Annals of Indian Academy of Neurology
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   2010| October-December  | Volume 13 | Issue 4  
    Online since December 24, 2010

 
 
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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 4,543 87
REVIEW: SYSTEMATIC REVIEW
Kleine-Levin syndrome: Etiology, diagnosis, and treatment
Santosh Ramdurg
October-December 2010, 13(4):241-246
DOI:10.4103/0972-2327.74185  PMID:21264130
Kleine-Levin syndrome (KLS) is a rare sleep disorder mainly affecting teenage boys in which the main features are intermittent hypersomnolence, behavioral and cognitive disturbances, hyperphagia, and in some cases hypersexuality. Each episode is of brief duration varying from a week to 1-2 months and affected people are entirely asymptomatic between episodes. No definite cause has been identified, and no effective treatments are available even though illness is having well-defined clinical features. Multiple relapses occur every few weeks or months, and the condition may last for a decade or more before spontaneous resolution. In this study, PubMed was searched and appropriate articles were reviewed to highlight etiology, clinical features, and management of KLS. On the basis of this knowledge, practical information is offered to help clinicians about how to investigate a case of KLS, and what are the possible treatment modalities available currently for the treatment during an episode and interepisodic period for prophylaxis. Comprehensive research into the etiology, pathophysiology, investigation, and treatments are required to aid the development of disease-specific targeted therapies.
  8 8,495 158
ORIGINAL ARTICLES
Utility of molecular and serodiagnostic tools in cerebral toxoplasmosis with and without tuberculous meningitis in AIDS patients: A study from South India
Sreenivas Adurthi, Anita Mahadevan, Radhika Bantwal, Parthasarthy Satishchandra, Sujay Ramprasad, Hema Sridhar, SK Shankar, Avindra Nath, RS Jayshree
October-December 2010, 13(4):263-270
DOI:10.4103/0972-2327.74197  PMID:21264134
Background: Antemortem diagnosis of cerebral toxoplasmosis, the second most common opportunistic infection (OI) in HIV-infected individuals in developing countries is a challenge. Materials and Methods: Toxoplasma gondii (T.gondii) -specific serology and nested polymerase chain reaction (nPCR) were evaluated in sera and ventricular/lumbar cerebrospinal fluid (CSF) of 22 autopsy confirmed cases of cerebral toxoplasmosis with HIV and 17 controls. Frequency of concomitant T.gondii infection was investigated in 17 cases of HIV-associated tuberculous meningitis (TBM). Results: The sensitivity, specificity, and positive and negative predictive values of T. gondii IgG on CSF (ventricular and lumbar) and sera was 100% in histology proven cerebral toxoplasmosis (concentrations: 258 ± 50, 231 ± 36, and 646 ± 243 IU/mL, respectively); majority (94%) being high avidity type, suggesting reactivation/reinfection. The sensitivity of B1 nPCR was 100% on ventricular CSF, whereas it was only 77% on lumbar CSF. Based on histology, nPCR, and IgG serology, T. gondii co-infection with TBM was observed in 65% (11/17) of cases. Discussion and Conclusion: CSF IgG serology and nPCR are tests with high sensitivity and specificity for the diagnosis of cerebral toxoplasmosis. TBM and cerebral toxoplasmosis can coexist and should be considered in the background of HIV infection in developing countries.
  5 4,930 82
SHORT COMMUNICATIONS
Cerebrospinal fluid hypovolemia syndrome with benign course
KN Ramesha, Kesavadas Chandrashekaran, Sanjeev V Thomas
October-December 2010, 13(4):293-296
DOI:10.4103/0972-2327.74202  PMID:21264139
Background: The cerebrospinal fluid hypovolemia syndrome (CHS) is an under recognized cause of headache. This study was designed to highlight the clinico-radiological and cerebrospinal fluid (CSF) picture of CHS and their long-term outcome from a tertiary referral center. Materials and Methods: The CHS was diagnosed on the basis of the criteria proposed by Chung et al. Cases with CSF rhinorrhoea or other CSF leak or head trauma were excluded from the study. Results: The study included eight consecutive cases of CHS diagnosed over the past 7 years from 2001. The mean age at diagnosis was 40.7 years (range, 34-56 years) and male-to-female ratio was 1:3. All patients presented with orthostatic headache of subacute onset and normal neurological examination. Magnetic resonance imaging studies of all patients showed hyperintensity of pachymeninges in T2W sequences, venous distension sign, and diffuse pachymeningeal gadolinium enhancement. The descent of the brainstem and subdural effusion were noted in two each (25%). CSF study (n = 5) showed low opening pressure in three (60%), and mild pleocytosis with elevated protein in two each (40%). The mean time to complete recovery with conservative treatment alone was 25.6 days. All radiological signs disappeared with clinical improvement in three patients where follow-up imaging was done. On mean follow-up period of 3.6 years, all were asymptomatic without any recurrence of CHS. Conclusion: CHS can resolve completely with conservative management and intervention with subdural blood patch or surgical repair would be required only if symptoms persist for more than 1 month.
