BackgroundVarious relaxation procedures have been proposed to reduce fatigue in multiple sclerosis (MS). However, it is unknown, which type of relaxation has the largest effect on fatigue reduction and on autonomic nervous system (ANS) activity.ObjectiveWe aimed to compare two biofeedback-supported relaxation exercises: a deep breathing (DB) exercise and progressive muscle relaxation (PMR), which may ameliorate MS fatigue and alter ANS activity.MethodsWe performed a single-blind randomized clinical trial, introducing MS patients (n = 34) to the DB or PMR exercise. We first tested cardiovagal integrity, reflected by changes in heart rate variability (HRV) in response to DB. Participants then performed a fatigue-inducing vigilance task, followed by the DB or PMR. State fatigue was recorded consecutively at baseline, after the vigilance task, and after the relaxation exercise, along with HRV reflecting ANS activity.ResultsOnly patients assigned to the PMR group experienced a significant drop in fatigue, whereas both relaxation exercises changed ANS activity. MS patients showed the expected autonomic response during the cardiovagal reflex test. The vigilance task elevated short-term feelings of fatigue and significantly reduced HRV parameters of parasympathetic activity. Trait fatigue was negatively correlated with HRV during the second half of the vigilance task.ConclusionPMR alleviates short-term feelings of fatigue in persons with MS. The vigilance task in combination with HRV measurements may be helpful for evaluating relaxation procedures as a treatment of fatigue. Hereby, future studies should ensure longer and more frequent relaxation exercises and focus on patients with weak to moderate fatigue.Trial registrationTrial Registry: DRKS00024358.

BackgroundCOVID-19 pandemic has affected the management of multiple sclerosis (MS).ObjectiveTo explore the impact of COVID-19 on healthcare delivery to people with MS and the subsequent recovery of the system.MethodsIn this population-based study in the Campania Region (Italy), we included people with MS across pre-COVID-19, lockdown, pre-vaccination, and vaccination periods. Differences in continuous outcomes between periods were explored using linear mixed models (annualized hospitalization rate (AHR) and adherence measured as medication possession ratio (MPR)). Differences in disease-modifying treatment (DMT) prescription rates (first DMT prescription, any DMT switch, switch from platform to highly effective DMT, and combination of first DMT prescription and any DMT switch) were assessed using an interrupted time series design.ResultsCompared with pre-COVID-19, AHR decreased during the lockdown (Coeff = 0.64;95%CI = -0.69, -0.59; p < 0.01), and remained lower during pre-vaccination and vaccination periods. Adherence decreased during pre-vaccination (Coeff = -0.04;95%CI = -0.05, -0.03; p < 0.01) and vaccination periods (Coeff = -0.07;95%CI = -0.08, -0.07; p < 0.01). After the lockdown, there was an increase in any DMT switch (IRR 2.05 95%CI 1.38,3.05; p < 0.01), in switch from platform to highly effective DMTs (IRR 4.45;95%CI 2.48,8.26; p < 0.01) and in first DMT prescriptions (IRR 2.48;95%CI 1.64,3.74; p < 0.01).ConclusionsDMT prescriptions quickly returned to pre-pandemic levels, reflecting good health system recovery. However, adherence has remained lower than the past, as from suboptimal care. Assessing long-term COVID-19 impact on MS healthcare is warranted.

Posterior reversible encephalopathy syndrome (PRES) is a rare, reversible neurological disease that is frequently associated with the use of targeted therapy agents. In this case study, we examine the development of posterior reversible encephalopathy syndrome (PRES) in a 44-year-old woman with metastatic colon cancer following 1 month of treatment with the vascular endothelial growth factor receptor (VEGFR) inhibitor, fruquintinib. The occurrence of PRES after 1 month of VEGFR inhibitor administration is a common phenomenon. However, it is noteworthy that this is the first reported case of PRES associated with fruquintinib. The patient’s neurological function improved upon discontinuing the drug for a week, but worsening was observed following a lower-dose fruquintinib treatment. This patient’s experience highlights the potential for neurological deterioration in those treated with fruquintinib, prompting physicians to consider the possibility of PRES. Notably, this may be the first reported case linking fruquintinib to the syndrome, underscoring the importance of recognizing the association between PRES and fruquintinib.

Thalamic hemorrhage (TH) is a devastating disease with a high mortality rate; however, no specific form of therapy has been proven to reduce mortality. Patients with hemorrhagic stroke undergo intracranial pressure (ICP) monitoring. However, cases involving pseudoaneurysms caused by ICP monitoring in patients with intracerebral hemorrhage have not been reported previously. Here, we report a case of pseudoaneurysm caused by an ICP monitor that was fitted due to hypertensive cerebral hemorrhage.

