Annals of Indian Academy of Neurology
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   2010| January-March  | Volume 13 | Issue 1  
    Online since March 26, 2010

 
 
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REVIEW: MANAGEMENT UPDATES
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 4,696 252
ORIGINAL ARTICLES
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 3,815 164
CASE REPORT
Acute myocardial infarction following intravenous tissue plasminogen activator for acute ischemic stroke: An unknown danger
Sweta Adatia, Sejal Sanghani, Prakash Sanzgiri, Vinay Chauhan, Shirish Hastak
January-March 2010, 13(1):64-66
DOI:10.4103/0972-2327.61282  PMID:20436751
Thrombolysis with intravenous tissue (IV) plasminogen activator (tPA) is considered for patients with acute ischemic stroke falling within the described inclusion criteria defined by The National Institute of Neurological Disorders and Stroke (NINDS) rtPA trial. Complications of IV thrombolysis with tPA are commonly related to hemorrhage, anaphylaxis, or arterial occlusion. We describe two cases of acute myocardial infarction (MI) following IV tPA infusion for acute stroke. One of the patients had underlying ischemic heart disease (IHD) while the other did not have any prior IHD. Both had presented with acute ischemic stroke within the window period of thrombolysis and had no contraindications for thrombolysis. Both the patients succumbed due to myocardial infarction and cardiovascular collapse due to new onset arrhythmias. Acute MI immediately following IV tPA for stroke is a rare but serious complication. The disruption of intracardiac thrombus and subsequent embolization to coronary arteries may be an important mechanism in the occurrence of MI after administration of tPA for acute ischemic stroke. As both the patients succumbed before the arrangement for coronary angiography, the demonstration of intracardiac or intracoronary thrombus was not possible. But clinically, the presence of chest pain with elevated troponin levels and ST segment elevation pointed to MI. We suspect that fragmentation and lysis of intracardiac thrombus may result in MI after use of tPA for acute ischemic stroke, though the remote possibility of simultaneous occurrence of two atherosclerotic events MI and stroke exists.
  8 4,084 110
REVIEW: MANAGEMENT UPDATES
Optimization of antiplatelet/antithrombotic therapy for secondary stroke prevention
Padma Srivastava
January-March 2010, 13(1):6-13
DOI:10.4103/0972-2327.61270  PMID:20436740
Role of antiplatelet therapy in secondary stroke prevention is of major significance. Antiplatelet agents predominantly in use are aspirin, clopidogrel, and combination regimes. The review focuses on the optimization of antiplatelet regimen based on evidence obtained from randomized-controlled trials, on different antiplatelet regimes and the risk assessment that may be unique to each patient.
  7 4,521 402
IMAGES IN NEUROLOGY
Idiopathic intracranial hypertension presenting as CSF rhinorrhea
K Saifudheen, Abdul Gafoor, G Arun, P Abdurahiman, James Jose
January-March 2010, 13(1):72-73
DOI:10.4103/0972-2327.61286  PMID:20436754
  6 4,350 156
ORIGINAL ARTICLES
Assessment of serum L-fucose in brain tumor cases
S Manjula, Flama Monteiro, Annaya Rao Aroor, Suryanarayan Rao, Raja Annaswamy, Anjali Rao
January-March 2010, 13(1):33-36
DOI:10.4103/0972-2327.61274  PMID:20436744
Background: Glycosylation of altered tumor cell in relation to cellular heterogeneity in human intracranial tumors remains relatively unexposed. Serum protein-bound carbohydrate, L-Fucose is reported to be overexpressed during tumor progression by many investigators. Therefore, there is a need to determine the diagnostic, prognostic, functional significance of glycoprotein elevations in various cases of tumors. Objective: The objective of the present study was to evaluate the clinical utility of serum L-fucose in patients with brain tumor. Materials and Methods: Serum glyco-conjugate levels were estimated in 99 patients with brain tumors. Estimation of L-fucose was carried out colorimetrically by the method of Winzler using cysteine hydrochloride. Results: There was a significant increase in L-fucose level in most of the patients. In the posttreatment cases, the L-fucose levels were apparently low compared to preoperative values. Conclusion: Our results showed that the rise in serum L-fucose may be used as a general marker for brain tumors in addition to other markers.
