Craniotomy with Ridges: A Time and Cost-Efficient Technique for Unwavering Fixation of Bone Flap.

After advent of the power driven tools, the ease of surgeons and pace of surgery has been enhanced. Nowadays, most of the neurosurgeons are tend to use the motorized drills for elevating a bone flap to make a craniotomy. The bone cutting by the craniotome is wide and nonbeveled, which mandates the fixation of bone flap at closure, either by wiring, miniplates, or other fixation techniques. This not only lengthens the duration of surgery but also adds extra cost of miniplates to the patient. Here we are presenting a novel technique of elevating a bone flap where fixation at the end of surgery is not obligatory, without any risk of sinking of bone flap into the craniotomy defect.

Endoscopic Management of Intraventricular Neurocysticercosis.

AIM: To evaluate the technique and outcome of endoscopic management of intraventricular neurocysticercosis (NCC). MATERIAL AND METHODS: We retrospectively analysed the records of 30 consecutive patients of intraventricular (intra-third and fourth ventricle) NCC who underwent endoscopic management. The clinical profiles of the patients were evaluated which included age, symptoms and signs. Transcranial endoscopy was performed through a frontal burr hole using a Gaab Universal Endoscope system with rigid 0° and 30° telescope for endoscopic third ventriculostomy and removal of the cyst was described. The mean follow-up period was 22.6 months. RESULTS: In 86.67% (26/30) patients we are able to visualize/excise/decompress the cyst. We were able to successfully excise all the third ventricular cysts (16/16) and in 66.67% (8/12) of the fourth ventricular cysts. In 90% (27/30) patients we were able to successfully divert the CSF flow and achieve long-term shunt free period. CONCLUSION: We found that endoscopic cerebrospinal fluid (CSF) diversion in cases of intraventricular NCC is feasible and associated with high success rate. Endoscopic CSF diversion in NCC related hydrocephalus usually produces a long-term cure.

Central nervous system mycosis: analysis of 10 cases.

AIM: To describe the clinicopathological features in patients with fungal infections of the central nervous system (CNS) presenting as mass lesions. MATERIALS AND METHODS: A retrospective analysis of records obtained from 10 patients was done with histopathologically confirmed fungal infections presenting as ICSOL, diagnosed in the department of pathology. Clinical features at presentation, findings of radiological investigations performed and histopathology were noted for each patient and subjected for analysis. RESULTS: Infection was higher in males, and paranasal sinusitis was the most common predisposing factor. Location was intraparenchymal followed by sphenoid wing. Four dural-based lesions mimicked meningioma clinically. The most common fungus identified was zygomycosis (seven cases), followed by phaeohyphomycosis (two cases) and aspergillosis (one case). CONCLUSION: There is a rising trend of CNS mycosis, both in immunocompromised and immunocompetent patients. Intracranial fungal granuloma may mimic radiologically as glioma or meningioma, therefore a high index of suspicion is needed to detect early CNS fungal infections, especially in immunocompetent young patients with no predisposing illness. Fungi should always be excluded in patients with inflammatory or granulomatous pathology of CNS.

Subcompartmentalization of extracellular extravascular space (EES) into permeability and leaky space with local arterial input function (AIF) results in improved discrimination between high- and low-grade glioma using dynamic contrast-enhanced (DCE) MRI.

PURPOSE: To modify the generalized tracer kinetic model (GTKM) by introducing an additional tissue uptake leakage compartment in extracellular extravascular space (LTKM). In addition, an implicit determination of voxel-wise local arterial input function (AIF) Cp (t) was performed to see whether these changes help in better discrimination between low- and high-grade glioma using dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI). MATERIALS AND METHODS: The modified model (LTKM) was explored and fitted to the concentration-time curve C(t) of each voxel, in which the local AIF Cp (t) could be estimated by a time invariant convolution approximation based on a separately measured global AIF Ca (t). A comparative study of tracer kinetic analysis was performed on 184 glioma patients using DCE-MRI data on 1.5T and 3T MRI systems. RESULTS: The LTKM analysis provided more accurate pharmacokinetic parameters as evidenced by their relative constancy with respect to the length of concentration-time curve used. In addition, LTKM with local AIF resulted in improved discrimination between low-grade and high-grade gliomas. CONCLUSION: LTKM with local AIF provides more accurate estimation of physiological parameters and improves discrimination between low-grade and high-grade gliomas as compared with GTKM.

