Seizure-outcome after surgery of low-grade epilepsy associated neuro-epithelial tumors.

BACKGROUND: Most patients with glioneuronal tumors present with seizures. Although several studies have shown that greater extent of resection improves overall patient survival, few studies have focused on postoperative seizure outcome after resection of these tumors. The aim of this study was to characterize seizure control rates in patients undergoing glioneuronal tumor resection and evaluate the association between poor seizure outcome and tumor recurrence or progression. METHODS: The study population included patients who had undergone resection of glioneuronal tumors between 2014 and 2019 at our institution. Seizure outcome was assessed using Engel grading. Preoperative seizure characteristics, tumor characteristics, surgical factors, and postoperative seizure outcomes were reviewed. RESULTS: Twenty-six patients (N.=16, temporal lobe; N.=6, frontal lobe; N.=4, parietal lobe) with mean seizures duration of 56.9-months, were assessed. Histopathologically, N.=15 dysembryoplastic neurepithelial tumor, N.=7 ganglioglioma and N.=4 Diffuse lepto-meningeal neuroepithelial tumor. There were 2 cases of complex DNET and one case of DLMNT had associated cortical dysplasia. At mean follow-up of 49.7 months, N.=20 Engel 1, N.=4 Engel 2 and N.=2 had Engel 3 outcome. N.=20 underwent gross total excision (N.=18 Engel 1 and N.=2 Engel 2) and N.=6 sub-total excision. Among the 4 patients who needed re-surgery, two were in Engel 2 and another two were in Engel 3. CONCLUSIONS: Good seizure-outcome is likely associated with extent of resection. Younger age of patient, less than one-year of seizure duration and absence of generalization of seizure are good prognostic indicators. The best seizure-control can be achieved by early surgical intervention.

Quadriparesis with different diagnoses after COVID-19 vaccination: Case series and literature review.

Following vaccination with adenoviral vector-based ChAdOx1 nCoV-19, serious neurological adverse events have been reported. Here we report two cases who presented with quadriparesis following the adenoviral vector-based ChAdOx1 nCoV-19 vaccine. A 55-year-old male patient presented with quadriparesis after 8 days of the second dose of ChAdOx1 nCoV-19 vaccination. Imaging showed features of stroke with right basilar artery thrombosis; he was started on anticoagulation following which the patient's neurological status improved and he was discharged during the 7th week of hospital stay. A 19-year-old male patient presented with quadriparesis after 16 days of the first dose of ChAdOx1 nCoV-19 vaccination. Cerebral spinal fluid and nerve conduction study was suggestive of Guillain-Barre syndrome (GBS). Two doses of intravenous immunoglobulin were given, following which the patient's neurological status improved and he was discharged in the 11th week of his hospital stay. Awareness of neurological adverse effects and emphasis on the underlying mechanism of vaccine-induced thrombotic thrombocytopenia (VITT) and molecular mimicry in patients presenting with quadriparesis following ChAdOx1 nCoV-19 vaccination is important.

Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India.

Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Nonstatin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals with statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).

Immune response in symptomatic and asymptomatic neurocysticercosis.

Innate immune system is crucial in the pathogenesis of neurocysticercosis (NCC) and helminth glycans can induce anti-inflammatory milieu via toll-like receptor 4 (TLR4) dependent mechanisms. The association of TLR4 and cytokines is yet to be explored in NCC. Therefore, the present study detected the serum levels of cytokines and soluble intercellular adhesion molecule (sICAM)-1 in asymptomatic and symptomatic NCC and their association with TLR4 expression. Sixty eight patients with NCC (asymptomatic, 36 and symptomatic, 32), and age and gender matched 37 healthy controls were enrolled to determine the levels of different pro- and anti-inflammatory cytokines, sICAM-1 in the serum by ELISA and expression of TLR4 in peripheral blood mononuclear cells (PBMCs) by flow cytometry. In asymptomatic NCC cases, the levels of IL-10 and IL-4 were significantly elevated compared to healthy controls and symptomatic NCC patients whereas the levels of IFN-γ, TNF-α, IL-17, IL-23 and sICAM-1 were higher in symptomatic NCC patients compared to healthy controls and asymptomatic NCC individuals. Frequency of TLR4 expressing PBMCs and CD14 positive cells were significantly higher in both groups of NCC. Although the number of TLR4 expressing cells was almost similar in both asymptomatic and symptomatic groups, the median fluorescence intensity was significantly higher in symptomatic group indicating that higher levels of TLR4 expression in symptomatic patients correlated with enhanced pro-inflammatory cytokine production.

Association of MMP-2 and MMP-9 with clinical outcome of neurocysticercosis.

