Deep Brain Stimulation for Parkinson's Disease-the Developing World's Perspective.

Background: Deep brain stimulation (DBS) is the most widely used device-assisted therapy in patients with moderately advanced stages of Parkinson's disease (PD) experiencing motor complications. Only a minority of eligible patients get the opportunity to undergo DBS in the developing world. Objectives: To examine the proportion and characteristics of patients with motor complications of PD who are willing for DBS and who undergo surgery. Methods: Patients with motor complications of PD eligible for DBS over a five-year study period (2016-2020) were included. The demographic, clinical and socio-economic characteristics and information on their status in 2021 were collected and analyzed. Results: Among 1017 patients, 223 had motor symptoms qualifying for DBS and follow-up information available. Only 78 (35%) opted for surgery. The willing patients had higher socioeconomic status, were older and had longer duration of PD and motor complications, more freezing of gait, cognitive symptoms, and neuropsychiatric disturbances. 37 of them were found unfit during pre-operative work-up; only 41 (18%) with motor complications were finally taken up for DBS. Age, duration or severity of motor symptoms did not differ between patients who were finally selected for surgery and those who were not. Conclusions: Less than one-fifth of our patients with motor complications of PD finally underwent DBS. The patients appeared to wait till the late stages of PD, before making a decision on availing surgical treatment. The delay resulted in nearly half of them being found unfit in pre-operative work-up. Our findings may enable clinicians to counsel eligible patients more efficiently.

Clinical profile and outcomes of childhood dilated cardiomyopathy - A single-center three-decade experience.

Introduction and Aims: Dilated cardiomyopathy (DCM) is an important cause of heart failure (HF) among children. Research on pediatric DCM remains surprisingly scarce. The primary objective of the study was to evaluate the clinical profile and outcomes of pediatric DCM and the secondary objective was to study the predictors of outcome. Methods and Results: We enrolled all patients with cardiomyopathy who presented to us between 1990 and 2020 and were younger than 18 years. During the 30-year study period, we identified 233 cases of pediatric cardiomyopathy. One hundred and nineteen (51%) cases had DCM. This retrospective cohort was analyzed to study their outcome and the possible predictors of outcome. Nearly, 8% presented in the neonatal period, and 37% in infancy. The most common mode of presentation was dyspnea on exertion (71%). Ninety-three patients presented in heart failure (78%). The median left ventricular dimension z-score in diastole was 4.3 (range 2.5-9.06). The median left ventricle (LV) ejection fraction was 31%. Seventy-two percent of this cohort were on angiotensin-converting-enzyme inhibitors, 40% on aldosterone antagonists, and 47% on beta-blockers. One-third had syndromic, metabolic, genetic, or any secondary cause identified. Twenty-seven patients satisfied the three-tiered clinical classification for the diagnosis of probable acute myocarditis. Over a mean follow-up of 3.29 years, 27% were lost to follow-up. Among the remaining patients who were on follow-up (n = 86), 39 (45%) died, 31 (36%) recovered, and 16 (18%) had persistent LV dysfunction. Heart Failure was the most common cause of death. Eight patients in this cohort (4.2%) had thromboembolic phenomena. Nine had sustained ventricular arrhythmias and six had atrial/junctional arrhythmias. Among the various risk factors studied, only infantile onset had a significant relationship with death or ventricular arrhythmias (P value- 0.05). The 5-year survival rate of DCM patients was 59%. Conclusion: A reasonably good percentage of our population showed recovery of the left ventricular function (36%). Only infantile onset had a significant relationship with death or ventricular arrhythmias. The outcome in our DCM cohort is similar to other population cohorts.

Treatment in a Stroke Unit and Risk Factor Control Reduce Recurrent Stroke Risk.

