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Nasopharyngeal carcinoma (NPC) is an epithelial carcinoma originating from lining of the nasopharyngeal mucosa usually at the fossa of Rosenmuller (pharyngeal recess). An early detection on endoscopy can be rewarding, however, often difficult as the tumor at the pharyngeal recess is hidden from the endoscopic view. Magnetic resonance imaging and positron emission tomography–computed tomography form the backbone of detection and spread of the carcinoma into local and distant regions. These modalities help further characterize the precise locoregional infiltration and lymph nodal involvement which aids in the planning of the surgery/chemoradiotherapy. They also help in the follow-up evaluation and further management strategies. Many research and treatment groups namely American Joint Committee on Cancer, National Comprehensive Cancer Network, American Society of Clinical Oncology, American College of Radiology, Radiological Society of North America, European Society of Radiology (iGuide), Indian Radiological & Imaging Association/Indian College of Radiology and Imaging, National Cancer Grid, etc. have devised guidelines for the optimal assessment and treatment of NPC. The present document aims at providing a comprehensive review of the clinicoradiological recommendations for the diagnosis and management of NPC based on these guidelines as well as personalized experience of the contributors.

Objective: Elasticity of the skeletal system in children and degenerative changes in adults are responsible for SCIWORA. The purpose of this study was to determine those degenerative changes on CT scan that predispose adults to SCIWORA, their correlation with MRI findings, clinical presentation and recovery. Materials and Methods: This prospective study was conducted over a period of 1.5 years and 30 patients were enrolled. Apart from the demographic profile, mode of injury, clinical symptoms, ASIA at admission, X-ray, CT and MRI findings were noted. All patients were managed conservatively and were followed up after 3 months. NCCT and MRI findings were correlated with each other, with clinical presentation and with recovery. Recovery was defined as any improvement in ASIA class. Statistical Analysis: Data was collected and organized. For normally distributed data parametric test and for others non-parametric test was used. Kendall tau rank correlation coefficient was used to measure the ordinal association between two measured quantities. Results: 28 (93.3%) patients were males and 2 (6.7%) were females. Patients with osteoporosis and/or osteophytes (n = 16) had a higher incidence of development of cord edema or non-haemorrhagic contusion (n = 15) (P = 0.028) while patients with canal stenosis and/or ligamentous calcification (n = 14) had a higher incidence of development of haemorrhagic contusion (n = 12) (P = 0.04). Patients with canal stenosis and/or ligament calcification showed significantly less recovery (n = 3) when compared with patients of osteophytes and/or osteoporosis (n = 6) (P = 0.04). Disc abnormality was seen in 1 patient only. 9 patients showed recovery and maximum recovery was seen in ASIA D (n = 4) class while no patient recovered in ASIA A class. Conclusion: Osteoporosis, osteophytes, canal stenosis and ligament calcification are the factors that predispose adults to SCIWORA. The final outcome seems to be poorer in cases of canal stenosis when compared with osteophytes and osteoporosis. NCCT findings can be used as an adjunct to MRI to predict clinical presentation, severity and recovery in adult SCIWORA.

Paradoxical intracranial hemodynamic steal (IHS) is a contradictory reduction of cerebral blood flow volume in the territory of the impaired perfusion area occurring spontaneously or in response to vasodilatory stimuli, which can be recorded and evaluated on transcranial doppler (TCD). IHS followed by early neurological worsening (change in National Institute of Health Stroke Scale [NIHSS]> 2) in acute ischemic stroke patients has been described as reversed Robin Hood syndrome (RRHS). We describe two cases of RRHS following carotid artery stenting (CAS) in patients with contralateral carotid occlusion and its further management. Two patients with a history of anterior circulation strokes presented with recent complaints of dizziness and a sensation of being pulled back (patient 1), and episodic numbness of upper limbs (patient 2). On CT angiogram, both of the patients had severe extracranial internal carotid artery (ICA) stenosis on the symptomatic side associated with complete occlusion of the ICA on the contralateral side. In addition, both patients had impaired vasomotor reactivity (VMR) on TCD in the bilateral middle cerebral artery (MCA). Therefore, CAS on the symptomatic side was performed in both patients by femoral artery access without any periprocedural and postprocedural complications. However, on day 1 post CAS, complaints of transient upper limb tingling (patient 1) and limb shaking (patient 2) were reported corresponding to the completely occluded ICA, and TCD examinations confirmed RRHS in both patients. Patients were managed by decreasing the dose of antihypertensive medication to augment the blood pressure for 2 weeks. Normalization of the VMR on TCD was seen on follow-up, and both patients remain asymptomatic.

