Journal of Neurosciences in Rural Practice
 
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July-September 2017
Volume 8 | Issue 3
Page Nos. 325-500

Online since Wednesday, June 14, 2017

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EDITORIALS  

Respiratory involvement in Guillain–Barre syndrome: The uncharted road to recovery p. 325
Meenal Garg
DOI:10.4103/jnrp.jnrp_96_17R1  
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Epidermoid cysts of the quadrigeminal cistern: Neuropsychiatric symptoms and management p. 327
Daniel de Araujo Paz
DOI:10.4103/jnrp.jnrp_126_17  
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Hypoparathyroidism should always be checked in papilledema p. 329
Peter Gradisnik
DOI:10.4103/jnrp.jnrp_463_16  
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ORIGINAL ARTICLES Top

Surgically relevant bony anatomical variations in paraclinoid aneurysms-three-dimensional multi-detector row computed tomography-based study p. 330
K Suprasanna, Ashvini Kumar
DOI:10.4103/jnrp.jnrp_416_16  
Objective: To evaluate the proportion of surgically relevant anatomical variations such as caroticoclinoid foramen, interclinoid osseous bridge, and anterior clinoid pneumatization in patients with paraclinoid aneurysms based on computed tomography (CT) cerebral angiography studies. Materials and Methods: Fifty-four CT cerebral angiography studies showing paraclinoid aneurysms involving the cavernous, clinoid, and supraclinoid internal carotid artery (ICA) were retrospectively evaluated. Source images were processed for three-dimensional reconstructions to evaluate the presence and type of caroticoclinoid foramen, interclinoid osseous bridge, and multiplanar reconstructions with bone algorithm to study the type of pneumatization. Results: The study included 30 female and 24 male patients with mean age of 45.61 (10.47) years. Among the 108 sides studied in 54 patients, caroticoclinoid foramen was seen in 24 cases (22.22%), interclinoid osseous bridge was seen unilaterally in 1 case (0.9%), and pneumatization of anterior clinoid process occurred in 12 cases (11.11%). Incomplete caroticoclinoid foramen (11 cases) and Type I pneumatization (7 cases) were seen to be predominant subtypes. There was no statistically significant gender difference in the occurrence of caroticoclinoid foramen and anterior clinoid pneumatization. Seventy-four aneurysms were detected in 54 patients. Based on their location, 46 aneurysms involved supraclinoid ICA, 18 aneurysms in the clinoid segment, and 10 aneurysms in the cavernous segment. Caroticoclinoid foramen was most prevalent in clinoid aneurysms with 12 cases occurring in the clinoid segment. Conclusion: Notable proportions of caroticoclinoid foramen and pneumatization occur in cases of paraclinoid aneurysm. Radiological reports should emphasize on these surgically relevant bony anatomical variations.
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Role of biofilm in cerebrospinal fluid shunt infections: A study at tertiary neurocare center from South India p. 335
Kirtilaxmi K Benachinmardi, R Ravikumar, B Indiradevi
DOI:10.4103/jnrp.jnrp_22_17  
Introduction: Biofilms are the source of persistent infections of many pathogenic microbes. They are responsible for nosocomial infection and also associated with many surgical conditions including indwelling medical devices such as ventriculoperitoneal shunt. A significant problem encountered in shunt procedures is obstruction followed by infection, with infection rate ranging from 2% to 27%, often with poor outcome. Materials and Methods: This study was conducted in the Department of Neuromicrobiology at a tertiary neuroinstitute for 6 months from July 1 to December 31, 2014. The samples comprised cerebrospinal fluid (CSF) from suspected cases of shunt infections. Laboratory diagnosis of causative agent was established by adopting standard procedures. Then, isolates were evaluated for production of biofilm by tissue culture plate (TCP) method and tube method. Results: Of the 1642 shunt CSF samples obtained from neurosurgery, 14.79% were culture positive which yielded 254 isolates. About 51.97% were Gram-negative bacilli (GNB), 46.46% were Gram-positive cocci (GPC), and 1.57% were Candida albicans. Among GNB, nonfermenters were the most common (51.52%) followed by Pseudomonas aeruginosa (15.9%). Among GPC, coagulase-negative Staphylococci were 88.13%, out of which 43.26% were methicillin-resistant. Other GPC were Enterococcus spp. (4.24%), Staphylococcus aureus (5.08%), and Streptococcus spp. (2.54%). Among all isolates, 120 were tested for biofilm production, out of which 57.5% were biofilm producers and 42.5% were nonproducers. Conclusions: TCP was the better method to detect biofilm. Most of the biofilm producers were resistant pathogens.
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Comparison of efficacy of intraoperative indocyanine green videoangiography in clipping of anterior circulation aneurysms with postoperative digital subtraction angiography p. 342
Vikas Kumar, Anita Jagetia, Daljit Singh, Arvind Kumar Srivastava, Monica Sehgal Tandon
DOI:10.4103/jnrp.jnrp_1_17  
Introduction: The aim of this study is to assess the efficacy of intraoperative indocyanine green videoangiography (ICG-VA) using postoperative digital subtraction angiography (DSA) in clipped anterior circulation aneurysms. Materials and Methods: A prospective study was conducted for 1 year which included thirty patients of anterior circulation aneurysm treated by clipping of aneurysm. Intraoperative ICG-VA was performed on all the patients. Postoperative DSA was performed to assess the efficacy of ICG-VA. Results: Intraoperative ICG-VA revealed the occlusion of aneurysm in all the thirty patients. Postoperative DSA revealed aneurysm neck remnant in two patients and demonstrated no branch occlusion. Conclusions: Intraoperative ICG-VA is useful in assessing the completeness of clipping of cerebral aneurysms and ensures patency of branch vessels, thus providing a better postoperative outcome. It replaces the need for invasive postoperative angiographic imaging in a selected group of patients and is also cost effective.
