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Background and Objectives: Indian ethnic and educational diversities necessitate obtaining normative cognitive data in different populations. We aimed to evaluate cognitive scores using a Marathi translation of the Kolkata cognitive battery (KCB) and to study the association of KCB components with depression and sociodemographic variables., Materials and Methods: We studied 2,651 individuals aged ≥40 years without preexisting neuropsychiatric conditions from urban (Mumbai) and rural districts of Maharashtra. For each component of KCB, the lowest 10th percentile score was used to define cognitive impairment., Results: We studied 1,435 (54%) rural and 1,216 (46%) urban residents equally divided by gender (1,316 women and 1,335 men), average age 54 years. KCB scores were significantly lower with female sex, older age, illiteracy, and depression. The largest effect sizes attributable to these factors were in the domains of calculation (gender), visuoconstructional ability (VCA) (rurality), and verbal fluency (VF) (depression). Scores remained significantly lower in rural residents after controlling for age, sex, and education, particularly for VCA, immediate recall, and calculation., Conclusion: This Marathi KCB, having been validated on large urban as well as rural samples, may be used to study cognition in Marathi-speaking populations with appropriate cutoffs tailored to the degree of urbanization of the population., (© Journal of the Association of Physicians of India 2024.)

Background: The term 'Capsular warning syndrome (CWS)' refers to recurrent, stereotypical transient ischemic attacks, either motor, sensory or both, without cortical symptoms or signs. Of these patients, 42-71% go on to develop infarcts. There are no defined treatment guidelines for this lesser known entity., Methods: We studied 9 patients who presented over last 2 years to our hospital with recurrent and stereotypical transient ischemic attacks suggestive of capsular warning syndrome. Their clinical characteristics, neuroimaging findings, relevant etiological investigations, management and outcomes were studied., Results: Seven out of 9 patients were under 40 years of age. The commonest presentation in our series was a pure motor syndrome. The duration of neurologic deficits ranged from 5 minutes to 20 minutes with complete recovery in between episodes. Three patients had concordant abnormalities on CT brain angiography. Five out of 9 patients received IV thrombolysis with t-PA. One patient worsened neurologically post thrombolysis, whilst the others improved clinically., Discussion: Despite multiple hypotheses, the pathogenesis and management of CWS has not been established clearly. Due to fluctuating neurological symptoms with complete recovery in between the episodes, there is a dilemma concerning treatment of such patients with intravenous thrombolysis. However, intravenous thrombolysis appears to be safe in CWS as in acute ischemic stroke, followed by treatment with antiplatelet agents., (© Journal of the Association of Physicians of India 2011.)

Background and Purpose: Various neurological complications have been reported in association with COVID-19. We report our experience of COVID-19 with stroke at a single center over a period of eight months spanning 1 March to 31 October 2020., Methods: We recruited all patients admitted to Internal Medicine with an acute stroke, who also tested positive for COVID-19 on RTPCR. We included all stroke cases in our analysis for prediction of in-hospital mortality, and separately analyzed arterial infarcts for vascular territory of ischemic strokes., Results: There were 62 stroke cases among 3923 COVID-19 admissions (incidence 1.6%). Data was available for 58 patients {mean age 52.6 years; age range 17-91; F/M=20/38; 24% (14/58) aged ≤40; 51% (30/58) hypertensive; 36% (21/58) diabetic; 41% (24/58) with O2 saturation <95% at admission; 32/58 (55.17 %) in-hospital mortality}. Among 58 strokes, there were 44 arterial infarcts, seven bleeds, three arterial infarcts with associated cerebral venous sinus thrombosis, two combined infarct and bleed, and two of indeterminate type. Among the total 49 infarcts, Carotid territory was the commonest affected (36/49; 73.5%), followed by vertebrobasilar (7/49; 14.3%) and both (6/49; 12.2%). Concordant arterial block was seen in 61% (19 of 31 infarcts with angiography done). 'Early stroke' (within 48 hours of respiratory symptoms) was seen in 82.7% (48/58) patients. Patients with poor saturation at admission were older (58 vs 49 years) and had more comorbidities and higher mortality (79% vs 38%). Mortality was similar in young strokes and older patients, although the latter required more intense respiratory support. Logistic regression analysis showed that low Glasgow coma score (GCS) and requirement for increasing intensity of respiratory support predicted in-hospital mortality., Conclusions: We had a 1.6% incidence of COVID-19 related stroke of which the majority were carotid territory infarcts. In-hospital mortality was 55.17%, predicted by low GCS at admission., (© Journal of the Association of Physicians of India 2011.)