Matrix metalloproteinases (MMPs) are the major endopeptidases involved in proteolysis of blood brain barrier (BBB) during central nervous system (CNS) infections. The present study detected serum levels and activities of MMP-2 and MMP-9 in patients with neurocysticercosis (NCC) and their association with symptomatic disease. In total, 68 individuals with NCC (36 symptomatic patients with active seizures and 32 asymptomatic individuals) and 37 healthy controls were enrolled for the study. Serum MMP-2 and MMP-9 levels and their activities were measured by ELISA and gel zymography respectively. Mean serum MMP-2 levels (ng/ml) were higher both in asymptomatic and symptomatic NCC cases compared to healthy controls. However, significantly higher levels of serum MMP-9 (ng/ml) were detected only in symptomatic NCC patients compared to asymptomatic NCC cases and healthy controls. Levels of both MMPs positively correlated with symptomatic NCC. Serum MMP-2 activities were significantly higher in symptomatic and asymptomatic NCC compared to healthy controls whereas serum MMP-9 activity was significantly associated with symptomatic NCC compared to healthy controls and asymptomatic NCC. In conclusion, the elevated level of MMP-9 in serum appears to play an important role in the development of symptoms i.e. active seizures in patients with NCC. However, further studies are needed to elucidate its precise role in disease pathogenesis.

Hydrocephalus in Tuberculous Meningitis - Pearls and Nuances.

Tuberculous meningitis (TBM) is associated with high mortality. A large proportion of patients with TBM, who survive, live with disabling neurological sequelae. Hydrocephalus is one of the common complications of TBM, seen in up to 80% of patients. Hydrocephalus may be a presenting feature or may develop paradoxically after the commencement of antituberculosis treatment. The Hallmark pathological feature of TBM is a thick gelatinous exudate, dominantly present at basal parts of the brain. Exudate encases and strangulates cranial nerve trunks like optic nerve, optic chiasma, and vessels of the circle of Willis. Basal exudate also blocks the cerebrospinal fluid (CSF) flow in the brain, resulting in ventriculomegaly. It is often difficult to differentiate between two common types (communicating and obstructive) of hydrocephalus on basis of routine neuroimaging. Progressive hydrocephalus, clinically manifests with a potentially life-threatening high intracranial pressure. Patients with deteriorating vision loss and deteriorating consciousness, often need a surgical CSF diversion procedure (ventriculoperitoneal shunt or endoscopic third ventriculostomy) to be performed. CSF diversion may be life-saving. However, the long-term benefits of CSF diversion are largely unknown.

Neuroimaging Patterns in Patients with COVID-19-Associated Neurological Complications: A Review.

BACKGROUND: A variety of neuroimaging abnormalities in COVID-19 have been described. OBJECTIVES: In this article, we reviewed the varied neuroimaging patterns in patients with COVID-19-associated neurological complications. METHODS: We searched PubMed, Google Scholar, Scopus and preprint databases (medRxiv and bioRxiv). The search terms we used were "COVID -19 and encephalitis, encephalopathy, neuroimaging or neuroradiology" and "SARS-CoV-2 and encephalitis, encephalopathy, neuroimaging or neuroradiology". RESULTS: Neuroimaging abnormalities are common in old age and patients with comorbidities. Neuroimaging abnormalities are largely vascular in origin. COVID-19-associated coagulopathy results in large vessel occlusion and cerebral venous thrombosis. COVID-19-associated intracerebral hemorrhage resembles anticoagulant associated intracerebral hemorrhage. On neuroimaging, hypoxic-ischemic damage along with hyperimmune reaction against the SARS-COV-2 virus manifests as small vessel disease. Small vessel disease appears as diffuse leukoencephalopathy and widespread microbleeds, and subcortical white matter hyperintensities. Occasionally, gray matter hyperintensity, similar to those observed seen in autoimmune encephalitis, has been noted. In many cases, white matter lesions similar to that in acute disseminated encephalomyelitis have been described. Acute disseminated encephalomyelitis in COVID-19 seems to be a parainfectious event and autoimmune in origin. Many cases of acute necrotizing encephalitis resulting in extensive damage to thalamus and brain stem have been described; cytokine storm has been considered a pathogenic mechanism behind this. None of the neuroimaging abnormalities can provide a clue to the possible pathogenic mechanism. CONCLUSIONS: Periventricular white-matter MR hyperintensity, microbleeds, arterial and venous infarcts, and hemorrhages are apparently distinctive neuroimaging abnormalities in patients with COVID-19.

Seizure Outcome after Lesionectomy With or Without Concomitant Anteromedial Temporal Lobectomy for Low-Grade Gliomas of the Medial Temporal Lobe.

