Objective:Our aim was to observe frequency of cranial autonomic symptoms (CAS) in migraineurs (primary) and its relation with laterality of headache or other factors, if any.Background:Migraine episodes have headaches with or without aura, and sometimes associated with systemic autonomic nervous system symptoms. Primarily presence of cranial autonomic symptoms suggests diagnosis of TACs. But many studies reported cranial autonomic symptoms (CAS) ranging from 26% to 80% in migraine patients.Material and Methods:Consecutive patients of migraine attending our headache clinic were included in our study. Presence of CAS was recorded with respect to ocular, nasal, facial and aural symptoms along with headache characteristics and laterality information. Detailed clinical examination was performed. We used ICHD 3 (beta version) criteria.Results:Our study cohort comprised of 200 patients having mean (± SD) age 31.12 (± 10.67) years. There were 157 (78.5%), females. Out of 200 patients, 148 (74%) were having at least one CAS, of which 70% were having 2 or more CAS. Frequency of CAS was lacrimation (45.5%), conjunctival injection (34.5%), eyelid edema (34%), aural fullness (27.5%), facial sweating (25%), facial flushing (17.5%), nasal congestion (9%), rhinorrhea (5%) and ptosis (4%). Bilateral CAS was present in 129 (87%) and unilateral CAS in 19 (13%) (OR 35.31; 95% CI 9.19 to 135.7), (P < 0.0001). Sunlight as a trigger was present in all 148 (100%) patients.Conclusion:Our study showed that CASs in migraine is common and bilateral. Sunlight triggers headache in almost all CAS positive patients.

Dopa-responsive dystonia also known as "Segawa's syndrome" was first described in 1976. The dystonia typically shows diurnal variations and is more marked toward the end of the day and improves in sleep. This entity is often misdiagnosed in the clinical setting, mostly due to the lack of awareness, and these patients are exposed to various treatment regimens and nonpharmacological measures. We present a boy being treated as dystonic cerebral palsy who showed significant improvement in dystonic symptoms with L-dopa therapy.

Acute encephalitis syndrome (AES) is a major health problem in developing countries including India. Neuronal injury in encephalitis is attributed to direct toxicity from pathogens and proinflammatory cytokines. In this study, we assessed cytokine levels in serum and cerebrospinal fluid (CSF), and their correlation with clinical symptoms. In our study, patients with AES for a duration of less than 2 weeks underwent brain imaging followed by CSF analysis for routine parameters and viral studies. We assessed interleukin (IL)-6, IL-10, and regulated on activation, normal T cell expressed and secreted (RANTES) levels in the serum samples of all patients and in 50 CSF samples and compared them with serum cytokine levels of 64 age- and sex-matched controls. Of the 87 AES patients, 13 had Japanese encephalitis (JE). Serum IL-6, IL-10, and RANTES levels were significantly elevated in patients with AES compared with that in controls. Serum IL-10 levels were significantly reduced while RANTES levels were significantly elevated in patients who died. CSF IL-6 and IL-10 levels were significantly elevated in the non-JE group compared with that in JE patients. RANTES levels in the CSF were high in patients who had no seizures. IL-10 exerts its anti-inflammatory effect by modulating the innate and adaptive immune response, thus limiting the production of pro-inflammatory cytokines. Higher IL-10 levels were found to be protective in patients with acute encephalitis.

INTRODUCTION:Varicella zoster (VZ) vasculopathy is a rare but well recognized cause of stroke. In the absence of zoster rash and infection in remote past, the disease can pose diagnostic challenge. We report 3 cases of anterior circulation stroke occurring in close temporal relation to VZ. Their clinical, radiologic, and angiographic features are discussed.CASE REPORT:Of the 3 patients, 2 had stroke within a span of 4 to 6 weeks of herpes zoster ophthalmicus while the third patient had zoster of cervical dermatome. Magnetic resonance imaging revealed acute subcortical infarcts in 2, while 1 patient showed acute on chronic infarct in left middle cerebral artery territory. The magnetic resonance angiography was abnormal in 2 patients while it was normal in third. All the patients were treated with acyclovir and antiplatelets with good recovery in 2.CONCLUSIONS:VZ associated vasculopathy may have diverse clinical profile and neuroimaging features. It should be considered as an important and treatable cause of stroke in appropriate clinical settings.

