Recurrent strokes involving various arterial territories can carry a broad differential diagnosis. Multiple progressive infarcts in a patient with clinical signs and symptoms out of proportion to their infarct pattern on imaging should compel the clinician to broaden the differential to include inflammatory causes of stroke also. A stepwise approach, using clinical, imaging and laboratory clues to direct further invasive testing is required for proper diagnosis and management in such cases. We present the case of a 66 year old woman with recurrent strokes over the span of a few weeks with deficits and mental status changes out of proportion to her infarcts on MRI brain and an inflammatory CSF. Since commencement of treatment for the underlying inflammatory cause of her strokes, she has remained stroke free for over two years in follow up.

Petroclival meningiomas are unique neurosurgical challenges that require planning an approach to the retrosellar and upper and mid retroclival locations. The classical subtemporal-transtentorial approach went into disrepute due to excessive brain retraction. To resolve this challenge Buchenek and Kukwa introduced extradural approach with drilling of the petrous bone and called it the extended middle fossa approach. It was Kawase et al who modified the extended middle fossa approach initially for dealing with basilar trunk aneurysms. This anterior transpetrosal approach has been described below for dealing with the petroclival meningiomas.

Over the last decade, research has intensified worldwide on the use of low-temperature plasmas in medicine and healthcare. Researchers have discovered many methods of applying plasmas to living tissues to deactivate pathogens; to end the flow of blood without damaging healthy tissue; to sanitize wounds and accelerate its healing; and to selectively kill malignant cancer cells. This review paper presents the latest development of advanced and plasma-based technologies used for applications in neurology in particular. Institute for Plasma Research (IPR), an aided institute of the Department of Atomic Energy (DAE), has also developed various technologies in some of these areas. One of these is an Atmospheric Pressure Plasma Jet (APPJ). This device is being studied to treat skin diseases, for coagulation of blood at faster rates and its interaction with oral, lung, and brain cancer cells. In certain cases, in-vitro studies have yielded encouraging results and limited in-vivo studies have been initiated. Plasma activated water has been produced in the laboratory for microbial disinfection, with potential applications in the health sector. Recently, plasmonic nanoparticle arrays which allow detection of very low concentrations of chemicals is studied in detail to allow early-stage detection of diseases. IPR has also been developing AI-based software called DeepCXR and AIBacilli for automated, high-speed screening and detection of footprints of tuberculosis (TB) in Chest X-ray images and for recognizing single/multiple TB bacilli in sputum smear test images, respectively. Deep Learning systems are increasingly being used around the world for analyzing electroencephalogram (EEG) signals for emotion recognition, mental workload, and seizure detection.

Tumefactive demyelination is a phenomenon involving the radiographic resemblance of an acute demyelinating process in the central nervous system to neoplasia. Although this has been described and characterized for multiple sclerosis, it has been reported in a few cases in patients with acute disseminated encephalomyelitis (ADEM) within the past decade. While it may be challenging to establish a diagnosis of tumefactive ADEM according to clinical and radiological data alone, a thorough review of the clinical history and following the patient over time can be supportive of the same. The principal diagnostic confounds include neoplastic disease and a first attack of multiple sclerosis. A definitive diagnosis can be made by biopsy, which reveals perivenular demyelination and mononuclear cell infiltration in ADEM, in contrast to confluent plaque-like areas of demyelination in patients with multiple sclerosis. Histopathologic evidence of neoplastic disease includes characteristic features, including nuclear atypia and polymorphism, cellular hyperproliferation, mitoses, necrosis, endothelial proliferation, rosettes, and/or pseudorosettes. ADEM responds excellently to treatment with corticosteroids and is monophasic, with recurrence occurring infrequently. We review the literature on tumefactive ADEM and discuss the clinical manifestations, imaging characteristics, and histopathologic findings used to distinguish it from other conditions.

