Background : Magnesium ion gates the N-methyl-D-aspartate (NMDA) receptor and may protect the brain from NMDA receptor-mediated asphyxial injury. The present study evaluated the neuroprotective role of magnesium in birth asphyxia. Material and Methods : Forty term neonates with severe birth asphyxia were randomized to either the study group or the control group. Neonates in the study group received magnesium sulfate in a dose of 250 mg/kg initially within half an hour of birth followed by 125 mg/kg at 24 and 48 h of birth. Cranial computed tomography (CT) scan and electroencephalography (EEG) were performed for all the babies. Denver II was used for developmental assessment at the age of 6 months. Results : Two babies in each group died of severe hypoxic ischemic encephalopathy. EEG abnormalities occurred in 43.75% of the cases in the control group compared with 31.25% in the study group. CT scan abnormalities were present in 62.5% of the control group compared with 37.5% of the cases in the study group. The Denver II assessment at 6 months revealed that there were five babies that were either abnormal or suspect in the control group compared with three in the study group. Conclusion : Magnesium is well tolerated and does appear to have beneficial effects in babies with severe asphyxia. More data is however needed and a large multicenter trial should be conducted.

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Background : Intracranial meningiomas are rare tumors in children accounting for 0.4-4.6% of all primary brain tumors in the age group of 0-18 years. Objective : To retrospectively analyze the epidemiological profile, clinical features, radiological findings, type of excision, histopathological findings, and overall management profile of these patients. Materials and Methods : Eighteen consecutive cases of meningioma in patients under 18 years of age admitted and operated at our institute between the years 1974-2005 were included in this study. Results : The mean age of patient at presentation to our hospital was 12.81 years. The male to female ratio was 1.57:1. The median preoperative duration of symptoms was 1.2 years. An increased incidence was seen in patients with neurofibromatosis. Intraventricular and skull base locations were common. Total tumor excision was achieved in all cases. Conclusion : A higher incidence of atypical and aggressive meningiomas is seen in children. Children with complete resection and a typical benign histology have a good prognosis.

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Epilepsy and cognition have a multi-tiered reciprocal relationship. Alteration in cognitive abilities and performance may occur in tandem with persistent seizures in a patient with epilepsy. Age at onset, type of seizures, frequency of seizures, types of underlying epilepsy syndrome, and the underlying pathological brain substrate driving epilepsy may all have variable and independent effects on cognition. Therapeutic intervention with anti-epileptic drugs (AEDs) variably modulates cognitive abilities in a patient with epilepsy. Pathological substrate specific effects can compound the potential negative effects of AEDs on cognition. In this review all these aspects are addressed with an analysis of relevant evidence from peer-reviewed publications.

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To review the clinical features and current understanding of spina bifida with an emphasis on the Indian Scenario. Selected articles and current English language texts were reviewed. The authors experience was also reviewed and analysed. Spina bifida is a common congenital anomaly encompassing a wide spectrum of neural tube defects.It is broadly classified as spina bifida aperta and occulta. With the prenatal screening, the incidence of aperta is gradually declining, whereas the detection of occulta has increased with the advent of magnetic resonance imaging. Over the years, the understanding of pathophysiology has made a significant changein the management of these anomalies. Early detection and complete correction can significantly reduce the neurological disability. This article is an overview of spina bifida with a special emphasis on Indian scenario.

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Hydatid disease is caused by the infestation of the larvae of Taenia echinococcus. The definitive hosts of echinococcus are various carnivores, the common being the dog. All mammals (more often being sheep and cattle) are intermediate hosts. Humans are infected through the falco-oral route by the ingestion of food or milk contaminated by dog faeces that contain the ova of the parasite or by direct contact with dogs. We are reporting three cases of craniospinal hydatid cyst. First case of large intracranial hydatid cyst in a 9-year-old male child presented with holocranial headache with diminution of vision and right hemiparesis. Second case of a 34-year-old female presented with weakness, tingling, and pain right upper limb for 4 months with painless swelling right supraclavicular region. Third case of a 8-year-old child presented with low backache and paraparesis with acute retention of urine for 3 months. All the patients of craniospinal hydatidosis were managed in our department surgically.

