Endovascular management of cerebral venous thrombosis: a tertiary-centre experience.

Background: Stroke related to cerebral venous thrombosis (CVT) is uncommon, with untoward lethal outcomes. Systemic anticoagulation is the treatment of choice. However, some patients can be resistant to this treatment. Endovascular management with thrombolysis and mechanical thrombectomy can be a viable option in such cases. Material and methods: We retrospectively reviewed the endovascular management used for CVT in 8 patients who failed to respond to standard anticoagulation therapy between December 2017 and December 2022 in our institute. Clinical profile, imaging parameters, endovascular procedure details, and outcomes in terms of angiographic findings and clinical follow-up were analysed. Results: In this period, a total of 8 patients underwent mechanical thrombectomy. The procedure was successful in all cases (8/8 = 100%), and 50% of them showed near total/complete recanalization; Perforation of the cortical veins was noted in 2 cases (~25%). Among the 8 patients, one died (1/8 = 12.5%) due to cardiac aetiology; the remaining 7 patients (87.5%) showed good clinical outcome with a modified Rankin Scale score 0 to 2. Conclusion: Catheter-directed thrombolysis with mechanical thromboaspiration is a safe and effective treatment for cerebral venous sinus thrombosis not responding to anticoagulation.

Inpatient Burden of Neurological Disorders: A Route Map for Allocation of Resources and Postgraduate Training.

Introduction There are limited data regarding the profile of inpatient neurological disorders in India. Understanding the spectrum of diseases and the profile of patients admitted in an inpatient setting will help to streamline services, allocate resources, develop management protocols, design curricula, and improve training programs of postgraduate students in neurology training. Objective The objective of this study is to study the profile of inpatient neurological disorders in 1000 consecutive patients admitted to a tertiary care neurological center. Methods Data from 1000 consecutive inpatients admitted to the Neurology Department at St. John's Medical College Hospital, Bengaluru from January 2018 to October 2018 were collected from the medical records. The data obtained from the case records were entered into a Microsoft Excel spreadsheet for descriptive analysis. Results The average age of the patients was 48 years (±18.18) and 606 of the 1000 patients were males. Strokes, including arterial and venous strokes, formed the major inpatient caseload, accounting for 48.7% of cases. Of these, 84% had ischemic arterial strokes, 7.4% had intracranial hemorrhage, and 8.4 % had cerebral sinus venous strokes; 19.3% of patients were admitted for seizures while 8.2% of patients were admitted for headache. Meningitis was diagnosed in 5.2% of patients; 4.8% of patients had central nervous system demyelinating and autoimmune diseases. A number of other diagnoses comprised less than 2.5% each and included movement disorders, peripheral nerve, spine and nerve roots disorders, neuromuscular diseases, neurodegenerative diseases, and medical and functional illness. Conclusion The most common disorders in the inpatient setting are stroke, seizure, headache, meningitis, and autoimmune/demyelinating disorders. These disorders should receive priority while planning the allocation of resources, educational curriculum, training, and teaching programs.

Long Term Outcomes in Idiopathic Inflammatory Myositis: An Observational Epidemiologic Study over 15 Years.

