Safety and Efficacy of Newer Oral Anticoagulants Versus Vitamin K Antagonists in the Management of Cerebral Venous Thrombosis: A Single-Center Ambispective Study from South India.

INTRODUCTION: Cerebral Venous Thrombosis (CVT) poses a rare but life-threatening challenge, warranting meticulous treatment approaches. Traditional therapy involves Vitamin K Antagonists (VKAs), but Newer Oral Anticoagulants (NOACs) offer potential advantages. This study addresses a crucial knowledge gap in the Indian context, analyzing real-world data to guide CVT management decisions. METHODS: A single-center, ambispective cohort study included consecutive adult CVT patients. Data collection encompassed demographics, clinical data, imaging, and treatment details. Patients were categorized into VKA and NOAC groups. Outcomes measured recanalization status, functional outcomes, bleeding events, and adverse drug reactions. RESULTS: Among 181 enrolled patients, NOACtreated (Group B) individuals had significantly higher rates of complete recanalization (58.5% vs. 31.1%) with a similar incidence of adverse events and also displayed better functional outcomes at weeks 8 and 12 compared to VKA-treated (Group A) patients. Recurrent thromboembolic events were absent in both groups during follow-up. CONCLUSION: This study highlights NOACs' potential advantages in CVT management, including improved functional outcomes, enhanced recanalization, and similar bleeding risk. Adverse events were milder with NOACs. While acknowledging limitations, these findings support NOACs as a promising alternative to VKAs, advancing CVT care and outcomes.

Camptocormia in a young man with anti-GAD-seropositive stiff-person syndrome.

Stiff-person syndrome (SPS) usually manifests as an autoimmune neuromuscular disorder characterised by pronounced and advancing rigidity, primarily affecting the trunk and proximal muscles. There are various clinical subtypes like classic SPS (truncal stiffness, generalised rigidity and muscle spasms), partial SPS (stiff-limb syndrome) and uncommon forms including progressive encephalomyelitis with rigidity and myoclonus. Camptocormia, defined as forward flexion of the spine in the upright position that disappears in the supine position, without fixed deformity, has been described only in two cases as an initial presentation of Anti glutamic acid decarboxylase (GAD) autoimmunity. We encountered a young male presenting with a progressive forward-leaning posture and involuntary rhythmic movements in the lower limb. Diagnostic workup included MRI, blood routines, autoimmune screening, genetic testing, lumbar puncture and electromyography. Elevated serum anti-GAD antibody levels, inflammatory CSF and certain other clinical features supported the diagnosis of SPS. Treatment involved benzodiazepines, muscle relaxants and immunotherapy with intravenous immunoglobulin. This case underscores the importance of considering immune-mediated causes, such as SPS, in patients presenting with camptocormia.

Bilateral vestibulopathy presaging clinically probable multisystem atrophy.

Bilateral vestibulopathy is a clinical diagnosis backed by investigative confirmation, which can be masked by the lack of lateralising signs. It has a broad aetiological spectrum including neurodegenerative conditions, though many such cases also have unknown aetiology. We present the case of an elderly gentleman who presented with progressive bilateral vestibulopathy nearly 1.5 years prior to his eventual diagnosis of clinically probable multisystem atrophy. This case highlights the need to serially re-evaluate for parkinsonism and cerebellar signs in idiopathic bilateral vestibulopathy and raises a possibility that bilateral vestibulopathy, similar to constipation or anosmia, could be an early syndrome presaging the onset of overt extrapyramidal or cerebellar symptoms in patients with multisystem atrophy.

Modified collision study to isolate and study small fibre neuropathy in patients with Type 2 diabetes.

Introduction: Diabetic distal symmetrical polyneuropathy (DSPN) can be categorized as small fibre, large fibre, and mixed neuropathy. Even though small fibre neuropathy is the most prevalent, unfortunately it is usually not recognized by routine electrophysiologic studies. In this study, we intend to examine the slow velocity small fibres responsible for small fibre DSPN, by isolating them using collision technique principle in patients with diabetes. Methods: This is an observational case-control study designed to compare nerve conduction values with application of collision technique in 60 patients with T2D and in 60 age and sex matched controls. Results: The collision study in patients with Type 2 Diabetes showed mean Latency of 10.5 ± 1.7 ms and mean Amplitude of 3.4 ± 2.3 mV on the right side and mean Latency of 10.5 ± 1.7 ms and the mean Amplitude of 3.5 ± 2.2 mV on the left side. There was a statistically significant difference (P value < 0.001) in the amplitute and latency of CNAPs of small fibres in median nerve innervated APBs of both arms between those with T2D and controls. Discussion and Conclusion: Collision study helps to examine the slower conducting fibres of the larger nerves. Our study suggests that the Collision Technique can be used to identify early peripheral neuropathy regardless of the diabetes status, thus making it more practically feasible and cost-effective.

Effect of recanalization on clinical outcomes in patients with cerebral venous thrombosis - An ambispective study.

