Focal Deficits Research Articles

Timely and Appropriate Administration of Inhaled Argon Provides Better Outcomes for tMCAO Mice: A Controlled, Randomized, and Double-Blind Animal Study.

Inhaled argon (iAr) has shown promising therapeutic efficacy for acute ischemic stroke and has exhibited impressive advantages over other inert gases as a neuroprotective agent. However, the optimal dose, duration, and time point of iAr for acute ischemic stroke are unknown. Here, we explored variable iAr schedules and evaluated the neuroprotective effects of acute iAr administration on lesion volume, brain edema, and neurological function in a mouse model of cerebral ischemic/reperfusion injury. Adult ICR (Institute of Cancer Research) mice were randomly subjected to sham, moderate (1.5h), or severe (3h) transient middle cerebral artery occlusion (tMCAO). One hour after tMCAO, the mice were randomized to variable iAr protocols or air. General and focal deficit scores were assessed during double-blind treatment. Infarct volume, overall recovery, and brain edema were analyzed 24h after cerebral ischemic/reperfusion injury. Compared with those in the tMCAO-only group, lesion volume (p < 0.0001) and neurologic outcome (general, p < 0.0001; focal, p < 0.0001) were significantly improved in the group administered iAr 1h after stroke onset (during ischemia). Short-term argon treatment (1 or 3h) significantly improved the infarct volume (1 vs. 24h, p < 0.0001; 3 vs. 24h, p < 0.0001) compared with argon inhalation for 24h. The concentration of iAr was confirmed to be a key factor in improving focal neurological outcomes relative to that in the tMCAO group, with higher concentrations of iAr showing better effects. Additionally, even though ischemia research has shown an increase in cerebral damage proportional to the ischemia time, argon administration showed significant neuroprotective effects on infarct volume (p < 0.0001), neurological deficits (general, p < 0.0001; focal, p < 0.0001), weight recovery (p < 0.0001), and edema (p < 0.0001) in general, particularly in moderate stroke. Timely iAr administration during ischemia showed optimal neurological outcomes and minimal infarct volumes. Moreover, an appropriate duration of argon administration was important for better neuroprotective efficacy. These findings may provide vital guidance for using argon as a neuroprotective agent and moving to clinical trials in acute ischemic stroke.

PREDICTORS OF CLINICAL OUTCOMES IN INDIAN PATIENTS WITH ACUTE ENCEPHALOPATHY: A PROSPECTIVE OBSERVATIONAL STUDY FROM A TERTIARY CARE CENTER IN INDIA

Objective: Objective of the study was to evaluate the predictors of poor disease outcome at discharge and at 1 month in patients with acute encephalopathy. Methods: This prospective, observational, single center study included adult patients meeting the diagnostic criteria for acute confusion state and admitted in the intensive care unit of a tertiary care hospital. A modified Rankin Scale (mRS) score of &lt;3 was considered as “good outcome,” while mRS ≥3 was considered as an indicator of “poor outcome.” Results: Among the total population of 219, 52.5% (n=115) were male, the mean age was 41.58 (±18.10) years and mean disease duration was 14.30 (±10.05) days (range: 1–30 days). Lethargy was the most common history at presentation (84.93%), while sleep abnormalities were least common (4.57%), and tuberculous meningitis was the most common etiology (21%). Diminution of vision, diplopia, dysarthria, cranial nerve symptoms, abdominal pain, difficulty in breathing, seizures, high-risk behavior, loss of appetite and the diagnosis of posterior reversible encephalopathy, retroviral disease, stroke and tuberculous meningitis were significant predictors of “poor outcome” at discharge (p&lt;0.05). A diagnosis of tuberculous meningitis, history of headache, diminution of vision, diplopia, dysarthria, seizures, sensory deficits and loss of appetite and neuroimaging findings of atrophy, intracranial bleeding, demyelination, and space-occupying lesion were found to be significant predictors of “poor outcome” at 1 month post-discharge in this population (p&lt;0.05). Conclusion: In patients with acute encephalopathy, tuberculous etiology, the presence of focal brainstem deficits and specific neuroimaging findings indicate poor outcomes at discharge as well as at 1 month follow-up.

