Journal of Neurosciences in Rural Practice
 
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April-June 2019
Volume 10 | Issue 2
Page Nos. 173-388

Online since Monday, March 25, 2019

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GUEST EDITORIAL  

Diet in stroke: Beyond antiplatelets and statins Highly accessed article p. 173
Joe James
DOI:10.4103/jnrp.jnrp_389_18  
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EDITORIALS Top

Depression, suicidal ideation, and resilience among rural farmers p. 175
Kabir Garg
DOI:10.4103/jnrp.jnrp_339_18  
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Depression, suicidal ideation, and resilience among rural drought-affected farmers: Methodological issues p. 176
Vikas Menon
DOI:10.4103/jnrp.jnrp_341_18  
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ORIGINAL ARTICLES Top

Developing normative reference values for nerve conduction studies of commonly tested nerves among a sample Pakistani population p. 178
Zaitoon Shivji, Anita Jabeen, Safia Awan, Sara Khan
DOI:10.4103/jnrp.jnrp_370_18  
Introduction: Most neurophysiology departments around the world establish their own normative data. However, ethnic differences are not taken into account. Our aim was to establish normal nerve conduction studies (NCS) data for routinely tested nerves in individuals of Pakistani (South Asian) origin and to compare with Western published data. Materials and Methods: One hundred healthy adults' nerves were assessed, using standardized techniques. Individuals were grouped into age groups. Gender differences were assessed. Results: Of the 100 volunteers, 49 were female and 51 were male. Their mean age was 39.8 years. Findings showed statistically significant prolongation of median distal motor latency (DML) and F-wave latency with age and reduction of median, ulnar, and sural sensory amplitudes as age increased. Gender differences showed consistent difference in the normal values for median, ulnar, and peroneal DMLs and respective F-wave latencies, which were significantly shorter in females. Sensory amplitudes of tested upper extremity nerves were significantly lower in males. Comparing with available data, our findings are similar to the Saudi population but significantly different from the American and multiethnic Malaysian populations. Pakistani individuals generally have significantly higher amplitudes and faster conduction velocities with similarities to South Asian studies. Conclusions: We recommend normative NCS parameters for commonly tested nerves for the Pakistani population, using standardized techniques to ensure highest quality testing and outcomes.
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Mindbomb Homolog-1 index in the prognosis of high-grade glioma and its clinicopathological correlation p. 185
Shyam Sundar Krishnan, Shanmugam Muthiah, Shilpa Rao, Suganthi Srinivasan Salem, Vasudevan Chakravarthy Madabhushi, Anita Mahadevan
DOI:10.4103/jnrp.jnrp_374_18  
Introduction: Gliomas are the most common brain tumors in adults originating from the glial cells. Glioblastoma multiforme is the most malignant and frequent among all gliomas. In recent years, the antibody Mindbomb Homolog-1 (MIB-1) has evolved as a measure of the proliferative nature of the glial tumors. This study aims to investigate the MIB-1 index value as an independent prognostic factor in high-grade gliomas and its correlation with outcome and survival. Materials and Methods: Mean MIB-1 index was determined in 51 high-grade glioma tissue samples in formalin. Its correlation with outcome by assessing the clinicoradiological parameters and median survival of patients in months were assessed. Survival analysis was studied by using the Kaplan–Meier bivariate analysis and Cox proportional ratio. Results: Preoperative Karnofsky Performance Score, WHO-PS, Neurological Performance Scale, and Mini–Mental Status Examination (MMSE) were statistically significant with respect to outcome and survival, whereas tumor factors such as size and perilesional edema were not. In particular, midline-crossing tumors and deep-seated tumors were significantly associated with high MIB-1 index and by correlation with outcome. There were significantly higher number (P < 0.0001) of patients with Grade IV tumors, with an MIB-1 index value above an arbitrary cutoff of 10% compared to Grade III tumors. In addition, median survival period of patients with low MIB-1 index was longer irrespective of tumor grade. Conclusion: Significant correlation between high-grade glioma and MIB-1 index suggests MIB-1 index to be a good prognostic tool, with MIB-1 index and midline-crossing variables being independent prognostic parameters.
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Does universal bypass before carotid artery occlusion obviate the need for balloon test occlusion: Personal experience with extracranial–Intracranial bypass in 23 patients p. 194
Girish Menon, Sudha Menon, Ajay Hegde
DOI:10.4103/jnrp.jnrp_381_18  
Aim: Carotid artery ligation carries a potential risk of ischemic complications even in patients with good collaterals and adequate cross-circulation. Preoperative assessment through balloon test occlusion (BTO) is technically challenging and not feasible in all patients. We analyze our experience with universal bypass without performing detailed cerebrovascular reserve (CVR) studies in 23 patients before carotid artery ligation. Patients and Methods: This was a retrospective analysis of the case records of 23 patients who underwent cervical carotid artery ligation for various indications since January 2009. Results: The study included 21 patients with cavernous carotid aneurysms, one patient with a large fusiform petrous carotid aneurysm, and one patient with recurrent glomus jugulare encasing the cervical internal carotid artery. The initial 12 patients underwent preoperative BTO with hypotensive challenge. All patients underwent a bypass procedure followed by carotid artery ligation irrespective of the BTO findings. Patients who successfully completed a BTO underwent a low-flow superficial temporal artery to middle cerebral artery bypass. A high-flow extracranial–intracranial bypass using a saphenous vein graft from external carotid artery to middle cerebral artery was done in all patients who either failed the BTO or did not undergo BTO. We had two operative mortalities and one poor outcome. All the other patients had a good recovery with a Glasgow outcome score of 5 at the last follow-up. Graft patency rates were 81.1% in both the low-flow and high-flow groups. Conclusion: Universal high-flow bypass is safe, effective, and should be preferred in all patients before carotid artery ligation. It obviates the need for detailed CVR assessment, especially in centers with limited resources.
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Oral health behavior and treatment needs among drug addicts and controls in Amritsar District: A case-controlled study p. 201
Preeti Chawla Arora, Komal Gurpreet Singh Ragi, Aman Arora, Ambika Gupta
DOI:10.4103/jnrp.jnrp_309_18  
Background: Substance and drug abuse is associated with severe psychosocial problems, violence and health complications. Aims: The aim of the study was to evaluate and compare the oral hygiene status and sugar eating patterns among drug addicts with their age, gender and socio-economic status matched controls. Settings and Design: The present study comprised of two groups-Group A comprised of 100 drug addicts and Group B included 100 controls. The study sample were interviewed and subjected to a comprehensive intra-oral examination. Methods and Material: Standardized methods of evaluation were performed using mouth mirror, dental probe, explorer and WHO probe. Statistical Analysis: The data was subjected to statistical analysis using Chi Square test and student t-test. Results and Conclusions: CPITN index revealed bleeding in 56% addicts and calculus in 20% addicts. The mean DMFT of group A was 5.71 as compared to 2.45 in group B. The frequency of sugar consumption was found to be high in addicts as compared to the controls. Significant P values (< 0.001) of DMFT index, periodontal status and frequency of sugar consumption were obtained on statistical analysis. The caries status was found to be poor in addicts, but the periodontal treatment needs were similar for both group A and B. Oral health promotion should be undertaken in drug rehabilitation centers for overall success of withdrawl treatment.