Unilateral hydrocephalus: atypical presentation of intracranial tuberculoma.

A 43-year-old male presented with 3-month history of low-grade fever and headache. Radiological investigations revealed unilateral hydrocephalus. Unilateral obstruction of the foramen of Monro due to chronic tubercular ependymal inflammation was suspected and endoscopic septostomy was planned. Though ventriculo-peritoneal shunt is a simple method to treat hydrocephalus, complications related to this procedure are numerous. Neuroendoscopy is a safe method to treat hydrocephalus in selected cases, and also provides access to biopsy the lesion in question. An isolated tuberculoma obstructing the foramen of Monro was seen during endoscopy. Presentation and management of this unusual tuberculoma is reported along with a review of the pertinent literature.

The transparaspinal approach: A novel technique for one-step removal of dumb-bell-shaped spinal tumors.

Complex dumb-bell spinal tumors are challenging surgical lesions. Combined antero-posterior exposures have traditionally been used in their management. This combined exposure has the disadvantage of a two-stage operation with transthoracic or retroperitoneal dissection. With better understanding of biomechanics of spine and evolution of microsurgical technique, there has been resurgence of single stage surgeries, among which the transparaspinal exposure provides the simplest and the most direct route for resection of dumb-bell tumors. A 16-year-old male was admitted with history of back pain with radiation to left lower limb for 6 months, progressive weakness of both lower limbs for two months, and hesitancy of micturition for 1 month. A clinical diagnosis of cauda-conus lesion was made. Radiological investigations revealed a complex dumb-bell spinal tumor extending from lower part of L2-L4 vertebra, with large paraspinal extension through left L3 intervertebral foramina. Tumor was successfully removed in one step using a transparaspinal approach. We discuss technical details of this novel approach along with limitations and possible complications.

Intraoperative ventriculo-stomographic evaluation of endoscopic cerebrospinal fluid diversion and flow restoration procedures.

PURPOSE: This prospective study was designed for intra-operative demonstration of cerebrospinal fluid (CSF) flow in ventricles and cisternal spaces before and after neuroendoscopic procedure. The aim of this study was to evaluate site of obstruction of CSF flow and subsequent stomal or aqueductal patency after endoscopic third ventriculostomy (ETV) or aqueductoplasty in patients with hydrocephalus of diverse aetiology. METHOD: Seventeen patients with hydrocephalus due to diverse aetiology underwent ETV (n = 15) and aqueductoplasty (n = 2) or cysto-ventrticulostomy (n = 1) or transaqueductal removal of neurocysticercus cyst (NCC) (n = 1). Intra-operatively, radio-opaque contrast agent (iohexol) instillation into the third ventricle was used for qualitative evaluation of obstruction and post-procedure CSF flow across the stoma into cisternal spaces. RESULT: 11 male and 6 female patients ranging from 3 to 50 years of age were included in the study. Post-procedure intra-operative ventriculo-stomography (IOVSG) showed free flow of dye across the endoscopic stoma (n = 13) or aqueduct (n = 2) into cisternal spaces. Diagnosis of fourth ventricular NCC was made in one patient with panventriculomegaly. In two patients of tuberculous meningitis hydrocephalus, poor flow of contrast in the prepontine area and basal cisterns was seen on IOVSG. They were subjected to ventriculoperitoneal shunt insertion in the same sitting. Cine MRI confirmed the patency of stoma or aqueduct in follow-up period in all patients with successful endoscopic procedure. CONCLUSION: IOVSG is a simple and safe technique that helps in confirming the adequacy of endoscopic procedure during surgery and thereby facilitates intra-operative decision about further management.

Central pontine myelinolysis in a pediatric head injury patient.

Central pontine myelinolysis occurs inconsistently as a complication of severe and prolonged hyponatremia, particularly when corrected too rapidly. It is a concentrated, frequently symmetric, noninflammatory demyelination within the central basis pontis. We describe a head injury patient who suffered this clinical entity as a consequence of rapidly corrected hyponatremia. Clinical manifestation and radiological findings are described along with a review of the pertinent literature.

Assessment of therapeutic response in patients with brain abscess using diffusion tensor imaging.

