Pediatric spinal cord infarct: a rare cause of a rare disorder, (wo)man in barrel syndrome.

The "man in barrel syndrome" is a condition which resembles the aspect of patient being constrained in a barrel in which patient presents with bilateral upper limb weakness. It has classically been attributed to supratentorial lesions in watershed zones. We present such a case in a 12-year-old child who presented with bibrachial weakness and was noted to have cervical cord infarct on imaging. Spinal cord infarct is a rare cause of this syndrome, and until now only 20 cases have been described in which cervical cord infarct led to this presentation, all of them being adults. We describe first case report of bibrachial diplegia due to cord infarct in a child. Our case adds to the limited literature of cervical cord ischemia as a cause of "(wo) man in barrel syndrome" and re-iterates the fact that imaging of cervical cord should be considered while evaluating these cases.

A Randomized, Double-Blind, Sham-Controlled Study of Transcranial Direct Current Stimulation as an Augmentation Intervention for the Attenuation of Motor Deficits in Patients With Stroke.

INTRODUCTION: Most studies of transcranial direct current stimulation (tDCS) for motor deficits in patients with stroke administered few sessions of tDCS and with low current amplitude. METHODS: During 2015 to 2019, we randomized 60 inpatients with ischemic/hemorrhagic stroke and motor deficits to true or sham tDCS. Transcranial direct current stimulation was administered at 2- to 3-mA current strength, twice daily, 6 days a week, for 2 weeks; anode and cathode were placed over ipsilesional and contralesional motor cortices, respectively. All patients received individualized motor and cognitive rehabilitation. Motor outcomes were assessed 1 day before and 1 day after the tDCS course using the Fugl-Meyer Assessment, the Jebson-Taylor Hand Function Test, and the Barthel index (all coprimary outcomes). Mood and cognition were also assessed. Motor outcomes were compared between groups using age, baseline scores, and latency to treatment as covariates. The study was prospectively registered (CTRI/2017/01/007733). RESULTS: The mean age of the patients was 46.9 years. The sample was 73.3% male. Six patients did not complete the study. The covariates were significantly related to motor outcomes. Although all patients showed motor improvements, after adjusting for covariates, tDCS was not superior to sham treatment on any motor, mood, or cognitive outcome. Laterality of hemispheric lesion influenced spatial but not motor outcomes with tDCS. One true tDCS patient developed blistering under the anode and was withdrawn from the study; 3 more reported transient itching during sessions. CONCLUSIONS: An intensive course of tDCS, as delivered in this study, does not improve motor, mood, and cognitive outcomes in ischemic/hemorrhagic stroke in patients undergoing individualized rehabilitation. The study provides important leads for directions for future research.

Structured headache services as the solution to the ill-health burden of headache: 1. Rationale and description

In countries where headache services exist at all, their focus is usually on specialist (tertiary) care. This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally supported primary care. At the same time, compartmentalizing divisions between primary, secondary and tertiary care in many health-care systems create multiple inefficiencies, confronting patients attempting to navigate these levels (the "patient journey") with perplexing obstacles.High demand for headache care, estimated here in a needs-assessment exercise, is the biggest of the challenges to reform. It is also the principal reason why reform is necessary.The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health-care solution to headache. It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments. First, only primary care can deliver headache services equitably to the large numbers of people needing it. Second, with educational supports, they can do so effectively to most of these people. The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them. At the same time, it is amenable to horizontal integration with other care services. It is adaptable according to the broader national or regional health services in which headache services should be embedded.It is, according to evidence and argument presented, an efficient and cost-effective model, but these are claims to be tested in formal economic analyses.

Clinical, electrophysiological and laboratory parameters, and outcome in patients with biopsy proven systemic and nonsystemic vasculitic neuropathy.

