Publications by authors named "Paramjeet Singh"

166 Publications

MRI in normal myelination: A pictorial review.

Curr Pediatr Rev 2021 Sep 24. Epub 2021 Sep 24.

Department of Radiodiagnosis and Imaging, PGIMER Chandigarh, India.

This article's primary goal is to provide an image-based review to paediatricians to gain insight into the typical appearance of myelin evolution. We briefly discuss the structure and development of myelination, the role of qualitative and quantitative MRI in myelin imaging, and provide an image-based review as a quick reference for understanding the pattern of myelination on MR imaging.
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http://dx.doi.org/10.2174/1573396317666210924115822DOI Listing
September 2021

Adolescent with Progressive Ptosis: Is there any Clue?

Neurol India 2021 Jul-Aug;69(4):1107-1108

Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.4103/0028-3886.325315DOI Listing
September 2021

Noncontiguous Radiation-Induced Brain Necrosis (RIBN) in a Patient with Aggressive Pituitary Adenoma and the Utility of Bevacizumab.

Neurol India 2021 Jul-Aug;69(4):1055-1057

Department of Neurosurgery, Graduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.4103/0028-3886.325385DOI Listing
September 2021

Cerebral Phaeohyphomycosis: Subacute Meningoencephalitic Presentation in a Child.

Neurol India 2021 Jul-Aug;69(4):1027-1031

Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Cerebral phaeohyphomycosis is a rare but serious fungal infection of the central nervous system caused by dematiaceous septate fungi characterized by the presence of melanin-like pigment within the cell wall that is a pale brown to black. It is associated with poor prognosis despite aggressive treatment. We report a previously well 3-year boy with cerebral phaeohyphomycosis who had subacute meningoencephalitic presentation with refractory raised intracranial pressure and had fatal outcomes. The diagnosis was confirmed by histopathological examination of brain tissue obtained by brain biopsy.
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http://dx.doi.org/10.4103/0028-3886.323890DOI Listing
September 2021

Role of age at onset in the clinical presentation of bipolar disorder in Indian population.

Ind Psychiatry J 2021 Jan-Jun;30(1):41-46. Epub 2021 Jun 17.

Department of Community Medicine, Dr. S.N. Medical College, Jodhpur, Rajasthan, India.

Objective: The objective of this study was to determine any association of age at onset (AAO) with clinical presentation of bipolar disorder (BD) and family history of illness.

Materials And Methods: A hospital-based cross-sectional observational study was conducted including 162 patients having a diagnosis of BD current episode manic. Individuals were divided into three subgroups according to AAO, i.e., early-onset BD (EOBD) (AAO ≤21 years), intermediate-onset BD (AAO - 22-34 years), and late-onset BD (AAO ≥35 years). The subgroups were compared on clinical variables; items of the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAM-D), and Scale for the Assessment of Positive Symptoms (SAPS); and family history of illness.

Results: The early-onset group had significantly more episodes per year than the other groups ( < 0.001). The prevalence of family history of mood disorder was also significantly higher in the early-onset group than the other subgroups. AAO was found to be significantly associated with different items of YMRS, HAM-D, and SAPS. The early-onset group had higher rating on irritability, motor activity-energy, sexual interest, depressed mood, delusions, and thought disorders, whereas the late-onset group had higher rating on elevated mood.

Conclusion: EOBD can be considered as a specific phenotype of BD, which is more homogenous, severe, and inheritable form of illness.
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http://dx.doi.org/10.4103/ipj.ipj_8_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8395538PMC
June 2021

Acute neurological complications during acute lymphoblastic leukemia therapy: A single-center experience over 10 years.

Indian J Cancer 2021 May 11. Epub 2021 May 11.

Pediatric Hematology Oncology unit, Department of Pediatrics, Advanced Pediatric Center, Chandigarh, India.

Background: Acute neurological complications occur in 3.6-11% of children treated for acute lymphoblastic leukemia (ALL). This analysis aimed to evaluate the profile of acute neuro-toxicity and its etiology in children with ALL.

Methods: A retrospective case analysis of central nervous system events in children treated for ALL at our center was performed. Details of events were retrieved from the case records (January 2006-December 2015) and analyzed.

Results: Ninety (9.5%) neurological events occurred in 923 patients treated for ALL. Phase of therapy were: induction (38), consolidation (5), interim maintenance (5), intensification (15) and maintenance (27). Seizures and neurological deficits were the presenting features in 64 and 40 children, respectively. Events included : neuro-infections in 18, posterior reversible encephalopathy syndrome (PRES) in 7, epilepsy in 6, intracranial bleed in 5, systemic infection with neurological complication in 4, hydrocephalus and aseptic meningitis in 3 each, methotrexate encephalopathy and metabolic seizures in 2 children each. Seizures and status epilepticus of unknown etiology and neurological deficits of unknown etiology was observed in 26 and 13 children, respectively. Seizures occurred mainly in induction (12) and intensification phase (9). Status epilepticus transpired in maintenance phase in 9/14 patients. Induction phase was complicated by PRES in 7, intracranial bleed in 5 and cerebral sinus venous thrombosis in 1 patient. Neuroimaging was done in 86% of events. There were 18 (20.6%) deaths: neuro-infections (8), status epilepticus (6), systemic infection (2), bleed (1), and unexplained encephalopathy (demyelination)(1). At last follow-up, 53 patients were well and 7 children persist to have a neurological disability.

Conclusion: Ten percent of children on treatment for ALL suffered an acute neuro-toxicity. Morbidity and high-incidence of neuroinfections are major concerns.
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http://dx.doi.org/10.4103/ijc.IJC_422_19DOI Listing
May 2021

MR vessel wall imaging in cerebral bacterial and fungal infections.

