Chronic Pregabalin Abuse with Subacute Encephalopathy Mimicking Autoimmune Encephalitis.

Pregabalin, a gabapentinoid frequently prescribed for neuropathic pain, also increasingly identified as a drug for abuse. We describe a unique case of 31-year-old man presented with subacute neuro-psychiatric symptoms and a spectrum of movement disorders, suspicious of autoimmune encephalitis. Initial response to IV methylprednisolone followed by recurrence of symptoms strengthened our suspicion for autoimmune encephalitis. His autoimmune encephalitis workup was negative, however, his two MRIs showed parenchymal changes. The patient, finally, confessed to chronic pregabalin abuse. He recovered completely upon stopping pregabalin abuse and remained asymptomatic at follow-up. To the best of our knowledge, we are the first to describe parenchymal changes in MRI mimicking autoimmune encephalitis in a case of pregabalin abuse. Despite the limited number of reports of pregabalin abuse in India, it is time to consider restricting the pregabalin availability, in line with many Western countries. This is particularly relevant to India, where, one legitimate prescription can be used by many to buy medicines at multiple stores without any questions being asked by the pharmacists.

Penetrating Injury to Cauda Equina from a Missile Fragment, Completely Recovered after Delayed Surgical Removal of Ballistic Fragment.

Penetrating injuries to cauda equina due to missile fragment are rare. The mechanism of injury may be more complex due to thermal effect of missile fragment, apart from mechanisms described in penetrating gunshot injuries or stab injuries. We report a case of a 42-year-old male with penetrating missile injury to cauda equina, improved completely after delayed surgical exploration and removal of ballistic fragment. Furthermore, his bowel and bladder dysfunction improved completely within 1 week of neurosurgical exploration. Although early neurosurgical intervention is recommended for penetrating injuries of the cauda equina, delayed intervention may also be beneficial in selected patients. Computed tomography (CT) scan and CT myelogram are extremely useful in surgical planning when magnetic resonance imaging contraindicated due to impregnated metal fragments.

Chiari I Malformation Associated with Turner Syndrome.

Turner syndrome (TS) is a rare genetic disease due to the absence of one X chromosome. Patients with TS have more subtle neurological/neuropsychiatric problems, while headache is an uncommon clinical presentation which needs attention. We report a 12-year-old child presenting with typical cough headache. Her magnetic resonance imaging revealed Chiari I malformation associated with TS. To the best of our knowledge, Chiari I malformation associated with TS is not described in literature. We report the first case of TS associated with Chiari I malformation. Interestingly, Chiari I malformation is also associated with Noonan's syndrome, which is a close morphological mimicker of TS, raising the possibility of sharing similar pathogenesis in both conditions.

Successful Endovascular Neurosurgical Practice in Resource-poor Exclusive Rural Neuro-hospital Setup.

AIM: The aim of this study to evaluate the feasibility of establishing endovascular neurosurgery in remote resource-poor neuro-hospital setup and evaluate its outcome. MATERIALS AND METHODS: Retrospective analysis of diagnostic and therapeutic endovascular neurosurgical procedures performed during September 2013-June 2016. RESULTS: A total of 174 diagnostic cerebral and spinal digital subtraction angiograms and 70 major endovascular neurosurgeries were performed during the period. The endovascular neurosurgical procedures included 54 aneurysms coiled, 4 cerebral arteriovenous malformation embolization, 2 dural arteriovenous fistulas embolization, 2 cerebral tumor embolizations, 2 intracranial stentings, 5 extracranial carotid stentings, 1 transverse sinus stenting. No complications were seen during diagnostic procedures. Operation related morbidity of 1.4% and mortality of 1.4% seen, with a procedural success rate of 97.2%. CONCLUSION: Endovascular neurosurgery is feasible in resource-poor remote rural exclusive neuro-hospital setup with procedural success rate and outcomes comparable to existing literature.

Susceptibility-weighted imaging in carotido-cavernous fistulas. A case control study.

This study determined the utility and accuracy of susceptibility-weighted MRI (SWI) for the detection of carotid cavernous fistulas. We retrospectively compared SWI images in nine patients (Group 1, case group) of DSA-proved carotid cavernous fistula (CCF) and 19 DSA negative cases for CCF as a control group (Group 2). Group 1 was again sub-grouped into direct and indirect types. Using uniform region-of-interest measurements, signal intensity within the superior ophthalmic vein (SOV) and the superior sagittal sinus (SSS) were measured on magnitude images of SWI. The SOV/SSS signal intensity ratio was calculated in each case and the mean values of the two groups were compared. Eleven SOV/SSS signal intensity ratios in Group 1 (7 unilateral and two bilateral CCF), 38 in Group 2 (both sides in 19 control subjects) were included. Median ± interquartile range of SOV/SSS ratios for Group 1, Group 2, indirect and direct type CCFs were 1.07 ± 0.43, 0.39 ± 0.23, 0.83 ±0.29, 1.4 ±0.38 respectively. Mann-Whitney test between Groups 1 and 2 was statistically significant with P<0.0001. All cases and controls were reliably distinguished with SOV/SSS signal intensity ratio of 0.64 as cut-off. Direct CCF cases had consistently higher ratios than indirect CCF. SWI was highly sensitive for detection and differentiation of both direct and indirect CCF. Only one case of corticovenous reflux was missed by SWI. SWI is useful for detection of CCF and to differentiate between direct and indirect CCF.

Imaging of vascular causes of trigeminal neuralgia.

Trigeminal neuralgia (TN) is a neuropathic disorder associated with severe recurrent episodic facial pain affecting predominantly elderly people. Though medical management is effective in pain control in first 2 years of symptom onset, many patients eventually require surgical intervention. Preoperative magnetic resonance imaging (MRI) evaluation of posterior fossa helps to identify major etiologies for TN. Neurovascular conflict is a common cause of TN. MRI is unique in imaging entire course of the trigeminal nerve, cisternal segment in particular. Microvascular decompressive (MVD) surgery is a safe and effective method for relieving neuralgic pain in neurovascular conflicts. We described vascular causes of TN, MR sequences useful in imaging of trigeminal nerve, the various vascular etiological possibilities, factors to be mentioned in MRI report.