Monday, November 6, 2017



1. STROKE is a disease that affects:
A. Heart
B. Brain
C. Kidney
D. Lungs
2. Common symptoms of stroke include:
A. severe chest pain
B. Fits or convulsions
C. Paralysis of face, arms, legs, slurred speech
D. Breathing difficulty
3. If someone suffers from stroke at 9 PM,
A. He can go to OPD the next day
B. He should rush to the nearest general physician
C. He should rush to a hospital with 24X7 CT scan and neurologist on call
D. He can try home remedies for the night.
4. Is there a treatment available for patients with stroke, which would minimise disability
A. Yes
B. No
5. Common risk factors for stroke include all the following EXCEPT
A. Diabetes mellitus
B. Hypertension
C. Running on treadmill
D. Smoking
6. Which of the following measures is NOT helpful in preventing a recurrence of stroke in a person who has suffered stroke?
A. Taking Aspirin
B. Controlling BP and sugars,
C. Quitting smoking,
D. Skipping breakfast, if overweight
7. Physiotherapy helps in better and faster recovery of stroke survivors.
A. True
B. False
8. Stroke affects only older people
A. True
B. False
9. Proportion of population that may suffer a stroke in their lifetime
A. 1 in 10
B. 1 in 8
C. 1 in 6
D. 1 in 4
10. Stroke is treated by
A. Neurologist
B. Cardiologist
C. Nephrologist
D. Chest physician
Please go through these questions and answer them. Answers are posted below
Thank you for going through the questions. Here are the answers:
1. B
Stroke affects brain. It most commonly occurs due to blockage of blood supply to a part of the brain. In some cases, it can also occur due to rupture of a blood vessel.
2. C 
Common symptoms of stroke include sudden onset facial weakness, weakness of arm or leg, slurred speech, loss of vision on one side, imbalance while walking or severe headache.
3. C
Stroke is a medical emergency. The brain tissue can suffer irreversible damage, if not treated within the first four hours. Therefore, the patient should be rushed to a hospital with 24X7 CT scan facility. The treatment is administration of clot-buster therapy under the guidance of a neurologist.
4. A
Clot-buster therapy with tissue plasminogen activator or tenecteplase within the first four and a half hours after stroke onset can minimise disability.
5. C
Running on treadmill is a healthy exercise and protects from stroke.
6. C
Skipping breakfast is an unhealthy habit. Moreover, it does not help in reducing weight.
7. A
Physiotherapy is very helpful in faster recovery of stroke survivors. It should be started as early as possible.
8. B
Stroke predominantly affects older people, however, it can affect all ages, including children.
9. C
Stroke is a common cause of death and disability (along with heart attacks and cancer) in the world, and affects i in 6 people in their lifetime.
10. A
Stroke is a disease of brain and is treated by neurologist.
I hope you enjoyed this mini-quiz. I would love to hear your comments or any further queries.

Dr Sudhir Kumar MD DM
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad



Choice of foods is important, when it comes to prevention and treatment of certain neurological disorders. The article on this topic was published in November 2017 issue of B Positive magazine, a health and wellness magazine.

Dr Sudhir Kumar MD DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad

Sunday, October 29, 2017


On the occasion of World Stroke Day (29th October), an article published in Times of India newspaper, to raise awareness about the diagnosis, treatment options and prevention of stroke. 

The article can be accessed in Times of India (Hyderabad edition), dated 29th October 2017 (Page 31), at the following link:

Dr Sudhir Kumar MD DM
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad

Tuesday, September 12, 2017



The mind is probably the strongest organ of the body. When the mind believes, anything is achievable, nothing is impossible! It is said, success or failure is more often decided in the mind, than the actual event itself. Thus, in the toughest sports tournaments, the players with stronger mind usually prevail.

