In the experimental models of Parkinson's disease (PD), a well-known neurotoxin 1-methyl-4-phenyl-1, 2, 3, 6-tetrahydropyridine or MPTP, pesticides like benomyl, paraquat,etc. are successfully used to induce a Parkinson's disease in human and nonhuman primates, which can be reversed by the drugs such as L-DOPA. A review on the alternative methods and alternative models in Parkinson's disease is documented here to understand their advantages and importance. Earlier researchers proved MPTP is effective in the goldfish, which reliably mirrors the neurochemical and behavioral changes caused by MPTP in the higher vertebrates. Gold fish brain has the “nucleus pars medialis,” similar to the substanitia nigra of the human brain can be destructed by chemicals like MPTP, 6-hydroxydopamine and has selective protection by L-Dopa (Levodopa) and MAO-B (Monoamine oxidase B) inhibitors. In addition, zebrafish along with mice was successfully employed in the study of pesticides leading to neurodegeneration in PD. As the current animal models often couldn't replicate the true pathophysiology of idiopathic PD, alternative models have gained importance in the research. Upon having a glance at different models utilized in Parkinson's disease studies, one can get an idea on preferring alternative models, especially the zebra fish model in the study of neurodegenerative disorders.

Background and Aims: During the last two decades important advances have been made regarding the knowledge of immunomediated neuropathies, which entitled them to evolve from a theoretical existence to subtype differentiation. Nevertheless, questions regarding antigen topography or antibody's pathogenicity still need to be answer. Moreover, antibody typification is not necessarily available during clinical practice and usually diagnostic decisions or follow-up are done without it. The aim of this study is to raise awareness of the importance of divergent clinical findings in patients with immunomediated neuropathies. Methods: We present an acute and a chronic case of anti-ganglioside neuropathy immunologically studied with the best anti-ganglioside antibody panel available nowadays in our country along with an update of the current knowledge of these entities. Results: Although there is no consensus regarding the pathogenicity of these antibodies, diverging clinical features (mainly ataxia and ophthalmoparesis) and disease prognosis (as markers of axonal damage) are known to be associated with different antibodies. Conclusions: Antibody characterization in anti-ganglioside neuropathies is an evolving field, which we believe should periodically updated and minded for patient's diagnosis and follow-up, even if laboratory confirmation is not immediate, if available at all.

Background: A terrible pandemic, Covid-19, has captivated scientists to investigate if SARS-CoV-2 virus infects the central nervous system (CNS). A crucial question is if acute respiratory distress syndrome (ARDS), the main cause of death in this pandemic, and often refractory to treatments, can be explained by respiratory center dysfunction. Objective: To discuss that ARDS can be caused by SARS-CoV-2 infection of the respiratory center in the brainstem. Materials and Methods: I reviewed literature about SARS-CoV-2 mechanisms to infect the respiratory center in the brainstem. Results and Conclusions: An increasing amount of reports demonstrates that neurotropism is a common feature of coronavirus, which have been found in the brains of patients and experimental models, where the brainstem was severely infested. Recent studies have provided tremendous indication of the incidence of acute respiratory failure due to SARS-CoV-2 infection of the brainstem. SARS-CoV-2 might infect the CNS through the olfactory bulb, spreading from the olfactory nerves to the rhinencephalon, and finally reaching the brainstem. Hence, the virus infection causes respiratory center dysfunctions, leading to ARDS in COVID-19 patients. I conclude that acute ARDS in Covid-19 can be caused by SARS-CoV-2 invasion of brainstem respiratory center, suggesting the needs of more specific and aggressive treatments, with the direct participation of neurologists and neurointensivists.

Cervical split cord malformations are extremely rare with less than 75 cases reported in the literature worldwide. The widely different terminologies used to describe the same pathoanatomy make the documentation of all reported cases a difficult task. We conducted a systematic review of 71 cases documented over 38 reports from 1889 to 2016. The controversy regarding prophylactic surgery in asymptomatic individuals remains. We advocate prophylactic surgery in all asymptomatic individuals to preclude severe neurological deficit following trivial trauma in future. The results of surgery in asymptomatic individuals are excellent while those in symptomatic individuals are good as well.

Migraine is a severe primary headache disorder that affects about 12% of the population, and it often occurs along with nausea, vomiting, and extreme sensitivity to light and sound. For patients with migraine, beta-blockers, antidepressants, anticonvulsants, are given as the first line of preventive treatment; alternatives include calcium channel blockers. Not only statins prevent the synthesis of cholesterol biosynthesis but also they have a pleiotropic effect such as antiinflammatory effects, antioxidant property, antiproliferative and immunomodulatory effects, the stability of plaque, normalization of sympathetic outflow, and inhibit of platelet aggregation. Here, we should focus on the evidence that works on the effect of the statins on migraine headaches, especially in patients who do not respond to first-line prevention treatments. The hypothesis may show that statins could be effective in the treatment of patients with migraine. Taken together, some epidemiologic, clinical, and experimental evidence suggest that statin may be a novel and promising candidate. For future treatment or prophylaxis of migraine, we hope that the use of this drug as cholesterol and triglycerides(blood lipids) leads to rebate drugs, as well as to reduce migraine headaches episodes agent to enhance the role of this drug in cure or prevent migraine attacks or recurrence, and finally to improve the patient's quality of life.

Background: The world is in the midst of the COVID crisis, which has forced the neurosurgical community to change its practices. Objective: To advocate the necessary adaptations in radio surgical practices to effectively manage the radio surgical patients, resource utilization, and protecting the healthcare provider during the COVID pandemic. Material and Methods: In addition to the literature review, pertinent recommendations are made in respect to the gamma knife radiosurgery (GKRS). Results: Every patient presenting to GKRS treatment should be considered as a potential asymptomatic COVID carrier. Patients should be categorized based on the priority (urgent, semi-urgent, or elective) on the basis of pathological and clinical status. The only urgent indication is a non-responding or enlarging cerebral metastasis. There is a high risk of aerosol dispersion during gamma radiation delivery in the gamma gantry. Conclusion: These recommendations should be used to minimize the chances of pathogenic exposure to the patient and caregivers both.

Background and Introduction: Patients with brachial plexus avulsion (BPA) injuries often suffer from chronic disabling drug refractory neuropathic pain. Dorsal root entry zone (DREZ) lesioning is currently the most effective surgical procedure for this intractable brachial neuralgia following BPA. Objective: To demonstrate a novel technique of “Micro-scissor DREZotomy” developed at our institution. Procedure: A 55-year-old gentleman underwent right cervical microscissor DREZotomy for post BPA neuralgia. Exclusive use of microscissors along the posterolateral sulcus, causing mechanical disruption of the nociceptive pathways through sharp dissection, results in precise lesioning with excellent pain free outcomes. Results: The patient had complete relief of the pain and uneventful recovery following the surgery and remains to be pain free at 1 year follow up. Conclusion: Microscissor DREZotomy is a simple cost-effective technique. It can easily be performed in the peripheral centers with limited resources and is a safe and effective technique in experienced hands.

