International Journal of Neurology and Neurosurgery

Oligodendrogliomas generally remain confined to the nervous parenchyma throughout their entire course. However, there are exceptionally rare cases, which show either transdural extension or extraneural spread. In reviewing the world literature on suchspread from oligodendrogliomas, very few cases were found, and the exit door from the CNS was almost always through the cranial base, anentitity termed as metastatic anaplastic oligodendrioglioma. Here we present one such rare case of a frontotemporal oligodendroglioma (WHO grade 3) with primary orbito-ethmoidal invasion. Patient presented with right sided proptosis and nasal cavity mass lesion causing epistaxis post. MRI revealedtransduralextension of tumor with right orbital and nasal cavity infiltration through the ethmoidal bone. Atransnasal endoscopic excision of the nasal mass conformed to the immunocytogenetics of an oligodendroglioma. The reporting of such cases is important because firstly following the advent of IHC and the new WHO 2016 classification, the lines between low and high grade gliomas have become blurred. Secondly, the pathogenesis underlying the invasion of neuroepithelial tumors outside the dural structures calls for further research and may promote anti-invasive therapy in the future.

Keywords: Oligodendroglioma; Extraneural; Orbitoethmoidal; Immunohistochemistry.

Hemodynamic aneurysm (HA) associated with arterio-venous malformation (AVM) is considered as one of the risk factors for intracranial hemorrhage.1–2 Aneurysm appears as a consequence of disruption in the cerebral autoregulatory mechanism which is induced by AVM. According to the previously reported literature, untreated HA after AVM exclusion can regress, remain unchanged, grow or rupture.1–4 Aim of the work: The aim of this case report is to describe a rare case of simultaneous presence of cortical arteriovenous malformation and saccular bifurcation aneurysm of a 48 years old patient for which he underwent clipping of aneurysm and total excision of AVM in sitting within very short interval of time and achieved favorable outcome. Case Report: A 48-year-old normotensive, non diabetic male presented with sudden onset of severe headache followed by loss of consciousness. After thorough radiological evaluation, he diagnosed as a case of right sided MCA bifurcation aneurysm and small cortical parietal AVM. At first sitting, he underwent right sided pterional craniotomy and clipping of the aneurysm. 5 days later, he underwent right parietal craniotomy, evacuation of hematoma and total excision of AVM. His postperative period was uneventful and discharged to home without having any neurological deficit. Conclusion: Proper preoperative work up, including angiogram should be done for any suspected vascular lesion. Considering the management of our reported case, the author recommended the simultaneous treatment of AVM and HA, which would be most beneficial to the patient.

Keywords: Aneurysm; Arterio-venous malformation; Hemodynamic instability.

Presence of sphenoid wing dysplasia fulfills one of the diagnostic criterias of neurofibromatosis type 1 (NF1). This defect of the skull base can manifests as pulsating proptosis. Associated calvarial defects, especially away from the lambdoid suture are a much rarer presentation. This report describes the successful removal of plexiform neurofibroma followed by reconstruction of the dysplastic sphenoid wing in an NF1 patient. Later on, he underwent blepharoplasty for scarring of the upper eyelid. After successful management of the overall procedure in three stages, the patient achieved improved visual outcome along with acceptable cosmetic appearance.

Key words: Sphenoid wing dysplasia; neurofibromatosis; proptosis.

