vasospasm play a role in functional outcome after the treatment of cerebral aneurysms.
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COMMENTARY Top

eNOS: A Passing Fad or the Crux of the Panacea? p. 1013
Sivashanmugam Dhandapani
DOI:10.4103/0028-3886.266243  PMID:31512623
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ORIGINAL ARTICLE Top

Endoscopic versus Microscopic Pituitary Adenoma Surgery: A Single-center Study p. 1015
Ajler Pablo, Beltrame Sofia, Toscano Maximiliano, Fainstein Day Patricia, Campero Alvaro, Yampolsky Claudio, Carrizo Antonio
DOI:10.4103/0028-3886.266241  PMID:31512624
Background: Transsphenoidal approach became the gold standard in the surgical treatment of pituitary adenomas in the past years, but the comparative efficacy of microscopic and endoscopic transnasal surgery has not been fully studied. Aims: To compare the microscopic and endoscopic transnasal approaches for the treatment of pituitary adenomas. Settings and Design: A retrospective analysis was performed, comparing adult patients with pituitary adenomas who had undergone transnasal microscopic surgery between January 2006 and December 2014 with the patients operated on with endoscopic surgery between March 2011 and December 2014 at Hospital Italiano de Buenos Aires. Material and Methods: Imaging, hormonal, and ophthalmological studies as well as complications were analyzed. Statistical Analysis: Due to the existence of dichotomous variables, Fisher's exact test was used for statistical analysis. Results: In all, 259 patients who had undergone microsurgery and 140 patients operated on with endoscopy were included. The pathologies compared were microsurgically resected nonfunctioning adenomas: 38.2% (n = 99) versus endoscopically resected: 42.1% (n = 59), and microsurgically resected functioning adenomas: 61.8% (n = 160) versus endoscopically resected: 57.9% (n = 81). A higher number of patients with invasive macroadenomas were reported in the group operated on with endoscopy (35.5% vs. 56.4%). When the patients with invasive pathology of the cavernous sinus were compared, percentages of total resection and hormonal control were higher for endoscopic surgeries (35% vs. 46.8%; 33.3% vs. 64%); however, this difference was not statistically significant. No statistically significant differences were found when postoperative complications were individually analyzed. Conclusion: The microsurgical and endoscopic approaches are safe and effective techniques to treat pituitary adenomas. For invasive adenomas, the endoscopic approach may report better results.
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COMMENTARY Top

Commentary on “Endoscopic versus Microscopic Pituitary Adenoma Surgery: A Single-center Study ” p. 1022
Yad Ram Yadav
DOI:10.4103/0028-3886.266272  PMID:31512625
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Endoscopic Transsphenoidal Surgery: A Revolutionary Evolution p. 1024
Dhananjaya I Bhat
DOI:10.4103/0028-3886.266248  PMID:31512626
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ORIGINAL ARTICLES Top

Impact of Hyperventilation and Sleep Deprivation Upon Visual Evoked Potentials in Patients with Epilepsy p. 1027
Edyta Dziadkowiak, Ryszard Podemski
DOI:10.4103/0028-3886.266246  PMID:31512627
Objectives: The diagnosis of epilepsy can cause many problems, especially when the routine electrophysiological tests are inconclusive. The aim of the present study was to assess the visual evoked potential (VEP) in patients with epilepsy using various kinds of stimulation and activation tests. The VEP parameters were also presented with reference to the type of seizure and abnormalities in electroencephalogram (EEG), including the response to the activation tests. Materials and Methods: This study comprised 81 patients with newly diagnosed epilepsy of unknown etiology before initiation of the treatment. The VEP tests were performed at rest, after hyperventilation, and deprivation of sleep. Visual stimulation included an alternating checkerboard pattern and a uniform flash light (FL) with a frequency of 1.88 and 15 Hz. Results: The VEP parameters obtained with the stimulation of a checkerboard pattern did not differ significantly between the patients and controls. Neither the presence of seizure activity in EEG nor the type of seizure significantly affected the VEP parameters. Using the FL stimulation, a significantly prolonged VEP latency was found at the FL frequency of 1.88 Hz and shortened at the frequency of 15 Hz. These changes were augmented after activation tests. In case of the patients with positive intermittent photic stimulation response in EEG, a significant prolongation of P100 latency was shown at rest and after FL stimulation at the frequency of 1.88 Hz. Conclusion: Standard activation methods significantly affect the VEP parameters in patients with epilepsy. Changes in the VEP parameters depend on the frequency and the type of the stimulus, as well as the activation method used. These findings suggest a disturbed balance between the glutamatergic and GABAergic systems in the visual excitability of neuronal networks in case of patients with epilepsy.
