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Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).
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Background & Objective: Covid-19 infection has diverse effect on human health. We aimed to evaluate the effect of COVID-19 pandemic on the young stroke cases in an emergency services in a tertiary hospital in Istanbul, Turkey. Method: A total of 86 patients younger than 50 years confirmed to have stroke seen between January 1, 2019 and December 31, 2020 were included in the study. The year 2019 was defined as the pre-pandemic period and the year 2020 as the pandemic period. The patients' stroke type, localization, mortality, laboratory and imaging data were evaluated. Results: Eighty-six patients were included in the study. The mean age was 38.69±5.39 years, 49 (57%) were female. Of the patients, 78 (90.7%) were ischemic and 8 (9.3%) were hemorrhagic stroke. In the pandemic group, ischemic stroke was observed in 55 (96.5%) and hemorrhagic stroke in 2 (3.5%) (p=0.010). While the mean age of the patients in the survival group was 39.24±5.70 years, it was 36.61±3.38 years in the mortality group (p=0.008). While the mortality was 18 (20.9%) overall, it was 16 (18.6%) patients during the pandemic period, and 2 (2.3%) patients in the pre-pandemic period, the difference was statistically significant. (p=0.014). Conclusion: COVID-19 infection appear to increase the risk of ischemic stroke and worsens the mortality among the young. More comprehensive and prospective studies are needed to confirm this observation. © 2023, ASEAN Neurological Association. All rights reserved.
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The proceedings contain 71 papers. The topics discussed include: experience of learning human anatomy and histology during COVID-19 pandemic in Kharkiv National Medical University;using musculoskeletal modelling to investigate the functional significance of craniofacial form variation within the genus homo;a morphometric analysis of the cranial fossae in patients with scaphocephaly;exploring the thalamus in young adolescents with psychotic experiences;to replace or not replace that is the question: addressing fate decisions during minipig tooth replacement;anatomy of termination of popliteal artery: a multidetector CT angiographic study;anatomical variation between populations of British red squirrels: the potential impact of supplementary feeding;revealing the biomechanics of the masticatory muscles in the eastern grey squirrel (Sciurus carolinensis) using multibody dynamics analysis;and myoepithelial and immune cell dynamics in the ovine mammary gland during postnatal development.
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Effective drug delivery to the brain is critical for the treatment of glioblastoma (GBM), an aggressive and invasive primary brain tumor that has a dismal prognosis. Radiation therapy, the mainstay of brain tumor treatment, works by inducing DNA damage. Therefore, inhibiting DNA damage response (DDR) pathways can sensitize tumor cells to radiation and enhance cytotoxicity. AZD1390 is an inhibitor of ataxia-telangiectasia mutated kinase, a critical regulator of DDR. Our in vivo studies in the mouse indicate that delivery of AZD1390 to the central nervous system (CNS) is restricted due to active efflux by P-glycoprotein (P-gp). The free fraction of AZD1390 in brain and spinal cord were found to be low, thereby reducing the partitioning of free drug to these organs. Coadministration of an efflux inhibitor significantly increased CNS exposure of AZD1390. No differences were observed in distribution of AZD1390 within different anatomic regions of CNS, and the functional activity of P-gp and breast cancer resistance protein also remained the same across brain regions. In an intracranial GBM patient-derived xenograft model, AZD1390 accumulation was higher in the tumor core and rim compared with surrounding brain. Despite this heterogenous delivery within tumor-bearing brain, AZD1390 concentrations in normal brain, tumor rim, and tumor core were above in vitro effective radiosensitizing concentrations. These results indicate that despite being a substrate of efflux in the mouse brain, sufficient AZD1390 exposure is anticipated even in regions of normal brain. SIGNIFICANCE STATEMENT Given the invasive nature of glioblastoma (GBM), tumor cells are often protected by an intact blood-brain barrier, requiring the development of brain-penetrant molecules for effective treatment. We show that efflux mediated by P-glycoprotein (P-gp) limits central nervous system (CNS) distribution of AZD1390 and that there are no distributional differences within anatomical regions of CNS. Despite efflux by P-gp, concentrations effective for potent radiosensitization are achieved in GBM tumor-bearing mouse brains, indicating that AZD1390 is an attractive molecule for clinical development of brain tumors.Copyright © 2022 American Society for Pharmacology and Experimental Therapy. All rights reserved.
