Annals of Indian Academy of Neurology
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October-December 2017
Volume 20 | Issue 4
Page Nos. 333-439

Online since Wednesday, October 25, 2017

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EDITORIAL  

As I sign off p. 333
Satish V Khadilkar
DOI:10.4103/aian.AIAN_361_17  PMID:29184332
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REVIEW: SYSTEMATIC (SYSTEMATIC REVIEW OF A SUBJECT) Top

Status of cognitive testing of adults in India p. 334
AP Porrselvi, V Shankar
DOI:10.4103/aian.AIAN_107_17  PMID:29184333
The assessment of cognitive function is a challenging yet an integral component of psychological, psychiatric, and neurological evaluation. Cognitive assessment tools either can be administered quickly for screening for neurocognitive disorders or can be comprehensive and detailed to identify cognitive deficits for the purpose of localization, diagnosis, and rehabilitation. This article is a comprehensive review of published research that discusses the current challenges for cognitive testing in India, available tools used for the assessment of cognitive function in India, and future directions for cognitive testing in India.
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REVIEW: MANAGEMENT UPDATES (REVIEWS ON ADVANCES IN TREATMENT) Top

Efficacy and safety of tacrolimus in myasthenia gravis: A systematic review and meta-analysis p. 341
Zuojie Zhang, Chunsong Yang, Lingli Zhang, Qiusha Yi, Zilong Hao
DOI:10.4103/aian.AIAN_97_17  PMID:29184334
Aims: This study was designed to determine whether treatments with tacrolimus would provide benefit for patients with myasthenia gravis (MG). Materials and Methods: The databases of Medline, EMBASE, the Cochrane Library, and four Chinese databases were searched for eligible studies. Weighted mean differences and standardized mean differences (SMD) with corresponding 95% confidence intervals (CIs) were used to summarize the primary outcome, namely, steroid-sparing effect of tacrolimus in maintaining minimal manifestations, and the secondary outcome, namely, the effect of tacrolimus in reducing the severity of MG, respectively. Results: After systematic retrieval, 13 researches with two randomized controlled trials (RCTs) and 11 prospective open-label single-arm clinical trials were included in the study. For the primary outcome of two RCTs, one RCT which was followed up for 1 year showed a positive effect and the other RCT which was associated with treatment duration of 28 weeks showed a negative result. For the secondary outcome, meta-analyses of other 11 trials showed a benefit effect, overall. For the quantitative MG (QMG) score, there were significant differences with high heterogeneity (SMD: 2.93; 95% CI: 1.14–4.73; I2 = 86%). In contrast, for MG activities of daily living (MGADL) score, it was reduced by tacrolimus with significant SMD and less heterogeneity (SMD: 0.59; 95% CI: 0.33–0.85; I2 = 7%). Adverse effects were mentioned as mild. Discussion: The opposite results of two RCTs showed that tacrolimus with enough treatment duration might have positive steroid-sparing effect. The most possible cause of heterogeneity in the outcome of QMG score between trials was the baseline severity of MG. Conclusion: The above finding suggests that there might be a potential beneficial role with no serious side effects of tacrolimus, and additional better RCTs including larger sample sizes and long-term study are needed to confirm or refute the results.
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HISTORY OF MEDICINE Top

Johann bernhard aloys von Gudden and the Mad King of Bavaria p. 348
Kalyan B Bhattacharyya
DOI:10.4103/aian.AIAN_489_16  PMID:29184335
Bernhard von Gudden was a psychiatrist in Prussia and he was summoned in March 1886 to examine King Ludwig II for his apparently insane activities like, profligate spending and erratic behaviour. A team of four estimable psychiatrists pronounced that he was not capable ruling. Consequently, he was dethroned and kept in a castle under supervision of von Gudden. Gudden championed the idea of 'no restraint' and advocated free movement of insane persons and one evening in June, he accompanied the King during an evening stroll to a lake. A few hours later, the corpus of both of them were recovered under mysterious circumstances. Autopsy suggested that the King was drowned but no post-mortem examination was performed on von Gudden. There are plenty of controversies regarding their death like, murder, accidental death or even natural death from cardiac arrest following immersion in cold water, but no incontrovertible conclusion could be arrived at, even after scrupulous analysis by historians and even the diagnosis of insanity of the King has been doubted. Some even suggested that the opinion of psychiatrists were sought as a pretense in order to depose the King.
