Neurophysiological monitoring is practiced as a diagnostic modality to determine intraoperative neural damage. There remains a dearth of significant research underlining its role in determining a patient's motor or sensory improvement, along with predicting postoperative neurological deficit. To study the intraoperative neurophysiological changes in somatosensory-evoked potential (SSEP) and motor-evoked potential (MEP) in spinal surgery cases and their use as determinants of postoperative outcome. A prospective observational study. Patients undergoing spine surgeries, irrespective of their etiology and procedure, were monitored using MEP and SSEP. Groups were made based on changes in intraoperative neuromonitoring data. Outcome was observed by clinical assessment, in the immediate postoperative phase (after 48 h) and after 6 months. Total of 68 patients were included. Patients who had transient MEP decline had no postoperative deficits. On the contrary, these patients, along with the cases with no MEP change or improved MEP trace from baseline, had improvement from baseline motor examination. Of the nine patients showing a permanent MEP decrease, eight had postoperative motor deficits. Similarly, three patients had intraoperative SSEP decline, of whom 1 had postoperative sensory deficit. In 38 patients, there was improvement in MEP/SSEP from baseline readings intraoperatively, showing neurological improvement too. Along with supporting the hypothesis of benefits of intraoperative neurophysiological monitoring at predicting postoperative outcome and preventing clinical deficit, this study also suggests higher sensitivity and specificity of MEP as compared to SSEP in spine surgery cases.

Chondrogenic tumors of the head and neck are exceptionally rare and pose significant diagnostic challenges due to their clinical and radiologic resemblance to more common sellar and spinal lesions. We report two unusual cases: a chondromyxoid fibroma involving the sellar region in a 32-year-old man presenting with diplopia and headache, and a cervical spine chondrosarcoma in a 42-year-old man presenting with progressive quadriparesis. Magnetic resonance imaging in the first case revealed a well-circumscribed extra-axial sellar mass that was completely excised, with histopathology demonstrating lobulated stellate-to-spindle cells in a chondromyxoid stroma and immunonegativity for EMA, GFAP, and Brachyury, confirming chondromyxoid fibroma. The second case showed an expansile C2 vertebral lesion with infiltrative chondrogenic histology, binucleated chondrocytes, and strong D2-40 positivity with SATB2 and Brachyury negativity, consistent with Grade II chondrosarcoma. While the chondromyxoid fibroma patient remains disease-free at 24-month follow-up, the chondrosarcoma patient experienced rapid progression and succumbed within eight months postoperatively. These cases highlight the critical role of integrating radiologic features, histomorphology, and targeted immunohistochemistry in distinguishing benign from malignant chondroid tumors at anatomically complex sites, enabling appropriate management and prognostication.

Chronic migraine (CM) is the most prevalent headache-related disorder that affects 1% to 2% of the world's population. OnabotulinumtoxinA (BoNT-A) is a potent neurotoxin produced by Clostridium botulinum. In this study, we explored the health-related quality of life (HRQol) and the output of BoNT-A as a preventative therapy in CM patients. To assess the HRQol of the patients with CM on BoNT-A therapy by the headache impact test (HIT-6) score. Patients with CM (n = 51) were diagnosed and enrolled for the study. The impact of CM on Qol was assessed using the HIT-6 questionnaire at the beginning, 1 month and 3 months of the therapy. A significant reduction of HIT-6 score was observed 1 and 3 months post-BoNT-A therapy (P < 0.0001) as compared to pre-BoNT-A therapy. Our findings suggest that BoNT-A therapy can improve HRQol by reducing the incidence of migraine headaches. Thus, BoNT-A can be effective in the management of CM.

Awake craniotomy (AC) is primarily performed for specific surgical indications; however, medical conditions requiring AC are rarely reported. Anesthetic challenges of a patient with severe chronic obstructive pulmonary disease (COPD) and pulmonary bullae who underwent craniotomy and tumor excision are reported here. A 65-year-old diabetic woman presented with acute right-sided weakness, fever, altered mental status, and COPD exacerbation. The investigation revealed a left frontal lesion with significant perilesional edema, right lung bullae, bronchopneumonia, and hyponatremia due to the syndrome of inappropriate antidiuretic hormone (SIADH). After optimization by a multidisciplinary team, she was scheduled for craniotomy and partial excision. Given her pulmonary and neurological conditions, several anesthetic options were considered: general anesthesia (GA) with intermittent positive pressure ventilation (IPPV) utilizing low tidal volume, single-lung ventilation using a double-lumen tube/bronchial blocker, and AC using monitored anesthesia care (MAC). The potential risks and benefits of each technique were discussed, and it was decided to proceed with AC under MAC, using scalp block, dexmedetomidine infusion, intermittent propofol, and fentanyl boluses. A backup plan for conversion to GA was established in the event of severe coughing or seizure, and the equipment and personnel for emergency intercostal drainage (ICD) were on standby to address potential bullae rupture during IPPV. The family was informed of the complications associated with GA, including the risk of pneumothorax, ICD insertion, prolonged mechanical ventilation, and extended intensive care and hospital stay. A coordinated perioperative care strategy, facilitated by a multidisciplinary team, prevented morbidity in this case.

