1
|
James CD, Lewis RL, Fakunmoju AL, Witt AJ, Youssef AH, Wang X, Rais NM, Prabhakar AT, Otoa R, Bristol ML. Fibroblast Stromal Support Model for Predicting Human Papillomavirus-Associated Cancer Drug Responses. bioRxiv 2024:2024.04.09.588680. [PMID: 38644998 PMCID: PMC11030318 DOI: 10.1101/2024.04.09.588680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Currently, there are no specific antiviral therapeutic approaches targeting Human papillomaviruses (HPVs), which cause around 5% of all human cancers. Specific antiviral reagents are particularly needed for HPV-related oropharyngeal cancers (HPV+OPCs) whose incidence is increasing and for which there are no early diagnostic tools available. We and others have demonstrated that the estrogen receptor alpha (ERα) is overexpressed in HPV+OPCs, compared to HPV-negative cancers in this region, and that these elevated levels are associated with an improved disease outcome. Utilizing this HPV+ specific overexpression profile, we previously demonstrated that estrogen attenuates the growth and cell viability of HPV+ keratinocytes and HPV+ cancer cells in vitro. Expansion of this work in vivo failed to replicate this sensitization. The role of stromal support from the tumor microenvironment (TME) has previously been tied to both the HPV lifecycle and in vivo therapeutic responses. Our investigations revealed that in vitro co-culture with fibroblasts attenuated HPV+ specific estrogen growth responses. Continuing to monopolize on the HPV+ specific overexpression of ERα, our co-culture models then assessed the suitability of the selective estrogen receptor modulators (SERMs), raloxifene and tamoxifen, and showed growth attenuation in a variety of our models to one or both of these drugs in vitro. Utilization of these SERMs in vivo closely resembled the sensitization predicted by our co-culture models. Therefore, the in vitro fibroblast co-culture model better predicts in vivo responses. We propose that utilization of our co-culture in vitro model can accelerate cancer therapeutic drug discovery.
Collapse
Affiliation(s)
- Claire D. James
- Philips Institute for Oral Health Research, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Rachel L. Lewis
- Philips Institute for Oral Health Research, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Alexis L. Fakunmoju
- Philips Institute for Oral Health Research, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Austin J. Witt
- Philips Institute for Oral Health Research, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Aya H. Youssef
- Philips Institute for Oral Health Research, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Xu Wang
- Philips Institute for Oral Health Research, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Nabiha M. Rais
- Philips Institute for Oral Health Research, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Apurva Tadimari Prabhakar
- Philips Institute for Oral Health Research, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Raymonde Otoa
- Philips Institute for Oral Health Research, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Molly L. Bristol
- Philips Institute for Oral Health Research, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
- VCU Massey Comprehensive Cancer Center, Richmond, Virginia, USA
| |
Collapse
|
2
|
Nair AV, Kandagaddala M, Sivadasan A, Prabhakar AT, Nair S, Mathew V, Aaron S, Alexander M. "De Novo" Hypercapnic Respiratory Failure Unmasking Neuromuscular Disorders: Experiences From a Tertiary Care Center and Review of Literature. J Clin Neuromuscul Dis 2024; 25:122-131. [PMID: 38441928 DOI: 10.1097/cnd.0000000000000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
OBJECTIVES Neuromuscular disorders could have respiratory involvement early or late into illness. Rarely, patients may present with a hypercapnic respiratory failure (with minimal motor signs) unmasking an underlying disease. There are hardly any studies which have addressed the spectrum and challenges involved in management of this subset, especially in the real-world scenario. METHODS A retrospective study comprising consecutive patients hospitalized with hypercapnic respiratory failure as the sole/dominant manifestation. The clinical-electrophysiological spectrum, phrenic conductions, diaphragm thickness, and outcomes were analyzed. RESULTS Twenty-seven patients were included, the mean age was 47.29 (SD 15.22) years, and the median duration of respiratory symptoms was 2 months (interquartile range [IQR] 1-4). Orthopnea was present in 23 patients (85.2%) and encephalopathy in 8 patients (29.6%). Phrenic nerve latencies and amplitudes were abnormal in 83.3% and 95.6%, respectively. Abnormal diaphragm thickness was noted in 78.5%. Based on a comprehensive electrophysiological strategy and paraclinical tests, an etiology was established in all. Reversible etiologies were identified in 17 patients (62.9%). These included myasthenia gravis (anti-AChR and MuSK), inflammatory myopathy, riboflavin transporter deficiency neuronopathy, Pompe disease, bilateral phrenic neuritis, and thyrotoxicosis. Respiratory onset motor neuron disease was diagnosed in 8 patients (29.6%). Despite diaphragmatic involvement, a functional respiratory recovery was noted at discharge (45%) and last follow-up (60%). Predictors for good outcomes included female sex, normal nerve conductions, and recent-onset respiratory symptoms. DISCUSSION A good functional recovery was noted in most of the patients including respiratory onset motor neuron disease. A systematic algorithmic approach helps in proper triaging, early diagnosis, and treatment. Clinical and electrodiagnostic challenges and observations from a tertiary care referral center are discussed.
