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Background: Bell’s palsy (BP) is the most common cause of lower motor neuron type facial nerve palsy and is one of the most frequently encountered presentations in Neurology. Treatment with corticosteroid and antiviral drugs within 72 hours of onset of symptoms along with supportive treatment is encouraged for better outcome. Despite good prognosis, a significant portion of the patients with BP suffer from disfiguring facial appearance and other complications which remain as great concern of the patients. We aimed to evaluate the factors contributing to favorable outcome in adult with BP. Methods: Data of patients with BP [House-Brackmann (H-B) Grading III and above], who attended and were followed up at the Department of Neurology of BIRDEM General Hospital, Dhaka, Bangladesh between January 2017 and December 2020, were reviewed from hospital records and patients’ personal files. Total 56 adult patients with BP were recruited from hospital records according to eligibility criteria. During recruitment and data analysis, patients of H-B Grade III- IV were considered as lower grade and Grade V-VI were considered as higher grade. During follow up Grade I and II were considered as recovered. Comorbidities including diabetes and hypertension were addressed. Patients with BP who attended within 72 hours of onset of symptoms were prescribed steroid and antiviral drugs, whereas patients attending after 72 hours of onset of symptoms received supportive treatment only. All patients of both the groups received physical therapy for facial asymmetry and medication for eye care along with close monitoring and management of diabetes and other comorbidities. H-B Grades were assessed at onset, after 10 days, at the end of 1st and at 3rd month after facial paralysis and depending upon this Grading patients were finally divided into two groups of favorable (H-B Grade I & II) and unfavorable (H-B Grade III or more) outcome. Univariate and multivariable logistic regression analyses were performed to assess the factors for favorable prognosis. Results: Among the total 56 patients, 45(80.4%) patients had favorable and 11 (19.6%) had unfavorable outcomes at the end of 3rd month. Multivariable logistic regression analysis revealed that younger (at or below 40 year) age group (OR= 1.33; 95% CI, 0.412-4.310, p=0.005), lower H-B Grade at presentation (Grade III – IV) (OR= 2.712; 95% CI, 1.951-3.612, p=0.044) and absence of hypertension (OR=1.14; 95% CI, 0.963- 2.035, p=0.023) were significant. Conclusion: We concluded that younger age group of patients with lower H-B grade at initial presentation and absence of hypertension all are contributing factors for favorable outcomes in adults with Bell’s palsy. BIRDEM Med J 2022; 12(3): 217-222

Background: Acute symptomatic seizures are clinical seizures occurring in close temporal relationship with an acute central nervous system (CNS) insult, which may be metabolic, toxic, structural, infectious or inflammatory. Currently there is dearth of information on the epidemiology of acute symptomatic seizures among adult medical admissions in Bangladesh. This study was designed to determine the frequency of presentation and etiology of acute symptomatic seizures among adults. Methods: This was a cross-sectional study of adult patients admitted with new onset seizure under Neurology Department of BIRDEM General Hospital during the period of January 2019 to December 2020. Clinical assessment and relevant investigations were done and data were collected regarding their etiological diagnosis. Data were analyzed using statistical package for the social sciences (SPSS) version 23. Results: Total admission during the study period was 2920 and among them, 100 patients (male 62, female 38) were having their first symptomatic seizures giving a prevalence of 3.4%. They were between 18 to 82 years of age. The main etiology of acute symptomatic seizure was metabolic encephalopathy (42.0%) .It was followed by acute cerebrovascular disease (31.0%) and acute CNS infection (16%) . Acute cerebrovascular disease and metabolic encephalopathy were predominant causes of symptomatic seizure among the elderly and CNS infections among the middle aged adults. The majority (70.0%) of patients had generalized onset seizures. Focal seizures and focal to bilateral tonic clonic seazure were present in 22% and 8% of the patients respectively. Conclusion: This study showed that metabolic encephalopathy, acute cerebrovascular disease and CNS infections were the prominent causes of acute symptomatic seizures. Treatment strategies should aim for promt identification and management of these conditions as seizures may not recur when the underlying cause has been removed or the acute phase has elapsed. BIRDEM Med J 2022; 12(2): 99-105

Background: Bell's palsy is the most common cause of lower motor neuron type facial nerve palsy and one of the most frequently encountered presentations in Department of Neurology. Initial treatment involves oral corticosteroids, possible antiviral drugs, protection of the eye from desiccation and physiotherapy. But in case of patients with Bell's palsy and diabetes mellitus (DM) decision of prescribing steroid is a major concern due to risk of hyperglycaemia and still a point of conflict. Aim of this study is to observe the outcome of diabetic patients with Bell's palsy with and without steroid therapy. Methods: This retrospective study was conducted from January 2017 to December 2020, in Department of Neurology of BIRDEM General Hospital, Shahbag, Dhaka, Bangladesh. During this period 50 adult diabetic patients with Bell's palsy were recruited retrospectively from hospital records according to inclusion criteria and divided into two groups depending upon the duration of symptoms and prescribing steroid. Group I consisted of patients with Bell's palsy who attended after 72 hours of onset of symptoms and was not prescribed steroid or antiviral drugs, whereas Group II included patients attending within 72 hours of onset of symptoms and received steroid and antiviral drugs. House-Brackmann (H-B) Grading system was used to assess the severity of facial dysfunction. Patients of Grade III and above were recruited in this study and during follow up Grade I and II were considered as recovered. All participants of Group II received prednisolone in divided doses of up to 60 mg for 5 days and then tapered over next 5 days along with the antiviral agents. Patients in the Group I were given supportive care. All patients of both the groups received physiotherapy for facial asymmetry and medication for eye care along with close monitoring and management of diabetes and other comorbidities. H-B Grades at onset, after 10 days, at the end of 1st and at 3rd month after facial paralysis were assessed. Recovery time and the number of patients who demonstrated improvement were compared between the groups. Results: Total 50 adult diabetic patients with Bell's palsy were included. Mean age at presentation was 48.5 ± 13.6 years, 44% were male and 56% female. Hypertension (HTN) was present in 50% cases. A total of 30 patients (60%) received oral steroid with anti-viral drugs and 20 (40%) received only supportive treatment. Significant statistical difference was observed with regard to H-B Grades, recovery time and number of patients between steroid group (Group II) in comparison to patients of non-steroid group (Group I) after 10 days (p 0.007), at 1st month ( p

