Publications by authors named "Subhash Kaul"

95 Publications

Picture-naming test for a linguistically diverse population with cognitive impairment and dementia.

Int J Lang Commun Disord 2022 May 6. Epub 2022 May 6.

Department of Neurology, All India Institute of Medical Sciences, Delhi, India.

Background: Picture-naming tests (PNTs) evaluate linguistic impairment in dementia due to semantic memory impairment, impaired lexical retrieval or perceptual deficits. They also assess the decline in naming impairment at various stages of dementia and mild cognitive impairment (MCI) that occurs due to progressive cognitive impairment. With the increasing numbers of people with dementia globally, it is necessary to have validated naming tests and norms that are culturally and linguistically appropriate.

Aims: In this cross-sectional study we harmonized a set of 30 images applicable to the Indian context across five languages and investigated the picture-naming performance in patients with MCI and dementia.

Methods & Procedures: A multidisciplinary expert group formed by the Indian Council of Medical Research (ICMR) collaborated towards developing and adapting a picture naming test (PNT) known as the ICMR-PNT in five Indian languages: Hindi, Bengali, Telugu, Kannada and Malayalam. Based on cross-cultural adaptation guidelines and item-wise factor analysis and correlations established separately across five languages, the final version of the ICMR-PNT test was developed. A total of 368 controls, 123 dementia and 128 MCI patients were recruited for the study. Psychometric properties of the adapted version of the ICMR-PNT were examined, and sensitivity and specificity were examined.

Outcomes & Results: The ICMR-PNT scores in all languages combined were higher in controls compared with patients with dementia and MCI (F = 139.85; p < 0.001). Furthermore, PNT scores for MCI was higher in comparison with patients with dementia in all languages combined (p < 0.001). The area under the curve across the five languages ranged from 0.81 to 1.00 for detecting dementia. There was a negative correlation between Clinical Dementia Rating (CDR) and ICMR-PNT scores and a positive correlation between Addenbrooke's Cognitive Examination-III (ACE-III) and ICMR-PNT scores in control and patient groups.

Conclusions & Implications: The ICMR-PNT was developed by following cross-cultural adaptation guidelines and establishing correlations using item-wise factor analysis across five languages. This adapted PNT was found to be a reliable tool when assessing naming abilities effectively in mild to moderate dementia in a linguistically diverse context.

What This Paper Adds: What is already known on this subject Picture-naming evaluates language impairment linked to naming difficulties due to semantic memory, lexical retrieval or perceptual disturbances. As a result, picture naming tests (PNTs) play an important role in the diagnosis of dementia. In a heterogeneous population such as India, there is a need for a common PNT that can be used across the wide range of languages. What this study adds to existing knowledge PNTs such as the Boston Naming Test (BNT) were developed for the educated, mostly English-speaking, Western populations and are not appropriate for use in an Indian context. To overcome this challenge, a PNT was harmonized in five Indian languages (Hindi, Bengali, Telugu, Kannada and Malayalam) and we report the patterns of naming difficulty in patients with MCI and dementia. The ICMR-PNT demonstrated good diagnostic accuracy when distinguishing patients with mild to moderate dementia from cognitively normal individuals. What are the potential or actual clinical implications of this work? With the growing number of persons suffering from Alzheimer's disease and other forms of dementia around the world, its critical to have culturally and linguistically relevant naming tests and diagnosis. This validated ICMR-PNT can be used widely as a clinical tool to diagnose dementia and harmonize research efforts across diverse populations.
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http://dx.doi.org/10.1111/1460-6984.12728DOI Listing
May 2022

Impact of the COVID-19 Pandemic on the Frequency, Clinical Spectrum and Outcomes of Pediatric Guillain-Barré Syndrome in India: A Multicentric Ambispective Cohort Study.

Ann Indian Acad Neurol 2022 Jan-Feb;25(1):60-67. Epub 2021 Nov 17.

Department of Neurology, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India.

Objective: To study impact of COVID-19 pandemic on frequency, clinical/electrophysiological profile and treatment outcomes in pediatric Guillain-Barré syndrome (GBS).

Background: GBS is the most frequent cause of pediatric acute flaccid paralysis. The effect of the COVID-19 pandemic on pediatric GBS is unclear in the literature.

Methods: We conducted an ambispective, multicentric, cohort study involving 12 of 27 centres in GBS Consortium, during two periods: pre-COVID-19 (March-August 2019) and during COVID-19 (March-August 2020). Children ≤12 years who satisfied National Institute of Neurological Diseases and Stroke criteria for GBS/variants were enrolled. Details pertaining to clinical/laboratory parameters, treatment and outcomes (modified Rankin Scale (mRS) at discharge, GBS Disability score at discharge and 3 months) were analysed.

Results: We enrolled 33 children in 2019 and 10 in 2020. Children in 2020 were older (median 10.4 [interquartile range 6.75-11.25] years versus 5 (2.5-8.4) years; = 0.022) and had more sensory symptoms (50% versus 18.2%; = 0.043). The 2020 group had relatively favourable mRS at discharge (median 1 (1-3.5) versus 3 (2-4); = 0.042) and GBS disability score at 3 months (median 0 (0-0.75) versus 2 (0-3); = 0.009) compared to 2019. Multivariate analysis revealed bowel involvement ( = 0.000) and ventilatory support ( = 0.001) as independent predictors of disability. No child in 2020 had preceding/concurrent SARS-CoV2 infection.

Conclusions: The COVID-19 pandemic led to a marked decline in pediatric GBS presenting to hospitals. Antecedent illnesses, clinical and electrophysiological profile of GBS remained largely unchanged from the pre-pandemic era.
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http://dx.doi.org/10.4103/aian.aian_392_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8954314PMC
November 2021

COVID-Inflicted Coagulopathy: Expert Consensus on Management with Novel Oral Anticoagulants in India.

J Assoc Physicians India 2022 Dec;69(12):11-12

Consultant Endocrinologist & Diabetologist, Magna Centres For Obesity, Diabetes & Endocrinology, Bangalore, Karnataka.

