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ORIGINAL ARTICLE
Neurological complications of Chikungunya virus infection
Nitin H Chandak, Rajpal S Kashyap, Dinesh Kabra, Poornima Karandikar, Sonali S Saha, Shweta H Morey, Hemant J Purohit, Girdhar M Taori, Hatim F Daginawala
March-April 2009, 57(2):177-180
DOI:10.4103/0028-3886.51289  PMID:19439849
Background: In May 2006, there was a large Chikungunya virus infection (CHIKV) outbreak in the Nagpur district of Maharashtra, a province in western India. Usually, CHIKV is a self-limiting febrile illness. However, neurological complications have been described infrequently. Aim: To study the clinical characteristics of various neurological complications associated with CHIKV infections. Materials and Methods: Patients with neurological complications following CHIKV infection during the outbreak were the subjects of the study. On the basis of clinical features and investigative findings, patients were grouped into various neurological syndromes: Encephalitis, myelopathy, peripheral neuropathy, myeloneuropathy, and myopathy. Cerebrospinal fluid (CSF) samples were also collected for biochemical and serological studies. Results: Of the 300 patients with CHIKV infection seen during the study period, June-December 2006, 49 (16.3%) [M : F: 42:7] had neurological complications. The neurological complications included: Encephalitis (27, 55%), myelopathy (7, 14% ), peripheral neuropathy (7, 14%), myeloneuropathy (7, 14%), and myopathy (1, 2%). Reverse Transcriptase polymerase chain reaction (RT-PCR) and real-time PCR was positive in the CSF in 16% and 18%, respectively. Conclusion: Recent CHIKV infection was associated with various neurological complications, suggesting neurotropic nature of the virus. The outcome of the neurological complications is likely to be good.
  84 15,155 836
Brain edema after intracerebral hemorrhage in rats: The role of inflammation
Xiangjian Zhang, Haiyan Li, Shuchao Hu, Liying Zhang, Chunyan Liu, Chunhua Zhu, Ruichun Liu, Chunyan Li
October-December 2006, 54(4):402-407
DOI:10.4103/0028-3886.28115  PMID:17114852
Background: Intracerebral hemorrhage (ICH) results in secondary brain edema and injury that may lead to death and disability. ICH also causes inflammation. It is unclear whether inflammation contributes to brain edema and neuron injury or functions in repairing the brain tissue. Aims: To understand the effect of inflammation in ICH, we have carried out an investigation on the various aspects and the dynamic changes of inflammation. Settings and Design: An ICH model was generated by injecting 50 ml autologous tail artery blood stereotactically into the right caudate nucleus of 30 rats, which were randomly divided into five ICH groups. Similarly, five Sham control groups were generated by inserting the needle to the right caudate nucleus of rats. Materials and Methods: Rat behavior was evaluated over the time course (6 h, 24 h, 48 h, 72 h and 7 d) in each group. The rats were then killed by administering an overdose of pentobarbital. Following the euthanasia, the brain water content, neuronal loss, glia proliferation, inflammatory infiltration and brain morphology of the rats were measured. Additionally, the expression of TNF-a,IL-6, ICAM-1, VEGF, NF-kB, C3 and CR2 was analyzed by immunohistochemistry. Statistical Analysis: The data were analyzed by student's t test. Results: Rat brain water content increased progressively over the time course and reached its peak at 48h followed ICH. The maximum of inflammatory infiltrate (especially neutrophils) and immunopositive cells of TNF-a, IL-6 and NF-kB, were at 48h. The expression of C3 and CR2 reached their peaks at 48-72h, while the expression ICAM-1 and VEGF were at maximum at 72h followed ICH. Conclusions: The results suggested that the inflammatory cytokines, complement system and VEGF may have a function in the development of the brain edema and neuron injury followed ICH.
  78 10,503 581
REVIEW ARTICLES
Imaging features of central nervous system fungal infections
Krishan K Jain, Shireesh K Mittal, Sunil Kumar, Rakesh K Gupta
July-September 2007, 55(3):241-250
DOI:10.4103/0028-3886.35685  PMID:17921653
Fungal infections of the central nervous system (CNS) are rare in the general population and are invariably secondary to primary focus elsewhere, usually in the lung or intestine. Except for people with longstanding diabetes, they are most frequently encountered in immunocompromised patients such as those with acquired immunodeficiency syndrome or after organ transplantation. Due to the lack of inflammatory response, neuroradiological findings are often nonspecific and are frequently mistaken for tuberculous meningitis, pyogenic abscess or brain tumor. Intracranial fungal infections are being identified more frequently due to the increased incidence of AIDS patients, better radiological investigations, more sensitive microbiological techniques and better critical care of moribund patients. Although almost any fungus may cause encephalitis, cryptococcal meningoencephalitis is most frequently seen, followed by aspergillosis and candidiasis. The biology, epidemiology and imaging features of the common fungal infections of the CNS will be reviewed. The radiographic appearance alone is often not specific, but the combination of the appropriate clinical setting along with computed tomography or magnetic resonance may help to suggest the correct diagnosis.
