Publications by authors named "Usha Kant Misra"

92 Publications

NMR based CSF metabolomics in tuberculous meningitis: correlation with clinical and MRI findings.

Metab Brain Dis 2022 Jan 14. Epub 2022 Jan 14.

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India.

We report the potential role of H Nuclear Magnetic Resonance (NMR) based metabolomics in tuberculous meningitis (TBM). We also correlate the significant metabolites with clinical-radiological parameters. Forty-three patients with TBM were included, and their severity of meningitis was graded as stages I to III, and patients with positive Mycobacterium tuberculosis or its nucleic acid was considered as definite TBM. H NMR-based metabolomic study was performed on (CSF) samples, and the significant metabolites compared to healthy controls were identified. Outcome at three months was defined as death, poor and good based on the modified Rankin Scale. These metabolites were compared between definite and probable groups of TBM, and also correlated with MRI findings. About 11 metabolites were found to be significant for distinguishing TBM from the controls. In TBM, lactate, glutamate, alanine, arginine, 2-hydroxyisobutyrate, formate, and cis-aconitate were upregulated, and glucose, fructose, glutamine, and myo-inositol were downregulated compared to the controls. For differentiating TBM from the controls, the AUC of the ROC curve generated using these significant metabolites was 0.99, with a 95% confidence interval from 0.96 to 1, demonstrating that these metabolites were able to classify cases with good sensitivity and specificity. Lactate concentration in CSF correlated with hemoglobin, CSF glucose, and infarction. The outcome did not correlate with metabolomics parameters. NMR-based CSF metabolomics have a potential role in differentiating TBM from the controls.
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http://dx.doi.org/10.1007/s11011-021-00860-yDOI Listing
January 2022

Recurrent Spontaneous Cerebrospinal Fluid Leaks at Multiple Levels.

Neurol India 2021 Nov-Dec;69(6):1828-1830

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Intracranial hypotension due to multiple spinal epidural cerebrospinal fluid (CSF) leak is rare and has multiple etiologies. These patients require epidural blood patches (EBP). We report a patient with recurrent paraplegia due to intracranial hypotension following recurrent epidural CSF leak. Cerebrospinal fluid leak was noted at D1, D10, D11, and L2 levels. Autologous epidural blood patch (EBP) at lower thoracic (3 ml) and lumbar region (4 ml) was performed. The patient developed paraplegia with sensory level at D2 for which 3 ml of EBP was done at D1 level after two months. Following EBP, the patient developed quadriplegia and root pain, which recovered in one month. The patient was free of symptoms for 18 months. Spinal epidural CSF leak should be suspected in patients with features of low pressure headache and recurrent paraplegia at multiple levels. Nuclear scintigraphy and CT myelography help in localizing the site of leak.
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http://dx.doi.org/10.4103/0028-3886.333501DOI Listing
January 2022

Prediction models for mechanical ventilation and outcome in Guillain-Barré syndrome.

J Clin Neurosci 2021 Oct 14;92:131-135. Epub 2021 Aug 14.

Department of Neurology, AIIMS, Rishikesh, Uttarakhand, India.

Various prediction models have been formulated to predict the need for mechanical ventilation (MV). In this study, we compare the sensitivity and specificity of Erasmus GBS Respiratory Insufficiency Score (EGRIS) and Sharshar score with single breath count (SBC) at 2 Hz to assess their usefulness in predicting MV and functional outcome. The primary outcome was prediction of MV and relative usefulness of all three models based on sensitivity and specificity. The secondary outcome was functional recovery at 6 months using the cut off points for MV and functional outcome at 6months was assessed using Hughes scale and categorized as good (<2) and poor (≥2). The median age was 30 years, and 64 (69.6%) were males. The sensitivity and specificity of EGRIS score was 78.1% and 67.2%, Sharshar score was 75.0% and 64.1%, and SBC at 2 Hz was 78.1% and 75.0%. The area under the receiver operating curves was maximum for SBC at 2 Hz (0.86) compared to other models, although insignificant. EGRIS score < 5 had better functional recovery compared to those with score ≥ 5 (66% vs 34%, p = 0.001). Similarly, in Sharshar score, 23/59 (39%) with score ≥ 4 had good recovery compared to 36 (61%) with score < 4 (p = 0.01). All the three models have comparable predictive values for MV. Outcome prediction is the best with EGRIS.
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http://dx.doi.org/10.1016/j.jocn.2021.07.060DOI Listing
October 2021

A study of hyperhomocysteinemia in cerebral venous sinus thrombosis.

Indian J Med Res 2020 Dec;152(6):584-594

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Background & Objectives: Vegetarianism may result in low vitamin B12 and acquired hyperhomocysteinemia leading to thrombotic conditions such as cerebral venous sinus thrombosis (CVST). The clinico-radiological presentation and outcome of patients with hyperhomocysteinemia may be different from those without, but there is a paucity of information. This study was undertaken to find out the relationship of homocysteine (Hcy) with vitamin B12, folic acid and methyltetrahydrofolate reductase (MTHFR) mutation in the patients with CVST, and compare clinico-radiological severity and outcome of patients with and without hyperhomocysteinemia.

