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   Table of Contents - Current issue
Coverpage
May-June 2020
Volume 68 | Issue 3
Page Nos. 531-724

Online since Monday, July 6, 2020

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NI FEATURE: THE FIRST IMPRESSION  

The Cover Page p. 531
Mahendra Singh Chouhan
DOI:10.4103/0028-3886.289013  
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EDITORIAL Top

Telemedicine: The Next Important Health Vertical for Neurosciences In India p. 532
P Sarat Chandra
DOI:10.4103/0028-3886.289012  
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NI FEATURE: JOURNEY THROUGH THE EONS - COMMENTARY Top

Unsolved Problems of Brain Trauma p. 534
Prakash N Tandon
DOI:10.4103/0028-3886.288988  
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SPECIAL NI FEATURE: CITADELS SCULPTING FUTURE Top

History of Department of Neurology at S.M.S. Medical College, Jaipur p. 540
RS Jain
DOI:10.4103/0028-3886.289022  
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SPECIAL NI FEATURE: COMMENTARY Top

Expert Commentary On Pearls From Past - “Mortality In Acute Head Injuries” p. 545
Prakash N Tandon
DOI:10.4103/0028-3886.289024  
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GUEST COMMENTARY Top

Predhiman Krishan Kaw (15 January 1948 – 18 June 2017) p. 547
PN Tandon
DOI:10.4103/0028-3886.289023  
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REVIEW ARTICLES Top

Safety of Pregnancy in Ventriculoperitoneal Shunt Dependent Women: Meta-analysis and Systematic Review of the Literature p. 548
Tariq Dhiyab Al-Saadi, Marija Glisic, Ali Al Sharqi, Safiya Al Kharosi, Malik Al Shaqsi, Noor Al Jabri, Awahir Al Sharqi
DOI:10.4103/0028-3886.288995  
Objective: To assess the safety of pregnancy in ventriculoperitoneal (VP) shunt-dependent women. Methods: Three electronic databases MEDLINE (PubMed), EMBASE, and the Cochrane Library were systematically searched to identify studies published in English between 1950 and 2019. We additionally searched Web of Science, Google Scholar, and ClinicalTrials.gov. Results: Among the 38 cases of pregnant VP shunt-dependent women, median age was 25.5 years and shunting duration was 15.5 years with 11 women being shunted at birth or soon after. Congenital diseases were the most common reason for shunting, present in 63.2% of women. The antepartum complications were reported in 50% of cases with the symptoms of increased ICP being the most commonly reported (73.7%). In the majority of cases the complications were resolved with cerebrospinal fluid aspiration (26.3%). Eight women (42.1%) had spontaneous vaginal delivery, 4 had assisted vaginal delivery, while 7 women underwent cesarian section. There was one fetal demise occurred in a woman that was diagnosed with tuberous sclerosis and presented with status epilepticus during the pregnancy. Conclusion: A multidisciplinary approach is needed in managing the VP shunts during the pregnancy and post-partum periods to ensure the best pregnancy outcome for both mothers and the fetus. Based on our findings, VP shunt appears not to be a contraindication for pregnancy. The routine use of prophylactic antibiotics to prevent shunt infection is not recommended. Vaginal delivery should be attempted unless a cesarean section is inevitably required for obstetrics reasons.
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Telemedicine and Neurological Practice in the COVID-19 Era p. 555
Krishnan Ganapathy
DOI:10.4103/0028-3886.288994  
Background: The COVID-19 pandemic has within months turned the world upside down. With personal distancing and shortage of personal protective equipment, face-to-face health care encounters are increasingly becoming problematic. Neurological manifestations are also being observed in clinical presentations. Objective: Worldwide most countries, the World Health Organization (WHO) and Centre for Disease Control (USA) have recommended use of Telemedicine during the current pandemic.With acute shortage of neurologists and neurosurgeons and their lopsided distribution, it becomes more difficult to provide neurological care to those who need it the most, particularly with travel restrictions. The author has since 2002 been advocating use of Telemedicine in Neurosciences. Materials and Methods: This article reviews the increasing deployment of Telemedicine in neurological practice in the last few years, particularly the radical exponential use in the last few months due to COVID-19. Conclusions: With possible reduction in face-to-face consultations, remote evaluation may become mainstream. Webinars will play an increasing role. CME's and resident training will become more and more digital. The world will never be the same again. It is imperative that we accept and start deploying the “New Normal”.
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Spectrum of Neurological Manifestations in Covid-19: A Review Highly accessed article p. 560
Ravindra K Garg
DOI:10.4103/0028-3886.289000  
COVID-19, in most patients, presents with mild flu-like illness. Elderly patients with comorbidities, like hypertension, diabetes, or lung and cardiac disease, are more likely to have severe disease and deaths. Neurological complications are frequently reported in severely or critically ill patients with comorbidities. In COVID-19, both central and peripheral nervous systems can be affected. The SARS-CoV-2 virus causes the disease COVID-19 and has the potential to invade the brain. The SARS-CoV-2 virus enters the brain either via a hematogenous route or olfactory system. Angiotensin-converting enzyme two receptors, present on endothelial cells of cerebral vessels, are a possible viral entry point. The most severe neurological manifestations, altered sensorium (agitation, delirium, and coma), are because of hypoxic and metabolic abnormalities. Characteristic cytokine storm incites severe metabolic changes and multiple organ failure. Profound coagulopathies may manifest with ischemic or hemorrhagic stroke. Rarely, SARS-CoV-2 virus encephalitis or pictures like acute disseminated encephalomyelitis or acute necrotizing encephalopathy have been reported. Nonspecific headache is a commonly experienced neurological symptom. A new type of headache “personal protection equipment-related headache” has been described. Complete or partial anosmia and ageusia are common peripheral nervous system manifestations. Recently, many cases of Guillain-Barré syndrome in COVID-19 patients have been observed, and a postinfectious immune-mediated inflammatory process was held responsible for this. Guillain-Barré syndrome does respond to intravenous immunoglobulin. Myalgia/fatigue is also common, and elevated creatine kinase levels indicate muscle injury. Most of the reports about neurological complications are currently from China. COVID-19 pandemic is spreading to other parts of the world; the spectrum of neurological complications is likely to widen further.
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ORIGINAL ARTICLE Top

