Annals of Indian Academy of Neurology
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Year : 2019  |  Volume : 22  |  Issue : 5  |  Page : 2-32


Date of Web Publication19-Sep-2019

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How to cite this article:
. Abstracts. Ann Indian Acad Neurol 2019;22, Suppl S1:2-32

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. Abstracts. Ann Indian Acad Neurol [serial online] 2019 [cited 2020 Jan 18];22, Suppl S1:2-32. Available from:

Friday, October 04, 2019, 08:30 AM-09:30 AM, Hall A

Platform Session 01: Stroke

SO1/9: Association between matrix metalloproteinases-9 (C1562T) gene polymorphism and risk of intracerebral Hemorrhage in North Indian population

Sagar R, Kumar A, Yadav AK, Raj R, Pandit AK, Dash D, Srivastava AK, Vivekanadhan S, Gupta G, Prasad K

Department of Neurology, All India Institute of Medical Science, New Delhi, India.

Background: MMP-9 is an inflammatory proteolytic enzyme having roles in extracellular matrix remodelling; BBB degradation and breakdown of vessel wall integrity may contribute to the pathophysiology of ICH. Objective: To investigate the relationship between MMP-9 gene polymorphisms and risk of ICH in North Indian population. Methods: Genotyping was performed by MALDI-TOF-Mass ARRAY method for 250 patients and 250 age-sex matched controls. Frequency distribution of genotypes and alleles were compared between cases and controls by using conditional logistic regression. We also estimated the serum MMP-9 levels of ICH cases. Results: Mean age of patients and controls were 54.9±12.8 and 55.5±12.8. A total of 109 (43.6%) deaths were observed at three months. Frequency distribution of alleles consistent with HWE. Conditional logistic regression analysis showed a significant association between MMP-9 gene polymorphism and risk of ICH under dominant model (OR=1.72; 95% CI 1.18 to 2.50; p<0.005) and after adjusting co-variates (OR=1.87; 95% CI 1.14-3.07; p<0.01) but not in recessive model. T allele was significantly higher in ICH cases (OR, 1.62; 95% CI, 1.15-2.28; P = <0.003). Serum MMP-9 level was significantly raised (p=0.02) in carrier homozygous polymorphic genotype of MMP-9 gene polymorphism compared to wildtype and heterozygous in patients with ICH. Conclusion: MMP-9 (C1562T) gene polymorphism significantly associated with increased risk of ICH in North Indians and also there is an association between serum MMP-9 level and mortality after ICH.

SO2/15: Determinants of aphasia recovery in first 3 months following first ever acute stroke: Experience from a tertiary care center stroke unit in Kolkata

Lahiri D, Dubey S, Ardila A, Sanyal D, Roy BK, Gangopadhyay G

Department of Neurology, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, Kolkata, West Bengal, India.

Introduction and Background: The recovery of aphasia following vascular event is a complicated subject because of multi-factorial interplay. Divergent evidences are available in literature regarding the predictors of aphasia recovery particularly in early post-stroke phase. The aim of the present study was to explore the determinants of aphasia recovery in first 3 months following first-ever acute stroke. Materials and Methods: Screened cases of first-ever acute stroke were included in this study. Bengali version of western aphasia battery (WAB), a validated scale, was used for language assessment. All patients underwent initial language examination during first week following stroke. Language tests were repeated between 90 and 100 days post-stroke in patients available for follow-up. Severity assessment was done by calculating aphasia quotient (AQ) and taking into account the severity scale as in WAB. Lesion assessment was done by using Magnetic resonance imaging (MRI) (3T) for ischemic stroke (if not contraindicated) and computed tomography (CT) for hemorrhagic stroke. Demographic factors (age, gender and number of years of formal education), lesion-related factors (type of stroke, lesion volume, cortical versus sub-cortical location and site of lesion) and initial severity and type of aphasia were taken as independent variables while aphasia recovery (in terms of no change versus change to a milder type or complete recovery) was the dependant variable. Chi square and Fisher's exact tests were done to study the factors associated with and without aphasia type change or recovery (as applicable). The means or medians of continuous variables were compared using the Student t test or Mann whitney U test (as applicable). Chi square automatic interaction detection (CHAID) was performed to assess predictor importance and formulate a predictive model for aphasia recovery. Results: Among 515 screened cases of first-ever acute stroke, 208 presented aphasia. At follow-up, 163 patients were available for repeat language assessment. On univariate analysis the following factors were associated with change to milder type or recovery-hemorrhagic stroke (p=0.000); pure sub-cortical stroke (p=0.001) and initial non-severe classification (p=0.000). From the perspective of initial aphasia type, most change (p=0.000) was observed with global aphasia and most recovery (p=0.000) was observed with milder aphasia types (trans-cortical motor, trans-cortical sensory and anomic). Sex and age were weaker predictors (p=0.291 and 0.512, respectively) with men and younger patients presenting better recovery. In CHAID analysis, most important predictor in favor of type change or recovery was found to be initial non-severe classification. The overall predictive value of the CHAID model was 67.2%. Conclusions: In our sample, the most important determinant of aphasia recovery in early post-stroke phase was initial severity of aphasia. Limitations: The effect of bi-or multi-lingualism on aphasia recovery was not considered in the present study. Further Scopes: The findings of the present study have potential towards building a scoring system for predicting post-stroke aphasia recovery.

SO3/53: Safety and clinical outcome of intra-arterial infusion of bone marrow derived mononuclear cells in subacute ischemic stroke: Randomized trial

Singh R, Khurana D, Sharma RR

Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Introduction: Stroke is a leading cause of death and the most common cause of physical disability in adults. Stroke causes a greater loss of healthy life years, as measured in disability adjusted life years, than other illnesses. Worldwide, 15 million people suffer a stroke each year; one-third die and one-third is left permanently disabled. A major unmet need exists for treatments that can reduce tissue injury progression and enhance functional recovery in patients with stroke. Aim: To assess safety and clinical outcome of intra-arterial infusion of bone marrow derived mononuclear cells in subacute ischemic stroke patients. Methodology: This was a single center; Prospective randomized open labeled blinded end point assessment that included five cases and ten controls. Subjects with subacute ischemic stroke were randomly assigned to the arm that received intra-arterial infusion of autologous BMSCs or to the control arm. Coprimary clinical effcacy outcomes were Barthel Index score and modified Rankin scale at day 30, 90 and 180 days. Secondary outcomes were change in infarct volume, National Institute of Health Stroke Scale (NIHSS) at day 30, 90 and 180. Main safety outcome was adverse events. Results: Five subjects received a mean of 4.16x107 CD 34 positive BMSCs at median of 26.2±14.89 days after stroke onset. There was no signifcant difference between BMSCs arm and control arm in the modifed Rankin scale (P value 0.247), Barthel's index (P value 0.484) and change in NIHSS score (P value 0.260) at 180 days. No adverse events were reported in two arms. Conclusion: This is the first randomized controlled trial for using intra-arterial BM-MNCs for treatment of subacute moderate to severe ischemic stroke. The present study concludes that intra-arterial infusion of BMSCs is safe, but without benefcial effect on treatment of stroke outcome.

SO4/61: Transcranial Doppler in assessment of intracranial arterial resistance in T2DM with stroke

Bhoyar V, Jawahar M, Ranganathan LN

Department of Neurology, Madras Institute of Neurology Madras Medical College, Chennai, Tamil Nadu, India.

Background: The majority of studies investigating the risk factors for stroke have focussed on extracranial arteries like carotids. Risk factors for involvement of intracranial arteries in stroke have not widely examined. The pulsatility index reflects the vascular resistance of intracranial arteries and could therefore be used as an estimate of the severity of vascular damage. Aim: The present study aimed to examine the influence of type 2 diabetes mellitus on intracranial vascular resistance in patients with a previous stroke. Materials and Methods: Transcranial doppler investigations were performed in 102 patients with previous stroke (40 with T2DM, 62 not with T2DM), at least 3 months after stroke occurred. blood flow velocities of ACA, MCA, PCA, BA and VA were measured and Gosling's pulsatility index was calculated. The maximal pulsatility index of intracranial arteries was defined to express the most pronounced damage. Results: Diabetic patients had a significantly higher pulsatility index than non-diabetic patients in all intracranial arteries. The maximal pulsatility index was also significantly higher in diabetics than in non-diabetics (1.29 +/-0.37 vs. 1.05 +/-0.20; p < 0.0001). The presence of diabetes (p<0.0001) and the age (p<0.0001) of patients were the only factors significantly predicting maximal pulsatility index. Conclusions: Diabetic patients with previous stroke have a higher pulsatility index than non-diabetic patients with previous strokes, indicating a higher increase in intracranial arterial resistance indicates a higher increase in intracranial arterial resistance and more severe damage to cerebral blood flow in diabetes mellitus.

SO5/75: Flow diverter devices in ruptured intracranial aneurysms

Pai P, Bhatkar S, Pillai D, Lahoti S, Alurkar A

Department of Neurology, King Edward Memorial Hospital, Pune, Maharashtra, India.

Background and Aims: Flow diverter devices (FDDs) are new generation stents placed in parent artery at the level of the aneurysm neck to disrupt the intra-aneurysmal flow thus favouring intracranial-aneurysmal thrombosis. The use of these stents is advisable mainly for unruptured aneurysms, particularly those located at the internal carotid artery or vertebral and basilar arteries, for fusiform and dissecting aneurysms with large necks and low dome to neck ratio. The role of FDDs in treating ruptured aneurysms is less clear. In this multi centre series, we retrospectively evaluated the effectiveness, safety and midterm follow up results of ruptured aneurysms treated by implantation of a Flow Diverter Device. Methods: Out of total 94 patients who underwent FDD treatment for aneurysms in last six years, the records of 44 patients who presented with SAH due to the rupture of an intracranial aneurysm treated with FDD were retrospectively reviewed. The average age at presentation was 48 years. Average WFNS score was 1.8. The mean delay between SAH and treatment was 4 days. Intraprocedural and periprocedural morbidity and mortality were recorded. Clinical and angiographic follow up evaluations were conducted between 6 and 12 months after the procedure. Results: Two ruptured aneurysms rebled post FDD treatment. Overall mortality rate was 9%. Overall morbidity rate was 12%. Follow up studies were available in 30 patients. Total occlusion of aneurysm was seen in 76.6% of patients. Conclusions: FDDs can be used in patients with ruptured aneurysms where conventional neurosurgical or endovascular treatments can be challenging.

SO6/125: Bedside prognostic scores for prediction of outcome in cerebral venous thrombosis patients

Anusha Challa, Raju GB, Gopi S, Kumar TS, Kumari UA

Department of Neurology, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India.

Background: Cerebral venous thrombosis has favourable prognosis but 15% die or become dependent. “User friendly risk scores” are required for clinical decision making and predicting prognosis. Objective: Clinical & radiological scores for assessment and predicting outcome in patients with CVT. Methods: We conducted Prospective Observational Study in 50 CVT patients from 2018 to 2019 in KGH Hospital and followed up for 3 months. Inclusion criteria-Patients with confirmative diagnosis of CVT based on history and radiological findings. Exclusion criteria - Age group < 18 yrs. Statistical analysis for cutoff of clinical scores - ROC curve. Components of CVT RISK SCORE (CVT-RS): coma, malignancy, deep venous thrombosis, male gender, intracranial haemorrhage, mental status disturbance. Components of CVT GRADING SCALE (CVT-GS): stupor/coma, parenchymal lesions > 6 cm, mixed CVT, meningeal syndrome, seizures. Components of CVST SCORE: venous sinuses effected with thrombus were noted. Results: Study included males-34, females-16 with mean age of 34 yrs and had predominantly subacute presentation. Main Risk factors for CVT - hyperhomocystenemia and postpartum. Common Clinical features were headache - 98% and seizures-71%. Thrombus commonly involved Superficial cerebral venous system (49) and deep veins (1). Cutoff scores predicting poor outcome, Sensitivity and Specificity for CVT RS: > 3,92 %, 20 %, CVT-GS: > 3, 92%, 95 %, and CVST score: 1.5, 85 %, 1% respectively. Conclusion: Analysis of Prognostic scores among CVT patients is a Novel Indian Study. These bed side scores useful to categorize CVT patients into low risk & high risk groups and allows timely interventions among high risk groups.

Friday October 4, 2019, 08:30AM-09:30AM, Hall B

Platform Session 02: Infections

IO1/41: Demography, clinical profile, radiology and Inflammatory markers in patients of SSPE-A prospective follow up study from tertiary care centre

Saurabh K, Chaurasia RN

Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.

Introduction: SSPE is a disease known since long time; its pathophysiology, epidemiology, clinical features and diagnostic criteria being well characterised. However in recent times due to widespread immunisation against measles, demographic features are ought to change. At the same time great progress has been made in the field of immunology, with new immunomodulatory therapies being constantly added to our armamenterium. Advances in MRI, like MRS and DTI can better delienate damaged areas of brain and provide us with more information. So, study of interleukines in CSF as well as MRS and DTI in SSPE cases hold great promise in current time. Aims and Objectives: 1) To study demographic features in patients of SSPE. 2) To study the clinical profile at baseline and follow up (after minimum period of 3 months). 3) To look whether inflammatory markers (IL2, IL4, IL6, IL10 etc) taken at baseline and followup correlate with disease severity. 4) Whether new modalities of MRI-MRS and DTI done at baseline and followup correlate with disease severity. Results: A total of 21 (14 male and 7 female) cases have been enrolled in study till date, with patients belonging mostly to poor socioeconomic strata and rural background. 13 patients had history of previous measles infection; 10 of these patients before age of 2 years. 6 patients presented in stage 2, 13 in stage 3 and 2 in stage 4. 6 patients have expired during study period. Most patients in stage 3 presented with a mixture of pyramidal and extrapyramidal signs apart from myoclonus.

IO2/65: Cranial nerve involvement in tubercular meningitis - Its role in diagnosis and prognosis

Synmon B, Kayal A

Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India.

Background: TBM is the most severe form of extra pulmonary involvement. Lack of specific and sensitive test calls for a multi-displinary approach to make the diagnosis at the earliest. Various factors help us to the aetiology ofmeningoencephalitis but cranial nerve involvement has the highest predictive value. Methods: A prospective study from August 2013 to September 2015 was carried in GMCH, Guwahati where 93 patients of intracranial tuberculosis was included. The diagnosis of intracranial tuberculosis was made based on a combination of clinical criteria, laboratory and Neuroimaging findings. Results: This present study comprised of 36 females (38.7%) and 57 males (61.3%) with a mean age of 32.3 ± 17.05 and a range of 2-72 years. The typical picture of meningitis was found in 78.6%. Focal neurological deficit and cranial nerve involvement was seen in 40 (43%) and 58 (62.4%) respectively. Among the cranial nerves (CN), the most commonly involved is the 2nd CN seen in 33 (35.5%), followed by 6th (16.1%), 7th (11.8%), 3rd (7.5%), 8th (3.2%), 9th & 10th, (2.2%) 4th (1.1%) and 5th (1.1%). Six patients developed visual loss and two patients hearing loss as sequelae. The presence of cranial nerve involvement and focal neurological deficit was shown to be associated with a bad outcome.(p value=0.04**, significant; Fisher's exact test). Conclusion: Bedside clinical examination of patients of meningoencephalitis to detect cranial nerve involvement will definitely help us with the diagnosis and prognosis of tubercular meningitis.

IO3/279: A clinicoradiological profile of skull base osteomyelitis: A short case series

Suresh L, Reddy MY, Parida S, Jaiswal SK, Kumar SB, Lalitha P, Osman MD, Murthy JMK

Department of Neurology, CARE Hospitals, Hyderabad, Telangana, India.

Background: Skull base osteomyelitis (SBO) is an uncommon condition with significant morbidity and mortality. We describe a short case series here. Materials and Methods: Prospective analysis of patients with SBO between January 2015 and March 2019. Diagnosis was based on radiology and organism isolation. Results: During the study period eleven patients (mean age 64.7 years; range 56-76) were admitted with SBO with duration of 1-12 months. Of them, 9 had diabetes, 4 had CKD. Source of infection was ear in 10 and paranasal sinuses in 1. The clinical syndromes were: polyneuritis cranialis in 8, cerebellar ataxia and hemiparesis in one patient each. Cranial neuropathies were unilateral in 6 patients and bilateral in 2 patients. Contrast MRI showed extensive SBO. Etiology was bacterial in all 6 originating from ear (Pseudomonas in 3; Streptococcus in 2; MRSA in 1) and fungus in one originating from paranasal sinuses and 2 from ear (Aspergillus). No organism was isolated in 2. All patients underwent extensive debridement of the source. Patients due to bacterial cause (6) were treated with appropriate antibiotics for 6 weeks/Patients with aspergillus etiology was treated with voriconazole for 6 months. Those with no organism isolated were treated with antibiotics (meropenam and vancomycin) for 6 weeks. All had favourable outcome. Conclusion: SBO is a potentially treatable disease and should be considered in diabetic patients with polyneuritis cranialis and adjacent ear or paranasal infections. Otogenic SBO type is most likely due to bacterial etiology and sinonasal due to fungus in tropical countries.

IO4/373: Clinico-radiological profile of pachymeningitis from a tertiary care centre in South India

Neeharika Mathukumalli, Kohat AK, Yareeda S, Tandra SR, Kandadai RM, Turaga S, Shaik J, Borgohain R, Kanikannan M

Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India.

Introduction: Hypertrophic pachymeningitis (HP) is a rare entity characterised by diffuse or localised thickening of the cranial dura mater with or without associated inflammation. There is scarcity of literature on pachymeningitis. Aim: To present the clinical and radiological features of all diagnosed HP cases in Nizam's Institute of Medical Sciences, Hyderabad from January, 2014 to June, 2019. Materials and Methods: Clinical, pertinent lab data and neuroimaging of all patients of HP were retrieved from the hospital database and analysed. Results: Fifty five patients were included. Headache was seen in all. Other common associations were cranial neuropathies and seizures. Ten of our patients were treated for chronic primary headaches in vain before the diagnosis of pachymeningitis. Supratentorial pachymenigeal involvement is more common than infratentorial, more so involving parietal and frontal convexities. 15 patients underwent dural biopsy - 5 turned out to be related to IgG4 disease, 5 tuberculous, 4 idiopathic and 1 remained inconclusive. Two patients had carcinomatous pachymeningitis. All patients received steroids. In addition, 22 patients were treated with ATT based on CSF cellular response/PCR based assays or other corroborative evidence elsewhere. Rituximab was given to one patient with IgG4 related pachymeningitis who did not respond to steroids. Conclusion: In our series, tuberculosis was the commonest cause of HP. A substantial number of patients with HP can have headache as the only presenting symptom. Physicians should be vigilant of this condition, especially when encountering a patient who did not respond to optimal treatment of chronic primary headache.

IO5/471: Serum CD4 count in patients with tubercular meningitis and its correlation with disease severity

Preetham Reddy A, Tandra SR

Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India.

Background: Tuberculous meningitis is one of the common infections of CNS. Tuberculosis infection require a cellular immune response for their control. CD4+ T-lymphocytes are most important in the protective response against Mycobacterium tuberculosis. Despite modern antituberculosis therapy, 20% to 50% of patients still die, and many of the survivors have significant neurological deficits. Methods: This is a single centre prospective observational study, done in between February 2018 to July 2018. All patients clinically suspected to have tubercular meningitis were included in this study. Serum CD4 levels were assessed and baseline data was collected. Results: The study population including 30 patients, consists of 16 males (53.33%) and 14 females (46.77%). The mean age of population is 28.07 (8-68). 13 (43.33%) and 7 (23.33%) patients belonged to Vellore grade 3 and grade 4 respectively. Hydrocephalous was present in 12 patients (40%) of patients. 8 patients (26.26%) had vasculitic infarcts on MRI imaging. TB GeneXpert in CSF was positive in 16 patients (56.33%). The mean CD4 count of study population was 293.83 cells/mm3 (87-707, SE:28.24). There is no correlation between disease severity based on Vellore grading and CD4 count (coefficient: -0.335, p=0.071). There is no statistical significant difference between CD4 counts in patients with or without vasculitic infarcts (coefficient:0.312, p=0.093) and with or without hydrocephalous (coefficient: 0.316, p= 0.089). Conclusion: Serum CD4 counts are lower than normal in patients with Tubercular meningitis. However, they are do not correlate with disease severity.

IO6/501: Spectrum of longitudinally extensive transverse myelitis in a tertiary-care centre: A study from Eastern India

Soumyadarshan Nayak, Mallick AK, Sahoo L, Mishra S

Department of Neurology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India.

