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   Table of Contents - Current issue
Coverpage
July-September 2021
Volume 18 | Issue 3
Page Nos. 153-218

Online since Saturday, September 18, 2021

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EDITORIAL  

COVID-19 and neurological problems p. 153
Pushpendra Nath Renjen, Raju Vaishya
DOI:10.4103/am.am_101_21  
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ORIGINAL ARTICLES Top

To evaluate efficacy of pregabalin for the prevention of etomidate-induced myoclonus: A prospective, randomized, placebo-controlled, double-blind study p. 154
Vinit Kumar Srivastava, Sanjay Agrawal, Sanjay Kumar, Ambikesh Pandey, Shweta Garewal, Pooja Shree
DOI:10.4103/am.am_8_21  
Context: The incidence of myoclonus after etomidate induction is 50%–80%. The present study evaluated the efficacy of oral pregabalin for the prevention of etomidate-induced myoclonus. Settings and Design: A prospective, randomized, placebo-controlled, double-blind study. Subjects and Methods: Seventy-four patients of the American Society of Anesthesiologists physical status Grade I or II scheduled for elective surgery under anesthesia were recruited. Following exclusion, 66 patients were randomized into two groups. In Group P patients received pregabalin 150 mg orally 1 h before induction of anesthesia and in Group C patients received placebo tablet. The primary outcome was the incidence and severity of myoclonus. The secondary outcome was the postoperative sedation level. Results: The incidence and severity of myoclonus were significantly decreased in Group P compared with Group C (P < 0.05). The postoperative sedation score was significantly higher in Group P compared to Group C (P > 0.05). Conclusion: Pretreatment with pregabalin 150 mg orally reduced the incidence and severity of etomidate-induced myoclonus however incidence of sedation was more.
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Leukocyte morphological changes in COVID-19, a peripheral smear study and analysis at a tertiary health care centre in India Highly accessed article p. 158
Gokula Kannan, Mamta Soni
DOI:10.4103/am.am_28_21  
Context: Coronavirus disease 2019 (COVID-19) as the name depicts, a contagious disease caused by the coronavirus that emerged in the year 2019 December, at the Wuhan province in China. The knowledge on the pathogenesis of the disease at the cellular level to correlate with the clinical severity is still evolving. Various clinicopathological features and nature of the disease were gradually identified from those who were affected by the disease. Apart from the clinical presentation, certain investigations played a major role in diagnosing and assessing the severity of the disease. Morphological impact on blood cells was also caused by the severe acute respiratory syndrome-CoV-2 virus. Aim: Morphological analysis of leukocytes on blood samples of COVID19 patients. Settings and Design: Peripheral smear study of blood samples of COVID19 patients admitted at our tertiary care center. Subjects and Methods: Microscopic peripheral smear examination of leukocyte morphology on study samples. Statistical Analysis Used: All the data were recorded and analyzed statistically using Ms-Excel. Results: Our study demonstrated certain acquired pathogenic abnormalities of the leukocytes, that are acquired neutrophilic nuclear projections (ANNP), plasmacytoid lymphocytes, acquired Pelger-Huet anomaly (APHA), myeloid left shift, neutrophils with toxic granules and cytoplasmic vacuoles, and apoptotic cells. Conclusion: To summarize, in our study we observed similar features that were recorded in few studies earlier, such as APHA and plasmacytoid lymphocytes in convincing percentages among the COVID-19 patients in our population. Adding to these ANNP was one more prominent feature we encountered in majority of COVID-19 cases.
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Role of oral corticosteroid and olfactory training for treatment of Post-COVID-19 olfactory dysfunction: Our experiences p. 162
Santosh Kumar Swain, Somya Ranjan Pani
DOI:10.4103/am.am_61_21  
Background: Coronavirus disease 2019 (COVID-19) infection is highly contagious and the increasing number of patients with variety of symptoms. Olfactory loss is currently a well-recognized symptom of COVID-19 infection. Many patients with COVID-19 infections recover with their normal sense of smell after few weeks, however certain portion of them develop long-standing olfactory dysfunction. Objective: The objective is to study the role of oral corticosteroids and olfactory training (OT) as a treatment for olfactory dysfunction in COVID-19 patient. Materials and Methods: This is a prospective and descriptive study on 78 COVID-19 patients who administered oral corticosteroids and OT. All of them were diagnosed with COVID-19 infection by reverse transcription polymerase chain reaction of nasopharyngeal swab. The detail clinical examination and treatment with intranasal corticosteroid and its outcome were analyzed. Results: In this study, 46 (58.97%) patients were male and 32 (41.02%) were female with male to female ratio of 1.43:1. The age ranges of 18–62 years. There were 36 (46.15%) patients in the age range of 18–30 years, 42 (53.84%) patients in the age range of 31–62 years. Out of 78 patients, 11 (14.10%) patients were recovered after 2 weeks, 34 (43.58%) patients recovered after 3 weeks, and 24 (30.76%) recovered after 4 weeks. Three patients lost follow-up during the treatment period. Conclusion: Combination of short course of oral corticosteroids and OT is a beneficial and safe treatment option for COVID-19 patients with olfactory dysfunction. However, there is a crucial demand for further studies to corroborate this outcome.
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REVIEW ARTICLES Top