Background Advanced ultrasound, intraoperative magnetic resonance imaging (MRI), neuromonitoring, and aminolevulenic acid have improved the resection and safety of eloquent area gliomas. However, availability of these modern gadgets is a major concern in resource-deficient countries. A two-dimensional ultrasonography 2D USG is cheaper, provides real-time imaging, and is already established but underutilized instrument. Objective Here, we revisited the principles of 2D USG and used it for eloquent-area glioma surgery. Materials and Methods Fifty-eight patients with eloquent area gliomas were operated in last 2 years with the aid of 2D USG with 6-13 MHz curvilinear probe. Preoperative diagnosis was high-grade glioma in 38 and low-grade glioma (LGG) in 20 patients. Tumors were categorized as predominantly hyperechoic (27), uniformly hyperechoic (7), mixed echogenicity (21), and cystic (3). Results Intraoperatively, 2D USG could define the tumor margins in 46 cases. Of these, USG suggested gross total excision in 38 patients and subtotal in 8 patients. The findings matched with follow-up MRI in 34 patients who showed hyperechogenicity (predominant/uniform). Injecting saline with air in to the resection cavity and insinuating through adjacent brain parenchyma helped in detecting residual lesion in three cystic gliomas and in two LGG where the tumor cavity collapsed. Conclusion 2D USG is a helpful tool in eloquent area glioma surgery, especially in resource-limited countries. Visualization through adjacent parenchyma and injection of saline–air mixture in to the resection cavity helped in delineating residual lesion. Extent of resection is best monitored by 2D USG when tumor appeared hyperechoic (predominant/uniform).

Purpose Central nervous system (CNS) bacterial and fungal infections can cause secondary vasculitis which worsens the prognosis due to development of complications like infarctions or hemorrhages. In this prospective study, we aim to study intracranial vessel wall imaging findings in bacterial and fungal infections. Methods We included 12 cases of nontubercular bacterial and fungal CNS infections each, in whom definitive microbiological diagnosis could be made. High-resolution vessel wall imaging (VWI) and time of flight MR angiography (TOF MRA) were incorporated in the routine imaging protocol. All cases were evaluated for the presence of vascular enhancement, pattern of enhancement, and stenosis on VWI. Statistical analysis was done to evaluate association between findings of vessel wall imaging and infarctions. Results We found infarctions in 5 out of 12 cases (41.7%) of the bacterial group and 7 out of 12 cases (58.3%) of the fungal group. Vessel wall enhancement was seen in 5 cases (41.7%) of the bacterial group and 9 cases (75%) of the fungal group. There was a significant association between infarctions and vessel wall enhancement in the fungal group. However, pattern of enhancement or stenosis on VWI was not significantly associated with presence of infarction. VWI detected more cases of vascular involvement than TOF MRA. Conclusion Secondary infectious vasculitis in bacterial and fungal infections can be detected by VWI, which can play an important role in better patient management as detection of vascular involvement can prompt early treatment to prevent complications like infarctions or hemorrhages.

Postradiosurgery symptomatic brain edema may be seen with parasagittal meningioma owing to its proximity to major venous sinuses and cortical veins. Venous preservation radiosurgery planning is less described. Here, we discuss a new method of tumor volume contouring on postcontrast magnetic resonance venogram (CEMRV) images safely excluding the adjacent cortical veins and sinuses. Six cases of parasagittal meningiomas where Gamma Knife radiosurgery was planned on CEMRV sequence were studied in detail. A double-contrast injection method was used to obtain CEMRV images. The differential contrast enhancement showed the displaced and compressed sinuses and cortical veins in the vicinity of meningioma. Tumor was contoured on both contrast magnetic resonance imaging (CEMRI) and MRV image for comparative analysis. 15 Gy at 50% marginal isodose was prescribed and quantitative assessment showed reduced exposure to the adjacent veins and sinuses on the MRV plan as compared to the CEMRI plan. All patients remain asymptomatic at a mean follow-up of 34.2 months. Postcontrast MRV is a simple sequence and can delineate the adjacent venous structures in parasagittal meningiomas. Tumor contouring directly on this sequence guides the surgeon to prescribe adequate radiation dose while sparing cortical veins and sinuses in radiosurgery planning.

