Feasibility and Efficacy of Online Neuropsychological Assessment.

Neuropsychological testing has intrinsic challenges, including the recruitment of patients and their participation in research projects. To create a method capable of collecting multiple datapoints (across domains and participants) while imposing low demands on the patients, we have developed PONT (Protocol for Online Neuropsychological Testing). Using this platform, we recruited neurotypical controls, individuals with Parkinson's disease, and individuals with cerebellar ataxia and tested their cognitive status, motor symptoms, emotional well-being, social support, and personality traits. For each domain, we compared each group to previously published values from studies using more traditional methods. The results show that online testing using PONT is feasible, efficient, and produces results that are in line with results obtained from in-person testing. As such, we envision PONT as a promising bridge to more comprehensive, generalizable, and valid neuropsychological testing.

Isolated cerebral mucormycosis in post-COVID-19 pneumonia

Background: Rhino-orbital-cerebral and isolated cerebral involvement of basal ganglia by mucormycosis are two different manifestations of CNS mucormycosis. The former variant caused by inhaled fungal spores and is common with immunosuppressive conditions. The latter form is caused by intravascular inoculation of spores as seen in intravenous drug abusers. Case report: Here we describe a case of young, non-addict patient with a history of recent mild COVID-19 pneumonia who presented with isolated cerebral mucormycosis involving bilateral basal ganglia. Discussion(s): The pulmonary vasculitis associated with COVID-19 is probably the cause of direct intravascular entry of inhaled fungal spores leading to direct isolated cerebral involvement. Such condition may rapidly turn fatal. Conclusion(s): This is the first reported case of isolated cerebral mucormycosis following post-COVID-19 infection. Early tissue diagnosis and intravenous amphotericin B is the key management.Copyright © 2022

Structural brain changes in patients with post-COVID fatigue: a prospective observational study.

Background: Post-COVID syndrome is a severe long-term complication of COVID-19. Although fatigue and cognitive complaints are the most prominent symptoms, it is unclear whether they have structural correlates in the brain. We therefore explored the clinical characteristics of post-COVID fatigue, describe associated structural imaging changes, and determine what influences fatigue severity. Methods: We prospectively recruited 50 patients from neurological post-COVID outpatient clinics (age 18-69 years, 39f/8m) and matched non-COVID healthy controls between April 15 and December 31, 2021. Assessments included diffusion and volumetric MR imaging, neuropsychiatric, and cognitive testing. At 7.5 months (median, IQR 6.5-9.2) after the acute SARS-CoV-2 infection, moderate or severe fatigue was identified in 47/50 patients with post-COVID syndrome who were included in the analyses. As a clinical control group, we included 47 matched multiple sclerosis patients with fatigue. Findings: Our diffusion imaging analyses revealed aberrant fractional anisotropy of the thalamus. Diffusion markers correlated with fatigue severity, such as physical fatigue, fatigue-related impairment in everyday life (Bell score) and daytime sleepiness. Moreover, we observed shape deformations and decreased volumes of the left thalamus, putamen, and pallidum. These overlapped with the more extensive subcortical changes in MS and were associated with impaired short-term memory. While fatigue severity was not related to COVID-19 disease courses (6/47 hospitalised, 2/47 with ICU treatment), post-acute sleep quality and depressiveness emerged as associated factors and were accompanied by increased levels of anxiety and daytime sleepiness. Interpretation: Characteristic structural imaging changes of the thalamus and basal ganglia underlie the persistent fatigue experienced by patients with post-COVID syndrome. Evidence for pathological changes to these subcortical motor and cognitive hubs provides a key to the understanding of post-COVID fatigue and related neuropsychiatric complications. Funding: Deutsche Forschungsgemeinschaft (DFG) and German Ministry of Education and Research (BMBF).

A 14-year-old boy with multiple trauma and bilateral basal ganglia hemorrhage due to coronavirus disease 2019: a case report.

