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Background The past three decades have seen palmistry as an interface to human health. There have been no previously organized attempts in utilizing this knowledge to predict the state of disease. Objective Due to unavailability of any biological marker for diagnosing amyotrophic lateral sclerosis (ALS) till date, we attempt to examine whether palmistry could be used for detecting the onset and survival of patient suffering from ALS. Methods Patients suffering from ALS attending the neurology outpatient department at Postgraduate Institute of Medical Education and Research, India were selected for study. Palm photographs were obtained from all patients including controls after their consent. Patients suffering from other comorbidities such as diabetes, hypertension, migraine, as well as smokers and nonsmokers were included in the study. Twenty-six ALS patients, 30 neurological controls, and 34 healthy age matched controls were recruited in the study. Retrospective analysis of the palm pictures based on blinding method was performed by academically qualified palmists. Results The results demonstrated the need for further studies in the subject even though the observations made were independent by both the palmists. Conclusion This study opens new vistas for cheiromancy to be further explored for analysis in larger samples.

Context: The data on the role of Transcranial Doppler (TCD) in the management of acute primary intracerebral hemorrhage (ICH) is meager. Aims: To study TCD variables associated with hematoma expansion in acute primary ICH. Settings and Design: The study was carried out in the neurosciences department of Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh from July 2010 to September 2011 employing a prospective, double blinded non randomized study design. Materials and Methods: Acute ICH patients within 24 h of symptom onset were recruited. Baseline neuroimaging study (Computerized tomography, CT scan of brain) was performed to assess the pure hematoma volume by AXBXC/2 method. Baseline TCD parameters were obtained from both the middle cerebral arteries (MCAs; affected and unaffected hemisphere): Peak Systolic velocity, End Diastolic velocity, Mean Flow velocity, Resistance Index, and Pulsatility Index. Follow up (24 h) assessment of hematoma volume and TCD were carried out. Each of the TCD variables were compared in hematoma expansion (>33% increase in hematoma volume on the follow-up CT) and non-expansion group. Statistical analysis: On univariate analysis, the Student's t-test and contingency tables with the X2 test were used. A forward stepwise multivariate logistic regression analysis with hematoma expansion at 24 h as the dependent variable and ROC analysis was carried out, using SPSS software version 16 (Chicago, IL). P value < 0.05 was considered significant. Results: Twenty-five patients completed the study. Ten patients (40%) had hematoma expansion. Multivariate analysis revealed unaffected hemisphere MCA Pulsatility Index ratio [unaffected hemisphere MCA Follow up Pulsatility Index/baseline Pulsatility Index] of > 1.055 as the lone correlate of hematoma expansion (sensitivity of 90% and specificity of 60%). Conclusion: Frequent assessment with TCD could aid in prediction of hematoma expansion by measuring unaffected hemisphere Pulsatility Index ratios.

Telephonic Barthel Index (BI) assessment is less time-consuming and more feasible than a face-to-face interview. The aim of this study was to test the validity as well as reliability of the BI administered by telephone in comparison with face-to-face assessment in a multi-centric study. The study was conducted during the course of a randomized controlled trial in which 120 patients with subacute strokes from five teaching hospitals from different parts of India were recruited. Central telephonic follow-up and face-to-face assessment of BI and modified Rankin Scale (mRS) at 3 and 6 months were done by trained and certified blinded researchers. Kappa or weighted kappa (wK) was estimated. Sensitivity and specificity at various cutoff levels of telephonic BI were calculated. Concurrent validity of the telephonic BI was assessed by correlating it with the mRS and National Institutes of Health Stroke Scales (NIHSS) at 3 and 6 months. We observed high sensitivity and specificity at various cutoff levels of BI. Moderate to substantial agreement was observed between the two methods at 6 months wK 0.72 (95% CI 0.70-0.77). Item-wise and center-wise kappa also reflected substantial agreement. The study shows that telephonic assessment of activities of daily living with the BI in moderate to severely disabled stroke patients is valid and reliable compared to face-to-face assessment. Our study shows that telephonic assessment requires smaller sample size compared to face-to-face assessment of BI.

The predictors of poor outcome in tuberculous meningitis (TBM) remain to be delineated. We determined role of various clinical, radiological and cerebrospinal fluid (CSF) parameters in prediction of outcome in TBM.Current study was a prospective observational study including 209 patients of TBM. All patients underwent detailed evaluation including Gadolinium enhanced Magnetic resonance imaging (GdMRI) of brain as well as tests to detect evidence of tuberculosis elsewhere in body. They also underwent GdMRI at three and nine month follow up. All patients received treatment as per standard guidelines.Mean age was 30.4±13.8years. 139 (66.5%) patients had definite TBM while 70 (34.5%) had highly probable TBM. 53 (25.4%) patients died. On univariate analysis, longer duration of illness, altered sensorium, stage III TBM, hydrocephalus and exudates correlated with poor outcome. On multivariate analysis presence of hydrocephalus (p=0.003; OR=3.2; 95% CI=1.5-6.7) and stage III TBM (p0.0001; OR=8.7; 95% CI=3.7-20.2) correlated with higher risk of mortality. In addition, there was significant positive association between presence of hydrocephalus (p=0.05; OR=2.2; 95% CI=0.97-5.1), stage III TBM (p0.0001; OR=28; 95% CI=4.9-158) and presence of altered sensorium (p=0.05; OR=22; 95% CI=0.99-4.8) with either death or survival with severe disability.It is possible to prognosticate TBM using a combination of clinical and radiological. The duration of illness (65.9±92days) before diagnosis of TBM continues to be unacceptably long and this stresses on need to educate primary care physicians about TBM. Future studies where intensity and duration of treatment is guided by these cues may help in sorting out some of the most difficult questions in TBM, namely duration of antitubercular therapy as well as dose and duration of steroid therapy etc.

Introduction: Apolipoprotein E (APOE) epsilon 4 is the major genetic risk factor for Alzheimer's disease (AD), but its prevalence is unclear because earlier studies did not require biomarker evidence of amyloid beta(A beta) pathology. Methods: We included 3451 A beta+ subjects (853 AD-type dementia, 1810 mild cognitive impairment, and 788 cognitively normal). Generalized estimating equation models were used to assess APOE epsilon 4 prevalence in relation to age, sex, education, and geographical location. Results: The APOE epsilon 4 prevalence was 66% in AD-type dementia, 64% in mild cognitive impairment, and 51% in cognitively normal, and it decreased with advancing age in A beta+ cognitively normal and A beta+ mild cognitive impairment (P

Accurate identification of neurocognitive impairment associated with HIV infection (and other CNS-involved conditions) is dependent upon utilization of appropriate normative neuropsychological test performance data from healthy individuals with a similar background, culture, and characteristics of the target individual or group to be tested. In India, regional differences in language, culture, and availability of resources can significantly affect performance on neuropsychological testing. This study developed age- and education-adjusted normative data for commonly used neuropsychological test scores for use in northern India.