  63 18,121 1,929
TOPICS OF THE ISSUE-DENGUE NEUROLOGY-REVIEW ARTICLES
Encephalitis in the clinical spectrum of dengue infection
Aravinthan Varatharaj
July-August 2010, 58(4):585-591
DOI:10.4103/0028-3886.68655  PMID:20739797
Dengue viral infections are common worldwide. Clinical manifestations form a broad spectrum, and include uncomplicated dengue fever, dengue hemorrhagic fever, and dengue shock syndrome. Encephalopathy has been well reported and has classically been thought to result from the multisystem derangement that occurs in severe dengue infection; with liver failure, shock, and coagulopathy causing cerebral insult. However, there is increasing evidence for dengue viral neurotropism, suggesting that, in a proportion of cases, there may be an element of direct viral encephalitis. Understanding the pathophysiology of dengue encephalopathy is crucial toward developing a more effective management strategy. This review provides an overview of the clinical spectrum of dengue infection, and examines evidence supporting the existence of dengue encephalitis.
  63 30,096 1,027
ORIGINAL ARTICLES
Isolation, characterization and differentiation potential of rat bone marrow stromal cells
Naresh Polisetti, VG Chaitanya, Phanithi Prakash Babu, Geeta K Vemuganti
March-April 2010, 58(2):201-208
DOI:10.4103/0028-3886.63789  PMID:20508336
Background: Bone marrow mesenchymal cells have been identified as a source of pluripotent stem cells with varying degrees of plasticity in humans. However, there are a few reports on rat-derived cells, which could be good models for the research purpose. We describe here a simple method of establishing the rat bone marrow stromal cells by the principle of adhesion and document their phenotype along with their differentiation potential to other lineages. Materials and Methods: Rat bone marrow stromal cells were isolated by three methods: direct plastic adherence, ficoll hypaque separation and a combination of both. The stromal cells obtained by these methods were characterized by fluorescent activating cell sorting (FACS) for established hematopoietic and non-hematopoietic markers. The cells obtained by combination method (combination of ficoll density gradient centrifugation and plastic adherence) were cultured and serially passaged. Transcriptional confirmation was done by reverse transcription polymerase chain reaction (RT-PCR) for vimentin and collagen type 1 alpha 1. Attempts were made to differentiate the marrow stromal cells into adipocytes, osteocytes and neuronal like cells. Results: Bone marrow samples from 10 rats yielded 4-5 million bone marrow mononuclear cells /ml per femur. Of the three methods tested, a combination method yielded good growth of spindle cells. The cells obtained by combined method showed high percentage of positivity for vimentin, fibronectin and CD90 and negative for hematopoietic markers. Further, RT-PCR confirmed vimentin and collagen type - 1 alpha 1 expression. Oil red O staining and Alizarin red staining confirmed adipocytic and osteogenic differentiation. On immunocytochemical analysis, the cells expressed nestin, β-tubulin III, neurofilament and synaptophysin. Conclusion: Adequate quantities of rat marrow stromal cell cultures can be established by a simple method based on adhesion properties. Their phenotypic characteristics and plasticity support the evidence that they are mesenchymal stem cells with a distinct tendency for neural lineage.
  62 11,918 708
INDIAN PERSPECTIVE
Management of hydrocephalus in patients with tuberculous meningitis
Vedantam Rajshekhar
July-August 2009, 57(4):368-374
DOI:10.4103/0028-3886.55572  PMID:19770534
Hydrocephalus is one of the commonest complications of tuberculous meningitis (TBM) occurring in up to 85% of children with the disease. It is more severe in children than in adults. It could be either of the communicating type or the obstructive type with the former being more frequently seen. The Vellore grading system for clinical grading of patients with TBM and hydrocephalus with grade I being the best grade and grade IV being the worst grade has been validated by several authors. The management of hydrocephalus can include medical therapy with dehydrating agents and steroids for patients in good grades and those with communicating hydrocephalus. However, surgery is required for patients with obstructive hydrocephalus and those in poor grades. Surgery can involve either a ventriculo-peritoneal shunt or endoscopic third ventriculostomy (ETV). Complications of shunt surgery in patients with TBM and hydrocephalus are high with frequent shunt obstructions and shunt infections requiring repeated revisions. ETV has variable success in these patients and is generally not advisable in patients in the acute stages of the disease. Mortality on long-term follow up has been reported to vary from 10.5% to 57.1% in those with altered sensorium prior to surgery and 0 to 12.5% in patients with normal sensorium. Surgery for patients in Vellore grade IV is usually associated with a poor outcome and high mortality and therefore, its utility in these patients is debatable
  59 31,710 1,747
REVIEW ARTICLE
Atlantoaxial fixation: Overview of all techniques
Praveen V Mummaneni, Regis W Haid
October-December 2005, 53(4):408-415
DOI:10.4103/0028-3886.22606  PMID:16565531
Over the past century, steady advances have been made in fixating an unstable atlantoaxial complex. Current options for fixation of the atlantoaxial complex include posterior clamps, posterior wiring techniques, C1-C2 transarticular screw fixation, posterior C1 lateral mass screw with C2 pars or pedicle screw fixation, and anterior transoral C1 lateral mass to C2 vertebral body fixation.
