Altered MicroRNA Expression in Intracranial Aneurysmal Tissues: Possible Role in TGF-ß Signaling Pathway.

The molecular mechanisms behind the rupture of intracranial aneurysms remain obscure. MiRNAs are key regulators of a wide array of biological processes altering protein synthesis by binding to target mRNAs. However, variations in miRNA levels in ruptured aneurysmal wall have not been completely examined. We hypothesized that altered miRNA signature in aneurysmal tissues could potentially provide insight into aneurysm pathophysiology. Using a high-throughput miRNA microarray screening approach, we compared the miRNA expression pattern in aneurysm tissues obtained during surgery from patients with aneurysmal subarachnoid hemorrhage (aSAH) with control tissues (GEO accession number GSE161870). We found that the expression of 70 miRNAs was altered. Expressions of the top 10 miRNA were validated, by qRT-PCR and results were correlated with clinical characteristics of aSAH patients. The level of 10 miRNAs (miR-24-3p, miR-26b-5p, miR-27b-3p, miR-125b-5p, miR-143-3p, miR-145-5p, miR-193a-3p, miR-199a-5p, miR-365a-3p/365b-3p, and miR-497-5p) was significantly decreased in patients compared to controls. Expression of miR-125b-5p, miR-143-3p and miR-199a-5p was significantly decreased in patients with poor prognosis and vasospasm. The target genes of few miRNAs were enriched in Transforming growth factor-beta (TGF-ß) and Mitogen-activated protein kinases (MAPK) pathways. We found significant negative correlation between the miRNA and mRNA expression (TGF-ß1, TGF-ß2, SMAD family member 2 (SMAD2), SMAD family member 4 (SMAD4), MAPK1 and MAPK3) in aneurysm tissues. We suggest that miR-26b, miR-199a, miR-497and miR-365, could target multiple genes in TGF-ß and MAPK signaling cascades to influence inflammatory processes, extracellular matrix and vascular smooth muscle cell degradation and apoptosis, and ultimately cause vessel wall degradation and rupture.

Heartbroken Child: A Rare Case Report of Neurogenic Pulmonary Edema and Takotsubo Cardiomyopathy following Recurrent Medulloblastoma Excision with Possible Aetio-Patho-Bio-Physiological Mechanisms.

INTRODUCTION: Takotsubo (Japanese fishing pot for trapping octopus) cardiomyopathy is a rare phenomenon of acute coronary syndrome presenting usually with the presence of transient apical ballooning of the left ventricle in the absence of obstructive coronary artery disease. It is mainly seen in women of older age secondary to emotional, physical, or psychological stress. In age less than 18 years, it is mainly seen in adolescents suffering from psychiatric disorders and substance abuse. In children, it is rarely described. CASE PRESENTATION: We present here a peculiar case of a 12-year-old child with neurogenic pulmonary oedema and takotsubo cardiomyopathy syndrome after surgery for recurrent medulloblastoma. Also, management challenges are discussed. DISCUSSION/CONCLUSION: Takotsubo cardiomyopathy is not just a classical or inverted type but indeed a spectrum. It can be seen in any case, be it a child or adult secondary to handling or injury to the ponto-medullary junction, rostral pons, or dorsolateral medulla. The density and distribution of beta-adrenergic receptors may be different in children and adults which needs further research. Prognosis is usually excellent across all ages.

Fulminant acanthamoebic meningoencephalitis in immunocompetent patients: an uncommon entity.

We are reporting two patients of fatal and rapidly progressive amoebic encephalitis in immunocompetent host from poor socioeconomic status. Both these patient had acute neurological worsening preoperatively and did not respond to subsequent surgical decompression. Biopsy report confirmed acanthamoebic cerebral infection.

A new comprehensive grading for giant pituitary adenomas: SLAP grading.

