Déjerine-Roussy syndrome presenting with atypical involuntary movements.

BACKGROUND: The Déjerine-Roussy syndrome is caused by a stroke in the posterior lateral nuclei of the thalamus. It has a 17 to 18% prevalence after a stroke involving the inferior lateral thalamus. METHODS: We reported a case of a 65-year-old, diabetic and hypertensive male who presented with sudden onset of superficial hemianesthesia, allodynia, severe and paroxysmal pain on the right side of the body with choreoathetoid movements in the upperN limb, along with slured speech, and unsteadiness while walking. CONCLUSIONS: It is characterized by superficial hemianesthesia, allodynia, severe paroxysmal pain, and choreoathetoid movements in the limbs on the paralyzed side. A posterior lateral thalamic lesion can present with ataxia hemiparesis contralateral to the side of the lesion.

A Case of Hypermotor Seizures in Posterior Insular Cortex Epilepsy.

Insular seizure is a rare entity. Insular spikes spread to the temporal, parietal, and frontal lobes and clinically manifest with seizure semiology specific to these areas. We report the case of a 19-year-old male patient who presented with complaints of left-sided hemimotor tonic-clonic focal seizures of the limbs occurring three times per day. Neuroimaging showed cortical-subcortical right posterior insular cortex hyperintensities on fluid-attenuated inversion recovery (FLAIR) sequence and T2-weighted MRI with no significant diffusion restriction on apparent diffusion coefficient (ADC) and no post-contrast enhancement, suggesting focal cortical dysplasia of right posterior insular cortex. Electroencephalogram (EEG) showed right frontal epileptiform activity with secondary bilateral synchrony. The patient's atypical hemimotor tonic-clonic focal seizure, the conventional video EEG showing right frontal spikes synchronizing with bilateral temporal ictal spikes, and insular cortical dysplasia on MRI led us to a diagnosis of insular epilepsy.

Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India.

Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Nonstatin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals with statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).

Metronidazole-Induced Encephalopathy (MIE).

Metronidazole is an antibiotic often used to treat bacterial infections in the vagina, skin, liver, stomach, joints, brain and spinal cord, heart, lungs, or bloodstream. It is an essential drug for treating anaerobic bacterial infections, microaerophilic bacterial infections, and protozoal infections. It is cytotoxic to many facultative anaerobic microorganisms. Metronidazole can be taken by most children and adults but might not be suitable for some people. It may produce different neurologic side effects like cerebellar dysfunction, peripheral neuropathy, vestibulotoxicity, visual impairment, encephalopathy, ataxic gait, seizures, dysarthria, and cochleotoxicity. We report a case of a gentleman in his early 60s with a liver abscess and a history of three weeks of use of metronidazole therapy presenting with altered sensorium, abnormal gait, and slurring of speech. MRI brain showed bilateral symmetrical hyperintensities involving the dentate nuclei of the cerebellum and dorsal brain stem without evidence of any diffusion restriction suggestive of metronidazole-induced encephalopathy (MIE).

Risk factors predisposing to acute stroke in India: a prospective study.

BACKGROUND: Stroke is an important neurological disorder with significant morbidity and mortality. In India, the risk factors for stroke (obesity, diabetes mellitus, alcoholism, hypertension, and sedentary lifestyle) are mounting with economic growth and increasing the disease burden. OBJECTIVE: To assess the severity and risk factors of stroke in India and identify any new predisposing factors. METHODS: A multicentric (six tertiary care hospitals across India) prospective observational study (from September 2016 to July 2017) was conducted on 526 stroke patients, presenting within the first 24 h to examine the risk factors for ischemic and hemorrhagic strokes. Severity was determined using the National Institutes of Health Stroke Scale (NIHSS). RESULTS: Predominantly male (72.3%), 75% of the sample was >50 years old, with a mean body mass index (BMI) of 25.8 ±â€Š4.3 kg/m2 and 14.6% obese patients. Hypertension and diabetes mellitus were the commonest comorbidities, followed by a history of ischemic heart disease and familial history of stroke. 20.5% of patients had mild strokes, 57.4% had moderate, 8.4% experienced moderate-severe strokes, whereas 7.2% had severe strokes. Regarding the admission diagnoses, 56.8% were ischemic, 18.6% were hemorrhagic, 1.1% had a transient ischemic attack, 6.6% suffered recurrent strokes, and 17% were other forms. CONCLUSION: The foremost risk factors for stroke in India, hypertension and diabetes, need to be controlled and treated like other global high-risk populations for stroke prevention. The NIHSS scores highlight the relationship between risk factors and stroke severity.

