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Objectives: Stroke is the second-leading cause of death and the third-leading cause of death and disability combined in the world. We need to find easy, available, and reliable parameters on which we can depend to prevent stroke, predict outcome, and determine prognosis. This will help in stroke management in the future. Materials and Methods: We noted blood counts and serum homocysteine levels in acute stroke patients after the exclusion of confounding factors. Our team recorded the detailed demographic and blood parameters (blood counts and homocysteine) of acute stroke patients who got admitted to different departments of our hospital in 5 months. We later correlated or tried to find the association between these parameters and stroke severity (NIHSS), other clinical parameters such as dysarthria and stroke outcome (Modified Rankin Score (mRS) at discharge and at 3 months). The team also tried to find relationships, if any, with different stroke subtypes as per the Trial of ORG 10172 in Acute Stroke Treatment classification. Results: Out of 100 patients (34 females and 66 males), we had 28 patients with hyperhomocysteinemia (HHcy). The high neutrophil count and total leukocyte count correlated with stroke severity, dysarthria, and outcome at 3 months (poor mRS). While, it was the opposite in the case of lymphocyte count. Homocysteine level did not correlate with stroke severity or outcome but with dyslipidemia. HHcy was more prevalent among patients with large artery atherosclerotic disease. Conclusion: Findings of our study were agreeable to earlier studies on the relationship between blood counts and stroke prognosis. Although high homocysteine level was associated with stroke, its level was not found to be related to stroke severity or outcome. However, further study with a larger sample size is required to draw a confident conclusion.

A 53-year-old lady with no known comorbidity had undergone cisternography for persistent rhinorrhea. Rhinorrhea resolved, and the report was normal. However, a week later, she complained of low back pain, followed by progressive quadriparesis and sphincter dysfunction. A detailed imaging revealed evidence of leptomeningitis around the brain stem, intradural cervical and dorsal collection with nodular enhancement, and clumping of cauda equina roots. Cerebrospinal fluid (CSF) showed pleocytosis with increased protein and hypoglycorrhachia. CSF cell count was 6000 (all lymphocytes), CSF proteins were 1138 mg%, and CSF glucose was 30 mg% (corresponding blood glucose level of 110 mg%). We did not get any systemic clue about the illness except progressive weight loss. Our team concluded either it is directly a deadly sequel of the dye-related complication of cisternography or activation of a chronic infection in the spine. We treated her with antitubercular drugs and steroids along with physiotherapy. We kept in mind the chronicity of the illness and endemicity of tuberculosis. She responded well and was mobilizable with minimal support. Hence, we continued the same regimen, keeping in mind the responsiveness of the patient to the same. We report this case to realize the possibility of this type of complication even with advanced dye and modern techniques of cisternography. Our case also underscores the requirement of prior imaging (magnetic resonance imaging of the spine) before undertaking such a procedure (cisternography). Last but not the least, sometimes we also need to make decisions based on our clinical knowledge as neurological investigations may be inconclusive in many circumstances.

Objectives: Intracerebral hemorrhage (ICH) is more common in the Indian subcontinent compared to the Western world and associated with significant morbidity and mortality. Hence, all possible modifiable factors should be searched and steps taken so that a single opportunity is not missed in preventing such a catastrophe. The aim of the study is to find out whether homocysteine and Vitamin B12 are related to ICH. Materials and Methods: We included acute ICH patients of 18 years and above who came to our institute and got admitted in 5 months (September 2021–January 2022). Our team noted the demographics, National Institutes of Health Stroke Scale (at admission and discharge) and other clinical parameters. Volume and site of the intracerebral hematoma (from the initial computed tomography [CT] scan of the brain) were noted. The outcome and prognostic markers like Modified Rankin Scale (mRS) at discharge, MRS at 3 months (also MRS at admission) and ICH score were calculated. The blood parameters, including serum homocysteine and Vitamin B12 level, were noted post admission in hospital. Results: We found out of 44 ICH patients; ten patients had hyperhomocysteinemia (HHcy): 22.72%. We detected significant correlation between HHCy with ICH score (inverse relationship) and dyslipidemia (direct relationship). Conclusion: We found an inverse correlation between serum homocysteine level and ICH score, which shows a short-term (1 month) prognosis. This might hint that homocysteine might have a protective role to play in ICH. However, we probably need larger study population to find a correlation strong enough so that we can make a stronger conclusion.

We often face situations when the exact etiological diagnosis of meningitis is difficult. The reason behind this is that many pathogens have similar clinical, radiological, and laboratory pictures. The low yield of the pathogen in cerebrospinal fluid (CSF), non-availability of detail tests in all corners of the world, delay in availability of reliable results (like cultures), and difficulty in performing confirmatory tests like brain biopsy (in inconclusive cases) make the job of a clinician challenging. We report here a case where a late diagnosis of a disease owing to inconclusive results leads to dissemination. The complications following the introduction of the treatment based on presumption lead to further difficulty. We remained inclined to our diagnosis based on clinical judgement, acknowledged and managed the inflammatory changes secondary to the infection, and finally won the long battle. So, sometimes we need to make decisions based on clinical grounds. We need to depend on the fact that uncommon presentations of common diseases are commoner than a common presentation of uncommon diseases.

A 47-year-old -lady without known co-morbidity had presented with a one-month history of respiratory distress and headache. Someone incidentally started her with antitubercular drugs and steroids outside our hospital. Her routine CT scan of brain was unremarkable. She had a partial response to the same, but she presented to us with an increased headache after a month. We found her to have diffuse nodular pulmonary involvement with bilateral pleural effusion. The pleural fluid diagnostic evaluation revealed adenocarcinoma of the lung. The MRI of the brain revealed multiple nodular involvements consistent with the rare intracranial miliary metastasis. Our case underscores the importance of careful history taking and evaluation of patients with respiratory distress along with headaches (our patient lacked a classical history of miliary tuberculosis). We may overlook the silent brain metastasis on routine CT scans of the brain and cause an important delay in diagnostic evaluation and intervention in life-threatening diseases, like our case.