First-Ever Ischemic Stroke In Covid-19: How Is It Different? - A Stroke Registry-Based Study From South India.

BACKGROUND AND AIMS: Stroke associated with COVID-19 has been characterised in several multicentre retrospective studies and meta-analyses. However, they did not distinguish first-ever ischemic strokes (F-AIS). Therefore, we aimed to study the incidence, clinical characteristics, and outcomes of a cohort of F-AIS associated with COVID-19 during the first wave of the pandemic and compare this cohort with those of F-AIS without COVID-19, COVID-19 without stroke. We also sought to compare the stroke admissions and mechanisms during the pandemic and immediate prepandemic periods.

Neuroimaging Pearls from the MDS Congress Video Challenge. Part 2: Acquired Disorders.

The MDS Video Challenge continues to be the one of most widely attended sessions at the International Congress. Although the primary focus of this event is the presentation of complex and challenging cases through videos, a number of cases over the years have also presented an unusual or important neuroimaging finding related to the case. We reviewed the previous Video Challenge cases and present here a selection of those cases which incorporated such imaging findings. We have compiled these "imaging pearls" into two anthologies. The first focuses on pearls where the underlying diagnosis was a genetic condition. This second anthology focuses on imaging pearls in cases where the underlying condition was acquired. For each case we present brief clinical details along with neuroimaging findings, the characteristic imaging findings of that disorder and, finally, the differential diagnosis for the imaging findings seen.

Decoding "guitar pick sign" in COVID-19-associated mucormycosis: A case series.

"Guitar pick sign," also referred to as posterior globe tenting, is a radiological surrogate marker of tense orbit and profound vision loss. It is seen commonly in traumatic retrobulbar hemorrhage and carotico-cavernous fistula and less frequently in orbital cellulitis, subperiosteal abscess, and invasive fungal infections. We report a case series of Coronavirus disease-19-associated rhino-orbito-cerebral mucormycosis with guitar pick sign, of which none survived, and discuss the causative pathomechanisms, severity grade, and the clinical relevance of this unique radiological finding.

Pathogenetic factors fanning the flames of COVID-19 to cause rhino-orbito-cerebral mucormycosis: An observational study.

BACKGROUND AND AIMS: Published studies on coronavirus disease 19 (COVID-19) associated rhino-orbito-cerebral mucormycosis (CAROCM) were primarily descriptive. Therefore, we aimed to identify features of COVID-19 that could predispose to CAROCM and explore the pathogenic pathways. PATIENTS AND METHODS: This retrospective hospital-based study was done during the first (March 2020 - January 2021) and the second (February 2021 - June 2021) waves of the COVID-19 pandemic. Subjects were grouped into four categories: first-wave CAROCM (n-4); second-wave CAROCM (n-27); first-wave non-mucor COVID (n-75), and second-wave non-mucor COVID (n-50). Data elements included age, gender, comorbidities, COVID-19 severity, steroid therapy, peak values of interleukin-6 (IL-6), serum ferritin and D-dimer, nadir values of absolute lymphocyte count (ALC), absolute neutrophil count (ANC) and platelet count (Pl. C). RESULTS: Thirty-one patients of CAROCM were included. The mean (SD) age was 51.26 (11.48) years. 27 (87.1%) were aged ≥ 40 years and males. Severe COVID-19 was seen more often in the second wave than the first wave (P-0.001). CAROCM group was significantly younger (P-0.008) and showed a higher incidence of uncontrolled diabetes (P-0.001) and renal dysfunction (P-0.004) than non-mucor COVID. While IL-6, ferritin and D-dimer were significantly elevated in CAROCM than non-mucor COVID, clinical severity, ANC, ALC and Pl. C showed no significant difference. CONCLUSION: CAROCM is seen often in middle-aged diabetic males with uncontrolled hyperglycaemia, diabetic ketoacidosis, renal dysfunction and those infected by more transmissible delta variants and treated with steroids. IL-6, D-dimer, serum ferritin are more often elevated in CAROCM and might play a pathogenic role.

Treatment outcomes in drug resistant juvenile myoclonic epilepsy: Valproate resistance may not be the end of the road.

