Journal of Neurosciences in Rural Practice
 
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October-December 2017
Volume 8 | Issue 4
Page Nos. 501-696

Online since Friday, November 17, 2017

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GUEST EDITORIAL  

Reoperation in spinal dysraphism p. 501
Aaron Mohanty
DOI:10.4103/jnrp.jnrp_238_17  
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EDITORIALS Top

Neurocardiology and atherosclerosis: The effect of ethnic differences on heart-brain interaction p. 504
George Markousis-Mavrogenis
DOI:10.4103/jnrp.jnrp_143_17  
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Is indocyanine green videoangiography a good substitute for postoperative digital subtraction angiography p. 506
Girish Menon
DOI:10.4103/jnrp.jnrp_118_17  
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ORIGINAL ARTICLES Top

Knowledge, attitude, and practice among practitioners regarding epilepsy in Bhutan: A rural and a remote country p. 507
Devender Bhalla
DOI:10.4103/jnrp.jnrp_272_17  
Purpose: Epilepsy is a major neurological disorder with many countries as scientifically silent and little-to-nothing known on various aspects of epilepsy. Methods: Taking background of a first multinational seminar on epilepsy in Bhutan and a short valid questionnaire pertaining to various aspects of epilepsy, before participation. Results: Large participation was achieved (76 out of 87 approached, 87.3%; 53.0% males). Based on the responses of 76.0% lecturers and clinician and medical administration, 21.0% nurses, and 3.0% traditional practitioners, important derivations were obtained: positively, (a) event provided at least an opportunity to bring service providers at a common platform toward initiating particular epilepsy goals, (b) none regarded epilepsy as contagious or due to past sins, (c) all responded favorably to that “they found this event useful' and 'this event added something meaningful to them personally or professionally,” (d) large participation indicated acceptance, need, and common interest among a number of stakeholders. Negatively, significant knowledge-deficit was noted: for 38.4% electroencephalogram is essential for diagnosis, 48.0% responded with incorrect definition of epilepsy, etc. Conclusions: Events, such as this, provides, for scientifically silent countries, basis for not only bringing service providers to a common platform but also to discuss to initiate particular epilepsy goals, to provide additional professional knowledge for strengthening service development, and to determine need and social acceptance around epilepsy. Important knowledge deficit was identified which cannot be fully explained through lack of time or limited training. There might be a need to reappraise the approach to teaching medical professionals about epilepsy.
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How long does denervation take in poliomyelitis? Or is it a lifetime?” p. 511
Mehmet Guney Senol, Cengiz Kaplan, Fatih Ozdağ, Mehmet Saraçoğlu
DOI:10.4103/jnrp.jnrp_173_17  
Background and Objective: This study aims to determine the period of reinnervation in patients with poliomyelitis. This research was conducted to identify the appearance of denervation potentials in patients with poliomyelitis as indicators for reinnervation. Materials and Methods: A total of 246 male patients with poliomyelitis were assessed electrophysiologically between 1988 and 2007. The mean age was 22.8 (18–42). It has been an average of 19.9 ± 4.9 years since the beginning of complaints from the patients. Results: The patients had no complaints of newly developing muscle weakness, fatigue, muscle and joint pain, and difficulties in breathing and swallowing. Neurological examinations revealed the absence of myotomal pain and sensory loss. Upon assessment of the patients' limbs, the following findings were revealed: two patients had left upper and lower limb involvement, two patients had left upper and right lower limb involvement, 6 patients had left upper limb involvement, 12 patients had both lower limb involvement, 105 patients had left lower limb involvement, 1 patient had both upper limb involvement, 2 patients had right lower and upper limb involvement, 12 patients had right upper limb involvement, 6 patients had both lower limb involvement, 95 patients had right lower limb involvement, and 3 had all the three extremities affected. The needle electromyography revealed the presence of denervation potentials in 25.2% (62) of the patients. Conclusion: When poliovirus attacks the motor neuron, this neuron may be completely destroyed, damaged, or unaffected. Reinnervation occurs when nearby functioning motor units send out terminal axon sprouts to reinnervate the damaged muscle fibers. As a consequence of poliomyelitis, several muscle fibers become atrophic and fibrotic, but others continue to survive. This study showed that patients with a history of poliomyelitis experienced denervation with subsequent reinnervation for many years.
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A clinical and electrophysiological study of peripheral neuropathies in predialysis chronic kidney disease patients and relation of severity of peripheral neuropathy with degree of renal failure p. 516
Dushyanth Babu Jasti, Sarat Mallipeddi, A Apparao, B Vengamma, V Sivakumar, Satyarao Kolli
DOI:10.4103/jnrp.jnrp_186_17  
Objective: To study the prevalence, clinical features, electrophysiological features, and severity of peripheral neuropathy in predialysis chronic kidney disease (CKD) patients with respect to severity of renal failure and presence of diabetes mellitus. Materials and Methods: Between May 2015 and December 2016, 200 predialysis CKD patients were assessed prospectively. Results: The prevalence of peripheral neuropathy in predialysis CKD patients in the present study was 45% based on clinical symptoms and 90% electrophysiologically. Mean age of 200 predialysis CKD patients who participated in the study was 53.2 ± 13.2 years. One hundred and thirty-six (68%) patients were male and 64 (32%) patients were female. Mean duration of disease was 2.2 ± 1.6 years. Nearly 45% patients of patients had asymptomatic peripheral neuropathy in the present study, which was more common in mild-to-moderate renal failure group. One hundred twenty-six patients (63%) had definite damage and 54 patients (27%) had early damage. In mild-to-moderate renal failure (n = 100) and severe renal failure patients (n = 100), 88% and 92% had significant peripheral neuropathy, respectively. Most common nerves involved were sural nerve, median sensory nerve, and ulnar sensory nerve. Diabetic patients (97%) showed more severe and high prevalence of peripheral neuropathy when compared to nondiabetic patients (83%). Most common patterns were pure axonal sensorimotor neuropathy and mixed sensorimotor neuropathy. Conclusion: Peripheral neuropathy is common in predialysis patients, prevalence and severity of which increases as renal failure worsens. Predialysis patients with diabetes show higher prevalence and severity of peripheral neuropathy when compared with nondiabetics.
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Outcome of early versus delayed evacuation of spontaneous lobar hematomas in unconscious adults p. 525
Hazem M Alkosha, Wael K Zakaria
DOI:10.4103/jnrp.jnrp_190_17  
Objective: To explore the difference in outcomes of medium-sized lobar hematomas evacuated in early versus delayed fashion among unconscious noncomatose individuals. Methods: A retrospective analysis of demographic, clinical, and radiological data of unconscious patients admitted with lobar hematomas during 18 years was performed. Time to surgery was compared in various patient variables and characteristics. Outcome groups (favorable and poor) were also compared to find out any association with surgery timing, as well as potential indicators of outcome and mortality. Results: The mean follow-up period in this study was 7.5 months after discharge. Two-thirds of the patients carried favorable prognosis at final follow-up with mortality (7.3%) included among poor cases. Time to surgery was not associated to any of the patient characteristics, except for international normalized ratio and associated chest problems which represented the main indicators of delayed surgery. Rebleeding after evacuation was associated with shorter time to surgery in clots ≤35 cc but not in the whole group. Poor outcome was significantly associated with higher basal glucose levels, bigger hematomas, rebleeding after surgery, and delayed evacuation of clots >35 cc. The presence of mild intraventricular hemorrhage (IVH) per se was not associated with increased mortality or poor outcome; however, its volume was. Conclusion: Smaller lobar hematomas (≤35 cc) in unconscious adults (Glasgow Coma Scale 8–13) may be managed with initial conservative treatment, while larger hematomas (>35 cc) are better evacuated as early as possible. Basal glucose levels and volume of mild IVH should be considered in the future management planes.
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Predictors of dropout from outpatient mental health services; A study from Rohtak, India p. 535
Nikhil Jain, Sidharth Arya, Rajiv Gupta
DOI:10.4103/jnrp.jnrp_119_17  