AIM: To describe the clinical and laboratory findings of patients with biopsy proven vasculitic neuropathy. INTRODUCTION: Peripheral neuropathies form one of the most common disorders of the nervous system. However, more than 50% of them are labelled as 'idiopathic' and, therefore, treatment options become less. In this study, we tried to evaluate the phenotypic as well as laboratory characteristics and outcome of patients with biopsy proven vasculitic neuropathy. PATIENTS AND METHODS: Review of biopsy proven definite or probable vasculitic neuropathy was done. RESULTS: The cohort consisted of 67 subjects. There were 21 patients of systemic vasculitis (SVS) and 46 of non-systemic vasculitic neuropathy (NSVN). The nerve biopsy revealed definite vasculitis in 37 and probable vasculitis in 30 patients. The symptoms at onset were paraesthesia (68.7%), and paraesthesia and weakness (28.4%). Diffuse polyneuropathy occurred in 70.1% patients. The course was chronic in the majority (80.59%) of patients. Electrophysiology revealed mononeuritis multiplex in 32.84%, and polyneuropathy in 67.16% of patients. Pure sensory neuropathy was present in 16.42%. Among the patients who had undergone bilateral nerve conduction studies, the majority (71.05%) of patients had an asymmetric neuropathy. An elevated erythrocyte sedimentation rate (ESR) was observed in 80.59% (mean 71.57 ± 30.81 mm/1hr [in SVS] and 35.24 ± 21.62mm/1 hr in NSVN) of patients. The treatment included steroids, other immunomodulators, and symptomatic medications. The mean follow up was 10.98 ± 9.58 months. The outcome was good in 73.46% (43.8% with SVS and 87.88% with NSVN) patients, with those having a NSVN having a significantly better outcome. CONCLUSION: Vasculitis is a potentially treatable cause of peripheral neuropathy. The clinical features, electrophysiology, laboratory results and nerve biopsy may help in the diagnosis and categorization of patients into non-systemic and systemic vasculitic neuropathies. The long-term outcome is better in patients with NSVN compared to those with systemic vasculitis.

Headache in cerebral venous sinus thrombosis revisited: Exploring the role of vascular congestion and cortical vein thrombosis.

Background and purpose Headache constitutes the most common symptom of cerebral venous sinus thrombosis (CVST), but its pathophysiology is unclear. We sought to investigate the potential mechanism for headache genesis in patients with CVST based on its imaging correlates. Methods A subgroup of CVST patients having headache as the predominant symptom without significant parenchymal lesion were retrospectively analysed for imaging features of vascular congestion (VC), in addition to cortical venous (CVT) and dural sinus thrombosis (DST) on magnetic resonance imaging. Headache and imaging patterns were classified into lateralized and nonlateralized phenotypes and their correlation was sought. Results Among 41 patients included, 28 had lateralized headache (LH group; 15 males; mean age 32.25 ± 9.19 years) while 13 had nonlateralized headache (non-LH group; six males; mean age 27.15 ± 8.65 years). Headache characteristics in both the groups were quite similar. Imaging showed VC in 39 of 41 and CVT among 35 of 41 patients, which were lateralized in 23 of 39 and 18 of 35 patients, respectively. Nearly all lateralized imaging patterns (21 of 23 for VC and 17 of 18 for CVT) occurred in the LH group and ipsilateral to (concordant) headache, while the non-LH group showed lateralized VC and CVT in only two and one patient respectively. Sinus thrombosis was lateralized in both groups irrespective of headache laterality. Whole cohort headache-imaging laterality (including patients with nonlateralized headache and nonlateralized imaging) concordance was 31 of 39, 24 of 35 and 18 of 41 for vascular congestion, cortical vein thrombosis and dural sinus thrombosis respectively. Conclusion Co-localization of VC and CVT with overlying headache might provide a possible explanation of headache and its laterality in patients with CVST.

Spinal Cord Infarction: Clinical and Radiological Features.