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ORIGINAL ARTICLES Top

Speech signal analysis and pattern recognition in diagnosis of dysarthria p. 352
Minu George Thoppil, C Santhosh Kumar, Anand Kumar, John Amose
DOI:10.4103/aian.AIAN_130_17  PMID:29184336
Background: Dysarthria refers to a group of disorders resulting from disturbances in muscular control over the speech mechanism due to damage of central or peripheral nervous system. There is wide subjective variability in assessment of dysarthria between different clinicians. In our study, we tried to identify a pattern among types of dysarthria by acoustic analysis and to prevent intersubject variability. Objectives: (1) Pattern recognition among types of dysarthria with software tool and to compare with normal subjects. (2) To assess the severity of dysarthria with software tool. Materials and Methods: Speech of seventy subjects were recorded, both normal subjects and the dysarthric patients who attended the outpatient department/admitted in AIMS. Speech waveforms were analyzed using Praat and MATHLAB toolkit. The pitch contour, formant variation, and speech duration of the extracted graphs were analyzed. Results: Study population included 25 normal subjects and 45 dysarthric patients. Dysarthric subjects included 24 patients with extrapyramidal dysarthria, 14 cases of spastic dysarthria, and 7 cases of ataxic dysarthria. Analysis of pitch of the study population showed a specific pattern in each type. F0 jitter was found in spastic dysarthria, pitch break with ataxic dysarthria, and pitch monotonicity with extrapyramidal dysarthria. By pattern recognition, we identified 19 cases in which one or more recognized patterns coexisted. There was a significant correlation between the severity of dysarthria and formant range. Conclusions: Specific patterns were identified for types of dysarthria so that this software tool will help clinicians to identify the types of dysarthria in a better way and could prevent intersubject variability. We also assessed the severity of dysarthria by formant range. Mixed dysarthria can be more common than clinically expected.
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Optical coherence tomography and subclinical optical neuritis in longitudinally extensive transverse myelitis p. 358
Prakash Kumar Sinha, Deepika Joshi, Virendra Pratap Singh, Sujit Deshmukh, Usha Singh, Abhishek Pathak, Vijay Nath Mishra, Rameshwar Nath Chaurasia, Vivek Sharda, Garima Gupta
DOI:10.4103/aian.AIAN_170_17  PMID:29184337
Objective: The aim is to compare the retinal nerve fiber layer (RNFL) thickness of longitudinally extensive transverse myelitis (LETM) eyes without previous optic neuritis with that of healthy control subjects. Methods: Over 20 LETM eyes and 20 normal control eyes were included in the study and subjected to optical coherence tomography to evaluate and compare the RNFL thickness. Result: Significant RNFL thinning was observed at 8 o'clock position in LETM eyes as compared to the control eyes (P = 0.038). No significant differences were seen in other RNFL measurements. Conclusion: Even in the absence of previous optic neuritis LETM can lead to subclinical axonal damage leading to focal RNFL thinning.
