Cerebral venous thrombosis (CVT) is an uncommon cause of stroke with extremely varied clinical presentations, predisposing factors, imaging findings, and outcomes, and thus can be extremely challenging to diagnose. Accurate and prompt diagnosis of CVT is crucial because timely and appropriate therapy can reverse the disease process and significantly reduce the risk of acute complications and long-term squel. In this article, we have reviewed the epidemiology, causative factors, clinical features, diagnosis and treatment of CVT from an Indian perspective. Over the last decade, a change in trends in the causative factors has been noted from India.

Brain abscess is an uncommon but a compelling reality in neurosurgical practice. Its focal, local, and systemic manifestations conceal its infective and obsessive nature. There are many a lesson that a brain abscess, as a bio-phenomenon, offers to the medical fraternity in general and the neurosurgeons, in particular. From Skt. puyati = to stink, comes the word "pus," meaning something foul, putrid, or rotten. From ab = away, and cedre = to go, comes the term "abscess" which is but nature's ingenious way of creating a fluid-filled cavity that will eventually rupture to an exterior to get rid of the non-self contents and proceed to healing. A brain abscess is special in the sense that it is, in general, more solid than fluid for reasons the human body and brain know best.

Context: Scientific publications are a reflection of the quality of the clinical and academic work being carried out in an institute. Training in the process of research and scientific writing are important components of the residency curriculum. Aims: The publication performance and research output of institutes training residents in neurology and neurosurgery were evaluated. Setting and Design: Internet-based study. Methods: This study was based on the data available on the websites of the Medical Council of India and the National Board of Examinations. The PubMed search interface was used to determine the publication output of institutes over the past 5 years (2010-2014). Google Scholar was used to determine the citation performance of each paper. The publication parameters were normalized to the number of faculty members in each institute as listed on the institutional web page. The normalized publication performance for an institute was computed by comparing the figures for that institute with the national average. Results: Institutes could be ranked on several criteria. There was a high degree of clustering of output from the top 5% of the institutes. About 13% of the neurology intake and 30.9% of neurosurgery intake over the past 5 years has been into the institutes that have not published a single paper during this period. Conclusions: This evaluation of the publication performance and research output of neurology and neurosurgery training institutes would serve as a baseline data for future evaluations and comparisons. The absence of any publication and research output from several training institutes is a matter of concern.

Objective: To ascertain whether rehabilitation interventions improve locomotion beyond 6 months post stroke. Site: The Neurological Rehabilitation Department of a university tertiary research hospital. Study Design: Prospective, repeated-measure study. Patients: Patients with first episode of supra-tentorial stroke of more than 6 months duration. Intervention: Twenty sessions of task-specific interventions consisting of lower limb resistive exercises and treadmill gait training to locomotor abilities (90 min/day, 5 days/week for 4 weeks). Evaluations were performed at the beginning and end of training and at a follow-up of 3 months. Outcome Measures: Stroke severity (Scandinavian Stroke Scale - SSS), balance (Berg Balance scale - BBS), ambulation (Functional Ambulation Category), walking ability (speed 10-m walk test - WS) and functional ability (Barthel Index - BI). Results: Forty patients (32 men and eight women; age range: 22-65 years; mean post-stroke duration of 18.90 ± 12.76 months) were included in the study. Thirty-two (80.0%) patients completed their training and 28 (70.0%) patients reported at a follow up of 3-months. At the beginning, the end of training and at follow-up, the mean SSS scores were 41.71, 44.09, and 43.96; the BBS scores were 36.28, 46.75 and 46.82; the WS scores were 0.41, 0.53 and 0.51; and the BI scores were 77.34, 89.06 and 92.32, respectively. All outcome measures showed statistically significant improvement (P < 0.001) at the end of training and at follow-up. Conclusion: Rehabilitation interventions significantly improve locomotor outcome even in the chronic phase following a stroke.

