Balancing between apoptosis and survival biomarkers in the patients with tuberculous meningitis.

BACKGROUND: The balancing factor of apoptosis, survival, inflammatory and oxidative stress biomarkers may determine the clinico-radiological severity and death in the patients with tuberculous meningitis (TBM). AIM: We report the relationship of death [caspase-3, malondialdehyde (MDA), tumor necrosis factor-α (TNFα), interleukin 6 (IL6)] and survival biomarkers [X-linked inhibitory apoptotic protein (XIAP), IL10, glutathione (GSH) and catalase] in TBM, and its role in determining disease severity and death. METHODS: The diagnosis of TBM was based on clinical, MRI and cerebrospinal fluid (CSF) findings. Their clinical and MRI findings were noted. The severity of TBM was categorized as stages I to III. Serum and CSF caspase-3 and XIAP were measured by ELISA, and TNFα, IL6 and IL10 gene expression in peripheral blood mononuclear cells using RT-PCR (reverse-transcriptase polymerase chain reaction). Plasma MDA, GSH and catalase were measured by spectrophotometer. RESULTS: There were 40 patients with TBM whose mean age was 31.6 years and 50% were females. TBM patients had higher expression of death (caspase-3, TNFα, IL6, and MDA) and suppression of survival biomarkers (XIAP, catalase and GSH) compared to the healthy controls. Caspase-3 positively correlated with TNFα, IL6 and MDA, and negatively with XIAP, GSH and catalase. Patients with longer duration of illness and definite TBM had higher expression of caspase-3. Patients who died has higher expression of caspase-3 and suppression of XIAP compared to those who survived. CONCLUSION: It can be concluded from this study that there is up-regulation of death signals and suppression of survival signals in TBM.

Oxidative stress and ER stress are related to severity of tubercular infection.

To report the markers of oxidative stress and endoplasmic reticulum (ER) stress in tuberculosis of differing severity. Ninety patients with tuberculosis, 30 each with pulmonary tuberculosis (PTB), Pott's spine (PS) and tuberculous meningitis (TBM) were included. The diagnosis and severity of the respective group was based on pre-defined criteria. Six-months outcome and complications (Hyponatremia, paradoxical worsening and Drug induced hepatitis(DIH)) were recorded. Serum Melanodehyde (MDA) , glutathione (GSH), total antioxidant capacity (TAC), ER stress markers ATF-4,GRP-78 and CHOP, were measured using spectrophotometry and real time PCR. The oxidative and ER stress markers were correlated with different subgroups, severity of TBM, complications and outcome. The severity of TBM correlated with alteration in oxidative and ER stress markers. MDA was related to hyponatremia (P = 0.045), paradoxical worsening (P = 0.035) and DIH (P = 0.038), TAC correlated with paradoxical worsening (P = 0.047) and DIH (P = 0.015). In PS, MDA correlated with paradoxical worsening (P = 0.032) and DIH (P = 0.032); and in PTB, MDA correlated with hyponatremia (P = 0.025) and DIH (P = 0.037). Changes in stress marker levels were more marked in TBM compared to PS and PTB. Outcome of TBM correlated with MDA (P = 0.002), PS to MDA(P = 0.004), TAC(P = 0.05) CHOP(P = 0.004), GRP78(P = 0.001), ATF4(P = 0.045) and PTB to MDA(P = 0.0450), TAC(P = 0.014), CHOP(P = 0.025) and GRP78(P = 0.035). Oxidative and ER stress markers seem to be related to severity of TB, its complications and outcome.

Predictors of fever response in tuberculous meningitis: A clinical, MRI and biomarker study.

