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Lyme disease is a tick-borne infectious disease caused by Borrelia burgdorferi which causes a multi-organ involvement. It is endemic in North America and Europe, but not very commonly seen in India. Neurological manifestations (Lyme’s Neuroborreliosis,) can occur in both the early and late disseminated stages, and the classic triad consists of aseptic meningitis, painful radiculoneuritis, and cranial neuropathy. If untreated, it can be fatal and may lead to significant morbidity. We report a case with neuroborreliosis who developed acute onset and rapidly progressive bilateral vision loss, and we also report characteristic features on neuroimaging, including a characteristic “rounded M sign.” This unusual presentation, along with the characteristic imaging features, should be borne in mind to avoid misdiagnosis.

Eight-and-a-half syndrome is a rare entity characterised by conjugate horizontal gaze palsy, ipsilateral internuclear ophthalmoplegia and ipsilateral lower motor neuron type facial palsy. It is due to a lesion affecting median longitudinal fasciculus, paramedian pontine reticular formation and facial nerve fascicle on the same side at the level of pons. The diagnosis is easily missed as it needs detailed ocular movement examination. It is mainly caused due to infarction or demyelinating conditions. We are reporting an interesting case of a 54-year-old man with right-side eight-and-a-half syndrome due to acute ischaemic stroke and ST-elevation myocardial infarction of the inferior wall.

Background As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected. Aims The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019. Methods The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points. Results A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods. Conclusions Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe.

Lithium is a popular drug in the field of psychiatry, used widely as a mood stabilizer in bipolar affective disorder. However, it has a narrow therapeutic index, between 0.6 and 1.5 mEq/L. Toxicity can occur at levels >1.5 mEq/L, hence thus monitoring of serum drug level is vital. Furthermore, the range of Lithium's therapeutic index can be further lower in the elderly, especially in the presence of renal disease, as the drug metabolism in this age group has considerable variation from an average adult. Following is a case report to exemplify Lithium Intoxication and of its narrow therapeutic index; and to develop further understanding on and the clinical implications of the age related changes that affect the pharmacokinetics and pharmacodynamics of the drug.