Dementia is an emerging public health challenge in India, particularly among older adults in rural and underserved regions. Early detection is crucial for timely intervention and care planning. However, existing screening tools, such as the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA), have limitations in low-literacy populations due to their reliance on reading, writing, and numeracy skills. In India's primary healthcare (PHC) settings-where time, training, and resources are limited-there is a critical need for a culturally appropriate, easy-to-administer cognitive screening tool. This study aimed to develop and validate a brief, culturally relevant, and literacy-independent tool-the Primary Healthcare Cognitive Screening (PHC-CS) tool-for the early detection of cognitive impairment among adults aged 50 years and above in Indian primary healthcare settings. The PHC-CS tool was developed through a multistep process, including a literature review, expert consultation, and field testing. The final 21-item tool assessed eight cognitive domains (memory, attention, language, visuospatial ability, executive function, orientation, constructional ability, and mental flexibility) using orally delivered tasks supported by visual aids. The tool was administered to 172 participants at a rural PHC in Karnataka. MoCA scores and neurologist-confirmed ICD-10 diagnoses served as reference standards. Psychometric validation included ROC curve analysis, internal consistency (Cronbach's alpha), test-retest reliability, and interrater agreement. At an optimal cutoff score of <45, the PHC-CS tool demonstrated an area under the ROC curve of 0.957 (95% CI: 0.922-0.992), with a sensitivity of 95%, a specificity of 92%, a positive predictive value of 96%, and a negative predictive value of 92%. Internal consistency was strong (Cronbach's alpha = 0.90), with good test-retest reliability (r = 0.88) and interrater agreement (κ = 0.88). The average administration time was 15 minutes. The PHC-CS tool demonstrates promising preliminary validity and feasibility for routine cognitive screening in Indian PHC settings, particularly for low-literate populations. Further multicentric validation is recommended.

The aim was to investigate reasons for a pre-hospital delay in patients with acute ischemic stroke (AIS) and patients within the thrombolytic window who did not receive thrombolysis. This study was conducted on AIS patients admitted to the stroke center through interviews and questionnaires. Of the 160 consecutive patients included, 67 (41.9%) arrived at the emergency department (ED) within 4.5 h, and 93 (58.1%) were delayed. The early arrival patients had shorter median onset-to-arrival times (P < 0.001). Of the 93 delayed patients, 70 (75.3%) were unaware of the occurrence of a stroke, and 17 (18.3%) had the stroke onset during sleeping. Multivariate logistic regression analysis showed that private car [odds ratio (OR) 4.310, 95% confidence interval (CI) 1.732-10.728] and other traffic tools (OR 6.189, 95%CI 1.843-20.786) were independent of a delayed arrival, whereas symptomatic remission, symptomatic aggravation, education of stroke, and the Oxfordshire Community Stroke Project classification were independently related to early arriving at the hospital after a stroke. Of the 67 patients, 33 (49.3%) who arrived within the window time did not receive thrombolytic therapy. Except for minor stroke (n = 9/27.3%) and contradictions (n = 2/6.1%), the main reasons for pre-hospital delay were patients' refusal (n = 12/36.4%) and misdiagnosis on the part of the physician due to atypical symptoms (n = 4/12.1%). Lack of stroke education, symptom stabilization, and non-emergency medical system utilization were the main reasons for the pre-hospital delay. Patients' refusal and misdiagnosis were the main reasons of patients who were eligible for thrombolytic treatment but did not finally receive thrombolysis.

