AKSONA

Lambert-Eaton Myasthenic Syndrome: A Review of Rare Neuromuscular Disease Related to Paraneoplastic and Autoimmune

Ichlasul Mahdi Fardhani, Cindy Graciella, Muhammad Isra Rafidin Rayyan — Wed, 29 Jan 2025 00:00:00 +0700

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LEMS is a rare neurological disease with fluctuating symptoms
Delays and misdiagnosis of LEMS disease often occur
The two main pathophysiologies of LEMS are autoimmune and paraneoplastic.

ABSTRACT

A rare condition known as Lambert-Eaton myasthenic syndrome (LEMS) affects the neuromuscular junctions, which are the connections between muscles and nerves. Tumor-associated or autoimmune causes trigger this condition. This mechanism depends on the presence of antibodies that directly attach to voltage-gated calcium channels located on the presynaptic nerve terminals. LEMS disease is divided into non-paraneoplastic or non-tumor LEMS (NT-LEMS) and paraneoplastic LEMS (P-LEMS). NT-LEMS is believed to be caused by an autoimmune process. On the other hand, P-LEMS has an underlying tumor, and LEMS symptoms are paraneoplastic manifestations of the tumor. Clinical signs of LEMS include proximal muscle weakness, autonomic dysfunction, and decreased deep tendon reflexes. The predominant sign of LEMS is weakness of the lower extremities. The defining characteristic of LEMS is a weakness that spreads from caudal to cranial, causing oculobulbar manifestations, and from proximal to distal, potentially involving the feet and hands. The diagnosis of LEMS depends on clinical, electromyographic, and serological findings of anti-VGCC antibodies. Therefore, comprehensive oncologic screening and monitoring should promptly follow a diagnosis of LEMS. The standard approach to treating LEMS symptoms is administering drugs that improve neurotransmission, such as potassium channel blockers and amifampridine. In refractory cases, immunosuppressants or immunomodulator agents, such as a combination of prednisone and azathioprine, are used. If a tumor is detected, oncological therapy should be a priority.

Neuroimaging and Intravenous Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke beyond 4.5 Hours: A Systematic Review

Wed, 29 Jan 2025 00:00:00 +0700

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Ischemic stroke is a major cause of disability and death globally, emphasizing the urgent need for timely and effective thrombolytic interventions within a narrow treatment window.
Neuroimaging has the potential to extend the therapeutic window for IV rt-PA beyond 4.5 hours, allowing clinicians to identify patients with salvageable brain tissue for treatment.
Extending the IV rt-PA treatment window with neuroimaging support can significantly improve outcomes in stroke patients, although careful risk assessment is crucial.

ABSTRACT

Introduction: Current guidelines suggest giving intravenous recombinant tissue plasminogen activator (rt-PA) within 4.5 hours after acute ischemic stroke onset or the time the patient was last-seen-well. Patients often arrive at the hospital after 4.5 hours, making thrombolysis treatment challenging. It is crucial to examine expanding this timeframe beyond 4.5 hours of onset or last-seen-well. Objective: This systematic review intended to examine the effectiveness and safety of IV rt-PA in patients presenting to the hospital beyond 4.5 hours of onset or last-seen-well. Methods: We searched PubMed, Scopus, and ScienceDirect for studies on acute ischemic stroke patients treated with IV rt-PA alteplase beyond 4.5 hours of onset or last-seen-well. Outcomes comprised the Modified Rankin Scale (mRS) score, intracranial hemorrhage (ICH), symptomatic ICH, and mortality. We assessed the risk of bias using Cochrane Risk of Bias Vol 2 and ROBINS-I. Results: Eleven randomized controlled trials and observational studies were selected. Most subjects were above 65 years, and their baseline mean or median NIHSS scores were 6–12. Seven studies had specific neuroimaging criteria for eligibility, such as DWI/FLAIR or T2WI mismatch, PWI/DWI mismatch, or CT/MR perfusion. In RCTs, alteplase group had 47.1% to 53.3% favourable results (mRS 0-1) compared to 41.3% to 48.3% in placebo/controls group and 23% to 85% in observational studies. Compared to the placebp/control group and onset within 4.5 hours, alteplase typically had better ourcomes. However, ICH, symptomatic ICH, and mortality were numerically higher, albeit not statistically significant. Conclusion: IV rt-PA alteplase can be given for up to 9-12 hours from onset or last-seen-well with neuroimaging evidence of salvageable tissue, such as the perfusion imaging RAPID criteria or DWI/FLAIR or T2WI mismatch, taking consideration of hemorrhage and mortality concerns.