Validation of the ECHS non trauma cranial CT rule in Australia: A prospective cohort study.

Computed tomography (CT) is a commonly used imaging modality in Emergency Departments (EDs), however its use is questionable in many low yield settings. The Emergency CT Head score (ECHS) is a recently published clinical tool that assists in stratifying the need for CT brain (CTB) for patients presenting without a history of trauma. We sought to validate this tool in an Australian ED setting. We prospectively evaluated 412 patients who received CTB without a history of trauma at a large Australian ED. We assessed them for the 4 main ECHS data points: focal neurological deficit on physical examination, new acute onset headache, transient neurological deficit, and a combination of new onset seizures with an altered conscious state. We examined their association with acute and chronic CTB findings. We then applied the ECHS to our data, calculating its sensitivity and its appropriateness at this single site via the calculation of a receiver operating curve (ROC). 10.2% of all CTB performed were positive for an acute or chronic abnormality. Only sex (male) and focal motor deficit were independent predictors of positive CTB at univariate analysis. The ECHS did not perform as anticipated in our population, with a ROC area under the curve of 0.498. An ECHS score of >0, which has been proposed as the threshold to not require imaging, had sensitivity of only 83.3% in our population. Further research and validation is required in order to safely implement the ECHS clinical score in the Australian ED setting.

SARS-CoV-2 vaccine-related neurological complications.

ObjectiveTo describe three cases with neurological symptoms after SARS-CoV-2 vaccination.MethodsA case series followed by a review of the literature, describing hypotheses on how neurological symptoms might develop after vaccination.ResultsThe different temporal relationship between the onset or worsening of different neurological symptoms suggests different pathophysiological mechanisms. Progression of post-infectious myoclonus, caused by a previous SARS-CoV-2-infection, shortly after vaccination suggests a renewed auto-immune mediated crossreaction of antibodies to both viral epitopes and central nervous system components. Thunderclap headache after vaccination suggests a similar pathophysiological mechanism to the headache and other flu-like symptoms described after vaccination against other viruses. This might be ascribed to the activation of immunoinflammatory mediators or accompanying fever. Although headache accompanied by encephalopathy and focal neurological deficit might occur as part of a cytokine release syndrome, this is clinically less likely.ConclusionsA variety of symptoms, including thunderclap headache, focal deficits and movement disorders, can occur after SARS-CoV-2 vaccination, and an activation or reactivation of the immune system is suggested as most likely cause. However, one should be careful about claiming a direct correlation. It remains important to exclude other causes, such as structural lesions, infections or subarachnoid hemorrhage, and future research is required to understand possible pathophysiological mechanisms and associations with the SARS-CoV-2 vaccine.

From Dysarthria to Tetanus: Case Report and Diagnostic Considerations.

IntroductionTetanus is a vaccine-preventable disease caused by a neurotoxin produced by Clostridium tetani that proliferates in wound sites. Toxin interference with neuromuscular function leads to spasms. Trismus, risus sardonicus and opisthotonus are classic features, but tetanus can begin with subtler symptoms.Case DescriptionAn 80-year-old man presented with dysarthria. His medical history included hypertension and dyslipidaemia. No other neurological compromise was apparent on admission. Cranioencephalic computed tomography suggested pontine and mesencephalic ischaemia and stroke treatment was implemented. Two days later, the patient displayed dysphagia that required nasogastric intubation. The next day, he developed an apparent tonic seizure with respiratory distress refractory to diazepam and phenytoin, which required sedation and invasive mechanical ventilation. Ultimately, he manifested trismus and generalized spasms. Once the diagnosis of tetanus was established, he was given anti-tetanus immunoglobulin, tetanus toxoid vaccine and metronidazole. Magnetic resonance imaging did not reveal any brain injury. During his intensive care stay, he showed cardiovascular instability, developed nosocomial pneumonia, and required prolonged ventilator support and tracheostomy. He gradually improved during a 70-day hospital stay and regained his previous functional status.DiscussionDysarthria in an older patient with known cerebrovascular risk factors in addition to possible brainstem ischaemia contributed to an incorrect diagnosis of acute ischaemic stroke. Early manifestations of tetanus can mimic focal deficits. The limitations of brainstem computed tomography should be kept in mind.ConclusionOlder patients present a broader range of signs suggesting tetanus, including a higher frequency of bulbar symptoms, on presentation. A careful anamnesis including previous vaccination history is key for identifying high-risk patients and to widen the differential diagnosis to include tetanus.LEARNING POINTSSymptoms of tetanus include bulbar symptoms such as dysphagia and dysarthria in addition to muscle spasms.Older patients, especially if unvaccinated, are a vulnerable group in which a diagnosis of tetanus should be considered.One-slice non-contrast enhanced computed tomography of the brainstem is unreliable given the high frequency of technical artifacts.

