Saturday, August 12, 2017



Amyotrophic lateral sclerosis (ALS) is an uncommon degenerative disease of nervous system, mainly affecting the motor nerves. The common symptoms of ALS include weakness of arms and legs, difficulty in swallowing & speaking and breathing problem. The symptoms of ALS continue to get worse over time and most people die within 3-5 years after diagnosis, often due to respiratory failure.
                                          Stephen Hawkings (suffering from ALS)      AFP

There is no cure available for ALS. There is only one medication, RILUZOLE, which was approved for treating ALS in 1995. Riluzole can be used to slow down the deterioration in muscle strength. However, it has limited benefit in most patients. (In India, riluzole is offered free of cost to patients with ALS by Sun Pharmaceuticals). 

Now, there is a new hope for patients with ALS. A new medicine, EDARAVONE INJECTION, has been approved by US FDA to treat patients with ALS.

What is basis of Edaravone efficacy?

A research was conducted in Japan on more than 100 patients suffering from ALS. Edaravone injections were given for a period of six months. After six months, patients who received edaravone had better functional status and better quality of life (as compared to those who did not receive edaravone). 

Which patients with ALS would benefit from Edaravone injections?

Patients with ALS of less than two years duration, with mild disease severity, would benefit from edaravone. In addition, they should not suffer from any respiratory failure. 

What is the treatment regimen?

Patients are given edaravone injection 60 mg per day as intravenous infusion (given over 60 minutes) for 14 days. Then there is a gap of 14 days. Edaravone injection is supplied as 30 mg/20 ml vials (in India). In US, it is usually supplied as 30 mg in 100 ml. So, two vials would be needed per day. 

In second month, the injection is given on 10 out of 14 days. There is a gap of 14 days. This is continued for five months. 

So, in total, patient receives 64 doses of edaravone injections (60 mg each time) over a period of six months.

How long is the treatment continued?

As of now, there is efficacy and safety data for six months, so, it should be continued for total of six months, as per the schedule mentioned above. 

Is Edaravone treatment safe?

Yes, there are no serious adverse effects with edaravone. Minor side effects are similar to placebo. 

Do we need to reduce the dose of Edaravone in patients with kidney or liver disease?

There is no need to reduce the dose in patients with renal or liver function impairment. 

What is the cost of edaravone injections?

Each 30 mg vial costs about INR 400 (in India). So, the per day cost is about INR 800. The total cost of 64 days course of edaravone would be INR 51,200 (approximately 800 USD). Additional room rent, nursing charges, doctors fees, etc may be incurred. 

How about Riluzole?

Riluzole tablets should be continued together with edaravone injections. 

So, in summary, now we have a new drug for ALS, which is the first drug approved in 22 years for ALS after Riluzole. 

Consultant Neurologist
Apollo Hospitals, Hyderabad

Friday, July 14, 2017


The traditional method of consultation involves a patient visiting a doctor's clinic. The doctor takes history, performs clinical examination, orders investigations (as necessary) and prescribes medicines. This is the "gold standard" when it comes to accurate diagnosis and correct treatment.
However, there are a number of limitations for the traditional method of consultation: 
1. Lack of time on the patient's side due to his/her work/family assignments; 
2. Lack of a specialist in his native place; 
3. Limited number of choices of specialists in his native place; 
4. Higher costs (travel costs, need to skip work, etc).
In this digital era, telemedicine consultations are feasible. This could include email chatting, audio or video consultation. By this method, a patient can choose a doctor in any part of the world, timing of consultation can be flexible and the costs are lower.
However, the major concern is the accuracy of telemedicine consultation. This issue was addressed in a recent research in patients with nonacute headaches. About 200 patients were treated on the basis of telemedicine consultation and another 200 patients with traditional method of consultation. At the end of one year, there was no difference in the outcomes in either group.
There is a fear of missing secondary causes of headache such as brain tumor, bleeding in brain, infection of brain, etc. One would need to provide 20,200 consultations by telemedicine to miss one such case. That is an extremely low risk.
In conclusion, telemedicine consultation seems to be an ideal alternative to traditional consultation for patients with nonacute headaches.
This study was published in recent issue of Neurology Journal (July 14, 2017 issue) and can be accessed at the below link:

