Spectrum of Posterior Cerebral Artery Dissection: A Retrospective Observational Study and a Critical Review

Background and Aims

Intracranial arterial dissections commonly involve the vertebrobasilar system leading to subarachnoid hemorrhage (SAH) or cerebral infarction attributable to a dissecting aneurysm of the vessel or occlusion of the lumen depending on the depth of dissection. However, isolated posterior cerebral artery dissections (PCADs) are rare and sparsely reported in the literature.

Methodology

A retrospective multicentric observational study was carried out after collecting data from 14 patients admitted with PCAD in three hospitals of Kolkata, Jaipur, and Patna within the period of July 2021 to June 2022.

Results

The median age of the population was 48.5 years, and 64.28% were females. SAH was the most common presentation with dissecting aneurysms in all patients barring one, who presented with a left occipital infarct consequent to ipsilateral PCAD. Among the 14 patients, three patients denied endovascular intervention and were lost to follow-up; one patient with an occipital infarct and another patient with a dissecting left P3 aneurysm, which underwent spontaneous thrombosis, were managed conservatively. Among the nine patients scheduled for endovascular coiling, one patient succumbed before intervention and one patient succumbed to sepsis in the postoperative period. A complete recovery was noted in six patients, whereas residual neurodeficits were present in three patients. Among the six patients who had an uneventful recovery at the end of 3 months, five patients had an endovascular intervention.

Conclusion

PCAD may present with large-scale neurodeficits and is associated with high morbidity and mortality, hence necessitating prompt management. Conservative management is preferable for consequent infarcts, whereas endovascular management is desirable in cases of dissecting aneurysms, which usually tend to have a favorable outcome if intervened early.

The Coexistence of Two Genetic Astrocytopathies-Megalencephalic Leukoencephalopathy and Vanishing White Matter Disease-in an Indian Child

A 9-month-old male child, born of second-degree consanguinity, presented with a progressively enlarging head since early infancy. The child had normal early development, but further acquisition of milestones after 6 months was delayed. He had afebrile seizures at 9 months, followed by the appearance of appendicular spasticity. First magnetic resonance imaging (MRI) showed nonenhancing, diffuse, bilaterally symmetrical T1/fluid-attenuated inversion recovery (FLAIR) hypointensity and T2 hyperintensity of the cerebral white matter and anterior temporal cysts. Subsequently, the periventricular and deep white matter developed microcystic changes with a pattern of radial stripes. Next-generation sequencing revealed homozygous autosomal recessive variations in the MLC1 gene [c.188T > G, (p.Leu63Arg)] on exon 3 and also in the EIF2B3 gene [c.674G > A, (p.Arg225Gln)] on exon 7, the parents being heterozygous carriers for both variations. This article highlights the rare occurrence of two leukodystrophies of diverse pathogenesis in a child from a nonpredisposed community.

Cerebral Venous Thrombosis as The Sole Presenting Manifestation of Human Immunodeficiency Virus and Hepatitis B Virus Co-Infection

BACKGROUND

Cerebral venous thrombosis (CVT) following either human immunodeficiency virus (HIV) infection or hepatitis B virus (HBV) infection is a very rare condition. Moreover, it has never been reported as the presenting manifestation of HIV and HBV co-infection, even more so when the patient had a normal CD4 count and no demonstrable opportunistic infections. We aimed to report the first case of an adult Indian male, an intravenous drug abuser who developed CVT as the presenting manifestation of HIV-HBV co-infection.

METHODS

Patient data were obtained from medical records from the Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India.

RESULTS

A 25-year-old male with a history of intravenous drug abuse and a normal CD4 count developed CVT as the presenting manifestation of HIV-HBV co-infection. His CD4 count was normal, and he had no demonstrable opportunistic infections. He had an uneventful recovery of the condition (CVT) following the institution of conventional anticoagulation therapy alongside anti-retroviral therapy.

CONCLUSION

Whether illicit drug abuse or HIV/HBV infection itself or all in combination led to this thrombotic event cannot be precisely established. Notwithstanding, we recommend serologic testing for HIV and HBV in patients suffering from CVT with high-risk behavior.

