Introduction: Critically ill patients often receive central nervous system drugs due to primary disorder or complications secondary to multiorgan failure. The aim of the study was to evaluate the current utilization pattern of central nervous system drugs among patients in the medical intensive care unit. Materials and Methods: A prospective observational study carried out over a period of 1 year. The relevant data on drug prescription of each patient was collected from the inpatient case record. Drugs were classified into different groups based on WHO-ATC classification. The demographic data, clinical data, and utilization of different classes of drugs as well as individual drugs were analyzed. Results: A total of 325 consecutive patients were included for the analysis; 211 (65%) patients were males; 146 patients (45%) were above 55 years of age. Encephalopathy [63(19.38%)] and stroke [62(19%)] were the common central nervous system diagnoses. In a total of 1237 drugs, 68% of the drugs were prescribed by trade name. Midazolam (N05CD08) 142 (43.69%), morphine (N02AA01) 201 (61.84%), and atracurium (M03AC04) 82 (25.23%) were the most commonly used sedative, analgesic, and neuromuscular blocker, respectively. Phenytoin (N03AB02) 151 (46.46%) had maximum representation among antiepileptic agents. Conclusions: Utilization of drugs from multiple central nervous system drug classes was noticed. Rational use of drugs can be encouraged by prescription by brand name.

Objective: Antibodies to ganglioside GM1 are associated with Guillain-Barré Syndrome (GBS) in patients with serologic evidence of a preceding infection with Campylobacter jejuni. Molecular mimicry between C. jejuni Lipopolysaccharide (LPS) and ganglioside GM1 has been proven to be the immunopathogenic mechanism of the disease in the axonal variant of GBS. GM1-positive sera cross-react with several Gal-GalNAc-bearing glycoproteins from the human peripheral nerve and C. jejuni (O:19). This study aimed to examine the immunoreactivity of the digested cross-reactive glycoproteins isolated from the human peripheral nerve and C. jejuni (O:19) with Peanut Agglutinin (PNA) as a marker for the Gal-GalNAc determinant, and with sera from patients with GBS. Materials and Methods: For this purpose, the cross-reactive glycoproteins from peripheral nerve and C. jejuni (O:19) were enzymatically digested with trypsin and the obtained peptides were incubated with PNA and GBS sera. Results: Western blot analysis of the separated peptides revealed several bands showing positive reactivity to PNA and to sera from patients with GBS, present in both digests from peripheral nerve and C. jejuni (O:19). Conclusions: These data indicate the possible molecular mimicry between the cross-reactive glycoproteins present in C. jejuni and human peripheral nerve and its potential role in the development of GBS following infection with C. jejuni (O:19).

Introduction: Newer anticonvulsants have a neuromodulatory effect on pain perception mechanisms in a hyperexcitable and damaged nervous system. Aim: This study was designed to study the analgesic effects of gabapentin alone and in combination with lamotrigine and topiramate in experimental pain models. Materials and Methods: Adult albino mice (n=490) weighing 20-30 g and rats (n=130) weighing 100-200 g were injected intraperitoneally with gabapentin, lamotrigine, and topiramate alone and in different dose combinations. The hot-plate method, tail-flick method, capsaicin-induced mechanical hyperalgesia, and formalin assay were used to assess the antinociceptive effects. Results: Of the three antiepileptic drugs, when given separately, gabapentin was more efficacious than either topiramate or lamotrigine in all the pain models. Combination of 25 mg/kg gabapentin with 25 mg/kg topiramate was more efficacious (P<.05) than 50 mg/kg gabapentin alone in the capsaicin-induced mechanical hyperalgesia test. Similarly, 50 mg/kg gabapentin with 50 mg/kg topiramate or 5 mg/kg lamotrigine was more efficacious (P<.05) than 50 or 100 mg/kg gabapentin alone in late-phase formalin-induced behaviors. Conclusions: Combination of gabapentin with either lamotrigine or topiramate produced better results than gabapentin alone in capsaicin-induced mechanical hyperalgesia test and in late-phase formalin-induced behaviors.

