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Aim Our study aimed to validate the revised neuroimaging radiological interpretation system (NIRIS), which would standardize the interpretation of noncontrast head CT of acute traumatic brain injury (TBI) patient and consolidate imaging finding into ordinal severity categories that would not only inform specific patient management actions but could also be used as a clinical decision support tool. Methods We retrospectively studied dispositions and their outcomes of consecutive patients brought to the Sawai Man Singh Hospital Trauma Centre, Jaipur, India, by any means of transport and who underwent a noncontrast CT scan for suspected TBI between April and December 2018. Results The revised NIRIS correctly predicted disposition and outcome in 62.9% (750/1192) of patients. After excluding patients with OMEI (other major extracranial injuries) and OMII (other major intracranial injuries), a correct prediction was observed in 88.3% (670/758) of patients. After excluding OMEI and OMII, the predictability of revised NIRIS in the adult population is 87.6% (446/509), while predictability in the pediatric population is 92.1% (224/249). Conclusion Revised NIRIS is a good tool for predicting patient dispositions, to specific management categories, and outcomes in TBI patients after noncontrast CT head.

Background This study has prospectively investigated pituitary function and their correlation with severity, pressure effect, and Glasgow outcome scale in the acute phase of traumatic subarachnoid hemorrhage (SAH). Most of the retrospective studies have demonstrated that traumatic SAH-mediated hypopituitarism could be more frequent than previously known. Objectives The aim of the study is to find the prevalence of endocrine dysfunction in traumatic SAH and its correlation with severity of injury and final outcome. Materials and Methods Eighty-four consecutive patients of traumatic SAH formed the study group. Apart from clinical assessment, noncontrast computed tomography of the head was performed on all patients on admission. The hormonal analysis (FT3, FT4, thyroid-stimulating hormone, growth hormone [GH], cortisol, prolactin, testosterone) was performed within 24 hours of traumatic brain injury and was repeated on the seventh day amongst the patients who survived. Results Most common hormone to increase on day one was cortisol (48.78%), while on day seven follicle-stimulating hormones and cortisol (15.38%) showed increment in levels. Most common hormone to decrease on day one was FT3 (36.84%) and GH (36.26%), while on day seven testosterone (66.67%) and FT4 (30.76%) showed decreasing levels. Hormone most resistant to change was prolactin. Conclusion Hormonal dysfunction is common in moderate to severe traumatic brain injury. There is a direct association between radiological grading (Fischer) of SAH and hormonal profile changes. Performance of hormonal analysis should be considered in patients with moderate to severe traumatic brain injury, preferably with high-grade SAH, so that appropriate hormonal replacement can be done to optimize the clinical outcome.

Aims: The objective of this study is to understand the association between bone mineral density (BMD), serum calcium, and Vitamin D in s (IA) patients. Subjects and Methods: A total of 100 patients with IA diagnosed at the department of neurosurgery between January 2019 and December 2019 were reviewed and analyzed in this study. Computed tomography angiography was used to confirm and locate the site of aneurysms. BMD, serum calcium, and Vitamin D levels were measured. Statistical Analysis Used: Linear or logistic regression statistical models were applied to found the association between BMD and IA size. To confirm the statistical significance, P < 0.05 (twos-tailed) was considered as statistically significant. Results: Of the studied 100 patients, 61 patients were female and 39 were male. According to the age group, patients were divided into five categories: below 30, 31–40, 41–50, 51–60, and ≥60 years. The most common site of aneurysm observed to be the anterior communicating artery (Acom); 39.25% of the patients had Acom aneurysm followed by the middle cerebral artery (18.69%). This clearly shows that the occurrence of aneurysm is more prominent in anterior circulation as compared to posterior circulation. The results showed that there is a negative linear correlation between BMD and size of aneurysm (P = 0.00043, r =−0.12). Sex-specific analysis showed that females have lower mean BMD value as compared to males (i.e., females 0.785 ± 0.13; males 0.887 ± 0.13; P = 0.0003). We also found that the multiplicity of IAs also shows an association with BMD (i.e. mean BMD: 0.825 ± 0.14, whereas BMD of patients with multiple aneurysms was 0.747 ± 0.08; P = 0.05). Of 100 patients, 66 were observed calcium deficient (normal range: 8.8–10.2 mg/dl). The obtained mean value of calcium was 8.56 ± 0.859 standard deviation (SD), i.e., below the normal range of calcium. In the case of Vitamin D, 85% of the patients were observed Vitamin D deficient, whereas 14 patients showed Vitamin D insufficiency and merely 1 patient has Vitamin D sufficiency. The mean 25-hydroxy Vitamin D level obtained in our study was 14.57 ± 5.60 (SD), which is considered as Vitamin D deficiency. Conclusions: The size and multiplicity of IA can be associated with BMD, calcium, and Vitamin D. The results from the research provide evidence of common pathophysiology between the development of IA and these factors.