Severe acute orthostatic headache: spontaneous intracranial hypotension (SIH).

The most common cause of spontaneous intracranial hypotension headache is a cerebrospinal fluid (CSF) leakage, but the underlying mechanisms remain unknown. Intracranial hypotension is characterised by diffuse pachymeningeal enhancement on cranial MRI features, low CSF pressure and orthostatic headaches mostly caused by the dural puncture. We report a 31-year-old woman who presented to our services with reports of continuous severe bifrontal headache, which increased on sitting up and resolved on lying down. MRI of the cervical and lumbosacral spine showed signs of CSF leak; hence, patient was diagnosed with spontaneous intracranial hypotension headache. A CT-guided epidural blood patch was done at L4-5 with fibrin glue injected at the site of leak. The patient's signs and symptoms improved after the procedure.

Paraneoplastic Cerebellar Degeneration Associated With Ovarian Adenocarcinoma: A Case Report and Review of Literature.

Paraneoplastic syndromes are a rare heterogeneous group of disorders that are indicators of the underlying occult malignancy. Subacute cerebellar ataxia in a patient with a known cancer is often due to metastatic invasion or other complications of the cancer, such as infection, coagulopathy, metabolic and nutritional deficits, or side effects of treatment. When tumor- and treatment-related causes have been excluded, the patient is considered to suffer from paraneoplastic cerebellar degeneration (PCD). We report a case of PCD that presented before any evidence of tumor, but early diagnostic workup and clinical vigilance helped us to find the underlying high-grade ovarian adenocarcinoma which was surgically removed later.

Nocardia Farcinica Brain Abscess in an Immunocompetent Old Patient: A Case Report and Review of Literature.

By definition, a brain abscess is an intraparenchymal collection of pus. Nocardia shows to have a special tropism for the neural tissue. Solitary abscess represents the most common manifestation in the central nervous system, accounting for 1%-2% of all cerebral abscesses. In this report, we present a case of primary multiple brain abscesses due to Nocardia farcinica in an immune competent patient. Early diagnosis and surgical intervention is significant for the patient.

Cognitive Impairment After Stroke.

BACKGROUND: Vascular dementia is extremely common and contributes to stroke-associated morbidity and mortality. The study of vascular dementia may help to plan preventive interventions. AIMS: To study the frequency of cognitive impairment after stroke in a series of consecutive patients with acute stroke, along with factors which influence it. METHODS: Fifty adults with acute infarct or hemorrhage (as seen on computed tomography of the brain) were included in the study. The National Institute of Health Stroke Scale (NIHSS) and Barthel's Index scores were done. Cognitive testing was done by PGI Battery of Brain Dysfunction (PGI-BBD) and Short Form of the Informant Questionnaire on Cognitive Decline in the Elderly (SIQCODE). Statistical analysis was by Student's t-test, Chi-square test, Fisher's exact test, and Mann-Whitney U test. RESULTS: Mean age of patients was 61.82 years; males and ischemic strokes predominated. Dementia was seen in 30%, cognitive impairment no dementia (CIND) in 42%, and normal cognition in 28% patients. Factors associated with vascular cognitive impairment included old age, male sex, low education, hemorrhages, recurrent or severe stroke, silent infarcts, severe cortical atrophy, and left hemispheric or subcortical involvement. CONCLUSIONS: Up to 72% of patients have some form of cognitive impairment after a stroke. Secondary stroke prevention could reduce the incidence of vascular dementia.

