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Background: Age is the most important prognostic factor in ischemic stroke. Thisstudy was carried out in patients with ischemic stroke to describe the association of age of the patients with stroke severity at presentation and at three months. Materials and Methods: The data, which were collected retrospectively from hospital records, we reanalyzed by using the Statistical Package for the Social Sciences (SPSS) version 26. Age was divided into younger (≤ 50 years) and older (> 50 years) based on standard definition. Age was also divided into younger (< 60 years) and older (≥ 60 years) based on the Senior Citizens Act of Nepal. The associations were analyzed by using Chi-square test. Results: One hundred and fifty-three patients were included in the study. The mean age of the patients was 60.9 years. There was no statistically significant association between baseline stroke severity and the age groups defined both ways. More younger patients had good outcomes (44.4% good outcome vs 25.6% poor outcome in patients ≤ 50 years, p= 0.03; 52.8% good outcome vs 31.6% poor outcome in patients < 60 years, p=0.02). More older patients had poor outcomes (74.4% poor outcome vs 55.6% good outcome in patients > 50 years, p = 0.03; 68.4% poor outcome vs 47.2% good outcome in patients ≥ 60 years, p= 0.02). Conclusion: There was no significant association between young and old patients and the baseline stroke severity; however, more younger patients had good outcomes compared to older patients at three months, the differences being significant.

Painful tonic spasms initially described in association with multiple sclerosis are actually more common in patients with neuromyelitis optica spectrum disorder. Characterized by fierce pain and tonic posture of limbs, painful tonic spasms are common in patients during the recovery phase after the first episode of myelitis. A 68-year-old man presented with painful tonic spasm after 2 months of diagnosis of neuromyelitis optica spectrum disorder. Eventual use of eslicarbazepine resulted in significant control of spasms. Early recognition of painful tonic spasms and appropriate therapeutic medications can significantly decrease the impact it can have on the quality of life among neuromyelitis optica spectrum disorder patients.

Purpose Although cognitive impairment is a known complication of acute encephalitis syndrome (AES), few studies have evaluated cognitive outcomes in patients with encephalitis. The primary objective of this study was to assess the cognitive profiles of patients diagnosed with AES, which is pivotal for improving rehabilitation strategies and prognostic measures. Methods This study was conducted at the Tribhuvan University Teaching Hospital. Adult patients with AES who met inclusion criteria were enrolled. The Montreal Cognitive Assessment (MoCA) tool was used to assess cognitive function at admission, discharge, and 3-month follow-up. Results Thirty-six patients were enrolled in our study. The mean age of the participants was 43 ± 18 years. Fourteen patients (38.9%) were female, and 22 (61.1%) were male. Tuberculous (TB) meningoencephalitis was present in 14 cases (38.9%), with herpes simplex virus (HSV) encephalitis in 14 (38.9%), bacterial meningoencephalitis in 4 (11.1%), autoimmune encephalitis in 2 (5.6%), and Japanese encephalitis in 2 (5.6%). Patients with bacterial meningoencephalitis had the highest MoCA scores at admission, whereas those with HSV encephalitis had the highest scores at discharge and follow-up. Compared with the scores at admission, the scores at discharge and follow-up increased significantly in patients with TB meningoencephalitis and HSV encephalitis. The MoCA score at discharge was established as a significant predictor of cognitive function at follow-up. Conclusion We found that active treatment can improve the outcomes of AES patients with cognitive impairment. Although infectious etiologies are most common in low-income countries such as Nepal, autoimmune etiologies should not be overlooked.

Neurotoxin-related optic neuritis (ON) after snake bite is uncommon. Here, we present a case of a 70-year-old female who developed bilateral painless loss of vision after she received treatment with anti-snake venom (ASV). She had only perception of light on assessment of visual acuity on admission which then improved drastically after administration of intravenous methylprednisolone (MP) after making the provisional diagnosis of ON on the basis of history and clinical findings of the patient. Imaging and visual-evoked potential could not be done initially, and they were done after the administration of intravenous MP which had normal findings. ASV, though being a lifesaving treatment, has been sometimes associated with ON.