Neuroradiology 2021 Aug 9. Epub 2021 Aug 9.

Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Purpose: Central nervous system (CNS) bacterial and fungal infections can cause secondary vasculitis which worsens the prognosis due to development of complications like infarctions or hemorrhages. In this prospective study, we aim to study intracranial vessel wall imaging findings in bacterial and fungal infections.

Methods: We included 12 cases of nontubercular bacterial and fungal CNS infections each, in whom definitive microbiological diagnosis could be made. High-resolution vessel wall imaging (VWI) and time of flight MR angiography (TOF MRA) were incorporated in the routine imaging protocol. All cases were evaluated for the presence of vascular enhancement, pattern of enhancement, and stenosis on VWI. Statistical analysis was done to evaluate association between findings of vessel wall imaging and infarctions.

Results: We found infarctions in 5 out of 12 cases (41.7%) of the bacterial group and 7 out of 12 cases (58.3%) of the fungal group. Vessel wall enhancement was seen in 5 cases (41.7%) of the bacterial group and 9 cases (75%) of the fungal group. There was a significant association between infarctions and vessel wall enhancement in the fungal group. However, pattern of enhancement or stenosis on VWI was not significantly associated with presence of infarction. VWI detected more cases of vascular involvement than TOF MRA.

Conclusion: Secondary infectious vasculitis in bacterial and fungal infections can be detected by VWI, which can play an important role in better patient management as detection of vascular involvement can prompt early treatment to prevent complications like infarctions or hemorrhages.
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http://dx.doi.org/10.1007/s00234-021-02778-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8349608PMC
August 2021

Assessment of Blood-Brain Barrier Integrity in Tuberculous Meningitis Using Dynamic Contrast-Enhanced MR Perfusion.

Indian J Radiol Imaging 2021 Jan 1;31(1):30-36. Epub 2021 Jun 1.

Department of Pediatric Neurology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Tuberculous meningitis (TBM) is the most common form of central nervous system tuberculosis. The aim of the study was to quantitatively evaluate blood-brain barrier (BBB) perfusion changes in TBM patients using dynamic contrast-enhanced (DCE) MR perfusion. Thirty untreated patients of TBM and 10 healthy controls were prospectively evaluated by conventional imaging and DCE MR perfusion. Mean permeability indices- trans and Ve-were calculated from multiple regions of interest (ROIs) placed in basal cisterns and comparison was done between the patients and controls. The permeability indices were significantly higher (where < 0.001) in cisterns of TBM patients who showed basal meningeal enhancement when compared with healthy controls. Significant differences in permeability were observed between "enhancing" cases and controls as well as in "enhancing" cases when compared with the "non-enhancing" cases. However, no significant difference was observed in the mean cisternal value between "non-enhancing" cases and the controls. trans with a cutoff value of > 0.0838 had 81.6% sensitivity and 78.6% specificity in differentiating cases and controls while e mean value with a cutoff value of 0.0703 showed 86.8% sensitivity and 91.4% specificity in predicting the permeability difference between the cases and controls. DCE MR perfusion is useful in the quantitative measurement of disruption of BBB and perfusion alterations in patients of TBM.
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http://dx.doi.org/10.1055/s-0041-1729119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299480PMC
January 2021

Neuroimaging Spectrum of Severe Hypernatremia in Infants with Neurological Manifestations.

Neuropediatrics 2021 08 30;52(4):316-325. Epub 2021 Jun 30.

Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: Variable neurological manifestations and imaging findings have been described in children with severe hypernatremia. We aimed to describe the spectrum of neuroimaging changes in infants with severe hypernatremia.

Methods: This retrospective study included infants with severe hypernatremia (serum sodium >160 mEq/L), abnormal neurological examination, and an abnormal magnetic resonance imaging (MRI) of the brain over a period of 2 years in a tertiary care hospital. Relevant clinical data, including the feeding practices, clinical features, complications, and biochemical and radiological parameters, were entered in a structured pro forma. MRI findings were classified as vascular (hemorrhages and cerebral sinus venous thrombosis), osmotic demyelination syndrome (pontine and extrapontine myelinolyses), and white matter changes.

Results: The common clinical features in the neonates were poor feeding ( = 4) and decreased urine output ( = 4); the older infants presented with gastrointestinal losses ( = 5). All cases had dehydration with encephalopathy. The patterns of radiological injury were vascular (hemorrhages,  = 5 and venous thrombosis,  = 3), osmotic demyelination ( = 8), and white matter changes ( = 7). Coagulopathy was correlated with the vascular complications ( = 0.8,  < 0.0001); the degree of dehydration was correlated with the venous thrombosis ( = 0.7,  < 0.04) and acute kidney injury ( = 0.8,  < 0.001). Neurological sequelae were seen in four cases and correlated with hypernatremia ( = 0.6,  = 0.03) and hyperosmolarity ( = 0.6,  = 0.03).

Conclusion: Characteristic neuroimaging findings are vascular changes in the form of venous thrombosis and hemorrhages, osmotic demyelination and white matter tract injury, and/or mostly combinations of these findings. Severe hypernatremia and resulting hyperosmolarity frequently cause neurological sequelae in neonates and infants.
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http://dx.doi.org/10.1055/s-0041-1730938DOI Listing
August 2021

Whole brain atlas-based diffusion kurtosis imaging parameters for evaluation of minimal hepatic encephalopathy.

Neuroradiol J 2021 Jun 29:19714009211026924. Epub 2021 Jun 29.

Department of Radiology, University of Miami, USA.

Background And Purposes: Minimal hepatic encephalopathy (MHE) has no recognizable clinical symptoms, but patients have cognitive and psychomotor deficits. Hyperammonemia along with neuroinflammation lead to microstructural changes in cerebral parenchyma. Changes at conventional imaging are detected usually at the overt clinical stage, but microstructural alterations by advanced magnetic resonance imaging techniques can be detected at an early stage.