  6 3,368 113
Post-stroke cognitive impairment at 3 months
Uma Sundar, Sikandar Adwani
January-March 2010, 13(1):42-46
DOI:10.4103/0972-2327.61276  PMID:20436746
Background: Vascular cognitive impairment, being the only treatable cause of dementia in the early stages, and having a diverse etiology, requires sensitive criteria for definition. Aim: This study aimed to study cognitive functions at 3 months post-stroke, utilising the Mini mental scale examination (MMSE) and the Frontal assessment battery (FAB), and to correlate the same with subgroups of ischemic stroke. Results: 164 patients were studied, 108 of these having multiple infarcts. Pure cortical infarcts were seen in 41 patients.At 3 months, 112/164 patients had MMSE more than 24, with no frontal executive dysfunction.MMSE score less than 24 was seen in 24 patients, all of them having FAB score below 10. Normal MMSE with impaired FAB was seen in 28 patients. Conclusions: Impairment on either the MMSE or the FAB was thus seen in 31.7% patients (52/164), at 3 months after stroke.FAB impairment alone, with MMSE in normal range, was seen in 28/52 (53.8 %) patients. Memory was significantly more commonly affected in muti-infarct strokes as compared to single infarcts. Frontal executive dysfunction was not significantly different when single and multiple infarcts, or cortical and subcortical infarcts, were compared.
  6 5,245 239
VIEW POINT
Stroke program for India
Nishant K Mishra, Satish V Khadilkar
January-March 2010, 13(1):28-32
DOI:10.4103/0972-2327.61273  PMID:20436743
India is silently witnessing a stroke epidemic. There is an urgent need to develop a national program towards "Fighting Stroke". This program should be specific to our national needs. In order to recommend on who should lead an Indian fight-stroke program, we examined the published opinions of stroke clinicians and the official documents on stroke care training abroad. We identified the resources that already exist in India and can be utilized to develop a national fight-stroke program. Through a review of published literature, we noted different opinions that exist on who would best manage stroke. We found that because stroke is a cardiovascular disorder of the central nervous system, its management requires a multi-disciplinary approach involving clinicians with background not limited to neurology. India has very few neurologists trained in stroke medicine and they cannot care for all stroke patients of the country. We propose a mechanism that would quickly put in place a stroke care model relevant in Indian context. We recommend for tapping the clinical expertise available from existing pool of non-neurologist physicians who can be trained and certified in stroke medicine (Strokology). We have discussed an approach towards developing a national network for training and research in Strokology hoping that our recommendations would initiate discussion amongst stroke academicians and motivate the national policy makers to quickly develop an "Indian Fight Stroke Program."
  6 5,620 440
CASE REPORT
Chronic relapsing inflammatory optic neuropathy
Monica Saini, Dheraj Khurana
January-March 2010, 13(1):61-63
DOI:10.4103/0972-2327.61280  PMID:20436750
Chronic relapsing inflammatory optic neuropathy (CRION) is a recently described recurrent optic neuropathy which is steroid responsive. Several features distinguish this entity from optic neuritis associated with demyelinating disorders and connective tissue diseases. The severe degree of visual loss, persistence of pain after onset of visual loss, and recurrent episodes are unique to this disorder. We describe here a patient who presented with recurrent episodes of painful visual loss, followed by resolution of deficits, over a period of ten years. He was diagnosed as isolated optic neuritis conforming to features of CRION.