Rationale and Objectives More than half of the bipolar depression (BD) subjects are misdiagnosed as unipolar depression (UD) due to lack of objective diagnostic criteria. We aimed to identify microstructural neuronal changes differentiating BD from UD groups using diffusion kurtosis imaging (DKI). The objective of the study is to identify an objective neuro-imaging marker to differentiate BD from UD. Materials and Methods A prospective, cross-sectional study included total of 62 subjects with diagnosis of bipolar depression ( n = 21), unipolar depression ( n = 21), and healthy controls ( n = 20). All subjects underwent diffusion-weighted imaging (b = 0,1000,2000) of the whole brain on 3-Tesla MR scanner. DKI data was analyzed using 189 region whole-brain atlas. Eight diffusion and kurtosis metrics including mean diffusivity (MD), axial diffusivity (AD), radial diffusivity (RD), fractional anisotropy (FA), mean kurtosis (MK), axial kurtosis (AK), radial kurtosis (RK), and kurtosis fractional anisotropy (FKA) were measured against these 189 regions. Principle component analysis (PCA) was utilized to identify the most significant regions of the brain. ANOVA with post hoc tests was used for analyzing these regions. Results BD group showed increased MD, RD, decreased AK at the left amygdala and decreased MK and RK at the right hemi-cerebellum. UD group showed increased MK and RK at the right external capsule; and increased AK, MK, and RK at the right amygdala. Conclusion The right and left amygdala, right external capsule, and right hemi-cerebellum showed microstructural abnormalities capable of differentiating BD and UD groups. Diffusion imaging especially DKI can aid in management of depression patients.

Background Haemorrhagic stroke (HS) accounts for nearly half of the paediatric strokes. The aetiology of HS in childhood is not well defined in the Indian context. Objectives To study the aetiological profile and short-term neurological outcome of children with HS from North India. Methods In a prospective observational study, consecutive patients >28 days to Results A total of 48 children with HS were enrolled. The median age was 6 months (1–58 months), and 33 (69%) were 2 years of age (p = 0.001). During hospitalization, 21 (44%) children died. Older age, low Glasgow coma score (0.5) at three month follow-up. Conclusion VKDB, inherited coagulation disorders, central nervous system infections and arteriovenous malformations were the most common risk factors for HS. VKDB is the single most important preventable risk factor for HS in infants.

Objective To examine demographic, clinical, and biochemical differences in patients with adrenocorticotropin (ACTH)-dependent Cushing syndrome (CS) based on etiology, sex, and tumor size. Methods This was a single-center study of 211 patients with ACTH-dependent CS followed for 35 years. Patients were stratified into 3 groups based on etiology: Cushing disease (CD)/transsphenoidal surgery, Cushing disease/total bilateral adrenalectomy (CD/TBA), and ectopic ACTH secretion (EAS). Patients were also stratified based on sex and tumor size (nonvisualized, microadenoma, and macroadenoma). Results CD was the commonest cause of ACTH-dependent CS (190; 90%). Most patients presented in the third decade (median age, 29 years). Clinical features, cortisol, and ACTH were significantly greater in the EAS group. The CD/TBA group had more nonvisualized tumors (22% vs 8%; P = .000) and smaller tumor size (4 vs 6 mm; P = .001) compared with the CD/transsphenoidal surgery group. There was female predominance in CD (2.06:1) and male predominance in EAS (2:1). Men had shorter duration of symptoms (2 years; P = .014), were younger (23 years; P = .001), had lower body mass index (25.1 kg/m2; P = .000), and had more severe disease (low bone mineral density, hypokalemia). Macroadenomas were frequent (46; 24.2%), and ACTH correlated with tumor size in CD (r = 0.226; P = .005). Conclusion Our cohort presented at an earlier age than the Western population with a distinct, but slightly lower, female predilection. Patients with CD undergoing TBA had frequent negative imaging. Men had a clinical profile suggesting aggressive disease. Microadenoma and macroadenoma were difficult to distinguish on a clinicobiochemical basis.

Aim: The aim was to study the brain connectivity using diffusion tensor imaging (DTI) among patients with treatment-resistant schizophrenia (TRS) and compare the same with a group of patients without TRS. Methods: Twenty-three patients with TRS and 15 patients without TRS underwent DTI using a 3T magnetic resonance imaging machine. DTI data were processed with the calculation of fractional anisotropy (FA) and apparent diffusion coefficient. Patients were also assessed on Brief Psychiatric Rating Scale, Positive and Negative Symptom Scale, Global Assessment of Functioning Scale, and Clinical Global Impression severity scale. Results: Patients with TRS and non-TRS differed significantly in the FA values in the region of right superior longitudinal fasciculus and right uncinate fasciculus, with more integrity of tracts in the non-TRS group. However, these differences disappeared when Bonferroni correction was used for multiple comparisons. Conclusion: The present study suggests lack of significant difference in DTI findings between patients with TRS and non-TRS.

Background Calvarial Ewing tumor is a relatively rare differential among bony neoplasms. We present our experience of managing primary calvarial Ewing sarcoma (EWS), highlighting their clinical and radiological findings. Method In a retrospective analysis, we evaluated our 12-year database for pathologically proven EWS. A literature search was conducted for the comparative presentation and update on the management and outcome. Result From January 2008 to December 2020, we managed eight patients (male:female = 5:3; age range 6 months to 19 years, mean 11.5 years) harboring primary calvarial EWS. All cases underwent wide local excision; two patients required intradural tumor resection, while one required rotation flap for scalp reconstruction. Mean hospital stay was 8 days. All patients received adjuvant chemo- and radiotherapy. Three patients remained asymptomatic at 5 years of follow-up, while two patients died. Conclusion Primary calvarial EWS is a rare entity. It usually affects patients in the first two decades of life. These tumors can be purely intracranial, causing raised intracranial pressure symptoms, which may exhibit rapidly enlarging subgaleal tumors with only cosmetic deformities or symptoms of both. Radical excision followed by adjuvant therapy may offer a favorable long-term outcome.

