Focal Motor Deficits Research Articles

A case of superior trunk brachial plexus injury after right mini-thoracotomy mitral valve repair.

We report a case of superior trunk brachial plexus injury following a right mini-thoracotomy mitral valve repair. A 45-year-old woman with systemic lupus erythematosus, who was on steroids and immunosuppressive drugs, underwent mitral valve repair via right mini-thoracotomy. The patient was positioned in the left semisagital position with the right upper arm elevated. Postoperatively, she exhibited focal motor and sensory deficits in the right upper extremity, and a superior trunk brachial plexus injury (BPI) on the right side was diagnosed through brachial plexus MRI and electrophysiological examination. The nerve injury was likely due to excessive left lateral flexion of the head during the procedure. Sensation returned to normal 4 weeks postoperatively, and muscle strength fully recovered 3 months postoperatively. Careful attention to positioning during minimally invasive cardiac surgery is crucial to prevent nerve compression in superficial areas and excessive lateral flexion of the head.

DC-CRP: Deep Cerebral Venous Thrombosis, Clinicoradiological Profile, and Treatment Outcome in Indian Population-A Tertiary Care Experience.

Deep cerebral venous thrombosis (DCVT) is an uncommon cause of stroke with diverse predisposing factors, clinical presentations, imaging findings, and functional outcomes, which makes the diagnosis of DCVT even more challenging. Retrospective observational study (December 2018 to January 2023). Cases with imaging data suggestive of DCVT were included. The neuroradiological assessment was performed using multimodality imaging to determine the location of parenchymal changes and the number of deep veins involved in isolation or with the superficial dural venous system. Clinical variables were tabulated. Of the 206 cases with CVT in the study period, 27 had DCVT (13.1%), of which four (14.8%) had isolated DCVT (male-to-female ratio 13:14; mean age = 33.4 years). Hyperhomocysteinemia (n = 11) is the most common risk factor associated with it. The most common presentations were headaches (n = 27) and focal motor deficits (n = 13). Raised intracranial tension (ICT) was present in almost half of the study population (n = 14). Mean and median modified Rankins score (mRS) at the time of discharge were 2.0 and 1, respectively. The most common deep vein involved was the straight sinus (SS) (n = 25), followed by the internal cerebral vein (n = 23). The mean and median mRS after 3 months from discharge were 0.3 and 0, respectively. A knowledge of diverse clinical presentations in DCVT, its neurovascular anatomy, and imaging characteristics with prompt diagnosis and timely interventions can assist in attenuating the risk of acute complications and long-term sequelae. Extensive deep grey matter involvement in DCVT is associated with neurological manifestations like altered sensorium and motor deficits, with increased severity of illness as measured by the mRS score.

Neuropsychiatric Manifestations, As a Rare Presentation of Venous Sinus Thrombosis Two Weeks After Cesarean Section: First Report in the Gambia

Cerebral venous sinus thrombosis (CVST) is a rare and potentially fatal condition, accounting for about 0.5% of all cerebrovascular disease cases globally. It is challenging to diagnose due to its rarity and diverse clinical presentations that can mimic other acute neurological conditions [1]. The reported worldwide incidence of CVST during pregnancy and postpartum is approximately 3 to 4 cases per million, with superior sagittal sinus thrombosis (SSST) being the most prevalent type. Risk factors include the prothrombotic state of pregnancy in the third trimester, obesity, accidental dural puncture, deficiencies in protein C and S, antiphospholipid syndrome, and the use of oral contraceptives among others. Symptoms typically manifest within the first three weeks postpartum, with severe headache being the most common complaint. The low number of reported cases in sub-Saharan Africa suggests underdiagnosing or underreporting, with infection being the primary cause in this region. We report a case at our facility who, two weeks after a cesarean section, presented with severe headache, confusion, irritability, restlessness, and later developed a focal motor deficit. Imaging studies were crucial in diagnosing SSST and ruling out other conditions causing acute brain injury. This is the first reported case in The Gambia, and one of the few described in West Africa related to an obstetric procedure. The onset, characterized by neuropsychiatric symptoms, is unusual and interesting, as these manifestations are less common than the typical headache, seizure, and focal motor deficit described in the literature.

