Progressive lacunar strokes behave differently from stable ones even at one year-An observational study.

BACKGROUND AND AIMS: Small fraction of lacunar stroke patients have an early fluctuating course, described as progressive lacunar syndrome [PLS].We studied the predictors and short term outcome of progressive lacunar strokes in comparison with those with an early stable course. MATERIALS AND METHODS: Single centre retrospective study where patients with lacunar strokes from 2016 to 2020 were included in the study. Progression was defined as increase in stroke severity [NIHSS] by ≥2 points from baseline without imaging evidence of new infarcts or haemorrhagic transformation. We compared the clinical variables, risk factors, imaging, treatment received and 1 year outcome of subjects with PLS with those with a stable course, with modified Rankin score 0-2 taken as good outcome. RESULTS: Of the 216 patients with a mean age 63.17 years, progressive course was noted in 56 subjects [26 %].Majority of the fluctuations occurred within 24 h of onset of symptoms. Though stroke severity at admission was comparable between the 2 groups, discharge and 1 year outcome was poorer in those with an early progressive course. We found that presentation as pure motor syndrome, hypertriglyceridemia and thrombolytic therapy were predictors of poor outcome in progressive lacunar strokes, while age, risk factors, infarct location or leukoaraiosis failed to show an association. Thalamic infarcts and atypical lacunar syndromes were associated with a stable course. CONCLUSION: Progressive course is seen in a quarter of lacunar strokes and they have poorer outcome at 1 year. Our finding of thrombolysis being associated with worse outcome in PLS patients, should alert physicians regarding need for more definitive therapies for this condition.

Soluble ST2 Predicts Poor Functional Outcome in Acute Ischemic Stroke Patients.

INTRODUCTION: There are very limited data on the role of biomarkers correlating with the outcome in acute ischemic stroke (AIS). We evaluated the predictive values of the plasma concentrations of soluble serum stimulation-2 (sST2), matrix metalloproteinase-9 (MMP-9), and claudin-5 in AIS. METHODS: The biomarker levels in the plasma samples of consecutive AIS patients collected at baseline, 12 h, and 24 h from stroke onset were quantified using immunoassays. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) and functional outcome at 90 days using the modified Rankin Scale (mRS), with scores above 3 defined as poor outcome. Receiver operating characteristic curve analysis and multiple logistic regression were performed for evaluating the discriminative power of each marker. RESULTS: We included 108 patients in the study (mean age 62.3 ± 11.7 years). Median NIHSS score was 12 (interquartile range 8-18). High baseline glucose levels, systolic blood pressure, baseline NIHSS, low Alberta Stroke Program Early CT Score, and hemorrhagic transformation were associated with poor outcomes. Elevated sST2 at 12 h (50.4 ± 51.0 ng/mL; p = 0.047) and 24 h (81.8 ± 101.3 ng/mL; p = 0.001) positively correlated with poor outcomes. MMP-9 (p = 0.086) and claudin-5 (p = 0.2) were not significantly associated with the outcome, although increased expressions of both markers were observed at 12 h. Multiple logistic regression showed that sST2 levels ≥71.8 ng/mL at 24 h, with a specificity of 96.9%, emerged as an independent predictor of poor functional outcome (OR: 6.44; 95% CI: 1.40-46.3; p = 0.029). CONCLUSION: Evaluation of sST2 may act as a reliable biomarker of functional outcome in AIS.

Association of 24 h Blood Pressure on Functional Outcome in Patients with Acute Ischemic Stroke Post Intravenous Thrombolysis.

INTRODUCTION: Elevated admission blood pressure (BP) and BP variability have been shown to be associated with poor outcomes in most studies, while few studies have not found such an association. We investigated the association of various BP parameters with 3-month functional outcomes, mortality, and symptomatic intracerebral hemorrhage (sICH) in patients with acute ischemic stroke (AIS) receiving intravenous thrombolysis (IVT). METHODS: Patients with AIS who received IVT between January 2012 and March 2020 were analyzed. Admission BP, 24 h mean BP, and BP variability were noted for all patients. Outcomes assessed were 3-month modified Rankin Scale (mRS), mortality, and sICH. RESULTS: Of the 237 patients, 161 were males. The mean admission systolic BP (SBP), 24 h mean SBP, and BP variability were 158.1 mm Hg (SD 30.25), 138 mm Hg (SD 16.78), 19.42 (SD 12.79), respectively. At 3 months, 147 (62%) patients had a good outcome (mRS 0-2). Multivariate analysis showed prior stroke, NIHSS >15, mean SBP ≥160 mm Hg, and SBP variability >45 to be significant predictors of poor outcome (mRS > 2) at 3 months. Eleven patients (4.6%) developed sICH. Age more than 60 years, presence of atrial fibrillation, admission blood sugar ≥180 mg/Dl, and SBP variability >45 predicted sICH. None of the above factors were predictive of 3-month mortality. CONCLUSION: An elevated mean SBP and greater SBP variability were predictive of poor functional outcomes, whereas a high SBP variability predicted sICH. Our study emphasizes the need for BP control and minimizing large fluctuations to achieve good poststroke outcomes.