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Introduction: Since 2019, COVID-19 pneumonia caused by SARS-CoV-2 virus has led to a worldwide pandemic. Since then, various neurological manifestations of COVID-19 pneumonia have been reported. Neurological manifestations include headache, anosmia, seizures, and altered mental status. In some cases, it presents as stroke, encephalitis, and neuropathy. Artery of Percheron (AOP) is a variant in the posterior circulation. Here, a single artery arises from the posterior cerebral artery p1 segment. It supplies bilateral thalamus with or without midbrain. Thrombosis in this artery leads to clinical symptoms like reduced level of consciousness, altered mental status, and memory impairment. Case Report: Here, we present a case who presented with fever and altered sensorium without any focal neurological deficits and without known risk factors for stroke. His COVID-19 PCR was positive. He was initially diagnosed as COVID-19 pneumonia with encephalitis and was started on treatment for the same. His initial CT brain and lumbar puncture were normal. The next day, when MRI brain with and without contrast was done, the thalamic stroke due to AOP infarction was diagnosed and appropriate treatment for stroke was initiated. Discussion(s): Many patients miss the window for thrombolysis because of variable presentation in clinical symptoms with negative imaging. It is also difficult to assess the time of onset of stroke in this varied presentation. Our patient had fever and cough for 2 days and had altered mental status since the morning of admission. During hospital stay, he developed bilateral third nerve palsy. This case also highlights the importance of detailed evaluation in COVID-19 patients with neurological complaints. This helps to avoid delays in treatment and to improve clinical outcomes. As our knowledge of COVID-19 and its varied neurological manifestations evolve, we need to be prepared for more atypical presentation to facilitate timely interventions.Copyright © 2022 The Author(s). Published by S. Karger AG, Basel.
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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).
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Introduction: An unusual case presentation of MOG-positive Acute Disseminated Encephalomyelitis (ADEM) in a preschool child following meta-pneumo viral infection responded to the combination of immune modulatory treatment with a favourable outcome. Material: Three-year-old female child presented with acute encephalopathy, high fever, vomiting, starring episodes, floppiness, and left abducent nerve palsy with rapid deteriorating GCS necessitating intubation and ventilation. Two weeks earlier, she was treated for suspected CNS infection with 10 days of antibiotics in the PICU with a positive meta-pneumo-virus. On admission, she had a GCS score of 6 with left-sided increased tone, bilateral hyperreflexia, and bilateral extensor response and on Day 14 demonstrated hyperkinetic movements of the upper and lower limbs. Method(s): Serum MOG antibody positive, CSF MOG low positive, metabolic investigations, Mycoplasma, EBV, Influenza, corona PCR, SARS-COV-2 Antibody, viral CSF panel unremarkable. MRI brain demonstrated T2 hyperintense signal in bilateral medial thalami and brain stem with a normal spine. Progressive changes were shown on repeated MRI Brains on day 4 and day 14 suggestive of multifocal changes involving deep cortical and subcortical white matter bilaterally with a new short segment of the spinal lesion at the T8 level. Repeated EEG and ambulatory EEG showed a diffusely slow background with intermittent slow runs of slow waves suggestive of generalized cerebral dysfunction. Result(s): After receiving the combination of high pulse steroids with a taper over 10 weeks, IVIG and 10 cycles of plasmapheresis she demonstrated gradual and remarkable clinical improvement over 10-12 weeks with a minimal focal neurological deficit. Conclusion(s): Initial differentiating CNS infection, metabolic disease and ADEM may be clinically challenging. Her clinical presentation, investigations and imaging were in keeping with the diagnosis of MOG-positive ADEM. Previous CNS infection may be related. MOG-positive ADEM treated with the early combination of immunomodulation may lead to positive clinical outcomes.