Materials And Methods: Whole brain diffusion kurtosis imaging (DKI) data acquired at 3T was analyzed to investigate microstructural parenchymal changes in 15 patients with MHE and compared with 15 age- and sex-matched controls. DKI parametric maps, namely kurtosis fractional anisotropy (kFA), mean kurtosis (MK), axial kurtosis (AK) and radial kurtosis (RK), were evaluated at 64 white matter (WM) and gray matter (GM) regions of interest (ROIs) in the whole brain and correlated with the psychometric hepatic encephalopathy score (PHES).

Results: The MHE group showed a decrease in kFA and AK across the whole brain, whereas MK and RK decreased in WM ROIs but increased in several cortical and deep GM ROIs. These alterations were consistent with brain regions involved in cognitive function. Significant moderate to strong correlations (-0.52 to -0.66; 0.56) between RK, MK and kFA kurtosis metrics and PHES were observed.

Conclusion: DKI parameters show extensive microstructural brain abnormalities in MHE with minor correlation between the severity of tissue damage and psychometric scores.
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http://dx.doi.org/10.1177/19714009211026924DOI Listing
June 2021

Long-term epilepsy control, motor function, cognition, sleep and quality of life in children with West syndrome.

Epilepsy Res 2021 Jul 2;173:106629. Epub 2021 Apr 2.

Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India. Electronic address:

Purpose: To assess epilepsy, motor function, cognitive, sleep, and quality of life outcomes and their predictors in a follow-up cohort with West syndrome (WS) at ≥5 years of age.

Methods: Cross-sectional evaluation in a follow-up cohort of WS (aged 5-14 years), between July 2018 and December 2019, was performed at a tertiary-care referral center in Northern India. 164 children were assessed in-person for epilepsy severity, functional status (gross motor and hand function), social quotient, behavioral comorbidities, sleep problems, and quality of life (QoL) using Early Childhood Epilepsy Severity Scale, Gross Motor Function Classification System, Manual Ability Classification System, Vineland Social Maturity Scale, Diagnostic and Statistical Manual of Mental disorders-5 criteria, Children's Sleep Habits Questionnaire, and PedsQL-Epilepsy module respectively. Furthermore, 238 children with the inability to visit the hospital were assessed through telephonic interview along with retrospective case record review for epilepsy control, gross and fine motor measures.

Results: 402 children with WS (75 % boys) with regular follow-up were studied and the majority (80 %) had underlying structural etiology. The median age (interquartile range) of the cohort was 92 (78-107) months. Of these, 60 % had evolved to Lennox-Gastaut syndrome (LGS). The following long-term outcomes were observed: ongoing epilepsy (261/402), unfavorable motor status (130/402), moderate to profound intellectual disability (111/164), autistic spectrum disorder (42/164), attention-deficit hyperactivity disorder (18/164), poor sleep (135/164), and impaired QoL (115/164). Non-structural etiology (odds ratio [OR] = 3.8, 95 % confidence interval [CI]: 2.1-5.5, p=<0·0001) and older age (>5 months) at the onset of epileptic spasms (OR = 2·9, 95 % CI: 1.5-5.0, p=<0·0001) were associated with enduring seizure freedom for more than two years.

Conclusion: The present study revealed a preponderance of structural etiology and a high rate of transition to LGS. Early age at onset of spasms (before five months) and structural etiology were the predictors of unfavorable long-term epilepsy outcome. QoL was impaired in more than two-thirds of patients and it correlated significantly with cognitive, sleep, motor, and behavioral outcomes. However, the results of our study should be interpreted in the context of significant attrition of the original cohort.
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http://dx.doi.org/10.1016/j.eplepsyres.2021.106629DOI Listing
July 2021

Carpal tunnel syndrome or C8/T1 radiculoneuropathy due to perinural cyst: A diagnostic conundrum.

Indian J Radiol Imaging 2020 Oct-Dec;30(4):510-512. Epub 2021 Jan 13.

Department of Radio-Diagnosis and Imaging, PGIMER, Chandigarh, India.

Perineural cysts are usually described in Lumbosacral region and are uncommonly seen in cervical spine. These are mostly asymptomatic, with only a few cases of symptomatic cervical perineural cysts. No previous case report of perineural cyst causing C8/T1 radiculoneuropathy mimicking clinically as Carpal tunnel syndrome is reported in the literature. We report a case of elderly female who was operated for presumed Carpal tunnel syndrome. However, her symptoms did not improve. The MRI of the patient revealed presence of perineural cysts at the level of C8/T1 exiting nerve root, compressing it and causing the symptoms. We present the clinical, nerve conduction study and radiological presentation of cervical perineural cyst mimicking Carpal tunnel syndrome in this patient.
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http://dx.doi.org/10.4103/ijri.IJRI_414_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954159PMC
January 2021

Posterior pituitary tumours: patient outcomes and determinants of disease recurrence or persistence.

Endocr Connect 2021 Apr;10(4):387-400

Department of Endocrinology, Postgraduate Institute of Medical Education and Research, (PGIMER), Chandigarh, India.

Objective: Posterior pituitary tumours (PPTs) are rare neoplasms with the four recognised subtypes unified by thyroid transcription factor -1 (TTF-1) expression, according to the 2017 WHO classification. Though traditionally defined as low-grade neoplasms, a substantial proportion of them show recurrence/persistence following surgery.

