Search

This prospective uncontrolled study was done to evaluate the role of acetazolamide as an adjunct in the treatment of partial and secondarily generalized seizures. Fourteen out of 15 patients responded to addition of acetazolamide. The mean follow up was 14.86 months. Three patients subsequently developed tolerance. The only side effect noted was paresthesia of limbs not disabling enough to stop the drug. Acetazolamide is a useful adjunct, in the management of partial and secondarily generalized seizures.

Background: Meningeal tuberculosis (TB) has higher mortality compared to other forms of central nervous system TB. However, data on predictors of mortality is limited. Aims: To determine the predictors of mortality in patients with meningeal TB. Materials and Methods: This study retrospectively analyzed the data of patients admitted with a diagnosis of meningeal TB between January 2006 and December 2008. Thwaites' index score of four or less was used for the diagnosis of meningeal TB which is a weighted diagnostic index score for dichotomised clinical variables. Predictors of mortality were analyzed separately for both patients with human immunodeficiency virus (HIV) infection and without. Statistical Analysis: Univariate analysis and multinomial logistic regression was done. Results: Univariate analysis showed age >40 years, Glasgow Coma Scale (GCS) score<8, absence of headache, cerebrospinal fluid (CSF) protein <=60 mg% and Medical Research Council (MRC) Stage III at presentation to predict in-hospital mortality. In multinomial logistic regression age >40 years was a risk factor for mortality when HIV patients were included (P=0.049) as well as when they were excluded (P=0.048). CSF protein 60 mg% was found to be a significant risk factor when both HIV seropositive persons (P=0.011) as well as seronegative persons (P=0.004) were included. HIV seropositivity, steroid treatment or delay in treatment did not affect mortality. Conclusions: Identification of factors predictive of in-hospital mortality will help to prognosticate patients with meningeal TB at the time of admission. [ABSTRACT FROM AUTHOR]

We present a rare case of intracranial candidal granuloma in an immunocompetant female. 24 year old immunocompetant female presented to the neurology OPD with signs and symptoms of left cavernous sinus syndrome. On investigation blood counts, blood sugar, liver and renal function tests and chest X-ray was normal; HIV was negative. CT brain with contrast showed irregular hyperdense lesion around cavernous sinus with normal paranasal sinuses. There was no history of any local nasal ayurvedic treatment or treatment with antibiotics or steroids prior to the present illness. Patient under gone lesionectomy and histopathotogy was suggestive of candidal granuloma. Patient was started on amphotericin, unfortunately patient did not tolerated amphotericine and later expired. Lessons learned from our case are: 1. Clinical diagnosis of fungal infections in immunocompetant is extremly difficult; biopsy and histopatholgy is gold standard. 2. Invasive fungal infections can occur even in immunocompetant people because of tropical climate that was reported in previous studies. 3. Treatment is difficult as most of the conventional antifungals have very poor side effect profile. Emerging antifungals with more efficacy and less side effects like capsofungin and voriconazole will also be discussed. [ABSTRACT FROM AUTHOR]

Background: The role of diabetes related variables like duration of diabetes, diabetic control and microvascular complications leading to cognitive decline in diabetics is not well studied. The contribution of hypertension to the cognitive decline in diabetic patients without dementia is conflicting. Aims: We wanted to see if cognition in diabetics with no dementia is associated with the duration of diabetes, control of diabetes, complications of diabetes, vascular risk factors, or depression. We also looked at association between non-compliance and lower cognitive, or depression. Settings and Design: We recruited ambulant type II diabetic patients more than 55 years attending the diabetic clinic. We excluded patients with dementia and with past history of stroke. Materials and Methods: We selected the time taken for the Trial A test, delayed recall on ten-word list from CERAD, Rowland Universal Dementia Assessment Scale (RUDAS) and CES-D screening instrument to assess these patients. Statistical Analysis Used: We utilized mean, standard deviation, chi square test and Pearson's correlation for statistical analysis. We considered P < 0.06 to be significant. Results: RUDAS scores inversely correlated (r = -0.360) with CES-D scores (P= 6.002). Scores of the screening instrument for depression, the CES-D was associated with the duration of diabetes mellitus (P= 0.018), fasting blood glucose (P=0.029) as well as with two-hour post prandial blood glucose (P= 0.017). Conclusions: There is correlation between depression and global cognitive score. Depression seems to be associated with duration of diabetes and control of diabetes. [ABSTRACT FROM AUTHOR]

We present a rare case of intracranial candidal granuloma in an immunocompetant female. 24 year old immunocompetant female presented to the neurology opd with signs and symptoms of left cavernous sinus syndrome. On investigation blood counts, blood sugar liver and renal function tests, chest X-ray was normal; hiv was negative. CT brain contrast showed irregular hyperdense lesion arond cavernous sinus with normal paranasal sinuses, there was no history of any local nasal ayurvedic treatment or treatment with antibiotics or steroids prior to the present illness. Patient was under gone lesionectomy and histopathology was suggestive of candidal granuloma. Patient was started on amphotericin, unfortunately patient not tolerated amphotericine and later expired. Lessons learned from our case are: 1. Clinical diagnosis of fungal infections in immunocompetant is extremly difficult; biopsy and histopatholgy is gold standard. 2. Invasive fungal infections can occur even in immunocompetant people because of tropical climate that was reported in previous studies. 3. Treatment is difficult as most of the conventional antifungale have very poor side effect profile. Emerging antifungals with more efficacy and less side effects like capsofungin and voriconazole will also be discussed. [ABSTRACT FROM AUTHOR]

