Central Variant Posterior Reversible Encephalopathy Syndrome in a Pregnant Woman With Eclampsia: A Case Report.

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiological diagnosis characterized by acute or subacute neurological symptoms. A 27-year-old woman at 35 weeks of pregnancy, who presented with generalized tonic-clonic seizures had persistently low Glasgow Coma Scale (GCS) score after delivery of the baby. Magnetic Resonance Imaging (MRI) of the brain showed T-2 Fluid Attenuated Inversion Recovery (FLAIR) hyperintensities in the brainstem, bilateral medial cerebellar hemispheres, bilateral medial temporal lobes, bilateral thalami, lentiform and caudate nuclei, and bilateral fronto-parieto-occipital lobes. There was diffusion restriction in bilateral caudate nuclei, left thalamus and right frontal lobe, and microhemorrhages in the left thalamus. These findings were suggestive of central variant PRES. She improved with strict blood pressure control and anti-edema measures. A repeat MRI brain on day 10 showed significant improvement, and she had no residual neurological deficits. The central variant of PRES is a rare entity that has to be considered in a patient presenting with neurological deficits in the setting of uncontrolled blood pressure, eclampsia, immunomodulatory medication use, or renal failure. While most patients with PRES fully recover with timely therapy targeted at reversing the primary cause, some may have residual neurological deficits or rarely, die.

A Rare Variant of Meningioma: Case Report and Review of Literature.

Meningioma is a morphologically heterogeneous tumour arising from meningothelial cells that has been classified by the World Health Organization into 15 different histological types and graded into three types groups (Grade I, II, and III) based on the biological behavior. Metaplastic meningioma is a rare subtype of meningioma characterized by focal or widespread mesenchymal differentiation in the form of bone, cartilage, fat, or xanthomatous tissue elements. Xanthomatous meningioma is a subclass of metaplastic meningioma which is exceedingly rare. Only a few cases have been reported in the literature. Here, we report the case of a 44-year-old man, who presented with left sided weakness and was diagnosed as a case of xanthomatous meningioma.

Metronidazole-induced reversible cerebellar dysfunction.

A 73-year-old man who presented with fever and abdominal discomfort was diagnosed to have a liver abscess. He was treated with antimicrobials which included metronidazole. One month into treatment, he developed neurological symptoms and signs that were suggestive of cerebellar pathology. MRI of the brain showed T2/fluid attenuated inversion recovery hyperintensities involving bilateral dentate, fastigial and interpositus nuclei. After excluding common aetiologies, the possibility of metronidazole-induced neurotoxicity was considered. After stopping metronidazole, his symptoms and signs resolved. A subsequent MRI scan of the brain showed reversal of changes. Neurotoxicity caused by metronidazole is an uncommon adverse effect of a commonly used antimicrobial drug and should be considered in the appropriate clinical scenario.

Demographics, Clinical Characteristics, and Management of Idiopathic Intracranial Hypertension in Kuwait: A Single-Center Experience.

Background: Idiopathic intracranial hypertension (IIH) affects predominantly obese females during their reproductive age period. The demographics of this condition has not been studied in Kuwait before. Objectives: To determine the demographics, clinical features, risk factors, and treatment modalities of IIH in the main neurology tertiary referral hospital in Kuwait and to compare our data with literature. Methods: A retrospective study was conducted to identify cases of IIH seen between January 1, 2018, and December 31, 2018. Patients were diagnosed in and referred from the neurology and neuro-ophthalmology clinics. Results: Our cohort consisted of 139 patients. We estimated a crude annual incidence rate of IIH of 3.28 per 100,000 population. Female-to-male ratio was 9.6:1. Mean age was 32.1 ± 10.8 years. Mean age of males was 31.46 ± 12.63 and that of females was 32.11 ± 10.67. The median of the duration from the first symptoms till diagnosis was 6 weeks (2-10 weeks). Headache was the most common symptom in 134 (96.4%) patients, followed by visual disturbances in 85 (61.2%) patients, transient visual obscurations (TVOs) in 84 (60.4%) patients, pulsatile tinnitus in 72 (51.8%) patients, diplopia in 22 (15.8%) patients, other symptoms (e.g., nausea, vomiting, radicular neck, and back pain) in 19 (13.7%) patients, and 1 (0.7%) patient had facial weakness. High body mass index (BMI) was seen in 89.9% of patients, either overweight or obese, and it was the most common risk factors in both males (46.2%) and females (61.1%). Anemia was found in 38.1%; 21.6% of patients used OCPs and 7.9% used vitamin A. Bilateral transverse sinus stenosis (BTSS) was detected in 47 (33.8%) patients. Only 2 (1.4%) patients developed "fulminant IIH" characterized by rapidly progressive disease. All the patients received medical treatment and only 12 (8.6%) needed surgical management. Conclusion: Incidence of IIH in Kuwait is similar to other regional studies but higher than Western studies. Demographics and clinical features of IIH in our study are comparable to international and regional figures. Most of our patients had a benign course. IIH is more prevalent in females and strongly associated with obesity.

Worsening of myasthenia gravis after administration of injectable long-acting risperidone for treatment of schizophrenia; first case report and a call for caution.