Background and Introduction: Dumbbell trigeminal schwannoma is the second most common type of intracranial schwannomas. Objective: Herein, we are describing and presenting a video of left trigeminal dumbbell schwannoma with a predominant posterior fossa component (modified Samii's grade C1), operated through left Retromastoid Intradural Suprameatal Approach (RISA). We demonstrate a step by step technique of a previously defined procedure for educational purpose. Surgical Technique: The patient was placed in the right lateral position, and left retromastoid craniotomy was done. Dura was opened based on transverse and sigmoid sinus to expose tumors in the suprameatal region. The tumor removed piecemeal under the microscope, and later endoscope was introduced to identify and remove the residual tumor in the superolateral part of Meckel's cave. Results: The patient had an uneventful recovery. Conclusion: Trigeminal schwannoma with a predominantly posterior fossa component can be excised through retromastoid sub-occipital craniotomy. Endoscopic-assisted microsurgery should be considered in all skull base tumors. Aim for complete excision, but safe maximal resection with GKRS for residual can be considered in difficult cases.

Objective: The following paper describes the technique and outcomes of fronto-orbital variant of supraorbital key hole approach (f-SOKHA) to clip anterior circulation aneurysms and compares the same with a similar cohort operated through pterional craniotomy (PT). Material and Methods: Ambispective study (2012–2019); Technique applied for anterior circulation aneurysms. Contraindications included: Large hematomas, tense brain, avoided in poor grade (Hunt and Hess grade III and IV). Large frontal sinus: Relative contraindication. Procedure included a trans-ciliary skin incision, burr hole over key point, cutting of orbital roof via the burr hole, and removal of a single small fronto-orbital flap (1). This was followed by drilling of the inner table of the frontal bone (2). Both 1 and 2 resulted in expansion of the operative space by 60%. Results compared with a similar cohort of PT. Results: n = 75 cases; most commonly used for ACom (anterior communicating: 43) followed by middle cerebral (16), internal cerebral (13), Posterior communicating (6), anterior cerebral (2), and anterior choroidal (1). Mean age: 47.9 ± 14 years; mean Hunt and Hess grade: 1.96 ± 1.35; duration of surgery: 203 ± 45 minutes, mean size of aneurysm: 6.96 ± 3.65 mm. Both blood loss and surgery duration was less (P: 0.099 and <0.001) when compared with a similar cohort with PT. It also demonstrated better cosmetic results and patient satisfaction. Conclusions: f-SOKHA provided a larger operating corridor (60% more) as compared with the standard supra-orbital key-hole approaches while preserving the same degree of minimally invasive nature and cosmetic results.

Background: Skull base chordomas in pediatric and adolescent patients are rare and challenging for surgeons. Objective: Well-specified diagnosis and treatment are of great value for the long-term control of chordoma. This study summarizes well-followed pediatric and adolescent chordoma (PAC) patients treated in a single Asian center. Methods: PAC patients were enrolled. Data collected included clinical presentation, tumor volume, texture, surgical approach, pathology, complications, adjuvant radiotherapy (RT), and long-term outcomes. Results: Sixty-two patients were identified from a total of 516 skull base chordoma patients (12%). Diplopia was the most prominent complaint (30%). The craniocervical junction area was the most common location (41.8%) and had the highest proportion of large tumors. The gross total resection (GTR) rate was 20.3%. The GTR rate was lowest for tumors located in the craniocervical junction area. Thirty-eight cases experienced surgical complications. Of note, there was a significant difference in the complication rate between endoscopic approaches (22.7%) and open approaches (57.9%) (P = 0.005). The mean follow-up was 66.5 months. The GTR group showed better survival compared with the non-GTR group (P = 0.043). Metastases were found in two cases. No significant difference in the overall survival (OS) time was found between the group with RT and the group without RT (P = 0.559). Conclusions: A higher proportion of PAC patients than previously reported exist in the population in Asia, and the metastatic rate is lower. GTR predicts excellent long-term control of the disease. RT should be considered on an individual basis.

Background and Purpose: Dengue can present with variable neurological complications including encephalitis, encephalopathy, acute disseminated encephalomyelitis (ADEM), and ischemic and hemorrhagic stroke. Our study describes a pattern-based approach to recognize different brain MRI findings in dengue-seropositive patients with neurological symptoms. Materials and Methods: Thirty-six serologically proven dengue patients with neurological symptoms and undergoing brain MRI over a 6-month period were included in this study. The diagnosis of dengue encephalopathy or encephalitis was established by presence of signs/symptoms of acute encephalitic syndrome with the presence of Immunoglobin M (IgM) antibody against dengue antibody in the serum and/or presence of dengue antigen (NS1) in serum. The MRI brain along with diffusion weighted imaging and susceptibility weighted imaging sequences were evaluated by an experienced neuroradiologist. Results: Eleven patients had normal MRI finding. In the rest 25 patients, 12 were found to have encephalitic pattern, 4 had encephalopathic (seizure related/metabolic) pattern, 3 had features of ADEM, and isolated micro- or macro-hemorrhages were found in 6 patients. In the encephalitis group, eight had concomitant involvement of brainstem, cerebellum, and ganglio-thalamic complexes with additional involvement of cortex and subcortical white matter (WM) found in three. Isolated brainstem and cerebellar involvement were seen in three in this group, whereas one had isolated cerebellar involvement. Interspersed hemorrhage was noted in the structures involved in eight patients in encephalitis group. Conclusion: Radiologists should be aware of various MRI brain findings in dengue and a pattern recognition approach often helps in reaching the correct diagnosis albeit after exclusion of other differentials based on laboratory studies.

Background: Glioblastoma (GBM) is one of the most deadly primary malignant brain tumors in adults. R132H mutation of isocitrate dehydrogenase 1 (IDH1) predicts a better prognosis of GBM. IDH1-R132H is associated with increased hypoxia-inducible factor-1α (HIF-1α) expression in GBM tumors. However, the molecular mechanism underlying IDH1-R132H-HIF-1α signaling in GBM is still unclear. Aim: We aimed to investigate the molecular pathway of IDH1-R132H-HIF-1α in the regulation of GBM. Materials and Methods: U87 and U251 GBM cells and xenograft tumor mice were used. Results: We found that overexpression of IDH1-R132H decreased cell proliferation, increased apoptosis, decreased migration and invasion, enhanced temozolomide (TMZ)-induced cytotoxicity, and reduced tumor growth in xenograft mice. Overexpression of IDH1-R132H increased the expression of HIF-1α and downregulation of HIF-1α suppressed IDH1-R132H-induced effect on GBM. Reactive oxygen species (ROS) level was increased by IDH1-R132H over expression and the use of antioxidant inhibited IDH1-R132H-induced increase of HIF-1α expression. FAT Atypical Cadherin 1 (FAT1) expression was increased by IDH1-R132H over expression. Knockdown of FAT1 blocked IDH1-R132H-induced reduction of tumor growth in xenograft mice. Down regulation of FAT1 decreased HIF-1α expression and inhibited IDH1-R132H-induced increase of ROS level. Conclusions: Our findings provide new insights into IDH1-R132H-regulated downstream signaling in GBM and highlight the importance of IDH1-R132H-FAT1-ROS-HIF-1α signaling pathway in potential therapeutic intervention of GBM.