Aim: To study the relation between gait abnormality and radiological findings in patients with Normal Pressure Hydrocephalus (NPH). Method: It was a retrospective study conducted in a tertiary referral centre. Patients with NPH and gait abnormality were included. NPH was diagnosed as per the NPH Guidelines Study Group's criteria. A two minute video recording of the gait was analyzed and a five point scoring was given. Higher scores indicated significant disability. All the patients had a CT scan, MRI scan or both done. Scores were given for imaging parameters including ventricular enlargement, periventricular hyper intensities and cortical atrophy. Patients with NPH but normal gait were excluded. Statistics: Pearson correlation coefficient and partial correlation coefficient was used and a p value. [ABSTRACT FROM AUTHOR]

Background: Montreal cognitive assessment (MoCA) is a tool that is widely accepted across the world to measure mild cognitive impairment (MCI). The original cut-off score of MoCA falsely screens a large population of Indians as having MCI., Objective: The aim of this study was to develop the normative data for MoCA for the older population of Kerala, South India., Material and Methods: We conducted the study among 959 cognitively normal older individuals of Kalliyoor village of Thiruvananthapuram district, Kerala. The validated Malayalam version of MoCA [MoCA-M] was administered by trained volunteers. The mean, median, and 10th percentile of the scores [domain-specific and total] were calculated in various age and educational groups., Results: The mean (SD) MoCA score was 19.4 (7.3). The 10th percentile for the total MoCA score was 9. The 10th percentile for all domains was zero, except for orientation. As age advanced, MoCA scores significantly reduced. The mean total MoCA scores dropped from 20.1 (7) [for ages between 65 and 75 years] to 7.4 (1.6) [for ages above 85 years]. We also obtained a significant improvement in scores among subjects with higher educational standards., Conclusion: The study throws light into the performance of MoCA among the Indian population. This study defines the norms for the Indian population and suggests redefining the threshold for positively screening for MCI using MoCA-M., (Copyright © 2024 Copyright: © 2024 Neurology India, Neurological Society of India.)

Fibromyalgia is a soft tissue rheumatism with significant qualitative and quantitative impact on sleep macro and micro architecture. The primary objective of this study is to analyze and identify automatically healthy individuals and those with fibromyalgia using sleep electroencephalography (EEG) signals. The study focused on the automatic detection and interpretation of EEG signals obtained from fibromyalgia patients. In this work, the sleep EEG signals are divided into 15-s and a total of 5358 (3411 healthy control and 1947 fibromyalgia) EEG segments are obtained from 16 fibromyalgia and 16 normal subjects. Our developed model has advanced multilevel feature extraction architecture and hence, we used a new feature extractor called GluPat, inspired by the glucose chemical, with a new pooling approach inspired by the D'hondt selection system. Furthermore, our proposed method incorporated feature selection techniques using iterative neighborhood component analysis and iterative Chi2 methods. These selection mechanisms enabled the identification of discriminative features for accurate classification. In the classification phase, we employed a support vector machine and k-nearest neighbor algorithms to classify the EEG signals with leave-one-record-out (LORO) and tenfold cross-validation (CV) techniques. All results are calculated channel-wise and iterative majority voting is used to obtain generalized results. The best results were determined using the greedy algorithm. The developed model achieved a detection accuracy of 100% and 91.83% with a tenfold and LORO CV strategies, respectively using sleep stage (2 + 3) EEG signals. Our generated model is simple and has linear time complexity., Competing Interests: Conflict of interestThe authors of this manuscript declare no conflicts of interest., (© The Author(s), under exclusive licence to Springer Nature B.V. 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Objectives: Stroke survivors have palliative care needs in multiple domains, which are overlooked. Accurate estimation of these is pivotal in ensuring proper rehabilitation and planning interventions to improve quality of life (QoL). We aimed to assess the palliative care needs of stroke patients in various domains in a structured manner at the neurology service of a tertiary care center in South India., Materials and Methods: Seventy-five consecutive stroke patients presenting to the neurology service were recruited over six months with assessment across various domains including symptom burden, physical domain, activities of daily living (ADL), psychiatric/psychological domain, and QoL at baseline and with follow-up at one month and three months., Results: Despite improvement in the conventional stroke impairment measures among stroke survivors, there were significant unmet needs across various domains; 98% were severely or entirely dependent on ADL at three-month follow-up; and pain and insomnia were the most frequent (33% incidence) troubling symptoms encountered. There were substantial mental health related issues. The QoL measurement tools employed were the stroke impact assessment questionnaire (SIAQ), a novel tool and the World Health Organization Quality Of Life Brief Version (WHO-QOL-BREF). SIAQ scores at one month showed that 19 patients (42.22%) had their QoL severely affected, and 36 patients (80%) showed the same trend at the three-month follow-up. WHO-BREF scores showed that 27 (62%) did not report good QoL, and 32 (73%) were found not to be satisfied with their health at a one-month follow-up., Conclusion: There is a significant burden of unmet palliative care needs among stroke survivors in India across various domains., Competing Interests: There are no conflicts of interest., (© 2024 Published by Scientific Scholar on behalf of Journal of Neurosciences in Rural Practice.)

