"Tailored" far lateral approach to anterior foramen magnum meningiomas - The importance of condylar preservation.

INTRODUCTION: Anterior and anterolaterally situated foramen magnum meningiomas are a technically complex subgroup of meningiomas. The need for an extensive exposure and bone work and their complex anatomy make them a difficult and challenging group of tumors to resect. The bone work has ranged from an extensive condylar resection to condylar preserving exposures. In this paper, we present our experience with condylar preserving or minimal condylar resection based approaches to these tumors. MATERIALS AND METHODS: All patients who underwent surgical resection of anterior and anterolaterally situated foramen magnum meningiomas were included in the analysis. The study period was more than 10 years from 2005 to 2015 at our institute; a tertiary referral centre in India. The records along with demographic profile, clinico-radiological features, surgical strategies, outcomes as well as mortality and morbidity were analysed. RESULTS: There were a total of 20 patients (9 males and 11 females) who were operated during the study period. The average age was 36.7 years. In 16 patients, gross-total or near-total resection could be achieved, four patients underwent subtotal resection. Eight patients had fresh morbidity in the form of new motor deficits, pseudomeningocele formation, worsening of the lower cranial nerve functions or post-operative adhesions leading to syrinx formation. The follow-up ranged from 6 months to 140 months. CONCLUSION: Foramen magnum meningiomas are an eminently treatable group of tumors. Condylar preservation provides a good visualization, while helping to preserve joint stability and in avoiding instrumental stabilization.

Peculiarities and Patterns of Cervical Spine Injuries in Children and Adolescents: A Retrospective Series of 84 Patients from a Single Institute.

Cervical spine injuries occur infrequently in children but are associated with significant disability and mortality. A retrospective analysis was performed of 84 consecutive pediatric spine injuries treated at our institute from January 2002 to December 2011. The mean age was 14.7 years. There were 18 patients (21%) in group A (0-12 years) and 66 patients (79%) in group B (13-18 years). Overall, injury was more common in boys (ratio of 6:1). Trivial fall was the predominant cause in group A and fall from height in group B. There were 30 children (36%) with injuries of the upper cervical spine, 53 (63%) with injuries of the lower cervical spine and 1 patient (1%) with a combined injury of upper cervical spine and thoracic spine. Overall, 22% of the group A children and 67% of the group B patients had more severe injuries (Frankel grades A, B and C); 21% (18/84) were treated by surgical fusion. Where follow-up was available, 17 out of 22 children (77%) had good outcome (Frankel grade >C). In conclusion, mechanisms and patterns of injury in children are age related and the majority of the children had good outcome.

Microsurgical treatment of distal anterior cerebral artery aneurysms: A 25 year institutional experience.

INTRODUCTION: We present a retrospective study of distal anterior cerebral artery (DACA) aneurysms operated at our institute. MATERIAL AND METHODS: From 1988 to 2013, a total of 132 DACA aneurysms were managed surgically. The retrospective data of these patients was collected and analysed. RESULTS: They comprised 6.2% of all 2137 aneurysms operated during the same period. The mean age at presentation was 48.3 years (range: 24-77 years) and the male: female ratio was 1:2. The notable symptom in 114 (86.4%) patients was headache, in 94 (71.2%) was loss of consciousness, in 25 (18.9%) was seizures, and in 17 (12.9%) was limb weakness. There were 99 (75%) patients in World Federation of Neurosurgical Societies (WFNS) grade <3 at admission. On plain computed tomography (CT) scan, intracerebral hemorrhage was seen in 49 (37.1%) and intraventricular hemorrhage in 23 (17.4%) patients. The most common site of aneurysm was the pericallosal (A3 segment) artery noted in 65 (49.2%) patients. Multiple aneurysms were observed in 16 (12.1%) cases. The mean timing of surgery from the first ictus was 17.8 days. The delay was due to a late referral, poor general condition, recurrent bleeding, and worse WFNS grade at presentation. Aneurysms were operated through the following approaches: parasaggital craniotomy in 61 (46.2%), bifrontal craniotomy in 64 (48.5%), and frontotemporal craniotomy in 7 (5.3%). Aneurysms could be successfully clipped in 93.2% of the cases. Postoperative mortality was 8 (6%). The follow-up data was available for 83 (62.9%) patients. The mean duration of follow-up was 15.1 months (1-70 months), with more than 41 (31%) patients having a follow-up of more than 6 months. A favorable outcome (good recovery or moderate disability) was seen in 71 (85.5%) cases. CONCLUSIONS: A meticulous attention to the surgical technique provides gratifying results in DACA aneurysms even in patients who present initially in a compromised clinical status.

