Characterization of Ocular Sonography Findings and their Relationship to Clinical Features from a South Indian Cohort of Idiopathic Intracranial Hypertension.

Background: Idiopathic intracranial hypertension (IIH) typically manifests with headache, accompanied by papilledema and visual loss, and has a higher prevalence in females. In recent years, ocular sonography, particularly, measurement of optic nerve sheath diameter (ONSD), is being investigated for diagnosis of IIH. Methods: A total of 35 patients over the age of 18 years, fulfilling the modified Dandy's criteria for diagnosis of IIH were included. Patients underwent assessment with magnetic resonance imaging, lumbar puncture, and ocular sonography to measure ONSD and ocular arterial indices. Results: The mean ONSD values (in centimeters) in the right eye of patients with IIH was 0.57 ± 0.13, while it was 0.48 ± 0.03 in controls. In the left eye, the mean ONSD value (cm) was 0.59 ± 0.13 in patients with IIH and 0.48 ± 0.03 in controls. ONSD was significantly higher in cases compared to controls (P < 0.001, Welch test). Pulsatility index of the central retinal artery was significantly higher in cases compared to controls (P < 0.001, Welch test). Resistance index of the ophthalmic artery was statistically significant (P < 0.005, Welch test). Receiver operating characteristic curve analysis revealed a cutoff value of 5.1 mm on the right side and 5 mm on the left side had a sensitivity and specificity of more than 80% for IIH diagnosis. Conclusion: Our study provides insights into the utility of optic nerve sheath measurements and arterial indices in the diagnosis of IIH in a South Indian cohort. Further research is needed to fully understand the longitudinal relationship of these parameters and treatment outcomes in IIH.

Retrieval of a microcatheter from arteriovenous malformations after hemorrhage following Onyx embolization.

Retained microcatheter is a rare complication during embolization of arteriovenous malformations (AVMs). Following the availability and popularization of Onyx, the incidence of retained catheter has become lesser. Though there have been reports of retained microcatheter during embolization of AVM with Onyx, there has been only one previous report of surgical retrieval of retained microcatheter. We report the second case of retrieval of retained microcatheter following embolization of AVM with Onyx.

Barriers to Thrombolysis at A Tertiary Care Public Hospital- A Prospective Observational Study from Southern Part of India.

Background: Intravenous thrombolysis (IVT) is an effective treatment for carefully selected acute ischemic stroke (AIS) patients. However, very few eligible candidates access it in time around the world, including India, due to multiple barriers. Objective: We explored the barriers to IVT in patients of AIS presenting within a 4.5-h window period in our hospital. Materials and Methods: This was a prospective study of AIS patients presenting in <4.5 h of symptom-onset, aged >18 years at the Neuro-casualty, Department of Neurology, from May 2016 to November 2017. Assessment of barriers to intravenous thrombolysis was done, and an attempt to delineate the reasons for the pre-hospital and the in-hospital delay was made. Results: A total of 103 (M:F: 67:36) patients aged between 18 and 80 years, were recruited, with 28 (27.2%) patients aged <45 years. Among them, 29 (28.2%) were thrombolysed. The major reasons for the pre-hospital delay were ignorance about the need for stroke center consultation- 94 (90.3%), consultation elsewhere before the presentation- 84 (81.5%), and non-availability of an ambulance at referring hospitals- 50 (59.52% out of 84). Sixty-four patients (62.1%) could not name any symptoms of stroke, 84 (83.5%) could not name any risk factor, and only 4 (3.9%) were aware of IVT. Key in-hospital barriers were crowded emergency- 80 (77.7%), financial constraints- 79 (76.7%), and delay in CT scan- 62 (61.4%). Delay in arriving at a consensus for IVT by the patient/relative and the treating neurologist, was noted in 24 (43.6%) of the 55 eligible. Conclusion: Many eligible patients remain deprived of thrombolysis due to lack of awareness, financial constraints, and organizational elements, which should be addressed to improve IVT rates.

Evaluating the Role of Perilesional Tissue in Pathobiology of Epileptogenesis of Vascular Malformations of the Central Nervous System.