Competing Interests: There are no conflicts of interest.

Introduction Parkinson's disease (PD) is a progressive complex degenerative disorder characterised by several motor and non-motor symptoms that result in disability and deterioration of the patient's quality of life (QOL). Depression is the most common non-motor symptom that may severely alter the QOL. The objective of this study was to examine the correlation between depression and QOL among patients with PD who received treatment from a movement disorder clinic of a tertiary care teaching hospital in South India. Methods This was an analytical cross-sectional study conducted among 220 PD patients who received treatment from a movement disorder clinic of a tertiary care teaching hospital in South India. The participants aged between 40 and 80 years, who can comprehend Malayalam or English and were clinically diagnosed with PD according to United Kingdom PD Society Brain Bank criteria were included in the study. Depression was assessed using the Hospital Anxiety and Depression Scale, motor function using the Movement Disorder Society Unified Parkinson's Disease Rating Scale Part III, and the quality of life was assessed using the Parkinson's Disease Questionnaire 39. Results The results of this study showed that there was a significant positive correlation between depression and QOL (r=0.699, p<0.01) among patients with PD who received treatment from a tertiary care teaching hospital. The correlation with domains of QOL also identified that depression was significantly correlated with all domains of QOL and more to the emotional domain of QOL (r=0.799, p<0.01). Conclusion Depression is the most common neuropsychiatric condition in PD and the most important determinant of QOL. Depression may occur at any stage of PD and can significantly impact the QOL of patients and their caregivers. Hence it should be recognized early and managed by pharmacological and nonpharmacological measures to improve the QOL., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Sujith et al.)

Electroencephalography (EEG) is a crucial non-invasive medical tool for diagnosing neurological disorder called encephalopathy. There is a requirement for powerful signal processing algorithms as EEG patterns in encephalopathies are not specific to a particular etiology. As visual examination and linear methods of EEG analysis are not sufficient to get the subtle information regarding various neuro pathologies, non-linear analysis methods can be employed for exploring the dynamic, complex and chaotic nature of EEG signals. This work aims identifying and differentiating the patterns specific to cerebral dysfunctions associated with Encephalopathy using Recurrence Quantification Analysis and Fractal Dimension algorithms. This study analysed six RQA features, namely, recurrence rate, determinism, laminarity, diagonal length, diagonal entropy and trapping time and comparing them with fractal dimensions, namely, Higuchi's and Katz's fractal dimension. Fractal dimensions were found to be lower for encephalopathy cases showing decreased complexity when compared to that of normal healthy subjects. On the other hand, RQA features were found to be higher for encephalopathy cases indicating higher recurrence and more periodic patterns in EEGs of encephalopathy compared to that of normal healthy controls. The feature reduction was then performed using Principal Component Analysis and fed to three promising classifiers: SVM, Random Forest and Multi-layer Perceptron. The resultant system provides a practically realizable pipeline for the diagnosis of encephalopathy., Competing Interests: Conflict of interestThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© The Author(s), under exclusive licence to Springer Nature B.V. 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background: India accounts for 13.3% of global disability-adjusted life years (DALYs) lost due to stroke with a relatively younger age of onset compared to the Western population. In India's public healthcare system, many stroke patients seek care at tertiary-level government-funded medical colleges where an optimal level of stroke care is expected. However, there are no studies from India that have assessed the quality of stroke care, including infrastructure, imaging facilities, or the availability of stroke care units in medical colleges., Aim: This study aimed to understand the existing protocols and management of acute stroke care across 22 medical colleges in India, as part of the baseline assessment of the ongoing IMPETUS stroke study., Methods: A semi-structured quantitative pre-tested questionnaire, developed based on review of literature and expert discussion, was mailed to 22 participating sites of the IMPETUS stroke study. The questionnaire assessed comprehensively all components of stroke care, including human resources, emergency system, in-hospital care, and secondary prevention. A descriptive analysis of their status was undertaken., Results: In the emergency services, limited stroke helpline numbers, 3/22 (14%); prenotification system, 5/22 (23%); and stroke-trained physicians were available, 6/22 (27%). One-third of hospitals did not have on-call neurologists. Although non-contrast computed tomography (NCCT) was always available, 39% of hospitals were not doing computed tomography (CT) angiography and 13/22 (59%) were not doing magnetic resonance imaging (MRI) after routine working hours. Intravenous thrombolysis was being done in 20/22 (91%) hospitals, but 36% of hospitals did not provide it free of cost. Endovascular therapy was available only in 6/22 (27%) hospitals. The study highlighted the scarcity of multidisciplinary stroke teams, 8/22 (36%), and stroke units, 7/22 (32%). Lifesaving surgeries like hematoma evacuation, 11/22 (50%), and decompressive craniectomy, 9/22 (41%), were performed in limited numbers. The availability of occupational therapists, speech therapists, and cognitive rehabilitation was minimal., Conclusion: This study highlighted the current status of acute stroke management in publicly funded tertiary care hospitals. Lack of prenotification, limited number of stroke-trained physicians and neurosurgeons, relatively lesser provision of free thrombolytic agents, limited stroke units, and lack of rehabilitation services are areas needing urgent attention by policymakers and creation of sustainable education models for uniform stroke care by medical professionals across the country., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Intravenous thrombolysis is an effective treatment of acute ischemic stroke but has a narrow therapeutic time window of 3-4.5 h. Pre-hospital delay is a major barrier to patients becoming eligible for thrombolysis. This single-center study assessed the factors causing longer onset-to-door (OTD) time to identify measures that will help decrease the delay., Materials and Methods: Patients with acute ischemic stroke presenting to the emergency department from August to October 2022 were included in the study. The data were collected using a structured questionnaire and was completed by interviewing the patient or the caregivers. Patients were classified as early and late arrivers with the cutoff being 3.5 h. We then analyzed the relationship between early arrival and demographic factors, clinical factors, patient response factors, and logistic factors., Results: Our study consisted of 153 patients. The average OTD time was 674.33 ± 812.713 min (median: 300; interquartile range: 151-885). The pre-hospital delay was present in 66% of patients. 16.9% of patients came beyond 24 h. In the multivariate analysis, the odds of early arrival were higher among patients who perceived their symptoms as serious (odds ratio [OR]: 18.801; confidence interval [CI]: 3.728-94.803) and lower among patients who experienced a delay in reaching due to traffic (OR: 0.085; CI: 0.008-0.873). Lack of knowledge about stroke centers among both patients and health professionals also contributed to longer OTD times. Out of 52 early arrivers, 24 received thrombolytic therapy after excluding wake-up strokes and contraindications., Conclusion: Pre-hospital delay continues to stand in the way of patients receiving thrombolysis. Comprehensive stroke education, increasing awareness regarding stroke centers, and promoting ambulance services are some of the interventions which could help tackle the issue., Competing Interests: There are no conflicts of interest., (© 2024 Published by Scientific Scholar on behalf of Journal of Neurosciences in Rural Practice.)

