International Journal of Neurology and Neurosurgery

 In infants and toddlers, growing skull fracture is a rare complication following head trauma. Letomeningeal cyst is characterized by progressive diastatic enlargement of the fracture line, producing a pulsatile cystic mass which is filled with cerebrospinal fluid in the diploic space. We report a case of 4 year old boy presented with huge soft, nontender pulsatile growing mass on the parietal aspect 9 months after sustaining head injury. CT imaging delineated it as a post traumatic leptomeningeal cyst in parietal bone.

Keywords: Growing Skull Fracture; Leptomeningeal Cyst; Craniocerebral Erosion.

 Background: Sports-related traumatic brain injury is an important public health concern that is often labeled as a silent epidemic. Soccer is a contact sport that may lead to concussion. The prevalence of soccer-related concussion in our region is not known. The aim of this study is to determine the occurrence of concussion among amateur adult male soccer players. Material and methodology: In August 2018, at King Abdulaziz Univesity, this cross-sectional study was conducted among amateur soccer players living in different regions of Jeddah, Saudi Arabia, using a self-administered Google form questionnaire. The questionnaire assessed demographic data, symptoms, knowledge, and awareness of concussion and its long-term complications. The mean and standard deviation were calculated for quantitative variables (e.g., age). The prevalence of concussion among our targeted population was given as a percentage with 95% confidence level. The correlation between different variables was calculated. Results: In July 2018 a total of 437 players in Jeddah city participated. The mean age of the participants was 24.39 years old (SD 5.97 years). The most common age for first concussion was between 15-19 years old (n=50, 73.5%). The mean age of first concussion was 18.3 years old (SD 5.1 years). First concussions occurred during a training match 46 (67.6%) and a competitive match 22 (32.4%). Fifty-five (80.9%) reported the most common symptom, headache. Twenty-two (32.4%) concussed players returned to play within an hour after injury. There was no significant correlation between positions of players in the field and concussions (r=.072, n=437, p=.132). Thirty-seven (54.4%) previously concussed players reported sleep disturbance and 39 (57.4%) concentration difficulty. Conclusion: The prevalence of concussion among amateur male soccer players in Jeddah, Saudi Arabia, is higher than in other regions. Concussed players may suffer from short- as well as long-term consequences. Educational programs and legislative reform are needed to reduce these possible consequences.

Keywords: Soccer; Concussion; Amateurs; Jeddah; Saudi Arabia.

 Introduction: CVJ anomalies are very common in Neurosurgical practice. The treatment modality & surgical technique, still remains a challenge. Objectives: To study the various congenital & Acquired CVJ anomalies, their clinical presentation, management and Post surgical functional outcome. Materials and Methods: About 50 patients of CVJ anomalies who were presented at the “Instiute of Neurosurgery, Madras Medical College, Chennai-3 were analysed by their demographic, clinical & radiological parameters, and various surgical procedures. Results: About 34 patients had congenital anomalies & 16 patients had acquired anomalies.. AAD is the commonest abnormality noted. ADI determines the postsurgical outcome. C1 C2 Stabilisation carries good results. Conclusions: Bony anomalies are more than soft tissue anomalies. Craniometric assessments are very arbitrary. Congenital anomalies are very common than that of acquired ones.

Keywords: Craniovertebral Junction Anomalies; Atlanto Dental Interval; Atlanto Axial Dislocation.

