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   Table of Contents - Current issue
Coverpage
October-December 2022
Volume 8 | Issue 4
Page Nos. 169-231

Online since Tuesday, December 6, 2022

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PERSPECTIVE  

Branch atheromatous disease and treatment p. 169
Honglian Duan, Ho Jun Yun, Xiaokun Geng, Yuchuan Ding
DOI:10.4103/bc.bc_56_22  
Branch atheromatous disease (BAD) is a subtype of ischemic stroke caused by perforating arteries occlusion due to proximal atherosclerosis of the arteries. Early neurological deterioration and recurrent stereotyped transient ischemic attacks are typical clinical manifestations of BAD. The optimal treatment for BAD has not been determined. This article explores a possible mechanism of BAD and effective treatment measures to prevent early progression and attack of transient ischemic events. This article explains the current status of intravenous thrombolysis, tirofiban, and argatroban for BAD and subsequent prognosis.
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REVIEW ARTICLES Top

Neuroprotective approach in acute ischemic stroke: A systematic review of clinical and experimental studies p. 172
Fettah Eren, Sueda Ecem Yilmaz
DOI:10.4103/bc.bc_52_22  
Ischemic stroke is a disease with worldwide economic and social negative effects. It is a serious disease with high disability and mortality. Ionic imbalance, excitotoxicity, oxidative stress, and inflammation are induced during and after ischemic stroke. Cellular dysfunction, apoptosis, and necrosis are activated directly or indirectly mechanisms. The studies about neuroprotection in neurodegenerative diseases have increased in recent years. Data about the mechanisms of progressive molecular improvement in the brain tissue are increasing in acute ischemic stroke. Based on these data, preclinical and clinical studies on new neuroprotective treatments are being designed. An effective neuroprotective strategy can prolong the indication period of recanalization treatments in the acute stage of ischemic stroke. In addition, it can reduce neuronal necrosis and protect the brain against ischemia-related reperfusion injury. The current review has evaluated the recent clinical and experimental studies. The molecular mechanism of each of the neuroprotective strategies is also summarized. This review may help develop future strategies for combination treatment to protect the cerebral tissue from ischemia-reperfusion injury.
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Cerebral venous sinus thrombosis in pregnancy and puerperium: A comprehensive review p. 180
Hussein Algahtani, Abdulrahman Bazaid, Bader Shirah, Raghad N Bouges
DOI:10.4103/bc.bc_50_22  
Cerebral venous sinus thrombosis (CVST) is a distinct neurological emergency caused by occlusion, either partial or complete, of the dural venous sinus and/or the cerebral veins. It occurs more frequently in women during pregnancy and puerperium as compared to the general population. The clinical diagnosis is difficult in some cases due to its variable clinical presentation with numerous causes and risk factors. The diagnosis can be made at an early stage if clinical suspicion is high with the help of advanced neuroimaging techniques that were developed recently. Early therapeutic intervention using anticoagulants allows for preventing complications and improving outcomes. In this article, we review the topic of CVST in pregnancy and the postpartum period with an emphasis on its epidemiology, pathophysiology, clinical presentation, and treatment. We also elaborate on several practical points that are important to the treating team. This review will help obstetricians, neurologists, and emergency physicians diagnose affected pregnant women as early as possible to provide prompt treatment and avoid adverse outcomes.
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Spontaneous chronic subdural hematoma as the cause of oculomotor cranial nerve palsy: A narrative review p. 188
Francesco Pellegrini, Emanuela Interlandi, Alessandra Cuna, Daniela Monaco, Andrew G Lee
DOI:10.4103/bc.bc_42_22  
Acute complete third nerve palsy with pupillary involvement is usually caused by a posterior communicating artery aneurysm (i.e. “the rule of the pupil”). The pupillary fibers run peripherally in the third nerve and are thus susceptible to the external compression. Headache is usually present, and urgent diagnosis and treatment are warranted. Rarely, however, neuroimaging shows other causes of third nerve palsy. In this study, we perform a literature review of spontaneous chronic subdural hematoma that, although rarely, may cause an acute pupil-involving third nerve palsy as a false localizing sign. We review the localizing, nonlocalizing, and false localizing nature of ocular motor cranial nerve palsy in this setting.
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ORIGINAL ARTICLES Top