Coronavirus disease 2019 (COVID-19) is a highly hypercoagulable viral infection complicated as COVID-inflicted coagulopathy (CIC), that is associated with increased risk of morbidity and mortality. International guidelines recommend low molecular weight heparin (LMWH) to treat CIC in both in-hospital and in-home settings. However, in India, using subcutaneous LMWH may not be a feasible option for a vast majority of patients under home management. Additionally, while some evidence advocates the use of novel oral anticoagulants (NOACs), in hospitalized settings, most guidelines find no role of NOACs in hospital settings. On the other hand, the resource crunch faced in recent COVID-19 pandemic in India forced physicians to treat many patients in home settings. These patients had been usually prescribed NOACs for ease of administration and adherence. Therefore, there is a need to form a consensus on the use of NOACs to manage CIC in India.
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December 2022

Impact of Pre-Stroke Antiplatelet Use on 3-Month Outcome After Ischemic Stroke.

Neurol India 2021 Nov-Dec;69(6):1645-1649

Department of Neurology, Stroke Service, Massachusetts General Hospital, Boston, USA.

Background: Pre-stroke anti-platelet (PAP) therapy can potentially influence the severity and outcome after ischemic stroke.

Methods: We analyzed data from the prospective multicenter Indo-US collaborative stroke project for the impact of PAP therapy. Outcome measures included the admission National Institute of Health Stroke Scale (NIHSS) score, 3-month modified Rankin scale (mRS) score, and rates of in-hospital mortality and post-ischemic intracerebral hemorrhage.

Results: Among 2048 of 2066 patients (M:F = 2:1) with known pre-stroke medication status, 336 (16.3%) were on PAP therapy. As compared to the non-PAP group, the PAP group had significantly higher mean age (62.2 vs 57.4 years, P < 0.001) and significantly more men, vascular risk factors, cerebral microbleeds (12.8% vs 6.2%, P = 0.001) and intravenous thrombolysis treatment (17% vs. 10.6%, P = 0.001). Cardioembolic strokes were significantly more in the PAP group (P < 0.001), but not large artery atherosclerosis. No significant differences were observed in the median NIHSS score (9 vs. 10, P = 0.274), 3-month mRS (score 0-2,51.4% vs. 49.0%, P = 0.428), in-hospital mortality (8.6% vs. 7.8%, P = 0.592), or symptomatic post ischemic intracerebral haemorrhage (12.2% vs. 10.6%, P = 0.382). The PAP group had more stroke recurrence (6.6% vs. 2.9%, P = 0.002) which was not significant (P = 0.065) after multivariate regression analysis adjusting for age, sex and vascular risk factors. PAP therapy was not an independent predictor of initial stroke severity or stroke outcome.

Conclusion: PAP therapy has no significant effect on initial stroke severity, rates of post-ischemic hemorrhage with or without thrombolysis, in-hospital mortality, stroke recurrence, and 3-month outcome after ischemic stroke.
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http://dx.doi.org/10.4103/0028-3886.333484DOI Listing
January 2022

Simultaneous Acute Pulmonary Thromboembolism and Stroke - A Management Dilemma.

Neurol India 2021 Sep-Oct;69(5):1371-1373

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

The management of established pulmonary thromboembolism (PTE) coexisting with acute ischemic stroke (AIS) is quite challenging. We report the case of a 52-year-old man with concurrent massive right middle cerebral artery AIS and acute PTE, who was successfully managed despite the contradictory guidelines to manage them simultaneously. The patient underwent decompression craniotomy followed by anticoagulant therapy. The current case report demonstrates that full-dose heparin, despite being relatively contraindicated in an AIS, can achieve a good outcome when given under close monitoring. The transesophageal echo with bubble contrast during the Valsalva maneuver demonstrated patent foramen ovale with a right to left shunt as a cause of AIS and PTE in this patient.
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http://dx.doi.org/10.4103/0028-3886.329553DOI Listing
November 2021

Awareness, Recognition, and Response to Stroke among the General Public-An Observational Study.

J Neurosci Rural Pract 2021 Oct 23;12(4):704-710. Epub 2021 Sep 23.

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

 To evaluate awareness and response to stroke among the general public.  In this prospective, observational study, self-reported stroke awareness questionnaire was administered in 2000 consecutive participants who visited outpatient clinic of a tertiary care hospital. For data analysis, comparison included for awareness of stroke and response in case of stroke.  The average age of the study participants was 39.64 ± 15.55 (17-85), with 651(32.6%) women. Among the respondents, 786(39.3%) participants mentioned stroke as blood clot in the brain; 268(13.4%) stated it as brain hemorrhage. Awareness of stroke was higher in people in cities (71.0 vs. 8.5%;  < 0.001) and graduates (75.3 vs. 60.9%;  < 0.001) or knew a family member or friend who had stroke (42.7 vs. 30.4%;  < 0.001). Most commonly recognized risk factors included stress (1,152; 57.6%) and hypertension (1,148; 57.4%). Most identified warning sign was weakness of one side of body (807; 40.4%) and speech impairment (658; 32.9%). Participants who were aware of stroke knew a greater number of risk factors (3.75 ± 2.88 vs. 2.45 ± 2.66;  < 0.001) and warning signs (2.85 ± 2.25 vs. 1.49 ± 1.41; <0.001). Among 1,138 participants who were aware of stroke, 166 (14.6%) participants knew one correct response in case of a stroke, either call a doctor (49.3 vs. 35.0%; <0.001) or call an ambulance (41.1 vs. 34.9%;  = 0.055). Participants who knew one correct response to stroke had at least a family member/friend who had stroke (44.1 vs. 34.3%;  < 0.022).  We report that among 56.9% of the participants who were aware of stroke most could not name more than four risk factors or three warning signs of stroke. Only 14.6% of those aware of stroke knew appropriate response to stroke.
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http://dx.doi.org/10.1055/s-0041-1735822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8559085PMC
October 2021

Validation of ICMR Neurocognitive Toolbox for Dementia in the Linguistically Diverse Context of India.

Front Neurol 2021 18;12:661269. Epub 2021 Oct 18.

Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India.

