Insular Involvement Research Articles

Heart rate and heart rate variability in patients with chronic inflammatory joint disease: the role of pain duration and the insular cortex

BackgroundChronic inflammatory joint diseases (CIJD) have been linked to increased cardiovascular morbidity and mortality. A decisive reason could be a dysregulation of the autonomic nervous system, which is responsible for the control of cardiovascular function. So far, the cause of changes in autonomic nervous system functions remains elusive. In this study, we investigate the role of chronic pain and the insular cortex in autonomic control of cardiac functioning in patients with CIJD.MethodsWe studied the autonomic nervous system through the assessment of heart rate and heart rate variability (HRV) at rest and under cognitive stimulation. Furthermore, we investigated insular cortex volume by performing surface-based brain morphometry with FreeSurfer. For this study, 47 participants were recruited, 22 individual age- and sex-matched pairs for the magnetic resonance imaging analyses and 14 for the HRV analyses. All available patients’ data were used for analysis.ResultsPain duration was negatively correlated with the resting heart rate in patients with chronic inflammatory joint diseases (n = 20). In a multiple linear regression model including only CIJD patients with heart rate at rest as a dependent variable, we found a significant positive relationship between heart rate at rest and the volume of the left insular cortex and a significant negative relationship between heart rate at rest and the volume of the right insular cortex. However, we found no significant differences in HRV parameters or insular cortex volumes between both groups.ConclusionsIn this study we provide evidence to suggest insular cortex involvement in the process of ANS changes due to chronic pain in CIJD patients.The study was preregistered with the German Clinical Trials Register (https://www.drks.de; DRKS00012791; date of registration: 28 July 2017).

Insular Involvement in Cases of Epilepsy Surgery Failure.

Background: Epilepsy surgery failure is not uncommon, with several explanations having been proposed. In this series, we detail cases of epilepsy surgery failure subsequently attributed to insular involvement. Methods: We retrospectively identified patients investigated at the epilepsy monitoring units of two Canadian tertiary care centers (2004–2020). Included patients were adults who had undergone epilepsy surgeries with recurrence of seizures post-operatively and who were subsequently determined to have an insular epileptogenic focus. Clinical, electrophysiological, neuroimaging, and surgical data were synthesized. Results: We present 14 patients who demonstrated insular epileptic activity post-surgery-failure as detected by intracranial EEG, MEG, or seizure improvement after insular resection. Seven patients had manifestations evoking possible insular involvement prior to their first surgery. Most patients (8/14) had initial surgeries targeting the temporal lobe. Seizure recurrence ranged from the immediate post-operative period to one year. The main modality used to determine insular involvement was MEG (8/14). Nine patients underwent re-operations that included insular resection; seven achieved a favorable post-operative outcome (Engel I or II). Conclusions: Our series suggests that lowering the threshold for suspecting insular epilepsy may be necessary to improve epilepsy surgery outcomes. Detecting insular epilepsy post-surgery-failure may allow for re-operations which may lead to good outcomes.

ECG monitoring of post-stroke occurring arrhythmias: an observational study using 7-day Holter ECG

Post-stroke arrhythmias represent a risk factor for complications and worse prognosis after cerebrovascular events. The aims of the study were to detect the rate of atrial fibrillation (AF) and other cardiac arrhythmias after acute ischemic stroke, by using a 7-day Holter ECG which has proved to be superior to the standard 24-h recording, and to evaluate the possible association between brain lesions and arrhythmias. One hundred and twenty patients with cryptogenic ischemic stroke underwent clinical and neuroimaging assessment and were monitored with a 7-day Holter ECG. Analysis of the rhythm recorded over 7 days was compared to analysis limited at the first 24 h of monitoring. 7-day Holter ECG detected AF in 4% of patients, supraventricular extrasystole (SVEB) in 94%, ventricular extrasystole (VEB) in 88%, short supraventricular runs (SVRs) in 54%, supraventricular tachycardia in 20%, and bradycardia in 6%. Compared to the first 24 h of monitoring, 7-Holter ECG showed a significant higher detection for all arrhythmias (AF p = 0.02; bradycardia p = 0.03; tachycardia p = 0.0001; SVEB p = 0.0002; VEB p = 0.0001; SVRs p = 0.0001). Patients with SVRs and bradycardia were older (p = 0.0001; p = 0.035) and had higher CHA2DS2VASc scores (p = 0.004; p = 0.026) respectively, in the comparison with patients without these two arrhythmias. An association was found between SVEB and parietal (p = 0.013) and temporal (p = 0.013) lobe lesions, whereas VEB correlated with insular involvement (p = 0.002). 7-day Holter ECG monitoring proved to be superior as compared to 24-h recording for the detection of all arrhythmias, some of which (SVEB and VEB) were associated with specific brain areas involvement. Therefore, 7-day Holter ECG should be required as an effective first-line approach to improve both diagnosis and therapeutic management after stroke.