Background and Purpose— Pilot studies have suggested benefit from intravenous administration of bone marrow mononuclear stem cells (BMSCs) in stroke. We explored the efficacy and safety of autologous BMSCs in subacute ischemic stroke. Methods— This was a phase II, multicenter, parallel group, randomized trial with blinded outcome assessment that included 120 patients. Patients with subacute ischemic stroke were randomly assigned to the arm that received intravenous infusion of autologous BMSCs or to control arm. Coprimary clinical efficacy outcomes were Barthel Index score and modified Rankin scale at day 180. Secondary outcomes were change in infarct volume, National Institute of Health Stroke Scale (NIHSS) at day 90 and 180. Main safety outcomes were adverse events, any new area of 18 fluorodeoxyglucose positron emission tomography uptake in any body part over 365 days. Results— Fifty-eight patients received a mean of 280.75 million BMSCs at median of 18.5 days after stroke onset. There was no significant difference between BMSCs arm and control arm in the Barthel Index score (63.1 versus 63.6; P =0.92), modified Rankin scale shift analysis ( P =0.53) or score >3 (47.5% versus 49.2%; P =0.85), NIHSS score (6.3 versus 7.0; P =0.53), change in infarct volume (−11.1 versus −7.36; P =0.63) at day 180. Adverse events were also similar in the 2 arms, and no patient showed any new area of 18 fluorodeoxyglucose uptake. Conclusions— With the methods used, results of this hitherto first randomized controlled trial indicate that intravenous infusion of BMSCs is safe, but there is no beneficial effect of treatment on stroke outcome. Clinical Trial Registration— URLs: http://ctri.nic.in/Clinicaltrials and http://www.clinicaltrials.gov . Unique identifiers: CTRI-ROVCTRI/2008/091/0004 and NCT0150177.

Background During the global H1N1 pandemic, neurological complications were reported in approximately 6–10% of children suffering from H1N1 infection, but only rarely in adults. Generalized convulsive status epilepticus (GCSE) as a presenting manifestation of H1N1 infection in an adult is exceedingly rare and has not been reported in literature. We report a patient who presented to us with GCSE as a presenting manifestation of H1N1 infection who improved following appropriate antiviral treatment. Methods and results This 20-year-old gentleman presented to us with history of fever followed by GCSE of 24 h duration. He was treated symptomatically and was evaluated in detail. He was diagnosed to be suffering from H1N1 infection based on appropriate serological tests. After start of antiviral therapy, he improved and is doing well at 4 months follow up. Conclusion This case report further expands the spectrum of clinical findings associated with sporadic H1N1 infection. A possibility of H1N1 infection should be considered in all patients who present with GCSE without any obvious cause so that appropriate diagnostic tests and treatment can be carried out at the earliest.

The present study was intended to explore the dynamics of viral and host factors determining the outcome of Japanese encephalitis viral infection. 223 patients with acute encephalitic syndrome, 126 with febrile illness suspected of JE and 79 apparently healthy individuals as control were enrolled. Elevated levels of TNF-α and IL-6 in encephalitis patients and IFN-γ in febrile JE patients without encephalitis were observed. A cutoff value of > 55 pg/ml of TNF-α and > 370 pg/ml of IL-6 in CSF was found as poor prognostic marker. Th1 shift (IFN-γ/IL-4: > 1) was observed in encephalitis patients.

Background: The present understanding of the clinical course, complications, and outcome of myasthenic crisis (MC) is based chiefly on observational studies and retrospective case series. Aim: To study the baseline demographic and clinical variables, risk factors, complications, outcome, and mortality in patients of MC. Materials and Methods: All patients of myasthenia gravis (MG) who presented with myasthenic crisis between July 2009 and December 2010 were included. Results: Ten patients of MC were included in this study. The median age of the patients was 40.5 years (range 14-71 years). Seven were females and three were males. Nine had generalized MG and one patient had oculobulbar involvement only. Median duration of disease was 3 years (range 1 month to17 years). Two patients had thymoma. Two patients had history of thymectomy in the past. Infection was the most common triggering factor accounting for five cases (50%) followed by inadequate treatment/drug withdrawal in three (30%) and steroid initiation and hypokalemia in the remaining two patients (20%). Median duration of MC was 12 days (range 3-28 days). Mortality was in 3 out of 10 (30%) during MC. Management in the intensive care unit (ICU) and treatment with plasma exchange/intravenous immunoglobulins were associated with good outcome. Conclusions: Ventilator support and management in intensive care unit are the most important components in the management of MC. The high mortality rate seen in present study may be more reflective of the actual ground reality in resource constrained developing countries, however, larger prospective studies are needed to confirm these findings.

Background Acute ischemic stroke (AIS) is a time-dependent treatable cause of morbidity and mortality. Despite the increasing stroke incidence in developing countries, parallel increasing stroke thrombolysis rates have not been documented. Aim This study aims to determine trends in patient characteristics and rates of recombinant tissue plasminogen activator (rtPA) use in AIS patients in a tertiary care center in northern India. Methods All AIS patients presenting within 8 hours of symptoms onset from January 2011 to December 2015 were enrolled and analyzed. Results A total of 867 AIS patients presented within 8 hours of symptoms onset. Out of 593 eligible patients, 189 (31.87%) underwent intravenous thrombolysis (IVT) with rtPA within 4.5 hours of the window period. Patients (undergoing) IVT had onset-to-door times of 2 hours or less (23.81%), 2-3 hours (33.86%), and 3.0-4.5 hours (42.33%). IVT rates in 2 hours or less of symptom onset increased from 22% to 25% and IVT rates in 2-3 hours increased from 38.9% to 43.8%. Door-to-computerized tomographic time (median 27 versus 11 minutes, P = .0001) and door-to-needle time (median 83 versus 67 minutes, P = .011) improved, with a significant improvement of computerized tomography imaging time within 25 minutes of arrival (from 50% to 78.4%, P = .014). Post-IVT symptomatic hemorrhage was noted in 5 patients (2.65%). The median National Institutes of Health Stroke Scale score at presentation was 11, whereas a favorable modified Rankin Scale score (0-1) at 3 months was seen in 39.68%. Conclusions Encouraging trends in IVT over the years may be indicative of increasing community awareness of stroke and improving quality of stroke care in developing countries such as India.