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Introduction: Patients undergoing Deep brain stimulator (DBS) insertion require a high-resolution MRI for treatment planning prior to DBS surgery. This group of patients has movement disorders therefore traditionally the planning MRI is done under General anaesthesia to ensure patient immobility and to obtain good quality MRI images. Providing sedation/anaesthesia for MRI procedure during COVID-19 pandemic was challenging. When we restarted elective surgery during Covid-19 pandemic we were worried about aerosol generating procedures, therefore we looked at the feasibility of using Dexmedetomidine-Propofol sedation for treatment planning MRI as an alternative to General anaesthesia to prevent aerosol generating procedure. Method(s): We conducted retrospective review of anaesthetic records of all patients who underwent MRI under sedation for DBS planning from August 2020 to July 2021. We collected the data on patient demographics, Indication & target site for DBS, duration of sedation, complications during the scan, cardiovascular side effects like hypotension and bradycardia during scan, quality of image, duration of PACU stay and post scan complications. The quality of MRI imaging was assessed by the neurosurgeon who did the treatment planning. Sedation protocol: sedation was commenced with Propofol target controlled infusion (TCI) using Schneider model with effector site concentration (Cet) of 2 to 3 and Dexmedetomidine bolus dose of 1 microgram per kilogram was infused over 10 minutes. All the patients were induced to a Ramsay Sedation Scale of at least 5 or 6. Sedation was maintained with Dexmedetomidine infusion at 0.5 mcg/kg/hr and Propofol TCI (Schneider model Cet of 2 mcg/mL). Result(s): During our study period 15 patients underwent MRI under sedation with Propofol-Dexmedetomidine for DBS treatment planning. Of this 7 were males and 8 were females. Age range was from 39 to 75 years. The target site was Subthalamic nucleus in 9 patients, Thalamic nuclei in 4 patients and Globus pallidus internus in 2 patients. Duration of sedation ranged from 40 minutes to 100 minutes with a median of 45 minutes. 2 patients developed movement artefacts during scanning and were converted to GA, 3 patients developed hypotension (20% reduction from pre-induction blood pressure) requiring treatment with ephedrine. Five patients had sinus bradycardia (20% reduction from pre-induction heart rate) but did not require treatment. The qualities of images were classified as good in 11 patients and acceptable in 2 patients by the neurosurgeon involved in treatment planning. None of the patients needed repeat MRI scanning. Patient's stay in PACU ranged from 20-50 minutes with a mean of 26.5 minutes. Discussion(s): Dexmedetomidine-Propofol sedation has been widely used for sedation to perform MRI scans in paediatric patients, its use in adult patients is not well documented in the literature. Propofol enables smooth induction of sedation and rapid recovery however it may cause hypotension, decreased respiratory drive and upper airway obstruction. Dexmedetomidine has been used as a single sedative agent for MRI however its onset of action is slow and when used as a sole sedative agent large dose of dexmedetomidine is required and this may contribute to delayed recovery after sedation. Propofol-Dexmedetomidine combination has synergistic effects and is advantageous. Propofol can induce sedation smoothly, Dexmedetomidine can reduce dose required for sedation and suppression of motor response in healthy subjects (1). Combination of Dexmedetomidine- Propofol infusion reduced total Propofol dose and decreased the incidence of airway complications in a paediatric study (2). During our study period 2 patients sedation were converted to General anaesthesia, both patients had raised BMI and had laboured breathing under sedation causing transmitted head movement, therefore patient selection is important for successful scan under sedation. Propofol-Dexmedetomidine sedation can be used safely for treatment planning MRI in selective movement disorder patients.
