Magna Neurologica

The Effect of Levofloxacin Addition on The Outcome of Tuberculous Meningitis Patients: A Systematic Review and Meta-Analysis

Lorisna Hardiknastia Damastiwi — 2024-01-01

Background: Tuberculous meningitis (TBM) is one of tuberculosis's deadliest extra-pulmonary manifestations. Although early initiation of anti-tuberculosis drugs can reduce mortality and morbidity, poor blood-brain barrier penetration hampered their effectiveness. Levofloxacin is an anti-tuberculosis drug with good BBB penetration.

Objective: We aim to explore whether levofloxacin addition to the TBM patients’ regimen has a potential benefit to improve their outcomes.

Methods: The literature search was done on PubMed, Google Scholar, and ProQuest databases without publication date limits to identify studies investigating the effect of augmenting levofloxacin in the outcome of TBM patients. The primary outcome of this study was to analyze the impact of these regimens in decreasing the risk of death and neurological deficit. The articles were collected using the PRISMA diagram, critically appraised using PICO analysis, then the data were analyzed using Review Manager 5.4.1 software with a Fixed Effect Model. The results were expressed as odds ratio (OR).

Results: Four randomized controlled trials with a total of 930 patients were identified. Two trials compared the effectiveness of levofloxacin addition only, whereas the other two used the regimen containing the increased dose of rifampicin alongside levofloxacin addition. Based on the analysis, neither levofloxacin addition only nor increasing rifampicin dose with levofloxacin addition had a significant impact on the mortality of TBM patients (OR=0.55; 95% CI 0.19-1.59; p=0.27, OR=1.01; 95% CI 0.74-1.36; p=0.97, respectively).

Conclusion: Additional Levofloxacin on TBM treatment shows no significant improvement in patient mortality. Routine levofloxacin use in TBM is discouraged due to limited evidence.

Diabetes Mellitus and Hypertension are Associated with Bell's Palsy

Romadhoni — 2024-01-01

Background: Bell's palsy occurs in approximately 40-70% of all cases of acute peripheral facial nerve paralysis, and its cause is unknown. Bell's palsy has several risk factors, including diabetes mellitus and hypertension.

Objective: This study aims to identify the association between diabetes mellitus and hypertension with the occurrence of Bell's palsy.

Methods: This research was conducted at RSUD Tugurejo Semarang in March 2022 using a retrospective study design and purposive sampling technique. Data collected included the history of diabetes mellitus, hypertension, and the occurrence of Bell's palsy. Medical records were used as research instruments. Hypothesis testing was performed using the Fischer exact test.

Results: A total of 32 samples were included in this study. There were 11 patients (34.4%) with a history of diabetes mellitus, 21 patients (65.6%) with a history of hypertension, 11 patients experienced acute Bell's palsy (34.4%), and 21 patients had subacute Bell's palsy (65.6%). The statistical analysis showed a significant association between diabetes mellitus (p=0.017) and hypertension (p=0.033) with the occurrence of Bell's palsy.

Conclusion: This study reveals a significant correlation between diabetes mellitus and hypertension and the occurrence of Bell's palsy. Several studies also suggest that hypertension is linked to a poorer prognosis in patients with comorbidities and facial paralysis in Bell's palsy. However, there are also studies stating that age and gender are associated with the occurrence of Bell's palsy independently of diabetes and hypertension.

The Correlation between The Number of Vascular Risk Factors and The Onset of Hemodialysis with Cognitive Impairement in Chronic Kidney Disease (CKD) Patients

Priyanka Ganesa Utami — 2024-01-01

Background: Cognitive impairment is common in chronic kidney disease (CKD) patients, affecting at least 50% due to ischemia linked to impaired vascular function. Changes during dialysis, like water loss and ultrafiltration, disrupt brain blood supply, worsening ischemia and cognitive function impairment.

Objective: Analyze the correlation between vascular risk factors, dialysis onset, and cognitive impairment in CKD patients.

Methods: This analytic observational study sampled CKD patients on hemodialysis between February-July 2023, using purposive sampling. Inclusion and exclusion criteria were applied, and cognitive function was assessed using MOCA-INA. Spearman's rho statistical analysis was employed at a 95% confidence level (p <0.05).

