Annals of Indian Academy of Neurology
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   2012| July-September  | Volume 15 | Issue 3  
    Online since August 14, 2012

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The split hand sign
Rajesh Benny, Kishore Shetty
July-September 2012, 15(3):175-176
DOI:10.4103/0972-2327.99700  PMID:22919187
Amyotrophic Lateral sclerosis (ALS) is a disease characterized by pure motor asymmetric wasting of various muscles with associated upper motor neuron signs. The split hand sign, which is because of dissociated muscle weakness in the hands (thenar muscles disproportionately wasted as compared to the hypothenar muscles) is a useful clinical sign for bed side diagnosis of ALS.
  12,849 349 2
Validation of the use of the ROSIER scale in prehospital assessment of stroke
He Mingfeng, Wu Zhixin, Guo Qihong, Li Lianda, Yang Yanbin, Feng Jinfang
July-September 2012, 15(3):191-195
DOI:10.4103/0972-2327.99713  PMID:22919191
Aim: To determine the utility of the Recognition of Stroke in the Emergency Room (ROSIER) scale as a stroke recognition tool among Chinese patients in the prehospital setting. Materials and Methods: Compared with the Cincinnati Prehospital Stroke Scale (CPSS), emergency physicians prospectively used the ROSIER as a stroke recognition tool on suspected patients in the prehospital setting. And, the final discharge diagnosis of stroke or transient ischemic attack made by neurologists, after assessment and review of clinical symptomatology and brain imaging findings, was used as the reference standard for diagnosis in the study. Then, the ROSIER and the CPSS like sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), related coefficient (r) and Kappa value were calculated. Results: In this study, 540 of 582 suspected stroke patients met the study criteria. The CPSS showed a diagnostic Se of 88.77% (95% confidence intervals [CI] 86.11-91.43%), Sp of 68.79% (95% CI 64.88-72.70%), PPV of 87.40% (95% CI 85.97-88.83%), NPV of 71.52% (95% CI 67.71-75.33%) and r of 0.503. Relatively, the ROSIER showed a diagnostic Se of 89.97% (95% CI 87.44-92.64%), Sp of 83.23% (95% CI 80.08-86.38%), PPV of 92.66% (95% CI 90.46-94.86%), NPV of 77.91% (95% CI 74.41-81.41%) and r of 0.584. According to the final discharge diagnosis, both the ROSIER and the CPSS were associated with the final discharge diagnosis (P < 0.05).The Kappa statistic value of the ROSIER and the CPSS were 0.718 and 0.582, respectively. However, there was no statistical significance of the positive rate between the ROSIER and the CPSS in this study (P > 0.05). Conclusions: The ROSIER is a sensitive and specific stroke recognition tool for health providers' use among Chinese patients in the prehospital setting. However, it cannot be used to confidently rule out or identify stroke as a diagnosis. Comprehensive clinical assessment and further examination on potential stroke patients are still important and cannot be replaced. When it is difficult to objectively complete the ROSIER for patients, the CPSS could replace it in the prehospital setting.
  9,186 225 13
Rabies viral encephalitis with proable 25 year incubation period!
SK Shankar, Anita Mahadevan, Silvano Dias Sapico, M. S. G. Ghodkirekar, R. G. W. Pinto, SN Madhusudana
July-September 2012, 15(3):221-223
DOI:10.4103/0972-2327.99728  PMID:22919200
We report a case of rabies viral encephalitis in a 48-year-old male with an unusually long incubation period, historically suspected to be more than 20 years. The case was referred for histological diagnosis following alleged medical negligence to the forensic department. The histology and immunocytochemical demonstration of rabies viral antigen established the diagnosis unequivocally. The case manifested initially with hydrophobia and aggressive behavior, although he suddenly went to the bathroom and drank a small amount of water. History of dog bite 25 years back was elicited retrospectively following clinical suspicion. There was no subsequent history to suggest nonbite exposure to a rabid dog to consider recent event causing the disease, although this cannot be totally excluded.
