RE-OPEN: Randomised trial of biosimilar TNK versus TPA during endovascular therapy for acute ischaemic stroke due to large vessel occlusions.

Rationale: Rapid and timely treatment with intravenous thrombolysis and endovascular treatment (EVT) in patients with acute ischaemic stroke (AIS) and large vessel occlusion (LVO) significantly improves patient outcomes. Bridging therapy is the current standard of care in these patients. However, an incompletely answered question is whether one thrombolytic agent is better than another during bridging therapy. Aim: The current study aims to understand if one thrombolytic agent is superior to the other during bridging therapy in the treatment of AIS and LVO. Sample size estimates: Using 80% power and an alpha error of 5 %, presuming a 10% drop out rate, a total of 372 patients will be recruited for the study. Methods and design: This study is a prospective, randomised, multicentre, open-label trial with blinded outcome analysis design. Study outcomes: The primary outcomes include proportion of patients who will be independent at 3 months (modified Rankin score (mRS) ≤2 as good outcome) and proportion of patients who achieve recanalisation modified thrombolysis in cerebral infarction grade 2b/3 at first angiography run at the end of EVT. Secondary outcomes include proportion of patients with early neurological improvement, rate of symptomatic intracerebral haemorrhage (ICH), rate of any ICH, rate of any systemic major or minor bleeding and duration of hospital stay. Safety outcomes include any intracranial bleeding or symptomatic ICH. Discussion: This trial is envisioned to confirm the theoretical advantages and increase the strength and quality of evidence for use of tenecteplase (TNK) in practice. Also, it will help to generate data on the efficacy and safety of biosimilar TNK. Trial registration number: CTRI/2022/01/039473.

The Prevalence of Mild Cognitive Impairment (Mci) among Older Population of Rural Kerala: A Cross-Sectional Study.

Background: There are only very few studies on estimating the prevalence of mild cognitive impairment (MCI) from India, particularly from a rural setting. The available studies were heterogeneous. Objective: The study estimated the prevalence of MCI in a rural setting in Kerala, India. Materials and Methods: We conducted a community-based, cross-sectional study among individuals aged 65 and above in rural Thiruvananthapuram, Kerala. A cluster-randomized sampling was adopted, the cluster being the wards in the village. It was a two-phase door-to-door survey. Grassroots-level health workers enrolled 366 elders in the selected four wards in the initial phase and collected information on the sociodemographic details, comorbidities, and other risk factors of the participants, using a semi-structured questionnaire. Additionally, the Everyday Abilities Scale for India (EASI) was administered to assess their activities of daily living. In the second phase, a neurologist and a psychologist examined those screened positive with EASI and diagnosed MCI and dementia based on the MCI Working Group of the European Consortium on Alzheimer's Disease and the DSM V criteria, respectively. Results: The prevalence of MCI and dementia was 18.6% (95% confidence interval [CI] 14.7%-23.4%) and 6.8% (4.46%-10.1%), respectively, among the study participants. The prevalence of MCI was higher among the unemployed and those above 70 years of age. Conclusion: The community prevalence of MCI is more than three times that of dementia among the elderly in rural Kerala.

Area postrema syndrome: An unusual presentation of neuromyelitis optica spectrum disorder.

Isolated area postrema syndrome (APS) is a rare neurological presentation of, neuromyelitis optica spectrums disorder (NMOSD), recognizable by uncontrollable hiccups, nausea, or vomiting. When it occurs as the first presentation of NMOSD, it may present as a diagnostic challenge as the condition may be frequently attributed to gastrointestinal pathology, and the subsequent diagnostic delay may result in debilitating neurological sequelae such as optic neuritis or myelitis. We report such a case of isolated APS in a young woman who presented with a clinical picture of bouts of vomiting and intractable hiccups causing considerable distress and was finally diagnosed to be a case of seronegative NMOSD.

Acetazolamide-Induced Periorbital Myokymia: A Case Report.

Acetazolamide, a carbonic anhydrase inhibitor, is primarily used in the treatment of glaucoma, due to its role in decreasing intraocular pressure by lowering the production of aqueous humor. Additionally, by lowering cerebrospinal fluid (CSF) production, it is also used in the treatment of raised intracranial pressure. Drug-induced myokymia has rarely been reported, with known triggers being clozapine, gabapentin and flunarizine, and topiramate. Acetazolamide-induced myokymia itself has only been reported once before, to the best of our knowledge, and the exact mechanism behind this occurrence remains unknown. We, therefore, report a rare case of periorbital myokymia induced by the use of acetazolamide in a patient diagnosed with idiopathic intracranial hypertension. The nature of her symptoms was significant, as they caused her considerable distress, and subsided almost immediately upon discontinuation of the drug.

Airpod Sign: A Diagnostic Radiological Finding of a Rare Cerebrovascular Accident.

