Neurological manifestations in coronavirus disease 2019 / Manifestaciones neurológicas en la enfermedad del coronavirus 2019

Abstract Coronavirus disease 2019 (COVID-19), an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is currently hitting the world in the form of a pandemic. Given that some reports suggest that this infection can also occur with neurologic manifestations, this narrative review addresses the basic and clinical aspects concerning the nervous system involvement associated with this disease. More than one third of patients hospitalized for COVID-19 can present with both central and peripheral neurological manifestations. The former includes dizziness and headache, while the latter includes taste and smell disturbances. Other reported neurological manifestations are cerebrovascular disease and epileptic seizures. According to published reports, neurological disorders are not uncommon in COVID-19 and can sometimes represent the first manifestation of the disease; therefore, neurologists should consider this diagnostic possibility in their daily practice. Since maybe not all COVID-19 neurological manifestations are due to SARS-CoV-2 direct effects, it is important to monitor the rest of the clinical parameters such as, for example, oxygen saturation. Similarly, follow-up of patients is advisable, since whether neurological complications may develop lately is thus far unknown.

Resumen La enfermedad del coronavirus 2019 (COVID-19), infección causada por el coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2), actualmente afecta al mundo en forma de una pandemia. Debido a que algunos reportes apuntan a que esta infección puede cursar también con manifestaciones neurológicas, en esta revisión narrativa se abordan los aspectos básicos y clínicos concernientes a la afectación del sistema nervioso por esta enfermedad. Más de un tercio de los pacientes hospitalizados por COVID-19 pueden presentar manifestaciones neurológicas, tanto centrales como periféricas. Entre las primeras se encuentran el mareo y la cefalea; y entre las segundas, las alteraciones del gusto y el olfato. Otras manifestaciones neurológicas reportadas son la enfermedad vascular cerebral y las crisis epilépticas. Según los informes publicados, los padecimientos neurológicos no son infrecuentes en COVID-19 y en ocasiones pueden representar la primera manifestación de la enfermedad, de modo que los neurólogos deberán considerar esta posibilidad diagnóstica en su práctica cotidiana. Dado que no todas las manifestaciones neurológicas de COVID-19 pudieran deberse a efectos directos de SARS-CoV-2, es importante monitorear el resto de los parámetros clínicos, por ejemplo, la oxigenación. De igual forma, es recomendable el seguimiento de los pacientes, ya que hasta el momento se ignora si las complicaciones neurológicas pueden desarrollarse tardíamente.

Neurological consultations and diagnoses in a large, dedicated COVID-19 university hospital / Consultas neurológicas e diagnósticos em um grande hospital universitário dedicado a COVID-19

ABSTRACT Background: More than one-third of COVID-19 patients present neurological symptoms ranging from anosmia to stroke and encephalopathy. Furthermore, pre-existing neurological conditions may require special treatment and may be associated with worse outcomes. Notwithstanding, the role of neurologists in COVID-19 is probably underrecognized. Objective: The aim of this study was to report the reasons for requesting neurological consultations by internists and intensivists in a COVID-19-dedicated hospital. Methods: This retrospective study was carried out at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, a 900-bed COVID-19 dedicated center (including 300 intensive care unit beds). COVID-19 diagnosis was confirmed by SARS-CoV-2-RT-PCR in nasal swabs. All inpatient neurology consultations between March 23rd and May 23rd, 2020 were analyzed. Neurologists performed the neurological exam, assessed all available data to diagnose the neurological condition, and requested additional tests deemed necessary. Difficult diagnoses were established in consensus meetings. After diagnosis, neurologists were involved in the treatment. Results: Neurological consultations were requested for 89 out of 1,208 (7.4%) inpatient COVID admissions during that period. Main neurological diagnoses included: encephalopathy (44.4%), stroke (16.7%), previous neurological diseases (9.0%), seizures (9.0%), neuromuscular disorders (5.6%), other acute brain lesions (3.4%), and other mild nonspecific symptoms (11.2%). Conclusions: Most neurological consultations in a COVID-19-dedicated hospital were requested for severe conditions that could have an impact on the outcome. First-line doctors should be able to recognize neurological symptoms; neurologists are important members of the medical team in COVID-19 hospital care.

