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Multiple cranial nerve palsies have many possible causes, including infective, inflammatory, neoplastic and infiltrative diseases of the meninges or skull base. We present the clinicopathological conference of a 27-year-old man with a smouldering course of sequential cranial nerve palsies. His imaging showed dural thickening and osteosclerosis of the skull base with otomastoiditis. Cerebrospinal fluid showed lymphocytic pleocytosis with reduced glucose and normal protein concentrations. There was a possible response to corticosteroids and anti-tubercular treatment. Initial biopsy from the thickened and enhancing dura was unremarkable. His condition deteriorated after the steroids were tapered; MR imaging showed progression of lesions and positron emission tomography showed intense hypermetabolism. Subsequently, a diagnostic test revealed the final diagnosis. This case was presented at the All India Institute of Medical Sciences’ monthly clinicopathological conference series in February 2021.

Background: Teleneurology consultations can be highly advantageous since neurological diseases and disabilities often limit patient's access to health care, particularly in a setting where they nee...

Purpose To compare epilepsy-related injuries in untreated or inadequately treated patients and patients on adequate treatment. Methods In a cross-sectional case-control study, seizure-related injuries in patients who were either on no treatment or inadequate treatment were compared with another group of patients receiving appropriate evidence-based epilepsy treatment. The inadequately treated patients or ‘cases’ were drawn from an outreach epilepsy clinic while the adequately treated patients or ‘controls’ were recruited from a tertiary care facility providing comprehensive epilepsy management. Results The odds of injury were eight times higher in inadequately treated patients or cases compared to the adequately treated patients or controls. After adjusting for gender, epilepsy duration, seizure frequency, current medication, and number of AEDs, the odds of injury were 15. 8 times higher in the cases. Major injuries such as burns, fractures, and tooth injuries were also higher in the cases. Conclusion Untreated or inadequately treated epilepsy patients have a significantly higher risk of injuries. With adequate treatment, some of the risks of injury can be mitigated.

Background. Coronavirus disease 2019 (Covid-19) has emerged as a pandemic by end-January 2020. Of the infected patients, 10%–15% may develop severe or critical illness. So far, no definite treatment is available for Covid-19. Cytokine release syndrome may underlie the pathogenesis of severe and critical disease. Anti-interleukin (IL)-6 therapies are being tried to improve clinical outcomes. Methods. We did a systematic review to identify the available literature on anti-IL-6 therapies in the treatment of Covid-19 and used the GRADE method to assess the quality of evidence. Results. Four case series and 10 case reports were identified. On critical assessment, we found that these studies reported some beneficial effect of anti-IL-6 therapy, but all the studies had a high risk of bias. The pooled estimate showed that 42% of patients improved but with a very wide confidence interval (CI) (95% CI 1%–91%) and substantial heterogeneity (I2 = 95%). The overall quality of evidence was graded as ‘very low’. Conclusions. Although promising, anti-IL-6 therapy for Covid-19 needs to be tested in randomized controlled trials to provide robust evidence.

Introduction There is no satisfactory treatment for post tubercular arachnoiditis (TB arachnoiditis). We did this study to investigate the efficacy and safety of cyclophosphamide as adjuvant therapy for post TB arachnoiditis refractory to corticosteroids and anti-tubercular therapy (ATT). Methods This was a retrospective case series of patients of refractory post TB arachnoiditis leading to paraparesis and vision loss who received cyclophosphamide as an adjuvant therapy along with standard ATT and corticosteroids. These patients were treated with intravenous cyclophosphamide (dose 500 mg/m2) once a month for 4 consecutive months after informed written consent and were assessed clinically and radiologically before and after cyclophosphamide therapy. Results We had 4 patients with refractory post TB arachnoiditis of whom three became independently ambulatory. There was significant clinical as well as radiological improvement in all the patients. Conclusions Cyclophosphamide therapy could be an effective therapy for patients with refractory post TB arachnoiditis. Well-designed randomized controlled studies are essential to study the safety and efficacy of cyclophosphamide in this condition.