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Depression as a manifestation of obstructive sleep apnea p. 346
Sheikh Shoib, Javid A Malik, Shariq Masoodi
DOI:10.4103/jnrp.jnrp_462_16  
Background: Obstructive sleep apnea (OSA) often results in a wide range of comorbid conditions, predominantly of the cardiovascular/respiratory, endocrine/metabolic, and neuropsychiatric symptoms. In view of the ambiguity of literature regarding the association between OSA and depression, we conducted this study to show any association between the two disorders. Objective: The aim of the study was to see the association between OSA and depression and to study the prevalence of OSA in patients suffering from depression. Methods: We performed polysomnography (PSG) studies of patients that were referred from various subspecialty clinics from July 2011 to August 2013. Psychiatric diagnosis was done using mini international neuropsychiatric interview plus scale. This was followed by application of Hamilton Depression Rating Scale (HAM-D). Standard methods of statistical analysis were used for data analysis. Results: Out of 182 patients who underwent PSG, 47 were suffering from depression with a mean age significantly more (P < 0.001) than that of other population (58.60 years vs. 53.60 years). In our 47 depressed patients, 44 (93.6%) had abnormal PSG. Based on apnea-hypopnea index score, 3 (6.8%) patients had mild, 18 (40.9%) had moderate, and 23 (52.3%) had severe OSA. The mean HAM-D score was significantly more in depression patients, (17. 35 ± 5.45) as compared to non depressive patents (8.64 ± 6.24) (P = 0.0001). Conclusion: This study demonstrates significant overlap between the sleep apnea and depression. Health specialists need more information about screening for patients with OSA to ensure proper diagnosis and treatment of those with the condition. Most of the clinicians do not suspect this important comorbidity of depression in the beginning resulting in delayed diagnosis.
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Cerebral and coronary vasculature in disease associations and dissociations in the South Indian population p. 352
Krishnan Srinivasan, Srinivasan Ravikumar, Sadanandavalli Retnaswami Chandra, Selva Ganapathy, GS Ravi
DOI:10.4103/jnrp.jnrp_31_17  
Introduction: Cerebrovascular accidents constitute the most common cause of disability all over the world. In India prevalence rate is 545 per 100000 and mortality rate is around 7.5 per thousand. Therefore the authors undertook a study on patients who underwent coronary artery bypass surgery (CABG). They were investigated for clinical and/or radiological evidence of cerebrovascular disease (CVD) with the aim to decide on early neurological intervention. Patients and Methods: 210 patients who had undergone CABG were evaluated with neck vessel Doppler using high resolution duplex scanner system and computed tomography (CT) scan as well as MR angiogram (MRA) in addition to assessment of co morbid risk factors. Results: 91% of patients who had undergone CABG had radiological evidence of CVD. The most common risk associated with CAD and CVD was Hypertension (HT), DM, dyslipidemia and combined HT and DM in that order. Neck vessels were normal in 59%. Significant disease was found in only 7.2%. Internal carotids were abnormal in 82%. Infarcts were seen in 82.1%. Discussion: This study reveals patients with CAD have a high degree of asymptomatic CVD. It is mostly due to small vessel disease including internal carotids but not so much with large vessels. Therefore, patients with CAD carry a high risk of vascular cognitive dysfunction. This can be reduced by effective management of the systemic risk factors. Screening for large vessel disease which is commonly done is likely to give a false sense of security. Conclusion: As against western population Indians seem to have small and medium sized vessels disease in the setting of CAD.
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Cognitive and functional outcomes following inpatient rehabilitation in patients with acquired brain injury: A prospective follow-up study p. 357
Maitreyi Patil, Anupam Gupta, Meeka Khanna, Arun B Taly, Amit Soni, J Keshav Kumar, K Thennarasu
DOI:10.4103/jnrp.jnrp_53_17  
Objectives: To study the effects of cognitive retraining and inpatient rehabilitation to study the effects of cognitive retraining and inpatient rehabilitation in patients with acquired brain injury (ABI). Design and Setting: This was a prospective follow-up study in a neurological rehabilitation department of quaternary research hospital. Patients and Methods: Thirty patients with ABI, mean age 36.43 years (standard deviation [SD] 12.6, range 18–60), mean duration of illness 77.87 days (SD 91.78, range 21–300 days) with cognitive, physical, and motor-sensory deficits underwent inpatient rehabilitation for minimum of 14 sessions over a period of 3 weeks. Nineteen patients (63%) reported in the follow-up of minimum 3 months after discharge. Type of ABI, cognitive status (using Montreal Cognitive assessment scale [MoCA] and cognitive Functional Independence Measure [Cog FIM]®), and functional status (motor FIM®) were noted at admission, discharge, and follow-up and scores were compared. Results: Patients received inpatient rehabilitation addressing cognitive and functional impairments. Baseline MoCA, motor FIM, and Cog FIM scores were 15.27 (SD = 7.2, range 3–30), 31.57 (SD = 15.6, range 12–63), and 23.47 (SD = 9.7, range 5–35), respectively. All the parameters improved significantly at the time of discharge (MoCA = 19.6 ± 7.4 range 3–30, motor FIM® = 61.33 ± 18.7 range 12–89, Cog FIM® =27.23 ± 8.10 range 9–35). Patients were discharged with home-based programs. Nineteen patients reported in follow-up and observed to have maintained cognition on MoCA (18.8 ± 6.8 range 6–27), significantly improved (P < 0.01) on Cog FIM® (28.0 ± 7.7 range 14–35) and motor FIM® =72.89 ± 16.2 range 40–96) as compare to discharge scores. Conclusions: Cognitive and functional outcomes improve significantly with dedicated and specialized inpatient rehabilitation in ABI patients, which is sustainable over a period.
