Ischaemic stroke in South Asians: The BRAINS study.

BACKGROUND AND PURPOSE: Studies on stroke in South Asian populations are sparse. The aim of this study was to compare differences in age of onset of ischaemic stroke in South Asian patients living in the United Kingdom and South Asian patients living in India versus White British stroke patients. METHODS: We studied the UK and Indian arms of the ongoing BRAINS study, an international prospective hospital-based study of South Asian stroke patients. The BRAINS study includes 4038 South Asian and White British patients with first-ever ischaemic stroke, recruited from sites in the United Kingdom and India. RESULTS: Of the included patients, 1126 were South Asians living in India (ISA), while 1176 were British South Asian (BSA) and 1736 were White British (WB) UK residents. Patients in the ISA and BSA groups experienced stroke 19.5 years and 7.2 years earlier than their WB counterparts, respectively (mean [interquartile range] age: BSA 64.3 [22] years vs. ISA 52.0 [18] years vs. WB 71.5 [19] years; p < 0.001). Patients in the BSA group had higher rates of hypertension, diabetes mellitus and hypercholesterolaemia than those in the ISA and WB groups. After adjustment for traditional stroke risk factors, an earlier age of stroke onset of 18.9 years (p < 0.001) and 8.9 years (p < 0.001) was still observed in the ISA and BSA groups, respectively. In multivariable stepwise linear regression analysis, ethnicity accounted for 24.7% of the variance in early age onset. CONCLUSION: Patients in the BSA and ISA groups experienced ischaemic stroke approximately 9 and 19 years earlier, respectively, than their WB counterparts. Ethnicity is an independent predictor of early age of stroke onset. Our study has considerable implications for public health policymakers in countries with sizable South Asian populations.

Neurological manifestations of HIV-AIDS at a tertiary care institute in North Eastern India.

BACKGROUND: The nervous system is among the most frequent and serious targets of human immunodeficiency virus (HIV) infection. The infection usually occurs in patients with profound immunosuppression. In 10 - 20% of the patients, the presence of a neurological disease is the first manifestation of symptomatic HIV infection. AIMS AND OBJECTIVE: Despite the wide prevalence of neurological manifestations in HIV, there is no study examining the clinical manifestations of this disease in the resource- limited communities from north-eastern parts of India. To characterize the neurological involvement in patients with HIV infection at a tertiary care institute in northeast India, we studied various neurological presentations of HIV. SETTING AND DESIGN: This was a retrospective observational study done at a tertiary care institute in northeast India over a period of 6 years from August 2008 to September 2014. MATERIAL AND METHODS: A total of 91 HIV seropositive patients of both genders, aged >18 years, showing clinical evidence of central nervous system (CNS) involvement, and admitted in a tertiary care institute were included. Their clinical manifestations, laboratory investigations, and imaging were studied. RESULT: Tuberculous meningitis was the most common presentation as secondary CNS illness (43.9%), followed by cryptococcal meningitis (14.2%) and cerebrovascular accidents (5.49%). Furthermore, 6.59% had neurosyphilis, 6.59% had acquired immune deficiency syndrome (AIDS) - associated dementia, and peripheral neuropathy occurred in 16.4% of the patients. Headache was the most common neurological symptom seen in 25% of the patients. Seizures were noted in 25% of the pateints. CD4 was significantly low in most of the patients with progressive multifocal leukoencephalopathy, HIV associated encephalopathy (HAD) and cryptococcal meningitis compared with other neurological manifestations. CD4 counts in tuberculous meningitis and HAD were 110.3/µl and 95/µl, respectively. CONCLUSION: CNS tuberculosis was the most common secondary infection seen in HIV patients followed by cryptococcal meningitis. A high index of clinical suspicion of neurological involvement in HIV patients helps in the early diagnosis and early institution of specific treatment, which in turn decreases the morbidity and mortality considerably.

Levetiracetam Use During Pregnancy in Women With Active Epilepsy: A Hospital-Based, Retrospective Study from a Tertiary Care Hospital in North Eastern INDIA.