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Cerebral Sinovenous Thrombosis (CSVT) is a serious complication of L-asparaginase chemotherapy for leukemia in children. Clinical features of headache, altered consciousness, focal neurological deficit, and seizures developing during or immediately after treatment with L-asparaginase should alert the treating physician to the possibility of CSVT. Immediate imaging of the brain should be done using CT and MRI and the veins should be visualized noninvasively by CT and MR venography. We report two children on induction therapy for acute leukemia who presented with seizures, headache, and altered consciousness. Venous infarcts with and without hemorrhage were seen on CT in one patient and the empty delta sign was seen after contrast injection; however, the early changes were missed by CT. MRI detected dural sinus thrombosis relatively earlier in another patient, while the CT findings were equivocal; in this patient, contrast-enhanced MRI showed the empty delta sign and MR venography confirmed absent flow in the superior sagittal sinus, which was diagnostic of sinus thrombosis. Rapid anticoagulation was started with heparin and maintained with warfarin. The child with a unilateral small nonhemorrhagic infarct made a complete recovery while the other, with bilateral hemorrhagic infarcts, did not survive. We stress the importance of early diagnosis of CSVT using CT and MRI in children with leukemia being treated with L-asparaginase; this will permit timely treatment.

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Objective : The minor physical anomaly (MPA) is believed to reflect abnormal development of the CNS. The aim is to find incidence of MPA and its behavioral correlates in Down syndrome and to compare these findings with the other causes of intellectual disability and normal population. Materials and Methods : One-hundred and forty intellectually disabled people attending a tertiary care set-up and from various NGOs are included in the study. The age-matched group from normal population was also studied for comparison. MPA are assessed by using Modified Waldrop scale and behavioral abnormality by Diagnostic assessment scale for severely handicapped (DASH II scale). Results : The Down syndrome group had significantly more MPA than other two groups and most of the MPA is situated in the global head region. There is strong correlation (P < 0.001) between the various grouped items of Modified Waldrop scale. Depression subscale is correlated with anomalies in the hands (P < 0.001), feet and Waldrop total items (P < 0.005). Mania item of DASH II scale is related with anomalies around the eyes (P < 0.001). Self-injurious behavior and total Waldrop score is negatively correlated with global head. Conclusion : Down syndrome group has significantly more MPA and a pattern of correlation between MPA and behavioral abnormalities exists which necessitates a large-scale study.

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Aim : To study the clinical profile of acute disseminated encephalomyelitis (ADEM) in children. Materials and Methods : All children admitted with ADEM during a period of one and a half years were included in the study. The diagnosis of ADEM was made based on the clinical presentation and suggestive MRI findings. All children were treated with intravenous methyl prednisolone, followed by oral prednisolone and followed up for varying periods up to three and a half years. Results : The sample consisted of 14 children with 11(79%) girls and 3 (21%) boys. The oldest child was 12 years and the youngest was a six-month-old infant. Acute febrile illness preceded the onset of neurological symptoms in 64% of children. The interval between the preceding illness and symptoms of ADEM varied from 7 days to 28 days (mean 12 days). The common presenting symptoms were fever, vomiting, headache, gait disturbance and generalized seizures. Neurological manifestations included altered sensorium, multiple cranial nerve involvement, quadriplegia and paraplegia, dystonia and choreiform movements, nystagmus, bladder involvement (both incontinence and retention), speech defect and double vision. Facial nerve was the most common cranial nerve involved. Psychological manifestations included aggressive behavior, psychotic symptoms and mood changes. One child each had features of acute psychotic episode and depressive episode. All children recovered fully. One child had multiphasic disseminated encephalomyelitis (MDEM) on follow up. Conclusion : Despite the serious neuropsychiatric manifestations, ADEM in children generally has good immediate outcome. Children with ADEM need long-term follow up for cognitive impairments.

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Central nervous system tuberculosis in children presents commonly as tubercular meningitis, post-tubercular meningitis hydrocephalus, and much more rarely as space-occupying lesions known as tuberculomas. The occurrence of this condition, though previously reported only in the developing world, is now frequently reported in human immunodeficiency virus positive migrants in the western world. The exact pathogenesis of this condition is still incompletely understood, and the mainstay of treatment is chemotherapeutic regimes. Neurosurgical intervention is rarely necessary, and is confined to cases of hydrocephalus after tubercular meningitis and to large tubeculomas with space-occupying effects.