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Environmental arsenic contamination and its effect on intelligence quotient of school children in a historic gold mining area Hutti, North Karnataka, India: A pilot study p. 364
R Manju, Amitha M Hegde, Paul Parlees, Anisha Keshan
DOI:10.4103/jnrp.jnrp_501_16  
Context: Arsenic is a rare crystal element that naturally occurs in all environmental media. A combination of regional and site-specific biogeochemical and hydrological factors governs its dispersion in the environment. It has far reaching consequences on human health. Exposure to arsenic in drinking water has been associated with a decline in intellectual function in children. Aim: The aim of this study is to assess the relationship between exposure to arsenic by drinking water and children's intelligence in Karnataka state, India. Settings and Design: Twenty school children of age 10–14 years from Sandur, Bellary, Karnataka, and from Hutti, Raichur, Karnataka, were categorized as control and study group, respectively. Subjects and Methods: Water samples were collected from both the villages for the analysis of arsenic and fluoride levels. Hair and nail samples were collected from the participants, and the arsenic levels were determined. Intelligence quotient (IQ) assessment was done using the Raven's Standard Progressive Matrices. Statistical Analysis Used: Chi-square test, Mann–Whitney U-test, and Fisher's exact test. P< 0.05 was considered statistically significant. Results: There was a significant increase in the arsenic content in the hair and nail samples of children in the study group. The mean IQ tests score in the control group and study group was 30.55 and 17.95, respectively, and this difference was statistically significant. Conclusion: Chronic arsenic exposure could be a possible cause for the reduced IQ scores seen in children residing in Hutti, Raichur District, North Karnataka.
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Prevalence of autism spectrum disorder among rural, urban, and tribal children (1–10 Years of Age) p. 368
Sunil Kumar Raina, Vishav Chander, Ashok K Bhardwaj, Dinesh Kumar, Seema Sharma, Vipasha Kashyap, Mitasha Singh, Amit Bhardwaj
DOI:10.4103/jnrp.jnrp_329_16  
Introduction: Studies on autism spectrum disorders (ASDs) have largely focused on children in specific settings. The current scenario of research in ASDs is limited largely to clinic-based case reports, case series, and retrospective chart reviews. The present study is the first population-based prevalence study conducted across rural, urban, and tribal populations in India. Materials and Methods: A cross-sectional two-phase study was conducted covering children in the age group of 1–10 years of age across geographical regions representing rural, urban, and tribal populations. The first phase (screening phase) involved administration of the Hindi version of the Indian Scale for Assessment of Autism. Those identified as suspected of ASD and 10% of all classified as nonsuspects for autism were also evaluated by the clinical team in second phase (evaluation phase). Results: Forty-three children out of a total of 28,070 children in rural, urban, and tribal area in the age group of 1–10 years were diagnosed as cases of ASD yielding a prevalence of 0.15% (95% confidence interval [CI] =0.15–0.25). Logistic regression analysis showed a two times significantly higher risk of diagnosing ASD in rural area as compared to tribal (odds ratio [OR]; 95% CI = 2.17 [1.04–4.52], P = 0.04). Male sex and upper socioeconomic group of head of family/father had a higher risk of getting diagnosed as autism as compared to lower socioeconomic group (OR; 95% CI - 3.23; 0.24–44.28, P = 0.38). Conclusions: Estimation of true prevalence of ASD in India is going to improve policies on developmental disabilities.
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Reoperation in spinal dysraphism: Does it help in reversing the neurological deficits? p. 375
Praful Suresh Maste, Yadhu Kasetti Lokanath, Shambhulingappa S Mahantshetti
DOI:10.4103/jnrp.jnrp_398_16R5  
Aims: After initial primary repair by inexperienced hands for the spectrum of pathological conditions in spinal dysraphism (SD), a few percentage of patients present with recurrent symptoms and worsening neurological status especially when primarily pathology is not identified and dealt properly. When the primary intradural tethering element is left untouched, worsening of symptoms is common. In this retrospective study, we tried to analyze the symptomatology, functional outcome at 1–2 months after the second surgery and associated complications. Subjects and Methods: All patients underwent second surgery at author's institution. Pre and post-operative data were evaluated using Necker –Enfants Malades (NEM) neurological and modified Hoffer ambulatory scale. Results: The main presenting complaints were bladder incontinence and limb weakness. Preoperative mean scores for motor and bladder were 3.56 and 2.78 out of 5, 2.67 out of 4, and 2.11 out of 3 for bowel and sensory function, respectively. Postoperative mean score for motor, sensory, bladder, and bowel function revealed good neurological improvement. Statistically neurological improvement in bladder and bowel function was significant. More than 60% of patients had normal ambulation at follow-up. Conclusions: Patients presenting with recurrent symptoms in an operated case of SD need to be investigated, cause of recurrence has to be identified, and if needed repeat surgery is recommended at the earliest. Long-standing neurological deficits can potentially improve, especially bladder and bowel function which gives a good quality of life to the patients. Furthermore, we want to stress the fact that since it is an intradural pathology, these cases should be operated by experienced neurosurgeons, and this fact should be made aware among referring doctors.
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Is depression related to low folate levels in people with epilepsy? An observational study and meta-analysis p. 381
Bhargavi Ramanujam, Bhupender Kumar Bajaj, Kirandeep Kaur, Kuljeet Singh Anand, Gurdeep Buxi
DOI:10.4103/jnrp.jnrp_468_16  
Background: Both depression and low serum levels of folate are common in people with epilepsy (PWE), the latter especially in patients on hepatic enzyme-inducing antiepileptic drugs (AEDs). We did a cross-sectional study and a meta-analysis to assess if lower folate levels have any relation with depression in PWE. Materials and Methods: Two hundred and one PWE were recruited and assessed for depression using the Inventory of Depressive Symptomatology-Self-Rated (IDS-SR) and Inventory of Depressive Symptomatology-Clinician Rated; serum folate levels were measured in them at the same time. Literature search was carried out and studies with data on depression as well as folate levels in PWE were included. Statistical analysis to determine frequency of depression, low folate levels, and relation between them among our cases and the pooled data from the included studies was done. Results: Depression was observed in 65.68% and low serum folate (<4 ng/ml) in 48.75% of PWE (over 80% on older AEDs); there was no statistically significant correlation between them. However, on analyzing the pooled data of six studies including the present, the Fisher's z-transformed correlation coefficient was −0.1690 (95% confidence interval [−0.3175, −0.0124], P = 0.0464). Conclusions: Depression and low folate levels are common in PWE. Low folate levels have a mild but significant negative correlation with depression in this population, and folate supplementation would be advisable for those on the older AEDs.