Morphometric Alterations of the Sphenoid Ostium and other Landmarks in Acromegaly: Anatomical Considerations and Implications in Endoscopic Pituitary Surgery p. 573
Niranjana Rajagopal, Sumit Thakar, Vinay Hegde, Saritha Aryan, Alangar S Hegde
DOI:10.4103/0028-3886.288996  
Background: The sphenoid ostium (SO) is an important landmark for the endoscopic surgeon. Changes in size and position of the SO and variations in other skull base landmarks in acromegalics have not been adequately evaluated. Aims: The authors evaluated the morphometry and location of the SO and other landmarks in acromegaly and compared these findings with those in nonfunctioning pituitary adenomas (NFPAs). Methods: In this retrospective case–control study, the dimensions and location of the SO and other skull base landmarks were radiologically evaluated in 18 patients with growth hormone (GH)–secreting adenomas. These findings were analyzed in relation to preoperative GH levels and compared with 18 age- and sex-matched controls with NFPAs. Results: The dimensions of the SO were significantly larger in the GH-adenoma group (P < 0.05). The SO was further from the midline (P = 0.04) and closer to the sphenopalatine foramen (SPF) (P = 0.02) in the GH-adenoma group, and this finding correlated with increasing preoperative GH levels. Acromegalics demonstrated larger intracavernous carotid diameters (P = 0.05) and smaller intercarotid distances than the patients with NFPAs (P = 0.02). Conclusion: The SO is larger and located higher up in the sphenoid face and closer to the SPF in patients with GH adenomas. Increasing GH levels in these patients correlate with the upward and lateral displacement of the SO. These patients demonstrate larger intracavernous carotid diameters and smaller intercarotid distances than patients with NFPAs. These morphological alterations are of particular relevance to the pituitary surgeon.
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COMMENTARY Top

Endoscopic Transnasal Transsphenoidal Pituitary Surgery in Acromegaly: Anatomical Variations and Surgical Considerations p. 579
N Jayashankar
DOI:10.4103/0028-3886.289017  
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ORIGINAL ARTICLE Top

Prevalence and Factors Influencing Visual Memory Dysfunction among Epilepsy Patients—A Single-Center Study p. 581
Hui-Chien Beh, Hui-Jan Tan, Rozita Hod, Ching-Soong Khoo, Khairiyah Mohamad
DOI:10.4103/0028-3886.289011  
Background: Epilepsy is associated with cognitive impairment due to the disease itself or side-effects of antiepileptic drugs. Objective: We aimed to study the prevalence of visual memory dysfunction among epilepsy patients and identify the predictors that could contribute to the impairment. Materials and Methods: This was a cross-sectional study. We analyzed 250 patients with epilepsy from neurology clinic at our tertiary center. Assessment of visual memory was done using Wechsler Memory Scale-IV (WMS-IV) with scores from subsets of visual reproduction I, II and designs I, II contributing to visual memory index (VMI) score. The correlation between continuous variables was analyzed using Pearson correlation; whereas the VMI scores of different factors were analyzed via a 1-way ANOVA test. The statistical significance was set at P < 0.05. Results: The prevalence of visual memory dysfunction in our epilepsy population was 37.2%. Analysis of individual predictors showed that older patients, lower educational level, combined generalized and focal types of epilepsy, longer duration of epilepsy, greater number of antiepileptic drugs (AEDs) used, and abnormal neuroimaging contributed to poor visual memory. Multiple logistic regression analysis showed that educational level, types of epilepsy, and the number of AEDs used were significant predictors for visual memory impairment. Conclusion: Visual memory dysfunction in patients with epilepsy was due to manifold confounding factors. Our findings enabled us to identify patients with visual memory dysfunction and modifiable factors that contribute to it. WMS-IV is a suitable assessment tool to determine visual memory function, which can help clinicians to optimize the patients' treatment.
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COMMENTARY Top

Visual Memory in People with Epilepsy- The Neglected Front!! p. 586
Bhargavi Ramanujan, Manjari Tripathi
DOI:10.4103/0028-3886.289020  
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ORIGINAL ARTICLE Top