Background: Idiopathic intracranial hypertension is an uncommon intracranial disorder in which intracranial pressure is increased without radiological evidence of lesions. Surgery is indicated when severe optic neuropathy is present or medical treatment fails. Objective: To assess the comparative effectiveness of lumboperitoneal (LPS) and ventriculoperitoneal shunt (VPS) with neuronavigation. Subjects and Methods: A retrospective study was performed based on our database. We analyzed demographics, pre and postoperative parameters, and follow-up data on patients who had undergone either LPS or VPS between January 2007 and December 2017. Results: Group I consisted of 17 VPS patients, of which 16 were female, and group II consisted of 29 LPS patients, of which 26 were female. The number of surgeries performed in the LPS group was higher (due to recurrence) than that in the VPS group. Moreover, the rate of complications was higher in the LPS group. Conclusions: VPS is safer and has a lower rate of complications and reinterventions compared to LPS.

Objective: The sinonasal anatomy in growing children undergoes change in size along with progressive pneumatization, this is of particular significance in endoscopic endonasal surgery. We aim to measure and quantify the sinonasal dimensions in the Indian paediatric population, which are relevant to skull base surgeons. Material and Methods: This is a retrospective radio anatomical study of sinonasal measurements and volumetric analysis of the sphenoid sinus performed on archived CT images of children less than 18 years of age. Results: CT scan images of 110 patients (male, 68; female, 42) were included for the study. The number of patients in each age groups was as follows [0–6 years, 17; 7–9 years, 20; 10–12 years, 27; 13–15 years, 29; 16–18 years, 17]. The distance from the nares to the sphenoid and from the sphenoid to the sella was significantly greater in children of 13–15 years (69.4 ± 5.2 mm) as compared to children less than six years (62.6 ± 6.7 mm) (P < 0.003). The volume of the sphenoid in children between 0 and 6 years was 4641.4 ± 1924.7 mm³. The pneumatized sphenoid volume in the same age group was 1655 ± 1631.1 mm³. In older children between 13 and 15 years, the total volume of sphenoid sinus was 11732.8 ± 2614.4 mm³. The volume of pneumatization in the sphenoid sinus in this group was 6287.5 ± 2157.9 mm³. The total volume of the sphenoid sinus (Pearson coefficient (r) = 0.704, P < 0.001) and the volume of pneumatization of the sphenoid sinus was also seen to have a positive correlation to the age of the child (r = 0.62, P < 0.0001). The narrowest distance between both the internal carotid arteries was seen at the level of the proximal dural ring. In children less than six years of age it was 13.4 ± 2.0 mm, a significant change was seen by the age of 10–12 years where this distance was 15.6 ± 2.2 mm (P = 0.036). Conclusion: The sinonasal anatomy shows progressive development between the age of 6 to 15 years after which it plateaus. The pneumatization in young children may be incomplete, which necessitates drilling in the sphenoid sinus. The intercarotid distance was not seen to be a hindrance for endoscopic endonasal surgery. None of the measurements of the skull-base, made in this study appear to restrict endoscopic endonasal surgery in children. However, a meticulous preoperative assessment of the CT scan may be needed for optimal surgical outcome.

Background and Purpose: Sex-related differences have been documented in risk factors distribution, etiologic subtypes, diagnostic evaluation, offered management, and outcome of patients with acute ischemic stroke (AIS) from all over the world. Nevertheless, studies from Saudi Arabia are lacking. This study aimed to investigate the influence of sex on distribution of risk factors and etiologic subtype of AIS in patients admitted to our hospital. Materials and Methods: Record of patients admitted to King Fahd Hospital of the University between 2010 and 2017 with ischemic stroke (IS) were reviewed. Base line characteristics, risk factors, and etiologic subtypes according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification were compared between men and women. Results: Among 453 patients with IS, 300 (66.2%) were men and 153 (33.7%) were women. The mean age of all patients was 61.5 ± 14.5 years. Women were older than men (P = 0.00). Hypertension (P = 0.00), atrial fibrillation (P = 0.00), and past history of stroke (P = 0.03) were more frequent in women compared to men. Fewer carotid Doppler studies (47.1 vs. 68.3%, P = 0.00) and echocardiogram (75.1 vs. 83%, P = 0.01) were done in women as compared to men. Cardioembolic etiologic subtype (26.1 vs. 17.7%) was found more frequently, whereas small vessel occlusive (23.5 vs. 31%) and large artery disease less (10.5 vs. 16.3%) frequently in women. Conclusion: Significant sex-related differences were found in risk factors and subtypes of AIS in our cohort of patients. Findings of our study are in general comparable with studies from all over the world.

Context: Longitudinally extensive transverse myelitis (LETM) is defined as a hyperintense spinal cord lesion extending over three or more vertebral levels on sagittal T2-weighted spinal magnetic resonance imaging (MRI). Among the different causes of LETM, neuromyelitis optica (NMO) is the most common and associated with bad prognosis. Aims: We aimed to study the clinicoradiological profile, etiology, and prognosis of LETM. Settings and Design: This is a hospital-based cross-sectional prospective study. Subjects and Methods: The study included 37 patients who presented with paraplegia/paresis or quadriplegia/paresis with MRI spine showing LETM. They were analyzed for their clinical features, routine blood parameters, MRI findings, serum aquaporin 4 (AQP4) antibodies. All patients were followed up for 1 year for prognosis. Statistical Analysis Used: Data analysis was performed using SPSS software (version 17, SPSS Inc.; Chicago, IL, USA). The different groups were compared with each other using Chi-square test. Results: The mean age in our series was 35.97 ± 13.2 years. There was a slight female predominance of LETM in our series with a female: male ratio of 1.05:1. Thoracic spinal cord segments were the most commonly (56.76%) affected. The tendency to involve three to five segments is more common (40.54%). Serum AQP4 antibody (Ab) test was done in 26 patients with LETM. Among them, AQP4 Ab was found positive in nine patients (34.62%). A total of 22 patients (59.46%) were clinically diagnosed as NMO, 4 patients as postinfectious myelitis, 1 each in tuberculous myelitis and subacute combined degeneration, and 9 were idiopathic LETM. Prognosis of LETM in the form of Expanded Disability Status Scale at 1 year was poor in patients with NMO particularly those with positive AQP4 Ab. Conclusion: NMO is the most common cause of LETM. Because of poor prognosis of LETM in patients with NMO, particularly those with positive AQP4 Ab, it is very essential for early and accurate diagnosis of etiology of LETM, so that appropriate treatment can be provided to the patient.

