Acute Neurological Syndromes Research Articles

Clinical, paraclinical and outcome features of 166 patients with acute anti-GQ1b antibody syndrome.

In this retrospective study, we aimed at defining the clinical, paraclinical and outcome features of acute neurological syndromes associated with anti-GQ1b antibodies. We identified 166 patients with neurological symptoms appearing in less than 1month and anti-GQ1b antibodies in serum between 2012 and 2022. Half were female (51%), mean age was 50years (4-90), and the most frequent clinical features were areflexia (80% of patients), distal upper and lower limbs sensory symptoms (78%), ophthalmoplegia (68%), sensory ataxia (67%), limb muscle weakness (45%) and bulbar weakness (45%). Fifty-three patients (32%) presented with complete (21%) and incomplete (11%) Miller Fisher syndrome (MFS), thirty-six (22%) with Guillain-Barre syndrome (GBS), one (0.6%) with Bickerstaff encephalitis (BE), and seventy-three (44%) with mixed MFS, GBS & BE clinical features. Nerve conduction studies were normal in 46% of cases, showed demyelination in 28%, and axonal loss in 23%. Anti-GT1a antibodies were found in 56% of cases, increased cerebrospinal fluid protein content in 24%, and Campylobacter jejuni infection in 7%. Most patients (83%) were treated with intravenous immunoglobulins, and neurological recovery was complete in 69% of cases at 1year follow-up. One patient died, and 15% of patients relapsed. Age > 70years, initial Intensive Care Unit (ICU) admission, and absent anti-GQ1b IgG antibodies were predictors of incomplete recovery at 12months. No predictors of relapse were identified. This study from Western Europe shows acute anti-GQ1b antibody syndrome presents with a large clinical phenotype, a good outcome in 2/3 of cases, and frequent relapses.

Current clinical findings of acute neurological syndromes after SARS-CoV-2 infection.

Neuro-COVID, a condition marked by persistent symptoms post-COVID-19 infection, notably affects various organs, with a particular focus on the central nervous system (CNS). Despite scant evidence of SARS-CoV-2 invasion in the CNS, the increasing incidence of Neuro-COVID cases indicates the onset of acute neurological symptoms early in infection. The Omicron variant, distinguished by heightened neurotropism, penetrates the CNS via the olfactory bulb. This direct invasion induces inflammation and neuronal damage, emphasizing the need for vigilance regarding potential neurological complications. Our multicenter study represents a groundbreaking revelation, documenting the definite presence of SARS-CoV-2 in the cerebrospinal fluid (CSF) of a significant proportion of Neuro-COVID patients. Furthermore, notable differences emerged between RNA-CSF-positive and negative patients, encompassing aspects such as blood-brain barrier integrity, extent of neuronal damage, and the activation status of inflammation. Despite inherent limitations, this research provides pivotal insights into the intricate interplay between SARS-CoV-2 and the CNS, underscoring the necessity for ongoing research to fully comprehend the virus's enduring effects on the CNS. The findings underscore the urgency of continuous investigation Neuro-COVID to unravel the complexities of this relationship, and pivotal in addressing the long-term consequences of COVID-19 on neurological health.

NeuroCOVID-19: a critical review.

The COVID-19 pandemic has challenged neurologists since its early days. Neurology consultation services were then overloaded by emergency department and intensive-care patients with acute neurological syndromes. These complications are better explained today, but the growing number of patients with reported longstanding neurological symptoms constitute an emerging, complex, and still poorly understood phenomenon. This review summarizes data on relevant neurological manifestations of acute SARS-CoV-2 infection and lasting post-infectious disease, also known as Long COVID. The complex history of Long COVID is examined to illustrate the upsides and challenges imposed by the active participation of patient communities in the production of medical knowledge. Narrative review. Infection with the severe acute respiratory syndrome coronavirus 2 is associated with encephalopathy/delirium, cerebrovascular disease, headache, and peripheral nervous system involvement. Long COVID is a living concept jointly defined by patient communities, physicians and scientists, including neurologists. Co-production of Long COVID knowledge between scientists and patients has initiated an era of patient-led research and evidence-based activism that acts as a two-edged sword - putting patient's suffering in the spotlight, but with a tradeoff in methodological consistency.

