Introduction: Inter-hospital transfer (IHT) of neurosurgical patients is common; however, little is known about the impact of transfer parameters on clinical outcomes in the South Asian population. Although the transfer process is an important aspect of the continuation of care, the principles of safe transfer are still evolving in low and middle-income countries like Nepal. So, this study aims to describe the current status of IHT in neurosurgical patients and identify the predictors for poor outcomes. Methods: This was a prospective, observational, and analytical study done in the Department of Neurosurgery, Tribhuvan University Teaching Hospital (TUTH). All adult neurosurgical patients with cranial pathology referred from other hospitals were eligible for participation. Patients were admitted and managed as per the departmental protocol. Patients were followed up for 3 months for clinical outcomes, recorded as favorable and unfavorable. Different clinical and transfer parameters were analyzed to identify the predictors of poor outcomes in this patient population. Results: Of 936 neurosurgical patients presenting to TUTH emergency, 337(36.0%) were IHT patients. After the exclusion of 13 patients, 324 patients were included in the final analysis. The median age was 56.9(± 16.1) years. Two hundred ninety (90.0%) patients were transferred in an ambulance with only 2.1% of them being accompanied by a health worker. The overall unfavorable outcome was noted in 134(41.0%) whereas the mortality was 46(14.2 %.) On multivariate regression analysis, low admission Glasgow Coma Scale (GCS) and diagnosis of intracerebral hemorrhage (ICH) were significant predictors of poor outcomes. Conclusion: Inter-hospital transfer is common in neurosurgical practice. Low GCS on admission and diagnosis of ICH were found to be associated with unfavourable outcomes in our study. Though unfavourable outcomes are comparable with those who come directly to the hospital based on the contemporary literature, the practice of safe transfer should be instituted in the country.

Introduction: Spontaneous intracranial hemorrhage is the presence of a parenchymal bleed in the absence of trauma or surgery in brain. The original Intracerebral hemorrhage score utilizes the cut-off age of 80 years, whereas the modified Intracerebral hemorrhage score used a lower cut-off age which may better prognosticate the outcome of Intracerebral hemorrhage in the populations with shorter life expectancy. The primary objective of this study was to compare the original with modified intracerebral hemorrhage scores in predicting mortality in Nepalese population with intracerebral hemorrhage. Materials and Methods: Patients ≥16 years, with spontaneous Intracerebral hemorrhage, who were admitted in Tribhuvan University Teaching Hospital in the Department of Neurosurgery and Neurology between 15th March, 2019 and 30th November, 2019, were included in the study. Original and modified Intracerebral hemorrhage scores were recorded separately at the time of admission. The outcome was measured using the modified Rankin Scale at 6 months. To compare the predictive ability of original and modified Intracerebral hemorrhage for mortality and outcome, receiver-operating characteristics curves were compared; and areas under the curve was calculated. DeLong’s test was used to compare the area under the Receiver Operating Characteristic. Sensitivity and specificity were calculated for the diagnostic accuracy; and were plotted in Receiver Operating Characteristic. Youden's index was calculated to determine the discrimination ability of both scores. Result: A total of 89 patients were enrolled in the study. Only thirteen patients (14.6%) were ≥80 years. The 30-day and 6-month mortality was 24.7% and 33.7% respectively. Hosmer-Lemeshow test showed a good model fit for both the scores for mortality and good outcome at 6 months. Conclusion: Prediction of 30-day mortality by modified intracerebral hemorrhage score is similar to the original intracerebral hemorrhage score. However, there was a slight trend of better prediction for good outcome at 6 months, using the modified score.

Introduction: Nepal’s population is 30 million, and 28% are under the age of 14. There are only 116 neurosurgeons, with none specifically committed to pediatric neurosurgical practice, nor is there a dedicated pediatric neurosurgery center. Consequently, there is an immediate need for developing pediatric neurosurgery practices, requiring analysis of the most prevalent neurosurgical disorders endemic to Nepal to identify areas of treatment focus, in addition to training for pediatric neurosurgical subspecialists. In response to these needs, we present our initial experience surveying the current pediatric neurosurgical caseload at the tertiary referral center in Nepal and summarize key learning points derived from a visiting rotation at a high-volume United States (US) pediatric neurosurgical practice. Materials and Methods: Retrospective case analysis at a tertiary level neurosurgical referral center in Nepal; all operative cases 18 years of age or younger over a 5-year period were included, categorized by pathology and treatment. Following this, a three-month rotation at Boston Children’s Hospital (BCH) was subsequently reviewed to identify key learning points relevant to impacting practice upon return to Nepal. Result: There were 601 cases performed during the 5-year period. Male to female ratio was ~2:1. Common operative cases included trauma, hydrocephalus, tumors, brain abscesses, vascular malformations, craniovertebral junction anomalies, spinal dysraphism and seizure. With a focus on these conditions, rotation lessons from BCH were identified to improve treatment of these specific conditions in Nepal, with major learnings in operative efficiencies and resource allocation. The learning was applied to make changes in practice in the hospital. Conclusion: This work provides a current review of pediatric neurosurgery in Nepal and has highlighted the common neurosurgical treatments provided. These data will direct future areas of focus for training and resource allocation for planning a dedicated unit in Nepal. In addition, the experience at the US teaching hospital has led to the development of novel treatment strategies upon return to Nepal.