BACKGROUND: In December 2019, coronavirus disease 2019 spread worldwide, causing acute respiratory distress syndrome. Coronavirus disease 2019 presents from an asymptomatic infection to severe disease causing multiorgan failure. Neurological manifestations were observed in some patients, including intracerebral hemorrhage. Bilateral basal ganglia hemorrhage is rare due to trauma. CASE PRESENTATION: Our patient was a 14-year-old Iranian boy with multiple trauma and loss of consciousness who tested positive for coronavirus disease 2019. The brain computed tomography scan reported bilateral basal ganglia hemorrhage. Bilateral ground glass opacity was reported through a chest computed tomography scan. DISCUSSION AND CONCLUSIONS: In this study, we reported a 14-year-old boy referred to the emergency room due to multiple trauma. Through the medical interventions, bilateral basal ganglia hemorrhage was discovered incidentally. Coronavirus disease 2019 was detected in this patient on the basis of findings in chest computed tomography scan and positive real reverse transcription polymerase chain reaction test. Several clinical reports and series exploring the relationship between coronavirus disease 2019 and ischemic strokes have been published. Coronavirus disease 2019, like other acute respiratory syndromes, can invade the central nervous system through hematogenous and neuronal dissemination or it can be an immune response to the cytokine storm. In conclusion, it is vital to know the pathophysiology of the neurological manifestations of coronavirus disease 2019 and prevent the mild neurological manifestations leading to severe conditions.

Bilateral Carotid Artery Dissections and Ischemic Stroke in a Patient With COVID-19: A Case Report.

An unresponsive patient with COVID-19 infection should prompt immediate evaluation with consideration of a vast differential diagnosis entailing a multitude of diagnostic and therapeutic interventions in the emergency department. We report a case of an unresponsive 41-year-old female with COVID-19 infection and a history of rheumatoid arthritis who presented to the emergency department with bilateral carotid artery dissections and left internal carotid artery thrombus that extended into the middle cerebral artery. This case calls into question if COVID-19 is coincidentally or causally associated with acute vascular and thromboembolic disease.

July Infographic

July Infographic : COVID‐19 Infection Enhances Susceptibility to Oxidative Stress–Induced Parkinsonism

The claustrum. . . and other stories

Air pollutants and acute coronary syndrome A huge case crossover study from China (more than one million patients from 2000 hospitals in 300 cities) links transient increases in exposures to fine particulate matter, nitrogen dioxide, sulphur dioxide, and carbon monoxide to the timing of the onset of acute coronary syndrome. Data from the English Longitudinal Study of Ageing show that any benefit from this restriction came at the cost of poorer mental health. Self-reported memory difficulties Subjective cognitive difficulties, defined as the self-report of deterioration in memory or other domains of cognition in the absence of any objective deficit, can be an early precursor of dementia, according to a longitudinal study of 6000 middle aged people in Saarland, Germany.

A 40-Year-Old Woman With COVID-19 and Bilateral Vision Loss.

Mucormycosis is a fast-spreading angioinvasive fungal infection with a very high mortality rate. It is associated with immunodeficiency, diabetes mellitus, iron overload, stem cell transplantation and the use of steroids. As cultures and histopathological biopsy may have low yield in invasive fungal infections, new generation sequencing of cfDNA (cell free deoxyribonucleic acid) has become a cornerstone for diagnosis. Over the past 18 months, increasing reports of COVID-19 associated Mucormycosis have emerged, most specifically in India and other nearby developing countries. Awareness and knowledge of this newly discovered association is of high importance and clinical relevance as the global COVID-19 pandemic continues. Herein, we present a case of a patient who was treated with steroids for COVID-19 in the outpatient setting and presented with unilateral periorbital pain and blurry vision. She progressively developed bilateral vision loss, fixed bilateral mydriasis, ophthalmoplegia and coma. Imaging findings included leptomeningeal, vascular, and subcortical enhancement accompanied with multifocal infarction. Subsequent biopsy of the paranasal sinuses revealed broad type fungal elements and cfDNA sequencing identified the pathogen as Rhizopus species. She was treated with intravenous amphotericin B, but succumbed to the infection.

Interventions for mild hyperparathyroidism . . . and other stories

Statins and parkinsonism Repeated assessments of 2800 community dwelling older adults suggest that statin users have a reduced risk of developing parkinsonian signs and symptoms. Exercise following a cardiovascular event Physical activity is well known to promote cardiovascular health. Consider the patient’s life expectancy before initiating intensive treatment of blood pressure (JAMA Intern Med doi:10.1001/jamainternmed.2022.1657).

