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EDITORIAL |
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Silver jubilee year of annals of Indian academy of neurology: Commemorative volume |
p. 327 |
M Gourie-Devi DOI:10.4103/aian.aian_455_22 |
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COVID-19-associated mucormycosis: What neurologists should know? |
p. 330 |
Rahul Kulkarni, Shripad Pujari DOI:10.4103/aian.aian_427_22 |
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Serotonin receptor agonists in the treatment of migraine: A meta-analysis considering possible connection with paresthesia |
p. 332 |
Darko Katalinic, Aleksandar Vcev, Martina Smolic, Ivan Aleric DOI:10.4103/aian.aian_266_22 |
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EDITORIAL COMMENTARIES |
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Peripheral neuropathy in children with chronic kidney disease: Are we looking enough? An Editorial |
p. 334 |
Shanthi Viswanathan DOI:10.4103/aian.aian_333_22 |
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COVID-19-associated mucormycosis: A battle against fatal menace |
p. 336 |
Pratap Sanchetee, Rajeswari Rajan DOI:10.4103/aian.aian_435_22 |
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Sleep disturbances in Parkinson's disease: Is it related to COVID-19? |
p. 338 |
Arunmozhimaran Elavarasi, Manvir Bhatia DOI:10.4103/aian.aian_472_22 |
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VIEW POINT |
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Pure autonomic failure-A localized alpha synucleinopathy with a potential for conversion to more extensive alpha synucleinopathies |
p. 340 |
Shakya Bhattacharjee, Rana Alnasser Alsukhni DOI:10.4103/aian.aian_1078_21
Pure autonomic failure (PAF) is an alpha synucleinopathy with predominant involvement of the autonomic ganglia and peripheral nerves. The hallmark clinical feature is orthostatic hypotension. However, genitourinary, sudomotor, and cardiac involvement is also common. Many patients also develop supine hypertension. Almost a quarter of patients can phenoconvert or evolve into Parkinson's disease, multiple system atrophy, and Lewy body dementia in the future. Early severe bladder involvement, higher supine noradrenaline level, early motor involvement, and dream enactment behavior increase the risk of phenoconversion. The diagnosis is confirmed via autonomic function testing and serum noradrenaline measurement. The treatment is mainly supportive. The non-pharmacological treatment includes adequate fluid, dietary salt, compression stockings, and abdominal binders. The drug therapies to improve blood pressure include midodrine, fludrocortisone, pyridostigmine, and droxidopa. The diagnostic criteria need to be updated to incorporate the recent understandings. The treatment of orthostatic hypotension and supine hypertension is mainly based on case series and anecdotal reports. Randomized control trials are needed to ascertain the best treatment strategies for PAF.
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Atypical migraine in clinical practice: Are we missing it? |
p. 347 |
MV Francis DOI:10.4103/aian.aian_997_21
In countries like India, many migraine patients presenting to primary care clinics fail to fulfill standard (ICHD 3) migraine diagnostic criteria. Since they do not present with typical ICHD 3 migraine diagnostic symptoms, it is necessary to define the criteria for atypical migraine. This would ensure that the patients receive the right treatment approach, both non-pharmacological and pharmacological. Looking for triggers, family history, activity affected and absolute normality in between attacks, past episodes of episodic syndromes, prodromal and oculonasal autonomic symptoms will help in identifying the migraine origin of these headaches.
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AIAN REVIEWS |
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Genetic testing in neurology: What every neurologist must know |
p. 350 |
Manish Salunkhe, Ayush Agarwal, Mohd. Faruq, Achal Kumar Srivastava DOI:10.4103/aian.aian_855_21
Approximately 80% genes have an active expression in the brain and 40% of known genetic disorders affect the central nervous system. Revolutionary techniques like next-genome sequencing have solved the problem of the diagnostic odyssey in neurological genetic diseases. As several studies have shown the cost-effectiveness of next-genome sequencing compared to the older tests available in our diagnostic armamentarium, it becomes imperative to know about these genetic mutations and the tests available to diagnose them. We have tried to explain the basic concepts of genetics, the selection of available tests and their interpretation for neurophysicians.
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Changing spectrum of acute encephalitis syndrome in India and a syndromic approach |
p. 354 |
Usha K Misra, Jayantee Kalita DOI:10.4103/aian.aian_1117_21
Acute encephalitis syndrome (AES) refers to an acute onset of fever and clinical neurological manifestation that includes mental confusion, disorientation, delirium, or coma, which may occur because of infectious or non-infectious causes. Cerebrospinal fluid (CSF) pleocytosis generally favors infectious etiology, and a normal CSF favors an encephalopathy or non-infectious AES. Among the infectious AES, viral, bacterial, rickettsial, fungal, and parasitic causes are the commonest. Geographical and seasonal clustering and other epidemiological characteristics are important in clinical decision making. Clinical markers like eschar, skin rash, myalgia, hepatosplenomegaly, thrombocytopenia, liver and kidney dysfunction, elevated serum CK, fronto-temporal or thalamic involvement on MRI, and anterior horn cell involvement are invaluable clues for the etiological diagnosis. Categorizing the AES cases into neurologic [Herpes simplex encephalitis (HSE), Japanese encephalitis (JE), and West Nile encephalitis (WNE)] and systemic (scrub typhus, malaria, dengue, and Chikungunya) helps in rational utilization of diagnostic and management resources. In neurological AES, cranial CT/MRI revealing frontotemporal lesion is consistent with HSE, and thalamic and basal ganglia lesions are consistent with JE. Cerebrospinal fluid nucleic acid detection test or IgM antibody for JE and HSE are confirmatory. Presence of frontotemporal involvement on MRI indicates acyclovir treatment pending virological confirmation. In systemic AES, CT/MRI, PCR for HSE and JE, and acyclovir therapy may not be useful, rather treatable etiologies such as malaria, scrub typhus, and leptospirosis should be looked for. If smear or antigen for malaria is positive, should receive antimalarial, if negative doxycycline and ceftriaxone should be started pending serological confirmation of scrub typhus, leptospira, or dengue. A syndromic approach of AES based on the prevalent infection in a geographical region may be developed, which may be cost-effective.
