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This systematic review was done with the aim to answer these three questions: 1) Is there any change in diffusion metrics in MRI-DTI sequences after mild traumatic brain injury in paediatric and young population?, 2) Is there any correlation of these changes in diffusion metrics with severity of post concussion symptoms?, 3) Is the change in diffusion metrics predictive of neurocognitive function or neurological recovery?Eligibility criteria- Mild TBI patients upto 22 years of age, MRI- DTI sequence done post injury, Outcome measurement with follow up at least for onemonth and articles published in English language only. Data sources- PubMed, EMBASE, CINAHL, Scopus and Cochrane RESULTS: Some studies show increased FA and some studies show decrease FA and few showed no change in white matter microstructure in mTBI patients and this depends on the duration of injury. Prediction of PCSs severity on the basis of changes in white matter microstructure showed inconsistent results. Radiological recovery in contrast to clinical recovery, is often delayed ranging from 6 months to 2-3 years. But change in diffusion metrics after mTBI is not definite predictive of neurocognitive outcomes.Large, properly designed, multicentric studies with appropriate extracranial or orthopedic control and long follow up are needed to establish the use of DTIin mTBI for predicting behavioral outcome.

Cisternostomy (CS) is a recently introduced procedure to mitigate the cerebrospinal fluid shift edema and secondary injury in traumatic brain injury patients. There have been numerous reports describing its efficacy in various cohorts of traumatic brain injury (TBI) patients; therefore, we review the current evidences examining its utility for the same. The systematic review was done according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline including all human studies published in English language indexed with MEDLINE and Google Scholar since 2013 evaluating CS as a standalone or as an adjuvant procedure. The studies were graded according to the Oxford center for evidence-based medicine levels of evidence. Case reports were excluded from the analysis. A total of 107 articles were found by using the given search criteria. Finally, three oxford level 3 study and one level 4 study were included in the analysis. CS in combination with decompressive craniectomy was seen to confer mortality benefit and better outcome at discharge. It led to statistically significant improvement in clinical outcome at 6 months in the patients for whom it was performed as a primary procedure. CS is a promising procedure in TBI leading to survival benefit as well as better clinical outcome. But the level of evidence supporting its effectiveness is still weak owing to the methodological limitations and small sample size. A well-designed multicentric randomized controlled trial is needed to critically examine its role in TBI patients.

Background and Importance: Chondrosarcoma is a rare malignant cartilage forming tumor, usually arising from long bones and rarely observed in the cranium. In the cranium, it commonly arises from the skull base with the skull vault being a highly unusual site. Case Presentation: We present the case of a 30-year female presenting with complaints of headache for 6 months. The patient was found to have large chondrosarcoma in the right frontoparietal region, which is an extremely rare location. The final diagnosis was based on histological examination, suggestive of well-differentiated chondrosarcoma [the World Health Organization (WHO); grade I]. Conclusion: Cranial vault chondrosarcoma is an uncommon histological diagnosis with surgery as the primary treatment option; however, adjuvant radiotherapy plays a definitive role, especially in aggressive or incomplete removed cases.

Objective This study was aimed to compare comparative efficacy of transsphenoidal endonasal endoscopic and microscopic pituitary surgery at single center of a developing country. Methods This study included 198 patients in which 50 patients were studied prospectively and 148 patients were studied retrospectively, diagnosed with pituitary adenoma who presented to neurosurgery department at Sawai Man Singh hospital in Jaipur, India, and were operated via transsphenoidal route between 2013 and 2018. Patients' records were reviewed and relevant clinical and surgical data were collected. Patients were divided into two groups based on the surgical procedure performed, endoscopic endonasal transsphenoid approach (group 1) and microscopic transsphenoidal approach (group 2). Outcomes, in terms of efficacy and the resulting complications of each procedure were compared and analyzed. Results A total of 198 patients with pituitary adenoma were operated during the study period. Among them, 119 (60.1%) patients were operated by endoscopic and 79 (39.9%) patients were operated by microscopic transsphenoidal approach. In endoscopic group, intraoperative cerebrospinal fluid (CSF) leak was present in 39 patients (32.77%) and 23 (29.11%) in microscopic group. Complete tumor removal was achieved in 69.75% in endoscopic and 48.13% in microscopic group (p = 0.004). Endocrine control was achieved in 78.94% (30 out of 38) in endoscopic and 68.18% (15 out of 22 patients) in microscopic group. Conclusion The transsphenoidal approaches for resection of pituitary adenoma, both endoscopic and microscopic approach, are minimally invasive and effective for disease control. Both the approaches lead to similar endocrine control, visual symptoms, complications, and long-term outcome. Therefore, the selection of the final approach should be individualized, ultimately depending on the surgeons' comfort, experience, and familiarity with the particular technique.