Background: We report a longitudinal observational cohort of idiopathic inflammatory myositis (IIM) focusing on the long-term clinical outcome and associated parameters. Methods: IIM patients were classified as per Bohan and Peter criteria. In those with ≥ 24 months of follow-up; the treatment response, functional outcomes, and damage at last follow-up were recorded. Complete clinical response and clinical remission as defined by Oddis et al., was used to define outcomes at last follow-up. Results: The cohort consists of 175 patients, mean age 40.9 (+12.6) years, M:F 1:3.3; and the major subsets were dermatomyositis (44.6%), overlap myositis (25.7%), antisynthetase syndrome (6.3%), polymyositis (14.3%), and juvenile DM/OM (8.6%). Ninety-four patients have followed up for 24 months or more, with the median (IQR) of 65(35,100.7) months. Of them, 74.1% and 11.8% had complete and partial clinical responses respectively at the last follow-up. In our cohort 40.2% were off-steroids and 13.8% were in clinical remission at the last follow-up. Complete clinical response was associated with better functional outcomes and lesser damage as determined by HAQ-DI of 0[OR10.9; 95%CI (3.3,160)], MRS [OR 3.2; 95%CI (1.4,7.3)] and lesser MDI [OR 1.7; 95% CI (1.1,2.7)] respectively as compared to partial response (unadjusted analysis). Baseline parameters and IIM subsets did not significantly influence the functional outcome and damage. The mortality rate in our cohort is 24/175 (13.7%), the disease-specific mortality rate being 9.1%. Large majority of deaths were early, associated with active disease. Conclusion: We report good long-term outcomes in all major myositis subsets. Partial clinical response to treatment is associated with worse functional outcomes and damage accrual. Death occurs early in association with active disease.

Neuropsychiatric manifestations are associated with increased mortality in Indian patients with lupus: A single centre retrospective observational study.

OBJECTIVE: To study the prevalence of different NPSLE manifestations in our cohort and to compare clinical and immunological features and outcomes including mortality of patients with NPSLE and SLE controls without NP involvement. METHODS: This was a retrospective study in a tertiary care referral centre. All patients of SLE seen in the last 10 years and fulfilling the SLICC criteria with neuropsychiatric manifestations as per the ACR definitions were included. Patients of SLE without NP involvement were sequentially assigned as controls in a ratio of 1:2. RESULTS: Of the 769 patients diagnosed with SLE from Jan 2011 to December 2020, 128 (16.6%) had NPSLE manifestations as per the ACR definitions. The commonest NPSLE manifestation was seizures (6.5%) followed by cerebrovascular accident (3.9%). NPSLE manifestation occurred at the first presentation of SLE in 99/128 (77.3%) patients and 58 (45.3%) patients had more than one NPSLE manifestation. Lupus anticoagulant and anticardiolipin antibody were tested in 120 patients and were positive in 16 (13.3%) and 12 (10%), respectively. No difference was found in anti-ribosomal p, lupus anticoagulant and anticardiolipin antibodies between the cases and controls. Twenty-one (16.4%) deaths occurred in patients with NPSLE (median follow-up of 40 months) as compared to 13 (5%) in controls (median follow-up of 32 months) (p = <0.001). The cumulative survival of patients with NPSLE was lower as compared to controls (p < 0.001). Relapse of NPSLE was seen in 11(8.6%) patients and was associated with mortality (p = 0.017). CONCLUSIONS: Seizures and cerebrovascular accidents are the commonest NPSLE syndromes in our patients. The presence of NPSLE was associated with high mortality in Indian patients with lupus.

Substance use related cluster headache: A case series.

BACKGROUND: Essential oils (EOs) with pro-convulsant properties are known to cause seizures and may worsen migraine. Here we report five cases of cluster headache (CH) secondary to the usage of toothpastes containing pro-convulsant EOs. METHODS: Patients were identified from the headache clinics of three tertiary care hospitals in south India. Detailed history, examination, and brain magnetic resonance imaging were done in all patients. CH was diagnosed according to the International Classification of Headache Disorders, 3rd edition. Descriptive statistics were used to analyze data. RESULTS: We had five cases of EO-related CH (EORCH), from February 2020 to August 2021; three females and two males, with age ranging from 19 to 54 years. Three had new onset CH, while two had previous cluster attacks which had become refractory to medications for the past 1 year. The toothpastes contained EOs of camphor, eucalyptus, sage, thujone, clove, and fennel in various combinations. These toothpastes were used for a period of at least 3 months in those with new onset CH and for 12 months or more by those with chronic CH. After stopping the usage of these toothpastes, the CH attacks resolved completely within 5-10 days in all patients. In one patient we re-challenged with the same toothpaste and got the CH attack after a period of 2 months. None of the patients had recurrence of CH attacks at follow-up, ranging from 1 to 2 years. CONCLUSION: EOs with pro-convulsive properties may trigger and sustain CH. Physicians may consider inquiring about the exposure to these pro-convulsant EOs in patients with CH and may consider advising the discontinuation of products like toothpastes containing them as a possible means of CH remission.

