Diagnosis of Pediatric Stroke in Resource Limited Settings.

Global awareness of stroke as a significant cause of neurologic sequelae and death in children has increased over the years as more data in this field becomes available. However, most published literature on pediatric stroke have limited geographic representation. Data on childhood stroke from developing countries remains limited. Thus, this paper reviewed geographic/ethnic differences in pediatric stroke risk factors highlighting those reported in low- and middle-income countries, and proposes a childhood arterial ischemic stroke diagnostic algorithm for resource limited settings. Stroke risk factors include cardiac disorders, infectious diseases, cerebral arteriopathies, hematologic disorders, inflammatory diseases, thrombophilia and genetic conditions. Infection of the central nervous system particularly tuberculous meningitis, is a leading cause of pediatric arterial ischemic stroke in developing countries. Stroke should be considered in children with acute focal neurologic deficit especially in the presence of aforementioned risk factors. Cranial magnetic resonance imaging with angiography is the neuroimaging modality of choice but if unavailable, cranial computed tomography with angiography may be performed as an alternative. If both are not available, transcranial doppler together with neurologic exam may be used to screen children for arterial ischemic stroke. Etiological diagnosis follows with the aid of appropriate laboratory tests that are available in each level of care. International collaborative research on stroke risk factors that are prevalent in low and middle income countries will provide information for drafting of stroke care guidelines that are universal yet inclusive taking into consideration regional differences in available resources with the goal of reducing global stroke burden.

Impact of a Hybrid-Virtual Teaching Model on the Physical Examination Skills of Fourth-Year Medical Students.

ABSTRACT: A required fourth-year advanced core neurology-physical medicine and rehabilitation clerkship was adapted to hybrid format (2-wk remote; 2-wk in-person) during the COVID-19 pandemic. With teaching of the neurological physical examination being shifted to the remote component, we sought to determine whether this negatively affected student performance on an Objective Structured Clinical Examination, particularly the physical examination component. Mean pandemic-era total Objective Structured Clinical Examination scores ( n = 79, 85.1 ± 7.3) were similar to prepandemic era ( n = 137, 83.5 ± 6.0, P = 0.082). Pandemic-era physical examination scores were slightly higher than prepandemic (86.9 ± 6.5 vs. 84.9 ± 6.6). Despite conversion of the clerkship to a hybrid curriculum, the performance of the students on the Objective Structured Clinical Examination and the physical examination were unchanged. Reasons for this lack of change may include the constructiveness and integration of the case-based virtual demonstrations combined with in-person learning or the flexibility of the virtual course to allow students more time to prepare for the Objective Structured Clinical Examination and the physical examination. Our findings demonstrate that a hybrid-virtual model can be used to teach foundational skills such as the basics of the physical examination, while allowing faculty to address higher-order skills such as integration of clinical data with medical knowledge.

Acute small fiber neuropathy after Oxford-AstraZeneca ChAdOx1-S vaccination: A report of three cases and review of the literature.

Small fiber neuropathy usually presents with gradual and progressive chronic length-dependent pain. Acute small fiber neuropathy is rarely reported. Three patients with acute onset neuropathic pain after Oxford-AstraZeneca ChAdOx1-S vaccination are described. Two patients were identified at the Oxford University NHS Foundation Trust, Oxford, UK and one patient in Red de Salud UC Christus, Santiago, Chile. All patients underwent a clinical assessment that included a detailed neurological examination, laboratory investigations, nerve conduction studies, thermal threshold testing, and skin biopsy for intra-epidermal nerve fiber density. Patients seen in Oxford underwent MRI of the brain and spinal cord. Cerebrospinal analysis was not performed. Neuropathic symptoms (burning pain, dysaesthesias) developed in the hands and feet within 2 weeks of vaccination. On clinical examination, there was pinprick and thermal hyposensitivity in the area of neuropathic pain. Laboratory investigation, nerve conduction tests, sympathetic skin responses, and MRI showed no relevant abnormalities. Thermal thresholds were abnormal and intra-epidermal nerve fiber density in the lower leg was reduced. In two cases symptoms persist after several months. Three cases of definite acute small fiber neuropathy after Oxford-AstraZeneca ChAdOx1-S vaccination are described. At follow up, neuropathic pain was present in two of the patients.

