Inpatient Burden of Neurological Disorders: A Route Map for Allocation of Resources and Postgraduate Training

Introduction There are limited data regarding the profile of inpatient neurological disorders in India. Understanding the spectrum of diseases and the profile of patients admitted in an inpatient setting will help to streamline services, allocate resources, develop management protocols, design curricula, and improve training programs of postgraduate students in neurology training. Objective The objective of this study is to study the profile of inpatient neurological disorders in 1000 consecutive patients admitted to a tertiary care neurological center. Methods Data from 1000 consecutive inpatients admitted to the Neurology Department at St. John's Medical College Hospital, Bengaluru from January 2018 to October 2018 were collected from the medical records. The data obtained from the case records were entered into a Microsoft Excel spreadsheet for descriptive analysis. Results The average age of the patients was 48 years (±18.18) and 606 of the 1000 patients were males. Strokes, including arterial and venous strokes, formed the major inpatient caseload, accounting for 48.7% of cases. Of these, 84% had ischemic arterial strokes, 7.4% had intracranial hemorrhage, and 8.4 % had cerebral sinus venous strokes; 19.3% of patients were admitted for seizures while 8.2% of patients were admitted for headache. Meningitis was diagnosed in 5.2% of patients; 4.8% of patients had central nervous system demyelinating and autoimmune diseases. A number of other diagnoses comprised less than 2.5% each and included movement disorders, peripheral nerve, spine and nerve roots disorders, neuromuscular diseases, neurodegenerative diseases, and medical and functional illness. Conclusion The most common disorders in the inpatient setting are stroke, seizure, headache, meningitis, and autoimmune/demyelinating disorders. These disorders should receive priority while planning the allocation of resources, educational curriculum, training, and teaching programs.

Long Term Outcomes in Idiopathic Inflammatory Myositis: An Observational Epidemiologic Study over 15 Years

Background

We report a longitudinal observational cohort of idiopathic inflammatory myositis (IIM) focusing on the long-term clinical outcome and associated parameters.

Methods

IIM patients were classified as per Bohan and Peter criteria. In those with ≥ 24 months of follow-up; the treatment response, functional outcomes, and damage at last follow-up were recorded. Complete clinical response and clinical remission as defined by Oddis et al., was used to define outcomes at last follow-up.

Results

The cohort consists of 175 patients, mean age 40.9 (+12.6) years, M:F 1:3.3; and the major subsets were dermatomyositis (44.6%), overlap myositis (25.7%), antisynthetase syndrome (6.3%), polymyositis (14.3%), and juvenile DM/OM (8.6%). Ninety-four patients have followed up for 24 months or more, with the median (IQR) of 65(35,100.7) months. Of them, 74.1% and 11.8% had complete and partial clinical responses respectively at the last follow-up. In our cohort 40.2% were off-steroids and 13.8% were in clinical remission at the last follow-up. Complete clinical response was associated with better functional outcomes and lesser damage as determined by HAQ-DI of 0[OR10.9; 95%CI (3.3,160)], MRS [OR 3.2; 95%CI (1.4,7.3)] and lesser MDI [OR 1.7; 95% CI (1.1,2.7)] respectively as compared to partial response (unadjusted analysis). Baseline parameters and IIM subsets did not significantly influence the functional outcome and damage. The mortality rate in our cohort is 24/175 (13.7%), the disease-specific mortality rate being 9.1%. Large majority of deaths were early, associated with active disease.

Conclusion

We report good long-term outcomes in all major myositis subsets. Partial clinical response to treatment is associated with worse functional outcomes and damage accrual. Death occurs early in association with active disease.

Endovascular management of cerebral venous thrombosis: a tertiary-centre experience

Background

Stroke related to cerebral venous thrombosis (CVT) is uncommon, with untoward lethal outcomes. Systemic anticoagulation is the treatment of choice. However, some patients can be resistant to this treatment. Endovascular management with thrombolysis and mechanical thrombectomy can be a viable option in such cases.

Material and methods

We retrospectively reviewed the endovascular management used for CVT in 8 patients who failed to respond to standard anticoagulation therapy between December 2017 and December 2022 in our institute. Clinical profile, imaging parameters, endovascular procedure details, and outcomes in terms of angiographic findings and clinical follow-up were analysed.

