Mild traumatic brain injury (mTBI) is the commonest form of TBI. Though the name implies, it may not be mild in certain cases. There is a lot of heterogeneity in nomenclature, classification, evaluation and outcome of mTBI. We have reviewed the relevant articles on mTBI in adults, particularly its definition, evaluation and outcome, published in the last decade. The aspects of mTBI like pediatric age group, sports concussion, and postconcussion syndrome were not reviewed. There is general agreement that Glasgow coma score (GCS) of 13 should not be considered as mTBI as the risk of intracranial lesion is higher than in patients with GCS 14-15. All patients with GCS of <15 should be evaluated with a computed tomography (CT) scan. Patients with GCS 15 and risk factors or neurological symptoms should also be evaluated with CT scan. The outcome of mTBI depends on the combination of preinjury, injury and postinjury factors. Overall outcome of mTBI is good with mortality around 0.1% and disability around 10%.

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Background: Alzheimer dementia (AD) and vascular dementia (VD) are the most common causes of dementia in the elderly. Depression is an important co-morbid disorder in these diseases, which is often challenging to recognize. We investigated the prevalence of depression in patients with AD and VD and estimated the influence of depression on the health-related quality of life (HrQoL) in these patients. Materials and Methods: We evaluated prevalence of depression in consecutively recruited patients with AD or VD (n= 98). Depression was diagnosed according to criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and scored using the Geriatric Depression Scale. The EuroQol (EQ-5D and visual analogue scale) was applied to evaluate HrQoL. The severity of cognitive impairment was measured by the Mini-Mental State Examination (MMSE). Multiple regression analysis was used to identify factors predicting severity of depression. Results: The prevalence of depression in AD/VD was 87%. In comparison to the general population, HrQoL measured on the visual analogue scale was reduced by 54% in patients with AD/VD. In the dimension "anxiety/depression" of the EQ-5D, 81% of patients with AD/VD had moderate or severe problems. Depression showed significant association with reduced HrQoL (P<0.01). Independent predictors of more severe depression were older age, male gender, better MMSE scores and being not married. Conclusions: Depression is a prevalent psychiatric co-morbidity in patients with AD/VD, which is often under-diagnosed being masked by cognitive impairment. Depression is a predictor of reduced HrQoL in elder people with AD/VD. Therefore, they should be screened for presence of depressive symptoms and receive adequate antidepressant treatment.

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Objectives: The study was undertaken to assess the adherence to World Health Organization (WHO)-multidrug therapy (MDT) and its successful completion by the leprosy patients and the extent of such defaulting, its correlates and reasons. Design: Retrograde cohort analysis was conducted during the first quarter of 2007 from the cases registered for WHO-MDT treatment during 2002 to 2005 in Kamrup district of Assam, India. Results: A total of 254 leprosy cases reflected the treatment seeking behavior of registered cases during the study period. Majority of the cases were from urban areas and defaulter rate higher in urban areas. The study group consisted of 60.63% males and 39.37% females.. Both the compliance and default was higher in the age group of 16 to 30 years. Majority of defaulters (32.28%) had passed the high school leaving certificate examination had per capita monthly income between Rs 500 - 749 (30.71%) and belonged to social class IV (33.86%) and V (30.71%). Significant statistical association was found between gender, literacy status, per capita income per month and socioeconomic status with treatment outcome. On analysis for the reasons of defaulting treatment; majority (33.07%) defaulted treatment due to loss of occupational hours when they come for receiving drugs at health center, 25.98% defaulted due to adverse reactions of drugs and 18.11% feared social stigma among major causes. Conclusions: The causes of defaulting treatment were related to gender, educational status, income as well as social class, or some combination of these. Recommendations, on strategic interventions to obviate the cause for noncompliance, were presented.

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Inca bones are accessory bones found in neurocranium of human skulls. Occurrence of Inca bones is rare as compared to other inter sutural bones such as wormian bones. These Inca ossicles are regarded as variants of the normal. The reporting of such occurrences is inadequate from Central India. Objectives: To find the incidence of Inca variants in Central India. Materials and Methods: In the present study, 380 dried adult human skulls were examined. All specimen samples were procured from various Medical colleges of Central India. They were analyzed for gross incidence, sexual dimorphism and number of fragments of Inca bones. Results: Gross incidence of Inca bones was found to be 1.315 %. Incidence rate was higher in male skulls than female skulls (male: 1.428%; female: 1.176%). The Inca bones frequently occurred signally. Out of the five observed Inca ossicles, two were fragmented. Conclusions: This data gives idea regarding gross incidence, sexual dimorphism and number of fragments of Inca bones in neurocranium of human skulls from Central India. The knowledge of this variable is useful for neurosurgeons, anthropologists and radiologists.

