Intraoperative electrocorticography-guided resection of the epileptogenic zone in an unusual porencephalic cyst: case report and literature review

Introduction

Porencephalic cysts resulting from perinatal artery infarctions typically manifest as large cysts accompanied by pre-existing neurological deficits. A small porencephalic cyst without any neurological deficit is a rare cause of medically refractory epilepsy.

Case presentation

A 23-year-old female presented with a history of medically refractory epilepsy secondary to a small right parieto-temporal porencephalic cyst. Despite optimal anti-seizure medications, seizures persisted. Surgical intervention was planned, and intraoperative electrocorticography (ioECoG) was used to delineate the epileptogenic zone (EZ), which was found to be two gyri posterior to the cyst.

Discussion

Very focal ischaemia resulting in a small porencephalic cyst from perinatal artery infarction exhibits a distinct organization of the EZ involving wider area posteriorly indicating involvement of arterial territory distal to the cyst. This contrasts with the typical perilesional EZ observed in other lesional epilepsy causes.

Conclusion

Our findings emphasize the need to consider aetiology during interpretation of ioECoG to better define the electrophysiological border between the normal and epileptogenic brain, aiding in achieving a better surgical outcome.

A case of intradural lumbar disc herniation

Key Clinical Message

MRI remains the best tool in the diagnosis of this disease entity however preoperative diagnosis remains a difficult task. A high degree of suspicion is raised when intraoperative findings and preoperative image description become incompatible.

Abstract

Lumbar disc herniation into the dural space is a rare phenomenon of lumbar disc degeneration with an unclear remaining pathogenesis. Intraoperative ultrasonography and histopathological examination of resected specimen help in the diagnosis of intradural disc herniation. Prompt surgery is recommended due to the high incidence of cauda equina syndrome.

Orbital Apex Syndrome caused by invasive aspergillosis in patient with post-Covid-19 infection - A case report

INTRODUCTION AND IMPORTANCE

Orbital Apex Syndrome (OAS) are characterized by multiple symptoms, such as impaired eye movement, periorbital pain, and visual disturbance. AS symptoms may be caused by inflammation, infection, neoplasm, or a vascular lesion, potentially involving a variety of nerves, such as the optic, oculomotor, trochlear or abducens, or the ophthalmic branch of the trigeminal nerve. However, OAS caused by invasive aspergillosis in post-COVID patient is a very rare phenomenon.

CASE PRESENTATION

A 43-year-old male with a history of diabetes mellitus and hypertension who had recently recovered from a COVID-19 infection developed blurred vision on the left eye field, followed by impaired vision on left eye field for 2 months then retro-orbital pain for a further 3 months. The blurring of vision and headache developed soon after recovering from COVID-19 and was progressive in left eye field. He denied any symptoms of diplopia, scalp tenderness, weight loss, or jaw claudication. The patient was treated with IV methylprednisolone for 3 days with as diagnosis of optic neuritis, followed by a course of oral corticosteroid therapy (prednisolone, starting at 60 mg for 2 days and then tapered for 1 month), which produced transient relief of symptoms that recurred when prednisone was discontinued. Then repeat MRI was perform with no evidence of lesion; treated again in a line of optic neuritis and symptoms relief transiently. After reoccurrence of symptoms repeat MRI was perform which showed a heterogeneously enhancing intermediate signal intensity lesion in the left orbital apex. The lesion was encasing and compressing the left optic nerve, without abnormal signal intensity or contrast enhancement within the left optic nerve either proximal or distal to the lesion. The lesion was contiguous with focal asymmetric enhancement in the left cavernous sinus. No inflammatory changes were seen in the orbital fat.

CLINICAL DISCUSSION

OAS due to invasive fungal infection is uncommon and most often caused by Mucorales spp., or Aspergillus, particularly in those with immunocompromising conditions or uncontrolled diabetes mellitus. In OAS due to Aspergillosis urgent treatment is necessary to avoid complications such as complete vision loss and cavernous sinus thrombosis.

CONCLUSION

OASs, represent a heterogenous group of disorders that results from a number of etiologies. OAS in a background of COVID-19 pandemic can be due to invasive Aspergillus infection as in our patient without any systemic illness and lead to miss diagnosis and delay in proper treatment.

Intra thecal baclofen pump as an ad hoc measure for a case of severe tardive dystonia refractory to multiple lesioning

Tardive dystonia is an infrequent ailment in patient reliant with chronic antipsychotic medication. The front-line envoy in the treatment of this illness is set into motion with oral agents including baclofen, benzodiazepines, and other antispasmodics. Regardless of an extensive therapy, the patients are not able to control of their spasticity/ dystonia. The authors reported a case of severe tardive dystonia treated with baclofen therapy in a patient frigid to medical therapy and multiple lesioning.

Case Report

A 31-year-old female, diagnosed as a case of depressive illness and being managed with neuroleptic medications, who went onto develop tardive dystonia progressively worsening over a 4-year duration. After a comprehensive and meticulous evaluation of her neurological and psychological stratum, globus pallidus interna lesioning was reputed as the best course of action. As intended, staged lesioning was executed bilaterally with a trivial resolution eventually succumbing into recurrence, compelling a repeat lesioning. It was inaptly discouraging to see her crippled with the plight. Determined, not to give upon her, a way out with a baclofen therapy was proposed. A test dose with a 100 mcg of baclofen with an increment up to 150 mcg over a 3-day period demonstrated a promising prospect. On that account, the insertion of the baclofen pump was performed with an outstanding aftermath in her neurological endeavor.

Clinical Discussion

Tardive dystonia is believed to be caused by striatal dopamine receptor super-sensitivity persuaded by the dopamine-antagonizing action of antipsychotic drugs. The first line of treatment being oral agents including oral baclofen, benzodiazepines, and antispasmodics. If the patient suffers from an early-onset primary generalized dystonia, then treatment with deep brain stimulation of the globus pallidus interna is the approved and preferred treatment approach. Recurrence of the symptoms despite of multiple lesioning can be overcome by intrathecal baclofen pump infusion as stated by many research. It is not uncommon to face complications in such a procedure, but the benefits outreach the risk, which makes it a choice of treatment.

Conclusion

The use of a continuous intrathecal baclofen pump for cases with tardive dystonia refractory to conventional therapy, it has been approved as one of the safest and capable procedures.

Euthanasia: Are we ready for it, or is it too late?

Euthanasia, also known as assisted suicide, is the act of intentionally ending the life of a person suffering from a terminal illness or incurable condition. The word "euthanasia" comes from the Greek words "eu," meaning "good," and "thanatos," meaning "death."1 Passive euthanasia entails the withholding treatment necessary for the continuance of life. Active euthanasia entails the use of lethal substances or forces (such as administering a lethal injection), and is more controversial. Euthanasia is a highly sensitive issue under scrutiny from medical, ethical, religious, cultural and socio-economic viewpoints.