Differences between Atrial Fibrillation Detected before and after Stroke and TIA: A Systematic Review and Meta-Analysis

Background: Preliminary evidence suggests that patients with atrial fibrillation (AF) detected after stroke (AFDAS) may have a lower prevalence of cardiovascular comorbidities and lower risk of stroke recurrence than AF known before stroke (KAF). Objective: We performed a systematic search and meta-analysis to compare the characteristics of AFDAS and KAF. Methods: We searched PubMed, Scopus, and EMBASE for articles reporting differences between AFDAS and KAF until June 30, 2021. We performed random- or fixed-effects meta-analyses to evaluate differences between AFDAS and KAF in demographic factors, vascular risk factors, prevalent vascular comorbidities, structural heart disease, stroke severity, insular cortex involvement, stroke recurrence, and death. Results: In 21 studies including 22,566 patients with ischemic stroke or transient ischemic attack, the prevalence of coronary artery disease, congestive heart failure, prior myocardial infarction, and a history of cerebrovascular events was significantly lower in AFDAS than KAF. Left atrial size was smaller, and left ventricular ejection fraction was higher in AFDAS than KAF. The risk of recurrent stroke was 26% lower in AFDAS than in KAF. There were no differences in age, sex, stroke severity, or death rates between AFDAS and KAF. There were not enough studies to report differences in insular cortex involvement between AF types. Conclusions: We found significant differences in the prevalence of vascular comorbidities, structural heart disease, and stroke recurrence rates between AFDAS and KAF, suggesting that they constitute different clinical entities within the AF spectrum. PROSPERO registration number is CRD42020202622.

Spatial Glioma Distribution and Development of Post-Radiation Injury: The Left Temporal Region

Post-radiation injury, such as early pseudoprogression or late-onset radionecrosis, is a relatively common finding after high-dose radiotherapy and occurs in 20%-30% of glioma patients treated with cranial radiotherapy. This side effect often leads to a treatment dilemma, as it can be difficult to distinguish from tumor progression on MRI. Associated risk factors are radiation dose and chemotherapeutic treatment. However, not much is known about the role of tumor location in development of these lesions. Therefore, we aimed to explore the spatial distribution, in location as well as volume, of glioma in relation to development of post-radiation injury.In a retrospective database of 144 adult cases of histologically confirmed WHO grade II-IV supratentorial gliomas, we identified 73 patients who received first surgery in 2012 till 2014 with postoperative MRI within 3 days, and subsequent radiotherapy with a follow-up of at least 6 months. Tumors were manually delineated on pre-operative T1 contrast-enhanced (T1-CE) MRI and location and volume were registered. Among the 73 patients, 15 had tumors which were not delineable on T1-CE, due to lack of clear contrast enhancement, and were thus excluded. Post-radiation injury lesions were defined as new enhancements on CE-T1 MRI which stabilized or decreased after at least 3 months follow-up. These lesions were investigated with regard to pre-operative tumor location and size. Tumor location was investigated after transformation to MNI space and determined with the neuroanatomical atlas by Neuromorphometrics Inc. and subsequently classified by frontal, insular, parietal, temporal and occipital involvement of either hemisphere.Incidence of tumors with and without post-radiation injury lesions did not differ between hemispheres. When considering tumor location, however, involvement of the left temporal region was significantly associated with development of post-radiation injury (P = 0.012). Pre-operative volumetric tumor size was not associated with development of post-radiation injury.Tumor location may predispose for post-radiation injury, either by local processes or factors involving prior surgical treatment. Our study showed a significantly increased occurrence of post-radiation injury in the left temporal region. Thorough examination of the spatial distribution of tumors and subsequent complications might be useful in further exploring etiology and eventually guiding treatment decisions.

