Ravi Uniyal

Three unusual presentations of plasmodium vivax malaria.

We present three cases of unusual and complicated malaria caused by Plasmodium vivax. Parenteral artemisinin derivatives or quinine should be used, irrespective of chloroquine sensitivity, for treatment of severe malaria.

Ventriculo-peritoneal shunt surgery for tuberculous meningitis: A systematic review

BACKGROUND Ventriculo-peritoneal shunt surgery is one of the most commonly performed surgery for the management of tuberculous hydrocephalus. There is decreased clarity on issues regarding the indication as well as timing of cerebrospinal fluid diversion procedures in tuberculous meningitis. We systematically analysed published literature on this subject with an objective to assess the value of cerebrospinal fluid diversion procedures in tuberculous meningitis. METHODS A systematic search of literature was performed using PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) for articles published till August 2016. All original studies, irrespective of their design, enrolling at least 10 patients with tuberculous meningitis and hydrocephalus, and in whom the outcome following ventriculo-peritoneal shunt was described, were included in this review. Data was extracted on a pre-formed data extraction sheet. Primary outcome was defined using Glasgow outcome scale (GOS). RESULTS Nineteen studies, comprising of 1038 patients, were included in the review. A majority of patients were children. Good outcome (GOS 5 and 4), following ventriculo-peritoneal shunt, was observed in 58.26% of patients; 78.57% of patients in grade I, 65.35% in grade II and 67.97% in grade III achieved a good outcome while only 31.51% in grade IV could achieve a good outcome. On subgroup analysis, 61.08% of HIV-negative patients achieved a good outcome as compared to only 25% of HIV-positive patients. There were 18.03% deaths in the HIV-negative group as compared to 66.67% deaths in the HIV-positive group after shunt surgery. The rate of complications following ventriculo-peritoneal shunt was 22.11%; shunt blockage, leading to shunt revision, was the most common complication. Majority of included studies were clinically and methodologically heterogeneous. CONCLUSION Outcome, following ventriculo-peritoneal shunt, depends on the clinical severity of tuberculous meningitis. HIV-infected patients have a worse prognosis when compared with HIV uninfected patients. Compared to children, corresponding data is sparse for adult patients with tuberculous meningitis.

Is palinopsia in migraineurs an enhanced physiological phenomenon

Background We report the occurrence of palinopsia in patients with migraine and its correlation with migraine characteristics, triggers and allodynia. Methods This study included 153 consecutive patients with migraine and recorded their clinical details, including allodynia and migraine triggers and characteristics. Palinopsia was evaluated in migraineurs and 101 controls by using a questionnaire and a novel method. Results According to the questionnaire assessment, 9.8% migraineurs had palinopsia. According to the novel method, 57.5% of migraineurs and 12% of controls had palinopsia. Migraineurs most frequently had palinopsia to red color (51.6%), followed by yellow (49.7%), blue (47.7%), green (46.4%) and the least to white (30.7%). A similar pattern with a lesser frequency was noted in controls. The duration of palinopsia was longer in migraineurs than in controls (32.68 ± 20.24 vs. 5.92 ± 4.55 seconds; p < 0.001). Migraineurs with palinopsia differed from those without in terms of noise as a migraine trigger (p < 0.001) and allodynia as a migraine-associated phenomenon (p = 0.03). In multivariable analysis, predictors of palinopsia were the frequency (p = 0.003) and severity (p = 0.04) of headache and the presence of headache during examination (p = 0.0001). Conclusion Migraineurs had a pattern of palinopsia to different colors that was similar to the controls, but the palinopsia of migraineurs was more frequent and of longer duration, especially during headaches.

Teaching NeuroImages: Amlodipine-responsive trigeminal neuralgia An alibi for vascular compression theory

A 55-year-old woman developed recurrent short-lasting shock-like pain involving her left lower face. Initiation of amlodipine for concurrently detected hypertension relieved her of pain besides normalizing her blood pressure. Interestingly, occasions of noncompliance with amlodipine brought her pain back. Her cranial MRI revealed tortuous blood vessels compressing the left rostro-antero-lateral medulla and left trigeminal nerve root (figure 1). Vascular compression of medulla is known to produce neurogenic hypertension1 (figure e-1 at Neurology.org). Possibly, a decrease in vessel tortuosity2 mediated by voltage-gated L-type calcium channels (antihypertensive effect) and an action on N-type channels (sympathetic modulation/antinociceptive effect) played a role in amlodipines inadvertent efficacy (figure e-2).

Lennox–Gastaut syndrome: A prospective follow-up study

Objectives: Lennox–Gastaut syndrome is a catastrophic epileptic encephalopathy. In Lennox–Gastaut syndrome, seizures are resistant to pharmacological treatment. In this prospective study, we evaluated the clinical features, neuroimaging, and response to treatment. Materials and Methods: Forty-three consecutive newly diagnosed patients of Lennox–Gastaut syndrome were enrolled in the study. Baseline clinical assessment included seizure semiology, seizure frequency, electroencephalography, and neuroimaging. Patients were treated with combinations of preferred antiepileptic drugs (sodium valproate [VPA], clobazam [CLB], levetiracetam [LVT], lamotrigine [LMT], and topiramate [TPM]). Patients were followed for 6 months. The outcome was assessed using modified Barthel index. Results: Tonic and generalized tonic-clonic forms were the most common seizures types. Features suggestive of hypoxic-ischemic encephalopathy (37.2%) were most frequent neuroimaging abnormality. Neuroimaging was normal in 32.6% of patients. With a combination valproic acid (VPA), CLB, and LVT, in 81.4% of patients, we were able to achieve >50% reduction in seizure frequency. Eleven (25.58%) patients showed an improvement in the baseline disability status. Conclusions: A combination of VPA, CLB, and LVT is an appropriate treatment regimen for patients with Lennox–Gastaut syndrome.

