Journal of Neurosciences in Rural Practice
 
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April-June 2017
Volume 8 | Issue 2
Page Nos. 163-323

Online since Wednesday, April 5, 2017

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EDITORIALS  

Cerebral microbleeds: Treatment conundrum in acute ischemic stroke p. 163
Ramnath Santosh Ramanathan
DOI:10.4103/0976-3147.203846  
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Red blood cell and platelet indices: A potential biomarker for panic disorder p. 164
Roshan Bhad
DOI:10.4103/jnrp.jnrp_33_17  
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ORIGINAL ARTICLES Top

Study of sleep disorders among young children using hindi translated and validated version of pediatric sleep questionnaire p. 165
Ravi Gupta, Ramjan Ali, Sunanda Verma, Kriti Joshi, Mohan Dhyani, Kanchan Bhasin, Neha Bhasin, Jatin Goyal
DOI:10.4103/jnrp.jnrp_428_16  
Objective: The objective of this study is to assess the prevalence of sleep disorders among children aging between 4 and 9 years using Hindi version of Pediatric Sleep Questionnaire (PSQ). Methods: This study had two parts first, translation and validation of PSQ into Hindi language, and second, assessment of the prevalence of sleep disorders using PSQ Hindi version. Hindi PSQ was distributed in randomly chosen primary schools in a semi-urban area. The children were requested to get them filled by their parents. When the questionnaires were returned, responses were analyzed. Results: Most of the items of the Hindi version had perfect agreement with original questionnaire in a bilingual population (κ =1). Totally, 435 children were included in the field study having average age of 6.3 years. Obstructive sleep apnea was reported in 7.5% children; symptoms suggestive of restless legs syndrome were reported by 2%–3%; teeth grinding by 13.9% and sleep talking by 22.6% children. Conclusion: PSQ Hindi version is a validated tool to screen for sleep disorders among children. Sleep disorders are fairly prevalent among young children in India.
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Indigenous inexpensive practice models for skill development in neuroendoscopy p. 170
Jitin Bajaj, Yad Ram Yadav, Anurag Pateriya, Vijay Parihar, Shailendra Ratre, Amitesh Dubey
DOI:10.4103/jnrp.jnrp_495_16  
Introduction: Neurosurgery is a branch having a tough learning curve. Residents generally get very less hands-on exposure for advanced procedures like neuroendoscopy. With the limited number of cadavers available and ethical issues associated with animal models, practice models, and simulators are becoming the able alternative. Most of these simulators are very costly. We tried to build indigenous inexpensive practice models that can help in developing most of the skills of neuroendoscopy. Materials and Methods: Models were built for learning hand-eye coordination, dexterity, instrument manipulation, cutting, fine dissection, keyhole concept, drilling, and simulation of laminectomy and ligamentum flavum resection. These were shown in the neuroendoscopic fellowship program conducted in authors' institute, and trainees' responses were recorded. Results: Both novice and experienced neuroendoscopic surgeons validated the models. There was no significant difference between their responses (P = 0.791). Conclusion: Indigenous innovative models can be used to learn and teach neuroendoscopic skills. The presented models were reliable, valid, eco-friendly, highly cost-effective, portable, easily made and can be kept in one's chamber for practicing.
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Mean platelet volume and platelet distribution width level in patients with panic disorder p. 174
Ramdas Sarjerao Ransing, Bharat Patil, Omityah Grigo
DOI:10.4103/jnrp.jnrp_445_16  
Background: Changes in platelet indices have been reported in patients with panic disorder (PD). However, previous study findings are contradictory and inconclusive. The aim of this study was to evaluate and compare the platelet indices in patients with PD. Materials and Methods: Patients with PD (n = 123) and healthy controls (n = 133) were enrolled in this case control study. The platelet indices (mean platelet volume [MPV] and platelet distribution width [PDW]) along with red blood cell (RBC) indices (RBC count and red cell distribution width [RDW]) were compared between the two groups using the unpaired t-test. Results: Patients with PD had lower MPV (7.53 ± 0.93 fL vs. 8.91 ± 1.24 fL, P < 0.0001), higher PDW (16.96 ± 0.85 fL vs. 14.71 ± 2.07 fL, P < 0.0001), and higher platelet count (274.2 ± 80.66 × 109 L−1 vs. 243.1 ± 93.89 × 109 L−1, P < 0.005) than the healthy controls. Furthermore, there were significant differences between patients with PD and healthy controls in terms of their RBC count (4.32 ± 0.56 × 1012 L−1 vs. 4.08 ± 0.80 × 1012 L−1, P = 0.007) and RDW (16.48 ± 2.26 fL vs. 15.01 ± 2.25 fL, P < 0.0001). Conclusion: Patients with PD have increased PDW and RDW. The platelet and RBC indices may prove to be useful etiological and prognostic markers in patients with PD.
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Psychiatric comorbidity in children with epilepsy: A cross-sectional 5 years rural prevalence study p. 179
Ambrish Sanjay Dharmadhikari, Vinod Kumar Sinha
DOI:10.4103/jnrp.jnrp_487_16  
Background: Epilepsy is one of the most common chronic neurological disorders. In children, it has long debilitating course and is associated with comorbidities including psychiatric comorbidity. To tackle this burden of comorbidities, we must know the extent of problem. Hence, there is a need for estimation of prevalence of psychiatry disorder in children with epilepsy. Aim: The present study was aimed at measuring the prevalence of various psychiatry disorders among children suffering from epilepsy. Settings and Design: Cross-sectional chart review. Methodology: We reviewed case record files of all patients with a diagnosis of epilepsy in the age group of 9–17 years. Chart review was done for 5 years, May 1, 2007, to April 30, 2012. A total of 718 patients record were included in the study after satisfying inclusion criteria and excluding nonepilepsy diagnosis. Statistical Analysis: Statistics was done using Statistical Package for Social Sciences (SPSS 18.0). Descriptive statistics were used to calculate the result, Chi-square and Mann–Whitney U-test used wherever applicable. Results: The prevalence of childhood psychiatric disorder among children with epilepsy found to be 31.2%. We also found that having a partial component (73.21%, n = 164) in seizure has more chances of psychopathology in comparison to generalized seizure (8.1%, n = 18). Among them, those having a partial component with generalization (66.96%, n = 150) had a greater prevalence of psychopathology. Mental retardation was most common psychiatric disorder among psychopathology followed by manic/depressive illness (unipolar) followed by unspecified nonorganic psychosis. Conclusion: From our study, we demonstrate the significant mental health needs of children with epilepsy. The evident high prevalence of psychiatry disorder emphasizes the need for psychopathology assessment and treatment as a part of any comprehensive epilepsy clinic.