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Introduction: Insomnia disorder (ID) and major depressive disorder (MDD) are highly comorbid, above 80% of MDD patients have insomnia disorder. Acupuncture as a major complementary and alternative medicine (CAM) therapy, is utilized extensively in Asia to treat mental health disorders.Transcutaneous electrical cranial-auricular stimulation (TECAS) is a potential new type of acupuncture treatment for MDD and ID which combines the scalp points and auricular points most commonly used by acupuncturists. It has the advantages of portability, quantifiable stimulation parameters and comfort, especially for home treatment under the normal situation of COVID-19, which can avoid the risk of infection due to frequent hospital trips. Materials / Methods: 10 ID-MDD patients were treated by TECAS which was administered at the bilateral auricular acupoints, Bai Hui (GV-20) and Yin Tang (GV-29) (waveform:4/20 Hz, wave width: 0.2ms+/-30%) for twice a day last 8 weeks. Pittsburgh Sleep Quality Index (PSQI) and Hamilton Depression Rating Scale(HAMD) of ID-MDD patients were evaluated before and after treatment. Result(s): HAMD-17 scores of 10 patients were lower at 4 and 8 weeks than before TECAS treatment, and the reduction was greater at 4 weeks than at 8 weeks. PSQI scores of 8 patients decreased at 4 and 8 weeks compared with before treatment, and the decrease was greater in the fourth week than in the 8th week. Insomnia of 2 patients improved at 4 weeks of treatment, but became worse in the 8th week as before treatment.7 out of 10 patients showed full insomnia response (50% reduction in PSQI) and 8 patients showed full depression response (50% reduction in HAMD-17 scores). Discussion(s): We suggest TECAS is a good therapeutic strategy to modulate the vagus nerve and trigeminal nerve propagate through electrical stimulation projected by neurons from peripheral sites to the central nervous system. Furthermore, we speculate that TECAS can make the trigeminal nerve afferent fibers and vagus nerve auricular branch carry messages from head facial stimulation to NTS, locus coeruleus, raphe nucleus, medullary reticular activating system and structure of the thalamus, and then to feel, edge, cortical and subcortical structures, so the electrical stimulation subcortical can cause direct regulation, namely the change of cortical excitability. Conclusion(s): These preliminary results in this group of CID-MDD patients are encouraging and need to be replicated in prospective sham-controlled studies with larger sample sizes. In addition, for patients with insomnia and depression, it is important to consider combining TECAS with psychotherapy to avoid the interference of acute negative emergency events. Acknowledgements: The support of National Key R&D Program of China (No.2018YFC1705800) and Key Laboratory of Acupuncture and Chronobiology of Sichuan Province(No.2021004) for this project is gratefully acknowledged. Learning Objectives: 1. To provide a new non-drug method for acupuncture treatment of insomnia and depression;2. Provide preliminary experimental results for the large-sample experimental design of TECAS for the treatment of insomnia and depression;3. Compared with previous studies on insomnia and depression, the regularity and characteristics of TECAS in treating insomnia and depression were found. Keywords: Transcutaneous Electrical Cranial-Auricular Stimulation (TECAS), insomnia disorder, a case series, acupuncture, Major Depressive Disorder Copyright © 2022
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Background: The COVID-19 pandemic has infected millions of people around the world and there has been a new surge of virulent strains in many parts of the world[2]. Patients with Systemic Lupus Erythematosus (SLE) were reported to be at higher risk of SARS-CoV-2 infection and worse outcomes from COVID-19, possibly due to their intrinsic immune dysfunction, demographics, disease activity, medications, associated organ damage, comorbidities and as such, have been among the frst to receive the vaccines [3]. The most common reason for vaccine refusal in patients with SLE is fear of SLE disease fare. Additionally, SARS-CoV-2 mRNA vaccines could potentially induce interferon production, associated with increased SLE disease activity[1]. Objectives: we report a case of SLE presented with lupus fare after receiving the 1st dose of phizer vaccine. Methods: A 30-year-old female patient, kown case of SLE since 2011 well controlled on low dose steroids, hydroxychloroquine and azathioprine. Upon receiving her 1st shot of Pfzer-BioNTech COVID-19 Vaccine, she developed high grade fever associated with generalized tender papulovesicular skin eruption mainly on the back of the trunk and the outer surface of both thighs, then she developed generalized tonic-clonic convulsions and transferred for Intensive Care Unit (ICU), intubated, mechanically ventilated and received intravenous anti-epileptic medications. During her admission, Cerebrospinal fuid (CSF) examination and Magnetic Resonance Imaging (MRI) brain were done.she regained her consciousness, extubated after 48 hours. Results: The initial laboratory invwstigations revealed COVID19-PCR: nega-tive,ESR: 35 mm/hr,CRP: 78,C3: 70 mg/dL (90-180) and C4: 8 mg/dL (10-40). CSF examination revealed proteins: 116.9 mg/dL (15-45),glucose: 46.3 mg/dL (50-60% of serum),LDH: 49.1 U/L (10% of serum) and no cells.Emergency MRI brain was performed revealed multiple bilateral symmetrical mainly cortical and subcortical abnormal signal with cortical swelling are seen mainly involving both occipito-temporo-parietal lobes with patchy enhancement of left cerebellar hemisphere, cerebellar vermis, both thalami, medulla and pons,Picture suggestive of Posterior Reversible Encephalopathy Syndrome (PRES).Accordingly the patient received received pulse steroid therapy for 3 days under cover of oral acyclo-vir.She also received levetiracetam and Oxcarbazepine.the condition markedly improved and discharged from the hospital for follow up after one month. Conclusion: 1)The mRNA COVID Vaccine may rarely cause CNS affection, or even SLE fare so, SLE patients must be well controlled before giving the Vaccine. 2) SLE patients must be monitored closely by clinical examination and laboratory investigations after taking mRNA COVID Vaccine.