Introduction: Neurologists in their clinical practice are faced with inquiries about the suitability of stem cell approaches by patients with a variety of acute and chronic (namely neurodegenerative) disorders. The challenge is to provide these patients with accurate information about the scope of stem cell use as well as at the same time, empowering patients with the capacity to make an autonomous decision regarding the use of stem cells. Methods: The Indian Academy of Neurology commissioned an Expert Group Meeting to formulate an advisory to practicing neurologists to counsel patients seeking information and advice about stem cell approaches. Results and Conclusions: In the course of such counselling, it should be emphasized that the information provided by many lay websites might be unsubstantiated. Besides, standard recommendations for the stem cell research, in particular, the application of several layers of oversight should be strictly adhered in order to ensure safety and ethical use of stem cells in neurological disorders.

Background Though animal studies have suggested a role for proinflammatory cytokines in pathogenesis their exact role in pathogenesis of human meningeal tuberculosis continues to be controversial with different studies yielding contradictory results. Aim and objectives To study the levels of proinflammatory cytokines in serum and cerebrospinal fluid (CSF) of patients with tubercular meningitis (TBM) and to determine whether these correlate with disease severity. Patients and methods Present study included 146 patients with TBM (90- Definite TBM; 56- Probable TBM), diagnosed according to criteria laid by Ahuja et al. which were modified to include CSF nucleic acid based tests. Serum ( n = 146) and CSF ( n = 140) levels of various proinflammatory cytokines (IL-1β, IL-2, IL-6, TNF-α and IFNγ) were compared between TBM patients and healthy volunteers ( n = 99). These levels were correlated with various clinical, radiological and CSF parameters of TBM patients. Results Proinflammatory cytokines include cytokines which promote systemic inflammation. In current study, the serum and CSF levels of various cytokines (IL-2, IL-4, IL-6, IL-1β, IFN-γ and TNF-α) were significantly elevated in TBM patients compared to controls. A significant correlation was found between a) Higher stage of TBM and various cytokines (except for serum IL-6 and CSF IFN-γ); b) High CSF TNF-α, IL-4 and IL-1β with severity of hydrocephalus; c) High CSF IL1β and IFN-γ with presence of exudates on MRI; d) Serum and CSF levels of all cytokines with poor outcome as determined by death or as defined by S and E ADL (Schwab and England activities of daily living) score or by GOS (Glasgow outcome scale) (except for interferon gamma); and e) Serum and CSF IL-4 and IL1β with presence of infarcts on MRI brain. Conclusion Proinflammatory cytokines play an important role in the pathogenesis of TBM and contribute significantly towards severity of disease.

Introduction: A reliable plasma biomarker in differentiating between Alzheimer’s disease (AD) and Vascular dementia (VaD) is the need of the hour, in most memory clinics. Hypothesis: We assessed the hypothesis that plasma inflammatory [Interleukin 6 (IL 6) and C-Reactive Protein (CRP)] and hemostatic (Fibrinogen and D dimer) biomarkers can aid in differentiating between AD and VaD. Methods: Neuropsychological assessment, MRI brain, FDG-PET brain and CSF biomarkers of AD (Aβ42 and total tau) were used for establishing the diagnosis of Mild Cognitive Impairment (MCI), AD or VaD. ELISA analyses for IL6, Fibrinogen, D dimer and CRP were performed according to the manufacturers’ protocols. Results: During the study period (January 2013-April 2014), 68 diagnosed patients of AD/MCI/VaD were included. FDG PET brain, plasma fibrinogen, D dimer, IL6 and CRP were done in all 68 patients while 48 patients underwent CSF biomarker analysis. Sixteen patients had MCI, of which 11 were MCI-AD and 5 were MCI-VaSC. There were 41 patients with AD (Mild AD- 9, Mod AD -23, Severe AD- 9) and 11 patients with VaD. The Alzheimer group (MCI-AD and AD) and Vascular group (MCI VaSC & VaD) consisted of 52 and 16 patients respectively. Table 1 depicts biomarker levels. Alzheimer and Vascular groups did not exhibit significant difference in IL6 and CRP levels. Plasma fibrinogen levels were significantly higher in VaD and vascular group as compared to Alzheimer group. But MCI-VaSC was not significantly different from MCI-AD. Plasma D dimer levels were significantly higher in all vascular subgroups compared to Alzheimer subgroups except between MCI-VaSC and MCI-AD. Conclusion: In conclusion, hemostatic biomarkers (Plasma Fibrinogen and D dimer) succeed, whereas inflammatory biomarkers (IL6 and CRP) fail in differentiating VaD from AD.

Background and purpose: North Indian patients with amyotrophic lateral sclerosis (ALS) exhibit substantially extended survival time after onset of the disease as compared to their Western counterparts. Earlier, we found that vascular endothelial growth factor-A (VEGF-A) may be associated with increased survival of these patients. We now measured soluble vascular endothelial growth factor receptor-1 (sVEGFR1), an inhibitor receptor for VEGF-A, in these patients with ALS. Methods: Patients with sporadic ALS (n = 36) attending the Neurology Outpatient at Post Graduate Institute of Medical Education and Research (PGIMER) at Chandigarh were included on the basis of El Escorial criteria. The sVEGFR1 levels were analyzed in serum of these patients using enzyme-linked immunosorbent assay (ELISA) and compared with normal controls (n = 36). Results: Soluble vascular endothelial growth factor receptor-1 was found to be decreased significantly in serum of patients with ALS. Serum obtained from definite ALS revealed significantly lower sVEGFR1 as compared to probable ALS. However, there was no difference in serum sVEGFR1 levels between male and female patients with ALS. Conclusions: Soluble vascular endothelial growth factor receptor-1 downregulation may result in increased serum VEGF-A reported previously in our patients with ALS and may indicate the activation of compensatory mechanism in response to neurodegeneration. The lower serum sVEGFR1 levels may have a possible clinicopathological association, if not causal, to the extended survival of North Indian patients with ALS; however, the result needs further investigations particularly in comparable Caucasian ALS population.

