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Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were “Temporary Clip,” “Temporary Clipping,” “Cerebral Aneurysm,” and “Aneurysm.” Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use.

Introduction: Oculomotor nerve palsy following mild traumatic brain injury is uncommon. The exact pathogenesis, management protocol and outcome of such patients is unclear in the absence of large series. This article attempts to analyze the patterns of injury and recovery in a series of twenty one patients with third cranial nerve palsy following mild traumatic brain injury (TBI). Materials and Methods: All patients admitted with mild head injury and third nerve involvement were included in the study. This retrospective study covered a three-year period from January 2015 to December 2017. Mild head injury was defined as patients with a Glasgow Coma score of 14 -15 and having a normal CT scan at admission. The clinical profile of the injury and recovery of the oculomotor nerve were jointly evaluated and followed up in the department of neurosurgery and ophthalmology. Results: Our study group included twenty one patients. Levator palpebrae superioris involvement with ptosis (95.23%) was the most consistently affected third nerve function followed by extraocular muscles (90.47%) and pupillary fibers (80.9%). Ptosis was partial in 11 patients and complete in nine. Of the extra ocular muscles, the most common muscles to be involved were the inferior rectus and the medial rectus which were involved in 19 patients (90.47%). Superior rectus involvement was seen in 13 patients and inferior oblique in nine patients. Imaging including thin section CT scans (all patients) and FIESTA MRI sequence (2 patients) did not reveal any significant abnormality. All our patients were managed conservatively. Steroids and corrective surgery was not tried in any patient. On follow up, after a mean period of 6 months, partial ptosis recovered completely while complete ptosis recovered only in four patients (44.4%). Of the seventeen patients with pupillary involvement, pupillary size and reaction improved in four (23.5%) and remained static in 13 patients. Of the extraocular muscles superior

Aim: Carotid artery ligation carries a potential risk of ischemic complications even in patients with good collaterals and adequate cross-circulation. Preoperative assessment through balloon test occlusion (BTO) is technically challenging and not feasible in all patients. We analyze our experience with universal bypass without performing detailed cerebrovascular reserve (CVR) studies in 23 patients before carotid artery ligation. Patients and Methods: This was a retrospective analysis of the case records of 23 patients who underwent cervical carotid artery ligation for various indications since January 2009. Results: The study included 21 patients with cavernous carotid aneurysms, one patient with a large fusiform petrous carotid aneurysm, and one patient with recurrent glomus jugulare encasing the cervical internal carotid artery. The initial 12 patients underwent preoperative BTO with hypotensive challenge. All patients underwent a bypass procedure followed by carotid artery ligation irrespective of the BTO findings. Patients who successfully completed a BTO underwent a low-flow superficial temporal artery to middle cerebral artery bypass. A high-flow extracranial–intracranial bypass using a saphenous vein graft from external carotid artery to middle cerebral artery was done in all patients who either failed the BTO or did not undergo BTO. We had two operative mortalities and one poor outcome. All the other patients had a good recovery with a Glasgow outcome score of 5 at the last follow-up. Graft patency rates were 81.1% in both the low-flow and high-flow groups. Conclusion: Universal high-flow bypass is safe, effective, and should be preferred in all patients before carotid artery ligation. It obviates the need for detailed CVR assessment, especially in centers with limited resources.

BACKGROUND: Spontaneous intracerebral hemorrhage carries a poor prognosis with a 30-day mortality rate of 35%e52%. There is no standardized surgical technique for treatment of spontaneous intracerebral hemorrhage. While minimally invasive techniques are popular, there has been renewed interest in decompressive craniectomy (DC). We compared surgical and functional outcomes of standard craniotomy and DC, both with hematoma evacuation, in the surgical treatment of supratentorial spontaneous intracerebral hemorrhage. METHODS: This 4-year retrospective study compared outcomes of 2 surgical techniques: standard craniotomy in group A (n [ 78) and DC in group B (n [ 54). To minimize bias in case selection, propensity matching was performed to match preoperative Glasgow Coma Scale score and hematoma volume (group C).RESULTS: Hematoma evacuation was performed in 132 patients. Mean age of patients was 53.3 years, 50.5 years, and 52.06 years in groups A, B, and C, respectively. Median preoperative Glasgow Coma Scale score was 9, 7, and 8 (P [0.01; P [ 0.45), and mean hematoma volume was 46.21 mL,50.91 mL, and 49.90 mL. Overall mortality was 26.5%; 62.9% (n[22) of deaths were in group A, and 37.1% (n[13) were in group B (P [ 0.69). Median modified Rankin Scale score was similar in both groups, both at discharge and at 3 months. After determining propensity scores, mortality and outcomes of matched groups remained similar.CONCLUSIONS: DC with hematoma evacuation does not appear to provide a significant advantage over standard craniotomy with regard to functional outcomes and mortality.DC may overcome the need for subsequent surgery in accommodating postoperative mass effect in residual bleeds and rebleeds but is associated with greater blood loss and longer operative duration

Background Adult primary intraventricular hemorrhage (PIVH) is a rare type of hemorrhagic stroke that is poorly understood. The study attempts to define the clinical profile, yield of diagnostic cerebral angiography, and prognosis of patients with PIVH. Patients and Methods Retrospective data analysis of all patients with PIVH admitted between February 2015 and February 2019 at a tertiary care center. Outcome was assessed using the modified Rankin scale (mRS) at 6 months. Results and Discussion Our study group of 30 patients constituted 3.3% (30/905) of our spontaneous intracerebral hemorrhage (SICH) patients in the study period. The mean Glasgow Coma Score on admission was 11 ± 3.33 and the mean IVH Graeb score was 5.2±2.4. All patients underwent angiography. Angiography detected moyamoya disease in four patients (13.3%) and aneurysms in two patients (6.6%) and these patients were managed surgically. Extraventricular drainage with intraventricular instillation of Streptokinase was performed in five patients. The rest of the patients was managed conservatively. At 6-month follow-up, 25 patients (83.33%) achieved favorable outcome (mRS score of 0.1 or 2), whereas five (16.66%) patients had a poor outcome (mRS score of 3 or more. Three patients succumbed to the illness. IVH Graeb score and presence of hydrocephalus have significant correlation with poor outcome. Conclusion PIVH is an uncommon entity but carries a better long-term prognosis than SICH angiography helps in diagnosing surgically remediable underlying vascular anomalies and is indicated in all cases of PIVH.

