Annals of Indian Academy of Neurology
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REVIEW ARTICLES
The effect of curcumin (turmeric) on Alzheimer's disease: An overview
Shrikant Mishra, Kalpana Palanivelu
January-March 2008, 11(1):13-19
DOI:10.4103/0972-2327.40220  PMID:19966973
This paper discusses the effects of curcumin on patients with Alzheimer's disease (AD). Curcumin (Turmeric), an ancient Indian herb used in curry powder, has been extensively studied in modern medicine and Indian systems of medicine for the treatment of various medical conditions, including cystic fibrosis, haemorrhoids, gastric ulcer, colon cancer, breast cancer, atherosclerosis, liver diseases and arthritis. It has been used in various types of treatments for dementia and traumatic brain injury. Curcumin also has a potential role in the prevention and treatment of AD. Curcumin as an antioxidant, anti-inflammatory and lipophilic action improves the cognitive functions in patients with AD. A growing body of evidence indicates that oxidative stress, free radicals, beta amyloid, cerebral deregulation caused by bio-metal toxicity and abnormal inflammatory reactions contribute to the key event in Alzheimer's disease pathology. Due to various effects of curcumin, such as decreased Beta-amyloid plaques, delayed degradation of neurons, metal-chelation, anti-inflammatory, antioxidant and decreased microglia formation, the overall memory in patients with AD has improved. This paper reviews the various mechanisms of actions of curcumin in AD and pathology.
  66 63,976 1,759
IMAGES IN NEUROLOGY
Acute dengue myositis with rhabdomyolysis and acute renal failure
Sourya Acharya, Samarth Shukla, SN Mahajan, SK Diwan
July-September 2010, 13(3):221-222
DOI:10.4103/0972-2327.70882  PMID:21085538
Dengue is an acute mosquito-borne infection caused by dengue viruses from the genus flavivirus. Neurologic complications have been attributed chiefly to metabolic alterations and to focal and sometimes massive intracranial haemorrhages, but anecdotal cases and limited case series have indicated the possibility of viral CNS and skeletal muscle invasion causing encephalitis and myositis. We present a case of a 40-year-old male who presented with severe dengue myositis resulting in quadriparesis, respiratory failure and acute renal failure with red urine. His elevated serum creatine kinase (CK), serum and urine myoglobin levels justified rhabdomyolysis as the cause of acute renal failure. A muscle biopsy revealed inflammatory myositis. He required ventilator support for respiratory failure and was treated conservatively. This case highlights the severe and persistent muscle involvement in dengue which is a rarity.
  17 5,526 96
REVIEWS
Confronting the stigma of epilepsy
Sanjeev V Thomas, Aparna Nair
July-September 2011, 14(3):158-163
DOI:10.4103/0972-2327.85873  PMID:22028525
Stigma and resultant psychosocial issues are major hurdles that people with epilepsy confront in their daily life. People with epilepsy, particularly women, living in economically weak countries are often ill equipped to handle the stigma that they experience at multiple levels. This paper offers a systematic review of the research on stigma from sociology and social psychology and details how stigma linked to epilepsy or similar conditions can result in stereotyping, prejudice and discrimination. We also briefly discuss the strategies that are most commonly utilized to mitigate stigma. Neurologists and other health care providers, social workers, support groups and policy makers working with epilepsy need to have a deep understanding of the social and cultural perceptions of epilepsy and the related stigma. It is necessary that societies establish unique determinants of stigma and set up appropriate strategies to mitigate stigma and facilitate the complete inclusion of people with epilepsy as well as mitigating any existing discrimination.
  16 5,944 111
VIEW POINT
UN millennium development goals: Can we halt the stroke epidemic in India?
Praful Dalal, Madhumita Bhattacharjee, Jaee Vairale, Priya Bhat
July-September 2007, 10(3):130-136
DOI:10.4103/0972-2327.34791  
India will soon have to bear an enormous socioeconomic burden due to the costs of the rehabilitation of stroke survivors; this is because the population is now surviving through the peak years (age 55-65) for the occurrence of stroke or cerebrovascular accident (CVA). Community surveys from many regions show crude prevalence rates for stroke (presumed to be of vascular origin) in the range of 90-222 per 100,000 persons. In India, the major risk factors identified have been hypertension (>95 mm Hg diastolic), hyperglycemia, tobacco use, and low levels (<10 gm%) of hemoglobin. The Global Burden of Disease (GBD) Study, in 1990, reported 9.4 million deaths in India, of which 619,000 deaths were due to stroke, suggesting a mortality rate of 73 per 100,000 persons. This mortality rate was almost 22 times greater, and the disability adjusted life years lost was nearly six times higher, than that due to malaria. For effective prevention strategies, the existing mass media must be used to build up public awareness and impart health education on the warning symptoms of hypertension and stroke. In the absence of facilities such as computerized tomography in rural areas, primary health care doctors should receive training on the nomenclature and clinical diagnosis of stroke. Community surveys to detect 'stroke-prone' subjects should be undertaken wherever feasible and medico-social workers should remain in contact with such patients to ensure intake of preventive medicines. Changes in lifestyle and dietary habits, and intensive campaigns against tobacco use, will prove rewarding. National councils should interact with various agencies (health, industry, finance, etc.) to coordinate activities at all levels.