Automated electrical source imaging with scalp EEG to define the insular irritative zone: Comparison with simultaneous intracranial EEG

ObjectiveTo evaluate the accuracy of automatedinterictallow-density electrical source imaging (LD-ESI) to define the insular irritative zone (IZ) by comparing the simultaneous interictal ESI localization with the SEEG interictal activity. MethodsLong-term simultaneous scalp electroencephalography (EEG) and stereo-EEG (SEEG) with at least one depth electrode exploring the operculo-insular region(s) were analyzed. Automated interictal ESI was performed on the scalp EEG using standardized low-resolution brain electromagnetic tomography (sLORETA) and individual head models. A two-step analysis was performed: i) sublobar concordance betweencluster-based ESI localization and SEEG-based IZ; ii) time-locked ESI-/SEEG analysis. Diagnostic accuracy values were calculated using SEEG as reference standard. Subgroup analysis wascarried out, based onthe involvement of insular contacts in the seizure onset and patterns of insular interictal activity. ResultsThirty patients were included in the study. ESI showed an overall accuracy of 53% (C.I. 29–76%). Sensitivity and specificity were calculated as 53% (C.I. 29–76%), 55% (C.I. 23–83%) respectively. Higher accuracy was found in patients with frequent and dominant interictal insular spikes. ConclusionsLD-ESI defines with good accuracy the insular implication in the IZ, which is not possible with classical interictalscalpEEG interpretation. SignificanceAutomated LD-ESI may be a valuable additional tool to characterize the epileptogenic zone in epilepsies with suspected insular involvement.

The cognitive side of ALS

The presence of cognitive and/or behavioral impairment, ranging from frontotemporal dementia (FTD) to selective neuropsychological dysfunction, in now established, and has been shown to have prognostic impact.The diagnosis is now defined on the basis of the revised diagnostic criteria proposed by Strong et al. (Amyotrophic lateral sclerosis and frontotemporal degeneration 18,153–174, 2017), which emphasize the impact of disorders of executive function, but acknowledge the possible presence of “mixed” patters of cognitive impairment. This is confirmed by the results of studies using data-driven approaches, which have indicated the presence of three main test clusters, two compatible with the behavioral (ALSbi) and cognitive (ALSci) profiles of Strong et al. criteria, and a third loading on social cognition, language and memory tests, representing a distinct pattern of non-motor manifestations in a subsample of patients. The latter pattern of cognitive dysfunction is of particular interest, as disorders of social cognition and language are the typical markers of, respectively, the behavioral and language variants of FTD, and are associated to the neurodegenerative involvement of the large scale networks specifically associated with these function. Magnetic resonance studies have confirmed the correlation of performance on social cognition test wth atrophy measures in the anterior cingulate cortex and right inferior frontal gyrus, and of language impairment with left temporal pole and insular involvement in ALS. Further studies on large patient populations are ongoing to confim the existence of consistent cognitive phenotype differences and their assoiciation with additional genetic, clinical and prognostic factors.