Importance of Suspecting a Hemorrhagic Intracranial Lesion as Metastatic Choriocarcinoma

Though the brain metastasis from gestational trophoblastic neoplasia is rare, incidence is 3-21.4%. In this article, we report the rare case of a young female, presented with the features of raised Intracranial Pressure (ICP) with intracranial space occupying lesion, who was treated for tubercular abscess because she was clinically diagnosed as case of pulmonary TB from core biopsy of lung mass and was under Anti tubercular treatment at other center and the differential diagnosis of cavernoma bleed made from imaging modalities. However, to our surprise the histopathology came out as metastatic choriocarcinoma. There was history of incomplete abortion 1 year back which could have developed from any gestational trophoblastic tissue resulting from a hydatidiform mole, miscarriage, or ectopic pregnancy.  She gave this history after the histopathology came out as metastatic choriocarcinoma. The social tabu and going through traumatic experience, would be the region for her not to disclose the history before surgery. Although miscarriages are common and women continue to suffer in silence. The rarity of brain metastasis from gestational trophoblastic neoplasia, there are still no guidelines on treatment strategies for these patients yet.

Cervical vagal schwannoma, a rare differential of a neck swelling: A case report

Cervical vagal schwannoma is a rare clinical entity that requires a different clinical approach than other neck swellings. Magnetic resonance imaging is the preferred initial diagnostic test. Complications may arise due to vagal stimulation in unsuspecting open biopsies. Surgical excision with perioperative vagal monitoring is recommended for the treatment of vagal schwannomas.

Venture of a Tertiary Care Neurosurgical Center in Course of COVID-19 Lockdown without RT-PCR

“I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.” Obliged by the aforementioned oath, no medical practitioner shall sit in a moral judgment on any patient but will treat their illness to the best of their ability whatever the circumstances. A clear concord was yet to be authorized after the World Health Organization (WHO) declared the global pandemic of severe acute respiratory syndrome coronavirus 2infection. As a diagnostic modality, WHO recommended real-time reverse transcription–polymerase chain reaction (RT-PCR) as a reliable test; however, its availability in a deprived nation like ours became a major restraining factor. Despite an asset of having high specificity, RT-PCR for coronavirus disease 2019has its own liability of having low sensitivity. Henceforth, as time passed by, the validity of the rapid diagnostic tests was put into question. In later months, a few centers around our periphery started conducting RT-PCR, but the time taken to obtain the result was long-drawn-out process and the patient who needed urgent neurosurgical intervention at Annapurna Neurological Institute and Allied Sciences had to wait. We would like to share our expedition through peaks and valleys of managing 215 patients during the vicious circle of lockdown and global pandemic.

Surgical Management among Patients with Spontaneous Supratentorial Intracerebral Haemorrhage Admitted in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Spontaneous intracerebral haemorrhage is the second most common form of stroke and the most deadly one. An understanding of changing trends in the epidemiology of intracerebral haemorrhage prevalence, its risk factors, current practice in management, case fatality, and long-term outcome is essential to measure the effectiveness of stroke prevention and various treatment efforts. The objective of this study was to find out the prevalence of surgical management among patients with spontaneous supratentorial intracerebral haemorrhage in a tertiary centre.

Methods

A descriptive cross-sectional study was conducted in the Department of Neurosurgery from January 2017 to December 2019. Ethical approval was obtained from the Institutional Review Committee (Reference number: 06/2020/IRC-ANIAS). A convenience sampling method was used. Data of the patients were retrieved from online medical records. Point estimate and 95% Confidence Interval were calculated.

Results

Among 221 patients with spontaneous supratentorial intracerebral haemorrhage, 115 (52.04%) (45.45-58.63, 95% Confidence Interval) underwent surgical management. In-hospital mortality was seen in 23 (20%) and survivors at 3 months were 78 (67.82%) patients.

Conclusions

The prevalence of surgical management among spontaneous supratentorial intracerebral haemorrhages was higher than in other studies done in a similar setting.

Keywords

intracerebral haemorrhage; mortality; surgical procedure.

An eminent rendezvous with a series of cranial vault remodeling for Craniosynostosis

In defiance with the meager tally of craniosynostosis, the surgical treatment of non syndromic craniosynostosis is one of the most common stratagem detained by craniofacial surgeon. By dint of the onerous anatomy secondary to the imperfection in embryogenesis, a long haul of drill is required to obtain perfection in surgical sequel.1  With the advancement in neurosurgical gadgetry and improvement in agility of neurosurgical authority, a multitude of strategy has evolved over time with the eminent intent to bring forth the supreme aftermath. Browsing through the archives of craniofacial reconstruction discloses vault remodeling techniques evolving over time with disparate modification tactics to the inception of state-of-the-art strategies like endoscopic suturectomy, spring treatment and cranial vault distraction osteogenesis.2 Regardless of all these alternatives, we still resort to the standard cranial vault remodeling with a fairly approving outcome. We herein attempt to disclose our result of vault remodeling in a series of patients with craniosynostosis.

Unusual case of spontaneous bilateral basal ganglia bleed

Hypertension is the most prevalent determinant condition embarking on the development of spontaneous intracerebral hemorrhage. Usually, the presentation is a unilateral hematoma. Spontaneous bilateral intracerebral hemorrhage is an outstandingly infrequent context, and not a lot of cases have been reported till date. Ensuing hypertension, trauma inflicted on the brain case is another common cause that out turn into the sequelae of bilateral intracerebral hemorrhage. Lately, a few cases of bilateral basal ganglia bleed have been revealed, as a repercussion of COVID‐19 infection. Globally, <40 such cases have been reported. A 39‐year‐old man presented with complaints of acute onset of weakness of right half of the body. Additionally, facial deviation was noticed by his family members. He then sought medical help from a local healthcare center where CT scan of head was advised. Unexpectedly, the scan demonstrated bilateral intracerebral hemorrhage. He was then managed conservatively with oral medications and rehabilitation. The course of his hospital stay was uneventful and was eventually discharged after 9 days. He then presented to our institution for further evaluation. Thereupon, he had slurring of speech but was able to walk with minimal support. Simultaneous Bilateral Basal Ganglia Hemorrhage (SBBGH) is an exceptionally rare ailment. This genre of cerebrovascular accident embraces a comprehensive span of morbidity and mortality. In an acute setting, CT scan of head is the most relevant imaging modality. Nonetheless, MRI is the gold standard for definitive diagnosis and should be performed urgently to further typify and delineate the lesion.

Cerebral venous sinus thrombosis as a complication of COVID-19 infection – A case report

Introduction and importance

Severe acute respiratory distress syndrome coronavirus 2 is the causative agent of COVID-19 (Coronavirus 2019) infection. Although symptoms are usually associated with the respiratory system, its neurological involvement should not be underestimated. The most common cerebrovascular complication following the infection is ischemic stroke however, CVST (Cerebral Venous Sinus Thrombosis) has been reported.