RESUMO Introdução: Mais de um terço dos pacientes com COVID-19 apresentam sintomas neurológicos que variam de anosmia a AVC e encefalopatia. Além disso, doenças neurológicas prévias podem exigir tratamento especial e estar associadas a piores desfechos. Não obstante, o papel dos neurologistas na COVID-19 é provavelmente pouco reconhecido. Objetivo: O objetivo deste estudo foi relatar os motivos para solicitar consultas neurológicas por clínicos e intensivistas em um hospital dedicado à COVID-19. Métodos: Estudo retrospectivo realizado no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brasil, um centro dedicado à COVID-19 com 900 leitos (incluindo 300 leitos para unidades de terapia intensiva). O diagnóstico de COVID-19 foi confirmado por SARS-CoV-2-RT-PCR em swabs nasais. Todas as interconsultas de neurologia hospitalar entre 23 de março e 23 de maio de 2020 foram analisadas. Os neurologistas realizaram o exame neurológico, avaliaram todos os dados disponíveis para diagnosticar a patologia neurológica e solicitaram exames adicionais conforme necessidade. Diagnósticos difíceis foram estabelecidos em reuniões de consenso. Após o diagnóstico, os neurologistas participaram da condução dos casos. Resultados: Foram solicitadas consultas neurológicas para 89 de 1.208 (7,4%) em pacientes internados por COVID-19 durante o período. Os principais diagnósticos neurológicos incluíram: encefalopatia (44,4%), acidente vascular cerebral (16,7%), doenças neurológicas prévias (9,0%), crises epilépticas (9,0%), transtornos neuromusculares (5,6%), outras lesões encefálicas agudas (3,4%) e outros sintomas leves inespecíficos (11,2%). Conclusões: A maioria das consultas neurológicas em um hospital dedicado à COVID-19 foi solicitada para condições graves que poderiam afetar o desfecho clínico. Os médicos na linha de frente devem ser capazes de reconhecer sintomas neurológicos. Os neurologistas são membros importantes da equipe médica no atendimento hospitalar à COVID-19.

Cerebrospinal fluid analysis in 58 ruminants showing neurological disorders / Análise do líquido cefalorraquidiano em 58 ruminantes com distúrbios neurológicos

Ruminants may be affected by a wide variety of central nervous system (CNS) diseases. Cerebrospinal fluid (CSF) analysis forms the basis for ante mortem diagnostic evaluation of ruminants with clinical signs involving the CNS. Despite its importance as a tool to aid diagnosis, data regarding CSF examinations in spontaneous cases of CNS diseases in ruminants from Brazil are limited, and most reports involve experimental studies. Therefore, this study aimed to report the results of CSF analysis in 58 ruminants showing signs of neurological disorders. CSF samples for analysis were obtained from 32 cattle, 20 sheep, and 6 goats by cerebello-medullary cistern (n=54) or lumbosacral space (n=4) puncture. These ruminants showed neurological signs related to viral (n=13), mycotic (n=3), or bacterial (n=15) infections, and toxic (n=21), traumatic (n=4), or congenital disorders (n=2). CSF analysis from ruminants with viral infections presented lymphocytic pleocytosis, even though CSF showed no changes in several cases of rabies. Neutrophilic pleocytosis, cloudiness, presence of fibrin clots, and abnormal coloration were evident in the CSF of most cases of CNS bacterial infection, such as meningoencephalitis, meningitis, abscesses, myelitis, and a case of conidiobolomycosis. On the other hand, CSF was unchanged in most cases of toxic disorders, as botulism and hepatic encephalopathy. Elevated CSF density was observed in 60% of ruminants diagnosed with polioencephalomalacia. Our findings show that evaluation of CSF is a valuable diagnostic tool when used in association with epidemiological, clinical and pathological findings for diagnosis of CNS diseases in ruminants.(AU)

Os ruminantes podem ser afetados por uma grande variedade de doenças do sistema nervoso central (SNC). A análise do líquido cefalorraquidiano (LCR) constitui a base da avaliação diagnóstica ante mortem de ruminantes com sinais clínicos envolvendo o SNC. Apesar de sua importância como ferramenta para auxiliar no diagnóstico, os dados referentes aos exames do LCR em casos espontâneos de doenças do SNC em ruminantes no Brasil são limitados, e, a maioria dos relatos envolve estudos experimentais. Portanto, este trabalho teve como objetivo relatar os resultados da análise do LCR em 58 ruminantes com distúrbios neurológicos. Amostras do LCR foram obtidas de 32 bovinos, 20 ovinos e 6 caprinos por punção da cisterna cerebelo-medular (n=54) ou espaço lombossacro (n=4) para posterior análise. Esses ruminantes apresentaram sinais neurológicos relacionados a infecções virais (n=13), micóticas (n=3) ou bacterianas (n=15), e desordens tóxicas (n=21), traumáticas (n=4) ou congênitas (n=2) A análise do LCR de ruminantes com infecções virais apresentou pleocitose linfocítica, embora, em vários casos de raiva, o LCR não tenha apresentado alterações. Pleocitose neutrofílica, turbidez, presença de coágulos de fibrina e coloração anormal foram evidentes no LCR da maioria dos casos de infecções bacterianas do SNC, como meningoencefalites, meningites, abscessos, mielite e um caso de conidiobolomicose. Por outro lado, o LCR não foi alterado na maioria dos casos dos distúrbios tóxicos, como botulismo e encefalopatia hepática. A densidade elevada no LCR foi observada em 60% dos ruminantes diagnosticados com polioencefalomalácia. Nossos resultados mostram que a avaliação do LCR é uma valiosa ferramenta de diagnóstico, quando usada em associação com os achados epidemiológicos, clínicos e patológicos para o diagnóstico de doenças do SNC em ruminantes.(AU)

Trastorno paroxístico no epiléptico en paciente referido por sospecha de epilepsia / Paroxysmal non-epileptic events in patients referred for suspicion of epilepsy