Evolution of MRI changes in Rasmussen's encephalitis.

PURPOSE: We studied the MRI findings in 16 patients with Rasmussen's encephalitis (RE), further analysed serial MRI changes in 11 of them and correlated it with clinical features. METHODOLOGY: The diagnosis of RE was based on the European consensus statement (Brain, 128, 2005, 454). Details related to demographical, clinical, MRI observations were analysed. RESULTS: Forty MRIs of brain of 16 patients were reviewed. Eleven patients had undergone serial brain MRIs ranging from two to five occasions. All the patients had unihemispheric focal cortical atrophy, predominantly in the perisylvian region (n = 13). Other features were white matter signal changes (n = 14), and ipsilateral caudate (n = 6) and putamen (n = 4) atrophy. Signal alterations in putamen and caudate were noted in four each. In all the 11 patients with serial MRI, there was progression of cerebral atrophy and a trend towards increase in MRI staging. The MRI signal changes remained same in five patients, resolved in three patients, differential change in two patients and increased in one patient. Diffusion-weighted imaging showed facilitated diffusion (n = 5), and MR spectroscopy showed reduced N-acetyl-aspartate and elevated lactate (n = 2). CONCLUSIONS: Pattern recognition of MRI findings and the changes in serial MRI might serve as a surrogate marker of disease viz. unihemispheric progressive focal cortical atrophy and signal changes predominantly in the perisylvian distribution and caudate followed by putamen involvement. This might assist in understanding and monitoring of the disease progression.

Central nervous system lymphoma: patterns of incidence in Indian population and effect of steroids on stereotactic biopsy yield.

BACKGROUND: Epidemiology of primary central nervous system lymphoma (PCNSL) world-wide shows an increase in incidence linked to human immunodeficiency virus (HIV) pandemic. MATERIALS AND METHODS: This retrospective review of case records analyzed the trends of hospital-based incidence of PCNSL over two decades (1991-2010), relation to immune status and effect of steroids on yield of stereotactic biopsy (STB). RESULTS: A total of 76 cases of PCNSL were diagnosed over a period of two decades. Incidence of lymphomas amongst all biopsied lesions showed a gradual increase from 0.18% at the beginning of study period to 0.41% at the end of study period. Only 8.6% (3 of 35 tested) of the PCNSL patients were positive for HIV. The mean age of patients with HIV infection (31.3 ± 3.5 years) was significantly lower compared with those without HIV infection (44.7 ± 10.9 years) (P = 0.033). Diagnosis was obtained by open biopsy in 32 patients (42.1%) and STB in 44 patients (57.9%). Open biopsy yielded a histological confirmation of PCNSL in all cases. Among those who underwent STB, the incidence of negative biopsy with short duration of steroids (≤ 1 week) was 33.3% and increased to 57.1% with increasing duration of steroid treatment (>1 week). CONCLUSIONS: This study documented an increase in hospital based incidence of PCNSL in our institute, independent of HIV association. Steroid intake administration for more than a week prior to biopsy adversely affected the yield of STB in PCNSL.