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Value of minimum apparent diffusion coefficient on magnetic resonance imaging as a biomarker for predicting progression of disease following surgery and radiotherapy in glial tumors from a tertiary care center in Northern India p. 185
Pramod Kumar Gupta, Rishi Awasthi, Shalini Singh, Sanjay Behari, KJ Maria Das, Rakesh Kumar Gupta, Shaleen Kumar
DOI:10.4103/0976-3147.203823  
Purpose: Studies have shown that cellularity of glial tumors are inversely correlated to minimum apparent diffusion coefficient (ADC) values derived on diffusion-weighted imaging (DWI). The purpose of this prospective exploratory study was to evaluate whether temporal change in “minimum ADC” values during follow-up predict progressive disease in glial tumors post radiotherapy and surgery. Materials and Methods: Adult patients of glial tumors, subjected to surgery followed by Radiotherapy (RT), were included in the study. Serial conventional magnetic resonance imaging with DWI at the following time points – presurgery, pre-RT, post-RT imaging at 3, 7, and 15 months were done. For “minimum ADC” values, multiple regions of interest (ROI) were identified on ADC maps derived from DWI. A mean of 5 minimum ADC values was chosen as “minimum ADC” value. The correlation was drawn between histology and minimum ADC values and time trends were studied. Results: Fourteen patients were included in this study. Histologies were low-grade glioma (LGG) - 5, anaplastic oligodendroglioma (ODG) -5, and glioblastoma multiforme (GBM) - 4. Minimum ADC values were significantly higher in LGG and GBM than ODG. Presurgery, the values were 0.812, 0.633, and 0.787 × 10−3 mm2/s for LGG, ODG, and GBM, respectively. DWI done at the time of RT planning showed values of 0.786, 0.636, 0.869 × 10−3 mm2/s, respectively. During follow-up, the increasing trend of minimum ADC was observed in LGG (P = 0.02). All these patients were clinically and radiologically stable. Anaplastic ODGs, however, showed an initial increase followed by the fall of minimum ADC in all the 5 cases (P = 0.00). Four of the five cases developed progressive disease subsequently. In all the 4 GBM cases, a consistent fall of minimum ADC values was observed (P = 0.00), and they all progressed in spite of RT. Conclusions: The DWI-derived minimum ADC values are an important yet simple quantitative tool to assess the treatment response and disease progression before they are evident on conventional imaging during the follow-up of glial tumors.
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Minimally invasive versus open spine surgery: What does the best evidence tell us? p. 194
Shearwood McClelland, Jeffrey A Goldstein
DOI:10.4103/jnrp.jnrp_472_16  
Background: Spine surgery has been transformed significantly by the growth of minimally invasive surgery (MIS) procedures. Easily marketable to patients as less invasive with smaller incisions, MIS is often perceived as superior to traditional open spine surgery. The highest quality evidence comparing MIS with open spine surgery was examined. Methods: A systematic review of randomized controlled trials (RCTs) involving MIS versus open spine surgery was performed using the Entrez gateway of the PubMed database for articles published in English up to December 28, 2015. RCTs and systematic reviews of RCTs of MIS versus open spine surgery were evaluated for three particular entities: Cervical disc herniation, lumbar disc herniation, and posterior lumbar fusion. Results: A total of 17 RCTs were identified, along with six systematic reviews. For cervical disc herniation, MIS provided no difference in overall function, arm pain relief, or long-term neck pain. In lumbar disc herniation, MIS was inferior in providing leg/low back pain relief, rehospitalization rates, quality of life improvement, and exposed the surgeon to >10 times more radiation in return for shorter hospital stay and less surgical site infection. In posterior lumbar fusion, MIS transforaminal lumbar interbody fusion (TLIF) had significantly reduced 2-year societal cost, fewer medical complications, reduced time to return to work, and improved short-term Oswestry Disability Index scores at the cost of higher revision rates, higher readmission rates, and more than twice the amount of intraoperative fluoroscopy. Conclusion: The highest levels of evidence do not support MIS over open surgery for cervical or lumbar disc herniation. However, MIS TLIF demonstrates advantages along with higher revision/readmission rates. Regardless of patient indication, MIS exposes the surgeon to significantly more radiation; it is unclear how this impacts patients. These results should optimize informed decision-making regarding MIS versus open spine surgery, particularly in the current advertising climate greatly favoring MIS.
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Platelet serotonin level and impulsivity in human self-destructive behavior: A biological and psychological study p. 199
S Era Dutta, Sriniwas Gupta, M.S. V. K. Raju, Abhishek Kumar, Alka Pawar
DOI:10.4103/jnrp.jnrp_425_16  
