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Mild traumatic brain injury (mTBI) is the commonest form of TBI. Though the name implies, it may not be mild in certain cases. There is a lot of heterogeneity in nomenclature, classification, evaluation and outcome of mTBI. We have reviewed the relevant articles on mTBI in adults, particularly its definition, evaluation and outcome, published in the last decade. The aspects of mTBI like pediatric age group, sports concussion, and postconcussion syndrome were not reviewed. There is general agreement that Glasgow coma score (GCS) of 13 should not be considered as mTBI as the risk of intracranial lesion is higher than in patients with GCS 14-15. All patients with GCS of <15 should be evaluated with a computed tomography (CT) scan. Patients with GCS 15 and risk factors or neurological symptoms should also be evaluated with CT scan. The outcome of mTBI depends on the combination of preinjury, injury and postinjury factors. Overall outcome of mTBI is good with mortality around 0.1% and disability around 10%.

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Alzheimer's disease (AD) is a devastative neurodegenerative disorder which needs adequate studies on effective treatment options. The extracts of plants and their effect on the amelioration of AD symptoms have been extensively studied. This paper summarizes the mechanisms like acetylcholinesterase (AChE) inhibition, modification of monoamines, antiamyloid aggregation effect, and antioxidant activity which are actively entailed in the process of amelioration of AD symptoms. These effects are induced by extracts of a few plants of different origin like Yizhi Jiannao, Moringa oleifera (Drumstick tree), Ginkgo Biloba (Ginkgo/Maidenhair tree), Cassia obtisufolia (Sicklepod), Desmodium gangeticum (Sal Leaved Desmodium), Melissa officinalis (Lemon Balm), and Salvia officinalis (Garden sage, common sage).

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Background: Trauma is one of the common surgical emergencies presenting at B. P. Koirala Institute of Health Sciences (BPKIHS), Nepal, a tertiary referral center catering to the needs of the population of Eastern Nepal and nearby districts of India. Objective: The objective of this study is to analyze the magnitude, epidemiological, clinical profile and outcome of trauma at B P Koirala Institute of Health Sciences. Materials and Methods: This descriptive case series study includes all patients with history of trauma coming to BPKIHS emergency and referred to the surgery department. We noted the detailed clinical history and examination, demographics, mechanism of injury, nature of injury, time of reporting in emergency, treatment offered (operative or non operative management) and analyzed details of operative procedure (i.e. laparotomy, thoracotomy, craniotomy etc.), average length of hospital stay, morbidity and outcome (according to Glasgow outcome scale). Collected data were analyzed using EpiInfo 2000 statistical software. Results: There were 1848 patients eligible to be included in the study. The mean age of the patients was 28.9 ± 19.3 years. Majority of the patients (38%) belonged to the age group of 21 - 40 years and the male to female ratio was 2.7:1. Most of the trauma victims were students (30%) followed by laborers (27%) and farmers (22%) respectively. The commonest causes of injury were fall from height (39%), road traffic accident (38%) and physical assault (18%); 78% of the patients were managed conservatively and 22% underwent operative management. Postoperative complications were seen in 18%. Wound infection 7.5%, neurological deficit including cerebrospinal fluid (CSF) otrorrhea was seen in 2.2% patients. Good recovery was seen in 84%, moderate disability in 5.2% patients and severe disability in 1.4% patients. The mortally was 6.3% and most of the deaths were related to traumatic brain injuries. Conclusions: In Nepal, trauma-related injury contributes significantly to morbidity and mortality and is the third leading cause of death. There are very few studies on trauma from this country and hence this study will help in understanding the etiology and outcome particularly in the Eastern region of Nepal.

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Introduction: Hand splinting after stroke is a common practice despite inadequate evidence. This warrants a better understanding of the therapists' splinting practice, to develop clinically meaningful treatment options. Aims: The study examined the nature and prevalence of the factors associated with therapists' hand splinting practice and their perceived splinting efficacy. Settings and Design: A cross-sectional national survey of hand-splinting practice among inpatient occupational therapists (OTs) in Ireland. Materials and Methods: Sixty-two therapists participated in this national survey.Statistical analysis used: A number of factors were analyzed to explore their relationship with therapists' perception of splint efficacy using Spearman's rank order correlation. Results: 53(85.5%) out of 62 survey respondents prescribed splints to their clients at the time of taking the survey. To reduce spasticity, to correct contractures and thus increase range of motion (ROM) were the commonly used splinting goals. These were the goals that were significantly associated with the therapists' splinting efficacy too. Conclusions: Hand-splint prescription following stroke was found to be a common practice among OTs who perceive splints to be quite effective. A custom-made, volar forearm-based wrist-hand splint is the preferred splint among therapists to achieve a number of clinical aims such as improving ROM, stretching soft tissue contractures and reducing spasticity in the upper extremity. A wide variety of splinting regimens is currently practiced, reflecting the lack of a universally accepted and comprehensive practice guideline to regulate therapy. Methodologically valid clinical trials evaluating the efficacy of therapist-preferred splints in achieving their favored outcomes are needed. Development of common, universally accepted therapeutic guidelines based on comprehensive scientific review of such studies is thus needed.