  16 8,470 582
ORIGINAL ARTICLES
Normobaric oxygen therapy in acute ischemic stroke: A pilot study in Indian patients
MV Padma, A Bhasin, R Bhatia, A Garg, MB Singh, M Tripathi, K Prasad
October-December 2010, 13(4):284-288
DOI:10.4103/0972-2327.74203  PMID:21264137
Purpose: Clinical and radiological assessment of effects of normobaric high-flow oxygen therapy in patients with acute ischemic stroke (AIS). Materials and Methods: Patients with anterior circulation ischemic strokes presenting within 12 h of onset, ineligible for intravenous thrombolysis, an National Institute of Health Stroke Scale (NIHSS) score of >4, a mean transit time (MTT) lesion larger than diffusion-weighted image (DWI) (perfusiondiffusion mismatch), and an evidence of cortical hypoperfusion on magnetic resonance imaging (MRI) were included into the trial. Active chronic obstructive pulmonary disease (COPD), requirement of >3/L min oxygen delivery to maintain SaO2 > 95%, rapidly improving neurological deficits, pregnancy, contraindications to MRI, or unstable medical conditions were excluded. The experimental group received humidified oxygen at flow rates of 10 L/min for 12 h. The NIHSS, modified Rankin Score (mRS), Barthel Index (BI) were measured at 0, 1, 7 day of admission and at 3 months follow-up. MRI with DWI/PWI was performed at admission, 24 h later and at 3 months follow-up. Results: Of 40 patients (mean age = 55.8 years ± 13.2) (range, 26-82), 20 patients were randomized to normobaric oxygen (NBO). The mean NIHSS in NBO and control groups were 14.25 and 12.7 at admission which decreased to 11.6 and 9.5 on the seventh day, and 9.4 and 9.05 at 3 months, respectively. The mean mRS (3.7/3.7) and BI (58.2/53.9) in NBO and control groups improved to 2/2.2 and 73.05/73.8 at the end of 3 months, respectively. Conclusions: NBO did not improve the clinical scores of stroke outcome in Indian patients with AIS.
  15 4,549 87
Neurological complications of dengue fever: Experience from a tertiary center of north India
Rajesh Verma, Pawan Sharma, Ravindra Kumar Garg, Veerendra Atam, Maneesh Kumar Singh, Hardeep Singh Mehrotra
October-December 2011, 14(4):272-278
DOI:10.4103/0972-2327.91946  PMID:22346016
Introduction: Dengue, an acute viral disease transmitted by Aedes mosquitoes, is highly endemic in many tropical and subtropical areas of the world. Neurological complications of dengue infection have been observed more frequently in the recent past and some studies highlighted varied neurological complications arising in the course of dengue illness. In this retrospective study, we report various neurological complications observed during the last 2 years in patients of dengue fever. Materials and Methods: The patients presenting with neurological complications with positive serology (IgM antibody) for dengue infection were consecutively recruited from the Department of Neurology/Medicine from a tertiary center of Lucknow, India. These patients were subjected to a detailed clinical evaluation, laboratory assessment including blood count, hematocrit, coagulation parameters, biochemical assays, serology for dengue fever, enzyme-linked immunosorbent assay for human immunodeficiency virus and other relevant investigations. Results: Twenty-six patients with neurological complications associated with confirmed dengue infection were observed during the last 2 years. Eighteen of these patients were male. Of the 26 patients, 10 patients were suffering from brachial neuritis, four patients had encephalopathy, three patients were consistent with the diagnosis of Guillain Barre syndrome, three patients had hypokalemic paralysis associated with dengue fever and two patients had acute viral myositis. Opsoclonus-myoclonus syndrome was diagnosed in two patients, myelitis in one patient and acute disseminated encephalo-myelitis also in one patient. Conclusion: Dengue fever was associated with widespread neurological complications. Brachial neuritis and opsoclonus-myoclonus syndrome were observed for the first time in this study.