Introduction Traumatic brain injury (TBI) is a global health issue, accounting for a significant number of adult and pediatric deaths and morbidity. Computed tomography (CT) is an important diagnostic modality for TBI. The primary goal of this study was to determine if there were any significant radiological differences in CT brain findings between adult and pediatric populations. Materials and Methods Data of individual patients were collected from admission to discharge/death, which included various parameters in terms of demographics, mechanism of injury, and patient outcome which were later analyzed. A total of 1,150 TBI patients were enrolled in the study. Results The most common mode of injury in adults is road traffic accident (RTA) followed by fall from height (FFH), while in pediatrics it is vice versa. Findings of basal cisterns on CT brain were found to be statistically significant in both groups; 65% adults and 71% pediatrics had only one abnormal CT finding. Most common combination CT finding in adults was acute subdural hematoma (ASDH) and basal cistern abnormality, while in pediatrics it was traumatic subarachnoid hemorrhage (SAH) and contusion. Rotterdam score (based on CT brain findings) was significantly lower for pediatric age group compared with adults. It was 2.2 ± 0.85 for adults and 1.99 ± 0.74 for pediatrics, which was statistically significant (p < 0.001). Conclusions The Rotterdam score has immense predictive power for prognostication of mortality status. Pediatric age group has better prognosis in terms of survival as compared with adults, thus justifying the role of Rotterdam CT score for mortality risk stratification in providing clinical care.

Objective: Various clinical trials have compared terlipressin and octreotide in the management of acute variceal bleed, but their results have been inconsistent. Therefore, the present meta-analysis was performed to compare the clinical efficacy and safety of terlipressin and octreotide and gather the strength of evidence regarding their use in variceal hemorrhage. Methods: Randomized control trials were identified using PubMed search engine and Cochrane clinical trial register (from 1994 to 2019). Initial hemostasis rate, rebleeding rate on the 5th day, and overall mortality rate during the study period were studied. The extracted data were analyzed using review manager 5.3 software. Odds ratio with 95% confidence intervals (CI) was estimated for the dichotomous outcomes. Results: A total of six randomized control trials were identified. Through comparisons of data for terlipressin and octreotide groups, we found no statistically significant differences in the initial hemostasis rate, rebleeding rate on the 5th day, and overall mortality rate between the different treatment approaches. Conclusion: The comparison of terlipressin and octreotide showed them to be equally effective and safe therapeutic agents in patients of acute variceal bleeding. Further, evidence from the future randomized controlled trials with higher quality and larger sample sizes is needed to confirm these findings.

Background: The use of Point-Of-Care Ultrasound (POCUS) has increased rapidly across various medical disciplines due to technological advancements providing high quality POCUS units. POCUS can help clinicians at the bed side with information regarding patient management in real time. However, literature reveals scant evidence of POCUS use in Palliative Care. This study’s objective was to examine the use of POCUS in a specialist palliative care setting. Methods: A retrospective chart review was conducted from January 2018 to June 2019 to evaluate characteristics of patients for whom POCUS was utilized. These patients were identified through pre-existing logs and descriptive information was collected from the electronic health records. This included demographic information, life-limiting diagnosis, patient assessment location, diagnosis made with POCUS and, if applicable, volume of fluid drained.Results: We identified 126 uses of POCUS in 89 unique patients. 62 patients (69.7%) had a cancer diagnosis, with patients most commonly suffering from GI, Lung and Breast pathologies. 61 POCUS cases (48.4%) were in the outpatient setting. 81 POCUS cases (64.3%) revealed a diagnosis of ascites and 21 POCUS cases (16.7%) revealed a diagnosis of pleural effusion. Other diagnoses made with POCUS included bowel obstruction, pneumonia and congestive heart failure. During the study period, 52 paracentesis and 7 thoracentesis procedures were performed using POCUS guidance.Conclusion: We identified multiple indications in our specialist palliative care setting where POCUS aided in diagnosis/management of patients in both inpatient and outpatient settings. Further studies can be conducted to identify the potential benefits in symptom burden, patient & caregiver satisfaction and health care utilization in palliative care patients receiving POCUS.

