Munish Kumar Goyal

Penumbra, the basis of neuroimaging in acute stroke treatment: Current evidence

In modern medicine brain imaging is an essential prerequisite not only to acute stroke triage but also to determining the specific therapy indicated. This article reviews the need for imaging the brain in acute stroke, penumbral pathophysiology, penumbral imaging techniques, as well as current status of various imaging modalities that are being employed to select patients for specific therapeutic approaches.

Warfarin versus Aspirin for Prevention of Stroke in Heart Failure: A Meta-analysis of Randomized Controlled Clinical Trials

BACKGROUND There is clinical equipoise between warfarin and aspirin for stroke prevention in patients with heart failure in sinus rhythm (SR). The objective of this meta-analysis was to pool risk estimates for stroke, mortality, and intracerebral hemorrhage (ICH) from published clinical randomized controlled trials (RCTs). METHODS MEDLINE, EMBASE, the Cochrane Library, and clinicaltrials.gov were searched for English-language RCTs comparing warfarin to aspirin in heart failure through May 2012. Pooled relative risk (RR) was calculated from a random-effects model. RESULTS Four RCTs (n=3681) met the criteria for study inclusion. Warfarin was associated with a lower risk of stroke compared with aspirin (pooled RR, .59; 95% confidence interval [CI], .41-.85; P=.004). The number needed to treat (NNT) was 61. There was no difference between warfarin and aspirin in mortality (pooled RR, 1; 95% CI, .88-1.13), and ICH (pooled RR, 2.17; 95% CI, .76-6.24). Among secondary outcomes, warfarin was associated with almost twice the risk of major hemorrhage (pooled RR, 1.95; 95% CI, 1.37-2.76; P=.0001) compared with aspirin. The number needed to harm (NNH) was 34. There was no significant difference between warfarin and aspirin in risk of myocardial infarction (MI) (pooled RR, 1.02; 95% CI, .65-1.6], and heart failure exacerbation (HFE) (pooled RR, 1.11; 95% CI, .76-1.63). CONCLUSIONS Compared with aspirin, warfarin reduced the risk of stroke while conferring an increased risk of major hemorrhage. Warfarin does not increase mortality or confer an increased risk of ICH compared with aspirin.

Levetiracetam-induced thrombocytopenia among inpatients: a retrospective study.

Lately, few case reports have brought forth limited cases of levetiracetam (LEV)‐induced thrombocytopenia. To estimate the burden of LEV‐induced thrombocytopenia, we reviewed medical records of 758 patients aged 18 years or older who received LEV during their stay at the University Hospital from June 2005 to December 2008. In patients identified with thrombocytopenia, records were reviewed to establish a cause of thrombocytopenia and possible causal role of LEV. Of 758 patients, 29 patients were identified with thrombocytopenia while on LEV therapy. For 23 patients, an alternative cause for thrombocytopenia was established; 4 patients had preexisting thrombocytopenia without any appreciable change in platelet count after addition of LEV. One patient had limited data for identifying the cause of thrombocytopenia. A single patient had clear temporal co‐relation and association of thrombocytopenia with LEV therapy. LEV‐induced thrombocytopenia is a rare but reversible complication of LEV therapy. The mechanism remains unknown.

Necrobacillosis resulting in isolated carotid thrombosis and massive stroke: A unique Lemierre variant?

We describe a healthy, young adult male patient who developed isolated carotid artery thrombosis and occlusion following acute pharyngitis due to Fusobacterium necrophorum. We believe this is the first case of isolated occlusion of internal carotid artery (ICA) with F.necrophorum without associated internal jugular vein (IJV) thrombosis. Lemierres syndrome (LS) is characterized by a history of recent oropharyngeal infection in previously healthy individuals, clinical or radiological evidence of internal jugular vein thrombosis, and isolation of anaerobic pathogens, mainly F.necrophorum. We discuss literature on this rare, previously unreported, variant of LS.

Reversible sensorineural hearing loss with normal brainstem auditory evoked potentials in pontine hemorrhage due to capillary telangiectasia

Capillary telangiectasias are vascular malformations most commonly found in the pons that are rarely associated with hemorrhage. We describe a unique case of pontine capillary telangiectasia causing central brainstem hemorrhage leading to reversible sensorineural deafness associated with a normal brainstem auditory evoked response.

Isolated Hypersomnia Due to Bilateral Thalamic Infarcts

We describe a unique patient who developed hypersomnia as the sole presenting symptom of bilateral thalamic infarcts.

Electroencephalographic abnormalities in baclofen-induced encephalopathy.

We report a patient in whom the characteristic electroencephalographic features of baclofen intoxication are highlighted and emphasize the role of electrographic abnormalities in the diagnosis of this condition.

Recurrent epileptic Wernicke aphasia

We report a patient with recurrent epileptic Wernicke aphasia who prior to this presentation, had been misdiagnosed as transient ischemic attacks for several years. This case report emphasizes the consideration of epileptic nature of aphasia when a clear alternate etiology is unavailable, even when EEG fails to show a clear ictal pattern. We also present a brief discussion of previously reported ictal aphasias.

Sleep Issues in Myopathic Disorders and Muscular Dystrophies

Myopathies and muscular dystrophies are disease inherent to muscles and have the common feature of muscle weakness. Multiple sleep disorders are associated with them. Sleep disordered breathing disorder (SRBD) is the most common sleep disorder in both myopathies and muscular dystrophies. Various different factors contributed to the development of SRBD that include diaphragmatic involvement, coexisting cardiac abnormalities, reduction in lung volumes and capacities, and airway obstruction. Other sleep disorders in these conditions include insomnia, restless legs syndrome, hypersomnolence, and parasomnias.

Headache Syndromes and Sleep

The enigmatic relationship between headache and sleep has been known for a long period of time. The basis of this relationship has been explored and validated by various studies. This has led to better understanding of the relationship between these two entities. Further, it has implications for diagnosis of headache type and management. We describe the association of various headache syndromes with sleep disorders.