OBJECTIVE: To determine treatment responses to various antiseizure medicines (ASMs) in patients with drug resistant juvenile myoclonic epilepsy (DRJME) METHODS: We reviewed records of all JME patients attending epilepsy clinics at 5 centers during a 5-year period. We used International Consensus Criteria to diagnose JME and International League Against Epilepsy Criteria to define drug resistance and sustained seizure freedom. We only used broad spectrum medicines which included valproate, lamotrigine, topiramate, levetiracetam, clobazam, phenobarbitone, clonazepam, and zonisamide. We considered an ASM successful if patient achieved seizure freedom within 3 months of attaining maintenance dose. RESULTS: We studied 116 patients (61 males) with DRJME. At terminal followup, 82 (70.7%) patients had achieved sustained seizure freedom with a mean followup of 3.2 ± 1.3 years after last dose change. In patients where valproate failed as first- or second-line ASM (n=70; 60.3%), 49(70%) became seizure-free. In this group, 33(67%) patients became seizure-free after addition of lamotrigine. Success rate of lamotrigine and valproate combination was 69% as compared to 9% with all other combinations (p = 0.001). In patients who were not exposed to valproate as initial therapy (n=46), 33 (71.7%) became seizure-free, 30 (91%) after adding valproate. At last follow-up, 75 (90%) seizure-free patients were receiving valproate including 45 (55%) patients with a combination of valproate and lamotrigine. Only one of 24 patients became seizure-free after failing valproate and lamotrigine combination. CONCLUSION: Seizure freedom can be achieved in two-thirds of patients with DRJME. A combination of valproate and lamotrigine is the most effective duotherapy.

Posterior Reversible Encephalopathy Syndrome Is the Common Cause of New-Onset Seizures in the Peripartum Period: A Tertiary Hospital-Based Study in South India.

BACKGROUND AND PURPOSE: To study the aetiolgic spectrum of new-onset seizures in the peripartum period in south India. METHODS: This is a retrospective analysis of case records of women with new-onset seizures in the peripartum period admitted between 2005 and 2018 (13 years). RESULTS: Of the 41 women (mean age, 26.20 years; range, 19-35 years) admitted, 20 patients (48.7%) had hypertensive disorders of pregnancy (HDP). Generalized tonic-clonic seizure (88%) was the common seizure type. The aetiologies of new-onset seizures were: 1) pregnancy-related aetiologies in 33 (80.5%) and 2) non-pregnancy-related aetiologies in eight (19.5%). Of the pregnancy-related aetiologies, posterior reversible encephalopathy syndrome (PRES) was the commonest cause in 24 patients (58.5%). Seizure cluster presentation was common in patients with PRES (p=0.0087). Of the eight women with non-pregnancy-related aetiologies, endemic central nervous system (CNS) infections accounted for three (7.3%; brain tuberculoma in one and neurocystocercosis in two) of the aetiology. All the women had Glasgow outcome scale-5 outcome. CONCLUSIONS: PRES was the common cause of new-onset seizures in peripartum period in this cohort. Endemic infections of CNS accounted for 7.3% of the total aetiological spectrum. This study suggests that the possibility of PRES should be considerd in woman with HDP and seizure cluster in peripartum period.

Apical pleural aspergillosis with pancoast's syndrome and posterior circulation stroke: a case report.

Pancoast's syndrome and subclavian arteritis are rarely caused by Aspergillus sp. . Here we report a case of a 22-yr-old, immunocompetent male who presented with fever, weight loss, right-sided facial anhidrosis and hand weakness of six months duration. Neurological examination confirmed right Horner's syndrome and weakness of small muscles of right hand. Contrast MRI of neck and chest revealed a pleural-based right apical mass abutting subclavian artery and C8-T1 root and multiple enlarged lymph nodes. He developed right hemiataxia due to cerebellar infarct before the planned excision of mass. Surgical exploration showed abscess encasing subclavian artery. Biopsy of the mass resulted in accidental injury of subclavian artery which was repaired. He developed bleeding from suture site postoperatively due pseudo-aneurysm of the subclavian artery which was stented. Histopathology of mass was suggestive of Aspergillus sp. . He was successfully treated with voriconazole. This is probably the first report of Pancoast's syndrome and large vessel angiitis caused by Aspergillus fumigatus which has been successfully managed.

Impact of COVID-19 pandemic on epilepsy practice in India: A tripartite survey.

OBJECTIVE: To assess the impact of ongoing COVID-19 pandemic on epilepsy care in India. METHODS: We conducted a three-part survey comprising neurologists, people with epilepsy (PWE), and 11 specialized epilepsy centers across India. We sent two separate online survey questionnaires to Indian neurologists and PWE to assess the epilepsy practice, seizures control, and access to care during the COVID-19 pandemic. We collected and compared the data concerning the number of PWE cared for and epilepsy procedures performed during the 6 months periods preceding and following COVID-19 lockdown from epilepsy centers. RESULTS: The survey was completed by 453 neurologists and 325 PWE. One third of the neurologist reported >50 % decline in outdoor visits by PWE and EEG recordings. The cumulative data from 11 centers showed 65-70 % decline in the number of outdoor patients, video-EEG monitoring, and epilepsy surgery. Working in a hospital admitting COVID-19 patients and use of teleconsultation correlated with this decline. Half of PWE had postponed their planned outpatient visits and EEG. Less than 10 % of PWE missed their antiseizure medicines (ASM) or had seizures due to the nonavailability of ASM. Seizure control remained unchanged or improved in 92 % PWE. Half of the neurologists started using teleconsultation during the pandemic. Only 4% of PWE were afflicted with COVID-19 infection. CONCLUSIONS: Despite significant decline in the number of PWE visiting hospitals, their seizure control and access to ASMs were not affected during the COVID-19 pandemic in India. Risk of COVID-19 infection in PWE is similar to general population.