Successful Management of Bilateral Subdural Hematoma: Combining Bilateral Middle Meningeal Arteries Embolization and Unilateral Burr Hole Craniostomy—A Case Report

Gameliel Wibowo Soetanto, Pieter Melchias Jacob Lilikwatil, Fritz Sumantri Usman — Wed, 29 Jan 2025 00:00:00 +0700

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The approach to bilateral SDH management was still tailor-made, especially in the elderly, due to the benefit of reducing intracranial pressure and the risk of increased complications and recurrent bleeding.
In cases of bilateral SDH, middle meningeal artery (MMA) embolization before surgery may increase the favorable outcome and lower the risk of SDH rebleeding.

ABSTRACT

Introduction: Subdural hematoma (SDH) is frequently seen in the elderly population. Although anticoagulant use and traumatic brain injury are recognized risk factors, the exact cause of subdural hematomas in certain cases remains unknown. Furthermore, unilateral or bilateral hemispheres may be involved in SDH, which can occur acutely or gradually. The old age group’s SDH profile, which includes several comorbidities, may complacte surgery, the gold standard for treatment. Embolization of the middle meningeal artery (MMA) may be a treatment option because it is safer and has a higher success rate in terms of improvement compared to complications. It can be done as either a standalone procedure or an adjuvant to surgery. Case: An elderly male patient experienced acute left-sided weakness that worsened over three days. Imaging revealed bilateral SDH, with symptomatic chronic SDH on the right side, asymptomatic acute SDH on the left side, and midline shift. Bilateral MMA embolization was done, followed by burr hole craniostomy, which resulted in clinical and radiological improvement throughout a three-month post-intervention period. Conclusion:MMA embolization can improve clinical outcomes and prevent recurrent bleeding, which makes it a potential treatment option for severe symptomatic SDH, especially in patients with comorbidities.

Fungal Meningoencephalitis Masquerading as Metabolic Encephalopathy: A Case Report in a 65-Year-Old Geriatric Patient

Nita Kurniawati, Ferdinand Erwin — Wed, 29 Jan 2025 00:00:00 +0700

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A geriatric patient may present with subtle or nonspecific symptoms of meningoencephalitis, such as confusion, altered mental status, or lethargy, rather than classic signs like fever and neck stiffness.
Negative CSF cultures of fungal infection should not delay the initiation of antifungal therapy.

ABSTRACT

Introduction: Infectious pathogens or autoimmune disorders can cause meningoencephalitis. Symptoms include headache, fever, altered mental status, seizure, or neurological deficits. Symptoms frequently manifest atypically in the elderly, which can result in delayed treatment. This case emphasizes how important it is to consider meningoencephalitis in elderly patients with altered consciousness, even without typical signs of it. Case: A 65-year-old female with a history of recurrent hyponatremia and hypokalemia arrived at the emergency room with sudden loss of consciousness, vomiting, and behavioral changes that persisted for a week. The neurological examination and brain CT scan revealed no abnormalities. Severe electrolyte imbalances prompted the initial diagnosis of metabolic encephalopathy. Following progressive electrolyte correction, the patient’s mental condition improved. On the second day, she had generalized seizures and developed right-sided hemiparesis. An MRI of the head with contrast showed thicker dura mater and leptomeningeal enhancement in both hemispheres, indicating meningoencephalitis. Ceftriaxone and dexamethasone were administered intravenously, along with levetiracetam, to treat seizures. The next day, cerebrospinal fluid analysis showed Candida spores, but cultures were negative. Intravenous fluconazole was then added to the therapy. Throughout her two-week stay, the patient’s neurological condition improved consistently. Conclusion:Fungal causes should be considered in cases with unclear meningoencephalitis in the elderly, even if fever or meningeal signs are not present. Although CSF culture continues to be the gold standard for diagnosing fungal CNS infection, negative results should not delay the start of antifungal therapy. Early initiation of targeted antimicrobial therapy is crucial for successful results in these cases.

