Browsing by Author "Sylaja, PN"

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    A rare cause of perioperative stroke
    (ANNALS OF INDIAN ACADEMY OF NEUROLOGY, 2013) Sreedharan, SE; Gayatri, P; Sylaja, PN
    Perioperative stroke can occur following 0.2-0.3% of general surgical and orthopedic procedures. We are reporting a patient who developed multiple strokes in the immediate postoperative period following total knee replacement, where etiological workup revealed multiple pulmonary arteriovenous fistulae (PAVF). The significance of PAVF with paradoxical embolism in perioperative settings has rarely been reported in the literature.
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    Antisynthetase syndrome with stroke
    (NEUROLOGY INDIA, 2013) Divya, KP; Sukumaran, S; Sreedharan, SE; Sylaja, PN
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    Autonomic dysfunction in first ever ischemic stroke: Prevalence, predictors and short term neurovascular outcome
    (CLINICAL NEUROLOGY AND NEUROSURGERY, 2016) Nayani, S; Sreedharan, SE; Namboodiri, N; Sarma, PS; Sylaja, PN
    Objectives: Central autonomic dysfunction(AD) is reported post-stroke. Very few studies have looked at its impact on neurovascular outcome. We sought to study the prevalence and predictors of autonomic dysfunction in patients with first ever acute ischemic stroke and its impact on discharge and short term outcome. Patients and methods: Consecutive patients who presented between 2-4 weeks post stroke were prospectively recruited. Study period was April 2012-March 2014 (2 years). Subjects underwent clinical autonomic function testing using Ewing's battery at bedside and 24 h Holter analysis for heart rate variability(HRV). HRV parameters studied included both time domain and frequency domain measures. Neurological and cardiovascular outcomes were assessed at discharge,3 months and 1 year. Results: Of 101 patients of mean age 63yrs, 72% were men.Majority had moderate to severe strokes at onset (Mean NIHSS-13.9,MRS-3.1). Clinical bedside autonomic testing criteria were comparable to Holter detected dysautonomia in our study population (p value 0.3). Clinical autonomic dysfunction had a positive association with male gender whereas onset stroke severity and Insular involvement were associated with significantly higher incidence of autonomic dysfunction with both methodology. Those with autonomic dysfunction had more stroke severity at discharge, which was independent of onset severity. Increasing age, hemispheric laterality or presence of comorbidities had no impact on post-stroke dysautonomia. Conclusions: Insular involvement and higher disability at onset are associated with greater incidence of autonomic dysfunction post-stroke. Those with AD had higher chance of infarct expansion and in hospital cardiovascular complications and poorer outcome at 1 year, independent of onset stroke severity. (C) 2016 Elsevier B.V. All rights reserved.
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    CEREBRAL AMYLOID ANGIOPATHY-A CLINICORADIOLOGICAL STUDY FROM SOUTH INDIA
    (INTERNATIONAL JOURNAL OF STROKE, 2016) Sreedharan, SE; Thomas, B; Sylaja, PN; Sarma, PS
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    Clinical characteristics of a South Indian cohort of juvenile myoclonic epilepsy probands
    (SEIZURE-EUROPEAN JOURNAL OF EPILEPSY, 2003)
    Despite the distinctive clinical and electroencephalographic features known for five decades, even today, juvenile myoclonic epilepsy (JME) is frequently unrecognised and misdiagnosed in both developed and developing countries. Utilising 183 JME probands belonging to the South Indian state of Kerala, assembled through a tertiary referral centre for molecular genetic studies, we explored the phenotypic peculiarities, clinical genetics, and problems and pitfalls in the diagnosis of JME. At referral, only six (3.3%) patients carried the diagnostic label of JME, default in diagnosis resulted from failure to elicit the history of myoclonic jerks by the referring physicians. During the mean delay of 8.6 +/- 7.0 years in diagnosing JME, seizure control in the majority was poor due to inappropriate antiepileptic drug (AED) therapy. A history of epileptic seizures was obtained in 6.2% of the first-degree and 2.2% of the second-degree relatives of the probands; 37.7 and 11.1% of them, respectively, were diagnosed as JME. Although most of the clinical features of our cohort were in accordance with the literature, two notable differences we observed were the relatively increased occurrence of absence seizures and low frequency of photoparoxysmal responses. Although the variability in the clinical characteristics of JME may be apparent due to differences in the ascertainment of the data, they may well be an expression of a true clinical heterogeneity, and are in accordance with the complex and variable mode of inheritance and conflicting linkage studies reported for this syndrome from different ethnic groups. (C) 2003 BEA Trading Ltd. Published by Elsevier Science Ltd. All rights reserved.