Introduction and Background: Acute transverse myelitis (ATM) is a pathologically heterogeneous inflammatory disorder of the spinal cord. Longitudinally extensive transverse myelitis (LETM) is defined as a hyperintense spinal cord lesion extending over three or more vertebral levels on sagittal T2-weighted (T2W) spinal magnetic resonance imaging (MRI). The objectives of the study was to know the aetiology, clinical profile and radiological features of patients presenting with longitudinally extensive transverse myelitis (LETM). Materials and Methods: Prospective clinical study was conducted in department of neurology from September 2016 – November 2018, in department of neurology, XXX medical college and hospital, XXX. All admitted patients with paraplegia/paresis or quadriplegia/paresis with MRI showing LETM were included in the study. Evaluation of the aetiology was done by serological and radiological evaluation. Data were documented and evaluated by SPSS Version 24. Results: Total 81 patients were included in the study. Female: male ratio of 1.05:1 and 20-40 years group was the most common age. Bladder and bowel dysfunction was the most common presentation. Thoracic spinal cord segments were most commonly (56.76%) affected. 48 (59.26%) patients of LETM were clinically diagnosed as NMO according to revised Wingerchuk criteria. 19 (23.4%) patients were seropositive for Aquaporin antibody. EDSS score at one year was higher in LETM patients with positive AQP4-Ab (5.28 ± 1.28) as compared to patients with negative AQP4-Ab (4.24 ± 2.46). Conclusion: This study demonstrated that most cases of LETM were NMO. LETM patients with positive AQP4-Ab were associated with more optic neuritis, more relapsing remitting course and poor prognosis. These results suggest that detection of anti-AQP4 antibodies may result in earlier diagnosis of NMO in patients with LETM, so that appropriate immunosuppressive therapy may be started earliest to prevent relapses and overall disability. Limitations: Our study didn't have MOG antibody done as it was not available at that time. Further Scopes: As our series continues we will be adding MOG positive cases to our series and comparison between MOG and AQP4 positive cases.

Friday, October 04, 2019. 08:30AM-09:30AM, Hall C

Platform Session 03: Clinical Neurophysiology

CNO1/17: Nerve conduction study in early diagnosis of leprosy

Vasanthy B, Nair VCP, Haris AA, George J

Department of Neurology, Medical College, Kottayam, Kerala, India.

Nerve damage causes disability and stigma in leprosy. Declared eliminated leprosy is reemerging. Reduction in expertise of field staff (deputed to other programs) is one of the reason. Nerve conduction study (NCS) with clinical examination will detect leprosy early before disability. Objectives: Study use of 1. NCS to know nerve involvement in leprosy 2. Nerve biopsy in diagnosing neuritic leprosy. Methods: From electrophysiology lab, data-clinical & NCS of 36 patients (including biopsy of 7 neuritic) were collected from January 2015-January 2017. Results: Thirty four (34/36) patients each had abnormal NCS & thickened nerves. NCS was abnormal in 204 nerves while thickening occurred in 154. Seven had neuritic leprosy and 2 had NCS abnormality without nerve thickening. Thus NCS identified 9 patients who would have gone undetected for nerve involvement. Disability occured in six of 7 neuritic and 11 of 29 others. Disability risk is more for neuritic leprosy (RR-2.0714; CI-1.2213-3.5133. p=0.02). Four of seven (presenting as peripheral neuropathy) nneuritic patients had grade 2 disability & 2 developed grade 1 disability in a year. Disability is due to delayed diagnosis and treatment. Hence in all unadiagnosed peripheral neuropathy, NCS and nerve biopsy should be done to rule out possible leprous neuritis. Conclusion: Diagnosis of leprosy requires more expertise than it used to be. NCS identified nerve involvement in leprosy early and along with clinical examination and biopsy in selected cases it will aid in early diagnosis and treatment. All neuropathy patients should be subjected to NCS and biopsy.

CNO2/34: Normative value of F-wave latency in healthy adult population in a tertiary center in Eastern India

Pattnaik S, Pandit A

Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India.

Introduction and Background: F waves are the late response, first recorded by Magaldery and Mcdougal in 1950 from small muscles of the foot, there by the name “f”. When a supramaximal stimulation is given to a nerve fiber, there is both antidromic and orthodromic conduction of stimulus. The antidromic conduction stimulates a population of anterior horn cell and produces a f wave. Hence f wave checks the integrity of entire nerve and a very sensitive parameter to diagnosis a disease affecting root or proximal nerve early. study conducted from China (Pan et al.) 6, Japan (Kohara et al.) and Brazil (Nobrega et al.) have shown that f wave has a strong correlation with height and some unknown geographical influence, making its value country specific. Materials and Methods: Healthy volunteers aged 18-45, from West Bengal and adjoining areas, without any neurological history or abnormal neurological examination were included in the study. After obtaining consent they were subjected to nerve conduction study to find out f wave latency in bilateral median, ulnar and tibial nerves. The same machine was used record f waves parameter in order to maintain uniformity. Height of the volunteers was recorded. This study is a descriptive cross sectional study. The statistical analysis was done by SPSS software. Results: Total participant: 120 (female 53, male 67), Mean age 32.15±8.19 years, Mean height 159.87± 9.07 cm, F latency of left median 25.04±2.02 ms, F latency of right median 25.00±2.05 ms, F latency of left ulnar 25.00±2.05 ms, F latency of right ulnar 25.19±2.10 ms, F latency of left tibial 45.82±4.03 ms, F latency of right tibial 45.80±3.77 ms. F latency was significantly correlated with height irrespective of age and gender. Also comparison between various country specific studies revealed that f wave parameter is unique to its population. Conclusion: Our study reveals that mean F min latency is strongly correlated with height and it is unique to our population, as different country specific studies have yielded different results. This normative data is essential to early diagnosis of disease related to peripheral nerve, roots or plexuses, in proper clinical context. F wave latency is a sensitive parameter in diagnosis of peripheral neuropathy. Our country/population specific data should be followed in electrophysiology laboratories in our area, which is much less than that of Western countries. This will lead to increased sensitivity to diagnosing a nerve root disease much earlier. Limitation: The bigger sample size will lead to more accurate results. Further Scope: The study may be extended to calculate various f wave parameter abnormalities in different disease affecting nerves and roots (e.g. Diabetic neuropathy, GB syndrome), so that normal values of f wave parameter in our population can be validated against the abnormal values in disease state, to obtain a cut off value.

CNO3/71: Comparison of high frequency sonography and nerve conduction study in the diagnosis of carpal tunnel syndrome

Shringi P, Sardana V, Maheshwari D, Bhushan B, Kiran RB

Department of Neurology, Government Medical College, Kota, Rajasthan, India.

Introduction and Background: Carpal tunnel syndrome (CTS) is the most commonly reported nerve compression syndrome. Carpal tunnel syndrome accounts for about 90% of all entrapment neuropathy. CTS occurs due to compression of median nerve in carpal tunnel. Nerve conduction study (NCS) is considered as gold standard for diagnosis. However, during the past few years, ultrasonographic (US) confirmation of CTS diagnosis has been the subject of many studies for several reasons. There is lack of Indian studies on comparison between sonography and NCS so this study was conducted to show efficacy of sonography as compared to Nerve conduction study in diagnosis of carpel tunnel syndrome. Objectives: To compare the diagnostic value of high-resolution ultrasound with nerve conduction studies (NCS) in patients with clinically defined carpal tunnel syndrome (CTS). Design, Materials and Methods: Cross sectional, case control study. This study has been conducted for period of one year after getting clearance from ethical committee. A total of 50 patients (61 wrist) has been studied who have score equal or more than 12 on CTS – 6 score. Statistical analysis is done with SPSS-22 and Microsoft office excel. Results: Total 50 patients or 61 wrist studied with predominantly females 84% have positive tinel'sign, 74% have positive phalen's sign. All parameters compared with age and sex matched controls. For determining a cut off cross section area of right median nerve ROC curve analysis was done and found that CSA of 8.5 mm2 had sensitivity 68% and 92% specificity. This study shows 78% sensitivity and 98% specificity for NCS. Conclusion: High Frequency sonography provides high resolution, precise anatomical and physiological information of the median nerve in carpal tunnel. This study shows that sonography has lower sensitivity but has higher specificity for diagnosis of carpal tunnel syndrome so present study highlights the complementary role of ultrasound in diagnosing CTS jointly with nerve conduction studies particularly in patients with clinical diagnosis of CTS and negative NCS and ultrasound also detects structural abnormalities that may have therapeutic implications. Limitations: 1. Our study had a lower sensitivity when compared to the above studies, which could be due to small sample size or due to the interobserver variability. 2. For comparison between sonography and NCS we estimates only CSA area of carpel tunnel inlet other parameters for median nerve swelling didn't measured. Further Scopes: 1. Present study showed slightly low sensitivity as compared to previous studies probably due to low sample size so further studies needed with larger sample size for showing promising role of sonography in diagnosis of carpel tunnel syndrome. 2. Future studies can also compared role of wrist MRI along with sonography and NCS in diagnosis of CTS.

CNO4/220: Evaluation of high resolution ultrasonographic parameters in patients with peripheral neuropathies and its correlation with electrophysiological study

Pradeep Kumar, Thacker AK, Singh AK, Maurya PK, Kulshreshtha D, Qavi A, Narayan S

Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Over the last few years, neuromuscular HRUSG has grown as a worthy tool for diagnosis of peripheral neuropathies. With the course of time, clinical knowledge and experience with ultrasonography along with research and development have made it demanding tool for evaluation of peripheral nerve disorders. The purpose of study was to evaluate various high-resolution ultrasonography (HRUS) parameters of the peripheral nerves in patients with peripheral neuropathies as well as in normal healthy subjects. We tried to establish normal reference values for commonly examined nerves and correlate these findings with electrophysiolocal changes in same patients. We have also considered whether HRUS or electrodianostic study is preferable. Patients with peripheral nerve disease (Mononeuropathy multiplex, Polyneuropathy and mononeuropathy simplex etc.) based on clinical examination and confirmed by electrophysiological evidence of neuropathy has been enrolled in the study. Patients having any other neuraxial involvement has been excluded. The cross sectional area (CSA) of ulnar nerve (at elbow, 3 cm above elbow), median nerve (at wrist, 3 cm above wrist), tibial nerve (at ankle, 3 cm above ankle), common peroneal nerve (at Fibular head, 3 cm above FH) and sural nerve has been examined and compared on both sides.

CNO5/243: Quality of sleep in patients recovering from critical care illness in ICU and HDU

Bala K, Prajapat B, Chaudhary D

Department of Neurology, Pt. BD Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India.

Introduction: Sleep quality in paents recovring from critical care illness in ICU and HDU remains poor. Aim: To evaluate the sleep pattern and architecture in recovering patients in ICU and when shifted to HDU. Methodology: Prospective, hospital bsaed, crossectional, observational study on 26 patients, (M 14, F 12) with mean age 35.96+-11.6 yrs, admitted to ICU who could give consent. All patients underwent 24 hrs PSG study with simultaneous recoding of illuminace, noise and nursing care events in ICU and after being shifted to HDU. Observations and Discussion: Percieved sleep quality was very poor with mean score of 4.19+-1.16, nursing intervention and noise being disturbing factors. In ICU majority sleep was N1 (28.80+-7.3%) and N2 (60.3+-8.65%) with reduction of N3 and REM (6.66+-2.30%,4.20+-3.68% respectively), Mean arousal index was22.65+-10.49 suggestive of highly fragmented sleep. Comparing PSG data in ICU and HDU showed reduction in N1 (p=0.0001) and N 2 (p=0.021) and improvement in N3 (p<0.0001) and REM (p=0.01) in HDU with significant reduction in mean arousal index (AI) (22.65+-10.49, 16.55769+-5.15:p=0.006). Conclusion: Patient's sleep in the ICU was found to be poor, highly fragmented and disturbed. Both patient related factors (Age, severity of illness, comorbidities, preexisting sleep disturbances) and other factors (noise, light, nursing care events, use of drugs, IMV) are involved in pathogenesis. However this sleep disruption showed a trend towards improvement in HDU.

CNO6/473: Study of low dose of valproic acid in Indian patients with juvenile myoclonic epilepsy

Navneet Kumar, Gupta G, Verma A

Department of Neurology, Government Medical College, Kannauj, Uttar Pradesh, India.

Aim: Valproic acid (VPA) is most efficacious in patients with Juvenile myoclonic epilepsy (JME) but the studies regarding use of low doses of VPA are limited. The use of low dose of VPA substantially reduces the cost and side effects burden to the patient. Methods: This was a retrospective, cross-sectional study and it included a total of 190 patients (104 male and 86 female) diagnosed with JME in neurology OPD from January 2015 to March 2018 at LLR Hospital, Kanpur. Remission was defined as a seizure-free period of at least 2 years. Exclusion criteria include female patients with reproductive age group. 80 patients receive low doses of VPA < 750mg/day as monotherapy initially instead of the recommended starting dose of 20mg/kg while rest of the patients receive >750mg/day of VPA initially or polytherapy. The dose was escalated if patients have breakthrough seizure. Results: Remission was achieved with VPA monotherapy in 63 (78.75%) patients. No significant difference was found in seizure remission between low dose VPA and high dose VPA (p value< 0.05). The side effects were less in low dose VPA group. Conclusions: Low dose of VPA can be effectively used in JME patients to achieve remission.

October 04, 2019, 08:30AM-09:30AM, Hall D

Platform Session 04: Movement Disorder

MDO1/42: Assessment of quality of sleep in Parkinson's disease patients with orthostatic hypotension

Mahale R, Ravi Yadav, Pramod Pal

Department of Neurology, National Institute of Mental Health and Neuro-Sciences, Bengaluru, Karnataka, India.

Background: Rapid eye movement sleep behavior disorder in Parkinson's disease (PD) has been associated with orthostatic hypotension (OH). However, the sleep quality in PD patients with OH has not been evaluated. Objectives: To determine the quality of sleep in PD patients with orthostatic hypotension (OH) and to note any difference from those without OH. Methods: One hundred and fifty six patients with Parkinson's disease (PD with OH-59, PD without OH-97) were clinically examined and quality of sleep was determined using Pittsburgh sleep quality index (PSQI), Parkinson's disease Sleep Scale (PDSS), Epworth Sleep Scale (ESS) and Rapid eye movement behavior disorder screening questionnaire. Other scales included Uni? ed Parkinson's Disease Rating Scale-part III (UPDRS-III), Hoehn & Yahr Stage, Mini Mental Status Examination, Hamilton anxiety rating scale and Hamilton depression rating scale. Results: PD patients with OH had higher frequency of RBD (32.2%) as compared to those without OH (11.3%) (p=0.001), higher global PSQI score (p=0.03), higher percentage of patients with global PSQI score >5 (59.3%) than those without OH (39.1%) (p=0.01), suggesting poor quality of sleep in PD patients with OH, higher total ESS score (p=0.04), and lower total PDSS score (p=0.008). Conclusions: PD patients with OH have higher frequency of RBD with a poor quality of sleep and excessive daytime sleepiness.

MDO2/224: Clinical and electrophysiologic characteristics of tremor in tremor dominant Parkinson's disease patients

Kanchana Soman Pillai, Rajan R, Pandit AK, Srivastava A, Prasad K, Goyal V

Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Patients of tremor dominant PD have a different clinical profile compared to akinetic rigid type of PD patients, and have a slower disease progression. Aims: To study the clinical and tremorogram characteristics of 15 tremor dominant PD patients. Materials and Methods: Parkinson's Disease patients with mean tremor score of one point greater than mean bradykinesia and rigidity score were considered as tremor dominant PD. Fifteen such patients studied, on whom UPDRS and Tremor analysis (Spectral analysis) was performed in rest, arms outstretched, hands in front of chest, weight bearing, distraction and finger nose finger manoeuvre. Results: Mean right upper extremity resting frequency was 4.3Hz, and on left was 3.5 Hz. Right and left upper extremity mean peak amplitudes at rest were 60 and 44 μv respectively; on arms outstretched posture was 200 and 20 μv. Peak frequency on distraction was 3.8 and 4 Hz in right and left extremity; peak amplitude was 208 and 43 μV. No significant change in tremor frequency in rest and postures (p= 0.1, paired t test). Significant increase in tremor amplitude on distraction (p= 0.01, paired t test). Discussion and Conclusion: Significantly higher mean tremor amplitude on right side compared to left. No significant change in tremor frequency between in rest and postures. Significant increase in tremor amplitude on postures compared to rest, and on distraction. Findings indicate that tremor of tremor dominant PD patients tends to behave like ET tremor, and might indicate some similarity in pathophysiology.

MDO3/266: Sociocognitive assessment of auditory emotion perception in patients with Parkinsons disease

Namrata Jayaharan, Ranganathan L, Shunmugasundaram K, Manickavasagam J

Department of Neurology, Institute of Neurology, Madras Medical College, Chennai, Tamil Nadu, India.

Introduction: Neurodegenerative disorders are associated with defects in social cognition. Early recognition of these defects enables effective rehabilitation in these patients. Successful social interaction requires perception and processing of social signals and formulation of response to these signals. Social cognition involves studying basic processes such as facial expression, prosody and body language recognition. Aging by itself affects emotion perception which is exacerbated in patients with degenerative disorders. This study aims to determine the ability of patients with Parkinsons disease to perceive prosody. Materials and Methods: This study was conducted in Madras Medical College between April to June 2019. Patients with Parkinsons disease and age and sex matched controls were made to listen to 20 audio recordings of prosody in the regional language of six emotions which include happiness, sadness, anger, fear, disgust, surprise in the regional language. They had to identify the emotion presented. Results: Our study includes 32 male and 18 female patients with Parkinsons disease and matched controls. It was found that these patients have difficulty in recognition of prosody compared to normal individuals. These defects were more in patients with longer duration of and greater severity of disease. These results correlated with that of sociocognitive assessment using the comprehensive affect testing system. Conclusion: Social perception is impaired patients with Parkinsons disease. Defective recognition of prosody is a early marker of parkinsons disease dementia. Further reasearch is required to characterise the extent of deficit.

MDO4/326: Status dystonicus in children: A cross-sectional study from a tertiary-care center

Arushi Saini, Hassan I, Goyal K, Dhawan S, Sankhyan N, Sahu J, Suthar R, Saini L

Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: Status dystonicus is a life-threatening movement disorder emergency in children. Pediatric cases differ from adults in etiopathogenesis and management options. Methods: Cross-sectional study of children presenting with 'dystonic crisis' to a tertiary-care pediatric centre in India over the past 5 years. Results: A total of 45 children with a diagnosis of 'status dystonicus' or 'dystonic storm' were reviewed. Of these, 24 patients were found to be eligible. Mean age was 6.27+3.7 years. Underlying causes were cerebral palsy (37%), tubercular meningitis with arteriopathy (14%), probable mitochondrial disorder (13%), neurowilson (9%), post-hypoxic sequelae (9%), neurodegeneration with brain iron accumulation (5%), neurometabolic disorders (5%), venous thrombosis (4%) and autoimmune encephalitis (4%). Symptoms at presentation were abnormal posturing (50%), fever (25%) and developmental delay (8.3%). Mean duration of hospital stay was 16+14 days (median 10.5 days). Underlying triggers were intercurrent illness/infection (75%) ormprogression of underlying disease. All patients were managed according to the standard management guidelines including airway support, hydration, analgesia, sedation and muscle relaxation. Common anti-dystonia drugs were trihexyphenidyl (95.8%), diazepam (71%), baclofen (66.7%) and midazolam infusion (54.2%). Majority (54.2%) had both respiratory complications and rhabdomyolysis. 37.5% required ventilatory support/supplemental oxygen; 25% had elevated CPK and dehydration (21%). Death occurred in 12.4% cases. Conclusion: Due to lack of robust Indian data, our study presents a unique cohort of children with status dystonicus and their management options. Further studies are required to formulate evidence-based guidelines for management in resource-constrained settings.

MDO5/343: Hemichorea-Hemiballism: Report of 16 patients

P Ashwin Kumar, Pandey S, Tater P

Department of Neurology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India.

Introduction: Chorea is a hyperkinetic movement disorder which consists of involuntary, continual, abrupt, rapid, brief, unsustained, irregular movements that flow randomly from one body part to another whereas ballism is defined as large amplitude choreic movements causing flinging and flailing of limbs. Hemichorea and Hemiballism (HC-HB) are considered to be a spectrum of the same disease which differ in phenomenology. The causes of HC-HB have been described as case reports and only few case series report the possible spectrum of diseases or causes leading to HC-HB. Aim: To study the clinical features and imaging findings in a case series of sixteen patients of Hemichorea/Hemiballism. Methods: This is a case series of sixteen patients of hemichorea/hemiballism who presented to our movement disorder clinic between 2016-2018 and were evaluated for the side of involvement, probable causes, associated movement disorders and imaging findings. Results: The common cause of HC-HB in our series was Stroke (n=10, 62.5%) followed by hyperglycaemia (n=5, 31.25%) and oligodendroglioma (n=1, 6.25%). We screened 157 (44 adult and 113 paediatric) patients with chorea. and around 10% patients had HC-HB. 11 patients had HC-HB (two patients had bilateral feet involvement) and five patients had monochorea. We found palatal chorea (n=2), tongue chorea (n=3), bruxism and blepharospasm (n=1), cervical dystonia (n=2), limb dystonia (n=3) in our series. All patients with hyperglycaemia had putaminal hyperintensity on MRI imaging. It involved the contralateral putamen (n=2) in patients with unilateral presentation, and bilateral putamen (n=3) in two patients with bilateral and one with unilateral presentation. Of the ten patients of stroke, two had HC-HB ipsilateral to the lesion whereas eight patients had contralateral hemichorea/hemiballism. Two patients had thalamic whereas the others had lesions outside the STN namely striatum (3), basal ganglia (4), cortical (1). Conclusion: Stroke followed by Hyperglycaemia are the most common causes of HC-HB. Stokes (ischemic or haemorrhagic) outside the STN more commonly cause HC-HB than STN lesions. Cortical lesions and mass lesions without directly involving the basal ganglia or STN can cause HC-HB due to involvement of motor networks. Ipsilateral HC-HB can be seen in strokes which can be due to a previous contralateral lesion or bilateral connections. Bilateral HC-HB can be seen in patients of hyperglycaemia induced HC-HB with a predilection towards the lower limbs. Other movement disorders like dystonia, palatal chorea, blepharospasm, bruxism can also be seen. Limitations: Perfusion studies were not done so acute or chronic involvement of the subthalamic nucleus cannot be in stroke patients with thalamic involvement. Future Scope: Long term multicentre studies are required for proper assessment of all probable causes leading to HC-HB. Perfusion studies are required to ascertain the pathways responsible for cortical lesions causing HC-HB. They would also delineate whether any acute or chronic lesions of STN are eventually responsible for HC-HB.