Higher topoisomerase 2 alpha gene transcript levels predict better prognosis in GBM patients receiving temozolomide chemotherapy: identification of temozolomide as a TOP2A inhibitor.

The search for molecular markers which predict response to chemotherapy is an important aspect of current neuro-oncology research. MGMT promoter methylation is the only proved marker of glioblastoma. The purpose of this study was to assess the effect of topoisomerase expression on glioblastoma survival and study the mechanisms involved. The transcript levels of all isoforms of the topoisomerase family in all grades of diffuse astrocytoma were assessed. A prospective study of patients with glioblastoma treated by a uniform treatment procedure was performed with the objective of correlating outcome with gene expression. The ability of TOP2A enzyme to relax the super coiled plasmid DNA in the presence of temozolomide was evaluated to assess its effect on TOP2A. The temozolomide cyctotoxicity of TOP2A-silenced U251 cells was assessed. The transcript levels of TOP2A, TOP2B, and TOP3A are upregulated significantly in GBM in comparison with lower grades of astrocytoma and normal brain samples. mRNA levels of TOP2A correlated significantly with survival of the patients. Higher TOP2A transcript levels in GBM patients predicted better prognosis (P = 0.043; HR = 0.889). Interestingly, we noted that temozolomide inhibited TOP2A activity in in-vitro enzyme assays. We also noted that siRNA knock down of TOP2A rendered a glioma cell line resistant to temozolomide chemotherapy. We demonstrated for the first time that temozolomide is also a TOP2A inhibitor and established that TOP2A transcript levels determine the chemosensitivity of glioblastoma to temozolomide therapy. Very high levels of TOP2A are a good prognostic indicator in GBM patients receiving temozolomide chemotherapy.

Differential expression of a novel voltage gated potassium channel--Kv 1.5 in astrocytomas and its impact on prognosis in glioblastoma.

INTRODUCTION: Ion channels are subjects of intense research, due to their easy access and potential for being drug targets. Kv1.5 is a voltage gated potassium channel, earlier thought to be cardiac specific. Recent studies have revealed that K(+) channels play an important role in apoptosis, glial cell proliferation and biology of various cancers. No study has so far been performed to assess their expression in astrocytomas and correlate its impact on the clinical behaviour of gliomas. METHODS: Sixty samples of astrocytoma which included 9 diffuse astrocytoma (DA) grade II, 11 anaplastic astrocytoma (AA) grade III and 40 glioblastoma (GBM), along with normal brain tissue (cerebral cortex; n = 5) were analysed for their Kv1.5 protein expression. Immunohistochemical expression of Kv1.5 in various grades was assessed semi quantitatively. The patients with GBM (n = 40) were treated with uniform protocol and their survival was documented. RESULTS: The mean expression of Kv1.5 in DA, AA and GBM was 22.2 ± 9.71%, 11.81 ± 12.3% and 10.37 ± 11.05%, respectively, the difference being statistically significant (p = 0.004). The mean expression in low grade astrocytoma (WHO II) was significantly higher than higher grades (22.2% and 10.7%; p = 0.005). On analysing the influence of Kv1.5 expression on survival of GBM patients, we noted that increasing Kv1.5 labelling index (LI) correlated with a favourable prognosis, albeit not being significant (p = 0.310; HR = 0.901). CONCLUSIONS: Kv1.5 expression occurs more in DA, when compared to high grade astrocytoma. GBM patients with higher Kv1.5 expression had better survival, though not reaching statistical significance.

Cerebral coenurosis mimicking hydatid disease - report of two cases from South India.