INTRODUCTION: Spinal cord infarction is an uncommon disease varying in its clinical presentation. This study describes the clinical and radiological presentation of spinal cord infarcts in 17 consecutive patients. MATERIAL AND METHODS: Clinical and MR imaging data of 17 patients were reviewed. Inclusion criteria were acute or subacute presentation (peak within 72 hours) and MRI showing typical signal changes on T2WI compatible with spinal cord infarct. Exclusion criteria were clinical or MRI findings suggesting other etiologies. RESULTS: Clinical presentation included dissociative anesthesia, weakness of limbs, back or neck pain, and autonomic symptoms with symptom onset to peak time ranging from few minutes to 48 hours in patients with anterior spinal artery infarct (n = 16), and weakness and sensory loss in ipsilateral upper limb in patient with posterior spinal artery infarct (n = 1). One patient presented with "man-in-the-barrel syndrome (MIB)." MRI findings in anterior spinal artery infarcts included pencillike hyperintensities on T2 sagittal (n = 16, 100%) and "owl eye" appearance on T2 axial (n = 6, 37.5%) images. Diffusion restriction was noted in 8 cases and enhancement was noted in 2 cases. The posterior spinal artery infarct showed T2 hyperintensity in left posterior paramedian triangular distribution in cervical cord (C2-C7). Follow-up was available for 9 patients (period ranging from 15-41 months). Four patients had a favorable outcome who could walk independently, 1 patient could walk with support, and 2 patients were wheelchair bound. Two patients died. CONCLUSION: Spinal cord infarction is a rare but important cause of acute spinal syndrome. Typical distribution and appropriate imaging can help in timely diagnosis.

Preliminary data on utility of subcutaneous unfractionated heparin in patients with deep cerebral venous thrombosis.

Subcutaneous unfractionated heparin (SCUFH) has been proved effective in puerperal cerebral venous thrombosis (CVT), but its efficacy in the more serious form of the disease such as deep CVT patients (DCVT) unreported. We describe the outcomes of 37 (isolated:combined: 11:26) patients of DCVT diagnosed by MRI, treated with SCUFH in a tertiary care stroke unit. It was a prospective observational cohort study using 5000 U of SCUFH every 6 hourly for 10 days with oral Acenocoumarol started on day 7, with monitoring. The outcome was assessed by modified Rankin scale (mRS), National Institute of Health Stroke Scale (NIHSS) and Barthel's activities of daily life (BADL) at 3 months. The mean age of the cohort was 27.9 ± 9.7 years, females (n = 24) outnumbering the males (n = 13). Mean duration of symptoms being 10.2 ± 15.9 days. MRI showed vein of Galen and straight sinus involvement in 36 (97.3%) patients, with sparing of the basal vein of Rosenthal in 28 (75%). Thalamus 27 (73%) basal ganglia 21 (56.7%) were commonly involved areas with hemorrhagic lesions in 18 (48.6%) patients. The median NIHSS score at presentation was 11 (1-21). Mean duration of SCUFH treatment was 9.3 ± 1.3 days and the mean aPTT on day 7 was 49.3 ± 9.8 s (control 32-39 s), mean PT INR on day 13 was 1.5 ± 0.45. All the patients improved with no mortality in the study group. At 3 months, good functional outcome (mRS: 0-2) was observed in 94.6% (n = 35) of patients. Two patients had mRS-3. The median mRS (3{1-5} to 0{0-3}) and BADL (8{0-20} to 20{8-20}) improved at 3 months. Complications seen were thrombocytopenia-1, infection-6 and deep vein thrombosis of leg-4. Our preliminary data suggests that SCUFH is safe, effective treatment option in patients with DCVT in a stroke unit with minimal monitoring.

Electrophysiological observations in critically ill Guillain-Barre syndrome.