Integrated (18)F-fluorodeoxyglucose positron emission tomography magnetic resonance imaging ((18)F-FDG PET/MRI), a multimodality approach for comprehensive evaluation of dementia patients: A pictorial essay.

Dementia, caused by irreversible neurodegenerative disorders such as Alzheimer's disease or reversible non-degenerative conditions, is rapidly becoming one of the most alarming health problems in our aging society. This cognitive disorder associated with a multitude of clinical differentials with overlapping clinical, pathological, and imaging features is difficult to diagnose and treat, as it often presents late after significant neuronal damage has already occurred. Novel disease-modifying treatments being developed will have to be corroborated with innovative imaging biomarkers so that earlier reliable diagnosis can be made and treatment initiated upon. Along with new specific PET radiotracers, integrated PET/MRI with combined methodological advantage and simultaneously acquired structural-cum-functional information may help achieve this goal. The present pictorial essay details our experiences with PET/MRI in dementing disorders, along with reviewing recent advances and future scope.

Reversible cardiomyopathy in Guillain Barre syndrome.

The clinical manifestations of Guillain Barre syndrome are usually confined to the nervous system, however in 20% cases there can be cardiovascular involvement in patients with dysautonomia contributing to the mortality. The cardiovascular manifestations of Guillain Barre syndrome are electrocardiographic changes, cardiac enzyme abnormalities and reversible left ventricular dysfunction. The term neurogenic stunned myocardium has been used to summarise these cardiovascular abnormalities in the setting of severe central nervous system injury, in the absence of coronary artery disease. Our case report of reversible cardiomyopathy in Guillain Barre syndrome documents the occurrence of cardiovascular changes in a case of Guillain Barre syndrome with dysautonomia which were reversible with appropriate treatment.

An unusual recurrence of dysembroplastic neuroepithelial tumours after a seizure-free period of 8 years.

Dysembryoplastic neuroepithelial tumours (DNETs) are grade 1 central nervous tumours, which can be diagnosed judiciously based on clinical features and radiological investigations, having a good prognosis after surgical resection. However, the recurrence of tumours due to variable epileptic zones leading to persistence of seizures can make the management of such cases challenging. We present a case of DNET where the patient had recurrence of the tumour with worsening of seizure activity 8 years after initial surgical resection.

Acquired hepatocerebral degeneration.

Acquired (non-Wilsonian) hepatocerebral degeneration is a rare irreversible neurological syndrome that occurs in patients with chronic liver disease associated with multiple metabolic insults. Van Woerkom was the first to describe acquired hepatocerebral degeneration in 1914 followed by the landmark article by Victor et al in 1965. Multiple bouts of hepatic coma are the only known risk factors that trigger this devastating neurodegenerative disease with features suggesting toxic exposure to the brain. Clinically and pathologically the disorder is similar to Wilson's disease although subtle differences in immunostaining of glial fibrillar acidic protein have been documented. Acquired hepatocerebral degeneration occurs in 0.8-2% of patients with cirrhosis. As acquired hepatocerebral degeneration is relatively rare, we are reporting one such case from our hospital in a 50-year-old male patient who had long-standing portal systemic shunt and presented with progressive cognitive decline, bradykinesia, tremors and bilateral extrapyramidal signs.

Intravascular large B-cell lymphoma confirmed by brain biopsy: a case report.

Intravascular lymphoma (IVL) is a rare variant of non-Hodgkin's lymphoma characterised by neoplastic lymphoid cells growing inside the lumina of medium and small vessels. The diversity of clinical presentation owing to the possibility of its occurrence in any organ often makes it a challenging diagnosis. We present an intriguing case of intravascular large B-cell central nervous system (CNS) lymphoma in which the patient presented with a non-specific neurological symptom and had no systemic symptoms or dermatological manifestations. The patient deteriorated rapidly after presentation and succumbed to multi-organ failure within 2 weeks of admission.