We report a case of striatal toe in an adolescent with an infarct in lentiform nucleus and briefly discuss its differential diagnoses.
Adolescent; infarct; striatal toe
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 (2nd), 4th, and 6th 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.
MEP was recordable in all patients at baseline, and reduced significantly over time (2nd week 43.52 ± 9.60, 4th week 38.84 ± 7.83, and 6th week 36.85 ± 7.27; P < 0.001). The CMCT was normal and remained unchanged over time.
The increase in excitability of the unaffected motor cortex suggests plasticity in the post-stroke phase.
Central motor conduction time; cortical excitability; ischemic stroke; plasticity; resting motor threshold; transcranial magnetic stimulation
Obstructive sleep apnoea (OSA) syndrome is an established and modifiable but under recognized risk factor for common disorders like stroke and hypertension.
To assess awareness level of health care practitioners and medical students about OSA as a risk factor for stroke and hypertension.
Questionnaire based survey with multiple response type and fill in the blanks type questions. The data was compiled and analyzed using SPSS version 19.
180 participants completed the survey questionnaire. Only 24 (13.3%) identified OSA as a reversible risk factor for ischemic stroke. 11 (6%) participants only could answer OSA as an identified risk factor for hypertension as per Seventh Joint National Committee report.
This study reveals dismal level of awareness, among health professionals and medical students, about OSA being an established and modifiable risk factor for hypertension and ischemic stroke.
Awareness; health professionals; hypertension; ischemic stroke; obstructive sleep apnoea
Fast micrographia is a rare clinical sign, which is reported in patients with pallidal pathology. A 68-year-old male presented with hypophonia and short shuffling gait with decreased arm swing. About 3 weeks before, he had an acute myocardial infarction and a period of hemodynamic and respiratory distress during which he required mechanical ventilatory support. He was found to have a fast handwriting with micrographia from the outset. His rapid alternating hand and finger movements were normal. Magnetic resonance imaging (MRI) of the brain showed features of hypoxic ischemic encephalopathy including hyperintensities on T1 and T2 weighted images in the globus pallidus, and putamen bilaterally.
Fast micrographia; globus pallidus hyperintensity
Transcranial Doppler (TCD) can be aptly called as the doctor’s stethoscope of the brain. Since its introduction in 1982, by Rune Aaslid, TCD has evolved as a diagnostic, monitoring, and therapeutic tool. During evaluation of patients with acute ischemic stroke, TCD combined with cervical duplex ultrasonography provides physiological information on the cerebral hemodynamics, which is often complementary to structural imaging. Currently, TCD is the only diagnostic tool that can provide real time information about cerebral hemodynamics and can detect embolization to the cerebral vessels. TCD is a noninvasive, cost-effective, and bedside tool for obtaining information regarding the collateral flow across various branches of the circle of Willis in patients with cerebrovascular disorders. Advanced applications of TCD help in the detection of right-to-left shunts, vasomotor reactivity, diagnosis, and monitoring of vasospasm in subarachnoid hemorrhage and as a supplementary test for confirmation of brain death. This article describes the basic ultrasound physics pertaining to TCD insonation methods, for detecting the flow in intracranial vessels in addition to the normal and abnormal spectral flow patterns.
Ischemic stroke; intracranial stenosis; transcranial doppler
Glycated hemoglobin A1c(HbA1c) indicates long-term uncontrolled hyperglycemia in the body, which in diabetic patients leads to various vascular complications as a part of generalized atherosclerosis culminating ultimately into ischemic stroke.
Study aims to show the association between marker of uncontrolled long-term hyperglycemia HbA1c and marker of atherosclerosis (Carotid intima media thickness [CIMT] and carotid plaque) in ischemic stroke patients.
Subjects and Methods:
Carotid sonography using high resolution 7.5 MHz sonography technique was done in each patient to find the occurrence of increased CIMT and presence of plaque according to Mannheim CIMT Consensus (2004-2006). Levels of HbA1c measured in blood in both diabetic and non-diabetic patients and a comparison made between them. Finally an association sought between HbA1c levels with CIMT and plaque.