Results

In this period, a total of 8 patients underwent mechanical thrombectomy. The procedure was successful in all cases (8/8 = 100%), and 50% of them showed near total/complete recanalization; Perforation of the cortical veins was noted in 2 cases (~25%). Among the 8 patients, one died (1/8 = 12.5%) due to cardiac aetiology; the remaining 7 patients (87.5%) showed good clinical outcome with a modified Rankin Scale score 0 to 2.

Conclusion

Catheter-directed thrombolysis with mechanical thromboaspiration is a safe and effective treatment for cerebral venous sinus thrombosis not responding to anticoagulation.

Neuropsychiatric manifestations are associated with increased mortality in Indian patients with lupus: A single centre retrospective observational study

OBJECTIVE

To study the prevalence of different NPSLE manifestations in our cohort and to compare clinical and immunological features and outcomes including mortality of patients with NPSLE and SLE controls without NP involvement.

METHODS

This was a retrospective study in a tertiary care referral centre. All patients of SLE seen in the last 10 years and fulfilling the SLICC criteria with neuropsychiatric manifestations as per the ACR definitions were included. Patients of SLE without NP involvement were sequentially assigned as controls in a ratio of 1:2.

RESULTS

Of the 769 patients diagnosed with SLE from Jan 2011 to December 2020, 128 (16.6%) had NPSLE manifestations as per the ACR definitions. The commonest NPSLE manifestation was seizures (6.5%) followed by cerebrovascular accident (3.9%). NPSLE manifestation occurred at the first presentation of SLE in 99/128 (77.3%) patients and 58 (45.3%) patients had more than one NPSLE manifestation. Lupus anticoagulant and anticardiolipin antibody were tested in 120 patients and were positive in 16 (13.3%) and 12 (10%), respectively. No difference was found in anti-ribosomal p, lupus anticoagulant and anticardiolipin antibodies between the cases and controls. Twenty-one (16.4%) deaths occurred in patients with NPSLE (median follow-up of 40 months) as compared to 13 (5%) in controls (median follow-up of 32 months) (p = <0.001). The cumulative survival of patients with NPSLE was lower as compared to controls (p < 0.001). Relapse of NPSLE was seen in 11(8.6%) patients and was associated with mortality (p = 0.017).

CONCLUSIONS

Seizures and cerebrovascular accidents are the commonest NPSLE syndromes in our patients. The presence of NPSLE was associated with high mortality in Indian patients with lupus.

A real world multi center study on efficacy and safety of natalizumab in Indian patients with multiple sclerosis

BACKGROUND

Natalizumab (NTZ) is increasingly being used in Indian multiple sclerosis (MS) patients. There are no reports on its safety and efficacy, especially with respect to the occurrence of progressive multifocal leukoencephalopathy (PML).

OBJECTIVES

To describe the patient characteristics, treatment outcomes, and adverse events, especially the occurrence of PML in NTZ-treated patients.

METHODS

A multicentre ambispective study was conducted across 18 centres, from Jan 2012 to Dec 2021. Patients at and above the age of 18 years treated with NTZ were included. Descriptive and comparative statistics were applied to analyze data.

RESULTS

During the study period of 9 years, 116 patients were treated with NTZ. Mean age of the cohort was 35.6 ± 9.7 years; 83/116 (71.6%) were females. Relapse rate for the entire cohort in the year before NTZ was 3.1 ± 1.51 while one year after was 0.20±0.57 (p = 0.001; CI 2.45 -3.35). EDSS of the entire cohort in the year before NTZ was 4.5 ± 1.94 and one year after was 3.8 ± 2.7 (p = 0.013; CI 0.16-1.36). At last follow up (38.3 ± 22.78 months) there were no cases of PML identified.

CONCLUSIONS

Natalizumab is highly effective and safe in Indian MS patients, with no cases of PML identified at last follow up.

