Cerebral Magnetic Resonance Imaging Research Articles

Tuberous sclerosis with negative genetic testing and multiple cerebral cavernomas: A new association (Case report)

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder with multisystemic involvement usually resulting from mutations in the tuberous sclerosis 1 (TSC1) or TSC2 genes. However, 10 to 25% of patients do not exhibit these mutations. Cerebral cavernous malformations (CCMs) are capillary-venous malformations that can be asymptomatic or cause variable neurological manifestations, including seizures. Familial CCMs are recognized. In both conditions, specific dermatological lesions are associated. We present the case of a 31-year-old female with TSC diagnosed at the age of 18 years who presented with negative genetic testing. She was admitted to our department in 2019 for a sudden increased frequency of focal seizures. Patient examination revealed multiple facial and intraoral angiofibroma, diplopia, right hemihypoesthesia, brisk deep tendon reflexes, and distal leg paresthesia. VideoEEG indicated a frontal paramedian epileptogenic focus. Cerebral magnetic resonance imaging (MRI) and angioMRI identified multiple fronto-parietal cortical tubers, as well as multiple CCMs, with evidence of bleeding in one. Under antiepileptic drug (AED) and mTOR inhibitor treatment, the seizure frequency significantly improved in a short period of time. This is the first reported case of tuberous sclerosis with negative genetic testing associated with multiple cerebral cavernoma. Such complex patients require multidisciplinary management and detailed genetic testing for increasing knowledge on neuro-cutaneous disorders.

Assessment of neurological function using the National Institute of Health Stroke Scale in patients with gliomas.

The evaluation of treatment response in patients with gliomas is performed using the Response Assessment in Neuro-Oncology (RANO) criteria. These criteria are based on cerebral magnetic resonance imaging (MRI), steroid use, and neurological function. However, a standardized tool for evaluating neurological function was lacking. We compared changes in the National Institute of Health Stroke Scale (NIHSS) to changes in the RANO categories to determine the relationship between clinical and neuroradiological findings. We reviewed data on all adult patients with supratentorial gliomas WHO grade II-IV who were treated at the Cantonal Hospital St. Gallen from 2008 to 2015. The NIHSS was performed prospectively at baseline and at 3-month intervals simultaneously to MRI. Associations between changes in the NIHSS and RANO categories were assessed using the Stuart-Maxwell test. Our cohort consisted of 61 patients from which 471 observations were analyzed. The most common histological diagnosis was glioblastoma (49.2%). In total, 74% of RANO categories and 81% of the NIHSS scores remained stable on follow-up. Statistically, contemporaneous changes in the RANO category did not correlate with changes in the NIHSS (P < .0001). The application of the NIHSS is easy and feasible in the heterogeneous population of glioma patients. In our cohort, the RANO categories did not reflect contemporaneous changes in the NIHSS. A validated clinical outcome measure with a well-defined minimal clinically important difference is warranted in neuro-oncological research and clinical practice.

P-PA004. Severe headache post coital: A case report

Introduction . Headache associated with sexual activity (HAS) is an acute headache that is often related to sexual intercourse. It may also be classified as benign or malignant. Though largely benign, the headache may seldom be a symptom of an underlying life threatening neurologic disorder such as aneurysmal subarachnoid hemorrhage. Results . We report a case of 40-year-old Indonesian man, admitted to hospital because of sudden onset of severe headache followed by nausea and vomiting during sexual intercourse, particularly at the time of orgasm. This complaint had been repeated three times a month. The patient had history of hypertension and diabetes mellitus. There was no history of head trauma. Neurological examination was normal. There were no signs of coagulopathy on the results of laboratory tests. A cerebral magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) showed a chronic active subdural hematoma and suspected left transverse sinus thrombosis. The patient underwent surgery and the complaints improved. Conclusion . Headache associated with sexual activity (HAS) could be primary or secondary. HAS is classified as secondary when it is associated with an underlying intracranial pathology, notable among which are cerebral artery aneurysms and other vascular disorders. Based on clinical criteria and neuroimaging result, these patients met the diagnostic criteria suspected for secondary HAS. To the best of our knowledge, this is the first case of subdural hematoma due to suspected left transverse sinus thrombosis in association with the physical exertion associated with sexual intercourse. Headache after sexual intercourse should always be carefully evaluated by cerebral imaging. The case highlights the importance of paying attention to post coital headache.

