Debabrata Chakraborty

An eighty-year-old gentleman without any comorbidity or significant medical illness had presented with headache of recent onset. A detail clinical evaluation and imaging (MRI of brain) ruled out secondary cause of headache. A month later, he presented to emergency with altered sensorium and quadriparesis. Repeat brain imaging revealed bilateral subdural hemorrhage requiring emergent surgery. He was back to normalcy within few days postoperatively. A confession was obtained about his daily habit of induced vomiting after drinking large amount of water (kunjala kriya). The repeated habit of induced vomiting might have been responsible for the slowly evolving subdural hemorrhage. Interestingly, though he had significant clinical symptoms at the initial presentation, he had normal initial MRI of brain (the more sensitive imaging modality). Our case highlights the interesting neurophysiology of subdural hemorrhage and the importance of close monitoring of elderly patients of recent onset headache. Keywords: Kunjala Kriya, Subdural hemorrhage, Burr-Hole Surgery.

Stroke in young is on rise in every corner of the world and is presently a very serious concern. So, a modifiable etiology of stroke if found, needs to be addressed seriously. Hyperhomocysteinemia is a prominent risk factor for vascular event in young population. It is known to play an important role in coronary artery disease, peripheral vascular disease and stroke. Perhaps, it also has a significant role in arterial dissection, a prominent stroke etiology in young population. It is proposed that hyperhomocysteinemia and genetic polymorphism probably interact with environmental factors leading to sequence of pathogenetic events resulting in arterial wall dissection. The prevalence of vegetarian diet, genetic predisposition and diet pattern subject Indians to increased chance of hyperhomocysteinemia and vascular insult. Here, we present a very rare case of isolated spontaneous vertebral arterial dissection in a young gentleman who had no vascular risk factor except very high serum homocysteine level. Perhaps, this case highlights serious consideration for addressing this modifiable vascular risk factor as a possible association with arterial dissection to avoid catastrophic events, especially in this part of the world. Keywords: Hyperhomocysteinemia, Stroke, Arterial dissection.

Stroke and infection have a close relationship! There is possibly interplay of inflammation with traditional risk factors of stroke such as hypertension, hyperlipidemia, diabetes, and smoking. Ricketssiae infection is already known to have multisystemic involvement. Stroke, both ischaemic and hemorrhagic though rarely reported to be associated with this infection often resulted in drastic consequences. Here, we will present a case where a gentleman who presented with stroke following a rickettsia infection only few days after he was thrombolysed for an initial event. We probably managed to avoid a catastrophe by treating the infection at earliest! Key Messages: Infection may interact with traditional risk factors of stroke and may precipitate a vascular event. Epidemiological knowledge of existing infections in community, early detection and intervention may prevent complications even if stroke is precipitated. Keywords: Ricketssiae, Postthrombolysis, Stroke.

Sinking skin flap syndrome (SSS) is a serious complication following decompressive craniectomy (DC). Although CSF hypovolemia and exposure to atmospheric pressure have been attributed as causative factors, the definite etiologies remain elusive. We present a case where a patient had a rapid deterioration without any warning sign following a diagnostic and therapeutic lumbar puncture after DC. The patient had rapid fluctuation of symptoms with change of position. She was managed conservatively and finally achieved a full neurologic recovery without cranioplasty. This case report shows the heterogeneity of SSS and that cranioplasty may not be required in acute cases. Keywords: CSF diversion, Cerebral herniation, Hemicraniectomy