Prevalence And Predictors of Restless Leg Syndrome in Adolescent and Young Adults in Bengaluru City, India - a Cross Sectional Study

INTRODUCTION

Restless leg syndrome (RLS) is a sensorimotor disease characterized by an urge to move the legs, often caused by uncomfortable and unpleasant sensations in the legs. It affects the quality of sleep which in turn affects scholastic performance in children and predisposes them to cardiovascular diseases in the long run. Hence, the primary aim of this study was to assess the prevalence and predictors of RLS, poor sleep quality and excessive daytime sleepiness (EDS) Methods: This was a cross sectional observational study conducted between September 2017 and March 2020 in Bengaluru, India including all consenting Pre - university college, Degree college, and Higher secondary school students. After parental consent and assent (if applicable) was obtained, a semi-structured standardized pilot tested questionnaire consisting of the RLS diagnostic criteria, Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS) and questions on sleep hygiene was administered. The prevalence was expressed as proportions and 95% confidence intervals (95% CI). Regression analysis was done to determine the predictors.

RESULTS

The overall prevalence (95CI; frequency) of students with RLS, poor sleep quality and EDS in our study population was 8.36% (7.54, 9.24; n=1544/4211), 36.67% (35.21, 38.14; n=1544/4211) and 39.87% (38.39, 41.37; n=1679/4211), respectively. PSQI and Epworth score were the significant predictors of RLS. Age, Epworth score, knowledge score and the number of unacceptable sleep habits were the significant predictors of sleep quality. Female gender, PSQI, RLS, knowledge score and the number of unacceptable sleep habits were the significant predictors of EDS.

CONCLUSIONS

The prevalence of RLS, those with poor sleep quality and EDS among adolescents and young adults was higher when compared to the historical data of general population in the same city.

Headaches associated with acute SARS-CoV-2 infection: A prospective cross-sectional study

Objectives:

The prevalence and characteristics of COVID-19-related headaches are not known in Indian patients. We aim to determine the prevalence and characteristics of headache in COVID-19-infected individuals and make a comparison with those without headaches.

Methods:

This prospective cross-sectional observational study was conducted from 1 October to 31 October 2020. Data were collected using a detailed questionnaire. We compared the data of those with and without headaches to identify the differences between the groups.

Results:

During the study period of 1 month, among 225 COVID-19-infected patients, 33.8% patients had headaches. The mean age of patients with headache was 48.89 ± 15.19 years. In all, 53.9% were females. In 65.8%, headache occurred at the onset of viral illness; 44.7% described the headache as dull aching; 39.5% had bifrontal headache; and 32.9% had holocranial headache. In total, 78.9% had complete resolution of headache within 5 days. A comparison between those with and without headaches showed that those with headaches were more younger (48.89 ± 15.19 vs 54.61 ± 14.57 years, p = 0.007) and of female gender (41/76(53.9%) vs 41/149 (27.5%), p = 0.001). Primary headache disorders were more common in the headache group. Levels of inflammatory markers such as leukocyte count (7234.17 ± 3054.96 vs 8773.35 ± 5103.65, p = 0.017), erythrocyte sedimentation rate (39.28 ± 23.29 vs 50.41 ± 27.61, p = 0.02) and ferritin (381.06 ± 485.2 vs 657.10 ± 863.80, p = 0.014) were lower in those with headaches.

Conclusions:

Headaches are a common and early symptom of acute SARS-CoV-2 infection more frequently seen in young females and in those with a history of primary headache disorders. The lower level of inflammatory markers in those with headaches suggests that these headaches are probably due to the local spread of virus through the trigeminal nerve endings, resulting in activation of the trigeminovascular system.

Effective Early Treatment of AChR Antibody-Positive Myasthenia Gravis with Rituximab; the Experience from a Neuroimmunology Clinic in a Developing Country

Background

Rituximab is reserved for treating refractory myasthenia gravis (MG) patients. Here we report our experience with rituximab in AChR antibody positive generalized MG (gMG) and impending myasthenic crisis (IMC).

Methods

This retrospective, observational study, conducted at a tertiary care, neuroimmunology clinic, analyzed the data of patients with AChR antibody positive gMG, treated with rituximab between 1st January 2016 and 30th October 2018.

Results

Eleven patients with AChR antibody positive gMG received rituximab. Mean age of the cohort was 50.54 ± 18.71 years with 9 males. Seven out of 11 patients received rituximab in the early stage (<2 years from onset) and had good response to treatment. Four of the 5 patients with IMC improved with rituximab alone. In the 10 patients who regularly followed up, there was a significant difference between the QMG scores at baseline and at 1, 2, 6, 12, and 18 months (P < .0001).

