Background: COVID-19 related strokes (CORS) are increasingly being diagnosed across the world. The knowledge about the clinical profile, imaging findings and outcomes are still evolving. Here we describe the characteristics of a cohort of 62 CORS patients from 13 hospitals, from Bangalore city, south India. Objective: To describe the clinical profile, neuroimaging findings, interventions and outcomes in CORS patients Methods: Multicenter retrospective study of all CORS patients from 13 hospitals from south India from 1st June 2020 to 31st August 2020.Demographic, clinical, laboratory and neuroimaging data were collected along with treatment administered and outcomes. SARS-CoV-2 infection was confirmed in all cases by RT- PCR testing. The data obtained from the case records were entered in SPSS 25 for statistical analysis. Results: During the 3-month period we had 62 CORS patients, across 13 centers. 60 (97%) had ischemic strokes while 2 (3%) had hemorrhagic strokes. The mean age of patients was 55.66 ±13.20 years, with 34 (77.4%) males. 26 % (16/62) of patients did not have any conventional risk factors for stroke. Diabetes Mellitus was seen in 54.8%, hypertension was present in 61.3%, coronary artery disease in 8% and atrial fibrillation in 4.8%. Base line NIHSS score was 12.7 ±6.44. Stroke severity was moderate (NIHSS 5-15) in 27 (61.3%) patients, moderate to severe (NIHSS 16-20) in 13 (20.9%) patients and severe (NIHSS 21-42) in 11(17.7%) patients. According to TOAST classification for ischemic strokes, 48.3% was stroke of undetermined etiology, 36.6% had large artery atherosclerosis, 10% had small vessel occlusion and 5% had cardioembolic strokes. 3 (5%) received intravenous thrombolysis with tenecteplase 0.2 mg/Kg and 3 (5%) underwent mechanical thrombectomy two endovascular and one surgical. Duration of hospital stay was 16.16± 6.39 days. 16% (13/62) died in hospital, while 37 (59.7%) had a mRS of 3-5 at discharge. Hypertension, atrial fibrillation and higher baseline NIHSS scores were associated with increased mortality. A comparison to 111 historical controls during the non COVID period showed a higher proportion of strokes of undetermined etiology, higher mortality and higher morbidity in CORS patients. Conclusion:CORS are increasing being recognized in developing countries like India. Stroke of undetermined etiology appears to be the most common TOAST subtype of CORS. CORS were more severe in nature and resulted in higher mortality and morbidity. Hypertension, atrial fibrillation and higher baseline NIHSS scores were associated with increased mortality.

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Neuro radiological findings in Dengue encephalitis are non specific. Here we report a case of Dengue encephalitis with transient splenial hyperintensity appearing as dot sign on magnetic resonance imaging of brain.

Objectives: The prevalence and characteristics of COVID-19-related headaches are not known in Indian patients. We aim to determine the prevalence and characteristics of headache in COVID-19-infected individuals and make a comparison with those without headaches. Methods: This prospective cross-sectional observational study was conducted from 1 October to 31 October 2020. Data were collected using a detailed questionnaire. We compared the data of those with and without headaches to identify the differences between the groups. Results: During the study period of 1 month, among 225 COVID-19-infected patients, 33.8% patients had headaches. The mean age of patients with headache was 48.89 ± 15.19 years. In all, 53.9% were females. In 65.8%, headache occurred at the onset of viral illness; 44.7% described the headache as dull aching; 39.5% had bifrontal headache; and 32.9% had holocranial headache. In total, 78.9% had complete resolution of headache within 5 days. A comparison between those with and without headaches showed that those with headaches were more younger (48.89 ± 15.19 vs 54.61 ± 14.57 years, p = 0.007) and of female gender (41/76(53.9%) vs 41/149 (27.5%), p = 0.001). Primary headache disorders were more common in the headache group. Levels of inflammatory markers such as leukocyte count (7234.17 ± 3054.96 vs 8773.35 ± 5103.65, p = 0.017), erythrocyte sedimentation rate (39.28 ± 23.29 vs 50.41 ± 27.61, p = 0.02) and ferritin (381.06 ± 485.2 vs 657.10 ± 863.80, p = 0.014) were lower in those with headaches. Conclusions: Headaches are a common and early symptom of acute SARS-CoV-2 infection more frequently seen in young females and in those with a history of primary headache disorders. The lower level of inflammatory markers in those with headaches suggests that these headaches are probably due to the local spread of virus through the trigeminal nerve endings, resulting in activation of the trigeminovascular system.

