Bilateral Carotid-Cavernous Fistula: A Diagnostic and Therapeutic Challenge.

Carotid-cavernous fistula (CCF) is an aberrant communication between the main trunk or branches of carotid artery and the cavernous sinus. Most of the cases of CCF occur following head trauma, but congenital and spontaneous cases have been reported. We report an interesting case of bilateral CCF with no history of trauma, thus most likely spontaneous form. Since it is rare, it was a diagnostic challenge. The suspicion of this diagnosis was made due to clinical features of headache, signs of increased Intracranial Pressure (ICP) (nausea, vomiting, and worsening headaches during Valsalva), exophthalmos, periorbital edema, periorbital erythema, chemosis, and conjunctival injection in both eyes. It was diagnosed with a 4-vessel angiography (digital subtraction angiography) which is the gold standard and was managed successfully with endovascular coil embolization.

Spectrum of Hemorrhagic Encephalitis in COVID-19 Patients: A Case Series and Review.

Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is an ongoing pandemic that has affected over 400 million people worldwide and caused nearly 6 million deaths. Hemorrhagic encephalitis is an uncommon but serious complication of COVID-19. The etiology of this disease is multifactorial, including secondary to severe hypoxemia, systemic inflammation, direct viral invasion, hypercoagulability, etc. The clinical spectrum of COVID-19-related hemorrhagic encephalitis is also varied, ranging from leukoencephalopathy with microhemorrhage, acute necrotizing hemorrhagic encephalitis (ANHE) involving the cortex, basal ganglia, rarely brain stem and cervical spine, hemorrhagic posterior reversible encephalopathy syndrome (PRES) to superimposed co-infection with other organisms. We report a case series of three young patients with different presentations of hemorrhagic encephalitis after COVID-19 infection and a review of the literature. One patient had self-limiting ANHE in the setting of mild COVID-19 systemic illness. The second patient had self-limiting leukoencephalopathy with microhemorrhages in the setting of severe systemic diseases and ARDS, and clinically improved with the resolution of systemic illness. Both patients were healthy and did not have any premorbid conditions. The third patient with poorly controlled diabetes and hypertension had severe systemic illness with neurological involvement including multiple ischemic strokes, basal meningitis, hemorrhagic encephalitis with pathological evidence of cerebral mucormycosis, and Epstein-Barr virus coinfection, and improved after antifungal therapy.

A Study on the Safety of Percutaneous Tracheostomy in Patients with Severe Acute Respiratory Syndrome Novel Corona Virus 2 (SARS-nCoV2) Infection: A Single-Center Observational Cohort Study in a CoVID Intensive Care Unit.

BACKGROUND: We studied the safety of percutaneous dilatational tracheostomy (PCDT) in severe acute respiratory syndrome novel coronavirus 2 (SARS-nCoV2). PATIENTS AND METHODS: From 01 March 20 to 30 November 2020, 1635 required hospital admission of which 145 (9%) required intensive (ICU) care. The primary outcomes are mortality and secondary outcomes were duration of invasive mechanical ventilation (IMV), length of stay (LOS) in ICU and hospital, and days required for decannulation. RESULTS: Out of the 145 (9%), 107 (73.7%) were males (mean 61.4 years, median body mass index (BMI) of 28.2 kg/m2), and 38 (26.2%) were females (mean 58.10 years, median BMI of 31.2 kg/m2). In the cohort of 80 (55.17%) requiring IMV, 19 (23.7%) died within 72 hours and were not included in the study, 37 (group "NT") and 24 (group "T") had a median duration of ventilation of 9 d (IQR, 6-11) and 12 d (IQR, 11-17.25) respectively. Patients in group "T" underwent PCDT based on clinical criteria (fraction of inspired oxygen (FiO2) of ≤ 50% with positive end-expiratory pressure (PEEP) of ≤ 10 cms of H2O with stable hemodynamics), and 16 (66.7%) had survived. The reverse transcription-polymerase chain reaction (RT-PCR) does not need to be negative, and none of the health care workers (HCW's) were infected. The Cox-hazard ratio [HR] is 0.19, 95% confidence interval [CI] (0.09, 0.41) with a P-value of <0.001, 83 (57.2%) were discharged with a mortality of 42.8%. CONCLUSIONS: PCDT is safe and effective in patients anticipated in need of prolonged mechanical ventilation.

Restoring the voids of voices by signs and gestures, in dentistry: A cross-sectional study.

