Sree Chitra Thirunal Institute for Medical Sciences and Technology

Background and Aims The main aim of this study was to evaluate the efficacy of real-time intraoperative transesophageal echocardiography (TEE) in guiding the central venous catheter (CVC) tip placement at the superior vena cava (SVC)–right pulmonary artery (RPA) junction. Materials and Methods One hundred patients aged between 18 and 65 years undergoing elective cardiac surgery were enrolled in the study. In the operation room, under ultrasound guidance, right internal jugular vein was punctured and CVC was inserted. The primary outcome was to determine the accuracy of placing the CVC tip under TEE guidance at the SVC–RPA junction by intraoperative surgical palpation and to correlate between the preoperative chest radiograph-predicted CVC depth and the TEE-guided placement of CVC depth. The secondary outcomes were to evaluate the position of CVC tip in relation to the carina in postoperative chest radiograph and the incidence of complications. Results A total of 98 patients were included in the analysis. The CVC tip was palpable by the surgeon intraoperatively at the SVC–RPA junction in 76 patients (77.6%). A significant direct correlation was observed between the predicted preoperative CVC depth and TEE-guided placement of CVC depth ( r = 0.7441, P < 0.0001). In the postoperative chest radiograph, 78 (79.5%) patients had the CVC tip positioned above the carina. Twenty-nine patients had atrial ectopics and six patients had ventricular ectopics during CVC insertion. Conclusions TEE-guided SVC–RPA junction is an accurate landmark for the intraoperative positioning of CVC tip in the extra-pericardial portion of SVC to prevent life-threatening cardiac complications.

Background Percutaneous closure of elliptical atrial septal defects remains challenging due to the circular configuration of conventional atrial septal defect occluders, making optimal device sizing difficult. Case Presentation A 14-year-old child, weighing 40 kg, with a large atrial septal defect, was evaluated at our center for closure. Transesophageal echocardiography demonstrated a large, highly elliptical atrial septal defect. It measured 27 mm in the superoinferior plane in the bicaval view and 13 mm in the anteroposterior plane. A 24-mm atrial septal occluder was selected based on mathematical derivation of the circle with area equivalent to the elliptical atrial septal defect and was successfully deployed via the right upper pulmonary vein approach on the first attempt. Conclusions A circle is an ellipse with identical major and minor axes. This case illustrates the successful application of this mathematical concept in transesophageal echocardiography for atrial septal defect device closure, preventing unnecessary device oversizing.

Stress-induced childhood-onset neurodegeneration with variable ataxia and seizures (CONDSIAS) is an exceptionally rare autosomal recessive neurodegenerative disorder. It is caused by biallelic inactivating variants in the ADP-ribosyl-serine hydrolase (ADPRS) gene that encodes for the enzyme ADP-ribosyl hydrolase3 (ARH3) involved in DNA repair. A distinctive feature of this condition is the exacerbation of clinical symptoms triggered by physical or emotional stress, as well as febrile illnesses. In this report, we describe three unrelated patients diagnosed with CONDSIAS, each having variable clinical phenotypes and responses to treatment. Patient 1 is a 26-year-old female with language delay, intellectual disability, and infrequent seizures in childhood. She later developed parkinsonism, truncal dystonia, ataxia, peripheral neuropathy, and neuropsychiatric symptoms in her second decade. Patient 2, an 8-year-old boy born to consanguineous parents, presented with infection-triggered episodic ataxia and ichthyosis. His elder sibling had suffered from progressive ataxia and succumbed to sudden death at the age of 8. Patient 3 is a 6-year-old girl who presented with progressive ataxia, myoclonus, oculomotor apraxia, and upward gaze palsy. Both patients 2 and 3 responded favourably to treatment with high-dose vitamin supplementation, while patient 1 showed stable disease progression without specific therapeutic intervention, suggesting spontaneous stabilization of her condition. Extra-neurological manifestations included ichthyosis in patients 1 and 2 and cataracts in patient 1. These three cases illustrate the heterogeneity in clinical presentation and prognosis of CONDSIAS, highlighting the occurrence of predominant extrapyramidal features and systemic involvement, thereby expanding the phenotypic spectrum beyond the typical manifestations of ataxia and seizures.

