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Oculomotor abnormalities are one of the cardinal clinical features of progressive supranuclear palsy (PSP). Vertical saccadic slowing is an early sign of PSP. The association between oculomotor abnormalities and sleep architecture has not been studied so far.To study the association of oculomotor abnormalities of PSP with the sleep stages by using video polysomnography (vPSG).This was a cross-sectional single-center study. Twenty-two patients with PSP and 15 age and gender-matched controls were recruited. Saccades, vestibulo-ocular reflex, and optokinetic nystagmus were assessed and graded clinically in all patients and one overnight vPSG was done in all cases.Vertical saccades, upward more than downwards, were affected in all cases. While horizontal saccades were normal only in 41% of cases. Vertical optokinetic nystagmus (OKN) was affected in all cases. Horizontal OKN was normal in 36% of patients. The vertical upward saccades had a negative correlation with N1% and duration (r = -0.418; p = 0.05, r = -0.457; p = 0.03), N3% and duration (r = -0.486; p = 0.02, r = -0.510; p = 0.01), REM% (r = -0.449; p = 0.04), total sleep time (r = -0.487; p = 0.02) and sleep efficiency (r = -0.444; p = 0.04). There was a positive correlation between horizontal OKN and sleep onset latency (r = 0.432; p = 0.05).Vertical saccadic restriction in PSP has significant negative correlation with total sleep time and sleep efficiency. The oculomotor and sleep abnormalities in PSP are probably interlinked and their assessment is useful in determining the characteristics of the disease.

Pediatric neurobrucellosis represents a common anthropozoonosis in endemic areas but only anecdotal reports are available till date. Using appropriate search terms in the database platforms of MEDLINE, SCOPUS and Web of Sciences, we performed a systematic review of all the cases of pediatric neurobrucellosis published in the medical literature till date, in the light of a case report. The protocol was registered under PROSPERO (CRD42022333907). Our search strategy yielded 187 citations of which 51 citations were included. A total of 119 cases were reviewed. Of these cases, eight of them had insufficient data. The most common presentation was meningitis with or without encephalitis (n = 79, 71.2%). A high prevalence of cranial neuropathies (n = 22, 20.7%) was observed in the pediatric population in which abducens palsy was the most common (n = 9, 8.1%). Diagnosis was based on multimodal investigations including standard agglutination test (n = 44, 39.6%), Rose Bengal test (n = 37, 33.3%), blood culture (n = 23, 20.7%), serology (n = 20, 18.0%) and cerebrospinal fluid (CSF) culture (n = 11, 9.9%). Rifampicin-based triple drug regimen was the most commonly employed (83/102, 81.4%). Pediatric neurobrucellosis was associated with greater frequency of sequalae (5.4%), deafness (2.7%) and mortality (2.7%), when compared to that of general population. Neurobrucellosis mimics neuro-tuberculosis in various aspects. The review highlights several unique aspects of this entity in children. A high index of suspicion can ensure prompt diagnosis, timely initiation of management and favorable outcomes.

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.

Movement disorders can present in emergency services in an acute severe form which can be life threatening if not recognized. The relative frequency and spectrum of movement disorder emergencies have not been studied extensively. We studied the frequency, spectrum, and outcome of patients presenting with movement disorders emergencies.This was a prospective, descriptive single center study. Patients presenting with acute movement disorders to the neurology emergency services of the institute during the study period from April 2019 to June 2021 were analyzed.A total of 71 patients presented with acute movement disorders during the study period. Out of them, 65 patients had hyperkinetic and 6 patients had hypokinetic movement disorders emergencies. Fifteen patients were below the age of 18 years. Chorea (59.1%) was the most common movement disorder emergencies followed by dystonia and myoclonus in adults. Dystonia (33.3%) was the common movement disorder emergencies in children. Hyperglycemia followed by stroke was the most common etiology of acute movement disorders.This study brings out some novel findings on the movement disorders emergencies in Indian scenario. Chorea was the most common movement disorder emergencies presenting to the neurology emergency services. Early recognition and management of movement disorders emergencies help in reducing morbidity.