This report describes the clinical, radiological and autopsy findings of a young male suffering from acute, monophasic demyelinating disease presenting with acute onset of altered sensorium and a short past history of progressive multiple neurological deficits. The radiological findings revealed acute infarcts in the territory of anterior cerebral artery. The antemortem diagnosis centred on an infective (tubercular) aetiology leading to demyelination based on presence of tubercle bacilli in bronchoalveolar lavage (BAL) fluid. The autopsy revealed multiple subacute and acute plaques showing demyelination, giant astrocytes, numerous macrophages and little perivascular inflammation, thereby confirming the diagnosis of Marburg's type of multiple sclerosis. Marburg's type is a fulminant demyelinating disorder characterised by a severe, rapidly evolving clinical course. Death occurs due to brain stem involvement or severe widespread cerebral lesions.

Summary Purpose: To determine the effect of administration of a short course of prednisolone on seizure and radiologic outcome in patients with solitary cysticercus granuloma (SCG). Methods: One hundred forty-eight subjects presenting with new-onset seizures (

Primary objective: To analyse the efficacy of bone marrow-derived mononuclear cells (MNCs) in traversing the blood–brain barrier (BBB) in an experimental model of stroke.Methods and procedures: The middle cerebral artery occlusion (MCAo) mouse model was established and behavioural and histological analysis was performed, subsequently the carboxyfluorescein diacetate (CFDA)-labelled MNCs were transplanted through the tail vein immediately after 23 hours of reperfusion. The fluorescence microscopic analysis of the brain sections was analysed in both acute and sub-acute phases of transplantation.Results: The neurological deficit was confirmed by TTC staining and contra lateral turning behaviour. After 2 and 7 days of transplantation, the CFDA-labelled MNCs were observed in the infarcted regions along the line of cortex.Conclusion: The presence of the CFDA-labelled cells in the ischaemic injured brain lesions proved homing of the implanted MNCs in the infarcted regions of the brain. The successful homing of M...

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/ AIDS) within the Indian subcontinent continues to spread. Although the primary clade of HIV in India differs from that of most Western countries, recent evidence suggests that the Indian clade (Clade C) also impacts neurocognitive functioning. India also has extremely high illiteracy rates that may confound detection of neurocognitive impairment, since many assessments to detect such impairment are heavily influenced by formal schooling. Among those with HIV/AIDS who have had limited educational opportunities and who are in the early stage of infection, the confounding effects of education on tests for neurocognitive impairment may be particularly salient. We therefore tested influence of HIV serostatus and education on a commonly used tool to screen for cognitive impairment, the International HIV Dementia Scale (IHDS), among Indian men and women in the catchment area of the Post Graduate Institute of Medical Education and Research (PGIMER) located in Chandigarh, India. Adjusted analyses showed that from a sample of 295 HIV-positive and HIV-negative individuals, only education was significantly associated with performance on the IHDS. HIV-negative and HIV-positive individuals, who were in the early stages of infection, performed similarly. Further development of this test to account for the effects of education on cut-off scores used to indicate possible dementia are needed, particularly for use in resource-limited settings such as India where low levels of education are widespread.

Background: Parkinson’s disease (PD) is a complex neurological disorder without any well-documented genotype-demography associations among sporadic variants. We recently reported PARK2 mutations to be constituting 40% of PD in this region and thus analysed how demographic variables associate with PARK2 mutations in 70 of these patients. Methods: PD samples were screened by PCR single-strand conformation polymorphism (SSCP) and sequencing and their demographic data collected. Demographic and religion data was obtained from 1,010 randomly selected individuals of 120,000 patients visiting the Neurology Clinic and was compared with state database and PD patients. Results: Sikhs from a rural background exhibited the majority of PARK2 mutations. The frequency of PARK2 mutations among females was significantly higher as compared to males (p < 0.015). The age of onset of PD patients with a rural background was found to be significantly lower as compared to patients with an urban background (p < 0.004). The demographic spectrum of the 1,010 randomly selected patients and the background population was found to be comparable. Conclusions: As PD patients with PARK2 mutations were found to be of sporadic origin and never-smokers, a non-redundant inverse relationship between founder PARK2 mutations and smoking is implicated to account for its high frequency. The predisposition of Sikhs to PARK2 mutations necessitates a larger study among its familial variants and a control smoker PD population. The spectrum of PARK2 mutations among Sikh smokers is difficult to study because of the religion-based aversion to smoking.

Among several aetiological factors, PARK2 mutations are the most common cause of Parkinson disease (PD) that result in degeneration of dopaminergic neurons in the substantia nigra.In order to examine the contribution of PARK2 mutations and corresponding Parkin expression in blood of North West Indian PD patients, the authors screened 120,000 patients from 2001 to 2006 for features of PD using UK Parkinson disease society brain bank clinical diagnostic criteria (UKPDBBC), and tested PARK2 mutations in 69 of those that fulfilled this criteria. 43 controls lacking extrapyramidal signs were also analysed.The PCR analysis revealed the occurrence of homozygous deletions in 28 of 69 samples analysed (40.5%) represented by exon-1 (15.9%), exon-3 (11.5%), and exon-12 (11.5%). Sequencing revealed point mutations in exon 4 and exon 9 in six of these patients (8.7%) including one novel missense Gly1083Trp mutation in one patient. Parkin estimation was done by combination of immunolocalisation and FACS analysis revealing reduced Parkin expression among PD patients. The mutations in exons 1, 3 and 12 among sporadic PD patients were found to be higher among younger onset variants (age45 years). This report also constitutes the first evidence that PARK 2 mutations contribute to the aberration in Parkin expression in blood leading to PD.

The course and outcome of epilepsy following central nervous system (CNS) infections has been poorly characterized. Likewise, the impact of antimicrobial treatment as well as other preventative and therapeutic interventions on the development of epilepsy following neurological infectious disorders has been insufficiently studied. The CNS infections that can cause epilepsy may be either acute or chronic-recurrent. For most acute infections, for example, viral encephalitis and bacterial meningitis, the effect of specific antimicrobial treatment on the development of epilepsy cannot be studied in a controlled manner due to logistic and ethical reasons. In the specific case of neurocysticercosis (NCC), the risk of seizures in the short term is reduced following either anthelminthic or corticosteroid treatment or both. The effect of anthelminthic treatment on seizure outcome in the long term has not been studied. Finally, treatment with antiepileptic drugs (AEDs) needs to be optimally defined in the case of epilepsy associated with neurological infectious disorders.

