International Journal of Neurology and Neurosurgery

  Primary malignant sarcomas of the spine are extremely rare. Because of biological heterogeneity, these tumors have variable sensitivity to radiation and chemotherapy. Presentation of severe radicular pain with MRI findings of an exradural lesion with extension through the neural foramen is rare to be an ewings sarcoma in any neurosurgeons carrier. We report about an eighteen years old female with primary Ewing´s sarcoma of the lumbosacral region which has been reported only a few times in literature. 

Keywords: Ewings Sarcoma; Primitive Neuro Ectodermal Tumor; Spine

Bilateral MCA (Middle Cerebral Artery) infarct following basal ganglia hemorrhage is a rare entity. We report a 52 year old lady with history of altered sensorium and weakness in right side of body for one day with past history of uncontrolled diabetes mellitus. On examination GCS (Glasgow Coma Scale) was E3V1M5 with right side hemiplegia. NCCT (Non Contrast Computed tomography) head showed left gangliocapsular hemorrhage with intraventricular extension. The patient was managed conservatively. The patient deteriorated three days after (GCS E1V1M1) and repeat NCCT head showed left basal ganglia hematoma with hypodensity in bilateral MCA territory suggestive of infarct. MRI brain confirmed CT findings of bilateral MCA infarct. Carotid doppler of neck vessels revealed a fibrofatty plaque at posterior wall of the carotid bulb on the left side extending into left ICA causing approximately 50% luminal compression. 2D ECHO revealed no clot or vegetations. The patient expired 1 day after. The clinical and radiological features of this rare entity are discussed.

Keywords: Bilateral; Infarct; Hemorrhage.

  We report a 23 year old female who concomitantly developed Chronic inflammatory polyradiculoneuropathy (CIDP) with Myasthenia gravis (MG). She initially presented with slowly progressing proximal and distal weakness in all four limbs with areflexia and elevated CSF protein. Electrophysiological studies confirmed the diagnosis of CIDP and started on corticosteroids and immunodulators. However, two months into treatment, her condition deterioted and she presented to emergency department with bilateral ptosis, breathing difficulty, dysphagia and no improvement in motor power. High titres of AchR antibodies, presence of ophthalmoplegia along with neostigmine test confirmed the concomitant diagnosis of MG with CIDP. Steroids along with acetylcholinesterase inhibitors were used to treat MG. Coexistence of two autoimmune disorders in the same patient can be a diagnostic labyrinth which can delay diagnosis and treatment. 

Keywords: Myasthenia Gravis; Chronic Inflammatory Demyelinating.

Unilateral cerebellar aplasia is a very rare developmental disorder usually most commonly seen in children after a prenatal insult. It hasmultifarious clinical presentations ranging from development delay to ataxia and cognitive impairment. Here we present a case of a 31­year old adult whopresented with acute confusional state (probable seizure) have incidentally found to haveunilateral left cerebellar aplasia. He had normal uneventful delivery with normal development and cognition.Though the exact cause is unknown, even with unilateral cerebellar aplasia there can still have an uneventful life with normal motor activity and intelligence. 

Keywords: Cerebellar Aplasia; Normal Adult; Incidental Finding

  Multiple Sclerosis (MS) is a chronic, individualized, and often unpredictable disease that attacks an individual’s central nervous system. Although the origin of MS is unknown, researchers to date point to a potential variety of causes, making prevention and even treatment difficult. The uncertainty of potential causes is further complicated by variation in reported symptoms as well as the potential for signs to disappear and even reappear. Furthermore, no singular test allows for the diagnosis of MS, leading to the need for multiple procedures over a period of time to rule out all other diagnoses prior to an individual being provided an MS diagnosis. Variations in physical, cognitive, and psychological symptoms, including the potential presence of numbness or tingling, memory loss, depression, and even sexual dysfunction, require family counselors to become knowledgeable of the medical aspects of MS, including possible symptoms and the necessary steps at which an individual should receive appropriate testing. A case illustration is presented with the goal to demonstrate ocular involvement (acute optic neuritis) which can be an early detector of multiple sclerosis in young individuals. 

Keywords: Optic Neuritis; Multiple Sclerosis.