Clinical Neurophysiology of Zika Virus Encephalitis.

Zika virus (ZIKV) has been shown to be highly neurotropic; neurologic disorders are a common complication of this infection. Encephalitis-an inflammation of the brain parenchyma associated with neurologic dysfunction-is a rare complication of ZIKV infections. It affects patients from young to elderly ages. Clinical presentation of ZIKV encephalitis may be heterogeneous, including altered mental status (decreased or altered level of consciousness, lethargy, or personality change), seizures, and focal deficits. Complementary diagnostic investigation should include neuroimaging, lumbar puncture, and EEG. Neuroimaging findings in ZIKV encephalitis are not specific and may be diverse, including normal findings, hyperintense lesions on MRI involving cortical or subcortical structures, symmetric or asymmetric lesions involving supra or infratentorial regions, and more widespread involvement such as brain swelling. A remarkable scarcity of neurophysiological data on ZIKV encephalitis was found in the literature. In line with other diagnostic examinations, there are no neurophysiological findings suggestive or specific of the disease. EEG in ZIKV encephalitis showed different results: normal or diffuse disorganization of background activity, asymmetry with abnormal focal slow waves, focal epileptic discharges or generalized spike-wave and multispike-wave complexes, and periods of generalized voltage attenuation.

Efficacy of Physiotherapy Rehabilitation for Hemiparesis following Cerebral Venous Sinus Thrombosis: A Rare Case Report

Background: In Cerebral Vascular Disease when one or more arteries are thrombosed it results in Cerebral Venous Sinus Thrombosis (CVST) and affects in all ages. This condition is very challenging as it is not diagnosed early due to diverse signs and symptoms and involvement of extensive collateral circulation. Superior sagittal sinus is a large sinus which is commonly affected. Usually, patient comes with clinical presentation of headache with papilledema, to focal deficit, seizures and coma. &#x0D; Aim: To investigate the efficacy of Physiotherapy Rehabilitation for Hemiparesis following Cerebral Venous Sinus Thrombosis.&#x0D; Presentation of Case: A 18-year-old male patient presented with a history of severe headache, weakness in his right arm and leg, dizziness upon rising from bed, and a unilateral headache. On investigation CT scan and MRI brain was done. The physiotherapy has started from 2 days after admission in AVBRH.&#x0D; Discussion: In the cases of cerebral venous sinus thrombosis the management of hemiparesis is shown to enhance the ADL and quality of life of patients.&#x0D; Conclusion: The rehabilitation protocol planned will help in improving the range of motion and ADL of patient when started as early as possible.

Rituximab in Rasmussen's encephalitis: A single center experience and review of the literature.

