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Coverpage
July-August 2017
Volume 65 | Issue 4
Page Nos. 693-942

Online since Wednesday, July 5, 2017

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NI FEATURE - COMMENTARY: THE FIRST IMPRESSION  

The cover page p. 693

DOI:10.4103/neuroindia.NI_511_17  PMID:28681730
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NI FEATURE - COMMENTARY: TIMELESS REVERBERATIONS Top

The making of a complete neurosurgeon Highly accessed article p. 694
K Ganapathy
DOI:10.4103/neuroindia.NI_173_16  PMID:28681731
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NI FEATURE: THE EDITORIAL DEBATE I-- PROS AND CONS Top

Dose fractionated gamma knife radiosurgery for large arteriovenous malformations p. 697
Ajay Niranjan, John C Flickinger
DOI:10.4103/neuroindia.NI_518_17  PMID:28681732
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Dose fractionated gamma knife radiosurgery for large arteriovenous malformations: A word of caution p. 699
L Dade Lunsford
DOI:10.4103/neuroindia.NI_525_17  PMID:28681733
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Fractionated gamma knife radiosurgery for large brain arteriovenous malformations p. 701
Manmohan Singh
DOI:10.4103/neuroindia.NI_519_17  PMID:28681734
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NI FEATURE: THE EDITORIAL DEBATE II-- PROS AND CONS Top

The enigma of neuroinflammation p. 703
Prakash N Tandon
DOI:10.4103/neuroindia.NI_517_17  PMID:28681735
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Inflammation and aneurysms p. 706
Sudheer Ambekar
DOI:10.4103/neuroindia.NI_289_16  PMID:28681736
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REVIEW ARTICLE Top

Alarm criteria for motor evoked potentials p. 708
Parthasarathy D Thirumala, Jessie Huang, Indraneel S Brahme, Karthy Thiagarajan, Hannah Cheng, Donald J Crammond, Jeffrey Balzer
DOI:10.4103/neuroindia.NI_1195_16  PMID:28681737
Objective: To evaluate three commonly used alarm criteria for interpreting the significance and diagnostic value of transcranial motor evoked potential (TcMEP) changes during spinal surgery. Materials and Methods: A systematic literature search was performed using PubMed/MEDLINE, Web of Science, and EMBASE from 1945 to January 2014. We included all those studies that were (1) randomized controlled trials, prospective studies, or retrospective cohort studies, (2) conducted among patients undergoing surgery on the spine or spinal cord with TcMEP monitoring, (3) conducted in a group of ≥50 patients, (4) that were inclusive of immediate postoperative neurological assessment (within 24 h), and (5) which were published in English. Results: Twenty-five studies involving 9409 patients were included. The incidence of neurological deficits was 1.82%. The overall sensitivity and specificity of all reported TcMEP changes was 82.1% (95% confidence interval [CI]: 73–88.6%) and 95.7% (95% CI: 93.7–97.1%), respectively. The sensitivity and specificity of each alarm criteria were evaluated: 50% reduction in amplitude, sensitivity 63.2% (95% CI: 47–76.8%), and specificity 96.7% (95% CI: 96.4–99.2%); 80% reduction in amplitude, sensitivity 71.7% (95% CI; 42–89.9%), and specificity 98.3% (95% CI: 96.4–99.2%); total signal loss, sensitivity 30% (95% CI: 17.6–46.4%), and specificity 99.3% (95% CI: 98.6–99.7%). Conclusions: No statistically significant differences between using reductions in amplitude of 50% and 80% as alarm criteria were found in terms of sensitivity and specificity. Total loss was found to have a statistically significant increase in specificity. TcMEP monitoring is a highly specific and sensitive diagnostic tool for the detection of neurological defects during spinal surgery.
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COMMENTARY Top

Motor evoked potential alarm criteria: Not yet at the finish line p. 716
Vedantam Rajshekhar, Srinivasa Babu
DOI:10.4103/neuroindia.NI_486_17  PMID:28681738
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Molecular mechanisms of the intracranial aneurysms and their association with the long noncoding ribonucleic acid ANRIL – A review of literature p. 718
Jiang Che
DOI:10.4103/neuroindia.NI_1074_15  PMID:28681739
Long noncoding ribonucleic acids (RNAs) are important regulators of gene expression. Antisense noncoding RNA in the INK4 locus (ANRIL), which was coded on the Chr9p21.3 loci, participates in the pathogenesis of tumor, coronary artery disease, type 2 diabetes mellitus, and other diseases. A genome-wide association study indicated ANRIL to be a candidate gene that may lead to the development of an intracranial aneurysm (IA) formation. However, the detailed molecular mechanisms are unknown and have not been studied. Through reviewing the molecular mechanisms responsible for the development of IA and the regulation pathway of ANRIL, this paper presents four possible molecular mechanisms that may be responsible for the influence of ANRIL on the development of IAs, that is, cell cycling, Krüppel-like factor 2 (KLF2), caspase recruitment domain family member 8, and retinoid metabolism. ANRIL may become a molecular marker or therapeutic target of IA in the future. To the best of our knowledge, this is the first paper elucidating the molecular linkage between ANRIL and IAs.
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ORIGINAL ARTICLE Top