ObjectiveThis study aimed to evaluate the effectiveness of robot-assisted gait training (RAGT) in treating lower extremity function in patients with cerebral palsy (CP) and compare the efficacy differences between different robotic systems.MethodsPubMed, Web of Science, Cochrane Library, Embase, CNKI, VIP, CBM, and Wanfang databases were searched to collect randomized controlled trials of RAGT for lower extremity dysfunction in patients with CP from the time the databases were created until December 26, 2022. The D and E of Gross Motor Function Measure-88 (GMFM-88) assessed lower limb motor function. Berg Balance Scale (BBS) was used to assess balance function. Walking endurance and speed were assessed using the 6-minute walk test (6MWT) and walking speed. The modified Ashworth Scale (MAS) was used to assess the degree of muscle spasticity in the lower extremities. The Cochrane Risk Assessment Scale and the Physiotherapy Evidence Database (PEDro) scale were used for qualitative assessment in the studies included. RevMan 5.4 was used for data merging and statistical analysis. R 4.2.0 and ADDIS 1.16.8 were used to map the network relationships and to perform the network meta-analysis.ResultsA total of 14 studies were included in the review. The meta-analysis showed that RAGT significantly improved GMFM-88 D and E, BBS, and 6MWT scores in CP patients compared with conventional rehabilitation. However, for walking speed and MAS, the intervention effect of RAGT was insignificant. The network meta-analysis showed that the best probability ranking for the effect of the 3 different robots on the GMFM-88 D score was LokoHelp (P = 0.66) > Lokomat (P = 0.28) > 3DCaLT (P = 0.06) and the best probability ranking for the GMFM-88 E score was LokoHelp (P = 0.63) > 3DCaLT (P = 0.21) > Lokomat (P = 0.16).ConclusionRAGT positively affects walking and balance function in patients with CP, while efficacy in improving gait speed and muscle spasticity is unknown. The best treatment among the different robots is LokoHelp. Future high-quality, long-term follow-up studies are needed to explore the clinical efficacy of RAGT in depth.

Glioblastoma (formerly named glioblastoma multiforme) is the most common primary central nervous system tumor, representing 45% of all cases and 15% of all intracranial neoplasms [1]. Its typical radiologic findings and localization make it often a lesion easy to diagnose. In MRI it usually appears as an irregularly shaped cystic lesion with ring contrast enhancement in T1-weighted images, localized in subcortical white matter and deep gray matter nuclei of the cerebral hemispheres. It involves more frequently the frontotemporal region followed by parietal lobes [1]. Few articles in literature described cases of intraventricular glioblastomas, defining those as secondary ventricular tumors because of their probable origin primarily from cerebral tissue with consequent transependymal development [2, 3]. Atypical presentations of these tumors make it more difficult to clearly differentiate them from other lesions more commonly located in the ventricular system. We describe a case with a unique radiological presentation: an intraventricular glioblastoma lying entirely within the ventricular walls, involving all the ventricular system, without mass effect or nodular parenchymal lesions.

BackgroundIntracranial dural arterio-venous fistulas are pathological anastomoses between arteries and veins located within dural sheets and whose clinical manifestations depend on location and hemodynamic features. They can sometimes display perimedullary venous drainage (Cognard type V fistulas—CVFs) and present as a progressive myelopathy. Our review aims at describing CVFs’ variety of clinical presentation, investigating a possible association between diagnostic delay and outcome and assessing whether there is a correlation between clinical and/or radiological signs and clinical outcomes.MethodsWe conducted a systematic search on Pubmed, looking for articles describing patients with CVFs complicated with myelopathy.ResultsA total of 72 articles for an overall of 100 patients were selected. The mean age was 56.20 ± 14.07, 72% of patients were man, and 58% received an initial misdiagnosis. CVFs showed a progressive onset in 65% of cases, beginning with motor symptoms in 79% of cases. As for the MRI, 81% presented spinal flow voids. The median time from symptoms’ onset to diagnosis was 5 months with longer delays for patients experiencing worse outcomes. Finally, 67.1% of patients showed poor outcomes while the remaining 32.9% obtained a partial-to-full recovery.ConclusionsWe confirmed CVFs’ broad clinical spectrum of presentation and found that the outcome is not associated with the severity of the clinical picture at onset, but it has a negative correlation with the length of diagnostic delay. We furthermore underlined the importance of cervico-dorsal perimedullary T1/T2 flow voids as a reliable MRI parameter to orient the diagnosis and distinguish CVFs from most of their mimics.

ObjectivesWe aimed to evaluate beat-to-beat blood pressure variability (BPV) during head-up tilt test (HUTT) in patients with mild and moderate myasthenia gravis (MG) compared to healthy controls (HCs), and its association with the severity of autonomic symptoms.MethodsA total of 50 MG patients and 30 HCs were evaluated. Patients were stratified into 2 groups regarding Myasthenia Gravis Foundation of America (MGFA) classification: mild (I,II MGFA), moderate form (III MGFA). Autonomic symptoms were assessed by COMPASS-31 questionnaire. Cardiovascular parameters, indices of very short-term systolic (SBPV), and diastolic blood pressure (BP) variability (DBPV) were assessed at rest, and during HUTT.ResultsModerate MG patients were characterized by an overall shift of sympathovagal balance toward sympathetic predominance, either at rest and during HUTT, as well as lower values of high frequency (HFnu) of DBPV during HUTT, compared to HCs and mild MG. Similarly, moderate MG showed higher resting low frequency (LFnu) of DBPV (p=0.035), higher COMPASS-31 score (p=0.031), and orthostatic intolerance sub-score (p=0.019) than mild MG patients. Compared to HCs, mild MG patients showed lower Δmean BP (p=0.029), Δdiastolic BP (p=0.016). Autonomic symptoms were associated with lower BP values, at rest and during HUTT, and lower LF BPV parameters during HUTT.ConclusionMG patients present significant alterations in BPV, both at rest and in response to orthostatic stress, which are related to autonomic symptoms and disease severity. This study confirms the importance of monitoring BPV when evaluating cardiovascular autonomic function and its evolution over the course of MG disease.