COVID-19 can cause blink reflex abnormalities.

Background and purpose: Neurological symptoms and complications associated with coronavirus 2019 (COVID-19) are well known. It was aimed to evaluate the brainstem and trigeminal/facial nerves and the pathways between these structures in COVID-19 using the blink reflex test. Methods: Thirty patients with post COVID-19 (16 males, 14 females) and 30 healthy individuals (17 males, 13 females) were included in this prospective study. Individuals who previously had a positive nose swap polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 and whose previously clinical features were compatible with COVID-19 were included in the post COVID-19 patient group. Neurological examination of the participants should be normal. Blink reflex test was performed on all participants. R1, ipsilateral R2 (IR2), and contralateral R2 (CR2) waves obtained from the test were analyzed. Results: The mean ages of healthy individuals and post COVID-19 patients were 34.0±6.4 and 38.4±10.6 years, respectively. Both age and gender were matched between the groups. R1, IR2, and CR2 latencies/amplitudes were not different between the two groups. The side-to-side R1 latency difference was 0.5±0.3 and 1.0±0.8 ms in healthy individuals and post COVID-19 patients, respectively (p=0.011). One healthy individual and 12 patients with post COVID-19 had at least one abnormal blink reflex parameter (p=0.001). Conclusion: This study showed that COVID-19 may cause subclinical abnormalities in the blink reflex, which includes the trigeminal nerve, the seventh nerve, the brainstem, and pathways between these structures.

Peripheral Neuropathy Evaluations of Patients With Prolonged Long COVID.

BACKGROUND AND OBJECTIVES: Recovery from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection appears exponential, leaving a tail of patients reporting various long COVID symptoms including unexplained fatigue/exertional intolerance and dysautonomic and sensory concerns. Indirect evidence links long COVID to incident polyneuropathy affecting the small-fiber (sensory/autonomic) axons. METHODS: We analyzed cross-sectional and longitudinal data from patients with World Health Organization (WHO)-defined long COVID without prior neuropathy history or risks who were referred for peripheral neuropathy evaluations. We captured standardized symptoms, examinations, objective neurodiagnostic test results, and outcomes, tracking participants for 1.4 years on average. RESULTS: Among 17 patients (mean age 43.3 years, 69% female, 94% Caucasian, and 19% Latino), 59% had ≥1 test interpretation confirming neuropathy. These included 63% (10/16) of skin biopsies, 17% (2/12) of electrodiagnostic tests and 50% (4/8) of autonomic function tests. One patient was diagnosed with critical illness axonal neuropathy and another with multifocal demyelinating neuropathy 3 weeks after mild COVID, and ≥10 received small-fiber neuropathy diagnoses. Longitudinal improvement averaged 52%, although none reported complete resolution. For treatment, 65% (11/17) received immunotherapies (corticosteroids and/or IV immunoglobulins). DISCUSSION: Among evaluated patients with long COVID, prolonged, often disabling, small-fiber neuropathy after mild SARS-CoV-2 was most common, beginning within 1 month of COVID-19 onset. Various evidence suggested infection-triggered immune dysregulation as a common mechanism.

An equation to calculate UPDRS motor severity for online and rural assessments of Parkinson's.

OBJECTIVE: Management of PD has largely been affected by COVID-19. Due to the restrictions posed by COVID-19, there has been a shift from in-person to online forms of assessment. This presents a challenge as not all motor symptoms can be assessed virtually. Two of the four cardinal symptoms of PD (rigidity and postural instability) cannot be assessed virtually using the gold-standard Unified Parkinson's Disease Rating Scale (UPDRS-III). As a result, an accurate total motor severity score can not be computed from the remaining subsections. Recently, one study stated that in order for accurate scores to be calculated, only three sections could be absent. Virtually, six sections are unable to be evaluated with online assessments. This inability to compute a total motor severity score may result in poor disease management. Thus, in this study a regression equation was developed to predict total motor severity scores from partial scores. METHODS: Total motor severity scores (UPDRS-III) from N = 234 individuals with idiopathic Parkinson's were retrospectively analyzed. In order to conduct a linear regression analysis predictor and outcome variables were created. The variables were then used for the linear regression. The equation was then tested on an independent data set N = 1168. RESULTS: The regression analysis resulted in the equation to predict total motor symptom severity of PD. CONCLUSIONS: In conclusion, the developed equation will be very useful for outreach in rural communities, as well as the continued remote management of PD during COVID-19 and beyond.