Presentation of case

We report a unique case of a young patient who had a history of headache and abnormal body movement immediately after COVID-19 infection. His brain Computed tomography scan and Magnetic Resonance Imaging (MRI) showed typical images of CVST. He was admitted and treated with Low Molecular weight heparin.

Discussion

CVST is a rare form of stroke which may have devastating complications. The diagnosis is clinically challenging due to its non-specific presentation like headache and altered sensorium alone. Inflammatory process and hypoxic state after the virus infection may favor the hypercoagulable state in CVST. Our patient did not have any other predisposing factor for a hypercoagulable state other than the COVID-19 infection.MRI and venography and computed tomographic venography are the preferred modalities. The Patient is generally treated with anticoagulation therapy.

Conclusion

High index of suspicion of CVST is necessary when a patient presents with unexplained neurological manifestation following a recent COVID-19 infection to prevent from life-threatening complications. Furthermore, clinicians should not underestimate the multisystem involvement of COVID-19.

•

COVID-19 infection usually manifests with respiratory symptoms however, neurological manifestations have been commonly reported.

•

CVST is one of the rare neurological manifestations which can present any time during COVID-19 infection or even present as a late complication after resolution.

•

The venous sinus thrombosis is more prone in patients who have a history of severe COVID-19 infection; therefore, an association of this disease can further worsen the patient's condition.

•

We aim to address that the neurological manifestation of COVID-19 may be unexpected, which may cause a delay in diagnosis and treatment.

Ganglioglioma Arising from the Septum Pellucidum

A 24-year-old gentleman presented to us with complaints of occasional headache for 2 years. Magnetic resonance imaging showed enhancing supra sellar mass with nonenhancing cystic components, extending superiorly up to the body of bilateral lateral ventricle, laterally displacing septum pellucidum, and compressing the third ventricle with obstructive hydrocephalus. Hormone profile depicted adrenocorticotropic hormone <5.00 pg/mL, growth hormone 1.32 ng/mL, insulin-like growth factor-1 <3.0 ng/mL. The patient underwent surgical resection. Histological finding was suggestive of ganglioglioma World Health Organization grade I. Customized immunohistochemistry panel was advised and revealed positive CD 56, NSE, and GFAP immunohistochemical stains. Gangliogliomas are less frequent neoplastic lesions confined to only a handful of case reports and studies. Accounting less than 2% of intracranial neoplasms, these lesions primarily affect those in the first 3 decades of their life. As ubiquitous it is in nature, we hereby present a case of ganglioglioma in a young adult male arising from septum pellucidum.

Study into the spread of heat from thermo-optic silicon photonic elements

Phase modulators based upon the thermo-optic effect are used widely in silicon photonics for low speed applications such as switching and tuning. The dissipation of the heat produced to drive the device to the surrounding silicon is a concern as it can dictate how compact and tightly packed components can be without concerns over thermal crosstalk. In this paper we study through modelling and experiment, on various silicon on insulator photonic platforms, how close waveguides can be placed together without significant thermal crosstalk from adjacent devices.

A case report of multiple isolated intradural neurocysticercosis of the lumbo-sacral spine

INTRODUCTION AND IMPORTANCE

Neurocysticercosis is the most common parasitic infection of the nervous system and it is mostly intracranial. Intradural intramedullary or extramedullary is the rarest involvement of intraspinal cysticercosis. Its isolated involvement is even rare, as it usually has intracranial association. We aim to report a rare case of isolated intraspinal neurocysticercosis and discuss the measures we can take for early management. Despite being an eradicable disease of public health importance, its prevalence is increasing widely in developed countries too. Therefore, we aim to discuss its pathogenesis, mode of spread, and preventive aspects as well.

PRESENTATION OF CASE

A 40-year-old woman presented to our hospital with pain over the lower back region radiating to the right thigh. Magnetic Resonance Imaging (MRI) of her lumbosacral spine revealed a cystic lesion at the spinal level L5-S1. We confirmed the diagnosis via Histopathological examination (HPE) following surgery.

DISCUSSION

Isolated intradural neurocysticercosis of the spine is extraordinarily rare involvement. It is caused by the larval stage of taenia solium. An MRI is the preferred imaging modality. Due to rarity and nonspecific clinic-radiological findings, diagnosis may often be missed. In our case, MRI revealed a cystic lesion at the L5-S1 level of the spine and multiple cystic lesions at the level were found intra-operatively. Its diagnosis is confirmed by HPE. Treatment can be medical or surgical according to the severity of the disease.

CONCLUSION

Although rare, neurocysticercosis can cause irreversible neurological damage. Therefore, surgeons should consider it in the differential diagnosis of intraspinal lesions.

Carotid stenting in Nepal: Our experience with two cases of carotid stenosis

Carotid artery stenosis is one of the important risk factors for stroke. Carotid endarterectomy and carotid artery stenting are the available treatment options for managing carotid artery stenosis patients. The technology shift towards carotid artery stenting is promising due to its less invasive approach. Carotid artery stenting has become an alternative for surgically high-risk patients and high carotid lesions (lesions located at or above the second cervical vertebra). Here, we present two cases with carotid artery stenosis who were successfully treated with open-cell type carotid stent with distal filter embolic protection device.

A case of postpartum chronic subdural hematoma

Headache is a common presentation during postpartum period. Anesthesiologist, obstetrician, and neurosurgeon should be aware of the possibility of subdural hematoma in patient complaining of headache following spinal anesthesia.

A Case of Sellar/Suprasellar Neurocysticercosis Mimicking a Craniopharyngioma

Neurocysticercosis (NCC) commonly presents with seizures in developing countries such as Nepal. It may also present with raised intracranial pressure due to obstructive hydrocephalus when cyst is located in the fourth ventricle or foramen of Monro. There are four main stages of NCC (1) Vesicular, (2) Colloidal vesicular, (3) Granular nodular, and (4) Nodular calcified. The colloidal vesicular stages can cause arachnoiditis and thus can cause hydrocephalus whereas obstructive hydrocephalus is usually caused by racemose type of NCC. This case was a suprasellar cyst mimicking craniopharyngioma, supported with clinical history of poor visual acuity, endocrine abnormality, suggested radiological findings by computed tomography scan, and magnetic resonance imaging. Suprasellar NCC was confirmed only by intraoperative findings and histopathology report.