Coenurosis, a rare zoonotic disease caused by the larval form of Taenia multiceps (bladderworm) is common in sheep rearing countries, but human infections are rare. Central nervous system involvement produces large giant sized cysts that radiologically closely mimic hydatid cysts. Most human infections resulting in cerebral coenuri have been reported from Europe and Africa. We report two cases of cerebral coenurosis from India, the first in a 55-year-old male presenting with a large cystic lesion in the right parietooccipital region and the second occurring in a 36-year-old male involving the left temporal trigonal region, that radiologically closely mimicked hydatid cyst. Histopathologic examination revealed characteristic features of coenuri with multiple protoscolices invaginating into a large cyst lined by outer cuticular layer. Awareness of this rare parasitic infestation is important to discriminate from the more common hydatid and giant cysticercal cysts.

Posterior fossa subdural empyema in children--management and outcome.

AIMS: The aims of this study were to analyze the clinical features, radiologic findings, bacteriologic spectrum, and management protocols and outcomes in posterior fossa subdural empyemas in children. MATERIALS AND METHODS: This study is a retrospective analysis of all children (age, <18 years) treated over a ten-year period (1994-2004) at NIMHANS, India. Clinical, bacteriologic, radiologic, and follow-up data were analyzed. RESULTS: Twenty-seven children with posterior fossa empyemas were treated during this period, making this the largest series to date dealing with this rare entity. Posterior fossa empyemas are seen more commonly in the summer months and in males. Of the patients, 74.1% were in altered sensorium. The clinical features included the triad of fever, headache, and vomiting, which is a nonspecific picture. Cerebellar signs were elicited only in 40%. The most common source was untreated middle ear infection. Pus usually accumulates over the cerebellar convexity and is associated with hydrocephalus in 74% of patients. Cultures of the empyema pus were positive in 74% of cases, and 18.5% had polymicrobial infections. Only 21% of the patients needed a permanent CSF diversion procedure. Craniectomy is the treatment of choice in these cases. CONCLUSIONS: The clinical features are nonspecific. Early surgery can salvage most patients and obviate the need for permanent CSF diversion procedures. Surgery (evacuation of empyema and mastoidectomy), antibiotics, and management of hydrocephalus are the mainstays of treatment.

Focal intradural brain infections in children: an analysis of management and outcome.

INTRODUCTION: Focal intradural infections of the brain include empyema and abscess in the supratentorial and infratentorial spaces. These are amenable to surgical management. Various other issues may complicate the course of management, e.g. hydrocephalus with infratentorial lesions or cortical venous thrombosis with supratentorial lesions. Here, we review the management and identify factors affecting outcome in these patients. MATERIALS AND METHODS: This is a retrospective analysis of all children (aged <18 years) treated at the National Institute of Mental Health and Neurosciences, Bangalore, India, between 1988 and 2004. Case records were analyzed to obtain clinical, radiological, bacteriological and follow-up data. RESULTS: There were 231 children who underwent treatment for focal intradural abscess/empyema at our institute. These included 57 children with cerebral abscess, 65 with supratentorial empyema, 82 with cerebellar abscess and 27 with infratentorial empyema. All patients underwent emergency surgery (which was either burr hole and aspiration of the lesion or craniotomy/craniectomy and excision/evacuation), along with antibiotic therapy, typically 2 weeks of intravenous and 4 weeks of oral therapy. The antibiotic regimen was empiric to begin with and was altered if any sensitivity pattern of the causative organism(s) could be established by culture. Hydrocephalus was managed with external ventricular drainage initially and with ventriculoperitoneal shunt if warranted. Mortality rates were 4.8% for cerebral abscess, 9.6% for cerebellar abscess, 10.8% for supratentorial subdural empyema and 3.7% for posterior fossa subdural empyema. The choice of surgery was found to have a strong bearing on the recurrence rates and outcome in most groups, with aggressive surgery with craniotomy leading to excellent outcomes with a low incidence of residual/recurrent lesions. CONCLUSIONS: Antibiotic therapy, emergency surgery and management of associated complications are the mainstays of treatment of these lesions. We strongly advocate early, aggressive surgery with antibiotic therapy in children with focal intradural infections.

Rosai-Dorfman disease presenting as cervical extradural lesion: a case report with review of literature.