Biomarkers predict hemorrhagic transformation and stroke severity after acute ischemic stroke.

OBJECTIVES: Hemorrhagic transformation (HT) is a complication occurring in patients with acute ischemic stroke (AIS) either spontaneously or post-thrombolysis leading to significant morbidity and mortality. We assessed circulating matrix metalloproteinase-9 (MMP-9), Claudin-5, and soluble serum stimulation-2 (sST2) in HT and stroke severity in AIS based on their temporal distribution. MATERIALS AND METHODS: We prospectively enrolled 111 AIS patients within 12 h from onset. Patient demographic, clinical, and imaging details were documented. Follow-up imaging was conducted 24-48 h after admission. Blood samples were taken at three time-points from stroke onset. HT was classified according to the European Co-operative Acute Stroke Study-III(ECASS-III). Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS). Multiple logistic regression and receiver operating characteristic curve were conducted to determine the discriminative capacity. RESULTS: Mean age was 62.3 ± 11.7 years and median baseline NIHSS was 12[IQR 8.0-18.0]. HT was detected in 30(27%) patients. Biomarker levels at 12 h were elevated with median MMP-9 concentration of 153.9 ng/mL[IQR 110.6-309 ng/mL] indicating a trend toward significant positive correlation with HT(P = 0.05). Claudin-5 levels at 12 h was elevated but was not statistically significant (43.1 pg/mL[IQR:26.7-72.6 pg/mL] vs 59.4 pg/mL[IQR:24.5-100.8 pg/mL];P = 0.4). Multiple logistic regression indicated Claudin-5 levels at 12 h (OR 9.46;95% CI:1.97-64.6;P = 0.010) and baseline low ASPECTS score(OR 20.3;95% CI:3.46-193; P = 0.003) independently predicted HT. MMP-9 at 12 h was significantly elevated in patients with moderate to severe strokes (P = 0.04). CONCLUSIONS: Claudin-5 and low ASPECTS independently predicted HT. MMP-9 was positively correlated with baseline stroke severity.

Yoga Nidra, a Nonpharmacological Technique in Management of Insomnia and Overall Health in Postmenopausal Women.

Yoga Nidra is a promising technique through which body is consciously simulated into a profound relaxation state similar to attained during naturally occurring deep sleep. It is aimed to attain complete emotional, physical, and mental relaxation of body and mind. In postmenopausal phase of life, regular practice of Yoga Nidra at home preferably in morning, can help in reduction in anxiety and pain associated with early morning awakenings. This nonpharmacological technique has a therapeutic potential to improve sleep quality and quantity, and overall well-being.

Carotid endarterectomy for symptomatic carotid stenosis: differences in patient profile in a Low-Middle Income Country.

INTRODUCTION: Carotid Endarterectomy (CEA) is the standard treatment for patients with symptomatic carotid stenosis. Data from Low- and Middle-Income Countries (LMIC) is sparse on CEA and its outcomes. We aimed to describe the profile of our patients, and factors associated with periprocedural cerebral ischemic events in patients with symptomatic carotid stenosis who underwent CEA in our institute. METHODS: Retrospective review of patients with symptomatic carotid stenosis(50-99%) who underwent CEA between January 2011 and December 2021 was done. Clinical and imaging parameters and their influence on periprocedural cerebral ischemic events were analysed. RESULTS: Of the 319 patients (77% males) with a mean age of 64 years (SD ±8.6), 207 (65%) presented only after a stroke. Majority (85%) had high grade stenosis (70%) of the symptomatic carotid. The mean time to CEA was 50 days (SD ±36), however only 26 patients (8.2%) underwent surgery within 2 weeks. Minor strokes and TIA occurred in 2.2%, while major strokes and death occurred in 4.1% patients. None of the clinical or imaging parameters predicted the periprocedural cerebral ischemic events. The presence of co-existing significant (50%) tandem intracranial atherosclerosis (n=77, 24%) or contralateral occlusion (n=24, 7.5%) did not influence the periprocedural stroke risk. CONCLUSION: There is a delay in patients undergoing CEA for symptomatic carotid stenosis. Majority have high grade stenosis and present late only after a stroke reflecting a lack of awareness. CEA can be performed safely even in patients with significant intracranial tandem stenosis and contralateral carotid occlusion.