BACKGROUND: Mesial temporal lobe epilepsy attributed to low-grade glioma is known for intractable seizures and choice of surgery range from lesionectomy (Lo) to lesionectomy with anteromesial temporal resection (L0 + AMTR) is still debatable. We intend to analyze the seizure outcome after lesionectomy alone or with AMTR. SUBJECTS AND METHODS: Retrospective analyses of patients operated for medial low-grade temporal lobe tumors with seizures were included in the study. Preoperative records include video-electroencephalographic, magnetic resonance imaging (epilepsy protocol), and neuropsychological evaluation for language, memory, and dominance were assessed. Two groups (Lo [Group I] and Lo + AMTR [Group II]) were assessed after surgery by the international league against epilepsy (ILAE) seizure outcome scale. RESULTS: A total of 39 patients underwent Lo (n = 20) and Lo + AMTR (n = 19) with a mean age of 26.92 ± 12.96 months, and mean duration of seizures was 36.87 46.76 months. A total of 23 patients had long-term intractable seizures for >1 year despite >2 drugs(Group I [n = 10], Group II [n = 13]); remaining 16 had frequent seizures of <1-year duration. In the postoperative period, on a mean follow-up of 49.72 ± 34.10 months, the ILAE outcome scale shown a significant difference (P = 0.05) in seizure outcome between two groups. Four (40%) patients out of 10 having refractory seizures in Group I and 8 (80%) from the Group II out of 10 patients could achieved ILAE Class 1 outcome after surgery. Histopathology analysis includes low-grade astrocytoma (n = 29) and in two patients there were associated CA1 neuronal loss in hippocampus, one patient had mesial temporal sclerosis from Group II attributed to its intractability in seizures. CONCLUSION: For the mesial temporal low-grade glioma presenting with seizures, the seizure outcome by lesionectomy with AMTR is superior than lesionectomy only.

Resistant Temporal Lobe Epilepsy: Initial Steps into a Bigger Epilepsy Surgery Program.

Background Among the patients of drug-resistant epilepsy, a subset which has focal impaired seizures localizes to the temporal lobe region (TLE). A majority of these cases are surgically amenable with anterior-medial temporal lobe resection or "lesionectomy." Objective In India, there is scarcity of "specialized centers" providing "comprehensive epilepsy care" and this dearth is further worse in populous states. In this article, we share our single center, observational, and retrospective experience of TLE in background of limited resources and utmost requirement. Methodology Our study is a retrospective analysis medically refractory epilepsy patients (2016-2019). Patients with medically refractory epilepsy were selected based upon our noninvasive protocol (clinical semiology, interictal scalp electroencephalography (EEG), long-term video EEG monitoring data, and magnetic resonance injury [MRI]). The follow-up was noted from the last out-patient visit record or through telephonic conversation (International League Against Epilepsy score). Results Of 23 cases of TLE ( n = 7, mesial temporal sclerosis; n = 16 temporal lobe like cavernomas, tumors, or arterio-venous malformations). Single photon emission computed tomography/positron emission tomography (SPECT/PET) was performed in five cases (three cases of ictal/interictal SPECT and two cases of PET scan) where there was discordance between EEG/clinical and MRI. The median follow-up was of 19 months with 18 cases being seizure free. Five cases were fully off the antiepileptic drug (AEDs) while in 15 cases, the AEDs dosages or the number were reduced. Average number of AEDs reduced from 2.9 in preoperative period to 1.2 postoperatively. Two cases had quadrantanopia and one case of cerebrospinal fluid leak. Conclusion A multidisciplinary and holistic approach is required for best patient care. The results of our initial surgical experience are encouraging.

Correlation of matrix metalloproteinases-2 and -9 with proinflammatory cytokines in Guillain-Barré syndrome.

The role of matrix metalloproteinases (MMPs) and cytokines in the pathogenesis of Guillain-Barré syndrome (GBS) largely remains unknown. We studied the role of MMP-2, MMP-9, tumor necrosis factor-α (TNF-α), and interleukin-1ß (IL-1ß) in disease progression and recovery of patients with GBS. Sixty-five patients with GBS and 68 healthy controls were enrolled in the study. Serum levels of MMP-2, MMP-9, TNF-α, and IL-1ß were analyzed by ELISA, and activities of MMPs were measured by zymography. Expression of MMP-9, TNF-α, and IL-1ß was higher in the progressive phase and lower in the recovery phase of GBS than in controls. A positive correlation of MMP-2 with IL-1ß and MMP-9 with TNF-α and IL-1ß was observed with progressive-phase GBS. The study shows that up-regulation of MMP-9 along with proinflammatory cytokines (TNF-α and IL-1ß) in the early course appears to be associated with immune-mediated disease progression resulting from inflammation in the peripheral nervous system, whereas, during the later phase, down-regulation of MMP-9 and proinflammatory cytokines is implicated in recovery from the disease.

