Stroke incidence, mortality, subtypes in rural and urban populations in five geographic areas of India (2018-2019): results from the National Stroke Registry Programme.

Background: Increasing stroke burden in India demands a long-term stroke surveillance framework. Earlier studies in India were urban-based, short term and provided limited data on stroke incidence and its outcomes. This gap is addressed by the establishment of five population-based stroke registries (PBSRs) of the National Stroke Registry Programme, India. This paper describes stroke incidence, mortality and age, sex, and subtypes distribution in the five PBSRs with urban and rural populations. Methods: First-ever incident stroke patients in age group ≥18 years, resident for at least one year in the defined geographic area, identified from health facilities were registered. Death records with stroke as the cause of death from the Civil Registration System (CRS) were included. Transient ischemic attack (TIA) was excluded. Three PBSRs (Cuttack, Tirunelveli, Cachar) included urban and rural populations. PBSRs in Kota and Varanasi were urban areas. The crude and age-standardized incidence rate (ASR) by age, sex, and residence (urban and rural), rate ratios of ASR, case fatality proportions and rates at day 28 after onset of stroke were calculated for years 2018-2019. Findings: A total of 13,820 registered first-ever stroke cases that included 985 death certificate-only cases (DCOs) were analysed. The pooled crude incidence rate was 138.1 per 100,000 population with an age-standardized incidence rate (ASR) of 103.4 (both sexes), 125.7 (males) and 80.8 (females). The risk of stroke among rural residents was one in seven (Cuttack), one in nine (Tirunelveli), and one in 15 (Cachar). Ischemic stroke was the most common type in all PBSRs. Age-standardized case fatality rates (ASCFR) per 100,000 population for pooled PBSRs was 30.0 (males) and 18.8 (females), and the rate ratio (M/F) ranged from 1.2 (Cuttack) to 2.0 (Cachar). Interpretation: Population-based registries have provided a comprehensive stroke surveillance platform to measure stroke burden and outcomes by age, sex, residence and subtype across India. The rural-urban pattern of stroke incidence and mortality shall guide health policy and programme planning to strengthen stroke prevention and treatment measures in India. Funding: The National Stroke Registry Programme is funded through the intramural funding of the Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, India.

IMPETUS Stroke: Assessment of hospital infrastructure and workflow for implementation of uniform stroke care pathway in India.

BACKGROUND: India accounts for 13.3% of global disability-adjusted life years (DALYs) lost due to stroke with a relatively younger age of onset compared to the Western population. In India's public healthcare system, many stroke patients seek care at tertiary-level government-funded medical colleges where an optimal level of stroke care is expected. However, there are no studies from India that have assessed the quality of stroke care, including infrastructure, imaging facilities, or the availability of stroke care units in medical colleges. AIM: This study aimed to understand the existing protocols and management of acute stroke care across 22 medical colleges in India, as part of the baseline assessment of the ongoing IMPETUS stroke study. METHODS: A semi-structured quantitative pre-tested questionnaire, developed based on review of literature and expert discussion, was mailed to 22 participating sites of the IMPETUS stroke study. The questionnaire assessed comprehensively all components of stroke care, including human resources, emergency system, in-hospital care, and secondary prevention. A descriptive analysis of their status was undertaken. RESULTS: In the emergency services, limited stroke helpline numbers, 3/22 (14%); prenotification system, 5/22 (23%); and stroke-trained physicians were available, 6/22 (27%). One-third of hospitals did not have on-call neurologists. Although non-contrast computed tomography (NCCT) was always available, 39% of hospitals were not doing computed tomography (CT) angiography and 13/22 (59%) were not doing magnetic resonance imaging (MRI) after routine working hours. Intravenous thrombolysis was being done in 20/22 (91%) hospitals, but 36% of hospitals did not provide it free of cost. Endovascular therapy was available only in 6/22 (27%) hospitals. The study highlighted the scarcity of multidisciplinary stroke teams, 8/22 (36%), and stroke units, 7/22 (32%). Lifesaving surgeries like hematoma evacuation, 11/22 (50%), and decompressive craniectomy, 9/22 (41%), were performed in limited numbers. The availability of occupational therapists, speech therapists, and cognitive rehabilitation was minimal. CONCLUSION: This study highlighted the current status of acute stroke management in publicly funded tertiary care hospitals. Lack of prenotification, limited number of stroke-trained physicians and neurosurgeons, relatively lesser provision of free thrombolytic agents, limited stroke units, and lack of rehabilitation services are areas needing urgent attention by policymakers and creation of sustainable education models for uniform stroke care by medical professionals across the country.

