Alok Mohan Kar

Short Course of Prednisolone in Indian Patients with Solitary Cysticercus Granuloma and New‐onset Seizures

Summary:  Purpose: To evaluate the role of a short course of oral corticosteroids in Indian patients with solitary cysticercus granuloma with seizures.

Neuroimaging abnormalities in Indian patients with uncontrolled partial seizures

In this series we performed clinical and imaging evaluation of 77 consecutive patients with uncontrolled partial seizures. Single cerebral parenchymal calcification (22 patients) was the most common imaging abnormality. Nine patients had multiple punctate calcifications. Other CT abnormalities included persistence of granulomatous lesion (enhancing) or multiple cystic lesions. In nine patients (of 22 patients with a normal CT scan) magnetic resonance imaging (MRI) was done, and two patients were seen to have circumscribed cystic lesions in the temporal lobes. The causes for uncontrolled seizures in India are totally different and revolve around neurocysticercosis, as the parasite sometimes runs a very long course of evolution in the brain. Sequelae of neurocysticercosis in the form of calcification is often a focus of epileptogenicity.

Neurological complications of miliary tuberculosis

INTRODUCTION The symptomatic central nervous system involvement is often seen in patients with miliary tuberculosis. MATERIALS AND METHODS In this study, we evaluated 60 consecutive miliary tuberculosis patients, who presented with some neurological manifestations. Evaluation included neurological examination, a battery of blood tests, HIV serology, sputum examination, cerebrospinal fluid (CSF) examination along with imaging of the brain and spinal cord. The patients were followed up after completion of 6 months of antituberculous treatment. RESULTS Patients ranged between 14 and 53 years in age. Three patients tested HIV positive. Forty-eight (80%) patients had tuberculous meningitis. In 12 (20%) patients, the CSF examination was normal. In 27 patients with tuberculous meningitis, neuroimaging revealed intracerebral tuberculoma. Fourteen patients showed multiple tuberculomas, while 7 had a solitary tuberculoma. In six patients, the tuberculomas were small and numerous. In two patients, neuroimaging revealed a spinal tuberculoma. For three patients with tuberculous brain masses, the CSF was normal. Nine (15%) patients presented with myelopathy. Three patients exhibited Potts paraplegia. Three patients had transverse myelitis (with normal neuroimaging). In three patients, the spinal MRI revealed an intramedullary tuberculoma. On follow-up, 15 (25%) patients expired. Thirty-one (52%) patients showed significant improvement. Eight patients (13%) showed nil or partial recovery. Six of the patients with no improvement developed vision loss. Six (10%) patients were lost to follow up. CONCLUSION A variety of neurological complications were noted in military tuberculosis patients, tuberculous meningitis and cerebral tuberculomas being the most frequent complications. However, a majority of patients improved following antituberculous treatment.

Intravenous methyl prednisolone in patients with solitary cysticercus granuloma: A random evaluation

PURPOSE To evaluate the role of intravenous methyl prednisolone in patients with solitary cysticercus granuloma with new-onset seizures. METHODS In this open-label, randomized, prospective, follow-up study, 52 patients with new-onset seizures and a single enhancing CT lesion of cysticercus were randomly divided in two groups to receive either intravenous methyl prednisolone for 5 days along with antiepileptic drug (n=25) or antiepileptic drug monotherapy (n=27) alone. The patients were followed up for at least for 9 months. Repeat CT scans were performed after 2 months. RESULTS After 2 months, lesion disappeared in 60% patients of intravenous methyl prednisolone group and 18.5% patients receiving only antiepileptic drug (p=0.001). As far as seizure recurrence was concerned, a lower number (16% versus 33%) of intravenous methyl prednisolone treated patient had recurrence, the difference was insignificant. CONCLUSION Intravenous methyl prednisolone therapy helps in early resolution of solitary cysticercus granuloma.

Multiple ring enhancing brain lesions on computed tomography: An Indian perspective

BACKGROUND Multiple enhancing computed tomography (CT) brain lesions are common neuroimaging abnormalities in India. Several published case reports suggest that multiple enhancing lesions of the brain can occur with a wide variety of infective and non-infective etiologies. METHODS In this prospective follow up study, 110 consecutive patients with two or more than two enhancing brain lesions were subjected to a clinical evaluation and a battery of common investigative tests. RESULTS Infective pathologies were the most common etiology for multiple enhancing lesions of the brain. Tuberculosis was the commonest infective pathology, followed by neurocysticercosis. Neoplastic diseases were common non-infective causes. In majority, brain lesions were metastatic manifestation of a systemic neoplastic disorder. Lung carcinoma was the commonest primary malignancy. One patient each had multiple brain abscesses, Behcets syndrome and systemic lupus erythematosus. Among 4 human immunodeficiency virus-infected patients, one had toxoplasmosis and two patients were diagnosed to have cryptococcal meningitis. In 45 patients, after initial work up, etiological diagnosis could not be ascertained. These undiagnosed patients were empirically treated with antituberculous drugs and corticosteroids. Six undiagnosed patients showed pulmonary metastasis on repeat X-ray chest. In 10 patients CT lesions completely disappeared. In 5 patients number of CT lesions decreased. Six patients died. However, in majority of the undiagnosed patients follow up CT scans of brain remained unaltered. CONCLUSION A large number of infectious and non-infectious diseases can cause multiple enhancing lesions of the brain. The work up of these patients should include clinical evaluation, imaging and a battery of laboratory tests. The specific diagnosis may remain a challenge in several cases.

Evaluation of role of steroid alone and with albendazole in patients of epilepsy with single-small enhancing computerized tomography lesions

This study was planned to evaluate the role of steroid alone and with albendazole in patients of single-small enhancing computerized tomography (CT) lesions in Indian patients presenting with new-onset seizures. In this study, 95 patients with new onset seizures and a single enhancing CT lesion were randomly divided in two groups to receive either antiepileptic drug and steroid alone (n=42) or antiepileptic drug with a steroid and albendazole (n=48). These patients were prospectively followed-up for six months. Repeat CT scans were performed after 30 days and six months of registration. The majority of patients were below 30 years of age. Simple partial seizure, with or without secondary generalization, was the commonest type of seizure encountered in these patients. Follow-up CT scans, after one month of registration showed complete disappearance of lesion in 16.7% of patients in Group I and in 25% of patients in Group II (χ2 =0.93, P =0.334). Follow-up CT scans, after six months of registration showed complete disappearance of lesion in 59.5% of patients in Group I and in 68.8% of patients in Group II (χ2=0.83, P =0.362). During the six months follow-up five patients (11.8%) in Group I and nine patients (18.7%) in Group II experienced seizures recurrence. Two patients in Group II experienced seizure recurrence despite complete disappearance of CT lesions. Seizure control and disappearance of lesion was same in both Groups. Albendazole does not seem to affect resolution.

Prednisolone-Responsive Headache in Patients With Solitary Cysticercus Granuloma and Seizures

Background.—Solitary cysticercus granuloma is the commonest imaging abnormality in Indian patients with new‐onset seizures. Few patients, in addition, complain of disabling headache.

Putaminal haemorrhage: An unusual imaging picture

CT scan images may show fluid level in cerebral hemorrhage secondary to anticoagulation, thrombolytic therapy or with amyloid angiopathy. Other causes of fluid levels are cerebral hemorrhage with underlying malignancy, cerebral arteriovenous malformations or radiation. We are reporting a putaminal hemorrhage with fluid level in a patient with high blood pressure. This case was unusual in the absence of any of these factors and rare location in the putamen.