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Rapid clinical score for the diagnosis of tuberculous meningitis: A retrospective cohort study p. 363
Raluca Jipa, Ioana D Olaru, Eliza Manea, Simona Merisor, Adriana Hristea
DOI:10.4103/aian.AIAN_219_17  PMID:29184338
Objective: The aim of our study was to retrospectively validate a previously described rapid clinical score (RCS) in distinguishing tuberculous meningitis (TBM) from viral meningitis (VM) in people who are at increased risk of tuberculosis, as well as from cryptococcal meningitis (CM) in HIV-infected patients. Methods: We performed a retrospective study of patients admitted with a diagnosis of aseptic meningitis between January 2012 and December 2015, to a referral hospital for infectious diseases. The variables included in RCS were duration of symptoms before admission, neurological stage, cerebrospinal fluid (CSF) to blood glucose ratio, and CSF protein. We included in this retrospective study 31 patients with definite or probable TBM including 14 HIV-infected patients, 62 HIV-noninfected patients with VM, and 18 HIV-infected patients with CM. Results: The sensitivity of RCS to distinguish TBM from VM was 96.7%, with a specificity of 81.1% and the area under the receiver operating characteristic (ROC) curve was 0.949 (0.90–0.99). When all four criteria from the RCS were present, the specificity increased at 100%. In HIV-infected patients, the sensitivity and specificity of RCS in differentiating TBM from CM were 86.6% and 27.7%, respectively, and the area under the ROC curve was 0.669 (0.48–0.85). Conclusion: This easy-to-use RCS was found to be helpful in differentiating TBM from VM, with a better sensitivity than molecular amplification techniques and a relatively good specificity. However, the RCS was not useful to differentiate between TBM and CM in HIV-infected patients.
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Bone health in patients with epilepsy: A community-based pilot nested case–control study p. 367
Shweta Singla, Sandeep Kaushal, Shalini Arora, Gagandeep Singh
DOI:10.4103/aian.AIAN_216_17  PMID:29184339
Background: Antiepileptic drugs (AEDs) adversely affect bone health and there are reports describing association of alternations of bone and mineral metabolism in epileptic patients. Objectives: This study was undertaken to evaluate the bone profile (bone mineral parameters and bone mineral density [BMD]) of patients with epilepsy and compare them to their age-, gender-, and socioeconomic status-matched healthy controls in a community. Materials and Methods: This was a nested case–control study conducted in fifty individuals, which included 25 cases (age above 18 years and on AEDs for at least 3 years) for which 25 controls were selected from the same community. Bone mineral parameters (serum calcium, proteins, phosphorous, alkaline phosphate, parathyroid hormone, and Vitamin D) and BMD were measured. Results: There was significant hypocalcemia (P = 0.003), hypoproteinemia (P = 0.014), hyperparathyroidism (P = 0.048), and increased levels of serum alkaline phosphatase (P = 0.019) in cases as compared to controls. The difference was insignificant in the serum levels of Vitamin D and phosphorous among both the groups. Vitamin D was significantly low in female patients as compared to males (P = 0.043). There was no significant difference in BMD at the lumbar spine and femur neck among both the groups. Mean duration of epilepsy was longest in patients with osteoporosis (23.6 years), and increasing duration of epilepsy was associated with reduction in age- and sex-corrected total BMD mean Z-score anteroposterior spine. There was negative correlation between cumulative drug load and T-score of patients with epilepsy. Conclusion: Patients on long-term AED treatment have altered bone profile as evident from biochemical parameters and reduced BMD. There is a need for more extensive research and that too on a larger sample size.
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Treatment-related fluctuations in guillain barre syndrome and the conundrum of additional cycles of plasmapheresis p. 372
Subasree Ramakrishnan, Veerendrakumar Mustare, Mariamma Philip, K Thennarasu, Sunder Periyavan
DOI:10.4103/aian.AIAN_242_17  PMID:29184340
Introduction: In Guillain Barre syndrome (GBS), worsening of weakness or disability after initial period of recovery or stabilization is described as treatment-related fluctuations (TRF). Aim: This study aims to describe the clinical characteristics and outcome of six patients with GBS and TRF. Patients and Methods: Six patients with GBS fulfilling NINCDS criteria, evaluated at a tertiary care university hospital during 2008–2017, were diagnosed to have TRF. They form the basis of this report. Results: All patients were men and their mean age was 40 years. At presentation, mean duration of illness was 15 days; the illness had plateaued in three and progressive in other three patients. Two of the four patients had variant GBS. Initially, five patients were treated with large volume plasmapheresis (LVPP) and one patient with methyl prednisolone. At 17–28 days after disease onset, three patients developed new neurologic deficits (bilateral facial paresis in two; paralytic ileus in one). Other three patients with worsening of limb weakness (medical research council sum score of >5) and disability (Hughes disability grade by ≥1) fulfilled Kleyweg's criteria for TRF. All the six patients were treated with the completion of five cycles or additional cycles of LVPP. Conclusion: Awareness about TRF is essential for correct diagnosis and management of patients with GBS.
