Background: SARS-CoV-2 can contribute to a number of neurological manifestations. 19.3% of patients with severe COVID-19 had evidence of marked skeletal muscle injury and 13.7% of patients with COVID-19 have high CK levels. Methodology: We retrospectively analyzed 413 COVID-19 patients. We reviewed electronic medical records and collected data. Skeletal muscle injury was defined as skeletal muscle pain and elevated serum creatine kinase level. The primary objective to determine the incidence of skeletal muscle injury in COVID-19 patients. Results: The most common risk factors were hypertension diabetes and obesity and neurological symptoms at onset of illness were myalgia. Multi-organ systems involvement including 47.8% had skeletal muscle injury, 15.7% had rhabdomyolysis, 36.7% had acute kidney injury, 27.5% had acute liver injury, 23.9% had acute myocardial injury. Discussion: In addition to respiratory system involvement, other extrapulmonary multiorgan systems involvement including skeletal muscle injury, acute kidney injury, acute liver injury, acute myocardial injury, rhabdomyolysis, acute heart failure, acute pancreatitis and post ICU critical illness neuromyopathy. SARSCoV- 2 may direct invade skeletal muscle, hematogenous dissemination, immunemediated skeletal muscles injury and inflammatory response with cytokine storm may lead to pathological changes in skeletal muscle tissue including muscle fiber proteolysis and fibrosis. Conclusion: Skeletal muscles injury with COVID-19 patient’s manifest as myalgia, generalized fatigue, myositis, rhabdomyolysis, dermatomyositis-like interferonopathy 1, immune-mediated necrotizing myopathy and respiratory failure. Further studies are requiring with focus on long term outcomes of skeletal muscles injury and benefits of using post COVID rehabilitation programs.

Background: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality globally. Currently, the association between hyperoxia and outcomes in patients with TBI remains debatable. We assessed the effect of hyperoxia on the neurological outcomes and survival of critically ill patients with moderate-severe TBI. Methods: This was a retrospective cohort study of all adults with moderatesevere TBI admitted to the ICU between 1st January 2016 and 31st December 2019 who required invasive mechanical ventilation. We noted ABGs performed with the first 3 hours of intubation, then 6-12 hours and 24-48 hours. The patients were divided into two categories: normoxia (PaO2 60-99 mmHg) and hyeroxia (PaO2 >100 mmHg). Multivariable logistic regression was performed to assess predictors of hospital mortality and good neurologic outcome (Glasgow outcome score [GOS] ≥ 4). In a second analysis the patients were divided into survivors and non-survivors. Results: The study included 308 patients: 23.4% (n=72) in normoxia group and 76.6% (n=236) in hyeroxia group. Hyperoxia was not associated with increased hospital (43% vs. 18%, p=0.20) mortality. Further, the hospital discharge GCS (10 ± 5 vs. 11 ± 4, p=0.10) and GOS (3 ± 1 vs. 3 ± 1, p=0.35) were similar. In multivariable logistic regression analysis, hyperoxia was not associated with increased mortality (adjusted odds ratio [aOR] 0.99, 95% CI 0.99-1.00, p=0.11). PaO2 within different ranges was also not associated with mortality: 100-200 mmHg: aOR 0.60, 95% CI 0.29-1.52; 201-300 mmHg: aOR 0.66, 95% CI 0.29-1.52; 301-400 mmHg: aOR 0.80, 95% CI 0.31-2.09; and >400 mmHg: aOR 0.39, 95% CI 0.14-1.08; reference: PaO2 60-99 mmHg. The Kaplan-Meier survival curve for normoxia verses hyperoxia showed no significant difference for all-cause mortality. In the survivors verse nonsurvivors analysis, the PaO2 were (median, IQT) 199 mmHg (111-329) and 165 mmHg (84-252), respectively. Conclusion: Hyperoxia (PaO2 >100 mmHg) was not associated with increased mortality or poor neurological outcomes (determined by GOS) in moderatesevere TBI patients.

