Neurology India : 2011 - 59(6)

Duchenne or Becker muscular dystrophy: A clinical, genetic and immunohistochemical study in China

Qian Wang — Mon,2 Jan 2012

Qian Wang, Xiaofeng Yang, Yang Yan, Nan Song, Changkun Lin, Chunlian Jin

Neurology India 2011 59(6):797-802

Background and Objective: Duchenne and Becker muscular dystrophies are X-linked diseases caused by mutations in the dystrophin gene, which affect approximately 1 in 3,500 and 1 in 18,000 boys, respectively. The aim of this work was to develop a method to assist the diagnosis and classification of the disease. Materials and Methods: A large data set of dystrophin mutations was detected in 167 Chinese patients by multiplex ligation-dependent probe amplification and sequencing. Muscle biopsy, immunohistochemistry and STR analysis were also carried out in the patients and carriers. Results: One hundred and three deletions, 23 duplications and two-point mutations. The deletion of one or more exons was detected in 103 (61.7%) patients. The region spanning exons 44-55 was the most frequent deletion. The duplication was identified in 23 (13.8%) patients, which was more common than previously reported. Most duplications were found in exons 2-18. Six out of the 45 muscle biopsies analyzed showed the presence of other muscle diseases. Conclusions: This study may be important to enable comparisons of mutation type and the most appropriate analytical approach for samples from different geographical areas and ethnicities.

Identification of deletions and duplications in the Duchenne muscular dystrophy gene and female carrier status in western India using combined methods of multiplex polymerase chain reaction and multiplex ligation-dependent probe amplification

Rashna S Dastur — Mon,2 Jan 2012

Rashna S Dastur, Munira Y Kachwala, Satish V Khadilkar, Madhuri R Hegde, Pradnya S Gaitonde

Neurology India 2011 59(6):803-809

Background: The technique of multiplex ligation-dependent probe amplification (MLPA) assay is an advanced technique to identify deletions and duplications of all the 79 exons of DMD gene in patients with Duchenne/Becker muscular dystrophy (DMD/BMD) and female carriers. Aim: To use MLPA assay to detect deletions which remained unidentified on multiplex polymerase chain reaction (mPCR) analysis, scanning 32 exons of the "hot spot" region. Besides knowing the deletions and/or duplications, MLPA was also used to determine the carrier status of the females at risk. Materials and Methods: Twenty male patients showing no deletions on mPCR and 10 suspected carrier females were studied by MLPA assay using P-034 and P-035, probe sets (MRC Holland) covering all the 79 exons followed by capillary electrophoresis on sequencing system. Results: On MLPA analysis, nine patients showed deletions of exons other than 32 exons screened by mPCR represented by absence of peak. Value of peak areas were double or more in four patients indicating duplications of exons. Carrier status was confirmed in 50% of females at risk. Conclusion: Combining the two techniques, mPCR followed by MLPA assay, has enabled more accurate detection and extent of deletions and duplications which otherwise would have remained unidentified, thereby increasing the mutation pick up rate. These findings have also allowed prediction of expected phenotype. Determining carrier status has a considerable significance in estimating the risk in future pregnancies and prenatal testing options to limit the birth of affected individuals.

Intraarterial nimodipine for the treatment of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage: A preliminary study

Amir R Dehdashti — Mon,2 Jan 2012

Amir R Dehdashti, Stefano Binaghi, Antoine Uske, Luca Regli

Neurology India 2011 59(6):810-816

Objective: Despite dramatic advances in all medical era, cerebral vasospasm is still the major complication in patients with subarachnoid hemorrhage (SAH). The purpose of this study was to assess the influence of intraarterial (IA) nimodipine in the treatment of symptomatic vasospasm and in preventing neurological disabilities. Materials and Methods: We retrospectively reviewed 10 patients of SAH who received IA nimodipine in 15 procedures. The decision to perform angiography and endovascular treatment was based on the neurological examination, brain computed tomography (CT) and CT-angiography. The procedure reports, anesthesia records, neurological examination before and after the procedure, brain imaging and short- and long-term outcome were studied. Results: The average dose of nimodipine was 2 mg. The median change in mean arterial pressure at 10 min was -10 mmHg. No significant change of heart rate was observed at 10 min. There was radiological improvement in 80% of the procedures. Neurological improvement was noted after eight out of 12 procedures when nimodipine was used as the sole treatment and after 10 out of 15, overall. Six patients clinically improved after the treatment and had good outcome. In one patient, an embolus caused fatal anterior and middle cerebral arteries infarction. There was no other neurological deficit or radiological abnormality due to the nimodipine treatment itself. Conclusion: Low-dose IA nimodipine is a valid adjunct for the endovascular treatment of cerebral vasospasm. Beneficial effects are achieved in some patients, prompting a prospective control study.