The growing prevalence of dementia, especially in low- and middle-income countries (LMICs), has raised the need for a unified cognitive screening tool that can aid its early detection. The linguistically and educationally diverse population in India contributes to challenges in diagnosis. The present study aimed to assess the validity and diagnostic accuracy of the Indian Council of Medical Research-Neurocognitive Toolbox (ICMR-NCTB), a comprehensive neuropsychological test battery adapted in five languages, for the diagnosis of dementia. A multidisciplinary group of experts developed the ICMR-NCTB based on reviewing the existing tools and incorporation of culturally appropriate modifications. The finalized tests of the major cognitive domains of attention, executive functions, memory, language, and visuospatial skills were then adapted and translated into five Indian languages: Hindi, Bengali, Telugu, Kannada, and Malayalam. Three hundred fifty-four participants were recruited, including 222 controls and 132 dementia patients. The sensitivity and specificity of the adapted tests were established for the diagnosis of dementia. A significant difference in the mean (median) performance scores between healthy controls and patients with dementia was observed on all tests of ICMR-NCTB. The area under the curve for majority of the tests included in the ICMR-NCTB ranged from 0.73 to 1.00, and the sensitivity and specificity of the ICMR-NCTB tests ranged from 70 to 100% and 70.7 to 100%, respectively, to identify dementia across all five languages. The ICMR-NCTB is a valid instrument to diagnose dementia across five Indian languages, with good diagnostic accuracy. The toolbox was effective in overcoming the challenge of linguistic diversity. The study has wide implications to address the problem of a high disease burden and low diagnostic rate of dementia in LMICs like India.
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http://dx.doi.org/10.3389/fneur.2021.661269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8558406PMC
October 2021

Frequency and Predictors of Early Seizures Following First Acute Stroke: Data from a University Hospital in South India.

Neurol India 2021 Jul-Aug;69(4):847-855

Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Punjagutta, Hyderabad, Telangana, India.

Background: Stroke is a common neurological condition, and post-stroke seizures are known to occur. Early seizures may suggest the severity of insult and may have an effect on the outcome. There are conflicting results on the frequency of early seizures, and studies from India are scarce.

Aim: To study the frequency and predictors of early seizures following the first acute stroke, both arterial and venous stroke, as well as to assess their effect on clinical outcome.

Patients And Methods: This is a hospital-based, prospective, observational study conducted among 279 eligible consecutive patients admitted in the Neurology department with first acute stroke, including venous stroke. The demographic data, clinical history, risk factors, examination, and all other relevant investigations are done. Early seizures occurring within 7 days of the acute stroke are identified and correlated to various risk factors.

Results: Out of the 279 patients enrolled in the study, ischemic stroke (IS) (62.4%) was the most common stroke subtype, followed by hemorrhagic stroke (HS) (20.4%), cerebral sinus venous thrombosis (CSVT) (15.8%), and IS with hemorrhagic transformation (ISH) (1.8%). Thirty-three patients (11.8%) had early seizures, among them CSVT 18 (40.9%) had the highest frequency followed by ISH 1 (20%), HS 5 (8.7%), and IS 9 (5.2%).

Conclusions: The frequency of early onset post-stroke seizures is 11.8%, with most of them occurring within 24 hours. Venous stroke, large lesion, cortical location, supratentorial location, hypercoaguable states, and hyperhomocysteinemia are independent predictors. Duration of hospital stay is increased in patients with early seizures, however, they did not influence the in-hospital mortality.
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http://dx.doi.org/10.4103/0028-3886.325345DOI Listing
September 2021

Role of Vitamin D in Cerebrovascular Disease.

Ann Indian Acad Neurol 2021 Mar-Apr;24(2):142-145. Epub 2021 Jan 25.

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

Introduction: Vitamin D deficiency is now a well-recognized public health problem affecting almost every second person throughout the world. Recent evidence from many population-based studies has indicated that a poor vitamin D status is a predictor of future strokes.

Materials And Methods: We reviewed recent studies on 25-hydroxyvitamin D [25(OH)D] and symptomatic ischemic stroke. A graded increase in the risk of symptomatic ischemic stroke with decreasing levels of plasma 25(OH)D has been found in most of the studies. Vitamin D also has a role in the poststroke period where its deficiency may hinder the rehabilitation process.

Conclusions: After reviewing current literature on the subject, we conclude that there are some data to suggest the role of vitamin D in patients with stroke but it cannot be concluded as a risk factor for stroke. Larger population-based studies are needed to confirm the causative role of vitamin D in stroke.
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http://dx.doi.org/10.4103/aian.AIAN_928_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232472PMC
January 2021

Impact of revascularization therapies on outcome of posterior circulation ischemic stroke: The Indo-US stroke project.

J Neurol Sci 2021 Aug 18;427:117499. Epub 2021 May 18.

Department of Neurology, Stroke Service, Massachusetts General Hospital, Boston, USA.

Introduction: Posterior circulation strokes (PCS) have been less extensively studied than anterior circulation strokes (ACS), especially regarding revascularization therapies. We analyzed the differences in baseline stroke characteristics, revascularization therapy and 3-month outcomes between PCS and ACS in a large prospective multicentre Indian stroke registry.

Methods: Patients with acute ischemic stroke recruited in the Indo-US collaborative stroke project from January 2012 to August 2014 were classified into PCS and ACS based on imaging-confirmed infarct location. Demographics, stroke severity, risk factors, and mechanisms were compared. We further compared these parameters in the subgroups who received revascularization therapies (RT) and no revascularization therapies (NRT). The primary outcome was 3-month modified Rankin scale (mRS).

Results: Of 1889 patients (1270 males), 1478 (78.2%) had ACS and 411 (21.8%) PCS. The median NIHSS was lower in PCS (7 vs 11, p < 0.001). Diabetes mellitus and hypertension were more common in PCS and rheumatic heart disease in ACS. Small artery occlusion was higher in PCS (23.8% vs 12.9%, p < 0.001). Only 28 (6.8%) PCS received RT compared to 213 (14.4%) ACS. At 90 days, a good functional outcome (mRS 0-2) was more common in PCS (56.4% vs 45.9%, p < 0.001) in NRT group, while no significant difference was noted in RT group. Stroke territory was not an independent predictor of 3-month outcome in regression analysis. In-hospital mortality was not different between the groups.