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Pattern of emergent head computed tomography findings in a tertiary care hospital during off working hours: Retrospective analysis p. 207
Rajneesh K Patel, Amit Kumar Choubey, Brijesh K Soni, Rajeev Sivasankar, Vikash Chauhan
DOI:10.4103/jnrp.jnrp_362_18  
Introduction: Emergency head computed tomography (CT) is rising exponentially during off working hours due to evidence-based medicine, patient's expectation and desires, easy availability and apprehension of medico-legal cases, thereby raising health-care cost. There is huge gap in demand and supply of radiologist, especially during off working hours. There is need to know the pattern of emergency head findings. Materials and Methods: A retrospective analysis of all emergent noncontrast CT head during off working hours in the Department of Radiodiagnosis of a Tertiary Care Hospital, Mumbai, India, which were performed from June 2017 to May 2018. CT findings of 308 patients were analyzed. Results: About 63.6% of total head CT showed no significant abnormality. The most common abnormality was intracranial hemorrhage which was just 9.1% followed by acute infarct which was 6.2%. Extradural hemorrhage, subdural hemorrhage, and subarachnoid hemorrhage was only 1% each of total head CT findings. No significant abnormality was detected in 74.65%, 70.21%, 89.13%, 31.37%, 100%, and 69.09% in cases of head injury, seizure, giddiness/dizziness/syncope, cerebrovascular accident, transient ischemic attack, and altered sensorium, respectively. Conclusion: Pattern analysis of emergent head CT reveals that most of the emergent CT head shows no significant abnormality. There is a need for stringent guidelines for emergent head CT, training of emergency physician as well as CT technician for common findings to bridge the radiologist demand-supply gap for providing effective health care in peripheral hospitals.
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Radiological parameters to predict hemorrhagic progression of traumatic contusional brain injury p. 212
Lal Rehman, Ali Afzal, Hafiza Fatima Aziz, Sana Akbar, Asad Abbas, Raza Rizvi
DOI:10.4103/jnrp.jnrp_335_18  
Introduction: Traumatic intracerebral contusion is a frequent factor culminating in death and disability, and its progression relates to unfavorable outcome. We evaluated the radiological factors associated with hemorrhagic progression of contusions (HPC). Materials and Methods: Two hundred and forty-six patients were enrolled in this prospective cohort over a period of 1 year. Contusion volume was quantified using the “ABC/2” technique, whereas progression was considered as >30% increase in the initial volume. Univariate and multivariate statistics were used to examine the correlation between the risk factors of interest and HPC. Results: HPC was seen in 110 (44.7%) patients. Binary logistic regression showed in the final adjusted model that multiplicity (relative risk [RR]: 2.24, 95% confidence limit [CL]: 1.00–5.48), bilateral lesions (RR: 2.99, 95% CL: 1.08–8.25), initial volume of contusion (RR: 4.96, 95% CL: 1.87–13.13), frontal location (RR: 1.42, 95% CL: 1.08–3.56), and presence of concomitant intracranial hematoma (extradural-RR: 3.90, 95% CL: 1.51–10.01, subdural-RR: 2.91, 95% CL: 1.26–6.69, and subarachnoid-RR: 2.27, 95% CL: 1.01–5.80) were significantly associated with HPC. The overall mortality was 18.7% and was almost equal among patients with and without HPC. Mortality was significantly associated with Glasgow Coma Scale on admission (adjusted RR: 12.386, 95% CL: 4.789–32.035) and presence of comorbid conditions (adjusted RR: 0.313, 95% CL: 0.114–0.860). Conclusion: Initial computed tomography scan is a good predictor of high-risk group for HPC.
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Prevalence of elder abuse and its association with psychiatric morbidity in a rural setting p. 218
Aseem Mehra, Sandeep Grover, Arun Agarwal, Mohammad Bashar, Ajit Avasthi
DOI:10.4103/jnrp.jnrp_338_18  
Aim: The aim of this study was to evaluate the prevalence of elder abuse in a rural setting. In addition, the study aimed to evaluate the association of elder abuse with psychiatric morbidity and demographic factors. Methodology: A total of 125 elderly (age ≥55 years) were evaluated for psychiatric diagnosis as per the International Classification of Diseases, 10th revision (ICD-10) criteria by the qualified psychiatrist and were evaluated on Vulnerability to Abuse Screening Scale for elder abuse. Results: More than half (58.4%) of the participants had one psychiatric disorder, with depression being the most common. Elder abuse was seen in more than one-third (41.6%) of the study participants. Those with psychiatric morbidity had significantly higher prevalence of abuse. None of the demographic factors was associated with abuse. Conclusion: Elder abuse is highly prevalent in rural setting, especially among those with psychiatric morbidity. Implications: Considering the high prevalence of elder abuse, there is an urgent need to address the problem. Public awareness, education, and sensitization of people toward the abuse are need of the day.
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Standalone instrumented posterior approach used as universal approach for tuberculosis spondylodiscitis p. 225
Mantu Jain, Rabi Narayan Sahu, Sudarsan Behera, Rajesh Rana, Sujit Kumar Tripathy, Ashish Pattnaik
DOI:10.4103/jnrp.jnrp_294_18  
Background: Surgical management of spinal tuberculosis (TB) has been classically the anterior, then combined, and of late increasingly by the posterior approach. The posterior approach has been successful in early disease. There has been a paradigm shift and inquisitive to explore this approach in the more advanced and even long-segment disease. Our study is a retrospective analysis by authors in variable disease pattern of TB Spine operated at an institute using a single posterior approach. Settings and Design: A retrospective case study series in a tertiary level hospital. Aims: The aim of this study is to evaluate the functional and radiological results of an all posterior instrumented approach used as a “universal approach” in tubercular spondylodiscitis of variable presentation. Materials and Methods: The study is from January 2015 to May 2018. Twenty-four of 38 patients met the inclusion criterion with a male: female = 8:16, and mean age 44.26 years. The initial diagnosis of TB was based on clinic-radiologic basis. Their level of affection, number of vertebrae affected, and vertebral body collapse, the kyphosis (preoperative, predicted, postoperative, and final residual) and bony fusion were measured in the preoperative, postoperative, and final X rays. Functional scoring regarding visual analog scale and Frankel neurology grading was done at presentation and follow-up of patients. Histopathological data of all patients were collected and anti-tubercular therapy completed for a period of 1 year with 4 drugs (HRZE) for 2 months and 2 drugs (HR) for rest of period. Statistical Analysis Used: The descriptive data were analyzed by descriptive statistics, and other parameters were calculated using the appropriate statistical tests such as the Student paired t-test for erythrocyte sedimentation rate, visual analog scale score, and kyphosis. Results: The mean number of vertebrae involved was 3.29 ± 0.86 (2–6) with mean vertebral body destruction was 0.616. Preoperatively, the mean kyphosis angle was 22.42° ± 12.56° and was corrected postoperatively to 13.08° ± 11.34° with an average correction of 9.34° (41.66%). At the latest follow-up, there was mean loss of correction of 0.80° resulting in 13.88° of final correction. Bony fusion was achieved in 20 patients (83.33%) cases. Neurological recovery occurred in all patients (100%), and 92% could be ambulatory at 1 year follow-up. There was improvement of visual analog scale from 6.33 ± 1.05 preoperatively to 1.042 ± 0.75 at 3 months of postoperative period. Two patients had bed sore, two had urinary infection, and one had neurological worsening requiring re exploration and cage removal eventually recovering to Frankel E. Two patients died due to unrelated cause. Conclusions: The procedure in safe and has satisfactory results in variable group affection of Pott's spine including early and late disease, multisegment involvement using pedicle screw fixation with/without cage support.