Craniovertebral junction tuberculosis is rare, accounting for 0.3 to 1% of all tuberculous spondylitis cases. MR imaging is the modality of choice to detect bone involvement, abscess formation, pre and paravertebral collection, sub ligamentous spreading of the pus and to differentiate from other lesions affecting the craniovertebral junction. It is also helpful to determine the modality of treatment and monitor the efficacy of treatment. Surgical treatment of patients with craniovertebral junction tuberculosis has been associated with highmortality rate ranging up to 10% and recurrence rate ranging up to 20%, conservative treatment is the modality of choice for most of the cases. We present a case of craniovertebral junction Mycobacterium tuberculosis infection diagnosed with clinical, serological and radiological evidence. A Philadelphia collar was applied for external immobilization and anti­tuberculous treatment with rifampicin, isoniazid, pyrazinamide and ethambutol was initiated. After completion of the initiation phase, the patient wasneurologically improved. MRI showed marked resolution of the craniovertebral mass. Antituberculous treatment was advised to continue for next 15 months. 

Keywords: Tuberculous Spondylitis; Craniovertebral Junction; Anti­TB Therapy.

  Antecedent infection with following organism likecytomegalovirus, Epstein Barr virus, Varicella zoster virus, Human immunodeficiency virus (HIV), Campylobacter jejuni, Mycoplasma pnemoniae and Shigella are implicated in the causation of the Guillain Barre Syndrome. In all the patients the following data were recorded: demographic data; season in which patient developed disease; detailed history of present and preceding (if any) illness; physical as well as neurological examination details; laboratory characteristics including CSF analysis (if done); electrophysiological findings, any need for assisted mechanical ventilation, duration of mechanical ventilation; duration of hospital stay; any complications; treatment given and outcome. The median duration to get admitted in hospital from disease onset was 8 (range 4­18) days, and the median time to reach nadir of the disease was 7 (range 5­14) days. The median duration of total hospital stay was 16 days, with minimum and maximum duration of hospital stay being 7 and 60 days, respectively. All patients presented with symmetrical weakness. Quadriparesis was present in 54 (88.5%) patients.
Global areflexia was present in 53 (88.6%) patients.

Keywords: Guillain­Barre Syndrome; Epstein Barr Virus; Clinical Profile.

  Background: Non aneurysmal subarachnoid hemorrhage accounts for about 15% of all spontaneous subarachnoid hemorrhages. Literature has less data of outcome of these patients. To analyze factors affecting the outcome of patients with angio­negative subarachnoid hemorrhage (SAH). Methods: Retrospective analysis of data of patients with angio­negative SAH admitted in a tertiary care hospital from 2013 to 2018. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months. Results: Total 44 patients (18 Males, 16 Females with a ratio of 1.1:1) were included in the study. The mean age of presentation was 48.9±11.8. On imaging, 24 (55.5%) patients had perimesencephalic SAH (PM­SAH) and 20 (45.5%) had non­perimesencephalic SAH (NPM­SAH). Among 44 patients, 37 (84 %) of were clinically in good conditions (WFNS I/III) at presentation. 91% (22 out of 24) of patients with PMSAH had a good clinical status compared to the patients with NPM­SAH (75%) which clinically was not significant (p=0.13). 19 (43%) Patients were having arterial hypertension (Systolic BP >140). 10 (23%) patients were on anticoagulation medications. Overall, 12 (27%) patients developed an early hydrocephalus and required an EVD. Good outcome was seen in 35 (83%) patients. On multivariate analysis early hydrocephalus and poor admission clinical status emerged as an independent factors for the poor outcomes [Table 2]. Conclusions: Early onset hydrocephalus and poor admission WFNS grade are the independent predictor of poor outcomes. Permanent shunt dependency is significantly higher in patients with NPM­SAH. Patients with a NPM­SAH special attention as they have relatively poor neurological course compared to the patients with PM­SAH.

Keywords: Spontaneous Subarachnoid Hemorrhage; Perimesenchalic; Aneurysm; Angionegative.

