Annals of Indian Academy of Neurology
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   2013| July-September  | Volume 16 | Issue 3  
    Online since August 26, 2013

 
 
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ORIGINAL ARTICLES
Etiological spectrum of hypokalemic paralysis: A retrospective analysis of 29 patients
Ravindra Kumar Garg, Hardeep Singh Malhotra, Rajesh Verma, Pawan Sharma, Maneesh Kumar Singh
July-September 2013, 16(3):365-370
DOI:10.4103/0972-2327.116934  PMID:24101818
Background: Hypokalemic paralysis is characterized by episodes of acute muscle weakness associated with hypokalemia. In this study, we evaluated the possible etiological factors in patients of hypokalemic paralysis. Materials and Methods: We reviewed the records of 29 patients who were admitted with a diagnosis of hypokalemic paralysis. Modified Guillain-Barre΄ Syndrome disability scale was used to grade the disability. Results: In this study, 15 (51.7%) patients had secondary causes of hypokalemic paralysis and 14 patients (42.3%) had idiopathic hypokalemic paralysis. Thyrotoxicosis was present in six patients (20.6%), dengue infection in four patients (13.7%), distal renal tubular acidosis in three patients (10.3%), Gitelman syndrome in one patient (3.4%), and Conn's syndrome in one patient (3.4%). Preceding history of fever and rapid recovery was seen in dengue infection-induced hypokalemic paralysis. Approximately 62% patients had elevated serum creatinine phosphokinase. All patients had recovered completely following potassium supplementation. Patients with secondary causes were older in age, had significantly more disability, lower serum potassium levels, and took longer time to recover. Conclusion: In conclusion, more than half of patients had secondary causes responsible for hypokalemic paralysis. Dengue virus infection was the second leading cause of hypokalemic paralysis, after thyrotoxicosis. Presence of severe disability, severe hypokalemia, and a late disease onset suggested secondary hypokalemic paralysis.
  7 3,027 150
REVIEW: SYSTEMATIC (MILD COGNITIVE IMPAIRMENT IN ADULTS: A NEUROPSYCHOLOGICAL REVIEW)
Mild cognitive impairment in adult: A neuropsychological review
Ouyang Yanhong, Mina Chandra, D Venkatesh
July-September 2013, 16(3):310-318
DOI:10.4103/0972-2327.116907  PMID:24101808
Mild cognitive impairment (MCI) is associated with an increased risk of developing dementia. This is clinically relevant as overt dementia can be prevented if treatment strategies are devised for MCI. Neuropsychological deficits in this condition are very common and are important clinically for treatment and outcomes. We aimed to review various neuropsychological deficits in MCI. Further, we have presented the current evidence for nosological status, neuroanatomical basis, and clinical outcome of this heterogeneous construct. All published papers on the topic of neuropsychological deficits in MCI on Medline and other databases were reviewed. A wide range of memory and executive function deficits are common in MCI patients. However, several studies are limited by either improper designs or inadequate sample sizes. Several neuropsychological impairments like memory function and executive functions can be diagnosed in MCI. The evidence base for the exact neuroanatomical basis of MCI is not robust yet. However, given the wide range of outcomes, controversies and debates exist regarding the nosological significance of the deficits. Hence, more studies are needed to specifically localise the impairments and further delineate the construct of MCI.
  5 3,245 141
SHORT COMMUNICATION
Evaluation of the motor cortical excitability changes after ischemic stroke
DK Prashantha, SJ Sriranjini, TN Sathyaprabha, D Nagaraja, Pramod Kr Pal
July-September 2013, 16(3):394-397
DOI:10.4103/0972-2327.116955  PMID:24101824
Background: We evaluated progressive changes in excitability of motor cortex following ischemic stroke using Transcranial Magnetic Stimulation (TMS). Materials and Methods: Thirty-one patients (24 men, 7 women; age 37.3 ± 8.2 years) were recruited and TMS was performed using Magstim 200 stimulator and a figure-of-eight coil. Resting motor threshold (RMT) was recorded from affected and unaffected hemispheres and motor evoked potential (MEP) was recorded from contralateral FDI muscle. Central motor conduction time (CMCT) was calculated using F wave method. All measurements were done at baseline (2 nd ), 4 th , and 6 th week of stroke. Results: Affected hemisphere: MEP was recordable in 3 patients at baseline (all had prolonged CMCT). At 4 weeks, MEP was recordable in one additional patient and CMCT remained prolonged. At 6 weeks, CMCT normalized in one patient. RMT was recordable (increased) in 3 patients at baseline, in one additional patient at 4 weeks, and reduced marginally in these patients at 6 weeks. Unaffected hemisphere: MEP was recordable in all patients at baseline, and reduced significantly over time (2 nd week 43.52 ± 9.60, 4 th week 38.84 ± 7.83, and 6 th week 36.85 ± 7.27; P < 0.001). The CMCT was normal and remained unchanged over time. Conclusion: The increase in excitability of the unaffected motor cortex suggests plasticity in the post-stroke phase.
  4 1,417 42
ORIGINAL ARTICLES
Heart rate and blood pressure variability in patients with myasthenia gravis
Chikkulikere Sivan Puneeth, Sadanandavalli Retanaswami Chandra, Ravi Yadav, Talakad Narasappa Sathyaprabha, Sajish Chandran
July-September 2013, 16(3):329-332
DOI:10.4103/0972-2327.116912  PMID:24101810
This cross-sectional case control study included subjects aged between 18 and 65 years with diagnosis of myasthenia gravis (MG) in Osserman's Stage I and Stage IIa and those in remission with positive and negative acetylcholine receptor antibody (AChRAb). They were evaluated for heart rate variability (HRV) and other conventional autonomic functions. Patients with co-morbidities that can affect autonomic nervous system were excluded. Repetitive nerve stimulation test (RNST), nerve conduction test, AChRAb assay, and computerized tomography (CT) of chest were done in all the patients. All patients of MG who fulfilled the inclusion criteria had a minimum drug-free period of 6 h which was followed by HRV and other conventional tests. Thirty subjects fulfilling study criteria and an equal number of age and gender-matched healthy subjects were enrolled as controls. Autonomic function tests revealed significant changes in HRV (both time and frequency domain) parameters suggestive of parasympathetic deficiency as well as shifting of sympathovagal balance towards raised sympathetic tone. With regards to conventional autonomic function tests, there was statistically significant decrease in values of heart rate-based tests as well as blood pressure-based test (isometric handgrip test) in study group compared with controls, again indicative of significant parasympathetic deficiency and minimal sympathetic deficiency. We conclude that in MG, cholinergic transmission is affected more diffusely than previously thought.