Collapse
Affiliation(s)
| | | | - Ajith Sivadasan
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - A T Prabhakar
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Shalini Nair
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Vivek Mathew
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Sanjith Aaron
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Mathew Alexander
- The Brunei Neuroscience Stroke and Rehabilitation Center, Brunei, Darussalam
| |
Collapse
|
3
|
Nehrujee A, Rajendiran N, Bombatkar R, Murugesan A, Balaraman S, Mani MK, Kamalesh kumar S, Prakash H, Bhattacharya S, Swami T, Aaron S, Prabhakar AT. Long-term Usability and Feasibility of Home-Based Hand Therapy With the Plug-And-Train Hand Rehabilitation Robot(PLUTO). Arch Phys Med Rehabil 2023. [DOI: 10.1016/j.apmr.2022.12.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
|
4
|
Thomson VS, Aaron S, Samson D N, Krupa J, Prabhakar AT, Jose J, George P, George OK, Joseph G, Yadav BK. Patent foramen ovale closure in India; Feasibility, challenges and mid-term outcomes. Indian Heart J 2021; 73:656-659. [PMID: 34627589 PMCID: PMC8514405 DOI: 10.1016/j.ihj.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/19/2021] [Accepted: 09/01/2021] [Indexed: 10/25/2022] Open
Abstract
Patent foramen ovale closure (PFO) is an underutilized therapy, and our study explored the challenges and feasibility of PFO closure in the Indian setting. Eighty patients with Embolic Stroke of Undetermined Source (ESUS) were screened by transcranial Doppler (TCD) for PFO. Twenty-nine patients underwent successful closure. High-risk features of a long tunnel, inter-atrial septal aneurysm, and large defect were present in 31%, 28%, and 59%. Transcranial Doppler had a sensitivity and specificity of 78% and 53% (p = 0.02) to detect PFO. Anticoagulation was withdrawn in 85% of patients post closure. Two patients had residual shunts at follow-up of 19 (9,34) months.
Collapse
Affiliation(s)
- Viji S Thomson
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India.
| | - Sanjith Aaron
- Department of Neurology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Nathaniel Samson D
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Jesu Krupa
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - A T Prabhakar
- Department of Neurology, Christian Medical College and Hospital, Vellore, 632004, India
| | - John Jose
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Paul George
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Oommen K George
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - George Joseph
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Bijesh Kumar Yadav
- Department of Biostatistics, Christian Medical College and Hospital, Vellore, 632004, India
| |
Collapse
|
5
|
Sivadasan A, Nair A, Miraclin A, Mani AM, Prabhakar AT, Jude Prakash JA, Mathew V. Infection-Associated Peripheral Nerve Hyperexcitability: An Under-Recognized Entity. Ann Indian Acad Neurol 2021; 24:243-246. [PMID: 34220070 PMCID: PMC8232500 DOI: 10.4103/aian.aian_427_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/21/2020] [Accepted: 05/27/2020] [Indexed: 11/18/2022] Open
Abstract
Background: Peripheral nerve hyperexcitability (PNH) and neuromyotonia have been mainly attributed to antibodies against voltage-gated potassium channels (VGKC). Concurrent autoimmune disorders, malignancies, and heavy metal toxicity have also been implicated. There is scarce mention about infection as a triggering factor for PNH. There are no reports of methicillin-resistant Staphylococcus aureus (MRSA) infection being a possible precipitating factor for development of PNH. Methods: Case series and literature review. Results: Four subjects were diagnosed to have features of PNH based on clinical and electrophysiological assessment. All the subjects had concurrent evidence of cutaneous abscesses requiring surgical intervention and antibiotic therapy. The cultures in all of them revealed growth of Staphylococcus aureus with three of them being MRSA isolates. Two subjects tested positive for anti-VGKC antibodies. There was remarkable resolution in neuromyotonia after antibiotics in three subjects. One subject succumbed to fulminant MRSA septicemia. Conclusion: There appears to be a definitive link between staphylococcal infection (MRSA in particular) and development of PNH. The temporal evolution of PNH associated with the infection and resolution following treatment of the infection does support a causal association. The enterotoxins produced by staphylococci act as superantigens and could trigger an inflammatory cascade along with development of cross reacting antibodies against VGKC in peripheral nerves. Future studies with animal models could provide more directions in this regard.
Collapse
Affiliation(s)
- Ajith Sivadasan
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Aditya Nair
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Angel Miraclin
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Arun Mathai Mani
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - A T Prabhakar
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Vivek Mathew
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
6
|
Vijayaraghavan A, Alexander PT, Nair AV, Sivadasan A, Mani AM, Mathew D, Shaikh A, Benjamin RN, Prabhakar AT, Jude J, Mani S, Aaron S, Mathew V, Alexander M. Clinical Spectrum, Therapeutic Outcomes and Prognostic predictors in Paraneoplastic Neurological Syndromes - Experiences from a Tertiary Care Center in India. Ann Indian Acad Neurol 2021; 24:32-39. [PMID: 33911377 PMCID: PMC8061505 DOI: 10.4103/aian.aian_975_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/21/2020] [Accepted: 10/14/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Paraneoplastic Neurological Syndromes (PNSs) are a heterogeneous group of immune-mediated disorders that often precede tumor diagnosis. There are few systematic studies on the spectrum and follow-up of PNSs. Objective: To analyze the clinical spectrum, associated tumors, antibody profile, outcomes, and prognostic predictors in a cohort of PNSs admitted in a tertiary care center. Methods: This retrospective study included 97 patients (2008-2019). PNSs were further classified as “classical,” “nonclassical,” “definite,” and “possible.” Clinical profile, diagnostic strategies, therapeutic options, and predictors of outcomes were identified. Results: The median age was 54 years (range 17–81). Thirty-nine (40.2%) had classical PNS, and 58 (59.8%) had nonclassical PNS, 74 (76.3%) had “Definite” PNS while 23 (23.7%) had “Possible” PNS. Cerebellar degeneration, peripheral neuropathy, and encephalopathy were the three most common neurological syndromes. Tumors were diagnosed in 66 (68%) patients; Lung cancer was the most common primary tumor. Antibodies were positive in 52 (53.6%). Anti-Yo antibody and anti-Ma2 antibody were the most common antibodies. The majority (57.7%) received immunotherapy in addition to definitive treatment for the tumor. A good outcome was seen in 53 (54.6%). Factors associated with good outcome were: early diagnosis, mRS <3 at presentation, absence of metastatic disease, and adjuvant immunotherapy. Conclusion: A high index of clinical suspicion is essential for early diagnosis and prompt management of PNS, especially the nonclassical syndromes. Multimodality diagnostic imaging techniques and antibody profiling play a crucial role in the diagnosis. A favorable prognosis can be expected with the judicious use of immunotherapy and definitive treatment of malignancy.
