SOFA and APACHE II scoring systems for predicting outcome of neurological patients admitted in a tertiary hospital intensive care unit

Background

The field of neurology encompasses the study and treatment of disorders that affect the nervous system, and patients with neurological conditions often require specialized care, particularly in the ICU. Predictive scoring systems are measures of disease severity used to predict patient outcomes. The aim of this study was to compare the discriminative power of commonly used scoring systems, namely the sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) in the ICU of a tertiary care hospital.

Methods

This retrospective study included patients with neurological disorders in the ICUs of Tribhuvan University Teaching Hospital from 1 January 2022 to 31 December 2022.

Results

A total of 153 patients were included. The mean age of the patients was 54.76 ± 17.32 years with higher male predominance (60.78%). Ischaemic stroke was the most common neurological disorder. There were 58 patients (37.9%) who required mechanical ventilation and all-cause mortality was 20.9%. The mean SOFA score was significantly higher (P=0.002) in survivors, whereas the mean APACHE II did not show a significant difference (P=0.238). Receiver operating characteristic (ROC) analysis showed the area of curve (AUC) of SOFA score was 0.765 and of APACHE II was 0.722.

Conclusions

SOFA score had comparatively higher discriminative power than APACHE II. Assessment of the performance of scoring systems in a specific ICU setting improves the sensitivity and applicability of the model to these settings.

Prevalence and Clinical Types of Tremor in Multiple Sclerosis and its Associated Disability: A Systematic Review

Objective

To describe the state of literature regarding prevalence, clinical types of tremor in Multiple Sclerosis and associated disability.

Background

Tremor has long been recognized as an important symptom of multiple sclerosis. This can be intention and postural tremor that affects the upper limbs. Patients with multiple sclerosis who experience tremor of any severity typically retire early or lose their jobs due to disability.

Methods

This systematic review was performed up to September 9, 2022. Article selection was performed by searching the MEDLINE (PubMed) and EMBASE electronic bibliographic databases. The search strategy was not limited by study design but only for articles in the English language.

Results

A total of nine full-text articles were included in the analysis. Six studies were cross-sectional studies; one each was a prospective observational study, a case-control study, a community-based cohort. The prevalence of tremor in the multiple sclerosis (MS) population among studies ranged widely, between 12.5% and 68.9%. The presence of severe tremor ranged from 3% to 33%. Younger age was a significant predictor of tremor in two studies. The most common tremor subtype was action tremor. Upper extremities were the most common site involved in the majority of our studies, followed by head and neck.

Conclusions

Prevalence of tremor ranged from 12.5% to 68.9% in the MS population with severe tremor being an infrequent complication. Severity of tremor correlated with increasing disability. Upper limb action tremor was the most common with rare occurrences of resting and rubral tremor.

Dyslipidemia and Obesity in Ischemic Stroke

Background Dyslipidemia and obesity are both important risk factors for the first and recurrent ischemic strokes. Dyslipidemia is highly prevalent among Asian populations, and the prevalence of obesity is also noted to be progressively increasing in this population. This study was carried out to determine the prevalence of dyslipidemia and central obesity and their association with each other and various cardiovascular risk factors among patients who presented with an acute ischemic stroke to a tertiary care university hospital in Nepal. Methods This study is a secondary analysis done on data from a prospective observational study that was carried out on patients who were either acutely admitted to or visited the outpatient department of the hospital with a diagnosis of ischemic stroke. Dyslipidemia was defined according to the third report of the National Cholesterol Education Program expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. Obesity was defined as central obesity by measuring waist circumference. Data were collected by convenience sampling and analyzed by IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. Significant variables were compared with logistic regression analysis. Other data were expressed as frequencies and percentages. Results Out of 145 patients, 77 were male (53.1%). The mean age of the patients was 60.15 years. Dyslipidemia and central obesity were present in 96.6% and 57.9% of the patients, respectively. The most common lipid abnormality was low-density lipoprotein cholesterol, present in 82.8% of the patients, followed by high triglycerides, present in 21.4% of them. Dyslipidemia was not associated with any vascular risk factors. Central obesity was significantly associated with female gender, diabetes, and low-density lipoprotein cholesterol in univariate analysis. However, in multivariate logistic regression analysis, it was significantly associated with only female gender (p=0.003) and diabetes (p=0.012). Conclusion Dyslipidemia and central obesity are very common in patients with ischemic stroke. Dyslipidemia is not associated with any vascular risk factors. However, central obesity is significantly associated with the female gender and diabetes.

A review of movement disorders in persons living with HIV

BACKGROUND

The human immunodeficiency virus (HIV) causes movement disorders in persons living with HIV (PLH).

OBJECTIVES AND METHODS

We conducted a systematic review on the spectrum of movement disorders in PLH using standard terms for each of the phenomenologies and HIV.

RESULTS

Movement disorders in PLH were commonly attributed to opportunistic infections (OI), dopamine receptor blockade reactions, HIV-associated dementia (HAD), presented during seroconversion, developed due to drug reactions or antiretroviral therapy (ART) itself and lastly, movement disorders occurred as a consequence of the HIV-virus. Parkinsonism in ART naïve PLH was associated with shorter survival, however when Parkinsonism presented in PLH on ART, the syndrome was indistinguishable from Idiopathic Parkinson's disease and responded to therapy. Tremor was often postural due to HAD, drugs or OI. Generalized chorea was most frequent in HIV encephalopathy and toxoplasmosis gondii caused most cases of hemichorea. Ataxia was strongly associated with JCV infection, ART efavirenz toxicity or due to HIV itself. Dystonia was reported in HAD, secondary to drugs and atypical facial dystonias. Both cortical/subcortical and segmental/spinal origin myoclonus were noted mainly associated with HAD. In patients with HIV related opsoclonus-myoclonus-ataxia-syndrome, seroconversion illness was the commonest cause of followed by IRIS and CSF HIV viral escape phenomenon.

CONCLUSIONS

Aetiology of movement disorders in PLH depend on the treatment state. Untreated, PLH are prone to develop OI and HAD and movement disorders. However, as the number of PLH on ART increase and survive longer, the frequency of ART and non-AIDS related complications are likely to increase.

Augmented reality-based training versus standard training in improvement of balance, mobility and fall risk: a systematic review and meta-analysis

Augmented reality (AR) technology is being used recently in healthcare, especially for rehabilitation purposes, owing to its ability for repetition, rapid feedback, and motivation for patients. This systematic review and meta-analysis aims to compare the efficacy of AR-based interventions to conventional physical interventions in improving balance, mobility, and fall risk.