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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.

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Spinal or paraspinal retained surgical sponges (gossybipoma or textiloma) are rare incidents and mostly asymptomatic in chronic cases, but can be confused with other masses such as a hematoma, an abscess or a tumor. In chronic cases, the presentation can be as late as decades after the initial surgery; however, some gossybipomas cause infection or abscess formation in the early stages. The authors report a 40-year-old woman with a history of operation for lumbar disk herniation before 8 months, and got admitted with a complaint of serous fluid leakage from the operation wound. In this report, the authors discuss the clinical presentation, the radiologic findings and the differential diagnosis of gossybipoma.

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Tuberculosis of pituitary gland is rare. We report a case of tuberculosis of pituitary gland in a 68-year-old male presented with holocranial headache of four months duration with left temporal hemianopia, with visual acuity of 6/6, without any localizing sign. Magnetic resonance imaging showed a sellar ring enhancing mass with suprasellar extension. Patient was taken up for surgery and put on antitubercular treatment and hormone replacement therapy.

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Background: Trauma is one of the common surgical emergencies presenting at B. P. Koirala Institute of Health Sciences (BPKIHS), Nepal, a tertiary referral center catering to the needs of the population of Eastern Nepal and nearby districts of India. Objective: The objective of this study is to analyze the magnitude, epidemiological, clinical profile and outcome of trauma at B P Koirala Institute of Health Sciences. Materials and Methods: This descriptive case series study includes all patients with history of trauma coming to BPKIHS emergency and referred to the surgery department. We noted the detailed clinical history and examination, demographics, mechanism of injury, nature of injury, time of reporting in emergency, treatment offered (operative or non operative management) and analyzed details of operative procedure (i.e. laparotomy, thoracotomy, craniotomy etc.), average length of hospital stay, morbidity and outcome (according to Glasgow outcome scale). Collected data were analyzed using EpiInfo 2000 statistical software. Results: There were 1848 patients eligible to be included in the study. The mean age of the patients was 28.9 ± 19.3 years. Majority of the patients (38%) belonged to the age group of 21 - 40 years and the male to female ratio was 2.7:1. Most of the trauma victims were students (30%) followed by laborers (27%) and farmers (22%) respectively. The commonest causes of injury were fall from height (39%), road traffic accident (38%) and physical assault (18%); 78% of the patients were managed conservatively and 22% underwent operative management. Postoperative complications were seen in 18%. Wound infection 7.5%, neurological deficit including cerebrospinal fluid (CSF) otrorrhea was seen in 2.2% patients. Good recovery was seen in 84%, moderate disability in 5.2% patients and severe disability in 1.4% patients. The mortally was 6.3% and most of the deaths were related to traumatic brain injuries. Conclusions: In Nepal, trauma-related injury contributes significantly to morbidity and mortality and is the third leading cause of death. There are very few studies on trauma from this country and hence this study will help in understanding the etiology and outcome particularly in the Eastern region of Nepal.

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The musculocutaneous nerve usually branches out from the lateral cord of brachial plexus. It innervates the corcobrachialis, biceps brachii and brachialis muscles and continues as the lateral cutaneous nerve of forearm without exhibiting any communication with the median nerve or any other nerve. We report unilateral variation in motor innervations of the left arm in a 58-year-old male cadaver. The musculocutaneous nerve was found to be absent. A muscular branch of the median nerve was supplying the coracobrachialis muscle. In the middle of arm, the median nerve was found to be branching out, bifurcating and supplying the long and short head of biceps. The median nerve was found to be giving a separate branch, which supplied the brachialis muscle and continued as the lateral cutaneous nerve of forearm. The right sided structures were found to be normal. Surgeons should keep such variations in mind while performing arm surgeries.

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Primary spinal hydatid cyst is very rare lesion affecting less than 1% of the total cases of the hydatid disease. In this study, we report a case of spinal hydatid in a 5-year old boy presented with a history of backache, leg pain, difficulty in walking, and bowel and bladder incontinence for 4 months. An intradural nonenhancing cystic lesion was detected using magnetic resonance imaging from L4 to sacral region, and histopathological findings were suggestive of hydatid cyst.

