Dizziness and vertigo in patients with tension-type headache: A case-control study.

BACKGROUND: A few studies have demonstrated dizziness and vertigo in patients with tension-type headache (TTH). However, the prevalence and other characteristics of vestibular symptoms in TTH has not been studied in a systemic manner so far. The aim of the study was to see the prevalence of vestibular symptoms in patients with tension-type headache as compared with controls. METHODS: This case-control study included 100 TTH patients and 100 controls who do not have significant history of headaches. RESULTS: Vestibular symptoms (Vertigo, dizziness, vestibulovisual or postural symptom) were experienced by 25% of patients with TTH and 10% in the control group (Odd Ratio = 3.0 [95% CI, 1.4-6.6], P = .006). The vestibular symptoms were statistically more in patients with chronic tension-type headache (CTTH) than episodic TTH (67% vs 9%. 9, P5 = < 0.005). Hospital Anxiety and Depression score (HAD-A and HAD-D) scores in patients with TTH with vestibular symptoms were significantly higher than TTH without vestibular symptoms- HAD-A (5.1 ± 1.7 vs 4.0 ± 1.5, P = 0.002) and HAD-D(5.8 ± 2.1 vs 4.2 ± 1.9, P = < 0.001). Phonophobia was also more frequent in TTH patients with vertigo (42% vs.13%, P5 = 0.005). CONCLUSION: Vestibular symptoms may be more common in patients TTH than control. The prevalence of vestibular symptoms depends on the frequency of TTH.

A Retrospective Comparative Study in Patients with SUNA and SUNCT.

Introduction: Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are rare primary headache disorders. Aim: The aim of the study is to describe and compare the clinical characteristics of patients with SUNA and SUNCT. Methods: Patients with SUNCT or SUNA observed in a neurology clinic of a tertiary hospital in India between January 2017 and December 2022 were evaluated. Results: Thirteen patients with SUNA (seven female, 54%) and 16 patients with SUNCT (nine female, 56%) were identified for the evaluation. The mean ages at the onset of SUNA and SUNCT were 36.8.5 ± 8.1 years and 37.2 ± 8.4 years, respectively. The age of onset in our patients was somewhat younger than that of other large series. The demographic and clinical features of SUNA patients were comparable to those of SUNCT patients. Orbital/retro-orbital area was the most common site of pain in both types of headaches. The pattern of pain was noted as single stab (in all patients), repetitive stabs (SUNA vs. SUNCT: 77% vs. 75%), and sawtooth patterns (SUNA vs. SUNCT: 23% vs. 25%). The majority of attacks in both groups lasted less than two minutes. Conjunctival injection and tearing were present in all SUNCT patients (as a part of the diagnostic criteria). The prevalence of conjunctival injection and tearing in SUNA was 46% and 31%, respectively. All patients reported spontaneous attacks. Triggers were reported in seven (54%) patients with SUNA and nine (56%) with SUNCT. Only one patient in each group had a refractory period following a trigger-induced episode. Two patients in the SUNCT group had compression of the trigeminal nerve by a vascular loop. Conclusion: This is the largest case series from India. There were no significant differences between patients with SUNA and SUNCT.

Current practices in epilepsy monitoring units (EMU) in India.

AIM: As an initial step to develop guidelines for epilepsy monitoring units (EMUs) appropriate for developing countries, we inquired the existing practices in EMUs in India. METHODS: After checking for the content and face validity as well for clarity, we sent a 52-item online non-anonymized questionnaire to all the 52 EMUs in India. RESULTS: The questionnaire was completed by 51 of the 52 EMUs (98% response rate). The majority of the EMUs are located in major cities and 51% are located in non-governmental corporate hospitals. There are total of 122 prolonged video-EEG monitoring (PVEM) beds in India and 70% EMUs have ≤2 beds. Approximately two-thirds of the EMUs have defined protocols for pre-procedure consent and risk assessment, management of seizure clusters and status epilepticus, continuous observation of patients, and peri­ictal testing. Only one-third of the EMUs have protocols for management of post-ictal psychosis, anti-suffocation pillows, and protected environment within bathrooms. The waiting period for PVEM is more (49.9 ± 101 vs. 4.9 ± 10.9 days; p = 0.04) and mean cost for 3-day PVEM is less (INR 8311 ± 9021 vs. 30,371 ± 17,563; p <0.0001) in public as compared to private hospitals. There was a negative correlation between cost of PVEM and the waiting period (r=-0.386; p = 0.01). Safety practices are similar in public and private hospitals. CONCLUSIONS: Although practices in EMUs in India vary widely, they are comparable to those in developed countries. India has severe shortage of EMUs and long waiting lists for affordable PVEM.

Antiepileptic drugs and serotonin syndrome- A systematic review of case series and case reports.