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Deficits in emotion perception and cognition in patients with Parkinson's disease: A systematic review |
p. 367 |
Mohit Gothwal, Shyam Sundar Arumugham, Ravi Yadav, Pramod K Pal, Shantala Hegde DOI:10.4103/aian.aian_573_21
Non-motor symptoms (NMS) are common among Parkinson's disease (PD) patients and have a significant impact on quality of life. NMS such as deficits in emotion perception are gaining due focus in the recent times. As emotion perception and cognitive functions share certain common neural substrates, it becomes pertinent to evaluate existing emotion perception deficits in view of underlying cognitive deficits. The current systematic review aimed at examining studies on emotion perception PD in the last decade. We carried out a systematic review of 44 studies from the PubMed database. We reviewed studies examining emotion perception and associated cognitive deficits, especially executive function and visuospatial function in PD. This review also examines how early and advanced PD differ in emotion perception deficits and how the presence of common neuropsychiatric conditions such as anxiety, apathy, and depression as well as neurosurgical procedure such as deep brain stimulation affect emotion perception. The need for future research employing a comprehensive evaluation of neurocognitive functions and emotion perception is underscored as it has a significant bearing on planning holistic intervention strategies.
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The quality of life of stroke survivors in the Indian setting: A systematic review and meta-analysis |
p. 376 |
Manju Dhandapani, Jaison Joseph, Suresh Sharma, Surekha Dabla, Biji P Varkey, Venkata L Narasimha, Abin Varghese, Sivashanmugam Dhandapani DOI:10.4103/aian.aian_1069_21
Background: The significant burden of stroke on the mortality rates of developing countries, including India, is well-documented in the literature. However, robust data regarding the aggregates of evidence on the quality of life (QOL) of stroke survivors is limited. Objective: To gather relevant information for policymakers on the QOL of stroke survivors based on observational studies conducted in the Indian setting. Methods: We searched PubMed, Scopus, and Google Scholar for studies conducted in the Indian setting. The methodological quality of each study was scored, and data were extracted from the published reports. The risk of bias assessment was conducted based on the JBI Critical Appraisal Checklist criteria. The relevant data regarding QOL were analyzed by a random effects model using R software. Results: 16 studies were included in the systematic review in which the majority of the studies recruited study participants in the hospital-based setting with an average duration of 3-6 months following the stroke episode. Our findings suggest that the pooled mean quality of life in the four dimensions of the World Health Organization Quality of Life instrument (WHOQOL-BREF) were ranged from 46.86 to 61.37 and the overall Stroke Specific Quality of Life scale (SS-QOL) mean score was 157.16. There was a significant inconsistency among the included studies as heterogeneity was high (I2 >97%). Conclusion: Assessment of the quality of life among stroke survivors is a crucial step to predict the illness' imposed burden and ascertain the effectiveness of the treatment. The present meta-analysis elucidates the aggregate estimates of quality of life and contributes to the research on the quality of life following a stroke in an Indian context.
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Genetics of menstrual migraine and their association with female hormonal factors |
p. 383 |
Iyshwarya B Kalarani, Vajagathali Mohammed, Ramakrishnan Veerabathiran DOI:10.4103/aian.aian_1116_21
Perimenopause is linked to increased migraine (Mg), especially menstrual Mg (MMg), influenced by hormonal changes. Compared to nonmenstrual attacks, menstrual attacks are more disabling and less responsive to treatment. Women with perimenstrual estrogen withdrawal have been linked to Mg during menstruation, whereas Mg during perimenopause has been linked to unpredictable fluctuations in estrogen levels. It has been widely established that female sex hormones play a role in Mg, but how it occurs remains unclear. This narrative review was identified using Medline and PubMed searches between 1946 and 2021. Search terms included “headache,” “migraine,” “menstrual migraine,” “menstruation,” “menopause,” “perimenopause,” “estrogen,” and “progesterone.” This article focuses on the candidate genes and female hormones that play a role in MMg. More study is necessary to understand better the environmental components that play a critical role in disease development. Currently, there is insufficient clinical evidence to support the function of menstrual Mg. The specific research facts examined MMg unique candidate genes and female hormonal factors that support their association and found MMg etiologic processes for generating an early diagnostic marker.
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ORIGINAL ARTICLES |
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Peripheral neuropathy in children with chronic kidney disease: Are we looking enough? |
p. 389 |
Ahibhushan Sonbhadra, Bandi V Chaithanya Reddy, Arushi G Saini, Kara Tiewsoh, Pradip Paria, Shivan Kesavan, Renu Suthar, Lesa Dawman, Savita Attri DOI:10.4103/aian.aian_1067_21
Background: Peripheral neuropathy in chronic kidney disease (CKD) is the most common neurological complication. We aimed to look at the prevalence and patterns of neuropathy in children with CKD. Methods: This cross-sectional study was conducted over 1 year in children with CKD, stage III and above. Nerve conduction studies (NCS) were performed as per standard protocols using surface electrodes on the muscles and by supramaximal stimulation of the corresponding nerves. Presence of electrophysiological abnormalities in the absence of clinical symptoms or signs was considered as subclinical neuropathy. Results: Nearly 45 children were evaluated. The majority were males (n = 39, 86.7%). The mean age was 7.9 ± 3 years (range 2–14). The mean estimated glomerular filtration rate (GFR) at enrolment was 23.3 ± 14.6 mL/min/1.73 m2 (range 5–67). The majority of children were in stage III (n = 19, 42%), followed by stages V (n = 15, 33%) and IV (n = 11, 25%). There was no evidence of clinical neuropathy; 13 children (29%) showed subclinical neuropathy. All the nerves had an axonal pattern of involvement. Motor polyneuropathy was most common type of peripheral neuropathy. The commonest nerves involved were tibial and common peroneal nerves. There were no biochemical or clinical predictors of neuropathy in our cohort. Conclusion: The prevalence of subclinical neuropathy is high in children with CKD, stage III and above. Axonal motor polyneuropathy is the predominant pattern. Electrophysiological assessment of nerve function should be routinely done in children with advanced stages of CKD to prevent chronic complications.
