Background Vitamin B12 deficiency is linked to impaired cognition and memory along with a sensation of tingling and numbness, an outcome of poor myelination. Elevated methylmalonic acid and serum homocysteine levels are markers of Vitamin B12 deficiency. Elevated homocysteine levels are also often associated with Alzheimer's disease and stroke. We conducted this study to determine the effect of vitamin B12 replacement therapy on vitamin B12-deficient patients with noted cognitive impairment. Methods We conducted a cross-sectional, multicenter study of patients with minimal cognitive impairment (MCI) to assess for Vitamin B12 and homocysteine levels. All patients found to be deficient in vitamin B12 underwent replacement therapy and were assessed again after three months via the Mini-Mental State Examination (MMSE) and a review of symptoms. Results A total of 202 patients were included in the study. Of those, 171 (84%) patients reported marked symptomatic improvement after vitamin B12 replacement while MMSE scores improved in 158 (78%) patients. Of the remaining 44 patients who reported no symptomatic improvement, MMSE scores improved in 26 while 18 patients showed no MMSE score improvements. Conclusions Vitamin B12 deficiency is linked to cognition, and replacement therapy may be an option to improve patient cognition outcomes. Further studies are needed to confirm and refine the observed associations over a larger scale and to determine whether these findings will translate to a reduction in cognitive decline.

Background and objectives Cerebral venous sinus thrombosis (CVST) is a relatively rare and underdiagnosed type of stroke. Rivaroxaban is licensed for venous thromboembolism in patients opting for elective knee and hip replacement surgeries, preventing pulmonary embolism and precluding stroke and systemic embolism in sufferers of non-valvular atrial fibrillation. Beneficial outcomes depicting the efficacious role of rivaroxaban in treating CVST are under study. Materials and methods We performed a prospective observational study in patients diagnosed with CVST in the medicine or neurology unit of a tertiary care hospital in Karachi, Pakistan, between January 2019 and December 2019. The diagnosis of CVST was made by magnetic resonance venography (MRV) in all the cases. Follow-up visits were scheduled at three months and six months, and the occurrence of thrombotic events or bleeding complications was recorded. Follow-up was done by magnetic resonance imaging at three and six months to assess vessel recanalization. Excellent outcome was defined as a modified Rankin Scale (mRS) of 0 or 1. A total of 31 patients were meeting the inclusion criteria and were inducted into the study after informed consent. Results The mean age of the study population was 35.11 ± 8.96 years with 71% females and 29% males. The most prevalent etiology was the pregnancy/postpartum period (52%) followed by antiphospholipid syndrome (23%). The frequent clinical manifestations were headache (84%) followed by vomiting (38%), altered level of consciousness (35%), focal deficit/limb weakness (32%), aphasia (29%), blurring of vision (26%), and seizures (23%). Radiological studies showed that the vessels chiefly occluded in our study were superior sagittal sinus (29%), transverse sinus (23%), sigmoid sinus (16%), jugular vein (9%), and cortical veins (3%). Common features on magnetic resonance imaging (MRI) were cerebral edema (45%), hemorrhage (39%), infarct incidence (32%), and raised intracranial pressure (26%). Clinical outcomes showed 55% of patients had partial recanalization and 39% had complete recanalization after a period of six months of the administration of rivaroxaban. Ninety-three percent (93%) of sufferers recovered excellently according to mRS and only 3% developed recurrent CVST within a span of six months. The frequency of thrombotic events and bleeding complications were reported in 6% of patients, respectively, while mortality reported was also 6%. Conclusion Rivaroxaban has shown promising results in the management of our CVST patients, hence, it further warrants randomized controlled trials of rivaroxaban against conventional treatments to prove its significant role.

Background: Transverse myelitis (TM) is an inflammatory disorder of spinal cord, characterized by acute or sub-acute dysfunction of spinal cord affecting the motor, sensory, and autonomic systems. It may be idiopathic or related to other diseases. Although some patients recover from TM with minor or no residual problems, others suffer permanent impairments that affect their ability to perform ordinary tasks of daily living. Our objective was to determine the frequency of different clinical outcomes in patients presenting with TM. Methods: It was a prospective cohort clinical study conducted from May 2018 till October 2018. Study was conducted in the Department of Neurology at Jinnah Medical College Hospital (JMCH), Karachi. In total 131 patients of TM were enrolled and treated as per standard protocol, and re-evaluated after eight weeks for assessment of clinical outcomes. Results: The average age of patients was 51.15 ± 6.56 years. Out of 131 cases, 36.6% of patients had full recovery and 63.4% had poor recovery while recurrence occurred in 66.7% cases. Urinary frequency was observed in 12.2% cases and incontinence in 6.9% cases. Conclusion: Acute TM has become transformed with recent developments, especially the advent of the MRI and the discovery of biomarkers.

Objectives. Migraine is a prevalent debilitating neurological disorder manifested by frequent episodes of pounding headache. Cranial autonomic symptoms are frequently reported in patients of trigeminal autonomic cephalgias, but various studies also documented these cranio-autonomic symptoms in migraine patients as well. The primary objective of our study is to evaluate the prevalence of cranio-autonomic symptoms (CAS) amongst the patients suffering from migraines. Material and methods. This study was conducted as a descriptive, cross-sectional survey involving patients attending the neurology clinic at Dow University Hospital. 132 patients met the inclusion criteria (according to ICHDIII) and were assessed for the frequency of cranio-autonomic symptoms. Outcomes. The mean age recorded was 26.37 ± 6.31 years, while the mean duration of diagnosis was 23.54 ± 16.52 months. The frequency of cranio-autonomic symptoms was observed among 55% of the patients suffering from migraines in our study. The prominent symptom observed was lacrimation (56%), followed by nasal congestion (31%) and rhinorrhea (28%). The least prevalent symptom was ptosis (4%). Lacrimation was found more likely to be associated with the male gender (p = 0.096), while forehead/ facial sweating was found more prevalent in females (p = 0.162). The ciliary injection was frequent in conjunction with unilateral rather than a bilateral headache in the migraine patients (p= 0.055), while lacrimation was the most common symptom in the 21-30 years of age group followed by ciliary injection which was exclusively conspicuous in the same age category (p = 0.020). Conclusions. Cranio-autonomic symptoms were detected prevailing in our study population, and may present as a confounding factor in physician’s daily practice to diagnose migraine.

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