Rasmussen's encephalitis (RE) is a rare chronic inflammatory disease of the brain resulting in unilateral hemispheric atrophy with drug-resistant focal epilepsy associated with a variable degree of progressive hemiparesis and cognitive decline. The precise etiology of RE is unknown but presumed to have a neuroinflammatory pathobiological basis. Only surgery halts progression of the disease, but may occur at the expense of a fixed but otherwise inevitable neurological deficit. Therefore, the question of medical management is an important consideration. Reports of rituximab use in patients with RE were presented at the American Epilepsy Society annual meeting in 2008. Good published evidence for its usage has been very slow to emerge since then. However, rituximab continues to be listed in discussions of treatment options for patients with RE, though other monoclonal antibodies have since been used with comparable outcomes. We describe a series of nine patients including two with adult-onset RE. Rituximab was used early in the disease course (range 1-108months; mean 32months). Of nine patients with RE, there was significant benefit in their seizure burden with rituxamab. Seizure freedom occurred in 3 patients. Epilepsia partialis continua (EPC) was present in 4/9 and no focal motor deficit noted in 4/9. No progression of a neurological deficit was present in 2/9 and evidence of progression with neuroimaging was terminated with rituxamab in 5/9 supporting early use of rituxamab in patients with RE.

Vascular intracranial malformations and dementia: An under-estimated cause and clinical correlation. Clinical note

Cerebrovascular malformations (CVMs) such as arteriovenous malformations (AVMs) or dural arteriovenous fistulas (DAVFs) represent a possible source of intracranial hemorrhage, but these malformations can also manifest with neurologic disorders secondary to ischemic penumbra from vascular steal. In the latter case, the clinical manifestations are less obvious and characteristic, and may include a varied clinical spectrum ranging from focal deficits to generalized malfunction of the brain parenchyma resulting in dementia. Dementias secondary to CVMs constitute a probably underestimated subpopulation of patients of great interest because they present with devastating but potentially reversible cognitive impairment. We examined the pertinent literature regarding the clinical manifestations of CVMs characterized by cognitive impairment and describe the distinctive clinical features. Our results confirm that cognitive impairment is one of the clinical manifestations of CVMs and is a frequently misrecognized and often late-diagnosed cause of reversible dementia.

Metastases to cranial base meningiomas. Clinical presentations and surgical outcomes. Literature overview

Tumour-to-meningioma metastasis (TTMM) is an uncommon phenomenon, however repeatedly found in the literature. Meningiomas occur to be the most frequent target of metastatic expansion of systemic cancers. Meningiomas often vary in symptoms and treatment, and this largely depends on the tumour location. Due to their variable locations, they can be classified as convexity meningiomas, which includes falcine and parasagittal tumours, and cranial base, which includes tumours located in the olfactory groove, sphenoid wing, petrous bone and other cranial base locations. The aim of this study was to analyse all data regarding metastases to cranial base meningiomas. We performed a literature search to locate all cases of metastases to cranial base meningiomas in PubMed and Medline databases using the following key words: metastasis to meningioma, meningioma metastasis, and cranial base meningioma. We collected patient and cancer parameters, exact meningioma location and clinical presentations including characteristics which may suggest TTMM. We found 100 articles describing 111 patients of metastasis to cranial base meningioma. Among these articles, 55 cases (49.55%) included metastases to non-skull base meningiomas. In 24 cases (21.62%), the location of meningioma was not precisely described or other data were unavailable, in particular histopathological examination. The most common location of TTMM was sphenoid wing, which was found in 9 patients. The other locations included cerebellopontine angle in 5 patients, and tuberculum sellae in 3 cases. 81.25% cases of TTMM were reported in women, and the most common cancer origins were the breast (28.3%), lung (18.7%), kidney (9.38%) and prostate (9.38%). In two cases the metastatic origin was unclear, and in 15.6% of cases the patients were in remission for more than 1 year. In 78.1% of cases patients presented focal deficits, followed by increased intracranial pressure, and seizures. In almost one-third of cases, TTMM first appeared from a previously unknown cancer. Rapid clinical presentation of cranial nerve palsies may suggest the dual nature of intracranial pathology. The metastasis to cranial base meningioma should be suspected in patients with oncological background, regardless of meningioma parameters or cancer status.