BACKGROUND: Respiratory muscle paralysis is a serious complication of Guillain-Barre syndrome (GBS). Factors that govern duration and recovery from respiratory paralysis are unclear. AIM: To correlate electrophysiological parameters in critically ill GBS with duration of mechanical ventilation and outcome at discharge. MATERIALS AND METHODS: Data of a large cohort (n=93; M:F 59:34; mean age: 33.51+21.4 years) of critically-ill patients with GBS seen over one decade was retrospectively analyzed. RESULTS: The duration of mechanical ventilation was <15 days (n = 38), 16-30 days (n = 24), and >30 days (n = 31). Majority of the patients had a demyelinating electrophysiology. Reduced amplitude or absent motor potentials correlated with requirement for longer duration of ventilation. Inexcitable sensory nerves were more common in patients who could be weaned off from the ventilator within 15 days. There was no relation between the conduction blocks in motor nerves and the duration of ventilation. Low amplitude of median nerve correlated with a poor outcome at hospital discharge as assessed by Hughes disability scale. CONCLUSION: Distinct patterns of electrophysiological abnormalities are noted in patients and they correlate with the duration of mechanical ventilation. Future studies to unravel the underlying pathophysiological processes that govern the patterns of progression and recovery in the critically ill patients with GBS will pave way for the development of better and more potent therapies that will hasten recovery, when combined with the prevalent treatment modalities including plasmapheresis and intravenous immunoglobulin.

Genetic variants of vitamin D receptor and susceptibility to ischemic stroke.

Vitamin D receptor (VDR) is a potential candidate for cardiovascular disease. To date the genetic association of VDR with ischemic stroke has not been explored. In the present study we aimed to evaluate the association between VDR gene variants and ischemic stroke in Asian Indian population. Overall, 557 subjects were investigated that included 313 ischemic stroke patients and 244 control subjects. Four single nucleotide polymorphisms of the VDR gene termed as Fok I, Apa I, Taq I and Bsm I were genotyped by using PCR-RFLP method. The genotype distribution of Bsm I polymorphism was found to deviate from the Hardy-Weinberg equilibrium in control subjects, and hence excluded from the study. Apa I and Taq I polymorphisms were not found to be associated with ischemic stroke. However, presence of ff genotype of Fok I was found to confer 2.97-fold risk of ischemic stroke (95% CI=1.16-7.63, P=0.02) as compared to FF genotype. This association was found to be independent of various demographic and important biochemical covariates including age, gender, smoking, alcohol intake, BMI, and serum glucose, lipid profile, insulin and HOMA-IR, 25-hydroxyvitamin D and plasma NOx levels [OR=2.27, 95% CI=1.25-4.09, P=0.01]. However, adjustment for lipid metabolites attenuated the genetic association [OR=1.68, 95% CI=0.75-3.78, P=0.21]. Fok I polymorphism was also found to be associated with total cholesterol levels; ff genotype carriers were found to have significantly higher cholesterol levels (203.56 ± 30.50mg/dl) as compared to FF carriers (177.38 ± 47.90 mg/dl) (P=0.04). On stratification by gender the genetic association between Fok I polymorphism and ischemic stroke remained significant in females only (OR=2.28, 95% CI=1.15-4.53, P=0.02). This genetic association was also found to attenuate on adjustment with lipid variables. In the present study we could associate the only known functional polymorphism of VDR i.e., Fok I, with ischemic stroke in a gender specific manner. Adjustment with lipid variables was found to attenuate this association indicating that impaired lipid metabolism may be the underlying mechanism of action of this polymorphism which leads to an increase in the risk of ischemic stroke. Further larger scale validations in other population are warranted in other population.

Profile of patients with craniovertebral junction anomalies with posterior circulation strokes.

BACKGROUND: Craniovertebral junction (CVJ) anomalies are rare and treatable risk factors for posterior circulation strokes (PCSs). Most of the literature comprises case reports and from varied specialities. METHODS: Chart review of patients with PCS with CVJ anomalies admitted in a single tertiary stroke care unit. We describe their clinical profile, investigative findings, and therapeutic outcomes. RESULTS: We saw 7 patients (6 males, mean age 20.1 ± 12.0 years), all previously undiagnosed during the 6-year period. Three patients had a combination of atlantoaxial dislocation (AAD), basilar invagination (BI) and Klippel-Feil anomalies, 2 patients had os odontoideum with AAD, and 1 patient each had isolated AAD and BI. Clinically, they presented with first or recurrent episodes of stroke with neck pain. Examination revealed noticeable skeletal markers and neurologic deficits involving the arterial territory. Routine stroke risk factors were absent. X-ray of CVJ was abnormal and diagnostic in all the patients. Other imaging modalities had their own contributions for identifying associated defects, demonstrating pathophysiology, and management of these patients. Acute care with anticoagulation and supportive measures helped in recovery of all of them. Posterior fusion was done in 4 patients, and 2 patients are awaiting the surgery. During follow-up all patients have improved and none had recurrences. CONCLUSIONS: In case of a young patient with PCS (first/recurrent) in the absence of routine risk factors for stroke, careful physical examination and imaging with basic X-ray may help in the diagnosis CVJ abnormalities, which may be effectively managed by a multidisciplinary team to prevent recurrences.

