Spectrum of neurological manifestations among acute COVID-19 and long COVID-19 – A retrospective observational study

Objective. Preliminary clinical data indicate that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with neurological symptoms. To compare the clinical features, imaging and treatments in patients with and without COVID-19. To compare the mortality and in-hospital stay among patients with and without COVID-19 and negative patients. Materials and methods. In this retrospective, single-center study, we included all the patients who attended the department of neurology with neurologic symptoms with confirmed COVID-19 and long COVID-19 from June 2020 to January 2021. Data on clinical signs, diagnosis, laboratory findings were collected and analyzed from the records for positive patients and compared with neurologic patients without COVID-19 admitted in the same period. Statistical analysis: The mean values between study groups were compared using an independent sample t-test and Mann Whitney u test. Categorical outcomes were compared using the Chi square test. Data was analyzed using coGuide software. Results. Headache was the common neurologic manifestation present in COVID positive patients compared to COVID negative patients (39.13%). There was no statistically significant difference between the two groups in baseline parameters. Laboratory parameters like CRP, Serum Ferritin, LDH, D-dimer, ESR, and IL-6 showed a significant increase in COVID positive patients (P <0.05). In-hospital mortality was more in COVID positive patients than COVID negative patients (P <0.011). Conclusion. The study showed varied neurologic symptoms in COVID patients, with headache as the common symptom. Hospital stay, morbidity, mortality, and inflammatory parameters were more in COVID positive patients compared to COVID negative patients.

Study of cerebrospinal fluid levels of lactate, lactate dehydrogenase and adenosine deaminase in the diagnosis and outcome of acute meningitis

BACKGROUND

Meningitis is a serious clinical health issue in most developing countries. Late diagnosis and treatment result in significant morbidity and mortality. This research aims to study the utility of CSF lactate, lactate dehydrogenase (LDH), and adenosine deaminase (ADA) as diagnostic markers in acute meningitis, and to differentiate among varied aetiologies of acute meningitis and their outcomes.

METHOD

A cross-sectional observational case-control study was conducted in 30 patients of suspected meningitis of varied aetiologies and 30 controls without any pre-existing neurological disorder and who underwent lumbar puncture during spinal anesthesia. A fresh CSF sample was collected in a heparinized vial following an aseptic lumbar puncture. The levels of lactate, LDH and ADA were estimated and recorded.

RESULT

CSF lactate was significantly elevated in bacterial meningitis (BM) and cryptococcal meningitis, with 100% sensitivity when compared to controls. Elevated LDH was found only in BM, hence elevated LDH levels may strongly signify bacterial etiology. Significantly elevated ADA levels were noted in tuberculous meningitis. Significantly elevated levels of lactate and ADA were suggestive of slower clinical recovery and a prolonged hospital stay (p < 0.001).

CONCLUSION

Estimation of CSF lactate, LDH, and ADA levels is a rapid, inexpensive and simple procedure and can play a major role in the early differentiation of bacterial, viral, tuberculous, and fungal meningitis. This would facilitate the initiation of appropriate treatment as early as possible, thereby decreasing mortality and complications.

Electrophysiological Evaluation of Audiovestibular Pathway Dysfunction in Parkinson's Disease and Its Correlates: A Case Control Study

Background:

Parkinson's disease (PD) is associated with brainstem dysfunction causing non-motor symptoms. Vestibular evoked myogenic potential (VEMP) and brainstem auditory evoked potential (BAEP) are electrophysiological tests to assess the vestibular and auditory pathways in the brainstem.

Objectives:

To study the abnormalities of cervical VEMP (cVEMP) and BAEP in PD and to correlate the findings with the symptoms related to brainstem involvement.

Patients and Methods:

cVEMP and BAEP were recorded in 25 PD patients and compared 25 age matched controls. The PD patients were assessed with the following clinical scales: REM Sleep Disorder Screening Questionnaire (RBD-SQ), Epworth Sleepiness Scale (ESS), mini-BESTest, Geriatric Depression Scale (GDS-15) and MMSE (Mini-mental state examination). The P13 and N23 peak latencies and the P13/N23 amplitude of cVEMP, the latencies of waves I, III and V, and the inter-peak latencies (IPL) of waves I-III, III-V and I-V of BAEP were measured.

