Microscope integrated Near infra red Indocyanine green video angiography (NIR ICG VA) has been frequently used in cerebrovascular surgery. It is believed to be a simple and reliable method with acquisition of real time high spatial resolution images. The aim of this review article was to evaluate the efficacy of intra operative Indocyanine green video angiography (ICG VA) in Aneurysm, brain arteriovenous malformations (AVM) and extracranial-intracranial (EC-IC) bypass surgeries and also to analyze its limitations. Intra operative imaging is a very useful tool in guiding surgery; thus, avoiding surgical morbidity. Now-a-days, many cerebrovascular units are using ICG VA rather than Doppler and intra operative DSA in most of their aneurysm surgeries, and surgeons are incorporating this technique for AVM and in EC-IC bypass surgeries too. This article is an overview of the beneficial effects of ICG VA in cerebrovascular surgery and will also point out its limitations in various circumstances. Intra operative ICG VA gives high resolution, real time images of arterial, capillary, and venous flow of cerebral vasculature. Although it gives adequate information about the clipped neck, parent/branching artery and perforator involvement, it has some limitations like viewing the neck residuals located behind the aneurysm, thick walled atherosclerotic vessels, and thrombosed aneurysms. In AVM surgery, it is useful in detecting the residual nidus in diffuse type AVM, but cannot be relied in deep seated AVMs and it gives exact information about the anastomosis site in EC-IC bypass, thus, avoiding early bypass graft failure. NIR ICG VA is a simple, reliable, and quick method to pick up subtle findings in cerebrovascular procedures. But in selected cases of aneurysms, endoscopy and intra operative Digital substraction angiography (DSA) may be helpful, whereas in deep seated AVMs, navigation may be required as an adjunct to confirm intra operative findings.

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We report an unusual case of pituitary hyperplasia secondary to primary hypothyroidism clinically masquerading pituitary apoplexy. A 22-year-old female presented with intermittent headache, easy fatigability, facial puffiness, coarseness of facial features, and hoarseness of voice for six months duration. Diplopia and diminution of vision was also observed for the last 15 days. Brain imaging findings showed pituitary enlargement, the thyroid function test were suggestive of primary hypothyroidism. Patient did well with thyroid hormone replacement therapy.

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Context: Kashmir, a snow bound and mountain locked valley, is populated by about 7 million ethnic and non-migratory Kashmiris who have specific dietary and social habits than rest of the world. The neurological disorders are common in Kashmiri population. Aims: To study the prevalence and outcome of spontaneous intracranial subarachnoid hemorrhage (SAH) in Kashmir compared withother parts of the world. Settings and Design: A retrospective and hospital based study from 1982 to 2010 in the single and only Neurosurgical Centre of the State of Jammu and Kashmir. Materials and Methods: A hospital based study, in which, information concerning all Kashmiri patients was collected from the case sheets, patient files, discharge certificates, death certificates, and telephonic conversations with the help of Medical Records Department and Central Admission Register of Sher-i-Kashmir Institute of Medical Sciences, Kashmir India. Statistical Analysis: Analysis of variance and students T-test were used at occasions. Results: Incidence of SAH in Kashmiris is about 13/100,000 persons per year. SAH comprises 31.02% of total strokes and aneurysmal ruptures are cause of 54.35% SAHs. The female suffers 1.78 times more than the male. Total mortality of 36.60% was recorded against a good recovery of 14.99%. The familial SAHs and multiple aneurysms were also common. Intra-operative finding of larger aneurysmal size than recorded on pre-operative computed tomography (CT) angiogram of same patients was noteworthy. In 493 patients of SAH, the angiography revealed 705 aneurysms. Conclusion: Spontaneous intracranial subarachnoid hemorrhage, due to aneurysmal rupture, is common in Kashmir, with worst outcome. Food habits like "salt-tea twice a day", group-smoking of wet tobacco like "Jejeer", winter season, female gender, hypertension, and inhalation of"Kangri" smoke are special risk factorsof SAH, in Kashmiris. The plain CT brain and CT angiography are best diagnostic tools. The preventive measures for aneurysmal formation and rupture seems most promising management of future. The detachable endovascular aneurysmal occupying video assisted micro-camera capsules or plugs may be future treatment.