Sinus histiocytosis with massive lymphadenopathy or Rosai-Dorfman disease is a rare, but well documented entity. We report a lady who presented with progressive quadriparesis, with cervical extradural lesion on magnetic resonance imaging. She underwent decompression of the lesion and histological diagnosis of the lesion was Rosai-Dorfman disease. On one-year follow-up, she had complete improvement of the deficits with no further progression of the lesion. The presentation of this disease as an isolated spinal extradural mass lesion is quite rare, with only six cases reported in literature.

Interhemispheric epidermoids--an uncommon lesion in an uncommon location: a report of 15 cases.

Of the intracranial epidermoids, interhemispheric epidermoids are extremely rare and only about 19 cases have been reported. This is a retrospective study of 15 patients with interhemispheric epidermoids surgically treated over a 13-year period. The age at the time of presentation varied between 17 and 45 years and there were 9 males. The presenting feature was seizures (focal with secondary generalization) in 12 patients, hemiparesis in 5 and features of raised intracranial pressure in 3. On computerized tomography scan the lesions were hypodense in the interhemispheric region. On magnetic resonance imaging, the lesions were located in the interhemispheric region with heterogenous signal intensities. Restricted diffusion was evident on diffusion-weighted images and apparent diffusion co-efficient images. All the lesions were predominantly located in the anterior interhemispheric region, with either basal or parietal extension along the interhemispheric fissure. Eleven patients underwent frontal or fronto-parietal craniotomies, 3 underwent bifrontal craniotomies and 1 patient underwent supra-orbital craniotomy and endoscopic procedure. Total excision could be achieved in 11 patients; near-total, in 3; and partial excision, in 1 patient. Follow-up was available in 10 patients. Three patients had recurrence of lesion at 5½, 8 and 10 years, respectively.

Factors predicting progression of low-grade diffusely infiltrating astrocytoma.

BACKGROUND: Low-grade diffuse astrocytoma (DA) is considered benign tumor (World Health Organization [WHO] grade II), but it has an inherent tendency for malignant progression, which is quite variable. AIM: To identify malignant progression in an individual case of DA, we studied the clinico-radiological and immunohistochemical factors and correlated with progression of DA at a dedicated tertiary level neurosciences centre NIMHANS, Bangalore, India. PATIENTS AND METHODS: Consecutive adult patients who had undergone tumor decompression for lobar supratentorial DA at our institute from 1994 to 1998 were retrospectively selected and followed up for clinico-radiological progression. The clinico-radiological and histomorphological features were studied. With the use of immunohistochemistry, proliferation index [MIB-1 labeling index (LI)], p53 protein expression, microvessel density (MVD) count [assessed using anti-CD34 antibody] were analyzed and correlated with progression-free survival (PFS) Results: There were 13 patients. Mean age was 34 years. The most common presenting symptom was seizures. The median follow-up was 54 months. There were four recurrences, with median interval of 75 months. Eight patients received radiotherapy. Younger patients (<40 years), seizure as the presenting symptom and postoperative radiotherapy were associated with longer PFS, while gemistocytic morphology (>20% gemistocytic cells), MVD value >20 correlated with shorter PFS, albeit statistically insignificant. MIB1 LI did not correlate with recurrence pattern. Moreover, p53 LI > 10% correlated with early progression (P = 0.04). CONCLUSION: Our study highlights some of the clinical, histological and immunohistochemical parameters that predict progression on DA. Validation on a larger sample may be useful to plan appropriate treatment in an individual case.

Neuropathological spectrum of drug resistant epilepsy: 15-years-experience from a tertiary care centre.