  3 1,945 77
CASE REPORTS
Methotrexate induced leucoencephalopathy: A stroke mimic
Tushar D Gosavi, Mohammed Tauqeer Ahmad, Lai-Heng Lee, Shih-Hui Lim
July-September 2013, 16(3):418-421
DOI:10.4103/0972-2327.116922  PMID:24101834
With increasing usage of thrombolysis in the treatment of acute ischemic strokes within 4.5- hour window, it is becoming more important to recognize stroke mimics. Though the incidence of stroke mimics being thrombolysed is less than 3%, it is essential to diagnose them so as to avoid wrong thrombolytic treatment which carries potential complications of bleeding. We describe the case of a 17 year old girl with acute lymphoblastic leukemia, who developed stroke like episodes on two consecutive challenges with a chemotherapeutic regime which included intravenous and intrathecal methotrexate. She had MRI changes consistent with acute ischemic stroke on both occasions. Her deficits recovered completely and spontaneously, as did the MRI changes. She did not have any further episodes when methotrexate was excluded from the chemotherapeutic regime.
  2 2,407 44
A Turkish family with Sjögren-Larsson syndrome caused by a novel ALDH3A2 mutation
Faruk Incecik, Ozlem M Herguner, Wiliam B Rizzo, Sakir Altunbasak
July-September 2013, 16(3):425-427
DOI:10.4103/0972-2327.116927  PMID:24101836
Sjögren-Larsson syndrome (SLS) is an inherited neurocutaneous disorder caused by mutations in the aldehyde dehydrogenase family 3 member A2 (ALDH3A2) gene that encodes fatty aldehyde dehydrogenase. Affected patients display ichthyosis, mental retardation, and spastic diplegia. More than 70 mutations in ALDH3A2 have been discovered in SLS patients. We diagnosed two brothers age of 12 and 20 years with characteristic features of this rare syndrome. Magnetic resonance imaging showed demyelinating disease in both of them. We described a novel homozygous, c. 835 T > A (p.Y279N) mutation in exon 6 in two patients.
  2 1,804 35
IMAGES IN NEUROLOGY
Giant racemose neurocysticercosis with mass effect: Unusual presentation
Suresh Kumar, Shruti Thakur, Anupam Jhobta, RG Sood
July-September 2013, 16(3):398-399
DOI:10.4103/0972-2327.116957  PMID:24101825
  2 2,691 85
ORIGINAL ARTICLES
Effects of oral motor therapy in children with cerebral palsy
Seray Nural Sigan, Tugçe Aksu Uzunhan, Nur Aydinli, Emine Eraslan, Baris Ekici, Mine Çaliskan
July-September 2013, 16(3):342-346
DOI:10.4103/0972-2327.116923  PMID:24101813
Aim: Oral motor dysfunction is a common issue in children with cerebral palsy (CP). Drooling, difficulties with sucking, swallowing, and chewing are some of the problems often seen. In this study, we aimed to research the effect of oral motor therapy on pediatric CP patients with feeding problems. Materials and Methods: Included in this single centered, randomized, prospective study were 81 children aged 12-42 months who had been diagnosed with CP, had oral motor dysfunction and were observed at the Pediatric Neurology outpatient clinic of the Children's Health and Diseases Department, Istanbul Medical Faculty, Istanbul University. Patients were randomized into two groups: The training group and the control group. One patient from the training group dropped out of the study because of not participating regularly. Following initial evaluation of all patients by a blinded physiotherapist and pedagogue, patients in the training group participated in 1 h oral motor training sessions with a different physiotherapist once a week for 6 months. All patients kept on routine physiotherapy by their own physiotherapists. Oral motor assessment form, functional feeding assessment (FFA) subscale of the multidisciplinary feeding profile (MFP) and the Bayley scales of infant development (BSID-II) were used to evaluate oral motor function, swallowing, chewing, the gag reflex, the asymmetrical tonic neck reflex, tongue, jaw, and mouth function, severity of drooling, aspiration, choking, independent feeding and tolerated food texture during the initial examination and 6 months later. Results: When the initial and post-therapy FFA and BSID-II scores received by patients in the training and the study group were compared, the training group showed a statistically significant improvement (P < 0.05). Conclusion: Oral motor therapy has a beneficial effect on feeding problems in children with CP.
  2 4,241 102
REVIEW: PROGRESS IN MEDICINE
A literature review of AD7c-ntp as a biomarker for Alzheimer's disease
Jian Zhang, Shengliang Shi
July-September 2013, 16(3):307-309
DOI:10.4103/0972-2327.116902  PMID:24101807
The cornerstone of diagnosis of Alzheimer's disease (AD) is still the clinical criteria for probable and possible AD established by the NINCDS-ADRDA Work Group in 1984, which had survived for over 27 years. However, with the increase in people's knowledge of clinical manifestations and biology of AD, this standard is gradually proving to be insufficient; the early diagnosis of AD is thus particularly important. Therefore, in 2011, the National Institute on Aging and the Alzheimer's Association revised the criteria and integrated biomarker evidence into it. Biomarker evidence is expected to enhance the pathophysiological specificity of the diagnosis of AD. According to Consensus Report of the Working Group on Molecular and Biochemical Markers of Alzheimer's Disease, a qualified biomarker for AD should have the following abilities: It should detect a fundamental feature of neuropathology and be validated in neuropathologically confirmed cases, reliably with an sensitivity >80% for detecting AD and a specificity >80% for distinguishing other dementias; be reproducible and non-invasive; and be simple to perform and inexpensive. Alzheimer-associated neuronal thread protein (AD7c-NTP) is a member of "neuronal thread proteins" (NTPs); it can be detected in increased concentration in cortical neurons, brain-tissue extracts, cerebrospinal fluid, and urine in the early course of AD neurodegeneration, and it level is proportional to the degree of dementia, which makes it a promising biomarker for AD. In this review, we have evaluated the feasibility of developing AD7c-NTP as a biomarker for AD.