ALTEPLASE-ASSOCIATED ANGIOEDEMA: NEW TREATMENT OPTIONS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Alteplase (recombinant tissue plasminogen activator or tPA) has revolutionized the management of acute ischemic stroke since its FDA approval in 1995. Intracerebral bleed is the most known and feared complication after tPA administration. tPA-associated orolingual angioedema (TAOA) is a less common but potentially fatal complication of tPA. We report a patient who developed hemi-orolingual angioedema after receiving tPA. CASE PRESENTATION: A 79-year-old female presented with sudden onset right-sided weakness with initial National Institutes of Health Stroke Scale score of 4. CT head was negative for intracranial bleed and a CT angiogram with perfusion of the head showed occlusion of P2 segment of the left posterior cerebral artery. She received tPA bolus followed by infusion and was transferred to the intensive care unit. She developed right hemi-orolingual angioedema without evidence of airway compromise one and half hours after tPA initiation. Administration of intravenous corticosteroids and antihistamines failed to improve angioedema. She was subsequently treated with 2 units of fresh frozen plasma (FFP) with complete resolution of swelling within 2 hours. DISCUSSION: Alteplase cleaves plasminogen to plasmin which degrades thrombus-bound fibrin. Plasmin also activates the kinin and complement pathways causing increased bradykinin and histamine release respectively. Bradykinin-mediated vasodilation appears to be the primary cause of TAOA. TAOA has an incidence of 0.2-5.1%. It usually develops hemi-lingually and tends to be contralateral to the ischemic side possibly due to autonomic dysfunction from insular cortex ischemia. However, this may not always be true since our patient had contralateral angioedema without insular cortex involvement. Initial management includes corticosteroids and antihistamines which are less effective for bradykinin-mediated angioedema. FFP contains kininase 2 which degrades bradykinin and hence is effectively used off label for angiotensin-converting enzyme inhibitor-induced angioedema. As TAOA also follows the bradykinin pathway, we treated our patient with FFP. To our knowledge, this is the first-ever case of TAOA treated with FFP. Other potential treatment options include C1 esterase inhibitor, icatibant (bradykinin receptor antagonist), and ecallantide (kallikrein inhibitor) which are being used for hereditary angioedema and need to be studied for TAOA. CONCLUSIONS: TAOA is a life-threatening complication that typically occurs in the first 4 hours after tPA administration. Physicians should be aware of this uncommon side effect for early recognition and treatment. Treatment targeting the bradykinin pathway like FFP might be more effective and needs further investigation. REFERENCE #1: Rathbun KM. Angioedema after thrombolysis with tissue plasminogen activator: an airway emergency. Oxf Med Case Reports. 2019;2019(1):omy112. Published 2019 Jan 24. doi:10.1093/omcr/omy11 REFERENCE #2: Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke. M. D. Hill, T. Lye, H. Moss, P. A. Barber, A. M. Demchuk, N. J. Newcommon, T. L. Green, C. Kenney, A. Cole–Haskayne, A. M. Buchan. Neurology May 2003, 60 (9) 1525-1527; DOI: 10.1212/01.WNL.0000058840.66596.1A DISCLOSURES: No relevant relationships by Robert Caldera, source=Web Response No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Bilal Khan, source=Web Response No relevant relationships by Nirav Mistry, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Fariborz Rezai, source=Web Response No relevant relationships by Aditi Saha, source=Web Response No relevant relationships by Sohaib Tariq, source=Web Response No relevant relationships by Lalithaa Thirunavukarasu Murugan, source=Web Response No relevant relationships by Paul Yodice, source=Web Response

The phenotypic spectrum of KCNT1: a new family with variable epilepsy syndromes including mild focal epilepsy.

Pathogenic variants in KCNT1 have been associated with severe forms of epilepsy, typically sleep-related hypermotor epilepsy or epilepsy of infancy with migrating focal seizures. To show that pathogenic variants in KCNT1 can be associated with mild extra-frontal epilepsy, we report a KCNT1 family with a wide spectrum of phenotypes ranging from developmental and epileptic encephalopathy to mild focal epilepsy without cognitive regression and not consistent with sleep-related hypermotor epilepsy. A large Canadian family of Caucasian descent including 9 affected family members was recruited. Family members were phenotyped by direct interview and review of existing medical records. Clinical epilepsy gene panel analysis and exome sequencing were performed. Phenotypic information was available for five family members of which two had developmental and epileptic encephalopathy and three had normal development and focal epilepsy with presumed extra-frontal onset. All three had predominantly nocturnal seizures that did not show hyperkinetic features. All three reported clusters of seizures at night with a feeling of being unable to breathe associated with gasping for air, choking and/or repetitive swallowing possibly suggesting insular or opercular involvement. Genetic analysis identified a heterozygous KCNT1 c.2882G > A, p.Arg961His variant that was predicted to be deleterious. This family demonstrates that the phenotypic spectrum associated with KCNT1 pathogenic variants is broader than previously assumed. Our findings indicate that variants in KCNT1 can be associated with mild focal epilepsy and should not be excluded during variant interpretation in such patients based solely on gene-disease validity.

