Small retrospective studies have shown the benefit of endovascular treatment with intrasinus thrombolysis (IST) or mechanical thrombectomy (MT) with/without IST (MT+/−IST) in cases of multifocal cerebral venous thrombosis (CVT). Our study compares the mortality, functional outcome and periprocedural complications among patients treated with MT +/– IST versus IST alone. We reviewed clinical and angiographic findings of 63 patients with CVT who received endovascular treatment at three tertiary care centers. Primary outcome variables were discharge mortality and neurological dysfunction, and intermediate (three months) and long-term (>six months) morbidity. The modified Rankin scale (mRS) was used to assess morbidity. mRS ≤1 was considered a good recovery. Neurological dysfunction was rated as neuroscore: 0, normal; 1, mild (ambulatory, communicative); 2, moderate (non-ambulatory, communicative); and 3, severe (non-ambulatory, non-communicative/comatose). In patients who received IST alone, presenting neurological deficits were comparatively minor (p<0.001). When the two groups were adjusted for admission neuroscore, there was no statistical significance between discharge mortality [7(21%) versus 4(14%), p=0.228], neurological dysfunction (p=0.442), intermediate (p=0.336) and long-term morbidity (p=0.988). Patients who received MT +/- IST had a higher percentage of periprocedural complications without reaching statistical significance. Compared to IST, MT was performed in severe cases with extensive sinus involvement. When adjusted for admission neurological dysfunction, both groups had similar mortality and discharge neurological dysfunction and similar intermediate and long-term morbidity.

Temporal lobe abnormalities on brain imaging have been described as strong evidence for herpes simplex encephalitis (HSE) in appropriate clinical settings. Extra temporal abnormalities are less well described in these patients. We retrospectively reviewed 20 patients of HSE and found extra temporal involvement in 11 (55%) patients. Three patients (15 %) had pure extra temporal abnormalities. Twelve patients (60%) had temporal lobe involvement, four patients (20%) had pure temporal lobe involvement and five patients (25%) had normal CT/MRI scans. Our study suggests that extra temporal involvement on brain imaging is common in HSE and in a significant minority of the patients this can even be the sole abnormality.

We describe retrospective data from the largest series of patients (n=142) with multiple sclerosis (MS) from Pakistan. Mean age at onset was 27 years, with a female to male ratio of 1.45:1. The disease onset was polysymptomatic in 75% patients. Motor weakness was the most common onset symptom (70%), followed by sensory symptoms (45%). Optico-spinal type of MS was seen in only 3% of patients The course was relapsing-remitting (RR) in 81%, primary progressive (PP) in 21%, and secondary progressive (SP) in 4% of patients. Almost three-fourths of the patients were moderately (45%) or severely (31%) disabled at the time of evaluation. Two-thirds of patients with severe disability had a mean disease duration of only 5.2 years. In conclusion, MS is not uncommon in Pakistan, and many patients were found to have severe disability despite short disease duration.

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Introduction: Adenovirus-based COVID-19 vaccines are extensively used in low- and middle-income countries (LMICs). In India alone, 1.67 billion ChAdOx1 nCoV-19 vaccines have been administered by August 23, 2022. Surprisingly however, there are only few reports of cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) from LMICs. We aimed to gain insight into the frequency, manifestations, treatment, and outcomes of CVST-VITT in LMICs. Methods: We report data from an international registry on CVST after COVID-19 vaccination. VITT was classified according to the Pavord criteria. We compared characteristics of CVST-VITT cases from LMICs to cases from high-income countries (HICs). Results: By August 15, 2022, 228 CVST cases after vaccination were reported, of which 63 cases from LMICs (all middle-income countries [MICs]: Brazil, China, India, Iran, Mexico, Pakistan, and Turkiye). Of these, 32/63 (51%) met the criteria for definite, probable or possible VITT. Only 5/32 (16%) CVST-VITT cases from MICs had definite VITT, mostly because anti-PF4 antibodies were not tested in 21/32 (66%) cases. Patients from MICs were diagnosed in a later time period than patients from HICs (1/32 [3%] vs 65/103 [63%] cases diagnosed before May 2021, respectively). Median age was 26 (IQR 20-37) vs 47 (IQR 32-58) years, and proportion of women was 25/32 (78%) vs 77/103 (75%) in MICs vs HICs, respectively. Clinical manifestations, such as focal neurologic deficits, coma, seizures, and intracranial hemorrhages, were similar. Concomitant venous thromboembolism was less frequent in MICs (3/31 [10%] vs 26/97 [27%]). Median platelet count nadir was higher in the MICs than the HICs group (65 x10 9 /L [IQR 36-115] vs 33 x10 9 /L [IQR 18-55], p =0.001). Intravenous immunoglobulin use was similar (19/30 [63%] vs 63/99 [64%]). In-hospital mortality was lower in the MICs than the HICs group (7/32 [22%, 95%CI 11-39] vs 44/102 [43%, 95%CI 34-53], p =0.031). Conclusions: The absolute number of CVST-VITT cases reported from LMICs was small despite the widespread use of adenoviral vaccines in these countries. Clinical manifestations and treatment of CVST-VITT cases were largely similar in MICs and HICs, while mortality was lower in patients from MICs.