Cerebral Venous Sinus Thrombosis Associated Subdural Hematoma: A Case Series on Clinical Presentation and Management.

Diagnosis and treatment of cerebral venous sinus thrombosis (CVT) associated with subdural hematoma (SDH) is challenging with an increased risk of rebleeding on using anticoagulation. There are no guidelines at present due to its rare presentation. In this report we describe three patients who presented with non-traumatic SDH and CVT over the last 3 years. Clinical assessment, investigations including neuroimaging, and management were reviewed both at time of admission and follow-up. These patients presented with varied CVT syndromes -isolated raised intracranial pressure (ICP), focal and diffuse encephalopathy. Neuroimaging helped in diagnosing CVT and SDH. Cases 1 and 3 had SDH alone, while case 2 had SDH along with intraparenchymal hemorrhage. Management of these patients was tailored individually as per mechanism of CVT. Case 1 was clinically stable, however, she had rebleeding after starting anticoagulation, requiring its discontinuation. Cases 2 and 3 underwent immediate neurosurgical intervention in view of deteriorated sensorium. Although CVT manifesting as SDH is rare, clinicians should have a high index of suspicion to accurately diagnose and manage these challenging cases. The decision regarding use of anticoagulation and apt time for neurosurgical intervention needs to be individualized depending on patients condition and response to treatment.

Mastoid fluid signal in acute cerebral venous thrombosis is is associated with increased clot burden.

PURPOSE: Mastoid air cell abnormalities in the form of hyperintense T2 fluid signal have been reported in cases of acute Cerebral Venous Thrombosis (CVT) without otologic infection and have been hypothesized to be a result of venous congestion rather than infectious mastoiditis. The aim of this study was to investigate a link between the spectrum of mastoid abnormalities and clot burden in patients with acute CVT. METHODS: A retrospective study of adult patients admitted to the National Institute of Mental Health and Neurosciences between 2016 and 2023 who were diagnosed with acute CVT and had no clinical evidence of active or recent ear infections was conducted. Pre- and post-contrast MR Images were analyzed to identify the dural sinuses and/or cerebral veins involved and the presence of fluid signal in the mastoid. Fluid signal in the mastoid was graded from 0 to 3 as described by Shah et al- no fluid signal (grade 0), thin curvilinear hyperintensities (grade 1), thick crescenteric hyperintensities (grade 2), and complete hyperintensity (grade 3). Clot Burden Score (CBS) was calculated by assigning one point for each sinus involved, one point for extension of thrombus into the intracranial Internal Jugular Vein (IJV), one point for thrombosis of cortical veins and one point for thrombosis of deep cerebral veins. RESULTS: A total of 89 patients with acute CVT were included in the final analysis. Median time from presentation to MRI was 2 days (range 0-13). 51 patients (57.3%) had fluid signal in the mastoid air cells on T2-weighted images, of whom 33 showed mucosal contrast enhancement. Higher grade of fluid signal in the mastoid was present ipsilateral to the side of venous thrombosis in 59 out of 60 patients with posterior fossa CVT. CBS was significantly different between patients with different grades of fluid signal (p = 0.002). Grade 2-3 fluid signal was associated with higher clot burden (CBS > 3) in both the entire study population (n = 89) - OR = 8.281, 95 %CI: 2.758-24.866 (p < 0.001) and among patients with posterior fossa CVT - OR = 4.375, 95 %CI: 1.320-14.504 (p = 0.016). Among patients with posterior fossa CVT, grade 2-3 fluid signal was associated with left sided transverse and/or sigmoid sinus thrombosis - OR = 5.600, 95 %CI: 1.413-22.188 (p = 0.014), and extension of thrombosis into the IJV - OR = 4.606, 95 %CI: 1.162-18.262 (p = 0.030). CONCLUSION: T2 fluid signal in the mastoid is associated with venous congestion in adults with acute CVT without evidence of otologic infection. Moderate-to-severe T2 fluid signal in the mastoid air cells is associated with increased clot burden.