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Context: Juxtafacet cysts of the lumbar spine are extradural degenerative lesions associated with symptoms of lower back pain and radiculopathy. Surgical treatment is indicated when there is failure of conservative measures. Primary spinal fusion at the time of surgical excision of the cyst is a matter of controversy. Few reports have described long-term follow-up for surgical treatment of spinal cysts. Aim: The purpose of this study is to assess the long-term outcome of the surgical excision of a Juxtafacet cyst without spinal fusion. Study Design: This is a retrospective case series study, level IV evidence. Materials and Methods: This is a retrospective case series study on 13 patients with Juxtafacet cysts, who were treated with surgical excision of the cysts without spinal fusion. A questionnaire scoring system was used for evaluation of the surgical outcome. Results: The study was conducted on 13 patients, seven females (54%) and six males (46%), their age ranging from 38 to 69 years, with a mean age of 52 (±9.93 STD) years. The mean duration of the symptoms was 10.5 (±6.22 STD) months. All patients got benefit from surgery, with six excellent (46%), six good (46%), and one fair outcome (8%), with no surgery-related complications. The mean follow-up period of the patients at the time of this study was 4.2 years (±1.43 STD). Conclusion: Long-term follow-up for surgical excision of symptomatic Juxtafacet cysts without spinal fusion revealed excellent to good results in 92% of the patients, with a satisfaction rate of 80% (±8.41 STD).

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Astroblastoma is a rare tumor belonging to the family of primary glial neoplasms. They are classified as neuroepithelial tumors; however, the World Health Organization grading is still not established. We report the case of a 4-year-old child who presented with an intra-axial space occupying lesion which turned out to be an astroblastoma. A complete excision was done and there was no recurrence at 20 months follow-up. This case report highlights the presence of such unusual tumor with invasion to the calvarium and reviews the current literature.

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Neuroleptic malignant syndrome (NMS) is a rare, but potentially lethal neurological emergency. Fifty percent of traumatic brain injury (TBI) patients will have emotional disorders and post-traumatic agitations. Haloperidol is a neuroleptic antipsychotic medication commonly used in the traumatic brain injury patients due to its advantage of no effect on respiration and conscious level. But it is one of the common medications causing NMS. A 19-year-old male driver involved in the road traffic accident had an acute subdural hematoma, which was immediately evacuated. Postoperatively, he was awake. He was weaned from ventilator and extubated. He received 20 mg of intravenous haloperidol in divided doses with in 24 hours to control his agitation. Next day, he became drowsy, spastic, febrile, and tachycardic with labile blood pressure. He was diagnosed to have NMS, needed intubation, aggressive hydration and pharmacological treatment with dentrolene sodium and bromocriptin. He was weaned from ventilator and extubated on day 17. He was transferred to the ward and then discharged to be followed in out-patient clinic. NMS in head injury patient is rare and difficult to diagnose. Diagnosis of NMS should be suspected if two of the four cardinal signs and symptoms are developed following the use of neuroleptic or dopamine agonist medication withdrawal.

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Background. Traumatic brain injury (TBI) remains a major cause of death and disability. Oxidative stress is an important element of the injury cascade following TBI. Progressive compromise of antioxidant defenses and free radical-mediated lipid peroxidation are one of the major mechanisms of secondary TBI. NR2B is a glutamate receptor and its activation is caused by TBI increasing a brain cell death, along with caspase-3 as a hall mark of apoptosis. Glutathione is a potent free radical scavenger that might prevent secondary TBI damage and inhibited apoptosis. Materials and Methods. In the present study, it aims to demonstrate the effect of glutathione on inhibition of brain oxidative damage in a TBI rat model. Results. In this study, the expressions of mRNA NR2B in placebo group and groups with glutathione administration at 0, 3, and 6 hours after TBI were 328.14, 229.90, 178.50, and 136.14, respectively (P<0.001). The highest caspase-3 expression was shown in placebo group with 66.7% showing strong positive results (>80%); as expected, glutathione administered in 0, 3, and 6 hours groups had lower strong positive results of 50%, 16.7%, and 16.7%, respectively, (P=0.025). Conclusion. In conclusion, this study showed that glutathione administration in a TBI rat model decreased NR2B gene- and caspase-3 protein-expression that lead to the inhibition of brain cell death. Our results suggest that glutathione, as a potent free radical scavenger, has a brain cell protective effect against oxidative damage and cell death induced by TBI in rat model.

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Sub-arachnoid hemorrhage (SAH) has been easily one of the most debilitating neurosurgical entities as far as stroke related case mortality and morbidity rates are concerned. To date, it has case fatality rates ranging from 32-67%. Advances in the diagnostic accuracy of the available imaging methods have contributed significantly in reducing morbidity associated with this deadly disease. We currently have computed tomography angiography (CTA), magnetic resonance angiography (MRA) and the digital subtraction angiography (DSA) including three dimensional DSA as the mainstay diagnostic techniques. The non-invasive angiography in the form of CTA and MRA has evolved in the last decade as rapid, easily available, and economical means of diagnosing the cause of SAH. The role of three dimensional computed tomography angiography (3D-CTA) in management of aneurysms has been fairly acknowledged in the past. There have been numerous articles in the literature regarding its potential threat to the conventional "gold standard" DSA. The most recent addition has been the introduction of the fourth dimension to the established 3D-CT angiography (4D-CTA). At many centers, DSA is still treated as the first choice of investigation. Although, CT angiography still has some limitations, it can provide an unmatched multi-directional view of the aneurysmal morphology and its surroundings including relations with the skull base and blood vessels. We study the recent advances in the diagnostic approaches to SAH with special emphasis on 3D-CTA and 4D-CTA as the upcoming technologies.