 Background: Migraine tops among the recurrent primary headaches in children and adolescents. Characteristics of migraine in children and adolescents differ significantly from adults. Migraine attacks are precipitated by triggers like dietary, environmental, emotional and behavioral stimuli. Characterization of clinical profile and triggers of migraine will help greatly in managing this group of migraine sufferers. Aim of the study: To study the clinical profile of migraine in children and adolescents and To find out and analyze the common triggers of migraine in them Materials and methods Study sample: Thirty children between 5 to 12 years and seventy adolescents between 13 to 18 years study place: Institute of Neurology, Govt Rajiv Gandhi General hospital and Institute of Child Health. A detailed history is taken from all patients regarding the characteristics of their migraine attacks and a thorough clinical examination was done.A questionnaire containing the common triggers of migraine were provided to them/ their parents in case of children and their responses were recorded. Results and analysis: There were 30 children and 70 adolescents in the study group. Of the total 100 children, 59 were female and 41 were male. Migraine without aura is the commonest type observed in this study. Abdominal migraine was seen in 2 and cyclical vomiting was seen in only 1 patient. Maternal history was more with 83% and paternal was 16%. Most children in the study group had 4 to 8 attacks per month, which falls under the category of mild disability in the migraine disability scales. Almost half of patients had migraine onset below 12 years of age. Migraine with aura forms only a small portion of patients. 9 adolescent girls had menstruation as their trigger factor. Aura is not seen in pediatric patients of this study group. Majority of children had more than one trigger. Most common triggers observed in this study are too much physical activity, changes in routine, skipping meals, sleep disturbances, noisy surroundings and bright lighting conditions. Modern era triggers like mobile games and TV watching play a role in both children and adolescents. Most common dietary triggers in children was found to be chocolate and ice creams. Conclusion: Migraine in children and adolescents differs from adults in several ways. Childhood periodic syndromes like abdominal migraine, cyclical vomiting syndrome are frequent in this population. Under diagnosis of migraine in children may be due to the poor expressibility of headache characteristics by them. Common migraine triggers in our population are noisy environment, excessive physical activity, skipping meals, sleep disturbance and change in the daily routine. Novel triggers like mobile games, video games are important precipitants of migraine attacks in children.

Keywords: Migraine; Aura; Disability; Triggers

 WHO defined stroke as “rapidly developing clinical symptoms and or signs of focal and at times global loss of brain function with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin”. Stroke is considered to be second commonest cause of death worldwide. CT imaging of the brain is the standard and plays a major role in CVA,to assess the site, size and nature of the lesion. Though MRI is superior to CT scan, the higher cost of MRI and easy availability of CT scan brain makes CT the commonest investigation in diagnosis and treatment of stroke. Aims and Objectives : 1. To correlate the nature of lesion based on the clinical grounds and CT scan brain findings. 2. To correlate the site and size of lesion based on the clinical grounds and CT scan brain findings. Material and Methods: This study was done in the department of General Medicine at Rajarajeswari Medical College and Hospital. Fifty patients presenting with Acute stroke (according to WHO definition) admitted to medical wards were considered for the study for a duration of one year. This was a cross sectional study. Results: Out of 50 cases studied, 17 (34%) patients had hemorrhagic stroke and 33 (66%) patients had ischemic stroke. Out of 50 cases studied, 33 patients had ischemic stroke clinically, but 29 patients had ischemic changes on CT scan brain. 17 patients had haemorrhagic stroke clinically but 16 had haemorrhage on CT scan brain. 5 patients had stroke clinically, but CT scan brain was normal in them. Out of 50 cases 8 (16%) had altered sensorium, 14 (28%) had speech defect, 43 (86%) had hemiplegia, 10 (20%) had headache, 2 (4%) had seizures, 12 (24%) had facial nerve palsy, 1 (2%) had cerebellar signs and 6 (12%) had brain stem signs.

Keywords: Stroke, Infarct; Cerebral Haemorrhage.

 Introduction: Malignant MCA infarct is a common cause of morbidity and mortality. Decompressive hemicraniectomy (DC) is a well-established mode of treating malignant MCA infarct. This article shares our experience with an insight into the problems faced and the lessons learnt in the process. Materials And Methods: Patients with Malignant MCA Infarct and subjected to decompressive hemicraniectomy at the Institute of Neurosurgery, Madras Medical College, Chennai, from January 2017 to January 2018 were included. Outcome was assessed in terms of mortality and modified Rankin scale (mRS). Results: A total of 28 patients underwent DC for malignant MCA infarct between January 2017 and January 2018 at our institute. The mean age of the study group was 47.1±13.73yr. Seventeen patients (60.7%) had left MCA territory infarct while 11 patients (39.3%) had right MCA territory infarct. 18% of patients had an mRS of 0-3 at discharge and 7% had mRS of 4 and more. Approximately, 20% of patients operated within 24 h had mRS 0–3 at discharge while only 12.5% patients operated after 48 h had mRS 0–3 at discharge. Conclusion: A subset of patients survives but remains in bedridden state. Mortality and functional outcome can be better with early access and prompt intervention. Interval between clinical deterioration and surgery is more relevant than early surgery in determining the outcome. Although age is an impediment to favourable outcome, deserving candidates should not be denied surgery because of age.

