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DR SUMESH HANDA did his MBBS from Govt Medical College, Patiala in 1996. After doing MBBS did his MD Medicine from same Medical College and stood Best Post graduate during exam. Did his DM Neurology from A Premier Centre of North India PGIMER Chandigarh. He was awarded Best S/R during an NSI Conference held at Lucknow. Afer DM he did his DNB Neurology. He credits many National and International publications.+ Read More

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Epilepsy Treatment
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Epilepsy Treatment

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Epilepsy is a common chronic neurological disorder characterized by recurrent unprovoked seizures. About 50 million people worldwide have epilepsy, with almost 90% of these people being in developing countries. Epilepsy is more likely to occur in young children, or people over the age of 65 years, however it can occur at any age.

Epilepsy is usually controlled, but usually cannot be cured with medication, although surgery may be considered in difficult cases. However, over 30% of people with epilepsy do not have seizure control even with the best available medications. Not all epilepsy treatments are lifelong – some forms are confined to particular stages of childhood.

Classification

Seizure types/ Types of Fits

Seizure/Fit types are organized firstly according to whether the source of the seizure within the brain is localized (partial or focal onset seizures) or distributed (generalized seizures). Partial seizures are further divided on the extent to which consciousness is affected. If it is unaffected, then it is a simple partial seizure; otherwise it is a complex partial (psychomotor) seizure. Generalized seizures are divided according to the effect on the body but all involve loss of consciousness. These include absence (petit mal), myoclonic, clonic, tonic, tonic-clonic (grand mal) and atonic seizures.

Conversion disorder can be distinguished from epilepsy because the episodes never occur during sleep and do not involve incontinence or self-injury.

Epilepsy syndromes

There are over 40 different types of epilepsy, including: Absence seizures, atonic seizures, benign Rolandic epilepsy, childhood absence, clonic seizures, complex partial seizures, frontal lobe epilepsy, Febrile seizures, Infantile spasms, Juvenile Myoclonic Epilepsy, Juvenile Absence Epilepsy, Hot Water Epilepsy, lennox-gastaut syndrome, Landau-Kleffner Syndrome , myoclonic seizures, Mitochondrial Disorders, Progressive Myoclonic Epilepsies, Psychogenic Seizures , Reflex Epilepsy, Rasmussen's Syndrome, Simple Partial seizures, Secondarily Generalized Seizures, Temporal Lobe Epilepsy, Tonic-clonic seizures, Tonic seizures, Psychomotor Seizures, Limbic Epilepsy, Partial-Onset Seizures, generalised-onset seizures, Status Epilepticus, Abdominal Epilepsy, Akinetic Seizures, Autonomic seizures, Massive Bilateral Myoclonus, Catamenial Epilepsy, Drop seizures, Emotional seizures, Focal seizures, Gelastic seizures, Jacksonian March, Lafora Disease, Motor seizures, Multifocal seizures, Neonatal seizures, Nocturnal seizures, Photosensitive seizure, Pseudo seizures, Sensory seizures, Subtle seizures, Sylvan Seizures, Withdrawal seizures, Visual Reflex Seizures amongst others.

Idiopathic epilepsies are generally thought to arise from genetic abnormalities that lead to alteration of basic neuronal regulation. Symptomatic epilepsies arise from the effects of an epileptic lesion, whether that lesion is focal, such as a tumor, or a defect in metabolism causing widespread injury to the brain. Cryptogenic epilepsies involve a presumptive lesion that is otherwise difficult or impossible to uncover during evaluation.
People who only have had a single seizure, or those with seizures that occur only after specific precipitants ("provoked seizures"), have "epilepsies" that fall into this category. Febrile convulsions are an example of seizures bound to a particular precipitant. Below are some common seizure syndromes:

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Movement Disorder
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Movement Disorder

