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Background and objective: Anti NMDA receptor (Anti-NMDAR) antibody encephalitis is an increasingly recognized form of auto immune encephalitis. The objective of this study was to determine the demographic, clinical and laboratory factors associated with this syndrome. Methods: All cases presenting to neurology, Pakistan institute of medical sciences, Islamabad, from June 2017 till January 2020 were reviewed retrospectively. Patients fulfilling the diagnostic criteria for Anti NMDA receptor (Anti-NMDAR) antibody encephalitis were included. All patients were evaluated with cerebrospinal fluid (CSF)routine examination, MRI brain, autoimmune encephalitis profile and for presence of oligoclonal bands (OCB) in CSF. Statistical analysis was done using SPSS version 23.0. Results: A total of 7 patients were diagnosed as having Anti-NMDARantibody encephalitis. Five patients were female and two were male. Four patients had some type of psychiatric disturbances upon presentation of these behavioral abnormalities and irritability were found in all four. Orofacial abnormal movements were found in four patients while one patient had myoclonic seizures. Conclusion: Anti-NMDARreceptor encephalitis is a common cause of encephalitis associated with neurological and psychiatric symptoms. Delay in diagnosis can occur due to non-specific symptoms and signs present in early stages of illness,this can lead to long term neurological disability.

The pandemic of severe acute respiratory virus (SARS-CoV-2) is characterized by respiratory symptoms with serious consequences, mainly associated with pneumonia and extreme ARDS. There is a lack of data about specific neurological manifestations of covid-19 infections literature. Epidemiological trials in fewer than 30% of a population reported symptoms of headache and delirium (Helms et al., 2020). Covid-19’s neurotropism is still debatable, uncertain and in the present case study patient with Covid-19 is identified. He suffered with extreme respiratory complications during hospitalization and eventually died.

Diabetic hemichorea/hemiballism is a spectrum of hyper kinetic involuntary, non patterned, continuous movements involving one side of the body. It involves contra lateral basal ganglia and often striatum in the brain. Here we are reporting an unusual case of choreiform movement disorder which was sudden in onset. It was accompanied with abnormally high values of blood glucose. Our patient had a complete remission of symptoms after an adequate control of blood glucose was achieved. This case illustrates the importance and rarity of having the knowledge about hyper glycemia as a rare cause of hemichorea as it recovers rapidly with a good prognosis. Screening for hyperglycemia even in those patients without a prior history of diabetes is very important, once they present with an involuntary movement disorder. Recognition and early treatment is beneficial to prevent adverse outcomes. Today, in the medical literature it is often referred to as CHBG (chorea, hyperglycemia, basal ganglia) syndrome.

The neurological manifestations of SARS-CoV-2 are wide-ranging from simple headache to severe demyelinating brain disease. This is a review of collected case reports of patients with SARS-CoV-2 with neurological manifestations presenting to the Pakistan Institute of Medical Sciences (PIMS). Neurological manifestations associated with SARS-CoV-2 such as encephalitis, acute cerebrovascular disease, encephalitis with chorea, post-COVID myositis and Guillain-Barre Syndrome (GBS) are of great concern but are often overlooked in the presence of life-threatening abnormal vital signs in severely ill SARS-CoV-2 patients. There is a need to diagnose these manifestations at the earliest opportunity to limit long-term consequences and complications. Much research is needed to explore the role of SARS-CoV-2 in causing these neurological manifestations by isolating it either from the cerebrospinal fluid (CSF) or the brain tissue of the deceased on autopsy. We also recommend exploring the risk factors that lead to the development of these neurological manifestations.

Objective: Study was conducted to find out correlation between degree of compliance to antihypertensives with severity of stroke. Methods: This correlational study was conducted in department of neurology, Pakistan Institute of Medical Sciences, Islamabad from December 2017 to May 2018. A total of 74 patients with clinically and radiologically confirmed diagnosis of stroke, having history of hypertension, were included in the study. According to the Modified Rankin Scale (MRS), scores were assigned from 0 to 6 in increasing order of severity. Quantitative assessment to drug compliance was calculated via Brief Adherence Rating Scale (BARS). According to BARS, scores were assigned from 1 to 4 in decreasing order of non-compliance or increasing order of compliance. Compliance was defined according to BARS as patients taking more than 76% of their prescribed dosage. Compliance of drug was checked for last 6 months. Data was finally analysed by SPSS v. 20. Appropriate statistical tests were applied. Results: Mean age of the stroke patients was 58.8 ± 14.91 years. Total 33 patients i.e. 44.6% were compliant and 41 were noncompliant. Strong negative correlation (r= -0.494, p-value= 0.00008) was found between degree of compliance according to BARS scale and severity of stroke according to MRS. Regression analysis showed R2 value of 0.41 and p-value of 0.0004. Most common cause of drug noncompliance according to patients was improper counselling followed by fear of getting used to medication, forgetting, cost, side effects, and dissatisfaction with treatment. Among other risk fac- tors for stroke, 18.9% had positive history for smoking, 43.2% for hyperlipidaemia, 18.9% for coronary artery disease, and 5.4% for atrial fibrillation. Conclusion: Adherence to antihypertensives can help in reducing severity of stroke which will result in better prognosis and reduced morbidity and mortality. Most important factor contributing to noncompliance is lack of awareness regarding disease and importance of antihypertensive medications.

