Middle Meningeal Artery Embolization for the Management of Chronic Subdural Hematoma.

Introduction Chronic subdural hematoma (cSDH) results from neovascularization of the subdural capsular membrane and embolization of the Middle Meningeal Artery (MMA) helps inhibit the same and prevent recurrence. Materials and methods We retrospectively reviewed the endovascular management for chronic SDH in 29 patients between 2018 to 2022. The parameters analyzed were clinical history, radiologic imaging findings, procedure details, and angiographic and clinical outcomes. Results Twenty-nine MMA embolization procedures were done. Follow-up MRI or CT done in 28 subjects, showed complete resolution in 25 patients and a significant reduction in bilateral SDH in three patients. One patient died due to renal failure and aspiration pneumonia-related complications. Ninety days mRS (modified Rankin scale) was 0 in 25 patients (86%), one in two patients, and two in one patient. Conclusions  MMA embolization for chronic SDH is a feasible, safe, and effective technique in patients with chronic and recurrent SDH.

Inpatient Burden of Neurological Disorders: A Route Map for Allocation of Resources and Postgraduate Training.

Introduction There are limited data regarding the profile of inpatient neurological disorders in India. Understanding the spectrum of diseases and the profile of patients admitted in an inpatient setting will help to streamline services, allocate resources, develop management protocols, design curricula, and improve training programs of postgraduate students in neurology training. Objective The objective of this study is to study the profile of inpatient neurological disorders in 1000 consecutive patients admitted to a tertiary care neurological center. Methods Data from 1000 consecutive inpatients admitted to the Neurology Department at St. John's Medical College Hospital, Bengaluru from January 2018 to October 2018 were collected from the medical records. The data obtained from the case records were entered into a Microsoft Excel spreadsheet for descriptive analysis. Results The average age of the patients was 48 years (±18.18) and 606 of the 1000 patients were males. Strokes, including arterial and venous strokes, formed the major inpatient caseload, accounting for 48.7% of cases. Of these, 84% had ischemic arterial strokes, 7.4% had intracranial hemorrhage, and 8.4 % had cerebral sinus venous strokes; 19.3% of patients were admitted for seizures while 8.2% of patients were admitted for headache. Meningitis was diagnosed in 5.2% of patients; 4.8% of patients had central nervous system demyelinating and autoimmune diseases. A number of other diagnoses comprised less than 2.5% each and included movement disorders, peripheral nerve, spine and nerve roots disorders, neuromuscular diseases, neurodegenerative diseases, and medical and functional illness. Conclusion The most common disorders in the inpatient setting are stroke, seizure, headache, meningitis, and autoimmune/demyelinating disorders. These disorders should receive priority while planning the allocation of resources, educational curriculum, training, and teaching programs.

Neurology Exit Examination System in India: A Survey of Examiners' Perceptions and Recommendations.

Background: The traditional Neurology exit examination in India has remained unchanged over the last few decades. In developed countries, objective evaluation methods have replaced the traditional ones. A need for such methods has not been explored in India. Objective: We aimed to study the perceptions and key recommendations of Neurology examiners on the existing examination pattern. Material and Methods: We conducted an online survey of examiners perceptions and recommendations using a set of 10 multiple-choice questions and an open-ended question. Results: 46 examiners provided completed responses suitable for analysis. Nearly equal proportions (30%) of the examiners had 10 years, 10-25 years and >25 years' experience. 92% were not satisfied with current system, 95% did not find adequate time for correction of theory scripts, 90% felt that theory questions were random, and 95% had legibility issues. 84% felt that the practical exams do not test true learning, 98% felt the examination stress impairs the performance and 85% felt that there are no objective criteria to pass the candidate. 83% felt the current system-needed changes. The key suggestions provided by the examiners to improve the system included objective assessments like MCQ, OSCE, OSLER and DOPS, inclusion of larger number of short answer type questions and periodic internal assessments of the candidates. Conclusions: A vast majority of examiners favoured changes to the current examination system and provided key recommendations. A larger study is needed to extrapolate these findings to the rest of India.

Characteristics of Headache in Children Presenting to Ophthalmology Services in a Tertiary Care Center of South India.

INTRODUCTION: Headache is a common cause of disability worldwide and can disrupt the education and social life of children. Children regularly present to ophthalmologists with headache. So, we aimed to describe the characteristics of headache in children presenting to the ophthalmology outpatient department (OPD) in our center. METHODOLOGY: We conducted this cross-sectional, prospective study in Bangalore, India. We included all children aged 5-18 years, presenting with headache to the ophthalmology OPD, from September 2018 to September 2020, and excluded nonverbal children, those with prior head trauma, diagnosed psychiatric illnesses, or epilepsy. We provided each child with a headache questionnaire, following which they received a detailed ophthalmologic evaluation. We performed relevant descriptive and inferential analyses. RESULTS: We included 311 children, with a mean age of 11.1 years. Sixty-eight percent were males. Fifty-one percent reported holocranial headache, and 28% reported frontal headache. Sixty-nine percent reported screen time of ≥2 hours/day. The most common refractive error (RE) was myopia, seen in 48%. The most common type of headache was headache associated with refractive errors (HARE), seen in 64%, followed by migraine, in 19%. Children with HARE were more likely to be males, have daily screen time of >2 hours/day, or have myopia. Their headache was more likely to be for >1 month, or have frontal localization. Children with headache due to other causes were more likely to be adolescents. DISCUSSION: We found that almost two-thirds of children presenting to our ophthalmology OPD had HARE. Our findings support the association of REs with headache. Children with HARE had a longer history and predominantly frontal localization. Further, they reported longer screen time, a significant finding in today's world. Ophthalmologists must be aware of the various etiologies of headache and ensure that each child with headache receives a full ophthalmologic evaluation.