Progressive multifocal leukoencephalopathy and spectrum of predisposing conditions: a 20-year retrospective cohort study in a tertiary center in São Paulo, Brazil.

Epidemiological studies on predisposing conditions and outcomes of progressive multifocal leukoencephalopathy (PML) cases have been carried out exclusively in high-income countries. We aim to report and compare the main characteristics and outcomes of patients with PML and several underlying diseases in a referral center in a middle-income country. We performed a retrospective cohort study of PML cases admitted to a tertiary care hospital in São Paulo, Brazil during 2000-2022. Demographic and PML-specific variables were recorded. One-year case-fatality rate and factors associated with death were identified using a multivariate Cox proportional hazards regression model. Ninety-nine patients with PML were included. HIV infection (84.8%) and malignancy (14.1%) were the most prevalent underlying conditions. Other predisposing diseases were autoimmune/inflammatory diseases (5.1%) and solid organ transplantation (1.0%). One (1.0%) patient had liver cirrhosis and another (1.0%) patient was previously healthy. Focal motor deficits (64.2%) and gait instability (55.1%) were the most common signs. The one-year case-fatality rate was 52.5% (95% CI 42.2-62.7). The one-year case-fatality rate (95% CI) in patients with or without malignancy (85.7%, 95% CI 57.2-98.2% and 47.1%, 95% CI 36.1-58.2%, respectively) were statistically different (P = 0.009). Crude and adjusted Cox regression models identified malignancy as independently associated with death (adjusted HR = 3.92, 95% CI 1.76-8.73, P = 0.001). HIV/AIDS was the predisposing condition in 84.8% of PML cases. The one-year case-fatality rate was 52.5% and having a malignancy was independently associated with death. This study reports emerging data on the epidemiology and outcome of PML in a middle-income country.

The Evolving Role of Monomethyl Fumarate Treatment as Pharmacotherapy for Relapsing-Remitting Multiple Sclerosis.

Multiple sclerosis is the most common autoimmune disease affecting the central nervous system (CNS) worldwide. Multiple sclerosis involves inflammatory demyelination of nerve fibers in the CNS, often presenting with recurrent episodes of focal sensory or motor deficits associated with the region of the CNS affected. The prevalence of this disease has increased rapidly over the last decade. Despite the approval of many new pharmaceutical therapies in the past 20 years, there remains a growing need for alternative therapies to manage the course of this disease. Treatments are separated into two main categories: management of acute flare versus long-term prevention of flares via disease-modifying therapy. Primary drug therapies for acute flare include corticosteroids to limit inflammation and symptomatic management, depending on symptoms. Several different drugs have been recently approved for use in modifying the course of the disease, including a group of medications known as fumarates (e.g., dimethyl fumarate, diroximel fumarate, monomethyl fumarate) that have been shown to be efficacious and relatively safe. In the present investigation, we review available evidence focused on monomethyl fumarate, also known as Bafiertam®, along with bioequivalent fumarates for the long-term treatment of relapsing-remitting multiple sclerosis.

Anti-Nogo-A Antibody Therapy Improves Functional Outcome Following Traumatic Brain Injury