Los Trastornos Paroxísticos No Epilépticos (TPNE), son diagnóstico diferencial de crisis epilépticas. En Chile no existen reportes de frecuencia. OBJETIVO: Determinar frecuencia de TPNE en pacientes derivados por sospecha de epilepsia a Unidad de Electroencefalografía, Hospital Roberto del Río. METODOLOGÍA: Estudio observacional, transversal. Se revisó registros clínicos de pacientes derivados por sospecha de epilepsia(2012- 2014). Inclusión: paciente con TPNE, >1 mes, sin epilepsia previa. Caracterización: sexo, edad, tipo/subtipo TPNE, comorbilidades, electroencefalograma (EEG), uso fármaco antiepiléptico (FAE). Aprobado por comité de ética. RESULTADOS: Derivados 913 pacientes por sospecha de epilepsia. 36% TPNE (2,3% con epilepsia concomitante), 22% epilepsia aislada. TPNE más frecuente: escolares (31%), adolescentes (29%), femenino (52%). 30,1% hipoxia cerebral (síncope, Espasmo Sollozo); 22,4% trastornos del comportamiento (Descontrol Episódico, Crisis Psicógena no Epiléptica). 32,8% con comorbilidades no epilépticas (Trastornos psiquiátricos/neurodesarrollo). 4,3 % recibieron FAE. CONCLUSIONES: La frecuencia de TPNE en niños/adolescentes supera a la de epilepsia. Es fundamental evaluación multidisciplinaria.

Paroxysmal non-epileptic events (PNE) are differential diagnosis of epileptic seizures. In Chile, there are no reports on its frequency. OBJECTIVE: To determine the frequency of PNE in patients referred for suspicion of epilepsy to the Electroencephalography Unit of Roberto del Río Hospital. METHODOLOGY: Observational, cross-sectional study. Clinical records of patients referred for suspicion of epilepsy (2012-2014) were reviewed. Inclusion: Patient with PNE, >1 month, without previous epilepsy. Characterization: gender, age, PNE type/subtype, comorbidities, electroencephalogram, use of antiepileptic drug (AED). Approved by the ethics committee. RESULTS: 913 patients were referred for suspected epilepsy: 36% PNE (2,3% with concomitant epilepsy), 22% isolated epilepsy. PNE were more frequent in children (31%) adolescents (29%), and in females (52%). 30.1% Cerebral hypoxia (syncope, breathholding-spells); 22,4% Behavioral disorders (Episodic loss of control, Non-Epileptic Psychogenic Seizures). 32.8% non-epileptic comorbidities (Psychiatric/ neurodevelopmental disorders). 4.3% received AEDs. CONCLUSIONS: The frequency of PNE in children and adolescents exceeds that of epilepsy. A multidisciplinary medical evaluation is of the outmost importance. Keywords: Paroxysmal Non-Epileptic Disorder, Non-epileptic episodes, Epilepsy.

Crisis sintomáticas agudas y epilepsia en niños y adolescentes en época de COVID-19 / Acute symptomatic crisis and epilepsy in children and adolescents in times of COVID-19

Objetivo: Describir los aspectos de mayor relevancia en niños y adolescentes con crisis sintomáticas agudas o diagnóstico de epilepsia, en tiempo de pandemia de la COVID-19. Métodos: La información se obtuvo de las bases de datos PubMed/Medline, Scielo, y Clinical Key utilizando palabras clave incluidas en el Descriptor de Ciencias de la Salud en idioma inglés o español, sin límite de tiempo, y todo tipo de publicación; se seleccionaron los artículos relacionados con epilepsia, crisis epilépticas, y COVID-19. Resultados: En la literatura se justifica la ocurrencia de crisis epilépticas por varias causas en enfermos con la COVID-19 y se insiste en la conducta terapéutica y la necesidad de vigilancia de las interacciones farmacológicas entre los medicamentos indicados para la prevención de recurrencia de las crisis epilépticas y los específicos para esta nueva enfermedad. Basado en estos criterios, presentamos una propuesta para la conducta a seguir en cada situación. Consideraciones finales: Esta comprobada la posibilidad de que ocurran complicaciones neurológicas en pacientes con la COVID-19 y específicamente en las crisis epilépticas y la epilepsia. El uso de interferón y lopinavir/ritonavir, en caso de estar indicado en los protocolos de actuación, y el mantenimiento del tratamiento previo con los medicamentos para prevenir la recurrencia de crisis en los epilépticos, considerando las posibles interacciones y la vigilancia requerida en cada caso, parece ser la mejor opción en la mayoría de los niños y adolescentes con COVID-19(AU)