  2 2,284 56
CASE REPORTS
Congestive myelopathy (Foix-Alajouanine Syndrome) due to intradural arteriovenous fistula of the filum terminale fed by anterior spinal artery: Case report and review of literature
Prasad Krishnan, Tapas Kumar Banerjee, Manash Saha
July-September 2013, 16(3):432-436
DOI:10.4103/0972-2327.116931  PMID:24101838
Spinal arteriovenous fistulas are rare entities. They often present with congestive myelopathy but are infrequently diagnosed as the cause of the patients' symptoms. Only one such case has been described previously in Indian literature. We describe one such case who presented to us after a gap of 3 years since symptom onset and following a failed laminectomy where the cause was later diagnosed to be an intradural fistula in the filum terminale fed by the anterior spinal artery and review the available literature.
  1 2,109 64
Chronic meningitis with multiple cranial neuropathies: A rare initial presentation of Wegener's granulomatosis
Vikas Gupta, Anjani Kumar Sharma, Rajendra Kumar Sureka, Sushant Kumar Bhuyan, Prashant Kumar Singh
July-September 2013, 16(3):411-413
DOI:10.4103/0972-2327.116920  PMID:24101832
Wegener's granulomatosis (WG) is a systemic necrotizing vasculitis that affects the small blood vessels. It mainly affects the upper and lower respiratory tract and kidneys. Central nervous system (CNS) involvement is rare, and has been reported only in about 8% of cases during the course of illness. Initial presentation with neurologic affection, particularly chronic hypertrophic meningitis is very unusual. We report the case of a 34 year old male who presented with chronic hypertrophic meningitis and multiple cranial nerve involvement as the initial manifestation, without respiratory and renal symptoms. This case highlights the difficulties in diagnosing a rare disease with rarer presentation, and at the same time illustrates that Wegener's granulomatosis should be considered in the differential diagnosis of chronic meningitis.
  1 1,693 58
Spinal coning after lumbar puncture in a patient with undiagnosed giant cervical neurofibroma
Prasad Krishnan, Siddhartha Roychowdhury
July-September 2013, 16(3):440-442
DOI:10.4103/0972-2327.116935  PMID:24101840
Lumbar puncture in the presence of an intracranial tumor with raised intracranial pressure is known to have catastrophic consequences due to herniation of intracranial contents through the tentorial hiatus or foramen magnum. There are relatively few case reports about the same sequence of events when lumbar puncture is performed below the level of a complete spinal block. The mechanism of such deterioration is also subject to conjecture as the spinal cord (unlike the uncus or cerebellar tonsils) is tethered by the dentate ligament and roots on either side, and is hence less mobile. We present one such case of spinal coning and review the available literature.
  1 2,333 37
IMAGES IN NEUROLOGY
Bilateral hypertrophic olivary degeneration
Sameer Vyas, Anuj Prabhakar, Ajay Kumar, Niranjan Khandelwal
July-September 2013, 16(3):404-405
DOI:10.4103/0972-2327.116971  PMID:24101828
  1 1,293 52
LETTERS TO THE EDITOR
Migraine and restless leg syndrome co-morbidity may be due to iron deficiency
Mehmet Yücel, Hakan Akgün, Oguzhan Öz, Seref Demirkaya
July-September 2013, 16(3):461-461
DOI:10.4103/0972-2327.116956  PMID:24101854
  1 520 33
Comment on "Pathophysiology of migraine" by professor PJ Goadsby in August 2012 edition of Ann Indian Acad Neurol
Elliot Shevel
July-September 2013, 16(3):455-456
DOI:10.4103/0972-2327.116946  PMID:24101848
  1 1,046 28
ORIGINAL ARTICLES
Clinico - diagnostic and therapeutic relevance of computed tomography scan of brain in children with partial seizures
Nehal H Patel, Ashish R Jain, Vivek K Iyer, Anand G Shah, Dipti A Jain, Anjanaben A Shah
July-September 2013, 16(3):352-356
DOI:10.4103/0972-2327.116928  PMID:24101815
Background: Therapeutic relevance of computed tomography (CT) in children with partial seizures is reported to be remarkably low (1-2%). However, in the developing countries where infections involving the nervous system are common, routine CT scan of brain may help in finding treatable causes of seizures. Objective: Aim of this study was to evaluate the significance of CT scan of brain in the management of children with partial seizures. Materials and Methods: Children with partial epilepsy, whose predominant seizure type was focal motor seizures, were included in the study. CT scan of brain was done in all children aged between 1 month and 12 years with partial seizures of unknown etiology prospectively. The clinical findings of these children were noted along with the CT findings. Results: Between August 2001 and July 2002, of the 200 children with seizure disorder 50 children who satisfied the inclusion criteria were included in the study. CT scan of brain was normal in 16 children (32%) and was abnormal in 34 children (68%). Twenty children (~60% of abnormal scan) had potentially correctable lesions: Tuberculoma ( n = 13), neurocysticercosis ( n = 3), and brain abscess ( n = 4). Five children had changes representing static pathology that did not influence patient management. The clinical features correlated with CT findings in 78% children. Conclusion: Children with partial motor seizures have high probability of having abnormal findings on CT scan of brain, especially, neuro-infections which are potentially treatable. Therefore, CT scan brain should be carried out in all children with partial motor seizures especially, in developing countries.