Gender differences in diagnostic tools, medication, time to medication, and nonmotor symptoms in Parkinsonian patients p. 192
Örjan Skogar, Mats Nilsson, Johan Lökk
DOI:10.4103/bc.bc_33_22  
BACKGROUND: Swedish National Quality Registers (NQRs) play an important role in collecting large amounts of diagnosis-specific data, symptoms, and treatments. The subset of data, Parkinson's Registry, has been in use for more than 20 years and represents all counties and hospitals in Sweden where neurological care is provided. OBJECTIVE: To study the differences between genders regarding diagnostic tools, pharmacological interventions, and self-reported symptoms in patients with symptoms originating from basal ganglia disease, either idiopathic or secondary Parkinsonism (PD). METHODS: PD-diagnosed patients from a mix of urban and rural locations were chosen from the NQR and sorted by gender. Self-reported, first-experienced PD-related symptoms defined the debut point of PD. RESULTS: In all, data from 1,217 patients were analyzed: 502 (41%) females/715 (59%) males. A total of 493 imaging investigations were performed, where of 239 (48% females/52% males) had a CT scan performed, 120 (24% females/29% males) had a dopamine transporter scans, and 134 (23% females/26% males) had a magnetic resonance imaging performed (Fisher's exact test, P = 0.19). The average time in years from symptom onset to start of first treatment, and from first to second added treatment was 2;7/2;9 (females) and 5;1/5;2 (males). Nonmotor symptoms were more prominent among males, especially in memory and gastrointestinal domains, including drooling and obstipation. Significantly more sexual problems were reported from males; 26% versus 7% (Fisher's exact test, P < 0.0001). CONCLUSIONS: Differences between genders were identified in this study. Sexual problems and cognitive decline were more frequent among males. More advanced diagnostic imaging techniques were performed among males. The time point for a second added medication was earlier for males than females.
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Comparison and evaluation of two different crystalloids - Normal saline and plasmalyte in patients of traumatic brain injury undergoing craniotomy p. 200
Renu Bala, Teena Bansal, Anshul Mundra, Kirti Kamal
DOI:10.4103/bc.bc_54_22  
BACKGROUND AND AIMS: Fluid therapy is one of the most important components of the management of patients with traumatic brain injury (TBI). The present study was planned to compare plasmalyte and normal saline (NS) in patients who underwent craniotomies for TBI in terms of their effects on acid–base equilibrium, renal functions, and coagulation profile. METHODS: Fifty patients of age 18–45 years of either sex, who underwent emergency craniotomy for TBI, were included in the study. The patients were randomized into two groups. Group P (n = 25) received isotonic balanced crystalloid (plasmalyte) and Group N (n = 25) received NS intraoperatively and postoperatively till 24 h after surgery. RESULTS: The pH was lower in Group N (P < 0.05) at different time points after surgery. Similarly, more patients in Group N had pH <7.3 (P < 0.05); while the rest of the metabolic parameters were comparable in the two groups. Blood urea and serum creatinine were higher in Group N. Coagulation profile was comparable in the two groups. CONCLUSION: Acid–base, electrolyte balance, and renal profile were better in patients receiving plasmalyte as compared to NS. Hence, it can be a wiser choice for fluid management in patients of TBI undergoing craniotomy.
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Effectiveness of pharmacologic interventions for prevention of cerebral hyperperfusion syndrome following bypass surgery p. 207
Georgios P Skandalakis, Aristotelis Kalyvas, Evgenia Lani, Spyridon Komaitis, Danai Manolakou, Despoina Chatzopoulou, Nikos Pantazis, Georgios A Zenonos, Constantinos G Hadjipanayis, George Stranjalis, Christos Koutsarnakis
DOI:10.4103/bc.bc_43_22  
BACKGROUND: Cerebral hyperperfusion syndrome (CHS) following bypass surgery is a major cause of neurological morbidity and mortality. However, data regarding its prevention have not been assorted until date. OBJECTIVE: The objective of this study was to review the literature and evaluate whether any conclusion can be drawn regarding the effectiveness of any measure on preventing bypass-related CHS. METHODS: We systematically reviewed PubMed and Cochrane Library from September 2008 to September 2018 to collect data regarding the effectiveness of pharmacologic interventions on the refers to pretreatment (PRE) of bypass-related CHS. We categorized interventions regarding their class of drugs and their combinations and calculated overall pooled estimates of proportions of CHS development through random-effects meta-analysis of proportions. RESULTS: Our search yielded 649 studies, of which 23 fulfilled inclusion criteria. Meta-analysis included 23 studies/2,041 cases. In Group A (blood pressure [BP] control), 202 out of 1,174 pretreated cases developed CHS (23.3% pooled estimate; 95% confidence interval [CI]: 9.9–39.4), Group B (BP control + free radical scavenger [FRS]) 10/263 (0.3%; 95% CI: 0.0–14.1), Group C (BP control + antiplatelet) 22/204 (10.3%; 95% CI: 5.1–16.7), and Group D (BP control + postoperative sedation) 29/400 (6.8%; 95% CI: 4.4–9.6)]. CONCLUSIONS: BP control alone has not been proven effective in preventing CHS. However, BP control along with either a FRS or an antiplatelet agent or postoperative sedation seems to reduce the incidence of CHS.
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CASE REPORTS Top