Background: In pediatric epilepsy, health-related quality of life (HRQOL) may be affected across the physical, psychological, social, and school domains. Studies have shown that antiepileptic drugs (AEDs) could have a significant negative impact on HRQOL, but these findings are scarce and inconsistent. Aim : To evaluate the influence that the adverse effects of AEDs have on HRQOL in pediatric epilepsy. Materials and Methods: A total of 75 children with epilepsy and at least one parent participated in this study. The Pediatric Quality of Life Inventory (PedsQL) was utilized to assess the HRQOL, while the Adverse Event Profile (AEP) was used to assess the presence and severity of the adverse effects of AEDs. Results: Assessing the children's ratings, the AEP score significantly influenced the PedsQL based psychosocial functioning score (P < 0.02; partial ç2 = 0.07); and, assessing the parents' ratings, the AEP score significantly influenced both the PedsQL based physical functioning score (P < 0.02; partial ç2 = 0.07) as well as the PedsQL psychosocial functioning score (P < 0.001, partial ç2 = 0.30). Conclusion: The frequency and severity of AED-related adverse effects could significantly predict the lowered levels of HRQOL among children with epilepsy, in particular having a large impact on their psychosocial functioning.

Aim: The diagnosis and treatment of acromegaly, a rare and possibly curable disease, has undergone a paradigm shift in the past few decades. Our aim was to study the changing trends in clinical presentation, management and outcome of the disease in the last fifteen years. Methodology: 271 consecutive patients with acromegaly treated at the Departments of Endocrinology and Neurosurgery, PGIMER, Chandigarh, between 2000 and 2014, were included in the study. Clinical and hormonal profiles, comorbidities, treatment modalities, outcome and mortality data were evaluated. The cure rate was assessed according to the present consensus criteria. Results: The gender distribution was equal with the mean age (±SD) of 37.1 ± 12.3 years at diagnosis. The average lag period to diagnosis was 4.7 ± 4.2 years. The most common presenting manifestations were acral enlargement and headache followed by visual deficits. The overall mortality rate was 5%, with the perioperative mortality being 1.5%. The most prevalent comorbidities in our series were hypertension (17.7%), diabetes mellitus (16.2%), arthropathy (11.8%) and obstructive sleep apnea (10.3%). Overall, 2 patients in our series suffered from extra-pituitary neoplasms and 12 patients had apoplexy as the presenting manifestation. As per the present consensus criteria, cure rate in our series was 28.5%. The cure rate was only 7.9% when many surgeons were operating. It increased to 25.5% when surgeries were being performed by one surgeon exclusively; and, when a sub-specialty clinic exclusively for pituitary diseases was set up, the cure rates improved upto 56%. Conclusion: Acromegaly has wide-ranging manifestations from acral enlargement to altered sensorium; incidental diagnosis was not prevalent in our series. Majority of the cases were due to the presence of a pituitary macroadenoma. Better cure rate can be achieved only when a dedicated group of multi-disciplinary team is involved.

Background: Rapid reperfusion in a patient with a favorable penumbral pattern is crucial to achieving a good outcome in acute ischemic stroke. Recanalization rates for tandem and terminal internal carotid artery (ICA) occlusion are better with endovascular management as compared with intravenous tissue plasminogen activator (IV-tPA) alone. We hypothesize that tissue-based selection would enable the identification of the ideal patient most suited for reperfusion therapy. We present our series of patients who developed tandem or terminal ICA occlusion and were selected for endovascular management based on their computed tomography (CT) perfusion (CTP) imaging. Results: In this prospective study, 14 (29.16%) of the 48 patients treated by endovascular intervention between January 2011 and March 2014 had either tandem or terminal ICA occlusion. In the tandem group, thrombolysis in cerebral infarction (TICI) 2b/3 reperfusion and a good outcome was observed in five (71.42%, n = 7) and six patients (85.71%, n = 6), respectively. Among the terminal ICA occlusion group, TICI 2b/3 reperfusion and a good outcome was observed in three (42.8%, n = 7) and two patients (28.5%, n = 7), respectively. In patients with early reperfusion, a strong correlation with a median difference of one, in cerebral blood volume (CBV) Alberta Stroke Program Early CT Score (ASPECTS) on CBV map and post-procedure 24-h non-contrast CT, was noted. The median imaging-to-puncture and puncture-to -meaningful reperfusion time was 70 and 68.5 min, respectively, and, overall, good outcomes were seen in 57.1% of the patients. Conclusion: The cerebral blood volume (CBV) core estimation reliably predicted the final infarct volume. The key reasons for the significantly better outcomes seen in our cohort were the stringent perfusion imaging-based patient selection and the rapid reperfusion.

