Tejendra S Chaudhari

Clinico-radiological predictors of vascular cognitive impairment (VCI) in patients with stroke: A prospective observational study

BACKGROUND AND PURPOSE Cognitive dysfunction occurs commonly following stroke and varies in severity. This study was aimed to determine the clinical, neuro-imaging, laboratory predictors of post stroke cognitive impairment and factors related to poor functional outcome in patients with post-stroke vascular cognitive impairment (VCI). MATERIAL AND METHODS We prospectively evaluated 102 of 240 consecutive stroke patients for 6 months after incident stroke for development of VCI. Patients with VCI comprised of those with VCI-no dementia (VCIND) and vascular dementia (VaD). Functional outcome was assessed by modified Barthel index (MBI). RESULTS Frequency of post-stroke VCI was 45.1% (46/102): 26.5% (27/102) having VCI-ND and 18.6% (19/102) having VaD. Patients with VCI were more likely to have lower educational and socioeconomic status, diabetes, hypertension, prior stroke, multiple risk factors, urinary incontinence, gait abnormality, peripheral signs of atherosclerosis, higher blood sugar level on admission and LDL levels, strategic site lesion, higher ARWMC (age related white matter changes) score, worse stroke severity (NIHSS) and functional outcome scores. On logistic regression analysis, lower educational status, strategic site lesion, higher ARWMC score and baseline stroke severity score were found to independently predict the risk of developing VCI. Worse stroke severity (NIHSS) scores and functional status scores at baseline predicted poor outcome in patients with VCI. CONCLUSION Post-stroke cognitive impairment is frequent and is associated with poor functional outcome. Predictors like lower educational status, strategic site lesion, greater severity of age related white matter changes and baseline stroke severity independently contributed to the risk of developing VCI in stroke patients.

Clinico-electrophysiological profile and predictors of functional outcome in Guillain–Barre syndrome (GBS)

INTRODUCTION Guillain-Barre syndrome (GBS) is an acute polyradiculoneuropathy with varied severity of presentation. AIMS To study the clinical and electrophysiological profile of patients with GBS and to determine the factors associated with poor functional outcome and need for mechanical ventilation. SETTINGS AND DESIGN It was a hospital-based prospective observational study. METHODS AND MATERIAL 90 patients with GBS diagnosed as per Asbury and Cornblath criteria were enrolled and followed up for 6 months. Various epidemiological, clinical and electrophysiological parameters were evaluated. Hughes motor scale was used to measure functional outcome. Factors associated with poor functional outcome and need for mechanical ventilation were determined. RESULTS 90 patients (56 males; 34 females; mean age of 29.3±15.2 years) were enrolled in this study. Amongst these 6 (6.7%) patients died during in-hospital stay. Antecedent infection was present in 29 (32.2%), autonomic dysfunction in 31 (34.4%), bulbar palsy in 21 (23.3%), neck flexor weakness in 52 (57.8%). 60 cases (66.7%) were of axonal variety and 30 (33.3%) of demyelinating variety. On univariate analysis, predictors associated with poor functional outcome at 6 months were autonomic dysfunction (p=0.013), neck flexor weakness (p=0.009), requirement of ventilatory assistance (p=<0.001), MRC sum score<30 on admission (p=<0.001) and axonal pattern on electrophysiological assessment (p=<0.001). On multivariate analysis, MRC sum score<30 on admission (p=0.007) and axonal pattern on electrophysiological assessment (p=<0.001) were independently associated with poor functional outcome at 6 months. Factors associated with need for mechanical ventilation were presence of autonomic dysfunction (p=<0.001), cranial nerve palsy including facial palsy (p=<0.001) and bulbar palsy (p=0.002), neck flexor weakness (p=<0.001), low MRC sum score (<30) (p=0.001), and low proximal CPN CMAP amplitude to distal CPN CMAP amplitude ratio (p=0.042); none of them being significant on multivariate analysis. CONCLUSIONS Detailed evaluation of the clinical and electrophysiological profile may help in predicting the functional outcome and need for mechanical ventilation in patients with GBS.

Two unusual variants of Guillain-Barre syndrome

Guillain-Barre syndrome (GBS) is a group of autoimmune diseases characterised by acute, acquired and immune-mediated polyneuroradiculopathy. A large number of clinical subtypes of GBS have been described over last 100 years since the first description of this syndrome. We report two such cases GBS variants—first, AMAN with brisk reflexes and second being acute motor axonal neuropathy with conduction block. Through this case report, we intend to make the treating physicians and neurologist aware of these rare variants so that such cases would be appropriately diagnosed and treated.

Unilateral facial palsy in Guillain-Barre syndrome (GBS): a rare occurrence

Guillain-Barre syndrome (GBS) is a postinfectious, autoimmune disorder which, apart from limb weakness, is characterised by cranial nerve involvement. Bilateral facial nerve palsy is the most common pattern of cranial nerve involvement in GBS. However, unilateral facial palsy, although uncommon, can be seen in GBS. We report a rare case of unilateral facial palsy in GBS and importance of electrophysiological tests including blink study in such cases has been emphasised.