Conclusions: The 3-month functional outcome and in-hospital mortality were not different between ACS and PCS. Compared to ACS, PCS received revascularization therapies less often.
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http://dx.doi.org/10.1016/j.jns.2021.117499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8325629PMC
August 2021

Semantic memory impairment in dementia: A cross-cultural adaptation study.

Neurol Sci 2022 Jan 8;43(1):265-273. Epub 2021 May 8.

Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Lakkasandra, Bengaluru, Karnataka, 560029, India.

Background: Semantic memory deficits are frequently encountered in dementia and distinct patterns of semantic impairment characterize the subtypes of dementia. Life course and cultural experiences significantly influence semantic memory. Hence, there is a need to assess semantic memory using culturally appropriate tests, to aid accurate diagnosis of dementia and facilitate cross-cultural collaborative research.

Aims: In this prospective study, we adapted and validated the Cambridge Semantic Memory (CSM) test battery to the Indian cultural context and studied the patterns of semantic memory impairment across dementia subtypes.

Methods: The CSM battery was modified using standard methods and by incorporating culturally appropriate changes and new semantic categories relevant to India. The adapted Indian Semantic Memory (ISM) test battery was administered to a cohort of 121 subjects, consisting of controls and dementia: Alzheimer's disease (AD), progressive non-fluent aphasia (PNFA), semantic dementia (SD), and behavioral variant fronto-temporal dementia (BvFTD). Profile of semantic memory performance across groups was examined.

Results: The ISM battery was found to be a valid measure of semantic memory. The novel semantic categories of gods/religious icons, vegetables, and food items added value to the diagnostic process. Distinct semantic memory profiles in SD, PNFA, AD, and BvFTD were demonstrated.

Conclusions: The cultural adaptation of a semantic memory battery for the Indian context provided sensitive evidence of semantic memory impairment in dementia and its subtypes. The clinical and research application of the ISM battery will enhance diagnostic evaluation that can aid in early and accurate identification of deficits and devising intervention strategies and enable research across cultures.
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http://dx.doi.org/10.1007/s10072-021-05272-5DOI Listing
January 2022

Bilingualism and Its Implications for Neuropsychological Evaluation.

Arch Clin Neuropsychol 2021 Mar 27. Epub 2021 Mar 27.

Department of Neurology, All India Institute of Medical Sciences, Delhi, India.

Objective: In the background of a large population of bilinguals globally, the study aimed to develop standards of neuropsychological testing in the context of bilingualism. Because bilingualism is known to affect cognitive processes, bilinguals and monolinguals were compared on their performance on cognitive tests, to investigate the possibility of the need for separate normative data for the two groups.

Method: A comprehensive neuropsychological test battery, standardized across five Indian languages: the Indian Council of Medical Research-Neuro Cognitive Tool Box (ICMR-NCTB) was administered to 530 participants (267 monolingual and 263 bilinguals matched for age and education). A systematic method of testing cognition in bilinguals was developed; to identify the appropriate language for testing, ensure language proficiency of examiner, and to interpret the bilingual responses. Additionally, the performance of bilinguals on the ICMR-NCTB was compared with monolinguals.

Results: Cognitive testing in the bilingual context was performed in the most proficient language of the participants, by examiners well versed with the language. Results from the language-based tests suggested that the frequent occurrence of borrowed- and language-mixed words required consideration while scoring. The reported bilingual effect on cognitive processes did not reflect as differences in the performance between bilinguals and monolinguals.

Conclusions: Observations from the study provide robust recommendations for neuropsychological testing in the context of bilingualism. Results indicate that separate normative data may not be required for bilinguals and monolinguals. The study will be relevant and provide a reference framework to address similar issues in the large population of bilinguals in other societies.
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http://dx.doi.org/10.1093/arclin/acab012DOI Listing
March 2021

Validation of Indian Council of Medical Research Neurocognitive Tool Box in Diagnosis of Mild Cognitive Impairment in India: Lessons from a Harmonization Process in a Linguistically Diverse Society.

Dement Geriatr Cogn Disord 2020 7;49(4):355-364. Epub 2021 Jan 7.

Departments of Neurology and Neuropsychology, All India Institute of Medical Sciences, Delhi, India.

Background/aims: In a linguistically diverse country such as India, challenges remain with regard to diagnosis of early cognitive decline among the elderly, with no prior attempts made to simultaneously validate a comprehensive battery of tests across domains in multiple languages. This study aimed to determine the utility of the Indian Council of Medical Research-Neurocognitive Tool Box (ICMR-NCTB) in the diagnosis of mild cognitive impairment (MCI) and its vascular subtype (VaMCI) in 5 Indian languages.

Methods: Literate subjects from 5 centers across the country were recruited using a uniform process, and all subjects were classified based on clinical evaluations and a gold standard test protocol into normal cognition, MCI, and VaMCI. Following adaptation and harmonization of the ICMR-NCTB across 5 different Indian languages into a composite Z score, its test performance against standards, including sensitivity and specificity of the instrument as well as of its subcomponents in diagnosis of MCI, was evaluated in age and education unmatched and matched groups.

Results: Variability in sensitivity-specificity estimates was noted between languages when a total of 991 controls and 205 patients with MCI (157 MCI and 48 VaMCI) were compared due to a significant impact of age, education, and language. Data from a total of 506 controls, 144 patients with MCI, and 46 patients with VaMCI who were age- and education-matched were compared. Post hoc analysis after correction for multiple comparisons revealed better performance in controls relative to all-cause MCI. An optimum composite Z-score of -0.541 achieved a sensitivity of 81.1% and a specificity of 88.8% for diagnosis of all-cause MCI, with a high specificity for diagnosis of VaMCI. Using combinations of multiple-domain 2 test subcomponents retained a sensitivity and specificity of >80% for diagnosis of MCI.

Conclusions: The ICMR-NCTB is a "first of its kind" approach at harmonizing neuropsychological tests across 5 Indian languages for the diagnosis of MCI due to vascular and other etiologies. Utilizing multiple-domain subcomponents also retains the validity of this instrument, making it a valuable tool in MCI research in multilingual settings.
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http://dx.doi.org/10.1159/000512393DOI Listing
May 2021

A Screening Tool to Detect Stroke Aphasia: Adaptation of Frenchay Aphasia Screening Test (FAST) to the Indian Context.