Detection of progesterone receptor and the correlation with Ki-67 labeling index in meningiomas

Sanghamitra Mukherjee — Mon,2 Jan 2012

Sanghamitra Mukherjee, Samarendra Nath Ghosh, Uttara Chatterjee, Sandip Chatterjee

Neurology India 2011 59(6):817-822

Context: Although most of the meningiomas are benign, some of them are associated with a less favorable clinical outcome. The major prognostic question regarding meningiomas is the prediction of recurrence which is largely dependent on the histopathological type, grading, proliferation indices and progesterone receptor status. Aims: Our study was done to assess the expression of Ki-67 and progesterone receptor (PR) in different histological types, grades, recurrent and non-recurrent meningiomas. Materials and Methods: A total of 60 cases were collected over a period of 2.5 years. Hematoxylin and eosin staining was done for histological typing and grading of the tumors. Immunohistochemical staining was done for Ki-67 and PR using standard immunoperoxidase technique and Ki-67 Labeling Index (LI) and PR score was calculated. Results: Mean Ki-67 LI was significantly higher in males versus females, in Grade II versus Grade I, in recurrent versus non-recurrent and in PR-negative versus PR-positive meningiomas. Moreover, considering Grade I and Grade II-meningiomas separately, mean Ki-67 LI was significantly higher in recurrent cases. PR positivity was significantly higher in females versus males, in Grade I versus Grade II and in non-recurrent versus recurrent meningiomas. Correlation between Ki-67 LI and PR expression was also evaluated and a strong inverse correlation was found between Ki-67 LI and PR expression. A strong negative correlation was also established between the values of Ki-67 LI and recurrence-free survival. Conclusion: Our results establish that the immunodetection of Ki-67 LI and PR expression in meningiomas provides a practical tool for assessing the biological behavior of meningiomas.

Factors affecting the outcome of patients undergoing corrective surgery for craniosynostosis: A retrospective analysis of 95 cases

Keshav Goyal — Mon,2 Jan 2012

Keshav Goyal, Arvind Chaturvedi, Hemanshu Prabhakar

Neurology India 2011 59(6):823-828

Background: Surgical procedures for correction of craniosynostosis are often performed in pediatric patients who have a small blood volume; it represents major surgery. Literature is scarce on factors affecting blood loss, intensive care unit (ICU) and hospital stay in these patients. Objectives: To identify the factors which directly affect the outcome of craniosynostosis surgery. Materials and Methods: A detailed review of records pertaining to preanesthetic evaluation, associated anomalies, intraoperative course, and postoperative follow-up was done for patients who underwent craniosynostosis surgery between June 2000 and June 2010. The correlation between different variables was evaluated using Spearman's rank correlation. Results: During the study period 95 patients (mean age 29 months, range: 3 months-13 years) underwent corrective surgery for craniosynostosis. Hospital stay was found to be significantly associated with type of surgery and postoperative complications (P<0.001) Factors such as number of associated medical conditions, number of postoperative complications, type of induction of anesthesia, duration of surgery, type of recovery affected the ICU stay in these patients (P = 0.01). Conclusion: The outcome of patients undergoing craniosynostosis in terms of ICU and hospital stay is affected by the number of medical and postoperative conditions, type of anesthesia induction, duration of surgery and type of recovery.

Preliminary evaluation of the role of surgical microscope-integrated intraoperative FLOW 800 colored indocyanine fluorescence angiography in arteriovenous malformation surgery

Yoko Kato — Mon,2 Jan 2012

Yoko Kato, Sukhdeep S Jhawar, Junpei Oda, T Watabe, Daikichi Oguri, Hirotoshi Sano, Yuichi Hirose

Neurology India 2011 59(6):829-832

Objective: To discuss the role of FLOW 800 innovative software for analytical color visualization and objective evaluation of fluorescence videos obtained by microscope-integrated intraoperative indocyanine green (ICG) fluorescence angiography in arteriovenous malformations (AVM) surgery. Materials and Methods: Microscope-integrated intraoperative FLOW 800 was used and evaluated in three consecutive AVM surgeries over a period of two months. The role of FLOW 800 to distinguish feeding arteries from arterialized veins and other arteries was evaluated. Its advantages and limitations over conventional intraoperative ICG angiography were evaluated. Results: This software was found to be useful in identifying arterial feeders, arterialized veins and other arteries in all the three patients and it gives additional information on the status of AVM before and after clipping suspected feeders which is sometimes difficult to interpret on conventional ICG angiography. Conclusion: Flow 800 is a reliable and useful addition to microscope-integrated color ICG video angiography. Although its role is limited in deep-seated AVMs, if properly dissected and exposed it can give useful information which can be easily interpretable and reproducible.