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Impact of etiology on efficacy of oral triclofos in recording pediatric electroencephalography: A tertiary care center study p. 234
Gopi Srikanth Matta, Ravi Prakash Peddisetty
DOI:10.4103/jnrp.jnrp_280_18  
Background and Objectives: Oral triclofos is a frequently used sedative in pediatric age to record sleep Electroencephalography (EEG). This study is aimed to assess efficacy, safety profile, need for second dose, and rescheduling of oral triclofos in relation to etiology. Materials and Methods: This is a retrospective study done enrolling all children aged 6 months to 5 years referred for EEG over 1 year. After a trial for natural sleep, the first dose of oral triclofos was given. If a child does not sleep after an hour, the second dose was given and rescheduled if does not sleep even with the second dose. Age, sex, diagnosis, sleep latency, sleep duration, adverse effects, EEG findings, patients needing second dose, and rescheduling were noted. Descriptive statistics and Chi-square test were used to analyze data. Results: A total of 384 children required oral triclofos. The common etiologies for sleep study were atypical febrile seizures, hypoxic-ischemic encephalopathy (HIE) sequelae, and behavioral disorders such as autism and attention-deficit hyperactive disorder (ADHD). Including the second dose, we were able to successfully record sleep EEG in 372 (96.8%) patients. Rescheduling was required in 3.2% of patients. Mean sleep-onset latency was 36 min and mean sleep duration was 84 min. Single dose was sufficient in 329 (85.6%) and the second dose in 55 (14.4%). Thirty (38.5%) children of HIE sequelae (P < 0.001) required the second dose followed by behavioral disorders (29.1%, P = 0.03). Irritability, vomiting, and dizziness were common side effects which resolved spontaneously. Conclusions: Oral triclofos was effective as sedative for recording EEG. Children with HIE sequelae and behavioral disorders such as autism/ADHD more commonly required second dosing and rescheduling.
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Depression, suicidal ideation, and resilience among rural farmers in a drought-affected area of Trichy District, Tamil Nadu p. 238
Deepak Justine Viswanathan, AM Veerakumar, Hemalatha Kumarasamy
DOI:10.4103/jnrp.jnrp_257_18  
Background: Changes in climatic conditions and other factors including trade and commerce have influenced agriculture worldwide. These factors have created a crisis among farmers. Objectives: The objective of this study was to find out the prevalence of depression and suicidal ideation, to measure the resilience, and to find out the factors that influence depression and resilience among farmers. Materials and Methods: A community-based cross-sectional analytical study was performed among farmers residing in a drought-affected area of Tiruchirappalli district of Tamil Nadu. The sample size was 191 and cluster sampling was used to select the participants. Structured, pretested questionnaires were used to find the prevalence of depression, suicidal ideation, and resilience among farmers. Pearson Correlation, Student's t-test, analysis of variance, and Pearson Chi-square test were used to identify the factors influencing depression and resilience. Results: A total of 194 farmers participated in the study. The mean age of the farmers was 46.68 ± 12.6 years, majority 64% were males and 89% were literates. Among the participants, 97.4% had some form of depression, and 67% had severe depression. About 60% of the farmers had suicidal ideation. Male farmers, farmers with few years of farming experience, and severe reduction in yield had a higher level of depression. Suicidal ideation was influenced by gender, small-scale farming, fewer years of experience in farming, and the impact of drought on yield. The mean resilience score was 49.4 ± 10. Gender and years of experience in farming had a significant association with resilience. Conclusion: High prevalence of depression and suicidal ideation and low level of resilience has been observed among the farmers. Interventions need to be provided for marginal and small-scale farmers, male farmers in the affected area to reduce the impact of drought in these farmers.
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Clinical characteristics of essential tremor in South India: A hospital-based cohort study p. 245
Sandhya Manorenj, Chintha Shravani, Srikant Jawalker
DOI:10.4103/jnrp.jnrp_348_18  
Introduction: Essential tremor (ET) is the most common adult movement disorder. Classic ET is characterized by action tremor of hands (95% cases), and tremor involving other regions is less common. Recent studies have revealed a few patients exhibiting nontremor features that include cognitive disorders, tandem gait abnormality, mood fluctuations, olfactory abnormality, hearing impairment, and sleep disorders. Very few studies on ET have so far been conducted in India, and the present study is a pioneering attempt to evaluate the clinical characteristics of patients diagnosed with ET. Materials and Methods: A standardized assessment protocol was used to collect data. Diagnosis of ET was established using consensus criteria established by the Movement Disorder Society. Tremor Research Group Essential Tremor Rating Assessment Scale was used to evaluate tremor impact. The severity of hand tremor was assessed by Glass Scale, and cognitive function was assessed by Mini–Mental Status Examination. Results: Out of the 45 patients enrolled, 73.3% were male and 26.6% were female, with a mean age of 44 ± 15 years. Postural tremor was observed in all, followed by intention tremor in 9 and rest tremor in 6 patients. Tremor of the hand was identified to be most predominant (100%). Voice tremor was observed in 15 (33.3%) patients and head tremor in 12 patients (26.6%) who were all females. Leg tremor was observed in 12 patients (26.6% of patients) and tongue tremor in 6 (13%) patients. Baseline asymmetry of tremor was observed in 60% of patients and positive family history in 35% of patients. The most common nontremor feature was tandem gait abnormality (40%). Moreover, most of the patients had Glass Scale II. Conclusion: Baseline asymmetry of tremor and male predominance were observed in the study. While hand tremor was the most common form of tremor, tandem gait abnormality was the most common nontremor feature as observed in patients with ET.
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Study of frontal alpha asymmetry in mild depression: A potential biomarker or not? p. 250
Ambrish S Dharmadhikari, Suyog Vijay Jaiswal, Avinash L Tandle, Deoraj Sinha, Nandini Jog
DOI:10.4103/jnrp.jnrp_293_18  
Background: Depression, despite being the most common of mental illness lacks any quantifiable and absolute biomarker. Frontal alpha asymmetry (FAA) is proposed as biomarker of depression both in resting and activated state. Yet, the location of extraction of alpha, clinical utility as well as validity of FAA is uncertain. With aim of obtaining clarity on this confusion we conducted this study. Methodology: Electroencephalographic frontal alpha power was calculated in patients of depression (n = 24) and compared with healthy controls (n = 17) for the assessment of FAA. Both groups were studied for resting phase and activation phase changes in FAA. For activation phase, auditory stimuli in the form of Indian classical music were used. Results: Frontal alpha power was measured across FP1, FP2, F3, F4, F7, and F8. Mean powers were compared in resting (before), activated (during) and postactivated resting stage (after). FAA was statistically significant in F7–F8 pair of electrodes and on F7 electrode when compared between cases and controls. Conclusion: Quest for biomarker for depression churned out FAA as frontrunner. Despite of vast amount of research on it, practical utility eludes us. We need to revisit our approach from conventional search of the diagnostic biomarker; as FAA might reflect component of depression but not totally disorder. In our opinion, we are not yet ready for it and have a road ahead to travel.