Serotonin syndrome (SS) is a drug­induced, potentially fatal, clinical syndrome resulting from drugs that have serotonergic properties. Several antiepileptic drugs (AEDs) are known to have serotonergic properties and it can be hypothesized that such AEDs can cause SS. This study aims to review the literature on SS in patients receiving AEDs. We performed a systematic review of Scopus and MEDLINE/PUBMED for case reports and case series of SS where patients had received at least one AED at the onset of symptoms. The cases published in the English literature between 1 January 1991 and 1 April 2021 were included. Initial search identified 1263 articles of which 63 (76 patients) were included in the final analysis. Most of the included cases (53 cases, 70%) have been published in the last 10 years. The mean age of the 76 patients was 40.6 ± 17.8 years, and 51% of cases were females. These patients had been exposed to a total of 8 different types of AEDs. Valproic acid was the most common drug (29, 38%), followed by lamotrigine (22, 29%), gabapentin (16, 21%), pregabalin (seven, 9%), topiramate (five, 7%) and carbamazepine (two, 3%). There has been one case each with phenytoin and oxcarbazepine. Seven (9%) patients received more than one AEDs. Most patients (67, 88%) also received other serotoninergic agents. Only nine (12%) patients were on AEDs alone. The most common clinical condition for using AEDs was psychiatric disorders (36 patients, 47.3%), followed by migraine (17, 22.4%), other painful conditions (15, 19.7%), epilepsy (7, 9.2%), and perioperative conditions (8, 10.5%). Death was reported in two patients. We suggest that AEDs, because of their serotonergic properties, may induce SS, especially in patients who are on another serotonergic agent.

Chronic serotonin syndrome: A retrospective study.

BACKGROUND: Serotonin syndrome (SS) is an underdiagnosed drug-induced clinical syndrome resulting from the excess intrasynaptic concentration of serotonin. Very limited information is available about chronic SS. AIM: To evaluate the epidemiological, clinical, and other aspects of the insidious onset SS. METHODS: We retrospectively evaluated 14 consecutive adult patients (> 18 years) who had complaints for more than 6 wk at the time of consultation and met the Hunter criteria for SS. RESULTS: The mean age was 41.1 years (range: 21-61 years), with a male preponderance (64%). Although tremors were observed in all patients, this was a presenting complaint in only 43% of patients. Generalized body pain, insomnia, and restlessness were common presenting features (50% each). Other common clinical features were stiffness of the limbs (43%), diaphoresis (43%), gait disturbances (36%), bowel disturbances (36%), dizziness (29%), sexual dysfunctions (21%), incoordination (14%), and fatigue (14%) The mean duration of symptoms before the diagnosis of SS was 13.5 ± 5.8 wk (range: 6-24 wk). Amitriptyline was the most common drug (n = 6, 43%), followed by tramadol (n = 5, 36%) and sodium valproate (n = 5, 36%). All patients received cyproheptadine, a 5- hydroxytryptamine2A antagonist, as treatment and noted an excellent response over the course of 4-14 d. CONCLUSION: This study represents the largest study on chronic SS. We suggest that patients receiving serotonergic drugs should be physically examined for the presence of SS upon the development of new symptoms.

Impact of COVID-19 pandemic on epilepsy practice in India: A tripartite survey.

OBJECTIVE: To assess the impact of ongoing COVID-19 pandemic on epilepsy care in India. METHODS: We conducted a three-part survey comprising neurologists, people with epilepsy (PWE), and 11 specialized epilepsy centers across India. We sent two separate online survey questionnaires to Indian neurologists and PWE to assess the epilepsy practice, seizures control, and access to care during the COVID-19 pandemic. We collected and compared the data concerning the number of PWE cared for and epilepsy procedures performed during the 6 months periods preceding and following COVID-19 lockdown from epilepsy centers. RESULTS: The survey was completed by 453 neurologists and 325 PWE. One third of the neurologist reported >50 % decline in outdoor visits by PWE and EEG recordings. The cumulative data from 11 centers showed 65-70 % decline in the number of outdoor patients, video-EEG monitoring, and epilepsy surgery. Working in a hospital admitting COVID-19 patients and use of teleconsultation correlated with this decline. Half of PWE had postponed their planned outpatient visits and EEG. Less than 10 % of PWE missed their antiseizure medicines (ASM) or had seizures due to the nonavailability of ASM. Seizure control remained unchanged or improved in 92 % PWE. Half of the neurologists started using teleconsultation during the pandemic. Only 4% of PWE were afflicted with COVID-19 infection. CONCLUSIONS: Despite significant decline in the number of PWE visiting hospitals, their seizure control and access to ASMs were not affected during the COVID-19 pandemic in India. Risk of COVID-19 infection in PWE is similar to general population.

The prevalence of serotonin syndrome in an intensive care unit: A prospective observational study.

