MRI of the brain mimicking autoimmune encephalitis in Sjögren syndrome with chorea: a case report.

Neurologic manifestations in primary Sjögren syndrome (SS) range in prevalence from 8 to 49%, and most of the studies suggest a prevalence of 20%. The incidence of SS patients developing movement disorders is about 2%. Case presentation: The authors herein report a case of a 40-year-old lady with MRI of the brain mimicking autoimmune encephalitis in SS who presented with chorea. Her MRI findings revealed T2 and FLAIR (fluid-attenuated inversion recovery) high signal intensity areas in bilateral middle cerebellar peduncles, dorsal pons, dorsal midbrain, hypothalami, and medial temporal lobes. Clinical discussion: There is still no evidence to support the definite use of MRI in characterizing the central nervous system involvement in primary SS, especially due to overlapping findings with age and cerebrovascular disease. Multiple areas of increased signal intensity in periventricular and subcortical white matter in FLAIR and T2-weighted image is commonly seen in primary SS patients. Conclusion: It is crucial to consider autoimmune diseases like SS as a cause of chorea in adults, even in those whose imaging findings are suggestive of autoimmune encephalitis.

Wallerian degeneration in the brain after organophosphorus poisoning: a case report.

The type, quantity, and potency of the organophosphorus compound (OPC) taken determine the symptoms of OPC poisoning as well as their severity. The exact etiology for organophosphorus (OP) poisoning delay neuropathy regulating Wallerian degeneration is still unknown. Case Presentation: We report here a rare case of a 25-year-old lady with Wallerian degeneration in the brain found in an MRI in a patient after OPC ingestion. MRI of the brain, in our case, shows Wallerian degeneration of the corona radiata, internal capsule, and midbrain. Clinical Discussion: Some OPCs can lead to OP-induced delayed neuropathy, a form of delayed neurotoxicity in humans (OPIDN). The distal axonopathy's (in OPIDN) morphological pattern resembles Wallerian degeneration, which happens in vitro following nerve damage. Although delayed Wallerian degeneration from organophosphate poisoning often affects the peripheral nervous system, it can also affect the central nervous system. Rehabilitation therapy combined with appropriate nursing care has been demonstrated to improve the disease. Conclusion: Central nervous system involvement after OP poisoning is rare, and MRI of the brain and spinal cord can document evidence of Wallerian degeneration after OP poisoning.

Stroke patterns and outcomes during the second wave of COVID-19 pandemic: a cross-sectional study.

The coronavirus disease 2019 (COVID-19) pandemic has affected the number of stroke activations, admission of patients with various types of strokes, the rate and timely administration of reperfusion therapy, and all types of time-based stroke-related quality assessment metrics. In this study, we describe the different types of strokes, different delays in seeking and completing treatment occurring during the second wave of the COVID-19 pandemic, and predictors of outcome at 3 months follow-up. Materials and methods: This is a single-centered prospective cross-sectional study carried out from May 2021 to November 2021, enrolling patients with stroke. Data collected were demographic characteristics, stroke types and their outcomes, and different types of prehospital delays. Results: A total of 64 participants were included in the study with a mean age of 60.25±15.31 years. Ischemic stroke was more common than hemorrhagic stroke. The median time of arrival to the emergency room of our center was 24 h. The most common cause of prehospital delay was found to be delays in arranging vehicles. The median duration of hospital stays [odds ratio (OR)=0.72, P<0.05] and baseline NIHSS (National Institute of Health Stroke Scale) score (OR=0.72, P<0.05) were found to be a predictor of good outcomes at 3 months follow-up on binary logistic regression. Conclusion: The factors that cause the delayed transfer to the hospital and onset of treatment should be addressed. Patient counseling about the likely prognosis can be done after evaluating the probable outcome based on the NIHSS score and median duration of hospital stay. Nevertheless, mechanisms should be developed to reduce the prehospital delay at the ground level as well as at the policy level.

Dyslipidemia in Acute Non-cardioembolic Ischemic Stroke Patients at a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Acute ischemic stroke is the second most common cause of death after ischemic heart disease worldwide and Nepal's top five diseases based on Disability-Adjusted Life Years. Dyslipidemia is a major risk factor for coronary heart disease but has an unclear role in the pathogenesis of ischemic stroke. The objective of this study was to find the prevalence of dyslipidemia in acute non-cardioembolic ischemic stroke patients at a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among 76 patients with acute noncardioembolic ischemic stroke admitted in the Neuromedicine unit of a tertiary care centre from August 2017 to July 2018. Ethical approval was obtained from the Institutional Review Committee of the same institute (Reference number: 478/2020). Patients underwent baseline investigations, including fasting lipid profile and Computed Tomography Scan/Magnetic Resonance Imaging head. Data were analysed using Statistical Package for the Social Sciences version 21.0. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Results: The prevalence of dyslipidemia among the acute non-cardioembolic ischemic stroke patients was 35 (46.05%) (35.05-57.05 at 95% Confidence Interval) where high total cholesterol was diagnosed in 11 (31.43%), high triglycerides in 25 (71.43%), high low-density-lipoprotein in 10 (28.57%), and low high-density-lipoprotein in 11 (31.43%) patients. Conclusions: The prevalence of dyslipidemia among acute non-cardioembolic ischemic stroke patients at our tertiary care centre is higher than the similar studies done in similar settings. Keywords: cardioembolic stroke; dyslipidemia; ischemic stroke; lipid; lipoprotein.

Dengue encephalitis featuring "double-doughnut" sign - A case report.