Objective: To describe the most outstanding aspects in children and adolescents with acute symptomatic crisis or diagnosis of epilepsy in times of the COVID-19 pandemic. Methods: The information was collected in PubMed/Medline, Scielo and Clinical Key databases using the keywords included in the Descriptor of Health Sciences in English or Spanish language, with not time limit, and looking for all kind of publications. There were selected articles related to epilepsy, epileptic seizures and COVID-19. Results: In the consulted literature, it was justified the occurrence of epileptic seizures due to different causes in patients with COVID-19 and it is highlighted the therapeutic behaviour and the need of surveillance of the pharmacologic interactions among the drugs indicated for the prevention of epileptic seizures and the specific of this new disease. Based in these precepts, we present a final proposal for the behaviour to follow in each situation. Final considerations: It is proved the possibility of neurologic complications in patients with COVID-19 and specifically in the epileptic seizures and epilepsy. The use of interferon and lopinavir/ritonavir, in case of being indicated in the action protocols, and to keep the previous treatment with the drugs to prevent the recurrence of crisis in epileptic patients considering the possible interactions and the required surveillance in each case, seems to be the best option in most of the children and adolescents with COVID-19(AU)

The Importance of Otoneurological Evaluation in Brazilian Workers Exposed to Pesticides: A Preliminary Study

Introduction: Agrochemicals, also known as pesticides, are widely used in agriculture and in public health. They are organic and inorganic chemical substances with a high level of toxicity not only for the environment, but also for human health. Objective: To verify findings on labyrinthine assessment in endemic disease control agents, and to recommend the inclusion of the vestibular exam in the set of tests for pesticide-exposed populations. Methods: Descriptive, prospective, cross-sectional study with a sample comprising 15 endemic disease control agents, males, mean age of 51.6 years old (standard deviation [SD] = 5.9). All of the participants were submitted to anamnesis, otorhinolaryngological screening, and vestibular assessment. Results: Regarding the most reported complaints, dizziness (73.4%), headache (60%), and tingling in the extremities (53.4%) were observed. The findings of the vestibular exams were normal in 53.3%, while 46.7% showed peripheral vestibular disorder, of which 26.7% were of deficitary type, and 20% of the irritative type. Conclusions: Alteration in the vestibular system was verified in 50% of the workers, with a greater prevalence in the caloric testing. Several disorders related to pesticides intoxication are scientifically known. Actions promoting knowledge and qualification of this population for the proper handling of chemicals are suggested, in addition to the elaboration and inclusion of protocols of vestibular assessment in hearing health programs for the prevention, diagnosis and treatment of vestibular disorders (AU)

Neurological signs described at the Federal University of Rio de Janeiro: connecting the past to the future / Sinais neurológicos descritos na Universidade Federal do Rio de Janeiro: conectando o passado ao futuro

ABSTRACT The Federal University of Rio de Janeiro (UFRJ) is one of the pillars of Brazilian Medicine and, in Neurology, has always shown prominence, with notable professors such as Antônio Austregésilo and Deolindo Couto. Historically, practitioners of the UFRJ Medical School have discovered neurological signs that, although used in medical and academic practice, have never been published. Objective Our aim was to bring these signs to the forefront so that they become properly recognized and studied. Methods We conducted our search by questioning 49 professors and physicians by e-mail about neurological signs that they remembered having had contact with at UFRJ. Results We report on the unpublished pillow sign in progressive supranuclear palsy; the Brazilian sandal sign in functional or malingering patients; the dermographism sign in acute meningitis; the reverse forearm rolling sign in functional palsies; the cycling maneuver in parkinsonian syndromes and the Sá Cavalcanti sign, a Babinski equivalent. We have also recollected the following published signs for their historical relevance: the Austregésilo sign (Antônio Austregésilo), another Babinski equivalent; the digiti quinti rolling sign in subtle palsies (Péricles Maranhão) and the digiti quinti sign in hemiplegic migraine (Maurice Vincent). These signs are easily reproduced and have potential clinical applicability, deserving to be more thoroughly studied. Conclusions Through a qualitative methodology, we have identified six original unpublished neurological signs known by the academic community, establishing the contribution of these individuals to the expansion of neurological semiology.

RESUMO A Universidade Federal do Rio de Janeiro é um dos pilares da Medicina brasileira. Na Neurologia sempre se destacou com notáveis professores, como Antônio Austregésilo e Deolindo Couto. Historicamente, professores da Faculdade de Medicina da UFRJ descreveram sinais neurológicos que, embora utilizados na prática médica e acadêmica, nunca foram publicados. Objetivo Fazer ressurgir sinais clínicos neurológicos nunca antes publicados, para que possam ser devidamente reconhecidos e estudados. Métodos Quarenta e nove professores e médicos foram contactados por e-mail. Dez responderam questionário semi-estruturado acerca de sinais neurológicos conhecidos pelos profissionais, porém nunca publicados. Resultados Foram relatados: 1- Sinal do Travesseiro - na Paralisia Supranuclear Progressiva; 2- Sinal da sandália- nos pacientes funcionais ou simuladores; 3- Sinal do dermografismo- nas meningites agudas da infância; 4- Sinal do rolamento reverso do antebraço- nas paralisias funcionais; 5- Manobra do pedalar- nas síndromes parkinsonianas; 6- Sinal de Sá Cavalcanti- um sucedâneo de Babinski. Revisamos também os seguintes sinais publicados, por sua relevância histórica: o sinal Austregésilo, outro sucedâneo de Babinski; sinal do rolamento do quinto dedo- nas paralisias sutis e o sinal do quinto dedo- na enxaqueca hemiplégia. Conclusão Por meio de metodologia qualitativa, identificamos seis sinais neurológicos inéditos originais. Esses sinais são de fácil reprodutibilidade e têm aplicabilidade clínica potencial, merecendo estudos adicionais.