Introduction: Dysphagia is frequently present in Parkinsonian syndromes and is associated with increased morbidity and mortality. Early identification of swallowing dysfunction is critical to minimize complications like aspiration pneumonia and malnutrition. Published prevalence rates for dysphagia in Parkinsonian syndromes vary widely with a very few studies from India. In this study we aimed to determine prevalence of dysphagia in Parkinson's disease and other Parkinson plus syndromes; to correlate it with severity of underlying illness and to determine the factors predicting dysphagia in patients of Parkinson's disease., Methods: It was a prospective observational study performed over 18 months in the neurology clinic of tertiary care public teaching hospital in Mumbai. All patients of Parkinson's disease (PD) diagnosed by UKPDS criteria and all patients of Parkinson-plus syndromes diagnosed clinically were included in the study serially. Patients with cognitive dysfunction (MMSE<24) and those having other neurological or non-neurological causes of dysphagia were excluded from the study. Swallowing dysfunction was assessed by MASA scoring sheet. Disease severity of PD was assessed by modified Hoehn and Yahr scale. Peripheral oxygen desaturation after swallowing water was monitored by pulse-oxymetry; as a bedside test for micro-aspiration. The data was tabulated and analyzed., Results: 70 patients were included in the study including 63 with PD, 5 with PSP and 2 with MSA. Dysphagia was present in 40 (57.4%). 27 had mild; 12 had moderate and 1 had severe dysphagia. In Parkinson's disease dysphagia was significantly associated with following predicting factors: age > 65 years, disease duration > 3 years, modified Hoehn and Yahr scale > 2 and MMSE < 27 (p < 0.001 for all). By multiple logistic regression analysis, the duration of disease and MMSE score were the independent predictors for dysphagia in Parkinson's disease. Severity of dysphagia directly correlated with severity of underlying disease demonstrated by decreasing MASA score with rising Hoehn and Yahr stage., Conclusions: Prevalence of dysphagia in Parkinsonian syndromes was overall 57.14%; being 55.16% in Parkinson's disease. Prevalence and severity of dysphagia showed direct correlation with severity of Parkinson's disease. Duration of disease and cognitive dysfunction are the independent predictors of dysphagia in Parkinson's disease., (© Journal of the Association of Physicians of India 2011.)

Background: White matter hyperintensities (WMH) on MRI brain in the periventricular and deep white matter regions are commonly seen in older persons with normal cognition and in patients with AD., Aims: To compare presence and severity of WMHs in patients with AD with that in a cognitively normal control group, and to evaluate effect of presence of Hypertension and Diabetes on WMHs in both groups., Material and Methods: Thirty four patients with AD were serially recruited from Neurology and Psychiatry OPDs. An age and gender matched cohort of 24 persons with MMSE over 27/30 from the community acted as controls. Vascular risk factors, MMSE and MRI brain were assessed in all. Fezeka's and Pasquier grading of WMH and atrophy were done. Periventricular WMHs (PVWMH) and Deep WMH (DWMH) were assessed separately., Results and Conclusions: Overall, Periventricular WMHs of grade 2 and over were seen in 19/34 patients, and in 7/24 controls (P value 0.044). Significantly higher grades of PVWMHs were seen in hypertensives as compared to nonhypertensives in the case group, and in women compared to men. In the control group, hypertension had no effect on severity of PVWMHs. Among both Diabetics and non-diabetics, no difference in PVWMHs was found between the case and control groups. DWMHs were, conversely, seen only in the control group. Overall, over a quarter of cognitively normal older persons had WM hyperintensities of grade 2 and over on MRI brain; 55% of AD patients had PVWMH of Gd 2 or over, and no DWMHs., (© Journal of the Association of Physicians of India 2011.)

