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Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves motor symptoms and motor complications of Parkinson’s disease (PD). The intervention is expected to result in some cognitive changes, the nature of which is not uniform across the studies which have reported them. PD itself is associated with progressive cognitive decline and hence longitudinal follow-up studies with medically managed control group of patients are needed to explore the cognitive deficits attributable to DBS. We conducted a prospective comparative observational study to assess the effects of bilateral STN DBS on cognition. Cognitive functions were assessed at baseline and after a minimum of two years after surgery, and compared with baseline and follow-up assessments in patients on medical management alone. Thirty-four patients with PD who underwent bilateral STN DBS and thirty-four medically managed patients participated in the study. At a mean follow-up of around 33 months, we found a significant decline in verbal fluency scores in the DBS group compared to those on medical management alone (1.15 ± 1.23 vs 0.59 ± 0.93, p = 0.034) and a trend for decline was noted in digit span test. There was no difference in the performance in tests addressing other cognitive domains, or tests of global cognitive function. No patient developed dementia. Motor functions and activities of daily living (ADL) were significantly better in the surgical group. STN DBS results in minor deficits in executive functions, particularly verbal fluency. These may be inconsequential, considering the marked improvement in motor functions and ADL.

Objective To test the feasibility and efficacy of multimodality stimulation combined with motor tasking as a corrective strategy for hemineglect following right hemispheric ischemic strokes. Material and methods A prospective randomized controlled single blinded clinical trial was conducted over eighteen months from January 2017. All patients with right hemispheric ischemic strokes were screened for hemineglect and those fulfilling criteria were recruited and randomized. Patients under the therapy group (TG) received the intervention based on a structured protocol in addition to standard physiotherapy. The control group (CG) received standard physiotherapy alone. NIHSS, mRS and Neuropsychological test scores were recorded at different time points. The primary outcome measures (neuropsychological test scores) were compared between the two groups (Student's t-test to find out the difference in outcome measures) at one and three months post-stroke. Results Of the 14 patients recruited, data from 12 were available for analysis, 5 patients in TG and 7 in CG. There was a trend for better hemineglect and functional outcomes in TG. Conclusion Multimodality stimulation, in addition to standard physiotherapy, is feasible and potentially results in better neurocognitive and functional recovery following right hemispheric ischemic strokes. However, larger studies are warranted to prove these preliminary observations beyond doubt.

Introduction: Risk factor control is an important predictor of risk of stroke recurrence. The attributable fraction which estimates the excess risk among the exposed stroke survivors has not been studied previously. We studied the attributable fraction for stroke recurrence in consecutive incident cases of recurrent stroke. Methods: A case-control study with incident cases of recurrent stroke and controls matched for age and poststroke period was done. A structured interview was done to collect data on sociodemographic variables, lifestyle, and medication adherence. The risk factors, treatment of index stroke, and outcome were collected. Logistic regression analysis was done to find out the factors associated with stroke recurrence. Attributable fraction and average attributable fraction were calculated. Results: Among the 103 matched pairs, more than 70% were rural residents. Male gender (OR 2.59; 95% CI 1.05–6.42), the presence of depression (OR 8.67; 95% CI 2.80–26.84), memory problem (OR 10.12; 95% CI 2.48–41.34), uncontrolled diabetes (OR 3.19; 95% CI 1.42–7.19), cardioembolic stroke (OR 4.45; 95% CI 1.12–17.62), and index stroke not being treated in a stroke unit (OR 6.60; 95% CI 2.86–15.23) were associated with increased risk of stroke recurrence. The maximum average attributable fraction for stroke recurrence risk was attributed to index stroke not being treated in the stroke unit and uncontrolled diabetes. Conclusion: The index stroke treated in a comprehensive stroke care unit and control of risk factors can reduce recurrent stroke risk among stroke survivors. This population-attributable risk is important in planning secondary stroke prevention strategies.

Background Non-contrast CT (NCCT) brain imaging biomarkers of hematoma expansion in intracerebral hemorrhage (ICH) has gained relevance in recent times. Though intra-hematoma hypodensities (IHH) can predict hematoma expansion and outcome, it is postulated to be time-dependent. Aim To assess the differential prevalence of IHH in spontaneous ICH over time and assess its predictive valve in early hematoma expansion and functional outcome at 3 months. Material and methods Patients with ICH within 48 h of stroke onset were included. Baseline clinical and demographic data were collected. Baseline NCCT brain was analyzed for hematoma volume, characterization of IHH, with 24-hours follow-up NCCT hematoma volume calculated for identification of hematoma expansion. Poor functional outcome was defined as mRS ≥3. Results Around 92 subjects were included in the study. IHH was found in 40%. Prevalence of IHH was higher in those with baseline NCCT performed within 3 h of symptom onset compared to those beyond 3 h (71% vs 29%, P = 0.002). The hematoma expansion was more common in patients with IHH compared to those without (54% vs 29%; P = 0.02). Multivariate analysis revealed the presence of IHH (rather than pattern or number) to be strongly associated with poor functional outcome at 3 months (OR 3.86; 95% CI: 1.11-13.42, P = 0.03). Conclusion There is a decreasing prevalence of IHH as the time from symptom onset to NCCT increases. Nevertheless, its presence is significantly associated with hematoma expansion and predicted poor short-term functional outcomes in spontaneous ICH.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves motor symptoms and motor complications of Parkinson's disease (PD). The intervention is expected to result in some cognitive changes, the nature of which is not uniform across the studies which have reported them. PD itself is associated with progressive cognitive decline and hence longitudinal follow-up studies with medically managed control group of patients are needed to explore the cognitive deficits attributable to DBS.We conducted a prospective comparative observational study to assess the effects of bilateral STN DBS on cognition. Cognitive functions were assessed at baseline and after a minimum of two years after surgery, and compared with baseline and follow-up assessments in patients on medical management alone.Thirty-four patients with PD who underwent bilateral STN DBS and thirty-four medically managed patients participated in the study. At a mean follow-up of around 33 months, we found a significant decline in verbal fluency scores in the DBS group compared to those on medical management alone (1.15 ± 1.23 vs 0.59 ± 0.93, p = 0.034) and a trend for decline was noted in digit span test. There was no difference in the performance in tests addressing other cognitive domains, or tests of global cognitive function. No patient developed dementia. Motor functions and activities of daily living (ADL) were significantly better in the surgical group.STN DBS results in minor deficits in executive functions, particularly verbal fluency. These may be inconsequential, considering the marked improvement in motor functions and ADL.

Introduction: Cerebral amyloid angiopathy (CAA) is a major cause of intracerebral hemorrhage (ICH) and cognitive decline in the elderly. Since it is rarely reported from the developing world, we looked into the clinical profile and neuroimaging associations of CAA. Materials and Methods: Ours was a retrospective case series of subjects diagnosed with probable/possible CAA between January 2006 and December 2015 as per Boston criteria. Clinical profile and neuroimaging were reviewed for markers of CAA. Details of any recurrent clinical events and functional status were collected from follow-up records. Results: We had 28 subjects in the series with men outnumbering women, and the mean age was 70.17 ± 8.85 years (55–87 years). At the initial presentation, ICH was most frequent—10/28 (35.7%) patients, followed by transient neurological events (TNE = 25%) and cognitive disturbances (21.4%). Less than half of the patients received a diagnosis of CAA at the initial presentation itself. In total, 68% of our patients had cognitive dysfunction at admission. In our series, 12 had seizures and 9 had a history of TNE. The majority of our patients had vascular risk factors also. Leukoaraiosis showed an association with cognitive dysfunction (P = 0.044). Superficial siderosis and subarachnoid hemorrhage (SAH) showed a positive association with seizures and TNE, respectively. However, ICH showed no association with risk factors or imaging markers of CAA. Conclusions: CAA patients, with a high prevalence of vascular risk factors mostly presented with ICH. The presence of SAH and superficial siderosis on MRI was associated with presentation as TNE and seizures, respectively.