Collapse
Affiliation(s)
- Asish Vijayaraghavan
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | | | | - Ajith Sivadasan
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Arun Mathai Mani
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Donna Mathew
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Atif Shaikh
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rohit Ninan Benjamin
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - A T Prabhakar
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - John Jude
- Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sunithi Mani
- Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
7
|
Miraclin A, Sivadasan A, Rima S, Mannam P, Gupta A, Devasia AJ, Prabhakar AT, Mathew V. Pearls & Oy-sters: Primary CNS Burkitt Lymphoma in Pregnancy: Management Challenges of a Rare Entity. Neurology 2021; 96:e2141-e2144. [PMID: 33402436 DOI: 10.1212/wnl.0000000000011495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Angel Miraclin
- From the Departments of Neurological Sciences (A.M., A.S., A.G., A.T.P., V.M.), Pathology (S.R.), Radiology (P.M.), and Haematology (A.J.D.), Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- From the Departments of Neurological Sciences (A.M., A.S., A.G., A.T.P., V.M.), Pathology (S.R.), Radiology (P.M.), and Haematology (A.J.D.), Christian Medical College, Vellore, Tamil Nadu, India.
| | - S Rima
- From the Departments of Neurological Sciences (A.M., A.S., A.G., A.T.P., V.M.), Pathology (S.R.), Radiology (P.M.), and Haematology (A.J.D.), Christian Medical College, Vellore, Tamil Nadu, India
| | - Pavithra Mannam
- From the Departments of Neurological Sciences (A.M., A.S., A.G., A.T.P., V.M.), Pathology (S.R.), Radiology (P.M.), and Haematology (A.J.D.), Christian Medical College, Vellore, Tamil Nadu, India
| | - Ankush Gupta
- From the Departments of Neurological Sciences (A.M., A.S., A.G., A.T.P., V.M.), Pathology (S.R.), Radiology (P.M.), and Haematology (A.J.D.), Christian Medical College, Vellore, Tamil Nadu, India
| | - Anup J Devasia
- From the Departments of Neurological Sciences (A.M., A.S., A.G., A.T.P., V.M.), Pathology (S.R.), Radiology (P.M.), and Haematology (A.J.D.), Christian Medical College, Vellore, Tamil Nadu, India
| | - A T Prabhakar
- From the Departments of Neurological Sciences (A.M., A.S., A.G., A.T.P., V.M.), Pathology (S.R.), Radiology (P.M.), and Haematology (A.J.D.), Christian Medical College, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- From the Departments of Neurological Sciences (A.M., A.S., A.G., A.T.P., V.M.), Pathology (S.R.), Radiology (P.M.), and Haematology (A.J.D.), Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
8
|
Nair AV, Mani A, Vijayaraghavan A, Alexander P, Shaikh A, Ninan R, Prabhakar AT, Sivadasan A, Aaron S, Jude J, Mathew V, Alexander M. Utility of stimulus induced after discharges in the evaluation of peripheral nerve hyperexcitability: Old wine in a new bottle? J Peripher Nerv Syst 2020; 26:90-98. [PMID: 33179828 DOI: 10.1111/jns.12422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/01/2020] [Accepted: 11/05/2020] [Indexed: 01/02/2023]
Abstract
Limited literature is available on stimulus induced after discharges (SIAD) in patients with peripheral nerve hyperexcitability (PNH). The aim of the study was to examine the diagnostic utility of SIAD in the diagnosis and monitoring of primary PNH disorders. In this retrospective study, we studied 26 patients who were admitted with a diagnosis of primary PNH to the department of Neurology from January 2013 to April 2019. Their clinical profile, immunological characteristics were extracted from the database and nerve conduction studies were relooked for the presence of SIAD. 76% of patients in the primary PNH cohort had SIAD with 90% of them being voltage-gated potassium channel complex antibody positive; predominantly against contactin-associated protein-2 antigen and rest being paraneoplastic. There was also resolution of SIAD following treatment indicating reversible hyperexcitability. SIAD is a sensitive marker for Primary PNH syndrome with monitoring and diagnostic implications.
Collapse
Affiliation(s)
| | - Arun Mani
- Department of Neurology, Christian Medical College, Vellore, India
| | | | | | - Atif Shaikh
- Department of Neurology, Christian Medical College, Vellore, India
| | - Rohit Ninan
- Department of Neurology, Christian Medical College, Vellore, India
| | - A T Prabhakar
- Department of Neurology, Christian Medical College, Vellore, India
| | - Ajith Sivadasan
- Department of Neurology, Christian Medical College, Vellore, India
| | - Sanjit Aaron
- Department of Neurology, Christian Medical College, Vellore, India
| | - John Jude
- Department of Clinical Microbiology, Christian Medical College, Vellore, India
| | - Vivek Mathew
- Department of Neurology, Christian Medical College, Vellore, India
| | - Mathew Alexander
- Department of Neurology, Christian Medical College, Vellore, India
| |
Collapse
|
9
|
Vanjare HA, Selvi BT, Karuppusami R, Manesh A, Gunasekaran K, Prabhakar AT, Mannam P, Jasper A. Clinical and Radiologic Findings of Acute Necrotizing Encephalopathy in Young Adults. AJNR Am J Neuroradiol 2020; 41:2250-2254. [PMID: 33122207 DOI: 10.3174/ajnr.a6803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/15/2020] [Indexed: 12/23/2022]
Abstract
Acute necrotizing encephalopathy after an acute febrile illness, although initially described exclusively in the pediatric age group, has been recently shown to have an adult onset as well. In this study, we describe 10 patients (16 years of age or older) with acute necrotizing encephalopathy. In our study, bilateral thalamic involvement with the trilaminar pattern of diffusion restriction on MR imaging was the predominant finding seen in all of the patients reviewed. Ancillary findings of cerebral white matter, brain stem, and cerebellum involvement with sparing of the basal ganglia were also noted. A poorer outcome was observed in patients with a higher degree of thalamic involvement. The cause of an underlying infection was identified in 4 patients (dengue in 3 and influenza in 1). Overall, a sizeable portion of young adults with acute necrotizing encephalopathy have shown a poorer outcome, with dengue being an important underlying trigger in an endemic region.