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Is freehand technique of pedicle screw insertion in thoracolumbar spine safe and accurate? Assessment of 250 screws p. 256
N Vijayeswaran, Raju Venkatesh, G Murugesan, S Balamurugan, K Indunesh, TT Pradeep
DOI:10.4103/jnrp.jnrp_183_18  
Background: Pedicle screw fixation is one of the widely used procedures for instrumentation and stabilization of the thoracic and lumbar spine. It has the advantage of stabilizing all the three columns in single approach. Various assistive techniques are available to place the pedicle screws more accurately but at the expense of increased exposure to radiation, prolonged surgical duration, and cost. Objective: The objective of this study is to determine the accuracy and safety of pedicle screw fixation in the thoracolumbar spine using freehand surgical technique. Materials and Methods: We evaluated all patients who underwent pedicle screw fixation of the thoracolumbar spine for various ailments at our institute from January 2016 to December 2017 with postoperative computed tomography scan for placement accuracy. We used Gertzbein classification to grade pedicle breaches. Screw penetration more than 4 mm was taken as critical and those less than that were classified as noncritical. Results: A total of 256 screws inserted in T1–L5 vertebrae were included from 40 consecutive patients. Six screws were excluded according to selection criteria. The mean age was 39 years. Trauma (36 patients) was the common reason for which the pedicle screw fixation was done followed by degenerative disease (2 patients) and tumour (2 patients). A total of ten pedicle screw breaches (4%) were identified in eight patients. Among these, three critical breaches (1.2%) were occurred in two patients which required revision. The remaining seven breaches were noncritical and kept under close observation and follow-up. Conclusion: Pedicle screw had become the workhorse of posterior stabilization of the spine. Based on external anatomy and landmarks alone, freehand technique for pedicle screw fixation can be performed with acceptable safety and accuracy avoiding cumulative radiation exposure and prolonged operative time.
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Caregivers' attitude and perspective on coercion and restraint practices on psychiatric inpatients from South India p. 261
Guru S Gowda, Channaveerachari Naveen Kumar, Sujoy Ray, Soumitra Das, Raveesh Bevinahalli Nanjegowda, Suresh Bada Math
DOI:10.4103/jnrp.jnrp_302_18  
Background: Coercion and restraint practices in psychiatric care are common phenomena and often controversial and debatable ethical issue. Caregivers' attitude and perspective on coercion and restraint practices on psychiatric inpatients have received relatively less research attention till date. Aims: Caregivers' attitude and perspective on coercion and restraint practices on psychiatric inpatients. Methodology: This is a hospital-based, a descriptive, cross-sectional study. A total of 200 (n = 200) consecutive patient and their caregivers were chosen between June 2013 and September 2014 through computer-generated random numbers sampling technique. We used a semi-structured interview questionnaire to capture caregivers' attitude and perspective on coercion and restraint practices. Sociodemographic and coercion variable were analyzed using descriptive statistics. McNemar test was used to assess discrete variables. Results: The mean age was 43.8 (±14.9) years. About 67.5% of the caregivers were family members, 60.5% of them were male and 69.5% were from low-socioeconomic status. Caregivers used multiple methods were used to bring patients into the hospital. Threat (52.5%) was the most common method of coercion followed by persuasion (48.5%). Caregivers felt necessary and acceptable to use chemical restraint (82.5%), followed by physical restraint (71%) and electroconvulsive therapy (ECT) (56.5%) during acute and emergency psychiatric care to control imminent risk behavior of patients. Conclusion: Threat, persuasion and physical restraint were the common methods to bring patients to bring acutely disturbed patients to mental health care. Most patients caregivers felt the use of chemical restraint, physical restraint and ECT as necessary for acute and emergency care in patients with mental illness.
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The impact of affective state on quality of life in focal epilepsy in Turkey p. 267
Emine Taskiran, Zeliha Matur, Günay Gül, Nerses Bebek, Betül Baykan, Aysen Gökyigit, Candan Gürses
DOI:10.4103/jnrp.jnrp_324_18  
Context: Seizures and accompanying situations including social, medical, and psychiatric problems threaten the quality of life (QOL) in patients with epilepsy. The World Health Organization defines health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. Aims: This study examines the prevalence of both depression and anxiety symptoms and also impact of the affective state on QOL in patients with focal epilepsy in Turkey. Settings and Design: One hundred and five patients with focal epilepsy over 18 years old were included in this study. The patients were classified into four groups according to the presence of AS and seizure control. Subjects and Methods: Patients' affective symptoms (AS) and QOL were examined using the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and QOL in Epilepsy Inventory-31 (QOLIE-31). Statistical Analysis Used: We used descriptive statistics, Chi-square test, independent samples t-test, one-way analysis of variance, Mann–Whitney U-test, Kruskal–Wallis H-test, and also Pearson's and Spearman's correlation test for correlations. Results: There were positive correlations between total QOLIE-31 score and epilepsy surgery, employment, and seizure freedom, whereas negative correlations were found with antiepileptic drug use, anxiety, and depression. Statistically significant differences were found in QOLIE-31 totals and subscores between Groups 3 and 4 (P < 0.05). Conclusions: The presence of AS has a negative impact on QOL in patients with focal epilepsy. Physicians should be aware that psychiatric comorbidities in epilepsy have a severe impact and epilepsy treatment requires comprehensive management.
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Timed vibration sense and joint position sense testing in the diagnosis of distal sensory polyneuropathy p. 273
Appaswamy Thirumal Prabhakar, Tharan Suresh, Dilu Susan Kurian, Vivek Mathew, Atif Iqbal Ahmed Shaik, Sanjith Aaron, Ajith Sivadasan, Rohit Ninan Benjamin, Mathew Alexander
DOI:10.4103/jnrp.jnrp_241_18  
Introduction: Distal sensory polyneuropathy (DSP) is one of the most common neurological disorders. Although several studies have studied the role of the neurological examination in DSP, there are only limited studies on the utility of timed vibration sense (VBS) and joint position sense (JPS) testing in the diagnosis of DSP. Objectives: The objective is to study the utility of timed VBS testing and JPS testing at the great toe in clinical detection of DSP. Methods: This study was prospectively conducted in the neurology department of a tertiary care hospital in India. Patients with DSP referred to the electrophysiology laboratory from August 2017 to December 2017 were screened. Patients with symptomatic DSP which was confirmed by electrophysiological studies were taken as cases and normal participants with no symptoms or electrophysiological findings suggestive of DSP served as controls. Results: We studied 127 patients and 194 controls. The mean age of the patients was 48.7 (14.5) years in the patient group and 39.7 (14.5) years in the control group. The male: female ratio was 77/50 in the patient group and 112/82 in the control group. Abnormal clinical examination was found in 95% of the patients with DSP. The most common abnormal examination components were impaired ankle reflexes (70%), vibration (85%), and JPS (39.6%) sensation. Using the receiver operating characteristic curve for the diagnosis of DSP, a vibratory response lasting <8 s at the great toe had a sensitivity of 85% and specificity of 42.8%. For JPS testing at the great toe, obtaining two or more incorrect responses had a sensitivity of 33% and specificity of 87.6%. Conclusion: VBS testing was more sensitive and JPS testing was more specific in making a clinical diagnosis of DSP. For timed VBS, duration of >8 s at the great toe was a useful test to rule out DSP, and for JPS testing at the great toe, obtaining two or more incorrect responses was a useful test in ruling in the diagnosis of DSP.