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CASE: A 64-year-old woman was brought in by husband for inability to care for patient. Previously active, she developed gait instability, slurred speech, and memory lapse to the point of selective mutism and being bed-bound within three months. Her medical history was notable for hypertension and Covid four months prior. She had had mild upper respiratory symptoms and recovered in ten days. Examination revealed general encephalopathy, dysarthria, limited ability to follow commands. She had decreased strength but increased tone and rigidity in all extremities. She had rhythmic jaw movement and bradykinesia with scatter myoclonic movements. Cerebellar exam was notable for ataxia, but she had normal cranial nerve and sensory exams and normal reflexes. MRI of the brain revealed restricted diffusion and T2/Flair signal abnormality involving bilateral basal ganglia, ventral medial thalami, hippocampi, and cerebral cortices. Toxic metabolic workup was unrevealing. CSF was positive for 14-3-3 protein and elevated total tau protein, confirming Creutzfeldt-Jakob disease. IMPACT/DISCUSSION: Creutzfeldt-Jakob Disease (CJD) is a prion disease with one in a million prevalence. Patients present with rapidly progressing dementia, myoclonus, and signs of cerebellar, corticospinal and extrapyramidal involvement including nystagmus, ataxia, hyperreflexia, spasticity, hypokinesia, bradykinesia, dystonia, and rigidity. CJD is fatal within months to two years. Patients with end stage disease may have akinetic mutism. Magnetic resonance imaging (MRI), electroencephalogram (EEG), and cerebrospinal fluid (CSF) analysis are important for evaluation of CJD. Most sensitive in early stages, MRI Brain commonly shows hyperintense signal involving the cerebral cortex, corpus striatum, caudate, and putamen. EEG may capture pattern of periodic bi-or triphasic period sharp wave complexes. CSF might detect 14-3-3 protein with elevation of tau protein but real-time quaking-induced conversion (RT-QuIC) has the highest specificity for diagnosis for CJD. Though brain biopsy is the sole method of definitive diagnosis, results of MRI, EEG, and CSF analysis along with presenting signs and symptoms are sufficient for clinical diagnosis of CJD. Our patient's dementia, myoclonus, ataxia, hypokinesia, bradykinesia, dystonia, and rigidity all progressing to akinetic mutism within three months are classic presentation of CJD. EEG was normal, but MRI with hyperintensity of basal ganglia and cerebral cortices and CSF analysis with positive 14-3-3 and elevated tau proteins are all lead to diagnosis of CJD. CONCLUSION: This case illustrates a classic case of a Creutzfeldt-Jakob Disease, a rare prion disease marked by rapidly progressive dementia with neuropsychiatric features.
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Objective: This study investigates the effects of COVID-19 on brain microstructure among those recently recovering from COVID-19 through self isolation. Background: Microstructural differences have previously been detected in comparisons of COVID-19 patients with controls, particularly in regions related to the olfactory system. The olfactory system is connected with the caudate, putamen, thalamus, precuneus, and cingulate regions. Design/Methods: Here we report diffusion magnetic resonance imaging (3 T Siemens MRI) findings from 40 patients (mean age: 43.7, 68% female) who self-isolated after testing positive for COVID (COV+), and 14 COVID negative (COV-) subjects (mean age: 43, 64% female) who had flu-like symptoms. This is part of the Canadian-based NeuroCOVID-19 study. Fractional anisotropy (FA), mean diffusivity (MD), mode of anisotropy (MO), free water fraction (F), tissue-specific FA (FAt) and tissue-specific MD (MDt) were obtained using data with b=700 and 1400 (DIPY free-water model). Regions of interest in the grey matter and white matter were delineated using FreeSurfer. Differences between groups were assessed using an analysis of variance (ANOVA), the Kruskal-Wallis Test and the Mann-Whitney Test, corrected for false-discovery rate of 0.05. Effect size (Cohen's d) was also computed (d>0.45 deemed large effect). Results: In the COV+ group, all three tests revealed decreased FA and FAt in the insula, and increased MD in the parstriangularis cortex. Increased FA and FAt in the cuneus (along with decreased MD) was also found. MD was reduced in COV+ in the temporal and supramarginal areas. MO was lower in COV+ in the insula and amygdala regions. Conclusions: In patients, higher MD with lower FA and MO suggest increased extracellular fluids, while lower MD with decreased FA and MO may suggest necrotic debris built up following inflammation. The cuneus and insula are involved in visual and taste processing, respectively. This study highlights the need to study neurological effects of COVID-19.