Background Traumatic brain injury (TBI) can cause sensorimotor deficits, and recovery is slow and incomplete. There are no effective pharmacological treatments for recovery from TBI, but research indicates potential for anti-Nogo-A antibody (Ab) therapy. This Ab neutralizes Nogo-A, an endogenous transmembrane protein that inhibits neuronal plasticity and regeneration. Objective We hypothesized that anti-Nogo-A Ab treatment following TBI results in disinhibited axonal growth from the contralesional cortex, the establishment of new compensatory neuronal connections, and improved function. Methods We modeled TBI in rats using the controlled cortical impact method, resulting in focal brain damage and motor deficits like those observed in humans with a moderate cortical TBI. Rats were trained on the skilled forelimb reaching task and the horizontal ladder rung walking task. They were then given a TBI, targeting the caudal forelimb motor cortex, and randomly divided into 3 groups: TBI-only, TBI + Anti-Nogo-A Ab, and TBI + Control Ab. Testing resumed 3 days after TBI and continued for 8 weeks, when rats received an injection of the anterograde neuronal tracer, biotinylated dextran amine (BDA), into the corresponding area contralateral to the TBI. Results We observed significant improvement in rats that received anti-Nogo-A Ab treatment post-TBI compared to controls. Analysis of BDA-positive axons revealed that anti-Nogo-A Ab treatment resulted in cortico-rubral plasticity to the deafferented red nucleus. Conclusions. Anti-Nogo-A Ab treatment may improve functional recovery via neuronal plasticity to brain areas important for skilled movements, and this treatment shows promise to improve outcomes in humans who have suffered a TBI.

Postpartum Listeria Meningitis: A Case Report (P2-10.006)

<h3>Objective:</h3> n/a <h3>Background:</h3> Acute bacterial meningitis is a neurological emergency and fatal if left untreated. Here we present a case of bacterial meningitis, highlighting postpartum listeria monocytogenes infection. <h3>Design/Methods:</h3> <h3>Description:</h3> We present a case of 27 years-old woman with past medical history of migraine and hyperthyroidism, brought to the hospital with acute onset of reduced level of consciousness. A day prior to presentation, she woke up with a severe retro-orbital headache of 10/10 intensity along with nausea, vomiting, photophobia and phonophobia. Her symptoms further progressed to worsening confusion/somnolence with agitation. She had an uncomplicated vaginal delivery a month earlier. On admission, vitals were significant for high grade fever, hypotension, tachypnea and tachycardia. On examination, she was restless, combative, was not following any commands. No focal motor deficit. Nuchal rigidity and Babinski were negative. Labs showed mild anemia, leukocytosis, mild hyponatremia and lactic acidosis. MRI Brain showed faint diffuse leptomeningeal enhancement. CSF analysis showed WBC 732/Ul, SEG: 66%, protein&gt; 300mg/dl and CSF glucose &lt;20mg/dl. Meningitis panel and CSF culture were positive for listeria monocytogenes. Post CSF analysis, her broad spectrum antibiotics were deescalated to ampicillin for 21 days and gentamycin for 7 days for synergistic effects. During the initial treatment phase, she developed horizontal binocular diplopia and her exam showed isolated sixth nerve palsy. MRI brain revealed worsening diffuse leptomeningitis, involving the basal cisterns and the ependymal walls of the lateral ventricles. Eventually, she responded to the treatment and her symptoms resolved slowly. <h3>Results:</h3> n/a <h3>Conclusions:</h3> Listeria Monocytogenes can be a possible cause of postpartum meningoencephalitis due to the underlying transient immunosuppressive condition. Return to a normal immune response may take as long as up to one year after childbirth. Treatment should not be delayed in highly suspicion cases to avoid complications like rhombencephalitis, progressive neurological deficits and eventually death. <b>Disclosure:</b> Mr. Tang has nothing to disclose. Dr. Kausar has nothing to disclose. Dr. Rivera has nothing to disclose. The institution of Dr. Cruz-Flores has received research support from University of Texas System. Dr. Yerram has nothing to disclose.

Seizures in the Contralateral hemisphere in Rasmussen Encephalitis after Disconnective hemispherectomy – True or False lateralizing? (P13-1.010)