Abstract Stiff Person Syndrome (SPS), a progressive Central Nervous System disorder is accompanied by progressive muscle rigidity, hyperreflexia, and spasms mainly in truncal and proximal leg muscles mainly associated with autoimmune disorders. Here, we report a rare case of SPS in a middle‐aged Nepalese man with uncontrolled diabetes mellitus and ketonuria.

Abstract Background and Aims Central nervous system (CNS) infection is one of the most common causes of morbidity, mortality, and hospital admission worldwide. The natural history of CNS infection is quite fatal. Early diagnosis and treatment have been proven to have a crucial role in patients' survival. The aim of this study was to identify the epidemiological and clinical patterns of patients diagnosed with CNS infections. Methods This study is a retrospective study conducted in a tertiary level hospital in Nepal in which patient diagnosed with CNS infections (September 2019 to 2021) were included. Data were collected and analyzed in SPSS. Results The mean age of the 95 patients included in the study was 45.18 ± 19.56. Meningoencephalitis (n = 44, 46.30%) was the most common infection diagnosed. Patients belonging to the age group 30−60 years had a higher frequency of focal neurological deficit, and other classical clinical features. All the patients who died during the treatment had associated comorbidities but no concurrent infections. Altered sensorium, fever, and headache were the common presenting symptoms in all the recovered patients. Conclusion To ensure optimum disease outcome, early diagnosis and prompt management are crucial. For this, recognizing the local disease patterns in terms of disease distribution, commonly implicated aetiologies, presenting symptoms, and prognostic factors is of utmost importance.

A rare case of chorea hyperglycemic basal ganglia syndrome in a 56-year-old woman who presented with left-sided hemichorea in the setting of uncontrolled, non-ketotic, type II diabetes mellitus is reported. Early blood glucose control could lead to complete resolution of symptoms. Despite an excellent prognosis, delayed recognition and management can lead to prolong disability due to movement disorder.

Osmotic demyelination syndrome is a rare condition reported mainly in the case of rapid correction of hyponatremia, but it can occur even in the case of complicated diabetes mellitus either during rapid correction of hyperglycemia or anytime during the complicated diabetes mellitus. We report a case of complicated diabetes mellitus developing osmotic demyelination syndrome. The patient had presented with altered sensorium and seizure, which was initially diagnosed as hyperglycemia, but during his treatment, the magnetic resonance imaging of brain revealed central pontine myelinolysis. Our search on the causes of osmotic demyelination syndrome other than rapid correction of hyponatremia has revealed several other causes like autoimmune liver disease, Sjogren’s syndrome and non-Hodgkin’s lymphoma in addition to diabetes mellitus.

Abstract Symptoms of Guillain–Barre Syndrome (GBS) may be mistaken for typical puerperal changes, delaying diagnosis. Surgery and anesthesia may be triggers for GBS with an overall increase in pro‐inflammatory cytokines in the postpartum period. We report a unique case of GBS in the postpartum period who made a good recovery with supportive measures.

Organophosphate-induced delayed neuropathy, a central-distal axonopathy, passes through latent, progressive, static and improvement phases. During the improvement phase, the peripheral nerves regenerate unmasking the spinal cord lesion with myelopathic features. We report a case of a 16-year-old male who developed myelopathy 6 weeks following chlorpyrifos poisoning. He had a motor weakness of 4/5 in bilateral hips and 3/5 in bilateral knees and ankles. Spasticity and exaggerated reflexes with ankle clonus were present in the lower limbs. Sensory and the upper limb motor examinations were all normal. Pertinent blood, cerebrospinal fluid and nerve conduction tests were normal. Magnetic resonance imaging of the spine showed features of cord atrophy. Three months following physiotherapy, his power improved to 5/5 in bilateral knee and hip joints and 4/5 in bilateral ankles with spasticity. Organophosphate-induced delayed neuropathy can present as earlier as 6 weeks with myelopathy. Previous history of organophosphorous exposure is important in myelopathy or peripheral neuropathy.

ChAdOx1 nCoV-19 is an effective and well-tolerated coronavirus disease 2019 vaccine. However, rare cases of serious adverse events have been reported with it. We report a patient who did not have active or prior coronavirus disease 2019 infection, who developed Guillain–Barré syndrome 7 days following the first dose of ChAdOx1 nCoV-19 vaccination. He was treated with intravenous immunoglobulin, with stabilization of the disease. Proper monitoring and prompt reporting of such cases are required to ensure the safety of the vaccine.