Background and Purpose: Seizures are common presentation of cerebral vascular malformation (CVM). Topography and haemodynamic alterations are proposed as mechanisms for epileptogenesis, but the role of glial/neuronal alterations in perilesional tissue has not received much attention. Identification of the exact pathophysiologic basis could have therapeutic implications. To evaluate whether angioarchitectural factors of CVM or alterations in neuroglial/stroma of the adjacent cortex contribute to seizures. Method: The clinical, imaging and histological characteristics of arteriovenous malformation (AVM) and cerebral cavernous malformation (CCM) with and without seizures was evaluated using neuroimaging imaging and digital subtraction angiography parameters and histopathology by morphology and immunohistochemistry. Results: Fifty-six cases of CVM were diagnosed over a 2-year study period. Of these, 32 had adequate perilesional tissue for evaluation (AVM, 24; CCM, 8). Seizures at presentation was seen in 12/24 (50%) of AVM and 5/8 (62.5%) CCM. In AVM, hemosiderin deposition and gliosis in parenchyma (p=0.01) had significant association with seizure. Siderotic vessels in the adjacent cortex was exclusively seen only in CCM with seizures (p=0.018). Angioarchitectural features of CVM on imaging and neuronal alterations in adjacent cortex on histology failed to show any statistically significant difference between the two groups (p>0.05). Conclusions: We propose that changes in adjacent cortex appear to be epileptogenic rather than the malformation per se. Reactive gliosis and hemosiderin deposits in perilesional tissue in AVM and siderotic vessels in CCM were associated with seizure. This explains the better outcomes following extended lesionectomy that includes epileptogenic perilesional tissues.

Effect of remote ischemic preconditioning on cerebral oxygen saturation in aneurysmal subarachnoid hemorrhage: Secondary analysis of a randomized controlled trial.

Remote ischemic preconditioning (RIPC) can ameliorate cerebral vasospasm and delayed cerebral ischemia and improve neurological outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). Monitoring of regional cerebral oxygen saturation (rScO2) during the critical phase after aSAH can help detect ischemia and assess the effect of RIPC intervention. We investigated the effect of RIPC on rScO2 in patients with aSAH. Our study was a single-center, prospective, parallel-group, randomized pilot trial. After approval by institutional ethics committee, consenting patients (n = 25) with aSAH presenting within 72 h of ictus and scheduled for surgical clipping of cerebral aneurysm were randomized 1:1 to true RIPC (inflation of upper extremity blood pressure cuff thrice to 30 mmHg above systolic blood pressure for 5 min) or sham RIPC (inflation of blood pressure cuff thrice to 30 mmHg for 5 min). In this secondary analysis, our outcome measures assessed by a blinded observer were incidence of cerebral oxygen desaturation (COD) during 7-10 days after ictus and Glasgow outcome scale extended (GOSE) at discharge. The incidence of COD (decrease in rScO2 > 20% from baseline) was lower in the RIPC group (15.4% versus 33.3%); p = 0.378. The absence of ipsilateral COD resulted in a higher mean GOSE (estimate 1.15, p = 0.015). The RIPC group had a higher mean GOSE compared to sham group (estimate 0.8, p = 0.027). This pilot trial demonstrated that RIPC has the potential to prevent COD in patients with aSAH. Larger trials with cerebral oxygenation as the primary outcome are needed to confirm our findings.

Clinical, electrophysiological, imaging, and ultrastructural description in 68 patients with neuronal ceroid lipofuscinoses and its subtypes.

PURPOSE: We evaluated the clinical, electrophysiological, imaging, and ultrastructural features of neuronal ceroid lipofuscinoses and its subtypes. METHODS: The clinical, electrophysiological, imaging, histopathological, and ultrastructural features of 68 (age at onset: 4.3 ± 5.4 years) neuronal ceroid lipofuscinoses and its subtypes (infantile neuronal ceroid lipofuscinoses [9], late infantile neuronal ceroid lipofuscinoses [34], juvenile neuronal ceroid lipofuscinoses [23], and adult neuronal ceroid lipofuscinoses [2] were evaluated. Skin (n = 56), brain (n = 12), muscle (n = 4) and nerve (n = 1) biopsies confirmed the diagnosis. RESULTS: Clinical manifestations were milestone regression (93%), involuntary movements (92%), seizures (89%), myoclonus (79%), and visual impairment (68%). Response to anticonvulsants was unsatisfactory. Electroencephalography (n = 59) was abnormal in 90%: background slowing (90%); epileptiform discharges (71%), and photoparoxysmal response (4/21). Visual-evoked (n = 33) and somatosensory evoked (n = 40) potentials were abnormal in 62% and 63% of patients. Cranial computed tomography (n = 33) showed diffuse cerebral (61%) and cerebellar (27%) atrophy. Magnetic resonance imaging was abnormal in all 43 patients who were scanned: diffuse atrophy (100%), cerebellar atrophy (40%), leukoencephalopathy (65%), and thalamic T2 W hypointensity (33%). Dermal inclusions such as curvilinear inclusions were the most common abnormality: late infantile neuronal ceroid lipofuscinoses (97%), juvenile neuronal ceroid lipofuscinoses (100%), and infantile neuronal ceroid lipofuscinoses (88%). Additional fingerprint inclusions were noted: juvenile neuronal ceroid lipofuscinoses (43%), late infantile neuronal ceroid lipofuscinoses (15%), and infantile neuronal ceroid lipofuscinoses (13%). Granular osmiophilic deposits were noted in 50% of infantile neuronal ceroid lipofuscinoses. In 75% of patients, there was good correlation between the clinical subtype and ultrastructural inclusion pattern. In 27% of neuronal ceroid lipofuscinoses, multiple inclusions were noted. CONCLUSIONS: The diagnosis of neuronal ceroid lipofuscinoses should be considered in individuals with characteristic clinical presentations and characteristic ultrastructural dermal inclusions. Three fourths showed morphological correlation of the inclusions with neuronal ceroid lipofuscinoses subtype.