Lower Prevalence of Chronic Pain in Manifest Huntington's Disease: A Pilot Observational Study.

Pain is a minor problem compared with other Huntington Disease (HD) symptoms. Nevertheless, in HD it is poorly recognized and underestimated. So far, no study evaluated the presence of chronic pain in HD. The aim of this pilot study was to evaluate the presence and features of chronic pain in a cohort of HD gene carriers. An observational cross-sectional study was conducted in a cohort of HD gene carriers compared to not gene carriers (n.134 HD subjects, n.74 not gene mutation carriers). A specific pain interview, alongside a neurological, cognitive and behavioural examination, was performed in order to classify the type of pain, subjective intensity. A significant prevalence of "no Pain" in HD was found, which tended to increase with HD progression and a reduced frequency of pain in the last 3 months. A clear difference was found between manifest and premanifest HD in terms of intensity of pain, which did not change significantly with HD progression; however, a tendency emerges to a progressive reduction. No significant group difference was present in analgesic use, type and the site of pain. These findings could support a lower prevalence of chronic pain in manifest HD. Prevalence and intensity of chronic pain seem directly influenced by the process of neurodegeneration rather than by an incorrect cognitive and emotional functioning.

Unusual Involvement of Basal Ganglia and Dentate Nucleus in Children with Acute Encephalopathy with COVID-19.

Children account for 1% to 5% of diagnosed COVID-19 infection with relatively mild presentation compared to adults. The frequency of neurological involvement in acute COVID-19 infection in children is unclear. COVID-19 is also considered to be a neurotropic virus, but so far, in the pediatric age group, very few cases with involvement of basal ganglia and no case of dentate nucleus involvement have been reported in the literature. The present paper reports two cases of acute encephalopathy with COVID-19, the first case with basal ganglia involvement and the second with dentate nucleus involvement. Both cases required aggressive management and had complete neurological recovery on follow-up. Hence, these cases are reported to make everyone aware of the neurological presentation with atypical neuroimaging finding of acute COVID-19 infection in the pediatric age group; timely management improves the outcome.

Bloody Ventriculography: Intracerebral Hemorrhage Artistically Casting the Ventricular System's Anatomy Into a Bird's Head.

Causes of intracerebral hemorrhage are mostly attributed to vascular anomalies or hypertension. It causes significant morbidity and mortality worldwide. This illustrative case report presents an interesting computed tomography image of hyperacute basal ganglia hemorrhage with intraventricular extension artistically casting the ventricular system. The intraventricular hemorrhage was moderate upon presentation; the blood had delineated the anatomic details of the ventricular system. It closely resembles a Crax rubra's head in the sagittal view. We believe that this radiographic finding is not seen frequently, especially early in the course of the condition. However, it could serve as an intriguing and reproducible sign of the radiographic anatomy of the ventricular system.

Isolated cerebral mucormycosis in post-COVID-19 pneumonia

Background : Rhino-orbital-cerebral and isolated cerebral involvement of basal ganglia by mucormycosis are two different manifestations of CNS mucormycosis. The former variant caused by inhaled fungal spores and is common with immunosuppressive conditions. The latter form is caused by intravascular inoculation of spores as seen in intravenous drug abusers. Case report : Here we describe a case of young, non-addict patient with a history of recent mild COVID-19 pneumonia who presented with isolated cerebral mucormycosis involving bilateral basal ganglia. Discussion : The pulmonary vasculitis associated with COVID-19 is probably the cause of direct intravascular entry of inhaled fungal spores leading to direct isolated cerebral involvement. Such condition may rapidly turn fatal. Conclusion : This is the first reported case of isolated cerebral mucormycosis following post-COVID-19 infection. Early tissue diagnosis and intravenous amphotericin B is the key management.

Higher limbic and basal ganglia volumes in surviving COVID-negative patients and the relations to fatigue.