Lymphocyte transformation test detects a response to Campylobacter jejuni antigens in patients with Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is an immune-mediated polyneuropathy. Campylobacter jejuni-associated gastrointestinal infection is identified as a major precipitating agent of GBS; however, a standard test to diagnose this infection in patients with GBS is lacking. The aim of the present study was to evaluate an outer membrane protein (OMP)-based lymphocyte transformation test (LTT) for the diagnosis of C. jejuni infection in GBS. Forty patients with GBS, age and gender matched 52 healthy controls (HC) and 46 disease controls (DC) were analyzed for C. jejuni infection by culture, polymerase chain reaction (PCR) and LTT. Lymphocytes at concentration of 1 x 10(6)/well isolated from GBS patients and controls were stimulated with 20 microg/ml of C. jejuni OMP, and (3)H-thymidine was incorporated to measure cell proliferation. LTT detected significantly higher C. jejuni infection compared to culture (77.5 vs. 2.5%; P < 0.05) and PCR (77.5 vs. 22.5%; P < 0.05). The cutoff value of lymphocyte proliferation by receiver operating characteristic (ROC) curve of 2.5 had 77.5% sensitivity and 96.5% specificity. Area under ROC curve was 0.92. The mean SI of the cell proliferation for GBS cases was significantly higher than the controls (GBS vs. HC; P < 0.001, GBS vs. DC; P < 0.001). LTT appears to be a sensitive tool for detecting preceding C. jejuni infection in GBS patients with reasonable sensitivity and specificity. It is possible that the activated lymphocytes might play role in the pathogenesis of neuronal damage in GBS.

Correlation of quantitative sensorimotor tractography with clinical grade of cerebral palsy.

INTRODUCTION: The purpose of this study was to determine whether tract-specific diffusion tensor imaging measures in somatosensory and motor pathways correlate with clinical grades as defined using the Gross Motor Function Classification System (GMFCS) in cerebral palsy (CP) children. METHODS: Quantitative diffusion tensor tractography was performed on 39 patients with spastic quadriparesis (mean age = 8 years) and 14 age/sex-matched controls. All patients were graded on the basis of GMFCS scale into grade II (n = 12), grade IV (n = 22), and grade V (n = 5) CP and quantitative analysis reconstruction of somatosensory and motor tracts performed. RESULTS: Significant inverse correlation between clinical grade and fractional anisotropy (FA) was observed in both right and left motor and sensory tracts. A significant direct correlation of mean diffusivity values from both motor and sensory tracts was also observed with clinical grades. Successive decrease in FA values was observed in all tracts except for left motor tracts moving from age/sex-matched controls to grade V through grades II and IV. CONCLUSION: We conclude that white matter tracts from both the somatosensory and the motor cortex play an important role in the pathophysiology of motor disability in patients with CP.

Gabapentin as a rescue drug in D-penicillamine-induced status dystonicus in patients with Wilson disease.

D-penicillamine induced status dystonicus is a unique but serious drug related complication in a subset of patients with Wilson disease. Patho-physiological basis of its occurrence is not known. It often responds poorly to anti dystonia medications. We present three patients with Wilson disease who developed severe paroxysmal dystonic spells after receiving D-penicillamine treatment. All three patients responded well to gabapentin after failing to respond to other anti dystonia drugs.

Endoscopic Endonasal Optic Nerve Decompression with Durotomy: Pis Aller in the Mind of a Blind.

BACKGROUND: Progressive vision loss is a dismal sequelae of idiopathic intracranial hypertension (IIH) and secondary intracranial hypertension with cerebro-venous sinus thrombosis (CVST). The initial management revolves around weight loss, acetazolamide, steroids, and diuretics. A subset of unfortunate patients, refractory to medical therapy, need surgical intervention in the form of CSF diversion or optic nerve decompression (OND). The ONDd is an emerging alternative with encouraging early results. AIM: In our study, we share our experience of ONDd by endoscopic endonasal corridor, highlighting the technical nuances of procedure and discuss the indications of the same in the era of advanced technology. MATERIALS AND METHODS: A retrospective, noncomparative review of the medical records of all the patients of IIH (ICHD-III criteria) with severe vision loss, refractory to medical treatment, and with established objective evidence of papilledema was done. All the patients were operated in our department by endoscopic endonasal sheath fenestration. RESULTS: Nine patients (M:F 3:6) underwent endoscopic endonasal optic nerve decompression (2016-2019) approach for medically refractive IIH (n = 6) and CVST (n = 3). The mean age of population was 21.44 ± 5.14 years; 6 patients had improvement in headache and 6 had improvement in visual acuity. The visual acuity deteriorated in two patients (n = 1 IIH and n = 1 CVST with dural AVF). One patient needed postoperative lumbar drain for CSF leak, while none had meningitis. CONCLUSION: Endoscopic optic nerve sheath fenestration is minimally invasive and effective alternative with promising outcome in the management of medical refractory IIH or CVST.