Context: Dropout from mental health services is problematic in both developed and developing nations and often leads to poor outcomes. There is a lack of hospital-based studies assessing the factors responsible for treatment dropout from mental health services in Indian settings. This study aims to contribute in that direction by presenting a study done in a tertiary care hospital in North India. Methodology: This was a hospital-based retrospective chart review carried out on randomly selected 139 patients at a tertiary hospital from January 1, 2014, to June 30, 2014. For this chart review, an abstraction form was designed that recorded six sociodemographic variables, nine clinical factors, and two outcome variables (more than one follow-up and active follow-up till 6 months). Results: Out of 139 patients, 53 patients dropped out after the first visit and 105 patients dropped out by the end of 6 months. Lower education status (odds ratio [OR] = 8.2, 95% confidence interval [CI]: 2.30–29.50), severe mental illness (OR = 2.6, 95% CI: 1.05–6.49), and early referral to clinical psychologist (CP) (OR = 7.8, 95% CI: 1.87–6.49) were predictors of better rates of follow-up after first visit. Lower education status (OR = 4.9, 95% CI: 1.45–17.08), early referral to CP (OR = 5.8, 95% CI: 2.09–38.35), and previous treatment history (OR = 8.9, 95% CI: 1.97–17.52) were predictors of better rates of follow-up at the end of 6 months. Conclusion: The findings that education status, diagnosis, utilizing services of CP, and psychiatric services in past are correlated with dropout rates may be helpful in targeting patients who are more vulnerable to dropping out of care in the given setting.
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Effect of scapular stabilization exercise during standing on upper limb function and gait ability of stroke patients p. 540
JO Kim, J Lee, BH Lee
DOI:10.4103/jnrp.jnrp_464_16  
Background: The purpose of this study was to determine the effect of scapular stabilization exercise during standing on a paretic side on upper limb function and gait ability of stroke patients. Methods: This study was a hospital-based, randomized controlled trial with a blinded assessor. A total of 17 patients with hemiplegic diagnosis after stroke were divided into two groups (9 patients in a study group and 8 patients in a control group). The study group received physical therapy and scapular stabilization exercise on a paretic side. Participants were subjected to initial evaluation before the treatment. Subjects were subsequently re-evaluated 4 and 8 weeks later to compare the changes. Measurements of hand function and gait ability were performed. Results: Based on multivariate analysis of variance for repeated-measures, there was a significant time effect for Timed Up and Go test (TUG) (F = 13.816, P = 0.000), Functional Gait Assessment (FGA) (F = 18.613, P = 0.000), and manual function test (MFT) (F = 16.777, P = 0.000). The group × time interaction effect was also significant for FGA (F = 4.966, P = 0.024) and MFT (F = 6.946, P = 0.003), but not for TUG test (F = 3.343, P = 0.069). Conclusion: Results of the present study indicated that scapular stabilization exercise during standing on a paretic side for 8 weeks had an effect on hand function and gait ability of hemiplegic patients after stroke. Further studies are needed to find the most proper exercise for stroke patients who have gait disability and upper limb dysfunction.
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Use of preoperative ependymal enhancement on magnetic resonance imaging brain as a marker of grade of glioma p. 545
Sumit Sharma, Shashi Kant Jain, Virendra Deo Sinha
DOI:10.4103/jnrp.jnrp_78_17  
Objectives: Neural stem cells within the subventricular zone (SVZ) are thought to be responsible for the origin and the heterogeneous nature of the gliomas. The relationship of the gliomas to the SVZ can be appreciated as ependymal enhancement on contrast magnetic resonance imaging (MRI). This study evaluates the rate of ependymal enhancement and its association with the histopathological grade of gliomas. Patients and Methods: Seventy-five patients with radiological features of glioma were recruited. Preoperative MRI was evaluated for the presence of ependymal enhancement and fluid-attenuated inversion recovery (FLAIR) signal proximity of tumor to ependyma, and the association to grade was investigated. Results: Seventy-five patients studied showed a male predominance (62.66%) with a mean age of 44.91 ± 13.64 years. Evidence of ependymal enhancement was positive in 24% (n = 18), 46.67% (n = 35) showed no evidence, and in 29.33% (n = 22), assessment was inconclusive. According to WHO grading, 76% (n = 57) were high-grade gliomas (HGGs) including Grade III (n = 17) and Grade IV (n = 40) and 24% (n = 18) were low-grade gliomas (LGGs) Grade II. HGGs were significantly associated with ependymal enhancement (P < 0.01) and FLAIR signal proximity to the ependyma (P < 0.001). Among HGGs, rate of ependymal enhancement and FLAIR signal proximity was more in Grade IV than Grade III but was not statistically significant (P > 0.05). Conclusion: SVZ is associated with HGGs. These MRI features can be helpful in predicting the tumor grade preoperatively and by including LGGs, the role of SVZ in the heterogeneous disease process of glioma can be studied as a whole, not only in the glioblastoma (GBM).
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A family study of consanguinity in children with intellectual disabilities in Barwani, India p. 551
Ram Lakhan, Rajshekhar Bipeta, Srinivasa S. R. R. Yerramilli, Vinayak K Nahar
DOI:10.4103/jnrp.jnrp_104_17  
Background: Intellectual disability (ID) can be inherited in families through consanguineous marriage. The ID in an individual can be associated with the ID, epilepsy, and mental illness in their parents. Such connections can be seen more closely among consanguineous marriages in tribal and nontribal population in India. Objective: This study shows a few common patterns of the consanguineous relationship in the parents of children with ID in India. Materials and Methods: This is a case series research design. Extreme or deviant case sampling was applied. Data were collected in homes, camps, and clinical settings in the Barwani district of Madhya Pradesh, India. The patterns of consanguineous marriages and the relationship between children with ID and their relatives with ID, epilepsy, and mental illness were analyzed and reported with pedigree charts. Results: Multiple patterns of consanguineous marriages in tribal and nontribal populations were observed. ID was found to be associated in children with their relatives of the first, second, and third generations. Conclusion: ID may inherit in individuals from their relatives of the first, second, and third generations who have ID, epilepsy, or mental illness and married in the relationship. Appropriate knowledge, guidance, and counseling may be provided to potential couples before planning a consanguineous marriage.
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Mental healthcare delivery in rural Greece: A 10-year account of a mobile mental health unit p. 556
Vaios Peritogiannis, Thiresia Manthopoulou, Afroditi Gogou, Venetsanos Mavreas
DOI:10.4103/jnrp.jnrp_142_17  
Introduction: Patients living in rural and remote areas may have limited access to mental healthcare due to lack of facilities and socioeconomic reasons, and this is the case of rural areas in Eastern Europe countries. In Greece, community mental health service delivery in rural areas has been implemented through the development of the Mobile Mental Health Units (MMHUs). Methods: We present a 10-year account of the operation of the MMHU of the prefectures of Ioannina and Thesprotia (MMHU I-T) and report on the impact of the service on mental health delivery in the catchment area. The MMHU I-T is a multidisciplinary community mental health team which delivers services in rural and mountainous areas of Northwest Greece. Results: The MMHU I-T has become an integral part of the local primary care system and is well known to the population of the catchment area. By the end of 2016, the majority of patients (60%) were self-referred or family-referred, compared to 24% in the first 2 years. Currently, the number of active patients is 293 (mean age 63 years, 49.5% are older adults), and the mean caseload for each member of the team is 36.6. A significant proportion of patients (28%) receive care with regular domiciliary visits, and the provision of home-based care was correlated with the age of the patients. Within the first 2 years of operation of the MMHU I-T hospitalizations of treatment, engaged patients were reduced significantly by 30.4%, whereas the treatment engagement rates of patients with psychotic disorders were 67.2% in 5 years. Conclusions: The MMHU I-T and other similar units in Greece are a successful paradigm of a low-cost service which promotes mental health in rural, remote, and deprived areas. This model of care may be informative for clinical practice and health policy given the ongoing recession and health budget cuts. It suggests that rural mental healthcare may be effectively delivered by integrating generic community mental health mobile teams into the primary care system.
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Clinical profile of cognitive decline in patients with Parkinson's disease, progressive supranuclear palsy, and multiple system atrophy p. 562
Sulena , Dipti Gupta, Anjani Kumar Sharma, Naveen Kumar
DOI:10.4103/jnrp.jnrp_154_17  
