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Objective: Numerous classification schemes have been used for carotid cavernous fistula (CCF), each describing some aspect of the disease process but none of them provides a complete description of the fistula including its clinical features, natural history, arterial and venous architecture.Methods: Retrospective clinical and radiological review was done for all the patients diagnosed with CCF and treated at our institute. The CCF were classified according to the proposed API-ACE classification along with Barrow and Thomas classification.Results: Overall 28 patients (M=21, F=7) were diagnosed and treated during the 6-year period. 89.2% of CCF developed following an episode of head injury. Orbital symptoms were the most common presenting complaints. Barrows type A was the most predominant subtype (n=24) and most of the patients (n=23) demonstrated decreased ipsilateral carotid filling. Combined anterior and posterior drainage pattern was the most common drainage pattern and anterior drainage was more commonly observed than posterior drainage.Conclusions: API-ACE classification helps to better understand and classify the angioarchitecture of CCF which could help better understand the clinical manifestations and guide in appropriate endovascular approach selection for treatment.

Background Based on angiographic features, a rare subgroup, different from classical brain AVMs, called cerebral proliferative angiopathy (CPA) was suggested by Lasjaunias et al. in 1989. There are only few reports of CPA described from Asia. Liu et al. has described 5 cases of CPA from China. The objective of study was to evaluate the clinico-radiological features of patients with CPA in our cohort and to find out the differences between our study and the study by Lasjaunias and Liu et al. Methods We retrospectively analysed cases of CPA from March 2012 to April 2020. All radiological images of the patients with AVMs were studied and findings suggestive of CPA were identified. We found 10 patients with CPA out of 272 cases of AVM (10/272) and described the various demographic and clinico-radiological features. Results The age of the patients with CPA in our series varied from 14 to 53 years and the mean age was 28.6 years. There was male preponderance (60%) with male to female ratio of 3:2. The most common presentation was seizure (70%). Intracranial haemorrhage was present in five patients. One patient had cerebral infarction. Conclusions There were substantial differences in clinico-radiological profile of patients with CPA in our cohort as compared to the study by Lasjaunias et al. and Liu et al. in form of male dominance, higher rate of ICH and seizure. In our knowledge, this is the second largest series of CPA worldwide and the first largest series in Asia.

We are describing a case of a 14-year-old girl who developed acute cerebral infarction which was documented on diffusion-weighted magnetic resonance imaging (DWI). On detailed evaluation, diagnosis of cerebral proliferative angiopathy (CPA) was made. Incidentally, she had capillary malformation on the forehead contralateral to cerebral vascular malformation. To our knowledge, this is the first case of CPA in the literature where DWI abnormality was due to acute cerebral infarction.

Objective Pseudoaneurysms (PSAs) of the internal carotid artery (ICA) and vertebral artery are rare entities but with varied treatment options. PSAs can be spontaneous or secondary to trauma, infections, malignancies or iatrogenic. To find out the efficacy of various endovascular interventions in the management of ICA and vertebral PSAs. Methods The study included 14 patients diagnosed with intracranial PSAs who underwent endovascular interventions in SMS Medical College, Jaipur (Rajasthan) between June 2015 to January 2019. The clinical and radiological findings (computed tomography angiography and digital subtraction angiography) were reviewed and the consequent endovascular intervention carried out and their results were analyzed. Results Total 14 patients were studied out of which 8 (57.1%) were anterior circulation PSAs and 6 (42.9%) were posterior circulation PSAs There were 10 (71.4%) females and 4 (28.5%) males between the age of 9 to 65 years. Only 2 patients with PSA had past history of trauma. Coiling was done in 8 patients (57.1%), stenting in 2 patients (14.2%), parent artery occlusion in 1 patient (7.1%), glue embolization in 1 patient (7.1%) while coiling with glue in 1 patient (7.1%) and flow diverter in 2 patients (14.2%). Immediate and complete occlusion was achieved in 11 (78.6%) patients while 3 (21.4%) patients had subtotal occlusion. 11 patients under follow up till June 2019 did not report recurrence or new neurological deficit. Conclusions Endovascular interventions is minimally invasive and safe treatment strategy for intracranial PSAs. The ultimate choice of technique depends on clinical and imaging characteristics.

Traumatic spondylolisthesis of axis or hangman’s fracture is the second most common C2 vertebra injury. We present a report of a young man presenting with a history of fall from height with C2 to C3 spondylolisthesis without any evidence of injury to pars interarticularis but with associated injury to capsular ligament of facet joint along with posterior spinous ligamentous injury. The patient underwent intraoperative reduction in listhesis with posterior screw fixation. The patient showed uneventful postoperative course with neurological improvement at 6-week follow-up. Hangman’s fracture refers to a diverse group of injury in which the soft tissue injury has an equally important part to play as the bone fracture.