Headaches associated with acute SARS-CoV-2 infection: A prospective cross-sectional study.

OBJECTIVES: The prevalence and characteristics of COVID-19-related headaches are not known in Indian patients. We aim to determine the prevalence and characteristics of headache in COVID-19-infected individuals and make a comparison with those without headaches. METHODS: This prospective cross-sectional observational study was conducted from 1 October to 31 October 2020. Data were collected using a detailed questionnaire. We compared the data of those with and without headaches to identify the differences between the groups. RESULTS: During the study period of 1 month, among 225 COVID-19-infected patients, 33.8% patients had headaches. The mean age of patients with headache was 48.89 ± 15.19 years. In all, 53.9% were females. In 65.8%, headache occurred at the onset of viral illness; 44.7% described the headache as dull aching; 39.5% had bifrontal headache; and 32.9% had holocranial headache. In total, 78.9% had complete resolution of headache within 5 days. A comparison between those with and without headaches showed that those with headaches were more younger (48.89 ± 15.19 vs 54.61 ± 14.57 years, p = 0.007) and of female gender (41/76(53.9%) vs 41/149 (27.5%), p = 0.001). Primary headache disorders were more common in the headache group. Levels of inflammatory markers such as leukocyte count (7234.17 ± 3054.96 vs 8773.35 ± 5103.65, p = 0.017), erythrocyte sedimentation rate (39.28 ± 23.29 vs 50.41 ± 27.61, p = 0.02) and ferritin (381.06 ± 485.2 vs 657.10 ± 863.80, p = 0.014) were lower in those with headaches. CONCLUSIONS: Headaches are a common and early symptom of acute SARS-CoV-2 infection more frequently seen in young females and in those with a history of primary headache disorders. The lower level of inflammatory markers in those with headaches suggests that these headaches are probably due to the local spread of virus through the trigeminal nerve endings, resulting in activation of the trigeminovascular system.

Effective Early Treatment of AChR Antibody-Positive Myasthenia Gravis with Rituximab; the Experience from a Neuroimmunology Clinic in a Developing Country.

BACKGROUND: Rituximab is reserved for treating refractory myasthenia gravis (MG) patients. Here we report our experience with rituximab in AChR antibody positive generalized MG (gMG) and impending myasthenic crisis (IMC). METHODS: This retrospective, observational study, conducted at a tertiary care, neuroimmunology clinic, analyzed the data of patients with AChR antibody positive gMG, treated with rituximab between 1st January 2016 and 30th October 2018. RESULTS: Eleven patients with AChR antibody positive gMG received rituximab. Mean age of the cohort was 50.54 ± 18.71 years with 9 males. Seven out of 11 patients received rituximab in the early stage (<2 years from onset) and had good response to treatment. Four of the 5 patients with IMC improved with rituximab alone. In the 10 patients who regularly followed up, there was a significant difference between the QMG scores at baseline and at 1, 2, 6, 12, and 18 months (P < .0001). CONCLUSION: Rituximab appears to be a potentially effective early treatment option for AChR antibody positive generalized MG and impending myasthenic crisis.

COVID-19-related strokes are associated with increased mortality and morbidity: A multicenter comparative study from Bengaluru, South India.