Effects of insular involvement on functional outcome after intracerebral hemorrhage.

Ischemic stroke, as well as intracerebral hemorrhage (ICH), involving the insular cortex tends to be more severe. The impact of insular involvement on outcome of ICH remains enigmatic. We analyzed 159 patients with supratentorial ICH. Depending on insular involvement the patients were classified into two groups (ICHnon-insular vs. ICHinsular ). Volume and symptom severity of ICH were assessed. Electrocardiography, chest X-ray, and laboratory examinations including myocardial enzymes and inflammatory markers were made. In-hospital death and outcome at discharge from hospital were assessed on the modified Rankin scale (mRS). The main finding was an association of insular involvement of ICH with worse short-term outcome as measured by mRS (common odds ratio: 4.08 (95% CI: 2.09-7.92); p<.001). This association survived adjustment to relevant covariates such as age, sex, ICH volume, intraventricular hemorrhage, pneumonia, and length of stay (adjusted common odds ratio: 2.51 (95% CI: 1.21-5.21); p=.014) but had no predictive value for side of ICH or rate of atrial fibrillation. There was no association of ICH localization with in-hospital death rate. Insular localization of ICH lesions predicts worse short-term functional outcome independent of side of bleeding or cardiac dysfunction such as new AF. These findings need clarification in larger prospective cohorts assessed by detailed autonomic/cardiac testing, as well as neuroimaging sub-localization of ICH within the insular region.

The Association Between Insular Subdivisions Functional Connectivity and Suicide Attempt in Adolescents and Young Adults with Major Depressive Disorder.

Previous studies demonstrated the possible involvement of insula in suicide owing to depression. However, the function of insula in young depressed patients with suicide attempt (SA) remains to be revealed. This study aimed to explore the association between resting-state functional connectivity (FC) of insula and SA in young depressed patients. Fifty-eight adolescents and young adults with major depressive disorder, including 22 with a history of at least one SA (SA group) and 36 without a history of SA (NSA group) were scanned with a 3.0T functional magnetic resonance imaging system, and the resting-state functional magnetic resonance imaging data was extracted. Whole brain resting-state FC of insular subdivisions were compared between the two groups. Significantly increased FC of the left posterior insula withthe orbital part of left inferior frontal gyrus, the right supplementary motor area and the bilateral paracentral lobule extending to the bilateral middle cingulate cortex was observed in the SA group compared with the NSA group. In addition, the orbital part of left superior frontal gyrus in the SA group exhibited significantly increased FC with the right posterior insula compared with the NSA group. However, no significant correlation was found between the insular subdivisions FC and different clinical variables in two groups. The present study highlighted the disruptions of the resting-state FC of the posterior insula with the orbitofrontal cortex and a series of motor cortices, and added incremental value to the knowledge of the neural mechanism underlying SA in young depressed patients.

The chapeau de gendarme sign can be evoked by lateral prefrontal epileptic seizures