BACKGROUND AND PURPOSE: Epilepsy during pregnancy is a therapeutic challenge. Since the 1990s, the number of licensed antiepileptic drugs has substantially increased, but safety data on managing epilepsy during conception, pregnancy, and postpartum period use of newer generation antiepileptic drugs and birth defects are limited. We analyzed efficacy and safety of levetiracetam during pregnancy in northeast Indian women with active epilepsy (WWAE) which is being presented here. DESIGN: Hospital based retrospective study. PATIENTS AND METHODS: A retrospective analysis was conducted based on clinical records at a tertiary care teaching hospital and referral center in Northeast India between June 2008 through June 2018 without any personal identifying information. The Obstetric data from pregnancy register was supplemented with detailed neurologic data retrieved from medical records. RESULTS: Of 103 women with active epilepsy, 47 (45.6%) received levetiracetam as monotherapy and 56 (54.4%) as polytherapy. During pregnancy, the seizure frequency was unchanged, or the change was better in the majority (61.1%) of the patients. With one twin pregnancy, there were 96 live births, 5 spontaneous abortions, 2 induced abortions, 1 stillbirth. However, the rate of small for gestational age was higher in WWAE, Apgar score at 5 min was lower in infants of WWAE, and the need for care in the neonatal ward and neonatal intensive care was higher. Seven of 103 exposed pregnancies had a major congenital malformation (6.79%), all 7 were exposed to other antiepileptic drugs. Generalized epilepsy accounted for 57.2%. CONCLUSION: Pregnancy course is uncomplicated and neonatal outcome is good in the majority of women with active epilepsy with proper antenatal and neurologic care. Levetiracetam taken in monotherapy can be considered as safer alternative for women with epilepsy of childbearing age. Long-term follow-up of neuropsychological and cognitive development of the children of WWAE is still needed.

Etiological and Radiological Spectrum of Longitudinal Myelitis: A Hospital-Based Study in North East India.

Introduction An inflammatory lesion of the spinal cord where three or more than three vertebral segments of the cord is involved is called longitudinal extensive myelitis (LETM). It has several varied causes out of which neuromyelitis optica (NMO) and its spectrum disorder have received a distinct entity. Various radiological and clinical features help us to suspect an etiology which then further guides us into the treatment protocol and prognosis of the patients. Materials and Methods A retrospective study performed in a referral center in North East India in 15 months. Thirty-two patients of LETM were enrolled based on clinical and radiological available data. An attempt was made to classify the various etiologies and correlate with their radiological findings. Results The most common etiology noted was NMO seen in 7 patients (21.8%) followed by tuberculosis (TB) (18.7%) and post-infection myelitis (18.7%). Other etiology seen was acute disseminated encephalomyelitis (6.24%), spinal cord infarct (3.12%), radiation myelitis (6.24%), Japanese encephalitis sequalae (3.12%), systemic lupus erythematosus (3.12%), and remained undiagnosed in six patients (18.7%). Radiologically, cervico-dorsal spine was most common location in NMO (71%) whereas dorsolumbar in TB (50%). The lesion was predominantly central in both NMO (100%) and TB (80%) as compared with the other causes of LETM. It was noted that more than 50% of the transverse area of the cord was involved in both NMO (71%) and TB (50%), but < 50% involvement were more common in the post-infectious and others causes of LETM. Conclusion LETM has a various differential diagnosis, infection need to be kept in mind while ruling out NMO. Radiological features can suggest or help differentiate the various etiologies of LETM but NMO and infection like TB almost has the same features except for a different cord site predilection.

Blast crisis of chronic myeloid leukemia initially presenting as severe acute intracerebral hemorrhage.

Intracerebral hemorrhage (ICH) is frequent pathology in emergency department. Coagulopathy leading to ICH are rare. Intracerebral hemorrhage is a leading cause of mortality among patients diagnosed with chronic myelogenous leukemia (CML). In this report we discussed the case of a previously healthy male patient, who presented with fatal ICH, newly diagnosed with blast crisis in CML.

General paresis of insane: A forgotten entity.

The manifestations of CNS syphilis are unfamiliar to a differential of patients with dementia to many physicians today as of the relative rarity of this condition. This is a classical case report of a patient with syphilis and dementia in a 55-year-old female. General paresis of insane is a progressive disease of the brain leading to mental and physical worsening. It is important to consider tertiary syphilis in the differential diagnosis of dementia. Conventional presentations of neurosyphilis such as tabes dorsalis and general paresis of insane are read in textbooks only and rarely encountered in clinical practice in the 21st century.

An audit of cerebral venous thrombosis associated with pregnancy and puerperium in teaching hospital in North Eastern India.