Background: Functional neurosurgery, particularly Deep Brain Stimulation (DBS) and ablative procedures like pallidotomy and thalamotomy, has emerged as a powerful tool in the treatment of medically refractory movement disorders. However, its application in low-resource countries like Nepal is limited. This study presents our early experience with surgical management of movement disorders at Bir Hospital using DBS and lesioning techniques. Methods: This is a prospective study from the period of April 2024 to June 2025 at the National Neurosurgical Referral Center (NNRC), National Academy of Medical Sciences (NAMS) Bir Hospital. Patients with advanced Parkinson’s disease or primary dystonia underwent surgical intervention. Four patients received bilateral Globus Pallidus internus (GPi) DBS, one patient received bilateral subthalamic nucleus(STN)DBS and three underwent unilateral radiofrequency pallidotomy. All surgeries were performed under local anesthesia except for IPG placement, which was done under general anesthesia. Patients were evaluated for improvement in tremor, rigidity, camptocormia, and dystonia. Clinical outcomes and complications were assessed over a follow-up period of up to one year. Results: All patients demonstrated significant clinical improvement in motor symptoms postoperatively. Four patients with over 1-year follow-up maintained sustained benefits. The remaining four, with early 1 month follow-up, also showed encouraging results. The outcomes between DBS and pallidotomy groups were clinically comparable. All procedures were completed safely with no perioperative complications. Cost remains the major barrier to widespread DBS adoption in Nepal. Conclusion: Both DBS and pallidotomy are effective and safe for the treatment of movement disorders. In resource-constrained settings, lesioning offers a viable and affordable alternative. Early surgical referral and government subsidy for DBS can improve access and patient outcomes in Nepal.

Introduction Modified electroconvulsive therapy (MECT) is widely utilized for severe psychiatric disorders, with ongoing exploration of stimulus parameters to maximize efficacy. The pulse width in electroconvulsive therapy (ECT), specifically brief pulse (1.5 ms) versus ultra brief pulse (0.5 ms), may significantly influence clinical outcomes. However, comparative data on efficacy in rural Indian settings are limited. Our objective was to compare the clinical efficacy of brief and ultra brief pulse widths in bitemporal modified ECT in patients with severe psychiatric disorders. Methods: This prospective, randomized comparative study was conducted at a rural tertiary care hospital in Northern India. Sixty-six patients aged between 18 and 60 years, diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, or severe depression, were randomly allocated to receive either brief or ultra brief pulse bitemporal MECT. Clinical efficacy was measured using standardized symptom rating scales including PANSS, BDI, YMRS, and CGI-S, administered pre- and post-treatment. Results: Both brief and ultra brief pulse width groups demonstrated comparable clinical efficacy across schizophrenia, schizoaffective disorder, bipolar disorder, and severe depression, with no statistically significant differences observed in symptom reduction between the two groups (p > 0.05). Conclusion: Brief and ultra brief pulse widths in bitemporal modified ECT exhibited similar clinical efficacy in the treatment of major psychiatric disorders. Given their equivalence in therapeutic outcomes, both pulse widths may be considered viable options for clinicians. Further studies with larger samples and diverse populations are recommended to reinforce these findings.