  5 5,071 213
CASE REPORTS
Guillain-Barre syndrome following snake bite: An unusual complication
Abhishek Srivastava, AB Taly, Anupam Gupta, Aumir Moin, T Murali
January-March 2010, 13(1):67-68
DOI:10.4103/0972-2327.61284  PMID:20436752
A 40-year-old man presented with a nonhealing wound on the left ankle for the last 5 weeks, a tingling sensation in both hands for 20 days, and weakness in all four limbs for 10 days. He had been bitten by a snake while working in a sugarcane field 6 weeks earlier and had received tetanus toxoid and anti-snake venom on the day of the bite. He had clinical, biochemical, and electrophysiological features of Guillain-Barré syndrome, with motor and sensory neuropathy-primarily suggestive of demyelination with secondary axonal degeneration. Recognition of this unusual complication following snake bite or use of anti-snake venom / tetanus toxoid has considerable epidemiological, therapeutic, and prognostic significance.
  5 3,643 140
ORIGINAL ARTICLES
Assessment of cerebrovascular reactivity during major depression and after remission of disease
Alireza Vakilian, Farhad Iranmanesh
January-March 2010, 13(1):52-56
DOI:10.4103/0972-2327.61278  PMID:20436748
Background: There are a growing number of studies suggesting that depression may increase the risk of stroke. Impaired autoregulation of vascular tone may contribute to a higher risk of developing cerebrovascular diseases. Cerebrovascular reactivity (CVR) reflects the compensatory dilatory capacity of cerebral arterioles to a dilatory stimulus and is an important mechanism that ensures constant cerebral blood flow. There is a hypothesis that CVR is reduced in major depression, which would explain the association between depression and stroke. Objectives: The aim of this study was to investigate the effect of depression on CVR in cerebral vessels by comparing CVR during the depression phase with that during remission. Material and Methods: Using the apnea test, we assessed CVR in 16 patients with unipolar depression during disease and after remission of disease by calculating the increase in cerebral blood flow velocity after breath-holding (the apnea test). Blood flow velocities were measured by transcranial Doppler ultrasound (TCD). Results: CVR was significantly reduced in the depression phase in comparison to that in the remission phase. However, this change was not seen in all the patients. Conclusion: CVR was reduced in most of the depressed patients. The decreased CVR, as indicated by the changes in peak systolic velocity (PSV) and mean flow velocity (MFV) of the middle cerebral artery, in depressed patients was more marked on the right side, which could point to a vascular basis for some kinds of depression. We recommend that other studies, with larger samples, be done; future studies should assess whether the changes in the CVR varies with the severity and type of depression.
  5 2,606 84
Clinical profile, evaluation, management and visual outcome of idiopathic intracranial hypertension in a neuro-ophthalmology clinic of a tertiary referral ophthalmic center in India
S Ambika, Deepak Arjundas, Veena Noronha, Anshuman
January-March 2010, 13(1):37-41
DOI:10.4103/0972-2327.61275  PMID:20436745
Aim: To discuss the clinical features and management of patients who presented with optic disc edema and had features of presumed idiopathic intracranial hypertension (IIH). Materials and Methods: Case series of all patients diagnosed to have IIH from January 2000 to December 2003 in the neuro-ophthalmology clinic of a tertiary referral ophthalmic institution, were retrospectively analyzed. Analysis was done for 50/106 patients who fulfilled modified Dandy's criteria and had optic disc edema and a minimal follow-up period of two years. Results: Most (40/50, 80%) of the patients were females and the mean age of presentation for all the 50 patients was 32.89 years. Chief complaints were headache in 38 (76%) patients, 24 (48%) patients had transient visual obscuration, 24 (48%) patients had reduced vision, 15 (30%) patients had nausea, vomiting, 4 (8%) patients had diplopia. Bilateral disc edema was seen in 46 (92%) patients and unilateral disc edema in 4 (8%) patients. 60 eyes had enlarged blind spot as the common visual field defect. Neuroimaging revealed prominent perioptic CSF spaces in 14 patients and empty sella in three patients. CSF opening pressure was 250-350 mm H2O (water) in 39 patients and was > 350 mm H2O in 11 patients. Medical treatment was started for all patients; whereas 35 [70%] patients responded, 15 [30%] patients had to undergo LP shunt.