Background: Among systemic abnormalities caused by the novel coronavirus, little is known about the critical attack on the central nervous system (CNS). Few studies have shown cerebrovascular pathologies that indicate CNS involvement in acute patients. However, replication studies are necessary to verify if these effects persist in COVID-19 survivors more conclusively. Furthermore, recent studies indicate fatigue is highly prevalent among 'long-COVID' patients. How morphometry in each group relate to work-related fatigue need to be investigated. Method: COVID survivors were MRI scanned two weeks after hospital discharge. We hypothesized, these survivors will demonstrate altered gray matter volume (GMV) and experience higher fatigue levels when compared to healthy controls, leading to stronger correlation of GMV with fatigue. Voxel-based morphometry was performed on T1-weighted MRI images between 46 survivors and 30 controls. Unpaired two-sample t-test and multiple linear regression were performed to observe group differences and correlation of fatigue with GMV. Results: The COVID group experienced significantly higher fatigue levels and GMV of this group was significantly higher within the Limbic System and Basal Ganglia when compared to healthy controls. Moreover, while a significant positive correlation was observed across the whole group between GMV and self-reported fatigue, COVID subjects showed stronger effects within the Posterior Cingulate, Precuneus and Superior Parietal Lobule. Conclusion: Brain regions with GMV alterations in our analysis align with both single case acute patient reports and current group level neuroimaging findings. We also newly report a stronger positive correlation of GMV with fatigue among COVID survivors within brain regions associated with fatigue, indicating a link between structural abnormality and brain function in this cohort.

Unusual case of spontaneous bilateral basal ganglia bleed.

Hypertension is the most prevalent determinant condition embarking on the development of spontaneous intracerebral hemorrhage. Usually, the presentation is a unilateral hematoma. Spontaneous bilateral intracerebral hemorrhage is an outstandingly infrequent context, and not a lot of cases have been reported till date. Ensuing hypertension, trauma inflicted on the brain case is another common cause that out turn into the sequelae of bilateral intracerebral hemorrhage. Lately, a few cases of bilateral basal ganglia bleed have been revealed, as a repercussion of COVID-19 infection. Globally, <40 such cases have been reported. A 39-year-old man presented with complaints of acute onset of weakness of right half of the body. Additionally, facial deviation was noticed by his family members. He then sought medical help from a local healthcare center where CT scan of head was advised. Unexpectedly, the scan demonstrated bilateral intracerebral hemorrhage. He was then managed conservatively with oral medications and rehabilitation. The course of his hospital stay was uneventful and was eventually discharged after 9 days. He then presented to our institution for further evaluation. Thereupon, he had slurring of speech but was able to walk with minimal support. Simultaneous Bilateral Basal Ganglia Hemorrhage (SBBGH) is an exceptionally rare ailment. This genre of cerebrovascular accident embraces a comprehensive span of morbidity and mortality. In an acute setting, CT scan of head is the most relevant imaging modality. Nonetheless, MRI is the gold standard for definitive diagnosis and should be performed urgently to further typify and delineate the lesion.

Secondary Fahr’s disease: A differential to be considered in a COVID-19 pneumonia patient with neuropsychiatric presentations

Background, aim. Fahr’s disease is a rare neurodegenerative disease caused by intracranial classifications. This case report aims to accentuate the importance of considering rare disease like Fahr’s disease as the differential diagnosis of neuropsychiatric deficits, especially in patients with a history of thyroidectomy. Case presentation. A 50-year-old female who underwent thyroidectomy 5 years previously presented with incoherent speech, behavioural problems, and hand stiffness. On evaluation, several neurobehavioral deficits and carpopedal spasms were observed, along with low Mini-Mental State Examination (MMSE), Hachinski, Activities of Daily Living (ADL), and Instrumental Activities of Daily Living Scale (IADL) score of 22, 4, 13, and 12, respectively. Clinically significant labo-ratory abnormalities include low serum calcium of 4.7 mg/dl, low thyroid stimulating hormone (TSH) level of 0.113 mIU/l, and low parathyroid hormone (PTH) level of 1.2 pg/ml. In addition, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) reverse transcription-polymerase chain reaction (RT-PCR) test showed a positive result. Meanwhile, brain computerized tomography (CT)-scan results showed multiple bilateral calcifications in the basal ganglia, bilateral corti-cal-subcortical calcifications in the frontal lobe, and subcortical calcification in the left frontal lobe. Results. The patient was diagnosed with Fahr’s disease secondary to post-thyroidectomy hypoparathyroidism and coro-navirus disease 2019 (COVID-19). The patient was treated with calcium lactate, levothyroxine, donepezil, favipiravir for COVID’s infection, vitamin B1, B6, and B12. Conclusions. Fahr’s disease should be considered in patients with neuropsychiatric deficits and spasm disorders, especially in patients with a history of thyroidectomy. Routine follow-up CT-scans after thyroidectomy are recommended. © 2021, Editura Medicala. All rights reserved.