SARS-CoV-2 Infection-Related Acute Parkinsonism and Encephalitis

COVID-19 infection can cause neurological manifestations as early and late complications (chronic COVID syndrome). These include headache, dizziness, confusion, acute cerebrovascular problems, ataxia, and seizures. COVID-19-related encephalopathy, encephalitis, and parkinsonism have been reported earlier; however, the possible links and pathophysiological mechanisms are unclear. In this report, we report a series of patients (n = 5) presenting with acute severe neurological syndromes such as parkinsonism, focal status epilepticus, or acute ataxia as a part of long-hauler COVID-19 infection. We categorized the clinico-radiological and electroencephalographic features in our cases to understand the clinical patterns in SARS-CoV-2 related brain cortex involvement. This might help in future for better clinical categorization for these COVID-19-related neurological manifestations.

Differential detection of zika virus based on PCR

Tropical countries are highly prone to infectious diseases such as the one caused by zika virus. Infection by zika is clinically and epidemiologically highly relevant. For example, when women are infected by zika during the first trimester of pregnancy, the child incurs a high risk of microcephaly and acute neurological syndromes. In adults, the virus is associated with the Guillain-Barré syndrome and other disorders. The worldwide emergency caused by zika in 2013/14 demonstrated the need for rapid and accurate diagnostic tools for the virus. Current diagnostic methods include virus isolation, serological tests, and molecular assays. However, virus isolation requires labor-intensive and time-consuming cell culture; serological detection suffers from cross-reactivity caused by previous exposure to homologous arboviruses that cause symptoms like those caused by zika, while molecular tools commonly are not designed for differential zika detection. This work reports on developing a specific molecular detection method based on phylogenetically conserved primers designed for the specific diagnosis of the zika virus. The zika primers were systematically selected through a rigorous bioinformatic analysis and demonstrated the capability to be highly specific. We tested our primers on synthetic DNA, cell cultures and samples from patients infected with zika, dengue and chikungunya and found that they detected zika with specificity high enough for differential virus diagnosis.

Nervous System-Systemic Crosstalk in SARS-CoV-2/COVID-19: A Unique Dyshomeostasis Syndrome.

SARS-CoV-2 infection is associated with a spectrum of acute neurological syndromes. A subset of these syndromes promotes higher in-hospital mortality than is predicted by traditional parameters defining critical care illness. This suggests that deregulation of components of the central and peripheral nervous systems compromises the interplay with systemic cellular, tissue and organ interfaces to mediate numerous atypical manifestations of COVID-19 through impairments in organismal homeostasis. This unique dyshomeostasis syndrome involves components of the ACE-2/1 lifecycles, renin-angiotensin system regulatory axes, integrated nervous system functional interactions and brain regions differentially sculpted by accelerated evolutionary processes and more primordial homeostatic functions. These biological contingencies suggest a mechanistic blueprint to define long-term neurological sequelae and systemic manifestations such as premature aging phenotypes, including organ fibrosis, tissue degeneration and cancer. Therapeutic initiatives must therefore encompass innovative combinatorial agents, including repurposing FDA-approved drugs targeting components of the autonomic nervous system and recently identified products of SARS-CoV-2-host interactions.

Respiratory Syncytial Virus–Associated Neurologic Complications in Children: A Systematic Review and Aggregated Case Series