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Background: The community-based mental health studies have revealed that the point prevalence of depressive disorders in the elderly population of the world varies between 10% and 20% depending on cultural situations. Objective: To determine the median prevalence rates of depressive disorders in the elderly population of India and various other countries in the world. Materials and Methods: A retrospective study based on meta-analysis of various study reports. Setting: Community-based mental health surveys on geriatric depressive disorders conducted in the continents of Asia, Europe, Australia, North America, and South America. Study Period: All the studies that constituted the sample were conducted between 1955 and 2005. Sample Size: After applying the inclusion and exclusion criteria on published and indexed articles, 74 original research studies that surveyed a total of 4,87,275 elderly individuals in the age group of 60 years and above, residing in various parts of the world were included for the final analysis. Inclusion Criteria: The researchers had included only community-based cross-sectional surveys and some prospective studies that had not excluded depression on baseline. These studies were conducted on homogenous community of elderly population in the world, who were selected by simple random sampling technique. Exclusion Criteria: All the unpublished reports and unavailable or unanalyzed or inaccessible articles from the internet were excluded from the study. Statistical Analysis: The median prevalence rate and its corresponding interquartile range (IQR), Chi-square test, and Chi-square for Linear Trend were applied. A P value < 0.05 was considered as statistically significant. Results and Conclusion: The median prevalence rate of depressive disorders in the world for the elderly population was determined to be 10.3% [IQR = (4.7%-16.0%)]. The median prevalence rate of depression among the elderly Indian population was determined to be 21.9% [IQR = (11.6%-31.1%)]. Although there was a significant decrease trend in world prevalence of geriatric depression, it was significantly higher among Indians in recent years than the rest of the world.

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Context: Literature is replete with studies on zidovudine-induced myopathy after prolonged use (use beyond 270 days on an average). However, all these studies have been done on patients of Caucasian, American and African ethnic origin. No such study has been carried out in Indian patients to our knowledge. Aims: To determine the correlation of zidovudine usage with serum creatine phosphokinase (CK) levels, clinical muscular weakness and muscle histology in Indian patients, we studied 147 physically active, Human Immunodeficiency Virus infected men on prolonged zidovudine-based antiretroviral therapy (ART). Settings and Design: Cross-sectional study on hospital follow-up patients of HIV infection. Materials and Methods: All cases on ART who reported to our canter during a period of 18 months were evaluated for symptoms (muscle fatigue, myalgia), objective muscle strength (testing clinically) and serum CK levels, and a select group was evaluated by muscle biopsy. These patients were on zidovudine for 1 to 7 years. Results: None of the patients studied had significant symptoms or objective muscle weakness and only a small fraction (10.8% of cases) had marginally raised serum CK levels. All muscle biopsies were normal on light microscopy. Conclusions: Zidovudine myopathy may be a constraint for use of the drug in the western population; however, it is a well-tolerated drug as regards myopathy in our study on Indian patients.

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Background: There is an indisputable relationship between tooth decay and oral hygiene. Caries can only be prevented by keeping tooth decay at bay. In several prophylactic methods, brushing is the most important. Brushing efficiency is directly related to an individuals' manual dexterity. Objective: To investigate whether there were differences in oral hygiene and caries prevalence between right- and left-handers. Materials and Methods: Forty-six elementary school students were included in the study. The subjects were 30 males and 16 females, ranging in age from 11 to 13 years. Handedness was ascertained by using the Edinburgh Handedness Scale. All students were examined intraorally. During this examination, the necessary values to determine oral hygiene status and to determine caries prevalence were recorded. Results: It was observed that subjects who used their right hands were in a better position in terms of oral hygiene than those using the left (P < 0.01). In terms of caries prevalence, however, averages for right-handed individuals were lower than those for left-handed subjects, although the difference was not statistically significant. Conclusions: It can be stated that the right-handed individuals have better oral hygiene and the lower incidence of caries because of their better manual dexterity and brush efficiency. So, dentists should consider better manual dexterity and brush efficiency in right-handed individuals before treatment planning. However, future well-designed neurologic studies involving larger numbers of subjects will be necessary to confirm the findings of this study and to understand more about the effects of handedness on oral hygiene performance.