 There is considerable geographical variation worldwide in the prevalence rates of the subtypes of GBS.AIDP is the most common subtype in the Europe and North America constituting for 90% cases, while in Japan and china it is the AMAN Subtype. In India there is disparity among the studies regarding the prevalence of subtypes. Serial nerve conduction studies (NCS) were done on the day of admission and in between 3­8 weeks from the onset of illness. Electrophysiology was performed according to conventional standard methods by a qualified senior technician trained and experienced in electromyography using Medelec synergy (VIASYS Health Care, USA) machine. In all the sub types men outnumbered women. Mean (SD) MRC sum score at admission of AIDP, AMAN, AMSAN patients at admission are 32 (9), 31 (11), 31 (11) respectively. At discharge the mean (SD) MRC sumscore at discharge of the AIDP, AMAN, and AMSAN patients are 47 (10) 41 (12) 43 (11) respectively (p=0.001).

Keywords: GBS; AIDP; NCS.

Background: Although the vertebral artery injuries (VAI) associated with cervical spine trauma are usually clinicallyoccult, they may cause fatal ischemic damage to the brain stem and cerebellum. Methods: We performed a prospective study using magnetic resonance angiography (MRA) to determine the frequency of VAI associated with cervical spine injuries and investigate the clinical and radiological characteristics. Between August 2011 TO January 2017, 108 consecutive patients with cervical spine fractures and/or dislocations were prospectively evaluated for patency of the VA, using the MRA, at the time of injury. Results: Complete disruption of blood flow through the VA was demonstrated in twenty two patients with unilateral occlusion in 20 patients (18.3%). There were 20 men and 4 women with a mean age of 45 (range, 24 ­50 years). Unilateral occlusion of the right and left vertebral artery occurred in 10 patients and of bilateralin 4. Regarding the cervical injury type, Distraction/extension, distraction/flexion, and lateral flexion injuries were the major mechanisms of injury. Dissection and occlusion were the frequent vascular injury patterns. Facet joint dislocations and the fractures extending into the transverse foramen were the spine injury patterns closely associated with VAI. All patients presented with good patency of the contralateral VA. None of the patients developed secondary neurological deterioration due to vertebrobasilar ischemia during the follow­up period with a mean duration of 60 months. Conclusions: VAI should be suspected in patients with cervical trauma that have cervical spine fractures and/or dislocations or transverse foramen fractures.

Keywords: Cervical Spine; Computed Tomographic Angiography; Injury; Vertebral Artery

Context: Epilespy should always be defined by its type. This helps in appropriate management and also guides the physician in prognosis. Management duration of epilepsy depends upon syndrome. For each epilepsy syndrome, the management varies. This is challenging to have precise diagnosis. Hence ILAE gave classification of epilepsy. Aims: Application of International League Against Epilepsy (ILAE) classification in patients with epilepsy. Settings and design: Hospital based cross sectional study was carried out at Osmania General Hospital and Niloufer Hospital for women and children. Methods and Material: The study material consisted of consecutive patients (both inpatients and outpatients) with all seizure disorder. Details about each patient’s birth and development, age at epilepsy onset, number of seizures, precipitating factors, and seizure description, family history, and neurologic findings were documented. Computerized tomography (CT) scans were performed on most patients and MRI scans in some cases. EEGs were recorded in most patients. Statistical analysis: Proportions were used to analyze the data. Results: In this study majority of the cases were children less than 10 years of age. Of the study population, 52.61% were classified as localization­related, 26.3% patients with generalized epilepsies and epileptic syndromes, 11.69% cases were Undetermined whether focal or generalized and 9.37% were Special syndromes (Situation ­ related). Symptomatic category of epilepsies was seen in majority of the localization related epilepsy cases. Ring enhancing lesion and cerebral calcified lesion on neuro imaging are common etiologic factors for epilepsy in our study. Conclusion: The 1989 ILAE classification is a good method of classification of epilepsies and related syndromes. 

Keywords: Epilepsy; Classification; Patients; Syndrome.

  Spine is the most common form of skeletal Tuberculosis with the vertebral body being its preferred site. Spinal Tuberculosis may cause neurological damage, deformity. Predominantly, treatment is anti­tubercular drugs but surgery is required in instability with neurological compromise or deformity. There is a controversy regarding surgical approach to these lesions. Initially anterior approach was used to these lesions and now posterior approach is preferred by some authors. We present to you our operative experience of spinal tuberculosis from Craniovertebral junction (CVJ) to lumbosacral junction at our tertiary care referral centre. Our preferred approach was anterior to 55 of these lesions and 21 lesions were addressed by posterior approach in 70 patients. 67 of 70 (95.4) patients had improvement on follow up. Authors feel the good old anterior approach to predominantly anterior compressive lesions holds well in tuberculosis. More studies and longer follow up is required to analyse and compare anterior versus posterior approach.