PURPOSE: In spite of life-threatening nature of serotonin syndrome (SS), it remains an under-diagnosed condition. The availability of epidemiological data about SS, especially in the ICU setting, may help physicians make early diagnoses and interventions. MATERIALS AND METHODS: This was a 6-month prospective study in a medical ICU of a tertiary hospital to find out the prevalence of SS. All consecutive adult patients admitted to the medical ICU were evaluated to see if they fulfilled the Hunter criteria of SS. Patients who met the Hunter criteria were evaluated further for other details. RESULTS: Overall, 309 patients were identified of which 24 (7.8%) met the Hunter criteria. The mean age was 52.4 years, and 75% were male. Most patients received two or more serotonergic drugs. Ondansetron was the most common serotonergic drug (58%), followed by tramadol (38%), and cough syrup (dextromethorphan or chlorpheniramine, 21%). None of the patients received a diagnosis of SS by the treating physicians. Chronic obstructive pulmonary disease exacerbation with respiratory failure and metabolic encephalopathy were the two most common admission diagnoses (17% each). Twenty-two patients received cyproheptadine. There were no fatalities. CONCLUSION: SS is not uncommon in the ICU setting. There is a need to increase awareness among physicians.

Prevalence of benign epileptiform variants from an EEG laboratory in India and frequency of their misinterpretation.

OBJECTIVE: To prospectively study the prevalence of benign epileptiform variants (BEVs) and their impact on epilepsy misdiagnosis. METHODS: Consecutive patients, older than one year, who underwent EEG from January 2016 to December 2019 were prospectively studied for the presence of BEVs. We used descriptions of Klass and Westmoreland (1985) to categorize the BEVs. We reviewed old EEG reports and records in patients with BEV to determine whether they were interpreted as abnormal. RESULTS: Of the 1862 subjects included, 1474 (79 %) patients had epilepsy while 388 (21 %) had other diagnoses. The mean age of the subjects was 23.1 ± 15.3 years and 1111 (60 %) were males. BEVs were noted in 223 (12 %) subjects undergoing EEG. The most common BEVs were wicket waves (n = 127, 6.8 %) and small sharp spikes (n = 69, 3.7 %) while 6 Hz spike-wave discharges (0.9 %), 14 and 6 Hz positive spikes (0.6 %), rhythmic mid-temporal theta burst of drowsiness (0.4 %) and subclinical rhythmic epileptiform discharges in adults (0.2 %) were less common. Patients with BEVs were older and were more likely to have normal EEG (68.2 % vs. 55.8 %; p < 0.001). BEVs were not mentioned in any of the 282 previous EEG reports. BEVS were considered to be over-interpreted as epileptiform abnormalities in 31 of 101 (30 %) records available for review. CONCLUSION: BEVs are present in 12 % of subjects undergoing EEG. BEVS are largely unrecognized and are misdiagnosed as epileptiform discharges in one third of the patients by the general neurologists.

Fatal serotonin syndrome: a systematic review of 56 cases in the literature.

INTRODUCTION: Serotonin syndrome (SS) is a drug-induced potentially life-threatening clinical condition. There is a paucity of data on the risk factors, clinical course, and complications associated with fatal SS. OBJECTIVE: To characterize the epidemiological profile, clinical features, and risk factors associated with fatal SS through a systematic review. METHODS: We performed a systematic review of MEDLINE and Google Scholar for case reports, case series, or cohort studies of fatal SS. RESULTS: Initial database search identified 2326 articles of which 46 (56 patients) were included in the final analysis. The mean age was 42.3 years (range 18-87 years) with female predominance (57%). North America and Europe constitute 80% of the reported fatal SS. The symptoms evolved very rapidly, within 24 h after the administration of serotonergic drugs in 59% of the cases. Fever (61%) was the most common symptom, followed by seizure (36%) and tremors (30%). The mean temperature in the reported cases (25 patients) was 41.6 ± 1.3 °C (range 38.3-43.5 °C). SS was reported to occur with the maintenance dosage of serotonergic agents, after initiation of the drug for the first time, and addition of the drugs for the development of another unrelated illness. Creatine kinase (CK) activities were elevated (>3 times of the upper limit of normal) in eighteen patients, and it was very high (>25,000 IU/L) in four patients. Presence of high grade fever, seizures, and high CK activities may be associated with severe SS. Nine patients (16%) received 5-HT2A antagonists as a therapy. About 50% of patients died within 24 h of the onset of symptoms. CONCLUSIONS: While fatal SS is rare, frequently observed features include hyperthermia, seizures, and high CK activities. Cyproheptadine use appears infrequent for these patients.

Outcome of therapeutic plasma exchange in Myasthenia gravis patients.