Background: The co-existence of psychiatric co-morbidities with Epilepsy in women is multifactorial and complex, being closely related to hormonal status, medication side effects, and psychosocial factors., Aims: We aimed to study associated Psychiatric co-morbidities in women with Epilepsy (WWE), and correlate the same with seizure subtype and medication , compliance with treatment and seizure control., Material and Methods: This was a prospective, interview based study in OPD over 18 months, evaluating WWE over 13 years of age with at least 1 seizure in the last 1 year. The primary outcome evaluated was the psychiatric diagnosis. Covariables assessed included sociodemographic data, details of seizures and treatment taken. Study population included 143 WWE. Thirty women with a chronic disease, viz., Diabetes and with no h/o seizures, and another group of 25 healthy women from the community with no seizures ever and no Diabetes, were evaluated as 2 sets of controls., Results and Conclusions: One hundred and forty three women with Epilepsy (WWE) were recruited into the study. Psychiatric co-morbidity prevalence was 28.6 % (41/143) in WWE, 13.7 % in women with Diabetes and 8.3 % in women with no Epilepsy or Diabetes (normal controls). Overall, Depression was the commonest psychiatric co-morbidity. Psychiatric co-morbidity was significantly more in WWE as compared to normal controls. Seizure duration over 2 years, complex partial seizures and Polypharmacy were significantly linked to Psychiatric co-morbidities.

Objectives: The study aimed to evaluate different imaging localizations of the classical Lacunar syndromes, including multiplicity of lacunes., Materials and Methods: This prospective study was conducted in a tertiary care municipal hospital over 2 years. Patients with clinical Lacunar syndromes, confirmed on imaging, were evaluated for etiopathogenetic factors, lesion localization, and presence of multiple simItaneous lacunes. Angiographic data and cognitive evaluation was done in a subset of the cohort., Results: 82 patients were studied, 12 undergoing DSA and 46 being evaluated cognitively. Commonest risk factors were Hypertension (97%) and tobacco usage (62%). Pure motor stroke (PMS-70.7%) was the commonest lacunar syndrome, Internal capsular lesions accounting for 53.4% of this syndrome. Among PMS, localisation to Carotid territory was seen in 84.4%, to vertebrobasilar territory in 10.3% and to both in 5.1% of patients. Sensorimotor lacunar syndrome was seen in 14.6% patients, half of them having a thalamic lesion. Overall, 17% patients had multiple simultaneous lacunes, over half of these being cortical, and multiplicity being seen in PMS most commonly. Of 46 patients tested for cognition, 69.5% showed significantly low scores on ACER, with a significant association with multiplicity of lacunes in this group., Conclusions: In our study, Pure motor stroke was the commonest lacunar syndrome, 84% of PMS being due to Anterior circulation stroke. Multiple lacunes of similar age were seen in 17% patients, the predominantly cortical localization of these raising a possibility of embolism. Postlacunar stroke executive dysfunction was seen in over two-thirds of our patients.

Background and Purpose: Lack of information is a major hurdle in combating stroke mortality and morbidity in India. This survey was undertaken in a slum area in Dharavi, Mumbai, to study the prevalence of stroke and post-stroke cognitive impairment in the elderly aged 60 years and above., Methods: Participants selected using systematic random sampling of households, were interviewed using a modified version of the World Health Organization Protocol for Screening of Neurological Diseases. Stroke was confirmed through clinical examination, medical records review and interviews with caregivers. Cognitive impairment was assessed using Addenbrooke's scale and Mini mental status examination., Results: Participants comprised 730 men and 996 women. Confirmed stroke in 66 individuals yielded a crude prevalence rate of 3.82% (95% CI 3.01 - 4.84); the prevalence standardized to WHO world population was 4.87% (95% CI 3.76 - 6.23). Prevalence rates increased with age and were higher in men than in women. Out of 27 stroke survivors evaluated for cognitive dysfunction, 18 (66.66%) had MMSE scores of less than 24., Conclusion: Stroke prevalence in slum-dwellers is comparable to that of other sections of society. Prevalence rates in this study are higher than rates seen in previous Indian studies, possibly due to the combined effects of population ageing with increased incidence of hypertension and diabetes mellitus, which also affect cognitive functions in stroke survivors.