Non-invasive brain stimulation therapies / Terapias de neuroestimulação não invasivas

Noninvasive brain stimulation therapies are a promising field for the development of new protocols for the treatment of neuropsychiatric disorders. They are based on the stimulation of neural networks with the intent of modeling their synaptic activity to adequate levels. For this, it is necessary to precisely determine which networks are related to which brain functions, and the normal activation level of each of these networks, so that it is possible to direct the stimulation to the affected networks in order to induce the desired effects. These relationships are under intense investigation by the scientific community, and will contribute to the advancement of treatments by neurostimulation, with the emergence of increasingly accurate and effective protocols for different disorders. Currently, the most used techniques are Transcranial Direct Current Stimulation and Transcranial Magnetic Stimulation, with the most common applications being for treating Major Depressive Disorder. The advancement of research in this field may determine new target networks for stimulation in the treatment of other disorders, extending the application of these techniques and also our knowledge about brain functioning.

As terapias biológicas não invasivas se apresentam como um campo promissor para o desenvolvimento de novos protocolos de tratamento de transtornos neuropsiquiátricos. Elas se baseiam na estimulação de redes neurais com intuito de modular sua atividade sináptica para níveis adequados. Para isso, é necessário a determinação precisa de quais redes estão relacionadas a quais funções cerebrais, e do nível de ativação normal de cada uma dessas redes, para que então seja possível direcionar a estimulação às redes afetadas a fim de induzir os efeitos desejados. Essas relações estão sob intensa investigação pela comunidade científica, e vão contribuir para o avanço dos tratamentos por neuroestimulação, com o surgimento de protocolos cada vez mais precisos e efetivos para diferentes transtornos. Atualmente, as técnicas mais utilizadas são a Estimulação Transcraniana por Corrente Contínua e a Estimulação Magnética Transcraniana, sendo a aplicação mais comum no tratamento do Transtorno Depressivo Maior. O avanço das pesquisas possivelmente determinará novas redes alvo para estimulação no tratamento de outros transtornos, estendendo a aplicação dessas técnicas e também do nosso conhecimento sobre o funcionamento cerebral.

Neurologic complications of HTLV-1: a review / Complicações neurológicas do HTLV: uma revisão HTLV-1

The human T-cell lymphotropic virus type 1 (HTLV-1) is a retrovirus that infects about 20 million people worldwide and causes immune-mediated diseases of the nervous system. The classical neurological presentation of HTLV-1 infection is the so-called HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). However, HAM/ TSP is not the only neurological outcome that can result from HTLV-1 infection. In this Review it is made an update on the many aspects of this important neurological condition, the HTLV-1 neurological complex.

O vírus linfotrópico de células T humanas tipo 1 (HTLV-1) é um retrovírus que infecta cerca de 20 milhões de pessoas em todo o mundo e causa doenças imunomediadas do sistema nervoso. A apresentação neurológica clássica da infecção pelo HTLV-1 é a chamada paraparesia espástica tropical / mielopatia associada ao HTLV-1 (HAM/TSP). HAM / TSP,no entanto, não é o único desfecho neurológico que pode resultar da infecção pelo HTLV-1. Nesta revisão, é feita uma atualização sobre vários aspectos desta importante condição neurológica, o complexo neurológico do HTLV-1.

Neuropatía precoz: Importancia de la evaluación neurofisiológica en el sindrome metabólico con o sin disregulación glucémica / Early neuropathy. Importance of neurophysiological assessment in cases of metabolic syndrome with or without hyperglycemia

La neuropatía periférica y autonómica es una de las complicaciones más comunes en pacientes con diabetes. La lesión nerviosa comienza tempranamente, en aquellos con diabetes mellitus de tipo II puede comenzar antes de la disregulación glucémica, en la etapa del síndrome metabólico. En un primer momento puede ser asintomática, por lo que es fundamental la realización de técnicas electrofisiológicas para su detección temprana, para implementar medidas terapéuticas que impidan su progresión. Se presentan nueve casos, tres con síndrome metabólico y alteración del metabolismo de la glucosa, uno con síndrome metabólico sin hiperglucemia y cinco con alteración del metabolismo de la glucemia sin otros criterios diagnósticos de síndrome metabólico. Todos estaban asintomáticos y el examen neurológico fue normal. Se realizaron técnicas de detección de neuropatía periférica temprana (razón sural/radial, ondas F, reflejo H, respuestas simpáticas de la piel, período silente cutáneo y variabilidad del intervalo RR). Ocho pacientes tuvieron neuropatía autonómica cardíaca incipiente y uno neuropatía autonómica establecida. Ocho presentaron neuropatía somática incipiente (siete con alteración de la razón sural/radial, y uno con alteración de las ondas F). Un paciente tuvo alteración sublínica de las fibras finas (alteración de las respuestas simpáticas de la piel y del período silente cutáneo). Es importante la detección de la neuropatía temprana antes de su manifestación clínica ya que existen tratamientos para detenerla e incluso revertirla.