  15 7,739 296
REVIEW ARTICLES
Pathophysiology of migraine
Peter J Goadsby
August 2012, 15(5):15-22
DOI:10.4103/0972-2327.99993  PMID:23024559
Migraine is a common disabling brain disorder whose pathophysiology is now being better understood. The study of anatomy and physiology of pain producing structures in the cranium and the central nervous system modulation of the input have led to the conclusion that migraine involves alterations in the sub-cortical aminergic sensory modulatory systems that influence the brain widely.
  14 9,229 225
REVIEW: MANAGEMENT UPDATES
Management of acute exacerbations in multiple sclerosis
Daniel Ontaneda, Alex D Rae-Grant
October-December 2009, 12(4):264-272
DOI:10.4103/0972-2327.58283  PMID:20182574
A key component of multiple sclerosis is the occurrence of episodes of clinical worsening with either new symptoms or an increase in older symptoms over a few days or weeks. These are known as exacerbations of multiple sclerosis. In this review, we summarize the pathophysiology and treatment of exacerbations and describe how they are related to the overall management of this disease.
  14 5,658 234
Clinical applications of magnetoencephalography in epilepsy
Amit Ray, Susan M Bowyer
January-March 2010, 13(1):14-22
DOI:10.4103/0972-2327.61271  PMID:20436741
Magnetoencehalography (MEG) is being used with increased frequency in the pre-surgical evaluation of patients with epilepsy. One of the major advantages of this technique over the EEG is the lack of distortion of MEG signals by the skull and intervening soft tissue. In addition, the MEG preferentially records activity from tangential sources thus recording activity predominantly from sulci, which is not contaminated by activity from apical gyral (radial) sources. While the MEG is probably more sensitive than the EEG in detecting inter-ictal spikes, especially in the some locations such as the superficial frontal cortex and the lateral temporal neocortex, both techniques are usually complementary to each other. The diagnostic accuracy of MEG source localization is usually better as compared to scalp EEG localization. Functional localization of eloquent cortex is another major application of the MEG. The combination of high spatial and temporal resolution of this technique makes it an extremely helpful tool for accurate localization of visual, somatosensory and auditory cortices as well as complex cognitive functions like language. Potential future applications include lateralization of memory function.
  14 4,929 255
ORIGINAL ARTICLE
Knowledge, attitude, and practices with regard to epilepsy in rural north-west India
RK Sureka, Rohit Sureka
July-September 2007, 10(3):160-164
DOI:10.4103/0972-2327.34795  
Objectives: To study the knowledge, attitudes, and beliefs about the causes and the treatment of epilepsy in rural North West India in the year 2000 and, again after 4 years, to study the effects of health education and regular treatment on the same parameters. Materials and Methods: The study was conducted twice, in 2000 and 2004. A structured questionnaire was used to collect information on demographic profile, seizure characteristics, knowledge regarding cause of epilepsy, details of alternative forms of treatment taken, and attitude towards medical treatment. Results: Generalized seizures were the most common (84%) type of seizure, followed by partial seizures (9.4%). The most common antiepileptic drug used was phenytoin, followed by phenobarbitone. Ayurvedic treatment was the most common alternative therapy used. Evil spirits were believed to be the cause of the disease by 26.4% of the patients in 2000, but only in 11.2% in 2004. Faith in the curative power of drugs increased from 18% in 2000 to 59% in the year 2004. Polytherapy was being resorted to by 60% of patients in 2000; this was reduced to 45.6% in 2004. Conclusion: Positive attitude changes over the four years from 2000 to 2004 confirm the need for effective health education that can remove misconcepts regarding disease.
  13 7,256 340
The impact of disability, fatigue and sleep quality on the quality of life in multiple sclerosis
Haleh Ghaem, Afshin Borhani Haghighi
October-December 2008, 11(4):236-241
DOI:10.4103/0972-2327.44559  PMID:19893680
Background: Only few papers have investigated the impact of multiple sclerosis (MS), especially MS-related fatigue and the impact of the quality of sleep on the quality of life (QoL) in MS patients. Objective: The objective of this study was to measure the quality of life in MS patients and the impact of disability, fatigue and sleep quality, using statistical modeling. Materials and Methods: A cross-sectional study was conducted and data was collected from 141 MS patients, who were referred to the Mottahari Clinic, Shiraz, Iran, in 2005. Data on health-related quality of life (MSQoL-54), fatigue severity scale (FSS), and Pittsburgh sleep quality Index (PSQI) were obtained in the case of all the patients. Epidemiology data concerning MS type, MS functional system score, expanded disability status scale (EDSS) etc. were also provided by a qualified neurologist. Spearman a coefficient, Mann-Whitney U test, and linear regression model were used to analyze the data. Results : The mean ±SD age of 141 MS patients was 32.6±9.6 year. Thirty five (24.8%) of them were male and the others were female. Eighty two (58.1%) of the patients had EDSS score of ≤ 2, 36 (25.5%) between 2.5 and 4.5, and 23 (16.3%) ≥ 5. As per PSQI scores, two (1.4%) of the patients had good sleep, 16 (11.3%) had moderate sleep and 123 (87.2%) had poor sleep. There was a significant high positive correlation between the quality of mental and physical health composite scores (r = 0.791, P <0.001). There was a significant negative correlation between the quality of physical score and age (r = -0.88, P <0.001), fatigue score (r = -0.640, P <0.001), EDSS score (r = -0.476, P <0.001) and PSQI (sleep quality r = -0.514, P <0.000). Linear regression analysis showed that PSQI score, EDSS, and fatigue score were predictors in the model between the quality of physical score and covariates ( P <0.001). Linear regression model showed that fatigue score and PSQI were predictors in the model between the quality of mental score and covariates ( P <0.001). Discussion and Conclusion: In conclusion, it may be said that MS patients had poor and moderate quality of mental and physical health. The quality of life was impaired as seen by PSQI, EDSS, and FSS. It is our suggestion that these patients require the attention of health care professionals, to be observed for the need of possible psychological support.