Chordoma and chondrosarcoma are locally aggressive tumors occurring in one-third cases at the base of the skull. These tumors often recur locally with significant morbidity and mortality. The mainstay of treatment is maximal safe tumor debulking. However, in spite of gross total resection, these tumors are likely to recur. Hence, adjuvant radiation is provided to reduce the risk of local recurrence and to improve outcomes. These tumors are considered relatively radioresistant; hence, high doses of radiation are generally required during treatment. However, the presence of several important structures around the lesion poses a major challenge with respect to covering the target with the prescribed high dose. In this regard, protons, for their physical and dosimetric advantages, have become the accepted modality of treatment in these tumors. With the evolution of proton beam therapy (PBT) over the years, especially pencil beam scanning techniques; which result in an extremely high conformal intensity-modulated proton beam therapy (IMPT), robust and Monte Carlo optimization, computational algorithms, and biological modelling are the significant advances which have further enhanced the value of this technology and have improved outcomes. Herein, we would like to report our experience of two cases of skull base tumors treated with intensity-modulated proton therapy at our center along with a review of the literature.

Introduction: The world is seeing a growth of the aging population and the number of surgical treatments in this age group which is also true for spinal conditions. The greatest increase in spinal fusion surgery has been observed in patients aged 65 years and above. Only a few works of literature were available on the issue, especially in India. Materials and Methods: An observational study in which 70 patients aged 70 years and above who underwent spinal surgery for degenerative and traumatic spinal injury, from January 2013 to July 2017 in the neurosurgery department of a single institute, were reviewed. Around 53 patients were assessed for disability/functional outcome and their health-related quality of life (HRQOL) using the Oswestry disability index (ODI) and RAND 36-item health survey 1.0 scoring method (SF-36) comparing the preoperative and postoperative status. Result: The mean age was 74.19 years (range 70–91 years). Laminectomy-19 (27.14%) was the most common surgical procedure performed. Overall there were nine (12.85%) major complications with mortality of five (7.14%) patients. There was a significant reduction of crippled patients (14–9, P = 0.009) in the ODI score. SF-36: There was significant improvement in degenerative patient (P = 0.000 to P = 0.012). In traumatic patient, only pain had significant improvement (P = 0.045). Conclusion: This study showed that the age of the patient should not be the limiting factor for the surgical management of a patient with a degenerative or a traumatic spinal condition.

Background: Progressive vision loss is a dismal sequelae of idiopathic intracranial hypertension (IIH) and secondary intracranial hypertension with cerebro-venous sinus thrombosis (CVST). The initial management revolves around weight loss, acetazolamide, steroids, and diuretics. A subset of unfortunate patients, refractory to medical therapy, need surgical intervention in the form of CSF diversion or optic nerve decompression (OND). The ONDd is an emerging alternative with encouraging early results. Aim: In our study, we share our experience of ONDd by endoscopic endonasal corridor, highlighting the technical nuances of procedure and discuss the indications of the same in the era of advanced technology. Materials and Methods: A retrospective, noncomparative review of the medical records of all the patients of IIH (ICHD-III criteria) with severe vision loss, refractory to medical treatment, and with established objective evidence of papilledema was done. All the patients were operated in our department by endoscopic endonasal sheath fenestration. Results: Nine patients (M:F 3:6) underwent endoscopic endonasal optic nerve decompression (2016–2019) approach for medically refractive IIH (n = 6) and CVST (n = 3). The mean age of population was 21.44 ± 5.14 years; 6 patients had improvement in headache and 6 had improvement in visual acuity. The visual acuity deteriorated in two patients (n = 1 IIH and n = 1 CVST with dural AVF). One patient needed postoperative lumbar drain for CSF leak, while none had meningitis. Conclusion: Endoscopic optic nerve sheath fenestration is minimally invasive and effective alternative with promising outcome in the management of medical refractory IIH or CVST.

Introduction: Although cranioplasty (CP) is a straightforward procedure, it may result in a significant number of complications. These include infections, seizures, intracranial hematomas, and others. Many reports have stated that early CP is associated with higher complications; however, more recent articles have contradicted this opinion. We intend to share our experience and results on outcomes of CP from our university hospital. Materials and Methods: This is a 3-year retrospective analysis of patients undergoing CP. Demographic profile, etiology of decompressive craniectomy (DC), DC-CP interval, operative details, complications, and follow-up data were analyzed. Correlation of complications with timing of CP and other factors was studied to look for statistical significance. Results: A total of 93 cases were analyzed. The majority were traumatic and ischemic stroke etiologies. There were eight open/compound head injuries (HIs). Eleven were bilateral and the rest unilateral cases. The mean and median CP interval were 8.5 weeks (range 4–28 weeks) and 8 weeks, respectively. All patients received 48 h to up to 5 days of postoperative antibiotics. Ten complications (10.7%) were noted (including one death). Poor Glasgow Outcome Scale at CP was the only statistically significant factor associated with higher complication rates. There was no statistical difference with respect to gender, CP material, and etiology; however, early CP had slightly fewer complications. Conclusion: Patients with poor neurological condition at the time of CP have a significantly higher risk of complications. Contrary to earlier reports, early CP (<12 weeks) was not associated with higher complications but rather fewer complications than delayed procedures. Adherence to a few simple steps may help reduce these complications.