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We present a 45-year-old patient who had acute radial nerve palsy following a blunt trauma without any fracture or dislocation. He was injured by strucking in a combat three months ago. The patient has been followed by application of a long-arm plaster cast before referred to our clinic. Preoperative electromyoneurography and magnetic resonance imaging (MRI) indicated that there was a radial nerve injury on humeral groove. The British Medical Research Council (MRC) grade was 2/5 on his wrist preoperatively. The patient underwent an operation under general anesthesia. It was seen to be a second-degree nerve injury. The patient has subsequently regained full movement on his wrist and finger extension in six months. We suggest that a detailed clinical and electrodiagnostical evaluation is necessary in patients who have radial nerve injury when deciding the treatment, conservative or surgical.

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Meningeal spread of spinal intramedullary astrocytoma into the cranium is rare. Only few case reports are available so far in the literature. We report a case of intramedullary high grade astrocytoma of the conus, developing intracranial metastasis after three months of partial excision of the spinal mass. The need for radical surgery, entire neuroaxis radiation, and adjuvant chemotherapy is suggested in the management of malignant spinal cord astrocytoma to prevent dissemination.

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Context: One of aneurysmal subarachnoid hemorrhage complication is delayed ischemic neurological deficits (DIND). It is postulated that cortisol dynamics might be associated with the severity of this complication. Aims: The goal of the study is to investigate whether the peak of morning serum cortisol levels are associated with the severity of its complication during the course of the disease. Settings and Design: This is a prospective cohort study conducted from January 2009 to June 2011, at our institution. Materials and Methods: The study follows a consecutive cohort of patients for 14 days after the aneurysmal subarachnoid hemorrhage. Serum cortisols, cortisol binding globulin, adenocorticotrophic hormone (ACTH) were measured pre operatively and then on post operative days (POD) 2, 4, 7, and 10. Blood was drawn to coincide with peak cortisol levels between 08.00-09.00 hours. Neurological examinations were conducted at least twice daily and patient outcome were graded according to modified Ranklin Scale. DIND was defined by a decrease in the Glasgow Coma Scale of two or more points compared to the status on POD 1. Statistical Analysis: All the results were analyzed using statistical software, Statistical Package for Social Sciences (SPSS v61; SPSS, Inc., Chicago, IL). Logistic regression analysis was used to compare the relationship between the variables. Results: Thirty six consecutive patients are collected, but only 28 patients (12 M and 16 F) were eligible for the cohort analysis. Average patient age is 50.75 years old (50.75±12.27), and more than 50% (15/28) arrived with World Federation of Neurologic Surgeons grade 3 or better. Elevated total cortisol levels of more than 24 mg/dl on day 2, 4, and 10 were associated with DIND, and the most significant being on day 4 (P=0.011). These patients also had a higher grade on the modified Ranklin scale of disability. Conclusions:This study shows that the elevated levels of morning total cortisol in the serum are associated with the onset of DIND during the disease course, and it's also associated with bad outcomes.

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Idiopathic hypertrophic cranial pachymenigitis is a rare clinical condition caused by localized or diffuse inflammatory thickening of dura matter. Described here is a person having diffuse thickening of dura matter of base of skull and he was on follow-up treatment for 5 years with us. Diagnosis was done by excluding other conditions and with biopsy. The patient responded to steroid and the MRI picture, which is given serially, shows improvement

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Subdural hematoma is a well known complication of ventriculoperitoneal shunt insertion for hydrocephalus and usually spreads out over the cerebral convexity, and appears as a crescent shaped lesion on imaging. Chronic subdural hematoma in a case of untreated compensated congenital hydrocephalus has not been reported in English literature. We report the rare case of an adult with congenital hydrocephalus with a huge unusual shaped hemispheric subdural hematoma.

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Primary melanotic meningeal neoplasms are extremely rare lesions and benign forms are even rarer though with better prognosis than the malignant ones. We describe a 40-year-old male with a history of gradually progressive weakness of both lower limbs with normal bowel, bladder control, and an intradural mass measuring 1.5×1.0 cm on radiologic investigations. The lesion was surgically excised. Histopathologic examination revealed heavily melanin-pigmented cells, nuclei with reticulogranular chromatin and small nucleoli, moderate amount of eosinophillic cytoplasm with indistinct cell boundaries, and symplasmic appearance. A probable diagnosis of meningeal melanocytoma was made. The diagnosis was confirmed on immunohistochemical analysis which revealed strongly positive expression of HMB-45 in the tumor cells. Vimentin and S-100 were also diffusely positive while neuron specific enolase showed focal and patchy positivity; however, epithelial membrane antigen was distinctly negative.

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