  1 1,592 72
Neuromyelitis optica-IgG testing in an Indian cohort with neuromyelitis optica and related demyelinating disorders: Our experience
Narayanan Unni, Kavita Barhate, Nisha Ahmad, Malti Ganeshan, Bhim Singhal
July-September 2013, 16(3):376-379
DOI:10.4103/0972-2327.116945  PMID:24101820
Background: Neuromyelitis optica (NMO) is an immune-mediated inflammatory demyelinating disorder of the central nervous system with a predilection for the optic nerves and the spinal cord. Immunopathological evidence suggests that the target antigen of the disease is aquaporin-4. An IgG antibody against this protein has been explored as a molecular marker for the disease and as a diagnostic tool due to its high sensitivity and specificity in various populations. Objective: To assess the value of NMO-IgG testing in Indian patients with clinical and magnetic resonance imaging features consistent with NMO and longitudinally extensive transverse myelitis (LETM). Materials and Methods: Forty-five patients with clinical and magnetic resonance imaging features consistent with NMO, LETM, and MS were tested for serum NMO-IgG. Of these patients, 22 patients satisfied revised (2006) Wingerchuk criteria for NMO (excluding NMO-IgG status) and 11 patients had LETM. Twelve patients satisfied the revised (2010) McDonald criteria for multiple sclerosis (MS). Results: Of the 21 patients, satisfying the criteria for NMO and for whom the test results were available, 17 were positive for NMO-IgG (80.9%), and of the 11 patients having LETM, 6 (54.5%) were positive for NMO-IgG. In one patient with NMO, the test result was not available. None of the 12 patients satisfying McDonald criteria for MS showed NMO-IgG seropositivity. Conclusion: Our study suggests that it is worthwhile to pursue NMO-IgG testing as a diagnostic tool for patients with clinical and Magnetic Resonance Imaging (MRI) features consistent with NMO and LETM in the Indian population.
  1 1,407 108
REVIEW: MANAGEMENT UPDATES (REVIEWS ON ADVANCES IN TREATMENT)
Outcomes of neuropsychological interventions of stroke
Xiao-Di Xu, Hong-Yan Ren, Ravi Prakash, Vijayadas , Rajesh Kumar
July-September 2013, 16(3):319-328
DOI:10.4103/0972-2327.116909  PMID:24101809
The reported prevalence of cognitive deficits within the first month of stroke ranges widely from 10% to 82%, depending primarily on the criteria used to define cognitive impairment and on the selected patient population. These cognitive defects progress toward impairment over a course of time if left untreated. Among the most common cognitive deficits are the attentional, the visuoperceptual, the memory and executive function deficits. As these impairments are being increasingly recognized in the scientific communities, more and more studies are being devoted to the outcomes of various therapies for these disorders. In this review, we focus on the outcomes of various therapies for these cognitive disorders over time. We reviewed all the possible medical databases using key words for individual cognitive deficit treatment outcomes. All the possible studies including randomized controlled trials, pre-post design studies, case series and single case reports were included in this study. On the basis of present literature review, we conclude that the evidence is definitively positive only for outcomes of attentional and visuoperceptive skill deficits. On the other hand, there have been very few studies to conclude for effectiveness of various therapies for memory and executive function outcomes.
  1 2,946 92
BOOK REVIEW
The Tell-Tale Brain: Unlocking the mystery of human nature
PN Tandon
July-September 2013, 16(3):450-451
  - 975 37
CASE REPORTS
Spectroscopic correlation and role of Azathioprine in long-term remission in patients of Hashimoto encephalopathy
Harpreet Singh, Sucharita Ray, Shalini Agarwal, Raj Pal Verma, Paulomi Talapatra, Vikas Gupta
July-September 2013, 16(3):443-446
DOI:10.4103/0972-2327.116936  PMID:24101841
Hashimoto encephalopathy remains a Rubik's cube for the present generation of clinical research. Myriad presentations have been noted, and observations recorded in few subgroups of patients have gone on only to be trashed by a second group of patients with a completely different clinical profile. Steroids have been traditionally held to be the treatment for this condition, but long-term side effects associated with it limits its use. Although multiple drugs have been tried, yet there exists no data for their long-term efficacy in maintaining remission. No radiological findings have been consistently associated with this condition. We report the use of azathioprine in maintaining long-term remission in one such patient with Hashimoto encephalopathy and the presence of lactate peak in magnetic resonance spectroscopy of the patient, which showed dramatic regression with institution of immunosuppression.
  - 1,695 64
Adductor laryngeal breathing dystonia in NBIA treated with botulinum toxin-A
Vinod Rai, Vinay Goyal, Garima Shukla, Girija Rath, Madhuri Behari
July-September 2013, 16(3):409-410
DOI:10.4103/0972-2327.116919  PMID:24101831
We report a rare case of neurodegeneration with brain iron accumulation (NBIA) presented with episodic inspiratory stridor. A 10-year-old boy presented with 3-year history of gradually progressive spastic gait and generalized dystonia (involving all four limbs, neck, jaw, and speech). MRI brain showed "Eye of Tiger" sign. He recently developed severe inspiratory stridor associated with almost gasping respiration. Direct video laryngoscopy showed paradoxical vocal cord closure during inspiration. He was treated with EMG-guided botulinum toxin-A injection given into bilateral thyroarytenoid muscles, resulting in dramatic response with complete disappearance of the stridor within a week. The effect lasted 18 months.
  - 1,702 50
Perineural spread of rhino-orbitocerebral mucormycosis caused by Apophysomyces elegans
Kirti Parsi, Raghavendra K Itgampalli, R Vittal, Anjani Kumar
July-September 2013, 16(3):414-417
DOI:10.4103/0972-2327.116921  PMID:24101833
Rhino-orbitocerebral mucormycosis (ROCM) is a fungal infection commonly affecting individuals with diabetes and those in immunocompromised states. However, infections caused by Apophysomyces elegans can involve immunocompetent individuals. The invasion pattern of cerebral mucormycosis is somewhat predictable and may occur by direct invasion or hematogenous spread. Perineural spread of the disease is unusual. Here, we report the first case of perineural extension of ROCM caused by A. elegans along the trigeminal nerve in a 25-year-old immunocompetent, nondiabetic individual.