Brain tumor masquerading as dengue in a three-year-old boy

Paediatric gliomas represent the most common brain tumour in children. Early diagnosis and treatment greatly improve survival. Paediatric gliomas depend on pathways and genes responsible for mitotic activity and cell proliferation as well as angiogenesis (mitogen-activated protein kinases, vascular endothelial growth factor, epidermal growth factor pathways). Symptoms seen as persistent headaches, behavior changes, early morning nausea, emesis, diplopia, and papilledema. Patients may also present with more specific localizing symptoms such as focal motor deficits, hemiplegia, pyramidal tract findings, dysmetria, and chorea; depending upon the tumor’s location can facilitate diagnosis, but they are not always present and therefore diagnosis is occasionally delayed. Here we report a case of a boy hailing from lower socioeconomic status with history of abdominal pain, irritability, fever and cough initially mimicking clinical features and symptoms of dengue encephalitis but subsequent deterioration of patient though on medication and review with MRI suggestive of a glioma.

CSF Neurofilament Light Chain Concentrations Predict Outcome in Bacterial Meningitis.

Background and ObjectivesNeurofilament light chain (NfL) is a biomarker for neuroaxonal damage and has been found to be elevated proportionally to the degree of neuronal damage in neurologic diseases. The objective of this study was to determine the prognostic accuracy of NfL concentrations on unfavorable outcome in adults with community-acquired bacterial meningitis.MethodsWe measured NfL concentration CSF samples from a prospective cohort study of adults with community-acquired bacterial meningitis in The Netherlands and determined associations between NfL CSF concentrations, clinical characteristics, and outcome in multivariate analyses. We identified independent predictors of an unfavorable outcome (Glasgow Outcome Scale scores 1–4) by logistic regression.ResultsCSF NfL concentrations were evaluated in 429 episodes of 425 patients with community-acquired bacterial meningitis. The median age of 429 episodes was 62 years (interquartile range, 50–69 years). Of note, 290 of 422 (68%) episodes presented with an altered mental status (Glasgow Coma Scale score < 14). Most common causative pathogens were Streptococcus pneumoniae (73%), Neisseria meningitidis (7%), and Listeria monocytogenes (5%). The overall case fatality rate was 62 of 429 (15%), and unfavorable outcome occurred in 57 (37%) of 429 episodes. In multivariate analysis, predictors of unfavorable outcome were older age (OR 1.03, 95% CI 1.01–1.05), cranial nerve palsy (OR 4, 95% CI 1.6–10.3), high serum C-reactive protein concentration (OR 1.3, 95% CI 1.01–1.05), and high CSF NfL concentration (OR 1.5, 95% CI 1.07–2.00). CSF NfL concentrations were higher in patients presenting with focal cerebral deficits (717 pg/mL [416–1,401] vs 412 pg/mL [278–731]; p < 0.001). The area under the curve (AUC) for predicting unfavorable outcome in bacterial meningitis of CSF NfL concentration was 0.69 (95% CI, 0.64–0.74).DiscussionCSF NfL concentration is independently associated with unfavorable outcome in adults with community-acquired bacterial meningitis, suggesting that CSF NfL concentration may be a useful biomarker for prognostic assessment in bacterial meningitis.Classification of EvidenceCan the level of NfL in CSF (the index test) predict unfavorable outcome in patients with bacterial meningitis, in a cohort of bacterial meningitis patients with a favorable and unfavorable outcome? This study provides Class II evidence that NfL level in CSF is a moderate predictor, with the AUC for predicting unfavorable outcome in bacterial meningitis being 0.69 (95% CI, 0.64–0.74).

The Prognostic Value of NANO Scale Assessment in IDH-Wild-Type Glioblastoma Patients