Background: There are very less data on the comparison between the cognitive profile in Parkinson's disease (PD) and Parkinson's-plus groups, especially in India. Aims: The aim of this study is to compare the cognitive profile across PD, progressive supranuclear palsy (PSP), and multiple system atrophy (MSA) groups and compare them using Mini–Mental State Examination (MMSE), frontal assessment battery (FAB), and verbal fluency tests. Settings and Design: This was a cross-sectional study. Materials and Methods: MMSE, FAB, and verbal fluency tests were administered in a total of 73 patients constituting 22 patients in MSA, 26 patients in PD, and 25 patients in PSP group, respectively. Twenty-six participants both age- and gender-matched were enrolled in control group. Statistical Analysis: Statistical analysis was done using SPSS Version 20.0. Descriptive statistics were done to find out the mean and standard deviation of different variables. ANOVA was done for followed by post hoc Bonferroni test to assess the cognitive function in three groups. Results: ANOVA showed that there is a significant difference for MMSE scores (P = 0.038) being worse scores for PSP and maximum for MSA. A significant difference was found for FAB scores within three groups. There is a significant difference for FAB scores (P = 0.00003) being worse scores for PSP and highest scores obtained for PD. All the subtests of FAB test differed significantly except motor programming across MSA, PSP, and PD groups. Conclusions: Our data suggest that global cognitive impairment and executive dysfunction are worst in PSP among the three groups. Patients with MSA had significant cognitive decline as opposed to previous experience. FAB scores and verbal fluency tests are good tests to assess cognitive impairment in these diseases. Subsets of FAB score have significant differences but cannot help differentiating conclusively between these three diseases.
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Usefulness of pulsed arterial spin labeling magnetic resonance imaging in new-onset seizure patients and its comparison with dynamic susceptibility contrast magnetic resonance imaging p. 569
Varun Bansal, Suresh Kumar, Sudhir Sharma, Sanjiv Sharma, RG Sood
DOI:10.4103/jnrp.jnrp_141_17  
Introduction: Dynamic susceptibility contrast (DSC) perfusion and pulsed arterial spin labeling (PASL) imaging are newer advanced magnetic resonance sequences which are capable of detecting vascular changes in patients with new-onset seizure disorder even when no significant abnormalities are visualized on conventional sequences. The purpose of our study is to establish utility of arterial spin labeling (ASL) in new-onset seizure patients and compare ASL with DSC perfusion sequence. Materials and Methods: Twenty-six patients coming to emergency department with new-onset seizure disorder were evaluated using DSC and ASL sequence. Perfusion asymmetry was assessed using region of interests taken at places where signal asymmetry was maximal. Results: PASL sequence showed focal vascular changes in form of hyperperfusion in four patients, hypoperfusion in nine patients, and normal perfusion in 13 patients. Altered perfusion whether hypo/hyperperfusion was detected in five out of 16 patients even when conventional sequences were normal. There was strong positive linear correlation between ASL and DSC with P = 0.001. Conclusion: Noninvasive PASL is capable of detecting vascular changes induced by seizure and is comparable to DSC sequence. Thus, it is recommended when there is a need for repeated evaluations; in follow-up/therapy response assessment and when contrast administration is contraindicated.
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Clinical evaluation and diagnostic utilities of different nerve conduction tests in 100 patients with carpal tunnel syndrome p. 575
Rameshwar Nath Chaurasia, Sagar S Kawale, Abhishek Pathak, Vijaya Nath Mishra, Deepika Joshi
DOI:10.4103/jnrp.jnrp_187_17  
Background and Purpose: The purpose of the study is to determine whether the clinical profile of patients with carpal tunnel syndrome (CTS) has been same over the years with the help of routine and comparative electrodiagnostic tests. Methods: A prospective study of 100 patients with suspected CTS was conducted without controls. Three provocative maneuvers were performed. Routine and comparison nerve conduction tests were performed, i.e., second lumbrical interossei motor latency difference (2 LIMLD), digit 4 median-ulnar sensory latency difference (D4MUSLD), palm wrist distal sensory latency difference (PWDSLD), and digit 1 median-radial sensory latency difference (D1MRSLD). Data entry, analysis, and statistical evaluation were done using International Business Machines Corporation Statistical Package for the Social Sciences statistics package (IBM, SPSS). Results: A total of 195 hands of 100 patients met the criteria for CTS. Forty-three percentage of patients were homemakers. Considering the rapidly changing communication technology, we observed 84% patients had aggravation of symptoms with continuous long-term daily mobile phone use (>30 min per session per day). We noted positive Tinel's sign in only 25%. Phalen's sign was positive in 53 right hands with mean duration of 11.49s (standard deviation [SD] ± 2.54 s) and was positive in 26 left hands with mean being 10.4 s (SD ± 1.91 s). The mean motor distal latency of median was 4.67 ms (SD ± 1.71 ms) and mean sensory distal latency of median was 3.24 ms (SD ± 1 ms). On internal comparison testing, mean difference in 2 LIMLD was 0.7 ± 0.3 ms, in D4MUSLD was 0.81 ± 0.32, in PWDSLD was 0.71 ± 0.20, and in D1MRSLD was 0.76 ± 0.32. Conclusion: Further analysis of clinical profile needs to be done, and new risk or provoking factors should be analyzed in patients with CTS.
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Role of biomarkers in differentiating new-onset seizures from psychogenic nonepileptic seizures p. 581
Mahendra Javali, Purushottam Acharya, Shripal Shah, Rohan Mahale, Pushparaja Shetty, Srinivasa Rangasetty
DOI:10.4103/jnrp.jnrp_139_17  
Introduction: Review of literature revealed very limited studies considering a combination of serum prolactin (PRL) and serum creatine kinase (CK) as markers for differentiating epileptic and psychogenic nonepileptic seizures (PNES). Therefore, in the present study, we analyzed the role of serum PRL and serum CK, individually and in combination. Methodology: This prospective study was conducted in a tertiary care medical teaching hospital over a period of 18 months. Patients aged over 15 years suspected to have new-onset seizures presenting within 5 h of ictus were included in this study. CK, serum PRL was measured at 0–1, 1–3, and 3–5 h after seizures. Results: Hundred subjects were studied for the role of serum PRL and serum CK in differentiating epileptic and PNES. The mean age was 42.24 years with a male:female ratio of 1.27:1. All patients of generalized tonic–clonic seizures (GTCS), who presented within 1 h, had elevated PRL, whereas 75% of patients with partial seizures had elevated PRL within 1 h of presentation. Nearly 91.66% of patients with GTCS who presented within 1 h had elevated CPK, whereas 70% of patients with partial seizures had elevated CPK. None of the patients diagnosed with PNES showed rise in either of the markers. Conclusion: In the present study, none of the patients with PNES showed raise in either serum PRL or CK. However, there was no correlation between the types of seizure and PRL or serum CK levels.
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Histologically confirmed intracranial tumors managed at Enugu, Nigeria p. 585
Chika Anele Ndubuisi, Samuel C Ohaegbulam, Linda U Iroegbu, Mike Ezeali Ekuma, Wilfred C Mezue, Uwadiegwu Alphonsus Erechukwu
DOI:10.4103/jnrp.jnrp_155_17  
Background: There is controversy about the global distribution of intracranial tumors (ICTs). The previous reports from Africa suggested low frequency and different pattern of distribution of brain tumors from what obtains in other continents. The limitations at that time, including paucity of diagnostic facilities and personnel, have improved. Objective: The objective of this study is to analyze the current trend and distribution of histology confirmed brain tumors managed in Enugu, in a decade. Methods: A retrospective analysis of ICTs managed between 2006 and 2015 at Memfys Hospital, Enugu. Only cases with conclusive histology report were analyzed. The World Health Organization ICT classification was used. Results: This study reviewed 252 patients out of 612 neuroimaging diagnosed brain tumors. Mean age was 42.8 years and male-to-female ratio was 1.2:1.0. Annual frequency increased from 11 in 2006 to 55 in 2015. Metastatic brain tumors accounted for 5.6%, and infratentorial tumors represented 16.3%. Frequency of the common primary tumors were meningioma (32.9%), glioma (23.8%), pituitary adenomas (13.5%), and craniopharyngioma (7.5%) (P = 0.001). Vestibular schwannoma accounted for 1.2%. Meningioma did not have gender difference (P = 0.714). Medulloblastoma, glioma, and craniopharyngioma were the most common pediatric tumors. About 8.7% presented unconscious (P < 0.001). There was no significant difference between radiology and histology diagnosis (P = 0.932). Conclusion: Meningioma is the most frequent tumor with increasing male incidence, but the frequency of glioma is increasing. Metastasis, acoustic schwannoma, lymphoma, and germ cell tumors seem to be uncommon. Late presentation is the rule.