The novel coronavirus pandemic had caused the closure of beverage outlets in Kerala in late March 2020. There were a few suicides in the immediate period, which were highlighted in the media attributing to non-availability of alcohol. An observational study of patients admitted at the De-addiction Centre, NEST and Jubilee Mission Medical College and Research Institute was done. We recorded our observations from the closure of the beverage outlets until two weeks after. Though the government anticipated at least 100 patients, we encountered only 17. Those admitted were brought in delirium, with seizures or injuries sustained during delirium. The possible reasons behind this disparity are discussed which included the sale of illicit liquor or use of home-made preparations. The current situation arose due to a lack of planning and sudden closure of beverage outlets without warning being issued to mental health professionals. Opinions regarding steps to be taken for similar situations in the future are posited.

Implication of the tumor size on oncological and functional outcomes of craniopharyngioma is inconsistently reported. The aim of this study is to assess the postoperative outcome of giant craniopharyngiomas (> 4 cm in diameter) and to elucidate the impact of tumor size on various outcome parameters and survival. Forty-four patients (children aged ≤ 18 years: 25; adults: 16) with giant craniopharyngioma, operated between January 2001 and December 2015, were included in this study. Various outcomes, progression-free survival (PFS) and overall survival (OS) were calculated. Gross total resection (GTR) was achieved in 17 (39%) and subtotal resection (STR) in 27 (61%) patients. Eleven patients (25%) received radiotherapy (RT) after STR. Postoperatively, new cranial nerve and motor deficits were noted in 12 (27%) and 9 (20%) patients, respectively. Tumor recurrence following GTR and STR without adjuvant RT was diagnosed in 3 (17%), and 5 (38%) patients, respectively. Following STR with RT, one (9%) experienced recurrence. PFS at 5-, and 10- year following GTR, STR, and STR + RT was 80.8%, 45.4%, and 90%, respectively. At 5- and 10- year, OS was 86.5%, 77.9% and 100% following GTR, STR, and STR + RT, respectively. The rate of GTR was significantly lower in patients with giant tumors (39% vs. 62%; Chi-square test, p value 0.008). Postoperatively, neurological deficit (20%), hypopituitarism (95%) and hypothalamic dysfunction (26%) were significantly higher for giant craniopharyngiomas. Hazards of recurrence were not significant between giant and non-giant tumors (hazard ratio 1.86; 95% CI 0.94–3.68; p 0.07). There was no significant difference in OS between the patients with giant and non-giant tumors (log-rank test 2.1; p value 0.14). Tumor size should be considered as an important predictor of the postoperative functional outcome. Although the rate of GTR is less than that of small tumors, the recurrence rate, progression-free survival, and overall survival of the patients with giant tumor are comparable to non-giant tumors.

Thalassemia presenting with compressive myelopathy secondary to extramedullary hematopoiesis (EMH) is rare. We report the rare case of spinal EMH with dorsal cord compression and myelopathy in a 28-year-old male with inadequately transfused beta thalassemia major who presented with paraparesis and acute sphincter disturbance.

Introduction Spontaneous intracerebral hemorrhage (SICH) is one of the most devastating forms of stroke with a mortality of 30 to 40%. We aimed to evaluate the effect of craniotomy size and volume of decompression on surgical outcome, complications, mortality, and morbidity in patients with supratentorial capsuloganglionic bleeds who underwent a decompressive craniectomy (DC) at our institute. Materials and Methods It is a retrospective study done between January 2015 and December 2019. All patients with capsuloganglionic bleeds who had DC and hematoma evacuation were included in the study. Results A total of 55 patients underwent DC for SICH at our hospital during the study period. Mean anteroposterior (AP) diameter of the bone flap was 12.42 cm. The volume of decompression did not influence mortality and morbidity in our study but a larger AP diameter was associated with a higher incidence of hydrocephalus. A smaller craniectomy with an AP diameter of < 12 cm caused a lesser reduction in midline shift (MLS). Persistent postoperative MLS had a significant impact on mortality and its reduction was dependent on the size of craniectomy (p =–0.037) Conclusion DC with a recommended AP diameter of 12 to 13 cm achieves optimal results in terms of reduction in MLS. Larger DC volume carries a higher risk of hydrocephalus and requires close follow-up.

Background Spheno-orbital meningiomas (SOMs) constitute a rare cause for orbital proptosis and visual impairment. This study aims to share our outcome experience with regard to vision and exophthalmos following the surgical management of 17 patients with SOM. Methods Retrospective analysis of the case records of all surgically treated SOMs in the last 10 years. Exophthalmos index (EI) was calculated based on preoperative magnetic resonance imaging/computed tomography imaging. Vision was assessed using the Snellen’s chart and Goldman’s perimeter. Orbital volume was calculated using three-dimensional volume rendering assisted region-of-interest computation. Preoperative duration of symptoms and extent of surgery were the other predictors analyzed. Results Patients’ age ranged from 17 to 72 years (mean, 50.57 y; median, 50.0 years). Women represented 13 (76.4%) of the entire study group. Proptosis (14/17; 82.4%) and visual impairment (14/17; 82.3%) were the two most common presenting complaints followed by headache (12/17; 70.1%). Gross total resection (GTR) was achieved in only 2 of the 17 patients (11.8%). Majority of the tumors were benign World Health Organization Grade I meningiomas (14/17; 84%). Mean follow-up time for the entire cohort was 56 months. Postoperatively, proptosis improved in nine (64.3%) and remained static in the rest five (35.7%) of patients. Four patients (28.6%) improved in vision following surgery. Vision remained static in eight patients (57.1%). Vision deteriorated in two (14.3%) patients who had severe preoperative visual deficits. New onset oculomotor palsy, trigeminal dysfunction, and mechanical ocular motility restriction were noticed in three (17.6%), two (11.2%), and six (35.3%) patients, respectively. The mean preoperative orbital volume was 21.68 ± 3.2 cm 3 and the mean postoperative orbital volume was 23.72 ± 3.4 cm 3. Orbital volume was inversely related to EI. Optic canal (OC) deroofing and extensive orbital wall decompression facilitated visual improvement and proptosis reduction. None of the variables including orbital volume proved to be statistically significant in predicting outcome. Conclusion SOMs constitute a rare subgroup of skull base meningiomas that pose considerable surgical challenges. A surgical strategy aimed at safe maximal resection rather than aggressive GTR provides favorable outcome with less morbidity. Adequate bony decompression of the orbital walls and OC provides satisfactory improvements in proptosis and vision. Residual disease is common, but the risk of symptomatic recurrence is low especially when combined with adjuvant radiotherapy. Visual outcome is likely to be poor in patients presenting with severely compromised vision.