BACKGROUND: Central nervous system (CNS) has a different immune surveillance system; therefore, fever at admission and timeline of fever response after antitubercular treatment (ATT) may follow a different course in CNS infection. We report the predictors of fever response in tuberculous meningitis (TBM) including the effect of tumour necrosis factor-α (TNF-α) in cerebrospinal fluid (CSF) and its gene expression at mRNA of peripheral blood mononuclear cells (PBMCs). METHODS: Fifty-seven patients with TBM were prospectively evaluated. Their clinical findings and severity of meningitis were recorded. The expression of TNF-α gene in PBMCs was quantified by real-time polymerase chain reaction and TNF-α concentration in CSF by cytokine bead array both in the patients and 14 matched controls. RESULTS: All the patients had history of fever for a median duration of 75 days. The admission temperature ranged between 37.2°C and 40°C and correlated with CSF cell counts (p < 0.05). Cranial MRI was abnormal in 54 (94.7%) and revealed exudates in 33(57.9%), hydrocephalus in 27(47.4%), infarction in 27(47.4%) and tuberculoma in 33(57.9%) patients. Fever subsided after a median duration of 18 (2 60) days of treatment. Twelve (21.8%) patients only became afebrile within 10 days. The expression of TNF-α gene correlated with CSF concentration of TNF-α (p = 0.02) and independently predicted duration of defervescence [adjusted hazard ratio 1.02 (95% CI 1.00-1.04; p = 0.01). CONCLUSION: In the patients with TBM, defervescence takes longer time, and TNF-α gene expression predicts the duration of defervescence. Future studies are needed to evaluate the role of TNF-α-modifying drugs in TBM.

Outcome of Guillain-Barré syndrome following intravenous immunoglobulin compared to natural course.

BACKGROUND AND PURPOSE: Intravenous immunoglobulin (IVIg) is recommended in Guillain-Barré syndrome (GBS), but its efficacy may vary in different subtypes. We report the outcomes of patients with GBS following IVIg treatment compared to the natural course (NC). We also compare the effect of IVIg treatment in different subtypes of GBS. METHODS: From a cohort of 528 GBS subjects, we have extracted 189 patients who received IVIg and compared their outcomes with 199 age- and peak disability-matched patients who did not receive IVIg, plasmapheresis, or corticosteroid. Disability was assessed using the 0-6 Guillain-Barré Syndrome Disability Scale (GBSDS). Clinical and neurophysiological subtypes were recorded. The primary outcome was functional disability at 6 months, which was categorized as complete (GBSDS ≤ 1), partial (GBSDS 2-3), or poor (GBSDS > 3). The secondary outcomes were in-hospital death, duration of hospitalization, and mechanical ventilation. RESULTS: In-hospital death (2.6% vs. 2%, p = 0.74) and 3-month poor recovery (20.7% vs. 18%) were similar in the IVIg and NC groups. At 6 months, however, a lesser proportion of patients in the IVIg group had poor recovery (2.2% vs. 8.3%, p = 0.026). The outcomes of IVIg and NC were compared in 72 acute motor axonal neuropathy (AMAN) and 256 acute inflammatory demyelinating polyradiculoneuropathy (AIDP) patients. IVIg therapy did not alter the outcome in AMAN but resulted in a lesser proportion of poor recovery at 6 months in AIDP (0.8% vs. 6.6%, p = 0.03). CONCLUSIONS: IVIg is beneficial in AIDP variants of GBS but not in the AMAN subtype. A customized treatment may be cost-effective until a randomized controlled trial is conducted in AMAN.

Racemose neurocysticercosis simulating tuberculous meningitis.

We report a patient with racemose neurocysticercosis, highlighting the diagnostic and management issues. A 37-year-old male had headaches, fever, and seizures for 8 months. He had a positive tuberculin test, cerebrospinal fluid pleocytosis, and hydrocephalus and exudates on MRI. His symptoms rapidly resolved following antitubercular and prednisolone treatment. After 2 months, he was readmitted with headache and vomiting, and his brain MRI revealed communicating hydrocephalus with a cyst in the lateral ventricle and subarachnoid space, which was confirmed as neurocysticercosis on the third ventriculostomy. The patient was managed with dexamethasone and a ventriculoperitoneal shunt. This case highlights that meningitis symptoms, CSF pleocytosis, and positive tuberculin tests may not always suggest tubercular etiology.

