Annals of Indian Academy of Neurology
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   2007| July-September  | Volume 10 | Issue 3  
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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
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.
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Knowledge, attitude, and practices with regard to epilepsy in rural north-west India
RK Sureka, Rohit Sureka
July-September 2007, 10(3):160-164
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.
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Epilepsy and religion
Geeta A Khwaja, Gurubax Singh, Neera Chaudhry
July-September 2007, 10(3):165-168
This study has focused on the interplay between epilepsy and religion. A total of 100 patients in the age range of 15-84 years were included in the study. The duration of epilepsy in these patients ranged from 1-35 years. The majority (66%) had generalized seizures and good to complete seizure control (77%). Regarding social/religious beliefs, 6% of the patients attributed their epilepsy to the curse of God and 14% saw their affliction as a form of punishment for bad deeds committed in the current or past life. Epilepsy was regarded as contagious by 13%. After the onset of epilepsy, 7% of the subjects became skeptics and less religious, while 29% became more religious. Only 2% reported mystic experiences. There was, however, no significant impact of the duration of epilepsy or seizure type on the pattern of religiosity. In 44 cases with symptomatic epilepsy, no definite correlation was observed between the lesion site and laterality and the religious temperament. Delay in seeking treatment and poor compliance due to false religious beliefs, ignorance, and superstition was observed in 33%. However, all religious beliefs were not maladaptive and overall, 80% cases felt that religion had helped them in coping with epilepsy.
  5 10,813 336
Management of treatment-resistant obsessive-compulsive disorder: An update on therapeutic strategies
Biswaranjan Mishra, Saddichha Sahoo, Baikunthanath Mishra
July-September 2007, 10(3):145-153
Background: Obsessive-compulsive disorder (OCD) is a chronic psychiatric disorder characterized by recurrent, persistent thoughts and/or repetitive compulsive behaviors that cause anxiety or distress, are time-consuming, and cause significant socio-occupational dysfunction. Although OCD can be alleviated with pharmacological and behavioral treatments, up to 40-60% of patients do not have a satisfactory outcome. This paper aims to review the operational definitions and management of treatment-resistant OCD. Materials and Methods: A computerized search on Pubmed carried from 1980 to April 2006 led to the summarization of the results. Results: There are several strategies to manage treatment-resistant OCD. To start with, it is necessary to define it and differentiate it from other comorbid psychiatric disorders. Adequate trials of selective serotonin reuptake inhibitors (SSRIs), including clomipramine, at the maximum recommended dosages for at least 12 weeks needs to be tried, along with cognitive behavioral therapy (CBT), before trying out other modalities of treatment, which include ECT, rTMS, and neurosurgery. Conclusion: OCD has various clinical and therapeutic implications as it has a chronic course. Unless diagnosed and treated in an effective manner, it carries the risk of becoming resistant to treatment. This paper attempts to present an algorithm of management that can be followed in treatment-resistant OCD. It also emphasizes the need to maximize the effect of each course of treatment before moving on to the next step of management.
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Conservative management of subdural hematoma in idiopathic thrombocytopenic purpura: Report of two cases and review of literature
R Sunitha, Robert Mathew, Mathew Thomas
July-September 2007, 10(3):184-186
Intracranial hemorrhage (ICH) is the most serious complication of idiopathic thrombocytopenic purpura (ITP) and is potentially fatal. It is rare, affecting 1% or less of patients and is usually subarachnoid or intracerebral. Isolated subdural hematoma (SDH) is rare and only few cases have been reported. Two cases of acute SDH (ASDH) are reported which resolved with conservative management. One of the patients later developed intracerebral hematoma also. In ITP, contrary to traumatic ASDH, the brain parenchyma is well preserved and hence conservative management may be safe in selected patients. However, only a prospective randomized control study will give the final answer. Both the patients developed the hematoma consequent to low platelet count, which was not detected earlier due to inadequate follow-up. In a developing country, where proper follow-up is often lacking these problems are likely to be more common and are probably underreported. Increased awareness is therefore important to ensure proper follow-up and early intervention.
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"Batwings dilatation" of sylvian fissures in glutaric aciduria type I
VV Ashraf, K Sudha
July-September 2007, 10(3):189-190
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Surveillance of stroke: WHO STEP-wise approach: A Chennai stroke unit report
Deepak Arjundas, Uma Pandiyan, G Arjundas, Baux Henry
July-September 2007, 10(3):154-159
Stroke is potentially the most devastating consequence of vascular disease, causing long-term disability and placing high medical, emotional, and financial burdens on the patient. WHO STEPS stroke surveillance study, provided the framework for our study of stroke patients in Chennai. In our center, we followed only the STEP 1 study and only hospital-based stroke data were collected. STEP 2 and 3 involved study of strokes in the community. We found that 78% of our patients were in the 6th to 8th decades of life; 72% had hypertension, either alone or in combination with other risk factors; 4 weeks after the stroke, 51% of our patients were independent with regard to mobility and the activities of daily living, while 14% had severe disability. We found a mortality rate of 14%. We concluded that the incidence of stroke in the community can be decreased further by effective risk factor modification. The admission delay needs to be shortened from >48 h to less than 6 h. Our data also gave us fresh information about the recovery of motor function in stroke survivors at 28 days after the stroke.