MDO6/400: Deducing differential diagnoses in movement disorders: Neurology residents versus a novel mobile medical application (neurology dx)

Vishnu VY, Rajan R, Goyal V, Srivastava P, Lal V, Sylaja PN, Narasimhan L, Dwivedi SN, Nair P, Ramachandran D, Gupta A, Wilson V

Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.

Introduction and Background: Clinical presentations in Movement Disorders often elicit an overwhelmingly large number of differential diagnoses. Mastering the art of drawing a complete list of relevant differential diagnoses from a constellation of patient attributes is a daunting task. Artificial Intelligence with its powerful algorithms holds the promise to fill this gap in deductive reasoning. Two of the authors designed a novel differential diagnosis App in iOS platform. Methods: A Multi-centre cross-sectional study involving seven leading teaching Neurology Institutes in India was conducted recruiting 100 Neurology residents. The aim of the study was to detect the diagnostic accuracy of Neurology Dx® vis-Á-vis Neurology Residents by comparing their differentials to differentials reasoned by experts (Gold Standard Differentials). Experts created 60 clinical vignettes related to Movement Disorders. These clinical vignettes were divided into sets, each comprising of 15 clinical vignettes. Each set comprised of clinical vignettes of varying difficulty, mild (5), moderate (5) and severe (5). Each resident was asked to attempt one set of these clinical vignettes. Primary outcome was proportion of correctly identified high likely gold standard differential diagnoses. Secondary outcomes were proportions of correctly identified first high likely, first three high likely, first five high likely and combined moderate plus high likely gold standard differentials. Based on a previous study on diagnostic accuracy of physicians with computer algorithms, a sample size of 1500 movement disorder clinical vignettes was estimated. The proportion of correctly identified differentials was compared between neurology residents and App using proportion test and absolute difference with 95% confidence interval is listed. Results: Four sets comprising of 15 vignettes each (total 60) were tested on 100 neurology residents (one set for each resident) and also on the App (60 vignettes). Residents correctly identified the gold standard “high likely” differentials with a frequency of 13.6% as against 41.5% by the App (95% CI: 21.9-34.1). On combining “high” and “moderate likely” differentials, residents could accurately identify gold standard differentials with a frequency of 10.8% as against 37.9% by the App, (95% CI 22.6-31.9). The residents correctly identified first five high likely gold standard differentials with a frequency of 13.5% versus 23.7% by the App (95% CI 5.3-15.9). The residents correctly identified first three high likely gold standard differentials with a frequency of 13.0% versus 15.8% by the App (95% CI-1.2-7.9). Residents correctly identified the first “high likely” gold standard differential in 32.3% as against 35% by the App (95% CI:-8.4-15.6). Conclusions: The present study suggests that an App (Neurology Dx®)is capable of generating differential diagnoses to complement clinical reasoning of Neurology residents. Limitations: The App had limited symptoms, signs, radiological findings and lab values to choose from while entering data from clinical vignettes. The App also generated more wrong differentials compared to residents, a limitation of most predefined knowledge based medical applications. Further Scope: A new algorithm factoring in onset and course of disease with machine learning features can increase the accuracy of the App.

Saturday, October 05, 2019, 08:30AM-09:30AM, Hall A

Platform Session 05: Headache and Miscellaneous Disorders

HO1/223: Burden of migraine in Indian population who have failed prophylactic treatments: Results from a global survey, my migraine voice

Ish Anand, Vo P, Carboni V, Quintana R, Gupta P, Kumar S

Department of Neurology, Sir Gangaram Hospital, New Delhi, India.

Introduction and Background: Migraine is a disabling headache disorder that hampers daily activities. The objectives of My Migraine Voice, a global cross-sectional survey, was to understand the impact (functional, emotional and economic) of migraine in patients having atleast 4 monthly migraine days (MMD) and a failure on prophylactic therapy. We performed sub-analysis of the global survey to determine migraine burden relevant to Indian context. Materials and Methods: The study was conducted across 31 countries, including India, from September 2017 until February 2018, using an online survey administered to adults with ≥4 MMDs in the last 3 months, with pre-specified criteria of 90% having used prophylactic treatment (80% with history of ≥1 treatment failure, defined as change in prophylactic treatment atleast once). The objective was to determine functional and emotional burden of migraine from the patient's perspective. The impact of migraine on work productivity and activities was also evaluated using the Work Productivity and Activity Impairment (WPAI) questionnaire. Results: My Migraine Voice was a multicentric, cross sectional online survey involving 11,266 patients across 31 countries of which India constituted 263 patients with ≥4 MMDs. As per criteria 90% (n=236) were on prophylactic medications. Eighty percent (n=188) had changed prophylactic medication at-least once (n=12) or more than once (n=176). Only 12% patients were accurately diagnosed within a month of their symptoms. Patients reported feeling “limited” ~85% of the time before, during and after the migraine attack. Sleep disturbance is very common (91%) and so is the impending fear of the next attack (71%). Patients have reported major limitations in their daily activities (68%). Seventy two percent reported migraine attacks impacting their social lives. As a disease, migraine appears to impact not only personal life but also professional life with a meagre 32% patients getting employers' support despite the awareness of diagnosis among employers (77% of the time). A migraine eur employee on an average takes 3.5 paid sick days off from work. As many as 72% patients reported being admitted to emergency room in the last 12 months. Seventy two percent patients reported overall work impairment due to migraine on WPAI questionnaire. Among the patients who reported no other comorbidities besides migraine (n=98), direct and indirect costs incurred per month due to migraine is approximately 15,000 INR. Conclusions: Migraine constitutes a significant functional, emotional and economic burden among Indian patients, the burden being substantial among those who have failed on prophylactic treatment more than once. There is an unmet need to recognize the impact of migraine in society. Limitations: Inclusion of patients with only ≥4 MMDs could have led to recruitment bias by excluding patients with 1-3 MMDs, Self-reported outcomes. Further Scope: The study provides an insight into the magnitude of migraine burden in India. Large scale studies in Indian population with a better representation of patients and economic impact could be instrumental in highlighting the true burden of disease.

HO2/352: Migraine and white matter hyperintensities

Monika Porwal

Department of Neurology, Mahatma Gandhi Memorial Medical College, Indore, Madhya Pradesh, India.

Background: Brain WMHs are more prevalent in migraine patients but etiopathogenesis is unclear. Studies have demonstrated an increased risk of stroke, dementia (Alzheimer's), cognitive decline, death. Methods: 76 migraine patients aged 18-50 years who were referred to the Department of Neurology, MGMMC Indore (M. P.) were included; Patients with smokers, HTN, DM2, CAD, Endocrine, Malignancy, Infection, Demyelination were excluded. Results: After applying MIGSEV scale, WMHs were significantly more frequent in grade III followed by grades II & I; which increases significantly with patients with aura, increased duration, frequency, intensity of headaches and age of patient. Supratentorial hyperintense lesions represented the majority of lesions in patients. Conclusions: WMHS are present in 73% of migraine patients. Age, presence of aura, increased duration and frequency, severe intensity of migraine headaches are considered a risk factor for development of WMHs.

HO3/407: Correlation of headache severity with visual fields and acuity in idiopathic intracranial hypertension

Vikas Lakhanpal, Ray S, Takkar A, Prabhat N, Awasthi AK, Lal V

Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: Idiopathic Intracranial Hypertension (IIH) is a severe headache disorder characterized by the signs and symptoms of elevated intracranial pressure (ICP), with a potential for vision loss if left untreated. Resolution of the determinants for this dreaded complication are the key to successful management of this condition. Aim: We attempt to find a relation between the duration of disease, severity of headache and the extent of vision loss in our patients. Materials and Methods: We present 15 patients of IIH (Friedman's Criteria), with different severities of headache and papilledema. 6 patients had severe headache (VAS> 6/10) and associated visual field constriction, out of these 1 had only perception to light positive, 1 had moderate vision loss, 4 had mild vision loss. Average duration of disease was 3 months. Moderate headache was present in 6 patients with visual field constriction in 5 patients, 1 had normal visual fields and out of these 4 had normal vision and 2 had mild vision loss. The remaining 3 had mild headache with normal visual fields and acuity. Discussion: In most patients of IIH papilledema produce insidious onset and progressive visual disturbances like enlargement of blind spot, inferonasal field defects, arcuate defects, and severe visual field constriction. Severe headache in IIH and associated papilledema can cause severe visual field constriction as compared to minor intracranial pressure excursions. Hence severity of headache is a clue to greater limitation in vision and must guide aggressive treatment decisions in patients of IIH. Conclusion: Headache severity correlates with visual disturbances in IIH patients. Conflicts: There are no conflicts of interest.

HO4/509: Effect of fingolimod and interferon beta-1a on brain volume loss in relapsing-remitting multiple sclerosis

Sameer S Deshmukh, Chaudhari KS, Tiwari NR

Department of Internal Medicine, Dr. Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India.

Introduction: Brain Volume Loss (BVL) resulting from autoimmune demyelination and neurodegeneration detectable on serial MRI serves as a quantifiable prognostic phenotype in Multiple Sclerosis (MS). BVL correlates with white matter loss, myelin instability, resultant disability and cognitive decline. Considering partial effectiveness and toxicities of disease-modifying MS therapies, continued prognostic evidence in form of attenuated brain atrophy progression becomes vital in predicting efficacy and long-term disability. Fingolimod, a sphingosine 1-phosphate receptor modulator that modulates lymphocyte trafficking and promotes myelination by stimulating astrocytes, is the first oral agent found effective in relapsing-remitting MS (RRMS). Longitudinal independent and comparative assessment of percentage annual brain volume change (PBVC) is made between fingolimod and interferon beta-1a (IFNβ-1a), a widely used injectable medication in RRMS. Discussion: Three phase III randomized control trials comparing PBVC measured by MRI co-registration based algorithm Structural Image Evaluation using Normalization of Atrophy (SIENA): FREEDOMS, FREEDOMS II and TRANSFORMS; showed rapid reduction (by one-third) in BVL with uninterrupted fingolimod compared to intramuscular IFNβ-1a (TRANSFORMS) and placebo (FREEDOMS II). Such improvement was independent of severity of lesions, disability at baseline and treatment history. The improvement with fingolimod was consistent in RRMS but not significant in primary progressive MS (PPMS). Convulsions occurred more often with fingolimod (5.6%) than IFNβ-1a (0.9%). The MS-MRIUS trial provides striking real-world evidence of PBVC falling below pathological cut-off (<0.4%) with expansion of ventricles (>3.5%). Conclusion: Fingolimod administered with routine structured monitoring of BVL esp. in young adults with relatively intact brain reserve capacity can significantly improve prognosis of RRMS.

HO5/295: Cerebellar atrophy in progressive supranuclear palsy: An MRI based study

Anjali Chouksey

Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.

Introduction: Recently there is increasing evidence of clinical as well as subclinical cerebellar involvement in progressive supranuclear palsy (PSP). The reported frequencies of cerebellar ataxia in PSP patients range from 6% – 40%. A novel subtype, PSP-C has been proposed for pathologically confirmed PSP patients with predominant cerebellar ataxia as their initial prominent symptom. Surprisingly, pathological studies suggest that cerebellar ataxia in PSP is not related to cerebellar tau pathology as the proportion of tau-positive Purkinje cells did not differ significantly between PSP-C and PSP in general. Radiological studies also suggest poor clinico-radiological correlation in these PSP-C patients. In fact, apart from this clinical entity of PSP-C, rarely a subgroup of PSP patients are also being recognized who have radiological evidence of cerebellar atrophy without cerebellar ataxia. Aim: We aimed to evaluate cerebellar involvement in PSP patients based on radiological findings using a magnetic resonance imaging (MRI) brain and correlate it with the clinical findings in these patients. Methods: This is a retrospective chart review of twenty-two patients of PSP diagnosed on the basis of MDS 2017 criteria. In this study, we analyzed clinical and radiological data based on MRI studies with particular focus on midbrain and cerebellar region. We also correlated the cerebellar involvement with particular subtypes of PSP. Results: Out of twenty-two PSP patients, seven patients had a prominent cerebellar atrophy along with midbrain atrophy. Out of these seven patients, six patients belong to PSP-RS subtype while one had PSP-PGF. None of our patients had cerebellar ataxia or autonomic failure, as these features are mandatory exclusion criteria in the MDS 2017 criteria. Conclusion: Clinically, PSP patients do not show cerebellar signs, except those with PSP-C subtype. In our study, none of our patients exhibited apparent cerebellar ataxia, but our radiological data demonstrate that the cerebellar atrophy is common in patients with PSP, particularly in the PSP-RS group. This finding is consistent with prior literatureindicating different atrophy patterns for different subtypes of PSP. These PSP patients with cerebellar atrophy on MRI are often misdiagnosed as multiple system atrophy (MSA-C). There are certain findings in our patients that can reliably differentiate these PSP patients with cerebellar atrophy from MSA-C. Firstly, atrophy of midbrain and superior cerebellar peduncles was present in all these patients, in addition to cerebellar atrophy. Previous other studies alsoshowed the involvement of the decussation of the superior cerebellar peduncle in PSP patients, and suggested it as a potential tool to differentiate PSP from MSA-P. Secondly, none of our PSP patient had features suggestive of autonomic failure, thus not fulfilling Gilman's criteria for probable MSA. Our finding raises the question that why these PSP patients with cerebellar atrophy do not exhibit overt clinical sign and symptoms of cerebellar involvement. Limitation: Our study is limited by the fact that the diagnosis of PSP was not proven pathologically. Further Scope: Larger follow-up studies are required to explore the cerebellar involvement in the pathogenesis of PSP.

HO6/153: Metabolic syndrome in migraine headache

Deepan Chakravarthi, Jayakumar M, Jawahar M, Ranganathan LN

Department of Neurology, Institute of Neurology, Madras Medical College, Chennai, Tamil Nadu, India.

Metabolic syndrome and migraine are two common conditions that often coexist but the relationship between these two is unclear. Many studies have demonstrated the association between these two. In our study we have compared the clinical characteristics of migraine in patients with and without metabolic syndrome. 140 patients with migraine diagnosed based on International Headache Society criteria were clinically evaluated. The frequency, severity and functional disability were recorded. Metabolic syndrome was diagnosed based on Adult Treatment Panel and International Diabetic Federation criteria. Among them 122 were females and their age ranged from 13 to 64. Metabolic syndrome was present in 32.4% patients. It was correlated with various factors such as age, gender, frequency, chronicity and duration of each attack. Based on this study, metabolic syndrome was found in 32.4 % of migraine patients mainly in elderly population who had longer duration of headache and multiple triggers.

Saturday, October 05, 2019, 08:30AM-09:30AM, Hall B

Platform Session 06: Autoimmune Disorders

AO1/21: Immunomodulation for chronic relapsing inflammatory optic neuropathy

Surya N

Department of Neurology, Bombay Hospital and Medical Research Center, New Marine Lines, Maharashtra, India.

Background and Objectives: CRION is a distinct nosological entity, which is seronegative for anti-aquaporin four auto-antibodies and recognized by and managed through its dependency on immuno-suppression. The purpose of this study was to describe the role of immunomodulation in CRION. Materials and Methods: Retrospective Case Series - November 2016-May 2018. Results: Three gentlemen presented with sudden painless sequential bilateral severe vision loss with “Optic Neuritis” partially responsive to Intravenous Methyl Prednisolone and oral steroids associated with severe debilitating relapses on tapering/cessation of steroids. Extensive investigations including NMO antibodies were inconclusive and immunomodulation was planned for the severe relapses with Oral Mycophenolate, Azathioprine and Intravenous Cyclophosphamide respectively to achieve complete benefit in one and partial benefit in the other patients. Conclusion: Early recognition of patients suffering from CRION is relevant because of the associated risk for blindness if treated inappropriately.


1. Petzold A, Plant GT. Chronic relapsing inflammatory optic neuropathy: A systematic review of 122 cases reported. J Neurol 2014;261:17-26.

AO2/150: A case series of autoimmune encephalitis from Government TD Medical College Alappuzha

Shaji CV, Kabeer KA

Department of Neurology, Government T D Medical College, Alappuzha, Kerala, India.

Objective: To study the clinical, radiological and electrophysiological profile of suspected cases of autoimmune encephalitis. Materials and Methods: Descriptive study.36 cases of clinically suspected autoimmune encephalitis who presented during the study period (1yr) was included under the study. Results: 36 cases of clinically suspected autoimmune encephalitis were there. Of these 16 were males and 20 females. Only 5 of these cases found to have antibody positivity. Of these 2 were Anti NMDA receptor Antibody, 1 was CASPR2 antibody, 1 was Anti TPO Antibody and 1 was Anti Yo Antibody positive. Rapidly progressive cognitive decline in 26 patients. Second most common manifestation was neuropsychiatric manifestations. Hyperkinetic movement was there in 2. Seizure was there in 4. Autonomic system involvement and peripheral neuropathy was there in 1patient each. Neuroradiology revealed cortical laminar necrosis in a patient. 11 patients had diffuse cerebral atrophy. One patient with initial normal MRI later had multiple infarcts. EEG showed extreme delta brush in one patient. 16 patients had diffuse cerebral dysfunction. 7 had beta fast activity. CSF study was done in 30 patients. None showed pleocytosis. Protein was elevated in 22. Sugar was low in 12. Steroid was given to all patients. Rituximab given to 5 patients in which steroid was not effective. 4 improved and 1 was not improving. Death occurred in 2. One with multiple infarcts and the other with aspiration pneumonia. Conclusion: Most common clinical feature was rapidly progressive cognitive decline. neuroimaging was normal in majority and EEG was showing diffuse dysfunction.

AO3/256: Study on assessment of fatigue in multiple sclerosis in a tertiary care centre

Karthika Ajit, Lakshminarasimhan R, Shunmughasundaram K, Manickavasagam J

Department of Neurology, Institute of Neurology, Madras Medical College, Chennai, Tamil Nadu, India.

Introduction: Multiple sclerosis is an inflammatory disease of the central nervous system that results in myelin destruction and axonal degeneration in the brain and spinalcord. Fatigue is considered to be one of the main causes of impaired quality of life among MS patients. Fatigue is also among the most common symptoms, reported by at least 75% of MS patients at some point in the disease course. For many, fatigue is considered to be the single most debilitating symptom and also imposes significant socioeconomic consequences. Even now, there is no objective measurement for fatigue. Objective: Assessment of fatigue in multiple sclerosis patients. Study Design: Crosssectional study. Materials and Methods: We included 15 patients of multiple sclerosis who is on treatment with interferon beta weekly regimen in Institute of Neurology, Madras Medical College. Assessment of fatigue was done using Modified Fatigue Impact Scale. Results: There were 11 female patients and 4 male patients. In our study, female patients had more fatigue symptoms than male patients. 1 out of 4 male (25%) patients had least fatigue symptoms and no psychosocial subscale. 75 % of male patients had more psychosocial subscale than physical and cognitive subscale. 9% of female patients had least fatigue symptoms and no psychosocial fatigue symptoms. In males, psychosocial subscale symptoms was present more than cognitive subscale symptoms. In females, physical subscale symptoms predominated compared to psychosocial and cognitive subscale symptoms. Conclusion: Evaluation of fatigue was done at a single point during the course of the disease. Multiple sclerosis patients may benefit in the early stage with intervention of fatigue symptoms.

AO4/338: MOG antibody disease: Clinical profile and MRI findings: An experience from a tertiary care center

Tanmayee Thombare, Mathew T, Sarma GRK, Nadig R, Badachi S, Dsouza D, Kumar S

Department of Neurology, St John's Medical College, Bengaluru, Karnataka, India.

Introduction: MOG spectrum disease has emerged as a distinct autoimmune disease of central nervous system involving brain, optic nerves and spinal cord due to MOG (Myelin Oligodendrocyte Glycoprotein) antibody. It has been detected positive in certain cases previously detected as seronegative NMOSD. Aim: To analyse clinical presentation and diverse MRI findings in MOG antibody positive disease. Methods: Clinical presentations and MRI findings of 23 patients from a tertiary care centre were analysed as a descriptive study. Results: Mean age 30 years with female preponderance was seen (13:9). 2 females were pregnant, 3 in post-partum period and 4 patients were from paediatric group. Optic neuritis was the commonest clinical presentation (43%) followed by myelitis (39%). Common MRI abnormalities were seen in spinal cord followed by subcortical hemispheric white matter and optic nerves. Spinal cord imaging showed patchy lesions more than longitudinally extensive transverse myelitis, with cervical cord being the commonest region affected. 2 patients presented with only cortical involvement. All patients had significant response to steroids. Only 4 patients had relapse, 2 of them were treated with Rituximab. Conclusions: MOG antibody disease should be suspected in patients presenting with demyelinating disease. In addition to optic nerves and spinal cord involvement, cortical and subcortical white matter involvement is also common. Pregnancy can carry a risk of flare of the disease. Though, relapses are seen, the disease is significantly steroid responsive.