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Atherosclerotic carotid plaques: Multimodality imaging with contrast-enhanced ultrasound, computed tomography, and magnetic resonance imaging p. 378
Divyata R Hingwala, Kesavadas Chandrasekhakan, Bejoy Thomas, PN Sylaja, M Unnikrishnan, TR Kapilamoorthy
DOI:10.4103/aian.AIAN_122_17  PMID:29184341
Introduction: The imaging of carotid plaques has undergone a paradigm shift increasing importance being given to plaque characterization. Patients with “vulnerable” plaques are more prone to develop future neurovascular events. Purpose: The purpose of this study is to analyze the role of multimodality imaging techniques in the assessment of carotid atherosclerotic plaques. Materials and Methods: Twenty-six patients were prospectively enrolled in the study. Patients underwent multidetector computed tomography (CT) angiography, ultrasound, contrast-enhanced ultrasound, and high-resolution magnetic resonance imaging (MRI) of the carotid arteries with special emphasis on the carotid bifurcation. Results: The mean age of patients was 65.41 years. Twenty-one were males. Plaque neovascularization was seen in 10 of the 18 plaques studied (55.56%). Based on the predominant components of the plaque, plaques were characterized as lipid (3), lipid with recent hemorrhage (1), fibrous (7), fibrofatty (4), fibrofatty with some hemorrhagic components (3), and recent hemorrhage (2). Conclusions: Together, contrast-enhanced ultrasound, CT, and MRI provide complete information about the plaque characteristics.
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Risk factors, vascular lesion distribution, outcome and recurrence of strokes due to intracranial atherosclerosis: One year data from Hyderabad stroke registry p. 387
Raghu Ram, Subhash Kaul, Suvarna Alladi, Jabeen S Afshan, T Surya Prabha, Abhijeet Kohat, Swetha Tandra, Jyotsna Y Rani
DOI:10.4103/aian.AIAN_227_17  PMID:29184342
Background: Intracranial atherosclerotic stenosis (ICAS) is a common cause of ischemic stroke in Asian countries and probably in India. Aim: The aim of this study was to describe the risk factors, distribution of vascular lesions, recurrence and outcome of stroke due to ICAS. Methodology: A total of 100 consecutive patients of ischemic stroke due to ICAS were enrolled prospectively from January 1, 2015, to December 31, 2015, and followed for 1 year for treatment compliance and recurrence. The details about demographics, risk factors, and vascular lesions were noted. Results: There were 68 males and 32 females. Hypertension (HTN), diabetes, alcohol, smoking, hyperlipidemia, and hyperhomocysteinemia was present in 82%, 52%, 34%, 33%, 28%, and 23%, respectively. The number of arteries involved were middle cerebral artery, 53 (37.3%); posterior cerebral artery, 24 (16.9%); internal cerebral artery, 21 (14.8%); vertebral artery, 18 (12.7%); basilar artery, 6 (4.2%); and anterior cerebral artery, 6 (4.2%). Seventeen (17%) patients had a recurrent stroke during 1 year follow-up. The presence of uncontrolled HTN and diabetes mellitus after discharge were significantly associated with stroke recurrence (P < 0.05). The use of dual antiplatelet agents and statins was found to have a significant effect in the prevention of recurrent stroke (P < 0.05). Severe stroke at presentation and presence of hemiparesis were the predictors for unfavorable outcome at 3 months (P < 0.05). Conclusion: Risk factors, distribution of vascular lesions and high recurrence of stroke due to ICAS in this study is similar to that reported from other Asian countries. Aggressive medical management and risk factor control remains the best strategy for preventing recurrence.