Background: Well controlled blood pressure (BP) is associated with decreased risk of kidney disease progression, cardiovascular events and death. Patients with chronic kidney disease (CKD) are frequently seen to have low rates of BP control. This study aimed to find out the proportion of adult type 2 diabetic CKD patients with hypertension achieving the goal of target blood pressure. Methods: This cross-sectional study included 105 hypertensive subjects having type 2 diabetes and CKD at the outpatient department of Nephrology, BIRDEM General Hospital in Dhaka, Bangladesh from May to August, 2012. Results: The mean age was 55.6 years and maximum numbers of patients were in the age group of 39-66 years. Among 105 subjects, 52.3% were male and rest 47.7% were female. The mean duration of diabetes, CKD and hypertension were 6.73 (±3.22), 3.12 (±2.47) and 3.1 (±1.77) years respectively. The study revealed that ischemic heart disease (30.5%), dyslipidemia (56.1%) and stroke (13.3%) were associated comorbidity along with diabetes and CKD. Mean estimated glomerular filtration rate was 52.19 ml/min. Mean serum creatinine level was 3.4 mg/ dl. It was observed that majority (49.5%) of the study subjects were prescribed at least two drugs to control hypertension. Three anti-hypertensive medications were given in 35.2% subjects. Among 105 study subjects, 25.7% were found to have high systolic blood pressure and 8.8% high diastolic blood pressure. It was observed that only 40% subjects achieved target systolic blood pressure and 68.6% reached the target diastolic pressure for CKD with diabetes. In correlation analysis, it was observed that both systolic and diastolic blood pressure was significantly correlated with age of the subject, duration diabetes and duration of HTN. Conclusion: From the present study it was seen that both the target systolic and diastolic blood pressure were correlated with numbers of medications used for controlling hypertension but only diastolic blood pressure control was significantly correlated with number of medication used in this present study. BIRDEM Med J 2021; 11(3): 212-217

Brain abscess is a relatively rare but potentially life threatening condition. The classic clinical triad of fever, headache and focal neurological sign may not be present in an immuno-compromised patient. The diagnostic delay may result in fatal outcome. A 52-year-old diabetic gentleman with history of chronic immunosuppressive therapy due to Evans syndrome presented with headache, generalized tonic- clonic seizure and right upper limb monoparesis. Clinical ground and neuroimaging was suggestive of pyogenic brain abscess. Patient was treated with antibiotic therapy for prolong period and there was complete clinical and radiological recovery. Birdem Med J 2021; 11(2): 137-141

Background: Patients of stroke or transient ischaemic attacks (TIA) are at risk of further stroke. Our objective was to study patients admitted with stroke/TIA regarding their knowledge about risk factors for having anew event of stroke/TIA, possible associations between patient characteristics and patients’ knowledge about risk factors, and patients’ knowledge about their preventive treatment for stroke/TIA. Methods: A questionnaire was used for 200 patients with stroke/TIA diagnoses. We asked 13 questions about diseases/conditions and lifestyle factors known to be risk factors and four questions regarding other diseases/ conditions (“distractors”). Additional questions concerned with the patients’ social and functional status and their drug use were asked. Categorical variables were analyzed using chi square test, while one-way analysis of variance and univariate analysis of variance were used for continuous variables. Logistic regression was employed to describe risk. A p value of, p < 0.05 was considered statistically significant. Results: The risk factors that were most often identified by the patients were Diabetes(75.9%), hypertension(83.3%), previous stroke or TIA(81.5%), smoking (85.2%), regular exercise(75.9%), older age(83.3%), overweight (75.9%) and patients with ischemic heart disease (70.4%). Atrial fibrillation and carotid stenosis were identified by less than 50% of the patients. 44.5% of the patients could identify 10 or more stroke/TIA risk factors. We observed that higher age, having a diagnosis of cerebral infarction/TIA, patients residing in urban area, high income group, businessman/retired service holder, family history of cardiovascular disease, past history of stroke / TIA were related to better knowledge of stroke/TIA risk factors. Anticoagulants and antiplatelets are important drugs for stroke/TIA prevention but only 20(9.3%) of the patients who reported anticoagulants and 76(35.2%) of the patients taking these drugs marked them as intended for prevention. Conclusion: Knowledge about diabetes, hypertension and smoking as risk factors was good, and patients who suffered from atrial fibrillation or carotid stenosis seemed to be less informed about these conditions as risk factors. The knowledge level was low regarding the use of anticoagulants and antiplatelets for stroke/TIA prevention. Better patient educational strategies for stroke/TIA patients should be developed. Furthermore, individuals with less knowledge should be given special consideration when developing strategies and programmes thus improving awareness of stroke risk factors. Birdem Med J 2021; 11(1): 22-29