Aneurysmal Subarachnoid Hemorrhage: Impact on Phenytoin Permeability across the Blood–Brain Barrier p. 588
Neha Dhir, Savita Verma Attri, Smita Pattanaik, M Praveen Kumar, Navjit Kaur Gill, Ajay Patial, Nidhi Rathore, Lekha Saha, Sandeep Mohindra
DOI:10.4103/0028-3886.288987  
Background: Phenytoin (PHT) is a routinely prescribed prophylactic antiepileptic following aneurysmal subarachnoid hemorrhage (aSAH). However, its prophylactic use in aSAH is controversial as emerging evidence suggests worsening of the neurological and functional outcomes. In addition, there is profound damage to the blood–brain barrier (BBB) in aSAH, posing uncertainty about the permeability of PHT across BBB in these patients. This pilot study was designed to evaluate the alteration in PHT permeability across BBB in aSAH patients. Materials and Methods: For conducting the study, 20 patients (control n = 10; aSAH (grade 3 or 4) n = 10) were recruited from a tertiary care hospital. The patients undergoing cranial surgery for pathology with intracerebral mass lesions on MRI were chosen as control for aSAH group. Both groups were administered PHT loading dose (20 mg/kg), infused in 5% dextrose, at a rate not more than 50 mg/min, followed by a maintenance dose (5 mg/kg). Quantification of PHT concentration was performed in brain tissue, plasma, and cerebrospinal fluid (CSF) by LC-MS/MS. Results: The median PHT concentration in brain was found to be significantly decreased (64.8%) in aSAH group (3.78 μg/g) as compared to control (10.73 μg/g), P = 0.010. Similarly, median PHT brain concentration as fraction of plasma was significantly decreased in aSAH group (36.72%) compared to that of control (89.55%), P = 0.003. There was no significant difference in PHT concentration in plasma, CSF, and CSF as a fraction of plasma between both the groups. Conclusion: There is a definite decrease in the penetration of PHT to the brain in patients with grade 3 and 4 aSAH.
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COMMENTARY Top

Use of Prophylactic Antiepileptics Following Aneurysmal Subarachnoid Hemorrhage: Time to Relook p. 593
R Girish Menon
DOI:10.4103/0028-3886.289016  
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ORIGINAL ARTICLES Top

