Cortical plasticity after brachial plexus injury and repair: a resting-state functional MRI study.

OBJECTIVE The authors aimed to understand the alterations of brain resting-state networks (RSNs) in patients with pan-brachial plexus injury (BPI) before and after surgery, which might provide insight into cortical plasticity after peripheral nerve injury and regeneration. METHODS Thirty-five patients with left pan-BPI before surgery, 30 patients after surgery, and 25 healthy controls underwent resting-state functional MRI (rs-fMRI). The 30 postoperative patients were subdivided into 2 groups: 14 patients with improvement in muscle power and 16 patients with no improvement in muscle power after surgery. RSNs were extracted using independent component analysis to evaluate connectivity at a significance level of p < 0.05 (familywise error corrected). RESULTS The patients with BPI had lower connectivity in their sensorimotor network (SMN) and salience network (SN) and greater connectivity in their default mode network (DMN) before surgery than the controls. Connectivity of the left supplementary motor cortex in the SMN and medial frontal gyrus and in the anterior cingulate cortex in the SN increased in patients whose muscle power had improved after surgery, whereas no significant changes were noted in the unimproved patients. There was a trend toward reduction in DMN connectivity in all the patients after surgery compared with that in the preoperative patients; however, this result was not statistically significant. CONCLUSIONS The results of this study highlight the fact that peripheral nerve injury, its management, and successful treatment cause dynamic changes within the brain's RSNs, which includes not only the obvious SMN but also the higher cognitive networks such as the SN and DMN, which indicates brain plasticity and compensatory mechanisms at work.

Role of substance P in cerebral edema and association with an estimated specific gravity of the brain and an outcome prediction in post-traumatic cerebral edema.

Purpose: The study aims to evaluate the role of substance P in cerebral edema and outcomes associated with acute TBI. Method: Patients with acute TBI who presented within 6 h and a CT scan showed predominantly cerebral edema were included in the study. Substance P level was assessed from a serum sample collected within 6 h of trauma. We also evaluated the brain-specific gravity using the Brain View software. Result: A total of 160 (128 male) patients were recruited. The median serum substance P concentration was 167.89 (IQR: 101.09-238.2). Substance P concentration was high in the early hours after trauma (p = 0.001). The median specific gravity of the entire brain was 1.04. Patients with a low Glasgow coma scale (GCS) at admission had a high concentration of the substance P. In the univariate analysis, low GCS, elevated serum concentrations of substance P level, high Rotterdam grade, high cerebral edema grade, a high international normalized ratio value, and high blood sugar levels were associated with poor outcomes at six months. In logistic regression analysis, low GCS at admission, high cerebral edema grade, and elevated blood sugar level were strongly associated with poor outcomes at six months. The area under the receiver operating characteristic curve was 0.884 (0.826-0.941). Conclusion: Serum substance P is strongly associated with the severity of cerebral edema after TBI. However, brain-specific gravity does not directly correlate with posttraumatic cerebral edema severity. Serum substance P does not influence the clinical outcome of traumatic brain injury.

A rare vascular complication of transsphenoidal surgery.

We report a rare case of anterior cerebral artery (ACA) thrombosis following transsphenoidal surgery in a case of growth hormone secreting pituitary macroadenoma. During the surgery, there was arachnoid breach with cerebrospinal fluid (CSF) leak. Post operatively, she became blind in both eyes for which re-exploration was done. A computed tomographic (CT) scan 16 hours after surgery showed a large tumor bed haematoma which was explored transcranially. During surgery, the right A1 was thrombosed while the ICA and middle cerebral artery (MCA) were patent as confirmed by post-operative magnetic resonance imaging (MRI). However, she died on the second post-operative day. ACA thrombosis following transsphenoidal surgery has not been reported before. A review of literature and possible mechanism of this complication has been discussed.

A clinical profile of 103 patients with secondary movement disorders: correlation of etiology with phenomenology.

