Chandrajit Prasad

Decrease in Cerebral and Cerebellar Gray Matter in Essential Tremor: A Voxel-Based Morphometric Analysis under 3T MRI

Though routine neuroimaging is usually normal in essential tremor (ET) there is clinical evidence of widespread involvement of central nervous system. This study aimed at determining morphological changes in brain of patients with ET using voxel‐based morphometry (VBM) analysis and also compare the subtypes of ET.

Diffusion tensor imaging: Tract based spatial statistics study in essential tremor

INTRODUCTION Essential tremor (ET) is a common movement disorder with motor and non-motor symptoms. We aimed to investigate the neurodegenerative changes in the brain white matter of patients with ET using Diffusion Tensor Imaging (DTI). METHODS Clinical and MRI data from 20 patients (5 women and 15 men; age-38.2 ± 16.5 yrs) with ET and 17 controls (3 women and 14 men; age-40.7 ± 16.5 yrs) were collected prospectively. The DTI data were analyzed using tract based spatial statistics (TBSS) software for tract wise analysis. Further region of interest (ROI) analysis was carried out in the genu of corpus callosum, anterior limb of internal capsule (ALIC), corticospinal tract (CS), and cerebellar peduncles. Effect of tremor severity, disease duration and age of onset on DTI metrics was also studied. RESULTS Patients with ET in comparison to controls showed significant (P(corrected) < 0.05) increase of mean diffusivity and radial diffusivity in right frontoparietal white matter. Axial diffusivity increase was seen in bilateral cerebral hemispheres, thalamus, brainstem and cerebellar hemisphere white matter. No significant change in fractional anisotropy of the white matter was seen. ROI analysis also revealed abnormalities in the ALIC and cerebellar peduncles. There was no correlation between the severity of white matter changes and clinical tremor severity score as well as disease duration. CONCLUSIONS This study provides in vivo evidence for axonal disintegration of the cerebral and cerebellar white matter fibres in patients with ET.

Tumefactive demyelination: clinical, imaging and follow-up observations in thirty-nine patients

We describe the clinical, neuroimaging and pathological features and therapeutic outcome in a large cohort of 39 patients with tumefactive demyelination.

Depression and sleep disturbances in patients with multiple sclerosis and correlation with associated fatigue

Objective: To observe prevalence of depression and sleep disturbances in multiple sclerosis (MS) patients and their correlation with associated fatigue. Study Design and Setting: Prospective observation study in a university tertiary research hospital in India. Materials and Methods: Thirty-one patients (6 male and 25 female) with definite MS (McDonalds criteria) presented in out-patient/admitted in the department of neurology (between February 2010 and December 2011) were included in the study. Depression was assessed using Becks Depression Inventory (BDI). Sleep quality was assessed using Pittsburg Sleep Quality Index (PSQI). Disease severity was evaluated using the Kurtzkes expanded disability status scale (EDSS). Fatigue was assessed using Krupps fatigue severity scale (FSS). We tried to observe correlation of depression and sleep disturbance with associated fatigue in MS patients. Results: The age of patients varied between 16 and 50 years (30.1 ± 9.1). The mean age at first symptom was 25.2 ± 6.4 years (range 14-39 years). The prevalence of sleep disturbance and depression was 51.6% (16/31) each and fatigue 58.1% (18/31) in the study group. The PSQI scores were significantly greater in the patients with fatigue as compared with those without fatigue indicating poorer sleep quality is associated with fatigue in MS (P = 0.005). The BDI scores were also significantly higher in the fatigue group showing that severity of depression also strongly correlated with fatigue (P = 0.001). Conclusions: Depression and sleep disturbance in patients with MS is significantly correlated with associated fatigue.