Keywords: Spinal Tuberculosis; Anterior Approach; Posterior Approach; Surgery.

Objective: To determine the diagnostic accuracy of pre operative Perfusion Magnetic Resonance Image Grading and its correlation with post operative Histopathological Grading of Primary Intra Axial Gliomas. Materials and Methods: In order to determine relative cerebral blood volume (rCBV), relative cerebral blood flow (rCBF), 30 patients with glioma underwent dynamic contrast enhanced T2 weighted and conventional T1 and T2 weighted imaging. rCBV and rCBF maps were obtained by fitting a gamma –variate function to the contrast material versus time curve. rCBV, rCBF ratios between tumor and corresponding area of normal side (maximum rCBV/ rCBF of tumor and rCBV/rCBF of contralateral white matter) were calculated and compared between glioblastomas (grade IV), anaplastic gliomas (grade III) and low grade gliomas (grade I & II). The grading obtained by the perfusion MR images was compared with the post operative histopathological grading. Results: Mean rCBV & rCBF ratios were 10.53±2.73 & 9.30±1.10 for glioblastomas (grade IV), 7.55±1.35 & 6.96±0.88 for anaplastic gliomas (grade III), 4.72±0.92 & 4.54±0.54 for diffuse astrocytomas and oligodendrogliomas (grade II), 1.84±0.94 & 1.59±0.79 for low grade gliomas (grade I), and were thus significantly different; p< 0.03 between glioblastomas and anaplastic gliomas, p< 0.02 between anaplastic gliomas and diffsuse astrocytomas, oligodendrogliomas, p< 0.003 between grade II and low grade gliomas, p<0.01 between glioblastomas and lowgrade gliomas. Stastistically significant correlation was seen by applying Chi­ square test (p <0.0001). Further the correlation of perfusion MR grading and Histopathological grading was proven by applying Speraman’s correlation value (p <0.0001). Conclusion: Perfusion MR imaging is a useful and reliable technique for estimating the histological grading of primary intra axial gliomas. 

Keywords: Perfusion Magnetic Resonance Imaging; Relative Cerebral Blood Volume; Primary Intra Axial Glioma.

  Context: Traumatic brain injury is the major cause of death and disability worldwide. Management of severe traumatic brain injury still remains elusive, some prefer surgical intervention while others advocate medical treatment. Objective: To compare the effect of decompressive craniectomy (DC) and maximal medical management with barbiturates in management of severe Traumatic Brain Injury (sTBI) patients with refractory Intracranial pressure (ICP). Settings and Design: 57 patients of severe traumatic brain injury admitted from September 2013 to august 2015 were evaluated based on inclusion and exclusion criteria and subjected to ICP monitoring. Materials and Methods: Patients with ICP refractory to conventional medical management (n=37) were randomized to decompressive craniectomy (n=23) or maximal medical management with addition of barbiturates (n=14). The primary outcome was functional status on Extended Glasgow Outcome Scale (GOS­E) at 7 days and 3 months. Secondary outcome measures were assessment of ICP control and days of hospitalization. Statistical Analysis used: Chi­square test and Student’s t­test were used for data analysis. Logistic regression analysis was employed to assess the effect of multiple variables in the outcome. Results: In decompressive craniectomy group (23), the mean ICP was reduced from 27.81 to 14.06 mmHg after surgery. Eight patientsin this group were alive at 3 months, among which 7 (30.43%) patients achieved good GOS­E of  4. Among 14 patients who underwent medical management with barbiturates the mean ICP reduced from 27.82 to 20.41 mmHg after therapy. In this group, one patient was alive (GOS­E 3) at 3 months. None of the patients in barbiturate group achieved good GOS­E (score 4) at 3 months. Conclusion: ICP monitoring of sTBI patients helps in early identification of patients whose ICP becomes refractory to conventional treatment methods. Decompressive craniectomy provides better outcome in terms of survival and achievement of good outcome as compared to maximal medical management with barbiturates

Keywords: Intracranial Pressure; Severe Traumatic Brain Injury; Decompressive Craniectomy; Barbiturate