Conclusion

Rituximab appears to be a potentially effective early treatment option for AChR antibody positive generalized MG and impending myasthenic crisis.

Essential oil related seizures (EORS): A multi-center prospective study on essential oils and seizures in adults

OBJECTIVE

Essential oils (EOs) like eucalyptus and camphor have pro-convulsant properties. These EOs are present in many over- the- counter balms and oils. The effect of exposure to these EOs and occurrence of seizure is not systematically studied. The aim of this study was to evaluate the relationship between essential oils and the first episode of seizure and breakthrough seizures in known epileptic patients.

METHODS

This was a multi-center prospective study, conducted in four hospitals over four years. Every person presenting with the first episode of seizure or breakthrough seizure was asked about exposure to EOs, mode of exposure, time to onset of a seizure in relationship to exposure, duration of seizure, type of seizure, and antiepileptic drug therapy.

RESULTS

During the four-year period there were 55 patients with essential oil-related seizure (EORS). 22(40 %) had essential oil-induced seizures (EOIS) and 33(60 %) had essential oil-provoked seizures (EOPS). The female: male ratio was 1:1.1, the age of the patients ranged from 8 months to 77 years. In the EOIS group, 95 % had generalized tonic-clonic seizures and 5% had focal impaired awareness seizures. In the EOPS group, 42.4 % had focal impaired awareness seizures, 27.3 % generalized tonic-clonic seizures, 15 % focal to bilateral tonic-clonic seizures, and 15 % focal aware motor seizures. EOs implicated were preparations containing eucalyptus and camphor.

CONCLUSION

Exposure to essential oils of eucalyptus and camphor is an under-recognized cause of the first and breakthrough seizure. Identifying the true causative factor will prevent unnecessary antiepileptic drug therapy and future recurrence.

COVID-19-related strokes are associated with increased mortality and morbidity: A multicenter comparative study from Bengaluru, South India

Background

COVID-19-related strokes are increasingly being diagnosed across the world. Knowledge about the clinical profile, imaging findings, and outcomes is still evolving. Here we describe the characteristics of a cohort of 62 COVID-19-related stroke patients from 13 hospitals, from Bangalore city, south India.

Objective

To describe the clinical profile, neuroimaging findings, interventions, and outcomes in COVID-19-related stroke patients.

Methods

This is a multicenter retrospective study of all COVID-19-related stroke patients from 13 hospitals from south India; 1st June 2020–31st August 2020. The demographic, clinical, laboratory, and neuroimaging data were collected along with treatment administered and outcomes. SARS–CoV-2 infection was confirmed in all cases by RT-PCR testing. The data obtained from the case records were entered in SPSS 25 for statistical analysis.

Results

During the three-month period, we had 62 COVID-19-related stroke patients, across 13 centers; 60 (97%) had ischemic strokes, while 2 (3%) had hemorrhagic strokes. The mean age of patients was 55.66 ± 13.20 years, with 34 (77.4%) males. Twenty-six percent (16/62) of patients did not have any conventional risk factors for stroke. Diabetes mellitus was seen in 54.8%, hypertension was present in 61.3%, coronary artery disease in 8%, and atrial fibrillation in 4.8%. Baseline National Institutes of Health Stroke Scale score was 12.7 ± 6.44. Stroke severity was moderate (National Institutes of Health Stroke Scale 5–15) in 27 (61.3%) patients, moderate to severe (National Institutes of Health Stroke Scale 16–20) in 13 (20.9%) patients and severe (National Institutes of Health Stroke Scale 21–42) in 11 (17.7%) patients. According to TOAST classification, 48.3% was stroke of undetermined etiology, 36.6% had large artery atherosclerosis, 10% had small vessel occlusion, and 5% had cardioembolic strokes. Three (5%) received intravenous thrombolysis with tenecteplase 0.2 mg/kg and 3 (5%) underwent mechanical thrombectomy, two endovascular and one surgical. Duration of hospital stay was 16.16 ± 6.39 days; 21% (13/62) died in hospital, while 37 (59.7%) had a modified Rankin score of 3–5 at discharge. Hypertension, atrial fibrillation, and higher baseline National Institutes of Health Stroke Scale scores were associated with increased mortality. A comparison to 111 historical controls during the non-COVID period showed a higher proportion of strokes of undetermined etiology, higher mortality, and higher morbidity in COVID-19-related stroke patients.