<h3>Objective:</h3> To describe a case that highlights diagnostic and treatment challenges when seizures recur after disconnective hemispherectomy. <h3>Background:</h3> Recurrence of seizures after hemispheric disconnection warrants careful evaluation to assess candidacy for additional surgery. Interpretation of EEG in the setting of post-hemispheric disconnection poses special challenges. <h3>Design/Methods:</h3> Retrospective chart review and literature search. <h3>Results:</h3> A 10-year-old right-handed girl presented with focal drug-resistant epilepsy from age 7 years. Initially, she had left face/arm motor seizures, but over the years developed other seizure types - myoclonic, generalized tonic-clonic, dialeptic, and atonic head drop. Neurological examination showed no focal motor deficit. Interictal EEG with abundant right frontocentral and secondary bilateral synchronous discharges, while ictally had a diffuse non-localized pattern. Serial MRI brain showed progressive right hemispheric atrophy predominantly around the perisylvian and perirolandic regions. She met the criteria for diagnosis of Rasmussen encephalitis. Due to the poor quality of life from daily seizures, after much contemplation, a right disconnective hemispherectomy was done. Pathology of brain tissue confirmed Rasmussen encephalitis. Her seizures recurred around 4 months post-surgery. Interictal EEG showed abundant independent epileptiform discharges from both hemispheres. Ictal EEG showed ictal patterns over the left hemisphere. Post-operative brain MRI showed no evidence for residual hemispheric disconnection. A possibility of bilateral Rasmussen encephalitis versus a false lateralizing EEG pattern with seizures still arising from the operated hemisphere was considered. She underwent a re-do right anatomic hemispherectomy and has been seizure free since surgery at a 2-year follow-up. Post-op EEG showed no epileptiform abnormalities over the left hemisphere. <h3>Conclusions:</h3> In the post-hemispherectomy setting, both interictal and ictal EEG patterns may be falsely lateralizing, and persistent seizures should raise the suspicion of an incomplete disconnection. Looking for an overt connection on MRI can help, but the lack of one is not always a reliable marker of complete disconnection. <b>Disclosure:</b> Dr. Natteru has nothing to disclose. Dr. Alzahrany has nothing to disclose. William Bingaman has nothing to disclose. Dr. Naduvil Valappil has nothing to disclose.

Abstract TP172: Predicting Poor Response To Anti-coagulation Therapy In Cerebral Venous Thrombosis Using A Simple Clinical-radiological Score

Few studies target to identify predictors of poor response to anticoagulation therapy in Cerebral Venous Thrombosis (CVT). We aimed to determine the predictors of poor clinical response to therapeutic anticoagulation in acute CVT. Methods: We performed a retrospective analysis of patients therapeutically anticoagulated for acute CVT. We defined poor clinical outcomes as death, need for mechanical thrombectomy during the hospitalization, or a modified Rankin Scale (mRS) &gt;3 at clinical follow-up. Multivariate analyses identified factors associated with poor outcomes in anticoagulated patients for acute CVT, and we used the identified factors to create the PRACT-CVT (Poor Response to Anticoagulation Therapy in CVT) score. Results: We included 109 patients anticoagulated with acute CVT. Twenty-one (19%) patients had poor clinical outcomes. Age &gt;65 or &lt;10 years (OR: 3.16, 95% CI: 1.06-9.44), a GCS ≤12 upon presentation (OR: 19.2, 95% CI: 4.05-91.4), focal motor deficits at admission (OR: 5.03, 95% CI: 1.64-15.44), clinical deterioration following admission (OR: 28.18, CI: 4.81-164.86), seizures following admission (OR: 5.59, 95% CI: 1.27-24.51), evidence of brain bleeding/ischemia on admission (OR: 4.67, 95% CI: 1.42-15.34), involvement of the superior sagittal sinus (OR: 3.88, CI: 1.33-11.32), or involvement of both transverse sinuses (OR: 3.87, 95% CI: 1.01-14.90) predicted poor clinical outcome despite therapeutic anticoagulation. A PRACT-CVT score (0-22 points) of ≥7 points provided a sensitivity of 71% and a specificity of 95% for predicting poor clinical outcomes with anticoagulation alone. Conclusion: Patients with acute CVT, presenting with a GCS ≤12, with focal motor deficits, showing clinical deterioration after admission, having seizures during hospitalization, with brain bleeding/ischemia on initial imaging, involvement of the superior sagital sinus, or involvement of both transverse sinuses had poor response to anticoagulation.

