PURPOSE:Midface fractures comprise 23-97% of all facial fractures. Due to the high-speed road traffic injuries (RTI), the fracture pattern has drastically changed from the classic Le Fort pattern to a combination of these lines with varieties. The purpose of this study is to observe the Le Fort fracture lines seen nowadays. MATERIALS AND METHODS:A retrospective observational study was conducted to evaluate the Le Fort fracture pattern lines. The fracture lines were traced using computed tomography of face to visualise the Le Fort fracture line course as described by Rene Le Fort. RESULTS:Out of 513 patients, isolated Le Fort fracture lines are seen in 40.28% of cases. Ideal fracture lines are seen in only 9%. Combination of Le Fort I and II lines seen in 23%, Le Fort II and III- 10.4%, Le Fort I and III- 6%. All the Le Fort I, II, and III lines were seen in 20% of cases. CONCLUSION:This study demonstrates that ideal Le Fort fracture lines are observed in 9%. Rest all fracture lines are either unilateral, incomplete, or in combination. This illustrates the influence of the direction and velocity of the force, along with the mechanism of injury applied to the face, leading to diverse presentations. Therefore, individualised CT-based analysis and reconstruction tailored to the displaced fractured segments are essential for optimal outcome.

Successful non-operative management (NOM) of penetrating injuries requires intensive patient monitoring and the immediate availability of advanced imaging and facilities for radiological interventions. We report a patient with multiple penetrating chest and neck injuries, including a traumatic pneumopericardium and a neck hematoma. While the focus was on the traumatic pneumopericardium, the neck injury manifested as a delayed vascular lesion and bleeding. However, both injuries were managed successfully non-operatively. This case emphasizes that NOM of multiple life-threatening penetrating injuries should be attempted in a facility with appropriate resources and that a multidisciplinary approach is crucial. We need to give equal importance to each injured region, with particular attention to the patient’s physiology.

BACKGROUND:Neurocysticercosis (NCC) remains a major cause of seizures in low- and middle-income countries, often progressing to chronic epilepsy due to calcified granulomas. The role of electroencephalographic (EEG) in predicting prognosis and guiding treatment in calcified NCC remains uncertain. OBJECTIVE:The objective was to estimate the prevalence of surface EEG abnormalities in 5-18 years old seizure or epilepsy patients with single calcified neurocysticercosis lesion (CNL) and to understand the concordance of topographic anatomic localization to surface EEG abnormality localization, semiology localization. METHODS:This cross-sectional study was performed in a tertiary care center in northern India. Children with epilepsy aged 5-18 years with single CNL on computed tomography (CT) scan were screened and those with seizure onset at least a year prior to recruitment and receiving standard of care for epilepsy were enrolled. The demographic profile, clinical details including seizure semiology, localization and lateralization, treatment history, CNL topography on CT scan, EEG findings and other relevant investigations were obtained. RESULTS:Out of the 366 pediatric patients screened, 61 cases were enrolled. EEG was performed on 60 patients. Focal seizures were most noted (88%, n = 53/60). Clinical localization was to frontal lobe (73.5%), temporal lobe (22.6%), parietal and occipital lobe in one patient each. EEG showed interictal discharges and or background EEG abnormalities in 48% (n = 29/60, 95% CI: 35%-61%). Interictal EEG abnormalities predominantly localized to frontal (86%, n = 25/29), parietal (7%, n = 2/29), and occipital (7%, n = 2/29) region. EEG and clinical semiology-based localization showed 78% crude agreement (P value - 0.02). Concordance between seizure semiology localization and anatomic localization on CT was 80% (P value- 0.0009). CONCLUSIONS:There was significant concordance between clinical, electrical, and radiological localization of CNL. Frontal and temporal lobe were most common symptomatic zones for focal epilepsy in this cohort.

Background Traumatic brain injury (TBI) sustained abroad creates major clinical, logistical, and psychosocial challenges. Guidance on the timing and safety of aeromedical repatriation after cranial surgery remains inconsistent and largely unvalidated. Case description A 26-year-old foreign national presented unconscious after a hotel-balcony fall. Computed tomography showed a right frontotemporoparietal acute subdural haematoma with bilateral basifrontal contusions. Intervention and outcome Following resuscitation, he underwent decompressive craniectomy and haematoma evacuation. After tracheostomy and neurocritical-care stabilization, multidisciplinary coordination was undertaken with his family, insurer, authorities, and receiving centre. Pre-flight assessment confirmed neurological and cardiopulmonary stability, secure airway and ventilation, and absence of pneumocephalus and pneumothorax. Three weeks after surgery, transfer by ventilator-equipped fixed-wing air ambulance was completed without reported complications. Systematic review A PRISMA 2020-aligned focused review was conducted on aeromedical transfers for patients after decompressive craniectomy for severe TBI. Of 737 records identified, 58 full-text reports were assessed, and twenty-six primary studies were included in the narrative synthesis; eight professional guidance, consensus, and regulatory documents were synthesized separately. Evidence was heterogeneous, comprising mainly retrospective military cohorts, surveys, mechanistic models, and case reports. Secondary physiological insults during transport—not elapsed postoperative time alone—were the recurring risk. Evidence relating intracranial-air volume to deterioration was inconsistent, and no universally safe volume or validated post-craniectomy interval was identified. Conclusion Long-distance repatriation after decompressive craniectomy may be feasible following structured multidisciplinary assessment, physiological optimisation, exclusion of trapped intracranial or thoracic air, and appropriate cabin-pressure and monitoring strategies. The proposed defer/conditional/ready pathway requires prospective validation.

