Introduction: Anomia is a problem with naming objects. Anomic aphasia, also called as anomia or amnesic aphasia, is characterised by word-finding difficulties in the absence of major syntactic impairment. Objectives: To determine the effectiveness of therapy techniques in recovery of language abilities in a patient with anomic aphasia. Materials and Methods: Prospective study of a patient diagnosed with anomic aphasia secondary to ischaemic stroke, whose response and progress was followed from the time of presentation, along the course of therapy with techniques including semantic feature analysis (SFA) and phonological component analysis (PCA), and scored according to the guidelines of Manual for Adult Non-Fluent Aphasia Therapy in Kannada (MANAT-K). Results: Significant improvement was noted in the patient's naming skills, with an increase in almost 20% in the score in confrontation naming, responsive naming, and word fluency, post-therapy, as compared to pre-therapy. Conclusion: Although there is contribution of spontaneous recovery in the betterment of a person with aphasia, timely planned therapy brings about a marked improvement in the patient's language abilities.

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Introduction: We present our experience of managing large and giant intracranial aneurysms by conventional endovascular techniques. We discuss the long-term clinical and angiographic outcome of coiling of these aneurysms. Materials and Methods: We assessed a prospectively maintained database of patients with large and giant intracranial aneurysms managed by the endovascular techniques from January 2010 to December 2014. In 412 patients with 468 aneurysms managed during this period, 58 patients with 60 aneurysms were identified as either large or giant. Each patient's records were reviewed with regard to size, location and morphology of the aneurysms, Hunt and Hess grade, occlusion and coiling/recoiling rates. Clinical outcome was assessed using the modified Rankin Scale (mRS) score with score of 0–2 and 3–6 taken as favourable and unfavourable outcome, respectively. Results: Overall complication rate was 13.8%, and no intraprocedural death was seen. Angiographic and clinical follow-up was available for 49 patients with 49 aneurysms at an average of 28.7 months. Recanalisation rate was 26.5% in this study and of them 38.5% required retreatment. Favourable mRS score (0–2) was seen in 82.6% of ruptured aneurysms and 92.3% in unruptured aneurysms. Conclusion: Coiling of large and giant aneurysms is a safe and viable option with a very good clinical outcome in the long run. However, long-term clinical and angiographic follow-up is necessary as angiographic results immediately after the procedure may be deceptive.

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Context: Adults with haemodynamic stroke secondary to cerebrovascular ischaemic events, continue to develop stroke despite optimum medical management. Aims: This study aims to identify patients with adult ischaemic stroke presenting with significant haemodynamic failure based on radiological and molecular imaging and perform Revascularisation procedure to prevent further stroke. Settings and Design: This is a retrospective database analysis of patients with CVOD requiring cerebral revasularisation procedure from 2013 to 2019. Materials and Methods: Twenty-two adult patients with age ranging from 26 to 72 years presenting with recurrent transient ischaemic attacks (TIAs) were evaluated for haemodynamic insufficiency by neuroimaging and acetazolamide challenged single-photon emission computed tomography perfusion. Those with decompensated haemodynamic insufficiency underwent cerebral revascularisation with superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. Results: Of the 22 patients, in 12 patients, the procedure was done electively and in remaining 10 patients as emergency (<48 h of the onset of symptoms). Ninety-one per cent of the patients recovered well without any further TIAs. Neurological worsening was observed in 4.5%. Two patients who presented with refractory migraine like symptoms improved dramatically without further headaches. Uneventful wound complications were associated in 9% of cases. Follow-up radiological evaluation showed good graft patency in 95% (21/22) patients. The single case of graft thrombosis developed new MCA territory infarct requiring prolonged rehabilitation for the neurological deterioration. Conclusion: Cerebral revascularisation with STA-MCA bypass in selected patients with impending haemodynamic insufficiency results in good outcome and prevents further strokes despite continuing optimum medical therapy.