Results:

The PD patients showed prolonged latencies and reduced amplitude in cVEMP responses. They had abnormal BAEP in the form of prolonged absolute latencies of wave V, followed by wave III and I–V IPL with no significant difference in waves I and I–III IPL. The cVEMP abnormality was correlated directly with RBD-SQ and inversely with mini-BESTest scores. There were no correlations between cVEMP/BAEP abnormality and disease severity, GDS-15, ESS and MMSE.

Conclusion:

PD is associated with cVEMP and BAEP abnormalities that suggest auditory and vestibular pathway dysfunction in the brainstem and cVEMP correlates with the symptoms of brainstem degeneration like RBD and postural instability.

Rash Decisions in Neurology: A Case Report of Brachioradial Pruritus Secondary to Cervical Intramedullary Lesion

Brachioradial pruritus (BRP) is an enigmatic condition often encountered by dermatologists and passed off as a benign itch. It is an "idiopathic" pruritus, presenting as severe itching on the radial aspect of the elbow. The physical examination may be unremarkable except for mild pruritic lesions. Hence, the patient is treated with local applications of sunscreens, anti-inflammatory agents, anti-histamines and steroids, most of which prove to be ineffective. Dermatomal localization of localization of pruritis has suggested cervical myeloradiculopathy as a novel aetiology and this has been elucidated in recent studies. Here we report a young man, who presented with brachioradial pruritus and was diagnosed to have a C6-7 intramedullary cervical cord lesion.

A Case of Possible IgG4-Related Disease with Bilateral Optic Neuropathy and Bilateral Hippocampal Bleed

IgG4-related disease (IgG4-RD) is a multisystem inflammatory disorder. The diagnosis requires consideration of clinical, radiographic, serological, and pathological evidence. Neurological involvement by IgG4-RD is relatively uncommon and is being increasingly recognized and reported with hypertrophic pachymeningitis and hypophysitis as the most frequent manifestations. IgG4-related involvement of brain parenchyma is rare, but isolated case reports exist. Here, we report a case of a young boy who presented to us with bilateral optic neuropathy and bilateral hippocampal bleed-related neurological involvement in a possible IgG4-RD, a rare entity.

Deep Cerebral Venous Thrombosis-A Clinicoradiological Study

Stroke is a common neurological emergency. Almost 80% of strokes are due to arterial occlusion. Venous thrombosis comprises less than 1–2% of all strokes. Involvement of the deep cerebral venous system is still rare and accounts for about 10.9% of all cerebral venous thromboses (CVT). CVT diagnosis is often delayed or missed, because of its variable clinical manifestations. We retrospectively (2015–18) and prospectively (2018–20) reviewed all the cases of CVT in a tertiary care center in south India. Out of a total of 52 CVT cases, 12 were due to the involvement of deep cerebral venous system. Their clinical presentation, imaging characteristics, and outcomes were assessed. The most frequent presentation was headache followed by seizures. Hyperhomocysteinemia was the most common risk factor noted. Imaging characteristics were variable, and a high index of suspicion was required for early diagnosis. All patients had favorable outcome in our study, and except one, all were treated conservatively.

Study of Short Latency Somatosensory and Brain Stem Auditory Evoked Potentials Patients with Acute Ischemic Stroke Involving Middle Cerebral Artery Territory

Background  The precise timings of evoked potentials in evaluating the functional outcome of stroke have remained indistinct. Few studies in the Indian context have studied the outcome of early prognosis of stroke utilizing evoked potentials.

Objective  The aim of this study was to determine somatosensory evoked potentials (SSEPs) and brain stem auditory evoked potentials (BAEPs), their timing and abnormalities in acute ischemic stroke involving the middle cerebral artery (MCA) territory and to correlate SSEP and BAEP with the functional outcome (National Institutes of Health Stroke Scale (NIHSS), modified Rankin scale (mRS) and Barthel’s index) at 3 months.

Methods  MCA territory involved acute ischemic stroke patients ( n = 30) presenting consecutively to the hospital within 3 days of symptoms onset were included. Details about clinical symptoms, neurological examination, treatment, NIHSS score, mRS scores were collected at the time of admission. All patients underwent imaging of the brain and were subjected to SSEP and BAEP on two occasions, first at 1 to 3 days and second at 4 to 7 days from the onset of stroke. At 3 months of follow-up, NIHSS, mRS, and Barthel’s index were recorded.