New frontiers in acute stroke management p. 166
Pushpendra Nath Renjen, Shivangi Garg, Anjali Mishra, Dinesh Mohan Chaudhari
DOI:10.4103/am.am_98_21  
Ischemic stroke is a common emergency presentation to hospital with improving survival rates owing to access to specialist organized stroke care. The approach to the treatment of ischemic stroke has undergone great transformation over the past 20 years. The negativism of older times has given the way to proven treatment strategies to reverse ischemia and prevent patients from severe neurological disabilities or death. Acute stroke care has three main ideologies: (1) timely achievement of occluded artery recanalization and reperfusion of the part of brain that is ischemic, (2) optimization of collateral flow, and (3) avoidance of the secondary brain injury. In this review article, we will focus on the new developments in the management of acute stroke in the past decade.
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Advances in traumatic brain injury research in 2020: A review article p. 172
Revanth Goda, P Sarat Chandra
DOI:10.4103/am.am_48_21  
Perhaps in no other area of neurosurgery, has a greater research been done as in traumatic brain injury (TBI). Despite this, TBI remains one of the biggest killers around the world and especially in India. Decompressive craniotomy still remains one of the mainstay paradigms in the management of TBI. The following article explores several new modalities of treatment, and these include the role of beta-blockers for TBI, updates on decompressive craniotomy, the results of DECRA and RESCUEicp trials, diagnostic and prognostic biomarkers in TBI, vascular dysfunction, neuroimaging, and role of neuroinflammation in TBI.
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Vestibular migraine p. 179
Santosh Kumar Swain, Sampada Munjal, Suryakanta Pradhan
DOI:10.4103/am.am_3_19  
Vestibular migraine (VM) is a distinct clinical entity which accounts for major vestibular symptoms among the adult and children. It is now accepted as a major cause for episodic vertigo. The pathophysiology for VM is not completely understood and is always a puzzling dilemma. Patients often present with vertigo, headache, photophobia, and phonophobia. The clinical examinations and laboratory investigations are usually within normal limit. The diagnosis of VM is often challenging as there are no confirmatory tests available. The treatment is often similar to the migraine headache. The present-day recommendation is to use the same prophylactic medications used for migraine including beta-blockers, antidepressants, and anticonvulsants. It is always a challenging disease for clinician and often creates a puzzle for diagnosis and treatment. Proper diagnosis and treatment of VM need a thorough understanding of the current literatures which are discussed details in this review article.
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Mucormycosis and COVID 19: From the desk of a periodontist p. 184
Malvika Singh
DOI:10.4103/am.am_54_21  
Oral mucormycosis is not a new disease and is known to occur in patients with low immunity such as in uncontrolled diabetes, posttransplant, and some cancer treatments. A sudden surge has been reported in mucormycosis in cases with COVID-19. Although rare, serious complication of COVID-19. The aim of this article is to discuss the periodontal presentation of oral mucormycosis in patients who currently have or have recovered from COVID-19 infection. Although fatal sometime, its successful treatment lies in the early diagnosis and for periodontists are the first doctors to identify the same, they should remain vigilant in its diagnosis so that the same can be treated by a multidisciplinary medical approach and fatalities can be avoided.
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COVID-19 in children p. 187
Tanu Singhal
DOI:10.4103/am.am_82_21  
COVID-19 disease is of mild severity in most children. The common symptoms include fever, sore throat, cough, nasal congestion, diarrhea, and vomiting. Prompt testing of suspect cases with rapid antigen test and/or reverse transcription–polymerase chain reaction in nasopharyngeal swabs is recommended. The routine use of computed tomography (CT) scan should be discouraged. For children with mild disease, only symptomatic therapy is required. Red flag signs include persistent high fever, breathlessness, drowsiness, and hypoxia. For children with moderate/severe disease, oxygen, steroids, and anticoagulation are standard of care. Vaccination of children against COVID-19 is not a priority at this time. The indirect effects of COVID-19 vastly outnumber the direct effects.