Context: Suicide is a disease and a global public health problem. Suicidology has come to become a topic of study for intervention and research. The serotonin (5-hydroxytryptamine [5HT]) system has remained a prime area of investigation. The neurons and platelets display structural and functional similarities. Ninety-nine percent of 5HT is contained in platelets, which shares similar 5HT uptake and release mechanisms with 5HT neurons. Aims: This study aims to study human self-destructive behavior (HSDB). Objectives: Exploring the biological (serotonin levels in platelets) and psychological aspects (impulsivity) of attempted suicide or HSDB. Settings and Design: Thirty-one patients, above the age of 18 years, with a recent history of HSDB, were studied and given an International Classification of Diseases-10 diagnosis, after a detailed interview. Subjects and Methods: For the platelet 5HT estimation, blood samples were collected, and enzyme immunometric assay carried out. Detailed assessment of the impulsivity was done by the 25-item structured diagnostic interview for borderlines by Zanarini et al. Statistical Analysis Used: We obtained both categorical and continuous data. Chi-square test, Fisher's test, Student's t-test, and Pearson's product moment correlation were used. Results: Female subjects outnumbered males by 2:1. Major depression, adjustment disorder, personality disorder were predominant diagnoses. The mean platelet serotonin concentration for males = 57.3 ng/ml, that of females = 56.05 ng/ml (P > 0.05). Platelet 5HT levels were found to be negatively correlated with impulsivity scores (P < 0.05). Conclusions: Platelet serotonin levels in our study sample were quite low when compared with those reported in published literature. Low serotonin levels were inversely related to impulsivity, but only in males.
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Clinical profile, outcome, and prognostic factors of cortical venous thrombosis in a tertiary care hospital, India p. 204
Basavaraj Fakkirappa Banakar, Vandana Hiregoudar
DOI:10.4103/0976-3147.203812  
Background: Cortical venous thrombosis (CVT) is a rare condition, compared to arterial stroke and often occurs in young individuals presenting with varying clinical features. Aim: The aim is to study clinical profile and assess the outcome and prognostic factors of CVT patients. Methodology: A case series study was done for 2 years. CVT cases confirmed by magnetic resonance imaging were included in this study. Clinical presentation and risk factors were noted then patients were assessed at the time of discharge for their physical and mental status. Modified Rankin scale was used to group patients, accordingly scores 0–2 were considered as good and 3–6 as poor outcome, respectively. Data were analyzed using Chi-square test to know the association between prognostic factors and outcome. Results: Out of 81 patients, more than half of the patients were in the age group of <35 years (55.6%), and majority of patients were females (79%). Most common symptom was headache (82.7%) and least was fever (14.8%). Superior sagittal sinus was most commonly involved (74.1%). Nearly half of the patients were in puerperal period (44.1%). Patients aged more than 35 years (odds ratio [OR]: 9.1, confidence interval [CI]: 4.463–19.750) presenting with symptoms such as fever (OR: 3.442, CI: 1.088–12.140), impaired consciousness (OR: 5.467, CI: 2.064–15.330) and having clinical signs such as coma (OR: 23.99, CI, 3.844–544.1), papilledema (OR: 25.15, CI: 7.565–101.5), and with focal neurological deficit (OR: 9.366, CI: 2.693–3.41) had statistically significant poor outcome. Conclusion: Females formed a major bulk of patients. Higher number patients showed poor outcome. Study showed association between age, headache, impaired consciousness, coma, papilledema, and neurological deficit to poor outcome.
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Factors influencing utilization of physiotherapy service among children with cerebral palsy in Jalandhar District of Punjab p. 209
Akhoury Gourang Sinha, Raju Sharma
DOI:10.4103/0976-3147.203852  
Background: Physiotherapy plays a central role in the management of children with cerebral palsy (CP); however, literature describing the use of physiotherapy service and the factors affecting utilization of physiotherapy service for this group of children in the Indian context remain unexplored. Aims and Objectives: To describe the utilization of physiotherapy services and explore the factors affecting utilization of physiotherapy services among children with CP of Jalandhar district of Punjab. Methodology: During June 2009 to March 2012 interview of family members of 248 children with CP (male = 159; female = 89) was conducted using a schedule focusing on demography, constraints of resources, expectations, beliefs, awareness, and service utilization. Cross tabulation with Chi-square, univariate, and multivariate logistic regression analysis were the tools of statistical analysis. Results: 44.4% children had not received any physiotherapy in their life time. In univariate analysis exposure to physiotherapy was found significantly associated with age of diagnosis (odds ratio [OR] = 2.47), finance constraint (OR = 2.27), personal constraint (OR = 2.54), transportation constraint (OR = 3.01), lack of advice for rehabilitation (OR = 2.36), ignorance about condition (OR = 11.94), and rehabilitation services (OR = 2.88). Multivariate model (χ2 = 57.16, df = 15, P < 0.001, pseudo R2 Cox and Snell = 0.22, Nagelkerke = 0.27) identified two main predictor variables of nonexposure to physiotherapy-ignorance about condition (OR = 7.3) and expectation of normalcy (OR = 0.43). Conclusion: The main drivers for the use of physiotherapy among children with CP in Jalandhar district of Punjab were awareness about the condition of CP and expectation of normalcy which demonstrated a complex relationship with sociodemographic factors.
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Prevalence of cerebral microbleeds in Thai patients with ischemic stroke p. 216
Artit Potigumjon, Arvemas Watcharakorn, Pornpatr A Dharmasaroja
DOI:10.4103/0976-3147.203836  
Background: With the widespread use of magnetic resonance imaging (MRI), cerebral microbleeds (CMBs) are commonly detected. Ethnicity seems to play a role in the prevalence of CMB, with higher prevalence in participants from Asian origin. The purpose of the study is to look for the prevalence of CMBs and associated factors in Thai patients with ischemic stroke. Methods: Patients with acute ischemic stroke who had MRI and magnetic resonance angiography during January–August 2014 were included in the study. T2*-weighted gradient-recalled echo was used to define CMBs. Baseline characteristics, stroke subtypes, and severity of white matter lesions were compared between patients with and without CMBs. Results: Two hundred patients were included in the study. Mean age of the patients was 61-year-old. Mean National Institutes of Health Stroke Scale was 8. The prevalence of CMBs was 20% (39/200 patients). Hypertension (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.07–8.68, P = 0.037), and moderate-to-severe white matter lesions (Fazekas 2–3, OR 7.61, 95% CI 3.06–18.95, P < 0.001) were related to the presence of CMBs. Conclusions: CMBs were found in 20% of patients with ischemic stroke, which was lower than those reported from Japanese studies but comparable to a Chinese study. CMBs were associated with hypertension and severity of the white matter lesions.