The dilemma of facing a facial cosmetic issue at a young age is the most troublesome symptom hampering social well-being. Beginning in the teen ages and progressing to variable extents, Parry Romberg Syndrome (PRS) leads to facial asymmetry in the form of hemiatrophy secondary to loss of subcutaneous tissues, often fat but sometimes the underlying muscles and bones. It is indistinctly associated with seizure disorders at times or with other neurological sequelae. The first case was an 18 year old Pakistani male who presented with progressive wasting of the left side of the face for the past two and a half years. The second case was an 18-year-old Pakistani girl who presented to the neurology OPD with primary complaints of a seizure disorder for 3 years. In addition, she had progressive subtle asymmetry of her face. Over the course of time, a faint curvilinear grooved line showed up towards the right side of her forehead reaching on to her head up to the vertex. She also had hair loss ipsilateral to the line. The presentation of above cases depicts that although some features of PRS like facial asymmetry is characteristic, the presentation of a patient primarily with seizures should ideally include a thorough search for a secondary cause or of possible associations so that prognosis can be defined and appropriate interventions planned.

Neurology still remains one of the most underserved specialties of medicine in Pakistan with roughly one neurologist per million people. Movement disorders (MD) are neurological problems that interfere with patient's motor abilities and diagnosis is typically clinical. In this review, we describe a practical approach to common MD emergencies that may be encountered by a non-neurologist physician, emphasizing on formulating a working diagnosis and their immediate management. Movement disorder emergencies can be classified based on MD phenomenology and we will provide a brief overview of dystonia including acute dystonic reaction, PAID syndrome and dystonic storm; chorea, myoclonus including serotonin syndrome and startle disease; and rigidity including neuroleptic malignant syndrome and malignant hyperthermia.

Context The role of glycated haemoglobin (HbA1c) in the prediction of ischaemic stroke in individuals without diabetes is underestimated. Aims We performed a study to analyse the role of HbA1c in the risk prediction of ischaemic stroke in Pakistani population without diabetes. We further studied the difference between HbA1c values of individuals with diabetes and without diabetes with stroke. Settings and design Single centre, case–control. Materials and methods In phase I, a total of 233 patients without diabetes with ischaemic stroke and 245 as controls were enrolled. Association of HbA1c levels, lipid profiles and blood pressure recordings with ischaemic stroke was analysed. In phase II, comparison was done between diabetics and non-diabetics with stroke. Statistical analysis Comparison of the mean variables was performed with Student's t-tests. Logistic regression analysis with ischaemic stroke as the dependent variable was performed for phase I. Results In phase I, the ischaemic stroke group had significantly higher HbA1c levels (5.9±2.9% vs 5.5±1.6%) compared with controls (p0.05). Conclusions Higher HbA1c indicated a significantly increased risk for ischaemic stroke. An HbA1c value above 5.6% (prediabetic range) predicted future risk of stroke and efforts to maintain glucose level within the normal range (≤5.6%) in individuals with high cardiovascular risk are important.

Mononeuritis multiplex (MM) is a common variant of a peripheral neuropathy which is characterized by neurological discrepancies that afflict two noncontiguous nerve systems. It is mostly associated with systemic illnesses such as diabetes mellitus, vasculitis, systemic lupus erythematosus (SLE), viral infections including human immunodeficiency virus (HIV) and paraneoplastic syndromes. Lymphoma is a common antecedent to paraneoplastic syndromes that cause peripheral neuropathies but a specific presentation of MM is a rare predicament per our literature analysis.

Mitral stenosis is a valvular heart disease characterised by narrowing of mitral orifice. It can lead to a dilated left atrium with atrial fibrillation culminating into thrombus formation. Patients with mitral stenosis, presenting with stroke-like episodes, most likely experience cardio-embolic phenomenon; but unusual and unprecedented associations do occur. Reported association of cardiac MS with demyelinating CNS MS has never been proven; but authors have speculated theories based on case reports and series. We narrate the case of a 28-year gentleman known to have severe mitral stenosis, who presented with history of multiple stroke-like episodes. During each episode, he had CT brain done and was labelled as having recurrent embolic strokes. We investigated in detail, and the patient was found to have classical MRI features and CSF findings of multiple sclerosis with multiple lacunar infarcts, warranting different line of treatment in addition to cardio-embolic strokes.

A 17-year-old Pakistani female patient presented with acute onset flaccid quadriparesis with nerve conduction studies showing demyelinating polyneuropathy consistent with Guillain-Barre' syndrome. She was treated with 4 plasmapheresis sessions. She developed raised blood pressure, headache, visual loss and generalised seizures on the 13th day of admission. MRI of the brain on contrast showed findings of altered signals low on T1-weighted image, high on T2-weighted image and fluid-attenuated inversion recovery in the white matter of bilateral occipital, parietal and right frontal lobe consistent with posterior reversible encephalopathy syndrome. The patient was administered antiepileptic and antihypertensive drugs to control seizures and blood pressure. She was discharged in a stable state. On follow-up her visual loss had recovered completely and she had regained full motor strength in all four extremities after 6 weeks. Fresh MRI of the brain revealed complete resolution of lesions. Antihypertensive and antiepileptic medication was discontinued. She is independent in all her daily activities.