Demographic and Clinical Features of Patients With Pediatric Stroke: A Cross-Sectional Study

Objective: In the pediatric age group, it is important to detect the risk factors of stroke and diagnose it early, and prevent the recurrence of the disease. This study aimed to conduct a descriptive analysis of demographic and clinical characteristics of pediatric stroke cases in the 0-18 age group and to evaluate the relationship between etiologic causes, risk factors and functional status of these cases. Material and Methods: The medical files of the patients followed up by the Department of Pediatric Neurology of Ankara Training and Research Hospital were retrospectively examined. Cerebral magnetic resonance imaging and laboratory data were recorded. The Gross Motor Function Classification System, Box and Block Test, Nine-Hole Peg Test were used to evaluate the patients’ current functional status. Results: In 34 pediatric hemiplegic stroke cases, the median age of the onset of symptoms was one year (minimum 0, maximum 15 years). At the time of evaluation, hemiparesis was found in 73.5% of the cases and 41.2% had active seizures. Heterozygous factor V Leiden mutation was present in 17.6% of the patients, and homozygous MTHFR (c677c) mutation in 5.9%. When the etiologic factors were evaluated, there was a mass effect due to venous bleeding in 50%, arterial bleeding in 44.1%, and intracranial bleeding in 5.9% of the cases. Prophylaxis had been performed in 47.1% of the patients. There were no significant differences in functional parameters according to thrombophilic risk factors, whether the etiology was of arterial or venous origin, or whether they underwent prophylaxis (p>.05). Conclusion: Half of the patients had a stroke of venous origin, and hemiparesis was present in approximately two-third of the cases. Functioning levels seemed to be independent of the presence of etiologic source or thrombophilic risk factors of the disease.

The role of MRI and CT of the brain in first episodes of psychosis and behavioural abnormality

To investigate whether computed tomography (CT)/magnetic resonance imaging (MRI) brain imaging is associated with detection of structural causes of a first episode of psychosis (FEP) or first episode of behavioural abnormality (FEB) in the paediatric population, as this has not been previously documented in the literature. Individuals with FEP/FEB but no neurological signs referred to a tertiary children's centre for cerebral MRI or CT were reviewed retrospectively. Individuals were evaluated independently with one technique (CT or MRI) only. Thirty-four consecutive cerebral MRI and six consecutive CT examinations were identified between 2017 and 2020. No patients were identified as having an organic cause for the psychosis at MRI or CT. Four patients (9%) had incidental findings on MRI, unrelated to the psychosis, such as prominent perivascular spaces, hypoplastic transverse sinus, and sinonasal mucosal wall thickening. No abnormal findings were seen on CT. There was therefore no obvious difference between MRI and CT imaging in detecting organic disease potentially responsible for FEP. Routine structural MRI or CT of the brain is unlikely to reveal disease leading to a significant change in management. MRI demonstrated only a few incidental findings, unrelated to the child's clinical history. Therefore, routine brain structural imaging of FEP/FEB in paediatric patients without focal neurology may not be routinely required. If imaging is requested, then there is no significant difference between CT and MRI in detecting clinically significant lesions.

Machine-learning method for localization of cerebral white matter hyperintensities in healthy adults based on retinal images.

Retinal vessels are known to be associated with various cardiovascular and cerebrovascular disease outcomes. Recent research has shown significant correlations between retinal characteristics and the presence of cerebral small vessel disease as measured by white matter hyperintensities from cerebral magnetic resonance imaging. Early detection of age-related white matter changes using retinal images is potentially helpful for population screening and allow early behavioural and lifestyle intervention. This study investigates the ability of the machine-learning method for the localization of brain white matter hyperintensities. All subjects were age 65 or above without any history of stroke and dementia and recruited from local community centres and community networks. Subjects with known retinal disease or disease influencing vessel structure in colour retina images were excluded. All subjects received MRI on the brain, and age-related white matter changes grading was determined from MRI as the primary endpoint. The presence of age-related white matter changes on each of the six brain regions was also studied. Retinal images were captured using a fundus camera, and the analysis was done based on a machine-learning approach. A total of 240 subjects are included in the study. The analysis of various brain regions included the left and right sides of frontal lobes, parietal–occipital lobes and basal ganglia. Our results suggested that data from both eyes are essential for detecting age-related white matter changes in the brain regions, but the retinal parameters useful for estimation of the probability of age-related white matter changes in each of the brain regions may differ for different locations. Using a classification and regression tree approach, we also found that at least three significant heterogeneous subgroups of subjects were identified to be essential for the localization of age-related white matter changes. Namely those with age-related white matter changes in the right frontal lobe, those without age-related white matter changes in the right frontal lobe but with age-related white matter changes in the left parietal–occipital lobe, and the rest of the subjects. Outcomes such as risks of severe grading of age-related white matter changes and the proportion of hypertension were significantly related to these subgroups. Our study showed that automatic retinal image analysis is a convenient and non-invasive screening tool for detecting age-related white matter changes and cerebral small vessel disease with good overall performance. The localization analysis for various brain regions shows that the classification models on each of the six brain regions can be done, and it opens up potential future clinical application.