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Quality indicators of intravenous thrombolysis from North India p. 393
Akanksha Grace William, Aman Pannu, Mahesh Pundlik Kate, Vineeth Jaison, Leenu Gupta, Smrithi Bose, Rajeshwar Sahonta, Ivy Sebastian, Jeyaraj Durai Pandian
DOI:10.4103/aian.AIAN_277_17  PMID:29184343
Background: Data on intravenous (IV) thrombolysis using tissue plasminogen activator (tPA) are limited from low- and middle-income countries. We aimed to assess the quality indicators of IV thrombolysis in our stroke unit. Methods All stroke patients admitted in our hospital from October 2008 to April 2017 were included in this study. Data were collected prospectively by trained research staff in a detailed case record form. Outcome was assessed using modified Rankin Scale (mRS, 0–1 good outcome). Results: Of the total 4720 stroke patients seen, 944 (20%) came within window period (<4.5 h). Of these, 214 (4.5%) were eligible for thrombolysis and 170 (3.6%) were thrombolysed, relatives of 23 (23/214, 10.7%) patients denied consent, and 21 (9.8%) patients could not afford tPA. The mean age of thrombolysed patients was 58.4 (range 19–95) years. Median NIHSS at admission was 12 (interquartile range 2–24). Average onset-to-door (O-D) time was 76.8 (5–219) min, door-to-examination (D-E) time was 17.8 (5–105) min, door-to-CT (D-CT) time was 48 (1–205) min, and door-to-needle (D-N) time was 90 (20–285) min. At 6 months, 110 (64.7%) patients were contactable and 82 (74.5%) patients had good outcome (mRS 0–1). Conclusion: Thrombolysis rate has steadily increased at the center without undue adverse effects even in the elderly. D-E and D-CT times have reduced, but O-D and D-N times need further improvement. More patients could be thrombolysed if the cost of tPA is reduced and the consent process is waived.
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CASE REPORTS Top

Nocardia Farcinica brain abscess in an immunocompetent old patient: A case report and review of literature p. 399
Dinesh Mohan Chaudhari, Pushpendra Nath Renjen, Raman Sardana, Hena Butta
DOI:10.4103/aian.AIAN_263_17  PMID:29184344
By definition, a brain abscess is an intraparenchymal collection of pus. Nocardia shows to have a special tropism for the neural tissue. Solitary abscess represents the most common manifestation in the central nervous system, accounting for 1%–2% of all cerebral abscesses. In this report, we present a case of primary multiple brain abscesses due to Nocardia farcinica in an immune competent patient. Early diagnosis and surgical intervention is significant for the patient.
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Vagus nerve stimulation modulates complexity of heart rate variability differently during sleep and wakefulness p. 403
Karthi Balasubramanian, K Harikumar, Nithin Nagaraj, Sandipan Pati
DOI:10.4103/aian.AIAN_148_17  PMID:29184345
Progressive loss of heart rate variability (HRV) and complexity are associated with increased risk of mortality in patients with cardiovascular disease and are a candidate marker for patients at risk of sudden cardiac death. HRV is influenced by the cardiac autonomic nervous system (ANS), although it is unclear which arm of the ANS (sympathetic or parasympathetic) needs to be perturbed to increase the complexity of HRV. In this case–control study, we have analyzed the relation between modulation of vagus nerve stimulation (VNS) and changes in complexity of HRV as a function of states of vigilance. We hypothesize that VNS – being a preferential activator of the parasympathetic system – will decrease the heart rate (HR) and increase the complexity of HRV maximum during sleep. The electrocardiogram (EKG) obtained from a 37-year-old, right-handed male with known intractable partial epilepsy and left therapeutic VNS was analyzed during wakefulness and sleep with VNS ON and OFF states. Age-matched control EKG was obtained from five participants (three with intractable epilepsy and two without epilepsy) that had no VNS implant. The study demonstrated the following: (1) VNS increased the complexity of HRV during sleep and decreased it during wakefulness. (2) An increase in parasympathetic tone is associated with increased complexity of HRV even in the presence of decreased HR. These results need to be replicated in a larger cohort before developing patterned stimulation using VNS to stabilize cardiac dysautonomia and prevent fatal arrhythmias.