  - 1,524 40
Spontaneous evolution of an unusual cortical malformation in SOX2 anophthalmia syndrome
Jay Desai, Tena Rosser
July-September 2013, 16(3):422-424
DOI:10.4103/0972-2327.116924  PMID:24101835
Brain malformations such as agenesis and dysgenesis of corpus callosum, pituitary hypoplasia, hypothalamic hamartoma, mesial temporal periventricular heterotopia, and abnormally oriented and misshapen hippocampi have been described with SOX2 gene mutations. A neocortical malformation is presented here in association with SOX2 deletion that over time underwent spontaneous evolution and decrease in size.
  - 1,520 29
Neoplastic Parkinsonism: An illustrative case report
Lekha Pandit, Ananthan Raghotham, Yasha Chickabasaviah, Ganesh Khandige, Rohan Kumar Shetty
July-September 2013, 16(3):437-439
DOI:10.4103/0972-2327.116933  PMID:24101839
Non-Hodgkin's lymphoma of T-cell types are rare neoplasms. Central nervous system metastasis is unusual. We are reporting a patient with peripheral T-cell lymphoma unspecified who had extra nodal metastasis into the brain that manifested with extrapyramidal dysfunction. The clinical presentation was exceptional in that the course was indolent and patient had no overt extra neural manifestations of malignancy for nearly 3 years after the onset of Parkinsonism. Striking brain imaging late in the disease supported by pathological findings enabled the diagnosis of this rare condition.
  - 1,670 50
A case of crossed aphasia with apraxia of speech
Yogesh Patidar, Meena Gupta, Geeta A Khwaja, Debashish Chowdhury, Amit Batra, Abhijit Dasgupta
July-September 2013, 16(3):428-431
DOI:10.4103/0972-2327.116929  PMID:24101837
Apraxia of speech (AOS) is a rare, but well-defined motor speech disorder. It is characterized by irregular articulatory errors, attempts of self-correction and persistent prosodic abnormalities. Similar to aphasia, AOS is also localized to the dominant cerebral hemisphere. We report a case of Crossed Aphasia with AOS in a 48-year-old right-handed man due to an ischemic infarct in right cerebral hemisphere.
  - 2,268 79
CLINICAL SIGN
Striatal toe
Sudhir Kumar, Chenna Rajesh Reddy, Subhashini Prabhakar
July-September 2013, 16(3):304-305
DOI:10.4103/0972-2327.116898  PMID:24101805
We report a case of striatal toe in an adolescent with an infarct in lentiform nucleus and briefly discuss its differential diagnoses.
  - 2,690 181
EDITORIAL
Neuropsychological aspects of clinical neurology: A glimpse of two universes in brain
Ravi Prakash
July-September 2013, 16(3):306-306
DOI:10.4103/0972-2327.116899  PMID:24101806
  - 1,097 71
IMAGES IN NEUROLOGY
Hot cross bun sign in a patient with cerebellar ataxia
Inuka Kishara Gooneratne, Manjula Chandragomi Caldera, Sujith Priyankara Perera, Ranjanie Gamage
July-September 2013, 16(3):406-406
DOI:10.4103/0972-2327.116973  PMID:24101829
  - 1,046 56
Myopathy with normal creatinine phosphokinase in a young man
Inuka Kishara Gooneratne, Manjula Chandragomi Caldera, Ranjanie Gamage, Shirani Samarathunga, Janakie Fernando
July-September 2013, 16(3):407-408
DOI:10.4103/0972-2327.116974  PMID:24101830
  - 1,088 35
Intractable nausea and vomiting as presenting manifestation of neuromyelitis optica
Sujit A Jagtap, Pournamy Sarathchandran, Harsha J Kambale, Muralidharan D Nair, C Sarada
July-September 2013, 16(3):400-401
DOI:10.4103/0972-2327.116958  PMID:24101826
  - 2,282 65
Aortic saddle embolism and paraplegia due to a large left ventricular thrombus
Boby Varkey Maramattom, Sudheer Ramattu Yousef, George Joseph
July-September 2013, 16(3):402-403
DOI:10.4103/0972-2327.116960  PMID:24101827
  - 953 24
LETTERS TO THE EDITOR
Serum iron may not be linked with migraine
Ravi Gupta, Vivekananda Lahan, Deepak Goel
July-September 2013, 16(3):462-462
DOI:10.4103/0972-2327.116959  PMID:24101855
  - 841 26
Efficacy of yoga in treatment of migraine
Arvind Kankane
July-September 2013, 16(3):462-463
DOI:10.4103/0972-2327.116961  PMID:24101856
  - 1,207 52
Symptomatic trigeminal neuralgia as the first presentation of acute lymphoblastic leukemia
Tamojit Chaudhuri, Dodul Mondal, Kamlesh Yadava
July-September 2013, 16(3):463-464
DOI:10.4103/0972-2327.116962  PMID:24101857
  - 1,507 46
A comment on idiopathic generalized epilepsy: Phenotypic and electroencephalographic observations in a large cohort from South India
Sunil K Raina
July-September 2013, 16(3):452-452
DOI:10.4103/0972-2327.116940  PMID:24101843
  - 752 39
Reversible dementia as presenting manifestation of racemose neurocysticercosis
Rajendra Singh Jain, Kadam Nagpal, Rahul Handa
July-September 2013, 16(3):452-453
DOI:10.4103/0972-2327.116941  PMID:24101844
  - 807 35
Opinions about the use of the recognition of stroke in the emergency room scale
Wu Zhixin, He Mingfeng
July-September 2013, 16(3):453-454
DOI:10.4103/0972-2327.116942  PMID:24101845
  - 717 3
Cerebrovascular ultrasonography: Quality control
Beuy Joob, Viroj Wiwanitkit
July-September 2013, 16(3):454-454
DOI:10.4103/0972-2327.116943  PMID:24101846
  - 713 24
A comment on sleep assessment of children with cerebral palsy: Using validated sleep questionnaire
Sunil K Raina
July-September 2013, 16(3):455-455
DOI:10.4103/0972-2327.116944  PMID:24101847
  - 842 26
Author's reply on Pathophysiology of migraine
Peter J Goadsby
July-September 2013, 16(3):456-457
PMID:24101849
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Plexitis or radiculitis secondary to bee sting
Hakan Akgün, Mehmet Yücel, Oguzhan Öz, Seref Demirkaya
July-September 2013, 16(3):457-457
DOI:10.4103/0972-2327.116948  PMID:24101850
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"Sleep in Wilson's disease: Questionnaire based study" - Comments on the article
Vikas Menon, KT Harichandrakumar
