Background: Stroke is a leading cause of death and disability in developing countries, afflicting individuals at a young age. The contribution of established vascular risk factors to ischaemic stroke in young adults has not been evaluated systematically in Indians. Methods: We conducted a case control study in 214 South Indian patients with first acute ischaemic stroke that occurred between the ages of 15 and 45 years, 99 age and sex matched hospital controls and 96 community controls. We compared the prevalence of the following risk factors: smoking, elevated blood pressure, high fasting blood glucose and abnormal lipids. Results: Compared with community controls, stroke patients had a higher prevalence of smoking (multivariable adjusted odds ratio (OR) 7.77, 95% CI 1.93 to 31.27), higher systolic blood pressure (OR per SD increment of 1.88, 95% CI 1.01 to 3.49) and fasting blood glucose (OR per SD increment of 4.55, 95% CI 1.63 to 12.67), but lower high density lipoprotein (HDL) cholesterol (OR per SD increment of 0.17, 95% CI 0.09 to 0.30). Compared with hospital controls, stroke patients had a higher prevalence of smoking (OR 3.95, 95% CI 1.61 to 9.71) and lower HDL cholesterol (OR per SD increment 0.27, 95% CI 0.17 to 0.44). The presence of >3 metabolic syndrome components was associated strongly with stroke (OR 4.76, 95% CI 1.93 to 11.76; OR 2.09, 95% CI 1.06 to 4.13) compared with community and hospital controls. Conclusions: Key components of the metabolic syndrome and smoking are associated with ischaemic stroke in young South Indian adults. Our observations underscore the importance of targeting adolescents and young adults for screening and prevention to reduce the burden of ischaemic stroke in young adults.

Summary:Despite major challenges, in the last decade several epilepsy centers in the developing world have successfully implemented epilepsy surgery programs and produced results comparable to those from developed countries. If the program is to have a lasting impact, it would be essential to work with and educate the local professionals and public about the recent advances in the treatment of epilepsies. The epilepsy surgery centers in developing countries should initially restrict their surgical candidates to patients with mesial temporal lobe epilepsy and those with circumscribed potentially epileptogenic lesions in whom the epileptogenic zone can be unquestionably localized by using locally available relatively inexpensive and noninvasive technologies, and in whom an excellent postoperative outcome can be guaranteed. It is important for such epilepsy center to assess its capabilities and limitations regularly and adopt a stepwise progressive approach to increasing levels of complex presurgical evaluation and surgical treatment strategies.

Dear Sirs,In a patient presenting with acute stroke it is essential to make a quick decision on thrombolysis based on history, clinical findings and the information obtained on an urgent CT or MRI. Though CT is considered the imaging technique of choice to rule out intracerebral haemorrhage, MRI using a gradient T2*/SWI sequence has been found to be equally good [1]. If the presentation is beyond the first 3 h, there is a need to image the salvageable penumbra. MRI gives information about the penumbra by using the diffusion-perfusion imaging. The role of susceptibility weighted imaging (SWI) in patients with stroke has already been documented [2]. We report two interesting cases of acute stroke where the findings in SWI helped in early diagnosis and management.A 43-year-old male presented with wake up stroke and was rushed to our hospital. The patient could not move the right sided limbs and had aphasia. Magnetic resonance imaging done at 7.30 a.m, soon after his arrival in the hospital, revealed a left middle cerebral territory infarct involving the frontal operculum, insular and lateral frontal cortex. The diffusion restriction was minimal. Prominent veins were noted in the SWI posterior to the area of infarct. The same area showed reduced regional cerebral blood flow and increased mean transit time (Fig. 1). The diffusion restricted areas showed normal cerebral blood flow and mean transmit time.The second patient was a 44-year-old male who presented with sudden onset of weakness of right sided limbs and complete inability to speak at 8.30 a.m. The patient was immediately taken to a local hospital from where a CT scan was done and this was reported to be showing a doubtable dense MCA sign. At around 10.30 a.m his weakness started improving, and by 11 a.m his speaking difficulty also improved. In view of complete improvement, thrombolysis was deferred. He was referred to our hospital for further evaluation. An MRI done on the same day in the afternoon revealed no areas of restricted diffusion. The SWI showed MCA susceptibility vessel sign [3] and prominent veins in the left MCA territory. Hyperintense vessel sign [3] was noted in the FLAIR sequence. The MR angiography showed thrombus close to the MCA bifurcation ( Fig. 2a-j). Since the patient improved and thrombolysis was not being planned, a perfusion MRI was not done. As part of workup for the transient ischemic attack, an MR angiography of neck vessels, FLAIR and diffusion weighted imaging of brain was repeated after 3 days. This revealed diffusion restriction in the left caudoputaminal region (Fig. 2k, l).In the first patient, the findings in SWI were corresponding to the areas showing change in the cerebral blood flow and mean transit time. Prominence of veins following stroke has been described earlier [4][5][6]. The prominence is thought to be due to increased deoxyhemoglobin in the veins. This may be secondary to increased oxygen extraction fraction due to reduced blood flow [7]. The findings in the second patient show that the SWI changes can be seen e...