Methods: Ninety-six CVST patients in whom Hcy level was measured, were included, and their risk factors and neurological, magnetic resonance (MR) imaging and MR venography findings were noted. They were evaluated for prothrombotic conditions including Hcy, vitamin B12, folic acid and MTHFR 677C→T mutation. Three month outcome was categorized as death, poor and good.

Results: Seventy three per cent patients had risk factors; hyperhomocysteinemia in 52.1 per cent, protein S deficiency in 47.8 per cent, protein C deficiency in 19.4 per cent, MTHFR 677C→T mutation in 30.7 per cent, antinuclear antibody 11 per cent, and Factor V Leiden mutation in two per cent each. Thirty two per cent patients with hyperhomocysteinemia had no other thrombotic cause, and 22 per cent of them had either vitamin B12 and or folic acid deficiency only. The patients with hyperhomocysteinemia more frequently had vitamin B12 deficiency (70 vs. 13%), MTHFR 677C→T mutation (47.5 vs. 9.1%) and superior sagittal sinus thrombosis (78 vs. 56.5%) than normal Hcy group. The clinico-radiological severity and outcome were similar.

Interpretation & Conclusions: Hyperhomocysteinemia was an important correctable risk factor of CVST in patients from northern India, and majority of them had either low vitamin B12 level or MTHFR mutation.
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http://dx.doi.org/10.4103/ijmr.IJMR_2125_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8224164PMC
December 2020

Insomnia matters in myasthenia gravis.

Sleep Med 2021 03 30;79:221-222. Epub 2020 Dec 30.

Department of Neurology, Vivekananda Polyclinic & Institute of Medical Sciences, Lucknow, 226014, India.

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http://dx.doi.org/10.1016/j.sleep.2020.12.031DOI Listing
March 2021

Standard versus sequential anti-tubercular treatment in patients with tuberculous meningitis: a randomized controlled trial.

Trans R Soc Trop Med Hyg 2021 01;115(1):94-102

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India.

Background: To compare the safety and efficacy of sequential anti-tubercular treatment (ATT) regimen with the standard regimen in tuberculous meningitis (TBM).

Methods: This single-centre, open-label, parallel group randomized controlled trial was conducted from May 2017 to June 2019 in India. Treatment-naïve patients with TBM fulfilling the inclusion criteria were randomized to four drug ATT regimens (rifampicin, isoniazid, ethambutol and pyrazinamide) administered either simultaneously (standard arm) or one after another (sequential arm) in a 1 : 1 ratio. The primary endpoint was drug-induced hepatitis (DIH) and the secondary endpoints were in-hospital death and disability at 3 and 6 months using a modified Rankin Scale.

Results: A total of 97 patients with TBM were recruited; 15 did not meet the inclusion criteria and 2 refused to participate. The median age of the patients was 26 y (range 15-75) and 37 (46.2%) were males. The patients in the sequential arm had fewer cases of DIH (20% vs 42.5%; p=0.03). The patients in the sequential arm had lower in-hospital mortality (2.5% vs 17.5%; p=0.025) and better 6-month outcomes (25.0% vs 50.0%; p=0.02) compared with the standard arm.

Conclusions: Sequential ATT was associated with a lower frequency of DIH, lower in-hospital mortality and better 6-month outcome.

Trial Registration: Clinical Trials Registry of India (ctri.nic.in) identifier: REF/2016/09/012214/CTRI/2017/10/010072.
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http://dx.doi.org/10.1093/trstmh/traa144DOI Listing
January 2021

Vitamin B12 deficiency presenting as acute febrile encephalopathy and retinopathy.

Postgrad Med J 2021 Mar 26;97(1145):141-142. Epub 2020 Mar 26.

Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

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http://dx.doi.org/10.1136/postgradmedj-2020-137520DOI Listing
March 2021

MRI findings in Pott's spine and correlating clinical progress with radiological findings.

Neuroradiology 2020 Jul 23;62(7):825-832. Epub 2020 Mar 23.

Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India.

Purpose: To document magnetic resonance imaging (MRI) changes in Pott's spine and to correlate these with clinical findings and outcome.

Methods: Patients with Pott's spine having more than one set of MRI were included in the study. Patients were grouped according to timing of their second MRI. The MRI findings included changes in bone, disc, spinal cord, and soft tissue. The MRI changes were categorized into improvement, no change, or worsening. "Paradoxical worsening" was defined as radiological worsening in setting of clinical improvement, as described by improvement of Nurick's grade. Outcome was defined by mRS scale at three, six, and 12 months. The MRI findings and outcome were correlated.

Results: The results are based on 36 patients. The MRI changes included vertebral changes in form of spondylodiscitis in 33 (92%), epidural abscess in 29 (81%), spinal cord changes including edema and granuloma in 17 (47%), paravertebral abscess in 29 (81%), and vertebral body collapse in 12 (33.3%) patients. At three months, clinical improvement occurred in eight out of 12 patients, deterioration in two, and no change in two. Spinal MRI revealed improvement in one patient only; whereas eight had deterioration and three had no change. At six months, all nine patients improved clinically, but MRI showed improvement in only four, while another four showed deterioration and one had no change. In the nine and 12 months group, while all patients clinically improved, MRI showed minimal worsening.

