Homocysteine (Hcy) is a sulfhydryl-containing amino acid, and intermediate metabolite formed in metabolising methionine (Met) to cysteine (Cys); defective Met metabolism can increase Hcy. The effect of hyperhomocysteinemia (HHcy) on human health, is well described and associated with multiple clinical conditions. HHcy is considered to be an independent risk factor for common cardiovascular and central nervous disorders, where its role in folate metabolism and choline catabolism is fundamental in many metabolic pathways. HHcy induces inflammatory responses via increasing the pro-inflammatory cytokines and downregulation of anti-inflammatory cytokines which lead to Hcy-induced cell apoptosis. Conflicting evidence indicates that the development of the homocysteine-associated cerebrovascular disease may be prevented by the maintenance of normal Hcy levels. In this review, we discuss common conditions associated with HHcy and biochemical diagnostic workup that may help in reaching diagnosis at early stages. Furthermore, future systematic studies need to prove the exact pathophysiological mechanism of HHcy at the cellular level and the effect of Hcy lowering agents on disease courses.
Background: T2 relaxation-based magnetic resonance imaging (MRI) signals may provide onset time for acute ischemic strokes with an unknown onset. The ability of visual and quantitative MRI-based methods in a cohort of hyperacute ischemic stroke patients was studied.
Methods: A total of 35 patients underwent 3T (3 Tesla) MRI (<9-hour symptom onset). Diffusion-weighted (DWI), apparent diffusion coefficient (ADC), T1-weighted (T1w), T2-weighted (T2w), and T2 relaxation time (T2) images were acquired. T2-weighted fluid attenuation inversion recovery (FLAIR) images were acquired for 17 of these patients. Image intensity ratios of the average intensities in ischemic and non-ischemic reference regions were calculated for ADC, DWI, T2w, T2 relaxation, and FLAIR images, and optimal image intensity ratio cut-offs were determined. DWI and FLAIR images were assessed visually for DWI/FLAIR mismatch.
Results: The T2 relaxation time image intensity ratio was the only parameter with significant correlation with stroke duration (r = 0.49, P = .003), an area under the receiver operating characteristic curve (AUC = 0.77, P < .0001), and an optimal cut-off (T2 ratio = 1.072) that accurately identified patients within the 4.5-hour thrombolysis treatment window with sensitivity of 0.74 and specificity of 0.74. In the patients with the additional FLAIR, areas under the precision-recall-gain curve (AUPRG) and F1 scores showed that the T2 relaxation time ratio (AUPRG = 0.60, F1 = 0.73) performed considerably better than the FLAIR ratio (AUPRG = 0.39, F1 = 0.57) and the visual DWI/FLAIR mismatch (F1 = 0.25).
Conclusions: Quantitative T2 relaxation time is the preferred MRI parameter in the assessment of patients with unknown onset for treatment stratification.
Myelin oligodendrocyte glycoprotein-antibodies (MOG-IgG) are associated with acquired inflammatory demyelinating syndromes, seen predominantly in children and young adults. The overlapping clinical and radiological features of the heterogenous spectrum of demyelinating central nervous system (CNS) diseases makes the detection of MOG-IgG antibodies important for prognosis and treatment decisions. Herein, we describe the occurrence of MOG-IgG associated disease presenting as acute disseminated encephalomyelitis (ADEM), with spinal MRI findings of centrally located long cord lesion in a 14-month old child.
This report aims to enhance the understanding of early longitudinal neuroimaging features of progressive multifocal leukoencephalopathy (PML) in human immunodeficiency virus (HIV). Neuroimaging has become crucial in the diagnosis and early recognition of PML. Recognition of magnetic resonance imaging (MRI) features in the early stages of PML is paramount to avoid misdiagnosis and facilitate the delivery of treatments aimed at reducing disease progression. A 49-year-old white man with HIV presented with 4-month progressive left-sided weakness. Neurological examination revealed mild cognitive impairment, left-sided hemiparesis, and somatosense impairment to all modalities. Brain MRI revealed a punctate pattern with innumerable T2-FLAIR (fluid attenuated inversion recovery) hyperintensities in the cortex, brainstem, cerebellum, subcortical, and periventricular areas. Susceptibility-weighted imaging (SWI) revealed hypointensities involving subcortical U-fibers and cortical architecture. A comprehensive diagnostic evaluation was inconclusive. John Cunningham virus (JCV) PCR in cerebrospinal fluid (CSF) was indeterminate. He was started on antiretroviral therapy. Repeat brain MRI performed 1.5 months later, in the setting of further neurological decline, demonstrated progression of the T2-hyperintensities into a large confluent white matter lesion in the right frontoparietal lobe. Despite an indeterminate JCV PCR, the appearance and characteristic progression of the lesions in successive imaging in the setting of severe immunosuppression, with extensive negative infectious workup, was indicative of PML. This clinical experience illustrates unique neuroimaging features of HIV-PML in early stages and its progression over time. It especially highlights the relevance of the SWI sequence in the diagnosis and features observed with disease evolution. Short-term imaging follow-up may assist with the recognition of MRI features consistent with the biology of the infection.
We report the case of a 37-year-old male patient with chronic amphetamine abuse who presented with vertebral artery dissection. Prior to presentation, he had increased the consumption of amphetamine from 5 times a year to once every week and had used amphetamine on the day of presentation. He attended with neck pain, vertigo and coordinating difficulties of his left arm. Computed tomography angiogram of the neck vessels showed a left vertebral stenosis and cerebral magnetic resonance imaging showed a left vertebral pseudolumen and a medullary stroke. Cervical artery dissection is a major cause of stroke in the young. To the authors' knowledge, this is the second reported case of vertebral artery dissection in a patient with amphetamine abuse. Amphetamine might contribute to an increased risk of vertebral artery dissection through its vasculopathic properties although more data are needed to establish a causal relationship.