To describe the features and frequency of respiratory syncytial virus (RSV)-associated severe acute neurologic disease in children. We performed a systematic review of the literature to identify reports of severe acute neurologic complications associated with acute RSV infection in children aged <15years (PROSPERO Registration CRD42019125722). Main outcomes included neurologic, clinical, and demographic features of cases and the frequency of disease. We aggregated available case data from the published literature and from the Australian Acute Childhood Encephalitis (ACE) study. We identified 87 unique studies from 26 countries describing a spectrum of RSV-associated severe acute neurologic syndromes including proven encephalitis, acute encephalopathy, complex seizures, hyponatremic seizures, and immune-mediated disorders. The frequency of RSV infection in acute childhood encephalitis/encephalopathy was 1.2%-6.5%. We aggregated data from 155 individual cases with RSV-associated severe acute neurologic complications; median age was 11.0months (IQR 2.0-21.5), most were previously healthy (71/104, 68%). Seizure was the most frequently reported neurologic feature (127/150, 85%). RSV was detected in the central nervous system of 12 cases. Most children recovered (81/122, 66%); however, some reports described partial recovery (33/122, 27%) and death (8/122, 7%). RSV-associated neurologic complications have been widely reported, but there is substantial heterogeneity in the design and quality of existing studies. The findings from our study have implications for the investigation, management, and prevention of RSV-associated neurologic complications. Further, this systematic review can inform the design of future studies aiming to quantify the burden of childhood RSV-associated neurologic disease.

Telestroke consultation can accurately diagnose ischemic stroke mimics

Introduction Telestroke (TS) networks are standard in many areas of the US. Despite TS systems having approximately 33% mimic rates, it is unknown if TS can accurately diagnose patients with acute ischemic stroke (AIS) versus stroke mimics. Methods We performed a retrospective review of consecutive TS consults to 27 TS sites in six states during 2018. Clinical information and diagnosis were extracted from discharge records and compared to those from the TS consult. Discharge diagnoses were verified and coded into 12 categories. Cases without a clear discharge diagnosis and intracerebral haemorrhage were excluded. We report agreement and a Cohen’s kappa between TS and discharge diagnoses for the category of AIS/transient ischemic attack (TIA) versus stroke mimic. Results We included 404 cases in the analysis (mean age 66 years; 54% women). Of these, 225 had a TS diagnosis of AIS/TIA; 102 (45%) received intravenous tissue plasminogen activator. Our study demonstrated a high diagnostic agreement for AIS/TIA (88%) with a kappa of 0.75 for stroke and mimics. Of the 179 patients diagnosed with a stroke mimic on TS, 27 (15%) were diagnosed with AIS/TA by discharge. TS mimic diagnosis had a positive predictive value (PPV) of 85% and a negative predictive value (NPV) of 90%; TS diagnosis of stroke/TIA had PPV 90%, NPV 85%. Discussion We found excellent correlation between TS and discharge diagnoses for patients with both stroke and stroke mimics. This suggests that TS systems can accurately assess a wider variety of patients with acute neurologic syndromes other than AIS.

718. Asymptomatic campylobacteriosis as a risk factor for developing acute neurological syndromes in Veracruz, Mexico

BackgroundCampylobacter infection is the main cause of diarrheal disease, however it is recognized as a risk factor for developing Guillain Barré syndrome, which has been previously corroborated in our population after analyzing the incidence of the syndrome during arboviral outbreaks of 2016-2018, resulting that 75% of the cases were due to infection by Campylobacter. Furthermore, of these patients, 83% did not present gastrointestinal symptoms, constituting an asymptomatic campylobacteriosis at the intestinal level, and Guillain Barré syndrome could be its primary manifestation. Reason why the need arose to look in this population for cases of asymptomatic campylobacteriosis.MethodsAnalytical, observational and prospective study. 200 healthy and asymptomatic individuals over 18 years of age were selected in the Veracruz Norte branch of the Mexican Institute of Social Security during September to December 2019, who were asked for a stool sample, which was subjected to a study to search for Campylobacter through a chromatographic immunoassay test for the qualitative detection of said bacteria (Certest). Patients who were positive to the Certest test underwent stool culture (Campy-bap) in order to typify the identified Campylobacter species.ResultsIn the search for Campilobacter, the Certest was positive in 6 (3.0%); In 5 (83.3%) subjects some variety of Campylobacter could be isolated by stool culture, in 4 (66.7%) Campylobacter Jejuni was isolated and in 1 (16.7%) Campylobacter Coli was isolated. The positive result of Certest was similar between women and men [4 (3.8%) women vs 2 (2.1%) men; p = 0.684)]. However, in relation to the culture, there was the percentage of women in whom the culture was positive for Campilobacter Jejuní was statistically significant [4 (100%) VS 0 (0.0%); p = 0.038]. Positive cases of campylobacter Positive cases by Certest and Campy-bap ConclusionAsymptomatic positive cases of Campilobacter were identified in this study population in 3%, mainly isolating Campilobacter jejuni, which leads to the conclusion that there are cases of asymptomatic Campylobacteriosis that could act as a risk factor for the development of acute neurological syndromes related to the presence of the bacteriaDisclosures All Authors: No reported disclosures