Cognition in advanced normal pressure hydrocephalus: A pilot study from South India p. 729
Robert Mathew, Sauda Pavithran
DOI:10.4103/neuroindia.NI_1219_15  PMID:28681740
Background: Literature on cognition in normal pressure hydrocephalus (NPH) is sparse and more so on cognition in advanced NPH. Objective: To study the cognitive profile in a hospital-based cohort of cognitively-advanced NPH. Settings and Design: This was a prospective cross-sectional study. The patients included those availing dementia care service from three different tertiary care centres during a period of 5 years from 2010 to 2014. Patients were considered to have cognitively-advanced NPH if the Addenbrooke's Cognitive Examination(ACE) score was 50 or less. In addition to ACE, the patients underwent a battery of other neuropsychologic tests including the digit forward test, Trail A and Trail B, Rey auditory verbal learning test, Cambridge behaviour inventory, hospital anxiety and depression scale, informant questionnaire for cognitive decline in the elderly, and scale for activities of daily living. Data analysis was done using the Statistical Package for the Social Sciences. Results: Dementia was confirmed in 326 cases, 193 (59.2%) with NPH, 77 (23.6%) with Alzheimer's disease (AD), 29 (8.9%) with frontotemporal dementia (FTD), and 27 (8.3%) with vascular dementia based on the commonly used criteria. Detailed neuropsychologic assessment could be done in 23 patients with NPH and 15 patients with AD. The mean age was 72.06 ± 9.62 years. Thirteen (56.5%) of the patients were males, and the mean duration of education was for 7.74 ± 3.21 years; the mean duration of illness was for 2.73 ± 2.72 years. The mean mini–mental state examination score was 11.6 ± 5.2 and the mean ACE score was 27.26 ± 1.3. The most severely impaired factor was memory (mean score 6.7 ± 4; percentage of maximum score [PMS] 19.41 ± 11.58) and the least affected was language (mean score 15.56 ± 8.25; PMS 37.06 ± 19.63. No significant difference was seen between ACE total score or subscores when the 15 advanced AD patients were compared. Discussion: The cognitive profile of NPH at an advanced stage was similar to that seen in advanced AD. Conclusion: As advanced NPH shows cognition similar to cortical dementia, the pathologic correlate in NPH may not be hydrocephalus alone.
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COMMENTARY Top

Quantifying dementia in normal pressure hydrocephalus: Precision versus pitfalls p. 732
Sita Jayalakshmi, Sudhindra Vooturi
DOI:10.4103/neuroindia.NI_520_17  PMID:28681741
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The effect of sensory level electrical stimulation of the masseter muscle in early stroke patients with dysphagia: A randomized controlled study p. 734
Ebru K Umay, Atilay Yaylaci, Guleser Saylam, Ibrahim Gundogdu, Eda Gurcay, Dehen Akcapinar, Zeynep Kirac
DOI:10.4103/neuroindia.NI_377_16  PMID:28681742
Background: Dysphagia is a serious cause of morbidity and mortality in stroke patients. Aims: As the first study in literature, we aimed to evaluate the effects of sensory-level electrical stimulation (SES) to bilateral masseter muscles in early stroke patients with dysphagia. Settings and Design: This study was conducted at the Physical Medicine and Rehabilitation Clinic of our hospital between 2013 and 2015. Materials and Methods: Ninety-eight patients with dysphagia within the first month after ischemic stroke were included in this study. Patients were evaluated by bedside screening tests (Bedside Dysphagia Score, Neurological Examination Dysphagia Score, Total Dysphagia Score, and Mann Assessment of Swallowing Ability test) and by flexible fibreoptic endoscopic evaluation of swallowing (FEES) methods. All patients were included in a traditional swallowing therapy. Patients were divided into two groups, namely the “stimulation group” and “sham group.” SES was applied to bilateral masseter muscles. Evaluation parameters were compared between the groups before and after therapy. Statistical Analysis: The Friedman test, Wilcoxon Signed Rank test, Mann–Whitney U test, and Fisher exact test were used in this study. Results: There was a significant improvement in dysphagia severity scores evaluated by bedside screening tests and FEES in cognitive and total functionality levels except in motor functional independence level in the stimulation group. In the sham group, there were no significant changes in the evaluation parameters. Conclusion: SES applied to bilateral masseter muscles may provide an effective treatment for both dysphagia and cognitive function in early stroke patients.
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COMMENTARY Top