Results: Spearman Rho revealed a correlation between hemodialysis for over 5 years and impaired cognitive function (P=0.02). Affected cognitive domains, in sequence, are memory/delayed recall, visuospatial, abstraction, language, attention, and naming. However, the number of vascular risk factors did not correlate with cognitive impairment (P=1.38).

Conclusion:CKD patients on hemodialysis for more than 5 years show a correlation with impaired cognitive function, primarily affecting memory/delayed recall, visuospatial, abstraction, language, attention, and naming. Vascular risk factors, however, exhibit no correlation with cognitive impairment.

Cerebral Proliferative Angiopathy as The Cause of Symptomatic Epilepsy in A Young Adult Male: A First Case Report from Indonesia

Jovian Philip Swatan — 2024-01-01

Background: Cerebral proliferative angiopathy (CPA) is a rare and distinct vascular malformation that was once considered a subset of cerebral arteriovenous malformation (AVM). Due to its relatively benign course with no distinctive clinical feature, CPA may often be overlooked and misdiagnosed with other diseases. We report a case of CPA as the underlying cause of symptomatic epilepsy.

Case: A 31-year-old male presented to the outpatient clinic with a history of focal to bilateral tonic-clonic seizure for 2 years. Following conservative management with an oral antiepileptic agent, the seizure frequency significantly decreased from once daily to once or twice monthly. The patient was lost to follow-up; however, he was incidentally referred back to our clinic two years later for further evaluation. A head Magnetic Resonance Imaging and Magnetic Resonance Angiography revealed a suspicion of giant AVM in the left hemisphere. Cerebral digital subtraction angiography (DSA) was performed and revealed a CPA in the left frontal area. The patient was managed conservatively and during the 6-month follow-up period, the patient did not have any seizures.

Discussion: In young adults, seizures may be caused by an underlying vascular abnormality. Cerebral DSA remained the gold standard for distinguishing various etiologies of vascular malformation, including CPA. Conservative treatment using oral antiepileptic agents was effective in controlling the seizure frequency in CPA. However, a complete diagnostic evaluation is still warranted to determine the most appropriate treatment, revealing some peculiar and unexpected etiologies in the process.

A Life-Threatening Neurotoxicity in Bungarus Candidus Snake Bite: A Case Report

Zaki Rusmana Putra — 2024-01-01

Background: Bungarus Candidus, a snake inducing severe neurotoxic symptoms.

Case: A 31-year-old female presented to the emergency department with complaints of pain in the whole body, limb weakness, shortness of breath after being bitten by a snake. Neurological examination, ptosis of both eyelids was found with normal movement of the eyeballs. Muscle strength in all extremities is 4 followed by decreased physiological reflexes. There are fang marks in the form of 2 slightly swollen and reddened black dots on the left foot. During observation, the patient had decreased consciousness, severe shortness of breath with desaturation without any signs of shock. Other clinical revealed bilateral dilated pupils, dysphonia, dysarthria, and muscle strength that was difficult to assess. The patient was intubated and subsequently admitted to the ICU. The patient regained consciousness but still had difficulty opening his eyes and weak muscle strength on the 2nd of ICU. The patient's condition improved on the 5th of ICU, extubating was performed and transferred to the non-ICU. The treatment obtained included 17 vials of SABU, analgesics, antibiotics, anticholinesterase, and anticholinergic. The patient was discharged after 11 days of hospitalization.

Discussion: The neurotoxicity of snake venom is related to mechanisms of neuromuscular transmission blockade, pre-synaptic and post-synaptic. Bungarus Candidus has a peculiar type of toxin, candoxin that acts by inhibiting nicotinic acetylcholine receptors at the postsynaptic site. Recognition of symptoms and management interventions in snakebite cases are critical to patient outcomes and survival.

Patient with Foreign Accent Syndrome in Post-infarct Thrombotic Stroke: A Case Report

Firstiafina Tiffany — 2024-01-01

Background: Stroke is the second leading cause of death in the world and the leading cause of disability worldwide. One of the disabilities is language disorder. Foreign Accent Syndrome (FAS) is a clinical condition associated with a noticeable change of accent, affecting verbal communication and social interaction skills. By identifying this case earlier, we hope the patient’s daily living is less disrupted.