Characteristics and endovascular treatment of intracranial vertebral artery aneurysms

Dongfeng Deng — Mon,2 Jan 2012

Dongfeng Deng, Dianshi Jin, Jinbing Zhou, Qingyong Chang, Kai Qu

Neurology India 2011 59(6):833-838

Objective: The clinical and angiographic characteristics of vertebral artery (VA) aneurysm were evaluated to demonstrate the safety and efficacy of endovascular techniques of VA aneurysms. Materials and Methods: Case records of 38 consecutive patients with 40 VA aneurysms admitted during a 2-year period were reviewed. The data analyzed included age, sex, size of aneurysm, ruptured or unruptured, endovascular techniques, angiographic results after embolization, duration of follow-up, angiographic follow-up results and Glasgow Outcome Score at follow-up. Results: Of the 38 patients, 33 patients had 35 dissecting aneurysms and five patients had five saccular aneurysms. Seventeen (42.5%) aneurysms were ruptured. Of the 34 patients treated with endovascular techniques, immediate post-procedural angiograms showed complete and subtotal occlusion (>90%) of 27 (67.5%) aneurysms and incomplete and no occlusion of 13 (32.5%) aneurysms, including four conservatively treated aneurysms. A clinical improvement or stable outcome was achieved in all the patients (100%) during a mean 12.1-month follow-up. There was no complication related to endovascular treatment and no rebleeding during the follow-up period. Angiographic follow-up (mean of 7.2 months, range 1-18 months) was available in all the patients. Complete and subtotal occlusion was observed in 31 (81.6%) patients, including one spontaneous thrombosis of a conservatively treated VA dissecting aneurysm. Recanalization in two patients (5.9%) at 6 and 9 months did not require retreatment. Conclusion: This series demonstrates the safety and efficacy of multimodality of endovascular techniques for VA aneurysms.

Detection of brain lesions at the skull base using diffusion-weighted imaging with readout-segmented echo-planar imaging and generalized autocalibrating partially parallel acquisitions

Xiao-Er Wei — Mon,2 Jan 2012

Xiao-Er Wei, Wen-Bin Li, Ming-Hua Li, Yue-Hua Li, Dan Wang, Yu-Zhen Zhang, Li-Xin Jin

Neurology India 2011 59(6):839-843

Objective: To analyze the value of readout-segmented echo-planar imaging (rs-EPI) with parallel imaging and a two-dimensional (2D) navigator-based reacquisition technique in the detection of brain lesions at the skull base. Materials and Methods: A total of 54 patients (male 37, female 17) with suspected skull-base intracranial lesions underwent magnetic resonance imaging (MRI), including pre-T1 weighted imaging, T2-weighted imaging, Fluid Attenuated Inversion Recovery (FLAIR), standard single shot echo-planar imaging diffusion weighted imaging (ss-EPI DWI) and rs-EPI DWI, post-contrast T1-weighted. The total number of lesions and the number of lesions at different sites on all MRI sequences were used as reference measures. Then differences in detecting lesions and image quality between standard ss-EPI DWI and rs-EPI DWI were analyzed. Results: There was a significant difference in the total number of lesions detected by rs-EPI DWI and standard ss-EPI DWI (P = 0.01). But this difference was mainly due to an improved ability of rs-EPI DWI to detect lesions located in the anterior cranial fossa, compared to ss-EPI DWI (P=0.02); the ability of ss-EPI and rs-EPI DWI to detect lesions in the middle cranial fossa and posterior cranial fossa was not significantly different (P = 0.471, P = 0.486, respectively). For image quality, rs-EPI images were significantly better than standard ss-EPI DWI images (P<0.001). Conclusion: The rs-EPI DWI technique is a useful tool for the detection and evaluation of lesions located at the skull base.

The role of repeat endoscopic third ventriculostomy after failure of the initial procedure

Pasquale Gallo — Mon,2 Jan 2012

Pasquale Gallo, Francesco Sala

Neurology India 2011 59(6):844-845

Therapy of obstructive hydrocephalus due to intraventricular hemorrhage: Is there a need for neuroendoscopy?