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Sleep disorders in patients with Parkinson's disease during COVID-19 pandemic: A case–Control study |
p. 394 |
Ishita Desai, Ravi Gupta, Mritunjai Kumar, Ashutosh Tiwari, Niraj Kumar DOI:10.4103/aian.aian_255_22
Objective: To assess the impact of coronavirus disease 2019 (COVID-19) pandemic on sleep disorders among Parkinson's disease (PD) patients using validated questionnaires. Materials and Methods: This prospective study involved 50 PD patients and 50 age, gender, and body mass index-matched controls. All participants underwent assessment of cognition using Montreal Cognitive Assessment scale, sleep quality using Parkinson's disease sleep scale-2 (PDSS-2; for PD patients) and Pittsburgh Sleep Quality Index (PSQI; for PD patients and healthy controls), excessive daytime sleepiness (EDS) using Epworth sleepiness scale (ESS), insomnia symptoms and severity using insomnia severity index (ISI), restless legs syndrome (RLS) using International RLS Study Group criteria, rapid eye movement sleep behavior disorder (RBD) using RBD Single-Question Screen (RBD1Q), and depression using Patient Health Questionnaire-9 scale. Results: Eighty-eight percent of PD patients reported one or more sleep disorders, compared to 28% controls. While 72% of PD patients reported poor sleep quality (PDSS-2 ≥15, PSQI >5), 60% had insomnia, 58% reported RBD, 50% had EDS, and 36% reported RLS. Depressive symptoms were reported by 70% patients. PD patients with and without poor sleep quality were comparable with regards to demographic and clinical variables, except for depressive symptoms (P < 0.001). Depressive symptoms showed a significant association with EDS (P = 0.008), RBD (P < 0.001), and insomnia (P = 0.001). Conclusion: Prevalence of sleep disorders increased in PD patients during the COVID-19 pandemic. Prevalence of EDS, RBD, and RLS in PD patients was higher compared to that reported in studies during the pre-COVID-19 times. Presence of depressive symptoms was a significant correlate of presence of sleep disorders in PD patients.
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Impact of antecedent infections on the antibodies against gangliosides and ganglioside complexes in Guillain-Barré syndrome: A correlative study |
p. 401 |
Debprasad Dutta, Monojit Debnath, Doniparthi V Seshagiri, Binu V Sreekumaran Nair, Sumit K Das, Rahul Wahatule, Sanjib Sinha, Vasanthapuram Ravi, Arun B Taly, Madhu Nagappa DOI:10.4103/aian.aian_121_22
Background and Aims: Guillain-Barré Syndrome (GBS), an immune-mediated neuropathy, is characterized by antibodies against gangliosides/ganglioside complexes (GSCs) of peripheral nerves. Antecedent infections have been reported to induce antibodies that cross-react with the host gangliosides and thereby have a pivotal role in conferring an increased risk for developing GBS. Data pertaining to the impact of various antecedent infections, particularly those prevalent in tropical countries like India on the ganglioside/GSC antibodies is sparse. We aimed at exploring the association between six antecedent infections and the profile of ganglioside/GSC antibodies in GBS. Methods: Patients with GBS (n = 150) and healthy controls (n = 50) were examined for the serum profile of antibodies against GM1, GM2, GD1a, GD1b, GT1b, and GQ1b and their GSCs by ELISA. These antibodies were correlated with immunoreactivities against Campylobacter jejuni, Japanese encephalitis (JE), dengue, influenza, zika, and chikungunya infections. Results: The frequencies of antibodies against six single gangliosides (P < 0.001) and their GSCs (P = 0.039) were significantly higher in patients as compared to controls. Except for GT1b-antibody which was more frequent in axonal GBS, none of the other ganglioside/GSC antibodies correlated with the electrophysiological subtypes of GBS. Antecedent JE infection was significantly associated with increased frequency of antibodies against GD1a, GD1b, GT1b, and GQ1b. Antibodies against GSCs were not influenced by the antecedent infections. Interpretation: This study for the first time shows an association between antecedent JE infection and ganglioside antibodies in GBS. This finding reinforces the determining role of antecedent infections on ganglioside antibody responses and the subsequent immunological processes in GBS.
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Genetic spectrum of inherited neuropathies in India |
p. 407 |
Shivani Sharma, Periyasamy Govindaraj, Yasha T Chickabasaviah, Ramesh Siram, Akhilesh Shroti, Doniparthi V Seshagiri, Monojit Debnath, Parayil S Bindu, Arun B Taly, Madhu Nagappa DOI:10.4103/aian.aian_269_22
Background and Objectives: Charcot-Marie-Tooth (CMT) disease is the commonest inherited neuromuscular disorder and has heterogeneous manifestations. Data regarding genetic basis of CMT from India is limited. This study aims to report the variations by using high throughput sequencing in Indian CMT cohort. Methods: Fifty-five probands (M:F 29:26) with suspected inherited neuropathy underwent genetic testing (whole exome: 31, clinical exome: 17 and targeted panel: 7). Their clinical and genetic data were analysed. Results: Age at onset ranged from infancy to 54 years. Clinical features included early-onset neuropathy (n=23), skeletal deformities (n=45), impaired vision (n=8), impaired hearing (n=6), facial palsy (n=8), thickened nerves (n=4), impaired cognition (n=5), seizures (n=5), pyramidal signs (n=7), ataxia (n=8) and vocal cord palsy, slow tongue movements and psychosis in one patient each. Twenty-eight patients had demyelinating electrophysiology. Abnormal visual and auditory evoked potentials were noted in 60.60% and 37.5% respectively. Sixty two variants were identified in 37 genes including variants of uncertain significance (n=34) and novel variants (n=45). Eleven patients had additional variations in genes implicated in CMTs/ other neurological disorders. Ten patients did not have variations in neuropathy associated genes, but had variations in genes implicated in other neurological disorders. In seven patients, no variations were detected. Conclusion: In this single centre cohort study from India, genetic diagnosis could be established in 87% of patients with inherited neuropathy. The identified spectrum of genetic variations adds to the pool of existing data and provides a platform for validation studies in cell culture or animal model systems.