Pediatric glioblastoma (pGBM) is a rare entity accounting for only approximately 3% of all childhood brain tumors. Treatment guidelines for pGBM have been extrapolated from those in adult glioblastoma. Rarity of pGBM and underrepresentation of pediatric population in major studies precludes from defining the ideal treatment protocol for these patients. Maximum safe resection is performed in most of the cases followed by postoperative radiotherapy in children over 3 years of age. Benefit of temozolomide is unclear in these patients. Here, we present the clinicopathological details and outcome of six pGBM patients treated at our institute in 2018-2019.

Tubercular meningitis (TBM) has the propensity to cause secondary vasculitis through various mechanisms leading to development of cerebrovascular complications. These vascular involvements can be detected by vessel wall imaging (VWI). In this study, we aimed to study detailed findings of vessel wall imaging in cases of tubercular meningitis. All consecutive patients of suspected tubercular meningitis in whom diagnosis of TBM could be made according to diagnostic criteria given by Ahuja et al. were included in the study. High-resolution MR VWI and time of flight (TOF) magnetic resonance angiography (MRA) were done along with routine MRI sequences. Arteries up to second-order branches were studied, and statistical analyses were done with respect to stage of tubercular meningitis, infarctions and TOF MRA findings. Out of all 101 cases of TBM, infarctions were found in 49 cases (48.5%), and vessel wall enhancement was seen in 67 cases (66.3%). With increasing severity of disease, more severe vascular involvement was seen on VWI. There was significant association between enhancement of individual arteries and infarctions in their territories. VWI had better sensitivity than the MRA, while MRA had better specificity than VWI for detection of vascular complications. Tubercular vasculitis can be detected by VWI in the form of nodular or smooth segmental enhancement of vessel wall with or without stenosis. Incorporation of VWI in routine MR imaging can play a greater role in early detection and management of cerebrovascular complications which can help to improve prognosis of the disease.

Background Pleomorphic xanthoastrocytoma (PXA), a relatively uncommon, World Health Organization grade II tumor of astrocytic origin, occurs in children and in general carries good prognosis. The recently identified anaplastic PXA (grade III) type shows poor outcome. Rarely, these said tumors can display an aggressive clinical course with features of leptomeningeal spread. Such cases are mostly seen in adults, with rare instances reported in the pediatric age group. Case Description In this report, we describe an 8-year-old child with anaplastic PXA with a rapid downhill course due to cerebrospinal fluid spread. This child is perhaps the first pediatric report in which the cerebrospinal fluid dissemination was established on cytology. Conclusions The case is an indicator of the need for craniospinal screening protocol in patients with PXA, especially the anaplastic variety, both at the time of initial diagnosis and follow-up.

Background Calcified neurocysticercosis (NCC) predisposes patients to an enduring state of epilepsy. The predictors for calcification in parenchymal neurocysticercosis are not well defined. Method In this prospective cohort study, consecutive children with single-lesion parenchymal NCC were enrolled and followed up for one year. All patients were investigated with brain 3 T-MRI and electroimmunotransfer blot (EITB). Clinical follow-ups were performed every 3 months. Radiology was repeated at the 6-month and one-year follow-ups. The proportion of calcified lesions at one year and the predictors of calcification were studied. Result During the study period from June 2013 to December 2015, 93 children with single lesion parenchymal NCC were enrolled. At presentation, 90 % of the lesions were in the colloidal stage, and 71 % of the lesions had moderate to severe perilesional oedema. All children had 6 months of follow-up, and 86 (92.5 %) had one year of follow-up. Seizure recurrence was present in 13 (14 %) children. Follow-up radiology at one year showed lesion resolution in 51 (59 %) lesions and calcification in 28 (32.5 %) lesions. Children with calcified lesions during follow-up had a higher odds of seizure recurrences {OR, 95 % CI 3.6(2.3–5.6)}. The presence at baseline of diffusion restriction {OR, 95% CI 2.9 (1.01–8.8)}, scolex or wall calcification in the T2 Star weighted angiography MRI images {OR, 95% CI 3.7 (1.7–8.2)} and >10 mm size of the lesion {OR, 95 % CI 2.4 (1.2–5.01)} predicted lesion calcification. Conclusion Children with calcification of the parenchymal NCC lesions have a higher risk for seizure recurrence during follow-up. The presence of diffusion restriction, calcified nidus in the colloidal nodular stage, and >10 mm size of the lesion at baseline predicted calcification of the lesion during follow-up.