A real world multi center study on efficacy and safety of natalizumab in Indian patients with multiple sclerosis.

BACKGROUND: Natalizumab (NTZ) is increasingly being used in Indian multiple sclerosis (MS) patients. There are no reports on its safety and efficacy, especially with respect to the occurrence of progressive multifocal leukoencephalopathy (PML). OBJECTIVES: To describe the patient characteristics, treatment outcomes, and adverse events, especially the occurrence of PML in NTZ-treated patients. METHODS: A multicentre ambispective study was conducted across 18 centres, from Jan 2012 to Dec 2021. Patients at and above the age of 18 years treated with NTZ were included. Descriptive and comparative statistics were applied to analyze data. RESULTS: During the study period of 9 years, 116 patients were treated with NTZ. Mean age of the cohort was 35.6 ± 9.7 years; 83/116 (71.6%) were females. Relapse rate for the entire cohort in the year before NTZ was 3.1 ± 1.51 while one year after was 0.20±0.57 (p = 0.001; CI 2.45 -3.35). EDSS of the entire cohort in the year before NTZ was 4.5 ± 1.94 and one year after was 3.8 ± 2.7 (p = 0.013; CI 0.16-1.36). At last follow up (38.3 ± 22.78 months) there were no cases of PML identified. CONCLUSIONS: Natalizumab is highly effective and safe in Indian MS patients, with no cases of PML identified at last follow up.

Prevalence and Predictors of Restless Leg Syndrome in Adolescents and Young Adults of Bengaluru City, India: A Cross-Sectional Study.

INTRODUCTION: Restless leg syndrome (RLS) is a sensorimotor disease characterized by an urge to move the legs, often caused by uncomfortable and unpleasant sensations in the legs. It affects the quality of sleep which in turn affects scholastic performance in children and predisposes them to cardiovascular diseases in the long run. Hence, the primary aim of this study was to assess the prevalence and predictors of RLS, poor sleep quality, and excessive daytime sleepiness (EDS). METHODS: This was a cross-sectional observational study conducted between September 2017 and March 2020 in Bengaluru, India, including all consenting PreUniversity College, Degree College, and Higher Secondary school students. After parental consent and assent (if applicable) was obtained, a semi-structured standardized pilot-tested questionnaire consisting of the RLS diagnostic criteria, Pittsburgh Sleep Quality Index (PSQI), Epworth sleepiness scale, and questions on sleep hygiene was administered. The prevalence was expressed as proportions and 95% confidence intervals (95% CI). Regression analysis was done to determine the predictors. RESULTS: The overall prevalence (95% CI; frequency) of students with RLS, poor sleep quality, and EDS in our study population was 8.36% (7.54, 9.24; n = 1,544/4,211), 36.67% (35.21, 38.14; n = 1,544/4,211), and 39.87% (38.39, 41.37; n = 1,679/4,211), respectively. PSQI and Epworth score were the significant predictors of RLS. Age, Epworth score, knowledge score, and the number of unacceptable sleep habits were the significant predictors of sleep quality. Female gender, PSQI, RLS, knowledge score, and the number of unacceptable sleep habits were the significant predictors of EDS. CONCLUSIONS: The prevalence of RLS, those with poor sleep quality and EDS among adolescents and young adults was higher when compared to the historical data of general population in the same city.

Headaches associated with acute SARS-CoV-2 infection: A prospective cross-sectional study.