Ann Indian Acad Neurol 2020 Sep 25;23(Suppl 2):S143-S148. Epub 2020 Sep 25.

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.

Background: Aphasia is a common consequence of stroke. To optimize recovery, it becomes critical as there are early identification and treatment of language deficits. The rising burden of stroke aphasia and lack of screening tools in the Indian context necessitates the need for a screening tool.

Objective: We aimed to adapt and validate the Frenchay Aphasia Screening Test (FAST) to the Indian context in two widely spoken Indian languages, Telugu and Kannada, for the literate and illiterate population.

Methods: A systematic process of adaptation and culturally appropriate modifications of the original FAST were done in 116 healthy controls and 115 patients. The validity of the adapted test was established.

Results: The optimum cut-off values for detecting aphasia in our sample ranged from 25 to 25.5 (literate) and 13.5 to 15.5 (illiterate) with high sensitivity and specificity. There was also a significant correlation between aphasia scores for adapted FAST and the Western Aphasia Battery (WAB), establishing good convergent validity.

Discussion: Results of the adaptation and validation of two Indian versions of FAST, suggest that it is an easy-to-use screening measure for detecting stroke-related language disabilities. The psychometric properties of the Indian version of FAST met the standardised requirements for adaptation and validation.

Conclusions: The Indian version of FAST was found to be a reliable and valid bedside screening tool for aphasia in stroke patients. We aim that this study will facilitate the use of the test across other Indian languages and a large clinical population in the future.
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http://dx.doi.org/10.4103/aian.AIAN_499_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731676PMC
September 2020

Consensus Statement - Suggested Recommendations for Acute Stroke Management during the COVID-19 Pandemic: Expert Group on Behalf of the Indian Stroke Association.

Ann Indian Acad Neurol 2020 Apr 22;23(Suppl 1):S15-S23. Epub 2020 Apr 22.

Department of Neurology, Krishna Institute of Medical Sciences, Hyderabad, Telangana, India.

The ongoing pandemic of COVID-19 is a global public health emergency. This has led to challenges for healthcare facilities to optimally manage other important medical emergencies. Stroke is an important public health emergency with significant mortality and morbidity. Timely treatment of acute stroke is critical to prevent disability. The current expert consensus statement on behalf of the Indian Stroke Association outlines the issues and suggestions related to the management of stroke during this ongoing COVID-19 pandemic.
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http://dx.doi.org/10.4103/aian.AIAN_302_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213027PMC
April 2020

Clinicoradiological Profile of Superficial Middle Cerebral Vein Thrombosis.

Neurol India 2020 Mar-Apr;68(2):373-377

Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.

Background: The diagnosis of isolated cortical vein thrombosis (ICVT) involving superficial middle cerebral vein (SMCV) remains challenging even in the present era of modern MRI protocols.

Objective: The purpose of this study is to review the clinical and radiological characteristics of SMCV thrombosis in our hospital.

Methods: Chart review of cases of SMCV thrombosis admitted in a tertiary care university hospital in South India during a 1-year period from September 2015 to August 2016.

Results: Five SMCV thrombosis patients were identified and presented with focal seizures. Neuroimaging showed edema (with or without hemorrhage) of cortex and white matter of inferior frontal gyrus, temporal pole, superior temporal gyrus, insular cortex, and external capsule. The thrombosis of SMCV was demonstrated by Spin echo T1-weighted, GRE-weighted axial, and postcontrast T1-weighted images in coronal and sagittal planes, with a slice thickness of <3 mm. Four received anticoagulation and all improved rapidly and completely.

Conclusion: SMCV thrombosis should be considered in patients having recent onset seizures in appropriate setting based on MRI evidence of parenchymal edema and/or hemorrhage in the perisylvian region along with evidence of thrombosed vein in that region. Appropriate imaging sequences help in confirmation of diagnosis.
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http://dx.doi.org/10.4103/0028-3886.280640DOI Listing
March 2021

Dementia Diagnosis in Seven Languages: The Addenbrooke's Cognitive Examination-III in India.

Arch Clin Neuropsychol 2020 Jul;35(5):528-538

Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, India.

Objective: With the rising burden of dementia globally, there is a need to harmonize dementia research across diverse populations. The Addenbrooke's Cognitive Examination-III (ACE-III) is a well-established cognitive screening tool to diagnose dementia. But there have been few efforts to standardize the use of ACE-III across cohorts speaking different languages. The present study aimed to standardize and validate ACE-III across seven Indian languages and to assess the diagnostic accuracy of the test to detect dementia and mild cognitive impairment (MCI) in the context of language heterogeneity.

Methods: The original ACE-III was adapted to Indian languages: Hindi, Telugu, Kannada, Malayalam, Urdu, Tamil, and Indian English by a multidisciplinary expert group. The ACE-III was standardized for use across all seven languages. In total, 757 controls, 242 dementia, and 204 MCI patients were recruited across five cities in India for the validation study. Psychometric properties of adapted versions were examined and their sensitivity and specificity were established.

Results: The sensitivity and specificity of ACE-III in identifying dementia ranged from 0.90 to 1, sensitivity for MCI ranged from 0.86 to 1, and specificity from 0.83 to 0.93. Education but not language was found to have an independent effect on ACE-III scores. Optimum cut-off scores were established separately for low education (≤10 years of education) and high education (>10 years of education) groups.

Conclusions: The adapted versions of ACE-III have been standardized and validated for use across seven Indian languages, with high diagnostic accuracy in identifying dementia and MCI in a linguistically diverse context.
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http://dx.doi.org/10.1093/arclin/acaa013DOI Listing
July 2020

Standardising Dementia Diagnosis Across Linguistic and Educational Diversity: Study Design of the Indian Council of Medical Research-Neurocognitive Tool Box (ICMR-NCTB).

J Int Neuropsychol Soc 2020 02 12;26(2):172-186. Epub 2019 Dec 12.

Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram 695011, India.

