A Retrospective Observational Study of Neurological Manifestations in COVID-19 (SON-CoV).

OBJECTIVES: Coronavirus disease 2019 (COVID-19) has neurologic manifestations associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study aimed to retrospectively analyze SARS COVID-19 patients with neurological manifestations and identify patterns of presentation including the site of neuroaxis involvement, neuroimaging, and associated systemic involvement. METHODS AND SUBJECTS: This retrospective observational study was conducted at two tertiary care hospitals in western Rajasthan. Data on age, sex, presenting symptoms, and comorbidities (hypertension, diabetes, cardiac, cerebrovascular disease, and cancer) were collected from 28th February 2020 to 31st December 2020 through medical records, discharge summaries, and radiological studies. Verbal/written patient consent was obtained due to the prevailing COVID-19 norms at the time of the first wave. Major inclusion criteria were as follows: age >18 years, consent from patient/surrogate, positive RT-PCR report in case of active COVID cases, or positive COVID antibody test in case of post-COVID neurological sequelae. All neurological manifestations were reviewed by at least two neurologists and were divided into central nervous system (CNS) and peripheral nervous system (PNS) manifestations. Systemic features and their temporal relationship with neurological features were recorded. Various other specialized assessments and therapeutic interventions were conducted. Statistical analysis was performed using the SPSS software. A Chi-square test was performed to determine the association between variables. Student's t-test and one-way analysis of variance were used to determine differences in mean values. Statistical significance was set at p < 0.05. RESULTS: The mean age was 57.32 years for the CNS group and 40 years for the PNS group (p = 0.025). Age was significantly lower in the PNS group than in the CNS group (p = 0.025). Anemia, leucocytosis, and elevated serum creatinine were more commonly seen in the CNS group, although the difference was not statistically significant. The most common CNS manifestations were stroke (41.8%), of which ischemic stroke constituted 83% of cases, followed by seizure (22%), encephalopathy (20.9%), headache (15.1%), and vertigo (3.8%). The most common PNS manifestation was neuropathy (57%), which included Guillain-Barré syndrome (GBS), critical illness neuropathy, and autonomic neuropathy Conclusion: CNS symptoms of COVID-19 are more common than PNS symptoms. Stroke is the most frequent (46%) COVID-CNS symptom, which occurs in people of age above 35 years and is associated with high mortality.

INSTRuCT: Protocol, Infrastructure, and Governance.

Background and Purpose: Very few large scale multicentric stroke clinical trials have been done in India. The Indian Council of Medical Research funded INSTRuCT (Indian Stroke Clinical Trial Network) as a task force project with the objectives to establish a state-of-the-art stroke clinical trial network and to conduct pharmacological and nonpharmacological stroke clinical trials relevant to the nation and globally. The purpose of the article is to enumerate the structure of multicentric stroke network, with emphasis on its scope, challenges and expectations in India. Methods: Multiple expert group meetings were conducted by Indian Council of Medical Research to understand the scope of network to perform stroke clinical trials in the country. Established stroke centers with annual volume of 200 patients with stroke with prior experience of conducting clinical trials were included. Central coordinating center, standard operating procedures, data and safety monitoring board were formed. Discussion: In first phase, 2 trials were initiated namely, SPRINT (Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India) and Ayurveda treatment in the rehabilitation of patients with ischemic stroke in India (RESTORE [Rehabilitation of Ischemic stroke Patients in India: A Randomized controlled trial]). In second phase, 4 trials have been approved. SPRINT trial was the first to be initiated. SPRINT trial randomized first patient on April 28, 2018; recruited 3048 patients with an average of 128.5 per month so far. The first follow-up was completed on May 27, 2019. RESTORE trial randomized first patient on May 22, 2019; recruited 49 patients with an average of 3.7 per month so far. The first follow-up was completed on August 30, 2019. Conclusions: In next 5 years, INSTRuCT will be able to complete high-quality large scale stroke trials which are relevant globally. REGISTRATION: URL: http://www.ctri.nic.in/; Unique Identifier: CTRI/2017/05/008507.

