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Background:Normal Pressure hydrocephalus (NPH) is treated by ventriculoperitoneal shunting. The cerebrospinal fluid tap test (CSF-TT) is widely used to identify candidates for shunt surgery in idiopathic NPH (iNPH). This study aimed to compare the CSF tap test responses and 24-week functional outcomes between patients with probable iNPH who underwent surgery and those who did not. Methods:This Ambispective cohort study included 40 patients with probable iNPH, as defined by the 2019 Japanese guidelines, from 2019 to 2024. All patients underwent a large-volume CSF-TT, and they were offered surgery based on the clinico-radiologic profile. Results:Twenty-four patients underwent ventriculoperitoneal shunt surgery, and 16 did not for various reasons. No significant differences were found in the baseline or 24-hour post-CSF tap test parameters between the groups. However, at 24 weeks, 62.5% of the operated patients showed at least a 1-point improvement in mRS. In contrast, only 14.3% in the non-operated group did, indicating the beneficial role of VP shunting in NPH. Those who were operated had a 10 times higher odds (95% CI 1.6-105) of achieving at least one point improvement in mRS at 24 weeks. Interestingly, 46.7% of patients whose mRS did not improve after CSF-TT but who underwent surgery still benefited from shunting. Conclusion:Shunt surgery leads to a favorable short-term functional outcome in patients with probable iNPH. However, the CSF-TT alone lacks sufficient discriminatory power to guide surgical decisions in a cohort of patients with clinico-radiological probable iNPH. A negative tap test should not preclude surgery in patients with supportive clinical and imaging features.
Transcranial magnetic stimulation (TMS) is an established treatment for depression, yet response rates remain at 50% 1 month after treatment. Despite two decades of clinical use, substantial room for improvement remains. This overview examines biomarker-guided personalization of brain stimulation. The authors trace the translational path from invasive circuit-level insights through noninvasive biomarkers to clinical deployment. With validated biomarkers, systematic optimization becomes possible: stimulation parameter tuning, state-dependent approaches, augmentation strategies, and closed-loop systems. The path forward requires randomized trials demonstrating that biomarker-guided personalization improves outcomes beyond standard care, justifying increased complexity and costs. Success would mark an important pathway in interventional psychiatry's evolution to precision medicine.
Primary orbital Ewing sarcoma (POES) is an exceptionally rare and aggressive malignant tumor, particularly in the pediatric population. We report the case of a 14-year-old girl who presented with progressive right eye proptosis, visual disturbances (finger counting at 2 m), headache, and vomiting over a 4-month period. Imaging revealed a mass involving both intraorbital and extraorbital compartments with signs of optic neuropathy. The patient underwent right frontotemporal craniotomy with subtotal debulking of the tumor. Histopathology and immunohistochemistry confirmed a diagnosis within the Ewing sarcoma family (diffuse CD99 and NKX2.2 positivity). Molecular confirmation for EWSR1 rearrangement by fluorescence in situ hybridization (FISH) or reverse transcription polymerase chain reaction (RT-PCR) could not be performed due to resource limitations. She received VAC/IE-based adjuvant systemic chemotherapy. At 6 months, the patient remained clinically stable with improved proptosis and visual function (right eye: finger counting at 6 m; left eye: 6/6), without clinical evidence of progression. The orbit is an extremely uncommon site for Ewing sarcoma, posing diagnostic and therapeutic challenges. This case reinforces the importance of early recognition, surgical decompression when vision is threatened, and coordinated multidisciplinary management; however, a 6-month follow-up is early and does not permit claims of durable remission or long-term oncologic control. To the best of our knowledge, POES remains exceedingly rare in the Asian subcontinent, with only a limited number of cases reported.
Background: The 3rd ECTRIMS Winter School highlighted regional and global disparities in resources needed to implement the 2024 McDonald diagnostic criteria for multiple sclerosis. Objectives: To assess the availability of paraclinical tools and regional differences in access reported by neurologists in an online survey. Results: The survey was completed by 328 neurologists from 44 countries. Core diagnostic tools, including magnetic resonance imaging and oligoclonal band testing, were widely available. Access to advanced imaging, optic nerve assessment, and laboratory biomarkers varied across regions. Conclusions: Variability in access to key paraclinical tests may impact on the implementation of the 2024 McDonald criteria globally.
Parkinson’s disease (PD) is a progressive neurological disorder that significantly impacts quality of life. Over the past 25 years, deep brain stimulation (DBS) has emerged as an effective treatment option for individuals with advanced PD.. However, in India, DBS remains underutilized primarily due to financial constraints and a general lack of awareness, compounded by biases towards certain treatment centers. Additionally, the absence of definitive guidelines for implementing DBS in India further hampers its accessibility and adoption. Based on expert consensus, we propose a stepwise, five-point approach to optimize clinical outcomes for deep brain stimulation (DBS). This approach focuses on key areas including patient selection, indications for DBS in cases of medically refractory levodopa-induced motor complications or resistant tremor, and precise target selection. We emphasize the necessity of ensuring psychiatric stability and highlight the importance of a multidisciplinary approach, a comprehensive preoperative evaluation by multidisciplinary team of specialists including movement disorder experts, functional neurosurgeons etc critical for better, long-term outcomes. Furthermore, we recommend that DBS procedures be performed at specialized centers to ensure the highest standards of care and expertise.