Collapse
Affiliation(s)
- H A Vanjare
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - B T Selvi
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - R Karuppusami
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - A Manesh
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - K Gunasekaran
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - A T Prabhakar
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - P Mannam
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - A Jasper
- From the Christian Medical College and Hospital, Tamil Nadu, India
| |
Collapse
|
10
|
Sooragonda BG, Agarwal S, Benjamin RN, Prabhakar AT, Sivadasan A, Kapoor N, Cherian KE, Jebasingh FK, Aaron S, Thomas N, Mathew V, Asha HS, Paul TV. Bone Mineral Density and Body Composition in Males with Motor Neuron Disease: A Study from Teaching Hospital in Southern Part of India. Ann Indian Acad Neurol 2020; 24:211-216. [PMID: 34220065 PMCID: PMC8232495 DOI: 10.4103/aian.aian_293_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 04/26/2020] [Accepted: 05/17/2020] [Indexed: 11/04/2022] Open
Abstract
Background Osteoporosis and sarcopenia are important aspects of motor neuron disease (MND). Individuals with amyotrophic lateral sclerosis (MND-ALS) have an increased risk of falls and fractures. Currently, the standard of care does not involve a routine assessment of bone mineral density (BMD) and body composition in these patients. We aimed to assess BMD, bone mineral parameters and body composition in men with MND and compared them with healthy controls. Methods Consecutive males between 50 and 80 years of age diagnosed as MND-ALS by revised El Escorial criteria and able to walk unassisted attending Neurology outpatient clinic were recruited into the study. Age, gender and body mass index (BMI) matched healthy controls were recruited from the local community. BMD and body composition were assessed by dual-energy x-ray absorptiometry (DXA). Bone mineral parameters and bone turnover markers (BTMs) were also assessed in them. Results A total of 30 subjects with MND-ALS and 33 controls were recruited. The mean age (years) was 59.2 in cases and 61.2 in controls. The mean BMD (g/cm2) between the two groups was similar; however, BTMs were significantly higher in the MND group (P < 0.05). Subjects with MND-ALS had significantly lower mean appendicular lean mass (ALM) (19.9 versus 22.4 kg; P = 0.007) and ALM corrected for BMI than the healthy control group (0.858 versus 0.934 kg/kg/m2; P = 0.034). Sarcopenic obesity (Percentage fat mass >27% + ALM/BMI <0.786 kg/kg/m2) was more prevalent in MND-ALS compared to controls (44.5% versus 16.7%; P = 0.03). Conclusion Although BMD was not significantly different between subjects with MND-ALS and healthy controls, BTMs were significantly higher in the MND group indicating a high bone turnover state. Sarcopenia and sarcopenic obesity were also more in MND-ALS group than controls. Routine assessment for bone health parameters and body composition indices may be included in management of the patients with MND.
Collapse
Affiliation(s)
| | - Sandeep Agarwal
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - A T Prabhakar
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nitin Kapoor
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Kripa E Cherian
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Felix K Jebasingh
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nihal Thomas
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Hesarghatta S Asha
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Thomas V Paul
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
11
|
Mani AM, Prabhakar AT, Mannam P, Benjamin RN, Ahmed Shaikh AI, Mathew D, Singh P, Nair A, Alexander PT, Vijayaraghavan A, Sivadasan A, Mani S, Mathew V, Aaron S, Alexander M. Clinical Spectrum and Outcome of Neurosarcoidosis: A Retrospective Cohort Study from a Teaching Hospital in India. Ann Indian Acad Neurol 2020; 23:528-535. [PMID: 33223672 PMCID: PMC7657274 DOI: 10.4103/aian.aian_638_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/02/2020] [Accepted: 02/08/2020] [Indexed: 11/04/2022] Open
Abstract
Context: Neurosarcoidosis (NS) is a chronic disease with a diverse clinical spectrum, therapeutic response, and outcome. There is scarce literature from our country regarding the same. Aims: The aim of this study was to evaluate the clinical spectrum, therapeutic responses, and outcomes of NS in an Indian cohort. Settings and Design: In a cross-sectional study, we included all patients with NS treated at a quaternary care teaching hospital in India from January 2007 to October 2019. Subjects and Methods: Patients older than 18 years of age fulfilling the diagnostic criteria for NS from the Neurosarcoidosis Consortium Consensus Group were included in the study. The therapeutic response and the degree of disability at last follow-up were assessed. Results: We identified 48 patients, among them 3 were categorized as having definite NS, 30 probable NS, and 15 possible NS. Cranial neuropathy was the most common presentation (47.9%), followed by myelopathy (25%). Systemic involvement was identified in 95.83% and mediastinal lymph nodes were the most common site. Clinical improvement was seen in 65.8% and disease stabilized in 28.9%, while 5.26% deteriorated. Fifty percent recovered without any residual disability, while 26.3% had minor and 23.7% had major residual sequelae. Conclusions: NS is a diverse illness, with a heterogeneous spectrum of clinical presentation, treatment response, and outcome. Cranial neuropathy is the most common presenting feature and has a good prognosis while myelopathy has an unfavorable prognosis. Meningeal and brain parenchymal disease is difficult to diagnose accurately unless systemic involvement is present. The diagnosis of NS should be clinically suspected in the appropriate clinical setting, the presence of systemic involvement should be investigated, and histologic confirmation should be attempted.
