Journal of Neurosciences in Rural Practice
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   Table of Contents - Current issue
October-December 2018
Volume 9 | Issue 4
Page Nos. 453-659

Online since Wednesday, August 29, 2018

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Stroke: A neglected epidemic in India Highly accessed article p. 453
Rajesh Verma
DOI:10.4103/jnrp.jnrp_193_18  PMID:30271031
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A brief review of giant occipital encephalocele Highly accessed article p. 455
Rajendra Kumar Ghritlaharey
DOI:10.4103/jnrp.jnrp_189_18  PMID:30271032
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Impact on cognitive improvement following burr hole evacuation of chronic subdural hematoma: A prospective observational study p. 457
Maneet Gill, Vikas Maheshwari, Amit Narang, TS Lingaraju
DOI:10.4103/jnrp.jnrp_126_18  PMID:30271033
Objective: Patients of Chronic subdural haematoma can present with only subtle cognitive impairment without any motor deficit. It is hence imperative for the treating clinician to be aware of this entity. The aim of the study was to identify any statistically significant improvement of cognitive functions following burr hole evacuation of Chronic SDH especially in the elderly patients. Methods and Material: A Prospective observational study of 30 patients of CSDH, from Jan 2015 to Dec 2016 was done at a tertiary level Armed Forces Hospital.The study had 23 male, 07 female, with age ranging from 7-85 years. The cognitive function of each patient was assessed at admission and 24 hours after surgery by MMSE. Radiological confirmation was done by CT head. Standard two burr holes were made and hematoma evacuated. The clinical, cognitive assessment and radiological data were collected and analysed. Results: There was no statistical significance preoperatively between age and pre operative cognitive impairment, headache, hemiparesis, dysarthria (p>0.05). We however found a statistically significant improvement postoperatively in cognitive impairment, headache ( p= 0.00),motor deficit (p=0.01) and dysarthria (p=0.046). Conclusion: The clinical features of dementia and other neurodegenerative disorders simulate CSDH in the geriatric population. These patients should have early neuroimaging and prompt surgical intervention to alleviate cognitive deficits.
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Assessment of utilization of rehabilitation services among stroke survivors p. 461
Chandel Mahak, Shashi , Yashomati , Hemlata , Nagi Manisha, Ghai Sandhya, Khurana Dheeraj, Manju Dhandapani, SS Dhandapani
DOI:10.4103/jnrp.jnrp_25_18  PMID:30271034
Background: Rehabilitation is probably one of the most important phases of recovery for many stroke survivors. The current study was conducted with the objective to assess the utilization of rehabilitation services and factors affecting nonutilization of rehabilitation services among the stroke survivors. Materials and Methods: The current study was carried out in the Neuro Outpatient Department of a tertiary care hospital in India. It was a descriptive study. Consecutive 55 stroke survivors who had met the inclusion and exclusion criteria were recruited in this study. Self-structured rehabilitation tool was used to collect the data. Results: Data were analyzed using the descriptive and inferential statistics. Majority of the patients comprised 70.9% of males and 29.1% of females. Among participants, 70.90% were aware about rehabilitation, 67% were utilizing rehabilitation services, whereas 33% were not utilizing rehabilitation services. In the current study, certain reasons were found behind not utilizing rehabilitation services. There were 83.3% of participants who had lack of awareness about rehabilitation services and 61.1% of participants who had no availability of rehabilitation services. Only 45.5% of rural inhabitants were utilizing rehabilitation services as compared to 81.2% of urban inhabitants and 83.23% of suburban inhabitants. Conclusion: Rehabilitation is of utmost importance. Hemiparesis, difficulty in performing activity of daily living, difficulty in performing social activities, and difficulty in reasoning were the most common problems faced by people suffering stroke after discharge from the hospital. There was lack of awareness and utilization of rehabilitation services by patients among Indian stroke population. Hence, health workers have an immense role in educating, motivating, and ensuring that rehabilitation services in rural inhabitants.
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Profile of patients from a neurology registry in resource-poor rural Northwest India p. 468
Amit Bhardwaj, Ashish Sharma, Girish Kumar, Monika Angra, Sapna S Bhardwaj, Sunil Kumar Raina, Sushant Sharma, Piyush Sharma
DOI:10.4103/jnrp.jnrp_550_17  PMID:30271035
Background: The neurology register is based in a tertiary care center in a rural north-west India. The center caters to a predominantly rural population. The present study is based on the data retrieved from this registry over a period of 1 year. Materials and Methods: Details of the patients reporting to the Department of Neurology are entered in a registry. For the purpose of this study, 1-year data (from August 1, 2013, to July 31, 2014) of patients (with complete information and final diagnosis) were analyzed. Results: Out of a total of 2431 patients, 1296 (53.3%) were males and 1135 (46.7%) were females. The six major neurological disorders identified were epilepsy and seizures, headache, spondolysis with neurological manifestations, cerebrovascular disease, Parkinsonism, and neuropathies. Conclusion: Six neurological disorders account for more than two-thirds of the patients with neurological disorders, whereas epilepsy, seizures, and headache together constituted more than one-third.
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Perception and attitude toward mental illness in antenatal mothers in rural population of Southern India: A cross-sectional study p. 473
Shivani Manjrekar, Sandeep Patil
DOI:10.4103/jnrp.jnrp_535_17  PMID:30271036
Background: Mental health disorders globally are on a rise due to various reasons. Gender differences have been one of the reasons. Pregnancy is a stressful event in mothers and it can either exacerbate preexisting mental illness or can give rise to other mental health disorders. Studies have shown that women residing in rural areas are at higher risk of developing mental health problems. Mental health problems have detrimental effects in post-partum period. Most of the complications can be prevented if psychiatric symptoms are detected in early part of pregnancy and if women are aware of these symptoms. Aim: To find the awareness, attitude and perception towards mental illness in antenatal mothers residing in rural area of India. Setting and Design: It's a descriptive cross sectional study conducted at primary health care centers. Methods and Materials: Total of 300 antenatal mothers attending primary health care centers were recruited into the study after a written informed consent was obtained. Statistical Analysis: Basic socio demographic data were collected and a semi structured questionnaire was designed. The participants were interviewed according to the questionnaire. Data collected was analyzed using SPSS software. Results and Conclusion: The mean age of the study participants was 24+5. Of the 300 study participants more than 90% were unaware that mental illness can occur during pregnancy and only around 07% could agree say that it can occur in pregnancy. There is poor awareness of mental health problems amongst pregnant women residing in rural part of southern India. The reasons for the same are lack of awareness, low levels of education, lower socio economic status, cultural beliefs and practices, lack of mental health services and stigma associated with mental illness. There is no routine screening for mental health problems during antenatal visits. If done otherwise could bring down adverse maternal outcome.