Introduction: Craniotomy is a neurosurgical operation done to remove brain tumor, repair vascular lesion, and relieve intracranial pressure. Complications can arise which may necessitate re-do craniotomy. The study is planned to find out the relationship between variables such as age, American Society of Anaesthesiologist (ASA), Glasgow coma score (GCS), frequency of re-do craniotomy, and surgical outcome of re-do craniotomy. Materials and Methods: This is a retrospective study of all the patients who had re-do craniotomy over a 4-year period. The data that were collected included age, sex, ASA classification, indication for re-do craniotomy, GCS, frequency of re-do craniotomy, postoperative complications, and outcome. Results: Twenty-five patients had indication for re-do craniotomy within the study period. Forty percent were male and 60% were female, and their mean age was 38.56 ± 17.38 years. The indications for re-do craniotomy were removal of residual tumor, evacuation of clot, and cerebrospinal fluid leakage. Seventy-six percent had good outcome, while 24% had poor outcome. Outcome was good for patients who had re-do craniotomy done once, while poor outcome was for patients with second and third craniotomies. Ninety percent of patients with ASA 2 had good outcome, while 9.1% had poor outcome; but 64.3% had good outcome with ASA 3, while 37.7% had poor outcome with a P-value of 0.18. Seventy-five percent had poor outcome in patients with GCS of less than 9, while 25% had good outcome; but 14.3% had poor outcome in patients with GCS above 9, while 85.7% had good outcome with a P-value of 0.031. Conclusions: Increasing frequency of re-do craniotomy and lower GCS were major factors affecting outcome in re-do craniotomy in our center. The outcome of these patients is valuable in the management of other patients with re-do craniotomy in future.

Introduction: Hand splinting after stroke is a common practice despite inadequate evidence. This warrants a better understanding of the therapists' splinting practice, to develop clinically meaningful treatment options. Aims: The study examined the nature and prevalence of the factors associated with therapists' hand splinting practice and their perceived splinting efficacy. Settings and Design: A cross-sectional national survey of hand-splinting practice among inpatient occupational therapists (OTs) in Ireland. Materials and Methods: Sixty-two therapists participated in this national survey.Statistical analysis used: A number of factors were analyzed to explore their relationship with therapists' perception of splint efficacy using Spearman's rank order correlation. Results: 53(85.5%) out of 62 survey respondents prescribed splints to their clients at the time of taking the survey. To reduce spasticity, to correct contractures and thus increase range of motion (ROM) were the commonly used splinting goals. These were the goals that were significantly associated with the therapists' splinting efficacy too. Conclusions: Hand-splint prescription following stroke was found to be a common practice among OTs who perceive splints to be quite effective. A custom-made, volar forearm-based wrist-hand splint is the preferred splint among therapists to achieve a number of clinical aims such as improving ROM, stretching soft tissue contractures and reducing spasticity in the upper extremity. A wide variety of splinting regimens is currently practiced, reflecting the lack of a universally accepted and comprehensive practice guideline to regulate therapy. Methodologically valid clinical trials evaluating the efficacy of therapist-preferred splints in achieving their favored outcomes are needed. Development of common, universally accepted therapeutic guidelines based on comprehensive scientific review of such studies is thus needed.

Background: Trigeminal neuralgia typically involves nerves supplying teeth, jaws and face of older females. Though the etiology is usually obscure, different treatment modalities have been tried for it viz. medicinal treatment, injection alcohol, peripheral neurectomy, rhizotomy, and microvascular decompression etc. Transcutaneous electric nerve stimulation (TENS) is an emerging and promising option for management of such patients. Aims and Design: The present study was designed with an aim to study the efficacy of TENS in management of trigeminal neuralgia. Materials and Methods: The study was conducted on 30 patients of trigeminal neuralgia confirmed by diagnostic nerve block. They were given bursts of TENS for 20-40 days over the path of the affected nerve and subsequently evaluated at 1 month and 3 month intervals by visual analogue scale (VAS), verbal pain scale (VPS), a functional outcome scales for main daily activities like sleep, chewing, talking, or washing face. Results: The results showed that, on VAS, the score decreased from 8.9 (Pre TENS) to 3.1 at 1 month and 1.3 at 3 months, and on VPS, the score decreased from 3.5 (Pre TENS) to 1.2 at 1 month and 0.3 at 3 months. Similarly, a considerable decrease in scores was seen on functional outcome scale for different activities. No side effects like irritation or redness of skin were seen in any of the patients. Conclusions: Thus, TENS was found to be a safe, easily acceptable, and non-invasive outdoor patient department procedure for management of trigeminal neuralgia.

Introduction: Tuberculous brain abscess (TBA) is a rare but serious condition. It resembles a pyogenic brain abscess clinically and radiologically and poses a problem in diagnosis and treatment. A final diagnosis is established by smear or culture demonstration of acid fast bacilli (AFB) within the abscess. Here, we report four such cases in our five-year study on brain abscesses, along with the different diagnostic modalities used. Materials and Methods: A total of 75 brain abscess pus specimens were collected during neurosurgery, either by burr hole or by craniotomy. These specimens were further subjected to Gram stain, Ziehl-Neelsen (ZN) stain, and conventional microbiological culture. Only those cases which showed presence of AFB on ZN stain along with the growth of Mycobacterium tuberculosis were considered as TBAs. Such TBA cases were further presented along with their In vitro Proton Magnetic Resonance (MR) Spectroscopic findings. Results: Of these four patients, three were males. Though this condition is more commonly seen in immunocompromised patients, three of the patients in this study were immunocompetent. All the four pus specimens showed presence of AFB in the ZN stain. Three of them grew M. tuberculosis as sole isolate. The fourth case was of concomitant tuberculous and pyogenic brain abscess. In vitro Proton MR spectroscopy of the pus specimens showed absence of multiple amino acids at 0.9 ppm, which was found to be hallmark of TBA. One patient died of four. Conclusions: TBA always poses a diagnostic dilemma. ZN stain and conventional microbiological culture for Mycobacteria always help to solve this dilemma. In vitro Proton MR Spectroscopy also seems to have the diagnostic utility.