Sleep disturbances have been reported to occur in progressive supranuclear palsy (PSP). The anatomical regions affected in PSP and those regulating sleep and wake cycle like dorsal raphe nucleus, locus coeruleus (LC), and pedunculopontine nucleus (PPN) overlap. There is a paucity of polysomnographic studies in PSP and they have shown altered sleep architecture.To study the sleep architecture in patients with PSP using video-polysomnography (vPSG) and correlate it with the disease severity and duration.This was a prospective, cross-sectional, case-control, single-center study. A total of 22 patients with PSP and 15 age and gender-matched controls were recruited. The cases and controls underwent clinical assessment, face-to-face interviews with sleep questionnaires, anxiety and depression scales, and one overnight vPSG. The sleep architecture was analyzed in detail.The sleep architecture was altered as compared to the controls. The total sleep time, stage N2 duration, stage N3 duration, rapid-eye-movement (REM) sleep duration, sleep efficiency %, and N2%, N3%, and REM% were significantly lesser in PSP patients. The wake duration, wake after sleep onset (WASO) duration, wake%, WASO%, stage N1 duration was significantly greater in PSP patients. The stage N2 and N3 latencies were significantly prolonged in patients. REM sleep without atonia was noted in four patients and no patients had vPSG proven REM sleep behavior disorder.Sleep architecture is altered in PSP even during the early stages of the disease. There is reduced total sleep including both non-REM and REM sleep, sleep efficiency, prolonged sleep latencies, and increased wake duration. This correlates with the neurodegenerative processes affecting the anatomical region regulating the sleep/wake cycle like dorsal raphe nucleus, locus coeruleus (LC), pedunculopontine nucleus (PPN).

Background: Disorders of tetrahydrobiopterin metabolism represent a rare group of inherited neurotransmitter disorders which manifest mainly in infancy or childhood with developmental delay, neuroregression, epilepsy, movement disorders and autonomic symptoms. Methodology: A retrospective review of genetically confirmed cases of disorders of tetrahydrobiopterin metabolism over a period of three years (Jan 2018 to Jan 2021) was performed across two paediatric neurology centres from South India.Results: A total of nine patients(M:F=4:5) fulfilled the eligibility criteria. The genetic variants detected include homozygous mutations in the QDPR(n=6), GCH1(n=2) and PTS(n=1) genes. The median age at onset of symptoms was 6-months(range 3-78 months), while that at diagnosis was 15-months (8-120 months) resulting in a median delay in diagnosis of 9-months. The main clinical manifestations included neuroregression (89%), developmental delay(78%), dystonia(78%) and seizures(55%). Management strategies included phenylalanine restricted diet, levodopa/carbidopa, 5-Hydroxytryphtophan, and folinic acid. Only, Patient-2 afforded and received BH4 supplementation at a sub-optimal dose later in the disease course. We had a median duration of follow up of 15 months (range 2-48 months). Though biochemical response has been marked, except for patients with GTPCH deficiency, only mild clinical improvement was noted with regards to developmental milestones, seizures or dystonia in others. Conclusion: Tetrahydrobiopterin deficiencies represent an rare yet potentially treatable cause for non-phenylketonuria hyperphenylalaninemia when diagnosed and treated early in life. Screening for disorders of biopterin metabolism in patients with hyperphenylalaninemia prevents delayed diagnosis. This study expands the genotype phenotype spectrum of patients with disorders of tetrahydrobiopterin metabolism from South India.

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.

Objectives: The objective of this study is to describe the clinical, biochemical, radiological, and genetic profile of patients presenting with progressive spastic paraparesis due to homocysteine remethylation pathway defect. Methods: This was a retrospective study conducted by reviewing the medical records of patients with serum homocysteine levels >50 μmol/L between January 2015 and January 2019 at our hospital. We included patients presenting with progressive spastic paraparesis, having serum homocysteine >50 μmol/L with low or normal blood methionine suggesting disorders of homocysteine remethylation. Demographic details, clinical manifestations, biochemical abnormalities, neuroimaging findings, and genetic profile were analyzed. Results: A total of seven patients (M: F = 5:2) fulfilled the study eligibility criteria. The mean age at onset of the disease was 13.4 ± 2.4 years (range: 9–17 years). Spastic paraparesis was the presenting manifestation in 4/7 (57.1%) patients. Other manifestations included cognitive decline, poor scholastic performance, behavioral disturbances, seizures, and spastic bladder. Severe hyperhomocysteinemia (>100 μmol/L) was noted in 6/7 (85.7%) patients with median levels of serum homocysteine being 185.7 μmol/L (range: 85.78–338.5 μmol/L). Neuroimaging showed parieto-occipital predominant leukoencephalopathy in 5/7 (71.4%) and diffuse cerebral atrophy in 1/7 (14.2%). Genetic analysis in three patients revealed pathogenic missense variants c.459C >G (p.Ile153Met), c.973C >T (p.Arg325Cys), and c.1031G >T (p.Arg344Met) in MTHFR gene. All the patients received vitamin B12 (injection and oral), folic acid, and pyridoxine and two patients received betaine. At the last follow-up of a median duration of 12 months, there was a good clinical and biochemical response with reduction in the median value of serum homocysteine by 77.5 μmol/L. Conclusion: Evaluation of serum homocysteine and blood methionine in adolescents presenting with progressive spastic paraparesis gives clue to a treatable homocysteine remethylation disorders.