  59 25,050 1,282
ORIGINAL ARTICLE
Frequent seizures and polytherapy can impair quality of life in persons with epilepsy
Sanjeev V Thomas, Samuel Koshy, CR Sudhakaran Nair, Sankara P Sarma
January-March 2005, 53(1):46-50
DOI:10.4103/0028-3886.15054  PMID:15805655
CONTEXT: Careful evaluation of pharmacotherapy, seizure control and quality of life (QOL) are helpful in improving epilepsy care but such data are relatively meager from developing countries. AIMS: To audit pharmacotherapy, seizure control and QOL in persons with epilepsy and to identify factors associated with impaired QOL. SETTINGS AND DESIGN AND MATERIALS AND METHODS: The study was carried out using a cross-sectional design in the setting of a tertiary care epilepsy center in India. Persons with epilepsy with >12 months follow-up at this Center and aged >16 years were eligible for enrollment. Persons with other disabilities or pregnancy were excluded. Subjects were interviewed with a standard questionnaire and an adapted version of Quality of Life in Epilepsy - 31 (QOLIE-31). Data pertaining to treatment at the time of referral to this center was extracted from medical records. STATISTICAL ANALYSIS USED: Chi-square test, analysis of variance and multiple regression analysis were carried out for statistical significance. RESULTS: One hundred and twelve patients with epilepsy (59 males, mean age 31.210.7 years) were included. Forty-seven (42%) persons had Generalized Epilepsy (GE) and 65 persons (58%) had Localization-Related Epilepsy (LRE). At entry 24 persons (21.4%) were not on treatment and 59 persons (64.8%) had frequent seizures. At last follow-up 64 persons (57.1%) were seizure-free, 83 persons (74.1%) were on monotherapy and 29 were (25.9%) on polytherapy. Cost of drug at entry was INR 2276 (monotherapy) and INR 3629 (polytherapy) (45 INR = 1 USD). At the time of last follow-up, it was 1898 and 4929 respectively. QOLIE-31 Total Score (TQOL) ranged from 22.6 to 94.4 (mean 68.0 15.8). Multiple regression analysis showed significant correlation between low TQOL score and polytherapy (P=0.002) and occurrence of one or more seizures per month (P=0.001). CONCLUSIONS: Frequent seizures and polytherapy are associated with lower QOL in persons with epilepsy.
  54 11,101 385
REVIEW ARTICLE
Dynamic stabilization devices in the treatment of low back pain
DK Sengupta
October-December 2005, 53(4):466-474
DOI:10.4103/0028-3886.22614  PMID:16565539
Soft stabilization has an important role in the treatment of the degenerative lumbar spine. Fusion of one or two motion segments may not make a big difference in the total range of motion of the lumbar spine, but preserving flexibility of a motion segment may prevent adjacent segment disease and may permit disc replacement, even when facet joints need to be excised. A favourable environment is created in the motion segment by unloading the disc and permitting near normal motion, the disc may be able to repair itself or may supplement reparative potential of gene therapy.