Introduction Cognitive impairment is one of the most important culprit influencing the long-term neurological outcome commonlyobserved in TBI survivors. Aims To examine the performance of patients with Mild and Moderate traumatic brain injury (TBI) on the Montreal Cognitive Assessment (MoCA) using as a screening tool. Results Total 228 (127 Mild TBI & 101 Moderate TBI) patients were recruited in this study. Results showed that patients with moderate TBI had lower score on the MoCA as compared to patients with mild TBI (p Value = 0.031). This difference was observed statistically significant among mild and moderate TBI for the cube copy (p = 0.039) and clock (p = 0.017) i.e. visuospatial/executive function, Digit span test (p value = 0.040) i.e. concentration and recall memory (p = 0.04). MoCA Score were higher for patients with higher GCS score at admission. Education status was also correlated with MoCA scores; those patients with higher level of education had significant association with higher MoCA scores (p value = 0.012). This study showed that age and gender were insignificant variables to determine cognitive function. Conclusion Assessment of cognitive impairment should be considered as a mandatory protocol while evaluating post TBI patients, even in cases of mild TBI. Visuospatial/Executive function, memory and attention are the most commonly impaired cognitive functions in patients of TBI, and these are the main domain of cognition which differentiates mild impairment from moderate impairment. This information enables us and provides insight to our experience to predict the burdens of problem and plan to develop post TBI dedicated rehabilitating programme.

Spinal arachnoid cysts are uncommon benign lesions of spine axis and most commonly present as compressive myelopathy. Intramedullary arachnoid cyst is uncommonly seen, hence, not much discussed in literature. Due to rarity of this entity, many questions are yet to be answered and should be addressed properly, particularly related to etiopathogenesis, accustomed course, behavior, differential diagnosis, and the best treatment modality. We report the clinicopathological profile of thoracic intramedullary arachnoid cysts in two adult patients, and present a detailed review of available literature on the spinal intramedullary arachnoid cyst. Most of the literature concerning with intramedullary arachnoid cysts are in the form of case reports from pediatrics population. As far to the best of our knowledge, only a few cases excluding our two were found in both pediatrics and adult population.

Background Traumatic posterior fossa hematoma is a rare entity. Traumatic posterior fossa hematomas are associated with considerable morbidity and mortality and their surgical management remained controversial. Methods From August 2011 to August 2017, approximately 5,100 patients with head injury were managed. Authors reviewed clinical and radiological findings, management criteria, and outcome of posterior fossa hematoma in 21 patients. Results Out of 21 cases, 13 survived with our management. The Glasgow Coma Scale (GCS) on admission was higher in favorable group than in poor outcome group. Factors associated with Glasgow Outcome Scale in two groups were status of fourth ventricle, basal cisterns, subarachnoid hemorrhage (SAH), hematoma volume, and their location (hemispheric or midline). Similarly, associated supratentorial lesions, age, gender, lesions in other parts of body, and timing from injury to reporting to hospital were taken into consideration. Conclusion The factors correlated with patient outcome were age, sex, mode of injury, GCS at admission, associated intracranial hematomas, associated SAH, hematoma volume, hematoma location, basal cisterns, status of fourth ventricle, and associated multiple injuries on other body parts. It is hereby concluded that timely surgical intervention should be employed whenever indicated without delay. Posterior fossa hematomas were rarely observed in the pediatric age group.

Posterior circulation territory stroke following mild head injury is a known entity although rarely seen. Numerous case reports appear in literature from time to time highlighting this complication. Blunt trauma to the head and neck possibly causes injury to the vertebrobasilar system in the form of angiorrhexis, subintimal, intramural and perivascular hemorrhage which causes secondary narrowing of the injured vessel. These processes can be complicated by progressive thrombosis & vascular occlusion. Here we are reporting a case of post traumatic vertebra-basilar dissection causing bilateral cerebellar and brainstem infarct.