Sleep disturbances in Parkinson's disease (PD) are common. Non -motor symptoms including sleep disturbance have gender difference in PD. The objective is to determine gender differences in PD in relation to the sleep quality.156 patients with PD with males (n = 119) and females (n = 37) were included. The sleep quality and sleep disturbances were assessed using Pittsburgh sleep quality index (PSQI), Parkinson's disease Sleep Scale (PDSS) and Epworth Sleep Scale (ESS).Females with PD had higher frequency with insomnia (56.7%) as compared to males with PD (44.5%) (p = 0.05), nightmares (32.4%) as compared to males with PD (16.8%) (p = 0.04), greater PSQI component score of habitual sleep efficiency (p = 0.008), sleep disturbance (p = 0.03) and daytime dysfunction (p = 0.02), greater global PSQI score (p = 0.03), higher percentage of patients with global PSQI score 5 (64.8%) than males with PD (41.1%) (p = 0.01), suggesting poor quality of sleep in females with PD. Higher total ESS score (p = 0.03), higher frequency of females with PD with total ESS score 10 (45.9%) than in males with PD (26.9%) (p = 0.02), and lower total PDSS score (p = 0.009). On correlation analysis, the global PSQI score in females with PD had strong positive correlation with duration of PD, HAM-A and HAM-D scores and negative correlation with MMSE scores.Females with PD had a poor sleep quality with higher frequency of insomnia, nightmares, and daytime sleepiness. The longer duration of PD, higher scores of anxiety and depression scale and lower MMSE scores are associated with poor sleep quality in females with PD.

Though reports of neurological manifestations of COVID-19 have emerged from various parts of the world, the cohorts reported are from the West and mostly derived from electronic databases. Much remains unknown regarding neuro-COVID in developing countries. India is the second-worst affected country, and this study reports the neurological manifestations of COVID-19 in a comprehensively evaluated cohort.The aim of this study was to describe the range of neurological manifestations of COVID-19 in India with an emphasis on the risk factors, laboratory and imaging findings and short-term outcome.Retrospective review of hospital records of all confirmed COVID-19 patients with neurological manifestations, receiving inpatient care in two neurology referral hospitals were done. All demographic, clinical details, investigations, and treatment were analysed.A total of 120 confirmed COVID-19 cases presenting with neurological symptoms were included. The mean age of illness and duration of illness was 48.03 ± 17.3 years and 10.9 ± 17.3 days respectively. New onset of neurological symptoms occurred in 100 cases while 20 patients had worsening of pre-existing neurological illness. Stroke was the commonest neurological disorder (43%), followed by encephalopathy (23%) and Guillain-Barre syndrome (10%). Other unusual neurological manifestations included new-onset headache (7%), seizures including denovo status epilepticus (5%) and meningo-encephalitis (5%). Nearly half of the patients had preceding COVID-19 symptoms. Poor outcome at discharge was seen in 40% and mortality occurred in 15%.Stroke and encephalopathy constitute the most common neurological manifestations. The absence of preceding COVID-19 symptoms in nearly half the cases is striking. Poor outcome was seen in nearly 50% despite early recognition and management.

OBJECTIVES: To find important clinical features in differentiating patients with Parkinson’s disease (PD) with and without rapid eye movement sleep behavior disorder (RBD). METHODS: This study was a prospective, questionnaire-based study performed at the National Institute of Mental health and Neurosciences, Bangalore, after prior institutional ethical approval. Patients with PD were clinically examined and the presence of RBD was diagnosed using the minimal criteria for the diagnosis of RBD (International Classification of Sleep Disorders-1). RBD screening questionnaire based on the minimal criteria was used. The bed-partners were interviewed with Mayo sleep questionnaire. Other scales included Unified Parkinson’s Disease Rating Scale-part III (UPDRS-III), Hoehn and Yahr Stage, Mini-Mental Status Examination (MMSE), Pittsburgh sleep quality index, Parkinson’s Disease Sleep Scale, Epworth Sleep Scale (ESS), Hamilton anxiety rating scale (HAM-A), and Hamilton depression rating scale (HAM-D). RESULTS: A total of 126 patients with PD without RBD (mean age: 61.1±9.8 years) and 30 with RBD (mean age 54.1±11.1 years) were enrolled. The patients with RBD had higher gait score (P < 0.05), higher HAM-A (P = 0.02), and higher ESS score (P < 0.001) as compared to patients without RBD. Patients with RBD had a mean MMSE score of 26.87±2.31 (range: 23–30), and in patients, without RBD it was 27.98±2.33 (range: 23–30;. P = 0.005). There was no difference in features as olfactory dysfunction, rigidity score, blink rate, tremors, stooped stance, and postural instability in the two groups. However, palmomental reflex was present in 63.3% of patients with RBD and only 34.9% with non-RBD (P = 0.007). CONCLUSIONS: Patients with PD with RBD have a significant presence of palmomental reflex that can be a useful clinical marker.