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Post-stroke Visual Gait Measure for Developing Countries: A Reliability and Validity Study p. 1033
Kamal Narayan Arya, Shanta Pandian, Vikas Kumar, GG Agarwal, Akash Asthana
DOI:10.4103/0028-3886.266273  PMID:31512628
Background: Visual gait assessment is a cost-effective clinical method to assess post-stroke gait deviations. The Rivermead Visual Gait Assessment (RVGA) is a one such measure that assesses the kinematic aspect of the gait deviations in stroke. However, the available information on psycho-clinocometric properties of the measure is not adequate. Objective: To establish reliability and validity of RVGA using walking-videos of the post-stroke subjects. Methods: Design: Observational study. Setting: A rehabilitation institute Participants: A convenience sample of 40 chronic stroke patients. Outcome Measures: RVGA, Fugl–Meyer assessment (lower extremity), 10-m walk test, Time up and go test, and Berg balance scale (BBS). Procedure: Walking was video-taped from the anterior aspect, posterior aspect, affected side, and less-affected side. After coding the tapes, a research staff member provided them to four different raters in a random order. Each rater scored the coded video on the RVGA data collection sheet twice: one at the baseline and another after 1 month to eliminate any recollection of the initial assessment. Results: The findings exhibit that there was good-to-excellent agreement between the scores of the raters and also between the assessments (correlation coefficient = 0.94 to 0.95; P < 0.001). The measure also exhibits acceptable validity when correlated with scores of BBS (r = 0.4; P < 0.001). Conclusion: Video-based RVGA is a reliable and valid tool to assess gait-related impairment in post-stroke hemiparesis. This cost-effective measure may be incorporated in the clinical and research practice to discern and quantify complex phenomenon of the gait deviation. RVGA may be considered as a useful tool, especially in developing countries where expensive gait analyzer is usually not available.
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Post-stroke Gait Analysis in Rehabilitation Set-up: Observational or Instrumental! p. 1041
Anupam Gupta, AB Taly
DOI:10.4103/0028-3886.266276  PMID:31512629
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Neurological Manifestations Do not Affect Cumulative Survival in Indian Patients with Antineutrophil Cytoplasmic Antibody Associated Vasculitis p. 1043
Aman Sharma, Roopa Rajan, Manish Modi, Benzeeta Pinto, Aadhaar Dhooria, Manish Rathi, Tarun Mittal, Susheel Kumar, Kusum Sharma, Varun Dhir, Ritambhra Nada, Ranjana W Minz, Surjit Singh
DOI:10.4103/0028-3886.266234  PMID:31512630
Background: Neurological manifestations are an important cause of morbidity in antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV). It is not clear whether or not they are indicative of a severe disease course with multiple organ involvement and shortened survival. Aims and Objectives: To characterize the neurological manifestations of AAV and analyze their relationship with other organ system and cumulative survival. Methods: This was a retrospective single-center cohort study of AAV patients at a tertiary care hospital in North India. Data was collected from medical records regarding clinical history, neurological examination, Birmingham Vasculitis Activity Score (BVAS), serology, electrophysiology, imaging, and histopathological examination findings of patients. Results: Ninety-two patients of systemic vasculitis were identified, 67 with granulomatosis with polyangiitis (GPA), 14 with microscopic polyangiitis, 8 with Churg–Strauss syndrome (CSS), and 3 with undifferentiated AAV. The median BVAS at presentation was 18.0 (interquartile range (IQR): 12.0). The median duration of follow-up was 31.3 months (IQR: 40.5). A total of 45.7% patients had neurological manifestations among which 23.8% presented with neurological complaints. Peripheral neuropathy was the most common manifestation noted in 23.9% of the patients. Among patients with GPA, 40.3% had neurological involvement (seen in 33.3% patients at presentation). Patients with nervous system disease were more likely to have associated musculoskeletal manifestations (P = 0.046) and less likely to have renal involvement (P = 0.017). The estimated cumulative survival of the subgroup with neurological involvement was 95.1 months from the time of diagnosis, which was not significantly different from the cohort without neurological involvement (113.8 months, P = 0.631). Conclusion: Neurological morbidity commonly accompanies systemic vasculitis. Nervous system disease does not affect the survival significantly in these patients.