Introduction: Encephalocele, midline defect of cranial bone fusion, occurs most frequently in the occipital region. Airway management in pediatric patients with craniofacial disorders poses many challenges to the anesthesiologist. The purpose of this study is to describe the airway problems encountered for such cases, and describe how these problems were managed. Materials and Methods: We reviewed the charts of occipital encephalocele newborn that were treated by surgical correction in Harran University Hospital during 2006-2008. The collected data were categorized into preoperative, intraoperative, and postoperative data. Results: The mean age of the patients was 5.17 days. Of these 17 patients, eight patients (47.1%) had hydrocephaly, one patient (5.8%) with Dandy Walker syndrome. Micrognathia, macroglossia, restriction in neck movements were recorded as the reasons in six cases each. No major anesthetic complication was found. Conclusions: We reported perioperative management in 17 occipital encephalocele infant. Comprehensive care during peroperative period is essential for successful outcome.

Cranioplasty is the surgical intervention to repair cranial defects. The aim of cranioplasty is not only a cosmetic issue; also, the repair of cranial defects gives relief to psychological drawbacks and increases the social performances. Many different types of materials were used throughout the history of cranioplasty. With the evolving biomedical technology, new materials are available to be used by the surgeons. Although many different materials and techniques had been described, there is still no consensus about the best material, and ongoing researches on both biologic and nonbiologic substitutions continue aiming to develop the ideal reconstruction materials. In this article, the principle materials and techniques of cranioplasty are reviewed.

Guillain-Barre syndrome (GBS) is usually a monophasic illness but relapses occur. A 55-year-old female with hypertension and vitiligo presented with acute inflammatory demyelinating polyradiculoneuropathy. She improved with immunoglobulin treatment started on day 6 of illness, but relapsed on day 14 warranting repeat immunoglobulin therapy. Thereafter recovery was complete. Her relapse was due to treatment-related fluctuation (TRF). TRF is improvement in the GBS disability scale of at least one grade after completion of immunotherapy followed by worsening of the disability scale of at least one grade within the first 2 months after disease onset. Recurrent GBS and chronic inflammatory demyelinating polyradiculoneuropathy were excluded. During the peak of the illness ANA titres were transiently high. The presence of other medical conditions, predominant proximal weakness and the absence of preceding diarrhea are predictors for TRF seen in this patient. Early treatment and evidence of ongoing immune activation have contributed toward TRF.

Severe respiratory muscle paralysis and ventilatory failure is rare in chronic inflammatory demyelinating polyneuropathy (CIDP). We report a 14 year child who presented with respiratory failure, bulbar and multiple cranial nerves involvement along with bilateral phrenic nerve paralysis. He was diagnosed with CIDP after electrophysiological evaluation. He required AMBU ventilation for about 4 months (including domiciliary use), after which he recovered significantly. Along with several unusual features of CIDP, this report highlights good example of steady basic intensive care to save lives and rewarding outcome of prolonged respiratory support, provided by AMBU ventilation which is a rather primitive, but inexpensive device.

Primary intraosseous cavernous hemangiomas (PICHs) of the cranium are rare benign vascular tumors that account for about 0.2 % of all bone tumors and 10 % of benign skull tumors. They generally present as osteolytic lesions with honeycomb pattern of calcification. Completely ossified cavernous hemangioma of the calvarium in an adult has not been reported previously. A 28-year-old female presented to us with a large right parietal skull mass that had been present since the last 15 years. Total resection of the lesion was performed. Pathological examination was suggestive of cavernous hemangioma of the skull bone. Cavernous hemangioma should be considered as one of the differential diagnosis in any case of bony swelling of the calvarium so that adequate preoperative planning can be made to minimize blood loss and subsequent morbidity.

The transmastoid branch of the occipital artery is an important supply to posterior fossa vascular malformations and tumors and is often difficult to catheterize due to tortuosity and a transforaminal course. In very difficult situations, we can try to induce spasm of the occipital artery just beyond the origin of the mastoid branch by repeated passages of the microcatheter/wire. This induces a temporary 'ligation' like effect so that the microcatheter can then be manipulated into the mastoid branch via the mastoid foramen. Rarely, the occipital artery has to be sacrificed if spasm cannot be induced or is short living, following which particles can be injected from a distance without entering the mastoid foramen. Occluding the occipital artery proximally has no effect on distal perfusion, as collaterals and anastomoses from superficial temporal artery, posterior auricular artery, and opposite occipital artery take over the supply.