A clinico-radiological study of deep cerebral venous thrombosis.

PURPOSE: Isolated deep cerebral venous thrombosis (DCVT) may have different presentation and outcome compared to DCVT with additional sinus thrombosis. We compare clinico-radiological findings and outcomes of patients with isolated DCVT with those having additional sinus thrombosis. METHODS: Forty-one DCVT patients with or without additional sinus thrombosis were included. Deep CVT was diagnosed if there was thrombosis of straight sinus, vein of Galen, internal cerebral vein, or basal vein of Rosenthal on MR venography (MRV). Isolated DCVT patients were classified as Group A and those with additional sinus thrombosis as Group B. The clinical features, risk factors, MRI findings, and outcomes at 1, 3, and 6 months were compared between Groups A and B. RESULTS: Median age was 28 years, and 22 (54%) were females. Eight (19.5%) patients were in Group A and 33 (80.5%) in Group B. Group B patients had shorter duration of illness (7 vs 30 days; p = 0.01), frequent vomiting [25 (75.7%) vs 2 (25%); p = 0.01], and papilledema [13 (39%) vs 0 (0%); p = 0.04]. Risk factors were comparable. MRI revealed bilateral thalamic [5 (62.5%) vs 6 (18.2%)] and basal ganglia [(4 (50%) vs 6 (18.2%)] lesions more frequently in Group A. At 1 month, 2 (6%) patients died in Group B and none in Group A, and 24 had good outcome (50% Group A and 60.6% in Group B). At 3 months, 30 had good outcome (62.5% Group A and 80.6% in Group B). Improvement after 3 months was negligible. CONCLUSION: Isolated DCVT is rare, and additional sinus thrombosis is associated with more severe illness and death. However, long-term outcomes in the survivors are similar between the two groups.

Renin, antidiuretic hormone (ADH), and ADH receptor levels in cerebral salt wasting associated with tuberculous meningitis.

BACKGROUND: To evaluate serum antidiuretic hormone (ADH), its receptors, and renin levels in cerebral salt wasting (CSW) in tuberculous meningitis (TBM). METHODS: Patients diagnosed with definite (n = 30) or probable TBM (n = 47) who developed hyponatremia (CSW, SIADH, or miscellaneous causes) were included. Sequential measurement of serum ADH, ADH-R, and renin activity by enzyme-linked immunosorbent assay was done and correlated with serum sodium level, urinary output, and fluid balance. RESULTS: Out of 79 TBM patients, CSW was observed in 36, SIADH in four, and miscellaneous hyponatremia in eight patients. CSW patients had a longer hospital stay (P < 0.001), lower GCS score (P < 0.007), higher MRC grade (P < 0.007), and a lower serum Na (P < 0.001) compared to non-CSW TBM patients. In severe CSW patients, serum ADH and ADH-R were correlated with hyponatremia and returned to baseline on correction; however, serum renin levels remained elevated. Serum ADH was related to hyponatremia but ADH-R and renin were not. ADH-R and renin levels did not significantly differ in CSW and SIADH. CONCLUSION: CSW is the commonest cause of hyponatremia in TBM and correlates with disease severity. ADH is related to hyponatremia, but ADH receptor and renin are not.

Paroxysmal spinal hemidystonia in neuromyelitis optica.

Paroxysmal dystonia occurs because of genetic or structural lesion in the basal ganglia or thalamus, and there is paucity of reporting in spinal pathology. We report a patient with paroxysmal hemidystonia admitted to a tertiary care hospital, India, and review the literature on spinal dystonia in neuromyelitis optica (NMO). A 19-year-old woman presented with recurrent visual loss and quadriparesis. She developed paroxysmal hemidystonia after 18 days of a second episode of quadriplegia, during which her muscle power improved to Grade 3. Magnetic resonance imaging (MRI) of her spine showed central T2 hyperintensity extending from C2 to C7 vertebral level, and a cranial MRI was normal. Tibial somatosensory evoked potentials were unrecordable. Aquaporin-4 antibody was positive in serum, confirming the diagnosis of NMO. Paroxysmal hemidystonia responded to carbamazepine 200 mg thrice daily. Paroxysmal dystonia may occur in a patient with myelitis and may respond to carbamazepine.

