Simultaneous sampling of both cingulate gyri using a single interhemispheric depth electrode: A technical note.

Background: Simultaneous sampling of the cingulate gyri through a single depth electrode inserted underneath the falx cerebri is clinically useful in certain cases of drug-resistant epilepsy. However, the frequency at which each region of the cingulate gyri - namely, anterior, middle, and posterior - can be simultaneously sampled with a single electrode remains uncertain. Methods: We assessed the anatomical relationship between the falx cerebri and the cingulate gyrus in 50 adults and children. Subsequently, we determined whether an arbitrary line, denoted as A (representing a 5 mm gap between the falx cerebri and corpus callosum necessary for depth electrode insertion), fell within the anterior, middle, or posterior cingulate gyrus. Results: The shape of the falx cerebri and its intersection point with the corpus callosum varied substantially across individuals, with a significant difference between children and adults (P = 0.02). The A line was located in the middle cingulate gyrus in 18 children (72%), while 3 (12%) and 4 (16%) had it located in the posterior and anterior cingulate gyrus, respectively. Among adults, 15 individuals (60%) had the A line in the middle cingulate gyrus, 10 (40%) in the posterior cingulate gyrus, and none in the anterior cingulate gyrus. Conclusion: This study demonstrates the feasibility of simultaneous sampling of both the anterior and middle cingulate gyri in adults and children. Moreover, it represents the first investigation to document the wide interindividual variability in the morphology of the falx cerebri and its association with the cingulate gyrus.

Common Risk Factors Involved In The Development Of Myocardial Infarction In Adults Younger Than 45 Years Of Age.

Background: Pakistan has got a very high prevalence of myocardial infarction (MI). MI presents at pretty young age in this country. The objective of present study was to determine the frequency of common risk factors associated with early development of MI in middle aged adults of less than 45 years. Methods: It was a cross sectional study conducted in the Cardiology department of Ayub Teaching Hospital (ATH) Abbottabad from 23rd June 2015 - 10th July 2016. A total of 255 consecutive patients diagnosed with MI admitted to the Cardiology Unit of ATH, Abbottabad. A detailed medical history and general physical examination of the patients was carried out with an emphasis on recording the presence or absence of common risk factors of MI in these patients. All routine investigations (Blood Complete Picture, Urea, Creatinine, Blood Sugar & Lipid Profile) were done. Results: Mean age of the subjects was 39.98±4.61 SD. The frequency of risk factors in descending order was smoking in (38.8%), obesity in (29.4%) and essential hypertension in (21.6%) of the patients. Other risk factors of MI in this study were diabetes mellitus (19.2%), family history of ischemic heart disease (IHD) was (18.8%) and disproportionate dyslipidemias in (12.9%). Sex of patients (male predominance) was found to be significantly associated with diabetes, smoking and dyslipidemia (p<0.05). Conclusion: Male sex, smoking, hypertension and obesity confer an increased risk of myocardial infarction in patients younger than 45 years of age.

Standardized reporting of complications of epilepsy surgery and invasive monitoring: A single-center retrospective study.

OBJECTIVE: Monitoring adverse effects related to epilepsy surgery is essential for quality control and for counseling patients prior to the procedure. The aim of this study was to analyze the rates of complications related to epilepsy surgery following invasive monitoring and to classify them according to the recently proposed protocol by the E-pilepsy consortium. METHODS: This is a retrospective study of collected data extracted from our routinely updated epilepsy surgery database which consisted of 173 surgical procedures: 89 surgeries for insertion of subdural grids, strips, and/or depth electrodes, and 84 resective surgeries. According to the protocol, complications were defined as unexpected postoperative adverse events and were stratified into transient (lasting less than 6 months) and permanent deficits (lasting 6 months or longer). In addition, we reported patients with postoperative psychiatric disturbances and calculated the rates of transient and permanent postoperative sequelae which were defined as expected postoperative deficits deemed inherent to the surgical procedure. RESULTS: Six potentially life-threatening complications requiring acceleration of the planned resective surgery occurred during invasive monitoring. Following resective surgery, 12 transient sequelae (8 motor deficits, three language deficits, and one transient dyscalculia) and 10 permanent sequelae (5 mild memory disturbances, four visual field cuts, and one contralateral dysesthesia) occurred. In addition, 7 patients experienced transient motor complications. Four permanent postoperative neurological complications (4.8%) occurred: motor deficits in three patients and a partial peripheral facial palsy in one. Finally, five patients developed de novo psychiatric disturbances (transient in four and permanent in one). CONCLUSIONS: This is the first study to classify complications of epilepsy surgery according to the E-pilepsy consortium protocol. Our findings demonstrate that epilepsy surgery following invasive monitoring is safe and associated with low morbidity when performed in specialized centers. Monitoring these complications according to a unified definition and using a multidimensional protocol will allow for a direct comparison across epilepsy surgery centers, will provide the epileptologists and surgeons with objective percentages to share with their patients and will help in identifying risk factors and improving the safety of epilepsy surgery.