Introduction: Genetic factors may play a role in the susceptibility of intracerebral hemorrhage (ICH). The present case-control study hypothesized that genetic polymorphisms in tumor necrosis factor- α (TNF-α) gene may affect the risk of ICH. Materials and Methods: In this study, we investigated the association of four single nucleotide polymorphisms (-308G/A, +488G/A, -857C/T, and -1031T/C) within TNF-α gene promoter and their haplotypes with the risk of ICH in a North Indian population. Genotyping was determined by using the SNaPshot method for 100 ICH patients and 100 age and sex-matched ICH-free controls. Conditional logistic regression analysis with adjusting multiple demographic and risk factor variables was used to calculate the strength of association between TNF-α gene polymorphisms and risk of ICH. Haplotypes were reconstructed using PHASE 2.0, and patterns of linkage disequilibrium (LD) analysis were performed using Haploview version 4.2 software. Results: TNF-α +488G/A gene polymorphism was found to be independently associated with the risk of ICH under dominant [GG + GA vs. AA] (OR = 3.1; 95% CI = 1.2–8.2; P = 0.001) and allelic [G vs. A] (OR = 2.2; 95% CI = 1.2–4.2; P = 0.007) models. However, no significant association between -308G/A, -857C/T, and -1031T/C gene polymorphisms and risk of ICH was observed. Haplotype analysis showed that 308A-488G-857C-1031T and 308G-488A-857T-1031T haplotypes were significantly associated with an increased risk of ICH. Strong LD was observed for + 488G/A and -857C/T TNF-α polymorphisms (D' = 0.72, r²= 0.01). Conclusion: Our findings suggest that the TNF-α +488G/A polymorphism may be an important risk factor for ICH, whereas -308G/A, -857C/T, and -1031T/C gene polymorphisms may not be associated with risk of ICH in North Indian population.

Introduction: There is a great deal of heterogeneity, both phenotypically and genotypically among the autosomal dominant cerebellar ataxias (ADCA). Their prevalence also varies in different populations. Trinucleotide repeat expansions (CTG/CAG) have been shown predominantly to cause a number of ADCAs. Aim: The present study describes the frequency of spinocerebellar ataxias (SCA) and the CAG repeat sizes among the different regions of India. Settings and Design: Molecular data from our central reference laboratory were retrospectively analyzed for SCAs 1, 2, 3, 6, 7, 10, 12, 17 and DRPLA. Correlation between age at diagnosis and the CAG repeats of the expanded and the normal alleles were tested with the Spearman correlation test. Results: The presence of SCAs vary according to geographical regions and ethnicities; SCA 12 was detected with the highest frequency (229/901), but was restricted to a specific ethnic population, followed by SCA 2 with a positivity of 12% (101/845). SCA 3 previously known as Machado-Joseph Disease had a prevalence of 4.05% (32/789), whereas SCA 1 was diagnosed in 30/773 (3.88%). No positivity was seen for SCA 10 from the 103 samples tested and for SCA 17 from the 131 samples tested either as a part of an extended panel or stand-alone. Conclusion: In this report, we are able to expand the portrait of SCAs in India by presenting the largest ever molecular data from a central reference laboratory.