Background and Purpose: Occurrence of stroke has been reported among patients with COVID-19. The present study compares clinical features and outcomes of stroke patients with and without COVID-19. Methods: The COVID-19 Stroke Study Group (CSSG) is a multicentric study in 18 sites across India to observe and compare the clinical characteristics of patients with stroke admitted during the current pandemic period and a similar epoch in 2019. The present study reports patients of stroke with and without COVID-19 (CoVS and non-CoVS, respectively) seen between February 2020 and July 2020. Demographic, clinical, treatment, and outcome details of patients were collected. Results: The mean age and gender were comparable between the two groups. CoVS patients had higher stroke severity and extent of cerebral involvement on imaging. In-hospital complications and death were higher among CoVS patients (53.06% vs. 17.51%; P < 0.001) and (42.31% vs. 7.6%; P < 0.001), respectively. At 3 months, higher mortality was observed among CoVS patients (67.65% vs. 13.43%; P < 0.001) and good outcome (modified Rankin score [mRS]: 0–2) was seen more often in non-CoVS patients (68.86% vs. 33.33%; P < 0.001). The presence of COVID-19 and baseline stroke severity were independent predictors of mortality. Conclusions: CoVS is associated with higher severity, poor outcome, and increased mortality. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and baseline stroke severity are independent predictors of mortality.

The ongoing COVID-19 pandemic has precipitated a global health crisis. Non-COVID diseases across specialties have been significantly compromised. The greatest challenge has been to continue providing care to non-COVID cases with minimum transmission risk to health care workers, patients, and caregivers. In this specter, better described as a medical holocaust, we present our experiences of dealing with acute neurological patients who could access our facility. We attempted to work on three key areas – initial screening using a more inclusive, dynamic checklist for COVID suspicion over and above the emergency triage, a mandatory initial holding on a separate floor of our inpatient service equipped with infection control strategies similar to a COVID-designated area, and daily screening of health care workers and caregivers for symptoms and possible exposures. It was a steep learning curve, a couple of close shaves, and many more lessons that went into the development of an algorithm that seems to be working well.

Cerebral venous sinus thrombosis (CVST) is relatively a rare cause of stroke and can have protean manifestations ranging from headache, seizures, diplopia, focal deficits or coma. It is usually managed with anticoagulation. However, various studies have shown a mortality of 13% to 30% and have elucidated certain risk factors such as poor sensorium at presentation and rapid deterioration in spite of anticoagulation, for poor outcomes. In these situations, it has been postulated that endovascular management using thrombolysis or mechanical thrombectomy can give better outcomes. This review tries to address the role of endovascular interventions in CVST.

A 54-year-old man had a 12 month history of weakness of both lower limbs with urge urinary incontinence, 6 month history of visual loss and hearing impairment and a 1 month history of cognitive dysfunction. He had no constitutional symptoms. On examination, his visual acuity was reduced to perception of light only in both eyes; funduscopy identified branch retinal artery occlusion (figure 1). He had spastic weakness and hyperreflexia in the lower limbs. Pure-tone audiometry suggested severe sensorineural hearing loss. MR scan of the brain showed characteristic features of Susac’s syndrome (figure 2). Following high-dose methylprednisolone pulses, intravenous immunoglobulin and rituximab, he …

LETM is a common syndrome and the diagnosis of CNS lymphoma is not usually considered in the list of differentials. Primary CNS lymphoma can present as longitudinally extensive transverse myelopathy. Failure to suspect and evaluate leads to delay in diagnosis and treatment. PCNSL may be non contrast enhancing on gadolinium enhanced MRI. CSF analysis should be done preferably before starting corticosteroids as it is usual practice in treatment of transverse myelitis, as steroids may lead to transient improvement and mask the correct diagnosis. Repeated CSF examinations may be needed to clinch the diagnosis.

Progressive multifocal leukoencephalopathy can complicate the course of a patient with sarcoidosis. Here we present a rare case of a 35-year-old patient with pulmonary sarcoidosis whose course was complicated by progressive multifocal leukoencephalopathy involving the cerebellum. Neuroimaging and cerebrospinal fluid PCR played a crucial role in the diagnosis.

Introduction: Meralgia paresthetica (MP) is a painful mononeuropathy of the lateral femoral cutaneous nerve. It is usually idiopathic and can be treated with drugs used for neuropathic pain such as pregabalin, gabapentin, and amitriptyline. Objectives: This study was done to study the effect of triamcinolone acetonide on drug refractory MP. Methods: This study was a retrospective case file review. Results: Eight patients were treated with local injections of triamcinolone. The patients were followed up for a period of 4 months to 54 months. There was significant symptomatic improvement with six patients having complete improvement and all patients reporting >50% improvement. Patients who had recurrence of symptoms on follow up received up to four injections as per their requirement and repeated injections also produced >50% symptom relief. Conclusion: Triamcinolone acetonide injected locally seems to be an effective and safe treatment for refractory MP. A randomized control trial has been planned to look for efficacy and safety.