Friday, June 16, 2017



Major Symptoms of Parkinson’s disease
Parkinson’s disease (PD) is a progressive neurological disease, characterised by tremors, rigidity, slowness of movements and postural imbalance. Though it is more common after the age of 40, people younger than 40 can also get affected (when it is known as young onset PD).
Other symptoms of PD include low volume speech (sometimes totally incomprehensible), expressionless face, reduced blink rate, reduced arm swing while walking, stooped posture, small handwriting (called micrographia), short-shuffling steps, tendency to fall forwards. Many people also have pain and aches in the affected limbs. Sleep disturbance and restless leg syndrome are common comorbid illnesses in people with PD. Severe memory impairment is NOT a feature of PD, however, in advance PD, mild memory impairment may occur in about 10% of patients. Similarly, loss of bladder control or erectile dysfunction is not a feature of PD. When these features are present, one should suspect multiple system atrophy (MSA).
Diagnosis of PD
The diagnosis of PD is still best made on the basis of clinical examination by an experienced neurologist (preferably trained in movement disorders, though not a must). PET and DaT scans are available to help in the diagnosis of PD, but they are not superior to a good clinical examination by an experienced neurologist.
Treatment of PD
Treatment of PD is still primarily medical and DBS is not the first option.
The most effective medicine is levodopa-carbidopa combination. If a patient does not respond to levodopa treatment, we should doubt the diagnosis (it may not be PD). Even though levodopa is the most effective medication, we should delay starting it by 2-3 years, to avoid side effects and lack of efficacy later on. Other medications in use are pramipexole, ropinirole, trihexiphenydyl, selegiline, rasagiline, amantadine, entacapone, safinamide, etc.
Role of Deep Brain Stimulation (DBS) surgery in PD
DBS was approved for PD in 2002. In the past 15 years, about 1,35,000 patients worldwide have undergone DBS for PD.
What does DBS surgery involve?
A neurosurgeon places the leads (thin wires) that carry electrical signals to specific areas of the brain. Then, the surgeon places a battery-run neurostimulator (like a pacemaker) under the skin of the chest.

The surgeon may use a programming device to adjust the settings. You may have a device, similar to a remote control, which allows you to turn the system on and off and check the battery. You may also be able to adjust the stimulation within options programmed by your doctor.
A neurologist initially evaluates a patient to determine whether he or she is the right candidate for DBS surgery. Then, further evaluations include brain imaging (MRI, CT, PET, etc), neuropsychological testing, UPDRS scoring, etc. Once the patient is found to be suitable for DBS, he is referred to the neurosurgeon.
Which patients are likely to benefit from DBS surgery?
1.     The diagnosis of PD should be definite.
2.     Patient has had PD for five years or more.
3.     Patient continues to respond to levodopa, even though the response may or may not be good.
4.     There are motor fluctuations, such as on-off phenomena, with or without dyskinesia.
5.     Various medical treatments have not had desired benefit.
6.     PD symptoms are severe enough to interfere with activities of daily living.
Which patients are NOT likely to benefit from DBS surgery?
1.     Patients with atypical Parkinsonian symptoms,
2.     Patients with multiple system atrophy (where bladder and sexual dysfunction are prominent symptoms),
3.     Patients with progressive supranuclear palsy,
4.     Patients with dementia or severe cognitive impairment,
5.     Patients with unstable psychiatric illnesses,
6.     Patients with advanced PD, who are confined to bed/wheelchair; despite being on medications,
7.     Patients with NO response to levodopa therapy,
Who are the best candidates for DBS surgery in PD?
1.     Excellent response to levodopa therapy,
2.     Younger age,
3.     Mild or no cognitive impairment,
4.     Few or no axial (affecting neck or trunk) motor symptoms,
5.     Absence of or well controlled psychiatric disease.
Are there any complications of DBS surgery?
DBS surgery is generally safe if performed by a trained group of specialists. However, complications may occur in upto 3% of patients, which include:
1.     Bleeding (hemorrhage) in the brain,
2.     Infection,
3.     Stroke,
4.     Speech impairment
5.     Erosion, migration or fracture of the lead,
6.     Death
What to expect after DBS surgery?
Most patients report a reduction in severity of symptoms after surgery. Tremors, dyskinesia, slowness all respond to the surgery.
PD medications, however, can not be stopped even after DBS. Most patients still need to take medications, however, at much lower doses.
The benefits are seen at five years after surgery, however, the effect tends to wane in later years.
DBS does not alter the disease progerssion, and disease continues to get worse even after DBS.
Is MRI safe after DBS?
Yes, MRI can be safely done after DBS surgery.
What is the cost of DBS surgery ?
The cost of surgery is approximately INR 9,00,000 to 10,00,000.