NMR based CSF metabolomics in tuberculous meningitis: correlation with clinical and MRI findings.

We report the potential role of 1H Nuclear Magnetic Resonance (NMR) based metabolomics in tuberculous meningitis (TBM). We also correlate the significant metabolites with clinical-radiological parameters. Forty-three patients with TBM were included, and their severity of meningitis was graded as stages I to III, and patients with positive Mycobacterium tuberculosis or its nucleic acid was considered as definite TBM. 1H NMR-based metabolomic study was performed on (CSF) samples, and the significant metabolites compared to healthy controls were identified. Outcome at three months was defined as death, poor and good based on the modified Rankin Scale. These metabolites were compared between definite and probable groups of TBM, and also correlated with MRI findings. About 11 metabolites were found to be significant for distinguishing TBM from the controls. In TBM, lactate, glutamate, alanine, arginine, 2-hydroxyisobutyrate, formate, and cis-aconitate were upregulated, and glucose, fructose, glutamine, and myo-inositol were downregulated compared to the controls. For differentiating TBM from the controls, the AUC of the ROC curve generated using these significant metabolites was 0.99, with a 95% confidence interval from 0.96 to 1, demonstrating that these metabolites were able to classify cases with good sensitivity and specificity. Lactate concentration in CSF correlated with hemoglobin, CSF glucose, and infarction. The outcome did not correlate with metabolomics parameters. NMR-based CSF metabolomics have a potential role in differentiating TBM from the controls.

Phonophobia and brainstem excitability in migraine.

Phonophobia in migraineurs may be due to lower hearing threshold (HT) and higher brainstem neuronal excitability. We report the correlation of phonophobia in migraineurs with HT, brain stem auditory evoked potential (BAEP) findings, and auditory triggers. Sixty-one migraineurs and 101 controls were included for HT, of whom 59 migraineurs and 31 controls had BAEP studies. Clinical details, migraine triggers, and headache frequency were noted. Hearing threshold was measured, and amplitudes of waves I to V of BAEP studies were measured. Migraineurs had lower HT compared with controls (41.61 ± 5.25 versus 45.39 ± 6.26 dB; p < 0.001) especially in chronic migraine (40.24 ± 4.81; p < 0.001). Hearing threshold correlated with headache frequency (p < 0.05) and auditory, visual, and tactile (p < 0.05) triggers. Hearing threshold was lower during headache (p < 0.001). Wave II, III, and IV amplitudes of BAEP were higher in migraineurs than the controls. Wave II (p < 0.05) and III (p < 0.05) amplitudes correlated with HT. Migraineurs have lower HT, especially in those having chronic migraine, ictal HT recording, and multiple sensory triggers. Higher amplitudes of BAEP waves in migraineurs and their relationship with the frequency of headache and HT suggest the sensitization of brainstem auditory neurons.

Rest or 30-Min Walk as Exercise Intervention (RESTOREX) in Myasthenia Gravis: A Randomized Controlled Trial.

