Pakistan Journal of Neurological Sciences

Focused Ultrasound: A New Era in Tremor Control

Sajid Hameed — 2025-08-02

Epidemiology of Stroke and Risk Factors in Punjab, Pakistan: A Comprehensive Hospital-Based Study

Saima Ahmad — 2025-09-29

Background: Stroke is a significant global health challenge, particularly burdening low- and middle-income countries where it leads to substantial mortality and disability-adjusted life years. Over the past four decades, these regions have witnessed a disturbing rise in stroke incidence. In Pakistan, the prevalence of stroke is of utmost public health concern, yet the absence of comprehensive epidemiological data obscures its true impact.

Method: This retrospective hospital-based study was conducted at a Tertiary Care Hospital in Lahore, Punjab, Pakistan, serving as the primary referral center for stroke cases. Medical records from January 2019 to December 2020 were reviewed using the International Classification of Diseases. A structured data collection form captured demographics, stroke types, risk factors, medical histories, and outcomes.

Results: Among 159,824 emergency department visits, 1654 patients were diagnosed with stroke, yielding an incidence rate of 1.03% in Punjab. The majority (26.13%) of stroke patients were aged 60-69 years, with an average age of 57.19 years. Males (51.75%) showed higher susceptibility than females (48.25%). A significant proportion (62.39%) of cases resulted in discharge with disability. Ischemic stroke was predominant (44.2%), followed closely by hemorrhagic stroke (43.4%). Hypertension (61.63%), diabetes (17.65%), and heart disease (8.73%) emerged as prevalent comorbidities. Lahore was the primary location for a substantial number of cases (46.3%).

Conclusion: The high incidence of stroke (1.03%) in Punjab underscores urgent public health needs. Our study highlights prevalent risk factors such as hypertension, diabetes, and ischemic heart disease, emphasizing the necessity for targeted prevention strategies. Comprehensive epidemiological studies are crucial to accurately quantify stroke burden in Pakistan and implement effective interventions.

Burden of Vascular Neurological Disorders: A Cross-sectional Multicenter Study

Shafaq Saleem — 2025-08-09

Background and Objective:

Stroke remains a leading cause of morbidity and mortality worldwide, with a particularly high burden in low- and middle-income countries (LMICs) such as Pakistan. Despite its growing prevalence, limited nationwide data exist on vascular diseases, their risk factors, and disability outcomes. The objective of this study was to identify the frequency and age-stratified type of vascular disease incidence among in-patient hospital admissions.

Methods:

A retrospective observational study was conducted across 39 neurology centers in Pakistan, spanning both public and private sectors from August 2017 to December 2019. Data on demographics, comorbidities, and stroke type were systematically collected from hospital records. The severity of disability was assessed using the Modified Rankin Scale (mRS). Statistical analyses were performed using SPSS.

Results:

Among 5,735 patients, stroke was the most prevalent vascular disease (78.6%), with ischemic stroke comprising 60.9% of cases. Stroke was more common among males (65.8%) and individuals with primary education (45.2%). Hypertension (62.2%) and diabetes (26%) were the most frequent comorbidities. Analysis of disability status revealed that 34.3% of stroke patients suffered from moderate to severe disability (mRS 3-5).

Conclusion:

This study highlights the substantial burden of stroke and vascular diseases in Pakistan, emphasizing the urgent need for preventive strategies, improved stroke care, and a nationwide registry to guide healthcare policies and interventions

Electrodiagnostic Patterns in Neuromuscular Disorders: A Retrospective Cross-Sectional Study from a Tertiary Care Hospital

Ayisha Farooq Khan — 2025-08-02

Background and objective:

Electromyography (EMG) and nerve conduction studies (NCS) are essential for diagnosing neuromuscular disorders and differentiating various peripheral nervous system conditions. The objective of this study was to assess the prevalence and trends of neuromuscular disorders based on EMG/NCS findings in a tertiary care center in Pakistan.