Background: Neurological manifestations of COVID-19 are being recognized day by day although predominant presentation is of respiratory illness. Understanding of impact of the virus on nervous system is important for selection and evolution of treatment now and in the future. The aim of the study was to describe the manifestations of COVID-19 affecting nervous system in a tertiary care hospital of Bangladesh Methods: This cross-sectional study was carried out in Department of Neurology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital from March, 2020 to October, 2020. Total forty patients who were admitted under neurology department were included in the study. Evidence of SARS-CoV-2 infection was confirmed in all the patients if RT-PCR of respiratory samples (eg, nasal or throat swab) was positive for viral ribonucleic acid (RNA). Clinical syndromes associated with COVID-19 were classified broadly as a cerebrovascular event, altered mental status and peripheral nervous system disorders. Data were collected on the basis of specific clinical case definitions. Results: Median age of the patients was 58.6 years (range 22–73). Among those, 26 (65%) were male and 14 (35%) were female. Twenty two (55%) of 40 patients presented with cerebrovascular event, of whom 15 (68%) had an ischaemic stroke, 5 (23%) an intracerebral haemorrhage. Two (9%) patients were diagnosed as cerebral venous sinus thrombosis on the basis of clinical presentation and magnetic resonance venography (MRV) finding. Apart from cerebrovascular events, 14 (35%) of 40 patients presented with altered mental status, comprising 9 (64%) patients with unspecified encephalopathy and 5 (36%) patients with encephalitis. Four (10%) patients were diagnosed as peripheral nervous system disorder among those 2 (50%) as Guillain-Barré syndrome (GBS) and 2 (50%) as Bell’s palsy. If we analyze the presenting features of the 40 patients, it is found that, 22 (55%) patients presented with headache, 20 (5%) with hemiparesis, 20 (50%) with speech problems, 19 (48%) with altered mental status, 10(25%) with facial asymmetry, 4 (10%) with seizure. Few percentages of patients presented with anosmia (10%), ageusia (5%) and quadriparesis (5%). Conclusion: Neurological involvement in COVID-19 is one of the major focuses of neurologist now a day. We have found cerebrovascular disese, encephalopathy and peripheral nervous system disorder as presentation of COVID-19 in our study. Prompt recognition of cases and early initiation of therapy will hasten better outcome of the patients. Neurological complications can cause permanent disability that will cost large scale health and economic burden. Further nationwide study is needed to quantify the association and disease burden. Birdem Med J 2020; 10, COVID Supplement: 33-40

Mononeuritis multiplex is a common manifestation of many illnesses which includes diabetes, leprosy, malignancy and certain types of systemic vasculitis. The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of rare diseases which show typical characteristic inflammatory cell infiltration and blood vessel wall necrosis. AAV syndromes include granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilicgranulomatosis with polyangiitis (EGPA). Here we present a patient who presented with mononeuritis multiplex and had features ofEGPA. The patient was treated with standard regimen of steroids and pulsed cyclophosphamide and she achieved good clinical response. Birdem Med J 2019; 9(3): 257-260

The electroencephalogram (EEG) and functional near-infrared spectroscopy (fNIRS) signals, highly non-stationary in nature, greatly suffers from motion artifacts while recorded using wearable sensors. This paper proposes two robust methods: i) Wavelet packet decomposition (WPD), and ii) WPD in combination with canonical correlation analysis (WPD-CCA), for motion artifact correction from single-channel EEG and fNIRS signals. The efficacy of these proposed techniques is tested using a benchmark dataset and the performance of the proposed methods is measured using two well-established performance matrices: i) Difference in the signal to noise ratio ({\Delta}SNR) and ii) Percentage reduction in motion artifacts ({\eta}). The proposed WPD-based single-stage motion artifacts correction technique produces the highest average {\Delta}SNR (29.44 dB) when db2 wavelet packet is incorporated whereas the greatest average {\eta} (53.48%) is obtained using db1 wavelet packet for all the available 23 EEG recordings. Our proposed two-stage motion artifacts correction technique i.e. the WPD-CCA method utilizing db1 wavelet packet has shown the best denoising performance producing an average {\Delta}SNR and {\eta} values of 30.76 dB and 59.51%, respectively for all the EEG recordings. On the other hand, the two-stage motion artifacts removal technique i.e. WPD-CCA has produced the best average {\Delta}SNR (16.55 dB, utilizing db1 wavelet packet) and largest average {\eta} (41.40%, using fk8 wavelet packet). The highest average {\Delta}SNR and {\eta} using single-stage artifacts removal techniques (WPD) are found as 16.11 dB and 26.40%, respectively for all the fNIRS signals using fk4 wavelet packet. In both EEG and fNIRS modalities, the percentage reduction in motion artifacts increases by 11.28% and 56.82%, respectively when two-stage WPD-CCA techniques are employed., Comment: 25 pages, 10 figures and 2 tables

Background: Carpal tunnel syndrome (CTS) is one of the most frequent entrapment neuropathies of the upper limb. CTS and diabetic polyneuropathy (DPN) are common conditions in patients with diabetes and therefore frequently occur concomitantly. Diagnosis of CTS in patients with DPN is important, as therapeutic interventions directed toward relief of CTS may be effective irrespective of diffuse neuropathy.Methods: This study was a hospital based descriptive cross sectional study done in a tertiary care hospital, Dhaka between July, 2015 and June, 2016. The initial clinical diagnosis of diabetic peripheral neuropathy was made from history and examination. It was confirmed by doing nerve conduction study. After having informed written consents, a standard preformed questionnaire was filled up for each case. Collected data were checked, verified for consistency and edited for final results. Data cleaning, validation and analysis were performed using Statistical Package for the Social Sciences (Version 20.0).Results: A total of 354 cases were finally analyzed with 153 (43.2) patients being symptomatic for CTS and among those 54 (58.7%) had electrophysiology proven CTS. It was observed that 26.0% of patients established as having DPN also had CTS. The frequency of CTS among those with symptoms was significantly higher than in asymptomatic participants. The mean age was found to be 55.99 ± 9.25 years with a range from 28 to 80 years. Majority (38.4%) of patients belonged to the age group of 51-60 years. Among all cases of electrophysiology proven CTS (92 patients), females (53.3%) numbered greater in comparison to males (46.7%). One hundred and ninety two (54.2%) patients were housewives, 57 (16.1%) were garment workers, 45 (12.7%) patients were businessmen and 60 (16.9%) patients were service holders. Study subjects with CTS had significantly higher body mass index, higher fasting blood glucose and higher HemoglobinA1c in comparison to patients without CTS. Examination of upper limb sensory nerves showed that nerve conduction velocity was significantly decreased and distal latency was found to be significantly increased in patients with CTS on median nerve examination. The mean compound motor action potential was not significantly different between patients with and without CTS.Conclusion: Symptoms and signs of CTS are mostly masked by the symptoms of DPN and patients presenting with such symptoms in the upper limbs should be evaluated for CTS as a separate entity to DPN. The finding of a frequency of CTS of 26% in subjects with diabetes with varying degrees of DPN is remarkably high. Given the high prevalence of CTS in subjects with DPN, it is recommended that therapeutic decisions be made carefully after nerve conduction study and proper diagnosis.Birdem Med J 2018; 8(3): 240-245