Object: Coagulopathy is a common occurrence following traumatic brain injury (TBI). There are various studies showing incidence and risk factors of coagulopathy and their correlation with poor outcome in adult as well as paediatric age groups. Exact incidence, associated risk factors, treatment guideline for coagulopathy and its impact on outcome are still lacking. In our study we compared the adults and paediatric age groups TBI patients for incidence and risk factors of coagulopathy and its impact on outcome. Methods: Prospective study of 200 patients including 152 adult patients (age > 18 years) and 48 paediatric (Age < 18 years) patients of TBI admitted in intensive care unit of trauma centre of a tertiary care centre was performed from august 2015 to march 2016. Both population were further subdivided into moderate TBI and severe TBI as per Glasgow coma score (GCS). Patient with long bone injury, chest injury and abdominal injuries, coagulation disorder, liver disease, medical disease like diabetes mellitus and hypertension were excluded from study. Coagulation profile were compared in the both groups (Adult and paediatric) and correlated with the outcome. Chi- Square test, student t test and Odds ratios were used for statistical analysis. Results: Mean age among the adult and paediatric population were 37.89 ± 11.88 years and 11.41 ± 5.90, respectively. Among the patient with moderate TBI, coagulopathy was seen in 30% patients of adult TBI whereas it was 12.5% among the paediatric TBI (P = 0.185). Among the severe TBI group coagulopathy was observed in 68.03% and 37.5% of adult and paediatric age group respectively (P = 0.0016). There was significant correlation found between midline shift and coagulopathy in the paediatric age group (P = 0.022; OR - 4.58). E. There was significant association of coagulopathy and contusion on CT scan among the adult population (P = 0.007; OR - 3.487) found whereas no such correlation were observed in paediatric population. Conclusion: Coagulopathy was significantly higher among the adult patient with severe TBI as compare to paediatric patient with severe TBI. There was no statistically significant difference in mortality among patients of both the age groups with coagulopathy.

Ischemic stroke of basal ganglia after head trauma is rare in children younger than 18 months and accounts for less than 2% of all ischemic strokes in childhood. The clinical history of these lesions is particularly favorable because they are usually small and facial-brachial-crural hemiparesis is typical of this pathology that regresses over a period of time. The most effective therapeutic approach appears to be a conservative one, although the best treatment regimen is still not well defined. It is necessary to exclude conditions such as heart disease, coagulopathies, and acute traumatic arterial dissections. The authors present a rare case of bilateral basal ganglia infarct in an 18-month-old child following head trauma managed conservatively with good recovery.

Primary central nervous system lymphoma (PCNSL) is a rare tumor that accounts for

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p

Sinonasal teratocarcinosarcoma (SNTCS) is one of the rarest, aggressive malignant neoplasms of sinonasal tract, consisting of primitive neuroepithelial elements with various malignant epithelial and mesenchymal components. Previously described as teratoid carcinosarcoma, malignant teratoma, or blastoma, SNTCS constitutes less than 1% of all cancers and approximately 3% of all malignancies of head and neck region, which is mainly located in the nasal cavity and paranasal sinuses, although tumors occurring in other locations including the nasopharynx and oral cavity have been described. Here, we are presenting a 22-year-old patient with SNTCS involving the nasal cavity, nasopharynx, and all paranasal sinuses with bilateral orbital and intracranial extension treated with surgery followed by radiotherapy and chemotherapy.

Objective To identify clinical and radiological factors to predict progression of contusion and its impact on clinical deterioration of neurological status, which will ultimately help deciding surgical intervention in initially conservatively managed patients. Methods This is a prospective, observational study containing a total of 110 patients who had contusions after traumatic brain injury with size of ≥2 mL by computed tomographic (CT) scan, managed conservatively in initial period, and had at least two subsequent CT scans within 72 hours after injury. Significant radiological progression was defined as >30% increase in volume from baseline in CT scan. Results The progression of contusion was significantly associated with age, sex, contusion volume in initial CT, effacement of cistern, subdural hematoma (SDH), subarachnoid hemorrhage(SAH), and coagulopathy. SDH and SAH (p Conclusions About half of the patients presenting with TBI managed conservatively in initial period show significant progression of contusion mostly within 24 hours after injury. Patients with SAH, SDH and deranged coagulation profile are particularly at high risk for progression of contusion.