A method for remotely measuring physical function in large epidemiologic cohorts: Feasibility and validity of a video-guided sit-to-stand test.

INTRODUCTION: Traditional measures of muscular strength require in-person visits, making administration in large epidemiologic cohorts difficult. This has left gaps in the literature regarding relationships between strength and long-term health outcomes. The aim of this study was to test the feasibility and validity of a video-led, self-administered 30-second sit-to-stand (STS) test in a sub-cohort of the U.S.-based Cancer Prevention Study-3. METHODS: A video was created to guide participants through the STS test. Participants submitted self-reported scores (n = 1851), and optional video recordings of tests (n = 134). Two reviewers scored all video tests. Means and standard deviations (SD) were calculated for self-reported and video-observed scores. Mean differences (95% confidence intervals (CI)) and Spearman correlation coefficients between self-reported and observed scores were calculated, stratifying by demographic characteristics. RESULTS: Participants who uploaded a video reported 14.1 (SD = 3.5) stands, which was not significantly different from the number of stands achieved by the full cohort (13.9 (SD = 4.2), P-difference = 0.39). Self-reported and video-observed scores were highly correlated (ρ = 0.97, mean difference = 0.3, 95% CI = 0.1-0.5). There were no significant differences in correlations by sociodemographic factors (all P-differences ≥0.42). CONCLUSIONS: This study suggests that the self-administered, video-guided STS test may be appropriate for participants of varying ages, body sizes, and activity levels, and is feasible for implementation within large, longitudinal studies. This video-guided test would also be useful for remote adaptation of the STS test during the COVID-19 pandemic.

Anti-SARS-CoV-2 and Autoantibody Profiles in the Cerebrospinal Fluid of 3 Teenaged Patients With COVID-19 and Subacute Neuropsychiatric Symptoms.

Importance: Neuropsychiatric manifestations of COVID-19 have been reported in the pediatric population. Objective: To determine whether anti-SARS-CoV-2 and autoreactive antibodies are present in the cerebrospinal fluid (CSF) of pediatric patients with COVID-19 and subacute neuropsychiatric dysfunction. Design, Setting, and Participants: This case series includes 3 patients with recent SARS-CoV-2 infection as confirmed by reverse transcriptase-polymerase chain reaction or IgG serology with recent exposure history who were hospitalized at the University of California, San Francisco Benioff Children's Hospital and for whom a neurology consultation was requested over a 5-month period in 2020. During this period, 18 total children were hospitalized and tested positive for acute SARS-CoV-2 infection by reverse transcriptase-polymerase chain reaction or rapid antigen test. Main Outcomes and Measures: Detection and characterization of CSF anti-SARS-CoV-2 IgG and antineural antibodies. Results: Of 3 included teenaged patients, 2 patients had intrathecal anti-SARS-CoV-2 antibodies. CSF IgG from these 2 patients also indicated antineural autoantibodies on anatomic immunostaining. Autoantibodies targeting transcription factor 4 (TCF4) in 1 patient who appeared to have a robust response to immunotherapy were also validated. Conclusions and Relevance: Pediatric patients with COVID-19 and prominent subacute neuropsychiatric symptoms, ranging from severe anxiety to delusional psychosis, may have anti-SARS-CoV-2 and antineural antibodies in their CSF and may respond to immunotherapy.

Mononeuropathy Multiplex After COVID-19.