A Novel Variation of the Short-Chain Enoyl-CoA Hydratase-1 Gene Presenting with a Novel Mild Phenotype: The Second Case Report from India

A 9-year-old girl presented with asymmetric abnormal twisting movements affecting her left side more than the right side, initially action induced, but later persistent. Examination revealed generalized persistent dystonia with choreoathetosis and right partial tonic ocular tilt reaction. Brain magnetic resonance imaging showed T1 and T2 fluid-attenuated inversion recovery (FLAIR) hypointense and T2 hyperintense signal changes in bilateral globus pallidi. Clinical exome sequencing revealed compound heterozygous variatnts in enoyl-CoA hydratase-1 (ECHS1) gene: a novel pathogenic variant in exon 6, chr10:g.133366045G > A (p.Gln224Ter) and a likely pathogenic variant in exon 5, chr10:g.133366990G > A (p.Ala173Val). Metabolic testing and arterial lactate levels were normal. She was treated with valine restricted diet, trihexiphenidyl, clonazepam, N-acetyl cysteine and mitochondrial cocktail, without significant improvement over the 6 months follow-up period.

Bickerstaff encephalitis: An uncommon sequalae of a bacterial infection

Bickerstaff brainstem encephalitis (BBE) is a rare neurological disorder characterised by the presence of the triad of ophthalmoplegia, ataxia and altered consciousness. It is thought to be associated to an autoimmune condition triggered by an antecedent infection. Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi, and it is associated with myriads of neurological complications. We hereby present an unusual case of BBE in a young lady, who was probably a sequalae of scrub typhus infection. Bickerstaff brainstem encephalitis in association with scrub typhus has not been reported till date.

Hypokalaemia with Guillain-Barré syndrome: a diagnostic and therapeutic challenge

Acute-onset quadriparesis is not only debilitating and a grave concern for the patient but also perturbs the clinician as it demands early diagnosis and prompt management to prevent catastrophic outcome due to respiratory failure. Guillain-Barré syndrome (GBS) and hypokalaemia are notorious causes of acute-onset lower motor neuron (LMN) quadriparesis and warrant a rapid evaluation to necessitate early management. However, coexistence of these two entities is extremely rare and may pose a diagnostic and therapeutic challenge and mandates exclusion of either condition to avoid a poor outcome. We hereby report a case of a young woman who presented with an acute-onset LMN quadriparesis, initially found to have significant hypokalaemia with poor response to supplementation and was further evaluated to have an axonal variant of GBS.

Disseminated Staphylococcal Disease Complicated with Intracranial Internal Carotid Artery Mycotic Pseudoaneurysm and Cerebral Infarcts—A Rare Presentation in a Malnourished Child

A 2.5-year-old girl child patient with moderate malnutrition presented with right forehead abscess followed by ipsilateral orbital cellulitis. She also developed a left hydropneumothorax within a week. Subsequently she had left focal onset seizures with secondary generalized status epilepticus followed by development of left hemiparesis. Neuroimaging showed infarcts of varying ages in the right cerebral hemisphere and basal ganglia. Angiography revealed right internal carotid artery pseudoaneurysm. Blood and pus cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Investigations for immunodeficiency were negative. The patient received vancomycin intravenously for 6 weeks and intercostal tube drainage for hydropneumothorax. She was discharged with an antiepileptic drug and aspirin. There was complete resolution of the orbital cellulitis and hydropneumothorax and also the pseudoaneurysm on follow-up angiography 3 months later.

Anticoagulation in COVID-19: current concepts and controversies

Rising incidence of thromboembolism secondary to COVID-19 has become a global concern, with several surveys reporting increased mortality rates. Thrombogenic potential of the SARS-CoV-2 virus has been hypothesised to originate from its ability to produce an exaggerated inflammatory response leading to endothelial dysfunction. Anticoagulants have remained the primary modality of treatment of thromboembolism for decades. However, there is no universal consensus regarding the timing, dosage and duration of anticoagulation in COVID-19 as well as need for postdischarge prophylaxis. This article seeks to review the present guidelines and recommendations as well as the ongoing trials on use of anticoagulants in COVID-19, identify discrepancies between all these, and provide a comprehensive strategy regarding usage of these drugs in the current pandemic.