Impact of the COVID-19 Pandemic on Neurosurgical Practice in India: Results of an Anonymized National Survey p. 595
Tejas Venkataram, Nishant Goyal, Chinmaya Dash, Prarthana P Chandra, Jitender Chaturvedi, Amol Raheja, Raghav Singla, Jayesh Sardhara, Bhoopendra Singh, Ravi Gupta
DOI:10.4103/0028-3886.289004  
Background: The COVID-19 pandemic has created an unprecedented challenge for medical professionals throughout the world to tackle the rapidly changing scenario. The objective of this survey was to analyze the change in neurosurgical practice in India following the COVID-19 outbreak and assess its impact on practising neurosurgeons. Materials and Methods: Between May 7th and 23rd, 2020, a validated questionnaire was circulated amongst practising neurosurgeons across the country by social media and e-mails, regarding changes in the patterns of patients seen, adaptations made in their practice, effect on surgeries performed, financial burden, and impact on their personal lives. The responses were kept anonymous and were analyzed for correlations between the changes observed and independent factors such as hospital affiliations, teaching professions, and neurosurgical experience. Results: Our survey showed a drastic fall in the number of neurosurgical patients seen in the outpatient department (OPD) as well as the number of surgeries performed. A drop of 76.25% was seen in OPD patients (P = 0.000) and that of 70.59% in surgeries performed (P = 0.000). There was no uniformity among the neurosurgeons in the number of COVID-19 tests being done before elective/emergency surgery and in the use of protective gear while examining patients. Private practitioners were more affected financially as compared to those in the government sector. The pandemic has affected the research work of 53.23% of all respondents, with those in the teaching profession (70.96%) more affected than those in the non-teaching profession (24.67%). Conclusions: Evidence-based policies, screening COVID-19 tests with better sensitivity, and better-quality personal protective equipment kits in adequate numbers are required to protect our medical professionals from COVID-19. Mental health issues among neurosurgeons may also be an issue, this being a high risk speciality and should be closely watched for.
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Management of Rehabilitation needs of “Unknown” Traumatic Brain Injury Survivors: A Medical and Psychiatric Social Work Perspective p. 603
Raju Birudu, TR Kanmani, B Indira Devi
DOI:10.4103/0028-3886.288985  
Traumatic brain injuries [TBI] caused by road traffic accidents [RTA] are a serious health problem for people of all countries across the globe. RTA will be a leading cause of mortality, morbidity, disabilities and creating many rehabilitation needs. Hence, this, article highlights the clinical concerns, burden, challenges, role of medical and psychiatric social worker, rehabilitation strategies and practical guidelines needed for successful rehabilitation of the unknown and abandoned TBI survivors.
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A Study of the Clinical Profile, Radiologic Features, and Therapeutic Outcomes in Neurosarcoidosis from Two Tertiary Care Centers in Southern India p. 609
Jitesh Goel, Ravi Anadure, Salil Gupta, Vinny Wilson, Rajeev Saxena, Samaresh Sahu, Deepti Mutreja
DOI:10.4103/0028-3886.288976  
Background: Sarcoidosis is an inflammatory granulomatous disease affecting multiple organ systems. Neurological manifestations are rare and seen in approximately 5% cases of sarcoidosis. They may commonly precede the diagnosis of sarcoidosis. Since there is paucity of Indian literature on this subject, we decided to review the clinical and radiological profile, laboratory abnormalities, treatment and long-term outcomes in our patients with neurosarcoidosis (NS). Methods: The study was done by retrospective review of medical records for all cases diagnosed as NS during the period Jan 2014–Jan 2018. These cases were classified as definite, probable, and possible NS, on the basis of established diagnostic parameters (Zajicek criteria). The follow-up record in these cases ranged from 6 months to 3 years, with special emphasis on monitoring the response to treatment and long-term disability. Results: The cases showed varied clinical abnormalities and imaging findings. Cranial neuropathies and myelopathy were the most common clinical presentations. Optic neuritis was most common cranial neuropathy, followed by facial nerve palsy and lower cranial nerve palsies. Most common magnetic resonance imaging findings were T2 hyperintense parenchymal lesions and meningeal enhancement. There was strong correlation between baseline clinico radiological parameters and long-term outcomes, as evidenced by relatively poor prognosis seen in cases with bilateral optic neuritis, myelopathy and imaging evidence of hydrocephalus, or leptomeningitis. Conclusion: The diagnosis of NS requires a high degree of suspicion, coupled with exclusion of alternate diagnosis. It commonly precedes the onset of systemic sarcoidosis. Central nervous system involvement in sarcoidosis is associated with poor clinical outcomes.
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Effect of Stellate Ganglion Block on Intraoperative Propofol and Fentanyl Consumption in Patients with Complex Regional Pain Syndrome Undergoing Surgical Repair of Brachial Plexus Injury: A Randomized, Double-blind, Placebo-controlled Trial p. 617