  13 5,477 269
ORIGINAL ARTICLES
Post-stroke depression: Prevalence and relationship with disability in chronic stroke survivors
Abhishek Srivastava, Arun B Taly, Anupam Gupta, Thyloth Murali
April-June 2010, 13(2):123-127
DOI:10.4103/0972-2327.64643  PMID:20814496
Objectives: To evaluate (1) the prevalence of operationally defined depressive disorder (ICD-10) in chronic stroke subjects and (2) the relationship of post-stroke depression (PSD) with disability. Design: Cross-sectional, descriptive study. Setting: Neurological rehabilitation unit of a tertiary care university research center. Materials and Methods: Participants were those with first episode of supratentorial stroke of more than 3 months' duration with impaired balance and gait who had been referred for rehabilitation. Data were collected on demographic data, stroke data (side and type of lesion and post-stroke duration), cognition (mini mental state examination), depressive ideation (Hamilton Depression Rating Scale - HRDS), impairment (Scandinavian Stroke Scale), balance (Berg Balance Scale), ambulatory status (Functional Ambulation Category), walking ability (speed), and independence in activities of daily living (Barthel Index). Statistical analysis was done using SPSS 13.0. We carried out the chi-square test for ordinal variables and the independent t test for continuous variables. Results: Fifty-one patients (M:F: 41:10) of mean age 46.06 ± 11.19 years and mean post-stroke duration of 467.33 ± 436.39 days) were included in the study. Eighteen of the 51 participants (35.29%) met the criteria for depression. Demographic variables like male gender, being married, living in a nuclear family, urban background, and higher HRDS score were significantly correlated with PSD (P < 0.05). Depression was related to functional disability after stroke but to a statistically insignificant level (P > 0.05) and was unrelated to lesion-related parameters. Conclusion: Depression occurs in one-third of chronic stroke survivors and is prevalent in subjects referred for rehabilitation. PSD is related primarily to demographic variables and only to a lesser extent to functional disability following stroke.
  13 9,850 258
REVIEW: MANAGEMENT UPDATES
Examination of the role of magnetic resonance imaging in multiple sclerosis: A problem-orientated approach
Henry F McFarland
October-December 2009, 12(4):254-263
DOI:10.4103/0972-2327.58284  PMID:20182573
Magnetic Resonance Imaging (MRI) has brought in several benefits to the study of Multiple Sclerosis (MS). It provides accurate measurement of disease activity, facilitates precise diagnosis, and aid in the assessment of newer therapies. The imaging guidelines for MS are broadly divided in to approaches for imaging patients with suspected MS or clinically isolated syndromes (CIS) or for monitoring patients with established MS. In this review, the technical aspects of MR imaging for MS are briefly discussed. The imaging process need to capture the twin aspects of acute MS viz. the autoimmune acute inflammatory process and the neurodegenerative process. Gadolinium enhanced MRI can identify acute inflammatory lesions precisely. The commonly applied MRI marker of disease progression is brain atrophy. Whole brain magnetization Transfer Ratio (MTR) and Magnetic Resonance Spectroscopy (MRS) are two other techniques use to monitor disease progression. A variety of imaging techniques such as Double Inversion Recovery (DIR), Spoiled Gradient Recalled (SPGR) acquisition, and Fluid Attenuated Inversion Recovery (FLAIR) have been utilized to study the cortical changes in MS. MRI is now extensively used in the Phase I, II and III clinical trials of new therapies. As the technical aspects of MRI advance rapidly, and higher field strengths become available, it is hoped that the impact of MRI on our understanding of MS will be even more profound in the next decade.