  Background and Aim: Meningitis is an inflammatory disease of the leptomeninges, the tissues surrounding the brain and spinal cord, and is defined by an abnormal number of white blood cells in the cerebrospinal fluid. Present study was performed with an aim to compare Standard Laboratory Test with Commercially Available Assay (Xcyton) for Diagnosis of Meningitis. Material and Methods: A cross sectional study of 101 patients admitted to Multidisciplinary Intensive Care Unit(MICU) at a tertiary care teaching hospital between January 2011 to December 2013 were included this study. Patients with suspected neuroinfection based on the history and clinical examination were subjected to lumbar puncture for CSF analysis after Computed tomography (CT scan) of brain. CSF was also collected in EDTA vacutainer (for XCyton) and extra sample was reserved for any further analysis. Results: Xcyton when compared to standard laboratory test had sensitivity and specificity of 76% and 71% while the positive predictive value (PPV) and negative predictive value(NPV) was 30% and 95%. Sensitivity and specificity was 20% and 50% when Xcyton was compared with diagnosis based on clinical and radiological criteria. Cryptococcal  meningitis had 50% sensitivity, 100% specificity, 100% PPV and 98% NPV when XCyton and standard laboratory was compare. Conclusion: Standard laboratory tests may miss many cases of neuroinfection. Also Xcyton assessment alone may not be sufficient in evaluation of patients with suspected neuroinfection.

Keywords: Meningitis, Syndrome Evaluation System, XCyton.

In this present world, Low Back Ache is a common debilitating problem. It is mostly because of degenerative disc disease. There is no definitive management available to evaluate the patient before surgery and predict the probable outcome. Objective: There is a discrepancy between the MRI findings and Clinical findings which creates false positive and false negative results. These shows there are no definitive investigation criteria and patient selection for degenerative disc disease and the surgical success rate is moderately high. So it is important that we identify the group of patients who will benefit from surgical procedure and we can give them a reliable prognosis. Methods: Nerve conduction study is done pre­ op and repeated twice after surgery on second and tenth post op day. Amplitude, latency and velocity results of all three Nerve conduction studies were analysed and compared. Results: Electrophysiological studies augments selection criteria of patients undergoing surgery for Low back pain. It is also helpful in Prognosticating Outcome. Conclusion: Combining Electrophysiological studies with Clinical and Imaging modalities gives better outcome.

Keywords: Lumbar Spine; Degenerative Disease; Neural Compression.

 Patients suffering Brain injury commonly develop Elevated intracranial pressure (EICP) . We need an easy,  reproducible method to detect EICP earlier. Objectives: Measurement of optic nerve sheath diameter (ONSD) to identify earlier, the development of EICP. Methods: We did a prospective, blinded observational study in our Institute emergency department (ED) on patients with possible EICP due to brain injury over a 6 months period. ONSD was measured 3mm behind the globe by using a 10 MHz linear probe on both the eyelids of supine patients. An upper limit value of above 4.5 mm was taken as abnormally high. Brain Computed tomography (BCT) indicative of EICP were a midline shift of 3 mm or more, effacement of sulci, presence of significant edema, and effaced cisterns. Student’s t test analyzed ONSDs in the normal and EICP groups and necessary values were documented separately for each patient. Results: Forty four patients in total were included in the study group. CT Brain showed features of raised ICP in 24 of them. All these patients were correctly identified by ONSD measurement with over 4.5 mm on USG. The sensitivity was 100%. Specificity was 95%. The positive predictive values were 93%. Negative prediction was 100%. Conclusions: USG measurement of ONSD is good and a possible bedside alternative in the early identification of EICP. 

Keywords: Brain Injury; Computerized Tomography; Intracranial Pressure; Ultrasonography.

