Singla, Ramit

Background. DEPDC5 (disheveled, Egl-10 and pleckstrin domain-containing protein 5) familial epilepsy syndrome is a group of epilepsy disorders caused by mutations in DEPDC5 gene, which is a part of the gap activity towards rag 1 (GATOR1) complex involved in regulating the mechanism target of rapamycin (mTOR) pathway. These mutations lead to hyperactivation of the mTOR pathway, disrupting the shaping of neurons and resulting in increased excitatory transmission and the development of epilepsy. The incidence and prevalence of DEPDC5 familial epilepsy syndrome are not well established, but studies suggest it may account for up to 10% of familial focal epilepsy cases. Genetic testing, electroencephalography (EEG), and brain magnetic resonance imaging (MRI) are important in diagnosing the disorder, although normal MRI results are common.Objective: to explain the rare sporadic mutation in DEPDC5 gene with p.R389H, a variant of unknown significance.Case report. A 6-year-old South-Asian girl was born at 34-weeks from non-consanguineous marriage without any prenatal events. She had hyperbilirubinemia by week-1, which was successfully treated with phototherapy. Her initial seizure occurred when she was three months old, just 2 days after the fever from the vaccination had subsided. It was considered a simple-febrile seizure and no treatment was given. At 3.5-months, she started having recurrent seizures. Workup including MRI/ infectious/metabolic panel was non-conclusive. EEG during the initial presentation showed epileptiform activity from the left temporal region. Despite being on multiple anti-epileptic drugs, the child was diagnosed with refractory epilepsy. Subsequently, EEG at 2.5-years showed inter-ictal bi-hemispheric epileptiform activity. EEG at 5-years showed inter-ictal spikes and wave discharges from bilateral fronto-temporal region with secondary generalization. By 3-years, MRI showed mildly deformed corpus callosum with inadequate thickening of splenium. DNA analysis confirmed heterozygous missense mutation in exon 16 of DEPDC5 gene, without chromosomal abnormalities. Mother was heterozygous for the same mutation but no mutations in the father was found. The child has grossly delayed milestones. Corrected age is approximately 1-year for fine motor and language, 1.5-years for gross motor, 2.5-years for cognition, social skills. She had developed autistic features as well with significant impaired auditory/visual processing. She had hypotonia (Right>Left), wide-based gait, and extrapyramidal movements.Conclusion. DEPDC5 gene mutation results in amino acid substitution of Histidine for Arginine at codon 389. This mutation has shown to be inherited in familial pattern. This R389H variant is not present in the 1000 genomes database and is predicted to be benign. However, It rather appears to be a sporadic mutation, which is a very rarely observed phenomena. Such patients may respond well to mTOR inhibitors such as rapamycin, making prompt diagnosis and treatment crucial.

Introduction: Acute ischemic stroke (AIS) is thesecond leading cause of death globally, accounting for approximately 11% of alldeaths, long-term disability, and functional impairments in survivors. TheCOVID-19 pandemic has raised concerns about its impact on AIS patients. Aim: This study aimed to assess the outcomes,including mortality and severity of disability in AIS hospitalizations withCOVID-19. Methods: We performed a retrospective cross-sectionalanalysis of the Nationwide Inpatient Sample (NIS-2020) in adulthospitalizations for AIS to compare the outcomes [death & APRDRGseverity/disability] in COVID-19 patients using ICD-10 codes. We performedweighted analyses using chi-square, unpaired t-test, and multivariate logisticregression models to evaluate COVID-19-associated poor outcomes amongst AISpatients. Results: Out of 504,460 AIS patients, 7,590 had AIStriggered by COVID-19. Amongst AIS hospitalizations, COVID-19 was more frequentin age group >65 year old 63.2%, male 52.6%, White race (51.4%), patientwith Medicare (58.7%), median household income 0-25 percentile (33.6%), Southzone (43.4%), and hypertensives (83.7%). AIS patients with COVID-19 had ahigher mortality (10.93% vs 3.8%) and severe/extreme disability (93.21% vs37.43%) rates in comparison to patients without COVID-19. (p<0.0001) Inregression analysis COVID-19 was associated with 213% higher odds of mortality(aOR: 3.13, 95% CI: 2.90-3.38, p<0.0001, c:0.671) and higher odds of severe/extreme disability(26.85, 24.53-29.39, p<0.0001, c:0.686) compared to AIS patients withoutCOVID-19. Conclusion: These findings emphasize the substantialimpact of COVID-19 on AIS patients by elevating mortality and risk of severedisability compared to their counterparts. Efforts should be directed towards earlyidentification of stroke population that is at higher risk ofCOVID-19-associated poor outcome and prompt management tomitigate the burden of the both diseases.

Background Pediatric stroke is a debilitating disease. There are several risk factors predisposing children to this life-threatening disease. Although, published literature estimates a relatively high incidence of pediatric stroke, treatment guidelines on intravenous tissue plasminogen activator and endovascular thrombectomy utilization remain a dilemma. There is a lack of large population-based studies and clinical trials evaluating the efficacy and safety outcomes associated with these treatments in this unique population. Aim We sought to determine the prevalence of risk factors, concurrent utilization of intravenous tissue plasminogen activator and endovascular thrombectomy, and associated outcomes in pediatric stroke hospitalizations. Methods We performed a retrospective analysis of the Nationwide Inpatient Sample data (2003–2014) in pediatric (1–21 years of age) acute ischemic stroke hospitalizations using ICD-9-CM codes. The multivariable survey logistic regression model was weighted to account for sampling strategy, evaluate predictors of hemorrhagic conversion, and treatment outcomes (mortality, morbidity, and discharge disposition) amongst pediatric stroke hospitalizations. Results In this analysis, 9109 patients between 1 and 21 years of age were admitted during 2003–2014 for acute ischemic stroke. Of these 9109 patients, 119 (1.30%) received endovascular thrombectomy alone, 256 (2.82%) intravenous recombinant tissue plasminogen activator, and 69 (0.75%) both endovascular thrombectomy and intravenous recombinant tissue plasminogen activator. We found overall high prevalence of conditions like epilepsy (19.59%), atrial septal defect (11.76%), sickle cell disease (8.63%), and moyamoya disease (5.41%) in pediatric acute ischemic stroke patients. Unadjusted analysis showed high prevalence of all-cause in-hospital mortality in combined endovascular thrombectomy and intravenous recombinant tissue plasminogen activator utilization group, and higher prevalence of hemorrhagic conversion and morbidity in endovascular thrombectomy utilization group compared to other groups ( p < 0.0001). Multivariate adjusted analysis showed that children with endovascular thrombectomy utilization (aOR: 19.19; 95% CI: 2.50–147.29, p = 0.005), intravenous recombinant tissue plasminogen activator utilization (aOR: 8.85; 95% CI: 1.92–40.76, p = 0.005), and both (endovascular thrombectomy and intravenous recombinant tissue plasminogen activator) utilization (aOR: 7.55; 95% CI: 1.16–49.31, p = 0.035) had higher odds of hemorrhagic conversion compared to no-treatment group. Conclusion We found various risk factors associated with pediatric stroke. The early identification can be useful to formulate preventive strategies and influence the incidence of pediatric stroke. Our study results showed that use of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy increase risk of mortality and hemorrhagic conversion, but we suggest to have more clinical studies to evaluate the idea candidates for utilization of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy based on risk: benefit ratio.