AIMS: To help dentists to communicate with the hearing impaired patients, reach an accurate diagnosis and explain the treatment plan by learning some signs and gestures used in the nonverbal communication (NVC) and by devising some new signs and gestures related to dentistry which shall be easy to learn and understand both by the hearing impaired patients and the dentists. SETTINGS AND DESIGN: The study was carried out on 100 hearing impaired students in the age group of 10-14 years in two special schools for hearing impaired children located in two different states of India, where different spoken languages and different sign languages are used. One dentist (expert dentist) was trained in the NVC and the other dentist (non expert dentist) had no knowledge of this type of communication, communicated the same sets of statements related to dentistry, to the hearing impaired children. One1 translator was assigned to judge their interactions. Students were asked to tell the interpreter at the end of each signed interaction what they understood from the statement conveyed to them by both the dentists. STATISTICAL ANALYSIS USED: All data collected were subjected to statistical analysis using Chi-square test and odds ratio test. RESULTS: In the special school of 1st state, the nonexpert dentist conveyed only 36.3% of the information correctly to the students, whereas the expert dentist conveyed 83% of the information correctly. In the special school of 2nd state, the nonexpert dentist conveyed only 37.5% of the information correctly to the students, whereas the expert dentist conveyed 80.3% of the information correctly. CONCLUSIONS: Dentists should be made aware of the NVC and signs and gestures related to dentistry should be taught to the hearing impaired students as well as the dental students.

Functional connectivity changes in the language network during stroke recovery.

OBJECTIVE: Several neuroimaging studies have examined language reorganization in stroke patients with aphasia. However, few studies have examined language reorganization in stroke patients without aphasia. Here, we investigated functional connectivity (FC) changes after stroke in the language network using resting-state fMRI and performance on a verbal fluency (VF) task in patients without clinically documented language deficits. METHODS: Early-stage ischemic stroke patients (N = 26) (average 5 days from onset), 14 of whom were tested at a later stage (average 4.5 months from onset), 26 age-matched healthy control subjects (HCs), and 12 patients with cerebrovascular risk factors (patients at risk, PR) participated in this study. We examined FC of the language network with 23 seed regions based on a previous study. We evaluated patients' behavioral performance on a VF task and correlation between brain resting-state FC (rsFC) and behavior. RESULTS: Compared to HCs, early stroke patients showed significantly decreased rsFC in the language network but no difference with respect to PR. Early stroke patients showed significant differences in performance on the VF task compared to HCs but not PR. Late-stage patients compared to HCs and PR showed no differences in brain rsFC in the language network and significantly stronger connections compared to early-stage patients. Behavioral differences persisted in the late stage compared to HCs. Change in specific connection strengths correlated with changes in behavior from early to late stage. CONCLUSIONS: These results show decreased rsFC in the language network and verbal fluency deficits in early stroke patients without clinically documented language deficits.

Hospital prenotification of stroke patients by emergency medical services improves stroke time targets.

BACKGROUND: Prenotification to hospitals by emergency medical services of patients with suspected stroke is recommended to reduce delays in time-dependent therapies. We hypothesized that hospital prenotification would reduce recommended stroke time targets. METHODS: We used the Robert Wood Johnson University Hospital (RWJUH) Brain Attack Database, which includes demographic and clinical data on all emergency department (ED) patients alerted as a Brain Attack between January 1, 2009 and June 30, 2010. Outcome variables included the time from door to stroke team arrival, computed tomographic (CT) scan completion, CT scan interpretation, electrocardiogram, laboratory results, treatment decision, and intravenous (IV) tissue plasminogen activator (tPA) administration. The primary independent variable was brain attack activation before arrival to the emergency department (ED; prenotification) versus on or after ED arrival (no prenotification). Analysis of covariance was used with patient predictors as covariates in addition to the one of interest (prenotification vs no prenotification). P ≤ .05 was considered statistically significant. RESULTS: There were 229 patients (114 prenotification and 115 no prenotification) alerted as having a brain attack within the study period. Patients with prehospital notification were older (69.5 years vs 61.5 years; P = .0002), had more severe strokes (National Institutes of Health Stroke Scale score of 11.1 vs 6.9; P < .0001), and received IV tPA twice as often (27% vs 15%; P = .024). Prenotification resulted in a significant reduction in all stroke time targets except door to treatment decision and tPA administration. CONCLUSIONS: Prehospital notification of suspected stroke patients reduces time to stroke team arrival, CT scan completion, and CT scan interpretation. IV thrombolysis occurred twice as often in the prenotification group.

Lacosamide-induced second-degree atrioventricular block in a patient with partial epilepsy.

Dose-dependent PR interval prolongation has been reported in preclinical studies of lacosamide (LCM), a recently U.S. Food and Drug Administration (FDA)-approved antiepileptic drug (AED). Here we report a case of second-degree atrioventricular block (AV) block caused by the addition of LCM to other AEDs known to prolong the PR interval, resulting in hypotension and bradycardia, with consequent seizure exacerbation. The patient recovered completely after withdrawal of LCM. This case demonstrates the need for caution and interval cardiac testing when adding LCM to other AEDs known to prolong the PR interval.