Garima Shukla

Low-dose topiramate versus lamotrigine in migraine prophylaxis (the Lotolamp study).

Objective.—To assess the efficacy and safety of topiramate and lamotrigine for prophylaxis in patients with frequent migraine as compared to each other and to placebo.

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

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 48 h (> or =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.

Validity of the Berlin Questionnaire in identifying obstructive sleep apnea syndrome when administered to the informants of stroke patients

Given the high prevalence of sleep-disordered breathing (SDB) in stroke and its importance as a vascular risk factor, a clinical instrument to assess its incidence would be useful. Acute stroke patients (n=121) were stratified into high- and low-risk groups for SDB using a modified Berlin Questionnaire (BQ) administered to the informants who were living with the patient. After a minimum of 4 weeks from stroke onset, patients who were fit underwent overnight polysomnography (PSG). On stratifying risk of obstructive sleep apnea (OSA) in these patients based on the BQ, 53% belonged to the high-risk group and 47% belonged to the low-risk group. There was poor correlation between the clinical questionnaire results and PSG findings, with sensitivity of 66.7%, specificity of 55.6%, a positive predictive value of 63.4%, and a negative predictive value of 58.8%.

Quantitative thermal sensory testing — value of testing for both cold and warm sensation detection in evaluation of small fiber neuropathy

OBJECTIVE Small fiber neuropathy is a common neurological disorder, often missed or ignored by physicians, since examination and routine nerve conduction studies are usually normal in this condition. Many methods including quantitative thermal sensory testing are currently being used for early detection of this condition, so as to enable timely investigation and treatment. This study was conducted to assess the yield of quantitative thermal sensory testing in diagnosis of small fiber neuropathy. MATERIAL AND METHODS We included patients presenting with history suggestive of positive and/or negative sensory symptoms, with normal examination findings, clinically suggestive of small fiber neuropathy, with normal or minimally abnormal routine nerve conduction studies. These patients were subjected to quantitative thermal sensory testing using a Medoc TSA-II Neurosensory analyser at two sites and for two modalities. QST data were compared with those in 120 normal healthy controls. RESULTS Twenty-five patients (16 males, 9 females) with mean age 46.8+/-16.6 years (range: 21-75 years) were included in the study. The mean duration of symptoms was 1.6+/-1.6 years (range: 3 months-6 years). Eighteen patients (72%) had abnormal thresholds in at least one modality. Thermal thresholds were normal in 7 out of the 25 patients. CONCLUSION This study demonstrates that quantitative thermal sensory testing is a fairly sensitive method for detection of small fiber neuropathy especially in patients with normal routine nerve conduction studies.

Comparative efficacy of low dose, daily versus alternate day plasma exchange in severe myasthenia gravis : A randomised trial

ObjectiveTo evaluate the comparative efficacy of low dose daily versus alternate day plasma exchange in patients with severe myasthenia.MethodsThirty three patients with myasthenia gravis (Ossermans stage II b and III) were randomized to receive alternate day (n = 17) or daily low dose plasma exchange (n = 16). Plasma exchange were carried on each patient, number of exchanges varying subject to their requirements and 20-25 ml/kg plasma was removed during each session. Myasthenia gravis disease scale (MGDS) score was evaluated before and after the procedure. Time to wean off ventilator, removal of nasogastric tube and total duration of hospital stay were also assessed.ResultsThere was no statistically significant difference between daily vs. alternate day group with regards to change in MGDS score, percentage change in MGDS score, and complication rates. A decreased hospital stay was observed in patients on daily plasma exchange which almost reached statistical significance.ConclusionWe conclude from our study that daily and alternate day plasma exchange are similar in their efficacy and complication rates, however the daily schedule could be a preferred modality due to decreased hospital stay.

Markedly disturbed sleep in medically refractory compared to controlled epilepsy - A clinical and polysomnography study

PURPOSE To evaluate sleep disturbances or sleep related events and their characteristics among patients with medically refractory epilepsy, compared to those with controlled epilepsy. METHODS In a prospective case-controlled study, patients of medically refractory and controlled epilepsy were recruited and history pertaining to epilepsy and sleep related events and Epworth sleepiness scores were recorded and all patients underwent over night polysomnography. RESULTS Among 40 patients, 20 with medically refractory (Group 1) and 20 with controlled epilepsy (Group 2) (median age 18, range 10-35 years), the self reported sleep parameters in Group 1 patients were found to be significantly different as compared to Group 2, in terms of the duration of night time sleep, day time sleep, day time nap frequency, total sleep hours per day, excessive daytime sleepiness (EDS)(45% vs. 15%) and average sleep hours over the week prior to polysomnography. On PSG, Group 1 patients showed significantly less total sleep time [340.4 min (147-673) vs. 450.3 min (330-570)] with delayed sleep latency and REM latency, poor sleep efficiency [80.45 (40.5-98.0) vs. 95.45 (88.4-99.7)] and frequent arousals and wake after sleep onset (WASO) compared to Group 2 patients. Four patients (20%) in Group 1 compared to none in Group 2 were found to have mild obstructive sleep apnea. CONCLUSIONS Our results indicate that medically refractory epilepsy patients believe that they spend more time sleeping, in contrast to the documented shorter sleep duration on polysomnography. This difference between perceived and actual sleep seems, by their data, to arise mainly from sleep fragmentation, disturbed architecture and the interesting finding of associated sleep apnea among the medically refractory epilepsy patients.

Surgical outcome of cortical dysplasias presenting with chronic intractable epilepsy: a 10-year experience.