We present the clinicopathologic conference of a 34-year-old lady with history of facial palsy 14 years ago who developed new deficits of mononeuritis multiplex, maculopapular rash, pancytopenia, splenomegaly, lung involvement and cognitive decline rapidly over three years. Investigations revealed pancytopenia, reversal of albumin globulin ratio, mediastinal adenopathy, ANA positivity, low C3 levels with the CSF being inflammatory and MRI showing extensive hemorrhagic lesions with mass effect. She had a rapidly progressive fatal course over three years with the disease being undiagnosed. This case was presented in the annual meeting of the Indian Academy of Neurology in September 2018.

Jumping stump syndrome is considered to be a peripherally induced movement disorder due to damage to peripheral nerves leading to dystonia, myoclonus or choreiform movements. Certain cases are considered to be due to propriospinal myoclonus. Psychogenic cases have also been reported.[1 2][1] Our

Type-2 diabetic patients may easily get suffered from cancer. The presented work in this paper predicts whether the diabetic patient has got cancer problem or not. If cancer is identified in the patient, the type of cancer such as breast cancer, colon cancer and liver cancer is classified. The parameters associated with cancer and diabetes are recognized and collected. Then the collected dataset is preprocessed. During preprocessing the null values in the dataset are replaced with mean values. The dataset is now ready for training. Cancer disease prediction is done by breast cancer, colon cancer and liver cancer. To classify the cancer type, random forest algorithm is used.

Primary leptomeningeal lymphomatosis is a rare disease with only a few hundred cases reported. We present a patient with a relatively short history of 25 days of headache followed by diplopia who was found to have primary leptomeningeal T-cell lymphoma without evidence of systemic lymphoma. The patient responded well to chemotherapy along with intrathecal medication and cranial irradiation and returned to a completely normal state of health. Not all chronic meningitis is due to infection or self-limiting inflammatory causes. It is important to consider lymphoma as a differential even in the absence of constitutional features such as loss of weight, appetite, night sweats, lymphadenopathy or hepatosplenomegaly. T-cell lymphoma with only Central Nervous system (CNS) involvement is a rare cause of chronic meningitis, which is eminently amenable to treatment and is fatal if missed.

The American Academy of Neurology and the European Federation of Neurological Societies (AAN/EFNS) guidelines for the management of trigeminal neuralgia (TGN) suggest anticonvulsant medications as first line therapy; the surgical options utilized drug-refractory cases [1]. However, many patients are refractory to drugs, and surgical treatment may not be feasible owing to associated comorbid illnesses. Interventional procedures on the peripheral trigeminal nerve or on the Gasserian ganglion may not always be possible because of the unavailability of skilled practitioners. Botulinum neurotoxin (BoNT) is a promising mode of treatment, which can help such patients and provide pain relief.

We describe a twenty six years old lady with tuberculous meningitis who developed new onset left ptosis and binocular diplopia with features of left fascicular 3rd nerve palsy after 9 months of anti tubercular therapy (ATT) and imaging revealed new onset tuberculoma in the mid-brain. Tuberculoma responded to steroids while continuing ATT. Formation of new tuberculoma as a part of immune reconstitution inflammatory syndrome (IRIS) is possible even after prolonged therapy of 9 months, which responded well to only steroids without altering ATT.

The present study was carried out to screen the phytochemicals of the polyherbal plants (mixture of Andrographis paniculata, Andrographis alata, Adhatoda zeylanica, Gymnema sylvestre, Syzygium cumini and Justicia glabra) through preliminary phytochemical screening and GC-MS analyses. The powder of polyherbal plant mixture was extracted using ethylacetate as solvent. The preliminary phytochemical screening of the extract revealed the presence of bioactive compounds such as flavonoids, alkaloids, carbohydrate, saponin, phenols, triterpenoids, coumarins, emodins and fatty acid and then the extract was subjected to GC- MS analysis. The GC-MS analyses showed the presence of 12 bioactive compounds and these compounds are recommended to treat antidiabetic activity.