MATERIAL AND METHODS

PubMed, Google Scholar, Scopus, and the Cochrane Central Register of Controlled Trials were systematically searched from inception to January 2023. Randomized trials and observational cohort studies comparing the effects of AR-based exercises with conventional training in patients 18 years and older were included in the analysis. Studies using virtual reality, case reports and series, reviews, meta-analyses, letters, and editorials were excluded. Post-intervention data on the Berg Balance Scale (BBS) and Timed Up and Go (TUG) Test were extracted and studied. The fixed-effects inverse variance model was utilized to pool the extracted data.

RESULTS

Out of 438 articles, seven articles (199 participants) comparing AR-based exercise with the standard training were included in the systematic review. Six articles with sufficient data on the parameters were included in the meta-analysis. AR-based exercises resulted in a significantly higher BBS score than conventional exercise (Hedge's g=0.48, 95% CI=0.19-0.77, P<0.001). The BBS value was significantly higher in AR-based training of 8 weeks or more (Hedge's g=0.88, 95% CI=0.46-1.31) when compared with trainings conducted for less than 8 weeks (Hedge's g=0.11, 95% CI=-0.30 to 0.52), P=0.01). Likewise, the TUG Test score was found to be to be significantly lower in ARgroup than the controls (Hedge's g= -0.54, 95% CI=-0.85 to -0.23, P<0.01).

CONCLUSION

In comparison to conventional methods, AR-based exercises had higher improvements in balance, mobility, and fall risk parameters. The use of AR technology in elderly patients can promote independence while preventing falls and associated morbidity and mortality. There is a need for a larger randomized controlled trial to provide a more accurate comparison on efficacy and safety of different modalities of training.

Stroke patterns and outcomes during the second wave of COVID-19 pandemic: a cross-sectional study

The coronavirus disease 2019 (COVID-19) pandemic has affected the number of stroke activations, admission of patients with various types of strokes, the rate and timely administration of reperfusion therapy, and all types of time-based stroke-related quality assessment metrics. In this study, we describe the different types of strokes, different delays in seeking and completing treatment occurring during the second wave of the COVID-19 pandemic, and predictors of outcome at 3 months follow-up.

Materials and methods

This is a single-centered prospective cross-sectional study carried out from May 2021 to November 2021, enrolling patients with stroke. Data collected were demographic characteristics, stroke types and their outcomes, and different types of prehospital delays.

Results

A total of 64 participants were included in the study with a mean age of 60.25±15.31 years. Ischemic stroke was more common than hemorrhagic stroke. The median time of arrival to the emergency room of our center was 24 h. The most common cause of prehospital delay was found to be delays in arranging vehicles. The median duration of hospital stays [odds ratio (OR)=0.72, P<0.05] and baseline NIHSS (National Institute of Health Stroke Scale) score (OR=0.72, P<0.05) were found to be a predictor of good outcomes at 3 months follow-up on binary logistic regression.

Conclusion

The factors that cause the delayed transfer to the hospital and onset of treatment should be addressed. Patient counseling about the likely prognosis can be done after evaluating the probable outcome based on the NIHSS score and median duration of hospital stay. Nevertheless, mechanisms should be developed to reduce the prehospital delay at the ground level as well as at the policy level.

Wallerian degeneration in the brain after organophosphorus poisoning: a case report

The type, quantity, and potency of the organophosphorus compound (OPC) taken determine the symptoms of OPC poisoning as well as their severity. The exact etiology for organophosphorus (OP) poisoning delay neuropathy regulating Wallerian degeneration is still unknown.

Case Presentation

We report here a rare case of a 25-year-old lady with Wallerian degeneration in the brain found in an MRI in a patient after OPC ingestion. MRI of the brain, in our case, shows Wallerian degeneration of the corona radiata, internal capsule, and midbrain.

Clinical Discussion

Some OPCs can lead to OP-induced delayed neuropathy, a form of delayed neurotoxicity in humans (OPIDN). The distal axonopathy's (in OPIDN) morphological pattern resembles Wallerian degeneration, which happens in vitro following nerve damage. Although delayed Wallerian degeneration from organophosphate poisoning often affects the peripheral nervous system, it can also affect the central nervous system. Rehabilitation therapy combined with appropriate nursing care has been demonstrated to improve the disease.

Conclusion

Central nervous system involvement after OP poisoning is rare, and MRI of the brain and spinal cord can document evidence of Wallerian degeneration after OP poisoning.

Magnetic resonance imaging of the brain mimicking autoimmune encephalitis in sjogren syndrome with chorea: a case report

Neurologic manifestations in primary Sjögren syndrome (SS) range in prevalence from 8 to 49%, and most of the studies suggest a prevalence of 20%. The incidence of SS patients developing movement disorders is about 2%.

Case presentation

The authors herein report a case of a 40-year-old lady with MRI of the brain mimicking autoimmune encephalitis in SS who presented with chorea. Her MRI findings revealed T2 and FLAIR (fluid-attenuated inversion recovery) high signal intensity areas in bilateral middle cerebellar peduncles, dorsal pons, dorsal midbrain, hypothalami, and medial temporal lobes.

Clinical discussion

There is still no evidence to support the definite use of MRI in characterizing the central nervous system involvement in primary SS, especially due to overlapping findings with age and cerebrovascular disease. Multiple areas of increased signal intensity in periventricular and subcortical white matter in FLAIR and T2-weighted image is commonly seen in primary SS patients.

Conclusion

It is crucial to consider autoimmune diseases like SS as a cause of chorea in adults, even in those whose imaging findings are suggestive of autoimmune encephalitis.

Stiff person syndrome in a Nepalese man with uncontrolled diabetes mellitus and ketonuria: A rare case report

Stiff Person Syndrome (SPS), a progressive Central Nervous System disorder is accompanied by progressive muscle rigidity, hyperreflexia, and spasms mainly in truncal and proximal leg muscles mainly associated with autoimmune disorders. Here, we report a rare case of SPS in a middle-aged Nepalese man with uncontrolled diabetes mellitus and ketonuria.

Epidemiological and clinical characteristics of central nervous system infections in a tertiary center: A retrospective study

Background and Aims

Central nervous system (CNS) infection is one of the most common causes of morbidity, mortality, and hospital admission worldwide. The natural history of CNS infection is quite fatal. Early diagnosis and treatment have been proven to have a crucial role in patients' survival. The aim of this study was to identify the epidemiological and clinical patterns of patients diagnosed with CNS infections.