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Etiologic and clinical features of cerebral venous sinus thrombosis in Saudi Arabia p. 278
Rizwana Shahid, Azra Zafar, Saima Nazish, Abdulla Alsulaiman, Majed Alabdali, Danah Aljaafari, Noman Ishaque, Aishah Ibrahim Albakr, Abdullah Alamri, Fahd A Alkhamis, Maher Saqqur
DOI:10.4103/jnrp.jnrp_305_18  
Objective: Our study aims to evaluate the etiologic and clinical features of cerebral venous sinus thrombosis (CVST) in Saudi Arabia, and secondarily whether gender plays a role in CVST. Materials and Methods: Data were collected retrospectively from the stroke registry during the period from January 2008 to April 2018, and the patients with the diagnosis of CVST were identified, and data were analyzed for any gender-specific differences in clinical presentation and etiology of cerebral venous thrombosis. Results: There were 15 females while 11 males with a female:male ratio of 1.4:1. The mean age was 29.4± standard deviation 8.9 with the age range of 15–49. Headache was the most common and usually the first presenting symptoms present in 65% followed by hemiparesis and cranial nerve palsies. The first neurological examination was normal in 9/26 (34.6%) of the patients, while the common abnormality was cranial nerve palsies. Infections and trauma played an important part in risk factor analysis of our patient after the pregnancy- and hormone-related conditions. Some significant differences between the clinical presentation and risk factors among males and females were noted as age at presentation was higher in females while trauma and infections were common in male patients, although the involvement of the sinuses and response to treatment did not prove to be statistically significant. Conclusion: The results of this study were similar to the available literature with few differences. The relatively higher proportion of males in our study can be explained partly with more cases of traumatic CVST. Some important differences were noted between the risk factors and clinical presentation among genders. Large-scale prospective studies are needed to further clarify these differences.
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Dietary pattern in adult patients with acute stroke in South India: A Case-Control Study from a Tertiary Care Center in Hyderabad Highly accessed article p. 283
Adabala Vijaya Durga, Sandhya Manorenj
DOI:10.4103/jnrp.jnrp_237_18  
Background and Objective: Diet plays a crucial role in the occurrence of stroke. But very few studies have so far been conducted with focus on this aspect of acute stroke in India. The objective of the study was to identify the dietary pattern in patients with acute stroke in South India. Materials and Methods: Patients with first-ever acute stroke (ischemic and hemorrhagic) admitted between June 2017 and November 2017 were enrolled and compared with age- and sex-matched controls. Information was collected using a pro forma. Results: Out of 293 acute stroke patients, 150 were enrolled and compared with 150 controls. The mean age was 52.3 ± 12.6; years 112 (74.6%) patients were male. The majority of them were on traditional diet that included a daily intake of rice (98.6%) and pulses (40.6%). Hypertension (73.3%) was the major vascular risk factor for stroke (P < 0.0001). Significant differences were observed in risk factors such as diabetes (P < 0.0001), smoking (P = 0.0001), alcohol use (P = 0.0017), and heart disease (P = 0.0002), when stroke patients were compared with controls. Stroke patients reported a lower intake of green leafy vegetables (P = 0.0001; odds ratio [OR] 0.17), roots and tubers (P = 0.0016; OR 0.21), and fruits (P = 0.0022; OR 0.29). There was at the same time a higher intake of red meat products (P = 0.04; OR 2.41), organ meats (P = 0.0093; OR 4.35), fried snacks (P = 0.0038; OR 2.01), and pickles (P = 0.04; OR 1.81) although the data suggested lesser consumption of prawn and crab (P = 0.04; OR 0.55) and water (P = 0.0001 OR 4.59) among stroke patients. Higher consumption of fruit juices (P = 0.0008) and junk foods (P = 0.03) was observed in young stroke patients (age ≤45 years) whereas the intake of chicken (P = 0.03) and alcohol (P = 0.0001) was observed to be more among men than among women. Conclusion: Majority of stroke-afflicted patients in South India consume white rice and dal. There is lower intake of water, green leafy vegetables, and fruits and higher consumption of red meat, organ meat, and pickles among stroke patients.
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Extended window for stroke thrombectomy Highly accessed article p. 294
Brian Snelling, David J Mccarthy, Stephanie Chen, Samir Sur, Omar Elwardany, Dallas L Sheinberg, Dileep R Yavagal, Eric C Peterson, Robert M Starke
DOI:10.4103/jnrp.jnrp_365_18  
Objective: Mechanical thrombectomy is the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke (AIS) up to 6 h after onset. Recent trials have demonstrated a benefit for wake-up strokes and patients beyond 6 h. Methods: A systematic literature review was conducted for multicenter randomized clinical trials (RCTs) investigating endovascular stroke treatment using perfusion imaging to identify patients that may benefit from mechanical thrombectomy for AIS beyond 6 h of onset. Random effects meta-analysis was used to analyze the following outcomes: 90-day functional independence rates with modified Rankin Scale (mRS ≤2), 90-day mortality, and symptomatic intracranial hemorrhage (sICH) rates. Further stratification was carried out by age and presentation. Results: Two multicenter RCT's were included as follows: DAWN and DEFUSE-3. Pooled 90-day functional independence rates favored endovascular management (odds ratio [OR] 5.01; P < 0.00001). Subgroup analysis demonstrated continued 90-day functional independence benefit for endovascular management regardless of age (≥80 years, OR 5.65, P = 0.01; ≤80 years, OR 4.92, P < 0.00001). When stratified for the manner of stroke discovery, 90-day functional independence rates favored endovascular management for wake-up strokes (OR 8.74, P < 0.00001) and known-time onset strokes (OR 5.08, 95% confidence interval [CI] 2.04–12.65, P = 0.0005), although no benefit was observed for unwitnessed strokes (OR 1.64, 95% CI 0.17–16.04, P = 0.67). No difference observed in 90-day mortality rates (OR 0.71; P = 0.14) or in SICH rates (OR 1.67; P = 0.29). Conclusions: This meta-analysis reinforces that endovascular management is superior to standard medical management alone for the treatment of AIS due to LVO beyond 6 h of onset in patients with perfusion-imaging selection.
