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Dwarakanath Srinivas, Bhavani Shankar Sharma and Ashok Kumar Mahapatra

✓Triple neural tube defects (NTDs) are rare; only 1 case exists in the available literature. There has been a divergent view on the etiogenesis of NTDs, and 2 main theories have been postulated: the more widely held orderly closure theory and the less accepted multisite closure theory. In this article the authors present 2 cases of patients with triple NTDs, and they examine the embryological basis of NTDs with special reference to the multisite closure theory. The patient in Case 1 had a 2-level myelomeningocele (MMC) along with an encephalocele; the patient in Case 2 had a 3-level MMC.

To the authors' knowledge, this paper outlines only the second and third cases described in world literature of triple NTDs including the first case of a triple MMC. The embryogenesis of triple NTDs can be better explained by the multisite closure theory. However, it fails to adequately explain the triple MMC in Case 2, given that the closure has to proceed in an orderly manner. The authors thus propose an additional closure site to explain this.

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Harsh Deora, Dwarakanath Srinivas, Dhaval Shukla, B. Indira Devi, Ajit Mishra, Manish Beniwal, Narasinga Rao Kannepalli and Sampath Somanna


Multiple-site neural tube defects (MNTDs) are very uncommon, with the predominant number of cases being reported in developing countries. The classic theory of neural tube closure fails to explain the occurrence of these defects. Multisite closure theory, first proposed in 1995, explains most of the occurrences with a few modifications specific to a few defects. In this paper, the authors endeavor to explain all the defects, along with their genetic and embryological bases, and to review the available literature and discuss their own experience in the management of these complex cases.


The authors retrospectively reviewed the data of all the patients treated surgically for MNTDs over that past 14 years. All possible demographic data, clinical details, and radiological imaging data were reviewed. In addition, surgical parameters, complications, and status at follow-up of more than 12 months were evaluated. All previously reported cases of MNTD were analyzed, and comparisons with the present series were made.


A total of 3 major series (including the present one) on MNTDs have been from India. A total of 57 such cases (including those of the present series) have been reported in the available literature. While previous series reported a higher incidence of spinal defects, the present series had a higher rate of cephalic defects (55%). Among the reported cases, insertion of a ventriculoperitoneal shunt was necessary in 12 (26%), and only 4 patients were operated on in 2 stages. Neurological status at presentation dictated outcome.


MNTDs are extremely rare, and their embryogenesis is different from that of single neural tube defects. Simultaneous repair of 2 or even 3 defects is possible in a single-stage surgery. The requirement of a shunt is uncommon, and complications following surgery are rare. Folic acid supplementation may reduce the incidence of defects.

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Thanga Thirupathi Rajan Vivakaran, Dwarakanath Srinivas, Girish Baburao Kulkarni and Sampath Somanna


Studies on the role of decompressive craniectomy for cerebral venous sinus thrombosis (CVST) in the literature are scanty. Randomized trials face a lot of drawbacks, including ethical issues. In this article the authors discuss their experience with this procedure for CVST and review the available literature.


This study was a retrospective analysis of all patients who underwent decompressive craniectomy for CVST between August 2006 and June 2008 at the National Institute of Mental Health and Neurosciences. The cases were evaluated for demographic and clinicoradiological features, operative findings, and outcome of surgery. Ethical clearance was obtained from the institutional ethics committee. The data for each patient were obtained from the database of the department. Follow-up data were obtained either through direct clinical evaluation or mailed self-report questionnaire. The Glasgow Outcome Scale (GOS) and the Rankin Disability Scale were used to assess the outcome.


A total of 34 patients (13 men and 21 women) were included; their mean age was 31.6 years, with a range from 18 to 65 years. In univariate analysis, the Glasgow Coma Scale (GCS) score prior to surgery and that in the immediate postoperative period had a statistically significant correlation with poor outcome. The GCS score immediately postoperatively was the only independent, significant predictor of poor outcome on multivariate analysis.


Decompressive craniectomy in a selected cohort of patients had a good outcome in a majority of the patients: 26 of 34 in this study had a GOS score of 4 or 5. In this series, which is the largest in the available literature, the authors review their experience and recommend usage of this procedure in selected patients.

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Paritosh Pandey, Srikantha Umesh, Dhananjaya Bhat, Dwarakanath Srinivas, Rojin Abraham, Shibu Pillai, Anandh Balasubramaniam, Indira Devi, Sommanna Sampath and Bengaluru A. Chandramouli


Cerebellar abscesses are common neurosurgical emergencies in developing countries, and have a distressingly high mortality rate of 10 to 15% even today. There is still no consensus on the standard approach to these lesions, and controversy persists over whether these lesions should be treated with primary excision or aspiration.


The authors retrospectively analyzed 82 cases of cerebellar pyogenic abscesses in children treated at their institution over a period of 10 years. This represents the largest such series being described in literature. All lesions except 1 were otogenic in origin. The clinical and radiological features are discussed.


Primary excision was undertaken in 66 patients (80%) and aspiration in 16 patients (20%). Five patients in whom the abscesses were initially treated with aspiration subsequently underwent elective excision. Nine (12.6%) of 71 patients in whom the abscesses were excised had residual abscesses on postoperative imaging; in those who had undergone aspiration as the primary treatment, 6 (54.5%) of 11 patients had recurrent abscesses. There were no deaths among the patients who underwent excision of the abscess. Also, excision of posterior fossa abscesses required fewer repeated procedures with lower recurrence rates, and statistically lower rate of complications.


Compared to primary aspiration, the authors found that primary excision is the preferred method for treating cerebellar abscesses.