Objective: Uric acid (UA) is a molecule known as an antioxidant. However, studies conducted in recent years indicate that elevated serum UA levels are an independent risk factor for stroke. The aim of our study is to determine the relationship between UA and acute ischemic stroke and subtypes. Methods: We retrospectively analyzed 110 patients with acute ischemic stroke within the first 24 hours who were admitted to Bakirkoy Prof Dr. Mazhar Osman, Mental and Neurological Diseases Training and Research Hospital (Istanbul, Turkey) between August 2016 and August 2017. The control group was composed of 82 healthy volunteers who were compatible with the patient group in terms of age and gender. Serum UA levels were estimated and stroke subtypes were determined by Bamford classification according to clinical findings and TOAST classification according to etiology. Results: Mean serum UA levels were found 5,5 mg/dL in the patient group versus 4,8 mg/dL in the control group. There was a statistically significant difference between patients and controls (p<0,0019). As for the stroke subtypes, elevated serum UA was found to be associated with all stroke subtypes except lacunar stroke according to Bamford classification and small vessel disease according to TOAST classification. In Multiple Logistic Regression Analysis, serum UA levels higher than 5,6 mg/dL were identified as independent risk factors for ischemic stroke. Conclusion: In our study, high UA levels were seen as an independent risk factor for stroke. Determination of UA as an etiological factor responsible for the pathogenesis of vascular diseases including stroke may also bring the treatment of hyperuricemia such as hyperlipidemia or hypertension, which are routinely treated after stroke.

Background: Despite technologic advances, stroke remains a difficult clinical diagnosis. We aimed to investigate the rate and characteristics of stroke mimics (SM) and missed strokes (MS). Research Methodology: We used data of consecutive “suspected stroke” admissions in a tertiary academic Hospital from January 2016 to July 2018. Diagnosis of SM was based on the absence of an ischaemic infarct on neuroimaging plus the presence an alternate discharge diagnosis. MS were defined as any patient with a discharge diagnosis of stroke whose stroke-like symptoms were missed in the Emergency Department (ED). Findings: Of 1745 patients reviewed, 63% were ischaemic stroke, 18% Intra-Cranial Haemorrhage (ICH), and 18% SM. We detected 95 MS. Stroke risk factors were significantly less common among SM and MS compared to stroke patients. Younger age, female gender, dizziness, ataxia, absence of limb weakness, and absence of certain vascular risk factors were predictors of SM. For MS, the predicting factors were young age (<55), confusion at presentation, hypercholesterolemia, and absence of hypertension. Conclusion: Atypical presenting symptoms can cause over and under-diagnosis of stroke. MS and SM are similar in many aspects. These diagnostic errors occur more often in younger patients with less severe neurological symptoms and symptoms attributable to posterior circulation.

Vertigo is a complicated symptom caused mainly by a dysfunctional vestibular system, either central or peripheral. Benign paroxysmal positional vertigo (BPPV), vestibular migraine (VM) and posterior circulation ischemia (PCI) are the three common causes of vertigo, all of which are related to abnormal calcium function. As a calcium antagonist, flunarizine has a multitude of mechanisms of action in vertigo treatment. The drug exerts neuroprotective effects on brain, endothelial and hair cells of the inner ear; reduces angiospasm, normalizes blood viscosity, improves the circulation of blood flow to the brain and inner ear; protects and restores injured neuronal or vascular cells from hypoxic-ischaemic damage; accelerates vestibular function recovery and inhibits cortical spreading depression (CSD). Many studies showed flunarizine to be effective especially against vertiginous attacks resulting from BPPV, VM and PCI with few serious side effects, probably due to its multiple mechanisms of action.

Background: Fingolimod, as an immunosuppressive drug, is used in the treatment of patients with Multiple Sclerosis. During recent pandemic, several controversies raised to stop or continue immunosuppressive drugs such as fingolimod in patients who developed coronavirus disease 2019. In this regard, most of consensuses advised to stop the consumption of this drug, but try to re-initiate before 6-8 weeks to prevent the disease’s activity or occurrence of rebound phenomenon. Case presentation: we report a 40-year old female patient with Multiple Sclerosis receiving fingolimod. Having peripheral lymphopenia, she developed coronavirus disease 2019 symptoms, tested for polymerase chain reaction of coronavirus, and the result was positive. Afterward, she stayed at home and did not stop fingolimod. However, her symptoms have improved and she did not need hospitalization for the entire course of coronavirus disease 2019 infection. Conclusion: The effects of the treatment with fingolimod on a patient infected by coronavirus disease 2019 are complex. On one hand, fingolimod withdrawal can increase the number of circulating lymphocytes, which consequently improves body defense against viral infections. On the other hand, it can also increase the risk of cytokine storm, which could be harmful. Therefore, further studies needed to find the risks and beneficial effects of fingolimod on coronavirus disease 2019 patients.