Goal-Directed Fluid Therapy and major postoperative complications in elective craniotomy. A retrospective analysis of a before-after multicentric study

BackgroundGoal-Directed Fluid Therapy (GDFT) is recommended to decrease major postoperative complications. However, data are lacking in intra-cranial neurosurgery.MethodsWe evaluated the efficacy of a GDFT protocol in a before/after multi-centre study in patients undergoing elective intra-cranial surgery for brain tumour. Data were collected during 6 months in each period (before/after). GDFT was performed in high-risk patients: ASA score III/IV and/or preoperative Glasgow Coma Score (GCS) < 15 and/or history of brain tumour surgery and/or tumour greater size ≥ 35 mm and/or mid-line shift ≥ 3 mm and/or significant haemorrhagic risk. Major postoperative complication was a composite endpoint: re-intubation after surgery, a new onset of GCS < 15 after surgery, focal motor deficit, agitation, seizures, intra-cranial haemorrhage, stroke, intra-cranial hypertension, hospital-acquired related pneumonia, surgical site infection, cardiac arrythmia, invasive mechanical ventilation ≥ 48 h and in-hospital mortality.ResultsFrom July 2018 to January 2021, 344 patients were included in 3 centers: 171 in the before and 173 in the after (GDFT) period. Thirty-six (21.1%) patients displayed a major postoperative complication in the Before period, and 50 (28.9%) in the After period (p = 0.1). In the propensity score analysis, we matched 48 patients in each period: 9 (18.8%) patients in the After period and 14 (29.2%) patients in the Before period displayed a major perioperative complication (p = 0.2). Sixty-two (35.8%) patients received GDFT in the After period, with great heterogeneity among centers (p < 0.05).ConclusionsIn our before-after study, GDFT was not associated with a decrease in postoperative major complications in elective intra-cranial neurosurgery.

Spontaneous pneumorrachia: a rare cause of thunderclap headache

Objective To present a rare cause of thunderclap headache Case presentation Female patient, 39 years old, was admitted to the emergency department of a private hospital in the city of São Paulo, after a sudden and explosive headache followed by two episodes of syncope and motor deficit in the left upper limb. Neurological examination showed weakness of the left upper limb without sensitive impairment. She had previous history of bipolar affective disorder, chronic anemia, and overweight with previous bariatric surgery. The patient was submitted to computed tomography (CT), arterial angiotomography of the skull and cervical neck, which showed rare small gaseous foci in the perivertebral soft tissues and extradural site on the left side in the craniovertebral transition, near the foramen magnum. Small foci of pneumocephalus were found in the posterior fossa, near the left sphenopetrous fissure. Electroneuromyography (ENMG) of four limbs and brain and cervical magnetic resonance imaging (MRI) were performed 48 hours after initial CT scan. ENMG was normal and MRI showed no more expression of the changes described on CT. She was treated with analgesia and was discharged with full reversion of initial symptoms. Conclusion Spontaneous pneumorrhachia is rare disease and is characterized by the presence of air in the spinal canal, both in the intradural and extradural compartments. It is usually benign with spontaneous resolution. Our patient was included in a stroke investigation protocol, due to the thunderclap headache and focal motor deficit. CT revealed the diagnosis. The cervical CT that was performed in the context of cervical CT angiography of the stroke protocol allowed the correct diagnosis. Key-words: Thunderclap headache, Spontaneous Pneumorrhachia, Cervical Computed Tomography Angiography.

Predicting poor response to anti-coagulation therapy in cerebral venous thrombosis using a simple clinical-radiological score