Purpose The success of epilepsy surgery lies in identifying the ictal onset zone accurately. The significance of auras has little been explored on surgical outcome in drug-resistant epilepsy. This study focuses on the clinicopathological correlation of aura(s) and its role in predicting surgical outcome in drug-resistant temporal lobe epilepsy (TLE). We compared surgical outcome in TLE between patients with and without aura and identified the clinico-pathological, radiological and surgical differences between the two groups. Methods Consecutive patients who underwent presurgical evaluation from January 2009 to December 2014 for drug-resistant TLE who underwent anterior temporal lobectomy (ATL) were included. Patients were followed up at 3months, 12 months and then annually. Results Among 456 patients, 344(75%) had aura. Multivariate logistic regression showed that prototype EEG pattern at ictal onset (OR 2.12, 95% CI 1.18–3.06, p = 0.012) and right sided epileptogenic zone (OR 1.82 95% CI 1.18–3.78, p = 0.007) were significantly associated with presence of aura. There was no difference in surgical outcome between those with and without aura. But patients with auditory aura (OR 7.28, CI 2.80–18.95, p = 0.0002) and vertiginous aura (OR 3.01, CI 1.55–7.85, p = 0.028) had a poor surgical outcome. Bivariate analysis showed that normal MRI (p = 0.028) and normal/indeterminate pathology (p = 0.001) were significantly more common with auditory/vertiginous auras. Conclusions Mere presence of aura does not affect outcome after TLE surgery. However, auditory and vertiginous auras are predictors of poor surgical outcome. These patients require more extensive screening for an ictal onset zone beyond standard limits of ATL before surgery.

Objective To evaluate the prognostic value of postoperative EEGs to estimate post anterior temporal lobectomy (ATL) seizure outcome. Methods We studied postoperative EEGs in 325 consecutive patients who had minimum five years of post-ATL followup. Interictal epileptiform discharges (IEDs) present only during sleep were classified as sleep IEDs. We defined favorable final-year outcome as no seizures during the final one year and favorable absolute-postoperative outcome as no seizures during the entire postoperative period. Results At mean follow-up of 7.3 ± 1.8 years, 281 (86.5%) patients had favorable final-year outcome while 161 (49.5%) had favorable absolute-postoperative outcome. IEDs on three months and one year EEG were associated with unfavorable outcomes while IEDs at 7th day had no association with outcomes. Sleep record increased the yield of IEDs by 30% at each time-point without compromising predictive value. EEG at one year predicted the risk of seizure recurrence on drug withdrawal. Conclusion While EEG at three months and at one-year after ATL predicted seizure outcome, EEG at 7th day was not helpful. Sleep record increases the sensitivity of postoperative EEG without compromising specificity. Significance Both awake and sleep EEG provide useful information in postoperative period following ATL.

Background The functional Ser9Gly single nucleotide polymorphism (SNP) in the dopamine D3 receptor gene is associated with impulse control disorders (ICD) in Parkinson's disease (PD) in Indian patients. Whether the same SNP modulates impulsivity in PD patients without active ICD is unknown. We aimed to compare decision-making under uncertainty in PD patients with DRD3 p.S9G (rs6280) variants CT/CC or TT. Methods We conducted a cross-sectional study including PD patients (n = 78) whose DRD3 p.S9G (rs6280) genotypic status was known (CC, CT, and TT). Decision-making was assessed using the Iowa Gambling Task (IGT). Results IGT total (p = 0.267) or block scores did not differ between the DRD3 rs6280 variant groups. Deck choice analysis revealed that the CT/CC group showed a skewed preference in deck choice (p = 0.002) due to significantly fewer draws from deck B, compared to all other decks (deck A, p < 0.001; deck C, p = 0.004; deck D, p = 0.002). Conclusions The functional Ser9Gly DRD3 variant is associated with aberrant decision-making under uncertainty in PD patients without active ICD. This ability to modulate impulsivity may underlie its association with clinical ICD in PD.

ObjectiveTo study the long-term outcome following seizure recurrence on antiepileptic drug (AED) withdrawal after anterior temporal lobectomy for mesial temporal lobe epilepsy.MethodsWe retrospectively studied the AED profile of patients who had a minimum of 5 years of postoperative follow-up after anterior temporal lobectomy for mesial temporal lobe epilepsy. Only those patients with hippocampal sclerosis or normal MRI were included. AED withdrawal was initiated at 3 months in patients on ≥2 drugs and at 1 year for patients on a single drug.ResultsThree hundred eighty-four patients with median postoperative follow-up of 12 years (range, 7–17 years) were included. Of them, 316 patients (82.3%) were seizure-free during the terminal 1 year. AED withdrawal was attempted in 326 patients (84.9%). At last follow-up, AEDs were discontinued in 207 patients (53.9%). Seizure recurrence occurred in 92 patients (28.2%) on attempted withdrawal. After a median postrecurrence follow-up of 7 years, 79 (86%) of them were seizure-free during the terminal 2 years. AEDs could be stopped in 17 patients (18.5%) and doses were reduced in another 57 patients (62%). Patients with febrile seizures, normal postoperative EEG at 1 year, and duration of epilepsy of ConclusionPatients with seizure recurrence on AED withdrawal have good outcome with 86% becoming seizure-free and 18% becoming drug-free after initial recurrence. A FND20 score helps in predicting recurrence on AED withdrawal.

Objective Interictal regional paroxysmal fast activity (RPFA) on scalp EEG is common in patients with focal cortical dysplasia (FCD). Little data exists regarding the presence of RPFA in other etiologies. Methods We studied the association between RPFA and etiology on MRI in patients with drug resistant focal epilepsy undergoing presurgical evaluation in 2011. RPFA was defined as ≥3 consecutive spikes with a frequency of ≥10 Hz lasting ≥300 ms but Results 626 patients fulfilled the inclusion criteria. Of these, 138 (22%) patients had RPFA while rest had other interictal epileptiform discharges (IEDs). RPFA was located at posterior head region in 52.2% patients, frontal regions in 24.6% patients and over temporal regions in 17.4% patients. Focal gliosis (61, 44%) and FCD (27, 19%) were common etiologies in patients with RPFA. Compared to patients with other IEDs, patients with RPFA were more likely to have focal gliosis (61/138 vs. 39/488; p Conclusion In developing countries, focal gliosis is more common than FCD as the underlying etiology in patients with RPFA on scalp EEG. Significance Focal gliosis should be considered as one of the common substrate for RPFA on scalp EEG.

Carotid cavernous sinus dural arteriovenous fistulas (CSDAVFs) are presumed to be located within the walls of the cavernous sinus, however the exact fistulous site has not yet been studied by angiographic or anatomical methods. The present study aimed to localize CSDAVFs with the help of 3D rotational angiography (RA) and correlated the observations with clinical and angiographic findings.The CSDAVFs were categorized as dural, extradural or osseous based on the site of convergence of feeders into the venous sac. Extradural CSDAVFs were further subcategorized into posteromedial, posterolateral and anterior subtypes, depending on proximity to a possible venous plexus. This classification was correlated with various clinical presentations and angiographic subtypes.Thirty-seven patients were included in the final analysis. The sac was identified in all the patients and the mean sac size of the fistula was small (4mm). Dural type was associated with exclusive cortical venous drainage. Extradural anterior CSDAVF showed tendency towards younger age predilection. Extradural posterolateral CSDAVF was more often associated with initial oculomotor nerve palsy and this observation was statistically significant. Discordancy between the location of the fistula and the side of clinical affection was observed in midline fistulas such as osseous CSDAVF and posteromedial type of extradural CSDAVF.CSDAVF is a heterogeneous vascular disorder involving the sphenoclival bone, extradural space and dura, homologous to the epidural-dural shunts of vertebra with a common clinical presentation of orbital manifestations. Preoperative localization of the fistula could explain enigmatic observations and potentially simplify its interventional management.

