Normotensive state during acute phase of hypertensive intracerebral hemorrhage.

Objectives: Hypertensive hemorrhage is a leading cause of intracerebral haemorrhage (ICH), although some of these patients may not present with high blood pressure (BP) at the time of ICH. Materials and Methods: This retrospective study included patients with history of hypertension presenting with ICH. Patients with systolic BP recording of more than 140 mmHg were included in hypertension group (group I). Patients whose BP rose to hypertension range after fluid correction were included in group II and patients with BP <140 mmHg on consecutive 1-week BP recordings were included in group III. Clinical features including volume of ICH of all the three groups were noted. Outcome in the form of mortality was analyzed. Chi-square test was used for categorical variables and independent t-test for continuous variables. P < 0.05 was considered significant. Results: Ninety-two ICH patients with history of hypertension were included in the study. Of them, 20 patients (22%) presented with BP <140 mmHg systolic at the time of ICH. After fluid correction, it rose to hypertensive range in 9 (10%) but remained normal in 11 patients (12%) during consecutive recordings for 1-week post-admission. On comparing normotensive and hypertensive groups, significant difference was seen in survival and volume of ICH. Conclusion: There is a subset of hypertensive patients who may present with normal BP recording during acute ICH. The BP rises subsequently with the correction of hypovolemia in some. The volume of hemorrhage in normotensives is relatively small but whether this translates into better prognosis needs further studies.

Neurocysticercosis or tuberculoma - Which one has more epileptic potential?

PURPOSE: The duration of antiepileptic drug (AED) treatment in the management of seizures due to ring enhancing lesions (REL) remains a matter of debate. We undertook a prospective cohort study to look into the seizure patterns and incidence of recurrence in association with two of the most common causes of RELs after gradually stopping AEDs at least 18 months after acheiving seizure control. METHODS: Ninety patients with neurocysticercosis (NCC) and twenty-nine patients with tuberculoma were treated with anti-helminthic and anti-tubercular drugs according to current recommended guidelines, and followed up for a minimum of 2 years after the last seizure free day. In every patient included in the study, AEDs were tapered within six months of attaining a seizure-free interval of 18 months. We looked at the incidence of recurrent seizures after stopping AEDs in both groups of patients. RESULTS: The frequency of baseline seizures (2.1 vs 1.5 per year, p < 0.001) and number of antiepileptic drugs (2.12 vs 1.48, p < 0.001) were greater in patients with NCC than those with tuberculoma. Patients with NCC had a greater incidence of recurrent seizures (1.17 vs 0.07 in the next six months, p < 0.001) after stopping the AEDs. The median interval to seizure recurrence after stopping AEDs was 2.2 months in patients with NCC. CONCLUSIONS: Among RELs, NCC lesions have a greater epileptogenic potential than tuberculomas. AEDs can be tapered in patients with tuberculoma after a seizure free period of 18 months with a very low risk of recurrence.

Antibody Negative Autoimmune Encephalitis- Does it Differ from Definite One?

CONTEXT: Autoimmune encephalitis (AE) is an emerging cause of non-infective encephalitis, presentations of which vary widely. Traditionally the diagnosis of AE is based on detection of antibodies in a patient with clinical picture suggestive of AE. AIM: To evaluate the clinical characteristics and response to immunotherapy in patients with antibody negative autoimmune encephalitis and to compare them with definite cases. SETTINGS AND DESIGN: A prospective follow-up study was done in patients presenting with presumptive symptoms of AE from January 2017 to January 2019. The study was done in a tertiary care institute of Northern India. PATIENTS AND METHODS: Demographic and clinical parameters were noted and relevant investigations for management were done according to well-defined protocol. The patients were treated with immunomodulatory therapy in the form of steroids and/or intravenous immunoglobulins (IVIg). They were followed up for treatment response and relapse at 2 monthly intervals. STATISTICAL ANALYSIS USED: The data was expressed as either proportions or mean/median. Chi-square test/Independent T test was used to compare antibody positive and antibody negative group. RESULTS: Out of 31 patients with presumptive AE, 16 patients tested positive for autoimmune antibodies (definite AE). Incidences of seizure, behavioral abnormalities, dementia and altered sensorium were similar between the 2 groups (p > 0.05). Complete or partial response was seen in all treated patients in both groups with no significant difference (p 0.716). CSF protein concentration and cellularity were higher in the definite group although only high protein concentration could reach statistical significance (p 0.002). Malignancy could be confirmed after extensive search in 2 out of 16 patients with definite AE and in 1 out of 15 antibody negative AE patients. CONCLUSIONS: Clinical presentation of antibody negative cases does not differ significantly from definite ones. Since treatment response is also similar in both the groups, starting immunotherapy in a patient presenting with presumptive symptoms of AE, while ruling out other common mimickers, seems to be the need of the hour in the management of this evolving entity.