OBJECTIVES: The prevalence and characteristics of COVID-19-related headaches are not known in Indian patients. We aim to determine the prevalence and characteristics of headache in COVID-19-infected individuals and make a comparison with those without headaches. METHODS: This prospective cross-sectional observational study was conducted from 1 October to 31 October 2020. Data were collected using a detailed questionnaire. We compared the data of those with and without headaches to identify the differences between the groups. RESULTS: During the study period of 1 month, among 225 COVID-19-infected patients, 33.8% patients had headaches. The mean age of patients with headache was 48.89 ± 15.19 years. In all, 53.9% were females. In 65.8%, headache occurred at the onset of viral illness; 44.7% described the headache as dull aching; 39.5% had bifrontal headache; and 32.9% had holocranial headache. In total, 78.9% had complete resolution of headache within 5 days. A comparison between those with and without headaches showed that those with headaches were more younger (48.89 ± 15.19 vs 54.61 ± 14.57 years, p = 0.007) and of female gender (41/76(53.9%) vs 41/149 (27.5%), p = 0.001). Primary headache disorders were more common in the headache group. Levels of inflammatory markers such as leukocyte count (7234.17 ± 3054.96 vs 8773.35 ± 5103.65, p = 0.017), erythrocyte sedimentation rate (39.28 ± 23.29 vs 50.41 ± 27.61, p = 0.02) and ferritin (381.06 ± 485.2 vs 657.10 ± 863.80, p = 0.014) were lower in those with headaches. CONCLUSIONS: Headaches are a common and early symptom of acute SARS-CoV-2 infection more frequently seen in young females and in those with a history of primary headache disorders. The lower level of inflammatory markers in those with headaches suggests that these headaches are probably due to the local spread of virus through the trigeminal nerve endings, resulting in activation of the trigeminovascular system.

Effective Early Treatment of AChR Antibody-Positive Myasthenia Gravis with Rituximab; the Experience from a Neuroimmunology Clinic in a Developing Country.

BACKGROUND: Rituximab is reserved for treating refractory myasthenia gravis (MG) patients. Here we report our experience with rituximab in AChR antibody positive generalized MG (gMG) and impending myasthenic crisis (IMC). METHODS: This retrospective, observational study, conducted at a tertiary care, neuroimmunology clinic, analyzed the data of patients with AChR antibody positive gMG, treated with rituximab between 1st January 2016 and 30th October 2018. RESULTS: Eleven patients with AChR antibody positive gMG received rituximab. Mean age of the cohort was 50.54 ± 18.71 years with 9 males. Seven out of 11 patients received rituximab in the early stage (<2 years from onset) and had good response to treatment. Four of the 5 patients with IMC improved with rituximab alone. In the 10 patients who regularly followed up, there was a significant difference between the QMG scores at baseline and at 1, 2, 6, 12, and 18 months (P < .0001). CONCLUSION: Rituximab appears to be a potentially effective early treatment option for AChR antibody positive generalized MG and impending myasthenic crisis.

Essential oil related seizures (EORS): A multi-center prospective study on essential oils and seizures in adults.

OBJECTIVE: Essential oils (EOs) like eucalyptus and camphor have pro-convulsant properties. These EOs are present in many over- the- counter balms and oils. The effect of exposure to these EOs and occurrence of seizure is not systematically studied. The aim of this study was to evaluate the relationship between essential oils and the first episode of seizure and breakthrough seizures in known epileptic patients. METHODS: This was a multi-center prospective study, conducted in four hospitals over four years. Every person presenting with the first episode of seizure or breakthrough seizure was asked about exposure to EOs, mode of exposure, time to onset of a seizure in relationship to exposure, duration of seizure, type of seizure, and antiepileptic drug therapy. RESULTS: During the four-year period there were 55 patients with essential oil-related seizure (EORS). 22(40 %) had essential oil-induced seizures (EOIS) and 33(60 %) had essential oil-provoked seizures (EOPS). The female: male ratio was 1:1.1, the age of the patients ranged from 8 months to 77 years. In the EOIS group, 95 % had generalized tonic-clonic seizures and 5% had focal impaired awareness seizures. In the EOPS group, 42.4 % had focal impaired awareness seizures, 27.3 % generalized tonic-clonic seizures, 15 % focal to bilateral tonic-clonic seizures, and 15 % focal aware motor seizures. EOs implicated were preparations containing eucalyptus and camphor. CONCLUSION: Exposure to essential oils of eucalyptus and camphor is an under-recognized cause of the first and breakthrough seizure. Identifying the true causative factor will prevent unnecessary antiepileptic drug therapy and future recurrence.