Prevalence of fatigue in patients with multiple sclerosis and its effect on the quality of life

Objective: This prospective study was carried out to observe the prevalence of fatigue in patients with multiple sclerosis (MS) and its effect on quality-of-life (QoL). Study Design and Setting: Prospective observational study in a University Tertiary Research Hospital in India. Patients and Methods: A total of 31 patients (25 females) with definite MS according to McDonalds criteria presented in out-patient/admitted in the Department of Neurology (between February 2010 and December 2011) were included in the study. Disease severity was evaluated using the Kurtzkes expanded disability status scale (EDSS). Fatigue was assessed using Krupps fatigue severity scale (FSS). QoL was assessed by the World Health Organization QoL-BREF questionnaire. Results: The mean age of patients was 30.1 ± 9.1 years. The mean age at first symptom was 25.23 ± 6.4 years. The mean number of relapses was 4.7 ± 3.6 in the patients. The mean duration of illness was 4.9 ± 4.4 years. The mean EDSS score was 3.5 ± 2.2. Mean fatigue score was 38.7 ± 18.5 (cut-off value 36 in FSS). The prevalence of fatigue in patients with MS was 58.1% (18/31). MS patients with fatigue were significantly more impaired (P < 0.05) on all QoL domains (i.e., physical, psychosocial, social, and environment) than MS patients without fatigue. Conclusion: Prevalence of fatigue was found to be high in the MS patients in the study. All four domains of QoL were significantly more impaired in the group with fatigue than in those without fatigue.

Reverse split hand syndrome: Dissociated intrinsic hand muscle atrophy pattern in Hirayama disease/brachial monomelic amyotrophy

Abstract Preferential involvement of C7, C8, T1 level anterior horn cells is a typical feature in Hirayama disease/brachial monomelic amyotrophy (BMMA). There are no clinico-electrophysiological studies to substantiate the peculiar pattern of muscle involvement. Thirty subjects, 10 in each group of BMMA, amyotrophic lateral sclerosis (ALS) and age-matched normal healthy subjects underwent detailed clinical and electrophysiological testing. Results showed that the mean age at evaluation for BMMA and ALS patients was 25.8 ± 3.8 and 51.8 ± 9.5 years, respectively; illness duration was 8.1 ± 5.7 years and 11.14 ± 2.85 months, respectively. Clinically, all BMMA patients had reverse of split hand (RSH) syndrome [abductor digiti minimi (ADM) affected more than abductor pollicis brevis (APB)], while 7/10 ALS patients had classical split hand syndrome (APB affected more than ADM). In BMMA, the compound muscle action potential (CMAP) of APB was preserved but reduced/absent in ADM compared to the ALS group which demonstrated reverse findings. APB/ADM ratio was >0.8 in the BMMA group (>1.4 in 80%), around 1.0 in normal controls (none had >1.4) and <0.8 in ALS (70% having values <0.6). In conclusion, RSH syndrome may provide valuable diagnostic clues to differentiate this relatively self-restricted disease from progressive degenerative disease like ALS.

Vitamin D status and vascular dementia due to cerebral small vessel disease in the elderly Asian Indian population

Vitamin D plays vital roles in human health and recent studies have shown its beneficial effect on brain functioning. The present study was designed to evaluate the association of vitamin D with vascular dementia (VaD) due to cerebral small vessel disease (SVD) in Asian Indian population. 140 VaD patients aged ≥ 60 years with neuroimaging evidence of SVD, and 132 age and gender-matched controls, were investigated. Vitamin D status was estimated by measuring serum 25-hydroxy vitamin D. Logistic regression model revealed that deficient levels of vitamin D (<12 ng/ml) were associated with 2.2-fold increase in odds of VaD after adjustment with covariates. Hypertension was independently associated with 11.3-fold increased odds of VaD. In hypertensives with vitamin D deficiency and insufficiency (12-20 ng/ml), the odds were increased to 31.6-fold and 14.4-fold, respectively. However, in hypertensives with vitamin D sufficiency (>20 ng/ml), the odds of VaD were increased by 3.8-fold only. Pearson correlation showed that serum vitamin D was inversely associated with systolic and diastolic blood pressure (r=-0.401 and -0.411, p<0.01, respectively) in vitamin D-deficient subjects. Since the combined presence of hypertension and vitamin D deficiency increases the probability of developing VaD, screening for vitamin D status in addition to regular monitoring of blood pressure, could reduce the risk of VaD associated with cerebral SVD in the elderly Asian Indian subjects.