BACKGROUND: Accurate assessment of therapeutic response in patients with brain abscess (BA) is essential to direct appropriate therapy. This study was performed with an aim to see the treatment-induced changes in diffusion tensor imaging (DTI) indices (i.e., fractional anisotropy [FA] and mean diffusivity [MD]) in follow-up patients with BA after treatment. METHODS: Twenty patients with BA were prospectively studied in this study. Diffusion tensor imaging in first follow-up was done in all after 1 week and in 6 at 4 weeks of the initial study. RESULTS: The mean FA and MD values in first, second, and third studies were 0.28 +/- 0.03 and (0.81 +/- 0.07) x 10(-3) mm(2)/s, 0.18 +/- 0.09 and (1.08 +/- 0.09) x 10(-3) mm(2)/s, and 0.13 +/- 0.04 and (0.99 +/- 0.13) x 10(-3) mm(2)/s, respectively. The FA value was significantly (P < .01) decreased along with no significant change in MD value (P = .08) for 3 study periods. The mean volume (in milliliter) of the abscesses was 2.14 +/- 1.04, 1.34 +/- 0.45, and 0.77 +/- 0.14 in first, second, and third studies, respectively. CONCLUSIONS: We conclude that the reduction in FA value reflects the down-regulation of the neuroinflammatory molecules in response to treatment in patient with BA and may be used to assess therapeutic response in these patients in future.

Proliferating cell nuclear antigen, p53 and micro vessel density: Grade II vs. Grade III astrocytoma.

Histological classification and grading are prime procedures in the management of patients with astrocytoma, providing vital data for therapeutic decision making and prognostication. However, it has limitations in assessing biological tumor behavior. This can be overcome by using newer immunohistochemical techniques. This study was carried out to compare proliferative indices using proliferating cell nuclear antigen (PCNA), extent of p53 expression and micro vessel morphometric parameters in patients with low grade and anaplastic astrocytoma. Twenty-five patients, each of grade II and grade III astrocytoma were evaluated using monoclonal antibodies to PCNA, p53 protein and factor VIII related antigen. PCNA, p53-labeling indices were calculated along with micro vessel morphometric analysis using Biovis Image plus Software. Patients with grade III astrocytoma had higher PCNA and p53 labeling indices as compared with grade II astrocytoma (29.14 plus/minus 9.87% vs. 16.84 plus/minus 6.57%, p 0.001; 18.18 plus/minus 6.14% vs. 6.14 plus/minus 7.23%, p 0.001, respectively). Micro vessel percentage area of patients with grade III astrocytoma was also (4.26 plus/minus 3.70 vs. 1.05 plus/minus 0.56, p 0.001), higher along with other micro vessel morphometric parameters. Discordance between histology and one or more IHC parameters was seen in 5/25 (20%) of patients with grade III astrocytoma and 9/25 (36%) of patients with grade II disease. PCNA and p53 labeling indices were positively correlated with Pearson's correlation, p less than 0.001 for both). Increased proliferative fraction, genetic alterations and neovascularization mark biological aggressiveness in astrocytoma. Immunohistochemical evaluation scores over meet the challenge of accurate prognostication of this potentially fatal malignancy.

Serial changes in diffusion tensor imaging metrics of corpus callosum in moderate traumatic brain injury patients and their correlation with neuropsychometric tests: a 2-year follow-up study.

OBJECTIVE: To assess longitudinally the severity of diffuse axonal injury in the corpus callosum in patients with moderate traumatic brain injury (TBI) through quantitative diffusion tensor imaging and to correlate these changes with neuropsychometric tests (NPT) at 6 and 24 months after injury. DESIGN: Prospective longitudinal study. PARTICIPANTS: Sixteen patients with TBI and 17 age/sex-matched healthy controls. METHODS: Patients underwent magnetic resonance imaging at 3 time points: within 2 weeks (range = 5-14 days), 6 months, and 24 months after injury. NPT could be performed only at 6 and 24 months. RESULTS: In patients with TBI, a significant increase in fractional anisotropy (FA) values in genu as well as an insignificant decrease in radial diffusivity (RD) and mean diffusivity values in genu and splenium were observed over time, respectively. FA, RD, and mean diffusivity values continued to be abnormal in patients compared with controls at the end of 2 years. Although some NPT scores improved over time in these patients, these were still significantly impaired compared with controls. CONCLUSIONS: FA and RD indices appear to be surrogate markers of microstructural alterations in patients over time and correlate significantly with some of the NPT scores. The recovery in these indices associated with recovery in neurocognitive deficits suggests that these indices may be used as an objective marker for residual injury in these patients.