Introduction: Depression, a common non-motor symptom in Parkinson's disease (PD), is often underdiagnosed and can significantly impact the quality of life (QOL) and treatment outcomes. Specific disease-related factors and non-specific factors may contribute to depression, and these factors should be identified early to plan the appropriate interventions that promote positive mood. The study aimed to assess the prevalence of depression in PD patients and to find out the factors associated with depression among patients with PD attending the neurology OPD of a tertiary care teaching hospital in Trivandrum., Methods: A cross-sectional study was conducted at the neurology OPD of Government Medical College Hospital, Trivandrum, from December 2021 to February 2023. We included patients with PD diagnosed according to the United Kingdom PD Society Brain Bank criteria. We collected data from 220 patients with PD by interview technique. Hospital Anxiety and Depression Scale (HADS) was used to assess depression and anxiety in this study. Staging and the severity of the motor symptoms were assessed using the Hoehn and Yahr scale and the Movement Disorder Society Unified Parkinson's Disease Rating Scale Part III (MDS UPDRS Part III), respectively., Results: Among 220 patients with PD, 31.8% (95% CI: 4.36-5.40) had depression. The non-specific variables, such as education, living arrangements, and gender, and disease-specific variables, such as the severity of motor symptoms (MDS UPDRS Part III score) and the Hoehn and Yahr staging of PD, had a statistically significant association with depression. Logistic regression analysis showed that the severity of motor symptoms (OR=2.69, p=0.004)) and female gender (OR=1.830, p= 0.05) were the independent factors associated with depression., Conclusion: Depression is a common non-motor symptom of PD that is often underdiagnosed and undertreated and can significantly impact the QOL of patients and their caregivers. Hence, it should be identified early and managed by pharmacological and non-pharmacological strategies., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Sujith et al.)

Background: Guillain-Barre syndrome (GBS) is one of the most common neurological manifestations associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Although data for a strong causal association is lacking, anecdotal reports, case series and systematic reviews linking the two have emerged in the literature. This prompted us to compare the clinical features, electrophysiology, and outcomes of GBS cases presenting during the pandemic with cases reported during a similar time period prior to the pandemic., Materials and Methods: Prospective data of GBS cases diagnosed as per the National Institute of Neurological Disorders and Stroke (NINDS) criteria was collected for a 6-month period (July-December 2021) at three tertiary care teaching hospitals during the coronavirus pandemic and compared with retrospective records-based data of cases prior to the pandemic (January-July 2019)., Results: A total of 40 cases were included in the cases, out of which 17 were in the prepandemic and 23 in the postpandemic period. A total of three cases temporally related to coronavirus disease 2019 (COVID-19) infection and four cases following COVID-19 vaccination were seen in the pandemic cohort. The clinical features, electrophysiological features, and outcomes were comparable during both periods. A slightly higher rate of in-hospital complications and single mortality was reported in the postpandemic period., Discussion: The number of GBS hospital admissions, clinical presentation, electrodiagnostic features, and short-term outcomes did not differ significantly between the prepandemic and postpandemic periods; a slightly higher incidence of in-hospital complications was observed during the pandemic period. How to cite this article: Panicker P, R D, V AG, et al. Comparison of Guillain-Barre Syndrome Cases during and Prior to the COVID-19 Pandemic: A Multicentric Study. J Assoc Physicians India 2023;71(9):69-71., (© Journal of the Association of Physicians of India 2023.)