Results  P37 and N20 amplitude had a strong negative correlation (at 1–3 and 4–7 days) with NIHSS at admission, NIHSS at 3 months, mRS at admission, and mRS at 3 months and a significant positive correlation with Barthel’s index ( p  < 0.0001). BAEP wave V had a negative correlation (at 1–3 and 4–7 days) with NIHSS at admission, NIHSS at 3 months, mRS at admission, and mRS at 3 months and a positive correlation with Barthel’s index ( p < 0.0001).

Conclusion  SSEP abnormalities recorded on days 4 to 7 from onset of stroke are more significant than those recorded within 1 to 3 days of onset of stroke; hence, the timing of 4 to 7 days after stroke onset can be considered as better for predicting functional outcome.

Role of High Frequency Oscillations of Somatosensory Evoked Potentials in Deciphering Pathophysiology of Migraine

Background  Habituation deficit is considered as a neurophysiological abnormality among migraineurs in the interictal period. For clear comprehension and clarity about the mechanism underlying habituation in migraine, a sophisticated method, i.e., high frequency oscillations (HFOs) evoked potentials, have been utilized. However, studies pertaining to this in the Indian context are rare.

Objective  The aim of the study is to determine the utility of HFO of somatosensory evoked potential (SSEP) in deciphering the pathophysiology of migraine.

Materials and Methods  Sixty subjects including 30 migraineurs in the interictal period and 30 healthy controls were considered for the study. Median nerve SSEP was recorded in patients and controls by standard protocols. HFO was extracted offline using the Digital zero-phase shift band-pass filtering at 450 and 750 Hz. The early and late HFOs were determined with respect to the N20 peak and were compared between the groups.

Results  Of total 30 migraineurs, 18 had hemicranial headache and 12 had holocranial headache. N20 latency, P25 latency, N20 onset to peak amplitude, and N20 onset to P25 amplitude were comparable in migraineurs and controls. The intraburst frequency of early HFOs in migraineurs was significantly higher ( p = 0.04), whereas the peak-to-peak amplitude was significantly lower ( p = 0.001).

Conclusion  Early HFOs on SSEP represent the thalamocortical excitatory drive in migraineurs. Overall, the study reports that reduced amplitude of early HFOs in the interictal period suggest reduced thalamocortical drive in migraineurs.

Adjunctive Brivaracetam in Indian Patients with Uncontrolled Focal Epilepsy: Results from a Pooled Analysis of Two Double-Blind, Randomized, Placebo-Controlled Trials

Background

Nearly one-third of patients don't achieve seizure control with existing antiepileptic drugs. Brivaracetam (BRV) is a new member of the racetam class of drug, designed to selectively target SV2A, with binding affinity 15- to 30-fold greater than that of levetiracetam.

Objective

This pooled analysis reports efficacy and tolerability data of adjunct BRV (50, 100, and 200 mg/day) compared with placebo in Indian patients with uncontrolled focal epilepsy.

Methods

Data of 104 patients (aged 16-80 years) from 2 studies (N01252 and N01358) were pooled for this analysis. The studies comprised an 8-week prospective baseline period, and a 12-week treatment period. The study endpoints included median percent reduction from baseline in focal seizure frequency/28-days, ≥50% responder rate, and seizure freedom (all seizure types). The safety analysis included treatment-emergent adverse events (TEAEs).

Results

The efficacy population comprised 101 patients. In the Indian sub-group population, median percent reduction from baseline in focal seizure frequency/28-days was greater in the BRV dose groups: 39.7% (p = 0.00868), 46.8% (p = 0.00180) and 48.2% (p = 0.05224), for BRV 50, 100, 200 mg/day, respectively, compared with 20.6% for placebo. Responder rates (≥50%) were 38.1%, 45.7%, and 45.5% for BRV 50, 100, and 200 mg/day, respectively, compared with 11.7% for placebo. Complete seizure freedom was reported by 4.8% (1/21) and 2.9% (1/35) of patients on BRV50 and 100 mg/day, respectively, and none out of the 11 and 34 patients on BRV200 mg/day and placebo, respectively. In the safety population (n = 104), most commonly reported TEAEs (reported by ≥5% of patients taking brivaracetam) were headache and cough; most TEAEs were mild or moderate in intensity.

Conclusion

This pooled analysis has provided evidence that adjunct brivaracetam, was effective and well-tolerated in Indian patients with uncontrolled focal epilepsy.