Conclusion: In Pott's spine, the clinical improvement precedes the radiological improvement.
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http://dx.doi.org/10.1007/s00234-020-02402-2DOI Listing
July 2020

Baclofen encephalopathy: uncommon side effect of a common drug.

Postgrad Med J 2020 Dec 29;96(1142):780-781. Epub 2020 Feb 29.

Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

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http://dx.doi.org/10.1136/postgradmedj-2020-137487DOI Listing
December 2020

Astrocyte activation following nitrous oxide exposure is related to oxidative stress and glutamate excitotoxicity.

Brain Res 2020 03 3;1730:146645. Epub 2020 Jan 3.

Department of Molecular Medicine and Biotechnology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow 226014, Uttar Pradesh, India.

Background And Aims: Nitrous oxide is commonly used as an anesthetic agent and its exposure produces prolonged inactivation of vitamin B12. Nitrous oxide toxicity is associated with central nervous system changes which are similar to sub-acute combined degeneration (SACD). Astrocytes have important role in neurotoxic injuries, but have not been evaluated in NO toxicity. In the present study, we have evaluated the changes in astrocytes in NO exposed rats and correlated with neurobehavioral changes, oxidative stress and glutamate level.

Material And Methods: Adult wistar male rats were exposed to NO oxygen mixture in 1:1 ratio at a rate of 2 L/min for 120 min for 60 days. Control rats underwent similar exposure to oxygen. At the end of exposure, spontaneous locomotor activities (total distance travelled, time resting, time moving, number of rearing, stereotypic count) and grip strength were evaluated. Plasma glutathione (GSH), total antioxidant capacity (TAC), serum malonodialdehyde (MDA) and serum homocysteine (Hcy) were measured by spectrophotometer. Glutamate in the cerebral cortex and cerebellum were measured by colorimetry. Immunohistochemistry for astrocyte (GFAP) phenotypic analysis and its activation in brain and spinal cord were measured using image J software in NO exposed and control rats.

Results: The NO exposed rats had significant reduction in total distance travelled, time moving and number of rearing whereas time resting increased compared to the control rats. Hcy, glutamate and MDA levels were significantly increased, however GSH and TAC level decreased in NO exposed group compared to the controls. Astrocyte phenotype and its activation was significantly altered more so in spinal cord compared to cerebral cortex and was associated with neurobehavioral changes, oxidative stress and glutamate level.

Conclusions: NO related clinical dysfunction may be related to changes in astrocyte activation which is related to oxidative stress and glutamate neurotoxicity.
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http://dx.doi.org/10.1016/j.brainres.2020.146645DOI Listing
March 2020

Renal salt wasting in Guillain-Barré syndrome.

Postgrad Med J 2019 Nov 2;95(1129):628-629. Epub 2019 Aug 2.

Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

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http://dx.doi.org/10.1136/postgradmedj-2019-136870DOI Listing
November 2019

Does adjunctive corticosteroid and aspirin therapy improve the outcome of tuberculous meningitis?

Neurol India 2018 Nov-Dec;66(6):1672-1677

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Background: Stroke is common in tuberculous meningitis (TBM), and aspirin has been shown to reduce mortality. A combination of aspirin and corticosteroid may be more useful in this condition.

Aim: To evaluate the effect of aspirin and corticosteroid adjunctive therapy alone or in combination in determining the outcome of TBM.

Materials And Methods: One hundred and fifty-three patients with TBM were evaluated from a prospectively maintained registry. The diagnosis of TBM was based on the clinical, magnetic resonance imaging (MRI)/computed tomography (CT), and cerebrospinal fluid criteria. The baseline clinical, laboratory, and radiological findings were noted. All patients received the standard 4-drug antituberculous (rifampicin, isoniazid, pyrazinamide, and ethambutol) treatment. Group I patients received in addition, aspirin, in the dose of 150 mg daily; group II patients received aspirin 150 mg plus prednisolone 40 mg daily; and, group III patients received none of these adjunctive therapies. The outcome at 3 months was defined in terms of death or functional disability.

Results: Group I had 44, group II had 50, and group III had 41 patients. The baseline characteristics of all these patients were similar, except in group II, where patients had more severe meningitis and focal deficits compared to the patients in group I and III. At 3 months, 32 (23%) patients died; 8 (18.2%) in group I, 9 (18%) in group II, and 14 (34.1%) in group III. There was insignificant survival benefit in group II (hazard ratio [HR], 1.55; 95% confidence interval (CI), 0.96-26.49; P = 0.07). The three-month functional outcome and side effects were not significantly different in the three groups.

Conclusion: Aspirin with corticosteroid adjunctive treatment seems to be beneficial in reducing mortality in TBM.
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http://dx.doi.org/10.4103/0028-3886.246278DOI Listing
September 2019

Evaluation of cholinergic functions in patients with Japanese encephalitis and Herpes simplex encephalitis.

Brain Res 2019 03 20;1707:227-232. Epub 2018 Nov 20.

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.