Background: Traumatic brain injury (TBI) is one of the leading cause of morbidity and mortality in the working class community in various part of the world including India. It is a common cause of coagulopathy, primarily due to blood loss and hemodilution secondary to fluid resuscitation. Traumatic injury-associated coagulopathy often follows a course of transition from hyper to hypocoagulable state exemplified in disseminated intravascular coagulation. The present study aims to ratify the cut-off value of INR to conform a prognostic value in isolated Traumatic Brain Injured patients. Patients and Methods: This was a pilot prospective observational study done at a tertiary care centre in coastal Karnataka. The study design was presented and prior approval was obtained from the Scientific Review Board and Ethics Committee of Kasturba Hospital, Manipal. Written informed consent was obtained from patients or their next-of-kin in accordance to the ethical committee pre-requisites. INR from the patients were tabulated and analysed using commercial software SPSS version 16.0 Results: 105 patients were enrolled for the study with an age range between 18 to 60 years. The patients who were dichotomised based on GCS and GOS. Based on GOS, 89.5% (94) of the patients fell into good prognosis group and 11 (10.5%) into the poor prognosis category. The GCS assessment saw 82 patients (78.1%) to be in the non-high risk category and 23 patients (21.9%) in high risk group. Using the ROC curve (Graph 1), the cut-off value of INR was found to be 1.06. This suggested that INR values lesser than 1.06 were likely to be associated with a better prognosis than those with an INR value which was higher than the cut-off. This was found to have a sensitivity of 59.6% and a specificity of 72.7%. The positive predictive value was at a staggering 94.9% and a negative predictive value of 17.4% with a 61.0% accuracy. Discussion: TBI is also known as acquired brain injury and can be classified in several ways2. Major mechanisms which are pivotal in primary injury are contact and acceleration-deceleration. These in turn cause anatomical and physiological impairment such as intracranial hematoma. There are several mechanisms proposed to explain acute traumatic coagulopathy in Traumatic Brain Injury. One of it is the tissue factor hypothesis. The other proposed hypothesis is explained via over-activation of the protein C pathway6. Trauma causes hypoperfusion and damages the endothelium, thus activating the protein C pathway. Protein C in-turn inhibits coagulation factors; Va and VIIa by cleaving them. Based on the results from this study, one could predict that patients with INR values lesser than or equal to 1.06 would improve significantly as compared to those with a higher INR value. However, at the same time it neither substantiates the need for prophylactic antifibrinolytic agents nor recommends the delay in any neurosurgical intervention8. Conclusion: INR is a good tool in predicting the prognosis in isolated TBI. Nonetheless clinical correlation should be considered before initiation of antifibrinolytic therapy and delaying neurosurgical intervention.

Keywords: Traumatic brain injury (TBI); Prognostic Factor; INR.

Introduction: Recent evidence is shedding insights into the functional alterations in the sensorimotor, visual and basal ganglia networks in Parkinson’s Disease (PD) patients. We evaluated the Functional Anisotropy (FA) and Apparent Diffusion Coefficient (ADC) values in PD patients with DTI using Region of Interest (ROI) basis and compare it with healthy controls. Methodology: A case control study was conducted comprising of 40 PD patients, and similar healthy controls. They were evaluated using 1.5 tesla MRI Machine and DTI were performed using a single-shot sequence with diffusion encoding in 31 directions. In each subject, four deep grey matter structures (Caudate nucleus, putamen, pallidum and substantia nigra) were segmented. Differences in FA and ADC between groups were assessed using t-test to compare means. Results: Mean FA values of PD cases when compared with control cases were significantly less on both sides. Mean ADC values of PD cases were significantly higher as compared to controls at caudate nucleus and substantia nigra on both sides. Mean ADC values for lentiform nucleus were not significantly different between PD cases and controls on both sides. ROC analysis found the cut off value of FA and ADC to be 0.26 and 8.05 at caudate nucleus, 0.26 and 7.5 at lentiform nucleus and 0.46 and 8.2 at substantia nigra respectively. Conclusions: Advanced image analysis is derived from improved image algorithms, which can help in automated differentiation of PD and related disorders. DTI is a promising tool to assess PD-related neurodegeneration and potentially could serve as marker for PD.

Keywords: Parkinson’s disease; Diffusion weighted imaging; Magnetic resonance imaging; Fractional anisotropy.