INTRODUCTION: Risk factor control is an important predictor of risk of stroke recurrence. The attributable fraction which estimates the excess risk among the exposed stroke survivors has not been studied previously. We studied the attributable fraction for stroke recurrence in consecutive incident cases of recurrent stroke. METHODS: A case-control study with incident cases of recurrent stroke and controls matched for age and poststroke period was done. A structured interview was done to collect data on sociodemographic variables, lifestyle, and medication adherence. The risk factors, treatment of index stroke, and outcome were collected. Logistic regression analysis was done to find out the factors associated with stroke recurrence. Attributable fraction and average attributable fraction were calculated. RESULTS: Among the 103 matched pairs, more than 70% were rural residents. Male gender (OR 2.59; 95% CI 1.05-6.42), the presence of depression (OR 8.67; 95% CI 2.80-26.84), memory problem (OR 10.12; 95% CI 2.48-41.34), uncontrolled diabetes (OR 3.19; 95% CI 1.42-7.19), cardioembolic stroke (OR 4.45; 95% CI 1.12-17.62), and index stroke not being treated in a stroke unit (OR 6.60; 95% CI 2.86-15.23) were associated with increased risk of stroke recurrence. The maximum average attributable fraction for stroke recurrence risk was attributed to index stroke not being treated in the stroke unit and uncontrolled diabetes. CONCLUSION: The index stroke treated in a comprehensive stroke care unit and control of risk factors can reduce recurrent stroke risk among stroke survivors. This population-attributable risk is important in planning secondary stroke prevention strategies.

Pattern and Severity of Leukoaraiosis and Microvascular Resistance- Inputs from a TCD Study from South Asia.

Background and Purpose: Leukoaraiosis is thought to be related to long-standing microvascular ischemia. The pathogenic mechanisms and hemodynamic changes could be different for periventricular and deep white matter leukoaraiosis. In this cross-sectional study, we examined whether the Pulsatility Index (PI) in Transcranial Doppler ultrasonography (TCD), which can give indirect information regarding downstream microvascular resistance and compliance, is different for leukoaraiosis in periventricular and deep locations. Correlation between presence of leukoaraiosis and PI was also studied since it was not studied in South-Asian patients before. Methods: Consecutive patients with suspected lacunar stroke or white-matter disease, undergoing MR brain imaging were included. Vascular imaging was done with CT or MR Angiography to rule out significant (>50%) stenosis. Fazeka's grading was done for severity of leukoaraiosis and mean PI in the middle cerebral artery (MCA) was obtained with trans-temporal TCD. Results: Ninety patients (Mean age 61 ± 10.9 years, 29% females) were available for final analysis. Age, hypertension, diabetes mellitus, CAD, and presence of leukoaraiosis were strongly associated with elevated mean PI in univariate analysis. In multivariate analysis, presence of leukoaraiosis was significantly associated with higher mean PI after adjusting for other variables. Mean PI strongly correlated with both periventricular (Spearman's correlation coefficient 0.56, P = 0.01) and deep white matter (Spearman's correlation coefficient 0.63, P = 0.01) leukoaraiosis. Conclusions: Our study confirms the correlation of Pulsatility Index with leukoaraiosis in South-Asian patients. Interestingly, changes in microvascular resistance appeared to be similar for both periventricular and deep white matter leukoaraiosis in spite of potential differences in etiopathogenesis.

Prevalence of Aortic Plaques in Cryptogenic Ischemic Stroke: Correlation to Vascular Risk Factors and Future Events.

Background and Purpose: Limited data is available regarding the prevalence of aortic plaques in cryptogenic ischemic strokes and its correlation with risk factors. Aim: To determine the prevalence of aortic plaques in patients with cryptogenic ischemic stroke and its association with vascular risk factors and future vascular events. Methodology: Patients with cryptogenic ischemic stroke/TIA evaluated with CT angiogram (CTA) were recruited. Aortic plaque thickness ≥4 mm, plaque ulceration, protruding components, and complex plaques were considered significant. Results: Of the 1,767 patients, 229 (12.9%) had cryptogenic ischemic stroke/transient ischemic attack (TIA). Of them, 36 (15.7%) patients were detected to have significant aortic plaques. The significant plaque group had a higher mean age (68.3 ± 8.3 vs 54.4 ± 13.2, P = 0.0005) and were more likely to have risk factors like hypertension (P = 0.025), coronary artery disease (CAD)(P = 0.015), and peripheral vascular disease (POVD) (P = 0.029). Plaque morphology showed plaques of ≥4 mm, ulcerated plaques, protruding components, and complex plaques in 14.8%, 5.6%, 3.1%, and 6.5% patients, respectively, which are predominantly located in the aortic arch (44%). At 1 year combined endpoint of stroke, TIA, and vascular death was significantly higher in the significant plaque group (19.4% vs 6.2%, P = 0.016). Advanced age (adjusted OR-1.11, 95% CI-1.07-1.17, P = <0.001) was identified as an independent risk factor for significant aortic plaques on multivariate analysis. Conclusions: Aortic plaques are an under-recognized cause of cryptogenic stroke. The significant risk factors in aortic plaque group highlight the importance of aggressive risk factor control for secondary stroke prevention.

