International Journal of Neurology and Neurosurgery

The Valsalva’s maneuver is a time-honored technique that is commonly used at the clinical practice for the evaluation of heart murmurs, left ventricular and autonomic dysfunction. Valsalva maneuver (VM) is commonly practiced in neurosurgical patients to check for CSF leak after closure of dura and to see venous oozing at the end of surgery. This VM method has also been used to facilitate removal of pituitary tumors in trans-sphenoidal approach. Though VM can result in marked hemodynamic changes, but if it is used judiciously and for brief duration, can result in improved outcomes of anaesthetised neurosurgical patients. We wish to share our experience of use of VM for the extrusion of intact fourth ventricle cyst which helped to minimize the dissection and thus helping to preserve neurological function.

Keywords: Valsalva’s Maneuver; 4th Ventricular Cyst; Neurocysticercosis.

 Arteriovenous malformation is an abnormal connection between arteries and veins, bypassing the capillary system. Majority of AVM occurs in cerebral parenchyma and infrequently encountered in the lateral ventricle and foramen Monro. We report an intraventricular AVM in an 8 year old girl mimicking tumor.

Keywords: Intraventricular Tumor; Arteriovenous Malformation; Lateral Ventricle.

 Background: Arachnoid cysts (AC) are benign, congenital, non-neoplastic, extra axial, intra-arachnoid lesions filled with cerebrospinal fluid (CSF). Only 10% of arachnoid cysts occur in Cerebello-Pontine Angle (CPA). Bilateral ACs are very rare. Case Description: In this case report we present a one month baby who was evaluated for failure to thrive and hydrocephalus. Patient examination revealed cranial nerve seven and eight paresis and imaging was suggestive of bilateral CPA ACs which was treated with surgery. Literature Review: Pubmed search showed only three cases of bilateral ACs -one in an adolescent and two in adult population. Clinical Relevance: This is probably first reported case of bilateral CPA AC in a newborn with facial paresis.

Keywords: Arachnoid cysts (AC); Cerebrospinal fluid (CSF); Cerebellopontine angle (CPA).

 A 35 year female with progressive proptosis of right eye since childhood with diminution of vision presented with a swelling extending into the upper eyelid with a pulsatile proptosis. Globe deviated inferionasally with a visual acuity of finger counting at 1 meter. 3D-NCCT/MRI- Complete aplasia of the right sphenoid wing with an intraorbital temporal lobe meningoencephalocele. Dura and orbital tissue were inseparable due to adhesions. Redundant dura was plicated and sutured to the surrounding dura & falxcerebri (> 270° periorbital circumference) with no additional mesh construct. Post op improvement in vision to 6/9 with minimal enophthalmos was seen.

Keywords: Sphenoid Wing Dysplasia; Orbital Encephalocele; Neurofibromatosis-1; Encephalocele; Proptosis.

 In adults and older age group, Low back pain is very common reason for seeking medical attention. Herniated lumbar disc accounts for majority of cases in them, requiring a refinement in management strategy. However, spontaneous disappearance of large herniated lumbar disc has been reported very rarely in the literature till the time being. The authors here report a distinctive case of spontaneous regression of a large extruded lumbar disc in a 50 year old male. The patient presented with remarkably large lumbar extruded disc with backache and progressive neurological deficits. Patient was advised for surgical discectomy but he was lost to follow up. Later on the disc regressed spontaneously as evident on MRI scan done after 6 months along with improvement in clinical symptoms. This paper has reviewed various literature & also discussed possible mechanism of disc regression with its impact on outcome.

Keywords: Lumbar Disc Herniation; Spontaneous Regression; MRI; Foraminal Stenosis; Cauda Equina Syndrome.

 Distal migration of shunt is a very common occurrence. Proximal migration of shunt is rare and possible pathophysiological mechanisms to explain this unusual complication is rarely attempted. A 5-month-old child shunted for posttraumatic hydrocephalus presented 1.5 years later with raised intracranial pressure (ICP) and seizures. Imaging showed subdural hygroma, partial intracranial migration of shunt / chamber. On endoscopy, choroid plexus was adherent to shunt tip and some pericranial tissue was found in the anchoring suture(intraventricularly displaced). Endoscopic retrieval of migrated shunt along with CSF diversion was established by endoscopic third ventriculostomy (ETV) with symptoms free follow-up. Hostrelated and surgical factors have been postulated. Tug-of – tie effect on the anchoring suture and collapsing cortex are the possible mechanisms that explain proximal migration in our case. Three-point fixation of the chamber to pericranium, small burr hole with a smaller durotomy, can prevent shunt migration. Proximal Shunt migrations should be dealt with endoscopy so as to avoid complications.