  1 5,808 343
Acute disseminated encephalomyelitis
JN Panicker
July-September 2007, 10(3):137-144
Acute disseminated encephalomyelitis (ADEM) presents as an acute-onset neurological dysfunction following a triggering event such as an infection or vaccination. Patients present with polysymptomatic neurological dysfunction, and imaging shows multifocal white matter lesions in the brain and spinal cord. Clinical evaluation, magnetic resonance imaging, and cerebrospinal fluid study are most useful in establishing the diagnosis and ruling out important differential diagnoses. Corticosteroids are the mainstay of treatment and the role of other modalities of treatment, such as plasma exchange and intravenous immunoglobulin, require further study. Prognosis is generally good. The recently proposed consensus definitions are likely to facilitate delineation of ADEM from other acquired demyelinating disorders.
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An assessment of the clinical equivalence of valproate chrono and extended release divalproex formulations
B Rajesh, R Ashalatha, Sankara P Sarma, K Radhakrishnan
July-September 2007, 10(3):169-174
Objective: No guideline currently exists to choose the clinically equivalent dose of divalproex extended release (ER) formulation while switching over from valproate chrono formulation. To address this issue, we evaluated the serum valproate concentration following switch over from valproate chrono to divalproex ER in persons with epilepsy. Materials and Methods: An open label study was conducted in two parts, each for a period of two months. During Part I, patients on regular twice-daily dose of valproate chrono were switched over to once daily divalproex ER (DESVAL ER ) based on the dose escalation recommended when switching over from divalproex DR to ER formulation as the guideline. During Part II, we switched from valproate chrono to divalproex ER with same dosage. Serum valproate concentration, seizure frequency and side effects were assessed serially for two months after changeover and compared with the preswitch data. Results: During Part I, compared to the baseline level, there was a significant increase in mean serum valproate level at two months (67.0 28.4 mg/ml versus 91.9 3.5 mg/ml, P 0.004). With the same dose conversion during Part II, the mean valproate level did not significantly differ before and after the switch (81.5 mg/dl versus 85.7 mg/dl, P 0.08). The mean monthly seizure frequencies and serum ammonia levels did not change during either part. No significant adverse effects occurred. Conclusion: The results of this open label study with small number of patients need to be replicated among larger patient sample through a randomized control design before recommending same dose conversion from valproate chrono to divalproex ER without change in efficacy and tolerability,
  1 12,536 442
Nemaline myopathy: A report of four cases
AN Deepti, N Gayathri, M Veerendra Kumar, Susarla K Shankar
July-September 2007, 10(3):175-177
Nemaline myopathies are a group of genetically determined (autosomal dominant/recessive) congenital myopathies characterized by the formation of nemaline rods within muscle fibers. Congenital, childhood, and adult forms with hypotonia, proximal muscle and facial weakness, and skeletal deformities have been described. The diagnostic hallmark is the presence of nemaline rods on modified Gomori's trichrome staining. We report the clinical and morphological features of four patients with nemaline rod myopathy: congenital classic (2), childhood (1), and adult (1), and speculate on the disease's evolution.
  1 5,475 176
Aortoiliac occlusive disease masquerading as cerebrovascular accident
BN Nandeesh, A Mahadevan, A Tandon, P Satishchandra, SK Shankar
July-September 2007, 10(3):178-181
Acute aortoiliac occlusion is an unusual but potentially catastrophic condition causing acute limb ischemia and associated with early and high rates of mortality and morbidity. It is caused by either embolic occlusion of the infra renal aorta at the bifurcation or beyond or thrombosis of the abdominal aorta and its large terminal branches. Neurological symptoms are rare manifestation of acute aortoiliac occlusion and when neurological symptoms predominate, patients are mistakenly considered to have cerebrovascular event. We present a 60-year-old man with atherosclerotic thrombotic occlusion of the left common iliac artery causing acute painful monoplegia. We mistook the acute monoplegia due to acute limb ischemia for cerebrovascular accident. Pathologic examination revealed a firm thrombus occluding the origin of left common iliac artery and extending along the length of the vessel. Acute aortic iliac occlusion can masquerade as a cerebrovascular stroke and a thorough clinical evaluation and imaging studies allow early diagnosis and instituting life-saving treatment timely.
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Neck massage induced dural sinus thrombosis
Ashish Verma, Suyash Mohan, Saurabh Guleria, Sunil Kumar
July-September 2007, 10(3):182-183
Thrombosis of the intracranial dural sinuses and internal jugular veins may occur as a complication of head and neck infections, surgery, central venous access, local malignancy, polycythemia, hyperhomocysteinemia, neck massage and intravenous drug abuse. A high degree of clinical suspicion followed by adequate imaging is prerequisite to early diagnosis and management. We report a young man who had dural sinus thrombosis with jugular venous thrombosis following neck massage.
  - 6,337 168
An unusual cause for weakness in a girl
S Khadilkar, Ajith Cherian, Sanjeev V Thomas
July-September 2007, 10(3):191-195
  - 5,601 298
Millennium development goals: Where are we?
Sanjeev V Thomas
July-September 2007, 10(3):129-129
  - 2,801 216
Isolated complete third nerve palsy due to midbrain hemorrhage: Clinico-radiological correlation
Sudhir Kumar, Garikapati Rajshekher, Subhashini Prabhakar
July-September 2007, 10(3):187-188
  - 4,007 179
A quiet morning
Sanjeev V Thomas
July-September 2007, 10(3):195-195
  - 2,010 143
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