Transcranial Doppler for Monitoring and Evaluation of Idiopathic Intracranial Hypertension

Background  Idiopathic intracranial hypertension (IIH) is a disorder of unknown origin, characterized by features of raised intracranial pressure (ICP). Existing literature is inconclusive about the role of transcranial Doppler (TCD) in the management of IIH. Objective  To study the TCD changes in IIH patients, pre- and post-cerebrospinal fluid (CSF) drainage. Materials and Methods  This was a prospective study, conducted between July 2017 and December 2019, in a tertiary care referral center in South India. Sixteen consecutive patients, suspected to have IIH, underwent magnetic resonance imaging ofthe brain, a baseline TCD, and lumbar puncture with CSF drainage and pressure monitoring. Post-CSF drainage, TCD was repeated and mean flow velocities, peak systolic velocities, end-diastolic velocities, and pulsatility index (PI), in the middle cerebral artery (MCA), vertebral artery, and basilar artery (BA) were noted. Thirteen patients had elevated CSF pressure, and fulfilled the diagnostic criteria for IIH. These patients were included in the final analysis and pre- and post-CSF drainage TCD blood flow velocities and PI were compared. Results  The mean age of study participants was 29.92 ± 6.92 years. There was a significant reduction in the cerebral flow velocities in bilateral MCA, after CSF drainage and normalization of ICP. Flow velocities in posterior circulation and PI in MCA, PCA, and BA showed an insignificant reduction. Two patients, who did not show any reduction in flow velocities after CSF drainage, developed optic atrophy on follow-up. Conclusion  TCD-derived systolic blood flow velocities can be used in the management and follow-up of patients with IIH.

Acute Hydrocephalus in a Case of Mumps Meningoencephalitis: A Rare Occurrence

Mumps is an acute viral illness, which presents with glandular and/or nervous system involvement. The most common central nervous system manifestations of mumps include aseptic meningitis and meningoencephalitis. Mumps meningoencephalitis, which is characterized by fever, vomiting, nuchal rigidity, and altered sensorium, usually develops at least 3-10 days after mumps parotitis. Acute hydrocephalus secondary to mumps meningoencephalitis is rare. Here we report a child who developed acute hydrocephalus following mumps meningoencephalitis and who was treated with external ventricular drainage following which he showed exceptional recovery.

Efficacy of Neuroprotective Drugs in Acute Ischemic Stroke: Is It Helpful?

Background Out of several neuroprotective drugs (NPDs) studied in animals and humans, four NPDs (citicoline, edaravone, cerebrolysin, and minocycline) have been found to have beneficial effects in acute ischemic stroke (AIS).

Objective The purpose is to evaluate the efficacy of citicoline, edaravone, minocycline, and cerebrolysin compared with placebo in patients with middle cerebral artery (MCA) territory AIS.

Materials and Methods This was a prospective, single center, single-blinded, and hospital-based study. One hundred patients with MCA territory AIS with 20 patients in each group including control group were included. Barthel index (BI), National Institute of Health Stroke Scale (NIHSS) score, and modified Rankin Scale score were recorded at admission, at day 11 and after 90 days.

Results The mean NIHSS score was significantly lesser at day 11 and after 90 days in citicoline, edaravone, and cerebrolysin group in comparison with placebo. Similarly, the mean BI score was significantly higher at day 11 and after 90 days in citicoline, edaravone, and cerebrolysin group in comparison with placebo. In minocycline group, there was no significant change in the NIHSS score and BI score at day 11 and after 90 days.

Conclusion There was significant improvement in the functional outcome of patients with AIS involving MCA territory at 90 days receiving citicoline, edaravone, and cerebrolysin. However, minocycline did not offer the same efficacy as compared with other neuroprotective agents.

Clinical impression and Western Aphasia Battery classification of aphasia in acute ischemic stroke: Is there a discrepancy?

Background:

Language disturbance is a common symptom of stroke, a prompt identifier of the event, and can cause devastating cognitive impairments. There are many inconsistencies and discrepancies between the different methods used for its evaluation. The relationship between Western Aphasia Battery (WAB) and a simple bedside clinical examination is not clear.

Aim:

The aim of this study is to determine if bedside clinical impression of aphasia type can reliably predict WAB classification of aphasia and to describe the discrepancies between them.