BACKGROUND AND PURPOSE: Studying patients with secondary movement disorders (SMD) provides a unique opportunity to determine the correlation between the etiology and phenomenology of movement disorders. METHODS: This was a prospective study of 103 patients (43 women, 60 men; age=28.7±17.3 years; range=2-70 years) with SMD, in a tertiary hospital over 4 years. RESULTS: The mean age of onset of SMD was 24.3±19.7 years, and duration of symptoms was 4.3±7.1 years (42 days to 40 years). Patients with pure tremor, pure dystonia (DYS), or a combination of tremor with dystonia had longest latency (10.9-18.5 months), whereas those with parkinsonism (PAR) and hemiballismus (HMB) had shorter latency (2.7-3.0 weeks). Pure dystonia was most prevalent (30.1%) followed by dystonia plus (13.6%), tremor (12.6%), PAR (11.7%), HMB (8.7%), mixed SMD (7.8%), tremor with dystonia (6.8%), myoclonus (5.8%), and chorea (2.9%). In approximately 60% of patients, the underlying etiologies were vascular (VAS), infections, and space-occupying lesions (SOL), and 25% had SMD following trauma or hypoxia (HYP). With reference to specific etiologies, the most frequent SMDs were tremor following SOL (46%), post-traumatic syndromes (25%), dystonia following HYP (56%), VAS lesions (50%), and infections (28%). With reference to specific SMDs, the most common etiologies were VAS for dystonia (39%), SOL for tremor (67%), and PAR (31%), and both SOL and trauma (37.5% each) for tremor with dystonia. CONCLUSIONS: Our study highlights the spectrum of SMDs and the lack of correlation between types of SMDs and underlying etiologies. Preventable causes such as infections, HYP, trauma, and kernicterus still play a major role in pathogenesis of SMD.

Intramedullary metastasis in a case of vermian medulloblastoma.

Medulloblastoma is one of the commonest primary CNS malignancies in children. Leptomeningeal dissemination and distant metastasis have been associated with medulloblastoma, but intramedullary metastases are very rare. CSF cytology and contrast-enhanced MRI are the main modalities used to diagnose leptomeningeal dissemination. However, intramedullary metastases are best picked up with contrast-enhanced axial sequences on MR imaging. In this report, a patient with medulloblastoma who developed intramedullary metastasis is described. The role of imaging and CSF cytology in diagnosing the spread along the CSF pathways is reviewed. Allusions are made to the possible mechanism of intramedullary metastasis in these tumors.

Transcranial approach for pituitary adenomas - An evaluation of surgical approaches over two decades and factors influencing peri-operative morbidity.

PURPOSE: Transcranial surgery(TCS) for pituitary adenoma(PA) is mostly reserved for lesions with widespread extensions. We sought to analyse the intraoperative challenges, morbidity and the factors associated with morbidity of transcranial approaches, in a large series from a tertiary neurosurgical institute. METHODS: We retrospectively evaluated 137 patients who underwent TCS for PA in our institute. The details of their clinical features, imaging, operative and peri-operative events and complications were collected and analysed. The factors associated with morbidity were evaluated. RESULTS: The mean age of the cohort was 40.86 ± 13.35 years. 21 (15.3%) patients developed significant post-operative hematoma, out of which 7 patients (5.1%) required re-exploration. Post-operative diabetes insipidus was noted in 45 patients (32.84%), while SIADH was noted in 10 patients (7.35%). Other complications were cranial nerve palsy in 14 patients (10.2%), visual deterioration in 7 patients (5.1%). Neither tumour characteristics nor the choice of approach was associated with occurrence of post op hematoma. SIADH was significantly associated with patients with tumours involving cavernous sinus (p = 0.019) and subfrontal extension (p = 0.031). Patients with post-operative hematoma had significantly higher incidence of post-op DI (57.1% vs 28.7%; p = 0.021), while similar correlation was not noticed with SIADH (4.7 vs 7.8%). CONCLUSION: TCS plays a distinct, albeit a small role in surgical management of pituitary adenoma. Tumour related or approach related factors are not significantly associated with the incidence of hematoma. Post-operative hematoma significantly influences the incidence of DI. A proper and judicious selection of approach and meticulous surgical technique should result in a reduction in associated morbidity and mortality.