Cognitive outcome following bilateral subthalamic nucleus deep brain stimulation for Parkinson's disease-a comparative observational study in Indian patients.

BACKGROUND: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves motor symptoms and motor complications of Parkinson's disease (PD). The intervention is expected to result in some cognitive changes, the nature of which is not uniform across the studies which have reported them. PD itself is associated with progressive cognitive decline and hence longitudinal follow-up studies with medically managed control group of patients are needed to explore the cognitive deficits attributable to DBS. METHODS: We conducted a prospective comparative observational study to assess the effects of bilateral STN DBS on cognition. Cognitive functions were assessed at baseline and after a minimum of two years after surgery, and compared with baseline and follow-up assessments in patients on medical management alone. RESULTS: Thirty-four patients with PD who underwent bilateral STN DBS and thirty-four medically managed patients participated in the study. At a mean follow-up of around 33 months, we found a significant decline in verbal fluency scores in the DBS group compared to those on medical management alone (1.15 ± 1.23 vs 0.59 ± 0.93, p = 0.034) and a trend for decline was noted in digit span test. There was no difference in the performance in tests addressing other cognitive domains, or tests of global cognitive function. No patient developed dementia. Motor functions and activities of daily living (ADL) were significantly better in the surgical group. CONCLUSION: STN DBS results in minor deficits in executive functions, particularly verbal fluency. These may be inconsequential, considering the marked improvement in motor functions and ADL.

Women and Stroke: Different, yet Similar.

BACKGROUND: The impact of gender on acute ischemic stroke, in terms of presentation, severity, etiology, and outcome, is increasingly getting recognized. Here, we analyzed the gender-related differences in etiology and outcome of ischemic stroke in South India. METHODS: Patients with first ever ischemic stroke within 1 week of onset presenting to the Comprehensive Stroke Care Centre, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India, were included in our study. Clinical and risk factor profile was documented. The stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) at onset, and stroke subtype classification was done using Trial of Org 10172 in Acute Ischemic Stroke criteria. The 3-month functional outcome was assessed using the modified Rankin Scale (mRS) with excellent outcome defined as an mRS ≤2. RESULTS: Of the 742 patients, 250 (33.7%) were females. The age, clinical profile, and rate of reperfusion therapies did not differ between the genders. Women suffered more severe strokes (mean NIHSS 9.5 vs. 8.4, p = 0.03). While large artery atherosclerosis was more common in men (21.3% vs. 14.8%, p = 0.03), cardioembolic strokes secondary to rheumatic heart disease were more common in women (27.2% vs. 19.7%, p = 0.02). Men had a better 3-month functional outcome compared to women (68.6% vs. 61.2%, p = 0.04), but was not statistically significant after adjusting for confounders. CONCLUSION: Our data, from a single comprehensive stroke unit from South India, suggest that stroke in women are different, yet similar in many ways to men. Guideline-based treatment can result in comparable short-term outcomes, irrespective of admission stroke severity.