The effect of sensory-level electrical stimulation of the masseter muscle in early stroke patients with dysphagia p. 743
Man Mohan Mehndiratta, Poonam Gupta, Mandeep Kaur
DOI:10.4103/neuroindia.NI_522_17  PMID:28681743
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Levodopa dose maintenance or reduction in patients with Parkinson's disease transitioning to levodopa/carbidopa/entacapone p. 746
Jongkyu Park, Younsoo Kim, Jinyoung Youn, Phil H Lee, Young H Sohn, Seoung B Koh, Jee-Young Lee, Jong S Baik, Jin W Cho
DOI:10.4103/neuroindia.NI_597_16  PMID:28681744
Background: Levodopa bioavailability is enhanced by adding entacapone. However, the optimal dose of levodopa while transitioning to levodopa/carbidopa/entacapone (LCE) in Parkinson's disease (PD) during the wearing-off period is unclear. Aims: The relative therapeutic efficacy and safety of different doses of levodopa were assessed when transitioning to the LCE combination for optimizing combined levodopa therapy. Materials and Methods: A randomized, multicenter, double-arm, open-label study was conducted in Korea. The patients were randomly assigned to either a maintained levodopa dose (Group 1, n = 66) or a reduced levodopa dose by 15–25% (Group 2, n = 41). Treatment efficacy, safety, and tolerability were assessed during an 8-week treatment period. Results: Eighty of the 107 (74.8%) participants completed the study (Group 1, n = 50; Group 2, n = 30). The patients' global impression of a change in scores indicated significant benefits of maintaining the levodopa dose (Group 1) compared to reducing the dose (Group 2). Although changes in the unified Parkinson's disease rating scale (UPDRS) scores, Hoehn and Yahr (H and Y) stages, and duration of ON, OFF and dyskinesia were not statistically different between the groups, an increased ON time and a reduced OFF time occurred in both the groups after LCE administration. Twenty-four participants (26.7%) experienced adverse events and 15 of them did not complete the study in the safety population (Group 1, n = 57; Group 2, n = 38). Significant drug-related withdrawal caused troublesome dyskinesia and aggravation of Parkinsonism in both Group 1 and Group 2, respectively. Conclusions: Direct transitioning to LCE, without levodopa dose reduction, is recommended in Asian patients with PD and wearing-off.
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A randomized controlled study of operative versus nonoperative treatment for large spontaneous supratentorial intracerebral hemorrhage p. 752
Mukesh K Bhaskar, Rakesh Kumar, Balakrishna Ojha, Sunil K Singh, Nishant Verma, Rajesh Verma, Anil Chandra, Chhitij Srivastava, Manish Jaiswal, Somil Jaiswal, Harsha Huliyappa
DOI:10.4103/neuroindia.NI_151_16  PMID:28681745
Context: Spontaneous intracerebral haemorrhage (ICH) accounts for 4–14% of all strokes and has a high mortality rate of 30–50% during the first month. Management of large hematomas is controversial, with some advocating medical management while others favoring surgical evacuation. Aim: This study was undertaken to compare the outcome of patients with a spontaneous supratentorial intracerebral hemorrhage (SSICH) managed with or without surgical evacuation. Settings and Design: Four hundred and eighty-two SSICH patients admitted from September 2013 to August 2015 were evaluated based on the inclusion and exclusion criteria. Materials and Methods: Among a total of 61 patients with Glasgow Coma Scale (GCS) of 4–14 and hematoma volume of >30 ml, 27 were randomized to receive medical management (MM) alone and the remaining 34 were randomized to combined surgical as well as medical management (SM). Primary and secondary outcomes were mortality and dependency at 3 months, respectively. Statistical Analysis Used: Student's t-test and X2 test were used for univariate analysis, and logistic regression analysis was employed for multiple variables. Results: On univariate analysis, mortality was significantly lower in the SM group (n = 21,61.8%) compared to the MM group (n = 23,85.2%) (P = 0.043); however, the groups showed no significant difference in dependency at 3 months. Further subgroup analysis showed that a hematoma volume of 30–60 ml, a deeply located hematoma, associated intraventricular hemorrhage, and a Glasgow Coma Scale (GCS) of 4–8 had a significantly lesser mortality in the SM group (P < 0.05). On multivariate analysis, a significant association was found between the mortality and the treatment arm (P = 0.006). Conclusions: In patients with SSICH, mortality was found to be significantly associated with the treatment arm and the results were in favour of SM among the patients presenting with GCS 4–8, hematoma volume 31–60 ml, midline shift of more than 5 mm, and intraventricular extension of the hematoma.
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COMMENTARY Top

Operation versus non-operative treatment for spontaneous supratentorial intracerebral haemorrhage: Is a change in current clinical practice required? p. 759
A David Mendelow
DOI:10.4103/0028-3886.209600  PMID:28681746
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ORIGINAL ARTICLE Top

Correlation of ubiquitin C terminal hydrolase and S100β with cognitive deficits in young adults with mild traumatic brain injury p. 761
Subir Dey, Jagathlal Gangadharan, Akhil Deepika, J Keshav Kumar, Rita Christopher, Shruthi S Ramesh, B Indira Devi, Dhaval P Shukla
DOI:10.4103/neuroindia.NI_884_15  PMID:28681747
Objective: To study the acute phase serum biomarkers in patients with mild traumatic brain injury (mTBI) and to correlate them with short term cognitive deficits. Materials and Methods: This is a prospective observational study conducted at a tertiary care center for neurotrauma. The participants included patients with mTBI (n = 20) and age, gender, and education-status matched healthy controls (n = 20). In both the groups, the serum concentrations of biomarkers ubiquitin C terminal hydrolase (UCH-L1) and S100 calcium-binding protein B (S100B) were measured. Both the groups underwent neuropsychological tests. The serum tests were done in the acute stage after injury and the neuropsychological tests were done 3 months after injury. Results: There was no significant increase in the serum S100B and UCH-L1 levels in patients with mTBI. Patients with mTBI had significant cognitive deficits at 3 months after injury, which was suggestive of involvement of diffuse areas of the brain, in particular, the premotor, prefrontal, and medial inferior frontal lobes and the basitemporal region. The correlation of biomarkers with cognitive deficits in patients with mTBI was found in the following domains: working memory, verbal learning, verbal fluency, and visual memory. Conclusion: The serum biomarkers of mTBI have a correlation with selective domains of neuropsychological outcome.
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COMMENTARY Top