Horner syndrome is a constellation of neurological findings consisting of ipsilateral ptosis, miosis and anhidrosis. Partial Horner syndrome, comprising ipsilateral ptosis and miosis in the absence of anhidrosis, is a well-documented but uncommon manifestation of internal carotid artery dissection. Internal carotid artery dissection (ICAD) is a rare entity that either results from traumatic injury or can be spontaneously preceded or not by aminor trauma such as sporting activities, is a common cause of ischaemic stroke in young patients. As many as 40 to 50% of patients with carotid dissection will develop an ipsilateral Horner’s sindrome.

Introduction: Diagnostic uncertainty results in admission and unnecessary treatment of stroke mimics (SMs), leading to substantial expenditure of limited existing resources. We investigated the costs of admitting SMs compared to the cost of MR imaging in the acute setting. Methods: In this retrospective cross-sectional study, we analyzed all suspected stroke admissions from January 2016 until July 2018. We evaluated the costs of admission of SMs to the stroke unit and compared it with the cost assumption of having performed MR instead of CT imaging in all patients who presented with stroke symptoms. Findings: A total of 1745 patients presenting with stroke symptoms was included. 1108 (63%) were diagnosed as ischemic strokes, 321 (18%) with intracranial haemorrhage and 316 (18%) with SMs. The calculated cost of the initial neuroimaging studies for all patients was A$631,291. The cost of performing MRI for these patients would have been A$657,167. Accordingly, the excess cost of performing MRI instead of CT scan in the acute setting would have been A$25,876.00. This is significantly lower than the costs of stroke admission of SMs (A$1,255,373). Conclusion: Unnecessary admission and stroke investigations for SM patients can impose huge expenses on health care system. Since MRI is highly sensitive and specific in diagnosis of acute stroke, utilizing it as the first imaging modality in diagnosis of acute stroke would reduce the cost of stroke admission of SMs.

Background: Drugs primarily affect the way individuals think, feel and behave. Illicit substances such as crystal methamphetamine show a strong association to abnormalities in the process of neurotransmission. Objective: The main aim of this review is to analyse substance abuse and abnormalities in neurotransmission focusing on crystal methamphetamine and its physiological, psychological and social implications. Methods: Extensive systematic electronic databases (EBSCOhost, JSTOR, ProQuest Science, Science Direct, Research Gate, Google Scholar and PubMed) were used. Research articles and books were searched using the keywords ‘effects of crystal methamphetamine’, ‘neurotransmission in substance abuse’, ‘substance abuse by homosexual males’. Discussion and Conclusion: This thematic review draws close attention to the physiological changes, psychological disorders and abuse of crystal methamphetamine among homosexual men tested positive for Human Immunodeficiency Virus (HIV) as well as a need for better social care services and treatment in order to overcome homophobic stigmatization.

The present study was designed to determine whether or not there are components of the ERPs that discriminate the erotic and negative pictures during affective picture processing. Participants viewed erotic, negative and neutral pictures form the International Affective Picture System (IAPS). Eighteen right-handed volunteer students from North-Eastern University participated in the experiment. Electrode from the frontal site (F3 and F4), C3 and C4 (central electrodes), P3 andP4 (parietal electrodes) and O1 and O2 (occipital electrodes) were averaged with the stimuli type and brain hemisphere. The change in spectral power of the brain signal and its main spectral bands of theta (3-7.5 Hz), Alpha (7.5-13 Hz) and Beta (13-25 Hz) were analyzed. Erotic stimuli showed ERP components deflected more negatively at the frontal electrode site than the negative picture stimuli during the time window of 200-300 ms whereas the negative valence stimuli processing reflected a positively twisted amplitude at the time window of 120-300 ms. The erotic and negative valence emotional picture stimuli show a significant difference in the spectral power of theta, alpha and beta frequency bands for the left vs. right hemisphere and frontal vs. occipital sites. Nonetheless, the time-frequency plots show us those emotionally valence visual stimuli triggered an increase of alpha band (7.5-13 Hz).