Developmental adversities early in life are associated with later psychopathology. Clustering may be a useful approach to group multiple diverse risks together and study their relation with psychopathology. To generate risk clusters of children, adolescents, and young adults, based on adverse environmental exposure and developmental characteristics, and to examine the association of risk clusters with manifest psychopathology. Participants (n = 8300) between 6 and 23 years were recruited from seven sites in India. We administered questionnaires to elicit history of previous exposure to adverse childhood environments, family history of psychiatric disorders in first-degree relatives, and a range of antenatal and postnatal adversities. We used these variables to generate risk clusters. Mini-International Neuropsychiatric Interview-5 was administered to evaluate manifest psychopathology. Two-step cluster analysis revealed two clusters designated as high-risk cluster (HRC) and low-risk cluster (LRC), comprising 4197 (50.5%) and 4103 (49.5%) participants, respectively. HRC had higher frequencies of family history of mental illness, antenatal and neonatal risk factors, developmental delays, history of migration, and exposure to adverse childhood experiences than LRC. There were significantly higher risks of any psychiatric disorder [Relative Risk (RR) = 2.0, 95% CI 1.8–2.3], externalizing (RR = 4.8, 95% CI 3.6–6.4) and internalizing disorders (RR = 2.6, 95% CI 2.2–2.9), and suicidality (2.3, 95% CI 1.8–2.8) in HRC. Social-environmental and developmental factors could classify Indian children, adolescents and young adults into homogeneous clusters at high or low risk of psychopathology. These biopsychosocial determinants of mental health may have practice, policy and research implications for people in low- and middle-income countries.

This paper presents a new fusion scheme for medical (CT-MRI) images which is based on the nonsubsampled shearlet transform (NSST). The various image pairs to be fused are obtained from primary and internet sources. Initially, the images are decomposed through NSST into general and detailed features. The smallest uni-value segment assimilating nucleus (SUSAN) and local sum of Gaussian weighted pixel intensities-based activity measures are proposed to fuse the detailed sub-bands and low-frequency sub-band of NSST, respectively, for faster execution of the algorithm. Visual and parametric comparison of the proposed scheme is done through five traditional fusion algorithms using nine fusion performance parameters. In addition, Wilcoxon signed ranks test is also applied to compare different methods scientifically with the proposed fusion scheme. It is observed that the presented method is better in retaining bone, calcification, cerebrospinal fluid (CSF), edema and tumor details of the source images and is faster than other classical fusion schemes. The fused images of the proposed method are suitable for locating the site of biopsy externally or incision location in the bone of the brain skull with minimum diagnostic time.

Paediatric pituitary adenomas (PPAs) are uncommon, with evidence confined to small cohorts.We aimed to elucidate the baseline profile and outcomes of PPAs in a large, contemporary, monocentric cohort.Pituitary clinic at PGIMER over 8 years (2010-2018).PPAs in patients (≤20 years at diagnosis) were included. A retrospective review of their baseline clinico-biochemical and radiological profiles and outcomes post pituitary surgery/medical management was performed.There were a total of 74 patients, of which 42 were female. The median age was 15 (IQR 13-18) years. Corticotropinomas (32.4%) and somatotropinomas (25.7%) were common, with 1 case of TSHoma and pituitary blastoma. The most common presentation was headache (57%) overall and menstrual irregularities (64.2%) in girls. Most (78%) had macroadenomas. Prolactinomas showed an excellent response to primary medical therapy (83.3%). Transsphenoidal surgery was performed in 81% of patients. Diabetes insipidus (30%) and hyponatremia (26.7%) emerged as common postoperative complications. Adjuvant medical management was required in 25%, and radiotherapy in 18%. Remission rates in Cushing's and acromegaly were 62.5% and 57.8%, respectively, with long-term hormone deficits noted in one-third of patients.PPAs have unique features and management challenges, including effects on growth and puberty. Functional tumours and macroadenomas are common. Remission can be achieved in more than half of the patients, with endocrine deficits persisting in about a third of cases, needing long-term surveillance.