Pain of any origin comprises an individual’s life. The prevention and management of pain is an important aspect of health care. Psychological factors play a key role in both onset and progress of any pain disorder. In pain disorders, pain is perceived in different anatomic locations such as lower back, head region, abdomen, and chest. Abnormal signal transmission and processing in the nervous system are the legitimate explanation for this condition. Although evidence suggests that pain disorder is widely prevalent in the general population, research still fails to address numerous aspects of pain diagnosis and management. Diagnostic criteria for pain differ in various Diagnostic and Statistical Manual of Mental Disorders (DSM) such as DSM-III, DSM-III revised, DSM-IV, and DSM-IV-textual revisions; hence, a more comprehensive classification is the need of the hour. The ability to understand and investigate the pathophysiologic process underlying a disorder depends on a valid, reliable classification system and common terminology to make effective communication among the academicians, clinicians, researchers, and patients. After the classification criteria are achieved, the validity and reliability of the criteria must be analyzed. Once the criteria have proven valid and reliable, research effort can be directed toward gaining better insight into prevalence, etiology, and natural course of a given disorder, eventually leading to more effective treatment. In this review, various definitions of pain along with few diagnostic classification systems for various pain disorders have been presented.

Background: Heart rate is the important key factor for determining the cardiac output, myocardial oxygen demand and coronary blood flow. Reduction in heart rate is the main stay of treatment for preventing and treating IHD. Due to the interactions with other drugs and adverse effects of the conventional drugs, the management of IHD focused on novel targets. Ivabradine is a novel specific and selective if current inhibitor of SA node. The objective of the study was to efficacy and safety of ivabradine as an add-on to atenolol in patients with chronic stable ischemic heart disease. Methods: Interventional, open label, prospective clinical study was done over a period of 1 year. Single centered study conducted in 50 patients in the Outpatient Department of cardiology, Tirunelveli Medical College Hospital, Tirunelveli. Endpoints noted were reduction in resting heart rate using 12 lead ECG and improvement in Canadian cardiovascular society (CCS) class of angina grading. Results: Ivabradine in reducing the heart rate at the end of 1 month (86.60±9.16) and at the end of 3 months (81.82±8.37) compared with baseline (93.08±11.67). CCS class of grade of angina also improved at the end of one month and 3 months compared with baseline. Grade IV (3 - 0 - 0), grade III (7 - 3 - 1) and grade II (40 - 8 - 9). Conclusions: Ivabradine is safe and effective in preventing and treating further anginal attacks in patients with chronic stable ischemic heart disease already on atenolol therapy.

Adult onset cerebellar dysfunction with neuropathy is a commonly encountered condition and is usually due to genetic causes such as spinocerebellar ataxia, gluten ataxia, alcohol related, toxic, degenerative, immune mediated, paraneoplastic causes and so on. Ataxia and neuropathy as presenting features of hepatitis-B related liver disease are very rare and have not been reported so far.

Normal-sized ventricles and absence of papilledema do not rule out shunt failure and raised intracranial pressure (ICP). Raised ICP can present with false localizing signs which may be cranial nerve palsies or extensive polyradiculopathy. Our patient with a history of ventriculoperitoneal (VP) shunt presented with rapidly progressive vision loss without papilledema, as well as multiple cranial nerve palsies and radiculopathy. Imaging did not reveal hydrocephalus, however, cerebrospinal fluid (CSF) manometry revealed high CSF opening pressure. After lumbar thecoperitoneal shunting, vision did not improve, but the rest of cranial nerve palsies and radiculopathy improved. In a patient in whom VP shunt is in situ, headache and vomiting should prompt evaluation for raised ICP though there is no ventriculomegaly of papilledema. Vision can be saved if raised ICP is suspected, CSF opening pressure measured at presentation and prompt surgery is performed.

Obstructive sleep apnea (OSA) is the most prevalent sleep disorder in the adult population. There is accumulating evidence that OSA is being considered as an independent risk factor for hypertension, diabetes mellitus, cardiovascular diseases and stroke leading to increased cardio metabolic morbidity and mortality. The prevalence of OSA is higher in patients presenting for surgery than in general population and a significant proportion of OSA patients remain undiagnosed, when they present for surgery. This is of concern to the anesthesiologist and the peri-operative physician, as OSA has been associated with increased peri-operative risk and post-operative complications. Hence a protocol designed to provide practical solutions and strategies for the peri- operative /post-operative care of these patients needs to be followed and optimal use of it requires our attention. Early recognition and treatment of OSA may prevent from adverse health consequences. A multidisciplinary approach to peri-operative care and constant vigilance by experienced anesthesia providers is paramount to ensuring positive patient outcome.