Cognitive and memory impairment are related to cholinergic dysfunction and are important complications of viral encephalitis, In view of paucity of studies on cholinergic dysfunction in encephalitis, this study has been undertaken. We report acetyl choline esterase (AChE) and muscurinic 2 (M2) receptor levels in herpes simplex encephalitis (HSE) and Japanese encephalitis (JE) patients, and correlate these with cognitive functions and MRI findings. Patients with JE and HSE were evaluated for consciousness, neurological and MRI findings, plasma AChE and M2 receptor levels on admission and after one year. Twenty-nine patients with JE and 23 with HSE were included. Admission AChE levels in JE (48.32 ± 5.36 nmol/min/ml) and HSE (41.92 ± 5.12 nmol/min/ml) were significantly lower compared with controls (70.50 ± 8.30 nmol/min/ml). M2 receptor levels were also low in JE (4.52 ± 0.56 ng/ml) and HSE (4.35 ± 0.57 ng/ml) compared with controls (7.95 ± 0.41 ng/ml). In JE, AChE activity (r = 0.43, p = 0.02) and M2 receptor levels (r = 0.43, p = 0.02) correlated with caudate involvement, and AChE activity (r = 0.76, p = 0.03) with Mini Mental State Examination ( MMSE) score. In HSE, M2 receptor levels (r = 0.53, p = 0.03) correlated with MMSE. The levels of AChE and M2 receptors increased at one year compared to the baseline, which was greater in JE than in HSE. Both AChE and M2 receptors were reduced in JE and HSE and correlated with cognition at one year. Recovery of these biomarkers was more in JE than HSE.
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http://dx.doi.org/10.1016/j.brainres.2018.11.028DOI Listing
March 2019

Evaluation of optic nerve functions in subacute combined degeneration using visual evoked potential and diffusion tensor imaging-a pilot study.

Br J Radiol 2018 Nov 20;91(1091):20180086. Epub 2018 Jul 20.

1 Department of Neurology, Sanjay Gandhi Post Graduate medical Sciences , Lucknow , India.

Objective:: To evaluate optic nerve involvement in subacute combined degeneration (SACD) using diffusion tensor imaging (DTI) and visual evoked potential (VEP) studies, and their changes following cobalamine treatment.

Methods:: Six patients with SACD and six healthy matched controls were included. Visual acuity, field of vision, and color vision were tested. Pattern shift VEP was done, and P100 latency and amplitude were measured. Optic nerve MRI, and DTI of optic nerve to muscle ratio were measured, and fractional anisotropy ratio (FAR), axial diffusivity ratio (ADR), radial diffusivity ratio (RDR), and mean diffusivity ratio (MDR) were calculated. The patients received hydroxyl cobalamine 1000 µg intramuscularly and their clinical examination, VEP and DTI studies were repeated at 3 months.

Results:: The age of the patients ranged between 16 and 60 years and two were females. Their visual acuity, field of vision, and color vision were normal. P100 latency was prolonged in five patients (10 eyes) and amplitude was reduced in one (1 eye). The SACD patients had reduced FAR (1.94 ± 0.55 vs 2.81 ± 0.42; p = 0.01) and increased MDR (1.00 ± 0.04 vs 0.95 ± 0.01; p = 0.01) and RDR (0.96 ± 0.03 vs 0.89 ± 0.01; p = 0.002) compared to the controls. The FAR value correlated with P100 latency (r = -0.88). At 3 months, FAR value increased which was associated with improvement in P100 latency.

Conclusion:: In SACD patients, optic nerve FAR is reduced and correlates with P100 latency. Both these parameters improve on cobalamine treatment.

Advances In Knowledge:: Subclinical VEP abnormalities are common in SACD but conventional MRI sequence of optic nerve is normal. DTI of optic nerve reveals reduced fractional anisotropy (FA) values which improve after cobalamine treatment. FA values correlate with prolongation of P100 latency. DTI and VEP abnormalities suggest subclinical optic nerve myelin dysfunction.
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http://dx.doi.org/10.1259/bjr.20180086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6475932PMC
November 2018

Beware of Phenytoin Self-Harm In Children.

J Neurosci Rural Pract 2018 Apr-Jun;9(2):283-284

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

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http://dx.doi.org/10.4103/jnrp.jnrp_522_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5912043PMC
May 2018

Does Metabolic Syndrome Determine Severity and Disability of Chronic Low Backache?

J Neurosci Rural Pract 2018 Apr-Jun;9(2):208-213

Department of Neurology, AIIMS, Bhubaneswar, Odisha, India.

Introduction: Obesity may be associated with more severe and disabling low backache (LBA) due to alteration in biomechanics, but there are no such studies from developing countries.

Aims: We report the frequency of metabolic syndrome (MS) in chronic LBA (CLBA) and its association with severity and disability of CLBA.

Subjects And Methods: Consecutive patients with CLBA attending to the neurology service from October 2015 to February 2016 were included in the study. Clinical and demographic parameters were recorded. Routine biochemical test was done. The severity of pain was assessed by a 0-10 Numeric Rating Scale (NRS) and disability by Oswestry Disability Index (ODI) version 2. Comparison of variables was done by Chi-square or independent -test and correlation by Karl Pearson or Spearman's rank correlation test.

Results: Seventy-none (39.3%) patients had MS as per the International Diabetic Federation (IDF) criteria and 68 (33.8%) as per the National Cholesterol Education Program Adult Treatment Panel III criteria. Abdominal obesity was the most common (171 [85.1%]) feature of MS. The patients with MS had longer duration of sitting work and did less frequently exercise. The NRS score (6.95 ± 1.06 vs. 6.65 ± 0.95; = 0.04) and ODI score (54.91 ± 8.42 vs. 51.89 ± 8.54; = 0.01) were higher in CLBA patients with MS compared to those without MS.