Context: Familial amyloidotic polyneuropathy (FAP) is often misdiagnosed as other neuropathic illnesses. Aim: To highlight the diagnostic “odyssey” in three families of Indian origin with FAP. Settings and Design: Cross-sectional, hospital-based study. Subjects and Methods: Clinical, radiological, and histological features as well as causes for delayed diagnosis were analyzed in genetically confirmed patients with FAP. Statistical Analysis: Descriptive. Results: Age at evaluation ranged from 24 to 42 years and symptom duration from 1 to 10 years. Referral diagnoses included: (i) in patients 1 and 2—familial dysautonomia, Shy–Drager syndrome, and spino-cerebellar ataxia with seizures, (ii) in patient 3—chronic inflammatory demyelinating polyradiculoneuropathy, and (iii) in patient 4—porphyria. In addition, patients 1 and 2 developed leptomeningeal involvement that was mistaken for tubercular meningitis. Reasons for missed diagnosis included: clinician's lack of awareness, not paying sufficient attention to family history, presence of laboratory distractors such as elevated urinary porphyrins, lack of meticulous search for amyloid in the biopsy, and not performing specific stain for amyloid viz. Congo red. Evidence of amyloid in histological studies of nerve and skin supported by genetic variations in transthyretin gene clinched the diagnosis. The variants identified in our cohort included p.Gly73Glu, p.Val71Ala, and p.Val50Met. Conclusion: Lack of awareness and meticulous work-up by clinicians and pathologists contributed to delayed diagnosis of FAP. It is important to establish an accurate diagnosis as these patients may be candidates for upcoming therapies.

Introduction: In the era of globalization, too much dependency on mobile phones is a cause of concern. Objective: The present study was designed to evaluate the risk assessment of microwave radiation (MWR) at 1800 MHz frequency and specific absorption rate 0.433 (W/kg) on male Wistar rats. Methodology: Animals were divided into two groups: the first group is the control group, and the second group was exposed to 1800 MHz radiation for 90 days at 4 h/5 days/week in a month. Results: Chronic exposure of MWR may alter GSH homeostasis due to alteration in various GSH cycle regulating enzymes such as GR, GPx, GST, and G6PDH which showed an imbalance in GSH content and causes an increase in the oxidative stress and release of inflammatory cytokines. A remarkable increase in the DNA damage was seen due to disorganization and pyknosis of neurons in exposed animal's brain when compared with the control group (P ≤ 0.05). There was also a significant decline in AChE level. Conclusion: The study concludes that MWR may cause neurochemical and pathophysiological damage by initiating the inflammatory process in various brain regions, especially in hippocampus and cerebral cortex. These effects are further associated with a remarkable elevation in the genotoxicity of neurons with reference to the control group.

Background: Stress response to surgery is mediated by the sympathetic nervous system and manifests as changes in hemodynamic and neuroendocrine parameters. Recently, the surgical pleth index (SPI) is employed for objective and continuous monitoring of nociceptive response during surgery. Opioids are the mainstay of managing stress response to nociception during the perioperative period. However, due to the well-known adverse effects of opioids, α2 agonists are increasingly used to ablate stress response and reduce opioid usage. Objectives: This study compared SPI and biomarkers of surgical stress between opioid (fentanyl) and non-opioid (dexmedetomidine) analgesia during craniotomy. Methods: Patients aged 18 to 60 years undergoing elective craniotomies for brain tumor resection under general anesthesia were randomized to receive fentanyl 1 μg/kg/h or dexmedetomidine 0.5 μ/kg/h infusion as the primary intraoperative analgesic. Our objective was to compare SPI and biomarkers of surgical stress—serum cortisol, blood glucose, arterial pH, and leucocyte count between the two groups. Results: Data of all 24 patients recruited into the study were analyzed. There was no difference in the demographic parameters between the groups. The SPI remained similar with both the drugs over various time points during the study period. There was no difference between the groups in the biomarkers of surgical stress—cortisol, blood glucose, and pH while leucocyte count was higher in the fentanyl group. Conclusions: The stress response to surgery during craniotomy for brain tumors is similar with opioid (fentanyl) and non-opioid (dexmedetomidine) analgesia as assessed by SPI and blood markers such as cortisol, glucose, and pH.

Background: The clinical phenotypes of myelin oligodendrocyte glycoprotein (MOG) antibody disease, its disease course, and treatment are poorly understood and much work needs to be done towards this. Objective: To characterize the clinico-radiologic spectrum and treatment outcomes of MOG antibody disease and differentiate it from aquaporin-4 (AQP-4) antibody positive neuromyelitis optica spectrum disorders (NMO-SD). Methods: A single-center, observational study from Western India during 2017–2019, of 48 patients with either MOG antibody positive (21 patients) or AQP-4 antibody positive (27 patients) central nervous system demyelination. Results: MOG antibody group had median age 32.2 years, no gender bias, median disease duration 40 months, relapses in 9 patients (43%), and median 2.5 (1–16) episodes per patient. Onset phenotypes included isolated bilateral optic neuritis (ON) (43%), isolated unilateral ON (19%), acute brainstem syndrome (19%), simultaneous ON with myelitis (9%), isolated myelitis (5%), and acute disseminated encephalomyelitis optic neuritis (ADEM-ON) (5%). Characteristic neuroimaging abnormalities were anterior segment longitudinally extensive ON, upper brainstem, and thoracic cord involvement (both short and long segment lesions). Most patients (86%) responded well to steroids, only 3/21 required rescue immunotherapy. In total, 6 out of 46 eyes affected developed permanent visual disability, while one patient had motor disability. The features differentiating MOG from AQP-4 antibody group were: no female predilection, preferential optic nerve involvement, characteristic neuroimaging abnormalities, and favorable therapeutic response and outcome. Conclusions: MOG disease commonly presents as severe ON, myelitis, acute brainstem syndrome, ADEM or their combinations. Early identification, treatment, and maintenance immunosuppression are necessary. It can easily be differentiated from NMO-SD using clinico-radiological features and therapeutic response.