Management of choroid plexus tumours: A comprehensive study from a tertiary hospital.

OBJECTIVE: Choroid plexus tumours (CPT) are rare intraventricular tumours representing less than 0.5 % of brain tumours. The tumour is commonly located in the supratentorial region, but the location varies depending on the age. We present our experience of managing these tumours in a tertiary hospital. METHODS: Retrospectively, we reviewed our operative database and recruited 80 cases of CPT who underwent surgical treatment in our institute from 1995 to 2018. We analysed the factors affecting the outcome and the perioperative complications of the choroid plexus tumour. RESULTS: A total of 80 choroid plexus tumours were recruited in our retrospective review, of which 44 were choroid plexus papilloma (CPP), 13 were atypical choroid plexus tumours (ACPP), 23 were choroid plexus carcinomas (CPC). The mean age was 16.75 (SD 16.71) in the overall cohort. Males were found to be predominant in all tumour groups (M/F: 46/34). Headache was the most common symptom (52.5 %). Hydrocephalus was seen in 53.8 % of cases. The median overall survival was 89.88 months. Gross total resection was achieved in 62.5 % cases (n = 50/80), and near-total resection in 27. 5 % cases (n = 22/80). The median overall survival was 89.88 months. The median overall survival for CPP, ACPP, CPC was 106.83, 37.37, 36.19 months, respectively. Median Event-free survival was 65.83 months. A Cox regression analysis of predictors of overall survival of atypical CPP and CPC was done, in which age, sex, location, size, the extent of the resection, and complications were considered. The extent of the resection (p = 0.01) and the size (p = 0.02) were related to overall survival CONCLUSION: CPT's are the rare intraventricular tumours, which requires aggressive resection strategies. The extent of resection offers survival benefit based on the histological grades.

Spinal actinomycosis: a rare disease.

Actinomycosis is an indolent, slowly progressive infection caused by Actinomyces species. Of human actinomycosis, the spinal form is rare and actinomycosis-related spinal neurological deficit is uncommon. We report two cases with cervical and dorsal actinomycosis and one of them with spinal neurological deficit.

Bilateral anomalous origin of ophthalmic artery from middle meningeal artery and coincidence of bilateral carotid artery aneurysm: Case report and literature review.

Ophthalmic artery (OA) is known for anomalous origin and aberrant course probably attributable to its complex embryology. Anomalous origin of OA can be associated with intracranial aneurysm. Anomalous origins have been reported from middle meningeal artery (MMA), cavernous carotid, posterior communicating, anterior cerebral and basilar artery. Even though bilateral anomalous origin of OA from MMA is a rare finding, to the author's best knowledge, association of above condition with bilateral internal carotid artery aneurysms has not been described in the literature. We present a case of such anomalous bilateral OA originating from MMA and associated with bilateral internal carotid artery aneurysms. We have also reviewed the pertinent literature regarding anomalous OA origin.

Endoscopic intervention for intraventricular neurocysticercal cyst: Challenges and outcome analysis from a single institute experience.

OBJECTIVE: Endoscopic intervention is presently proposed as standard approach for the treatment of Intraventricular neurocysticercal cyst (IVNCC) as it helps to retrieve the cyst as well as CSF diversion. We present our series of 61 patients with IVNCC managed by endoscopic intervention and analyze the outcome. METHOD: A retrospective analysis of 61 patients with IVNCC managed between 1998-2019 at our institute was performed. We reviewed the clinical details of consecutive patients, management, and outcome. RESULTS: There were 61 patients with 34 males and 27 females. The mean age was 25 years. Fourth ventricular location is the most common (n = 34) followed by third ventricle(n = 14) and lateral ventricle (n = 13). Cyst retrieval could be done in 43 cases, while the cyst could not be retrieved in 18 cases due to intraventricular bleed, CSF turbidity, adhesion of cyst wall etc. Along with cyst retrieval, some patients underwent Endoscopic Third ventriculostomy, septostomy, foraminotomy for internal CSF diversion. Seven patients had a preoperative VP shunt surgery. The median follow-up was 12 months. Preoperative shunt (CI:1.33-62, P = 0.02) was associated with failure of cyst retrieval in univariate analysis as well as in multivariate regression analysis (CI: 0.02-0.94, P = 0.04). Two patients underwent shunt surgery at follow-up period due to the failure of endoscopic CSF diversion. CONCLUSION: Endoscopic management of IVNCC is a safe and effective management option, avoiding an indwelling shunt system. Endoscopic third ventriculostomy should be considered for patients with IVNCC and hydrocephalus.

