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Syed, Maryam J., Ismail A. Khatri, Wasim Alamgir, and Mohammad Wasay. Stroke at moderate and high altitude. High Alt Med Biol 00:000–000, 2021. Background: Stroke at high altitude is an understudie...

Objective: To compare the yield of interictal epileptiform discharges on prolonged (1-2 hours) electroencephalogram (EEG) as compared to standard routine (30 minutes) electroencephalogram (EEG). Study Design: Comparative observational study. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi from Oct 2019 to Sep 2020. Methodology: A total of 364 outdoor patients with suspected epilepsy were recruited for the study. Out of these 55 electroencephalograms were excluded after applying exclusion criteria and 309 were included for final analysis. Electro-encephalograms were recorded using a 10-20 international system of electrode placement. The duration of each standard electroencephalogram was 30 minutes. It was followed by recording for an extended period of 60 minutes at least. The time to the appearance of the first abnormal interictal epileptiform discharge was noted. For analytical purposes, epileptiform discharges were classified as “early” if they appeared within the first 30 minutes and as “late” if appeared afterward. All electro-encephalograms were evaluated independently by two neurologists. Results: A total of 309 electroencephalograms were included for final analysis. Interictal epileptiform discharges were seen in 48 (15.6%) recordings. The mean time to appearance of first interictal epileptiform discharge was 14.6 ± 19.09 minutes. In 36 (11.7%) cases, discharges appeared early (within the first 30 minutes) whereas in the remaining 12 (3.9%) cases, discharges appeared late. This translates into a 33% increase in the diagnostic yield of electroencephalogram with an extended period of recording. Conclusion: Extending the electroencephalogram recording time results in a significantly better diagnostic yield of outdoor electroencephalogram.

Hemichorea-hemiballismus, secondary to hyperglycemia, is a rare but easily treatable condition that is usually associated with type II diabetes mellitus. This is a case of a 68- year lady, with long-standing, poorly controlled diabetes mellitus, who presented with disabling right-sided hemichorea-hemiballismus. The T1-weighted magnetic resonance imaging revealed hyperintensity in the basal ganglia. The abnormal movements subsided within a few days after achieving euglycaemia with insulin therapy. This case highlights the importance of treatment of hyperglycaemia in a diabetic patient presenting with acute or sub-acute abnormal movement disorder. Key Words: Hemichorea, Hemiballismus, Hyperglycemia, T-1 hyperintensity.

Objective: To determine the prevalence of cognitive decline among the patients of stroke and analyze the associated socio demographic factors. Study Design: Cross sectional study. Place and Duration of Study: Tertiary care hospital of Rawalpindi, from May 2018 to Aug 2018. Methodology: The sample population comprised of n=180 patients of hemorrhagic or ischemic stroke presenting at a tertiary care hospital in Rawalpindi, Pakistan. Cognitive decline was assessed by using the British Columbia Cognitive Complaints Inventory (BC-CCI) four weeks after the acute stroke. Relationship of age, gender, marital status, education, type of stroke, presence of physical impairment and tobacco smoking was assessed with the presence of cognitive decline among the patients of stroke. Results: Out of 180 patients of stroke screened through British Columbia Cognitive Complaints Inventory, 129 (71.7%) showed the presence of cognitive decline while 51 (28.3%) had no cognitive decline. After applying the logistic regression we found that female gender and presence of physical impairment had significant association with the presence of cognitive decline among the patients of stroke. Conclusion: This study showed a high prevalence of cognitive decline among the patients of stroke in Pakistan. Routine screening for cognitive decline should be done at the stroke follow up clinic and special attention should be paid to the female patients of stroke and those with physical impairment.

Background Hydroxychloroquine (HCQ) has been considered for the treatment of coronavirus disease 2019 (COVID-19), but data on its efficacy are conflicting. We analyzed the efficacy of HCQ along with standard of care (SOC) treatment, compared with SOC alone, in reducing disease progression in mild COVID-19. Methods A single-center open-label randomized controlled trial was conducted from April 10 to May 31, 2020 at Pak Emirates Military Hospital, Rawalpindi. Five hundred patients of both genders between the ages of 18 and 80 years with mild COVID-19 were enrolled in the study. A total of 349 patients were assigned to the intervention group (standard dose of HCQ plus SOC) and 151 patients were assigned to SOC only. The primary outcome was progression of disease while secondary outcome was polymerase chain reaction (PCR) negativity on days 7 and 14. The results were analyzed on Statistical Package for Social Sciences (SPSS; IBM Corp., Armonk, NY) version 23. A p-value