July-September 2013, 16(3):458-458
DOI:10.4103/0972-2327.116949  PMID:24101851
  - 1,262 35
Authors' reply
Archana B Netto, Sanjib Sinha, Arun B Taly, Samhita Panda, Shivaji Rao
July-September 2013, 16(3):459-460
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Improved sensitivity of Kernig's and Brudzinski's sign in diagnosing meningitis in children
Thirunavukkarasu Arun Babu
July-September 2013, 16(3):460-461
DOI:10.4103/0972-2327.116954  PMID:24101853
  - 1,259 33
ORIGINAL ARTICLES
Early language development in Indian children: A population-based pilot study
Manjit Sidhu, Prahbhjot Malhi, Jagat Jerath
July-September 2013, 16(3):371-375
DOI:10.4103/0972-2327.116937  PMID:24101819
Objectives: To study the prevalence of language delay and to examine its socio-economic correlates in children less than 3 years. Materials and Methods: Participants were 130 children (males = 56%) aged 12-35 months (mean age = 1.81 years, SD = 0.58), from an urban center in north India. The language quotient (LQ) of the child was measured by the Clinical Linguistic Auditory Milestone Scale (CLAMS). Children with an LQ score of less than 70 were considered language delayed. Results: Overall, 6.2% of the children were language delayed with a higher prevalence found for girls (7%) than for boys (5.5%), although the difference was not statistically significant. Several significant correlations between socio-economic and demographic variables and the LQ of the child were found. Stepwise multiple regression analysis revealed that 31.4% of the variance in the LQ scores of girls was accounted for by income ( F = 23.80, P = 0.000) and 18.1% of the variance in the LQ scores of boys was accounted for by education of the mother and income ( F = 15.67, P = 0.000). Conclusions: Developmental problems in early years are often precursors of problems in later life and early intervention can facilitate favorable outcomes among children with multiple risks. The high prevalence of language difficulties in young children underscores the need to target language delay in early years, to reduce the likelihood of adverse outcomes and thus optimize chances of improvement.
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A cross-sectional study on thyroid status in North Indian elderly outpatients with dementia
Rachna Agarwal, Suman Kushwaha, Neelam Chhillar, Alok Kumar, Dharmendra Kumar Dubey, Chandra Bhushan Tripathi
July-September 2013, 16(3):333-337
DOI:10.4103/0972-2327.116916  PMID:24101811
Background: Several population based studies have demonstrated an association between hypo-or hyperthyroidism and dementia in last two decades. As a consequence, thyroid stimulating hormone has become part of the screening laboratory test for dementia. Aim: The aim of the present study was to evaluate the association between thyroid function and Alzheimer's disease (AD) and vascular dementia (VaD) and to determine the risk of AD and VaD in clinically euthyroid patients. Materials and Methods: A cross-sectional hospital based study was carried out in subjects diagnosed with AD/VaD and were assessed for thyroid status as routine screening test. Results: Free T3, free T4 and TSH were studied in 114 AD patients (mean age: 65 years), 35 VaD patients (mean age: 62 years) and 105 control subjects (mean age: 62 years). In AD group, TSH levels were significantly lower than controls (P = 0.00) and for each unit increase in TSH level, the odds of having dementia decreased by 37.1%. No such relation was seen in VaD. Conclusion: The results suggest a consistent association of subclinical hyperthyroidism and AD.
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Congenital myasthenic syndromes: Natural history and long-term prognosis
Sujit Abajirao Jagtap, Kuruvilla Abraham, C Sarada, MD Nair
July-September 2013, 16(3):338-341
DOI:10.4103/0972-2327.116918  PMID:24101812
Introduction: Congenital myasthenia syndrome (CMS) is a rare, heterogeneous group of genetically determined, disorder of neuromuscular transmission. They have a varied presentation and progression and very few studies have addressed the natural history. Aim of the present study is to describe the clinical profile and natural history of patients with CMS. Materials and Methods: Study includes patients with CMS who attended comprehensive-neuromuscular-clinic (CNMC) during the period January, 2000-2008 with a minimum follow-up of 2 years, with inclusion criteria: (1) Onset in infancy or childhood with fluctuating ocular, bulbar, respiratory or limb muscle weakness (2) Acetylcholine receptor antibody negative (3) normal computed tomography (CT) thymus (4) Abnormal repetitive nerve stimulation (RNS) testing (5) Exclusion of other autoimmune disorders. Results: Out of 314 patients with myasthenia who attended the CNMC during study period, 15 (4.8%) were with CMS (8 boys, 7 girls). Patients were divided as infantile and childhood onset. The mean age of onset and diagnosis in infantile and childhood onset groups were 5.5 months/3.1 years and 3.6 years/6.5 years respectively. Eleven patients had ptosis and 4 had generalized presentation. Most common site of decremental response was over facial nerve in 12 (75%) patients. All patients showed good response to treatment with acetyl cholinesterase inhibitor with stable course on follow-up without exacerbations. Mean dose for neostigmine was 28 mg/day and for pyridostigmine was 153 mg/day. Conclusion: Ptosis is most common symptom at onset in CMS, emphasing importance of RNS of the facial nerve, in the absence of molecular diagnosis of CMS. Our CMS cohort had relatively stable course without intermittent exacerbations with fair response to acetyl cholinesterase inhibitor.