An unusual etiology of recurrent cerebral abscesses-a report of 3 cases.

BACKGROUND: Cerebral abscess commonly occurs secondary to trauma, hematogenous spread from distant infection, or otitis media. Pulmonary AVF is an uncommon cause of recurrent cerebral abscess and is often overlooked. We report 3 cases of cerebral abscesses secondary to pulmonary AVF. CASE DESCRIPTION: A 20-year-old man who presented with fever, headache, and vomiting of short duration was diagnosed as having right parietal abscess and underwent burr hole and tapping and antibiotic treatment. He later presented with many episodes of cerebral abscess at various locations involving both sides and required multiple surgical procedures. The routine workup for the source did not reveal any etiology. His hematological examination revealed polycythemia. A pulmonary angiogram was performed, which revealed pulmonary AVF. He underwent embolization of the fistula and had no further recurrence. Two other adult men were treated surgically for cerebral abscess. One patient had polycythemia and hypoxemia, and another had clubbing. Both patients were investigated with CT of the chest and were diagnosed as having pulmonary AVF. None of them had features of HHT. CONCLUSIONS: Pulmonary AVF is an unusual cause of cerebral abscess. Patients with multiple recurrences of cerebral abscess, signs of pulmonary disease, and hypoxia should be investigated for pulmonary AVF.

Tuberculous osteitis of clivus.

Tuberculous osteitis of clivus is rare. Its diagnosis is difficult because of the rarity of the site and the non-specific nature of the disease. Management consists of confirmation of diagnosis by biopsy and chemotherapy with anti-tubercular drugs. Meningitis may complicate the clinical course, increase morbidity and mortality.

Spinal extradural cavernous haemangioma.

A case of spinal extradural cavernous haemangioma without a vertebral lesion is reported. Clinical and radiological features of the lesion are discussed. Relevant literature is reviewed.

Large exophytic chondrosarcoma of cervicodorsal spine without spinal cord compression : a case report with review of literature.

A case of well differentiated chondrosarcoma arising from the laminae and spinous processes of cervicodorsal spine is reported in a 22-years-old patient. He had presented with a painless progressive mass in the cervicodorsal region, without any neurological deficit. The tumour had a large exophytic growth without any intraspinal component. Radiological appearance of cartilaginous calcification suggested the diagnosis of a cartilaginous tumour. Fine needle aspiration cytology (FNAC) from the mass failed to differentiate between a chondroma and a well differentiated chondrosarcoma. The final histopathological diagnosis of the surgically excised tumour was possible only after a detailed radiological and clinicopathological correlation. Total surgicalexcision of the tumour was followed by radiation therapy. A review of literature is included in view of the rarity of this condition and scarcity of similar reports in the Indian literature.

Prognosis in children with head injury: an analysis of 340 patients.

BACKGROUND: The outcome in children with head injury is distinctive because of the different biophysical properties of the child's skull and brain, and their reaction to injury. METHODS: In this retrospective study of three hundred and forty children with head injury, managed from January 1993 to December 1998, at NIMHANS, the factors influencing outcome were analyzed. RESULTS: On admission there were 40 children in GCS 3-5, 55 children in GCS 6-8, 96 in GCS 9-12 and 152 children in GCS 13-15. Eleven patients were under 2 years of age, 53 were between 3-5 years, 140 were between 6-10 years and 156 were between 11-15 years of age. The prognosis in various intracranial pathologies due to head injury was evaluated and outcome assessed at discharge. There were 95 children with EDH and 8.4% had poor outcome (vegetative state or death). There were 85 patients with contusion and poor outcome was noted in 18.8%. One hundred patients had diffuse cerebral oedema on CT scan and outcome was poor in 25% of these patients. The clinical features associated with poor prognosis were, absence of ocular movements (50%), abnormal pupillary size and reaction (49%) and age less than 2 years (27%).