Sonja Vulcu — Mon,2 Jan 2012

Sonja Vulcu, Joachim Oertel

Neurology India 2011 59(6):846-847

Endoscopic third ventriculostomy for hydrocephalus: A review of indications, outcomes, and complications

Ranjith K Moorthy — Mon,2 Jan 2012

Ranjith K Moorthy, Vedantam Rajshekhar

Neurology India 2011 59(6):848-854

Endoscopic third ventriculostomy (ETV) has been in vogue for the past two decades, as a tool in the armamentarium of the neurosurgeon, for the management of hydrocephalus. Its utility has been proven consistently in congenital / acquired aqueductal stenosis, although the outcomes in communicating hydrocephalus as well as hydrocephalus secondary to other etiologies have not been as impressive. It is a relatively safe procedure with the appropriate selection of patients with a low rate of permanent morbidity. This review aims to define the current indications, management outcomes, and complications of ETV.

Endoscopic third ventriculostomy in tubercular meningitis with hydrocephalus

Yad Ram Yadav — Mon,2 Jan 2012

Yad Ram Yadav, Vijay Parihar, Moneet Agrawal, Pushp Raj Bhatele

Neurology India 2011 59(6):855-860

Background: Endoscopic third ventriculostomy (ETV) is increasingly being used as an alternative treatment in tubercular meningitis (TBM) hydrocephalus. This study is aimed to evaluate the role of ETV in TBM hydrocephalus. Materials and Methods: This is a prospective study of 59 patients with TBM and obstructive hydrocephalus. The diagnosis was confirmed by a computed tomography scan and/or magnetic resonance imaging scan preoperatively. The procedure was performed using the standard technique or water jet dissection. Results: Three (5.1%) patients had blocked stoma, 31 (53%) had associated malnutrition, and 13 (22%) had complex hydrocephalus. Clinical improvement was seen in 34 (58%) after ETV and in 47 (80%) patients after ETV with lumber peritoneal shunt. Thirteen patients with patent stoma and complex hydrocephalus did not improve after ETV alone; an additional lumber peritoneal shunt was required. Clinical outcome was significantly better in good grade. Early recovery was observed in 81%. Results of ETV were better in patients without cisternal exudates, good nutritional status, thin and identifiable floor of third ventricle compared to cases with cisternal exudates, malnourished, thick and unidentifiable floor respectively, although the difference was statistically insignificant. There was no operative death. Three patients with normal ICP did not show any improvement. The radiological recovery after 3 weeks of surgery was 52%; follow-up ranged between 7 and 54 months. Six patients developed CSF leak. Conclusion: Endoscopic third ventriculostomy was safe and effective in TBM hydrocephalus. Complex hydrocephalus and associated cerebral infarcts were the major causes of failure to improve. Good results were observed in better grades.

Application of neuroendoscopy in the treatment of obstructive hydrocephalus secondary to hypertensive intraventricular hemorrhage

Hsien-Chih Chen — Mon,2 Jan 2012

Hsien-Chih Chen, Chi-Cheng Chuang, Wen-Ching Tzaan, Peng-Wei Hsu

Neurology India 2011 59(6):861-866

Objective: Neuroendoscopy has become an integral part of neurosurgery, in particular in the ventricular system. Obstructive hydrocephalus secondary to intraventricular hemorrhage (IVH) is a good indication for neuroendoscopic surgery. We evaluated its efficacy and limitations in these patients. Materials and Methods: During a 5-year period, 13 patients with obstructive hydrocephalus secondary to hypertensive IVH were studied. Patients with IVH with no evidence of obstructive hydrocephalus or with a large parenchymal hematoma or IVH of vascular origin were excluded. Rigid endoscope was used to evacuate hematoma in lateral ventricles and third ventricle in all patients. Glasgow Coma Scale (GCS), Graeb score and ventriculo-cranial ratio were evaluated before and after endoscopic intervention and Glasgow Outcome Scale (GOS) was appraised at 1 month and 12 months, postoperatively. Results: Of the 13 patients, eight (61.5%) patients had thalamus hemorrhage. A successful endoscopic removal of intraventricular hematoma was achieved in all patients. Complications observed included, fornix contusion (1) and meningitis (1) and there was no procedure-related mortality. The mean Graeb score reduced from 8.69 ± 1.89 to 6.00 ± 2.68 (P=0.001) and ventriculo-cranial ratio decreased from 0.41 ±0.05 to 0.39 ± 0.05 (P=0.085) following the procedure. The mean GOS scores at 1 month and 12 months both were 2.7, but a bipolar distribution was observed at 12 months. The Graeb score changed significantly with positive correlation to GCS score change (=0.565 and P<0.05). Conclusions: Endoscopic management of severe IVH with obstructive hydrocephalus allows effective reduction of the amount of ventricular blood and improves level of consciousness. Future refinement in instrumentation and discreet case selection may make this method more applicable and effective.