Purpose To compare the seizure outcome following early and late complete antiepileptic drug (AED) withdrawal following anterior temporal lobectomy (ATL) for mesial temporal lobe epilepsy (MTLE). Method All the patients who were seizure free for one year following ATL were offered early or late AED withdrawal. AEDs were discontinued starting at one year in those who opted for early withdrawal. Patients who opted for late withdrawal were continued on single AED for three years following surgery before attempting complete discontinuation. Results Of the 135 study patients, 65 opted for early AED withdrawal and 70 for late withdrawal. The mean postoperative follow-up duration was 10.4 ± 1.3 (Range, 8–12) years. At three years following surgery, seizure recurrence occurred in 23 (35.4 %) patients in the early withdrawal group and in 10 (14.3 %) patients in late withdrawal group (p = 0.005; relative risk [RR], 2.48; 95 % confidence interval [CI], 1.28–4.80). At last follow-up, 27 (41.5 %) patients in the early withdrawal group and 26 (37.1 %) in late withdrawal group had recurrence (p = 0.60; RR, 1.12, 95 % CI, 0.74–1.70). At last followup, 80 (59.3 %) patients were off AEDs. During the terminal one year, 123 (91 %) patients were seizure free, similar in the two groups. Conclusions This nonrandomized controlled study suggests that early complete AED withdrawal starting one year following ATL is associated with a higher risk of early seizure recurrence. However, long term seizure outcome is similar in early and late AED withdrawal groups.

Background: Risk assessment (RA) for mass gathering events is crucial to identify potential health hazards. It aids in planning and response activities specific to the event but is often overlooked by the event organizers. This paper reports the content validity process of a newly developed tool called Mass Gathering Risk Assessment Tool (MGRAT), which intends to assess the risks associated with religious mass gathering events in Indian settings. Methods: Qualitative approach was followed to identify the risks associated with mass gathering events and to identify the domains and items to be included in the RA tool. The draft tool was shared with six experts who were selected by the convenient method; selected experts were requested to assess the tool and give their comments about the domains, items, relevant responses, and overall presentation of the tool using content validity questionnaire. Content validity index and Fleiss kappa statistics were calculated to assess the agreement between multiple raters. Results: Agreement proportion expressed as scale-level content validity index (S-CVI) calculated by the averaging method is 0.92. S-CVI; calculated by universal agreement is 0.78. Fleiss kappa statistics to measure the agreement between multiple experts after adjusting the component of the chance agreement is 0.522 (95% CI: 0.417, 0.628, P value: 0.001). Conclusion: MGRAT is a valid tool, which has an appropriate level of content validity. As the number of raters increases, there will be difficulty in achieving consensus among all the items, which is the reason for lower Content Validity Index/Universal Average (CVI/UA) when compared with Content Validity Index/Average (CVI/Ave). Fleiss kappa statistics also indicated moderate agreement among the raters beyond the chance agreement, which also supports the appropriate content validity of MGRAT.

Background Religious mass gatherings (MGs) have always been an integral part of our society. At the outset, mass-gathering events provide challenging settings to plan a suitable emergency public health response. Published studies basically talk about retrospective reviews, case studies of the public health preparedness, or health care provided at individual events. Developing an understanding of the variables associated with MGs is the first step for public health managers. Risk assessment (RA) is a crucial part of pre-event planning as it helps foresee potential risks. Based on RA, one can develop preventive measures and ensure that the infrastructure to control the potential problems is in place. This study is an attempt to systemize RA process during MG events in a country that is culturally rich but with poor resources to handle such events. A RA tool will be developed for planning and management of religious MG events of India. Methods/design Various strategies will be used to develop the risk assessment tool (RA tool). Extensive review of literature clubbed with key informant interviews will be done in order to identify the risk variables and decide the domains and items of the tool. Further, this tool will be developed as a mobile-based application. The feasibility of the mobile-based RA tool will be tested in real-time MG event in one part of the country. Concurrently in the same event, a community survey of residents and visitors will be done in order to assess public perceptions of public health and environmental risks associated with MG events. Discussion The findings of this study will provide insights into the public health and environmental concerns that need to be considered if preventive strategies and intervention programs are to be designed for MG events. A “RA Tool,” which can be used in the planning and management of MG events by the public health managers will strengthen the existing health systems preparedness plans for MGs.

Introduction Impulse control disorders (ICD) are reported to occur at variable frequencies in different ethnic groups. Genetic vulnerability is suspected to underlie the individual risk for ICD. We investigated whether the allelic variants of dopamine (DRD3), glutamate (GRIN2B) and serotonin (HTR2A) receptors are linked to ICD in Indian Parkinson’s disease (PD) patients. Methods We conducted a prospective, case-control study which included PD patients (70 with ICD, 100 without ICD categorized after direct psychiatric interview of patient and caregiver) and 285 healthy controls. Single nucleotide polymorphism (SNP) variants of DRD3 p.S9G (rs6280), GRIN2B c.2664C>T (rs1806201) and HTR2A c.102T>C (rs6313) were genotyped. Results Multivariate regression analysis revealed that DRD3 p.Ser9Gly (rs6280) heterozygous variant CT (OR = 2.22, 95% CI: 1.03–4.86, p = 0.041), higher daily Levodopa equivalent doses (LED) of drugs (for 100 mg LED, OR = 1.14, 95% CI: 1.01–1.29, p = 0.041), current dopamine agonist but not Levodopa use (OR = 2.16, 95% CI: 1.03–4.55, p = 0.042) and age of onset of motor symptoms under 50 years (OR 2.09, 95% CI: 1.05–4.18, p = 0.035) were independently associated with ICD. Conclusion DRD3 p.Ser9Gly (rs6280) CT genotype is associated with ICD in Indian PD patients and this association is novel. Enhanced D3 receptor affinity due to gain-of-function conferred by the glycine residues could impair reward-risk assessment in the mesolimbic system and contribute to development of impulsive behaviour, in carriers of this genotype.

Objectives “Long-term epilepsy associated tumors (LEATs)” by definition are tumors primarily causing drug-resistant seizures for two years or more. They include low-grade glial and glioneuronal tumors with normal life expectancy. We studied a large cohort of patients with LEATs who underwent surgery through our epilepsy program. Patients & methods From 1998–2011, 105 patients with LEATs underwent surgery in our center. We utilized their data archived in a prospective registry to evaluate their electro-clinical-imaging characteristics affecting the long-term seizure outcome. Results Of 105 patients (age 3–50 years), mean age at surgery was 20 years and mean pre-surgical duration of epilepsy was 10.9 years. 66 (62.8%) had secondary generalized seizures. 82 had temporal tumors, 23 had extra temporal (13 frontal, 3 parietal, 2 occipital and 5 multilobar lesions) and four had associated hippocampal sclerosis. The interictal discharges and ictal onset were concordant to the lesion in 82 (78%) and 98 (93%) patients respectively. Lesionectomy and/or adjoining corticectomy or temporal lobectomy was done. Ganglioglioma was the most dominant pathological substrate in 61 (58%). During a mean follow-up of 7.5 years (range 3–16 years), 78/105 (74.2%) were seizure-free and 45 (57.4%) were totally off drugs. Secondary generalized seizures (p-0.02), temporal location of tumor (p-0.008) and spikes in third month post-operative EEG (p-0.03) caused unfavorable seizure outcome. A pre-surgical duration of epilepsy of more than 6.6 years caused less than optimal surgical outcome Conclusions Early surgery should be considered a priority in LEATs. Presence of secondary generalized seizures is the single most important predictor of a poor seizure outcome.