Background: Fungal infections of the central nervous system (CNS) usually present as subacute meningitis or intracranial space-occupying lesion with mass effect on surrounding structures and consequent focal neurological deficits. Intracranial fungal granulomas are often misdiagnosed clinically and radiologically as neoplastic lesions. Biopsy of the lesion is the only reliable technique to establish the correct diagnosis as well as to detect the causative fungal species. Voriconazole is a broad-spectrum triazole antifungal agent. It can be given orally and intravenously and has lesser adverse effects. Methods and Materials: In this article, we report a series of 6 cases of biopsy-proven fungal granuloma with varied clinical and radiological presentations who were given treatment with voriconazole for 6 months and demonstrated favorable response. Results: Out of 6 patients (4 males and 2 females), 1 was immunocompromised (DM with uncontrolled hyperglycemia). Headache was the most commonly observed symptom. Paranasal sinus and anterior cranial fossa were the most commonly affected site. Four patients received voriconazole therapy for 12 months and 1 received the same for 6 months before showing clinical resolution of disease. There was 1 death in the study group from non-related medical complications. Conclusion: Our series focuses on the correct diagnosis of fungal granuloma which can be achieved by biopsy and clinical evidence of the efficacy of voriconazole against intracranial fungal granuloma.

Mineral oil has been used as an insulating fluid in the power industry. However, surplus waste oil poses serious environmental threats because of disposal concerns. Waste to biofuel is an excellent way to deal with waste material from various sources. In this study, the trans-esterification method was utilised to convert the waste-insulating mineral oil into a quality bio-fuel. Waste-insulating transformer oil was converted to biodiesel, and it was tested according to ASTM standards. Four different blends of waste-insulating biodiesel with diesel in 25 per cent (WIOBD25), 50 per cent (WIOBD50), 75 per cent (WIOBD75), and 100 per cent fractions (WIOBD100), were used for performance testing in a direct injection compression ignition (DICI) engine. The combustion parameters such as BSFC, EGT, and BTE were evaluated with varying crank angles and constant engine speed. The waste-insulating biodiesel performance results are then compared with diesel fuel. BSFC increased as the biofuel mixture in diesel was raised, and the brake thermal efficiency (BTE) was significantly reduced compared to diesel for all WIOBD diesel mixtures. Due to the combustion process, a high pressure and heat release rate (HRR) were noticed inside the cylinder with the waste-insulating oil-derived biodiesel samples. WIOBD biodiesel blends produced lower levels of hydrocarbon, carbon monoxide, and smoke emissions than diesel fuel, but greater levels of nitrogen oxides (NOx) were produced than diesel fuel. In addition to lower emissions combined with improved engine performance, the WIOBD25 fuel blend has been found to be experimentally optimal for practical application. As a result, the test findings indicated that WIOBD biodiesel might be used as a substitute for conventional diesel fuel.

This paper mainly deals with the prevention of flutter instability in fin with shroud of a typical Rocket body through parametric studies. Flutter is an aeroelastic instability which occurs when aerodynamic loads cause deformation of the body which in turn initiates an oscillation in the body and further interacts with aerodynamics. The crew escape system is an emergency escape structure designed to swiftly pull the crew module along with the astronauts to a secure distance from the launch vehicle during launch abort. For the control of crew escape system during the ascent phase of trajectory, sweep back fins are used at the bottom of the vehicle. Finite element modelling of the fin was done using MSC/PATRAN software. Flutter analysis is carried out in MSC/NASTRAN using in-built aerodynamics. MSC/NASTRAN uses plate theories such as Doublet Lattice Method for subsonic Mach number, ZONA51 for transonic and low supersonic Mach numbers and Piston theory for high supersonic Mach numbers to generate the aerodynamic force within NASTRAN. MSC/PATRAN is a software developed to provide a systematic approach towards making finite element modeling fast and accurate; MSC/NASTRAN is a general purpose finite element analysis computer program that addresses a wide range of engineering problem and is also capable to focus on particular types of analysis. In this work, initially normal mode analysis was carried out for the modeled fin and flutter analysis was performed. It was observed that flutter instability occurred in most of the Mach numbers. In order to prevent flutter, the method of mass redistribution is adopted. Mass addition is carried out on leading edge and trailing edge to see the effect of movement of C.G with respect to the shaft axis. By carrying out various mass redistribution studies, the flutter instability in the fin is alleviated. This effort will be helpful for flutter prevention in control surfaces of upcoming vehicles also.