Aim To study the long-term prognostic value of early magnetic resonance imaging (MRI) in unconscious patients with traumatic brain injury with findings of NCCT of the brain suggestive of diffuse axonal injury (DAI). Background Studies addressing the correlation of MRI with the pattern and duration of loss of consciousness due to DAI are few. The utility of MRI in predicting the functional outcome has not been reported in the Indian population. Materials and Methods In patients with DAI, MRI sequences including T1, T2*GRE (gradient recall echo), fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and susceptibility-weighted imaging (SWI) were obtained. Glasgow coma scale (GCS) and Glasgow outcome scale (GOS) scores were documented at admission, on discharge, and at 3 months. Results A total of 54 patients (53 males, 1 female) were included in the study. The mean age was 27 ± 11.7 years. The mean GCS score on admission and at follow-up were 9.14 ± 2.3 and 11.7 ± 2.3, respectively. The mean GOS score on discharge and at 3 months were 2.6 ± 0.8 and 3.18 ± 1.02, respectively. SWI sequence detected maximum number of lesions followed by GRE and DWI. Patients with lesions in brainstem and basal ganglia were found to have a less favorable outcome as assessed by GCS and GOS at 3 months. There was no correlation between the total lesion load and outcome at 3 months. Conclusion In patients with DAI, SWI was found to be the most sensitive MRI sequence detecting maximum number of lesions. Patients with lesions in the brainstem and basal ganglia appear to have longer duration of unconsciousness and poorer outcome at 3 months.

Lumbar diskectomy is a common procedure in neurosurgery, besides the common complications broken scalpel blade during disc removal is a rare event. Usually retrieval of such sharp retained fragments in same sitting is difficult and to prevent further complications another session is warranted [1]. We report a case of broken scalpel blade during L1-L2 lumbar intervertebral disc removal and successful surgical retrieval of that tip of knife with the help of operative microscope under fluoroscopic guidance during same sitting before any hazardous complications develop.

Vertex extradural hematomas (VEHs) are rare and account for only 1.3 to 8.2% of all traumatic hematomas. The clinical picture of VEH is variable. Three cases of traumatic VEH with coronal suture diastasis following head injury on neuroimaging presented in emergency. All underwent emergency surgery and had excellent outcome.

Aneurysmal bone cyst (ABC) is an expansile, osteolytic lesion. The association of ABC with pregnancy is a very rare entity. We are reporting a unique case of spinal ABC, presenting as pathological fracture, paraplegia, and abdominal mass in the 28th week of pregnancy. A brief review of the literature is discussed. Dyshomeostasis of bone calcium, hormonal, and mechanical stress can aggravate the severity of ABC during pregnancy. A multidisciplinary approach is required to manage such cases, depending on the fetal gestational age and maternal neurological features.

Spontaneous onset extradural hematoma (EDH) is a very rare entity and has been seen mostly to be associated with adjacent infective pathologies, dural vascular malformations, extradural metastasis, or coagulopathies. We report a series of two such cases and review the literature. One case presented with spontaneous EDH that was managed conservatively and was diagnosed to have chronic kidney disease later; the other had deranged coagulation profile and liver function secondary to drug induced hepatitis and was operated. Both patients were discharged in a stable condition and were improving on follow up.

Dissecting anterior inferior cerebellar artery (AICA) aneurysms are extremely rare, and only nine cases are reported till date. We are reporting a case of ruptured dissecting distal AICA aneurysm with spontaneous resolution; first of its kind in the indexed literature.

Central nervous system (CNS) tuberculosis commonly manifests as tubercular meningitis. CNS tuberculomas are more common intracranially and less frequently involve the spinal cord. Combination of intramedullary with intracranial tuberculomas is extremely rare. We report a case of concurrent occurrence of intramedullary tuberculoma with multiple intracranial tuberculomas in a young 16-year-old boy, who presented with two weeks history of paresthesias and weakness of the lower limbs and diminution of vision in left eye, who had been treated for pulmonary tuberculosis. Magnetic resonance imaging (MRI) spine showed a well-circumscribed lesion opposite L1, which was diagnosed as intramedullary tuberculoma. As for vision complaint, on cranial imaging, he was found to have multiple round contrast enhancing lesions, which were diagnosed as intracranial tuberculomas based on their typical MRI findings. He had complete recovery with conventional treatment of anti-tubercular therapy and steroids, without any surgical intervention. We suggest that MRI of the brain should be performed in all case of intramedullary spinal tuberculoma because of the possible presence of early asymptomatic/mild symptomatic intra-cranial tuberculomas.