Background and Purpose: Coronavirus disease 2019 (CO­VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients. Methods: This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged >18 years) with symptomatic CVT and recent COVID-19 infection. Results: Twenty patients (70% men) were included. Their mean age was 42.4 years, with a male-to-female ratio of 2.3:1. Headache (85%) and seizures (65%) were the common presenting symptoms, with a mean admission Glasgow Coma Scale (GCS) score of 13. CVT was the presenting feature in 13 cases (65%), while 7 patients (35%) developed CVT while being treated for COVID-19 infection. Respiratory symptoms were absent in 45% of the patients. The most common imaging finding was infarction (65%), followed by hemorrhage (20%). The superior sagittal sinus (65%) was the most common site of thrombosis. Acute inflammatory markers were raised, including elevated serum D-dimer (87.5%), erythrocyte sedimentation rate (69%), and C-reactive protein (47%) levels. Homocysteine was elevated in half of the tested cases. The mortality rate was 20% (4 patients). A good functional outcome was seen in the surviving patients, with a mean modified Rankin Scale score at discharge of 1.3. Nine patients (45%) had a modified Rankin Scale score of 0–1 at discharge. Conclusion: COVID-19-related CVT is more common among males at older ages when compared to previously reported non-COVID-19-related CVT cases. CVT should be suspected in COVID-19 patients presenting with headache or seizures. Mortality is high, but functional neurological outcome is good among survivors.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel infectious disease of multi-system involvement with significant pulmonary manifestations. So far, many prognostic models have been introduced to guide treatment and resource management. However, data on the impact of measurable respiratory parameters associated with the disease are scarce. OBJECTIVE: To demonstrate the role of Comorbidity-Age-Lymphocyte count-Lactate dehydrogenase (CALL) score and to introduce Respiratory Assessment Scoring (RAS) model in predicting disease progression and mortality in COVID-19. METHODOLOGY: Data of 252 confirmed COVID-19 patients were collected at Pak Emirates Military Hospital (PEMH) from 10th April 2020 to 31st August 2020. The CALL score and proposed factors of RAS model, namely respiratory rate, oxygen saturation at rest, alveolar arterial gradient and minimal exercise desaturation test, were calculated on the day of admission. Progression of disease was defined and correlated with measured variables. Univariate and multivariate Cox regression analysis for each variable, its hazard ratio (HR) and 95% confidence interval (CI) were calculated, and a nomogram was made using the high-risk respiratory parameters to establish the RAS model. RESULTS: Progression of disease and death was observed in 124 (49.2%) and 49 (19.4%) patients, respectively. Presence of more than 50% of chest infiltrates was significantly associated with worsening disease and death (p-value

Background Cytokine release syndrome (CRS) plays a pivotal role in the pathophysiology and progression of Coronavirus disease-2019 (COVID-19). Therapeutic plasma exchange (TPE) by removing the pathogenic cytokines is hypothesized to dampen CRS. Objective To evaluate the outcomes of the patients with COVID-19 having CRS being treated with TPE compared to controls on the standard of care. Methodology Retrospective propensity score-matched analysis in a single centre from 1st April to 31st July 2020. We retrospectively analyzed data of 280 hospitalized patients developing CRS initially. PSM was used to minimize bias from non-randomized treatment assignment. Using PSM 1:1, 90 patients were selected and assigned to 2 equal groups. Forced matching was done for disease severity, routine standard care and advanced supportive care. Many other Co-variates were matched. Primary outcome was 28 days overall survival. Secondary outcomes were duration of hospitalization, CRS resolution time and timing of viral clearance on Polymerase chain reaction testing. Results After PS-matching, the selected cohort had a median age of 60 years (range 32–73 in TPE, 37–75 in controls), p = 0.325 and all were males. Median symptoms duration was 7 days (range 3–22 days’ TPE and 3–20 days controls), p = 0.266. Disease severity in both groups was 6 (6.6%) moderate, 40 (44.4%) severe and 44 (49%) critical. Overall, 28-day survival was significantly superior in the TPE group (91.1%), 95% CI 78.33–97.76; as compared to PS-matched controls (61.5%), 95% CI 51.29–78.76 (log rank 0.002), pth day (p = 0.0045). Conclusion An earlier use of TPE was associated with improved overall survival, early CRS resolution and time to discharge compared to SOC for COVID-19 triggered CRS in this selected cohort of PS-matched male patients from one major hospital in Pakistan.