Keywords: Shunt Chamber Migration; Neuroendoscopy; V-P Shunt; ETV.

 Ependymomas commonly arise from conus medullaris, cauda equina and filum terminale. Ependymoma involving single nerve root is rare. We report a case of young male with disabling low back pain without motor- sensory deficits whose magnetic resonance imaging (MRI) showed a intradural lesion opposite L2- 3 vertebral body which was confined only to the S1 nerve root and was resected without incurring any post operative deficits. Pathologic examination was suggestive of myxopapillary ependymoma. Patient was asymptomatic postoperatively and MRI did not show residual disease. Ependymomas can cause central nervous system dissemination (CNS), recur and undergo malignant transformation, knowledge of which is essential for management and follow up. We believe this is the first reported case of S1 nerve root Ependymoma.

Keywords: Ependymoma; Nerve Root; Sacral.

 Objective: PrimaryEwing’ Sarcoma (ES) of spine is rare entity but causes significant morbidity if not diagnosed in time and not managed properly, so the optimal management of primary Ewing’s Sarcoma spine should be analysed to improve the final outcome. Patients &Methods: We retrospectively analysed eight cases of spine ES who had been operated in last 8 years in one of the tertiary centre of northern India. Result: Male: female ratio was 7:1. Most common presenting symptoms was paraparesis in all 8 patients. Most common site of spine involvement was dorsal spine in all patients.MRI spine showed lobulated lesion well demarcated and enhancing, extending in paravertebral tissue in six out of eight cases.Histopathological examination of specimens after surgical decompression from all patients showed small blue round cell tumors, arranged in sheets. CD99 was positive in all the cases. One patient developed recurrence after 2 years of surgery and further lost follow up. 5 patients died (one immediate due to surgical complication, one early chemo-radiation phase due to neutropenia and subsequent septicemia & 3 patients at 9, 13 and 15 months of primary surgery. Only two out eight patients were recurrence free who had undergone chemo-radiation after surgery. Conclusion: Primary Ewing’s sarcoma of spine has poor outcome even after surgical decompression and chemo-radiation as multimodality management. Strict follow up is must for improving the outcome.

Keywords: Ewing’s Sarcoma Spine; CD99; Spinal Tumour; Round Cell Tumour

 Objective: Establishing a reliable prognosis after surgery for traumatic brain injury(TBI) is difficult. Majority of the prognostic models help in morbidity and mortality assessment. In a developing country, unexpected prolonged hospital stay can have a cumulative effect on limited hospital resources and lessen the caretaker’s compliance. Patients &Methods: Records of 256 patients who had hospital stay for more than 15 days during a period of 3 years were obtained and grouped into 15-30 days (Group 1) and > 30 days (Group 2) of hospital stay groups. Demographic data, comorbid factors, mode of injury, Glasgow coma scale (GCS), pupil status, Computed tomography (CT) features, tracheostomy, associated significant injuries, septic foci with cultures and second-surgeries were compared and analyzed.Results: In Group 1, age<50 years, GCS:3-5 at presentation, bilateral fixed but normal sized pupils, bilateral fixed and dilated pupils, CT features of Extradural hematoma (EDH), subdural hematoma (SAH), cerebral edema & Midline Shift (MLS) of >6mm were found to be significantly associated with prolonged stay (p<0.001). In Group 2, GCS 6-8, unilateral fixed and dilated pupils, CT features of SDH & ischemia and infarcts, associated orthopedic injuries, abdominal injuries and soft tissue loss, comorbidities, pneumonia, tracheostomy, wound infection, meningitis, and second surgery, were found to have significant association ( p<0.001). No association was found with the mode of injury, GCS>9, contusions/IVH/ depressed fracture, chest injuries, chronic kidney disease, deranged coagulation, an appearance of seizures and microbial flora. Conclusion: Age, GCS at presentation, pupil size and reaction, CT features, second surgery, comorbid conditions and presence of tracheostomy with recurrent lower respiratory tract infection (LRTI)/ upper respiratory tract infection (URTI) were significant predictors of prolonged hospital stay. As majority of these can be assessed at the time of admission and happens in the due course, a fairly reliable prediction regarding duration of hospital stay can be can be established.