Purpose Orbital haemangiomas are common orbital tumors known for their slow growth. Acute presentation with haemorrhage into the tumor is a rare occurrence with only nine cases reported in literature. Methods: The authors present a case of an elderly female with sudden onset of proptosis and swelling of the eye. There was a transient relief of symptoms with steroids with residual proptosis and ptosis at two weeks. Magnetic resonance imaging revealed an intraconal soft tissue mass in the inferolateral quadrant of the left orbit with a differential diagnosis of haemangioma with bleed or metastasis. Results: Patient underwent a lateral orbitotomy and tumour excision and histopathological examination revealed a cavernous haemangioma with a thrombus. The patient had complete symptomatic recovery following surgery. Conclusion: Orbital haemangiomas presenting with haemorrhage is rare and should be differentiated from orbital venous anomalies prior to surgery.

Background: Studies on isolated primary thalamic hematomas are limited. This study analyses 117 patients with primary thalamic hematomas and attempts to identify the various prognostic factors influencing the outcome. Materials and Methods: A retrospective analysis of the case records was carried out to analyse the following prognostic parameters - GCS on admission, comorbidities like systemic hypertension and diabetes mellitus, side and site of hematoma, volume of the clot, presence of intraventricular haemorrhage (IVH), development of hydrocephalus, and the role of surgical intervention. A Chi-square test was used to compare categorical variables, and Student t-test and Mann Whitney test were applied to calculate the P-value for continuous variables for univariate statistics. Binary Logistic regression was used for multivariate analysis. Results and Discussion: This study group comprised 67 men and 50 women with a mean age of 62.05±11.71years. The mean GCS on admission in the study group was 11.56±3.28. The mean clot volume was 13±9.5ml and majority (89.74%) of the patients had clots with a volume of less than 20 ml. An intraventricular extension was noted in 98 patients. Craniotomy and surgical evacuation were performed in only two patients while external ventricular drainage with urokinase instillation was performed in 23 patients. Of the 117 patients, 3 had anterior thalamic clots, 19 had posterior thalamic clots, 13 had medial clots, 53 had lateral thalamic bleeds and 29 had global clots. The overall three-month mortality with thalamic bleeds was 28.2%. At the end of three months, 59 patients (50.42%) had a favourable outcome (mRS < 4). On univariate analysis, male sex, dominant side bleed, preoperative GCS of less than 8 (p < 0.001), presence of hydrocephalus (p< 0.004) and a need for EVD (p Conclusion: Thalamic hematomas include a spectrum of clots of varying dimensions at different locations and the outcomes need not be uniformly poor. Isolated thalamic hemorrhages are generally small in volume preferentially located in the lateral thalamus. Patients with right-sided bleeds and small clot volume perform well. Male sex, poor GCS on admission, clot volume above 20 ml, intraventricular extension and a need for external ventricular drainage adversely influence the outcome.

Objective: Thoracic myelopathy has gradually risen to be a prominent diagnosis in patients with persistent upper back pain, bladder symptoms and spastic paraparesis. Often encountered, these conditions pose a serious dilemma to neurosurgeons with respect to surgical planning, timing of surgery, prognosis and possible complications and outcome assessment. In view of these queries and to clarify the indications of when to intervene the following study has been undertaken.To analyze the clinical presentation, radiological features, clinical implications and surgical nuances and outcomes in patients with single and multiple level dorsal canal ossified ligamentum flavum (D-OLF) and associated dural ossification (DO). Patients and methods: Nineteen patients with the diagnosis of thoracic myelopathy (TM) were identified between January 2012 and March 2017. All patients were treated surgically, with decompressive laminectomies, in a single tertiary care center in Southern India. mJOA was calculated preoperatively and assessed postoperatively and a mean mJOA was calculated to assess the significance in neurological improvement. The data was collected from the medical records department and various factors were analyzed, using SPSS software, for correlation. Results: Mean age of our group was 50.84 years with a range of 29 to 71 years. It comprised of 11 males and 8 females. All patients had features of myelopathy. Surgery did have a positive effect on neurological improvement (p = 0.001) in all patients except one. Dural ossification had correlation with pre op and post op urinary disturbances with p value of 0.02. (Mann Whitney Test for 2 independent variables used). A total of ten patients had urinary symptoms pre operatively, out of which six patients showed postoperative improvement at the end of one year. Four of these patients continued to have symptoms, two patients were on Clean Intermittent Catheterisation (CIC), and one patient had features of hesitancy and frequency. Preoperative bladder dysfunction was a strong predictor for continued bladder dysfunction at the end of 1 year (p

Background: Application of Machine Learning (ML) techniques in the prediction of Neurological Disorders has been growing rapidly. ML techniques require novel computer programming skills along with domain knowledge to produce a useful tool. We used Google Auto ML and Google ML Tables, a Cloud based front-end tools to develop, validate and deploy a prognostic model for Intracerebral Hemorrhage (ICH) without a single line of programming code. Methods: Data from Kasturba Medical College (KMC) Hospital ICH Stroke Registry between January 2015 and May 2019 was accessed. Google Auto ML Tables splits the dataset into training, validation and testing sets. 80% of the dataset was used for training, 10% for validation, and 10% for testing. Cramers V correlation statistic ( ϕ c ) between 30 variables and outcome was used to select 20 variables to predict the dichotomous outcome of good (mRS 0-3) vs bad outcome (mRS 4-6). The ML model generated was evaluated using Area Under the Curve (AUC) and Receiver Operating Characteristic (ROC) measures and by confusion/error matrix. Logistic Regression model was developed in parallel using Wizard Pro with the same set of 20 variables. Results: 1000 patients from KMC Registry were analysed. Cramers V correlation was highest for Glasgow Coma Scale (GCS) on admission ( ϕ c =0.6), followed by hematoma volume ( ϕ c =0.57). The AUC ROC of the model for good and bad outcome was 0.89 with an accuracy of 85.6%. Confusion matrix predicted 84% patients with good outcome and 87% with poor outcome. Feature importance chart showed that GCS had the highest relative importance at 25.7, followed by hematoma volume and age. A similar model created with simple logistic regression yielded a ROC of 0.87 with comparable results to the machine learning platform. Conclusion: Useful ML models can be easily developed and implemented by clinicians possessing domain expertise using Google Auto ML without computer programming experience.

Cavernous carotid aneurysms (CCA) pose considerable dilemmas in management. It is still unclear as to whether an asymptomatic CCA should be subjected to treatment. Similarly, the ideal management strategy for a symptomatic aneurysm is controversial. We present the case of a 60-year-old female with a giant CCA and discuss the management issues.