Dr Sudhir Kumar MD (Med) DM (Neuro)
Senior Consultant Neurologist
Apollo hospitals, Hyderabad


Thursday, December 8, 2016




1. Irresistible urge to move legs accompanied by uncomfortable or unpleasant sensations in the legs,
2. The urge to move legs is more during periods of immobility or rest,
3. The urge is partially or completely relieved by movement,
4. The urge to move legs is more in evenings or nights as compared to day time (or is present only during evenings or nights).

These symptoms should occur at least three times per week, and should be present for at least three months, before we can put a label of RLS. Also, these symptoms should cause significant distress or impairment in social, occupational and daily life. 

85% of patients with RLS also have periodic leg movements (involuntary forceful dorsiflexion of foot lasting 0.5-5 seconds, occurring every 20-40 seconds throughout sleep) at nights. 

Many people suffering from RLS also have sleep disturbance at nights and daytime fatigue. 

What age-group patients are affected with RLS?

Symptoms of RLS may start in infancy, however, most patients are diagnosed in their middle ages. There is often a delay of 10-20 years in diagnosis.

RLS is quite common and about 5-15% of population may be affected. 

Women are more commonly affected than men, in a ratio of 2:1. 

What are the causes of RLS?

Majority of cases of RLS are idiopathic (no obvious cause) due to a disturbance in brain neurotransmitters (dopamine or serotonin). These are also called primary RLS. 25-75% of idiopathic RLS is familial with a genetic component. Familial cases start early (<45 years of age) and progress slowly.

RLS is called secondary RLS, if it is caused due to another disease. There are several such causes:

  • Peripheral neuropathy,
  • Iron deficiency,
  • Folate deficiency,
  • Magnesium deficiency,
  • Diabetes mellitus,
  • Rheumatoid arthritis,
  • Renal failure,
  • Vitamin B12 deficiency,
  • Frequent blood donation,
  • Pregnancy,
  • Drug-induced (neuroleptics, antidepressants, beta blockers, lithium, alcohol, caffeine).
Are there any tests needed to confirm the diagnosis of RLS?

No tests are needed to confirm a diagnosis of RLS, and the diagnosis can be made on the basis of clinical symptoms. Tests may be done to exclude secondary causes of RLS. 

What is the long-term outcome in patients with RLS?

The symptoms of RLS get worse over time and most have significant problems after age 50. Sleep impairment is common. There is increased risk of getting hypertension and headaches (including migraines). 

How is RLS treated?

There are effective medications available to treat RLS:

1. Dopamine agonists: ropinirole, pramipexole, rotigotine, cabergoline.
2. Levodopa,
3. Gabapentin or pregabalin,
4. Opioids in severe cases. 