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Neurological Manifestations of ANCA-associated Vasculitides: Not Good but Not Bad or Ugly Either p. 1048
Gagandeep Singh, Amol Nanak Singh
DOI:10.4103/0028-3886.266269  PMID:31512631
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Need of Immediate Drug Reduction after Epilepsy Surgery – A Prospective Observational Study p. 1050
Jitin Bajaj, Sarat P Chandra, Bhargavi Ramanujam, Shabari Girishan, Ramesh Doddamani, Manjari Tripathi
DOI:10.4103/0028-3886.266282  PMID:31512632
Background: Patients undergoing epilepsy surgery are on polytherapy. Drug tapering is usually done after 1 year in adults and after 6 months in children. Sometimes, drugs have to be altered during the perioperative period, which is more commonly seen in hemispherotomy (HS) patients. The present study was done to compare perioperative drug alterations between HS and temporal (TL) lobectomy patients. Materials and Methods: Prospective analysis of postoperative HS and TL patients was done. Primary outcomes were drug number, dosage changes, and seizure outcome. Secondary outcome studied was a change in intelligence quotient (IQ) in the two groups. Results: At total of 71 patients were included. Perioperative drug stopping (clobazam – CLB) was needed in 3/38 patients in the HS group, due to sedation. Dosage was reduced in 23/38 (60.52%) in HS group, and in 2/33 (6%) in TL group P < 0.001. The most common drug was CLB, with reduction in 21/27 (77.77%) patients, with a mean reduction of 41.21 ± 4.01%. Two patients required drug substitution in the HS group. About 64/71 (90.1%) patients achieved Class I outcome at a 1-year postoperative time point (TL – 90.9%, HS – 89.47%). There was no change in IQ in any of the groups. Conclusion: Perioperative drug alteration is often needed in the HS patients as compared to TL patients. Benzodiazepines have to be reduced to maintain alertness in the HS patients. The increased sedation postoperatively can be due to decreased cortical drive over the reticular activating system, gamma-aminobutyric acid (GABA) receptor denervation hypersensitivity, or increased activity of drugs over the remaining active hemisphere.
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Remaining Alert to Sedation by Antiepileptic Drugs Just after Epilepsy Surgery p. 1054
Parampreet S Kharbanda, Jitupam Baishya
DOI:10.4103/0028-3886.266285  PMID:31512633
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Antiplatelets versus Anticoagulants in the Treatment of Extracranial Carotid and Vertebral Artery Dissection p. 1056
VS Vineetha, Sapna E Sreedharan, PS Sarma, PN Sylaja
DOI:10.4103/0028-3886.266290  PMID:31512634
Background: Very few studies have compared the safety and efficacy of antiplatelets and anticoagulants in the treatment of extracranial carotid and vertebral artery dissection. Our study was aimed at comparing the two types of antithrombotic treatment in extracranial dissection and to study the predictors of outcome in these patients. Materials and Methods: Prospective data of 200 consecutive patients with a confirmed diagnosis of extracranial carotid (n = 132) or vertebral (n = 68) artery dissection (76% males; mean age, 43.5 ± 13 years) treated with antiplatelets (n = 136) or anticoagulants (n = 64) were analyzed retrospectively. The presenting symptom was stroke in 74.5%, transient ischemic attack (TIA) in 18.5%, and local symptoms in 7% of the patients. Follow-up was done at three and six months. Primary outcome measures were TIA or stroke and symptomatic intracerebral hemorrhage (SICH) at three months. Results: At the three-month follow-up, 106 (53%) patients had an excellent outcome. Recurrent ischemic events occurred in 7 (3.5%) and SICH in 11 (5.55%) patients. Six (4.41%) patients in the antiplatelet group and 1 patient (1.56%) in the anticoagulant group had recurrent ischemic events (P = 0.434); SICH was more frequent in the anticoagulant group (9.4% vs 3.7%, P = 0.185). On multivariate analysis, significant predictors of a poor three-month outcome were stroke as the presenting event and severity of stroke at onset. Conclusions: The risk of recurrent ischemic events in carotid and vertebral artery dissection is low and is irrespective of the type of antithrombotic treatment. Stroke as the presenting event and severity of stroke at onset were significant predictors of a poor three-month outcome.