Aims: To study and compare the electrophysiological changes in neuroparalytic or vasculotoxic snakebites. Materials and Methods: 40 patients who had a definite history of snakebite, either vasculotoxic or neuroparalytic, were selected. They were grouped as Group A, 20 patients having a neuroparalytic snakebite with definite envenomation at the time of admission, and Group B, 20 patients having a vasculotoxic snakebite with definite envenomation at the time of admission. All patients underwent a detailed clinical examination, all relevant investigations and nerve conduction studies according to protocol. Results: In this study, we noticed that the motor nerve conduction amplitude, conduction velocity and distal latency were within normal limits in both the groups. On RNS (repetitive nerve stimulation study) of facial and median nerves, a decremental response was seen in 13 (65%) patients in facial nerve and in 7 (35%) patients in median nerve in Group A; while, the same response was seen in 8 (40%) patients in facial nerve and 3 (15%) patients in median nerve in Group B. A post exercise decremental response was seen in 13 (65%) patients in median nerve and 16 (80%) patients in facial nerve in Group A; and, in 3 (15%) patients in median nerve and 8 (40%) patients in facial nerve in Group B. Conclusions: In our study, we noticed that the decremental response on RNS was not only present in neuroparalytic snake bite (post-synaptic neuromuscular blockade) but also in vasculotoxic snakebite [pre-synaptic neuromuscular blockade] (seen in Russel's viper).

Context: Variability in dimensions and course of vertebral artery (VA) makes it vulnerable to injury during surgery for congenital atlanto-axial dislocation (AAD) with or without an occipitalized atlas. Aims: This prospective study attempts to define anatomical variations that render VA at the craniovertebral junction (CVJ) vulnerable to injury during transoral decompression and posterior stabilization procedures; and, to propose a classification that helps in preoperative risk stratification. Settings and Design: A prospective study. Materials and Methods: 104 patients (65 with AAD; 39 controls) underwent a three-dimensional multiplanar computed tomographic angiogram to study anatomical variations in VA size, course, and anomalous medial deviation as well as in the type of axial isthmus and rotational deformity/tilt at the CVJ. The VA/foramen transversarium diameter; "stretched loop" sign of VA; and C1-2 facet joint angle were also assessed. Statistical Analysis Used: A medial VA deviation that brought it in close proximity to the trajectory of the surgical approach was evaluated (P ≤ 0.05 significant). Results: An increased predisposition to VA injury was present in 23 (35.4%) patients (persistent first intersegmental artery [n = 20; 30%]; fenestrated VA [n = 1; 1.53%], and low-lying posterior inferior cerebellar artery [n = 2; 3.0%]) where VA crossed the C1-2 facet joint; 8 (12%) with an anomalous medial deviation; 12 (18%) with a high-riding VA at C2 and a narrow axial isthmus; and 13 (20%) with rotation/tilt at the CVJ. A normal score of 5 was obtained in 21 patients; and a score of 6-9 (that progressively indicated an increased vulnerability of VA to iatrogenic injury) in 44 patients. The "AAD with an occipitalized atlas" group was associated with a significant medial deviation of VA (right: P = 0.00 and left: P = 0.001). Conclusions: A preoperative detailed risk assessment of anatomical variations in the size and course of VA at the CVJ significantly reduces chances of its iatrogenic injury.

An ectopic breast, that is present at a distance from the embryonic milk line, is an uncommon condition in the normal population. We describe a case with the presence of a breast in the dorsal region occurring in a patient with meningomyelocele and split cord malformation type I. A dorsally situated breast in a case of split cord malformation has never been reported previously in the literature. This case report highlights that an ectopic breast could be a marker of occult spinal dysraphism. This lesion should be corrected only after appropriate radiological investigations ascertain the underlying pathology.