  7,749 257 11
Can Alberta infant motor scale and milani comparetti motor development screening test be rapid alternatives to bayley scales of infant development-II at high-risk infants
Zeynep Hosbay Yildirim, Nur Aydinli, Baris Ekici, Burak Tatli, Mine Çaliskan
July-September 2012, 15(3):196-199
DOI:10.4103/0972-2327.99714  PMID:22919192
Purpose: The main object of the present study is to assess neuromotor development of high-risk infants by using three tests, and to determine inter-test concordance and the feasibility of these tests. Materials and Methods: One-hundred and nine patients aged between 0 and 6 months and identified as "high-risk infant" according to the Kliegman's criteria were enrolled to the study. Three different tests were used to assess neuromotor development of the patients: Bayley scales of infant development-II (BSID-II), Alberta infant motor scale (AIMS), and Milani Comparetti Motor Development Screening Test (MCMDST). Results: Correlation analysis was performed between pure scores of BSID-II motor scale and total scores of AIMS. These two tests were highly correlated (r:0.92). Moderate concordance was found between BSID-II and AIMS (k:0.35). Slight concordance was found between BSID-II and MCMDST; and the concordance was slight again for AIMS and MCMDST (k:0.11 and k:0.16, respectively) too. Conclusion: AIMS has a high correlation and consistency with BSID-II and can be used with routine neurological examination as it is based on observations, has few items, and requires less time to complete.
  6,072 155 4
Bilateral Charcot arthropathy of shoulder secondary to syringomyelia: An unusual case report
Ashok Panagariya, Arun Kumar Sharma
July-September 2012, 15(3):202-204
DOI:10.4103/0972-2327.99718  PMID:22919194
Neuropathic arthropathy of the shoulder is a relatively rare disorder characterized by destruction of joint secondary to loss of sensory innervation. Bilateral Charcot arthropathy is an even rarer disorder, with very few cases reported in the English literature. We herein present a case of bilateral shoulder arthropathy secondary to syringomyelia with classical clinical and radiological findings. Radiological finding on one side was of resorptive type and resorptive mixed with productive on the other side.
  6,070 106 7
Ocular signs in Wilson disease
Deepak S Amalnath, D. K. S. Subrahmanyam
July-September 2012, 15(3):200-201
DOI:10.4103/0972-2327.99716  PMID:22919193
  5,767 284 2
Cryptoccocal menigitis as a primary manifestation in a patient with intestinal lymphangictasia
Shaik Afshan Jabeen, Aruna Murthy, Rukmini Mridula Kandadai, AK Meena, Rupam Borgohain, Megha S Uppin
July-September 2012, 15(3):218-220
DOI:10.4103/0972-2327.99725  PMID:22919199
Opportunistic infections usually occur in patients with an immunocompromised state, and can be severe. Cryptoccocal meningitis is a fatal condition if left untreated, and is usually found in such patients. We report the case of an adult patient with cryptoccocal meningitis secondary to intestinal lymphangiectasia. A 30 year old female was admitted to our hospital for meningitis. Biochemical and radiological investigations were performed. A cerebrospinal fluid latex agglutination test showed positive cryptoccocal antigen. In addition, there were features of humoral and cell mediated immunity deficiency (lymphopenia, hypoalbuminemia, hypogammaglobulinemia), with a negative human immunodeficiency virus (HIV) test by enzyme linked immunosorbent assay and polymerase chain reaction. An upper gastroduodenoscopy was performed, which showed multiple lymphangiectasias, and a biopsy confirmed the diagnosis of primary intestinal lymphangiectasia (PIL). The patient was treated with intravenous amphotericin B and oral flucytosine, and the meningitis resolved. PIL should be suspected in patients with cryptoccocal meningitis, combined with humoral and cell mediated immunity with a negative HIV test. The management issues, in addition to antifungal therapy, include nutritional supplements for the protein losing enteropathy.