Comparison of the Tinetti and Short Physical Performance Battery test specificities for detecting neuromotor pathologies / Comparativo da especificidade das escalas de Tinetti e Short Physical Performance Battery na detecção de patologias neuromotoras

Introduction: Increasing elderly populations require specific and accurate health assessment tools. Purpose: To compare the specificities of the short physical performance battery (SPPB) and the Tinetti Index validated in Brazil in patients with and without neuromotor dysfunctions. Materials and methods: Thirty-nine individuals (19 healthy and 20 with neuromotor changes) of both sexes aged 60­75 years, living in Coari (Amazonas state in Brazil), underwent SPPB and Tinetti scale assessments on alternate dates. Results and discussion: We observed significant differences between the scales, where the distribution was very concentrated after the Tinetti assessment and more dispersed after the SPPB in healthy individuals. This demonstrated that SPPB can detect minimal differences in gait and balance between healthy individuals, while the Tinetti scale is better at discriminating between healthy and those affected by mobility disorders. Conclusion: SPPB was more specific than the Tinetti Index in detecting changes in gait and balance.

Introdução: o aumento do público idoso nos serviços de saúde requer instrumentos de avaliação cada vez mais específicos e precisos no diagnóstico deles. Objetivo: comparar a especificidade da SPPB e Índice de Tinetti validadas no Brasil em pacientes com e sem disfunções neuromotoras. Materiais e Métodos: 39 sujeitos (19 saudáveis e 20 com alterações neuromotoras) de ambos os sexos com idade entre 60 e 75 anos, residentes em Coari ­ AM, realizaram em datas alternadas avaliação pelas escalas SPPB e Tinetti. Resultados e discussão: foi observada diferença significativa entre as escalas, onde a distribuição mostrou-se muito concentrada em Tinetti e mais dispersa na SPPB para o grupo saudável, demonstrando que a SPPB conseguiu detectar as mínimas diferenças em marcha e equilíbrio entre indivíduos saudáveis; enquanto a escala de Tinetti discriminou melhor os indivíduos saudáveis dos patológicos. Conclusão: a SPPB mostrou-se mais específica que Tinetti, sendo capaz de detectar melhor alterações em marcha e equilíbrio.

Evaluation of Tooth Brushing in Slovak Patients with Sclerosis Multiplex

Objective: To analyse issue of teeth brushing according to age, gender and length in Slovak patients with multiple sclerosis disease (MS). Material and Methods: In this descriptive study, the questionnaires were collected in neurologists from December 2016 until September 2017. The study sample consisted of 103 MS patients (44.7% of men) in a mean age of 38.4 ± 9.95 years. The study sample of MS patients was divided into two sub-groups. The first sub-group consisted of MS patients who were restricted in teeth brushing (n=56) and the second group of MS patients, which had no restrictions in teeth brushing (n=47). Descriptive statistics were used to calculate the absolute and relative frequencies, mean and standard deviation. A two-sample ttest was used to compare of the proportion between sub-groups with restrictions and sub-group no restrictions in teeth brushing. The statistically significant level was determined at p<0.05. Results: The significant higher mean age (40.4 ± 10.8 years) was found in MS patients who had restrictions in teeth brushing (p=0.043). Females described often no restrictions in teeth brushing than males (59.6% vs. 40.4%; p<0.05). Length in MS disease (≤3 years) has significant impact on patients in who were not found restrictions in teeth brushing (31.9%; p=0.037). Conclusion: We recommend individual doctor approach to MS patients in older age and using of electric toothbrushes in MS patients who have hand functioning restrictions.

Morbilidad neurológica en el Policlínico Ramón López Peña, Santiago de Cuba, enero a diciembre de 2018 / Morbidade neurológica na policlínica Ramón López Peña, Santiago de Cuba, janeiro a dezembro de 2018 / Neurological morbidity in the Ramón López Peña Polyclinic, Santiago de Cuba, January to December 2018

Introducción: la demanda neurológica ambulatoria ha ido creciendo constantemente. Existen pocos datos estadísticos sobre las patologías neurológicas en nuestra población. Objetivo: caracterizar la morbilidad neurológica del Policlínico Docente "Ramón López Peña" en el periodo comprendido de enero a diciembre de 2018. Método: se realizó un estudio descriptivo transversal de 247 pacientes que asistieron a consulta de Neurología del Policlínico Docente "Ramón López Peña" de Santiago de Cuba, de enero a diciembre de 2018. Las variables estudiadas fueron edad, sexo, enfermedades neurológicas, grupos etiopatogénicos, origen de la remisión y concordancia diagnóstica. Resultados: predominó el sexo femenino con un 63,9 por ciento y el grupo de edad entre los 55 a 64 años representados por 61 pacientes para un 25 por ciento, la enfermedad neurológica más frecuente fue la cefalea con 63 pacientes, para 25,5 por ciento, seguidas de la epilepsia con 34 pacientes (13,7 por ciento) y las polineuropatías con 31 pacientes (12,5 por ciento), los pacientes fueron remitidos predominantemente por el médico de familia y no hubo concordancia diagnóstica en un tercio de los pacientes, para un 37,44 por ciento. Conclusiones: el trastorno neurológico más frecuente fue la cefalea en féminas de 55 a 64 años de edad y las remisiones en su mayoría fueron realizadas por el médico de familia, no existió coincidencia diagnóstica en un por ciento considerable de los casos lo que denota la necesidad de superación a todos los niveles en el conocimiento de la semiología y patología del sistema nervioso(AU)