Background: CSF free light chains help diagnose multiple sclerosis, but no data is available on the Asian population. Our objective was to study the diagnostic utility of CSF free light chains for diagnosing multiple sclerosis in Indian patients., Methods: Prospective multicentric case-control study. Cases included those who were tested for oligoclonal bands and fulfilled the modified McDonald criteria 2017 for multiple sclerosis and clinically isolated syndromes. Those tested for oligoclonal bands (OCB) but with other diagnoses- inflammatory and non-inflammatory were included as controls. Clinical details were collected from electronic medical records. CSF and serum kappa and lambda free light chains were measured, apart from oligoclonal bands, immunoglobulin, and albumin in paired serum and CSF samples., Results: There were 70 patients (31 cases and 39 controls). The mean age was 43.41(SD 16.073) years, and 43(61.4%) were females. CSF kappa showed highest specificity 97.4%, at a cut off 2.06 mg/L (sensitivity 71%) and highest sensitivity 90.3%, at a cut off 0.47 mg/L (specificity 79.5%). Best balance of sensitivity and specificity for CSF kappa was seen at a cut-off of ≥ 0.63 mg/L {sensitivity 87·1 (CI - 70.17-96.37), and specificity 87·18 (CI -72.57-95.70)}. The ratio of Kappa/lambda showed highest specificity of 100%(similar to OCB) with a sensitivity of 71% at a cut off of 1.72. The ratio of sum of kappa and lambda light chains, and Qalb (∑CSF FLC/Qalb), showed the highest specificity (94.87%)among the blood brain barrier corrected ratios., Conclusion: This study showed that the diagnostic utility of CSF kappa was comparable to OCB to diagnose multiple sclerosis in sensitivity, but not specificity, so can be a screening test before testing for OCB in our population., Competing Interests: Declaration of Competing Interest None of the authors report any conflicts of interest., (Copyright © 2023. Published by Elsevier B.V.)

Background: There are only very few studies on estimating the prevalence of mild cognitive impairment (MCI) from India, particularly from a rural setting. The available studies were heterogeneous., Objective: The study estimated the prevalence of MCI in a rural setting in Kerala, India., Materials and Methods: We conducted a community-based, cross-sectional study among individuals aged 65 and above in rural Thiruvananthapuram, Kerala. A cluster-randomized sampling was adopted, the cluster being the wards in the village. It was a two-phase door-to-door survey. Grassroots-level health workers enrolled 366 elders in the selected four wards in the initial phase and collected information on the sociodemographic details, comorbidities, and other risk factors of the participants, using a semi-structured questionnaire. Additionally, the Everyday Abilities Scale for India (EASI) was administered to assess their activities of daily living. In the second phase, a neurologist and a psychologist examined those screened positive with EASI and diagnosed MCI and dementia based on the MCI Working Group of the European Consortium on Alzheimer's Disease and the DSM V criteria, respectively., Results: The prevalence of MCI and dementia was 18.6% (95% confidence interval [CI] 14.7%-23.4%) and 6.8% (4.46%-10.1%), respectively, among the study participants. The prevalence of MCI was higher among the unemployed and those above 70 years of age., Conclusion: The community prevalence of MCI is more than three times that of dementia among the elderly in rural Kerala., Competing Interests: None

Background: The Angio-invasive Rhino-orbito-cerebral mucormycosis (ROCM) producing strokes is a less explored entity. Our hospital, a stroke-ready one, had an opportunity to manage mucormycosis when it was identified as the nodal center for mucormycosis management. We are sharing our experiences and mistakes in managing the cerebrovascular manifestations of ROCM., Methods: We conducted a prospective observational study during the second wave of the COVID-19 pandemic from 1st May 2021 to 30th September 2021, where consecutive patients aged more than 18 years with microbiologically confirmed cases of ROCM were included. Clinical details (timing of stroke onset after ROCM symptoms, GCS, NIHSS), imaging findings (ASPECTS, the territory of stroke, the pattern of infarct, hemorrhagic transformation, cavernous sinus thrombosis), angiogram findings, management details (IV thrombolysis), and outcomes (mRS at discharge and duration of hospital stay) were documented. We also compared the demographics, clinical features (NIHSS), radiological findings, treatment details, duration of hospital stay, and functional outcome at the discharge of the ROCM stroke patients with stroke patients without ROCM., Results: Stroke developed in 42% of patients with ROCM, predominantly anterior circulation border zone ischemic infarcts. Strokes occurred after a median of five days from the onset of ROCM symptoms. The most common vessel involved was the ophthalmic artery, followed by the cavernous ICA. We could not thrombolyse ROCM stroke patients. ROCM patients who developed stroke compared with patients without stroke had a more infiltrative fungal infection and higher inflammatory markers. Mucormycosis associated stroke patients had higher in-hospital mortality and poor functional outcomes., T Conclusion: Due to delayed recognition of stroke symptoms, none received reperfusion strategies, leading to poor functional outcomes. For early stroke detection, ROCM cases need frequent monitoring and education of patients and their relatives about the ALS acronym (loss of ambulation, limb weakness, and loss of speech)., Competing Interests: Disclosures None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Many neuropsychological tests are primarily developed in high-income countries, and normative data are not readily available for low- and middle-income countries (LMICs). We need culturally appropriate cognitive screening tests for India., Objective: Hence, we decided to translate the Hindi cognitive screening test battery (HCSTB) tool to Malayalam and establish the age and education-stratified norms for a Malayalam cognitive screening test battery (MCSTB)., Material and Methods: HCSTB was translated to Malayalam, back-translated by bilinguals conversant in Malayalam and English, and pretested on 30 older normal adults. Using a multistage sampling technique, we conducted a descriptive cross-sectional survey in the Thiruvananthapuram district of Kerala, India. We approached older adults aged ≥60 years for informed and written consent. We excluded subjects with depression, functional impairment, cognitive impairment, history of stroke, psychosis, and visual/hearing loss that impaired cognitive assessment., Results: The normative data were derived from 441 older adults: 226 (51%) from rural areas and 215 (49%) from urban areas. Age and education affected the cognitive scores. The time to administer MCSTB among normal adults was approximately 17 minutes., Discussion and Conclusion: The derived normative data showed lower values than the published literature. A limitation of our study was the small number of older people with ≥12 years of education and the lack of neuroimaging of the subjects., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Annals of Indian Academy of Neurology.)