Prevalence of Anxiety and its Associated Factors Among Patients Admitted at a Tertiary Neurosurgical Center in Kathmandu, Nepal

Introduction: The co-existence of anxiety disorders in patients with neurological and neurosurgical disease is in association with barriers to treatment and worsening medical outcomes. This study aims to identify the prevalence and correlation of anxiety in a tertiary neurological center in Kathmandu, Nepal.  Methods: This was a hospital-based cross-sectional study conducted at a tertiary neurological center in Kathmandu in patients undergoing major neurosurgical procedure. A semi-structured questionnaire including socio-demographic characteristics and medical history were used to collect data. Nepali translated Hospital Anxiety Scale, AUDIT, and Fragesterum Questionnaire were used to assess the anxiety level, alcohol dependence and tobacco dependence among the participants respectively. Chi-square tests and multiple logistic regression were used to test the association of anxiety with independent variables. Results: A total of 260 patients participated in this study with the mean age of 45.7 ( SD 17.9) years. Out of total participants, 174 (66.9%) were found to have anxiety. Anxiety was found to be associated with older age group (OR=0.333, 95% CI=0.19-0.58), low education level (OR=2.176, CI=1.28-3.70) and presence of at least one chronic disease other than neurological condition (OR=2.034, 95% CI=1.14-3.63). Conclusions: This study revealed a high prevalence of anxiety in patient who are undergoing neurosurgical procedure. The need for a focused approach to mental health care within the hospital should be implemented with a friendly environment making better relationships between patient and healthcare staff.

Customized Cost-Effective Polymethyl-Methacrylate Cranioplasty Implant Using Three-Dimensional Printer

There is no doubt that many synthetic materials used in cranioplasty have given good result regarding patient's calvarial shape. However, the use of these materials is costly to the patient and requires complex intraoperative process. There has been a long history regarding the use of acrylic bone cement called as polymethyl-methacrylate (PMMA) as an implant due to its desirable properties. Here, we present three cases of simple, cost effective manually sculpted calvarial defect using three-dimensional (3D) printer. Sharing the achievement and challenges, we want to focus that the 3D customized implant of PMMA can be used as bone substitute.

Digital Subtraction Angiography a Door Opener for Neurosurgical Residents who want to Perform Neurointerventional Procedures

Digital subtraction angiography (DSA) has been a fluoroscopic golden investigative tool to know the vascular angiography of the brain and spinal cord. The technique in performing this procedure exposes residents in accessing the major vessels, branches of the arch of aorta, selective angiography and diagnosing different vascular anomalies of brain and spine. They are also exposed to the knowledge of different diagnostic catheters, its manipulation, use of dye and radiation exposure and safety. We would like to share our experience in training and disseminating the knowledge of digital subtraction angiography to the residents.

Antioxidant, anticancer and antimicrobial effects of In vitro developed protocorms of Dendrobium longicornu

In vitro seed germination and protocorms formation were successfully established in traditionally used Dendrobium longicornu. Fresh protocorms (178.34 g - 183.90 g) were produced on the elicitor of Alternaria sp, Bacillus subtilis and Fusarium solani supplemented MS-medium. Methanol extract of D. longicornu protocorms has scavenged 94.31 % of DPPH radicals at 1000 μg/mL. Its 117.56 μg/mL concentration has scavenged 50 % DPPH radical (IC50). Similarly, it inhibits 25.39 % and 27.80 % HeLa and U251 cells at 500 μg/mL. The IC50 was found as 350.06 μg/mL and 507.22 μg/mL for HeLa and U251 cells respectively. Further, it inhibited the growth of E. coli, K. pneumoniae and E. cloacae with the zone of inhibition 4, 2 and 2 mm respectively. In conclusion, protocorms developed through in vitro seeds culture have accumulated and synthesized bioactive secondary metabolites. Therefore, protocorms could be utilized to the isolation of compounds for formulation of herbal drugs without damaging natural populations.

Study of anterior commissure-posterior commissure distance among Nepalese cohort

Introduction:

The main aim of this study is to determine the anterior commissure-posterior commissure (AC-PC) distance in Nepalese cohort and has comparison of intercommissural distance of Nepalese cohort with some other races.

Materials and Methods:

The 47 patients, with mean age of 50 years, included in the study had undergone DBS or lesioning (Pallidotomy). Data were collected through the magnetic resonance imaging under DBS protocol and the manipulation, marking of AC and PC was done in Inomed Planning Software (IPS).

Results:

The data revealed average AC-PC distance of Nepalese cohort to be 24.86 ± 2.08 mm, ranging from 16 mm to 30 mm. The study among 29 males and 18 females illustrated male to have longer AC-PC as compared to female (25.38 mm male and 24.02 mm female). The results also confirmed age related changes in AC-PC distance which was linearly increasing with the age.

Conclusion:

Comparison of data from other studies revealed Nepalese cohort to have almost similar AC-PC distance with Asian population, while that was longer in Caucasian and shorter in Hispanic Population.

Remote Cerebellar Hemorrhage after Removal of Large Convexity Meningioma

Remote cerebellar hemorrhage is a rare postoperative complication. It can occur after infratentorial or supratentorial craniotomies, later being more common. Remote cerebellar hemorrhage is considered to be a self-limited and benign condition. The exact pathophysiology of remote cerebellar hemorrhage remains unclear, but reports have suggested an association with excessive loss of cerebrospinal fluid. We report a case of remote cerebellar hemorrhage after supratentorial craniotomy for large convexity meningioma without excessive loss of cerebrospinal fluid.

Organizing a Medical Conference: Management Perspective

It is an incredibly formidable as well as meritorious task to plan and implement a successful medical conference. Organizing a medical conference requires a tremendous amount of planning, preparation, lots of pre conference works, and working on logistics to achieve its vision and goal. The two most important aspects for the success of any event is planning and implementation which requires a plenty of brainstorming sessions and meetings, and for medical practitioners and academicians, we are confronted with the dual role of organizing the conference as well as regular work juggling. Despite the fact that medical conferences play a major role in ongoing professional development, academic growth, and networking, there is little guidance in form of literature for those who want to hold a  conference inbound or outbound. This paper seeks to incorporate all the possible steps, plans and procedures in order to organize a successful conference. 

Epidemiology and Pattern of Traumatic Brain Injuries at Annapurna Neurological Institute & Allied Sciences, Kathmandu, Nepal

BACKGROUND

Traumatic brain injury (TBI) constitutes a major health and socioeconomic problem worldwide. It represents the greatest contribution to death and disability among all trauma-related injuries globally. TBIs are a leading cause of death and disability in Nepal, despite improvements in safety regulations and implementation of strict drunk driving laws. We describe the epidemiology of patients with TBI following admission to our hospital. We discuss the implementation of specific strategies to reduce its incidence.

METHODS

We conducted a retrospective cross-sectional study of patients presenting to Annapurna Neurological Institute & Allied Sciences (ANIAS), Kathmandu, with a TBI between September 2018 to September 2019.