Hypodensities within Hematoma is Time-Dependent and Predicts Outcome after Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Non-contrast CT (NCCT) brain imaging biomarkers of hematoma expansion in intracerebral hemorrhage (ICH) has gained relevance in recent times. Though intra-hematoma hypodensities (IHH) can predict hematoma expansion and outcome, it is postulated to be time-dependent. AIM: To assess the differential prevalence of IHH in spontaneous ICH over time and assess its predictive valve in early hematoma expansion and functional outcome at 3 months. MATERIAL AND METHODS: Patients with ICH within 48 h of stroke onset were included. Baseline clinical and demographic data were collected. Baseline NCCT brain was analyzed for hematoma volume, characterization of IHH, with 24-hours follow-up NCCT hematoma volume calculated for identification of hematoma expansion. Poor functional outcome was defined as mRS ≥3. RESULTS: Around 92 subjects were included in the study. IHH was found in 40%. Prevalence of IHH was higher in those with baseline NCCT performed within 3 h of symptom onset compared to those beyond 3 h (71% vs 29%, P = 0.002). The hematoma expansion was more common in patients with IHH compared to those without (54% vs 29%; P = 0.02). Multivariate analysis revealed the presence of IHH (rather than pattern or number) to be strongly associated with poor functional outcome at 3 months (OR 3.86; 95% CI: 1.11-13.42, P = 0.03). CONCLUSION: There is a decreasing prevalence of IHH as the time from symptom onset to NCCT increases. Nevertheless, its presence is significantly associated with hematoma expansion and predicted poor short-term functional outcomes in spontaneous ICH.

Differential Distribution of Cerebral Microbleeds in Subtypes of Acute Ischemic Minor Stroke and TIA as well as its Association with Vascular Risk Factors.

BACKGROUND: Cerebral microbleed (CMB) is a novel neuroimaging marker of cerebral small vessel disease. OBJECTIVE: To determine the prevalence of CMB in the subtypes of acute ischemic minor stroke (AIS) and transient ischemic attack (TIA) and to identify the risk factors associated with location and number of CMB. MATERIALS AND METHODS: Patients with AIS (National Institute of Health Stroke Scale of 5 or less) or TIA were included. CMB was characterized using the Microbleed Anatomical Rating Scale (MARS). RESULTS: Of the 488 subjects [mean age (standard deviation): 57.5 years (14.4 years), males (77.7%)] recruited, CMB was noted in 140 (28.7%). About 35% with CMB had a lacunar stroke etiology, whereas LAA and CE subtype constituted 33.6 and 10.7%, respectively (P = 0.000). Lacunar subtype was more likely to harbor multiple CMB (four or more) and CMB in all locations (lobar, deep or infratentorial). On multivariate analysis, systemic hypertension [P = 0.025; odds ratio (OR) 0.33 (95% confidence interval (CI) 0.129-0.874)], serum triglyceride (TG) levels below 150 mg/dL [P = 0.001; OR 3.70 (95% CI 1.698-8.072)], and presence of white matter hyperintensities on magnetic resonance imaging brain [P = 0.026; OR 2.18 (95% CI 1.096-4.337)] were associated with the presence of CMB. Those with serum TG levels of less than 150 mg/dL were more likely to harbor lobar (P = 0.002) or infratentorial CMB (P = 0.022), whereas those with serum creatinine levels of more than1.5 mg/dL have lobar CMB (P = 0.033). CONCLUSION: Our study showed a differential distribution of CMB in ischemic stroke subtypes and association of risk factors with the presence, number and location of CMB.

Cerebral Amyloid Angiopathy: A Clinico-Radiological Study from South India.

INTRODUCTION: Cerebral amyloid angiopathy (CAA) is a major cause of intracerebral hemorrhage (ICH) and cognitive decline in the elderly. Since it is rarely reported from the developing world, we looked into the clinical profile and neuroimaging associations of CAA. MATERIALS AND METHODS: Ours was a retrospective case series of subjects diagnosed with probable/possible CAA between January 2006 and December 2015 as per Boston criteria. Clinical profile and neuroimaging were reviewed for markers of CAA. Details of any recurrent clinical events and functional status were collected from follow-up records. RESULTS: We had 28 subjects in the series with men outnumbering women, and the mean age was 70.17 ± 8.85 years (55-87 years). At the initial presentation, ICH was most frequent-10/28 (35.7%) patients, followed by transient neurological events (TNE = 25%) and cognitive disturbances (21.4%). Less than half of the patients received a diagnosis of CAA at the initial presentation itself. In total, 68% of our patients had cognitive dysfunction at admission. In our series, 12 had seizures and 9 had a history of TNE. The majority of our patients had vascular risk factors also. Leukoaraiosis showed an association with cognitive dysfunction (P = 0.044). Superficial siderosis and subarachnoid hemorrhage (SAH) showed a positive association with seizures and TNE, respectively. However, ICH showed no association with risk factors or imaging markers of CAA. CONCLUSIONS: CAA patients, with a high prevalence of vascular risk factors mostly presented with ICH. The presence of SAH and superficial siderosis on MRI was associated with presentation as TNE and seizures, respectively.