Does thrombus imaging characteristics predict the degree of recanalisation after endovascular thrombectomy in acute ischaemic stroke?

BACKGROUND: Identification of computed tomography (CT) thrombus imaging characteristics can predict the degree of recanalization and outcome after endovascular thrombectomy (EVT) in patients with acute ischaemic stroke and large vessel occlusion. AIM: We analyzed the thrombus imaging characteristics and procedural factors and correlated with the degree of recanalization and functional outcome after EVT. METHODS: We evaluated the thrombus imaging characteristics (hyperdense MCA sign, thrombus location, length and thrombus permeability) from thin slice CT and CT angiogram. In addition, groin to recanalization time, number of passes, and EVT technique were documented. The primary outcome was degree of recanalization (mTICI score) and secondary outcome was modified Rankin scale (mRS) at 3 months. RESULTS: The mean age of 102 patients was 60.5±11.8 years. Patients with hyperdense MCA sign (90 % vs 75%, p=0.07) and permeable thrombus (86 % vs 70 %, p=0.09) had good recanalization (mTICI grade 2b,2c or 3). The requirement of <3 passes (90 % vs 62 %, p= 0.001) was associated with good recanalization. Multiple logistic regression analysis showed thrombus permeability (OR 5.9; 95% CI 1.3-26.6, p=0.02), use of stent retreiver alone (without aspiration) (OR 5.4; 95% CI 1.3-22.5, p=0.02) and a puncture to recanalization ≤60 minutes (OR 7.9; 95% CI 1.7-36.8; p=0.008) were associated with good recanalization. The requirement of ≥3 passes was associated with poor functional outcome (OR 3.4;95% CI 1.2-9.8; p=0.02). CONCLUSIONS: Thrombus permeability was a predictor of successful recanalization after EVT. The requirement of three or more passes during EVT was associated with poor recanalization and poor functional outcome.

The Impact of Time to Reperfusion on Recanalization Rates and Outcome After Mechanical Thrombectomy: A Single Center Experience.

Background: Timely and effective recanalization to salvage the penumbra is the main determinant of outcome in acute ischemic strokes. Randomized controlled trials on late window mechanical thrombectomy (MT) have proved its safety and efficacy upto 24 h after stroke onset. We looked at the impact of time to reperfusion on vessel recanalization rates and short-term outcome in patients undergoing MT for large vessel occlusion. Methods: The clinical, imaging, and outcome of all patients undergoing MT upto 24 h from last seen normal was extracted from a prospectively maintained ischemic stroke database from January 2012 till September 2019. Results: There were 145 patients with a mean (SD) age of 58.2 (±14) years. Of them, 28 had wake up/unknown time of onset stroke and 9 presented beyond >360 min. There were 23 vertebrobasilar strokes. Median National Institute of Health Stroke scale score (NIHSS) at admission was 16.4 (Inter quartile range (IQR) 12-21). CT-Alberta Stroke program early CT score (CT-ASPECTS) was excellent (8-10) in 39 (31.6%) and fair (5-7) in 77 (63.6%) patients in anterior circulation strokes. About 25% underwent bridging therapy. Recanalization rates did not differ between those presenting early (<6 h) versus wake up strokes and late presenting patients (81.79% vs 71.9%). Symptomatic Intracerebral hemorrhage (ICH) occurred in 5%. At 3 months, excellent outcome (modified rankin scale <2) was observed in 28.9%. While Admission NIHSS remained strong predictor of poor outcome at 3 months, delay in presentation did not impact MT outcome (37.5% vs 45.79% and P = 0.460). Conclusions: The recanalization rates were similar in patients irrespective of the time to reperfusion from stroke onset. The functional outcome was not inferior in late presenters selected by advanced imaging.