Introduction: Dengue is a common febrile illness caused by Dengue virus and spread by Aedes mosquitoes. The neurological complications like encephalopathy or encephalitis or immune-mediated neurological syndromes are uncommon though. Discrete neuroimaging findings in this setting are even rarer. We report a case of dengue encephalitis with uncommon MRI features in a young female. Case presentation: The patient presented with complains of fever, vomiting, weakness in all limbs and difficulty in speech. Neurological examination revealed bilateral horizontal gaze palsy with impaired oculo-cephalic reflex, bulbar dysarthria and quadriplegia with bilateral planters up-going. Laboratory reported anemia, thrombocytopenia and positive NS1 antigen while excluding other tropical and immunological diseases. Brain MRI revealed extensive thalamic involvement as unique "double-doughnut" sign along with lesions in brainstem. The patient received supportive treatment in intensive unit and was discharged following improvement in clinical condition and laboratory reports. Clinical discussion: Dengue can infect the central nervous system directly as encephalitis or can have neurological consequences following multi-organ dysfunction and shock as encephalopathy or post-infection immunological syndromes as Guillain-Barré Syndrome or cerebrovascular complications or dengue muscle dysfunction. The MRI appearance of "double-doughnut" sign points towards dengue encephalitis in appropriate setting. Conclusion: A high index of suspicion is required to make a diagnosis of dengue encephalitis. The "double-doughnut" sign in MRI sequences has the potential to become a diagnostic marker for dengue encephalitis.

Delayed Visual Loss in a Patient with Snake Bite: Case Report of an Unusual Neuro-Ophthalmic Presentation.

Neurotoxin-related optic neuritis (ON) after snake bite is uncommon. Here, we present a case of a 70-year-old female who developed bilateral painless loss of vision after she received treatment with anti-snake venom (ASV). She had only perception of light on assessment of visual acuity on admission which then improved drastically after administration of intravenous methylprednisolone (MP) after making the provisional diagnosis of ON on the basis of history and clinical findings of the patient. Imaging and visual-evoked potential could not be done initially, and they were done after the administration of intravenous MP which had normal findings. ASV, though being a lifesaving treatment, has been sometimes associated with ON.

Guillain-Barré syndrome following coronavirus disease vaccine: First report from Nepal.

ChAdOx1 nCoV-19 is an effective and well-tolerated coronavirus disease 2019 vaccine. However, rare cases of serious adverse events have been reported with it. We report a patient who did not have active or prior coronavirus disease 2019 infection, who developed Guillain-Barré syndrome 7 days following the first dose of ChAdOx1 nCoV-19 vaccination. He was treated with intravenous immunoglobulin, with stabilization of the disease. Proper monitoring and prompt reporting of such cases are required to ensure the safety of the vaccine.

Isolated extrapontine myelinolysis with neuropsychiatric manifestation: A case report from Nepal.

A referred case of a 34-year-old woman was brought to the emergency room with features of mutism and whole-body rigidity following rapid correction of hyponatremia. On presentation, she was ill looking with tremors on her both hands and legs. She was unresponsive to command and developed involuntary outbursts of laughter and crying. Based on clinical features and neuroimaging, diagnosis of isolated extrapontine myelinolysis was made. She was treated with quetiapine, vitamin B1 and B12 supplements, trihexyphenidyl, levodopa-carbidopa and physiotherapy of limbs. Due to lack of clinical trials for adequate diagnosis and management of extrapontine myelinolysis, this case report highlights the importance of extrapontine myelinolysis with neuropsychiatric manifestation in research world.

Recurrent Bilateral Optic Neuritis Associated with Myelin Oligodendrocyte Glycoprotein Antibody: A Case Report from Nepal.

Neuromyelitis optica spectrum disorder (NMOSD) is an immune-mediated inflammatory condition involving spinal cord and optic nerves. Diagnosis of NMOSD is done by aquaporin-4 antibody (AQP4) in patients with optic neuritis. Myelin oligodendrocyte glycoprotein (MOG) expressed on the oligodendrocyte cell surface and on the outermost cell surface of the myelin sheath may also be present in patients with NMOSD bilateral optic neuritis. Here, we describe a case of a thirty-nine-year-old-female with recurrent bilateral optic neuritis with positive anti-MOG antibody, and anti-MOG syndrome has not previously been reported from Nepal.

Predictors of outcome in refractory generalized convulsive status epilepticus.

OBJECTIVE: Refractory status epilepticus is a serious condition in which seizure continues despite use of two antiepileptic medications. Retrospective studies have shown that 29%-43% of SE patients progress into RSE despite treatment. Mortality following RSE is high. We aimed to evaluate the predictors of outcome in patients with RSE at a tertiary care center. METHODS: Sixty-eight consecutive patients with RSE who presented to our hospital between February 2018 and January 2020 were evaluated for outcome. RESULT: In our study 28(41.2%), patients who failed to respond to first- and second-line antiepileptic drug responded to the third-line antiepileptic drug thus avoiding mechanical ventilation and intravenous anesthesia. Low GCS at admission (P < .001), need for mechanical ventilation and intravenous anesthesia (P = .018), and long duration of RSE before recovery (P = .035) were strongly associated with worse outcome. Duration of RSE before starting treatment (P = .147), previous history of seizure (P = .717), and age of the patient (P = .319) did not influence the outcome. SIGNIFICANCE: In our study, we prospectively evaluated patients with RSE and followed them for one month after discharge from the hospital. Unlike some of the previous studies, we identified an interesting finding whereby a significant proportion of the patients responded to the third-line antiepileptic drug and thus avoiding the complications related to mechanical ventilation.