Brivaracetam (BRV) is a new antiepileptic drug (AED) approved for adjunctive treatment of focal (partial-onset) seizures in adults. It is a selective, high-affinity ligand for synaptic vesicle 2A (SV2A) with much higher affinity than Levetiracetam (LEV). It has a high lipid solubility and rapid brain penetration, and has been shown to have potent broad-spectrum antiepileptic activity in animal models. The aim of the study was to evaluate the efficacy and tolerability of BRV in everyday clinical practice. This observational study included 35 participants, suffering from different types of epilepsy. Patients were observed over a period of 1 year and data was collected using an interview design model. After the initial interview, a final interview took place after 1 year. Various parameters studied included demographic parameters, seizure frequency and duration, any side effects such as behavioral issues. This study included total 35 patients. The mean age of the participants was 33 years (range 3 – 90 years). Approximately 63% patients demonstrated a decrease in seizure frequency after switching to Brivacetam. Out of these patients, 76% patients were those patients, who were earlier treated with Levetiracetam, and it was discontinued either due to inadequate control of seizures or prominent side-effects. Brivaracetam also improved emotional balance in the treated patients (treatment naïve or Levetiracteam associated behavioral issues).Brivaracetam seems to be an effective and safe antiepileptic drug in the routine clinical setting.

Pseudoaneurysm of the middle meningeal artery, presenting as a delayed sequela of trauma, being a rare entity, may sometimes present as an acute intraparenchymal hemorrhage, with a risk of rerupture and mortality. The optimal management in acute settings remains undetermined. We, hereby, report a case of elderly gentleman with a history of a road traffic accident. Noncontrast computed tomography (NCCT) brain was reported to have left parietal hemorrhagic contusion without any mass effect. The patient was managed conservatively without any major neurological deficits. After 7 months, the patient presented with severe headache, altered sensorium, and right hemiparesis. NCCT brain showed acute left thalamocapsular hemorrhage with minimal subarachnoid hemorrhage with associated mass effect and impending herniation. Considering the fall in patient's baseline Glasgow comma scale response, pupillary asymmetry, and CT findings, immediate decompression and hematoma evacuation were advised. In view of atypical morphology, the patient was planned for urgent digital subtraction angiography prior to the surgery to rule out the ruptured aneurysm or pial arterio-venous fistula. Selective angiography of the left external carotid artery demonstrated a dissecting pseudoaneurysm feeding from the middle meningeal artery (MMA), which was embolized using n-butyl cyanoacrylate (NBCA). Postprocedure DynaCT revealed the left temporal bone fracture, indicating this pseudoaneurysm to be most likely posttraumatic delayed sequelae. Postembolization, the patient underwent surgical decompression and excision of hematoma. Patient's neurological status gradually improved and was discharged with the minimal deficit. Our case highlights the importance of awareness of the posttraumatic MMA pseudoaneurysm as an uncommon but treatable entity, which can be easily diagnosed using cerebral angiography and amenable to safe and effective endovascular embolization using NBCA.

: Understanding the exact etiology of stroke in the young has great relevance to its prevention and management. Recent development in the surgical and interventional therapy of extra cranial and intracranial vascular diseases have made it necessary to correctly identify the causative as well as contributory factors of stroke.This cross sectional observational study was done on patients admitted in the stroke unit of Geetanjali Medical College, Udaipur of aged 15 to 50 years with stroke and who have underwent at least one standard vessel imaging procedure within 2 weeks of stroke onset. Out of 310 patients, majority of the strokes occurred in the setting of a rheumatic valvular heart disease (63.6%), with mitral valve disease being the most frequent association. Almost 80% of patients had normal ECG whereas 20% of the patients had an ECG abnormality.70% of patients had normal ECHO and the most frequent etiologic abnormality detected was valvular heart disease. Scan and MRI was done in 180 patients. The most commonly performed angiographic procedure was CT angiogram. TOF MRA was the next most commonly performed angiographic procedure. The highest yield for picking up abnormalities was noted in the CT Angiography. The yield of CT angiography was 35.4% and 37.7% for extracranial and intracranial vasculature respectively.Arterial dissections are fairly common in young population and should be considered in appropriate clinical setting and all patients should have a good and timely angiographic assessment to rule out dissections. Thus, this study highlights the importance of risk factor evaluation, and control, complete etiological evaluation including angiographic assessment in the diagnosis, management and planning of secondary prevention strategies in young patients with stroke.

Tortuosity in anterior circulation has been associated with the outcomes of mechanical thrombectomy (MT). We classified vertebral artery (VA) tortuosity and investigated the effect of VA tortuosity on the outcomes of basilar artery occlusion (BAO) after MT. We enrolled patients who underwent MT for BAO. VA tortuosity was classified into three-types; Type-I: non-tortuous, Type-II: S-shape or VA with acute angulation (<90°), and Type-III: coiled, kinked, or VA with multiple acute angulations. The 3-month modified Rankin Scale (mRS), successful recanalization, and post-MT hemorrhagic transformation (HT) were assessed. A total of 106 patients were included. Age, baseline stroke severity, and the 3-month mRS score were significantly different according to the VA tortuosity (P=0.003, P=0.002, and P<0.001, respectively). A multivariable analysis demonstrated that VA tortuosity was a predictor for mRS score 0-3 (Type-I: reference; Type- II: 0.26 [0.07–0.95], P=0.041; Type-III: 0.12 [0.02–0.82], P=0.031). Moreover, Type-III was associated with less successful recanalization (Type-I: reference; Type-III: 0.12 [0.02–0.84], P=0.032) and was a potential factor for post-MT HT (Type-I: reference; Type-III: 3.09 [0.83– 11.56], P=0.094). VA tortuosity was significantly associated with the stroke outcome after MT for BAO. Initial stroke severity and successful recanalization might affect the stroke outcome.