Spectrum of Neurological Illnesses in Pregnancy - An Observational Study from a Tertiary Care Centre of Eastern India

INTRODUCTION

Neurological disorders in pregnancy may be observed in patients with a pre-existing neurological disorder; patients developing a primary neurological disorder during the course of pregnancy or puerperium; and in patients with primary medical disorders presenting with neurological manifestations.

OBJECTIVES

The objectives of the study were to find out the magnitude of neurological disorders in pregnancy in a tertiary care hospital along with assessment of proportion of women with particular disorders among total number of neurological disorders during the course of pregnancy or puerperium (6 weeks after child birth) and also to elicit the effect of neurological disorders on pregnancy outcome, if any.

METHODS

A prospective observational longitudinal study was carried out in a tertiary care centre of Eastern India from July 2018 to June 2020 including all pregnant women attending the department of Obstetrics and Gynaecology. We screened 886 pregnant women, out of which 91 cases were identified and investigated. For the purpose of comparison of fetal and maternal outcome, 91 control subjects were chosen from the screened patients in a randomized fashion, so that the baseline characteristics of the two groups were comparable Results: In our study, 10.3% population had neurological disorders, among which 30.8% had primary headache, 3.2% had secondary headache, 8.5% had neurological low back pain, 19.1% had epilepsy, 6.4% had cerebrovascular disorders, 27.6% had peripheral neuropathy, 4.2% had other disorders such as neuropsychiatric Wilson's disease, myasthenia gravis and compressive myelopathy. Moreover, 10.2% of the total study population was hypertensive and 2.9% were diabetic.

CONCLUSION

10.3% mothers did have some neurological disorder, the commonest of which was migraine (primary headache) followed by carpal tunnel syndrome (peripheral neuropathy) and neurological low back pain. Overall fetomaternal outcomes were favorable barring cerebro-vascular disorder and Posterior reversible encephalopathy syndrome (PRES). We recommend screening for neurological disorder from early pregnancy for early detection and appropriate management of that condition.

Post-COVID-19 HSV encephalitis: a review

BACKGROUND

Herpes simplex virus encephalitis (HSVE) is one of the most common infectious causes of sporadic encephalitis. Coronavirus disease (COVID-19) has been associated with immune dysregulation of the host that might increase the risk of infections like HSVE following SARS-CoV-2 infection. There is paucity of literature on post COVID-19 HSVE. This study was conducted with the aim of analyzing the clinical presentation, brain imaging, and outcome of patients presenting with HSVE within 6 weeks of COVID-19 and providing a comprehensive review on the possible mechanisms of post-COVID-19 HSVE.

METHODS

This observational study included patients who had laboratory-confirmed HSVE (type 1 or type 2) and a history of COVID-19 within the previous 6 weeks. Patients were followed up for 3 months.

RESULTS

Eight patients were included and all of them had type 1 HSVE. The mean latency of onset of neurological symptoms from being diagnosed with COVID-19 is 23.87 days and a majority of the patients have received injectable steroids with a mean duration of 6.5 days. Behavioral abnormality was the commonest neurological presentation and typical brain imaging involved T2 FLAIR hyperintensities of the medial temporal lobes. All patients received intravenous acyclovir 10 mg/kg every eight hourly for atleast 14 days. One patient with concomitant rhinocerebral mucormycosis succumbed while the majority had a complete recovery.

CONCLUSION

Possible immune dysregulation in COVID-19 may increase the susceptibility of HSVE in patients with a history of recent SARS-CoV-2 infection. The clinical manifestations and laboratory findings of HSVE in such patients are similar to typical HSVE.

Space occupying lesion presenting as Millard-Gubler syndrome

Millard-Gubler syndrome (MGS) is a ventral pontine syndrome due to an ipsilateral involvement of abducens and facial nerve with a contralateral hemiparesis or hemiplegia. Although classically described as a vascular brainstem syndrome, various other aetiologies such as infection or demyelination may lead to MGS. In this case, a young female presented with MGS, which was attributed to a strategically located infective granuloma of the brainstem. In countries, where tuberculosis is still considered an endemic, central nervous system involvement due to tuberculosis may have protean manifestations.