  5 5,588 58
CASE REPORTS
Leukoencephalopathy with intracranial calcifications and cysts in an adult: Case report and review of literature
K Ummer, KA Salam, Mohan L Noone, VG Pradeep Kumar, Neena Mampilly, S Sivakumar
October-December 2010, 13(4):299-301
DOI:10.4103/0972-2327.74198  PMID:21264141
Leukoencephalopathy, intracranial calcifications, and cysts (LCC) is a very rare cerebral disorder, first described in 3 children in 1996. It has subsequently been reported in adults and children from Europe and America, but has not so far been reported from Asia. We report an adult patient with pathologically proven LCC from a tertiary care hospital in South India. He presented with features of ataxia and raised intracranial pressure. Magnetic resonance imaging of the brain showed multiple bilateral cerebral cystic lesions along with diffuse white matter lesions in the cerebral and cerebellar white matter, and computed tomography of brain showed multiple calcifications in the white matter and basal ganglia. A large right cerebellar cyst causing mass effect was surgically excised. Histopathologic features were consistent with earlier reports of LCC and showed Rosenthal fibers, angiomatous changes, and calcifications. Our report suggests that although it is rare, LCC has a global distribution.
  4 6,015 64
Hyperreflexic Guillain-Barré syndrome
Neeraj N Baheti, Davis Manuel, Pranav D Shinde, Ashalatha Radhakrishnan, Muraleedharan Nair
October-December 2010, 13(4):305-307
DOI:10.4103/0972-2327.74195  PMID:21264143
Guillain-Barré syndrome (GBS) is an acquired acute autoimmune polyradiculoneuropathy. The 2 features considered essential for the diagnosis of GBS are progressive motor weakness and areflexia. There have been several descriptions of reflex preservation and hyperreflexia in axonal variant of GBS in Chinese, Japanese, and European populations but it is not common in the Indian subcontinent. We report 2 such cases discussing the pathophysiology and management aspects. This case report is to impress upon treating physicians and neurologists in training that a hyperreflexic variant of GBS albeit rare, should not be missed in a given clinical setting.
  4 3,355 153
ORIGINAL ARTICLES
Clinical, electrophysiologic, and histopathologic profile, and outcome in idiopathic inflammatory myositis: An analysis of 68 cases
KN Ramesha, Abraham Kuruvilla, PS Sarma, VV Radhakrishnan
October-December 2010, 13(4):250-256
DOI:10.4103/0972-2327.74190  PMID:21264132
Objectives: To study the electroclinical and histopathologic profile of idiopathic inflammatory myositis (IIM) with reference to prognosis and survival rate. Materials and Methods: Diagnosis of IIM was based on the Bohan and Peter criteria. Patients who improved and those whose condition worsened or who expired due to IIM per se at last follow-up were classified to have favorable and poor outcomes, respectively. Fisher's exact test was used for univariate analysis of prognostic factors. Results: The study cohort consisted of consecutive 68 patients with IIM. The mean age at diagnosis was 36.5 years and females constituted 71%. Of these patients, 62% had definite IIM, 49% had polymyositis, 20% had dermatomyositis, and 29% had overlap syndrome. The mean follow-up period was 5.4 years. Prednisolone alone was used in 55 (80%), and azathioprine (1-3 mg/kg/day) alone in 12 (17.6%) as the initial treatment. Relapse of IIM with drug withdrawal was seen in 15 patients (22%); 70% had favorable outcome and 16% had expired. The treatment delay of ≤6 months (P = 0.001), absence of cardiac or lung involvement (P < 0.001), and positive biopsy (P = 0.033) were predictive of a favorable prognosis in the univariate analysis. In multivariate analysis, only the duration of illness of ≤6 months (P = 0.008) and the absence of cardiac or lung involvement (P = 0.001) predicted the favorable outcome at last follow-up. Cumulative survival rate was 95% at 1 year, 86% at the 5th year, and 80% at the 10th year. Conclusions: Approximately, two-thirds of the patients showed good electroclinical and histopathologic correlations and an equal number improved with treatment. The treatment delay (≥6 months), presence of cardiac or pulmonary involvements, and negative muscle biopsy are bad prognostic factors.
