Fenestration of the posterior communicating artery.

A 21-year-old male presented with sudden onset of right-sided third nerve paresis. Angiogram showed a fenestrated posterior communication artery on the right side and no other vascular anomalies. There was no other lesion that could suggest a cause for the third nerve weakness. Fenestration of the posterior communicating artery has not been reported till date. The case is discussed and the literature on the subject is reviewed.

The lateralizing significance of version of head and dystonic limb posturing in epileptic seizures.

Several clinical signs have been described for lateralization and localization of seizure focus in complex partial seizures; however, the specificity of each of these has been widely debated upon. The present study was done to evaluate 'dystonic unilateral limb posturing' and 'versive head movements' for lateralization and localization of epileptic foci in patients with intractable partial complex seizures, being investigated with long term Video-EEG monitoring. Fifteen patients with 46 seizures, studied with long term Video EEG, had either one or both of these signs. The video recordings of the clinical behaviour were noted and later compared with the corresponding EEG. Unilateral dystonic limb posturing and versive head movements had good lateralising value in complex partial seizures, suggestive of temporal lobe origin, contralateral to the seizure focus, with a specificity of 87.5% and 86% respectively. In addition, turning of the whole body to one side was associated with a contralateral seizure focus in 100% cases. Appendicular automatisms were found to be of no lateralising significance, as they occurred on either side with equal frequency. These motor phenomena should, therefore, be enquired about in detail, during history taking for lateralization or localization of seizure focus.

Electrophysiological evaluation of 140 hands with carpal tunnel syndrome.

AIM: To study various electrophysiological parameters in clinically suspected carpal tunnel syndrome (CTS). MATERIAL AND METHODS: Electrophysiological (EPS) evaluation of 70 patients (140 hands) of clinically suspected CTS was done as per AAEM recommendation. EPS grading was done as described by Padua, et al. RESULTS: The mean age was 44.21 +/- 10.29 (range 24-66) years with female predominance (M:F 3:11). Sixty four (91.4%) patients had bilateral involvement. The mean EPS grade was 3.18 +/- 1.41. One hundred and six (75.5%) hands had moderate to severe (EPS grade 1-3) CTS. Median distal motor latency (DML) (mean 4.76 +/- 1.4 msec) was prolonged in 92 (65.71%) hands and was not recordable in seven (5%) hands. Median sensory distal latency (SDL) (mean 3.54 +/- 0.82 msec) was prolonged in 38 (27.1%) hands and not recordable in 49 (35%) hands. Sensory median mid-palm latency (MPL) (2.42 +/- 0.56 msec) was commonest EPS abnormality present in 128 (91.4%) hands. EMG was abnormal in 75% hands. CONCLUSION: This study suggests incorporation of median sensory midpalm latency as a screening test for electrophysiological diagnosis of CTS. In addition, bilateral studies are recommended as there is bilateral involvement in 64 patients.

Usefulness of short term video-EEG monitoring in children with frequent intractable episodes.

A prospective study was done to evaluate the role of short-term Video EEG (VEEG) recording in assessing the nature of clinical behaviour and in classification of seizures in children with frequent intractable seizure episodes. Forty five children upto 12 years of age with frequent intractable seizure episodes (> or =3/week) were included in the study. VEEG was done on an outpatient basis until an event was recorded or for a minimum period of 6 hours. The events were detected in 78% of cases. The seizures were classified in all children with recorded events and seizure classification was changed in 22%. Anti-epileptic drugs could be stopped or reduced in 11%. Short term VEEG monitoring was useful in characterising events and in classification of seizures in children with frequent, intractable seizure episodes. Use of this investigation as a screening procedure for diagnosis in children with frequent episodes is stressed, thereby reducing the cost associated with prolonged VEEG recordings and disability associated with misdiagnosis of epilepsy.

Epilepsy surgery in India: All India Institute of Medical Sciences experience.