Introduction: Tumours arising in posterior fossa are of special concern because it is a small and closed space near critical brain structures including the brainstem and cranial nerves. The percentage of pre operative shunting in hydrocephalic posterior fossa tumours has been quite variable in different studies. The aim of this study is to check the factors that will help in prediction and thus isolate the patient group which wil require postoperative VP shunting. Materials and Methods: One hundred children of posterior fossa tumour were included in the study and out of these sixty were associated with hydrocephalus external ventricular drain (Surgiwear shunt and drain systems) was put just prior to surgery in all patients with established clinical and radiological signs of raised intracranial pressure. CSF was drained as required and the EVD was removed on fifth postoperative day. Postexternal ventricular drain removal, patients were reassessed in terms of clinical and radiological signs of raised intra cranial pressure and a VP shunt (Surgiwear’s Chabbra slit n spring system shunt) was put in the presence of the same. Various parameters like age, sex, type and location of tumour, type of surgery and extent of resection were recorded, data was compiled and results were tabulated. Results: Out of total of 18 children who required postoperative VP shunting, age less than 3 years, midline location of tumours and residual lesion were found to be the properties in the shunted group which showed statistically significant results. On the other hand, type of tumour(intra/extra axial) and sex of the patient proved to be insignificant for predicting the need of a postoperative VP shuting in patients of posterior fossa tumour. Discussion: Treatment of hydrocephalus in posterior cranial fossa tumours is still a matter of controversy and the incidence of this association is stil quite unclear and the factors determining the need of VP shunt in this study, i.e. age <3 years, midline location of tumour and subtotal resection are also validated by other authors. Conclusion: Children with posterior fossa tumours with hydrocephalus are particularly at risk of a permanent VP shunt if age of the patient is < 3years, tumour is located in midline and residual tumour postoperatively.

Keywords: Hydrocephalus; Posterior fossa tumour; CSF Diversion Surgery.

Introduction: Cervical spondylotic amyotrophy (CSA) is characterized by muscle atrophy in the upper extremities without gait disturbance. Aims: To analyze the pathophysiology, clinical features and various treatment options in cervical spondylotic myelopathy and the pattern of neurological recovery, prognosis and outcome following surgery. Materials and methods:The present study is a prospective study, observational study evaluate prognosis and outcome following surgery in cervical spondylotic myelopathy comprising of 47 cases studied over a period of 2 years. Results: Cervical spondylotic myelopathy is commonly seen in elderly age group (mean age is 50 years) and it affects more commonly males. The neurological recovery was apparently best in the upper limb function, followed by lower limb function and least in the sphincter function. The neurological recovery was less in patients with age greater than 60 years, duration of symptoms more than 1 year, sphincter disturbances and hyperintense signal changes in the cord on T2W1 images. Conclusions: There is no significant difference in the outcome between anterior vs. posterior surgery. Anterior surgery had more complications at the early stage after operation which gradually improved.

Keywords: Cervical spondylotic myelopathy; Neurological recovery; Surgical decompression.

Context: The skull vertex is an uncommon site for epidural hematoma (EDH) formation. The usual cause of a hematoma is a tear in the sagittal sinus due to trauma or saggital suture diastasis. Vertex EDH, even of small volumes, can cause rapid neurologic deterioration and death. Hence, rapid diagnosis is important to limit morbidity and mortality. There are only few isolated case reports or small series of VEDH in the literature. We analysed all cases of VEDH managed at our trauma centre over the last 10 years. Case records of all traumatic brain injury were analysed. Aims: To analyze a series of VEDH patients seen in our institute. Settings and Design: Retrospective observational study. Subjects and Methods: This is an analysis of case records of patients with VEDH during 10 years period from 2008 to 2018. Statistical Analysis Used: Nil. Results: Twenty cases of VEDH were encountered over a period of 10 years, which included 17 males and 3 females. The majority of cases were due to road traffic accidents, and most of these presented with altered sensorium. The diagnosis was made by axial and coronal sections of computerized tomography (CT) scan. 16 patients were operated and 4 managed conservatively. The most common source of bleeding was superior sagittal sinus. One patient expired during treatment. Conclusions: A high degree of suspicion should be maintained to diagnose vertex EDH as it may be easily missed especially working in a high workload trauma centre. Early diagnosis and judicious decision with regards to surgery and medical management is the key for successful treatment in these cases. This is second largest case series reported so far.