Methods: We selected patients with PPTs in our cohort of 1760 patients operated for pituitary tumours over the past 10 years (2010-2019). The clinical, radiological, hormonal, histopathological profiles and long-term outcomes of the three cases identified (two pituicytomas and one spindle cell oncocytoma, SCO) were analysed. Following a literature review, data of all published cases with documented TTF-1 positive pituicytomas and SCOs were analysed to determine the predictors of recurrence/persistence in these tumours.

Results: Patients presented with compressive features or hypogonadism. Two had sellar-suprasellar masses. One had a purely suprasellar mass with a pre-operative radiological suspicion of pituicytoma. Two were operated by transsphenoidal surgery and one transcranially guided by neuronavigation. Histopathology confirmed spindle cells in a storiform arrangement and low Ki67 index. Immunohistochemistry showed positive TTF-1, S-100 expression and variable positivity for EMA, vimentin and GFAP. Re-evaluation showed recurrence/persistence in two patients. A literature review of recurrent/persistent pituicytoma (n = 17) and SCO (n = 9) cases revealed clinical clues (headache for pituicytomas, male gender for SCO), baseline tumour size (≥20.5 mm with sensitivity exceeding 80%) and longer follow-up duration as determinants of recurrence/persistence.

Conclusion: PPTs are rare sellar masses with quintessential TTF-1 positivity. Recurrent/persistent disease following surgery is determined by greater tumour size at baseline and duration of follow-up. This warrants intensive and long-term surveillance in these patients.
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http://dx.doi.org/10.1530/EC-20-0621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142326PMC
April 2021

Cerebral Sinovenous Thrombosis due to Hypernatremic Dehydration in a Neonate.

Neurol India 2021 Jan-Feb;69(1):164-166

Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Cerebral sinus venous thrombosis is an uncommon complication of hypernatremic dehydration in neonates. Non-improvement in neurological status even after correction of hypernatremia should lead to suspicion of intracranial complications due to hypernatremia or its overtreatment. Slow correction of hypernatremia, calculated fluid administration, and anticoagulation improve outcome in neonates with CSVT.
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http://dx.doi.org/10.4103/0028-3886.310090DOI Listing
June 2021

MR vessel wall imaging in tubercular meningitis.

Neuroradiology 2021 Oct 27;63(10):1627-1634. Epub 2021 Feb 27.

Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India.

Purpose: Tubercular meningitis (TBM) has the propensity to cause secondary vasculitis through various mechanisms leading to development of cerebrovascular complications. These vascular involvements can be detected by vessel wall imaging (VWI). In this study, we aimed to study detailed findings of vessel wall imaging in cases of tubercular meningitis.

Methods: All consecutive patients of suspected tubercular meningitis in whom diagnosis of TBM could be made according to diagnostic criteria given by Ahuja et al. were included in the study. High-resolution MR VWI and time of flight (TOF) magnetic resonance angiography (MRA) were done along with routine MRI sequences. Arteries up to second-order branches were studied, and statistical analyses were done with respect to stage of tubercular meningitis, infarctions and TOF MRA findings.

Results: Out of all 101 cases of TBM, infarctions were found in 49 cases (48.5%), and vessel wall enhancement was seen in 67 cases (66.3%). With increasing severity of disease, more severe vascular involvement was seen on VWI. There was significant association between enhancement of individual arteries and infarctions in their territories. VWI had better sensitivity than the MRA, while MRA had better specificity than VWI for detection of vascular complications.

Conclusion: Tubercular vasculitis can be detected by VWI in the form of nodular or smooth segmental enhancement of vessel wall with or without stenosis. Incorporation of VWI in routine MR imaging can play a greater role in early detection and management of cerebrovascular complications which can help to improve prognosis of the disease.
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http://dx.doi.org/10.1007/s00234-021-02678-yDOI Listing
October 2021

MRI Spectrum of Meningoencephalitis in Children.

Ann Indian Acad Neurol 2020 Sep-Oct;23(5):616-620. Epub 2019 Dec 24.

Department of Pediatrics, Medanta, The Medicity, Gurugram, NCR, Haryana, India.

Background And Purpose: type b (Hib) infection occurs mostly in children and is transmitted from person to person through the respiratory pathway. Hib strain is associated with meningitis or encephalitis. It is not an uncommon infection, particularly, in the developing world. This prospective cohort study was done with the aim of describing imaging findings in patients with Hib meningoencephalitis.

Materials And Methods: In a prospective cohort study, consecutive children admitted in the pediatric emergency unit with acute febrile encephalopathy were enrolled. The clinical details, CSF analysis, and microbiological and serological investigations were recorded on a case record proforma. Children with confirmed Hib meningoencephalitis were included in this study. Clinicoradiological features were assessed.

Results: A total of 16 patients with acute febrile encephalopathy, in whom CSF latex agglutination, CSF culture, or CSF multiplex PCR were positive for were included in this study. All these children were investigated with magnetic resonance imaging (MRI) brain. Important imaging findings were meningitis, predominantly around frontoparietal lobes (43%), cerebritis (28%), ventriculitis (14%), and subdural collections (21.5%). One patient had features consistent with acute disseminated encephalomyelitis (ADEM) while four patients had normal MRI scan.

Conclusions: is still a common cause of meningitis in infants and children in the developing world. We have tried to study the most common MRI features associated with Hib infection to help radiologists alert the treating clinicians to further investigate these patients for appropriate prognostication.
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http://dx.doi.org/10.4103/aian.AIAN_500_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887487PMC
December 2019

Comparative Evaluation of Diffusion Kurtosis Imaging and Diffusion Tensor Imaging in Detecting Cerebral Microstructural Changes in Alzheimer Disease.

Acad Radiol 2021 Feb 18. Epub 2021 Feb 18.

Department of Radiology, University of Miami, Miami, Florida.

Objective: Comparative evaluation of diffusion kurtosis imaging (DKI) and diffusion tensor imaging (DTI) using a whole-brain atlas to comprehensively evaluate microstructural changes in the brain of Alzheimer disease (AzD) patients.