Aims: The objective of this article is to report our experience with the two treatment approaches in patients with PICA aneurysms and find predictive factors for treatment-related complications. Materials and Methods: Between January 2011 and December 2015, patients with PICA aneurysm who underwent surgical and endovascular treatment were retrospectively collected and reviewed. Patients' demographic features, treatment-related complications, and long-term angiographic and clinical outcomes (modified Rankin Scale [mRS]) between the two groups were compared. Multivariable logistic analysis was used to find statistically significant predictive factors for treatment-related complications. Results: A total of 55 PICA aneurysms were identified, 13 were ruptured, and 42 unruptured. Endovascular treatment was performed in 26 patients and surgical clipping in 29 patients. Treatment-related complications occurred in one patient in the embolization group compared with 9 in the microsurgical surgery group (3.8% vs. 31.0%, P = 0.010). Multivariate logistic analysis showed that treatment modality was the only predictor for treatment-related complications. A lower recurrence rate was found in the microsurgical surgery group compared with the embolization group (3.4% vs. 7.7%, P = 0.493). Clinical follow-up showed that endovascular treatment achieved better outcomes (mRS ≤2) compared with surgical treatment (96.2% vs. 89.7%, P = 0.359). Conclusions: This study of PICA aneurysms demonstrates that results of both treatment modalities are comparable. To obtain the best treatment outcomes, cooperation between interventional neuroradiologist and endovascular neurosurgeons in deciding the optimal treatment is essential.

Background: Posttraumatic hydrocephalus (PTH) adds to the morbidity and mortality of traumatic brain injury (TBI) and there are insufficient clinical data to suggest usefulness of ventriculoperitoneal shunt (VPS) over endoscopic third ventriculostomy (ETV) in PTH or vice versa. Objective: To evaluate the usefulness of VPS and ETV in the treatment of PTH and to establish the indications for their usage. Materials and Methods: This was an ambispective study of 141 patients who developed PTH out of 2500 cases of TBI treated during the study duration (2012–2016). These patients were segregated into two groups depending on the primary procedure for PTH-ETV group and VPS group. The two groups were compared to analyze the differences in radiological and clinical outcome. Results: 141 patients were included in the study and 175 procedures were performed in these patients. ETV group had 30 procedures and VPS had 145 procedures. In the ETV group, 37% of cases showed improvement v/s 73% cases in the VPS group. A statistically significant number of patients had improvement in presenting symptoms in the VPS group, as compared with the ETV group (P = 0.001). There was no significant difference in Glasgow coma scale (GCS) at discharge (P = 0.15) and Glasgow outcome score at 6 months of follow-up (P = 0.22) between the two groups. Poor GCS, previous cerebrospinal fluid infection, and postoperative meningitis were found to have significant effect on the failure-free period of the procedure. On comparing the probabilities of failure-free period of ETV v/s VPS, the chances of VPS failure are 61% lesser than ETV. Conclusions: VPS is an effective modality for the management of PTH and has a much lower failure rate as compared to ETV. However, ETV can be considered as a salvage procedure in difficult situations of recurrent shunt malfunction or infection.

Background: There is a significant knowledge gap and anxiety among health care workers (HCWs) including neurosurgeons regarding in-hospital disease transmission and use of personal protective equipment (PPE) during the ensuing COVID-19 pandemic. Objective: To assess present practice and perceptions among Indian neurosurgeons with respect to type of surgeries performed, PPE usage and SARS-CoV-2 testing. Materials and Methods: A 12-item questionnaire on surgeries performed in the 6 weeks prior to the survey date, PPE usage, and preoperative SARS-CoV-2 testing was circulated electronically to Indian neurosurgeons from May 12, 2020 to May 31, 2020 and their responses analyzed. Results: Two hundred forty-four neurosurgeons (237 males) participated in the survey; of whom, 230 had performed surgeries during the pandemic period. In total, 84.3% of respondents were performing semiemergency or emergency procedures only. N95 masks were utilized by only 83% of the respondents (n = 230) while performing surgical procedures. Only 40.9% of the respondents were satisfied regarding adequacy of available PPE. Preoperative SARS-CoV2 testing as well as testing of all asymptomatic patients prior to admission into ward/intensive care unit was perceived to be beneficial in reducing transmission risk by more than 85% respondents. More than 90% respondents felt that HCWs including neurosurgeons were at risk of acquiring infection through an outpatient consultation from an asymptomatic individual. Conclusions: Access to and utilization of appropriate PPE was lacking among the one-fifth of neurosurgeons who participated in this survey. To gain the confidence of neurosurgeons, hospitals should address their concerns regarding PPE and testing of patients prior to surgery and admission to the hospital.

Background: Cerebral microbleed (CMB) is a novel neuroimaging marker of cerebral small vessel disease. Objective: To determine the prevalence of CMB in the subtypes of acute ischemic minor stroke (AIS) and transient ischemic attack (TIA) and to identify the risk factors associated with location and number of CMB. Materials and Methods: Patients with AIS (National Institute of Health Stroke Scale of 5 or less) or TIA were included. CMB was characterized using the Microbleed Anatomical Rating Scale (MARS). Results: Of the 488 subjects [mean age (standard deviation): 57.5 years (14.4 years), males (77.7%)] recruited, CMB was noted in 140 (28.7%). About 35% with CMB had a lacunar stroke etiology, whereas LAA and CE subtype constituted 33.6 and 10.7%, respectively (P = 0.000). Lacunar subtype was more likely to harbor multiple CMB (four or more) and CMB in all locations (lobar, deep or infratentorial). On multivariate analysis, systemic hypertension [P = 0.025; odds ratio (OR) 0.33 (95% confidence interval (CI) 0.129–0.874)], serum triglyceride (TG) levels below 150 mg/dL [P = 0.001; OR 3.70 (95% CI 1.698–8.072)], and presence of white matter hyperintensities on magnetic resonance imaging brain [P = 0.026; OR 2.18 (95% CI 1.096–4.337)] were associated with the presence of CMB. Those with serum TG levels of less than 150 mg/dL were more likely to harbor lobar (P = 0.002) or infratentorial CMB (P = 0.022), whereas those with serum creatinine levels of more than1.5 mg/dL have lobar CMB (P = 0.033). Conclusion: Our study showed a differential distribution of CMB in ischemic stroke subtypes and association of risk factors with the presence, number and location of CMB.

Background: Folic acid and multivitamin supplements ((FAMVS) and genetics involvement is one of the major roles in the development of neural tube defects (NTDs). Objective: Our prior aim and objective is to establish an unique guideline and helps the policy decision making for our country India and the World. Materials and Methods: We have collected the data through the literature from the World for their necessary action, rehabilitation part all objectively in PubMed/Medline, Scopous, Embase, Cochrane Review, Hinari, and Google scholar. Statistical Analysis: Statistical analysis was performed with very simple and logistic statistics, percentage, mean, total as collection through the available software SPSS with new version 17.0. Results: The overall (70-95%) we find out those infants with neural tube defects (NTDs) associated with genes involvement and maternal vitamin intake (MVI). Before pregnancy relative risk (PRR) prior to non intake noted as 90% significantly reduced their risk of the NTDs. Now (40-60%) of the women of child-bearing age (CBA) don't use the folic acid intake and supplements (FAISs) in proper way in villages, urban, industrial and sewage areas. We find out that the genetic variants of the fourteen special reported genes, had the major risk factor (MRF) for the (NTDs) and associated abnormalities rate (AAR) within the developmental process in the human brain. Conclusions: The (45-55%) people still having at ignorant zone, due to lack of education, genetic counseling, and awareness till date.