AO5/408: Profile of myelin oligodendrocyte glycoprotein antibody disease in Eastern India: A comprehensive study

Shubhankar Mishra, Mallick AK, Mohanty G, Nayak SD

Department of Neurology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India.

Introduction: MOG antibody disease is an autoimmune disease of the central nervous system associated with a serological antibody against MOG, myelin oligodendrocyte glycoprotein. MOG is a glycoprotein expressed on the outer membrane of myelin and solely found within the central nervous system, including in the brain, optic nerves and spinal cord. The objectives of this study were to observe the pattern of presentation of MOG antibody positive patients along with its clinic-radiological correlation. Materials and Methods: Prospective clinical study from January 2017-December 2018 in the inpatients department of neurology of SCB Medical College. All the patients who were hospitalised with clinical diagnosis of idiopathic inflammatory demyelinating disease of CNS (IIDDC) along with positive MOG Antibody in serum were included in the study. Those with other pathologies and positivity for other antibodies were excluded. Enlisted cases were evaluated exclusively by CSF Studies, MRI of Brain and spinal cord along with electrophysiological studies. Data were analysed by SPSS software version 20.0. Results: Total patients included in the study were 14 in numbers. <20 year age group was most common age of presentation. Most of the patients presented clinically as acute demyelinating encephalomyelitis (ADEM). The second spectrum of presentation was like neuromyelitis optica spectrum disorder (NMOSD). Seizure with altered behaviour was the most common complaint of hospital admission. Large fluffy lesion in grey and white matter junction was most common MRI finding. Longitudinally extended necrotizing transverse myelitis was commonest presentation in cord. Treatment response to steroids with favourable outcome in follow up was seen in all patients. Prophylactic therapy were used by azathioprine and if presented with multiphasic involvement, rituximab to prevent relapse. Conclusion: MOG antibody disease is a type of IIDDc. It may vary in presentation. Both ADEM like presentation and NMO like presentations are seen. Other varied presentation in form of recurrent bilateral optic neuritis (BRON), isolated longitudinally extended transverse myelitis are also seen. Response to steroid is very good. Early diagnosis by antibody estimation with neuroimaging and proper therapy can prevent disastrous consequences. Limitations: This is an ongoing study. The numbers of included patients are less in numbers. Further Scopes: Antibody specific disorders in demyelinating spectrum are gaining importance now. MOG Antibody positive diseases cover wide clinical profile. It holds huge future scope in understanding demyelinating disorders and their pattern of clinical presentation.

AO6/417: Clinical and electrophysiological profile in 10 patients of Morvan's syndrome

Swayang Sudha Panda, Anita M, Nalini A, Netravathi M

Departments of Neurology and Neuropathology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Background: Morvan syndrome is characterized by central, autonomic & peripheral hyperexcitability due to CASPR-2 antibodies. CNS symptoms include confusion, cognitive dysfunction, hallucinations, insomnia, myoclonus. Autonomic features are hyperhidrosis, fluctuant blood pressure. Peripheral hyperexcitability are painful cramps, myokymia & neuromyotonia. Objective: To study the clinical, electrophysiological profile and prognosis in Morvan's syndrome. Methods and Results: This is a chart review of 10 (M: F:8:2) Morvan's syndrome cases from 2016-2019. Age range was 17-65 years (34.7±17.79yr). The clinical features-muscle twitching (80%), insomnia (80%), pain (70%), behavioural abnormalities (60%), hyperhidrosis (50%), hallucinations (10%), cold intolerance (10%). Preceding fever at onset (70%); fever with rash (20%). Neurological examination-myokymia (90%) & pyramidal signs (80%). Autonomic function tests-reduction in heart rate variability (70%), cardiac dysfunction (50%), postural tachycardia syndrome (30%) & orthostatic hypotension (10%). Electrophysiological abnormalities (EMG) were present-neuromyotonia (60%), spontaneous activity (30%). Malignancy was negative for all patients. All were treated with steroids and plasmapheresis in acute period. Oral steroids were continued for 6months in 3patients. On follow-up 50% had persistent neuropathic pain, 40% had completely improved, mild fatigability (10%). Conclusions: Morvan's syndrome is most commonly seen in male population. Though reported to be commonly associated with malignancy; it can run a benign course especially when they are triggered by fever. In the absence of malignancy, they may require only steroids without the addition of other immunosuppressants.

Saturday, October 05, 2019, 08:30AM-09:30AM, Hall C

Platform Session 07: Epilepsy

EO1/10: Autistic features in Unverricht-Lundborg disease

Tandon R, Pradhan S

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Science, Lucknow, Uttar Pradesh, India.

Introduction: Unverricht–Lundborg disease (ULD) is an autosomal recessive progressive myoclonic epileptic disorder characterized by onset at the age of 6–15 years, severe incapacitating stimulus-sensitive progressive myoclonus, tonic–clonic epileptic seizures, absence seizures and characteristic abnormalities in the electroencephalogram. Unique social features seen in Autism Spectrum Disorder (ASD) may not be a recognized feature of ULD. Autistic features may however be co-associated with epilepsy. Aims: We studied three patients of Unverricht-Lundborg disease (ULD) for autistic features along with other clinical features. Materials and Methods: We diagnosed this disease based on noise and touch sensitive myoclonus, ataxia, cognitive decline, typical (electroencephalogram) EEG changes with normal MRI head and applied Children's Global Assessment Scale (CGAS) and Childhood Autism Spectrum Test (CAST) to these children. Results: CGAS score was 35 in two and 50 in one of them. CAST scores were above 15 in all of them. Conclusions: There is some overlap between ULD and Autism Spectrum Disorder (ASD). Hence, identifying autism in ULD patients could be important.

EO2/52: Application of 1981 and 2017 ILAE Epilepsy classification of seizure types in an outpatient setting

T Kartheek, Jayalakshmi S, Babu SP, Patil A

Department of Neurology, KIMS Hospital, Hyderabad, Telangana, India.

Aim: To compare the application of 1981 and 2017 International League Against Epilepsy (ILAE) classification of seizures and epilepsies an outpatient setting. Methods: We prospectively applied the 1981 and 2017 ILAE classification in 1063 patients attending the outpatient epilepsy clinic. Differences in seizure, epilepsy and etiology classifications were identified. Results: The two most frequently encountered seizure types based on the 2017 classification were focal impaired awareness (309; 29.1%) and focal to bilateral tonicclonic (290; 27.3%). Unknown onset seizures were (118; 11.6%). Based on the 1981 classification, the two most frequently encountered seizue types were complex partial seizures (313; 29.4%) and secondary generalized tonicclonic (sGTCS) (289; 27. 2% and unclassifiable (157; 14.8%). One hundred and twentyfour of 157 (78.9%) unclassified cases based on the 1981 classification were classifiedusing the 2017 classification mainly due to the addition of the “unknown origin” category anda combination of different levels of terms (level of awareness and motor/nonmotor features). In 33 cases, seizures were unclassifiable using both classification systems; Conclusion: The 2017 seizure classification greatly reduces the number of unclassifiable cases. The combination of awareness level and motor/nonmotor features introduces greaterflexibility and allows fordetailed seizure description. Several cases, however, remain unclassified. The 2017 seizure classification demonstrates a steady transition from the 1981 classification with acceptable consistency and improvements.

EO3/167: Comparative study on risk of osteoporosis assosiated with valproate versus levetiracetam in epileptic patients and its relationship with MTHFR genotype

Akhilesh Kumar N, Jawalkar S, Fareedullah M, Mohiuddinn MJ, Ishaq M, Naaz N, Shams BA, Rafi R

Department of Neurology, Deccan College of Medical Science, Hyderabad, Telangana, India.

Introduction: Epilepsy is one of the most prevalent neurological disorders which is unpredictable in character due to incomplete understanding of the pathophysiology of seizures. Sodium valproate (VPA) has a broad spectrum of anticonvulsant activity. Levetiracetam (LEV) is one of the newest AEDs. Patients with epilepsy who are on anti-epileptic drugs (AEDs) have a higher than normal risk of bone loss, abnormal mineralization, and fractures, but exact pathogenic factors underlying these AED associated risks remain unclear. Pathogenic mechanisms include the induction of hepatic enzyme activity with increases in the metabolism of 25-OH vitamin-D3, impaired calcium absorption, direct effects of old generation AEDs on bone cells, resistance to parathyroid hormones, and an inhibition of calcitonin secretion. Several large epidemiological studies found that patients with epilepsy have a two-to six fold higher risk of fractures than the general population. Thus, a determination of the presence of osteoporosis prior to the emergence of clinical signs is important. Thus, the present study analyzed the levels of serum calcium, ionized calcium, and 25-OH vitamin-D3 and its relationship with MHTFR gene, in patients using VPA or LEV monotherapies. Aim: To compare the effect of two anti-convulsant drugs, VPA v/s LEV on the bone mass and to correlate the results with different MTHFR genotypes for assessing the risk of osteoporosis. Materials and Methods: This is a Comparative Prospective Study for 6 months. Study Population: 35 patients, Inclusion criteria: Generalized Tonic clonic seizures, Focal seizures, Age group 15-40 years. On Monotherapy of either VPA or LEV for more than 2 year. Exclusion Criteria: Pregnancy, Neonates. Patients with Cardiovascular diseases/known H/O Osteoporosis. Plan of work: The Bone Mineral density of Femur/Calcaneus bone estimation. Identify the MTHFR genotypes. Correlation of findings to assess the risk of developing Osteoporosis in them. Results: Of the 18 patients on VPA, 8 had a normal BMD, 9 had Osteopenia and 1 had Osteoporosis. Of the 17 patients on LEV, no patient had a normal BMD and all 17 were diagnosed with Osteopenia. Out of the 35 subjects, mutant MTHFR CT had a frequency of 52.38% while the wild CC type had a frequency of 45.71%. The rare mutant TT had a frequency of 4.76%. The controls have shown a higher frequency (95.23%) of the wild CC type, the mutant MTHFR CT was shown a frequency of 4.76% and the rare mutant TT was not observed. Conclusion: The collected data and results conclude that the effect of VPA vs LEV on the bone mineral density of an epileptic patient was found to be higher in case of LEV with lower margins. The patients receiving LEV have all shown Osteopenia despite the MTHFR polymorphism whereas epileptic patients on VPA showed diversity in their effect. Limitations: Short duration of the study. Small sample size. unwillingness of participants for the diagnostic tests of BMD and MTHFR polymorphism. Further Scopes: Furthur studies are required with larger study population and longer duration of study to establish the findings.

EO4/331: Modified atkins diet versus low glycemic index treatment in drug-resistant epilepsy in children: A randomized open labeled controlled trial

Jaya Shankar Kaushik, Gupta S, Dabla S, Bala K

Department of Neurology, Pt B D Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India.

Background: Dietary therapies including ketogenic Diet, modified Atkins diet and low glycemic index treatment has been used among children with drug-resistant epilepsy with variable success rates. Objective: To compare the efficacy and safety of modified Atkins diet (MAD) and low glycemic index diet (LGIT) among children with drug-resistant epilepsy in terms of seizure reduction at 12 weeks and nature of adverse events. Methods: A randomized parallel arm, open-labeled, controlled trial was conducted among sixty children aged 6 months to 14 years with drug-resistant epilepsy who had failed to respond to more than two appropriate anti-epileptic-drugs. The trial was registered in CTRI (CTRI/2017/12/010898). Children were randomly assigned to receive MAD (n=30) or LGIT (n=30) as an add-on to the ongoing antiepileptic drugs. Results: Proportion of children with > 50% seizure reduction was significantly more in the LGIT group as compared to the mAD group (73.3% vs 43.3%, p < 0.02). The proportion of children with 90% seizure reduction (30% vs 13.3%, p = 0.21) and seizure freedom (16.6% vs 6.6%, p = 0.42) was comparable between the two groups at 12 weeks. Lethargy was the commonest side effect seen in mAD and LGIT group (53.3% vs 66.7%, p=0.43). Conclusion: Low glycemic index treatment is an effective alternative to modified Atkins diet for treatment of children with drug-resistant epilepsy considering its superior efficacy and comparable adverse effect profile.

EO5/392: Intraoperative ultrasound: The newest tool effective in identification and delienation of depth of sulcus dysplasias

Sujit Kumar, Nayak D, Rao R, Lakshminarayanan K, Kumar SV, Arul K, Kumar SGG

Department of Neurology, Apollo Hospitals, Bengaluru, Karnataka, India.

Introduction: Complete excision of the dysplastic cortex is the most important prognostic factor for postsurgical seizure freedom. Electrocorticography (ECoG), neuronavigation, and intraoperative MRI, are used intraoperatively to delineate the lesion. Intraoperative ultrasound (IOUS) is fast emerging as an exciting mode for dysplasia delineation including the borders, and guiding depth ECoG, thereby enabling complete resection. Methods: Consecutive Medically Refractory Epilepsy cases presenting to Apollo Hospitals, Seshadripuram and Gleneagles Global Hospitals, Chennai, from May 2017 to June 2019, who underwent presurgical evaluation including, Video EEG, MRI brain, PET Brain were included, if the epileptogenic lesion was subcortical. All patients underwent ECOG, Neuronavigation and IOUS guided lesionectomies. Results: 12 patients were included. The mean age was 10.04 years. 6 were male. 10 patients had frontal depth of sulcus dysplasia, while 2 had frontal tubers. 6 were Right sided; Intraoperatively, all patients underwent IOUS, which showed hyperechoic focus throughout the dysplasia, thus identifying the borders. ECoG was carried out using strip electrodes on the surface and depth electrodes, introduced under IOUS guidance, along the anterior and posterior borders of the dysplasia. Spiking was seen more frequently from the depth electrodes, guiding the lesionectomy. All patients achieved complete freedom with a mean follow up of 10.8 months. 1 patient, worsened in power after surgery, and improved over 2 months. Histopathology revealed FCD type 2 in 8 patients, type 1 in 2 and tubers in 2 patients. Conclusions: IOUS is a very useful tool for FCD detection, identification, delineation and guiding ECoG during surgery.

EO6/395: Association of histopathologic findings with seizure outcome in an epilepsy surgery cohort

Mohammed Salman Hadi, Jayalakshmi SS, Mohandas S, Panigrahi M, Sudhindra V

Department of Neurology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India.

Aim: This study aims to evaluate the association between seizure freedom and pathological findings in a relatively large cohort of people with medically refractory epilepsy (MRE). Methods: The pathology records of 839 people with MRE who underwent epilepsy surgery at a tertiary referral centre were reviewed by a trained Neuro-pathologist and categorized. A comparison for clinical and histopathological data was done after dividing the study population into two groups based on outcome according to Engels classification. Results: The mean age of the cohort was 22.32±11.77 years with 476 (56.6%) men. The average duration of epilepsy was 12.54±8.60 years. Favorable outcome at latest follow-up was observed in 695 (82.6%). On histopathological evaluation, hippocampal sclerosis was the most frequent finding, observed in 470 (55.9%) people with MRE, followed by dual pathology in 162 (19.3%). While isolated focal cortical dysplasia (FCD) was seen in 80 (9.5%), tumor with FCD was observed in 16 (1.9%) with MRE. Gliosis and vascular pathology were observed in 16 (1.9%) and 12 (1.4%) MRE. Whereas, tumor was observed in 54 (6.4%). While tumoral pathology (7.3% vs 2.1%;p<0.015) was associated with favorable outcome, gliosis (1.4% vs 4.15; p=0.044) was associated with unfavorable outcome. Isolated FCD showed a trend towards unfavorable outcome (8.6% vs 13.7%; p=0.063). None of the other pathologies were significantly associated with outcome. Conclusions: Among the various histo-pathological features in a large epilepsy surgical cohort described, tumoral pathology was associated with favorable seizure outcome. The rationale of our findings could be potential future research.

Saturday, October 05, 2019, 08:30AM-09:30AM, Hall D

Platform Session 08: Miscellaneous

MiO1/49: Traumatic disc disorder is a treatable condition, surgery indicated when the spinal cord is compromised a new vast field for neurologists

Majumder US, Majumder N

Departments of Neurology and Neuropathology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Introduction: Yearly 1% Indian suffer from Prolapseintravertibraldisc (PIVD). Mild case (50%) relieved with analgesic, rest. Other require surgery (if pain over 48 hours, disrupt sleep, physiological activities, posture disturbance with neurological sign). vertibral fusion, laminecktomy with disectomy, microdisectomy and now microdisectomy with steroid therapy is practiced. Aim: We recommended conservative treatment only with immobilisation, low dose steroid, analgesic with musclerelaxant and sedative which gave good results like surgery. Materials and Methods: All patients have h/o trauma, MRI evalueation, neurological feature for surgery, record of treatment and follow up data. 40 post operative cases and 40 conservatively treated cases are clinically selected and followed up for improvement, relapse or detoriation for last eight years. Results: (video evidence) Eight fusion surgery cases--all bad prognnosis--developed spastic paraplegia, catheterised, llatrophy, wheel chair bound, resistant to treatment. 7 laminectomy with, disectomy cases 11.8 neurological feature 23.5% perisistant LBP, stressincontinence, 52.4% parasthesia, 23.5% relapse in 6M, 52.4 24M, 88.2 60M--more relapse rate. Microdisectomy--16% relapse 6M, 48% 24M. Microdisecomy with Steroid 10% Relapse 24M.. Conservative treatment 10% Relapse 24M. Conclusion: <45--trauma> 45 DOA, Ambulatory weak E X L = l5, weak EDM = l4 weak FHL = S1, knee EXT = l3. Fusion surgery complicated procedure = compound fracture vertebrae. Laminectomy, more relapse. Low dose steroid for 7-8 weeK (MAUNKNOWN) equally effective. Surgeryindicated (canaldiameter > 50%).

MiO2/142: A study of non-motor manifestations in patients with amyotrophic lateral sclerosis

Chowdhury A, Biswas A, Pandit A

Department of Neurology, Bangur Institute of Neurosciences, IPGME and R and SSKM, Kolkata, West Bengal, India.

Introduction and Background: Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative disorder of motor neurons in brain and spinal cord. Recent studies have suggested ALS to be a multisystem disorder, where spreading of the disease pathology to the neighboring nonmotor brain areas may lead to development of nonmotor symptoms. Most of these symptoms remain underdiagnosed and are left unreported leading to significant distress to the patient and worsens prognosis. So detection and treatment of these nonmotor symptoms are essential for a modern and comprehensive care of ALS patients. This Study, which is probably the first of such kind in India, aims to investigate the various nonmotor symptoms in patients suffering from ALS. Materials and Methods: 30 patients with definite, probable or possible ALS (according to the revised El Escorial Criteria) and 60 controls were included in this study. Controls were healthy volunteers aged between 25-75 years without any neurological symptoms or abnormal neurological examination. Severity of ALS was assessed using the ALS functional rating scale. After obtaining informed consent, both the cases and control were subjected to oral questionnaires including NMS questionnaire, Beck's Depression Inventory, Drooling severity and frequency scale, Epworth Sleepiness scale & CNS-LS for pseudobulbar affect. Statistical Analysis was done using the SPSS software. Results: 30 cases (Male 25, female 5) with a mean age of 49 years and 60 controls (male 44, female 16) with a mean age of 46years constituted the study population. Out of the 30 ALS patients, 26 (86.7%) were clinically definite ALS and 4 (13.3%) were probable ALS. 11 (36.7%) patients had bulbar onset symptoms and 19 (63.3%) patients had limb onset symptoms. ALS patients reported significant higher nonmotor scores in comparison to controls. There was statistically significant (p<0.05) increased prevalence of daytime drooling, altered taste/smell, dysphagia, nausea, constipation, unexplained weight loss, loss of interest, difficulty in concentrating, feeling sad/anxious, difficulty performing sex, falling, insomnia, nightmares, leg swelling and unpleasant sensations in leg in ALS patients as compared to controls. There was also statistically significant (p<0.05) increase in suicidal ideation, pseudobulbar affect and mild to moderate day time sleepiness in ALS patients. Unexplained sensory symptoms were reported by 13 (43.33%) ALS patients and itching was reported by 5 (16.67%) ALS patients. Correlation study also showed increased NMS scores with disease progression. Conclusion: Nonmotor symptoms were significantly more prevalent in ALS patients than in control group and could be broadly categorized into neuropsychiatric, autonomic, vascular and gastrointestinal disturbances. Nonmotor symptoms in ALS patients seemed to increase with disease progression fitting with the concept of “disease spreading hypothesis”. Therefore these nonmotor symptoms should be actively sought & treated during the clinical management of ALS patients to lessen their distress and disease burden. Limitations: Smaller sample size. Further Scopes: Similar multicentric blinded studies over larger populations may help in better estimation of prevalence of nonmotor symptoms in ALS patients. This may pave the way for future research on multimodality treatment of such patients, thus helping in improving their quality of life.