Advances in AI-Driven Retention Prediction for Different Chromatographic Techniques: Unraveling the Complexity.

Retention prediction through Artificial intelligence (AI)-based techniques has gained exponential growth due to their abilities to process complex sets of data and ease the crucial task of identification and separation of compounds in most employed chromatographic techniques. Numerous approaches were reported for retention prediction in different chromatographic techniques, and consistent results demonstrated that the accuracy and effectiveness of deep learning models outclassed the linear machine learning models, mainly in liquid and gas chromatography, as ML algorithms use fewer complex data to train and predict information. Support Vector machine-based neural networks were found to be most utilized for the prediction of retention factors of different compounds in thin-layer chromatography. Cheminformatics, chemometrics, and hybrid approaches were also employed for the modeling and were more reliable in retention prediction over conventional models. Quantitative Structure Retention Relationship (QSRR) was also a potential method for predicting retention in different chromatographic techniques and determining the separation method for analytes. These techniques demonstrated the aids of incorporating QSRR with AI-driven techniques acquiring more precise retention predictions. This review aims at recent exploration of different AI-driven approaches employed for retention prediction in different chromatographic techniques, and due to the lack of summarized literature, it also aims at providing a comprehensive literature that will be highly useful for the society of scientists exploring the field of AI in analytical chemistry.

Current trends in chromatographic prediction using artificial intelligence and machine learning.

Artificial intelligence (AI) and machine learning (ML) gained tremendous growth and are rapidly becoming popular in various fields of prediction due to their potential abilities, accuracy, and speed. Machine learning algorithms employ historical data to analyze or predict information using patterns or trends. AI and ML were most employed in chromatographic predictions and particularly attractive options for liquid chromatography method development, as they can help achieve desired results faster, more accurately, and more efficiently. This review aims at exploring various AI and ML models employed in the determination of chromatographic characteristics. This review also aims to provide deep insight into reported artificial neural network (ANN) associated techniques which maintained better accuracy and significant possibilities for chromatographic characteristics prediction in liquid chromatography over classical linear models and also emphasizes the integration of a fuzzy system with an ANN, as this integrated study provides more efficient and accurate methods in chromatographic prediction than other linear models. This study also focuses on the retention prediction of a target molecule employing QSRR methodology combined with an ANN, highlighting a more effective technique than the QSRR alone. This approach showed the benefits of combining AI or ML algorithms with the QSRR to obtain more accurate retention predictions, emphasizing the potential of artificial intelligence and machine learning for overcoming adversities in analytical chemistry.

Propensity of Stroke in Standard versus Various Aortic Arch Variants: A 200 Patients Study.

Background: Abnormal origin of arteries from the aortic arch could alter the hemodynamics. Therefore, aortic arch variations might predispose patients to atherosclerosis, which would increase the stroke risk by impending thrombus formation. Objectives: To investigate the prevalence of various types of the anatomy of the aortic arch in ischemic stroke patients and determine if aortic morphology has any effect on early-onset strokes. Materials and Methods: Observational study including 200 imaging-confirmed (Non Contrast Computed Tomography(NCCT)/magnetic resonance imaging [MRI] of the brain) acute ischemic stroke patients. This was followed by computed tomography [CT]/MRI angiography of the arch of the aorta, neck vessels, and intracranial arteries. The occurrence of various types of standard and other aortic arch variants was studied. The prevalence of stroke and its characteristics were analyzed for demographics, types, location, and the predominant side of involvement among standard arch variants and standard versus various aortic arch variants. A P value < 0.05 was considered significant. Results: Standard arch Type I was the most common (P < 0.0001). Age at stroke onset in Type 1 was 61.83 years ± 2.78 years, in Type 2 was 59.8 years ± 3.55 years, and in Type 3 was 60.96 years ± 3.56 years (P = 0.0012). Among the bovine aortic arch, age at stroke presentation in Type A was 53.33 years ± 8.35 years, in Type B was 53.36 years ± 7.4 years, and in Type C was 63.25 years ± 9.25 years (P < 0.0001). Conclusions: Standard aortic arch Type 2, bovine aortic arch Type A, and Type B are associated with an early age at stroke presentation. During routine carotid evaluation by CT or MR angiography in stroke patients, it would be better to evaluate the aortic arch as well, especially in young patients.

Assessment of Therapeutic Response of Edaravone and Riluzole Combination Therapy in Amyotrophic Lateral Sclerosis Patients.