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Single parietal burr-hole craniostomy with irrigation and drainage for unilateral chronic subdural hematoma in young adults <40 years: A rationale behind the procedure p. 389
Raj S Chandran, Milesh Nagar, MS Sharmad, Rajmohan B Prabhakar, Anil K Peethambaran, Shailesh Kumar, Saurabh Sharma, Sourabh K Jain
DOI:10.4103/jnrp.jnrp_64_17  
Background: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. It is mostly a disease of elderly population with very little data about the young patients. There is also the debate regarding treatment strategies. We decided to determine the overall efficacy of the single burr-hole craniostomy (SBHC) for unilateral CSDH in young adults <40 years. Subjects and Methods: We performed a retrospective study of young patients undergoing SBHC for unilateral CSDH between January 2013 and June 2016 at our institution. Medical records were assessed based on patient characteristics in the form of sex of the patient, etiology, presenting symptoms, comorbidities, and signs including Glasgow Coma Scale, computed tomography (CT) brain findings (site and thickness of SDH with midline shift), and intraoperative presence of chronic/subacute component. Results: Mean age of the patient was 33.69 years (range 18–40 years), mean thickness of SDH was 15.47 mm, and mean midline shift was 11.26 mm. 61.54% patients were male, trauma being the most common etiology (92.31%) with most common presenting complaint being headache (90.38% patients). 69.23% patients presented within 1 day of onset of symptoms. On CT scan, most of the patients were having SDH thickness between 11 and 20 mm (67.31%) with midline shift of 6–10 mm (53.85%). Right-sided SDH was present in 53.85%. Intraoperatively, 63.46% patients had subacute SDH whereas 34.61% had chronic component. There were total 2 recurrences (3.85%). Conclusions: Young adults who present with unilateral CSDH usually have a history of trauma. They have shorter duration of symptoms and present mainly with the features of raised intracranial pressure such as headache and vomiting. SBHC with irrigation and drainage has excellent result for unilateral CSDH in young adults compared to other methods of drainage and should be considered treatment of choice unless contraindicated.
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Mental health orientation for self-help group members: A feasibility study p. 395
Basavaraj Shrinivasa, Navaneetham Janardhana, Bergai Parthsarathy Nirmala
DOI:10.4103/jnrp.jnrp_484_16  
Background: Treatment gap for mental health care in low- and middle-income (LAMI) countries is very large, and building workforce using the locally available resources is very much essential in reducing this gap. The current study is a preliminary work toward this direction. Materials and Methods: A single group pre- and post-design was considered for assessing the feasibility of Mental Health Orientation (MHO) Program for Self-Help Group members. Assessment of participants' MHO using Orientation Towards Mental Illness (OMI) scale was undertaken at three levels: baseline assessment before the intervention, after completing 2 days orientation program, and 6 weeks later. Results: Analysis of data resulted in statistically significant mean scores in the domains of areas of causation (F[1.41, 40.7] = 21.7, P< 0.000, ηp2 = 0.428), perception of abnormality (F[1.27, 36.8] = 15.8, P< 0.000, ηp2 = 0.353), treatment (F[1.42, 41.3] = 34.8, P< 0.000, ηp2 = 0.546), and after effect (F[1.36,39.4] = 26.7, P< 0.000, ηp2 = 0.480). Although the overall mean scores of all the domains of OMI were found to be statistically significantly different, there was no significant difference in the mean scores between post and follow-up assessments on areas of causation (μd = 1.27, P = 0.440) and treatment (μd = 1.00, P = 0.156). Conclusion: Overall, the findings of our study demonstrate that brief MHO program can exert a beneficial effect on bringing about significant change in the orientation of the participants toward mental illness but need to be refreshed over time to make the impact of the program stay longer.
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Nonalcoholic Wernicke's encephalopathy: A retrospective study from a tertiary care center in Northern India p. 401
Irfan Ahmad Shah, Ravouf Parvaiz Asimi, Yuman Kawoos, Maqbool Wani, Tahir Saleem, Waqas Nabi Baba
DOI:10.4103/jnrp.jnrp_14_17  
Objective: The objective of this study was to describe the demographic features, clinical presentation, and management and outcome of fifty cases of nonalcoholic Wernicke's encephalopathy from a tertiary care hospital of a region with reported incidence of thiamine deficiency disorders. Materials and Methods: In a retrospective study, fifty adult cases of Wernicke's encephalopathy were analyzed. The diagnosis of Wernicke's encephalopathy was made according to the European federation of neurological societies guidelines 2010. Response to thiamine replacement and associated brain magnetic resonance imaging (MRI) findings were also considered as supportive evidence. Results: The mean age of patients was 50.38 years with 20 males and 30 females. The most common clinical manifestations were alteration in sensorium in 30 (60%), ataxia in 18 (36%), memory impairment in 15 (30%), nystagmus in 35 (70%), ophthalmoparesis in 11 (22%), and seizures in 4 (8%). A total of 42 patients had a history of recurrent vomiting. All patients had polished rice as their staple diet. Thirty-five patients had associated polyneuropathy and 15 had a gastrointestinal disorder. Twenty patients underwent MRI which showed both typical and atypical lesions. Majority of patients showed partial or complete response to intravenous thiamine. On discharge, the most common residual symptoms were lower limb weakness, ataxia, and memory impairment. Conclusion: The study shows high incidence of nonalcoholic Wernicke's encephalopathy in the region with predominant causative factor being a thiamine deficient diet. Recurrent vomiting can be a prominent early symptom of thiamine deficiency and its recognition can help in the early diagnosis of Wernicke's encephalopathy and related thiamine deficiency disorders. Thiamine fortification of food should be done in areas with reported incidence of thiamine deficiency disorders.