AimGiant pituitary adenomas are difficult to resect due to multicompartmental extension. We developed a new grading system for giant pituitary adenomas (GPAs) considering possible extension in superior, lateral, anterior, and posterior (SLAP) directions. We also related the degree of resection to the SLAP grading.MethodsA review of case files and radiological images of patients with the GPAs defined as pituitary adenomas with a size of more than 4 cm in any dimension was done. The extent of the tumour was noted and scored as per the SLAP system. The maximum total score is 10 and represents a large tumour with maximum extensions in all directions. The subtotal resection (STR) was defined as a residual tumour volume of more than 10%. The association between individual and total score on the degree of resection was determined.ResultsA total of 103 cases of GPAs were analyzed. All patients had a suprasellar (S) extension. The lateral (L) extension was seen in 97.3% of cases. The anterior (A) extension was seen in 28 (27.2%) cases. The posterior (P) extension was seen in 45 (43.7%). Forty-eight (46.6%) had a total score of 5 or more. The STR was achieved in 64 (62.2%) cases. On regression analysis, a total score of ≥5 was associated with odds of 5.02 (1.69-14.93), p-value 0.004 for STR.ConclusionThe SLAP grading is a comprehensive grading system that can be applied easily to the GPAs and gives a complete picture of the extension of the tumour.

DREZotomy in the management of post brachial plexus root avulsion neuropathic pain: fMRI correlates for pain relief.

BACKGROUND: Deafferentiation pain following brachial plexus root avulsion has been documented to be severe enough to affect activities of daily living in patients. Microsurgical DREZotomy is known to alleviate the symptoms by decreasing the afferent signals transmitted from the spinal cord to sensory cortex. OBJECTIVES: To document and analyse the effectiveness of DREZotomy and to evaluate the role of 'sensory cortex' in the cause and relief of dysesthetic pain, using fMRI. MATERIALS AND METHODS: This was a prospective study conducted between 2010 and 2016 and included all patients who underwent DREZotomy for dysesthetic pain following traumatic brachial plexus injury (TBPI). Patients were evaluated both preoperatively and postoperatively with Visual Analogue Scale(VAS), Hospital Anxiety and Depression score (HADS) and SF36 questionnaire and effectiveness of surgery was assessed. Functional magnetic resonance imaging (fMRI) of the brain in resting state was performed before and after surgery and was also compared with controls. Patients underwent standard microsurgical DREZotomy from C5 to D1. Postoperative assessment was done at 6 weeks and 6 months following surgery. RESULTS: Our series had 18 patients aged between 22 and 63 years. RTA was the most common cause of injury. There was significant decrease in pain at 6 months follow up compared to pre-operative values as assessed by VAS, HADS, SF36 questionnaire. fMRI analysis revealed cluster activations in the sensory, motor cortex and in the right cingulate gyrus in the preoperative group which was higher than in normal controls. In the postoperative group, the size of the resting state activation was significantly reduced. CONCLUSION: DREZotomy is an effective procedure for TBPI patients. We hypothesize that these fMRI findings reflect the cortical reorganization that occurs not only after injury but also following successful surgery which explains the cause and relief of dyesthetic pain.

Estrogen receptor alpha gene variant, PvuII (rs2234693), as a potential pharmacogenetic biomarker for aneurysmal subarachnoid hemorrhage in postmenopausal women.

Aneurysmal subarachnoid hemorrhage (aSAH) occurs more often in postmenopausal women than in men. Estrogen plays an important role in vascular homeostasis. Our aim was to elucidate whether a drop in circulating estradiol in conjunction with variants of estrogen receptor genes have a role in female gender susceptibility to aSAH. A total of 709 subjects were enrolled (349 aSAH patients, 360 controls) and genotyped for rs2234693 or PvuII (intron 1, T>C) in the ESR1 gene and rs4986938 or AluI (exon 8, 1730G>A) of ESR2 gene by PCR-RFLP. Serum estradiol was estimated by ELISA. Estrogen receptor gene expression was studied by qRT-PCR. Logistic regression analysis indicated a significant recessive effect of the T allele of PvuII on aSAH in females, and this association remained statistically significant even after adjusting for confounders (OR 1.702, CI 95% 1.062, 2.726, P value = 0.027). ESR1 gene expression was significantly reduced (P value = 0.0089) in subjects carrying PvuII T allele. In postmenopausal women with TT genotype and low serum estradiol, the odds for developing aSAH were found to be 3.5-fold increase compared with premenopausal women (CI 95% 1.424-8.828, P value = 0.0074). However, this variant showed no significant association with aSAH in men. No significant difference was found in genotype and allelic distribution of AluI polymorphism in ESR2 gene, between patients and controls. We propose that the PvuII T allele could be a potential pharmacogenetic marker for strategizing personal medicine for preventing aSAH in postmenopausal women with low circulating estradiol. Further larger studies in other population are warranted.

Trapped fourth ventricle-treatment options and the role of open posterior fenestration in the surgical management.

