Association of Glycated Hemoglobin With Acute Ischemic Stroke in a Tertiary Care Center in a Tribal Region of Jharkhand.

BACKGROUND: Increased glycated hemoglobin (HbA1c) levels have shown an association with an increased risk of stroke in patients admitted to a tertiary care center in Jharkhand. OBJECTIVES: To find out and estimate the risk of acute ischemic stroke in patients with increased HbA1c levels compared with controls. METHODS: This observational case-control study was conducted on patients admitted to the department of general medicine at a tertiary care center in Ranchi from June 2021 to November 2022. The patients included in this study were those aged 18 years or older and who were clinically and radiologically diagnosed with acute ischemic stroke. Only patients with a first episode of stroke were included, and patients with hemorrhagic stroke or transient ischemic attack were excluded from this study. An equal number of control participants were also included. Ion exchange high-performance liquid chromatography was used to perform the HbA1c tests. The same method was used to measure HbA1c levels in the controls. All findings were recorded in a Microsoft Excel sheet (Microsoft Corporation, Redmond, WA), and the data were analyzed using SPSS version 22.0 software (IBM Corp., Armonk, NY). After performing a descriptive statistical analysis, the findings were classified over a range of values and described accordingly. For each variable, an independent t-test was performed to compare the cases with the controls. A multivariable logistic regression analysis was used to choose the appropriate potential factors to determine the association in the multivariable analysis. RESULTS: A total of 185 cases and 185 controls were included. The mean age of the cases with ischemic stroke was 63.77 ± 10.312, and that of the controls was 53.18 ± 11.35 (p < 0.01). The mean HbA1c level in the patients of acute ischemic stroke was 6.97 ± 1.84, and that of the controls was 5.99 ± 1.69 (p < 0.01). The mean random blood sugar (RBS) value in the ischemic stroke cases was 170.21 ± 84.16, and that of the controls was 150.03 ± 82.25 (p = 0.02). To compare the factors that were determined to be statistically significant between ischemic stroke cases and controls, a multivariable logistic regression analysis was performed. The HbA1c p-value was 0.01, the odds ratio (OR) was 1.280, and the 95% CI was 1.11-1.48. The other variables apart from HbA1c that were statistically significant between the ischemic stroke cases and the controls were age (p < 0.01, OR: 1.280, 95% CI: 1.06-1.11), hypertension (p = 0.618, OR: 1.130, 95% CI: 0.70-1.83), and high-density lipoprotein (p = 0.055, OR: 0.975, 95% CI: 0.95-1.00). When other cofounders were considered, it was concluded that with a 1% increase in HbA1c, the risk of stroke increases by 28% (OR: 1.28, 95% CI: 1.11-1.48). To compare the variables that were determined to be statistically significant between the control and ischemic stroke case groups, a multivariable logistic regression was used. The area under the receiver operating characteristic curve for HbA1c was 0.773 and RBS was 0.600. CONCLUSION: This study shows that higher HbA1c levels in patients increase the risk of ischemic stroke. This study brings to light the need to screen the population periodically for diabetes by routinely testing for Hba1c in those who are at high risk of diabetes. Stroke risk can be reduced with early management and intervention. This study also concludes that HbA1c is a better predictor for assessing the risk of ischemic stroke than RBS levels.

Post-Traumatic Headache is Associated with Worse Anxiety and Mood Symptoms in Adolescent Mild Traumatic Brain Injury.

This study examined the relationships between post-traumatic headache (PTH) and mental health symptoms after concussions to inform adolescent concussion management. Headache is the most common complaint following adolescent concussion. In this sample of 123 adolescents with concussion, there was a 5-fold increase in odds of clinically elevated anxiety, as well as increased mental health symptoms (anxiety, depression, anger, and disruptive behaviours), among adolescents with PTH relative to those without PTH. Adolescents with headache following concussions are vulnerable to worse mental health outcomes, particularly anxiety, and may benefit from routine monitoring of mental health symptoms for early detection and intervention.

Mechanism of olfactory deficit in neurotrauma and its related affective distress: A narrative review.