Introduction: There is paucity of data on acute disseminated encephalomyelitis (ADEM) in adults in India. Recent reports indicate that demyelinating disorders in the eastern hemisphere are quite distinct from conventional western type multiple sclerosis., Aims: This study aimed to study the clinical profile, laboratory and imaging parameters, in-hospital morbidity/ mortality and clinical and imaging predictors of in-hospital outcome in ADEM., Results: A total of 29 patients were studied, gender ratio being not significantly different. Prior infection was present in 55.1% patients. Motor deficits (68.9%), bowel bladder abnormalities (65.5%) and sensory deficits (24.1%) were the commonest presenting features. Encephalopathy was seen in 24.1% patients. 10.3% patients had seizures and meningism. A polysymptomatic presentation was seen in 79.3% patients. Pure spinal cord affection (41.3%) was the commonest MRI pattern followed by subcortical (31%) and periventricular white matter involvement (24.1%). A normal MRI was seen in 17.2% of patients. 63% patients showed raised Cerebrospinal fluid (CSF) protein. The commonest in-hospital morbidity was urinary tract infection (18.5%). At admission; 81.4% patients had modified Rankin's score (MRS) between 4 and 6. At 6 weeks post admission, 90.4% patients had MRS score between 0-3, i.e, a favourable MRS., Conclusion: This short term, in-hospital study of ADEM showed preponderance of polysymptomatic onset with motor deficits, commonest MRI pattern being pure spinal cord involvement. A good prognosis for short-term recovery at 6 weeks was noted, despite moderate to severe disability at admission.

The association of muscle tyrosine kinase (Musk) antibody with recurrent bulbar weakness in acetylcholine receptor antibody (Ach-R Ab) negative myasthenia gravis (MG) has been well documented. We describe 2 patients, a middle aged man and a 9-year-old girl, both seronegative for Ach R antibody who had recurrent bulbar weakness and MUSK antibody positivity. Patients made a full recovery from the acute episode with intravenous immunoglobulin (IV Ig) therapy. The peculiar clinical features of this condition and its management are discussed.

Neurocysticercosis is endemic in India, cerebral and ocular manifestations being common. A 32 yr old man on treatment with Albendazole for cerebral neurocysticercosis for 10 days presented with 3 days of painful uniocular blindness. He had only light perception in the left eye, left pupil was non-reactive to light and left disc was edematous. B-scan of eye revealed retinal detachment due to sub retinal cyst and CT brain showed multiple parenchymal cysticerci. The natural history of ocular neurocysticercosis or enhanced sub-retinal inflammation due to Albendazole therapy could have resulted in the retinal detachment in this case.

Gitelman' syndrome, although a relatively frequent cause of chronic hypokalemia in adults, is rarely diagnosed correctly. It is frequently confused with overt diuretic abuse or Bartter's syndrome. We describe a 60 year man with 2 year history of recurrent paralytic ileus attributed to recurrent hypokalemia. Investigations in this patient revealed hypokalemia, metabolic alkalosis, hypocalciurea, and hypomagnesemia a tetrad diagnostic of Gitelman's syndrome. The peculiar clinical features of this condition and its management are discussed.

Aims: To determine etiopathogenetic factors, predictors of in-hospital morbidity and mortality, and discharge status in a serially recruited cohort of PCS patients at a tertiary care hospital. Comparison of data between ACS and PCS groups was also done., Methods: Seventy six cases of PCS and 108 cases of ACS were serially recruited, within 48 hrs of stroke onset, over a 2 year period. Vascular territory determination, stroke subtype and classification, risk factor profile and outcome measures were determined., Results: 77.6% of PCS strokes were ischemic in origin. A cardioembolic source was seen in 12/29 (42%) PCS cases. Intraarterial cause was seen in 5/29 (17.2%) PCS cases. 22.3% of PCS and 24% of ACS patients developed dysphagia. Pneumonia developed in 70% and 65% of dysphagic patients in PCS and ACS groups respectively. Mortality in PCS group was 14/76 (18%) and in ACS group 17/108 (15.7%). The principal contributory factors to mortality in PCS were low Glasgow coma score at presentation, development of respiratory morbidity, and vascular lesions in 'middle plus distal' territory. At discharge, 62% PCS patients were in group 2-3 of modified Rankin scale and 64% of ACS patients were in group 3-4., Conclusions: A cardiac source of distal territory infarct was significantly commoner in PCS as compared to ACS. Incidence of post-stroke complications, viz. dysphagia, pneumonia, deep venous thrombosis, bed-sores and urinary infection, was comparable in the two groups. Dysphagia, seen in 22% PCS and 24% of ACS, was the principal causation of pneumonia. Mortality and disability status at discharge were comparable in the 2 groups.