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Movement disorders include:
• Akathisia
• Akinesia (lack of movement)
• Associated Movements (Mirror Movements or Homolateral Synkinesis)
• Athetosis (contorted torsion or twisting)
• Ataxia
• Ballismus (violent involuntary rapid and irregular movements)
• Hemiballismus (affecting only one side of the body)
• Bradykinesia (slow movement)
• Cerebral palsy
• Chorea (rapid, involuntary movement)
• Sydenham's chorea
• Rheumatic chorea
• Huntington's disease
• Dystonia (sustained torsion)
• Dystonia muscularum
• Blepharospasm
• Writer's cramp
• Spasmodic torticollis (twisting of head and neck)
• Dopamine-responsive dystonia (hereditary progressive dystonia with diurnal fluctuation or Segawa's disease)
• Geniospasm (episodic involuntary up and down movements of the chin and lower lip)
• Myoclonus (brief, involuntary twitching of a muscle or a group of muscles)
• Parkinson's disease
• Restless Legs Syndrome RLS (WittMaack-Ekboms disease)
• Spasms (contractions)
• Stereotypic movement disorder
• Stereotypy (repetition)
• Tardive dyskinesia
• Tic disorders (involuntary, compulsive, repetitive, stereotyped)
• Tourette's syndrome
• Tremor (oscillations)
o Rest tremor (4-8 Hz)
o Postural tremor
o Kinetic tremor
o Essential tremor (6-8 Hz variable amplitude)
o Cerebellar tremor (6-8 Hz variable amplitude)
o Parkinsonian tremors (4-8 Hz variable amplitude)
o Physiological tremor (10-12 Hz low amplitude)
• Wilson's disease

Treatment

Treatment depends upon the underlying disorder.

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Multiple Sclerosis
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Multiple Sclerosis

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Multiple sclerosis (abbreviated MS, also known as disseminated sclerosis or encephalomyelitis disseminata) is a disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms. Disease onset usually occurs in young adults, and it is more common in females. It has a prevalence that ranges between 2 and 150 per 100,000. MS was first described in 1868 by Jean-Martin Charcot.

Although much is known about the mechanisms involved in the disease process, the cause remains unknown. Theories include genetics or infections. Different environmental risk factors have also been found.

Almost any neurological symptom can appear with the disease, and often progresses to physical and cognitive disability. MS takes several forms, with new symptoms occurring either in discrete attacks (relapsing forms) or slowly accumulating over time (progressive forms). Between attacks, symptoms may go away completely, but permanent neurological problems often occur, especially as the disease advances.

There is no known cure for MS. Treatments attempt to return function after an attack, prevent new attacks, and prevent disability. MS medications can have adverse effects or be poorly tolerated, and many patients pursue alternative treatments, despite the lack of supporting scientific study. The prognosis is difficult to predict; it depends on the subtype of the disease, the individual patient's disease characteristics, the initial symptoms and the degree of disability the person experiences as time advances. Life expectancy of patients is nearly the same as that of the unaffected population.
Classification

Progression of MS subtypes

Several subtypes, or patterns of progression, have been described. Subtypes use the past course of the disease in an attempt to predict the future course. They are important not only for prognosis but also for therapeutic decisions
1. relapsing remitting,
2. secondary progressive,
3. primary progressive, and
4. progressive relapsing.

The relapsing-remitting subtype is characterized by unpredictable relapses followed by periods of months to years of relative quiet (remission) with no new signs of disease activity. This describes the initial course of 85–90% of individuals with MS. When deficits always resolve between attacks, this is sometimes referred to as benign MS, although patients will still accrue some degree of disability in the long term. Secondary progressive MS (sometimes called "galloping MS") describes around 65 % of those with an initial relapsing-remitting MS, who then begin to have progressive neurologic decline between acute attacks without any definite periods of remission. Occasional relapses and minor remissions may appear. The primary progressive subtype describes the approximately 10–15% of individuals who never have remission after their initial MS symptoms. Progressive relapsing MS describes those individuals who, from onset, have a steady neurologic decline but also suffer clear superimposed attacks. This is the least common of all subtypes.
Multiple sclerosis also behaves differently in children, taking more time to reach the progressive stage. Nevertheless they still reach it at a lower mean age than adults.

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Myasthenia Gravis
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Myasthenia Gravis

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Myasthenia gravis is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatiguability. It is an autoimmune disorder, in which weakness is caused by circulating antibodies that block acetylcholine receptors at the post-synaptic neuromuscular junction, inhibiting the stimulative effect of the neurotransmitter acetylcholine. Myasthenia is treated medically with cholinesterase inhibitors or immunosuppressants, and, in selected cases, thymectomy. At 200–400 cases per million it is one of the less common autoimmune disorders.

Signs and symptoms
The hallmark of myasthenia gravis is fatiguability. Muscles become progressively weaker during periods of activity and improve after periods of rest. Muscles that control eye and eyelid movement, facial expression, chewing, talking, and swallowing are especially susceptible. The muscles that control breathing and neck and limb movements can also be affected.

The onset of the disorder can be sudden. Often symptoms are intermittent. The diagnosis of myasthenia gravis may be delayed if the symptoms are subtle or variable.