  5,826 97 2
Paraneoplastic cerebellar degeneration in Hodgkin's lymphoma
Vinit Suri, Nadeem I Khan, Nilesh Jadhao, Rohan Gupta
July-September 2012, 15(3):205-207
DOI:10.4103/0972-2327.99720  PMID:22919195
Paraneoplastic cerebellar degeneration (PCD) is a rare disorder presenting typically with acute or subacute severe cerebellar ataxia. PCD is most commonly associated with small cell lung cancer followed by adenocarcinoma of breast and ovary, and Hogdkin's lymphoma. We report a case of a 54-year-old male with acute-onset pancerebellar syndrome with underlying Hodgkin's lymphoma. A high index of suspicion of PCD resulted in arriving at an early diagnosis of underlying Hodgkin's disease. The patient was managed with six cycles of chemotherapy, which resulted in clinical stabilization and reversal of magnetic resonance imaging abnormalities. Antitumor therapy appears to have a significant impact on reversing PCD and hence early diagnosis and intervention for the primary remains the corner stone in stabilizing the neurological condition.
  5,525 140 1
Time course of inflammatory cytokines in acute ischemic stroke patients and their relation to inter-alfa trypsin inhibitor heavy chain 4 and outcome
Amit R Nayak, Rajpal S Kashyap, Dinesh Kabra, Hemant J Purohit, Girdhar M Taori, Hatim F Daginawala
July-September 2012, 15(3):181-185
DOI:10.4103/0972-2327.99707  PMID:22919189
Background: Biomarker for prognosis of stroke is urgently needed for the management of acute ischemic stroke (AIS) patients. Objective: To evaluate the course of inflammatory cytokines in AIS patients and its comparison with inter-alfa trypsin inhibitor heavy chain 4 (ITIH4) and outcome after AIS. Materials and Methods: A panel of 12 inflammatory cytokines and ITIH4 were estimated in serial blood samples collected at admission, 24 h, 48 h, 72 h, 144 h and at discharge of AIS patients (n = 5). Results: Out of the 12 cytokines, only interleukin (IL)-2, tumor necrosis factor-alfa (TNF-a), IL-10, IL-6, IL-1B and IL-8 were in the measurable range of the kit (10 pg/mL). We found high IL-2 at admission, which decreased (P < 0.05) in the follow-up samples. TNF-a initially increases (P < 0.05) at 24 h followed by gradual decrease (P < 0.05) after 72 h. IL-10 decreases initially (P < 0.05) till 72 h as compared with its level at admission and then increases (P < 0.05) after 144 h. Similarly, ITIH4 was down-regulated in the early 72 h followed by further increase with improvement of the patient. ITIH4 correlates with IL-10 and computed tomography scan infarct volume. Serum IL-6, IL-1B and IL-8 increased in the AIS patients, but did not show any pattern. Conclusions: Serial measurement of IL-10, IL-2 and TNF-a and ITIH4 may be useful for the follow-up of clinical outcome after AIS.
  5,440 184 27
Megalencephalic leukoencephalopathy with subcortical cysts in all three siblings of a non-Aggarwal Indian family
Mani Kant Kumar, Brish Bhanu Singh
July-September 2012, 15(3):214-217
DOI:10.4103/0972-2327.99723  PMID:22919198
Megalencephalic leukoencephalopathy with subcortical cysts (MLC) is a rare neurodegenerative disease seen mainly in the Aggarwal community in India. It is characterized by early-onset macrocephaly with mild motor developmental delay, gradual onset ataxia, spasticity, seizures and usually late onset mild cognitive deterioration. Very few familial cases of MLC have been reported in the world literature, and to the best of our knowledge, there is no published study of all three siblings affected with MLC in a same family. Here, we are reporting three siblings belonging to a non-Aggarwal Hindu family, affected with MLC, who presented with early-onset macrocephaly and gradual onset ataxia.