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Cutaneous adverse drug reactions to lamotrigine and human leukocyte antigen typing in North Indian patients: A case series p. 408
Shivani Srivastava, Bhargavi Ramanujam, Kavish Ihtisham, Manjari Tripathi
DOI:10.4103/aian.AIAN_234_17  PMID:29184346
Cutaneous adverse drug reaction (cADR) has limited epidemiological data in India. The older antiepileptic drugs, i.e., carbamazepine, phenytoin, valproic acid, phenobarbitone, etc., induce severe cADRs that have a strong associated with human leukocyte antigen (HLA)-related genetic risk factors. There is also evidence of association of certain HLA alleles with lamotrigine (LTG)-induced cADRs, but this has not been reported in the Indian population. Here, we report case series of three patients with LTG-induced “Stevens-Johnson syndrome (SJS).” Their HLA-B typing was also performed which showed the presence of HLA-B*15:02 in one case with SJS.
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Anti myelin oligodendrocyte glycoprotein associated immunoglobulin G (AntiMOG-IgG)-associated neuromyelitis optica spectrum disorder with persistent disease activity and residual cognitive impairment p. 411
Lekha Pandit, Ichiro Nakashima, Sharik Mustafa, Toshiyuki Takahashi, Kimhiko Kaneko
DOI:10.4103/aian.AIAN_250_17  PMID:29184347
Antibodies targeting myelin oligodendrocyte glycoprotein (MOG) have been recently reported in association with idiopathic inflammatory central nervous system disorders. Initially believed to be a benign disorder, anti MOG-IgG was noted to cause steroid responsive recurrent optic neuritis and isolated longitudinally extensive myelitis. However, there is growing evidence that the disease may be predominantly relapsing, often producing severe visual loss and involving regions other than the spinal cord and optic nerve. We report an adolescent male with an aggressive disease course previously undescribed in anti MOG-IgG-associated disease that left him with residual cognitive dysfunction.
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IMAGES IN NEUROLOGY Top

Subdural empyema in disseminated histoplasmosis p. 414
Mansoor C Abdulla, Ram Narayan, Neena Mampilly, Prem Kumar
DOI:10.4103/aian.AIAN_306_17  PMID:29184348
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A rare presentation of a nondiscogenic cause of acute lumbar radiculopathy p. 416
Lobo Manuel Alexander, Vivek Jacob Philip
DOI:10.4103/aian.AIAN_245_17  PMID:29184349
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SHORT COMMUNICATIONS Top

Female caregivers and stroke severity determines caregiver stress in stroke patients p. 418
Bindu Menon, P Salini, K Habeeba, Jyoti Conjeevaram, K Munisusmitha
DOI:10.4103/aian.AIAN_203_17  PMID:29184350
Background: Stroke is among the major causes of short- and long-term disability. This study aimed to understand the caregivers (CGs) stress in stroke survivors. Materials and Methods: A 22-item questionnaire was administered to 201 CGs of stroke survivors. The variables tested were physical and mental health, social support, financial, and personal problems. CGs were divided into Group A (Barthel index [BI] <75) and B (BI >75) according to patient's BI, according to gender (male and female CG) and relation; spouses (wife, husband), daughters, sons, daughter-in-law, grandchildren, and rest (father, mother, brother, sister, and in-laws). Data were analyzed using SPSS software version–21. Data were analyzed to determine which variables of the patient effects the CG stress. Results: Majority of the CGs (74.62%) were females. 65% of CGs graded their burden as moderate to severe. 81% of CGs had left their work for caregiving. More than half of the CGs felt sleep disturbance and physical strain. Psychological instability and financial burdens were reported in 3/4th of CGs. Group A CGs faced more sleep, financial, health, and social life disturbance. Patient's bladder and bowel problems, shoulder pain, patients noncooperative attitude for medication administration, and physiotherapy were more upsetting for Group A CGs. Female CGs were subjected to more sleep disturbance, physical and psychological stress, faced more difficulty regarding the patient's bladder, bowel, personal hygiene needs, and physiotherapy. Female CGs felt less motivated in caregiving than male CGs. Wives and daughters-in-law experienced more burden. Time spent and burden perceived was more by female CGs (χ2 = 15.199, P = 0.002) than males (χ2 = 11.931, P = 0.018); wives and daughters than other relations (χ2 = 32.184, P = 0.000), (χ2 = 35.162, P = 0.019). Conclusion: Our study showed that caregiving burden was predominantly shouldered by females CGs. CGs faced physical, psychological, and socioeconomic burden. The burden was more evident in female CGs and in patients with severe stroke.