MO324A RARE CASE OF GRANULOMATOSIS WITH POLYANGIITIS ASSOCIATED WITH FACTOR II DEFICIENCY

Abstract Background and Aims Granulomatosis with polyangiitis (GPA) (formerly called Wegener's) is a systemic disorder that is characterized by necrotizing vasculitis of small arteries and veins. The kidney damage is severe. We report an observation of a young patient whose exploration of rapidly progressive renal failure revealed GPA with an original association with factor II deficiency. Method This a case report of a patient who was admitted to the nephrology, dialysis and transplantation in the sahloul university hospital in Tunisia. She was transferred from the regional hospital of sidi bouzid. Results This a case of a 19-year-old patient. She had the only a history of allergic rhinitis. She presented recently epistaxis and headache. The explorations reported a kidney failure with level of creatinine at 5.6 mg/dl. On examination: The blood pressure was normal (120/70 mmHg), she had signs of acute sinusitis and edema in both lower limbs and she developed anuria. For the biology: creatinine = 11.3 mg/dl (clearance = 4.6 ml/min), urea = 50 mmol/l, Proteinuria = 2.5 g/24h and Hematuria = 100/mm3. The cANCA type PR3 was positive. The diagnosis of rapidly progressive glomerulonephritis (RPGN) was suspected. She had microcytic hypochromic anemia of 6.9 g/dL and a low Prothrombin time (PT) of 54%. The exploration concluded to an isolated Factor II deficiency (59%). The Ear, Nose and throat (ENT) examination revealed nasal inflammation, sinusitis and nasal crusting. The kidney ultrasound showed two kidneys of normal size. The computed tomography showed bilateral maxillary sinusitis and there were no intra-alveolar hemorrhage. The Kidney biopsy could not be performed initially due to the risk of bleeding. On hospitalization, the patient presented a generalized tonic clonic seizures. The exploration by a cerebral Magnetic resonance imaging (MRI) showed signs of cerebral vasculitis and the electroencephalography (EEG) showed no focal abnormalities. The association of ENT involvement, the cerebrovascular disease, the rapid evolution of the creatinine, the positivity of the cANCA, the diagnosis of granulomatosis with polyangiitis was established. The therapeutic management was to start symptomatic treatment: diuretics, antibiotic therapy, transfusions, hemodialysis initially and antiepileptic therapy. The immunosuppressive treatment was based on pulses of methylprednisolone followed by full dose corticosteroid therapy, cyclophosphamide intravenous and sessions of plasma exchange. The evolution was characterized by clinical and biological improvement with creatinine = 1.3 mg/dl, a PT at 100% and a factor II at 70 % stable after stopping the plasma exchange in favor of the immunological cause of this deficit. Conclusion The early diagnosis and treatment of RPGN is important even if the biopsy cannot be performed. We reported a rare association between granulomatosis with polyangiitis and factor II deficiency. The normalization of the factor II after the treatment is in favor of the immunological cause of this deficit.

S100B protein, cerebral ultrasound and magnetic resonance imaging patterns in brain injured preterm infants.

The early detection of preterm infants (PI) at risk for intraventricular hemorrhage (IVH) and neurological sequelae still constitutes an unsolved issue. We aimed at validating the role of S100B protein in the early diagnosis and prognosis of IVH in PI by means of cerebral ultrasound (CUS) and magnetic resonance imaging (MRI) today considered standard of care procedures. We conducted an observational case-control study in 216 PI of whom 36 with IVH and 180 controls. Standard clinical, laboratory, radiological monitoring procedures and S100B urine measurement were performed at four time-points (first void, 24, 48, 96h) after birth. Cerebral MRI was performed at 40-42weeks of corrected gestational age. Elevated (p<0.001, for all) S100B levels were observed in the IVH group at all monitoring time-point particularly at first void when standard monitoring procedures were still silent or unavailable. S100B measured at first void correlated (p<0.001) with the grade of hemorrhage by means of CUS and with the site and extension of neurological lesion (p<0.001, for all) as assessed by MRI. The present results showing a correlation among S100B and CUS and MRI offer additional support to the inclusion of the protein in clinical daily management of cases at risk for IVH and adverse neurological outcome. The findings open the way to further investigations in PI aimed at validating new neurobiomarkers by means of S100B.

Cluster headache due to structural lesions: A systematic review of published cases.