Healthcare professionals' perspectives of the provision of, and challenges for, eating, drinking and psychological support post stroke: findings from semistructured interviews across India.

AIM: This qualitative study explores with health professionals the provision of, and challenges for, postdischarge stroke care, focussing on eating, drinking and psychological support across India. DESIGN: Qualitative semistructured interviews. SETTING: Seven geographically diverse hospitals taking part in a Global Health Research Programme on Improving Stroke Care in India. PARTICIPANTS: A purposive sample of healthcare professionals with current experience of working with patients who had a stroke. RESULTS: Interviews with 66 healthcare professionals (23 nurses (14 staff nurses; 7 senior nurse officers; 1 intensive care unit nurse; 1 palliative care nurse)); 16 doctors (10 neurologists; 6 physicians); 10 physiotherapists; 5 speech and language therapists; 4 occupational therapists; 4 dieticians; 2 psychiatrists; and 2 social workers resulted in three main themes: integrated inpatient discharge care planning processes; postdischarge patient and caregiver role and challenges; patient and caregiver engagement post discharge. CONCLUSIONS: Discharge planning was integrated and customised, although resources were limited in some sites. Task shifting compensated for a lack of specialists but was limited by staff education and training. Caregivers faced challenges in accessing and providing postdischarge care. Postdischarge care was mainly hospital based, supported by teleservices, especially for rural populations. Further research is needed to understand postdischarge care provision and the needs of stroke survivors and their caregivers.

Barriers to Thrombolysis at A Tertiary Care Public Hospital- A Prospective Observational Study from Southern Part of India.

Background: Intravenous thrombolysis (IVT) is an effective treatment for carefully selected acute ischemic stroke (AIS) patients. However, very few eligible candidates access it in time around the world, including India, due to multiple barriers. Objective: We explored the barriers to IVT in patients of AIS presenting within a 4.5-h window period in our hospital. Materials and Methods: This was a prospective study of AIS patients presenting in <4.5 h of symptom-onset, aged >18 years at the Neuro-casualty, Department of Neurology, from May 2016 to November 2017. Assessment of barriers to intravenous thrombolysis was done, and an attempt to delineate the reasons for the pre-hospital and the in-hospital delay was made. Results: A total of 103 (M:F: 67:36) patients aged between 18 and 80 years, were recruited, with 28 (27.2%) patients aged <45 years. Among them, 29 (28.2%) were thrombolysed. The major reasons for the pre-hospital delay were ignorance about the need for stroke center consultation- 94 (90.3%), consultation elsewhere before the presentation- 84 (81.5%), and non-availability of an ambulance at referring hospitals- 50 (59.52% out of 84). Sixty-four patients (62.1%) could not name any symptoms of stroke, 84 (83.5%) could not name any risk factor, and only 4 (3.9%) were aware of IVT. Key in-hospital barriers were crowded emergency- 80 (77.7%), financial constraints- 79 (76.7%), and delay in CT scan- 62 (61.4%). Delay in arriving at a consensus for IVT by the patient/relative and the treating neurologist, was noted in 24 (43.6%) of the 55 eligible. Conclusion: Many eligible patients remain deprived of thrombolysis due to lack of awareness, financial constraints, and organizational elements, which should be addressed to improve IVT rates.

Smartphone-Based Telestroke Vs"Stroke Physician" led Acute Stroke Management (SMART INDIA): A Protocol for a Cluster-Randomized Trial.