MiO3/194: Nonalcoholic Wernicke's encephalopathy: A retrospective study of a reemerging neurological deficiency disorder from Kashmir, Northern India

Irfan Ahmad Shah, Asimi RP, Wani MAW, Kawoos Y, Waqas N Baba

Department of Neurology, Government Medical College, Srinagar, Jammu and Kashmir, India.

Objective: To describe the demographic features, clinical presentation and management and outcome of 50 cases of non-alcoholic Wernicke's encephalopathy from a tertiary care hospital of Kashmir valley of North India. Methods: In a retrospective study, 50 adult cases of Wernicke's encephalopathy were analyzed. The diagnosis of Wernicke's encephalopathy was made according to the European federation of neurological societies (EFNS) guidelines criteria 2010. Response to thiamine replacement and associated brain MRI findings were also considered as supportive evidence. Results: The mean age of patients was 50.38 years with males 20 and females 30. The most common clinical manifestations were alteration in sensorium in 30 (60%), ataxia [18 (36%)], memory impairment [15 (30%)], nystagmus [35 (70%)], ophthalmoparesis [11 (22%)] and seizures in 04 (8%). 42 patients had history of recurrent vomiting. All patients had polished rice as their staple diet. Thirty-five patients had associated polyneuropathy and 15 had a gastrointestinal disorder. Twenty patients underwent MRI which showed both typical and atypical lesions. Majority of patients showed significant improvement after treatment with intravenous thiamine. On discharge, the most common residual symptoms were lower limb weakness, ataxia and memory impairment. Conclusion: The study shows high incidence of nonalcoholic Wernickes encephalopathy in the region with predominant causative factor being a thiamine deficient diet. Recurrent vomiting can be an early symptom of thiamine deficiency and its early recognition can prevent the development of Wernicke's encephalopathy. Maintenance therapy with oral thiamine should be given when the diet is thiamine deficient to prevent recurrence.

MiO4/292: Significant spectral EEG anomalies in South Indian non-syndromic autistic spectral disorder children

Sunil Narayan, Rao MJS, Nagarajan K, Kandasamy P, Mahadevan S

Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.

Background and Objectives: We investigated for Spectral EEG anomalies and syndromic genetic mutations in South Indian Tamilian Autistic Sectral Disorders children. Methods: 49 Children from Child Guidance clinic of a quaternary referral institute full filling DSM IV Diagnostic criteria were recruited over 2 years. Seamen 1.5/3.0 T MRI, brain imaging done to rule out structural and specific developmental anomalies. DNA analysed for mutations of Exon 2, 3 and 4 of the MeCP2 gene and for FMR mutations. All children underwent 25 minute awake scalp EEG. Spectral EEG analysis was done on 1 – 2 epochs of 15 seconds of awake, seizure discharge and artefact free digital EEG record, with MATLAB. Results: Of 58 ASD, Male: female= 3.8, mean age at diagnosis 3.6. Mean CARS score was 35.8. All children were negative for MeCP2 and FMR mutations. Normal EEG was seen in 44 and 5 had abnormal patterns on eye-balling. 21 had seizures disorders, most commonly GTCS with 2 having generalised and 1 focal epilepsy. Spectral EEG patterns were distinct and remarkably varied in the power spectrum for different frequency bands compared to the age and gender matched normal controls. Power spectrum for different frequency bands were distinctly uniform as compared to normal children with frequency wise differences, except for the occipital lobe. No significant asymmetry between the dominant and none dominant lobes for any frequency band. Conclusions: Spectral EEG anomalies were marked in non-syndromic autistic South Indian Tamilian children.

MiO5/360: A study of affordable rehabilitation care in semi-urban & rural area: A single centre prospective study from India

Devashish Ruikar, Kokane S, Ruikar P, Khubba A

Department of Neurology, MIMSR Medical College, Latur, Maharashtra, India.

Objective: Rehabilitation care in rural has different set of challenges and not commonly reported. In this descriptive study We present different issues faced in low cost rehab care in predominantly rural in India. Background: Low Affordability and poor follow ups are one of the two main issues. Poor follow ups are mainly due to distances and loss of wages on the day when person and his attendant have to attend the clinic. Design/Methods: This descriptive study is from single Neuro-rehabilitation center from Latur, which is one remote district of India, and one of the most drought prone zones of India. The data collected prospectively from March2014 to Dec2017. Results: During the study period there were 2700 patients received service from the center. Majority of patients were from rural area. Rehabilitation center need regular follow up of patient however due to long distance to travel most of our patients were not able to come for regular follow up. Regional pain syndromes are most frequent reason to attend the service than stroke or other neurological diseases. Average cost of therapy was INR 300 [USD 4.01] only which includes Physiotherapist consultation, stretching session, IFT, intophoresis, Local therapy etc. Conclusions: Working in center which serves predominantly rural area has different set of challenges. Despite very low charges of treatment followups were poor due to non medical factors. To serve better we tried to teach them yoga/stretching which they can do at home. We tried to cater maximum in single session. Use of low cost technology has came up in recent times as a useful tool. We tried to use booklets, flyers, Cd etc so that they can do exercises at home. One of the best ways was patients own smartphone! which patient carry himself !! We asked them to record or take photo of exercises, communicate on whats app, showing youtube video for discussion during session.

MiO6/450: Infantile spasms: A prospective study of the long term outcome beyond 5 years of age

Mary Iype, Jain AR, Kunju PAM, George B, Sreedharan M, Ramteke P, Sheikh H, Venugopal R, Thankappan B, Geethi S

Department of Pediatric Neurology, SAT Hospital, Medical College Trivandrum, Kerala, India.

Introduction: Infantile spasms is a catastrophic epilepsy with difficult to control seizures and a poor long-term cognitive outcome. Materials and Methods: All consenting patients with infantile spasms in our department from January 2008 to December 2013, who have now attained more than 5 year age, were included. The seizure status and motor and cognitive outcome were assessed. Results: One hundred and three patients were enrolled. Four were lost to follow up and therefore excluded. The mean age of onset of spasms was 6.7 +/-4.5 months. The mean latent period was 8.9 weeks. Seventeen patients had onset of spasms at an age below 3 months. Forty patients (40.4%) each were seizure free for 2 years at least and had mRS score 3/<3. Cognitive outcome was good (VSMS score of >70) in only 13 children (13.1%). Only 34 (34.3%) had no autism on CARS scoring. On multivariate analysis, persistence of seizures was seen in children with symptomatic aetiology and presence of other seizures in addition to infantile spasms. Severe motor sequelae (mRS>3) was significantly more in children with age of onset of spasms < 3 month, aetiology (symptomatic) and in firstborn. Cognitive outcome was poor in children “with other seizures also”. Presence of autism was seen in children who took >8 weeks for initial remission of spasms. Conclusion: Though the seizure and motor outcome at beyond 5 year age is encouraging, the cognitive outcome, even in children with seizure control for more than 2 years continues to be poor.

Saturday, October 05, 2019, 16:00PM-17:00PM, Hall A

Platform Session 09: Stroke

SO7/172: A prospective study comparing bedside swallowing tests for dysphagia among new-onset stroke patients

Abhilash Somasundaran, Kannan V, Chandramouleeswaran V, Ranganathan LN

Department of Neurology, Institute of Neurology, Madras Medical College, Chennai, Tamil Nadu, India.

Introduction: Dysphagia is a common complication after stroke. Water swallowing test (WST) and Viscous swallowing test are two commonly used bedside tests to assess swallowing. Water swallowing test (WST) is a recognized but limited tool in providing details about dysphagia, including severity and how to adjust the diet based on the test results. Methods: Our study is a prospective observational study comparing WST and volume–viscosity swallow test (V-VST) in patients with acute stroke within 14 days of onset. The study was done in Madras Institute of Neurology. All patients were subjected to WST and if failed would have V-VST. The primary outcome was to compare the dysphagia levels assessed by these two test tools. The secondary outcome was to explore the predictive capability in patients who were at high risk of pneumonia by these two swallowing tests. Results: Consecutively 175 patients with stroke were enrolled in our study, and 95 had normal WST. Among 80 patients who had both WST and V-VST, 20 showed swallowing safety and effectiveness by V-VST. The probability of being on tube feeding was strongly related to the positive results of failed WST (p<0.001). Both tests showed good predictive ability in patients with stroke for pneumonia (p=0.001 in WST and p<0.001 in V-VST). Conclusion: V-VST performed better as a clinical screening test for dysphagia in patients with acute stroke at the bedside.

SO8/302: Evaluation of large vessel stenotic disease in patients with border zone infarcts

Ashwini Hiremath, Jain RS, Srivastava T

Department of Neurology, SMS Medical College, Jaipur, Rajasthan, India.

Introduction: Cerebral Borderzone infarcts occur between two arterial territories and have been traditionally classified as external border-zone and internal border-zone infarcts. There are hardly any studies of borderzone infarcts in India, dedicated to identifying stenotic patterns of large vessels in these cases. There are western studies, but the results could vary because of the differences in ethnicity and demographic characters. The cost of doing angiographic studies may be justified if effective neuro-intervention could be planned in the stenotic vessels. Aims and Objectives: 1. Evaluation of stenotic large vessel disease in patients with border zone infarct patients. 2. To compare the clinical characteristics among the different sugroups of borderzone infarcts. Methodology: It was an observational study of 96 border zone infarcts, of a total 477 ischemic stroke cases over a year and half. The infarcts were divided into 3 groups-Group IÁ external anterior borderzone infarcts, group IIÁexternal posterior borderzone infarcts and group 3Á internal watershed infarcts. Borderzone Infarcts were studied in MRI-DWI films. The patient was subjected to CT/MR angiographic studies. Stenosis of large arteries were identified according to NASCET criteria. >50% stenosis was taken to be significant. Large vessels studied were Common carotid artery (CCA), Internal carotid artery (ICA), M1 segment of Middle Cerebral Artery (MCA), A1 segment of Anterior communicating artery (ACA), P1 segment of Posterior cerebral artery (PCA), Basilar and vertebral arteries. Results: The over all cases of borderzone infarcts were higher when compared to the previous studies (20.16%). Internal borderzone group constituted the majority number, compared to external anterior and external posterior borderzone group. Majority of the borderzone patients had Extracranial artery stenosis. Ipsilateral ICA artery stenosis was most common followed by CCA stenosis. In anterior external borderzone infarcts, finding of ICA stenosis was significant (P< 0.03). Significant ipsilateral ICA stenosis was associated with internal borderzone infarcts (P0.02). Among the posterior circulation external borderzone infarcts, ipsilateral ICA stenosis (P=0.08) and PCA-P1segment (P=0.09) stenosis and extra-cranial segment of verterbral artery (P=0.002) had significant associations. Males of elderly age group outnumbered females (72.9 % versus 27.1%) and smoking and hypertension at presentation were significant risk factors, with most of them presenting with TIA's. 12.5 % had bilateral borderzone infarcts and rest 87.5 % had unilateral infarcts. 3 patients expired of which two of them had sepsis. There was no significant difference in risk factors when compared amongst groups. Though Coronary artery disease, Hypotension at presentation and basilar artery stenosis were significant independent risk factors in bilateral borderzone infarct cases. Conclusions: Internal carotid artery stenosis in internal borderzone infarcts and Extracranial vertebral artery stenosis and basilar artery was found in posterior circulation stroke and hence has to be carefully looked for. Limitations: There is a definite need for larger sample size and this is still an ongoing study. Moreover we couldn't accurately delineate posterior internal border-zone infarct cases and assess them as a separate group which was merged with the internal borderzone cases.

SO9/303: Prevalence of obesity: Baseline data from a prospective population based Cohort study of 7137 elderly people at AIIMS, New Delhi

Vivek Verma, Kumar S, Prasad K, Kant S, Dwivedi SN, Vibha D, Pandit AK

Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.

Background: A prospective population cohort study has been funded by Department of Biotechnology, Government of India. Objective: Among various risk factors for stroke and cognitive decline, the body mass index (BMI) plays an important role, as it measures the general health status of an individual based on height and weight. This abstract is aimed to determine the proportion of obese people in the community. Methods: A systematic house to house survey in Vasant Kunj and Munirka Colony of South Delhi, India was conducted to recruit the eligible individuals. Those consented were administered a questionnaire to record medical history, dietary habits, physical activity, health status, ability to perform activities of daily living, sleep quality, neuro-cognitive function and MRI brain. Results: The data of 7137 participants have been entered and analysed for the present study. It is found through their anthropometric and physical examination that 26% are obese in the community. Among females, 35% are obese, whereas, only 16% of males are found to be obese. This association is statistically significant (p<0.0001). Conclusion: It is found that about 26% of persons are living with obesity and it is more prevalent among females as compared to males. The obtained result indicates that females are on higher risk of developing cardiac diseases. The association of obesity will be studied when outcome events are analysed.

SO10/309: The correlation of blood pressure and ICH score with the outcome at 90 days in cases of spontaneous hypertensive intracerebral hemorrhage

R Srinath, Nanda SK, Ahmad F, Sirohi YS

Department of Neurology, Armed Forces Medical College, Pune, Maharashtra, India.

Aims: To correlate the Blood pressure and the ICH score with the functional outcome at 90 days in cases of spontaneous hypertensive intracerebral hemorrhage. Settings and Design: An Observational study where a total of 50 consecutive cases of Hypertensive Intracranial hemorrhage were studied from a tertiary hospital of Command Hospital Pune. Methods and Materials: The admission Blood pressure was measured along with the calculation of ICH score. This was correlated with the functional score at 90 days. Statistical Analysis: Analysis of Variance (ANOVA). Results: A total of 50 patients were studied. There was a strong correlation of the MAP at 72hrs with the outcome at 90 days in the subjects who were undertaken MAP lowering therapy as compared to those in whom MAP was not lowered. This study showed that the ICH score had a significant effect on outcome the higher the score, the worse was the outcome. Conclusions: It was observed that admission BP and BP at 72 hours post symptom onset and the ICH score had a bearing on the functional outcome at 90 days.

SO11/231: Application of six sigma methodology for initiating acute stroke intervention program in a large tertiary care hospital

Srijithesh PR, Raja P, Gijo EV, Kulkarni G, Saini J

Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Introduction: Six Sigma is a process improvement methodology widely used in industry for reducing variation and improving quality. Recently it has been in used healthcare sector in trauma care and neonatal resuscitation. In this paper we report adaptation of Six Sigma concepts in initiating an acute stroke pathway in a large tertiary care academic hospital where the acute stroke intervention was halted for a period of 18 months. Methodology: We used the Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control) methodology to address the problem. Data were collected by developing a system for audit of the patients attending the hospital emergency. Based on the audit data, an Ishikawa cause-effect diagram was prepared. A cause validation plan was developed and the potential causes for delay were validated further by the use of statistical and graphical techniques of Six Sigma. Statistical analysis like Test of hypothesis and graphical analysis like box plot, control chart was used to analyze the data. Results: We started the audit in March 2017 and repeated it in January 2018. The stroke intervention began to gather pace from July 2018. The median duration of door to CT reduced form 30 minutes to 20 minutes. The median duration of door to CT angiography reduced from 54 to 43 minutes from March-July 2018 to July-Dec 2018. The significance of these results was validated through Mann-Whitney test and Box plot. The number of intervention improved from none from January 2018 to June 2018 to 5 to 17 in July 2018 to March 2019. The total number of intervention improved from 4 from June 2016 to July 2017 to 47 between July 2018 to June 2019. The result of intervened patients for favorable clinical outcome as assessed using modified Rankin scale 2 or less reached 63% at June 2019. The average bed occupancy of intervened patients is 5+/-3 days. Conclusion: This paper reports the novel application of six sigma methodology for initiating acute stroke intervention in a large tertiary care hospital. It is one of the first reports of application of Six Sigma methodology in all aspects of care pathway in acute stroke care. Time-critical interventions such as acute stroke care can benefit from a systematically implemented protocol-driven approach. Data driven approach for solving institutional bottlenecks is an effective methodology that can be widely applied in health care. Complex intervention in medicine can be divided into multiple sub-processes and critically examined. Limitation: The conclusions presented in this article are based on the collected data of the selected patients in a single hospital. The study did not employ real-time digitalized tools to capture data. The study carries the risk of bias related to an observational study. Future Direction: Use of digitalized tools, real-time data capturing and extensive statistical modeling can bring further consistency the inferences and actions taken. There is further scope for application of similar methodology for developing a standardized care pathway in the pre-hospital and post-hospital sphere.

SO12/467: Defining neuropsychiatric symptom profile in young onset strokes

Indira Priya D, Rajeswari Aghoram, Sunil K Narayan

Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.

Introduction: Neuropsychiatric symptoms are common post-stroke. Only a few studies aimed to characterise psychiatric and behavioural symptoms in young strokes. In the current study, we aimed to evaluate neuropsychiatric symptoms in young stroke. Aim: To evaluate the frequency and patterns and associations of neuropsychiatric symptoms among young stroke survivors. Materials and Methods: Our Hospital-based cross-sectional study comprised of a sample of 150 young strokes with index stroke between 18-45 years of age were recruited at >3months of ictus. Clinical and demographic data were collected. Neuropsychiatric symptoms were evaluated using the Neuropsychiatric inventory questionnaire (NPI-Q) was administered to principal caregivers. Symptoms were categorised into 4 clusters (euphoria, mood, psychosis, behavioural) Center for epidemiological depression scale (CES-D) was administered to all patients and clinical dementia rating scale (CDR) to all patients and caregivers. Descriptive statistics were used to describe patterns of neuropsychiatric symptoms. Univariate and multivariate analysis was performed to describe the factors associated. All statistical analysis was carried out using IBM SPSS version 21. Results: One hundred and fifty patients were recruited in to study with mean age of 39.3 (SD:6.6) with male to female ratio of 3:1. Median age at onset of stroke is 39 (IQR:18-45) and median time of assessment from ictus is 24 months (IQR:7-181). 56.7% (85) patients had one or more neuropsychiatric symptoms. Median NPI score was 4 (IQR:0-36) with most common symptom cluster being mood 46.7% (70), followed by behavioural cluster 26.6% (40) and psychosis 2.6% (4). None of the subjects had euphoria. Most common symptom noticed is depression 30% (44) while the patient-reported depressive symptoms in (CES-D scale) were noted in 52.7% (79). Other common symptoms noted were agitation 22% (33) and anxiety 16% (24). 45% (68) subjects (CDR scale) had vascular dementia. The presence of neuropsychiatric symptoms was not significantly associated with increasing motor disability and cognitive disability but prevalence increased with age <35years of stroke onset (OR-1.1; 95%CI-0.7-1.9), in female sex (OR-1.7; 95%CI – 1.0 - 3.0), years of formal education less than 10 years (OR – 1.05; 95%CI-0.7-1.3) and with after 2 years of ictus (OR – 1.02 ; 95% CI – 0.7-1.4). Conclusion: Psychiatric and behavioural symptoms are common in young strokes with mood symptoms being most common symptom. Limitations: There may be an overestimation of symptom frequency being a hospital-based study and drawbacks of using NPI-Q. Further Scope: The current study emphasizes the need for screening for neurocognitive symptoms in all young strokes. It could be interesting to conduct a more comprehensive study focussing on standard methods for characterizing neurocognitive profile helping clinicians intervene at the earliest.

Saturday, October 05, 2019, 16:00PM-17:00PM, Hall B

Platform Session 10: Neurogenetics

NGO1/82: Genotype-phenotype correlates of early-onset infantile epileptic encephalopathy syndromes in South India: A single centre experience

Nandini M, Menon R, Thomas S, Sundaram S, Nampoothiri S, Radhakrishnan A

Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.

Introduction and Background: Early onset infantile epileptic encephalopathies (EIEEs) have seizure onset before 1 year of age and are characterised by refractory seizures, severe electroencephalographic (EEG) abnormalities, and developmental delay. It is a genetically heterogeneous disorder and many cases are sporadic. An increasing number of novel genetic causes are being identified in EIEE. In the absence of studies with regard to genotype-phenotype correlates of 'cryptogenic' (unknown etiology) EIEE from India, this study was conducted with the objective to identify potential pathogenic disease causing variants in well-defined electroclinical phenotypes in accompaniment with developmental implications. Materials and Methods: Hospital-based cohort study including children who underwent genetic testing during a three year time period (2015-2018) by targeted next generation sequencing (NGS)in view of refractory seizures within 1 year of life, EEG favouring EE, absence of culpable epileptogenic lesion(s) on MRI and coexistent developmental delay or regression. Results: Forty out of 94 (42.5%) children with EIEE had potential disease causing variants (37 denovo including 11 novel). The patients were divided into the following groups based on underlying genetic causes: (1) Developmental encephalopathies causing epileptic encephalopathy-15 (36.5%) (2) Neurometabolic causes-7 (17%) (3) Chromosomal aberrations-2 (4.8%) (4) Dravet syndrome-16 (36.5%). Developmental encephalopathies included three with Ohtahara syndrome having STXBP1 (1), SCN2A (1) and SCN8A (1) mutations, One with early myoclonic encephalopathy having MT-ATP6 mutation, three girls with West syndrome (WS) having CDKL5 mutation and one with WS having ARHGEF9 mutation, two with migrating partial seizures of infancy having CACN1A and KCNT1 positivity and Neonatal-onset infantile convulsions with developmental encephalopathy noted with KCNQ2 (2), SCN8A (1), AP3B2 (1) and ZEB2 (Mowat wilson syndrome) mutations. Neurometabolic etiologies identified included SUOX (Sulfite oxidase deficiency), ALDH7A1 (2) with pyridoxine dependency (severe focal epilepsies), GLDC (Glycine encephalopathy-Myoclonic epilepsy with ataxia), ADSL (Adenosuccinate lyase deficiency-WS), D2HGDH (Hydroxy-Glutaric aciduria) and DLD (Dihydrolipoamide dehydrogenase deficiency-WS). Two children had chromosomal aberrations - 1p36 deletion and 2q24.3 microdeletion syndromes. Sixteen patients with refractory early infantile-onset fever provoked focal and generalized seizures including febrile status epilepticus with/without photosensitivity had Dravet syndrome and had mutations in SCN1A gene in 13 (9 missense including 5 novel, 4 truncation mutations including monozygotic twin probands); One with SCN1B missense mutation; 2 novel mutations CHD2 and CACNA1H were identified with concurrent photosensitivity. 17 (42.5%) of 40 patients (SCN1A, SCN2A, SCN8A, KCNQ2, ALDH7A1, GLDC) could be offered targeted therapy. Conclusions: This is the largest cohort from India with high yield of genetic testing using NGS in EIEE across defined electroclinical phenotypes with potential diagnostic, therapeutic, prognostic and predictive implications and this approach is highly relevant from a developing country perspective. Limitations: Retrospective single center study hinders generalisability of conclusions. Parental testing could also not be performed in all children. Further Scopes: This study will help in providing recommendations regarding phenotypes amenable to an early genetic diagnosis in EIEE. Diligent phenotyping as seen in this study is important to increase the yield of NGS/whole exome sequencing panels.