BACKGROUND: The functional Ser9Gly single nucleotide polymorphism (SNP) in the dopamine D3 receptor gene is associated with impulse control disorders (ICD) in Parkinson's disease (PD) in Indian patients. Whether the same SNP modulates impulsivity in PD patients without active ICD is unknown. We aimed to compare decision‐making under uncertainty in PD patients with DRD3 p.S9G (rs6280) variants CT/CC or TT. METHODS: We conducted a cross‐sectional study including PD patients (n = 78) whose DRD3 p.S9G (rs6280) genotypic status was known (CC, CT, and TT). Decision‐making was assessed using the Iowa Gambling Task (IGT). RESULTS: IGT total (p = 0.267) or block scores did not differ between the DRD3 rs6280 variant groups. Deck choice analysis revealed that the CT/CC group showed a skewed preference in deck choice (p = 0.002) due to significantly fewer draws from deck B, compared to all other decks (deck A, p < 0.001; deck C, p = 0.004; deck D, p = 0.002). CONCLUSIONS: The functional Ser9Gly DRD3 variant is associated with aberrant decision‐making under uncertainty in PD patients without active ICD. This ability to modulate impulsivity may underlie its association with clinical ICD in PD.

Background The risk of stroke in patients with 50% or more asymptomatic carotid stenosis (ACS) on intensive medical treatment is low. Hence, the optimal treatment of ACS remains controversial at this point of time. Aim We assessed the risk of stroke/transient ischemic attack (TIA) and cardiac events in patients with 50% or more ACS on intensive medical treatment. Methods All patients with TIA/minor stroke (National Institutes of Health Stroke Scale score ≤5) who had undergone vessel imaging as part of their evaluation and patients with coronary artery disease who had undergone vessel imaging before cardiac intervention were screened for the presence of asymptomatic carotid stenosis. The risk of TIA/stroke, cardiac events, and vascular deaths were evaluated. Results Of 1,800 patients, 92 patients (.05%) had ACS having 50% to 99% stenosis; 63 had TIA/minor stroke, and 29 had coronary artery disease, of whom 7 patients had bilateral ACS, thus constituting 99 study units of ACS. The mean follow-up was 34.7 months (range 3-120 months). Two patients developed ischemic events on the side ipsilateral to the ACS and 9 patients developed cardiac events during the follow-up. The average annual event rate for cerebral ischemic events was .93% (95% confidence interval [CI], .11-3.37), 4.21% (95% CI, 1.92-7.98) for cardiac events, and 3.27% (95% CI, 1.31-6.74) for death. Conclusions Although the risk of stroke in patients with ACS is low, acute coronary events and vascular deaths were significant. This highlights the importance of intensive risk factor modification to reduce adverse cardiovascular events in ACS rather than revascularization of the carotid stenosis.

We aimed to compare the sociodemographics, health care utilization pattern, and out-of-pocket (OOP) expenses of 149 insured and 147 uninsured below-poverty-line households insured under the Comprehensive Health Insurance Scheme, Kerala, through a comparative cross-sectional study. Family size more than 4 (odds ratio [OR] = 2.34; 95% confidence interval [CI] = 1.13-4.82), family member with chronic disease (OR = 2.05; 95% CI = 1.18-3.57), high socioeconomic status (OR = 2.95; 95% CI = 1.74-5.03), and an employed household head (OR = 2.69; 95% CI = 1.44-5.02) were significantly associated with insured households. Insured households had higher inpatient service utilization (OR = 1.57; 95% CI = 1.05-2.34). Only 40% of inpatient service utilization among the insured was covered by insurance. The mean OOP expenses for inpatient services among insured (INR 448.95) was higher than among uninsured households (INR 159.93); P = .003. These findings show that urgent attention of the government is required to redesign and closely monitor the scheme.

Introduction: Several studies have shown that high admission glucose is associated with poor outcomes after stroke, but the impact of maintenance of normoglycemia on functional outcome during hospitalization for acute ischemic stroke is less well established. Aims: The aim of this study was to examine the independent association of postadmission glycemic status in the 1st week with 3-month functional outcome in patients with acute ischemic stroke. Methods: Patients with acute ischemic stroke admitted within 48 h of symptom onset with National Institutes of Health Stroke Scale (NIHSS) of ≥4 were selected from a prospectively maintained database by chart review. Demographic data, risk factors, NIHSS, and blood glucose values in the 1st week were collected. The primary outcome was Modified Rankin Scale (mRS) score at 3 months (good outcome-mRS ≤2). Results: Over 3 years, 342 patients were enrolled with 220 (64.32%) males. Mean age was 60.5 ± 13.4 years, and median admission score on NIHSS was 10 (interquartile range: 6–16). Blood glucose values persistently

Introduction: Primary angiitis of central nervous system (PACNS) is a rare and serious disorder of uncertain cause, with significant morbidity and mortality. Objective: To determine the clinical profile, response to treatment and outcome in patients with PACNS. Methodology: This is retrospective study of 47 patients from January 2000 to Dec 2015 with either angiographically or biopsy proven PACNS. Outcome at 6 months was considered poor, if modified rankin scale was &gt 2. Relapse was defined as occurrence of new neurological deficits after clinical improvement, progression of existing disability or radiological worsening. Results: The median age at diagnosis was 36 years (IQR 17) and 33 (70.2%) were males. Twenty-nine patients (61.7%) had angiography positive, 14 patients (38.3%) had biopsy confirmed and 4 patients (8.5%) had both angiography and biopsy positive PACNS .Stroke was the initial presentation in 33 patients (70.2%) followed by rapidly progressive dementia in 11 patients (23.4%) and myelopathy in 3 patients (6.4%). After a median follow-up of 2.8 years (range 0.5-15) , poor 6 month outcome was observed in 12 (25.5%), relapse in 24 (51.1%) and mortality in 3 (6.4%) patients. The median delay from onset of symptoms to start of immunosuppressive medication was 3.5 months (0.5- 63).More number of patients in the delayed treatment group had relapse compared to the early treatment group (59.1% vs 52.2%, p= 0.76). Among the 34 patients who received steroids as the initial treatment, 61.8% had relapse, whereas in patients on steroid with cyclophosphamide, only 38.5% had relapse (p=0.176). Of the 25 patients with abnormal CSF, 16 (64%) had relapse (p=0.209) and of the 18 patients with abnormal meningocortical biopsy, 15 patients (83.3%) had relapse. The NIHSS at admission &gt 5 (p=0.046), and presence of severe small vessel ischemic changes in MRI (p= 0.04) were predictors of relapse. Conclusion: PACNS is a rare disease with delayed diagnosis. Severity of neurological deficit at presentation and presence of severe small vessel ischemic changes in MRI were predictors of future relapse.