RESULTS

One-hundred and sixty-seven patients presented with a TBI. The most common age groups were younger than 15 years old and 15-25 years old, and the majority were male (73%). The commonest cause of TBI was road traffic accidents (RTA) (59%). Drivers riding motorcycles were the predominant mechanism of RTA (38%). Helmet use was seen in 57% of patients riding 2-wheelers. Alcohol consumption was reported in 22% of all patients. Skull fractures were the most common diagnosis. Most patients were managed conservatively (84%).

CONCLUSIONS

TBI should be recognized as an important public health problem in Nepal. TBI is responsible for a considerable number of neurosurgical admissions to ANIAS. Our study showed patients most vulnerable to TBI are males younger than 25 years old. The implementation of stricter traffic rules and regulations, helmet law enforcement, and public education programs may be helpful in decreasing the number of TBI.

Cytotoxic effect of selected wild orchids on two different human cancer cell lines

Majority of the orchid species are used in the traditional medicines for the treatment of several diseases. They are the sources of polysaccharides, phenanthrenes, bibenzyl derivatives, revesteral, stilbenoids and polyphenol compounds. This study explored the cytotoxic activity of seven wild orchid species and identification of medicinally active compounds. The extracts of orchid species were screened for cytotoxic effect on the human cervical cancer cells (HeLa) and human glioblastoma cells (U251) using an MTT assay. The medicinally active compounds of high cytotoxic extracts were identified by GC-MS resulting in many stilbenoids and phenolic derivatives. The extract of Dendrobium transparens (DTs) and Vanda cristata (VCw) showed high cytotoxic effect towards the HeLa and U251 cell lines (IC50 of DTs: 382.14 μg/ml and 75.84 μg/ml respectively and IC50 of VCw: 317.23 μg/ml and 163.66 μg/ml respectively). This study concludes that they could be used as cancer therapeutics.

Extradural Hydatid Cyst of the Lumbo-Sacral Spine

Primary spinal hydatid cyst is a rare and uncommon entity but a significant manifestation of hydatid disease. Here, we report a case of primary extramural hydatid cyst of the sacral region causing cord compression. Pre-operative differential diagnosis was that of Tarlov cyst owing to the radiological appearance and location of the cyst. The diagnosis of hydatid cyst was established intra-operatively which was later confirmed by histopathology report. Hydatidcyst may not fall under differential diagnosis of extramural lesions of the spine due to its rarity but should be kept under high suspicion in endemic countries.

A Case Report of Lhermitte-Duclos Disease in a 10-Month-Old Child Presenting with Hydrocephalus

Lhermitte–Duclos Disease is a rare entity characterized by diffuse or focal enlargement of cerebellar folia. Clinical manifestations are usually related to a mass effect and secondary obstructive hydrocephalus. Increased intracranial pressure symptoms and cerebellar symptoms are the most frequent patient complaints. We present a 10-month-old male child with his mother who presented to the outpatient department with complaints of enlargement of size of head since the last one week. Magnetic Resonance Imaging scan revealed the features of Lhermitte–Duclos Disease involving the right cerebellar hemisphere with marked post contrast gyral enhancement. He underwent endoscopic third ventriculostomy. Lhermitte–Duclos Disease is very rare in early childhood and should be considered in the differential diagnosis of posterior fossa lesions.

Organizing a Health Camp: Management Perspective

Health camps or outreach clinics are the effective strategies adopted by both government and non-government organizations, associations, and societies with various interests and scope. A well-organized health camp with a concentration on the various principles of planning, coordination, collaboration, tools, and techniques will not only make the health camp successful but also aids in improving the health status of the unreached community who are often deprived of basic to advance health care facility due to different circumstances.

Fungal Planet description sheets: 868-950

Novel species of fungi described in this study include those from various countries as follows: Australia, Chaetomella pseudocircinoseta and Coniella pseudodiospyri on Eucalyptus microcorys leaves, Cladophialophora eucalypti, Teratosphaeria dunnii and Vermiculariopsiella dunnii on Eucalyptus dunnii leaves, Cylindrium grande and Hypsotheca eucalyptorum on Eucalyptus grandis leaves, Elsinoe salignae on Eucalyptus saligna leaves, Marasmius lebeliae on litter of regenerating subtropical rainforest, Phialoseptomonium eucalypti (incl. Phialoseptomonium gen. nov.) on Eucalyptus grandis × camaldulensis leaves, Phlogicylindrium pawpawense on Eucalyptus tereticornis leaves, Phyllosticta longicauda as an endophyte from healthy Eustrephus latifolius leaves, Pseudosydowia eucalyptorum on Eucalyptus sp. leaves, Saitozyma wallum on Banksia aemula leaves, Teratosphaeria henryi on Corymbia henryi leaves. Brazil, Aspergillus bezerrae, Backusella azygospora, Mariannaea terricola and Talaromyces pernambucoensis from soil, Calonectria matogrossensis on Eucalyptus urophylla leaves, Calvatia brasiliensis on soil, Carcinomyces nordestinensis on Bromelia antiacantha leaves, Dendryphiella stromaticola on small branches of an unidentified plant, Nigrospora brasiliensis on Nopalea cochenillifera leaves, Penicillium alagoense as a leaf endophyte on a Miconia sp., Podosordaria nigrobrunnea on dung, Spegazzinia bromeliacearum as a leaf endophyte on Tilandsia catimbauensis, Xylobolus brasiliensis on decaying wood. Bulgaria, Kazachstania molopis from the gut of the beetle Molops piceus. Croatia, Mollisia endocrystallina from a fallen decorticated Picea abies tree trunk. Ecuador, Hygrocybe rodomaculata on soil. Hungary, Alfoldia vorosii (incl. Alfoldia gen. nov.) from Juniperus communis roots, Kiskunsagia ubrizsyi (incl. Kiskunsagia gen. nov.) from Fumana procumbens roots. India, Aureobasidium tremulum as laboratory contaminant, Leucosporidium himalayensis and Naganishia indica from windblown dust on glaciers. Italy, Neodevriesia cycadicola on Cycas sp. leaves, Pseudocercospora pseudomyrticola on Myrtus communis leaves, Ramularia pistaciae on Pistacia lentiscus leaves, Neognomoniopsis quercina (incl. Neognomoniopsis gen. nov.) on Quercus ilex leaves. Japan, Diaporthe fructicola on Passiflora edulis × P. edulis f. flavicarpa fruit, Entoloma nipponicum on leaf litter in a mixed Cryptomeria japonica and Acer spp. forest. Macedonia, Astraeus macedonicus on soil. Malaysia, Fusicladium eucalyptigenum on Eucalyptus sp. twigs, Neoacrodontiella eucalypti (incl. Neoacrodontiella gen. nov.) on Eucalyptus urophylla leaves. Mozambique, Meliola gorongosensis on dead Philenoptera violacea leaflets. Nepal, Coniochaeta dendrobiicola from Dendriobium lognicornu roots. New Zealand, Neodevriesia sexualis and Thozetella neonivea on Archontophoenix cunninghamiana leaves. Norway, Calophoma sandfjordenica from a piece of board on a rocky shoreline, Clavaria parvispora on soil, Didymella finnmarkica from a piece of Pinus sylvestris driftwood. Poland, Sugiyamaella trypani from soil. Portugal, Colletotrichum feijoicola from Acca sellowiana. Russia, Crepidotus tobolensis on Populus tremula debris, Entoloma ekaterinae, Entoloma erhardii and Suillus gastroflavus on soil, Nakazawaea ambrosiae from the galleries of Ips typographus under the bark of Picea abies. Slovenia, Pluteus ludwigii on twigs of broadleaved trees. South Africa, Anungitiomyces stellenboschiensis (incl. Anungitiomyces gen. nov.) and Niesslia stellenboschiana on Eucalyptus sp. leaves, Beltraniella pseudoportoricensis on Podocarpus falcatus leaf litter, Corynespora encephalarti on Encephalartos sp. leaves, Cytospora pavettae on Pavetta revoluta leaves, Helminthosporium erythrinicola on Erythrina humeana leaves, Helminthosporium syzygii on a Syzygium sp. bark canker, Libertasomyces aloeticus on Aloe sp. leaves, Penicillium lunae from Musa sp. fruit, Phyllosticta lauridiae on Lauridia tetragona leaves, Pseudotruncatella bolusanthi (incl. Pseudotruncatellaceae fam. nov.) and Dactylella bolusanthi on Bolusanthus speciosus leaves. Spain, Apenidiella foetida on submerged plant debris, Inocybe grammatoides on Quercus ilex subsp. ilex forest humus, Ossicaulis salomii on soil, Phialemonium guarroi from soil. Thailand, Pantospora chromolaenae on Chromolaena odorata leaves. Ukraine, Cadophora helianthi from Helianthus annuus stems. USA, Boletus pseudopinophilus on soil under slash pine, Botryotrichum foricae, Penicillium americanum and Penicillium minnesotense from air. Vietnam, Lycoperdon vietnamense on soil. Morphological and culture characteristics are supported by DNA barcodes.