BACKGROUND: COVID-19-related strokes are increasingly being diagnosed across the world. Knowledge about the clinical profile, imaging findings, and outcomes is still evolving. Here we describe the characteristics of a cohort of 62 COVID-19-related stroke patients from 13 hospitals, from Bangalore city, south India. OBJECTIVE: To describe the clinical profile, neuroimaging findings, interventions, and outcomes in COVID-19-related stroke patients. METHODS: This is a multicenter retrospective study of all COVID-19-related stroke patients from 13 hospitals from south India; 1st June 2020-31st August 2020. The demographic, clinical, laboratory, and neuroimaging data were collected along with treatment administered and outcomes. SARS-CoV-2 infection was confirmed in all cases by RT-PCR testing. The data obtained from the case records were entered in SPSS 25 for statistical analysis. RESULTS: During the three-month period, we had 62 COVID-19-related stroke patients, across 13 centers; 60 (97%) had ischemic strokes, while 2 (3%) had hemorrhagic strokes. The mean age of patients was 55.66 ± 13.20 years, with 34 (77.4%) males. Twenty-six percent (16/62) of patients did not have any conventional risk factors for stroke. Diabetes mellitus was seen in 54.8%, hypertension was present in 61.3%, coronary artery disease in 8%, and atrial fibrillation in 4.8%. Baseline National Institutes of Health Stroke Scale score was 12.7 ± 6.44. Stroke severity was moderate (National Institutes of Health Stroke Scale 5-15) in 27 (61.3%) patients, moderate to severe (National Institutes of Health Stroke Scale 16-20) in 13 (20.9%) patients and severe (National Institutes of Health Stroke Scale 21-42) in 11 (17.7%) patients. According to TOAST classification, 48.3% was stroke of undetermined etiology, 36.6% had large artery atherosclerosis, 10% had small vessel occlusion, and 5% had cardioembolic strokes. Three (5%) received intravenous thrombolysis with tenecteplase 0.2 mg/kg and 3 (5%) underwent mechanical thrombectomy, two endovascular and one surgical. Duration of hospital stay was 16.16 ± 6.39 days; 21% (13/62) died in hospital, while 37 (59.7%) had a modified Rankin score of 3-5 at discharge. Hypertension, atrial fibrillation, and higher baseline National Institutes of Health Stroke Scale scores were associated with increased mortality. A comparison to 111 historical controls during the non-COVID period showed a higher proportion of strokes of undetermined etiology, higher mortality, and higher morbidity in COVID-19-related stroke patients. CONCLUSION: COVID-19-related strokes are increasingly being recognized in developing countries, like India. Stroke of undetermined etiology appears to be the most common TOAST subtype of COVID-19-related strokes. COVID-19-related strokes were more severe in nature and resulted in higher mortality and morbidity. Hypertension, atrial fibrillation, and higher baseline National Institutes of Health Stroke Scale scores were associated with increased mortality.

An evaluation of factors affecting adherence to antiepileptic drugs in patients with epilepsy: a cross-sectional study.

INTRODUCTION: Adherence to antiepileptic drug (AED) therapy is important for controlling seizures in patients with epilepsy (PWE). It is vital to identify the factors influencing adherence to AED therapy using validated tools. This study aimed to evaluate the pattern and extent of AED adherence among PWE and to identify the factors that influence adherence. METHODS: This was a cross-sectional study involving PWE who had a confirmed diagnosis. Treatment adherence was assessed using the four-item Morisky Medication Adherence Scale. Univariate analysis with chi-square test was used to observe the association between different variables and AED adherence. Binary logistic regression analysis was used to identify the predictors of adherence. RESULTS: 451 PWE (mean age 27.3 ± 8.1 years) were enrolled in the study; 251 (55.7%) were male and 198 (43.9%) were from the lower socioeconomic class. 326 (72.3%) patients had high adherence to AED therapy, while 125 (27.7%) had low adherence. AED adherence was significantly associated with socioeconomic status (p = 0.043) and type of epilepsy (p = 0.033). However, no significant difference was observed between adherence and age, gender, marital status, epilepsy duration, number and type of AEDs, and occurrence of adverse drug reactions. Patients with focal epilepsy and those from the middle/lower-middle socioeconomic classes were less likely to be nonadherent. The primary reason for nonadherence was forgetfulness. CONCLUSION: This study found that a majority of PWE have optimal rates of AED adherence and that forgetfulness is the primary reason for nonadherence among PWE.

Evaluation of efficacy and safety of gabapentin, duloxetine, and pregabalin in patients with painful diabetic peripheral neuropathy.

AIM: To compare the efficacy and safety of gabapentin (GBP), duloxetine (DLX), and pregabalin (PGB) in patients with painful diabetic peripheral neuropathy (DPNP). METHODS: A prospective, randomized, open label, 12-week study was conducted. A total of 152 patients with history of pain attributed to DPNP with a minimum 40-mm score on visual analogue scale (VAS) were randomized to receive GBP, DLX, or PGB. The primary efficacy measure was pain severity as measured on 11 point VAS. Secondary efficacy measures included sleep interference score, Patient Global Impression of Change (PGIC), and Clinical Global Impression of Change (CGIC). Assessment of safety was done by recording the occurrence of adverse drug reactions. Data was analyzed using descriptive statistics, Chi square test, analysis of variance (ANOVA), and repeated measures ANOVA. RESULTS: Of total 152 patients, 50 patients received GBP, DLX each while 52 received PGB. A significant reduction in pain score (VAS), sleep interference score, PGIC, and CGIC was seen in all the three treatment groups across time (P<0.05) with no statistically significant difference between the groups. There was a significant interaction between the time and treatment groups (P<0.001) for pain score (VAS), sleep interference score, and PGIC. The improvement in pain scores (VAS) and sleep interference score was higher with PGB compared to DLX and GBP. Adverse drug reactions were mild and occurred in 9.2% of all cases. CONCLUSIONS: Monotherapy with GBP, DLX, or PGB Produced a clinically and subjectively meaningful pain relief in patients with DPNP with onset of pain relief being faster and superior with PGB.