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The effect of statins in epilepsy: A systematic review p. 478
Loraine De Jesús Quintana-Pájaro, Yancarlos Ramos-Villegas, Eileen Cortecero-Sabalza, Andrei F Joaquim, Amit Agrawal, Alexis Rafael Narvaez-Rojas, Luis Rafael Moscote-Salazar
DOI:10.4103/jnrp.jnrp_110_18  PMID:30271037
Background and Objectives: Statins are inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, used for the management of hypercholesterolemia and related atherosclerotic diseases. Several studies have indicated the neuroprotective effects of statins on several neuropathological conditions. However, the role of these medications in epilepsy is still unclear. The purpose is to evaluate and summarize the level of evidence on the efficacy of statins in neuronal hyperexcitability and the neuroinflammatory processes of epilepsy. Methods: A systematic review was performed. Eligibility Criteria: This review involved studies conducted in humans and nonhuman experimental models, covering the use of an inhibitor of HMG-CoA reductase, alone or accompanied by another medication, in epilepsy. Information Sources: A systematic literature search was performed in PubMed, Embase, Ebsco Host, Scopus, Science Direct, Medline, and LILACS. Risk of Bias: It was evaluated with the Newcastle–Ottawa Scale and the experimental studies were evaluated using the GRADE tool. Results: Twenty articles of the 183 evaluated were included. Sixteen studies were conducted in animal models and four studies in humans. Most studies in mice reported a reduction in epileptiform activity and reduction in systemic inflammation with the treatment of statins, potentially influencing epilepsy control. Few studies in humans were performed in the geriatric population with variable results (neuroinflammation, seizure prevention, cell death, prevention of kindling, increase in convulsive threshold, increase in latency, decrease in frequency of crisis, and reduction in mortality) related to reduction in the rate of hospitalizations, mortality, and prevention of epilepsy. Studies in mice found a decrease in interleukin-1β (IL-1β), IL-6, and tumor necrosis factor alpha and an increase in IL-10 and endothelial nitric oxide synthase. Conclusions: The possible antiepileptic mechanism of statins may be related to the reduction in neuroinflammation mediated by a decrease in pro-inflammatory cytokines and action in the nitrergic system. Further studies evaluating the impact of statins on seizure control are necessary.
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Sociodemographic profile, semiology, and etiology of patients with status epilepticus: A study from a tertiary care hospital in North India p. 487
Wasim Qadir, Khurshid Ahmad Wani, Bilal Ahmad Bhat
DOI:10.4103/jnrp.jnrp_102_18  PMID:30271038
Background and Objectives: Despite advance in treatment of status epilepticus (SE), a major neurological emergency, it is still associated with mortality and morbidity. The objective of our study was to estimate sociodemographic profile, semiology, and etiology in the children with SE admitted in pediatric intensive care. Materials and Methods: Children between 1 month and 18 years with continuous seizure activity of >5 min or two or more sequential seizures without full recovery of consciousness between seizures, admitted in the Pediatric Intensive Care Unit of the Department of Pediatrics, Government Medical College, Srinagar, were included in the study. A semi-structured tool was designed to record the sociodemographic details. Detailed history, clinical examination, and investigations (including neuroimaging as and when needed) were used to determine the type of seizure and etiology. Results: A total of 51 patients were included in our study. Most of the patients were <5 years with 47.10% in 1–5 years' age group and 43.10% in >1-year age group. Males (60.80%) outnumbered females. Thirty-nine patients (76.47%) belonged to “known” or “symptomatic” group with 35 (68.60%) of them presenting with SE as their fresh seizure. Thirty-nine (76.47%) of our patients had generalized tonic–clonic seizure (GTCS) type of SE. Conclusion: Most of the children (90%) were below the age of 5 years with male predominance. Most of the patients had SE as their first seizure without prior history of seizures with GTCSs was the most frequent seizure type.
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A short weight loss intervention in a neurosurgical subspecialist clinical setting p. 492
Cara L Sedney, Treah Haggerty, RN Patricia Dekeseredy
DOI:10.4103/jnrp.jnrp_2_18  PMID:30271039
Context: The relationship between back pain and obesity is well characterized; therefore, the neurosurgical consultant visit for back pain may be a key interventional opportunity for weight loss. Aims: The aim of this project was to evaluate efficacy of an educational intervention for back pain. Methods: A retrospective study was undertaken to evaluate effectiveness of an educational intervention (Show patient's own MRI, Explain degenerative disc disease, Relate to weight issues, Reference other weight-related comorbidities, and Encourage a plan of action for weight loss [SERRE]). This has been performed since 2014 for patients presenting to the first author's neurosurgical spine clinic with nonsurgical back pain and body mass index (BMI) over 35. Results: The average BMI was 50.7. Fifty-five percent of patients had additional weight-related comorbidities. After SERRE intervention, 82% of patients were open to weight loss interventions. However, only 22% of patients went on to follow-up with a formal weight management program and only 9% of patients went on to have a documented weight loss. The lack of success was largely attributed to social issues and severe medical comorbidities within the specific population. Conclusions: Incorporation of patient education regarding the relationship of weight loss to back pain and other weight-related comorbidities is well received in a rural specialist consultation setting. Improved communication with primary care physicians regarding this message and further supportive actions may improve follow-through, and therefore success of ultimate weight loss interventions.
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Lipoprotein-Associated phospholipase A2 is linked with poor cardio-metabolic profile in patients with ischemic stroke: A study of effects of statins p. 496
Hayder M Alkuraishy, Ali I Al-Gareeb, Huda J Waheed
DOI:10.4103/jnrp.jnrp_97_18  PMID:30271040
Objectives: The objective of the study is to investigate the effects of statins on the lipoprotein-associated phospholipase A2 (Lp-PLA2) mass in patients with ischemic stroke. Materials and Methods: A total number of 59 patient ages 43–69 years with cerebral stroke compared to 39 healthy controls that matching the age and body weight. The patients were divided into 32 patients on statins therapy assigned as statins users and 27 patients, not on statins therapy assigned as nonstatins users. Anthropometric and biochemical measurements were done including lipid profile and inflammatory biomarkers. Results: Stroke patients on statins therapy showed a comparable low of Lp-PLA (29.82 ± 3.19 IU/mL) to nonstatins user stroke patients (15.58 ± 5.73 IU/mL). Lp-PLA2 mass levels were positively correlated with body mass index, blood pressure changes, total cholesterol, triglyceride, and very low-density lipoprotein and stroke risk (SR) percentage. Conclusions: Patients on statins with ischemic stroke had low levels of Lp-PLA2 mass levels compared to nonstatins user with ischemic stroke. Lp-PLA2 mass levels were higher in men than women and correlated with lipid profile and SR in patients with ischemic stroke.