  54 22,971 1,134
REVIEW ARTICLES
Cryptococcal meningitis: Clinical, diagnostic and therapeutic overviews
P Satishchandra, T Mathew, G Gadre, S Nagarathna, A Chandramukhi, A Mahadevan, SK Shankar
July-September 2007, 55(3):226-232
DOI:10.4103/0028-3886.35683  PMID:17921651
Cryptococcal meningitis has emerged as a leading cause of infectious morbidity and mortality in patients with AIDS. Among the human immunodeficiency virus (HIV)-seropositive subjects, cryptococcal meningitis is the second most common cause of opportunistic neuro-infection. Current trends are changing due to the marked improvement of quality and length of life produced by highly active antiretroviral therapy (HAART). The introduction of generic HAART in India has resulted in an increase in the number of individuals getting treatment for HIV infection, as the cost of highly active antiretroviral therapy (HAART) has decreased 20- fold. Cryptococcal meningitis occurs in non-HIV patients who are immunodeficient due to diabetes, cancer, solid organ transplants, chemotherapeutic drugs, hematological malignancies etc and rarely in healthy individuals with no obvious predisposing factors. Diagnosis of cryptococcal meningitis is fairly straightforward once the diagnosis is considered in the differential diagnosis of chronic meningitis. Treatment of a patient with cryptococcal infection is a challenge for both the physician and the patient, but rewarding, as many would recover with timely and adequate antifungal therapy.
  54 27,934 1,823
Management of the trigeminocardiac reflex: Facts and own experience
Belachew Arasho, Nora Sandu, Toma Spiriev, Hemanshu Prabhakar, Bernhard Schaller
July-August 2009, 57(4):375-380
DOI:10.4103/0028-3886.55577  PMID:19770535
The trigeminocardiac reflex (TCR) is defined as the sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, apnea, or gastric hyper-motility during stimulation of any of the sensory branches of the trigeminal nerve. The proposed mechanism for the development of TCR is-the sensory nerve endings of the trigeminal nerve send neuronal signals via the Gasserian ganglion to the sensory nucleus of the trigeminal nerve, forming the afferent pathway of the reflex arc. It has been demonstrated that the TCR may occur with mechanical stimulation of all the branches of the trigeminal nerve anywhere along its course (central or peripheral). The reaction subsides with cessation of the stimulus. But, some patients may develop severe bradycardia, asystole, and arterial hypotension which require intervention. The risk factors already known to increase the incidence of TCR include: Hypercapnia; hypoxemia; light general anesthesia; age (more pronounced in children); the nature of the provoking stimulus (stimulus strength and duration); and drugs: Potent narcotic agents (sufentanil and alfentanil); beta-blockers; and calcium channel blockers. Because of the lack of full understanding of the TCR physiology, the current treatment options for patients with TCR include: (i) risk factor identification and modification; (ii) prophylactic measures; and (iii) administration of vagolytic agents or sympathomimetics.
  53 8,410 461
ORIGINAL ARTICLE
Vertebral artery in relationship to C1-C2 vertebrae: An anatomical study
Francesco Cacciola, Umesh Phalke, Atul Goel
April-June 2004, 52(2):178-184
PMID:15269464
BACKGROUND: Ten randomly selected adult cadaveric specimens were dissected to analyse the anatomy of the vertebral artery during its course from the C3 transverse process to its entry into the spinal dural canal at the level of C1. In addition, 10 dry cadaveric C1-C2 bones were studied. The course of the artery and the parameters relevant during surgery in the region are evaluated. METHODS: Ten adult cadaveric specimens and 10 adult dry cadaveric C1 and C2 bones were studied. In five cadaveric specimens, the arteries and veins were injected with coloured silicon. The artery during its course from the transverse process of C3 to the transverse process of C2 was labelled as V1 segment, the artery during its course from the C2 transverse process to the C1 transverse process was labelled as V2 segment and the segment of the artery after its exit from the transverse foramen of C1 to the point of its dural entry was labelled as V3 segment. The relationship of the artery to the C1-2 joint and facets, distance of the location of the artery from the midline, from the C2 ganglion and from the other surgery related landmarks were evaluated. The extent of occupancy of the artery into the vertebral artery groove on the inferior surface of the superior facet of the C2 vertebra, and over the posterior arch of the atlas was studied. RESULTS: The V1 segment of the vertebral artery takes a varying degree of loop inside the vertebral artery foramen on the inferior aspect of the superior facet of the C2 vertebra. The loop extends towards the midline and was at an average distance of 14.6 mm from the midline of the vertebral body. The V2 segment of the artery takes an initial lateral loop after its exit from the transverse process of the C2 vertebra. The average distance of the artery from the lateral end of the C2 ganglion was 7.2 mm and from the dural tube was 15.3 mm. The vertebral artery groove in the superior facet of C2 and the groove over the posterior arch of the atlas were completely occupied by the vertebral artery only in six sides and in none respectively, suggesting the possibility of the dynamic nature of the relationship of the artery to the bone. CONCLUSIONS: The vertebral artery adopts a serpentine course in relationship to the C2 vertebra, making it susceptible to injury during the surgical procedures in the region. The multiple loops of the artery and a buffer space within the vertebral artery groove on the inferior surface of the superior facet of the C2 vertebra and over the posterior arch of atlas provide the artery an extra length and space, probably essential to avoid any stretch during neck movements.