Conclusion: About 40% patients with CLBA have metabolic syndrome, and they have more severe pain and disability.
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http://dx.doi.org/10.4103/jnrp.jnrp_430_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5912026PMC
May 2018

The Role of Clinical Variables and VKORC1 Polymorphism in Efficacy and Stability of Acenocoumarol in Neurological Patients.

J Neurosci Rural Pract 2018 Apr-Jun;9(2):186-192

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Objective: To analyze the clinical importance of VKORC1 polymorphism and its correlation with stability of oral anticoagulation.

Patients And Methods: In a hospital-based study, the patients on oral anticoagulant (OAC) were included during 2013-2016. The patients received OAC for cardioembolic stroke, cerebral venous sinus thrombosis (CVST), and prevention of deep vein thrombosis (DVT). Demographic, clinical, and neurological findings were recorded. Stability of anticoagulation was determined by percentage of time international normalized ratio (INR) values were in therapeutic range. Time in therapeutic range (TTR) >65% was defined as stable and <65% was defined unstable. VKORC 1 polymorphism was studied by polymerase chain reaction and correlated with daily dose of OAC and stability of INR.

Results: A total of 157 patients with a median age of 40 years were included in the study. Ninety-two patients received OAC for secondary stroke prevention, 62 for CVST, and 3 for DVT. Out of 2976 INR reports, 1458 (49%) were in the therapeutic range, 997 (33.1%) were below the therapeutic range, and 521 (17.5%) were above the therapeutic level. Stable INR was obtained in 75 (47.77%) patients which was improved by drug modification in 3 and dietary adjustment in 12 patients. VKORC1 polymorphism revealed GG genotype in 127 (80.9%), GA genotype in 22 (14%), and AA genotype in 8 (5.1%) patients. Therapeutic range of INR was seen in 49%, below therapeutic range was seen in 31.5%, and above in 17.5%.

Conclusion: VKORC1 polymorphism was related to mean daily dose of OAC but not to the stability of INR.
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http://dx.doi.org/10.4103/jnrp.jnrp_306_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5912022PMC
May 2018

Reliability and validity of telephonic Barthel Index: an experience from multi-centric randomized control study.

Acta Neurol Belg 2018 Mar 24;118(1):53-59. Epub 2018 Jan 24.

All India Institute of Medical Sciences, New Delhi, India.

Telephonic Barthel Index (BI) assessment is less time-consuming and more feasible than a face-to-face interview. The aim of this study was to test the validity as well as reliability of the BI administered by telephone in comparison with face-to-face assessment in a multi-centric study. The study was conducted during the course of a randomized controlled trial in which 120 patients with subacute strokes from five teaching hospitals from different parts of India were recruited. Central telephonic follow-up and face-to-face assessment of BI and modified Rankin Scale (mRS) at 3 and 6 months were done by trained and certified blinded researchers. Kappa or weighted kappa (wK) was estimated. Sensitivity and specificity at various cutoff levels of telephonic BI were calculated. Concurrent validity of the telephonic BI was assessed by correlating it with the mRS and National Institutes of Health Stroke Scales (NIHSS) at 3 and 6 months. We observed high sensitivity and specificity at various cutoff levels of BI. Moderate to substantial agreement was observed between the two methods at 6 months wK 0.72 (95% CI 0.70-0.77). Item-wise and center-wise kappa also reflected substantial agreement. The study shows that telephonic assessment of activities of daily living with the BI in moderate to severely disabled stroke patients is valid and reliable compared to face-to-face assessment. Our study shows that telephonic assessment requires smaller sample size compared to face-to-face assessment of BI.
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http://dx.doi.org/10.1007/s13760-017-0843-2DOI Listing
March 2018

Moyamoya syndrome in a child with methyl tetrahydrofolate reductase mutation.

Neurol India 2017 Nov-Dec;65(6):1408-1409

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, Uttar Pradesh, India.

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http://dx.doi.org/10.4103/0028-3886.217935DOI Listing
June 2019

Tuberculous meningitis.

Nat Rev Neurol 2017 Oct 8;13(10):581-598. Epub 2017 Sep 8.

Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Vietnam.

Tuberculosis remains a global health problem, with an estimated 10.4 million cases and 1.8 million deaths resulting from the disease in 2015. The most lethal and disabling form of tuberculosis is tuberculous meningitis (TBM), for which more than 100,000 new cases are estimated to occur per year. In patients who are co-infected with HIV-1, TBM has a mortality approaching 50%. Study of TBM pathogenesis is hampered by a lack of experimental models that recapitulate all the features of the human disease. Diagnosis of TBM is often delayed by the insensitive and lengthy culture technique required for disease confirmation. Antibiotic regimens for TBM are based on those used to treat pulmonary tuberculosis, which probably results in suboptimal drug levels in the cerebrospinal fluid, owing to poor blood-brain barrier penetrance. The role of adjunctive anti-inflammatory, host-directed therapies - including corticosteroids, aspirin and thalidomide - has not been extensively explored. To address this deficit, two expert meetings were held in 2009 and 2015 to share findings and define research priorities. This Review summarizes historical and current research into TBM and identifies important gaps in our knowledge. We will discuss advances in the understanding of inflammation in TBM and its potential modulation; vascular and hypoxia-mediated tissue injury; the role of intensified antibiotic treatment; and the importance of rapid and accurate diagnostics and supportive care in TBM.
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http://dx.doi.org/10.1038/nrneurol.2017.120DOI Listing
October 2017

Hyponatremia in Stroke: Simpler May Be Better.