BackgroundMultiple studies have attempted to determine predictors of poor clinical outcomes in cerebral venous thrombosis (CVT). Fewer studies target to identify predictors of poor response to anticoagulation therapy in CVT. ObjectiveWe aimed to determine the predictors of poor clinical response to therapeutic anticoagulation in patients with acute CVT. MethodsWe performed a retrospective analysis of patients therapeutically anticoagulated for acute CVT. We defined poor clinical outcomes as death, need for mechanical thrombectomy during the hospitalization, or a modified Rankin Scale (mRS) > 3 at clinical follow-up. Bivariate and multivariate analyses identified factors associated with poor outcomes in anticoagulated patients for acute CVT, and we used the identified factors to create the PRACT-CVT (Poor Response to Anticoagulation Therapy in CVT) score. ResultsWe included 109 patients anticoagulated with acute CVT. The mean patient age was 37 years old (SD 19); nine patients were > 65 years, ten patients were < 10 years, and 64 (59%) were female. Twenty-one (19%) patients had poor clinical outcomes. Age > 65 or < 10 years (OR: 3.16, 95% CI: 1.06–9.44), a GCS ≤ 12 upon presentation (OR: 19.2, 95% CI: 4.05–91.4), focal motor deficits at admission (OR: 5.03, 95% CI: 1.64–15.44), clinical deterioration following admission (OR: 28.18, CI: 4.81–164.86), seizures following admission (OR: 5.59, 95% CI: 1.27–24.51), evidence of brain bleeding/ischemia on admission (OR: 4.67, 95% CI: 1.42–15.34), involvement of the superior sagittal sinus (OR: 3.88, CI: 1.33–11.32), or involvement of both transverse sinuses (OR: 3.87, 95% CI: 1.01–14.90) predicted poor clinical outcome despite therapeutic anticoagulation. A PRACT-CVT score (0–22 points) of ≥ 7 points provided a sensitivity of 71% and a specificity of 95% for predicting poor clinical outcomes with anticoagulation alone. ConclusionPatients with acute CVT aged > 65 or < 10 years old, presenting with a GCS ≤ 12, with focal motor deficits, showing clinical deterioration after admission, having clinical seizures during hospitalization, with brain bleeding/ischemia on initial neuroimaging, involvement of the superior sagittal sinus, or involvement of both transverse sinuses had poor response to anticoagulation. Clinicians may employ the PRACT-CVT score to predict poor response to anticoagulation for acute CVT.

Abstract P122: Posterior Reversible Encephalopathy Syndrome Following Moderna M-RNA Booster Vaccination Secondary To Hypertension Vs Vaccine Adverse Effect?

Clinical Case: A 76-year-old female presented to our ED with acute onset confusion, unsteady gait and blurry vision within 24 hours after receiving the m-RNA Moderna booster vaccine. Medical history: notable for uncomplicated hypertension on metoprolol. She was awake, oriented intermittently x 3, with periods of confusion, blurry vision and intermittent unsteady gait and normal speech without any focal motor or sensory deficits. BP=192/80 mmHg bilaterally. Labs: showed hypercalcemia with elevated vitamin D 25-OH. Hypertension was managed with home dose of metoprolol succinate 150 mg/day and hypercalcemia improved with IV fluids. On Day 3 the patient was found lying in bed unresponsive to sternal rub with motor twitching of left arm, seizure like activity. Transfer to ICU for BP =185/104mmHg, T = 100.8 F, airway protection and treatment with diazepam. Empirical antibiotics were started for presumed encephalitis. EEG demonstrated seizure foci in bilateral posterior quadrants. MRI imaging on day # 3 showed T2/FLAIR hyperintensities in the parieto-occipital lobes and pulvinar of the thalami suggestive of posterior reversible encephalopathy syndrome (PRES). Discussion: PRES syndrome is both a clinical and radiological diagnosis with neurological changes coupled with MRI FLAIR hyperintensities in the parietal, occipital and frontal bilateral areas. This condition has been associated with uncontrolled hypertension, endothelial injury and side effect from certain drugs. Her hypertension was aggressively managed with amlodipine, enalapril, and IV metoprolol to decrease cerebral perfusion pressure. Repeat MRI imaging on day #14 demonstrated resolution of the hyperintensities without episodic blurry vision, confusion and our patient's mentation improved. At her 7 weeks follow our patient continued to have residual deconditioning and could only follow 2 step commands. We emphasize the importance of timely diagnosis with MRI imaging and preventing delay in management with adequate anti-hypertensives to prevent irreversible neurological damage from PRES syndrome. We also encourage reporting similar findings to VAERS as we are unable to exclude a reaction to her m-RNA vaccine booster.