Keywords: Malignant Middle Cerebral Artery Infarct; Neurological Outcome; Morbidity; Decompressive Hemicraniectomy; Mrs.

Introduction: Chronic Subdural Hematoma (Chronic SDH) is one of the most common clinical entities faced by neurosurgeons in their day to day practice. It is more common in old age where brain atrophy with increased space between the brain and skull facilitates of Chronic SDH. Burr hole craniostomy is accepted as the most common treatment especially in the older patients with pulmonary and cardiac complications and the aim will be minimal intervention with minimal anesthesia. Aim of the Study: To Evaluate Pre –Operative And Post Operative Radiological Findings in Chronic Subdural Hematoma Patients Who Under Gone Burr-Hole Surgery. Materials and Methods: We selected 100 cases with chronic subdural hematoma who were admitted in Emergency head injury ward of Department of Neurosurgery, Government Mohan Kumaramangalam Medical College, Salem and all underwent double burr hole craniostomy. Based on the CT scan findings, persistent midline shift of 5 mm and/or residual hematoma thickness +10 mm was considered an indication for reexploration. All the patients were followed up with a CT scan of the brain taken on the 4th postoperative day. The CT scan was perused for residual hematoma and midline shift. Results: There was a significant reduction in the midlan line shift with a standard deviation of 3.39 in patients who underwent evacuation of CSDH with drain whereas the other group yielded a standard deviation of 3.14 with a significant p-value of less than 0.033. the clot thickness prior to and after surgery in patients who underwent without drain was 5.22 and 3.79 with a p-value of equal to 0.001 thus proving the former the better and statistically significant. Out of 52 of those who underwent surgery with drain, 10 developed pneumocephalus of which 2 were of moderate severity. On the other hand, out of 48 of those who underwent surgery without drain, 27 marked an incidence of pneumocephalus, which is almost more than 50% thus establishing the superiority of the drains over no drains in terms of preventing recurrence. Conclusion: The reduction in the hematoma thickness and midline shift was also marked and the difference was statistically significant in those with drains than in the other. The recurrence rate was markedly less and the difference was statistically significant in those with drains than in the other. The rate of occurrence of pneumocephalus was definitely very low and was statistically significant in those with drains than in the other.

Keywords: Pneumocephalus; Chronic Subdural Hematoma; Midline Shift; Clot Thickness.   

 Introduction: Standard vestibular evoked myogenic potentials (VEMP) are widely used in the assessment of vestibular disorders in clinical practice. But studies have shown that role of VEMP alone in the diagnosis of vestibular dysfunction is not entirely satisfactory. In the recent years’ ocular myogenic potentials, produced by the synchronous activity in the extra ocular muscles in response to vestibular stimulation, is being studied extensively for identifying vestibular diseases Aims & Objective: In this study we evaluate the usefulness of acoustic vestibular evoked ocular myogenic potentials (Ac oVEMP) along with traditional cVEMP (Cervical vestibular evoked myogenic potentials) and BAER (Brain stem auditory evoked Response) for diagnosing vestibular neuronitis. Materials and Methods: 100 subjects were included in this study (Group A 50 -normal subjects; Group B – 50 patients with vestibular neuronitis). Ac oVEMP was performed on both the groups and the results were analyzed for difference and statistical significance. Patients in Group B were additionally subjected to cVEMP and BAER. Results: Ac oVEMP in Group A subjects produced n and p response that was consistent and reproducible. There was no inter-aural difference. Ac oVEMP in Group B showed prolongation of n and p latencies when compared with normal subjects (p≤0.01). 23 patients in group B demonstrated abnormal Ac oVEMP (46%) whereas 10 patients in group B had abnormal cVEMP (20%). This was attributed to the more common involvement of superior division of vestibular nerve in vestibular neuronits, which is best tested by Ac oVEMP. Conclusion: Acoustic vestibular evoked ocular myogenic potential (Ac oVEMP) plays an important role as an electrophysiological tool in the diagnosis of vestibular neuronitis.