Traumatic brain injury (TBI) is among the leading causes of death and disability all over the globe. TBI is also commonly associated with clinical sequelae of posttraumatic depression, and reports of other subsequent affective distress are common. Similarly, posttraumatic changes in chemoreceptive sensory functions, primarily due to coup-contrecoup injury induced shearing of the olfactory nerve fibers, leading to anosmia and ageusia are also well documented in the literature. However, the current literature is limited in addressing the intersections between said variables. The aim of this study was to provide a focused narrative review of the literature, to address these intersections found in clinical sequelae of TBI. As chemoreceptive sensory deficits are also linked to significant affective distress of their own, this review addresses the bidirectionality between sensory deficit and affective distress. Prevalence, demographics, mechanisms, and clinical implications are presented. Previous research is presented and discussed, in an effort to highlight the importance of consideration for all factors in TBI patient care and future research.

Direct and indirect costs associated with stereotactic radiosurgery or open surgery for medial temporal lobe epilepsy: Results from the ROSE trial.

OBJECTIVE: To determine whether a less-invasive approach to surgery for medically refractory temporal lobe epilepsy is associated with lower health care costs and costs of lost productivity over time, compared to open surgery. METHODS: We compared direct medical costs and indirect productivity costs associated with treatment with stereotactic radiosurgery (SRS) or anterior temporal lobectomy (ATL) in the ROSE (Radiosurgery or Open Surgery for Epilepsy) trial. Health care use was abstracted from hospital bills, the study database, and diaries in which participants recorded health care use and time lost from work while seeking care. Costs of use were calculated using a Medicare costing approach used in a prior study of the costs of ATL. The power of many analyses was limited by the sample size and data skewing. RESULTS: Combined treatment and follow-up costs (in thousands of US dollars) did not differ between SRS (n = 20, mean = $76.6, 95% confidence interval [CI] = 50.7-115.6) and ATL (n = 18, mean = $79.0, 95% CI = 60.09-103.8). Indirect costs also did not differ. More ATL than SRS participants were free of consciousness-impairing seizures in each year of follow-up (all P < 0.05). Costs declined following ATL (P = 0.005). Costs tended to increase over the first 18 months following SRS (P = 0.17) and declined thereafter (P = 0.06). This mostly reflected hospitalizations for SRS-related adverse events in the second year of follow-up. SIGNIFICANCE: Lower initial costs of SRS for medial temporal lobe epilepsy were largely offset by hospitalization costs related to adverse events later in the course of follow-up. Future studies of less-invasive alternatives to ATL will need to assess adverse events and major costs systematically and prospectively to understand the economic implications of adopting these technologies.

Visual field defects after radiosurgery versus temporal lobectomy for mesial temporal lobe epilepsy: Findings of the ROSE trial.

PURPOSE: Stereotactic radiosurgery (SRS) may be an alternative to anterior temporal lobectomy (ATL) for mesial temporal lobe epilepsy (MTLE). Visual field defects (VFD) occur in 9-100% of patients following open surgery for MTLE. Postoperative VFD after minimally invasive versus open surgery may differ. METHODS: This prospective trial randomized patients with unilateral hippocampal sclerosis and concordant video-EEG findings to SRS versus ATL. Humphries perimetry was obtained at 24 m after surgery. VFD ratios (VFDR = proportion of missing homonymous hemifield with 0 = no VFD, 0.5 = complete superior quadrantanopsia) quantified VFD. Regressions of VFDR were evaluated against treatment arm and covariates. MRI evaluated effects of volume changes on VFDR. The relationships of VFDR with seizure remission and driving status 3 years after surgery were evaluated. RESULTS: No patients reported visual changes or had abnormal bedside examinations, but 49 of 54 (91%) of patients experienced VFD on formal perimetry. Neither incidence nor severity of VFDR differed significantly by treatment arm. VFDR severity was not associated with seizure remission or driving status. CONCLUSION: The nature of VFD was consistent with lesions of the optic radiations. Effective surgery (defined by seizure remission) of the mesial temporal lobe results in about a 90% incidence of typical VFD regardless of method.

Radiosurgery versus open surgery for mesial temporal lobe epilepsy: The randomized, controlled ROSE trial.