Quadriplegia or dysesthesia in all four limbs may be the initial symptom of bilateral medial medullary infarction (MMI), a very rare cerebrovascular accident with a dismal prognosis. Clinical diagnosis of bilateral MMI is still challenging and can be confirmed by diffusion-weighted (DW) magnetic resonance imaging (MRI) in the early stage. Here, we report the case of a 60-year-old male who presented to the emergency department complaining of numbness in all four limbs. DW-MRI was used to identify brain lesions 24 hours after the symptom onset. The infarct, on axial MRI sections, showed the characteristic 'airpod sign'/heart-shaped appearance due to the morphology of the area involved in the medulla.

Changing Demographics of Stroke Mimics in Present Day Stroke Code Era: Need of a Streamlined Clinical Assessment for Emergency Physicians.

Background There is an apparently high incidence of stroke mimics in the present-day stroke code era. The reason being is the intense pressure to run with time to achieve the "time is brain"-based goals. Methods The present study was a retrospective analysis of the data collected over a duration of 6 months from April 2019 to September 2019. We observed the incidence of stroke mimics among the patients for whom rapid response stroke code was activated during the study period. We also performed a logistic regression analysis to identify the clinical features which can act as strong predictors of stroke and mimics. Results A total of 314 stroke codes were activated of which 256 (81.5%) were stroke and 58 (18.5%) were the mimics. Functional disorders and epilepsy were the most common mimics (24.1% each). Female gender ( p = 0.04; odds ratio [OR] 2.9[1.0-8.8]), isolated impairment of consciousness ( p < 0.01; OR 4.3[1.5-12.6]), and isolated dysarthria ( p < 0.001) were the strong independent predictors for a stroke mimic. Hemiparesis was the strong independent predictor for a stroke ( p < 0.001; OR 0.0[0.0-0.1]). Conclusion In the present epoch of rapid response stroke management, a streamlined assessment by the emergency physicians based on the above clinical predictors may help in avoiding the misdiagnosis of a mimic as stroke.

Lessons Learned from a Fulminant Case of Reversible Cerebral Vasoconstriction Syndrome: Past Medical History Misleads the Diagnosis and Intra-Arterial Milrinone Offers Diagnostic Utility.

A 34-year-old post-partum female having dermatomyositis developed headache and became comatose after a seizure episode. Magnetic resonance imaging of brain showed a massive left ganglio-capsular bleed for which decompressive surgery was done. Computed tomographic angiography showed multiple foci of narrowing and irregularities in distal cerebral vessels. In view of dermatomyositis, the diagnosis of vasculitis was considered and pulse therapy of intravenous methylprednisolone was started. The patient, however, showed no improvement and developed new brain infarcts. She was subsequently taken up for a diagnostic cerebral angiography which showed multifocal severe narrowing in bilateral major cerebral arteries. These angiographic abnormalities showed excellent reversibility to intra-arterial milrinone and hence, reversible cerebral vasoconstriction syndrome (RCVS) was diagnosed. Normal angiographic findings in the first week do not rule out the disease and a repeat angiography should be considered if the clinical suspicion of the RCVS is high. Intra-arterial milrinone has a high diagnostic utility.

Predictors of Levo-dopa induced Dyskinesias in Parkinson's Disease.

BACKGROUND: Levodopa has a superior antiparkinsonian effect than dopamine agonists making it the standard of care for patients with Parkinson's disease (PD). During the initial stages, PD patients show a steady response to levodopa. Response fluctuations and levodopa-induced dyskinesias (LID) develop subsequently. The timing and onset of dyskinesias vary among individuals, and there are very few studies identifying the predictors of dyskinesia in India. AIMS: We aimed to study the clinical profile, disability, and predictors of LID in a patient with PD. MATERIALS AND METHODS: This was a cross-sectional observational study of consecutive patients with PD attending our movement disorder clinic. Patients on levodopa treatment with a minimum follow-up of 6 months were included in the study. All patients were observed before and after administration of levodopa to assess onset, duration of action, and timing of dyskinesias. Dyskinesias were video recorded and classified. Bivariate analysis was performed using Chi-square test or Fisher's exact test and multivariate analysis using binary logistic regression. RESULTS: This study recruited 110 patients with PD on levodopa therapy. Thirty-one (28.1%) out of 110 had LID. Of these, 25 patients (80.6%) had on-time dyskinesia, 19 patients (61.3%) had off-time dystonia, and 13 patients (41.9%) had diphasic dyskinesia. Majority had only mild-to-moderate dyskinesia. Incapacitating dyskinesias were during off time, primarily affecting the foot. Age, disease duration, disease severity, duration of treatment, and total dose of levodopa were found to be predictors of LID. Multivariate regression analysis showed younger age and longer duration of levodopa treatment to be independent predictors for LID. CONCLUSIONS: LID is fairly common in PD though not severely disabling. Patients with younger age of onset, longer disease duration, and severe disease were more likely to get early LID. We observed the lower prevalence of LID when initiating at lower doses and slow titration of levodopa.