Objective: The aim of this study is to present a comprehensive profile of clinical and psychosocial characteristics of children with psychogenic nonepileptic seizures and to assess the short-term outcome of these patients. Materials and Methods: The subjects were consecutive cases of children with a diagnosis of nonepileptic seizures (N=17, mean age = 10.7 years, S.D. = 1.26) and two groups of control groups matched on age and sex: true seizure group and healthy controls. All the children were recruited from the out-patient services of the Department of Pediatrics of a tertiary care teaching hospital in North India. Detailed history taking and clinical examination was done in the case of every child. A standard 18 channel EEG was done in all the children and a video EEG was done in 12 cases of children with nonepileptic seizures. The Childhood Psychopathology Measurement Schedule (CPMS) and Life Events Scale for Indian Children (LESIC) were used to measure the children′s emotional and behavioral functioning at home, and the number of life events and the stress associated with these events in the preceding year and the year before that. Short-term outcome was examined three to six months after the diagnosis of nonepileptic seizures was made. Results: Unresponsiveness without marked motor manifestations was the most common "ictal" characteristic of the nonepileptic seizures. Pelvic thrusting, upper and lower limb movements, head movements, and vocalization were observed in less than one-third of the patients. Increased psychosocial stress and significantly higher number of life events in the preceding year were found to characterize children with nonepileptic seizures, as compared to the two control groups. The nonepileptic seizures and true seizures groups had a higher proportion of children with psychopathology scores in the clinically significant maladjustment range, as compared to those in the healthy control group. A majority of the patients (82.4%) either recovered completely or had more than 50% reduction in the frequency of their symptoms, after three to six months of initiation of therapy. Conclusions: Psychosocial stress is common among children with nonepileptic seizures. Confirmatory diagnosis by video EEG, along with prompt psychosocial intervention, often results in a favorable outcome for most children with nonepileptic seizures.

Present study was to assess lipid peroxidation and antioxidant enzymes in the blood of the Parkinson's disease (PD) patients in the Indian population. It may be useful to develop peripheral markers, for the diagnosis and prognosis of Parkinson's disease during lifetime. Malondialdehyde content was increased in patients with PD (2 fold), with respect to the activity of superoxide-dismutase (p

We profiled 141 consecutive patients of writer's cramp (WC). Simple WC (n=108) had a mean (SD) disease duration of 3.65 (2.7) years and a severity score of 2.8 (0.91) by Burke-Fahn-Marden (BFM) scale (handwriting score: 0-4 ), whereas complex WC (n=33) had a disease duration of 5.8 (2.81) years and severity score of 3.6 (0.52). Compared with focal WC, generalized WC cases had longer disease duration, severer disability, and were older. Mirror dystonia was seen in 65 patients (46.1%). Co-existent Meige's syndrome (n=4) and cervical dystonia (n=6) were seen. Some patients had abnormal posturing of the neck (n=5) and of the oromandibular region (n=3) only while writing. Those receiving botulinum toxin fared significantly better than those on oral therapy, at 1 month post treatment.

Summary: Purpose: To assess the association of long-term sodium valproate therapy with reproductive endocrine disorders in Indian women with generalized epilepsy. Methods: Clinical parameters, ovarian morphology, and serum reproductive hormone concentrations were evaluated in 30 clinically normal and eumenorrheic reproductive age women with generalized epilepsy who were newly initiated on valproate. Longitudinal evaluations were done in 25 of these women after 1 year, and in some of them after 2 and 3 years of therapy. Results: Of the 25 women who completed 1 year follow-up, we observed clinically relevant weight gain in 40%, hirsutism in 20%, menstrual abnormalities in 24%, polycystic ovaries (PCO) in 16%, polycystic ovarian syndrome (PCOS) in 20%, and a significant increase in mean serum testosterone (p = 0.046). A significant positive correlation existed between weight gain and the development of menstrual abnormalities (r = 0.66, p < 0.0001), hirsutism (r = 0.53, p = 0.006) and PCO (r = 0.51, p = 0.012). No correlation existed between weight change and serum reproductive hormonal changes. Yearly follow-up for next 2 years in some of these women revealed persistence of menstrual abnormalities, hirsutism and PCO, a significant linear increase in mean body weight, body mass index, and serum testosterone concentrations, and an increase in serum LH levels from second year onwards. Limitations: Limitations include small sample size and a high dropout rate on follow-up. Conclusions: Long-term valproate therapy in Indian women with generalized epilepsy is associated with development of hirsutism, significant weight gain, stable or progressive alterations in reproductive hormonal function, and ultimately a higher occurrence of PCOS. Key Words: Epilepsy—Menstrual disorders—Polycystic ovarian syndrome—Valproate—Druginduced reproductive abnormalities.

Importance: Allgrove syndrome is a rare autosomal recessive disorder characterised by achalasia, alacrima, adrenal insufficiency, autonomic dysfunction and amyotrophy. The syndrome has been described in childhood and adult presentation, as in our case, is very rare. There is a considerable delay in diagnosis due to lack of awareness about the syndrome. Observations: We report a single case of a 36year old man who was initially diagnosed and treated for achalasia cardia in our institute 14years before. After 8years he presented again with weakness and wasting predominantly distally. He had tongue fasciculations, brisk reflexes and extensor plantar. After supportive electrophysiological studies he was diagnosed as Amyotrophic lateral sclerosis. After 5years he presented with generalised fatigue without any significant worsening of his neurological status. On reevaluation he had alacrimia, autonomic dysfunction and mild ACTH resistance. Conclusions and relevance: Allgrove syndrome may be an underdiagnosed cause of multisystem neurological disease due to the heterogeneous clinical presentation as well as for ignorance of clinician about the syndrome. Based on our case, we also believe that there does exist a subgroup of patients who follow a less severe and chronic course. Recognition of syndrome allows for treatment of autonomic dysfunction, adrenal insufficiency and dysphagia.