While fat embolism commonly occurs following fractures of the long bones and the pelvis, it is also frequently reported after procedures such as hip or knee arthroplasty and intramedullary nailing. Contributing risk factors include obesity, immobilization, and osteoporosis. In contrast, its association with vertebral fractures is exceptionally rare. We hereby report an unusual case of fat embolism following an anterolisthesis and a right facet joint fracture of the C5-C6 vertebra. The review of literature reports only four cases in which the fat embolism was seen associated with vertebral compression or displacement fractures. Fat embolism following an isolated facet fracture of the vertebra has not been reported so far. Through this case report, we address a rare yet important association between fat embolism and vertebral fracture.

OBJECTIVE:Paradoxical reactions (PR) in pediatric HIV-negative CNS tuberculosis remain underexplored. This study prospectively analyzes incidence and pattern of PR and its impact on functional outcome. METHODS:Children (6 months-14 years) with newly diagnosed CNS Tuberculosis using the Lancet Consensus Scoring System, were enrolled. All participants received standard anti-tubercular therapy (ATT). Clinical evaluation, CSF analysis and neuroimaging were performed at baseline, during clinical worsening, or at 8 weeks. PR patterns defined as worsening or new tuberculosis lesions or symptoms following initial improvement after ≥10 days of ATT, were documented. Functional outcomes were assessed at 6-months using the Pediatric Cerebral Performance Category (PCPC) scale. RESULTS:Of the 57 participants enrolled [04 with rifampicin resistance were excluded; 24/53 had deterioration within initial 12-weeks of which 17 children qualified for PR (32%; median onset-3.5 weeks; range: 2-7 weeks). Two children developed late-onset PR beyond 12 weeks. [Total PR = 19 (Early-17; Late-2)] Common clinical features included focal neurological deficits (47%) and fever (42%). Prominent radiological patterns were infarction (47%), new or enlarging tuberculomas (37%) and spinal arachnoiditis (37%). Thirteen of 19 cases required additional anti-inflammatory treatment. BMRC Stage 2 and 3 independently predicted PR. PR was associated with unfavourable outcome on PCPC scale (adjusted OR = 34.3; 95% CI: 3.42-343.71; p = 0.001). CONCLUSION:PR occurs in approximately one-third of pediatric HIV-negative CNS tuberculosis cases, typically early in treatment. Early recognition is essential to distinguish PR from disease progression or drug resistance and to avoid inappropriate treatment modifications.

Background Traumatic Brain Injury (TBI) poses a significant public health challenge in India, with nearly 2 million cases annually and limited CT availability causing delays in diagnosis. This study evaluated CEREBO®, a machine learning-enhanced near-infrared spectroscopy (mNIRS) device, as a rapid, non-invasive triage tool for TBI. Methodology A prospective quasi-experimental study was conducted at AIIMS, New Delhi, enrolling 202 suspected TBI patients. Participants were divided into control (standard care) and experimental (standard care + CEREBO®) groups. CEREBO® findings were compared with CT as the gold standard. Diagnostic performance (sensitivity, specificity, accuracy), time to preliminary diagnosis, and potential of impact on triage decisions were assessed. Results CEREBO® demonstrated high diagnostic performance with 98% sensitivity, 90% specificity, and 93.9% accuracy for detecting intracranial pathology. In a post-hoc exploratory simulation, using CEREBO®’s negative result as a hypothetical criterion for deferring CT suggested that CT imaging could have been potentially avoided in 82.1% of red (critical condition) cases and 80.6% of yellow (stable but urgent) cases. These simulations also indicated that CEREBO® may help identify patients whose urgency of care could be underestimated by initial triage classification. Conclusion The NIRS device demonstrated rapid, non-invasive assessment capability across a broad patient population, supporting its potential utility as an adjunct screening tool in resource-limited trauma settings. These findings suggest that the device may help streamline triage, optimize CT utilization, and improve workflow efficiency in high-volume emergency environments.