Background: The Monro-Kellie hypothesis states that the cranial compartment is incompressible, and cranial volume cannot expand. Human cranial volumes vary widely. However, the present guidelines for surgical evacuation are based on the volume of a single bleed. We hypothesized that the ratio of the total volume of blood clots in the brain to the volume of normal brain tissue must reflect the chances of developing increased intracranial pressure more accurately. Objective: Compare the ratio of bleed volume to intracranial brain volume (bleed--brain ratio, BBR) in head trauma patients who had undergone surgery with those who did not require surgery. Estimate the cutoff value for this ratio that could predict the need for surgery. Materials and Methods: An exact planimetric method using a Hounsfield unit bracketing strategy was used to derive total bleed volume and the intracranial volume in 212 head trauma patients. Receiver operating characteristics (ROC) curve was used to assess the predictive power of BBR for surgery. A cutoff value for the BBR with clinically significant sensitivity and specificity was estimated. Results: The intracranial volume varied from 955 ml to a maximum of 1,525 ml. The total bleed volume and BBR was significantly different in the two groups. Using the ROC curve, we found that a BBR of 0.0535 had a sensitivity of 90.6% and a specificity of 52.6% to predict the need for surgery. Conclusions: We demonstrated that the BBR was superior to bleed volume alone in predicting the need for surgery. Although the ratio estimated by the tedious planimetric method was more accurate, an easier less precise method had reasonable accuracy and can be considered for everyday use. BBR could be particularly useful in those head trauma patients who have multiple irregular sized bleeds where the surgeon is undecided on the need for surgery.

Background: A paucity of literature on the effect of spinal endoscopic surgery replacing a large percentage of open and microscopic minimally invasive surgery on outcomes in patients. Objective: Evaluation of the effect of endoscopic practice expansion in degenerative spinal conditions and disc herniations on patients' outcome as we shifted from first-generation endoscopic discectomy to second-generation decompression and finally third generation of endoscopic spinal fusion practice. Subjects and Methods: Retrospective cohort study on surgical treatment of degenerative spinal conditions for 616 spinal cases. Basic demographics, preoperative, postoperative 1 week, 6 months, and final follow-up of patients' clinical outcomes in terms of pain score, Oswestry disability index, and MacNab's criteria for pain score were evaluated. Results: 75%, 91%, and 97% of the surgeries with complications rate of 8.2%, 9%, and 3.4% were found in Generation 1, 2, and 3 of endoscopic surgery, respectively. Compared to preoperative scores, each generation VAS and ODI scores all statistically significantly improved. In the final follow-up, compared to preoperative state, the mean VAS improvement was 4.75 ± 1.7, 5.49 ± 1.66, and 5.37 ± 1.70, mean ODI improvement was 45.99 ± 11.8, 48.93 ± 11.2, and 48.43 ± 11.41, and MacNab's criteria showed a trend of upward improvement of 87.3%, 96.0%, and 98.7% cases, which showed good-to-excellent outcome, in Generation 1, 2, and 3, respectively. Conclusions: Generation change of increasing percentage of endoscopic surgeries and expansion of endoscopic spinal indications over open surgeries in degenerative spinal conditions and disc herniations are possible as a surgeon gets more experience with endoscopic spine surgery producing a good clinical outcome.

Situational awareness (SA) is a cognitive skill that is crucial in crisis resource management. Its importance has been known extensively in aviation; however, no methodical training and structured evaluation of SA exist in Neurosurgery. Like aviation, Neurosurgery is a complex and dynamic field where the stakes are high and the permissible errors are nil or negligible. This article describes the concept of SA, by illustrating two common clinical scenarios. On the foundation of these clinical vignettes, the author builds up a strong case for incorporating SA training at all levels of seniority to prevent surgical errors. The author also proposes a safety loop that can be recalled by the surgeon when faced with an adverse surgical event.

Coronavirus disease (COVID-19) has posed immense challenges for healthcare workers, among them are procedures related to suctioning of bodily fluids during surgery or intensive care. These procedures are potentially aerosol-generating and can lead to disease transmission. We have modified the usual suction apparatus in a simple and easy to do manner so that all suctioned material first passes through the 0.1% sodium hypochlorite solution, which is virucidal and decontaminates the suctioned material. This innovation may help in addressing the safety concerns of all healthcare providers working in operation rooms and intensive care units.

Introduction: The cranium is a host to a variety of neoplasms and includes small round cell tumors (SRCTs) as an important malignant subset. Although SRCTs are histomorphologically similar, they are histogenetically diverse comprising of malignancies of epithelial, hematolymphoid, neuroectodermal, and mesenchymal origin. Objective: The study aimed to review the clinical and pathological profile of cranial SRCTs. Materials and Methods: Study is a retrospective review (clinical, imaging, and histopathology) of cranial (extra-axial) SRCTs diagnosed on histology (period: 3.5 years). Results: Study included 126 cases constituting 1.5% of all intracranial neoplasms and age ranging from 11 months to 82 years (mean: 34.3 years; M:F = 1.46:1). Peripheral primitive neuroectodermal tumors (pPNET-8.2%) was the commonest neoplasm followed by plasmacytoma (14.2%), poorly differentiated carcinomas (13.5%), lymphomas (9.5%), and sarcomas (8.7%). Rare tumors included glioma (undifferentiated) deposits, germ cell tumors, melanoma, neuroendocrine neoplasms, and embryonal tumor. Children constituted one-third of the total with PNETs, embryonal tumors, and round cell sarcomas being the common neoplasms. Elderly patients constituted 14% with plasmacytomas and epithelial neoplasms being common. Three percent of the tumors remained unclassified. Clinical symptomology was location dependent, headache being the commonest followed by visual symptoms. Radiopathological discordance was high (60%). Conclusion: SRCTs are unusual tumors with a wide spectrum of histogenesis, biology and clinical presentation. Their rarity in cranium, atypical localization, overlapping clinical, and imaging features pose significant difficulty for clinicians, radiologists, and pathologists. A combined algorithmic analysis of the clinical, radiological, and histolopathological findings, supplemented with immunohistochemistry can aid in specific diagnosis which is crucial for optimal management.

Background: Although low-and middle-income countries (LMIC) bear the burden of the pituitary adenomas, most research is conducted in developed countries. However, there has been significant growth in research on pituitary adenomas in India from 1995 to 2020. The cost of patient treatment, management, and surgery of pituitary lesions are comparatively lower in India in comparison to high income countries. Objective: The intended goal is to highlight the current scenario of pituitary research in India with regards to prevalence/incidence, tumor size, treatment modalities, cost of pituitary surgery, and potential strategies for tackling pituitary adenoma disease burden in the country. Methodology: In addition to the literature review, recommendations were included from neurosurgeons, endocrinologists, and radiologists from various centers in India. Results: There is an increasing evidence of pituitary adenoma heterogeneity compared to western populations. Although there has been significant increase in research on pituitary tumors from India, it is considerably less as compared to the data from the rest of the world. The major challenges for the treatment of this benign disease in India are lack of imaging facility in rural areas, poor patient follow up, and financial constraints for periodic imaging and biochemical assessment. Conclusion: A computerized pituitary registry and genetic screening and testing will significantly boost research and lead to better patient outcome in the country. Special emphasis should be laid on multimodal management to ascertain optimal long-term tumor control with best hormonal outcome.