Background Revascularization surgery (RS) is the therapy of choice in moyamoya disease (MMD). Due to rarity of disease and ethical concerns, randomized controlled trials about the treatment options are lacking. Very little information is available on the long-term outcome of conservatively treated moyamoya patients. Aim We compared the long-term outcome of moyamoya patients treated conservatively to those who underwent RS. Methods Our study population included all patients with moyamoya disease/syndrome from 2002 to 2012. The demographic, clinical characteristic and imaging details were reviewed. The outcome was obtained prospectively. Results Of the 36 patients, 26 (72.2%) had MMD and 10 (27.8%) had moyamoya syndrome. The median age at onset of symptoms was 17.5 years (range, 10 months–55 years). Fifteen patients belonged to pediatric group and 21 were adults. All the pediatric patients had ischemic events at onset and 10 (47.6%) of the adults presented with hemorrhage. Twenty (55.6%) patients received conservative treatment and 16 (44.4%) underwent revascularization procedures. The median duration of follow-up was 28 months (range, 3–90 months). Three (18%) of the surgically treated patients had recurrent ischemic events on follow-up, but none of the conservatively treated patients had events. An excellent outcome (Modified Rankin Scale of ≤ 2) was seen in 12 (75%) surgically treated and 16 (94%) conservatively treated patients (p = 0.17). Conclusion Compared to East Asians, our patients had a lower stroke recurrence rate and good functional outcome even with conservative treatment. Future studies should focus on clinical and imaging predictors of progression to select moyamoya patients for RS.

Background: Most of the neurointerventional procedures use various anticoagulants, antiplatelets, and fibrinolytic drugs, and it can predispose arterial access site complications. Safe and efficient closure arteriotomy site has extreme importance in reducing the morbidity. Percutaneous vascular closure devices (VCDs) enable us to close the arteriotomy sites. In this prospective study, we evaluated the factors affecting the safety and efficacy of Perclose ProGlide VCD in neurovascular interventions. Materials and Methods: In this prospective study, we have evaluated the safety and efficacy of 327 Perclose ProGlide devices deployed in 217 patients who underwent various neurointerventions in our institute from October 2014 to October 2016. Time to achieve hemostasis (TAH) was calculated for various groups and the statistical significance of mean values between groups was estimated. Results: Out of the 327 Perclose ProGlide deployed, complication rate was 0.91% and the mean TAH was 77.14 s. Assessment of TAH mean value showed statistically significant prolongation of TAH in obesity and those with larger arterial sheaths. Age, sex, post-heparin ACT, peri-procedure medications, and type of diseases had no significant role in increasing TAH. The evaluation also showed the presence of a learning curve in using this device. Conclusion: Perclose ProGlide VCD is safe and effective in closing the arteriotomy after neurointerventions. Obesity and larger arterial sheaths are independent factors prolonging the TAH. Learning curve associated with this device mildly increases the hemostatic time and device-related complications.

To study the usefulness of the Wada test for predicting seizure outcome following anterior temporal lobectomy (ATL).From 1996 to 2002, all patients with left mesial temporal lobe epilepsy and hippocampal sclerosis (MTLE-HS) and selected patients with right MTLE-HS underwent the Wada test before ATL at our center. Patients were selected for ATL on the basis of unilateral HS on MRI and concordant electro-clinical data. Twelve-item recognition paradigm was used for Wada memory testing. Score of +1 was awarded for a correct response and -0.5 for an incorrect response. We defined Wada failure as a contralateral score of5, ipsilateral score of8, and difference score of0. No patient was denied surgery based on the Wada results. Means of the three scores were compared between seizure free and non-seizure free patients. Sensitivity, specificity and receiver operator characteristic curves of various scores for predicting seizure outcome were calculated.151 patients (129 left MTLE; mean age: 27.80±8.72 years) formed the study group. At mean postoperative follow-up of 6.4±2.0 years, 127 patients were seizure free. Mean contralateral score was lower in the seizure-free group (7.15±3.07 vs. 8.71±4.13; p0.001) while ipsilateral and difference scores were similar between the two seizure outcome groups. Areas under the curves for contralateral, ipsilateral and difference scores for predicting seizure-free outcome were 0.49, 0.58 and 0.59, respectively, suggesting its modest usefulness in individual patients. Results remained same when the analysis was restricted to left MTLE patients.Wada test has limited usefulness for predicting seizure outcome following ATL.

Aim: The duration of improvement in quality of life after subthalamic nucleus deep brain stimulation (STN DBS) for Parkinson's disease (PD) and the presurgical identification of factors predicting sustained clinical benefits have implications in patient selection and timing of surgery. These aspects were assessed in patients who underwent yearly assessment for at least 7 years after surgery. Materials and Methods: The quality of life, motor and cognitive outcomes of 25 patients who completed the 7-year assessment, and 12 patients who completed the 10-year assessment, were analyzed. Results: The improvement in quality of life was sustained only for 5 years, while the severity of motor signs and motor fluctuations remained reduced at 7 and 10 years. Tremor and rigidity showed more enduring reduction than bradykinesia and axial signs. The dose reduction in medications could be maintained until 7 years, by which time, the axial scores were worse than that seen at the pre-DBS levels. At 10 years, a higher levodopa requirement and recurrence of dyskinesias were noted. Patients with greater pre-DBS levodopa-responsive motor signs had greater long-term motor improvement. Conclusions: STN DBS performed in patients with advanced motor fluctuations and severe dyskinesias provide only an average of 5 years of quality of life improvement. STN DBS in patients with motor signs that are less responsive to levodopa results in shorter duration of clinical benefits. The improvements in the severity of motor fluctuations, rigidity, and tremor are the most enduring benefits of STN DBS that last a decade . However, these are offset by worsening axial and cognitive functions, bradykinesia, a higher levodopa requirement, and recurrence of dyskinesias by the end of the decade.

Carbohydrate intolerance is the most common metabolic complication of pregnancy. Gestational diabetes mellitus (GDM) poses numerous problems for both mother and fetus. The objective of this study was to compare the maternal and perinatal outcome between women with gestational diabetes mellitus and non-diabetic women.A case-control study with 286 cases and 292 age-matched controls was conducted for a period of 11 months (August 2007-June 2008) in Sree Avittom Thirunal Hospital, Thiruvananthapuram, India.Universal screening was applied by means of glucose challenge test (GCT) using 50 g of glucose. If GCT130 mg%, the patients were subjected to oral glucose tolerance test with 100 g of glucose. National Diabetes Data Group criteria was taken to assign patients to study group. These women were further followed up and the maternal and perinatal outcomes were assessed.Univariate analysis was done by means of t test, Odd's ratio, Chi-square test, and Fisher Exact test. P 0.05 was taken as significant.The frequency of induction of labor was significantly higher than spontaneous labor (OR = 1.84, P = 0.001). 40.1 % GDM mothers and 35.8 % of non-diabetic mothers were delivered by Cesarean section. Premature rupture of membranes (PROM) was the most common complication of labor (OR = 1.66, P = 0.04). Babies of diabetic mothers had a positive trend toward prematurity (OR = 2.3, P = 0.007). Hypoglycemia was the most common neonatal complication (OR = 11.97, P 0.001) and nine babies of diabetic mothers were macrosomic (OR = 5.2, P = 0.02).Maternal morbidities and neonatal complications such as neonatal hypoglycemia, macrosomia, and prematurity were significantly higher in GDM.