Recurrent Ischemic Strokes: "Discontinuation of Antiplatelet Drugs Appears to be an Important Preventable Cause".

BACKGROUND: Antiplatelet therapy (APT) is an integral part of secondary stroke prevention. Noncompliance to APT is an important factor in stroke recurrence. In this study, we have evaluated the reasons for noncompliance to APT. OBJECTIVE: The aim of this study was to identify the various causes of nonadherence to APT in recurrent stroke patients. MATERIAL AND METHODS: The study was conducted in a tertiary care hospital in south India with a huge stroke burden. The study period was from October 2017 to September 2018. A total of 60 consecutive patients of recurrent stroke who were nonadherent to antiplatelet therapy were evaluated for various factors that prevented compliance. RESULTS: During the 12-month study period among 604 ischemic stroke patients, 128 (21%) had recurrent strokes. Of this 128, 60 (46.8%) were due to discontinuation of APT. The main factor for nonadherence to APT was lack of awareness about the need for lifelong medication (41/60; 68.3%). 10 patients (16.7%) stopped treatment as they opted for alternative therapy and 4 (6.7%) discontinued antiplatelets due to side effects. A small proportion of the patients (3.3%) cited financial constraints and forgetfulness as the issue, while 1.7% had difficulty in finding assistance to administer medicine. 27 (45%) patients had recurrent stroke within 2-15 days of stopping APT. CONCLUSIONS: The main reason for nonadherence to antiplatelet therapy is lack of awareness about the need for lifelong antiplatelet therapy. Stroke patients should be educated about the importance of lifelong antiplatelet therapy to prevent recurrent strokes.

COVID-19-related strokes are associated with increased mortality and morbidity: A multicenter comparative study from Bengaluru, South India.

