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Background: COVID-19 has been associated with cerebral microbleeds (CMB). Previously, an association of ApoE4 with COVID-19 severity and CMBs in autopsy was found. In this study, we investigated if carrying the Apoe4 allele relates to the number of CMBs in magnetic resonance imaging (MRI) in patients recovered from COVID-19. Material(s) and Method(s): Adult patients recovered from COVID-19 and a control group without a history of COVID-19 was recruited. Exclusion criteria were major neurologic disease, developmental disability or pregnancy. The participants underwent brain MRI 6 months after infection, and a blinded neuroradiologist analyzed the findings. ApoE was genotyped using a microarray. Statistical analysis was performed using the statistical software R. A negative binomial model was chosen based on the distribution of CMBs. Result(s): Of the 216 subjects that underwent MRI, 168 consented to genetic testing, additionally 2 patients were excluded due to extensive CMBs and 1 due to diffuse axonal injury. We included 113 COVID-19 patients (49 ICU-treated, 29 ward-treated and 35 home-isolated) and 52 controls. The most prevalent comorbidities were hypertension, asthma and diabetes. CMBs was found in 47 subjects, with the number of CMBs ranging from 0 to 26. The ApoeE4 allele was carried by 37%, equally distributed among the groups. After adjustment, age (aRR = 1.06, p = 0.007) and COVID-19 (aRR = 2.59, p = 0.038) were independently associated with CMBs. The ApoE4 allele (aRR = 2.16, p = 0.07, CI = 0.94-5.10) was not significant. Conclusion(s): Age and previous COVID-19, but not possession of the ApoeE4 allele, were independently associated with the number of CMBs.
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51-year-old man (C.P.) had a diffuse-axonal-injury after falling from a 5-meter height, followed by a 22-minute anoxia due to a cardiac arrest. In the ICU, he tested positive to COVID-19, and needed intubation. After coronavirus infection, C.P. presented Guillain-Barre syndrome. 2months after discharge, he was admitted to rehabilitation. DTI tractography for evaluation of the structural integrity of white matter tracts revealed: i) Lesions in the basal ganglia;ii) Sequelary lesions in the right frontal, cortical, subcortical, temporal, parieto-occipital and cerebellar hemispheres;iii) Asymmetry of the corticospinal tracts - less fibers on the left;iv) Poor definition of the fibers of the right arcuate fasciculus;v)Asymmetrical thinning of the cortico-ponto-cerebellar tracts, worse on the left, and more discreetly in the spinocerebellar tracts. Based on this, C.P. underwent 4 different 30-session tDCS protocols consisting of twice-daily 20min 2mA sessions (10min interval), 5days/week (120sessions total), combined with physiotherapy, cognitive, swallowing and speech therapy. Montages: Pr1 (anode: Cz - 5x10cm;cathode: 10th Thoracic Vertebra - 5x7cm);Pr2 (1 - anode:C3;cathode:Fp2 / 2 - anode: Cerebellum;cathode:Fp2);Pr3 (anode:F3;cathode:Fp2) and Pr4 (anode:Cp5;cathode:Fp2). Except for Pr1, electrode size for all protocols were 5x7cm. We used the Coma Recovery Scale (CRS-R) and Rancho Los Amigos Scale (RLAS) for clinical assessments at the baseline and after every 10 sessions until the end of the intervention. At the baseline, C.P. presented a minimal responsive state of consciousness (CRS-R: 3;RLAS: Level 1) and tolerated well the tDCS interventions. CRS-R scores gradually improved in various domains during the treatment. At the end, RLAS score was level 5 and CRS-R, 19. Our preliminary results suggest DTI tractography may be a potential biomarker to guide more personalized tDCS interventions for complex cases of patients with acquired brain injuries. A second DTI tractography will be made in the future for comparison purposes. Research Category and Technology and Methods Clinical Research: 9. Transcranial Direct Current Stimulation (tDCS) Keywords: Acquired Brain Injury, Traumatic Brain Injury, COVID-19, Guillain Barre SyndromeCopyright © 2023