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Acute hemiplegia in children: A prospective study of etiology, clinical presentation, and outcome from Western India p. 504
Vasant Chinnabhandar, Amitabh Singh, Anirban Mandal, BJ Parmar
DOI:10.4103/jnrp.jnrp_574_17  PMID:30271041
Background: Hemiplegia/hemiparesis denotes the weakness of one side of the body. In contrast to adults, hemiparesis in children occurs secondary to a variety of etiological conditions. Aims: The aim of this study was to assess the clinical, laboratory, and radiological features of children with acquired hemiparesis/hemiplegia of nontraumatic origin and intended to find its underlying etiology in the Indian children. Settings and Design: This prospective, observational study was carried out at a tertiary care hospital in western India. Materials and Methods: Children aged between 3 months and 14 years admitted to the in-patient department of a tertiary care hospital with acquired hemiparesis/hemiplegia were included over 2 years. Children with perinatal insult, preexisting neurological diseases, neurotrauma, hemiplegic migraine, and Todd's paralysis were excluded from the study. Detailed clinical examination, laboratory, and radiological investigations were done, and an attempt was made to find the underlying etiology. These children were also followed up after 1 month of discharge to look at short-term outcomes. All clinical information was recorded in a predesigned performa and was managed with Microsoft Excel spreadsheet. Frequency was presented as number (N) and percentage (%). Results: Fifty-five children (male:female = 1.2:1), predominantly between 1 and 5 years of age were studied. Apart from weakness (92.8%), vomiting (70.9%), fever (58.2%), and seizure (58.2%) were the predominant presenting complaints. One-fifth of them had comorbidities; most commonly congenital heart disease. Cerebral infarction was the most common pathology in neuroimaging. Central nervous system infection (45.5%) was the most common identified etiology followed by vascular events (21.8%). Among those who could be followed up at 1 month, about 65% had some improvement in their power. Conclusion: Infections continue to be an important cause of neurodisability in the developing countries.
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Preliminary results of the macedonian-adapted version of ages and stages developmental questionnaires Highly accessed article p. 510
Blagica Stanoevska, Luis Anunciação, Jane Squires, Ajay Singh, Vladimir Trajkovski
DOI:10.4103/jnrp.jnrp_61_18  PMID:30271042
Context: Early detection of developmental problems is critical, and interventions are more effective when they are carried out early in a child's life. In Macedonia, there are only four centers providing early intervention services. Aims: In this research, we determined the reliability of the translation and adaptation of Ages and Stages Questionnaires 3rd edition (ASQ-3-M) for assessment of children aged 3–5 years old in Macedonia, and reported preliminary results of the gender differences in the development. Materials and Methods: ASQ-3-M was completed by 165 parents and 40 educators in seven kindergarten classrooms. Children were 3–5 years old. Statistical Analysis Used: Cronbach's alpha, Intraclass Correlation coefficient (ICC), and interrater reliability (IRR) were used to assess ASQ-3-M psychometric properties. The Bayesian t-test was performed to estimate the difference in means between males and females. Results: The Cronbach's alpha ranged from 0.65 to 0.87. The overall ICC was 0.89 (ranged from 0.8 to 0.95), which indicates a strong to almost perfect strength of agreement between test-retest. IRR correlation revealed an average of 0.88 (ranged from 0.74 to 0.95), suggesting that ASQ-3-M is reliable and stable. Conclusions: The results from the comparison between males and females on all dimensions of ASQ-3-M were not statistically significant (BF10 <3), indicating no significant gender difference. That said, the ASQ-3 is recommended for routine use in screening children aged 3–5 years old.
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Astrocytic tumors in Mexico: An overview of characteristics and prognosis in an open reference center for low-income population p. 516
Jesús Quetzalcoatl Beltrán,, Julian Eduardo Soto-Abraham, Jorge Vidaurreta-Serrano, Laura Graciela Chavez Macias, Erick Gómez Apo, Elizabeth Ogando-Rivas
DOI:10.4103/jnrp.jnrp_106_18  PMID:30271043
Objective: The authors aimed to analyze the current epidemiology of high- and low-grade gliomas, follow-up strategies, and prognosis in a national reference center of a developing country. Materials and Methods: Medical records of patients diagnosed with intracranial gliomas from January 2012 to January 2016 were reviewed. Data were classified by age, symptoms, Karnofsky functional scale (KFS), tumor location, extent of resection (EOR), histopathology, hospital stay, Glasgow outcome scale (GOS), adjuvant treatments, overall survival (OS), and mortality. Results: Astrocytomas accounted for 28.2% of the intracranial tumors and 53.5% were male. Headache was the most common symptom, while sensory disturbance was the least frequent. The right cerebral hemisphere was involved in 56.5% of cases and frontal lobe in 31.3%. Gross total resection (GTR) was achieved in 18.1% cases, 35.3% subtotal resection, and 46.4% biopsy. Regarding the astrocytomas, 43.3% were low grade and 56.4% high grade. Low-grade tumors had the highest frequency in the fourth decade of life, while Grade III and IV in the fifth and seventh decades of life, respectively. In high-grade lesions, there was a slight male predominance (~1.4:1). The initial KFS was regularly 80 for low-grade gliomas and 60 for high-grade. By 1-month postdischarge, the score decreased by 10 points. About half of the patients (47.5%) received adjuvant therapy after surgery. From the Glasgow Outcome Scale (GOS), the majority had a form of disability and 30-month OS was above 88% for Grade I-II and 0% for Grade III and IV. Conclusions: Astrocytic tumors were the most frequently noted intra-axial tumors. Age, histological grade, and EOR are important prognostic factors. These results are similar to other reports; however, increased variability was noted when treatment-related factors were considered. Additional studies are necessary to identify the factors related to these treatment results. Highlights:
  • There are no data describing the basic epidemiology and prognosis of high-grade and low-grade gliomas in Mexico.
  • Intracranial astrocytomas account for 28.2% tumors in our institution.