Dysphagia Continues to Impact Recovery at One Year After Stroke-An Observational Study.

OBJECTIVES: Dysphagia is one of the most common medical complication after acute stroke, which can impact hospital stay and discharge outcome. Here we sought to study the predictors and 1 year outcome of patients with acute post stroke dysphagia. METHODS: Single centre hospital based observational study of all acute ischemic stroke patients who had undergone formal swallow assessment within 24 hours of admission with a 1 year completed follow-up were recruited by screening of medical records. Clinical, imaging and swallow assessment details were extracted as per proforma. 3 month and 1 year outcome were assessed using modified Rankin scale. Correlations were made with clinical and imaging findings, in hospital worsening and dysphagia at discharge with short and long term functional outcome. RESULTS: We had 469 patients included in our study, with a mean age 61. 04(±19. 09) years and median NIHSS 9. 52(IQR 4). 56. 75% of AIS patients had some degree of dysphagia at admission. We found that admission stroke severity and in-hospital worsening were independently predictive of severe swallow dysfunction at discharge. At 3-4 weeks after stroke, only 20.27% of the patients with moderate-severe dysphagia at baseline has persistent swallow deficits requiring modification of feeds. Dysphagia continued to have a significant association with outcome at 1 year, independent of admission stroke severity. CONCLUSIONS: Majority of patients with acute post stroke dysphagia recover well within 3-4 weeks after stroke. Patients with post stroke dysphagia had more in hospital neurological worsening. Post stroke dysphagia continued to have an impact on functional outcome up to 1 year after stroke.

Yogic Sleep and Walking Protocol Induced Improvement in Sleep and Wellbeing in Post-menopausal Subject: A Longitudinal Case Study During COVID Lockdown.

Purpose: Post-menopausal life is fairly long period of life that is marked by poor health and sleep. Fatigue amidst extraordinary pandemic stress had taken a toll on the sleep quality and overall wellbeing. Yogic sleep can be instrumental in relaxing the brain and help in achieving self-control of mind and body in the post-menopausal life. This can be a non-pharmacological intervention to improve the wellbeing of women. Methods: Effect of 24 weeks of yoga-nidra practice and exercise module was tested in a post-menopausal subject after taking baseline of 4 weeks on parameters like sleep latency, total sleep time, mood on waking and during day, BMI, and activity rhythm of body using 24 h actigraphy and sleep diary. Results: After administering the dual protocol, there was remarkable elevation in mood both on waking up and entire day from 5th week onwards. Mood shifted toward a happier state. Latency to sleep decreased after 4 weeks, while total sleep time improved only after 16 weeks of dual management strategy. The BMI was also reduced to 28.4 from initial value of 30.3. Morning awakening patterns did not change, but it was not accompanied by pain or headache. Conclusion: The results indicated the therapeutic potential of yoga-nidra and exercise package in this actigraphy-based longitudinal pilot study. Yoga-nidra can be easily practiced at home, and thus, it is a promising non-pharmacological strategy for aging population in improving their wellbeing.

High-Resolution Vessel Wall Imaging in Primary Angiitis of Central Nervous System.

BACKGROUND: High-resolution vessel wall imaging (HRVWI) can aid in differentiating the various intracranial vasculopathies, but has been sparingly used in the diagnosis of primary angiitis of central nervous system (PACNS). This study is aimed to describe the vessel wall imaging characteristics of PACNS. MATERIALS AND METHODS: Patients with confirmed diagnosis of PACNS according to the Calabrese and Mallek criteria who had abnormal HRVWI were included in this retrospective descriptive study. Magnetic resonance image of brain, conventional four-vessel cerebral digital subtraction angiogram, and HRVWI were read by a neuroradiologist. The vessel wall parameters assessed were T1W and T2W appearances, pattern of wall thickening and contrast enhancement, and remodeling index. RESULTS: HRVWI done in 21 patients with PACNS yielded abnormality in 20 (95.2%) who were included in the analysis. The mean age at presentation was 42.55 ± 9.48 years and 14 (70%) were males. The median number of vessels involved were four (range 2-12). The commonest vessels affected were proximal middle cerebral artery (70%) and internal carotid artery (55%). Vessel wall thickening was concentric, eccentric, and absent in 12 (60%), 1 (5%), and 7 (35%) patients, respectively. Vessel wall enhancement was diffuse in 17 (85%), eccentric in 1 (5%), and absent in 2 (10%) patients. One patient had T2W hyperintense stenotic lesion. Remodeling index was negative in 11 (55%) patients. CONCLUSION: Distinctive vessel wall appearances were observed by HRVWI in PACNS, concentric vessel wall thickening and enhancement being more frequent. Hence, HRVWI can be considered as an additional noninvasive imaging modality in the diagnosis of PACNS.