OBJECTIVES: Surgical treatment of epilepsy should be considered an important alternative to medical therapy. The identification of a suitable candidate, pre-operative evaluation requires a multidisciplinary team. The specific diagnostic studies required depend on the operative strategy and objective of surgical treatment. METHODS: In twenty patients with medically intractable epilepsy, who had clinical evaluation, electroencephalography (EEG), video-EEG monitoring using scalp electrodes, high resolution magnetic resonance imaging (MRI), neuropsychology, single photon emission computed tomography (SPECT) was done to localise the seizure focus. If the investigations were concordant resective surgery was performed. In case of frequent falls, atonic and tonic seizures, with generalised/multifocal discharges on EEG, a callostomy was done. Surgical outcome was assessed using Engel's 4 point scale. RESULTS: In 18 patients the seizure focus was localised, 13 had temporal lobectomy, five extra-temporal resection, and two had callosotomy. Fifteen patients had a follow-up of more than eight months, mean 20.5 (range 8-35 months), 13 had outcome I (seizure free), two had outcome II (occasional seizures), one-outcome III. Three were lost to follow-up and one patient died. There were no major post-operative complications. CONCLUSIONS: Surgical treatment of epilepsy is a safe, effective mode of therapy. Suitable candidates should be identified early and referred to appropriate centres.

Distribution of vascular lesions in ischaemic stroke: a magnetic resonance angiographic study.

BACKGROUND: Carotid endarterectomy is now an accepted modality for reducing the threat of recurrence of ischaemic strokes in patients with severe carotid artery stenosis. However, the incidence of carotid artery stenosis, and hence the applicability of carotid endarterectomy in the Indian population is not known. We conducted a prospective study to detect and quantify extracranial and intracranial arterial lesions using magnetic resonance angiography in consecutive patients with ischaemic strokes. METHODS: All patients with recent onset of ischaemic stroke (< 4 months) had a magnetic resonance angiography done to evaluate the neck vessels as well as the circle of Willis and its branches. The degree of stenosis of the internal carotid or common carotid artery was measured according to the criteria described by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) collaborators. The site and extent of the extracranial and intracranial arterial lesions were correlated with the clinical features and the pattern of infarcts on magnetic resonance imaging or computerized tomographic scan of the brain. RESULTS: The magnetic resonance angiography was abnormal in 56 out of 100 patients included in the study. Severe stenosis (> 70%) of the extracranial carotid arteries was seen in 26 patients. Lesions suitable for carotid endarterectomy were present in only 11 patients (42.3% of those with severe stenosis). CONCLUSION: Our results are in contrast to those reported from western countries where the likelihood of a surgically correctable lesion being present is 60%-70%. We found operable lesions in only 11%. Intracranial atherosclerotic disease causing strokes is probably more common in India. Therefore, although carotid endarterectomy is the only accepted surgical procedure for secondary prophylaxis of stroke, there is a need to find an alternative surgical intervention for the predominantly intracranial pathology found in the Indian population.

Oral clonazepam sensitive focal status epilepticus (FSE).

Focal status epilepticus (FSE) and Epilepsia partialis continua (EPC) are relatively uncommon disorders. Antiepileptic drugs do not usually alter the FSE-EPC. An 11 year old female patient with progressive neurologic deficits and FSE showed a remarkable response to clonazepam, both clinically and electrophysiologically.

Video--EEG monitoring in intractable attacks of uncertain etiology.

Video-EEG monitoring was done in 26 patients with paroxysmal intractable attacks of uncertain etiology to determine the nature and cause. Two broad categories were identified: Those with prominent motor activity and those with attacks of collapse/limpness. Events were recorded in 16 patients of which 11 showed no abnormality on the simultaneously recorded EEG, thus helping to confirm their diagnosis of pseudoseizures.

Vasopressor responses in autosomal dominant cerebellar ataxia.

Thirteen patients with autosomal dominant cerebellar ataxia were investigated for autonomic functions using standard tests. Patients showed no significant reduction in parasympathetic responses as measured by heart rate response to slow breathing and Valsalva manoeuvre. Measurement of blood pressure response to isometric exercise, cold exposure and 70 degrees head-up tilt showed a significant decrease in sympathetic pressor response.