  52 24,095 916
Clinical and laboratory features and response to treatment in patients presenting with vitamin B12 deficiency-related neurological syndromes
S Aaron, Sudhir Kumar, J Vijayan, J Jacob, M Alexander, C Gnanamuthu
January-March 2005, 53(1):55-58
DOI:10.4103/0028-3886.15057  PMID:15805657
AIMS AND OBJECTIVES: To study the clinical and laboratory features of patients admitted with vitamin B12 deficiency-related (B12def) neurological syndromes. SETTINGS AND DESIGN: A hospital-based retrospective and prospective study conducted at a referral teaching hospital. MATERIALS AND METHODS: Consecutive patients admitted with vitamin B12 deficiency-related neurological disorders during a three-year period from June 2000 to May 2003 were included. Data regarding clinical and laboratory features were obtained. Follow-up was done at least six months following treatment with parenteral vitamin B12. Chi-square test was used for statistical analysis. RESULTS: A total of 63 patients (52 males) with a mean age of 46.2 years were studied. The mean duration of symptoms at presentation was 10.3 months. Myeloneuropathy (54%) was the commonest neurological manifestation, followed by myeloneuropathy with cognitive dysfunction (34%), and peripheral neuropathy (9%). Neuropsychiatric manifestations and dementia were observed in 38% and 19% of patients respectively. All the patients had megaloblastic changes in the bone marrow smear. Eleven (17.5%) patients had both hemoglobin and the mean corpuscular volume (MCV) within the normal range. Follow-up after at least six months of therapy with parenteral B12 showed improvement in 54% patients. CONCLUSIONS: A high index of suspicion of B12def is required in patients presenting with myelopathy, cognitive decline, or neuropathy. A normal hemoglobin or MCV does not exclude B12def; therefore, other tests such as bone marrow smear and serum vitamin B12 assay are essential, as the condition is often reversible with treatment.
  49 21,254 647
REVIEW ARTICLE
Thoracic pedicle screw placement: Free-hand technique
Yongjung J Kim, Lawrence G Lenke
October-December 2005, 53(4):512-519
DOI:10.4103/0028-3886.22622  PMID:16565545
  49 33,937 1,423
ORIGINAL ARTICLES
Etiological factors of traumatic peripheral nerve injuries
Filiz Eser, Lale Akbulut Aktekin, Hatice Bodur, Cigdem Atan
July-August 2009, 57(4):434-437
DOI:10.4103/0028-3886.55614  PMID:19770544
Background: Traumatic injury of peripheral nerves is a worldwide problem and can result in significant disability. Management of peripheral nerve injuries (PNIs) requires accurate localization and the assessment of severity of the lesion. Aim: The purpose of this study is to analyze the data of patients with PNIs referred for electromyography to a tertiary care hospital. Materials and Methods: This is a retrospective study of clinical and electromyographic data of patients with PNIs seen over a period of eight-years (1999-2007) in a tertiary hospital. The data collected included: Demographic data, cause, type of lesion, anatomical location of the lesion, and the mechanism of lesion. Results: During the study period 938 patients were seen with nerve injuries and the distribution of nerve injuries was: PNIs: 1,165; brachial plexus lesions: 76; and lumbar plexus lesions: 7. The mean age was 31.8 years (range 2-81 years) and the male to female ratio was 2.4:1. The most frequent nerve injuries were ulnar nerve in the upper extremity and sciatic nerve in the lower extremity. The most common cause of nerve injury was motor vehicle accidents. Two-thirds of the PNIs were partial. Conclusion: This study can serve as a guide to determine the epidemiology and classification of traumatic peripheral and plexus injuries.
  47 8,913 370
REVIEW ARTICLE
Artificial cervical disc replacement: Principles, types and techniques
L H.S Sekhon, JR Ball
October-December 2005, 53(4):445-450
DOI:10.4103/0028-3886.22611  PMID:16565536
Cervical arthroplasty after anterior decompression with insertion of a prosthetic total disc replacement has been suggested as an alternate to anterior cervical fusion. Currently there are four cervical arthroplasty devices available on the market whose results in clinical use have been reported. Each device varies in terms of materials, range of motion, insertion technique and constraint. It is not known which device is ideal. Early studies suggest that in the short term, the complication rate and efficacy is no worse than fusion surgery. Long-term results have not yet been reported. This review examines the current prostheses available on the market as well as discussing issues regarding indications and technique. Pitfalls are discussed and early experiences reviewed. In time, it is hoped that a refinement of cervical arthroplasty occurs in terms of both materials and design as well as in terms of indications and clinical outcomes as spinal surgeons enter a new era of the management of cervical spine disease.