Background: Drug interactions are major cause of concern in hospitalized patients with cardiac illness especially in elderly population. Therefore, the study was conducted to determine the prevalence and pattern of potential drug-drug interactions (pDDI) and risk factors, if any.Methods: It was a prospective observational study involving 75 elderly in-patients with cardiac diseases. IHEC approval was taken before commencement of study and written informed consent was taken from all the study participants. Data was collected using structured data collection tool. pDDI were analyzed using MEDSCAPE databse. Data was analyzed using SPSS 20.0 in terms of descriptive statistics. Pearson correlation coefficient was used to find the association between the risk factors and potential DDIs. P value of ≤0.05 was considered statistically significant.Results: The prevalence of pDDI was found to be 100%. Total 593 pDDI and 33 interacting drug pairs were observed in the study. The common drug interacting pairs were aspirin and furosemide 140 (23.61%), followed by aspirin+ enalapril 98 (16.53%) and heparin and clopidogrel 56 (9.44%). Majority of pDDI 480 (81%) were found to be of moderate severity. A significant association was documented between length of hospital stay (p=0.041) and occurrence of pDDI. A statistically significant correlation (r =0.621; p

Introduction: Fatigue has been cited as a common problem associated with traumatic brain injury. A positive association of fatigue has been suggested with insomnia and depression which are also considered to be significantly associated with traumatic brain injury. Aims and Objectives: The present study in post-traumatic brain injury patients is planned to assess the prevalence of fatigue, depression and insomnia, the correlation of fatigue with depression and insomnia and the risk factors associated with fatigue. Material and Methodology: Total 100 patients were recruited in the present study. Interview was focused on assessment of severity of traumatic brain injury, fatigue, insomnia and depression using Glasgow Coma Scale, Fatigue Severity Scale, Insomnia Severity Index and Patients Health Questionnaire(PHQ-9) respectively. Results: Prevalence of depression was found 84% while that of fatigue and insomnia was 50% and 49% respectively. All patients with fatigue had depression whereas those patients without fatigue were also found to have depression (68%) and this correlation was found statistically significant. Similarly, insomnia was reported in 70% of patients who were fatigued against 28% of patients with no fatigue. This was also found statistically significant (P

Background The objective of the study was to compare the patient-reported outcome measures (PROM) of patients with post-traumatic arthritis (PTA) versus patients with osteoarthritis (OA) undergoing total knee arthroplasty (TKA) and compare the rates of revision among these two groups. Methods Using a prospectively held institutional registry, we retrospectively reviewed patients ≥60 years of age who underwent unilateral TKA between May 2007 and February 2012. Patients with previous or concomitant diagnosis of inflammatory arthropathy or an initial open fracture were excluded. PTA patients were matched 1:5 with OA patients undergoing TKA. Validated PROMs were recorded at baseline before index TKA and the last follow-up. Reason and time to revision surgery was reported, and survivorship was compared using Kaplan-Meier curves. Results Seventy-five PTA patients were matched to 375 OA patients. There was no difference between these groups with respect to age (67.7 ± 5.6 vs 67.8 ± 5.5 years; P = .876), body mass index (28.6 ± 5.4 vs 28.7 ± 5.3 kg/m2; P = .948), sex (65.3% vs 65.3% females; P = .999), Charlson Comorbidity Index (21.3% vs 21.3% Index 1-2, P = .999), and time to follow-up (93.0 ± 13.4 vs 88.2 ± 13.7 months; P = .999). No statistically significant difference was found in PROMs at baseline and the last follow-up (P > .05), the rate or time to revision surgery between the two groups (P-value = .635; log-rank test). Conclusion Unlike previous studies, TKA for PTA does not pose lower PROMs or higher revision rates when compared to TKA for OA. These results could help provide surgeons with a frame of reference in terms of expectations for patients with PTA undergoing TKA.