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Outcome of Guillain-Barré Syndrome (GBS) during peripartum period: A hospital-based observational study |
p. 417 |
Anil Kumar Patra, Marami Das, Saswati Sanyal Choudhury, Munindra Goswami, K Vanlalzami DOI:10.4103/aian.aian_362_22
Objective: 1. To study the clinical profile, progression and outcome of GBS during peripartum period in a tertiary care hospital. 2. To identify the determinants of outcome in GBS during peripartum period. Background: Guillain-Barré Syndrome (GBS) is an acute, autoimmune disorder of the peripheral nervous system triggered by a bacterial or viral infection or other antecedent events. Modern day critical care has dramatically improved the outcome of GBS. GBS during pregnancy is rare with an annual incidence of 2.8/100,000 population. Pregnancy itself is a life-threatening condition and full of complications. GBS during pregnancy makes its more complicated in terms of both maternal and fetal care during peripartum period. Methods: This was a prospective study conducted by the Department of Neurology, Gauhati Medical College including 36 patients of GBS presenting during peripartum period in between December 2019 and November 2021. Their clinical and electrophysiological features were analyzed. Hughes grading, EGRIS, mEGOS, MRC sum score were used. The fetal outcome was observed and patients were followed up for GBS outcome at 3 months and 6 months. Results: The mean age of patients was 25.97 years. AIDP was the most common subtype found in 21 (58.33%) patients followed by AMAN in 7 (19.4%), AMSAN in 3 (8.33%). In 3 cases NCS was equivocal and in 3 cases inexcitable. Respiratory distress was found in 13 (36.1%) cases, out of which 4 (11.1%) required mechanical ventilation and 1 (2.8%) died. The pre-term birth rate and stillbirth rate were 35.7% (n = 10) and 8.33% (n = 3), respectively with 66.7% (n = 24) spontaneous vaginal delivery(SVD). At 3 month 26 (72.2%) had complete recovery. 5 (13.9%) and 4 (11.1%) had partial and poor recovery, respectively. 78.9% of primigravidae had complete recovery in comparison to 64.7% in multigravidae indicating better outcome in primigravidae in this study. Conclusion: The outcome of GBS during peripartum period is favorable. Primigravidae are more commonly affected but have better outcome than the multigravidae. The risk of developing GBS in pregnancy decreases significantly after delivery and is minimal after 2 weeks. GBS is not an indication for LSCS. Stillbirth rate and preterm birth rate is higher in pregnancy associated with GBS without fearsome neonatal complications.
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Smartphone-based telestroke Vs“Stroke Physician” led acute stroke management (SMART INDIA): A protocol for a cluster-randomized trial |
p. 422 |
Venugopalan Y Vishnu, Rohit Bhatia, Dheeraj Khurana, Sucharita Ray, Sudhir Sharma, Girish Baburao Kulkarni, Girish N Rao, Pooja Mailankody, Butchi Raju Garuda, Amit Bharadwaj, Monika Angra, Teresa Ferriera, Ashish Sharma, Vinny P Wilson, Neha Kuthiala, Sakshi Sharma, Ashu Bhasin, Aprajita Mukherjee, Ayush Agarwal, Suhas Murali, Nilima Nilima, MV Padma Srivastava DOI:10.4103/aian.aian_1052_21
Background: One of the major challenges is to deliver adequate health care in rural India, where more than two-thirds of India's population lives. There is a severe shortage of specialists in rural areas with one of the world's lowest physician/population ratios. There is only one neurologist per 1.25 million population. Stroke rehabilitation is virtually nonexistent in most district hospitals. Two innovative solutions include training physicians in district hospitals to diagnose and manage acute stroke ('Stroke physician model') and using a low-cost Telestroke model. We will be assessing the efficacy of these models through a cluster-randomized trial with a standard of care database maintained simultaneously in tertiary nodal centers with neurologists. Methods: SMART INDIA is a multicenter, open-label cluster-randomized trial with the hospital as a unit of randomization. The study will include district hospitals from the different states of India. We plan to enroll 22 district hospitals where a general physician manages the emergency without the services of a neurologist. These units (hospitals) will be randomized into either of two interventions using computer-generated random sequences with allocation concealment. Blinding of patients and clinicians will not be possible. The outcome assessment will be conducted by the blinded central adjudication team. The study includes 12 expert centers involved in the Telestroke arm by providing neurologists and telerehabilitation round the clock for attending calls. These centers will also be the training hub for “stroke physicians” where they will be given intensive short-term training for the management of acute stroke. There will be a preintervention data collection (1 month), followed by the intervention model implementation (3 months). Outcomes: The primary outcome will be the composite score (percentage) of performance of acute stroke care bundle assessed at 1 and 3 months after the intervention. The highest score (100%) will be achieved if all the eligible patients receive the standard stroke care bundle. The study will have an open-label extension for 3 more months. Conclusion: SMART INDIA assesses whether the low-cost Telestroke model is superior to the stroke physician model in achieving acute stroke care delivery. The results of this study can be utilized in national programs for stroke and can be a role model for stroke care delivery in low- and middle-Income countries. (CTRI/2021/11/038196)
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Neuropathy in Parkinson's disease: Risk determinants and impact on quality of life |
p. 428 |
Ravi Soumiya, Birinder S Paul, Riya Aggarwal, Gunchan Paul DOI:10.4103/aian.aian_902_21
Neuropathy has been described in significantly higher proportion of PD patients than in control subjects. This study ascertains the prevelance of neuropathy and its determinants in PD patients, in particular relation with nutritional status, along with impact of neuropathy on Quality of life. Methods: This was a hospital based observational cross-sectional study of PD patients attending the Neurology OPD of a tertiary care hospital. The prevalence and type of neuropathy was determined using the validated MNSI scale. The nutritional status was assessed using MNA score and PDQ-39 was used for assessing quality of life. Patients with and without neuropathy were compared to ascertain risk factors for neuropathy. Results: Twenty-four out of 93 PD patients (26%) had neuropathy and 12 (50%) out of them had painful neuropathy. Older patents and those who had longer duration of disease had higher prevalence of neuropathy. In addition there was significant correlation with malnutrition and neuropathy. 79% of patients with neuropathy had abnormal nutritional status. On comparison of patients with painful neuropathy as compared to those without pain, Vitamin B 12 levels were found to be low only in the former group. Conclusions: Our study shows that there is significant prevalence of neuropathy in PD patents that affects the quality of life of PD patients. Neuropathy in PD is disease dependent and is precipitated by malnutrition. Hence, neuropathy must be timely diagnosed and effective nutritional management may help to improve the patient's quality of life.
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Efficacy and tolerability of erenumab for prevention of episodic migraine in India |
p. 433 |
Debashish Chowdhury, Jaydip R Chaudhuri, Pahari Ghosh, Rahul Kulkarni, Sumit Singh, Sneha Thakur, Anup V Thorat DOI:10.4103/aian.aian_199_22
Background: EMPOwER, a 12-week, double-blind (DB), randomized, placebo-controlled study evaluated the efficacy and safety of erenumab in adult patients with episodic migraine (EM) from Asia, the Middle East, and Latin America. This study analyzes the Indian experience for the use of erunumab for prevention of episodic migraine. Objective: The study aimed to evaluate the efficacy and tolerability of erenumab (70 mg and 140 mg) in EM patients from India. Methods: Randomized patients received monthly subcutaneous injections of placebo and erenumab 70 mg or 140 mg for 3 months. The primary endpoint was a change from the baseline in monthly migraine days (MMDs) at month 3. Other endpoints included achievement of ≥50%, ≥75%, and 100% reduction in MMD; a change in monthly acute migraine-specific medication treatment days; a change in patient-reported outcomes; and safety assessment. Results: Of the 539 patients screened, 351 patients were randomized (erenumab, 70 mg: n = 133 and 140 mg: n = 94; placebo: n = 124). The mean (±SD) age, disease duration, and MMD were 35.1 (±8.6) years, 6.77 (±6.01) years, and 7.82 (±2.89) days, respectively. The placebo-adjusted difference in mean MMD for erenumab 70 mg was -0.88 (95% CI, -2.16, 0.39; P = 0.174) days, and that for erenumab 140 mg was -1.01 (-2.42, 0.41; P = 0.164) days versus placebo. Secondary and exploratory endpoints demonstrated consistently better results in both erenumab dosage groups versus placebo. Treatment-emergent adverse events were comparable across groups (erenumab, 70 mg: 22.7% and 140 mg: 24.5%; placebo: 25.2%). Conclusion: Both doses of erenumab showed numerical improvement for efficacy endpoints and were well-tolerated in the Indian population. No new safety signals were reported.