Introduction: Patients with Parkinson’s disease have episodes of worsening of motor and nonmotor symptoms. Such exacerbations can be mistaken as intrinsic worsening of the disease per se, leading to unnecessary dose adjustments. Whereas in reality, these are due to secondary causes. In spite of the clinical significance and social impact of motor exacerbations, there is little research work available from the literature. Aim: To study on the causes, consequences and predictors of motor exacerbations in Idiopathic Parkinson’s disease. Materials and Methods: Place of study; Institute of Neurology, Madras Medical College & Rajiv Gandhi Government General Hospital, Chennai. Study design and duration; Between August 2012 and December 2014, prospective observational study. Results: The study group consisted of 87 subjects which includes 28 females. The Exacerbations group had a later age of onset and longer duration. The mean UPDRS ADL for exacerbations group is 27.2 whereas the mean for control group is 22.6. The basic MMSE had a significant p value. Various causes for motor exacerbations were: medication errors, medical illness, psychiatric problems, alcohol, smoking, and surgical procedure. The commonest cause in our study was medication errors followed by medical illnesses. Two patients had worsening of motor features following episode of binge drinking. One patient had worsening of motor features due to surgical problem. Two patients had worsening who were having depression and anxiety. A combination of these occurred in majority of the cases. Patients presenting with worsening of tremor had better prognosis and they recovered almost fully. Conclusion: This study reveals that Medication errors, Systemic medical problems, Psychological causes, Alcohol and surgical problems can worsen the motor exacerbations. Medication errors followed by diverse medical conditions are the common causes. Motor exacerbations due to various causes is reversible in most of the cases.

Keywords: Parkinson’s Disease; Motor Exacerbation; Medication Errors.

  Aim: To study the etiological, clinical and radiological profile of patients diagnosed to have PRES Methodology: A descriptive study done by analyzing the medical records of patients diagnosed to having PRES this study was done in a tertiary care medical college hospital between jan 2012 to jan 2014 over a period of 2 years. The study population was the patients who were admitted with the clinical features of suggestive of PRES. The clinical data, etiological and radiological features of these patients were collected for the study purpose. Results: There is a varied etiology of PRES ranging from the commonest Pregnancy related PRES to the rare causes such as SLE, porphyria, OPC poisoning and a case of PRES following a blunt injury abdomen. Females in the age group 20 – 40 were commonly affected. Head ache and seizures were the commonest clinical presentation of PRES. Documented hypertension was noted on 50% of the patients in our study. Vasogenic odema involving both the occipital and parietal lobe was the commonest radiological presentation. All the symptoms and signs were completely reversible following prompt and appropriate treatment. Conclusion: The commonest cause of PRES is PIH. The other causes include any clinical condition causing an abrupt raise in BP or drugs causing endothelial damage. High index of suspicion to PRES is essential for the early diagnosis. It is a reversible condition if diagnosed and treated early. 

Keywords: PRES; Pregnancy Induced Hypertension [PIH]; Varied Etiology; Vasogenic Edema; Headache; Seizures; Papilloedema; Early Diagnosis; Reversible.

Context: The elderly are the most rapidly growing segment of the population. When compared to other age groups, the incidence and prevalence of seizures and epilepsy are higher in the elderly. Clinical manifestations and causes of seizures are different in older age group than in younger ones. In addition, establishing the diagnosis of seizures in old age can be more difficult than in younger people because of the extensive range of differential diagnoses. Aims: To analyse and find out the various aetiologies and clinical characteristics of late onset seizure. Settings and Design: This was an observational study, designed to analyse patients more than 60 years of age and who presented with new onset seizure in their lifetime. The sample size was 80 and the study period was from December 2016 to February 2018. Clinical data was collected from patients and witnesses in a systematic manner and added to a database, which included a checklist of seizure antecedents and the symptoms associated with seizure. Methods and Material: Total number of 80 patients whose age ranged from 60 to 84 years were included. Analysis initiated with history, neurological examination and clinical examination of other systems. Investigations like blood sugar, urea, serum creatinine, sodium, potassium, calcium, magnesium, 12 lead electrocardiography and other relevant investigations were carried out. All the patients underwent neuroimaging with CT brain. Interictal EEG was done for all the patients. Statistical analysis used: The data was entered in MS Excel and appropriate simple frequencies and statistical were used for data analysis. Results: Aetiologies found in this study were: seizure due to metabolic disturbances 33.7%, cerebrovascular disease 26.2%, malignancy related seizures 6.2%, seizure in calcified cerebral granuloma 3.7%, others 7.5%. In remaining 22.5% patients, cause could not be found (idiopathic seizure). Generalized tonic clonic seizure (GTCS) was the commonest semiology, seen in 83.8% patients and focal seizures in 12.5% patients. In remaining 3.8% patients, started as focal followed by secondary generalisation. EEG abnormalities were noticed in 25 patients. CT brain abnormalities were noticed in 28 patients. Conclusion: Our study illustrates the various causes and clinical characteristics of late onset seizure. In a patient with late onset seizure, all efforts to identify the aetiology should be made out. Thorough search to rule out metabolic disturbances and other treatable causes for seizures should be given early priority. Blood biochemistry, CT brain and EEG are indispensable in patients more than 60 years with new onset seizures. 