  47 20,178 989
Neurological syndromes following organophosphate poisoning.
S Singh, N Sharma
October-December 2000, 48(4):308-13
PMID:11146591
Organophosphorous compounds, the anticholinesterases, produce significant morbidity and mortality in India. Although exact estimates are not available, hospital based statistics suggest that nearly half of the admissions to emergency with acute poisoning are due to organophosphates. Following accidental or suicidal exposure, these anticholinesterases lead to three well defined neurological syndromes i.e. initial life threatening acute cholinergic crisis which often requires management in intensive care unit, intermediate syndrome in which cranial nerve palsies, proximal muscle weakness and respiratory muscle weakness are common and patients often require respiratory support and delayed organophosphate induced polyneuropathy. In addition to these three classical neurological syndromes following acute exposure and in some following low dose chronic exposure, several neurobehavioural changes have been observed and these have been termed together as 'chronic organophosphate induced neuropsychiatric disorders' (COPIND). Organo-phosphate compounds produce significant pesticide related illness in developing countries. There is, thus, a need to determine exact extent of the problem and to develop appropriate strategies to manage these cases with available resources in these countries.
  46 60,052 1,915
CASE REPORTS
Glioblastoma multiforme with long term survival
Prabal Deb, Mehar Chand Sharma, Ashok Kumar Mahapatra, Deepak Agarwal, Chitra Sarkar
July-September 2005, 53(3):329-332
DOI:10.4103/0028-3886.16934  PMID:16230803
Glioblastoma multiforme (GBM) Patients generally have a dismal prognosis, with median survival of 10-12 months. GBM with long-term survival (LTS) of 5 years is rare, and no definite markers indicating better prognosis have been identified till date. The present study was undertaken to evaluate GBMs with LTS in order to identify additional correlates associated with favourable outcome. The cases were evaluated for relevant clinicopathological data, proliferation index and expression of tumortumour suppressor gene ( p53 ), cyclin-dependant kinase-inhibitors ( p27 and p16 ) and epidermal growth factor receptor (EGFR) proteins. Six cases of GBM with LTS with an average survival of 9 years (range 5-15 years) were identified. All were young patients with mean age of 27 years (range 8-45 years). Histology of three cases was consistent with conventional GBM, while two showed prominent oligodendroglial component admixed with GBM areas. One was a giant cell GBM, which progressed to gliosarcoma on recurrence. The mean MIB-1LI was 12% (range 6-20%). p53 was immunopositive in 4 out of 5 cases. EGFR and p27 were immunonegative in all, whereas p16 was immunonegative in 3 out of 5 cases. Currently, in the absence of specific molecular and genetic markers, GBM in young patients should be meticulously evaluated for foci of oligodendroglial component and/or giant cell elements, in addition to proliferative index and p53 expression, since these probably have prognostic connotations, as evident in this study. The role of p16 and p27 however needs better definition with study of more number of cases.
  46 27,000 453
ORIGINAL ARTICLE
Change in tissue thromboplastin content of brain following trauma
Ashis Pathak, S Dutta, N Marwaha, D Singh, N Varma, SN Mathuriya
April-June 2005, 53(2):178-182
DOI:10.4103/0028-3886.16404  PMID:16010055
Background: Tissue thromboplastin (TTP) is an integral membrane protein contributing to coagulopathy after trauma of brain, which is a rich source of TTP. Aims: A study was undertaken to establish the TTP content of various areas of normal brain and estimate the changes in TTP activity of brain in response to varying degrees of trauma. Materials and Methods: Samples from different areas of brain of ten cadavers were used as controls and they were compared with contused brain tissue obtained after surgery in 25 head injury (HI) patients of varying severity. Results: In the study group, the TTP activity of the frontal, parietal, and temporal lobes after HI was significantly raised in contrast to that of the control group. The TTP activity was also significantly higher in the severe HI patients than those having moderate HI. The mode of injury and the time lapse after HI had no significant bearing on the TTP activity. Subjects above 40 years of age demonstrated a higher mean TTP activity after HI, though it was not statistically significant. Conclusion: The study provides quantitative data on TTP activity of normal brain and highlights the role of TTP in coagulopathy following HI through its increased activity after HI, more so in the severe HI group.