  4 3,083 116
ORATION
Presidential Oration: The 18 th Annual Conference of the Indian Academy of Neurology, Trichi, Tamil Nadu, September 24-26, 2010, Epilepsy Care in Developing Countries
Kurupath Radhakrishnan
October-December 2010, 13(4):236-240
DOI:10.4103/0972-2327.74184  PMID:21264129
Nearly 80% of the 50 million people with epilepsy worldwide reside in developing countries that are least equipped to tackle the enormous medical, social and economic challenges posed by epilepsy. These include widespread poverty, illiteracy, inefficient and unevenly distributed health care systems, and social stigma and misconceptions associated with epilepsy. Several studies have reported that a large proportion of patients with epilepsy in developing countries never receive appropriate treatment for their condition, and many, though diagnosed and initiated on treatment, soon discontinue treatment. Unaffordable cost of treatment, unavailability of antiepileptic drugs, and superstitious and cultural beliefs contribute to high epilepsy treatment gap in resource-poor countries. A significant proportion of the current burden of epilepsy in developing countries can be minimized by educating the public about the positive aspects of life with epilepsy and the primary and secondary physicians about current trends in the management of epilepsies, scaling up routine availability of low-cost antiepileptic drugs, and developing cost-effective epilepsy surgery programs.
  3 2,961 134
SHORT COMMUNICATIONS
Central nervous system inflammatory demyelinating disorders of childhood
Mahesh Kamate, Vivek Chetal, Venkatesh Tonape, Niranjana Mahantshetti, Virupaxi Hattiholi
October-December 2010, 13(4):289-292
DOI:10.4103/0972-2327.74204  PMID:21264138
Background and Objectives: Childhood Central Nervous System (CNS) inflammatory demyelinating disorders (CIDD) are being diagnosed more commonly now. There is ambiguity in the use of different terms in relation to CIDD. Recently, consensus definitions have been proposed so that there is uniformity in studies across the world. The prevalence of these disorders and the spectrum varies from place to place. This study was undertaken to study the clinico-radiological profile and outcome of children with CIDD using the recent consensus definition. Study design: Prospective descriptive study. Materials and Methods: All patients admitted in pediatric ward and pediatric intensive care with neurological symptoms and signs suggestive of CNS inflammatory demyelinating disorders from July 2007−August 2008 were enrolled. The details of clinical presentation, neuroimaging findings, laboratory results, treatment, and outcome were noted and analyzed. Results: Fifteen patients (11 with acute disseminated encephalomyelitis and 4 with clinically isolated syndrome) were diagnosed with CIDD. Clinical presentation was quite varied. Eight patients recovered completely; 4 cases were left with sequelae and 3 patients expired. There were no cases of multiple sclerosis or neuromyelitis optica. Conclusions: CNS inflammatory demyelinating disorders are common illnesses in developing countries because of recurrent infections. Even the spectrum of CIDD is different. Neuroimaging in the form of magnetic resonance imaging is essential for diagnosis.