Abstract Coronavirus disease 2019 (COVID‐19) has now spread widely after the outbreak since December 31, 2019. Guillain‐Barré syndrome is an immunological postinfectious neuropathy, which has been reported to be a rare but possible complication COVID‐19. We report a case of Guillain‐Barré syndrome associated with COVID‐19 in Nepal.

Abstract Creutzfeldt‐Jakob Disease is a rare neurodegenerative disease and earlier diagnosis is usually difficult. Combining clinical features with electroencephalogram, laboratory parameters, and neuroimaging findings will facilitate the diagnosis.

Abstract Background Magnetic resonance imaging (MRI) features are typical findings in Hirayama disease (HD) and are useful diagnostic entities but may not be present in all patients. Case presentation We present the case of a 22-year-old Nepalese man who presented with insidious onset of weakness of his right upper limb of more than 5 years duration. His weakness was progressive for the first 3 years, and then remained static. On examination, weakness of the interossei, thenar, hypothenar, flexor, and extensor muscles were present in his right upper limb, power was normal in his left upper and bilateral lower limbs. Minipolymyoclonus was present in both upper limbs, less prominent on the left side. Electrophysiological findings showed motor axonal neuropathy in his right upper limb, neurogenic discharges and fibrillations, and fasciculations in both upper limbs. Contrast magnetic resonance imaging (MRI) of his cervical spine in flexion was normal. Our patient was diagnosed with HD based on clinical and electrophysiological findings. Our patient was advised to use a cervical collar and regular physiotherapy and was found to have subjective benefit. Conclusion A normal cervical MRI does not rule out HD and the diagnosis can also be made based on clinical and electrophysiological studies. Progressive distal upper limb weakness or tremor in young patients should be evaluated for HD, because early diagnosis and intervention might halt the progression.

Abstract Background Japanese encephalitis (JE) is a potentially fatal viral infection with a wide range of manifestations and can also present with a variety of movement disorders (MD) including dystonia. Dystonic features in JE are uncommon. Here, we have tried to summarize the clinical features and management of dystonia among JE patients with a comprehensive literature search. Methods Various databases, including PubMed, Embase, and Google Scholar, were searched against the predefined criteria using suitable keywords combination and boolean operations. Relevant information from observational and case studies was extracted according to the author, dystonic features, radiological changes in the brain scans, treatment options, and outcome wherever provided. Result We identified 19 studies with a total of 1547 JE patients, the diagnosis of which was confirmed by IgM detection in serum and/or cerebrospinal fluid in the majority of the patients (88.62%). 234 (15.13%) of JE patients had dystonia with several types of focal dystonia being present in 131 (55.98%) either alone or in combination. Neuroimaging showed predominant involvement of thalami, basal ganglia, and brainstem. Oral medications including anticholinergics, GABA agonists, and benzodiazepines followed by botulinum toxin were the most common treatment modalities. Conclusion Dystonia can be a disabling consequence of JE, and various available medical therapies can significantly improve the quality of life. Owing to insufficient studies on the assessment of dystonia associated with JE, longitudinal studies with a larger number of patients are warranted to further clarify the clinical course, treatment, and outcome of dystonia.

Abstract The diagnosis of rabies, a potentially fatal neuroinfectious disease, should be strongly considered in all patients who develop encephalitis following an infected animal bite even when they have received post‐exposure prophylaxis. In the absence of confirmatory tests, typical magnetic resonance imaging findings help confirm the clinical diagnosis of rabies.

Abstract We should suspect cerebral venous sinus thrombosis in patients with subacute onset progressive headaches with brain imaging evidence of localized cerebral edema with superimposed parenchymal, convexity subarachnoid as well as subdural hemorrhages.

Abstract Apart from the usual differentials of transverse myelitis and cord compression, paraparetic GBS should be considered when sudden, flaccid paralysis of the lower limbs occurs, as prompt diagnosis and management can minimize sequel and unnecessary procedures. We do report a case wherein we managed a similar situation without the use of an immunomodulatory therapy.