A young adult in their 20s with recurrent presyncope, a diagnosed case of complete heart block, underwent a dual-chamber pacemaker implantation with left bundle branch area pacing (LBBAP). An immediate post-procedure electrocardiogram (ECG) showed atrial and ventricular paced complexes. However, an ECG two hours later showed no pacing pulses with an extremely prolonged PR interval of 400 ms. What is the probable mechanism?

Background The effect of Ayurvedic Rehabilitation therapy (ART) in improving the sensorimotor recovery of patients with ischemic stroke is unclear irrespective of the fact that ayurveda is a commonly practiced alternate system of medicine in India and south Asia. The trial hypothesised that ayurvedic treatment is superior to physiotherapy in recovery of ischemic stroke patients. Methods We performed investigator-initiated, multi-centre prospective, parallel arm randomized, controlled trial (RCT) with blinded outcome assessment across four comprehensive stroke centres in India. Participants were randomly assigned in a 1:1 ratio to the ART arm (intervention group) or on to the conventional physiotherapy (C PT) arm (control group). The primary outcome was sensory motor recovery of upper extremity assessed using Fugl Meyer Assessment -upper extremity (FMA-UE) and secondary outcome, a composite of functional disability, activities of daily living, postural balance and quality of life at one month and three-month follow-up. The safety outcomes were serious adverse events during the study duration. Results Of 403 participants screened, 140 patients were enrolled, 70 in intervention (ART) and 70 in control (CPT) group. At three months, compared to ayurveda group, the sensory motor impairment (FMA-UE) score was significantly better in the physiotherapy group (71.97+ 23.88 Vs 81.97 +24.57, p=0.023) but after adjusting for age, stroke severity, baseline FMA-UE scale and risk factors, the group differences were not significant (p= 0.057). None of the secondary outcomes were significantly better in ayurveda group. During the trial, no major serious adverse events were reported. Conclusion This pragmatic first-ever RCT of Ayurveda in stroke looked into benefit of ayurveda treatment in first ever stroke survivors. The current intervention protocol of ART was not superior to CPT in improving the sensorimotor recovery of patients with ischemic stroke. This is the first RCT of its kind. Funding Funded by Indian Stroke Clinical Trial (INSTRuCT) Network , Indian Council of Medical Research ,registered in Clinical Trial Registry- India (CTRI/2018/04/013379)

Background Brain relaxation is attained using several techniques while sleep remains nature’s ultimate remedy. Currently, various machine learning (ML) tools are applied to identify and understand the neural correlates of relaxation from the electroencephalography (EEG) signals. Majority of earlier studies focused on comparing power in the EEG bands during eyes-open and eyes-closed resting state paradigm to train the datasets. However, several Yogic practices are performed using sitting and supine positions. Purpose This study was aimed to elucidate the relaxation correlates in EEG between supine and sitting position during eyes-closed condition using ML classifiers. Methods EEG signals were recorded on five different days from O1, OZ, O2, C3, CZ, C4, F3, FZ and F4 brain region using nine unipolar electrodes for 25 minutes during eyes-closed supine and eyes-closed sitting postures each on, along with electrocardiogram (ECG) for heart rate variability (HRV) analysis in a healthy participant. Relaxation was assessed by extracting the relative power of the alpha and theta waves from the EEG data and corroborated with the alpha and theta lateralisation index (LI) and HRV parameters. These EEG metrics were analysed by leveraging ML classifiers (K-nearest neighbours (KNN), support vector machine(SVM), random forest (RF) and XGBoost) for relaxation states under sitting and supine states. Results Out of all the used classifiers, performance indices of SVM excelled in classifying relaxation states from the EEG alpha and theta band data that was verified with the HRV data and correlated with LI. Conclusion This study demonstrates that ML especially the SVM was effective in classifying the relaxation states during different postures from the EEG. LI and HRV metrics effectively decoded the underlying message in the EEG and ECG respectively.