Introduction: Traumatic brain injury (TBI) is a major cause of disability. Assessment and treatment of TBI typically focus on physical and cognitive impairments, yet psychological impairments represent significant causes of disability. Depression may be the most common and disabling psychiatric condition in individuals with TBI. Objective: This cross-sectional study was design to investigate prevalence and risk factors of depression in Traumatic brain injury (TBI). Material and method: The Group studied consists of 204 patients of mild and moderate TBI between 14-days to one-year post injury. Demographic characteristics of the participants were assessed on a self-designed semi structured performa. Interviews focused on assessment of severity of TBI, depression and quality of life (Qol) using GCS, PHQ-9 and WHOBREF-QOL respectively. Results: Total 204 patients were included. 42.15% participants were found to have depression. None of the demographic variables were associated with depression except female sex, severity and time since injury. Moderate TBI patient (55.80%) had significantly higher occurrence of depression than the mild cases (44.2%). Patients with lesser duration (time since injury) of TBI had high incidence (50.2%) of depression compare to longer duration of TBI. Depressed patients also had poor Qol than those without depression in all domains except physical health domain. Neuroanatomical localization was also correlated with depression. Cerebral contusions were the most common (44.24%) lesions associated with depression. Conclusion: Depression is commonly associated, yet under diagnosed clinical entities in head injury and have tremendous impact in overall outcome measures. Every patient of head injury warrants psychiatric evaluation and concomitant treatment if required to ensure the attainment of not only neuroanatomical intact but overall productive and qualitative life vindicating the holistic and multidisciplinary treatment approach.

Objective To assess quality of life (QOL) in individuals with mild and moderate traumatic brain injury (TBI) and their relationship with demographic, posttraumatic insomnia, and injury-related factors. Method The present study was a cross-sectional study conducted at Sawai Man Singh Medical College and group of hospitals over a period of 6 months from January 2013 to June 2013. The groups studied consists of 204 patients of mild and moderate TBI between 14 days and 1 year postinjury and equal number of controls by recruiting close relatives of the patients for comparison. Patients were assessed on semistructured sociodemographic proforma along with WHOQOL BREF, insomnia severity index, and GCS to assess QOL, insomnia, and severity of TBI, respectively. Result The number of participants included was 204. Mean age was 33.34 years. QOL was found impaired in all four domains of patients with TBI as compared with control group. The most unsatisfying domain among all was environmental health. None of the sociodemographic variables were associated with impaired QOL in TBI except duration and severity of head injury. Patients with longer duration (time since injury) of TBI and higher GCS had better QOL. Patients with insomnia had significantly poor QOL compared with those with TBI without insomnia. Conclusion QOL is an important aspect to be considered while management of TBI is performed especially during follow-ups. Impact of severity and the duration of injury with associated sleep problems have significant bearing on QOL.

Pituitary masses are common lesions accounting for about 15-20% of all brain tumours. Oozing blood is an annoyance in microscopic sublabial trans-sphenoidal approach for these masses. There have been many ways of reducing the ooze, having their own pros and cons.To find out the efficacy and safety of clonidine in reducing blood loss in pituitary adenoma surgery through a randomized masked trial.It was a prospective randomized controlled trial done. Total 50 patients of pituitary adenomas were randomized into two groups. Group A (25 patients) was given 200 μg clonidine orally, while Group B (25 patients) was given placebo. Surgeon, anaesthesiologist and patient were blinded for the trial. Sublabial trans-septal trans-sphenoidal approach to sella and excision of mass was performed in each patient. Patients were studied for pre-, intra- and post-operative blood pressure and heart rate, pre- and post-operative imaging findings, intra-operative blood loss, bleeding grading by surgeon, surgeon's satisfaction about condition of specific part and quality of surgical field, operative time and extent of resection.Blood loss during the surgery, operative time and bleeding grading by the surgeon were found significantly less in the clonidine group, while quality of surgical field, condition of the specific part and extent of resection were found significantly better in the clonidine group (p value .05). There was no untoward adverse effect of the drug in the test group.Clonidine is a safe and effective drug to reduce bleeding in trans-sphenoidal microscopic pituitary adenoma surgeries.

Animal bite injuries are common worldwide, but head injuries caused by animal bite is uncommon, and specially, head injuries caused by camel bite is further uncommon. Seriousness of head injuries depends on the size and shape of the teeth of animal. Camel bites causing depressed skull fracture with injury to the dura are extremely rare. Here, we present a case report of camel bite injury causing depressed fracture and dural tear.