Introduction: the ambulatory neurological demand has been growing steadily. There are few statistical data on neurological diseases in our population. Objective: to characterize the neurological morbidity of the "Ramón López Peña" Polyclinic in the period from January to December 2018. Method: a cross-sectional descriptive study of 247 patients who attended the Neurology clinic of the Ramón López Peña polyclinic in Santiago de Cuba, from January to December 2018. The variables studied were age, sex, neurological diseases, etiopathogenic groups, origin of remission and diagnostic concordance. Results: the female sex predominated with 63.9 percent and the age group between 55 to 64 years represented by 61 patients for 25 percent, the most frequent neurological disease was headache with 63 patients, for 25.5 percent, followed by epilepsy with 34 patients (13.7percent) and polyneuropathies with 31 patients (12.5 percent), the patients were predominantly referred by the family doctor and there was no diagnostic agreement in a third of the patients for a 37, 44 percent. Conclusions: the most frequent neurological disorder was headache, in females from 55 to 64 years of age and the remissions were mostly made by the family doctor, there was no diagnostic agreement in a considerable percentage of the cases, which denotes the need to overcome at all levels in the knowledge of the semiology and pathology of the nervous system(AU)

Introdução: a demanda neurológica ambulatorial vem crescendo de forma constante. Existem poucos dados estatísticos sobre doenças neurológicas em nossa população. Objetivo: caracterizar a morbidade neurológica Policlinico "Ramon Lopez Peña" no período de janeiro a dezembro de 2018. Métodos: Estudo descritivo de 247 pacientes atendidos na clínica visita Neurology "Ramon Lopez Peña" Santiago de realizada Cuba, de janeiro a dezembro de 2018. As variáveis estudadas foram idade, sexo, doenças neurológicas, grupos etiopatogênicos, origem da remissão e concordância diagnóstica. Resultados: predominância do sexo feminino com 63,9 por cento e o grupo de idade entre 55 e 64 representadas por 61 a 25 por cento dos pacientes, a doença neurológica mais frequente foi a dor de cabeça com 63 pacientes, para 25,5 por cento, seguido 34 pacientes com epilepsia (13,7 por cento) e polineuropatias com 31 pacientes (12,5 por cento) pacientes foram referidos predominantemente pelo médico de família e nenhum acordo diagnóstico em um terço dos pacientes 37, 44 por cento. Conclusões: O distúrbio neurológico mais comum foi dor de cabeça, em mulheres de 55 a 64 anos e referências em sua maioria foram feitas pelo médico de família, não havia concordância diagnóstica em uma porcentagem considerável de casos que denota precisa superar em todos os níveis no conhecimento da semiologia e patologia do sistema nervoso(AU)

Identification of factors related to cases of benign paroxysmal positional vertigo refractory to canalicular repositioning maneuvers and evaluation of the need for magnetic resonance imaging in their management: retrospective analysis of a series of 176 cases

Introduction: Benign paroxysmal positional vertigo (BPPV) is the most common form of peripheral vertigo, and, in most cases, it presents a favorable prognosis. The treatment is based on a series of specific canalicular repositioningmaneuvers that offer an efficacy close to 100%. Despite this, there are cases that are refractory to treatment, with the persistence of the vertigo symptoms. Objectives: The objective of the present paper is to analyze the factors associated with an increased risk of refractory BPPV and the importance of nuclear magnetic resonance in the study of these patients. Methods: We retrospectively reviewed the cases of 176 patients diagnosed with BPPV in our center.We divided them into two groups: responders and non-responders to the treatment, and analyzed the possible risk factors associated with a higher risk of refractory vertigo. Fischer exact test was used. Results: We found 11 cases refractory to treatment; all of them underwent magnetic resonance imaging (MRI) with gadoliniumaccording to our protocol. Of these, four had an otoneurologic background or pathology, and two other patients presented a multicanal involvement. The difference between the two groups was statistically significant (p < 0.05). Conclusion: Otoneurologic background and multicanal involvement were associated with a higher risk of refractory BPPV. When dealing with a BPPV with persistent symptomatology/nystagmus or with early relapse after an initial improvement, other entities that enter into the differential diagnosis must always be considered. We consider it essential to perform an MRI with gadolinium to rule out cases of BPPV that have a central cause (AU)

Deterioro neurológico progresivo como forma de presentación inusual del neurobehçet / Progressive neurological deterioration as unusual form of neuro-behçet presentation