Conclusion

COVID-19-related strokes are increasingly being recognized in developing countries, like India. Stroke of undetermined etiology appears to be the most common TOAST subtype of COVID-19-related strokes. COVID-19-related strokes were more severe in nature and resulted in higher mortality and morbidity. Hypertension, atrial fibrillation, and higher baseline National Institutes of Health Stroke Scale scores were associated with increased mortality.

Essential oil-related status epilepticus: A small case series study

OBJECTIVE

Essential oils are plant-derived oils and are widely used as an over-the-counter remedy for common ailments. Many essential oils are found to have proconvulsant effects. Here we report a small case series of 3 adults with eseential oil-related status epilepticus.

METHODS

This was an observational study conducted in a tertiary care hospital in south India from January 2018 to December 2019. We collected the demographic, clinical, and imaging features of all cases of status epilepticus resulting from exposure to essential oils. Cases of status epilepticus secondary to all other causes were excluded.

RESULTS

There were 3 young adults with essential oil-related status epilepticus. Two had de novo generalized tonic-clonic status epilepticus, and 1 with posttraumatic occipital lobe epilepsy had focal-impaired awareness status epilepticus. The first 2 cases presented with histories of ingestion of eucalyptus oil. The third case had focal-impaired awareness status epilepticus after topical application of various balms containing eucalyptus and camphor.

CONCLUSIONS

Proconvulsant essential oils of eucalyptus and camphor can cause both generalized and focal status epilepticus. Physicians dealing with patients of status epilepticus should enquire about the exposure to proconvulsant essential oils.

SAT0227 CLINICAL AND IMMUNOLOGICAL PROFILE OF NEUROPSYCHIATRIC LUPUS IN SOUTH INDIA

Background:

Neuropsychiatric manifestations are one of the least understood aspects of SLE.

Objectives:

To study the prevalence of NPSLE manifestations in our cohort and compare clinical and immunological features of patients with controls.

Methods:

This was a retrospective study in a tertiary care centre. Classification of SLE was as per SLICC criteria. All patients of SLE diagnosed in the last 5 years with NP manifestations as per the ACR definitions were included. Consecutive patients of SLE over last 2 years without NP manifestations were taken as controls.

Results:

Six hundred and thirty one patients with SLE were seen in our centre from Jan 2013 to Jun-2019. NPSLE manifestations as per the ACR definitions were seen in 100 patients (95 females) .137 (130 females) consecutive SLE patients without NP manifestations were included as controls. The commonest NPSLE manifestation was seizures followed by cerebrovascular accident (Table 1). NPSLE manifestation occurred at the first presentation in 77 patients. Forty patients had more than one NPSLE manifestation. Antiphosholipid (APl) antibodies (lupus anticoagulant and anticardiolipin antibody) were tested in 94 patients and positive in 25 (26.3%). Only 10 of the 23 patients with CVA were positive for APl. NPSLE syndromes were similar in APl positive and negative patients. As compared to controls, NPSLE patients had lower prevalence of mucocutaneous and musculoskeletal manifestations. There were no differences in the autoantibody profile in NPSLE patients versus controls. MRI of the brain was available in 65 NP episodes and 51 were abnormal. Ischaemic changes (22) were the commonest followed by T2/FLAIR hyperintensities (16). Cyclophosphamide was used for induction in 46 and Mycophenolate in 19 patients. Follow up of ≥ 6 months duration was available 93 patients. Over a mean follow up duration of 31.1 ± 22.7 months, 6 patiens had a NPSLE relapse and 10 died.

Table 1.