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Predictors of in-hospital mortality of acute ischemic stroke in adult population p. 591
Bhupendra Shah, Bijay Bartaula, Janak Adhikari, Hari Shankar Neupane, Birendra Prasad Shah, Gunaraj Poudel
DOI:10.4103/jnrp.jnrp_265_17  
Introduction: Stroke is the second most common cause of mortality worldwide. Data regarding the predictors of mortality of acute ischemic stroke are widely discordant. Identifying the predictors and providing the utmost care to a high-risk patient is still an unmet need in middle- to low-income countries. We did this study to identify the predictor of in-hospital mortality of acute ischemic stroke. Materials and Methods: We conducted a retrospective study of patients with acute ischemic stroke presented to the tertiary care center in eastern Nepal from January 2012 to December 2016. We enrolled patients of age 18 years and older with acute ischemic stroke in this study. The primary outcome of the study was in-hospital mortality of enrolled patients. Predictors of mortality were analyzed by comparing the patients with acute ischemic stroke who had mortality with those who survived. Results: The mean age of enrolled patients was 66 years. Among 257, the in-hospital mortality rate was 20.5%. The patients with in-hospital mortality had lower Glasgow coma scale (GCS) score (9 vs. 12, P < 0.001) compared to those who survived. During admission, a patient with in-hospital mortality had significantly lower arterial oxygen saturation (92 vs. 95, P < 0.001), higher pulse rate (91 vs. 83, P = 0.009), and higher respiratory rate (24 vs. 21, P < 0.001) than those patients with acute ischemic stroke who survived. Conclusion: Lower GCS score, baseline higher pulse rate, higher respiratory rate, and lower arterial oxygen saturation are the predictors of in-hospital mortality of adult with acute ischemic stroke.
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Cranioplasty using autoclaved autologous skull bone flaps preserved at ambient temperature p. 595
Dominic Anto, Raju Paul Manjooran, Rajeev Aravindakshan, Kumar Lakshman, Raymond Morris
DOI:10.4103/jnrp.jnrp_270_17  
Context: Decompressive craniectomy followed by cranioplasty (CP) uses autologous craniectomy flaps or synthetic materials like titanium. Sterilization and preservation methods for the autologous bone flaps continue to be the surgeon's choice. Aim: This study aimed to assess the short-term as well as long-term clinical outcomes of CP using autoclaved autologous bone grafts. Settings and Design: This retrospective observational study was performed on patients admitted in a tertiary care teaching neurosurgery department. Patients and Methods: Seventy-two patients who underwent CP with autoclaved autologous skull flaps preserved under ambient conditions with strict aseptic precautions were included in the study. Statistical Analysis Used: Frequencies and percentages of the various characteristics before and after the surgery were tabulated. Continuous variables were summarized as means and standard deviations. Results: The primary CP had a satisfactory clinical outcome in 62 cases (86.11%). Osteomyelitis was observed in four patients (5.56%) nearly 2 months after the surgery. Radiologically significant bone resorption was noted in a single patient (1.39%) after 1 year. Five patients (6.94%) developed bone fragmentation or fracture, and the mean time taken for this was about 36 months. In all these ten cases, secondary CP was successfully done using a prefabricated, patient-specific titanium mesh. Conclusions: The efficacy and safety of the studied craniectomy flaps used for cranial reconstruction showed a good patient outcome. Further retrospective studies with larger cohorts and prospective case–control studies are essential so as to issue standard guidelines for sterilization and preservation of autologous bone flaps.
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Impact of road traffic injury to pediatric traumatic brain injury in Southern Thailand p. 601
Thara Tunthanathip, Nakornchai Phuenpathom
DOI:10.4103/jnrp.jnrp_381_17  
Background: Motor vehicle is a major transportation in Southern Thailand as the result of road traffic injury and death. Consequently, severe disability and mortality in pediatric traumatic brain injury (TBI) were observed from traffic accident, particularly motorcycle accident. To identify the risk of intracranial injury in children, the association of treatment outcome with various factors including mechanisms of injury, clinical characteristics, and intracranial pathology can be assessed. Materials and Methods: This was a retrospective study conducted on children, who were younger than 15 years old with TBI and were enrolled from 2004 to 2015. Several clinically relevant issues were reviewed and statistically analyzed. Results: A total of 948 casualties were enrolled. Compared with falling down, the motorcycle accident was significantly associated with intracranial injury (odds ratio 1.73, 95% confidence interval [CI] 1.08–2.76). Other factors associated with intracranial injury were hemiparesis (odds ratio 5.69, 95% CI 1.44–22.36), positive of basal skull fracture signs (odds ratio 15.66, 95% CI 3.44-71.28), and fixed reaction to light of both pupils (odds ratio 5.74, 95% CI 1.71–19.23). Mortality found in thirty cases (3.2%). Furthermore, the risk of death correlated with motorcycle accident (P = 0.02) and severe head injury (P < 0.001). Neurosurgical intervention was not associated with outcome, but severe head injury, hemorrhagic shock, epidural, and subdural hematoma were impact factors. Conclusion: The findings demonstrate road traffic injury, especially motorcycle accident leading to brain injury and death. Prevention program is a necessary key to decrease mortality and disability in pediatric TBI.
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Trend of neuropsychiatric morbidity in sub-Himalayan region: An audit of retrospective data mining p. 609
Manoj Kumar Gandhi, Piyush Sharma, Mitasha Singh, Sunil Kumar Raina, Ranabir Pal
DOI:10.4103/jnrp.jnrp_278_17  
Background: There is a paradigm shift in health loss due to premature mortality and disability from neuropsychiatric disorders with major burden in low- and middle-income countries. Objective: To study the trend of admissions with neuropsychiatric and substance-use disorders in 3 years in psychiatry and medicine wards of tertiary care hospital in rural Himachal Pradesh. Methodology: A retrospective data mining was done from records of Inpatient wards of Dr. R. P. Government Medical College, Tanda, Himachal Pradesh, for the year 2013–2015. Demographic details and diagnosis of neuropsychiatric disorders, licit and illicit drug use, and their consequences in the form of hanging and poisoning were analyzed. Results: Majority of admissions were attributed to alcohol abuse which increased in 3 years significantly in the months of July–September (P = 0.02) and October–December (P = 0.00). Almost all cases of neuropsychiatric disorders and majority of poisoning (58.2%) were observed among females. The productive young and middle age group (21–40 years) was mostly affected by all cause neuropsychiatric disorders (80.9%) and presented with poisoning (66.2%). Illicit drug abuse was on increasing drift among females. Conclusion: Indoor admissions were attributed to alcohol use and poisoning while neuropsychiatric disorders and substance abuse were probably dealt with at outpatient level. Treatment pertaining to mental illnesses was sought in severe cases only. Data demonstrating population burden are needed urgently to address the barriers to treatment to reduce burden.
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Behavioral problems and intelligence quotient changes in pediatric epilepsy: A case–control study p. 617
Shyama Choudhary, N Niranjan, Satyendra Khichar, Pramod K Berwal, Abhijeet Singh Barath
DOI:10.4103/jnrp.jnrp_57_17  
Background: Epilepsy is the most common chronic neurological disease and has neurological impairment as an important comorbidity. Objective: To find behavioral problems and intelligence quotient (IQ) changes associated with epilepsy and to know the association of variables such as frequency, type of seizures, and duration of disease with cognitive impairment. Materials and Methods: A descriptive cross sectional study, consisting of 50 cases (patients of epilepsy) and 50 controls (other patients of same socioeconomic status) was conducted at S.P. Medical College, Bikaner. The patients were subjected to detailed clinical history, thorough examination, Pediatric Symptom Checklist, and Bhatia's Battery of Performance intelligence Test. Data analysis was carried out with the help of SPSS 22 software. Results: The prevalence of behavioral problems in generalized and partial seizure group was high (42% and 53.8%) as compared to control group (9%). Low IQ was present more in the patients (44%) of generalized and partial seizure group as compared with the control group, and results were statistically significant. Furthermore, behavioral problems were more in patients who were having more number of seizures (≥3 per year) with significant P values (χ2 = 5.067, P = 0.024). Conclusion: We conclusively found that behavioral problems and cognitive factors, apart from control of seizures, must be kept in mind to determine how well a child with epilepsy progresses toward independence.
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REVIEW ARTICLE Top

