Diagnostic challenges in neoplastic meningitis presenting as intracranial hypertension.

A diagnosis of idiopathic intracranial hypertension should be considered only after careful exclusion of all possible aetiologies. We report a case of neoplastic meningitis presenting as intracranial hypertension with inconclusive repeated cerebrospinal fluid (CSF) cytology and MRI of brain, emphasising the importance of meticulous CSF analysis and role of early whole-body PET-CT scan for diagnosis of systemic malignancy.

Does Tc-99m ECD ictal brain SPECT have incremental value in localization of epileptogenic zone and predicting postoperative seizure freedom in cases with discordant video electroencephalogram and MRI findings?

OBJECTIVE: Localization of epileptogenic focus in drug-refractory epilepsy using Tc-99m ethylene cystine dimer (ECD) brain single photon emission computed tomography (SPECT) is less studied in patients with discordant findings on video electroencephalogram (VEEG) and MRI. The study was done to evaluate brain SPECT for epileptogenic focus localization and postoperative seizure freedom. METHODS: Epilepsy patients with discordant VEEG and MRI findings underwent brain SPECT at ictal and interictal phases. Various groups unilateral/bilateral mesial temporal sclerosis (MTS), solitary and multifocal lesional, nonlesional epilepsy were studied for localization of epileptogenic focus and postoperative seizure freedom (>2 years) using Engels classification. Reasons for nonoperability was evaluated in nonoperated group. RESULTS: SPECT could localize epileptogenic focus in 49/67 (73.13%) and guided surgery in 19/33 (57.57%) patients in operated group. SPECT was useful in 12 (46.12%) of unilateral (2)/bilateral (10) MTS. Postoperative seizure freedom of Engels Class I and II in 22 (66.67%), III in six (18.2%) and IV in one patient based on SPECT findings (P = 0.0086). Overall sensitivity and specificity were 79.3% and 85.7%, respectively. SPECT could localize epileptogenic focus in 23/34 (67.64%) patients in nonoperated group; 10 (29.41%) patients refused for surgery and no epileptogenic focus was localized in the rest of 14 (41.2%). CONCLUSION: Ictal SPECT showed incremental value and was found necessary for epileptogenic focus localization and subsequent surgery in unilateral/bilateral MTS in this study. Seizure freedom in patients undergoing epilepsy surgery based on ictal SPECT assistance was comparable to the surgical group not requiring ictal SPECT.

Guidelines versus ground lines: Tuberculosis of the central nervous system.

AIM: This questionnaire-based national survey is aimed at understanding the patterns of practice of various aspects of central nervous system (CNS) tuberculosis (TB) among neurologists. SETTINGS AND DESIGN: Neurology department of a tertiary medical college. MATERIALS AND METHODS: A questionnaire was sent through email to all practicing neurologists in India. The responses were analyzed. STATISTICAL ANALYSIS: Inferential statistics. RESULTS: In all, 144 responses were received (out of the 853 questionnaires sent). The major discrepancies were in the primary antitubercular drug regimen (HRZE + HR), duration for tubercular meningitis (TBM) [12 months] and tuberculoma (12-18 months) to develop, follow-up (varied), linezolid use (varied), proportion of drug-resistant cases (<25%), and not taking histological aids (91%). The cerebrospinal fluid (CSF) TB polymerase chain reaction (PCR) utility (75%), not using CSF adenosine deaminase [ADA] (58%), the strategy to stop antitubercular drugs, and the use of steroids (77%) were according to guidelines. CONCLUSION: The present survey, for the first time, provides ground-level evidence of various aspects of CNS TB as practiced by neurologists in India. The major diversity was observed in therapeutics such as the choice of antitubercular drugs, its duration, linezolid use beyond the recommended duration, and knowledge of drug resistance. The monitoring aspects of CNS TB also showed variations. The investigational aspects of CNS TB such as using TB PCR, not using CSF ADA, and regular neuroimaging revealed a good clinical practice. Other CSF parameters require uniformity. This survey thus helps to identify areas of future work in CNS TB in India.

A systematic and quantitative evaluation of plantar stimulation: The effect of type, pattern, force of stimulation in eliciting an accurate plantar response.

OBJECTIVES: Systematic and quantitative evaluation of the plantar reflex has been infrequently studied in the past and can help assess the vexing variables encountered in its elicitation. The objective of this study was to determine the effect of type, pattern and force of stimulation in eliciting an accurate plantar response in patients with pyramidal dysfunction and healthy individuals. PATIENTS AND METHODS: A special instrument was designed to give a predesigned force of stimulus. The plantar surface of foot was divided into nine parts and point and stroke stimulations were studied systematically in pyramidal weakness feet (cases) and healthy control feet (controls) with predefined forces. Results were tabulated and statistically analysed. RESULTS: Stroke stimulation was superior to point stimulation in eliciting plantar response. There was no significant difference in the responses to the three predefined forces used for stroke stimulations. Sensitivity of Babinski sign was 72.9% and specificity was 100%. In pyramidal weakness feet, extensor responses were significantly elicited from lateral starting stroke patterns (67%) and on moving medially they were replaced by flexor responses (44%). Withdrawal responses increased with the stimulations reaching the distal foot and with the curvilinear component of stimulations. Sensitivity responses (related to the sensitivity of an individual) contaminate the plantar response and occasionally make its interpretation difficult. In subjects with bilateral sensitivity with unilateral disease, knowing the sensitivity pattern on the normal side improved the interpretation of plantar response on the abnormal side. CONCLUSIONS: Based on this study, the optimal method for eliciting Babinski sign accurately is to stroke the lateral aspect of the sole of the foot in a straight line up to mid foot. This should be performed in both feet three times, and if the weakness is unilateral, it should be performed in the normal leg first to aid interpretation of the affected leg.

Does the Tempo and Pattern of Neurological Syndrome Help Diagnose Paraneoplastic Etiology?

BACKGROUND: Paraneoplastic neurological syndromes (PNS) are defined as remote effects of cancer that are not caused by the tumor and its metastasis, or by infection, ischemia or metabolic disruptions. In most patients, the neurological disorder is the manifesting condition and cancer is not detectable clinically at that time. Hence, most often it will be upon the neurologist and not the oncologist to detect paraneoplastic syndrome. AIMS AND OBJECTIVES: To identify characteristic features of a neurological syndrome (presentation pattern and tempo of illness- onset, duration, progression and response to treatment) which indicate a paraneoplastic etiology. MATERIALS AND METHODS: This is a retrospective study. Medical records of all patients who were discharged/ died in Neurology unit of a tertiary care center over a study period of two years with a diagnosis of Paraneoplastic neurological syndrome as per the diagnostic criteria given by F Graus et al1 were studied. RESULTS: Seven PNS cases were identified of which, five had peripheral and two had central nervous system syndrome consistent with the anatomical localisation. Painful pure motor quadriparesis was present in three cases. Subacute onset and rapid progression was seen in six out of seven patients. Ill sustained response to corticosteroid treatment was seen in three patients whereas the remaining four showed no response. In five patients, tumour was detected after the diagnosis of neurological syndrome, as against one patient which had an antecedent tumour and the remaining one patient had classical onconeural antibody without evidence of any detectable tumor. Average time to tumor diagnosis from neurological symptom was 3.5 months. CONCLUSION: A subacute onset, rapidly progressive painful, pure motor quadriparesis; Ganglionopathy in elderly and autoimmune encephalitis with ill sustained or no response to corticosteroids merits consideration of paraneoplastic etiology.