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The Saga of How to Stitch the Tear … p. 1060
MV Padma Srivastava
DOI:10.4103/0028-3886.266270  PMID:31512635
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Endovascular Nuances in Management of Multiple Intracranial Aneurysms p. 1062
MN Tejus, Daljit Singh, Anita Jagetia, Hukum Singh, Monica Tandon, Rajiv Chawla, P Ganjoo
DOI:10.4103/0028-3886.266249  PMID:31512636
Background: Endovascular treatment of aneurysm is the accepted standard of treatment. Multiple intracranial aneurysms are frequently detected due to advances in imaging. Objective: The purpose of this study was to determine aneurysm properties, management strategies, and outcome of patients with multiple intracranial aneurysms managed by endovascular approach. Materials and Methods: Data of all patients with multiple intracranial aneurysms who were managed at our institute over a period of 1 year were retrospectively studied. Data of 20 consecutive patients with single aneurysm who were endovascularly managed during the same study period were also collected. Patient demographics, intraprocedural radiation exposure, hardware used, and clinical and angiographic outcome at discharge were analyzed. Results: A total of 112 patients with intracranial aneurysm were managed during the study period, of which 11 patients had multiple intracranial aneurysms, with a total of 23 aneurysms. Incidence was more among females (63.6%). Proximal of multiple aneurysms ruptured more commonly (63.6%), and internal carotid artery (ICA) bifurcation was the most common site (45.4%). Of the 23 aneurysms, 18 were coiled. Seven patients had good outcome and it was found to be influenced by preoperative Hunt and Hess scale. Based on Raymond–Roy grading, 17 of 18 aneurysms (94.4%) were completely coiled; angiographic outcome was comparable in both the groups. Patients with multiple aneurysm had statistically significant high radiation exposure (4.5 vs 3.8 m SV) as compared to patients with single aneurysm (P < 0.05), but had low stochastic effect. In patients with aneurysm involving different arterial compartment, 66.2% required change of microcatheter. Conclusion: Single-stage treatment of multiple aneurysm can be achieved with good outcome. Even though radiation exposure is high while treating multiple aneurysm as compared to single aneurysm cases, its stochastic risks are low.
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Influence of Oncotherapy and Clinical Parameters on Survival of Glioblastoma Patients: A Single Center Experience p. 1066
Almos Klekner, Judit Tóth, József Virga, Tibor Hortobágyi, Ádám Dér, Csaba Szemcsák, Judit Reményi-Puskár, László Bognár
DOI:10.4103/0028-3886.266257  PMID:31512637
Background: Routine administration of temozolomide (TMZ) in the treatment protocol of glioblastoma in the last few years resulted in improving survival parameters of these patients but efficacy of supplementary bevacizumab (BVC) monotherapy has not been evidently proven. In this study, the effectiveness of different postoperative therapy for glioblastoma patients treated in our institute was evaluated. In addition, the prognostic value of clinical parameters on survival was also analyzed. Methods: Accordance of clinical parameters (age, gender, tumor localization, size, side, Karnofsky performance score, and extension of tumor removal), postoperative treatment (radiotherapy [RT], RT + TMZ, RT + TMZ + BVC), and survival data were tested by 104 patients operated on glioblastoma in the Department of Neurosurgery, University of Debrecen between 2002 and 2012. Results: Concurrent chemo-RT resulted in significant longer overall survival (OS) than RT alone (PRTvs.RT + TMZ = 0.0219) and BVC treatment after progression during TMZ also elongated survival significantly (PRT vs. RT + TMZ + BVC < 0.0001; PRT + TMZvs.RT + TMZ + BVC = 0.0022), respectively. Clinical parameters showed no significant influence on OS in comparison with different methods of postoperative oncotherapy. Conclusions: Both TMZ and BVC had a beneficial effect on glioblastoma patients' survival, but tested clinical parameters showed no evident accordance with final outcome. Although neurosurgery has an indispensable role in resecting space occupying tumors and providing good postoperative performance score patients for oncotherapy, the survival of glioblastoma patients depends rather on radio- and chemo-sensitivity than tested clinical parameters.
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Clinical Significance of Fractional Anisotropy Measured in Peritumoral Edema as a Biomarker of Overall Survival in Glioblastoma: Evidence Using Correspondence Analysis p. 1074
Eduardo Flores-Alvarez, Coral Durand-Muñoz, Filiberto Cortes-Hernandez, Onofre Muñoz-Hernandez, Sergio Moreno-Jimenez, Ernesto Roldan-Valadez
DOI:10.4103/0028-3886.266284  PMID:31512638
Introduction: Fractional anisotropy (FA), a diffusion tensor image (DTI) derived biomarker is related to invasion, infiltration, and extension of glioblastoma (GB). We aimed to evaluate FA values and their association with intervals of overall survival (OS). Materials and Methods: Retrospective study conducted in 36 patients with GB included 23 (63.9%) males, 46 ± 14 y; and 13 (36.1%) females, 53 ± 13; followed up for 36 months. We measured FA at edema, enhancing rim, and necrosis. We created two categorical variables using levels of FA and intervals of OS to evaluate their relationships. Kaplan-Meier method and correspondence analysis evaluated the association between OS (grouped in 7 six-month intervals) and FA measurements. Results: Median FA values were higher in healthy brain regions (0.351), followed by peritumoral edema (0.190), enhancing ring (0.116), and necrosis (0.071). Pair-wise comparisons among tumor regions showed a significant difference, P < 0.001. The median OS for all patients was 19.3 months; variations in the OS curves among subgroups was significant χ2 (3) = 8.48, P = 0.037. Correspondence analysis showed a significant association between FA values in the edema region and the survival intervals χ2 (18) = 30.996, P = 0.029. Conclusions: Alternative multivariate assessment using correspondence analysis might supplement the traditional survival analysis in patients with GB. A close follow-up of the variability of FA in the peritumoral edema region is predictive of the OS within specific six-month interval subgroup. Further studies should focus on predictive models combining surgical and DTI biomarkers.