INTRODUCTION: There is a lack of evidence about the usefulness of exercise or rest in myasthenia gravis (MG). This study is aimed to evaluate the efficacy and safety of exercise or rest in MG. METHODS: In a single-center open-labeled randomized controlled trial, the patients with mild to moderate MG were randomized to 30-min walk or rest in addition to the standard treatment. The primary endpoint was 50% improvement in the MG Quality of Life (MG-QOL15), and secondary endpoints were change in the Myasthenic Muscle Score (MMS), MG Activities of Daily Living (MGADL), grip strength, dose of acetylcholine esterase inhibitor and prednisone, 6-min walk test (6MWT), decrement in trapezius on the low-rate repetitive nerve stimulation test, and adverse events. The outcomes were defined at 3 months, by >50% improvement in these outcome parameters. RESULTS: Forty patients with MG were randomized to the exercise or rest arm. The 2 arms were matched for demographic and clinical parameters. The patients in the exercise arm had significantly better QOL evidenced by MG-QOL15 (p = 0.02). The secondary endpoints, distance covered in 6MWT (p = 0.007), were also better in the exercise arm without any adverse event. CONCLUSION: Regular exercise for 30 min in mild and moderate MG improves quality of life and walking distance compared to rest and is safe. CLINICAL TRIAL REGISTRATION: The clinical trial registration number is CTRI/2019/11/021869.

MRI findings in Pott's spine and correlating clinical progress with radiological findings.

PURPOSE: To document magnetic resonance imaging (MRI) changes in Pott's spine and to correlate these with clinical findings and outcome. METHODS: Patients with Pott's spine having more than one set of MRI were included in the study. Patients were grouped according to timing of their second MRI. The MRI findings included changes in bone, disc, spinal cord, and soft tissue. The MRI changes were categorized into improvement, no change, or worsening. "Paradoxical worsening" was defined as radiological worsening in setting of clinical improvement, as described by improvement of Nurick's grade. Outcome was defined by mRS scale at three, six, and 12 months. The MRI findings and outcome were correlated. RESULTS: The results are based on 36 patients. The MRI changes included vertebral changes in form of spondylodiscitis in 33 (92%), epidural abscess in 29 (81%), spinal cord changes including edema and granuloma in 17 (47%), paravertebral abscess in 29 (81%), and vertebral body collapse in 12 (33.3%) patients. At three months, clinical improvement occurred in eight out of 12 patients, deterioration in two, and no change in two. Spinal MRI revealed improvement in one patient only; whereas eight had deterioration and three had no change. At six months, all nine patients improved clinically, but MRI showed improvement in only four, while another four showed deterioration and one had no change. In the nine and 12 months group, while all patients clinically improved, MRI showed minimal worsening. CONCLUSION: In Pott's spine, the clinical improvement precedes the radiological improvement.

A study of hyperhomocysteinemia in cerebral venous sinus thrombosis.

BACKGROUND & OBJECTIVES: Vegetarianism may result in low vitamin B12 and acquired hyperhomocysteinemia leading to thrombotic conditions such as cerebral venous sinus thrombosis (CVST). The clinico-radiological presentation and outcome of patients with hyperhomocysteinemia may be different from those without, but there is a paucity of information. This study was undertaken to find out the relationship of homocysteine (Hcy) with vitamin B12, folic acid and methyltetrahydrofolate reductase (MTHFR) mutation in the patients with CVST, and compare clinico-radiological severity and outcome of patients with and without hyperhomocysteinemia. METHODS: Ninety-six CVST patients in whom Hcy level was measured, were included, and their risk factors and neurological, magnetic resonance (MR) imaging and MR venography findings were noted. They were evaluated for prothrombotic conditions including Hcy, vitamin B12, folic acid and MTHFR 677C→T mutation. Three month outcome was categorized as death, poor and good. RESULTS: Seventy three per cent patients had risk factors; hyperhomocysteinemia in 52.1 per cent, protein S deficiency in 47.8 per cent, protein C deficiency in 19.4 per cent, MTHFR 677C→T mutation in 30.7 per cent, antinuclear antibody 11 per cent, and Factor V Leiden mutation in two per cent each. Thirty two per cent patients with hyperhomocysteinemia had no other thrombotic cause, and 22 per cent of them had either vitamin B12 and or folic acid deficiency only. The patients with hyperhomocysteinemia more frequently had vitamin B12 deficiency (70 vs. 13%), MTHFR 677C→T mutation (47.5 vs. 9.1%) and superior sagittal sinus thrombosis (78 vs. 56.5%) than normal Hcy group. The clinico-radiological severity and outcome were similar. INTERPRETATION & CONCLUSIONS: Hyperhomocysteinemia was an important correctable risk factor of CVST in patients from northern India, and majority of them had either low vitamin B12 level or MTHFR mutation.