Objective: To identify the rate of successful antiepileptic drug (AED) withdrawal after resective surgery and the predictors of postwithdrawal seizure recurrence in patients with extratemporal epilepsy. Methods: We retrospectively analyzed the postoperative AED profile of 106 consecutive patients who had completed 2 or more years after resections involving frontal, parietal, and occipital lobes for AED-resistant epilepsy. To identify the potential predictors of seizure recurrence, we compared the attributes of recurred and nonrecurred groups by univariate and multivariate analyses. Results: We attempted AED withdrawal in 94 (88.7%) patients. Forty-four (41.5%) patients had seizure recurrence while reducing AED, of which 14 (31.8%) did not become seizure-free subsequently. On multivariate analysis, an abnormal postoperative EEG and longer preoperative duration of epilepsy predicted seizure recurrence, while early postoperative seizures and presence of gliosis or dysplasia were additional predictors on univariate analysis. At mean follow-up duration of 4.6 years, 63 (59.4%) patients were seizure-free. The cumulative probability of achieving complete AED-free status was 20% at fourth year, 34% at sixth year, 40% at eighth year, and 52% at 10th year after surgery. Conclusions: Following resective extratemporal epilepsy surgery, AED can be successfully discontinued in only in a minority of patients. One-third of patients who recur fail to regain seizure control upon AED reintroduction. Longer duration of epilepsy prior to surgery, abnormal postoperative EEG, early postoperative seizures, and focal gliosis or dysplasia as substrate predispose to seizure recurrence. This information will be helpful in making rational decisions on AED withdrawal following extratemporal resective epilepsy surgery.

Background: Nonmotor symptoms in Parkinson's disease are frequent and affect health-related quality of life of patients. The severity and domains of nonmotor symptoms involved in Parkinson's disease and normal aging have not been compared before. Methods: We performed a prospective case–control study to assess the frequency and severity of nonmotor symptoms in patients with Parkinson's disease (n = 174) and age-matched normal controls (n = 128) using the Non-Motor Symptoms Scale. Results: Nonmotor symptoms in Parkinson's disease were ubiquitous, more frequent, and more severe than in normal aging, particularly in women. Cardiovascular, mood/cognition, and perceptual problems/hallucinations domains were rarely involved in age-matched controls. Age had no effect and sex some influence on nonmotor symptoms in Parkinson's disease. In contrast, in controls, nonmotor symptoms increased with age, and sex had no effect. Conclusions: Nonmotor symptoms in Parkinson's disease differ from those in aging in frequency, severity, sex predilection, and domain involvement. © 2011 Movement Disorder Society

Objective: To assess the value of postoperative EEG in predicting seizure outcome and seizure recurrence following antiepileptic drug (AED) withdrawal in patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). Methods: We studied 262 consecutive patients with MTLE-HS with serial EEGs at 3 months, and at 1, 2, and 3 years after anterior temporal lobectomy (ATL), and considered the presence of interictal epileptiform discharges (IED) as abnormal. We attempted AED withdrawal in all seizure-free patients. We defined favorable outcome as freedom from seizures/auras during the entire follow-up period (outcome 1) and during terminal 1-year follow-up (outcome 2). Results: During mean follow-up period of 7.6 (range 5–12) years, 129 (49.2%) patients had favorable outcome 1 and 218 (83.2%) had favorable outcome 2. Of 225 (85.9%) patients in whom AED withdrawal was attempted, 61 (27.1%) had seizure recurrence. Compared to patients with normal EEG, those with IED on 1-year post-ATL EEG had a 3-fold increased risk for unfavorable outcome 1 and 7-fold increased risk for unfavorable outcome 2. The patients in whom all the 4 EEGs were abnormal had 9-fold odds for unfavorable outcome 1 and 26-fold odds for unfavorable outcome 2. An abnormal EEG at 1 year increased the risk of seizure recurrence following AED withdrawal by 2.6-fold. Conclusions: Post-ATL EEG predicts seizure outcome and seizure recurrence following AED withdrawal. Serial EEGs predict outcome better than single EEG. This information will be helpful in counseling of patients after ATL, and in making rational decisions on AED withdrawal.

Reports of long-term effects of subthalamic (STN) stimulation for Parkinson's disease (PD) are few, mostly open-label evaluations and from Western centers. We used single-blind and open-label motor, cognitive and quality of life (QOL) evaluations to study the effects of bilateral STN stimulation in 45 patients over 5 years. Our patients showed a stable and substantial reduction in the cardinal signs of PD, motor fluctuations, and dyskinesias but less so for axial signs. The reduction in medications and the intensity of electrical stimulation needed also remained stable during follow up. Although the total QOL and its parkinsonism and social components showed sustained benefits till 5 years, the gains in emotional and systemic subsets were short lasting. Global scores for mood and cognition did not show significant worsening. Benefits of STN stimulation on the cardinal signs, motor complications, and QOL of advanced PD were substantial and sustained till 5 years. The initial benefits in axial motor signs and emotional and psychological aspects of QOL did not show similar stability. In general, the procedure had insignificant impact on cognition and mood. This is the first report of STN stimulation in Asian patients with PD.

To investigate diagnostic value, therapeutic benefit and cost-effective utilization of video-EEG monitoring (VEM) in a comprehensive epilepsy program in a developing country. The authors prospectively recruited all patients who underwent long-term (> or =3 hours) inpatient VEM during a 10-month period. The cohort was followed to gather information about the proportion of patients in whom long-term management was altered by VEM and resultant impact on direct health care costs. Out of 143 study subjects (median age 22 years), 102 (71.3%) were referred for presurgical evaluation. The median duration of VEM was 61 hours, and median number of events recorded per patient was 3. Video-EEG monitoring helped to clarify the epilepsy syndromic diagnosis in 123 of 132 (93.2%) patients referred with the diagnosis of epileptic seizures. Video-EEG monitoring confirmed coexistent complex partial seizures in 4 of 11 (36.4%) patients with a referral diagnosis of psychogenic nonepileptic events. During mean follow-up period of 2.2 years, 48 patients (33.6%) underwent epilepsy surgery. A significant decrease in antiepileptic drug polytherapy, and minimization in recurring direct medical and nonmedical costs occurred. In addition to immediate diagnostic usefulness, VEM contributes significantly to long-term therapeutic and economic benefits for patients with difficult to diagnose and treat paroxysmal events.

BACKGROUND The incidence of Guillain-Barre syndrome (GBS) and its subtypes varies throughout the world. OBJECTIVE AND METHODS We present a retrospective analysis of 142 GBS cases, treated at our center, aimed at classifying GBS electrophysiologically, to study the sequential electrophysiological changes in cases with acute inflammatory demyelinating polyradiculoneuropathy (AIDP), and to look for any clinical and cerebrospinal fluid parameters that can also help in distinguishing the subtypes. RESULTS One hundred twenty-one (85.2%) cases had AIDP, 15 (10.6%) had acute motor axonal neuropathy, and 6 (4.2%) were unclassifiable. CONCLUSIONS Motor conduction blocks and temporal dispersion could be observed from days 3 and 5 onward, respectively. Progression of motor conduction slowing in AIDP was most impressive in the median nerves. Varying affection of deep tendon reflexes, cranial nerves, and cerebrospinal fluid albuminocytological dissociation can also help make a distinction between AIDP and acute motor axonal neuropathy. Sural sparing, a marker of demyelinating neuropathy, is more commonly seen in later than in early stages of AIDP.

There is a dearth of information on the critical utility of positron emission tomography (PET) in choosing candidates for epilepsy surgery especially in resource-poor countries where it is not freely available. This study aimed to critically analyze the utility of FDG-PET in the presurgical evaluation and surgical selection of patients with DRE based on the results obtained through its use in our comprehensive epilepsy program.From 2008 to 2012, 117 patients with drug-resistant epilepsy underwent F-18 fluoro-deoxy-glucose (FDG) PET in our center. We utilized their data to audit the utility of PET in choosing/deferring patients for surgery.Of the 117 patients (age: 5-42years) who underwent F-18 FDG-PET, 64 had normal MRI, and 53 had lesions. Electroclinical data favored temporal ictal onset in 48 (41%), extratemporal in 60 (51.3%), and uncertain lobar localization in 9 (7.7%). The topography of PET hypometabolism was localizing in 53 (45.3%), lateralizing in 12 (10.3%), and 52 (44.4%) had either normal or discordant results. In the nonlesional group, focal hypometabolism was concordant to the area of ictal onset in 27 (41.5%) versus 38 (58.5%) in the lesional group (p=0.002). Greater concordance was noted in temporal lobe epilepsy (TLE) (78.0%) as compared to extratemporal epilepsy (ETPE) (28.6%) (p0.001). Positron emission tomography was more concordant in patients with mesial temporal sclerosis than in those with other lesions (82.8% versus 50%) (p=0.033). Positron emission tomography helped in surgical decision-making in 68.8% of TLE and 23.3% of ETPE cases. Overall, 37 patients (31.6%) were directly selected for resective surgery based on PET results.Positron emission tomography, when utilized judiciously, remained an ancillary tool in the surgical selection of one-third of patients with drug-resistant partial epilepsy, although its utility as an independent tool is not very promising.