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    Collateral Assessment by CT Angiography as a Predictor of Outcome in Symptomatic Cervical Internal Carotid Artery Occlusion
    (AMERICAN JOURNAL OF NEURORADIOLOGY, 2017) Sundaram, S; Kannoth, S; Thomas, B; Sarma, PS; Sylaja, PN
    BACKGROUND AND PURPOSE: Cervical internal carotid artery occlusion can present with varied clinical manifestations such as transient ischemic attack, stroke, and chronic ocular ischemia, or can be asymptomatic. The outcome in these patients is considerably influenced by cerebral hemodynamic compensatory adaptation of the intracranial collateral pathways. Our aim was to study whether collateral circulation as assessed by CT angiography can predict 3-month outcome and initial stroke severity in patients with symptomatic cervical ICA occlusion. MATERIALS AND METHODS: This was a retrospective study of 65 patients with symptomatic cervical ICA occlusion from January 2011 to December 2013. The collateral vessels (anterior and posterior communicating arteries, ophthalmic artery, and leptomeningeal arteries) were assessed by CTA. The outcome at 3 months was defined as poor if the modified Rankin Scale score was >= 3. RESULTS: The mean age of subjects was 57 +/- 11.6 years (range, 32-80 years), and 92% were men. Thirty-three (50.8%) patients had poor outcome. Absence of the ipsilateral ophthalmic artery, poor leptomeningeal collaterals, and <2 collaterals were predictors of stroke severity at onset and poor 3-month outcome in univariate analysis. In the multiple logistic regression analysis, inadequate flow through the secondary collaterals.(ipsilateral ophthalmic artery or leptomeningeal collaterals; OR, 4.5; 95% CI, 1.4-14.9; P =.01) and higher NIHSS score at stroke onset (OR, 19.2; 95% CI, 2.2-166.2; P =.007) independently predicted poor outcome at 3 months. CONCLUSIONS: Assessment of collateral circulation with CTA can be a useful predictor of 3-month outcome in patients with symptomatic cervical ICA occlusion.
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    Complementary and Alternative Medicine Treatments Among Stroke Patients in India
    (TOPICS IN STROKE REHABILITATION, 2012) Pandian, JD; Toor, G; Arora, R; Kaur, P; Dheeraj, KV; Bhullar, RS; Sylaja, PN
    Background: Complementary and alternative medicine (CAM) is commonly used by persons with stroke throughout the world, particularly in Asia. Objective: The objectives of this study were to determine the frequency of CAM use and the factors that predict the use of CAM in stroke patients. Methods: This study was carried out in the stroke units of Christian Medical College, Ludhiana, and Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India, from June 2010 to December 2010. Participants were interviewed using a structured questionnaire (>= 6 months post stroke). Outcomes were assessed using a modified Rankin Scale (mRS). Results: Three hundred fourteen stroke patients were interviewed; mean age was 57.4 +/- 12.9 years, and 230(73.2%) patients were men. Of 314 patients, 114 (36.3%) had used the following CAM treatments: ayurvedic massage, 67 (59.3%); intravenous fluids, 22 (19.5%); herbal medicines, 17 (15%); homeopathy, 15 (13.3%); witchcraft, 3 (2.7%); acupuncture, 3 (2.7%); opium intake, 10 (8.8%); and other nonconventional treatments, 10 (8.8%). Patients with severe stroke (P < .0001), limb weakness (P < .0001), dysphagia (P = .02), dyslipidemia (P = .007), hypertension (P = .03), or hemorrhagic stroke (P < .0001) and patients with poor outcome (mRS >2; P < .0001) often used CAM treatments. Conclusion: More than one-third of the patients in this study opted for CAM. Presence of limb weakness, dysphagia, dyslipidemia, hypertension, hemorrhagic stroke, severe stroke, and poor outcome predicted the use of CAM.
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    Complications in acute stroke in India (CAST-1): A multicenter study.