Peripheral neuropathy is usually the presenting feature of POEMS syndrome. Approximately 50% of patients with POEMS syndrome are associated with osteosclerotic myeloma, a rare variant of multiple myeloma, and some with Castleman's disease, an unusual lymphoproliferative disorder. The multicentric plasma cell variant of Castleman's disease is usually associated with systemic disorders rather than its localized form of mediastinal lymphoid hyperplasia characterized by hyalinization of follicles and interfollicular vascular proliferation. We report a 48-year-old woman who presented with progressive sensorimotor demyelinating polyradiculoneuropathy, bilateral optic disc edema, hepatosplenomegaly, generalized lymphadenopathy, and skin changes. There was associated thrombocytosis, hypothyroidism, hypoparathyroidism, mixed osteolytic and osteosclerotic bone lesions, monoclonal gammopathy of IgG lambda type, and hyaline vascular type of Castleman's disease. This combination of POEMS syndrome, osteosclerotic myeloma with a hyaline vascular type of Castleman's disease is uncommon.

Brucellosis remains an important public health problem especially in the underdeveloped countries as well as the Middle East. It may be a "master mimic" leading on to grave diagnostic dilemmas. Chronic neurobrucellosis is seldom associated with signs and symptoms of toxaemia due to multi organ dysfunction. We report the case of a 23-year-old man who presented with fever of 8 weeks associated with ascending weakness of lower limbs and sensorineural type of hearing loss of 6 weeks duration with prominent systemic findings in the form of hepatosplenomegaly and significant loss of weight. He responded well to treatment with combination antimicrobials with clinicoradiological resolution after 6 months of therapy. Even though a rare complication of brucellosis, neurobrucellosis causes significant morbidity if not promptly recognised and treated. Favourable outcomes can be achieved in neurobrucellosis with appropriate protracted polymicrobial antibiotic therapy as was illustrated in our patient.

Racemose cysticercosis is a less frequent presentation of neurocysticercosis (NCC). It's presentation and management is quite different from cerebral parenchymal NCC. Diagnosis of racemose cysticercosis is based on the combination of clinical, epidemiologic, radiographic, and immunologic information. Compared with cysticercus cellulose, which most commonly presents as seizures, racemose NCC due to its extraaxial location presents with raised intracranial pressure and meningitis, and frequently requires neurosurgical intervention. Dementia as a sole presenting feature of NCC is rare. We report a case of racemose NCC with dementia as the presenting manifestation. The outcome of dementia patients with NCC seems favorable in most cases therefore a high index of suspicion for NCC should be kept especially in endemic areas.

A mobile plaque in the carotid artery is an uncommon entity, usually detected incidentally on a carotid duplex scan or angiography. It is associated with an indeterminate risk of an embolic stroke and should be managed on an emergent basis. We report here a case of a mobile plaque in the internal carotid artery that was detected serendipitously in a carotid duplex scan.

Neurocysticercosis commonly presents with seizures, raised intracranial tension and dementia. The unusual location of the cysts may result in uncommon manifestations mimicking a host of neurological disorders. Ten patients with neurocysticercosis with rare clinical presentations have been described in this series. These include dorsal midbrain syndrome, isolated bilateral ptosis, papillitis, cerebral hemorrhage, painful cervical radiculopathy, progressive swelling of arm, paraplegia due to intramedullary cyst, third ventricular cyst, dystonia and nominal aphasia masquerading as transient ischaemic attacks. The clinical details and possible mechanisms for these rare presentations are discussed.

Importance Post-encephalitic parkinsonism (PEP) is believed to be caused by a viral illness which causes degeneration of the nerve cells in the substantia nigra, resulting in clinical parkinsonism. Although common during the period of the First World War, the diagnosis of PEP is rarely entertained today. Observation We report an adolescent boy of PEP, who was bedridden due to severe parkinsonism following the encephalitis attack. After relevant imaging and investigation, he was treated with levodopa which made him independent from a year long total dependent condition. Relevance and conclusion Encephalitis lethargica or PEP is one of the rare parkinsonian syndromes which may be amenable to treatment. Proper diagnosis and treatment may help the patient become ambulatory from the dreaded lethargic condition.

Alzheimer's disease (AD) is the most common cause of dementia worldwide. Although, many putative biomarkers are reported for AD, only a few have been validated in the clinical setting. Ubiquitin levels increase in cerebrospinal fluid (CSF) of patients with AD, but its diagnostic value is not clear. In this present study we evaluate the performance of ubiquitin as a diagnostic marker and deduce a statistical association with disease pathology in AD. Ubiquitin levels were estimated in subjects with AD, other forms of dementias, neurological disorders and healthy age matched population. The levels of ubiquitin were significantly higher in subjects with AD when compared with other groups (p

BACKGROUND: “Swirl sign” on an initial CT scan indicates ongoing hemorrhage in a hematoma and has been associated with increased mortality. OBJECTIVE: To assess CT swirl sign(CTSS) for predicting outcome in acute primary intracerebral hemorrhage. METHODS: Acute ICH patients within 24 hours of symptom onset were recruited. Baseline Non contrast and contrast enhanced CT scan and CT angiography of the brain was done. Follow up CT(FU CT) scan was done 24 hours from baseline.Hematoma volume(HV), CT spot and swirl sign were assessed. All patients were managed as per standard guidelines. Outcome assessment with modified rankin scale(mRS) was carried out at 1 month and 3 months RESULTS: 25 patients were recruited.Mean age was 52.44+11.35years,72% males, time from symptom onset ranged from 180-990 mins (mean-499 mins), GCS range 7-15 ,NIHSS range 6-33 (Mean 19.76), Mean systolic, diastolic and mean arterial pressures at baseline were 186.40 ,108.72 and 134.32 mm Hg. 10 (40%) had hematoma expansion (HE; > 33% increase in hematoma volume on FU CT). Mortality was 36% (9). Prevalence of CT spot sign was 4% . CTSS at baseline and follow-up was 24% (6)and 32%(8) respectively. 87.5% with delayed CTSS had a poor outcome (mRS>2). Delayed CTSS was associated with increased early mortality (1 month) (p = 0.005) and poor outcome at 3 months (p=0.03). CONCLUSION: Delayed CT Swirl sign (>24 hours) is a predictor of mortality and outcomes in acute primary supratentorial intracerebral hemorrhage. It may serve as a marker for aggressive BP lowering even in patients presenting after 6-8 hours

407 patients (248 men, 159 women) of epilepsy attending the neurology clinic were evaluated to find out the profile of epilepsy, cost-effectiveness of various investigations, therapeutic regimens and efficacy of referring physicians in a developing country. At the time of onset of seizures 67.2% of patients were in the second and third decade. Generalised tonic clonic seizures were the commonest seizure type seen. Specific aetiology was established in 20.8% cases only. Neurocysticercosis was the commonest cause observed. The main source of referral (50.1%) was general practitioners. Referral diagnosis was incomplete in 52.8% of the cases. Investigations did not alter the diagnosis in 62.5% cases. The EEG was useful in the management of 15.1% cases of epilepsy. The skull x-ray and chest x-ray were abnormal in 1.7% and 2% cases respectively. CT scan revealed abnormality in 39.4% cases. Most of the patients were treated with monotherapy. Phenytoin, phenobarbitone and carbamazepine were the common drug used. Out of 246 cases who were started on anticonvulsant therapy prior to referral, the choice of drug was wrong in 78 (31.7%) cases and dose was inappropriate in 121 (49.2%) cases. It was concluded that most important factor for cost effective management of epilepsy is proper clinical evaluation and education of general physicians in this direction.