The average value of HbA1c of this cohort was 7.51 ± 1.75% with higher values in diabetic patients (9.29 ± 1.73%). The patients with high CIMT (>0.8 mm) had higher values of HbA1c then that of normal CIMT patients and this was nearly significantly (P = 0.06). However, HbA1c levels of blood were significantly associated with stroke patients with presence of carotid arteries plaque (P = 0.008).
Prediction of future risk and prevention strategies for ischemic stroke could be formulated by utilizing HbA1c levels in both diabetic and non-diabetic population.
Atherosclerosis; carotid intima media thickness; diabetes mellitus
Brachial plexus injury can occur as a result of trauma, inflammation or malignancies, and associated complications. The current topic is concerned with various forms of brachial plexopathy, its clinical features, pathophysiology, imaging findings, and management. Idiopathic brachial neuritis (IBN), often preceded with antecedent events such as infection, commonly present with abruptonset painful asymmetric upper limb weakness with associated wasting around the shoulder girdle and arm muscles. Idiopathic hypertrophic brachial neuritis, a rare condition, is usually painless to begin with, unlike IBN. Hereditary neuralgic amyotrophy is an autosomal-dominant disorder characterized by repeated episodes of paralysis and sensory disturbances in an affected limb, which is preceded by severe pain. While the frequency of the episodes tends to decrease with age, affected individuals suffer from residual deficits. Neurogenic thoracic outlet syndrome affects the lower trunk of the brachial plexus. It is diagnosed on the basis of electrophysiology and is amenable to surgical intervention. Cancer-related brachial plexopathy may occur secondary to metastatic infiltration or radiation therapy. Traumatic brachial plexus injury is commonly encountered in neurology, orthopedic, and plastic surgery set-ups. Trauma may be a direct blow or traction or stretch injury. The prognosis depends on the extent and site of injury as well as the surgical expertise.
Hereditary neuralgic amyotrophy; myokymic discharges; neurography; Pancoast tumor; plexopathy
Although the clinical features in some patients with cerebrovascular ischemia may be ill defined, majority of the patients present with focal neurological deficits caused by an arterial occlusion, and the clinical presentations are usually referable to the involved arterial territory. Therefore, vascular imaging constitutes an important component of the diagnostic workup. Cervical duplex ultrasonography of carotid and vertebral arteries is employed to evaluate the extracranial vasculature while transcranial Doppler provides important information about intracranial hemodynamic changes in cerebrovascular ischemia. These two components of cerebrovascular ultrasonography are fast and reproducible, and can be performed at the bedside. They provide real-time information about the status of cervico-cranial arterial patency and various hemodynamic alterations, including collateral flow. The information obtained from cerebrovascular ultrasonography is useful for diagnostic as well as prognostic purposes. Furthermore, it can be used to monitor cerebral blood flow for extended periods and aid in decision making for various interventions. The hemodynamic information obtained from cerebrovascular ultrasonography helps in determining the underlying mechanisms of brain ischemia, and is complementary to the clinical examination and other imaging modalities.We describe the technique of performing cervical duplex sonography, diagnostic criteria for arterial stenosis, characterizing plaque morphology, measuring intima–media thickness and various pitfalls while performing the test.
Cervical duplex; ischemic stroke; transcranial Doppler; ultrasonography
Electrodiagnosis (EDX) is a useful test to accurately localize the site, determine the extent, identify the predominant pathophysiology, and objectively quantify the severity of brachial plexopathies. It can also be used to examine muscles not easily assessed clinically and recognize minimal defects. Post-operatively and on follow up studies, it is important for early detection of re-innervation. It can be used intra-operatively to assess conduction across a neuroma, which would help the surgeon to decide further course of action. Localization of the site of the lesion can be very challenging as there may be multiple sites of involvement and hence the electroneuromyographic evaluation must be adequate. The unaffected limb also needs to be examined for comparison. The final impression must be co-related with the type and severity of injury.
Brachial-plexopathy; electrodiagnosis; traumatic
Adult post traumatic Brachial plexus injury is unfortunately a rather common injury in young adults. In India the most common scenario is of a young man injured in a motorcycle accident. Exact incidence figures are not available but of the injuries presenting to us about 90% invole the above combination This article reviews peer-reviewed publications including clinical papers, review articles and Meta analysis of the subject. In addition, the authors′ experience of several hundred cases over the last 15 years has been added and has influenced the ultimate text. Results have been discussed and analysed to get an idea of factors influencing final recovery. It appears that time from injury and number of roots involved are most crucial.