Case: A 54-year-old woman came with complaints of weakness and tingling in the right limbs accompanied by a change in language accent. Weakness in the right limbs was felt since 4 years ago, then 1 year later the patient began to experience a change in the speech accent, from a Javanese accent to a Madurese accent, where previously the patient had never lived or studied Madurese. The results of the neurobehavior examination showed the patient had disturbances in the language and memory domain. MRI revealed cerebral infarction in the bilateral hippocampi, small vessel ischemic in the bilateral frontal lobes, and corona radiata.

Discussion: The accent change, known as FAS experienced by the patients, is thought to be due to neurological causes, which was stroke. In a study using a lesion network mapping approach, it was concluded that the lesion causing accent disorder was located within a single network in the bilateral frontal lobe. In line with the existing theory, the MRI results in this patient showed ischemia in the blood vessels of the bilateral frontal lobes.

The Effectiveness of Transcranial Magnetic Stimulation in Post-stroke Dysphagia: A Case Report

Suska Lara Ginting — 2024-01-01

Background: A 72-year-old male, experiencing dysphagia and left-sided weakness for six months post-stroke, encountered challenges such as coughing and choking during the consumption of liquids and soft foods, along with a prolonged meal-swallowing process. Bilateral thrombotic infarction and left lateralization were revealed through Magnetic Resonance Imaging (MRI).

Case: The Gugging Swallowing Screening Scale (GUSS) assessment demonstrated severe impairment with a total score of 7, persisting despite conventional physiotherapy attempts to improve swallowing function. Subsequently, repetitive transcranial magnetic stimulation (rTMS) was implemented, involving high-intensity stimulation in the ipsilesional hemisphere and low-intensity stimulation in the contralesional hemisphere. Remarkably, one month post-rTMS, the patient displayed significant progress, evidenced by an improved GUSS score of 15, indicating enhanced swallowing function.

Discussion: This case emphasizes the positive impact of bilateral rTMS hemispheric stimulation on post-stroke dysphagia. The strategic application of high-intensity ipsilesional and low-intensity contralesional stimulation emerged as an effective intervention for alleviating swallowing difficulties. These findings highlight the potential of rTMS as an innovative therapeutic approach for persistent dysphagia following a stroke.

Efficacy of Repetitive Transcranial Magnetic Stimulation (r-TMS) Therapy on Improving Motor Strength in Stroke Patients at Dr. Moewardi Surakarta

Ari Revianto — 2024-01-01

Background: Stroke, an acute neurological dysfunction, poses a health challenge with potential fatality, emerging as a leading cause of long-term disability. This study explores the efficacy of repetitive Transcranial Magnetic Stimulation (r-TMS) with medical rehabilitation in enhancing stroke patients' motor strength, comparing it with standard therapy, focusing on the Medical Research Council score.

Objective: Stroke is an acute manifestation resulting from neurological dysfunction, persisting for ≥24 hours or leading to death due to blood vessel disorders. The study aims to determine the effectiveness of r-TMS therapy in improving stroke patients' motor strength, comparing it with standard therapy based on the Medical Research Council score.

Methods: A quasi-experimental study with a pre-post control group design involved 30 respondents selected through consecutive sampling in stroke units and outpatient clinics. Upper extremity muscle strength, measured with the Medical Research Council score, was analyzed using the Mann-Whitney U test, with a significance level set at p < 0.05.

Result: The post-test ranking value of the r-TMS group (20.56) exceeded that of the Non r-TMS group (10.46). The Mann-Whitney U test indicated a significant difference in the average ranking of the Medical Research Council scores between the two groups (p < 0.05, 0.001), highlighting the efficacy of r-TMS therapy in enhancing motor strength.

Conclusion: This study shows that stroke patients receiving standard therapy and transcranial magnetic stimulation exhibit improvements in extremity motor strength compared to those undergoing medical rehabilitation alone. The r-TMS group notably showed a significant increase in extremity motor strength.