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NI FEATURE: CENTS (CONCEPTS, ERGONOMICS, NUANCES, THERBLIGS, SHORTCOMINGS) - COMMENTARY Top

Give an Inch and Get a Mile – Simple Modification in the Pial Stay Suture Technique for Intramedullary Spinal Tumors p. 1082
Arun Kumar Srivastava, Deepak Khatri, Kamlesh Singh Bhaisora, Kuntal Kanti Das, Ved Prakash Maurya, Sanjay Behari
DOI:10.4103/0028-3886.266240  PMID:31512639
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Know Some Vital Statistics: What is P Value? p. 1086
Kameshwar Prasad
DOI:10.4103/0028-3886.266277  PMID:31512640
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CASE REPORTS Top

Longitudinally Extensive Transverse Myelitis with Aquaporin-4 Antibody Positivity in Renal Cell Carcinoma: Rare Occurrence p. 1087
Rohan R Mahale, Anish Mehta, Kiran Buddaraju, Mahendra Javali, Abhinandan K Shankar, Aju Abhraham John, Rangasetty Srinivasa
DOI:10.4103/0028-3886.266293  PMID:31512641
The occurrence of longitudinally extensive transverse myelitis (LETM) in an elderly patient should evoke search for underlying systemic malignancy. Intramedullary spinal cord metastases and paraneoplastic myelopathy are the most common etiology for LETM in patients with systemic malignancy. The occurrence of LETM in association with renal cell carcinoma with aquaporin-4 (AQP4) antibody positivity has not been reported. We report an elderly woman who presented with acute paraplegia and was diagnosed as having LETM with AQP4 positivity and renal cell carcinoma.
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Parry Romberg Syndrome: A Unique Clinico-radiological Entity p. 1090
Chirag K Ahuja, Anuj Prabhakar, Vivek Gupta, Manish Modi, Niranjan Khandelwal
DOI:10.4103/0028-3886.266253  PMID:31512642
Parry Romberg syndrome (PRS) is an unusual neurological entity characterized by progressive hemifacial atrophy. We describe the case of a 17-year-old male who presented with recurrent seizures and facial asymmetry of 1 year duration. Computed tomography (CT) of the head showed right-sided hemifacial atrophy involving the subcutaneous fat, muscles, and bones alongwith subcortical white matter hypodensity, having parenchymal foci of calcification. The etiology of PRS is debated from being secondary to abnormalities in fat metabolism to autoimmune and inflammatory causes. The treatment is symptomatic and is targeted at relief of seizures and migraine. Steroids and other immunomodulators have proven successful in some cases. Surgical correction may be done once the disease stabilizes.
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Drug Refractory Epilepsy – A Series of Lesions with Triple Pathology p. 1093
Vivek Tandon, Poodepedi Sarat Chandra, Raghav Singla, Jitin Bajaj, Aanchal Kakkar, Mehar Chand Sharma, Ashok Kumar Mahapatra, Manjari Tripathi
DOI:10.4103/0028-3886.266289  PMID:31512643
The associations between gangliogliomas, dysembryoplastic neuroepithelial tumors (DNETs), and cortical dysplasias remain debatable. We report five cases of drug refractory epilepsy with temporal lobe lesions. On resection, histopathological examination showed distinctive areas of gangliogliomas and DNETs with cortical dysplasia. The coexistence of the above three lesions as distinct entities in a single lesion is virtually unknown. This points to the presence of a possible etiological relationship among them. Finally, we also delve into a plausible hypothesis for such a pathogenesis.
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Neurogenic Fever in Severe Traumatic Brain Injury Treated with Propranolol: A Case Report p. 1097
Mayank Garg, Kanwaljeet Garg, Pankaj K Singh, Guru Dutta Satyarthee, Deepak Agarwal, Ashok K Mahapatra, Bhawani S Sharma
DOI:10.4103/0028-3886.266258  PMID:31512644
The causes of intractable fever in severe traumatic brain injury (TBI) patients can be diverse. Neurogenic fever (NF) which is a rare entity can develop due to autonomic dysregulation in the absence of infection or any other cause of fever. It manifests as fever, tachycardia, paroxysmal hypertension, dilated pupils, tachypnea, and extensor posturing in cases of severe TBI, brain neoplasms or brain haemorrhage. We found propranolol to be effective in controlling many of the manifestations of neurogenic fever in our patients with severe TBI. Fever in severe TBI patients is not an uncommon phenomenon, but when intractable with negative fever workup, a central cause should be considered. Propranolol is deemed as one of the most efficacious drugs for managing NF due to dysautonomia. We want to apprise the readers about this entity and its treatment with beta-blockers.