Methods

This study is a retrospective study conducted in a tertiary level hospital in Nepal in which patient diagnosed with CNS infections (September 2019 to 2021) were included. Data were collected and analyzed in SPSS.

Results

The mean age of the 95 patients included in the study was 45.18 ± 19.56. Meningoencephalitis (n = 44, 46.30%) was the most common infection diagnosed. Patients belonging to the age group 30-60 years had a higher frequency of focal neurological deficit, and other classical clinical features. All the patients who died during the treatment had associated comorbidities but no concurrent infections. Altered sensorium, fever, and headache were the common presenting symptoms in all the recovered patients.

Conclusion

To ensure optimum disease outcome, early diagnosis and prompt management are crucial. For this, recognizing the local disease patterns in terms of disease distribution, commonly implicated aetiologies, presenting symptoms, and prognostic factors is of utmost importance.

Painful tonic spasms in a patient with neuromyelitis optica spectrum disorder: A case report

Painful tonic spasms initially described in association with multiple sclerosis are actually more common in patients with neuromyelitis optica spectrum disorder. Characterized by fierce pain and tonic posture of limbs, painful tonic spasms are common in patients during the recovery phase after the first episode of myelitis. A 68-year-old man presented with painful tonic spasm after 2 months of diagnosis of neuromyelitis optica spectrum disorder. Eventual use of eslicarbazepine resulted in significant control of spasms. Early recognition of painful tonic spasms and appropriate therapeutic medications can significantly decrease the impact it can have on the quality of life among neuromyelitis optica spectrum disorder patients.

Patient Age and Outcome in Ischemic Stroke

Background: Age is the most important prognostic factor in ischemic stroke. Thisstudy was carried out in patients with ischemic stroke to describe the association of age of the patients with stroke severity at presentation and at three months. Materials and Methods: The data, which were collected retrospectively from hospital records, we reanalyzed by using the Statistical Package for the Social Sciences (SPSS) version 26. Age was divided into younger (≤ 50 years) and older (> 50 years) based on standard definition. Age was also divided into younger (< 60 years) and older (≥ 60 years) based on the Senior Citizens Act of Nepal. The associations were analyzed by using Chi-square test. Results: One hundred and fifty-three patients were included in the study. The mean age of the patients was 60.9 years. There was no statistically significant association between baseline stroke severity and the age groups defined both ways. More younger patients had good outcomes (44.4% good outcome vs 25.6% poor outcome in patients ≤ 50 years, p= 0.03; 52.8% good outcome vs 31.6% poor outcome in patients < 60 years, p=0.02). More older patients had poor outcomes (74.4% poor outcome vs 55.6% good outcome in patients > 50 years, p = 0.03; 68.4% poor outcome vs 47.2% good outcome in patients ≥ 60 years, p= 0.02). Conclusion: There was no significant association between young and old patients and the baseline stroke severity; however, more younger patients had good outcomes compared to older patients at three months, the differences being significant.

Chorea hyperglycemia basal ganglia syndrome: A case report from Nepal

A rare case of chorea hyperglycemic basal ganglia syndrome in a 56-year-old woman who presented with left-sided hemichorea in the setting of uncontrolled, non-ketotic, type II diabetes mellitus is reported. Early blood glucose control could lead to complete resolution of symptoms. Despite an excellent prognosis, delayed recognition and management can lead to prolong disability due to movement disorder.

Multicentre registration of wake-up stroke in China (MCRWUSC): a protocol for a prospective, multicentre, registry-based cohort study

INTRODUCTION

Wake-up stroke (WUS) is a type of acute ischaemic stroke (AIS) that occurs during sleep with unknown time of symptom onset. The best treatment is usually not suitable for WUS, as thrombolysis is usually provided to patients who had a symptomatic AIS within a definite 4.5 hours, and WUS remains a therapeutic quandary. Efforts to explore the onset time characteristics of patients who had a WUS and the risk factors affecting poor prognosis support a role for providing new insights by performing multicentre cohort study.

METHODS AND ANALYSIS

This multicentre, nationwide prospective registry will include 21 comprehensive stroke centres, with a goal of recruiting 550 patients who had a WUS in China. In this study, clinical data including patient's clinical characteristics, stroke onset time, imaging findings, therapeutic interventions and prognosis (the National Institutes of Health Stroke Scale Score and the modified Rankin Scale Score at different time points) will be used to develop prediction models for stroke onset time and prognostic evaluation using the fast-processing of ischemic stroke software. The purpose of this study is to identify risk factors influencing prognosis, to investigate the relationship between the time when the symptoms are found and the actual onset time and to establish an artificial intelligence-based model to predict the prognosis of patients who had a WUS.

ETHICS AND DISSEMINATION

This study is approved by the ethics committee of Shanghai Pudong Hospital (Shanghai, China) and rest of all participating centres. The findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

ChiCTR2100049133.

Levetiracetam versus Oxcarbazepine as monotherapy in newly diagnosed focal epilepsy: A systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of Levetiracetam (LEV) and Oxcarbazepine (OXC) as monotherapy for the treatment of newly diagnosed focal epilepsy.

METHODS

We searched PubMed, Cochrane Library, EMBASE, and Google Scholar from January 1, 2000 to May 11, 2022, with no language restrictions along with The ClinicalTrials.gov website and the WHO International Controlled Trials Registry platforms. We pooled the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for the efficacy and safety outcomes. The quality of included trials was assessed using the Cochrane Collaboration's tool.

RESULTS

Two RCTs included a total of 574 newly diagnosed focal epilepsy patients (the LEV group [282 patients] and the OXC group [292 patients]). LEV group when compared with the OXC group had no significant difference in the pooled estimate of seizure freedom at week 24. (RR: 0.81; 95% CI: 0.62-1.05, p = .11). Similarly, there was no significant difference in the pooled estimate of withdrawal due to adverse events (AEs) (RR: 0.87; 95% CI: 0.34-2.23, p = .77). The commonly reported AEs in both trials were dizziness, headache, rash, somnolence, and nasopharyngitis with zero medication-related death and few serious AEs.

CONCLUSIONS

LEV is noninferior to OXC in terms of seizure freedom at week 24 and treatment withdrawal rate due to AEs among adults but long-term treatment data is still missing. Future multicentric double-blinded RCTs and real-world studies are of great need.