Keywords: Seizure; Late Onset; Elderly; Aetiology; Stroke; Metabolic Disturbances and Neuroimaging  

  Aim: Current study aimed to analyze the clinical and radiological presentation of severe head injury in pediatric population and the outcome and their comparison with that of adult severe head injury. Methods: This is a prospective study consisting of 764 children with head injury admitted in the period of 5 year duration. All children under 14yrs of age were included in the study. In all the children variety of clinical and radiological parameters were collected and analyzed Glasgow outcome scale was noted in all these patients at the time of discharge and at the end of 3 months and the outcome is compared with adults with severe head injury. Results: Out of 764 children, 156 had severe head injury. Documentation and analysis of various clinical factors was done and the results were compared, with adults with severe head injury. In this study majority of patients were < 3 yrs old. But incidence of severe head injury was more in the 9­14 yrs age group i.e., 56.4%. In this study, 64% were male children and 35.9% are female children. Most common cause was fall from height 63.35%, followed by RTA 27.2%. In 132 cases managed conservatively, out of which, diffuse brain injury (56), Small SDH (28), Small EDH (24), Contusions (12), SAH (8), Skull fracture (40). Surgery was done for all compound depressed fracture and for significant intracranial hematomas. Thirty children with head injury needed surgical intervention (3.93%). In adults 9.69% (612 out of 6316 admissions) cases were managed surgically. Post­Operative Complications­Wound infection noted in 5 (16.7%), CSF leak in 3 (10%), post­Operative Seizures in 3 (10%), Meningitis in 2 (6.7%) and one patient (3.3%) developed acute hydrocephalus who underwent ventriculoperitoneal shunt. In children with severe head injuries, 20.5% mortality rate was noted and good recovery is noted in 58% at the time of discharge and 64% at the end of 3 months. Conclusions: Good recovery is noted in 58% of children compared to 47% in adults with severe head injury. Poor GCS at presentation, presence of shock, presence of diffuse cerebral edema on CT scan where the factors found to be associated with poor prognosis. Though age less than three years and pupillary abnormality were associated with increased mortality they were not found statistically significant in this series. Most of the accidents and deaths from head injury are preventable, what we need is caution, prevention is the best way to decrease this morbidity.

Keywords: Pediatric Head Injuries; GCS Scale; Mortality

  Background: Current hypotheses on pathophysiology of restless legs syndrome (RLS) implicate iron as a cofactor in dopamine synthesis. Vitamin B12 also plays an important role in dopamine synthesis, but its role in the pathogenesis of RLS has not been studied. We hypothesize that Vitamin B12 deficiency can potentially reduce the synthesis of dopamine and thus RLS may be an early manifestation of this deficiency. Aims: To  measure serum vitamin B12 levels in patients with RLS and assess the response of RLS to its replacement. Methods and Material: To test this a Prospective, Open Label, Non­Randomized clinical Study was conducted. Fasting serum Vitamin B12 levels were measured in 44 consecutive patients who fulfilled the International RLS study group criteria. The response of RLS to dopamine agonists and to additional Vitamin B12 replacement therapy in those with low B12 levels, was measured. Results: Low serum Vitamin B12 levels (<211 pg/mL) were detected in 45% of patients with RLS. Those with normal B12 levels had a longer duration of symptoms, female preponderance and greater likelihood of positive family history. They were more likely to have a relapse of RLS symptoms after withdrawing dopamine agonists. Those with low vitamin B12 levels had shorter duration of illness, no gender preference, no family history and could be rapidly weaned off dopamine agonists without worsening of RLS symptoms, after B12 supplementation. None of the patients with low vitamin B12 levels had classical manifestations of B12 deficiency. Conclusion: As a significant number of our patients with RLS have low Vitamin B12 levels and respond well to its replacement, we propose that RLS may be an early neurological manifestation of vitamin B12 deficiency. 