The artery of Percheron is a rare anatomic variant supplying the thalamus and the rostral midbrain. Infarct in this territory results in a wide array of neurological signs and symptoms causing diagnostic dilemma and management issues. We describe the clinical presentations in three cases admitted and evaluated for neurological symptoms and diagnosed as artery of percheron infarct after brain imaging. In one patient, the etiology turned out to be infective while the other two patients had cerebrovascular accident secondary to dilated cardiomyopathy and hyper homcystinimea respectively. Artery of percheron infarction is a rare entity and should be considered in patients with altered sensorium and behavioral manifestations with associated eye abnormalities. MRI brain is the investigation of choice to detect this rare variant of thalamic circulation.

Background: Leprosy is a chronic granulomatous infection primarily affecting the peripheral nervous system, skin and reticuloendothelial system. Cutaneous nerves are severely affected in lepra reaction and this leads to morbidity. Objective: To study electrophysiological pattern of different nerves involved in Type-II reactions in leprosy. Method: The present study was undertaken in 21 leprosy patients with Type-II reactions attending in and out-patient department of Dermatology & Venereology, B.R.D. Medical College, Gorakhpur from July 2005 to October 2006. This was a prospective case control study in which 20 healthy, age and sex matched people with no evidence of any disease (particularly nerve involvement) were included. Limitation: Lesser number of cases were studied. Result: The proximal motor conduction latency was significantly prolonged in both ulnar and common peroneal nerve and proximal motor conduction velocity was also significantly reduced. On examining the values beyond 2S.D. of the control value, distal latency was not affected and only proximal conduction was affected in ulnar nerve. Conclusion: In Type II lepra reaction the motor conduction abnormalities are not prominent. Abnormalities are relatively more marked in the proximal segment.

Objective: To evaluate the effects of proprioceptive neuromuscular facilitation (PNF) exercises on functional outcome and quality of life (QoL) in patients with acute stroke. Materials and methods: Ninety patients were recruited in this study and divided into two groups: Patients admitted within 48 hours after stroke (group I, n = 41) and patients referred from elsewhere after 2 to 3 weeks (group II, n = 49). Both groups were given PNF exercises for 4 weeks. Functional outcome was assessed by Barthel Index (BI), and QoL was assessed by Stroke-Specific Quality of Life (SSQOL) scale before and after the intervention. Patients were followed up in the outpatient department of the Department of Neurology at 1, 3, and 6 months and BI and SSQOL scores were again assessed. Results: Group I showed significant and better recovery in functional activities (p < 0.05) and better QoL as compared with group II (p < 0.05). We also compared functional outcome and QoL in ischemic vs hemorrhagic stroke (p = 0.284) and left vs right stroke (p = 0.973) and found there was no significant difference. Conclusion: Improvement in activities of daily living may result in better QoL. The PNF exercises are very effective in improving muscle tone, functional outcome, and QoL. The PNF exercises should be given from the first day after stroke.

Objectives: Dengue is a mosquito-borne disease caused by arbovirus and well known for its typical fever with thrombocytopenia syndrome. Acute hypokalemic quadriparesis is a rare presentation of dengue with uncertain pathogenesis. We aim to describe the clinical and biochemical characteristics of rapidly resolving weakness related to hypokalemia in patients infected with dengue virus. Methods: A retrospective review of the records of patients with diagnosis of dengue-associated hypokalemic weakness was performed. Demography, clinical, biochemical characteristics, and outcome of the patients were recorded during acute phase of illness. Results: Our study cohort comprised 12 patients and all were males from urban dwelling. The median age was 34.5 years (range, 18–50). Presentation was acute onset rapidly worsening pure motor quadriparesis preceded by short lasting febrile episode. Weakness ranged from 2/5 to 4/5 on Medical Research Council (MRC) scale with generalized hyporeflexia or areflexia. The baseline serum potassium was mean ± SD (2.7 ± 0.48 mmol/L). All patients showed elevation of liver transaminases and elevated creatine phosphokinase level. Weakness improved in 24–72 hours in all patients with correction of serum potassium. Conclusions: Dengue-associated acute hypokalemic paralysis is an underrecognized entity having favorable outcome. It should be suspected in patients presenting as acute pure motor quadriparesis after febrile illness in dengue endemic areas.