Women and Stroke: Different, yet Similar.

BACKGROUND: The impact of gender on acute ischemic stroke, in terms of presentation, severity, etiology, and outcome, is increasingly getting recognized. Here, we analyzed the gender-related differences in etiology and outcome of ischemic stroke in South India. METHODS: Patients with first ever ischemic stroke within 1 week of onset presenting to the Comprehensive Stroke Care Centre, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India, were included in our study. Clinical and risk factor profile was documented. The stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) at onset, and stroke subtype classification was done using Trial of Org 10172 in Acute Ischemic Stroke criteria. The 3-month functional outcome was assessed using the modified Rankin Scale (mRS) with excellent outcome defined as an mRS ≤2. RESULTS: Of the 742 patients, 250 (33.7%) were females. The age, clinical profile, and rate of reperfusion therapies did not differ between the genders. Women suffered more severe strokes (mean NIHSS 9.5 vs. 8.4, p = 0.03). While large artery atherosclerosis was more common in men (21.3% vs. 14.8%, p = 0.03), cardioembolic strokes secondary to rheumatic heart disease were more common in women (27.2% vs. 19.7%, p = 0.02). Men had a better 3-month functional outcome compared to women (68.6% vs. 61.2%, p = 0.04), but was not statistically significant after adjusting for confounders. CONCLUSION: Our data, from a single comprehensive stroke unit from South India, suggest that stroke in women are different, yet similar in many ways to men. Guideline-based treatment can result in comparable short-term outcomes, irrespective of admission stroke severity.

Clinical profile and outcome of non-COVID strokes during pandemic and the pre pandemic period: COVID-Stroke Study Group (CSSG) India.

BACKGROUND: As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected. AIMS: The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019. METHODS: The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points. RESULTS: A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods. CONCLUSIONS: Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe.

Preoperative screening for obstructive sleep apnea in cardiovascular patients - How useful is STOP-BANG questionnaire in the Indian context?

Background: Obstructive sleep apnea (OSA) is reported in a high proportion of cardiac surgical patients, up to 73%. STOP-BANG is a validated questionnaire for screening of outpatients for OSA with high sensitivity. There is sparse literature from India regarding the prevalence of OSA in preoperative cardiovascular patients and the utility of screening tools. Aims: We sought to study the utility of the STOP-BANG questionnaire as a screening tool for OSA in cardiovascular patients validating it with ambulatory level 3 polysomnography. Materials and Methods: It was a prospective study where consecutive patients getting admitted for coronary artery bypass surgery (CABG) from August 2017-February 2019 were recruited. All the patients were screened with the STOP-BANG questionnaire. 53 patients underwent overnight level 3 polysomnography using Apnea-Link. Correlations were made between clinical symptoms, STOP-BANG score, and OSA severity, measured using Apnea hypopnea index (AHI). Results: We had 120 patients(103 males) with a mean age 60 years. Snoring was the most common sleep complaint. Our cohort had a high prevalence of vascular risk factors (DM 72.3%, hypertension 59.2%, dyslipidemia 60%) and 11.7% were obese (BMI >30). The median STOP-BANG score was 3 (IQR 2) with 83 having scores ≥3. Median AHI was 5.6 with AHI ≥5 in 28 patients and AHI 15 or above in 14 patients. Among the clinical parameters, arousals with respiratory difficulty at night, higher neck circumference, and tonsillar hypertrophy showed a significant association with PSG-proven OSA.STOP-BANG scores 3 or above had a sensitivity of 75% in predicting OSA. Conclusions: Our study shows that in cardiovascular patients less symptomatic for sleep complaints, the STOP-BANG questionnaire is a useful screening tool for OSA in outpatient settings. Among clinical parameters, airway narrowing and neck circumference can predict OSA.