Objectives: Social cognitive impairments are an essential aspect of general disability in patients with multiple sclerosis (MS). They can manifest independently or in addition to physical deficits. Aim: To examine the impairment of social cognition and its potential relationship with the grade of disability in MS patients. Settings and Design: Our study included 17 healthy controls and 36 patients with clinically definite MS (relapsing-remittent form) according to the McDonald Criteria (2010). The patients were divided into two groups – patients with Expanded Disability Status Scale (EDSS) <3.5 (N = 18) and those with EDSS ≥3.5 (N = 18). The neuropsychological battery included empathy assessment (Self-Compassion, “Reading the Mind”) and theory of mind tests – ToM (Faux pas, cartoons). Results: We did not register a change in self-assessment empathy in MS. Reading the Mind in Eye test showed a clear tendency for deterioration with increasing physical disability. The statistically significant difference (P < 0.05) between the results of controls and patients with EDSS ≥3.5 was registered. The tests for interpreting stories perceived in an auditory manner (“faux pas”) showed a clear trend toward “failure” among patients (P < 0.05). The results of patients with high disability in ToM cartoons task were statistically worse (P < 0.01) both in comparison to those of controls and patients with EDSS <3.5. Conclusion: Our study found that, during the course of MS, deterioration of both social cognitive skills and basic cognitive abilities occurs, which is parallel to physical disability.

Introduction: The management of aneurysmal subarachnoid hemorrhage (SAH) in the elderly is challenging. Clipping as the definitive treatment is less well tolerated by the elderly population. The outcome is anticipated to be more glimmer in poor grade SAH and in a setup which lacks modern neurovascular gadgets. We present our experience of surgical clipping in elderly patients in such a basic neurovascular unit. Materials and Methods: A retrospective analysis of hospital records of elderly patients between 70 and 79 of age who underwent surgical clipping of intracranial aneurysms between 2015 and 2017 was done. The patients' characteristics, comorbidities, aneurysm characteristics, intraoperative complications, and postoperative complications were studied to determine the factors influencing an unfavorable outcome. All information was entered into a database (Microsoft Excel) and analyzed using SPSS trial version 16. Outcomes were grouped into a favorable outomce which included Glasgow Outcome Scale scores of 4 and 5, whereas an unfavorable outcome which included Glasgow Outcome Scale scores of 1, 2, and 3. Results: There were 21 patients with aneurysms located either in the anterior or posterior circulation or both. All underwent standard craniotomy and clipping pertaining to that particular type of aneurysm. A favorable outcome was achieved in 48% of the patients and 52% had an unfavorable outcome. The duration of surgery, number of days on ventilator, and presence of hydrocephalus were the factors found to be statistically significantly associated with unfavorable outcomes. Conclusion: A team approach consisting of a neuroanaesthetist, neurosurgeons, and critical care personnel can have a huge impact on the postoperative outcome.

Purpose: To evaluate the usefulness of the “Motion Correction” function of the dual volume-3D-volume-rendering technique (DV-3D-VRT) in follow-up digital subtraction angiography (DSA) of intracranial coiled aneurysms. Materials and Methods: This study used data collected from consecutive, follow-up DSAs after the coiling of 64 intracranial aneurysms in 59 patients. We performed subtracted 3D-rotational angiographies (3D-RAs) on all DSAs and obtained DV-3D-VRT images. We then assessed recurrence using DV-3D-VRT images with and without the motion correction functions (MC(+) vs. MC(-)) and observed which method showed better agreement with the reference assessment (using a combination of 2D DSA and TOF MRA images). Results: The recurrence of MC(-) DV-3D-VRT images showed 51.6% (33/64) agreement with the reference assessment, whereas the MC(+) DV-3D-VRT images showed 78.1% (50/64) (P = 0.035, McNemar test). Conclusion: Motion correction is a useful complementary imaging technique in evaluating aneurysm recurrence after endovascular embolization. MC(+) DV-3D-VRT image showed higher inter-observer agreement than MC(-) DV-3D-VRT.

Background: Spinal dural arteriovenous fistula (SDAVF) is a known cause of progressive myelopathy which can be treated either by surgery or embolization. Indocyanine green angiography videoangiography (ICG-VA) during surgery can locate the exact location of AV shunting. Objective: To determine the clinical outcome following obliteration of the fistula and to study the role of ICG in identifying the presence and location of SDAVF; to add a comparative study of patients treated by embolization. Materials and Methods: Patients treated for SDAVF in our centre from 2005 to 2015 were studied for clinical and radiological features, and outcome following obliteration of fistula. Results: Of the total 33 patients (27 males, six females), 19 patients were operated without the use of ICG, nine were operated with the use of ICG and successful embolization was done in five. Acute presentation was seen in five. Single feeder was seen in 20 patients, multiple in 13. Mean follow-up was 58 months. All patients in ICG group improved. Three out of 19 patients in the non-ICG group (15.78%) required re-operation. With the use of ICG, the improvement in Aminoff Logue score was significantly better (P < 0.005). Embolization was tried in 13 cases, but successful in five (38%). Conclusions: Surgery with intraoperative ICG shows the exact location of AVF. This decreases the chance of postoperative clinical deterioration and improves patient outcome.