Objectives: While the burden of dementia is increasing in low- and middle-income countries, there is a low rate of diagnosis and paucity of research in these regions. A major challenge to study dementia is the limited availability of standardised diagnostic tools for use in populations with linguistic and educational diversity. The objectives of the study were to develop a standardised and comprehensive neurocognitive test battery to diagnose dementia and mild cognitive impairment (MCI) due to varied etiologies, across different languages and educational levels in India, to facilitate research efforts in diverse settings.

Methods: A multidisciplinary expert group formed by Indian Council of Medical Research (ICMR) collaborated towards adapting and validating a neurocognitive test battery, that is, the ICMR Neurocognitive Tool Box (ICMR-NCTB) in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam), for illiterates and literates, to standardise diagnosis of dementia and MCI in India.

Results: Following a review of existing international and national efforts at standardising dementia diagnosis, the ICMR-NCTB was developed and adapted to the Indian setting of sociolinguistic diversity. The battery consisted of tests of cognition, behaviour, and functional activities. A uniform protocol for diagnosis of normal cognition, MCI, and dementia due to neurodegenerative diseases and stroke was followed in six centres. A systematic plan for validating the ICMR-NCTB and establishing cut-off values in a diverse multicentric cohort was developed.

Conclusions: A key outcome was the development of a comprehensive diagnostic tool for diagnosis of dementia and MCI due to varied etiologies, in the diverse socio-demographic setting of India.
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http://dx.doi.org/10.1017/S1355617719001127DOI Listing
February 2020

Implant for Augmentation of Cerebral Blood Flow Trial-1 (ImpACT-1). A single-arm feasibility study evaluating the safety and potential benefit of the Ischemic Stroke System for treatment of acute ischemic stroke.

PLoS One 2019 3;14(7):e0217472. Epub 2019 Jul 3.

Tel Aviv Medical Center,Tel Aviv, Israel.

Background: The Ischemic Stroke System is a novel device designed to deliver stimulation to the sphenopalatine ganglion(SPG).The SPG sends parasympathetic innervations to the anterior cerebral circulation. In rat stroke models, SPG stimulation results in increased cerebral blood flow, reduced infarct volume, protects the blood brain barrier, and improved neurological outcome. We present here the results of a prospective, multinational, single-arm, feasibility study designed to assess the safety, tolerability, and potential benefit of SPG stimulation inpatients with acute ischemic stroke(AIS).

Methods: Patients with anterior AIS, baseline NIHSS 7-20 and ability to initiate treatment within 24h from stroke onset, were implanted and treated with the SPG stimulation. Patients were followed up for 90 days. Effect was assessed by comparing the patient outcome to a matched population from the NINDS rt-PA trial placebo patients.

Results: Ninety-eight patients were enrolled (mean age 57years, mean baseline NIHSS 12 and mean treatment time from stroke onset 19h). The observed mortality rate(12.2%), serious adverse events (SAE)incidence(23.5%) and nature of SAE were within the expected range for the population. The modified intention to treat cohort consisted of 84 patients who were compared to matched patients from the NINDS placebo arm. Patients treated with SPG stimulation had an average mRS lower by 0.76 than the historical controls(CMH test p = 0.001).

Conclusion: The implantation procedure and the SPG stimulation, initiated within 24hr from stroke onset, are feasible, safe, and tolerable. The results call for a follow-up randomized trial (funded by BrainsGate; clinicaltrials.gov number, NCT03733236).
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217472PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609146PMC
February 2020

Age, sex, and setting in the etiology of stroke study (ASSESS): Study design and protocol.

J Neurol Sci 2019 Apr 14;399:209-213. Epub 2019 Feb 14.

Department of Clinical Neurological Sciences, University Hospital, London Health Sciences Center, Western University, ON, Canada; Department of Epidemiology and Biostatistics, Western University, ON, Canada. Electronic address:

Rationale: Stroke etiology and risk factors vary by age, sex, setting (hospital or community-based) and by region. Identifying these differences would improve our understanding of stroke etiology, diagnosis, and treatment.

Aim: The Age, Sex and Setting in the Etiology of Stroke Study (ASSESS) is a multicenter cohort study to assess differences in stroke etiology.

Methods And Design: Data from all centers will be categorized according to age, sex, setting, stroke subtypes. Centers with extensive hospital- or community-based data regarding stroke from Argentina, Australia, Canada, India, Iran, Italy, Ghana, Nigeria, Thailand, the United Kingdom and the United States have agreed to participate so far.

Study Outcomes: The primary outcome includes differences in stroke etiology in study centers. The secondary outcomes include stroke incidence, risk factors, preventive strategies, and short- and long-term outcomes.

Conclusion: ASSESS will enable comparisons of data from different regions to determine the age and sex distribution of the most common causes of stroke in each setting. This will help clinicians to tailor the assessment and treatment of stroke patients on the basis of their specific local characteristics. It will also empower stroke epidemiologists to design preventive measures by targeting the specific characteristics of each population.
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http://dx.doi.org/10.1016/j.jns.2019.02.024DOI Listing
April 2019

Regional differences in ischemic stroke in India (north vs. south).

Int J Stroke 2019 10 31;14(7):706-714. Epub 2019 Jan 31.

Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.

Background: India is a large country with geographically diverse populations and varying risk factors. Identification of regional differences can improve healthcare policy decisions.

Aim: To study regional differences in stroke between North and South India.

Methods: We analyzed data from the Indo-US Collaborative Stroke Project, a National Institute of Health-funded multicentre prospective study conducted in five academic centers in India with a US-based coordinating center. Risk factors, severity, mechanisms, management, complications, and outcomes among ischemic stroke patients were compared between North and South Indian centers.

Results: Of the 2066 patients enrolled from North ( = 1060) and South India ( = 1006), North Indian patients were significantly older with fewer men and had lower rates of diabetes (32.8% vs. 38.7%,  < 0.01), dyslipidemia (3.5% vs. 25.7%,  < 0.01), tobacco use (27% vs. 38%,  < 0.001), and alcohol use (30.1% vs. 38.6%,  < 0.01). North Indian patients had higher median National Institute of Health stroke scale scores (10 vs. 9,  < 0.01), more frequent large-artery atherosclerosis mechanism (34% vs. 25.6%,  < 0.001), intravenous thrombolysis (14.0% vs. 6.1%,  < 0.001), and lower rates of pneumonia (10.5% vs. 15.1%,  = 0.02). The three-month outcome (modified Rankin Scale score 0-2, 45.8% vs. 50.3%,  = 0.08) did not differ; however, North Indian patients had higher 90-day mortality (23.5% vs. 13.5%,  < 0.0001).