Prevalence of NP SLE manifestations (N=631) and clinical and immunological features

NPSLE manifestationsPrevalence (%)Clinical FeatureNPSLE (n=100)Controls (n=137)P valueAll100(15.85%)Age29.1±11.628.18±9.79NSCentral Nervous System65(10.3%)M:F5:957:130NSAseptic meningitis2(0.3%)Mucocutaneous55(55%)105(76.6%)<0.001Acute Confusional State12(1.9%)Musculoskeletal57(57%)96(70%)0.03Cerebrovascular Disease23(3.6%)Hemolytic Anaemia19(19%)40(29.2%)NSCognitive Dysfunction2(0.3%)Leucopenia25(25%)40(29.2%)NSDemyelinating Syndrome3(0.5%)Thrombocytopenia22(22%)36(26.3%)NSHeadache12(1.9%)Serositis10(10%)16(11.7%)NSMovement Disorder7(1.1%)Lupus Nephritis41(41%)38(27.7%)NSMyelopathy5(0.8%)Direct Coomb’s Test44(44%)55(45.5%)NSSeizures35(5.5%)Lupus anticoagulant15(15%)21(18.6%)NSAnticardiolipin12(12%)14(12.5%)NSPeripheral Nervous system28(4.4%)Low complements78(78%)98(78.4%)NSAIDP3(0.5%)dsDNA44(44%)67(52.8%)NSAutonomic Disorders1(0.1%)Smith38(38%)51(40.8%)NSCranial Neuropathy5(0.8%)Nucleosome43 (43%)52 (41.9%)NSMono neuropathy9(1.4%)Histone27 (27%)40 (32.3%)NSMyasthenia Gravis0Ribo P25(25%)37(29.6%)NSPlexopathy0RNP/Sm43(43%)52(41.6%)NSPolyneuropathy12(1.9%)scl704(4%)5(4%)NSSSA34(34%)42(33.6%)NSPsychiatric17(2.7%)SSB10(10%)18(14.5%)NSMood Disorders8(1.3%)Ro5232(32%)39(31.2%)NSPsychosis13(2.1%)PmScl05(4%)NSAnxiety Disorder4(0.6%)PCNA2(2%)6(4.8%)NS

Conclusion:

Seizures and CVA are the commonest NPSLE syndromes. APl positivity was not associated with NPSLE in our cohort.

Disclosure of Interests:

None declared

Efficacy and safety of rituximab in multiple sclerosis: Experience from a developing country

BACKGROUND

Rituximab is increasingly being used in treatment of multiple Sclerosis (MS) in our centers due to its easy availability, efficacy and favorable side effect profile. Here we describe experience with rituximab over a period of 4 years from three MS centers from south India.

METHODS

The data of MS patients who were treated with rituximab in three MS centers at Bangalore, India, from December 2015 to December 2019 were collected and evaluated with respect to relapse rate, EDSS score and adverse events.

RESULTS

Over the four-year study period 118 MS patients were evaluated, 80 of whom were on rituximab. 58 (72%) had RRMS, 15 (19%) SPMS and 7 (9%) PPMS. Most patients (89%) received rituximab at a dose of 500 mg every 6-12 months. Nine patients (11%), all with progressive MS were on 1 gm to 2 gm every 6 months. Follow up ranged from 1 year to 3 years, with a median of 2 years. 56 (97%) RRMS patients had no relapses during follow up. EDSS score improved by a score of 0.5-2.0 in 68 (85%) patients, remained same in 10 (12.5%) and worsened in 2 patients (2.5%). Most patients (91%) tolerated rituximab infusions well. There were no opportunistic infections or neoplasms.

CONCLUSION

Anti B cell therapy with rituximab appears effective, safe and affordable in the treatment of MS in developing countries like India with resource limited settings.

Burning Feet, Dilated Heart and Failed Kidneys

Fabry's disease, X-linked lysosomal storage disease, results from deficient activity of alpha galactosidaseA (α-GalA). Renal manifestation usually begins at third decade of life. We report a 16 year male with initial presentation with end stage renal disease (ESRD) and the diagnosis confirmed by presence of myeloid bodies on electron microscopy of kidney biopsy and low serum α-GalA level.

Outpatient burden of neurological disorders: A prospective evaluation of 1500 patients

INTRODUCTION

Neurologists spend a significant amount of time in providing out-patient services. No comprehensive studies are there from India which have looked into the real burden of these common disorders in the out-patient population. This study was done to get a clear data on the burden of these disorders.

OBJECTIVES

The aim of this study was to determine the incidence of various neurological disorders in the out-patient department services.

