Blood-transfusion-related posterior reversible encephalopathy syndrome - A description of a new case and review of the literature.

Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome associated with headache, altered mental status, seizures, and visual disturbances and characterized by white matter vasogenic edema affecting predominantly the posterior occipital and parietal lobes of the brain. Neurological complications of blood transfusion are uncommon, and blood-transfusion-related PRES is seldom reported. We report here one such case of PRES. A 61-year-old Asian woman with chronic anemia presented with a history of fall, causing fracture of the left femur neck. As her hemoglobin was 5 g per deciliter, she was transfused with four units of packed cells in three consecutive days. At the time of admission, she was alert, normotensive, and afebrile. Later, she developed mild headache and had a generalized tonic-clonic seizure. Her brain magnetic resonance (MR) imaging showed edema in bilateral frontal lobes and parieto-occipital lobes with normal MR venogram, consistent with PRES. We described her disorder as blood-transfusion-related PRES. Immunologic, as well as non-immunologic complications of blood transfusion, are known but, PRES is rare. Cumulative effects of blood transfusion on blood flow, blood viscosity, endothelial dysfunction leads to blood-brain barrier dysfunction, which culminates into vasogenic edema and vasoconstriction despite normal systemic blood pressure, leading to blood-transfusion-related PRES.

Twenty-and-a-half syndrome: a case report.

BACKGROUND: In the list of named numerical neuro-ophthalmological syndromes, such as one-and-a-half syndrome and others, we report for the first time twenty-and-a-half syndrome, which is characterized by one-and-a-half syndrome with bilateral seventh and right fifth nerve palsy (1.5 + 7 + 7 + 5 = 20.5) in a patient with ischemic stroke. CASE PRESENTATION: A 45-year-old Asian Hindu woman presented with vomiting and imbalance of 1 day's duration. She had left-sided ataxic hemiparesis with one-and-a-half syndrome with bilateral seventh and right fifth nerve palsy. Magnetic resonance imaging of her brain revealed acute non-hemorrhagic infarct in the right posterolateral aspect of pons and medulla, with normal brain vessels angiography. We described her disorder as twenty-and-a-half syndrome. She was put on antiplatelet therapy. CONCLUSIONS: Twenty-and-a-half syndrome is reported for the first time. It is due to posterior circulation stroke; in our case, it was due to lacunar infarcts in the pons and medulla, manifesting as one-and-a-half syndrome with bilateral seventh and right fifth nerve palsy.

Determinants of Remission in Medically Treated Carpal Tunnel Syndrome: Study from Central India.

BACKGROUND: The factors associated with the spontaneous remission (SR) of symptoms in carpal tunnel syndrome (CTS) are not well known. OBJECTIVES: To look for determinants of SR in medically treated, electrophysiologically proven patients of CTS. METHODS: We revisited the medical records and nerve conduction study data of 130 hands with CTS and divided them into two groups as per the absence or persistence of the symptoms when contacted after a median time lapse of 3 years following the diagnosis. RESULTS: SR occurred in 46.1% of the hands. Higher odds of SR were linked with female gender, symptoms restriction to lateral fingers, symptom duration <10 months, mildly delayed median motor and sensory distal latencies, and median sensory amplitude >20 µV. We developed a seven-point scale, on which a score of ≥4 had a strong association (odds ratio 4.31) with SR. DISCUSSION AND CONCLUSION: No single risk factor, standalone, can predict SR in patients with CTS, which could lead to an invasive treatment (Surgery or local injection) to them. We propose that patients scoring ≥4 on our 7 point scale should be treated medically for the initial 10 months after the symptom onset.

Value of Motor Nerve Conduction Studies in the Diagnosis of Idiopathic Tarsal Tunnel Syndrome: A Single-center Prospective Observational Study from India.

BACKGROUND: Nerve conduction studies are considered to be the gold standard for diagnosing secondary tarsal tunnel syndrome (s TTS), but their utility in the diagnosis of idiopathic tarsal tunnel syndrome (i TTS) is largely unknown. OBJECTIVE: We sought to investigate the value of motor nerve conductions studies (MNCS) in the diagnosis of clinically suspected iTTS. MATERIALS AND METHODS: Twenty-six (52 limbs) adult patients of clinically suspected iTTS were subjected to motor nerve conductions of posterior tibial nerve, and its branches and motor conduction parameters were compared with those of 45 healthy controls. RESULTS: Symptoms were bilateral in 70% (P = 0.02), with heel pain in 95% of symptomatic limbs. MNCS was abnormal in 32 (80%) of symptomatic limbs and 8 (66.6%) of asymptomatic limbs (P = 0.004). Out of electrophysiologically abnormal nerves (n = 67), the pathological process could be identified in all the nerves with abnormal MNCS (P = 0.02). Probable demyelination was seen in 58.2% of the electrophysiologically abnormal nerves. DISCUSSION: The present study shows that iTTS are gender and Body Mass Index neutral with bilateral symptoms being common. Tinel's sign was inconsistent. Heel pain did not correlate with abnormal inferior calcaneal nerve conductions. Motor nerve conduction study was abnormal in a significant number of symptomatic limbs. "Probable demyelination" was more frequent in symptomatic limbs. CONCLUSION: MNCS is significantly abnormal in symptomatic limbs of subjects with iTTS. Demyelination is slightly more common than axonopathy in iTTS. With a sensitivity of 80% and specificity of 33.3%, MNCS seems to be useful as a screening tool in clinically suspected iTTS. This study is Level II: Lesser quality randomized controlled trial or prospective comparative study.

Outcome of Myasthenia gravis treated with high-dose prednisolone and azathioprine: A single centre ambispective study from India.

PURPOSE: Myasthenia gravis (MG) is treated with many disease modifying therapies, namely corticosteroids, thymectomy and immunosuppressants, alone or in various combinations. But still, till today no consensus over the optimum therapy for MG has been made. METHODS: Out of total 101 patients with MG, 37 patients fulfilled the inclusion criteria and in them we ambispectively studied factors affecting the outcome in MG treated, to induce leukopenia, with prednisolone (PSL) plus azathioprine(AZA), from January 1993 through July 2014. Patients were grouped according to the outcome: pharmacological remission (PR), complete stable remission (CSR), non-remitter and remitters with or without relapse. Their demographic characteristics, MGFA Class, dose of PSL and AZA, time to achieve remission, duration of remission, leukocyte counts, thymus status, follow-up duration, results of repetitive nerve stimulation, and side effects profile were compared. RESULTS: Total 81% patients remitted; PR (83%) was commoner than CSR (p=0.003). Factors favoring remission were early onset disease, therapeutic leukopenia (p=0.003) and longer follow-up (OR5, p=0.08); those associated with relapse were abnormal thymus (CI-1.1-3.4; p=0.09), MGFA class IIb (CI 0.9-3; p=0.09) and male gender. Side effects occurred in 48%. CONCLUSION: Aggressive therapy with prednisolone plus azathioprine induces remission in a high percentage of patients with generalized MG.