NGO2/101: Association of mthfr C677T polymorphism with ischemic and hemorrhagic stroke in Kashmiri population: A case control study

Kawoosa A

Department of Neurology, Government Super Speciality Hospital, Srinagar, Jammu and Kashmir, India.

Introduction: Methyl Tetra Hydro Folate Reductase (MTHFR) C 677-T Polymorphism is a widely studied genetic mutation all over world not only because of its association with the prevalence of stroke, but also because of the associated hyperhomocystinemia and potentially preventive nutritional interventions. Methodology: We conducted a hospital based case control study with 75 confirmed cases each of Ischemic (ISC) and Hemorrhagic (ICH) strokes against 100 matched controls, and employed the PCR-RFLP technique to study MTHFR C677T Polymorphism. Results: Among the controls we found the frequency of MTHFR CC, CT and TT genotypes to be 66 (66%), 29 (29%) and 5 (5%), while in the ICH cases it was 62 (82.66%), 13 (17.33%) and 0%; and in the ISC cases it was 57 (76%), 18 (24%) and 0% respectively. No statistically significant differences in the allelic and genotypic frequencies between ISC patients and controls were found in this polymorphism (p=0.18; OR=0.61; CI=0.31-1.2). However, the allelic and genotypic frequencies of MTHFR C677T in ICH cases and controls was found to be significantly different (p=0.01; OR=0.40; CI=0.19-0.8). Conclusion: MTHFR C677T Polymorphism was not associated significantly with ischemic stroke while as in ICH patients it was protective (negatively associated). Furthermore its association with the various clinical parameters of ISC and ICH cases was not found to be significant.

NGO3/148: Tumour necrosis factor-alpha gene polymorphisms and risk of ischemic stroke in North Indians: A case control study

Kameshwar Prasad, Kumar A, Sagar R, Mishra A, Rawat D, Raj R, VIbha D, Pandit AK, Srivastava AK, Vivekanadhan S, Goyal V, Gupta G

Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.

Background: TNF-α gene is thought to be involved in the etiology and pathogenesis of ischemic stroke (IS) with damaging effects on cerebral arteries by promoting inflammation and apoptosis in vascular cells. Due to ethnic diversity, studies of the association between these polymorphisms and IS are inconclusive. Aim and Objective: To investigate the relationship between TNF-α (C857T, T1031C, G488A, G308A) gene polymorphisms and risk of IS in North Indian population. Methods: In a case-control study, DNA was isolated by chloroform-phenol method and genotyping was performed by MALDI-TOF MassARRAY method for 540 patients and 540 age-sex matched controls. Frequency distribution of genotypes and alleles were compared between cases and controls through conditional logistic regression by using STATA software. Results: Mean age of patients and controls were 53.3±12.6 and 51.8±12.8; 35.2% were females. Frequency distribution of alleles was consistent with HWE. Conditional logistic regression analysis showed a statistically significant association between TNF-α (G488A) and IS under recessive model (OR=0.46; 95%CI 0.24 to 0.89; p=0.02) in univariate analysis but not in multivariable. We did not observe the significant relationship between TNF-α and risk of IS under dominant model. We did not observe the significant association between TNF-α (C857T, G488A, G308A, T1031C) gene polymorphisms and risk of IS under allelic model. Conclusion: TNF-α (G488A) gene polymorphism showed a protective role for IS under recessive model in North Indians. Additional studies with adequate sample and subtype of ischemic stroke is essential to understanding of their precise significance.

NGO4/305: Clinical and genetic profile of Autism-Epilepsy overlap syndrome: Two sides of the same coin!

Soumya Sundaram, Sudhakar K, Menon R

Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.

Introduction: Epilepsy is reported to co-occur in the range of 4-38% in patients with ASD and the prevalence increases with the age of the child or when associated with intellectual disability and speech related problems.1 ASD-epilepsy (ASD-E) phenotype is the common neurological presentation in various genetic disorders, irrespective of the underlying genetic mechanisms such as copy number variations, single gene mutations, genomic imprinting or epigenetic modification. 2 Through this article, we have elaborated the type of seizures, epilepsy syndrome, electroencephalography pattern and the genetic basis in thirteen patients with ASD-E phenotype. Methodology: This is a retrospective descriptive study of genetically proven cases of patients with ASD-E phenotype. Patients satisfying the Diagnostics and statistical manual (DSM) V criteria for ASD and ILAE definition for epilepsy were included in the study. The demographic profile, clinical features, co-existent neurological conditions, age of onset of seizures, type of seizures and epilepsy syndrome as per the recent ILAE classification 2017 was recorded. The EEG data was analysed for the background activity, interictal epileptiform discharges (IEDs), sleep structures, electrical status epilepticus in sleep (ESES) pattern and other abnormalities. Results: We had included 13 cases with ASD-epilepsy (ASD-E) phenotype with an underlying genetic cause in this study. Genetic analysis showed CDKL5 mutations (3) MECP2 mutation (2), 1p36 deletion (2), Prader Willi Syndrome (1), and one patient each had KCNQ2, SCN1A, SCN8A and KIF1A mutation. One patient had hemizygous mutation involving both CUL4B and CDKL5. The median age was 4.5 years (range 0.8 – 16.5 years) and 5 patients (38 %) were males. The median age of onset of clinical seizures was 0.83 years (range 0.03-11). The most common seizure type was focal onset seizures with impaired awareness seen in 8 (61.5%) patients followed by generalized tonic clonic seizures in 5 (38.5%), epileptic spasms in 4 (30.8%), atonic and tonic seizures in 3 (23.1%) and myoclonic seizures in one (7.7%) patient. More than one clinical seizure types were seen in 8 (61.5%) patients. EEG showed diffuse back ground slowing in 8 (61.5%) patients and focal slowing in 3 (23.1%) patients. Focal and multifocal interictal epileptiform discharges (IEDs) were seen in 7 (53.8) and 6 (46.2%) patients respectively. Two (15.4%) patients had ESES and one (7.7%) patient had hypsarrythmia. While classifying the type of epilepsy syndrome, 9 (69.2%) had epileptic encephalopathy, whereas 4 (30.8%) had focal epilepsy. Among epileptic encephalopathy, 5 patients had Lannox Gastaut syndrome, two had ESES, one had West syndrome and the other patient type of epileptic encephalopathy was uncertain. Conclusion: In patients with autism and refractory epilepsy, chromosomal microarray or next generation exome sequencing should be included in clinical practice as part of evaluation. Limitations: Retrospective nature, heterogenous and small sample size are the limitations of this study. Further Scopes: The ASD-E phenotype is probably a good model for understanding the molecular mechanism underlying both the genesis of epilepsy and autism and further research in this direction is required.

NGO5/460: Neuroregression in children: Clinical spectrum and genetic profile in children attending neurology outpatient

Ayesha Mariam, Venkataraman V

Department of Neurology, Kanchi Kamakoti Child Trust Hospital, Chennai, Tamil Nadu, India.

Introduction and Background: Neurodegenerative disorders is an umbrella term for over 600 conditions characterized by varied clinical manifestations, complex molecular biology and protean investigations. Our study aims to assess the spectrum of clinical manifestations and use of the specific investigations in children with neurodegenerative disorders. Materials and Methods: It is an observational prospective study conducted for a duration of 1 year (May 2018 to May 2019) by Neurology department, XXX. Children aged 6 months - 18 years, with history of neuro regression or positive family history were included in the study. Children with static encephalopathies were excluded. Data was collected via parent interview and review of old records after obtaining consent. Data was entered in the excel worksheet and descriptive statistics were calculated. Results: The study included 83 children who satisfied the inclusion criteria. Children were classified clinically at presentation - white matter degeneration 34.9% (n=29), grey matter degeneration 33.7% (n=28), progressive ataxias 12% (n=10) and extrapyramidal disorders 19.2% (n=16). There were 16.8% children with suspected mitochondrial disorders and 12% with a metabolic abnormality with predominant extra-neural features. 42.1 % (n=35) of children had onset of illness at < 2 years of age. 42 % of children had significant contributory ophthalmological findings (Optic disc pallor (26.9%), Optic atrophy (11.5%), Cherry red spot (3.8%), Cortical blindness (11.5%), Telangiectasia (11.5%), Glaucoma (3.8%), Retinitis pigmentosa (11.5%), KF ring (7.6%), Cataract (3.8%), Nystagmus (3.8%). 80% of patients had MRI findings supporting the clinical diagnosis. Enzyme assays, gene analysis done in 43 (51.8 %) and were positive for 81 % of cases. A rare form of hypomyelinating leukodystrophy who presented with features of oligodontia, hypogonadotropic hypogonadism and hypomyelination was confirmed by identifying a mutation in the POLR3B gene. Another rare mutation in GJC2 gene was identified in a child with severe dysmyelination. A child with clinical and MRI features suggestive of hereditary spastic paraparesis was confirmed with identification of mutation in K1F1A gene, a pointer towards an autosomal dominant inheritance. There are more than 430 mutations identified in Neuronal ceroid lipofuschinosis. Our study reports mutations in CLN6 gene, rare mutations in MFSD8 and TPP1 gene. Few other genetic reports include Leighs disease (SURF1 gene), Mitochondrial DNA depletion syndrome (TWNK gene), Congenital disorder of glycosylation (STT3 gene), Manganese transporter defect-1 (SLC30A10 gene), HARP syndrome (PANK-2 gene), Rett's syndrome (MECP-2 gene). Conclusions: White matter degeneration was the most common presentation of Neurodegenerative diseases in our study. Majority of the clinical manifestations had a significant overlap making it difficult to categorize them accordingly. Few rare mutations are reported from our study which further help in contributing to the expanding genotypic and phenotypic spectrum of neurodegenerative disorders. Limitations: Cost of next generation sequencing was a limiting factor for detailed analysis. Non-availability of detailed mitochondrial studies. Further Scope: Detailed family screening for similar mutations would help in prevention, Therapeutic options could be devised for specific region specific mutations.

NGO6/22: A study of mutation in ATP7B gene and its correlation with clinical phenotype and radiological features in patients of Wilson disease

Chaudhuri J, Biswas A, Biswas S, Mukherjee A, Dutta A, Ganguly G

Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India.

Introduction: The present study was aimed at exploring the mutation profile of Eastern Indian Wilson's Disease (WD) patients and analyzing the effect of mutations. Background: WD is an autosomal recessive disease caused by mutation in the ATP7B gene. More than 700 mutations have been described in ATP7B according to the Human Gene Mutation Database. Clinical manifestations of WD are variable, even differing among persons carrying the same homozygous mutation. Identification of the prevalent mutations in a given population is necessary to provide mutation-based molecular diagnosis. Previous studies have detected common mutations in this part of the world and our study aims to correlate genotype with clinical features and radiological features. Methods: A descriptive cross sectional observational study was conducted over a period of two years in a tertiary care hospital and neurology referral unit, India. All WD patients within the study period and meeting the inclusion criteria were included. Included patients are WD based on Sternlieb's criteria characterized by suggestive clinical features with evidence of positive KF ring, low serum ceruloplasmin, high urinary copper excretion. KF ring negative hepatic cases had no clinical or lab evidence of the etiology of other disease, aged ≥5 years. Excluded were subjects with only hepatological manifestations of Wilson's Disease, viral hepatitis, childhood cirrhosis due to other causes, preexisting developmental delay. Demographic data collection, clinical examination and relevant laboratory investigations were done. Magnetic resonance imaging of brain, and cognitive assessment by Mini Mental Score Exam (MMSE) were also performed. Blood was collected for genetic analyses. PCR-Sanger sequencing of exons 2, 4, 8, 14, 18 and 19 of ATP7B gene was done based on previous reports of mutation hotspots of ATP7B gene for WD in Eastern India. Results: Of 34 WD patients were included in the study, 55.9% were males. The median age was 16.5 years (range 10-38 years) while the median age at diagnosis was 12 years (range 5-31 years). Majority (21/34, 61.8%) of the patients had dystonia on presentation, followed by dysarthria (41.2%), tremor (17.6%) and ataxia (11.8%). The median MMSE score in the study population was 24 (IQR 22-25.5). Both mutations were detected in 11 (32.4%) patients, all of whom were compound heterozygotes, while a single mutation was found in 14 (41.2%) patients. No likely pathogenic mutation was detected in 9 patients. c.813C>A (p. C271X) was the commonest identified mutation, representing 30.6% of all characterized coding mutant alleles. Conclusions: WD patients in eastern India have significant genotypic and phenotypic diversity. Further studies with larger samples and screening of remaining exons are warranted. Limitations: Small study sample size and cognitive assessment could not be done uniformly in all patients. Further Scopes: We intend to carry out this study in a much larger scale and then it will be first of its kind to correlate genotype with complete phenotype including cognition and also radiological features and this genotype database in future may direct therapeies in WD.

Saturday, October 05, 2019, 16:00PM-17:00PM, Hall C

Platform Session 11: Dementia

DO1/95: Transcranial cerebral blood flow differences in Alzheimer's dementia and vascular dementia

Joby Thomas Mammen, M Jawahar, Lakshminarasimhan R

Department of Neurology, Madras Medical College, Chennai, Tamil Nadu, India.

Introduction: Transcranial Doppler (TCD) is a non-invasive and inexpensive method for cerebral hemodynamic assessment. The cerebral arteries in Alzheimer's dementia (AD) are morphologically altered and dysfunctional than in age matched non demented controls possibly related to amyloid cascade hypothesis in AD. Aims: To evaluate the TCD blood flow hemodynamics of AD and compare with that of vascular dementia (VD) and normal control patients. Methods: Thirty AD patients were studied and compared with 30 age matched VD patients and 20 controls at the Institute of Neurology, Madras Medical College. Two values namely Pulsatility index (PI) and mean blood flow velocity (MBFV) in the middle cerebral artery (MCA) were studied. Patients satisfying probable NINDS-AIREN and NINCDS-ACRCA criteria for VD and AD respectively were included. Patients with significant carotid artery disease, H/O head trauma and cardiac illness were excluded. Results: The MCA MBFV in VD [37.5, p< 0.05 (CI 95%)] and AD (38.3, p<0.05 (CI95%)) were significantly lower than in controls (51.4) but did not vary significantly between AD and VD. Similarly, PI in VD [1.3, p<0.05] and AD [1.09, p< 0.05] were significantly higher than in controls (.8). Although MCA PI was higher in VD than AD this was not statistically significant. Conclusion: In our study, although TCD did not help to distinguish between VD and AD, it showed vascular flow and resistance changes in AD similar to VD. The significance of vascular pathology in AD needs further research and evaluation.

DO2/102: P 300 latency in patients with Parkinson's disease without dementia and its association with motor symptoms and cognitive performance

Shrivarthan R, Manickavasagam J, Narasimhan LR

Department of Neurology, Institute of Neurology, Madras Medical College, Chennai, Tamil Nadu, India.

Parkinson's disease (PD) is a neurodegenerative disorder with a plethora of symptoms attributable to dopaminergic and nodopaminergic neurotransmitter dysfunction, involving subcortical and cortical networks. Sensitive tests for early cognitive dysfunction identification in PD are unavailable. A late evoked potential, P300, has utility in identifying cognitive dysfunction. The aim of this study was to measure P300 wave latencies in PD patients without dementia(MoCA score>21/30) and to assess its association with motor features of PD and performance in cognitive tests (MOCA & FAB). A total of 30 patients with confirmed diagnosis of PD (UK Brain Bank criteria) were selected and 9 were excluded because of a MoCA score < 21/30. In the rest UPDRS score, MoCA & FAB score and P 300 latencies using an auditory stimulus with odd ball paradigm obtained. All patients had prolonged P300 latencies, mean of 328.7 ms (SD=9.8). The mean age of patients was 61.19 years (SD=6.75), median duration of illness 60 months (IQR:36-90 months), mean UPDRS score 71.57 (SD=6.9), mean MoCA score 26.1 (SD=0.9), mean FAB score 13.05 (SD=1.5). P300 latency showed statistically significant positive correlation with UPDRS score (r=.68, p<0.01), presence of dyskinesia (r=0.6, p<0.01), gait freezing (r=.45, p-0.04) and postural abnormalities (r=.48, p-0.03) and negative correlation with FAB score (r=.47, p-0.03). Our study shows P300 latency prolongation in patients with PD with normal MoCA.

DO3/208: Cognitive effects of endemic fluorosis - A comparative study

Anjana Prabhakar, Shaji CV, Kabeer KA

Department of Neurology, Government TD Medical College, Alappuzha, Kerala, India.

Background: Fluoride has beneficial effects on teeth at low concentrations in drinking water, but excessive exposure to fluoride in drinking water can give rise to a number of adverse effects including detrimental neurological effects. This study aims at investigating if there is a link between fluorosis and the cognitive function of school going children. Methods: This cross sectional Study was conducted in collaboration with the the Fluorosis Control Programme, Department of Health services, Alappuza district. School going children aged 8 – 10 years studying in Govt. LPS, Kalarcode, Alappuzha district with confirmed endemic fluorosis were picked up. Normal healthy age and sex matched children without fluorosis were selected from the same school. Both groups were subjected to neuropsychological assessment with Raven's Standard Progressive Matrices and MISIC digit span subtest. Results: A total of 40 children with confirmed fluorosis were selected by simple random sampling and an equal number of age and sex matched normal children were also selected. Majority of study subjects in both groups were females (55%) and were 9 years of age (75%). The mean age of the children was 8.95. 30% of the children without fluorosis had Grade I (Intellectually superior) and Grade II (Definitely above the average in intellectuall capacity) Raven's SPM grades as compared to 15% of those with fluorosis. None of the children without fluorosis had scores in the Grade V (Intellectually impaired) category whereas 20% of the fluorosis affected children belonged to the same. The mean digit span (backward) was found to be significantly higher in the normal children than those with fluorosis. An increase in Raven's SPM grade was observed with increase in Dental fluorosis Index. Conclusion: This study establishes a significant relationship between the presence of fluorosis and impaired cognition in children. Severity of dental fluorosis is significantly associated with the grade of cognitive dysfunction. Measures to reduce fluoride intake might prevent cognitive dysfunction in children.

DO4/433: Neuroimaging signatures of behaviour and cognition in frontotemporal dementia spectrum disorders

Faheem Arshad, Vandana VP, Raghvendra K, Jennifer K, Saini J, Ramakrishnan S, Pal PK, Chandra SR, Nalini A, Alladi S

Departments of Neurology and Neuropathology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Introduction: Frontotemporal dementia (FTD) is a complex disorder affecting distributed areas and connectivity between brain regions. Clinically too, it is a heterogenous disorder consisting of classical and overlap FTD-syndromes reflected in the different clinical phenotypes. Both behaviour and cognition are impaired in classical FTD and emerging evidence suggests that their neural correlates are specific. While neural correlates of classical FTD are recognised, less is known about overlap FTD-syndromes which include FTD-Progressive Supranuclear Palsy (FTD-PSP) and FTD-Amyotrophic lateral sclerosis (FTD-ALS). Aim: Aim of the present study was to determine patterns of brain atrophy and neural correlates of behaviour and cognition in FTD spectrum disorders. Methods: This study used culturally validated clinical tests and voxel-based morphometry (VBM) to study behaviour and cognition in FTD. Sixty patients with FTD spectrum disorder were subjected to cognitive assessment using Addenbrooke's Cognitive Examination (ACE III) and Indian Semantic battery to assess range of cognitive functions like attention, memory, language and visuospatial functions. In addition, social cognition was assessed using tests of empathy, (Interpersonal Reactivity Index, IRI) and emotion recognition using pictures of facial affect (POFA) and behaviour using Frontal Systems Behaviour scale (FrSBe). All patients underwent neuroimaging. T1 MPRAGE sequences were acquired. Processing of images was done using CAT12 toolbox for determining volume of gray, white matter and CSF. Further analysis across groups was done using SPSS version 21. Results: While all FTD subtypes had behavioural changes, apathy and disinhibition were most common in behavioural variant-FTD (bvFTD) and FTD-ALS, and executive dysfunction and language were more common in progressive nonfluent and semantic variant aphasia. All FTD subtypes showed significantly lower levels of empathy and perspective taking. Comparison of VBM between FTD subtypes showed significantly increased total CSF volume in FTD-ALS group compared to bvFTD, gray matter volume in thalamus and cerebellum was significantly reduced in FTD-PSP compared to other subtypes and lingual gyrus was more involved in FTD-ALS, bvFTD and SD compared to FTD-PSP and PNFA. Positive correlation was seen between total ACEIII scores and gray matter volume of bilateral insular, parahippocampus, basal ganglia and cerebellum. Total POFA score across the groups correlated positively with bilateral lingual, fusiform, thalamus and cerebellar gray matter volume. Tests of empathy which include perspective taking (PT) and empathic concern (EC) correlated positively with left insula, bilateral lingual, hippocampus, thalamus, putamen and cerebellum. Conclusion and Further Scopes: We have shown deficits in behaviour and cognition across FTD spectrum disorders and variable patterns of atrophy across the groups. Deficits in general and social cognition correlated significantly with different areas of brain suggesting involvement of multiple areas in different subtypes. This study provides understanding of such different neuroimaging patterns of atrophy which are not limited to frontotemporal lobes but may also involve basal ganglia, cerebellum, lingual gyrus and thalamus, and thus substantiates the literature as there is paucity of data and may need further studies to strengthen the evidence for same.