Keywords: Acoustic Vestibular Evoked Ocular Myogenic Potentials (Ac oVEMP); Vestibular neuronitis; Vestibular nerve divisions; Evoked potentials.

 Introduction: Meningiomas of WHO grade I can, display invasive growth [2], even though there is no histopathologic difference between invasive and non-invasive tumors. Lack of homogeneity in the WHO grade I meningioma group itself, which is histologically divided into different subtypes with variable biological behaviour [3], Intra-tumoral heterogeneity, which might be spatial (due to the genetic aberrations in the different geographical regions of the same tumor) or temporal (between the primary tumor and the local recurrence), has not been studied adequately in meningiomas [4]. It is necessary to develop a comprehensive scoring system which can predict outcome in meningioma patients based on CLASS Algorithm, Histopathology, Simpson Grading and Radiology characteristics Objective: To develop a comprehensive scheme to prognosticate and to predict recurrence for meningioma based on pre-operative CLASS algorithm assessment with Preoperative imaging, Intraoperative completeness of resection-Simpson grading- WHO Classification 2016. Materials and Methods 1. A retrospective study based on hospital records and patient follow up who were treated surgically in Institute of Neurosurgery Madras Medical College. 2. Fifty cases of meningioma that were treated surgically in our hospital between June 2017 and February 2018 were included in the study. 3. Computed tomography (CT) was performed before and after contrast administration in all cases. 4. Magnetic resonance imaging (MRI) including pre- and post-contrast T1- weighted imaging using spin-echo (SE) sequences and T2-weighted imaging using fast spin-echo (FSE) sequences was performed in all cases. 5. Early outcome at 6 weeks and late outcome at 12 months was assessed using the Glasgow outcome scale (GOS), and postoperative neurologic and medical complications were recorded. 6. Chi-square and Fisher’s exact test were used for the comparison of the groups. 7. A logistic regression model was built to compare each group in terms of the odds of having “bad” GOS (GOS 1–3) and neurologic/medical complications. 8. A p-value of 0.05 and below was accepted as statistically signi cant. Results: Out of 50 patients 27 (54%) were male, 23 (46%) female. Youngest patient age was 10 years and oldest was 75 years. Mean age presentation was 47.62 years; median age was around 48 years. Most common location being convexity followed by parasagittal and skull base regions. GROUP III patients of CLASS algorithm had the worst outcome The completeness of resection was a major predictor of outcome with better outcomes seen with greater extent of resection. Higher Grade according to WHO classification was associated with a worse outcome. However, it was not a predictor of recurrence. High Risk’ imaging characteristics had a significantly worse outcomes Conclusion: Our study was able to concur that these indicators when factored together can predict the outcome and disease-free survival. The WHO Grading and Simpson’s Grading while important predictors of outcome, by themselves fail to predict the chances of recurrence. CLASS HSR is a useful predictor of Recurrence and Outcome of patients with Meningioma.With the individual components all having significant correlation with outcome, the combination offers an advantage in predicting disease free survival period.

Keywords: Meningioma; Who Classification 2016; Simpson Grading Class Algorithm.

 Migraine variants are atypical presentations of migraine in form of associated clinical features with or without headache in episodic pattern. These disorders are difficult to diagnose and require out of the box thinking and high index of suspicion. None of the cases described in this article are classified in ICHD-3 (international classification of headache disorders 3) and, in that way, are unique migraine variant cases. First two clinical cases are unexplained vertigo; the third case is of undetermined neurocardiogenic syncope and fourth case is dual variant of Alice in Wonderland Syndrome with abdominal migraine. All four cases are not associated with headache and suspected due to past or family history of migraine. Fifth case is of migrainous headache in which headache and the upper motor neuron facial palsy occur on the same side. This is a unique brainstem aura migraine variant. None of the cases described in this article are classified in ICHD-3 (international classification of headache disorders 3) and, in that way, are unique migraine variant cases. Migraine variant should be suspected in episodic neurological disorder of unexplained aetiology with normal neurological examination and undetermined investigations.