Cerebral hyperperfusion syndrome (CHPS) can result after anastomotic surgery as the reperfusion is established in chronically ischemic cerebral territories in patients of moyamoya disease (MMD). In this study, we have evaluated the feasibility of arterial spin labelling (ASL) perfusion MRI to predict cerebral hyperperfusion syndrome based on changes of cerebral blood flow (CBF) after revascularisation surgery in patients of MMD. Our prospective study included 25 patients with MMD who underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass with or without dural/muscle synangiosis. ASL MRI was performed before and 1–7 days after surgery. On the side planned for operation, 5-mm ROI circle was drawn on the predetermined regions in frontal lobe, temporal lobe, parietal lobe and basal ganglia in proximal and distal territories of MCA to calculate ipsilateral CBF values (CBFi). An attempt was made to select the same location on contralateral side (non-operative) (CBFc) for each measurement for calculation of hemispheric normalised CBF (nCBFh) ratios. To adjust for inter individual variation among MR imagers and CBF, additional regions of interest were drawn within the cerebellum (CBFcbl) for cerebellar CBF normalised ratios (nCBFCbl). Of the 25 patients (26 operated hemispheres), 5 patients showed significant immediate postoperative symptoms suggestive of CHPS. Based on our findings, sensitivity and specificity of ASL perfusion to detect CHPS were evaluated. ASL was found to have 47–100% sensitivity and 45–88% specificity to detect CHPS. We have tried to calculate the prevalence of CHPS in postoperative patients of moyamoya disease, which in our study ranged from 6.83 to 40.70%. Based on our results, we concluded that ASL perfusion is an appropriate alternative to standard nuclear medicine studies to monitor the changes in perfusion after STA-MCA bypass surgery in moyamoya patients. ASL MR perfusion can be used to identify changes in cerebral blood flow (CBF) for early detection of cerebral hyperperfusion syndrome in patients with otherwise normal conventional MRI sequences with very high sensitivity but moderate specificity.

Despite widespread popularity of navigation and angled endoscopes in endonasal endoscopy, there are hardly few studies on their efficacy with the extent of resection or retreatment. This is probably the first study to assess the independent impact of these adjuncts among pituitary tumors. Patients with pituitary tumors undergoing endonasal endoscopy were prospectively studied for their demographics, clinico-radiological features, intraoperative use of navigation, and angled endoscopes, in relation to gross total resection (GTR), near total resection (NTR), endocrine remission, and retreatment. Pertinent statistical analyses were performed. Among a total of 139 patients, navigation and angled endoscopes could be used in 54 and 48 patients, respectively, depending upon their availability rather than chosen as per the case. There was no significant difference in baseline characteristics in relation to their use. The surgeon's perception of immediate benefit was noted among 51.9% while using navigation. The use of angled endoscopes towards the end of resection could help with additional tumor removal in 62.5% of patients. Overall, the use of navigation resulted in a significantly higher GTR (80.8% vs. 59.7%, OR 2.83, p = 0.01), a higher GTR/NTR (86.5% vs. 70.8%, OR 2.65, p = 0.04), and a lower retreatment rate (7.7% vs. 20.8%, OR 3.15, p = 0.05) than the others. In functioning tumors with cavernous sinus invasion, navigation had significantly increased remission rates (69.2% vs. 0%, p = 0.03). The use of angled endoscopes yielded a significantly higher GTR/NTR (91.7% vs. 70.6%, p = 0.04) and a lower retreatment rate (0% vs. 15.7%, p = 0.05) among only non-functioning adenomas. In multivariate analyses, the use of neuronavigation had a significant association with both GTR and retreatment rates (p values 0.005 and 0.02 respectively), independent of other confounding factors. The elective intraoperative use of navigation has a significant independent impact on the extent of resection and retreatment overall. While navigation results in better remission rates among functioning tumors with cavernous sinus invasion, angled endoscopy has a significant association with surgical outcomes in non-functioning tumors.

Anatomical brain templates are commonly used as references in neurological MRI studies, for bringing data into a common space for group‐level statistics and coordinate reporting. Given the inherent variability in brain morphology across age and geography, it is important to have templates that are as representative as possible for both age and population. A representative‐template increases the accuracy of alignment, decreases distortions as well as potential biases in final coordinate reports. In this study, we developed and validated a new set of T1w Indian brain templates (IBT) from a large number of brain scans (total n = 466) acquired across different locations and multiple 3T MRI scanners in India. A new tool in AFNI, make_template_dask.py, was created to efficiently make five age‐specific IBTs (ages 6–60 years) as well as maximum probability map (MPM) atlases for each template; for each age‐group's template–atlas pair, there is both a “population‐average” and a “typical” version. Validation experiments on an independent Indian structural and functional‐MRI dataset show the appropriateness of IBTs for spatial normalization of Indian brains. The results indicate significant structural differences when comparing the IBTs and MNI template, with these differences being maximal along the Anterior–Posterior and Inferior–Superior axes, but minimal Left–Right. For each age‐group, the MPM brain atlases provide reasonably good representation of the native‐space volumes in the IBT space, except in a few regions with high intersubject variability. These findings provide evidence to support the use of age and population‐specific templates in human brain mapping studies., Highlights A new set of age‐specific T1w Indian brain templates for ages 6–60 yr are developed and validated.A new AFNI tool, make_template_dask.py, for the creation of group‐based templates.Maximum probability map atlases are also provided for each template.Results indicate the appropriateness of Indian templates for spatial normalization of Indian brains.