BackgroundIDH-wild-type glioblastoma (GBM) is the most frequent brain-derived malignancy. Despite intense research efforts, it is still associated with a very poor prognosis. Several parameters were identified as prognostic, including general physical performance. In neuro-oncology (NO), special emphasis is put on focal deficits and cognitive (dys-)function. The Neurologic Assessment in Neuro-Oncology (NANO) scale was proposed in order to standardize the assessment of neurological performance in NO. This study evaluated whether NANO scale assessment provides prognostic information in a standardized collective of GBM patients.MethodsThe records of all GBM patients treated between 2014 and 2019 at our facility were retrospectively screened. Inclusion criteria were age over 18 years, at least 3 months postoperative follow-up, and preoperative and postoperative cranial magnetic resonance imaging. The NANO scale was assessed pre- and postoperatively as well as at 3 months follow-up. Univariate and multivariate survival analyses were carried to investigate the prognostic value.ResultsOne hundred and thirty-one patients were included. In univariate analysis, poor postoperative neurological performance (HR 1.13, p = 0.004), poor neurological performance at 3 months postsurgery (HR 1.37, p < 0.001), and neurological deterioration during follow-up (HR 1.38, p < 0.001), all assessed via the NANO scale, were associated with shorter survival. In multivariate analysis including other prognostic factors such as the extent of resection, adjuvant treatment regimen, or age, NANO scale assessment at 3 months postoperative follow-up was independently associated with survival prediction (HR 1.36, p < 0.001). The optimal NANO scale cutoff for patient stratification was 3.5 points.ConclusionNeurological performance assessment employing the NANO scale might provide prognostic information in patients suffering from GBM.

20-HETE Participates in Intracerebral Hemorrhage-Induced Acute Injury by Promoting Cell Ferroptosis.

Intracerebral hemorrhage (ICH) is a highly fatal type of stroke that leads to various types of neuronal death. Recently, ferroptosis, a form of cell death resulting from iron-dependent lipid peroxide accumulation, was observed in a mouse ICH model. N-hydroxy-N′-(4-n-butyl-2-methylphenyl)-formamidine (HET0016), which inhibits synthesis of the arachidonic acid metabolite 20-hydroxyeicosatetraenoic acid (20-HETE), has shown a protective effect after ICH. However, the underlying mechanisms of the neuroprotective effect need further investigation. We explored whether 20-HETE participates in ICH-induced ferroptosis ex vivo by using hemoglobin-treated organotypic hippocampal slice cultures (OHSCs) and in vivo by using a collagenase-induced ICH mouse model. Ex vivo, we found that the 20-HETE synthesis inhibitor HET0016 and antagonist 20-6,15-HEDGE reduced hemoglobin-induced cell death, iron deposition, and lipid reactive oxygen species levels in OHSCs. Furthermore, 20-HETE inhibition in OHSCs increased the expression of glutathione peroxidase (GPX) 4, an antioxidant enzyme that serves as a main regulator of ferroptosis. In contrast, exposure of OHSCs to the 20-HETE stable mimetic 20-5,14-HEDGE induced cell death that was significantly inhibited by the ferroptosis inhibitor ferrostatin-1. In vivo, HET0016 treatment ameliorated focal deficits, reduced lesion volume, and decreased iron accumulation around the lesion at day 3 and 7 after ICH. In addition, lipid peroxidation was decreased and expression of GPX4 was increased in the HET0016-treated ICH group. The mitogen-activated protein kinase pathway also was inhibited by HET0016 in vivo. These results indicate that 20-HETE contributes to ICH-induced acute brain injury in part by activating ferroptosis pathways, thereby providing an upstream target for inhibiting ferroptosis.

Abstract 1122‐000216: Evacuation of Bilateral Intracerebral Hemorrhages Using a Novel Disposable Surgiscopic System: A Case Report