Background: Stroke is an important cause of disability among adults and is one of the leading causes of death worldwide. Strokes in young adults can have a significant impact on the affected individuals, their families and societies in general as the affected patients are in the economically productive period of their lives.This study was aimed to find out the demographic profile and explore the associated risk factors of the first-ever ischemic stroke of young adults.Methods: This retrospective study reviewed the records of 64 patients, age 18-49 years, ischemic stroke patients consecutively admitted in the Neurology department, BIRDEM General Hospital during the period January 2016 to June 2017. Study variables included hematological and biochemistry investigations and radiological and imaging findings. Stroke sub-typing was done following to TOAST criteria. Data of follow-up data at 3 month were also included. Data were expressed as number (percent) and managed by SPSS for Windows Version 15.Results: Of the 634 patients diagnosed as acute ischemic stroke 64 (9.90%) were in the 18-49 (yr) age range and the majority (55.4%) were male. Stroke was more common (47 out of 54) among the 31-49 years category as compare with the

Background: Intraventricular hemorrhage (IVH) is an acute neurosurgical condition. The aim of this study was to identify the relationship between modified Graeb score (mGS) and intraventricular hematoma volume with Glasgow outcome scale (GOS) and modified Rankin scale (mRS).Methods: This is a Quasi-experimental study conducted in the department of neurosurgery, Chittagong Medical College Hospital, Chittagong, Bangladesh during the period from 24 July 2018 to 23 July 2019. After a detailed history and clinical examination, 150 patients were selected for this study. The study participants were divided into two major groups- external ventricular drainage (EVD) and conservative; both groups consisted of 44 patients. Written informed consent were taken from the participants. Data were analyzed using statistical package for the social sciences (SPSS) software.Results: Overall mean age was around 60 years with an age range from 15-85 years. More than three fourth of the patients in both groups were from the age group of >50 years (73.83%). There were no differences between EVD and conservative groups regarding medical comorbidities. Most prevalent comorbidity among the patients of both groups’ hypertension, followed by diabetes and previous ischemic stroke. Overall the most frequent symptoms in the studied patients were vomiting, followed by loss of consciousness, headache and convulsion. There were no significant differences between the two groups regarding presenting symptoms. The mean Glasgow coma scale (GCS) score level was significantly lower in the patients with EVD than their counterpart from 1st post-operative day to 8th post-operative day. However, within-group comparison shows that the GCS score was significantly increased from 1st day to 8th day in both groups of patients.Conclusions: These findings can be used to identify patients in whom an EVD may provide measurable outcomes benefit with respect to patient mortality and help guide neurosurgical decision-making in particular patient subgroups with acute IVH.

Introduction. Carpal tunnel syndrome (CTS) is one of the most frequent entrapment neuropathies of the upper limb. Carpal tunnel syndrome (CTS) and diabetic polyneuropathy (DPN) are common conditions in patients with diabetes and therefore frequently occur concomitantly. Diagnosis of CTS in patients with DPN is important, as therapeutic interventions directed toward relief of CTS may be effective irrespective of diffuse neuropathy. Methods. This study was a hospital based descriptive cross sectional study done in BIRDEM general hospital between July, 2015 and June, 2016, for a period of twelve months. The initial clinical diagnosis of DPN was made and was confirmed by doing nerve conduction study. After having informed written consents, a standard preformed questionnaire was filled up for each case. Results. A total of 354 cases were finally analyzed with 153 (43.2%) patients being symptomatic and among those 54 (58.7%) had electrophysiology proven CTS. It was observed that 26.0% of patients established as having DPN also had CTS. The frequency of CTS among those with symptoms was significantly higher than in asymptomatic participants. Majority (38.4%) of patients belonged to the age group of 51-60 years. The mean age was found to be 55.99 ± 9.25 years with a range from 28 to 80 years. Among all cases of electrophysiology proven CTS (92 patients), females (53.3%) numbered greater in comparison to males (46.7%). Study subjects with CTS had significantly higher BMI, higher fasting blood sugar and higher HbA1c in comparison to patients without CTS. The mean compound motor action potential was not significantly different between patients with and without CTS. Conclusion. Given the high prevalence of CTS in subjects with DPN, it is recommended that therapeutic decisions should be made carefully after nerve conduction study and proper diagnosis.

In young adults 20%-47% cases of stroke is due to cardiac embolism. Cardiac Myxoma is an infrequent cause of embolic stroke in young. We are reporting a case of a ischemic stroke in a young adult of 34 years with a history of recreational drug use who was eventually diagnosed with Left Ventricular Apical Myxoma, Systemic Lupus Erythematous (SLE), Lupus Nephritis, Secondary Anti phospholipid Syndrome, Hyper homocysteinemia, and Dyslipidemia.Bangladesh Heart Journal 2017; 32(1) : 55-61

Background: Complications of diabetes mellitus (DM) represent the major cause of morbidity and mortality in the modern era, diabetic polyneuropathy (DPN) being one of the most frequents. Nerve conduction study is employed to detect neuropathy. This study is done to see the electrophysiological pattern of diabetic polyneuropathy in a tertiary care setting.Methods: Study was carried out in 100 diagnosed DM patients attending department of neurology, BIRDEM General Hospital from July, 2015 to June, 2016. Diabetic patients with good glycaemic control were grouped in group A and that with poor glycaemic control in group B. Clinical questionnaire and neurological examination were administered, and nerve conduction study (NCS) were performed using standard techniques.Results: Among the 100 patients studied, 54 (54%) patients were Male and 46 (46%) patients were Female. 39% patients who had normal HbA1C was designated as group A and 61% patients having high HbA1c was designated as group B. Mean age of patients in group A was 55.02±10.45 years and group B was 54.94±11.13 years. Mean duration of diabetes in group A was 10.49±4.43 years and group B was 12.44±5.14years. Alterations in NCS included lowered amplitudes and slowed conduction velocities. Most common axonal pattern was found in peroneal nerves and most common demyelinating pattern was found in sural nerves. Sensory conduction velocity in significantly reduced in all sensory nerves in group B in comparison to group A. Compound motor action potential (CMAP) is significantly reduced on peroneal nerve in group B.Conclusion: Risk of neuronal involvement is increased as Diabetes mellitus progresses further which can be accelerated by poor glycaemic control. NCS is used to as an important tool to diagnose the peripheral neuropathy. Early diagnosis of neuropathy can be done by routine NCS and complications of neuropathy can be prevented by controlling Diabetes mellitus more meticulously.Birdem Med J 2017; 7(2): 114-120