Background: One of the major challenges is to deliver adequate health care in rural India, where more than two-thirds of India's population lives. There is a severe shortage of specialists in rural areas with one of the world's lowest physician/population ratios. There is only one neurologist per 1.25 million population. Stroke rehabilitation is virtually nonexistent in most district hospitals. Two innovative solutions include training physicians in district hospitals to diagnose and manage acute stroke ('Stroke physician model') and using a low-cost Telestroke model. We will be assessing the efficacy of these models through a cluster-randomized trial with a standard of care database maintained simultaneously in tertiary nodal centers with neurologists. Methods: SMART INDIA is a multicenter, open-label cluster-randomized trial with the hospital as a unit of randomization. The study will include district hospitals from the different states of India. We plan to enroll 22 district hospitals where a general physician manages the emergency without the services of a neurologist. These units (hospitals) will be randomized into either of two interventions using computer-generated random sequences with allocation concealment. Blinding of patients and clinicians will not be possible. The outcome assessment will be conducted by the blinded central adjudication team. The study includes 12 expert centers involved in the Telestroke arm by providing neurologists and telerehabilitation round the clock for attending calls. These centers will also be the training hub for "stroke physicians" where they will be given intensive short-term training for the management of acute stroke. There will be a preintervention data collection (1 month), followed by the intervention model implementation (3 months). Outcomes: The primary outcome will be the composite score (percentage) of performance of acute stroke care bundle assessed at 1 and 3 months after the intervention. The highest score (100%) will be achieved if all the eligible patients receive the standard stroke care bundle. The study will have an open-label extension for 3 more months. Conclusion: SMART INDIA assesses whether the low-cost Telestroke model is superior to the stroke physician model in achieving acute stroke care delivery. The results of this study can be utilized in national programs for stroke and can be a role model for stroke care delivery in low- and middle-Income countries. (CTRI/2021/11/038196).

Prognosis of patients with Guillain-Barré syndrome requiring mechanical ventilation.

INTRODUCTION: Severe Guillain-Barré syndrome (GBS) is associated with significant morbidity and also mortality. Identification of modifiable risk factors may help in reducing the morbidity and mortality. OBJECTIVE: To study the prognostic factors in a selected cohort of mechanically ventilated GBS patients. MATERIALS AND METHODS: Case records of GBS patients requiring mechanical ventilation admitted between 1997 and 2007 were analyzed. All patients satisfied the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) criteria for GBS. Primary outcome parameters included mortality and GBS disability (Hughes) scale score at discharge. RESULTS: During the study period, 173 (118 men and 55 women; mean age of 33.5 ± 21 years) GBS patients were mechanically ventilated. A history of antecedent events was present in 83 (48%) patients. In addition to motor weakness, In all facial palsy was present in 106 (61%), bulbar palsy in 91 (53%), sensory involvement in 74 (43%), and symptomatic autonomic dysfunction in 27 (16%). The overall mortality was 10.4%. On univariate analysis the risk factors for mortality included elderly age (P = 0.014), autonomic dysfunction (P = 0.002), pulmonary complications (P = 0.011), hypokalemia (P = 0.011), and bleeding (P = 0.026). All these factors were significant in multivariate analysis except for bleeding from any site and hypokalemia. In univariate analysis factors associated with Hughes scale score ≤ 3 at discharge included younger age (P = 0.02), presence of bulbar symptoms (P = 0.03) and less severe weakness at admission (P = 0.02), slower evolution of disease over more than 3 days (P = 0.01), electrodiagnostic evidence of demyelinating neuropathy (P = 0.00), and absence of sepsis (P = 0.01), hyperkalemia (P = 0.0001), and anemia (P = 0.02). In multivariate analysis age was the only significant factor. CONCLUSIONS: Early identification of modifiable risk factors, such as pulmonary involvement, autonomic dysfunction, hypokalemia, sepsis, bleeding, and nutritional complications, may reduce the mortality and morbidity associated with GBS.