Lesion Localization and Prognosis Using Electrodiagnostic Studies in Facial Diplegia: A Rare Variant of Guillain-Barre Syndrome.

Background The etiology of facial nerve palsy is diverse and includes herpes zoster virus, Guillain-Barre syndrome (GBS), otitis media, Lyme disease, sarcoidosis, human immunodeficiency virus, etc. The lower motor neuron type facial nerve palsy is usually caused by an ipsilateral facial nerve lesion; however, it may be caused by a central lesion of the facial nerve nucleus and tract in the pons. Facial diplegia is an extremely rare condition that occurs in approximately 0.3% to 2.0% of all facial palsies. Electrodiagnostic studies including direct facial nerve conduction, facial electromyography (EMG), and blink reflex studies are useful for the prognosis and lesion localization in facial nerve palsy. Methodology This retrospective, observational study was conducted at the Neurophysiology Unit, Hamad General Hospital, Doha, Qatar. This study included 11 patients with bilateral facial weakness who visited for electrodiagnostic studies in the neurophysiology laboratory. Results In total, eight (72.7%) patients had facial diplegia, eight (72.7%) had hypo/areflexia, seven (63.6%) had facial numbness, and five (45.5%) had cerebrospinal fluid albuminocytological dissociation. The most frequent cause of facial diplegia in this study was GBS (81.9%). Direct facial nerve conduction stimulation showed that nine (81.8%) patients had bilateral facial nerve low compound muscle action potential amplitudes. The bilateral blink reflex study showed that eight (88.8%) patients had absent bilateral evoked responses. Finally, the EMG study showed that five (55.5%) patients had active denervation in bilateral sample facial muscles. Conclusions Bilateral facial nerve palsy is an extremely rare condition with a varied etiology. Electrodiagnostic studies are useful in detecting the underlying pathophysiologic processes, prognosis, and central or peripheral lesion localization in patients with facial diplegia.

Acute Neurological Manifestations of COVID-19 Patients From Three Tertiary Care Hospitals in Qatar.

Introduction Worldwide, there are more than 424 million confirmed cases of COVID-19. Most of the hospitalized critical COVID-19 patients manifested neurological signs and symptoms and higher mortality. The majority of COVID-19 fatalities occurred mostly in patients with advanced age and underlying medical comorbidities. This is the first local retrospective study in Qatar, which reported neurologic manifestations (48.5%) of hospitalized COVID-19 patients. The primary objective of this study is to evaluate acute neurological manifestations in COVID-19 hospitalized patients in the country. Methods This is a retrospective, observational study of 413 hospitalized COVID-19 patients. They were admitted to three different COVID-19 designated hospitals (Hazm Mebaireek, Ras Laffan, and Cuban tertiary care Hospitals) under the Hamad Medical Corporation, Qatar from 1st January 2020, to 31 January 2021. We evaluated electronic medical records of these patients and data were collected while their neurological manifestations were confirmed by two trained neurologists. These neurologic manifestations were categorized into three major groups: central nervous system (CNS), peripheral nervous system (PNS), and neuromuscular system. Results Of 413 patients, 94% (389) were male and 6% (24) were female; the mean age was 52 years. Among all different nationalities of COVID-19 patients, 20.3% (84) were Indian, 12.5% (52) were Bangladeshi, 10.1% (42) were Qatari and 9.2% (38) were Nepali. The most common symptoms at the onset of COVID-19 illness were as follows: 77.5% (321) had a fever, 67.4% (279) experienced cough, 58.7% (243) experienced shortness of breath and 26.1% (108) developed a sore throat. Overall 48.5% (201) patients developed different neurologic manifestations. The most common neurologic symptoms were myalgia (28%; 116), headache (10.4%; 43), dizziness (5.8%; 24) and hemiparesis due to strokes (5.3%; 22). In this study, the most common risk factors were hypertension (47.6%), diabetes (46.9%), obesity (21%), chronic kidney disease (10%), ischemic heart disease (9.7%), and smoking (6.8%). About 45.2% (187) patients were admitted to MICU and 8.5% (35) died due to COVID-19 complications. Significant other extrapulmonary multiorgan system involvement were skeletal muscle injury (39.4%), kidney injury (36.7%), liver injury (27.5%), myocardial injury (23.9%), rhabdomyolysis (15.7%) heart failure (11.4%) and acute pancreatitis (11.1%). Discussion The most common neurologic signs and symptoms were myalgia, headache, dizziness, and strokes, mainly due to large vessel thrombosis, lacunar, and posterior circulation strokes. Conclusions Patients with COVID-19 are at high risk of developing neurological manifestations. The most common COVID-19-related acute neurological manifestations were myalgia, headache, dizziness, and acute ischemic stroke. Prompt recognition, early diagnosis, and appropriate management of these manifestations could potentially lead to better patient outcomes in COVID-19 patients.