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Tocilizumab: A potent immunomodulatory agent in the treatment of COVID-19 pneumonia p. 189
Sameer Bansal, Uma Karjigi, Ravindra M Mehta
DOI:10.4103/am.am_88_21  
Inflammation plays a major role in the pathophysiology of COVID-19, and corticosteroids are validated as initial potent broad-spectrum anti-inflammatory agents. IL-6 is one of the culprit pro-inflammatory cytokines identified for this cytokine storm. Tocilizumab is a recombinant humanized monoclonal antibody that inhibits binding of interleukin (IL)-6 to both membrane and soluble IL-6 receptors. The role of tocilizumab was controversial with conflicting evidence, but recent data validate the use of this agent under specific circumstances of rapidly worsening COVID acute respiratory distress syndrome with escalating respiratory support or gradually worsening COVID-19 pneumonia in a hospital setting. One of the benchmark tocilizumab studies is the REMAP-CAP trial that showed the benefit of IL-6 antagonists in terms of survival, number of organ support-free days, and even probability of discharge from the hospital. This benefit was seen when tocilizumab was administered within 24 h of patients requiring either respiratory or hemodynamic support. A recently concluded meta-analysis showed that tocilizumab treatment predicts better overall survival in COVID-19 patients (hazard ratio [HR] =0.45, 95% confidence interval [CI]: 0.24–0.84, P = 0.01), especially in severe cases (HR = 0.58, 95% CI: 0.49–0.68, P < 0.00001).
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COVID-19–associated central nervous system mucormycosis p. 192
Anjali Mishra, Dinesh Mohan Chaudhari, Pushpendra Nath Renjen
DOI:10.4103/am.am_84_21  
Mucormycosis is a life-threatening infection caused by fungi of the order Mucorales. Central nervous system (CNS) mucormycosis is usually an extension of the infection from the sinuses to the eyes and brain. CNS mucormycosis arises from an adjacent paranasal sinus infection (rhinocerebral) by direct extension or hematogenous dissemination from the lungs, but isolated CNS mucormycosis is a rare presentation. During an episode of fungemia, seeding may occur in brain tissue, leading to this infection. The most common clinical presentation of mucormycosis is rhino-orbital-cerebral infection, which is presumed to start with inhalation of spores into the paranasal sinuses of a susceptible host. In this article, we emphasize on the COVID-19–associated mucormycosis, particularly the involvement of CNS.
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Multiple sclerosis in 2020 p. 196
Anshu Rohatgi, Neha Pandita
DOI:10.4103/am.am_90_21  
Recent developments in the management of multiple sclerosis (MS) are ushering in a new era in MS treatment. The novel therapeutic disease-modifying agents that have been recently approved for the treatment of MS are B-cell therapies and various sphingosine-1-phosphate inhibitors. The Bruton's tyrosine kinase inhibitor therapies provide a novel therapeutic approach in the treatment of MS. Numerous studies have demonstrated a high degree of efficacy with autologous hematopoietic stem cells. There are upcoming trials focusing on remyelination strategies in MS. In this yearly review, we will focus on all these latest developments which are leading to a promising change in the diagnosis, treatment, and prognosis of this disease.
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Major advances in amyotrophic lateral sclerosis in 2020 p. 200
Divyani Garg, Achal Kumar Srivastava
DOI:10.4103/am.am_91_21  
Research in amyotrophic lateral sclerosis (ALS), a neurodegenerative condition, has seen advancement in several key areas of research in 2020. These include a thrust to move the classification of ALS from a neuromuscular condition to a neurodegenerative condition, due to research suggesting involvement of cortical areas, and early cortical hyperexcitability. A new criterion for ALS, called the Gold Coast criterion, has been described. The Gold Coast criteria have removed the categories of possible, probable, and definite ALS, to make the diagnosis of ALS more inclusive and permit enhanced eligibility of patients in clinical trials for ALS. New biomarkers, both imaging and protein based, have been described. Advances in therapy have also occurred, with a large phase II clinical trial reporting benefits with sodium phenylbutyrate-taurursodiol.
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CASE REPORTS Top