Toxoplasma Lymphadenopathy in an Immunocompetent Host

Toxoplasma infection can be congenital or acquired. Infection with <i>Toxoplasma gondii</i> can result in multi-organ involvement in immunocompromised patients; whereas in immunocompetent patients, it usually remains asymptomatic. <i>Toxoplasma</i> is a rare cause of isolated lymphadenopathy especially in immunocompetent individuals, though it is a common manifestation of this protozoal infection. We present a 27-year-old male who presented to us with isolated cervical lymphadenopathy. Histopathology and serological studies confirmed the diagnosis of toxoplasma lymphadenopathy. It usually affects the posterior cervical group of lymph nodes, but in our case, it had also affected anterior group and presented without any constitutional symptom. The patient was treated with cotrimoxazole double strength tablet once daily for 1 month and responded well.

Metronidazole Induced Neurotoxicity

NONE

COVID-19 associated symmetrical peripheral gangrene: A case series

BACKGROUND AND AIMS

The novel coronavirus disease (COVID-19) caused by SARS-CoV-2 has turned the world topsy-turvy since its onset in 2019. The thromboinflammatory complications of this disease are common in critically ill patients and associated with poor prognosis. Symmetrical peripheral gangrene (SPG) is characterized by symmetrical distal gangrene in absence of any large vessel occlusion or vasculitis and it is usually associated with critical illness. Our aim was to report the clinical profile and outcome of patients diagnosed with SPG associated with COVID-19. To the best of our knowledge, no such similar cases have been reported till date.

METHODS

In this case series, we have discussed the clinical presentation, laboratory parameters and outcome in a series of two patients of SPG associated with COVID-19 and also compared those findings. Due to paucity of data, we also reviewed the literature on this under-diagnosed and rarely reported condition and association.

RESULTS

Two consecutive patients (both males, age range: 37-42 years, mean: 39.5 years) were admitted with the diagnosis of COVID-19 associated SPG. Both patients had clinical and laboratory evidence of disseminated intravascular coagulation (DIC). Leucopenia was noted in both patients. Despite vigorous therapy, both patients succumbed to their illness within a fortnight of admission.

CONCLUSION

SPG in the background of COVID-19 portends a fatal outcome. Physicians should be aware of its grim prognosis.

A Case of Systemic Lupus Erythematosus without Antiphospholipid Syndrome Causing Superior Vena Cava Syndrome

Systemic lupus erythematosus (SLE) is an autoimmune disease with multisystem involvement. Superior vena cava (SVC) syndrome is mainly caused by malignant tumors such as lung carcinoma, lymphoma, and metastatic tumors. We report a 20-year-old woman who was admitted with features of SVC syndrome secondary to SVC thrombus. Further evaluation confirmed the diagnosis of SLE without associated antiphospholipid syndrome (APS). The patient was treated with heparin with oral anticoagulant, steroids, and hydroxychloroquine. Complete resolution of thrombus was documented within a few weeks. SVC thrombosis as an initial presenting feature of SLE without associated APS has not been reported so far in the literature.

Recurrent ataxia and dysarthria in myelin oligodendrocyte glycoprotein antibody-associated disorder

The spectrum of central nervous system demyelinating disorders is vast and heterogeneous and, often, with overlapping clinical presentations. Misdiagnosis might occur in some cases with serious therapeutic repercussions. However, introduction of several new biomarkers such as aquaporin-4 IgG and myelin oligodendrocyte glycoprotein IgG has made distinction between diseases such as multiple sclerosis and myelin oligodendrocyte glycoprotein antibody-associated disorder easier. Here, we report a case of a 15-year-old male patient with subacute multifocal neurological presentation without encephalopathy, eventually diagnosed as myelin oligodendrocyte glycoprotein antibody-associated disorder.

Covid-19 associated Guillain-Barré syndrome: A series of a relatively uncommon neurological complication

BACKGROUND AND AIMS

The COVID-19 pandemic has turned the world topsy turvy since its emergence and has claimed innumerable lives worldwide. Neurological manifestations of the disease have raised several eyebrows around the world among which Guillain-Barré syndrome (GBS) deserve special mention. Although majority of the cases of the coronavirus disease 2019 (COVID-19) present with respiratory symptoms, extrapulmonary manifestations are being increasingly reported. We conducted this study to analyze detailed clinical presentations and outcome in a series of eight cases (n = 8) with COVID-19 associated GBS.