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The challenges of management of high-grade gliomas in Nigeria p. 407
Chika Anele Ndubuisi, Wilfred C Mezue, Martin Nzegwu, Okwuoma Okwunodulu, Gabriel Ejembi, Samuel C Ohaegbulam
DOI:10.4103/jnrp.jnrp_18_17  
Background: High-grade gliomas (HGG) are among the most challenging brain tumors despite many research efforts worldwide. Aim: The aim of this study was to evaluate the local challenges that may influence outcome of HGG managed in a neurosurgical center in Nigeria. Methodology: Retrospective analysis of prospectively recorded data of patients managed for intracranial HGG at Memfys Hospital for Neurosurgery, Enugu, Nigeria, between the year 2006 and 2015. Only cases with conclusive histology following surgery were analyzed. Results: Glioma was 60 (23.8%) of 252 histology confirmed brain tumors. HGG represented 53.8% of gliomas with male:female ratio of 2.2:1.0 and peaked from fifth decade of life. Glioblastoma multiforme accounted for 69% of HGG. At 1-year postsurgery, 53% of HGGs were dead and 88% of these deaths were in the World Health Organization Grade IV group. Only 40% of cases could receive adjuvant treatment with only 15% mortality at 1 year in this subgroup that received adjuvant therapy. In addition, 19% of cases had surgery at Karnofsky score (Ks) of ≥70%. However, 94% of mortality at 1 year was related to surgery at Ks of ≤60%. Only four patients had a tumor volume of ≤50 cm3, and among these cases, three patients were independent at 1 year. Patients with tumor volume above 50 cm3 accounted for 94% of mortality. Conclusion: The peak age incidence for HGG seems to be lower than in Caucasians. Most cases present late with poor Ks and big tumor volume. The proportion with access to adjuvant treatment is still poor. Preoperative Karnofsky, extent of resection, duration of hospital, and Intensive Care Unit stay have impact on outcome.
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Pulmonary involvement in patients with Guillain–Barré syndrome in subacute phase p. 412
Meeka Khanna, Nidhi Rawat, Anupam Gupta, Madhu Nagappa, Arun B Taly, MR Rukmani, TN Sathyaprabha, Partha Haldar
DOI:10.4103/jnrp.jnrp_11_17  
Objectives: To evaluate the pulmonary function in Guillain–Barre syndrome (GBS) patients in subacute phase and find clinical correlates of pulmonary dysfunction. Methods: This was a single-center, prospective, cross-sectional, hospital-based study in GBS patients performed in Department of Neurological Rehabilitation at a tertiary care institute. Clinical examination for pulmonary function was done by measuring chest expansion. The pulmonary function tests were carried out by Spirometry kit Microquark Cosmed, Italy. Fatigue was assessed by Fatigue Severity Scale, disability status by Hughes Disability Scale (HDS), and muscle weakness by Medical Research Council sum scores. Statistical Analysis: Statistical analysis was performed by Stata 11. The significance of P value was adjudged against an alpha of 0.05. Results: Twenty-eight patients were included with 17 (61%) men and mean age of 31 years. Median duration of symptoms was 16.5 days. There were 10 (36%) demyelinating and 18 (64%) axonal variants. Twenty-six (93%) patients scored more than 2 on HDS. All study participants reported fatigue. Twenty-two (78.6%) patients had chest expansion of <2.5 cm. Spirometry showed restrictive pulmonary dysfunction in 23 (79%) patients. Significant correlation was found between abnormal pulmonary function test and chest expansion (P = 0.003). Conclusion: Pulmonary dysfunction in GBS is common even during subacute phase. It needs to be identified and managed appropriately for better clinical outcome.
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Adherence to antiepileptic therapy in adults p. 417
Sowmya Chinnaiyan, Sarala Narayana, Venkatarathnamma Puttappa Nanjappa
DOI:10.4103/jnrp.jnrp_392_16  
Context: Epilepsy is a neurological disorder affecting 70 million worldwide. The high incidence of relapse can be attributed to nonadherence, thus increasing the incidence of refractory epilepsy to 10%–20%. Aims: This study was planned to determine rate of adherence and factors affecting adherence using Antiepileptic Adherence Questionnaire and Baseline Adherence Questionnaire. Materials and Methods: A cross-sectional, questionnaire-based study was carried out at a rural hospital from May to September 2015. Patients of either gender aged 18–60 years, diagnosed with epilepsy were interviewed after they consented. Patient details, responses to questionnaires were collected and analyzed using descriptive statistics. Results: Among the participants, 67.8% were males and 32.2% were females with the mean age of 38.3 ± 13.9 years. The response rate was 75% (90/120). The majority were literate (64.4%) and employed (58.9%). The duration of disease was <5 years in most individuals; 50% were highly, 21.1% moderately, and 28.9% nonadherent to treatment. Among the highly adherent, 66.7% never skipped medications because they had knowledge of the disease and treatment. More than 97% were satisfied with the social support, and 89% expressed that their family and friends reminded them to take medications. Patients who were nonadherent to treatment attributed it to the lack of knowledge of the disease (57%) and treatment (96%). Reasons for nonadherence were patients assumed drug was harmful, felt cured of the disease, and wanted to avoid side effects. Conclusion: Nearly, 70% expressed the lack of satisfactory support from the social circle. We observed that nearly seventy percent epileptic patients were moderate-highly adherent. Nonadherence was attributed to patient feeling cured of disease and assuming medications to be harmful. Counseling of patients will help in adherence to treatment.
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REVIEW ARTICLE Top

Neuropsychiatric manifestations of scrub typhus p. 421
Sanjay K Mahajan, Sanyam K Mahajan
DOI:10.4103/jnrp.jnrp_44_17  
Scrub typhus is caused by Orientia tsutsugamushi characterized by focal or disseminated vasculitis and perivasculitis which may involve the lungs, heart, liver, spleen and central nervous system. It was thought to have been eradicated from India. Recently it is being reported from many areas of India. The clinical picture and severity of the symptoms varies widely. The neurological manifestations of scrub typhus are not uncommon but are diverse. Meningoencephalitis is classical manifestation of scrub typhus but cerebellitis, cranial nerve palsies, plexopathy, transverse myelitis, neuroleptic malignant syndrome and Guillan-Barré syndrome are other manifestations reported in literature. The availability of literature on the neurological manifestations of scrub typhus is limited to case reports mainly. This article reviews various neurological manifestations of scrub typhus reported in literature.