Authors’ contributions This work was carried out in collaboration between all authors. Author Anand Sharma participated in the design of the study and performed the statistical analysis. Author Achal Sharma participated in the design and conception of the study and its coordination, acquisition of data, carried out statistical analysis and drafted the manuscript. Author AJ participated in the conception of the study and participated in the design of the study, acquisition of data and manuscript revision. Authors RSM and IDG participated in reviewing of article. All authors read and approved the final manuscript.

Bilateral thalamic infarction is rarely seen in cases with artery of Percheron embolization. Artery of Percheron is a rare variant of arterial supply to both thalamus and midbrain. Occlusion of this artery following trauma and causing bilateral thalamic infarction is rare and very few cases are reported in world literature.

Myelocystocele is a rare variety of spinal dysraphism that presents as a skin covered, midline, lumbosacral mass. Many a time it is associated with other congenital anomalies but isolated myelocystocele is rarely associated with neurological deficit. MRI is the modality of choice for preoperative diagnosis. A 3 years old female child presented with skin covered lumbosacral mass since birth. There was no associated neurological deficit. MRI revealed single cyst, which was continuous with central canal of spinal cord. Peroperatively, myelocystocele was found with tethering of cord. Untethering of cord and repair of myelocystocele was performed with uneventful recovery.

This study is designed to investigate prevalence and risk factors of insomnia in TBI. This study has also tried to explore the connection between insomnia with neuroanatomical localization of TBI as well as depression.Prospective study.All eligible participants were evaluated initially after two week interval for first 4 weeks and monthly interval subsequently till one year. Demographic and injury characteristics of the participants were assessed on a self-designed semi structured performa. Interviews focused on assessment of severity of TBI, insomnia and depression using GCS, ISI and PHQ-9 respectively.Total 204 patients were included, mean age was 33.34 years. 40.2% participants were found to have insomnia. None of the demographic variables were associated with insomnia except severity and duration of TBI. Moderate TBI patient (70.73%) had significantly higher occurrence of insomnia than the mild cases (19.67%) (P=0.000, df 1). First three month after TBI witnessed more than half (63.41%) of those patient who had insomnia. This was found statistically significant (P0.017). Neuroanatomical localization was also correlated with insomnia. Cerebral contusion was the most common (40.24%) site of impact. Almost half (42.42%) of the patients with insomnia had multiple contusions. 32.84% of the study population had depression. No significant correlation could be established between depression and insomnia.Insomnia is a prevalent condition after TBI requiring more clinical and scientific attention as it may have important repercussions on rehabilitation.

The incidence of the epidermoid tumor is approximately 0.2-1.8% of all intracranial tumors. Epidermoid tumors are typically intradural, but extra-axial in location and only rarely found within the brain substance. We are reporting the first case of incidental mixed density frontal epidermoid tumor in a patient of head injury. Difficulty in the preoperative diagnosis and uncommon presentation of the intracranial epidermoid tumor prompted us to report this case.

Aim: In this study, symptoms at presentation, indication for surgery, surgical treatment modalities, postoperative results and complications were studied. Material and methods: We retrospectively compiled the details of patients with IAC from admission and operative records admitted through our OPD during the period between January 1995 and January 2015. Only those patients were admitted whose symptoms attributes to the cyst and asymptomatic patients were followed on OPD basis. This is a single institutional study. Results: This study includes 56 patients of IAC who were operated. Posterior fossa cysts (62.5%) were found more commonly symptomatic. Headache (32%) was the most common symptom in a patient with IAC. Out of all, 24 patients presented with headache and underwent surgery subsequently; 20 showed satisfactory relief after surgery while four showed partial relief. Size of cyst was significantly reduced after surgery in 52 patients after 12 weeks but four patients, who underwent cystoperitoneal shunt, required re-operation as patients showed no decrease in size of cyst due to shunt malfunction. Head circumference was reduced following intervention in infant patients. Three patients who presented with visual field defects with IAC in sellar region showed improvement after endoscopic fenestration of cyst. One of the patient with cerebellopontine angle arachnoid was died immediately after marsupialization due to unexplained bleeding. Conclusions: IAC is not an uncommon finding on imaging but only few are symptomatic. Patients with Intracranial arachnoid cyst should be treated only if the patient’s symptoms are attributable to the cyst.

