Progressive lacunar strokes behave differently from stable ones even at one year-An observational study.

BACKGROUND AND AIMS: Small fraction of lacunar stroke patients have an early fluctuating course, described as progressive lacunar syndrome [PLS].We studied the predictors and short term outcome of progressive lacunar strokes in comparison with those with an early stable course. MATERIALS AND METHODS: Single centre retrospective study where patients with lacunar strokes from 2016 to 2020 were included in the study. Progression was defined as increase in stroke severity [NIHSS] by ≥2 points from baseline without imaging evidence of new infarcts or haemorrhagic transformation. We compared the clinical variables, risk factors, imaging, treatment received and 1 year outcome of subjects with PLS with those with a stable course, with modified Rankin score 0-2 taken as good outcome. RESULTS: Of the 216 patients with a mean age 63.17 years, progressive course was noted in 56 subjects [26 %].Majority of the fluctuations occurred within 24 h of onset of symptoms. Though stroke severity at admission was comparable between the 2 groups, discharge and 1 year outcome was poorer in those with an early progressive course. We found that presentation as pure motor syndrome, hypertriglyceridemia and thrombolytic therapy were predictors of poor outcome in progressive lacunar strokes, while age, risk factors, infarct location or leukoaraiosis failed to show an association. Thalamic infarcts and atypical lacunar syndromes were associated with a stable course. CONCLUSION: Progressive course is seen in a quarter of lacunar strokes and they have poorer outcome at 1 year. Our finding of thrombolysis being associated with worse outcome in PLS patients, should alert physicians regarding need for more definitive therapies for this condition.

Autism Spectrum Disorders: Barriers to Implementing Parent-Based Home Programs.

An exploratory survey to identify the barriers experienced by caregivers of children with autism spectrum disorders (ASD) when implementing home programs (HP) was conducted with a newly developed questionnaire, 'barriers in the parent-based home program for ASD (BHPQ-ASD)' in English and Malayalam. The questionnaire has 25 items in Likert scale response format and underwent face validation and cognitive debriefing. It was administered to 50 caregivers of ASD children for factor extraction and reliability analysis. Seven questions under service provider-related barriers emerged to have good psychometric properties in the principal axis factoring method and were grouped to form the 'service provider-related BHPQ-ASD' scale, which has very good internal consistency (Cronbach alpha 0.903). In regression analysis, parents of children not receiving occupational therapy (OT) reported 6.6 times more barriers when compared to those undergoing OT (OR 6.6, CI 1.5-29.7, p = 0.014). BHPQ-ASD is a useful valid tool for detecting the barriers to implementing HPs.

Predictors of outcome after surgery in 134 children with drug-resistant TLE.

PURPOSE: To determine the factors predicting seizure outcome in children who underwent anterior temporal lobectomy (ATL) for drug-resistant temporal lobe epilepsy (TLE). METHODS: Among the 664 patients who underwent ATL for TLE from 1995 to 2008, there were 134 children. "Excellent" outcome in them was defined as seizure freedom during the entire follow-up (Engel class I a); "good outcome", if in remission last 2 years, and the rest as "unfavorable outcome". To identify the potential predictors of seizure recurrence, the attributes of recurred and non-recurred groups was compared by univariate and multivariate analysis. RESULTS: Of the 134 children, at a mean post-operative follow-up of 8.1 years, there were 82 (61.1%) with excellent outcome and 26 (19.4%) with good outcome (category-1; seizure-free, 80.6%). Drugs could be successfully withdrawn in 69 (63.9%). 26 patients (22.4%) had seizure recurrence, (category-2, treatment/surgical failure).Whereas, of the 530 adults who underwent ATL during this time period, only 46.8% never had seizures (category-1) and 53.2% had seizure recurrence in the form of acute post-operative seizures or auras or habitual or non-habitual seizures (category-2).The hazard of seizure recurrence in children increased with positive family history of seizures and /or epilepsy, normal neuroimaging, spikes in post-operative EEG at 3-months, normal histopathology and duration of epilepsy ≥5 years. CONCLUSIONS: The information on the predictive factors causing seizure recurrence/freedom in children with drug-resistant TLE is important in surgical selection. Surgery for pediatric TLE results in favorable outcome, hence one should subject children for resective surgery at the earliest especially in lesions known to cause refractoriness.

Do sphenoidal electrodes aid in surgical decision making in drug resistant temporal lobe epilepsy?

OBJECTIVE: The utility of sphenoidal electrodes (SPh) in analyzing interictal epileptiform discharges (IEDs) and ictal electrography remains controversial, despite its widespread use. METHODS: One hundred and twenty-two consecutive patients with presumed temporal lobe epilepsy (TLE) who underwent presurgical evaluation were prospectively studied. SPh and Silverman's electrodes were placed, in addition to routine electrodes in 10-20 international system. IEDs and ictal electroencephalography (EEG) were analyzed separately in bipolar and referential montages. The proportion of patients selected for surgery after adjusting for SPh placement based on the earlier ictal onset and IEDs were analyzed. RESULTS: Of the 8701 IEDs in SPh, only 65% were seen over the scalp bipolar montage; 1392 (16%) IEDs were confined to SPh electrodes, and were not seen at scalp bipolar montage (p<0.001). Spike amplitudes were highest at SPh (p<0.001). Of the 592 seizures analyzed, 62 (61%) had simultaneous SPh and scalp onset, while in 26 (25%) SPh onset preceded the scalp. CONCLUSIONS: Out of the 35 patients with unilateral mesial temporal sclerosis (MTS) with additional neocortical changes and/or non-lateralized bitemporal IEDs and/or diffuse ictal onset (group 1), 27 were selected for surgery (77%). About 7% was selected for surgery in this group by SPh placement. Also, in patients with bilateral MTS (group 2), 25% (5/20) were chosen for anterior temporal lobectomy, SPh provided an additional benefit in 11% (p<0.001). Patients with normal magnetic resonance imaging (group 3) and temporal plus epilepsy (group 4) had a lower surgical yield, only 12% and 9.5% could undergo surgery. They were denied surgical candidacy with SPh (p<0.001). SIGNIFICANCE: One-third of patients after SPh placement were selected for resective surgery obviating the need for invasive monitoring. The maximum yield was noted in unilateral MTS (associated with additional neocortical features or non-lateralized bilateral temporal interictal IEDs or diffuse ictal onset in scalp EEG) and in bilateral MTS. Those with normal MRI/temporal plus epilepsy could be excluded from direct resective surgery.