BACKGROUND AND PURPOSE: Cerebral venous thrombosis (CVT) is characterized by its clinical pleomorphism and pathogenetic variability. We studied 87 patients with CVT associated with pregnancy, and puerperium to find clinical profile, neuroradiological presentation and prognosis. METHODS: A retrospective analysis was conducted based on clinical records at our institute between June 2008 and June 2018 without any personally identifying information. The diagnosis of CVT was confirmed by magnetic resonance imaging, angiography, or neuropathological study. RESULTS: Among 87 patients, there were 82 of CVT associated with puerperium and 5 during pregnancy. Fifty-five women were multiparous. Cesarean delivery, hypertension, and anemia were strongly and significantly associated with CVT. Final outcome was considered good with anticoagulation; mortality rate was 10.34%. CONCLUSION: CVT associated with pregnancy, and puerperium is not an uncommon entity and has acute onset and a better prognosis. Pregnancy-related hypertension and Cesarean delivery and anemia are important risk factors for CVT. Further studies are needed to evaluate the need for therapeutic strategies for patients with CVT during pregnancy and puerperium.

Cortical Laminar Necrosis as a Presenting Manifestation of Migraine in an Apparently Normal Patient: A Rare Case Report.

We present a 27-year-old female, a known case of classical migraine headache, who had a severe episode of migraine with visual aura attack which continued late into night. The next morning, she had persistent headache and developed abrupt onset of dysarthria and right hemiparesthesias. She attributed symptoms to her long-lasting headache problem and hence did not seek medical help for the next 2 weeks. The symptoms persisted despite her headache subsiding over the next 36 hours. Her condition worsened 2 weeks later during another such episode of headache. This time she developed right hemiparesis, right hemihypoesthesia, and brief and autolimited left-clonic facial movements. Extensive neurological workup done to rule out other known causes of cerebral infarct with cortical laminar necrosis (CLN) was unrevealing. Magnetic resonance imaging of the brain showed left frontoparietal T2-/T1-/fluid-attenuated inversion recovery hyperintensity without diffusion restriction in diffusion-weighted imaging and subtle blooming in gradient recalled-echo and was radiologically compatible with cortical laminar necrosis. The patient improved with antiplatelets, antimigraine prophylaxis, and stroke rehabilitation therapy. Our present case is a unique one where CLN can be associated with cerebral ischemic infarct due to migrainous etiology.

Hashimoto's encephalopathy in a pregnant female: A diagnosis in disguise.

While Hashimoto's encephalopathy (HE) is quite rare, it is also likely that there are many more undiagnosed sufferers. Because it is little known and its symptoms are primarily neurological, it is easy to misdiagnose or overlook and the symptoms frequently lead to mistaken neurological diagnoses. We report a case of a 21-year-old female diagnosed with HE at 6 months of gestation. She was successfully treated. HE is a neuropsychiatric disorder of exclusion. As a good response can be obtained with corticosteroid therapy, early diagnosis and treatment is very beneficial for patients. To the best of our knowledge, there is no such report in the literature.

Cervical Myelopathy after High-voltage Electrical Burn of the Head: Report of an Unusual Case.

High-voltage electrical injuries are uncommonly reported and may predispose to both immediate and delayed neurologic complications. We present a case of 27-year-old male who experienced a high-voltage electrical burn of the head resulting in quadriparesis. High-voltage electrocution injuries are a serious problem with potential for immediate, delayed, and long-term neurologic sequelae. The existing literature regarding effective treatment of neurologic complications is limited. Multidisciplinary management and long-term follow up are required.

A Hospital-Based Study of Stroke in Young from North East India.

INTRODUCTION: A study of stroke among young adults and children has recently become a subject of interest. This is because it has a major impact on the individual and society. Studies of stroke in young can lead to therapeutical results affecting both short- and long-term outcomes. METHODS: This paper is based on a hospital-based retrospective study, of stroke in young, for a duration of 1 year. RESULTS: The study revealed stroke in young in 31.38% of all strokes, with cerebral infarction in 50.66%, followed by intracerebral hemorrhage in 41.33%, subarachnoid hemorrhage in 4.66%, and cerebral venous thrombosis in 3.33%. The most common presenting symptom was hemiparesis. The most prevalent risk factor for stroke in young was alcohol consumption, followed by traditional risk factors such as hypertension and smoking. Diabetes was detected less in our study. CONCLUSION: Although traditional risk factors are associated with stroke in young, unfavorable behavioral pattern such as alcohol abuse may cause and promote development stroke in young.

Guillain-Barré syndrome complicating pregnancy and correlation with maternal and fetal outcome in North Eastern India: A retrospective study.