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SHORT COMMUNICATIONS Top

Does gender influence electroconvulsive therapy sessions required across psychiatric diagnoses? A 5-year experience from a single center p. 427
Harshini Manohar, Karthick Subramanian, Vikas Menon, Shivanand Kattimani
DOI:10.4103/jnrp.jnrp_482_16  
Context: There is a paucity of systematic data reflecting the practice of electroconvulsive therapy (ECT) from developing countries. Aim: We aimed to identify the number of ECT sessions required to yield response and gender differences in the number of sessions across various diagnostic categories. Setting and Design: A record-based study from a teaching cum tertiary care hospital in South India. Subjects and Methods: Case records of patients who received modified ECT from January 2011 to January 2016 were reviewed. The sociodemographic details and ECT-related data were collected. Psychiatric diagnoses were ascertained as per the International Classification of Diseases, 10th Revision criteria. Statistical Analysis Used: Kruskal–Wallis test and Mann–Whitney U-test. Results: Among 148 patients, 82 (55.4%) had mood disorder (bipolar disorder and recurrent depressive disorder), 43 (29.1%) had schizophrenia, and 22 (14.9%) had other acute and transient psychotic disorders (ATPDs). Patients with mood disorders, schizophrenia, and other ATPD received 7.3 (± 3.8), 9.7 (± 6.1), and 5.4 (± 2.0) ECT sessions, respectively, to achieve response. There was no gender difference in the number of sessions received. Conclusion: Our findings show that number of ECT sessions required to yield response may be disorder-specific. Gender does not influence the ECT dose requirement. Variations in ECT parameters across settings may limit the generalizability of results.
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Whether superficial abdominal reflex is affected by subcostal transverse abdominal incisions? A prospective, observational early experience p. 431
Jitin Bajaj, Anurag Pateriya, Dileep Singh Thakur, Shailendra Ratre, Vijay Parihar, Uday Somashekar, Yad Ram Yadav, Dhananjaya Sharma
DOI:10.4103/jnrp.jnrp_394_16  
Introduction: Superficial abdominal reflex (SAR) is an important part of the neurologic assessment. It is normally present and may be present or absent in various physiological as well as pathological conditions. The presence of an abdominal incision creates a dilemma in the mind of the clinician for it affecting this reflex. As there is no literature on this, we decided to study the effect of abdominal incisions on SAR. Materials and Methods: It was a prospective, observational study. We evaluated the patients requiring transverse subcostal incision (range 3–12 cm) both preoperatively and postoperatively, for their abdominal reflexes. Patients with preoperative normal and symmetrical abdominal reflexes were included in the study. Postoperatively, we compared the change of SAR with the preoperative status and analyzed the data. Results: A total of 94 patients underwent surgeries, out of which 54 patients came under inclusion criteria, comprising 36 males and 18 females. Subcostal transverse abdominal incisions were made for surgeries including both gastrointestinal and ventriculoperitoneal shunts. SAR was found unaffected by the incisions in all patients. Conclusions: Although the study was small, subcostal transverse abdominal incisions were not found to affect SAR.
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CASE SERIES Top

Osteolytic skull lesions–our experience p. 434
BV Sandeep, Manpreet Singh Banga, Suniti Kumar Saha, Kaushik Roy
DOI:10.4103/jnrp.jnrp_243_16  
Objective: To present an overview of varied clinical presentations, investigations and treatment options for Osteolytic skull lesions. Study Design: It is a prospective study. Materials and Methods: We conducted this study from January 2013 to December 2015 in the Department of Neurosurgery, Nil Ratan Sircar Medical College and Hospital, Kolkata. During this period, 14 patients presented with osteolytic skull lesions through the outpatient department. All patients were thoroughly investigated with appropriate hematological and radiological investigations and treated following admission, and surgery was performed in the Neurosurgery Department. All were followed regularly in OPD. Results: Total 14 patients were included in the study. Amongst these 7 were male and 7 female. Age group of patients ranged from 5 to 72 years. Of 14 cases, three cases had dermoid cyst, four cases had metastasis, and one each case had epidermoid cyst, intradiploic meningioma, benign cystic lesion, tuberculosis, histiocytosis X, hemangioma, and osteomyelitis. All underwent diagnostic/therapeutic procedures and referred for Radio or chemotherapy where indicated. Conclusion: All scalp/skull lesions need careful clinical correlation, appropriate radiological investigations to establish diagnosis and subject them to suitable treatment.
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IMAGES IN NEUROSCIENCES Top

Advanced magnetic resonance imaging of glioblastoma multiforme p. 439
Reddy Ravikanth
DOI:10.4103/jnrp.jnrp_423_16  
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Acute disseminated encephalomyelitis presenting as an isolated mesodiencephalic junction lesion p. 441
Kondanath Saifudheen, VV Ashraf, R Praveenkumar
DOI:10.4103/jnrp.jnrp_493_16  
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CASE REPORT Top

Mood disorder as an early presentation of epidermoid of quadrigeminal cistern p. 443
Sujita Kumar Kar, Kuntal Kanti Das, Awadhesh Kumar Jaiswal, Sushila Jaiswal
DOI:10.4103/jnrp.jnrp_507_16  
Intracranial epidermoids are space-occupying lesions of rare variant. Although cerebropontine angle and parasellar region are common sites of occurrence, it has been reported in various other parts of the intracranial cavity. Headache and features of increased intracranial tension are the common clinical manifestation. Report of psychiatric symptoms as the initial presentation of epidermoid is not known in literature except a single case report, which describes mutism to be the manifestation of intracranial epidermoid. We present here the case of a young male, who presented with long depressive episode persisting for 3 years with subsequent switch to mania, which persisted for more than 3 years. An episode of unconsciousness warranted neuroimaging, which revealed a large epidermoid of the quadrigeminal cistern. Surgical resection of the epidermoid was done. Persisting mood symptoms had responded to mood stabilizer and antipsychotic treatment.