Background: The incidence of intracerebral hematoma among patients with aneurysmal subarachnoid hemorrhage is up to third of the cases (12%–35%). The presence of an aneurysm with ICH negatively influences the patient's presentation, course, and outcome, and may be associated with an increased re-hemorrhage rate, vasospasm, cerebral edema, and hydrocephalus. Aneurysm obliteration and hematoma evacuation have been associated with a favourable outcome. Aim of Study: To explore the effectiveness and the prognostic factors for patients with middle cerebral artery aneurysm associated with intracerebral hematoma treated by early surgical clipping of the aneurysm with hematoma evacuation. Patients and Method: We analysed 21 patients with intracerebral hematoma caused by ruptured middle cerebral artery aneurysm presented to the Neurosurgery teaching hospital from January 2017 to January 2019. Parameters included five broad categories: demographic, clinical, radiological, surgical, and outcome. Results: We found the following factors significantly related with unfavorable patient outcome: Preoperative cranial nerves deficit, dysphasia, severe contralateral weakness, presence of dilated ventricles in CT scan, presence of IVH in CT scan, aneurysm location in the dominant (left) hemisphere, high modified-Fisher grade, duration of surgery more than six hours, occurrence of intraoperative aneurysm rupture, poor postoperative GCS, occurrence postoperative vasospasm, more severe postoperative contralateral weakness, and the presence of postoperative seizure. While the good initial GCS and early surgery significantly related to favourable patient outcome. Conclusion: Early surgical intervention of intracerebral hematoma caused by ruptured middle cerebral artery aneurysm has a favourable outcome in general and should be supported with consideration of the significant prognostic factors for each patient before the commencement of the surgery.

Background: Development of cerebral infarcts following clipping of ruptured intracranial aneurysm is one of the major determinants of functional outcome in patients with subarachnoid hemorrhage (SAH). The aim of this study is to evaluate the factors affecting development of postoperative infarcts, its incidence, pattern, and functional outcome. Material and Methods: This study includes 118 patients of spontaneous SAH because of ruptured anterior communicating artery aneurysm, who underwent clipping. Relevant points in history, preoperative and intraoperative findings, and postoperative outcome are evaluated. Results: 29 of 118 (24.5%) patients developed postoperative radiological infarcts. Approximately 37.9%, 17.2%, and 3.4% patients developed isolated infarcts, respectively, in anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) territory. About 20.7% patients developed infarcts in deep perforator territory. Nine of 29 (31.3%) patients developed multiple-vessel territory infarcts. Patients with poor preoperative neurologic status, prior history of seizure, and history of intraoperative rupture had higher chances of development of infarcts. Development of infarct was irrespective of temporary clipping (TC), duration of clipping, and elective versus rescue clipping. Development of infarcts adversely affected the outcome in significant proportions. Among patients with infarcts, unilateral ACA territory infarcts showed best prognosis, whereas all patients with multiple territory infarcts and PCA territory infarcts died. Age or sex of the patients did not affect the functional outcome. Timing of development of infarcts has no influence on functional recovery. Conclusion: Development of symptomatic infarct is the sole important predictor of functional outcome. A crowded neurovascular neighborhood and complex variations in local angioarchitecture make anterior communication (ACOM) territory predisposed to operative insults. Elective TC and aggressive management of cerebral vasospasm are recommended to prevent development of infarcts.