  46 9,007 225
Concomitant upregulation of nuclear factor-kB activity, proinflammatory cytokines and ICAM-1 in the injured brain after cortical contusion trauma in a rat model
Chun Hua Hang, Ji-Xin Shi, Jie-Shou Li, Wei Wu, Hong Xia Yin
July-September 2005, 53(3):312-317
DOI:10.4103/0028-3886.16930  PMID:16230799
Background: Nuclear factor kappa B (NF-kB), proinflammatory cytokines and intercellular adhesion molecule 1 (ICAM-1) are frequently upregulated in the injured brain after traumatic brain injury (TBI). However, the temporal pattern of upregulation is not well defined. Aims: The current study was undertaken to investigate the temporal profile of the expression of NF-kB, proinflammatory cytokines and ICAM-1 in the injured brain after cortical contusion trauma of the rat brain. Settings and Design: A rat model of cortical contusion was produced by a free-falling weight on the exposed dura of right parietal lobe. The rats were randomly divided into control group and TBI groups at hours 3, 12, 24 and 72, and on day 7. Material and Methods: NF-kB binding activity in the surrounding brain of injured area was studied by electrophoretic mobility shift assay (EMSA). The levels of TNF-a and IL-6 were detected using ELISA and ICAM-1 expression studied by immunohistochemistry. Statistical analysis: The data were analyzed by one-way ANOVA followed by Student-Newman-Keuls post hoc test. Relation between variables was analyzed using bivariate correlation with two-tailed test. Results: Compared with that of control group, NF-kB binding activity in the injured brain was significantly increased through 12 h and 7 days postinjury, with the maximum at 72 h. The concentrations of TNF-a and IL-6 in the injured brain were significantly increased from 3 h to 7 days and maximal at 24 h postinjury. The number of ICAM-1 immunostained microvessels was significantly increased in the injured brain from 24 h to 7 days postinjury, with its peak at 72 h. Concomitant upregulation of TNF-a, IL-6, ICAM-1 and the cytokine mediators NF-kB in the injured brain was observed in the injured brain after cortical contusion, and there was a highly positive relation among these variables. Conclusions: Cortical contusion trauma could induce a concomitant and persistent upregulation of NF-kB binding activity, TNF-a, IL-6 and ICAM-1 in the injured rat brain which might play a central role in the injury-induced immune response of brain.
  45 9,574 277
TOPICS OF THE ISSUE-DENGUE NEUROLOGY-REVIEW ARTICLES
Neurological complications of dengue infection
J. M. K. Murthy
July-August 2010, 58(4):581-584
DOI:10.4103/0028-3886.68654  PMID:20739796
Dengue infection is endemic in more than 100 countries, mostly in the developing world. Recent observations indicate that the clinical profile of dengue is changing, and that neurological manifestations are being reported more frequently. The exact incidence of various neurological complications is uncertain. The pathogenesis of neurological manifestations is multiple and includes: neurotrophic effect of the dengue virus, related to the systemic effects of dengue infection, and immune mediated. In countries endemic to dengue, it will be prudent to investigate for dengue infection in patients with fever and acute neurological manifestations. There is need for understanding of the pathogenesis of various neurological manifestations.
  45 16,483 1,014
ORIGINAL ARTICLE
Hyperacute thrombolysis with IV rtPA of acute ischemic stroke: Efficacy and safety profile of 54 patients at a tertiary referral center in a developing country
MV Padma, MB Singh, R Bhatia, A Srivastava, M Tripathi, G Shukla, V Goyal, S Singh, K Prasad, M Behari
January-March 2007, 55(1):46-49
DOI:10.4103/0028-3886.30426  PMID:17272899
Background: Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries. Prothrombin time (PT), platelet count and activated partial thromboplastin time (aPTT) may not be feasible within the time window. Aim: To evaluate the safety and efficacy of thrombolysis in selected patients without the coagulation profile. Design: Open, nonrandomized, observational study. Materials and Methods: Fifty-four stroke patients were classified using TOAST criteria (large artery atherosclerotic = 13; cardioembolic = 12; small vessel occlusion = 22; other determined etiology =three; undetermined etiology = four). The mean time to reach emergency was 2.4h (1.15-3.4), the mean door to CT, 24 min (10-47) and the door to recombinant tissue plasminogen activator (r-tPA) injection, 26.8 min (25-67). The NIHSS scores ranged from 11 to 22 (mean = 15.5 2.7). Patients with history of liver or renal disease or those on anticoagulants were excluded. The PT, aPTT and platelet count were not done. Recombinant tissue plasminogen activator was administered at a dosage of 0.9 mg/Kg. Results: Thirty-five patients (65%) significantly improved on NIHSS at 48h (4 points) (mean change = 10; range= 4-17). At one month, 43 (79%) improved on Barthel Index (mean change = 45%). One each developed small frontal lobe hemorrhage and recurrent stroke; one died of aspiration; and eight showed no improvement. Conclusions: Hyperacute thrombolysis was found useful and safe in selected patients with AIS even without the coagulation studies.
