C.M. Pandey

Serial changes in the white matter diffusion tensor imaging metrics in moderate traumatic brain injury and correlation with neuro-cognitive function.

Diffuse axonal injury (DAI) that follows traumatic brain injury (TBI) is thought to be a major contributor to neurocognitive dysfunction that sometimes follows TBI. Conventional magnetic resonance imaging (MRI), diffusion tensor imaging (DTI) and neuropsychological tests (NPT) were performed on 38 TBI patients [hemorrhagic DAI (H-DAI, n=8), non-hemorrhagic (Nh-DAI, n=7), with no apparent DAI on conventional MRI (NA-DAI, n=23)] with a Glasgow Coma Scale score ranging between 9 and 13. The fractional anisotropy (FA) and mean diffusivity (MD) were quantified from different regions of the corpus callosum (CC), and peri-ventricular white matter (PWM) within 5-14 days and 6 months following TBI. Patients in all three groups showed decreased FA in the anterior limb of the internal capsule (ALIC) and the posterior limb of the internal capsule (PLIC), while the genu of the CC showed a decrease in the H-DAI group during the early period following TBI that persisted 6 months later, which appeared to be consistent with axonopathy. In patients without abnormalities on conventional MRI and DTI in the initial phase, a significant decrease in FA and increase in MD were observed in a few regions of the CC at 6 months, which was suggestive of demyelination/gliosis. The changes in FA and MD in the CC and PWM at 6 months follow-up showed significant correlation with some of the NPT performed in the three groups. DTI demonstrates axonopathy in the acute stage, as well as at secondary stages, at 6 months post-injury in the CC and PWM in regions of normal-appearing white matter on conventional MRI.

In Vivo Proton MR Spectroscopy Evaluation of Pyogenic Brain Abscesses: A Report of 194 Cases

BACKGROUND AND PURPOSE: The combination of nonspecific clinical findings and similarities in morphologic appearances on imaging often makes it difficult to distinguish abscesses from other brain lesions. We present a retrospective analysis of in vivo 1H-MR spectroscopy data for characterization of the etiology of the brain abscess based on the established criteria and demonstrate the sensitivity and specificity of metabolite markers assigned to specific bacterial groups defined by the microbial culture in 194 patients. MATERIALS AND METHODS: Conventional MR imaging and in vivo 1H-MR spectroscopy data were evaluated from patients with pyogenic brain abscesses, with ages ranging from 3 to 60 years. Imaging and 1H-MR spectroscopy were performed on a 1.5T scanner. After MR imaging was performed and analyzed, pus aspirates were obtained in all patients. The causative organisms were confirmed by pus cultures. RESULTS: Resonance of AAs with or without other metabolites on in vivo 1H-MR spectroscopy was observed in 80% of abscesses, with a sensitivity and specificity of 0.72 and 0.30, respectively. Most obligate anaerobes and some facultative anaerobes showed the presence of Lac/Lip, AAs, and Ac with or without Suc. Mostly obligate aerobes or facultative anaerobes showed the presence of Lac and AAs, with or without lipids. CONCLUSIONS: The presence of AAs on in vivo 1H-MR spectroscopy is a sensitive marker of pyogenic abscess, but its absence does not rule out a pyogenic etiology. The presence of Ac with or without Suc favors an anaerobic bacterial origin of the abscess; however, this may also be seen in some of the abscesses secondary to facultative anaerobes.

DTI correlates of cognition in term children with spastic diplegic cerebral palsy

BACKGROUND AND AIMS Presently, there is no published study that shows association between cognition and white matter injury in spastic cerebral palsy. We aimed to correlate cognitive functions with diffusion tensor imaging derived metrics in spastic diplegic children. METHODS Twenty-two term children with spastic diplegia and 22 healthy controls were recruited. All patients were graded on the basis of gross motor function. The Indian children intelligence Test was used to quantify cognition and diffusion tensor imaging was used to quantify microstructural changes in various white matter regions. Diffusion tensor imaging metrics were quantified by placing regions of interests in different white matter regions like corona radiata, anterior limb of internal capsule, posterior limb of internal capsule, mid brain, pons, medulla, genu, splenium, temporal white matter, parietal white matter, frontal white matter and occipital white matter. RESULTS Spastic diplegic children showed significantly lower neuropsychological test scores as compared to controls. A significantly decreased fractional anisotropy values were observed in corona radiata, anterior limb of internal capsule, posterior limb of internal capsule, mid brain, pons, medulla, genu, splenium and occipital white matter; however significantly increased mean diffusivity values were observed in corona radiata, anterior limb of internal capsule, posterior limb of internal capsule, mid brain, pons and genu in spastic diplegic as compared to controls. A significant positive correlation in fractional anisotropy and negative correlation in mean diffusivity was observed with neuropsychological test scores. CONCLUSION These results suggest that these imaging metrics may be used as a biomarker of cognitive functions in term children with spastic diplegia.