Objectives:While the burden of dementia is increasing in low- and middle-income countries, there is a low rate of diagnosis and paucity of research in these regions. A major challenge to study dementia is the limited availability of standardised diagnostic tools for use in populations with linguistic and educational diversity. The objectives of the study were to develop a standardised and comprehensive neurocognitive test battery to diagnose dementia and mild cognitive impairment (MCI) due to varied etiologies, across different languages and educational levels in India, to facilitate research efforts in diverse settings.Methods:A multidisciplinary expert group formed by Indian Council of Medical Research (ICMR) collaborated towards adapting and validating a neurocognitive test battery, that is, the ICMR Neurocognitive Tool Box (ICMR-NCTB) in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam), for illiterates and literates, to standardise diagnosis of dementia and MCI in India.Results:Following a review of existing international and national efforts at standardising dementia diagnosis, the ICMR-NCTB was developed and adapted to the Indian setting of sociolinguistic diversity. The battery consisted of tests of cognition, behaviour, and functional activities. A uniform protocol for diagnosis of normal cognition, MCI, and dementia due to neurodegenerative diseases and stroke was followed in six centres. A systematic plan for validating the ICMR-NCTB and establishing cut-off values in a diverse multicentric cohort was developed.Conclusions:A key outcome was the development of a comprehensive diagnostic tool for diagnosis of dementia and MCI due to varied etiologies, in the diverse socio-demographic setting of India.

Objective In the background of a large population of bilinguals globally, the study aimed to develop standards of neuropsychological testing in the context of bilingualism. Because bilingualism is known to affect cognitive processes, bilinguals and monolinguals were compared on their performance on cognitive tests, to investigate the possibility of the need for separate normative data for the two groups. Method A comprehensive neuropsychological test battery, standardized across five Indian languages: the Indian Council of Medical Research-Neuro Cognitive Tool Box (ICMR-NCTB) was administered to 530 participants (267 monolingual and 263 bilinguals matched for age and education). A systematic method of testing cognition in bilinguals was developed; to identify the appropriate language for testing, ensure language proficiency of examiner, and to interpret the bilingual responses. Additionally, the performance of bilinguals on the ICMR-NCTB was compared with monolinguals. Results Cognitive testing in the bilingual context was performed in the most proficient language of the participants, by examiners well versed with the language. Results from the language-based tests suggested that the frequent occurrence of borrowed- and language-mixed words required consideration while scoring. The reported bilingual effect on cognitive processes did not reflect as differences in the performance between bilinguals and monolinguals. Conclusions Observations from the study provide robust recommendations for neuropsychological testing in the context of bilingualism. Results indicate that separate normative data may not be required for bilinguals and monolinguals. The study will be relevant and provide a reference framework to address similar issues in the large population of bilinguals in other societies.

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