Correlation of biomarkers with cognitive deficits in young adults with mild traumatic brain injury p. 767
Deepak Gupta, Amol Raheja
DOI:10.4103/neuroindia.NI_524_17  PMID:28681748
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Bilateral anterior capsulotomy for patients with refractory obsessive-compulsive disorder: A multicenter, long-term, follow-up study p. 770
Hong Bin Liu, Qi Zhong, Wei Wang
DOI:10.4103/neuroindia.NI_510_16  PMID:28681749
Objective: The objectives of this retrospective study were to analyze the short-term and long-term effects and complications of stereotactic anterior capsulotomy for patients with refractory obsessive-compulsive disorder (OCD). The advantages and disadvantages of stereotactic anterior capsulotomy have been discussed. Materials and Methods: Between October 2007 and June 2010, 37 patients with OCD underwent anterior capsulotomy in West China Hospital of Sichuan University or Mian Yang Central Hospital. The clinical effects were evaluated by an independent psychiatrist preoperatively and after 1 week, and after 1, 3, 6, 12, 36, and 60 months postoperatively. The main parameters were evaluated by scores on the Yale–Brown obsessive compulsive scale (Y-BOCS), Hamilton depression scale (HAMD), and Hamilton anxiety scale (HAMA). 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and diffusion tensor imaging (DTI) were performed preoperatively and at 3 and 6 months postoperatively. Results: On comparing the scores obtained at various time points, the effects of anterior capsulotomy were as follows: The Y-BOCS score of the 37 patients decreased in the fifth year postoperatively (P < 0.05); 27 (73.0%) patients exhibited significant improvement (>50% decrease in the Y-BOCS score); 6 (16.2%) patients exhibited partial improvement (20–50% decrease in the Y-BOCS score); and, 4 (10.8%) patients exhibited no evident improvement (<20% decrease in the Y-BOCS score). Moreover, depression and anxiety improved among all the patients (P < 0.05). FDG-PET showed that the glucose metabolic rate had decreased in bilateral frontal cerebral lobe and basal ganglia. DTI showed that the transverse fibers in bilateral anterior limb of the internal capsule were disconnected. Conclusion: Using MRI guidance, stereotactic treatment of refractory OCD via bilateral anterior internal capsulotomy significantly improved several OCD symptoms such as compulsive behavior, depression, and anxiety. In addition, the assessment of the effects and complications of this treatment was most accurate at 6 months postoperatively.
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Neurosurgery for psychiatric disorders p. 777
Paresh K Doshi
DOI:10.4103/neuroindia.NI_521_17  PMID:28681750
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Assessment of surgical risk factors in the development of ventilator-associated pneumonia in neurosurgical intensive care unit patients: Alarming observations p. 779
Deepashu Sachdeva, Daljit Singh, Poonam Loomba, Amandeep Kaur, Monica Tandon, Ishu Bishnoi
DOI:10.4103/neuroindia.NI_814_16  PMID:28681751
Background: Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in patients receiving mechanical ventilation (MV) and contributes to a longer intensive care unit (ICU) stay, duration of MV, and a high morbidity and mortality. Objective: The purpose of study was to determine the incidence of VAP in neurosurgery ICU patients and to assess the probable contributing neurosurgical risk factors like the site and nature of the lesion in the brain, the duration of surgery, blood loss during surgery, and infection elsewhere in the body, in the development of VAP. Materials and Methods: The prospective clinical study included patients with a Glasgow Coma Scale (GCS) score>8 undergoing a neurosurgical procedure and postoperatively receiving MV for >48 hours, who were followed for the development of VAP. The diagnosis of VAP was in accordance with the Centers for Disease control (CDC) guidelines and was confirmed with a positive quantitative culture in the endotracheal tube aspirate samples. Results: The incidence of VAP in our study was 70%. Aneurysmal subarachnoid hemorrhage (SAH) [Grade 3, 4 and 5] was the most common underlying condition followed by posterior fossa surgery, and surgery of the craniovertebral junction and cervical spine. Patients with a supratentorial compartment etiology had a slightly higher incidence (53%) of VAP as compared to the infratentorial compartment one. Patients with significant intraoperative blood loss and receiving blood transfusion had a higher incidence of pulmonary complications. Acinetobacter baumannii was the most common pathogen isolated followed by Pseudomonas aeruginosa, with high resistance trends being prevalent among the commonly used antibiotics in the ICU. Conclusion: The incidence of VAP is high. Patients of aneurysmal SAH are at higher risk and VAP is as common in patients with supratentorial lesions as in those with infratentorial pathologies. The increase in resistance to the commonly used antibiotics is a cause for concern. Efforts should be taken to evolve more effective preventive measures.
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The bug does not stop here: The exasperating problem of ventilator associated pneumonia p. 785
Ganne S Umamaheswara Rao
DOI:10.4103/neuroindia.NI_965_16  PMID:28681752
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Incidence of deep venous thrombosis in patients undergoing elective neurosurgery – A prospective cohort based study p. 787
Tushar D Borde, Chandrajit Prasad, Arivazhagan Arimappamagan, Dwarakanath Srinivas, Sampath Somanna
DOI:10.4103/neuroindia.NI_1237_15  PMID:28681753
Introduction: The exact incidence of deep vein thrombosis (DVT) in the Indian neurosurgical patient population is uncertain. This situation is quite different from its well-documented incidence in the Caucasian population.This study aims to analyze the incidence, etiopathogenesis, and risk factors in the development of DVT in Indians. This will enable us to formulate country-specific guidelines for its appropriate and timely prophylaxis. Aims and Objectives: To study the incidence of deep venous thrombosis in patients undergoing elective neurosurgery. Materials and Methods: This was a prospective cohort based study analyzing a total of 273 adult (>18 years) patients who underwent elective neurosurgery during a period of 1 year from November 2013 to December 2014.A preoperative baseline Doppler ultrasonography and coagulation profile was performed, followed by postoperative surveillance Doppler ultrasonography biweekly until discharge. Statistical analysis was performed using chi-square test and Pearson's correlation analysis. Results: A total of 33 patients (12.08%) developed DVT in the postoperative period. Hypertension, frequent alcohol intake, smoking, and obesity were found to be the risk factors (P = 0.001). Significant association was observed between malignant tumors, meningiomas, and DVT (P = 0.001). Intraoperative supine and lateral position for more than 5 h, the severity of postoperative motor deficit, and ambulation delay of more than 2 days were significant risk factors (P = 0.001). Conclusion: Our study, one of the first of its kind, details the incidence and etiopathogenesis of DVT in the Indian neurosurgical population. We recommend an early usage of prophylaxis (mechanical and/or pharmacological) in the perioperative period for the high risk category of patients. We hope that this data can be used for preparing country-specific guidelines for DVT prophylaxis.
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Microsurgical anatomy of the superior sagittal sinus and draining veins Highly accessed article p. 794
Mariano Anto Bruno-Mascarenhas, Vengalathur G Ramesh, Sundar Venkatraman, Jolarpettai V Mahendran, S Sundaram
DOI:10.4103/neuroindia.NI_644_16  PMID:28681754
Background: The superior sagittal sinus and the draining cerebral veins are often encountered during the surgery for parasagittal and falx meningiomas and during the interhemisperic transcallosal approaches. A knowledge about the variations from the normally described anatomy helps in anticipating and avoiding problems related to these structures during surgery. Aim: The normal variations in the disposition of the superior sagittal sinus and the number and direction of the draining veins in the Indian population have been studied. Settings and Design: This is an anatomical study in the fresh cadavers. Materials and Methods: Sixty fresh cadavers were examined in the autopsy theatre of the Forensic Medicine Department of the Hospital between March 2011 and February 2013. Statistical Analysis Used: Epi-Info, MS-Excel, and the Statistical Package for the Social Sciences (SPSS) were used for data analysis. Results: The position of the superior sagittal sinus was variable and was up to within 1cm on either side of the sagittal suture. The origin of the superior sagittal sinus varied from the level of foramen caecum to a little posterior from the foramen caecum. The total length of the superior sagittal sagitttal sinus varied from 321 mm to 357 mm (average length 338.77mm); vertical compartments of the sinus were found in three-fourth of the cases studied. Tributaries were found in the herringbone pattern and varied from 13 to 19 on the right and 14 to 19 on the left. The Rolandic vein was the largest draining vein in most of the cases. The superior sagittal sinus drained predominantly to the right transverse sinus in three-fourth of the cases studied. The position of the torcula was variable; often towards the right side and at a higher level. The central sulcus was 49.93 mm posterior to the coronal suture and 130.78 mm anterior to the lambdoid suture. Conclusions: This is the first study of its kind in Indian population studying the anatomical variations in the anatomy of the superior sagittal sinus that may have a significant bearing on the neurosurgical approaches adopted.
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CASE REPORTS Top