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Intraoperative squash smear in central nervous system tumors and its correlation with histopathology: 1 year study at a tertiary care centre p. 221
Arpita Jindal, Himanshi Diwan, Kanwalpreet Kaur, VD Sinha
DOI:10.4103/0976-3147.203811  
Background: Intraoperative squash smear cytology is a simple and reliable technique for rapid intraoperative diagnosis of neurosurgical specimens. The study was designed to assess the accuracy of intraoperative squash smear in the diagnosis of central nervous system (CNS) space-occupying lesions. Materials and Methods: One hundred and fifty cases of CNS space-occupying lesion were studied in a period of 15 months. Smears were prepared from the biopsy sample obtained at the time of operation and were stained with rapid hematoxylin and eosin method. Results: One hundred and forty-one cases showed complete correlation with histopathology, two cases showed partial correlation, and seven cases were discrepant. The overall diagnostic accuracy was found to be 94%. Conclusion: Intraoperative squash smear thus provides diagnosis with fair accuracy in brain tumors and is of great value in intraoperative consultation.
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Lennox–Gastaut syndrome: A prospective follow-up study p. 225
Bhanu Pratap Rathaur, Ravindra Kumar Garg, Hardeep Singh Malhotra, Neeraj Kumar, Praveen Kumar Sharma, Rajesh Verma, Ravi Uniyal
DOI:10.4103/0976-3147.203820  
Objectives: Lennox–Gastaut syndrome is a catastrophic epileptic encephalopathy. In Lennox–Gastaut syndrome, seizures are resistant to pharmacological treatment. In this prospective study, we evaluated the clinical features, neuroimaging, and response to treatment. Materials and Methods: Forty-three consecutive newly diagnosed patients of Lennox–Gastaut syndrome were enrolled in the study. Baseline clinical assessment included seizure semiology, seizure frequency, electroencephalography, and neuroimaging. Patients were treated with combinations of preferred antiepileptic drugs (sodium valproate [VPA], clobazam [CLB], levetiracetam [LVT], lamotrigine [LMT], and topiramate [TPM]). Patients were followed for 6 months. The outcome was assessed using modified Barthel index. Results: Tonic and generalized tonic-clonic forms were the most common seizures types. Features suggestive of hypoxic-ischemic encephalopathy (37.2%) were most frequent neuroimaging abnormality. Neuroimaging was normal in 32.6% of patients. With a combination valproic acid (VPA), CLB, and LVT, in 81.4% of patients, we were able to achieve >50% reduction in seizure frequency. Eleven (25.58%) patients showed an improvement in the baseline disability status. Conclusions: A combination of VPA, CLB, and LVT is an appropriate treatment regimen for patients with Lennox–Gastaut syndrome.
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Impairments in quality of life and cognitive functions in long-term survivors of glioblastoma p. 228
Chirag Solanki, Divya Sadana, Arivazhagan Arimappamagan, K.V.L.N. Rao, Jamuna Rajeswaran, DK Subbakrishna, Vani Santosh, Paritosh Pandey
DOI:10.4103/0976-3147.203829  
Background: The incidence of long-term survival in glioblastoma (GBM), i.e., >3 years, ranges from 3% to 5%. Although extensive research is performed in novel therapies for prolonging survival, there is a scarcity of research focusing on the impact of tumor and treatment on cognitive, psychological, and social status of survivors. This study is an attempt to look into this poorly addressed important issue. Materials and Methods: Nine patients (six adults and three children) with GBM who had survived >3 years were included in the study. The quality of life (QOL) functions were assessed with the World Health Organization QOL Questionnaire BREF questionnaire. The neuropsychological assessment was done using the National Institute of Mental Health and Neurosciences neuropsychology battery for adults and children. The scores were compared with normative data. Results: The physical and psychological health-related QOL of long-term GBM survivors were affected considerably due to fatigue, poor quality of sleep, inability to concentrate, presence of depression, financial burden with impaired personal and social relationships (P < 0.05). Different domains of cognitions such as motor speed (P = 0.0173), mental speed (P = 0.0022), sustained attention (P = 0.0001), long-term memory (P = 0.0431), mental flexibility (P < 0.05), and planning and executive functions (P < 0.05) were significantly impaired affecting personal, social, and professional lives. Conclusion: The health-related QOL and cognition are significantly impaired in GBM long-term survivors. As the incidence of long-term survival is very less, there is a need for larger multicenter studies to come up with definitive results, which in turn can help in formatting the rehabilitative and support programs for these patients.
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Advanced age and higher national institutes of health stroke scale score as predictors of poor outcome in ischemic stroke patients treated with alteplase: A study from a tertiary care centre in rural North-west India p. 236
Amit Bhardwaj, Girish Sharma, Sunil Kumar Raina, Ashish Sharma, Monica Angra
DOI:10.4103/jnrp.jnrp_431_16  