A Study of Hyponatremia in Acute Encephalitis Syndrome: A Prospective Study From a Tertiary Care Center in India.

PURPOSE:: To evaluate the frequency and causes of hyponatremia in acute encephalitis syndrome (AES) and its effect on outcome. PATIENTS AND METHODS:: Consecutive patients with AES were subjected to neurological evaluation including Glasgow Coma Scale, focal weakness, movement disorder, and reflex changes. The etiology of AES was based on blood and cerebrospinal fluid enzyme-linked immunosorbent assay and polymerase chain reaction. We have categorized patients into neurological or systemic AES. Hyponatremia was diagnosed if 2 consecutive serum sodium levels were below 135 mEq/L, 24 hours apart. Serum and urinary osmolality and electrolytes were measured on alternate days. Fluid intake, output, and body weight were measured daily. The hyponatremia was categorized into syndrome of inappropriate secretion of antidiuretic hormone (SIADH), cerebral salt wasting (CSW), or miscellaneous group. Outcome at 1 month was assessed by modified Rankin scale. RESULTS:: Of 79 patients, 34 had neurologic AES and 45 had systemic AES; 22 (27.8%) patients had hyponatremia. The neurologic AES as compared to systemic AES was more commonly associated with hyponatremia (38.2% vs 20%, P = .07), need longer hospitalization (25.0 vs 12.5 days, P = .003), and longer time for sodium correction (13.3 vs 8.2 days, P = .05). The hyponatremia was due to CSW in 12 patients, SIADH in 2 patients, and indeterminate in 8 patients. Thirty-six patients had poor outcome (15 died) and 43 had good outcome which was not related to hyponatremia. CONCLUSION:: Hyponatremia occurs in one-third of patients with AES, being commoner in neurologic AES, and CSW is the commonest cause.

Role of IV Immunoglobulin in Indian Children With Guillain-Barré Syndrome.

OBJECTIVES: To evaluate the outcome of Indian children with Guillain-Barré syndrome who received IV immunoglobulin compared with those who did not receive any specific therapy. DESIGN: Single center, prospective cross-sectional study. SETTING: Tertiary care neurology teaching hospital. PATIENTS: Children (≤ 18 yr old) with Guillain-Barré syndrome were included from a prospectively maintained Guillain-Barré syndrome registry from January 2008 to April 2017. Children were classified into acute inflammatory demyelinating polyradiculoneuropathy, acute motor axonal neuropathy, acute motor-sensory axonal neuropathy, and inexcitable motor nerves based on nerve conduction study. INTERVENTIONS: Out of 138 pediatric Guillain-Barré syndrome, 50 received IV immunoglobulin and another 50 age and peak disability matched controls (who did not receive IV immunoglobulin or plasmapheresis) were selected from the same registry for comparison. MEASUREMENTS AND MAIN RESULTS: Outcome at 3 and 6 months was defined on the basis of a 0-10 Clinical Grading Scale into complete (Clinical Grading Scale < 3), partial (Clinical Grading Scale 3-5), and poor (Clinical Grading Scale > 5) recovery. The primary outcome was proportion of patients with complete recovery at 3 and 6 months in IV immunoglobulin and non-IV immunoglobulin groups. Secondary outcomes included in-hospital deaths, duration of mechanical ventilation, and hospital stay. Subgroup analysis was done in acute motor axonal neuropathy and acute inflammatory demyelinating polyradiculoneuropathy groups. The baseline characteristics were similar except for shorter duration of illness and higher proportion of facial palsy in IV immunoglobulin group. Hospital deaths, duration of mechanical ventilation, hospital stay, and outcome at 3 and 6 months were not different between the two groups. Children with acute motor axonal neuropathy had better recovery at 6 months on IV immunoglobulin (58.3% vs 11.1%; p = 0.03), but not those with acute inflammatory demyelinating polyradiculoneuropathy (58.3% vs 72.2%; p = 0.22). In nonambulatory Guillain-Barré syndrome children, complete recovery at 6 months was similar in IV immunoglobulin and non-IV immunoglobulin group (57.4% vs 57.1%; p = 0.98). CONCLUSIONS: In Indian children with Guillain-Barré syndrome, the outcome at 6 months in IV immunoglobulin treated group was similar to non-IV immunoglobulin group. Children with acute motor axonal neuropathy responded better to IV immunoglobulin.

