Kamalesh Das

Awareness of warning symptoms and risk factors of stroke in the general population and in survivors stroke

Awareness among the general population of the risk factors and warning symptoms of stroke is essential for preventative purposes and for immediate effective treatment. The aim of the present study was to assess the awareness, among the general population and stroke survivors, of the risk factors and warning symptoms of stroke, to develop an educational strategy for its prevention and immediate effective treatment. Six hundred and sixty stroke patients (370 male, 290 female) and 4000 people from the general population who accompanied the patients (2800 male, 1200 female) were interviewed, using three sets of questionnaires, on the risk factors and warning symptoms of stroke. Poor knowledge or awareness of the risk factors and warning symptoms of stroke was found in both groups. Both groups suggested educational programs for stroke using printed information, audiovisual programs and community survey programs using simple and understandable information for the prevention and immediate effective treatment of stroke. Poor awareness of stroke contributes to a delay in the arrival of patients in hospital emergency departments for immediate effective treatment. Multifaceted programs regarding stroke, including printed information, audiovisual programs and stroke service programs, are advocated by both patients and the general population to improve stoke treatment and prevention.

Familial, environmental, and occupational risk factors in development of amyotrophic lateral sclerosis.

Background: Definite etiology of amyotrophic lateral sclerosis (ALS) is still a matter of debate. Aims: The study was designed to evaluate the role of environmental, occupational, and familial risk factors in development of ALS. Materials and Methods: This was a case control study of 110 cases of definite ALS with 240 age and sex matched controls. Investigations were done on the following aspects- family history, occupation, living place, source of drinking water, exposure to industrial, chemical, agricultural toxins and heavy metals, physical and electrical injury, working under magnetic field for more than 10 years in both the groups. Clinical examinations, electrophysiological, and neuroimaging studies were done in every patient. Chi square test, logistic regression analysis, and calculation of odds ratio were used to analyze the data. Results: Rural livings (odds ratio = 1.99), smoking (odds ratio = 1.88), insecticides, and pesticides exposures (odds ratio = 1.61), electrical injury (odds ratio = 6.2) were detected as the associated factors in development amyotrophic lateral sclerosis. Conclusions: The study expressed the need of extensive research globally in molecular and genetic levels to detect the associated factors in etiopathogenesis of ALS for better understanding the etiology and for remedial aspects.

Role of antiparasitic therapy for seizures and resolution of lesions in neurocysticercosis patients: An 8 year randomised study

Neurocysticercosis is a common cause of acquired seizure disorder in developing countries, including India. The role of antiparasitic (albendazole) therapy for seizure control and resolution of lesions is still controversial due to a lack of adequately controlled studies. The objective of the present study was to evaluate the role of albendazole therapy for neurocysticercosis patients with two or more lesions to achieve seizure-free status and resolution of lesions. This was a randomised controlled study in which patients suffering from neurocysticercosis were prospectively followed up for more than 5 years (from January 1997 to January 2005). Patients were divided into two groups: patients in group A (n=150) were treated with a combination of tapered doses of dexamethasone and albendazole, plus antiepileptic drugs; patients in group B (n=150) were treated with antiepileptic drugs plus a placebo control. Patients were followed up every month for the first 6 months and then at 3-month intervals thereafter up to 5 years. Variables of interest were (i) recurrence of seizures; (ii) encephalopathy (headache/vomiting/altered sensorium); (iii) need for subsequent hospital admission; (iv) death; (v) resolution of lesions on follow-up CT. During the first 6 months and at intervals thereafter, increased seizure frequency and hospital readmissions, and increased incidence of encephalopathy were observed in group A (p=0.01), and two patients in this group died with intractable seizures and encephalopathy. A greater proportion of lesions completely resolved in group B (p=0.05), whereas a greater proportion of lesions calcified in group A (p=0.05). Albendazole plus antiepileptic drugs did not have greater beneficial effects than antiepileptic drugs alone, but may have an adverse effect with respect to seizure control, encephalopathy, recurrent hospital admissions, calcification of lesions and cost of treatment.