Sacroiliac pain: A clinical approach for the neurosurgeon p. 622
Luis Rafael Moscote-Salazar, Hernando Raphael Alvis-Miranda, Andrei Fernandes Joaquim, Jessica Amaya-Quintero, Huber S Padilla-Zambrano, Amit Agrawal
DOI:10.4103/jnrp.jnrp_171_17  
Pain originating from sacroiliac joint may also cause pain in the lumbar and gluteal region in 15% of the population. The clinical manifestation represents a public health problem due to the great implications on the quality of life and health-related costs. However, this is a diagnosis that is usually ignored in the general clinical practice; probably because of the unknown etiology, making harder to rule out the potential etiologies of this pathology, or maybe because the clinical criteria that support this pathology are unknown. By describing several diagnostic techniques, many authors have studied the prevalence of this pathology, finding more positive data than expected; coming to the conclusion that even though there is no diagnostic gold standard yet, an important amount of cases might be detected by properly applying several tests at the physical examination. Thus, it is necessary to have knowledge of the physiopathology and clinical presentation so that diagnosis can be made to those patients that manifest this problem. We present a clinical approach for the neurosurgeon.
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COMMENTARY Top

Commentary p. 627
Manish Ranjan
DOI:10.4103/jnrp.jnrp_282_17  
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REVIEW ARTICLES Top