Introduction : Patients presenting with intracerebral hemorrhage (ICH) face higher rates of morbidity and mortality than other stroke patients. Currently, these patients are managed by surgical intervention and decompression or medical management, depending on categorization of the hemorrhage. Simultaneous, multifocal hemorrhages are a rare presentation of ICH that portend a worse prognosis. Here we report the treatment of bilateral simultaneous ICHs in a young patient with diagnostic cerebral angiography, biopsy, and bilateral minimally invasive surgiscopic ICH evacuation in a single procedure. Methods : The patient was a young female who presented to an outside hospital after two days of progressively worsening headaches and vomiting. Her medical history was significant for systemic lupus erythematosus (SLE), hypertension, chronic migraines, and opioid use disorder. In the emergency department, her mental status deteriorated, and she was intubated. Computed tomography (CT) scan was performed and showed a right parietal 43.3 cc ICH and a left parietal 38.7 cc ICH. MR angiogram and venogram showed no evidence of vascular malformations but were suggestive of potential cerebral venous sinus thrombosis. Upon arrival, the patient remained intubated but was able to open her eyes, follow commands, and respond to stimulation. The patient was brought to the angiosuite for diagnostic cerebral angiography which revealed diffuse intermittent arterial narrowing suggestive of vasculitis and patent venous sinuses. The patient was then positioned in the prone position and bilateral parietal 1.5 cm craniectomies were performed. Surgiscopic evacuation was performed sequentially using stereotactic navigation to access and evacuate each clot. A right parietal brain biopsy was performed at the minimally invasive cortical access point. Results : Active bleeding was encountered in both hematoma sites and was treated with a combination of irrigation and monopolar cautery transmitted through the Aurora Evacuator. After complete evacuation of the hematomas on both sides, an intraoperative conebeam CT was performed, demonstrating good right‐sided evacuation and resident left‐sided hematoma. Additional evacuation was performed on the left side and repeat conebeam CT demonstrated good bilateral evacuation. CT head on post operative day 1 showed 97.7% right‐sided evacuation and 81.5% left‐sided evacuation. The patient was treated with steroids for presumed vasculitis given the angiographic findings, which was later supported by the results of the brain biopsy. The patient made a good recovery and was discharged from the hospital alert and oriented, with CN II‐XII grossly intact, no focal deficits, and 5/5 strength in all extremities. Conclusions : Minimally invasive ICH evacuation can be performed in the angiosuite for ICH‐associated with vasculitis and even multifocal ICH when appropriate. Performing the procedure in the angiosuite permits completion of the diagnostic cerebral angiogram, brain biopsy, and hematoma evacuation at the same time, accelerating time to treatment for a patient with severe, symptomatic vasculitis.

An Unusual Case of Posttraumatic Visual Agnosia Posing Challenges to Rehabilitation

Acquired focal visuoperceptual deficits are rarely reported, and rehabilitation strategies are not well established. This is a report on visuoperceptual deficit after traumatic brain injury that initially went unnoticed. Missing visual agnosia is not unusual especially when perceptual deficits present with visual field defects, impaired insight, and inattention. This case is made more interesting because of the rarity of visual agnosia with predominant ventral pathway involvement, affecting object and face recognition. This report provides a brief discussion on visual agnosia spectrum deficits and rehabilitation measures.

Complex Skull Fracture in a Toddler.

Complex Skull Fracture in a Toddler.

VARIATIONS IN CLINICAL PRESENTATION, NEUROIMAGING AND EEG PATTERNS OF SUBACUTE SCLEROSING PANENCEPHALITIS

Objective: To determine the variations in clinical presentation, neuroimaging and electroencephalography patterns of subacute sclerosing panencephalitis.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Children’s Hospital &amp; Institute of Child Health, Lahore, Pakistan, from Jul to Dec 2020.&#x0D; Methodology: We recruited children presented with clinical features suggestive of subacute sclerosing panencephalitis, along with positive anti-measles antibodies on cerebrospinal fluid. Association between variables was determined to formulate an early diagnosis of subacute sclerosing panencephalitis.&#x0D; Results: Out of 47 children, 29 were males with a mean age of 6.54 ± 2.9 years. Only 23% were fully immunized against measles, 36.2% were unvaccinated and 40.4% received partial immunization. The mean age of measles infection was 1.49 ± 1.2 years; the mean interval between measles and onset of SSPE was 4.13 ± 3 years. Atypical clinical presentation was seen in 38.3% with intractable epilepsy (8.5%), focal deficit (8.5%) and extrapyramidal symptoms (8.5%) being commonest followed by coma (6.4%), visual loss (4.3%) and psychosis (2.1%). Neuroimaging was suggestive of cortical hyperintensities in 46.8% and was normal in 46.8%. Electroencephalography showed burst suppression in 55.3% and atypical findings in 19.1%. Younger age (1-1.5 years) of measles and unimmunized status were associated with early onset of SSPE with a p-value of 0.001 and 0.05 respectively. Non-immunized status was associated with atypical presentation of SSPE (p-value &lt;0.05).&#x0D; Conclusion: The younger age of measles infection and failure to receive complete immunization led to early onset of Subacute sclerosing panencephalitis with an atypical presentation.