  3 6,063 142
IMAGES IN NEUROLOGY
Spinal meningeal melanocytoma: A rare meningeal tumor
Vissa Shanthi, BA Ramakrishna, Vydehi Venkata Bheemaraju, Nandam Mohan Rao, Venkata Ramana Murthy Athota
October-December 2010, 13(4):308-310
DOI:10.4103/0972-2327.74192  PMID:21264144
  2 2,759 56
ORIGINAL ARTICLES
Role of vitamin B 12 , folate, and thyroid stimulating hormone in dementia: A hospital-based study in north Indian population
Rachna Agarwal, Neelam Chhillar, Suman Kushwaha, Neeraj Kumar Singh, Chandra Bhushan Tripathi
October-December 2010, 13(4):257-262
DOI:10.4103/0972-2327.74193  PMID:21264133
Background: Vitamin B 12 and folate represent modifiable risk factors for dementia. They may increase the risk of Alzheimer's dementia (AD) and vascular dementia (VaD) as their deficiency can increase the homocysteine level due to slowed methylation reaction. Homocysteine has a neurotoxic effect that could lead to neurologic disturbances. Hence, it is important to explore the status of serum B 12 and folate in AD and VaD to evolve the treatment strategies for the same. Objectives: A retrospective study was conducted to assess the levels of vitamin B 12 , folate, and thyroid stimulating hormone (TSH) in serum and the relationship of these factors, including age and sex to cognitive decline in VaD, AD, and dementia due to other causes (DOC). Materials and Methods: Serum vitamin B 12 , folate, TSH, and total cholesterol were studied in 32 AD patients (mean age: 65 years), 12 VaD patients (mean age: 61 years), 83 DOC (mean age: 65 years), and 127 control subjects (mean age: 49 years). Results: In AD, VaD, and DOC, the levels of vitamin B 12 and folate were significantly lower (P < 0.002; 0.026; 0.002 for vitamin B 12 and P < 0.000 in all the 3 groups for folate) as compared with the controls. Similarly, TSH levels were significantly lower in AD and DOC (P < 0.008; 0.038) as compared with the controls. Conclusion: Vitamin B 12 and folate were significantly low in both AD and VaD patients. Hence, B vitamin supplementation should be considered as possible targets for the therapeutic intervention in dementia.
  2 4,249 110
LETTER TO THE EDITOR
Beta-interferons in multiple sclerosis
Sourabh Aggarwal, Vishal Sharma, Jesna S Mathew
October-December 2010, 13(4):313-313
DOI:10.4103/0972-2327.74189  PMID:21264146
  1 1,619 55
ORIGINAL ARTICLES
Reliability and validity of Hindi translation of the migraine disability assessment and headache impact test-6 questionnaires
Ratish Juyal, Rajesh Verma, Ravindra Kumar Garg, Rakesh Shukla, Atul Agarwal, Maneesh Kumar Singh
October-December 2010, 13(4):276-283
DOI:10.4103/0972-2327.74201  PMID:21264136
Objective: The objective of the study was to assess the reliability and validity of the Hindi translation of the Migraine Disability Assessment (MIDAS) and Headache Impact Test-6 (HIT-6) questionnaires. Materials and Methods: The study was conducted on the migraine patients. For test-retest reliability, the respondents filled the MIDAS and HIT-6 questionnaires twice, at an interval of three weeks. For validity, the same population of patients filled the headache diary for three months. After three months they filled the MIDAS and HIT-6 questionnaires again. The patients were subgrouped according to their occupation and level of education. The test-retest reliability and validity were calculated by the Pearson correlation coefficient. Internal consistency was calculated using the Cronbach alpha. Results: A total of 236 migraine patients were screened. Seventy-nine patients fulfilled the inclusion criteria. A total of 69 patients completed the study. The HIT-6 questionnaire was applicable to all the subgroups of patients and had better comprehensibility than the MIDAS. Housewives missed out on the first two questions of the MIDAS and had lower mean MIDAS scores than HIT-6. The test-retest correlation coefficients for the total MIDAS and HIT-6 scores were 0.94 and 0.81, respectively. The correlation coefficients between the total score in the headache diary equivalent and the MIDAS and HIT-6 total score were 0.91 and 0.77, respectively. Cronbach alpha, a measure of internal consistency for the MIDAS questionnaire was > 0.90 at all the compilations. For the HIT-6 questionnaire, it ranged from 0.67 to 0.79. Conclusion: The Hindi versions of MIDAS and HIT-6 questionnaires were reliable and valid, but could not be interchanged. HIT-6 had better comprehensibility.
