Spinal cord stimulation for complex regional pain syndrome type I with spinal myoclonus - a case report and review of literature.

BACKGROUND: Complex regional pain syndrome (CRPS) is a chronic neuropathic painful condition, sometimes associated with spinal myoclonus. For intractable cases spinal cord stimulation is an important modality of treatment but the response of specifically myoclonus to this treatment is not well described. CASE DESCRIPTION: A 40-year old male, had a history of trauma 12 years back since when he had intractable neuropathic pain in his both upper limbs with superimposed severely disabling myoclonic jerks. He had been through multiple treatment failures. We inserted a cervical spinal cord stimulator which led to immediate cessation of myoclonic jerks, with significant improvement in visual analogue score and Oswestry disability index. CONCLUSION: In patients of chronic intractable cervico-brachial pain disorder with superimposed myoclonus, cervical spinal cord stimulation may be effective against the myoclonus as well as the pain.

Conservative treatment of exposed implant following anterior cervical instrumentation surgery - A case report and review of literature.

We report a case of traumatic C3-C4 disc prolapse in a 58 years old male, who underwent ACDF at our centre. On the third post-operative day, a hypopharyngeal rent with implant exposure was discovered. The patient suffered aspiration pneumonitis. He was tracheostomised and percutaneous endoscopic gastrostomy (PEG) feeding was started. He was managed conservatively with appropriate antibiotics and physiotherapy. He recovered and after 6 months the PEG was removed and oral feeding resumed. He was doing well 42 months after the initial surgery.

Paediatric Moyamoya Disease and Tourette's Syndrome: An Unusual Association Responding Favourably to Direct and Indirect Cerebral Revascularisation Surgery.

BACKGROUND: Moyamoya disease, an uncommon chronic intra-cerebral arteriopathy asymmetrically affecting the proximal vasculature, is rarely associated with clinical features pertaining to movement disorders. CASE DESCRIPTION: A 5-year-and-9-month-old boy developed repetitive episodic involuntary winking of the right eye along with ipsilateral shoulder shrugging movements in an absolutely conscious state, associated with paroxysmal shouts and loud laughs and punctuated with abusive verbal expressions (coprolalia). These episodic features, over the course of the next 1.5 years, got progressively accentuated by situations which evoked stress. In addition, there was progressive regression of verbal and cognitive milestones, emotional lability and aspects of attention deficit hyperkinetic disorder. The child was evaluated by a neurologist with magnetic resonance imaging of the brain, which showed characteristic ischaemic areas involving the basal ganglia and fronto-parietal cortical areas along the middle cerebral artery territory, predominantly on the left side. Subsequent cerebral angiography revealed extensive stenosis of bilateral (predominantly left-sided) internal cerebral arteries and middle cerebral arteries with evidence of diffuse leptomeningeal collaterals. The electroencephalography was reported to be normal. He was eventually diagnosed to be suffering from Moyamoya disease with associated Tourette's syndrome. Subsequently, the child underwent left-sided superficial temporal artery to middle cerebral artery anastomosis along with encephalo-duro-arterio-myo-synangiosis. Significant clinico-radiological improvement was noted after 3 months. The clinical deficiencies had dramatically resolved. There was evidence of excellent development of both direct and indirect surgical collaterals along the left middle cerebral artery territory. He could go back to school. CONCLUSION: Ours is probably the first case reporting an association of paediatric Moyamoya disease with Tourette's syndrome, which significantly resolved after cerebral revascularisation surgery.

Survival trends in glioma: Experience at a tertiary care centre.

BACKGROUND: Even after decades of research in the field of gliomas, the overall prognosis is still quite dismal. Several factors have been proposed that affect the outcome and survival length of patients with a glioma. Here, we present a series of 471 patients, who underwent surgical resection of their glioma at a tertiary level neurosurgical centre. MATERIALS AND METHODS: We noted retrospective data of patients' age, histological tumor grade, and whether or not intraoperative magnetic resonance imaging (MRI) was used, and assessed the survival length of these patients from the day of surgery. RESULTS: The overall survival in our series was approximately 14 months. Predictably, those with age less than 40 years and those with Karnofsky performance score (KPS) ≥80 had longer survival than those with a higher age and KPS <80; those with World Health Organisation (WHO) grade IV lesions had the shortest survival length compared to all the other grades. However, while comparing survival among other tumor grades, we did not find significant difference. Further, use of intraoperative MRI did not offer any statistically significant difference in survival. CONCLUSION: In addition to the conventional prognostic factors we need more definate ways to accurately predict survival in patients harbouring a glioma. Probably, assessing molecular characteristics of the individual tumors, such as presence of isocitrate dehydrogenase (IDH) mutation versus wild-type IDH, would help us in predicting survival more accurately.

Draining vein shielding in intracranial arteriovenous malformations during gamma-knife: a new way of preventing post gamma-knife edema and hemorrhage.

BACKGROUND: Following gamma knife (GK) therapy for intracranial arteriovenous malformations (AVMs), obliteration of the nidus occurs over several years. During this period, complications like rebleeding have been attributed to early draining vein occlusion. OBJECTIVE: To evaluate if shielding the draining vein(s) during GK therapy prevents early draining vein obliteration and complications following GK therapy. METHODS: This was a nonrandomized case-control study over 5 years (January 2009-February 2014) and included patients with intracranial AVM who underwent GK therapy at our center. All patients who underwent draining vein shielding by the senior author (D.A.) were included in the test group, and patients who did not undergo draining vein shielding were put in the control group. Patients were followed up for at least 6 months (and every 6 months thereafter) clinically as well as radiologically with computed tomography head scans/magnetic resonance imaging brain scans to check for postradiosurgery imaging (PRI) changes. RESULTS: One hundred eighty-five patients were included in this study, of which 96 were in the control group and 89 were in the test group. Both groups were well matched in demographics, comorbidities, adjuvant treatment, angioarchitecture, and radiation dosing. Because of shielding, the test group patients received significantly less radiation to the draining vein than the control group (P = .001). On follow-up, a significantly lower number of patients in the test group had new neurological deficits (P = .001), intracranial hemorrhage (P = .03), and PRI changes (P = .002). CONCLUSION: Shielding of the draining vein is a potent new strategy in minimizing PRI and hemorrhage as well as clinical deterioration following GK therapy for intracranial AVMs.