Qualitative electroencephalogram and its predictors in the diagnosis of stroke.

Introduction: Stroke is a typical medical emergency that carries significant disability and morbidity. The diagnosis of stroke relies predominantly on the use of neuroimaging. Accurate diagnosis is pertinent for management decisions of thrombolysis and/or thrombectomy. Early identification of stroke using electroencephalogram (EEG) in the clinical assessment of stroke has been underutilized. This study was conducted to determine the relevance of EEG and its predictors with the clinical and stroke features. Methods: A cross-sectional study was carried out where routine EEG assessment was performed in 206 consecutive acute stroke patients without seizures. The demographic data and clinical stroke assessment were collated using the National Institutes of Health Stroke Scale (NIHSS) score with neuroimaging. Associations between EEG abnormalities and clinical features, stroke characteristics, and NIHSS scores were evaluated. Results: The mean age of the study population was 64.32 ± 12 years old, with 57.28% consisting of men. The median NIHSS score on admission was 6 (IQR 3-13). EEG was abnormal in more than half of the patients (106, 51.5%), which consisted of focal slowing (58, 28.2%) followed by generalized slowing (39, 18.9%) and epileptiform changes (9, 4.4%). NIHSS score was significantly associated with focal slowing (13 vs. 5, p < 0.05). Type of stroke and imaging characteristics were significantly associated with EEG abnormalities (p < 0.05). For every increment in NIHSS score, there are 1.08 times likely for focal slowing (OR 1.089; 95% CI 1.033, 1.147, p = 0.002). Anterior circulation stroke has 3.6 times more likely to have abnormal EEG (OR 3.628; 95% CI 1.615, 8.150, p = 0.002) and 4.55 times higher to exhibit focal slowing (OR 4.554; 95% CI 1.922, 10.789, p = 0.01). Conclusion: The type of stroke and imaging characteristics are associated with EEG abnormalities. Predictors of focal EEG slowing are NIHSS score and anterior circulation stroke. The study emphasized that EEG is a simple yet feasible investigational tool, and further plans for advancing stroke evaluation should consider the inclusion of this functional modality.

Atypical presentation of an atypical pneumonia: a case report.

BACKGROUND: Neurologic impediments occur in only 0.1% of Mycoplasma pneumoniae infections. Although direct intracerebral infection can occur in these patients, autoimmune-mediated reactions secondary to molecular mimicry are the most common pathophysiology of such neurological complications. These complications include immune-mediated encephalitis, peripheral neuritis such as Guillain-Barré syndrome, and many others. Miller Fisher syndrome is a one of the variants of Guillain-Barré syndrome that has been rarely linked to Mycoplasma pneumoniae infection. It is a condition classically characterized by the triad of ophthalmoplegia, areflexia, and ataxia. Most patients with Miller Fisher syndrome will have positive anti-ganglioside GQ1b antibodies found in their serum, making this autoantibody a very useful serological confirmation parameter. We report a case of a Miller Fisher syndrome in a woman with Mycoplasma pneumoniae infection. To the best of the authors' knowledge, such cases have been only rarely described in literature. CASE PRESENTATION: A 35-year-old Chinese woman presented with sudden onset of double vision and ataxia 5 days after fever and mild flu symptoms. Her Mycoplasma pneumoniae antigen was positive with 1 over 2560 titer of total mycoplasma antibody and presence of immunoglobulin M antibody, suggesting acute infection, and her nerve conduction study revealed mild sensory axonal polyneuropathy with segmental demyelination. the Miller Fischer syndrome variant of Guillain-Barré syndrome secondary to Mycoplasma pneumonia was suspected and later confirmed by presence of serum anti-GQ1b autoantibody. She was treated with intravenous immunoglobulin 0.4 g/kg once daily for 5 days. CONCLUSIONS: The objective of this report is to share a case of an uncommon neurological complication of Mycoplasma pneumoniae infection, to increase the level of suspicion among clinicians that Miller Fischer syndrome can occur as an atypical presentation of an atypical pneumonia.

'Crescendo transient ischemic attack'-an uncommon presentation of a very common disease: a case report on capsular warning syndrome.

Capsular warning syndrome is a rare presentation of transient ischaemic attack, which described as recurrent episodes of motor and/or sensory deficits which typically sparring the cortical function. It has a significant risk to progress into a massive stroke with permanent disability, thus important to be recognise early. Here, we report a middle-age gentleman with no known medical illness presented with eight episodes of transient ischaemic attack within the span of 24 h. He was treated with double anti-platelet for 21 days and was not subjected to thrombolysis at time of presentation because it was outside the window period of 4.5 h, and has fully recovered after each episode. The purpose of this case report is to share the uncommon clinical presentation of transient ischaemic attack, which is still not fully understood and warrant more studies especially on the treatment that can affect the progression of the disease.

Prevalence and associated risk factors of undiagnosed depression among people with epilepsy in a multiethnic society.

BACKGROUND: Depression is the most frequent psychiatric comorbidity of epilepsy. However, clinicians often neglect to screen for depressive symptoms among patients with epilepsy and, therefore, fail to detect depression. Many studies have described the risks associated with depression in patients with epilepsy, but few studies have elaborated whether these risks are similar in those with undiagnosed depression, especially in a multiethnic community. METHODS: In the present cross-sectional study conducted at a tertiary teaching hospital, we aimed to investigate the prevalence and associated risk factors of undiagnosed depression in patients with epilepsy. We recruited patients with epilepsy aged 18-65 years after excluding those with background illnesses that may have contributed to the depressive symptoms. In total, 129 participants were recruited. We collected their demographic and clinical details before interviewing them using two questionnaires-the Neurological Disorders Depression Inventory for Epilepsy and Beck's Depression Inventory-II. Subsequently, if a participant screened positive for depression, the diagnosis was confirmed using the Diagnostic and Statistical Manual of Mental Disorders questionnaire, and a psychiatric clinic referral was offered. RESULTS: Among the 129 participants, 9.3 % had undiagnosed major depressive disorder, and there was a female preponderance (66.7 %). The risk factors for undiagnosed depression among patients with epilepsy included low socioeconomic background (p = 0.026), generalized epilepsy (p = 0.036), and temporal lobe epilepsy (p = 0.010). Other variables such as being underweight and unmarried were more common among patients diagnosed with depression than without but no statistically significant relationship was found. CONCLUSION: The prevalence of undiagnosed depression among patients with epilepsy was higher than that in population-based studies conducted in Western countries. Although questionnaires to screen for depression are widely available, some clinicians rarely use them and, therefore, fail to identify patients who may benefit from psychosocial support and treatment that would improve their disease outcomes and quality of life. The present study indicated that clinicians should use screening questionnaires to identify undiagnosed depression in people with epilepsy.

A case of Hashimoto encephalopathy in a Malay woman with Graves disease.

Hashimoto encephalopathy (HE) is a poorly recognised steroid-responsive encephalopathy, with prominent neuropsychiatric features. Diagnosis is often difficult due to its heterogeneous clinical presentation, especially since the thyroid status or anti-thyroid antibody titres may not be related to the disease state. Here, the case of a 23-year-old Malay woman with Graves disease who presented with progressive encephalopathy diagnosed as HE is presented. She responded dramatically to high dose intravenous and then oral corticosteroid. A month after the initiation of treatment, she regained full independency.