Neuropathology of drug resistant epilepsy (DRE) has direct bearing on the clinical outcome. Classification of the most common pathologies, hippocampal sclerosis (HS) and focal cortical dysplasia (FCD) have undergone several revisions and studies on the surgical pathology of DRE employing the updated ILAE classification are scarce. Here, we report the neuropathological spectrum of 482 surgically treated cases of DRE from a single institute using the latest ILAE classifications along with clinicoradiologic correlation. Majority of the cases (324, 67.2%) had temporal lobe epilepsy (TLE), with 158 (32.8%) having extratemporal seizure focus. Among TLE, HS was most common (n = 208, 64.2%), followed by neoplasms (42, 13%), FCD (26, 8%) and dual pathology (23, 7%). Less frequent were vascular malformations (cavernoma-3, arteriovenous malformation-1), mild malformation of cortical development (mMCD, 3), gliotic lesions (5), cysticercosis (2), double pathology (2) and polymicrogyria (1). Among extratemporal epilepsies, FCD was most common (46, 29.1%), followed by neoplasms (29, 18.3%), gliotic lesions (27, 17.1%), Rasmussen encephalitis (18, 11.4%), hypothalamic hamartoma (12, 7.6%), malformations of cortical development (10, 6.3%) and vascular malformations (6, 3.8%). Less frequent were double pathology (2, cysticercosis + FCD type IIb, DNET + FCD type IIb), mMCD (2), cysticercosis (1) and dual pathology (1). No underlying pathology was detected in 12 cases (2.5%). Radiopathological concordance was noted in 83%. In 36 cases (7.5%), histopathology detected an unsuspected second pathology that included FCD type III (n = 16) dual pathology (n = 18) and double pathology (n = 2). Further, in four MRI negative cases, histopathology was required for a conclusive diagnosis.

Proteomic identification of haptoglobin α2 as a glioblastoma serum biomarker: implications in cancer cell migration and tumor growth.

Glioblastoma (GBM; grade IV astrocytoma) is the most malignant and common primary brain tumor in adults. Using combination of 2-DE and MALDI-TOF MS, we analyzed 14 GBM and 6 normal control sera and identified haptoglobin α2 chain as an up-regulated serum protein in GBM patients. GBM-specific up-regulation was confirmed by ELISA based quantitation of haptoglobin (Hp) in the serum of 99 GBM patients as against lower grades (49 grade III/AA; 26 grade II/DA) and 26 normal individuals (p = 0.0001). Further validation using RT-qPCR on an independent set (n = 78) of tumor and normal brain (n = 4) samples and immunohistochemcial staining on a subset (n = 42) of above samples showed increasing levels of transcript and protein with tumor grade and were highest in GBM (p = <0.0001 and <0.0001, respectively). Overexpression of Hp either by stable integration of Hp cDNA or exogenous addition of purified Hp to immortalized astrocytes resulted in increased cell migration. RNAi-mediated silencing of Hp in glioma cells decreased cell migration. Further, we demonstrate that both human glioma and mouse melanoma cells overexpressing Hp showed increased tumor growth. Thus, we have identified haptoglobin as a GBM-specific serum marker with a role on glioma tumor growth and migration.

Dexmedetomidine for awake fibreoptic intubation and awake self-positioning in a patient with a critically located cervical lesion for surgical removal of infra-tentorial tumour.

Cervical lesions compressing the spinal cord pose a significant risk of exacerbating the existing neurological condition during tracheal intubation and subsequent positioning. Awake fibreoptic-assisted intubation is a suitable option in such situations. We describe how the use of dexmedetomidine for sedation during awake fibreoptic intubation also facilitated self-positioning before surgery in a patient with a cervical cord compressive lesion and raised intracranial pressure undergoing excision of a cerebellopontine angle lesion in the lateral position, without any adverse neurological outcome.

Pediatric intracranial subdural empyema caused by Mycobacterium tuberculosis--a case report and review of literature.

