Neurology India最新文献

Abstract: Awake craniotomy (AC) is primarily performed for specific surgical indications; however, medical conditions requiring AC are rarely reported. Anesthetic challenges of a patient with severe chronic obstructive pulmonary disease (COPD) and pulmonary bullae who underwent craniotomy and tumor excision are reported here. A 65-year-old diabetic woman presented with acute right-sided weakness, fever, altered mental status, and COPD exacerbation. The investigation revealed a left frontal lesion with significant perilesional edema, right lung bullae, bronchopneumonia, and hyponatremia due to the syndrome of inappropriate antidiuretic hormone (SIADH). After optimization by a multidisciplinary team, she was scheduled for craniotomy and partial excision. Given her pulmonary and neurological conditions, several anesthetic options were considered: general anesthesia (GA) with intermittent positive pressure ventilation (IPPV) utilizing low tidal volume, single-lung ventilation using a double-lumen tube/bronchial blocker, and AC using monitored anesthesia care (MAC). The potential risks and benefits of each technique were discussed, and it was decided to proceed with AC under MAC, using scalp block, dexmedetomidine infusion, intermittent propofol, and fentanyl boluses. A backup plan for conversion to GA was established in the event of severe coughing or seizure, and the equipment and personnel for emergency intercostal drainage (ICD) were on standby to address potential bullae rupture during IPPV. The family was informed of the complications associated with GA, including the risk of pneumothorax, ICD insertion, prolonged mechanical ventilation, and extended intensive care and hospital stay. A coordinated perioperative care strategy, facilitated by a multidisciplinary team, prevented morbidity in this case.

Background: Dementia is an emerging public health challenge in India, particularly among older adults in rural and underserved regions. Early detection is crucial for timely intervention and care planning. However, existing screening tools, such as the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA), have limitations in low-literacy populations due to their reliance on reading, writing, and numeracy skills. In India's primary healthcare (PHC) settings-where time, training, and resources are limited-there is a critical need for a culturally appropriate, easy-to-administer cognitive screening tool.

Objective: This study aimed to develop and validate a brief, culturally relevant, and literacy-independent tool-the Primary Healthcare Cognitive Screening (PHC-CS) tool-for the early detection of cognitive impairment among adults aged 50 years and above in Indian primary healthcare settings.

Methods: The PHC-CS tool was developed through a multistep process, including a literature review, expert consultation, and field testing. The final 21-item tool assessed eight cognitive domains (memory, attention, language, visuospatial ability, executive function, orientation, constructional ability, and mental flexibility) using orally delivered tasks supported by visual aids. The tool was administered to 172 participants at a rural PHC in Karnataka. MoCA scores and neurologist-confirmed ICD-10 diagnoses served as reference standards. Psychometric validation included ROC curve analysis, internal consistency (Cronbach's alpha), test-retest reliability, and interrater agreement.

Results: At an optimal cutoff score of <45, the PHC-CS tool demonstrated an area under the ROC curve of 0.957 (95% CI: 0.922-0.992), with a sensitivity of 95%, a specificity of 92%, a positive predictive value of 96%, and a negative predictive value of 92%. Internal consistency was strong (Cronbach's alpha = 0.90), with good test-retest reliability (r = 0.88) and interrater agreement (κ = 0.88). The average administration time was 15 minutes.

Conclusion: The PHC-CS tool demonstrates promising preliminary validity and feasibility for routine cognitive screening in Indian PHC settings, particularly for low-literate populations. Further multicentric validation is recommended.

Abstract: Various neurologic manifestations are observed in the course of hematologic malignancies. Clinical neurologic symptoms and manifestations of malignancies may result from the malignancy itself, inflammatory responses, or paraneoplastic syndromes. Therefore, differential diagnosis on the basis of clinical presentation is challenging. This is the first study to report a patient with central nervous system lymphoma and elevated glutamic acid decarboxylase antibody levels who presented with uveitis masquerade syndrome (UMS), followed by progressive consciousness change, mimicking autoimmune encephalitis.

Background: Differentiating prolactinomas from non-functioning sellar masses causing hyperprolactinemia due to stalk effect is a common diagnostic challenge. While both can result in elevated serum prolactin, accurate discrimination is essential for appropriate management.

Objective: To determine the upper limit of serum prolactin in non-functioning sellar masses attributable to stalk effect.

Methods: This retrospective study was conducted at a tertiary care center in South India from January 2015 to December 2024. Patients with both non-pituitary sellar masses and pituitary tumors with negative prolactin immunohistochemistry were included. Patients with functioning pituitary adenomas, hyperprolactinemia-inducing drugs, chronic kidney disease, severe hepatic dysfunction, and PCOS were excluded. The primary objective was to determine the upper limit of serum prolactin levels attributable to stalk effect in patients with non-functioning sellar masses. Preoperative serum prolactin levels were measured using a chemiluminescent immunoassay. The 97th percentile value was taken as the upper limit.

Results: Of 288 cases of non-functioning sellar masses, 57 met inclusion criteria. Most of them (87.7%, 50/57) were >1 cm, with 68% (39/57) classified as pituitary adenomas-49% (19/39) being gonadotroph adenomas and 41% (16/39) null cell adenomas. Hyperprolactinemia was observed in 32% of patients. The median serum prolactin level was 14.8 ng/mL, and the 97th percentile was 70 ng/ml. No significant correlation was found between tumor size and serum prolactin level (r = 0.13, P = 0.35). Gender did not significantly affect serum prolactin levels. A serum prolactin threshold of 70 ng/mL was identified, above which non-functioning sellar masses are highly unlikely.

Conclusion: In patients with non-functioning sellar masses, serum prolactin levels rarely exceed 70 ng/ml. This threshold may serve as a useful diagnostic marker to distinguish stalk effect from prolactinomas. Prospective validation in larger cohorts is warranted.

Abstract: Orbital apex lesions present significant surgical challenges due to their deep location and proximity to critical neurovascular structures. The endoscopic uninostril transnasal transethmoidal approach offers a minimally invasive alternative to traditional open techniques. We demonstrate the technical nuances, feasibility, and outcome of endoscopic uninostril transnasal transethmoidal excision of an orbital apex lesion using a case example, emphasizing key anatomical landmarks, dissection techniques, and strategies to avoid complications. The approach provides direct access to the orbital apex with minimal morbidity. The lesion was excised completely with preservation of critical structures. The patient had an uneventful postoperative recovery. The endoscopic uninostril transnasal transethmoidal approach is a valuable addition to the armamentarium of skull base surgeons, providing a safe, precise, and effective method for excising orbital apex lesions while preserving key neurovascular structures.

Abstract: Distal anterior cerebral artery (DACA) aneurysms are rare and account for less than 10% of all intracranial aneurysms. "Kissing" bilateral mirror-image DACA aneurysms are even more uncommon. Securing these aneurysms pose considerable challenges in terms of access, periprocedural risks and difficulty in identifying the culprit aneurysm. We share our experience with the surgical clipping of kissing DACA aneurysm in a 48-year-old patient and discuss the concerns involved.