The cavum septum pellucidum (CSP) is defined as a crevice-like space of variable width between the left and right transparent septum. In this report, a rare case of pseudo primary abscess formed in the CSP due to ventriculitis is presented.

The growing skull fracture (GSF) occurs in younger age group as a sequel of trauma. The most common site of these lesions is parietal region. Here we are presenting a case of GSF of posterior fossa with cerebrospinal fluid (CSF) fistula. As per literature, we have not found a single case of GSF in the posterior fossa with CSF fistula. The aim of this presentation is discussing the unusual presentation of GSF and its management.

Introduction: Various studies have been carried out proposing the concept of knee spine syndrome measuring simultaneous changes in knee flexion and sacral inclination, but none regarding its management. Here in this study, we put forward the management and diagnostic algorithm for the knee and spine disease operated by the same surgeon. Materials and methods: This is a prospective study of 10 patients having knee spine syndrome operated by the same surgeon from January 2016 to January 2018. They were selected and treated as per the treatment protocol put forward and clino-radiological outcomes were evaluated with visual analog scale (VAS), oswestry disability index (ODI) scoring, and radiographs. Results: Age of the patients included in this study ranged from 55–80 years. In 6 patients, the spine was operated first and in others, knee replacement was done as an index procedure. Average pre-operative ODI score was 28.9 which decreased to 7.5 postoperatively at 2-year follow-up. VAS score decreased from 7.4 preoperatively to 1.5. Conclusion: Knee spine syndrome is one of those entities which need to be identified and treated as a whole and not as two different symptomatic diseases. According to our proposed algorithm, radicular symptoms (spinal pathology) should be treated first. In cases of predominant back pain which could be either due to loss of lumbar lordosis or precipitated by deformity caused by malalignment in osteoarthritis knee, knee replacement was considered first. Despite the proposed algorithm, the clinical acumen of the surgeon in determining the leading cause of morbidity may help prevent unnecessary further staged surgeries.

A composite type of SCM is very rare and only a few cases have been reported until today. The frequency of composite- type SCM is lower than 1% in the literature. In this report, we presented an unusual case of long segment composite type split cord malformation with double level bony spur with multiple associated bony anomalies.

Bilateral cerebellopontine angle (CPA) arachnoid cysts (ACs) are very rare: only one case is reported in literature. Pathogenesis of those cysts is unknown; they are thought to be congenital. The presenting symptoms of CPA AC are frequently nonspecific or otological. The management of ACs of the CPA is controversial. We are reporting two cases of bilateral CPA AC with their pathophysiology and review of literature.

Introduction: Traumatic brain injury (TBI) is a major cause of disability. Depression is one of the major squeal of TBI in both in-patient and out-patient populations. Depression is associated with numerous negative outcomes, thus affecting quality-of-life (QOL) adversely in these patients. Addressing depression in treatment regimen of TBI may improve QOL of these patients. Objective: The present study is designed to evaluate the role of sertraline in post TBI depression and its impact on QOL. Materials and Methods: Eighty male patients with post TBI depression were included in the study among the 250 male patients of mild to moderate TBI recruited for the evaluation. Half of the patients were given sertraline 50 mg PO, whereas other half served as control without sertraline treatment. Participants were assessed on Glasgow Coma scale, Patient Health Questionnaire-9 (PHQ-9) and World Health Organization QOL (WHOQOL) at regular interval till the end of 6 months. Result: Depression was found in 35.6% of total patients recruited. Most of the patients (63.1%) were below 35 years of age. Depression was more common in mild TBI cases than those with moderate TBI (53.7% vs. 46.25%, P = 0.04). Left side brain injury (56.25%) with cerebral contusions was more commonly associated with depression (P = 0.04). Patients in sertraline group responded well to treatment with significant improvement in mod symptoms (PHQ-9 score 14.88 ± 3.603 vs. 5.33 ± 2.98, P = 0.04)). All the four domains of QOL improved significantly in sertraline group than the control group with sertraline treatment. Conclusion: Management of TBI should also focus on treatment of associated mood symptoms, which is likely to be associated with poor QOL in these patients. Sertraline has been found to be effective in the treatment of depression with significant improvement in QOL in TBI patients.