The Gross Total Resection and Molecular Markers in Grade II Glioma

Objective: The study determined the importance of gross total resection in grade II Glioma and evaluated the importance of tumor markers as prognostic factors.&#x0D; Material and Methods: We included the 240 patients aged 13 – 65 years with supratentorialsuspected low-grade Glioma. Craniotomy was done in all my patients under general anesthesia and excised the tumor safely with the help of a microscope and CUSA without causing any focal deficit or hemodynamic instability. The 3D conformal radiotherapy and or Temozolomide chemotherapy was started as advised by the oncologist, postoperatively. The 5 and 10 years’ overall survival and progression-free survival were evaluated in my study.&#x0D; Results: Median age of the patients was 45 years. The 46.66% patients were IDH mutant Astrocytoma, 39.1 6% patients were IDH mutant Oligodendroglioma with loss of heterozygosity at I p/l9q levels, and 14.16% patients had IDH wild type Astrocytoma. The gross total resection was done in 113 patients, subtotal in 53 patients, partial resection in 45 patients, and biopsy in 29 patients. Postoperative radiotherapy was done in 170 patients and Temozolomide chemotherapy in 67 patients. The 5 and 10 years’ progression-free survival was 80% and 49% and overall survival was 86.3% and 67%. The 10 – year overall survival for Oligodendroglioma, the IDH mutant Astrocytoma, and IDH wild Astrocytoma were 93%, 61.6%, and 34.7% (respectively), and progression-free survival were 89.2%, 48%, and 34% (respectively). &#x0D; Conclusion: The gross total resection of IDH mutant Astrocytoma had a good outcome.

Acute haemorrhagic leukoencephalitis (AHLE) – our experience and a short review

BackgroundAcute haemorrhagic leukoencephalitis (AHLE), a rare variant of acute disseminated encephalomyelitis (ADEM), often presents differently from classical ADEM, thereby posing a diagnostic challenge to the clinician. AimTo report AHLE, its clinic-radiological manifestations, process of diagnosis and prognosis. Method and resultsEight patients presented with altered sensorium, acute focal deficits with or without seizures. Initial workup showed evidence of haemorrhagic lobar or thalamic lesions in seven patients. All patients underwent extensive evaluation for collagen vascular disease and vasculitis profile, autoimmune encephalitis panel and aquaporin-4 antibody, which were found to be normal. Cerebrospinal fluid (CSF) biochemistry and microscopy was non-contributory and CSF viral PCRs, toxoplasma antibodies, cryptococcal antigen were also negative. All patients had progressively worsening sensorium and neurological deficits. Repeat MRIs showed increase in oedema in the lesions and appearance/expansion of haemorrhage in the thalamic/hemispherical lesions. All patients received intravenous methylprednisolone (IVMP) without any benefit. Four patients underwent plasmapheresis (PLEX), one received intravenous immunoglobulin (IVIG) and one received both second line immunotherapies, without significant improvement. Brain biopsy (performed in three patients) showed inflammatory demyelination and areas of haemorrhage, thus confirming the diagnosis. Six patients succumbed in 7–30 days of the illness, despite aggressive treatment and only two survived, albeit with a significant disability. ConclusionAHLE is a rare, yet very severe variant of ADEM. MRI shows lesions with haemorrhages, oedema and mass effect and histology findings reveal inflammatory infiltrates, haemorrhagic foci and fibrinoid necrosis of vessel walls. Prognosis is worse as compared to the classic ADEM, with a high mortality rate. To the best of our knowledge, this is one of the largest series of AHLE to have been reported anywhere in the world. KeymessageAcute encephalopathy, multifocal deficits accompanied by haemorrhagic CNS demyelinating lesions with oedema and mass effect are the key features of AHLE. It is a rare, yet very severe form of ADEM with very high morbidity and mortality.