Drug resistant neuroleptic malignant syndrome and the role of electroconvulsive therapy.

Neuroleptic malignant syndrome is considered as a rare but potentially fatal complication of neuroleptic medications e.g.,antipsychotics, sedatives and anti emetics. It is characterized by hyperthermia, muscle rigidity, an elevated creatine kinase level and autonomic instability. The syndrome often develops after the start of antipsychotic or a sudden increase in dosage of the neuroleptic medication or in states of dehydration. Treatment is mainly supportive and includes withdrawal of the neuroleptic medication and, possibly, administration of drugs such as dantrolene and bromocriptine. In rare cases where drugs treatment remains ineffective a trial of electroconvulsive therapy is being given. The case presented is a drug resistant case of Neuroleptic Malignant Syndrome where finally electroconvulsive therapy was effective.

Acute Treatment of Migraine: Expert Consensus Statements from the United Arab Emirates (UAE).

INTRODUCTION: Migraine, characterized by recurrent headaches and often accompanied by other symptoms like nausea, vomiting, and sensitivity to light and sound, significantly impacts patients' quality of life (QoL) and daily functioning. The global burden of migraines is reflected not only in terms of reduced QoL but also in the form of increased healthcare costs and missed work or school days. While UAE (United Arab Emirates)-specific consensus-based recommendations for the effective use of preventive calcitonin gene-related peptide (CGRP)-based migraine therapies have been published previously, an absence of such regional guidance on the management of acute migraine represents a gap that needs to be urgently addressed. METHODS: A task force of eight neurologists from the UAE with expertise in migraine management conducted a comprehensive literature search and developed a set of expert statements on the management of acute migraine that were specific to the UAE context. To ensure diverse perspectives are considered, a Delphi panel comprising 16 neurologists plus the task force members was set up. Consensus was achieved using a modified Delphi survey method. Consensus was predefined as a median rating of 7 or higher without discordance (if > 25% of the Delphi panelists rate an expert statement as 3 or lower on the Likert scale). Expert statements achieving consensus were adopted. RESULTS: The Modified Delphi method was used successfully to achieve consensus on all nine expert statements drafted by the task force. These consensus statements aim to provide a comprehensive guide for UAE healthcare professionals in treating acute migraine. The statements cover all aspects of acute migraine treatment, including what goals to set, the timing of treatment, treatment strategy to use in case of inadequate response to triptans, safety aspects of combining gepants for acute attacks with preventive CGRP-based therapies, special population (pregnant and pediatric patients) considerations, and the management of the most bothersome symptoms (MBS). CONCLUSIONS: Adopting these consensus statements on the treatment of acute migraine can help enhance patient care, improve outcomes, and standardize treatment practices in the UAE. The collaborative effort of experts with diverse experiences in developing these consensus statements will strengthen the credibility and applicability of these statements to various healthcare settings in the country.

An Unusual Presentation of the Cervicobrachial Variant of Guillain-Barré Syndrome in a 32-Year-Old Previously Healthy Male.

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder characterized by acute peripheral nerve demyelination. The cervicobrachial (CB) variant presents with predominant upper limb weakness and has distinct clinical features. This case report aims to detail the clinical manifestations, diagnostic methodology, treatment outcomes, and broader implications of the CB variant of GBS. This case report presents a 32-year-old male, with a rare CB type of GBS, characterized by upper limb weakness and distinctive clinical features. Following a recent flu-like illness, the patient exhibited sudden onset weakness and neck pain. Neurological examination revealed proximal muscle weakness in the upper limbs with associated impaired pinprick sensation. Relevant laboratory investigations and imaging supported the diagnosis. The patient was diagnosed based on clinical suspicion, presentation, and cerebrospinal fluid (CSF) albuminocytological dissociation. The patient responded to intravenous immunoglobulin (IVIG) therapy, highlighting the importance of early recognition and intervention. The diagnostic approach involved nerve conduction studies (NCS), CSF analysis, and imaging, with normal findings on CT, MRI brain & cervical spine, and NCS. IVIG therapy resulted in significant improvement in muscle power. In conclusion, this case shows the significance of early recognition and intervention in the CB variant of GBS. The diagnostic methodology, encompassing advanced modalities, played a crucial role in confirming the diagnosis.