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Craniostenosis is a disease characterized by untimely fusion of cranial sutures resulting in a variety of craniofacial deformities and neurological sequelae due to alteration in cranial volume and restriction of brain growth. This involves vault sutures predominantly, but cranial base is not immune. Association with a variety of syndromes makes the management decision complex. These children need careful evaluation by multiple specialists to have strategic treatment options. Parental counseling is an important and integral part of the treatment. Recent advancements in the surgical techniques and concept of team approach have significantly enhanced the safety and outcome of these children. We had an opportunity of treating 57 children with craniostenosis in the last 15 years at our craniofacial service. Out of them, 40 were nonsyndromic and 17 were syndromic variety. We describe our successful results along with individualized operative technical modifications adopted based on the current understanding of the disease.

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Human tail refers to a congenital cutaneous appendage protruding at the lumbosacral region. This interesting anomaly is often associated with occult spinal dysraphism and presents with treatment dilemma. Management of such lesions must include complete neurological examination and magnetic resonance imaging. Appropriate management including early diagnosis and microsurgical intervention can prevent development or progression of severe neurological deficits in later life. In this article, three cases of human tails are reported along with their successful treatment and review of the literature.

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We describe the extrusion of a ventriculo peritoneal shunt tube from the anus into a 6-year-old boy following the placement of a ventriculo peritoneal shunt for postoperative periventricular tumor-induced hydrocephalus. He was admitted with a complaint of extrusion of a tube through anus on and off during bowel evacuation. He was evaluated with an X-ray of the abdomen which was showing a coiled tube in descending and sigmoid colon, confirmed by sigmoidoscopy. The proximal end was exposed for external ventricular drainage and distal end was removed endoscopically. The patient was watched for peritonitis and managed conservatively. The proximal end of the tube was removed after 5 days of external ventricular drainage and after ruling out ventriculitis and meningitis. Bowel perforation by a ventriculo peritoneal tube is a rare complication. Diagnosis is often difficult and delayed. Most of the bowel perforation is seen in young patients.

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Background : Adhesion molecules play a role in leukocyte recruitment during central nervous system (CNS) inflammation. Aim: This study was designed to compare serum, cerebrospinal fluid (CSF) concentrations of adhesion molecules in children with meningitis and sepsis, and to evaluate their sources. Setting : This study was carried out at Pediatric Department, King Abdulaziz University Hospital from January 2007 to June 2008. Design: Serum and CSF samples were collected on admission from meningitis (n = 40), sepsis (n = 20) patients, and sera from controls (n = 20). Materials and Methods : Endothelial (E), leukocyte (L), platelet (P) selectins intercellular cell adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecules-1 (VCAM-1) were measured using ELISA. Statistics : ANOVA and Spearman's correlations were used. Adhesion molecules with albumin concentration were estimated in CSF/serum to calculate concentration quotients. Results : In meningitis, serum sE-, sL-, sP-selectins sICAM-1, sVCAM-1 levels were higher than controls. Compared to sepsis, serum sE-selectin, sL-selectin, sVCAM-1, CSF-sL-selectin, CSF-sVCAM-1, VCAM-1 ratio and index were higher, while serum sP-selectin was lower than meningitis. sE-selectin ratio, CSF sICAM-1 were higher in meningitis with positive than negative culture. The sE-selectin index was higher in meningitis with neurological complication than those without it. In meningitis, correlation was found between CSF protein and CSF white blood cell counts (WBCs), CSF sICAM-1, CSF sVCAM-1 and between CSF sE-selectin and CSF sICAM-1. Conclusions : This study supports the role of adhesion molecules especially sL-selectin, sVCAM-1 in meningitis and suggests further research to determine their use as biomarkers for meningitis and use of their antagonists as therapeutic for CNS inflammation. The presence of discrepancy of CSF/serum ratios for molecules of same molecular weight suggest intrathecal shedding in addition to diffusion through the blood-CSF barrier.

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Background : The pattern of pediatric stroke displays ethnic and geographical variations. There are few reports from black Sub-Saharan Africa, although relevant data are important in prevention, clinical diagnosis, treatment and prognostication. Aim : To describe subtypes, risk factors, localization, age and gender distribution of pediatric stroke in the black Kenyan population. Study Design and Setting : Retrospective cross-sectional study in a single regional referral and teaching hospital. Statistical Analysis : Data were analyzed by SPSS version 13.0 for Windows and presented in tables and bar and pie charts. Materials and Methods : The study was performed at the Kenyatta National Hospital, a level-6 regional referral health facility with an annual pediatric in-patient turnover of about 40,000 patients. Files of patients aged 1 month to 18 years over a period of 5 years were analyzed for stroke subtypes, localization, risk factors, age and sex distribution. Only those files with complete information were included. Results : Thirty-two of the 712 stroke patients (4.5%) were pediatric. The male:female ratio was 1.7:1. Ischemic stroke comprised 56.3% (n = 18). Mean age was 7.7 years (range, 1.5-18 years). The most common sites were cortical (51%), lacunar (41%) and brain stem (8%). The most common risk factors were connective tissue disorders (28.1%), heart disease (25%), human immunodeficiency virus (9.4%) and infection (9.4%). Conclusion : Pediatric stroke is not uncommon in the Kenyan population. The risk factor profile comprising connective tissue disorders and infection differs from that reported in other populations, inviting large community-based studies.