Senior Consultant Neurologist
Apollo Hospitals, Jubilee Hills, Hyderabad
Phone- 040-23607777/60601066 

Wednesday, September 7, 2016



Brain is, without any argument, the most important organ of our body. We depend on brain to ensure better performance of all useful activities, be it related to our jobs or household chores. Some of the important functions of brain include memory, reasoning, judgment, language, calculation, etc. Having understood the importance of brain and its functions, it is equally important to understand the measures needed to take good care of the brain.

Nutritious diet, regular physical activity, freedom from stress and anxiety, sound & adequate sleep, regular brain “exercises” (solving crossword puzzles, Sudoku, etc), preventing head injury and avoiding smoking, are important measures that ensure good brain health.

The purpose of this article is to emphasize the important role played by silence in the wellbeing of brain. Who has not heard this- “If speech is silver, silence is gold”!

In our daily lives, we are surrounded by different kinds of noise and sounds most of the time. These include sound of vehicles, loud music, ringing of smartphones, and so on. This “noise pollution” has a detrimental effect on our brain and body. Various research studies have shown that exposure to noise leads to higher incidence of elevated blood pressure, which is an important risk factor for heart attacks and brain strokes. Noise pollution also causes impairment of hearing; sleep disturbances, and problems with memory and concentration. Studies have concluded that children exposed to households or classrooms near airplane flight paths, railways or highways have lower reading scores and are slower in their development of cognitive and language skills.  

If noise has so much of adverse effects on brain, silence should have just the opposite effect- and it is indeed so.
1. Silence leads to lowering of heart rate and blood pressure. This effect on BP lowering is seen with as little as two minutes of silence. Lowering the BP would lead to a lesser incidence of brain strokes.
2. Silence is relaxing and rejuvenating. In this 24X7 work environment with exposure to various sounds, our brain gets muddled and then, we cannot focus and concentrate. Therefore, we need periods of quiet and calm to allow our brains to recharge. Some people use music to relax. While music does relax the brain, it is interesting to note that silence has far greater effects on brain relaxation than music.
3. Silence promotes better sleep. We have all experienced the difficulties in falling or maintaining good sleep, when exposed to sounds or noise. In silent environment, on the other hand, sleep is sound and relaxing. Better sleep translates into better functioning of brain. Growth hormone is secreted in brain during sleep. Consolidation of memory and learning also occurs during sleep. Good sleep is also a stress buster and lowers BP.
4. Silence may improve memory. In an interesting experiment conducted on mice, it was found that exposing them to two hours of silence per day led to development of new neurons in the hippocampus area of the brain. Hippocampus is mainly involved in memory, emotion and learning. So, there is a high possibility that these brain functions would improve, if one is exposed to even short periods of silence on daily basis.
5. Silence is a stress buster. When a person is stressed and anxious, one of the best and easiest quick fixes is to take rest (sit or lie down) in complete silence. While it may be tempting to get a counseling done by a family member or a psychologist for stress, it is equally important to have periods of silence to overcome stress.
6. Silence improves our ability to concentrate and focus. In our daily lives, we are constantly exposed to stimuli- sounds as well as sights. This makes our brains foggy and inattentive, leading to difficulty in concentrating. In this situation, the ability to solve problems or to come up with new ideas is greatly hampered. Silence, even for short periods, comes to our rescue in this condition. Silence makes the brain fresh and energetic. One can solve complex problems and come up with bright new ideas after a brief period of silence.
7. Silence helps us tap the hidden talents and strengths in our own brain. Brain has immense capacity and resources, which largely remain untapped. This is because one cannot look deep inside his brain, when exposed to distractions of sounds/noise. On the other hand, in a silent environment, one can daydream, fantasise or think and be more creative. As Herman Melville once wrote, "All profound things and emotions of things are preceded and attended by silence."
8. Silence reduces the risk of heart attacks and brain strokes by reducing plaque formation in the arteries. 
All these beneficial effects of silence on brain should prompt us to seek silence everyday in our busy lives, even if it is for a brief period. Moreover, sitting in silence is free, easily accessible, and has no side effects.

This article was modified and published in September 2016  issue of B POSITIVE magazine, a heath and wellness magazine.