This is a report of three cases of intraventricular meningiomas treated in our department wherein the tumors recurred along the surgical tract. The meningioma in each case was histologically “benign” at the time of first surgery and even at the time of recurrence. Although reported earlier, such cases of recurrence of meningiomas along the surgical tract are relatively rare.

Objective: The purpose of this study was to report three patients COVID-19 infection with severe respiratory syndrome requiring intubation, who developed acute demyelinating encephalomyelitis (ADEM). Methods: Patient data were obtained from medical records from the North Memorial Hospital, Robbinsdale, MN, USA. Results: Three patients (two men and one woman, aged 38–63) presented with fatigue, cough, and fever leading to acute respiratory distress syndrome secondary to COVID-19 infection requiring ventilatory support. Two patients were unresponsive and the third patient had severe diffuse weakness. MRI in all patients showed findings consistent with ADEM. CSF showed elevated protein in all patients with normal cell count and no evidence of infection, including negative COVID-19 PCR. All three patients were treated with intravenous corticosteroids and one improved markedly. The other two had minimal response to steroids and no further improvement after IVIG. Conclusion: Neurological complications from COVID-19 are being rapidly recognized. Our three cases highlight the occurrence of ADEM as a postinfectious/immune-mediated complication of COVID-19 infection, which may be responsive to corticosteroid treatment.

Background: Crimean–Congo hemorrhagic fever is a sporadic zoonotic viral illness recently becoming endemic in regions in the western parts of India. It usually presents as a viral hemorrhagic fever with severe liver and kidney failure. Case Report: An 18-year-old male from the western part of Rajasthan presented with rapidly progressing areflexic weakness of limbs a week after brief fever. He deteriorated rapidly with drowsiness, fulminant liver failure, and acute kidney injury with high creatine kinase. He also developed thrombocytopenia and hemorrhage from various sites. Workup for viral hemorrhagic fever revealed IgM positivity for Crimean–Congo hemorrhagic fever. The patient kept worsening and died of multiorgan failure and diffuse alveolar bleeding after 14 days. Conclusions: This report highlights the need to expand the differential diagnoses in the commonly encountered presentation of acute quadriparesis to include the possibility of tick-borne diseases like Crimean–Congo hemorrhagic fever in the setting of bleeding diathesis and acute hepatorenal syndrome.

The common causes of mediastinal widening are lymphadenopathy, pericardial effusion, paravertebral abscess, and aortic aneurysm. We present a patient with spinal tuberculosis, paravertebral abscess, and plural effusion that led to mediastinal widening. In this patient, Chest X-ray was deceptive.

Trochlear nerve cavernous hemangioma (CH) is a rare disease. There have been only five such cases reported in the world literature till date. The authors report a case of trochlear nerve CH in the Asian population and review the relevant literature. A 49-year-old Asian woman presented with gradually worsening double vision for 6 years. Physical examination identified a complete paralysis of left trochlear nerve. In imaging, a circular lesion measuring about 1 cm in diameter was found in the left ambient cistern. The lesion was completely excised through the left-side subtemporal approach, with a diagnosis of trochlear nerve CH confirmed by pathological examination. Further nerve anastomosis was not adopted, and the patient remained clinically stable in a two years' follow-up. This report provides more information about the history characteristics, imaging features, and surgical treatment strategies for trochlear nerve CH.

Ligamentum flavum cysts (LFC) are uncommon and their differentiation from other Juxta-facetal cysts & epidural cystic lesions is difficult based on imaging techniques. We present one such rare case of ligamentum flavum cyst with relevant review of the literature. An eighty-eight years male presented with progressively worsening radicular symptom in the left lower limb. His neurological examination was unremarkable. Magnetic resonance imaging of lumbar spine revealed an epidural cystic lesion narrowing the left lateral recess. Intra-operatively, a mass was found originating from ventral surface of ligamentum flavum. Pathological examination was suggestive of fibro-collagenous tissue without synovial lining. The exact pathogenic mechanism for the formation of LFCs is not well understood. Association with segmental instability and degenerative conditions of spine is postulated. They are commonly seen at the mobile junctional levels of the spine. Persistent micro-traumatic events with abnormal movement maybe contributory to their origin. They present either with radiculopathy or neurogenic claudication symptoms owing to compressive effect on adjacent neural structure. LFC should be considered as a differential in patients with radicular pain or claudication symptoms with epidural cystic lesion seen on MRI. Complete excision of such lesion provides excellent pain relief in symptomatic individuals.

The concept of minimally invasive spine surgery (MISS) has gained increasing popularity in the last decades. While MISS holds promise for faster patient recovery, and shorter hospital stays, the removal of the surgical fixation, when required, is still performed by an extensive approach often resulting in disabling pain and discomfort. We describe a novel minimal invasive microscope-assisted technique for lumbar spinal fixation removal. This technique has been successfully applied in a 35-year-old man, affected by back pain despite a previous posterior dynamic MISS L4–S1 fixation. The previous skin incisions were opened and under microscopic vision, the screws and the roads were dissected from the scars and removed. The patient was discharged on postoperative day-1. He reported a progressive improvement of the symptoms with a satisfactory cosmetic result. Minimal invasive microscope-assisted technique for spinal fixation removal offers a simple and effective surgical alternative to the traditional open surgery.

Background: Hypophysitis occurs predominantly in women, usually during pregnancy or postpartum period. Hypophysitis involving the anterior pituitary often presents with adrenal insufficiency. Design/Methods: We describe a 43-year-old woman who presented with recurrent episodes of alteration of sensorium due to hyponatremia. She had a 3-month history of amenorrhea and on evaluation had evidence of pan-hypopituitarism. The magnetic resonance images of the brain showed mild pituitary enlargement and thickened pituitary stalk with homogenous contrast enhancement indicating hypophysitis. She was treated with oral steroids and thyroxine supplements. She remained asymptomatic at 15-month follow-up on low-dose oral steroids and thyroxine supplements. Results: Hypopituitarism due to hypophysitis resulted in recurrent episodes of hyponatremia in our patient. Conclusion: Our case highlights the importance of a systematic search for the etiology for hyponatremic encephalopathy.