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Inca bones are accessory bones found in neurocranium of human skulls. Occurrence of Inca bones is rare as compared to other inter sutural bones such as wormian bones. These Inca ossicles are regarded as variants of the normal. The reporting of such occurrences is inadequate from Central India. Objectives: To find the incidence of Inca variants in Central India. Materials and Methods: In the present study, 380 dried adult human skulls were examined. All specimen samples were procured from various Medical colleges of Central India. They were analyzed for gross incidence, sexual dimorphism and number of fragments of Inca bones. Results: Gross incidence of Inca bones was found to be 1.315 %. Incidence rate was higher in male skulls than female skulls (male: 1.428%; female: 1.176%). The Inca bones frequently occurred signally. Out of the five observed Inca ossicles, two were fragmented. Conclusions: This data gives idea regarding gross incidence, sexual dimorphism and number of fragments of Inca bones in neurocranium of human skulls from Central India. The knowledge of this variable is useful for neurosurgeons, anthropologists and radiologists.

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Cranioplasty is the surgical intervention to repair cranial defects. The aim of cranioplasty is not only a cosmetic issue; also, the repair of cranial defects gives relief to psychological drawbacks and increases the social performances. Many different types of materials were used throughout the history of cranioplasty. With the evolving biomedical technology, new materials are available to be used by the surgeons. Although many different materials and techniques had been described, there is still no consensus about the best material, and ongoing researches on both biologic and nonbiologic substitutions continue aiming to develop the ideal reconstruction materials. In this article, the principle materials and techniques of cranioplasty are reviewed.

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Background: The community-based mental health studies have revealed that the point prevalence of depressive disorders in the elderly population of the world varies between 10% and 20% depending on cultural situations. Objective: To determine the median prevalence rates of depressive disorders in the elderly population of India and various other countries in the world. Materials and Methods: A retrospective study based on meta-analysis of various study reports. Setting: Community-based mental health surveys on geriatric depressive disorders conducted in the continents of Asia, Europe, Australia, North America, and South America. Study Period: All the studies that constituted the sample were conducted between 1955 and 2005. Sample Size: After applying the inclusion and exclusion criteria on published and indexed articles, 74 original research studies that surveyed a total of 4,87,275 elderly individuals in the age group of 60 years and above, residing in various parts of the world were included for the final analysis. Inclusion Criteria: The researchers had included only community-based cross-sectional surveys and some prospective studies that had not excluded depression on baseline. These studies were conducted on homogenous community of elderly population in the world, who were selected by simple random sampling technique. Exclusion Criteria: All the unpublished reports and unavailable or unanalyzed or inaccessible articles from the internet were excluded from the study. Statistical Analysis: The median prevalence rate and its corresponding interquartile range (IQR), Chi-square test, and Chi-square for Linear Trend were applied. A P value < 0.05 was considered as statistically significant. Results and Conclusion: The median prevalence rate of depressive disorders in the world for the elderly population was determined to be 10.3% [IQR = (4.7%-16.0%)]. The median prevalence rate of depression among the elderly Indian population was determined to be 21.9% [IQR = (11.6%-31.1%)]. Although there was a significant decrease trend in world prevalence of geriatric depression, it was significantly higher among Indians in recent years than the rest of the world.

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We report an unusual association of pulmonary tuberculosis with moyamoya syndrome in a 30-year-old Filipino female who was admitted to our hospital with a 1-week history of fever and cough. Chest X-ray showed widespread bilateral consolidation with cavity, whereas sputum was positive for acid fast bacilli (AFB). Two weeks after starting antituberculous treatment, the patient developed two episodes of loss of consciousness, which were unwitnessed. Urgent brain computed tomography (CT) showed multiple infarctions, suggesting vasculitis. The electroencephalogram showed epileptic discharges. Magnetic resonance angiography showed a picture consistent with moyamoya disease. Brain CT angiography was performed and it showed the same pictures. The patient was diagnosed with pulmonary tuberculosis-associated moyamoya syndrome. On the following days, she was discharged on antituberculous medications, antiepileptic and oral hypoglycemic treatment. After 1 year, the patient was seen in the clinic, she was well and seizure-free.