Introduction: Hyperosmotic agents are used to decrease intracranial pressure (ICP). We aim to compare the effect of euvolemic solutions of 3% hypertonic saline (HTS) and 20% mannitol on intraoperative brain relaxation in patients with clinical or radiological evidence of raised ICP undergoing surgery for supratentorial tumors. Materials and Methods: A prospective double-blind study was conducted on 30 patients randomized into two equal groups. Each patient was administered 5 ml/kg of either 20% mannitol or 3% HTS over 15 minutes (min) after skin incision. Hemodynamic data, brain relaxation and serum electrolyte levels were recorded. Results: Intraoperative brain relaxation was comparable between the two groups. There was a statistically significant difference in the mean arterial pressures (MAPs) between the two groups after one minutes (min) with a greater degree of decrease in blood pressure recorded in the mannitol group (P = 0.041). MAP with mannitol was significantly lower than the preinduction value after 75 min of administration of drug (P = 0.003). Urine output was significantly higher in the mannitol group (P = 0.00). Administration of HTS was associated with a transient increase in serum sodium concentrations, which was statistically significant but returned to normal within 48 h (P < 0.001). Conclusions: Both mannitol and HTS provided adequate intraoperative brain relaxation. On the contrary, there was no statistically significant fall in blood pressure with HTS. Thus, we advocate the use of HTS over mannitol as it maintains better hemodynamic stability.

Background and Aim: Liver transplantation (LT) is the only curative treatment for patients with the end-stage liver disease. Amongst the complications post-LT, the neurological complications (NC) are particularly relevant. Our aim is to assess the incidence, risk factors and clinical presentation of NC in recipients after living donor liver transplantation. Methods: Between November 2011 and December 2013, 149 patients were admitted to ICU in 3 different centres in Egypt after LDLT and were evaluated by full clinical examination, laboratory investigations, neuroimaging and the NC were observed over one month. This study was approved by the ethical committee of the National Research Center. Results: 46 recipients (30.9%) developed neurological complications. The most common neurological complication was Encephalopathy (14.1%) while the least were both central pontine myelinolysis and meningoencephalitis (0.7%). In addition, 7 patients developed cerebrovascular events (either ischemic or hemorrhagic strokes). Patients were then classified into uncomplicated and complicated subgroups according to the highest percentage of neurological complication symptoms. These were encephalopathy, delirium with agitation, hallucinations, and delusions. Conclusion: A high incidence of neurological complications (30.9%) after LDLT was recorded, prolonging patient hospital stays. The most common complications were encephalopathy, delirium, hallucinations, delusions, and seizures some of which were drug related.

Many neurological conditions may result in long-term disability. The measures of prevalence and mortality vastly understate the disability they cause. In the Persons with Disabilities Act 1995 (equal opportunities, protection of rights, and full participation), neurological conditions are ignored. Although Indian Disability Evaluation and Asessment Scale (IDEAS), which assesses psychiatric conditions, does include dementia as one of the neurodegenerative conditions. Additionally, according to the global burden of disease report, 33% of years lived with neurological disability and 13% of disability-adjusted life years (DALYs) are due to neurological and psychiatric disorders. In 2001, the World Health Organization (WHO) established a new definition of disability, declaring it an umbrella term with the following three major components; 1) impairments: problems in body function or structure, 2) activity limitations: difficulties encountered by a person in executing a task or action, and 3) participation restrictions: problems of involvement in life situations experienced by a person. Hence, an attempt was made to rectify the above concerns. To address the above mentioned concerns, we think that there is a need of a comprehensive format for neurological disabilities assessment which would also include objective neuropsychological assessments. As future directions, national level meetings are required to formulate 'Indian Standard Track for Assessing Neurological Disability' (I-STAND) and uniform guidelines for disability assessment in 'chronic neurological conditions' with a special focus on “neuropsychological disability”.