Dravet syndrome with SCN1B gene mutation: A rare entity p. 801
Devdeep Mukherjee, Swapan Mukherjee, Prabal Niyogi, Manas Mahapatra
DOI:10.4103/neuroindia.NI_1115_15  PMID:28681755
Early infantile epileptic encephalopathy has a grave outcome. Dravet syndrome (DS), characterized by early onset, refractory seizures, and intellectual deficit is one of the variants of the condition. SCN1B gene mutation is one of the lesser known variants of DS. Increased awareness of genetic analysis has increased the early diagnosis of DS for an early prognostication as well as genetic counselling of parents. We present the case of a 7-month old male child who started having recurrent febrile, and thereafter, afebrile seizures, following administration of a vaccination at 3 months. He developed global developmental delay, and is presently on multiple anticonvulsants. Genetic analysis was suggestive of SCN1B gene mutation associated with DS.
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Familial Guillain-Barré syndrome: A case report with literature review p. 804
Binod Sarmah, Narayan Upadhyaya
DOI:10.4103/neuroindia.NI_1045_15  PMID:28681756
Guillain–Barré syndrome (GBS) is the most common acute immune-mediated polyneuropathy characterized by symmetrical weakness of limbs and hyporeflexia or areflexia. Familial occurrence of GBS is rare, and only 42 patients from 20 families have been reported so far. Majority of them are from European countries. Familial occurrences do suggest the involvement of some as yet unidentified genetic susceptibility factors. We report the clinical and detailed electrophysiological findings of three affected brothers from Arunachal Pradesh who presented with possible familial GBS.
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NI FEATURE: PATHOLOGY PANORAMA - CASE REPORT Top