T1-Weighted Dynamic Contrast-Enhanced MR Evaluation of Different Stages of Neurocysticercosis and Its Relationship with Serum MMP-9 Expression

BACKGROUND AND PURPOSE: Epileptogenesis in NCC is associated with perilesional inflammation and disruption in BBB. We quantified BBB in different stages of NCC by using DCE-MR imaging to look for the differences in perfusion indices and to correlate these indices with serum MMP-9 expression. MATERIALS AND METHODS: DCE-MR imaging along with conventional MR imaging was performed in 57 single cysticercous brain lesions to quantify the kep, Ktrans, and ve around the lesions, which were in different stages of evolution. There were 6 lesions in the vesicular stage and 17 lesions each in the colloidal, granular-nodular, and calcified stages. Serum MMP-9 was quantified from all patients, whereas perfusion indices were quantified from all stages except for the vesicular stage. RESULTS: We observed significant differences among the 3 stages of NCC in serum MMP-9 expression as well as DCE-derived kep values. In addition, kep showed a strongly significant positive correlation with MMP-9 expression when modeled with the individual stage of the disease as well as with all stages when pooled together. Other DCE-derived hemodynamic and pharmacokinetic parameters showed inconsistent differences with each stage of the disease. The correlation of DCE-derived parameters with serum MMP-9 expression and edema volume also showed inconsistency with the stage of the disease. CONCLUSIONS: We conclude that kep correlates best with serum MMP-9 expression among the pharmacokinetic indices and most closely represents the degree of BBB breakdown, which is highest in the colloidal stage and lowest in the calcified stage. kep may be used as a noninvasive image biomarker of BBB breakdown in different stages of NCC.

DTI Correlates of Cognition in Conventional MRI of Normal-Appearing Brain in Patients with Clinical Features of Subacute Combined Degeneration and Biochemically Proven Vitamin B 12 Deficiency

BACKGROUND AND PURPOSE: Vitamin B12 deficiency may cause neural injury that results in cognitive deficits. The main purpose of our study was to evaluate morphometric and microstructural changes in the brain and relate them to cognition in subacute combined degeneration of the spinal cord and patients with biochemically deficient vitamin B12. MATERIALS AND METHODS: Fifty-one patients were recruited and underwent nerve-conduction velocity tests and routine hematologic examinations. Serum vitamin B12 and homocystine levels were also measured. All patients and 46 age- and sex-matched controls underwent cervical spine and brain MR imaging along with cognition tests. MR imaging included conventional scans and DTI. Voxel-based morphometry was performed for determining the WM and GM volumes, based on T1-weighted images. DTI measures that included fractional anisotropy, ADC, radial diffusivity, and axial diffusivity were determined by using tract-based statistics. RESULTS: None of the patients showed any abnormality on conventional MR imaging. No significant changes in GM and WM volumes were observed in patients compared with controls. Significant reductions in the fractional anisotropy and an increase in ADC and radial diffusivity values were observed in multiple brain regions in patients compared with controls. These changes were confirmed on the region-of-interest analysis. Neuropsychological scores were significantly different in patients compared with controls and showed significant correlation with fractional anisotropy and radial diffusivity in a few brain regions. CONCLUSIONS: Microstructural changes are seen in WM regions on DTI in patients with vitamin B12 deficiency and correlate with cognition scores. DTI can be used for objective assessment of microstructural changes in the brain in vitamin B12 deficiency.

Diffusion tensor tractography and neuropsychological assessment in patients with vitamin B12 deficiency

IntroductionStructural imaging of the brain does not demonstrate any changes in a vast majority of patients with vitamin B12 deficiency, even in advanced stages. In this study, we aimed to assess and correlate the functional integrity of the brain fiber tracts using diffusion tensor tractography with neuropsychological examination in patients with vitamin B12 deficiency.MethodsThe study was conducted at two tertiary care centers. Thirty-two patients with vitamin B12 deficiency were enrolled and subjected to diffusion tensor tractography, as an extension of diffusion tensor imaging, and neuropsychological assessment. Tests of significance were done to detect changes, pre- and post-vitamin B12 supplementation in the diffusivity parameters (fractional anisotropy and mean diffusivity) and the neuropsychological test scores.ResultsStatistically significant changes were observed in the diffusivity parameters and the neuropsychological test scores between the controls and the patients with vitamin B12deficiency in the pre- and post-treatment phases.ConclusionsThis is the first study to evaluate the diffusion tensor tractography (DTT) parameters in the light of clinical neuropsychological assessment in patients with vitamin B12 deficiency. Utilization of DTT parameters may antedate structural changes and may quantify the neurocognitive deficits.