Background: Amyotrophic lateral sclerosis (ALS) is a progressive disease characterized by chronic degeneration of upper and lower motor neurons and finally death within 3-5 years usually because of respiratory failure. Riluzole and edaravone are presently available treatments. It may be better to try combination therapy rather than taking individual medications. Objectives: To compare the effectiveness of (edaravone + riluzole) combination therapy versus riluzole therapy alone in slowing down the progression of ALS and to evaluate the role of serum creatinine as a marker of disease progression. Materials and Methods: Observational, randomized, parallel assignment, open label study. Thirty patients with definite and probable ALS were randomly assigned to two treatment groups. The case group received (riluzole + edaravone) for the initial 6 months, followed by riluzole for the next 6 months. The control group received riluzole for 12 months. After 6 and 12 months, changes in ALS functional rating scale (ALSFRS-R), mRS, and Japanese ALS scores were determined. P value <.05 was considered significant. Results: An increase in mRS at 6 months in the case group versus control group was 0.07 versus 0.20, respectively (p =0.02). At 12 months, it was 0.47 versus 0.53, respectively (p =0.17). A decrease in serum creatinine at 6 months in case group versus control group was 0.08 versus 0.09, respectively (p =.82). There was no change in ALS FRS for bulbar symptoms (salivation), 3.46 versus 3.46 in the case group (p =.018) for the first 6 months. Conclusions: Combined with riluzole, edaravone slows disease progression and is safe, but the effect is short-term. Bulbar symptoms respond better to combination therapy. The serum creatinine is helpful in monitoring disease progression.

Stroke and the Bovine Aortic Arch: Incidental or Deliberate? A Comparative Study and our Experience.

Aim and Objectives: We aimed to find the prevalence of bovine aortic arch in stroke and non-stroke patients and to study the relationship between bovine aortic arch and the occurrence of stroke. Materials and Methods: One hundred patients with and without stroke underwent computed tomography (CT) angiography of the thoracic aorta and its arch. Fifty diffusion-weighted magnetic resonance imaging (MRI)-confirmed anterior circulation stroke patients who had undergone digital subtraction angiography (DSA) afterward formed the case group. As controls, another 50 patients who had thoracic CT angiograms for disease other than stroke during this time period were randomly selected. Demographics and prevalence of bovine arch were compared between cases and controls. In the case group, demographics and prevalence of bovine arch variants and their relationship to stroke were studied. Results: Prevalence of bovine aortic arch variant in anterior circulation stroke was 22%, compared to 6% in non-stroke patients (P = 0.043). The bovine aortic arch was associated with the younger onset of stroke occurrence (P = 0.046). In the bovine arch group, the proportion of left-sided strokes (P = 0.022) and bilateral strokes (P < 0.00001) was significantly higher. As compared to type A (P = 0.140), type B bovine aortic arch had a better association (P = 0.092). Conclusions: Bovine aortic arch is a risk factor for young-onset anterior circulation stroke. Bilateral and left-sided infarcts were more common. Endovascular procedures are difficult to perform through conventional routes, so brachioradial access is preferred.

Role of Surgical Procedures (VP Shunt and ETV) in Tuberculous Meningitis with Hydrocephalus (TBMH): A Systematic Review.

OBJECTIVE: Hydrocephalus is one of the most common complications of tuberculous meningitis. Various cerebrospinal fluid diversion procedures, endoscopic third ventriculostomy (ETV) and shunt surgery, are performed for the management of the hydrocephalus associated with tuberculous bacterial meningitis (TBM). There is decreased clarity on the type of procedure to be done. So, this study aims at generating knowledge to understand the conditions in which either of the two procedures, ETV and shunt surgery, is a better option and to develop good practice guidelines for the treatment of tubercular meningitis hydrocephalus (TBMH). MATERIALS AND METHODS: A systematic search of literature was performed by using PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) for articles published from January 2001 to April 2020. A total of 15 studies were included irrespective of their design and having diagnosis with TBMH treated with ventriculoperitoneal shunt surgery (VPS) or ETV. Then, a systemic review was done regarding outcomes, complications, and recommendations made in different studies. RESULTS: The total number of patients diagnosed with TBMH was 603; among them, 348 patients had VPS and 255 patients had ETV. In the VPS group, the patient's good outcome varied from 25% to 68% and complication rate ranged from 10% to 43.8%. The average percentage of good outcome in the VPS group was 51.8%. In the ETV group, the patient's good outcome varied from 41% to 77% and complication rate ranged from 10% to 23.5%. The average percentage of good outcome in the ETV group was 68%. There was a significant difference in the average percentage of good outcome in the ETV versus the VPS shunt group (P-value was 0.008). CONCLUSION: There was a significant difference in the average percentage of good outcome after ETV than VPS, and complication rate was also slightly lower after ETV than VPS during the chronic phase of illness. So during the acute phase of illness VPS placement is preferred whereas in the chronic burnout phase ETV is preferred because poor anatomy leads to more complications with ETV during the acute phase of the disease.