METHODS

The study was conducted in a tertiary care medical center. Clinical data of 1500 consecutive out-patients who attended the out-patient services were collected over a period of 2 months from December 2014 to January 2015. All patients were evaluated by a resident trainee and a senior consultant. Necessary investigations were done wherever applicable. The most probable clinical diagnosis was made after a detailed history and a thorough neurological evaluation. Age, sex, and the diagnosis were recorded and entered in an Excel sheet. Appropriate statistical methods were used for descriptive analysis.

RESULTS

Out of the 1500 patients, 766 were male and 734 were female. The most common complaints with which patients came to the outpatient services were headaches (28.6%), muscular and radicular pains (24.7%), seizures (12.7%) and hemiparesis/monoparesis (11.9%). Movement disorders, neuropathies, and nerve palsies were also present in a significant number of patients.

CONCLUSION

The most common neurological disorders in the outpatient services are headache, neck pain, backache, fibromyalgia, stroke, epilepsy, and neuropathies. Newly joined residents should be well trained to efficiently manage these common outpatient disorders.

HIV infection associated neuromyelitis optica spectrum disorder: Clinical features, imaging findings, management and outcomes

INTRODUCTION

HIV Infection associated NMOSD (HIV-NMOSD) is a recently recognized entity. Management of patients with HIV-NMOSD is a challenge. Here we report our own experience of HIV-NMOSD along with a complete review of all the cases of HIV-NMOSD reported in literature.

OBJECTIVE

Describe the clinical features, radiological findings, treatment patterns and outcomes in patients with HIV-NMOSD.

METHODS

The details of all cases of HIV- NMOSD were searched from our NMOSD registry. A literature search was also done using the terms NMO, NMOSD and HIV infection in PUBMED, Google Scholar and EMBASE. The details of all the reported cases and cases from our registry were collected and analyzed.

RESULTS

Six cases of HIV-NMOSD were identified from the literature and one from our registry. There were four males and three females with age ranging from 8 years to 49 years. Duration of HIV infection ranged from newly detected to 15 years. Optic neuritis followed by myelitis was the commonest presentation, occurring in 5 out of 7 patients. 3 patients were anti-aquaporin 4 antibody positive while 3 were negative and in one anti- aquaporin 4 antibody assay was not done. All patients received immunomodulatory treatment. 5/7 patients had poor recovery from acute attacks but no patient had further relapses while on immunomodulatory treatment and antiretroviral therapy.

CONCLUSION

HIV associated NMOSD is a recently recognized entity. A high index of suspicion is needed to diagnose these patients. In all patients with HIV infection presenting with optic neuritis or/and myelitis, anti aquaporin 4 antibody status should be checked and in all patients of NMOSD, HIV infection should be ruled out.

Post herpes zoster SUNCT like syndrome: Insights from two case reports

Background

SUNCT like syndrome secondary to post herpes zoster infection has not been reported in literature.

Case

We are reporting two cases of SUNCT like syndrome secondary to post herpes zoster infection of the V1 distribution of the trigeminal nerve. Treatment with pregabalin and lamotrigine achieved complete symptomatic relief in both patients.

Conclusion

SUNCT like syndrome can occur after herpetic infection of the trigeminal nerve. Unlike primary SUNCT syndrome, post-herpetic SUNCT like syndrome seems to respond well to pharmacological treatment and has a good prognosis.

Trigeminal autonomic cephalalgia as a presenting feature of Neuromyelitis Optica: "A rare combination of two uncommon disorders"

Neuromyelitis Optica (NMO) can have atypical presentations like hiccups, vomiting, etc. which is classically described as the area postrema syndrome. Here we report a case of a 39 year old male patient who presented with features of Trigeminal Autonomic Cephalalgia (TAC). MRI spine showed long segment myelitis. Diagnosis of NMO was confirmed by a positive Anti aquaporin 4 antibody assay. TACs are a rare group of headache disorders characterized by severe unilateral headache in the V1 distribution of the trigeminal nerve and autonomic symptoms. This presentation in NMO is hitherto unreported in literature.