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Background: Perioperative outcomes following surgery for brain tumors are an important indicator of the safety as well as efficacy of surgical intervention. Perioperative morbidity not only has implications on direct patient care, but also serves as an indicator of the quality of care provided, and enables objective documentation, for comparision in various clinical trials. We document our experience at a tertiary care referral, a dedicated neuro-oncology center in India. Materials and Methods: One hundred and ninety-six patients undergoing various surgeries for intra-axial brain tumors were analyzed. Routine microsurgical techniques and uniform antibiotic policy were used. Navigation/ intraoperative electrophysiological monitoring was not available. The endpoints assessed included immediate postoperative neurological status, neurological outcome at discharge, regional complications, systemic complications, overall morbidity, and mortality. Various risk factors assessed included clinico-epidemiological factors, tumor-related factors, and surgery-related factors. Univariate and multivariate analysis were performed. Results: Median age was 38 years. 72% had tumors larger than 4 cm. Neurological morbidity, and regional and systemic complications occurred in 16.8, 17.3, and 10.7%, respectively. Overall, major morbidity occurred in 18% and perioperative mortality rate was 3.6%. Although a few of the known risk factors were found to be significant on univariate analysis, none achieved significance on multivariate analysis. Conclusions: Our patients were younger and had larger tumors than are generally reported. Despite the unavailability of advanced intraoperative aids we could achieve acceptable levels of morbidity and mortality. Objective recording of perioperative events is crucial to document outcomes after surgery for brain tumors.

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Background: Dengue infections may present with neurological complications. Whether these are due to neuromuscular disease or electrolyte imbalance is unclear. Materials and Methods: Eighty-eight patients of dengue fever required hospitalization during epidemic in year 2010. Twelve of them presented with acute neuromuscular weakness. We enrolled them for study. Diagnosis of dengue infection based on clinical profile of patients, positive serum IgM ELISA, NS1 antigen, and sero-typing. Complete hemogram, kidney and liver functions, serum electrolytes, and creatine phosphokinase (CPK) were tested. In addition, two patients underwent nerve conduction velocity (NCV) test and electromyography. Results: Twelve patients were included in the present study. Their age was between 18 and 34 years. Fever, myalgia, and motor weakness of limbs were most common presenting symptoms. Motor weakness developed on 2 ^nd to 4 ^th day of illness in 11 of 12 patients. In one patient, it developed on 10 ^th day of illness. Ten of 12 showed hypokalemia. One was of Guillain-Barré syndrome and other suffered from myositis; they underwent NCV and electromyography. Serum CPK and SGOT raised in 8 out of 12 patients. CPK of patient of myositis was 5098 IU. All of 12 patients had thrombocytopenia. WBC was in normal range. Dengue virus was isolated in three patients, and it was of serotype 1. CSF was normal in all. Within 24 hours, those with hypokalemia recovered by potassium correction. Conclusions: It was concluded that the dengue virus infection led to acute neuromuscular weakness because of hypokalemia, myositis, and Guillain-Barré syndrome. It was suggested to look for presence of hypokalemia in such patients.

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Central nervous system tuberculosis (TB) is the most devastating manifestation of TB. It is a challenge for clinicians because of the difficulty in making an early diagnosis and the severe consequences of delayed treatment. The aim of this report is to point out the relation between migration and TB based on a 14-year-old child with tuberculous meningoencephalitis (TBM) of an immigrant family. Migration, crowded living conditions and positive family history contribute to the severe course of TB as TBM and miliary TB forms. TB control may prevent these severe manifestations of the disease among immigrants. Prompt diagnosis with helpful early diagnostic tools like polymerase chain reaction in TBM is crucial due to the high mortality and morbidity.

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Dolichoectasia of vertebrobasilar artery is a condition in which the vertebral/basilar artery is elongated, distended and tortuous. It is usually asymptomatic. It may present with compressive or ischemic symptoms. Hydrocephalus as a complication of vertebrobasilar dolichoectasia is rare. We present a case of a 60-year-old male with dolichoectasia of the basilar artery causing compression of the third ventricular outflow and, thus, presenting with noncommunicating hydrocephalus.

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Background: A study to investigate the level of the neurobiochemical marker, Neuron-Specific Enolase (NSE), at the time of admission and its correlation with the blood sugar level in ischemic stroke patients. Patients and Methods: We investigated 90 patients with complete stroke who were admitted to the Stroke Unit of the Department of Neurology at Sri Aurobindo Institute of Medical Sciences. NSE was measured with commercially available quantitative 'sandwich' enzyme-linked immunosorbent assay kits obtained from R and D Systems. Hyperglycemia was defined as blood glucose concentration ≥ 7 mmol / L, and measured using the glucose oxidase method immediately. Results: Significantly increased NSE and lipid profile levels were found in ischemic stroke patients as compared to the control. Hyperglycemic ischemic stroke patients had increased levels of NSE, lipid profile, and National Institute of Health stroke scale scores (NIHSS score) compared to normoglycemic ischemic stroke patients. In addition the serum NSE level of hyperglycemic stroke patients was also positively correlated with the blood sugar level (r = 0.734 P < 0.001). Conclusions: Hyperglycemia predicts an increased risk of poor outcome after ischemic stroke and it is reflected by a significantly increased level of Neuron-Specific Enolase.