BACKGROUND: Trapped fourth ventricle (TFV) is a rare and difficult to treat condition. Most patients have a past inciting event (infection, IVH, trauma) and history of prior CSF diversion. The symptoms are due to the mass effect on brainstem and cerebellum. Rarely, TFV can also be associated with syrinx formation due to a dissociated craniospinal CSF flow near the fourth ventricle outlets. We present our experience and outcomes of open posterior fenestration in 11 cases, along with an overview of the surgical management of TFV. METHODS: Between 2011 and 2018, 11 patients of TFV were operated by the posterior approach fenestration of the fourth ventricle outlets and arachnoid dissection. The clinical and radiological findings of the patients were retrieved from the hospital database. The surgical technique is described in detail. The patients' neurological status and imaging findings in the follow-up were recorded and compared. RESULTS: The average age of the patients was 23.55 years. The most common presenting symptoms were headache (9/11) and gait imbalance (7), with TB meningitis being the commonest etiology. Ten patients had a history of prior CSF diversion with two presenting with shunt malfunction. Mean follow-up duration was 33.33 months. The improvement in neurological status was observed in 9/11 patients, 2 remained status quo. On follow-up imaging, 8/11 (72.72%) patients had a decrease in the size of TFV while syrinx improved in 3/5 (60%). CONCLUSION: Multiple surgical approaches have been described for TFV. Endoscopic fourth ventriculostomy with aqueductoplasty is gaining popularity in the past two decades. However, an open posterior fenestration of the midline fourth ventricle outlet (magendieplasty) along with sharp arachnoid dissection (adhesiolysis) along the cerebello-medullary cisterns and paracervical gutters is relatively simple and provides physiological fourth ventricular CSF outflow. This is especially useful in TFV with syrinx as the craniospinal CSF circulation is established.

Comparison of equiosmolar dose of hyperosmolar agents in reducing intracranial pressure-a randomized control study in pediatric traumatic brain injury.

INTRODUCTION: There are no comparative studies available for hyperosmolar therapy in children. The present study is a prospective open label randomized control trial to compare the effect of equiosmolar doses of mannitol and hypertonic saline in reducing intracranial pressure in children who sustained severe traumatic brain injury. METHODS: This is a prospective open-label randomized controlled trial. Thirty children aged less than or equal to 16 years with severe traumatic brain injury and raised intracranial pressure as measured by ventricular catheter insertion were enrolled. Sixteen children received 20% mannitol, and 14 children received 3% saline as 2.5 ml/kg bolus for episodes of intracranial pressure above cutoff value for age. The mean reduction in intracranial pressure and Glasgow outcome scale at 6 months after injury was measured. RESULTS: The mean reduction in intracranial pressure in mannitol group was 7.13 mmHg and in hypertonic saline group was 5.67 mmHg, and the difference was not statistically significant, p = 0.33. The incidence of death or survival in vegetative state was 23.07% in mannitol group and 16.66% in hypertonic saline group, and the difference was not statistically significant, p = 0.69. CONCLUSION: Both mannitol and hypertonic saline were equally effective for treatment of raised intracranial pressure in children with severe traumatic brain injury.

Surgical management of traumatic extradural hematomas in children: an analysis of 201 patients at a tertiary neurosurgical center.

INTRODUCTION: The effects of traumatic extradural hematoma (EDH) are potentially reversible if treated early. Pediatric EDH differs from its adult counterpart because of the differential elastic and adherence properties of skull bone and dura respectively. There is a paucity of literature regarding prognosis and factors predicting the outcome of pediatric EDH. In this study, we aimed to study the factors predicting outcome and prognosis of traumatic EDH in the pediatric age group. MATERIALS AND METHODS: We did a retrospective chart review of all pediatric EDH operated in our center between 2011 and 2017. Factors affecting prognosis were analyzed through univariate and multivariate analyses. RESULTS: Two hundred one patients qualified for the study. There were 159 boys and 42 girls with a sex ratio of 3.78:1. The most common modes of injury were road traffic accidents (n = 108, 53.3%) followed by falls from a height. The most common clinical presentation was vomiting (n = 168, 83.3%), followed by headache (n = 72, 35.8%). Pupillary asymmetry was present in 11.4% (n = 23) patients. The mean GCS at presentation was 12.71. The mean volume of EDH was 37.18 cc, with a mean maximum thickness of 23.19 mm. The most common location of the EDH was at temporoparietal region (n = 67, 33.3%). The median time of diagnosis from injury was 14.69 h (SD, 32.9 h). The mean GCS at discharge was 14.43 (SD ± 0.51). Sixteen patients were lost to follow; 185 patients were available for follow-up and were included in the outcome analysis. The mean GOS at follow-up was 4.9 (SD ± 0.368) with a median follow-up of 13.46 months. In our cohort, only one child died. Univariate and multivariate analyses revealed that pupillary asymmetry, pyramidal signs, low GCS at presentation, associated parenchymal injuries, and post-operative complications correlated negatively with outcome, whereas vomiting correlated positively with outcome. CONCLUSION: Pediatric EDH differs from adults in complications as well as outcome. EDH in this pediatric cohort had a better outcome with very less mortality. Increased transportation facilities and the industrial revolution may have facilitated the shift of mode of injury from fall of height in the past to road traffic accidents in this study. A large study comparing the outcomes with pediatric and adult patients is warranted.