Imaging characteristics of supratentorial ependymomas: Study on a large single institutional cohort with histopathological correlation

Background: Supratentorial ependymoma (STE) is a tumor whose unique clinical and imaging characteristics have not been studied. Histopathologically, they resemble ependymoma elsewhere. We retrospectively reviewed the imaging findings with clinicopathological correlation in a large number of patients with STE to identify these characteristics. Materials and Methods: Computed tomography (CT) magnetic resonance images (MRI), pathology reports, and clinical information from 41 patients with pathology-confirmed STE from a single institution were retrospectively reviewed. CT and MRI findings including location, size, signal intensity, hemorrhage, and enhancement pattern were tabulated and described separately in intraventricular and intraparenchymal forms. Results: STE was more common in pediatric age group and intraparenchymal was more common than intraventricular form. The most common presentation was features of raised intracranial tension. There were equal numbers of Grade II and Grade III tumors. The imaging characteristics in adult and pediatric age group were similar. The tumor was large and had both solid and cystic components. Advanced imaging such as diffusion, perfusion, and spectroscopy were suggestive of high-grade tumor. Only differentiating factor between Grade II and Grade III was the presence of calcification. 1234 rule and periwinkle sign which we have described in this article may help characterize this tumor on imaging. Conclusion: This series expands the clinical and imaging spectrum of STE and identifies characteristics that should suggest consideration of this uncommon diagnosis.

MRS Findings in Cerebral Coenurosis due to Taenia Multiceps

Cerebral coenurosis due to Taenia multiceps is a rare infection with no case reports from India. A 55‐year‐old male patient had presented with progressive symptoms of hemiparesis of 1‐year duration. Magnetic resonance imaging (MRI) with magnetic resonance spectroscopy (MRS) of the lesion was performed that showed a septated cystic lesion in left parieto‐occipital lobe. Multivoxel MRS through the lesion was performed using repetition time of 1500 ms and time to echo of 144 ms at 3T MRI. MRS showed mildly elevated choline (Cho), depressed creatine (Cr), and N‐acetyl aspartate (NAA), a large peak of lactate, pyruvate, and acetate peaks. To best of our knowledge, there has been no reported case of in vivo proton MRS finding ever reported. We present MRS findings in this operatively proven case of T. multiceps cyst of the brain.

Factors determining cognitive dysfunction in cerebral small vessel disease

Introduction: Vascular dementia consists of cognitive and functional impairment due to cerebrovascular brain injury. With reference to small vessel disease (SVD), even though the radiological evidence of SVD is present in a large number of persons above the age of 80 years, less than one-third of the people progress to dementia. Hence, if those factors are identified, we may be able to formulate strategies to protect that percentage of patients who progress to dementia. In this study, we have analyzed some genetic and nongenetic factors in patients with and without a cognitive impairment in the presence of radiological SVD. Patients and Methods: Two hundred and ten patients who satisfied the criteria for the study were included. All medical comorbidities, demographic factors, substance abuse, etc., were documented and neuropsychological evaluation done. In addition, the genetic testing was done for the polymorphisms of TT, TC, and CC alleles of CYP11B2 based on the literature evidence of the association of CYP11B2 polymorphism and hypertension. Results: This prospective hospital-based study revealed a significant relationship among hypertension, hyperhomocysteinemia, and severity of white matter changes but other comorbidities did not correlate. No significant correlation was seen between cognitive dysfunction and severity of white matter changes or genotypes TT, TC, and CC. However, TC genotype was more common in male hypertensives. Even though hypertension and hyperhomocysteinemia were associated with leukoaraiosis, none of the factors studied trigger conversion of these radiological changes to clinical cognitive impairment. Discussion and Conclusion: Severity of cerebral white matter changes seems to correlate with hypertension and hyperhomocysteinemia, however, none of the co-morbidities studied including the three polymorphisms of CYP11B2, that is, TT, TC, and CC seem to determine the conversion of leukoaraiosis to dementia.