Background: Information on the epidemiology of temporal lobe epilepsy associated with hippocampal sclerosis (TLE-HS) from Qatar and the developing countries is scarce. To acquire knowledge on the incidence and prevalence of drug-resistant TLE-HS in Qatar, we designed this analytical and extrapolative systematic review of the existing literature.
Material and methods: We searched the electronic database PubMed from 1947 until April, 2018, using the following search terms in the title: "epilepsy" OR "temporal lobe" OR "hippocampal sclerosis" AND "epidemiology" OR "incidence" OR "prevalence." Relevant original studies, reviews, and their references, were included. We extrapolated from the previous international literature to estimate the epidemiology of drug-resistant TLE-HS in Qatar.
Results: The estimated Qatar incidence of epilepsy varies from 50 to 61 per 100 000 persons per year, and the estimated prevalence of epilepsy is 6.54 per 1000 population; the estimated incidence of TLE varies from 9.5 to 11.6 patients per 100 000 population per year and the estimated prevalence of TLE is 1.76 patients per 1000 people, with 4721 patients having TLE in Qatar. Finally, the reviewed studies also helped in making an estimate of the Qatar prevalence of drug-resistant TLE-HS to be between 0.3 and 0.6 cases per 1000 people (804-1609 current patients) and the Qatar incidence of drug-resistant TLE-HS (2.3-4.3 cases per 100 000 people, per year) with 62 to 116 new patients per year.
Conclusion: Our study suggests that 804 to 1609 current patients (with 62-116 additional patients per year) in Qatar are suffering from drug-resistant TLE-HS; emphasis should be placed on the surgical aspect of the current Qatar Comprehensive Epilepsy Program.
Purpose: The establishment of early diagnostic methods for Parkinson disease (PD) is one of the key features to clinically control the rate of PD progression. This study aimed to give a first step toward recognizing the efficacy of multiple postural indices of balance control in differentiating medicated PD patients from health participants.
Methods: Nine individuals with PD (Hoehn and Yahr Stage up to 2), 9 staged 2.5 and up, and 9 healthy age-matched Controls performed bipedal stances for 120 seconds with eyes either open or closed on a stable force platform. All participants with PD were under anti-Parkinsonian medication. Non-parametric tests investigated the effects of PD and visual input on postural indices extracted from the center of pressure coordinates.
Results: Independent of the stage of the disease, individuals with PD presented faster and shakier body sway compared with Controls. Advanced stages of PD also revealed increased body sway length and variability. In addition, medio-lateral postural instability was more pronounced in all stages of PD when visual inputs were not allowed.
Conclusion and significance: Body sway velocity, jerkiness, length, and its variability revealed to be potential markers for subclinical signs of adjustments in the neuromechanisms of balance control and postural instability even at early stages of disease and under anti-Parkinsonian medication. Results produced here will direct future studies aiming to investigate the efficacy of these same indices on recognizing subclinical development of PD as well as those individuals susceptible to faster rates of progression.
Background: Carbamazepine and valproate are widely used in the treatment of epileptic seizures. However, these agents exhibit certain adverse effects including hematopoietic disorders (carbamazepine) and severe hepatotoxicity (valproate).
Purpose: To determine the extent of monitoring of the hematologic effects of carbamazepine as well as the extent of monitoring of the hepatic effects of valproate in patients with epilepsy receiving treatment with these agents.
Method: A cross-sectional antiepileptic drug use study using case notes of patients with epilepsy managed at the neurologic clinics of 2 tertiary medical facilities in Nigeria between January and December 2017.
Results: Carbamazepine was the most frequently prescribed antiepileptic drug (48.24%), followed by valproate (29.34%) and levetiracetam (9.24%). Pretreatment monitoring of hematologic effect was carried out in only 61.11% of patients placed on carbamazepine therapy while follow-up monitoring was done in 3.7% of these patients. Also, in patients placed on valproate therapy, pretreatment and follow-up monitoring of the hepatic effect was done in only 33.71% and 19.0% of the patients, respectively.
Conclusions: The extent of monitoring of the hematologic effects of carbamazepine, as well as the hepatic effects of valproate in the cohort studied, is poor.
Background: Health-related quality of life (HRQOL) is an important measure that enables evaluation of rehabilitation outcomes. Stroke and Aphasia Quality of Life Generic Scale-39 (SAQOL-39g) is a disease-specific questionnaire that measures HRQOL of patients with stroke. This study was conducted to adapt the preliminary version of proxy-rated Sinhala version of the SAQOL-39g.
Methods: The study was conducted with the participation of 115 proxies of the patients with stroke. The SAQOL-39g was translated and back translated, and culturally adapted by evaluating the items of the questionnaire. The culturally adapted scale was evaluated for its internal consistency, test-retest reliability, and validity.
Results: The mean age of the patients with stroke was 67.07 (standard deviation [SD] = 11.2) years; males comprising two-thirds of the study sample (67% [n = 77]). The proxy-rated Sinhala version of the SAQOL-39g showed excellent internal consistency (α = 0.98 [overall score]), 0.97, 0.96, and 0.95 for physical, communication, and psychosocial domains, respectively. The intraclass correlation coefficient (ICC) was 0.92 for overall, and 0.93, 0.92, and 0.91 for physical, communication, and psychosocial domains, respectively. Factor analysis extracted 3 factors with 72.4% of the variance.
Conclusions: Proxy-rated Sinhala version of the SAQOL-39g is a psychometrically sound, reliable, and valid tool to assess the post-stroke quality of life of Sinhala-speaking patients with stroke and aphasia.
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