A referred case of a 34-year-old woman was brought to the emergency room with features of mutism and whole-body rigidity following rapid correction of hyponatremia. On presentation, she was ill looking with tremors on her both hands and legs. She was unresponsive to command and developed involuntary outbursts of laughter and crying. Based on clinical features and neuroimaging, diagnosis of isolated extrapontine myelinolysis was made. She was treated with quetiapine, vitamin B 1 and B 12 supplements, trihexyphenidyl, levodopa-carbidopa and physiotherapy of limbs. Due to lack of clinical trials for adequate diagnosis and management of extrapontine myelinolysis, this case report highlights the importance of extrapontine myelinolysis with neuropsychiatric manifestation in research world.

Abstract Background Stroke is a major disabling disease, especially for low and middle‐income countries like Nepal. The aim of our study is to assess knowledge, attitude, and practice (KAP) among the students preparing for undergraduate medical entrance examination regarding risk factors, warning signs and symptoms, and management of stroke. Methods A cross‐sectional, single staged study using self‐structured questionnaire intended to assess KAP about stroke and thrombolysis was conducted. Results A total of 378 students participated in our study (53% male; mean age = 18.12 ± 0.97). Majority of the participants (88.4%) had heard about stroke. The more common risk factors identified by them were hypertension (86.2%), oily food (48%), alcohol (37.8%), and smoking (32.8%). Limb weakness, slurring of speech and facial weakness as symptoms and signs of stroke were indicated by 43.4%, 30.2%, and 18.8% of the participants, respectively. Only 23.8% of the participants had heard about thrombolysis and 10% of all could rightly mention the window period of thrombolysis. Male participants had better knowledge about smoking [86 (43.0) vs 38 (21.3); P

Abstract When a patient presents with undulating fever and neuropsychiatric features, neurobrucellosis should be considered as a differential diagnosis. If diagnosed early, neurobrucellosis is a treatable disease with a favorable outcome.

Introduction: Intravenous Immunoglobulin is an approved therapy for Guillain Barre Syndrome. Our objective is to understand the management and outcome in Guillain Barre Syndrome patients treated with Immunoglobulin. Materials and Methods: All consecutive patients were retrospectively evaluated in the study were of age ≥16 years and were being admitted in the department of Neurology of Tribhuvan University Teaching Hospital, Kathmandu, Nepal from 2016 March to 2017 February. Results: A total of 46 patients were included, mean age= 36.5±16.2 years, range = 16years to 80 years. Thirty-two patients (70%) were axonal variant, acute motor axonal neuropathy is more common (18 patients). Intravenous immunoglobulin was used in 23 patients (50%), 17 of them were axonal variant and 6 were demyelinating. Guillain Barre Syndrome patients with bilateral facial weakness (70% vs 30%; p

The objective of this study was to explore the outcome differences among is chemic stroke sub types based on “Trial of ORG 10172 in Acute Stroke Treatment (TOAST)” system in a tertiary referral hospital. A hospital based prospectiv elongitudinal study was conducted involving 182 patients. Modified Rank in Scale (MRS) was used to assess functional out come, Kaplan-Meierproduct- limit method and Coxproportional hazards regression analys is were used to evaluate rates and identify predictors of survival and recurrent stroke. MRS were statistically different across stroke subtypesat 30 days and 6 months (p

Neuromyelitis optica spectrum disorder (NMOSD) is an immune-mediated inflammatory condition involving spinal cord and optic nerves. Diagnosis of NMOSD is done by aquaporin-4 antibody (AQP4) in patients with optic neuritis. Myelin oligodendrocyte glycoprotein (MOG) expressed on the oligodendrocyte cell surface and on the outermost cell surface of the myelin sheath may also be present in patients with NMOSD bilateral optic neuritis. Here, we describe a case of a thirty-nine-year-old-female with recurrent bilateral optic neuritis with positive anti-MOG antibody, and anti-MOG syndrome has not previously been reported from Nepal.