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Background: Anterior communicating artery (ACoA) aneurysms are one of the most common cerebral aneurysms encountered by neurovascular surgeons. They are surgically complex and sensitive and the scope for dialogue and exchange towards development are never over rated. Aims and objectives: The authors seek to discuss and emphasize on key lessons learnt from the observations from ACoA aneurysms treated by micro-vascular clipping. Materials and Methods: Hospital based retrospective observational study of 237 cases of ACoA aneurysms admitted to the study hospital and treated by micro-vascular clipping. Conclusion: The lessons learnt are broadly under the headings: exposure, intracranial pressure, gyrus rectus resection, vascular anatomy, perforator preservation, temporary clipping, damage control, lamina terminalis fenestration, team play, cognitive and morbidity assessment, and timing of surgery.

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Acute subarachnoid haemorrhage (SAH) generally appears hyperdense on computed tomography (CT) scan. However, in some rare circumstances, it may appear hypodense which can pose a diagnostic problem and compromise patient care. We report the case of a 32-year-old man who had presented with acute posterior fossa SAH. A cranial CT scan revealed a hypodense posterior fossa lesion mimicking cerebellar infarct. Surgical intervention confirmed that it was an acute bleed in the subarachnoid space. Treating physicians should be cautious in interpreting CT images as that can sometimes be misleading leading to misdiagnosis and incorrect treatment choices.

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When two or more adjacent intracranial aneurysms, arise from the same or different arteries, with separate origins and partially adherent walls, they are referred to as 'kissing aneurysms'. These are rare aneurysms. Among different locations of kissing aneurysms reported in the literature, kissing aneurysms of bilateral distal anterior cerebral arteries (DACAs), two different aneurysms situated symmetrically on opposite DACA are very rare. A 69-year-old woman with multiple comorbidities was admitted with anterior interhemispheric bleed. Magnetic resonance angiography and digital subtraction angiography (DSA) showed ruptured bilateral DACA aneurysms in mirror position to each other forming a Mickey mouse head appearance. The patient was managed surgically by craniotomy and clipping of both aneurysms. Kissing aneurysms of bilateral DACA aneurysms are very rare. DSA is essential to be useful for pre-operative diagnosis and planning. The basic principle of securing the parent artery proximally and clipping the neck after meticulous dissection should be followed.

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Intracranial aneurysms are a subject of controversy. Anterior circulation aneurysms are usually considered surgical territory, yet endovascular prowess can affect good results with minimal morbidity and comparable long-term results. We present a complex anterior cerebral artery aneurysm that would require either a bypass or a complex vessel reconstructive procedure. Instead, we proceeded to perform a stent-assisted coiling trapping the coils inside the aneurysm through a covered stent, thereby ensuring vascular continuity and complete aneurysm control. A brief review of the literature is also added to put this report in perspective.

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The human body abounds in micro-organisms that maintain the vital balance of the internal ecosystem. Though it is well known that several benefit the human body while others are linked to disease, how the microbiota affects the pathology of intra-cranial aneurysms is an interesting arena that still requires exploration. Studies have suggested possible association between the excess of bacteria, such as those causing gingivitis, as well the deficit of bacteria, such as loss of gut flora due to antibiotics, to intracranial aneurysms and their subsequent behavior. The authors review existing literature on the subject and outline the scope for further research on the subject.