OBJECTIVES: COVID-19 is a novel coronavirus that emerged in 2019 and is responsible for a global pandemic. Numerous neurologic manifestations have been described in the literature regarding COVID-19, but most studies are focused on the central nervous system. The authors have noted an association between prior COVID-19 infection and the development of a systemic neuropathy that manifests with asymmetric sensorimotor loss in the peripheral nervous system. We describe 4 cases of mononeuropathy multiplex that were diagnosed after COVID-19 infection. METHODS: All patients included were treated for severe COVID-19 infection at New York Presbyterian Hospital and subsequently referred to the Columbia Peripheral Neuropathy Center for persistent neuropathy. RESULTS: Patient history, COVID-19 disease course, and mononeuropathy multiplex diagnostic evaluation of the 4 patients are recounted. CONCLUSIONS: We postulate a connection between COVID-19 and the development of mononeuropathy multiplex with implications in prognostication, rehabilitation strategies, and future treatments.

Guillain-Barré syndrome associated with COVID-19 infection: a case from the UK.

Originating from Wuhan, China, COVID-19 has rapidly spread worldwide. Neurological manifestations are more commonly associated with severe COVID-19 infection. Guillain-Barré syndrome (GBS) is a rare immune-mediated postinfectious neuropathy. It has been reported as a possible rare complication of COVID-19. We report a case of GBS associated with COVID-19 in the UK.

Automated Computer Vision Assessment of Hypomimia in Parkinson Disease: Proof-of-Principle Pilot Study.

BACKGROUND: Facial expressions require the complex coordination of 43 different facial muscles. Parkinson disease (PD) affects facial musculature leading to "hypomimia" or "masked facies." OBJECTIVE: We aimed to determine whether modern computer vision techniques can be applied to detect masked facies and quantify drug states in PD. METHODS: We trained a convolutional neural network on images extracted from videos of 107 self-identified people with PD, along with 1595 videos of controls, in order to detect PD hypomimia cues. This trained model was applied to clinical interviews of 35 PD patients in their on and off drug motor states, and seven journalist interviews of the actor Alan Alda obtained before and after he was diagnosed with PD. RESULTS: The algorithm achieved a test set area under the receiver operating characteristic curve of 0.71 on 54 subjects to detect PD hypomimia, compared to a value of 0.75 for trained neurologists using the United Parkinson Disease Rating Scale-III Facial Expression score. Additionally, the model accuracy to classify the on and off drug states in the clinical samples was 63% (22/35), in contrast to an accuracy of 46% (16/35) when using clinical rater scores. Finally, each of Alan Alda's seven interviews were successfully classified as occurring before (versus after) his diagnosis, with 100% accuracy (7/7). CONCLUSIONS: This proof-of-principle pilot study demonstrated that computer vision holds promise as a valuable tool for PD hypomimia and for monitoring a patient's motor state in an objective and noninvasive way, particularly given the increasing importance of telemedicine.

Effects of SARS-CoV-2 infection on neuroimaging and neurobehavior in neonates.

BACKGROUND: We collected neonatal neurological, clinical, and imaging data to study the neurological manifestations and imaging characteristics of neonates with coronavirus disease 2019 (COVID-19). METHODS: This case-control study included newborns diagnosed with COVID-19 in Wuhan, China from January 2020 to July 2020. All included newborns had complete neurological evaluations and head magnetic resonance imaging. We normalized the extracted T2-weighted imaging data to a standard neonate template space, and segmented them into gray matter, white matter, and cerebrospinal fluid. The comparison of gray matter volume was conducted between the two groups. RESULTS: A total of five neonates with COVID-19 were included in this study. The median reflex scores were 2 points lower in the infected group than in the control group (P = 0.0094), and the median orientation and behavior scores were 2.5 points lower in the infected group than in the control group (P = 0.0008). There were also significant differences between the two groups in the total scale score (P = 0.0426). The caudate nucleus, parahippocampal gyrus, and thalamus had the strongest correlations with the Hammersmith neonatal neurologic examination (HNNE) score, and the absolute correlation coefficients between the gray matter volumes and each part of the HNNE score were all almost greater than 0.5. CONCLUSIONS: We first compared the neurological performance of neonates with and without COVID-19 by quantitative neuroimaging and neurological examination methods. Considering the limited numbers of patients, more studies focusing on the structural or functional aspects of the virus in the central nervous system in different age groups will be carried out in the future.

Lower motor neuron facial palsy in a postnatal mother with COVID-19.