A simplified overview of World Health Organization classification update of central nervous system tumors 2016 p. 629
Anshu Gupta, Tanima Dwivedi
DOI:10.4103/jnrp.jnrp_168_17  
After 8 years, an update of central nervous system (CNS) tumors was published in 2016 after 2007. First time ever, molecular markers along with histology have been used in classification of any tumor. Major changes are seen in glioma and medulloblastoma groups. Few entities have been added such as diffuse midline glioma, H3 K27M-mutant, RELA fusion-positive ependymoma, embryonal tumor with multilayered rosettes, C19MC-altered, and hybrid nerve sheath tumors. Few variants and patterns that no longer have diagnostic and/or biological relevance and have been deleted such as glioblastoma cerebri, protoplasmic and fibrillary astrocytoma, and cellular ependymoma. Other changes include deletion of term “primitive neuroectodermal tumor,” addition of criterion of brain invasion in atypical meningioma, separation of melanotic schwannoma from other schwannoma, and combination of solitary fibrous tumors and hemangiopericytoma as one entity. There is also expansion of entities in nerve sheath tumors and hematopoietic/lymphoid tumors of the CNS. In this review article, we tried to review CNS tumors 2016 classification update in a simplified manner; comparing the differences between 2016 and 2007 CNS tumors classifications with brief description of important molecular markers and finally utility as well as challenges of this classification.
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POINT OF VIEW Top