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.

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.

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.

Plasminogen Activator Inhibitor-1 (PAI-1) Gene Polymorphisms Associated with Cardiovascular Risk Factors Involved in Cerebral Venous Sinus Thrombosis.

Cerebral venous sinus thrombosis (CVST), accounting for less than 1% of stroke cases, is characterized by various causes, heterogeneous clinical presentation and different outcome. The plasminogen activator inhibitor-1 (PAI-1) gene polymorphisms has been found to be associated with CVST. The aim of this retrospective study was to determine the potential association of PAI-1 675 4G/5G polymorphisms and homocysteine levels with cardiovascular risk factors in a group of young patients with CVST. Eighty patients with CVST and an equal number of age and sex matched controls were enrolled. The protocol included demographic and clinical baseline characteristics, neuroimagistic aspects, genetic testing (PAI-1 675 4G/5G polymorphisms), biochemical evaluation (homocysteine—tHcy, the lipid profile, blood glucose, glycohemoglobin—HbA1c, high-sensitive C-reactive protein—hsCRP) data, therapy and prognosis. The PAI-1 675 4G/5G gene polymorphisms were significantly correlated with increased homocysteine level (tHcy) (p < 0.05), higher total cholesterol (TC) (p < 0.05), low- density lipoprotein cholesterol (LDLc) (p = 0.05) and high- sensitive C- reactive protein (hsCRP) (p < 0.05) in patients with CVST when compared with controls. From the PAI-1 gene polymorphisms, the PAI-1 675 4G/5G genotype presented statistically significant values regarding the comparisons of the blood lipids values between the CVST group and control group. The homocysteine (tHcy) was increased in both groups, patients versus controls, in cases with the homozygous variant 4G/4G but the level was much higher in the group with CVST (50.56 µmol/L vs. 20.22 µmol/L; p = 0.03). The most common clinical presentation was headache (91.25%), followed by seizures (43.75%) and focal motor deficits (37.5%). The superior sagittal sinus (SSS) was the most commonly involved dural sinus (56.25%), followed by the lateral sinus (LS) (28.75%). Intima—media thickness (IMT) values were higher in the patients’ group with CVST (0.95 mm vs. 0.88 mm; p < 0.05). The fatal outcome occurred 2.5% of the time. PAI-1 675 4G/5G gene polymorphisms and higher homocysteine concentrations were found to be significantly associated with CVST in young patients.

Reliability of Bystander Recognition of Clinical Features in Pre-Hospital Classification of Acute Cerebrovascular Syndromes: Preliminary Findings.

The recognition of stroke symptoms by patients or bystanders directly affects the outcomes of patients with acute cerebrovascular disease. The objective of the study was to assess the predictive value of the medical his- tory and clinical features recognized by the patients' bystanders to classify neurovascular syndromes in pre-hospital settings. We included 150 stroke patients of two Mexican referral centers: 50 with acute ischemic stroke (AIS), 50 with intracerebral hemorrhage (ICH), and 50 with subarachnoid hemorrhage (SAH). The performance of clinical prediction rules (CPR) to identify the stroke types was evaluated with features recognized by the patients' bystanders before hospital arrival. The impact of CPRs on early arrival and in-hospital mortality was also analyzed. Overall, 72% of the patients had previous medical evaluations in other centers before final referral to our hospitals, and therefore, only 45% had a final onset- to-door time <6 h, even when the first medical assessment had occurred in ≤1 h in 75% of cases. Clinical features noticed by the patients' bystanders had low positive predictive values (PPV) for any stroke type. The CPR "language or speech disor- der + focal motor deficit" had 93% sensitivity and a negative predictive value (NPV) of 84% to distinguish AIS. In SAH, head- ache alone showed a sensitivity of 84% and NPV of 97%. No CPR had an adequate performance on ICH. CPRs were not as- sociated with final onset-to-door time. Altered consciousness, age ≥65 years, indirect arrival with stops before final referral, and atrial fibrillation increased in-hospital mortality. Clinical features referred by the witness of a neurovascular emergency have limited PPV, but adequate NPV in ruling-out AIS and SAH among stroke types. The use of CPRs had no impact on onset-to-door time or in-hospital mortality when the final arrival to a third-level center occurs with previous medical refer- rals.