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COMMENTARY Top

Commentary p. 446
G Lakshmi Prasad
DOI:10.4103/jnrp.jnrp_132_17  
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CASE REPORTS Top

Late-onset familial amyloidotic polyneuropathy with Bence Jones proteinuria and cardiomyopathy p. 448
Sira Carrasco García de León, Amalia Hernández González, Carmen Orellana Alonso, Laura Burriel Lobo
DOI:10.4103/jnrp.jnrp_498_16  
Familial amyloidotic polyneuropathy is a genetically determined disease characterized by deposition of an anomalous transthyretin. A high index of suspicion is needed for this multisymptomatic and lethal disease to be diagnosed. The patient was a 70-year-old male examined due to hypesthesia in the hands and feet, plus difficulty walking. A neurophysiological study delivered the diagnosis of axonal sensorimotor polyneuropathy. He later developed cardiac symptoms and diarrhea. Urine laboratory analyses revealed a monoclonal spike of light chains (kappa). Biopsies of abdominal fat and bone marrow yielded normal results. The genetic study was compatible with a heterozygous Val30Met-transthyretin mutation. Very few case studies have described an association between familial amyloidotic polyneuropathy and monoclonal gammopathy. We stress that genetic confirmation is important regardless of the type of amyloid deposition revealed by the biopsy.
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Facial diplegia as initial manifestation of acute, myelomonocytic leukemia with isolated trisomy 47, XY,+11[14]/46, XY[6] p. 451
Josef Finsterer, Michael Panny
DOI:10.4103/jnrp.jnrp_410_16  
Bilateral peripheral facial palsy (facial diplegia) has been repeatedly reported as a neurologic manifestation of acute myeloid leukemia but has not been reported as the initial clinical manifestation of myelomonocytic leukemia. A 71-year-old male developed left-sided peripheral facial palsy being interpreted and treated as Bell's palsy. C-reactive protein (CRP) and leukocyte count 4 days later were 2.5 mg/l and 16 G/l, respectively. Steroids were ineffective. Seven days after onset, he developed right-sided peripheral facial palsy. Three days later, CRP and leukocyte count were 234.3 mg/l and 59.5 G/l, respectively. Cerebrospinal fluid investigations revealed pleocytosis (62/3) and elevated protein (54.9 mg/dl). Two days later, pleocytosis and leukocytosis were attributed to myelomonocytic leukemia. Leukemic meningeosis was treated with cytarabine and methotrexate intrathecally. In addition, cytarabine and idarubicin were applied intravenously. Under this regimen, facial diplegia gradually improved. Facial diplegia may be the initial clinical manifestation of myelomonocytic leukemia, facial diplegia obligatorily requires lumbar puncture, and unilateral peripheral facial palsy is not always Bell's palsy. Patients with alleged unilateral Bell's palsy and slightly elevated leukocytes require close follow-up and more extensive investigations than patients without abnormal blood tests.
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Junctional chiasmatic syndrome due to large anterior communicating artery aneurysm p. 455
Maruthi Kesani, Pavan Kumar Pelluru, Suchanda Bhattacharjee, Rajesh Alugolu, AK Purohit
DOI:10.4103/jnrp.jnrp_512_16  
Even though aneurysm involving the anterior communicating artery (A Com A) was common in clinical practice, producing compressive symptoms such as visual loss was rare. We report a case, in which patient had gradually progressive visual loss with features of the junctional chiasmatic syndrome, imaging revealed partially thrombosed large A Com A aneurysm. Intraoperatively, aneurysm was found compressing the optic chiasm and right optic nerve, following clipping and decompression of the optic nerve and chiasm there was gradually improvement in the vision over 2 weeks postoperatively.
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Symptomatic vertebral hemangioma in a young child p. 458
William Martin, Ravi Rajmohan, Muhittin Belirgen
DOI:10.4103/jnrp.jnrp_324_16  
Vertebral hemangiomas (VHs) are the most common benign vertebral neoplasm and typically are asymptomatic, only to be discovered incidentally on imaging from the fourth to fifth decade of life. Seldom do they enlarge to a point of compression, causing pain and focal neurologic deficits. We present the rare case of an 8-year-old female who presented with paraparesis after a fall. Imaging revealed a pathological fracture of the T8 vertebra with retropulsion and spinal cord compression from both fracture and epidural tumor tissue. The patient underwent an anterior and posterior removal of the tumor, decompression, and fusion. Pathological report of specimen biopsy confirmed a benign hemangioma. To the best of our knowledge, this is the same age as the youngest previously reported case of symptomatic VH and it is the longest to be recurrence-free at follow-up. The hemangioma was successfully treated with tumor removal, decompression, and fusion. No adjuvant treatment was required, and she remained asymptomatic without recurrence at her 4-year follow-up.
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Delayed facial palsy after microvascular decompression: Report of two cases p. 461
G Lakshmi Prasad, Vinod Kumar, Girish Menon
DOI:10.4103/jnrp.jnrp_429_16  
Microvascular decompression (MVD) is a novel surgical procedure predominantly performed for treating trigeminal neuralgia (TN) and hemifacial spasm (HS). Multiple studies have proven the long-term success of MVD for both these conditions. The most common complications of MVD reported include chemical meningitis, facial hypesthesia, cerebrospinal fluid leak, facial paresis, and hearing loss. Delayed facial palsy (DFP) is an uncommon complication mostly noted in MVD for HS and after the removal of acoustic tumors. We report two cases of DFP occurring after performing MVD, one each for HS and TN. This is also the first case of DFP to be reported after MVD for TN. Both were young females who developed DFP 2 weeks after surgery. They were managed with oral steroids and acyclovir for 2–3 weeks and achieved excellent outcome at an average of 4.5 weeks from the onset. We conclude that although majority of the cases improve spontaneously, steroids and acyclovir might assist in faster recovery.