Introduction: Thrombolytic therapy in acute ischemic stroke has been approved for treatment of acute stroke for past two decades. However, identification of predictors of poor outcome after the intravenous (IV) alteplase therapy in acute stroke patients is a matter of research. The present study was conducted with the aim of identifying poor prognostic factors in patients of acute ischemic stroke patients. Methods: The data of 31 acute stroke patients treated with alteplase were gathered to identify the factors that were independent predictors of the poor outcome. Outcome was dichotomized using modified Rankin scale (mRS) score and National Institutes of Health Stroke Scale (NIHSS) score at 3 months after treatment into good outcome mRS - 0–2 and poor outcome mRS - 3–6. Predictors of poor outcome were analyzed. Results: Good outcome (mRS – score 0–2) was seen in 15 (48.4%) patients with median age of (60) and poor outcome (mRS – score 3–6) was seen in 16 (51.6%) patients median age of 75 years, which was statistically significant with the P = 0.002. The presence of risk factors such as hypertension, diabetes, dyslipidemia, smoking, alcohol intake, history of stroke, coronary artery disease, and rheumatic heart disease among the two groups did not seem influence outcome. The severity of stroke as assessed by NIHSS score at the time of presentation was significantly higher among the patients with poor outcome, with P = 0.01. Conclusion: Advance age and higher NIHSS score at the time of onset of stroke and are the independent predictors of the poor outcome after thrombolysis with IV alteplase treatment in acute ischemic stroke patients.
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Factors determining the clinical spectrum, course and response to treatment, and complications in seronegative patients with central nervous system tuberculosis p. 241
Sadanandavalli Retnaswami Chandra, Sikandar Advani, Ravi Kumar, Chandrajith Prasad, Anupama R Pai
DOI:10.4103/jnrp.jnrp_466_16  
Introduction: Tuberculous meningitis remains a major health issue in the community affecting young adults of both genders predominantly from rural background. In India, the disease continues to kill 2 people every 3 min or nearly 1000 daily, according to the Tuberculosis Control Society India. Tuberculosis (TB) of central nervous system (CNS) is the most devastating form of TB. As this disease is associated with very high prevalence in young adults and will ultimately contribute to great workforce loss, we decided to assess the factors deciding the disease and its course in our patients. Patients and Methods: Seronegative patients with probable CNS TB and attending our outpatient department were included and followed up for 2 years. Results: Low body mass index, low proteins, albumin, and low CD3 and CD4, pulmonary TB appears to be a common denominator in a vast majority of these patients. Delay in diagnosis and hyponatremia contributes to morbidity. The location of exudates causes morbidity when they are seen in optochiasmal region. Bacille Calmette–Guerin (BCG) vaccination status in the community appears to be very small. Conclusion: CNS TB causes considerable morbidity and mortality in rural young adults resulting in severe manpower loss. Awareness into the possible role of BCG in reducing the complications of TB, role of nutrition and immunity even in seronegative patients and high-degree suspicion in medical professionals can bring down the burden of this deadly disease in the society.
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Management and outcome of infantile hydrocephalus in a tertiary health institution in Nigeria p. 249
Ayodeji Salman Yusuf, Habeeb Kayodele Omokanye, Nurudeen Abiola Adeleke, Rukeme Oluaseun Akanbi, Sikiru Olalekan Ajiboye, Hakeem Gbadebo Ibrahim
DOI:10.4103/jnrp.jnrp_321_16  
Background: Hydrocephalus is a leading cause of disability among children worldwide. The outcome depends on morphology and whether insult is pre- or post-natal. There has been improvement in morbidity in developed countries due to improved surgical care. A paucity of trained personnel impacts negatively on care and outcome of infants with hydrocephalus in many low-income countries resulting poorer outcome. We conducted an audit of patients with hydrocephalus managed in our institution to determine common etiology and outcome. Object: The objective of this retrospective review was to conduct an audit of hydrocephalus care in our institution. Materials and Methods: Information was retrieved from case notes, ward records, imaging results, operation notes, and follow-up clinic charts. Type of hydrocephalus, onset, treatment offered, outcome, complications, and follow-up duration were documented. Results: Management of 58 infants with complete data was analyzed. Most hydrocephalus 40 (69%) were congenital with 14 (35%) occurring in association with myelomeningocele and 8 patients confirmed with aqueductal stenosis. Ventriculoperitoneal shunts insertion 53 (91%) was the most common treatment modality. Conclusions: There is need to improve surgical intervention in the form of endoscopic third ventriculostomy in suitable patients. Subsiding cost of care may be considered for indigent patients.
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Treatment discontinuation in schizophrenia: A qualitative exploration from a rural South Indian community p. 254
K Shanivaram Reddy, Jagadisha Thirthalli, C Naveen Kumar, N Krishna Reddy, Somashekar Bijjal, NR Renuka Devi, Vikram Singh Rawat
DOI:10.4103/0976-3147.203809  
Background: Medication discontinuation remains a big hurdle for retaining persons with schizophrenia under the treatment AMBIT. It is imperative to understand reasons for the same to effectively tackle it. Methods: The study was carried out in Turuvekere, a rural South Indian taluk (an administrative block). Qualitative interviews were conducted with consenting consecutive nineteen patients (along with their family members) who had discontinued medications. All interviews were transcribed. Enlisted reasons were then color coded to synthesize different factors. From the 16th patient onward, no new reason emerged. Three more interviews were done to ensure that there was no additional reason. Results: The following factors (average 4.26 factors per patient) led to medication discontinuation: (1) lack of support/supervision from family/well-wishers (n = 14/19 [73.68%]); (2) lack of insight and cooperation from the patient (n = 11; [57.89%]); (3) lack of awareness about the illness (8 [42.10%]); (4) adverse effects of medications (n = 8; [42.10%]); (5) financial factors (n = 8; [42.10%]); (6) distance/transport (n = 8; [42.10%]); (7) lack of knowledge about treatment process (n = 7; [36.84%]); (8) perceived lack of beneficial effects of treatment (n = 5; [26.32%]); (9) treatment center-related issues (n = 4; [21.05%]); and others. Conclusions: Medication discontinuation is driven by a diverse set of interrelated factors among community-living persons with schizophrenia. Professionals need to be aware of this complexity to effectively manage the problem.
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REVIEW ARTICLE Top