Keywords: Migraine Variants; Atypical Migraine; Vertigo; Syncope; ICHD-3

 Objectives: The Petroclival lesions are difficult to excise surgically because of their location. Anterior petrosectomy by an extradural subtemporal route is the standard procedure for removal of Petroclival meningiomas but has many complications. This cadaveric study was done to identify landmarks for safe surgeries using intradural approach via the transylvian-transtentorial route for petroclival lesions. As neurosurgeons are more comfortable with transsylvian approaches and the corridor is definitely wider through this approach. Patients and Methods: This study was conducted in the department of anatomy over a period of two years. Cadaveric anterior intradural petrosectomy was conducted in 13 complete unfixed heads (26 sides), important anatomical landmarks for anterior intradural petrosectomy were identified and distance between these landmarks were measured and recorded as D1 to D7. Results: Cadaveric dissection of skull was performed on 13 cadavers (26 sides). Eight males (16 sides) and five females (10 sides). No significant difference was found in measurements between males and females. In most specimens the distance was between 10-13 mm from the entry of the third nerve to the fourth nerve. In practice a cut on the tentorial edge > 1.7 cm will not injure the fourth nerve. The distance of dura cut from tentorial edge to superior petrosal sinus was 09 to 22 mm (mean 13.96 mm). Total dura to be cut from tentorial edge was 21 to 40 mm (mean 27.57 mm). Distance from petrous ridge to superior medial edge of internal auditory meatus (IAM) was found to range from 05 to 15 mm (mean 09.03mm). Internal carotid artery (ICA) was found at a minimum distance of 04 mm with a mean of 08.88mm from the point of drilling on petrous ridge. The distance from lateral edge of gassarian ganglion (GG) to the arcuate eminence was between 16 to 28 mm (mean 21.5 mm) Conclusions: In order to avoid injury to nerves, ICA and brainstem, dura should be cut at right angles just proximal to fourth nerve, arcuate eminance (AE) identified and dura stripped. Drilling should be done from petrous ridge, not more than 05mm deep, not more than 04 mm laterally, should not exceed 07 mm towards GG and should lie inside the line joining arcuate eminence (AE) to petrous ridge.

Keywords: Petroclival Region; Gassarian Ganglion (GG); Internal Carotid Artery (ICA), Arcuate Eminence (AE); Intradural Anterior Petrosectomy; Internal Auditory Meatus (IAM).

 Background: DAI is considered the most important factor in determining morbidity and mortality in victims of TBI and is the most common cause of posttraumatic coma, disability, and a persistent neurovegetative state. Aim: To predict the outcome with GCS at admission and CT Scan and MRI findings. Materials and methods: It was a prospective cohort study in a group of 59 patients with head injury cases with GCS < 12. All the head injury cases with normal CT scan and > 6 hrs were taken in study. Mode of injury, incidence among various age groups, sex distribution, post resuscitative Glasgow Coma Scale were noted in patients. Mortality and morbidity analysed with respect to GCS and CT & MRI Scan findings. Results: DAI constitutes 1.72% of total head injury admissions & 20.06% in severe head injury. MRI is more sensitive compared to CT. Mortality in our series is 32.20%. Most of DAI are due to road traffic accidents. Second and third decade populations are more in DAI. Neurological deficits improved almost completely (over the 1½ years to 2 years) and early recovery seen in younger age groups compared to elder age groups. In 27.5% of cases recovery is good as per GCS. Conclusion: In Patients with diffuse axonal injury the help of GCS, CT Scan and MRI findings one can know which patients can be salvaged. Keywords: Diffuse Axonal Injury (DAI).