Objectives To develop an adherence questionnaire specific to stroke and measure the level of adherence to home-based exercises among community-dwelling stroke survivors. Methods We developed and validated the "Stroke-Specific Measure of Adherence to Home-based Exercises" (SS-MAHE). We measured the exercise adherence among 92 community-dwelling stroke survivors in a cross-sectional study. Results The SS-MAHE has two sections covering (a) the dosage of prescribed exercises and (b) dosage of actual exercises done by the participants. It was found to be reliable with ICC score of 0.81 (95% CI, 0.44, 0.94, p = .001.) Adherence was measured by comparing prescribed exercises to the actual exercises performed at home. We rated participants as "adherent" if they were following more than 70% of the prescribed exercise dosage. In our sample of 92 stroke survivors, only 28% of participants were adherent to prescribed home-based exercises. Conclusion SS-MAHE is a practical and reliable tool to measure adherence to home-based exercises after a stroke. Exercise adherence among stroke survivors is less than ideal. There is a need for strategies to specifically target exercise adherence in stroke survivors.

Although cranioplasty (CP) is a straightforward procedure, it may result in a significant number of complications. These include infections, seizures, intracranial hematomas, and others. Many reports have stated that early CP is associated with higher complications; however, more recent articles have contradicted this opinion. We intend to share our experience and results on outcomes of CP from our university hospital.This is a 3-year retrospective analysis of patients undergoing CP. Demographic profile, etiology of decompressive craniectomy (DC), DC-CP interval, operative details, complications, and follow-up data were analyzed. Correlation of complications with timing of CP and other factors was studied to look for statistical significance.A.total of 93 cases were analyzed. The majority were traumatic and ischemic stroke etiologies. There were eight open/compound head injuries (HIs). Eleven were bilateral and the rest unilateral cases. The mean and median CP interval were 8.5 weeks (range 4-28 weeks) and 8 weeks, respectively. All patients received 48 h to up to 5 days of postoperative antibiotics. Ten complications (10.7%) were noted (including one death). Poor Glasgow Outcome Scale at CP was the only statistically significant factor associated with higher complication rates. There was no statistical difference with respect to gender, CP material, and etiology; however, early CP had slightly fewer complications.Patients with poor neurological condition at the time of CP have a significantly higher risk of complications. Contrary to earlier reports, early CP (12 weeks) was not associated with higher complications but rather fewer complications than delayed procedures. Adherence to a few simple steps may help reduce these complications.

Background: Patients suffering from subarachnoid hemorrhage (SAH) have poor long-term outcomes. There are predictive models for ischemic and hemorrhagic stroke. However, there is paucity of models for SAH. Machine learning concepts were applied to build multi-stage Neural Networks (NN), Support Vector Machines (SVM) and Keras/Tensor Flow models to predict SAH outcomes. Methods: A database of ~800 aneurysmal SAH patients from Kasturba Medical College was utilized. Baseline variables of World Federation of Neurosurgeons 5-point scale (WFNS 1-5), age, gender, and presence/absence of hypertension and diabetes were considered in Stage 1. Stage 2 included all Stage 1 variables along with presence/absence of radiologic signs vasospasm and ischemia. Stage 3 includes earlier 2 stages and discharge Glasgow Outcome Scale (GOS 1-5). GOS at 3 months was predicted using 2-layer NN/SVM/Keras-TensorFlow models on the five point categorical scale as well as dichotomized to dead/alive and favorable (GOS 4-5) or unfavorable (GOS 1-3). Prediction accuracy of models was compared to the recorded GOS. Results: Prediction accuracy shown as percentages (See Table) for all three stages was similar for SVM, NN and Keras/TensorFlow models. Accuracy was remarkably higher with dichotomization compared to the complete five point GOS categorical scale. Conclusions: SVM, NN, and Keras-TensorFlow based machine learning models can be used to predict SAH outcomes to a high degree of accuracy. These powerful predictive models can be used to prognosticate and select patients into trials.

Background. This article attempts to evaluate the clinical profile and outcome determinants following hypertensive SICH in a South Indian population. The study represents the largest series of SICH reported from a single centre in India. Materials and Methods. Prospective data collection and analysis of patients with SICH admitted to our centre between 1st January 2015 and 31st December 2018. The variables analysed include: age, sex, comorbidities, Glasgow coma score (GCS) on admission, radiological features, treatment modality, and outcome at three months. Modified Rankin score (mRS) was used to assess the outcome at discharge and three months. Results. Our study group of 905 patients included 638 males and 267 females and the mean age at presentation was 58.10 ± 12.76 years. The study group included 523 patients (57.8%) previously diagnosed hypertensive, of whom 36.3% (n=190) were on irregular medication. The most frequent locations of hematoma were basal ganglia (478), thalamus (202), lobar (106), cerebellar (61), brainstem (31), and primary intraventricular haemorrhage (27). Secondary intraventricular extension was seen in 425 (47%) patients on admission. The mean volume of the clot on admission was 23.45 ± 19.79 ml, and clot progression was seen in only 46 (5.08%) cases. Surgical evacuation through craniotomy was done in 147 (16.8%) patients, and external ventricular drainage (EVD) was placed in 56 (6.2%) patients. Overall 3−month mortality was 30.1% (266 patients). On the last follow up a favorable outcome (mRS 0−3) was observed in 412 (45.53%) patients and a poor outcome (mRS 4−5) in 207 patients (22.87%). Independent predictors of mortality are Age >70 (p=<0.001, OR 4.806, 95% CI 3.064–7.54), admission GCS p=<0.001, OR7.684, 95% CI 5.055#x2013;11.68), and Hematoma volume >30 ml (p=<0.001, OR 2.45, 95% CI 1.626–3.691). Intraventricular haemorrhage was an additional poor outcome predictor (p<0.015, CI 1.105–2.585). Surgical evacuation reduced mortality in the group, but morbidity rates remained the same. Conclusions. SICH predominantly affects a younger population in India in comparison to the Western society. Elderly age, poor GCS on admission, clot volume above 30 ml and intraventricular extension remain the most consistent predictors of death and poor outcome. Further studies are needed to assess the risk of SICH among hypertensive patients and to prognosticate the outcome after SICH using novel predictors, including biomarkers.

Concomitant cerebral infarction developing soon after a parenchymal intracerebral hemorrhage is a rare occurrence. Usually, these remote site changes follow tumor decompression and are associated with hemorrhagic changes rather than infarcts. We report a case of a fatal malignant internal carotid territory infarct in a hospitalized patient being conservatively managed for a vermian hematoma and discuss the probable pathophysiology. Stroke physicians need to be aware that spontaneous intracerebral hematoma patients have a potential threat of developing large vessel occlusion with malignant cerebral infarcts, especially after surgical decompression. Although the exact pathogenesis is unknown, size of the clot, intraventricular hemorrhage, hydrocephalus, and aggressive reduction of blood pressure appear to be predictive factors.