Background and Objectives The role of muscle biopsy needs to be redefined in an era where genetic studies have largely supplanted the need for a pathological diagnosis. The objective of the study was to evaluate the utility of muscle biopsy in suspected myopathies in terms of diagnostic confirmation and modifying therapy in a developing country. Methods We conducted a retrospective observational study of patients who underwent muscle biopsy in our center between April 2017 and 2019. The diagnostic utility and therapeutic impact of muscle biopsy were assessed descriptively and using an ordinal score. We further analyzed the correlation of the pathological diagnosis with the genetic and immunological data. Results Among the 70 patients included in the study over a 2-year period, 33 (47.1%) were aged 18 years or less and the mean age was 23.4 (±16.2) years. A specific diagnosis or diagnostic category could be established in 39 (55.7%) of all patients and 21 (63.6%) among pediatric patients by muscle biopsy. The most common categories were muscular dystrophies in 27 (38.6%) patients and inflammatory myopathies in seven (10%) patients. Mitochondrial myopathy was confirmed in two (2.9%), while three (4.3%) had other specific diagnosis and 31 (44.2%) had indeterminate/normal biopsy reports. Muscle biopsy confirmed the pre-biopsy diagnosis in 29 (41.4%) patients and changed the clinical diagnosis in 16 (22.9%) patients. Category-wise, the change in pre-biopsy diagnosis was significant only in suspected mitochondrial myopathies, but not in other categories. Conclusions Muscle biopsy helped in securing a specific diagnosis in approximately one-half of the patients. This study underscores the enduring relevance of muscle biopsy in settings where resources for advanced genetic testing and data analysis are constrained.

Background Dural arteriovenous fistulas (dAVFs) are anomalous connections between the meningeal arteries supplying the dura and the brain venous system. dAVFs are known to cause thalamic dementia, with studies showing its reversible nature post treatment. Purpose To assess changes in brain perfusion following embolization in dAVF patients using quantitative arterial spin labeling (ASL) MRI and to investigate their correlation with changes in post‐embolization cognitive status. Study Type Prospective study. Population Twenty patients with angiographically diagnosed intracranial dAVF (mean age = 45.2 years, 70% males) who underwent cognitive assessment and ASL perfusion MRI pre and post embolization. Field Strength/Sequence 3D phase contrast pseudo‐continuous arterial spin labeling (pcASL), 3D T2 fluid attenuated inversion recovery, and 3D T1 fast spoiled gradient recalled brain volume (BRAVO) sequences at 3 T. Assessment Baseline and 1 month post embolization, cerebral blood flow was assessed in the left and right thalamus, precuneus, posterior cingulate, and parahippocampal regions, with averaged bilateral values to account for laterality. Baseline and post‐embolization Addenbrooke's cognitive examination (ACE) scores were obtained in five domains (attention, memory, fluency, language, and visual orientation) and in total. Statistical Tests Paired t tests and Wilcoxon signed rank tests were performed to assess changes in brain perfusion and cognitive scores, respectively. Spearman correlation analysis was performed to assess the correlation between changes in brain perfusion and cognitive scores. Statistical significance was set at p < 0.05. Results Post‐embolization, significant increases were observed in left (35.16–42.92 mL/100 g/min) and averaged thalamic perfusion (35.25 to 40.74 mL/100 g/min). Median total ACE score (75–80), visuospatial (10–11.5), and language (20–21.5) domains also improved significantly. Positive correlations were found between increased averaged and right thalamic perfusion and improvements in memory and language scores (r = 0.55–0.58). Data Conclusion Improved thalamic perfusion post‐embolization was positively correlated with cognitive gains, especially in language and memory. ASL MRI brain perfusion has the potential to be a marker for neurocognitive status and may help in the treatment planning of intracranial dAVF. Level of Evidence 2. Technical Efficacy Stage 3.