J Stroke Cerebrovasc Dis 2017 07 15;26(7):1654. Epub 2017 May 15.

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India.,. Electronic address:

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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.04.014DOI Listing
July 2017

Pregabalin and lamotrigine in central poststroke pain: A pilot study.

Neurol India 2017 May-Jun;65(3):506-511

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Background: Comparative study of Class I drugs in central poststroke pain (CPSP) is lacking.

Objective: To evaluate the safety and efficacy of pregabalin and lamotrigine in patients with CPSP.

Setting: Tertiary care teaching referral hospital.

Methods: We included consecutive patients with CPSP having ≥50 mm score on Visual Analog Scale (VAS) and randomized them to receive either oral pregabalin or oral lamotrigine. Their clinical findings, serum chemistry, and cranial magnetic resonance imaging findings were noted. The severity of CPSP was assessed by VAS while the allodynia was assessed on a 0-10 scale. The hospital anxiety and depression (HAD) score was also recorded. The primary outcome was> 50% reduction in the VAS score while the secondary outcome was> 50% reduction in the severity of allodynia and improvement in HAD score at 3 months. Adverse reactions were noted in both the groups.

Results: There were 30 patients with CPSP with a median age of 54.5 years (Male:Female = 36:4). While both pregabalin (P < 0.0001) and lamotrigine (P < 0.0001) resulted in significant improvement in the VAS score (63.3% vs. 53.3%), allodynia (66.7% vs. 75%), and HAD score (80% vs. 81.8%) compared to the baseline, the was no significant intergroup difference. Lamotrigine had to be withdrawn in three patients due to skin rash.

Conclusions: Both pregabalin and lamotrigine are equally effective in CPSP, but significant side effects leading to drug withdrawal occured with lamotrigine administration.
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http://dx.doi.org/10.4103/neuroindia.NI_45_16DOI Listing
July 2019

A Study of Hyponatremia in Acute Encephalitis Syndrome: A Prospective Study From a Tertiary Care Center in India.

J Intensive Care Med 2019 May 10;34(5):411-417. Epub 2017 Apr 10.

1 Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Purpose:: To evaluate the frequency and causes of hyponatremia in acute encephalitis syndrome (AES) and its effect on outcome.

Patients And Methods:: Consecutive patients with AES were subjected to neurological evaluation including Glasgow Coma Scale, focal weakness, movement disorder, and reflex changes. The etiology of AES was based on blood and cerebrospinal fluid enzyme-linked immunosorbent assay and polymerase chain reaction. We have categorized patients into neurological or systemic AES. Hyponatremia was diagnosed if 2 consecutive serum sodium levels were below 135 mEq/L, 24 hours apart. Serum and urinary osmolality and electrolytes were measured on alternate days. Fluid intake, output, and body weight were measured daily. The hyponatremia was categorized into syndrome of inappropriate secretion of antidiuretic hormone (SIADH), cerebral salt wasting (CSW), or miscellaneous group. Outcome at 1 month was assessed by modified Rankin scale.

Results:: Of 79 patients, 34 had neurologic AES and 45 had systemic AES; 22 (27.8%) patients had hyponatremia. The neurologic AES as compared to systemic AES was more commonly associated with hyponatremia (38.2% vs 20%, P = .07), need longer hospitalization (25.0 vs 12.5 days, P = .003), and longer time for sodium correction (13.3 vs 8.2 days, P = .05). The hyponatremia was due to CSW in 12 patients, SIADH in 2 patients, and indeterminate in 8 patients. Thirty-six patients had poor outcome (15 died) and 43 had good outcome which was not related to hyponatremia.

Conclusion:: Hyponatremia occurs in one-third of patients with AES, being commoner in neurologic AES, and CSW is the commonest cause.
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http://dx.doi.org/10.1177/0885066617701422DOI Listing
May 2019

Role of β endorphin in pain relief following high rate repetitive transcranial magnetic stimulation in migraine.

Brain Stimul 2017 May - Jun;10(3):618-623. Epub 2017 Feb 24.

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Background: In migraine, high rate repetitive transcranial magnetic stimulation (rTMS) has been reported to be effective, and β endorphin (BE) may have a role in headache relief.

Objective: To report the role of BE and its μ (MOR) and δ opioid receptors (DOR) in headache relief following high rate rTMS in migraine.

Methods: Ninety-three migraine patients having more than 4 attacks per month were included. 10 Hz rTMS (600 pulses in 10 trains) was delivered to left motor cortex; 3 sessions to 24 (group 1), 1 session to 22 (group II) and sham stimulation to 47 patients (group III). Plasma BE, and MOR and DOR RNA expressions were measured before and third session of rTMS. The improvement in headache frequency and severity was assessed at 1month.