BACKGROUND:This study was undertaken to validate the 2023 myelin oligodendrocyte glycoprotein (MOG) antibody (Ab)-associated disease (MOGAD) diagnostic criteria among children with acquired demyelinating syndromes. METHODS:In this multicentric retrospective study, all children aged <18 years, diagnosed or followed up by pediatric neurologists for acquired demyelination between January 1, 2017, and December 31, 2022, were included if they had undergone at least one MOG-Ab testing. The 2023 MOGAD diagnostic criteria were applied retrospectively. The pediatric neurologist's clinical diagnosis of MOGAD served as the gold standard to assess the criteria's performance using sensitivity, specificity, PPV, and NPV. RESULTS:A total of 388 children were subjected to the 2023 MOGAD criteria. A clinical diagnosis of MOGAD was made in 190 children (true-positives), having a median (IQR) age of 7 (4.7-10) years and a median (IQR) follow-up of 48 (41-56) months; 196 children were true-negatives, not fulfilling 2023 criteria or diagnosed as MOGAD. Two children were false-positives, fulfilling criteria but diagnosed as multiple sclerosis. The 2023 MOGAD diagnostic criteria demonstrated a sensitivity of 100% (95% CI = 98.02%, 100%), specificity of 98.99% (95% CI = 96.39%, 99.82%), PPV of 98.96% (95% CI = 96.28%, 99.81%), NPV of 100% (95% CI = 98.08%, 100%), and diagnostic accuracy of 99.48% (95% CI = 98.15%, 99.94%). MOGAD criteria performed similar to MOG-Ab alone, as all MOGAD diagnoses were confined to seropositive patients. CONCLUSION:The study demonstrates excellent performance of the 2023 MOGAD diagnostic criteria among children with acquired demyelination; however, the criteria did not enhance the diagnostic accuracy of antibody testing alone.

BACKGROUND:This study discusses results of multimodal evaluation of biomarkers of neuroinflammation and neurodegeneration in cerebrospinal fluid (CSF) and Fluorodeoxyglucose-positron emission tomography (18F-FDG-PET) findings in Subacute sclerosing panencephalitis (SSPE). METHODS:Consecutive children (3-14 years) with SSPE fulfilling the Dyken criteria during the study period (2020-2022) were enrolled. Clinical profile, radiological and electroencephalography data were chronicled. CSF interleukins (ILs) IL-4, IL-6, and IL-10; interferon-gamma; and neurofilament heavy chain (NFH) levels were analysed and compared with age matched pseudo-controls. 18F-FDG-PET imaging was performed in a subset of children who consented for the same. RESULTS:Thirty-three children with SSPE were enrolled [mean age 8.06 ± 2.67 years; males: 82%; Jabbour Stage I-6%, Stage II-67%, Stage III-27%]. Two forms of presentation were seen: short/absent stage I with early onset myoclonic jerks (N = 22; mean age of onset 7.85 ± 2.45) and prolonged stage I with late onset epilepsy (N = 11; mean age 6 ± 1.9 years, P = 0.03). CSF NFH was significantly elevated in SSPE [132.62 (53.6-388.9) vs 0.0 (0-16.9) pg/ml; P = 0.0001] compared to the pseudo-controls. CSF IL-6 (pg/ml) in 21/22 SSPE [1.72 (0.85-3.04)] children and 16/17 pseudo-controls [2.60 (1.72-3.83); P = 0.17] were similar. IL-4, IL-10, and interferon-gammas were undetectable in both the groups. 18F-FDG-PET showed putaminal hypermetabolism in 7/9 (78%) and thalamo-cerebellar hypometabolism in 8/9 (88%) with variable foci of cortical hypometabolism. CONCLUSIONS:Elevated CSF NFH levels suggest ongoing neuronal loss in SSPE. Cell mediated immunity is altered, and active neuroinflammation (T-cell mediated) may not be contributing to the ongoing neurodegeneration. 18F-FDG-PET imaging consistently reveals putaminal hypermetabolism alongside thalamo-cerebellar hypometabolism, which may prove valuable in diagnosing challenging SSPE cases.

We report the case of a 50-day-old infant with a nasopharyngeal mass causing respiratory distress at birth. Imaging revealed a mass from the clivus and features indicative of tuberous sclerosis complex (TSC), including cortical tubers and subependymal nodules. The mass was surgically excised, with histopathology confirming chordoma. Genetic analysis identified pathogenic mutation in TSC2 gene. Postsurgery, he had residual disease and was treated with mammalian target of rapamycin (mTOR) inhibitor sirolimus, leading to complete resolution. This case is notable as it represents the first instance of mTOR inhibitor use resulting in complete resolution of TSC-associated chordoma, suggesting potential for further research into mTOR therapy for chordomas.