Prediction of Clinical Outcome in Acute Hemorrhagic Stroke from a Single CT Scan on Admission

Background: From a single CT scan in primary intracerebral hemorrhage (ICH), clinical outcome can be assessed on admission by using the CT scan parameters. Aims: The study aims to find out how hematoma volume, location of stroke, midline shift, intraventricular extension of bleed and ventricle compression influence the clinical outcome in patients with acute ICH. Materials and Methods: Non-contrast CT scan was done on admission in hospital for every patient with acute hemorrhagic stroke and was analyzed accordingly. Clinical assessments were done in National Institute of Health Stroke Scale (NIHSS). Chi-square test and multiple logistic regression analysis were used for statistical analysis. Results: Mean hematoma volume associated with death before 30 days is 33.16 cm3 (P < 0.0001), with survived after 30 days is 15.45 cm3 (P < 0.0001), with NIHSS score ≥16 is 29.03 cm3 (P < 0.0001) and with NIHSS score <16 is 13.69 cm3 (P < 0.0001). Independent poor prognostic factors were hematoma volume > 30 cm3 (OR = 27.857), brain stem hemorrhage (OR = 6.000), intraventricular extension of bleed from other location (OR = 7.846), presence of ventricular compression alone (OR = 2.700) and in combination with midline shift of ≥ 5 mm (OR = 2.124). Conclusions: From a single CT scan during hospital admission, mortality and morbidity in next 30 days can be predicted. A hematoma volume >30 cm3, brain stem hematoma, intraventricular extension of bleed and ventricular compression along and with midline shift are associated with early mortality in ICH.

Role of Familial, Environmental and Occupational Factors in the Development of Parkinson’s Disease

Background: Despite intensive research during the past several decades, the cause of Parkinson’s disease remains unknown. Infections, toxins, lifestyle and hereditary factors have all been supposed to play a role in the genesis of Parkinson’s disease. The final mechanisms of neuronal injury and death are probably similar, where both genetic and environmental factors are important, and these two factors interact along the etiopathogenic pathway. Objective: The purpose of the present study is to evaluate the role of familial, environmental and occupational factors in the development of Parkinson’s disease. Methods: We evaluated 345 cases of idiopathic Parkinson’s disease (215 males, 130 females; mean age 62 ± 2 years) and 370 controls (220 males, 150 females; mean age 62 ± 3 years) between January 2003 and January 2008 with regard to the following aspects in detail: place of living, family history of Parkinson’s disease and tremor, source of drinking water, exposure to insecticides, pesticides, herbicides and industrial toxins, acute poisoning, CNS infections and head injury. The duration of exposure to the risk factors and the history of Parkinson’s disease among the cases were investigated after obtaining written informed consent from cases and controls. Results and Conclusions: Family history of Parkinson’s disease and familial tremor (p = 0.035), exposure to insecticides and pesticides (p = 0.049), well water use for drinking purposes (p = 0.03), Japanese B encephalitis (p = 0.04) and acute organophosphate poisoning (p = 0.046) were associated with the development of Parkinson’s disease in this region of India. Further research is needed at the epidemiological, genetic and molecular levels for a better understanding of the etiopathogenesis of Parkinson’s disease as well as remedial aspects.

Joubert syndrome: the molar tooth sign of the mid-brain.

Joubert syndrome (JS) is a very rare, autosomal-recessive condition. It is characterized by agenesis of cerebellar vermis, abnormal eye movements with nystagmus, episodes of hyperpnea and apnea, delayed generalized motor development, retinal coloboma and dystrophy and, sometimes, multicystic kidney disease. The importance of recognizing JS is related to the outcome and its potential complications. Prenatal diagnosis by ultarsonography and antenatal magnetic resonance imaging (MRI) is also possible. We have diagnosed a case of JS in a male infant with history of delayed mental and motor milestone development, history of abnormal breathing pattern, abnormal limb movement, generalized hypotonia and abnormal head movements with nystagmus. MRI showed hypoplastic cerebellar vermis with hypoplasia of the superior cerebellar peduncle resembling the “Molar Tooth Sign” in the mid-brain.