Ostomy closure and the role of repeat endoscopic third ventriculostomy (re-ETV) in failed ETV procedures

Anand Mahapatra — Mon,2 Jan 2012

Anand Mahapatra, Sujit Mehr, Daljit Singh, Monica Tandon, Pragati Ganjoo, Hukum Singh

Neurology India 2011 59(6):867-873

Background: Endoscopic third ventriculostomy (ETV) has replaced shunt surgery for several indications. Failure of ETV secondary to restenosis can result in recurrence of symptoms of raised intracranial pressure. Objective: To analyze the rates of restenosis due to ostomy closure and factors resulting in failures and to assess the role of re-ETV in such cases. Materials and Methods: Re-ETV was performed after counselling and obtaining informed consent. The technique of re-ETV was essentially the same as in primary ETV. Video analysis of primary ETV was performed before selecting a patient for re-ETV. Factors analyzed included age, gender, etiology of hydrocephalus, cerebrospinal fluid (CSF) findings, presence of shunt tube and adequacy of ETV and bleeding at the time of ETV. Results: Thirty-two patients underwent re-ETV. The mean interval between the first ETV and re-ETV was 1.4 years (3 days to 2.9 years). Overall failure of ETV due to restenosis was 8.78%. The technical success rate of performing re-ETV was 93.2%. The overall clinical recovery following surgery was observed in 89% of the patients, three from early and 25 from delayed ETV failures. The radiological recovery was seen in 20 (63%) patients. The good flow of CSF via the re-ETV site was documented with cine mode magnetic resonance imaging (MRI) in seven patients. Unlike primary ETV, the success of re-ETV in children aged less than 2 years was 90% (P < 0.005). There were 56.25% failure of ETV in patients with previous infection or foreign body within the ventricle (P < 0.001). While the chances of restenosis were high in the procedure with some infections, the outcome was equally better. Gender of the patients and CSF findings had no influence on ostomy closure. Conclusions: re-ETV can be considered in carefully selected patients of failed ETV. It is more useful in delayed ETV failures and can be offered before a patient is advised VP shunt.

A retrospective analysis of perioperative complications during intracranial neuroendoscopic procedures: Our institutional experience

Gyaninder P Singh — Mon,2 Jan 2012

Gyaninder P Singh, Hemanshu Prabhakar, Parmod K Bithal, Hari Hara Dash

Neurology India 2011 59(6):874-878

Background: Neuroendoscopic procedures are now being performed more frequently, and with advancement in technology, complications related to the procedure and equipments have also minimized or changed. We report our experience with 223 patients who underwent intracranial neuroendoscopic procedures. Materials and Methods: The rates of various perioperative complications, both surgical and anesthesia related, during intracranial neuroendoscopic surgeries were studied. Data collected included demographics, patient's medical history and any associated comorbid conditions, diagnosis, procedure performed, anesthetic management, intraoperative and postoperative complications and outcomes. Results: Of the 223 patients studied, 119 were pediatric (age <14 years) and 104 were adults. Hypothermia (25.1%) and cardiovascular complications (such as tachycardia 18.8%, bradycardia 11.3%, hypertension 16.1%, and hypotension 16.6%) were the commonly observed complications during intraoperative period both in pediatric and adult patients. At the end of the procedure, delayed arousal was observed in 17 patients and 19 patients required postoperative ventilatory support. Postoperative frequent complications included: fever (34.1%), tachycardia (32.7%), nausea and vomiting (18.8%). Potentially fatal complications such as intraoperative hemorrhage, air embolism, etc. were rare. Most of the complications were transient and self-limiting. Conclusion: Although endoscopic procedures are considered minimally invasive, at times may lead to life-threatening complications and one should be aware of them.