  44 9,559 1,374
Acute disseminated encephalomyelitis.
JM Murthy
July-September 2002, 50(3):238-43
PMID:12391446
Acute disseminated encephalomyelitis (ADEM) is an uncommon inflammatory demyelinating disease of the central nervous system. The true incidence of the disease in India is undetermined and is likely to be more frequent than reported, as the common antecedent events, exanthematous fevers and Semple antirabies vaccination, which predispose to ADEM, are still prevalent. The existing evidence suggests that ADEM results from a transient autoimmune response towards myelin or other self-antigens, possibly via molecular mimicry, or by non-specific activation of auto-reactive T cell clones. ADEM is a monophasic illness with favourable long-term outcome. Involvement of neuroaxis is variable and can be diffuse or multifocal and site restricted. Magnetic resonance imaging (MRI) is highly sensitive in detecting white matter lesions and the lesions described are rather extensive and subcortical in location. Involvement of the deep gray matter, particularly basal ganglia, is more frequent. Oligoclonal bands in CSF are usually absent. No therapy has been established by controlled trials in ADEM. Use of high-dose methylprednisolone, plasma exchange, and IVIG are based on the analogy of the pathogenesis of ADEM with that of multiple sclerosis (MS). Differentiation of ADEM from the first attack of MS is important from prognostic as well as therapeutic point of view. However, in the absence of biological marker, at times differentiation of ADEM from the initial presentation of MS may not be possible even by combination of clinical, CSF analysis, and MRI. This differentiation is more relevant to India where the incidence of MS is low.
  43 59,630 1,384
REVIEW ARTICLES
Epidemiology of central nervous system mycoses
Arunaloke Chakrabarti
July-September 2007, 55(3):191-197
DOI:10.4103/0028-3886.35679  PMID:17921647
Fungal infections of the central nervous system (CNS) were considered rare until the 1970s. This is no longer true in recent years due to widespread use of corticosteroids, cytotoxic drugs and antibiotics. Immunocompromised patients with underlying malignancy, organ transplantations and acquired immune deficiency syndrome are all candidates for acquiring fungal infections either in meninges or brain. A considerable number of cases of CNS fungal infections even in immunocompetent hosts have been reported. A vast array of fungi may cause infection in the CNS, but barring a few, most of them are anecdotal case reports. Cryptococcus neoformans , Candida albicans, Coccidioides immitis. Histoplasma capsulatum are common causes of fungal meningitis; Aspergillus spp., Candida spp., Zygomycetes and some of the melanized fungi are known to cause mass lesions in brain. Few fungi like C. neoformans, Cladophialophora bantiana, Exophiala dermatitidis, Ramichloridium mackenzie, Ochroconis gallopava are considered as true neurotropic fungi. Most of the fungi causing CNS infection are saprobes with worldwide distribution; a few are geographically restricted like Coccidioides immitis . The infections reach the CNS either by the hematogenous route or by direct extension from colonized sinuses or ear canal or by direct inoculation during neurosurgical procedures.
  43 13,604 1,351
Current concepts in the management of pyogenic brain abscess.
BS Sharma, SK Gupta, VK Khosla
April-June 2000, 48(2):105-11
PMID:10878771
Current philosophy of treatment of brain abscess includes aspiration, appropriate antibiotics, treatment of sequelae and eradication of the primary source. Early clinical suspicion and diagnosis with CT is crucial. Small abscesses (<3 cm) in cerebritis or capsular stage located deep in clinically stable, poor surgical risk patients with diagnosis firmly supported by CT, may be treated with medical treatment only. Biweekly CT scan must be done to monitor the treatment response. CT or ultrasound guided aspiration should be performed in the event of clinical deterioration, failure of reduction in size or enlargement of abscesses. Encapsulated abscess (>3 cm), presence of significant neurological deficit or mass effect, doubt in the diagnosis and presumed resistant organisms are best treated with aspiration. Excision is required in large superficial abscesses resistant to multiple aspirations, post-traumatic abscess with a foreign body or fistula and multiloculated abscess of nocardial or actinomycotic aetiology. Results are directly related to the sensorium at the time of presentation. Stereotactic aspiration of all the loculi of multiloculated abscess in single or staged aspiration, and more completed drainage and lavage with endoscopic stereotactic evacuation may cut down indications of excision of brain abscess in future. It is concluded that, with diagnostic and technical advancements, a trend of adequate drainage of brain abscess via minimally invasive surgery is emerging. Confirmation of diagnosis and monitoring of treatment response with magnetic resonance spectroscopy may allow greater number of patients in future to be managed with medical treatment only.
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