Keywords: Restless Leg Syndrome; Vitamin B12 Deficiency; Clinical Manifestation

Aim: To analyse various presentations and surgical outcome of supratentorial meningiomas. Materials and Methods: n order to analyse the various presentations and surgical outcome of supratentorial meningiomas we did a prospective study in 42 patients and analysed headache, seizure, limb weakness, cognitive deficit and visual symptoms. we also correlated the location of meningiomas with age, sex, surgical outcome with respect to Simpson’s grading, Discharge & death and stay in hospital. The results obtained were statistically analysed. Results: When the results  were observed, among all the meningiomas convexity meningioma were the most common types with female predominance presented in the 5th decade of life. HPE grading GRADE 1 was the most commonly observed. Overall patients were discharged in 2 to 4 weeks but convexity meningiomas were discharged in less than 2 weeks. Most of them had complete resection with Simpson’s grade I & II. Headache and seizure were commonly observed in convexity meningiomas. Cognitive deficit was observed frequently in convexity and falx meningiomas. Limb weakness observed most commonly among falx meningiomas. Paraseller, tuberculumsella,predominantly had visual disturbances. Conclusion: In this study of 42 patients we found good surgical outcome in terms of shorter hospital stay, Simpson’s grade I & II resection and low mortality rates was observed with convexity and Falx meningioma. Longterm follow­up needed in assessing seizure control and other symptoms.
Keywords: Meningioma; Supratentorial Meningioma; Supratentorial Tumors.

  Background: Intradural extramedullary spinal cord tumours prevelance approximately two thirds of all intraspinal neoplasm. Current study designed to analyze the clinical history, radiological aspects and resectability to identify the incidence of variou tumors in intradural extramedullary compartment and their management to understand the surgical outcome. Methods: 35 patients with intradural extramedullary tumors were thoroughly evaluated to know the symptoms and signs with particular stress on motor and sensory deficits and evaluated with MRI. Intradural extramedullary tumors were surgically managed by posterior or posterolateral approach and they were followed up regularly to measure the outcome. Based on Nurick grading scheme, patient’s ambulatory status was classified. Results: Most of the tumors belong to intradural extramedullary spinal tumors (60%) in total spine tumors and Nerve sheath tumours incidence is 37%. Mean age of meningioma patients was 38 years and nerve sheath tumour patients was is 40 years. Male predominance (70%) in nerve sheath tumour. Thoracic region is the mostly affected area. 85% of cases were excised their tumor. Mean follow up period was 11 months, no recurrence of tumor noted clinically. Immediate improvement is seen in (60%) and gradual improvement is seen in (30%). Conclusion: In the current study, intradural extramedullary tumors detected by MRI are mostly benign and good clinical results can be obtained by treated surgi­cally. Total surgical excision potentially minimizes neurologic morbidity and improved outcome. 

Keywords: Extramedullary Spinal Tumors; Meningiomas; Nerve Sheath Tumours.

Background: 5­209 of patients may have persistent symptoms including cognitive deficits following mild traumatic brain in6ury (mTBI). The Montreal Cognitive Assessment (MOCA) is a simple tool specifically designed to screen for mild cognitive impairment. Obective: To compare MOCA with the commonly used Mini Mental Status Examination (MMSE). Setting: The study was conducted at the institute of neurosurgery, Madras Medical College from April to June 2017. Subects: A non­randomi@ed cohort of 50 patients presenting to the trauma ward with an antecedent history of trauma to the head (irrespective of cause). Results: A total of 28 patients were deemed to have cognitive impairment by the MOCA, 8 patients were deemed to have cognitive impairment by the MMSE representing a highly significant difference (p value A0.01). Both the scores agreed in a total of 30 cases, of which 22 cases were deemed to have no cognitive impairment by both tests and 8 patients were deemed to have cognitive impairment by both tests. Of particular importance is that no patient found to be cognitively impaired by the MMSE was deemed normal by the MOCA. Conclusion: The number of patients being categori@ed as being cognitively impaired by the MOCA, while being higher than that of the MMSE, conforms more to the pattern of cognitive deficits that are currently seen in patients with mTBI. MOCA may be superior to the MMSE to detect mild cognitive deficits in the setting of neurotrauma and at the very least maybe used in its stead. 

Keywords MOCAB MMSEB Traumatic Brain In6uryB Cognitive Defects.