  • Age, histological grade, and EOR are important prognostic factors.
  • Poor overall survival was achieved in our target population.
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Depressive and anxiety symptoms in relatives of intensive care unit patients and the perceived need for support p. 522
Maria Bolosi, Vaios Peritogiannis, Petros Tzimas, Athanasios Margaritis, Konstantinos Milios, Dimitrios V Rizos
DOI:10.4103/jnrp.jnrp_112_18  PMID:30271044
Background: Admission of a patient in the Intensive Care Unit (ICU) and the recovery process may be stressful for family members. Objectives: This study aimed to explore the families' psychological symptoms and their evolution over the 1st week of patients' ICU stay. Additional objectives were the estimation of the families' need for support and the estimation of satisfaction regarding the information provided by ICU physicians. Methods: A total of 108 individuals were participated in the study. Participants were interviewed with the Hamilton Anxiety Rating Scale and filled the Beck Depression Scale II on days 1 and 7 of patients' ICU admission. They also filled a self-reported questionnaire which was created by the investigators, involving decision-making procedures; the satisfaction of the families of the patients' care; and the support of the families by medical and nursing staff. Results: Anxiety levels were not significantly different among 2-time points, whereas rates of depressive symptoms raised significantly from 38% (day 1) to 58.3% (day 7). In cases of anxiety changes, age, education, closeness of relationship, and APACHE II score were the factors been associated. Changes in depressive symptoms were not associated with any of those factors. Over a week, there were significant differences in relatives' views on participating in the decision-making procedure, and on expressing their opinion and concerns regarding the treatment process. Their attitudes about receiving support by the ICU personnel and even by mental health specialists, such as psychologists also changed. Conclusions: Over the 1st week of ICU admission, depressive symptoms in patients' relatives were gradually evolving, while anxiety symptoms fluctuated and they were affected by the severity of the patients' condition. Attitudes toward treatment procedures and the perceived need for support also changed. These findings should be taken into account by the ICU personnel.
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Association between indoor air pollution and cognitive impairment among adults in rural Puducherry, South India p. 529
Yuvaraj Krishnamoorthy, Gokul Sarveswaran, K Sivaranjini, Manikandanesan Sakthivel, Marie Gilbert Majella, S Ganesh Kumar
DOI:10.4103/jnrp.jnrp_123_18  PMID:30271045
Background: Recent evidences showed that outdoor air pollution had significant influence on cognitive functioning of adults. However, little is known regarding the association of indoor air pollution with cognitive dysfunction. Hence, the current study was done to assess the association between indoor air pollution and cognitive impairment among adults in rural Puducherry. Methodology: A community-based cross-sectional study was done among 295 adults residing in rural field practice area of tertiary care institute in Puducherry during February and March 2018. Information regarding sociodemographic profile and household was collected using pretested semi-structured questionnaire. Mini-Mental State Examination was done to assess cognitive function. We calculated adjusted prevalence ratios (aPR) to identify the factors associated with cognitive impairment. Results: Among 295 participants, 173 (58.6) were in 30–59 years; 154 (52.2%) were female; and 59 (20.0%) were exposed to indoor air pollution. Prevalence of cognitive impairment in the general population was 11.9% (95% confidence interval [CI]: 8.7–16.1). Prevalence of cognitive impairment among those who were exposed to indoor air pollution was 27.1% (95% CI: 17.4–39.6). Individuals exposed to indoor air pollution (aPR = 2.18, P = 0.003) were found to have two times more chance of having cognitive impairment. Conclusion: About one-fourth of the participants were exposed to indoor air pollution, out of which more than one-fourth was found to have cognitive impairment which is twice that of the general population. Hence, prevention of exposure to indoor air pollution needs to be done through increased availability to cleaner fuels for household usage.
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Assessment of sleep quality among medical doctors in a Tertiary Hospital in a semi-rural setting p. 535
Ibrahim Aliyu, Ismail Inuwa Mohammed, Taslim O Lawal, Mustapha Gudaji, Nuhu Garba, Kehinde Fasasi Monsudi, Godpower Chinedu Michael, Igoche David Peter
DOI:10.4103/jnrp.jnrp_91_18  PMID:30271046
Introduction: Sleep is an integral part of human physiology; therefore, disorders of sleep may result in significant derangement in human functionality. Sleep medicine has received little attention in Nigeria. Against this backdrop, this survey seeks to evaluate the quality of sleep among doctors. Methodology: This was a cross-sectional descriptive study involving 59 doctors working with Federal Medical Centre Birnin Kebbi, Kebbi State, Nigeria; it was done between August 2017 and December 2017. Purposive sampling method was adopted. The Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS) were adopted. The questionnaire was self-administered. Results: There were 34 (57.6%) males and 25 (42.4%) females. Their age ranged from 20 to 66 years, with a mean of 34.39 ± 8.00. The Epworth score ranged from 8 to 29, with a mean of 16.1 ± 4.4, while the PSQI score ranged from 5 to 19, with a mean of 9.5 ± 2.7. The mean work hour per week was 90.3 ± 36.2 h, and majority of the respondents worked for >80 h and or >24 h consecutively in the preceding week, and most had high ESS scores; however, this observation was not statistically significant (Fisher's exact test = 4.0904, P = 0.213). All respondents were poor sleepers and majority sleep for <7 h in the night. Respondents had worked for 5 years and less; house officers and medical offers had more tendencies for daytime sleepiness. Conclusion: All respondents were poor sleepers and also had prolonged work hours per week; there was also heightened daytime sleepiness.
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Feasibility and utility of tele-neurorehabilitation service in India: Experience from a quaternary center p. 541
Meeka Khanna, Guru S Gowda, Virupaksha Irappa Bagevadi, Anupam Gupta, Karishma Kulkarni, RP S. Shyam, Vinay Basavaraju, Manjunatha B Ramesh, HN Sashidhara, Narayana Manjunatha, Naveen Kumar Channaveerachari, Suresh Bada Math
DOI:10.4103/jnrp.jnrp_104_18  PMID:30271047
Background: Neurological rehabilitation service in developing countries like India is a great challenge in view of limited resources and manpower. Currently, neurological rehabilitation with a multidisciplinary team is limited to a few major cities in the country. Tele-neurorehabilitation (TNR) is considered as an alternative and innovative approach in health care. It connects the needy patients with the health-care providers with minimum inconvenience and yields cost-effective health care. Aim: The aim of this study was to study the socioclinical parameters, feasibility, and utility of TNR services in India. Methodology: A retrospective file review of TNR consultations provided through Telemedicine Center at a quaternary hospital-based research center in south India between August 2012 and January 2016. Results: A total of 37 consultations were provided to the patients belonging to four districts of Karnataka. The mean age of the patients was 34.7 (±19.5) years, 23 (62.1%) were aged between 19 and 60 years, and 31 (83.8%) were male. Thirty-one patients (83.8%) had central nervous system-related disorders such as stroke, cerebral palsy, and tubercular meningitis with sequelae or neuromuscular disorders such as Guillain–Barre Syndrome and Duchenne muscular dystrophy. Twelve patients (32.4%) were advised to consult higher centers in the vicinity, and the rest was referred to the district hospital. Conclusion: The findings suggest that TNR services are feasible, effective, and less resource intensive in delivering quality telemedicine care in India. More clinical studies are required to elucidate its full utility at different levels and in different parts of the country.
