Cerebral venous thrombosis presenting as subarachnoid haemorrhage

We present a 31 years old lady who was 19 days postpartum who was admitted with fits and loss of consciousness. At presentation Glasgow Coma Scale was 8/15. No focal deficit. CT scan brain showed findings suggestive of subarachnoid haemorrhage(SAH) in left sylvian fissure along with few parenchymal haemorrhagic areas in frontal and parietal lobes. MRI brain and MRV confirmed superior sagittal sinus thrombosis, inferior sagittal, straight and right transverse and sigmoid sinus thrombosis. Patient was treated conservatively and was anticoagulated for 6 months and had a complete recovery. Further workup of thrombophilia was negative. Postpartum being the only risk factor for cerebral venous thrombosis (CVT) in her. SAH can be a rare presenting symptom of CVT and should not preclude patients from receiving anticoagulation

Stroke like migraine attacks after Radiation therapy (smart) vs radiation Vasculopathy

Stroke like migraine attacks after radiotherapy (SMART) syndrome is a phenomenon of reversible neurologic dysfunction which occurs rarely years after radiotherapy for brain tumors. We present a 35years old patient who had new onset neurological dysfunction with fits twice in between a symptom free interval of one year. He had radiotherapy for grade 1 astrocytoma about 27 years ago. Tumor recurrence or growth was ruled out both times by neuroimaging. Alternate diagnosis like meningoencephalitis were also ruled out by appropriate workup. Patient was managed on antiepileptics and antiplatelets. Radiation induced vasculopathy was an important differential. The mechanism of both SMART and radiation induced vasculopathy appears similar. Having knowledge of such rare but important conditions is important for neurologist as it can save patients from unnecessary investigations

An uncommon and elusive cause of cerebral venous thrombosis

We present a case of of young 27year male who was admitted with history of headache and vomiting for one week. He was diagnosed as having dural sinus thrombosis of superior sagittal, right lateral, right sigmoid sinus. There was previous history of uveitis 6 months prior to it. All thrombophilia workup was negative except homocysteine levels were moderately high. He was also found to be having recurring genital and oral ulcers. Pathergy test was negative. His HLA B 51/5 testing came back positive. Final diagnosis of Bechet’s disease was made and responded well to long term steroids and Colchicine. A multisystem vasculitis like Bechet’s disease should always be thought in patients with venous thrombosis with negative thrombophilia screening and recurrent oral and genital ulcers

Neurosarcoidosis presenting as psychiatric Symptoms: a diagnostic challenge

Among patients having neurosarcoidosis, psychiatric manifestations can be seen in 20% of the patients.Sarcoidosis is extremely rare in Asia, being almost unknown in some countries like China and Southeast Asia.Neurosarcoidosis occurs in approximately 5% of patients with sarcoidosis. Neurosarcoidosis presenting as psychiatric manifestations has rarely been reported. We report a case of a young male who presented with psychiatric symptoms,was diagnosed with neurosarcoidosisand responded well to oral steroids.His symptoms were diffuseheadaches, and feelings of movement of fluid on top of headand certain other vague somatic complaints like body aches, vertigo etc. Such patients are difficult to diagnose as sarcoidosis is rare in our part of the world and symptoms are often nonspecific. A high index of suspicion should be kept to identify these cases. We emphasize the importance of recognizing sarcoidosis in patients presenting with variable neuropsychiatric manifestations

Frequency of intraventricular extension in intracerebral hemorrhage and its outcome at day 30.

Intracerebral hemorrhage (ICH) accounts for 10 to 15% of all strokes, and is found to have a disproportionately high morbidity and mortality.1 Extension of the hemorrhage intothe ventricles (40% occurrence) can happen early or late in the course of events.2 OBJECTIVE: To determine the frequency of Intraventricular extension in patients with intracerebralhaemorrhage and its outcome at day 30 by measuring disability using Modified Rankin Scale.STUDY DESIGN: Descriptive case series.PLACE AND DURATION OF STUDY: Study was carried out from 1st December 2010 to 31st May, 2011 in the department of Neurology, PIMS, Islamabad, Pakistan SUBJECT AND METHODS:93 patients of intracerebralhaemorrhage were enrolled in the study and the site of bleeding and its intraventricular extension noted on CT scan and outcome was measured by using mRS at discharge and at day 30. RESULTS:Total numbers of patients were 93. Mean age was 61.31±16.37 years. Mean duration of hospital stay was 4.06±2.08 days. Mean mRS at Admission was 4.55±0.69.Intraventricular extension of the intracerebral hemorrhage was seen in about half of the cases (50.5%). A higher number of patients were seen in mRS 5 in patients withintraventricular extension at admission. At Discharge 17 patients were dead in intraventricular extension group compared to 5 with no intraventricular extension group. The outcome was poor at day 30 as about half of patients (23 out of 47) with intraventricular extension of hemorrhage were dependent.CONCLUSION:Intraventricular extension of the intracerebral hemorrhage was seen in about half of the cases andits outcome at day 30 was poor

Brainstem tuberculoma as a manifestation of paradoxical reaction in a patient with tuberculous meningitis.

