Atul Agarwal

Serial changes in the white matter diffusion tensor imaging metrics in moderate traumatic brain injury and correlation with neuro-cognitive function.

Diffuse axonal injury (DAI) that follows traumatic brain injury (TBI) is thought to be a major contributor to neurocognitive dysfunction that sometimes follows TBI. Conventional magnetic resonance imaging (MRI), diffusion tensor imaging (DTI) and neuropsychological tests (NPT) were performed on 38 TBI patients [hemorrhagic DAI (H-DAI, n=8), non-hemorrhagic (Nh-DAI, n=7), with no apparent DAI on conventional MRI (NA-DAI, n=23)] with a Glasgow Coma Scale score ranging between 9 and 13. The fractional anisotropy (FA) and mean diffusivity (MD) were quantified from different regions of the corpus callosum (CC), and peri-ventricular white matter (PWM) within 5-14 days and 6 months following TBI. Patients in all three groups showed decreased FA in the anterior limb of the internal capsule (ALIC) and the posterior limb of the internal capsule (PLIC), while the genu of the CC showed a decrease in the H-DAI group during the early period following TBI that persisted 6 months later, which appeared to be consistent with axonopathy. In patients without abnormalities on conventional MRI and DTI in the initial phase, a significant decrease in FA and increase in MD were observed in a few regions of the CC at 6 months, which was suggestive of demyelination/gliosis. The changes in FA and MD in the CC and PWM at 6 months follow-up showed significant correlation with some of the NPT performed in the three groups. DTI demonstrates axonopathy in the acute stage, as well as at secondary stages, at 6 months post-injury in the CC and PWM in regions of normal-appearing white matter on conventional MRI.

Focal Wallerian degeneration of the corpus callosum in large middle cerebral artery stroke: Serial diffusion tensor imaging

To detect lesion‐related focal Wallerian degeneration (WD) changes in different segments of the corpus callosum (CC) in patients with large middle cerebral arterial (MCA) territory stroke using diffusion tensor imaging (DTI).

Diffusion Tensor Imaging in Late Posttraumatic Epilepsy

Summary:  Purpose: The main objective of this study was to use diffusion tensor imaging (DTI) to search and quantify the extent of abnormality beyond the obvious lesions seen on the T2 and fluid‐attenuation inversion recovery (FLAIR) magnetic resonance images in patients with chronic traumatic brain injury (TBI) with and without epilepsy.

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.

Vision impairment in tuberculous meningitis: Predictors and prognosis

BACKGROUND Vision impairment is a devastating complication of tuberculous meningitis. In the present study we evaluated the predictors and prognostic significance of vision impairment in tuberculous meningitis. METHODS In this study, 101 adult patients with tuberculous meningitis were evaluated for vision status and physical disability and were followed up for 6 months. Contrast enhanced magnetic resonance imaging (MRI) was performed at baseline and 6 months. RESULT Out of 101 patients, 74 patients had normal vision and 27 patients had low vision or blindness at enrollment. Thirteen patients died during the study period. Out of 88 patients who survived at 6 months, 68 patients had good vision, 11 patients had low vision and 9 patients had blindness. Predictors of vision deterioration were papilledema, cranial nerve palsies, raised cerebrospinal fluid protein (>1g/L), and presence of optochiasmatic arachnoiditis in MRI. Predictors of blindness, at 6 months, were found to be papilledema, vision acuity < or =6/18, cranial nerve palsies, tuberculous meningitis stage II or III, raised cerebrospinal fluid protein (>1g/L), optochiasmatic arachnoiditis, and optochiasmal tuberculoma. At 6 months, 27 patients had death or severe disability. Predictors of death or severe disability at 6 months were vision acuity < or =6/18, cranial nerve deficits, hemiparesis, clinical stage II or III, and presence of infarct in MRI. CONCLUSION Vision impairment occurred in one-fourth of patients with tuberculous meningitis. Principal causes of vision loss were optochiasmatic arachnoiditis and optochiasmal tuberculoma. Impaired vision predicted death or severe disability.

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.

Paradoxical vision loss associated with optochiasmatic tuberculoma in tuberculous meningitis: a report of 8 patients.

BACKGROUND Paradoxical appearance of new or expansion of existing optochiasmatic tuberculoma, leading to severe vision loss, is a devastating complication in patient with tuberculous meningitis. METHODS We report a series of 8 cases of tuberculous meningitis that developed paradoxical vision loss associated with optochiasmatic tuberculoma. Clinical assessment and magnetic resonance imaging (MRI) done at presentation, at the time of deterioration, and at 9 months were analyzed. RESULTS All patients had good vision acuity and normal visual field at baseline. None of them had optochiasmatic tuberculoma on magnetic resonance imaging at baseline, though 3 patients had optochiasmatic arachnoiditis. The mean interval of onset of paradoxical optochiasmatic tuberculoma was 41 days after starting antituberculosis therapy. Paradoxical optochiasmatic tuberculoma was associated with vision deterioration in all patients, 6 of whom developed severe vision loss (vision acuity <or=6/60). Repeat neuroimaging showed new optochiasmatic tuberculoma in all patients. All patients were treated with extended course of dexamethasone for 6 weeks along with antituberculosis therapy. Two patients died at 62 and 211 days respectively. Repeat neuroimaging in rest of the patients showed resolution of optochiasmatic tuberculoma. At 9 months follow-up, vision improved completely in 3 patients and partially in 3 patients. CONCLUSION Prompt recognition of paradoxical optochiasmatic tuberculoma with the help of vision assessment and neuroimaging is vital for patients life and vision. Paradoxical reactions should not be labeled as a new or resistant infection. The prior treatment schedule should continue, and dexamethasone may be added or its dose enhanced.

Extensive meningoencephalitis, retrobulbar neuritis and pulmonary involvement in a patient of neurobrucellosis.

We report an unusual case of neurobrucellosis who presented with headache, vision loss, confusional state, retrobulbar neuritis and left hemiparesis. Neuroimaging studies showed features of ischemic infarct and white matter abnormalities. Pulmonary involvement in form of lobar pneumonia of left basal lobe was another unusual manifestation. Diagnosis was based on the rising titers of antibrucella antibody. Patient showed remarkable improvement on triple drug therapy in form of doxycycline, rifampicin and streptomycin.

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.