Materials and Methods:

Eighty-two consecutive cases of acute ischemic stroke and aphasia were evaluated with bedside aphasia assessment, handedness by Edinburgh Handedness Inventory and WAB scoring was done. Kappa statistics was used to find the overall agreement of clinical impression and WAB.

Results:

Disagreement was seen predominantly for the nonfluent aphasias when the clinical impression was compared with WAB classification. WAB also had diagnosed three cases as having anomic aphasia using taxonomic classification, but same cases had normal language by aphasia quotient scoring of WAB. There was an overall agreement of 63.4% between patient's bedside clinical impression and WAB classification of aphasia, with a P < 0.001.

Conclusion:

Clinical impression was fairly reliable, as compared to WAB in assessing the type of aphasia. Clinical impression was appropriate in an acute setting, but WAB was required to quantify the severity of deficit, which may help in accessing prognosis, monitoring progression, and rehabilitation planning. Along with WAB, a bedside clinical impression should be done for all the patients to strengthen the description of aphasic deficit.

Intravenous Thrombolysis for Acute Ischemic Stroke: Review of 97 Patients

BACKGROUND

Intravenous thrombolysis (IVT) has now become a standard treatment in eligible patients with acute ischemic stroke (AIS) who present within 4.5 h of symptom onset.

OBJECTIVE

To determine the usefulness of IVT and the subset of patients who will benefit from IVT in AIS within 4.5 h.

MATERIALS AND METHODS

Patients with AIS within 4.5 h of symptom onset who underwent IVT were studied prospectively. The study period was from October 2011 to October 2015.

RESULTS

A total of 97 patients were thrombolysed intravenously. The mean onset to needle time in all patients was 177.2 ± 62 min (range: 60-360). At 3 months follow-up, favorable outcome was seen in 65 patients (67.1%) and poor outcome including death in the remaining 32 patients (32.9%). Factors predicting favorable outcome was age <65 years (P = 0.02), the National Institute of Health Stroke Scale (NIHSS) <15 (P < 0.001), small vessel occlusion (P = 0.006), cardioembolism (P = 0.006), and random blood sugar (RBS) <250 mg/dl (P < 0.001). Factors predicting poor outcome was diabetes mellitus (P = 0.01), dyslipidemia (P = 0.01), NIHSS at admission >15 (P = 0.03), RBS >250 mg/dl (P = 0.01), Dense cerebral artery sign, age, glucose level on admission, onset-to-treatment time, NIHSS on admission score >5 (P = 0.03), and occlusion of large artery (P = 0.02).

CONCLUSION

Milder baseline stroke severity, blood glucose <250 mg/dL, younger patients (<65 years), cardioembolic stroke, and small vessel occlusion benefit from recombinant tissue plasminogen activator.

Wake-Up Sleepyhead: Unilateral Diencephalic Stroke Presenting with Excessive Sleepiness

Altered sleep architecture and stroke share a reciprocal relationship. More than half of the stroke patients display sleep abnormalities including hypersomnia, insomnia, parasomnia, periodic limb movements, or sleep-disordered breathing. Conversely, one of the major causes of severe organic hypersomnia is acute brainstem strokes, involving thalamic infarctions, which may be reversible over 6-12 months. Here, we report a patient with increased lethargy and drowsiness who was diagnosed to have a right thalamic and hypothalamic ischemic stroke.

Paramedian Midbrain Infarction Presenting as Bilateral Asymmetric Ptosis: A Case Report and Review of Literature

Brainstem strokes can have protean ophthalmological manifestations including pupillary and extraocular muscle pareses. Incomplete paresis of oculomotor function is more common than complete paresis owing to the selective involvement of subnuclei or fascicles for various extraocular muscles. Here, we report a case of right paramedian midbrain stroke presented with asymmetric bilateral ptosis. We discuss the anatomical correlation of this presentation with the structure of oculomotor nerve nuclei and its fascicles.

Efficacy and Safety of Intravenous Tenecteplase Bolus in Acute Ischemic Stroke: Results of Two Open-Label, Multicenter Trials

BACKGROUND

Tenecteplase (TNK-tPA) is a promising third-generation plasminogen activator, because of its greater fibrin specificity and longer half-life than alteplase. There is a paucity of studies on intravenous thrombolysis using TNK-tPA in developing countries. The present study has been undertaken to compare the efficacy and safety of TNK-tPA with alteplase.