Tuberculosis commonly involves the CNS, During drug treatment of CNS tuberculosis paradoxical response (PR) may occasionally occur. The term “paradoxicalresponse”refers to the development of previously nonexistent tuberculosis lesions or worsening of preexisting lesions during antituberculosis treatment( ATT). Etiology is still not clear but delayed type hypersensitivity and alteration in immune system is thought to be a cause. Continued treatment improves PR without severe sequelae. We report a 41 year-old female patient with tuberculous meningitis(TBM) who developed brainstem tuberculomaduring the course of ATT, after about 9 months of treatment as a paradoxical response to ATT. Early identification, continuation of ATT with steroids and ventriculoperitoneal shunting to relieve raised intracranial pressure resulted in complete recovery of our patient. Clinicians should be aware of this phenomenon as it can lead to clinical worsening as late as 9 months. The objective of this case report is to increase knowledge of clinicians about this phenomenon and also to report its such late occurrence

“More than meets the eye” non secretory myeloma presenting as cidp in a patient with longstanding diabetic polyneuropathy. a diagnostic and therapeutic challenge.

Diagnosing chronic inflammatory polyradiculopathy in patients with pre-existing diabetic sensorimotor polyneuropathy is a diagnostic challenge. We present a case of a 69 years old who presented with weakness of legs for two months,he was diagnosed as having CIDP on the background of diabetic sensorimotor polyneuropathy, further and extensive workup revealed the final diagnosis of nonsecretory myeloma. Diagnosing non secretory myeloma is itself a diagnostic challenge and usually first line investigations for the workup of myeloma are negative as was the case in our patient. Our patient with CIDP had raised free light chains of kappa which made the final diagnosis of kappa associated plasma cell dyscrasia

Vgkc antibody (anti lg1) associated limbic Encephalitis in a young adult with full Recovery.

A young boy with no premorbids was admitted with fever, fits and psychosis. His initial investigations including cerebrospinal fluid (CSF) routine examination, electroencephalogram(EEG) and MRI brain with contrast were normal. His autoimmune encephalitis panel revealed positive voltage gated potassium channel(VGKC) antibodies, anti -leucine rich glioma inactivated 1 antibody (LG1) group and was give five doses of methylprednisolone and five sessions of plasmapheresis. Psychiatric symptoms took one month to respond. He had a complete recovery. Autoimmune limbic encephalitis should be diagnosed promptly in young patient with fit, psychosis and a high index of suspicion should be kept as initial work up including MRI brain with contrast, EEG and CSF examination can be normal in such patients

STROKE AS A FIRST PRESENTATION OF MALIGNANCY

Stroke is a frequent complication in patients with cancer occurring in nearly 15% of the cases. However cerebrovascular disease as the first presentation of malignancy has rarely been reported. We report two such cases who were admitted with acute stroke but were later on found to be having malignancy. Routine workup was unrewarding in both patients. Both patients developed pulmonary embolism as well during hospital stay suggesting hypercoagulable state as likely etiology. Reaching to the final diagnosis was an arduous journey but can help guide other clinicians facing similar cases. Non Hodgkins B cell lymphoma and Carcinoma Gall bladder were the final diagnosis in our patients. Therefore, we recommend workup for malignancy if no likely cause is found on routine extensive workup before labelling stroke as cryptogenic stroke. Ultrasound abdomen was particularly rewarding in our patients

NMDA encephalitis in an elderly with poor prognosis

We present a case of a 65 years old man from Islamabad who presented with six months history of psychiatric and behavioural symptoms, significant weight loss. Later on he developed difficulty swallowing and altered sensorium. This was followed by an episode of shortness of breath leading to respiratory arrest, followed by ICU stay on ventilator support, then developed focal deficit in form of left sided weakness, dysautonomia, bradycardia leading to cardiac arrest and another cardiopulmonary resuscitation, myoclonic jerks, orofacial dyskinesias, status epilepticus, coma ultimately resulting in death of the patient. Patient was found to be NMDA receptor antibody positive. CT chest and abdomen did not reveal any hidden malignancy. Patient was given intravenous pulse steroids for 5 days followed by five sessions of plasmapheresis but did not respond. He stayed on ventilator support for 40 days and did not improve. This is the second case of antibody proven NMDA encephalitis from Pakistan, the first being from Islamabad as well and published in this journal