  1 6,130 99
CASE REPORTS
Accidental spinal cord injury during spinal anesthesia: A report
M Netravathi, AB Taly, S Sinha, PS Bindu, G Goel
October-December 2010, 13(4):297-298
DOI:10.4103/0972-2327.74200  PMID:21264140
  - 5,358 66
Fractional arm weakness as presentation of stroke due to posterior borderzone infarct: A report of two cases
Kaukab Maqbool Hassan
October-December 2010, 13(4):302-304
DOI:10.4103/0972-2327.74196  PMID:21264142
A 41-year-old male presented with acute onset weakness of the left hand. Magnetic resonance imaging (MRI) of the brain showed hyperacute infarct in the right middle cerebral artery (MCA)-posterior cerebral artery (PCA) watershed territory. Magnetic resonance angiography (MRA), Doppler ultrasonography, and digital subtraction angiography revealed severe right internal carotid artery (ICA) stenosis. The patient underwent carotid endarterectomy. The second patient was a 48-year-old male with acute onset right wrist drop. MRI of brain showed acute infarct in the left MCA-PCA watershed territory. MRA of brain and neck, Doppler ultrasonography of the neck vessels, and echocardiography were normal. Both the cases were not initially considered strokes by the referring physicians. Isolated hand palsy is a rare presentation of stroke, often mistaken for peripheral lesion. Fractional limb weakness as a presentation of acute ischemic stroke due to borderzone infarction involving parietal lobe is a rarely reported entity.
  - 5,503 44
EDITORIAL
Toward prevention of stroke
Sanjeev V Thomas
October-December 2010, 13(4):235-235
DOI:10.4103/0972-2327.74182  PMID:21264128
  - 1,929 94
IMAGES IN NEUROLOGY
Every non-obstructive hydrocephalus is not due to tuberculous basal meningitis
Deepak Goel, KK Bansal, Manish Mittal, Ranjeet
October-December 2010, 13(4):311-312
DOI:10.4103/0972-2327.74191  PMID:21264145
  - 1,769 53
LIGHTER MOMENTS
Locked-in between free will and the flying wings
Mahesh Pundlik Kate
October-December 2010, 13(4):307-307
  - 1,154 46
ORIGINAL ARTICLES
Use of intravenous immunoglobulin in the Department of Neurology at Ninewells Hospital, 2008-2009: Indications for utilization and cost-effectiveness
Jonathan O' Riordan, Robert J Swingler, Naveed M Malek
October-December 2010, 13(4):271-275
DOI:10.4103/0972-2327.74199  PMID:21264135
This study was designed to identify the indications for prescription of intravenous immunoglobulin (IVIg) in neurology and the cost effectiveness of this therapy. Objectives: IVIg is a relatively costly therapy and the annual budget spent on providing this therapy for various indications at Ninewells Hospital was close to £1.5 million. In today's economic times, a cost-benefit analysis of all therapies is prudent. This is of relevance to countries in the developing world as well where perhaps not everybody could afford such cost-intensive therapy. Materials and Methods: We audited 2 time periods over 12 months each in 2004-2005 and 2008-2009 to look at the patterns of utilization of IVIg over these periods. We searched the literature for alternative and cost-effective therapies for the most common indications for use of IVIg. Results: Fiscal costs on prescription of IVIg have rocketed up by almost 300% in this Neurology Department comparing data from 2004-2005 vs 2008-2009 and this is disproportionate to the increase in the annual admission rate (bed usage), partly because of the soaring costs of the drug available in the market and also because of the increased prescription of IVIg for numerous indications where clinical trials data are yet not so robust. Conclusion: We have looked at the cost of alternative therapies and offer some proposals that if implemented could potentially save £330,000 annually from the health budget at this NHS Trust. Perhaps similar models could evolve for better cost-effective utilization of IVIg in countries in the developing world where health budgeting is more acutely relevant.
  - 3,206 46
REVIEW: SYSTEMATIC REVIEW
Guidelines for epilepsy management in India classification of seizures and epilepsy syndromes
Sridharan Ramaratnam, P Satishchandra
October-December 2010, 13(4):247-249
DOI:10.4103/0972-2327.74187  PMID:21264131
This article is part of the Guidelines for Epilepsy management in India. This article reviews the classification systems used for epileptic seizures and epilepsy and present the recommendations based on current evidence. At present, epilepsy is classified according to seizure type and epilepsy syndrome using the universally accepted International League Against Epilepsy (ILAE) classification of epileptic seizures and epilepsy syndromes. A multi-axial classification system incorporating ictal phenomenology, seizure type, epilepsy syndrome, etiology and impairments is being developed by the ILAE task force. The need to consider age-related epilepsy syndromes is particularly important in children with epilepsy. The correct classification of seizure type and epilepsy syndrome helps the individual with epilepsy to receive appropriate investigations, treatment, and information about the likely prognosis.
  - 3,047 339
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