Predictors of outcome of subdural empyema in children.

OBJECTIVE: The aim of this study was to report the etiology, clinical features, microbiology, surgical outcome, and predictors of outcome of spontaneous subdural empyema (SDE). METHODS: The authors conducted a retrospective study in a tertiary hospital. Children up to 18 years of age, with a diagnosis of SDE with infective etiology, were included in the present cohort. Patients with posttraumatic, postsurgery, and tubercular origin of SDE were excluded from the study. The Glasgow Outcome Scale was used for outcome assessment at the end of 3 months. For analysis purposes, the demographic data, clinical features, radiological data, microbiology, type of surgery, and complication data were categorized, and univariate and multivariable logistic regression analyses were performed to identify the factors associated with outcome. RESULTS: Ninety-eight children were included in the study and the mean age was 10.9 years. Otogenic origin (34.7%) was the most common source of infection, followed by meningitis (14.3%). The mean duration of symptoms was 12 days. Seventy-six children presented with Glasgow Coma Scale (GCS) score > 8 and the supratentorial location was the most common location. Almost 75% of the children underwent craniotomy or craniectomy and the rest had burr-hole evacuation. Beta-hemolytic Streptococcus (10%) was the most common organism isolated. Cerebral venous thrombosis (CVT; 10.2%) was the most frequent complication in this cohort. The other complications were infarction (6.1%), new-onset seizure (4.1%), and bone flap osteomyelitis (4.1%). Thirteen cases had a recurrence of pus collection, which was more common in the craniotomy group than in the burr-hole group. Age (p = 0.02), GCS score ≤ 8 (OR 8.15, p = 0.001), CVT (OR 15.17, p = 0.001), and presence of infarction (OR 7, p = 0.05) were strongly associated with unfavorable outcome. In multivariable logistic regression analysis, only GCS score ≤ 8 (p = 0.01), CVT (p = 0.02), and presence of infarction (p = 0.04) had a significant impact on unfavorable outcome. CONCLUSIONS: Prompt diagnosis and immediate intervention is the goal of management of SDE, especially in children as a delay in diagnosis can result in unconsciousness and secondary complications such as CVT and infarction, which adversely affect outcome.

Intracranial fungal granuloma: a single-institute study of 90 cases over 18 years.

OBJECTIVE: Intracranial fungal granuloma (IFG) remains an uncommon entity. The authors report a single-institute study of 90 cases of IFG, which is the largest study until now. METHODS: In this retrospective study, all cases of IFG surgically treated in the years 2001-2018 were included. Data were obtained from the medical records and the pathology, microbiology, and radiology departments. All relevant clinical data, imaging characteristics, surgical procedure performed, perioperative findings, and follow-up data were recorded from the case files. Telephonic follow-up was also performed for a few patients to find out their current status. RESULTS: A total of 90 cases consisting of 64 males (71.1%) and 26 (28.9%) females were evaluated. The mean patient age was 40.2 years (range 1-79 years). Headache (54 patients) was the most common presenting complaint, followed by visual symptoms (35 patients), fever (21 patients), and others such as limb weakness (13 patients) or seizure (9 patients). Cranial nerve involvement was the most common sign (47 patients), followed by motor deficit (22 patients) and papilledema (7 patients). The mean duration of symptoms before presentation was 6.4 months (range 0.06-48 months). Thirty patients (33.3%) had predisposing factors like diabetes mellitus, tuberculosis, or other immunocompromised status. A pure intracranial location of the IFG was seen in 49 cases (54.4%), whereas rhinocerebral or paranasal sinus involvement was seen in 41 cases (45.6%). Open surgery, that is, craniotomy and decompression, was performed in 55 cases, endoscopic biopsy was done in 30 cases, and stereotactic biopsy was performed in 5 cases. Aspergilloma (43 patients) was the most common fungal mass, followed by zygomycosis (13 patients), chromomycosis (9 patients), cryptococcoma (7 patients), mucormycosis (5 patients), and candida infection (1 patient). In 12 cases, the exact fungal phenotype could not be identified. Follow-up was available for 69/90 patients (76.7%). The mean duration of the follow-up was 37.97 months (range 3-144 months). The mortality rate was 52.2% (36/69 patients) among the patients with available follow-up. CONCLUSIONS: A high index of suspicion for IFG should exist for patients with an immunocompromised status and diabetic patients with rhinocerebral mass lesions. Early diagnosis, aggressive surgical decompression, and a course of promptly initiated antifungal therapy are associated with a better prognosis.