Vanitha Rajagopalan, Rajendra Singh Chouhan, Mihir Prakash Pandia, Ritesh Lamsal, Parmod Kumar Bithal, Girija Prasad Rath
DOI:10.4103/0028-3886.288992  
Introduction: Stellate ganglion block (SGB) is commonly performed to treat chronic painful conditions, such as complex regional pain syndrome (CRPS) and postherpetic neuralgia. However, whether it is effective in reducing anesthesia and analgesia requirement during surgery (acute pain) is not known. Materials and Methods: Sixty American Society of Anesthesiologists (ASA) physical status I and II patients with CRPS type II undergoing surgery for repair of brachial plexus injury were randomized (1:1) to receive SGB with either 10 mL of 0.5% bupivacaine (Group B) or a matching placebo (Group S) before induction of anesthesia. Results: There was a significant reduction in the requirement of total intraoperative propofol (1659.7 ± 787.5 vs. 2500.7 ± 740.9 mg, P = 0.0003) and fentanyl (190.0 ± 82.5 vs. 327.3 ± 139.3, P = 0.0001) in Group B compared with Group S. Similarly, in Group B, the time to first analgesic was much longer (328 ± 219 vs. 64 ± 116 min, P = 0.000) and postoperative fentanyl requirement for 24 h was lesser compared to Group S (0.6 ± 1.1 vs. 2.1 ± 1.3 μg/kg, P = 0.000). Conclusion: SGB is effective in reducing the requirement of intraoperative propofol and fentanyl as well as decreasing opioid requirement in the postoperative period in patients with CRPS type II undergoing surgery.
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Transient Global Amnesia - Risk Factors and Putative Background p. 624
Marta Waliszewska-Prosol, Marta Nowakowska-Kotas, Joanna Bladowska, Paulina Papier, Sławomir Budrewicz, Anna Pokryszko-Dragan
DOI:10.4103/0028-3886.288979  
Objectives: Transient global amnesia (TGA) is a temporary short-term reversible memory loss. Etiology of TGA remains unclear with various hypotheses. We analyzed clinical characteristics, neuroimaging, and electrophysiological findings as well as comorbidities and seasonal variation in TGA patients with regard to possible background of the syndrome. Materials and Methods: A total of 56 patients (42 women and 14 men) with TGA hospitalized from 2008 to 2016 in the Department of Neurology, Wrocław Medical University. Results: A total of 52 patients (92.9%) underwent their first-ever episode of TGA. The potential triggers or events before episode could be recognized in 22 patients (39.3%). 35.7% patients had TGA in summer and 26.8% in winter months. In 92.9% patients chronic diseases were found, included: Hypertension (60.7%), dyslipidemia (48.2%), autoimmune thyroiditis (17.9%), and ischemic heart disease (14.3%). One patient (1,8%) suffered from migraine. Doppler ultrasonography of carotid arteries revealed abnormalities in 29 patients (51.8%). Electroencephalography abnormalities were observed in 10 (17.6%) of patients. Conclusion: Our findings suggest a putative cerebrovascular background of transient global amnesia. No evidence has been provided for the association between TGA and epilepsy or migraine. Among comorbidities, autoimmune thyroiditis deserves further investigation with regard to its potential links with TGA.
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The Multiple Cranial Nerve Palsies: A Prospective Observational Study p. 630
Manan Mayur Mehta, Ravindra Kumar Garg, Imran Rizvi, Rajesh Verma, Madhu Mati Goel, Hardeep Singh Malhotra, Kiran Preet Malhotra, Neeraj Kumar, Ravi Uniyal, Shweta Pandey, Praveen Kumar Sharma
DOI:10.4103/0028-3886.289003  
Background: Neurological presentation with isolated multiple cranial nerve palsies is common and its diverse causes include infectious, neoplastic, and inflammatory pathologies. The aetiological spectrum may depend upon geographical regions. We undertook this study to explore clinical spectrum and aetiological profile of multiple cranial nerve palsies. Methods: This hospital-based prospective observational study was conducted from August 2015 to August 2017. All the consecutive patients of multiple cranial palsies presenting to the neurology department were included in the studies. Primary objectives were to define anatomical syndromes/cranial nerve combinations and to establish aetiology. Secondary objectives were to study associated factors. The multiple cranial nerve palsy was defined as involvement of two or more non-homologous nerves. Patients of neuromuscular junction disorders, anterior horn cell disorders, myopathies, brain stem syndromes were excluded. All patients underwent structured protocol of clinical evaluation, investigations and few specialized investigations in accordance with clinical suspicion to establish the diagnosis. Results: Fifty-four patients with a mean age of 39.9 ± 14.2 years were included. Commonest cranial nerve involved was the abducens (75.9%) among all nerve combinations. The cavernous sinus syndrome (37%), orbital apex syndrome (22.2%) and jugular foramen syndrome (11.1%) were the most frequent anatomical patterns. Infections (40.7%) were the commonest aetiology followed by neoplastic and idiopathic in four patients. Conclusion: Cavernous sinus syndrome was the commonest anatomical syndrome of multiple cranial nerve palsies and infections were the commonest cause in this study.