PURPOSE: Achieving complete recanalization has possible but unproven benefits in cerebral venous/sinus thrombosis (CVST). We reported a cohort of patients with CVST and assessed the factors associated with recanalization and its effect on outcomes. METHODS: We included 123 patients with CVST in this single-center, ambispective, observational study from October 2018 to November 2019. We noted their demographic, clinical, and radiological features, modified Rankin scale (mRS), recanalization status, and the presence of any recurrences while having periodic follow-ups every three months for one year or until complete recanalization, whichever was earlier. RESULTS: Out of the 123 patients enrolled, we completed the etiological evaluation in 122 and assessed the outcome at discharge in 120. One (0.8%) patient went against medical advice, 2 (1.6%) died in the hospital, and 8 (6.5%) were lost to follow-up at various time points. The majority of the patients were males (75 [60.98%]). Thrombophilia (71 [58.2%]) and hematological conditions (51[41.8%]) were the predominant risk factors for CVST. The majority (107 [95.5%] at three months) of the patients had an mRS of 0-1. Eighty-one (67.5%) and 26 (21.7%) patients attained complete and partial recanalization at their last follow-up, respectively. Involvement of transverse and sigmoid sinus was an independent predictor of poor recanalization (Odds Ratio [OR] {Confidence Intervals [CI]} - 0.2 (0.04-0.7); p = 0.01). Moreover, failure to achieve at least partial recanalization (OR [CI] - 94 [6.8-1296]; p = 0.01) and undergoing a decompression craniectomy (OR [CI] - 26.4 [1.2-582]) were the only factors that independently predicted poor functional outcomes in our cohort. CONCLUSION: Most of the patients with CVST had favorable outcomes. Recanalization was a strong predictor of good functional outcomes. Therefore, recanalization status should be considered while deciding when to stop the anticoagulation. However, we found no differences in the outcomes between those who achieved partial and complete recanalization.

Memantine Ameliorates Migraine Headache.

BACKGROUND AND OBJECTIVE: A significant number of migraine patients do not find effective and safe treatment to reduce the frequency and severity of their migraine attacks. Hence, a need for newer therapeutic agent exists. In this study, we examined the efficacy and safety of memantine for the treatment of migraine. MATERIALS AND METHODS: It was a randomized, placebo-controlled, double-blind study including adult patients with 3-12 migraine headache for the last 6 months conducted in India. Patients received memantine (10 mg/day, once a day) or placebo for the period of 24 weeks after a washout period. Migraine frequency per month, the 50% responder rate, rescue medication use, and adverse events were recorded every 4 weeks. RESULTS: Among 81 patients screened, 60 were enrolled for the study. Thirty patients received memantine and other 30 received placebo. Data were analyzed for 28 patients in memantine group and 29 patients in placebo group. At the baseline, all the parameters were similar in both groups. By 24 weeks, migraine frequency/4 weeks was memantine group versus placebo; 2.57 (±0.38) versus 5.07 (±0.69), P = 0.003 and rescue medication use was 0.75 (±0.23) versus 3.72 (±0.63) P = 0.0001. The 50% responder rate was 85.7% versus 51.7% (P = 0.005). Only a few mild adverse events were recorded in both the groups. No severe adverse events and death were recorded during the study. CONCLUSION: Memantine (10 mg oral, once daily) is effective, well tolerated, and safe for patients with migraine.

False positive immunoassay for acetyl choline receptor antibody (AChR Ab) in patients exposed to polyvalent antisnake venom.

Acute flaccid paralysis is a neuromuscular emergency characterized by rapidly worsening weakness that evolves quickly to cause diaphragmatic failure. The challenge for the treating physician is to stabilize the patient, generate the differential diagnosis and determine the management; all in quick time. Neurotoxic snake bites have inadequate signs of inflammation and are easily missed. Myasthenic crisis, on the other hand, could be the first sign of myasthenia gravis in up to 20% of patients. Both present with acute respiratory failure and inadequate history. Two of our patients presented with similar clinical picture, and received polyvalent anti-snake venom obtained from hyperimmunised horses (Equus caballus). Both tested positive for anti-acetyl choline receptor antibody. After recovery, both patients narrated a history suggestive of neurotoxic envenomation. We later discovered that patients, who are exposed to polyvalent anti-snake venom (Equus caballus) prior to radioimmunoassay, demonstrate high titers of Anti-AChR Ab in their serum erroneously.

Evaluating the efficacy of memantine on improving cognitive functions in epileptic patients receiving anti-epileptic drugs: A double-blind placebo-controlled clinical trial (Phase IIIb pilot study).

OBJECTIVES: People with epilepsy have greater cognitive and behavioral dysfunction than the general population. There is no specific treatment available for cognitive impairment of these patients. We aimed to evaluate the effects of memantine, an N-methyl-D-aspartate-type glutamate receptor noncompetitive antagonist, on improving cognition and memory functions in epileptic patients with cognitive and memory impairment, who received anti-epileptic drugs (AEDs). METHODS: We did a randomized, double-blind, placebo-controlled parallel group trial, in SRM Medical College Hospital and Research Centre, Kattankulathur, Kancheepuram, Tamil Nadu, India between April 2013 and September 2013. Fifty-nine epileptic patients taking AEDs with subjective memory complaints were recruited and randomized to either Group 1 to receive 16 weeks of once-daily memantine, (5 mg for first 8 weeks, followed by memantine 10 mg for next 8 weeks) or Group 2 to receive once daily placebo. This trial is registered with Clinical Trial Registry of India CTRI/2013/04/003573. RESULTS: Of 59 randomized patients, 55 patients completed the study (26 memantine and 29 placebo). Memantine group showed statistically significant improvement in total mini mental state examination score from baseline (P = 0.765) to 16(th) week (P < 0.001) in comparison with the placebo. The Weshler's Memory Scale total score in memantine group improved significantly after 8 weeks (P = 0.002) compared with baseline (P = 0.873) and highly significant at the end of 16(th) week (P < 0.001). The self-rated quality of life and memory in memantine group also significantly improved at the study end. CONCLUSION: We conclude that once-daily memantine (10 mg) treatment significantly improved cognition, memory and quality of life in epileptic patients with mild to moderate cognitive impairment and was found to have a favorable safety profile.