Tumor irrigation fluid enhances diagnostic efficacy in endoscopic biopsies of intracranial space-occupying lesions.

PURPOSE: Intraventricular neuroendoscopic CNS biopsiesare small, fragmented, and tissue is frequently inadequate for diagnosis. We have attempted to increase cellular yield using tumor irrigation fluid (TIF) and a cyto-histological approach for diagnosis of intracranial tumors, cysts, and infections. METHODS: A retrospective group of 147 cases, where only endoscopic biopsies were obtained, was compared with a prospective group of 31 cases where along with the endoscopic biopsies, tumor irrigation fluid (TIF) was collected. Tumor cyst fluid was obtained from cystic tumors (n=6). Small tumor fragments in the TIF were utilized to make squash smears (n=31). Clotted fragments were processed for sections in (n=3). Centrifuged deposit smears were prepared from tumor irrigation fluid and tumor cyst fluid. RESULTS: Conclusive pathological diagnosis in endoscopic biopsies could be arrived at in 77.4% (24/31) prospective cases and 80.3% (118/147) in retrospective cases. Collection of TIF with a cyto-histological diagnostic approach gave a significantly higher rate of conclusive pathological diagnosis in 93.5% (29/31) cases in the prospective group. CONCLUSIONS: Additional tissue from TIF preserves the original biopsy, provides more material for diagnosis and gives a better morphological picture in smears. Hence diagnosis of endoscopic CNS biopsies can be rendered in more cases and with greater degree of confidence.

Correlation of DTI metrics in the wall and cavity of brain abscess with histology and immunohistochemistry.

Diffusion tensor imaging (DTI) was performed in eight patients with brain abscess (BA). The aim of this study was to see the difference in the relationship between intercellular cell adhesion molecule-1 (ICAM-1) and lymphocyte function-associated antigen-1 (LFA-1) expression and DTI metrics measured in vivo in the wall and cavity of BA and its possible explanation vis-à-vis histology and immunohistochemistry. Neuroinflammatory molecules (NMs) were quantified from BA cavity aspirate of the patients and quantitative immunohistochemical analysis was performed for ICAM-1 and LFA-1 in the BA wall, showing maximal positive staining and correlated with DTI metrics. The fractional anisotropy (FA) significantly increased while mean diffusivity and spherical anisotropy significantly decreased in the BA wall compared to the BA cavity. In the BA wall, FA and linear anisotropy (CL) showed a significant positive correlation with ICAM-1 and LFA-1 expression whereas FA and planar anisotropy positively correlated with NMs quantified from aspirated pus respectively. Higher FA values in the BA wall compared to BA cavity, even when ICAM-1 and LFA-1 were expressed only in the macrophages and not in the collagen fibers, suggests that a combination of both concentric layers of collagen fibers as well as neutrophils and macrophages provide structural orientation and are responsible for increased FA. In the BA wall, increased CL was found compared to the cavity, indicating the presence of concentrically laid collagen fibers responsible for the diffusion of water molecules in the direction parallel to the collagen fibers. We conclude that in the BA, different mechanisms are operative for the changes in the DTI metrics in the wall and cavity; these conclusions are validated by histology and immunohistochemistry.

Comparative evaluation of corpus callosum DTI metrics in acute mild and moderate traumatic brain injury: its correlation with neuropsychometric tests.

PRIMARY OBJECTIVE: To look for differences in vulnerability of corpus callosum (CC) in patients of mild and moderate traumatic brain injury (TBI) in the acute stage using quantitative diffusion tensor imaging (DTI) and to correlate these with neuropsychometric tests (NPT) done at 6 months post-injury. RESEARCH DESIGN, METHODS AND PROCEDURES: Conventional MRI, DTI and NPT were performed on 83 patients (moderate TBI, n = 57; mild TBI, n = 26) within 5-14 days after TBI. Thirty-three age- and sex-matched healthy controls were also included for comparison. RESULTS: Significantly decreased fractional anisotropy (FA) in genu and splenium; significantly increased radial diffusivity (RD) values in genu, midbody and splenium with significant increase in mean diffusivity (MD) and a decrease in axial diffusivity (AD) only in genu, respectively, in patients with moderate TBI compared to healthy controls were observed. However, in moderate TBI, significantly decreased FA was found only in genu compared to mild TBI. Moderate TBI showed poor NPT scores compared to mild TBI, but this did not reach statistical significance. CONCLUSIONS: It is concluded that DTI abnormalities in the regions of CC were more in patients with moderate TBI compared to mild TBI and this was associated with relatively poor neuropsychological outcome 6 months post-injury.

Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic third ventriculostomy: prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy.

OBJECT: Endoscopic third ventriculostomy (ETV) is increasingly being used as an alternative treatment for post-tuberculous meningitis (TBM) hydrocephalus. The aim of this study was to affirm the role of ETV in patients with TBM hydrocephalus and also to study the usefulness of cine phase-contrast MR imaging (cine MR imaging) for functional assessment of the ETV stoma. An additional goal was to identify factors that influence the outcome of ETV, so as to define patients with TBM hydrocephalus in whom ETV is warranted. METHODS: Twenty-six patients with TBM hydrocephalus treated with ETV were evaluated clinically and with cine MR imaging postoperatively. The duration of follow-up ranged from 1 to 15 months. The authors evaluated flow void changes in the floor of the third ventricle and analyzed parameters from the preoperative data, which they then used as a basis for comparison between endoscopically successful and endoscopically unsuccessful cases. RESULTS: The overall success rate of ETV in TBM hydrocephalus was 73.1% in this case series. Cine MR imaging showed a sensitivity of 94.73% and specificity of 71.42% for the functional assessment of third ventriculostomy in these patients, with the efficacy being maintained during follow-up. The outcome of ETV showed a statistically significant correlation with the stage of illness and presence of intraoperative cisternal exudates. Although duration of symptoms and duration of preoperative antituberculous therapy (ATT) appeared to influence the outcome, their correlation with outcome was not statistically significant. CONCLUSIONS: Endoscopic third ventriculostomy should be considered as the first surgical option for CSF diversion (that is, before shunt surgery) in patients with TBM hydrocephalus. Cine MR imaging is a highly effective noninvasive tool for the postoperative functional assessment of stomata. Patients who presented with a history of longer duration and those who were administered preoperative ATT for a longer period had a better outcome of endoscopic treatment. Outcome was poorer in patients who presented with higher stages of illness and in those in whom cisternal exudates were observed intraoperatively.

Combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic decompression of a giant pituitary adenoma: case report.

OBJECTIVE: This is the first report of the simultaneous combined use of trans-sphenoidal and trans-ventricular-endoscopic route for decompression of a giant pituitary adenoma. METHOD: A 38 year old man presented to us with symptoms of raised intracranial pressure along with visual and hypothalamic disturbances. The CT scan revealed destruction of the sella by a large (5 x 3.5 x 2.5 cm) well defined enhancing mass in the sella and suprasellar region extending laterally up to the cavernous sinuses and both carotid arteries and superiorly into the lumen of the 3rd ventricle producing obstructive hydrocephalus. On T2WI of the non-contrast MRI scan the mass was iso-intense to grey matter suggesting the possibility of a firm nature of the adenoma. The tumour was first approached by the standard trans-sphenoidal route and as predicted from the pre-operative MRI, the tumour was found to be firm and not amenable to suction. After decompression of the intra-sellar part of the tumour, the intracranial pressure was raised in an attempt to make the remainder of the tumour descend into the sella but without success. The suprasellar part of the tumour was then simultaneously addressed via a trans-ventricular-endoscopic route but the firm tumour did not yield to endoscopic instruments viz. biopsy forceps, angiographic catheter and electrosurgical probes. It was then gently pushed down towards the sella and decompressed piecemeal by using trans-sphenoidal instruments. The sellar cavity was reconstructed using fat, fascia lata graft and a piece of septal bone. RESULTS: Post-operatively, the patient showed a remarkable improvement of his symptoms of raised intracranial pressure, hypothalamic dysfunction and visual disturbances. Follow-up imaging at 2 months and 1 year, did not show any residual or recurrent tumour. CONCLUSIONS: This novel technique of the combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic approach is a viable option for patients with giant fibrous pituitary adenoma when the tumour is not yielding to the trans-sphenoidal route alone.

Serial changes in the white matter diffusion tensor imaging metrics in moderate traumatic brain injury and correlation with neuro-cognitive function.