Collapse
Affiliation(s)
- Arun Mathai Mani
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - A T Prabhakar
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Pavithra Mannam
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rohit Ninan Benjamin
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Atif Iqbal Ahmed Shaikh
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Donna Mathew
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Pankaj Singh
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Aditya Nair
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - P T Alexander
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Asish Vijayaraghavan
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sunithi Mani
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Neurology Unit, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
12
|
Aaron S, Lakshmanan J, Sudarsanam TD, Benjamin K, Durairaj J, Mathew V, Sivadasan A, Prabhakar AT, Keshava SKN, Mannam PR, Kirubakaran P, Muliyil J, Alexander M. Cerebral Venous Thrombosis, Seasonal Trends, and Climatic Influence: A Region-SpecificStudy. Ann Indian Acad Neurol 2019; 23:522-527. [PMID: 33223671 PMCID: PMC7657288 DOI: 10.4103/aian.aian_409_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 08/28/2019] [Accepted: 09/05/2019] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose: Studies looking at seasonal variation on cerebral venous thrombosis (CVT) are few with conflicting conclusions. In this region-specific study, we looked for climatic influence and seasonal trends on the incidence of CVT. Methods: Imaging proven adult CVT cases treated over a period of 18 years from a specific geographical location with similar seasons and climatic conditions were studied. Metrological parameters prepared using 30 years of data was used. Quantum geographical information system (QGIS software) and SPSS v 22 were used for patient plotting and analysis. Results: Total of 970 cases were studied. The incidence was significantly higher in summer 411 (42.3%) compared with autumn 317 (32.7%) and winter 242 (25.05); P = 0.038. This trend was consistent across all the 18 years in time series analysis. Mean age was 33.5 years (range 18–88 years). A significant majority 673 (69.4%) were below 40 years of age; P = 0.012. Females constituted 394 (40.6%) of cases. Postpartum CVT cases constituted 237 (30%). Interaction analysis showed younger age (<40 years) were more vulnerable for CVT in summer; P = 0.009. There was no seasonal influence on postpartum CVT. Apart for a weak positive correlation between rain fall (r = 0.18, P < 0.01); humidity and cloud cover was not influencing the incidence. Conclusions: Higher ambient temperatures were consistently associated with higher incidence of CVT. This is the largest region-specific study on CVT in the world. These results may be applicable to other regions with similar climatic conditions.
Collapse
Affiliation(s)
- Sanjith Aaron
- Department of Neurology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Jeyaseelan Lakshmanan
- Department of Biostatistics, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Thambu D Sudarsanam
- Department of General Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Kenneth Benjamin
- Department of Radiology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Jothilakshmi Durairaj
- Department of Biostatistics, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - A T Prabhakar
- Department of Radiology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Shyam Kumar N Keshava
- Department of Radiology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Pavitra R Mannam
- Department of Radiology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Prabhu Kirubakaran
- Department of Neurology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Jayaprakash Muliyil
- Department of Community Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Department of Neurology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| |
Collapse
|
13
|
Alexander M, Sivadasan A, Aaron S, Mathew V, Nair S, Muthusamy K, Prabhakar AT, Benjamin R, Shaikh A, Rynjah G. Comorbidities and long-term outcomes in a cohort with myasthenic crisis: Experiences from a tertiary care center. Ann Indian Acad Neurol 2019; 22:464-471. [PMID: 31736571 PMCID: PMC6839309 DOI: 10.4103/aian.aian_197_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/26/2019] [Accepted: 06/30/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction: There is scarce literature regarding the clinical course, comorbidities and long-term outcomes after myasthenic crisis (MC). The natural history of myasthenia gravis (MG) in this subset remains uncertain. Methods: The study included a cohort admitted with MC (2007–2017) in a tertiary care hospital. The comorbidities, outcomes after discharge, and prognostic factors were analyzed. Results: Sixty-two patients (89 episodes of MC) were included. Demographic data was comparable between the early- (<50 years) and late-onset (≥50 years) groups. Comorbidities included stress cardiomyopathy (14.5%), arrhythmias (6.4%), neuropathy (17.7%), pancytopenia (12.9%), encephalopathy (11.2%), neuromyotonia (4.8%), myelopathy (3.2%), and myositis (3.2%). Pulmonary embolism (P < 0.008), dysautonomia (P < 0.002), sepsis (P < 0.008), neuropathy (P < 0.002), and phrenic dysfunction (P < 0.016) were associated with prolonged ventilation. Majority of the patients (42, 67.7%) had a favorable outcome (disease status) as defined by remission/minimal manifestations at the time of last follow-up (median 36 months, IQR 15–66). Persistent bulbar weakness (P < 0.001), neuropsychiatric illness (P < 0.001), and comorbidities (P < 0.017) were associated with refractory MG. Eighteen patients (29%) had recurrent crisis. Eleven patients succumbed in the cohort. The main predictors of mortality were tumor progression (P < 0.001) and cardiac illness (P < 0.004). Discussion: A comprehensive treatment approach in MC will translate to good short- and long-term outcomes. The main cornerstones of therapy will include (1) Identification of refractory MG with the implementation of phenotype-based therapy; (2) Addressing comorbidities including cardiac autonomic neuropathy, bulbar weakness, phrenic dysfunction; and (3) Meticulous tumor surveillance.