Conclusions: The substantial regional differences in stroke risk factors and mechanisms may be partly explained by factors such as differing dietary habits and lifestyle, which can be addressed at a national level. Differences in acute and inpatient stroke care suggest a need for better adoption of national stroke management guidelines.
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http://dx.doi.org/10.1177/1747493019828538DOI Listing
October 2019

Stroke Prevention Strategies in the Developing World.

Stroke 2018 12;49(12):3092-3097

Department of Clinical Neurological Sciences, University of Western Ontario, Canada (V.H.).

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http://dx.doi.org/10.1161/STROKEAHA.118.017384DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6942540PMC
December 2018

Predictors of Intracerebral Hemorrhage in Acute Stroke Patients Receiving Intravenous Recombinant Tissue Plasminogen Activator.

Ann Indian Acad Neurol 2018 Jul-Sep;21(3):214-219

Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.

Background: Symptomatic Intracerebral hemorrhage (sICH) is a serious complication of recombinant tissue-plasminogen activator (rt-PA) therapy for acute ischemic stroke (AIS).

Objective: To estimate the prevalence and predictors of sICH in patients after receiving IV rt-PA for AIS.

Material And Methods: Consecutive patients of AIS thrombolysed between January 2010 and June 2016 in a University hospital in Hyderabad (India) were studied prospectively for sICH and it's various variables compared with the control group without sICH to determine any sigificantant difference.

Results: Out of 113 patients , sICH was detected in 12 (10.61%) whose mean age(58±12.0 years) and gender ratio ( 2:1 ) was not statistically significant from controls. In s ICH group mean NIHSS score was 16.53± 5.81 vs 10.19± 5.06 in controls (<0.001), gap between stroke onset and thrombolysis was 227.50±46.15 min vs 178.50± 69.20 min in controls(=0.018). At presentation mean blood sugar was 208.75±90.97 mg/dl in sICH group vs 146.83±70.21 mg/dl in controls (=0.002). Prior diabetes was in 7(53.30%) vs 23 (22.8%) in controls (= 0.014)and hypertension in 11 (91.7%) vs (56(55.4%) in controls (= 0.026) The mortality in sICH was 7 (58.30%)vs 4 (4.94%) in controls (<.0.001). At 3 months mean mRS ofsICH patients was 5.57± 0.54 vs 2.17± 1.69 in controls (<.05).

Conclusion: High NIHSS score, increased stroke onset to thrombolysis time , high blood sugar at presentation ,prior diabetes and hypertension increase the chances of sICH. None of these contraindicate thrombolysing strokes but should caution the physician.
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http://dx.doi.org/10.4103/aian.AIAN_228_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137634PMC
September 2018

Intracranial Atherosclerosis is the Most Common Stroke Subtype: Ten-year Data from Hyderabad Stroke Registry (India).

Ann Indian Acad Neurol 2018 Jul-Sep;21(3):209-213

Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.

Aim: Limited data regarding stroke subtypes exist from South Asian countries. The aim of the study was to determine the pattern of ischemic stroke subtypes and their associated risk factors, in a 10-year long hospital-based registry in the South Indian city of Hyderabad.

Materials And Methods: The Hyderabad stroke registry systematically collected clinical, radiological, and laboratory data of fully investigated consecutive stroke patients and studied pattern of ischemic stroke subtypes and their risk factor association.

Results: The cohort comprised of 2642 patients: 2072 (78.4%) were ischemic and 570 (21.6%) were hemorrhagic strokes. In the ischemic stroke cohort, the mean age was 54.1 years and 1622 (78.3%) were men. The most common ischemic stroke subtype was large artery atherosclerosis (LAA) comprising 37.6% ( = 779), followed by small vessel occlusion comprising 19.9% ( = 413) and cardioembolism 11% ( = 228). Stroke of other determined etiologies constituted 4.2% ( = 86) and stroke of undetermined etiology was observed in 27.3%. Among patients with LAA, 610 (78.3%) patients had intracranial and 169 (21.7%) had extracranial disease as the underlying mechanism. Risk factor profile demonstrated that hyperlipidemia was significantly associated with LAA and ischemic heart disease with cardioembolic strokes.

Conclusions: The study reveals a distinct pattern of ischemic stroke subtypes in the Indian context that has overlapping features of registries from West and East Asian countries. Both large artery and small vessel diseases are substantially represented with a predominance of intracranial atherosclerosis. The study results have significant implications for developing preventive and management strategies for stroke care and research in India.
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http://dx.doi.org/10.4103/aian.AIAN_86_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137626PMC
September 2018

Comparison of Best Medical Management with Carotid Intervention Procedures in the Prevention of Stroke Recurrence in Patients with Symptomatic Internal Carotid Artery Stenosis.

Ann Indian Acad Neurol 2018 Jul-Sep;21(3):179-183

Department of Neurology, Krishna Institute of Medical Sciences, Hyderabad, Telangana, India.

Background: As per the current recommendations, carotid interventional procedures (carotid endarterectomy/carotid artery stenting) are considered superior to medical management in reducing the stroke recurrence in patients with symptomatic extracranial internal carotid artery (ICA) stenosis.

Objective: The objective of this study is to compare the best medical management with carotid interventional procedures in the prevention of stroke recurrence in the patients with symptomatic extracranial ICA stenosis.

Materials And Methods: This was a parallel, prospective, two-arm, open-label, observational study. Participants were selected consecutively and prospectively among patients from Outpatient and Inpatient Departments of Neurology at Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. The study period was from January 2012 to December 2017.