METHODS

Two studies were conducted. Study I was an open-label, randomized study in which two doses of TNK-tPA (0.1 and 0.2 mg/kg) were compared. Study II was an open-label study in which TNK-tPA 0.2 mg/kg bolus was compared with historical controls. The primary endpoint for study I and study II was an improvement of ≥ 8 points or a score of 0 on the National Institutes of Health Stroke Scale (NIHSS) [major neurological improvement (MNI)] at 24 h. Secondary endpoints for both studies were neurological improvement as assessed using the NIHSS score, modified Rankin Scale (mRS) score and the Barthel Index (BI) on days 7, 30 and 90. Minimal disability was defined as an mRS score of 0 or 1 and good functional recovery as a BI score of 50-90. Safety was assessed by the proportion of patients having symptomatic intracranial hemorrhage (sICH) within 36 h and asymptomatic intracranial hemorrhage at 48 h after treatment.

RESULTS

In study I, 20 patients received 0.1 mg/kg and 30 received 0.2 mg/kg TNK-tPA. There was no significant difference in MNI at 24 h between 0.1 and 0.2 mg/kg TNK-tPA doses. The patients given 0.2 mg/kg TNK-tPA had a significantly better 3-month outcome (minimal disability, p = 0.007). There was no sICH in study I. In study II, 62 patients (one lost to follow-up) received 0.2 mg/kg TNK-tPA. MNI was noted in ten patients (16.4%), 3-month minimal disability was noted in 37 patients (60.7%), and good functional recovery was seen in 33 patients (54.1%). sICH occurred in one patient, and four patients died. Pooled data of patients in study I and study II receiving 0.2 mg/kg TNK-tPA were compared with data from the historical National Institute of Neurological Disorders and Stroke (NINDS) trial. For comparison, the primary endpoint of the NINDS trial (improvement on NIHSS of ≥ 4 points or a score of 0 at 24 h) was taken. The primary endpoint though was not significantly different (58.2% vs. 47%, p = 0.08), but with TNK-tPA, greater neurological improvement, minimal disability (70.3 vs. 39%, p < 0.001) and good functional recovery (36.3 vs. 16%, p < 0.001) was noted at 3 months. There was a lower incidence of sICH (1.1 vs. 6.4%, p = 0.05) and lower 3-month mortality (5.5 vs. 17%, p = 0.01) noted with TNK-tPA compared with alteplase.

CONCLUSIONS

Intravenous TNK-tPA 0.2 mg/kg administered within 3 hours of symptom onset seems to be well tolerated and effective option in patients with acute ischemic stroke.

TRIAL REGISTRATION

Clinical Trials Registry-India, www.ctri.nic.in ; unique identifiers: CTRI/2009/091/000251 and CTRI/2015/02/005556.

Use of multiplex PCR based molecular diagnostics in diagnosis of suspected CNS infections in tertiary care setting-A retrospective study

OBJECTIVES

CNS infections like meningitis and encephalitis pose enormous healthcare challenges due to mortality, sequelae and socioeconomic burden. In tertiary setting, clinical, microbiological, cytological and radiological investigations are not distinctive enough for diagnosing microbial etiology. Molecular diagnostics is filling this gap. We evaluated the clinical impact of a commercially available multiplex molecular diagnostic system - SES for diagnosing suspected CNS infections.

PATIENTS AND METHODS

This study was conducted in our tertiary level Neurology ICU. 110 patients admitted during Nov-2010 to April-2014 were included. CSF samples of patients clinically suspected of having CNS infections were subjected to routine investigation in our laboratory and SES test at XCyton Diagnostics. We studied the impact of SES in diagnosis of CNS infections and its efficacy in helping therapeutic management.

RESULTS

SES showed detection rate of 42.18% and clinical specificity of 100%. It had 10 times higher detection rate than conventional tests. Streptococcus pneumoniae and Mycobacterium tuberculosis were two top bacterial pathogens. VZV was most detected viral pathogen. SES results elicited changes in therapy in both positive and negative cases. We observed superior patient outcomes as measured by GCS scale. 75% and 82.14% of the patients positive and negative on SES respectively, recovered fully.

CONCLUSION

Detecting causative organism and ruling out infectious etiology remain the most critical aspect for management and prognosis of patients with suspected CNS infections. In this study, we observed higher detection rate of pathogens, target specific escalation and evidence based de-escalation of antimicrobials using SES. Institution of appropriate therapy helped reduce unnecessary use of antimicrobials.