Hemifacial Spasm Due to Contralateral Supratentorial Tumor: A Case Report

Priya Nugraha, Nazla Ananda Rachmi Puti, Muhammad Hamdan — Wed, 29 Jan 2025 00:00:00 +0700

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A rare case of hemifacial spasm due to contralateral supratentorial tumor.
Improvement of hemifacial spasm after tumor removal treatment.
A comprehensive patient examination can establish the correct diagnosis and treatment.

ABSTRACT

Introduction: A rare neurological disorder known as hemifacial spasm (HFS) is characterized by involuntary, unilateral facial muscle contractions, typically caused by facial nerve irritation. In this report, we looked at a rare and fascinating case of hemifacial spasm (HFS) caused by a large contralateral supratentorial meningioma. The HFS went away amazingly after the tumor was removed and the patient was treated with corticosteroids. The complex connection between neurological disorders and intracranial tumors is highlighted in this case, along with potential treatment approaches for the patient. Cases: A 48-year-old woman complained of uncontrolled movements and spasms in her right eyelid and right lip corner for the past two years. The symptoms were accompanied by headaches, cognitive impairment, and a history of syncope. A neurological examination revealed right-sided central facial palsy. An MRI revealed a large atypical meningioma in the left frontal lobe. This resulted in significant brain displacement and perifocal edema, but no neurovascular contact with the 7th cranial nerve. Her hemifacial spasms significantly decreased following surgical resection, even with medication reduction. Conclusion:As an uncommon manifestation of contralateral supratentorial tumors, HFS requires careful evaluation of the patient’s history, physical examination, and radiological findings, as well as consideration of a wide range of potential causes. Accurate diagnosis and effective management can help reduce the risk of poor prognosis.

Pain Type and Quality of Life in Cervicogenic Headache Patients

Devi Ariani Sudibyo, M Reza Fathoni, Nazla Ananda Rachmi Puti — Wed, 29 Jan 2025 00:00:00 +0700

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Cervicogenic headache is the most incapacitating type, leading to significant physical impairment.
Based on the data, there were 15 subjects in the nociceptive pain group and 15 subjects in the neuropathic pain group.
There was a statistically significant correlation between the type of pain and the mental quality of life. In patients with cervicogenic headaches and neuropathic pain, there was a stronger relationship than those with nociceptive pain.

ABSTRACT

Introduction: Cervicogenic headache is classified as a secondary headache under the International Classification of Headache Disorders, third edition (ICHD-3). Significant neuropathic and nociceptive pain components are believed to be present in this condition, which eventually lowers quality of life by causing problems like anxiety, depression, and sleep disruptions. Objective: This study aimed to correlate pain types with quality of life in those suffering from cervicogenic headaches. Methods: A cross-sectional observational study was conducted at the Neurology Outpatient Clinic of Dr. Soetomo General Academic Hospital in Surabaya from June to August 2020. Quality of life and pain types were evaluated using the painDETECT and SF-36 questionnaires. A painDETECT score of 12 or less indicated nociceptive pain, but a score of more than 12 indicated neuropathic pain. An SF-36 score below 50 indicated a poor quality of life. Conclusion:Patients with cervicogenic headaches and neuropathic pain exhibited a lower quality of life compared to those experiencing nociceptive pain. These findings emphasize the importance of evaluating pain types to support the maintenance of a good quality of life.

