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To investigate the opinions of physicians about brain surgery for drug-resistant epilepsy worldwide.Practicing neurologists, psychiatrists, and neurosurgeons from around the world were invited to participate in an online survey. The survey anonymously collected data about demographics, years in clinical practice, discipline, nation, work setting, and answers to the questions about beliefs and attitudes about brain surgery for drug-resistant epilepsy.In total, 1410 physicians from 20 countries and different world regions participated. The propensity to discuss brain surgery with patients, who have drug-resistant seizures, was higher among men (versus women) [Odds Ratio (OR) 1.67, 95% CI 1.20-2.31; p = 0.002]. In comparison to neurologists, psychiatrists were less likely (OR 0.28, 95% CI 0.17-0.47; p 0.001) and neurosurgeons were more likely (OR 2.00, 95% CI 1.08-3.72; p = 0.028) to discuss about it. Survey participants working in Africa, Asia, the Middle East, and the Former Union of Soviet Socialist Republics showed a lower propensity to discuss epilepsy surgery with patients.This study showed that on an international level, there is still a knowledge gap concerning epilepsy surgery and much needs to be done to identify and overcome barriers to epilepsy surgery for patients with drug-resistant seizures worldwide.

To investigate the opinions and attitudes of neurologists on the counseling about sudden unexpected death in epilepsy (SUDEP) worldwide.Practicing neurologists from around the world were invited to participate in an online survey. On February 18th, 2021, we emailed an invitation including a questionnaire (using Google-forms) to the lead neurologists from 50 countries. The survey anonymously collected the demographic data of the participants and answers to the questions about their opinions and attitudes toward counseling about SUDEP.In total, 1123 neurologists from 27 countries participated; 41.5% of the respondents reported they discuss the risk of SUDEP with patients and their care-givers only rarely. Specific subgroups of patients who should especially be told about this condition were considered to be those with poor antiseizure medication (ASM) adherence, frequent tonic-clonic seizures, or with drug-resistant epilepsy. The propensity to tell all patients with epilepsy (PWE) about SUDEP was higher among those with epilepsy fellowship. Having an epilepsy fellowship and working in an academic setting were factors associated with a comfortable discussion about SUDEP. There were significant differences between the world regions.Neurologists often do not discuss SUDEP with patients and their care-givers. While the results of this study may not be representative of practitioners in each country, it seems that there is a severe dissociation between the clinical significance of SUDEP and the amount of attention that is devoted to this matter in daily practice by many neurologists around the world.

Background: Migraine is a common primary headache disorder and Episodic migraine is characterized by the occurrence of up to 14 headache days in a month. The preventive treatment of migraine is useful in patients with frequent migraine attacks, impaired activities of daily living, failure of acute pain management, disabling aura and limitations in the use of acute treatment. It is aimed at reducing headache frequency and intensity, improve response to acute treatment of migraine and improve the quality of life. Aim: To analyze the evidence for the efficacy and tolerability of preventive oral drugs used in the management of episodic migraine. Methods: A narrative review of the references were reviewed by searching the literature for the articles published in PubMed in English language using all the following MeSH keywords “preventive treatment”, “preventive oral treatment”, AND “episodic migraine”, “migraine”. Results: Out of articles identified in the search, 38 articles were reviewed for evidence and summarized. The various oral drugs used in the prevention of episodic migraine are antihypertensives (beta-blockers, calcium channel blockers and Angiotensin-converting enzyme inhibitors/Angiotensin receptor blockers), antidepressants (tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors), antiepileptic drugs (valproic acid, topiramate, lamotrigine) and other miscellaneous agents. HURT questionnaire and HALT 30 index are useful in assessing response to treatment in the follow up of migraine patients. Conclusion: An appropriately chosen oral drug is useful in the preventive treatment of episodic migraine. In patients, who fail to respond to the preventive treatment, it is essential to review the diagnosis of migraine, titrate the dosage and duration of preventive treatment and ensure patient compliance. In those patients who fail to respond to monotherapy, polytherapy is a useful option to be considered.