"Sequential multimodality stimulation" for post-stroke-hemineglect: Feasibility and outcome in a pilot randomized controlled trial.

OBJECTIVE: To test the feasibility and efficacy of multimodality stimulation combined with motor tasking as a corrective strategy for hemineglect following right hemispheric ischemic strokes. MATERIAL AND METHODS: A prospective randomized controlled single blinded clinical trial was conducted over eighteen months from January 2017. All patients with right hemispheric ischemic strokes were screened for hemineglect and those fulfilling criteria were recruited and randomized. Patients under the therapy group (TG) received the intervention based on a structured protocol in addition to standard physiotherapy. The control group (CG) received standard physiotherapy alone. NIHSS, mRS and Neuropsychological test scores were recorded at different time points. The primary outcome measures (neuropsychological test scores) were compared between the two groups (Student's t-test to find out the difference in outcome measures) at one and three months post-stroke. RESULTS: Of the 14 patients recruited, data from 12 were available for analysis, 5 patients in TG and 7 in CG. There was a trend for better hemineglect and functional outcomes in TG. CONCLUSION: Multimodality stimulation, in addition to standard physiotherapy, is feasible and potentially results in better neurocognitive and functional recovery following right hemispheric ischemic strokes. However, larger studies are warranted to prove these preliminary observations beyond doubt.

Early versus late antiepileptic drug withdrawal following temporal lobectomy.

PURPOSE: To compare the seizure outcome following early and late complete antiepileptic drug (AED) withdrawal following anterior temporal lobectomy (ATL) for mesial temporal lobe epilepsy (MTLE). METHOD: All the patients who were seizure free for one year following ATL were offered early or late AED withdrawal. AEDs were discontinued starting at one year in those who opted for early withdrawal. Patients who opted for late withdrawal were continued on single AED for three years following surgery before attempting complete discontinuation. RESULTS: Of the 135 study patients, 65 opted for early AED withdrawal and 70 for late withdrawal. The mean postoperative follow-up duration was 10.4 ± 1.3 (Range, 8-12) years. At three years following surgery, seizure recurrence occurred in 23 (35.4 %) patients in the early withdrawal group and in 10 (14.3 %) patients in late withdrawal group (p = 0.005; relative risk [RR], 2.48; 95 % confidence interval [CI], 1.28-4.80). At last follow-up, 27 (41.5 %) patients in the early withdrawal group and 26 (37.1 %) in late withdrawal group had recurrence (p = 0.60; RR, 1.12, 95 % CI, 0.74-1.70). At last followup, 80 (59.3 %) patients were off AEDs. During the terminal one year, 123 (91 %) patients were seizure free, similar in the two groups. CONCLUSIONS: This nonrandomized controlled study suggests that early complete AED withdrawal starting one year following ATL is associated with a higher risk of early seizure recurrence. However, long term seizure outcome is similar in early and late AED withdrawal groups.

Prospective Evaluation of Factors Affecting the Safety and Efficacy of Perclose Proglide Vascular Closure Device in Neurovascular Interventions.