Background and Objectives This study aimed to look at the utility of the clock drawing test (CDT) and cube construction test (CCT) in diagnosing early cognitive impairment (ECI) and the correlations among various demographic variables and neuropsychological tests. Methods This is a retrospective study with data collected from an ongoing registry. Elderly with at least 8 years of formal education were categorized into cognitively normal (CN), mild cognitive impairment (MCI), and early dementia (ED) as per established criteria. Their CDT and CCT scores were assessed using a scoring system and errors were also analysed by the principal investigator blinded to the clinical diagnosis. Results A total of 228 subjects with a mean age of 69 ± 6.7 years were categorized into three groups: 80 CN subjects, 77 with MCI, and 71 with ED. Age was negatively and the level of education was positively correlated to CDT and CCT scores among CN, but not in ECI. Qualitative errors on CDT included significantly more graphic, spatial, and conceptual errors and stimulus-bound responses among ED compared to CN and the latter two error subsets compared to MCI. Logistic regression revealed that higher age and lower quantitative CDT scores were independent predictors for classifying ECI from CN. The addition of qualitative errors of CDT rendered a greater effect size in classifying ED from MCI and CN. Conclusions CDT and CCT scores performed better in diagnosing ED and MCI from CN. CDT scored better as a diagnostic tool than CCT possibly due to better objectivity in the scoring system with qualitative information.

Postoperative hyperglycemia with ketosis immediately following fourth ventricular medulloblastoma surgery for a non-diabetic child with normal intraoperative blood glucose, is an uncommon clinical entity, and has seldom been reported in the literature. We present the management of this rare complication in a child. Surgical manipulation in and around the fourth ventricle and brainstem region may have disrupted central energy metabolic control involving the brain-islet axis, leading to impaired glucose homeostasis. Tumor’s molecular characteristics may have also contributed to altered glucose metabolism. We emphasize the importance of being aware of this rare complication for their safe management.

Background Post-residency fellowship training is essential for neurosurgeons to gain expertise in specialized subspecialties. In India, where residency programs are not standardized, inadequate exposure to subspecialties, in many institutes, drives young neurosurgeons to seek fellowship training. The fellowship landscape remains fragmented, with formal programs accredited by bodies like CAST (USA) and RCS (UK), alongside informal observer ship. Understanding the expectations and barriers faced by fellowship aspirants can help tailor Indian fellowship programs to meet these needs effectively. Objective This study aims to evaluate the needs and preferences of young neurosurgeons in India regarding fellowship training. It also seeks to understand the perspectives of fellowship directors to align aspirants’ expectations with available training opportunities. Methods and Materials A cross-sectional survey was conducted among members of the Neurological Society of India (NSI) under 40 years of age. Eligible participants included neurosurgeons in residency or within 4 years of completion. The survey assessed demographic details, residency exposure, preferred fellowship duration, location, subspecialty interests, barriers to training, and directors’ perspectives. Responses were collected electronically over 3 months. Results A total of 177 respondents participated, with 81.9% currently in or recently out of residency. Exposure to subspecialties varied significantly, with high exposure in trauma (61.5%) but low exposure in functional, epilepsy, and endovascular neurosurgery (46.3% and 43.5% reporting “less than adequate”). A majority (52%) pursued fellowships for skill enhancement, preferring domestic programs (65.5%) over international ones. The most cited barriers included financial constraints (37.9%) and relocation concerns (12.4%). Fellowship directors emphasized the need for structured training, technical proficiency, and accreditation to enhance career prospects. Conclusion This study highlights systemic gaps in Indian neurosurgical fellowship training, emphasizing the need for modular programs, improved financial aid, and standardized curricula. Strengthening domestic training infrastructure and fostering global collaborations can bridge these gaps, ensuring young neurosurgeons receive adequate subspecialty training.