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REVIEW ARTICLE Top

Substance use disorder in people with intellectual disabilities: Current challenges in low- and middle-income countries p. 301
Ram Lakhan, Hari Krishna Raju Sagiraju, Olúgbémiga Ekúndayò, Manoj Sharma
DOI:10.4103/jnrp.jnrp_393_18  
Use of illegal and prescription drugs has significantly increased in recent years all over the world in most populations. Greater worldwide awareness in this regard has substantially improved the epidemiological understanding of substance use, its risk factors, and impact on life. People with intellectual disabilities constitute 0.5%–1.5% of the world's population. It can be conjectured that they might be experiencing similar or even a greater burden of substance use in their lives. This article highlights some important aspects of substance use among this population in low- and middle-income countries that need urgent attention.
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CASE SERIES Top

Symptomatic thoracic intramedullary arachnoid cyst: “A Rare Entity” report of two cases with short review of literature p. 306
Naresh Panwar, Devendra Kumar Purohit, Somnath Sharma, Sanjeev Chopra
DOI:10.4103/jnrp.jnrp_246_18  
Spinal arachnoid cysts are uncommon benign lesions of spine axis and most commonly present as compressive myelopathy. Intramedullary arachnoid cyst is uncommonly seen, hence, not much discussed in literature. Due to rarity of this entity, many questions are yet to be answered and should be addressed properly, particularly related to etiopathogenesis, accustomed course, behavior, differential diagnosis, and the best treatment modality. We report the clinicopathological profile of thoracic intramedullary arachnoid cysts in two adult patients, and present a detailed review of available literature on the spinal intramedullary arachnoid cyst. Most of the literature concerning with intramedullary arachnoid cysts are in the form of case reports from pediatrics population. As far to the best of our knowledge, only a few cases excluding our two were found in both pediatrics and adult population.
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Symptomatic extracranial carotid artery thrombus: An Indian experience p. 312
Vivek Karan, Devashish Vyas, Vikram Bohra, Vikram Huded
DOI:10.4103/jnrp.jnrp_225_18  
Introduction: Symptomatic intraluminal carotid artery thrombus (ICT) is an uncommon finding, whose incidence increases with the percentage of stenosis. The optimal treatment modality to address carotid artery thrombus is not well established. We present our data of medical management of carotid artery thrombus with antiplatelet and anticoagulation. Methods: We reviewed our data from January 1, 2016 to December 31, 2017. Patients with extracranial carotid artery thrombus underwent a catheter digital subtraction angiogram to confirm the presence of thrombus. Medical management was done with dual antiplatelets along with low-molecular-weight heparin, and a check angiogram was done after 14 days. Factors contributing to the persistence of thrombus were analyzed. Results: A total of 21 patients diagnosed with acute ischemic stroke and extracranial carotid artery thrombus. Three patients opted for endarterectomy. Eighteen patients underwent medical management. Nine (50%) had a resolution of thrombus. Those with persistent thrombus were significantly older (average age 64 vs. 43 years, P = 0.008). They also had significantly higher proportions of hypertension (100% vs. 44%, P = 0.029), diabetes mellitus (89% vs. 11%, P = 0.003), and underlying carotid stenosis (100% vs. 33%, P = 0.009). Conclusion: Our regimen of dual antiplatelets plus short-term anticoagulation is safe and effective in the management of ICT. Large-scale studies are warranted to determine the optimal regimen and duration of medical treatment.
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Spinal cord ependymoma – Surgical management and outcome p. 316
Wail Mohammed, Michael Farrell, Ciaran Bolger
DOI:10.4103/jnrp.jnrp_267_18  
Background: Ependymoma is a common primary neoplasm of the spinal cord and filum terminale. Patients with spinal ependymoma usually experience gradual symptoms due to slow progression of the tumor; thus, early diagnosis can be challenging to make. Objective: The objective of this study was to report 5 years' experience in treating spinal intramedullary ependymomas and to illustrate the advantage of aggressive complete resection whenever possible. Patients and Methods: Retrospective medical notes of all patients with spinal ependymoma treated surgically over a 5-year period between January 2003 and January 2008 were recorded. Clinical presentation, spinal level, extent of resection, and complications were recorded. A prolonged follow-up was documented. Results: There were 20 patients – 11 males, and nine females –included in this study. Their median age was 48 years (range 3–75 years). In 18 patients, total gross resection was achieved. Subtotal resection was only possible in one patient due to surgical difficulty. One patient underwent biopsy and referred for further surgery and subsequently had total resection. Conclusions: Radical total resection is achievable in spinal ependymomas, with minimal resultant morbidity.
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IMAGES IN NEUROSCIENCES Top

Sandwich neurovascular conflict of optic chiasm p. 321
Manchikanti Venkatesh, GH Jhansi Priya, Amit Agrawal
DOI:10.4103/jnrp.jnrp_279_18  
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Aneurysm masquerading as a pure seller lesion p. 323
Sunil Munakomi
DOI:10.4103/jnrp.jnrp_238_18  
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CASE REPORTS Top

A treatable encephalopathy in a peritoneal dialysis patient - cefepime-induced encephalopathy p. 324
Ching Soong Khoo, Tze Yuan Tee, Hui Jan Tan, Raymond Azman Ali
DOI:10.4103/jnrp.jnrp_315_18  
We report a patient with end-stage renal disease on peritoneal dialysis, who developed encephalopathy after receiving a few doses of cefepime. He recovered clinically and electroencephalographically after having discontinued the culprit agent and undergone hemodialysis. This case highlights the importance of promptly recognizing this reversible encephalopathy, which can lead to the avoidance of unnecessary workup, reduce the length of hospital stay, and thereby improve the patients' outcome.
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Tuberculosis: A common infection with rare presentation, isolated sellar tuberculoma with panhypopituitarism p. 327
Vivek Mahesh Agrawal, Pramod Janardhan Giri
DOI:10.4103/jnrp.jnrp_332_18  
Isolated sellar tuberculoma is a very rare condition and usually presents with headache and decreased vision. It can present with panhypopituitarism with 3rd nerve palsy. Tuberculoma mimics pituitary adenoma clinically as well as radiologically and requires endoscopic transsphenoidal surgery and histopathological examination for the final diagnosis. We present a rare case of a 40-year-old female presented with headache, decreased vision, and unilateral 3rd nerve palsy with panhypopituitarism.
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Microsurgical management for aneurysm arising from a low-lying internal carotid artery-posterior communicating artery bifurcation through the anterior temporal approach p. 331
Taro Suzuki, Hiroshi Kashimura, Yosuke Akamatsu, Kenta Aso
DOI:10.4103/jnrp.jnrp_274_18  
A low-lying internal carotid artery (ICA) running closer to the skull base than in usual cases prevents use of the standard transsylvian approach (TSA) to view an aneurysm through the retrocarotid space. A 75-year-old male had a 10-day history of headache and left eyelid ptosis. Initial computed tomography (CT) showed no evidence of subarachnoid hemorrhage. Emergency three-dimensional CT angiography showed a saccular aneurysm with bleb arising from the left horizontally projecting ICA. The aneurysm was approached through the TSA but could not be visualized well. We used the anterior temporal approach (ATA) followed by the TSA, offering a more lateral line of vision and allowing the surgeon to visualize the aneurysmal neck. The aneurysm was successfully obliterated. The ATA provided a better lateral view than the standard TSA for the ICA aneurysm. We emphasize the effectiveness of ATA for aneurysm arising from a low-lying IC-posterior communicating artery bifurcation.