PurposeThe ‘chapeau de gendarme’ (CDG) sign, characterised by a symmetric down-turned mouth, has been considered as a semiological hallmark of focal epileptic seizures with cingulate or insular involvement. We report three cases in which the CDG sign featured in habitual seizures. MethodsThe epileptogenic zones of these three patients were localized in the lateral prefrontal cortex by video-stereoelectroencephalography monitoring. A sulcal resection has led to a seizure-free outcome in each patient. ResultsIctal stereoelectroencephalography demonstrated that ictal discharges arising from the lateral prefrontal cortices were immediately followed by low-voltage fast activity, concomitantly involving the anterior insulo-cingulate cortices, and preceding the onset of the CDG signs. Limited sulcal resection and seizure freedom after surgery confirmed the restricted distributions of the epileptogenic zones in the lateral prefrontal cortex. ConclusionOur observations led us to speculate that the epileptic discharges could enter the emotional insulo-cingulate cortical system through the prefrontal-cingulate inhibitory projections (feedforward pattern) —arising from the supragranular layers of the lateral prefrontal cortex—and proceed to the deeper layers of the anterior-middle cingulate cortex, trigger the co-occurrence of gamma bands, and evoke a set of exaggerated behaviours, which is often accompanied by the unique facial sign.

It's more than just interoception: The insular cortex involvement in alcohol use disorder.

Understanding brain structures and circuits impacted by alcohol use disorder is critical for improving our future prevention techniques and treatment options. A brain region that has recently gained traction for its involvement in substance use disorder is the insular cortex. This brain region is multi-functional and spatially complex, resulting in a relative lack of understanding of the involvement of the insular cortex in alcohol use disorder. Here we discuss the role of the insular cortex in alcohol use disorder, particularly during periods of abstinence and in response to alcohol and alcohol-related cues and contexts. We also discuss a broader role of the insular in alcohol-associated risky decision making and impulse control. Finally, we canvas potential challenges associated with targeting the insular cortex to treat individuals with alcohol use disorder.

Study protocol for a systematic review and meta-analysis of comorbidities and stroke characteristics associated with troponin elevation after acute stroke

IntroductionIt is unknown which comorbidities and stroke characteristics are associated with elevated cardiac troponin (cTn) levels after stroke. The main objective of this systematic review and meta-analysis is to assess...

The Case for Incorporating EEG in Clinical TMS Practice

TMS psychiatrists are seeking methods to identify subtypes of clinically complex treatment-resistant depression (TRD), requiring rigorous, in-depth assessment. Advances in affordable neurotechnology and software have made it possible to record, process, and analyze EEGs within the clinic. Psychiatrists can learn to decipher the electroencephalograph (EEG) according to the EEG phenotype model developed by Johnston, Gunkelman, & Lunt (2005). We reviewed and processed raw EEG recordings, using WinEEG software, from 50 recent TRD TMS patients. Their primary diagnoses included: MDD recurrent (54%), MDD recurrent with mixed features (22%), bipolar 1 depression (4%), and bipolar 2 depression (20%). Secondary diagnoses included chronic PTSD (72%), dysthymia (32%), comorbid anxiety disorder (48%), OCD (6%), substance use disorder in full remission (18%), alcohol use disorder (6%), cannabis use disorder (4%), personality disorders (10%), and ADHD (12%). Baseline EEGs showed the following features, in ranking order: dysfunctional insular involvement seen in independent component analysis (80%), a marker of severity of depression; hypercoherent frontal alpha, reflecting diminished cognitive and emotional control (80%); excess alpha at right temporoparietal junction (76%), likely a marker relating to comorbid chronic PTSD; and tonic midline theta (38%), a marker of anterior cingulate involvement, often reflecting fear and dread, and excess beta abnormalities (80%) reflecting issues of overarousal. We currently use EEG data to inform medication choices and TMS protocol indications and contraindications. We believe these findings have helped guide successful treatment choices and hope to validate that observation with these and an additional 300 patients’ EEG, clinical, and TMS treatment response data.

Lateralized Rhythmic Delta Activity in Patients With Infectious or Autoimmune Insular Lesions.