Coma With Absent Brainstem Reflexes and a Burst Suppression on EEG Secondary to Baclofen Toxicity.

Baclofen, a muscle relaxant prescribed for the alleviation of symptoms of spasticity acts primarily at the spinal level but with high doses, it penetrates the blood-brain barrier and can result in prominent central nervous depression. Baclofen toxicity has been associated with a variety of symptoms ranging from dizziness to deep coma. We report the clinical course, management, and outcome of a case of baclofen overdose who presented in deep coma with loss of brainstem reflexes and a burst suppression (BS) pattern on his electroencephalogram (EEG). In addition, we reviewed the presentation and outcomes of all reported cases of baclofen toxicity with a BS pattern on EEG to evaluate if those cases share a common clinical presentation and for the presence of signs and symptoms that would help the clinician to consider this diagnosis. There appears to be a common clinical picture associated with severe baclofen toxicity consisting of deep coma associated with loss of all brainstem reflexes including pupillary reactivity, frequent association with seizures/myoclonic jerks, and a BS pattern on EEG. The outcome is generally good, and serial EEGs are recommended to document a reversal of the abnormal electrographic features.

Treatment of generalized convulsive status epilepticus: An international survey in the East Mediterranean Countries.

PURPOSE: Three Chapters of the Commission of the East Mediterranean Affairs (CEMA) of the ILAE conducted a survey to assess the availability of drugs used for the treatment of generalized convulsive status epilepticus (GCSE) across the CEMA countries and to evaluate the treatment choices of adult and pediatric neurologists for the treatment of this condition. METHOD: The web-based survey consisted of two similar vignettes of GCSE in a child and an adult. The questions evaluated the sequential drugs of choice based on drug availability and with the assumption that all drugs were at the disposition of the neurologists. The neurologists were also asked about the timing of introduction of anesthetic drugs and how they monitor patients in drug induced coma. RESULTS: Our data showed that the availability of drugs differ substantially across CEMA countries. A benzodiazepine and phenytoin/phenobarbital were the initial drugs of choice for the majority of adults and pediatric neurologists. In cases of refractory status, most neurologists would use a third agent before proceeding to treatment with an anesthetic agent. Although the vast majority would prefer to monitor patients in drug-induced coma with continuous EEG, only 38% are using this modality because of its unavailability at their institutions. CONCLUSIONS: Our data emphasize that an algorithm for the treatment of GCSE in the CEMA countries should be flexible and should propose different treatment options at each step of the protocol that are based on the best available data while taking into consideration the drug availability across the CEMA countries.

Role of ATP-Binding Cassette Transporter Proteins in CNS Tumors: Resistance- Based Perspectives and Clinical Updates.

Despite gigantic advances in medical research and development, chemotherapeutic resistance remains a major challenge in complete remission of CNS tumors. The failure of complete eradication of CNS tumors has been correlated with the existence of several factors including overexpression of transporter proteins. To date, 49 ABC-transporter proteins (ABC-TPs) have been reported in humans, and the evidence of their strong association with chemotherapeutics' influx, dissemination, and efflux in CNS tumors, is growing. Research studies on CNS tumors are implicating ABC-TPs as diagnostic, prognostic and therapeutic biomarkers that may be utilised in preclinical and clinical studies. With the current advancements in cell biology, molecular analysis of genomic and transcriptomic interplay, and protein homology-based drug-transporters interaction, our research approaches are streamlining the roles of ABC-TPs in cancer and multidrug resistance. Potential inhibitors of ABC-TP for better clinical outcomes in CNS tumors have emerged. Elacridar has shown to enhance the chemo-sensitivity of Dasatanib and Imatinib in various glioma models. Tariquidar has improved the effectiveness of Temozolomide's in CNS tumors. Although these inhibitors have been effective in preclinical settings, their clinical outcomes have not been as significant in clinical trials. Thus, to have a better understanding of the molecular evaluations of ABC-TPs, as well as drug-interactions, further research is being pursued in research labs. Our lab aims to better comprehend the biological mechanisms involved in drug resistance and to explore novel strategies to increase the clinical effectiveness of anticancer chemotherapeutics, which will ultimately improve clinical outcomes.

A Surgical Case of Complete Resection of the Focal Cortical and Subcortical Dysplasia in the Motor Cortex.