DO5/444: Semantic memory deficits in patients with fronto temporal dementia

Darshini KJ, Vandana VP, Alladi S, Paplikar A, Arshad F, Mekala S, Ramakrishnan S, Chandra SR

Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Objectives: Frontotemporal dementia (FTD) is associated with significant deterioration in behaviour, language and semantic memory. The semantic memory deficits are culturally specific and cause significant difficulty in performing daily activities. We aimed at profiling the semantic memory in FTD subtypes i. e. semantic dementia (SD), frontal/behavioural variant FTD (BvFTD) and progressive non fluent aphasia (PNFA) using a culturally relevant and validated semantic battery. Methods: 19 individuals (12 males and 7 females) with FTD i. e. 9-PNFA, 6-SD and 4-BvFTD in the age range of 47-68 years (Mean age=59.63 years) were recruited. The patients had either mild or moderate dementia and cognitive functions were evaluated using Addenbrooke's Cognitive Examination-Revised (ACE-R). Semantic memory was evaluated using a culturally appropriate adaptation of semantic battery. The study was approved by Institutional Ethics committee of NIMHANS. Results: The results revealed different semantic profiles across the FTD subtypes. Performance of patients with SD was significantly poor whereas patients with PNFA had milder semantic deficits, as demonstrated by a preserved performance on non verbal tasks. Patients with BvFTD outperformed SD and PNFA across all semantic memory tasks. Conclusions: FTD is a complex clinical syndrome. Although majority of the patients present with overlapping cognitive-linguistic profiles, there is an immense need to establish accurate clinical diagnosis using culturally appropriate tools. Evaluating semantic memory across verbal and non-verbal modalities of stimulus and/or response using a culturally relevant semantic battery was found to be helpful in differential diagnosis across FTD subtypes.

DO6/459: ACE-III in seven Indian languages: A cognitive screening tool for dementia diagnosis

Leena Shingavi, Suvarna Alladi, Shailaja Mekala, Avanthi Paplikar, Eneida Mioshi, Ratnavalli Ellajosyula, Ramsekhar Menon, Sunil Narayan, Ashima Nehra, Manjari Tripathi, Lekha Saru, John Hodges

Departments of Neurology and Neuropathology, National Institute of Mental health and Neurosciences, Bengaluru, Karnataka, India.

Introduction: Around 58% of population with dementia reside in low and middle income countries and will witness an increase to 63% and 68% by 2030 and 2050 respectively. There exists epidemiological variability both between and within countries like India. This has been attributed to a limited availability of harmonised and standardised methodologies and variable screening instruments. Hence, the need to develop a cognitive screening tool to diagnose dementia in the Indian context. Aim: To standardise and validate Addenbrooke's Cognitive Examination-III across seven Indian languages (Hindi, Kannada, Telugu, Malayalam, Urdu, Tamil, English) and to assess the diagnostic accuracy of the test to detect dementia and mild cognitive impairment in the context of linguistic diversity. Methods: A total of 1203 subjects (757-control, 242-dementia, 204 MCI) were recruited from multiple centres. Culturally appropriate modifications were formulated in ACE-III. ROC curve was obtained. Results: The sensitivity and specificity of ACE-III in identifying dementia ranged from 0.90 to 1.00 across different languages. The sensitivity to identify MCI ranged from 0.86-1 and specificity from 0.83-0.93. High education group controls had higher test scores and likewise. Optimum cut-off values to diagnose dementia in low education group were established to be 80-83 and 82-85 in high education group and for MCI were 84-86 in low education group and 87-89 in high education group. Conclusion: The study provides a cognitive screening tool that can be used to uniformly diagnose cognitive impairment in people speaking different Indian languages.

Saturday, October 05, 2019, 16:00PM-17:00PM, Hall D

Platform Session 12: Neuromuscular

NMO1/77: A comparison study of myasthenia gravis with and without thymoma

Singh VK, Kalita J, Misra UK

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Introduction: Myasthenia Gravis (MG) patients with thymoma may have more severe illness and poor outcome. Aim: To compare clinical, laboratory parameters and outcome of MG with thymoma to those without thymoma. Methods: This is a longitudinal study and patients with MG attended neurology service of SGPGIMS were included. Their baseline Myasthenia Gravis Foundation of America stage, comorbidities, crisis, AchR antibodies, decremental response, CT thorax and biochemical parameters were noted. Patients with radiologically suspected thymoma and some nonthymoma patients also underwent thymectomy. Patients were treated with AchEIs and prednisolone with or without other immune modulating drugs. The outcome after a median of 5 years (range:3 mon-25 yrs) was compared between thymoma and non thymoma groups. Results: One hundred fourteen patients with MG were included whose age ranged between 2 to 75 years (median 42.5 years) and 67 were males. CT thorax revealed thymoma in 25, thymic hyperplasia in 8 and normal in 81 patients. 30 patients underwent thymectomy; 19 (17%) patients had thymoma. Thymomatous patients were frequently males (72% Vs 55%), had more severe illness, higher hemoglobin (13.54±1.78 Vs 12.58±1.92 gm/dl), AchR antibody (100% Vs 83%), myasthenic crisis (48% Vs 22%), higher doses of AchEIs (240 mg Vs 180 mg) and death (20% Vs 6%). At last follow up improvement was more marked in thymectomy patients compared to nonthymectomy group. Conclusion: Thymoma in MG is more common in male and associated with more severe illness and death.

NMO2/100: A comparative Study of IVIG versus IVIG with IV methylprednisolone in Guillain Barre syndrome

Bhattiprolu RK, Sardana V, Maheshwari D, Bhushan B, Shringi P

Department of Neurology, Government Medical College, Kota, Rajasthan, India.

Introduction: Guillain-Barre Syndrome (GBS) is an acute severe polyradiculoneuropathy of autoimmune in nature and is the most common cause of acute or subacute generalized paralysis. Even after administration of approved therapies like Intravenous immunoglobulin (IVIg) and Plasma Exchange (PLEX), about 15% of GBS patients die or left disabled. The role of Steroids has been debated since many decades and till date there is still no strong evidence demonstrating or denying the efficacy of high dose steroids. In a developing country like India, Steroids are affordable and user friendly making them the theoretically reasonable agents for the treatment of GBS. Our study is mainly intended to investigate whether adding steroids to the standard treatment with IVIg will have positive outcome or not. Materials and Methods: A total of 46 patients were recruited for this study with clinical and Electrophysiological findings consistent with GBS and equally divided into two groups. One group treated with IVIg, the other with IVIg and ivMPS. Primary outcome was improvement of ≥1 score on GBS disability or modified Rankin Scale (mRS) scores four weeks after randomization, compared with the score at entry. Data was analysed using the following statistical tests: Chi-square test, Independent Sample T Test and Mann Whitney U test. Results: In our prospective study done over a period of one year, totally 46 patients were included with a follow up period of 1 month. There was male preponderance and Male: female ratio is 2.53. Mean age of presentation was 40. Of the total patients, half of the patients had AIDP and the other half had AMAN variant of GBS. The percentage of patients that reached the primary endpoint in IVIg only group and IVIg with ivMPS group were 18 (78%) and 19 (82%) respectively (p>0.05). All variables which can affect treatment response and thereby prognosis were compared between two groups, but the result was not significant (p>0.05). No considerable differences in side effects were found between the two groups. Conclusion: In the past, there were only very few studies done to know the effect of adding steroids to standard treatment in GBS patients. Unfortunately, there were no large Indian studies done previously comparing the available immunosuppressant modalities in GBS. We conclude that ivMPS along with the standard treatment IVIg offers no added benefit in patients with GBS. Though our findings did not indicate a significant outcome difference when ivMPS is added to IVIg, these two drugs might work synergistically to influence the disease outcome. Due to lack of previous studies, limited side effects, easy availability and cost effectiveness of steroids, our study highlights the need for further investigation of this combined treatment in GBS patients. Also our study highlights the need for newer immunosuppressive agents in GBS.

NMO3/112: Study of pattern of muscle involvement by imaging in various muscle diseases

Aravind S, Balasubramanian S, Lakshminarasimhan R, Shanmugasundaram N

Department of Neurology, Institute of Neurology, Madras Medical College, Chennai, Tamil Nadu, India.

Introduction: Muscle magnetic resonance imaging is a noninvasive tool that can contribute to the diagnosis and assessment of disease severity and progression in a number of neuromuscular disorders. Objectives: To study the pattern of muscle involvement in various muscle diseases. To correlate the clinical findings with imaging findings in various muscle diseases. Materials and Methods: All patients presenting in neurology outpatient department with weakness due to muscle diseases were included in the study. All MRI studies were done on a 3 Tesla mri system. Results: Out of 28 patients studied Limb girdle muscular dystrophy was present in 16 patients, polymyositis was present in 10 patients and Fascioscapulohumoral dystrophy in 2 patients (1 male and 1 female). MRI showed fatty degeneration of hip girdle muscles in all the LGMD cases with sparing of psoas muscle seen in 14 (88%) cases. Thigh muscles were involved in 14 cases with Gracilis muscle spared in all of them and Sartorius muscle spared in 12 (86%). Tibialis posterior was spared in 5 (62.5%) out of 8 patients with leg muscle involvement. Fatty degeneration of shoulder girdle muscles were seen in 8 patients. STIR hyper intensity suggesting myoedema seen in 6 patients. MRI in polymyositis patients showed diffuse symmetrical homogenous STIR hyperintensity of affected muscles in all the patients. FSHD cases showed asymmetrical involvement of muscles with sparing of supraspinatus, infraspinatus and subscapularis muscles. Conclusion: Hyperintensities in STIR images were present in inflammatory myopathies, LGMD and FSHD. A specific pattern of muscular involvement was observed in LGMD and FSHD.

NMO4/159: Mutation spectrum of fatty acid oxidation disorders presenting as myopathy - A case series from India

Vengalil S, Polavarapu K, Veeramani P, Nashi S, Mahajan N, Maddasu K, Arunachal G, Christopher R, Gayathri N, Faruq M, Nalini A

Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Objective: To know the molecular defect underlying FAO. Methodology: 10 cases suspected of FAO underwent clinical exome sequencing (CES). Results: Five patients had Multiple Acyl CoA dehydrogenase deficiency (5 men). Age of onset =10-25 years (mean-19), age at presentation=14-29 years (mean-21.6). All had exertional myalgia and progressive proximal weakness. One patient had recurrent abdominal pain and vomiting. Two were siblings and 2 were born of consanguineous parentage. Two had head drop. Muscle biopsy had shown vacuolar myopathy in 3 cases with Oil Red O positivity and two cases were diagnostic of MADD by TMS. CES identified compound heterozygous and homozygous mutations in ETFDH in 2 patients and 3 patients respectively. Two unrelated male patients had symptom onset in 3rd decade with episodic myalgia, proximal weakness and exertional fatigue. While one patient presented at 33 y with mild progression and a homozygous mutation identified, 2nd patient with minimal or no progression at 44 y had a heterozygous mutation, both in the crucial mitochondrial domain of CPT2. A 36 y male who presented with exertional myalgia and weakness since 6 y, was found to have a reported pathogenic homozygous mutation in FLAD1 gene. Very long chain acyl CoA dehydrogenase deficiency was confirmed in an 18 y girl, symptomatic since 7 y with myoglobinuria and exertional weakness. She had 2 heterozygous variants in ACADVL gene. Neutral lipid storage disorder was diagnosed in a 29 y old man with proximal limb weakness since 22 years of age. He had homozygous mutation in PNPLA2 gene.

NMO5/411: CSF neurofilament H levels as a potential prognostic marker in patients of Gullain Barre syndrome

Tanveer Hassan, Wani M, Shah Z

Department of Neurology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India.

Aims and Objectives: To study if CSF phosphorylated neurofilament H (pNf-H) levels during the acute phase of GBS can act as a prognostic marker at six months follow up. Materials and Methods: 62 patients who fulfilled the diagnostic criteria for GBS and presented within the first 2 weeks of onset of symptoms were included in this prospective study. The control group consisted of age and gender matched 35 patients with headache in whom no other neurological pathology was found. CSF levels of pNf-H were measured using a sandwich enzyme immunoassay. The outcome was assessed using the Hughes functional grading scale (F-score). Outcome was classified as “poor” if F-score was ≥3 and “good” if F-score was <3. Results: In our study 49 (79%) patients had a good outcome, whereas 13 (21%) patients had a poor outcome at six months follow up. The mean CSF pNf-H level in patients with good outcome was 325.3 pg/ml whereas the mean level in poor outcome patients was 3655.2 pg/ml. There was a high degree of positive correlation between CSF Nf-H levels and clinical outcome (F-score) at 6 months (R=0.684;P-value<0.001). Pathological levels of Nf-H (>730pg/ml) predicted poor outcome (P value < 0.001), with an odds ratio of 17.1. Conclusion: This study provides evidence that high CSF pNf-H levels in acute stage of GBS can act as a prognostic marker, with high levels indicating a poor prognosis.

NMO6/502: Diagnostic tests in the evaluation of ocular myasthenia gravis

Veerendra Kumar Mustare, Navalli D, Krishnan A, Subasree R

Departments of Neurology and Neuropathology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Aim: To ascertain diagnostic yield of various tests in the evaluation of patients with suspected Ocular Myasthenia gravis (OMG). Patients and Methods: 102 patients with suspected OMG seen during the years 2000-2014 underwent clinical evaluation, Acetyl choline Receptor antibody (AChR-ab) assay, Neostigmine test (0.03-0.4 mg/Kg), 5 minute Icepack test (IPT), RNS studies, Frontalis and Orbicularis oculi muscle SFEMG. Compatible clinical profile + abnormal SFEMG was considered as gold standard for diagnosis of definite OMG (d-OMG); patients with normal SFEMG and or incompatible clinical profile were considered as non-OMG. Results: 72 men and 30 women (age range: 14-78 years; mean age 42± 0.8 years) were evaluated. Duration of symptoms was 8 days - 6 years. History of remission and relapse was present in 9/102 patients and diurnal fluctuation in 55/102. 63 patients were diagnosed to have d-OMG and 39 patients as non-OMG. Evaluation showed fatigability of levetor palpebrae superioris in 45/63 and 10/39, positive AchR antibody assay in 34/54 and 17/33, positive Neostigmine test in 50/60 and 1/36, positive IPT in 53/62 and 7/39, abnormal RNS studies in 11/60 and 0/38, and abnormal jitter in facial muscles in 58/60 and 6/39 in d-OMG and non-OMG patients respectively. Conclusion: Because of low sensitivity of RNS studies (18%), Neostigmine test and IPT with >80% sensitivity and specificity are useful adjuncts for evaluation of patients with suspected OMG.

Saturday, October 05, 2019, 19:00PM-20:00PM, Hall C

Platform Session 13: Miscellaneous Disorders

MiO7/488: Connective tissue disorders/vasculitis: A study from Western India window from neurology perspective

Nishtha Jain, Ramrakhiani N, Dubey B, Sharma A

Department of Neurology, Fortis Hospital, Jaipur, Rajasthan, India.

Introduction: Neurological involvement can occur in a number of connective tissue disorders (CTD)/vasculitis and can often be presenting feature of these diseases in clinical practice. Pattern identification in these uncommon diseases in neurological practice is useful. Materials and Methods: This is a retrospective study in which data of 10 years was collected in prepared case report forms. Adult patients with various neurological syndromes from outpatients' and indoor records with clinical features suggestive of Vasculitis/CTD according to American College of rheumatology criteria were enrolled. Diagnosis was made with consensus of two neurologists and a rheumatologist. Most cases were either biopsy proven or have positivity for immunological markers. Outcome was analyzed by comparing Modified Oxford Handicap Scale scoring at the time of first visit and the last follow up visit. Patients of infectious vasculitis, entrapment neuropathy and inflammatory myopathies without vasculitis were excluded. Aims and Objectives: To study the spectrum of neurological manifestations in various connective tissue disorders/vasculitis. Results: Total of 46 patients were enrolled in this study with 16 (34.8%) males and 30 (65.2%) females. The mean age of onset of the disease was 45.5 years and age of onset of neurological manifestations was 47 years (18yrs-71yrs). Of all the disease entities, Sjogren syndrome was seen as the most common diagnosis, seen in 10 (21.7%) patients followed by Granulomatosis with polyangiitis in 7 (15.2%) patients, Systemic lupus erythromatosus in 4 (8.7%) patients, Giant cell arteritis in 3 (5.8%) patients, Bechet's syndrome in 3 (5.8%) patients, mixed connective tissue disorder in 3 (6.5%) patients, Rheumatoid vasculitis in 2 (4.2%) patients and one patient each of Polyarteritis nodosa, sarcoid vasculitis, Systemic Sclerosis, Susac syndrome, Eosinophilic granulomatosis with polyangiitis and overlap syndrome. There were 5 patients who were characterized in undifferentiated vasculitis. As far as the neurological symptoms are concerned 24 patients were having CNS and 19 patients were having PNS involvement. In peripheral nervous system manifestations, neuropathy was most common manifestation seen in 14. The most common pattern of neuropathy seen was mononeuritis multiplex. Spinal cord involvement was more common in dorsal segment followed by cervical involvement and mostly presented as acute entity as long segment involvement. Central nervous system manifestations included headache, seizures, cognitive decline, weakness, ataxia, extrapyramidal symptoms. The mean ESR (Erythrocyte Sedimentation rate) levels in these patients was 65.8 and CRP (C-Reactive Protein) levels were 72.5. 20 patients have biopsy proven vasculitis changes. Autoimmune markers were positive in 41 (89.1%) patients. Mean MOHS at the time of first visit was 2.78 which reduced to 1.71 at the last follow up visit. Conclusion: CNS manifestation were found more commonly than PNS. Mononeuritis multiplex was commonest form of PNS manifestation. Dorsal cord involvement with long segment myelitis was commonly seen. Most patients had increase in acute phase reactants and improved outcome on treatment. Limitations: Study may not depict the natural history as patients were enrolled from primary neurological practice. Due to waxing and waning course of the disease we may not have recorded the best clinical outcome.

MiO8/466: Can SMS reminders improve monitoring of international normalized ratio in patients on Vitamin K antagonists: A randomized controlled trial

Manish Bahartiya, Kameshwar Prasad, Achal Kumar Srivastava, Awadh Kishor Pandit, Deepti Vibha

Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Oral anticoagulants are widely used in neurological disorders as secondary prevention for stroke, recurrent CVST. The therapeutic efficacy of VKAs is monitored by International normalized ratio (INR). INR has to be monitored at least monthly but it is hardly done in practices as evidenced by a cross-sectional study which showed only 37% of patients adhering to regular INR monitoring. Our study aimed at increasing the adherence to regular monitoring of INR in patients on Vit K antagonists by the use of SMS based reminders. Methodology: The study was a open label double blinded randomized controlled trial and the intervention was in the form of SMS which was sent on two consecutive days prior to the scheduled INR testing. Only those patients who were on Vit K antagonists and could understand SMS were recruited. Follow up period was 06 months. Primary outcome was percentage of patients adhering to INR monitoring. Secondary outcome measures included time in therapeutic range for all the patients, factors associated with poor INR monitoring. Results: Sample size was 98 (49 in each group). Complete follow up has been done for 80 patients (42 intervention group and 38 in non intervention group). In the intervention group 35 out of 42 patients and 25 out of 38 patients were adherent to timely INR monitoring. The factors associated with poor INR monitoring include poor educational status and residence in rural areas. Initial trends show that SMS reminders may be helpful in regular monitoring of INR in patients on Vit K antagonists.

MiO9/73: Profile and severity correlation of ataxia patients in a tertiary care institute in Eastern India

Bhuin S, Kundu TN, Pandit A, Ganguly G

Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India.