Background:Acute management of ischemic stroke involves thrombolysis within 4.5 h. For a successful outcome, early recognition of stroke, transportation to the hospital emergency department immediately after stroke, timely imaging, proper diagnosis, and thrombolysis within 4.5 h is of paramount importance.Aim:To analyze the obstacles for thrombolysis in acute stroke patients.Materials and Methods:The study was conducted in a tertiary care center in South India. A total of hundred consecutive patients of acute ischemic stroke who were not thrombolysed, but otherwise fulfilled the criteria for thrombolysis were evaluated prospectively for various factors that prevented thrombolysis. The constraints to thrombolysis were categorized into: i) Failure of patient to recognize stroke symptoms, ii) patient's awareness of thrombolysis as a treatment modality for stroke, iii) failure of patient's relative to recognize stroke, iv) failure of primary care physician to recognize stroke, v) transport delays, vi) lack of neuroimaging and thrombolysis facility, and vii) nonaffordability.Results:The biggest hurdle for early hospital presentation is failure of patients to recognize stroke (73%), followed by lack of neuroimaging facility (58%), nonaffordability (56%), failure of patient's relative to recognize stroke (38%), failure of the primary care physician to recognize stroke (21%), and transport problems (13%). Awareness of thrombolysis as a treatment modality for stroke was seen only in 2%.Conclusion:Considering the urgency of therapeutic measures in acute stroke, there is necessity and room for improvement to overcome various hurdles that prevent thrombolysis.

Background SUNCT like syndrome secondary to post herpes zoster infection has not been reported in literature. Case We are reporting two cases of SUNCT like syndrome secondary to post herpes zoster infection of the V1 distribution of the trigeminal nerve. Treatment with pregabalin and lamotrigine achieved complete symptomatic relief in both patients. Conclusion SUNCT like syndrome can occur after herpetic infection of the trigeminal nerve. Unlike primary SUNCT syndrome, post-herpetic SUNCT like syndrome seems to respond well to pharmacological treatment and has a good prognosis.

Sir, Transient signal alteration in the splenium of corpus callosum on magnetic resonance imaging (MRI) has been reported in a variety of neurologic and non-neurologic conditions. [1] We report a case of rickettsial encephalitis with transient splenial hyperintensity (TSH) in the splenium of corpus callosum, appearing like a boomerang on MRI.A 17-year-old male had high-grade fever for five days. On day 5 of fever, he developed maculopapular pruritic rashes all over the body including palms and soles. Later he developed frontal headache, nausea and vomiting followed by altered sensorium. There was mild enlargement of liver and spleen. Neurological examination revealed a drowsy patient with neck stiffness and left oculomotor palsy. Cerebrospinal fluid showed ten lymphocytes and elevated proteins with normal sugars. Blood tests for malaria, dengue and leptospirosis were negative. Weil-Felix reaction showed rising titers for Ox-K antigen. MRI brain diffusion weighted image (DWI) showed lesions with restricted diffusion in the splenium and genu of the corpus callosum [ Figure 1]. On apparent diffusion coefficient (ADC) mapping, these lesions had low apparent diffusion coefficient [ Figure 2]. Magnetic resonance imaging-fluid-attenuated inversion recovery/ T2w (MRI FLAIR/T2w) imaging showed hyperintense lesions in the splenium of corpus callosum [ Figure 3]. However, the hyperintensity was less prominent in these sequences when compared to DWI and ADC images. The lesion was hypointense on T1w image [ Figure 4] and did not show any enhancement on contrast administration [ Figure 5]. The splenial lesion mimicked Figure 1: MRI diffusion weighted imaging showing splenial hyperintensity (boomerang sign-long black arrow) and hyperintensity in the genu of corpus callosum (short black arrow) a boomerang. Patient improved completely with doxycycline and a short course of steroids.The TSH has been reported in a variety of conditions, including infections, demyelination, ischemia and metabolic abnormalities [ Table 1]. Infectious etiology for TSH can be viral, bacterial, spirochetal or mycobacterial. [2] Rickettsial encephalitis as a cause of TSH has not been reported in literature. TSH can be seen in two distinct patterns, either as a well-circumscribed, small, oval lesion in the midline within the substance of the corpus callosum or as a more extensive ill-defined irregular lesion extending throughout the splenium and into the adjacent hemispheres. In our patient, MRI Brain showed involvement of both anterior and posterior regions of corpus callosum. Posterior (Splenial) lesion mimicked a boomerang.Corpus callosum is the largest commissural pathway consisting of a cross-sectional area representing twice the magnitude of the sum of all the other commissural structures in the brain of an adult. It consists of myelinated axons that cross the midline in the developing brain in order to connect homologous regions of the two hemispheres.

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