In myasthenic crisis a paralysis of the respiratory muscles occurs, necessitating assisted ventilation to sustain life. In patients whose respiratory muscles are already weak, crises may be triggered by infection, fever, an adverse reaction to medication, or emotional stress


Pathophysiology
Myasthenia gravis is an autoimmune channelopathy: it features antibodies directed against the body's own proteins. Up to 75% of patients have an abnormality of the thymus; 25% have a thymoma, a tumor (either benign or malignant) of the thymus, and other abnormalities are frequently found. The disease process generally remains stationary after thymectomy (removal of the thymus).

The acetylcholine receptor.
In MG, the autoantibodies are directed most commonly against the nicotinic acetylcholine receptor (nAChR) , the receptor in the motor end plate for the neurotransmitter acetylcholine that stimulates muscular contraction. Some forms of the antibody impair the ability of acetylcholine to bind to receptors.

 

Associated condition
Myasthenia Gravis is associated with various autoimmune diseases, including:
• Thyroid diseases, including Hashimoto's thyroiditis and Graves' disease
• Diabetes mellitus type 1
• Rheumatoid arthritis
• Lupus, and
• Demyelinating CNS diseases

In pregnancy
In the long term, pregnancy does not affect myasthenia gravis.

Diagnosis
Myasthenia can be a difficult diagnosis, as the symptoms can be subtle and hard to distinguish from both normal variants and other neurological disorders. A thorough physical examination can reveal easy fatiguability, with the weakness improving after rest and worsening again on repeat of the exertion testing.

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Intensive Care Unit
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Intensive Care Unit

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Intensive-care unit

An intensive care unit (ICU), critical care unit (CCU), intensive therapy unit or intensive treatment unit (ITU) is a specialized department used in many countries' hospitals that provides intensive care medicine. Many hospitals also have designated intensive care areas for certain specialities of medicine, as dictated by the needs and available resources of each hospital. The naming is not rigidly standardized.

Equipment and systems
Common equipment in an ICU includes mechanical ventilator to assist breathing through an endotracheal tube or a tracheotomy opening; cardiac monitors including telemetry, external pacemakers, and defibrillators; dialysis equipment for renal problems; equipment for the constant monitoring of bodily functions; a web of intravenous lines, feeding tubes, nasogastric tubes, suction pumps, drains and catheters; and a wide array of drugs to treat the main condition(s). Medically induced comas, analgesics, and induced sedation reduce pain and prevent secondary infections.

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Nerve Conduction Study
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Nerve Conduction Study

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A nerve conduction study (NCS) is a test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body.

Purposes
Nerve conduction studies are used mainly for evaluation of paresthesias (numbness, tingling, burning) and/or weakness of the arms and legs. Some of the common disorders which can be diagnosed by nerve conduction studies are:
• Peripheral neuropathy
• Carpal tunnel syndrome
• Ulnar neuropathy
• Guillain-Barré syndrome
• Facioscapulohumeral muscular dystrophy
• Spinal disc herniation

Description
The nerve conduction study consists of the following components:
• Motor NCS
• Sensory NCS
• F-wave study
• H-reflex study

Motor NCS
Motor NCS are performed by electrical stimulation of a peripheral nerve and recording from a muscle supplied by this nerve. By stimulating in two or more different locations along the same nerve, the NCV across different segments can be determined.

Sensory NCS
Sensory NCS are performed by electrical stimulation of a peripheral nerve and recording from a purely-sensory portion of the nerve, such as on a finger.

F-wave study
F-wave study uses supramaximal stimulation of a motor nerve and recording of action potentials from a muscle supplied by the nerve.


 H-reflex study
H-reflex study uses stimulation of a nerve and recording the reflex electrical discharge from a muscle in the limb.
Interpretation of nerve conductions
The interpretation of nerve conduction studies is complex, but in general, different pathological processes result in changes in latencies, motor and/or sensory amplitudes, or slowing of the conduction velocities to differing degrees.

Patient risk
Nerve conduction studies are very helpful to diagnose certain diseases of the nerves of the body. The test is not invasive, but can be a little painful due to the electrical shocks. The shocks are associated with a low amount of electrical current so they are not dangerous to anyone. Patients with a permanent pacemaker or other such implanted stimulators such as deep brain stimulators or spinal cord stimulators must tell the examiner prior to the study. This does not prevent the study, but special precautions are taken.

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Electroencephalography

Electroencephalography

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Headache Health Treatment Services
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A headache or cephalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the pain-sensitive structures around the brain. Several areas of the head and neck have these pain-sensitive structures, which are divided in two categories: within the cranium (blood vessels, meninges, and the cranial nerves) and outside the cranium (the periosteum of the skull, muscles, nerves, arteries and veins, subcutaneous tissues, eyes, ears, sinuses and mucous membranes).

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