Results: Of 150 patients with symptomatic extracranial ICA stenosis of ≥50%, 100 preferred best medical management (m = 75, f = 25) and 50 (m = 37, f = 13) opted for carotid intervention. The mean age of the patient cohort was 59.8 ± 12.7. Follow-up was done at regular intervals from 3 months to 1 year. In the medical group, the recurrence occurred in 10 patients; 4 (40%) within 6 months, 5 (50%) within 6-12 months, and 1 (10%) after 1 year. In the intervention group, the recurrence occurred in 6 patients; 5 (83%) within the first 6 months and 1 (17%) within 6-12 months.

Conclusions: Overall, there was no statistically significant difference in the rate of recurrence between the best medical management and the carotid interventional procedures.
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http://dx.doi.org/10.4103/aian.AIAN_124_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137635PMC
September 2018

Quality of care for ischemic stroke in China vs India: Findings from national clinical registries.

Neurology 2018 10 29;91(14):e1348-e1354. Epub 2018 Aug 29.

From Vascular Neurology (Z.L., X.Z., Yongjun Wang), Tiantan Clinical Trial and Research Center for Stroke (Yilong Wang, C.W.), and Neuro-Intensive Care Unit (L.L.), Department of Neurology, Beijing TianTan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Z.L., Yilong Wang, X.Z., L.L., C.W., Yongjun Wang), Beijing; Department of Neurology (J.P., D.A.), Christian Medical College and Hospital, Ludhiana; Department of Neurology (P.N.S.), SreeChitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India; Center of Stroke (Yilong Wang, X.Z., C.W., Yongjun Wang), Beijing Institute for Brain Disorders, China; Department of Neurology (D.K.), Postgraduate Institute of Medical Education and Research, Chandigarh; Department of Neurology (M.V.P.S.), All-India Institutes of Medical Sciences, New Delhi; Department of Neurology (S.K.), Nizam's Institute of Medical Sciences, Hyderabad, India; and Department of Neurology (L.H.S., A.B.S.), Massachusetts General Hospital, Boston.

Objective: To understand stroke risk factors, status of stroke care, and opportunities for improvement as China and India develop national strategies to address their disproportionate and growing burden of stroke.

Methods: We compared stroke risk factors, acute management, adherence to quality performance measures, and clinical outcomes among hospitalized ischemic stroke patients using data from the Indo-US Collaborative Stroke Project (IUCSP) and China National Stroke Registry-II (CNSR-II). The IUCSP included 5 academic stroke centers from different geographic regions (n = 2,066). For comparison, the CNSR-II dataset was restricted to 31 academic hospitals among 219 participating sites from 31 provinces (n = 1,973).

Results: Indian patients were significantly younger, had health insurance less often, and had significantly different risk factors (more often diabetes mellitus, dyslipidemia, and coronary heart disease; less often prior stroke, hypertension, atrial fibrillation, and smoking). Hospitalized Indian patients had greater stroke severity (median NIH Stroke Scale score 10 vs 4), higher rates of IV thrombolysis within 3 hours (7.5% vs 2.4%), greater in-hospital mortality (7.9% vs 1.2%), and worse outcome (3-month modified Rankin Scale score 0-2, 49.3% vs 78.1%) (all < 0.001). The poorer clinical outcomes were attributable mainly to greater stroke severity in IUCSP patients. Chinese patients more often received antithrombotics, stroke education, and dysphagia screening during hospitalization.

Conclusion: These data provide insights into the status of ischemic stroke care in academic urban centers within 2 large Asian countries. Further research is needed to determine whether these patterns are representative of care across the countries, to explain differences in observed severity, and to drive improvements.
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http://dx.doi.org/10.1212/WNL.0000000000006291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6177271PMC
October 2018

Necrotizing Autoimmune Myopathy: Clinicopathologic Study from a Single Tertiary Care Centre.

Ann Indian Acad Neurol 2018 Jan-Mar;21(1):62-67

Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.

Background: Idiopathic inflammatory myopathies (IIMs) are a group of chronic, autoimmune disorders which include a new entity, necrotizing autoimmune myopathy (NAM). NAM lacks inflammation and presents with markedly elevated creatinine phosphokinase (CPK) levels. It is associated with connective tissue diseases (CTDs), statin use, malignancies, and most cases are idiopathic.

Objectives: The objectives of this study are to describe the clinicopathologic features in muscle biopsy-proven cases of NAM. To emphasize the role of laboratory parameters such as CPK levels and myositis profile in the diagnosis of NAM.

Materials And Methods: This is a retrospective study including 15 patients of NAM diagnosed on muscle biopsy over a period of 2 years. The slides of the biopsies were reviewed, and clinical data, electromyography findings, and CPK levels were obtained. Myositis profile was done.

Results: Necrotizing myopathy accounted for 13.63% (15 cases) of total inflammatory myopathies (110 cases) in the study. These were grouped into CTD-associated NAM, statin-associated NAM, paraneoplastic NAM and idiopathic NAM which was the common type. All cases presented with progressive proximal muscle weakness and had markedly elevated CPK levels. Anti-3-hydroxy-3-methyl-glutaryl-coenzyme A reductase and antisignal recognition particle antibodies were seen to be positive in six patients. Muscle biopsies showed predominant fiber necrosis with significant fiber degeneration and regeneration in the absence of inflammation. All patients received immunotherapy with significant improvement was seen in six patients with two mortalities.

Conclusion: Necrotizing myopathy is a new addition to the spectrum of IIM. Clinicopathologic correlation is important for appropriate diagnosis. It is found to be refractory to corticosteroids monotherapy. The course of illness is not uniform, and in some patients, there can be rapid worsening with mortality.
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http://dx.doi.org/10.4103/aian.AIAN_389_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5909148PMC
May 2018

Brain at Risk.

Authors:
Subhash Kaul

Ann Indian Acad Neurol 2018 Jan-Mar;21(1)

Department of Neurology, Niazm's Institute of Medical Sciences, Hyderabad, Telangana, India.

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http://dx.doi.org/10.4103/aian.AIAN_55_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5909140PMC
May 2018

Nasu-Hakola disease (polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy): First report from India.

Neurol India 2018 Mar-Apr;66(2):538-541

Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.

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http://dx.doi.org/10.4103/0028-3886.227319DOI Listing
September 2019
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