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Concurrent venous stenting of the transverse and occipito-marginal sinuses: An analogy with parallel hemodynamic circuits p. 334
Thomas J Buell, Daniel M S. Raper, Dale Ding, Ching-Jen Chen, Tony R Wang, Davis G Taylor, Adeel Ilyas, Mohammad Y S. Kalani, Min S Park, Kelly B Mahaney, Kenneth C Liu
DOI:10.4103/jnrp.jnrp_259_18  
Nonthrombotic intracranial venous occlusive disease (NIVOD) has been implicated in the pathophysiology of idiopathic intracranial hypertension (IIH) and various non-IIH headache syndromes. Endovascular stenting of stenotic, dominant transverse sinuses (TSs) may reduce trans-stenosis pressure gradients, decrease intracranial pressure, and alleviate symptoms in a subset of NIVOD patients. We present a case in which concurrent stenting of the occipito-marginal sinus obliterated the residual trans-stenosis pressure gradient across an initially stented dominant TS. We hypothesize that this observation may be explained using an electric-hydraulic analogy, and that this patient's dominant TS and occipito-marginal sinus may be modeled as a parallel hemodynamic circuit. Neurointerventionalists should be aware of parallel hemodynamic drainage patterns and consider manometry and possibly additional stenting of stenotic, parallel venous outflow pathways if TS stenting alone fails to obliterate the trans-stenosis pressure gradient.
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Blooming in the hypothalamus p. 339
Santosh P V. Rai, Shrijeet Chakraborti, Parvathi Chandran, Muralidhar V Pai
DOI:10.4103/jnrp.jnrp_282_18  
Cavernomas are vascular malformations which are collections of endothelium-lined sinusoids without intervening cerebral parenchyma. Hypothalamic location of cavernoma is extremely rare. We present a case of a 34-year-old male who presented with complaints of recent memory loss and vomiting. On magnetic resonance imaging with gradient sequences and contrast, a diagnosis of hypothalamic cavernoma was suggested. Excision of lesion was performed by a right parasagittal pericoronal craniotomy via transcallosal approach. Intraoperative findings and histopathology examination corroborated the diagnosis. The uniqueness of this case report is in the susceptibility-weighted sequence which led to the radiological diagnosis.
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Ventriculoperitoneal shunt disconnection, shunt migration, and silent bowel perforation in a 10-year-old boy p. 342
Rajendra Kumar Ghritlaharey
DOI:10.4103/jnrp.jnrp_329_18  
A 10-year-old boy was admitted with chest wall infection around the implanted ventriculoperitoneal shunt (VPS) catheter of 5 days. He had received a right-sided, medium pressure, whole-length VPS for hydrocephalus, following tubercular meningitis at the age of 3 years. Seven years, 9 months following VPS implantation, he was admitted with shunt tract infection at the chest area for 5 days. He had neither fever nor features of meningitis, raised intracranial pressure, or peritonitis. His clinical examination and radiological investigations revealed that the VPS catheter was disconnected at the cranial site, and it was migrated downward up to the upper chest. He was managed well with the removal of the entire VPS catheter. The removed peritoneal catheter along with the shunt chamber was loaded with fecal matter and was presumed that the peritoneal catheter was within the colon. His postoperative recovery was excellent. This is a rare case of VPS catheter disconnection, shunt migration, and silent bowel perforation by peritoneal catheter, and all the above-mentioned complications were detected in a child at the same time and were managed well with the removal of the entire VPS catheter.
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Isolated lingual dystonia as the manifestation of acute extrapyramidal syndrome induced by metoclopramide p. 346
Rajesh Verma, Chetan Shettigar
DOI:10.4103/jnrp.jnrp_355_18  
Oromandibular dystonia is characterized by persistent contractions and repetitive spasms of masticatory muscles surrounding the oral cavity and lingual muscles. The lingual dystonia is rare hyperkinetic movement disorder, often occurring secondary to drugs. The common drugs which can cause acute focal dystonia are neuroleptics, antiemetics, and antipsychotics. Isolated lingual dystonia is a rare form of disabling focal dystonias. We report a young female, who developed tongue dystonia in isolation and responding favorably to antihistaminics. The physicians are advised to make inquiry about administered drugs in isolated lingual dystonia.
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Dural ectasia of the optic nerve: A rare presentation in neurofibromatosis Type I p. 349
Minhaj Shaikh, Pushpinder Khera, Taruna Yadav, Pawan Garg
DOI:10.4103/jnrp.jnrp_232_18  
Neurofibromatosis Type 1 (NF-1) is a common neurocutaneous syndrome with a characteristic spectrum of pathologies affecting the optic pathway. Optic pathway glioma and optic nerve meningioma are two such common afflictions of the optic nerve in NF-1. Dural ectasia of the optic nerve also known as optic nerve meningocele is a rare manifestation of optic nerve involvement in NF-1. Magnetic resonance imaging (MRI) is an excellent modality to accurately identify, characterize, delineate, and differentiate dural ectasia of the optic nerve from the commoner lesions such as optic glioma and meningioma in NF-1. We describe a case of a young woman with NF and a large recurrent palpebral neurofibroma. MRI evaluation of the orbits revealed extensive ectasia of the dura lining the cerebrospinal fluid sheath around all the segments of the optic nerve and around the optic chiasm.
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Dorsal spinal intradural intramedullary epidermoid cyst: A rare case report and review of literature p. 352
Siddartha Reddy Musali, Imran Mohammed, Prakash Rao Gollapudi, Sai Kumar Maley
DOI:10.4103/jnrp.jnrp_304_18  
Epidermoid cysts are commonly seen intracranial lesions but their occurrence in the spine is rare. They account for <1% of all the benign tumors of the spine. These are benign epithelial-lined cysts filled with keratin. They are classified into two types: congenital or acquired. Congenital epidermoid cysts are more commonly associated with spinal dysraphic states such as syringomyelia, dermal sinus and spina bifida whereas the acquired cysts are associated with repeated lumbar punctures. Based on the location, they can be extradural, intradural, extramedullary, or intramedullary. Most of the epidermoids are intradural extramedullary. Intramedullary epidermoid cysts are very uncommon. We report a case of a 6-year-old female patient with dorsal epidermoid cyst with neurological deficits. Magnetic resonance imaging of the spine showed a well-defined lesion from D9 to D12 which was hypointense on T1W1 and heterogeneously hyperintense on T2W2. Surgery was performed to excise the lesion and to decompress the spinal cord. Histopathological examination of the excised lesion confirmed it as an epidermoid cyst.