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Malignant Transformation of Pediatric Low-grade Gliomas: Report of Two Cases and Review of a Rare Pathological Phenomenon p. 1100
KS Avinash, Sumit Thakar, Saritha Aryan, Nandita Ghosal, Alangar S Hegde
DOI:10.4103/0028-3886.266259  PMID:31512645
Low-grade gliomas (LGGs) are the commonest benign central nervous system (CNS) tumors seen in children. Unlike LGGs in adults, pediatric LGGs rarely undergo malignant transformation. The incidence of malignant transformation of LGGs in the pediatric population has been reported to be up to 10%. Of these, a few patients have demonstrated this phenomenon even without adjuvant radiation therapy. We report two such unusual cases. A 7-year-old girl presented with a left temporal lesion that was operated upon and was reported as pilocytic astrocytoma (WHO grade I). She presented with a malignant transformation of the tumour 8 years later. The second case was a 10-year-old boy, who had a left frontoparietal ganglioglioma (WHO grade I) that demonstrated malignant transformation to an anaplastic ganglioglioma (WHO grade III) 10 months after the initial surgery. Multiple studies have thrown light on the molecular genetics behind malignant transformation of LGGs in children. These genetic changes can perhaps serve as targets for potential future therapeutic interventions. It is important that patients with LGGs at risk of malignant transformation must be identified early so that a more aggressive treatment strategy can be adopted.
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Solitary Intracerebral Phaeoid Fungal Granuloma: A Case Report p. 1107
Sureswar Mohanty, Pranita Mohanty, Lipsa Priyadarshini
DOI:10.4103/0028-3886.266263  PMID:31512646
Fungal granuloma in the brain parenchyma caused by pheohyphomycosis is extremely rare. Antifungal drugs are not very effective. The present report is a case of solitary pheohyphomycosis granuloma, which underwent surgical excision followed by antifungal drug treatment with excellent result.
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Refractory Open Jaw Oromandibular Tardive Dystonia with a Sensory Trick, Treated with Botulinum Toxin: A Case Report p. 1110
Ali S Shalash, Abdelrahman Ibrahim Abushouk, Mohammed Yasser Elsherbeny, Hanan Elrassas, Taha Kamel
DOI:10.4103/0028-3886.266235  PMID:31512647
Jaw-opening oromandibular dystonia (O-OMD) is a clinical subtype of OMD, commonly resistant to treatment. Here, we report a distinct case of tardive O-OMD with a characteristic sensory trick, successfully treated with high-dose botulinum toxin (BTX) injection. A 34-year-old male patient presented with involuntary jaw opening, tongue protrusion, dysarthria, and mild cervical dystonia. The patient reported improved abilities to talk and close his mouth after putting something, like a cigarette, between his teeth. After an unsuccessful treatment with anticholinergic medications, the patient received electromyography-guided BTX injection to the lateral pterygoids (through an extraoral approach), sternocleidomastoids, trapezius, tongue, and platysma muscles. Following the injection, the patient reported marked improvements in his ability to talk and close his mouth without using his sensory trick. One month later, we detected a 58.2% improvement in the Abnormal Involuntary Movement Scale score. Therefore, high-dose BTX injection may be an effective alternative in refractory O-OMD.
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Pathophysiological Evaluation in a Case of Wernicke's Encephalopathy by Multimodal MRI p. 1112
Yuelei Lyu, Tao Jiang
DOI:10.4103/0028-3886.266252  PMID:31512648
To report a patient with Wernicke's encephalopathy (WE) using multimodal magnetic resonance imaging (MRI) including conventional MRI, diffusion-weighted MRI (DWI), arterial spin labeling (ASL), and proton MR spectroscopy (MRS). A 50-year-old woman of WE with a history of cholecystectomy and acute pancreatitis was given MRI scans including DWI, MRS, and ASL pre- and post-thiamine treatment. Two weeks after admission, the patient's condition rapidly improved. The typical MRI findings and lesions in the frontal cortex at baseline disappeared or resolved partially. The reduced apparent diffusion coefficient value in part of the thalamus lesion, the elevated cerebral blood flow in the frontal cortex, the lactate doublet peak in the right thalamus lesion, and in cerebral spinal fluid, all resolved after treatment. The combination of conventional MRI with DWI, proton MRS, and ASL, offers a powerful diagnostic tool and a better understanding of the pathophysiological and hemodynamic mechanisms.