PurposeTo evaluate the outcome of patients with COVID-19 triggered CRS treated with Therapeutic Plasma Exchange (TPE) as compared to propensity score matched (PSM)-controls not receiving TPE.Material and methodsUsing PS 1:1 matching, 90 patients were assigned 2 groups (45 receiving TPE and 45 controls). Forced matching and covariate matching was done to overcome bias between two groups.ResultsMedian age was 60 years (range 32-73 in TPE and 37-75 in non-TPE group), p= 0.325. Median duration of symptoms 7 days (range 3-22 days in TPE and 3-20 days in non-TPE), p=0.266. Disease severity in both groups was 6.6% moderate, 44.4% severe and 49% critical. Twenty-eight-day survival was significantly superior in TPE group (91.1%) as compared to PS-matched controls (61.5%), HR 0.21, 95% CI for HR 0.09-0.53, log rank 0.002. Median duration of hospitalization was significantly reduced in TPE treated group as compared to non-TPE controls 10 days and 15 days respectively (p< 0.01). CRS resolution time was also significantly reduced in TPE treated group (6 days vs. 12 days) (p< 0.001).ConclusionUse of TPE is associated with superior overall survival, early resolution of CRS and time to discharge as compared to standard therapy for COVID-19 triggered CRS.Highlights□Cytokine release syndrome (CRS) plays a pivotal role in pathophysiology and progression to severe and critical disease in patients with COVID-19.□Beyond supportive care, there are currently no proven effective treatment options (including Tocilizumab) for coronavirus disease (COVID-19)□Therapeutic plasma exchange (TPE) may dampen CRS of COVID-19 by removing circulating cytokines and toxins□TPE is the cheapest of all novel treatments available so far to treat severe to critical COVID-19□By intervening early with TPE, mortality and morbidity associated with COVID-19 triggered CRS can be reduced

Objective: An association between cerebral venous sinus thrombosis (CVST) and high altitude has been previously proposed, but limited published data exist to support this association. We investigated 28 cases of CVST occurring at high altitude and sought to describe patient demographics, altitude and acclimatization, hematological laboratory findings, neuroimaging, treatment, and prognosis in these cases. Methods: Twenty-eight cases of symptomatic CVST occurring at high altitude were identified between the months of August 2017 and December 2018, in collaboration with Military Hospital, Rawalpindi and Combined Military Hospital, Skardu (Pakistan). Follow-up visits were performed at 1 and 6 months. Results: Twenty-seven (96%) of the patients were males, and the mean age was 33 years. In total, 32.1% were smokers. The mean NIHSS score on presentation was 5.5. 85.7% of the cases occurred at altitude higher than 8,000 feet. On average 107.8 days were spent at a high altitude prior to CVST. Totally, 71.4% had acclimatized for >2 weeks. The mean hemoglobin (Hb) value was 16.7 g/dL and 50% had d-dimer levels higher than 1,000 ng/mL. On MRI, 25% showed signs of hemorrhage and 14.3% showed infarcts. Treatments provided include low-molecular-weight heparin and Rivaroxaban and were associated with good outcomes. Conclusion: CVST is not uncommon at high altitude (>8,000 feet). It is predominantly a male disease. Most patients have high Hb and high D-dimer levels. The overall outcome was good.

The objective of this study was to determine the association between Body Mass Index (BMI) and migraine. This prospective study took place from 5th February, 2017 to 5th August, 2017 at a Military Hospital in Rawalpindi. Migraine in subjects was diagnosed according to the ICHD-III criteria by clinicians after taking an informed, written consent from 78 patients and the data was analysed using SPSS 22. Of the 78 patients, 35(44.9%) were males and 43(55.1%) were females. Out of the 78 subjects, 9(11.5%) were underweight, 33(41.0%) were of normal weight, 9(14.10%) were overweight, 19(24.4%) were obese and 7(9.0%) were morbidly obese. The p-value calculated was 0.892 which indicates no significant evidence of any association between BMI and migraine in the survey population reporting at the Rawalpindi Military Hospital. A follow-up study at a national level with much larger sample size will be able to better predict the changing results in our country, because as of now the association between BMI and migraine is debatable.