INTRODUCTION: Intracranial subdural tubercular empyema is an extremely rare entity. To our knowledge, only one such case has been previously reported in the pediatric population (Cayli et al. J Neurosurg 94(6):988-991, 2001). We report a case of intracranial tubercular subdural empyema in a child, with both convexity and interhemispheric fissure involvement. CASE MATERIAL: A 12-year-old boy with history of exposure to an active case of pulmonary tuberculosis (his father) presented to our institution with features of raised intracranial pressure and fever for 1 month and altered sensorium for 2 days. Computerized tomography (contrast enhanced) revealed a left fronto-parietal and interhemispheric subdural space abscess. A left fronto-parietal craniotomy was performed and the subdural empyema was evacuated, and adjacent calvarium was normal. Ziehl-Neelsen staining revealed acid-fast bacilli and the subsequent polymerase chain reaction test was positive. Histopathological examination showed granulation tissue including scattered multinucleated giant cells and caseation. Mycobacterium tuberculosis bacilli were the sole organisms cultured after 6 weeks. Anti-tuberculous treatment was given in appropriate doses for 18 months at the end of which the patient was doing well with no deficits. CONCLUSION: Intracranial tubercular subdural empyema in the pediatric age group is an extremely rare but curable entity.

Intraventricular ganglioglioma with bleed: a rare case report.

Gangliogliomas are benign lesions that are predominantly temporal in location and present with chronic epilepsy. Intraventricular gangliogliomas are extremely rare and still rarer is intratumoral hemorrhage. Till date only 9 cases of lateral ventricular gangliogliomas have been reported. To the best of our knowledge only 1 case of intratumoral hemorrhage has been reported. We report a rare case of lateral ventricular ganglioglioma with intratumoral hemorrhage in a 27-year-old man.

Is there a need to diagnose Rathke's cleft cyst preoperatively?

BACKGROUND: Rathke's cleft cyst is a rare benign sellar lesion. The exact preoperative diagnosis of this lesion by clinical and radiological features is difficult. Hence it is often misdiagnosed as craniopharyngioma. AIM: To identify the radiological pointers for pre operative diagnosis of Rathke's cleft cyst. MATERIALS AND METHODS: This study presents the details of nine patients who were operated in our institution between 1998 and 2008. Radiological and histopathological variations were studied. RESULTS: The possibility of Rathke's cleft cyst was considered pre operatively in one patient only. On reviewing the images, characteristic imaging findings were observed in a few cases. CONCLUSION: As minimally invasive trans-sphenoidal approach is sufficient for treating these lesions, pre operative diagnosis is important.

Apolipoprotein E polymorphism and outcome after mild to moderate traumatic brain injury: a study of patient population in India.

BACKGROUND: The nature and extent of recovery after traumatic brain injury (TBI) is heterogeneous. Apolipoprotein E (APOE) plays a major role in repair of cell membrane and growth of neurites following injury to cells. Studies done on the western population have shown that the APOE e4 genotype is associated with poor survival following neurotrauma. AIM: To explore the association of APOE polymorphism and outcome following TBI in a patient population from a tertiary care hospital exclusive for neurological diseases in south India. PATIENTS AND METHODS: Ninety eight patients who sustained mild to moderate TBI (computed tomography (CT) scan brain showing traumatic parenchymal contusions) were the subjects of the study and the study period was from November 2003 to December 2008. APOE polymorphism status was determined by PCR technique using venous blood. Patients were assessed on follow-up with a battery of four neuropsychological tests as well as Glasgow outcome scale. RESULTS: Of the 98 patients, 20 (20%) patients had at least one APOE e4 allele. A follow-up of minimum six months was available for 73 patients. None of the 12 patients who had at least one APOE e4 allele had a poor outcome at six-month follow-up whereas 11(18%) patients without an APOE e4 allele had a poor outcome (Fisher's Exact test, P=0.192). On the neuropsychological tests, performance of patients with APOE e4 allele did not differ significantly from those without these alleles. CONCLUSION: This study does not support the current contention that the presence of APOE e4 allele should have a significant negative effect on the outcome after TBI.