Congenital myopathies: Clinical and immunohistochemical study

Fazil Thaha — Mon,2 Jan 2012

Fazil Thaha, N Gayathri, A Nalini

Neurology India 2011 59(6):879-883

Congenital myopathies (CMs), a group of relatively non-progressive disorders presents with weakness and hypotonia of varying severity, morphologically recognized by specific structural abnormalities within the myofiber. This report presents the clinical and Histopathological features of 40 patients with CMs. Centronuclear myopathy was the commonest (40%) followed by congenital fiber type disproportion (37.5%). Other less common CMs included: myotubular myopathy (5%), nemaline myopathy (5%), central core disease (5%), multicore disease (2.5%) and congenital myopathy with tubular aggregate (5%). Immunolabeling to desmin corresponded to morphological changes within the myofibers while vimentin was negative in all the patients. There is no combined role of these proteins in the disease process.

Glycogen storage disease type V (Mc Ardle's disease): A report on three cases

Naveen Krishnamoorthy — Mon,2 Jan 2012

Naveen Krishnamoorthy, Vani Santosh, TC Yasha, Anita Mahadevan, SK Shankar, Dilip Jethwani, AB Taly, K Bhanu, N Gayathri

Neurology India 2011 59(6):884-886

McArdle's disease (myophosphorylase deficiency), an uncommon autosomal recessive metabolic disorder, is characterized clinically by exercise intolerance beginning in childhood, myalgia, cramps, exercise-induced rhabdomyolysis, "second wind" phenomenon, elevated Creatine Kinase (CK) levels at rest, and previous episodes of raised CK levels following exercise. Several mutations in the PYGM gene and geographic variations have been described. We report three biopsy confirmed cases of McArdle's disease.

Dual pathology of corticobasal degeneration and Parkinson's disease in a patient with clinical features of progressive supranuclear palsy

Tomin Mooney — Mon,2 Jan 2012

Tomin Mooney, Anthony Tampiyappa, Thomas Robertson, Rohan Grimley, Chris Burke, Kenneth Ng, Peter Patrikios

Neurology India 2011 59(6):887-890

Corticobasal degeneration and Parkinson's disease are pathologically distinct disorders with unique histological and biochemical features of a tauopathy and a-synucleinopathy respectively. We report the first case of co-occurrence of these pathologies in the same patient. Convergence of such distinctly separate neuropathology in the same brain highlights the need for extensive brain banking and further research in supporting the hypothesis that tauopathies and a-synucleinopathies might share common pathogenic mechanisms.

Unique case of postpartum cerebral angiopathy requiring surgical intervention: Case report and review of literature

Jai Deep Thakur — Mon,2 Jan 2012

Jai Deep Thakur, Prashant Chittiboina, Imad Saeed Khan, Anil Nanda

Neurology India 2011 59(6):891-894

Postpartum cerebral angiopathy (PPCA) is a rare form of reversible cerebral vasoconstriction syndrome. A 39-year-old female presented with a 5×6 cm left frontal intracerebral hemorrhage (ICH) and following an emergent neurosurgical evacuation of ICH, she developed a contralateral ICH and intraventricular hemorrhage. Her postoperative course was highlighted by the finding of diffuse bilateral segmental vasospasm on angiography and trans-cranial Doppler, left anterior cerebral artery region infarct and intractable elevated intracranial pressure (ICP). Medical management including osmotic therapy, nimodipine, corticosteroids, and phenytoin was unable to control ICP. Intractable elevated ICP led to evacuation of the right-sided ICH. After 3.5 years, the patient appears to be cognitively intact but continues to have right lower extremity weakness and is wheelchair-bound. Our case suggests that PPCA can rarely manifest as a life-threatening emergency for which neurosurgical intervention may be life-saving.

Covered coronary stent grafts as a treatment option for carotid-cavernous fistulas: Our initial experience

Tejas M Kalyanpur — Mon,2 Jan 2012

Tejas M Kalyanpur, Kaustubh Narsinghpura, Manish Yadav, Pankaj Mehta, Kiruba Paul, Mathew Cherian

Neurology India 2011 59(6):895-898

Treatment of Type 1 carotid-cavernous fistula (CCF) is complex and endovascular stent grafting is proving to be an excellent technique not only in successful treatment of fistula but also preserving patency of parent artery. We describe our initial experience in the use of covered coronary stent grafts in the treatment of three patients with Type 1 post-traumatic CCF. All patients were successfully treated with placement of stent grafts. Immediate closure of fistula was achieved in all the three patients. One patient developed partial in-stent thrombosis. In this patient antiplatelet therapy had to be stopped as he developed a small intracerebral hematoma post procedure. Subsequently, he was restarted on antiplatelets and recovered completely. Except for this no other complication was observed. Covered stent grafts may be the procedure of choice for treatment of post-traumatic Type 1 CCF especially in young patients with favorable anatomy.