 Introduction: Vitamin B12 deficiency can affect all age groups. This can present with varying neurological Manifestataions apart form heamatological and skin changes. This case series study is presented with an aim to identify the diverse clinical manifestations. Materials and methods: Patients admitted in neurology department government general hospital with neurological manifestations attributable to Vitamin B12 deficiency and reduced Vitamin B12 levels were taken and analysed. Results: The dietary differences was not the sole or significant influencing factor. Myeloneuropathy was seen in 80% with posterior column and pyramidal signs. Cognitive signs, psychiatric features, cerebellar, extrapyramidal features, urinary urgency, optic atrophy were seen in few patients. Discussion: The most common presentation had been myeloneuropathy with posterior column and pyramidal signs. 26.66% had pyramidal signs in lower limb alone, remaining had in upper and lower limbs with earlier involvement in thoracic portion of the spinal cord. The atypical features like cerebellar, extrapyramidal features have been observed in previous studies. Conclusion: Vitamin B12 deficiency to be suspected when confronted with any of the neurological manifestations even in an atypical presentation with any atypical features with pyramidal signs even without significant posterior column signs or neuropathy.

Keywords: Vitamin B12 Deficiency; Subacute Combined Degeneration; Myeloneuropathy.

Background: Tuberculosis is a very common disease affecting the impoverished and is a source of morbidity causing significant burden to the society. Involvement of the spine is fairly common and it causes significant discomfort to the patient affecting their quality of life. Definite role of surgery continues to be debatable in the era of novel ATT drugs. Objective: To define the role of surgery in TB spine and to assess outcome in terms of symptom relief. Methods: Forty patients with TB Spine who were admitted in our department were retrospectively evaluated thoroughly and the outcome of both conservative treatment and surgical management was analyzed. Results: Dorsolumbar TB was the commonest site of involvement and among those cases, 3 patients had demonstrable pulmonary lesions. Surgery gave good neurological outcome in cases that presented with deficits and for cases that didn’t respond to ATT. Conclusions: Surgery continues to be a mainstay in treatment of TB spine and we had successful outcome in our observation.

Keywords: Pott’s Spine; TB Spine; Posterior Stabilization for TB Spine; Spinal Fusion for TB Spine; Management of TB Spine.

 Introduction: Refractory status epilepticus is defined as the status epilepticus which is refractory to two intravenous anti-epileptic drugs, one of which is a benzodiazepine. RSE occurs in 23–43%, this progression being time dependent with early management being advocated to achieve control. Methods: The study included the adult patients of convulsive refractory status epilepticus admitted at the Neurology, General Medicine and Surgical intensive treatment units of Calcutta National Medical College, Kolkata, between 1st January to 31st August 2018. The patient’s demographic data, medical history, treatment received and outcome were documented. We titrated all the drugs to the suppression of the seizure activity. The data are presented according to the treatment type [general anesthesia and antiepileptic drugs], and according to the outcome [favorable (modified Rankin Score or mRS<2), and unfavorable (mRS≥2)] and analyzed by univariate and subsequent multivariate analysis. Statistical analysis was done using SPSS version 22.0 software. Results: 24 patients were included in the study, 62.5% being males. Inflammatory central nervous system diseases followed by stroke were the commonest causes of convulsive refractory status epilepticus. Mortality rate was 25% and 41.67% had the favorable outcome. Multivariate analysis identified complex partial status epilepticus [Adjusted Odds Ratio=7.6 (95% CI=1.5-54.4), p=0.04], partial onset seizures [Adjusted Odds Ratio=9.8 (95%CI=1.4-69.34), p=0.034 and hyponatremia [Adjusted Odds Ratio=7.7 (95% CI=1.32-53.37), p=0.037) as the factors responsible for failure of control of convulsive refractory status epilepticus by antiepileptic drugs alone. The need for GA was associated with unfavorable outcome [Adjusted Odds Ratio=11.7 (95% CI=1.22-125.31), p=0.037]. Patients with lower Glasgow coma score and higher Status Epilepticus Severity Score at the time of admission in intensive treatment units, those with longer time being elapsed between seizure onset and hospital admission had significant higher incidence of need for general anaesthesia and the unfavorable outcome. Conclusion: The etiology of convulsive refractory status epilepticus does not affect the refractoriness and outcome, which are more dependent on the Glasgow coma score, Status Epilepticus Severity Score at admission and the time gap between seizure initiation and hospital admission.

Keywords: Epilepticus Severity Score; hyponatremia; modified Rankin Score.