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Background: Cerebral Arteriovenous Malformation represent a particularly challenging subset of lesions, given their overall low incidence and the high frequency with which some form of multimodality monitoring may be required for complete obliteration. Materials and Methods: We report retrospective analysis of 9 cases with unruptured cerebral arteriovenous malformation who got admitted in the Banbuntane Hotokokai Hospital, Fujita Health University, and Nagoya, Japan .from the year 2014 to 2017.surgical treatment was appropriate craniotomy and resection based on the location of the arteriovenous malformation with multimodality monitoring with Dual Image Video Angiography, Motor Evoked Potential, and FLOW 800. We studied the following factors: Sex, Age, Arteriovenous Malformation size, Location, occurrence of Intracranial Hemorrhage, Seizure type, Duration of Seizure history, Treatment modality, and Arteriovenous Malformation obliteration. We tested for statistical associations between these factors and seizure presentation and outcomes with Clinical follow-up. Outcome was compared with modified Rankin Scale Results: Out of 9 cases operated for intracranial arteriovenous malformation 5 patients were female and 4 were male. Age [ Mean 39.4 + 16.7] of the patients ranged from 20 to 66 , 5 patients were 25 - 40 and 2 were > 65 and < 25 each.6 patients were Spetzler - Martin Grade 2 ,1 patient was Spetzler - Martin Grade 4,Grade 3 and Grade 5. 3 patients were draining into superficial venous system and 2 patient were asymptomatic and incidentally diagnosed during screening procedure. There is no Mortality in this study.1 patient underwent Gamma Knife stereotactic radiosurgery. Conclusion: The increasing use of advance imaging techniques will increase the incidence of asymptomatic arteriovenous malformations. Non-ruptured arteriovenous malformation Spetzler Martin Grade 1 or Spetzler Martin Grade 2 have a good outcome for microsurgery [modified Rankin Scale and complete obliteration and there is better outcome with microsurgery.

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Chronic subdural hematoma (cSDH) is a common cranial neurosurgical condition with morbidity and mortality ranging from 2% to 5%. Conventional treatment includes conservative and surgical evacuation. Minimally invasive middle meningeal artery (MMA) embolisation is emerging as a potential treatment option. We report our case successfully managed by MMA embolization and review the literature. cSDH development and progression is related to the cycle of chronic inflammation and angiogenesis following the original hemorrhage due to trivial trauma. Due to growth factor, stimulation-initiating angiogenesis leading to growth of leaky blood vessels causing microhaemorrhages resulting in the progressive enlargement of subdural collection as the physiologic absorption capability is outpaced by the rate of collection. Strategies for the management of cSDH are aimed at interrupting the vicious cycle of its development and tilting the balance toward reabsorption of haemorrhage. Conservative management, medical treatment and surgical treatments are conventional treatment options with surgical evacuation considered as the gold standard option. However, challenges include recurrence and reversal of anti-platelets and anti-coagulants and its associated risk of ischaemic complications. cSDH being a pathology of meninges deriving blood the dura causing microhaemorrhages, it is prudent to seal off the vessels to tilt the balance towards resorption. MMA embolisation as a treatment option has been used with significant published data. It may be used as a stand-alone therapy in minimally symptomatic patients. Technical success rate is high both with polyviny alcohol and liquid embolic agents. Recurrence rate is consistently low in spite of significant patients having antiplatelets and anti-coagulants on board. It eliminates the ischemic complication due to stoppage of antiplatelets and anticoagulants. MMA embolization is also emerging as an adjunct to surgically evacuated cSDH that is considered high risk for recurrence.

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We present a case of bilateral subdural haematomas secondary to spontaneous intracranial hypotension. The diagnostic features and the management issues are discussed.

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Introduction: Since the outbreak of the coronavirus pandemic, much has changed in the protocol for management of healthcare setups and patients presenting with any illness including neurological and neurosurgical emergencies. Patients are themselves deterred from visiting a hospital in an emergency, and healthcare workers require stringent precautions and plans to prevent the spread of the virus to themselves and others, without compromising on the care that is to be provided. Aims and objectives: To outline the importance of identifying neurological emergencies requiring urgent intervention even in the time of a pandemic, and methods to effectively manage patients without compromising on safety and infection prevention measures. Materials: Guidelines reviewed from existing literature and retrospective analysis of management protocol and care delivered in a neurovascular unit during the COVID-19 pandemic.. Conclusion: Acute neurovascular care should not be compromised upon even during a pandemic, but neither should the safety of healthcare workers. Safety guidelines and protocols require strict adherence.

