Bilateral vestibulopathy presaging clinically probable multisystem atrophy.

Bilateral vestibulopathy is a clinical diagnosis backed by investigative confirmation, which can be masked by the lack of lateralising signs. It has a broad aetiological spectrum including neurodegenerative conditions, though many such cases also have unknown aetiology. We present the case of an elderly gentleman who presented with progressive bilateral vestibulopathy nearly 1.5 years prior to his eventual diagnosis of clinically probable multisystem atrophy. This case highlights the need to serially re-evaluate for parkinsonism and cerebellar signs in idiopathic bilateral vestibulopathy and raises a possibility that bilateral vestibulopathy, similar to constipation or anosmia, could be an early syndrome presaging the onset of overt extrapyramidal or cerebellar symptoms in patients with multisystem atrophy.

Effect of recanalization on clinical outcomes in patients with cerebral venous thrombosis - An ambispective study.

PURPOSE: Achieving complete recanalization has possible but unproven benefits in cerebral venous/sinus thrombosis (CVST). We reported a cohort of patients with CVST and assessed the factors associated with recanalization and its effect on outcomes. METHODS: We included 123 patients with CVST in this single-center, ambispective, observational study from October 2018 to November 2019. We noted their demographic, clinical, and radiological features, modified Rankin scale (mRS), recanalization status, and the presence of any recurrences while having periodic follow-ups every three months for one year or until complete recanalization, whichever was earlier. RESULTS: Out of the 123 patients enrolled, we completed the etiological evaluation in 122 and assessed the outcome at discharge in 120. One (0.8%) patient went against medical advice, 2 (1.6%) died in the hospital, and 8 (6.5%) were lost to follow-up at various time points. The majority of the patients were males (75 [60.98%]). Thrombophilia (71 [58.2%]) and hematological conditions (51[41.8%]) were the predominant risk factors for CVST. The majority (107 [95.5%] at three months) of the patients had an mRS of 0-1. Eighty-one (67.5%) and 26 (21.7%) patients attained complete and partial recanalization at their last follow-up, respectively. Involvement of transverse and sigmoid sinus was an independent predictor of poor recanalization (Odds Ratio [OR] {Confidence Intervals [CI]} - 0.2 (0.04-0.7); p = 0.01). Moreover, failure to achieve at least partial recanalization (OR [CI] - 94 [6.8-1296]; p = 0.01) and undergoing a decompression craniectomy (OR [CI] - 26.4 [1.2-582]) were the only factors that independently predicted poor functional outcomes in our cohort. CONCLUSION: Most of the patients with CVST had favorable outcomes. Recanalization was a strong predictor of good functional outcomes. Therefore, recanalization status should be considered while deciding when to stop the anticoagulation. However, we found no differences in the outcomes between those who achieved partial and complete recanalization.

Modified collision study to isolate and study small fibre neuropathy in patients with Type 2 diabetes.

Introduction: Diabetic distal symmetrical polyneuropathy (DSPN) can be categorized as small fibre, large fibre, and mixed neuropathy. Even though small fibre neuropathy is the most prevalent, unfortunately it is usually not recognized by routine electrophysiologic studies. In this study, we intend to examine the slow velocity small fibres responsible for small fibre DSPN, by isolating them using collision technique principle in patients with diabetes. Methods: This is an observational case-control study designed to compare nerve conduction values with application of collision technique in 60 patients with T2D and in 60 age and sex matched controls. Results: The collision study in patients with Type 2 Diabetes showed mean Latency of 10.5 ± 1.7 ms and mean Amplitude of 3.4 ± 2.3 mV on the right side and mean Latency of 10.5 ± 1.7 ms and the mean Amplitude of 3.5 ± 2.2 mV on the left side. There was a statistically significant difference (P value < 0.001) in the amplitute and latency of CNAPs of small fibres in median nerve innervated APBs of both arms between those with T2D and controls. Discussion and Conclusion: Collision study helps to examine the slower conducting fibres of the larger nerves. Our study suggests that the Collision Technique can be used to identify early peripheral neuropathy regardless of the diabetes status, thus making it more practically feasible and cost-effective.

False positive immunoassay for acetyl choline receptor antibody (AChR Ab) in patients exposed to polyvalent antisnake venom.

Acute flaccid paralysis is a neuromuscular emergency characterized by rapidly worsening weakness that evolves quickly to cause diaphragmatic failure. The challenge for the treating physician is to stabilize the patient, generate the differential diagnosis and determine the management; all in quick time. Neurotoxic snake bites have inadequate signs of inflammation and are easily missed. Myasthenic crisis, on the other hand, could be the first sign of myasthenia gravis in up to 20% of patients. Both present with acute respiratory failure and inadequate history. Two of our patients presented with similar clinical picture, and received polyvalent anti-snake venom obtained from hyperimmunised horses (Equus caballus). Both tested positive for anti-acetyl choline receptor antibody. After recovery, both patients narrated a history suggestive of neurotoxic envenomation. We later discovered that patients, who are exposed to polyvalent anti-snake venom (Equus caballus) prior to radioimmunoassay, demonstrate high titers of Anti-AChR Ab in their serum erroneously.

Mystery of a cryptogenic stroke solved by an abdominal angiogram.

Despite advances in the field of imaging and diagnostics, the incidence of cryptogenic stroke is still around 30-40% in modern stroke databases. Our patient presented with recurrent midbrain infarcts over 3 years and was initially labelled as a patient with cryptogenic stroke. His blood investigations were normal, work up for autoimmune disorders was negative, CT brain angiogram was normal and a two-dimensional echo showed a small patent foramen ovale with a left to right shunt. He later presented with a right perinephric haematoma and an abdominal angiogram revealed multiple microaneurysms of the renal arteries, coeliac trunk and the mesenteric arterial system. The feeding renal artery was embolised. A diagnosis of polyarteritis nodosa was made. The patient was subjected to digital subtraction angiography of neck and intracranial vessels, which revealed multiple microaneurysms in internal and external carotid artery territory. He was discharged with steroids and azathioprine.