Methods:

This retrospective cross-sectional study was conducted at the neurophysiology laboratory of Aga Khan University Hospital from 1^st January 2023 to 31^st December 2023. A total of 961 EMG/NCS records were analyzed, including both inpatient and outpatient cases. Data was extracted from the EMG registry, and findings were categorized into mononeuropathy, chronic sensorimotor axonal polyneuropathy, chronic inflammatory demyelinating polyneuropathy, Guillan Barre syndrome, plexopathy, radiculopathy, anterior horn cell disorders, myopathy, and neuromuscular junction disorders. Statistical analysis was performed using SPSS version 23.0.

Results:

Among 961 patients, 651 (67.7%) had abnormal EMG findings. The most common diagnosis was radiculopathy (n=205; 21.3%), followed by mononeuropathies (171 cases, 17.8%), chronic sensorimotor axonal polyneuropathy (n=143; 14.9%), and myopathy (n=60; 6.2%). Carpal tunnel syndrome was the most frequent mononeuropathy, while lumbosacral radiculopathy was the predominant radiculopathy. Myopathies and neuromuscular junction disorders were less common. The 40–49-year age group was the most frequently affected.

Conclusion:

EMG/NCS plays a crucial role in diagnosing and classifying neuromuscular conditions, as evidenced by the high proportion of abnormal findings in our study. Expanding access to EMG/NCS and enhancing electrophysiology training for neurologists can further improve diagnostic accuracy and patient care.

Electrographic significance of Periodic Discharges and association with etiology and outcome in a tertiary care hospital, a retrospective cohort study

Hina Imtiaz — 2025-08-13

Background and Objective:

Periodic discharges on electroencephalograms (EEGs) are rhythmic waveforms that may indicate acute or subacute brain injury. This aim of this study was to determine the frequency distribution of periodic discharge subtypes on EEG and to assess their association with underlying etiologies and clinical outcomes in a tertiary care hospital.

Methods:

This retrospective observational cohort study included neurological patients aged ≥18 years admitted to the medical ICU or ward of Aga Khan University Hospital between January 1, 2021, and January 1, 2023, with periodic discharges on EEG. Patients with prior traumatic brain injury were excluded. Data on demographics, clinical presentation, EEG subtype, neuroimaging findings, management, and outcomes were extracted from medical records. Statistical analysis was performed using SPSS version 22, with categorical variables presented as frequencies and percentages, continuous variables as mean ± standard deviation, and significance set at p ≤ 0.05.

Results:

Out of f 41 patients, 51.2% were female, with a mean age of 58.5 years. Generalized tonic-clonic seizures were the most common presentation (48.8%), and ischemic stroke was the leading etiology (31.7%). Lateralized periodic discharges were the most frequent EEG subtype. Chronic imaging changes were present in 34%, most often encephalomalacia and gliosis. Most patients (87.8%) were discharged home, while mortality occurred in 12.2%, often linked to status epilepticus or metabolic encephalopathy.

Conclusion:

Periodic discharge subtypes, particularly lateralized patterns, are often associated with ischemic stroke and severe neurological presentations. Their recognition and etiological correlation are essential for timely intervention and improved patient outcomes.

Clinical and Radiological Profile of Patients Presenting with Neurolisteriosis: A retrospective study from a Tertiary Care Hospital

Zainab Memon — 2025-08-02

Background
Neurolisteriosis, a central nervous system (CNS) infection caused by Listeria monocytogenes, is associated with significant morbidity and mortality, particularly in elderly and immunocompromised individuals. The objective of this study was to analyze the clinical and radiological data from the patients of this disease presenting to a tertiary care hospital.

Methods
This retrospective review analyzed clinical, laboratory, and neuroimaging data from 12 patients diagnosed with neurolisteriosis at Aga Khan University Hospital between September 2018 and March 2024. Diagnosis was confirmed through blood and/or cerebrospinal fluid cultures or polymerase chain reaction assays. Data was analyzed using Statistical Package for Social Sciences (version 25.0).