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Covid-19 and mucormycosis superinfection: Prospective, obsevational study in a single center |
p. 441 |
Shubham Garg, Dilip Masheshwari, Bharat Bhushan, Vijay Sardana, Raj Kumar Jain DOI:10.4103/aian.aian_1097_21
Background: Mucormycosis (MCR) has been increasingly described in patients with coronavirus disease 2019 (COVID-19), but the epidemiological factors, neurological presentation, and outcome of such patients are not well described. Aims: To study the patient demographics, presenting symptoms and signs, the role of co-morbidities, medications used to treat COVID-19, and the outcomes of management and to study the spectrum of neuraxis involvement and its outcome. Methods: It was a prospective, observational, cross-sectional hospital-based single center cohort study. Confirmed MCR cases with and without COVID-19 were collected. The study was carried out over a period of 3 months from May to July 2021, followed by 3-month follow-up. Information on epidemiological factors, neurological findings, treatment (including medical and surgical treatment), and outcome was recorded. Results: A total of 141 patients were diagnosed with MCR, out of which 98 were COVID-associated MCR (CAM). The CAM incidence was 0.39% among COVID-19-positive patients. The MCR case fatality rate at 90 days was 43.9% but was higher for CAM than for non-CAM patients. Older ages (>50 years), diabetes mellitus, multiple risk factors, diabetic ketoacidosis on admission, brain involvement, and history of COVID-19 pneumonitis were associated with a higher risk for death. Conclusions: Possibly because of improper usage of corticosteroids, zinc, oxygen, and tocilizumab, there was sudden surge of cases of MCR in the COVID-19 pandemic. Therefore, treating physicians should use the COVID-19 pneumonia regimen judiciously. Neurological involvement itself is a poor prognostic sign, but combined surgical and medical management exhibited better outcome.
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Cross-sectional area reference values of nerves in the upper and lower extremities using ultrasonography in the Indian population |
p. 449 |
DM Sindhu, Akshata Huddar, Jitender Saini, Seena Vengalil, Saraswati Nashi, Mainak Bardhan, Gopikrishnan Unnikrishnan, Rahul Reddy Rajula, Thennarasu Kandavel, Lokesh Bathala, Leo H Visser, Atchayaram Nalini DOI:10.4103/aian.aian_727_21
Background and Purpose: Cross-sectional area (CSA) is the most important parameter to study peripheral nerves by high-resolution ultrasonography. The aim was to acquire normative data of CSA of the main upper and lower limb nerves in the Indian population. Methods: CSA of nerves was determined in 100 healthy volunteers at 11 predetermined sites: median and ulnar at the wrist, mid-forearm, elbow; radial (spiral groove); tibial (popliteal fossa, medial malleolus); common peroneal (CPN, fibular head) and sural (lateral malleolus). Results: The mean age of participants was 40.7 ± 13.0 years (range: 18-79). Fifty were < 40 years of age. The mean height, weight and BMI were 161.5 ± 8.3 centimeters (range: 145—179), 58.6 ± 10.1 kilograms (range: 32-90) and 22.4 ± 3.2 kilogram/square meter (range: 14.03-30.44), respectively. The median and ulnar nerve measurements were non-uniform throughout its course, and the CSA was largest at the elbow and ulnar groove, respectively. With advancing age, there was a significant difference for median and ulnar nerves at the wrist (median P = 0.002, ulnar P = 0.009) and tibial nerve (popliteal fossa, P = 0.045, medial malleolus, P = 0.005), CPN (P = 0.047). Men had greater CSA of upper limb nerves and tibial nerves at popliteal fossa (P < 0.05) as compared to women. A positive correlation was noted with weight. Conclusion: It is apt for every defined population to have its own set of normative data of CSA as it varies with ethnicity, age, and the built of individuals. We provide a valuable set of CSA data for nerves in the Indian population, which can be used for comparison while investigating peripheral nerve disorders.
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Establishment of normative data for autonomic function tests in Indian population |
p. 457 |
Sheena Singh, Vineeth Jaison, Himani Khatter, Silky Adya, Bharat Singh, Jeyaraj D Pandian DOI:10.4103/aian.aian_579_21
Background: Normative data for autonomic function tests (AFT) is not available for Indian population. Objective: The aim of the study was to establish normative data in AFT and its correlation with age, gender, and body mass index. Material and Methods: The study was done on 254 healthy subjects of age ≥18 years. All AFTs were done in autonomic laboratory at the Department of Neurology, Christian Medical College and Hospital, Ludhiana. Cardiovascular tests (heart rate response to deep breathing, HR changes in Valsalva maneuver and head-up tilt test (HUT)) and quantitative sudomotor axon reflex testing (QSART) were performed in all the subjects. Fifty subjects underwent thermoregulatory sweat test (TST). Results: The mean age (SD) of study participants was 43 (16.0) years (range 20–84), and 129 (50.8%) were men. The normative value range (2.5–97.5 percentile) for HR difference, E: I ratio, and Valsalva ratio (VR) was 3.5–47.0, 1.05–1.93, and 1.11–2.64, respectively, for all the subjects. HR difference and E: I ratio showed an significant inverse relation with age (r = -0.623 and r = -0.584, respectively). VR also showed an inverse relation with age (r = -0.575, P =< 0.001), and female had a lower value than male (1.63 vs 1.78, P =< 0.001). In QSART, mean (SD) sweat volume was higher in males 0.630 (0.230) compared to females 0.513 (0.132) for all sites, P < 0.001, and similar trend was noticed for sweat area in TST. Discussion and Conclusion: Normative AFT data has been established for Indian population for the first time. The values are comparable to previously published studies.