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Measurement of Choroid Thickness Using Optical Coherence Tomography to Monitor Intracranial Pressure in an Idiopathic Cranial Hypertension Model p. 636
Ibrahim Ozdemir, Serdar Çevik
DOI:10.4103/0028-3886.288980  
Background: Idiopathic intracranial hypertension (IIH) is a condition with increased intracranial pressure (ICP) without mass lesion or a known etiology with normal cerebrospinal fluid (CSF) composition. With optical coherence tomography (OCT), which is a noninvasive imaging technique, cross-sectional scans of the retina, choroid, and optic nerve head can be obtained with a resolution that is close to histological resolution. Aim: The study aimed to evaluate the efficacy of OCT in providing practical and sensitive measurements to follow-up patients with IIH. Materials and Methods: This retrospective study included 22 patients with IIH and 22 healthy controls. OCT was used to measure peripapillary retinal nerve fiber layer thickness (RNFLT), ganglion cell layer (GCL) thickness and inner plexiform layer (IPL) thickness, and subfoveal choroidal thickness (CT). Lumbar puncture (LP) was performed to evaluate ICP. An association between subfoveal CT and ICP was noted in patients with IIH—a finding that has not been reported previously. Results: Patients with IIH had increased RNFLT (P < 0.000) and CT (P < 0.000) compared with healthy controls. In addition, subfoveal CT was significantly correlated with ICP (rs= 0.851; P < 0.000). Conclusion: Measurement of CT by OCT, which reflects ICP, allows for the follow-up of patients with IIH. In addition, it can be used to monitor other diseases with high ICP.
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Magnetic Resonance Spectroscopy in Adolescent Cannabis Users: Metabolites in the Anterior Cingulate Cortex Reflects Individual Differences in Personality Traits and can Affect Rehabilitation Compliance p. 640
Giada Zoccatelli, Franco Alessandrini, Claudia Rimondo, Alberto Beltramello, Giovanni Serpelloni, Elisa F M Ciceri
DOI:10.4103/0028-3886.288984  
Introduction: The anterior cingulate cortex (ACC) has shown to play a role in impulsivity, fear, and anxiety. Considering, its high glutamate receptor density, it was chosen as a region of interest to investigate the role of glutamate transmission in drug dependance. We investigated the correlations between personality trait scores and glutamate-to-glutamine (Glx) ratio concentrations in the ACC in order to evaluate if (1) personality traits may increase the probability of drug use and (2) drug use can modify cerebral metabolic pattern contributing to addictive behaviors. Materials and Methods: Glx ratio concentrations in the ACC region were measured with high-resolution multivoxel proton magnetic resonance spectroscopy (1H-MRS). Personality traits were evaluated utilizing Cloninger's TCI-revised test. Bivariate correlations between personality scores of 28 teens cannabis users (males, mean age = 18.54 ± 2.80) were evaluated. Results: In the ACC, we observed negative correlation between GG concentrations (r = −0.44, P = 0.05) and co-operativeness values (CO), choline (cho), and novelty seeking (NS) values (r = −0,45, P = 0.05). Low levels of glutamate and high levels of cho in the ACC were closely related to the CO and NS personality traits. Conclusions: Metabolic and personality patterns seems to be related to the risk of substance predisposition in adolescents. Our data contribute a possible support to the “top-down” control of the ACC on brain metabolism, due to the particular cerebral metabolic pattern found in “drug-using” adolescents.
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Noninvasive Ventilation in Myasthenia Gravis p. 648
Usha K Misra, Surendra Kumar, Varun Kumar Singh, Deepanshu Dubey, Jayantee Kalita
DOI:10.4103/0028-3886.289001  
Background: Myasthenic crisis (MC) is mainly managed by invasive ventilation (IV) which is associated with prolonged intubation and ventilation and respiratory complication. Aim: To report the characteristics of patients who can be managed by noninvasive ventilation (NIV) and also predictors of NIV in myasthenia gravis (MG). Patients and Methods: In a retrospective study at tertiary care hospital in India during 2013–2015, patients with MG were evaluated. MG was diagnosed by clinical, repetitive nerve stimulation, and acetylcholine receptor antibodies. Patients were intubated based on arterial blood gas criteria. Demographic variables, Myasthenia Gravis Foundation of America (MGFA) score, and clinical examination were done. NIV success was defined if patient did not need mechanical ventilation (MV) in the management or for 72 h after extubation and was considered unsuccessful if patients required MV during this period. Results: Twenty three out of 68 MG patients had MC, 16 patients were given NIV, and 16 IV. Median intensive care unit stay was 18 (4–94) days. Predictors of crisis were infection, bulbar weakness, MGFA > 2b, and history of crisis. NIV was the only respiratory support in 7 patients and reintubation was prevented in 3 patients. NIV failed in 9 patients. Comparison of NIV success and failure did not reveal any difference. Conclusion: With NIV, intubation was prevented in 7 and reintubation in 3 patients. NIV has lower incidence of complications. NIV should be tried in patients with impending MC.
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BRIEF REPORT Top