Guillain-Barre Syndrome following lower segment caesarean section under spinal anesthesia: A case report

Symptoms of Guillain–Barre Syndrome (GBS) may be mistaken for typical puerperal changes, delaying diagnosis. Surgery and anesthesia may be triggers for GBS with an overall increase in pro‐inflammatory cytokines in the postpartum period. We report a unique case of GBS in the postpartum period who made a good recovery with supportive measures.

Guillain–Barre Syndrome (GBS) symptoms may be misinterpreted as usual puerperal changes. Prompt diagnosis and management are crucial to minimize complications. We report a case wherein we managed a post‐surgical GBS with conservative agents resulting full recovery.

Safety and efficacy of endovascular thrombectomy in patients with severe cerebral venous thrombosis: A meta-analysis

Background

Cerebral venous thrombosis (CVT) is a rare thrombotic condition which is traditionally treated with anti-coagulation therapy. Subsets of patients with severe CVT have been treated with endovascular thrombectomy (EVT). Despite the high estimated mortality associated with severe CVT, there has been only one randomized control trial done regarding safety and efficacy of EVT in severe CVT compared to standard medical management. Evidence in this area is lacking.

Objective

The aim of this systematic review is to analyze all existing literature and generate robust information regarding the role of EVT in the management of patients with severe CVT.

Methods

This systematic review and meta-analysis followed PRISMA guideline. PubMed, Embase, Google Scholar, and CNKI were searched for eligible studies from 2007 to 2021. Safety and efficacy of EVT were evaluated by meta-analyzing recanalization status, the good functional outcome at follow-up, recurrent CVT, new hematoma. A pooled proportion with a 95% confidence interval was derived from a meta-analysis of various outcomes (CI).

Results

A total of 33 studies comprising 610 patients treated with EVT were included for analysis which comprised one randomized control trial, one prospective study and 31 retrospective studies. Based on pooled data, 85% of patients had good functional outcome, 62% had complete recanalization, 5% had all-cause mortality, and 3% had catheter related complications. The efficacy outcomes in this analysis had a significant heterogeneity and a subgroup analysis was also done to explain these findings. The minimum time of follow up was 3 months and varied EVT techniques were used across the studies.

Conclusion

This meta-analysis suggests EVT may be safe and efficacious in treating patients with severe CVT.

Registration

Our protocol was registered with PROSPERO: International prospective register of systematic reviews with the registration number CRD42021254760.

Swing phase considerations in prosthetic knee design: Case series to validate simulations

BACKGROUND

Previously reported simulations comparing a new polycentric knee (called IPK) and a single-axis knee suggested that polycentricity could lead to improved performance during swing phase and negate the need for an extension assist. They also showed that an anteriorly translated socket adapter for enhanced stance stability compromises foot clearance during swing.

OBJECTIVES

The objectives of this study are to validate those findings using gait trials to enable further improvement in the IPK design before mass production.

METHODS

Three subjects regularly using three different passive knees, single-axis knee without extension assist, single-axis knee with extension assist (SAK-EA), and polycentric knee with extension assist (Mobility India-sourced polycentric knee), participated in this study. Their gait with their regular prosthesis and with IPK (having no extension assist) were analyzed, compared, and broadly correlated with simulation results.

RESULTS

Extension assist in single-axis knee with extension assist improved swing performance, affected foot clearance in Mobility India-sourced polycentric knee, and was found to be unnecessary in the IPK. With an anteriorly placed socket adapter in the IPK, compensatory strategies were necessary for foot clearance. The IPK was found to provide better knee extension characteristics with lower hip effort (up to 42% reduction) than other knees.

CONCLUSIONS

This case series confirmed previously reported simulation results on the swing phase behavior of passive prosthetic knees. The performance of the IPK during swing obviated the need for an extension assist, thereby simplifying the design. Appropriate design changes in the IPK's socket adapter location are required to achieve both stance stability and reduce gait compensations for foot clearance.

Amyotrophic lateral sclerosis and retinal changes in optical coherence tomography: A systematic review and meta-analysis

INTRODUCTION

Increasing evidence suggests Amyotrophic Lateral Sclerosis (ALS) as a widespread pathological process comprising nonmotor features like fatigue, mild sensory symptoms, cognitive decline, and visual impairment. Measurements of retinal nerve fiber layer (RNFL) thickness using Optical Coherence Tomography (OCT) may correlate with the neurodegeneration associated with ALS. In addition to RNFL thickness, other OCT parameters have been explored in the context of diagnosing ALS and predicting disease severity. In this study, we explore the possibility that OCT parameters of patients with ALS may differ significantly from those of healthy controls and thus serve as biomarkers for the disease and its progression.

MATERIALS AND METHODS

Between 2010 and 2021, the PubMed and EMBASE databases were examined for English language literature. ALS severity was assessed using the revised ALS functional rating scale (ALSFRS-R). The pooled mean differences in RNFL thickness between ALS patients and controls were calculated using the Standard Mean Difference (Hedges's g) with a 95% confidence interval (CI) in STATA software version 16.

RESULTS

Eleven studies were reviewed for data collection. RNFL thickness was not statistically significantly different between ALS patients (n = 412) and controls (n = 376) (Hedges's g = -0.22; 95% CI: -0.51 to 0.07, I² = 73.04%, p = .14). However, the thickness of inner nuclear layer was significantly different between ALS patients and controls (Hedges's g = -0.38; 95% CI: -0.61 to 0.14, I² = 14.85%, p = .00).

CONCLUSION

Our meta-analysis found that RNFL thickness as a whole or by individual quadrants was not significantly different between ALS patients and controls while the inner nuclear layer (INL) was substantially thinner.

Guillain-Barré syndrome following coronavirus disease vaccine: First report from Nepal

ChAdOx1 nCoV-19 is an effective and well-tolerated coronavirus disease 2019 vaccine. However, rare cases of serious adverse events have been reported with it. We report a patient who did not have active or prior coronavirus disease 2019 infection, who developed Guillain-Barré syndrome 7 days following the first dose of ChAdOx1 nCoV-19 vaccination. He was treated with intravenous immunoglobulin, with stabilization of the disease. Proper monitoring and prompt reporting of such cases are required to ensure the safety of the vaccine.