Methods: Twenty-seven AzD patients and 25 age-matched controls were included. MRI data was analyzed using a whole-brain atlas with inclusion of 98 region of interests. White matter (WM) microstructural changes were assessed by Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), radial diffusivity (RD), Kurtosis fractional anisotropy (KFA), mean kurtosis (MK), axial kurtosis (AK) and radial kurtosis (RK). Gray matter (GM) integrity was evaluated using KFA, MK, RK, AK and MD. Comparison of the DKI and DTI metrics were done using student t-test (p ≤ 0.001).

Results: In AzD patients widespread increase in MD, AD and RD were found in various WM and GM region of interests. The extent of abnormality for DKI parameters was more limited in both GM and WM regions and revealed reduced kurtosis values except in lentiform nuclei. Both DKI and DTI parameters were sensitive to detect abnormality in WM areas with coherent and complex fiber arrangement. Receiver operating characteristic curve analysis for hippocampal values revealed the highest specificity of 88% for AK <0.6965 and highest sensitivity of 95.2% for MD >1.2659.

Conclusion: AzD patients have microstructural changes in both WM and GM and are well-depicted by both DKI and DTI. The alterations in kurtosis parameters, however, are more limited and correlate with areas in the brain primarily involved in cognition.
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http://dx.doi.org/10.1016/j.acra.2021.01.018DOI Listing
February 2021

Utility of Imaging of Nigrosome-1 on 3T MRI and Its Comparison with 18F-DOPA PET in the Diagnosis of Idiopathic Parkinson Disease and Atypical Parkinsonism.

Mov Disord Clin Pract 2021 Feb 2;8(2):224-230. Epub 2020 Oct 2.

Department of Neurology Post Graduate Institute of Medical Education and Research Chandigarh India.

Background: Loss of nigrosome-1 on 3T and 7T magnetic resonance imaging (MRI) is a recently explored imaging biomarker in the diagnosis of neurodegenerative parkinsonism.

Objectives: This study was undertaken to evaluate the utility of imaging of nigrosome in the diagnosis of neurodegenerative parkinsonism on 3T MRI.

Methods: An institution-based prospective case-control study was conducted at a tertiary care center in North India. 3T venous blood oxygen level-dependent (VenoBOLD) and high-resolution susceptibility-weighted imaging (SWI) imaging sequences in MRI were performed in 100 patients with parkinsonism (56 with idiopathic Parkinson's disease [IPD], 30 with young onset Parkinson's disease [YOPD], 12 with progressive supranuclear palsy, and 2 patients with multiple system atrophy) and 15 controls. Grading of nigrosome was done in both the sequences. Each patient underwent 18F-DOPA positron emission tomography (PET), detailed neurological examination including Hoen and Yahr (H&Y) staging and Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) scoring.

Results: The diagnostic sensitivity and specificity of the detection of loss of nigrosome-1 on VenoBOLD and SWI sequence at 3T MR imaging were 90% and 66.7% and 94% and 80%, respectively. A weak negative correlation was found between the grading of the nigrosome and clinical parameters (H&Y and UPDRS III). There was no correlation between the side of nigrosome loss and clinical asymmetry. However, nigrosome imaging was not able to differentiate between Parkinson's disease and atypical parkinsonism.

Conclusions: The loss of nigrosome-1 on 3T MRI on SWI and VenoBOLD sequences may serve as a potential imaging marker in the diagnosis of degenerative parkinsonian syndromes. However, it cannot differentiate between idiopathic Parkinson's disease and atypical parkinsonian syndromes.
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http://dx.doi.org/10.1002/mdc3.13091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853191PMC
February 2021

Role of Plasma Exchange in a Steroid- and IVIG-Refractory Patient with Acute Disseminated Encephalomyelitis: A Case Report.

Transfus Med Hemother 2020 Oct 20;47(5):420-423. Epub 2020 Feb 20.

Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Background: Acute disseminated encephalomyelitis (ADEM) is a demyelinating disease usually affecting children and is treated with high-dose steroid therapy.

Case Report: An 8-year boy presented with limbs weakness and complete loss of vision and was resistant to steroid therapy. He was further treated with plasma exchange and showed full recovery from the neurological deficit.

Conclusion: Therapeutic plasma exchange appears to be effective in ADEM patients in reversing the neuropathological process especially refractory to steroids and intravenous immunoglobulin.
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http://dx.doi.org/10.1159/000504987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588735PMC
October 2020

Pattern Recognition Approach to Brain MRI Findings in Patients with Dengue Fever with Neurological Complications.

Neurol India 2020 Sep-Oct;68(5):1038-1047

Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Background And Purpose: Dengue can present with variable neurological complications including encephalitis, encephalopathy, acute disseminated encephalomyelitis (ADEM), and ischemic and hemorrhagic stroke. Our study describes a pattern-based approach to recognize different brain MRI findings in dengue-seropositive patients with neurological symptoms.

Materials And Methods: Thirty-six serologically proven dengue patients with neurological symptoms and undergoing brain MRI over a 6-month period were included in this study. The diagnosis of dengue encephalopathy or encephalitis was established by presence of signs/symptoms of acute encephalitic syndrome with the presence of Immunoglobin M (IgM) antibody against dengue antibody in the serum and/or presence of dengue antigen (NS1) in serum. The MRI brain along with diffusion weighted imaging and susceptibility weighted imaging sequences were evaluated by an experienced neuroradiologist.