Brown‐Vialetto‐Van Laere Syndrome (BVVLS) is a rare disorder characterized by progressive neuropathy, optic atrophy, hearing loss, bulbar dysfunction, and respiratory insufficiency associated with mutations in SLC52A2 and SLC52A3 genes that code for human riboflavin transporters RFVT2 and RFVT3, respectively. Nearly 70 cases have been reported by molecular diagnosis.^[2],[3] The majority of familial cases are autosomal recessive^[2],[4] with female to male ratio of 3:1.^[5] We describe the clinical course of a 16-year-old boy with BVVLS who presented with 6 years duration of insidious onset gradually progressive sensory neural hearing loss, optic atrophy, amyotrophy of both upper limbs, and wasting of the tongue with fasciculations. Novel homozygous mutation c.1245C>T in the SLC52A2 gene was identified. At times, the clinical spectrum mimics the juvenile onset motor neuron disease (MND) as in this case. It was important to identify the BVVLS that can respond to high doses of riboflavin.

Background: Fibromuscular dysplasia affects generally renal artery, causing renovascular hypertension. The most classical angiographic pattern, string-of-beads, can be found in cervical and more rarely in other arteries. With the advance of endovascular procedures techniques, the number of open surgeries is decreasing, and complications related to the selective catheterization of diseased vessels are increasing. Case Report: A 37-year-old man presenting with subarachnoid hemorrhage was submitted to angioplasty for dissecting aneurysms of vertebral artery with a good outcome. Several arteries were angiographically diagnosed with the dysplasia (renal, carotid, femoral), and some complications like stenosis, dissection, arteriovenous fistula, and dissecting aneurysm occurred in sequence. Conclusions: FMD of cervical arteries is usually asymptomatic. There are no guidelines or protocols to cervical FMD treatment, being indicated only for the complications. Because of the vessels fragility, a several spontaneous or post endovascular procedure complications can be disastrous.

Arriving at a definitive diagnosis in case of a patient with neurological symptoms after a low altitude flight is very critical, while at the same time presenting a dilemma in aeromedical decision making. Symptoms of stroke can closely mimic those of neurologic manifestations of decompression sickness. This paper discusses the approach to a case of a 28-year-old male helicopter passenger who developed left-sided numbness of the body after a 1.5 h flight at 13,000 feet altitude and was hospitalized with the diagnosis of transient ischemic attack.

Background: Improved function, through balance and mobility, has been demonstrated in individuals with an acquired brain injury (ABI) following various exercise interventions; however, the feasibility of implementing “McGill's Big 3” exercises, typically prescribed for people with back pain, to improve function in people with ABI requires investigation. Objective: The aim of this case report was to determine the feasibility of implementing “McGill's Big 3” exercises on balance and mobility when prescribed to an individual with an ABI who ambulates independently. Methods and Materials: A 40-year-old female with an ABI completed an 8-week exercise intervention consisting of “McGill's Big 3” exercises. Balance and mobility testing were completed pre and post intervention, including, heel-to-toe standing; the foot tap test; forward reach test; pick-up test; stand-to-floor test; and three-meter timed up-and-go. Results: The results demonstrated improvement across all tests. Conclusions: These findings support the use of “McGill's Big 3” exercises in a rehabilitation program, for individuals with neurological impairments such as an ABI.

Mollaret's meningitis refers to the classical description by Pierre Mollaret of recurrent episodes of fever and meningism lasting 2–5 days, followed by spontaneous recovery. It remains a rare entity and most often is attributed to reactivation of latent Herpes Simplex virus (HSV)-2 virus. Though considered self-limiting and innocuous, there are exceptional cases in which neurological sequelae have been reported. From a clinician's perspective, narrowing down the diagnosis may not be straightforward and would require judicious use of investigations. Here we report two cases of Mollaret's meningitis, both of whom had negative cerebrospinal fluid (CSF) polymerase chain reaction (PCR) for HSV. These reports also highlight an unusual pattern of presentation of this rare entity and the utility of CSF cytology in clinching the diagnosis.

Hereditary neuropathy with liability to pressure palsy (HNPP) often manifests via peripheral nerve entrapment including median nerve compression at the carpal tunnel. However, there are few reports on surgical interventions for focal compression of the median nerve at the wrist in patients with HNPP. We report a case of a patient with HNPP who improved clinically, electrophysiologically, and ultrasonographically after carpal tunnel release (CTR). A 56-year-old woman presented with an 18-month history of pain in both thumbs. Nerve conduction study (NCS) revealed bilateral median neuropathy at the wrist. Ultrasonography demonstrated a markedly increased cross-sectional area (CSA) of both median nerves. Gene analysis revealed a deletion of the PMP22 gene. She received bilateral CTR. Follow-up NCS at one year demonstrated the improvement of motor and sensory conduction; follow-up ultrasonography revealed significantly reduced CSA. Our case suggests that surgical decompression can be applicable to well-selected patients with HNPP.

Case Presentation: We report a case of a young female who had magnetic resonance imaging (MRI) brain lesions typical of multiple sclerosis (MS) with cerebrospinal fluid (CSF) oligoclonal bands (OCBs) and definite multiple sclerosis based on revised McDonald criteria; however, she also had atypical features of mild pleocytosis, brainstem and cerebellar peduncle involvement apart from opticospinal (OS) involvement. She also turned out to be positive for anti-myelin oligodendrocyte glycoprotein (MOG) antibody; hence, she was diagnosed with atypical multiple sclerosis. This case highlights when to suspect atypical MS and its management approach. Discussion: Typical MS cases are largely anti-MOG-negative. In a study of 50 Japanese cases, with anti-aquaporin 4 (AQP4)-immunoglobulin (IgG)-negative OSMS, just 2 were MOG-IgG-positive, but they had some features atypical for MS, such as bilateral optic neuritis, longitudinally extensive transverse myelitis, or moderate pleocytosis. In another study, antibodies to MOG were found in about 5% (5/104) of preselected adult patients with MS. Patients with MS with antibodies to MOG showed typical MS lesions on brain MRI with concomitant severe brainstem and spinal cord involvement and had a severe disease course with high relapse rates. Conclusion: In conclusion, any patient showing typical MS lesions on brain MRI with OCB present in CSF but has atypical features like mild pleocytosis with brainstem, cerebellar, or OS involvement should also be tested for autoantibodies to MOG, and if positive, then he/she would require aggressive treatment approach in the form of plasma exchange, if resistant to pulse steroid therapy, followed by either rituximab or natalizumab rather than trying other disease modifying therapies (DMTs).

Pathology of the spinal venous system, unlike that of the spinal arterial system, is rarely considered as a possible cause of clinical symptoms. As the imaging features of the spinal venous anatomy and its diseases are not well-known, related pathologies may be overlooked or misdiagnosed. The major noninvasive technique enabling optimal visualization of spinal venous plexuses is magnetic resonance imaging (MRI). We report MRI findings from three cases of spinal venous plexus engorgement of different etiologies that resulted in neurologic symptoms, including radiculopathy and/or back pain. These cases are discussed in the context of the relevant anatomic and pathophysiologic background.