Background: Guillain-Barré syndrome (GBS) is the commonest cause of acute flaccid paralysis worldwide, with an incidence of 0.6-4 per 100.000 inhabitants per year. It affects all age groups and carries an incapacity burden of up to 20%. The aims of this study were to evaluate the demographic and clinical presentation, hospital care and outcome with different modalities of treatment in adult patients suffering from GBSadmittedina tertiary care hospital in Dhaka.Methods: This observational study was done in the Neurology department of a tertiary care hospital in Dhaka.The studystarted in July-2011 and the first fiftypatients suffering from GBSwereenrolledconsecutively. Subjects included in this study were>18years of age.All the patients were interviewed and clinically examined. Relevant data were documented in a structured questionnaire. Nerve conduction Study (NCS) and Cerebrospinal fluid (CSF) study results were also documented. All of patients were watched for respiratory insufficiency and those who developed respiratory paralysis were transferred to ICU for respiratory assistance. According to clinical and electrophysiological criteria, the patients were classified into different variants of GBS. Patients were treated with intravenous immunoglobulin (IVIg), plasmapheresis, supportive care and outcome was observed. The patient who recovered and were discharged were later followed up on out –patientbasis for one month Results: The commonest age group affected was 31-50 yrs with male preponderance .The mean age of study subjects was 46years. In most of the patient their weakness progressed for 3-5 days. Clinical evidence of a preceding infection was present inforty-six percent of the patientsbutcausative organism was not identified.Clinical presentations were quadriparesis in 84 % of patients, cranial nerve palsy in 48% of patients. Severe respiratory involvement requiring mechanical ventilation developed in 10% of patientsafter admission. CSF study was done and only10 subjects displayed typical findings of albumino cytological dissociation. NCS wasabnormal in all study subjects and revealed Acute Motor Sensory Axonal Neuropathy (AMSAN) in58%of study population. Among the fifty patients 23received plasmapheresis and another 9 receivedstandard IVIg therapy. Of these patients 20(88%) and 7 (77.6%) patients made significant recovery, respectively. Residual neurodeficit persisted in 6 of the remaining patients who received treatment in the form of only physiotherapy at the end of one month follow-up.Conclusion: Rapidly progressive quadriparesis with cranial nerve involvement was the commonest presentation. In this group of patients NCS proved to be a sensitive study for early diagnosis of patients with GBS in both diabetic and non-diabetic population. The axonal variety of GBS was more common than the demyelinating type. Although not statistically significant, the better response to plasmapheresis seemedencouraging. Again the patients who received IVIg or plasmapheresis early in the course of disease had faster recovery as compared to patients who received only supportive line of treatment.Birdem Med J 2017; 7(1): 38-42

Background: Carpal tunnel syndrome (CTS) is the most frequent compressive focal mononeuropathy found in clinical practice. Patients mostly experience pain, paresthesia, and less commonly, weakness in the median nerve distribution which badly affects dexterity and grip. Common risk factors include repetitive wrist movements, metabolic and degenerative diseases, connective tissue disease and pregnancy. Nerve conduction study is one of the most sensitive and specific tools to diagnose CTS. This study was aimed to grade the CTS cases according to the severity based on electrophysiological findings and explore its association with clinical presentation of diabetic patients had nerve conduction study at BIRDEM General Hospital. Materials and Methods: This observational study was done in the electro diagnostic clinic of Neurology department, BIRDEM during the period Sept 2015 to Feb 2016. The study included 100 hands of 84 patients suffering from CTS consecutively attending the clinic. All the patients were interviewed and clinically examined. Demographic data including age, gender, occupation, affected hand and hand dominance along with duration of disease were recorded. Patients were graded according to clinical history and objective findings and again based on the Canterbury NCS Severity Scale. Results: Of these 84 diabetic patients presenting with impression of CTS 96% were females. Mean age of the study subjects was 49.6±10.1 (28-85). Most of the female patients were housewives. Clinical grading of CTS was as follows: mild symptoms in 54.76%, moderate symptoms in 23.8% and severe symptoms in 28.58% patients. According to The Canterbury NCS Severity Scale out of total 100 hands,3.5% had Grade 2 (Mild ) 30.5%had Grade 3 (Moderate) ,29.4 % had Grade 4 (Severe), 34.1% had Grade 5 (Very severe) disease. Only 2 patients had Grade 6 (extremely severe) lesion. Of the study subjects 22 (26.19%) had bilateral and rest (73.81%) had unilateral disease. Conclusion: Data demonstrated female preponderance of the diabetic CTS cases of middle age. Proportional graded deterioration of electrophysiological parameters along with the clinical severity grades highlights the fact that NCS provide additional and independent objective evidence in the diagnosis and severity assessment of CTS and plausibly has important role in prioritizing treatment plan. Bangladesh Journal of Neuroscience 2016; Vol. 32 (2): 98-105

Background and Objectives: Diabetes in the young patients, less than 30 years of age, usually has sudden onset and severe hyperglycemia who are resistant to ketosis. Taking the advantage of this uniqueness of this group of patients the present study was aimed to evaluate their peripheral nerve functional status, explore its relationship with glycemic status and find out utility of nerve conduction study for detection of neuropathy at diagnosis to introduce timely intervention in the necessary cases.Materials and Methods: A total number of 32 newly diagnosed untreated diabetic patients, age 30 years or less, consecutively attending the BIRDEM Out-patient department were recruited. Age-matched healthy subjects (n=30) with no family history of diabetes served as controls. Motor and sensory conduction velocities (NCV), distal latencies (DL), compound muscle and sensory nerve action potentials (CAMP, SNAP) of ulnar, peroneal and sural nerves were studied following standard protocol. Glucose was determined by glucose-oxidase, Fructosamine by enzymatic colorimetric method.Results: Ulnar motor NCV (m/sec, mean±SD) was significantly slower in diabetic group compared to the controls [58.29±6.88 vs 66.56±6.13; p