Neurosyphilis - A Forgotten Disease: Case Reports with Ten Years Follow-Up and Review of Literature.

Neurosyphilis is a rare disease. We describe two patients of neurosyphilis with their clinical course and long-term follow-up. Our first patient was a 47-year-old male who presented with ataxia, headache, papilledema, sensorineural hearing loss, and myelopathy. Investigations revealed pachymeningitis and cervicodorsal myelitis. Cerebrospinal fluid (CSF) was reactive with positive CSF Venereal Disease Research Laboratory (VDRL) and blood Treponema pallidum hemagglutination (TPHA). His clinical, laboratory, radiological findings, and follow-up of the last 10 years are discussed with serial imaging. Case 2 was a 61-year-old male, who presented with neuropsychiatric symptoms, which resolved with treatment. We have reviewed the Indian case reports of this disease. It is easy to confuse neurosyphilis with tubercular meningitis in an Indian setting. The role of steroids in myelitic form has also been discussed. Worldwide reported cases of syphilitic myelitis are tabulated with their outcomes.

Clinical Profile, Risk Factors and Outcomes in Patients with Cerebral Venous Sinus Thrombosis: A Study from Western India.

AIM: Study of cause and clinical profile of venous sinus thrombosis in Western India. SETTINGS AND DESIGN: A retrospective study was conducted to ascertain the clinical profile, etiology, and follow up of patients with venous sinus thrombosis. METHODS AND MATERIAL: Hospital database of patients suffering from venous sinus thrombosis from two tertiary care hospitals in West India were studied. A telephonic follow up was taken for assessment of outcome. Inclusion criteria were a) Age more than 15 years of age b) clinically symptomatic patients c) Diagnosis confirmed by Magnetic resonance Venography (MRV) or CT Venography (CT Venography) Exclusion criteria: Patients with infarct in arterial territory, hypertensive hemorrhage, metabolic encephalopathy and eclampsia were excluded from the study. STATISTICAL ANALYSIS USED: Descriptive statistic was performed as frequency, mean and standard deviation or percentages. Difference in continuous variables was evaluated by using independent t-test while chi-square test was performed in categorical variables. Statistical P<0.05 was considered statistically significant. RESULTS: We conducted a retrospective study of patients with venous sinus thrombosis in Rajasthan in western India. Out of 71 patients in our study group the mean age of presentation was 36.64 years. 42 patients were male (59.2%) and 29 were female (40.8%). Only 9 patients (12.6%) had pregnancy or puerperium related venous sinus thrombosis. The most common presenting feature was headache 47/71(66.2), followed by seizures 33 (46.5%), paresis 20/71 (28.16%) and coma 15/71(21.1%). MRI Brain recorded infarcts in 32/71 patients and predominant hemorrhage was recorded in 34/71. 4 cases were associated with malignancy (one CNS, one outside CNS and 2 hematological). Raised homocysteine level was found in 26/35 (74.3%) patients in whom they were measured. 9 patients had moderately elevated homocysteine levels (15-30), another 9 had intermediate values (31-64) and 5 patients had elevated homocysteine level >65. Hyperhomocysteinemia was the commonest causative factor and was far more common in men (21/25) than in women (5/10). (p value 0.019). 24 out of 71 patients were found to be anemic (33.8%). Anemia was far more common in women than in men. (p value .002). Protein C level was found abnormal in 5/27 patients, Protein S in 6/27 patients and Anti thrombin III in 1/23 patient studied respectively. History of oral contraceptive intake was recorded in only a minority of women with venous sinus thrombosis 7(24.1%) compared to the western data where most of the venous sinus thrombosis are related to the contraceptive pills. CONCLUSION: The clinical presentation of venous sinus thrombosis in tertiary care centers is changing outside the traditional peurperium / pregnancy related venous sinus thrombosis. Common risk factors include hyperhomocysteinemia, anemia, coagulopathy, pregnancy related, vasculitis, malignancy and oral contraceptive usage. Male involvement was far more common than females and was usually associated with a higher level of homocysteine.