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Cerebral amyloid angiopathy (CAA) is an important cause of primary intracerebral hemorrhage (PICH) in the elderly. Although there are no pathognomic clinical features of CAA-related PICH, the association of white matter changes with lobar, recurrent, or multiple simultaneous hemorrhages in older patients should raise the suspicion of its diagnosis. A definitive diagnosis of CAA requires pathologic examination of the affected tissue. However, with modern imaging techniques, it is possible to diagnose the "probable CAA" in patients presenting with PICH. Gradient-echo magnetic resonance imaging is a very sensitive, noninvasive technique for identifying microhemorrhages in life. The diagnosis of CAA is important because of the likely implication it has on future management targeted to reduce risk of future bleeding.

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Varicella zoster infection is known to cause neurological involvement. The infection is usually self-limiting and resolves without sequelae. We present a series of three cases with neurological presentations following chicken pox infection. The first case is a case of meningitis, cerebellitis and polyradiculopathy, the second is a florid case of acute infective demyelinating polyradiculoneuropathy (Guillian-Barrι syndrome) in a middle-aged female and the third case is a young man in whom we diagnosed acute transverse myelitis. All these cases presented with distinct neurological diagnoses and the etiology was established on the basis of history and serological tests confirmatory for chicken pox. The cases responded differently to treatment and the patients were left with minimum disability.

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The authors present a rare case of calcified (ossified) chronic epidural hematoma developed in a six-and-a-half-year-old female patient who was operated for cerebellar astrocytoma 6 months earlier. There was no history of trauma. Ossified epidural hematoma was seen as an incidental finding in the follow-up in computed tomography scan after 6 months of primary glioma surgery. Ossified chronic epidural hematoma with thick collagenous wall and newly formed bone on dura was excised. The development of calcified chronic subdural hematoma after decompressive intracranial surgery is a well-known occurrence, but the fact that a calcified epidural hematoma, which is rare and which can also develop after decompressive surgery, and the occurrence of calcified (ossified) epidural hematoma after postfossa a glioma surgery is not yet reported. The second case is a 9-year-old male anemic child with a history of fall while playing 5 months earlier who presented with headache of 3 months duration. He had bifrontal calcified epidural hematoma operated by craniotomy and excision of calcified dural edge.

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Background: Trigeminal neuralgia typically involves nerves supplying teeth, jaws and face of older females. Though the etiology is usually obscure, different treatment modalities have been tried for it viz. medicinal treatment, injection alcohol, peripheral neurectomy, rhizotomy, and microvascular decompression etc. Transcutaneous electric nerve stimulation (TENS) is an emerging and promising option for management of such patients. Aims and Design: The present study was designed with an aim to study the efficacy of TENS in management of trigeminal neuralgia. Materials and Methods: The study was conducted on 30 patients of trigeminal neuralgia confirmed by diagnostic nerve block. They were given bursts of TENS for 20-40 days over the path of the affected nerve and subsequently evaluated at 1 month and 3 month intervals by visual analogue scale (VAS), verbal pain scale (VPS), a functional outcome scales for main daily activities like sleep, chewing, talking, or washing face. Results: The results showed that, on VAS, the score decreased from 8.9 (Pre TENS) to 3.1 at 1 month and 1.3 at 3 months, and on VPS, the score decreased from 3.5 (Pre TENS) to 1.2 at 1 month and 0.3 at 3 months. Similarly, a considerable decrease in scores was seen on functional outcome scale for different activities. No side effects like irritation or redness of skin were seen in any of the patients. Conclusions: Thus, TENS was found to be a safe, easily acceptable, and non-invasive outdoor patient department procedure for management of trigeminal neuralgia.

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Penetrating cranial injury is a potentially life-threatening condition. Injuries resulting from the use of angle grinders are numerous and cause high-velocity penetrating cranial injuries. We present a series of two penetrating head injuries associated with improper use of angle grinder, which resulted in shattering of disc into high velocity missiles with reference to management and prevention. One of those hit on the forehead of the operator and the other on the occipital region of the co-worker at a distance of five meters. The pathophysiological consequence of penetrating head injuries depends on the kinetic energy and trajectory of the object. In the nearby healthcare center the impacted broken disc was removed without realising the consequences and the wound was packed. As the conscious level declined in both, they were referred. CT brain revealed fracture in skull and changes in the brain in both. Expeditious removal of the penetrating foreign body and focal debridement of the scalp, skull, dura, and involved parenchyma and Watertight dural closure were carried out. The most important thing is not to remove the impacted foreign body at the site of accident. Craniectomy around the foreign body, debridement and removal of foreign body without zigzag motion are needed. Removal should be done following original direction of projectile injury. The neurological sequelae following the non missile penetrating head injuries are determined by the severity and location of initial injury as well as the rapidity of the exploration and fastidious debridement.