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Case Diagnosis: Critical Illness Polyneuropathy following COVID-19 Infection Case Description or Program Description: A 58-yearold female presented to PM&R clinic following a prolonged hospitalization for COVID-19, after which she developed bilateral wrist and foot drop. Prior to her hospitalization, she ambulated independently. At the time of evaluation, she was wheelchair bound. Physical exam demonstrated bilateral wrist and foot drop, with bilateral foot numbness. EMG demonstrated bilateral common peroneal incomplete axonal neuropathy, with bilateral incomplete axonal brachial plexopathy affecting mainly the lower trunk on the left side and the middle cord on the right side. Setting(s): Tertiary-care teaching hospital Assessment/Results: Outpatient physical and occupational therapy were initiated and she was prescribed bilateral ankle foot orthoses. She was referred to neurology, with diagnosis of multifocal axonal neuropathy, with critical illness polyneuropathy, post viral (COVID) immune axonopathy with mononeuritis multiplex. Repeat EMG obtained 8 months later demonstrated mild improvement on the needle study with decreased denervation potentials of the muscles tested however, NCS remained unchanged. Over a 1-year span of therapy, her strength, function and numbness improved. She progressed to ambulate independently without an assistive device. Discussion (relevance): Critical illness polyneuropathy (CIP) is a neurologic manifestation of systemic inflammatory response syndrome, causing axonal injury by unclear mechanism. It is suspected that distal nerve microcirculation causes ischemia and axonal degeneration. There are increasing reports of polyneuropathy following COVID-19 infection. Diagnosis involves EMG, which demonstrates axonal loss without demyelinating features, with NCS showing decreased amplitude of SNAPs. CIP treatment includes reduction of dose and duration of steroids and neuromuscular blocking agents, rehabilitation programs, and careful extremity positioning. Conclusion(s): Our patient experienced functional improvement with conservative management, including outpatient physical and occupational therapy with bracing. As the COVID-19 pandemic continues, CIP must be considered in patients with weakness and a history of COVID-19 infection, particularly in those with severe infection and ICU stay.
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COVID-19-related neuropathy in Colombia: The experience during the first 23 months of pandemic Introduction: The SARS-CoV-2 virus has a high neuroinvasive capacity due to the increased expression of angiotensin-converting enzyme receptor 2 (ACE-2) in neurons (1) and it is believed that the mechanism by which it can cause injury to the nervous system peripheral nervous system is immunemediated, although a direct cytotoxic effect of the virus cannot be ruled out (2). Multiple types of neuropathy associated with SARS-CoV-2 infection have been described, the most frequent being Guillain- Barré syndrome, pre-existing diabetes, compression neuropathies and drugs used to treat symptoms of COVID-19 (3). Objetives: To characterize the patients who were referred to the electromyography laboratory at the Fundacion Santa Fé de Bogotá, Colombia due to suspected COVID-19-related neuropathy Methods: Descriptive observational study, case series type. The electrodiagnostic studies carried out between January 2020 and December 2022 in the electromyography laboratory at the Fundacion Santa Fé de Bogotá, Colombia with suspected COVID- 19-related neuropathy were reviewed. Results: 94 patients were evaluated in the electromyography laboratory with suspected COVID 19-related neuropathy between January 2020 and December 2021, of which 53% (50/94) were men. The average age was 54.8 years. 32% (30/94) had severe COVID and 31% (29/94) were hospitalized in the ICU. Most of the studies were normal: 35% (33/94). of the abnormal findings, it was found in order of frequency: Symmetric motor and sensory axonal polyneuropathy in 21.2%, and of this group of patients, 55% were in the ICU, 35% had no data and 20% were hospitalized-not ICU. 18% presented compression neuropathy of the median nerve in the carpal tunnel, 6.3% asymmetric motor and sensory axonal neuropathy, 6.3% suggestive findings of cervical and/or lumbosacral root involvement, 4.2% Guillain Barré syndrome, 4.2% compression neuropathy of the peroneal nerve , 2.1% brachial plexus axonal injury, 2.1% peroneal nerve axonal injury, 2.1% radial axonal injury, 2.1% myopathic changes, 1% hypoglossal nerve axonal injury, 1% symmetric axonal and demyelinating polyneuropathy, 1% hereditary neuropathy, 1% asymmetric demyelinating neuropathy, 1% axonal injury of the sciatic nerve, 1% axonal injury of the median nerve in the forearm, 1% axonal injury of the lumbosacral plexus, 1% compression neuropathy of the ulnar nerve in the elbow and 1% axonal injury from a sensory branch of the median nerve. Conclusions: The most frequent abnormality in the study was symmetric motor and sensory axonal polyneuropathy, which can be explained by the prolonged ICU stay, which increases the risk of Critical illnes Neuropathy.