Myasthenia gravis is an autoimmune disease characterized by muscle weakness due to autoantibodies affecting the neuromuscular junction. Co-occurrence of myasthenia gravis and schizophrenia is very rare and raises a challenge in management of both diseases. Antipsychotic drugs exhibit anticholinergic side effects and have the potentials of worsening myasthenia. Long-acting risperidone is an injectable atypical antipsychotic drug that has not been previously reported to worsen myasthenia gravis in literature. We report the first case report of worsening of myasthenia after receiving long-acting risperidone injection for schizophrenia in a 29-year-old female with both diseases. She started to have worsening 2 weeks following the first injection and her symptoms persisted despite receiving plasma exchange. This could be explained by the pharmacokinetics of the drug. We recommend that long-acting risperidone should be used with caution in patients with myasthenia gravis, and clinicians must be aware of the potential risks of this therapy.

Venous thrombosis of the brain. Retrospective review of 110 patients in Kuwait.

OBJECTIVE: To highlight the importance of neurological presentation and complications in the early diagnosis and management of cerebral venous thrombosis (CVT). METHODS: We performed a retrospective case analysis of 110 patients with CVT treated at the Neurology Center, Ibn Sina Hospital, in Kuwait from January 2000 to September 2013. The records of patients with CVT were retrieved and entered in a data sheet. The different neurological presenting signs and symptoms were analyzed based on their frequency, pathogenesis, and treatment. RESULTS: One hundred and ten (110) patients were included in this study, with a male to female ratio of 1:1.7. Neurological signs and symptoms were headache (82%), seizures (42%), and focal neurological deficits (33%). Papilledema with raised intracranial pressure was recorded in 35 patients (32%). Venous and hemorrhagic venous infarctions were recorded in 27 patients, and multiple intracerebral or subarachnoid hemorrhages in 7 patients. The venous sinuses involved were the superior sagittal sinus in 54.5%, and transverse sigmoid sinuses in 52%. CONCLUSION: Headache, seizures, and focal neurological deficits were the most common neurological presentation. Anticoagulants (systemic heparin) were used as first-line therapy, including patients with intracerebral hemorrhage. The use of steroids and osmotic diuretics as anti-edema measures were recorded in 25% of cases. Treating raised ICP by repeated lumbar puncture and CSF drain could prevent visual failure.

Unusual presentation of Guillain-Barré syndrome following traumatic bone injuries: report of two cases.

OBJECTIVE: To report two cases of Guillain-Barré syndrome (GBS) which occurred following traumatic bone injuries. PRESENTATION AND INTERVENTION: Two patients presented with traumatic bone injuries. The first was a 47-year-old female who was admitted with fracture of both tibial bones sustained during a road traffic accident. One week after surgical fixation of the fracture, she developed areflexic weakness of all four limbs and respiratory muscle weakness. The nerve conduction study was consistent with GBS. She was administered intravenous immunoglobulins which was repeated after 2 weeks. She recovered gradually. The second patient was a 31-year-old male who was admitted with 4-days history of severe back pain which occurred when he lifted a heavy weight. He then developed ascending areflexic weakness of all four limbs and bifacial weakness. X-ray and magnetic resonance imaging of the lumbosacral spine revealed fracture of L1 and L2 vertebrae. Nerve conduction studies confirmed the diagnosis of GBS. He was given mechanical ventilatory support and was treated with intravenous immunoglobulins and later plasmapheresis. However, his condition gradually deteriorated as he developed aspiration pneumonia and sepsis with multi-organ failure and finally expired. CONCLUSION: These cases highlight the importance of considering GBS as a differential diagnosis when patients with traumatic bone injuries develop acute neuromuscular weakness. Early diagnosis and treatment may prevent morbidity and mortality.

Cerebral venous thrombosis in Kuwait. Clinical presentation, risk factors, and management.

OBJECTIVE: To explore the pattern of clinical presentations, risk factors, and the sinuses involved in cases of cerebral venous thrombosis (CVT) treated in a tertiary neurological center in Kuwait. METHODS: A retrospective analysis of cases of CVT treated at Ibn Sina Hospital, Kuwait, from January 2000 to October 2010. The records of 71 patients were retrieved and entered in a database. All patients were evaluated with hypercoagulable work up and relevant neuro-imaging studies. RESULTS: Seventy-one patients were included in our study, with a male to female ratio of 1:1.5. The clinical presentations were: headache (93%), seizures (31%), and focal neurological signs (37%). Over two-thirds (n=30) of female patients had a history of oral contraceptive use. Papilledema with raised intracranial pressure was recorded in 20 patients (28%), ovarian hyper-stimulation syndrome with CVT in one patient, and possible Neuro-Behcet`s in 10% (n=7). The venous sinuses involved were superior sagittal sinus in 59% (n=42), and transverse and straight sinuses in 54% (n=38). Hemorrhagic venous infarctions were seen in 18% (n=13). Fifty percent of patients recovered within 2-4 weeks, 15 patients (21%) recovered within 4-12 weeks, and 15 patients (21%) required intensive care unit care with ventilator support for 1-2 weeks. CONCLUSION: Oral contraceptive use was the primary risk factor in female patients. Early diagnosis and immediate treatment with anticoagulants reduce the morbidity and mortality. Serum D-dimer level is more helpful for early diagnosis with sensitivity of 58%.