Navigating Neurosurgery into an Optimal Future PN Tandon Neurology India 2019 67(4):966-967 The Cover Page Neurology India 2019 67(4):963-963 We Stand on the Shoulders of Our Teachers … So that We Can See Further … P Sarat Chandra Neurology India 2019 67(4):964-965

Deep Brain Stimulation in Parkinson's Disease Naveed Malek Neurology India 2019 67(4):968-978 Deep brain stimulation (DBS) has become an established therapeutic tool for treating patients with Parkinson's disease (PD) who have troublesome motor fluctuations and dyskinesias refractory to best medical therapy. In addition to its proven efficacy in patients with late PD, the EARLYSTIM trial not only demonstrated the efficacy of DBS in patients with early motor complications but also showed that it did not lose its therapeutic efficacy as the years passed by. However, like all other therapies for PD, DBS is not offered to patients either as a cure for this disease nor is it expected to stop the progression of the neurodegenerative process underlying PD; these important issues need to be highlighted to patients who are considering this therapy. This article aims to provide an introduction to residents or trainees starting a career in movement disorders of the technical aspects of this therapy and the evidence base for its use. For the latter objective, PUBMED was searched from 1946 to 2017 combining the search terms “deep brain stimulation” and “Parkinson's disease” looking for studies demonstrating the efficacy of this therapy in PD. Inclusion criteria included studies that involved more than 20 patients with a physician confirmed diagnosis of PD and a follow-up of greater than or equal to at least 12 months. The findings from those studies on motor symptoms, medication requirements, quality of life, and independence in activities of daily living in PD patients are summarized and presented in tabulated form in this paper at the end.

Eye Signs in Pituitary Disorders Yan Chen, Zhihong Liu, Zhihui Lin, Xiaozhe Shi Neurology India 2019 67(4):979-982 The eye is a vital sense organ and plays a vital role in conveying the underlying physical and mental state of wellbeing of an individual. A comprehensive examination of the eye is often required in patients presenting with systemic complaints. Many endocrine disorders have characteristic manifestations pertaining to the eye, the classical being the exophthalmos in thyrotoxicosis. However, a cursory eye evaluation may lead to the identification of early features that can help in the diagnosis of other endocrine disorders. This is more common in cases of pituitary mass lesions, who often present with the functional hormonal alterations rather than the visual symptoms. The definitive therapy during the late stages of the disease leads to persisting visual disabilities and affects the quality of life. Hence, the endocrinologists and ophthalmologists need to be aware of various ophthalmic features in the pituitary disorders. In this review, we highlight the eye signs in pituitary disorders, along with a brief description of uncommon ocular-pituitary syndromes.

The Benefits and Risks of Statin Therapy in Ischemic Stroke: A Review of the Literature Wang Zhao, Zhi-Jie Xiao, Shui-Ping Zhao Neurology India 2019 67(4):983-992 Statins are effective cholesterol-lowering drugs for reducing the risks of mortality and morbidity of cardiovascular diseases. Increasing evidence has shown that statin use is associated with a significant beneficial effect in patients with ischemic stroke. Both pre-stroke and post-stroke statin use has been found to be beneficial in ischemic stroke. Furthermore, good adherence is associated with a better clinical outcome, and statin withdrawal is associated with a poor functional outcome in patients with ischemic stroke. High-intensity statin therapy is advocated for the treatment of ischemic stroke. However, there are concerns regarding the adverse effects associated with statin use in ischemic stroke such as intracranial hemorrhage. In this review, we summarize the beneficial effect of statin use in ischemic stroke and discuss the potential risks associated with statin therapy.

Role of Aspirin in Tuberculous Meningitis: A Systematic Review and Meta-analysis Imran Rizvi, Ravindra K Garg, Hardeep S Malhotra, Neeraj Kumar, Ravi Uniyal Neurology India 2019 67(4):993-1002 Objectives: Aspirin is a drug that has been found to be useful in reducing the incidence of infarctions. This systemic is aimed at review evaluating the benefits of aspirin in the management of tuberculous meningitis. Methods: A systematic literature search was performed using PubMed, Cochrane Central Register of Controlled Trials, and SCOPUS for articles published on or before September 22, 2018. The meta-register of controlled trials and bibliography was also searched. Randomized controlled trials wherein aspirin was used were included in the systematic review. The data was extracted using a predetermined format. The risk ratio (RR) for dichotomous data was calculated and a random-effects model was used to combine the data. Death and occurrence of new infarctions were considered as primary outcomes. The quality of evidence was assessed using the GRADE approach. Results: Four trials including 546 patients were found eligible. The addition of aspirin to anti-tuberculosis drug regimens did not significantly reduce mortality [RR = 0.66 (0.42–1.02); low-quality evidence] but significantly reduced the risk of new infarctions [RR = 0.52 (0.29–0.92); moderate-quality evidence]. Aspirin did not differ from the placebo with regard to the adverse event outcome. Conclusion: Aspirin reduces the risk of new infarctions in patients with tuberculous meningitis but does not affect mortality (moderate-to-low level of evidence).