Background:Injuries, especially maxillofacial fractures, pose a significant global health burden exacerbated by increasing traffic activities. Early detection is vital for preventing complications. This study assesses ultrasound's diagnostic efficacy, aiming to improve patient management and minimise treatment delays by detecting maxillofacial fractures promptly and accurately. Objective:The main aim was to assess point-of-care ultrasound (POCUS) in diagnosing maxillofacial fractures against computed tomography (CT) scans. Secondary goals included identifying ocular injuries, mandibular fractures, assessing probe feasibility and comparing Le Fort classification via ultrasound and CT. Methodology:Between January 2019 and February 2021, 150 trauma patients (136 male) with a mean age of 28.5 ± 5 years (range, 18-62 years) suspected of maxillofacial fractures were enrolled. A trained physician performed facial ultrasound, and findings were documented alongside CT scan results. Using the SPSS software, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of POCUS against CT scans were analysed. Results:Among 150 patients, CT scans diagnosed 137 with maxillofacial fractures, primarily due to road traffic accidents. Zygomatic fractures were most common, followed by nasal bone and mandibular parasymphysial fractures. POCUS exhibited high sensitivity (98.9%), specificity (99.1%), PPV (92%), and NPV (99.8%) for overall facial fractures, varying by bone. Associated occult ocular injuries occurred in two patients. Sensitivity and specificity were high for mandibular fractures. 5-10 MHz frequency linear probe, footprint-50 mm was optimal for midfacial bones, but Le Fort fractures could not be reliably identified using ultrasound. Conclusion:The study underscores the value of POCUS in the Emergency Department for detecting maxillofacial fractures, despite limitations such as anatomical challenges. POCUS showed high diagnostic accuracy, emphasising its potential in clinical practice, requiring further validation and exploration.

BACKGROUND:Low frequency repetitive transcranial magnetic stimulation (rTMS) can suppress local neural circuits beyond the stimulation period and can be a potential treatment option for focal epilepsy. This study analysed the short-term effect of rTMS on seizure frequency, EEG, behavior, and cognition in children with drug refractory focal epilepsy (DRFE). METHODS:This is a single center, randomized double-blind sham controlled clinical trial (CTRI/2019/02/017,440). Children aged 5 to 18 years with DRFE with ≥ four focal seizures per month despite on ≥ two appropriately chosen antiseizure medications (ASMs) randomly received active or sham rTMS treatment along with the ongoing ASMs. Intervention comprised of 45 min rTMS sessions of 0.5 Hz (1200 pulses at 110 % of resting motor threshold (RMT) targeted over seizure focus using figure-of-8 coil for 10 consecutive days. The primary outcome was to compare the proportion of children who achieved >50 % seizure reduction in active and sham arm at 8-week post-therapy. RESULTS:Forty-nine children were enrolled in the trial (25 active and 24 sham). All randomized participants received the allocated treatment. No attrition occurred. Active rTMS therapy led to >50 % seizure reduction in 76 % (19/25) children versus 12.5 % (03/24) in sham arm (p < 0.0001) with absolute risk difference (95 % CI) between the groups was 0.68 (0.52, 0.84). Mean (SD) reduction in spike wave index (SWI) in sleep EEG was 34.4(29.9) with rTMS vs -1.89(22.5) in sham arm with absolute risk difference (95 % CI) -36.4(-51.7, -21.1). Between active and sham group mean (SD) change in Intelligence quotient (IQ) was 3.7(2.8) vs -0.91(3.1), p value 0.001; Child Behavior Checklist (CBCL) scores improved in behavioral domains of inattention (-5.5(3.8) vs 0.41(2.7), p < 0.001; hyperactivity -3.8(4.1) vs -0.5(2.8), p < 0.006 and aggression -4.1(2.4) vs 0.40(2.8), p < 0.001. Adverse effects were primarily limited to headache and scalp discomfort. CONCLUSION:Adjunctive low frequency rTMS may induce better short-term seizure control and electrographic improvement compared to sham stimulation in children with DRFE. These results will serve as a basis for a larger multicentric clinical trial.

Hematopoietic stem cell transplant(HSCT) is the only modality that, if performed in the early- stages of cerebral X-linked adrenoleukodystrophy(X-ALD) can lead to good outcomes. Loes- score, calculated based on the findings of the magnetic resonance imaging(MRI) of the brain, helps in the selection of patients for HSCT. As per recommendations, the Loes-score should be <10 for a patient to be eligible for HSCT. Here we report a child of cerebral X-ALD with Loes of 12, but a good neurological function score(NFS), who was treated with HSCT, and had good outcomes. It is therefore important to utilize other parameters along with the Loes score, in selecting patients for HSCT in X-ALD.