Collapse
|
14
|
Tharmalingam J, Prabhakar AT, Gangadaran P, Dorny P, Vercruysse J, Geldhof P, Rajshekhar V, Alexander M, Oommen A. Host Th1/Th2 immune response to Taenia solium cyst antigens in relation to cyst burden of neurocysticercosis. Parasite Immunol 2017; 38:628-34. [PMID: 27493081 DOI: 10.1111/pim.12351] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 08/02/2016] [Indexed: 01/02/2023]
Abstract
Neurocysticercosis (NCC), Taenia solium larval infection of the brain, is an important cause of acquired seizures in endemic countries, which relate to number, location and degenerating cysts in the brain. Multicyst infections are common in endemic countries although single-cyst infection prevails in India. Single-cyst infections in an endemic country suggest a role for host immunity limiting the infection. This study examined ex vivo CD4(+) T cells and in vitro Th1 and Th2 cytokine responses to T. solium cyst antigens of peripheral blood mononuclear cells of healthy subjects from endemic and nonendemic regions and of single- and multicyst-infected patients for association with cyst burden of NCC. T. solium cyst antigens elicited a Th1 cytokine response in healthy subjects of T. solium-endemic and T. solium-non-endemic regions and those with single-cyst infections and a Th2 cytokine response from subjects with multicyst neurocysticercosis. Multicyst neurocysticercosis subjects also exhibited low levels of effector memory CD4(+) T cells. Th1 cytokine response of T. solium exposure and low infectious loads may aid in limiting cyst number. Th2 cytokines and low effector T cells may enable multiple-cyst infections to establish and persist.
Collapse
Affiliation(s)
- J Tharmalingam
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India. ,
| | - A T Prabhakar
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - P Gangadaran
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - P Dorny
- Laboratory of Parasitology, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium.,Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - J Vercruysse
- Laboratory of Parasitology, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - P Geldhof
- Laboratory of Parasitology, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - V Rajshekhar
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - M Alexander
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - A Oommen
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
15
|
Lindley RI, Anderson CS, Billot L, Forster A, Hackett ML, Harvey LA, Jan S, Li Q, Liu H, Langhorne P, Maulik PK, Murthy GVS, Walker MF, Pandian JD, Alim M, Felix C, Syrigapu A, Tugnawat DK, Verma SJ, Shamanna BR, Hankey G, Thrift A, Bernhardt J, Mehndiratta MM, Jeyaseelan L, Donnelly P, Byrne D, Steley S, Santhosh V, Chilappagari S, Mysore J, Roy J, Padma MV, John L, Aaron S, Borah NC, Vijaya P, Kaul S, Khurana D, Sylaja PN, Halprashanth DS, Madhusudhan BK, Nambiar V, Sureshbabu S, Khanna MC, Narang GS, Chakraborty D, Chakraborty SS, Biswas B, Kaura S, Koundal H, Singh P, Andrias A, Thambu DS, Ramya I, George J, Prabhakar AT, Kirubakaran P, Anbalagan P, Ghose M, Bordoloi K, Gohain P, Reddy NM, Reddy KV, Rao TNM, Alladi S, Jalapu VRR, Manchireddy K, Rajan A, Mehta S, Katoch C, Das B, Jangir A, Kaur T, Sreedharan S, Sivasambath S, Dinesh S, Shibi BS, Thangaraj A, Karunanithi A, Sulaiman SMS, Dehingia K, Das K, Nandini C, Thomas NJ, Dhanya TS, Thomas N, Krishna R, Aneesh V, Krishna R, Khullar S, Thouman S, Sebastian I. Family-led rehabilitation after stroke in India (ATTEND): a randomised controlled trial. Lancet 2017; 390:588-599. [PMID: 28666682 DOI: 10.1016/s0140-6736(17)31447-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/17/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Most people with stroke in India have no access to organised rehabilitation services. The effectiveness of training family members to provide stroke rehabilitation is uncertain. Our primary objective was to determine whether family-led stroke rehabilitation, initiated in hospital and continued at home, would be superior to usual care in a low-resource setting. METHODS The Family-led Rehabilitation after Stroke in India (ATTEND) trial was a prospectively randomised open trial with blinded endpoint done across 14 hospitals in India. Patients aged 18 years or older who had had a stroke within the past month, had residual disability and reasonable expectation of survival, and who had an informal family-nominated caregiver were randomly assigned to intervention or usual care by site coordinators using a secure web-based system with minimisation by site and stroke severity. The family members of participants in the intervention group received additional structured rehabilitation training-including information provision, joint goal setting, carer training, and task-specific training-that was started in hospital and continued at home for up to 2 months. The primary outcome was death or dependency at 6 months, defined by scores 3-6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) as assessed by masked observers. Analyses were by intention to treat. This trial is registered with Clinical Trials Registry-India (CTRI/2013/04/003557), Australian New Zealand Clinical Trials Registry (ACTRN12613000078752), and Universal Trial Number (U1111-1138-6707). FINDINGS Between Jan 13, 2014, and Feb 12, 2016, 1250 patients were randomly assigned to intervention (n=623) or control (n=627) groups. 33 patients were lost to follow-up (14 intervention, 19 control) and five patients withdrew (two intervention, three control). At 6 months, 285 (47%) of 607 patients in the intervention group and 287 (47%) of 605 controls were dead or dependent (odds ratio 0·98, 95% CI 0·78-1·23, p=0·87). 72 (12%) patients in the intervention group and 86 (14%) in the control group died (p=0·27), and we observed no difference in rehospitalisation (89 [14%]patients in the intervention group vs 82 [13%] in the control group; p=0·56). We also found no difference in total non-fatal events (112 events in 82 [13%] intervention patients vs 110 events in 79 [13%] control patients; p=0·80). INTERPRETATION Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges. A future avenue of research should be to investigate the effects of task shifting to health-care assistants or team-based community care. FUNDING The National Health and Medical Research Council of Australia.