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Determinants of timing of presentation of neurotrauma patients to a neurosurgical center in a developing country p. 545
Toluyemi Adefolarin Malomo, Toyin Ayofe Oyemolade, Amos Olufemi Adeleye
DOI:10.4103/jnrp.jnrp_502_17  PMID:30271048
Background: A major goal in neurotrauma management is the prevention of secondary neuronal injuries. This goal is time bound as neurological deficits once established are usually irreversible. Late presentation is the norm in most neurotrauma patients in developing countries. Aims: The aim of the study was to review the timing of presentation of neurotrauma patients and the possible causes of their late presentation for neurosurgical care in our practice. Methods: A cross-sectional study of a 4-month prospective database of neurotrauma patients presenting to the University College Hospital, Ibadan, was done. The participants' biodata, injury characteristics, initial-care details before referral, and information on timing and causes of delay were analyzed. Results: The study subjects included 111 patients, 80.2% (89/111) were males, and 52.8% aged 21–40 years. Head injury (HI), spinal cord injury (SCI), and combined HI and SCI occurred, respectively, in 80.2%, 14.4%, and 5.4%. Road accidents followed by falls were seen in 73.9% and 14.4% (16), respectively. Just 46.8% (52/111) cases presented within 12 h of injury and only 37 (33.3%) within 4 h. Majority, 83.8% (93/111) were referrals from primary care. These referrals were delayed in 81.7% (76/93) of these. The referring health facilities were located intracity with our center in 54%. Other causes of delayed presentation of these study participants included long-distance travel to our center, lack of funds, or a combination of the above factors. Eighty-nine patients (80.2%) were brought in by family members and the remaining minority by passers-by and road safety personnel. Conclusions: Delayed referral from primary care features prominently in timing of presentation of neurotrauma patients in Nigeria. There is a need for collaboration as well as continuing medical education between the neurotrauma specialists and primary care physicians.
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Nonfatal stroke and all-cause mortality among community-dwelling older adults living in rural ecuador: A population-based, prospective study p. 551
Oscar H Del Brutto, Robertino M Mera, Victor J Del Brutto
DOI:10.4103/jnrp.jnrp_79_18  PMID:30271049
Background: Stroke is a leading cause of disability in developing countries. However, there are no studies assessing the impact of nonfatal strokes on mortality in rural areas of Latin America. Using a population-based, prospective cohort study, we aimed to assess the influence of nonfatal strokes on all-cause mortality in older adults living in an underserved rural setting. Methods: Deaths occurring during a 5-year period in Atahualpa residents aged ≥60 years were identified from overlapping sources. Tests for equality of survivor functions were used to estimate differences between observed and expected deaths for each covariate investigated. Cox proportional hazards models were used to estimate Kaplan–Meier survival curves of variables reaching significance in univariate analyses. Results: Of 437 individuals enrolled over 5 years, follow-up was achieved in 417 (95%), contributing 1776 years of follow-up (average 4.3 ± 1.3 years). Fifty-one deaths were detected, for an overall cumulative 5-year mortality rate of 12.2% (8.9%–15.6%). Being older than 70 years of age, having poor physical activity, edentulism, and history of a nonfatal stroke were related to mortality in univariate analyses. A fully adjusted Cox proportional hazards model showed that having history of a nonfatal stroke (P = 0.024) and being older than 70 years of age (P = 0.031) independently predicted mortality. In contrast, obesity was inversely correlated with mortality (P = 0.047). Conclusions: A nonfatal stroke and increasing age increase the risk of all-cause mortality in inhabitants of a remote rural village. The body mass index is inversely related to death (obesity paradox).
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Magnetic resonance imaging findings in viral encephalitis: A pictorial essay p. 556
Kalaivani Jayaraman, Rajeswaran Rangasami, Anupama Chandrasekharan
DOI:10.4103/jnrp.jnrp_120_18  PMID:30271050
Viral encephalitis by definition is the result of human virus affecting the brain and sparing the meninges. The other nervous system manifestations are meningitis, meningoencephalitis, encephalomyelitis, and encephalomyeloradiculitis. Encephalitis can involve any age group from children to old people. The severity of the disease depends on the viral agent and the host immune system. The patient can present with fever, headache, seizure, neurological deficit, or altered sensorium. Laboratory investigations, imaging, and cerebrospinal fluid analysis are crucial in the diagnosis of encephalitis. Magnetic resonance imaging (MRI) findings may be nonspecific or specific and plays a major role in the diagnosis of encephalitis and predicting the possible cause. This pictorial essay reviews the MRI findings of common types of viral encephalitis.
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Neuro-Ophthalmology at the bedside: A clinical guide p. 561
Josef G Heckmann, Ivana Vachalova, Christoph J G. Lang, Susanne Pitz
DOI:10.4103/jnrp.jnrp_145_18  PMID:30271051
Neuro-ophthalmological signs and symptoms are common in the emergency department but are a frequent source of diagnostic uncertainties. However, neuro-ophthalmological signs often allow a precise neuro-topographical localization of the clinical problem. A practical concept is presented how to perform a neuro-ophthalmological examination at the bedside and to interpret key findings under the aspect of emergency medicine with limited resources.
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Minimally invasive sacroiliac fixation for extension of fusion in cases of failed lumbosacral fusion p. 574
Mazda K Turel, Mena Kerolus, Harel Deutsch
DOI:10.4103/jnrp.jnrp_18_18  PMID:30271052
Sacroiliac fusion and instrumentation extension for correction of failed lumbosacral fusions traditionally requires a long revision surgery. Reopening of the prior surgical incision to expose the prior instrumentation requires a large incision with increased blood loss, increased operative time, increased risk of infection, and longer hospitalization times. We describe the first case series using a minimally invasive surgical sacroiliac screw technique for extension of a prior fusion to the pelvis. Using two small 3-cm paramedian incisions on each side, we were able to obtain autologous iliac crest bone graft, place the sacroiliac screw minimally invasive, perform an arthrodesis, and connect the prior surgical hardware to the sacroiliac screw safely. A detailed review of surgical technique, clinical cases, and brief review of the literature is discussed.