Cerebral Venous Sinus Thrombosis Score and its Correlation with Clinical and MRI Findings.

BACKGROUND: It is plausible that extent of cerebral venous sinus thrombosis (CVST) may determine clinical severity, magnetic resonance imaging (MRI) lesion, and outcome, therefore this study was undertaken. METHODS: A total of 160 CVST patients were included and their clinical details, risk factors, Glasgow Coma Scale score, and parenchymal lesion on MRI were noted. The extent of venous sinus thrombosis on magnetic resonance venography was assessed by using CVST score which was computed giving 1 point for each thrombosed sinus and 3 points to superior sagittal sinus (SSS). Death and outcome at 6 months were assessed using modified Rankin Scale (mRS) as good (≤2) and poor (mRS 3-5). RESULTS: Their median age was 29.5 years, and 76 (47%) were females. The median CVST score was 3 (range 1-9). CVST score did not correlate with clinical severity and risk factors. Insignificantly higher proportion of patients had parenchymal lesion with a CVST score of more than 2 (76.5% versus 64.2%). Superficial venous system thrombosis, however, correlated with seizure, papilloedema, and frontal lobe lesion. Frontal, temporal lesion correlated with SSS thrombosis, frontal and temporal with transverse sinus, temporal and cerebellar involvement in sigmoid, and basal ganglia and thalamus in straight sinus thrombosis. Seventeen patients (11%) died, and at 6 months, 132 (82%) had good and 11 (7%) poor recovery. Death and 6 months outcomes were not related to CVST score. CONCLUSIONS: Extent of CVST does not determine clinical severity, MRI lesion, and outcome. The location of parenchymal lesion however is related to thrombosis of draining sinus.

Prospective comparison of acute motor axonal neuropathy and acute inflammatory demyelinating polyradiculoneuropathy in 140 children with Guillain-Barré syndrome in India.

INTRODUCTION: There have been few reports on subtypes of Guillain-Barré syndrome (GBS) in children. We compared clinical and laboratory findings of acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and acute motor axonal neuropathy (AMAN). METHODS: One hundred forty children with GBS were included. Based on nerve conduction study (NCS) findings, patients were subclassified as AIDP, AMAN, acute motor sensory axonal neuropathy (AMSAN), and equivocal. RESULTS: Clinically, 72.1% of patients had pure motor, 24.3% motor sensory, and 3.4% Miller Fisher syndrome. Based on NCS, 67.8% of patients had AIDP, 23.6% had AMAN, and 4.3% had AMSAN. By 3 months, 2.1% patients had died, 47.1% had complete recovery, and 24.3% had poor recovery (wheelchair-bound). Children with AMAN had more frequent lower limb weakness (P = 0.02) and a lower probability of complete recovery (P = 0.01) at 3 months than children with AIDP (56% vs. 30%). DISCUSSION: AIDP is the most common GBS subtype in children. It is characterized by better recovery at 3 months when compared with AMAN. Muscle Nerve 57: 761-765, 2018.

A study of oxidative stress in migraine with special reference to prophylactic therapy.