Background: CSF drainage from the ventricular system is a popular and effective technique for intraoperative brain relaxation as it reduces ICP, enlarges extra-axial operative corridors, and slackens the brain increasing its tolerance for surgical manipulation. However, sometimes when the ventricular chambers distant from the site of pathology are tapped, there is a risk of neurological worsening due to paradoxical herniation of the brain, exemplified by the phenomenon of upward transtentorial herniation observed in posterior fossa tumors, consequent to a supratentorial ventriculostomy. Expectation of an analogous phenomenon precludes contralateral ventricular drainage in supratentorial brain tumors producing midline shift, subfalcine herniation, and resultant distension of the opposite lateral ventricles. Objective: Demonstrating the safety and efficacy of intraoperative contralateral ventricular drainage in the presence of sub-falcine herniation. Methods: Clinical and imaging information were retrospectively collected for four cases in which this technique was adopted. Results: The first case was a large clinoidal meningioma with a midline shift and contralateral ventriculomegaly. EVD from the dilated ventricle provided optimum brain conditions for safe resection of the tumor through an orbitopterional approach. The second case required a contralateral EVD to reduce ICP intraoperatively, for a recurrent anaplastic ependymoma with severe mass effect. It reduced the venous hypertension related to raised ICP minimizing the blood loss. Contralateral EVD was utilized to enlarge the working corridor for interhemispheric approach in two cases. Conclusion: Contralateral ventricular drainage is a safe, effective, and convenient operative step for reducing brain turgor in the presence of sub-falcine herniation produced by large supratentorial tumors.

In this case report, we describe successful tremor capture via stimulation of the posterior subthalamic area (PSA) for a patient with tremor-predominant Parkinson's disease. In this scenario, the patient had a deep brain stimulation (DBS) lead placed in the PSA of the right hemisphere and a DBS lead placed in the subthalmic nucleus (STN) of the left hemisphere. Therefore, we were able to directly compare tremor capture in the same patient receiving stimulation in two different brain areas. We show that both placements are equally efficacious for tremor suppression, though the DBS lead placed in the PSA required slightly higher current intensity. This comparison in the same patient confirms that stimulation of the PSA can successfully suppress tremor in Parkinson's disease.

A 40-day-old female child presented to us with an oral cavity mass, noticed at birth and progressively increasing in size. Preoperative computed tomography revealed intracranial extension of the lesion. Airway management, securing and maintaining invasive vascular access peri-operatively and transport of the patient to MRI suite were the major challenges. Mask ventilation was difficult and successful intubation required three attempts. Otorhinolaryngologists were present in the theatre during induction to perform a tracheostomy if the situation so demanded.

Standard treatment of drug-refractory epilepsy, due to left mesial temporal sclerosis, is anterior temporal lobectomy with amygdalohippocampectomy (ATL). This carries a risk of cognitive deficits, including comprehension, verbal memory, and visual memory. Preoperative language lateralization and localization is important to preserve these functions. Often Wada testing is used for these, but it carries risk due to its invasive nature. In addition, it can lateralize but not localize and may not be readily available. We hereby present a mathematics genius who underwent left ATL under the guidance of functional MRI and neuropsychological assessment alone, resulting in the preservation of all of his cognitive abilities even in the immediate postoperative period. A video demonstration of his calendar likeability is also shown.

Basilar artery dissections are rare events which present with subarachnoid hemorrhage (SAH), brain ischemia, and usually have a fatal outcome. Few case reports of mycotic dissections are published in literature. We report a case of a young male who underwent surgical treatment for post-traumatic CSF rhinorrhea. He presented 3 years later with signs of bacterial meningitis. During medical management with antibiotic therapy, he developed basilar artery aneurysm in a span of 2 days, had subarachnoid hemorrhage and deteriorated. CSF culture grew alpha hemolytic streptococci. Despite medical management, he developed brain stem infarcts and succumbed. This report highlights a rare fatal complication of mycotic dissecting aneurysm of the basilar artery following meningitis, which developed acutely in hospital, while on treatment. Antibiotic therapy had not altered the course of disease. It is advisable to investigate for presence of ruptured mycotic aneurysms or dissection in cases of bacterial meningitis leading to SAH.

Understanding the pathogenesis and the typical imaging features of carotid artery web, and accurately diagnosing the carotid artery web will help to implement targeted intervention for cryptogenic stroke and reduce the recurrence of stroke events. Carotid web (CW) can be defined as an endoluminal shelf-like projection often noted at the origin of the internal carotid artery just beyond the bifurcation. It is recognized as a possible cause of ischemic stroke in young adults. We describe here a case of ischemic stroke caused by a CW in a healthy man. Detection of this vascular abnormality required the use of computed tomography angiography. CW is a specific anatomical structure. Its imaging and clinical manifestations are different from atherosclerosis. It's also is a latent etiology to cryptogenic stroke. CW should be considered in patients with otherwise cryptogenic stroke, otherwise healthy patients presenting with stroke and without the typical risk factors for atherosclerotic carotid disease and stroke.