Tuberous sclerosis is a disorder affecting multiple organs leading to morbidity and mortality. It is important to make an early diagnosis of tuberous sclerosis so that lifelong monitoring, early recognition of complications and proactive treatment can lower the morbidity and mortality rates. Here we report a case of a 50-year-old male who presented with seizure. This case report emphasizes the importance of complete evaluation of a case presenting with seizures. Tuberous sclerosis must be included in the differentials if patient presents with seizures, skin manifestations and mental retardation.Birdem Med J 2016; 6(2): 127-129

Complete Annular pancreas (AP) is a rare congenital anomaly, often presented and operated at the early age of life. Adult presentation group usually presents with either biliary or duodenal or pancreatic symptoms. We report a case of 43 years old female presenting with concurrent enteric, biliary and pancreatic symptoms admitted on April 2016 in Hepatobiliary and Pancreatic Surgery Department of BSMMU, Dhaka, Bangladesh. A complete type of annular pancreas with partial duodenal stenosis and dilated common bile duct was observed during laparotomy. We performed gastrojejunostomy as well as hepaticojejunostomy (Roux-en-Y anastomosis). Patient was discharged in a good symptom free condition. Complete Annular Pancreas can present at any age, with any one or all of the biliary, pancreatic or duodenal symptoms. Surgery is the treatment of choice and has a good outcome.

Small cell lung cancer (SCLC) is the most frequent cancer histology associated with paraneoplastic syndromes. These syndromes are typically caused by ectopic hormone production or immune-mediated tissue destruction caused by neural antigen expression from cancer cells. Lambert-Eaton myasthenic syndrome is well known to be a classical paraneoplastic syndrome of small cell lung carcinoma (SCLC).Only a few cases of myasthenia gravis (MG) and SCLC were previously reported. The causal association between lung cancer and non-thymomatous myasthenia gravis has not been clarified yet. To date, there has been no evidence supporting the speculation that association of myasthenia gravis with lung cancer might be one of the phenotypes of paraneoplastic syndrome. We present a case of a 47-year-old male ex-smoker with SCLC associated with myasthenia gravis evidenced by the clinical findings of ptosis, dysphagia, proximal weakness, and positive repetitive nerve stimulation (RNS) test. Bangladesh Journal of Neuroscience 2015; Vol. 31 (1): 50-55

Central nervous system (CNS) tuberculous meningitis is a progressive disease that presents in many ways. CNS TB is encountered frequently in areas of high prevalence of tuberculosis and dissemination is common. An 18 year old female presented with complaints of headache, low grade fever & double vision. We found cranial nerve palsy & focal neurological signs during examination. Work up revealed cerebral spinal fluid (CSF) study consistent with acute lymphocytic meningitis. Magnetic resonance imaging (MRI) revealed multiple tuberculomas with gadolinium enhancement & cerebral infarction on basal ganglia. Given the characteristic CSF and MRI finding for Tuberculosis (TB), positive MT & choroidal tubercle on fundoscopy, ischemic stroke due to tubercular meningitis is made. The patient showed significant improvement after anti tuberculosis therapy was begun. CNS TB is a treatable disease but can be fatal if not detected or treated. Clinicians should be aware of key clinical features of TB meningitis, and maintain a high level of suspicion when patients present with focal neurological signs.Bangladesh Crit Care J September 2016; 4 (2): 128-130

Intramedullary spinal cord metastasis is one of the rare manifestations of systemic neoplasm causing diagnostic dilemma. Here we report a case of metastatic renal cell carcinoma presented initially as spinal cord lesion. A 62 years old Bangladeshi gentleman presented with spastic paraparesis, bone pain with unexplained weight loss. After thorough examination & detailed investigations we found intramedullary spinal cord metastasis with infiltrative lesion on bone scan. We confirmed renal cell carcinoma after doing CT Abdomen and histopathology as primary site of lesion. He was treated by radical nephrectomy & radiotherapy. It is imperative that clinicians should be cautious of occult carcinoma as the cause of suspicious intramedullary spinal cord lesion.Bangladesh Crit Care J March 2016; 4 (1): 51-53

Aims: The study was aimed to evaluate vascular territories of infarcts involved in patients with stroke for the first time with diabetes on CT and/ or MRI of brain. Methodology: This cross sectional descriptive study was carried on a total of 100 adult patients with first ever stroke consecutively reported in the Department of Neurology, BIRDEM General Hospital, Dhaka, over a period of six months. Results: The mean age was 61.45 years and majority (35%) belongs to age group of 50-59. Ten (10%) subjects had age above 80 years. Male were 68% and 32% were female. Majority (89%) of the subjects had hemiplegia following acute stroke. Aphasia (71%), headache (39%), convulsion (23%), vomiting (18%) and cranial nerve palsy (17%) were also found. Additional preexisting risk factors were hypertension (72%), dyslipidaemia (59%), smoking (56%) and alcohol abuse (2%). Among the study subjects the diabetic complications were peripheral vascular disease (4% ), neuropathy (8%), nephropathy( 9%)and retinopathy(25%). CT scan and/ or MRI brain showed parietal lobe lesion in 57% cases. Majority (76%) had infarcts in middle cerebral artery territory. Involvement of anterior and posterior cerebral artery territory was found in 7% and 5% subjects respectively. Vertebro-basilar arterial system involvement was observed in 6% cases. 4% subjects had involvement of both middle and posterior cerebral arteries. Both anterior and posterior arterial territory infarcts were found in 2% cases. Conclusions: In conclusion most of the diabetic subjects with first ever ischemic stroke had involvement of middle cerebral artery. DOI: http://dx.doi.org/10.3329/bccj.v2i1.19951 Bangladesh Crit Care J March 2014; 2 (1): 16-20