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LETTERS TO EDITOR Top

Dengue-related Longitudinally Extensive Transverse Myelitis p. 1116
Wendy Tan, Christopher Thiam Seong Lim
DOI:10.4103/0028-3886.266296  PMID:31512649
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A Case Report of Recurrent Hypokalemic Paralysis—missing the “Period” p. 1117
Siddhesh Rajadhyax, Bhumir Chauhan, Vikram Huded, Siddaramappa J Patil, Anuradha Kannan, Venkatraman Bhat, Subramanian Kannan
DOI:10.4103/0028-3886.266245  PMID:31512650
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Baclofen-induced Coma and Respiratory Depression in a Patient with Cervical Spondylotic Myelopathy with Chronic Kidney Disease p. 1120
Thotalampatti Pachiyappan Jeyaselvasenthilkumar, Deiveegan Kunjithapatham, Sekar Chinnasamy, Mohamed Abith Ali
DOI:10.4103/0028-3886.266260  PMID:31512651
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Miller Fisher Syndrome Following Tetanus, Diphtheria, and Pertussis (Tdap) Vaccine p. 1122
Rajat Garg, Shyam S Moudgil
DOI:10.4103/0028-3886.266262  PMID:31512652
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Actinomyeces Cerebral Abscess Masquerading as Tuberculosis: Delayed Presentation following Head Trauma and Scalp Infection p. 1123
Manish Kumar, Ankur Bajaj, Manjul Tripathi, Bishan D Radotra, Manoj K Tewari, Chirag K Ahuja
DOI:10.4103/0028-3886.266291  PMID:31512653
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A Case of Artery of Percheron Infarct: Need for High Clinical and Radiological Suspicion p. 1126
Arun K Agrawal, Kuljeet S Anand, Pawan Kumar, Jyoti Garg
DOI:10.4103/0028-3886.266283  PMID:31512654
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Tuberculous Meningitis in a Patient with Cushing's Disease: Glucocorticoid-mediated Immunosuppression: Case Report, and Review of the Literature p. 1128
Gregoire P Chatain, Gautam U Mehta, Lynnette K Nieman, Susmeeta Sharma, Susan Yuditskaya, Ray Y Chen, Lynne Yockey, Steven M Holland, Prashant Chittiboina
DOI:10.4103/0028-3886.266237  PMID:31512655
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Kikuchi Disease: A Rare Cause of Aseptic Meningitis p. 1131
Dhiren R Patel, Arun B Shah, Hardik R Shah, Kiran B Thorat
DOI:10.4103/0028-3886.266242  PMID:31512656
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Aspergilloma Masquerading as Meningioma: An Experience of Two Cases and Review of Literature p. 1133
Ravi Sharma, Kanwaljeet Garg, Manoj Phalak, Vivek Tandon, Kalpana Kumari, Vaishali Suri, Ashish Suri, Ajay Garg, SS Kale, AK Mahapatra
DOI:10.4103/0028-3886.266244  PMID:31512657
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HyperCKemia Can Occur Due to This! A Less Recognized Etiology p. 1136
Rohan R Mahale, Anish Mehta, Abhishek Miryala, Rangasetty Srinivasa
DOI:10.4103/0028-3886.266288  PMID:31512658
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Upper Limb Monochorea Due to Cerebral Venous Sinus Thrombosis: Rare Occurrence p. 1138
Rohan Mahale, Anish Mehta, Akshay Konnur, Purushottam Acharya, R Srinivasa
DOI:10.4103/0028-3886.266255  PMID:31512659
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Chiari Type I Malformation with Syringomyelia Presenting with Isolated Hemi-anhidrosis: Report of a Rare Case p. 1140
Gautam Dutta, Daljit Singh, Anita Jagetia, Manish Garg, Mohd Iqbal, AK Srivastava
DOI:10.4103/0028-3886.266256  PMID:31512660
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Cyclooxygenase-2 Gene Polymorphisms and Risk of Alzheimer's Disease: A Possible Biomoleular Explanation p. 1142
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/0028-3886.266266  PMID:31512661
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Cerebellar Demyelination: Rare Presentation of HIV Infection p. 1142
Vijay Sardana, Parag Moon
DOI:10.4103/0028-3886.266287  PMID:31512662
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Sporadic CADASIL: A Rare Occurrence p. 1145
Amandeep Singh, Sudhir Mehta, Laxmi Kant Goyal, Gunja Jain, Dilip Ramrakhiani
DOI:10.4103/0028-3886.266292  PMID:31512663
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Varicella-related Multifocal Vasculopathy: Under-recognized Cause of Young Stroke p. 1147
Amith S Kumar, Darakhshan Naheed, Dheeraj Khurana, Chirag Ahuja
DOI:10.4103/0028-3886.266233  PMID:31512664