BACKGROUND: COVID-19-related strokes are increasingly being diagnosed across the world. Knowledge about the clinical profile, imaging findings, and outcomes is still evolving. Here we describe the characteristics of a cohort of 62 COVID-19-related stroke patients from 13 hospitals, from Bangalore city, south India. OBJECTIVE: To describe the clinical profile, neuroimaging findings, interventions, and outcomes in COVID-19-related stroke patients. METHODS: This is a multicenter retrospective study of all COVID-19-related stroke patients from 13 hospitals from south India; 1st June 2020-31st August 2020. The demographic, clinical, laboratory, and neuroimaging data were collected along with treatment administered and outcomes. SARS-CoV-2 infection was confirmed in all cases by RT-PCR testing. The data obtained from the case records were entered in SPSS 25 for statistical analysis. RESULTS: During the three-month period, we had 62 COVID-19-related stroke patients, across 13 centers; 60 (97%) had ischemic strokes, while 2 (3%) had hemorrhagic strokes. The mean age of patients was 55.66 ± 13.20 years, with 34 (77.4%) males. Twenty-six percent (16/62) of patients did not have any conventional risk factors for stroke. Diabetes mellitus was seen in 54.8%, hypertension was present in 61.3%, coronary artery disease in 8%, and atrial fibrillation in 4.8%. Baseline National Institutes of Health Stroke Scale score was 12.7 ± 6.44. Stroke severity was moderate (National Institutes of Health Stroke Scale 5-15) in 27 (61.3%) patients, moderate to severe (National Institutes of Health Stroke Scale 16-20) in 13 (20.9%) patients and severe (National Institutes of Health Stroke Scale 21-42) in 11 (17.7%) patients. According to TOAST classification, 48.3% was stroke of undetermined etiology, 36.6% had large artery atherosclerosis, 10% had small vessel occlusion, and 5% had cardioembolic strokes. Three (5%) received intravenous thrombolysis with tenecteplase 0.2 mg/kg and 3 (5%) underwent mechanical thrombectomy, two endovascular and one surgical. Duration of hospital stay was 16.16 ± 6.39 days; 21% (13/62) died in hospital, while 37 (59.7%) had a modified Rankin score of 3-5 at discharge. Hypertension, atrial fibrillation, and higher baseline National Institutes of Health Stroke Scale scores were associated with increased mortality. A comparison to 111 historical controls during the non-COVID period showed a higher proportion of strokes of undetermined etiology, higher mortality, and higher morbidity in COVID-19-related stroke patients. CONCLUSION: COVID-19-related strokes are increasingly being recognized in developing countries, like India. Stroke of undetermined etiology appears to be the most common TOAST subtype of COVID-19-related strokes. COVID-19-related strokes were more severe in nature and resulted in higher mortality and morbidity. Hypertension, atrial fibrillation, and higher baseline National Institutes of Health Stroke Scale scores were associated with increased mortality.

Essential oil-related status epilepticus: A small case series study.

OBJECTIVE: Essential oils are plant-derived oils and are widely used as an over-the-counter remedy for common ailments. Many essential oils are found to have proconvulsant effects. Here we report a small case series of 3 adults with eseential oil-related status epilepticus. METHODS: This was an observational study conducted in a tertiary care hospital in south India from January 2018 to December 2019. We collected the demographic, clinical, and imaging features of all cases of status epilepticus resulting from exposure to essential oils. Cases of status epilepticus secondary to all other causes were excluded. RESULTS: There were 3 young adults with essential oil-related status epilepticus. Two had de novo generalized tonic-clonic status epilepticus, and 1 with posttraumatic occipital lobe epilepsy had focal-impaired awareness status epilepticus. The first 2 cases presented with histories of ingestion of eucalyptus oil. The third case had focal-impaired awareness status epilepticus after topical application of various balms containing eucalyptus and camphor. CONCLUSIONS: Proconvulsant essential oils of eucalyptus and camphor can cause both generalized and focal status epilepticus. Physicians dealing with patients of status epilepticus should enquire about the exposure to proconvulsant essential oils.

Efficacy and safety of rituximab in multiple sclerosis: Experience from a developing country.

BACKGROUND: Rituximab is increasingly being used in treatment of multiple Sclerosis (MS) in our centers due to its easy availability, efficacy and favorable side effect profile. Here we describe experience with rituximab over a period of 4 years from three MS centers from south India. METHODS: The data of MS patients who were treated with rituximab in three MS centers at Bangalore, India, from December 2015 to December 2019 were collected and evaluated with respect to relapse rate, EDSS score and adverse events. RESULTS: Over the four-year study period 118 MS patients were evaluated, 80 of whom were on rituximab. 58 (72%) had RRMS, 15 (19%) SPMS and 7 (9%) PPMS. Most patients (89%) received rituximab at a dose of 500 mg every 6-12 months. Nine patients (11%), all with progressive MS were on 1 gm to 2 gm every 6 months. Follow up ranged from 1 year to 3 years, with a median of 2 years. 56 (97%) RRMS patients had no relapses during follow up. EDSS score improved by a score of 0.5-2.0 in 68 (85%) patients, remained same in 10 (12.5%) and worsened in 2 patients (2.5%). Most patients (91%) tolerated rituximab infusions well. There were no opportunistic infections or neoplasms. CONCLUSION: Anti B cell therapy with rituximab appears effective, safe and affordable in the treatment of MS in developing countries like India with resource limited settings.