BACKGROUND: Guillain-Barré syndrome (GBS) is rare in pregnancy with an estimated incidence between 1.2 and 1.9 cases per 100,000 people annually, and it is generally accepted that it carries a high maternal risk. Most reports of GBS with pregnancy are case reports only. AIM: Purpose of this retrospective study was to find the correlation between pregnancy and GBS. SETTINGS AND DESIGN: Records of patients admitted in neurology division were analyzed in a tertiary care teaching hospital in the northeastern Indian pregnant female population with GBS between 15-49 years during the period of 2009-2013. MATERIALS AND METHODS: We analyzed the records of 47 patients with pregnancy and GBS, evaluated and treated in our institute from August 2009 to December 2013. This is retrospective observational study done in North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), India. RESULT: Predominant form of GBS was acute inflammatory demyelinating polyneuropathy (AIDP). The weakness started from the lower limbs in majority of patients. Ten percent of women had bifacial weakness. Most of patients had good maternal and fetal outcome. Two patients received intravenous immunoglobulin (IVIG). Only two patient required ventilator supports and one patient had intrauterine death (IUD) and died due to respiratory failure. CONCLUSION: Our results indicate that risk of GBS increases in third trimester and first 2 weeks after delivery. Demyelinating variety of GBS was common in our population. GBS natural course during pregnancy is mild and showed quick recovery. Maternal and perinatal outcome was good.

Directly observed treatment, short course in tuberculous meningitis: Indian perspective.

BACKGROUND: Effectiveness of intermittent short course chemotherapy for tuberculous meningitis (TBM) has not been well studied. There are scarce reported studies on this issue in the world literature. Neurologists all over India are reluctant to accept Directly Observed Treatment Short course (DOTS) for TBM since its introduction in India. AIM: We did a prospective study to assess effectiveness of Revised National TB Control Program (RNTCP-DOTS) regimes among TBM patients. MATERIALS AND METHODS: In this study we include the TBM patients admitted from September 2008 to March 2011. All were referred to RNTCP for treatment. Diagnostic Algorithm as per RNTCP guidelines was strictly followed and treatment outcome and follow-up status were recorded. We exclude HIV and pediatric age group. RESULTS: A total of 42 cases registered for DOTS regimen were included in the study, of which 35 completed the treatment (83%). All the patients were started with DOTS but finally 78% received actual DOTS. All patients were given 9 months intermitted regimen as per RNTCP guidelines. Seven patients died during the treatment (16%). CONCLUSION: We found intermitted short course chemotherapy was effective in TBM.

An undiagnosed myasthenia gravis presenting as isolated recurrent acute respiratory failure.

Acute respiratory failure is an uncommon initial presentation of myasthenia gravis (MG). In our case a 22-year-old woman of unrecognized MG presented to the emergency department with isolated respiratory failure as the first presenting symptom. Initially she presented with dysphonia and was managed by speech therapist and ENT surgeons for 3 months. Subsequently, she presented with signs and symptoms of sepsis and went into acute respiratory failure. This case highlights the need to consider MG in the differential diagnosis of an otherwise unexplained respiratory failure in the critical care setting.

Bio-repository of DNA in stroke: a study protocol of three ancestral populations.

Stroke is a leading cause of death and disability in the world. Identifying the genes underlying stroke risk may help us to improve our understanding of the mechanisms that cause stroke and also identify novel therapeutic targets. To have sufficient power to disentangle the genetic component of stroke, large-scale highly phenotyped DNA repositories are necessary. The BRAINS (Bio-repository of DNA in stroke) study aims to recruit subjects with all subtypes of stroke as well as controls from UK, India, Sri Lanka and Qatar. BRAINS-UK will include 1500 stroke patients of European ancestry as well as British South Asians. BRAINS-South Asia aims to recruit 3000 stroke subjects and 3000 controls from across India and Sri Lanka. BRAINS-Middle East aims to enrol 1500 stroke patients from Qatar. The controls for BRAINS-Middle East will be recruited from a population-based Qatari Biobank. With the addition of new recruitment centres in India and Qatar, we present an updated version of the BRAINS study protocol. This is the first international DNA biobank for stroke patients and controls from the Middle East. By investigating the influence of genetic factors on stroke risk in European, South Asian and Middle Eastern populations, BRAINS has the potential to improve our understanding of genetic differences between these groups and may lead to new population-specific therapeutic targets.