31/M, Rt. handed, Engineer, Oct. 2003 - C/o Neck pain and occipital headache - 1 month. On 10/11/2003 - had an episode of blurring of vision associated with headache, slurring of speech and vomiting - Lasting 3-4 hours. On 22/11/2003 - had acute onset of blurring of vision associated with gait ataxia, headache, vomiting and slurred speech. Became drowsy 3 hours later. CT - Brain done was normal. Next day MR - Brain showed lesions in B/L thalami, hypothalami, Lt. cerebral peduncle and Sup. cerebellar hemispheres. Started on anti-platelets and clexane 60 mg. S/c bid, then shifted to BH. Past H/o - used to do jerky twisting movements of neck. On Ex ( 25/11/2003) - Conscious obeys verbal commands, had restricted horizontal eye movements with absence of vertical movements with extensor plantars. Relevant investigations were normal except for elevated homocysteine levels. Same treatment continued. MR - Angio showed absence of flow in Lt. VA, Lt. SCA, distal BA and P1 segment of both PCA. No evidence of dissection. On 2/12/2003 - Pt sensorium worsened. Repeat MRA showed fresh infarcts in Lt. inf cerebellar area with partial recanalisation of Lt. VA but distal basilar and P1 segment of B/L PCA were not seen. Same day DSA done showed thrombus at BA bifurcation, Prox. SCA and B/L PCA. Prox., thrombotic occlusion of Lt VA with normal distal flow with evidence of dissection in Lt. VA. ASA was arising distal to dissection. 1000 units Heparin injected into Lt VA during DSA. On 3/12/2003 - Pt sensorium worsened further, became unconscious. Urgent CT - Brain showed mod. cerebellar haematoma with raised ICT. Anti-platelets and LMWH stopped. Pt underwent post. fossa decompression with insertion of Rt ventricular drain. After 3 days, pt gradually regained consciousness with spontaneous eye opening and occasionally obeying simple verbal commands. Following neuro-surgical intervention, pt has developed CNS-infection and is currently undergoing Rx for the same in ICU.

Uncontrolled hypertension (HT) is an established risk factor for the development of vascular diseases. Prevalence varies in different communities and no such study has been conducted in the Parsi community living in Mumbai, India. The objective of this study was to determine the prevalence of HT in this community.

We used a 1 in 4 random selection of subjects who were ³ 20 years of age. A questionnaire was administered and the blood pressure (BP) was measured by a doctor. HT was defined as diastolic blood pressure (DBP) > 90 mm Hg ± systolic pressure (SBP) > 140 mm Hg. Isolated systolic hypertension (ISH) was defined as SBP ³ 160 mm Hg with DBP < 90 mm Hg. Subsequently, we reanalysed the data using current definition of ISH as SBP ³ 140 mm Hg with DBP < 90 mm Hg.

Results
2879 subjects ³ 20 years of age were randomly selected of which 2415 (84%) participated in the study (45.5% men and 54.5% women). Prevalence of HT (including ISH) using current criteria was 32.8% in men and 39.4% in women (mean 36.4%). The prevalence of ‘diastolic’ HT peaks at the 50-59 years age group in both men (24.3%) and women (24.2%). Prevalence of ISH and overall prevalence progressively increases with age; in those ³ 70 years overall prevalence was 52.8% in men and 72.9% in women. Prevalence of ISH was 6.9% using the SHEP criteria and 19.5% (15% in men and 23.3% in women) using the current criteria. The proportion of hypertensives suffering from ISH increases with age; in those ³ 70 years 75.6% of men and 82.1% of women with HT had ISH rather than ‘diastolic’ HT.

Conclusion
This study shows that prevalence of HT in the Parsi community is high with more than one-third the adult population having HT. Prevalence of HT progressively increases with age with more than 60% of those ³70 years having HT. In the elderly, the major form of HT is ISH, with more than 75% of hypertensives ³ 70 years having ISH. The overall prevalence of HT, especially ISH, is significantly more in women than in men. The study highlights the need for regular screening to detect and treat HT and ISH, conditions which are known to result in significant morbidity and mortality when left untreated.

Multiple sclerosis (MS) is an autoimmune disease involving predominantly the white matter of the brain and spinal cord. It is one of the common neurological disorders of younger adults and substantial cause of neurological disability. Immunosuppressive agents - Interferon beta - 1b, interferon beta - 1 a and glatiramer acetate are approved for remitting - relapsing multiple sclerosis. These drugs are expensive and many patients in India cannot afford its cost of treatment. Mitoxantrone is the first drug approved for the treatment of secondary progressive MS and worsening relapsing-remitting MS. We have used this drug in view of economical consideration of our patients and also the toxicity of the drug is reported to be low in the dosage used. Presentation considers use of mitoxantrone in MS including its pharmacology, selection criteria for treatment and potential for serious toxicity in individual patients. An ongoing assessment is presented an open study wherein, 13 patients till date have been selectively administered least one dose of mitoxantrone, given as 12 mg/m2 intravenously, every 3 months for a duration of 24 months. We have 4 patients who have received more than one dose of mitoxantrone. Clinical assessment of using kurtze expanded durability score has shown disease stabilization in these patients. Mitoxantrone may have a beneficial effect of disease progression in patients with relapsing MS whose clinical condition is worsening. It may also reduce acute exacerbations in remitting relapsing MS.

No single clinical feature is diagnostic of multiple sclerosis (MS). Obtaining objective evidence of dissemination in space and time of vision either clinically or in combination with laboratory or para-clinical (MRI, VEP and BAER) investigations is essential for diagnosis of MS. MRI imaging is integrated into diagnostic scheme in recent reviews because of its unique sensitivity to pathologic change. Aim of the study is to observe various MRI changes in central nervous system in patients of MS diagnosed on clinical bases alone (CDMS - clinically definite multiple sclerosis). Total of 85 patients (F:M 48:36) who were diagnosed to have clinically definite MS were included in the study. Mean age in females was 30 years and males 34 years. MRI scan of brain and spinal cord was studied with respect to characteristic lesions which are more likely MS. They were a) T2 W hyperintense lesions - multiple > 9. b) 3 or more periventricular lesions c) 1 or more infra-tentorial lesions. d) one or more juxta cortical lesions. Pattern of gadolinium enhancement of any. Repeat scans which were available in few patients were looked for any fresh lesions appearing other time. Our results show that 52.9% patients had multiple (73) periventricular lesions, 47% had one or more infra-tentorial lesion, 34.1% had multiple white matter lesions (79) including cerebrum, cerebellum, brain stem and spinal cord. 38% of patients had spinal cord lesion and 9% lesions in brain were Juxta-cortical. Although contrast was given in only 50 patients, 10 scans show gadolinium enhancement (20%). In 8 out of 15 patients, repeat MRI scan showed new lesions other time, which was done between 3 months and 2 years after initial scan. Conclusion : MRI scan features typical in MS were seen in majority of patients studied. Spinal cord involvement is more common in Indian subjects. Large scale studies are required to determine sensitivity and specificity of these MR lesions in Indian MS patients.