Detailed Anatomical Volumetric Study of Deep Nuclei of Brain and Other Structures Between Parkinson's Disease Patients Who Had Deep Brain Stimulation and Control Group.

BACKGROUND: Deep brain stimulation (DBS) was pioneered by Neuroscience team of Hospital Universiti Sains Malaysia (HUSM) nearly a decade ago to treat advanced medically refractory idiopathic Parkinson's disease (IPD) patients. OBJECTIVES: Brain volume reduction occurs with age, especially in Parkinson plus syndrome or psychiatric disorders. We searched to define the degree of volume discrepancy in advanced IPD patients and correlate the anatomical volumetric changes to motor symptoms and cognitive function. METHODS: We determined the magnetic resonance imaging (MRI)-based volumetry of deep brain nuclei and brain structures of DBS-IPD group and matched controls. RESULTS: DBS-IPD group had significant deep nuclei atrophy and volume discrepancy, yet none had cognitive or psychobehavioural disturbances. Globus pallidus volume showed positive correlation to higher mental function. CONCLUSION: The morphometric changes and clinical severity discrepancy in IPD may imply a more complex degenerative mechanism involving multiple neural pathways. Such alteration could be early changes before clinical manifestation.

Biotin-thiamine responsive basal ganglia disease in the era of COVID-19 outbreak diagnosis not to be missed: A case report.

BACKGROUND: Biotin-thiamine-responsive basal ganglia disease (BTRBGD) is a rare treatable autosomal recessive neurometabolic disorder characterized by progressive encephalopathy that eventually leads to severe disability and death if not treated with biotin and thiamine. BTRBGD is caused by mutations in the SLC19A3 gene on chromosome 2q36.6, encoding human thiamine transporter 2 (hTHTR2). Episodes of BTRBGD are often triggered by febrile illness. CASE REPORT: The patient was 2 years 10 months old male child presented with fever and progressive acute encephalopathy associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus infection. MRI revealed bilateral symmetrical high signal involving both basal ganglia and medial thalami which is swollen with central necrosis, initially diagnosed as acute necrotizing encephalomyelitis with increased severity. Genetic analysis revealed BTRBGD. CONCLUSION: BTRBGD requires high index of suspicion in any patient presenting with acute encephalopathy, characteristic MRI findings (that are difficult to differentiate from necrotizing encephalopathy), regardless of the existence of a proven viral infection.

Basal ganglia infarction and COVID-19 infection in an elderly patient: A case report.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has spread rapidly worldwide since the first cases were observed in Wuhan, China. Patients with COVID-19 develop multiple neurological symptoms, including headache, disturbed consciousness, and paresthesia, in addition to systemic and respiratory symptoms. CASE PRESENTATION: We presented a 57-year-old woman admitted to the emergency department - in December 2020 - with complaints of slurred speech, confusion, and left upper limb weakness after one week of positive nasopharyngeal swab sample SARS-CoV-2. CONCLUSIONS: While the patient had previous comorbidities like hypertension and diabetes, she had no prior history of ischemic stroke or thrombosis, so we conclude that unilateral acute basal ganglia infarction may be a unique neurological manifestation after COVID-19 infection in an elderly patient with previous comorbidities.

Hypoxic-Ischemic Injury of Basal Ganglia Associated with the COVID-19 Infection: Case Report.

There is emerging evidence of a broad spectrum of neurological manifestations in COVID-19 patients. We report a case of a patient diagnosed with COVID-19 who presented bilateral lesions of the basal ganglia related to a severe acute respiratory distress syndrome. This observation allows expanding the neurological spectrum of COVID-19 particularly in patients with a more severe clinical course.