Tuberculous Meningitis – Adjunctive Therapy: Corticosteroids, Aspirin, or Both J M K Murthy Neurology India 2019 67(4):1003-1005

The Correlation of Endothelial Nitric Oxide Synthase (eNOS) Polymorphism and Other Risk Factors with Aneurysmal Subarachnoid Hemorrhage: A Case-Control Study Subhas K Konar, Shruthi Ramesh, Rita Christopher, A Prasanthi, Dhananjaya I Bhat, Dhaval Shukla, R Bharath, B Indira Devi Neurology India 2019 67(4):1006-1012 Objective: Endothelial nitric oxide synthase gene (eNOS) polymorphism is an association with cerebral aneurysm formation, rupture, and vasospasm and plays a role in the a functional outcome. Patients and Methods: The aim of the study was to evaluate the role of eNOS gene polymorphism and further assess the predictors of outcome in the aneurysmal subarachnoid hemorrhage (aSAH). A prospective case-control study was conducted from 2009 to 2012 among those who presented with aSAH. A serum sample was collected from aSAH patients along with age and sex-matched healthy controls. The frequency of polymorphism of eNOS gene and other factors (demographic and aneurysmal) were correlated with functional outcome at six month of follow-up. Results: 100 patients with aSAH and 100 healthy controls were enrolled in the cohort. The mean age of the patient group was 51.61 years and control group was 45.81 years with a male:female ratio of 1:1.38 and 1:1.08 for patients and controls, respectively. Among all eNOS polymorphisms, 4BB (65%) 24-VNTR, TT (71%) of T-786C, and GG (71%) of G947T were the most common and frequency was similar in the control group. The occurrences of hypertension, smoking, diabetes were 32%, 37%, and 7% respectively in the patient group. Maximum patients were in WFNS grade 1 (53%) followed by 23% grade 2 and only 10% in grade 4. Fisher grade 3 (57%) was the most common followed by Fisher grade 4 (28%). Most aneurysms (97%) were in anterior circulation. 83% of the aneurysms were clipped and 10% underwent coiling. Size-wise most of the aneurysms were in the middle group (6–9 mm) followed by bigger group (>10 mm) (37%); only 6% aneurysms were in the small aneurysm (<6 mm) group. 33% of the patients had evidence of vasospasm. TT of G894T polymorphism (60%) had the highest incidence of vasospasm. Univariate analysis showed smoking (OR: 3.19, CI: 1.19–8.84, P = 0.01), 4AA (OR: 12.15, CI: 1.13–624.9, P = 0.03) variety of 24-VNTR polymorphism, CC (OR: 15.39, CI: 1.60–762.8, P = 0.01) variety of T786C polymorphism, Fisher grade 4 (OR: 3.43, CI: 1.24–9.68, P = 0.01), WFNS grade (poor vs. good) (OR: 3.42, CI: 1.17–10.12, P = 0.02), vasospasm (OR: 3.84, CI: 1.42–10.75, P = 0.006), intraoperative rupture (OR: 4.77, CI: 1.55–15.27, P = 0.004) were significantly related with unfavorable outcome at 6 months follow-up. In regression analysis, smoking (CI: 0.06–0.69, P = 0.01), Fisher grade 4 (CI: 0.09–1.00, P = 0.05), and intraoperative rupture (CI: 0.05–0.89, P = 0.03) were correlated with an unfavorable outcome at 6 months follow-up. Conclusion: The eNOS gene polymorphism, smoking, clinical grade (WFNS), Fisher grade, intraoperative rupture, and vasospasm play a role in functional outcome after the treatment of cerebral aneurysms.

eNOS: A Passing Fad or the Crux of the Panacea? Sivashanmugam Dhandapani Neurology India 2019 67(4):1013-1014