La enfermedad de Behçet puede afectar a varios órganos y tiene dentro de sus características la presencia de úlceras recurrentes genitales, orales y la uveítis. El neurobehçet es una de las manifestaciones clínicas más serias e infrecuente de la enfermedad de Behçet y debe ser considerado en el diagnóstico diferencial con enfermedades inflamatorias, infecciosas o desmielinizante del sistema nervioso central. Este reporte de caso describe a una paciente con manifestaciones neurológicas aguda severas, lo cual es inusual en esta enfermedad(AU)

Behçet's disease can affect several organs and the presence of recurrent genital, oral and uveitis ulcers characterize it. Neuro-Behçet's is one of the most serious and uncommon clinical manifestations of Behçet's disease, so it should be taken into account in the differential diagnosis with inflammatory, infectious or demyelinating diseases of the central nervous system. This case report describes a female patient with acute severe neurological manifestations, unusual in this disease(AU)

Potential role of dengue virus, chikungunya virus and Zika virus in neurological diseases

This study showed that laboratory markers of recent infection by dengue, Zika or chikungunya arboviruses were detected in the biological samples of approximately one-third of patients with encephalitis, myelitis, encephalomyelitis or Guillain-Barré syndrome, in a surveillance programme in Piauí state, Brazil, between 2015-2016. Fever and myalgia had been associated with these cases. Since in non-tropical countries most infections or parainfectious diseases associated with the nervous system are attributed to herpesviruses, enteroviruses, and Campylobacter jejuni, the present findings indicate that in tropical countries, arboviruses may now play a more important role and reinforce the need for their surveillance and systematic investigation in the tropics.

Alteraciones del neurodesarrollo en pacientes con hipotiroidismo congénito: Recomendaciones para el seguimiento / Neurodevelopmental assessment of patients with congenital hypothyroidism

Congenital hypothyroidism (CH) is the most common cause of preventable cognitive disability worldwide. Generally, it is produced by an alteration in the embryogenesis of the thyroid gland or by an alteration in the synthesis of thyroid hormones, which determine that affected patients have low or absent thyroid hormone concentrations. The importance of this fact is that brain development during the first three years of life is highly dependent on thyroid hormones. Prior to the implementation of national neonatal screening programs around the world, 8 to 27% of children with CH had an IQ lower than 70. Nowadays, this percentage is close to 0 in countries that have implemented the program. In Chile, CH neonatal screening program achieved national coverage in 1996. Currently, the incidence of the disease in our country is 1: 3163. The degree of disability produced by CH not only depends on the time of detection of the disease and the prompt start of therapy, but also on an adequate monitoring. Despite screening programs, neurocognitive impairment in schoolchildren and teenagers with CH is still observed, reflected in lower scores in cognitive, language and gross motor assessments, receptive communication, expressive communication, fine motor and gross motor skills compared to healthy children. Also, lesser achievements in learning and language disorders are observed. The objective of this review is to update the information available on neurodevelopment of patients with CH.

Acute Onset Neurological Disorders during Pregnancy: A Literature Review / Doenças neurológicas de início durante a gravidez: análise crítica da literatura

Abstract Objectives To characterize the most common peripheral and central neurological disorders during pregnancy. Methods Original research and review of the literature on neurological complications during pregnancy. We searched for keywords related to the topic on different databases. Results Pregnancy involves physiological changes that can trigger peripheral neurological and/or central nervous system pathologies, which can sometimes be associated with hypertensive disorders. A definitive diagnosis of neurological disorders can be made according to the trimester of pregnancy and the clinical findings. Carpal tunnel syndrome and peripheral facial palsy are common peripheral neurological disorders, more frequent in the second half of pregnancy. Central nervous disorders are more complex and a precise diagnosis must be made in order to improve perinatal outcomes, provide correct management and treatment and to prevent acute and long-term complications. Conclusions It is possible to achieve a precise diagnosis,management and treatment of neurological disorders during pregnancy, but these require a multidisciplinary approach, crucial to improve perinatal outcomes.

Resumo Objetivos Caracterizar as alterações neurológicas centrais e periféricas mais comuns durante a gravidez. Métodos Foi efetuada uma revisão da literatura acerca de complicações neurológicas durante a gravidez. Foram utilizadas diversas bases de dados usando palavras-chave relacionadas com o tema. Resultados A gravidez envolve alterações fisiológicas que podem desencadear alterações neurológicas periféricas e/ou do sistema nervoso central, por vezes associadas a distúrbios hipertensivos. Um diagnóstico definitivo pode ser feito tendo em conta o trimestre de gravidez e os achados clínicos encontrados. A síndrome do túnel carpal e a paralisia facial periférica são alterações neurológicas periféricas comuns que ocorrem mais frequentemente na segunda metade da gravidez. As alterações em termos do sistema nervoso central são mais complexas. Um diagnóstico preciso é fulcral, não só para melhorar os desfechos perinatais, mas também para efetuar uma vigilância e tratamento adequados e para prevenir complicações agudas e a longo prazo. Conclusões Um diagnóstico preciso e um acompanhamento e tratamento apropriados dos distúrbios neurológicos durante a gravidez são ações exequíveis. Contudo, requerem uma abordagem multidisciplinar, crucial para melhorar os desfechos perinatais.