Traits of a Strong Mind
A strong mind always looks at the positive aspect of things, because with regard to everything in life, there are both, positive and negative aspects.
·      Winners always focus on the positive aspect. Halfway in a marathon race, a person with a weak mind thinks, “half the distance is still yet to go and I may not be able to complete it well”. On the other hand, a person with a strong mind thinks, “I have finished half the race well, I can easily finish the second half equally well”. Needless to say, the runner with the stronger mind succeeds.
·      A person with a strong mind has a lot of self-belief. “When you do not believe in yourself, how can others believe in you?” So, you need to strongly inculcate the sense of self-belief in yourself at all times. This is considered as s stepping stone towards success.
·      Another feature of a person with strong mind is that he/she is always hopeful. They always hope for and expect a good outcome. Even when the whole world thinks otherwise, a person with strong mind always hopes for success. You would certainly agree to this one- how many times you have seen players winning a match from almost a losing position?! So, it is obvious that unwavering hope and self-belief are important for winning, even from “losing situations”.
·      A person with a strong mind looks at only the good qualities in another person and oversees the bad traits. Every individual has both good and bad qualities. It is always easy to focus on negative qualities of a person and criticize him. It takes a person with strong mind to focus on good qualities of others and appreciate them. This virtue makes them appear more congenial among masses. After all, no one likes a person who is always critical about him or her.
·      The most important quality in a person with strong mind is their ability to control emotions. Emotions and sensitivity are important for good social interactions; however, exaggerated emotional responses may interfere with daily life. A person with a weak mind may suffer from sadness and depression after a failure. On the other hand, a person with strong mind treats failure as a medium to work on flaws and successfully outgrows them. If one remains pre-occupied with negative emotions after a failure, there is no time and energy left to sharpen the skills to excel later. However, the person with a strong mind puts the failure behind and works harder in order to succeed at the next available opportunity.
·      Anger is a negative emotion, which a person with strong mind lacks. Strong-minded people are able to smile at all instances and events and strongly believe in letting bygones be bygones, because they know that anger does not solve a problem; on the contrary, it may aggravate it. Everyone likes a smile and appreciation- who likes getting reprimanded?! There is no wonder, then that people who often smile have a large number of admirers as compared to those who get angry with small issues.

The Making of a Strong Mind
From the above discussion, it is quite evident that a strong mind is vital for a fulfilling and successful life. So, is the “strong mind” inherited from one’s ancestors or can one do something to make the minds stronger? Well, here’s how you can build a strong mind. Just follow these methods:
1.     Regular exercises not only help you making physically fit, but also impacts your memory and thinking skills. There is a release of good chemicals such as endorphins and dopamine post-exercise, which elevate our mood and keeps depression away. So, stay active!
2.     Good nutrition is important to keep the brain strong. Timely balanced meals are the key. So, dig into foods that are good for the brain. These foods include fish, eggs, broccoli, asparagus, spinach, blueberries, dry fruits like almonds and walnuts, etc.
3.     Ensure adequate sleep of seven to eight hours at night, as it relaxes the body and mind. The mind gets re-energized after a restful sleep and is ready to take on the everyday challenges of life.
4.     The brain gets bored and inactive with a monotonous schedule and activities, and the risk of cognitive impairment increases with this schedule. On the other hand, challenging the brain with newer activities, such as learning a new language or playing a musical instrument, would make the brain sharper and stronger. This also boosts the self-confidence in a person.
5.     Avoiding smoking and alcohol as both these vices  have a negative influence on brain and mind functions, making them weaker and prone to mental illnesses.
6.     Socialize whenever you can! Isolation and loneliness are detrimental to brain and mind and make them weaker. On the other hand, greater social interactions, especially spending quality time with family and friends are healthy for brain and makes it stronger.

(This article was first published in the September 2017 issue of B POSITIVE, a health and wellness magazine)

Dr Sudhir Kumar MD DM (Neurology)
Apollo Hospitals, Hyderabad

Wednesday, August 23, 2017



Antibiotics are commonly prescribed for treating infections. Although they are generally safe, sometimes, rare and serious adverse effects can occur.
In a recent research study, fluoroquinolones and tetracycline group of antibiotics were found to increase the risk of developing benign intracranial hypertension (BIH). Fluoroquinolones include some commonly used antibiotics such as ciprofloxacin, levofloxacin, norfloxacin, ofloxacin and moxifloxacin.
The adverse event of BIH was noted within 15 day and 30 day period of starting fluroquinolones. The risk of developing BIH was about five times more than non-users. 

Patients with BIH present with headache, double vision and tinnitus (ringing sound in ears). If left untreated, there is a risk of vision loss.
Fluoroquinolones can also increase the risk of seizures and confusion, especially in older people.
The research study was published in the August 22, 2017 issue of Neurology Journal and can be accessed at the following link:

1. Fluoroquinolones can increase the risk of BIH, and hence caution is needed while prescribing them.
2. Patients who are taking fluoroquinolone antibiotics, and develop headache, double vision or tinnitus, should consult a neurologist.
3. Patients who have suffered from BIH in the past should avoid using fluoroquinolones, as much as possible.

Consultant Neurologist
Apollo Hospitals, Hyderabad

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