Suction Pressure Control Valve for Microneurosurgery p. 652
Abhijeet S Barath, Om P Thakur, Mayank Garg, Suryanarayanan Bhaskar, Deepak K Jha
DOI:10.4103/0028-3886.288977  
A suction pressure control valve (SPCV) for microneurosurgery is designed to place control of safe suction pressure in the hands of an operating neurosurgeon. Tumor tissue needs more negative suction pressure as compared to normal brain tissue, cranial nerves, and vessels in the neurosurgical operating field. The authors present the details of a prototype of a simple and inexpensive device for dynamic adjustment of negative suction pressure by the surgeon or the assistant while working on different tissue types during microneurosurgery.
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KNOW YOUR VITAL STATISTICS Top

Why There Are So Many Measures of Effect size (Relative Merits and Demerits)? p. 654
Kameshwar Prasad
DOI:10.4103/0028-3886.289025  
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CASE REPORTS Top

A Case of Ollier's Disease with P53 Mutation Positive and IDH1 (R132H) Negative Multicentric Gliomas p. 657
Y Nishtha, B Maya, Safal S Shetty, VH Ganaraj, P Nupur, TC Yasha, M Netravathi
DOI:10.4103/0028-3886.288998  
Ollier disease is a rare nonhereditary disorder characterized by multiple enchondromas (enchondromatosis). To report a rare case of Ollier disease with gliomas and its mutation analysis. We hereby report a young lady who presented with seizures. She had a past history of multiple bony swellings in the right foot (operated) and swelling over the anterior chest wall for the past 15 years. MRI brain revealed multiple expansile T2/FLAIR hyperintense lesions in right superior and middle frontal gyri, left basifrontal lobe, and left precuneus in the cortical–subcortical location suggestive of glioma. She underwent biopsy which revealed left basifrontal anaplastic astrocytoma, not otherwise specified, WHO grade III, IDH1 (R132H) negative, P53 mutation positive, and ATRX loss of expression. We hereby report a rare case of Ollier disease with multicentric intracranial glioma—IDH1 (R132H) negative, P53 mutation positive, and ATRX loss of expression.
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Postcryptococcal Moyamoya Syndrome: Case Report and Review of Literature p. 660
Boby Varkey Maramattom
DOI:10.4103/0028-3886.288983  
There could be an association between cryptococcal meningitis and the later development of moyamoya syndrome. We performed serial clinical and radiological assessments in an immunosuppressed post-renal transplant patient who had previously suffered from cryptococcal meningitis and then went on to develop a moyamoya syndrome (MMS). We also performed a literature search and review of post-infectious MMS cases from 1976 to 2019. The clinical course and radiological findings were consistent with a diagnosis of MMS. After exclusion of other causes, accelerated MMS secondary to cryptococcal meningitis, developing over 1–2 months, was considered. Our observation adds further evidence to the concept of a post-infectious MMS. This report is the first to add fungal meningitis to the etiology of an MMS.
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Paradoxical Embolism in a Case of Hereditary Hemorrhagic Telangiectasia: Case Report with Literature Review p. 665
Neena Baby, Sabu George Kunnathuparambil, Prasanth Varghese, Aneesh Mangalasseril Kuriakose
DOI:10.4103/0028-3886.288990  
Ischemic stroke involving multiple artery territory with normal vessels gives a clue for an embolic stroke. Paradoxical embolization is a recognized cause of ischemic stroke. We describe a 48-year-old male who presented with acute onset giddiness, mild dysarthria, right hemiparesis, and ataxia. Clinical examinations indicated left cerebellar signs with right hemiparesis. Additionally, the patient had significant clubbing and mild cyanosis. A strong family history of epistaxis and hemoptysis was noted. His Magnetic resonance imaging of the brain showed acute left cerebellar and left frontal cortical infarct with normal vessels. The routine stroke and cardiac workup were normal. Chest X-ray showed bilateral lower zone opacities. Contrast-enhanced computerized tomogram (CT) of the chest showed bilateral pulmonary arteriovenous malformation. Paradoxical embolism due to pulmonary arteriovenous malformation resulted in ischemic stroke in our patient. He fulfilled all of the four criteria for diagnosing definite hereditary hemorrhagic telangiectasia. Our case highlights the importance of a systematic search for paradoxical embolism in a cryptogenic stroke.
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Van der Knaap Disease (Vanishing White Matter) – Unusual Presentation in a Neonate: A Case Report Highly accessed article p. 669
Malay Jhancy, Ammar Al Homsi, Fatema Chowdhury, Samiha Hossain, Reshme Ahamed
DOI:10.4103/0028-3886.289018  
Van der Knaap disease, also known as megalencephalic leukoencephalopathy with subcortical cysts (MLC), is a rare autosomal disorder, with no exact prevalence but more than 150 cases were reported in the literature. It was more prevalent in some ethnicities where consanguinity is common.[1] It is usually characterized by infantile-onset macrocephaly, cerebral leukoencephalopathy and mild neurological symptoms, and a slow course of functional deterioration.[2] Diagnosis is determined by suggestive clinical features and MRI findings that include leukodystrophy and subcortical cysts. Herein, we present a rare occurrence of Van der Knaap disease, in a 24-day-old female neonate with similar MRI findings, who presented with neonatal seizures for evaluation.
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Enigma of Rabies: Prolonged Survival in a Boy with Rabies Brachial Plexitis and Encephalomyelitis p. 673
Kanika Goyal, Chandana Bhagwat, Renu Suthar, Arushi Gahlot Saini, Namita Ravikumar, Paramjeet Singh, Reeta S Mani, Meenu Singh
DOI:10.4103/0028-3886.288993  
Rabies encephalitis is a universally fatal disease. Prolonged survival in children with rabies encephalitis has only been anecdotally reported. Case report: An 11-year-old boy presented with right-handed paraesthesia followed by flaccid weakness, progressive quadriparesis and encephalopathy following an unprovoked, class III dog bite over the right wrist 1 month previously. He received five doses of the rabies vaccine as post exposure prophylaxis. Diagnosis of rabies encephalitis was supported by typical MRI brain and spine findings in addition to marked elevation of anti-rabies neutralizing antibody titers in serum and CSF. He was treated with supportive care, methylprednisolone, dexamethasone and simvastatin and was discharged after 6 weeks of hospital stay in a minimally conscious state, with tracheostomy and naso-gastric feeding tubes. At 9 months follow-up, his neurological status showed minimal improvement. Paralytic rabies with brachial plexitis and encephalomyelitis is an atypical presentation of rabies. Very few surviving cases have been reported from India. Survival from rabies is possible with effective clearing of virus with post exposure prophylaxis, but with severe neurological sequelae.
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Bruns Syndrome – An Unusual Presentation p. 677
Sweety Trivedi, Ashis Datta, Santosh Trivedi, A Shobhana, Dipendra K Pradhan, Kajari Bhattacharya, Moulima Banerjee
DOI:10.4103/0028-3886.289006  
Bruns syndrome is characterized by attacks of sudden severe headache, vomiting, and vertigo precipitated due to abrupt movements of the head due to presence of mobile deformable intraventricular lesion causing episodic obstructive hydrocephalus. Proposed underlying mechanism is intermittent or positional CSF obstruction resulting from ball-valve mechanism. Most common etiologies are NCC and intraventricular tumors. Here we present an unusual case of Bruns syndrome that was initially MRI negative.
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Sudden-onset Encephalopathy: Do not ignore the Possibility of Hashimoto's Encephalopathy p. 681
Erum Mubbashir Shariff
DOI:10.4103/0028-3886.289015  
Hashimoto's encephalopathy (HE) is an uncommon neurological disorder of unknown etiology, found in association with thyroid autoimmunity, mostly uncommon in males. The disease occurs primarily in the fifth decade of life and may occur in two forms; a sudden vasculitic type or a progressive subacute type associated with cognitive dysfunction, confusion, and memory loss. We report a case of a 51-year-old Sri Lankan gentleman with no comorbidities who was presented with one episode of the generalized tonic- clonic seizure (GTCs) followed by prolonged agitation and disorientation. His EEG showed generalized slowing while CT scan and MRI brain were unremarkable. CSF examination showed high protein level with normal cell count and glucose. Routine serologic examination showed very high thyroid-stimulating hormone (TSH) level, with significantly high antithyroid antibodies. He was diagnosed as a case of Hashimoto's encephalopathy and treated with a high dose of steroid and showed remarkable improvement.
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Secondary Bacterial Infection of a Solitary Cysticercus Granuloma p. 684
Ananth P Abraham, Mandeep Singh Bindra, Ari George Chacko
DOI:10.4103/0028-3886.288991  
The most common presenting form of neurocysticercosis in the Indian subcontinent is a solitary cysticercus granuloma (SCG). Patients with typical SCGs almost never require any form of surgical intervention. Herein, we report an extremely rare case of bacterial superinfection of a left frontal SCG in a 23-year-old female, resulting in severe perilesional edema and mass effect. The patient had to undergo an emergency left decompressive hemicraniectomy and excision of the infected granuloma. Serum enzyme-linked immunoelectrotransfer blot (EITB) for cysticercal antibodies was positive and histopathological examination of the lesion revealed a cysticercus. The culture of the pus from within the lesion grew vancomycin-resistant Enterococcus spp. for which she was treated with linezolid for 6 weeks. At 6 months follow-up, she had residual motor dysphasia, right homonymous hemianopia, and right hemiparesis but was steadily improving. Secondary bacterial infection of an SCG is very uncommon and can be devastating. A high index of suspicion is therefore required when there is disproportionate perilesional edema and mass effect.
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LETTERS TO EDITOR Top