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Background: Screening at the community level will provide keys to promoting health and preventing diseases at the community level and serve as the fulcrum for timely detection and intervention. This study aims to assess the prevalence and nature of mental disorder among the general population using the patient health questionnaire (PHQ). It also compares the use of PHQ and GHQ as general screening tools for mental disorders. Materials and Methods: This community-based study is cross sectional in design. Multistage sampling technique was used to obtain a representative sample of the communities. The PHQ and GHQ-12 questionnaires were concurrently administered by health care workers that were nondoctors to screen for psychiatric symptoms. Results: A total of 758 participants took part in the study, 496 (65.4%) of the subjects had a form of psychopathology or the other using PHQ and 143 (18.9%) using GHQ questionnaire (χ² = 20.92, P = 0.000). Three hundred and thirty one subjects (43.7%) met the criteria for Somatoform disorder but 6.0% ever treated at PHC, 269 (35.5%) for depression and 4.8% ever treated, 127 (16.8%) for panic disorder and 5.5% ever treated, while 165 (21.8%) for general anxiety and 4.8% ever treated. Predictors of psychopathology were individuals who were singles (OR = 0.64, CI = 0.49-0.93) concerns about their health (OR = 3.06, CI = 2.06-4.56), worried about finance (OR = 1.84, CI = 1.27-2.67), worried about family life (OR = 2.68, CI = 1.61-4.72), and stressed at work (OR = 1.16, CI = 1.06-1.28). Conclusion: There is a high prevalence of psychopathology at the community level in this African population and few had ever been treated. PHQ as a general screening tool has a higher false-positive value compared to GHQ when used by nondoctors. PHQ should be used as an instrument to screen for specific mental disorders rather than a general screening tool for psychiatric morbidity at the community level.

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Background: Use of tobacco, alcohol, and other substances is a worldwide problem and affects many adolescents. Objective: (1) To find out the magnitude of licit and illicit substance use among students; and (2) to find out the association between socioeconomic and demographic characteristics of the students and habits of use. Materials and Methods: This was a population-based cross-sectional study conducted during June 2003 to May 2004. In a multistage random sampling among all the districts and schools in West Bengal, India, 416 high school students from two schools were selected. The main outcome measures were substance use, namely, tobacco, alcohol, and cannabinoids. From the schools, all the students in the classes VIII, IX, and X were taken as the study population and were administered a pretested close-ended anonymous self-administered questionnaire relating to pattern, frequency, and correlates of substance use. Results: The ultimate response rate was 87.02% and 416 students could be covered in our study. The overall prevalence rates among rural and urban students were 6.14% and 0.6% for illicit drug use, 8.60% and 11.04% for tobacco, and 7.37% and 5.23% for alcohol consumption, respectively. Both licit and illicit substance use was associated more with male students. Current and regular use were mostly restricted to tobacco, and the use of a substance by family members had a significant impact on its use by their children. "Enjoyment" and "Curiosity" were found to have the major influence in their decision to use a substance. Conclusions: Early identification of the magnitude and the factors related to substance use can improve scopes for planning and preventive approaches for this vulnerable group before the problems get serious after which interventions become difficult.

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Objectives: The study was undertaken to assess the adherence to World Health Organization (WHO)-multidrug therapy (MDT) and its successful completion by the leprosy patients and the extent of such defaulting, its correlates and reasons. Design: Retrograde cohort analysis was conducted during the first quarter of 2007 from the cases registered for WHO-MDT treatment during 2002 to 2005 in Kamrup district of Assam, India. Results: A total of 254 leprosy cases reflected the treatment seeking behavior of registered cases during the study period. Majority of the cases were from urban areas and defaulter rate higher in urban areas. The study group consisted of 60.63% males and 39.37% females.. Both the compliance and default was higher in the age group of 16 to 30 years. Majority of defaulters (32.28%) had passed the high school leaving certificate examination had per capita monthly income between Rs 500 - 749 (30.71%) and belonged to social class IV (33.86%) and V (30.71%). Significant statistical association was found between gender, literacy status, per capita income per month and socioeconomic status with treatment outcome. On analysis for the reasons of defaulting treatment; majority (33.07%) defaulted treatment due to loss of occupational hours when they come for receiving drugs at health center, 25.98% defaulted due to adverse reactions of drugs and 18.11% feared social stigma among major causes. Conclusions: The causes of defaulting treatment were related to gender, educational status, income as well as social class, or some combination of these. Recommendations, on strategic interventions to obviate the cause for noncompliance, were presented.