Hypophonia as only presenting symptom in myasthenia gravis - a diagnostic dilemma in poor countries: a case report

INTRODUCTION

The autoimmune disease myasthenia gravis can mimic a variety of neurological disorders leading to a delay in diagnosis and treatment. In the older population, due to confusion with signs of the ageing process or comorbidities due to ageing, there are many underdiagnosed or misdiagnosed cases of myasthenia gravis. A majority of myasthenia gravis symptoms appear as ocular or motor symptoms and there are very few cases of bulbar symptoms. We present a case of myasthenia gravis with only hypophonia as a clinical feature.

CASE PRESENTATION

We present a case of a 51-year-old Madheshi woman whose only complaint was sudden onset of hypophonia which later showed a fluctuating nature throughout the daytime. There was only reduced pitch in her voice with no nasal tone or dysarthria (so-called dysphonia), which created a diagnostic dilemma. Later, a neurological examination and other relevant investigations suggested myasthenia gravis.

CONCLUSIONS

Sudden onset and focal neurological deficit can raise the diagnostic dilemma of myasthenia gravis. Relevant laboratory tests and clinical examinations are important to diagnose this disease properly. In resources-deprived nations like Nepal, where several investigations are expensive and access to them is difficult, it becomes very difficult to achieve a solid diagnosis for rare presentations of diseases.

Abstract WP570: Associations Between Stroke Symptoms and Cognition in Nepal

Introduction: Low and middle income countries have the largest burden of stroke, accounting for more than 85% of stroke deaths globally. As many low- and middle-income countries, including Nepal, transition from communicable to non-communicable diseases (NCDs), the impact of stroke on cognition becomes increasingly important.

Methods: Data on cardiovascular risk factors and cognition were collected as part of the Dhulikhel Heart Study, a longitudinal study to evaluate risk factors for heart disease and stroke in Dhulikhel, a community outside of Kathmandu, Nepal. In Phase 1 of the baseline exam, 252 randomly-selected adults age 50 and older completed the Mini-Mental Exam (MMSE) and Digit Spans ( DST) forward and backward as part of a home interview. Mild stroke symptoms were collected by self-report the Questionnaire for Verifying Stroke-Free Status (QVSFS). Multiple linear regression evaluated associations between stroke symptoms and cognition adjusted for demographics (age, sex, education, religion, and ethnicity) and CVD risk factors (smoking, exercise, BMI, blood pressure, hypertension, and diabetes).

Results: Mean age of study participants was 62.4 years (SD 9.2) and 57.5% were women. The mean MMSE score (weighted for illiteracy) was 18.7 (SD 6.4) and 19% reported to have had at least one of five stroke symptoms (sudden one-sided numbness or weakness, sudden vision-loss, inability to express oneself or inability to understand). An increased risk of lower memory score was found with report of a previous episode of numbness (DST backward: B=-1.17, SE=0.34, p=0.001). Borderline associations (.05 < p<.10) were found between any stroke symptoms and Digit Span forward, numbness and MMSE, and numbness and DST forward. When adjusted for demographic and cardiovascular risk factors, significant associations were found between having experienced any stroke symptom and Digit Span backward (B=-1.46, SE=0.66, p=.03) as well as numbness (B=-1.75, SE=0.72, p=0.02).

Conclusions: Associations between previous stroke symptoms and reduced cognition emphasize the need to screen and treat persons with undiagnosed stroke or TIAs in low-resource settings. A reduction in modifiable vascular risk factors is also needed to reduce CVD and associated dementia.

Technical Notes and Result of Stereotactic Evacuation of Hematoma in Spontaneous Supratentorial Intracerebral Hematoma

Primary intracerebral hematoma constitutes about 10-15% of all strokes and is associated with high mortality and severe disability. Surgical treatment of intracerebral hemorrhage is quite controversial. It is believed that minimal invasive stereotactic surgery may reduce hematoma volume and decrease secondary neurotoxicity. The technical note of stereotactic surgery has been illustrated. A retrospective study from March 2016 to March 2018 has been conducted and all patients who underwent stereotactic evacuation of hematoma were included in this study. Baseline characteristics of patients and outcome in terms of Glasgow Coma Scale (GCS) and Modified Rankin Scale (mRS) have been shown. We have found significant improvement in GCS postoperatively, however mRS did not improve immediately but was significantly better in three months follow up period.