Introduction: Review of literature revealed very limited studies considering a combination of serum prolactin (PRL) and serum creatine kinase (CK) as markers for differentiating epileptic and psychogenic nonepileptic seizures (PNES). Therefore, in the present study, we analyzed the role of serum PRL and serum CK, individually and in combination. Methodology: This prospective study was conducted in a tertiary care medical teaching hospital over a period of 18 months. Patients aged over 15 years suspected to have new-onset seizures presenting within 5 h of ictus were included in this study. CK, serum PRL was measured at 0–1, 1–3, and 3–5 h after seizures. Results: Hundred subjects were studied for the role of serum PRL and serum CK in differentiating epileptic and PNES. The mean age was 42.24 years with a male:female ratio of 1.27:1. All patients of generalized tonic–clonic seizures (GTCS), who presented within 1 h, had elevated PRL, whereas 75% of patients with partial seizures had elevated PRL within 1 h of presentation. Nearly 91.66% of patients with GTCS who presented within 1 h had elevated CPK, whereas 70% of patients with partial seizures had elevated CPK. None of the patients diagnosed with PNES showed rise in either of the markers. Conclusion: In the present study, none of the patients with PNES showed raise in either serum PRL or CK. However, there was no correlation between the types of seizure and PRL or serum CK levels.

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.

Cerebral venous sinus thrombosis (CVST) is common in Asians, accounting for 15% of all strokes in the young. CVST causing malignant cerebral oedema with brain herniation and death are referred as malignant CVST. This study was aimed at evaluating the outcome of patients and factors predicting the outcome with malignant CVST after decompressive surgery. It was a retrospective, observational, single centre, hospital-based and cross-sectional study. Records of patients with malignant CVST who had decompressive surgery were analysed. Over 5 years (2010–2015), 30 patients (15 men and 15 women) underwent decompressive surgery. In univariate analysis, age more than 50 years (p = 0.05); presence of midline shift of more than 10 mm (p = 0.03) and total effacement of basal cisterns (p = 0.01) had significant correlation with poor outcome. On multivariate analysis, presence of midline shift of more than 10 mm (p = 0.01) was a significant predictor of poor outcome. Decompressive surgery is a life saving therapeutic intervention in patients with malignant CVST and more than two-thirds of patient shows favourable outcome. Age more than 50 years, midline shift >10 mm and total effacement of basal cisterns determine poor outcome following decompressive surgery.

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 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

Rapid eye movement sleep behavior disorder (RBD) is common in Parkinson's disease (PD). Little information exists about RBD in women with PD. The aim of this study was to determine the clinical expression of RBD in women with PD and note any differences in women with PD with and without RBD. One hundred fifty-six patients with PD were recruited. There were 37 women with PD and probable RBD was diagnosed using the RBD Screening Questionnaire. Other scales included Pittsburgh Sleep Quality Index, Parkinson's Disease Sleep Scale, Epworth Sleep Scale, Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale. Probable RBD was diagnosed in 10 women with PD (27%). Most often (70%) RBD occurred after the onset of parkinsonian symptoms. Women with probable RBD were older, had shorter duration of PD symptoms, lower tremor score, and higher axial signs score. They had insomnia (80% versus non-probable RBD patients 44%, p=0.019), and poor sleep quality with excessive daytime sleepiness. Anxiety and depression were common in women with probable RBD. Episodes were brief and confined to vocalization and simple limb movements. No injury to self or bed partners was noted. Women with PD have fewer fights and less aggressive dream enacting behaviour than men, but suffer from significant disturbed sleep, and levels of anxiety and depression.

Background: Liquefied petroleum gas geysers are used very frequently for heating water in developing countries such as India. However, these gas geysers emit various toxic gases; one among them is colorless, odorless carbon monoxide (CO). In the past few years, there were reports of unexplained loss of consciousness in the bathroom. However, the exact cause for these episodes has been recognized as toxic encephalopathy due to toxic gases inhalation mainly CO. Objective: To analyze the clinical profile and outcome of patients brought with loss of consciousness in the bathroom while bathing using gas geyser. Materials and Methods: Case records of patients with the diagnosis of gas geyser syndrome from 2013 to 2015 were retrieved and analyzed. Twenty-four cases were identified and included in the study. This was a retrospective, descriptive study. Results: Twenty-four patients were brought to our Emergency Department with loss of consciousness in the bathroom while bathing. Twenty-one cases had loss of consciousness during bathing and recovered spontaneously. Two cases were found dead in the bathroom and were brought to the Department of Forensic Medicine for postmortem. One case was brought in deep altered state of consciousness and succumbed to illness within 1 week.Conclusion: Awareness regarding CO intoxication due to usage of ill-fitted, ill-ventilated gas geyser is necessary as they are entirely preventable conditions.