Retinal hemangioblastomas are one of the most common and early manifestations of Von Hippel-Lindau disease. Early detection is the key in their management. When left untreated, these benign neoplasms may continue to grow and result in scleral infiltration and extraocular extension warranting enucleation of the globe.

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.

Background: Optic pathway gliomas (OPGs) are rare neoplasms where the management strategy is still evolving. The purpose of this study is to present our experience of twenty cases of OPGs with an intent to add to the general fund of knowledge. Materials and Methods: Retrospective chart review of patients with OPGs surgically managed in a single tertiary centre over a period of 5 years. Variables analysed include Age at diagnosis, sex, clinical manifestations, neurofibromatosis (NF1) status, tumour location, treatment modality, symptomatic progression, and complications. Results: Of the 20 patients with OPG in the study with a mean age of 12.8 years, four patients had NF1 and 16 had sporadic OPG. Dimness of vision (80%) and headache (55%) were the most common presenting symptoms. Majority of the tumours were chiasmatic (40%) in location and vision was affected bilaterally. Subtotal resection could be achieved in 12 (60%) partial decompression in 4 (30%) and gross total resection in 2 (10%). Four patients required additional shunt surgery for hydrocephalus. Postoperative radiotherapy was administered to thirteen patients and only one patient received chemotherapy. At the end of a mean follow up period of 44 months tumour recurrence was noticed in 11/20 (55%) patients. Vision improved in none, remained stable in fifteen and deteriorated in five. Three patients (15%) succumbed to tumour regrowth in the follow up period. Conclusions: OPGs are uncommon tumours with unpredictable outcome. Visual deficits are often irreversible and progressive. Curative resection is difficult and adjuvant therapy has variable response. Overall survival rates are good but progression free and survival rates are suboptimal.

Pilocytic astrocytomas (PAs) are seemingly innocuous and benign tumors. However, in recent times, many case series have documented high rates of hemorrhage in these neoplasms. We hereby provide a detailed analysis on hemorrhagic pilocytic astrocytomas (HPA) in adults and report one such case managed at our institute. In addition, salient differences between adult and pediatric hemorrhagic PA have been briefed. Hospital records were retrieved for our case. Literature review was conducted by searching online databases for the following keywords-pilocytic astrocytoma, hemorrhage, cranial, pediatric, and adults. A 22-year-old male with neurofibromatosis-1 presented with sudden onset headache and vomiting of 3-day duration. Imaging revealed a lobulated suprasellar lesion with obstructive hydrocephalus. Pterional transsylvian approach and subtotal resection were performed. Histopathology showed features of PA with bleed. Including current report, a total of 26 cases have been reported. Mean age was 37 years (21-75 years) and they are mostly found in the third decade. The male:female ratio was 2.1:1. Sudden headache with vomiting was the most common symptoms. Tumors were mostly located in cerebral hemispheres (n = 9/34.6%), hypothalamus/suprasellar region (n = 7/27%), and cerebellum (n = 6/23%). Two-thirds underwent gross total excision. There were two deaths and except one case, no recurrences were reported in those with available follow-ups. Hemorrhagic presentation of a PA is rare, although more commonly seen in adults and most commonly located in cerebral hemispheres. Maximal safe resection is the standard treatment and recurrences are rare.

Microvascular decompression (MVD) is a novel surgical procedure predominantly performed for treating trigeminal neuralgia (TN) and hemifacial spasm (HS). Multiple studies have proven the long-term success of MVD for both these conditions. The most common complications of MVD reported include chemical meningitis, facial hypesthesia, cerebrospinal fluid leak, facial paresis, and hearing loss. Delayed facial palsy (DFP) is an uncommon complication mostly noted in MVD for HS and after the removal of acoustic tumors. We report two cases of DFP occurring after performing MVD, one each for HS and TN. This is also the first case of DFP to be reported after MVD for TN. Both were young females who developed DFP 2 weeks after surgery. They were managed with oral steroids and acyclovir for 2–3 weeks and achieved excellent outcome at an average of 4.5 weeks from the onset. We conclude that although majority of the cases improve spontaneously, steroids and acyclovir might assist in faster recovery.

Traumatic head injuries are often encountered in the emergency triage, and usually these patients have open head injuries or traumatic pneumocephalus secondary to base of skull fractures. The first line of management involves conservative approaches that include the use of carbonic anhydrase inhibitors, loop diuretics, and, occasionally, lumbar CSF diversion techniques. Surgical intervention is considered once conservative management fails after 2 weeks of institution of conservative management. Here, we discuss the various clinical scenarios, clinical presentation, treatment dilemmas, and possible complications in patients with traumatic pneumocephalus.

Fourth ventricular dilatation is usually seen along with tri-ventriculomegaly in patients with communicating hydrocephalus. Isolated fourth ventricular dilatation is uncommon, especially as a sequelae following infective or post hemorrhagic communicating hydrocephalus. Communicating hydrocephalus is reported in vestibular schwannoma with an incidence of 3.7 to 23.5%, but 4th ventricular dilatation following its treatment has not been reported in the literature. We report a novel case of isolated fourth ventricular obstruction following surgery for recurrent vestibular schwannoma and ventriculoperitoneal shunt placement for communicating hydrocephalus. Management strategies range from endoscopic procedures to ventricular shunt placement. We describe the surgical technique for the placement of a fourth ventricular shunt with the use of a Y connector.

A person with haemophilia is at risk of intracranial haemorrhage caused by spontaneous or traumatic events, potentially resulting in long-term disability. Early initiation of timely treatment is essential to prevent this. In developing countries, morbidity and mortality is common in intracerebral haemorrhage (ICH) cases with haemophilia as a result of patients and family members having inadequate knowledge, lack of awareness regarding referral, lack of availability of treatment products, and delays in the treatment decision. These barriers can potentially be managed by the haemophilia nurse taking responsibility for the coordination of care. This case report addresses the nurse-coordinated care of a haemophilic patient with ICH in a developing country, and may provide insight into the benefits of a haemophilia nurse undertaking a coordinating role.

Aneurysms arising from anterior inferior cerebellar artery-posterior inferior cerebellar artery (AICA-PICA) variant are extremely rare. They usually present with subarachnoid hemorrhage. This is probably the second case report of a large thrombosed AICA-PICA variant aneurysm presenting as a cerebellopontine angle mass lesion with cranial nerve palsy, managed successfully by surgical clipping.