The objective of this study was to explore the functional anatomy of the globus pallidus internus (GPi) by studying the effects of unilateral pallidotomy on parkinsonian \`off' signs and levodopa-induced dyskinesias (LID). We found significant positive correlations between the preoperative levodopa responsiveness of motor signs and the levodopa responsiveness of scores in timed tests (Core Assessment Program for Intracerebral Transplantations) in the contralateral limbs and the improvement in these scores after surgery, whereas there was no correlation with the improvement in LID. We also found a highly significant correlation ( P < 0.0001, r = 0.8) between the volume of the ventral lesion in the GPi and the improvement in LID in the contralateral limbs, whereas there was no correlation between the ventral volume and the improvement in parkinsonian \`off' signs. The volumes of the total lesion cylinder and the dorsal lesion did not correlate with the outcome of either dyskinesias or parkinsonian \`off' signs. The differential predictive value of levodopa responsiveness for the outcome of parkinsonian \`off' signs and LID and the different correlations of ventral lesion volume with dyskinesias and parkinsonian \`off' signs indicate that different anatomical or pathophysiological substrates may be responsible for the generation of parkinsonian \`off' signs and dyskinesias. Whereas cells in a wider area of the GPi may be implicated in parkinsonism, the ventral GPi seems to be crucial for the manifestation of LID. We suggest that our observations are additional proof of the functional somatotopy of the systems within the GPi that mediate parkinsonism and dyskinesias, especially along the dorsoventral trajectory used in pallidotomy. The outcome of pallidotomy in which the lesion involves the ventral and dorsal GPi could be the net effect of alteration in the activity of pathways which mediate different symptoms, and hence could be variable.

In order to define the EEG spectrum and the prevalence of breach activity, as well as the factors contributing to its genesis, we studied 50 patients with surgically induced skull defects. We observed breach activity in 32 (64%) patients. Focally enhanced alpha, beta, and mu rhythms with or without decreased amplitude of eye movement artifacts were the EEG findings encountered in our patients. The amplitude asymmetry never exceeded a factor of 3 or more. Of the variables compared between patients with and without breach activity, only the time between surgery and the EEG recording correlated positively with the development of breach activity. The delay in the development of breach activity may indicate that breach activity is not due solely to the discontinuity of bone. The development of meningocortical adhesions and gliosis could contribute to the pathogenesis of breach activity.

Summary Use of antiepileptic drugs (AEDs) in pregnant women with epilepsy (WWE) is associated with an increased risk of major congenital malformations (MCM). Previous studies have suggested that WWE who had a malformation in their index pregnancy were at an increased risk of recurrence in future pregnancies. We aimed to assess the risk of recurrence of MCM in 1,616 WWE from Kerala Registry of Epilepsy and Pregnancy. The pregnancy outcome of women (n = 246) with two prospective pregnancies in the registry were analyzed. They had partial seizures with or without generalization (57.3%) or generalized seizures (42.7%). Polytherapy was used in 26.4% (index pregnancy) and 23.6% (follow-up pregnancy). The mean dosage of AED for valproate was 498 mg/day and carbamazepine was 555 mg/day. The malformation rate in the index pregnancy was 8.5% (21/246) and in the follow-up pregnancy was 8.9% (22/246) with only one recurrence. There was no increased risk of MCM in follow-up pregnancy for those who had MCM in the index pregnancy (p = 0.70; OR 0.49; 95% CI 0.06–3.80). The use of any specific drug, continuation of the same drug or a change in drug therapy between two pregnancies did not alter the recurrence risk.

Stroke leaves at least 60% of the survivors with moderate to severe disability limiting their employment status and social functioning leading to high levels of caregiver burden. Aim We sought to study the employment status and level of change of social functioning of stroke survivors and their principal caregiver and correlate it with severity of stroke, functional disability, and anxiety and depression scores. Methods One hundred and fifty stroke survivors and principal caregivers (3 months–2 years post-stroke) were recruited for the study. The employment status pre- and post-stroke was assessed. The social function of the patient and caregiver was analyzed using a 6 item social function scale developed for the study, encompassing culturally relevant questions. A 20 point scale adapted from Burden assessment schedule was used to assess the caregiver burden. Results Mean age of the study group was 54.37 ± 12.072 (range 22–75 years), with 116 males and 34 females. Spouse was the principal caregiver for 142/150 patients (94.6%). In the stroke survivors, compared to the pre-stroke employment status of 62.7%, only 20.7% were employed post-stroke with half having change of job. But the employment status of caregiver was not reduced post-stroke (34.7% vs 33.3%). Employment loss in stroke survivors had a statistically significant association with severity of functional disability, male gender and presence of limb weakness (p values 0.037, 0.0001 and 0.043 respectively). There was an overall decline in social functions among the 6 parameters assessed in both the stroke survivors and caregivers. Of the caregiver burden, financial burden was more among female and older caregivers. The functional status and motor weakness of the stroke survivors did not tend to worsen the overall caregiver burden. Conclusions Loss of occupation among stroke survivors is high. The decline in social function among stroke survivors and caregivers was significant. Even though functional disability contributed to employment loss and social function decline among stroke survivors, it did not have a significant impact on caregiver burden.

We compared the screening performance of risk scores for Asians and whites for diabetes, dysglycemia, and metabolic syndrome. Our subjects were 451 people aged 15 to 64 years who participated in a cohort study from May 2003 through September 2010 in a rural area of the Thiruvananthapuram district of Kerala, India. All outcome measures showed overlap in the range of area under the receiver operating characteristic curves of Asian and white diabetes risk scores (DRSs). Asian and white DRSs performed similarly in rural India.

Aims To assess the functional and clinical outcome in a sizeable cohort of patients with osmotic demyelination syndrome (ODS) and to characterise the factors which could predict the final outcome. Methods Twenty five consecutive patients with ODS formed the study cohort. The diagnosis of ODS was based on clinical features with corroborating imaging findings. Two functional scales—Functional Independent Measure (FIM) and Disability Rating Scale (DRS)—were applied to assess the functional status at the time of admission, discharge and last follow-up. Patients who became independent for activities of daily living (ADL) at last follow-up were classified as favourable outcome, and those who died or became dependent for ADL were classified as a poor outcome group respectively. The Fisher exact test and Mann–Whitney U test were used to assess categorical and continuous variables respectively. Results The mean age at diagnosis was 53±14 years. Five (20%) had central pontine myelinolysis, seven (28%) had extrapontine myelinolysis, and 13 (52%) had both. Hyponatraemia and hypokalaemia were noted in 20 (80%) and 10 (40%) patients respectively. Six (24%) received intravenous methylprednisolone. Eleven (46%) had a favourable outcome at a mean follow-up of 2.2±2.5 years. Hyponatraemia ≤115 mEq (p=0.04), associated hypokalaemia (p=0.04) and low Glasgow Coma Scale (GCS) (p=0.008) at presentation were predictive of poor outcome. The mean FIM score at admission (p=0.05) and at discharge (p=0.01), and mean DRS at admission (p=0.05) were predictive of poor outcome. Conclusions Higher GCS scores, better scores in functional scales in hospital, less severe hyponatraemia and absence of superadded hypokalaemia predicted favourable outcome.