Modern aircraft structures uses more lightweight materials such as composites for their design. This makes the aeroelastic study an extremely important aspect of aircraft design. By having more light weight control surfaces, the control effectiveness study becomes vital in today’s scenario. Control effectiveness is the ability of a control surface such as an aileron or a rudder to produce aerodynamic forces and moments to change the airplane orientation and manoeuvre it along the intended flight path. This paper presents the static aeroelastic analysis of a typical reusable launch vehicle focusing on control effectiveness of elevon. A Reusable Launch Vehicle (RLV) is the space analogy of an aircraft. Ideally it takes off vertically on the back of a dispensable rocket and then glides back down like an aircraft. MSC PATRAN and MSC NASTRAN were the software’s used for Finite Element Modeling and Analysis. The main aim of the analysis is to compute the control effectiveness of launch vehicle along its trajectory to determine whether it is efficient to control the vehicle. The objectives of this work are, to study the control surface effectiveness of elevon by carrying out static aeroelastic analysis using NASTRAN inbuilt aerodynamics, for a typical Reusable Launch Vehicle (RLV).

Introduction The detachable balloons are not frequently used nowadays for endovascular occlusion of carotid-cavernous fistula (CCF) because of lack of availability and supposed high risk of recurrence. This study describes the various way of detachable balloon embolization for traumatic CCF. Materials and Methods We have used endovascular detachable balloon to occlude the traumatic CCF under local anesthesia in various ways in 12 traumatic cases of CCF from March 2013 to April 2015. Clinical and computed tomographic (CT) angiography follow-up was done at 6 and 12 months. Results Clinical follow-up from 6 to 12 month showed persistent resolution of symptoms in 10 cases; 2 cases had developed slight proptosis and chemosis. CT angiography done in nine cases after 6 to 9 months showed no residual filling in CCF. Conclusion The detachable balloon either single or double with or without coils can be used in the management of CCF by different methods. Detachable balloon is a cheaper alternative compared with coiling. It is technically easier to perform and can be performed under local anesthesia.

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.

MISME syndrome, also known as neurofibromatosis type-2 (NF2), stands for multiple inherited schwannomas, meningiomas, and ependymomas (MISME) in the peripheral and central nervous system. It is a rare disorder of autosomal dominant inheritance due to mutations of a tumor-suppressor gene on the chromosome 22q12. Clinically, it is characterized by multiple benign tumors arising in both the central and the peripheral nervous system, particularly from the bilateral vestibular nerve in more than 90% of the patients and more than two thirds of them develop spinal tumors. Simultaneous occurrence of bilateral vestibular schwanoma with cervical and lumbar ependymoma without neuro cutaneous marker with weakness of limb as initial presentation is rare finding in single patient. Here, we are reporting a rare case of MISME syndrome harbouring bilateral vestibular schwanoma with cervical and lumbar ependymoma tumors in a 45 year old male patient having no other lesion and neurocutaneous marker with weakness of limb as initial presentation without posterior subcapsular cataract.

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.

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.

Penetrating head injury is a life threatening condition. In the workplace, these are mostly non missile type, low velocity civilian injuries caused by sharp objects. Angle grinders are used to cut stones, metal etc, and cause penetrating head injuries due to shattered rotating discs from the grinder at home and workplaces. We report a series of three cases of penetrating head injuries due to unsafe use of angle grinders. The relevant literature is reviewed and management of such cases is discussed.

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].

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.

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.

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.

Background Dermatologic surgery requires precision and accuracy given the delicate nature of procedures performed. The use of the most appropriate instrument for each action helps optimize both functionality and cosmetic outcome. Objective To review the history of surgical instruments used in dermatology, with a focus on mechanism and evolution to the instruments that are used in current practice. Materials and methods A comprehensive literature search was conducted via textbook and journal research for historic references while review of current references was conducted online using multiple search engines and PubMed. Results There are a number of articles that review instruments in dermatology, but this article adds a unique perspective in classifying their evolution, while also presenting them as levers that serve to increase human dexterity during the course of surgery. Conclusion Surgical instruments allow fine manipulation of tissue, which in turn produces optimal outcomes. Surgical tools have been around since the dawn of man, and their evolution parallels the extent to which human civilization has specialized over time. This article describes the evolution of instruments from the general surgical armamentaria to the specialized tools that are used today.