Results
The median age was 68.5 years, with 58.3% being elderly (>65 years) and 58.3% male. Most patients (91.7%) had underlying comorbidities, with diabetes mellitus and hypertension being the most common. Acute onset of symptoms was observed in two-thirds of cases. Fever (83.3%) and altered consciousness (75%) were the predominant presenting features. Meningeal enhancement was the most frequent neuroimaging finding (66.6%), followed by hydrocephalus (25%). The median time to radiological diagnosis (24 hours) was significantly shorter than to microbiological confirmation (72 hours). The mortality rate was 25%, with complicated clinical courses observed in 75% of patients.

Conclusion
Neurolisteriosis predominantly affects elderly and immunocompromised populations and presents with non-specific CNS infection symptoms. MRI plays a crucial role in early detection and management, given the delay in microbiological confirmation. Heightened clinical suspicion and prompt imaging can improve diagnosis and outcomes.

Tocilizumab in the management of Neuromyelitis Optica Spectrum Disorder: A Narrative Review of Literature and Critical Appraisal

Salman Mansoor — 2025-08-02

Background:

This review discusses tocilizumab, a monoclonal antibody, as a promising therapeutic option for Neuromyelitis optica (NMO) spectrum disorders. NMO is characterized as an autoimmune disorder that is rare. It affects the eyes and the spinal cord. By binding to the IL-6 receptor, tocilizumab reduces inflammatory cytokines and inhibits the immune response that leads to NMO.

Methodology:

For this article, a comprehensive search of the relevant literature was conducted using electronic databases namely PubMed, Cochrane Library, and Embase, from inception till August 2021.

Results:

Clinical trials that were included in this literature review showed promising results that tocilizumab reduces disease activity, and relapses, and improves clinical outcomes.

Conclusion:

In conclusion, tocilizumab represents a significant advance in treating NMO, but more studies might be needed to determine its long-term safety and the best way to use it for treating NMO spectrum disorders. However, the optimal dosing regimen and long-term safety of tocilizumab are yet to be determined.

Houge-Janssens syndrome-1 Associated With Protein Phosphatase 2 Regulatory Subunit B′ Delta and Epilepsy: A Case Report

Dua Saleem — 2025-08-02

Houge-Janssens syndrome 1 is a rare autosomal dominant disorder with approximately 100 case reports worldwide. Here, we present a case of a Pakistani toddler who presented with epilepsy and developmental delay. Family history was significant with reported and documented developmental delays in both father and elder sister, with subsequent improvement. Trio-whole-genome sequencing (WGS) and Sanger sequencing were performed, revealing a heterozygous LP variant NM_006245.4: c.626A>C, p.(His209Pro) in the girl. The same variant was also identified in her father and sister. This case sheds light on the variability of phenotypic expression amongst affected individuals and recommends the need for further genotype-phenotype correlation and studies.

High Dose Methylprednisolone in Children with Severe Headache in Viral Encephalitis: A Case Series

Abia Abdullah — 2025-08-02

Severe headache is a common symptom in children with viral encephalitis (VE), yet effective symptom-specific therapies are limited. In this case series, we present three children of ages 15, 14, and seven diagnosed with VE who presented with severe headaches unresponsive to standard analgesics but showed significant clinical improvement following high-dose methylprednisolone therapy. Although this is not first line treatment, these cases suggest a possible role for methylprednisolone in alleviating severe VE-associated headaches. Further controlled studies are needed to establish its effectiveness and safety in such settings.