METHODS

An observational prospective study was conducted among patients with post-infectious/para-infectious GBS. 8 patients were subclassified into acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN) and acute motor and sensory axonal neuropathy (AMSAN) as per electrodiagnostic criteria and were followed up from admission to 6 months post discharge, to obtain a comprehensive clinical profile and outcome in these patients.

RESULTS

The diagnosis of GBS was confirmed as per Asbury criteria, supported by electrodiagnostic features in nerve conduction velocity test. Among the series of 8 patients, 3 were diagnosed as AIDP, 3 had AMAN and the remaining 2 patients had AMSAN. 3 patients of GBS were afebrile and were diagnosed as COVID-19 after a positive assay on routine screening. Cerebro-spinal fluid analysis for SARS-Cov-2 RT-PCR and serum anti-ganglioside antibodies were negative in all the patients.

CONCLUSION

GBS in patients with COVID-19 should be differentiated from critical illness neuropathy and myopathy. Early diagnosis is important as it is associated with poor outcome and prolonged invasive ventilation.

Moyamoya disease: a spectrum of clinical and radiological findings in a series of eight paediatric patients

Moyamoya disease (MMD) is a progressive steno-occlusive vasculopathy at the circle of Willis, characteristically involving the supra-clinoid segment of internal carotid arteries and their proximal branches with prominent collateral artery formation. Here we present, a series of imaging findings and varied clinical presentation of eight cases (n = 8) of MMD in the pediatric population (aged 0-18 years) after a retrospective review and detailed clinical evaluation. Detailed clinical history and examination were performed of eight pediatric patients of MMD with varied presentations. Magnetic resonance imaging (MRI) of the brain along with time of flight (TOF) sequence magnetic resonance angiography (MRA) was performed for all patients with a 3 T ((T) SEIMENS MRI scanner. Three out of eight cases (37.5%) presented with imaging findings of acute parenchymal infarction involving one or more major vascular territories showing diffusion restriction on DWI (diffusion-weighted image) sequence. Two of the patients (25%) showed chronic infarction with areas of gliosis and encephalomalacia. One child presented with watershed areas of infarction involving bilateral parieto-occipital region. In one of the patients (12.5%) being evaluated for dystonia, the only parenchymal finding detected was that of asymmetric ventriculomegaly. A solitary patient being evaluated for intermittent focal seizure followed by Todd's hemiparesis had normal parenchymal brain imaging. Leptomeningeal pattern of enhancement was noted in one patient (12.5%). Although predominantly an intracranial vasculopathy, MMD may have myriad presentations apart from stroke, some of which are highlighted in this series.

Isolated tricuspid valve endocarditis in immunocompetent juvenile patients: a series of three cases

Right-sided native valve infective endocarditis is common in patients with congenital or valvular heart disease, intracardiac device, central venous catheter and intravenous drug abuse, usually manifesting in adulthood. However, in the absence of predisposing risk factors and in younger age groups, this disease may pose a diagnostic challenge. We report a case series of three juvenile patients with isolated tricuspid valve infective endocarditis without any risk factors and paucity of cardiovascular findings in two of them, in an attempt to highlight the importance of maintaining a high index of suspicion to arrive a timely diagnosis.

Tropical pyomyositis in scrub typhus: a rare association

Tropical pyomyositis manifests as single or multiple abscesses inside skeletal muscles and it has a higher prevalence in immunocompromised patients. Scrub typhus, a zoonotic disease is caused by Orientia tsutsugamushi and the clinical manifestations range from simple febrile illness to organ threatening complications. Here, we present a rare case of an immunocompetent young man diagnosed as tropical pyomyositis in association with scrub typhus. Imaging of both thighs revealed multiple intramuscular abscesses. Blood and aspirated pus were culture negative. Patient was treated aggressively with parenteral antibiotics (linezolid, clindamycin and meropenem) and surgical debridement. But, fever did not subside and total leucocyte count remained persistently high. After serological confirmation of scrub typhus, the patient was put on oral doxycycline and he had a dramatic improvement within next few days. To the best of our knowledge, this is probably the first reported case of tropical pyomyositis in association with scrub typhus.