OBJECTIVE: To compare stereotactic radiosurgery (SRS) versus anterior temporal lobectomy (ATL) for patients with pharmacoresistant unilateral mesial temporal lobe epilepsy (MTLE). METHODS: This randomized, single-blinded, controlled trial recruited adults eligible for open surgery among 14 centers in the USA, UK, and India. Treatment was either SRS at 24 Gy to the 50% isodose targeting mesial structures, or standardized ATL. Outcomes were seizure remission (absence of disabling seizures between 25 and 36 months), verbal memory (VM), and quality of life (QOL) at 36-month follow-up. RESULTS: A total of 58 patients (31 in SRS, 27 in ATL) were treated. Sixteen (52%) SRS and 21 (78%) ATL patients achieved seizure remission (difference between ATL and SRS = 26%, upper 1-sided 95% confidence interval = 46%, P value at the 15% noninferiority margin = .82). Mean VM changes from baseline for 21 English-speaking, dominant-hemisphere patients did not differ between groups; consistent worsening occurred in 36% of SRS and 57% of ATL patients. QOL improved with seizure remission. Adverse events were anticipated cerebral edema and related symptoms for some SRS patients, and cerebritis, subdural hematoma, and others for ATL patients. SIGNIFICANCE: These data suggest that ATL has an advantage over SRS in terms of proportion of seizure remission, and both SRS and ATL appear to have effectiveness and reasonable safety as treatments for MTLE. SRS is an alternative to ATL for patients with contraindications for or with reluctance to undergo open surgery.

Chronic Neuropsychological Sequelae in a Patient with Nontumorous Anti-NMDA-Receptor Encephalitis.

Anti-N-methyl-D-aspartate receptor encephalitis is a neurological, autoimmune disorder tightly conceptualized only as recently as the mid-2000s. It presents itself in a combination of psychiatric, neurological, and autonomic features. We observe a unique case with probable earlier episode (prior to the mid-2000s conceptualization of the disease) and a later relapse, accompanying a comprehensive neuropsychological profile tracked after the relapse and subsequent improvement. Neurocognitive findings revealed residual frontal deficits with mood changes even in the state after plasmapheresis. This case is the first to describe posttreatment cognition in anti-NMDAR encephalitis after probable serial autoimmune episodes.

Pharmacokinetics and Clinical Utility of Valproic Acid Administered via Continuous Infusion.

INTRODUCTION: Valproic acid is a versatile antiepileptic drug that is often used in the acute care setting. Intravenous valproic acid lends itself well to a continuous infusion as it exhibits a relatively short half-life. We evaluated the pharmacokinetics and clinical efficacy of continuous infusion valproic acid in hospitalized patients with migraine and seizures. METHODS: A retrospective cohort study was performed utilizing information from the medical records of patients receiving an intravenous continuous infusion of valproic acid. Patients were included if they were aged 1 month to 85 years and they received a continuous infusion of valproic acid. Therapeutic response, common adverse effects, and the pharmacokinetic profile of valproic acid were evaluated. RESULTS: Continuous infusion valproic acid led to a concentration within the desired range (50-100 µg/ml) in 83.4% of patients, a rate that was higher in pediatric patients. The clinical response rate was also higher in pediatric patients with seizures or migraines and appeared to be better when the concentration was >75 µg/ml. Analysis of safety parameters suggests similar safety considerations to valproic acid when administered via intermittent infusion. CONCLUSIONS: Continuous infusion valproic acid appears to be a safe, effective, and predictable manner by which to administer valproic acid to pediatric and adult patients admitted to the hospital.

Headache attributed to cranial or cervical vascular disorders.

Cranial or cervical vascular disease is commonly associated with headaches. The descriptions may range from a thunderclap onset of a subarachnoid hemorrhage to a phenotype similar to tension type headache. Occasionally, this may be the sole manifestation of a potentially serious underlying disorder like vasculitis. A high index of clinical suspicion is necessary to diagnose the disorder. Prompt recognition and treatment is usually needed for many conditions to avoid permanent sequelae that result in disability. Treatments for many conditions remain challenging and are frequently controversial due to paucity of well controlled studies. This is a review of the recent advances that have been made in the diagnosis or management of these secondary headaches.