Combined retinal vascular occlusion in a recovered case of COVID-19 p. 205
Jaydeep Avinash Walinjkar
DOI:10.4103/am.am_38_21  
Hypercoagulability in COVID-19 can be described as a “sepsis-induced coagulopathy” and may be a precursor for thromboembolic events. There are other reported milder ocular manifestations of COVID-19 disease such as conjunctivitis, as well as a few reported central retinal vein occlusions (CRVOs), combined retinal vascular occlusion has never been reported. We report the case of a 66-year-old male, who presented to us with combined central retinal artery occlusion and CRVO with proven COVID-19 infection, diagnosed after presentation.
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Tuberous sclerosis complex patient fulfilling the criteria set by the 2012 international tuberous sclerosis complex consensus conference p. 208
Aimen Malik, Arshia Akbar, Gohar Ashraf, Hammad Akram
DOI:10.4103/am.am_63_21  
Tuberous sclerosis complex (TSC) is a rare multisystem neurocutaneous disorder associated with the growth of benign tumors in different organs such as the brain, lungs, kidneys, heart, and eyes. The dermatological findings of this disorder are very common, present at early age and not easy to miss. The neurological manifestations of TSC include seizures, autism, and intellectual disabilities. Furthermore, intracranial abnormalities and hamartoma formation in the heart and other organs are found among sufferers. The clinical diagnostic criteria have been critically evaluated and updated in the 2012 International Tuberous Sclerosis Conference. The diagnosis is based on genetic criteria, clinical criteria, and various manifestations of skin, kidneys, lungs, and brain. The management involves multispecialty and multidisciplinary approaches. Here, we present a case of a 13-year-old female with characteristic clinical, radiological, and pathological features of TSC.
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The utility of “heart sign” on neuroimaging in acute-onset quadriparesis: A series of three cases p. 212
S Sheetal, Antony Kalliath, Aswathy Sasidharan, S Vijayalekshmi
DOI:10.4103/am.am_66_21  
The “heart sign” is a well-described radiological sign in bilateral medial medullary infarction, which is a rare stroke syndrome. It has also been rarely reported in infarction of bilateral paramedian pons and caudal paramedian midbrain. Bilateral brainstem infarcts usually present with varying degree of quadriparesis and in the initial stages, it is difficult to distinguish from other conditions such as Guillain–Barre syndrome and brainstem encephalitis. Recognizing the “heart sign” on magnetic resonance imaging in a stroke-like episode may be helpful in differentiating these conditions from bilateral brainstem infarcts.
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Spontaneous extensive pneumocephalus with rare frontoethmoidal recess skull base defect presenting with acute headache p. 215
Manisha Sharma, Bindu Menon, VK Anand, Yashwanth Sandeep, Gayatri Manam
DOI:10.4103/am.am_47_21  
We report a 40-year-old diabetic female with acute headache and case of skull base defect causing pneumocephalus. The highlights of the present case are acute clinical presentation, extensive radiological findings, and rare skull base defect in frontoethmoidal recess.
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CLINICAL IMAGES Top

Caudal regression sequence: A costly vascular steal p. 217
Nitin P Ghonge
DOI:10.4103/am.am_49_21  
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