Etiological Spectrum of Non-compressive Myelopathies in Tertiary Care Centre.

AIMS: To study the clinical, radiological, cerebrospinal fluid profile of noncompressive myelopathy and to study various etiologies of non-compressive myelopathies in causation of quadriplegia and paraplegia. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Neurology, Govt. Medical College, Kota in year 2015 and 2016. METHODOLOGY: All the patients presented with myelopathy and MRI spine not showing any significant compression included in study. To know the etiology of non-compressive myelopathy patients were investigated including routine blood tests, cerebrospinal fluid analysis and visual evoked potentials, MRI of the brain, and immunological, infectious, and metabolic profile based on the pattern of involvement. RESULTS: The study had 80 patients with a median age of 38 years and male: female ratio 1.5:1. Patients were divided into acute myelopathy and chronic myelopathy. Forty four patients presented with acute myelopathy whereas 36 patients had chronic myelopathy. The causes of Acute myelopathy were post infectious myelitis (13), neuromyelitis optica spectrum disorder (NMOSD) (6), multiple sclerosis (MS) (2), connective tissue disorders (1), acute disseminated encephalomyelitis (4) and Idiopathic (18). The causes of Chronic myelopathy were Vitamin B12 deficiency (8), MS (2), mixed connective tissue disease (1), Copper deficiency (1), hepatic myelopathy (1), radiation (1), hereditary spastic paraparesis (1) and idiopathic (21). CONCLUSION: Underlying etiology like demyelinating, infectious/post infectious, autoimmune or nutritional was found in 52% patients of non-compressive myelopathy.

Clinical Profile of Patients with Acute Intracerebral Hemorrhage and ICH Score as an Outcome Predictor on Discharge, 30 Days and 60 Days Follow-up.

BACKGROUND: Intracerebral Hemorrhage (ICH) is one of the most common causes of morbidity and mortality worldwide accounting for 10-15 % of all strokes types. ICH score is a validated tool to predict mortality and morbidity at 30 day follow up period. OBJECTIVE: : To prospectively evaluate the predictive utility of ICH score in patients presenting with Acute ICH on discharge,30 days and 60 days follow-up period. DESIGN: Prospective observational study. MATERIALS AND METHOD: This study was conducted in the Department of Neurology, Government Medical College, Kota, Rajasthan, India from January 2016 to August 2016. 120 consecutive patients presenting with acute ICH were studied. Data collected included demographics, clinical parameters, cranial Computed Tomography(CT) findings and ICH score on presentation. Primary outcome was defined as mortality/morbidity during hospitalisation, on discharge, 30 days and 60 days follow-up. Modified Rankin score (mRS) was used to assess the outcome. STATISTICAL ANALYSIS USED: SPSS 19 statistical software. RESULTS: Of the total 120 patients with Acute ICH(108 supratentorial and 12 infratentorial) studied, 48(40%) patients died during hospitalisation. Mean age was 66.9 ± 13.5 Years. Hydrocephalus, midline shift and IV extension on presenting CT scan was observed in 20 (16.6%), 44 (36.6%) and 48 (40%)patients respectively. The independent predictors of increased mortality with statistical significance (p<0.001) were presence of vomiting, seizures, loss of consciousness, lower GCS (≤ 8), higher ICH score and ventilator requirement. Statistically significant (p≤0.001) radiological features associated with mortality included infratentorial location, presence of hydrocephalus,higher midline shift (58.3% vs 22.2% OR=2.6), intraventricular extension of hematoma and a higher baseline hematoma volume. ICH score on admission was significantly (p<0.001) positively correlated with the mRS score on discharge (R=0.667), 1 month (R=0.66) and 2 months (R=0.765) follow-up. CONCLUSION: ICH Score is a useful tool to predict outcome during hospitalisation, on discharge, 1 month and 2 month follow-up. We suggest that ICH score assessment and documentation should become standard procedure in acute care and follow up of patients with Intracerebral Hemorrhage.

Immune-mediated neurological manifestations of dengue virus- a study of clinico-investigational variability, predictors of neuraxial involvement, and outcome with the role of immunomodulation.