Psychiatric presentations heralding Hashimoto's encephalopathy: A systematic review and analysis of cases reported in literature p. 261
Vikas Menon, Karthick Subramanian, Jaiganesh Selvapandian Thamizh
DOI:10.4103/jnrp.jnrp_440_16  
Hashimoto's encephalopathy (HE) may often present initially with psychiatric symptoms. These presentations are often variable in clinical aspects, and there has been no systematic analysis of the numerous psychiatric presentations heralding an eventual diagnosis of HE which will guide clinicians to make a correct diagnosis of HE. This systematic review was done to analyze the demographic characteristics, symptom typology, and clinical and treatment variables associated with such forerunner presentations. Electronic databases such as PubMed, ScienceDirect, and Google Scholar databases were searched to identify potential case reports that described initial psychiatric presentations of HE in English language peer-reviewed journals. The generated articles were evaluated and relevant data were extracted using a structured tool. We identified a total of forty articles that described 46 cases. More than half of the total samples (54.4%) were above the age of 50 years at presentation. The most common psychiatric diagnosis heralding HE was acute psychosis (26.1%) followed by depressive disorders (23.9%). Dementia (10.9%) and schizophrenia (2.2%) were uncommon presentations. Antithyroid peroxidase antibodies were elevated in all patients but not antithyroglobulin antibodies. Preexisting hypothyroidism was absent in majority of cases (60.9%). Steroid doses initiated were 500–1000 mg of intravenous methylprednisolone for majority (52.1%) of patients while oral steroid maintenance was required for a significant minority (39.1%). Psychiatric manifestations of HE may be heterogeneous and require a high index of clinical suspicion, especially in older adults. A range of clinical and treatment variables may assist clinicians in making a faster diagnosis and instituting prompt and effective management.
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POINT OF VIEW Top