Introduction/aims: Studies conducted during the coronavirus disease 2019 (COVID-19) pandemic have reported varied data regarding the incidence of Guillain-Barre syndrome (GBS). The present study investigated demographic and clinical features, management, and outcomes of patients with GBS during a specified period of the COVID-19 pandemic, and compared these features to those of GBS in the previous year., Methods: A multicenter, ambispective cohort study including 26 centers across India was conducted. Data from a pre-COVID-19 period (March 1 to August 31, 2019) were collected retrospectively and collected ambispectively for a specified COVID-19 period (March 1 to August 31, 2020). The study was registered with the Clinical Trial Registry India (CTRI/2020/11/029143)., Results: Data from 555 patients were included for analysis: pre-COVID-19 ( n = 334) and COVID-19 ( n = 221). Males were more commonly affected during both periods (male:female, 2:1). Gastroenteritis was the most frequent antecedent event in 2019 (17.4%), whereas fever was the most common event in 2020 (10.7%). Paraparesis (21.3% versus [vs.] 9.3%, P = 0.001) and sensory involvement (51.1% vs. 41.3%; P = 0.023) were more common during COVID-19 in 2020, whereas back pain (26.3% vs. 18.4%; P = 0.032) and bowel symptoms (20.7% vs. 13.7%; P = 0.024) were more frequent in the pre-COVID period. There was no difference in clinical outcomes between the two groups in terms of GBS disability score at discharge and 3 months after discharge. Independent predictors of disability in the pre-COVID period included areflexia/hyporeflexia, the requirementfor intubation, and time to bulbar weakness; in the COVID-19 period, independent predictors included time from onset to admission, intubation, and intubation requirement. The mortality rate was 2.3% during the entire study period (13/555 cases)., Discussion: Results of this study revealed an overall reduction in the frequency of GBS during the pandemic. The lockdown likely reduced the risk for antecedent infections due to social distancing and improved hygiene, which may have resulted in the reduction of the frequency of GBS., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Annals of Indian Academy of Neurology.)

Introduction: The unprecedented challenges during the COVID pandemic and the subsequent lockdown had resulted in a delay in treatment metrics for acute stroke. There is a rising concern that COVID-19 co-infection can adversely affect stroke outcome. We aim to investigate the impact of COVID-19 in the management of stroke patients. We also compared the differences in stroke manifestations, etiological pattern, treatment course, and outcome of acute stroke patients in COVID-19 confirmed cases., Methodology: A single-center retrospective study was done at the Stroke Unit, Government Medical College, Thiruvananthapuram. Consecutive patients of acute stroke confirmed by imaging, presenting within 24 hours of the onset of symptoms in May to July 2020 and May to July 2019, were included. The primary data variables included baseline demographics, risk factors, admission NIHSS, stroke timings, thrombolysis rate, TOAST etiology, mRS at discharge, and in-hospital mortality., Results: Strokes with higher NIHSS, arrival blood sugar and blood pressure, and delays in door-to-CT and door-to-needle time were more during the pandemic. Intravenous thrombolysis was less and mortality was higher in COVID-19 strokes during the pandemic. COVID-19-positive stroke patients had more hemorrhagic strokes, more severe strokes with low CT ASPECTS, more hemorrhagic transformation, high in-hospital mortality, and poor functional outcome at discharge and 3 months., Conclusion: Our study was a hypothesis-generating study with a limited number of patients. This study has reconfirmed the higher severity of the stroke, with a higher mRS score and mortality during the pandemic, especially among COVID-19-positive stroke patients., Competing Interests: None