Management in chordoid glioma: Avoiding the pitfalls in this rare and challenging entity p. 808
Sergio Garcia-Garcia, Iban Aldecoa, Luis Alberto Caral, Enrique Ferrer, Teresa Ribalta, José Juan González-Sánchez
DOI:10.4103/neuroindia.NI_1008_15  PMID:28681757
Chordoid glioma (CG) of the third ventricle is an unusual neoplasm of glial nature, which is almost exclusively located in the anterior wall of the third ventricle, in close relation with the hypothalamus. Magnetic resonance images show CG as a suprasellar, hypo- to isointense mass, homogeneously enhancing after the administration of gadolinium. Since its description in 1998 by Brat et al., approximately 85 cases have been reported. Some of its pathological features are under discussion and its histological origin still remains unclear. In this study, we present a patient having this rare entity. We review the management of CG reported in literature. We also studied its pathological features, the postoperative mortality and morbidity related to radical surgical resection, and the implemented adjuvant therapies. Due to its classical clinical features and its close resemblance to other lesions in the region, it is an entity unlikely to be suspected prior to its histological diagnosis. Despite the benign nature of this tumor, the clinical outcome might be poor. Its treatment may represent a real challenge because it involves critical anatomical areas, leading to high postoperative morbidity and mortality rates. An initial minimally invasive management and adjuvant therapies, such as radiosurgery, in case of symptomatic recurrences, can be effective handling strategies.
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NI FEATURE: THE QUEST - COMMENTARY Top

Basal ganglia: Their role in complex cognitive procedures in experimental models and in clinical practice p. 814
Rita Moretti, Paola Caruso, Elena Crisman, Silvia Gazzin
DOI:10.4103/neuroindia.NI_850_16  PMID:28681758
Apart from the well known role of the basal ganglia (BG) in motor control, their important role in regulating the cognitive functions is emerging. This article traces the scientific work that explores this role of BG in reinforcement learning, perceptual decision making, and other nonmotor pathways (speech fluency, cognition, attention and behaviour). It also highlights the important role played by the BG networks in determining the development of a child's brain. It retraces the various pathways and connections of the BG with the cerebral cortex, cerebellum and other regions that may be utilized in the establishment of complex cognitive procedures. Various diseases that may be the direct result of disruption of these basal ganglionic networks and interconnections are also recounted.
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NI FEATURE: CENTS (CONCEPTS, ERGONOMICS, NUANCES, THERBLIGS, SHORTCOMINGS) - ORIGINAL ARTICLE Top

Dose fractionated gamma knife radiosurgery for large arteriovenous malformations on daily or alternate day schedule outside the linear quadratic model: Proof of concept and early results. A substitute to volume fractionation p. 826
Kanchan Kumar Mukherjee, Narendra Kumar, Manjul Tripathi, Arun S Oinam, Chirag K Ahuja, Sivashanmugam Dhandapani, Rakesh Kapoor, Sushmita Ghoshal, Rupinder Kaur, Sandeep Bhatt
DOI:10.4103/neuroindia.NI_220_17  PMID:28681759
Background: To evaluate the feasibility, safety and efficacy of dose fractionated gamma knife radiosurgery (DFGKRS) on a daily schedule beyond the linear quadratic (LQ) model, for large volume arteriovenous malformations (AVMs). Material and Methods: Between 2012-16, 14 patients of large AVMs (median volume 26.5 cc) unsuitable for surgery or embolization were treated in 2-3 of DFGKRS sessions. The Leksell G frame was kept in situ during the whole procedure. 86% (n = 12) patients had radiologic evidence of bleed, and 43% (n = 6) had presented with a history of seizures. 57% (n = 8) patients received a daily treatment for 3 days and 43% (n = 6) were on an alternate day (2 fractions) regimen. The marginal dose was split into 2 or 3 fractions of the ideal prescription dose of a single fraction of 23-25 Gy. Results: The median follow up period was 35.6 months (8-57 months). In the three-fraction scheme, the marginal dose ranged from 8.9-11.5 Gy, while in the two-fraction scheme, the marginal dose ranged from 11.3-15 Gy at 50% per fraction. Headache (43%, n = 6) was the most common early postoperative complication, which was controlled with short course steroids. Follow up evaluation of at least three years was achieved in seven patients, who have shown complete nidus obliteration in 43% patients while the obliteration has been in the range of 50-99% in rest of the patients. Overall, there was a 67.8% reduction in the AVM volume at 3 years. Nidus obliteration at 3 years showed a significant rank order correlation with the cumulative prescription dose (p 0.95, P value 0.01), with attainment of near-total (more than 95%) obliteration rates beyond 29 Gy of the cumulative prescription dose. No patient receiving a cumulative prescription dose of less than 31 Gy had any severe adverse reaction. In co-variate adjusted ordinal regression, only the cumulative prescription dose had a significant correlation with common terminology criteria for adverse events (CTCAE) severity (P value 0.04), independent of age, AVM volume, number of fractions and volume of brain receiving atleast 8 Gy of radiation. Conclusion: DFGKRS is feasible for large AVMs with a fair nidus obliteration rate and acceptable toxicity. Cumulative prescription dose seems to be the most significant independent predictor for outcome following DFGKRS with 29-30 Gy resulting in a fair nidus obliteration with least adverse events.
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NI FEATURE: CITADELS SCULPTING FUTURE - COMMENTARY Top

Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial (K.E.M.) Hospital, Mumbai p. 836
Sunil Pandya, Atul Goel
DOI:10.4103/neuroindia.NI_523_17  PMID:28681760
Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial (K.E.M.) Hospital, Mumbai were inaugurated in 1925. This article traces its illustrious history and of the eminent neurosurgeons who shaped its destiny.
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NI FEATURE: THE FOURTH DIMENSION - COMMENTARY Top

A summary of some of the recently published, seminal papers in neuroscience p. 850
K Sridhar, Mazda K Turel, Manjul Tripathi, Ravi Yadav, PR Srijithesh, Aastha Takkar, Sahil Mehta, Kuntal K Das, Anant Mehrotra
DOI:10.4103/neuroindia.NI_516_17  PMID:28681761
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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTERS TO EDITOR Top