    (J Stroke Cerebrovasc Dis, 2012-12) Pandian, JD; Kaur, A; Jyotsna, R; Sylaja, PN; Vijaya, P; Padma, MV; Venkateswarlu, K; Sukumaran, S; Mathew, R; Kaur, P; Singh, YP; Radhakrishnan, K
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    Complications in Acute Stroke in India (CAST-I): A Multicenter Study
    (JOURNAL OF STROKE & CEREBROVASCULAR DISEASES, 2012) Pandian, JD; Kaur, A; Jyotsna, R; Sylaja, PN; Vijaya, P; Padma, MV; Venkateswaralu, K; Sukumaran, S; Mathew, R; Kaur, P; Singh, YP; Radhakrishnan, K
    The prognosis and final outcome in patients who sustain stroke are significantly affected by medical complications occurring during the acute phase of stroke. Only limited information is available from India and other developing countries regarding acute complications of stroke. This study examined the frequency of acute stroke and the factors associated with complications of stroke in India. In this prospective multicenter study, running from March 2008 to September 2009, 6 hospitals collected information on complications of first-ever stroke during admission. Complications were defined in accordance with standard criteria. Outcome at 30 days poststroke was assessed using the modified Rankin Scale. Stroke characteristics, length of hospital stay, and stroke severity (based on the National Institutes of Health Stroke Scale) were documented. Hematologic (ie, hemoglobin) and biochemical (ie, total proteins and albumin) parameters also were obtained. A total of 449 patients out of the recruited 476 completed follow-up. The mean age was 58.1 +/- 13.7 years (range, 16-96 years), and the majority were men (n=282; 62.8%). The mean National Institutes of Stroke Scale score was 10.2 +/- 5.3. Overall, 206 patients (45.9%) experienced complications during admission. In the logistic regression analysis, limb weakness (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.02-0.67; P=.01), anemia (OR, 0.35; 95% CI, 0.15-0.81; P=.01), length of hospital stay (OR, 0.89; 95% CI, 0.85-0.94; P<.0001), and stroke severity (OR, 0.27; 95% CI, 0.10-0.72; P=.01) were the variables associated with complications. Such complications as urinary tract infection (OR, 0.31; 95% CI, 0.13-0.78; P=.01), chest infection (OR, 1.81; 95% CI, 1.12-2.93; P=.02), bedsores (OR, 3.52; 95% CI, 1.02-12.08; P=.05), other pain (OR, 0.21; 95% CI, 0.09-0.49; P<.0001), and depression (OR, 2.22; 95% CI, 1.30-3.80; P<.01) were associated with poor outcome. Our study shows high rates of complication in acute stroke. Limb weakness, stroke severity, length of hospital stay, and anemia were the factors associated with complications. Other complications, such as urinary tract infection, chest infection, bedsores, other pain, and depression, can lead to poor outcome.
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    Complications of pregnancy and delivery in women with epilepsy
    (EPILEPSIA, 2005) Sindhu, K; Thomas, SV; Ajaykumar, B; Sylaja, PN; Sulekhadevi, PB; Jacob, S
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    CT angiogram as a predictor of outcome in symptomatic ICA occlusion
    (INTERNATIONAL JOURNAL OF STROKE, 2014) Sundaram, S; Sylaja, PN; Kannoth, S; Thomas, B
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    Differential diagnosis of patients with intracranial sinus venous thrombosis related isolated intracranial hypertension from those with idiopathic intracranial hypertension
    (JOURNAL OF THE NEUROLOGICAL SCIENCES, 2003)
    In patients presenting with intracranial hypertension without hydrocephalus, mass lesions, and with normal cerebrospinal fluid (CSF) composition (pseudotumor cerebri syndrome), the diagnosis of intracranial sinus venous thrombosis (ISVT) has crucial etiological, therapeutic and prognostic implications. Utilizing two well-defined groups of pseudotumor cerebri patients, one with magnetic resonance imaging (MRI) or angiography confirmed ISVT (17 patients) and the other in whom ISVT has been excluded (idiopathic intracranial hypertension [IIH], 27 patients), we investigated the characteristics that might be helpful in distinguishing them. No clinical or auxiliary findings differed between the ISVT and IIH groups except for female gender and lower CSF protein level, which were significantly associated with the latter. While the syndrome pseudotumor cerebri could be due to multiple causes including ISVT, the term IIH should be restricted for patients with isolated intracranial hypertension attributable to no other neurological or systemic disease. Since CT frequently misses ISVT, patients with pseudotumor cerebri syndrome should undergo MRI and MR venography before being labeled as IIH. We conclude that Modified Dandy's Diagnostic Criteria of pseudotumor cerebri, formulated prior to MRI era, can no longer be applied for the diagnosis of IIH. (C) 2003 Elsevier B.V. All rights reserved.
