Cognitive behavioural impairment with irreversible sensorineural deafness as a complication of West Nile encephalitis.

Despite common clinical features to suggest encephalitis, different viral encephalitides are known to have some specific clinical features, which if present, may suggest infection by a particular virus. West Nile viral (WNV) encephalitis has not been described with any specific diagnostic feature so far. In this context, we describe three patients of West Nile encephalitis (WNE) who had behavioural and cognitive impairment with acute irreversible bilaterally symmetrical sensorineural deafness. Clinical profiles of these cases suggest that the patients who present with prominent behavioural and cognitive changes and have in addition features of bilateral sensorineural deafness may be considered as the possible case of WNE.

Clinical characterization of neck pain in migraine.

INTRODUCTION:: Several extracranial symptoms, including somatic pain syndormes, are known to occur in migraine. Though neck pain has been occasionally described with migraine, its precise association and nature is not yet clear. OBJECTIVE:: To study the incidence and characteristics of neck pain in migraine with particular emphasis on its occurrence as a trigger or a part of the symptom complex of migraine, as well as its association with different phases of the migraine attack. MATERIALS AND METHODS:: We interviewed 391 migraine patients for 18 months. All patients who reported neck pain anytime during the migraine phase were analyzed for their demographic profile, headache and neck pain characteristics, the associated conditions, and other clinical features. RESULTS:: One hundred and sixty-six (42.5%) patients reported neck pain anytime during the attack (61.5% were female patients and the mean age was 35.8 years). A total of 82.7% patients had migraine without aura and 75.3% had episodic migraine at the onset. In 53 patients (32%), neck pain was a trigger, and in the rest (n = 113, 68%), neck pain was a part of migraine symtomatology. Fifty-seven patients (34.3%) noticed neck pain before the onset of headache; 148 patients (89.2%) reported neck pain at the onset of headache, and 46 patients (27.7%) experienced neck pain after the resolution of headache. The characteristic feature of migraine, such as the unilateral side shifting type of headache, was seen in only 54.2% of the patients, and the throbbing pain quality was seen in 75.2% of the patients. There was no significant difference in the nonheadache symptoms (P = 0.587) and cranial autonomic symptoms (P = 0.596) between the neck pain triggered migraine patients and those having neck pain as a part of the attack. CONCLUSION:: These data indicate that neck pain is a very common feature of migraine attacks and is likely to be either a trigger or a part of the migraine attack. Contrary to the established concept, however, neck pain as a prodromal or postdromal migraine symptom was less common. Careful history taking is required to diagnose neck pain as a feature of migraine and to differentiate it from secondary headache due to a cervical pathology for avoiding unnecessary imaging or other investigations.

Tumefactive acute disseminated encephalomyelitis.

Tumefactive demyelinating lesions are tumour-like presentations of acute demyelinating lesions. They have been described with multiple sclerosis only and not with other varieties of acquired demyelination like acute disseminated encephalomyelitis (ADEM). The uncertainty about the diagnosis at the onset of the disease in tumefactive ADEM makes it important that the physicians should be aware of this entity. Various radiological similarities with more sinister lesions like central nervous system gliomas or lymphomas may lead to this confusion. Appropriate supportive treatment with steroids and follow up is required in these cases to avoid unnecessary interventions.

Complete middle cerebral artery block without brain infarction.

We report a patient with progressive supranuclear palsy and incidentally detected the absence of right middle cerebral artery (MCA) without any old or acute infarct in its territory. The magnetic resonance angiography and computed tomography angiography failed to detect any significant collateral circulation. We discuss the embryogenesis of brain circulation and offer a possible explanation for the nonvisualization of the right MCA in our patient.

Scrub typhus with opsoclonus-myoclonus-ataxia-seizure as primary presentations.

Scrub typhus is a simple acute febrile illness with rash or an eschar, with up to one-fifth of the patients complicated with the nervous system. Hence, certain cases present to physicians with rather a different systemic manifestation and incidentally have been diagnosed with scrub typhus. We present two such cases of scrub typhus with neurological manifestations. The first case was of a 14-year-old boy with no previous history of any comorbidities who presented with bilateral opsoclonus with multifocal spontaneous myoclonus with cerebellar ataxia with a preceding history of fever and acute gastroenteritis. The second case of a 30-year-old gentleman with no previous history of any comorbidities presented to us with generalized tonic-clonic seizures and spontaneous multifocal myoclonus with a preceding history of fever. Both cases had no motor, sensory, cerebellar, or autonomic involvement. The pathophysiology of central nervous system (CNS) infections in scrub typhus is attributed to three major mechanisms of vasculitis, direct invasion, and immune-mediated. CNS involvement in scrub typhus is a significant marker for risk of mortality or morbidity. The most common CNS manifestations in scrub include meningitis, encephalitis, and seizures. Opsoclonus, myoclonus, and parkinsonism are comparatively rare manifestations.Scrub typhus infection must be considered in the differential diagnosis of clinical neurological features with even a remote history of acute febrile illnesses in endemic regions like ours, despite the absence of any eschar, rashes, and unremarkable neuroimaging.

Dorsal medullary cavernous hemangioma presenting as obstinate hiccups and its surgical treatment: illustrative case.

BACKGROUND: Hiccups are characterized by involuntary, intermittent, repetitive, myoclonic, and spasmodic contractions of the diaphragm. Hiccups are termed "intractable" when they last for over 1 month. OBSERVATIONS: A rare case of intractable hiccups due to an uncommon location of cavernous hemangioma in the dorsal medulla is illustrated. With respect to the management, surgical excision was performed, and postsurgical complete recovery was witnessed, which has been reported only in six cases worldwide to date. LESSONS: A mechanism of the hiccups reflex arc is discussed in detail with special reference to the need for equal emphasis on evaluating central nervous system causes and peripheral etiologies for pertinent hiccups.