Spontaneous extensive spinal epidural abscess presenting as acute quadriparesis

An extensive spinal epidural abscess (SEA), sometimes referred to as a panspinal or holocord SEA, is a rare neurosurgical emergency. We present an interesting case of spontaneous extensive SEA that was managed with multilevel laminectomy along with intravenous antibiotics. A 35-year-old-man presented with high-grade fever and excruciating backache of 20 days duration, quadriparesis for 3 days and respiratory distress a day before admission. Quadriparesis evolved symmetrically over 24 h, initially affecting the lower extremities followed by upper extremities within few hours. There was no history of diabetes, trauma, intravenous drug abuse or any other medical comorbidity. On examination, his vital …

Neurogenic vision loss: Causes and outcome. An experience from a tertiary center in Northern India

Introduction: Vision loss can be a consequence of numerous disorders of eye and neural pathway conveying visual input to brain. A variety of conditions can affect visual pathway producing neurogenic vision loss. The presentation and course of vision loss depends on the site of involvement and underlying etiology. We conducted this unprecedented study to evaluate the characteristics and outcome of various diseases of the visual pathway. Materials and Methods: In this prospective cohort study, we evaluated 64 patients with neurogenic visual impairment. Ophthalmological causes were excluded in all of them. Their presentation, ophthalmological characteristics and investigation findings were recorded. These patients were followed up till 6 months. Results: Out of 69 patients evaluated, 5 were excluded as they had ophthalmological abnormalities. The remaining 64 cases (113 eyes) were enrolled. 54 cases were due to diseases of anterior visual pathway and rest 10 had cortical vision loss. The etiologic distribution is as follows: Isolated optic neuritis- 12 (19%), multiple sclerosis- 4 (6.3%), neuromyelitis optica- 5 (7.9%), tubercular meningitis- 15 (23.8%), non-arteritic ischemic optic neuropathy, ischemic optic neuropathy complicating cavernous sinus thrombosis, cryptococcal meningitis, malignant infiltration of optic nerve, Crouzons syndrome, calvarial thickening and traumatic occipital gliosis- 1 (1.6%) case each, idiopathic intracranial hypertension, pituitary adenoma, acute disseminated encephalomyelitis, posterior reversible leukoencephalopathy- 3 (4.8%) cases each, cortical venous thrombosis 5 (7.9%), subacute scleroing panencephalitis- 4 (6.3%) cases. Conclusions: The diseases of anterior visual pathway were much more common than cortical vision loss. A majority of our patients had severe impairment of vision at presentation.

Spinal cord tuberculosis: a paradoxical response to antituberculous therapy

A 22-year-old man, with a known case of definitive tuberculous meningitis (TBM) on antitubercular therapy (ATT) for 5 months, presented with subacute onset sensorimotor paraparesis with urinary urgency since 1 month. He had also received dexamethasone therapy 0.4 mg/kg/24 h for 1 month followed by reducing course over next 2 weeks as per British Infection Society guidelines. MRI of the spine revealed a ring enhancing intramedullary lesion at D4 level suggestive of …

Laryngeal carcinoma presenting as polymyositis: A paraneoplastic syndrome

Laryngeal carcinoma is rarely associated with paraneoplastic syndrome. Inflammatory myopathy presenting as paraneoplastic event is commonly associated with carcinomas of ovary, lung, pancreas, stomach, colorectal, and non-Hodgkin′s lymphoma. We report a case of elderly male, who presented with proximal muscle weakness and found to be associated with laryngeal carcinoma. Diagnosis of polymyositis (PM) was confirmed based on clinical features, laboratory test, and muscle biopsy. Exclusion of other commonly associated malignancies was done. This patient improved gradually after 6 months of immunosuppressive therapy and management of underlying cancer.

Face of the giant panda with bright eyes in metronidazole neurotoxicity.

Sir, Metronidazole, a 5-nitroimidazole compound, is often used for prolonged treatment of anaerobic bacterial and protozoal infections including those caused by Entamoeba histolytica, especially in developing countries. Metronidazole induced encephalopathy (MIE) is one of the rare adverse neurological effects associated with metronidazole therapy. Herein, we share our experience of unusual neuro-imaging features encountered in this rare condition.

Acute onset anarthria without hepatic manifestation: a rare presentation of Wilson disease

Wilson disease (WD) is one of the few inherited but treatable disorder mainly affecting the liver and brain resulting in severe disability or death if left untreated. Hence, it is important to keep a high index of suspicion for diagnosing this clinical entity in appropriate clinical settings. The clinical presentation can be quite variable and they may present solely with neurological features sans hepatic symptoms. Such neurological manifestations usually follow subacute to chronic course. Acute onset anarthria as the heralding and predominant presenting feature has been rarely reported in the literature. We reported a case of a 12-year-old girl who presented with acute onset anarthria and dystonia of 1-month duration. On further evaluation, a diagnosis of WD was made. The patient showed partial improvement after she was started on copper chelating agents and anticholinergics.