Lateralized rhythmic delta activity (LRDA) is a rare pattern on the ictal-interictal continuum (IIC) encountered in critically ill patients. Its association with acute seizures is yet to be fully explored. Insular involvement is a common finding in patients with infectious and autoimmune encephalitis. The association between acute insular lesions and the ictal-interictal continuum, particularly LRDA, has not been explored before. A case series of 4 patients with either herpetic or autoimmune encephalitis and prominent insular cortex involvement who had LRDA when monitored on continuous EEG is being presented. Two patients had herpetic encephalitis and 2 patients had autoimmune encephalitis. All patients had either clinical or electrographic seizures with 1 patient progressing into new-onset refractory status epilepticus. LRDA can be seen in patients with insular cortex acute inflammation. In this group of patients, LRDA may be associated with a higher risk of acute seizures. The presence of this otherwise not clearly epileptiform pattern should raise the clinical suspicion for the development of acute seizures. Patients with LRDA and ipsilateral insular lesions should be carefully monitored for the development of recurrent electrographic or electroclinical seizures and status epilepticus.

Electrocardiographic Abnormalities in Hospitalized acute Cerebrovascular Events

Background: - Physicians are confronted on having ECG in patients with acute stroke as it can mimic that of myocardial infarction or ischaemia. Repolarization and ischemic-like electrocardiographic (ECG) changes observed during acute phase of stroke may cause diagnostic and management dilemmas for the physicians.&#x0D; Aim:- The aim and objective of this study to identify the prevalence of ECG changes in acute stroke patients admitted to medicine units of Dhaka Medical College Hospital.&#x0D; Materials and Method: - This 6-month period observational study was carried out among 100 of acute stroke patients admitted in different medicine wards of Dhaka Medical College Hospital (DMCH). ECG was done in all patients after their admission to hospital within 48 hours of developing their symptoms. Association of various types of ECG changes were identified and observed.&#x0D; Results: - Among 100 patients,55% had ischaemic stroke and 45% had haemorrhagic stroke. 43.63% aged between 61-70 years had ischaemic stroke and 28.28% aged between 61-80 years had haemorrhagic stroke. Female had higher frequency of ischaemic stroke 52.72% and male had higher frequency of haemorrhagic stroke 75.56%. Abnormal ECG found 84.44% in haemorrhagic stroke and 54.54% in ischaemic stroke. Of all abnormal ECG, ST depression is most frequent and 42.22% in haemorrhagic stroke, T inversion is next 20% in ischaemic stroke, AF is present in 18.18% in ischaemic stroke and QT prolongation is found in 17.77% in hemorrhagic stroke. There considerable variation of ECG changes according to CT scan evidence of particular area of brain involvement like ST depression (28.88%) found in gangliothalamic bleed in haemorrhagic stroke, AF is found (16.36%) in insular area involvement in ischaemic stroke, T inversion is more (12.72%) in large MCA territory infarctive stroke and QT prolongation (11.11%) is found in intracerebral haemorrhage including SAH. Predictable early in hospital mortality is associated with AF 37.5% and with QT prolongation 31.25%.&#x0D; Conclusion:- In haemorrhagic stroke the ECG abnormalities were more frequent then in ischaemic stroke. The most common abnormalities were ST depression, T wave inversion, AF and QT prolongation. AF and QT prolongation has association of early in hospital mortality.&#x0D; J Bangladesh Coll Phys Surg 2020; 38(4): 166-171

The timelines of MRI findings related to outcomes in adult patients with new-onset refractory status epilepticus.

To identify the timelines of magnetic resonance imaging (MRI) abnormalities and their relationships with the clinical outcomes of patients with new-onset refractory status epilepticus (NORSE). This retrospective observational study enrolled patients with NORSE who were admitted from March 2008 to July 2018. MRI abnormalities were analyzed visually with the readers blinded to the clinical characteristics of the patients. Poor functional outcome was defined as a Glasgow Outcome Scale score≤3 at discharge. Subsequent pharmacoresistant epilepsy was defined as seizures not controlled by two or more anti-seizure medications 6months after discharge. Among 39 patients with NORSE, 32 (82.1%) exhibited an MRI abnormality. The most common abnormalities were persisting mesial temporal lobe signal abnormality (51.3%); initial diffuse leptomeningeal enhancement within 16days from seizure onset (15/35, 42.9%); and hippocampal atrophy, which started to appear 26days after seizure onset (15/26, 57.7%). Only three patients had claustrum abnormalities. Patients with insular involvement had longer treatment delay than those without (24.0 vs 5.5hours, respectively, P=.02). Duration of status epilepticus (SE) tended to have a linear association with hippocampal atrophy (P=.055). Patients with diffuse leptomeningeal enhancement were more likely to have a poor functional outcome and to develop subsequent pharmacoresistant epilepsy than those without this finding (93.3% vs 15.0%, P<.001; 75.0% vs 22.2%, P=.004, respectively); the results were significant even after adjusting for age, sex, and duration of SE. Hippocampal atrophy and diffuse cortical atrophy were also significantly associated with poor functional outcomes (P=.001 and P=.002, respectively), and patients with these conditions were more likely to develop subsequent pharmacoresistant epilepsy than those without these conditions, after adjusting for age and sex (P=.035 and P=.048, respectively), but not after adjusting for duration of SE. Initial diffuse leptomeningeal enhancement and later hippocampal atrophy were associated with a poor functional outcome and subsequent pharmacoresistant epilepsy.