  13 3,710 212
ORIGINAL ARTICLE
Various types of intercommunications between musculocutaneous and median nerves: An analytical study
R Chitra
April-June 2007, 10(2):100-104
DOI:10.4103/0972-2327.33217  
Intercommunications between musculocutaneous nerve and median nerve deserve important interest in view of their clinical significance. In the study of 50 upper limb specimens, the various communications between the musculocutaneous and median nerve in the arm were observed carefully. The communications between the two nerves were found in 13 arms. Variations in the present study involving the median nerve and musculocutaneous nerve are important in repairs for trauma to the shoulder and the understanding of the median nerve and the musculocutaneous nerve dysfunction.
  11 5,921 255
ORIGINAL ARTICLES
Urodynamics post stroke in patients with urinary incontinence: Is there correlation between bladder type and site of lesion?
Anupam Gupta, Arun B Taly, Abhishek Srivastava, Murali Thyloth
April-June 2009, 12(2):104-107
DOI:10.4103/0972-2327.53078  PMID:20142855
Objective: Assessment of bladder by urodynamic study (UDS) in patients with urinary incontinence following stroke, and correlation with site of lesion. Study Design and Setting: Retrospective cross-sectional study in the neurological rehabilitation unit of a tertiary care institute. Materials and Methods: Forty patients (22 males) with arterial or venous, ischemic or hemorrhagic stroke, with urinary incontinence in the acute phase following the event, underwent UDS. Seventeen patients had right hemiplegia, 18 had left hemiplegia, and five had posterior circulation stroke with brainstem/cerebellar features. Bladder type was correlated with age, side, and site of lesion. Results: The mean age was 46.80 ± 16.65 years (range: 18-80 years). Thirty-six patients had arterial stroke and four had cortical venous thrombosis. UDS was performed after a mean of 28.32 ± 10.27 days (range: 8-53 days) after the stroke. All but one patient had neurogenic bladder dysfunction, with 36 patients (90%) having overactive detrusor (OD) and three having underactive/areflexic detrusor. Among the 36 patients with OD, 25 patients (62.5%) had OD without detrusor-sphincter dyssynergy (DSD) and 11 (27.5%) had OD with DSD. Bladder management was advised based on the UDS findings. No significant correlation ( P > 0.05) was found between type of bladder and age or side and site of lesion. Conclusions: UDS is a useful tool to assess and manage the bladder following stroke with urinary incontinence. In this study, no significant correlation was found between UDS findings and site of lesion.
  11 6,254 253
Comparison of oxidative stress among migraineurs, tension-type headache subjects, and a control group
Ravi Gupta, Rahul Pathak, Manjeet Singh Bhatia, Basu Deb Banerjee
July-September 2009, 12(3):167-172
DOI:10.4103/0972-2327.56316  PMID:20174497
Background: A primary headache, particularly migraine, is associated with oxidative stress during the attack. However, data regarding the interictal state in migraineurs and in those with tension-type headache (TTH) is limited. Objectives: (1) To assess the oxidative stress in migraineurs and TTH subjects in between the episodes and (2) to see if there is a difference in the degree of oxidative stress in the different subtypes of migraine and TTH. Materials and Methods: Fifty migraineurs, 50 patients with TTH, and 50 control subjects were included in this study after screening for the exclusion criteria. Diagnosis of headache was made according to the International Classification of Headache Disorders (ICHD)-2 criteria. A venous blood sample was collected from the antecubital vein at least 3 days after the last attack of headache. The sample was centrifuged immediately and the plasma was stored at −70΀C. The ferric reducing activity of plasma (FRAP) and the malondialdehyde (MDA) levels were assessed using colorimetric methods. Statistical analysis was done with the help of SPSS for Windows, v 11.0. One way ANOVA with post hoc Tukey test, independent sample t test, univariate regression, and multivariate regression analysis were done as indicated. Results: Migraineurs had higher values of MDA and FRAP than the subjects in the other two groups (P<0.001). No difference was observed between the TTH group and the control group. FRAP levels were significantly higher in subjects who had mixed migraine (migraine with aura and without aura) as compared to those with only migraine without aura (mean difference 196.1; 95% CI = 27.3 to 364.9; P = 0.01). Similarly, oxidative stress was significantly higher in patients with episodic TTH as compared to those with chronic TTH (FRAP t = 3.16; P = 0.003 and MDA t = 2.75; P = 0.008). Conclusions: This study suggests that oxidative stress continues even between headache episodes in migraineurs but not in those with TTH. This could probably be consequent to the different pathophysiological mechanisms of TTH and migraine.