Intradural spinal arachnoid cyst – A complication of lumbar epidural steroid injection p. 863
Mazda K Turel, Mena G Kerolus, Harel Deutsch
DOI:10.4103/neuroindia.NI_56_17  PMID:28681762
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Contralateral brachial plexus injury following retromastoid suboccipital craniotomy: A report and review of literature p. 864
Raghav Singla, Ravi Sharma, Shashwat Mishra, Hemanshu Prabhakar
DOI:10.4103/neuroindia.NI_264_17  PMID:28681763
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Acute necrotizing encephalitis associated with cardiovascular manifestations p. 867
Jithangi Wanigasinghe, Tharanga Jayathunge, Pyara D Ratnayake
DOI:10.4103/neuroindia.NI_1125_16  PMID:28681764
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Griscelli syndrome: A rare disorder p. 869
Chandradev Sahu, Satyabhuwan Singh Netam, Bhagyashri R Bhutada, Shreyas J Jaiswal
DOI:10.4103/neuroindia.NI_762_16  PMID:28681765
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LETTERS TO EDITOR Top

Novel mutations c. [453dupA] + [663G>A] of the SPG11 gene associated with hereditary spastic paraplegia with a thin corpus callosum p. 871
Jianmei Xiong, Jianyong Li, Fang Cui
DOI:10.4103/neuroindia.NI_1149_16  PMID:28681766
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Under recognized cause of reversible cognitive decline: A radiological aid p. 872
Amith S Kumar, Ritu Shree, Julie Sachdeva, Anuja Patil, Manoj K Goyal, Vivek Lal
DOI:10.4103/neuroindia.NI_1244_16  PMID:28681767
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Kleine–Levin syndrome: A neurological rarity p. 873
Samhita Panda
DOI:10.4103/neuroindia.NI_1061_16  PMID:28681768
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Gas in the venous sinus: An incidental finding p. 878
Muhammed Alif, Muhammed J. A Jalal, Nimish Vijayakumar, Jacob Chacko, Gigy Kuruttukulam
DOI:10.4103/neuroindia.NI_1036_16  PMID:28681769
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Reversed Robin Hood syndrome treated with verapamil p. 880
Karim M Mahawish
DOI:10.4103/neuroindia.NI_1031_16  PMID:28681770
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Isolated primary intradural extramedullary spinal cysticercosis p. 882
Ravi Sharma, Kanwaljeet Garg, Deepak Agarwal, Ajay Garg, MC Sharma, Bhawani S Sharma, Ashok Kumar Mahapatra
DOI:10.4103/neuroindia.NI_98_17  PMID:28681771
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Commentary: Neurocysticercosis: Evolution of our understanding p. 885
Natarajan Muthukumar
DOI:10.4103/neuroindia.NI_288_17  PMID:28681772
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Long-term follow-up of a case of adult-onset Alexander disease presenting with cognitive impairment as the initial symptom p. 887
Yoshinari Kawai, Makoto Hattori, Keiko Mori, Toshiaki Ieda
DOI:10.4103/neuroindia.NI_630_16  PMID:28681773
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Fluctuation of diffusion-weighted imaging and apparent diffusion coefficient in acute stroke following tissue plasminogen activator administration p. 889
Aníbal S Chertcoff, Juan Chomont, Lucrecia Bandeo, Fátima Pantiu, Claudia Uribe Roca, Pablo Bonardo, Carlos Rugilo, Ricardo Reisin
DOI:10.4103/neuroindia.NI_1218_16  PMID:28681774
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An unusual combination of patent foramen ovale with pulmonary arteriovenous malformation in a young patient with stroke p. 891
Pushpendra N Renjen, Dinesh Chaudhari, Mahir Meman
DOI:10.4103/neuroindia.NI_817_16  PMID:28681775
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A longitudinal clinicopathological study of two unrelated patients with Charcot–Marie–Tooth disease type 1E p. 893
Jee Young Kim, Sung-Hee Kim, Ji-Young Park, Haesoo Koo, Kee-Duk Park, Young Bin Hong, Ki Wha Chung, Byung-Ok Chot
DOI:10.4103/neuroindia.NI_783_16  PMID:28681776
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A case of anti- N-methyl-D-aspartate (NMDA) receptor encephalitis possibly triggered by an episode of Japanese B encephalitis p. 895
Harsh Pastel, Biswaroop Chakrabarty, Lokesh Saini, Atin Kumar, Sheffali Gulati
DOI:10.4103/neuroindia.NI_340_16  PMID:28681777
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Forehead tuning fork swing test: A simple and useful test for functional numbness p. 897
Praful Kelkar
DOI:10.4103/neuroindia.NI_590_16  PMID:28681778
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Solitary primary leptomeningeal astrocytoma – An extremely rare pathology p. 898
Ravi Sharma, Kanwaljeet Garg, Madhu Rajeshwari, Meher C Sharma, Shashank Sharad Kale
DOI:10.4103/neuroindia.NI_260_17  PMID:28681779
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Lumbar extradural arteriovenous malformation mimicking a schwannoma in a child: Rare presentation of neurofibromatosis type-1 p. 900
Gandham E Jonathan, Bijesh R Nair, Vivek Joseph, Sunithi Mani, Geeta Chacko
DOI:10.4103/neuroindia.NI_585_16  PMID:28681780
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Pediatric cemento-ossifying fibroma of the orbital roof: Rare pathology at a rare location p. 902
Satish K Verma, Kanwaljeet Garg, Vivek Tandon, Kalpana Kumari, Mehar C Sharma, Shashank S Kale, Bhawani S Sharma
DOI:10.4103/neuroindia.NI_793_16  PMID:28681781
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Calvarial Ewing's sarcoma, a rare childhood tumor: Report and a review of literature p. 904
Prakash Nair, Varun Aggarwal, Krishna Kumar, Anitha Mathews, Mathew Abraham, Suresh Nair
DOI:10.4103/neuroindia.NI_777_16  PMID:28681782
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Idiopathic ventral thoracic spinal cord herniation with duplicated dura mater and subarachnoid septum p. 906
Ravikanth Reddy, Furruqh Farha, Philip Babu
DOI:10.4103/neuroindia.NI_1064_16  PMID:28681783
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Recurrent brown tumor of the vertebral column p. 908
Michal Paradowski, Joanna Bladowska, Agnieszka Halon, Boguslaw Paradowski
DOI:10.4103/neuroindia.NI_1060_16  PMID:28681784
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Tuberculoma of the pituitary gland presenting as diabetes insipidus p. 909
Ravikanth Reddy
DOI:10.4103/neuroindia.NI_1051_16  PMID:28681785
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NEUROIMAGES Top