Hypodensities within Hematoma is Time-Dependent and Predicts Outcome after Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Non-contrast CT (NCCT) brain imaging biomarkers of hematoma expansion in intracerebral hemorrhage (ICH) has gained relevance in recent times. Though intra-hematoma hypodensities (IHH) can predict hematoma expansion and outcome, it is postulated to be time-dependent. AIM: To assess the differential prevalence of IHH in spontaneous ICH over time and assess its predictive valve in early hematoma expansion and functional outcome at 3 months. MATERIAL AND METHODS: Patients with ICH within 48 h of stroke onset were included. Baseline clinical and demographic data were collected. Baseline NCCT brain was analyzed for hematoma volume, characterization of IHH, with 24-hours follow-up NCCT hematoma volume calculated for identification of hematoma expansion. Poor functional outcome was defined as mRS ≥3. RESULTS: Around 92 subjects were included in the study. IHH was found in 40%. Prevalence of IHH was higher in those with baseline NCCT performed within 3 h of symptom onset compared to those beyond 3 h (71% vs 29%, P = 0.002). The hematoma expansion was more common in patients with IHH compared to those without (54% vs 29%; P = 0.02). Multivariate analysis revealed the presence of IHH (rather than pattern or number) to be strongly associated with poor functional outcome at 3 months (OR 3.86; 95% CI: 1.11-13.42, P = 0.03). CONCLUSION: There is a decreasing prevalence of IHH as the time from symptom onset to NCCT increases. Nevertheless, its presence is significantly associated with hematoma expansion and predicted poor short-term functional outcomes in spontaneous ICH.

Rituximab for refractory primary angiitis of the central nervous system: Experience in two patients.

Primary Angiitis of the Central Nervous System (PACNS) is an aggressive disease with a high rate of relapse and mortality. Majority of patients attains clinical remission with a combination of glucocorticoids and cyclophosphamide. However, there is limited evidence on further management in patients who relapse or does not achieve clinical improvement while on first line treatment. Here, we present two cases of PACNS in whom clinical course was complicated by recurrent strokes and radiological progression despite receiving optimal immunosuppression with glucocorticoids and cyclophosphamide. Rituximab, a monoclonal antibody, as second line agent was administered with which both patients had clinical improvement and was relapse free at one year followup.

Mucopolysacharidosis Type I Presenting as Bipolar Affective Disorder: A Case Report.

Mucopolysacharidosis type I is a multisystem disease and often presents with neurobehavioral problems, corneal clouding, cardiac valve involvement, hepatomegaly, coarse facies, and skeletal abnormalities. It has three subtypes - with Hurler subtype (MPS-1H) being the most severe phenotype with early neurological involvement, rapid progression and mortality, while the other two subtypes - Hurler-Scheie (MPS-1H/S) and Scheie (MPS-1S) are of intermediate and milder severity, respectively. Even though neuropsychiatric symptoms have often been reported in the pediatric age group, MPS type I presenting as a major psychiatric illness in adulthood has rarely been reported in literature. Here, we report a female presenting as bipolar affective disorder in the fourth decade of life, where neuroimaging and systemic involvement gave a clue to the diagnosis.

Dysphagia and disability in minor strokes - An institutional study.

BACKGROUND: Minor strokes, defined as NIHSS ≤5 are considered non-disabling, associated with a favourable outcome. AIM: Our aim was to study prevalence and predictors of dysphagia in patients with minor stroke and its impact on functional outcome. METHODS: Single centre retrospective study of all minor strokes admitted to Comprehensive Stroke care centre with 1 year completed follow-up were recruited. Clinical and imaging details and follow-up data were extracted from medical records. RESULTS: We had 147 patients with minor stroke, 72.1% men with median age 61 years. 71% presented within 24 h of symptom onset. Most common etiology was lacunar .Median NIHSS at admission was 3(IQR 2). 85 patients had anterior circulation strokes and 34 had chronic infarcts in imaging.19 had significant dysphagia and 10 were discharged with nasogastric feeding tube. Admission NIHSS and white mater changes in imaging were predictive of post stroke dysphagia. Excellent recovery of dysphagia was found within 1 month post stroke in all, except one who required percutaneous gastrostomy. At 3 months 76% had excellent outcome. Presence of dysphagia and diabetes were found to be predictive of short term outcome, independent of admission stroke severity. At 12 months, post stroke dysphagia, female gender and white mater changes in imaging were predictive of unfavourable outcome. CONCLUSIONS: Minor strokes are disabling in a small fraction of patients. Over 10% of them can have significant post stroke dysphagia necessitating nasogastric feeding short term. This patient subgroup tend to have less favourable outcome on short and long term follow-up.