Results: Plasma BE level was lower in the migraine patients compared to controls (P = 0.01). Post-stimulation BE level was higher in group I compared to group III (P = 0.02). The responders had higher BE level than non-responders (P = 0.004). Post-stimulation BE level above 4 ng/ml was associated with improvement in headache frequency in 43 (81.1%) patients, whereas only 23 (57.5%) improved if BE was below 4 ng/ml (P = 0.02) irrespective of type of rTMS.

Conclusion: 10 Hz rTMS relieves headache by increasing BE level. BE level above 4 ng/ml is critical in headache relief irrespective of type of rTMS.
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http://dx.doi.org/10.1016/j.brs.2017.02.006DOI Listing
December 2017

Cerebral Salt Wasting Is the Most Common Cause of Hyponatremia in Stroke.

J Stroke Cerebrovasc Dis 2017 May 16;26(5):1026-1032. Epub 2017 Jan 16.

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. Electronic address:

Objective: The study aimed to evaluate the frequency, severity, and causes of hyponatremia in stroke and its influence on outcome.

Materials And Methods: Consecutive computed tomography- or magnetic resonance imaging-proven stroke patients within 7 days of stroke were included. Severity of stroke was assessed using the National Institute of Health Stroke Scale and consciousness using the Glasgow Coma Scale. Hyponatremia was defined if 2 consecutive serum sodium levels were <135 mEq/L and hypernatremia if >145 mEq/L. Causes of hyponatremia, such as cerebral salt wasting (CSW) and syndrome of inappropriate secretion of antidiuretic hormone (SIADH), were based on predefined criteria. Patients with CSW were managed by salt supplementation and normal saline, and fludrocortisone was used in refractory cases. In SIADH, fluid was restricted. Outcome on discharge was defined using the modified Rankin Scale (mRS).

Results: One hundred patients with stroke were included: 47% had ischemic stroke and 53% had intracerebral hemorrhage. Forty-three percent of the patients had hyponatremia, 6% had hypernatremia, and 4% had both. Hyponatremia was due to CSW in 19 (44.2%), SIADH in 3 (7%), miscellaneous causes in 14 (32.6%), and indeterminate in 7 (16.3%) patients. Duration of hospitalization was the independent predictor of hyponatremia and CSW. Fourteen patients died, whereas 15 had good outcome (mRS score of ≤2) and 71 had poor outcome (mRS score of 3-5). Hypernatremia was associated with high mortality compared with eunatremia and hyponatremia.

Conclusion: Hyponatremia occurred in 43% of stroke patients. CSW was the most common cause of hyponatremia. Hyponatremia, however, was not related to death or disability.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.12.011DOI Listing
May 2017

A study of glutamate levels, NR1, NR2A, NR2B receptors and oxidative stress in rat model of Japanese encephalitis.

Physiol Behav 2017 03 17;171:256-267. Epub 2017 Jan 17.

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Science, Raebareily Road, Lucknow, India.

There is paucity of studies on the role of glutamate excitotoxicity in cell damage in Japanese encephalitis. In this study the glutamate levels and its NMDA receptors, and oxidative stress markers in different brain regions have been evaluated and correlated with neurobehavioral changes at different time points. Twelve day old Wistar rats were inoculated with 3×10pfu/ml intracerebrally. The neurobehavioral effects were evaluated by spontaneous locomotor activity (SLA), grip strength and rota rod test on 10, 33 and 48days post inoculation (dpi). Glutamate level was evaluated by enzyme linked immunosorbent assay, mRNA gene expression of ionotropic glutamate receptors N-methyl d-aspartate (NMDA) receptor 1, 2A and 2B (NR1, NR2A and NR2B) were evaluated by real time PCR. Malondialdehyde (MDA), glutathione (GSH) and glutathione peroxidase (GPx) levels were measured by spectrophotometer in different brain regions of JEV infected rats on 10, 33 and 48dpi. There was significant increase in motor deficit, grip strength and decreased locomotor activity on 10 and 33dpi. Glutamate levels were increased in thalamus, midbrain, frontal cortex, striatum and cerebellum on 10 and 33dpi and were followed by a recovery on 48dpi. Glutamate NMDR receptors NR1, NR2A and NR2B were reduced in thalamus, midbrain, frontal cortex, striatum and cerebellum on 10dpi which was followed by recovery after 33dpi. A significant increase in MDA level in thalamus, midbrain, frontal cortex, striatum and cerebellum was noted on 10 and 33dpi. The antioxidant GSH and GPx were significantly reduced in these brain regions on 10 and 33dpi. Glutamate, MDA, GSH and GPx correlated in different brain regions as the disease progress. Increased Glutamate level may be related to oxidative stress and may be responsible for behavioral alterations in rat model of Japanese encephalitis.
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http://dx.doi.org/10.1016/j.physbeh.2017.01.028DOI Listing
March 2017

Cerebral Venous Sinus Thrombosis Presenting Feature of Systemic Lupus Erythematosus.

J Stroke Cerebrovasc Dis 2017 Mar 5;26(3):518-522. Epub 2017 Jan 5.

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India. Electronic address:

Background: CVST (cerebral venous sinus thrombosis) may sometimes be associated with autoimmune disorders that require specific treatment. The clinical and magnetic resonance imaging (MRI) findings of systemic lupus erythematosus (SLE) patients with CVST are presented and contrasted with CVST without SLE.