Introduction Infarctions of the corpus callosum are rare vascular events. It is relatively immune to vascular insult because of its rich vascular supply from anterior and posterior circulations of brain. Objective Report of 3 patients with largely diffuse acute corpus callosum infarction. Methods 3 patients with largely diffuse acute corpus callosum infarction were studied and each of these 3 patients had 3 different aetiologies. Results The 3 different aetiologies of largely diffuse acute corpus callosum infarction were cardioembolism, tuberculous arteritis and takayasu arteritis. Conclusion Diffuse corpus callosum infarcts are rare events. This case series narrates the three different aetiologies of diffuse acute corpus callosum infarction which is a rare vascular event.

Antiplatelet therapy has established clinical benefit on cardiovascular outcome and has reduced the rates of re-infarction/in stent thrombosis following percutaneous coronary intervention in acute coronary syndromes. Major bleeding episodes can occur with antiplatelet therapy and intracranial hemorrhage (ICH) is one of the most feared complications resulting in significant morbidity and mortality. Identification of high risk groups and judicious use of antiplatelet therapy reduces the bleeding risk. Ticagrelor is a newer P2Y12 receptor antagonist with established clinical benefit. However, risks of having an ICH with these newer molecules cannot be ignored. Here, we report a case of spontaneous acute subdural hematoma developing in a patient on antiplatelet therapy with aspirin and ticagrelor. Early recognition, discontinuation of the medication and appropriate management resulted in resolution of hematoma and good clinical outcome. Authors have reviewed the antithrombotic drugs and their tendencies in causing intracranial bleeds from a neurophysicians perspective.

Background: Central nervous system (CNS) involvement in tuberculosis is around 5–10%. Of the various manifestations of CNS tuberculosis, meningitis is the most common (70–80%). Delay in diagnosis and treatment results in significant morbidity and mortality. Objective: To study the cerebrospinal fluid (CSF) cortisol levels in tubercular meningitis and compare the levels with controls. Methods: Cross-sectional, prospective, observational, hospital-based study done in 20 patients of tubercular meningitis, 20 patients of aseptic meningitis (AM) and 25 control subjects without any preexisting neurological disorders who have undergone lumbar puncture for spinal anesthesia. Results: Cortisol was detected in all 40 CSF samples of patients (100%). Mean CSF cortisol level was 8.82, 3.47 and 1.05 in tubercular meningitis, AM and controls, respectively. Mean CSF cortisol level in tubercular meningitis was significantly higher as compared to AM and controls (P < 0.0001). Conclusion: Cortisol level estimation in CSF is one of the rapid, relatively inexpensive diagnostic markers in early identification of tubercular meningitis along with CSF findings of elevated proteins, hypoglycorrhachia and lymphocytic pleocytosis. This aids in earlier institution of appropriate treatment and thereby decreasing morbidity and mortality. This is the first study on the estimation of CSF cortisol level in tuberculous meningitis.