Clinical diagnostics for SARS-CoV-2 infection usually comprises the sampling of throat or nasopharyngeal swabs that are invasive and create patient discomfort. Hence, saliva is attempted as a sample of choice for the management of COVID-19 outbreaks that cripples the global healthcare system. Although limited by the risk of eliciting false-negative and positive results, tedious test procedures, requirement of specialized laboratories, and expensive reagents, nucleic acid-based tests remain the gold standard for COVID-19 diagnostics. However, genetic diversity of the virus due to rapid mutations limits the efficiency of nucleic acid-based tests. Herein, we have demonstrated the simplest screening modality based on label-free surface enhanced Raman scattering (LF-SERS) for scrutinizing the SARS-CoV-2-mediated molecular-level changes of the saliva samples among healthy, COVID-19 infected and COVID-19 recovered subjects. Moreover, our LF-SERS technique enabled to differentiate the three classes of corona virus spike protein derived from SARS-CoV-2, SARS-CoV and MERS-CoV. Raman spectral data was further decoded, segregated and effectively managed with the aid of machine learning algorithms. The classification models built upon biochemical signature-based discrimination method of the COVID-19 condition from the patient saliva ensured high accuracy, specificity, and sensitivity. The trained support vector machine (SVM) classifier achieved a prediction accuracy of 95% and F1-score of 94.73%, and 95.28% for healthy and COVID-19 infected patients respectively. The current approach not only differentiate SARS-CoV-2 infection with healthy controls but also predicted a distinct fingerprint for different stages of patient recovery. Employing portable hand-held Raman spectrophotometer as the instrument and saliva as the sample of choice will guarantee a rapid and non-invasive diagnostic strategy to warrant or assure patient comfort and large-scale population screening for SARS-CoV-2 infection and monitoring the recovery process., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Background: Stroke affects the quality of life through its devastating effects on physical, psychological, social, and economic domains. Patient-reported outcome measures help to capture the patient's perspective to changes in the quality of life. The available stroke-specific outcome measures of stroke do not comprehensively measure all the domains., Objective: We describe the development and validation of the Stroke Impact Assessment Questionnaire (SIAQ) an interviewer-administered new instrument developed using patient-centered approaches to assess the long-term problems of stroke survivors., Materials and Methodology: We used a sequential exploratory mixed methods approach (QUAL → QUAN) to develop the SIAQ. The design involves an initial qualitative phase aimed at generating the item pool and a subsequent second phase aimed at testing of items using quantitative techniques (Psychometric evaluation)., Result: SIAQ, a thirty-item tool, under the eight domains (sensory, motor, social, economic, emotional, behavioral, cognitive, and communication) emerged from Principal Component Analysis. The factor loadings ranged from 0.421 to 0.880. The intraclass coefficient in test-retest reliability r is 0.958 (95% CI 0.9249-0.9799) and in interobserver reliability is 0.9473 (95% CI 0.9125 - 0.9733). The internal consistency Cronbach's alpha for the final 30 item tool was 0.88., Conclusion: SIAQ is a culturally appropriate psychometrically robust questionnaire assessing the long-term outcome of stroke. However, SIAQ is applicable only in stroke survivors for up to 65 years., Competing Interests: None

Mycobacterium tuberculosis adenylyl cyclase (AC) Rv1625c/Cya is an evolutionary ancestor of the mammalian membrane ACs and a model system for studies of their structure and function. Although the vital role of ACs in cellular signalling is well established, the function of their transmembrane (TM) regions remains unknown. Here, we describe the cryo-EM structure of Cya bound to a stabilizing nanobody at 3.6 Å resolution. The TM helices 1-5 form a structurally conserved domain that facilitates the assembly of the helical and catalytic domains. The TM region contains discrete pockets accessible from the extracellular and cytosolic side of the membrane. Neutralization of the negatively charged extracellular pocket Ex1 destabilizes the cytosolic helical domain and reduces the catalytic activity of the enzyme. The TM domain acts as a functional component of Cya, guiding the assembly of the catalytic domain and providing the means for direct regulation of catalytic activity in response to extracellular ligands., Competing Interests: VM, BK, DS, IK, IV, AK, TI, SS, PP, VK No competing interests declared, (© 2022, Mehta, Khanppnavar et al.)

Introduction: In India, a national program for stroke (national programme for the control of cardiovascular diseases, diabetes, cancer, and stroke) and stroke management guidelines exist. Its successful implementation would need an organized system of stroke care in practice. However, many challenges exist including lack of awareness, prehospital notification systems, stroke ready hospitals, infrastructural weaknesses, and rehabilitation. We present here a protocol to investigate the feasibility and fidelity of implementing a uniform stroke care pathway in medical colleges of India., Methods and Analysis: This is a multicentric, prospective, multiphase, mixed-method, quasi-experimental implementation study intended to examine the changes in a select set of stroke care-related indicators over time within the sites exposed to the same implementation strategy. We shall conduct process evaluation of the implementation process as well as evaluate the effect of the implementation strategy using the interrupted time series design. During implementation phase, education and training about standard stroke care pathway will be provided to all stakeholders of implementing sites. Patient-level outcomes in the form of modified Rankin Scale score will be collected for all consecutive patients throughout the study. Process evaluation outcomes will be collected and reported in the form of various stroke care indicators. We will report level and trend changes in various indicators during the three study phases., Discussion: Acute stroke requires timely detection, management, and secondary prevention. Implementation of the uniform stroke care pathway is a unique opportunity to promote the requirements of homogenous stroke care in medical colleges of India., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Annals of Indian Academy of Neurology.)