Chordoid meningioma: a clinico-pathological study of an uncommon variant of meningioma.

Chordoid meningioma is a rare variant of meningioma, with a higher incidence in the young and a supposed association with Castleman's syndrome. They have an aggressive clinical course, and are assigned as WHO grade II meningiomas. To the best of our knowledge, 284 chordoid meningiomas have been reported in the literature. This series reporting 33 cases is the third largest series in published literature from a single Institution. We reviewed Clinico-pathological characteristics of 33 patients diagnosed with chordoid meningioma between 2001 and 2015 in our institution. Forty-one specimens were available for review of histopathological and immunohistochemical characteristics. There were 15 men and 18 women with mean age of 36.8 years (median 36 years, range 9-62 years) at diagnosis with three cases occurring in pediatric age group. The majority were supratentorial in location with 11 convexity, 1 falcine, 5 parasagittal, 1 intraventricular, skull base involvement in 12 with 4 being petroclival location and 3 had spinal lesions. Lymphoplasmacytic infiltrates were seen in 23 cases with majority being T cells. MIB index varied from 1 to 14%. Five patients received radiotherapy for residual lesion. Two patients died (recurrence-1, post-operative complication-1). Three patients were lost to follow up after surgery. The mean post-operative follow up period for the remaining was 55.3 months. Seven patients had recurrence of which three had it twice. This study adds to the pool of available data for better understanding of this variant of meningioma. These meningiomas occur in middle age; spinal lesions and pediatric cases are not uncommon. We did not find any association between surgery, post-operative radiotherapy and histopathological features with recurrence and survival. Small number of cases may be responsible for this statistical insignificance.

Predictors of Surgical Outcomes of Traumatic Peripheral Nerve Injuries in Children: An Institutional Experience.

AIM: This study was undertaken to address the epidemiological characteristics, operative details, and surgical outcome of peripheral nerve injuries in children treated in a tertiary hospital in India (NIMHANS, Bangalore). MATERIALS AND METHODS: This is a retrospective study of epidemiology, operative findings, and surgical outcomes over the period of 2000-2016. Our series includes 102 children with peripheral nerve injuries of various causes. RESULTS: Intramuscular injections were the most common cause (52.9%), followed by entrapment (15.6%). The most common nerve involved was the sciatic nerve (54.9%), followed by the common peroneal nerve (13.7%), the ulnar nerve (10.8%), and the radial nerve (10.8%). Perineural adhesion was the most common intraoperative finding (74.5%), followed by a neuroma in continuity (14.7%) and gap (10.8%). Most of the children with peripheral adhesion underwent external and internal neurolysis (75.5%). Follow-up was available for 67 children. The median follow-up period was 7 months (range 3-36). The outcome was assessed according to MRC grading. Favorable functional improvement was noted in 76.1% of the children. Age less than 10 years (p = 0. 06), injury before 6 months (p = 0.03), and MRC motor grade (<3) (p = 0. 01) were positive predictive factors related to the final outcome. CONCLUSION: Early surgical intervention, age less than 10 years, and incomplete motor palsy were the best predictors of a superior functional outcome. This study can serve as a guide to determine the epidemiology, duration of intervention, and surgical outcome of traumatic peripheral nerve injuries in the pediatric population.

Aggressive management of vasospasm with direct intra-arterial nimodipine therapy.