COVID-19-Associated Acute Transverse Myelitis: A Case Series of a Rare Neurologic Condition.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral infection is not confined to the respiratory system, but has also shown extra-pulmonary invasion including the nervous system. About 36.4% of hospitalized patients in China with confirmed coronavirus disease 2019 (COVID-19) infection had neurological manifestations. SARS-CoV-2 virus enters the human body through angiotensin converting enzyme-2 (ACE-2) receptors on the surface of human cells and causes disease. ACE2 receptors are also expressed on the surface of spinal cord cells. More rare neurologic conditions have been reported in the literature to be associated with COVID-19 such as acute transverse myelitis (ATM), Guillain Barre syndrome, acute flaccid myelitis, etc. We report two cases of confirmed COVID-19 who presented four to five days of their COVID-19 symptoms and progressive bilateral lower limb weakness and urinary retention. ATM is an acquired spinal cord disorder. ATM is a relatively common neurological complication of COVID-19, accounting for 1.2% of all neurological complications associated with COVID-19. The mechanism by which COVID-19 causes ATM is not completely understood but has been assumed to be due to the structural resemblance of RNA viruses. Entrance of SARS-CoV-2 to the nervous system can take place through two pathways, either directly or indirectly. The direct pathway is through trans-synaptic transmission from the peripheral nervous system or by hematogenous spread into the blood-brain barrier through ACE-2, while the indirect pathway is through a systemic immune response.

Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association guidelines.

OBJECTIVE: To determine the feasibility and safety of treatment of acute hypertension in patients with intracerebral hemorrhage within 24 hrs of symptom onset. Elevated blood pressure, observed in up to 56% of patients with intracerebral hemorrhage, may predispose to hematoma expansion; on the other hand, reduction of blood pressure may reduce hematoma expansion and subsequent death and disability. DESIGN: Single-center prospective registry supplemented by retrospective chart review. SETTINGS: University-affiliated medical center with dedicated stroke service. PATIENTS: All patients admitted to the stroke service with spontaneous intracerebral hemorrhage and acute hypertension within 24 hrs of symptom onset. INTERVENTION: Patients were treated with intravenous nicardipine within 24 hrs of symptom onset to reduce and maintain mean arterial pressure of <130 mm Hg. The mean arterial pressure goal was consistent with the American Heart Association guidelines. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the tolerability of the treatment as assessed by achieving and maintaining the mean arterial pressure goals for 24 hrs after initiation of intravenous nicardipine infusion. Other end points ascertained were: neurologic deterioration defined by a decline in Glasgow Coma Scale from pretreatment assessment by >or=2 points or increase in National Institutes of Health Stroke Scale score by >or=2 points and hemorrhage growth defined as an increase in the volume of intraparenchymal hemorrhage of >33% as measured by image analysis on the 24-hr computed tomographic scan compared with the baseline computed tomographic scan. Rates of favorable outcome and death were ascertained at 1 month. Of the total 46 patients admitted with intracerebral hemorrhage in our service, 29 patients were treated. Mean age of the treated patients was 58 +/- 13 yrs; ten were women. Initial National Institutes of Health Stroke Scale ranged from 1 to 38. The primary outcome of tolerability was achieved in 25 of the 29 patients (86%). Neurologic deterioration was observed in 4 of 29 patients. Hematoma enlargement was observed in five patients. Favorable outcome (defined as modified Rankin scale of