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Introduction: In the field of medical research, large volumes of data need to be analysed accurately, and it is crucial to pre-process the data before it can be analysed. The 'R' environment is a programming language and environment for statistical computing and graphics suitable for the analysis of data sets. Objectives: To provide examples on how to utilise the R language for data processing, and its usefulness for medical researchers. Materials and Methods: Two real world datasets, ie, data for: 'Effect of Morning Blood Pressure Peak on Early Progressive Ischemic Stroke: A Prospective Clinical Study' and data for: 'Impact of early surgery of ruptured cerebral aneurysms on vasospasm and hydrocephalus after SAH: our preliminary series' have been used to present an example for two different approaches for the process of data analysis using R. Results: Accurate and tidy data sets were obtained. Conclusions: R is a reliable environment for the processing of large data sets.

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Existing literature is devoid of data on true trifurcations of the internal carotid artery (ICA). The authors present a rare case of trifurcation of the ICA, discovered during the evaluation of a patient with subarachnoid haemorrhage, and discuss the surgical implications of the anomaly.

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Introduction: Arteriovenous fistulae (AVF) are rare lesions. Patients typically present with slowly progressive myelopathy that is often mistaken for degenerative cervical or lumbar stenosis. Cranial presentations are even more innocuous ranging from seizures to tinnitus. The purpose of this study is to present a series of cases to aid in the assessment, diagnosis and treatment of this unusual pathology. Case Series: We present 11 cases of AVFs treated at our centre over an 4-year period. Seventy percent of patients were male. The mean age of presentation was 62.6 years. The most common lesion was a dural AVF emanating from the craniovertebral junction with single feeder. All patients underwent either microsurgical correction or endovascular embolization as the primary procedure. Eight patients showed improvement following treatment as graded by the Nurick system. Two patients failed to improve. None of the patients worsened. One patient had a cortical venous thrombosis after embolization that resolved well with anticoagulants. Conclusion: The successful treatment of AVF requires a detailed understanding of clinical presentation and imaging findings to allow for precise treatment. Owing to the rarity of the condition, clinicians must continue to share their experiences to advance our knowledge.

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Background: The endovascular coiling of ruptured aneurysms with complicated geometry presents a significant treatment challenge, especially with the non-availability of adequate sized coils and balloon/stent. The dual microcatheter technique is an alternative treatment for stent-assisted coiling in acutely ruptured wide-necked aneurysms because of no antiplatelet therapy. Objective: We report our initial experience with the use of a dual microcatheter technique in seven patients. The technique provided an efficient strategy for treating aneurysms with complicated configurations and high risks. Patients and Methods: We describe a technique used to treat seven patients with irregular shaped and wide-necked aneurysms. In the initial attempts at embolisation, coil instability within the aneurysm or significant impingement of coil loops on the parent artery was observed. The advancement of a second microcatheter into the aneurysm allowed two coils to be braced across the aneurysmal neck before the detachment of either coil. This technique permitted successful coil treatment. Conclusion: The dual microcatheter technique is a safe and effective treatment for acutely ruptured wide-necked aneurysms due to few treatment-related complications and mortality rate.

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Introduction: Neurosurgery has evolved with the times and as with all things with a rich history, there is much to be learnt from experience and much to be re-iterated in the present. Aims and objectives: To reinforce the key basic points in AVM surgery, for the benefit of all neurosurgeons operating on AVMs. Materials: Based on personal experience from over he author recollects integral points and principles of the surgical management of intra-cranial arterio-venous malformations (AVMs), highlighting the basic elements such as planning, exposure, equipment use, intra-operative identification, and safe approach, execution and hemostasis. Conclusion: The success of AVM surgery depends highly on methodical planning and precise execution.

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Giant intracranial aneurysms, and aneurysms in the posterior circulation of the brain, are each rare entity when considered separately. It is more uncommon to find both coexisting. Aneurysms usually present when they rupture and haemorrhage, and for one to present with non-haemorrhagic symptoms, is rarer. The authors present an unusual case of a giant aneurysm of the anterior inferior cerebellar artery masquerading as a cerebellopontine angle tumour with cerebellar signs. The patient was treated with a retromastoid suboccipital craniectomy and microsurgical clipping and excision, with excellent results. A PubMed search of existing literature was carried out and reviewed and has been discussed.