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Introduction: During Covid-19 pandemic periods, various studies have been revealed the coexistence of these two diseases, raising the question of whether SARS-CoV-2 has a role in triggering GBS or it's just co-incidentally. So far, 255 cases of this concurrence have been reported. In this study, we publish 45 patients' demographic, clinical, electro diagnostic study, response to treatment and prognostic features association of Covid- 19 and GBS during the 5 corona's epidemiologic peaks in Isfahan province. Methods: This cross-sectional, multi-central study was performed during covid-19 pandemic since 2020 February until 2021 October. In this period 5 epidemiologic peaks of corona virus occurred in Isfahan (one of providence of Islamic republic of Iran) and total of 417166 people became infected. 45 patient with definitive Covid-19 (based on positive nasopharynx Reverse transcription polymerase chain reaction (RT-PCR) or highly suggestion of Highresolution computed tomography (HRCT) for covid- 19) were referred to one of the 2 referral hospitals (Alzahra and Kashani hospital). All patients whom suspected of peripheral nerve symptoms referred to the neuromuscular fellowship for further examination and performing EDx. Demographic, clinical, therapeutic and prognostic features were collected according to Hospital records. Results & discussion: 45 patients (60% male, 40% female) were surveyed. The mean age was 54.66±10.021 (max: 84, min:14, range:80). The most EDx pattern was AIDP (57.8%, n=26).42.2%(n=19) of patients had axonal pattern. 8 of them were Acute motor axonal neuropathy(AMAN) and 11 patients were Acute motor-sensory axonal neuropathy(AMSAN). The most (91%) GBS phenotype was classic pattern which defined as acute-sub acute flaccid length dependent paralysis. 2 patients had pure para paretic pattern and 2 had miller-fisher pattern. The most common symptom of covid-19 was fever (89.7%), Other symptoms included dyspnea (48.7%), cough (46.2%), myalgia (28.2%), headache (28.2%), diarrhea (28.2%) and the less common was anosmia (12.8%). No significant difference was found between any of the covid-19 symptoms with EDx patterns. 7 patients had a history of GBS which were more than 1 year before the onset of new symptoms. 13.6% of patients had no any symptoms of covid-19 on the day of the onset of neurological symptoms, either the symptoms of covid-19 developed after the neurological symptoms or covid-19 was discovered accidentally. Mean distance between onset of covid-19 and neurological symptoms was 18.05±8.88 which was significantly lower in the axonal injury groups (12.00±800 pvalue: 0.013). Also There was also signifi cant difference between frequency of para/post infectious patient in axonal and demyelinating subtypes (p value: 0.045). So that Para infection was more associated with axonal injuries. Among other prognostic findings, include respiratory equipment (33% no equipment, 44% none-invasive and 22.2% mechanical ventilation), required to ICU admission (46.7%), length of ICU admission (16.66 ±12.03), length of intubation (12.10±6.24) , length of hospitalization( 23.66±14.13) and mortality(8.9%) no Significant differences were detected among each subgroups of EDx patterns and also between axonal/ demyelinating injuries. There was also significant difference among erythrocyte sedimentation rate and C-reactive protein among axonal patterns that means axonal patterns (AMAN and AMSAN) had more level of ESR and CRP at the first neurological symptom's day.