Brachial plexus injury; adult; surgical strategy
Effectiveness of intermittent short course chemotherapy for tuberculous meningitis (TBM) has not been well studied. There are scarce reported studies on this issue in the world literature. Neurologists all over India are reluctant to accept Directly Observed Treatment Short course (DOTS) for TBM since its introduction in India.
We did a prospective study to assess effectiveness of Revised National TB Control Program (RNTCP-DOTS) regimes among TBM patients.
Materials and Methods:
In this study we include the TBM patients admitted from September 2008 to March 2011. All were referred to RNTCP for treatment. Diagnostic Algorithm as per RNTCP guidelines was strictly followed and treatment outcome and follow-up status were recorded. We exclude HIV and pediatric age group.
A total of 42 cases registered for DOTS regimen were included in the study, of which 35 completed the treatment (83%). All the patients were started with DOTS but finally 78% received actual DOTS. All patients were given 9 months intermitted regimen as per RNTCP guidelines. Seven patients died during the treatment (16%).
We found intermitted short course chemotherapy was effective in TBM.
Directly observed treatment short; Intermitted therapy; tuberculous meningitis
We report a case of alien hand sign in a male with stroke and briefly discuss the pathogenesis of this rare condition symptom.
Alien hand sign; frontal variant; involuntary masturbation
Background and Objectives:
The present study evaluated the direct costs of active epilepsy and looked at the pattern of drug prescription and utilization in epileptic patients visiting the neuroscience centre of a national hospital of India.
Materials and Methods:
A total of 134 epileptic patients were studied over a period of 4 months. Patients demography, commonly prescribed antiepileptic drugs (AEDs), socioeconomic status, direct costs, response ratio (RR) for newer drugs, and quality of life (QOLIE-10) was evaluated.
Results and Discussion:
We found a higher percentage of male patients (67.9%) as compared with females. Most of the patients were in the age group 11–30 years and majority of them (39.6%) belonged to lower middle group. A higher percentage (68.7) of drugs was prescribed as polytherapy. Higher monthly cost was observed for some of the newer AEDs including the lamotrigine, levetiracetam, and lacosamide as compared with older drugs. Among the newer drugs, clobazam had the lowest cost. RR was calculated for 12 patients out of which 8 had a RR < –0.50. The QOL domains, following conventional or newer drugs, were not much affected.
The study indicates an increasing trend toward clinical usage of newer AEDs, increasing trend of poly-therapy with significant escalations in the cost of therapy.
Antiepileptic drugs; direct cost; prescription pattern; response ratio; quality of life
Few studies have been done to see the level of knowledge among patients and caregivers about Parkinson's disease (PD).
The aim of the current study was to determine the knowledge of PD among patients and caregivers at a movement disorder clinic in India.
Settings and Design:
A tertiary care neurology facility in north India.
Materials and Methods:
We conducted a questionnaire based interview among the subjects collected on the annual PD day in 2006.
Out of 200 questionnaires that were distributed 172 subjects responded. Of these, there were 103 (59.8%) patients with PD and 69 (40.11%) caregivers. Mean age of the patients and caregivers was 55.4 ± 13.3 years and 49.4 ± 15.9 years respectively. Mean duration of PD was 6.8 ± 4.7 years (range-21). Ninety nine patients out of the 103 (96.1%) and 57 caregivers out of 69 (82.6%) had previously attended the PD education program. High scores (>90%) were obtained to questions on body parts affected, pathology in PD, main drug treatment, epidemiology and effect of exercise. Low scores were seen to questions on surgery in PD and biochemical abnormality in PD. No significant difference was noted in correct answers among patients and caregivers on duration of PD.
Patients and caregivers had adequate knowledge about PD. Patient and caregiver education programs may be useful in imparting knowledge about PD.
India; Knowledge; Parkinson's disease
Jean-Martin Charcot is known as father of modern neurology. Before him, neurology was only limited to select disorders like chorea. His contributions were not limited to neurology only, as he was instrumental in many new developments in the field of pathology, psychiatry, and internal medicine. Even after 100 years, Charcot`s clinical methods remain the pillar of modern neurology.
Jean-Martin Charcot; neurology; Sâlpetrière Hospital