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.

Clinical and Radiological Profile of Cerebrovascular Disease in Polycythemia: Analysis of Neurologic Manifestations from a Tertiary Center in South India.

PURPOSE: Patients with polycythemia, either primary or secondary, are at elevated risk for thrombotic complications, including stroke. We aimed to investigate the clinical and radiological characteristics of cerebrovascular disease (CVD) in polycythemia, and describe other neurologic manifestations. METHODOLOGY: We conducted a cross-sectional study of patients diagnosed with polycythemia between 2014 and 2019 at a tertiary care center and collected relevant medical data with a special focus on cerebrovascular disease and neurologic manifestations. We performed descriptive and inferential analyses. We have also described and analyzed the available neuroimaging features. RESULTS: We analyzed data from 56 patients. 20 patients (35.7%) had ischemic stroke. The incidence of CVD was higher in those with primary polycythemia (43%) than in those with secondary polycythemia (8%). The most common subtype of stroke was large vessel disease, and the most common arterial territory was the anterior circulation. There was no statistically significant difference in the hematocrit level between those with or without CVD. Neuroimaging revealed multiple large vessel intracranial stenoses on MR Angiography, and hyperdense vessels on plain CT. Other neurologic manifestations included headache, seizures, dizziness, visual symptoms and papilledema, and these were significantly more common in primary polycythemia. CONCLUSIONS: CVD is common in patients with polycythemia. The most common type observed was large vessel occlusion, predominantly in the anterior circulation. In stroke patients, multiple vessel stenosis and hyperdense vessels may be clues to polycythemia.

Rare case of myasthenia gravis associated with situs inversus totalis: Implications in management.

A rare case of simultaneous occurrence of myasthenia gravis and situs inversus totalis is reported. The implications of the presence of these two entities on management are discussed.

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.

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.

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.

Feasibility study of stroke surveillance: data from Bangalore, India.

BACKGROUND & OBJECTIVE: Stroke is a leading cause of deaths, and disabilities in India. Reliable and good quality data on epidemiological characteristics of stroke are essential to plan, implement and evaluate stroke prevention and control programmes. A feasibility study was undertaken in Bangalore to examine the possibility of establishing stroke surveillance and to develop methodology for a larger programme. METHODS: The study adapted WHO STEPs-STROKE methodology to collect data on hospitalized stroke events and fatal stroke events in the city of Bangalore. In STEP I, Information was collected from 1,174 stroke patients in three large hospitals and were followed till discharge and 28 days; outcome was measured as death or disability. Stroke cases fulfilling diagnostic criteria, evaluated by neurologists and CT/MRI confirmed cases were included. Brief information on major risk factors was collected from all stroke patients / family members and from medical records by trained research officers. In STEP II, death records of Bangalore Mahanagara Palike for 2004 (n=23,312) were analyzed to identify stroke related deaths. RESULTS: Using WHO-STEPs approach, a methodology was developed for stroke surveillance in a geographically defined population. By STEP 1 method--7 per cent of medical and 45 per cent of neurological admissions were due to stroke with a fatality rate of 9 per cent at hospital discharge and 20 per cent at 28 days. With a mean age of 54.5 (+/- 17.0) yr and male preponderance, nearly half had one or more risk factors. Weakness or paresis (92%) was the commonest presentation and ischaemic stroke was most frequent (73.8%). One third of total stroke patients were dependent at both discharge and 28 day follow up. By STEP II method the proportional mortality rate for Bangalore city was observed to be 6 per cent and more than 50 per cent of total stroke deaths had occurred in 10 major hospitals. INTERPRETATION & CONCLUSION: The present study has shown that stroke surveillance is possible and feasible. Institution based (hospitals and vital registry data) stroke surveillance supplemented with periodical population based information can provide comprehensive information on vital aspects of stroke like mortality, risk factors, disability and outcome. There is a need to develop stroke surveillance in a phased manner along with mechanisms to apply data for prevention and control programmes.

Trigeminal autonomic cephalalgia as a presenting feature of Neuromyelitis Optica: "A rare combination of two uncommon disorders".

Neuromyelitis Optica (NMO) can have atypical presentations like hiccups, vomiting, etc. which is classically described as the area postrema syndrome. Here we report a case of a 39 year old male patient who presented with features of Trigeminal Autonomic Cephalalgia (TAC). MRI spine showed long segment myelitis. Diagnosis of NMO was confirmed by a positive Anti aquaporin 4 antibody assay. TACs are a rare group of headache disorders characterized by severe unilateral headache in the V1 distribution of the trigeminal nerve and autonomic symptoms. This presentation in NMO is hitherto unreported in literature.

A statistical model for stroke outcome prediction and treatment planning.

Stroke is a major cause of mortality and long-term disability in the world. Predictive outcome models in stroke are valuable for personalized treatment, rehabilitation planning and in controlled clinical trials. We design a new multi-class classification model to predict outcome in the short-term, the putative therapeutic window for several treatments. Our model addresses the challenges of class imbalance, where the training data is dominated by samples of a single class, and highly correlated predictor and outcome variables, which makes learning the effects of treatments on the outcome difficult. Empirically our model outperforms the best-known previous predictive models and can infer the most effective treatments in improving outcome that have been independently validated in clinical studies.

Antiepileptic Drugs and Quality of Life in Patients with Epilepsy: A Tertiary Care Hospital-Based Study.

OBJECTIVES: The present study evaluated patterns of the use of antiepileptic drugs (AEDs) and their impact on quality of life (QOL) in patients with epilepsy. METHODS: In this cross-sectional study, patients with epilepsy (age >18 years) receiving AEDs for at least 1 year were enrolled. Demographic, clinical, and treatment parameters were recorded. QOL was measured using the modified Quality of Life in Epilepsy Inventory-10 (QOLIE-10) questionnaire for epilepsy. RESULTS: Of 200 patients, 53.5% were males and 60% were younger than 30 years. Seizures were predominantly partial (58%) and of idiopathic origin (61%). Monotherapy to polytherapy ratio was 1:1, with 70% of the patients on one new AED. Clobazam (37%) was used most frequently followed by phenytoin (25.5%), levetiracetam (23%), oxcarbazepine (21.5%), and carbamazepine (21%). Patients on polytherapy experienced a significantly more number of adverse drug reactions than did those on monotherapy (P < 0.0001). The mean QOLIE-10 score was 74.58 ± 20.60. There was no significant difference in seizure frequency, number of adverse drug reactions, and QOLIE-10 score among patients receiving old and new AEDs. Multiple linear regression analysis identified increased seizure frequency (standardized ß -0.157; P = 0.003), more number of AEDs (standardized ß 0.107; P = 0.05) as well as adverse drug reactions (standardized ß -0.692; P = 0.0001) as significant predictors of poor QOL. CONCLUSIONS: Appropriate tools for early detection, selection of rational and safer AED treatment options, and regular monitoring for adverse effects play a crucial role in achieving seizure freedom and optimal QOL in patients with epilepsy.

Nadroparin plus aspirin versus aspirin alone in the treatment of acute ischemic stroke.

Low-molecular-weight-heparin (LMWH) has been widely used in the treatment of acute ischemic stroke but controlled trials are few. In this study, 40 patients with acute ischemic stroke of less than 24 hours duration were randomized to receive either aspirin (325 mg/day) alone or aspirin (325 mg/day) plus subcutaneous nadroparin 4100 units/day. At the end of 4 weeks, the morbidity and mortality were significantly less in the nadroparin group as compared to the aspirin group. There was no increased risk of clinically significant intracranial hemorrhage in either group. The combination of aspirin and LMWH deserves to be tested in larger studies.