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Objective: To draw attention towards a devastating presentation of Acute Hemorrhagic Leukoencephalitis (AHLE) in an immunocompromised patient with cerebral toxoplasmosis. Background: AHLE is a rare, hyper-acute variant of Acute Disseminated Encephalomyelitis (ADEM). It is often preceded by an upper respiratory infection, and associated pathogens include influenza, Epstein Barr Virus (EBV), mycoplasma pneumonia, and SARS-CoV-2. Design/Methods: NA Results: A 27-year-old man presented to our hospital with a three day history of headaches and altered mental status. He was having seizures on arrival. He had a Glasgow Coma Scale (GCS) of 4 upon arrival. His pupils were anisocoric and sluggish to light. His brainstem reflexes were intact. Motor exam revealed extensor posturing in bilateral upper extremities and triple flexion in bilateral lower extremities in response to noxious stimuli. He received lorazepam in the emergency room with minimal improvement and was ultimately intubated for airway protection. Computed tomography (CT) head showed regions of hypoattenuation involving bilateral basal ganglia and thalami with superimposed acute hemorrhage, significant mass effect, and patchy regions of acute hemorrhage in the cerebellum. Magnetic resonance imaging (MRI) brain revealed areas of confluent FLAIR signal abnormality in the deep white matter, bilateral basal ganglia and thalami, brainstem, and throughout the cerebellum. He had a hypercellular cerebral spinal fluid (CSF) analysis that showed white blood cell count of 218 with lymphocytic predominance. Protein was elevated to 412 mg/dl and glucose was 17 mg/dl. He was found to be HIV-1 positive with a CD4 count of 6 cells per cubic centimeter. CSF specific toxoplasmosis PCR showed 730,000 copies/milliliter. He was treated with solumedrol and broad-spectrum antimicrobials with minimal improvement in his clinical picture and ultimately succumbed to his disease. Conclusions: This report highlights AHLE as a rapidly progressive hemorrhagic demyelination of white matter. It is imperative to recognize it to implement life saving therapies earlier in the course.
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BACKGROUND: Diagnosis of epileptic seizures, particularly regarding status epilepticus (SE), may be challenging in an emergency room setting. The aim of the study was to study the diagnostic yield of perfusion computed tomography (pCT) in patients with single epileptic seizures and SE. METHODS: We retrospectively reviewed the records of patients who followed an acute ischemic stroke pathway during a 9-month period and who were finally diagnosed with a single epileptic seizure or SE. Perfusion maps were visually analyzed for the presence of hyperperfusion and hypoperfusion. Clinical data, EEG patterns, and neuroimaging findings were compared. RESULTS: We included 47 patients: 20 (42.5%) with SE and 27 (57.5%) with single epileptic seizure. Of 18 patients who showed hyperperfusion on pCT, 12 were ultimately diagnosed with SE and eight had EEG findings compatible with an SE pattern. Focal hyperperfusion on pCT had a sensitivity of 60% (95% CI 36.4-80.2) and a specificity of 77.8% (95% CI 57.2-90.6) for predicting a final diagnosis of SE. The presence of cerebral cortical and thalamic hyperperfusion had a high specificity for predicting SE presence. Of note, 96% of patients without hyperperfusion on pCT did not show an SE pattern on early EEG. CONCLUSIONS: In acute settings, detection by visual analysis of focal cerebral cortical hyperperfusion on pCT in patients with epileptic seizures, especially if accompanied by the highly specific feature of thalamic hyperperfusion, is suggestive of a diagnosis of SE and requires clinical and EEG confirmation. The absence of focal hyperperfusion makes a diagnosis of SE unlikely.