Metastatic intracranial tumours : experience and review of literature.

Eighty five patients with histopathologically confirmed intracranial metastatic lesions were analysed retrospectively. There were 55 males and 30 females. More than half of the patients were in fourth and fifth decades. Headache (69 percent), vomiting (50 percent) and altered sensorium (46 percent) were the common presenting features. Failing vision and epileptic seizures were present in 18 percent and 15 percent of the cases, respectively. Papilloedema was present in 68 percent of patients. Motor weakness and cranial nerve involvement was found in 42 percent and 22 percent of the patients, respectively. In 87 percent of the cases the lesions were located within the cerebral hemispheres. Only 6 percent of the patients had lesions in the cerebellum. Carcinoma of the lung was responsible for 36 percent of all intracranial metastases, followed by malignancy of the gastrointestinal tract (15 percent), genito-urinary tract (7 percent) and breast (6 percent). The primary lesion could not be located in 19 percent of the cases. 80 percent patients underwent surgery and less than half of those received postoperative irradiation and chemotherapy. The immediate postoperative mortality was 21 percent. The overall survival at five years was 6 percent.

Electrophysiological evaluation of tremors secondary to space occupying lesions and trauma: correlation with nature and sites of lesions.

BACKGROUND: Electrophysiological evaluation of tremor secondary to intracranial space occupying lesions (SOL) and cranial trauma may provide information regarding pathophysiology of tremors. OBJECTIVES: To compare the electrophysiological characteristics of tremor secondary to SOL and trauma and to correlate tremor characteristics with sites of lesion, and types of SOL. METHODS: Multi-channel tremor recording and MRI were performed in 18 patients with predominantly tremor secondary to SOL (F: M = 5:6; age +/- SD: 26.6 +/- 15.0 years) and following trauma (7 men; age: 27.3 +/- 11.0 years). RESULTS: In both groups, there was a wide range in the frequency of tremor (2.5-7.5 Hz in the SOL group and 2-7.5 Hz in the post-trauma group) and a strong inverse correlation of the frequency with the duration of EMG bursts (SOL group: r = 0.8, p = 0.004; post-trauma group: r = 0.9, p = 0.02). While all the patients with SOL had regular EMG bursts (synchronous - 54.6%, alternating - 27.3%, mixed - 18.2%), 85.7% of post-trauma patients had irregular EMG bursts (synchronous - 42.9%, alternating - 14.3%, mixed - 42.9%). In SOL group, those with predominantly intrinsic destructive lesions of brainstem, thalamus, or basal ganglia (n = 7) had a statistically significant lower mean frequency of tremor than those (n = 4) with either extrinsic or intrinsic compressive lesions (3.5 +/- 0.9 Hz vs 6.7 +/- 0.6 Hz; p = 0.0001). In the post-trauma group, the patients with additional lesions in thalamus or striatum, apart from white and grey matter lesions had lower mean tremor frequency (3.7 +/- 1.0 Hz vs 6.1 +/- 1.5 Hz; p = 0.05). CONCLUSIONS: The electrophysiological characteristics of tremor secondary to SOL and trauma differ and correlate with the nature and sites of lesions. This information, which need to be validated in larger cohort of patients, may be useful in understanding the pathogenesis of tremor.

Haemangioma calcificans.

Haemangioma calcificans is a relatively rare intracranial tumour, which is characterized by the presence of a calcified nodule in or near the brain. The patient is most often an adult of either sex, who develops seizures. The lesion can be large enough to produce raised intracranial pressure. The location of tumour is subcortical and often in the temporal lobe. It is usually solitary and benign in nature. Microscopically, there are thin-walled blood vessels separated by dense fibrous bands containing deposits of haemosiderin and calcium. On electron microscopy, tubular structures limited by a wall of electrodense material and irregular calcium deposits within them are prominent features. Four cases of haemangioma calcificans are described here with review of literature.