Burden of Disease of Guillain-Barré Syndrome in Brazil before and during the Zika virus epidemic 2014-2016.

To estimate the burden of disease of Guillain-Barré syndrome (GBS) in Brazil in 2014, 1year before the Zika virus epidemic, and in 2015 and 2016 during the epidemic. The burden of disease of GBS was estimated using the summary measure of population health: Disability Adjusted Life Years (DALY), that combines both mortality (Years of Life Lost YLLs) and morbidity (Years Lived with Disability) components. The study population was composed of GBS hospitalised cases and deaths from the information systems of the Brazilian Unified Health System. The GBS incidence rate in 2014, 2015 and 2016 was 0.74, 0.96, 1.02/100000 respectively, and the mortality rate in the same period was 0.08, 0.009 and 0.11/100000 habitants. The DALYs calculated using the point estimate of GBS disability weight and its values of the confidence interval (0.198 and 0.414) were 5725.90 (5711.79-5742.89) in 2014, 6054.61 (6035.57-6077.54) in 2015 and 7588.49 (7570.20-7610.51) in 2016. The DALYs were high among the male population and in age groups between 20 and 50years. The increase in DALYs in the years 2015 and 2016 compared to 2014 probably resulted from the introduction of ZIKV in Brazil, reinforcing the importance of investments in the prevention of ZIKV infection and in the care of GBS patients.

Posterior reversible leukoencephalopathy syndrome: Case series and review of the literature.

To describe clinical manifestations, antecedents, comorbidities and associated treatments, imaging findings, and follow-up in patients with posterior reversible encephalopathy syndrome. A retrospective, descriptive analysis of admitted patients was performed between June 2009 and May 2014 in a third-level care hospital. We evaluated age, sex, comorbidities, symptoms, values of blood pressure at admission, renal function, medication and time elapsed until the disappearance of symptoms. Thirteen patients were included. In all, 77% of them had a history of hypertension at baseline and 85% had impaired renal function. The most prevalent comorbidity was renal transplantation, and 85% had deterioration of renal function. Five of the patients had undergone renal transplantation. The most common clinical manifestation was seizures. All had subcortical lesions and bilateral parietooccipital involvement was the finding most frequently observed. This syndrome should be taken into account in the differential diagnoses of patients presenting with acute neurological syndromes and the abovementioned risk factors.

Abstract WP301: Telestroke Consultation Can Accurately Diagnose Ischemic Stroke Mimics

Introduction: Telestroke (TS) networks have become standard in many areas of the US, increasing thrombolysis rates in patients with acute ischemic stroke (AIS). By providing an early, accurate diagnosis, patients with stroke mimics may also benefit from TS consultation and avoid unnecessary treatments and transfers. However, despite TS systems having up to 50% mimic rates, it is unknown if TS can accurately diagnose patients with stroke vs stroke mimics. Methods: This was a retrospective review of consecutive TS consults at the University of Utah Hospital to 27 TS sites in 6 states from Jan-Dec 2018. Clinical information and diagnosis were extracted from discharge records and compared to those from the TS consult. Discharge diagnosis was determined by the discharging physician, recorded by the TS coordinator, and verified and coded into 12 categories by 2 physicians. Cases without a clear discharge diagnosis were excluded. When multiple TS diagnoses were listed without priority, the first one was used as the diagnosis. We report agreement and a Cohen’s kappa between TS and discharge diagnoses for the category of AIS/TIA versus stroke mimic. Results: We reviewed 476 TS cases (mean age 66 years; 54% women); 71 were excluded for lack of discharge diagnosis leaving 405 cases for analysis. Of these, there were 225 TS diagnoses of AIS/TIA; 102 (45%) received IV tPA. Our study demonstrated high diagnostic agreement for AIS/TIA (88%) with a kappa of 0.75 for stroke and mimics. Of the 180 patients diagnosed with a stroke mimic on TS, 27 (15%) were diagnosed with AIS/TA by discharge . (Figure 1 ). TS mimic diagnosis had a PPV of 85% and NPV of 90%; TS diagnosis of stroke/TIA had PPV 90%, NPV 85%. Only 3% of stroke mimics were transferred. Conclusion: The Utah TS system has excellent correlation between TS and discharge diagnoses for patients with both stroke and stroke mimics. This suggests that TS systems can accurately assess a wider variety of patients with acute neurologic syndromes other than AIS.