Abstract Aim We aim to review the literature to collate and describe features of encephalitides arising from autoantibodies against leucine‐rich glioma‐inactivated 1 (LGI1), gamma aminobutyric acid receptor (GABABR), and contactin‐associated protein‐like 2 (CASPR2) in Asian populations and compare them with findings of Western studies. Methods Peer‐reviewed articles published till 24 May 2020 were searched, and original, full‐text studies from Asia with serum/CSF antibody‐based diagnosis and at least 2 patients were selected. Twenty‐four studies with 263 patients (139 anti‐LGI1, 114 anti‐GAGABR, and 10 anti‐CASPR2) were included. Data were pooled to produce descriptive information on demographics, clinical characteristics, diagnostics, treatments, and outcome. Results The mean age was 54.2 (anti‐LGI1), 55.2 (anti‐GABABR), and 47.7 years (anti‐CASPR2), with an overall male predominance of 62.0%. Commonest clinical features across all types were seizures (87.5%), memory deficits (80.7%), psychiatric disturbances (75.9%), and altered consciousness (52.9%). Four anti‐LGI1, 40 anti‐GABABR, and 1 anti‐CASPR2 patients had tumors. CSF, MRI, and EEG were abnormal in 33.3%, 54.1%, and 75% patients in anti‐LGI1; 60.0%, 49.6%, and 85.7% in anti‐GABABR; and 50%, 44.4%, and 100% in anti‐CASPR2 patients, respectively. 95.6% patients received first‐line therapy alone (steroids/IVIG/Plasma therapy), and 4.4% received second‐line therapy (rituximab/cyclophosphamide). 91.7%, 63.6%, and 70% of patients had favorable outcomes (modified Rankin Score 0–2) with mortality rates at 2.5%, 23.2%, and 0% in the three types, respectively. Conclusion Our findings suggest that these disorders present in Asian patients at a relatively young age often with features of seizures, memory deficits, and psychiatric disturbances and usually demonstrate a favorable clinical outcome.

Myasthenia gravis (MG) has a cosmopolitan distribution and can affect people of all age group. Sometimes atypical presentation causes difficulty in the early diagnosis and management. Our aim is to study the clinical subtypes and manifestations of MG along with serological and electrophysiological diagnostic methods. Patients who were admitted in Neurology department or presented in Neurology outpatient department of Tribhuvan University Teaching Hospital from 2015 March to 2016 November were retrospectively reviewed. Out of 28 patients reviewed, 23 patients were included in the study. Their mean age of onset was 40.4±19.2 years; range=12 – 78 years, and 12 of them were female (52.2%). Eight patients (34.8%) were diagnosed with ocular myasthenia and 15 were patients (65.2%) of General Myasthenia. Seventeen patients (73.9%) were acetylcholine receptor (AChR) antibodies positive, one female patient was found to be muscle specific kinase (MuSK) positive. Decremental pattern in Repetitive Nerve stimulation (RNS) was reported in 11 patients (47.8%) and ice pack test was positive in 16 patients (69.3%). Ophthalmological findings are the most common presentation of MG patients. Icepack test is an easy clinical diagnostic tool for outpatient department which has both high sensitivity and specificity. RNS and antibody tests are the supporting tests useful for confirming the diagnosis.

The aim of this study was to determine the frequency and origin of fever in patients admitted with acute stroke and the characteristics associated with the development of fever.This was a cross sectional observational study involving 151 patients admitted with acute stroke. The various attributes associated with the development of fever were documented and their characteristics were analyzed. Fever was noted in 21.2% of 151 patients; 11.9% had a documented infection and 9.3% had no documented infection. Older age was associated with the presence of fever (P = 0.009). The development of fever was associated with haemorrhage rather than ischemic infarct (P = 0.0001), presence of mass effect (P =0.03), and larger size of ischaemic infarct and haemorrhage (P = 0.002 and 0.0001, respectively). Patients with fever had lower scores on admission on the Glasgow Coma Scale (GCS) (P = 0.009) and higher score on the National Institute of Health Stroke Scale (NIHSS) (P = 0.0001). The development of fever was associated with prior use of an invasive technique (P =0.0001), particularly urinary catheterization and endotracheal intubation (P = 0.0001 and 0.0001). In multivariate analysis, age, NIHSS and endotracheal intubation were found to be significantly associated with fever (P = 0.018, P = 0.001 and P = 0.0001, respectively). Patients with fever without documented infection had an earlier onset than those with infection (P = 0.012). Fever in acute stroke patients is associated with older age, severity of stroke and the use of invasive techniques. Urinary tract and respiratory infections are the most common infections. Fever starts earlier where a focus of infection is not identified.