Trigeminal neuralgia or SUNA/SUNCT: a dilemma unresolved.

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache with cranial autonomic features (SUNA) are rare primary headaches characterized by short-lasting unilateral orbito-temporal neuralgiform headache attacks with ipsilateral eye lid edema, ptosis, forehead flushing/sweating or rhinorrhoea. In addition to these autonomic features, SUNCT is associated with both conjunctival injection and tearing; whereas, SUNA may have tearing or conjunctival injection or none of them [1]. Since, SUNCT and SUNA have considerable overlap of autonomic features, SUNCT is considered as a subset of SUNA. However, trigeminal neuralgia (TN) that closely mimics SUNCT/SUNA is considered a different disorder [1]. Despite different nosologic entities, the clear etiopathological divide between trigeminal neuralgia and SUNCT/SUNA are lacking. Herein, we present a patient with basilar artery ectasia who recently progressed to SUNCT/SUNA from long-standing trigeminal neuralgia and upon recovery, transformed back to trigeminal neuralgia but involved the maxillary division in addition to ophthalmic division.

Vision loss in tuberculous meningitis

Vision loss is a disabling complication of tuberculous meningitis. Approximately, 15% of survivors are either completely or partially blind. All structures of the visual pathway may be affected in tuberculous meningitis. Optic nerve and optic chiasma are most frequently and dominantly affected. Thick-gelatinous exudates lying over the base of brain, are the pathological hallmark of tuberculous meningitis and are responsible for almost all of its major complications, including vision loss. Strangulation of optic nerves and optic chiasma by the exudates, compression over optic chiasma by the dilated third ventricle, raised intracranial pressure, endarteritis, shunt failure, bacterial invasion of optic nerves and drug-induced optic nerve damage are important reasons that are considered responsible for vision loss. Prompt antituberculosis treatment is the best management option available. Immunomodulatory drugs and cerebrospinal fluid diversion procedures are of limited help. Early recognition and treatment of tuberculous meningitis is the only way forward to tackle this problem.

Study of sleep disorders and polysomnographic evaluation among primary chronic daily headache patients

Objective: Studies related to sleep disorders and polysomnography (PSG) among chronic daily headache patients are rare. We studied this and compared chronic migraine (CM) with chronic tension-type headache. Methods: Eighty-three patients were recruited. They were evaluated by semi-structured interview, headache, and sleep diaries along with Epworth Sleepiness Scale score and insomnia symptom score. Overnight PSG was performed and data compared. Results: Chronic tension-type headache was more common than CM, both having female preponderance. Insomnia followed by excessive daytime sleepiness was prevalent sleep disorder. Sleep efficiency and Stage 3 sleep were lower in CM compared to chronic tension-type. ESSS was significantly increased among chronic tension-type patients. No significant correlation was found among PSG parameters in patients with or without sleep disorders. Conclusion: Insomnia being most common sleep disorder among chronic headache population. Chronic tension-type headache had slightly better slow-wave sleep than CM and significantly increased daytime sleepiness.

New daily persistent headache: An evolving entity

New daily persistent headache (NDPH) is characterized by an abrupt onset of headache that becomes a daily entity, is unremitting and continuous from the onset, and lasts for more than 3 months. Dr Walter Vanast first described NDPH in the year 1986. Originally, it was proposed as a chronic daily headache but it was placed under “other primary headaches” in the International Classification of Headache Disorder Second Edition (ICHD 2nd edition). However, with evolving literature and better understanding of its clinical characteristics, it was classified as a “chronic daily headache” in the ICHD 3rd edition beta. There are still many knowledge-gaps regarding the underlying cause, pathophysiology, natural history and treatment of NDPH. This review tries to revisit the entity and discusses the current status of understanding regarding NDPH.

Magnetic resonance venographic findings in patients with tuberculous meningitis: Predictors and outcome

BACKGROUND This study evaluated the prevalence and predictors of venographic abnormalities in tuberculous meningitis. MATERIAL AND METHODS Consecutive patients of tuberculous meningitis were included in the study. Clinical evaluation, cerebrospinal fluid examination and contrast-enhanced MRI of brain were done. Every participant was subjected to time of flight magnetic resonance venography (MRV). Presence of filling defects at superior sagittal sinus, dominant transverse or sigmoid sinus, and non-visualization of deep venous system was considered suggestive of thrombosis. The presence of filling defects at non-dominant transverse or sigmoid sinus was considered suggestive of thrombosis only in the presence of corresponding changes in T1, T2, and GRE sequences, parenchymal changes or presence of collaterals. The patients were followed up for 6 months. A modified Barthel index ≤12 at 6 months was taken as poor outcome. RESULTS Out of 107 patients, MRV was found to be abnormal in 12 patients (11.2%). The superior sagittal sinus was the most commonly involved sinus. On univariate analysis, the presence of vomiting (P = 0.004), altered sensorium (P = 0.004), seizures (P < 0.001), vision impairment (P = 0.038), papilledema (P < 0.001), diplopia, oculomotor palsies, basal exudates (P = 0.004) and MBI ≤12 at baseline (P = 0.004) were significantly associated with an abnormal MRV. On multivariate analysis, none of the above factors were found to be significant. No association was found between an abnormal MRV and poor outcome. CONCLUSION MRV abnormalities suggestive of venous sinus thrombosis can occur in about 11% patients. Superior sagittal sinus is the most commonly involved sinus. An abnormal MRV may not predict a poor outcome in patients with tuberculous meningitis.