A Rare and Challenging Presentation of Acute Hemorrhagic Leukoencephalitis With Tumefactive Demyelinating Lesions in a 41-Year-Old Male.

Acute hemorrhagic leukoencephalitis (AHLE) is a rare and severe inflammatory condition of the central nervous system (CNS), characterized by hemorrhagic lesions in the brain's white matter. Here, we present a case of AHLE with concurrent tumefactive demyelinating disease, highlighting the diagnostic and management challenges associated with this complex presentation. Tumefactive multiple sclerosis (MS) is a rare variant of MS characterized by large, space-occupying lesions in the CNS. Concurrently, hemorrhagic leukoencephalitis (HLE) represents a severe inflammatory disorder characterized by hemorrhagic lesions within the CNS white matter. The diagnosis of tumefactive MS with associated HLE posed significant diagnostic challenges due to overlapping clinical and radiological features. Management involved high-dose corticosteroid therapy and supportive care measures, with longitudinal follow-up to assess treatment response and prevent complications. The patient exhibited a favorable clinical response to treatment, with gradual improvement in symptoms and resolution of radiological abnormalities. The coexistence of tumefactive MS with HLE is exceptionally rare and presents diagnostic and therapeutic challenges. We report a 41-year-old male presenting with acute neurological symptoms, including severe headache, confusion, left-sided body weakness, slurred speech, and blurred vision. Neurological examination revealed dysarthric speech, right homonymous hemianopia, left upper motor neuron facial palsy, and motor deficits. MRI demonstrated multifocal areas of T2 hyperintensity with associated hemorrhage, suggestive of tumefactive MS with associated HLE. Diagnostic workup included neurological examination, MRI imaging, cerebrospinal fluid analysis, and serological testing. Management involved high-dose corticosteroid therapy and supportive care measures. The patient exhibited a favorable clinical response to treatment, with gradual improvement in symptoms and resolution of radiological abnormalities. Longitudinal follow-up confirmed sustained improvement. In conclusion, the coexistence of tumefactive MS with HLE poses diagnostic challenges due to overlapping features. This case underscores the importance of considering rare and atypical presentations of CNS demyelinating disease and the potential complications, including associated HLE. Comprehensive evaluation, multidisciplinary collaboration, and individualized management are essential for optimizing outcomes in patients with complex CNS inflammatory disorders.

Consensus-Based Recommendations on the Use of CGRP-Based Therapies for Migraine Prevention in the UAE.

INTRODUCTION: Migraine is a common debilitating neurological disorder affecting a large proportion of the general population. Calcitonin gene-related peptide (CGRP), a 37-amino acid neuropeptide, plays a key role in the pathophysiology of migraine, and the development of therapies targeting the anti-CGRP pathway has revolutionized the field of migraine treatment. METHODS: An expert task force of neurologists in the United Arab Emirates (UAE) developed and critically assessed recommendations on the use of CGRP-based therapies in migraine treatment and management in the UAE, based on available published literature. A consensus was reached for each statement by means of an open-voting process, based on a predefined agreement level of at least 60%. RESULTS: The consensus recommendations advocate the need for guidelines for the appropriate use of CGRP-based therapies by defining patient cohorts and appropriate monitoring of therapeutic response as well as standardizing the initiation, assessment, and cessation of treatment. The consensus recommendations were primarily formulated on the basis of international studies, because of the limited availability of regional and local data. As such, they may also act as guidelines for global healthcare providers. CONCLUSIONS: These are the first consensus recommendations for the UAE that address the use of CGRP-based therapies in the treatment and management of migraine, integrating both clinical evidence and medical expertise to enhance clinical judgment and decision-making.

Multidisciplinary headache clinic-impact of a new model for headache care in Dubai.

