MRI outcomes in patients with acute-onset vertigo in the emergency department - A prospective study.

INTRODUCTION: Vertigo is an abnormal sensation of motion which arises due to a mismatch between various sensory modalities involved in maintaining balance. Vertigo can be due to central or peripheral causes and intensely debilitating for some patients. Acute onset vertigo is defined as the commencement of vertigo within 24 h. This can present with a variety of overlapping symptoms, making it difficult to distinguish central from peripheral causes. In the emergency setting, mis-diagnosing acute onset vertigo as benign may have serious implications. METHODS: This prospective study included consecutive patients presenting to our Emergency Department with acute vertigo between March 2019 and March 2020. We aimed to evaluate and validate the utility of magnetic resonance imaging (MRI) of the brain among patients with acute onset vertigo. RESULTS: A total of 70 patients with acute onset vertigo were recruited. MRI of the brain revealed acute changes in 23 (32.9%) out of the 70 patients included in the study. Even among the 29 (41.4%) patients who presented with isolated vertigo without any other clinical signs, MRI of the brain showed acute changes in 3 (10.3%) of them. CONCLUSION: MRI is a useful tool in diagnosing and differentiating peripheral from a central cause of vertigo. It avoids misdiagnosis in the emergency setting and facilitates early administration of appropriate treatment.

A rare cause of median neuropathy at the carpal tunnel: Thrombosis of the persistent median artery.

Carpal tunnel syndrome is a common peripheral nerve entrapment neuropathy caused due to compression of the median nerve at the level of the wrist joint. Bifid median nerve associated with a persistent median artery is a rare entity and in itself asymptomatic anatomical variant. However, distension of the persistent median artery due to a thrombus can be symptomatic due to compression on the median nerve and can compromise the blood flow to the palm. We report a case of persistent median artery thrombosis in a young female patient who presented with symptoms of carpal tunnel syndrome diagnosed on the ultrasonography and confirmed on the MRI with subsequent improvement post anticoagulation therapy.

Initial clinical and radiological findings in patients with SSPE: are they predictive of neurological outcome after 6 months of follow-up?

Subacute sclerosing panencephalitis (SSPE) is a progressive, devastating neurologic disorder caused by mutant measles virus. In this study we evaluated the prognostic value of neuroimaging abnormalities in SSPE. Thirty consecutive patients with SSPE were included. Diagnosis of SSPE was based on the criteria described by Dyken. Patients were followed for 6 months. Neuroimaging studies were performed at inclusion and after 6 months. Regression or progression of the disease was defined as a change of one, or more than one, stage in Jabbour's staging system. Degree of disability was assessed using the modified Rankin scale (mRS) score. Neuroimaging abnormalities were seen in 27 patients. Dominant imaging abnormalities were cerebral atrophy, white matter signal changes, cortical grey matter abnormalities and signal change in the basal ganglia. After 6 months of follow-up, 18 (60%) patients had a poor outcome (mRS score: 3-6); one patient died. The remaining 12 patients (40%) had a stabilized clinical condition (mRS score: 0-2). On univariate analysis, predictors of death or disability were: poor mRS score at baseline (p = 0.003) and Jabbour's clinical stage III (p = 0.019). None of the neuroimaging abnormalities were associated with a poor prognosis or clinical deterioration (p > 0.05). We conclude that we did not observe any association between cerebral neuroimaging at baseline and neurological outcome after 6 months in patients with SSPE.

Intracranial tuberculomas in patients with tuberculous meningitis: predictors and prognostic significance.

SETTING: Intracranial tuberculomas are commonly observed neuroimaging abnormalities in tuberculous meningitis (TBM). OBJECTIVE: to evaluate the predictors and prognostic significance of tuberculomas in patients with TBM. DESIGN: In a retrospective follow-up study, contrast-enhanced magnetic resonance imaging was performed at study inclusion and after 9 months of follow-up. Univariate analysis and multivariate analysis were used to identify predictive factors for tuberculoma. Prognosis (death and severe disability) was assessed using the modified Rankin scale. RESULTS: At inclusion, 43 of 110 patients had cerebral tuberculomas. Seven patients developed paradoxical tuberculomas. Predictors of tuberculomas were raised cerebrospinal fluid (CSF) protein (>3 g/l) and meningeal enhancement. Multivariate analysis did not show any significant predictors. During follow-up, the only significant predictor of paradoxical development of tuberculomas was raised CSF protein (>3 g/l). After 9 months of follow-up, 32 patients had died or had severe disability. Survival analysis revealed that patients with tuberculomas and those without tuberculomas had a similar prognosis. CONCLUSION: Tuberculomas occurred in approximately 39% of the patients with TBM. Significant predictors were meningeal enhancement and raised CSF protein. TBM patients with or without tuberculomas had a similar prognosis.