BACKGROUND: Focal cortical dysplasias (FCDs) are highly epileptogenic and frequently associated with medically refractory focal epilepsy. FCDs are frequently located in the frontal lobe, making its complete resection highly challenging when in proximity to the motor cortex. CASE DESCRIPTION: We report a case of a 25-year-old woman with medically refractory epilepsy secondary to a focal cortical dysplasia in the motor cortex and extending deeply into the subcortical white matter. A detailed presurgical evaluation and invasive electroencephalographic monitoring performed at our epilepsy monitoring unit, along with the use of motor mapping, functional magnetic resonance imaging, diffusion tensor imaging, and the Stealth navigation system resulted in the complete resection of the lesion without a permanent postoperative motor deficit. The patient remained seizure-free at a 63-month follow-up while being maintained on a single antiepileptic drug. CONCLUSION: A detailed presurgical evaluation, accurate mapping of the functional and dysplastic cortex, and a well-planned tailored and complete surgical resection of the cortical dysplasia can result in a favorable outcome with relatively little risk of postoperative neurologic deficit.

JC virus seroprevalence and seroconversion in multiple sclerosis cohort: A Middle-Eastern study.

OBJECTIVES: To estimate JCV seroprevalence and risk of seroconversion against JCV among MS patients in the Middle East. METHODS: This multicenter study was conducted by implementing a cross-sectional design to assess JCV seroprevalence, and a longitudinal design to assess the risk of JCV seroconversion. Multivariable logistic and Poisson regression analyses were used to assess the relationship between clinical variables and JCV seropositivity and risk of seroconversion. RESULTS: Of 581 MS patients, 64.9% patients were females. Mean age and mean disease duration were 33.9 and 8.4years respectively. JCV seroprevalence was 48.7%. Male gender (p=0.002), age at onset (p=0.001) and disease duration of 20 or more years (p=0.007) were significantly associated with JCV seropositivity. Among patients (n=125), followed longitudinally, the risk of JCV seroconversion was 17.6% (95% CI: 11.4%-25.4%) during a median follow-up of 18months. The proportion of seroreverted and pseudoconverted patients was 4% and 3.2% respectively. CONCLUSIONS: JCV seroprevalence among MS patients in the Middle East was lower than international figures. Male gender, age at onset and disease duration were significantly associated with JCV seropositivity. Risk of JCV seroconversion was higher than previously reported figures. Observed JCV sero-reversion or pseudo-conversion entail watchful period before embarking on a clinical decision.

Mean contact quotient using electroglottography in patients with multiple sclerosis.

OBJECTIVE: To compare the mean and standard deviation (SD) of the contact quotient (CQ) of the sustained vowels ([a] and [e]) in multiple sclerosis (MS) patients versus controls. STUDY DESIGN: Cross-sectional study. MATERIALS AND METHODS: Thirty-nine subjects (24 patients and 15 controls) participated in this study. Laryngeal electroglottography was performed on all subjects while phonating the vowels [a] and [e] at a comfortable pitch and loudness. The fundamental frequency, mean CQ, SDs, and jitter were computed for both vocal tasks. RESULTS: The mean age of the MS group was 36.25+10.61 years. All laryngeal examinations were normal and five patients with MS had dysphonia described as voice breaks and fatigue in connected speech. For both vowels [a] and [e], the mean closed quotients were comparable in groups, MS and control (43.90 vs 53 for [a] and 44.75 vs 43.63 for [e]) with no significant difference. When comparing five MS patients with dysphonia versus controls, for the vowel [a], the mean closed quotient was significantly lower in MS patients with dysphonia (P values of 0.043). CONCLUSION: The mean closed quotient for sustained vowels [a] and [e] are comparable in MS patients and healthy controls except in patients with dysphonia.

Voice-related quality of life in patients with multiple sclerosis.

Objective. To investigate the voice-related quality of life in a group of patients with multiple sclerosis. Participants. A total of 87 subjects (59 MS subjects and 28 controls) participated in this study. Main Outcome Measures. Variables included presence or absence of phonatory symptoms, duration of the disease, the expanded disability status scale (EDSS), the severity of fatigue, and depression. All patients were asked to fill the Voice Handicap Index. Results. The average age was 35.47 years + 10.92 with 39% being males. The average duration of the disease was 77.93 months. The EDSS score was 1.94 + 1.84, the FSS score was 4.07 + 2.09, and the HRSD was 7.28 + 7.70. Only 7 subjects out of the 59 had vocal symptoms compared to 3 in the control group. There was no significant difference in the VHI total score between cases (5.9 + 15.5) and controls (5.4 + 8.2). There was a positive correlation between VHI total score, FSS score, and HRSD (P values of 0.011 and <0.01. Conclusion. The voice-related quality of life in MS is within normal with no disability.