Histopathological analysis of central nervous system tumor; an observational study

Background:  Though the central nervous system tumor comprises ~2% of all the tumors, an overall increase has been observed especially in less developed countries. This increase in the incidence may be due to exposure of population to various risk factors or improved diagnosis with advancement in the ancillary studies. This study aims to provide a single centre histopathological spectrum of this type of tumor.Materials and Methods: A retrospective cross sectional study on a series of cases was performed in the Department of Pathology, Annapurna Neurological Institute & Allied Science , Maitighar , Kathmandu, Nepal from April 2013 to Jan 2016. Data were analyzed using SPSS version 21.0.Results: A total of 221 brain and CNS tumors (125 females and 96 males) were studied. The mean age at diagnosis was 43.77 years. The most common tumor was meningioma(67 cases, 30.3%), followed by astrocytic tumor (57 cases, 25.7%) and pituitary adenoma(30 cases,13.6%). The frequency of WHO grade I, II,III and IV tumor were 94 cases (55%), 34 cases (19.9%),10 cases (5.8%), and 33 cases (19.3%) respectively. The astrocytic tumor was most frequent tumor in children (7/20 caes, 37 %).Conclusion: This study showed the most common CNS tumor to be meningioma followed by astrocytic tumors and pituitary adenoma. The spectrum of CNS tumor in children showed divergent histologic pattern according to the age. In age group 0-10 years embryonal tumors were common whereas ages group of 12-years showed propensity towards astrocytoma as in adults.  

Initial experience with aneurysm coiling in Nepal

The aim of this study is to show the result of aneurysm coiling despite the difficulty in initiating neurointervention in Nepal. It is a retrospective study where only aneurysm that has undergone coiling are taken from 2017 to 2018.A total of eleven patients (male: female = 1: 10) with aneurysm were treated with Endovascular therapy. 9 cases were ruptured aneurysm while 3 were unruptured. 5 aneurysm were located in anterior circulation while 6 were located in posterior circulation. Out of eleven cases 4 were treated by simple coiling technique, while 2 underwent balloon assisted coiling, 3 stent assisted coiling, 1 pConus assisted coiling and 1 simple coiling and stent assisted coiling. Statistical analysis showed significant correlation between fisher grading scale with mRS score (P=0.013) suggesting lower fisher grade, and improved outcome similar to the result of prospective one year follow up of Barrow Ruptured Aneurysm Trial ( BRAT) study. With limited resources aneurysm coiling was performed at ANIAS with similar results to literature.Nepal Journal of Neuroscience, Volume 15, Number 2, 2018, page: 30-35

Deep Brain Stimulation in Parkinsons Disease in Nepal

Background Parkinsons disease is a central nervous system degenerative disorder affecting motor system and characterized by progressive tremor, rigidity, gait abnormalities. Surgical treatment of Parkinsons disease is based on the changes in the basal gangliothalamocortical circuits which is altered in Parkinsons disease. Currently pallidotomy and Deep Brain Stimulation are available modes of surgical treatment of Parkinsons disease. Objective To know efficacy of deep brain stimulation in Parkinsons Disease in Nepal. Method All patients of idiopathic Parkinsons disease who underwent Deep Brain Stimulation in Annapurna Neurological Institute and Allied sciences since 2014 were included. The standard functional coordinates for Subthalamic nucleus and Globus pallidus internus was used. We used Zamarano-Dujovny (ZD) Fisher Frame with its software. Patients' Unified Parkinsons disease rating score, Modified Hoehn and Yahr Staging and Schwab and England Activities of daily living Scale were evaluated preoperativelyv as well as postoperatively. Result Ten patients underwent Deep Brain Stimulation. The male is to female ratio was 2:1. The mean age was 55.4±8.9 years and duration of illness was 5.5±2 years. There was a significant improvement in the scores for the main motor manifestations of the disease between the preoperative off-dopa and postoperative off-dopa/on-stim conditions. There was a significant improvement in Schwab and England Activities of daily living scale scores in the off-dopa condition between the preoperative score and the postoperative M6 score. Conclusion Our result of Deep Brain Stimulation is quite promising. However, it is very expensive and requires frequent follow-up for neuromodulation.

Cerebral venous thrombosis secondary to hyperthyroidism: A case report

Cerebral Venous Thrombosis (CVT) is a rare form of Stroke characterized by thrombus formation in the cerebral veins. CVT is a result of various reasons among which the hyperthyroidism is not so frequently encountered. This is probably the first case report published from Nepal. The aim of this case report is to give the message that persistent severe headache in patient with hyperthyroidism can be the red flag and needs to be investigated further. We present a case of a 35 years old female who presented with complaints of severe headache and persistent in nature associated with vomiting since 5 days. She was a diagnosed subacute thryroiditis and under medicine from 1 month before presenting to us. Her Magnetic Resonance Venography (MRV) brain showed venous thrombosis within superior saggital sinus, left transverse sinus and sigmoid sinus. Her thyroid function test showed pretreatment T3 of 2.98 ng/ml T4 of 1.02 mg/ ml and TSH of 0.12 μIU/L. She was kept on anticoagulants and other supportive measures. The patient showed improving status with the conservative management.Nepal Journal of Neuroscience 15:29-31, 2018

Deep Brain Stimulation of bilateral Subthalamic nucleus (STN) following pallidotomy with Parkinsons crisis: A case report

We present a case of 57 years old patient with Idiopathic Parkinsons disease(PD) who had right sided Globus PallidusInternus (GPi) lesioning or pallidotomy as surgical treatment modality of PD. However this patient went into Parkinsons crisis postoperatively which is a rare form of complication. We had to admit in critical care for two weeks before he gradually improved and reached to preoperative state. This patient finally underwent deep brain stimulation(DBS) of bilateral Subthalamic nucleus (STN) and he has improved in terms of Unified Parkinson’s Disease Rating Scale(UPDRS) score.Nepal Journal of Neuroscience 15:40-42, 2018

Antioxidant and cytotoxic activities of Dendrobium moniliforme extracts and the detection of related compounds by GC-MS

Background

The medicinal orchid Dendrobium moniliforme contains water-soluble polysaccharides, phenanthrenes, bibenzyl derivatives, and polyphenol compounds. This study explored the antioxidant and cytotoxic activities of D. moniliforme extracts and detected their bioactive compounds.

Methods

Plant material was collected from the Daman of Makawanpur district in central Nepal. Plant extracts were prepared from stems using hexane, chloroform, acetone, ethanol and methanol. The total polyphenol content (TPC) in each extract was determined using Folin-Ciocalteu’s reagent and the total flavonoid content (TFC) in each extract was determined using the aluminium chloride method. The in vitro antioxidant and cytotoxic activities of each extract were determined using DPPH (2,2-diphenyl-1-picrylhydrazyl) and MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assays respectively. Gas chromatography and mass spectrometry (GC-MS) analysis was used to detect bioactive compounds.