Central neurocytomas (CNs) are rare, benign neoplasms arising from a neuronal lineage and account for 0.1%–0.5% of all central nervous system tumours. Typical location of CNs is the lateral ventricle touching the foramen of Munro.[1][1] Occurrence of the tumours in the posterior fossa is

Objectives Intracerebral Hemorrhage (ICH) is a devastating form of stroke and accounts for 10–15% of all cases. The management of ICH has predominantly been directed towards medical management. Multiple trials have failed to prove the superiority of surgical evacuation over conservative methods. However, surgery in a carefully selected set of patients is beneficial in reducing mortality and limiting disability. In this article, we retrospectively analysed our ICH register to compare the outcomes of surgical and conservative management of patients Patients and Methods We retrospectively analysed patients with ICH admitted at our centre between January 2015 and December 2017. A total of 119/624 patients with supratentorial hematoma volume >30 ml, GCS ≥ 5 and age less than 70 were included in this study. Results The group was dichotomised into two groups A & B based on the management. Seventy-two (60.5%) patients underwent surgical intervention in group A and the remaining 47 (39.5%) were managed by best possible conservative methods in group B. The mean age in Group A was 51.01 years and 55.89 years in group B (P = 0.012). The volume of hematoma in the surgical group was 46.5 ± 14.9 ml in comparison to 38.53 ± 10.84 ml in the medically managed group (p = 0.002). Mortality at 90 days was 27/47 (57.44%) in the medically managed group while 23/72 (31.9%) in the surgical group (p = 0.006). Median mRS at discharge and 90 days were nearly identical and there was no significant difference in the dichotomized outcome among the two different management cohorts (p > 0.05). Mortality was the highest in the 30–50 ml medically managed group and >51 ml surgical group (p = 0.024). Age of the patient, GCS on presentation and medical management were independent predictors of mortality on logistic regression. The Cox Regression survival analysis of the two groups showed a clear survival advantage in the surgically managed group adjusting for age and GCS (p = 0.002) at 90 days. Conclusion Surgical Evacuation of spontaneous intracerebral haemorrhage has a survival advantage at 90 days in moderate to large sized hematomas. It, however, did not demonstrate any quantifiable improvement in functional outcome. Surgical evacuation of moderate-sized hematomas reduces mortality caused by delayed perihematomal oedema.

Purpose To prospectively assess the feasibility of establishing low cost epilepsy surgery programs in resource poor settings. Method We started epilepsy surgery centers in Tier 2 and Tier 3 cities in India in private hospitals. This model is based on the identifying and operating ideal epilepsy surgery candidates on the basis of clinical history, interictal and ictal video-EEG data, and 1.5 T MRI without other investigations and without regular involvement of other specialists. Trained epileptologists formed the fulcrum of this program who identified ideal candidates, offered them counseling, and read video-EEG and MRI. We also spread epilepsy awareness among locals and physicians and established focused epilepsy clinics. The expenses were subsidized for deserving patients and policies were devised to keep video-EEG duration and staff requirement to minimum. Difficult epilepsy surgery cases were referred to established centers. Initial surgeries were performed by invited epilepsy surgeons and subsequently by local neurosurgeons. Results A total of 125 epilepsy surgeries were performed at three centers since 2012. This included 81(64.8%) temporal lobe resections, 26 (20.8%) extratemporal focal resections, and 13 (10.4%) hemispherotomies. Of the 93 patients with more than 1 year of postoperative followup, 86 (92.5%) had Engel class IA outcome. There were minor complications in 5% patients. Average cost of presurgical evaluation and surgery was Rs. 92,707 (USD 1,324). Conclusions It is possible to establish successful epilepsy surgery programs in resource poor setting with reasonable costs. This low cost model can be replicated in other parts of world to reduce the surgical treatment gap.

Inflammation plays a role in secondary brain injury after intracerebral haemorrhage (ICH). Peripheral biomarkers of inflammation especially the neutrophil-to-lymphocyte ratio (NLR) have been shown to influence outcome following ischemic stroke and traumatic brain injury. Role of NLR in outcome prognostication following haemorrhagic stroke has not yet been conclusively established. This study analyses the prognostic significance of admission neutrophil to lymphocyte ratio on mortality and 90-day outcome in patients admitted with acute SICH.A total of 851 patients with spontaneous ICH were retrospectively investigated. Admission haematological parameters were retrieved from our hospital laboratory systems and NLR was then calculated using the formula ANC/ALC. (Absolute neutrophil count/Absolute lymphocyte count) Clinical outcome was assessed by modified Rankin Scale at 90 days. Logistic regression was performed to identify independent risk factors of mortality and 90-day outcome. Receiver operator curve (ROC) test was used to determine the predictive value of NLR for 30-day death.A total of 851 patients enrolled in the study. Our 30 day and 90 day mortality were 125 (17.7 %) and 244 (28.7 %) respectively. The mean NLR in the entire cohort was 9.03 ± 7.6. NLR was significantly higher in the mortality group compared to the survivors (11.98 ± 9.91 vs 8.52 ± 7.05) P 0.001. NLR in patients with a good outcome at 90 days (7.21 ± 6.06) was a lower in comparison to patients with poor outcome(10.66 ± 8.48).(p=0.001). NLR was dichotomised at 8.2 which was computed based on ROC curve. Mortality and poor outcome were higher in the NLR 8.2 group at 140 (40.1 %) and 23 (67.8 %) respectively (p 0.001). Age, GCS 8, Volume of Hematoma, Intra ventricular extension of hematoma and NLR 8.2 were found to be independent predictors of outcome. GCS 8 had a greater predictive value (5.236) compared to NLR.8.2 (1.78).Elevated levels of admission NLR were independently related to poor mortality and 90-day outcome after ICH. NLR is a novel, easily available and cost effective prognostic biomarker following ICH.

Ocular trauma and retained foreign bodies in the eye form a common occurrence in ophthalmic practice. Mild trauma may often be overlooked and patients, quite often, present late with serious complications. The clinical presentations and management of three patients who presented with a FB in the anterior chamber, within the lens, and within the orbit, respectively, are discussed. The diagnostic and management issues are highlighted along with a brief review of relevant literature.

Proximal A1 segment aneurysms are technically challenging aneurysms that require careful and meticulous adherence to surgical principles for optimising the outcomes. They usually present with rupture and headache and visual symptoms are uncommon due to the optic nerve not being in proximity to the aneurysm. Important, delicate perforators arise from the segment and their preservation is the key to a good surgical outcome.