Background: Stroke leads to impairment in upper extremity function and hence impairment in performance of activities of daily living. The studies that emphasize the effects of PNF (Proprioceptive Neuromuscular Facilitation) in acute stroke are still lacking. Aim: In this study we aim to investigate the effects of PNF exercises on upper extremity function in acute stroke. Methods: Total 35 patients were recruited from the OPD of Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow. Written informed consent was obtained from their legal relatives. Patients were given PNF exercises for scapula from the first day of their admission to the hospital and then arm pattern (D1 and D2 flexion , extension) by using rhythmic initiation technique until discharge from the hospital (Mean 15.2+ 3.9days). PNF was given twice daily for 30 minutes for 5 days a week. Arm recovery was assessed by Fugl- Meyer scale and arm function was assessed by Arm Motor Ability Test (AMAT). Patients were followed up in neurology OPD on monthly basis up to 6 months. Results: Out of 35, 26 were of ischemic stroke and 9 were of haemorrhagic stroke. 17 were left sided and 18 were right sided hemiplegics. 15 were females and 20 were males. Mean age of the patient was 56.45 + 12.14. Glasgow coma scale at the time of admission was 14.6+ .338. Mean NIH stroke severity was 7.48 + 3.95, shows all the patients were of mild to moderate stroke. The mean Fugl- Meyer score before the intervention was 151.60+ 41.72 with SE= 7.05 and after intervention was 209.9. Paired t - test was run to determine if PNF is effective in improving upper extremity function in acute stroke t (34)= - 9.920, p= .001. There was significant improvement in upper extremity functions. The mean AMAT score before intervention was 63.53+ 28.32 and after intervention was 120.22+ 12.12 and t(34)= 5.92 p= .026 which shows significant improvement in upper extremity function. Conclusion: Proprioceptive neuromuscular facilitation exercises are very effective in generating voluntary control and improving functional activities of daily living if given from the first day of stroke. For improvement in arm function the intervention should be started first from scapula. Due to the irradiation effect, there is generation and improvement of tone and power in upper extremity. Acknowledgements: This study was supported by the department of Science and Technology, New Delhi, India.

Japanese encephalitis (JE) is numerically the most important global cause of encephalitis and so far confirmed to have caused major epidemics in India. Most of the reported studies have been in children. This largest study involving only adults, belonging to four epidemics, is being reported from Gorakhpur. The aim of this study is to detail the acute clinical profile (not viral) outcome and to classify the sequelae at discharge. This prospective study involved 1,282 adult patients initially diagnosed as JE admitted during the epidemics of 1978, 1980, 1988, and 1989, on identical clinical presentation and CSF examination. In the meantime, the diagnosis of JE was confirmed by serological and/or virological studies in only a representative number of samples (649 of 1,282 cases). Eighty-three left against medical advice (LAMA) at various stages, so 1,199 of 1,282 were available for the study. Peak incidence of [1,061 of 1,282 (83%)] of clinically suspected cases was from September 15 to November 2. Serum IgM and IgG were positive in high titers in 50.87% (330 of 649) and IgM positive in CSF in 88.75% (109 of 123) of the cases. JE virus could be isolated from CSF and brain tissue in 5 of 5 and 4 of 5 samples, respectively. Altered sensorium (AS) in (96%), convulsions (86%), and headache (85%) were the main symptoms for hospitalization by the third day of the onset. Other neurological features included hyperkinetic movements in 593 of 1,282 (46%)-choreoathetoid in 490 (83%) and bizarre, ill-defined in 103 (17%). The features of brain stem involvement consisted of opsoclonus (20%), gaze palsies (16%), and pupillary changes (48%) with waxing and waning character. Cerebellar signs were distinctly absent. Dystonia and decerebrate rigidity was observed in 43 and 6%, respectively, paralytic features in 17% and seizures in 30%. Many non-neurological features of prognostic importance included abnormal breathing patterns (ABP) (45%), pulmonary edema (PO) (33%), and upper gastrointestinal hemorrhage (UGIH) (16%). Injection dexamethasone was used in 1978 in all 208 cases, including 21 of PO. Patients were later randomized alternately in dexa and non-dexa groups. Forty-six cases of PO from the non-dexa group were transferred to the dexa group as an ultimate life-saving measure. Thus, it was administered in 737 of 1,199 patients including 529 patients from the later epidemics in doses of 4 mg IV every 8 h for 7 days. Of 1,199, 462 did not receive it. There was no significant difference in mortality (p > 0.05) between the dexa (42.47%) and the non-dexa group (42.86%). All PO cases expired; so after the exclusion of the PO cases from dexa group, the difference of 6.14% (42.86 and 36.72) became significant (p < 0.01) (511 of 1,199 (43%) expired, [320 of 511 (63%) died within 3 days of hospitalization]). Out of a total of 1,199 patients treated, 688 (57%) were discharged; 23 of 688 (3%) without any sequelae and 665 of 688 (97%) with neuropsychiatric deficits classified into nine groups. During the four epidemics, the diagnosis of JE was basically on identical clinical presentation of acute encephalitic syndrome (AES) consisting of (1) abrupt onset of fever, headache, and AS, (2) dystonias and various movement disorders, (3) opsoclonus and gaze palsies, (4) CSF findings, and (5) the presence of residual neuropsychiatric and neurological features in the survivors.