  4 3,553 223
REVIEW: MANAGEMENT UPDATES
Cerebellar mutism syndrome and its relation to cerebellar cognitive and affective function: Review of the literature
Ozlem Yildiz, Serdar Kabatas, Cem Yilmaz, Nur Altinors, Belma Agaoglu
January-March 2010, 13(1):23-27
DOI:10.4103/0972-2327.61272  PMID:20436742
Tumors of the cerebellum and brainstem account for half of all brain tumors in children. The realization that cerebellar lesions produce clinically relevant intellectual disability makes it important to determine whether neuropsychological abnormalities occur in long-term survivors of pediatric cerebellar tumors. Little is known about the neurobehavioral sequale resulting specifically from the resection of these tumors in this population. We therefore reviewed neuropsychological findings associated with postoperative cerebellar mutism syndrome and discuss the further implications for cerebellar cognitive function.
  4 7,672 197
SHORT COMMUNICATION
Preliminary report of directly observed treatment, short course in tuberculous meningitis
Thomas Iype, Sinchu Chacko, Sivadasan Raghavan, Robert Mathew, Madhusudanan Mohan
January-March 2010, 13(1):57-60
DOI:10.4103/0972-2327.61279  PMID:20436749
Background: Diagnosis of tuberculous meningitis (TBM) is a challenge because of the manifold clinical presentation, and diagnosis is often delayed. Objectives: We wanted to share our experience of directly observed treatment short course (DOTS) in TBM. We did a retrospective analysis to look at the presentation, management and outcome of TBM patients from November 2006 to April 2008. Materials and Methods: TBM was diagnosed based on clinical criteria. We excluded patients with HIV. Results: We had 11 patients on DOTS regime. One died following hepatitis and another patient died of unrelated gastroenteritis. The only patient on daily regime died. Our patients generally presented late, at a median duration 20 days from onset of symptoms, and 50% had stage 3 disease at presentation. The median delay in diagnosis was 4.5 days. Discussion: We found DOTS to be effective in TBM but not without side effects.
  4 2,693 150
ORATION
Epilepsy: The future scenario
HV Srinivas
January-March 2010, 13(1):2-5
DOI:10.4103/0972-2327.61269  PMID:20436739
  2 3,059 303
CASE REPORTS
Alpha coma evolving into spindle coma in a case of acute fulminant hepatic failure: What does it signify?
Abhijit Das, Ajith Cherian, GK Dash, Ashalatha Radhakrishnan
January-March 2010, 13(1):69-71
DOI:10.4103/0972-2327.61285  PMID:20436753
A 44-year-old male developed acute fulminant hepatic failure of unknown etiology and expired within four days. His serial electroencephalograms (EEGs) showed diffuse background slowing on day one, which evolved into "alpha coma" and later into "spindle coma" over the ensuing two days. Such EEG transition is hitherto undescribed in patients with hepatic encephalopathy and gives fresh insight into the etiopathogenesis of specific EEG patterns in diffuse encephalopathy.
  1 3,039 105
EDITORIAL
Neurology and the new decade
Sanjeev V Thomas
January-March 2010, 13(1):1-1
DOI:10.4103/0972-2327.61268  PMID:20436738
  - 1,823 146
LETTERS TO EDITOR
Neuropathy due to lead poisoning
Viroj Wiwanitkit
January-March 2010, 13(1):74-74
DOI:10.4103/0972-2327.61287  PMID:20436756
  - 1,567 89
Dyslexic savants
Sourabh Aggarwal
January-March 2010, 13(1):74-74
DOI:10.4103/0972-2327.61288  PMID:20436757
  - 1,595 70
Author's reply
Ambar Chakravarty
January-March 2010, 13(1):74-74
DOI:10.4103/0972-2327.61289  PMID:20436755
  - 1,246 51
LIGHTER MOMENTS
The ringing ambulance
Mahesh Kate
January-March 2010, 13(1):63-63
  - 1,341 63
LIGHTER MOMENTS (ARTWORK OR PHOTOGRAPHY)
Barren back and forlorn future
K Rajasekharan Nair
January-March 2010, 13(1):66-66
  - 1,384 53
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