Subject(s)
Epilepsy , Ischemic Stroke , Status Epilepticus , Cerebral Cortex , Electroencephalography , Emergency Service, Hospital , Epilepsy/complications , Humans , Perfusion , Retrospective Studies , Seizures/diagnostic imaging , Status Epilepticus/complications , Status Epilepticus/diagnostic imaging , Tomography, X-Ray Computed/methodsABSTRACT
Background: Severe Acute Respiratory Syndrome Corona Virus 2(SARS-Cov2) is well known to cause a multitude of neurologic conditions out of which remains the rather rare condition of Acute Necrotizing Encephalopathy. It's a devastating condition with early immunotherapy bringing a more favorable outcome. Pathophysiology suggests the dysregulation of the blood brain barrier secondary to the cytokine storm. Pituitary apoplexy is an unrelated acute condition in which there is either hemorrhagic or non- hemorrhagic necrosis of the pituitary gland. It again has multiple predisposing factors including changes in intracranial pressure and underlying coagulation disorders. Case Presentation: A thirty-five-year-old male patient with poorly controlled diabetes presented to our emergency department with fever, cough and progressive respiratory distress for three days. He was drowsy with clinical features of bronchopneumonia and his COVID PCR was positive (He had taken only the first dose of Sinopharm nearly a month before). Within twenty-four hours, he was sent to the ICU for ventilatory support mainly due to low GCS. His HRCT Chest revealed severe COVID pneumonia. MRI brain revealed high signal intensities involving cerebellum, brainstem, bilateral thalami and mesial temporal lobes compatible with acute necrotizing encephalopathy with a pituitary macroadenoma and bleeding into it. He received high dose steroids followed by plasma exchange leading to resolution of the above changes within a month but passed away at the end of six weeks due to secondary bacterial sepsis. Discussion: Here the pituitary macroadema was an incidental finding and the bleeding was postulated to be secondary to changes in intra cranial pressure. Both the Necrotizing encephalopathy and the pituitary apoplexy might have resulted in the reduced conscious level in the above patient in the background of severe COVID pneumonia. The immunotherapy was successful in resolution of the radiologic changes though the patient deteriorated clinically following a transient improvement due to bacterial sepsis.
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The artery of Percheron (AOP) is a rare variant of thalamic vasculature and is a single dominant thalamoperforating artery supplying bilateral paramedian thalamic territories. Occlusion of the AOP results in a characteristic pattern of bilateral paramedian thalamic infarcts and is estimated to represent between 0.1%-0.3% of all ischemic strokes and 4% to 35% of all thalamic strokes. Four distinct ischemic patterns of AOP infarcts have been identified: bilateral paramedian thalamic region with midbrain (43%), bilateral paramedian thalamic without midbrain (38%), bilateral paramedian thalamic with anterior thalamus and midbrain involvement (14%), and bilateral paramedian thalamic with anterior thalamus without midbrain involvement (5%). Despite our knowledge of the characteristic radiologic features of an AOP stroke, the true incidence of AOP strokes is challenging to estimate due to non-specific clinical symptoms and subtle findings on computed tomography (CT) and/or magnetic resonance imaging (MRI). Here, we present a case series of three patients seen within a 3-month span at one community hospital seen by one single neurologist with confirmed AOP stroke by radiologic imaging. The frequency of these cases suggests that the incidence of AOP infarctions may be higher than previously estimated and instead are underreported due to broad differential on clinical and imaging presentation.
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Occupational burnout has become a pervasive problem, especially among medical professionals who are highly vulnerable to burnout. Since the beginning of the COVID-19 pandemic, medical professionals have faced greater levels of stress. It is critical to increase our understanding of the neurobiological mechanisms of burnout among medical professionals for the benefit of healthcare systems. Therefore, in this study, we investigated structural brain correlates of burnout severity in medical professionals using a voxel-based morphometric technique. Nurses in active service underwent structural magnetic resonance imaging. Two core dimensions of burnout, namely, emotional exhaustion and depersonalization, were assessed using self-reported psychological questionnaires. Levels of emotional exhaustion were found to be negatively correlated with gray matter (GM) volumes in the bilateral ventromedial prefrontal cortex (vmPFC) and left insula. Moreover, levels of depersonalization were negatively correlated with GM volumes in the left vmPFC and left thalamus. Altogether, these findings contribute to a better understanding of the neural mechanisms of burnout and may provide helpful insights for developing effective interventions for medical professionals.