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Introduction: Aneurysms of the vertebrobasilar system comprise approximately 10%–15% of all intracranial aneurysms and most occur at the bifurcation of the basilar artery. Posterior circulation perforator artery aneurysms are sparsely reported in the literature. The natural history of these rare lesions remains unclear and their diagnosis and management are not well defined. Materials and Methods: All case reports and case series from the past 20 years were analysed, and the results tabulated. Based on broad trends, guidelines were proposed for management. Results: Forty-two cases from 22 case reports and case series were analysed. Most were managed endovascularly, with a complication rate approaching 43%. Observation was another popular treatment option with however a comparable morbidity of 42% only surgery proved to be better overall. Aneurysm size was inversely correlated with complication rate with smaller lesions more prone to rupture and complications. The nature of the perforating artery was also found to be a factor, where direct brain stem perforators from the upper two-third of the basilar artery were found to be difficult to treat both by surgery and endovascular methods, leading to significant failures and complications as compared to the wider circumflex perforating arteries. Conclusion: Scarce published literature that addresses the limited understanding of the natural course of this entity lead to difficulties in proposing broad-based recommendations that are fail proof. Nevertheless, we hope this analysis of 20 years of data helps in shedding light on this difficult disease and its possible treatment options along with risks and outcomes.

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Foot drop is defined as the weakness of the tibialis anterior muscle and is frequently accompanied by weakness of the extensor hallucis longus and extensor digitorum longus. Dural arteriovenous (AV) fistula present mainly as progressive myelopathy, though it can also appear as amalgam of upper and lower motor involvement signs. Digital subtraction angiography is the definitive radiological procedure in the pre-treatment evaluation of vascular malformation. Treatment modalities include surgical resection or angiographically guided embolisation of malformation. We are reporting a case of spinal AV fistula presenting as unilateral foot drop, which showed significant improvement following the neuro-radiological intervention. Here, we report a rare presentation of spinal AV fistula as foot drop, showing good recovery following glue embolisation.

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Background: Aneurysms with neck diameter >4 mm or dome to neck ratio <2 are wide-neck aneurysms. Balloons and stents are used to assist in coiling the wide-neck aneurysms, but these are associated with increased intra-procedure and peri-procedure risk in ruptured aneurysms. Microcatheter-assisted coiling (MAC) is an alternative salvage technique in these situations which is under reported. Materials and Methods: We describe our experience in a cohort of 16 patients with ruptured wide neck aneurysm treated with MAC technique. Our primary objective of intervention in acute setting was to secure the aneurysm to prevent rebleed. Results: Anterior communicating artery aneurysm was the most common (56.3%) followed by middle cerebral artery bifurcation aneurysm (18.8%), paraclinoid aneurysm (12.5%), posterior communicating artery aneurysm (6.3%) and basilar tip aneurysm (6.3%). Mean greatest dimension of dome and neck were 8.9 mm and 4.6 mm, respectively. Mean neck to dome ratio was 1.8. Fisher grade 3 and grade 4 subarachnoid haemorrhage (SAH) were observed in 56.3% and 43.7% patients, respectively. Immediate post-procedure digital subtraction angiography (DSA) showed Raymond Roy grade 1, grade 2 and grade 3 embolisation in 62.5%, 33.3% and 6.7% patients, respectively. No distal embolus, vessel occlusion, vessel perforation or aneurysm rupture was observed. Immediate post-procedure DSA showed good distal flow in all patients. Infarct was observed at 24 and 48 hours respectively, in two patients with Fisher Grade 3 SAH. Conclusion: Ruptured wide neck aneurysms can be embolised with complete preservation of branching vessel and distal flow. Total occlusion can be achieved in 2/3^rd of patients.

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