We share our experience with stereotactic gamma knife thalamotomy (GKT) for medically refractory Holmes tremor (HT). A 22-year-old patient underwent gamma knife thalamotomy at ventrointermediate nucleus for disabling HT of the right upper limb. A single 4-mm isocenter was used to target the ventral intermediate nucleus with 130 Gy radiation. At 4 months follow up, we observed 84% improvement in his Fahn-Tolosa-Marin (FTM) rating scale with significant improvement in the right upper limb dystonic tremor. There was only subtle improvement in the ataxic component of the right lower limb. At 1 year after stereotactic GKT, there was sustained neurological improvement with no side effect, We present the stereotactic GKT as a treatment modality for drug-resistant HT. Moreover, it may be considered an alternate treatment modality especially in patients reluctant or contraindicated for any invasive surgical technique. CLINICAL TRIAL REGISTRATION NUMBER: Not required.

Background Posterior circulation stroke resulting from atlantoaxial dislocation (AAD), although uncommon, is a well-described entity. The normally coursed V3 segment of the vertebral artery (VA) is likely to be stretched because of C1-C2 dislocation and further compromised by the C1-C2 translational mobility. The persistent first intersegmental artery (PFIA), an anomalous variant does not course through the C1 transverse foramen, but rather crosses the posterior C1-C2 joints and is unlikely to be affected by the C1-C2 dislocation. Therefore, a patient with AAD and anomalous VA presenting with stroke should be evaluated for other etiologies of VA compromise. Case Description We report a patient of AAD with PFIA who presented with posterior circulation stroke. Careful radiological evaluation revealed a loose body (LB) adjacent to the medial aspect of the left C1-C2 facet compressing the anomalous VA. Intraoperatively, there was a large LB on the posteromedial border of the joint, compressing the VA. The anomalous VA was mobilized, and the offending element removed followed by fixation of the C1-C2. Conclusions One should be aware of such an etiology of arterial compromise in cases of AAD with coexistent anomalous VA. An underlying LB or large osteophytes resulting from instability may be the offending cause, and needs to be dealt with, as fusion alone may not benefit the patient.

Purpose: Nelson’s syndrome (NS) is regarded as an aggressive complication of total bilateral adrenalectomy (TBA) for Cushing’s disease (CD). This challenge may be addressed by using clinical criteria to guide frequency of neuroimaging to enable timely management of NS and also avoid unnecessary frequent imaging. Methods: All patients (n = 43) with CD subjected to TBA over 35 years at a tertiary care centre were included. NS was defined as a newly appearing or expanding (> 2 mm) pituitary adenoma with or without ACTH levels exceeding 500 pg/ml. Pre-and post-TBA parameters like clinical symptomatology, cortisol, ACTH and radiology were analysed for the prediction of NS. Results: NS developed in 39.5% (n = 17) patients with a median follow-up of 7 years. Half of them had new appearance, while rest had an expansion of pre-existing pituitary tumour. Majority (90%) had ACTH above 500 pg/ml. On Cox proportional hazards analysis, frequent discriminatory features of protein catabolism (≥ 4) (HR 1.15, CI 0.18, 7.06), proximal myopathy (HR 8.82, CI 1.12, 69.58) and annual ACTH increment of 113 pg/ml (HR 12.56, CI 1.88, 88.76) predicted NS. First post-operative year ACTH indices predicting NS included ACTH rise of 116 pg/ml and absolute ACTH of 142 pg/ml (sensitivity, specificity exceeding 90%). Annual ACTH increment exceeding 113 pg/ml, ≥ 4 discriminatory features and uncontrolled hypertension had the best overall prediction. Conclusion: Patients who developed NS had higher rebound rise of ACTH following TBA and a more severe disease phenotype at baseline. Consistent ACTH increment can be used as a marker for predicting the development of NS.