Charcot Marie Tooth (CMT) disease is a group of hereditary motor sensory neuropathies with significant genetic heterogeneity. This disorder has been scarcely reported in the Indian literature. Here, we report a case of the rare but relatively more severe autosomal recessive CMT type 4C disease with a few features that are distinct from its regular presentation. Our patient was proven to have one of the common mutations in the SH3TC2 gene, which has so far not been described in Indian patients.

Background: Despite the conventional acceptance of the matrix metalloproteinases (MMP)-2 and MMP-9, as markers of invasion in glioblastoma (GBM), there is no large body of evidence supporting their role as prognostic markers. Since the co-expression of MMPs with p53 was noted to be prognostic in other cancers, we evaluated the protein expression of MMP-2 and MMP-9 in GBM and explored their prognostic relevance with respect to p53 expression. Materials and Methods: Tumor tissues from a uniformly treated cohort of 132 GBM patients were examined for MMP-2, MMP-9, and p53 protein expression by immunohistochemistry (IHC). Survival analyses were performed by Cox-regression and Kaplan-Meier (KM) survival analysis. P53 IHC-based stratification of all GBM cases was performed, and subgroup-specific expression of MMP-2 and MMP-9 was correlated with survival. Results: MMP-2 and MMP-9 were expressed in p53 positive as well as p53 negative GBM tumors. MMP-2 and MMP-9 protein expressions had no correlation with prognosis. MMP-9 expression, however, emerged as a strong independent predictor of poor survival in p53 positive GBMs on both Cox-regression analysis (P = 0.036) and KM survival analysis (P = 0.008). Further, even on multivariate analysis, MMP-9 remained strongly associated with poor prognosis (P = 0.010). Conclusions: MMP-9 expression strongly associates with poor prognosis in p53 positive GBMs, but the absence of such correlation in p53 negative GBMs, skews the overall relation of this molecule with prognosis. The study highlights that the dual positivity of MMP-9 and p53 is of prognostic relevance in GBM.

The surgical treatment of craniopharyngiomas is challenging. An optimal surgical approach is extremely important to achieve complete removal of the tumor, which is often the goal of treatment. Conventionally, the endoscopic transsphenoidal approach is used for resection of craniopharyngiomas that are essentially confined to the sellar cavity, or have smaller suprasellar extension. However, the tumors located in the retrochiasmatic space are difficult to remove surgically due to a poor access. Traditionally, various transcranial microsurgical routes have been employed with limited success for resection of retrochiasmatic craniopharyngiomas. The transcranial approaches generally do not provide adequate exposure of the tumors originating in the space under the optic chiasm and nerves. Recently, the extended endonasal endoscopic surgical route, obtained by removal of the tuberculum sellae and planum sphenoidale, has been used with great success in the surgical management of tumors lying ventral to the optic chiasm, including craniopharyngiomas. It offers a direct midline access to the retrochiasmatic space and provides excellent visualization of the undersurface of the optic chiasm. It also allows extracapsular dissection using binostril-bimanual technique and facilitates complete removal of these formidable tumors. In this report, we describe step-by-step, the technical details of the endonasal endoscopic transplanum transtuberculum approach with emphasis on the operative nuances for removal of retrochiasmatic craniopharyngiomas.

King George Medical University is one of the oldest and most prestigious medical universities of India. The Department of Neurology has trained many illustrious neurologists who are offering yeoman's service to the nation. This brief review traces the history and milestones of the department and its current areas of focus.

Neurointerventional surgery has evolved rapidly over the last two-and-a-half decades. It is now the treatment of choice for many neurovascular conditions, and its techniques and indications are rapidly expanding. It is the need of the hour that residents in training programs should familiarize themselves with the basic concepts of neurointerventional surgery. There are no set guidelines regarding neuroendovascular training of residents in India. The current article provides an insight into the basic concepts of neurointerventional surgery for residents in training.