Methods: Consecutive patients with CVST admitted in neurology service during 2012-2016 were included. The diagnosis of CVST was confirmed by MR venography or digital subtraction angiography. SLE was diagnosed according to American College of Rheumatology criteria. The clinical and MRI findings of CVST with SLE and those without SLE were compared.

Results: Forty-three consecutive patients with CVST were included during the study period, 3 of whom had SLE .Their age ranged between 20 and 35 years and all were females. The clinical markers of SLE were present in all and included oral ulceration in 3 patients, serositis in 2 patients, and arthritis and psychosis in 1 patient. The SLE patients did not have antiphospholipid antibodies or lupus anticoagulant. The manifestation of CVST in SLE was similar to the other patients with CVST. The CVST in SLE required long-term anticoagulation and immunosuppression with cyclophosphamide pulse in 1 patient and oral prednisolone in 2 patients. The outcome was good, partial, and poor in 1 patient each.

Conclusions: CVST may be the presenting feature of SLE, but these patients often have clinical clues to SLE. These patients need prolonged anticoagulation and immunosuppression.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.12.001DOI Listing
March 2017

A Cost-Effective Approach to the Diagnosis and Management of Acute Infectious Encephalitis.

Eur Neurol 2017 8;77(1-2):66-74. Epub 2016 Dec 8.

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.

Setting: A tertiary care teaching hospital in India.

Objective: To report a syndromic approach to acute encephalitis syndrome (AES) and propose a cost-effective model.

Study Design: AES patients were categorized by the presence or absence of myalgia/rash into systemic and neurological AES. The patients with systemic AES were investigated for dengue, scrub typhus, leptospira, chikungunya, and malaria, and those with neurological AES were investigated for herpes and Japanese encephalitis (JE). Sensitivity and specificity of syndromic categorization were tested, and cost effectiveness was calculated.

Results: There were 210 patients with infectious AES; neurological in 45 and systemic in 165. Specific etiology could be found in 130 (62%) patients, and after excluding 36 patients with co-infections, 94 patients were tested for sensitivity and specificity. Twenty patients had neurological AES (herpes 12, JE 8), and 74 systemic (scrub typhus 42, dengue 20, malaria 6, leptospira 6). The absence of myalgia/rash categorized neurological AES with 100% specificity. In neurological AES, thalamic involvement predicted JE with 100% specificity. In systemic AES, differentiation could not be made between etiologies based on hypotension, thrombocytopenia, and muscle, liver, and kidney dysfunction. In these patients, MRI and acyclovir therapy were warranted, saving cost. By targeted investigations and treatment, the cost was reduced by 70%.

Conclusions: A syndromic approach to AES and goal-directed investigations and treatment substantially reduces the cost of management.
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http://dx.doi.org/10.1159/000453662DOI Listing
September 2017

Direct and indirect cost of myasthenia gravis: A prospective study from a tertiary care teaching hospital in India.

J Clin Neurosci 2017 Apr 23;38:114-117. Epub 2016 Nov 23.

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India. Electronic address:

Myasthenia gravis (MG) requires lifelong treatment. The cost of management MG is very high in developed countries but there is no information on the cost of management of MG in the developing countries. This study reports the direct and indirect cost and predictors of cost of MG in a tertiary care teaching hospital in India. In a prospective hospital based study, from a tertiary hospital in India 66 consecutive patient during 2014-2015 were included. The age of the patients ranged between 6 and 75years. The severity of MG was assessed by myasthenia gravis foundation association (MGFA) class (MGFA) I-V. The patient data was collected s and their direct cost was calculated from the computerized Hospital information system. The indirect cost was calculated from patient's memory, checking the bills of transportation and wages loss by the patient or the care giver. Total annual cost of MG ranged between INR (4560-532227) with median INR 61390.5 (US$911.64). The median cost of outpatient department (OPD) consultation of 16 patients was INR 20439.9 (US$303.53), of 50 admitted patients was INR 44311.8 (US$658.03) and 21 intensive care unit (ICU) patients was INR 59574.3 (US$ 884.6) and the direct cost of thymectomy was INR 45000 (US$ 668.25). Direct cost was related to indirect cost (r=0.55; p=0.0001). Predictors of patient outcome were severity of MG, ICU admission, and thymectomy. The total median cost for management of myasthenia gravis was INR 61390.5 (4560-532227, US$911.64) per year, and the cost was mainly determined by the severity of MG.
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http://dx.doi.org/10.1016/j.jocn.2016.11.003DOI Listing
April 2017

Neurology at Sanjay Gandhi PGI: Beginning, progress and hope.

Neurol India 2016 Sep-Oct;64(5):1010-5

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

High quality publications, patient care and educational standard have made Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India a favored destination for the patients and medical students, for getting treatment and education, respectively. The current article traces the history and milestone of the Department of Neurology, SGPGIMS, Lucknow and summarizes its achievements and facilities. The uniqueness of the department lies in being sensitive to the expectation of the patients, students and its faculty's own aspirations in research, keeping the patient as the center of focus.
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http://dx.doi.org/10.4103/0028-3886.190247DOI Listing
November 2018
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