Discontinuation of secondary preventive treatment of stroke: An unexplored scenario in India

OBJECTIVE This prospective study will evaluate the socioeconomic factors responsible for the discontinuation of secondary preventive treatment of stroke in India and its outcome. DESIGNS METHODS: A total of 1212 stroke patients (male=708, mean age 58 ± 2 years; female=504, mean age 56 ± 2 years; intra-cerebral haemorrhage=496; ischaemic=716) were enrolled in the stroke clinic for secondary preventive treatment from 1st January 2006 to 1st January 2008 and were followed up at 4-6-week intervals. Among them, 512 patients were grouped as being below the poverty line. Discontinuation of treatment for more than 2 weeks by a patient placed that patient in a group labelled discontinued. Outcomes of discontinuation of secondary preventive treatment were evaluated with respect to (1) control of risk factors, (2) recurrence of stroke, and (3) mortality rate. Reasons for the discontinuation were comparatively analysed with respect to awareness, education, economy, distance, and daily cost of treatment, types of stroke and disability status. RESULTS AND ANALYSIS During the study period of 2 years, the following was observed: 420 patients (34.65%) discontinued secondary preventive treatment; 112 patients (9.24%) dropped out; 680 patients (56.10%) continued. Chi-square and null hypothesis procedures were applied for statistical analysis. Distance, economy, poor awareness on stroke, low educational level, types of stroke, cost of treatment and disability status all were significant factors in the discontinuation of treatment. The discontinued group had poor control of risk factors, higher recurrence of both types of stroke and higher mortality. CONCLUSIONS Discontinuation of secondary preventive treatment due to diverse socioeconomic factors results in greater recurrence and disabilities among stroke survivors, and these findings should be reported to national and international planning authorities to strengthen preventive measures to achieve better outcomes and reductions of the stroke burden globally.

Use of anti-epileptic drugs in a tertiary care hospital of Eastern India with emphasis on epilepsy due to neurocysticercosis.

Introduction: Epilepsy is a chronic disease and neurocysticercosis is an important cause of secondary seizures. Its therapy is modified by a number of parameters and thus the pattern of anti-epileptic drugs used varies in different clinical settings. It was our objective to evaluate clinico-demographic and treatment profile of epilepsy patients attending neurology outpatient department, efficacy and side-effect profile of anti-epileptic drugs with special emphasis on epilepsy resulting from neurocysticercosis. Materials and Methods: This was a cross-sectional descriptive study of epilepsy patients over four months in neurology outpatient department. Clinico-biological data were obtained by interrogating patients and from recorded data using standard case-report form. Results: 79 patients were studied with 54.43% having primary etiology, 40.51% having seizures secondary to neurocysticercosis. 81% had generalized tonic-clonic seizure, 17.7% partial and 1.3% myoclonic seizures. Phenytoin (86.08%), valproate (30.38%), clobazam (26.58%) and carbamazepine (10.13%) were used either alone or in combination, with no use of anthelmintics even in cases of neurocysticercosis. Control of seizure was obtained in 79.7% with significant decrease in seizure frequency from 2.92 to 0.51 (P < 0.0001). Weight loss, nausea, decreased appetite, increased sleep, drowsiness, tremors were found to be significantly associated (P < 0.05) with phenytoin use. Conclusion: Phenytoin is the primary antiepileptic in spite of its side effects; though addition of other anti-epileptic drugs (valproate, clobazam) was required for better seizure control. Cases of neurocysticercosis respond to anti-epileptic drugs without addition of anthelmintics. Side effects observed were mostly neurological in nature.