Dos and Don'ts of venous accidents around the vein of Galen p. 268
Chandramouli Balasubramanian, Bhoresh Dhamija, Luis Rafael Moscote-Salazar, Amit Agrawal
DOI:10.4103/0976-3147.203821  
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IMAGES IN NEUROSCIENCES Top

Characteristic vertebral imaging in sickle cell disease p. 270
Rajaraman Kartikueyan, Siddhartha Roy Chowdhury, Prasad Krishnan, Sayan Das
DOI:10.4103/0976-3147.203816  
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Dentate hyperintensities-The imaging signature of metronidazole induced encephalopathy p. 272
Gaurav Kumar Mittal, Sachin Sureshbabu, Sudhir Peter, Laxmi Khanna
DOI:10.4103/0976-3147.203817  
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CASE REPORTS Top

Metastatic intracranial adenoid cystic carcinoma with unknown primary: Case report and review of literature p. 274
Jitender Chaturvedi, Subas Kanti Konar, Dilip Jethwani, Dwarakanath Srinivas, Anita Mahadevan
DOI:10.4103/0976-3147.203810  
Adenoid cystic carcinoma (ACC) is an epithelial malignancy comprising approximately 8–10% of all salivary gland tumors. Intracranial ACC without a known primary is an extremely rare pathobiological event. Only 13 cases have been reported in available literature. We report a case of a rare intracranial ACC in a 35-year-old gentleman presenting with features of raised intracranial pressure. Patient had a lesion in the right parieto-occipital lobe and underwent gross total decompression. There was no evidence of any primary after a thorough systemic evaluation. In the postoperative period, he showed a good clinical improvement and was recurrence free at follow-up of 18 months. We also discuss and review the existing relevant literature.
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Chiari I malformation associated with turner syndrome p. 277
Kamble Jayaprakash Harsha, Jeevan S Nair
DOI:10.4103/0976-3147.203840  
Turner syndrome (TS) is a rare genetic disease due to the absence of one X chromosome. Patients with TS have more subtle neurological/neuropsychiatric problems, while headache is an uncommon clinical presentation which needs attention. We report a 12-year-old child presenting with typical cough headache. Her magnetic resonance imaging revealed Chiari I malformation associated with TS. To the best of our knowledge, Chiari I malformation associated with TS is not described in literature. We report the first case of TS associated with Chiari I malformation. Interestingly, Chiari I malformation is also associated with Noonan's syndrome, which is a close morphological mimicker of TS, raising the possibility of sharing similar pathogenesis in both conditions.
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Mild encephalitis with a reversible splenial lesion: A clinical benign condition, often underrecognized – Clinical case and literature review p. 281
Sandro Zambito Marsala, Eleonora Antichi, Michele Pistacchi, Manuela Gioulis, Rosa Maria Candeago, Roberta Taranto Montemurro, Manrico Gentile, Paolo D'Andrea, Franco Ferracci
DOI:10.4103/0976-3147.203828  
Mild encephalitis with reversible lesion in the splenium is a clinicoradiological syndrome characterized by a variegated symptomatology with a solitary mass in the central portion of the splenium of the corpus callosum. Complete spontaneous resolution is the hallmark of this syndrome, though its pathogenesis is still unknown. We describe the clinical picture of a 51-year-old woman who developed a partial sensitive seizure, with MRI evidence of a lesion localized in the posterior portion of the corpus callosum. The patient made a full recovery thanks to the administration of antiepileptic drugs. Acquiring knowledge of this syndrome, in the wide diagnostic panel which includes vertebrobasilar diseases besides the broad range of metabolic and electrolyte disorders, is crucial to a prompt clinical diagnosis and in establishing a reliable prognosis at an early stage.
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Cavernous carotid aneurysms: To do or not to do? p. 284
Sudha Menon, R Girish Menon
DOI:10.4103/0976-3147.203831  
Cavernous carotid aneurysms (CCA) pose considerable dilemmas in management. It is still unclear as to whether an asymptomatic CCA should be subjected to treatment. Similarly, the ideal management strategy for a symptomatic aneurysm is controversial. We present the case of a 60-year-old female with a giant CCA and discuss the management issues.
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COMMENTARY Top