Introduction: Guillain Barre Syndrome or GBS is an acute immune mediated polyradiculoneuropathy which continues to be a serious problem worldwide ,causing respiratory insufficiency requiring mechanical ventilation in up to 30 percent of patients. This study aims to look at the clinico epidemiological profile and treatment outcome in GBS patients admitted in a tertiary level hospital in India. Methods: We conducted a retrospective study of adult patients with Guillain barre Syndome admitted at MOSC Hospital Kolenchery, Kerala, a tertiary care centre in south India, from January 2021 to January 2024. The case records of the study population were retrieved from medical records department and the clinical profile and outcomes were studied. Results: A total of 28 patients were recruited on the study of which 17 (61%) were male and 11 female. The mean age of the study population was found to be 50 years. A preceding history of infection was found in 68% of patients and included respiratory infections and gastroenteritis. Limb weakness was the most common symptom noted followed by sensory symptoms including pain and paraesthesiae in the extremities. Intravenous immunoglobulin was the most common treatment modality given in 65% of patients. The most common clinical variant was Acute Motor Axonal Neuropathy(AMAN) seen in 54% of patients followed by the demyelinating and bulbar onset forms. Ventilatory support was needed in 18% of patients and no cases of mortality were reported in the study population. Good treatment outcomes as calculated by the Hughes disability grading was achieved in 71 % of patients. Significant association was found between male sex and good outcomes. Conclusions: Guillain Barre syndrome affects patients of all ages with a male predominance and a preceding infection seen in the majority of patients. Axonal form of GBS is the most common variety seen and a good outcome is noted in the majority of patients.

Posterior reversible encephalopathy syndrome (PRES) is a relatively rare central nerve condition. Here, we report a case of PRES that developed during acute pancreatitis in a previously healthy man in his 40s. On the third day, his respiratory status worsened during management of acute pancreatitis, requiring sedated ventilatory support. During ventilator management, his blood pressure was well-controlled, and no electrolyte abnormalities were observed; however, the patient was in a state of marked systemic inflammation. On the 12th day, after improvement in acute pancreatitis and respiratory status, with discontinuation of mechanical ventilation, the patient presented with mild disturbance of consciousness and visual field disturbance. Magnetic resonance imaging (MRI) showed diffuse vasogenic cerebral edema, mainly in the bilateral occipital and parietal white matter. The patient was provisionally diagnosed with PRES and was administered oral verapamil, along with supportive care. On the 23rd day, his neurological symptoms disappeared. Cerebral edema completely disappeared on MRI four months later. In the present case, it was speculated that endothelial dysfunction secondary to the severe inflammatory state accompanying acute pancreatitis caused PRES.

Substance use disorder (SUD) remains a deeply entrenched public health challenge in Nepal. Despite advances in understanding addiction as a chronic medical condition, the national response continues to be shaped by cultural taboo, inadequate treatment models, and insufficient pathways for societal reintegration. This editorial argues that unless Nepal transitions from punitive and institutional approaches to a rights‑based, evidence‑driven model, the cycle of relapse, stigma, and marginalization will persist.

The peripartum period, covering late pregnancy through postpartum, brings significant changes that increase the risk of neurological disorders such as cortical vein thrombosis (CVT), osmotic demyelination syndrome (ODS), pituitary apoplexy, postpartum cerebral angiopathy (PCA), posterior reversible encephalopathy syndrome (PRES), and intracranial hypotension (IH). Accurate diagnosis relies heavily on MRI and CT, with MRI being especially useful for its detailed images. CVT often presents with severe headaches and seizures, detected on MRI through characteristic signs like the “empty delta sign.” ODS, linked to the rapid correction of low sodium levels, appears as T2 hyperintense lesions at specific locations. Pituitary apoplexy, involving sudden hemorrhage within a pituitary adenoma, typically requires high-dose corticosteroids and, in severe cases, surgery. PCA results from hormonal changes and shows as transient artery narrowing on MR angiography, managed with supportive care. PRES, associated with high blood pressure disorders, manifests as vasogenic brain edema, treated by managing blood pressure. IH, often seen after a dural puncture, leads to positional headaches and shows brain sagging on MRI, with treatments ranging from rest to epidural blood patches. Recognizing these imaging patterns is critical for timely diagnosis and effective treatment, ultimately enhancing outcomes for mothers & preventing peripartum morbidity & mortality.

Cerebral venous thrombosis (CVT) is one of the rarest causes of stroke in general population, where thrombosis occurs in cerebral venous system. Treatment of CVT is mainly done by heparin followed by vitamin K antagonist. Direct oral anticoagulants are introduced which are safe and effective against traditional therapy, however recent protocol do not recommend. A 22 year-male came to emergency department with chief complaints of severe headache, multiple episodes of vomiting and 2- 3 episodes of loose stool for 3 days. He had two episodes of abnormal body movement in emergency department. Computed tomography (CT) scan of head and then CT venography of head also were done after admission that reported venous thrombosis in superior sagittal sinus, bilateral transverse sinus and internal cerebral vein. Patient was admitted and treated with direct oral anticoagulant (rivaroxaban). He was discharged on 8th day of admission without any neurological deficits.