  5,211 224 3
Role of magnesium sulfate in neuroprotection in acute ischemic stroke
Harpreet Singh, Sunil Jalodia, MS Gupta, Paulomi Talapatra, Vikas Gupta, Ishwar Singh
July-September 2012, 15(3):177-180
DOI:10.4103/0972-2327.99705  PMID:22919188
Aims: To study the effect of intravenous magnesium sulfate infusion on clinical outcome of patients of acute stroke. Materials and Methods: Sixty consecutive cases of acute ischemic stroke hospitalised within 24 h of an episode of stroke were taken as subjects. All subjects underwent a computed tomography head, and those found to have evidence of bleed/space-occupying lesions were excluded from the study. The subjects taken up for the study were divided into two groups of 30 subjects each. Both the groups received the standard protocol management for acute ischemic stroke. Subjects of Group 1 additionally received intravenous magnesium sulfate as initial 4 g bolus dose over 15 min followed by 16 g as slow infusion over the next 24 h. In all the subjects of the two study groups, serum magnesium levels were estimated at the time of admission (Day 0), Day 1 and Day 2 of hospitalization using an atomic absorption spectrometer. Statistical Analysis Used: Scandinavian stroke scores were calculated on Day 3, day of discharge and Day 28. Paired t-test was employed for comparison of stroke scores on Day 3, day of discharge and Day 28 within the same group and the unpaired t-test was used for the intergroup comparison, i.e. comparison of stroke scores of control group with corresponding stroke scores of magnesium group. Results: Comparison of stroke scores on Day 3 and day of discharge, on the day of discharge and Day 28 and on Day 3 and Day 28 in the magnesium group produced a t-value of 5.000 and P <0.001, which was highly significant. However, the comparison of the mean stroke scores between the magnesium and the control groups on Day 3, day of discharge and Day 28 yielded a P-value of >0.05, which was not significant. Conclusions: The study failed to document a statistical significant stroke recovery in spite of achieving a significant rise in serum magnesium level, more than that necessary for neuroprotection, with an intravenous magnesium sulfate regime.
  5,078 206 7
Recurrent and atypical posterior reversible encephalopathy syndrome in a child with hypertension
Mustafa Komur, Ali Delibas, Ali Ertug Arslankoylu, Cetin Okuyaz, Engin Kara
July-September 2012, 15(3):208-210
DOI:10.4103/0972-2327.99721  PMID:22919196
Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiologic entity with typical symptoms including headache, seizures, visual disturbance, altered mental status, vomiting, nausea and focal neurologic signs. In this article, we report recurrent and atypical PRES in a child with hypertension due to end-stage renal disease (ESRD) who was on a peritoneal dialysis program for 6 months. After the second hypertension attack, PRES findings did not recover and persisted as encephalomalacia. As far as we know, this case is the first child with ESRD who developed encephalomalacia after recurrent episodes of PRES. When a patient with a history of PRES presented with new clinical and neuroradiological findings, recurrent PRES should be considered.