Spontaneous intracerebral haemorrhage (SICH) is the second most common cause of stroke, accounts in contrast to ischaemic stroke and carries a high risk of morbidity and mortality. SICH refers to brain haemorrhage in the absence of trauma and is often associated with hypertension. It is a conventional belief that hypertension is the aetiology in most of the haemorrhage in the basal ganglia region, and angiography is rarely performed in such patients. This protocol carries a risk of missing potentially curable underlying vascular conditions such as arteriovenous malformations and aneurysms, especially in younger patients without a history of hypertension. Performing an angiogram for all patients however is an overkill and unnecessary waste of resources. The role of cerebral angiography to distinguish a primary SICH from secondary SICH in all patients with SICH is thus controversial. Hence, it is the choice of the type of angiogram between digital subtraction angiogram Digital Subtraction Angiography (DSA) and computerised tomography angiogram Computerised Tomography Angiography (CTA). This article attempts to review the current diagnostic angioimaging guidelines for intracerebral haemorrhage with an aim to evolve a management protocol.

Sylvian arachnoid cysts pose considerable management dilemmas. Surgical options include cyst fenestration, either endoscopically or microsurgically, and cysto-peritoneal shunt. One of the rare complications after rapid decompression of the arachnoid cysts is haemorrhage in the surrounding brain as well as in remote areas. We describe a case of multiple remote-site intra-parenchymal haemorrhage as a rare complication after surgical decompression of a sylvian fissure arachnoid cyst.

Brain abscess is usually of polymicrobial etiology involving aerobic and obligate anaerobic bacteria. Anaerobic bacteria are mainly seen in brain abscesses secondary to otogenic and odontogenic source. Investigating for anaerobic etiology is usually neglected considering the tedious and time consuming process of anaerobic culture. It is necessary to perform anaerobic cultures along with routine aerobic cultures as a part of microbiological workup of abscess aspirates in patients with brain abscess which aid in providing appropriate antibiotic therapy. To highlight the significance of anaerobic cultures, we report four cases of brain abscess with anaerobic etiology from a tertiary care hospital in coastal Karnataka.

Background: Cystic vestibular schwannomas (VS) form a rare subgroup that differs from the solid variant clinically, radiologically, and histopathologically. These tumors also vary in their surgical outcome and carry a different risk of post-operative complications. We analyzed our series of 64 patients with cystic VS and discuss the technical difficulties related to total excision of these tumors and focus on complication avoidance. Materials and Methods: A retrospective review of cystic VS surgically managed over a span of 11 years. The case records were evaluated to record the clinical symptoms and signs, imaging findings, surgical procedure, complications, and follow-up data. Post-operative facial nerve palsy was analyzed with respect to tumor size and tumor type. Results: Progressive hearing impairment was the most common initial symptom (76.6%). Atypical initial symptoms were present in 15 patients (23.4%). Preoperatively, 78% patients had good facial nerve function (HB grade 1, 2) and 22% had intermediate (HB grade 3, 4) to poor (HB grade 5 and 6) function. Mean tumor size was 4.1 cm. Complete tumor removal was achieved in 53 patients (83%). The facial nerve was anatomically intact but thinned out after tumor excision in 38 patients (59.4%). Ninety percent patients had either intermediate or poor facial nerve function at follow-up. Poor facial nerve outcome was associated with giant tumors and peripherally located, thin-walled cystic tumors. Conclusion: Resection of cystic VS is complicated by peritumoral adhesions of the capsule to the nerve. Extensive manipulation of the nerve in order to dissect the tumor–nerve barrier results in worse facial nerve outcome. The outcome is worse in peripherally located, thin-walled cystic VS as compared to centrally located, thick-walled cystic tumors. Subtotal excision may be justified, especially in tumors with dense adhesion of the cyst wall to the facial nerve in order to preserve nerve integrity.

Background Foramen magnum decompression (FMD) is the standard procedure for Chiari I malformation. Although seemingly a straightforward procedure, recent articles have reported an increase in various complications. We describe a rare complication of coexistent supratentorial and infratentorial subdural hygromas (SDHs) with hydrocephalus noted after FMD and provide a detailed review of the literature on this topic. Methods A 34-year-old woman presented with strain-related suboccipital headache and myelopathy for 6 months. Imaging revealed tonsillar herniation up to C2 level and cervical syringomyelia. A standard FMD, C1 posterior arch removal, and tonsillar reduction was performed. After an initial uneventful postoperative course, she had 2 readmissions with headache, vomiting, and ataxia. Imaging showed a tense pseudomeningocele and concomitant supratentorial and infratentorial (initially right-sided, followed by left-sided) SDHs with ventriculomegaly. She was conservatively managed with antiedema measures and had excellent relief of symptoms. For the literature review, only cases with concomitant supratentorial and infratentorial SDHs with hydrocephalus were searched online and analyzed. Results Including ours, 10 cases have been reported. Mean age was 25.3 years. The male-to-female ratio was 1:2.3. Symptoms appeared an average of 12.6 days postoperatively. Treatment was with conservative management in 3 cases, and 3 cases required permanent cerebrospinal fluid diversions. Mean follow-up duration was 9.4 months (range, 1–27 months). Conclusions Coexistent supratentorial and infratentorial SDHs with hydrocephalus after Chiari decompression is a very rare occurrence. Treatment needs to be individualized based on the predominant symptomatic lesion, and surgical options need to be judiciously considered. Good prognosis is the rule in most cases.

Context: Colloid cysts are benign intracranial lesions that usually involve the anterior third ventricle with varying appearance on imaging studies. The number of articles debating the origin of this tumor is surpassed by papers proposing the best modality available for its treatment Aim: The purpose of this study is to analyze the clinical presentation and surgical outcome of colloid cysts surgically managed over a period of thirty-two years and evaluate the technical issues based on our experience. Study Design: This is a retrospective case series study. Materials and Methods: This is a retrospective case series study on 297 consecutive patients with colloid cysts who were operated. The case records of all the patients were evaluated to record the clinical symptoms and signs, imaging findings, surgical procedure, complications and follow-up data. Results: There were 178 (60%) males and 119 (40%) females, their age ranging from 9 to 66 years with a mean age of 28 years. The mean duration of symptoms was 1.8 months. Raised intracranial pressure headache was the most common initial presenting symptom followed by visual blurring, memory disturbance and drop attacks with gait unsteadiness. The tumor was an incidental imaging finding in five patients (2%). While an interhemispheric transcallosal approach was used in 275 (92.6%) patients, it was trans-cortical in 22 (7.4%). Twenty-two patients required emergency surgery in view of worsening sensorium. Postoperative complications included memory impairment, limb weakness and seizures. Despite documented complete excision of the tumor in 6 cases, 8 patients had recurrence of tumor during follow-up. Conclusion: Colloid cysts are potential life threatening but benign lesions that can be removed safely with low morbidity and mortality through the interhemispheric transcallosal approach and its variants. The possibility for recurrence warrants, close imaging follow-up after surgery. It is essential for neurosurgeons to be familiar with the different transcallosal approaches to reach the third ventricle especially for a posteriorly situated cyst and a narrow foramen of Munro.