COVID-19 in Patients with Myasthenia Gravis: Mechanisms of Respiratory Failure.

This report describes a patient with thymomatous myasthenia gravis (MG) with aplastic anemia in pharmacological remission and COVID-19 who developed respiratory failure in the course of the disease and reviews the published literature on this topic. Analysis of the clinical characteristics of the eight patients with MG including our patient suggests two possible mechanisms for respiratory failure: myasthenic crisis (MC) or pulmonary complications of COVID-19. Patients with MC were young women in high-grade MGFA Class whereas patients with respiratory failure due to pulmonary complications of COVID-19 were elderly men in pharmacological remission or MGFA Class I. These observations suggest that COVID-19, like other infections, may precipitate MC in patients with severe grade MG before COVID-19. The only differentiating feature between the two types of failure was severity myasthenic weakness. This clinical distinction has management implications. These observations need to be validated in a larger sample.

Incidence Study of Epilepsy using the ILAE 2017 Classification of Epilepsies in a Cohort of School Children Accessing Education in Government Primary Schools in South India.

BACKGROUND: Recently, the International League Against Epilepsy (ILAE) has proposed new classification schemes for seizures and epilepsy. The applicability of these classification schemes has not been studied in resource-poor countries. AIM: To determine the incidences of epilepsies in a cohort of school children using the ILAE 2017 classification of epilepsies. MATERIALS AND METHODS: The study cohort included 7,408 school going children [age range 5-15 years]. They were followed for new-onset unprovoked seizure and seizure recurrence through first grade to fifth grade. The data collected during the first visit included clinical details including details of seizure semiology. All children had EEG and contrast CT scan. All these data were used to classify seizure type and epilepsy using ILAE classification schemes. The ILAE 2014 epilepsy definition was used to diagnose epilepsy. The average annual incidence rates (AAIR) and 95% confidence intervals (CI) were calculated for epilepsies by onset and by etiology. RESULTS: The AAIR of epilepsy was 57.85 (95% CI 39.0-82.6) per 100,000 population. The AAIRs per 100,000 for different epilepsies by mode of onset were focal epilepsies 25.07 (95% CI 13.35-42.87); generalized epilepsies 13.5 (95% CI 5.43-27.8); and unknown onset epilepsies 19.28 (95% CI 9.25-35.46). The AAIRs per 100,000 of epilepsies by etiology were focal genetic epilepsies 7.71 (95% CI 2.1-19.75); genetic generalized epilepsies 13.5 (95% CI 5.43-27.8); and epilepsies due to structural cause 17.36 (95% CI 9.25-35.46). The lesional epilepsies seen in this cohort were geographically specific to resource-poor countries. The AAIR of epilepsy due to calcific neurocysticercosis (cNCC) was 9.64 (95% CI 3.1-22.5) per 100,000. CONCLUSIONS: This study demonstrates that the ILAE 2017 classification of epilepsies can be applied in resource-poor countries with limited workup. Lesional epilepsies seen in this study is geographically specific to resource-poor countries.

Nocardiosis-an uncommon infection in patients with myasthenia gravis: report of three cases and review of literature.

Nocardiosis is a rare infection in patients with myasthenia gravis (MG). We identified three cases of MG admitted with nocardiosis in our unit. We performed systematic literature search of previous publications and identified 18 patients. This paper presents three patients and reviews the clinical characteristics of 21 patients. The first case was a 69-year-old woman with thymomatous MG who presented with pustules and left lower limb pain. Evaluation showed osteomyelitis of the pubic ramus and ileopsoas abscess. The second case was a 54-year-old man who presented in myasthenic crisis due to pulmonary nocardiosis. The third case was a 48-year-old man with thymomatous MG who presented with lung abscess. All of them recovered completely after treatment with co-trimoxazole. Analysis of the 21 patients identified four risk factors for nocardiosis in MG: elderly men; thymoma; immunosuppressant medication, mainly steroid therapy; and pre-existing lung disease. Lungs was the most common site of infection. Suppurative disease was common manifestation regardless of organ involved. Clinical course is not unfavourable.