Japanese encephalitis, the commonest Arbovirus encephalitis, has been endemic in many parts of Asia, the Pacific Islands, and India; also, there have been many epidemics. Most of the post JE cases have been associated with neurological and neuropsychiatric deficits but have not been properly classified and followed. Practically all the previous studies were in children or young adults. The aim of this study, involving only adult cases, the largest ever being reported, has been to follow the 688/1,199 survivors of JE patients out of 1,282 of acute cases admitted during four epidemics for a period of 14 years after properly classifying the sequelae. This prospective study was conducted in B.R.D. Medical College Gorakhpur (India), involving 665/688 post JE cases with neuropsychiatric deficits from four epidemics of 1978, 1980, 1988 and 1989 which were properly classified in nine groups. While the first epidemic of 1978 was being studied, more disastrous episodes flared up and the patients were subsequently added. Hence, the total duration of this prospective study was from November 1978 to December 2003. There were 14 defaulted initially from 688 followed (23/688 without sequelae and 665/688 with neuropsychiatric deficits), and later 130 were lost from time to time at various stages of follow up. Four out of 23/688 discharged without any deficit had to be readmitted for bizarre movements, assaultative behaviour and euphoria without fever and altered sensorium. All of them improved by symptomatic treatment. Progressive improvement occurred in all the parameters consisting of psychological disturbances, higher cerebral dysfunction, speech disorders (dysphonia, dysarthria, dysphasias, apraxia and agnosia), extra pyramidal, pyramidal features, and hypothalamic disturbances, cranial nerves including pupils and fundi and seizures. Maximum cases improved between 6 months (55%) to 1 year (78%). Only some features improved between 5 to 14 years. Four patients of hemiplegia remained bed ridden. Some non disabling features like dysarthria and corticospinal features without paralysis persisted in 5% (95% improved) and 74% (26% improved) respectively. One patient with bizarre movement and nine with marked tremors could not regain normalcy. A large number of patients of JE are left with several minor or gross residual neuropsychiatric and neurological features after the acute phase. In this series also the discharged patients with neurological deficits who were quite disabled initially and needed constant care by family members and also those who required some help intermittently improved with passage of time and eventually returned to normal life. Some of them were left with non-disabling residual neurological signs even after 14 years. Fourteen of 544 (3%) could not return to their livelihood.

PURPOSE:Despite recent advances in the management of epilepsy the efforts to assess knowledge, attitude and practice towards epilepsy are limited, particularly in the developing countries. To delineate the magnitude and scope of this problem, present study was conducted to assess the knowledge attitude and practice about epilepsy amongst schoolteachers in Northeast Uttar Pradesh, the most populous state of India. The basis of involving schoolteachers was their special role in Indian society with their larger interaction among the segment of population most affected by epilepsy.METHODS:Simple self-administered questionnaires were sent to the schoolteachers of primary and secondary levels. The questionnaires contained 15 questions related to awareness and attitudes towards epilepsy with details of first aid management of seizures.RESULTS:We found that 97% of schoolteachers were aware of epilepsy with majority including it as a brain disease. A substantial proportion (38.2%) was uncertain about relation of epilepsy and insanity and 31.7% felt epileptics to be of below average intelligence. Only about half of them (55.3%) preferred their children to play with an epileptic. An overwhelming no was obvious about marriage with an epileptic (86.8%). Only 27.8% of the respondents had given any first aid measure to a seizing patient with only 16.3% giving it properly.CONCLUSION:Despite a great degree of awareness about epilepsy amongst schoolteachers in India negative and wrong attitudes still exist. Stress on proper first aid measure to a seizing child needs greater emphasis to remove fright and fear amongst the public. Besides adequate management, public education to address existing biases and fear are equally important to improve the quality of life of epileptics.