Diffuse axonal injury (DAI) that follows traumatic brain injury (TBI) is thought to be a major contributor to neurocognitive dysfunction that sometimes follows TBI. Conventional magnetic resonance imaging (MRI), diffusion tensor imaging (DTI) and neuropsychological tests (NPT) were performed on 38 TBI patients [hemorrhagic DAI (H-DAI, n=8), non-hemorrhagic (Nh-DAI, n=7), with no apparent DAI on conventional MRI (NA-DAI, n=23)] with a Glasgow Coma Scale score ranging between 9 and 13. The fractional anisotropy (FA) and mean diffusivity (MD) were quantified from different regions of the corpus callosum (CC), and peri-ventricular white matter (PWM) within 5-14 days and 6 months following TBI. Patients in all three groups showed decreased FA in the anterior limb of the internal capsule (ALIC) and the posterior limb of the internal capsule (PLIC), while the genu of the CC showed a decrease in the H-DAI group during the early period following TBI that persisted 6 months later, which appeared to be consistent with axonopathy. In patients without abnormalities on conventional MRI and DTI in the initial phase, a significant decrease in FA and increase in MD were observed in a few regions of the CC at 6 months, which was suggestive of demyelination/gliosis. The changes in FA and MD in the CC and PWM at 6 months follow-up showed significant correlation with some of the NPT performed in the three groups. DTI demonstrates axonopathy in the acute stage, as well as at secondary stages, at 6 months post-injury in the CC and PWM in regions of normal-appearing white matter on conventional MRI.

Role of diffusion tensor imaging metrics and in vivo proton magnetic resonance spectroscopy in the differential diagnosis of cystic intracranial mass lesions.

The purpose of this study was to determine whether proton magnetic resonance spectroscopy (PMRS) and diffusion tensor imaging (DTI) indices, fractional anisotropy (FA) and mean diffusivity (MD) can be used to distinguish brain abscess from cystic brain tumors, which are difficult to distinguish by conventional magnetic resonance imaging (MRI). Fifty-three patients with intracranial cystic mass lesions and 10 normal controls were studied. Conventional MRI, PMRS and DTI of all the patients were performed on a 1.5-T GE scanner. Forty patients were with brain abscess and 13 with cystic tumors. Cytosolic amino acids (AAs) were present in 32 of 40 brain abscess patients. Out of 13 patients with cystic tumors, lactate and choline were seen in 3 and only lactate was present in 10 patients on PMRS. All 40 cases of abscess had high FA, while all 13 cases of tumor cysts had high MD values. We conclude that FA measurements are more sensitive in predicting the abscess, while PMRS and MD are more specific in differentiating abscess from cystic tumors. We suggest that PMRS should be combined with DTI rather than with diffusion-weighted imaging as FA can be used as an additional parameter for separation of abscess from other cystic intracranial mass lesions.

Endoscopic diagnosis of a pineal papillary glioneuronal tumor with extensive ventricular involvement: case report with review of literature.

Papillary glioneuronal tumor (PGNT) is a newly described mixed glioneuronal tumor, recently included in the World Health Organization classification of central nervous system tumors. We report morphologic and immunohistochemical characteristics PGNT of the pineal region extending into the third and lateral ventricles in a four-year-old male child and reviewed all the cases reported in the international literature till date. In this child the diagnosis of PGNT was established by endoscopic biopsy and squash smear examination.

DTI derived indices correlate with immunohistochemistry obtained matrix metalloproteinase (MMP-9) expression in cellular fraction of brain tuberculoma.

We performed in vivo diffusion tensor imaging (DTI) in a total of 33 patients with brain tuberculomas (BT). Thirteen of them had surgical excision of the lesion as it was clinically indicated, and in these samples matrix metalloproteinase-9 (MMP-9) expression was quantified. We correlated the results of DTI indices like fractional anisotropy (FA), mean diffusivity (MD), linear anisotropy (CL), planar anisotropy (CP) and spherical anisotropy (CS) with MMP-9 expression. In addition, the remaining 20 patients had serial DTI studies while on specific anti-tuberculous drug therapy and DTI indices in these patients were quantified. The FA, CL and CP significantly decreased while MD and CS significantly increased in BT compared to normal white matter. The FA, CL and CP showed negative correlation with MMP-9 while CS correlated positively. In serial follow-up studies in 20 patients FA, CL and CP showed significant increase while CS decreased significantly over time. We conclude that DTI indices show strong correlation with MMP-9 and these may be used as a surrogate marker of MMP-9 expression in BT. In addition, these indices may be of value in assessing the therapeutic response in patients with BT who are treated only with specific anti-tuberculous drugs.