Spontaneous spinal discitis and spondylodiscitis: Clinicotherapeutic remarks p. 642
Alessandro Landi, Giovanni Grasso, Giancarlo Iaiani, Fabrizio Gregori, Cristina Mancarella, Alessandro di Bartolomeo, Maurizio Domenicucci, Roberto Delfini
DOI:10.4103/jnrp.jnrp_67_17  
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SHORT COMMUNICATIONS Top

Sir Hugh Cairns: The neurosurgeon who introduced crash helmets p. 647
Shahsivadhanan Sundaravadhanan
DOI:10.4103/jnrp.jnrp_167_17  
Statistics prove that more Indians die in Road traffic related accidents than in wars. Prior to World War II, the death toll across the world used to be very high. It was at this juncture that a Military Neurosurgeon named Hugh Cairns introduced the compulsory wearing of crash helmets and brought about a reduction in mortality by more than 50%. Within a decade of introduction of crash helmets in Britain, the entire world followed suit. The results of his efforts are here for all of us to see. This innovative military neurosurgeon is credited as the one who introduced the concept of mobile neurosurgical units during world war and also the first proponent of usage of penicillin in war. His concepts in war surgery are still followed by militaries across the world. This article comes as a tribute to this great Neurosurgeon who helped in saving millions of lives.
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Symptoms of neurotoxicity among carpenters living in rural ecuador: A population-based study (The Atahualpa project) p. 649
Oscar H Del Brutto, Robertino M Mera, Ani Reich de Amador, Mauricio Zambrano, Pablo R Castillo
DOI:10.4103/jnrp.jnrp_286_17  
Background: There is no information on the prevalence of symptoms related to neurotoxicity among carpenters working in underserved populations. To assess the magnitude of the problem, we conducted a population-based study in Atahualpa, a rural Ecuadorian village, where most men work as carpenters under poor safety conditions. Methods: All men aged 40–75 years living in Atahualpa were identified during a door-to-door survey and evaluated with a general demographic questionnaire, the Q16 questionnaire, the depression axis of the Depression Anxiety Stress Scale-21, and the Montreal Cognitive Assessment (MoCA). Results: Among 230 participants, 63% were carpenters. Seventy participants (30%) had a positive Q16 questionnaire (≥6 points), which suggested neurotoxicity. In a logistic regression model adjusted for age, education, alcohol intake, symptoms of depression, and MoCA score, the proportion of Q16 positive persons was 39.1% for carpenters and 15.9% for noncarpenters (odds ratio: 3.53, 95% confidence interval: 1.75–7.15, P < 0.0001). In a generalized linear model, adjusted mean scores in the Q16 questionnaire were 4.9 for carpenters and 3.6 for noncarpenters (β: 1.285, standard error: 0.347, P < 0.0001). There was no correlation between scores in the Q16 questionnaire and the MoCA (Pearson correlation coefficient = −0.02), and the only significant covariate in the multivariate linear model was age, with every 10 years of age difference contributing 0.64 points in the Q16 questionnaire. Conclusion: This study shows a high prevalence of symptoms associated with neurotoxicity among carpenters after adjusting for a number of confounders. Long-term exposure to toxic solvents is the most likely explanation to this finding.
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IMAGES IN NEUROSCIENCES Top

Intracranial ossified metaplastic meningioma: Unusual cause of headache p. 653
Venkatraman Indiran
DOI:10.4103/jnrp.jnrp_277_17  
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CASE REPORTS Top

Subarachnoid hemorrhage due to ruptured intracranial aneurysm arising from a vertebral artery-bihemispheric posterior inferior cerebellar artery bifurcation p. 654
Yasushi Ogasawara, Hiroshi Kashimura, Kenta Aso, Hiroaki Saura
DOI:10.4103/jnrp.jnrp_285_17  
Although the anatomy of the posterior inferior cerebellar artery (PICA) is highly variable, a solitary PICA supplying both hemispheres of the cerebellum is rare. A 76-year-old woman presented with severe headache and subsequent loss of consciousness and was admitted to our hospital. Initial computed tomography showed subarachnoid hemorrhage. Three-dimensional digital subtraction angiography revealed a saccular aneurysm arising from the right vertebral artery (VA)-PICA bifurcation. The PICA branching from the right VA was enlarged, tortuous, and crossed the midline to supply both cerebellar hemispheres. This right PICA was interpreted as a bihemispheric PICA. Recognizing this variant preoperatively could help prevent complications of surgery. Careful follow-up studies are necessary in cases with bihemispheric PICA to monitor for the development of aneurysm at the junction between the bihemispheric PICA and the VA or the distal portion of the bihemispheric PICA.
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White matter changes in corpus callosum in a patient with idiopathic normal pressure hydrocephalus p. 657
Naresh Mullaguri, Anusha Battineni, Christopher R Newey, Premkumar Nattanmai
DOI:10.4103/jnrp.jnrp_329_17  
Idiopathic normal pressure hydrocephalus (INPH) is characterized by the clinical triad of gait and cognitive dysfunction and urinary incontinence. Ventriculoperitoneal (VP) shunting is often required for treatment. Review of literature shows few case reports discussing benign magnetic resonance imaging (MRI) T2 hyperintense changes in the corpus callosum of NPH patients after shunting due to mechanical compression of the middle and posterior regions of the body against falx cerebri leading to ischemic demyelination. These changes can be a delayed phenomenon and may interfere with clinical evaluation and may lead to unnecessary procedures and investigations. We present a patient with NPH who was admitted to the neurocritical care unit in coma with quetiapine and trazodone overdose. Diffuse changes in the body of the corpus callosum were seen on MRI suspicious for acute vasogenic edema due to drug overdose. However, it was later determined to be due to the VP shunting for the NPH. We report this case to raise the awareness of neuroimaging changes in patients with NPH who have VP shunting.
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Chromosome 15 duplication and attention-deficit hyperactivity p. 660
Sundar Gnanavel
DOI:10.4103/jnrp.jnrp_316_17  
Chromosome 15 duplication has been associated with a number of psychiatric illnesses including psychosis and autism. However, literature on association with attention-deficit hyperactivity disorder (ADHD) is scant. This case report describes a patient with chromosome 15 duplication diagnosed with ADHD in our neurodevelopmental clinic. The possible biological underpinnings are discussed along with possible challenges in diagnosis and management. The need for better understanding ADHD as a behavioral phenotype in such cases along with need for tailored management strategies is emphasized.
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COMMENTARY Top

Commentary p. 662
Pooja Patnaik Kuppili
DOI:10.4103/jnrp.jnrp_408_17  
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CASE REPORTS Top

