Reversible cerebral vasoconstriction syndrome (RCVS) is a cerebrovascular disorder associated with multifocal arterial constriction and dilation. RCVS is associated with nonaneurysmal subarachnoid hemorrhage, pregnancy and exposure to certain drugs. The primary clinical manifestation is recurrent sudden-onset and severe (‘thunderclap’) headaches over 1–3 weeks, often accompanied by nausea, vomiting, photophobia, confusion and blurred vision. The primary diagnostic dilemma is distinguishing RCVS from primary CNS arteritis. Diagnosis requires demonstration of the characteristic ‘string of beads’ on cerebral angiography with resolution within 1–3 months, although many patients will initially have normal vascular imaging. Many treatments have been reported to ameliorate the headaches of RCVS, but it is unclear whether they prevent hemorrhagic or ischemic complications.

Objective Prophylactic antiseizure drugs (PAD) are commonly prescribed for nontraumatic intracerebral hemorrhage (ICH) despite limited evidence for this indication. We sought to determine the current prescribing patterns of the use of a PAD for ICH. Methods A 36-item survey was distributed to physicians that manage ICH patients soliciting details of PAD prescription in their practice. Results A total of 199 physicians responded to the survey, all of who manage between one and 50 or more ICH patients per year. The respondents were neurologists (32%), neurosurgeons (11%), and intensivists (57%) in academia (69%) and private practice (31%). PAD prescriptions were used: never (33%), 1–33% (35%), 34–66% (14%), 67–99% (9%) of the time, or always (9%). Most respondents performed electroencephalographic and serum level monitoring in at least some patients. Levetiracetam was used most often (60%), followed by fos/phenytoin (37%), for a usual duration of days (36%), weeks (47%), or months (17%). PAD prescription varied by patient characteristics and physician specialty. Perception of physician community consensus regarding PAD use for ICH among respondents ranged from strongly (7%) or weakly (23%) against the practice, to a fairly equal division of opinion (41%), to weakly (27%) or strongly (4%) in favor of the practice. Conclusions We found variability of multiple aspects of the current prescribing patterns and opinions regarding the use of a PAD for ICH. This variability is likely secondary to insufficient data. Clinical equipoise exists for this issue, and controlled trials would be both justified and useful.

Objective:Association between Intellectual disability (ID) and psychiatric disorders in children & adolescents is well established but there is a paucity of published studies from Pakistan on this topic. The main aim of the study was to assess the frequency of ICD-10 psychiatric diagnosis in the hospital outpatient sample of children with ID in Lahore, Pakistan as well as to find out which challenging behaviors, caregivers find difficult to manage in this setup.Methods:Socio-demographic information was collected, Wechsler Intelligence Scale for Children-Revised & ICD-10 diagnostic criteria was used to assess children (age range 6 – 16 years) with suspected ID along with identification of behaviors found to be difficult to manage by caregivers.Results:150 children were assessed with mean age of 10.7 years (males 70 %). Majority (72%) had mild ID while 18.7% and 9.3% had moderate and severe ID respectively. Thirty percent of children met the criteria for any psychiatric diagnosis, the most common being Oppositional Defiant Disorder (14%) and Hyperkinetic Disorders (10%). Verbal and physical aggression, school difficulties, socialization problems, inappropriate behaviors (e.g. disinhibition), sleep & feeding difficulties were the significant areas identified by the caregivers as a cause of major concern.Conclusions:Significantly high prevalence of ICD-10 psychiatric diagnosis in children with ID was found in Lahore, Pakistan. Support services for these children should be responsive not only to the needs of the child, but also to the needs of the family.

Background The anterior communicating (ACom) artery is the most common location of cerebral aneurysms harbouring upto 30–37% of all treated aneurysms. Amongst all ruptured aneurysms, the proportion of patients with very small aneurysms ranges from 12–18%. Treatment of very small aneurysms (<3 mm) of the anterior communicating artery presents a unique set of challenges for both surgical as well as endovascular techniques. Objective To report the immediate and long-term clinical as well as radiographic outcomes of consecutive patients with ruptured very small anterior communicating artery (ACOM) aneurysms treated with endovascular technique. Methods A prospectively maintained single institution neuro-endovascular database was accessed to identify consecutive cases of very small (<3 mm) ruptured ACom aneurysms treated endovascularly between 2006 and 2013. Clinical, demographic, radiographic, and procedural data were retrospectively obtained through chart review. Results A cohort of 20 consecutive patients with ruptured very small (<3 mm) ACom artery aneurysms were treated endovascularly including 13 females and 7 males with a mean age of 58.4 ± 12.9 yrs. Average maximum aneurysm diameter was 2.66 (± 0.41) mm. Hunt-Hess grade 1–3 for 14 (70%) patients and 4 for 6 (30%) patients. Dome to neck ratio was less than 2 for 13 (65%) of the aneurysms. Four (20%) aneurysms were bilobed. Aneurysm projection was antero-superior in 11 (55%), antero-inferior in 6 (30%) and postero-superior in 3 (15%). Primary coiling was performed for 16 (80%) aneurysms and balloon assistance was used for 4 (20%). Complete aneurysm occlusion was achieved for 17 (85%) aneurysms and near complete for 3 (15%) aneurysms. There were no symptomatic peri-procedural complications. Intra-operative perforation (IOP) occurred in 2 (10%) patients without any clinical worsening or need for an external ventricular drain. Thromboembolic event (TEE) occurred in 1 (5%) patient without clinical worsening or new radiologic infarct. Median clinical follow up was 12 (± 14.1) months and median imaging follow up was 12 (± 18.4) months. There were no instances of re-bleeding during follow up. At the 3 month clinic follow up, modified Rankin scale was 6 for one patient related to anaplastic astrocytoma. Of all the surviving 19 patients, post treatment clinical status either improved or remained stable. Recanalization with a neck residual occurred in two (10%) aneurysms and both were retreated with additional primary coiling and stent assistance. Conclusion Endovascular treatment of very small ACom aneurysms can be performed with acceptable rates of complications and recanalization. Robust conclusions can be drawn only after further evaluation with larger number of patients and longer follow-up. Disclosures K. Asif: None. M. Teleb: None. A. Sattar: None. M. Lazzaro: None. B. Fitzsimmons: None. J. Lynch: None. O. Zaidat: None.

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