Annals of Indian Academy of Neurology
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Year : 2006  |  Volume : 9  |  Issue : 2  |  Page : 129-130

Neurological practice: An Indian perspective

Department of Neurophysiology and Senior Consultant Neurologist, Sir Ganga Ram Hospital, New Delhi, India

It is well known that the spectrum of neurological disorders varies considerably between countries and even in different regions of large countries depending on the environment, nutritional status, genetic profile and delivery of health care particularly with reference to preventive and promotive health programmes. Understandably, the pattern of diseases, natural history and outcome are different in developed and developing world. This profile is also undergoing rapid change as exemplified by the demographic and epidemiological transition in India with increased life expectancy, the burden of noncommunicable diseases being added to that of communicable diseases. Among the noncommunicable diseases, neurological disorders are emerging as a major concern to health policy makers and health providers. Half a century ago, western-trained neurologists had to grapple with the difference in the pattern of neurological diseases, as has been aptly stated by the editor, NH Wadia, in the introduction to this book. This scenario has changed considerably. The vast majority of neurologists practicing in India are trained in this country but generally depend on the books written by western authors. In this context, this book "Neurological practice. An Indian perspective", fulfills the long felt need of Indian neurologists and perhaps also neurologists in other developing nations with similar disease pattern. The neurologists in the developed countries may also be enriched by the panorama of Indian neurology.

Dr. Wadia needs to be complimented for getting together authors who have made significant contributions in their chosen areas of interest. This book has 30 chapters under nine sections on infections, epilepsy, vascular diseases, movement disorders, degenerative diseases, diseases of central nervous system myelin, environmental diseases, nutritional deficiency diseases, diseases of spinal cord, peripheral nerves and muscle and in the final section chapters on pediatric neurology and imaging of CNS infections.

Infections of the nervous system constitute one third of the book and rightly so, since tuberculosis, bacterial infections and neurocysticercosis and in the last two decades the additional burden of HIV with the consequent scenario of emerging and reemerging infections, pose problems in diagnosis and management. In this section, there are comprehensive chapters on acute viral encephalitis, neurological manifestations of AIDS, subacute sclerosing panencephalitis, enterovirus 70 and associated neurological manifestations, poliomyelitis, acute bacterial infections, neurotuberculosis, neuropathy in leprosy, neurocysticercosis, cerebral malaria and Creutzfield-Jakob disease. In Japanese encephalitis the involvement of anterior horn cells, the frequent occurrence of movement disorders during the acute stage and their persistence, association of Guillain-Barre syndrome, co-infection with cerebral cysticercosis have been highlighted. The main problem in HIV in India is opportunistic infections constituting 70-80% of neurological manifestations. Paucity of basal exudates on CT scan of brain in HIV positive tuberculous meningitis is an interesting observation to distinguish it from TBM without HIV infection. The challenge is to provide HAART to all HIV positive people, which will considerably alter the prognosis of these individuals. Lumbosacral radiculomyelitis observed with EV 70 usually after a variable latent period of acute hemorrhagic conjunctivitis was first documented in India. Large series of cases with neurological manifestations included in the registry, contributed by 42 neurologists in the country, provide the full profile of this interesting disorder. The well recognized entity of single cysticercus granuloma, contribution by Indian neurologists, and disseminated cysticercosis, have been well described with excellent illustrations showing clinical and imaging features. The Creutzfieldt-Jacob disease registry provides valuable information on the clinical and epidemiological features of CJD in India. It is reassuring that scrapie has never been documented in India and no case of "new variant" CJD has been reported.

The two chapters, epidemiology of epilepsy and medical, surgical and societal aspects of epilepsy provide detailed account of community based surveys conducted in different regions of the country during the last three decades and prevalence of epilepsy across the country. That it was possible to achieve seizure control in 65% with either phenobarbitone or phenytoin are important observations, useful for countries with limited resources, grappling to provide epilepsy care to large populations. Development of protocol for presurgical evaluation of refractory epilepsy without invasive monitoring and the impressive results of surgery yielding seizure freedom in 72%, are encouraging, and hopefully more centres in the country will initiate surgery for refractory epilepsy.

A number of community-based studies had focused on prevalence of stroke but very few on incidence. Indians appear to be more susceptible to stroke and mortality due to stroke is two to three times higher than in Caucasians. The burden of stroke is considerably high in India and stroke in young is a disturbing feature calling for recognition of CVD as a public health problem and for initiating national programme for risk reduction.

The low prevalence rates of Parkinson's disease in India, with the exception of Parsis, and the account of use of ayurvedic drug mucuna pruriens for the treatment of Parkinson's disease are of interest and need further exploration. In the chapter on "hyperkinetic movement disorders", infantile tremor syndrome - a unique disorder, first described from India and the high frequency of Wilson's disease, particularly in South India, make interesting reading.

Rapidly increasing elderly population in India has focused attention on degenerative diseases particularly dementias. Based on surveys the prevalence rate of dementia is less than 3.5% and Alzheimer's dementia less than 1.5%. In the Indian context, vitamin B12 deficiency particularly in vegetarians contributing to dementia is of great relevance, and therefore the authors have stressed the importance of recognition of this eminently treatable disorder. Spinocerebellar ataxia-2, the commonest type in India with the characteristic marker of "slow saccades" has been comprehensively dealt with data on electro-oculographic recording, the pathological correlates and genetic analysis. The oft neglected and ignored 'end of life" issues in amyotrophic lateral sclerosis have been dealt with sensitivity and compassion. The variants of motor neuron disease seen in India, the Madras motor neuron disease and monomelic amyotrophy have been extensively reviewed and the issues of nomenclature have also been discussed. The distinct clinical syndrome, megalencephalic leukodystrophy seen predominantly in the Aggarwal community, with unique imaging features is considered to be due to mutation in MLC1 gene. Although more cases of multiple sclerosis are diagnosed after availability of imaging, still MS is less frequent in India compared to the west. Various environmental agents, biological, non-biological and physical agents producing central and peripheral nervous system damage have been dealt in three well-written chapters. No book on neurology in India can afford to ignore the effect of malnutrition on the nervous system, from the very infancy to old age. Various disorders due to vitamin deficiency and protein energy malnutrition have been extensively reviewed. Chapters on congenital atlanto-axial dislocation, noncompressive myelopathy are well written focusing on Indian contributions. New observations of valley sign in Duchenne muscular dystrophy and poly-hill sign in facioscapulohumeral dystrophy have been elegantly described with supportive illustrations. The chapters on pediatric neurology and imaging of CNS infections provide very useful information to the neurologists.

The final statement is that this is a book worth possessing and is a must for every library.

This article has been cited by
1 Infantile tremor syndrome
RG Holla, AN Prasad
Medical Journal Armed Forces India. 2010; 66(2): 186
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