INTRODUCTION: Our aim was to study dengue-related immune-mediated neurological complications (IMNC) during the recent epidemic. MATERIALS AND METHODS: This was a cross-sectional observational study of 79 IMNC cases from 1627 laboratory confirmed dengue cases from January 2015 to January 2016 and their follow-up for 3 months. According to the World Health Organization, cases were categorized into those having dengue fever (DF), and those having a severe syndrome that includes dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Laboratory as well as clinicoradiological data, the predictors of outcome, and the role of immunomodulation in determining the final result were analyzed. RESULTS: Out of the 1627 confirmed dengue cases, 14.6% developed neurological complications and only 4.86% cases had IMNC. Among the IMNC seen, the majority of the patients had the onset of their manifestations in the subacute (7-30 days) latency period; however, there was no mortality seen. We found Miller Fisher syndrome (MFS), limbic encephalitis, and immune-mediated cerebellar demyelination (IMCD) as the new findings in the IMNC spectrum. Patients with DF were more prone to developing brachial plexus neuritis and polyneuritis cranialis, whereas those patients with a severe syndrome were more commonly associated with Guillain-Barre syndrome (GBS). Significant (P < 0.001) predictors of central nervous system involvement were anemia, an elevated hematocrit, and the presence of DSS, whereas patients with a higher mean body temperature, DF, and elevated hematocrit were more prone to developing peripheral nervous system manifestations. The platelets counts and the hemoglobin levels had a negative correlation whereas the hematocrit value, the mean body temperature, and the alanine aminotransferase levels had a moderately significant positive correlation for the development of IMNC. The immunomodulatory therapy (IMT), if initiated after fever abatement led to a significant clinically favorable outcome at 3 months, especially in patients with GBS, polyneuritis cranialis, and brachial plexus neuritis. CONCLUSION: The spectrum of IMNC is vast and may include MFS, limbic encephalitis and IMCD. Early initiation of IMT, in the presence of significant predictors, may reduce the IMNC-related morbidity.

Characteristics of nerve conduction studies in carpal tunnel syndrome.

BACKGROUND: Numerous nerve conduction tests are used for the electrodiagnosis of carpal tunnel syndrome (CTS), with a wide range of sensitivity and specificity reported for each test in clinical studies. AIMS: The purpose of this study was to compare the diagnostic accuracy of various nerve conduction tests and determine the properties of the most accurate test. SETTINGS AND DESIGN: A prospective observational case control study. PATIENTS AND METHODS: Eighty patients with clinically confirmed CTS and 80 asymptomatic healthy controls were included in the study. All patients underwent the routine hematological investigations as per the protocol. All cases and controls were subjected to various nerve conduction study protocols for CTS. Results were analyzed statistically. STATISTICAL ANALYSIS USED: The two-tailed Student's t-test was used for the comparative statistical analysis. The sensitivity of each test was calculated as (the number of hands with an abnormal study result/the number of CTS hands) × 100. Comparison between percentages was performed by the McNemar test. RESULTS: The mean age was 38.19 ± 10.13 years and the female:male ratio was 1.5:1. The mean duration of disease was 0.89 ± 0.61 years. Hypothyroidism was present in 21 (26.25%) patients, whereas 13 (16.25%) and 4 (5%) patients had diabetes mellitus and rheumatoid arthritis, respectively. The median nerve motor latency was 4.73 ± 0.83 ms while the sensory latency was 3.44 ± 0.56 ms. The median nerve orthodomic sensory latency was found to be 2.57 ± 0.31 ms. The conduction velocity across the palm and wrist was 41.37 ± 0.67 ms. The sensitivity was the highest in the inching method (86.25%) and lowest for the conventional median motor and sensory latencies (56.25% and 45%, respectively). CONCLUSIONS: Addition of a single test of median and ulnar sensory latency, the median and radial sensory latency or the inching method, in routine protocol will improve the sensitivity for the diagnosis of CTS in all patients.

Mirror Aneurysm with Right Frontal ICH in a Patient with Osteogenesis Imperfecta.

Osteogenesis imperfecta (OI) is a heterogeneous group of inherited disorders that occur owing to the abnormalities in type 1 collagen, and is characterized by increased bone fragility and other extraskeletal manifestations. OI may be associated with vascular complications such as aortic and cervical artery dissection, carotid cavernous fistula, and coronary artery aneurysms but unlike other connective tissue diseases, the cerebrovascular system is less frequently involved. We report rare case of 50 year female patient who was diagnosed with OI following right frontal haemorrhage secondary to a ruptured middle cerebral artery mirror aneurysm.