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Validation of a new graphic facial nerve grading system: FAME scale |
p. 464 |
Pawan T Ojha, Shashank Nagendra, Afroz Ansari, Nikhil Dhananjay Kadam, Ajay Mathur, Neeraja Gopinathan, Nishu Ojha, Hardik Patel, Akshay Bansode, Orpah Kalel, Kishan P Morwani, Digvijay Jagtap, Sumant Kumar, Vinod Vij DOI:10.4103/aian.aian_662_21
Background and Objective: Most of the existing qualitative facial nerve grading systems are very subjective while the quantitative grading systems are more complex, require longer data input time and specific software. There is a need for having a scoring system with graphic criteria to improve the subjectivity, reliability and convenience. We aimed to develop and validate such a reliable graphic scale for use in Bell's palsy. Methods: Face videos of patients with unilateral facial paralysis were recorded using smartphones and analyzed for six items including five voluntary facial movements apart from complications of facial palsy (synkinesis, hyperkinesis, and contracture). 15 videos were used for pilot study, 75 for the development of scale and 110 for its validation. Each video was rated on two separate occasions by 3 independent raters, a score of 0-4 was assigned to each item using the graphic scoring criteria, and a composite score was obtained (range 0–24). Five disease severity categories: normal (score 0), mild (score 1–6), moderate (score 7-12), severe (score: 13–18) and profound facial weakness (score: 19-24). Results: The proposed scale and its component items had high inter-rater and intra-rater reliability (Kappa >0.7). Good correlation (Pearson co-efficient >0.7) was seen among the voluntary movements. The proposed scale is a valid tool to score motor deficits and complications of facial palsy. Conclusions: The proposed scale is a valid and reliable graphic scale to describe facial motor dysfunction and its secondary defects.
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Significance of neuronal autoantibodies in comparison to infectious etiologies among patients presenting with encephalitis in a region with a high prevalence of infections |
p. 473 |
Thashi Chang, Teresa Moloney, Leslie Jacobson, Neelika Malavige, Janarthani Lohitharajah, Jithangi Wanigasinghe, Sian Peach, Mark Woodhall, Antonio Berretta, Patrick Waters, Angela Vincent DOI:10.4103/aian.aian_280_21
Background: Prevalence of antibody-mediated autoimmune encephalitis (AE) is reported to be comparable to infectious encephalitis in Western populations. We evaluated the frequency and significance of AE and neuronal autoantibodies in comparison to infectious etiologies among patients presenting with encephalitis in a South Asian population. Methods: Ninety-nine consecutive patients with a clinical diagnosis of encephalitis/meningoencephalitis admitted to two of the largest tertiary-care hospitals in Sri Lanka were studied. PCR and ELISA were used to screen viruses while Gram stain and culture were used to screen bacteria. Sera were tested for antibodies binding to primary embryonic rat hippocampal neuronal cultures and cell-based assays for antibodies to NMDAR, LGI1, CASPR2, Contactin2, AMPAR, GABAAR, GABABR, aquaporin-4 and MOG. Results: Patient ages ranged from 1 month to 73 years (mean = 24.91; SD = 21.33) with a male: female ratio of 1.75:1. A viral etiology was identified in 27.3% and bacterial meningoencephalitis was diagnosed in 17.1%. Sera of nine patients had antibodies binding to live primary neurons, but only five had specific antibodies to CASPR2 (n = 1), NMDAR (n = 2) or GABABR-antibodies (n = 2). Moreover, the patients with CASPR2 antibodies and NMDAR-antibodies were also positive for dengue antibodies. Only the two patients with NMDAR-antibodies had features and responses to immunotherapy consistent with AE. Conclusions: Identified infectious forms of meningoencephalitis (44.4%) greatly exceeded the occurrence of neuronal autoantibodies (9.1%) and AE (2%) in Sri Lanka, and this may be common in those regions where infections are prevalent.
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Medial plantar sensory nerve action potential: A study for reference data in Indian subjects |
p. 479 |
Alika Sharma, Priyanka Chavan, Khushnuma A Mansukhani DOI:10.4103/aian.aian_53_22
Context: The medial plantar nerve (MP) sensory nerve action potential (SNAP) has been shown to be a sensitive indicator for detecting a length-dependent axonal peripheral neuropathy. However, literature survey shows paucity of age stratified data. This study was undertaken to obtain age stratified reference data for MP SNAP amplitude and latency. Aim: To establish age-stratified reference data in Indian subjects for the MP SNAP. Study Setting and Design: The study was conducted in the electrodiagnostic laboratory of a tertiary city hospital and is retrospective study. Materials and Methods: A retrospective study was conducted using the nerve conduction study reports of 173 patients with only upper limb symptoms and findings. Patients were between the ages of 18 and 86 years, stratified into six groups, a = 18-30 years, b = 31- 40 years, c = 41-50 years, d = 51- 60 years, e = 61-70 years, f ≥70 years. Statistical Methods: Stata 12.1 statistical program was used. Lower limit of the SNAP amplitude was obtained using mean-2SD of transformed data. Analysis of variance defined the intergroup variability, linear regression and Pearson's correlation assessed the statistical significance. Results: The lower limit of normal MP SNAP amplitude for each age group is as follows: a: 8.7uv b: 7.5uv c: 3.7 uv d: 2.9uv e: 2.0 uv f: 1.4uv. The amplitude difference between the groups b & c, c & d and e and f using analysis of variance with Bonferroni correction and Tukey post-hoc test was not significant, but the other groups showed statistically significant variance. The equation of regression for the predicted amplitude value with age was defined as Y^ = {3.5 + age (-.0233) – 2 (0.389)}3. Conclusion: This study provides age stratified reference data for MP SNAP. There is evidence to suggest that MP SNAP amplitude varies with age hence age stratified data should be used to define abnormality.