We aimed to identify the role of vascular endothelial growth factor (VEGF) and monocyte chemoattractant protein (MCP-1) as a serum biomarker of symptomatic carotid atherosclerotic plaque in North Indian population. Individuals with symptomatic carotid atherosclerotic plaque have high risk of ischemic stroke. Previous studies from western countries have shown an association between VEGF and MCP-1 levels and the incidence of ischemic stroke. In this study, venous blood from 110 human subjects was collected, 57 blood samples of which were obtained from patients with carotid plaques, 38 neurological controls without carotid plaques, and another 15 healthy controls who had no history of serious illness. Serum VEGF and MCP-1 levels were measured using commercially available enzyme-linked immunosorbent assay. We also correlated the data clinically and carried out risk factor analysis based on the detailed questionnaire obtained from each patient. For risk factor analysis, a total of 70 symptomatic carotid plaque cases and equal number of age and sex matched healthy controls were analyzed. We found that serum VEGF levels in carotid plaque patients did not show any significant change when compared to either of the controls. Similarly, there was no significant upregulation of MCP-1 in the serum of these patients. The risk factor analysis revealed that hypertension, diabetes, and physical inactivity were the main correlates of carotid atherosclerosis (p 0.05). We conclude that the pathogenesis of carotid plaques may progress independent of these inflammatory molecules. In parallel, risk factor analysis indicates hypertension, diabetes, and sedentary lifestyle as the most significant risk factors of ischemic stroke identified in North India. This could be helpful in early identification of subjects at risk for stroke and devising health care strategies.

Background & Objective We have completed a randomized controlled clinical trial (CTRI-PROVCTRI/2008/091/00046) to evaluate the safety and efficacy of administering bone marrow mononuclear cells intravenously to patients with subacute ischemic stroke. Methods A total 120 consecutive, eligible and consenting patients, aged 18 to 75 years with ischemic stroke involving MCA or ACA territory infarct between 7 to Results Stem cell arm has been administered bone marrow mononuclear cells (mean 280.73 million with CD34+ mean 2.85 million). Central telephonic follow up has been completed in 117 patients. Data on SAEs, clinical outcome (mRS, BI, NIHSS), cerebral infarct volume, whole body FDG-PET scan and EEG will be presented. Conclusion Intravenous bone marrow MNC therapy is safe in patients of subacute stroke. Further results will be presented.

Background: Guillain-Barre syndrome (GBS), is a common post-infectious polyradiculoneuropathy worldwide. The commonest implicated causative organism the world over is Campylobacter jejuni (C. jejuni). This study was carried out to determine the relationship between C. jejuni infection and GBS in an Indian setting. Materials and Methods: This prospective study was carried out on a cohort of 50 patients with GBS who were treated in a tertiary care hospital in India. Based on electrophysiological findings the patients were divided into various subtypes. Serology for C. jejuni (Immunoglogulin G, IgG and Immunoglogulin, IgM) using an enzyme-linked immunosorbent assay method (ELISA) was done both in patients and 40 age, sex and geographically matched controls. Results: Evidence of recent C. jejuni infection was present in 30% of GBS patients compared to 8% of controls (15/50 vs. 3/40 P

The clinical diagnosis of amyotrophic lateral sclerosis (ALS) usually takes several months. The delay in diagnosis compromises the effective therapeutic interventions. Therefore, the present study was aimed to develop a statistical model for predicting the risk of ALS at earlier stages for better management of ALS patients.The study recruited 44 sporadic ALS patients and 29 normal controls. Thirteen different independent variables (predictors) which were believed to be associated with ALS were included in the study. Forward stepwise (likelihood ratio) binary logistic regression was used to find significant variables and probability of disease prediction.The Hosmer-Lemeshow goodness of fit statistic (χ(2)=4.379, df=8, p=0.821) indicate the appropriateness of forward stepwise (likelihood ratio) binary logistic regression model. Serum chemokine ligand-2, chemokine ligand-2 mRNA, vascular endothelial growth factor-A mRNA, smoking and alcohol consumption are the independent variables found significant to predict risk of ALS (p0.05). The current model yielded 93.2% sensitivity and 86.2% specificity with 90.4% overall validity of correct ALS prediction.Forward stepwise (likelihood ratio) binary logistic regression model is an accurate method to predict ALS in the presence of serum CCL2, CCL2 mRNA, VEGFA mRNA, smoking and alcohol consumption with high sensitivity and specificity. However, bed side diagnostic utility of these variables needs to be validated further in larger ALS cohorts.

Malaria is one of the most common treatable and preventable infectious diseases in the world; and 300–500 million malaria cases occur annually, leading to 1.5–2.7 million deaths in tropical countries. About one-third of these cases occur in Asia. In hyperendemic area, most of the children acquire infection by the age of 5 years. Children younger than 6 months enjoy immunity from their mothers. In India the disease occurs in all the agegroups. Most clinicians would consider any manifestation of cerebral dysfunction in a patient with malaria as cerebral malaria. These manifestations include impairment of consciousness (confusion, delirium, obtundation, stupor, or coma), convulsions, focal neurologic deficit, and psychosis. These abnormalities can as well be due to hypoglycemia or high fever only. Hence a precise definition has been recommended, which has been summarized in Box 1. Box 1 Definition of cerebral malaria Practical definition