Results: Eleven patients had normal MRI finding. In the rest 25 patients, 12 were found to have encephalitic pattern, 4 had encephalopathic (seizure related/metabolic) pattern, 3 had features of ADEM, and isolated micro- or macro-hemorrhages were found in 6 patients. In the encephalitis group, eight had concomitant involvement of brainstem, cerebellum, and ganglio-thalamic complexes with additional involvement of cortex and subcortical white matter (WM) found in three. Isolated brainstem and cerebellar involvement were seen in three in this group, whereas one had isolated cerebellar involvement. Interspersed hemorrhage was noted in the structures involved in eight patients in encephalitis group.

Conclusion: Radiologists should be aware of various MRI brain findings in dengue and a pattern recognition approach often helps in reaching the correct diagnosis albeit after exclusion of other differentials based on laboratory studies.
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http://dx.doi.org/10.4103/0028-3886.294556DOI Listing
May 2021

Non-invasive assessment of cerebral microvascular changes for predicting postoperative cerebral hyperperfusion after surgical revascularisation for moyamoya disease: an arterial spin labelling MRI study.

Neuroradiology 2021 Apr 24;63(4):563-572. Epub 2020 Oct 24.

Department of Neurosurgery, Post Graduate institute of Medical Education and Research, Chandigarh, India.

Purpose: Cerebral hyperperfusion syndrome (CHPS) can result after anastomotic surgery as the reperfusion is established in chronically ischemic cerebral territories in patients of moyamoya disease (MMD). In this study, we have evaluated the feasibility of arterial spin labelling (ASL) perfusion MRI to predict cerebral hyperperfusion syndrome based on changes of cerebral blood flow (CBF) after revascularisation surgery in patients of MMD.

Methods: Our prospective study included 25 patients with MMD who underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass with or without dural/muscle synangiosis. ASL MRI was performed before and 1-7 days after surgery. On the side planned for operation, 5-mm ROI circle was drawn on the predetermined regions in frontal lobe, temporal lobe, parietal lobe and basal ganglia in proximal and distal territories of MCA to calculate ipsilateral CBF values (CBFi). An attempt was made to select the same location on contralateral side (non-operative) (CBFc) for each measurement for calculation of hemispheric normalised CBF (nCBFh) ratios. To adjust for inter individual variation among MR imagers and CBF, additional regions of interest were drawn within the cerebellum (CBFcbl) for cerebellar CBF normalised ratios (nCBFCbl).

Results: Of the 25 patients (26 operated hemispheres), 5 patients showed significant immediate postoperative symptoms suggestive of CHPS. Based on our findings, sensitivity and specificity of ASL perfusion to detect CHPS were evaluated. ASL was found to have 47-100% sensitivity and 45-88% specificity to detect CHPS. We have tried to calculate the prevalence of CHPS in postoperative patients of moyamoya disease, which in our study ranged from 6.83 to 40.70%.

Conclusion: Based on our results, we concluded that ASL perfusion is an appropriate alternative to standard nuclear medicine studies to monitor the changes in perfusion after STA-MCA bypass surgery in moyamoya patients. ASL MR perfusion can be used to identify changes in cerebral blood flow (CBF) for early detection of cerebral hyperperfusion syndrome in patients with otherwise normal conventional MRI sequences with very high sensitivity but moderate specificity.
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http://dx.doi.org/10.1007/s00234-020-02583-wDOI Listing
April 2021

Clinico-radiological Profile of Children with Pontocerebellar Hypoplasia.

J Pediatr Neurosci 2020 Apr-Jun;15(2):94-98. Epub 2020 Jun 27.

Department of Pediatrics, Medanta - The Medicity, Gurugram, Haryana, India.

Aims And Objectives: Pontocerebellar hypoplasia (PCH) constitutes a heterogeneous group of neurodegenerative/neurodevelopmental disorder of pons and cerebellum with onset in prenatal period. This study aimed to discuss the clinical, radiological profile, and outcome of four infants with PCH attending our center.

Materials And Methods: Data of children with psychomotor retardation seen between January 2015 and December 2015 at neurodevelopmental clinic was retrieved. PCH was defined by clinical and radiological criteria. Clinical features included were delay in attainment of milestones in more than two developmental domains accompanied by severe microcephaly. Radiological evidence of cerebellar volume loss with hypoplasia of pons was included. Patient charts were reviewed for clinical features, neuroimaging, electroencephalography, and biochemical investigations including serum and cerebrospinal lactate. Molecular genetic testing for the common p.A307S mutation in of the cases and their parents were also analyzed.

Results: During this period, 101 children with psychomotor retardation were evaluated at our center. Of the 101, four children were with clinical and radiological evidence of PCH. In addition to psychomotor retardation and severe microcephaly, spasticity, bipyramidal signs, and epileptic spasms were universal in all four children. Three of the four children had optic atrophy and two had sensorineural hearing loss. Severe cerebellar hypoplasia with attenuated pons was seen in all four children. Two children had dragonfly appearance of cerebellum on coronal section. The commonest p.A307S mutation in children and their parents was not detected.

Conclusion: A heightened index of suspicion for PCH is merited in infants with progressive psychomotor retardation and severe microcephaly. Cerebellar hypoplasia with pontine attenuation forms the mainstay of diagnosis of PCH.
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http://dx.doi.org/10.4103/jpn.JPN_6_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7519739PMC
June 2020

Newer magnetic resonance imaging techniques in neurocysticercosis.

Neuroradiol J 2020 Dec 26;33(6):538-544. Epub 2020 Aug 26.

Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, India.

Introduction: The definitive diagnosis of neurocysticercosis continues to be challenging. We evaluate the role of newer magnetic resonance imaging techniques including constructive interference in steady state, susceptibility-weighted imaging, arterial spin labelling and magnetic resonance spectroscopy in the diagnosis of neurocysticercosis.

Aims And Objectives: To study the utility of newer magnetic resonance imaging sequences in the diagnosis of neurocysticercosis.