BACKGROUND There has been sparse description of cortical dysplasias (CDs) causing intractable epilepsy from India. AIM Clinical retrospective study of CDs causing intractable epilepsy that underwent surgery. MATERIALS AND METHODS Fifty-seven cases of CDs reviewed (1995 till July 2006) are presented. All patients had intractable epilepsy, and underwent a complete epilepsy surgery workup (inter ictal electroencephalography (EEG), video EEG, MRI as per epilepsy protocol, SPECT {interictal, ictal with subtraction and co-registration when required}, and PET when necessary). Surgical treatment included a wide exposure of the pathology with a detailed electrocorticography under optimal anesthetic conditions. Mapping of the sensori-motor area was performed where indicated. Procedures included resection either alone or combined with multiple subpial transactions when extending into the eloquent areas. RESULTS Our study had 28 (49.12%) cases of isolated focal CDs, and 29 (50.67%) with dual pathology. Average age at the time of onset of seizures in our series was 7.04 years (three months to 24 years), and average age at the time of surgery was 10.97 years (eight months to 45 years). Among coexistent pathologies, one had associated MTS, 16 had coexistent gangliogliomas and 12 (dysembryonic neuroepithelial tumor) DNTs. At an average follow-up of 3.035 years (range 5-10 years), three patients were lost to follow-up. Fifty-one per cent (29/57) patients had a good outcome (Engel Grade I) and 26%(15/57) had a Grade II outcome. CONCLUSION Cortical dysplasias have a good outcome if evaluated and managed with concordant electrical and imaging modalities.

Clinical speech impairment in Parkinson's disease, progressive supranuclear palsy, and multiple system atrophy

CONTEXT Speech abnormalities are common to the three Parkinsonian syndromes, namely Parkinsons disease (PD), progressive supranuclear palsy (PSP) and multiple system atrophy (MSA), the nature and severity of which is of clinical interest and diagnostic value. AIM To evaluate the clinical pattern of speech impairment in patients with PD, PSP and MSA and to identify significant differences on quantitative speech parameters when compared to controls. DESIGN AND SETTING Cross-sectional study conducted in a tertiary medical teaching institute. MATERIALS AND METHODS Twenty-two patients with PD, 18 patients with PSP and 20 patients with MSA and 10 age-matched healthy controls were recruited over a period of 1.5 years. The patients were clinically evaluated for the presence and characteristics of dysarthria. This was followed by quantitative assessment of three parameters: maximum phonation time (MPT), semantic fluency and reading speed. The outcome measures were compared between the patient groups and with controls. RESULTS Patients with PD had hypophonic monotonous speech with occasional rushes of speech while patients with MSA and PSP had mixed dysarthria with ataxic and spastic elements respectively. All quantitative parameters were affected when compared to controls (P values<0.001, 0.012 and 0.008 respectively). Maximum phonation time was significantly less in PSP when compared to MSA and PD (P=0.015). Reading speed also showed a similar trend which was not statistically significant. Semantic fluency was comparable in all three groups. CONCLUSION Dysarthria in PD, PSP and MSA have many overlapping but certain distinctive features as well which could serve as a diagnostic clue. Patients with PSP had profound speech impairment probably indicative of the more severe frontostriatial pathology.

Serum prolactin levels for differentiation of nonepileptic versus true seizures: limited utility

Frequently occurring nonepileptic psychogenic seizures (PNES) are a cause of substantial morbidity. Differentiation of these from true seizures may sometimes be very difficult. Serum prolactin level estimation following the event has been described as a useful test for this purpose. We conducted this study to assess the role of this test in diagnosis of PNES. Serum prolactin was estimated from venous blood samples of 19 patients (13 females, 6 males) with PNES and 17 patients (5 females, 12 males) with true complex partial seizures with or without secondary generalization. The age range was 12-39 years in the PNES group and 9-42 years in the true seizure group. Five patients (all females) in the PNES group (26.3%) had raised prolactin levels, all of them having greater than twice normal levels. In the true seizure group, 10 of 17 (58.8%) patients had raised levels; only 3 (17.6%) of these had greater than twice normal levels. The difference in percentage of patients with abnormal prolactin levels between these groups was not found to be significant. We demonstrate that serum prolactin level estimation is not a useful method for differentiation of psychogenic nonepileptic from true epileptic seizures.

RBD in Parkinson's disease: A clinical case control study from North India

OBJECTIVES Sleep related complaints and rapid eye movement (REM) behavior disorder (RBD) are commonly reported in patients with Parkinsons disease (PD). The study aimed to compare the characteristics of patients with PD with RBD versus those without RBD. METHODS Consecutive patients with PD were evaluated with detailed clinical history, examination and questionnaire on sleep RBD over a two year period. Clinical scores included Unified Parkinsons Disease Rating Scale (UPDRS), Hoehn & Yahr Stage (H & Y), Schwab and England (S & E) scale, Mini Mental Status Examination (MMSE), EuroQol, Parkinsons disease Sleep Scale (PDSS) and Epworth Sleep Scale (ESS). The qualitative data was analyzed using chi square/Fischers exact test and continuous variables were analyzed using Students t-test. RESULTS The study included a total of 134 patients. RBD was present in 26 (19.4%) patients. There was increased occurrence of hallucinations in patients with RBD. None of the patients had familial PD. Patients with RBD had significantly higher prevalence of insomnia, nocturnal awakening, early morning awakenings and snoring. Most clinical events were brief and confined to vocalization or limb movements. CONCLUSION RBD may precede or follow PD onset. RBD has association with higher occurrence of hallucinations and other nocturnal problems; although most of these episodes were brief, had static course and were not associated with violent behavior.