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Introduction: Tuberculous brain abscess (TBA) is a rare but serious condition. It resembles a pyogenic brain abscess clinically and radiologically and poses a problem in diagnosis and treatment. A final diagnosis is established by smear or culture demonstration of acid fast bacilli (AFB) within the abscess. Here, we report four such cases in our five-year study on brain abscesses, along with the different diagnostic modalities used. Materials and Methods: A total of 75 brain abscess pus specimens were collected during neurosurgery, either by burr hole or by craniotomy. These specimens were further subjected to Gram stain, Ziehl-Neelsen (ZN) stain, and conventional microbiological culture. Only those cases which showed presence of AFB on ZN stain along with the growth of Mycobacterium tuberculosis were considered as TBAs. Such TBA cases were further presented along with their In vitro Proton Magnetic Resonance (MR) Spectroscopic findings. Results: Of these four patients, three were males. Though this condition is more commonly seen in immunocompromised patients, three of the patients in this study were immunocompetent. All the four pus specimens showed presence of AFB in the ZN stain. Three of them grew M. tuberculosis as sole isolate. The fourth case was of concomitant tuberculous and pyogenic brain abscess. In vitro Proton MR spectroscopy of the pus specimens showed absence of multiple amino acids at 0.9 ppm, which was found to be hallmark of TBA. One patient died of four. Conclusions: TBA always poses a diagnostic dilemma. ZN stain and conventional microbiological culture for Mycobacteria always help to solve this dilemma. In vitro Proton MR Spectroscopy also seems to have the diagnostic utility.

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Background: Dengue infections may present with neurological complications. Whether these are due to neuromuscular disease or electrolyte imbalance is unclear. Materials and Methods: Eighty-eight patients of dengue fever required hospitalization during epidemic in year 2010. Twelve of them presented with acute neuromuscular weakness. We enrolled them for study. Diagnosis of dengue infection based on clinical profile of patients, positive serum IgM ELISA, NS1 antigen, and sero-typing. Complete hemogram, kidney and liver functions, serum electrolytes, and creatine phosphokinase (CPK) were tested. In addition, two patients underwent nerve conduction velocity (NCV) test and electromyography. Results: Twelve patients were included in the present study. Their age was between 18 and 34 years. Fever, myalgia, and motor weakness of limbs were most common presenting symptoms. Motor weakness developed on 2 ^nd to 4 ^th day of illness in 11 of 12 patients. In one patient, it developed on 10 ^th day of illness. Ten of 12 showed hypokalemia. One was of Guillain-Barré syndrome and other suffered from myositis; they underwent NCV and electromyography. Serum CPK and SGOT raised in 8 out of 12 patients. CPK of patient of myositis was 5098 IU. All of 12 patients had thrombocytopenia. WBC was in normal range. Dengue virus was isolated in three patients, and it was of serotype 1. CSF was normal in all. Within 24 hours, those with hypokalemia recovered by potassium correction. Conclusions: It was concluded that the dengue virus infection led to acute neuromuscular weakness because of hypokalemia, myositis, and Guillain-Barré syndrome. It was suggested to look for presence of hypokalemia in such patients.

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We present a case of a 42-year-old male, an old case of deep vein thrombosis on warfarin and other drugs like quetiapine, aspirin, diclofenac sodium, fenofibrate, atorvastatin, propanolol and citalopram for concurrent illnesses, who presented with widespread mucocutaneous bleeding and epidural spinal hematoma. The epidural bleed presented clinically as a nontraumatic, rapidly improving myeloradiculopathy. Magnetic resonance imaging (MRI) of the spine revealed an epidural hematoma at D12-L1 level. The case was managed conservatively due lack of neurosurgical facilities. The patient gained full neurological recovery on conservative management alone. This case highlights the problem of drug interaction on warfarin therapy and also an unusual spontaneous recovery of spinal hematoma. Our case was anticoagulated in the recommended therapeutic INR range of 2.2 to 2.4. Most of the similar cases reported in literature were also anticoagulated in the therapeutic range. Thus intraspinal hemorrhage is a rare but dangerous complication of anticoagulant therapy. It must be suspected in any patient on anticoagulant agents who complains of local or referred spinal pain associated with neurological deficits. Drug interactions with warfarin are common. High suspicion and immediate intervention are essential to prevent complications from intraspinal hemorrhage.

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