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    Direct visualization of thrombus load in MCA in acute stroke on susceptibility weighted imaging
    (NEUROLOGY INDIA, 2011) Thomas, B; Lingegowda, D; Kesavadas, C; Sylaja, PN
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    Early risk and predictors of cerebrovascular and cardiovascular events in transient ischemic attack and minor ischemic stroke
    (NEUROLOGY INDIA, 2012) Kate, M; Sylaja, PN; Chandrasekharan, K; Balakrishnan, R; Sarma, S; Pandian, JD
    Background: Transient ischemic attack (TIA) and minor ischemic stroke (MIS) are associated with early recurrence and deterioration respectively. The aim of the present study was to assess the risk of new cerebrovascular and cardiovascular events in a prospective, emergently enrolled patient cohort with TIA and MIS and the predictors of risk. Materials and Methods: Patients with TIA and MIS (NIH Stroke Scale [NIHSS] <= 5) presenting within the first 48 h between July 2008-June 2009 were prospectively enrolled. The primary outcome was new-onset stroke, TIA, cardiovascular events and vascular death at 90 days and early deterioration in patients with minor stroke. The 90-day outcome was also assessed (excellent outcome; modified Rankin scale [mRS] <= 2). Results: Eighteen (15.3%) of the 118 patients enrolled developed new cerebrovascular or cardiovascular events during the 90 days of follow-up, nine (50%) of which occurred within seven days. Of the all new events 5.9% (7/118) had new stroke, 4.2% (5/118) patients developed early deterioration, 2.5% (3/118) patients had recurrent TIA and 2.5% (3/118) had cardiovascular events at 90 days. Eight (6.7%) patients had poor outcome at 90 days (mRS>2). The factors predicting new vascular events were presence of coronary artery disease (CAD), and stroke etiology being large artery atherosclerosis (LAA). Conclusion: In patients with TIA and MIS, despite urgent evaluation and aggressive management, the short-term risk of stroke and other vascular events is high. Those with CAD and LAA should be monitored closely for early deterioration.
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    Employment status, social function decline and caregiver burden among stroke survivors. A South Indian study
    (JOURNAL OF THE NEUROLOGICAL SCIENCES, 2013) Sreedharan, SE; Unnikrishnan, JP; Amal, MG; Shibi, BS; Sarma, S; Sylaja, PN
    Stroke leaves at least 60% of the survivors with moderate to severe disability limiting their employment status and social functioning leading to high levels of caregiver burden. Aim: We sought to study the employment status and level of change of social functioning of stroke survivors and their principal caregiver and correlate it with severity of stroke, functional disability, and anxiety and depression scores. Methods: One hundred and fifty stroke survivors and principal caregivers (3 months-2 years post-stroke) were recruited for the study. The employment status pre- and post-stroke was assessed. The social function of the patient and caregiver was analyzed using a 6 item social function scale developed for the study, encompassing culturally relevant questions. A 20 point scale adapted from Burden assessment schedule was used to assess the caregiver burden. Results: Mean age of the study group was 54.37 +/- 12.072 (range 22-75 years), with 116 males and 34 females. Spouse was the principal caregiver for 142/150 patients (94.6%). In the stroke survivors, compared to the pre-stroke employment status of 62.7%, only 20.7% were employed post-stroke with half having change of job. But the employment status of caregiver was not reduced post-stroke (34.7% vs 33.3%). Employment loss in stroke survivors had a statistically significant association with severity of functional disability, male gender and presence of limb weakness (p values 0.037, 0.0001 and 0.043 respectively). There was an overall decline in social functions among the 6 parameters assessed in both the stroke survivors and caregivers. Of the caregiver burden, financial burden was more among female and older caregivers. The functional status and motor weakness of the stroke survivors did not tend to worsen the overall caregiver burden. Conclusions: Loss of occupation among stroke survivors is high. The decline in social function among stroke survivors and caregivers was significant. Even though functional disability contributed to employment loss and social function decline among stroke survivors, it did not have a significant impact on caregiver burden. (C) 2013 Elsevier B.V. All rights reserved.