INTRODUCTION: Primary headache disorders pose a huge burden to health systems around the world. A new model for headache care was introduced at two primary health centers (PHCs) in Dubai, UAE. Our objective is to describe the model, and the impact it had on increasing the number of patients receiving specialist care as well as on patient's response and satisfaction level. METHODS: The model consisted of a weekly multi-disciplinary headache clinic with a neurologist, a general physician, a psychologist and a nurse, at each of the two PHCs. Patients were referred from all PHCs in Dubai. Follow up visits were either with the general physician or through tele-headache with the neurologist. We used the HURT questionnaire to evaluate the headache for each patient at baseline and then again at follow up. Information on patient satisfaction was also collected. Data were analyzed using SPSS version 21. RESULTS: The model proved to be effective in terms of increase in the number of headache patients receiving specialist care. Using HURT questionnaire, improvement was seen in good control and in the sense of control over headache, and in risk of medication overuse between baseline and follow up visits. Patient satisfaction with various aspects of headache care was 80-90% after the first visit and improved further at follow up. CONCLUSION: Our multi-disciplinary headache model improved the access of patients to neurologists, and resulted in improved headache control and patient satisfaction levels. Other countries can adopt such models to improve headache care for their patients.

Cerebrospinal fluid confirmed COVID-19-associated encephalitis treated successfully.

The COVID-19 pandemic that attracted global attention in December 2019 is well known for its clinical picture that is consistent with respiratory symptoms. Currently, the available medical literature describing the neurological complications of COVID-19 is gradually emerging. We hereby describe a case of a 31-year-old COVID-19-positive patient who was admitted on emergency basis. His clinical presentation was primarily neurological, rather than the COVID-19's classical respiratory manifestations. He presented with acute behavioural changes, severe confusion and drowsiness. The cerebrospinal fluid analysis was consistent with COVID-19 encephalitis, as well as the brain imaging. This experience confirms that neurological manifestations might be expected in COVID-19 infections, despite the absence of significant respiratory symptoms. Whenever certain red flags are raised, physicians who are involved in the management of COVID-19 should promptly consider the possibility of encephalitis. Early recognition of COVID-19 encephalitis and timely management may lead to a better outcome.

Mycoplasma pneumoniae infection presenting as stroke and meningoencephalitis with aortic and subclavian aneurysms without pulmonary involvement.

A 39-year-old Philipino man presented with acute onset fever and headache. Neurological examination was normal except for neck stiffness. There was no history of chest pain, cough or breathlessness. Cerebrospinal fluid (CSF) showed a mild increase in protein with normal sugar and lymphocytic pleocytosis. CSF PCR for herpes simplex and varicella zoster virus was negative. He developed acute right haemiplegia a week after hospitalisation. MRI showed acute infarct in the left centrum semiovale. His angiogram showed aneurysm in the left subclavian artery and aortic arch. The mycoplasma antibody test came positive with very high titres, while rest of the workup was negative. He was treated with azithromycin and his symptoms improved completely.He was asymptomatic on follow-up after a month. His repeat immunoglobulin G mycoplasma antibody titre showed elevation. Mycoplasma infection is a treatable cause of meningoencephalitis and stroke secondary to vasculitis. Arterial aneurysms are known to occur with mycoplasma infection although rare.

Cerebral venous thrombosis presenting with subdural haematoma as first presentation for systemic lupus erythematosus with negative antiphospholipid antibodies.

We report the case of a 30-year-old woman, without any previous comorbidities presenting with acute onset headache, altered sensorium and unsteadiness of gait. Neurological evaluation revealed a drowsy patient with papilloedema, bilateral lateral rectus palsy, generalised hyper-reflexia and up going plantar responses. Urgent imaging performed showed extensive cortical venous sinus thrombosis. Workup for secondary causes of cortical venous sinus thrombosis revealed very high titres of antinuclear antibody and anti-dsDNA, but negative antiphospholipid antibodies (APLA). In hospital she started developing other complications of systemic lupus erythematosus (SLE). Urine evaluation revealed proteinuria and granular casts suggestive of glomerulonephritis. Cardiac evaluation revealed moderate pericardial effusion. We have discussed neurolupus as initial presentation of SLE and the rare occurrence of major neurovascular complications without secondary APLA syndrome.