Keywords: Traumatic Brain Injury; GCS; Hospital Stay; Prognostic Factor.

 Objective: Acute sub dural hematomas (ASDH) are one of the most common sequel following traumatic brain injury. Most of the ASDH constitutes neurosurgical emergency requiring urgent evacuation of the hematoma. There are very few and rare instances of Spontaneous and rapid resolution of ASDH. We share our experiences of Patients having spontaneous resolution of ASDH in a view to establish the pathophysiology & predicting factors and to improve the management of ASDH.Patients & Methods: We retrospectively analyzed Clinical & radiological findings as well as outcomes of 8 patients having ASDH who had spontaneous and rapid resolution. Result: Certain predicting factors such as, presence of cerebrospinal fluid (CSF) band or sub duralhygro-hematoma, large CSF spaces in computed tomography (CT) brain were consistent with these patients. Conclusion: Spontaneous & rapid resolution of ASDH though rare, is a possibility even in a patient with thick ASDH with significant midline shift. A repeat CT before surgery should be done especially in neurologically improving patients. Presence of the CSF band or sub duralhygro- hematoma/large CSF spaces in CT brain maybe a guide in identifying such patients and to avoid high risk surgery.

Keywords: Acute Sub dural hematoma; Spontaneous Resolution; Head Injury; CSF Band.

 Background: Dementia is a decline in cognitive abilities of sufficient severity to interfere with activities of daily living and is not caused by delirium or other medical or psychiatric disorder. The subset of Very Young Onset Dementia (VYOD) with onset before 25 years is not studied well in India. In this study we aimed at describing the clinical profile, higher mental functions, investigations and etiological factors in these patients. Methodology: We conducted an observational, retrospective, single-cohort study to study the clinical profile of dementia patients presenting to the Department of Neurology at Topiwala National Medical College & BYL Nair Charitable Hospital, Mumbai. We searched for patients with dementia with onset between 10 to 25 years. We collected patient related demographic and clinical information from the records. All the collected data will be entered in Microsoft excel sheet and imported in to Statistical Package for Social Sciences (SPSS) version 16 for statistical analalysis. Results: 21 patients were included in the study, 18 males, average age of onset is 13.1 years. Subacute Sclerosing Panencephalitis, Hereditary Spastic Paraplegias, Wilson’s disease were common aetiologies. 33% patients had Mini Mental Status Examination score of less than 10. 42% patients had Frontal Assessment Battery score less than 5. 42% patients had frontal, temporal and parietal lobes involvement. MRI brain was abnormal and revealed T2 hyperintensity in basal ganglia, brainstem and cerebellum. Conclusion: Early onset dementia is an underestimated problem in developing countries. Preventable conditions such as Subacute Sclerosing Panencephalitis (SSPE) and treatable condition such as Wilson’s disease (WD) are leading causes in dementia with onset before 25 years. Awareness of these conditions is important while evaluating patients with VYOD.

Keywords: Dementia; Wilson’s disease (WD); Very Young Onset Dementia (VYOD); Subacute Sclerosing Panencephalitis (SSPE).

 Background: Multiple system atrophy is a sporadic, progressive, neurodegenerative disease of undetermined etiology characterized clinically by extra pyramidal, pyramidal, cerebellar, and autonomic dysfunction in any combination. It is recognized by various names as Shy-Dragger syndrome, Striato-niagral degeneration and sporadic Olivopontocerebellar atrophy depending upon the predominant presentation. Objective: To study the variability in initial clinical presentation and progression of patients of multiple system atrophy. Material and Methods: Six patients of MSA diagnosed during December 2008 to March 2010 in a tertiary care teaching hospital were analyzed. Bedside autonomic function testing and MRI Brain was done for all these patients. Results: Five patients satisfied the criteria for probable MSA, one patient for possible MSA. Four patients were sub categorized as MSA-C and two as MSA-P. All patients had remarkably different modes of presentation and findings at onset. Duration between initial symptoms and combined motor and autonomic dysfunction varied in all of these patients. Conclusion: The clinical presentation of MSA is variable even within a particular subtype. Detailed clinical evaluation including Autonomic functions (and close follow-up) is essential for diagnosis.

Keywords: Multiple System Atrophy; Variable Presentation; Autonomic Dysfunction.

 Not Provided.