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Association of intercellular adhesion molecular-1 gene polymorphism in ischemic stroke patients
Ching-Hsiang Lu, Chiao-Wen Hwang, Nan-Fu Chen, Wen-Sheng Liu, Wen-Tung Wu
July-September 2013, 16(3):380-383
DOI:10.4103/0972-2327.116950  PMID:24101821
Background: Ischemic stroke (IS) is a prevalent disease causing a body disability, the third leading cause of death in Taiwan. It shows that the level of intercellular adhesion molecular-1 (ICAM-1) in IS patients is higher than control subjects. Objective: This study is to investigate the possible association of ICAM-1 (G1548A) polymorphism in IS patients. Materials and Methods: A total of 646 subjects were enrolled in this study, including 312 IS patients, and 334 controls without a history of symptomatic IS. The ICAM-1 (G1548A) polymorphism was analyzed by polymerase chain reaction and restriction fragment length polymorphism. Clinical factors were also determined. Results: The frequencies of the ICAM-1 (G1548A) polymorphism for G/G, G/A, and A/A were 74.8%, 23.9%, and 0.3%, respectively, in healthy controls, and 62.8%, 32.1%, and 5.1%, respectively, in patients. The frequency of the ICAM-1 (G1548A) A allele (21.2% versus 13.2%, respectively; P = 0.007) and the carriers of the ICAM-1 (G1548A) A allele (37.2% versus 25.2%; P = 0.019, OR 1.76, 95% CI 1.1-2.83) are great in IS patients compared with healthy controls. There is a higher risk of IS associated with homozygosity for the ICAM-1 (G1548A) A allele (AA genotype) compared with the control population (5.1% vs. 0.3%, respectively, P = 0.04; OR 5.1, 95% CI 1.19-21.66). We also observed both hypertension and diabetes has shown a positive association with IS. Conclusions: The ICAM-1 (G1548A) polymorphism was associated with independent risk factor for the development of IS.
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Usefulness of medial temporal lobe atrophy visual rating scale in detecting Alzheimer's disease: Preliminary study
Jae-Hyeok Heo, Min-Ky Kim, Jun-Hyung Lee, Jeong-Heon Lee
July-September 2013, 16(3):384-387
DOI:10.4103/0972-2327.116951  PMID:24101822
Background: The Korean version of Mini-Mental Status Examination (K-MMSE) and the Korean version of Addenbrooke Cognitive Examination (K-ACE) have been validated as quick neuropsychological tests for screening dementia in various clinical settings. Medial temporal atrophy (MTA) is an early pathological characteristic of Alzheimer's disease (AD). We aimed to assess the diagnostic validity of the fusion of the neuropsychological test and visual rating scale (VRS) of MTA in AD. Materials and Methods: A total of fifty subjects (25 AD, 25 controls) were included. The neuropsychological tests used were the K-MMSE and the K-ACE. T1 axial imaging visual rating scale (VRS) was applied for assessing the grade of MTA. We calculated the fusion score with the difference of neuropsychological test and VRS of MTA. The receiver operating characteristics (ROC) curve was used to determine optimal cut-off score, sensitivity and specificity of the fusion scores in screening AD. Results: No significant differences in age, gender and education were found between AD and control group. The values of K-MMSE, K-ACE, CDR, VRS and cognitive function test minus VRS were significantly lower in the AD group than control group. The AUC (Area under the curve), sensitivity and specificity for K-MMSE minus VRS were 0.857, 84% and 80% and for K-ACE minus VRS were 0.884, 80% and 88%, respectively. Those for K-MMSE only were 0.842, 76% and 72% and for K-ACE only were 0.868, 80% and 88%, respectively. Conclusions: The fusion of the neuropsychological test and VRS suggested clinical usefulness in their easy and superiority over neuropsychological test only. However, this study failed to find any difference. This may be because of small numbers in the study or because there is no true difference.
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A combined approach of bedside clinical examination and flexible endoscopic evaluation of swallowing in poststroke dysphagia: A pilot study
Sureshkumar Radhakrishnan, Unnikrishnan K Menon, Anandkumar Anandakuttan
July-September 2013, 16(3):388-393
DOI:10.4103/0972-2327.116953  PMID:24101823
Background: As with most neurologic conditions, stroke involves impairment of the swallowing mechanism. This could be a spectrum of issues, the worst of which is aspiration. At the same time, the prolonged presence of a naso-gastric tube (NGT) has its own morbidity. Flexible endoscopic evaluation of swallowing (FEES) is one reliable method to assess the structural and functional status of the oropharynx and larynx, during the swallowing process. Objective: To study the utility of FEES in decision-making with respect to resumption of oral intake in stroke patients. To document the findings of FEES in stroke patients, and to look for correlations between these and the site of stroke. Materials and Methods: Protocol insertion of naso-gastric tube in all stroke patients, at presentation. Initial assessment by a neurologist and swallowing therapist, depending on cognitive status of the patient. All patients underwent MRI Brain with diffusion weighted sequences. After detailed clinical examination, they underwent swallow exercises under the supervision of a trained swallowing therapist. The decision to remove NGT was taken clinically by the combined decision of neurologist and swallowing therapist. Then all patients underwent FEES by the ENT surgeon. The final decision for NGT removal was taken as per the FEES findings. Result: Sixteen stroke patients underwent the FEES procedure during a period of six months. The oropharyngeal and laryngeal findings varied depending on the area of stroke involvement. Of these, change in decision regarding swallowing rehabilitation or NGT removal was needed in four patients, following the FEES findings. Conclusions: FEES is an easy, efficient and reliable method to evaluate the swallowing status in stroke patients. In combination with good bedside clinical examination and swallow exercises, it can be a good tool in assessing patients with post- stroke dysphagia. Post-stroke rehabilitation and prevention of aspiration pneumonia can be effectively done with the help of FEES.