Neurocysticercosis (NCC) in Children: A Review

Neurocysticercosis (NCC) is the commonest parasitic infestation of the brain caused by Taenia solium larvae and a preventable cause of epilepsy worldwide. NCC may be parenchymal or extraparenchymal, and its clinical presentation may vary based on the location, number, and host immuneresponse to the cysts. Seizures are more frequently seen in children, and single colloidal parenchymal cyst is the common radiologic finding in pediatric NCC. The diagnosis is generally by neuroimaging, a scolex within the cyst being pathognomic; however, serology may help when the neuroimaging is inconclusive. Initial treatment generally focuses on symptomatic management by antiepileptics and corticosteroids. Albendazole is the cysticidal drug of choice in most cases; praziquental is added for multiple lesions. The outcome depends on the type, location, number of lesions, seizure recurrences and radiologic resolution of the lesions. Single lesions have a better prognosis. In endemic areas, NCC should be a differential in any child presenting with recentonset seizures, headache, vomiting, or focal motor deficits, in the absence of another known neurological condition. Due to the potentially eradicable nature of cysticercosis, preventive measures need to be encouraged.

Traumatic Brain Injury in the Elderly: Clinical Features, Prognostic Factors, and Outcomes of 133 Consecutive Surgical Patients.

ObjectiveWith the aging of the global population, an increase in the proportion of elderly patients presenting with traumatic brain injury (TBI) is expected. This population presents several distinctive characteristics that impact management and outcome of TBI, such as comorbidities, frailty, and preinjury use of medications - specially antiplatelets and anticoagulants. The purpose of this study was to assess the general characteristics and prognostic factors of elderly patients with TBI that were surgically managed at a single institution.MethodsThe authors performed a retrospective review of all elderly patients (age ≥ 65 years) with a history of TBI that underwent cranial neurosurgical procedures at their institution, between 2015 and 2019. Clinical characteristics, laboratory tests, and radiological scans, as well as surgeries, performed, outcome, and prognostic factors were analyzed, comprising 133 consecutive cases overall.ResultsThe mean age of patients was 76.6 ± 7.3 years, ranging from 65 years to 97 years. There was a predominance of males (71.4%) and the most frequent mechanism of injury was fall (80.4%). Mild TBI comprised 57.1% of the cases, followed by severe TBI in 25.6%. Frequent signs and symptoms were impaired consciousness (69.9%), focal motor deficits (32.3%), and gait disturbances (12.8%). The majority had reported comorbidities upon admission (79.7%), with cardiac disease (79.2%) and diabetes (24.5%) as the most frequent. Preinjury anticoagulation was reported in 18.8% and use of antiplatelet drugs in 17.3%. The most common finding in the head CT was chronic subdural hematoma (48.1%), followed by acute subdural hematoma (37.6%). Coagulation was found to be altered in 12.8% of the patients. The most common neurosurgical procedure performed was trephination for hematoma evacuation (56.3%), followed by craniotomy (21.2%). Blood product transfusion was needed in 61.7% of the patients. Overall mortality was 42.1%, with the majority in the first month after admission (83.9%). Unfavorable outcome (Glasgow Outcome Scale <5) at discharge was identified in 73% of the patients. Identified prognostic factors were TBI severity, absent pupillary reactivity, acute intracranial bleeding on head CT, basal cisterns obliteration, altered coagulation status, and need for blood transfusion.ConclusionsTBI severity, pupillary reactivity, coagulation status, need for blood products transfusion and acute bleeding, as well as basal cisterns obliteration found in head CT, are factors that influenced the outcome in this series of elderly patients with TBI that need surgical management. It is paramount to observe the particularities of this population in this context, to optimize outcomes, avoid complications and ultimately generate awareness focused on prevention.