COVID-19 is caused by the novel SARS-CoV-2 and is a potentially fatal disease that is of great global public health concern. In addition to respiratory symptoms, neurological manifestations have been associated with COVID-19. This is attributed to the neurotropic nature of coronaviruses. The authors present a case of Bell's palsy associated with COVID-19 in a term primigravida.

Neurological examination course in an interactive webinar as a solution during a pandemic. An overview of the implementation, optimization as well as critical considerations.

Situation: The COVID-19 pandemic made the traditional bedside teaching inaccessible for medical students. Problem: Within a short period of time, established bedside teaching concepts had to be converted into online formats to meet the requirements of the health authorities. Approach: The Department of Neurology at the University Hospital Essen transformed the examination course in the 5th clinical semester into a live stream, taking into account data protection guidelines. This enabled students to participate from a distance, allowing them to take the medical history from a patient and to interact with the medical examiners. Thus, this concept goes beyond the video-based formats of the examination course. Optimization: During the course, we performed online evaluations to ensure an immediate feedback from the students. This enabled us to implement ongoing changes that had a positive impact on the course format, for example using better equipment to ensure a better video and audio quality. In the future, we hope to create a clinic's own online channel to further increase data security.

Radiologic Assessment of the Sinonasal Tract, Nasopharynx and Mastoid Cavity in Patients with SARS-Cov-2 Infection Presenting with Acute Neurological Symptoms.

BACKGROUND: Acute neurological sequela in patients with COVID-19 infection include acute thromboembolic infarcts related to cytokine storm and post infectious immune activation resulting in a prothrombotic state. Radiologic imaging studies of the sinonasal tract and mastoid cavity in patients with COVID-19 infection are sparse and limited to case series. In this report, we investigate the radiologic involvement of nasal cavity, nasopharynx, paranasal sinuses, and mastoid cavity in patients with SARS-CoV-2 infection who presented with acute neurological symptoms. METHODS: Retrospective review of medical records and neuroradiologic imaging in patients diagnosed with acute COVID-19 infection who presented with acute neurological symptoms to assess radiologic prevalence of sinus and mastoid disease and its correlation to upper respiratory tract symptoms. RESULTS: Of the 55 patients, 23 (42%) had partial sinus opacification, with no evidence for complete sinus opacification. The ethmoid sinus was the most commonly affected (16/55 or 29%). An air fluid level was noted in 6/55 (11%) patients, most commonly in the maxillary sinus. Olfactory recess and mastoid opacification were uncommon. There was no evidence of bony destruction in any of the studies, Cough, nasal congestion, rhinorrhea, and sore throat were not significantly associated with any radiological findings. CONCLUSION: In patients who present with acute neurological symptoms, COVID-19 infection is characterized by limited and mild mucosal disease within the sinuses, nasopharynx and mastoid cavity. LEVEL OF EVIDENCE: 4.

Aerospace Implications of Key Neurological Conditions.

INTRODUCTION: The neurological impact (or lack thereof) of certain medical histories and imaging findings is important to understand in the context of air and spaceflight. There are a number of neurological conditions that, if present in pilots and astronauts, carry variable (and sometimes adverse) functional implications for safety and overall mission success. In this systematic overview, the authors will refer to the relevant clinical and radiological features of brain tumors and vascular anomalies, cerebral edema and intracranial hypertension, concussion and the traumatic brain injury (TBI) spectrum, hematomas, cerebrospinal fluid circulation anomalies including hydrocephalus and sequestrations, spinal degenerative changes, and cerebral ischemia and demyelination. It is notable that these last two conditions have recently been reported to be a complication in some people with coronavirus disease 2019 (COVID-19). A paradigm for practical neurological workup of symptomatic pilots and astronauts will be discussed, as will the controversial notion of pre-emptive radiological screening (vs. not screening) in asymptomatic or clinically occult situations. The concepts of medical surveillance in the setting of known or diagnosed pathologies, and expert panel review and simulator and flight checks in complex neurological cases, are also elaborated on in this paper. We believe this overview will contribute toward the enhancement of a broad understanding of neurological conditions, their clinical workup, and their precautionary management in the setting of aviation and aerospace.Khurana VG, Jithoo R, Barnett M. Aerospace implications of key neurological conditions. Aerosp Med Hum Perform. 2021; 92(2):113119.