Chorea as a Rare Manifestation of Neuropsychiatric Systemic Lupus Erythematosus: a Case Report

Qurat ul ain — 2025-08-02

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with multisystemic involvement. It has variable clinical presentations and a relapsing and remitting course. Clinical manifestations are broad, ranging from mild mucocutaneous involvement to major organ involvement. We present a case of a 32-year-old female with repeated movements of the right arm, and confusion with a background of pains in multiple joints. She was diagnosed as a case of Neuropsychiatric Systemic Lupus Erythematosus (NPSLE). She was managed with pulse therapy of cyclophosphamide (CYC) along with other supportive medications. After six months of intensive immunosuppressive therapy, she remained well and continued maintenance therapy.

New Onset Seizures Evolving into Refractory Status Epilepticus in the Setting of COVID-19: a Case Report

Mahira Mushtaq — 2025-08-02

The novel Coronavirus disease (COVID-19) has been shown to involve the nervous system (both central and peripheral), with or without respiratory involvement in multiple ways. Although not much is known about this disease yet, seizures and status epilepticus which may evolve into refractory status epilepticus have been associated with it along with other manifestations like encephalopathy, neuropathies etc. The mechanism for development of seizures with COVID-19 related disease is not entirely known however it can be the consequence of “cytokine release syndrome” or “cytokine storm” which has been associated with this virus. Patients with COVID-19 infection who develop resistant status epilepticus may have increased morbidity hence early recognition and starting appropriate therapy are key to avoid possible poor outcomes. Here, we present a case of a patient with new onset seizures that rapidly progressed to refractory status epilepticus in the context of COVID-19 infection. Our case report highlights the need of testing for systemic viral infections like SARS-CoV-2 in refractory status epilepticus and using therapies like corticosteroids and IVIG that have shown a role in COVID-19 induced seizures and encephalitis.

Acute Flaccid Myelitis Caused by Enterovirus Infection- A Case Report

Ahmad Bilal — 2025-08-02

Enterovirus is a member of the Picornaviridae family, an enterovirus. It is suspected of causing a polio-like disorder called acute flaccid myelitis (AFM). This case report aims to present a 10-year-old boy who presented with neurological manifestations of weakness of lower limbs and urinary retention. He had reduced tone, absent reflexes, and palpable bladder. MRI spine revealed inflammation in grey matter of spinal cord. He was treated with high dose steroids and IVIG but no improvement was observed. Enterovirus was isolated from his stool sample. The patient received supportive care and physiotherapy with gradual improvement after months, having no evidence of spasticity. We report this case as a rare non polio virus related acute flaccid myelitis in our local population to highlight the importance of alternative diagnosis leading to timely recognition and early management.

Epilepsy in Pakistani Adolescents Amid the Vaping Epidemic

Maheen Kalwar — 2025-08-02

Pakistan Ischemic Stroke Guidelines

Anjum Farooq — 2025-09-05

Stroke is the second most common cause of morbidity and death globally, and even with great advancements in prevention and treatment techniques, the burden is still high worldwide¹. Stroke related mortality and morbidity is particularly high in countries with low and moderate incomes(LMIC). In 2016, number of death reported from stroke was very high (56%) in countries with low and moderate incomes compared with high-income countries (HICs) where it was only 29% ².True prevalence of stroke in Pakistan is not exactly known because of lack of epidemiological studies.³ Integrated population and health survey from Khyber Pakhtunkhwa determined the estimated stroke prevalence of 1.2% in KP province of Pakistan⁴. In Pakistan, risk factors of stroke in Pakistan are enormous. According to a cross-sectional study conducted at a community health center, 39% of adults over the age of 18 have a history of active smoking, hypertension, or dyslipidemia. The same study found that 42% of the individuals had a positive family history of ischemic heart disease, 24% were obese, 19% had hypertension, and 15% had diabetes mellitus.⁵. Majority of patients with stroke first consult general practitioner in Pakistan. Existing evidence-based guidelines for managing acute ischemic strokes are applicable in those areas where CT scan facility is available and can be applied in many areas of Pakistan with minimal level of resource availability and where District Hospitals lack the facility of neuroimaging. These guidelines will focus on acute ischemic stroke and its secondary prevention.