Lack of association between Glu298Asp polymorphism and coronary artery disease in North Indians

Nitric Oxide (NO) is an important molecule carrying number of different functions in humans. Published studies suggest that it may inhibit several key steps involved in the pathogenesis of atherosclerosis. Inhibition or reduction of NO due to Glu298Asp polymorphism may accelerate atherosclerosis. The aim of this study was to determine whether Glu298Asp polymorphism is implicated in the pathogenesis of coronary artery disease (CAD) among North Indian population from the state of Uttar Pradesh, India. We selected 253 CAD patients and 174 healthy, normotensive, non-diabetic controls, which were matched for gender and ethnicity. The Glu298Asp (rs1799983) variant was detected by genotyping subjects, using a polymerase chain reaction followed by restriction fragment length polymorphism. There was no significant difference found in the genotypic and allelic frequencies between patients and controls. Our study indicated that Glu298Asp polymorphism does not play any critical role in the pathogenesis of CAD, at least in North Indian population.

ROLE OF BILIRUBIN, VITAMIN C AND CERULOPLASMIN AS ANTIOXIDANTS IN CORONARY ARTERY DISEASE (CAD).

A study has been carried out on 250 CAD patients to see how the serum levels of three antioxidants i.e., Vitamin C, Bilirubin and Ceruloplasmin are related to the CAD risk factors and characteristics in these patients. The number of severe category CAD patients declined by 7–18% with increasing serum levels of the three antioxidants and, triple vessel disease declined by 14–20%. A decline of 39% in Myocardial Infarction (MI) occurred with increasing serum Ceruloplasmin. Serum Ceruloplasmin was significantly lower in the MI group compared to the non MI group CAD patients. There was a steady and a significant decline in the mean values of serum levels of cholesterol, Triglyceride, VLDL cholesterol along with BMI with increasing serum level. The study indicates that with increasing serum levels of the three antioxidants studied, the % MI along with % Triple vessel disease and severity of CAD goes down suggesting that the modifiable risk factors have to be suitably modified in order to maintain a reasonably high level of these antioxidants, as the risk factors are inversely related to the serum antioxidant levels.

Disparity in maternal, newborn and child health services in high focus states in India: a district-level cross-sectional analysis

Objectives To examine the level and trend in the coverage gap of a set of interventions of maternal and child health services using a summary index and to assess the disparity in usage of maternal and child health services in the districts of high focus states of India. Design Data for the present study are taken from the Annual Health Survey (AHS), 2010–2013 and Census of India, 2011. Settings This study used secondary data from states having higher mortality and fertility rates, termed as high focus states in India. Participants District-level information regarding children aged 12–23 months and ever married women aged 15–49 years has been extracted from the AHS (2010–2013), and household amenities, female literacy and main workforce information has been obtained from the Census of India 2011. Measures 2 summary indexes were calculated first for maternal and child health services and another for socioeconomic and development status, using data from AHS and Census. Cronbachs α was used to assess the internal consistency of the items used in the index. Results The result shows that the coverage gap is highest in Uttar Pradesh (37%) and lowest in Madhya Pradesh (21%). Converge gap and socioeconomic development are negatively correlated (r=−0.49, p=0.01). The average coverage gap was highest in the lowest quintile of socioeconomic development. There was an absolute change of 1.5% per year in coverage gap during 2009–2013. In regression analysis, the coefficient of determination was 0.24, β=−30.05, p=0.01 for a negative relationship between socioeconomic development and coverage gap. Conclusions There is a significant disparity in the usage of maternal and child healthcare services in the districts of India. Resource-rich people (urban residents and richest quintile) are way ahead of marginalised people (rural residents and poorest quintile) in the usage of healthcare services.

Intermediate outcomes of rheumatic mitral stenosis post-balloon mitral valvotomy.

Background Balloon mitral valvotomy is a standard therapeutic modality for managing rheumatic mitral stenosis. Data on intermediate outcomes of this procedure are limited. Thus we investigated the intermediate outcome after balloon mitral valvotomy performed at a large tertiary center in India. Methods Case records and follow-up data of 2330 patients who underwent valvotomy from June 1999 to December 2005 were retrieved from the hospital information system and analyzed. Results The median age of the patients was 32 ± 11 years, 1363 were female including 36 who were pregnant, and 379 were in atrial fibrillation. Follow-up ranged from 1 to 14 years (mean 4.5 years, median 4.0 years). The procedural success rate was 93%. Atrial fibrillation, higher functional class, and worse valve morphology were independent predictors of a poor procedural outcome. Patients with sinus rhythm had better event-free survival (10.43 years, 95% confidence interval: 10.1–10.7) compared to those with atrial fibrillation (8.17 years, 95% confidence interval: 7.5–8.8). Patients who achieved a valve area >1.75 cm2 had a better event-free survival (11.7 years, 95% confidence interval: 11.4–12.0) than those with a valve area of 1.5–1.74 cm2 (9.3 years, 95% confidence interval: 9.0–9.7). On multivariate analysis, higher functional class, worse valve morphology, and new significant mitral regurgitation were predictors of a poor outcome. Achieved mitral valve area >1.75 cm2 was an independent predictor of a good outcome. Conclusion Patients with sinus rhythm, less gross valve deformity, and a post-balloon mitral valvotomy area >1.75 cm2 had better intermediate outcomes.