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Clinico-Electrophysiological and genetic overlaps and magnetic resonance imaging findings in Charcot–Marie– Tooth disease: A pilot study from Western India p. 425
Satish Vasant Khadilkar, Nahush D Patil, Nikhil Dhananjay Kadam, Khushnuma A Mansukhani, Bhagyadhan A Patel
DOI:10.4103/aian.AIAN_316_17  PMID:29184351
Background: Charcot–Marie–Tooth (CMT) disease is clinically and genetically heterogeneous. There are no published series describing clinical, electrophysiological, and genetic information on CMT from the Indian subcontinent. Magnetic resonance imaging (MRI) neurography technique provides useful information about the plexus and roots and can be employed in patients with CMT. Settings and Design: A prospective, observational study carried out at a tertiary care hospital in Western India. Subjects and Methods: CMT patients fulfilling the UK Genetic Testing Network criteria were included. They underwent clinical, electrophysiological, radiological, and multigene panel testing. Results: Totally 22 patients (19 males, 3 females; 18 sporadic and 4 familial cases) were studied. Pes cavus (19), hammer toes (16), and scoliosis was seen in 1 patient. Electrophysiology revealed motor predominant neuropathy with 15 demyelinating (10 uniform and 5 multifocal) and 7 axonal patterns. Thickened lumbosacral plexuses on MRI neurography were evident in 6/10 studied patients, all 6 having demyelinating neuropathy. Genetic analysis identified PMP22, GJB1, SH3TC2, HSPB1, SPTLC2, MPZ, AARS, and NEFH gene mutations. Conclusions: This small series documents the pattern of CMT neuropathies as seen in Western India. Clinico-electrophysiological and genetic diagnosis showed general concordance some overlaps and reiterated advantages of gene panel testing in this heterogeneous group of neuropathies. MRI neurography was useful as an additional investigation to detect nerve enlargement in patients with demyelinating neuropathies.
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LETTERS TO THE EDITOR Top

Subcutaneous injection of botulinum Toxin-A in postherpetic neuralgia during pregnancy p. 430
Pratik Jain, Meena Jain, Shailendra Jain
DOI:10.4103/aian.AIAN_555_15  PMID:29184352
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Simultaneous miliary lesions of brain and lungs: A diagnostic challenge p. 431
Ravindra Kumar Garg, Hardeep Singh Malhotra, Neeraj Kumar, Rajan Ingole, Shweta Pandey
DOI:10.4103/aian.AIAN_261_17  PMID:29184353
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Carbamazepine-induced seizure in a nonepileptic child p. 432
Rajesh Benny, Vyankatesh Bolegave, Sameer Sadavarte, Vinayak Khatav
DOI:10.4103/aian.AIAN_169_17  PMID:29184354
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A sibling pair with autosomal recessive Charcot–Marie–Tooth disease due to novel ganglioside-induced differentiation-associated protein 1 mutation p. 434
Poornima Amit Shah, Amit M Shah
DOI:10.4103/aian.AIAN_251_17  PMID:29184355
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Parkinsonism and tremor complicating long-term cinitapride use p. 435
Aaron de Souza, Rainha J de Souza
DOI:10.4103/aian.AIAN_225_17  PMID:29184356
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Refractory myasthenia gravis treated successfully with rituximab: A case report p. 436
L Yadav Rahul, Tulsiprasad Dakua, Arabinda Mukherjee
DOI:10.4103/aian.AIAN_233_17  PMID:29184357
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Spinocerebellar ataxia type 7 sans retinal degeneration: A phenotypic variability p. 438
Rohan R Mahale, Anish Mehta, Abhishek Miryala, Rangasetty Srinivasa
DOI:10.4103/aian.AIAN_236_17  PMID:29184358
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