An uncommon case of allergic fungal rhinosinusitis presented to the ophthalmology outpatient department of our hospital with complaints of blurred vision in the right eye of a few days duration and vague complaints of pain around the eyes. The visual acuity on examination was grossly reduced in the right eye and normal in the left eye. Color vision was normal. Anterior segment examination including pupils was normal. Dilated fundus examination was normal except for temporal pallor in the right optic disc. Automated perimetry and magnetic resonance imaging (MRI) scan of brain and orbit were done. The imaging report showed a bilateral pansinusitis with pressure on the right optic nerve. Perimetry showed a superior field defect on the right side. ENT consultation and computed tomography (CT) with contrast helped to diagnose this as a case of allergic fungal rhinosinusitis. The patient was started on systemic steroids under the care of the ENT surgeon. After a few days, pre-operative assessment showed a gross improvement of visual acuity. Endoscopic sinus surgery was done to remove the polyps and thick mucus material. Histopathologic examination confirmed allergic fungal mucin. Days after surgery, the visual acuity improved further and repeat perimetry showed gross improvement in the visual field. Good history taking and a detailed ophthalmic examination, keeping in mind the probable causes of loss of vision of few days duration with no findings other than a decreased visual acuity and a suspicious disc, were key to the early diagnosis and investigation in this case. This helped in early referral and management of the case before permanent damage and irreversible visual loss occurred. The optic nerve is a cranial nerve which, once damaged permanently, will not regenerate. The amount of sinus involvement was extensive on both sides and invariably the left optic nerve would have been involved in a few days, if intervention was delayed.

Autonomic dysreflexia due to distended bladder is well known. Reflux of blood during endovascular procedure is also a common observation. It happens due to difference in pressure gradient between arterial pressure and that of infusing solution. Generally it happens when the infusion bottle is empty or the pressure in infusion bottles fall. We present an uncommon situation where distended bladder mechanically resulted in reflux of blood into endovascular catheters as well as alteration in hemodynamic parameters. Both settled once the bladder was empty.

Cystic mature teratomas of the spinal cord are rare lesions. Teratomas account for up to 0.1% of all spinal cord tumors. Teratomas include tissues that originate from the three germ layers. Several congenital disorders may accompany the teratoma. Teratomas are classified as mature, immature or malignant type according to their histological characteristics. Thoracic spinal teratomas are uncommon in the pediatric age group. More than half of the patients are adults. We present herein a five-year-old male patient who was referred to our clinic with cystic mature teratoma at the T12 level.

Hereditary spastic paraparesis (HSP) is an inherited group of neurological disorders with progressive lower limb spasticity. HSP can be clinically grouped into pure and complicated forms. Pure HSP is one without any associated neurological/psychiatric comorbidity. Depression is the most common psychiatric comorbidity. Presence of mania or bipolar affective illness with HSP is a rare phenomenon. We report a case of a 17-year-old boy who presented with classical features of HSP with complaints of excessive happiness, irritability, increased self-esteem and decreased sleep since 1 month. The patient also had complex partial seizure ever since he had features of HSP. The patient's father and younger sister suffer from pure HSP. The patient was diagnosed to have first episode mania with complicated HSP. The details of treatment and possible neurobiology are discussed in this case report.

There have been few reports on secondary parkisonism caused by chronic subdual hemorrhage (CSDH). In most reports, rigidity-bradykinesia syndrome resolved gradually after decompressive operation for CSDH. We report a 74-year-old male patient who suffered from CSDH status post burr hole drainage twice, and followed secondary parkinsonism thereafter. Decompression by burr hole drainage was successful. However, the conscious level was still altered and the patient began to present with rigidity and bradykinesia. Fortunately, the symptoms dramatically improved after taking L-dopa. CSDH-related parkinsonism may have pre-operative nigrostriatal dysfunction, which can not compensate further insults to the basal ganglia. Prescription of L-dopa may be helpful in these patients

A complete examination of a head injured patient in the hospital requires a number of instruments. These include a stethoscope, sphygmomanometer, ophthalmoscope, otoscope, cotton wool, safety pin, tuning fork, reflex hammer and a small key to test the plantar response. Few of these are required at the accident scene. This is because, in the hospital, the aim is optimal definitive treatment. At the accident scene, the aim is prevention of secondary injury, rapid recording of the most important findings and safe efficient transport to the hospital. This short paper reviews how the local doctor should undertake a neurosurgical assessment of traumatic brain injury patients. Moreover, the primary management at accident scenes is described and the rationale behind the approach is outlined