Magnetic resonance imaging in neuronal ceroid lipofuscinosis and its subtypes.

Studies on magnetic resonance imaging (MRI) observations in neuronal ceroid lipofuscinosis (NCL) are few and far between. We evaluated the MRI characteristics of patients with NCL and its subtypes. Forty-three out of 68 patients with ultrastructurally confirmed NCL (M:F=46:22; age at evaluation: 6.3±5.2 years) underwent brain MRI evaluation (1998-2010). The demography, phenotype and subtypes of NCL (n=43) [infantile (I-NCL): 5; late infantile (LI-NCL): 26; Juvenile (J-NCL): 11; adult (A-NCL): 1] were recorded. MRI (brain) was carried out using standard sequences in all. Brain atrophy and signal alterations were assessed visually. Brain MRI was abnormal in all 43 patients - diffuse cerebral atrophy (100%), cerebellar atrophy (40%), cerebral leucoencephalopathy (65%) and thalamic T2W-hypointensity (33%). Diffuse cerebral atrophy was noted in: I-NCL (100%), LI-NCL (62%), J-NCL (36%) and A-NCL (100%) [p=0.05]. Cerebellar atrophy was present in: LI-NCL (42%) and J-NCL (55%). Leucoencephalopathy was observed in: I- NCL (100%), LI-NCL (65%), J-NCL (45%) and A-NCL (100%)). Thalamic T2W-hypointensity was most frequent in I-NCL (80%) followed by J-NCL (36%) and LI-NCL (23%). This is the largest study of its kind. The presence of cerebellar/cerebral atrophy, leucoencephalopathy and thalamic T2W-hypointensity in an appropriate clinical setting might provide clues to the diagnosis of NCL: leucoencephalopathy and thalamic hypointensity (T2W) were noted more frequently in I-NCL, periventricular and parieto-occipital hyperintensities in LI-NCL, and cerebellar atrophy in J-NCL.

Rosette-forming glioneuronal tumor -- evidence of stem cell origin with biphenotypic differentiation.

Rosette-forming glioneuronal tumor (RGNT) of the fourth ventricle is a new addition to the WHO classification of central nervous system tumors. To date, 72 cases have been described in literature. In the present study, we report the clinical and imaging features, with detailed histopathological and immunohistochemical profile, of eight cases. Confocal microscopic evidence of stem cell origin with biphenotypic, glial and neurocytic differentiation is presented with a comprehensive review of literature.

Nitrate and fluoride levels in ground waters of Davanagere Taluka in Karnataka.

The quality of ground water supplies in Davanagere Taluk, situated in central part of Karnataka has been investigated with respect to pH, dissolved solids, chlorides, nitrates and fluorides. The levels of pH, dissolved solids and chlorides were found within the safe limits as prescribed by BIS, for more than 95% of the samples. Out of the 61 different borewell samples analysed, selected from different areas of Davanagere taluk, 26% of the samples are found to contain fluorides less than 0.50 PPM (lower safe limit prescribed by BIS) and 11.5% of the samples are found to contain more than 1.5 PPM of fluorides (higher safe limit prescribed by BIS). Further, it was also found during study that, 16.00% of the borewell samples analyzed, were found to contain more than 100.00 PPM of nitrates (measured as NO3 mg/L, safe limit prescribed by BIS). The values of fluorides and nitrates observed in different samples were in the range of 0.19 - 2.06 PPM and 0.08 - 308 PPM, respectively.