Therapeutic drug level of tacrolimus causing intracranial hemorrhage in a patient with renal transplant

Tacrolimus is used in solid organ transplant patients to prevent rejection, and no case of intracerebral hemorrhage (ICH) has been reported till date. We report a case of 31‐year‐old man with diabetes and hypertension for ten years who had a renal transplant four years back; diagnosed with tacrolimus‐induced ICH.

Evaluating cognitive outcomes in adult patients with acute encephalitis syndrome: a prospective study from a tertiary care center in Nepal

Purpose

Although cognitive impairment is a known complication of acute encephalitis syndrome (AES), few studies have evaluated cognitive outcomes in patients with encephalitis. The primary objective of this study was to assess the cognitive profiles of patients diagnosed with AES, which is pivotal for improving rehabilitation strategies and prognostic measures.

Methods

This study was conducted at the Tribhuvan University Teaching Hospital. Adult patients with AES who met inclusion criteria were enrolled. The Montreal Cognitive Assessment (MoCA) tool was used to assess cognitive function at admission, discharge, and 3-month follow-up.

Results

Thirty-six patients were enrolled in our study. The mean age of the participants was 43 ± 18 years. Fourteen patients (38.9%) were female, and 22 (61.1%) were male. Tuberculous (TB) meningoencephalitis was present in 14 cases (38.9%), with herpes simplex virus (HSV) encephalitis in 14 (38.9%), bacterial meningoencephalitis in 4 (11.1%), autoimmune encephalitis in 2 (5.6%), and Japanese encephalitis in 2 (5.6%). Patients with bacterial meningoencephalitis had the highest MoCA scores at admission, whereas those with HSV encephalitis had the highest scores at discharge and follow-up. Compared with the scores at admission, the scores at discharge and follow-up increased significantly in patients with TB meningoencephalitis and HSV encephalitis. The MoCA score at discharge was established as a significant predictor of cognitive function at follow-up.

Conclusion

We found that active treatment can improve the outcomes of AES patients with cognitive impairment. Although infectious etiologies are most common in low-income countries such as Nepal, autoimmune etiologies should not be overlooked.

Delayed Visual Loss in a Patient with Snake Bite: Case Report of an Unusual Neuro-Ophthalmic Presentation

Neurotoxin-related optic neuritis (ON) after snake bite is uncommon. Here, we present a case of a 70-year-old female who developed bilateral painless loss of vision after she received treatment with anti-snake venom (ASV). She had only perception of light on assessment of visual acuity on admission which then improved drastically after administration of intravenous methylprednisolone (MP) after making the provisional diagnosis of ON on the basis of history and clinical findings of the patient. Imaging and visual-evoked potential could not be done initially, and they were done after the administration of intravenous MP which had normal findings. ASV, though being a lifesaving treatment, has been sometimes associated with ON.

Guillain-Barré syndrome associated with Coronavirus disease 2019: A case from Nepal

Coronavirus disease 2019 (COVID-19) has now spread widely after the outbreak since December 31, 2019. Guillain-Barré syndrome is an immunological postinfectious neuropathy, which has been reported to be a rare but possible complication COVID-19. We report a case of Guillain-Barré syndrome associated with COVID-19 in Nepal.

C-reactive protein levels in patients with amyotrophic lateral sclerosis: A systematic review

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease affecting cortical and spinal motor neurons. There is a lack of optimal biomarkers to diagnose and prognosticate the ALS patients. C-reactive protein (CRP), an inflammatory marker, has shown promising results in ALS patients.

MATERIALS AND METHODS

PubMed, Embase, and Google Scholar databases were searched from 2000 to June 1, 2021 for suitable studies showing the relationship between CRP and ALS. The concentration of CRP levels was assessed between ALS patients and controls. Further, end outcomes like ALS functional rating scale (ALSFRS-R), survival status, and mortality risks were assessed in relation to CRP levels.

RESULTS

Eleven studies including five case-control, five cohorts, and one randomized control study were assessed. There were 2785 ALS patients and 3446 healthy controls. A significant increment in CRP levels among ALS patients in comparison with healthy controls were seen in most of the studies. ALSFRS-R and disease progression were found to be significantly correlated with CRP levels. Overall accuracy of CRP in CSF was 62% described in a single study.

CONCLUSION

Although CRP has shown promise as a prognostic biomarker, extensive cohort studies are required to assess its prognostic value and accuracy in diagnosing ALS taking into account the confounding factors.

Clinical spectrum and management of dystonia in patients with Japanese encephalitis: A systematic review

BACKGROUND

Japanese encephalitis (JE) is a potentially fatal viral infection with a wide range of manifestations and can also present with a variety of movement disorders (MD) including dystonia. Dystonic features in JE are uncommon. Here, we have tried to summarize the clinical features and management of dystonia among JE patients with a comprehensive literature search.

METHODS

Various databases, including PubMed, Embase, and Google Scholar, were searched against the predefined criteria using suitable keywords combination and boolean operations. Relevant information from observational and case studies was extracted according to the author, dystonic features, radiological changes in the brain scans, treatment options, and outcome wherever provided.

RESULT

We identified 19 studies with a total of 1547 JE patients, the diagnosis of which was confirmed by IgM detection in serum and/or cerebrospinal fluid in the majority of the patients (88.62%). 234 (15.13%) of JE patients had dystonia with several types of focal dystonia being present in 131 (55.98%) either alone or in combination. Neuroimaging showed predominant involvement of thalami, basal ganglia, and brainstem. Oral medications including anticholinergics, GABA agonists, and benzodiazepines followed by botulinum toxin were the most common treatment modalities.

CONCLUSION

Dystonia can be a disabling consequence of JE, and various available medical therapies can significantly improve the quality of life. Owing to insufficient studies on the assessment of dystonia associated with JE, longitudinal studies with a larger number of patients are warranted to further clarify the clinical course, treatment, and outcome of dystonia.

Safety and efficacy of Direct Oral Anticoagulants in cerebral venous thrombosis: A meta-analysis

Cerebral venous thrombosis (CVT) is caused by partial or complete occlusion of the major cerebral venous sinuses or the smaller feeding cortical veins which predispose to the risk of venous infarction and hemorrhage. Current guidelines recommend treating CVT with either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) followed by an oral vitamin K antagonist (VKA) for 3-12 months. Direct oral anticoagulants (DOACs) have already established benefit over warfarin as a long-term treatment of symptomatic venous thromboembolic disorder like deep vein thrombosis (DVT), and pulmonary embolism (PE) given its equal efficacy and better safety profile. The benefit of DOACs over warfarin as a long-term anticoagulation for CVT has likewise been extensively studied, yet it has not been approved as first-line therapy in the current practice. We therefore performed a systematic review and meta-analysis of relevant studies to generate robust evidence regarding the safety and efficacy of DOACs in CVT. This meta-analysis demonstrates that the use of DOACs in CVT has similar efficacy and safety compared to VKAs with better recanalization rate.