Results

TPC content was highest (116.65 μg GAE/mg of extract) in D. moniliforme chloroform extract (DMC) and TFC content was highest (116.67 μg QE/mg of extract) in D. moniliforme acetone extract (DMA). D. moniliforme hexane extract (DMH) extract showed the highest percentage of DPPH radical scavenging activity (94.48%), followed closely by D. moniliforme ethanol extract (DME) (94.45%), DMA (93.71%) and DMC (94.35%) at 800 μg/ml concentration. The antioxidant capacities of DMC, DMA, DMH and DME, which were measured in IC₅₀ values, were much lower 42.39 μg/ml, 49.56 μg/ml, 52.68 μg/ml, and 58.77 μg/ml respectively than the IC₅₀ of D. moniliforme methanol extract (DMM) (223.15 μg/ml). DMM at the concentration of 800 μg/ml most inhibited the growth of HeLa cells (78.68%) and DME at the same concentration most inhibited the growth of U251 cells (51.95%). The cytotoxic capacity (IC₅₀) of DMM against HeLa cells was 155.80 μg/ml of extract and that of DME against the U251 cells was 772.50 μg/ml of extract. A number of bioactive compounds were detected in both DME and DMM.

Conclusion

The fact that plant extract of D. moniliforme has a number of bioactive compounds which showed antioxidant and cytotoxic activities suggests the potential pharmacological importance of this plant.

Electronic supplementary material

The online version of this article (10.1186/s12906-018-2197-6) contains supplementary material, which is available to authorized users.

Comparative Study of GeneXpert MTB/RIF Assay and Multiplex PCR Assay for Direct Detection of Mycobacterium tuberculosis in Suspected Pulmonary Tuberculosis Patients

Pulmonary tuberculosis (PTB) is one of the major infectious diseases in developing countries. The objective of this study was to compare rapid diagnostics technique, GeneXpert MTB/RIF (GeneXpert) and Multiplex PCR assay (MPCR) targeting IS6110 segment and mpb64 gene for direct detection of Mycobacterium tuberculosis (MTB) in suspected PTB patients. A cross sectional study was carried among 105 sputum samples from suspected PTB patients to evaluate GeneXpert and Multiplex PCR who visited National Tuberculosis Center, Nepal. The patient's sputum samples were used directly for the GeneXpert whereas DNA extraction by CTAB method was followed to process the sample for MPCR. The sensitivity and specificity of GeneXpert and MPCR in smear positive cases was 78.6, 33.3, and 100.0%, 66.7%, respectively (P = 0.125). However, in smear negative cases sensitivity and specificity of both methods exhibited 90.9, 95.2, and 100.0%, 100.0% respectively (P = 0.625). Finally, the sensitivity and specificity of GeneXpert and MPCR were 82.9, 95.3 and 100.0%, 98.5% respectively, (P = 0.549) in pulmonary cases. Comparatively, we observed higher sensitivity and specificity for MPCR than GeneXpert for both smear positive and negative samples. Thus, we recommend MPCR alongside GeneXpert for the better diagnostic accuracy of PTB in a resource-limited country where tuberculosis is endemic.

Transient Cortical Blindness after Digital Subtraction Angiography of Cerebral Vessels

Transient blindness following cerebral angiography is a rare but known entity. We report a case of transient cortical blindness after cerebral angiography. The patient presented with is chemic stroke and the angiography was performed to rule out carotid artery stenosis. The patient, however, gradually regained his vision over a period of 3 days. This article is to understand one of the most unusual complications that may occur while performing angiography Nepal Journal of Neuroscience, Vol. 14, No. 2,  2017 Page: 36-38

Post-Traumatic Glioma: Report of a Case

Development of malignant glioma after trauma is a rare occurrence. Trauma and scarring have been known to be the predisposing factor for the development of meningiomas. Many people have discussed about the development of glioma post trauma but without proper evidence of documents prior to trauma with no evidence of tumor. We present you a case with evidence of not having tumor during trauma. Nepal Journal of Neuroscience, Vol. 14, No. 2,  2017 Page: 43-46

Balloon Test Occlusion for an Option to Decide Whether Simple ICA Ligation is Better Option than Trapping and High Flow Bypass of The Giant ICA Cavernous Aneurysm

Balloon Test occlusion (BTO) is a preoperative angiographic test used to estimate the risk of stroke after permanent therapeutic occlusion of an internal carotid artery (ICA) involved by aneurysms. Temporary balloon occlusion at the cavernous ICA aneurysm neck was performed in an attempt to assess the adequacy of cross flow from the opposite ICA. Adequate fl ow following BTO are preferred to have simple ICA ligation and incase of those who did not pass BTO trapping and high flow bypass is preferred .We have done Right ICA Ligation on our case report.Nepal Journal of Neuroscience, Vol. 14, No. 2,  2017 Page:32-35

Central Pontine Demyelination: A Case Report

Central Pontine Demyelination is a neurological disease caused by rapidly fl uctuating serum osmolality resulting in severe damage of the myelin sheath of nerve cells in the brainstem, more precisely in the area of pons. This condition is associated with electrolyte disorders, especially severe hyponatremia and its rapid correction. Its clinical course is characterized by alterations in the mental status to debilitating neurological status i.e. coma. Chronic hyponatremia and its correction, with or without evaluating safe limit could result in pontine demyelination. Demyelination might also occur with normal sodium levels, and even if serum sodium levels are corrected within safe limits. The objective of this case report is to give a broad perspective on Central Pontine Demyelination and to discuss about the different factors contributing to the demyelination and the various causes, pathophysiology and the management of this condition. Nepal Journal of Neuroscience. Vol. 13, No. 2, 2016, Page: 99-101

Result of Pallidotomy in Parkinson’s Disease in Nepal

Surgical treatment of Parkinsons disease (PD) has already been an established treatment. Currently pallidotomy, Deep Brain Stimulation (DBS) of Globus pallidus internus (GPi) and Subthalamic nucleus (STN) are available mode of surgical treatment of PD. We have included all patients of idiopathic Parkinosons disease who underwent pallidotomy in Annapurna Neurological Institute and Allied Sciences since 2014. The demographics of the patients have been shown and the patient’s improvement has been shown by Unifi ed Parkinsons Disease Rating Score (UPDRS). We have found that pallidotomy is still a promising surgical modality but it is advised to perform either unilaterally or staged bilaterally with at least 3 months gap inbetween.Nepal Journal of Neuroscience. Vol. 13, No. 2, 2016, Page: 68-72 

Propofol, An Alternative to Amobarbital in Wadas Test in Electro corticography Based Epilepsy Surgery for Determining Dominance of Brain

Amobarbital which is used rampantly for Wadas test is not available in Nepal and to find a dominant hemisphere in a functional Electro corticography (ECoG) based epilepsy surgery is a must. So we have used propfol under Digital Subtraction Angiography (DSA) for both cerebral hemisphere.Nepal Journal of Neuroscience. Vol. 13, No. 2, 2016, Page: 116-118