Dural arteriovenous fistula with spinal perimedullary venous drainage

Xianli Lv — Mon,2 Jan 2012

Xianli Lv, Xinjian Yang, Youxiang Li, Chuhan Jiang, Zhongxue Wu

Neurology India 2011 59(6):899-902

The purpose of this study was to investigate the characteristics of six patients with dural arteriovenous fistula (DAVF) with drainage directly into the perimedullary venous system. In five patients with subarachnoid hemorrhage (SAH), cerebral angiography revealed a DAVF with spinal venous drainage located at the petrosal sinus in one, at the tentorium in one, and at the craniocervical junction in four. In the patient with myelopathy, angiographic exploration began with a spinal angiogram. Bilateral vertebral angiography initially failed to demonstrate the fistula, and a tentorial DAVF was established with carotid artery angiography. Patients had no myelopathy when the venous drainage was limited to the cervical cord; myelopathy was present when the venous drainage descended toward the conus medullaris. Diagnosis of a DAVF presenting with myelopathy is more challenging than of those presenting with SAH.

Chronic encapsulated intracerebral hematoma associated with cavernous angioma: Expression of vascular endothelial growth factor and its receptor

Satoru Takeuchi — Mon,2 Jan 2012

Satoru Takeuchi, Hiroshi Nawashiro, Kojiro Wada, Kenzo Minamimura

Neurology India 2011 59(6):903-904

Segmental myoclonus and marked ataxia in a patient of pulmonary tuberculosis

VV Ashraf — Mon,2 Jan 2012

VV Ashraf, Praveenkumar , EK Sureshkumar, Rajeev Anand, Shalini Kuruvilla, AS Girija

Neurology India 2011 59(6):904-906

Diagnosing paroxysmal autonomic instability with dystonia following intracerebral hemorrhage

Prashant Chittiboina — Mon,2 Jan 2012

Prashant Chittiboina, Menarvia Nixon, Anil Nanda, Bharat Guthikonda

Neurology India 2011 59(6):906-908

Acute embolic occlusion of the accessory middle cerebral artery mimicking an internal carotid artery terminus aneurysm

Bijoy K Menon — Mon,2 Jan 2012

Bijoy K Menon, Sanjith Aaron, Simerpreet Bal, Michael D Hill, Andrew M Demchuk, Mayank Goyal

Neurology India 2011 59(6):908-909

Infectious psychosis: Cryptococcal meningitis presenting as a neuropsychiatry disorder

Anil Kumar — Mon,2 Jan 2012

Anil Kumar, Siby Gopinath, Kavitha R Dinesh, Shamsul Karim

Neurology India 2011 59(6):909-911

Deep brain stimulation surgery complicated by Parkinson hyperpyrexia syndrome

Ezequiel Goldschmidt — Mon,2 Jan 2012

Ezequiel Goldschmidt, Federico Landriel, Pablo Ajler, Carlos Ciraolo

Neurology India 2011 59(6):911-912

Anti-Ma2-positive paraneoplastic brainstem encephalitis associated with prostatic adenocarcinoma

Bengt Edvardsson — Mon,2 Jan 2012

Bengt Edvardsson

Neurology India 2011 59(6):912-913

Magnetic resonance perfusion and spectroscopy in a giant tuberculoma

Prashant S Naphade — Mon,2 Jan 2012

Prashant S Naphade, Abhijit A Raut, Bhujang U Pai

Neurology India 2011 59(6):913-914

Idiopathic hypertrophic pachymeningitis successfully treated with intravenous cyclophosphamide

Chen Zhuoyou — Mon,2 Jan 2012

Chen Zhuoyou, Qian Chuanzhong, Ding Xinsheng

Neurology India 2011 59(6):915-916

Role of endovascular embolisation in treatment of pediatric dural arteriovenous fistula: A case report with a review of the literature

Lakshmi Sudha Prasanna Karanam — Mon,2 Jan 2012

Lakshmi Sudha Prasanna Karanam, Sridhar Reddy Baddam, Santhosh Joseph

Neurology India 2011 59(6):917-918

Glioblastoma multiforme with epithelial differentiation

R Neelima — Mon,2 Jan 2012

R Neelima, CV Gopalakrishnan, B Thomas, VV Radhakrishnan

Neurology India 2011 59(6):918-920

Traumatic giant pseudoa-neurysm of the middle meningeal artery causing intracerebral hematoma