  5,173 103 3
Comparative study of thyrotoxic periodic paralysis from idiopathic hypokalemic periodic paralysis: An experience from India
J Kalita, G Goyal, SK Bhoi, S Chandra, UK Misra
July-September 2012, 15(3):186-190
DOI:10.4103/0972-2327.99708  PMID:22919190
Objective: There is paucity of reports on thyrotoxic periodic paralysis (TPP) from India. We report the patients with TPP and compare them with idiopathic hypokalemic periodic paralysis (IHPP). Materials and Methods: Patients with hypokalemic periodic paralysis (HPP) treated during the past 11 years were evaluated retrospectively. Their demographic parameters, family history, clinical features, precipitating factors, severity of weakness, laboratory parameters and rapidity of recovery were recorded. The demographic, clinical and laboratory parameters of TPP and IHPP were compared. Results: During the study period, we managed 52 patients with HPP; nine (17.3%) of whom had TPP and 27 (52%) had IHPP. The demographic, precipitating factors, number of attacks and severity of limb weakness were similar between the TPP and IHPP groups, except in the IHPP group, bulbar weakness was present in four and respiratory paralysis in six, needing artificial ventilation in two patients. Serum potassium was significantly lower in TPP (2.21 ± 0.49) compared with IHPP (2.67 ± 0.59, P = 0.04). Four patients with TPP had subclinical thyrotoxicosis and two had subclinical hyperthyroidism. Rebound hyperkalemia occurred in both TPP and IHPP (three versus eight patients). The recovery was faster in IHPP (26.7 ± 15.4 h) compared with TPP (34.0 ± 14.0 h), but was statistically insignificant. Conclusion: TPP constitutes 17.3% of HPP, and absence of clinical features of thyrotoxicosis and subclinical hyperthyroidism in TPP is not uncommon. Clinical features, demographic profile and rebound hyperkalemia are similar in both TPP and IHPP. The serum potassium level is significantly low in the TPP compared with the IHPP group.
  4,771 214 5
Painless orbital myositis
Rahul T Chakor, NS Santhosh
July-September 2012, 15(3):224-226
DOI:10.4103/0972-2327.99729  PMID:22919201
Idiopathic orbital inflammation is the third most common orbital disease, following Graves orbitopathy and lymphoproliferative diseases. We present a 11 year old girl with 15 days history of painless diplopia. There was no history of fluctuation of symptoms, drooping of eye lids or diminished vision. She had near total restricted extra-ocular movements and mild proptosis of the right eye. There was no conjunctival injection, chemosis, or bulb pain. There was no eyelid retraction or lid lag. Rest of the neurological examination was unremarkable.Erythrocyte sedimentation rate was raised with eosinophilia. Antinuclear antibodies were positive. Liver, renal and thyroid functions were normal. Antithyroid, double stranded deoxyribonucleic acid and acetylcholine receptor antibodies were negative. Repetitive nerve stimulation was negative. Magnetic resonance imaging (MRI) of the orbit was typical of orbital myositis. The patient responded to oral steroids. Orbital myositis can present as painless diplopia. MRI of orbit is diagnostic in orbital myositis.
  4,659 120 1
Publication trends of neurology articles in a biomedical journal from India
K. V. S. Hari Kumar, K Aravinda
July-September 2012, 15(3):170-174
DOI:10.4103/0972-2327.99695  PMID:22919186
Background: The details about the research productivity in the neurology specialty from India is lacking. We analyzed the publishing trends and the research productivity of neurology-related articles in the Journal of the Association of Physicians of India (JAPI). Materials and Methods: We carried the bibliometric analysis of articles related to neurology specialty from JAPI published between 2000 and 2011. Data were derived from the journal's website and the articles were analyzed for type (original article, case reports, etc.), disease (infection, vascular, etc.), place, and timelines for publication. Results: Out of total 2977 articles published, 256 articles belong to neurology. Neurology contributed to 7--20% of the published articles per year in JAPI. Case reports (52%) constitute the majority type of articles followed by Original Articles (20%), Correspondence and Images (15% each). Infections (27%), structural disorders (19%), cerebrovascular and peripheral nervous system disorders (16% each) contribute the majority of research articles in Neurology. Mumbai (15%), Delhi (13%), and Chennai (9%) are the top three contributors followed by Lucknow and Varanasi. All types of articles took about 9--10 months for acceptance and another 4--5 months for publication. Letters to the Editor were published faster when compared to other articles (P=0.0035). Conclusion: Neurology specialty contributes an average 14% of articles per annum in JAPI. Infections, vascular, structural, and peripheral nervous system disorders together account for 80% of published literature with a small representation from other diseases. Mumbai and Delhi are the leading contributors toward research productivity in neurology.