Objective.— Ophthalmoplegic migraine (OM) is a rare disorder characterized by recurrent oculomotor nerve palsy in children, following migraine headaches. We report 62 adults, seen consecutively, who developed acute ophthalmoplegia with severe attacks of migraine over a 10-year (1996-2005) period. An overwhelming majority of these patients had an antecedent worsening in severity of migraine headaches, before the ophthalmoplegic attack. Methods.— Sixty-two patients, aged 15-68 years, with an acute attack of OM underwent detailed clinical, biochemical, and neuroradiological evaluation. Results.— There were 62 patients with 86 attacks of OM. Whereas 48 patients had a single attack, 14 had 2 or more attacks, fulfilling the International Headache Society criteria for probable and definite OM, respectively. At presentation, isolated abducens, oculomotor, and trochlear nerve involvements were seen in 35 (56.5%), 21 (33.9%), and 5 (8.1%) patients, respectively. One patient had simultaneous involvement of 3rd and 6th nerves. Fifty-one (82.3%) patients exhibited an antecedent worsening in severity of migraine, before developing ophthalmoplegia during (59/95.2%) or within 24 hours (3/4.8%) of a severe migraine attack, respectively. Detailed biochemistry and cranial neuroimaging were normal. No case had any nerve enhancement. Use of steroids hastened recovery (P

The high incidence and prevalence of epilepsy in developing countries has partly been attributed to an increased frequency of central nervous system (CNS) infections. Of the CNS infections, bacterial meningitis is endemic in many countries and several epidemics have also been reported in these regions. Unprovoked seizures and epilepsy (recurrent unprovoked seizures) can be long-term sequelae of bacterial meningitis. The probability of developing an unprovoked seizure or epilepsy varies according to the etiologic agent responsible for meningitis and this probability appears to be higher for Streptococcus pneumoniae. The risk factors for late unprovoked seizures/epilepsy include early seizures during the acute phase of meningitis and persistent neurological deficits other than sensorineural hearing loss. The majority of unprovoked seizures occur within 5 years of the meningitis episode and tend to be recurrent. The burden of epilepsy associated with bacterial meningitis depends upon the incidence of the latter and hence is to some extent preventable. Implementing vaccination programs against the three most important meningeal pathogens can reduce the incidence of bacterial meningitis. In developed countries, a decline in the incidence of bacterial meningitis has been accomplished with the implementation of vaccination programs.

There is paucity of data regarding occurrence of reproductive endocrine disorders in Asian women with epilepsy (WWE) on antiepileptic drug (AED) therapy.To determine the occurrence of reproductive endocrine disorders in Indian WWE, by seizure type and the AED use.Consecutive 427 reproductive age WWE receiving various AEDs were screened for the occurrence of menstrual abnormalities, weight change, and hirsutism. Of these, 53 WWE with menstrual disturbances and/or hirsutism were further evaluated for ovarian morphology and reproductive hormonal profile.Menstrual abnormalities and/or hirsutism were observed in 83 of 427 (19.4%) WWE irrespective of epileptic seizure type; of these, 50 (60.2%) received valproate, 21 (25.3%) received carbamazepine, 11 (13.3%) received phenytoin, and one (1.2%) received phenobarbitone as the primary AED. Almost half of valproate-treated women had significant weight gain and obesity. Among 53 of 83 women evaluated further, 23.5% and 63.6% of valproate-treated women, 25% and 58.3% of carbamazepine-treated women, and none and 20% of phenytoin-treated women had polycystic ovaries (PCO) and hyperandrogenemia (HA), respectively. Valproate-treated women had significantly higher frequency of polycystic ovarian syndrome (PCOS) (11.8% vs. 2.5%, p0.0001) and mean serum testrosterone levels (1.78 vs. 1.36 ng/ml, p = 0.03), compared with women treated with other AEDs.Limitations include small number of women in antiepileptic subgroups and a high drop out rate in women who underwent ultrasound and endocrinological investigations.Menstrual abnormalities, weight gain, obesity, and PCOS are frequent and significantly higher in WWE receiving valproate, independent of seizure type.

The data on sociocultural, demographic, and psychosocial aspects and types of treatment strategies adopted by families of patients with epilepsy in northwestern India were collected by the interview schedule method from 400 patients (200 idiopathic and 200 symptomatic) at the outpatient department of the Neurology and Epilepsy Clinic of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Epilepsy was classified as idiopathic or symptomatic on the basis of clinical tests (EEG, CT scan, and MRI). It was observed that socioeconomic factors had no bearing on epilepsy in the present sample. Early onset, that is, before 20 years of age, reduced the chances of patients' finding a spouse among those who disclosed the disease information, thereby impacting the nuptial and fertility rates of patients with epilepsy. The present sample of patients was well informed about and sensitized to the efficacy of the modern system of medicine, as 80% of patients sought medical treatment on the very same day as or within a week of onset of seizures. The data were compatible with the framed hypothesis that well-being and safety of the patient would override the stigma burden factor, as 94% of the affected families made no attempt to hide the disease from their neighbors, friends, and colleagues, and teachers of the affected patients. Surprisingly, only 7.5% of the families admitted that they consulted a faith healer. Families did adopt some culturally prevalent methods to control involuntary movements during seizures. It can be concluded that trust in faith healers exists strongly as an undercurrent, but is not overtly admitted by the majority of patients. Some families concurrently visited modern hospitals and occult healers seeking a cure for the disease. The fear of having a child with epilepsy or other abnormalities discouraged married patients from becoming pregnant after developing epilepsy.

balloon angioplasty and stent deployment was used. Results: A total of 35 patients and 36 occlusions treated between 2007 and 2014 were evaluated. Treatment indications were acute clinical symptoms in 21/35 (60%) patients. Target vessels were ICA (n = 5), MCA (n = 2), VA (n = 13), BA (n = 7) or a combination thereof (n = 9). The attempted vessel reconstruction was achieved in 32/36 (88.8%) procedures. Clinical improvement was confirmed in 30 patients (83.3%), two of them despite failed attempt. At follow-up, permanent neurological deficit was encountered in 16 patients. Four patients died, one as a consequence to the procedure. Conclusion: Haemodynamic compromise of the dependent circulation is a possible reason for the endovascular reconstruction of extraand intracranial vessels in the status of subacute or chronic occlusion. The procedure can be quite demanding (e.g., for basilar and MCA reconstruction). Long-term dual anti-aggregation, angiographic follow-up and treatment of in-stent re-stenoses are part of the concept. Clinical results reach from considerable improvement to major morbidity and procedural mortality.