BACKGROUND: Most of the neurointerventional procedures use various anticoagulants, antiplatelets, and fibrinolytic drugs, and it can predispose arterial access site complications. Safe and efficient closure arteriotomy site has extreme importance in reducing the morbidity. Percutaneous vascular closure devices (VCDs) enable us to close the arteriotomy sites. In this prospective study, we evaluated the factors affecting the safety and efficacy of Perclose ProGlide VCD in neurovascular interventions. MATERIALS AND METHODS: In this prospective study, we have evaluated the safety and efficacy of 327 Perclose ProGlide devices deployed in 217 patients who underwent various neurointerventions in our institute from October 2014 to October 2016. Time to achieve hemostasis (TAH) was calculated for various groups and the statistical significance of mean values between groups was estimated. RESULTS: Out of the 327 Perclose ProGlide deployed, complication rate was 0.91% and the mean TAH was 77.14 s. Assessment of TAH mean value showed statistically significant prolongation of TAH in obesity and those with larger arterial sheaths. Age, sex, post-heparin ACT, peri-procedure medications, and type of diseases had no significant role in increasing TAH. The evaluation also showed the presence of a learning curve in using this device. CONCLUSION: Perclose ProGlide VCD is safe and effective in closing the arteriotomy after neurointerventions. Obesity and larger arterial sheaths are independent factors prolonging the TAH. Learning curve associated with this device mildly increases the hemostatic time and device-related complications.

Content validity of the newly developed risk assessment tool for religious mass gathering events in an Indian setting (Mass Gathering Risk Assessment Tool-MGRAT).

BACKGROUND: Risk assessment (RA) for mass gathering events is crucial to identify potential health hazards. It aids in planning and response activities specific to the event but is often overlooked by the event organizers. This paper reports the content validity process of a newly developed tool called Mass Gathering Risk Assessment Tool (MGRAT), which intends to assess the risks associated with religious mass gathering events in Indian settings. METHODS: Qualitative approach was followed to identify the risks associated with mass gathering events and to identify the domains and items to be included in the RA tool. The draft tool was shared with six experts who were selected by the convenient method; selected experts were requested to assess the tool and give their comments about the domains, items, relevant responses, and overall presentation of the tool using content validity questionnaire. Content validity index and Fleiss kappa statistics were calculated to assess the agreement between multiple raters. RESULTS: Agreement proportion expressed as scale-level content validity index (S-CVI) calculated by the averaging method is 0.92. S-CVI; calculated by universal agreement is 0.78. Fleiss kappa statistics to measure the agreement between multiple experts after adjusting the component of the chance agreement is 0.522 (95% CI: 0.417, 0.628, P value: 0.001). CONCLUSION: MGRAT is a valid tool, which has an appropriate level of content validity. As the number of raters increases, there will be difficulty in achieving consensus among all the items, which is the reason for lower Content Validity Index/Universal Average (CVI/UA) when compared with Content Validity Index/Average (CVI/Ave). Fleiss kappa statistics also indicated moderate agreement among the raters beyond the chance agreement, which also supports the appropriate content validity of MGRAT.

Protocol for development of a risk assessment tool for planning and management of religious mass-gathering events of India-a health system-strengthening initiative.

BACKGROUND: Religious mass gatherings (MGs) have always been an integral part of our society. At the outset, mass-gathering events provide challenging settings to plan a suitable emergency public health response. Published studies basically talk about retrospective reviews, case studies of the public health preparedness, or health care provided at individual events. Developing an understanding of the variables associated with MGs is the first step for public health managers. Risk assessment (RA) is a crucial part of pre-event planning as it helps foresee potential risks. Based on RA, one can develop preventive measures and ensure that the infrastructure to control the potential problems is in place. This study is an attempt to systemize RA process during MG events in a country that is culturally rich but with poor resources to handle such events. A RA tool will be developed for planning and management of religious MG events of India. METHODS/DESIGN: Various strategies will be used to develop the risk assessment tool (RA tool). Extensive review of literature clubbed with key informant interviews will be done in order to identify the risk variables and decide the domains and items of the tool. Further, this tool will be developed as a mobile-based application. The feasibility of the mobile-based RA tool will be tested in real-time MG event in one part of the country. Concurrently in the same event, a community survey of residents and visitors will be done in order to assess public perceptions of public health and environmental risks associated with MG events. DISCUSSION: The findings of this study will provide insights into the public health and environmental concerns that need to be considered if preventive strategies and intervention programs are to be designed for MG events. A "RA Tool," which can be used in the planning and management of MG events by the public health managers will strengthen the existing health systems preparedness plans for MGs.

Dopamine Receptor D3 rs6280 is Associated with Aberrant Decision-Making in Parkinson's Disease.