Flow-diverting stent-assisted coil embolization of a ruptured internal carotid artery blister aneurysm with the pipeline flex embolization device p. 664
Dale Ding, Robert M Starke, Ayton Hope, Stefan Brew
DOI:10.4103/jnrp.jnrp_336_17  
Internal carotid artery (ICA) blister aneurysms are rare and challenging to successfully treat, using contemporary surgical or endovascular approaches, without partial or complete compromise of the parent vessel. We describe the use of a resheathable flow diverter, the Pipeline Flex Embolization Device (PFED) to perform stent-assisted coiling of a ruptured supraclinoid ICA blister aneurysm in a 56-year-old female who presented with a high-grade subarachnoid hemorrhage (SAH). The first PFED was deployed across the aneurysm neck to jail a microcatheter within the aneurysm dome, and then, two small coils were delivered into the aneurysm. After removing the coiling microcatheter, the second PFED was telescoped into the first PFED. There were no postprocedural complications, and follow-up magnetic resonance angiography 15 months after embolization showed complete aneurysm obliteration. Flow-diverting stent-assisted coiling should be considered as a reconstructive, vessel-preserving, endovascular treatment option for appropriately selected patients with ruptured ICA blister aneurysms. However, future studies are necessary to assess the periprocedural safety in the setting of acute SAH.
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Staged multimodality treatment of a large ruptured fusiform supraclinoid internal carotid artery aneurysm: Microsurgical clip-assisted endovascular coiling p. 668
Dale Ding, Thomas J Buell, Ching-Jen Chen, Daniel M Raper, Kenneth C Liu, Dennis G Vollmer
DOI:10.4103/jnrp.jnrp_293_17  
In the contemporary era of aneurysm management, large fusiform aneurysms presenting with subarachnoid hemorrhage (SAH) remain particularly challenging lesions to successfully manage. We describe a staged, multimodal treatment strategy for a 71-year-old patient who presented with a large ruptured fusiform aneurysm of the supraclinoid internal carotid artery (ICA) and a fetal posterior communicating artery which originated from the inferomedial aspect of the aneurysm. In the first stage, we performed a partial microsurgical clip reconstruction of the fusiform aneurysm and secured its rupture site, which was identified intraoperatively. This left two residual saccular components of the aneurysm, which were targeted with endovascular coiling in the same hospitalization after the patient had convalesced from the SAH and was beyond the vasospasm window. We believe that this combined approach of clip-assisted coiling can be employed instead of endovascular flow diversion or microsurgical bypass for appropriately selected patients with ruptured fusiform ICA aneurysms.
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Venous sinus stenting using transcranial access for the treatment of idiopathic intracranial hypertension in a pediatric patient p. 672
Thomas J Buell, Robert M Starke, Dale Ding, Harry R Hixson, Daniel M. S. Raper, Ching-Jen Chen, Kenneth C Liu
DOI:10.4103/jnrp.jnrp_135_17  
A 4-year-old male with headaches, papilledema, intracranial hypertension, and bilateral transverse sinus (TS) stenosis underwent attempted percutaneous placement of a right TS stent. Stent deployment was not technically feasible due to the stiffness of the stent and tortuosity of the patient's jugular bulb. Therefore, the patient underwent hybrid endovascular stenting of the right TS using neuronavigation and direct access of the TS following a single burr hole craniectomy. Two Express 8 mm × 17 mm balloon-mounted stents were deployed into the right TS, which resulted in obliteration of the preexisting trans-stenosis pressure gradient and decreased intracranial parenchymal pressure as monitored through an intracranial pressure bolt. The patient's headaches and papilledema resolved, and follow-up imaging demonstrated no in-stent or stent-adjacent stenosis. This case demonstrates the feasibility of combining minimally invasive open surgical access to allow direct cannulation for venous sinus stenting.
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COMMENTARY Top

Commentary p. 675
Aaron Mohanty
DOI:10.4103/jnrp.jnrp_315_17  
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CASE REPORTS Top

Postepidural spinal intradural arachnoid cyst: A rare case report p. 677
Muhammad Sohail Umerani, Gabr Ahmed Mostafa, Mona A F. Nada, Amjad Abdel Qader Darwish
DOI:10.4103/jnrp.jnrp_335_17  
Compression of the neural structures in spine by an intradural arachnoid cyst is a rare entity. At times such a cyst is an incidental finding. Spinal epidural injection is one of the few rare etiological factors for its development. Symptomatic cysts can present with variable neurological manifestations depending on the spinal level involved. This includes back pain, lower limb weakness, and sphincteric dysfunction. If asymptomatic, they can be followed radiologically. Surgical decompression along with a histological diagnosis is reserved for cysts that are enlarging, symptomatic or the ones for whom the diagnosis is uncertain. Incomplete excision of cyst wall or simple fenestration and decompression mandates close follow-up, clinically and radiologically for further recurrences.
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Delayed visual loss following transcranial surgery for tuberculum sella meningioma p. 680
Sudha Menon, Girish Menon
DOI:10.4103/jnrp.jnrp_258_17  
Postoperative visual loss is a dreaded complication following transcranial excision of tuberculum sella meningioma. Visual deterioration is commonly noticed immediately after surgery, and delayed deterioration after 72 h is uncommon. We report a case of delayed postoperative deterioration in a 48-year-old female and discuss the possible mechanisms.
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LETTERS TO THE EDITOR Top

Papilledema: A comprehensive assessment p. 683
Bruno Fortaleza de Aquino Ferreira
DOI:10.4103/jnrp.jnrp_257_17  
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Simultaneous convexity meningioma and prolactinoma p. 684
Vladimir Figueroa-Angel, Willem Guillermo Calderon-Miranda, Nidia Escobar-Hernandez, Andrei F Joaquim, Luis Rafael Moscote-Salazar, Emericella Renna Roldan-Medellin, Estefania Casasa Velez, Maria del Rocio Estrada-Hernandez
DOI:10.4103/jnrp.jnrp_374_17  
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Intraventricular bleed following surgery for giant cystic vestibular schwannoma: A rare complication p. 686
Dhananjaya I Bhat, Indira Devi Bhagavatula
DOI:10.4103/jnrp.jnrp_69_17  
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Proprioceptive-induced reflex postinfarct seizures: A rare occurrence p. 687
Rohan Mahale, Anish Mehta, Rangasetty Srinivasa
DOI:10.4103/jnrp.jnrp_263_17  
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International neurosurgery rotation in New Zealand: Analysis of operative experience p. 689
Dale Ding
DOI:10.4103/jnrp.jnrp_387_17  
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Friedreich ataxia: Clinical feature and electrophysiological symptoms p. 691
Masayoshi Oguri
DOI:10.4103/jnrp.jnrp_248_17  
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Hydrocephalus caused by H3N2 type A influenza virus or cerebellopontine angle schwannoma? p. 692
Jakob Nemir, Ivan Domazet, Klara Brgic, Natasa Kovac, Goran Mrak
DOI:10.4103/jnrp.jnrp_256_17  
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Commentary p. 694
Amauri Dalla-Corte
DOI:10.4103/jnrp.jnrp_432_17  
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OBITUARY Top

Professor Jean Holowach Thurston: Renowned and true pioneer of pediatric neurology as well as neurochemist p. 695
Guru Dutta Satyarthee
DOI:10.4103/jnrp.jnrp_339_17  
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