  11 3,400 137
Pattern of neurological admissions in the tropics: Experience at Kano, Northwestern Nigeria
LF Owolabi, MY Shehu, MN Shehu, J Fadare
July-September 2010, 13(3):167-170
DOI:10.4103/0972-2327.70875  PMID:21085525
Background: Kano is the most populated state in Nigeria with a population totaling 9,383,682. The pattern of neurologic diseases in this area is not known. Objective: To determine the of pattern of neurologic diseases warranting admission in a tertiary hospital in Kano and compare it with those elsewhere in the country with the view to using the data generated as a baseline for planning purposes and for future studies. Materials and Methods: The medical records of all cases admitted with neurologic diseases in the Aminu Kano Teaching Hospital, Kano between January 2005 and September 2008, were retrospectively reviewed and the frequency of neurologic diseases, sex, age, and outcome of these diseases analyzed. Result: Stroke, predominantly ischemic, accounted for 77.6% of the neurological cases for the period of study. Central nervous system infections, comprising mainly of meningitis and tetanus, accounted for 6.6% (64) and 3% (29) of cases, respectively. The myelopathies were the cause of neurologic admissions in 5.4% (53) with paraplegia and quadriplegia resulting from myelopathies accounting for 5% (49) and 0.4% (4) of the cases. Hypertensive encephalopathy and status epilepticus as the causes of admissions accounted for 1.6% each. Gullain Barre syndrome, Parkinson's disease, and cerebral malaria were relatively rare causes of neurologic admissions in this study. The average duration of hospitalization was 25 days, and regarding outcome, 219 (22.4%) of these cases died. Conclusions: Stroke appeared to be the most common neurologic admission and the most common cause of neurologic and medical death in Kano as observed in other regions of the country and a little over one-fifths of stroke patients die. Central nervous system infections mainly meningitis and tetanus are the next common cause of admission. In view of these findings, the provision of a regional stroke unit, the improvement of the sanitary conditions of the home and environment; the widespread use of immunizations against meningitis, tetanus cannot be over-emphasized. These interventions will go a long way to reduce morbidity and mortality of stroke and neurologic infections.
  11 3,959 37
REVIEW: MANAGEMENT UPDATES (REVIEWS ON ADVANCES IN TREATMENT)
Status epilepticus
Ajith Cherian, Sanjeev V Thomas
July-September 2009, 12(3):140-153
DOI:10.4103/0972-2327.56312  PMID:20174493
Status epilepticus (SE) is a medical emergency associated with significant morbidity and mortality. SE is defined as a continuous seizure lasting more than 30 min, or two or more seizures without full recovery of consciousness between any of them. Based on recent understanding of the pathophysiology, it is now considered that any seizure that lasts more than 5 min probably needs to be treated as SE. GABAergic mechanisms play a crucial role in terminating seizures. When the seizure persists, GABA-mediated mechanisms become ineffective and several other putative mechanisms of seizure suppression have been recognized. Early treatment of SE with benzodiazepines, followed if necessary by fosphenytoin administration, is the most widely followed strategy. About a third of patients with SE may have persistent seizures refractory to the first-line medications. They require aggressive management with second-line medications such as barbiturates, propofol, or other agents. In developing countries where facilities for assisted ventilation are not readily available, it may be helpful to use nonsedating antiepileptic drugs (such as sodium valproate, levetiracetam, or topiramate) at this stage. It is important to recognize SE and institute treatment as early as possible in order to avoid a refractory state. It is equally important to attend to the general condition of the patient and to ensure that the patient is hemodynamically stable. This article reviews current knowledge regarding the management of convulsive SE in adults.
  11 8,955 814
CASE REPORTS
Meningitis caused by Rhodotorula mucilaginosa in human immunodeficiency virus seropositive patient
VP Baradkar, S Kumar
October-December 2008, 11(4):245-247
DOI:10.4103/0972-2327.44561  PMID:19893682
Rhodotorula species may be responsible for systemic infection in immunocompromised patients. Meningitis by Rhodotorula species in human immunodeficiency virus (HIV) infected persons has been reported previously. We report a case of meningitis caused by Rhodotorula mucilaginosa in a 36-year-old HIV seropositive male patient who presented with fever, altered sensorium and features of meningeal irritation i.e. neck rigidity. The Cerebrospinal fluid (CSF) cell counts were high, showing 150 cells/mm 3 , with 60% lymphocytes and 40% polymorphs, and protein content of 100 mg%; glucose was 60 mg%. The diagnosis was confirmed by culture on Sabouraud's Dextrose agar. The patient was treated successfully with intensive Amphotericin B (1 mg/kg), for two weeks, followed by oral Itraconazole (400 mg daily), for a period of two months. The patient was started on anti retroviral therapy. He did not show any relapse of the symptoms when the last follow up was done six months after the date of discharge.