CORRELATION OF SERUM CORTISOL LEVEL WITH THE PROGNOSIS OF STROKE: A CROSS SECTIONAL STUDY

Introduction: Cortisol is a hormone of immense importance in the hypothalamo-pituitary-adrenal axis &amp; it has got paramount effects on the metabolism of lipid, glucose &amp; protein. With reference to stroke, a stress response implies rise in the levels of catecholamines &amp; cortisol during the 1st week after the acute episode. Such kind of response is evident in infarction of cerebrum &amp; bleeding in the cerebral cortex. There is ample amount of evidence from past studies that raised levels of serum cortisol levels are associated with volume of ischemic lesion.&#x0D; Patients and methods: Subjects included were patients who were admitted in the hospital within six hours after the stroke episode. Every patient was monitored for Scandinavian Stroke Scale (SSS) after the admission. This test was conducted per two hours in first twenty four hours, then per four hours in the next 48 hours &amp; then every day up-to seventh day. Blood samples were extracted for the estimation of serum cortisol. Time duration of 01:00 AM to 07:00 AM was excluded for sample extraction.&#x0D; Results: Serum cortisol level was significantly higher in subjects with insular involvement (635 nmol/l) as compared to patients without insular involvement.&#x0D; Conclusion: It’s quite clear from our study that raised cortisol levels are highly associated with bad outcome &amp; poor response in patients with stroke.&#x0D; Keywords: Serum Cortisol, hypothalamo-pituitary-adrenal axis, Stroke.

Insular Cell Integrity Markers Linked to Weight Concern in Anorexia Nervosa-An MR-Spectroscopy Study.

Objective: An insular involvement in the pathogenesis of anorexia nervosa (AN) has been suggested in many structural and functional neuroimaging studies. This magnetic resonance spectroscopy (MRS) study is the first to investigate metabolic signals in the anterior insular cortex in patients with AN and recovered individuals (REC). Method: The MR spectra of 32 adult women with AN, 21 REC subjects and 33 healthy controls (HC) were quantified for absolute N-acetylaspartate (NAA), glutamate + glutamine (Glx), total choline, myo-inositol, creatine concentrations (mM/L). After adjusting the metabolite concentrations for age and partial gray/white matter volume, group differences were tested using one-way multivariate analyses of variance (MANOVA). Post-hoc analyses of variance were applied to identify those metabolites that showed significant group effects. Correlations were tested for associations with psychometric measures (eating disorder examination), duration of illness, and body mass index. Results: The MANOVA exhibited a significant group effect. The NAA signal was reduced in the AN group compared to the HC group. The REC and the HC groups did not differ in metabolite concentrations. In the AN group, lower NAA and Glx signals were related to increased weight concern. Discussion: We interpret the decreased NAA availability in the anterior insula as a signal of impaired neuronal integrity or density. The association of weight concern, which is a core feature of AN, with decreased NAA and Glx indicates that disturbances of glutamatergic neurotransmission might be related to core psychopathology in AN. The absence of significant metabolic differences between the REC and HC subjects suggests that metabolic alterations in AN represent a state rather than a trait phenomenon.