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Diffuse midline glioma is a WHO grade IV tumor of the central nervous system (CNS). The most common sites from which diffuse midline glioma arises are the spinal cord, brain stem, thalamus, and rarely cerebellum. This is a highly aggressive and rare tumor of CNS, more common in the pediatric population. MRI brain lesions are T1-weighted (T1W) image hypointense and T2-weighted (T2W) image hyperintense and may show subtle contrast enhancement, with a more exophytic component and adjacent structure infiltration. Here, we report a case of 30 years old male who presented with symptoms of headache since 15 days, associated with one episode of transient blurring of vision and imbalance while walking. On examination, bilateral early papilledema and subtle bilateral cerebellar signs were present. MRI brain study showed multiple rounds to oval lesions in the corpus callosum, left thalamus, left periventricular region, vermis, and right cerebellar hemisphere, with low apparent diffusion coefficient and diffusion restriction and no blooming on gradient echo sequences images. Initially, no postcontrast enhancement was seen. Later on, the patient’s condition deteriorated despite intravenous steroids and anti-epileptics. On repeat, MRI contrast showed subtle contrast enhancement with an increase in the size of lesions. Stereotactic biopsy from the corpus callosum lesion was done. Histopathology showed diffuse midline glioma WHO grade IV tumor. Even after receiving chemotherapy and radiotherapy, patient succumbed within 4 months of diagnosis. This is a case of adult-onset diffuse midline glioma with a very atypical lesion on the MRI brain as compared to prior studies where the midline structure is more commonly involved.

A 17-year-old girl was admitted to a private hospital with history of being bitten by snake. She had signs of neurotoxic envenomation in the form of breathing difficulty, chest pain, drooping of both eyelids, and difficulty in swallowing. Report of coagulation parameters was not available. She was treated with anti-snake venom and ventilataory support. She made uneventful recovery after a week and was extubated. There was no history of hypotension/hypertension before or after intubation. Following extubation she developed difficulty in vision which improved over next 2 days. On 9th day after snake bite she was noted to have abnormal movements of all four limbs and tongue tremors so she was transferred to our hospital for further management. On arrival to our hospital she was found to have generalized chorea and tongue tremors. There was no other neurological deficit. Initial MRI brain revealed diffusion restrction in both parieto-occipital regions involving white matter. MRI of spinal cord was normal. Repeat MRI brain after one week showed T2 and FLAIR hyperintesities in both caudate and lentiform nuclei in addition. Cerebrospinal fluid (CSF) examination was normal. On the basis of MRI she was diagnosed as a case of PRES (posterior reversible encephalopathy syndrome) and treated with tetrabenazine. She gradually improved and was discharged. Only few cases of PRES following snake bite have been reported and no case of only movement disorder as manifestation of PRES has been reported.

Antisynthetase syndrome is characterized by autoantibodies against one of many aminoacyl transfer RNA synthetases. The clinical features include interstitial lung disease (ILD), non-erosive arthritis, Raynaud’s phenomenon, myositis, unexplained fever, and/or mechanic’s hands. There is higher incidence of ILD compared to polymyositis or dermatomyositis. Antisynthetase syndrome associated with Pl-7 and Pl-12 antibodies is rare and accounts for less than 10% of all cases. We present a case of 63-year-old lady who presented with only polymyositis without any ILD or other features of antisynthetase syndrome and was positive for anti Pl-7 and anti Pl-12 antibodies.

Spinal cord involvement in COVID-19 infections can be varied and may present as acute transverse myelitis, acute necrotizing myelitis, neuromyelitis optica spectrum disorder, Myelin oligodendrocyte-associated glycoprotein (MOG) antibody myelitis, and SARS-CoV-2 myelitis. We retrospectively analyzed eight cases of COVID-19-associated myelitis. All patients had only mild antecedent symptoms of COVID-19 infection and were admitted with clinical features of acute transverse myelitis confirmed on neuroimaging. Seven patients had longitudinally extensive transverse myelitis (LETM). Serum Aquaporin-4 antibodies (NMO), cerebrospinal fluid (CSF) oligoclonal bands, and RT PCR for COVID-19 were negative. Serum MOG antibodies were positive in three patients; out of this two had CSF pleocytosis. All patients were treated with steroids followed by plasmapheresis. Five cases showed good improvement (increase in power by grade 2 or more), while three cases that were MOG positive had poor outcomes with either minimal or no improvement. The severity of COVID-19 infection was not related to the development of myelitis. Seven cases had LETM. Response to therapy was not uniform and the presence of MOG antibodies and CSF pleocytosis was associated with poor outcomes.

Idiopathic hypertrophic pachymeningitis (IHP) is a rare inflammatory disease characterized by inflammation and hypertrophy of the dura mater. Spinal form of IHP is extremely rare. We report an idiopathic hypertrophic spinal pachymeningitis case, a 67-year-old female who presented with neck and upper back pain with progressive paraparesis and sensory level. Her magnetic resonance imaging cervico-dorsal spine showed abnormal epidural hypointensity on T2-weighted images from C5 to T4 with significant cord compression and intramedullary cord signal changes at T2 and T3 levels. The lesional biopsy was done suggestive of chronic inflammatory changes. She was treated with steroids and was able to walk unaided.