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Brain stem lesions are pathologically heterogeneous. Pre-operative radiological diagnoses prove to be wrong in 10 to 20% of cases. It is therefore imperative to have a tissue diagnosis for appropriate therapeutic measures. We report a series of 24 patients (14 males, ten females, age range: 6-17 years) CT guided stereotactic biopsy for brain stem lesions approached via the suboccipital transcerebellar route in semi sitting position with principle used to violate only one pial plane with the biopsy probe not entering the ventral surface of the cerebellum. The inclusion and exclusion criteria with detailed material and method are discussed. Histological diagnosis was established in 23 patients (96%) with no procedure-related mortality. Our results indicate that stereotaxic approach to brain-stem lesions provides a high yield of positive histological diagnoses with a low incidence of morbidity. Awake CT-guided stereotactic biopsy via the suboccipital transcerebellar route in a semi-sitting position is a safe, reliable, and effective method for brainstem lesions that can obtain adequate tissue for histological diagnosis, thus providing each patient with the best available treatment.

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Objective : To re-emphasize that indirect revascularization surgery alone, where multiple burr holes and arachnoid openings are made over both cerebral hemispheres, is beneficial in the treatment of moyamoya disease (MMD) in children. Clinical Presentation : We report a 10-year-old boy who presented with complaints of episodic headache for the last 5 years. At the peak of his headache he had visual disturbances and acute onset weakness of left-sided limbs, recovering within a few minutes. He had no focal neurological deficits. Radiological investigations revealed abnormal findings, demonstrating the features of MMD. Surgical Management : He underwent bilateral multiple burr holes, dural and arachnoid opening over the frontal, parietal and temporal regions of each hemisphere. The elevated periosteal flap was placed in contact with the exposed brain through each burr hole. Results : On 6-months follow-up he had only one episode of transient ischemic attack. Postoperative four vessel angiogram demonstrated excellent cerebral revascularization around the burr hole sites, and single photon emission computerized tomography imaging showed hypoperfusion in the right temporo-occipital area suggestive of an old infarct with no other perfusion defect in the rest of the brain parenchyma. Conclusion : In children with MMD this relatively simple surgical technique is effective and safe, and can be used as the only treatment without supplementary revascularization procedures. This procedure can be done in a single stage on both sides and the number of burr holes made over each hemisphere depends on the extent of the disease.

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Primary thalamic tumors are rare and bilateral thalamic tumors are even rarer. The incidence, clinical manifestations, natural history and prognosis of primary bilateral thalamic gliomas (PBTT) remain relatively obscure. In this article, four cases of bilateral thalamic gliomas are discussed and the available literature is reviewed. We conclude that primary bilateral thalamic tumors are distinct lesions, as proven by their specific neuroradiological and metabolic properties, unresponsiveness to radiotherapy and chemotherapy as well as a rapidly fatal clinical evolution. Early diagnosis and prompt therapy may delay the devastating effects of this tumor.

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Entrapped temporal horn is due to obstruction of one lateral ventricle in the region of trigone. The isolated temporal horn presents itself as a mass lesion. Intraventricular hydatid cyst presenting as an entrapped temporal horn has not been reported in literature till date. We report a case of intraventricular hydatid cyst causing entrapped right temporal horn in a 25-year-old female.

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Primary intraspinal primitive neuroectodermal tumors (PNETs) are rare. We report a 3-year-old boy presented with rapidly progressive paraparesis and neurogenic bladder. A thoracolumbar magnetic resonance imaging demonstrated an intrasipnal mass from the T12 to L3 level. An operation was performed with gross total tumor removal. Histologic examination revealed a small round cell tumor and immunohistochemical characteristics of PNET. There was no clinical or radiological evidence for existence of intracranial tumor. The parents denied chemotherapy and radiotherapy. Metastases to lung was noted at 6 months after surgery and died due to respiratory failure at his local hospital. The clinical, imaging, and pathological features are discussed with a review of the literature.