Background and Objectives Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India (SPRINT INDIA) trial was a randomized control trial that enrolled 4298 stroke patients and administered educational interventions at 31 centers across India, with the aim to reduce recurrent stroke through increased stroke knowledge. This SPRINT INDIA trial post hoc study aims to investigate the incidence of recurrent stroke, high-risk transient ischemic attack (TIA), acute coronary syndrome (ACS), death, and lifestyle behavioral factors at 1 year. In addition, it examines the relationship between patients’ baseline characteristics and education levels, risk factors, and outcomes and performs subgroup analysis within the intervention and control groups. Methods Participants were randomly assigned (1:1) to either intervention or control group through computer-based randomization on web. Intervention included stroke prevention Short Message Service messages, short-duration videos, and printed workbooks. Baseline assessments captured demographic and educational data, classifying patients into three categories: no schooling, less than high school, and high school or above. Primary outcome was a composite of recurrent stroke, high-risk TIA, ACS, and mortality at 1 year. Chi-square tests and analysis of variance were used to evaluate educational disparities across various variables. Results The intervention did not reduce primary outcomes at 1 year among patients with different educational levels. Higher educational group was associated with enhanced medication adherence (94.3% vs 85.4%; P < 0.001), increased physical activity (5497.91 ± 4117.7 vs 6169.91±4828.8; P < 0.001), lower triglyceride levels, and decreased engagement in behavioral risk factors like alcohol intake (5.1% vs 6.8%; P = 0.013) and tobacco use (smoked and chewed) (4% vs 7.9%; P < 0.001 and 5.8% vs 11.6%; P = 0.020). Conclusions Personalized secondary stroke prevention, tailored to educational levels, is crucial for effective stroke management.

Introduction NCDs arise from complex interactions of modifiable factors such as unhealthy lifestyles, poor diet, and psychosocial challenges, along with non-modifiable factors like age and genetics. Notably, medication non-adherence is a widespread and growing concern, significantly contributing to disease progression and poor outcomes globally. Objective This scoping review aims to synthesize evidence on medication adherence scales used for selected non communicable diseases. It examines their development methods, psychometric properties, and assessed domains, while identifying gaps or limitations in their design and application. Materials and methods The Joanna Briggs Institute methodological framework guided this scoping review and the protocol was registered prospectively to ensure methodological transparency and rigor. Electronic databases, the reference list of included articles, and grey literature were searched. Studies published in English from January 1950 to June 2024 were included. Two reviewers independently screened all articles, and a third reviewer settled any conflicts between the reviewers. Critical appraisal of the screened-in articles was done using JBI critical appraisal scales. The data was compiled into tables and a narrative summary that is consistent with the review’s goal. Results Our study included 140 articles, identifying 57 medication adherence scales. These scales, developed using qualitative methods (10.8%), literature review (32.4%), and mixed methods (45.9%), primarily focus on behavior, often neglecting cost-related non-adherence, self-efficacy, and systemic barriers. Psychometric findings varied widely, reflecting heterogeneity in study designs and scale development approaches. Many scales lack validation in diverse settings, underscoring the need for comprehensive, context-sensitive tools. Conclusion This scoping review highlights gaps in existing medication adherence scales for NCDs, particularly their limited consideration of socioeconomic and cultural factors and incomplete adherence assessment. Future research should focus on developing more holistic, contextually relevant adherence scales that integrate these dimensions. Strengthening adherence measurement methodologies can enhance patient-centered care, inform policy interventions, and improve health outcomes.