Background This is a rare association of pituitary adenoma with apoplexy with arteriovenous malformation as only single case was reported prior to this case as per our knowledge. Case Description A 25-year-old man presented with chief complaints of headache of sudden onset, severe in intensity with sudden loss of vision. Imaging shows pituitary adenoma with apoplexy with right parietal arteriovenous malformation. The patient was managed with embolization for parietal arteriovenous malformation and medically for pituitary adenoma with apoplexy. Conclusion Pituitary apoplexy can be treated conservatively if no features of mass effect present. Follow-up of the patient must be done regularly to look for the size of pituitary adenoma and recurrence of arteriovenous malformation.

Rhombencephalosynapsis is a rare congenital intracranial malformation. Partial rhombencephalosynapsis is a variation of this anomaly with few reported cases. We report a unique case of a patient with partial rhombencephalosynapsis associated with Chiari II, and various spinal malformations, which is very rare, and only few such cases have been reported in literature. These findings suggest that rhombencephalosynapsis can be associated with spinal malformations and, furthermore, that cases with the common features of rhombencephalosynapsis and Chiari II malformation can exist. Such an association likely represents a new anomaly of the hind brain with spine.

Solitary fibrous tumor (SFT) is a rare neoplasm that is thought to be of mesenchymal origin. Occurrence of such a tumor in the orbit is rare, more so in its malignant form. Histopathologically, it can mimic several other tumors of the orbit and can be differentiated by CD34 positivity. We report a case of malignant transformation of an SFT of the orbit that recurred after 15 years. The differentiating histopathological features with special stress on the importance of CD34 positivity and principles of management are outlined. The need for long-term follow-up to detect recurrence and malignancy is stressed.

Acute bilateral facial nerve paralysis is a rare clinical entity, and its management remains very controversial (operative or conservative). Here we are presenting a case of acute onset bilateral facial nerve palsy following head injury with bilateral temporal bone fracture with clinico-radiographic contrary. Patient was managed conservatively with complete recovery. By this article, authors want to stress on combining clinical examination and radiological findings for decision making of this rare entity and tried to evaluate the management.

Traumatic subdural hematomas of the posterior fossa are rare but dangerous neurosurgical emergencies that require prompt diagnosis and management to avoid the uniformly poor outcome. We present a case of a teenager with severe TBI and acute subdural hematoma of the posterior fossa that deteriorated rapidly before surgery but eventually made a good recovery. We also the review the literature concerning traumatic posterior fossa subdural hematomas [PFSDH].

Spinal Teratomas are rare tumor and cervical intramedullary location in infancy still rarer. Only eleven cases of cervical intramedullary teratoma in pediatric patients is reported in available literature (1, ll). We are reporting a case of an infant presenting with cervical mature teratoma with associated dysraphism, adding the next in this rare case series. Arising as a result of dysembryogenesis, these lesions by virtue of their content are difficult to diagnose preoperatively. Heterogeneous intensities on MRI produced by intralesional lipomatous and osseous elements are helpful but rarely enough to diagnose the tumor. Histology is confirmatory. Mature teratomas generally have good prognosis and a timely intervention can prevent further neurological deterioration. However a strict clinical and radiological follow up is recommended.

Orbital roof fractures after a blunt injury are an uncommon complication of trauma. Traumatic encephaloceles in the orbital cavity are even rarer, with only 15 cases published till date. Raised intraorbital pressure leading to irreversible damage to the optic nerve can be prevented by early diagnosis and management. Orbital computed tomography (CT) with thin axial and coronal sections is helpful in trauma patients with a concurrent orbital trauma. Decompression of the orbital roof is the key step in surgical treatment and should be performed in every case. Repairing the orbital roof has to be performed to avoid transmission of variation in the intracranial pressure to the orbit. We present a case of traumatic orbital encephalocele who underwent surgical treatment via a frontobasal approach with evacuation of the contused herniated brain and reconstruction of the orbital roof using temporalis fascia which is readily available in contrast to costly materials like titanium mesh, screws, bone powder, fibrin glue, and so on, which are not easily available in every hospital. Rapid resolution of proptosis and visual symptoms along with excellent cosmetic outcome was seen at follow‑ups after three and nine months. We emphasize the early diagnosis of this rare condition and also emergency treatment to prevent permanent visual loss as well as to achieve good cosmetic results.