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Pathway to care of epilepsy patients: Exploratory study from an urban slum in Northern India
Kathiresan Jeyashree, Smita Sinha, Binod Kumar Patro
July-September 2013, 16(3):357-360
DOI:10.4103/0972-2327.116930  PMID:24101816
Introduction: Epilepsy is a chronic neurological disorder with major psychosocial correlates. Most epilepsy patients in developing countries are untreated or inadequately treated. It is essential to understand the pathway, to care taken by epilepsy patients in a community, to be able to target appropriate services to them. Materials and Methods: A community based study was conducted on all epilepsy patients in an urban slum in Northern India to study their pathways to care. A list of persons suffering from epilepsy was generated by house to house visits, snowballing, and key informant contacts. In-depth interview and Medical Record Review were used to document their pathway to care. Results: Thirteen of the twenty two patients had contacted a health-care provider for their first episode. The most common first link of care for the patients was secondary level Government hospitals. The next common was private practitioners, followed by Tertiary Care Hospitals, and registered medical practitioners. Eleven out of twenty two patients had to contact a Tertiary Level Center for seeking care. The number of health-care facilities consulted before arriving at their latest point of care ranged from 0 to 5. Traditional or faith healers were consulted at some point of time for cure. Conclusion: There is a need to focus on strengthening and capacity building of the primary care settings for managing epilepsy to enable their better utilization. This shall prevent unnecessary referrals and hence the load on the already burdened higher facilities.
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Stroke and aphasia quality of life scale in Kannada-evaluation of reliability, validity and internal consistency
S Kiran, Gopee Krishnan
July-September 2013, 16(3):361-364
DOI:10.4103/0972-2327.116932  PMID:24101817
Background: Quality of life (QoL) dwells in a person's overall well-being. Recently, QoL measures have become critical and relevant in stroke survivors. Instruments measuring QoL of individuals with aphasia are apparently rare in the Indian context. The present study aimed to develop a Kannada instrument to measure the QoL of people with aphasia. Study objectives were to validate Stroke and aphasia quality of life-39 (SAQOL-39) into Kannada, to measure test-retest reliability and internal consistency. Materials and Methods: The original English instrument was modified considering socio-cultural differences among native English and Kannada speakers. Cross-linguistic adaptation of SAQOL-39 into Kannada was carried out through forward-backward translation scheme. The scale was administered on 32 people from Karnataka (a state in India) having aphasia. For a direct understanding of the subject's QoL, scores were categorized into QoL severity levels. Item reliability of the Kannada version was examined by measuring Cronbach's alpha. Test-retest reliability was examined by calculating the intraclass correlation coefficient (ICC). Results: Kannada SAQOL-39 showed good acceptability with minimum missing data and excellent test-retest reliability (ICC = 0.8). Value of Cronbach's α observed for four items modified in the original version was 0.9 each and the mean α of all Kannada items was 0.9, demonstrating high internal consistency. Conclusions: The present study offers a valid, reliable tool to measure QoL in Kannada-speaking individuals with aphasia. This tool is useful in a cross-center, cross-national comparison of QoL data from people with aphasia. This instrument also permits direct translation into other Indian languages as the items are culturally validated to the Indian population. This study promotes future research using the Kannada SAQOL-39.
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Pattern of seizure cases in tertiary care hospitals in Karnataka state of India
Nitin Joseph, Ganesh S Kumar, Maria Nelliyanil
July-September 2013, 16(3):347-351
DOI:10.4103/0972-2327.116925  PMID:24101814
Background: The prevalence and incidence of epilepsy is higher in developing countries than in developed countries. Understanding pattern and risk factors of seizure cases will help in suggesting appropriate preventive measures. Objectives: This study was carried out to assess the pattern of seizure, its management and compliance with treatment. Materials and Methods: Data from medical records of seizure cases in three tertiary care hospitals of Mangalore city in south India admitted from January 2006 to December 2011 were collected and analyzed. Results: Nearly half (44.4%) of the 196 cases belonged to productive age group (15-45 years) and 2/3 rd (60.7%) were males. Majority (>80% cases) were unskilled workers and of low socio-economic status groups. Family history of seizures was present in 8.4% cases. Mean age of onset of seizure was found to be 19.9 years. Proportion of generalized tonic clonic seizure cases was 78.1%. Secondary seizures were seen in 66 (33.7%) cases with the most common cause being trauma to the head (24.2%). Refractory seizures were present in 2.7% cases. Monotherapy was the most commonly followed treatment regimen and phenytoin was the most popular anti-epileptic drug (AED) used. Non-compliance with AEDs was seen in 18.1% cases and was more among patients on polytherapy (P = 0.032). Conclusion: Seizure manifestations and treatment compliance vary widely in the studied population. In depth analysis of each seizure type will give more information about the factors associated with it.
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RESIDENTS CORNER
A resident's (unique) position on non-epileptic seizures
Vaishnav Krishnan
July-September 2013, 16(3):447-449
DOI:10.4103/0972-2327.116938  PMID:24101842
  - 1,064 59
REVIEW: SYSTEMATIC (SYSTEMATIC REVIEW OF A SUBJECT)
An update on Spino-cerebellar ataxias
Banashree Mondal, Pritikanta Paul, Madhuparna Paul, Hrishikesh Kumar
July-September 2013, 16(3):295-303
DOI:10.4103/0972-2327.116896  PMID:24101804
The dominantly inherited ataxias, also known as Spino-cerebellar ataxias (SCAs), are rapidly expanding entities. New mutations are being identified at remarkable regularity. Recent awareness of molecular abnormalities in SCAs has addressed some of the long sought questions, but gaps in knowledge still exist. Three major categories of SCAs, according to molecular mechanisms, have evolved over recent few years: Polyglutamate expansion ataxia, non-coding zone repeat ataxia, and ataxia due to conventional mutation. Using the fulcrum of these mechanisms, the article provides an update of SCAs. Shared and specific clinical features, genetic abnormalities, and possible links between molecular abnormalities and cerebellar degeneration have been discussed. Emphasis has been placed on the mechanisms of polyglutamate toxicity.
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