Keywords: Vertex EDH; Traumatic brain injury.

Introduction: The Posterior Atlanto Dental Interval (PADI) is the effective canal diameter, measured from the posterior surface of the Dens to the Posterior arch of the Atlas. Objective: To study the role of PADI, in producing the symptoms and also the postoperative outcome in patients with bony CranioVertebral Junction anomalies. Materials and Methods: About 34 patients from March 2016 to Oct 2018 who were operated at Rajiv Gandhi government General Hospital,were prospectively studied. The PADI and the preoperative & Postoperative“Kumar and Kalra Score “ (K and K score) was calculated for all patients. The patients were divided into three groups based on the PADI, into 5 mm to 10 mm group, 10 mm to 15 mm group and >15 mm group. Results: There were 26 male (79.1%) patients and 8 female patients (20.9%) with the mean age of presentation 26.10 years. The PADI was 8.012 mm with range of 5–15 mm. The mean Pre-operative K and K score was 19.52. There were 19 patients with, PADI of 5 mm to 15 mm,12 patients with PADI of 15 mm to 20 mm and 3 patients with PADI more than 20 mm.The correlation coefficient, between the PADI and the Preoperative & Postoperative “K & K Score“ at the time of discharge, 3 months & 6 months postoperative were 0.404, 0.320 and 0.284 respectively. Conclusions: The correlation between PADI and the Preoperative K and K score, was strongest in patients with PADI of about 5 to 10 mm. The correlation between PADI and the Preoperative K & K score became less stronger, as the follow- up period was increased even though they are significantly related to each other.

Keywords: Posterior Atlanto Dental Interval; Craniovertebral Junction anomalies; Kumar and Kalra Score.

Background: The Posterior fossa meningiomas constitute about 15 to 20% of all types of intracranial meningiomas. They usually become large, while they start producing clinical symptoms, because of their slow and indolent growth. Even though the microsurgical excision is the mainstay of treatment, the tumors’s location, encroachment of adjacent neurovascular structures and it’s invasive behavior, the surgery still remains challenging. Material and Methods: This is a prospective clinical study of about 32 cases of posterior fossa meningiomas, operated at “ Institute of Neurosurgery, Rajiv Gandhi Government General Hospital & Madras Medical College, Chennai-3”during the period. The incidence, various surgical procedures, postoperative complications & outcome were analysed. Results: In about 72% of cases, Gross total resection was done. Subtotal excision was done in Petroclival, Jugular foramen with extra cranial extension, Tentorial meningiomas with sinus extension and ventrally placed foramen magnum tumors. Postoperative complications in the form of CSF leak was found in about 12.5% cases and new onset or aggravation of preexisting neurological deficit in about 33% of cases. We had encountered two recurrent cases over a mean follow up of 1 year. Conclusion: Because of its close proximity to the sinus and adjacent neurovascular structures, posterior fossa meningiomas are very difficult to excise. Judicious use of Microscope, CUSA, intra operative nerve monitor helps in preserving the significant anatomical substrates. The postoperative recovery occurs completely, even though the neurological deterioration is common.

Keywords: Posterior fossa meningioma; Gross total resection; Postoperative complications.

