A Randomized, Open Label, Exploratory Trial Comparing Efficacy of Amantadine and Ropinirole in Restless Legs Syndrome

Objective  Amantadine has both anti-glutamatergic and dopaminergic action and may improve restless legs syndrome (RLS). We compared the efficacy and adverse-effect profile of amantadine and ropinirole in RLS. Methods  In this randomized, open-label, 12-week flexible-dose exploratory study, RLS patients with international RLS study group severity scale score (IRLSS) > 10 were randomized to receive either amantadine(100-300mg/day) or ropinirole (0.5-2mg/day). Drug dose was increased until week-6 if IRLSS failed to improve by ≥10% of previous visit score. IRLSS change from baseline at week-12 was the primary outcome. Secondary outcomes included change in RLS-related quality of life (RLS-QOL) and insomnia severity index (ISI), along with clinical-global-impression of change/improvement (CGI-I), and proportion of patients with adverse-effects and resulting discontinuation. Results  Twenty-four patients received amantadine and 22 received ropinirole. Both groups had a significant effect for visit*treatment arm (F (2.19,68.15) =4.35;P = 0.01). With a similar baseline IRLSS, both intention-to-treat (ITT) and per-protocol analyses revealed comparable IRLSS until week-8, with ropinirole appearing superior from week-10 to week-12 (week-12 IRLSS, amantadine vs ropinirole:17.0  ±   5.7 vs 9.0  ±   4.4;P < 0.001). ITT analysis at week-12 showed comparable proportion of responders (≥10% IRLSS reduction) in both groups (P = 0.10). Both drugs improved sleep and QOL, but week-12 scores favoured ropinirole [(ISI:14.4  ±   5.7 vs 9.4  ±   4.5; P = 0.001) ;(RLS-QOL:70.4  ±   17.9 vs 86.5  ±   9.8; P = 0.005)]. CGI-I at week-12 favoured ropinirole (Mann-Whitney U = 35.50, S. E = 23.05;P = 0.01). Four patients in amantadine and two in ropinirole group developed adverse effects, with resulting discontinuation in two patients on amantadine. Conclusions  The present study reports equivalent reduction in RLS symptoms with both amantadine and ropinirole until week-8, with the latter being superior from week-10 onwards. Ropinirole was better tolerated.

Tenecteplase and Alteplase for Thrombolysis of Acute Ischemic Stroke within 4.5 Hours: An Efficacy and Safety Study

Objective

To compare the efficacy and safety of thrombolysis using Tenecteplase (TNK) versus alteplase in acute ischaemic stroke (AIS) patients within 4.5-hour window period.

Methods

This retrospective study involved the collection of data from consecutive AIS patients who underwent thrombolysis in the Department of Neurology at a tertiary care university hospital, between May 2018 to January 2021. Data including clinical history, neurological assessment using modified Rankin score (mRS), National Institutes of Health Stroke Scale (NIHSS), brain neuroimaging, treatment, and outcome details were collected. The primary efficacy outcome was the proportion of patients with good functional recovery (mRS of 0-2) at 90 days of follow-up.

Results

Total of 42 patients with AIS underwent thrombolysis, of which 19 received alteplase and 23 got TNK. The median (range) onset to door time [120 (20-210) versus 120 (30-210) minutes; P = 0.823] and median (range) onset to needle time [150 (60-255) versus 160 (50-240) minutes; P = 0.779] were comparable in both alteplase and TNK groups, respectively. The primary outcome of good functional recovery (mRS ≤2) at 3 months was observed in more than half the patients in each group and was comparable (P = 0.701). Post-thrombolysis complications including cerebral haemorrhage (symptomatic or asymptomatic) were comparable between the two groups (31.6% vs 30.4%; P = 0.936), except a significantly higher proportion of patients on TNK required mechanical ventilation (10.5% v/s 43.5%; P = 0.019).

Conclusions

This study showed a comparable efficacy and safety profile of alteplase and TNK in thrombolysis of AIS throughout the 4.5 hours window period. Moreover, the ease of administration and better pharmacodynamic properties favors tenecteplase.

Syringomyelia after spinal anaesthesia: A case report

Lumbar spinal or epidural anaesthesia has a lower complication rate compared to general anaesthesia. An occasional patient may develop spinal cord injury during the procedure and develop neurological complications. We report an interesting case of paraparesis due to dorsal spinal cord involvement and syrinx formation following spinal anaesthesia for abdominal surgery.

Non-COVID Neurological Emergencies: A Silent Killer Going Unnoticed during COVID-19 Pandemic

Objective  This study assesses the impact of coronavirus disease 2019 (COVID-19) on the pattern of neurological emergencies reaching a tertiary care center.

Materials and Methods  This is a retrospective and single center study involving 295 patients with neurological emergencies mainly including acute stroke, status epilepticus (SE), and tubercular meningitis visiting emergency department (ED) from January 1 to April 30, 2020 and divided into pre- and during lockdown, the latter starting from March 25 onward. The primary outcome was number of neurological emergencies visiting ED per week in both periods. Secondary outcomes included disease severity at admission, need for mechanical ventilation (MV), delay in hospitalization, in-hospital mortality, and reasons for poor compliance to ongoing treatment multivariate binary logistic regression was used to find independent predictors of in-hospital mortality which included variables with p <0.1 on univariate analysis. Structural break in the time series analysis was done by using Chow test.

Results  There was 53.8% reduction in number of neurological emergencies visiting ED during lockdown (22.1 visits vs. 10.2 visits per week, p = 0.001), significantly affecting rural population ( p = 0.004). Presenting patients had comparatively severe illness with increased requirement of MV ( p < 0.001) and significant delay in hospitalization during lockdown ( p < 0.001). Poor compliance to ongoing therapy increased from 34.4% in pre-lockdown to 64.7% patients during lockdown ( p < 0.001), mostly due to nonavailability of drugs ( p < 0.001). Overall, 35 deaths were recorded, with 20 (8.2%) in pre-lockdown and 15 (29.4%) during lockdown ( p = 0.001). Lockdown, nonavailability of local health care, delay in hospitalization, severity at admission, and need for MV emerged as independent predictors of poor outcome in stroke and delay in hospitalization in SE.

Conclusion  COVID-19 pandemic and associated lockdown resulted in marked decline in non-COVID neurological emergencies reporting to ED, with more severe presentations and significant delay from onset of symptoms to hospitalization.

Spinal Muscular Atrophy and Progressive Myoclonic Epilepsy: A Rare Association

The association of spinal muscular atrophy (SMA) with progressive myoclonic epilepsy, also known as “SMA plus,” is a unique syndrome linked to non-survival motor neuron (non-SMN) genes. The disease starts in childhood with progressive weakness and atrophy of muscles; myoclonic epilepsy develops during later childhood, after the onset of motor symptoms. In this report, we describe a case of SMN gene unrelated SMA and myoclonic epilepsy, supported by electrophysiological and neuropathological evidences.