Patients And Methods: Eighty-five consecutive patients with neurocysticercosis attending a tertiary care hospital and teaching centre in northern India were included in the study. The diagnosis of neurocysticercosis was made by the Del Brutto criteria. All patients received treatment according to standard guidelines and were followed at 3-month intervals. The following magnetic resonance sequences were performed at baseline: T1 and T2-weighted axial sequences; T2 fluid-attenuated inversion recovery axial sequences; diffusion-weighted imaging; susceptibility-weighted imaging; pre and post-contrast T1-weighted imaging; heavily T2-weighted thin sections (constructive interference in steady state); arterial spin labelling ( = 19); and magnetic resonance spectroscopy ( = 24).

Results: The mean (±SD) age was 29.4 ± 12.9 years and 76.5% were men. Seizures were the commonest symptom (89.4%) followed by headache (24.3%), encephalitis (9.4%) and raised intracranial pressure (9.4%). Scolex could be visualised in 43.7%, 55.5% and 61.2% of neurocysticercosis patients using conventional, susceptibility-weighted angiography and constructive interference in steady state imaging sequences, respectively. Susceptibility-weighted angiography and constructive interference in steady state images resulted in significantly higher ( < 0.01) visualisation of scolex compared to conventional sequences.

Conclusion: Newer magnetic resonance imaging modalities have a lot of promise for improving the radiological diagnosis of neurocysticercosis.
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http://dx.doi.org/10.1177/1971400920949394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7788671PMC
December 2020

Progressive quadriparesis and inflammation: A common disease, a rare presentation.

Indian J Tuberc 2020 Jul 19;67(3):336-339. Epub 2019 Jun 19.

Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.

A previously healthy, 10-years-old girl presented with progressively worsening pain and weakness of the limbs for the past 2 weeks. It initially started with low-grade fever lasting for 4 days followed by severe pain over bilateral lower and upper limbs. Gradually she became bed-ridden. On examination, she had severe neck rigidity, generalized tenderness all over the body, generalized hyperalgesia, hyporeflexia, bilateral extensor plantar response and toe-walking. An initial clinical diagnosis of Landry-Guillain Barry syndrome was considered. Nerve conduction study showed generalized, demyelinating polyneuropathy. She was administered IVIG and was evaluated for other causes of arachnoiditis. MRI brain and spine showed enhancement and clumping of nerve roots in the conus and cauda equina. CECT chest showed necrotic mediastinal lymphnodes. A final diagnosis of disseminated tuberculosis with tuberculous arachnoiditis was considered and she was administered ATT, pulse methylprednisolone followed by maintenance oral corticosteroids. Currently, after 5 months of therapy, she has recovered clinically.
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http://dx.doi.org/10.1016/j.ijtb.2019.06.001DOI Listing
July 2020

Unusually dislodged tracheostomy tube with intact airway.

BMJ Case Rep 2020 Jul 16;13(7). Epub 2020 Jul 16.

Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.1136/bcr-2020-237195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368489PMC
July 2020

[Tc]-Bis-Methionine-DTPA Single-Photon Emission Computed Tomography Impacting Glioma Management: A Sensitive Indicator for Postsurgical/Chemoradiotherapy Response Assessment.

Cancer Biother Radiopharm 2021 Sep 9;36(7):568-578. Epub 2020 Jul 9.

Division of Cyclotron and Radiopharmaceutical Sciences, Institute of Nuclear Medicine and Allied Science, DRDO, New Delhi, India.

The present study evaluated the prognostic value of [Tc]MDM (bis-methionine-DTPA) follow-up single-photon emission computed tomography (SPECT) imaging for response assessment to chemoradiotherapy in glioma postoperatively. One hundred fourteen glioma patients (80 M:34 F) were followed postoperatively by sequential [Tc]MDM SPECT, dynamic susceptibility contrast-enhanced (DSCE)-MRI, and magnetic resonance spectroscopy (MRS) at baseline, 6, 12, and 22.5 months postchemoradiotherapy. The quantitative imaging results and the clinical outcome were used for response assessment and for the final diagnosis. The quantitative parameter of [Tc]MDM SPECT were also used for survival analysis. A significantly ( = 0.001) lower target to nontarget (T/NT) ratio was observed in responders than in nonresponders. The sensitivity and specificity of [Tc]MDM-SPECT for identifying tumor recurrence from radiation necrosis at a cutoff ratio of 1.90 were estimated at 97.9% and 92%. Whereas, the sensitivity and specificity of DSCE-MRI with the normalized cerebral blood volume (nCBV) cutoff of 3.32 for this differentiation was found to be 84.6% and 93.0%. MRS intensity ratios of Cho/NAA and Cho/Cr provided comparatively lower sensitivity of 81.0% and 85.3% and specificity of 73.0% and 73.7%. T/NT ratios correlated with nCBV ( = 0.775,  < 0.001) and to a moderate extent with Cho/NAA ratios ( = 0.467,  = 0.001). [Tc]MDM SPECT and DSCE-MRI provided comparable results for predicting response assessment to chemoradiotherapy. There was a final diagnosis in 72 patients, of which 47 cases were tumor recurrence and 25 were radiation necrosis. The Kaplan-Meier analysis indicated that patients with T/NT ratio <1.9 showed prolonged survival (53.8 months) as compared (37.2 months) with those who demonstrated T/NT ratio >1.9 ( = 0.0001). Thus, this low-cost SPECT technique in combination with DSCE-MRI can be used accurately for mapping the disease activity, response assessment, and survival in glioma. [Tc]MDM SPECT and DSCE-MRI had the same diagnostic efficacy to detect recurrent/residual tumor and radiation necrosis while MRS was inferior to both the techniques.
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http://dx.doi.org/10.1089/cbr.2020.3696DOI Listing
September 2021

Enigma of Rabies: Prolonged Survival in a Boy with Rabies Brachial Plexitis and Encephalomyelitis.