Background The risk of falls in people with Multiple Sclerosis (MS) is much greater than that of the general population due to impaired coordination, gait, sensation, muscle tone, strength, and cognition. These MS related falls hamper the day to day living of these individuals and are one of the prime factors aggravating the disease related morbidity. The fear of falling itself may make these individuals more dependent and hinder their professional and leisurely activities. Hence, the significance of identifying individuals who are at risk of falling and instituting preventive counter-measures cannot be overemphasized. Various simple clinical tests and questionnaires have been recommended for this purpose, but are far from ideal. Objective The objective was to find accurate measures to predict a future fall in MS patients. We also aimed to enquire about the prevalence of falls in MS population and its clinical profile which included detailed history about the past falls, Expanded disability status scale (EDSS) scores, Timed 25 foot walk (T25FW) scores, Activities specific balance confidence (ABC) scores, Falls efficacy scale international (FESI) scores, Multiple Sclerosis Walking Scale 12 (MSWS12) questionnaire. Design/Methods This was a prospective cohort study conducted at the Institute of Neurology, Chennai from January 2015 to August 2017. MS patients of any subtype attending Neurology OPD satisfying revised 2010 McDonald criteria were recruited. 134 subjects with MS consented to participate in this study and 113 of them who met the criteria were included. Baseline history was obtained about the number of falls in the previous year. EDSS, T25FW, ABC, FESI, and MSWS12 scores were obtained at the baseline. VEMP and SEP tests were done and the baseline P13/N23 cVEMP latencies, N10 oVEMP latency, and P37 lower limb SEP latency were obtained. These subjects were followed up for one year and were enquired if they had fallen during that period and the number of falls was recorded. Logistic regression models were used to compute the area under receiver operating characteristic curve (AUC) for each variable tested. Pearson correlation coefficients were calculated for each variable with the number of future falls. Results Among the 113 patients, 72% (n = 81) had one or more falls during follow-up. Among all variables tested P13 cervical VEMP latency had the highest predictive accuracy (AUC = 0.820) followed by N10 ocular VEMP latency (AUC = 0.794) and P37 SEP latency (AUC = 0.732). P13 latency also had the highest correlation coefficient (R = 0.689, R2 = 0.475) with the number of future falls. Conclusion P13, N10 and P37 latencies were the most accurate in predicting a future fall when compared to clinical measures.

Background Although cognitive fatigue plays a significant part in Multiple Sclerosis (MS) related impairment, knowledge regarding it is largely lacking. Until now, not many tools are available to a clinician to detect cognitive fatigue. The subjective tools of fatigue have never been reliable.tabl Objectives To assess the prevalence and clinical/ demographic profile of cognitive fatigue in MS using novel clinical and electrophysiological measures and to find their accuracy. We also aimed to test the three leading hypotheses - the temporal fatigue, cognitive load and cognitive domain hypotheses of cognitive fatigue in MS. Methods 50 consecutive MS patients attending the Neurology OPD in Madras Medical College, Chennai from May 2015 to February 2016 satisfying the 2010 revised McDonald criteria for MS with an equal number of matched controls were recruited. Modified versions (a shorter version, and longer and more demanding versions) of the Stroop test, symbol digit modalities test, and serial addition tests were used in addition to modified tests of P300 latency and amplitude each specifically tailored to reveal cognitive fatigue. Results Out of the seven measures of cognitive fatigue used, 46% (n=23) of MS patients had impairment in two or more of the scores compared to that of 8% (n=4) in the healthy control group. The Expanded disability status scale (EDSS) scores were significantly higher for MS patients with cognitive fatigue compared to those without. All the clinical and electrophysiological measures used in this study had a relatively high sensitivity and specificity. In addition, all the clinical measures correlated with the electrophysiological measures of cognitive fatigue in this study. Our data also supported all three hypotheses implying that cognitive fatigue in MS may be a multifaceted entity. Conclusion Cognitive fatigue is widely prevalent in MS and can be detected with specific tools. The tools developed and described in this study may be used as an effective means of detecting cognitive fatigue in MS patients and thus allowing patients to realise their limitations. Institution of appropriate remedial measures like advising such patients to break up a more cognitively demanding task into smaller subtasks may help to improve their quality of life.

Atrial fibrillation is a common arrhythmia that increases the risk of stroke by 4.5 times. Anticoagulant/antithrombotic therapy in atrial fibrillation has been inconsistent and inappropriate. Warfarin enjoyed the monopoly of being the primary medication used to reduce the risk of thromboembolic events. Warfarin has many limitations in its use as an ideal anticoagulant. To overcome this difficulty, now there are two main alternative groups to warfarin namely, direct thrombin inhibitors (ximelagatran and dabigatran) and factor Xa inhibitors (apixaban, rivaroxaban, edoxaban, etc.). The advantages of the newer anticoagulants over the conventional warfarin are numerous. There are three landmark trials which have shown some light to the path of newer anticoagulant era, which include the following: RE-LY, ROCKET AF and ARISTOTLE. Head to head comparison of warfarin with newer anticoagulants showed the superiority of newer anticoagulants over warfarin in terms of efficacy and favorable side effect profile. After few decades of using warfarin, it‘s high time to enter into the era of newer anticoagulants and bid adieu to warfarin.