Penetrating injury to the spine is the third most common cause of spinal injury. Injuries due to bullet, glass, nails and pencil injuries are well documented in literature. We report a rare case of delayed onset intramedullary abscess following thorn prick and have reviewed the literature for similar forms of injuries.

Although unilateral abducens nerve palsy has been reported to be as high as 1% to 2.7% of traumatic brain injury, bilateral abducens nerve palsy following injury is extremely rare. In this report, we present the case of a patient who developed isolated bilateral abducens nerve palsy following minor head injury. He had a Glasgow Coma Score (GCS) of 15 points. Computed tomography (CT) images & Magnetic Resonance Imaging (MRI) brain demonstrated no intracranial lesion. Herein, we discuss the possible mechanisms of bilateral abducens nerve palsy and its management.

Objective: Spinal intramedullary tuberculoma (SIMT) is rare, accounting for 2/100,000 cases of tuberculosis and only 0.2% of all cases of central nervous system (CNS) tuberculosis. We share our experiences of 11 cases of this entity for improving diagnosis and conceptualize the management of this rare disease. Methods: The clinical profile, radiological data and management of 11 cases of SIMT which were managed either conservatively or by surgical intervention during last 27 years (1987-2014) were analysed. Results: Male:female ratio was 1.75:1. Five cases had associated pulmonary Koch’s. Most common site was thoracic cord. Two cases had concurrent multiple intracranial tuberculoma. Most common presentation was paraparesis. X-ray myelography was performed in two patients in the initial period of study suggesting intramedullary pathology. In the subsequent nine cases who had magnetic resonance imaging (MRI), seven showed typical ‘‘target sign’’ and conglomerate ring lesion. Out of 8 surgically managed patients, 6 cases improved rapidly and in 2 patients gradual improvement was seen in follow-up. Most common indication of surgical excision was rapid neurological deterioration followed by diagnosis in doubt. Histopathology confirmed tuberculous etiology of the intramedullary lesion in all. Clinical and radiological improvement was seen in all 3 conservatively managed patients in follow-up. Conclusion: MRI findings of SIMT were specific and proven histologically correct. Surgical intervention may be indicated if there is no response to chemotherapy, the diagnosis is in doubt, or there is a rapid deterioration in neurological function because surgical outcome is good in these circumstances.

Background: Growing skull fracture (GSF)/pseudomeningocele is a rare complication of head injury in children. Post-traumatic intradiploic arachnoid cyst (PTIAC) is a variant but it is extremely rare. PTIACs are usually asymptomatic or with mild symptoms like headache. The rupture of PTIAC due to re-trauma leading to pseudomeningocele formation has not been seen or reported before. Patient and Method: We present a case of occipital PTIAC where pseudomeningocele developed after re-trauma, and discuss the pathogenesis and management. Result: En masse removal of the ruptured PTIAC was performed along with dural-defect repair. The post-operative recovery was good. Conclusion: PTIAC is an extremely rare occurrence as a variant of GSF. It is usually asymptomatic, but it may rupture with trivial trauma due to a thinned-out outer table and then converts into pseudomengocele. En masse excision with dural-defect repair gives good results in cases of ruptured PTIAC due to re-trauma.

Nasofrontal dermoid with sinus tract extending to the nasal tip is rare in adults. It is unique in its embryological origin, presentation, and management. Pathogenesis involves the incomplete obliteration of the developing neuroectoderm. A sinus opening with intermittent oily discharge is characteristic. Associated intracranial extension may lead to meningitis and brain abscess. We present a case of a 21-year-old adult having a nasofrontal sinus tract with intracranial extension who presented with recurrent episodes of meningitis and discuss the physical findings with relevance to embryology, elaborating on the importance and means of addressing the intracranial as well as extracranial components for complete treatment.

Lymphoplasmacyte-rich (LPR) meningioma is a rare variant of meningioma, which is characterized by conspicuous infiltration of plasma cells and lymphocytes and a variable proportion of meningothelial elements, and is classified as a grade I tumor in World Health Organization (WHO) classification of tumors of central nervous system. The origin and biological behavior of this rare variant of meningioma is still not clear. Till date, very few cases of LPR meningioma have been reported globally. Here, we are presenting a case of right parietal convexity LPR meningioma with invasion of bone in a 32-year-old male patient, who presented to us with complaints of focal seizures and weakness in left upper limb.