Neurol India 2020 May-Jun;68(3):673-676

Department of Pediatrics, PGIMER, Chandigarh, India.

Rabies encephalitis is a universally fatal disease. Prolonged survival in children with rabies encephalitis has only been anecdotally reported. Case report: An 11-year-old boy presented with right-handed paraesthesia followed by flaccid weakness, progressive quadriparesis and encephalopathy following an unprovoked, class III dog bite over the right wrist 1 month previously. He received five doses of the rabies vaccine as post exposure prophylaxis. Diagnosis of rabies encephalitis was supported by typical MRI brain and spine findings in addition to marked elevation of anti-rabies neutralizing antibody titers in serum and CSF. He was treated with supportive care, methylprednisolone, dexamethasone and simvastatin and was discharged after 6 weeks of hospital stay in a minimally conscious state, with tracheostomy and naso-gastric feeding tubes. At 9 months follow-up, his neurological status showed minimal improvement. Paralytic rabies with brachial plexitis and encephalomyelitis is an atypical presentation of rabies. Very few surviving cases have been reported from India. Survival from rabies is possible with effective clearing of virus with post exposure prophylaxis, but with severe neurological sequelae.
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http://dx.doi.org/10.4103/0028-3886.288993DOI Listing
June 2021

Role of DMARD Naïve Period in the Development of Severe Rheumatoid Arthritis.

Indian J Orthop 2020 Jul 10;54(4):513-517. Epub 2020 Mar 10.

Department of Medicine, Government Medical College, Haldwani, Uttarakhand 263139 India.

Background: Rheumatoid arthritis (RA) is a symmetric poly-arthritis predominantly affecting the small synovial joints, although any synovial joint can be involved. The underlying cause is not known; however, predilection for the disease is impacted by genetic and environmental factors. Several factors predict disease severity in RA including development of erosions, female sex and duration of disease. This study evaluates the role of disease duration, early initiation of disease modifying anti-rheumatic drugs (DMARDs) and auto-antibodies like rheumatoid factor in predicting erosive disease in Indian patients with rheumatoid arthritis.

Methods: A 2-year hospital-based cross-sectional observational study was conducted in the Department of Medicine in a tertiary care centre in Kumaon region of Uttarakhand in northern India. 260 patients diagnosed with RA on the basis of 2010 ACR/EULAR criteria were included.

Results: A total of 135 patients had erosive disease, with DMARD naive median period of 3 years compared to 125 patients with non-erosive disease, with DMARD naive median period of 2 years. On the basis of this data and after evaluation for radiographic erosions, it was found that a longer DMARD naive period predicts higher odds of developing erosive disease.

Conclusion: Early diagnosis of rheumatoid arthritis and initiation of DMARDs is crucial in increasing quality of life and preventing severe disease with deformities, erosive changes and extra-articular manifestations.
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http://dx.doi.org/10.1007/s43465-020-00077-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270310PMC
July 2020

Black Holes in the Brain and Spine: A Dark Disease.

J Pediatr Neurosci 2020 Jan-Mar;15(1):63-64. Epub 2020 Mar 18.

Pediatric Neurology Unit, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

A 7-year-old girl presented with difficulty in walking and bilateral vision impairment since past 15 days. On examination, she had disc pallor, flaccid paraparesis with positive Babinski sign, and reduced sensations below clavicle. She was diagnosed as anti-aquaporin-4 (AQP-4)-positive neuromyelitis optica. This article emphasizes the importance of recognizing its classical neuroimaging findings distinct from other disorders.
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http://dx.doi.org/10.4103/JPN.JPN_110_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227761PMC
March 2020

Neurological Manifestations of Influenza A (H1N1): Clinical Features, Intensive Care Needs, and Outcome.

Indian J Pediatr 2020 Oct 2;87(10):803-809. Epub 2020 May 2.

Department of Pediatrics, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.

Objectives: To describe neurological manifestations in children with Influenza A (H1N1).

Methods: This retrospective study was conducted in the Pediatric intensive care unit (PICU) and Pediatric Neurology unit of a tertiary care teaching hospital in North India involving children with PCR confirmed Influenza A (H1N1) with neurological manifestations during 2019 outbreak.

Results: Six children (5 females, 1 male) were enrolled. All presented with neurological symptoms (seizures and altered sensorium) accompanied with fever and respiratory symptoms with duration of illness of 2-7 d. The admission Glasgow Coma Scale ranged from 4 to 12. Only 2 cases showed cerebrospinal fluid pleocytosis. Neuroimaging was suggestive of diffuse cerebral edema, acute necrotizing encephalopathy of childhood, and acute disseminated encephalomyelitis. All were treated with Oseltamivir. Four cases had clinical features of raised intracranial pressure (ICP) and were managed in PICU, 3 of them needed mechanical ventilation, 3 needed vasoactive drugs, 3 received 3% saline infusion, 1 underwent invasive ICP monitoring, and 3 (cases 4, 5 and 6) received intravenous methylprednisolone (30 mg/kg) for 5 d. Total duration of hospital stay was 10-30 d. Case 2 expired due to refractory raised ICP. Among survivors, 3 children had residual neurological deficits and the remaining 2 had achieved premorbid condition.

Conclusions: Influenza A (H1N1) can present with isolated or predominant neurological manifestations which can contribute to poor outcome. The authors suggest to rule out H1N1 in any child who presents with unexplained neurological manifestations during seasonal outbreaks of H1N1.
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http://dx.doi.org/10.1007/s12098-020-03297-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222163PMC
October 2020
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