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IMAGES IN NEUROLOGY |
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Extraocular muscle atrophy in myasthenia gravis |
p. 483 |
Radhakrishna Pedapati, Uma Ravishankar, Philo Hazeena, Sundar Shanmugam, Anupama Chandrasekharan, Shankar Venkatasubramanian DOI:10.4103/aian.AIAN_1039_21 |
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An unusual EEG pattern associated with a complex malformation of cortical development |
p. 485 |
Aruna Setumadhava Jyostna, Kollencheri Puthenveettil Vinayan, Vaishakh Anand, Akash Shridharani, Sonu Ravindran DOI:10.4103/aian.aian_1066_21 |
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Electroclinical response to a vitamin: Simple remedy for a profound deficiency |
p. 487 |
Chandana Bhagwat, Pradip Paria, Gunjan Didwal, Arushi Gahlot Saini DOI:10.4103/aian.aian_1071_21 |
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Bilateral optic tract enhancement: An unusual imaging finding in neurosyphilis |
p. 489 |
Lakshminarayanapuram G Viswanathan, Madhu Nagappa, Doniparthi V Seshagiri, Karthik Kulanthaivelu, S Nagarathna, Sanjib Sinha DOI:10.4103/aian.aian_937_21 |
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LIGHTER MOMENTS (ARTWORK OR PHOTOGRAPHY) |
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The treadmill of life |
p. 491 |
Prahlad K Sethi, Nitin K Sethi DOI:10.4103/aian.aian_1084_21 |
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The locked classrooms |
p. 492 |
Pallerla Srikanth DOI:10.4103/aian.aian_995_21 |
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HUMOR IN WHITE COAT |
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The art of guile |
p. 493 |
Ajith Cherian DOI:10.4103/aian.aian_920_21 |
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GRAND ROUND |
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Chronic T cell encephalitis responsive to immunotherapy |
p. 495 |
Arunmozhimaran Elavarasi, Garima Shukla, Deepti Vibha, Vaishali Suri, Chandra Sekhar Bal DOI:10.4103/aian.aian_982_21
Chronic encephalitis manifesting as an epilepsy syndrome most commonly presents as Rasmussen's syndrome, usually characterized by epilepsia partialis continua, hemiparesis, and progressive cortical deficits such as aphasia, hemianopia, and cognitive decline. It is characterized by progressive hemispheric cortical atrophy on imaging and is usually seen in childhood. Adult-onset of the syndrome is rare, and only a few cases have been reported with bilateral symptoms. We present a patient with pseudobulbar affect and frontal lobe dysfunction who developed multifocal myoclonic jerks, right hemibody focal motor seizures, and right hemiparesis with bilateral cerebellar signs. Magnetic resonance imaging showed progressive hemispheric atrophy and bilateral features in Positron emission tomography–computed tomography (PET CT). Brain biopsy revealed chronic T-cell infiltrate. We discuss this case as the patient had several features that were atypical for Rasmussen's encephalitis (or syndrome).
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LETTERS TO THE EDITOR |
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Post-COVID thunderstorm in online conferences |
p. 499 |
Pratap C Sanchetee DOI:10.4103/aian.aian_511_21 |
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Allgrove syndrome: A frequently under-diagnosed ALS mimic |
p. 500 |
Ayush Agarwal, Animesh Das, Awadh K Pandit, Divya M Radhakrishnan, Roopa Rajan, Mohd. Faruq, Achal Kumar Srivastava DOI:10.4103/aian.aian_594_21 |
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Dose of isoniazid in renal disease for treatment of tuberculosis |
p. 502 |
G Sarma DOI:10.4103/aian.aian_729_21 |
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Juvenile tay sachs disease due to compound heterozygous mutation in Hex-A gene, with early sign of bilateral tremors |
p. 502 |
Jayesh Sheth, Ira Mohapatra, Gangotri Patra, Riddhi Bhavsar, Chandni Patel, Siddharth Shah, Aadhira Nair DOI:10.4103/aian.aian_577_21 |
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Impact of tele-neuromuscular clinic on the accessibility of care for patients with inherited neuromuscular disorders during COVID-19 pandemic in India |
p. 505 |
Alisha Reyaz, Ayush Agarwal, MV Padma Srivastava, Rohit Bhatia, A Sharif, Roopa Rajan, Anu Gupta, MB Singh, Venugopalan Y Vishnu DOI:10.4103/aian.aian_565_21 |
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Clinicians heuristic impression of the presentations of restless legs syndrome: A survey among medical graduate trainees in an academic hospital in India |
p. 507 |
Pritam Raja, PR Srijithesh, S Mythirayee, Ravi Yadav DOI:10.4103/aian.aian_655_21 |
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Cerebral Malaria, COVID-19 and complete blood examination |
p. 511 |
Rujittika Mungmunpuntipantip, Viroj Wiwanitkit DOI:10.4103/aian.aian_839_21 |
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Acute hemorrhagic necrotizing encephalopathy in patients with COVID-19 |
p. 511 |
Ravi Nandan, Garima Sharma, Khanak Nandolia, Sudhir Saxena, Prashant K Verma DOI:10.4103/aian.aian_528_21 |
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Neuromyotonia: A sequel to indigenous medication |
p. 513 |
Laxmi Khanna, Chandrashekar Agrawal, Mandaville Gourie-Devi, Ankkita S Bhandari DOI:10.4103/aian.aian_697_21 |
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Dilemmas in acute-onset chronic inflammatory demyelinating polyneuropathy: A new axonal variant? |
p. 515 |
Sanjiv Sharma, Samhita Panda, Sarbesh Tiwari DOI:10.4103/aian.aian_665_21 |
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'Seatbelt Effect' of spasticity: Contrasting velocity dependence from the clasp knife phenomenon |
p. 517 |
Venkateswaran Ramanathan, Dipti Baskar, Hariswar Pari DOI:10.4103/aian.aian_817_21 |
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Levodopa non-responsive parkinsonism in tuberculous cerebral arteritis: A rare occurrence |
p. 519 |
Rohan Mahale, Arun Gokul Pon, M Sandeep, Hansashree Padmanabha, Pooja Mailankody, Mathuranath Pavagada DOI:10.4103/aian.aian_561_21 |
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COVID-19 and a mysterious case of transient cerebral arteriopathy |
p. 521 |
Debabrata Chakraborty, Nirmalya Ray, Lawni Goswami, Sanjay Bhaumik, Sadanand Dey DOI:10.4103/aian.aian_738_21 |