Background Echocardiographic predictors of procedural success of redo‐percutaneous balloon mitral valvuloplasty (redo‐pBMV) have not been extensively studied, and current indications are primarily based on the Wilkins score (WS). Aim This study aims to evaluate the role of real‐time 3D echocardiography in predicting the success rates of redo‐pBMV. Methodology We analyzed 42 patients who underwent pBMV at our center from January 2022 to November 2022. These patients were divided into two groups: Group I (patients undergoing redo‐pBMV) and Group II (patients undergoing pBMV for the first time). Immediate procedural outcomes were assessed, and the 3D echocardiographic score was compared with the traditional WS. Results The mean WS was 9.69 ± 1.08 in Group I, compared to 9.5 ± 1.33 in Group II ( p = 0.575). The 3D echocardiographic analysis revealed a numerically higher 3D score in Group I (11.2 ± 1.83 vs. 10.9 ± 1.52, p = 0.631). ROC curve analysis showed an area under the curve (AUC) of 0.9785 for the 3D score, indicating that it was a better predictor of success compared to the WS (ROC AUC = 0.8289). Conclusion The real‐time 3D echocardiographic score provides a detailed morphological assessment of the mitral valve and was found to be a better predictor of procedural success than the traditional WS in patients undergoing redo mitral stenosis intervention.

Autism spectrum disorder (ASD) is characterized by deficits in social communication and interaction in various contexts, along with restrictive and repetitive behaviors. Individuals with ASD often have cooccurring neurodevelopmental, neuropsychiatric, and neurological disorders. The prevalence of epilepsy in ASD ranges from 2 to 60%. The notable association between autism and epilepsy highlight the shared neurobiological features in both conditions that include synaptic dysfunction, abnormalities in cell signalling and proliferation, chromatin modification and transcription, and an imbalance between excitation and inhibition. Recent advances in next-generation sequencing techniques have revealed similar etiological and molecular mechanisms underlying autism and epilepsy through the identification of various genes linked to their pathophysiological processes. Older age, female sex, the presence of intellectual disability, developmental delay, and severe symptoms of autism are risk factors for epilepsy reported in autistic individuals. In this review, we will focus on the underlying molecular mechanisms, clinical characteristics, predictive factors for developing epilepsy in autism, and the common genetic disorders associated with the ASD-epilepsy phenotype. Key Points • The prevalence of epilepsy in ASD ranges from 2 to 60%. • Shared pathobiology in ASD and epilepsy involves synaptic dysfunction, abnormalities in cell signalling and proliferation, chromatin modification and transcription, and excitation and inhibition imbalance. • Older age, female sex, the presence of intellectual disabilities, developmental delays, and severe symptoms of autism are risk factors for epilepsy in individuals with autism.

Interventricular septal hematoma (IVSH) is a rare complication following pediatric heart surgery involving interventricular septum (IVS). We present the case of an adult who developed IVSH after cone repair for Ebstein’s anomaly and the management challenges involved.

The successful engineering of vascular grafts that promote contractile SMC differentiation relies on a multifaceted approach that includes the selection of appropriate cell sources, materials, and environmental cues. The integration of insights from molecular regulation, stem cell biology, and material science is essential for advancing the field of vascular tissue engineering. In this study, a bilayered vascular graft was produced using the electrospinning technique. The electrospun inner layer is composed of polyvinyl alcohol co‐ethylene, which provides mechanical stability, and the outer layer is a blend composition of gelatin vinyl acetate copolymer and polycaprolactone, which provides a microenvironment for cell growth. Morphological analysis, wall thickness, and fiber diameter measurements were performed using scanning electron microscopy. Mechanical properties, fluid uptake, and degradation studies were assessed for both mono‐ and bilayer scaffolds. The findings revealed that the bilayered samples exhibited an ultimate stress, Young's modulus, and suture retention of 1.98 ± 0.15 MPa, 46.53 ± 5.3 MPa, and1.19 ± 0.58 N, respectively. Furthermore, the bilayered grafts demonstrated good cytocompatibility. The study also explores the use of all‐trans retinoic acid to initiate the differentiation of sheep adipose‐derived mesenchymal stem cells cultured on the 3D bilayered scaffold system toward smooth muscle lineage via a two‐step induction protocol. The differentiation was assessed by immunostaining for the specific markers SMA, calponin, and SM22α. The bilayered scaffold was shown to possess similar mechanical strength as native tissue and provided an ideal matrix for stem cell differentiation to smooth muscle cells and promoted vascular reconstruction.