Sheehan syndrome, characterized by postpartum pituitary necrosis, is an important cause of hypopituitarism in developing countries. We report the case of a 50-year-old female with Sheehan syndrome, who had two spontaneous conceptions following severe postpartum hemorrhage in her first delivery and presented 27 years later with moderate pericardial effusion and features of pseudohypertrophic myopathy mimicking muscular dystrophy.

A 34-year-old man presents with recurrent episodes of acute reversible muscle weakness, soreness, pain, cramps and myoglobinuria with elevated creatine kinase. Symptoms were triggered by fasting, sustained long duration exercise and viral infection. A metabolic myopathy was suspected. Genetic testing showed a homozygous pathogenic variant in CPT2 gene resulting in deficiency of Carnitine Pamitoyl transferase II, an enzyme in the carnitine cycle. The cycle plays a vital role in transport of long chain hydrophobic fatty acids from the cytosol into the mitochondrial matrix for the production of energy via β-oxidation. Carnitine Pamitoyl transferase II deficiency is the most common inherited disorder of lipid metabolism affecting the skeletal muscle of adults. It is also the most frequent cause of hereditary myoglobinuria across all ages. Our case presents an analysis of important clinical features of carbohydrate and lipid metabolism disorders. It highlights how thermolability of the mutant enzyme, rather than its actual deficiency, explains triggering of muscle symptoms by prolonged exercise, infections, febrile episodes, or exposure to cold.

Acute aortic dissection (AAD) complicated with acute cerebral infarction lacks a unified treatment plan. We report probably the most effective treatment of a type A AAD with acute cerebral infarction leading to coma. A 43-year-old man presented with acute hemiplegia and unconsciousness. He was diagnosed as acute cerebral infarction. After an ineffective emergency intravenous thrombolysis, a Digital Subtraction Angiography (DSA) examination revealed the severe cerebral artery occlusion, and the TICI 3 level was achieved by stent implantation in the left common carotid artery with significant neurological recovery. A type A AAD was found at the 1 month follow-up ultrasound examination and a further thoracic surgery was performed successfully. Carotid ultrasound is helpful for the diagnosis of AAD from acute cerebral infarction. Carotid artery stenting followed by thoracic surgery is effective in this kind of emergency situations. Further studies are needed to determine the exact indications.

We recently started India's first proton beam therapy facility. Proton beam therapy because of its unique physical characteristics of minimal exit dose has an unequivocal dosimetric superiority over high-end photon/standard X-ray beam therapy and is particularly advantageous in growing children with curable cancers in view of their very high probability of long-term cures. We hereby report a case of a 7-year-old boy with a craniopharyngioma which had been subtotally resected and was subsequently treated with modern pencil beam proton therapy under high-precision image guidance. This is the first ever child ever to be treated with proton therapy in India.

A 38-year-old woman 12 days after delivery of her second pregnancy was admitted to emergency room for a severe occipital headache started 3 days before, associated with confusion, nausea, vomiting and walking impairment. Neurological examination showed left hemiparesis, hypoesthesia in left arm and leg. Brain computer tomography images showed a large intraparenchymal hematoma in the right frontoparietal lobes with mass effect on adjacent subarachnoid spaces and on lateral ventricle. The third day during hospitalization, the patient experienced a sudden worsening of the neurological symptoms and a severe headache peaking within 1 minute (min); a new brain computed tomography and brain magnetic revealed another small intraparenchymal hematoma in the left parietal lobe with increase of the amount of subarachnoid hemorrhage. Digital subtraction angiography discloses multifocal narrowing of the middle and small arteries in both anterior and posterior circulation with a relative spare of large vessels. Postpartum reversible cerebral vasoconstriction syndrome with intracranial hemorrhage is a rare clinical condition that can be misdiagnosed with other dramatic neurological diseases such as eclamptic encephalopathy, cortical venous thrombosis, primary angiitis of the central nervous system or posterior reversible encephalopathy syndrome with whom may share predisposing factors and neurological presentation but clinical course, treatment and prognosis is quite different and emergency physicians and neurologists should consider this diagnosis in postpartum patients with hemorrhage.