Most clinicians consider a peripheral nerve lesion in patients with drop foot. However, causes stemming from the central nervous system represent rare, important, and underappreciated differential etiologies. Central causative lesions usually occur at locations where pyramidal tract connections are condensed and specific and the function is somatotopically organized. Here we report case presenting as central foot drop or spastic foot-drop and other myriad clinical features which after investigations was found due to bilateral parasagittal meningiomas. DOI: http://dx.doi.org/10.3329/birdem.v4i1.18559 Birdem Med J 2014; 4(1): 52-55

Despite all of our advances, women with epilepsy face obstacles when it comes to pregnancy and childbearing. Many of these obstacles are social, based on incorrect and inappropriate attitudes of the public towards persons with epilepsy. Most women with epilepsy can conceive and bear healthy children. They have higher probabilities of infertility but this is often amenable to treatment. Complications of pregnancy are higher and revolve primarily around the increased risk of maternal seizures. Careful monitoring of the clinical condition of the patient and the free anticonvulsant levels will obviate much of this difficulty. Maternal seizures themselves can pose hazards for women with epilepsy and their offspring and generalized convulsive seizures are clearly to be avoided. Adverse pregnancy outcomes tend to be seen more often in particular: congenital malformations, dysmorphic features, neonatal hemorrhage and fetal death. Neonatal and infant mortality is increased to two to threefold over the general population; and an uncertain risk of developmental delay particularly in the area of language acquisition. Risks can be reduced by ensuring good seizure control, monotherapy, preconceptual use of multivitamins with folate. The plethora of new anticonvulsants offers us new opportunities for improving the function and control of persons with epilepsy. All of the risks aside, the majority of women with epilepsy can and will have healthy children. DOI: http://dx.doi.org/10.3329/birdem.v4i1.18552 Birdem Med J 2014; 4(1): 38-42

Cauda equina compression following vertebral compression fractures or vertebral plasmacytomas is relatively uncommon presentation of multiple myeloma. Here we describe a case of cauda equina syndrome due to multiple myeloma in an elderly Bangladeshi male who presented with difficulty in walking, urinary complaints & unexplained weight loss. CT guided FNAC from lesion of spine, bone marrow study, skeletal survey, MRI of spine & immune electrophoresis confirmed the diagnosis of multiple myeloma. We treated the patient with radiotherapy, dexamethasone, antimyeloma therapy, physiotherapy & bisphosphonates in collaboration with hematologists & neurosurgeons. He showed significant improvement both clinically & biochemically in the follow up. Bangladesh Journal of Neuroscience 2014; Vol. 30 (1): 57-61

Medication Overuse Headache (MOH) was previously termed analgesic rebound headache, drug-induced headache, and medication-misuse headache. It is not a primary headache but frequently coexists with primary chronic daily headache. All acute symptomatic medications used to treat headaches have the potential for causing MOH. Highest with opioids, butalbital-containing combination analgesics, and aspirin/ acetaminophen/caffeine combinations. The development is typically preceded by an episodic headache disorder, usually migraine or tension-type headache, that has been treated with frequent and excessive amounts of acute symptomatic medications. The diagnosis is based upon clinical impression. A history of analgesic use averaging more than two to three days per week in association with chronic daily headache is suggestive. The diagnosis is made when the pattern of frequent headaches fulfills the diagnostic criteria for MOH. The basic steps in the management: Patient education, withdrawal of the offending medication, bridge (transitional) therapy, establishment of a headache treatment regimen covering acute and preventive care, follow up and relapse prevention. Birdem Med J 2013; 3(2): 94-98 DOI: http://dx.doi.org/10.3329/birdem.v3i2.17213

DOI: http://dx.doi.org/10.3329/bccj.v1i2.17202 Bangladesh Crit Care J September 2013; 1 (2): 93-98

Background and Aims: Diabetes mellitus and dyslipidemia, in particular triglyceridemia pose independent risk factors of stroke. Hypertriglyceridemia implicated in the pathogenesis of ischemic stroke by imparting endothelial dysfunction, oxidative stress and lowering fibrinolytic activity. This study was aimed to explore risk incurred by blood triglyceride level for ischemic stroke in type 2 diabetic patients. Materials and Methods: A total number of 80 [50 with acute ischemic stroke and 30 without stroke] type 2 diabetic patients consecutively admitted in the neurology department, during the period of April to September 2012, fulfilling the recruitment criteria were included in the study. Ischemic stroke was confirmed by CT-scan. Informed written consent from the legal attendant of each patient was obtained. Data regarding clinicobiochemical and images studies were retrieved from patient’s record form. Results: Male to female ratio was 1.2:1 of the study subjects. Mean (±SD) age (yrs) was 61.0±10.6 in patients with ischemic stroke (Group I) and 57.0±12.3 in patients without stroke (Group II). Risk factors like BMI, lifestyle, smoking, alcohol intake did not show any statistical significance with incidence of ischemic stroke. Mean (±SD) triglyceride (mg/ dl) was 241±56 and 217±102 in Group I and Group II respectively (p=0.024). Eighty eight percent patients had triglyceride 150 mg/dl in Group I and 70 percent in Group II. Triglyceride level (mean±SD, mg/dl) was significantly higher (335±101) in overweightobese patients (BMI 25 Kg/m2) compared to those (232±68) with normal body weight (BMI

DOI: http://dx.doi.org/10.3329/bccj.v1i1.14369 Bangladesh Crit Care J March 2013; 1: 45-48