Dear Sir: Cerebral venous thrombosis (CVT) is a rare variety of cerebrovascular disease that can occur at any age and generally has a favorable outcome. However, poor outcome in CVT has been documented [1]. It is caused by a wide range of etiologies, polycythemia is one among them. Polycythemia is a myeloproliferative disorder that is caused by a variety of etiologies [2]. The occurrence of malignant CVT as a presenting manifestation of polycythemia has not been reported so far. Here, we report a 58-year-old man, who presented with status epilepticus and had mixed density lesion in left fronto-parietal region, which rapidly progressed within 24 hours to cause transtentorial herniation, requiring decompressive surgery. A 58-year-old man was brought with history of 2 episodes of generalized tonic-clonic seizures (GTCS) with no regaining of consciousness in between the episodes of 1 day duration. There was preceding history of holocranial headache with vomiting 1 day prior, which lasted for 2 hours and subsided with analgesics. He did not have fever or loose stools. In the emergency room, he had 1 more episode of GTCS. He was a smoker and used to consume alcohol. On examination, he was stuporous. Pupils were equal but reacting sluggishly to light. There was bilateral papilledema. Gaze preference to left was present. Motor examination showed paucity of movement in right upper and lower limb with right plantar extensor response. Hematological investigations revealed high hemoglobin (Hb) level (22 g/dL) and a hematocrit of 57.5%. Total leukocyte and platelets counts were normal. Renal, hepatic and thyroid function tests, serum electrolytes were normal. Computed tomography (CT) brain at admission showed mixed density lesion in left fronto-parietal region with hemispheric edema and anterior inter-hemispheric fissure bleed (Figure 1). Magnetic resonance venography (MRV) brain showed non-visualization of left transverse, sigmoid sinuses and internal jugular vein (Figure 2). Serum homocysteine, protein C, S, anti-thrombin III and factor V leiden levels were normal. Anti-phospholipid and anti-nuclear antibodies were negative. Serum erythropoietin level was normal and JAK2 mutation was negative. Abdominal ultrasonography was normal. Therapeutic phlebotomy was carried out. He was started on heparin anticoagulation and anti-edema measures (mannitol, oral glycerol). Figure 1. Non-contrast CT brain (A) & (B) at time of admission shows bleed in anterior interhemispheric fissure (red arrow) (A); (B) hemorrhagic lesion in left fronto-parietal region with hemispheric edema; (C) At 12 hours after admission shows increase ... Figure 2. MRV brain (A) & (B) showing non-visualization of left transverse, sigmoid sinuses and left internal jugular vein. His sensorium remained the same and repeat CT brain after 12 hours revealed increase in the size of the lesion with mass effect. Anti-edema measure was intensified and was put on ventilator for hyperventilation. He developed pupillary asymmetry within the next 12 hours. Repeat CT brain showed worsening of lesion with mass effect and midline shift suggestive of trans-tentorial herniation (Figure 1). Patient was taken up for emergency decompressive craniectomy. There was no improvement in sensorium following surgery. Post operative Hb level was 16 g/dL. Within the next 24 hours, his Hb level rose to 21 g/dL. Therapeutic phlebotomy was carried out. The expertise for endovascular intervention was not available. Patient succumbed to illness within 36 hours of surgery. A wide range of etiologies have been implicated in the causation of CVT. Hypercoagulable disorders, like factor V Leiden mutation, presence of anticardiolipin antibody, antithrombin gene mutation and myeloproliferative neoplasms like polycythemia vera and essential thrombocythemia are one among them [2,3]. Thrombosis is a serious complication of polycythemia and can lead to death in up to 8.3% of patients as reported by Ferro et al. [4]. Polycythemia can be primary (caused mainly by mutation in the JAK2 gene) or secondary [5]. Chronic hypoxia causes secondary polycythemia by increasing serum erythropoietin levels leading to excess production of erythrocytes from the bone marrow [6]. Polycythemia causes stasis of blood that result in hyperviscosity leading to the development of thrombosis. Thrombosis of cerebral veins or sinuses results in raised venular and capillary pressure. As local venous pressure rises, there is decrease in cerebral perfusion causing ischemic injury and cytotoxic edema. Along with cytotoxic edema, disruption of the blood-brain barrier leads to vasogenic edema, and venous and capillary rupture culminates in parenchymal hemorrhage. Thrombosis of cerebral sinuses impairs CSF absorption, leading to increased intracranial pressure. Consequently, increased intracranial pressure worsens venular and capillary hypertension and contributes to parenchymal hemorrhage and vasogenic and cytotoxic edema [7]. CVT has a favorable outcome with timely diagnosis and intervention. However, unfavorable outcome do occur. Factors related to acute mortality in CVT includes advanced age, disturbed consciousness, focal neurological deficits, recurrent seizures, and hemorrhagic infarct [8]. In the prospective International Study on CVT (ISCVT) cohort of 624 patients, death occurred in 8% and moderate to severe disability in 5.1% of patients, despite the use of anticoagulant treatment [4]. Transtentorial herniation is the most frequent cause of death. Endovascular treatment appears to be reasonably safe and can be considered in severe cases that do not respond to heparin therapy. However, impending transtentorial herniation does not benefit from endovascular thrombolysis and needs cranial decompressive surgery. But, Coutinho et al. [9] reported successful treatment of CVT with impending herniation with decompressive hemicraniectomy followed by endovascular thrombosuction. Malignant CVT refers to supratentorial cortical lesions attributable to superficial venous system thrombosis with or without sinus involvement; with clinical or radiological signs of transtentorial herniation; either at onset or after worsening despite anticoagulation [10]. In a series by Theaudin et al. [10] regarding the performance of decompressive surgery in malignant CVT, none of the 12 patients with malignant CVT had polycythemia as a risk factor. The only identifiable risk factor for CVT in our patient was polycythemia. Even though JAK2 mutation results were negative, primary polycythemia cannot be ruled out as 20% of cases of polycythemia vera possess a negative JAK2 mutation, and serum erythropoietin levels were normal. Bone marrow studies could not be done in view of poor general condition. The possible etiology for polycythemia may be smoking. Smoker’s polycythemia presenting as CVT is uncommon, and there is a paucity of evidence suggesting such an association. Smoker’s polycythemia is diagnosed after exclusion of other causes of primary polycythemia, such as JAK2 mutation and erythropoietin level. Polycythemia is one of the causes for occurrence of the CVT. However, the occurrence of malignant CVT in association with polycythemia has not been reported so far.