Collapse
|
16
|
Aaron S, Mani S, Prabhakar AT, Babu PS, Kumar S, Benjamin RN, Sivadasan A, Muthusamy K, Patil AKB, Mathew V, Alexander M. Sonothrombolysis for acute ischemic stroke - Break on through to the other side. Neurol India 2017; 65:52-57. [PMID: 28084238 DOI: 10.4103/0028-3886.198213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intravenous (IV) tissue plasminogen activator (tPA) infusion combined with transcranial low-frequency ultrasound waves targeted on the occluded arterial segment (sonothrombolysis) can increase recanalization in large artery-acute ischemic stroke (LA-AIS). AIMS To evaluate the benefits of sonothrombolysis in LA-AIS. SETTINGS AND DESIGNS An open-labeled observational study done in a quaternary care teaching hospital. METHODOLOGY Patients with LA-AIS within the window period (<4.5 h) with no contraindications for IV-recombinant tPA were sonothrombolysed. Recanalization was monitored and graded using the transcranial Doppler thrombolysis in brain ischemia (TIBI) flow criteria and also by time of flight magnetic resonance angiography using a modified thrombolysis in myocardial infarction score. Parenchymal changes were assessed using computed tomography (CT) or diffusion-weighted imaging-Alberta Stroke Programme Early CT Score. National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were used to assess the outcome. RESULTS Eighteen patients underwent sonothrombolysis and the mean onset to needle time was 138 min (range 65-256). TIBI residual flow grade of ≥2 was seen in 15 of 18 patients (83%). Immediate dramatic improvement (NIHSS score ≤3 points or improvement by ≥10 points) was seen in 6 of 18 patients (30%) and in 9 of 18 patients (50%) within the next 24 h. Two patients (one with TIBI 0, another with re-occlusion) underwent mechanical thrombectomy post-sonothrombolysis. Symptomatic hemorrhage occurred in 5.5% of the patients. At 6 months, 2 of 18 patients (11%) died and 10 of 16 patients (63%) achieved mRS ≤2. CONCLUSIONS Sonothrombolysis appears to be a safe way to augment the effect of tPA without increasing the door to needle time with the added advantage of observing flow through the occluded artery in real time.
Collapse
Affiliation(s)
- Sanjith Aaron
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sunithi Mani
- Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - A T Prabhakar
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - P Suresh Babu
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjeev Kumar
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rohith Ninan Benjamin
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Karthik Muthusamy
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anil Kumar B Patil
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
17
|
Kohli S, Pasangulapati SB, Yoganathan S, Rynjah GL, Prabhakar AT, Aaron S, Alexander M, Mathew V. Study of Refractory Status Epilepticus from a Tertiary Care Center. Ann Indian Acad Neurol 2017; 20:116-121. [PMID: 28615895 PMCID: PMC5470165 DOI: 10.4103/aian.aian_385_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives: To determine the proportion of refractory status epilepticus (RSE) and super-RSE (SRSE) among patients with status epilepticus (SE) and to analyze RSE and non-RSE (NRSE) in terms of etiology and predictors for RSE. Materials and Methods: Patients were identified from discharge summaries database with keywords of SE and records of the portable electroencephalogram (EEG) machine from January 2011 to March 2016. Results: Two hundred and eighteen events were included in the study with 114 (52.3%) males, bimodal age preponderance age <5 years 30%, and second peak in age 15–65 years 52.8%, preexisting seizures were present in 34.4% (n = 75). Nearly 77.1% had NRSE (n = 168) and 22.9% had RSE (n = 50). This included 17 patients with SRSE (n = 17, 7.8% of all SE). Central nervous system (CNS) infection was a single largest etiological group in SE (69/218, 31.7%). In RSE, autoimmune encephalitis (17/50) and CNS infection (13/50) were the largest groups. De novo seizures (P = 0.007), low sensorium at admission (P = 0.001), low albumin at admission (P = 0.002), and first EEG being abnormal (P = 0.001) were risk factors on bivariate analysis. An unfavorable status epilepticus severity score (STESS) was predictive for RSE (P = 0.001). On multivariate analysis, de novo seizures (P = 0.009) and abnormal EEG at admission (P = 0.03) were predictive for RSE. Conclusions: Fifty patients had RSE (22.9%), of which 17 went on to become SRSE (7.8%). Unfavorable STESS score was predictive for RSE on bivariate analysis. On multivariate analysis, de novo seizures and abnormal initial EEG were predictors of RSE.
Collapse
Affiliation(s)
- Sahil Kohli
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Sangeetha Yoganathan
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - A T Prabhakar
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
18
|
Muthusamy K, Ekbote AV, Thomas MM, Aaron S, Mathew V, Patil AB, Sivadasan A, Prabhakar AT, Yoganathan S, Alexander M. Biotin thiamine responsive basal ganglia disease-A potentially treatable inborn error of metabolism. Neurol India 2016; 64:1328-1331. [PMID: 27841215 DOI: 10.4103/0028-3886.193797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Karthik Muthusamy
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Alka V Ekbote
- Department of Medical Genetics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Maya M Thomas
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anil B Patil
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - A T Prabhakar
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sangeetha Yoganathan
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
19
|
Aaron S, Shyamkumar NK, Alexander S, Babu PS, Prabhakar AT, Moses V, Murthy TV, Alexander M. Mechanical thrombectomy for acute ischemic stroke in pregnancy using the penumbra system. Ann Indian Acad Neurol 2016; 19:261-3. [PMID: 27293343 PMCID: PMC4888695 DOI: 10.4103/0972-2327.173302] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Even though intravenous thrombolysis with tissue plasminogen activator (IV tPA) is the standard of care in acute ischemic stroke, its use in pregnancy is not clearly defined. Mechanical thrombectomy devices can be an option; however, literature on the use of such mechanical devices in stroke in pregnancy is lacking. Here we describe two cases that developed acute embolic stroke during pregnancy who were successfully treated by mechanical clot retrieval using the Penumbra system 28 (Penumbra Inc., Alameda, California, USA). To the best of our knowledge, these are the only case reports on the use of the Penumbra device in pregnant patients with acute ischemic stroke.