Epidemiological Study of Stroke Disease in the Southeast Maluku Islands Region in 2023

Wed, 29 Jan 2025 00:00:00 +0700

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The prevalence of stroke in Southeast Maluku is 14.1 per 1,000 population for 2023.
Ischemic stroke is the most common type of stroke in the Southeast Maluku Islands.
The most prevalent chronic disease among stroke patients in Southeast Maluku Islands is hypertension.

ABSTRACT

Introduction: Stroke is a serious health problem with a high mortality rate and incidence, especially in low- and middle-income regions like Southeast Maluku, Indonesia. Inadequate facilities and risk factors causing high stroke rates in this region provide major healthcare challenges. Epidemiological data highlight the pressing need for healthcare development. Objective: This epidemiological study aimed to provide insight on the prevalence of stroke in the Southeast Maluku Islands in 2023, with the goal of enhancing the urgency of measures to reduce stroke incidences there. Methods: This study used a descriptive methodology with a cross-sectional design. Data were collected by obtaining thorough medical records from stroke patients at Karel Sadsuitubun Regional General Hospital. Demographic information, stroke type, and comorbidities were analyzed, as well as the prevalence rate calculated from the entire patient population of 8,436 as reported in 2023, while also classifying patients by age and gender. Results: In the Southeast Maluku Islands, 107 stroke cases were reported, equal to a stroke prevalence rate of 12.6 per 1,000 people. The most common type was ischemic stroke (95.33%), followed by hemorrhagic stroke (4.67%). Hypertension, which affected 67.2% of patients, was the most common comorbidity, followed by type II diabetes mellitus and coronary artery disease. Conclusion:Stroke rates have increased in the Southeast Maluku Islands due to a variety of factors, including socioeconomic conditions and unhealthy lifestyles. The study’s findings emphasize the urgent need for interventions to reduce stroke rates.

Epidemiologic Profile of Ischemic Stroke Patients with Dyslipidemia in Dr. Soetomo General Academic Hospital Patient

Wed, 29 Jan 2025 00:00:00 +0700

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This study provides insights into the epidemiologic profile of ischemic stroke patients with dyslipidemia in Dr. Soetomo General Academic Hospital.
The majority of patients had hypertension, the most common comorbidity with low HDL-C levels
Most patients showed moderate stroke severity and high levels of consciousness, with a majority proportion demonstrating recovery.

ABSTRACT

Introduction: Ischemic stroke is a major medical issue, especially in individuals with dyslipidemia, as it can elevate both the likelihood and severity of stroke incidents. This study is essential due to the rising prevalence of stroke and limited data regarding ischemic stroke patients with dyslipidemia in Indonesia. Understanding these traits is important for enhancing preventative and treatment strategies. Objective: This study intended to assess the epidemiologic profile of ischemic stroke patients with dyslipidemia in a tertiary hospital in Indonesia. Methods: This descriptive study assessed 116 medical records of ischemic stroke patients with dyslipidemia admitted to Dr. Soetomo General Academic Hospital in Surabaya, Indonesia, from January to June 2023. The collected data encompassed demographics, comorbidities, lipid profiles, and clinical outcomes. Dyslipidemia was defined based on the PERKENI guidelines, and stroke severity was assessed using the GCS and NIHSS scales. Results: The majority of ischemic stroke patients with dyslipidemia (77.6%) had low HDL-C levels. There were 64 males and 52 females; most of them were between the ages of 56 and 65. Hypertension was the most common comorbidity (64.7%), followed by diabetes (39.7%), heart disease (12.9%), and obesity (11.2%). Of 40 NIHSS-assessed patients, 26 had moderate, 8 mild, 2 moderate-to-severe, and 4 severe strokes. The majority of patients (70.7%) recovered. Conclusion:The majority of dyslipidemia-related ischemic stroke patients, aged 56 to 65, had low HDL-C levels. Hypertension was the main comorbidity, with many experiencing their first stroke. Most patients had high consciousness, moderate stroke severity, and showed improvements.