  10 4,112 112
Valproate-induced hyperammonemic encephalopathy enhanced by topiramate and phenobarbitone: A case report and an update
S Vivekanandan, S Dinesh Nayak
April-June 2010, 13(2):145-147
DOI:10.4103/0972-2327.64638  PMID:20814502
Although sodium valproate (VPA)-induced hepatic encephalopathy is a well-recognized entity, VPA can occasionally produce encephalopathy secondary to hyperammonemia in the presence of normal hepatic function, namely valproate-induced non-hepatic hyperammonemic encephalopathy (VNHE). Known risk factors include therapy with multiple antiepileptic drugs, especially when topiramate is one of the drugs; presence of underlying inborn errors of metabolism; febrile states; and insufficient nutritional intake. We describe a 5-year-old male child who developed VNHE while on polypharmacy with topiramate and phenobarbitone; the child also had poor nutritional intake. The encephalopathy reversed with withdrawal of VPA and treatment with L-carnitine. We emphasize the need for early recognition, investigation, and treatment of this potentially life-threatening condition. We also recommend that VPA, topiramate, and phenobarbitone should not be given in combination.
  10 4,820 218
ORIGINAL ARTICLES
Primary headaches in restless legs syndrome patients
Ravi Gupta, Vivekananda Lahan, Deepak Goel
August 2012, 15(5):104-108
DOI:10.4103/0972-2327.100031  PMID:23024558
Earlier studies conducted among migraineurs have shown an association between migraine and restless legs syndrome (RLS). We chose RLS patients and looked for migraine to exclude sample bias. Materials and Methods: 99 consecutive subjects of idiopathic RLS were recruited from the sleep clinic during four months period. Physician diagnosis of headache and depressive disorder was made with the help of ICHD-2 and DSM-IV-TR criteria, respectively. Sleep history was gathered. Severity of RLS and insomnia was measured using IRLS (Hindi version) and insomnia severity index Hindi version, respectively. Chi-square test, one way ANOVA and t-test were applied to find out the significance. Results: Primary headache was seen in 51.5% cases of RLS. Migraine was reported by 44.4% subjects and other types of 'primary headaches' were reported by 7.1% subjects. Subjects were divided into- RLS; RLS with migraine and RLS with other headache. Females outnumbered in migraine subgroup (χ2 =16.46, P<0.001). Prevalence of depression (χ2 =3.12, P=0.21) and family history of RLS (χ2 =2.65, P=0.26) were not different among groups. Severity of RLS (P=0.22) or insomnia (P=0.43) were also similar. Conclusion: Migraine is frequently found in RLS patients in clinic based samples. Females with RLS are prone to develop migraine. Depression and severity of RLS or insomnia do not affect development of headache.
  10 3,503 61
A prospective study of brain natriuretic peptide levels in three subgroups: Stroke with hypertension, stroke without hypertension, and hypertension alone
Zeynep Cakir, Ayhan Saritas, Mucahit Emet, Sahin Aslan, Ayhan Akoz, Fuat Gundogdu
January-March 2010, 13(1):47-51
DOI:10.4103/0972-2327.61277  PMID:20436747
Aim: To study brain natriuretic peptide (BNP) levels in three subgroups: patients having stroke with hypertension (HT), those having stroke without HT, and those with HT alone. We also tried to identify whether BNP levels predict the length of stay in hospital and mortality. Materials and Methods: The groups were formed by patients who had been admitted to the emergency department in the first 4-12 h after the onset of symptoms. There were 30 stroke patients with a history of HT (group I), 30 stroke patients without a history of HT (group II), and 20 HT patients without stroke (group III). Patients with congestive heart failure, chronic cor pulmonale, severe valvular heart disease, chronic renal failure, liver insufficiency, diabetes mellitus, atrial fibrillation, and those with a history of stroke were excluded from the study since these diseases can affect the plasma BNP levels. Results: The demographic characteristics, except the age distribution, were similar among the groups. The mean BNP levels in the three groups were 168.8 ± 223.9 pg/ml, 85.0 ± 75.1 pg/ml, and 84.8 ± 178.3 pg/ml, respectively. The differences between the groups were statistically significant. Conclusion: The mean BNP levels were affected by HT and/or stroke. The simultaneous presence of HT and stroke results in a more significant increase BNP than the presence of either stroke or HT alone. When diseases that can affect the plasma BNP levels are excluded, the BNP levels in stroke patients without a history of HT are similar to the levels seen in patients with only HT.