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Isolated Cerebellar Abscess by Burkholderia pseudomallei in an Immunocompromised Host: A Rare Case p. 1149
Ashoka Mahapatra, Sagarika Dhal, Sumit Bansal, Jyotirmayee Turuk, Snigdharani Choudhury, Pritinanda Mishra
DOI:10.4103/0028-3886.266238  PMID:31512665
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Proximal Myopathy as a Presenting Manifestation of Wilson's Disease p. 1152
Hansashree Padmanabha, Aruna Sethuraman, Gosala RK Sarma
DOI:10.4103/0028-3886.266239  PMID:31512666
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Synchronous Glioma of the Brainstem in a Patient with Recurrent Aggressive Vestibular Schwannoma p. 1153
Rahul Lath, Pankaj Sharma, Rajesh R Sannareddy, Meenakshi Swain, Alok Ranjan
DOI:10.4103/0028-3886.266250  PMID:31512667
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Changes in Evoked Potentials in a Hybrid Surgery of Spinal Arteriovenous Malformations Associated with Nerve Root AVF p. 1156
Xiao-Yu Li, Hong-Qi Zhang, Feng Ling, Li-Yong Sun, Jia-Xing Yu, Jian Ren, Jian-Hua He
DOI:10.4103/0028-3886.266251  PMID:31512668
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Intracranial Bleed Presenting as an Acute Cardiac Failure; Brain Heart Interaction at Its Apogee! p. 1159
Ajay Prasad Hrishi P, Karen Ruby Lionel
DOI:10.4103/0028-3886.266254  PMID:31512669
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Schwartz–Jampel Syndrome Mimicking Myotonia Congenita p. 1160
Hansashree Padmanabha, Thomas Mathew, T Manjusha
DOI:10.4103/0028-3886.266261  PMID:31512670
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Unilateral Tongue Atrophy and Fasciculations in Medullary Hemorrhage p. 1162
Neeraj Kumar, Ravindra K Garg, Sudhakar Pandey, Arun K Singh, Hardeep S Malhotra, Imran Rizvi, Ravi Uniyal
DOI:10.4103/0028-3886.266264  PMID:31512671
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The Syndrome of Acute Bilateral Basal Ganglia Lesions in a Patient with Diabetes Mellitus and Uremia p. 1163
Kubra Mehel Metin, Ceyla Ataç, Burç Esra Şahin, Tahir Kurtuluş Yoldaş
DOI:10.4103/0028-3886.266236  PMID:31512672
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NEUROIMAGES Top

Bare Orbit Sign/Empty Orbit Sign – Is It Really Empty? p. 1166
Ramakrishna Narra, Sushil Kumar Kamaraju, Anusha Putcha
DOI:10.4103/0028-3886.266298  PMID:31512673
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Poland Syndrome with Amastia-athelia p. 1167
Rudrarpan Chatterjee, Kruti Patel, Deepika Pandey, Bharat Rathod
DOI:10.4103/0028-3886.266297  PMID:31512674
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Susac's Syndrome p. 1168
Malgorzata Blauciak, Joanna Bladowska, Boguslaw Paradowski
DOI:10.4103/0028-3886.266278  PMID:31512675
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Marchiafava-Bignami Disease in a Patient with No Alcohol Abuse p. 1169
Satoshi Sera, Toshihisa Ichiba
DOI:10.4103/0028-3886.266247  PMID:31512676
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CORRESPONDENCE Top

Assessment of Cardiavascular Changes following Trans-sphenoidal Surgery in Acromegalic Patients p. 1170
Antonio Ribeiro-Oliveira, Márta Korbonits, Claudia M V Freire
DOI:10.4103/0028-3886.266294  PMID:31512677
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MRI Findings in a Case of Genetically Proven CADASIL with Emphasis on Differential Diagnosis p. 1171
Suganya Subbulakshmi, Garg P Rattanlal, Devanand, Rajakumar
DOI:10.4103/0028-3886.266275  PMID:31512678
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Multi-functional Magnetic Resonance Imaging and Clinicopathological Characteristics of Ventricular Schwannoma: A Case Report and Review of the Literature p. 1173
Yan Tan, Hui Zhang, Xiao-Chun Wang, Jiang-Bo Qin, Xiao-Feng Wu, Lei Zhang, Le Wang
DOI:10.4103/0028-3886.266295  PMID:31512679
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Chordoid Glioma of the Third Ventricle p. 1178
Rajeshwari K Muthusamy, Sangita S Mehta
DOI:10.4103/0028-3886.266267  PMID:31512680
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BOOK REVIEW Top

Closed Doors, Open Windows: The Autobiography of Prof. P. N. Tandon p. 1180
Sanjay Behari
DOI:10.4103/0028-3886.266279  
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Online since 20th March '04
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