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Background: People with epilepsy have impairment in their quality of life (QOL) due to effect of epilepsy on various aspects of their life and the medication effects. Systematic studies on QOL in epilepsy from developing countries are sparse. Objectives: To assess the QOL in people with epilepsy and to evaluate various factors affecting the QOL in them. Materials and Methods: People with generalized and partial epilepsy on medication aged more than 18 years were included in the study. The QOL was assessed with QOLIE-89 instrument. Statistical significance was evaluated by the use of Chi-square test and one-way analysis of variance (ANOVA). Results: Sixty people with epilepsy were studied among whom the older patients had lower overall QOL scores compared to younger patients. Female patients had lower scores compared to males. Married people had lower quality of health score. Patients with simple partial seizures had lowest overall QOL mean score. There was reduction in the overall QOLIE scores with increasing duration of the epilepsy. Patients who had their last seizure within 10 months prior to evaluation had lower mean overall scores. Conclusion: QOL was impaired in people with epilepsy with increased impairment in women, older patients, simple partial seizures, and those with recent seizure.

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Background: Neurotrauma is one of the most important causes of death and disability. Some of the severely head injured patients, failed to show significant improvement despite aggressive neurosurgical management and ended up in a vegetative state. Aims: To assess the outcome at six months and one year using Glasgow outcome scale (GOS), in this prospective study on patients with severe head injury, who remained vegetative at one month. Materials and Methods: This prospective study was carried out in the department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), New Delhi, over a period of a year and a half (March 2002 through July 2003). Materials and Methods: In patients with severe head injury (GCS < 8), post resuscitation, neurological assessment was done with Glasgow coma scale (GCS), pupillary light reflex, doll's eye movement and cold caloric test in all cases. Fifty patients, who remained vegetative post injury according to the criteria of Jennett and Plum, at one month, were considered for the study. Brain SPECT (Single Photon Emission Computed T omography) Scanning was carried out in selected cases. Statistical analysis: Data analysis was done by Pearson's chi-square test on computer software SPSS, Version 10 (California, USA). Results: Patients with preserved brainstem reflex and with no perfusion defect on SPECT scan had statistically significant favorable outcome. More than 40% of vegetative patients regained consciousness by the end of one year, of whom 24% had favorable outcome in the form of moderate disability and good recovery. Conclusion: SPECT is better than computed tomography/magnetic resonance imaging (CT/MRI) as it assesses the cerebral perfusion and functional injury rather than detecting the lesions only. Further study with a control group is necessary to establish the role of SPECT in head injury.

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Background: Use of tobacco, alcohol, and other substances is a worldwide problem and affects many adolescents. Objective: (1) To find out the magnitude of licit and illicit substance use among students; and (2) to find out the association between socioeconomic and demographic characteristics of the students and habits of use. Materials and Methods: This was a population-based cross-sectional study conducted during June 2003 to May 2004. In a multistage random sampling among all the districts and schools in West Bengal, India, 416 high school students from two schools were selected. The main outcome measures were substance use, namely, tobacco, alcohol, and cannabinoids. From the schools, all the students in the classes VIII, IX, and X were taken as the study population and were administered a pretested close-ended anonymous self-administered questionnaire relating to pattern, frequency, and correlates of substance use. Results: The ultimate response rate was 87.02% and 416 students could be covered in our study. The overall prevalence rates among rural and urban students were 6.14% and 0.6% for illicit drug use, 8.60% and 11.04% for tobacco, and 7.37% and 5.23% for alcohol consumption, respectively. Both licit and illicit substance use was associated more with male students. Current and regular use were mostly restricted to tobacco, and the use of a substance by family members had a significant impact on its use by their children. "Enjoyment" and "Curiosity" were found to have the major influence in their decision to use a substance. Conclusions: Early identification of the magnitude and the factors related to substance use can improve scopes for planning and preventive approaches for this vulnerable group before the problems get serious after which interventions become difficult.

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