A 6-year-old child presented with a holocranial headache with vomiting for 1 month. On examination, the child had an ataxic gait with swaying towards left side and papilloedema. MRI brain showed a well-defined extra-axial altered signal intensity mass, measuring 4×4.5×4 cm, which was

Objective The optimal therapeutic approach to craniopharyngioma has not been established conclusively. The surgical outcome following radical excision and conservative resection with adjuvant radiotherapy are comparable or even better with the later in pediatric or mixed populations. This study is aimed at reviewing the role of extent of resection in local tumor control and long-term outcome in adults with craniopharyngioma. Patients and methods Ninety-five adults operated between 2001 and 2013 were included. Progression-free survival (PFS) and overall survival (OS) were calculated. Predictors of various outcome parameters were analyzed. Results The predominant presenting symptom was visual impairment (78 %) followed by symptoms of hypothalamic involvement (29 %). Total and subtotal excisions (TE, STE) were achieved in 63 %, and 47 % of patients, respectively. Vision improved in 62 % of patients in the early postoperative period. Thirteen patients (14 %) experienced vision deterioration postoperatively. On multivariate analysis, tumor >3 cm and optic atrophy predicted poor visual outcome. Hormonal replacement for hypopituitarism was required in 83 % during follow-up. Diabetes insipidus was seen in 73 %. Imaging evidence of 3rd ventricular floor destruction by tumor emerged as an independent predictor of postoperative hypothalamic morbidities. The recurrence rate following TE and STE was 11.6 % and 72 %, respectively. Unlike radical excision, PFS following STE was significantly shorter (p- 0.02). TE was not associated with increased visual impairment or hypothalamic-pituitary dysfunction postoperatively as compared to STE. Most of the patients (85 %) were independent and able to return to the premorbid occupation. Conclusion Subtotal resection provides equally good long-term visual, endocrinological, and hypothalamic outcomes as radical surgery. When used with adjuvant radiotherapy, it also gives a better local control of the tumor. Hence, subtotal resection with adjuvant radiotherapy should be considered as an effective alternative strategy to radical excision.

We present a case of bilateral subdural haematomas secondary to spontaneous intracranial hypotension. The diagnostic features and the management issues are discussed.

Traumatic Brain Injury (TBI) is a significant cause of disability, mortality and socio-economic loss in developing countries. Prognostication and early prediction of outcome will help in judicious allocation of resources. The three CT scoring systems, commonly employed in predicting outcome are the Marshall, Rotterdam and the Helsinki CT Scoring system. This is a prospective observational study to compare the above scoring systems and their role in predicting the outcome after TBI. A total of 157 patients were included in this study. Primary objective was early outcome assessed by Glasgow Outcome Scale at discharge and 3 months. On comparing the three CT scoring systems, the Helsinki CT score provided a better positive predictive value of 87.5% for mortality in comparison with Marshall (79.3%) and Rotterdam Score (82.5%). Summarising the results for ROC analysis of the three CT scoring systems, the area under curve was 0.742 for Marshall score, 0.751 for the Rotterdam score and 0.815 for the Helsinki score, which upholds the superiority of the Helsinki CT score in predicting the mortality compared to other two. The linear relationship of higher the score with added risk of mortality was seen with Rotterdam score and Helsinki score. Individual CT findings of positive midline shift, obliteration of suprasellar cisterns, presence of subarachnoid haemorrhage, intraventricular haemorrhage and large mass lesions were found to be independent predictors of mortality. The Helsinki Scoring system is a better prognostic model with significantly improved outcome prediction accuracy, although the Marshall and Rotterdam scoring systems have good predictability for assessing mortality.

INTRODUCTION: Acute kidney injury (AKI) is an independent risk factor for adverse clinical outcomes in patients with hemorrhagic stroke. There is limited data regarding the occurrence and impact of AKI in the setting of spontaneous intracerebral hemorrhage (SICH). Considering this, we sought to determine the incidence and risk factors for AKI in patients with SICH and to determine the role of AKI on SICH mortality in our population. - MATERIALS AND METHODS: This is a retrospective analysis of the data recorded in the stroke registry maintained by the Department of Neurosurgery, Kasturba Hospital, Kasturba Medical College, Manipal Academy of Higher Education after ethical committee clearance. Information regarding clinical features, demographics, laboratory data, prescribing patterns, and the use of contrast- mediated imaging were collected. AKI was defined according to the Kidney Disease: Improving Global Outcomes criteria. Logistic multivariate regression was used to determine predictors of AKI. Analysis of variance was used to measure the effect of AKI on SICH outcome. - RESULTS: Of 316 patients with SICH admitted to the hospital, 20% of patients developed AKI. It was found that risk factors for AKI were lower baseline estimated glomerular filtration rate (odds ratio, 1.60; 95% confidence interval, 1.21 SICH 2.2; P < 0.001) and infectious complications (odds ratio, 3.37; 95% confidence interval, 1.9e5.7;P < 0.001). The incidence of 30 days’ mortality was higher in the group with AKI (14% vs. 5.5%). There was a significant association between AKI severity and short-term mortality (P < 0.001). Patients with AKI had a lower Glasgow Coma Scale on admission (11.81 � 3.17 vs. 10.83 � 3.2) and discharge (12.44 � 3.44 vs. 10.38 � 3.2) compared to patients without AKI (P < 0.001). Greater severity of AKI was associated with worse neurologic outcome (P < 0.001). - DISCUSSION: Various studies in literature have evaluated the incidence of AKI after a stroke episode. The incidence of AKI was ranging from 8%e21% in those studies. In our study, we found that 20% of SICH patients developed AKI. The incidence of AKI in our study falls along the spectrum described in these previous studies. - CONCLUSIONS: AKI is a common complication of SICH. Lower estimated glomerular filtration rate at admission and infections were the significant risk factors. Patients with AKI had poor neurologic outcome and higher mortality and it increased with the severity of AKI.