Commentary p. 287
Babu G Welch, H Hunt Batjer
DOI:10.4103/jnrp.jnrp_506_16  
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CASE REPORTS Top

Unilateral vision loss without ophthalmoplegia as a rare complication of spinal surgery p. 288
Elif Akpinar, Mehmet Sabri Gürbüz, Gülfidan Bitirgen, Mehmet Özerk Okutan
DOI:10.4103/jnrp.jnrp_470_16  
Postoperative visual loss is an extremely rare complication of nonocular surgery. The most common causes are ischemic optic neuropathy, central retinal artery occlusion, and cerebral ischemia. Acute visual loss after spinal surgery is even rarer. The most important risk factors are long-lasting operations, massive bleedings, fluid overload, hypotension, hypothermia, coagulation disorders, direct trauma, embolism, long-term external ocular pressure, and anemia. Here, we present a case of a 54-year-old male who developed acute visual loss in his left eye after a lumbar instrumentation surgery and was diagnosed with retinal artery occlusion.
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Dilated Virchow–Robin spaces mimicking a brainstem arteriovenous malformation p. 291
Thomas J Buell, Arjun Ramesh, Dale Ding, Daniel M. S. Raper, Ching-Jen Chen, Robert M Starke, Sugoto Mukherjee, R Webster Crowley
DOI:10.4103/0976-3147.203826  
Virchow–Robin spaces (VRS) are ubiquitous and commonly observed as the resolution of magnetic resonance imaging (MRI) continues to improve. The function of VRS and the etiology of their dilation is still a subject of research. Diagnosing dilated VRS (dVRS) can be challenging because they may appear similar to other pathologies such as cystic neoplasms, infectious cysts, and even arteriovenous malformations (AVMs) on certain MRI pulse sequences. We reported a unique case of brainstem dVRS mimicking an AVM. Furthermore, the extensive pontine involvement of our patient's lesion is rarely described in neurosurgical literature. Understanding the imaging characteristics of dVRS is critical to accurately diagnose these lesions and avoid unnecessary tests and procedures.
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Aripiprazole in tardive dyskinesia: Is it a safe choice? p. 294
Nimisha Doval, Soumitra Das, Vikas Moun
DOI:10.4103/jnrp.jnrp_359_16  
Tardive dyskinesia (TD) is a potentially irreversible drug-induced movement disorder associated with prolonged administration of antipsychotics. Conventionally, first generation antipsychotics were the agents thought to have a higher risk of TD as compared to second and third generation antipsychotics. Aripiprazole is a third generation antipsychotic with a novel mechanism of action, and until recently, cases of drug-induced movement disorders were less well known with it. But off late, several cases of TD with aripiprazole have been reported. We present here a case of middle-aged women with preexisting tardive movements, which exacerbated with aripiprazole use and reduced in frequency and intensity on withdrawal of the drug.
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Guillain–Barre syndrome following tuberculosis: A rare association p. 296
Akshay Navalkishor Lakhotia, Dinesh Chouksey, Rahul Jain, Ajoy Kumar Sodani
DOI:10.4103/jnrp.jnrp_387_16  
The co-occurrence of Guillain–Barre syndrome (GBS) and tuberculosis is rare. Even in countries like India, where tuberculosis is common, there is only one case report of co-occurrence of GBS with tuberculosis. We report a case of GBS in association with sputum-positive pulmonary tuberculosis. The earliest treatment with intravenous immunoglobulin in acute motor axonal neuropathy variant of GBS would show good early recovery despite associated pulmonary tuberculosis.
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COMMENTARY Top

Commentary p. 299
Juan Manuel Duarte
DOI:10.4103/jnrp.jnrp_35_17  
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LETTERS TO THE EDITOR Top

R141C mutation of NOTCH3 gene in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy p. 301
Halil Onder, Kemal Kurtcu, Ethem Murat Arsava, Mehmet Akif Topcuoglu
DOI:10.4103/jnrp.jnrp_496_16  
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Moyamoya disease as a cause of stroke in a child with tetralogy of fallot p. 303
Shambhavi , Priyanka Udawat, Sadasivan Sitaraman
DOI:10.4103/jnrp.jnrp_308_16  
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Reversible parkinsonism due to vitamin D toxicity Highly accessed article p. 305
Rudrarpan Chatterjee, Krishnarpan Chatterjee, Chetana Sen
DOI:10.4103/jnrp.jnrp_497_16  
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Extensive restricted diffusion in bilateral hemispheric white matter following diffuse hypoxic injury due to hanging p. 306
K Parameswaran, M Anand
DOI:10.4103/0976-3147.203841  
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Spontaneous complete absorption of a large prolapsed lumbar intervertebral disc with extrusion and cranial migration p. 307
Prasad Krishnan
DOI:10.4103/0976-3147.203839  
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An aberrant presentation of delusional body dysmorphic disorder - importance of early psychiatry liaison p. 309
Harshini Manohar, Vikas Menon
DOI:10.4103/0976-3147.203824  
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Measurement of the optic nerve in a resource-limited setting p. 310
Nicola Rosa, Maddalena De Bernardo
DOI:10.4103/0976-3147.203830  
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Dynamic contrast-enhanced magnetic resonance imaging in diagnosis of cavernous hemangioma of cavernous sinus p. 311
Suprava Naik, Rajendra V Phadke, Arpit Taunk, Vivek Singh, Sanjeev Kumar Bhoi
DOI:10.4103/0976-3147.203832  
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Acute bilateral supranuclear vertical gaze palsy: Vertical one-and-a-one syndrome – Report of three cases p. 313
Rohan R Mahale, Kiran Buddaraju, Anish Mehta, Mahendra Javali, Purushottam Acharya, Rangasetty Srinivasa
DOI:10.4103/jnrp.jnrp_478_16  
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A case of acute paraplegia due to aortic dissection in Marfan syndrome p. 316
B Prakash, R Krishnanand Pai, V Chaitra, P Ramasamy, N Shuba
DOI:10.4103/0976-3147.203825  
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Simultaneous occurrence of deep vein thrombosis and carotid artery thrombosis in antiphospholipid antibody syndrome p. 320
Rohan R Mahale, Anish Mehta, Srinivasa Rangasetty
DOI:10.4103/0976-3147.203827  
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NOTICE OF RETRACTION Top

Retraction: Assessment of intracranial metastases from neuroendocrine tumors/carcinoma p. 322

DOI:10.4103/0976-3147.203854  
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ERRATUM Top

Erratum: Brachial branches of the medial antebrachial cutaneous nerve: A case report with its clinical significance and a short review of the literature p. 323

DOI:10.4103/0976-3147.203853  
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