Extradural hematoma (EDH) is considered to be a rare in head trauma associated with arrested hydrocephalus, and represents a serious pathology from which complete recovery can be expected if urgent intervention done in time. In this case report, the authors present an arrested hydrocephalus patient who was apparently asymptomatic at the time of hospital admission with a mild head injury and developed rapidly increasing size of EDH. The value of repeated early Computed tomography (CT) scan and the pathogenesis of rapidly increasing size of EDH in arrested hydrocephalic patient are discussed.

Bilateral basal ganglia haemorrhage following motor vehicle accident is extremely rare in field of neurosurgery. This is presumed to be secondary to rupture of lenticulostriate or Anterior Choroidal artery by shearing, as a result of acceleration/deceleration forces. Although the exact mechanism is still not known. Isolated bilateral basal ganglia haemorrhage carries favourable prognosis. We report a rare case of 50 years old lady having bilateral basal ganglia haemorrhage with diffuse axonal injury following motor vehicle accident. Patient was managed conservatively and improved.

Aneurysmal bone cyst ( ABC) is an expansive osteolytic lesion. Association of ABC with pregnancy is a very rare entity. We are reporting a unique case of spinal ABC, presenting as pathological fracture, paraplegia and abdominal mass in 28th week of pregnancy. A brief review of the literature is discussed. Dyshomeostasis of bone calcium, hormonal and mechanical stress can aggrevate the severity of ABC during pregnancy. A multidisciplinary approach is required to manage such cases, depending on the fetal gestational age and maternal neurological features.

Ganglioglioma of the conus region is quite rare with only 12 reported cases. Ganglioglioma shares biologic features with neurofibromatosis leading to suggestions that the co-existence of the two diseases may be more than coincidental. We report a case of ganglioglioma of the conus medullaris in a patient of neurofibromatosis and explore the possible association of the two diseases.

Primary non-Hodgkin's lymphoma (NHL) of the cranium with extra- and intracranial extension without systemic or skeletal manifestation in a non-immunocompromised patient is extremely rare. These lesions are most of the time misdiagnosed because they mimic other conditions like meningioma. Here, we report a case presented with huge bulky scalp mass which on magnetic resonance imaging (MRI) brain showed involvement of scalp, cranial vault, meninges, and the brain parenchyma, mimicking a meningioma. After gross total resection, biopsy and CD marker study revealed primary non-Hodgkin's diffuse large B-cell lymphoma (DLBCL). Malignant NHL should be considered in differential diagnosis of bulky scalp mass lesion.

Burr hole evacuation of chronic subdural hematoma (SDH) with or without drainage system is the most common surgical method among various techniques. There are various complications of burr hole drainage evacuation of chronic SDH, but there is no case report regarding impaction and prolapse of brain parenchyma through burr hole as a complication. Herewith, we are reporting a case of bilateral chronic SDH with prolapse of brain parenchyma through burr holes. Magnetic resonance imaging (MRI) of brain showed a characteristic look and we named it “Tiger hide appearance”. We failed to find such characteristic appearance in MRI brain on reviewing the available literature.

Traumatic carotid-cavernous fistula (TCCF) is a direct communication between cavernous portion of the internal carotid artery (ICA) and cavernous sinus due to tear in ICA. Most of the cases are treated by endovascular embolization. Spontaneous resolution of high-flow TCCFs is extremely rare. We report a case of posttraumatic, direct, high-flow carotid cavernous fistula (Barrow type A) that resolved spontaneously after cerebral angiography.

Juvenile Xanthogranuloma (JXG) is a rare disorder of central nervous system. It rarely produces compressive myelopathy. On reviewing world literature, we could find only nine cases of this disease involving spine and of which only four cases were in adults' i.e., 18 years and above. We are presenting a case of Spinal JXG in an18-year-old male with thoracic compressive myelopathy presenting as short duration progressive paraparesis. Magnetic Resonance Imaging of Spine showed mass lesion in epidural space compressing cord from behind without any bony involvement at D7 to D10 vertebral segment. It was isointense on T1 and hyperintense on T2 with no contrast enhancement. D7 to D10 Laminectomy with complete excision of firm epidural mass was carried out. The histopathology with tumor markers confirmed the diagnosis of JXG. Post-operative neurological recovery in this patient was good. His power improved to grade 5/5 with decreased spasticity. Follow-up MRI at 3 months showed no residual tumor. This case appears to be the first in the series with entirely extradural component in adult thoracic spine.