R Jinendra Kumar — Mon,2 Jan 2012

R Jinendra Kumar, Ponraj K Sundaram, Jaykumar D Gunjkar

Neurology India 2011 59(6):921-922

Cysticercosis of filum terminale

Bharti Ahuja — Mon,2 Jan 2012

Bharti Ahuja, Ashru K Banerjee, VK Kak

Neurology India 2011 59(6):922-923

Intraparenchymal schwannoma of brainstem in a pediatric patient

Arun Kumar Srivastav — Mon,2 Jan 2012

Arun Kumar Srivastav, Arun Tungaria, Raj Kumar, Rabi Narayan Sahu

Neurology India 2011 59(6):924-926

Distant extraventricular recurrence in central neurocytoma

BV Savitr Sastri — Mon,2 Jan 2012

BV Savitr Sastri, A Arivazhagan, V Santosh, BA Chandramouli

Neurology India 2011 59(6):926-927

Cholesterol granuloma of the petrous apex: A benign lesion with aggressive behavior

Vijay Bohra — Mon,2 Jan 2012

Vijay Bohra, SS Sangha, Sunil Goyal, G Manoj

Neurology India 2011 59(6):927-929

Extraskeletal intracranial mesenchymal chondro-sarcoma: Report of a rare case

VG Ramesh — Mon,2 Jan 2012

VG Ramesh, Shantha Ravisankar, R Vimal Chander, P Saminathan

Neurology India 2011 59(6):929-931

Acute cauda equina syndrome due to primary Ewing's sarcoma of the spine

R Krishnakumar — Mon,2 Jan 2012

R Krishnakumar, J Renjitkumar

Neurology India 2011 59(6):931-933

Hemorrhagic subependymal giant cell astrocytoma in a patient with tuberous sclerosis: Case report and review of the literature

Rishi Wadhwa — Mon,2 Jan 2012

Rishi Wadhwa, Imad S Khan, Jaiyeola O Thomas, Anil Nanda, Bharat Guthikonda

Neurology India 2011 59(6):933-935

A large vertex extradural hematoma due to traumatic bilateral coronal suture diastasis

P Arun — Mon,2 Jan 2012

P Arun

Neurology India 2011 59(6):935-937

Sporadic pituitary stalk hemangioblastoma

Hui Fu — Mon,2 Jan 2012

Hui Fu, Shuyu Hao, Zhen Wu, Junting Zhang, Liwei Zhang

Neurology India 2011 59(6):937-938

Traumatic calvarial stone: A rare case report and review of the literature

Mohana Rao Patibandla — Mon,2 Jan 2012

Mohana Rao Patibandla, Amit K Thotakura, Manas K Panigrahi, Gurram L Paniraj

Neurology India 2011 59(6):938-940

Traumatic bilateral frontal extradural hematomas with coronal suture diastases

Sudhansu Sekhar Mishra — Mon,2 Jan 2012

Sudhansu Sekhar Mishra, Satya Bhusan Senapati, Rama Chandra Deo

Neurology India 2011 59(6):940-942

Direct visualization of thrombus load in MCA in acute stroke on susceptibility weighted imaging

Bejoy Thomas — Mon,2 Jan 2012

Bejoy Thomas, Dayananda Lingegowda, Chandrasekharan Kesavadas, PN Sylaja

Neurology India 2011 59(6):943-943

Microsurgical management of prolactinomas - Clinical and hormonal outcomes

S Vivekanandan — Mon,2 Jan 2012

S Vivekanandan, Dinesh Nayak

Neurology India 2011 59(6):944-945

Encephalopathy as an initial symptom of rhabdomyolysis: A commentary

Rishi V Lohiya — Mon,2 Jan 2012

Rishi V Lohiya

Neurology India 2011 59(6):945-945

Authors' reply

Zhaoshi Zheng — Mon,2 Jan 2012

Zhaoshi Zheng, Xuemei Han, Yin Chang, Songyan Liu

Neurology India 2011 59(6):946-946

Spontaneous cerebrospinal fluid leak associated with idiopathic intracranial hypertension

C Kurtzhals — Mon,2 Jan 2012

C Kurtzhals, K Hansen, D Kondziella

Neurology India 2011 59(6):946-947

The efficacy of transforaminal epidural steroid injections in lumbosacral radiculopathy: A commentary

R Krishnakumar — Mon,2 Jan 2012

R Krishnakumar

Neurology India 2011 59(6):948-948

Authors' reply

Chinmoy Roy — Mon,2 Jan 2012

Chinmoy Roy, Nilay Chatterjee, Satya Narayan Patro, Amit Chakraborty, GR Vijay Kumar, Robin Sengupta

Neurology India 2011 59(6):948-949