Importance of evaluating posterior circulation flow to confirm brain death p. 912
Ramanan Rajagopal, Shalini Nair
DOI:10.4103/neuroindia.NI_1185_16  PMID:28681786
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Intracranial extramedullary hematopoiesis in primary myelofibrosis p. 913
Ravikanth Reddy
DOI:10.4103/neuroindia.NI_1151_16  PMID:28681787
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Atypical pantothenate kinase-associated neurodegeneration with novel genetic mutation p. 914
Anil V Israni, Anirban Mandal
DOI:10.4103/neuroindia.NI_1260_16  PMID:28681788
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An unexpected manifestation of extensive plexiform neurofibroma p. 916
Chi-Yung Yeung, Tsung-Ying Li
DOI:10.4103/neuroindia.NI_1025_16  PMID:28681789
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Giant serpentine aneurysm of the posterior cerebral artery: A rare clinical entity and technical challenge in diagnosis and treatment p. 917
Yu-Wei Hsu, Hung-Wen Kao, Guan-Yu Lin, Chun-Hao Lai, Jiunn-Tay Lee
DOI:10.4103/neuroindia.NI_123_17  PMID:28681790
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Symptomatic critical stenosis of the basilar artery treated with enoxaparin p. 918
Karim M Mahawish, Amber Lui
DOI:10.4103/neuroindia.NI_594_16  PMID:28681791
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Vertical gaze palsy due to acute bilateral thalamic infarct without midbrain ischemia p. 919
Shakya Bhattacharjee, Kher Lik Ng
DOI:10.4103/neuroindia.NI_4_17  PMID:28681792
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CORRESPONDENCE Top

Management of brain tumour-related epilepsy: Rationale for labelling the first line medications p. 921
M Tariq Ansari, Ankit S Shah, Manish Garg, Daljit Singh
DOI:10.4103/neuroindia.NI_423_17  PMID:28681793
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Author's Reply: Choice of antiepileptic drugs in the treatment of tumor-related epilepsy p. 921
Sandeep Mittal, Aashit K Shah
DOI:10.4103/neuroindia.NI_541_17  PMID:28681794
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Myotonic dystrophy-Besides the limbs p. 922
Anubhav Chauhan, Lalit Gupta
DOI:10.4103/neuroindia.NI_1084_16  PMID:28681795
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Author's Reply: Myotonic dystrophy: The occurrence of early-onset cataract p. 923
Constantinos Papadopoulos, Grigoris Panagopoulos, Kyriaki Kekou, Vassilios Fardis, Sofia Kitsiou-Tzeli, George K Papadimas
DOI:10.4103/neuroindia.NI_481_17  PMID:28681796
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Be careful while using albendazole/praziquantel in neurocysticercosis p. 924
Ravindra Kumar Garg, Ravi Uniyal, Hardeep Singh Malhotra
DOI:10.4103/neuroindia.NI_424_16  PMID:28681797
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Author's Reply: Rationale for medical therapy in neurocysticercosis p. 926
Rudrarpan Chatterjee, Krishnarpan Chatterjee, Chetana Sen
DOI:10.4103/neuroindia.NI_477_17  PMID:28681798
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Stroke health and research initiatives (SHRI): 'Following the heart' for prehospital and acute stroke care policy p. 927
Shriram Varadharajan
DOI:10.4103/neuroindia.NI_430_17  PMID:28681799
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BOOK REVIEW Top

Puzzling cases in stroke p. 930
MV Padma Srivastava
DOI:10.4103/neuroindia.NI_529_17  
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Status epilepticus. Practical guidelines in management p. 932
Usha Kant Misra
DOI:10.4103/neuroindia.NI_513_17  
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The beautiful brain. The drawings of Santiago Ramon y Cajal p. 934
Sunil Pandya
DOI:10.4103/neuroindia.NI_514_17  
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OBITUARY Top

Light fades into oblivion…its warm and inspiring glow remains: Kanchan Kumar Mukherjee (6th December 1965-17th June 2017) p. 938

DOI:10.4103/0028-3886.209599  
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Online since 20th March '04
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