Stroke in Young Heralding the Diagnosis of Congenital Adrenal Hyperplasia p. 688
Liza Das, Nimisha Jain, Anshita Aggarwal, Pinaki Dutta, Anil Bhansali
DOI:10.4103/0028-3886.289002  
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Pontine Tegmental Cap Dysplasia- the Role of MRI and DTI in Diagnosis p. 691
Jenny Mukeshchandra Gandhi, Shilpa Sankhe, Prasad Udmale
DOI:10.4103/0028-3886.289019  
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Bacterial Meningitis in Patient with Sigmoid Sinus Diverticulum p. 694
Menachem Weiss, Jorge Risco
DOI:10.4103/0028-3886.288978  
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Cardiac Asystole During Deep Brain Stimulation Surgery p. 696
Ninad Dhokte, Charulata S Sankhla, Chelani Ratan, Milind Sankhe
DOI:10.4103/0028-3886.289005  
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Reruptured Previously Coiled Aneurysm - Is it the Ideal Time to Perform Check Angiography at Six Months after Endovascular Coiling? p. 698
Anshu Mahajan, Gaurav Goel, Biplab Das, Vinit Banga
DOI:10.4103/0028-3886.289007  
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Comments on “Sternberg's Canal—A Rare Cause of Spontaneous Cerebrospinal Fluid Rhinorrhea” p. 701
Harrison M Thompson, Bradford A Woodworth
DOI:10.4103/0028-3886.289009  
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In the Differential for Glossopharyngeal Neuralgia, do not Forget the Esophagus p. 702
Sylvain Redon, Anne Donnet
DOI:10.4103/0028-3886.288989  
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Central Nervous System Inflammatory Myofibroblastic Tumor Presenting as a Scalp Abscess p. 703
Binoy D Thavara, Bijukrishnan Rajagopalawarrier, Jyothi C Ramaswamy, Geo Senil Kidangan
DOI:10.4103/0028-3886.289026  
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Pachymeningitis in Patient with Lung Cancer: A Diagnostic Challenge p. 706
Ferrante Enrico, Pontrelli Giuseppe, Trimboli Michele
DOI:10.4103/0028-3886.288997  
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Vertebrobasilar Junction Aneurysm Associated with Subclavian Steal: Yet another Hemodynamic Cause for Aneurysm Development and Associated Challenges p. 708
Chirag Kamal Ahuja, Manisha Joshi, Sandeep Mohindra, Niranjan Khandelwal
DOI:10.4103/0028-3886.288981  
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Periodic Hyper Somnolence as Initial Presenting Manifestation of Nocturnal Frontal Lobe Epilepsy p. 710
Shri Ram Sharma
DOI:10.4103/0028-3886.288982  
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Invasive Medial Temporal Pilocytic Glioma p. 713
Rajesh K Meena, Ramesh S Doddamani, Kanwaljeet Garg, Dipanshu Narula, Deepak Agrawal
DOI:10.4103/0028-3886.289010  
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NEUROIMAGES Top

Intraventricular Neurocysticercosis: The Role of Advanced MRI Sequences p. 716
Bruno F Guedes, Fernando Freua, Jacy B Parmera, Breno G Milano, Luiz R Comerlatti, Guilherme D Silva, Leandro T Lucato
DOI:10.4103/0028-3886.288999  
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Contrast-induced Encephalopathy p. 718
Mauro Monforte, Giacomo Della Marca, Emilio Lozupone
DOI:10.4103/0028-3886.288986  
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Giant Panda in ADEM p. 720
Divya Nagabushana, S Praveen Kumar, Karthik Nagaraj
DOI:10.4103/0028-3886.289008  
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OBITUARY Top

Dr. Jayant Misra p. 722
Maheep S Gaur
DOI:10.4103/0028-3886.289014  
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Dr. A. Simon Hercules - Community Neurosurgeon Whose Life was Nipped in Bud Highly accessed article p. 724
VG Ramesh
DOI:10.4103/0028-3886.289021  
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Online since 20th March '04
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