Occurrence of osmotic demyelination syndrome in diabetes mellitus: A case report and literature review of various etiologies for osmotic demyelination syndrome

Osmotic demyelination syndrome is a rare condition reported mainly in the case of rapid correction of hyponatremia, but it can occur even in the case of complicated diabetes mellitus either during rapid correction of hyperglycemia or anytime during the complicated diabetes mellitus. We report a case of complicated diabetes mellitus developing osmotic demyelination syndrome. The patient had presented with altered sensorium and seizure, which was initially diagnosed as hyperglycemia, but during his treatment, the magnetic resonance imaging of brain revealed central pontine myelinolysis. Our search on the causes of osmotic demyelination syndrome other than rapid correction of hyponatremia has revealed several other causes like autoimmune liver disease, Sjogren’s syndrome and non-Hodgkin’s lymphoma in addition to diabetes mellitus.

Delayed myelopathy after organophosphate intoxication: A case report

Organophosphate-induced delayed neuropathy, a central-distal axonopathy, passes through latent, progressive, static and improvement phases. During the improvement phase, the peripheral nerves regenerate unmasking the spinal cord lesion with myelopathic features. We report a case of a 16-year-old male who developed myelopathy 6 weeks following chlorpyrifos poisoning. He had a motor weakness of 4/5 in bilateral hips and 3/5 in bilateral knees and ankles. Spasticity and exaggerated reflexes with ankle clonus were present in the lower limbs. Sensory and the upper limb motor examinations were all normal. Pertinent blood, cerebrospinal fluid and nerve conduction tests were normal. Magnetic resonance imaging of the spine showed features of cord atrophy. Three months following physiotherapy, his power improved to 5/5 in bilateral knee and hip joints and 4/5 in bilateral ankles with spasticity. Organophosphate-induced delayed neuropathy can present as earlier as 6 weeks with myelopathy. Previous history of organophosphorous exposure is important in myelopathy or peripheral neuropathy.

Magnetic resonance imaging abnormalities in encephalomyelitis due to paralytic rabies: A case report

The diagnosis of rabies, a potentially fatal neuroinfectious disease, should be strongly considered in all patients who develop encephalitis following an infected animal bite even when they have received post-exposure prophylaxis. In the absence of confirmatory tests, typical magnetic resonance imaging findings help confirm the clinical diagnosis of rabies.

Clinical Manifestations, Neuroimaging Findings, and Treatment of Idiopathic Intracranial Hypertension in a Nepalese Tertiary Centre

Introduction: Idiopathic Intracranial Hypertension is characterized by headache, visual impairment, papilledema, and increased cerebrospinal fluid opening pressure. We aim to evaluate clinical manifestations, neuroimaging findings, and treatment of Idiopathic Intracranial Hypertension in a Nepalese tertiary center. Materials and Methods: We retrospectively included patients with the diagnosis of Idiopathic Intracranial Hypertension who were admitted to the Neurology department of Tribhuvan University Teaching Hospital from 2019 June to 2021 May and presented to the Neuro-ophthalmology outpatient clinic of the hospital for follow-up. Results: Out of 16 Idiopathic Intracranial Hypertension patients, 12(75%) patients had either headache or ocular pain.  Reduced visual acuity and progressive visual loss were found in 44% of patients. Normal CSF opening pressure was found in 19%, 44% had CSF opening pressure at a range of 20-30 cm H20 and > 30 cm H20 in 37.5%. 15 Idiopathic Intracranial Hypertension patients (93.7%) were subtyped as Typical and 1 patient was diagnosed as Fulminant Idiopathic Intracranial Hypertension. Acetazolamide was used for treatment in 15 patients and 1 patient needed ventriculoperitoneal shunting. 56% Seven patients (44%) had some abnormal findings: partial empty sella (44%), and tortuous optic nerve (31%), flattened posterior eyeball (31%), and hypoplastic transverse sinus (19%). Conclusions: Idiopathic Intracranial Hypertension is an uncommon diagnosis but should be suspected in patients with chronic headaches with visual impairment. In low-resource settings, proper history along with neurological and ophthalmological examinations can even detect the early features and timely referral can save the vision and disability of Idiopathic Intracranial Hypertension patients.

Safety and efficacy of interleukin-6-receptor inhibitors in the treatment of neuromyelitis optica spectrum disorders: a meta-analysis

BACKGROUND

Interleukin-6-receptor inhibitors like Tocilizumab and Satralizumab are showing promising results in the treatment of Neuromyelitis Optica spectrum disorder (NMOSD). We aimed to investigate the efficacy and safety of various Interleukin-6-receptor inhibitors in the management of NMO/NMOSD.

METHODS

PubMed, Embase, and The Cochrane Library were systematically searched for suitable studies. Change in Annualized Relapse Ratio (ARR), Change in Extended Disability Status Scale (EDSS) s, the proportion of relapse-free patients and proportion of patients with adverse events, including serious adverse events and mortality were the parameters considered for the meta-analysis for Tocilizumab. Mean difference (MD) with 95% CI was used to quantify the change in ARR and change in EDSS before and after treatment. A forest plot was prepared to indicate the efficacy and adverse effects outcomes. The results were compared with those of Satralizumab included in two trials.

RESULTS

A total of nine studies with 202 patients were included in our study. Tocilizumab found a good proportion (76.95% CI: 0.61-0.91; p < 0.001) of relapse free patients at follow up. It also significantly reduced mean ARR (mean difference: -2.6, 95% CI: - 2.71 to - 1.68; p < 0.001) and but did not show significant difference in change in EDSS score (mean difference = - 0.79, 95% CI: - 1.89 to - 0.31; p = 0.16). Also, the toxicity profile of Tocilizumab was acceptable considering the proportions of patients with adverse events 56% (95% C.I.;0.27-0.85, I2 = 88.95%, p < 0.001), proportions of patients with serious adverse events 11% (95% C.I.; 0.05 to 0.17, I2 = 0%, p < 0.001) and zero treatment related deaths. SAkura studies for Satralizumab showed similar relapse free patients (70% to 80%) and reduction of ARR and EDSS from baseline. Some studies of Tocilizumab have shown to reduce pain and fatigue while trials of Satralizumab had non-significant findings.