Background: Sleep disorders occur commonly in Parkinson's disease and are often under-recognized and under treated in clinical practice. Objectives: To determine the quality of sleep in patients with Young onset Parkinson's disease (YOPD) and to note whether there is any difference in quality of sleep from those patients with older onset Parkinson's disease (OOPD). Methods: One hundred and fifty six patients with Parkinson's disease (YOPD-51, OOPD-105) were clinically examined and quality of sleep was determined using Pittsburgh sleep quality index (PSQI), Parkinson's disease Sleep Scale (PDSS) and Epworth Sleep Scale (ESS). Other scales included Unified Parkinson's Disease Rating Scale -part III (UPDRS-III), Hoehn & Yahr Stage, Mini Mental Status Examination, Hamilton anxiety rating scale and Hamilton depression rating scale. Results: The frequency of insomnia was higher in OOPD (55.2%) as compared to YOPD (27.5%) group (p1⁄4 0.001). The frequency of nightmareswas lower in YOPD (7.8%) when compared to OOPD (24.8%) group (p1⁄4 0.012). The mean hours of actual sleep per night were higher in YOPD patients. Global PSQI score was better in YOPD indicating good overall sleep quality in YOPD patients. The total ESS score was significantly lower in YOPD (p 1⁄4 0.019). The total PDSS score was significantly better in YOPD patients (p 1⁄4 0.018). Conclusions: Patients with YOPD had an overall better quality of sleep with lesser incidence of insomnia, nightmares, daytime sleepiness and restlessness during sleep. © 2015 Elsevier Ltd. All rights reserved.

Background: Hashimoto encephalopathy (HE) is a poorly understood and often misdiagnosed entity with variable clinical spectrum. There are many uncertainties that still remain about this condition and the pathological significance of thyroid peroxidase (TPO) antibody. Objective: To characterize the clinical, laboratory and radiologic findings in patients with HE. Design: Retrospective analysis of clinical features and diagnostic test data. Main Outcome Measures: Clinical features, laboratory, radiologic, electroencephalography (EEG) findings associated with HE and therapeutic outcome. Results: Thirteen consecutive patients were identified as having HE. The median age at onset was 48.5 years (range, 19-62 years). There was a female preponderance (76.9%). Clinical manifestations were cognitive impairment and behavioral changes in 10 (76.9%), sleep disturbance in 9 (69.2%), seizures in 6 (46.1%), headache in 4 (30.8%), psychosis or paranoia in 5 (38.5%), transient symptoms in 6 (46.1%), myoclonus in 4 (30.8%), ataxia or gait disorder in 4 (30.8%). The most frequent laboratory abnormalities were increased TPO (n = 13) in all cases, increased thyroid stimulating hormone levels (n = 6), and increased erythrocyte sedimentation rate (n = 5). The cerebrospinal fluid protein level was elevated in 8 of 9 patients (88.8%). Magnetic resonance imaging abnormalities were present in 2 patients (15.4%). EEG changes were seen in 7 patients (53.8%). All but two patients showed significant therapeutic benefit with steroids. Conclusions: HE has a wide range of clinical, laboratory, and radiologic findings. All patients with an unexplained encephalopathy should be screened for this condition as treatment response is excellent. To the best of our knowledge, this is the largest single center clinical series of HE from the Indian subcontinent.

Introduction: Creutzfeldt-Jakob disease (CJD) is a progressive, fatal, neurodegenerative disease classified under transmissible spongiform encephalopathies (TSE) or prion diseases. It is characterized by long asymptomatic period followed by rapid clinical deterioration leading to the death within months. The disease is still under-reported in India. Objective: The aim of this study was to describe the clinical, radiological and electroencephalographic characteristics of eight cases of CJD encountered in MS Ramaiah Medical college and Hospital, Bangalore over the past 3 years (2010-2013). This was retrospective, observational, hospital-based study. Results: The mean age of patients was 66.6 years (range: 54-82) and there was female predominance (five patients). The main clinical manifestations were cognitive disturbance (8/8) and myoclonus (8/8), followed by behavioral disturbance (5/8), ataxia (5/8) and extra-pyramidal symptoms/signs (4/8). Time interval (mean) between onset of disease to death was 6.6 months (range: 3-14). Brain MRI abnormalities were noted in 6 patients: Fluid-attenuated inversion recovery hyperintensities with restriction on diffusion-weighted image/apparent diffusion coefficient (DWI/ADC) in caudate and putamen, and diffusion hyperintensities without restriction on ADC in parieto-occipital, frontal and temporal regions. Classical electroencephalogram (EEG) changes of periodic triphasic waves were seen in 87% of patients. The CSF 14-3-3 protein assay was positive in two patients (out of four). Seven cases were probable CJD and one was possible CJD. Conclusion: A strong clinical suspicion aided by characteristic brain MRI and EEG abnormalities is essential for timely diagnosis of this fatal disease.