Collapse
Affiliation(s)
- Sanjith Aaron
- Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - N K Shyamkumar
- Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sunithi Alexander
- Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - P Suresh Babu
- Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - A T Prabhakar
- Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Vinu Moses
- Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - T V Murthy
- Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| |
Collapse
|
20
|
Patil AKB, Prabhakar AT, Sivadasan A, Alexander M, Chacko G. An unusual case of inflammatory necrotizing myopathy and neuropathy with pipestem capillaries. Neurol India 2015; 63:72-6. [PMID: 25751473 DOI: 10.4103/0028-3886.152642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Necrotizing myopathy with pipestem capillaries is a form of chronic inflammatory myopathy, with histopathology showing necrotizing myopathy, minimal cellular infiltration, and microangiopathy. A 30-year-old female presented with progressive limb weakness of 6 months, with skin pigmentation and Raynaud's phenomenon. Serum creatine phosphokinase was 3990 u/L. Muscle biopsy showed necrotic fibers, focal sparse perivascular inflammation/perifascicular atrophy, endomysial/epimysial vessel wall thickening with luminal narrowing. The features were of inflammatory necrotizing myopathy and neuropathy with pipestem capillaries/microangiopathy. She was pulsed with intravenous immunoglobulin, methylprednisolone, and cyclophosphamide and showed a good improvement. In the absence of widespread inflammatory response and classical histopathology findings, it is important to diagnose this condition as it shows a good response to aggressive and prolonged immunotherapy.
Collapse
Affiliation(s)
| | | | | | - Mathew Alexander
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | |
Collapse
|
21
|
Abstract
BACKGROUND Strokes caused by normal variants of the cerebral circulation can be difficult to diagnose, hence a high index of suspicion is needed. This case series discusses the clinical and radiological aspects of one such stroke caused by occlusion of the artery of Percheron (AOP). MATERIALS AND METHODS Computerized discharge summaries, outpatient records and imaging from picture archiving and communication system (PACS, GE), of patients with AOP infarction over a period of 12-years (2002-2014) were identified and their clinical and radiological features analyzed. RESULTS Of 3589 strokes (both ischemic and hemorrhagic), 17 (0.47%) were due to AOP infarction. Their mean age was 50 years (range: 31-72 years). Disorders of consciousness (94%) were the most common presenting symptoms followed by gaze (53%) and memory impairment (24%). At follow-up, 2/17 (12%) patients developed extrapyramidal features. All patients had bilateral paramedian thalamic infarcts on magnetic resonance imaging (MRI). Associated anterior thalamic (5/17; 30%) and mid brain (10/17; 59%) infarcts were also seen. CT scan done in 11/17 patients prior to the MRI picked up only 6/11 (55%) of these infarcts. The most common etiological factors detected using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria were cardio embolic (8/17; 47%) followed by small vessel occlusion (7/17; 41%). Mortality occurred in 2/17 (12%) patients. At 6 months, a modified Rankin score of 2 or less was seen in 8/17 (47%) patients. CONCLUSIONS Artery of Percheron infarcts should be considered in the differential diagnosis of patients presenting with sudden alterations in consciousness. MRI should be the investigation of choice. An embolic etiology should be actively looked for.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Mathew Alexander
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| |
Collapse
|
22
|
Alexander M, Prabhakar AT, Aaron S, Thomas M, Mathew V, Patil AK. Utility of neurophysiological criteria in Guillain Barre΄ syndrome: subtype spectrum from a tertiary referral hospital in India. Neurol India 2011; 59:722-6. [PMID: 22019658 DOI: 10.4103/0028-3886.86548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The Guillain Barre' syndrome (GBS) is a heterogeneous disease with various subtypes, the prevalence of which would depend on the geographic region. Recognition of these subtypes is of clinical importance since each subtype has an independent pathogenesis and different type of pathology and prognosis. OBJECTIVES To study the various subtypes of GBS using the various published electrophysiological criteria. DESIGN Retrospective descriptive study. MATERIALS AND METHODS In a tertiary care hospital setting, the study compared the various published criteria for demyelination in GBS. The charts of 115 consecutive patients referred for electrodiagnostic evaluation to the Electromyography laboratory between July 2000 and June 2006 were reviewed. RESULTS Of the 115 patients, 51 (44.4%) patients had axonal forms of GBS and 44 (38.2%) patients had acute inflammatory demyelinating polyradiculoneuropathy (AIDP). Applying the various published criteria, the number of patients categorized under the AIDP subtype ranged between 23.4% and 67.2%. CONCLUSION In this study 44% patients had axonal forms of the disease, 38.2% patients had AIDP subtype and 17% remained unclassified. The most sensitive criteria to identify AIDP were the criteria proposed by Albers and colleagues and the Dutch group.
Collapse
Affiliation(s)
- M Alexander
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India.
| | | | | | | | | | | |
Collapse
|
23
|
Abstract
Aminoglycoside-induced renal toxicity is well known and may manifest with nonoliguric renal failure or renal tubular dysfunction. Aminoglycoside-induced renal tubular dysfunction could result in diffuse damage or manifest as a Fanconi-like syndrome, Bartter-like syndrome, or distal renal tubular acidosis. We discuss a patient who developed severe renal tubular dysfunction secondary to short-term therapy with Amikacin, resulting in refractory hypokalemia, hypocalcemia, hypomagnesemia, metabolic alkalosis, and polyuria. This constellation of biochemical abnormalities mimic Type 5 Bartter's syndrome, where there is activating mutation of the calcium sensing receptor in the thick ascending loop of Henle and the distal tubule. In this case this activation of the calcium sensing receptor was triggered by amikacin. This phenomenon has been described with gentamicin though never with amikacin. Recovery of the tubular dysfunction took 15 days following cessation of the offending drug, Amikacin.
Collapse
Affiliation(s)
- A Chrispal
- Department of Medicine II, Christian Medical College, Vellore, India.
| | | | | | | |
Collapse
|