Background: During the first wave of the pandemic, stroke care suffered globally and there were reduced stroke admissions and delays in time metrics. Stroke care was reorganized during the second wave learning from the experience of previous wave. This study shares our experience in stroke time metrics during the second wave of pandemic compared to the first wave., Methods: We did a single-center prospective study, where consecutive acute ischemic stroke patients within 24 hours of the onset of symptoms and aged more than 18 years, who presented to Stroke Unit, Department of Neurology, Government Medical College, Thiruvananthapuram from June 1st to 31st August, 2020 and June 1st to 31st August in 2021 were included. In-hospital time metrics (door to CT time and door to Needle time) were compared during the two time periods. We also compared functional outcomes at discharge and in-hospital mortality during the two periods. Functional outcome at discharge was assessed by modified Rankin scale (mRS)., Results: From June to August 2021 (second wave of the COVID 19 pandemic), compared to the same months during the first wave (2020), our study demonstrated better in-hospital time metrics (door to CT time and door to needle time). We also found lower admission systolic blood pressure and higher baseline CT early ischemic changes during the second wave. There was no difference in functional outcome at discharge and in-hospital mortality. Intravenous thrombolysis rates also remained the same during the two periods., Conclusion: Our study has confirmed that time metrics in stroke care can be improved through system rearrangement even during the pandemic. Acute stroke treatments are time-dependent and hospital administrators must stick to the maxim "Time is Brain" while restructuring stroke workflows during future challenges., (Copyright © 2022. Published by Elsevier Inc.)

Electroencephalogram (EEG) signals portray hidden neuronal interactions in the brain and indicate brain dynamics. These signals are dynamic, complex, chaotic and nonlinear, the nature of which is represented with features - fractal dimensions, entropies and chaotic features. This study aims at examining the discriminative power of individual features and their combination in the diagnosis of a neuro-pathological condition called encephalopathy. Feature combination is accomplished with the help of feature selection using Gini impurity score that improves discriminative power and keeps redundancy minimal. Further, three widely used non-parametric classifiers which are known to be effective with wavelet features on EEG signals - Support Vector Machine, Random Forest, Multilayer Perceptron - are employed for disease classification. The models created by the combination of aforementioned stages are analysed and evaluated with performance scores, leading to an optimal model for automated diagnostic applications., (Copyright © 2021. Published by Elsevier B.V.)

Background: In patients with Parkinson's disease (PD), the occurrence of motor and non-motor symptoms increases with disease progression. The range of neuropsychiatric symptoms (NPS) vary among individuals and can be burdensome for caregivers. Only a few studies have identified the contributing factors of NPS and caregiver burden in India., Objectives: We aimed to study the clinical profile, disability, and predictive factors of NPS in PD patients and associated caregiver's burden., Methods and Material: This was a cross-sectional observational study carried out in PD patients and their respective caregivers attending a movement disorder clinic in a tertiary care teaching hospital in Kerala. A total of 104 patients diagnosed with idiopathic PD receiving levodopa therapy and who had a primary caregiver were enrolled in the study. Structured questionnaires were administered to both patients and caregivers to collect data. Data analysis was done using an independent t-test, linear, and multiple regression analysis., Results: Among 104 patients recruited for the study, 61.5% of patients had shown at least one NPS and 40.44% showed multiple NPS. Results from the study showed that depression is the primary NPS occurring in IPD patients (55.8%) followed by irritability, anxiety, and apathy. On linear regression models, the prime determinant of NPS was the Everyday Abilities Scale for India (EASI). For caregiver burden, the main determinants were the presence of NPS, duration of caregiving, EASI, and RBDSQ score., Conclusions: NPS in PD are highly associated with and are determinants of caregiver burden. Detailed assessment and specific interventions aimed at NPS could alleviate caregiver burden., Competing Interests: None

Background and Objectives: To determine whether cognitive reserve attenuates the association of vascular brain injury with cognition., Methods: Cross-sectional data were analyzed from 2 harmonized studies: the Canadian Alliance for Healthy Hearts and Healthy Minds (CAHHM) and the Prospective Urban and Rural Epidemiology (PURE) study. Markers of cognitive reserve were education, involvement in social activities, marital status, height, and leisure physical activity, which were combined into a composite score. Vascular brain injury was defined as nonlacunar brain infarcts or high white matter hyperintensity (WMH) burden on MRI. Cognition was assessed using the Montreal Cognitive Assessment Tool (MoCA) and the Digit Symbol Substitution Test (DSST)., Results: There were 10,916 participants age 35-81. Mean age was 58.8 years (range 35-81) and 55.8% were female. Education, moderate leisure physical activity, being in a marital partnership, being taller, and participating in social groups were each independently associated with higher cognition, as was the composite cognitive reserve score. Vascular brain injury was associated with lower cognition (β -0.35 [95% confidence interval [CI] -0.53 to -0.17] for MoCA and β -2.19 [95% CI -3.22 to -1.15] for DSST) but the association was not modified by the composite cognitive reserve variable (interaction p = 0.59 for MoCA and p = 0.72 for DSST)., Conclusions: Both vascular brain injury and markers of cognitive reserve are associated with cognition. However, the effects were independent such that the adverse effects of covert vascular brain injury were not attenuated by higher cognitive reserve. To improve cognitive brain health, interventions to both prevent cerebrovascular disease and promote positive lifestyles are needed., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

Background: As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected., Aims: The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019., Methods: The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points., Results: A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods., Conclusions: Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe., (Copyright © 2021 Elsevier B.V. All rights reserved.)