  10 4,073 166
REVIEW: MANAGEMENT UPDATES (REVIEWS ON ADVANCES IN TREATMENT)
Diagnosis and treatment of chronic insomnia
Sahoo Saddichha
April-June 2010, 13(2):94-102
DOI:10.4103/0972-2327.64628  PMID:20814491
Insomnia is a disorder characterized by inability to sleep or a total lack of sleep, prevalence of which ranges from 10 to 15% among the general population with increased rates seen among older ages, female gender, White population and presence of medical or psychiatric illness. Yet this condition is still under-recognized, under-diagnosed, and under-treated. This article aims to review the operational definitions and management of chronic insomnia. A computerized search on PubMed carried from 1980 to January 2009 led to the summarization of the results. There are several strategies to manage chronic insomnia. To initiate treatment, it is necessary to define it and differentiate it from other co-morbid psychiatric disorders. Non-pharmacologic strategies such as stimulus control therapy and relaxation and cognitive therapies have the best effect sizes followed by sleep restriction, paradoxical intention and sleep hygiene education which have modest to less than modest effect sizes. Among pharmacotherapeutic agents, non-benzodiazepine hypnotics are the first line of management followed by benzodiazepines, amitryptiline and antihistaminics. However, adequate trials of combined behavior therapy and pharmacotherapy are the best course of management.
  10 11,276 287
ORIGINAL ARTICLES
Clinical and psychosocial characteristics of children with nonepileptic seizures
Sri Sankar Chinta, Prahbhjot Malhi, Pratibha Singhi, Sudesh Prabhakar
July-September 2008, 11(3):159-163
DOI:10.4103/0972-2327.42935  PMID:19893662
Objective: The aim of this study is to present a comprehensive profile of clinical and psychosocial characteristics of children with psychogenic nonepileptic seizures and to assess the short-term outcome of these patients. Materials and Methods: The subjects were consecutive cases of children with a diagnosis of nonepileptic seizures (N=17, mean age = 10.7 years, S.D. = 1.26) and two groups of control groups matched on age and sex: true seizure group and healthy controls. All the children were recruited from the out-patient services of the Department of Pediatrics of a tertiary care teaching hospital in North India. Detailed history taking and clinical examination was done in the case of every child. A standard 18 channel EEG was done in all the children and a video EEG was done in 12 cases of children with nonepileptic seizures. The Childhood Psychopathology Measurement Schedule (CPMS) and Life Events Scale for Indian Children (LESIC) were used to measure the children's emotional and behavioral functioning at home, and the number of life events and the stress associated with these events in the preceding year and the year before that. Short-term outcome was examined three to six months after the diagnosis of nonepileptic seizures was made. Results: Unresponsiveness without marked motor manifestations was the most common "ictal" characteristic of the nonepileptic seizures. Pelvic thrusting, upper and lower limb movements, head movements, and vocalization were observed in less than one-third of the patients. Increased psychosocial stress and significantly higher number of life events in the preceding year were found to characterize children with nonepileptic seizures, as compared to the two control groups. The nonepileptic seizures and true seizures groups had a higher proportion of children with psychopathology scores in the clinically significant maladjustment range, as compared to those in the healthy control group. A majority of the patients (82.4%) either recovered completely or had more than 50% reduction in the frequency of their symptoms, after three to six months of initiation of therapy. Conclusions: Psychosocial stress is common among children with nonepileptic seizures. Confirmatory diagnosis by video EEG, along with prompt psychosocial intervention, often results in a favorable outcome for most children with nonepileptic seizures.
  9 4,845 226
REVIEW: PROGRESS IN MEDICINE
Immunopathogenesis of multiple sclerosis
Michael K Racke
October-December 2009, 12(4):215-220
DOI:10.4103/0972-2327.58274  PMID:20182567
Multiple sclerosis (MS) is a suspected autoimmune disease in which myelin-specific CD4+ and CD8+ T cells enter the central nervous system (CNS) and initiate an inflammatory response directed against myelin and other components of the CNS. Acute MS exacerbations are believed be the result of active inflammation, and progression of disability is generally believed to reflect accumulation of damage to the CNS, particularly axonal damage. Over the last several years, the pathophysiology of MS is being appreciated to be much more complex, and it appears that the development of the MS plaque involves a large number of cell populations, including CD8+ T lymphocytes, B cells, and Th17 cells (a population of helper T cells that secrete the inflammatory cytokine IL-17). The axonal transection and degeneration that is thought to represent the basis for progressive MS is now recognized to begin early in the disease process and to continue in the progressive forms of the disease. Molecules important for limiting aberrant neural connections in the CNS have been identified, which suppress axonal sprouting and regeneration of transected axons within the CNS. Pathways have also been identified that prevent remyelination of the MS lesion by oligodendrocyte precursors. Novel neuroimaging methodologies and potential biomarkers are being developed to monitor various aspects of the disease process in MS. As we identify the pathways responsible for the clinical phenomena of MS, we will be able to develop new therapeutic strategies for this disabling illness of young adults.
  9 4,036 237
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