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    FACTORS PREDICTING RETURN TOWORK POST STROKE IN INDIA
    (INTERNATIONAL JOURNAL OF STROKE, 2016) Chahal, A; Pandian, JD; Pannu, A; Arora, D; Sylaja, PN; Kaul, S; Khurana, D; Padma, MV; Thankachan, T; Singhal, AB
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    Factors predictive of return to work after stroke in patients with mild-moderate disability in India
    (EUROPEAN JOURNAL OF NEUROLOGY, 2016) Bonner, B; Pillai, R; Sarma, PS; Lipska, KJ; Pandian, J; Sylaja, PN
    BackgroundSuccessful return to work after stroke may improve economic circumstances, quality of life and overall life satisfaction, but not all stroke survivors are able to return to work. AimOur aim was to determine what proportion of previously employed patients return to work after an acute stroke resulting in mild to moderate disability and to examine factors associated with a successful return to work. MethodsPatients 18-60 years of age who were previously employed and who had a first-ever stroke 3 months to 2 years previously resulting in mild to moderate disability (modified Rankin score 3) were recruited. Socio-demographic and clinical information was collected and anxiety, depression and social support were assessed using previously validated instruments. Multivariate logistic regression was used to assess factors associated with a successful return to work. ResultsOf 141 patients (mean age SD 48 +/- 8.8 years), 74 (52.5%) returned to work after stroke. Multivariate analysis demonstrated that a lower modified Rankin scale at 3 months [odds ratio (OR) 3.70, 95% confidence interval (CI) 1.77-7.76], younger age (OR 2.24, 95% CI 1.07-4.67) and a professional or business job (OR 3.02, 95% CI 1.44-6.34) were significantly associated with successful return to work and revealed that anxiety, depression and social support score did not affect patients' decision to return to work (P = 0.17, 0.61 and 0.27, respectively). ConclusionsAmongst patients with mild to moderate disability after stroke, almost half do not return to work, and this is determined by functional disability and type of job rather than psychosocial factors such as anxiety and depression.
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    Global White Matter Hypoperfusion on CT Predicts Larger Infarcts and Hemorrhagic Transformation after Acute Ischemia
    (CNS NEUROSCIENCE & THERAPEUTICS, 2016) Bivard, A; Cheng, X; Lin, LT; Levi, C; Spratt, N; Kleinig, T; O'Brien, B; Butcher, K; Lou, M; Zhang, JF; Sylaja, PN; Cao, WJ; Jannes, J; Dong, Q; Parsons, M
    IntroductionPresence of white matter hyperintensity (WMH) on MRI is a marker of cerebral small vessel disease and is associated with increased small vessel stroke and increased risk of hemorrhagic transformation (HT) after thrombolysis. AimWe sought to determine whether white matter hypoperfusion (WMHP) on perfusion CT (CTP) was related to WMH, and if WMHP predisposed to acute lacunar stroke subtype and HT after thrombolysis. MethodsAcute ischemic stroke patients within 12 h of symptom onset at 2 centers were prospectively recruited between 2011 and 2013 for the International Stroke Perfusion Imaging Registry. Participants routinely underwent baseline CT imaging, including CTP, and follow-up imaging with MRI at 24 h. ResultsOf 229 ischemic stroke patients, 108 were Caucasians and 121 Chinese. In the contralateral white matter, patients with acute lacunar stroke had lower cerebral blood flow (CBF) and cerebral blood volume (CBV), compared to those with other stroke subtypes (P = 0.041). There were 46 patients with HT, and WMHP was associated with increased risk of HT (R-2 = 0.417, P = 0.002). Compared to previously reported predictors of HT, WMHP performed better than infarct core volume (R-2 = 0.341, P = 0.034), very low CBV volume (R-2 = 0.249, P = 0.026), and severely delayed perfusion (Tmax>14 second R-2 = 0.372, P = 0.011). Patients with WMHP also had larger acute infarcts and increased infarct growth compared to those without WMHP (mean 28 mL vs. 13 mL P < 0.001). ConclusionWhite matter hypoperfusion remote to the acutely ischemic region on CTP is a marker of small vessel disease and was associated with increased HT, larger acute infarct cores, and greater infarct growth.