We are reporting a case of 28-year-old young lady who presented with sensory stroke. Magnetic resonance imaging (MRI) of brain showed bilateral watershed infarcts in middle and anterior cerebral territories. Brain angiography showed stenosis of supraclinoid portion of both internal carotid arteries (ICAs) without any moyamoya vessels (collaterals). Contrast MRI of brain showed enhancement of vessel wall in supraclinoid portion of both ICAs suggestive of inflammation. She was a known case of hyperthyroidism on irregular treatment. Work up for vasculitis was negative. Temporal artery biopsy was normal. She was diagnosed as a case of moyamoya syndrome associated with Graves' disease. She showed good response to immunosuppressants, aspirin, and treatment of hyperthyroidism. She had no ischemic events for 6 months but was later lost to follow-up. After 1 year she again presented with two episodes of transient ischemic attacks. Repeat imaging showed reduction in the wall thickening and enhancement and no new infarcts.

Introduction: Posterior Reversible Encephalopathy syndrome (PRES) is an emergency medical condition with varied etiology, presentation and outcome reported in literature. The objective of this study was to determine the clinical and radiological presentations, and clinical outcomes in cases of PRES admitted over the last one year at a tertiary care hospital. Materials and Methods: We retrospectively analysed all cases diagnosed with PRES from May 2019 to May 2020. We reviewed clinical presentations, etiological history, imaging characteristics, management and clinical outcomes. Results: Five patients diagnosed with PRES were identified. All patients were females, with age range between 16 to 32 years. Etiological factors were eclampsia (2/5), drug (tacrolimus), massive blood transfusion and chronic kidney disease with hypertension. Headache was the most common clinical presentation. Other clinical presentations were visual symptoms, seizures, altered sensorium, vertigo and vomiting. The most common imaging characteristic was supratentorial T2/FLAIR white matter hyperintensity on MRI, predominantly in parieto-occipital region. Other areas of white matter involvement were cerebellum and brainstem. One patient had hemorrhage complicating PRES. All patients were primarily managed by elimination and treatment of the precipitating factors, along with standard anti-oedema measures and anti-epileptic drugs. There was complete recovery in all patients within one week. Conclusion: PRES has variable clinical and radiological presentation. Early diagnosis and elimination of precipitating factors are vital for complete recovery.

Charles Bonnet Syndrome (CBS) or visual release hallucinations are a type of psychophysical visual disturbance and the experience of complex visual hallucinations (VHs) in a person with partial or severe blindness. We present a case of 73-year-old blind male, who lost his vision due to glaucoma, presented with a history of complex VHs. The investigations for alternative pathological causes of VHs were negative and therefore, the etiology of hallucinations was attributed to CBS. Excellent response to low-dose olanzapine was seen, with complete remission by the end of 5th week after starting olanzapine.

Aim and Objective: Motor-evoked responses using transcranial magnetic stimulation (TMS) have been studied in India in various diseases. However, no normative data are available for young healthy Indian adults. The aim was to generate normative data for young healthy Indian adults in our laboratory so that it can be used as normative data for comparison in various disorders. Materials and Methods: Motor-evoked responses using TMS in 15 young healthy Indian adults (mean age 32.8 years, mean height 166 cm) was studied using circular flat coil capable of delivering 1.5 tesla magnetic energy. Various parameters such as cortical threshold (CT), cortical latency (CL), central conduction time (CCT), root latency (RL), and amplitude of motor-evoked potentials (MEP) were studied. Results: The mean CT was 830 standard deviation (SD) 45 mv (55%) for abductor pollicis brevis (APB), 930 SD 65 mv (62%) for biceps brachii, and 1260 SD 52 mv (84%) for extensor digitorum brevis (EDB). The mean CL was 21.2 SD 1.14 ms for APB, 11.5 SD 0.1 ms for biceps, and 37.6 SD 0.75 ms for EDB. The mean RL was 14.7 SD 0.96 ms in APB, 6.12 SD 0.78 ms in biceps, and 21.33 SD 1.30 ms in EDB. The mean CCT was 6.53 SD 1.02 ms in APB, 5.6 SD 1.1 ms in biceps, and 16.7 SD 0.92 ms in EDB. The mean MEP amplitude was 4.20 SD 2.14 mv in APB, 3.21 SD 1.37 mv in biceps, and 1.10 SD 0.38 mv in EDB. The mean normal value of MEP/MAP ratio for APB was 0.29 SD 0.09, for EDB 0.12 SD 0.03. Conclusion: Various studies have been done using TMS to study motor-evoked responses. However, there has been a slight difference in values among them due to the type of coil used, energy delivered, and interobserver difference. Every electrophysiology laboratory should have its own value to act as a baseline for comparison with that in disorders of nervous system. No data for normal values in Indian population is available.

Isolated epileptic nystagmus is defined as a quick, repetitive jerky movement of the eyeball associated with seizure activity on electroencephalography. However, there are no clinical seizures apart from nystagmus. We report a case of 56-year-old male, not a known case of diabetes or hypertension, nonsmoker, who presented with frequent episodes of dizziness along with difficulty in reading in that the lines in newspapers were moving side to side. He was conscious during episodes. He was found to have episodes of gaze deviation to the left with left beating nystagmus lasting for about 30 s. Routine hematological and biochemical parameters were normal. Electroencephalogram showed right parieto-temporo-occipital epileptogenic activity. Magnetic resonance imaging (MRI) brain showed diffusion restriction in the right temporo-occipital region suggestive of small ischemic infarct. Repeat MRI after 1 month was normal. He responded to levetiracetam.