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”Bovine aortic arch” in a patient with simultaneous bihemispheric embolic infarcts p. 578
Prasad Krishnan
DOI:10.4103/jnrp.jnrp_32_18  PMID:30271053
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Traumatic complete lateral spondyloptosis of the thoracic vertebrae p. 580
Sunil Munakomi
DOI:10.4103/jnrp.jnrp_532_17  PMID:30271054
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Bedside intracranial hematoma evacuation and intraparenchymal drain placement for spontaneous intracranial hematoma larger than 30cc in volume: Institutional experience and patient outcomes p. 582
Tyler Carson, Hammad Ghanchi, Marc Billings, Vladimir Cortez, Raed Sweiss, Dan Miulli
DOI:10.4103/jnrp.jnrp_93_18  PMID:30271055
Introduction: Intracranial hemorrhage (ICH) accounts for significant morbidity and mortality in the United States. Many studies have looked at the benefits of surgical intervention for ICH. Recent results for Minimally Invasive Surgery Plus Recombinant Tissue-type Plasminogen Activator for Intracerebral Hemorrhage-II trials have shown promise for a minimally invasive clot evaluation on improving perihematomal edema. Often rural or busy county medical centers may not have the resources available for immediate operative procedures that are nonemergent. In addition, ICH disproportionally affects the elderly which may not be stable for general anesthetics. This study looks at a minimally invasive bedside approach under conscious sedation for evacuation of ICH. Materials and Methods: Placement of the intraparenchymal hemorrhage drain utilizes bony anatomical landmarks referenced from computed tomography (CT) head to localize the entry point for the trajectory of drain placement. Using the hand twist drill intracranial access is gained the clot accessed with a brain needle. A Frazier suction tip with stylet is inserted along the tract then the stylet is removed. The clot is then aspirated, and suction is then turned off, and Frazier sucker is removed. A trauma style ventricular catheter is then passed down the tract into the center of hematoma and if no active bleeding is noted on postplacement CT and catheter is in an acceptable position then 2 mg recombinant tissue plasminogen activator are administered through the catheter and remaining clot is allowed to drain over days. Results: A total of 12 patients were treated from October 2014 to December 2017. The average treatment was 6.4 days. The glascow coma scale score improved on an average from 8 to 11 posttreatment with a value of P is 0.094. The average clot size was reduced by 77% with a value of P = 0.0000035. All patients experienced an improvement in expected mortality when compared to the predicted ICH score. Discussion: The results for our series of 12 patients show a trend toward improvement in Glasgow Coma Scale after treatment with minimally invasive intraparenchymal clot evacuation and drain placement at the bedside; although, it did not reach statistical significance. There was a reduction in clot size after treatment, which was statistically significant. In addition, the 30-day mortality actually observed in our patients was lower than that estimated using ICH score. Based on our experience, this procedure can be safely performed at the bedside and has resulted in better outcomes for these patients.
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Response of syrinx associated with Chiari I malformation to posterior fossa decompression with or without duraplasty and correlation with functional outcome: A prospective study of 22 patients p. 587
Anil Kumar, Nupur Pruthi, B Indira Devi, Arun Kumar Gupta
DOI:10.4103/jnrp.jnrp_10_18  PMID:30271056
Background: The aim of the study is to correlate the surgical outcome with radiological changes in patients with Chiari I malformation (CMI) with syrinx. We also compared long-term functional and radiographic outcome in CM1 patients treated with posterior fossa decompression (PFD) with or without duroplasty. Patients and Methods: From December 2013 to October 2015, 22 patients who underwent surgery with the diagnosis of CMI and syrinx were included in the study. Measurements were performed on preoperative and postoperative magnetic resonance (MR) scans using the same software. All patients underwent PFD with or without duroplasty. Clinical results were evaluated on the basis of the Chicago Chiari Outcome Scale (CCOS). We assessed the degree of resolution of syrinx and outcome of Chiari decompression with PFD versus PFD with duroplasty. Mean duration of follow-up was 12.4 ± 5.37 months (range: 6–24 months). Results: Out of 19 patients in whom syrinx diameter decreased on postoperative MR imaging, 17 (89.5%) improved based on CCOS and 2 (10.5%) were unchanged while out of three patients in whom syrinx worsened, 2 (66.7%) improved and 1 (33.3%) was unchanged (P = 0.37). The cord diameter was found to have decreased in 12 patients and of these 11 (91.7%) improved. The cord diameter increased in 10 patients, but 8 (80%) improved (P = 0.57). The mean changes in syrinx, cord, and syrinx/cord ratio were studied in both groups with and without duroplasty, were not statistically significant. In this study, radiological parameters failed to predict functional outcome. Conclusions: The outcome does not correlate with change in any of the syrinx-related factors. Surgical decompression with or without duroplasty does not have a statistically significant relationship in the degree of syrinx resolution. Surgical decompression without duroplasty provides the benefits of surgical decompression while avoiding the complications of intradural techniques.
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Multiple, primary brain tumors with diverse origins and different localizations: Case series and review of the literature p. 593
Thara Tunthanathip, Kanet Kanjanapradit, Sanguansin Ratanalert, Nakornchai Phuenpathom, Thakul Oearsakul, Anukoon Kaewborisutsakul
DOI:10.4103/jnrp.jnrp_82_18  PMID:30271057
Background: Multiple, primary brain tumors with different histological types occurring in the same patient are extremely rare. Several hypotheses have been proposed, and the pathophysiology of coexisting tumors has long been debated; however, due to low incidence, standard practices for this scenario are still inconclusive. Case Description: The authors describe 6 cases of coexisting tumors. By conducting a literature research focused on the computed tomography (CT) era and patients without prior radiation or phakomatosis. Sixty-five such reported cases were identified. In addition, the authors summarize their experience in 6 patients including histopathological features, chronological presentations, outcomes, mortality, and management from their series as well as from previous cases from the reported literature. Conclusion: The coexistence of multiple, primary brain tumors is an interesting condition. Surgical management remains the major treatment; malignant histology has a poor prognostic factor.