Cystic hygroma is a benign congenital malformation of lymphatic system, common location being cervico-facial region and axilla. We report a child with cystic hygroma, who had recurrent attacks of lower respiratory tract infection for surgery and the eventual anesthetic challenges associated with it.

Chronic meningitis is a common syndrome with multiple aetiological causes. It can be associated with visionproblems as well as multifocal involvement of the central nervous system. Often it presents with constitutional symptoms as well. The intervention commonly practised in a tropical country like India is starting antitubercular therapy with corticosteroids. This practice though may be correct in a majority of situations, may lead to diagnostic delay and may be fatal.

Introduction: Tubercular meningitis (TBM) is a common cause of chronic meningitis in India; however, there is a paucity of literature on optimum duration and choice of drug therapy. Materials and Methods: This was an ambispective cohort study. Results: Two hundred and forty-four patients of central nervous system tuberculosis (CNS TB) who were seronegative for HIV were studied of whom 198 had TBM and 46 patients had tuberculoma without meningitis. Before completion of treatment, 84% of TBM patients underwent imaging. There was no difference in disability or mortality in patients, who were treated with various drug regimens in terms of duration of therapy or number of drugs at initiation of treatment. However when patients developed new complications, adding more drugs improved survival. Prolonging corticosteroid administration in patients with nonsatisfactory improvement at 8 weeks was not associated with prevention of disability. Conclusions: CNS TB is treated by neurologists and physicians in India, as per their experience due to different recommendations in various guidelines. There is a tendency to decide when to stop treatment based on neuroimaging given the fear of poor outcomes associated with recurrence of the disease. The duration of treatment or choice of drugs at the start of treatment did not affect disability.

Obstructive sleep apnea (OSA) and obstructive sleep apnea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences among the general public as well as the majority of primary care physicians across India is poor. This necessitated the development of the Indian initiative on obstructive sleep apnea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health and Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep-related symptoms or co-morbidities or ≥15 such episodes without any sleep-related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents, and high-risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers, and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography is the "gold standard" for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances (OA) are indicated for use in patients with mild to moderate OSA who prefer OA to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioral measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Lymphoepithelial cysts are benign, slowly growing unilocular or multilocular lesions that appear in the head and neck. They are also called Branchial cyst. The head and neck sites are the salivary glands(more commonly parotid and rarely submandibular gland) and the oral cavity (usually the floor of the mouth). there are various methods of investigation available today, of which Fine needle aspiration cytology (FNAC) can be used to provide an immediate diagnosis of a lymphoepithelial cyst. The other investigations include, Ultrasonogram,and Computed tomography. It usually occurs due to the process of lymphocyte-induced cystic ductular dilatation and the confirmatory diagnosis is always made postoperatively by histopathological examination. The mainstay in the treatment of a lymphoepithelial cyst remains the surgical approach, which includes complete enucleation of the cyst along with total excision of the involved salivary gland. This is a report of a lymphoepithelial cyst involving the submandibular salivary gland and its management.

A three-and-half-year-old child with developmental delay presented to the paediatric department with a 2-day history of high-grade fever with chills and rigours. There was associated weakness of the right upper and lower limbs with an episode of seizure that lasted for 10 min. The child was known to have seizures from 8 months of age and was on anticonvulsant treatment, which was stopped 3 months earlier. Clinical examination revealed macrocephaly, port-wine stains on the left half of the body and reduced tone in right upper and lower limbs. CT and MRI of the brain revealed subcortical calcifications depicting ‘tram-track’-like appearance in the left …

Introduction Congenital rubella syndrome (CRS) is a spectrum of clinical findings in a patient that results from primary maternal infection with rubella virus. Diagnosis is usually made clinically but imaging findings can prompt the diagnosis in appropriate clinical setting. The features of congenital rubella include sensorineural deafness, cataract, cardiac anomalies, mental retardation and microcephaly. ### Case report We report a case of 10-year-old girl who presented with a history of global developmental delay, intellectual disability and having been treated for patent ductus arteriosus. There was no maternal history of exposure to infection or vaccination during her pregnancy. …