OBJECTIVE: The role of oxidative stress markers in migraine and effect of treatment on these has been reported. SUBJECTS AND METHODS: One hundred and fifty patients having > four attacks of migraine headache/month were included. Headache severity, Migraine Index (MI) and frequency of headache were noted. 120 patients received repetitive transcranial magnetic stimulation (rTMS) therapy and 30 patients received Amitriptyline (AMT). Recovery was defined by 50% improvement in frequency, severity or reduction in MI. Oxidative stress and antioxidant markers have been estimated in patients before and after treatment and correlate the clinical and outcome parameters. RESULTS: Glutathione (GSH) (P < 0.001), glutathione-S-transferase (GST) (P = 0.049) and total antioxidant activity (TAC) (P < 0.001) level were significantly reduced in migraine patients. GSH (P = 0.02), GST (P = 0.05) and TAC (P < 0.001) were reduced in ictal migraineurs compared to controls. GSH (P < 0.001) and TAC (P = 0.003) levels increased after treatment compared to the base line. There is an increase in GSH levels in the patients who had improved following rTMS (P = 0.003); placebo (P = 0.001) and AMT (P = 0.013). TAC levels were also increased following rTMS (P = 0.009) and AMT (P = 0.020). CONCLUSION: There is evidence of oxidative stress in migraine pathophysiology. Following treatment, oxidative stress declined following both pharmacological and rTMS.

Pellets in the Eye: Cerebral Aneurysm and Encephalomyeloneuropathy as Presenting Syndromes.

Lead poisoning following retained gunshot pellets resulting in recurrent episodes of encephalomyeloneuropathy is rare and association of intracranial aneurysm with lead poisoning is interesting. The case report describes about a 58-year ayurvedic doctor who was hospitalized for recurrent abdominal pain and limb weakness appearing spontaneously and improving in a few days to weeks. He had 20 such attacks in last 30 years starting at 25 years after the gunshot wound that resulted in retention of 2 lead pellets in his skull. Cranial imaging demonstrated left posterior communicating aneurysm. His initial blood lead level was 206.10 µg/dl, and following chelation with oral d-penicillamine, the lead level declined and was asymptomatic. After 4-year follow-up, he developed subarachnoid hemorrhage, which was managed with intravascular coiling of the ruptured aneurysm. The gunshot pellets are generally not removed, especially, if they are in inaccessible location. Our patient highlights that such cases should be closely monitored.

Does adjunctive corticosteroid and aspirin therapy improve the outcome of tuberculous meningitis?

BACKGROUND: Stroke is common in tuberculous meningitis (TBM), and aspirin has been shown to reduce mortality. A combination of aspirin and corticosteroid may be more useful in this condition. AIM: To evaluate the effect of aspirin and corticosteroid adjunctive therapy alone or in combination in determining the outcome of TBM. MATERIALS AND METHODS: One hundred and fifty-three patients with TBM were evaluated from a prospectively maintained registry. The diagnosis of TBM was based on the clinical, magnetic resonance imaging (MRI)/computed tomography (CT), and cerebrospinal fluid criteria. The baseline clinical, laboratory, and radiological findings were noted. All patients received the standard 4-drug antituberculous (rifampicin, isoniazid, pyrazinamide, and ethambutol) treatment. Group I patients received in addition, aspirin, in the dose of 150 mg daily; group II patients received aspirin 150 mg plus prednisolone 40 mg daily; and, group III patients received none of these adjunctive therapies. The outcome at 3 months was defined in terms of death or functional disability. RESULTS: Group I had 44, group II had 50, and group III had 41 patients. The baseline characteristics of all these patients were similar, except in group II, where patients had more severe meningitis and focal deficits compared to the patients in group I and III. At 3 months, 32 (23%) patients died; 8 (18.2%) in group I, 9 (18%) in group II, and 14 (34.1%) in group III. There was insignificant survival benefit in group II (hazard ratio [HR], 1.55; 95% confidence interval (CI), 0.96-26.49; P = 0.07). The three-month functional outcome and side effects were not significantly different in the three groups. CONCLUSION: Aspirin with corticosteroid adjunctive treatment seems to be beneficial in reducing mortality in TBM.