Neurological aspects of the COVID-19 pandemic caused by the SARS-CoV-2 coronavirus

By the spring of 2020 the COVID-19 outbreak caused by the new SARS-CoV-2 coronavirus has become a pandemic, requiring fast and efficient reaction from societies and health care systems all over the world. Fever, coughing and dyspnea are considered the major signs of COVID-19. In addition to the involvement of the respiratory system, the infection may result in other symptoms and signs as well. Based on reports to date, neurological signs or symptoms appear in 30-50% of hospitalized COVID-19 patients, with higher incidence in those with more severe disease. Classical acute neurological syndromes have also been reported to associate with COVID-19. A drop in the volume of services for other acute diseases has been described in countries with healthcare systems focusing on COVID-19. During the COVID-19 epidemic it is also important to provide appropriate continuous care for those with chronic neurological disorders. It will be the task of the future to estimate the collateral damage caused by the COVID-19 epidemic on the outcome of other neurological disorders, and to screen for the possible late neurological complications of the SARS-CoV-2 coronavirus infection.

Re-profiling of drugs in radiological pharmacology: N-acetylcysteine

Acetylcysteine (ACC) is a mucolytic, expectorant medicine with antioxidant, anti-inflammatory, anti-infective, radioprotective, pulmonary protective, anticarcinogenic and antitoxic effects. The review describes the examples of ACC application in radiation diagnostics and therapy for pharmacological radioprotection of the patient’s body and organs. ACC mitigates the negative effects of radiation therapy on the healing of a postoperative wound by reducing oxidative stress markers. ACC significantly reduces the x-ray density of breast tissue, that is, reduces the cancer risk. It has been proven that intravenous and oral administration of ACC prevents nephropathy caused by radiopaque agents. The clinical effectiveness of ACC in the treatment of acute and chronic neurological syndromes of radiation disease is assumed.

Identification of acute brain failure using electronic medical records

PurposeUp to 80% of critically ill patients have acute neurologic dysfunction syndromes. We evaluated interrater reliability between the examination by the investigator and the charted assessment by the nurse because the accuracy and reliability of detailed data sets extracted from the electronic medical records represents a keystone for creating EMR-based definitions. Materials and methodsWe conducted a prospective observational study of intensive care unit (ICU) patients to assess the reliability of charted Confusion Assessment Method for the ICU, Glasgow Coma Scale (GSC), Full Outline of Unresponsiveness, and Richmond Agitation Sedation Scale (RASS) scores, and a composite measure of ABF defined as new-onset coma or delirium. Trained investigator blinded to nursing assessments performed the neurologic evaluations that were compared with nursing documentation. ResultsA total of 202 observations were performed in 55 ICU patients. Excellent correlation was noted for GCS and Full Outline of Unresponsiveness scores on Bland-Altman plots (Pearson correlation 0.87 and 0.92, respectively). Correlation for Confusion Assessment Method for the ICU was also high (κ= 0.86; 95% confidence interval [CI], 0.70-1.01). Richmond Agitation Sedation Scale had good agreement when scores were dichotomized as oversedated (less than −2) vs not oversedated, with κ= 0.76 (95% CI, 0.54-0.98). Investigator assessment and nurse charting were highly concordant (κ= 0.84; 95% CI, 0.71-0.99). ConclusionNeurologic assessments documented on the EMR are reliable.