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A rare complication of ventriculoperitoneal (VP) shunt is presented. A 6-year-old boy presented with a tube coming out of the mouth. He had a VP shunt done earlier. Clinical features and imaging studies showed that the peritoneal end had perforated the stomach and then migrated to and excited from the mouth. The shunt was removed and he made an uneventful recovery. Though migration of the peritoneal end of the shunt tube into various organs is known, only five cases have been reported in the English literature of a shunt tube coming out of the mouth and this is the sixth. The management of this very rare problem is discussed and the literature reviewed.

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Ventricular shunts are commonly employed in the management of hydrocephalus, and numerous complications such as dissection or migration have been reported in the literature besides shunt malfunction. We present a case of the migration of the peritoneal catheter into the scrotum who attended at our institute. He was managed successfully, but subsequently developed intraabdominal cystic swelling for which he was reoperated.

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It is presently a universal practice to administer vitamin K at birth. Hence, the serious bleeding manifestations from vitamin K deficiency are nowadays very rare. We describe a case of late vitamin K deficiency bleeding presenting as intracranial hemorrhage with impending coning and the related review of literature. Such severe bleeding episodes due to vitamin K deficiency are associated with multiple cranial involvement and impending brain herniation is probably rare.

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Background: In Acute Myeloid Leukemia (AML), malignant clones of immature myeloid cells (primarily blasts) proliferate, replace bone marrow, circulate in blood and invade other tissues. The unique presentation of bilateral proptosis and bilateral temporal swelling in AML is being reported. Case Report: A 6-year-old girl presented with low-grade fever, progressively increasing bitemporal swelling and bilateral proptosis. Contrast Enhanced Computed Tomographic (CECT) images revealed enhancing infiltrates occupying the lateral orbital wall, causing proptosis. The infiltrate extended toward the bilateral temporal fossae beneath the temporalis muscle and extradurally beneath the frontal and temporal bones. A high total leucocytic count with immature and deformed cells and, Fine Needle Aspiration Cytology (FNAC) from the temporal swelling, the bone marrow aspirate and biopsy showing leukemic blast cells confirmed the diagnosis of AML. Chemotherapy brought about remission of the disease. Conclusions: To the best of the authors' knowledge, simultaneous presence of both bilateral proptosis and bitemporal swellings have not been previously reported in AML. A peripheral blood smear with bone marrow aspirate and biopsy help in the early detection of AML. Institution of early intervention in this potentially fatal disease is often associated with gratifying survival rates.

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Spinal injuries in the pediatric population are relatively rare. Hence there is not enough knowledge, experience and exposure amongst pediatric neurosurgeons about spinal injuries in children. They have to rely on general spinal or pediatric orthopedic colleagues for a comprehensive management of spine and spinal cord trauma. In addition, the advances in spinal instrumentation techniques and vast array of implantable devices for spinal stabilization add to the complexity of the problem. It is imperative that a pediatric neurosurgeon should be aware of the mechanics of spinal injury and recent advances in the management strategy of pediatric spinal injuries.

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Aims and Objectives: To review the clinical features and current understanding of the epidemiology, biology and management of pediatric atypical teratoid/rhabdoid tumors and analyzing the different treatment modalities. Materials and Methods: The MEDLINE database, bibliographies of selected articles and current English-language texts on the subject were reviewed. A Pubmed search was made with keywords pediatric atypical teratoid/rhabdoid tumors, intracranial, surgery, chemotherapy and radiotherapy. Most recent articles and also significant older articles having all above said words were selected and their results were reviewed in detail. Results: Atypical teratoid/rhabdoid tumors (AT/RT) of the central nervous system (CNS) most frequently diagnosed in smaller than 3 years of age and incidence is 1-2% of all brain tumors in children. 63% of the AT/RT of the CNS is seen in infra-tentorial compartment, there are no precise imaging features that differentiate AT/RT from the other posterior fossa tumor. The "rhabdoid" cells are characteristic on cytopathology. It has been established now that CNS, AT/RT often show deletion of the long arm of chromosome 22q11.2. The initial treatment for most children with AT/RT is surgical with and without cerebrospinal fluid diversionary procedure. Children with less than 3 years of age offered chemotherapy but in older children radiotherapy is given in addition.

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