CONCLUSION

Interleukin-6-receptor inhibitors therapy showed a promising result with good efficacy and acceptable adverse events profile for treatment of NMOSD.

Extensive bilateral intracranial calcifications and seizure in iatrogenic hypoparathyroidism: A case report

Postoperative permanent hypoparathyroidism can exhibit extensive intracranial calcifications involving basal ganglia, thalamus, cerebellum, and cerebral cortex.

Cryptococcal meningitis in an immunocompetent individual: A case report

Cryptococcal meningitis (CM) is mostly seen in immune-compromised patients and rarely occurs in immune-competent individuals. Immunocompetent individuals with CM present with indolent neurological disease and have better clinical outcomes after treatment. However, misdiagnosis is common and these patients may suffer from serious complications with high mortality.

Cerebral venous sinus thrombosis with concomitant subdural hemorrhage and subarachnoid hemorrhages involving cerebral convexity and perimesenchephalic regions: A case report

We should suspect cerebral venous sinus thrombosis in patients with subacute onset progressive headaches with brain imaging evidence of localized cerebral edema with superimposed parenchymal, convexity subarachnoid as well as subdural hemorrhages.

Paraparetic Guillain-Barre syndrome: An uncommon diagnosis of acute flaccid paralysis of the lower limbs

Apart from the usual differentials of transverse myelitis and cord compression, paraparetic GBS should be considered when sudden, flaccid paralysis of the lower limbs occurs, as prompt diagnosis and management can minimize sequel and unnecessary procedures. We do report a case wherein we managed a similar situation without the use of an immunomodulatory therapy.

Safety and efficacy of Magnesium Sulfate in the management of Tetanus: A systematic review

Tetanus is a rare life-threatening condition often complicated by repetitive spasms, dysautonomia and neuromuscular respiratory failure contributing to high fatality rates in its severe form. Benzodiazepines used to treat muscle spasms pose a high risk of respiratory failure requiring mechanical ventilation, which is unaffordable and inaccessible for many. Magnesium sulfate, a cheap and widely available medication in all urban and rural health centres of LMICs for the treatment of eclampsia, can be used to control muscle spasms and dysautonomia. We thus conducted a systematic review of evidence to assess the safety and efficacy of magnesium sulfate in the treatment of tetanus. Any study published before April 15, 2021, discussing the efficacy and/or safety of MgSO4 infusion in the treatment of tetanus was systemically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Our systematic review included data from 13 studies, three were randomised, double-blind and controlled trials. The remaining ten studies were observational; six prospective and four retrospective studies. Our review showed no mortality benefit associated with the use of magnesium sulfate. However, magnesium sulfate was found to be effective in reducing spasms along with diazepam, leading to better control of dysautonomia, reduced need for mechanical ventilation and shorter hospital stay by 3-7 days. The incidence of magnesium toxicity was very low in the studies included.

Isolated extrapontine myelinolysis with neuropsychiatric manifestation: A case report from Nepal

A referred case of a 34-year-old woman was brought to the emergency room with features of mutism and whole-body rigidity following rapid correction of hyponatremia. On presentation, she was ill looking with tremors on her both hands and legs. She was unresponsive to command and developed involuntary outbursts of laughter and crying. Based on clinical features and neuroimaging, diagnosis of isolated extrapontine myelinolysis was made. She was treated with quetiapine, vitamin B₁ and B₁₂ supplements, trihexyphenidyl, levodopa-carbidopa and physiotherapy of limbs. Due to lack of clinical trials for adequate diagnosis and management of extrapontine myelinolysis, this case report highlights the importance of extrapontine myelinolysis with neuropsychiatric manifestation in research world.

Neurobrucellosis: A differential not to be missed in patients presenting with neuropsychiatric features

When a patient presents with undulating fever and neuropsychiatric features, neurobrucellosis should be considered as a differential diagnosis. If diagnosed early, neurobrucellosis is a treatable disease with a favorable outcome.

Neurological Manifestations of COVID-19 Associated Multi-system Inflammatory Syndrome in Children: A Systematic Review and Meta-analysis

BACKGROUND

Children comprise only 1-5% of COVID-19 cases. Recent studies have shown that COVID-19 associated multisystem inflammatory syndrome in children (MIS-C) can present with neurological signs and symptoms. In this systematic review and meta-analysis, we have reviewed neurological involvement in these patients.

METHODS

A comprehensive electronic literature search was done on PubMed, Google Scholar, Embase, Cochrane database, and SCOPUS for the published English language articles from December 1, 2019, to February 28, 2021. A meta-analysis of the proportion was expressed as a pooled proportion with a 95% confidence interval (CI). Representative forest plots showing individual studies and the combined effect size were generated to provide an overview of the results.

RESULTS

This systematic review and meta-analysis analyzed 15 published MIS-C studies with a total of 785 patients. Neurological manifestations in patients with MIS-C was found in 27.1%. We found that 27% developed headaches, 17.1% developed meningism/meningitis and 7.6 % developed encephalopathy. Other uncommon neurological manifestations of MIS-C includes anosmia, seizures, cerebellar ataxia, global proximal muscle weakness and bulbar palsy. In MIS-C patients with neurological feature, neuroimaging showed signal changes in the splenium of the corpus callosum. Electroencephalography showed slow wave pattern and nerve conduction studies and electromyography showed mild myopathic and neuropathic changes.

CONCLUSIONS

Our study revealed that neurological manifestations are not uncommon in patients with MIS-C. Further large prospective studies are needed to better explore the disease spectrum and to unravel the underlying pathophysiology.