AIMS: The aim of this study was to evaluate the indications, adverse reactions, and outcome of therapeutic plasma exchange (TPE) in myasthenia gravis (MG) patients. SETTINGS AND DESIGN: Retrospective Observational study. METHODS AND MATERIAL: A total of 18 patients of MG had undergone 18 cycles and 87 session of TPE at our Institution, a tertiary care center in Western India. It was performed using a single volume plasma exchange with intermittent cell separator (Freseniouscomtec), subclavian central line access, and with alternate day interval. Outcome was assessed shortly after each session and overall outcome at the time of discharge. RESULTS: Total of 68 patients of MG were admitted to Neurology Intensive care unit (ICU) during the study period [January 2016-December 2019]. Out of them, TPE was done in 18 patients. Among the 18 patients, 11 patients had myasthenic crisis and 7 patients had worsening of MG. The mean number of TPE session was 4.2(SD ± 1.2), volume exchange was 2215 ml (SD ± 435); overall incidence of adverse reaction was 33.3%. All patients had immediate benefits of each TPE cycle. Good acceptance of procedure was observed in 72.2% of patients. CONCLUSIONS: TPE is cost-effective rapid therapy for myasthenic crisis and progressive myasthenia gravis. It reduces ICU stays and improves outcome.

Knowledge, Attitude, and Practice (KAP) Study on Serotonin Syndrome Among Neuro Physicians.

BACKGROUND AND AIMS: Serotonin syndrome (SS) is a highly underdiagnosed drug-induced clinical syndrome. Under diagnosis is partly due to the unawareness of this syndrome by physicians. The aim of this study is to assess the knowledge, attitude and practice of SS among neuro physicians in India. METHODS: A cross-sectional survey using a self-administered questionnaire was carried out among neuro physicians in India. Neuro physicians attending the various neurological conferences and meetings were approached to participate in the study. RESULT: A total of 150 neuro physicians responded to the survey. About 31% of participants correctly recognized the criteria for SS. Only 17% of the neuro physicians considered clonus as the most important feature in SS. Very few physicians correctly identified serotonergic agents causing serotonin syndrome. Similarly, a very low percentage of neuro physicians correctly identified the drugs used in the management of SS. Drugs used for the treatment of SS were incorrectly recognized as drugs causing SS. Clonus is the most specific feature for SS. However, examination for clonus is not a routine phenomenon in clinical practice among neuro physicians. CONCLUSION: This study shows great deficiencies in all domains of SS among neuro physicians. There is a need to make every doctor aware of SS by educational programs.

Refining the Clinical Features of Serotonin Syndrome: A Prospective Observational Study of 45 Patients.

INTRODUCTION: Serotonin syndrome (SS) is a drug-induced clinical syndrome that results from the excess intrasynaptic concentration of serotonin. Prospective observations are limited for SS. METHODS: We prospectively recruited 45 consecutive adult patients (>18 years) fulfilling the Hunter's criteria for SS. All patients were subjected to a detailed clinical history and examinations. Patients were subjected to appropriate investigations to find out the other causes. The causation of SS to serotonergic drugs was assessed according to Naranjo adverse drug reaction probability scale. RESULTS: The mean age was 37.3 years (range: 18-59 years). Sixty-two percent of patients were male. There were 15 different underlying clinical syndromes for which serotonergic drugs were started. Psychiatry conditions (36%) and cough/respiratory tract infection (16%) were the two most common clinical conditions for starting serotonergic drugs. We noted 49 different symptoms and physical signs. Overall, tremor (78%) and dizziness (47%) were the two most common symptoms. Headache (16%) and dizziness (16%) were the two most common initial (or first) symptoms. However, gait difficulty and febrile encephalopathy were the two most common reasons to visit the hospital. We noted 18 different drugs causing SS. Thirty-eight percent of patients received single serotonergic agent antidepressants, pain medicines and cough syrups were other important drugs causing SS. CONCLUSIONS: This study represents the largest clinic-based study on SS. SS is not rare in clinical practice. However, various aspects of this syndrome are still to be determined. All patients on serotonergic drugs should be physically examined for the presence of SS on the development of any new symptom.

Chewing-induced facial dystonia: a rare presentation of task-specific dystonia.

This case is an addition to scarce literature available for a rare condition, chewing-induced task-specific dystonia. The patient was a 63-year-old woman who presented with a 4-year history of progressive difficulty in eating food only during chewing associated with abnormal facial grimaces without any difficulty in drinking, swallowing, speaking or singing. Examination revealed dystonia of facial muscles every time she chewed but absent during drinking and speaking. As movements were consistent and reproducible with the specific task, other differential diagnosis like motor tics, psychogenic disorder, tardive dystonia and parkinsonism syndrome were excluded leading to a diagnosis of task-specific facial dystonia triggered by chewing. Treatment was started with trihexyphenidyl and later on tetrabenazine was also added but she got only mild relief of symptoms. As she did not agreed for botulinum toxin therapy, so we continued with the same treatment without much improvement.