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Detailed clinical and electrophysiological illustration of a patient with Sturge–Weber syndrome presenting with prolonged transient neurological symptoms p. 608
Halil Onder
DOI:10.4103/jnrp.jnrp_11_18  PMID:30271058
Although transient neurological deficits in Sturge–Weber syndrome (SWS) have been acknowledged for many years, the underlying pathogenesis still constitutes a major topic of discussion. Here, we present the case of a 10-year-old boy with SWS presenting with a progressive clinically mimicking right middle cerebral artery syndrome. Cranial magnetic resonance imaging showed unremarkable findings except extensive right hemisphere leptomeningeal angiomas. Antiepileptic drug (AED) treatments provided recovery of the patient, and concurrently recorded electroencephalography (EEG) revealed delta slowing of the lesional hemisphere in the acute period. However, slowing of the background activity extended to the contralateral hemisphere in subacute period, while ipsilateral background activity started to recover. In the 3rd week of follow-up on intensive AED treatments, the patient totally recovered as well as nearly the normalization of EEG was achieved. In this report, we focus on the dramatic revolution of EEG activity in both hemispheres during the recovery period. Based on this rare illustration and limited literature data, the author suggests some hypotheses regarding the pathophysiology of this mysterious manifestation (transient neurological deficit) in SWS. Future studies of large case series, including detailed paraclinical parameters and remarkably electrophysiological data, are warranted to clarify these arguments.
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A young patient with stroke and primary tuberculosis p. 613
Narenraj Arulprakash, Lavanya Narayanan, Senthil Narayanan
DOI:10.4103/jnrp.jnrp_59_18  PMID:30271059
A 21-year-old woman presented with left hemiparesis, fever, dyspnea, tachycardia, and pericardial rub on examination. She was provisionally diagnosed with infective endocarditis and received the final diagnosis of the primary pulmonary tuberculosis (PTB) and extra PTB (EPTB) with pericardial effusion and thoracic lymphadenitis. Left hemiparesis due to a pontine infarct was attributed to TB with neurovasculitis. The diagnosis was supported by findings on imaging studies such as echocardiography, computed tomography of the thorax, and magnetic resonance imaging of the brain. She improved with anti-TB treatment. It is interesting to note that she was not immunodeficient, with the usual suspects such as acquired immunodeficiency syndrome, diabetes mellitus, and renal failure ruled out. We conclude that PTB and EPTB must be considered in any febrile illness, even in patients who are not immunodeficient, considering its atypical presentation and prevalence in India.
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A case report of misdiagnosis of psychotic symptoms predominant Wilson's disease p. 616
Bhupendra Shah, Suren Limbu
DOI:10.4103/jnrp.jnrp_515_17  PMID:30271060
Wilson's disease is an autosomal recessive disease of abnormal copper metabolism. Psychosis is a rare manifestation of Wilson's disease. Few cases of misdiagnosing Wilson's disease as an etiology of psychosis were reported in the literature. We report a case of a 42-year-old patient, who was diagnosed with a schizoaffective disorder and treated with antipsychotics for 3 years with no significant improvement. On reevaluation, we the patient was diagnosed to have Wilson's disease. The patient's symptoms improved significantly with chelation therapy.
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Giant occipital encephalocele with chiari malformation Type 3 p. 619
Davendran Kanesen, Azmin Kass Rosman, Regunath Kandasamy
DOI:10.4103/jnrp.jnrp_103_18  PMID:30271061
Encephaloceles are rare embryological mesenchymal developmental anomalies resulting from inappropriate ossification in the skull through which herniate the intracranial contents of the sac. Occipital encephaloceles are described as giant when they are larger than the head from which they arise, and they pose a great surgical challenge. Herein, we present a case of a giant occipital encephalocele in a neonate with Chiari malformation Type 3 to highlight the problems encountered in its management and the outcome of the surgery.
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Cerebral hydatid cyst in a young immunocompromised patient in Parakou p. 622
Thierry Adoukonou, Donald Accrombessi, Mendinatou Agbetou
DOI:10.4103/jnrp.jnrp_76_18  PMID:30271062
We report the case of a 30-year-old human immunodeficiency virus (HIV)-positive HIV patient who was poorly followed. She was admitted on November 30, 2017, for the management of febrile encephalitis syndrome with motor deficit of the left hemicorps and generalized seizures. In biology, we found a nonspecific inflammatory syndrome. The cerebral imaging without and with injection found a cystic formation multilobed right fronto-parietal of approximately 83 mm × 62 mm, the presence of an annular calcification of approximately 8 mm with a commitment under falcator, and a contralateral ventricle dilation. Treatment with antiepileptic, antibiotic, antiparasitic, and corticosteroid therapy was marked by death the day before the neurosurgical procedure after initial improvement.
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Emergent neurosurgical management of a rapidly deteriorating patient with acute intracranial hemorrhage and alcohol-related thrombocytopenia p. 625
Hansen Deng, John K Yue, Beata Durcanova, Javid Sadjadi
DOI:10.4103/jnrp.jnrp_50_18  PMID:30271063
Alcohol intoxication is a common risk factor of traumatic brain injury (TBI) and carries a significant health-care burden on underserved patients. Patients with chronic alcohol use may suffer a spectrum of bleeding diatheses from hepatic dysfunction not well studied in the context of TBI. A feared sequela of TBI is the development of coagulopathy resulting in worsened intracranial bleeding. We report the clinical course of an intoxicated patient found down with blunt head trauma and concurrent alcoholic cirrhosis who was awake and responsive in the field. Hospital course was characterized by a rapidly deteriorating neurological examination with progressive subdural and subarachnoid hemorrhage and precipitating neurosurgical decompression and critical care management. Our experience dictates the need for timely consideration of the possibility of rapid deterioration from coagulopathic intracranial bleeding in the initial assessment of intoxicated patients with head trauma of unknown severity, for which a high index of suspicion for extra-axial hemorrhage should be maintained, along with the immediate availability of operating room and the necessary medical personnel.
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Accidental strangulation while playing with hammock in a child p. 628
C Anitha, K Jagadishkumar, N Nanda, M Meghana
DOI:10.4103/jnrp.jnrp_545_17  PMID:30271064
In children, strangulation is a fatal injury due to asphyxia, a terminal event of partial or complete hanging. Homemade hammocks are routinely used as a cradle which is potentially dangerous. We are hereby reporting a 12-year-old female with accidental strangulation occurring as a result of swinging on a hammock made of saree and also in a view to educate the public about the hazards of using homemade hammocks.