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Decompression hemicraniectomy for refractory intracranial hypertension in reversible cerebral vasoconstriction syndrome p. 355
Naresh Mullaguri, Anusha Battineni, Pravin George, Christopher Ryan Newey
DOI:10.4103/jnrp.jnrp_334_18  
Reversible cerebral vasoconstriction syndrome (RCVS) is a disorder of dysregulation of cerebrovascular tone resulting in transient segmental vasoconstriction which resolves in 1–3 months. Cerebral edema is an underrecognized complication in RCVS. It is likely multifactorial. This edema can lead to intracranial hypertension that can be refractory to medical management. Limited evidence exists regarding surgical management of intracranial hypertension in RCVS. We present a 29-year-old Caucasian right-handed female patient with a medical history of migraine, polysubstance abuse presented to the emergency department (ED) daily for 3 days with the chief complaint of recurrent thunderclap headache. She declined neuroimaging and lumbar puncture. She was treated for migraine with abortive medications with no improvement. During the third ED visit, she became lethargic with right-sided homonymous hemianopia. Computerized tomography of the brain showed left parietal intracerebral hemorrhage with intraventricular extension, cortical subarachnoid hemorrhage, and diffuse cerebral edema. Digital subtraction angiography showed multifocal moderate-to-severe segmental vasoconstriction suggestive of vasculopathy. Oral verapamil was initiated. Continuous intracranial pressure monitoring showed uncontrolled intracranial hypertension, despite maximal medical management with hyperosmolar therapy, induced coma, and hypothermia. Decompressive hemicraniectomy with duraplasty was performed for refractory intracranial hypertension. We provisionally diagnosed her with RCVS. She was discharged to inpatient rehabilitation with residual right homonymous hemianopia. Transcranial Doppler study during follow-up showed improved mean flow velocities. She continued to have residual cognitive deficits with complete resolution of headache.
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Cerebellar liponeurocytoma: A rare fatty tumor and its literature review p. 360
Harsh Deora, AR Prabhuraj, Jitender Saini, TC Yasha, Arivazhagan Arimappamagan
DOI:10.4103/jnrp.jnrp_266_18  
Cerebellar liponeurocytoma is a rare oncological entity, and the knowledge about the treatment and outcome of these rare tumors is still evolving. Very few cases have been described in literature. We report a middle-aged male who presented with raised intracranial pressure features and gait ataxia. His imaging features revealed classical features of liponeurocytoma in cerebellar vermis, with abundant fat component evident in both computed tomography and magnetic resonance imaging. He underwent resection of the lesion and has been asymptomatic for 4 years. This report describes the classical radiological and immunohistochemical features of this rare entity with favorable outcome and reviews the existing literature.
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A rare case of an extensive multi-compartment epidermoid presenting with pure motor trigeminal neuropathy, case report and review of literature p. 364
Jaypalsinh Gohil, Gopikrishnan Rajasekar, Pankaj Shivhare, Prakash Nair, Mathew Abraham
DOI:10.4103/jnrp.jnrp_277_18  
Epidermoid cysts are benign slow-growing tumors, clinical signs and symptoms at the time of presentation are related to the location and extent of the lesion. The motor fibers of the trigeminal nerve are fairly resistant to extraneous compression. Intracranial lesions in the vicinity of the trigeminal nerve usually present with sensory symptoms without affecting the motor component. We report a rare case of a middle cranial fossa epidermoid presenting with pure motor trigeminal neuropathy.
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Cerebral coenurosis masquerading as malignancy: A rare case report from India p. 367
Shamila Mohamed Ali, P Somashekara Reddy, S Venugopal, Manmeet Chhabra, Anita Mahadevan
DOI:10.4103/jnrp.jnrp_296_18  
Human coenurosis is a rare zoonotic disease caused by the larvae of Tinea multiceps seen in sheep-rearing countries. We report the case of a 63-year-old male who was referred to our hospital with a working diagnosis of skull base chondrosarcoma. Histopathological examination after surgical excision revealed characteristic feature of coenurus with multiple scolices invaginating from the outer cuticular layer. Coenuri are often mistaken for giant cysticercal cysts and hydatid cysts. Despite its wide prevalence in cattle, only two cases of human coenurosis are reported from India till date. We report the third case from India.
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Intracranial hemorrhage in a young woman: An unusual initial presentation of undiagnosed choriocarcinoma p. 371
Navneet Agarwal, SK Jain, Vinod Sharma, Shashi Singhvi, Sapna Gandhi
DOI:10.4103/jnrp.jnrp_307_18  
Choriocarcinoma is an uncommon tumor. Undiagnosed choriocarcinoma initially presenting with intracranial hemorrhage in an apparently healthy female is rare and presents a diagnostic difficulty. The authors report a case presenting as intracranial hemorrhage of unsuspected choriocarcinoma. As the measurement of beta-human chorionic gonadotropin (β-hCG) would have helped in the preoperative diagnosis, estimation of serum β-hCG levels is suggested in the diagnostic workup of a female of reproductive age group when radiological investigations are inconclusive. Craniotomy and excision of tumor followed by chemotherapy and radiotherapy may improve the outcome.
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Concurrent spinal epidural tubercular and pyogenic abscess of cervical spine without bony involvement p. 374
Batuk Diyora, Swapnil Patil, Bhagyashri Bhende, Mehool Patel, Gagan Dhall, Naren Nayak
DOI:10.4103/jnrp.jnrp_318_18  
Spinal epidural abscess (SEA) presents with vertebral body involvement. SEA is mostly pyogenic in developed countries, but in developing countries, tuberculosis is more common cause. Young female presented with fever, neck, and right upper limb pain for 1 month followed by acute onset weakness in the right upper limb. Magnetic resonance imaging study of cervical spine showed contrast-enhancing lesion in C2–C3 epidural region. Surgery-aided by initiation of antibacterial and antitubercular treatment based on culture and histopathological study of pus helped us to get good clinical outcome. One should always keep in mind possibility of tubercular abscess while treating cases of spinal epidural lesions, though it is rare in the absence of osseous involvement. Pyogenic and tubercular abscess can present concurrently and sending pus for culture and sensitivity is must as it plays important role in identifying dual organisms.
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LETTERS TO THE EDITOR Top

Consider stroke-like episodes as a differential in children with acute hemiparesis p. 379
Josef Finsterer
DOI:10.4103/jnrp.jnrp_357_18  
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A rare case of thoracic subdural hematoma after recovery from dengue fever p. 380
Shalendra Singh, Deepak Dwivedi, Navdeep Sethi, Debashish Paul
DOI:10.4103/jnrp.jnrp_314_18  
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Extramedullary tanycytic ependymoma in a 12-year-old boy p. 381
Preston D’Souza, William E Martin, Surender Bodhireddy, Muhittin Belirgen
DOI:10.4103/jnrp.jnrp_263_18  
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Commentary p. 383
Dilip Kumar Das
DOI:10.4103/jnrp.jnrp_431_18  
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Commentary p. 385
Sujata Chaturvedi
DOI:10.4103/jnrp.jnrp_426_18  
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Intravenous use of lemon juice with brown sugar: A potentially fatal cook-up technique? p. 386
Sourav Khanra, Amiya Krushna Sahu, Christoday Raja Jayant Khess
DOI:10.4103/jnrp.jnrp_333_18  
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