Introduction and Background: The clinical, epidemiological profile and progression of ataxia patients in any population is varied and mostly an unexplored area. Hence, this study is taken up to explore the profile of ataxia with its severity correlation in our population. Materials and Methods: A cross-sectional study was conducted at XXX. Clinico-etiological parameters with severity correlation with SARA scale in selected patients of ataxia was determined and compared. Results: Out of 188 patients studied, 127 patients had cerebellar ataxia (SCA – spinocerebellar ataxia type 2, 3, 1, 6 and 12, MSA C - multiple system atrophy cerebellar type followed by Wilsons disease). 42 patients had sensory ataxia mainly Sensory ataxic variant of Guillain-Barré syndrome (GBS), Miller fischer, CIDP (Chronic immune demyelinating polyneuropathy, CISP-chronic immune sensory polyradiculopathy followed by Sjogrens disease. 19 patients had Mixed cerebellar and sensory ataxia (Multiple sclerosis most common followed by Vitamin E deficiency). The gait abnormality onset (most prevalent) is significantly earlier than the onset of speech (p<0.05). Cerebellar ataxias had higher disability at presentation (higher mean SARA score - 21.87) as compared to mixed ataxias (SARA – 19.68) and gait disability as main indicator. Increase in SARA score was seen more in mixed category (3.64) than cerebellar ataxia alone category (3.01) with significant association (p<0.05) showing higher disability progression in mixed category of ataxia. The estimated mean increase of SARA Total Score (at 6 months follow up) was maximum in MSA C (5.38) followed by Wilsons disease (4.2), Friedreichs ataxia (3.6) and SCA 3 (2.8). The progression of the severity and disability of ataxia disease is more in MSA C whereas SCA 2 has lesser degree of progression of ataxia (despite being the most severe - highest SARA score - 28.5 at presentation). Whereas Autoimmune diseases (Anti GAD, Anti Gliadin), Multiple sclerosis, Vitamin E deficiency and drugs/toxins related etiologies showed decreasing SARA score trends on 6 monthly follow up (hence improved outcomes in terms of disability). Increase in SARA score is found to be significantly associated (p<0.05) with other clinical features (Pyramidal, extrapyramidal, cognitive) followed by duration of illness, and male sex. Conclusion: Though epidemiological studies are there previously, correlation with SARA score and its associated determinants is still an unexplored area which is attempted in this study to give an insight of the ataxia predominant diseases prevalent in Eastern India for earlier detection and predicting disease progression. Limitations: Further follow up of the patients with ataxia required to get a clear insight of disease progression. Further Scope: Early diagnosis and management strategies can be validated for better disease management and prevention of deterioration to make the otherwise debilitating ataxia disorders a preventable one.

MiO10/158: A study of clinico-radiological profile with special emphasis on cognitive changes in patients of Multiple Sclerosis

Kumar S, Ganguly G, Biswas A

Department of Neurology, Bangur Institute of Neurosciences, Kolkatta, West Bengal, India.

Introduction and Background: Multiple sclerosis (MS) is a demyelinating disorder of the central nervous system (CNS), characterized by inflammatory demyelination and axonal loss. Although cognitive impairment is a well-recognized disabling symptom of MS, occurring in up to 65% of patients, cognitive function is not routinely assessed neither in clinical practice nor in clinical trials. Furthermore, this domain has been under-explored in our country due to various socio-economic reasons. Detailed studies of cognitive impairment in MS are rare and guidelines for the assessment of cognitive function in MS are lacking. Materials and Methods: This was a descriptive cross-sectional study involving 28 MS patients, diagnosed as per 2010 MacDonald's criteria, admitted in Department of Neurology, Bangur Institute of Neurosciences. Patients were interviewed using pre-tested proforma. Detailed clinical history was taken, clinical examination was done, Expanded disease disability score (EDSS) was assessed and detailed cognitive testing was done using Mini-mental score examination (MMSE), Frontal assessment battery (FAB) and Kolkata cognitive battery. Relevant investigations were done, including 3 Tesla Magnetic resonance imaging (MRI) of brain, spinal cord and orbits using gadolinium contrast, Cerebrospinal fluid (CSF) testing, including oligoclonal bands (OCB) and/or IgG index and visual evoked potential (VEP) testing. Data was analysed using appropriate statistical tools. This is an ongoing study. Results: Of 28 patients, 18 (64%) were females. Mean age of patients were 34.7 (26-51). Median disease duration was 7.5 years (1.5-15). Most common clinical feature was optic neuritis (64%) followed by myelitis (50%), brainstem symptoms (42%), bowel and bladder (35%), sensory (35%), cerebellar (28%) and cerebral (21%). Median EDSS score was 3.5 (1-6.5). Most common cognitive domain affected was executive dysfunction (100%) including set-shifting (78%), abstraction and mental flexibility (64%), followed by complex attention and information processing speed (71%), visuo-constructional (57%), language (50%), memory (28%). Median MMSE was 29 (24-30), median FAB score was 15 (10-18). 78% patients had high lesion load on MRI (>9 T2/T2 flair hyperintensities) with 35% Gadolinium enhancing lesions. CSF OCB/IGG index positivity was seen in 35%. Retino-optic pathway dysfunction as evidenced by VEP was present in 64% of which 28% were unilateral. Conclusion: Cognitive impairment though subtle was seen in a significant proportion of patients in our study with Executive dysfunction, Complex attention and information processing speed being the most commonly affected domains as picked up by Detailed cognitive assessment. Subtle cognitive impairments were overlooked when assessed using MMSE and FAB. Hence detailed cognitive assessment using tool such as the one used in this study should be a part of routine evaluation of all MS patients as most of them don't complain of these problems. Limitations: This was a cross sectional study without any follow up, with a relatively small sample size. Also cerebral volume loss could not be measured due to limited resources. Future Scope: Larger well controlled studies and well noted clinical registry are indicated.

MiO11/260: Clinico-radiologic profile of myelin oligodendrocyte glycoprotein antibody associated cns demyelination

Vikram Aglave, Ojha P, Singh R, Soni G, Jagiasi K, Singh R, Khadilkar S, Kharat S

Department of Neurology, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India.

Introduction and Background: Myelin Oligodendrocyte Glycoprotein (MOG) antibody associated CNS demyelination has recently emerged as a distinct disease entity, and knowledge regarding its clinical spectrum is evolving. We aimed to characterise the clinical and radiologic profile of patients with MOG antibody associated CNS demyelination admitted to a tertiary care hospital in India. Materials and Methods: We recruited 13 patients of MOG antibody associated CNS demyelination admitted from Jan 2018 to June 2019. Detailed clinical, serologic and radiologic data was collected and treatment outcomes assessed. Data was compared with a cohort of 22 aquaporin-4 antibody positive patients admitted during the same time. Results: The mean age at onset was 28 years (range 5 to 54 years), 7/13 patients were female while 5/13 were < 18 years of age at onset. Infectious prodrome was found in 4/13 patients. Bilateral optic neuritis (5/13) was the most common phenotype at onset, while optic nerve was involved at onset in 8/13 patients. Total 5/13 patients had relapses. The mean Functional Status Score (FSS) at last follow up was 2.1. Optic nerve involvement was most commonly anterior segment, however long segment and chiasmal involvement was also common. MRI brain showed abnormalities in 7/13 patients. Upper brainstem was more commonly involved compared to lower brainstem. Spinal cord abnormalities were seen in 5/13 patients, out of which thoracic segments were involved in all. A specific pattern of contrast enhancement was not found. Eleven patients responded to acute treatment with steroids, one received additional plasmapheresis and one IVIg. On last follow up, 10 were on maintenance Azathioprine with low dose steroids, while 1 each on low dose steroids only, Rituximab and Mycophenolate with low dose steroids. Compared with the MOG group, Aquaporin-4 group had less patients in the paediatric group (5/22), a striking female predominance (18/22), isolated myelitis was the most common presentation (11/22) and more patients experienced relapses (14/22). The FSS at last follow up was 4.2. Radiologic findings indicated more frequent involvement of the medulla and area postrema, cervical cord and corpus callosum. More patients required additional acute treatment in the form of plasmapheresis (5/22). Conclusions: Bilateral optic neuritis was the most common presentation of MOG antibody associated CNS demyelination, especially in females. Males were more likely to present with non-optic neuritis phenotype. Thoracic cord was the most common site of cord involvement, while upper brainstem was more commonly affected with brainstem syndrome. Patients in the MOG cohort were more likely to respond to acute treatment with steroids and had better functional outcomes. Limitations: Small sample size caused difficulty in interpretation, chances of false positive observations and inability to use statistical analysis. More patients with relapses in the aquaporin-4 group could be partially attributed to the longer disease duration and follow-up in that group. Further Scope: There are no established treatment guidelines and a debate regarding maintenance immunosuppresion in MOG antibody disease. Hence there is a need for more published data.

MiO12/299: Population based neuroscience: Baseline data of 7137 participants from cohort study at AIIMS, New Delhi

Kameshwar Prasad, Kant S, Dwivedi SN, Vibha D, Pandit AK, Kumar S, Verma V

Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.

Background: A prospective population cohort study has been funded by Department of Biotechnology, Government of India. Objective: To determine the proportion of various risk factors associated with stroke and cognitive decline in community dwelling persons aged 50 years and above and to determine the proportion of participants with more than one risk factor. Methods: A systematic house to house survey in Vasant Kunj and Munirka Colony of South Delhi, India was conducted to recruit the eligible individuals. Those consented were administered a questionnaire to record medical history, dietary habits, physical activity, health status, ability to perform activities of daily living, sleep quality assessed using neuro-cognitive battery and MRI brain. Results: The data of 7137 participants have been entered and analysed for the present study. Males and females are found to be in almost equal proportion. Approximately 70% of the participants have high BP. Among all the participants almost 26% have higher BMI, 43% low physical activity, 10% self reported heart disease, 21% ever smoker, while 41% have high blood sugar at the time of survey. In the community, approximately 24% have any of the one risk factor, 34% two and 42% have 3 or more risk factors. Conclusion: In the urban population of Delhi, alarmingly 70% persons have hypertension and approximately 42% have three or more risk factors.

Saturday, October 05, 2019, 19:00PM-20:00PM, Hall D

Platform Session 14: Miscellaneous Disorders

MiO13/173: Study of the seasonal trends in relapses of multiple sclerosis

Dulari Gupta, Maheshwari U, Shunmugasundaram K, Bhoopathy RM, Govindarajan S, Lakshminarasimhan R

Department of Neurology, Institute of Neurology, Madras Medical College, Chennai, Tamil Nadu, India.

Introduction: Multiple Sclerosis is a primary demyelinating disease which is characterized by a relapsing remitting course. A seasonal trend in relapses has been demonstrated in many studies from different countries. Materials and Methods: In this observational retrospective study Multiple Sclerosis patients presenting to the Demyelination Clinic at Institute of Neurology, Rajiv Gandhi Government General Hospital Chennai, as well as the Department of Neurology Tamil Nadu Government Multi Super Specialty Hospital, Omandurar Chennai were recruited after informed consent. Relapses in Multiple Sclerosis were ascertained by history and confirmed by documentary evidence. Correlation between the month of relapse and environmental factors (temperature, rainfall) were studied. Results: Out of 54 patients with multiple sclerosis 19 (35.2%) were male. The mean age of disease onset was 26.20 years (Range 13-48 years). The mean duration of disease was 4.93 years (Range 1-20 years). Most patients had remitting relapsing MS (53, 98.14%). CSF oligoclonal bands were positive in 20 (37%); negative in 26 (48%). Out of a total of 165 relapses the of onset of 45 (27.27%) were not known. One hundred and forty two relapses occurred before initiation of disease modifying therapy and 23 relapses occurred afterwards. The relapses were classified into optico-spinal (30, 18.18 %) and brain type (133, 80.60%; missing data for 2). In forty three patients who received disease modifying therapy for greater than 1 year the number of relapses significantly reduced (CI 0.40-0.73, p<0.001). The frequency of relapses was greatest during April and December (11.6% each). Conclusion: There appears to be a bimodal distribution of relapses in Multiple sclerosis. There is a peak in April just before the onset of summer and another peak in December which has the lowest temperatures.

MiO14/442: When people with epilepsy evade a public care initiative: Pith and perils

Rajinder Bansal, Singh G, Chawla A, Sharma S, Sander JW

Department of Neurology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Introduction: Community-based, public care programs are a requisite to close the epilepsy treatment gap in disadvantaged communities in low and middle income countries. These initiatives are, however, often challenged by poor acceptance by potential beneficiaries. Aims: to describe factors associated with, and mortality consequences of non-acceptance of public epilepsy care initiative. Methods: We attempted contact with 207 (36%) individuals out of 575 who screened positive for epilepsy during a population-based survey and were invited for neurological evaluation and care provision (including antiseizure medications) but chose not to engage. Structured qualitative interviews were conducted to determine reasons for their non-engagement. Factors associated with non-engagement were evaluated by univariate and multivariate analysis. Verbal autopsies were conducted for those who died. Results: Ten (4.8%) of the 207 individuals dies, six due to epilepsy-related causes. of those who could be contacted, 40 were confirmed to have epilepsy. Non-engaging subjects were likley to be older (OR: 1.02; 95%CI, 1.01, 1,11), locals (OR: 4.32; 95%CI,1.55, 12.03), and earn less than Rs 5500-00/month (OR: 3.6, 95%CI, 1.62, 8.06). Conclusions: Non-acceptance of a community-based public epilepsy care initiative seems to be associated with premature mortality. Most deaths may be directly attributed to epilepsy.

MiO15/399: Frequency of obstructive sleep apnea syndrome in patients with epilepsy at a tertiary care center

Nishanth Ponaganti, Suryaprabha, Sambasivarao

Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India.

Background: Epilepsy is one of the common neurological disorders with a median lifetime prevalence of 14 per 1000 subjects. Sleep disorders can influence epileptic seizure. The most frequent sleep disorder is obstructive sleep apnoea syndrome (OSAS) which occurs in 2% of adult women and 4% of adult men in the general population. Aim and Objectives: The aim of this study is to estimate the frequency of OSAS among patients with epilepsy and to study the seizure characteristics among those patients with co-morbid OSAS. Methods: Patients with a confirmed diagnosis of epilepsy who attended the Nizam's institute of medical sciences neurology clinic were recruited for the study between June 2017 and April 2012. Patients were screened for OSAS by direct interview using the Berlin questionnaire. Patients identified as high-risk underwent polysomnography. Results: A total of 63 patients with epilepsy (22 men and 41 women) were screened for OSAS. 38.09% of the sample was found to have OSAS. BMI, Age of the patient was significantly associated with occurrence of OSAS. No significant correlation was found between risk of OSAS, type and duration of epilepsy. Conclusion: The prevalence of OSAS was greater in patients with epilepsy compared to the general population with the overall prevalence of 38.09%.

MiO16/57: A series of sporadic  Creutzfeldt-Jakob disease More Details from the Himalayan belt in India: uncommonly suspected, rarely reported

Madhaw G, Kumar N, Shree R, Radhakrishnan D

Department of Neurology, All India Institute of Medical Science, Rishikesh, Uttarakhand, India.

Background: Creutzfeldt-Jakob disease (CJD) is a rapidly progressive fatal neurodegenerative disease caused by infectious protein particles called prion. It is often underdiagnosed in developing countries including India due to lack of awareness about the disorder along with non-availability of specific investigations as well as post-mortem autopsy for the diagnosis. Although there is no extensive Indian study, its prevalence has been suspected close to that in the United States i. e., 0.5 to 1 per million. CJD registry of NIMHANS Bangalore reports 69 cases over 30 years (1968-1997). Objective: To report a series of probable sporadic CJD (sCJD) from a tertiary care centre in the Himalayan belt of India. Materials and Methods: Patients of rapidly progressive neurological dysfunction including features such as cognitive decline, myoclonus, ataxia and other features fulfilling the diagnostic criteria for sCJD were included. All cases underwent a detailed work-up to rule out other possible treatable differentials including autoimmune and paraneoplastic disorders, electroencephalography (EEG), magnetic resonance imaging (MRI) of brain, and cerebrospinal fluid analysis. Results: A total four patients of probable sCJD were diagnosed using the European diagnostic criterion between May 2018 to May 2019. The clinical features are consistent with other reported series. While three patients had the classical EEG findings, all had typical MRI brain findings. The average age of symptom onset was 63.5 years with male to female ratio being 1:1. Two patients began with extrapyramidal symptoms i. e. tremor and dizziness, while one with vision loss and another with episodic anxiety and depressive symptoms. Myoclonus, apathy and akinetic rigid syndrome appeared in all four at the time of diagnosis. All cases had hyperintense signal in caudate and putamen nucleus in DWI and FLAIR sequences in MRI brain. Two patients had raised protein in CSF but none had pleocytosis. Autoimmune including anti-NMDA and anti-VGKC and paraneoplastic panel came negative in all four cases along with normal thyroid profile and other metabolic workup. The mean duration from onset of first symptom to disease diagnosis was 5 months. All cases had a probable diagnosis. Three of them were given trial of methylprednisolone pulse with none showing any improvement. Conclusion: CJD is a clinically heterogeneous neurological disorder. EEG and MRI brain are essential to detect abnormalities in early stages of the disease. Although definitive diagnosis requires histopathological study, currently available ancillary tests allowed us to obtain the diagnosis. This is first report of a series of sCJD cases from the Himalayan belt of India raising concerns about under-diagnosis and hence underestimating the true prevalence of CJD in India.

MiO17/32: Prevalence, clinical profile and outcome of neurodegenrative diseases in indo-gangetic belt in North India

Patil S, Mishra VN, Pathak A, Joshi D, Chaurasia R

Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.

Introduction: Indo-Gangetic belt is the most populated area in the India and Prevalence of neurodenerative diseases is different in Gangetic plane owing to chemical and heavy metal exposure around Ganges. Aims: To assess the Hospital based prevalence, pattern and clinical profile of Neurodenerative diseases (Amyotrophic lateral sclerosis, Parkinson's disease & major neurocognitive decline) in Indo-Gangetic belt. Materials and Methods: All consecutive patients with Neurodegenrative diseases residing 25 km on either side of Ganges River were included over the period of 2 years and demographic details, clinical features and investigations were noted. Results: Of 124 total patients 69 (55%) were male and 55 (45%) were female. Mean age of the patients was 57.07 years. Amyotrophic lateral sclerosis was most common neurodenerative disease in our study with total 45 patients and 27 were Idiopathic Parkinsons disease, 08 were Young onset PD and 01 patient of Juvenile onset PD. In dementia spectrum 15 were Alzheimer's disease and Multiple system atrophy in 17 patients of which 12 were Parkinsons type and 05 were cerebellar type. FTD was found in 05 patients, DLB in 02 and Progressive supranuclear palsy in 07 patients. 31% patients were residing 0-5 km from the Ganges rivers and 39% (5-10 km), 14.5% (10-15 km) 4.5% (15-20 km) 12.5% (20-25 km) and during hospital stay 3 (2.4%) patients expired. Conclusion: Pattern of neurodegenerative varies as per environmental exposure to heavy metals. Amyotrophic lateral sclerosis was most common followed by Parkinsons disease in our study.

MiO18/39: Clinico-epidemiologic and environmental factors in young onset Parkinson's disease: A prospective study

Remanan R, Shaji CV, Kabeer KA, Prasanth SR

Department of Neurology, Government Thirumala Devaswom Medical College, Alappuzha, Kerala, India.

Introduction and Background: Young onset parkinson's disease and Idiopathic Parkinson's disease differ considerably in clinical presentation and treatment response. Multiple environmental factors are increasingly being identified as the probable etiological factor in YOPD. Aim: To study the clinico-epidemiologic and environmental factors in YOPD. Methods: Prospective case series study. Conducted in inpatients, in Dept of neurology of a tertiary care centre. Inclusion Criteria: All cases meeting the UK Parkinson's Disease Society Brain Bank clinical diagnostic criteria. Methods: Study period: January 2015 and December 2017. Ethical clearance obtained from Institutional Ethical committee. Clinical features, epidemiological and environmental factors noted in proforma. Chemical analysis of possible environmental factors done in Regional soil analytical laboratory, under govt. of Kerala, Trivandrum. Results: 34 cases were included in the study 18 cases (52.9%) were females. Mean age was 43.12 yrs. Tremor was the most common presenting symptom. Hypokinesia [34 in 34 cases] was the most common clinical feature. Family history of movement disorder was noted in 6 Cases (17.6%). In all the cases basal ganglia structures were normal. Akinetorigid group was 12 out of 34 cases (35.3%) Fatty liver with deranged liver function was noted in 29.1%. Pesticide exposure was present in 8 out of 34 and all of these cases were tremor dominant YOPD. Elevated soil manganese in 41.1% cases, elevated soil phosphorous levels in 58%, and 70.5% had elevated soil potassium levels. Conclusions: Majority of patients belonged to tremor dominant variety. Levodopa induced dyskinesia is more common in akineto-rigid variety. No radiological abnormalities were detected in basal ganglia. Co-morbid conditions observed are: Fatty liver, lipomatosis and Dental fluorosis. Soil analysis shows increased concentration of manganese which has direct correlation with YOPD. Limitations: 1. Absence of controls. 2. Soil sample from work place was not analysed due to financial constraints. 3. limited sample size. Further Scope: Extension of study to larger groups can throw light on unknown etiologies of YOPD so that preventive measures and possible treatment options could be explored.


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