To define the determinants of impaired facial emotion recognition (FER) in patients with mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE-HS), we examined 76 patients with unilateral MTLE-HS, 36 prior to antero-mesial temporal lobectomy (AMTL) and 40 after AMTL, and 28 healthy control subjects with a FER test consisting of 60 items (20 each for anger, fear, and happiness). Mean percentages of the accurate responses were calculated for different subgroups: right vs. left MTLE-HS, early (age at onset

Objective: To derive population norms on the Malayalam adaptation of Addenbrooke’s Cognitive Examination (MACE) and the inclusive Malayalam mini mental state examination (M-MMSE). Materials and Methods: Education-stratified norms were obtained on randomly selected cognitively unimpaired community elders (n = 519). Results: Valid data on norms was available on 488 subjects (age 68.5 ± 7.1 and education 7.9 ± 5.4). Education and age, but not gender had a significant effect on both MACE and M-MMSE. When compared to the effect of age, the effect of education was sevenfold more on the M-ACE and ninefold more on the M-MMSE. The mean composite score on the M-ACE (and the M-MMSE) was 42.8 ± 9.8 (14.9 ± 3.1) for those with 0 (n = 72), 55.9 ± 12.5 (19.7 ± 4.1) with 14 (n = 96), 62.6 ± 11.4 (21.9 ± 3.7) with 5-8 (n = 81), 77 ± 10.2 (25.7 ± 2.4) with 9-12 (n = 136) and 83.4 ± 7.2 (26.7 ± 1.6) with >12 (n = 103) years of formal education. Conclusions: Education has the most potent effect on performance on both M-ACE and M-MMSE in the Indian cohort. Education-stratified scores on the M-ACE and the M-MMSE, will provide a more appropriate means of establishing the cognitive status of patients. It is also our feeling that these cut-off scores will be useful across India.

The stigma attached to epilepsy often restricts early diagnosis and optimal care, particularly among the underprivileged. We aimed to ascertain any gender bias in the utilization of services for epilepsy in a tertiary and community care facility in Kerala State, India.The R. Madhavan Nayar Center for Comprehensive Epilepsy Care (RMNC) is a leading tertiary care facility in South India. The District Mental Health Program (DMHP) is a community-based care facility that provides medical consultation and anti-epileptic drugs (AED) free of charge. We analyzed the sex ratio (SR) - number of women per one thousand men - of all registrations in these centers according to year of registration, age, religion, income, distance from domicile to the center, and religion.The SR in the RMNC (1976-2004, n = 12354) was 729. At RMNC, age-specific SR increased up to the 3rd decade (864), and progressively declined beyond 50 years. The SR was lower for those domiciliated at more than 200 km from the center when compared to others. The SR at the DMHP (1999-2004, n = 221) was high (1125). The age-specific SR at DMHP showed two peaks at 21-30 years (1368) and 51-60 years (2333).Fewer women with epilepsy (particularly in lower socioeconomic groups) receive tertiary care in this state, in spite of a higher SR in the community (907 for epilepsy and 1058 for all population). The tertiary treatment gap is wider for women over 30 years (particularly over 50 years), when their longer life expectancy is also taken into consideration.

BACKGROUND: Very few studies have specifically addressed surgical treatment and outcome of patients with tumor-related temporal lobe epilepsy (TLE). AIM: To define the postoperative seizure outcome and the factors that influenced the outcome of patients with tumor-related TLE. MATERIALS AND METHODS: We selected patients whose surgical pathology revealed a temporal lobe neoplasm and who had completed > 1 year of postoperative follow-up. We reviewed the clinical, EEG, radiological and pathological data, and the seizure outcome of these patients and assessed the factors that influenced the outcome. RESULTS: Out of the 409 patients who underwent surgery for refractory TLE during the 8-year study period, there were 34 (8.3%) patients with temporal lobe neoplasms. The median age at surgery was 20 years and the median duration of epilepsy prior to surgery was 9.0 years. MRI revealed tumor in the mesial location in 21 (61.8%) patients. Interictal and ictal epileptiform EEG abnormalities were localized to the side of th lesion in the majority. Mesial temporal lobe structures were included in the resection, if they were involved by the tumor; otherwise, lesionectomy alone was performed. During a median follow-up of 4 years, 27 (79%) patients were completely seizure-free. The only factor that predicted long-term seizure-free outcome was being seizure-free during the first two postoperative years. CONCLUSIONS: Our results emphasize the fact that in patients with tumoral TLE, when the seizures are medically refractory, surgery offers potential for cure of epilepsy in the majority.

Background: Transient ischemic attack (TIA) and minor ischemic stroke (MIS) are associated with early recurrence and deterioration respectively. The aim of the present study was to assess the risk of new cerebrovascular and cardiovascular events in a prospective, emergently enrolled patient cohort with TIA and MIS and the predictors of risk. Materials and Methods: Patients with TIA and MIS (NIH Stroke Scale [NIHSS] ≤ 5) presenting within the first 48 h between July 2008-June 2009 were prospectively enrolled. The primary outcome was new-onset stroke, TIA, cardiovascular events and vascular death at 90 days and early deterioration in patients with minor stroke. The 90-day outcome was also assessed (excellent outcome; modified Rankin scale [mRS] ≤2). Results: Eighteen (15.3%) of the 118 patients enrolled developed new cerebrovascular or cardiovascular events during the 90 days of follow-up, nine (50%) of which occurred within seven days. Of the all new events 5.9% (7/118) had new stroke, 4.2% (5/118) patients developed early deterioration, 2.5% (3/118) patients had recurrent TIA and 2.5% (3/118) had cardiovascular events at 90 days. Eight (6.7%) patients had poor outcome at 90 days (mRS>2). The factors predicting new vascular events were presence of coronary artery disease (CAD), and stroke etiology being large artery atherosclerosis (LAA). Conclusion: In patients with TIA and MIS, despite urgent evaluation and aggressive management, the short-term risk of stroke and other vascular events is high. Those with CAD and LAA should be monitored closely for early deterioration.

Objective: No guideline currently exists to choose the clinically equivalent dose of divalproex extended release (ER) formulation while switching over from valproate chrono formulation. To address this issue, we evaluated the serum valproate concentration following switch over from valproate chrono to divalproex ER in persons with epilepsy. Materials and Methods: An open label study was conducted in two parts, each for a period of two months. During Part I, patients on regular twice-daily dose of valproate chrono were switched over to once daily divalproex ER (DESVAL ER® ) based on the dose escalation recommended when switching over from divalproex DR to ER formulation as the guideline. During Part II, we switched from valproate chrono to divalproex ER with same dosage. Serum valproate concentration, seizure frequency and side effects were assessed serially for two months after changeover and compared with the preswitch data. Results: During Part I, compared to the baseline level, there was a significant increase in mean serum valproate level at two months (67.0 ± 28.4 mg/ml versus 91.9 ± 3.5 mg/ml, P 0.004). With the same dose conversion during Part II, the mean valproate level did not significantly differ before and after the switch (81.5 mg/dl versus 85.7 mg/dl, P 0.08). The mean monthly seizure frequencies and serum ammonia levels did not change during either part. No significant adverse effects occurred. Conclusion: The results of this open label study with small number of patients need to be replicated among larger patient sample through a randomized control design before recommending same dose conversion from valproate chrono to divalproex ER without change in efficacy and tolerability