BACKGROUND: The conventional medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is associated with uncertainty of outcome and complications. AIMS AND OBJECTIVES: To examine the effect of direct intra-arterial nimodipine therapy on outcome in patients with delayed cerebral ischemia (DCI). SETTINGS AND DESIGN: The retrospective observational study was conducted at a single neurosurgical unit and interventional neuroradiolgy suite of a center managing SAH. MATERIALS AND METHODS: Data analysis of SAH managed surgically during the period from January 2014 through October 2015 was performed. Any decline in the neurological status on clinical examination, such as consciousness, motor and speech deficits, without other identifiable causes such as hydrocephalus, hyponatremia, seizure, intracranial hematoma, or infection, was used to define the presence of DCI. Patients with suspected DCI underwent computed tomography (CT) scan of the head followed by angiography. When vasospasm was detected in the absence of any major arterial territory infarct, the patients were managed with intra-arterial nimodipine therapy. The outcome at discharge was assessed. STATISTICAL ANALYSIS: Mid-P exact, two-tailed P value was used for categorical variables. RESULTS:: A total of 106 patients underwent surgical clipping of an aneurysm following SAH. DCI was diagnosed in 26 (24.5%) patients. Twenty three (88.5%) patients underwent intra-arterial nimodipine therapy. Angiographic response was seen in 22 (95.7%) patients and clinical response in 20 (87%) patients. At discharge, 19 patients (73.1%) with vasospasm had a favorable outcome. There was no significant difference in the outcome of patients with or without vasospasm. CONCLUSIONS: Aggressive management with intra-arterial nimodipine therapy is effective in preventing disability caused by DCI.

A preliminary study of natural history of mild traumatic brain injury by using multidimensional approach.

BACKGROUND & OBJECTIVES: Spectrum of post-traumatic symptoms is frequent among mild traumatic brain injury (mTBI) patients. They account for symptoms in 30-80 per cent of patients during 3-4 months and 20-30 per cent of patients six months post-injury. There are no studies from India in this area. The present longitudinal study was conducted to evaluate the natural recovery of post-traumatic symptoms in mTBI patients. METHODS: Twenty five mTBI patients presenting with initial Glasgow coma scale score of 15 were recruited initially 2-3 wk post-injury. All patients were followed up twice, after 3-4 and 6-7 months. The patients were evaluated with neuropsychological test, post-traumatic symptoms and quality of life after injury. RESULTS: Sustained attention and sensory registration were first to improve. Memory and executive domains improved partially until three months and then after complete recovery. However, a few facets of learning/memory did not improve even at six months. The post-traumatic symptoms decreased since baseline from 76 to 52 per cent at 3-4 months and further to 28 per cent at 6-7 months. The quality of life improved partially from baseline till 3-4 months and much more by 6-7 months. INTERPRETATION & CONCLUSIONS: The study findings showed the course of changes in cognition, traumatic symptoms and quality of life since the time of injury till 6-7 months post-injury. Though majority of post-traumatic symptoms recovered after mTBI without any intervention, but residuals were not uncommon.

Isolated brainstem tuberculomas.

BACKGROUND: Isolated brainstem tuberculomas are rare lesions and account for up to 5% of all intracranial tuberculomas in endemic areas. The difficulties in diagnosis and management of this condition are sparsely reported. The aim of this study is to illustrate the nuances in managing brainstem tuberculomas, define prognosis, and demonstrate a shift in management strategies with newer imaging modalities. METHOD: A retrospective review of 14 patients diagnosed and treated with a diagnosis of 'isolated brainstem tuberculoma' between 2011 and 2015 was done. Diagnosis was made after combining the findings at clinical history, examination, as well as imaging features. Patients were treated with steroids for 6 weeks or until they made a meaningful clinical recovery, and antitubercular therapy (ATT) for a minimum of 18 months or until there was resolution of the tuberculoma. Confirmation of tubercular pathology was done by observing if response to treatment resulted in clinical improvement, which happened in all of our cases. RESULTS: Mean age at diagnosis was 24.7 years and nine were males. Twelve patients had a combination of cranial nerve deficits with pyramidal weakness or sensory symptoms. Mean duration of symptoms was 4.7 months and tests for human immunodeficiency virus (HIV) infection were negative in all patients. Only two patients had a previous history of tubercular meningitis. Most lesions were located in the pons with size ranging from 1 to 22.2 cm3. Eight patients showed complete resolution of the lesion at latest follow-up and the rest were still on ATT. Mean duration of ATT received for resolution of the lesion was 22 months. Almost all of our patients improved clinically on steroids and ATT. CONCLUSIONS: Intracranial tuberculomas may present with or without meningitis. A high index of suspicion is essential, especially in endemic areas. A combination of clinical symptoms, investigations, and imaging features help in coming to a diagnosis. Biopsy of a brainstem lesion is fraught with complications. Antitubercular therapy has a very good prognosis, though the duration of therapy required may be longer.