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Cervical intramedullary cystic teratoma with dermal sinus tract: A case report and review of literature p. 631
Batuk Diyora, Sanjay Kukreja, Mazhar Mulla, Bhagyashri Bhende, Naren Nayak
DOI:10.4103/jnrp.jnrp_30_18  PMID:30271065
Intramedullary spinal teratomas are rare. We report a case in a 40-year-male who presented with progressive weakness over the right side of the body and gait imbalance. He had dermal sinus with hair patch over nape of the neck. Magnetic resonance imaging revealed cervical (C4–C7) intramedullary tumor with dermal sinus tract. C3–C7 laminectomy was performed and tumor excised along with the sinus tract. Histopathological examination revealed mature cystic teratoma. Gait ataxia was improved immediately while near complete recovery in motor power was achieved over a period of 2–3 weeks.
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Orbital tuberculosis with intracranial extension p. 636
Batuk Diyora, Sachin Ashok Giri, Bhagyashri Bhende, Deepali Giri, Sanjay Kukreja, Alok Sharma
DOI:10.4103/jnrp.jnrp_70_18  PMID:30271066
We report a case of orbital tuberculosis (OTB) with intracranial extension without active tuberculosis in the rest of the body organs or a history of tuberculosis infection. A 29-year-male patient presented with left-sided painful periorbital swelling with pus discharging sinus and visual impairment. Orbital computed tomography revealed contrast enhancing cystic mass lesion in the left orbit with erosion of the lateral and superior orbital wall with intracranial extension. After the failure of 3 weeks' course of oral antibiotics, the patient underwent left lateral orbitotomy, pus was drained out, and granulation tissues were excised. Histopathological examination confirmed OTB. The patient had received antituberculous treatment. Periorbital swelling completely disappeared and vision improved over a period of 2 weeks. OTB should be considered in differential diagnosis of periorbital swelling especially when it does not respond to oral antibiotics.
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Giant bilateral calvarial hyperostosis secondary to small unilateral frontal meningioma p. 639
Satyashiva Munjal, Sanjay Dhawan, Sunila Jain, VS Mehta
DOI:10.4103/jnrp.jnrp_559_17  PMID:30271067
A 28-year-old male patient presented to us with bilateral frontal hyperostosis associated with a small unilateral frontal intracranial meningioma. He underwent successful excision of the involved bone and repair of the large cranial defect using a titanium mesh. Histological examination revealed tumor infiltration of the overlying bone. Surgical challenges in the management of such a case are also discussed.
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Origin of thyrolingual trunk from the common carotid artery p. 642
Sumit Goyal, Manish S Jain, Amit Shrivastava, Rahul Jain
DOI:10.4103/jnrp.jnrp_66_18  PMID:30271068
Common carotid artery (CCA) usually does not have any branches in the neck and divides into internal and external carotid artery. Superior thyroid and lingual artery (commonly called as thyro lingual trunk) are the branches of external carotid artery. We report a case of rare origin of thyrolingual trunk from the CCA in a case of ruptured intracranial aneurysm.
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Neurobrucellosis presenting as acute psychosis p. 644
Irfan Ahmad Shah, Yuman Kawoos, Bashir Ahmad Sanai, Stanzen Rabyang, Dawood Banday
DOI:10.4103/jnrp.jnrp_16_18  PMID:30271069
A 45-year-old female without any past or family history of psychiatric illness presented to the emergency department with complaints of abnormal behavior, irrelevant talking, restlessness, episodic crying, and decreased sleep of 2-day duration. On detailed interview, the attendants gave a history of an intermittent headache of 6-month duration and hearing impairment of 4-month duration. On investigation, her cerebrospinal fluid was reactive, and brucella titers were positive. She received appropriate treatment for 6 months and a short course of antipsychotics. Her symptoms settled, but she had persistent hearing loss. Psychosis as well as hearing loss is a very rare presentation of brucellosis. The case highlights the importance of considering neurobrucellosis as a differential diagnosis in patients with any unexplained neuropsychiatric symptoms such as acute psychosis or hearing loss.
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Isolated wrist drop presenting as acute stroke: Rare case report with review of literature p. 647
Khushbu Goel, Saraj Kumar Singh, Himanshu Agarwal, Joy Dev Mukherji, Mukesh Kumar
DOI:10.4103/jnrp.jnrp_115_18  PMID:30271070
Isolated wrist drop is very unusual clinical presentation due to cerebral stroke. It is highly confused with peripheral neuropathy. However, timely detection of acute stroke as one of the causes of wrist drop is necessary as it changes the line of treatment and prognosis significantly. Here we are presenting a 62 year-old diabetic and hypertensive male patient who came with acute onset weakness of right hand. Initial Magnetic resonance imaging (MRI) of the brain showed hyperacute infarct in the splenium of corpus callosum. Magnetic resonance angiography (MRA) was normal. Repeat brain MRI on next day showed acute infarct at hand area of motor strip in posterior frontal region. The patient underwent intravenous thrombolysis and thereafter improved significantly. Isolated hand palsy is a rare presentation of stroke, often mistaken for peripheral lesion.
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Cisternostomy in neurosurgery: A new proposed general classification based on mechanism and indications of the cisternostomy proper p. 650
Samer S Hoz, Abdullah H Alramadan, Aseel Q Hadi, Luis Rafael Moscote Salazar
DOI:10.4103/jnrp.jnrp_92_18  PMID:30271071
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Acute basilar artery occlusion: Early computed tomography finding predicts catastrophic outcome p. 653
Chen Fei Ng, Chia Yin Chong
DOI:10.4103/jnrp.jnrp_40_18  PMID:30271072
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Identifying patient profiles suitable for cognitive behavior Therapy: The role of psychological mindedness p. 654
Sivapriya Vaidyanathan, Vikas Menon, Siddharth Sarkar
DOI:10.4103/jnrp.jnrp_100_18  PMID:30271073
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Extracranial vertebral artery aneurysm: An unpleasant consequence of neck massage p. 655
Sachinkumar Maheshbhai Patel, Sabyasachi Ojha, Sayan Das, Prasad Krishnan
DOI:10.4103/jnrp.jnrp_118_18  PMID:30271074
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A Case of Lennox–Gastaut syndrome in a 6-year-old child with moyamoya disease p. 658
Jaya Shankar Kaushik, Harish Bhardwaj, Surekha Dabla, Kiran Bala
DOI:10.4103/jnrp.jnrp_85_18  PMID:30271075
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