BACKGROUND: The functional Ser9Gly single nucleotide polymorphism (SNP) in the dopamine D3 receptor gene is associated with impulse control disorders (ICD) in Parkinson's disease (PD) in Indian patients. Whether the same SNP modulates impulsivity in PD patients without active ICD is unknown. We aimed to compare decision-making under uncertainty in PD patients with DRD3 p.S9G (rs6280) variants CT/CC or TT. METHODS: We conducted a cross-sectional study including PD patients (n = 78) whose DRD3 p.S9G (rs6280) genotypic status was known (CC, CT, and TT). Decision-making was assessed using the Iowa Gambling Task (IGT). RESULTS: IGT total (p = 0.267) or block scores did not differ between the DRD3 rs6280 variant groups. Deck choice analysis revealed that the CT/CC group showed a skewed preference in deck choice (p = 0.002) due to significantly fewer draws from deck B, compared to all other decks (deck A, p < 0.001; deck C, p = 0.004; deck D, p = 0.002). CONCLUSIONS: The functional Ser9Gly DRD3 variant is associated with aberrant decision-making under uncertainty in PD patients without active ICD. This ability to modulate impulsivity may underlie its association with clinical ICD in PD.

Do auras predict seizure outcome after temporal lobe epilepsy surgery?

PURPOSE: The success of epilepsy surgery lies in identifying the ictal onset zone accurately. The significance of auras has little been explored on surgical outcome in drug-resistant epilepsy. This study focuses on the clinicopathological correlation of aura(s) and its role in predicting surgical outcome in drug-resistant temporal lobe epilepsy (TLE). We compared surgical outcome in TLE between patients with and without aura and identified the clinico-pathological, radiological and surgical differences between the two groups. METHODS: Consecutive patients who underwent presurgical evaluation from January 2009 to December 2014 for drug-resistant TLE who underwent anterior temporal lobectomy (ATL) were included. Patients were followed up at 3months, 12 months and then annually. RESULTS: Among 456 patients, 344(75%) had aura. Multivariate logistic regression showed that prototype EEG pattern at ictal onset (OR 2.12, 95% CI 1.18-3.06, p = 0.012) and right sided epileptogenic zone (OR 1.82 95% CI 1.18-3.78, p = 0.007) were significantly associated with presence of aura. There was no difference in surgical outcome between those with and without aura. But patients with auditory aura (OR 7.28, CI 2.80-18.95, p = 0.0002) and vertiginous aura (OR 3.01, CI 1.55-7.85, p = 0.028) had a poor surgical outcome. Bivariate analysis showed that normal MRI (p = 0.028) and normal/indeterminate pathology (p = 0.001) were significantly more common with auditory/vertiginous auras. CONCLUSIONS: Mere presence of aura does not affect outcome after TLE surgery. However, auditory and vertiginous auras are predictors of poor surgical outcome. These patients require more extensive screening for an ictal onset zone beyond standard limits of ATL before surgery.

Multimodality Neuroimaging in Mild Cognitive Impairment: A Cross-sectional Comparison Study.

BACKGROUND AND PURPOSE: Mild cognitive impairment (MCI) is a focus of considerable research. The present study aimed to test the utility of a logistic regression-derived classifier, combining specific quantitative multimodal magnetic resonance imaging (MRI) data for the early objective phenotyping of MCI in the clinic, over structural MRI data. METHODS: Thirty-three participants with cognitively stable amnestic MCI; 15 MCI converters to early Alzheimer's disease (AD; diseased controls) and 20 healthy controls underwent high-resolution T1-weighted volumetric MRI, diffusion tensor imaging (DTI), and proton magnetic resonance spectroscopy (1H MR spectroscopy). The regional volumes were obtained from T1-weighted MRI. The fractional anisotropy and mean diffusivity maps were derived from DTI over multiple white matter regions. The 1H MRS voxels were placed over posterior cingulate gyri, and N-acetyl aspartate (NAA)/creatine (Cr), choline (Cho)/Cr, myoinositol (mI/Cr), and NAA/mI ratios were obtained. A multimodal classifier comprising MR volumetry, DTI, and MRS was prepared. A cutoff point was arrived based on receiver operator characteristics analysis. Results were considered significant, if P < 0.05. RESULTS: The most sensitive individual marker to discriminate MCI from controls was DTI (90.9%), with a specificity of 50%. For classifying MCI from AD, the best individual modality was DTI (72.7%), with a high specificity of 87.9%. The multimodal classifier approach for MCI control classification achieved an area under curve (AUC) (AUC = 0.89; P < 0.001), with 93.9% sensitivity and 70% specificity. The combined classifier for MCI-AD achieved a highest AUC (AUC = 0.93; P < 0.001), with 93% sensitivity and 85.6% specificity. CONCLUSIONS: The combined method of gray matter atrophy, white matter tract changes, and metabolite variation achieved a better performance at classifying MCI compared to the application of individual MRI biomarkers.