Zika virus outbreak in Brazil.

Zika virus (ZIKV) infection is spreading rapidly within the Americas after originating from an outbreak in Brazil. We describe the current ZIKV infection epidemic in Brazil and the neurological symptoms arising. First cases of an acute exanthematic disease were reported in Brazil's Northeast region at the end of 2014. In March 2015, autochthonous ZIKV was determined to be the causative agent of the exanthematic disease. As cases of neurological syndromes in regions where ZIKV, dengue and/or Chikungunya viruses co-circulate were reported, ZIKV was also identified in the cerebrospinal fluid of patients with acute neurological syndromes and previous exanthematic disease. By the end of September 2015, an increasing number of infants with small head circumference or microcephaly were noted in Brazil's Northeast which was estimated to be 29 cases between August and October. ZIKV was identified in blood and tissue samples of a newborn and in mothers who had given birth to infants with microcephaly and ophthalmological anomalies. In 2015, there were an estimated 440,000 - 1,300,000 Zika cases in Brazil. There have been 4,783 suspected cases of microcephaly, most of them in the Northeast of Brazil associated with 76 deaths. The Ministry of Health is intensifying control measures against the mosquito Aedes aegypti and implemented intensive surveillance actions. Further studies are needed to confirm the suspected association between ZIKV infection and microcephaly; to identify antiviral, immunotherapy, or prophylactic vaccine; to introduce diagnostic ELISA testing. Clinical and epidemiological studies must be performed to describe viral dynamics and expansion of the outbreak.

NONCONVULSIVE STATUS EPILEPTICUS CAUSED BY VIRAL ENCEPHALITIS: CASE REPORT

In pediatric patients Epstein-Barr virus (EBV) infection may have miscellaneous neurological manifestations. Children with acute viral encephalopathy may present prolonged electrographic seizure activity consistent with non-convulsive status epilepticus (NCSE). NCSE condition is difficult to diagnose due to absence of motor seizures, presenting only changes in behavior and consciousness. In this report we present a clinical case of EBV infection in 3.5-year-old girl. On admission she suffered of confusional state and irritability after an episode of motor partial complex seizure being in good health. The condition evolved twenty five days after an episode of respiratory infection diagnosed as bacterial tonsillitis by the family physician and treated with antibacterials. Laboratory blood evaluation as well as chest radiography, urinalysis, bleeding time, fibrinogen were within the normal range. Magnetic resonance imaging of the brain and spinal cord revealed a subcortical increased signal in the left occipital lobe on T2-weighted image. Electroencephalography (EEG) pattern revealed non-convulsive status epilepticus (NCSE). EBV infection was revealed by serum antibody test. The present case emphasizes the importance to evaluate the role of EBV in acute neurological syndromes in pediatric patients, in particular, in presence of behavioral changes with EEG evidence of seizures. NCSE in children denotes electrographic seizures without convulsive activity and often manifests as altered mental status. It may be difficult to diagnose in pediatric patients in whom changes of behavior and consciousness may not be as easily recognized as in adults.

Libman-Sacks Endocarditis: Detection, Characterization, and Clinical Correlates by Three-Dimensional Transesophageal Echocardiography