To the Editors: Levetiracetam (LEV) is considered a new antiepileptic drug with proven efficacy primarily as add-on treatment in adult patients with intractable partial seizures (Klitgard, 2001). In our ongoing uncontrolled, prospective open-ended clinical trial of LEV on patients with refractory epilepsy, we noticed a paradoxical increase in seizure frequency on LEV administration in 23.3%. We introduced LEV in 30 patients with difficult to treat epilepsy (25 partial seizures, 4 generalized seizures, 1 Lennox–Gastaut syndrome). The etiology of seizures was established in 13. Mean duration of epilepsy was 11.2 ± 7.2 years with mean duration of treatment as 6.3 ± 5.7 years. LEV was introduced in adults as 500 mg/day after 3 months of baseline period, and the dose was escalated by 500 mg/month. Mean seizure frequency (MSF) per month was recorded at each visit. The follow-up ranged from 2 to 20 months. MSF was reduced in 21 patients (>50% reduction in 18) and was unchanged in 2. Seven patients recorded a paradoxical increase in seizure frequency. All of them had complex partial seizures with long duration of epilepsy (>15 years in five, >10 years in two). Barring one, all were adults (mean age 32 ± 12.5 years) with four males. No specific EEG abnormality was noted. The etiology of epilepsy could be established in all but one (neurocysticercosis in three, focal cortical gliosis in two, left cerebral hemiatrophy in one). The increase in MSF ranged from 50% to several hundred times. The daily LEV dose at escalation was <1,000 mg in four, <2,000 mg in two, and >2,000 mg in one. Paradoxical increase was noted after 2–12 months of LEV introduction (<6 months in four). The escalated seizures were complex partial seizures in all but one, with generalized tonic–clonic seizures. None developed status epilepticus. The commonest concomitant AED was carbamazepine/oxcarbazepine. The paradoxical worsening was accompanied with adverse reactions like sedation in four and vertigo in two. Reduction in LEV doses resulted in decrease in seizures in 7–15 days. It reached below baseline frequency in four patients, returned to baseline in two, but persisted above it in one. The sedation and vertigo also disappeared on reduction of dose. In one patient with neurocysticercosis, the paradoxical increase was reported at a daily dose of 2,000 mg. On further escalation to 2,500 mg, seizure frequency increased by >1,000%. LEV dose was reduced to 1,000 mg with marked reduction in seizure frequency (150% of baseline). Addition of 250 mg LEV led to further aggravation of seizure by 200%, with reduction of seizures on cutting the dose back to 1,000 mg. The paradoxical exacerbation of seizures by LEV has been reported (Nakken et al. 2003). Exacerbation of seizures on reintroduction of LEV dose with decreased frequency on reducing the dose in one of our patients implies LEV as the aggravating factor and argues well against natural fluctuation of disease. Detailed pharmacokinetic studies with serum LEV level and clinical response are desirable to establish cause and effect.

Association of dyslipidemia with stroke is conflicting though recent studies point to their positive role. Sixty consecutive patients with stroke were analyzed for fasting lipid profile values. Highly significant alteration in LDL-cholesterol, non-HDL cholesterol and serum triglyceride was observed in patients with stroke. No significant alteration was noted in total cholesterol and HDL cholesterol. Low HDL cholesterol values were more frequently observed in normotensive stroke patients. Non HDL cholesterol, a marker for atherogenic activity was high in both ischemic as well as haemorrhagic stroke. Estimation of LDL cholesterol, non-HDL cholesterol and triglycerides is recommended in patients with stroke.

Two hundred consecutive patients of non-traumatic coma, were investigated to establish its aetiology. Neurologic profile of these patients included assessment of Glasgow Coma Scale (GCS) score and evaluation of brainstem reflexes. 102 patients died and only 54 patients could make good recovery. Cerebrovascular diseases (33%), CNS infections (21%), and hepatic encephalopathy (18%) were the frequent causes of non-traumatic coma, with the first two carrying relatively poor prognosis. Poor outcome was also associated with low GCS score and absence of brainstem reflexes specially absent pupillary, oculocephalic and oculovestibular responses and decerebrate posture.

During the year 1994-1995, 20 of the 67 leprosy patients attending the dermatology department with any kind of nerve involvement were found to be having nerve abscess. These abscesses occurred in all types of leprosy (except the Indeterminate) and a variety of nerve trunks and cutaneous nerves. In none of the instances the abscess was associated with reaction. All the patients were surgically treated, without any steroid therapy. All cases showed significant improvement whenever there was nerve function deficit. Similarly, pain was relieved in all cases, when it was present.