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Isolated intracranial myeloid sarcoma occurring as relapse in acute myeloid leukemia p. 466
Geetha Narayanan, Lali V Soman, Lakshmi Haridas, Harish Sugathan
DOI:10.4103/jnrp.jnrp_376_16  
Myeloid sarcoma (MS) or chloroma is a rare extramedullary tumor composed of extramedullary proliferation of blasts of granulocytic, monocytic, erythroid, or megakaryocytic lineage occurring at sites outside the bone marrow. MS occurs in 2%–8% of patients with acute myeloid leukemia (AML), sometimes it occurs as the presenting manifestation of relapse in a patient in remission. We describe the case of a young male with AML in remission for 6 years presenting with central nervous system symptoms. Magnetic resonance imaging showed an extra-axial altered intensity lesion in the parasagittal parietal region, infiltrating anterosuperiorly into anterior falx, and posterosuperior aspect of the superior sagittal sinus. A biopsy from the lesion was diagnostic of MS which was positive for myeloperoxidase. He did not have any other sites of disease. He has received chemotherapy with FLAG ( Fludarabine, Cytosine arabinoside) followed by cranial irradiation and is in complete remission.
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Predicting prognosis of psychosis in Huntington's disease: Case report and review of literature p. 469
Sujita Kumar Kar, Mohit Kumar Shahi, Adarsh Tripathi, Praveen Kumar Sharma
DOI:10.4103/jnrp.jnrp_453_16  
Huntington's disease (HD) is rare variant of progressive neurodegenerative disorder which follows an autosomal dominant pattern. Psychiatric comorbidities are not uncommon with HD. Mood disorder, cognitive disturbances, anxiety disorders, and psychosis are the psychiatric comorbidities reported with HD. We report here a case of HD, where psychosis developed during illness. Prognosis of psychosis in HD is emphasized in this report with review of literature.
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Primary paraspinal hydatidosis causing acute paraplegia p. 472
Srihari Sridharan, GS Jagan Narayana, Kalyanasundarabharathi Chidambaram, Anand Prasath Jayachandiran
DOI:10.4103/jnrp.jnrp_513_16  
The zoonotic infection hydatidosis is caused by the tapeworm cestode, Echinococcus granulosus. Though considered endemic in India where association of humans with sheep and dogs form part of the livelihood, primary skeletal muscle involvement of the disease is an extremely rare event. We report a case of primary paraspinal hydatidosis with extradural extension causing acute paraplegia. Excision of the cyst and decompression of the cord was done along with albendazole therapy. Paraspinal hydatid disease is a rare entity, and in regions where hydatid disease is endemic, it can be involved in the differential diagnosis of acute compressive myelopathy. Although antihelminthic chemotherapy forms the mainstay of the treatment, surgical intervention forms a major part of the management.
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Guillain–Barre syndrome in postpartum period: Rehabilitation issues and outcome – Three case reports p. 475
Anupam Gupta, Maitreyi Patil, Meeka Khanna, Rashmi Krishnan, Arun B Taly
DOI:10.4103/jnrp.jnrp_474_16  
We report three females who developed Guillain–Barre Syndrome in postpartum period (within 6 weeks of delivery) and were admitted in the Neurological Rehabilitation Department for rehabilitation after the initial diagnosis and treatment in the Department of Neurology. The first case, axonal variant (acute motor axonal neuropathy [AMAN]) had worst presentation at the time of admission, recovered well by the time of discharge. The second case, acute motor sensory axonal neuropathy variant and the third case, AMAN variant presented at the late postpartum period. Medical treatment was sought much later due to various reasons and both the patients had an incomplete recovery at discharge. Apart from their presentations, rehabilitation management is also discussed in some detail.
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LETTERS TO THE EDITOR Top

Medicine revisited: Safeguard yourself against “oblivious to the obvious” p. 478
Sachin A Adukia, Gopal Krishna Dash
DOI:10.4103/jnrp.jnrp_485_16  
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Cerebellar cystic oligodendroglioma in a young adult p. 479
Mukesh Kumar Bhaskar, Manish Jaiswal, Balakrishna Ojha, Mukta Meel, Arshinagere Huliyappa Harsha
DOI:10.4103/jnrp.jnrp_436_16  
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Anterior pituitary hormonal disturbances in patients suffering with traumatic brain injury p. 481
Guru Dutta Satyarthee, Kanwaljit Garg
DOI:10.4103/jnrp.jnrp_438_16  
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Venous air embolism during removal of bony spur in a child of split cord malformation p. 483
Narender Kaloria, Hemant Bhagat, Navneet Singla
DOI:10.4103/jnrp.jnrp_508_16  
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Using of open biopsy microseparator in the fresh cadaveric cow brain for the evaluation of clinical usability p. 485
Cengiz Cokluk
DOI:10.4103/jnrp.jnrp_509_16  
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Afebrile seizures as initial symptom of hypocalcemia secondary to hypoparathyroidism p. 486
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/jnrp.jnrp_510_16  
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Headache, facial palsy, and diplopia: An unusual presentation of ruptured distal anterior cerebral artery aneurysm p. 487
Sushant Sahoo, Chhitij Srivastava
DOI:10.4103/jnrp.jnrp_467_16  
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Photosensitive posthypoxic reflex myoclonus in a postcardiac arrest individual: An interesting finding p. 489
Rohan R Mahale, Anish Mehta, R Srinivasa
DOI:10.4103/jnrp.jnrp_13_17  
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Paraganglioma of the filum terminale: An extremely uncommon neuroendocrine neoplasm located in spine p. 490
Guru Dutta Satyarthee, Kanwaljit Garg, Sachin A Borkar
DOI:10.4103/jnrp.jnrp_477_16  
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Suboccipital extraspinal extracranial atypical teratoid rhabdoid tumor p. 494
YR Karthikeyan, Ashok Gupta, Tarun Varshney, Amit Pratap Singh Deora
DOI:10.4103/jnrp.jnrp_388_16  
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How to improve adherence to medication and follow-up in chronic mental illnesses: Stakeholder views p. 496
Kaliaperumal Mathan, Siddharth Sarkar, Shivanand Kattimani, Arun Kumar Vivek, V Muthukrishnan, P Venkatlakshmi
DOI:10.4103/jnrp.jnrp_289_16  
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Pontine hemorrhage causing bilateral hypertrophic olivary degeneration p. 498
Suprava Naik, Rajendra V Phadke, Vivek Agarwal, Vivek Singh, Sanjeev Kumar Bhoi
DOI:10.4103/jnrp.jnrp_303_16  
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