It is with profound grief and deep sorrow that we mourn the passing of Dr. Arnold Menezes, Professor and Vice Chairman of the Department of Neurosurgery at the University of Iowa Roy and Lucille Carver College of Medicine and the University of Iowa Health Care Center. A towering figure in global neurosurgery, Dr. Menezes passed away peacefully on October 30, 2025, in Iowa City, at the age of 81. His death marks the end of an era in skull-base surgery, particularly in the treatment of craniovertebral junction disorders and complex pediatric neurosurgery. Born in Mumbai (then Bombay), India, Dr. Menezes came from a distinguished lineage of physicians—his father was a doctor, and both his grandfather and great-grandfather were surgeons. As a medical student at Topiwala National Medical College, Bombay University, he graduated at the top of his class in the mid-1960s. Even then, he recognized the tragic outcomes faced by children requiring neurosurgical care, at a time before CT and MRI imaging. Determined to change this reality, he set his sights on the United States as a place of opportunity for himself and his wife, Dr. Meenal Menezes, also a physician. Despite extraordinary academic merit, Dr. Menezes encountered overt discrimination while seeking training in the U.S., with many institutions rejecting him solely because of his nationality. He later kept some of those rejection letters as reminders of the barriers he overcame. The University of Iowa, however, recognized his potential and offered him the opportunity that would define his life’s work. He completed two years of general surgery training, four years of neurosurgery residency, and a fellowship in pediatric neurosurgery at Iowa—beginning a 50-year association that would transform the institution into a global authority in craniovertebral junction surgery. Early in his career, Dr. Menezes confronted the alarmingly high morbidity and mortality associated with disorders at the junction of the skull and spine. Refusing to accept the limitations of conventional approaches, he pioneered safer and more effective surgical techniques, including transoral approaches that were rare and poorly understood at the time. Working across disciplines—orthopedics, otolaryngology, biomechanics, radiology, and pediatric neurology—he personally designed and interpreted imaging studies to fully understand each patient’s anatomy and pathology. Through this meticulous and fearless approach, Iowa became recognized worldwide as a center of excellence in craniovertebral surgery. Dr. Menezes’ scholarly contributions were immense. He helped define the modern understanding and treatment of conditions such as basilar invagination, Chiari malformation, and craniovertebral abnormalities associated with Down syndrome. He was a founder of the North American Skull Base Society and an active leader in major neurosurgical organizations. His work laid the foundation for how these disorders are treated across the world today. Equally important was his devotion to education and mentorship. The University of Iowa’s neurosurgery residency program, shaped by Dr. Menezes, became one of the most respected in the United States. He also established a preclinical fellowship program that opened doors for aspiring neurosurgeons, many of whom went on to successful academic careers. Through visiting professorships, international courses, and the establishment of spinal neurosurgery programs across Europe, Asia, Africa, and beyond, he fostered a truly global community of neurosurgeons. Dr. Menezes received countless honors during his lifetime, but he held special pride in the Franc D. Ingraham Award for Distinguished Service and Achievement, awarded in 2019, the highest recognition in pediatric neurosurgery. In 2016, his legacy was permanently honored with the establishment of the Arnold H. Menezes Chair in Neurosurgery, made possible through philanthropic support from grateful patients and their families. Beyond medicine, Dr. Menezes was deeply committed to family, culture, and community. Together with his wife Meenal, he co-founded Kala Mandali, an organization dedicated to promoting South Asian arts and culture in Iowa, reflecting his belief that a life of science must also be enriched by humanity and heritage. Dr. Arnold Menezes’ journey—from facing rejection and prejudice to becoming a global legend in neurosurgery—is a testament to resilience, brilliance, and compassion. He leaves behind an enduring legacy in the countless patients whose lives he changed, the surgeons he trained, and the field of neurosurgery he helped redefine. He will be remembered not only as a master surgeon and scholar, but as a mentor, visionary, and humanist whose influence will continue for generations.

Sir, Restless leg syndrome (RLS) is a common neurological disorder characterized by an uncontrollable urge to move the legs, often accompanied by discomfort, especially during periods of rest or inactivity in the evening or at night.[1] RLS affects roughly 5–10% of the global population, with a female-to-male ratio of 2:1. While RLS traditionally involves the legs, it can also manifest in other regions, leading to diagnostic challenges. We present a rare case of restless jaw syndrome (RJS), a regional variant of RLS that is confined to the jaw. A 36-year-old male presented with a three-year history of intermittent burning sensations in the right jaw extending to the anterior neck, accompanied by a strong urge to move his jaw. Symptoms worsened during periods of rest but improved with activities like chewing, talking, or singing. To alleviate his discomfort, the patient developed a habit of chewing substances such as cardamom. A neurological examination was unremarkable, and an MRI of the brain revealed an incidental arachnoid cyst in the right temporal region without significant mass effect. An MRI of the face, including a trigeminal nerve protocol, was not performed. Comprehensive laboratory tests, including serum ferritin levels, were normal (serum ferritin: 75 μg/L). Trials of gabapentin (300 mg twice daily) and carbamazepine (200 mg twice daily) resulted in minimal improvement. Given the symptom pattern, RJS—a potential isolated variant of RLS was considered. The patient was started on low-dose pramipexole (0.125 mg twice daily), with a gradual increase to three times daily. Over three months, the patient reported a 70–80% reduction in symptoms, as assessed subjectively and using the patient global impression of change (PGIC) scale, without adverse effects. RLS is primarily diagnosed clinically, with secondary causes ruled out through targeted investigations. While it predominantly affects the legs, isolated regional variants involving other areas have been documented.[2] This case met the International RLS Study Group diagnostic criteria, and the significant improvement following dopaminergic therapy supports the diagnosis. Differential diagnoses such as trigeminal neuralgia and burning mouth syndrome were ruled out based on clinical features, absence of intraoral sensory disturbances, and poor response to non-dopaminergic treatments. The distinction from burning mouth syndrome is critical, as the latter primarily involves intraoral dysesthesia rather than an urge to move the jaw.[3] The limited improvement with gabapentin and carbamazepine suggests that the underlying pathophysiology of RJS may be more closely linked to dopaminergic dysfunction rather than neuropathic mechanisms. While dopaminergic therapy was effective in this case, long-term follow-up is needed to assess the durability of symptom relief and potential relapses. This report underscores the need for heightened awareness of atypical presentations of RLS, such as RJS. Dopaminergic dysfunction and brain iron dysregulation are key mechanisms in the pathophysiology of RLS, and these regional variants likely share similar underlying pathways.[4] Recognizing such variants can facilitate early intervention with dopaminergic agents, providing substantial symptom relief. We recommend further research into isolated RLS variants to improve diagnostic criteria and management strategies, ensuring timely and appropriate care for affected patients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.