Asymptomatic elevation of liver enzymes due to levetiracetam: a case report.

Levetiracetam is a commonly used broad-spectrum anticonvulsant efficacious in both partial and generalized seizures. It has an extremely favorable side effect profile with few drug-drug interactions, low potential for hematological and hepatic toxicity, and thus has rapidly become the preferred drug in patients with traumatic brain injuries who need seizure prophylaxis. We report, here, a patient who was started on levetiracetam for seizure prophylaxis after developing large bifrontal-parietal traumatic subdural hematomas (SDH) following a fall from a horse necessitating bifrontal craniotomies for evacuation. The patient developed an asymptomatic elevation of the liver enzymes. The liver enzymes trended back to normal after levetiracetam was stopped, and topiramate was initiated in its place.

Delayed left anterior and middle cerebral artery hemorrhagic infarctions after attempted strangulation: a case report.

The 2 common carotid arteries bifurcate in the neck into the internal and external carotid arteries. The internal carotid artery enters the skull and further divides into the anterior and middle cerebral artery. During its short course in the neck, the carotid artery travels encased in the carotid sheath along with the vagus nerve and the internal jugular vein. During its course in the neck, the carotid artery is quite superficial, making it vulnerable to both penetrating and blunt traumatic injuries. We report here a case of a 40-year-old man who presented to the emergency department after sudden collapse and loss of consciousness a day after an attempted strangulation. Imaging revealed large hemorrhagic infarcts in the left anterior cerebral artery and middle cerebral artery territories as well as a smaller infarcts in the right anterior cerebral artery territory necessitating emergency decompressive hemicraniectomy. Our case report adds to the existing literature on nervous system injury due to strangulation. Physicians should be aware of the possibility of delayed presentation of neurological deficit after attempted strangulation.

Central nervous system tuberculosis masquerading as primary dementia: a case report.

Primary dementias are the most common cause of memory impairment in patients above the age of 60. Hypothyroidism, depression, vitamin B12 deficiency and infectious diseases such as syphilis at times may present with memory impairment mimicking primary dementias in their clinical presentation. We present here a 64-year-old female who presented with complaints of forgetfulness, confusion, memory loss and impaired concentration for the past 3 months. Neuroimaging and computed tomography of the chest were suggestive of active tuberculosis. Anti-tubercular therapy led to resolution of enhancing lesions in the brain and abatement of memory deficits.

Head-supporting sign during reclining: an indication of craniovertebral junction involvement.

The craniovertebral (CV) junction can be involved in many diseases, e.g. rheumatoid arthritis, as well as destructive bone pathologies such as tumour and tuberculosis (craniovertebral Pott's disease). While some of these patients present acutely with neck pain and neurological deficits, in others the signs and symptoms may be more subtle. Two patients with CV junction involvement are described. One patient suffered from fracture of the anterior arch of atlas after being involved in a motor vehicle accident and the other had craniovertebral Pott's disease. A detailed history and clinical examination was carried out paying special attention to the situation when patients attempted to recline or while getting up from a reclining position. Patients were further investigated with imaging studies which focused on the CV junction. It was noted that patients with CV junction involvement frequently support their head while attempting to recline or when getting up from a reclining posture. This head supporting sign may be the sole neurological finding in some patients with involvement of the CV junction.

Central nervous system fungal infections: observations from a large tertiary hospital in northern India.

OBJECTIVE: To report our observations regarding fungal infections of the brain over two years from a large tertiary hospital in northern India. To identify fungal infections in immunocompetent and immunocompromised patients and to compare the two groups with respect to their age of occurrence, demographic data, clinical profile, radiological findings, response to treatment and outcome. METHODS: All consecutive cases of central nervous system (CNS) fungal infections admitted to the hospital over two years were included in this study. The patients were categorized as immunocompetent and immunocompromised, the predisposing factors, symptoms and clinical presentation were studied in detail and the outcomes of the two groups were compared. RESULTS: Of the 50 cases, 25(50%) were that of mucormycosis, 17(34%) were cryptococcosis and 8(16%) cases were that of aspergillosis. 14(28%) cases were immunocompetent and 36(72%) were immunocompromised. The outcome studied was as follows: 28% died of which 4% were HIV positive, 12% were diabetics with severe rhinorbital involvement, 2% had idiopathic thrombocytopenic purpura (ITP), 6% had advanced cancer and 4% had no predisposing illness. CONCLUSIONS: We observed fungal infections of the brain in both immunocompetent and immunocompromised patients. In immunocompetent patients, early diagnosis and appropriate treatment frequently leads to recovery from the illness. The mortality and morbidity of fungal infections are less in the immunocompetent group of patients.

Vocal cord palsy: An uncommon presenting feature of myasthenia gravis.

Vocal cord palsy can have myriad causes. Unilateral vocal cord palsy is common and frequently asymptomatic. Trauma, head, neck and mediastinal tumors as well as cerebrovascular accidents have been implicated in causing unilateral vocal cord palsy. Viral neuronitis accounts for most idiopathic cases. Bilateral vocal cord palsy, on the other hand, is much less common and is a potentially life-threatening condition. Myasthenia gravis, an autoimmune disorder caused by antibodies targeting the post-synaptic acetylcholine receptor, has been infrequently implicated in its causation. We report here a case of bilateral vocal cord palsy developing in a 68-year-old man with no prior history of myasthenia gravis 2 months after he was operated on for diverticulitis of the large intestine. Delay in considering the diagnosis led to endotracheal intubation and prolonged mechanical ventilation with attendant complications. Our case adds to the existing literature implicating myasthenia gravis as an infrequent cause of bilateral vocal cord palsy. Our case is unusual as, in our patient, acute-onset respiratory distress and stridor due to bilateral vocal cord palsy was the first manifestation of a myasthenic syndrome.