An unusual case of Takayasu's arteritis: Evaluation by CT angiography.

Takayasu's arteritis is a chronic, idiopathic, medium and large vessel vasculitis involving aorta and its main branches. Frequent neurological manifestations include postural syncope, seizures, and blindness. Stroke, as presenting feature of Takayasu's arteritis, is unusual. CT angiography reveals characteristic involvement of aortic arch and its branches. Involvement of intracranial vasculature is rather unusual. We are describing an unusual patient of Takayasu's arteritis who presented with recurrent disabling syncopal attacks and had extensive involvement of intracranial vasculature. CT angiography revealed severe involvement of aortic arch. There was near complete occlusion at origins of both subclavian arteries, distal flow was maintained by collateral vessels along the chest wall. There was near total occlusion (at origin) of right common carotid with normal flow in distal part. The left common carotid was more severely involved showing greater than 80% narrowing in proximal half of the vessel. CT angiography also revealed involvement of left internal carotid artery, narrowing of left middle cerebral artery and involvement of cortical vessels. Patient was treated with oral corticosteroids. She improved remarkably after two and half months of follow up.

Predictors of stroke in patients of tuberculous meningitis and its effect on the outcome.

BACKGROUND: Stroke is a devastating complication of tuberculous meningitis and is an important determinant of its outcome. AIM: To prospectively evaluate the predictive factors for stroke in patients with tuberculous meningitis and to assess the impact of stroke on the overall prognosis and outcome. METHODS: We evaluated and followed 100 patients of tuberculous meningitis for 6 months. Magnetic resonance imaging was performed at inclusion and after 6 months. We evaluated the predictors of stroke and also assessed the effect of stroke on the outcome. Outcome was defined with the help of modified Rankin scale. RESULTS: Of the 100 patients, 6 lost to follow-up. Thirty patients had stroke, 27 of them had stroke at inclusion. Three patients developed stroke during follow-up. In most of the patients, stroke was a manifestation of advanced stages of tuberculous meningitis. Internal capsule/basal ganglia were the most frequently involved sites. Infarcts commonly involved the middle cerebral arterial territory. On univariate analysis, predictors of stroke were aged >25 years (P < 0.001), cranial nerve involvement (P < 0.001), sylvian fissure exudates (P = 0.026), posterior fossa exudates (P = 0.016), optic chiasmal exudates (P = 0.04) and vision impairment (P = 0.004). Stage III tuberculous meningitis (P < 0.001) was also a predictor of stroke. On multivariate analysis aged >25 years was found a significant predictor of stroke. Strokes in patients with tuberculous meningitis were associated with poor prognosis. CONCLUSION: Stroke occurred in 30% of cases with tuberculous meningitis. Advanced stage of tuberculous meningitis, basal exudates, optochiasmatic arachnoiditis and vision impairment were significant predictors of stroke. Stroke independently predicted the poor outcome of tuberculous meningitis.

Paradoxical vision loss associated with optochiasmatic tuberculoma in tuberculous meningitis: a report of 8 patients.

BACKGROUND: Paradoxical appearance of new or expansion of existing optochiasmatic tuberculoma, leading to severe vision loss, is a devastating complication in patient with tuberculous meningitis. METHODS: We report a series of 8 cases of tuberculous meningitis that developed paradoxical vision loss associated with optochiasmatic tuberculoma. Clinical assessment and magnetic resonance imaging (MRI) done at presentation, at the time of deterioration, and at 9 months were analyzed. RESULTS: All patients had good vision acuity and normal visual field at baseline. None of them had optochiasmatic tuberculoma on magnetic resonance imaging at baseline, though 3 patients had optochiasmatic arachnoiditis. The mean interval of onset of paradoxical optochiasmatic tuberculoma was 41 days after starting antituberculosis therapy. Paradoxical optochiasmatic tuberculoma was associated with vision deterioration in all patients, 6 of whom developed severe vision loss (vision acuity