Objective To use anatomic measurements on magnetic resonance imaging (MRI) and ultrasonography (USG) in diagnosing and grading carpal tunnel syndrome (CTS) using nerve conduction studies (NCS) as the gold standard. Material and methods In this prospective study, 26 patients with CTS (45 wrists; 22 female and 4 male patients; mean ± SD age of 49.42 + 14.47 years) and 19 age and sex matched healthy volunteers (32 wrists; 15 female and 4 male volunteers, mean ± SD age of 42.52 + 10.85 years) underwent MRI and USG. Cross-sectional area (CA) of median nerve was measured using free hand ROI at four levels: hamate hook (H0), pisiform bone (PI0), 1 cm proximal (PI1) and 2 cm proximal to PI0 (PI2). Relative median nerve signal intensity (MNSI) was calculated as ratio of median nerve signal intensity with hypothenar muscle signal intensity. Flexor retinacular bowing was calculated at hamate hook level. Echogenicity and Power Doppler vascularity of median nerve were assessed on USG. Independent t-test, chi square test and receiver operating characteristic curve analysis were used as appropriate. Results On USG, CA measured at PI0 (95% confidence interval of 0.872-0.987) and retinacular bowing (0.816-0.912), while, on MRI, CA at PI1 (0.874-0.997) were most useful in diagnosing CTS based on the ROC and Zombie plot analysis. Area under curves for CA measurements on USG and MRI were not significantly different. CA at PI1 on MRI (0.752-0.965) was significantly different between minimal to moderate CTS and severe to extreme CTS groups (on NCS). Conclusion CA of median nerve is the most useful parameter to diagnose and grade CTS and USG and MRI are comparable for measurements. Increased retinacular bowing on USG and hypoechogenicity of median nerve increase the diagnostic confidence while MRI helps in picking up important associated conditions.

Pendular see-saw nystagmus is an extremely rare form of nystagmus characterised by cyclical movement of the eyes with a conjugate torsional component and a disjunctive vertical component. Intorsion and elevation of one eye is accompanied by simultaneous extorsion and depression of the contralateral eye. Most commonly it results from a suprasellar/parasellar mass compressing the meso-diencephalic region. Herein, we report a case of a 5-year-old girl who presented with pendular see-saw nystagmus secondary to a craniopharyngioma. The nystagmus resolved following excision of the lesion.

Paradoxical intracranial hemodynamic steal (IHS) is known in patients having persistent proximal arterial occlusions and is linked with early neurological worsening. However, stroke risk specific to symptomatic internal carotid artery occlusions (SICAO) having paradoxical IHS is unknown. Therefore, we aimed to investigate the association of paradoxical IHS in SICAO patients with stroke recurrence during a one-year follow-up.We prospectively enrolled adult patients having SICAO with a recent history of ischemic events. Steal magnitude (SM) to classify patients in IHS and non-IHS categories was evaluated by a breath-holding test using bilateral transcranial doppler (TCD). Patients were prescribed optimal medical therapy and followed up for one year for any ischemic stroke/TIA/cardiovascular death.36 SICAO patients, mean age of 56 years, were assessed using TCD at median 22.5 days (Interquartile range, IQR= 9-42), and 11 (30.6%) had paradoxical IHS with median SM 12% (IQR= 6%-18%). On follow-up, 7 (19.4%) patients had event recurrence and its association with IHS was non-significant (IHS vs non-IHS, 18.2% vs 20%; Log-rank statistics=0.006; P=0.940). On Cox regression analysis, event recurrence was independently associated with the presence of significant contralateral stenosis only (regression coefficient= 2.237; P= 0.012; 95% CI= 1.63-53.89).IHS prevalence among SICAO is high. However, paradoxical IHS was not associated with an increased risk of stroke in SICAO. Therefore, the presence of paradoxical IHS in SICAO may be considered a transit state and does not necessarily imply an increased risk of stroke.

Context Temozolomide (TMZ) is endorsed as the treatment of choice in aggressive or malignant pituitary adenomas. Objective Herein we describe a case of an aggressive prolactinoma that was resistant to TMZ. We performed a literature review of similar nonresponsive, aggressive prolactinomas. Methods A 40-year-old woman presented with a giant prolactinoma that required cabergoline, transsphenoidal surgery, and radiotherapy to achieve near-normal prolactin and apparently no residual tumor. A year later, she presented with multiple cranial nerve involvement due to a recurrent tumor extending to the infratemporal fossa. She underwent transfrontal surgery, second radiotherapy, and was started on TMZ. Despite 8 cycles of temozolomide (200 mg/m2, 5/28-day cycle), she had progressive disease and ultimately succumbed to the disease. PubMed/MEDLINE, Google Scholar, and prior review articles were searched for manuscripts about patients with aggressive prolactinomas who had been treated with TMZ. Data on demography, duration of therapy, and management outcomes were analyzed in those with progressive disease. Results We identified 94 cases of patients with aggressive/malignant prolactinomas in the literature who had received TMZ. Progressive disease despite TMZ was present in 36 cases (38%). There was a male preponderance (65%) among these and 40% had aggressive prolactinomas, whereas the rest had carcinomas. Patients received a median of 8 cycles (interquartile range, 3.5-11.5) of TMZ. O6-methylguanine-DNA-methyltransferase (MGMT) immunostaining was negative in 35%. Overall mortality at the time of publication was 40%, at a duration varying from 2 to 20 years from diagnosis. Conclusion TMZ resistance in aggressive/malignant prolactinomas is challenging. Progressive disease on optimal TMZ treatment entails the use of newer agents.