Hurdles in stroke thrombolysis: Experience from 100 consecutive ischemic stroke patients

Background:

Acute management of ischemic stroke involves thrombolysis within 4.5 h. For a successful outcome, early recognition of stroke, transportation to the hospital emergency department immediately after stroke, timely imaging, proper diagnosis, and thrombolysis within 4.5 h is of paramount importance.

Aim:

To analyze the obstacles for thrombolysis in acute stroke patients.

Materials and Methods:

The study was conducted in a tertiary care center in South India. A total of hundred consecutive patients of acute ischemic stroke who were not thrombolysed, but otherwise fulfilled the criteria for thrombolysis were evaluated prospectively for various factors that prevented thrombolysis. The constraints to thrombolysis were categorized into: i) Failure of patient to recognize stroke symptoms, ii) patient's awareness of thrombolysis as a treatment modality for stroke, iii) failure of patient's relative to recognize stroke, iv) failure of primary care physician to recognize stroke, v) transport delays, vi) lack of neuroimaging and thrombolysis facility, and vii) nonaffordability.

Results:

The biggest hurdle for early hospital presentation is failure of patients to recognize stroke (73%), followed by lack of neuroimaging facility (58%), nonaffordability (56%), failure of patient's relative to recognize stroke (38%), failure of the primary care physician to recognize stroke (21%), and transport problems (13%). Awareness of thrombolysis as a treatment modality for stroke was seen only in 2%.

Conclusion:

Considering the urgency of therapeutic measures in acute stroke, there is necessity and room for improvement to overcome various hurdles that prevent thrombolysis.

"Dot sign" in dengue encephalitis

Neuro radiological findings in Dengue encephalitis are non specific. Here we report a case of Dengue encephalitis with transient splenial hyperintensity appearing as dot sign on magnetic resonance imaging of brain.

Temporal arteritis: A case series from south India and an update of the Indian scenario

OBJECTIVE

To study the clinical, pathological and prognostic profile of patients with temporal arteritis in India.

MATERIALS AND METHODS

The study was conducted in a tertiary care center from south India from 2005 to 2010 in the departments of neurology and medicine. The details of all patients that satisfied the ACR 1990 criteria for diagnosis of temporal arteritis were reviewed. The clinical presentation, laboratory parameters and biopsy findings of the patients were analyzed and compared with other studies from India done over the last decade.

RESULTS

A total of 15 patients were diagnosed with temporal arteritis. The male:female ratio was 1.5:1. The mean age of onset was 67.58 years. Mean time for detection after onset of symptoms was 2.56 months. Typical manifestations included headache (100%), temporal artery tenderness (100%), jaw claudication (20%), polymyalgia rheumatica (53%) and visual manifestations (20%). The erythrocyte sedimentation rate was elevated in all patients. Biopsy was done in 13 patients, with 11 of them being positive. All patients responded to steroids well, with most patients being symptom-free within the first 48 h of treatment.

CONCLUSIONS

Temporal arteritis seems to be underdiagnosed in India, with all patients previously misdiagnosed, and with a mean time from symptom onset to diagnosis of 2.5 months. The clinical presentation of temporal arteritis in India appears to be similar to that of the West, with no gender preference and a slightly younger age group.

Topiramate-induced somnambulism in a migraineur: a probable idiosyncratic adverse effect

Somnambulism (sleepwalking) is a disorder of arousal that falls under "parasomnia" group and is more common in children. These phenomena occur as primary sleep events or secondary to systemic disease or can be drug induced. Medications that can cause sleepwalking include neuroleptics, hypnotics, lithium, amitriptyline, and β-blockers. This report presents an unusual adverse effect of topiramate on sleep in a patient with migraine.

Heat stress associated with the use of vapor-barrier garments

Use of personal protective devices in the workplace, while intended to diminish risk of injury, may in some cases increase personal risk from environmental hazards. A case of a juvenile diabetic with complaints of near syncope while working in a plastics laminating process is analyzed. Although his symptoms might be attributed to a variety of causes, they were traced to the effects of heat stress related to wearing vapor-barrier disposable coveralls in a warm environment (85 degrees F). A field study of asbestos workers involved in abatement of asbestos steam pipe insulation illustrates how clothing impermeable to sweat may result in elevation of core body temperature. When workers use vapor-barrier coveralls, work practices or wet bulb globe temperature limits may need to be revised to prevent heat-related injury.