Growing Skull Fracture and the Orbitocranial Variant: Nuances of Surgical Management.

AIMS: Growing skull fracture (GSF) is a rare complication resulting from diastatic enlargement of a pediatric skull fracture. Orbitocranial GSF is a distinct variant with more complex management issues due to the displacement of the globe. This study aims to discuss surgical considerations in the management of GSF, with particular reference to orbitocranial variants. METHODS: We conducted a retrospective analysis of 7 children operated for GSFs at our institute from 2008 to 2015. RESULTS: Four boys and 3 girls were operated during this period. The mean age at initial trauma was 2 years, and most of them sustained falls. The most frequent symptoms of GSF were progressive scalp swelling and proptosis. The most common location was the orbitofrontal region. Duraplasty with cranioplasty was performed in 5 patients, while duraplasty alone was only required in 2 patients. A postoperative complication was noted in 1 patient and managed successfully. Good cosmetic results were obtained in all of the cases. CONCLUSIONS: Duraplasty is essential in the repair of GSF and should be followed by cranioplasty to prevent recurrent leptomeningeal herniation. We recommend the use of autologous bone from the surgical site for cranioplasty. Orbital roof repair is advisable for good visual and cosmetic outcome in orbitocranial variants of GSF.

Demonstration of autonomic dysfunction in traumatic brachial plexus injury using quantitative sudomotor axon reflex test: Preliminary results.

OBJECTIVE: To objectively document autonomic dysfunction in the affected arm with traumatic brachial plexus injury (TBPI) using quantitative sudomotor axon reflex test (QSART). MATERIALS AND METHODS: Patients with TBPI presenting to the neurosurgical outpatient department from August 2013 to November 2014 were included in the study. The QSART was administered to each patient with prior informed consent detailing the procedure. A total of 20 patients with TBPI were included in the study. The age, sex, mode of injury, date of injury, side of injury, and type of injury (pan brachial plexus vs preserved distal function) were recorded. The presence of any pain was also recorded. The injuries were also grouped as preganglionic and postganglionic injuries based on clinical, electroneuromyography (ENMG) and magnetic resonance imaging (MRI) findings. The results of the test for the affected and normal limb were recorded and analyzed with appropriate statistical tests to determine any significant differences. RESULTS: The study included 20 patients, with their age ranging from 15 to 50 years. Out of the 20 patients, one was female and the rest 19 were males. Seven (35%) of the injuries were complete (pan brachial plexus) and 13 (65%) were incomplete (preserved distal function). All patients had preganglionic TBPI. There was no evidence of any statistically significant difference between the affected and normal arm for total sweat volume (P = 0.20) and latency period (P = 0.42). However, the average mean values for the same were lower in the affected arm as compared to the normal. The baseline sweat output (P = 0.010), however, was significantly lower in the affected arm as compared to the normal arm. CONCLUSION: QSART has demonstrated reduced baseline sweat output in the affected arm in patients with TBPI. This indicates the presence of autonomic dysfunction in the injured arm.

Vertebral artery dolicoectasia with brainstem compression: role of microvascular decompression in relieving pyramidal weakness.

Vertebral artery dolicoectasia (VAD) can cause brainstem compression and dysfunction. Reports of pyramidal tract involvement by brainstem compression and the surgical benefits and its long-term results are sparsely reported. We hereby report three cases of medullary compression by VAD causing pyramidal weakness. Two patients with bilateral compression with quadriparesis did not want surgical treatment and were still disabled at 58 months and 50 months of follow-up, respectively. One patient with unilateral medullary compression with hemiparesis underwent microvascular decompression using Teflon sling retraction. This patient was relieved of symptoms and is asymptomatic at 14-month follow-up. This report emphasizes the need of surgical decompression in cases of brainstem compression by VAD with caution about appropriate case selection.