Outpatient burden of neurological disorders: A prospective evaluation of 1500 patients.

INTRODUCTION: Neurologists spend a significant amount of time in providing out-patient services. No comprehensive studies are there from India which have looked into the real burden of these common disorders in the out-patient population. This study was done to get a clear data on the burden of these disorders. OBJECTIVES: The aim of this study was to determine the incidence of various neurological disorders in the out-patient department services. METHODS: The study was conducted in a tertiary care medical center. Clinical data of 1500 consecutive out-patients who attended the out-patient services were collected over a period of 2 months from December 2014 to January 2015. All patients were evaluated by a resident trainee and a senior consultant. Necessary investigations were done wherever applicable. The most probable clinical diagnosis was made after a detailed history and a thorough neurological evaluation. Age, sex, and the diagnosis were recorded and entered in an Excel sheet. Appropriate statistical methods were used for descriptive analysis. RESULTS: Out of the 1500 patients, 766 were male and 734 were female. The most common complaints with which patients came to the outpatient services were headaches (28.6%), muscular and radicular pains (24.7%), seizures (12.7%) and hemiparesis/monoparesis (11.9%). Movement disorders, neuropathies, and nerve palsies were also present in a significant number of patients. CONCLUSION: The most common neurological disorders in the outpatient services are headache, neck pain, backache, fibromyalgia, stroke, epilepsy, and neuropathies. Newly joined residents should be well trained to efficiently manage these common outpatient disorders.

HIV infection associated neuromyelitis optica spectrum disorder: Clinical features, imaging findings, management and outcomes.

INTRODUCTION: HIV Infection associated NMOSD (HIV-NMOSD) is a recently recognized entity. Management of patients with HIV-NMOSD is a challenge. Here we report our own experience of HIV-NMOSD along with a complete review of all the cases of HIV-NMOSD reported in literature. OBJECTIVE: Describe the clinical features, radiological findings, treatment patterns and outcomes in patients with HIV-NMOSD. METHODS: The details of all cases of HIV- NMOSD were searched from our NMOSD registry. A literature search was also done using the terms NMO, NMOSD and HIV infection in PUBMED, Google Scholar and EMBASE. The details of all the reported cases and cases from our registry were collected and analyzed. RESULTS: Six cases of HIV-NMOSD were identified from the literature and one from our registry. There were four males and three females with age ranging from 8 years to 49 years. Duration of HIV infection ranged from newly detected to 15 years. Optic neuritis followed by myelitis was the commonest presentation, occurring in 5 out of 7 patients. 3 patients were anti-aquaporin 4 antibody positive while 3 were negative and in one anti- aquaporin 4 antibody assay was not done. All patients received immunomodulatory treatment. 5/7 patients had poor recovery from acute attacks but no patient had further relapses while on immunomodulatory treatment and antiretroviral therapy. CONCLUSION: HIV associated NMOSD is a recently recognized entity. A high index of suspicion is needed to diagnose these patients. In all patients with HIV infection presenting with optic neuritis or/and myelitis, anti aquaporin 4 antibody status should be checked and in all patients of NMOSD, HIV infection should be ruled out.

Post herpes zoster SUNCT like syndrome: Insights from two case reports.

Background SUNCT like syndrome secondary to post herpes zoster infection has not been reported in literature. Case We are reporting two cases of SUNCT like syndrome secondary to post herpes zoster infection of the V1 distribution of the trigeminal nerve. Treatment with pregabalin and lamotrigine achieved complete symptomatic relief in both patients. Conclusion SUNCT like syndrome can occur after herpetic infection of the trigeminal nerve. Unlike primary SUNCT syndrome, post-herpetic SUNCT like syndrome seems to respond well to pharmacological treatment and has a good prognosis.