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Successful plasma exchange in a pregnant patient with Guillain-Barré syndrome and thyrotoxicosis |
p. 524 |
Hülya E Toydemir, Vildan Yayla, Metin Mercan, Hacı Ali Erdoğan, İbrahim Acır, Mehmet Hurşitoğlu, Meral Mert, Bahar Özdemir, Yasemin Tekdöş Şeker, Deniz Özel Bilgi, Gülsüm O Hergünsel, Zeynep Topkarcı DOI:10.4103/aian.aian_698_21 |
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Urbach--Wiethe disease: A rare cause of bilateral mesial temporal lobe involvement and cerebral hemorrhage |
p. 526 |
Hüseyin Nezih Özdemir, Cem Çallı, Figen Gökçay, Ahmet Gökçay DOI:10.4103/aian.aian_832_21 |
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Sporadic hemiplegic migraine with CACNA1A mutation masquerading as acute meningoencephalitis |
p. 528 |
Siddhartha Gajam, Rachel Ranitha Peterson, Ann Agnes Mathew, Asha Thomas DOI:10.4103/aian.aian_908_21 |
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Electrophysiological evaluation of audiovestibular pathway dysfunction in Parkinson's disease and its correlates: A case-control study |
p. 529 |
Ravi Rohilla, Anoushka Chaudhary DOI:10.4103/aian.aian_932_21 |
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CANVAS is an oligosymptomatic disease |
p. 530 |
Emilio Ruiz-Fernández, Leonor María Calatayud-Lallana, Jesús Fraile-Rodrigo, José Gazulla DOI:10.4103/aian.aian_914_21 |
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Adverse effects of telemedicine |
p. 533 |
Pathums Sookaromdee, Viroj Wiwanitkit DOI:10.4103/aian.aian_963_21 |
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Triple pathology in Rasmussen's encephalitis: A new pathological phenotype |
p. 534 |
Ayush M Makkar, Snigdha Komakula, Ayush Agarwal, Saumya Sahu, Vaishali Suri, Achal K Srivasatava DOI:10.4103/aian.aian_815_21 |
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Vanishing brain lesions in a patient with vision loss and ataxia: A case of CNS lymphoma with corticosteroid related regression |
p. 536 |
Arunmozhimaran Elavarasi, Shilpa Rao, Subasree Ramakrishnan, Dhananjay Bhatt DOI:10.4103/aian.aian_949_21 |
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Apply the brighton criteria for diagnosing SARS-CoV-2 associated GBS despite pandemia-imminent restrictions |
p. 540 |
Josef Finsterer DOI:10.4103/aian.aian_775_21 |
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Rare causes of hypertrophic spinal pachymeningitis primarily identified on spinal MRI |
p. 541 |
Meena Nedunchelian, Pushpa T Bhari, Ajoy Prasad Shetty, Shanmuganathan Rajasekaran, S Jayanthi Kamashi DOI:10.4103/aian.aian_840_21 |
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Myelin-oligodendrocyte glycoprotein antibody-positive longitudinally extensive transverse myelitis following ChAdOx1-S/nCoV-19 vaccine |
p. 544 |
Jabir Sayed Mappila Veettil, Naajia Perothayil, Abdul Razik, Lisa Merin Joseph, Nalakath. A Uvais DOI:10.4103/aian.aian_811_21 |
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Para-infectious opsoclonus myoclonus syndrome with COVID-19 |
p. 546 |
Jacob Chacko, Boby V Maramattom DOI:10.4103/aian.aian_773_21 |
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A “Cyst” in the tale: Atypical Parinaud's syndrome as a heralding feature of midbrain neurocysticercosis |
p. 548 |
Divyani Garg, Sagar Tomer, Rajiv Motiani DOI:10.4103/aian.aian_736_21 |
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Cerebral venous thrombosis as a complication of plasmodium vivax Malaria: A report of 2 cases |
p. 549 |
Ayush Agarwal, Suhas Murali, Anand Warrier, Aneesha Thomas, Yamini Antil, Aanchal Chadha, Venugopalan Y Vishnu, Ajay Garg, MV Padma Srivastava DOI:10.4103/aian.aian_996_21 |
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Congenital muscular dystrophy due to POMGNT1 mutation presenting as cardioembolic stroke |
p. 551 |
Mary Iype, Omana Surendran Mithran, Anitha Ayyappan, Mathew Iype DOI:10.4103/aian.aian_944_21 |
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A case of eosinophilia myalgia syndrome: Imaging features of a unique and rare entity |
p. 553 |
Marisa Yadav, Suresh Kumar, Anupam Jhobta, Sushma Makhaik DOI:10.4103/aian.aian_844_21 |
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A novel mutation of CAPN1 gene causing hereditary spastic Paraplegia-76 |
p. 555 |
Vijayendra R Chinta, Pramod Krishnan DOI:10.4103/aian.aian_977_21 |
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Management of raised intracranial pressure—When three is better than two |
p. 558 |
Bhavik Bansal, Arunmozhimaran Elavarasi, Prasanna U Bidkar DOI:10.4103/aian.aian_988_21 |
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Oculodigital sign: A clinical clue for diagnosis |
p. 560 |
Sangeetha Yoganathan, Madhan Kumar, Deepa John, Sumita Danda, Samuel P Oommen, Sayli B Umakant, Maya Thomas DOI:10.4103/aian.aian_755_21 |
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Adult-onset dystonia with late-onset epilepsy in TUBB4A-related hypomyelinating leukodystrophy—A new intermediate phenotype |
p. 562 |
Peyalee Sarkar, Adreesh Mukherjee, Sumanta Sarkar, Raju Agrawal, Souvik Dubey, Alak Pandit DOI:10.4103/aian.aian_952_21 |
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The temporal course of the MRI findings of inferior oliver hypertrophy: The clinicoradiologic presentation of a rare patient with holmes tremor and palatal myoclonus |
p. 565 |
Halil Onder, Bilge Kocer, Selcuk Comoglu DOI:10.4103/aian.aian_983_21 |
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Increased ICP as the first sign of pediatric-onset multiple sclerosis: A case report and brief review of the literature |
p. 567 |
Gkiourtzis Nikolaos, Tramma Despoina, Panagopoulou Paraskevi, Evangeliou Athanasios DOI:10.4103/aian.aian_877_21 |
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Predictors of late seizures in patients with cerebral venous sinus thrombosis: A retrospective analysis |
p. 569 |
Pritam Raja, Ravindranadh C Mundlamuri, Prathyusha P Vasuki, Girish B Kulkarni, Raghavendra Kenchaiah, Ajay Asranna, LG Viswanathan, Rohan Mahale, VH Ganaraja, Shamick Biswas, Karthik Kulanthaivelu, Sanjib Sinha DOI:10.4103/aian.aian_911_21 |
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Vascular parkinsonism with dystonia in moyamoya disease: An expansion of movement disorder phenomenology |
p. 572 |
Rohan R Mahale, Rohin Dubbal, Hansashree Padmanabha, Pooja Mailankody DOI:10.4103/aian.aian_768_21 |
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