Unlabelled: Guillain-Barre Syndrome (GBS) has an unpredictable clinical course with up to 30% of patients requiring assisted ventilation during the course of their illness. Successful management mandates anticipation, prompt recognition and optimal treatment of neuromuscular respiratory failure in GBS., Aims: To identify clinical and electrodiagnostic predictors of neuromuscular respiratory paralysis in GBS., Materials and Methods: Forty six patients of GBS were studied over a 6 year period, the study being 2 year retrospective and 4 year prospective. Clinical and electrodiagnostic data were compared between ventilated (28) and non-ventilated (18) patients. The clinical parameters assessed were median age, gender, antecedent infection, prior lung disease, time to peak disability, bifacial weakness, upper limb weakness, bulbar paralysis, neck weakness and autonomic dysfunction. Electrodiagnostic studies included motor nerve conduction studies in 11 ventilated and 13 non-ventilated patients, done prior to maximum disability in each group. Multiple logistic regression analysis was used to compare the two groups., Results: Comparing the clinical data in the ventilated and non-ventilated groups, 'early peak disability', autonomic dysfunction and bulbar weakness predicted the onset of respiratory paralysis. Age, gender, neck or bifacial weakness, upper limb paralysis, or preceding infection did not influence the development of neuromuscular respiratory weakness. Electrodiagnostic testing revealed abnormal H reflex and F waves to be the commonest abnormality in either group. Although data was not sufficient for statistical analysis, the presence of markedly attenuated Compound Muscle Action Potentials inexcitable motor nerves and denervation changes on the electromyography, was commoner in the ventilated group. Thirty six patients received treatment with either plasmapheresis (12) or intravenous immunoglobulin (24). Overall mortality was 5, all 5 patients being on assisted ventilation., Conclusion: Early progression to peak disability, bulbar dysfunction and autonomic instability predicted the development of neuromuscular respiratory paralysis in GBS. Early electrodiagnostic studies in this series suggest axonopathic GBS as a predictor of respiratory paralysis, a finding that needs to be evaluated with sufficient data to permit statistical analysis.

Dementia is the development of multiple cognitive deficits that includes memory impairment and at least one of the following--Aphasia, apraxia, agnosia or disturbances in executive functioning. The common causes of dementia among the elderly are Alzheimer's disease, vascular dementia, mixed dementia and Lewy body disease. The concept of reversible dementia was introduced in 1980 when a task force sponsored by National Institute of Ageing found 10-12% of dementia cases in older group to have reversible causes such as metabolic-nutritional, drugs, infections, psychiatric disorders etc. In our series of 76 patients in the presenile age group (<65 years), 34.21% (26/76) had a reversible condition underlying the dementia. 43.42% (33/76) had vascular dementia, 13.15% (10/76) had Alzheimer's disease and 9.21% (7/76) had mixed dementia. Hypertension, hyperlipidemia and diabetes mellitus were commoner in the vascular dementia group as compared to the Alzheimer's group. Evaluation of MRI as a tool in diagnosis of dementia showed increased sensitivity of MRI towards detecting lacunes. The potentially reversible dementias comprised infections 14.47% (11/76), metabolic-nutritional 14.47% (11/76) and autoimmune diseases 3.94% (3/76). These were characterized by a subcortical dementia. Four month follow up of MMSE in this group showed significant and sustained improvement in the metabolic nutritional group.

The spectrum of degenerative ataxia includes the symptomatic degenerative ataxias and the primary degenerative ataxias. The later may be sporadic and idiopathic or hereditary, being genetically determined. When an individual ataxic patient presents with an adult-onset degenerative ataxia and has a negative family history, the physician is faced with a diagnosis of pure idiopathic sporadic degenerative ataxia or one of the hereditary ataxias. The clinical spectrum of olivopontocerebellar atrophy (OPCA) usually consists of pancerebellar signs with pyramidal and abnormal eye movements. Although Stridor is more commonly found in multisystem atrophy, it is rarely seen in OPCA. We, here report a case of third decade onset of ataxia presenting with stridor.