Background and objectives: Carotid atherosclerosis constitutes an important cause of ischemic stroke. Type 2 diabetes mellitus is known to be an independent risk factor for stroke and its recurrence. This study was aimed to explore relationship between carotid atherosclerosis and ischaemic stroke in patients with diabetes and its association with other risk factors. Materials and Methods: A total number of 50 ischemic stroke patients, as confirmed by CT/MRI, patients with type 2 diabetes mellitus, of both sexes, age range 40-79 years, were recruited in the study from in-patient Neurology department, BIRDEM. Carotid duplex study was done. Ischemic Stroke patients were sub grouped into normal, mild (4) on the basis of ICA/CCA flow velocity ratio. Blood glucose and fasting lipid levels and blood pressure were recorded. Lipid abnormality ,LDL 130mg/dl, total cholesterol 200 mg/dl was defined following NCEP and AHA guidelines. Data were collected in a pre-formed printed case record form and analyzed using SPSS software. Results: Of the 50 cases only 9 (18%) had normal ICA/CCA flow velocity ratio. Their mean age was 48.0±4.4 years. Three (6%) cases had severe form of ICA/CCA flow velocity ratio 47.67±2.08. Subjects with stroke having mild to moderate compromised flow velocity ratio were significantly older (p

Background.Stroke is an important morbidity for low and middle income countries like Bangladesh. We established the first stroke registry in Bangladesh.Methods.Data was collected from stroke patients who were admitted in Department of Neurology of BIRDEM with first ever stroke, aged between 30 and 90 years. Patients with intracerebral hemorrhage, subarachnoid and subdural hemorrhage, and posttrauma features were excluded.Results.Data was gathered from 679 stroke patients. Mean age was 60.6 years. Almost 68% of patients were male. Small vessel strokes were the most common accounting for 45.4% of all the patients followed by large vessel getting affected in 32.5% of the cases. Only 16 (2.4%) died during treatment, and 436 (64.2%) patients had their mRS score of 3 to 5. Age greater than 70 years was associated with poor outcome on discharge [OR 1.79 (95% CI: 1.05 to 3.06)] adjusting for gender, duration of hospital stay, HDL, and pneumonia. Age, mRS, systolic blood pressure, urinary tract infection, pneumonia, and stroke severity explained the Barthel score.Conclusion.Mortality was low but most of patient had moderate to severe disability at discharge. Age, mRS, systolic blood pressure, urinary tract infection, pneumonia, and stroke severity influenced the Barthel score.

Background & objective: Stroke is the third major cause of morbidity and mortality in the world immediately following ischemic heart disease and malignancy. Diabetes mellitus increases risk of ischemic stroke and mortality and morbidity after stroke. This cross sectional study was carried out to observe clinical profile of ischemic stroke in Type 2 diabetic patient. Materials & Methods: This cross-sectional study was done in the Department of Neurology, Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine, and Metabolic Disorders (BIRDEM) Hospital, from April to September 2010. A total of 50 ischemic stroke patients with type-2 diabetes were consecutively recruited. Ischemic stroke was confirmed by clinical examination and CT imaging. Data were analysed using SPSS (Statistical Package for Social Sciences) and were presented as mean ± SD and frequencies with corresponding percentages as appropriate. Results: Of the 50 ischemic patients, over one-third (36%) was in their 6th decades of life. A male preponderance (1.5:1) in the series. Most of the patients presented with weakness on either side of the body (90%) followed by difficulties in speech (80%), altered consciousness (24%) and facial weakness (4%). On examination 76% were conscious and oriented. Other examination findings were hemiparesis (60%), hemiplegia (30%), dysarthria (72%) and dysphagia (4%). The major co-morbid condition was hypertension (86%) with mean systolic and diastolic blood pressures being 153 ± 5 and 97 ± 4 mmHg respectively. On admission 94% had normal pulse and 40% abnormal fundoscopic examination in the form of hypertensive and diabetic retinopathy. Only 2% had carotid bruit. Conclusion: Elderly males are more prone to develop ischemic stroke. Hemiparesis and dysarthria are the major clinical presentation and hypertension might be an important risk factor for ischemic stroke. Further study is recommended to conclusively comment on the clinical features of diabetic ischemic stroke patients and also to compare the clinical profile between diabetic stroke patients. Ibrahim Cardiac Med J 2012; 2(2): 14-18

Mucormycosis is a form of fulminant invasive fungal infection of the sinonasal tract that often extends to the orbit, brain, palate, and skin. It is caused by members of the order Mucorales, and it is considered to be the most fatal fungal infection known to man. It is most commonly associated with diabetic ketoacidosis, hematologic malignancies, acquired immunodeficiency syndrome acquired immunodeficiency syndrome, see AIDS. , and immunosuppressive therapy. This rare opportunistic infection exists in many forms, the most common of which is rhinocerebral mucormycosis. Treatment includes aggressive surgical debridement of the necrotic tissue combined with systemic antifungal therapy. In this case report, we describe the successful management of rhinoorbitocerebral mucormycosis, a subtype of the rhinocerebral variety, complicated by osteomyelitis of cranium. We review the diagnostic work-up and discuss the literature with respect to the presentation, pathophysiology, management, and outcome of the disease.DOI: http://dx.doi.org/10.3329/birdem.v2i2.12331(Birdem Med J 2012; 2(2):124-127)

Hydatid disease is one of the diseases that have been discovered in the ancient times. Liver and lung are the most commonly affected organs, though it can involve any organs. Hydatid disease involving both the liver and the lung is reported about 10% of the cases. Here we report a case of 34 year old male presented with upper abdominal pain and intermittent fever for 3 months admitted in October 2016. His chest radiograph and computed tomography scan revealed large cystic lesion at right lung and another similar large lesion in the right lobe of liver. Echinococcus antibody was found positive. We treated him surgically. Histopathology reports confirmed concomitant hydatid cyst of both the lung and the liver.

Polycystic disease of the pancreas is very rare and only few cases have been reported in the literature. We report a case of 27 year old female presented with recurrent upper abdominal pain associated with nausea and vomiting. Her ultrasonography of whole abdomen and computed tomography (CT) scan revealed polycystic pancreas associated with hepatic cysts. She underwent distal pancreatectomy with splenectomy. Histological examination revealed typical features of polycystic pancreatic disease in the resected specimen. Previously two of her sisters and her mother were also diagnosed as cases of polycystic pancreatic disease and they all underwent operative treatments. Among them one of those sisters and her mother received treatment under our department in 2009 and 2014 accordingly.