Levetiracetam is a novel, broad spectrum anti-epileptic drug with proven efficacy in generalized as well as focal onset seizures. It has renal elimination with no hepatic metabolism. Levetiracetam induced encephalopathy is rarely reported in literature. Triphasic waves in the electroencephalogram are seen in toxic-metabolic encephalopathies of various aetiology like hepatic encephalopathy, uraemia. We report a patient who was on levetiracetam for acute symptomatic seizures and developed encephalopathy with electroencephalogram showing generalised triphasic waves. These triphasic waves disappeared with intravenous lorazepam but without clinical improvement in sensorium. The electroencephalographic abnormality appeared as electrical status epilepticus which got normalised on discontinuation of levetiracetam. This is the first report of levetiracetam induced encephalopathy presenting as electrical status epilepticus and also depicts electroencephalographic correlate of levetiracetam induced encephalopathy.

Congenital facial palsy (CFP) is clinically defined as facial palsy of the seventh cranial nerve which is present at birth or shortly thereafter. It is generally considered to be either developmental or acquired in origin. Facial palsy of developmental origin is associated with other anomalies including those of pinna and external auditory canal, which range from mild defects to severe microtia and atresia. We report a 2-day-old male newborn that had right CFP with bilateral anotia and atresia of external auditory canals which is rare.

The occurrence of longitudinally extensive transverse myelitis (LETM) in an elderly patient should evoke search for underlying systemic malignancy. Intramedullary spinal cord metastases and paraneoplastic myelopathy are the most common etiology for LETM in patients with systemic malignancy. The occurrence of LETM in association with renal cell carcinoma with aquaporin-4 (AQP4) antibody positivity has not been reported. We report an elderly woman who presented with acute paraplegia and was diagnosed as having LETM with AQP4 positivity and renal cell carcinoma.

Involuntary movements following stroke are relatively common. They can be hyperkinetic, like hemichorea and hemiballism or hypokinetic, like parkinsonism. The most common hyperkinetic movement disorder following stroke is hemichorea. Monochorea following stroke are rarely reported. We report a patient who presented with sudden onset left upper limb choreo-athetosis. Magnetic resonance imaging of brain revealed infarct in right corona radiata. He was treated with anti-platelets and tetrabenazine. There was near complete disappearance of choreo-athetosis at 1 month follow-up. To the best of our knowledge, focal choreo-athetosis of limb following an infarct in corona radiata is unusual and has not been reported. This case demonstrates the complexity of pathophysiology of chorea.

Amyotrophic lateral sclerosis (ALS) is the most common type of motor neuron disease (MND) [1] . It is usually associated with an irreversible course, and treatable causes of ALS are rare. Here, we present a case report of a 35-year-old male, with progressive weakness and wasting of muscles in all four limbs with fasciculation and electro diagnostic features compatible with a diagnosis of probable ALS. He was later diagnosed to have HIV infection and initiated on anti-retroviral therapy. On 6 months follow-up, he had a weight gain of 8 kg and electro diagnostic studies revealed near total normalization of the neurogenic pattern. Reversible ALS like illness in HIV infection has been documented in literature but most of them are diagnosed cases of HIV infection. This case identifies the importance of identifying reversible causes of ALS and near total response to treatment in a patient who presented to us with MND features as the only manifestation of HIV infection.

"Eight-and-a-half" syndrome is a rare condition involving the ipsilateral abducens nucleus or paramedian pontine reticular formation (PPRF), the ipsilateral medial longitudinal fasciculus (MLF), and the adjacent facial colliculus/facial nerve fascicle. The condition is often caused by a lesion (vascular or demyelinating) in the dorsal tegmentum of the caudal pons. There are new variants of this syndrome caused by extension of lesion to involve new adjacent structures in pontine tegmentum. We report two patients with different etiology presenting with clinical features suggestive of eight-and-a-half syndrome associated with hemiataxia representing "nine" syndrome (8½ + ½ = 9) adding new dimension to "eight-and-a-half" syndrome.