Mechanical thrombectomy with a novel beveled tip aspiration catheter: A technical case report p. 215
Cagin Senturk
DOI:10.4103/bc.bc_47_22  
Recent data suggested aspiration thrombectomy as the first-pass approach in endovascular treatment of acute stroke and is accepted as a safe and efficient alternative to stent-retriever thrombectomy. The efficiency of mechanical thrombectomy for complete removal of the clot is directly related to the catheter trackability, aspiration force, and inner diameter of the aspiration catheter. Zoom 71 Aspiration catheter (Imperative Care, Campbell, California, USA) is a novel aspiration catheter with a beveled tip aiming to increase the tip surface area, increased suction force, and advanced trackability. This case report describes the successful use of Zoom 71 aspiration catheter in a left middle cerebral artery M2 branch occlusion and highlights technical details including navigation without the support of a microcatheter microwire combination.
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Diffuse large B-cell lymphoma: An uncommon diagnosis at the cerebellopontine angle - A case report p. 219
Punit Kumar, Amit Kumar Ghosh, Soutrik Das
DOI:10.4103/bc.bc_46_22  
Primary central nervous system lymphoma (PCNSL), a rare variant of extranodal non-Hodgkin's lymphoma, has shown an increased incidence over the last 3–4 decades in both immunocompromised and immunocompetent individuals. Only <20 cases of cerebellopontine (CP) angle lymphoma have been reported so far in the literature. Hereby, we report a case of primary lymphoma of the CP angle mimicking vestibular schwannoma and other common pathologies at the CP angle. Hence, while evaluating a lesion at CP angle, PCNSL should always be considered in the differential diagnosis.
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Extracranial reversible cerebral vasoconstriction syndrome associated with vertebral artery dissection: A case report p. 222
Miyeon Yoon, Taewon Kim
DOI:10.4103/bc.bc_58_22  
In the present vignette, we describe a lateral medullary infarction developed immediately after strenuous straining owing to constipation in a 42-year-old female. There was a dissection in left vertebral artery V4 segment. Computed tomography (CT) angiography revealed beaded appearance of cervical V2 and V3 segments of bilateral vertebral arteries. A follow-up CT angiogram performed about 3 months later showed resolution of vasoconstriction and normalization of vertebral arteries. Reversible cerebral vasoconstriction syndrome (RCVS) is usually known as an intracranial pathologic condition. Extracranial RCVS is very rare. Therefore, the diagnosis of RCVS could be challenging when its location is extracranial, particularly when comingling vertebral artery dissection (VAD) is present because of their similar vascular luminal morphology. Physician should be vigilant about the possibility of a concomitant presence of RCVS and VAD, even in extracranial vessels.
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Isolated cerebellar infarction in a case of JAK 2 mutation-negative polycythemia vera: A case report p. 225
Prasad Krishnan
DOI:10.4103/bc.bc_37_22  
Polycythemia vera is a myeloproliferative disorder caused by clonal expansion of erythroid precursors in the bone marrow commonly due to a mutation in the Janus kinase 2 (JAK2) gene located in the short arm of chromosome 9. Hyperviscosity of blood due to high hematocrit causes a low flow state that may predispose to infarct. These commonly occur in the supratentorial compartment. The case of a 46-year-old man who had an isolated cerebellar infarct with high hematocrit and hemoglobin levels and low serum erythropoietin levels is described. Further investigations eventually led to the unmasking of a JAK2 mutation-negative polycythemia vera.
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SHORT COMMUNICATION Top

Unaffected ex vivo clotting cascade by experimental hemostatic nanoparticles when introduced in the presence of recombinant tissue plasminogen activator p. 228
Margaret Beyer, John France, Tavarekere N Nagaraja, Erin B Lavik, Robert A Knight, Christopher A Lewandowski, Joseph B Miller
DOI:10.4103/bc.bc_45_22  
CONTEXT: Hemostatic nanoparticles (hNPs) have shown efficacy in decreasing intracerebral hemorrhage (ICH) in animal models and are suggested to be of use to counter tissue plasminogen activator (tPA)-induced acute ICH. AIMS: The objective of this study was to test the ability of an hNP preparation to alter the clotting properties of blood exposed to tPA ex vivo. MATERIALS AND METHODS: Fresh blood samples were obtained from normal male Sprague-Dawley rats (~300 g; n = 6) and prepared for coagulation assays by thromboelastography (TEG) methods. Samples were untreated, exposed to tPA, or exposed to tPA and then to hNP. TEG parameters included reaction time (R, time in minutes elapsed from test initiation to initial fibrin formation), coagulation time (K, time in minutes from R until initial clot formation), angle (α, a measure in degrees of the rate of clot formation), maximum amplitude (MA, the point when the clot reaches its MA in mm), lysis at 30 min after MA (LY30, %), and clot strength (G, dynes/cm2), an index of clot strength. STATISTICAL ANALYSIS USED: Kruskal–Wallis test was employed to compare TEG parameters measured for untreated control samples versus those exposed to tPA and to compare tPA-exposed samples to samples treated with tPA + hNPs. Significances were inferred at P ≤ 0.05. RESULTS: Compared to untreated samples, tPA-treated samples showed a trend toward decreased angle and G suggesting potentially clot formation rate and clot strength. The addition of hNP did not affect any of these or other measured indices. CONCLUSIONS: The data demonstrated no hemostatic effects when the hNP was used in the presence of tPA. The lack of change in any of the TEG parameters measured in the present study may indicate limitations of the hNPs to reverse the thrombolytic cascade initiated by tPA.
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