Introduction: Recognizing the magnitude of neurological disorders and the disabilities associated with it in the community is the first step towards integration of neurology care with general health care. Increase in neurological disorders and mismatch between need and available resources (Manpower and infrastructure) are posing challenges for providing neurological care to the community. Objective: To study prevalence of neurological disorders and the utilization of health services in a sub-center area in Udupi Taluk Methods: A community based cross sectional study was conducted for a period of two years among individuals in 1027 households of the study population Results: Study targeted 1132 families out of which 1027 families were covered comprising of 5031 individuals. Among them about 10% suffered from neurological disorders with almost 50% of then having various types of pains/aches. Headaches followed by stroke and seizures were the next common neurological disorders. A large majority utilized allopathic services predominantly at primary and secondary centers. Only 10% of those with neurological disorders visited a qualified neurospecialist. Most of this population was unaware regarding availability of neurological care. Conclusion: Headache, Pains and aches are the most common neurological disorders in this population with underutilization and poor awareness about neurological services. Large scale population based surveys are the need of the hour for developing hospital and community based neurological services in India.

Keywords: Community based study; Prevalence; Neurological disorders; Utilization.

Context: Stroke is responsible for death and disability in developing low and middle income countries like India. Colour Doppler ultrasound is a safe, low economical and non invasive tool for evaluation of extra cranial insufficiency of carotid arteries. Aims: To find the prevalence of carotid artery stenosis among acute ischemic stroke patients and to assess the association between carotid artery stenosis and modifiable risk factors like hypertension, smoking, diabetes and alcoholism. Settings and Design: An observational study at a tertiary care hospital for a period of two years in department of neurology after ethical committee approval. Methods and Material: Carotid Doppler ultrasonography and CT scan imaging was done in cases of acute ischemic stroke. Socio demographic data, risk factors, general and thorough clinical examination was done and findings were noted. Statistical package for social sciences (SPSS) version 20 for windows 8 was used for analysis. Results: 175 cases with 108 males and 67 females were included. 42.29% were above 50 years and mean age was 65 ± 4 years. Hypertension and diabetes were major and significant risk factors. 27.43% of cases presented with pure motor hemiplegia and site of lesion was in Capsulo ganglionic area. Middle cerebral artery (MCA) site is the most common territory involved and infarct was the common finding on CT scan. 33.06% of cases demonstrated severe carotid stenosis (>70%). 35.5% of cases had plaque in the carotid bulb. Conclusion: The role of colour Doppler Ultrasonography of carotid in assessing the carotid stenosis, plaque formation and atherosclerosis associated with multiple risk factors is justified.

Keywords: Acute Ischemic stroke; Carotid Doppler; Carotid stenosis; Plaque.

Context: Stroke is one of the major disorders associated with severe morbidity and mortality. Diabetes is associated with occurrence, poor outcome and also chance of recurrence in stroke patients. Aims: The present study was aimed to identify the severity of stroke among diabetics and how it differs from non diabetics and also to evaluate the outcome of acute ischemic stroke among diabetics and non diabetics for a short course of three and six months period. Settings and Design: A prospective observational cross sectional study for one year period was conducted by Neurology department after ethical approval on cases of acute ischemic stroke. Materials and Methods: Cases were divided into diabetics and non diabetics and socio- demographic data, risk factors were noted and severity of the stroke was assessed by using National Institute of Health stroke scale at the time of admission and Grouped into four based on the score. Outcome of the cases was categorized as dependent/ death and independent and placed in two groups based on modified Rankin score (mRS). Follow up of the cases was done for third and sixth month. Analysis was done by Microsoft excel and Probability <0.01 were considered Results: 300 cases of acute ischemic stroke with 198 males, 102 females and 108 (36%) diabetics and 192 non diabetics (64%) were included. 60-69 years was the most common age group (34%), 62.7% were admitted in <24 hours. Majority of the cases were placed in Group 2 and statistical significance was associated with prognosis among diabetics and non-diabetics. The mortality percentage at the end of third and sixth month in the overall study group was 5.3% and 7.04%. Conclusion: To conclude, our study found a signicant association between diabetes and severity of stroke with NIHSS scoring as a tool of predictor in severity. Diabetes increased the risk of severity of stroke and dependent outcome among the acute ischemic stroke patients.

Keywords: Acute Ischemic stroke; Diabetics: Modi ed Rankin score; NIHSS.