  3,900 159 1
Hip dysplasia associated with a hereditary sensorimotor polyneuropathy mimics a myopathic process
Mohammad Javad Hadianfard, Alireza Ashraf
July-September 2012, 15(3):211-213
DOI:10.4103/0972-2327.99722  PMID:22919197
Some orthopedic complications have been reported in the hereditary neuropathies. However, the association of the hip dysplasia with this category of neuropathy is rarely recognized. We present a 13-year-old boy with the progressive weakness of the lower extremities, difficulty in walking, climbing stairs, and rising from floor; a wide-based, hyper-extended and waddling gait similar to a myopathic process. Hip radiography showed dysplastic acetabulae with hip subluxation, broken Shenton's lines, and valgus femoral necks. In electrodiagnosis, there was a significant neuropathic process (absent all evoked sensory potentials, abnormal evoked motor responses, and neurogenic electeromyography) which eventually was found to be a hereditary mixed axonal and demyelinating sensorimotor polyneuropathy with concomitant hip dysplasia confirmed with thorough physical examination and the electrodiagnostic study. In patients with gait difficulties such as waddling gait mimicking a myopathic process, hereditary polyneuropathy complicated with hip dysplasia should be considered as well.
  3,603 75 1
Management of hydrocephalus in tuberculous meningitis
Suryanarayanan Bhaskar
July-September 2012, 15(3):231-231
DOI:10.4103/0972-2327.99736  PMID:22919205
  3,154 168 -
Klinefelter's syndrome associated with progressive muscular atrophy simulating Kennedy's disease
Pedro Enrique Jiménez Caballero
July-September 2012, 15(3):227-229
DOI:10.4103/0972-2327.99730  PMID:22919202
Kennedy's disease, an X-linked spinal and bulbar muscular atrophy, is characterized by loss of lower motor neurons. Mild sensory deficits, gynecomastia and infertility may be observed. Klinefelter's syndrome is a variation of sex chromosome disorder characterized by hypogonadism, gynecomastia and azoospermia, and the most frequent karyotype is XXY. A 55-year-old man who presented with slowly progressive and diffuse neurogenic muscle atrophy without bulbar or sensory symptoms. He also had Klinefelter's syndrome. Genetic study of Kennedy's disease was normal. Our patient differs from those with Kennedy's disease in the absence of bulbar and sensory symptoms. It is suggested that the X chromosome plays an important role in the biology of motor neurons.
  3,183 53 2
Endoscopic third ventriculostomy in tuberculous meningitis needs more evidence
Usha K Misra, J Kalita, S Prabhakar, A Chakravarty, D Kochar, PP Nair
July-September 2012, 15(3):233-233
DOI:10.4103/0972-2327.99739  PMID:22919207
  2,755 88 1
In this issue
Satish V Khadilkar
July-September 2012, 15(3):169-169
  2,715 113 -
Low cholesterol as a risk factor for primary intracerebral hemorrhage: A case-control study: A comment on the study
Yi-Chung Wu
July-September 2012, 15(3):230-230
DOI:10.4103/0972-2327.99732  PMID:22919203
  2,597 101 -
Brachial plexitis following bee sting
P Jithendranath, N Byju, K Saifudheen, James Jose
July-September 2012, 15(3):234-234
DOI:10.4103/0972-2327.99740  PMID:22919208
  2,500 157 2
Why need for five anti-tubercular drugs in a child with CNS TB?
Praveen S Bagalkot
July-September 2012, 15(3):234-235
DOI:10.4103/0972-2327.99741  PMID:22919209
  2,465 115 -
Authors' reply
VV Ashraf, Nilesh V Chaudhary, R Praveen Kumar, Biju Gopalakrishnan, AS Girija
July-September 2012, 15(3):230-231
  2,257 65 -
Decompression sickness in an Indian diver
Rohit Verma, Shivanand S Dalawayi
July-September 2012, 15(3):232-232
DOI:10.4103/0972-2327.99738  PMID:22919206
  2,142 80 -
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