Longitudinally Extensive Transverse Myelitis: A Retrospective Study Differentiating Neuromyelitis Optica Spectrum Disorder From Other Etiologies

Background Longitudinally extensive transverse myelitis (LETM) is characterized by contiguous immune-mediated inflammatory lesion of the spinal cord extending more than three vertebral segments. Neuromyelitis optica spectrum disorder (NMOSD) is the most common and important cause of LETM. This study aims to evaluate the demographic profile, clinical presentations, neuroimaging features, laboratory parameters, and etiologies of LETM and differentiates NMOSD from other etiologies of LETM. Methodology This retrospective cross-sectional study was conducted at the Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. After receiving clearance from the ethical committee, a retrospective chart review was conducted and records of all the inpatient LETM cases admitted from March 2018 to June 2020 were obtained. From the patient records, the following information was extracted: the demographic profile, clinical presentations, neuroimaging features, cerebrospinal fluid analysis, serum anti-aquaporin-4 (AQP4) immunoglobulin G status, hemogram, infectious disease profile, inflammatory markers, and auto-immune panels. Descriptive analysis of data was performed with SPSS statistics 23.0 version (IBM Corp, Armonk, NY, USA). Results In our study, the mean age of LETM patients was 36.58 years, and 12 out of 19 (63.15%) patients were young, with an age less than 40 years. A total of 13 (68.40%) patients were male, with a male-to-female ratio of 2.16. Seven (36.80%) patients had a clinical diagnosis of NMOSD with anti-AQP4 antibody-positive status, four (21.10%) had unknown etiology, three (15.8%) had post-infectious transverse myelitis, and three (15.80%) had a diagnosis of idiopathic transverse myelitis. There was a single case (5.30%) of cervical spondylotic myelopathy and leukemic transverse myelitis each. The common presenting symptoms of LETM were bladder dysfunction, paraparesis, quadriparesis, and visual impairment. Visual involvement, either unilateral or bilateral, was common in NMOSD and LETM of unknown etiology category. Similarly, brain lesion was common in patients with NMOSD and LETM of unknown etiology category. Conclusion LETM is a heterogeneous disorder with diverse etiologies and clinical presentations. NMOSD is an important cause of LETM that predominantly affects females. Optic neuritis can be seen in LETM of various etiologies, but it is more common in anti-AQP4-positive NMOSD patients. Brain lesions in LETM are common in anti-AQP4-positive NMOSD.

Sporadic Creutzfeldt-Jakob disease: A case report and review of literature

Creutzfeldt-Jakob Disease is a rare neurodegenerative disease and earlier diagnosis is usually difficult. Combining clinical features with electroencephalogram, laboratory parameters, and neuroimaging findings will facilitate the diagnosis.

Efficacy and safety of rituximab in autoimmune encephalitis: A meta-analysis

BACKGROUND

Autoimmune encephalitis (AE) is a rare but debilitating neurological disease where the body develops antibodies against neuronal cell surface/synaptic proteins. Rituximab is an anti-CD20 chimeric monoclonal antibody which shows promise in AE treatment observational studies. To our knowledge, there has been no previous meta-analysis providing robust evidence on the effectiveness and safety of rituximab as second-line therapy for the treatment for AE.

METHODS

This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement. Investigators independently searched PubMed, Web of Science, Google Scholar, WANFANG, CNKI, and J-STAGE for studies. Meta-analysis via representative forest plots was conducted for good functional outcome (mRS ≤ 2), proportion of relapse, and mRS score change pre- and post-treatment.

RESULTS

Good functional outcome at last follow-up following rituximab therapy occurred in 72.2% of patients (95% CI: 66.3%-77.4%). Mean mRS score decreased by 2.67 (95% CI: 2.04-3.3; P < .001). Relapses following the rituximab therapy occurred in only 14.2% of patients (95% CI: 9.5%-20.8%). Infusion related reactions, pneumonia, and severe sepsis were seen in 29 (15.7%), 11 (6.0%), and two patients (1.1%), respectively. The efficacy and side effect profile of rituximab are comparable to outcomes seen in rituximab use in other autoimmune and inflammatory CNS disease.

CONCLUSION

Our meta-analysis showed that rituximab is an effective second-line agent for AE with an acceptable toxicity profile.

The dangers of mass drug administration of albendazole in Nepal, a Neurocysticercosis-endemic region

The majority of cases of Neurocysticercosis (NCC) are asymptomatic. Injudicious use of antihelmintics like albendazole (ALB) can cause cyst degeneration and perilesional inflammation, thus rendering asymptomatic individuals symptomatic with seizures, headache, vascular events, or cerebral edema. Mass drug administration (MDA) using ALB is a very common practice in developing countries like Nepal to contain transmission of soil-transmitted helminths (STH) and lymphatic filariasis (LF). Although the benefits of ALB-based MDA in the general population cannot be undermined, there can be severe consequences in certain groups, especially those with latent NCC. In this commentary, we discuss the effect it may have on such patients, and suggest potential solutions.

Anti-LGI1, anti-GABABR, and Anti-CASPR2 encephalitides in Asia: A systematic review

AIM

We aim to review the literature to collate and describe features of encephalitides arising from autoantibodies against leucine-rich glioma-inactivated 1 (LGI1), gamma aminobutyric acid receptor (GABABR), and contactin-associated protein-like 2 (CASPR2) in Asian populations and compare them with findings of Western studies.

METHODS

Peer-reviewed articles published till 24 May 2020 were searched, and original, full-text studies from Asia with serum/CSF antibody-based diagnosis and at least 2 patients were selected. Twenty-four studies with 263 patients (139 anti-LGI1, 114 anti-GAGABR, and 10 anti-CASPR2) were included. Data were pooled to produce descriptive information on demographics, clinical characteristics, diagnostics, treatments, and outcome.

RESULTS

The mean age was 54.2 (anti-LGI1), 55.2 (anti-GABABR), and 47.7 years (anti-CASPR2), with an overall male predominance of 62.0%. Commonest clinical features across all types were seizures (87.5%), memory deficits (80.7%), psychiatric disturbances (75.9%), and altered consciousness (52.9%). Four anti-LGI1, 40 anti-GABABR, and 1 anti-CASPR2 patients had tumors. CSF, MRI, and EEG were abnormal in 33.3%, 54.1%, and 75% patients in anti-LGI1; 60.0%, 49.6%, and 85.7% in anti-GABABR; and 50%, 44.4%, and 100% in anti-CASPR2 patients, respectively. 95.6% patients received first-line therapy alone (steroids/IVIG/Plasma therapy), and 4.4% received second-line therapy (rituximab/cyclophosphamide). 91.7%, 63.6%, and 70% of patients had favorable outcomes (modified Rankin Score 0-2) with mortality rates at 2.5%, 23.2%, and 0% in the three types, respectively.

CONCLUSION

Our findings suggest that these disorders present in Asian patients at a relatively young age often with features of seizures, memory deficits, and psychiatric disturbances and usually demonstrate a favorable clinical outcome.