Predictors of seizure outcome following resective surgery for drug-resistant epilepsy associated with focal gliosis.

OBJECTIVEThe authors studied the clinical characteristics and postoperative outcomes of drug-resistant epilepsy associated with focal gliosis.METHODSFrom their epilepsy surgery database, the authors selected the patients with drug-resistant epilepsy and MRI-defined focal gliosis who underwent focal resective surgery. All patients underwent standard presurgical evaluation. Intracranial electroencephalography (EEG) was performed in patients with discordant presurgical data, ill-defined lesions, and lesions close to eloquent regions. Completeness of resection was defined on the basis of extraoperative and intraoperative electrocorticography studies. Favorable postoperative outcome was defined as Engel class I outcome during the last 2 years of follow-up.RESULTSSixty-six patients fulfilled inclusion criteria. An initial precipitating injury was present in 38 (57.6%) patients, mainly in the form of perinatal injury (n = 10), trauma (n = 10), and meningoencephalitis (n = 8). Gliosis involved a single lobe in 38 (57.6%) patients and 2 adjacent lobes in 14 (21.2%) patients; the remaining 14 (21.2%) patients had multilobar gliosis. In patients with unilobar or bilobar gliosis, the posterior region of the head was involved in 34 (65%) patients and the frontal lobes in 12 (23%) patients. During a median follow-up of 4 years (range 2-9 years), 41 (62.1%) patients had favorable outcome. On multivariate analysis, the presence of a well-defined aura (p = 0.019), electrocorticographically defined completeness of resection (p = 0.024), and normal postoperative EEG findings at 1 year (p = 0.003) were predictive of favorable postoperative seizure outcome.CONCLUSIONSFocal gliosis is a common etiology for drug-resistant extratemporal epilepsy in developing countries and is most often located in the posterior region of the head. The majority of these patients have perinatal injuries or neurological infections as initial precipitating injuries. Patients with focal gliosis have good postoperative seizure outcomes after well-planned resective surgery.

Optimal timing and differential significance of postoperative awake and sleep EEG to predict seizure outcome after temporal lobectomy.

OBJECTIVE: To evaluate the prognostic value of postoperative EEGs to estimate post anterior temporal lobectomy (ATL) seizure outcome. METHODS: We studied postoperative EEGs in 325 consecutive patients who had minimum five years of post-ATL followup. Interictal epileptiform discharges (IEDs) present only during sleep were classified as sleep IEDs. We defined favorable final-year outcome as no seizures during the final one year and favorable absolute-postoperative outcome as no seizures during the entire postoperative period. RESULTS: At mean follow-up of 7.3 ±â€¯1.8 years, 281 (86.5%) patients had favorable final-year outcome while 161 (49.5%) had favorable absolute-postoperative outcome. IEDs on three months and one year EEG were associated with unfavorable outcomes while IEDs at 7th day had no association with outcomes. Sleep record increased the yield of IEDs by 30% at each time-point without compromising predictive value. EEG at one year predicted the risk of seizure recurrence on drug withdrawal. CONCLUSION: While EEG at three months and at one-year after ATL predicted seizure outcome, EEG at 7th day was not helpful. Sleep record increases the sensitivity of postoperative EEG without compromising specificity. SIGNIFICANCE: Both awake and sleep EEG provide useful information in postoperative period following ATL.