Libman-Sacks endocarditis, characterized by Libman-Sacks vegetations, is common in patients with systemic lupus erythematosus and is commonly complicated with embolic cerebrovascular disease. Thus, accurate detection of Libman-Sacks vegetations may lead to early therapy and prevention of their associated complications. Although two-dimensional (2D) transesophageal echocardiography (TEE) has high diagnostic value for detection of Libman-Sacks vegetations, three-dimensional (3D) TEE may allow improved detection, characterization, and clinical correlations of Libman-Sacks vegetations. Twenty-nine patients with systemic lupus erythematosus (27 women; mean age, 34±12years) prospectively underwent 40 paired 3D and 2D transesophageal echocardiographic studies and assessment of cerebrovascular disease manifested as acute clinical neurologic syndromes, neurocognitive dysfunction, or focal brain injury on magnetic resonance imaging. Initial and repeat studies in patients were intermixed in a blinded manner with paired studies from healthy controls, deidentified, coded, and independently interpreted by experienced observers unaware of patients' clinical and imaging data. The results of 3D TEE compared with 2D TEE were more often positive for mitral or aortic valve vegetations, and 3D TEE detected more vegetations per study and determined larger sizes of vegetations (P≤.03 for all). Also, 3D TEE detected more vegetations on the anterior mitral leaflet, anterolateral and posteromedial scallops, and ventricular side or both atrial and ventricular sides of the leaflets (P<.05 for all). In addition, 3D TEE detected more vegetations on the aortic valve left and noncoronary cusps, coronary cusps' tips and margins, and aortic side or both aortic and ventricular sides of the cusps (P≤.01 for all). Furthermore, 3D TEE more often detected associated mitral or aortic valve commissural fusion (P= .002). Finally, 3D TEE detected more vegetations in patients with cerebrovascular disease (P= .01). Three-dimensional TEE provides clinically relevant additive information that complements 2D TEE for the detection, characterization, and association with cerebrovascular disease of Libman-Sacks endocarditis.

Diagnostic Accuracy of Cincinnati Pre-Hospital Stroke Scale.

Stroke is recognized as the third cause of mortality after cardiovascular and cancer diseases, so that lead to death of about 5 million people, annually. There are several scales to early prediction of at risk patients and decreasing the rate of mortality by transferring them to the stroke center. In the present study, the accuracy of Cincinnati pre-hospital stroke scale was assessed. This was a retrospective cross-sectional study done to assess accuracy of Cincinnati scale in prediction of stroke probability in patients referred to the emergency department of Poursina Hospital, Rasht, Iran, 2013 with neurologic symptoms. Three criteria of Cincinnati scale including facial droop, dysarthria, and upper extremity weakness as well as the final diagnosis of patients were gathered. Sensitivity, specificity, predictive values, and likelihood ratios of Cincinnati scale were calculated using SPSS version 20. 448 patients were assessed. The agreement rate of Cincinnati scale and final diagnosis was 0.483 ± 0.055 (p<0.0001). The sensitivity of 93.19% (95% Cl: 90.11-95.54), specificity of 51.85% (95% Cl: 40.47-63.10), positive predictive value of 89.76% (95% Cl: 86.27-92.62), negative predictive value of 62.69% (95% Cl: 55.52-72.45), positive likelihood ratio of 1.94% (95% Cl: 1.54-2.43), and negative likelihood ratio of 0.13% (95% Cl: 0.09-0.20) were calculated. It seems that pre-hospital Cincinnati scale can be an appropriate screening tool in prediction of stroke in patients with acute neurologic syndromes.

Case Report: Severe bilateral amyotrophic neuralgia associated with major dysphagia secondary to acute hepatitis E

Introduction:Several acute neurological syndromes can be triggered by immune events. Hepatitis E virus (HEV), an emerging infectious disease, can be one of these triggers.Case report:We report the case of a 36-year-old man that presented nausea and a dull abdominal pain for a week and then felt an acute neuralgic pain involving both shoulders that lasted for 8 to 10 hours. Immediately after, the patient presented a severe bilateral muscular weakness of the proximal part of both upper limbs, corresponding to an amyotrophic neuralgia. Two days after the shoulder pain, the patient presented a dysphagia necessitating tube feeding. A blood sample confirmed hepatitis caused by hepatitis E virus (HEV; genotype 3F). Oral feeding resumed progressively after five months. The patient was fully independent for the activities of daily living but was still unable to work after six months.Conclusion:Amyotrophic neuralgia and hepatitis E are both under-diagnosed. It is noteworthy that HEV can trigger amyotrophic neuralgia. Antiviral drugs, oral steroids and intravenous immunoglobulins can be proposed, but the optimal treatment has not yet been determined.