BACKGROUNDCluster headache (CH) is a severe incapacitating headache disorder. By definition, its diagnosis must exclude possible underlying structural conditions.AIMTo review available information on CLH caused by structural lesions and to provide better guides in the distinguishing process and to ensure that there is not a potentially treatable structural lesion.METHODSWe conducted a systematic review of 77 published cases of symptomatic CH and cluster-like headache (CLH) in PubMed and Google Scholar databases.RESULTSStructural pathologies associated with CH were vascular (37.7%), tumoral (32.5%) and inflammatory (27.2%). Brain mass-like lesions (tumoural and inflammatory) were the most common diseases (28.6%), among which 77.3% lesions were at the suprasellar (pituitary) region. Cases of secondary CH related to sinusitis rose dramatically, occupying 19.5%. The third most common disease was internal carotid artery dissection, accounting for 14.3%. Atypical clinical features raise an early suspicion of a secondary cause: Late age at onset and eye and retroorbital pains were common conditions requiring careful evaluation and were present in at least one-third of cases. Abnormal neurological examination was the most significant red flag for impaired cranial nerves. CLH patients may be responsive to typical CH treatments; therefore, the treatment response is not specific. CLH can be triggered by contralateral structural pathologies. CLH associated with sinusitis and cerebral venous thrombosis required more attention.CONCLUSIONSince secondary headache could perfectly mimick primary CH, neuroimaging should be conducted in patients in whom primary and secondary headaches are suspected. Cerebral magnetic resonance imaging scans is the diagnostic management of choice, and further examinations include vessel imaging with contrast agents and dedicated scans focusing on specific cerebral areas (sinuses, ocular and sellar regions). Neuroimaging is as necessary at follow-up visits as at the first observation.

Enhancement of cerebrovascular 4D flow MRI velocity fields using machine learning and computational fluid dynamics simulation data

Blood flow metrics obtained with four-dimensional (4D) flow phase contrast (PC) magnetic resonance imaging (MRI) can be of great value in clinical and experimental cerebrovascular analysis. However, limitations in both quantitative and qualitative analyses can result from errors inherent to PC MRI. One method that excels in creating low-error, physics-based, velocity fields is computational fluid dynamics (CFD). Augmentation of cerebral 4D flow MRI data with CFD-informed neural networks may provide a method to produce highly accurate physiological flow fields. In this preliminary study, the potential utility of such a method was demonstrated by using high resolution patient-specific CFD data to train a convolutional neural network, and then using the trained network to enhance MRI-derived velocity fields in cerebral blood vessel data sets. Through testing on simulated images, phantom data, and cerebrovascular 4D flow data from 20 patients, the trained network successfully de-noised flow images, decreased velocity error, and enhanced near-vessel-wall velocity quantification and visualization. Such image enhancement can improve experimental and clinical qualitative and quantitative cerebrovascular PC MRI analysis.

Diagnosis and Therapy of Infectious Encephalitis in Children: A Ten-Years Retrospective Study.

Infectious encephalitis represents a rare but potentially severe clinical condition. However, limited international data are available in pediatric age. We conducted a retrospective study to review (a) the clinical presentation; (b) laboratory, radiology, and neurophysiology findings; (c) the correlations between these exams and outcome; and (d) the therapy performed. Fifty-six patients were enrolled [22 female (39.6%), mean age 4.7 years, IQR 0.7-8.7 years], 19.6% presented neurologic sequelae. HSV was the single most frequently isolated pathogen (19.6%), although in most cases, the etiology remained undefined. 41.1% children presented prodromal before the development of neurologic signs. Fever was the most frequent constitutional symptom (83.9% of cases). Cerebrospinal fluid was normal in 48.5% of cases and electroencephalograpy in 24.5% cases. Brain computed tomography scans was normal in 33 (91.7%) cases, while cerebral magnetic resonance imaging (MRI) showed pathologic findings in 62.5% of cases. MRI was the only parameter associated with neurologic sequalae [P = 0.01; OR, 8.1 (95% CI: 1.52-42.84)]. Pediatric encephalitis is a heterogeneous entity with nonspecific clinical and laboratory findings, with undefined etiologies in most times. MRI can play a primary role, both on a diagnostic and prognostic point-of-view, and its role should be implemented and made more accessible. Further studies are needed to define the exact role and timing of steroids.

A Multiparametric MRI-Based Radiomics Analysis to Efficiently Classify Tumor Subregions of Glioblastoma: A Pilot Study in Machine Learning

Glioblastoma multiforme (GBM) carries a poor prognosis and usually presents with heterogenous regions of a necrotic core, solid part, peritumoral tissue, and peritumoral edema. Accurate demarcation on magnetic resonance imaging (MRI) between the active tumor region and perifocal edematous extension is essential for planning stereotactic biopsy, GBM resection, and radiotherapy. We established a set of radiomics features to efficiently classify patients with GBM and retrieved cerebral multiparametric MRI, including contrast-enhanced T1-weighted (T1-CE), T2-weighted, T2-weighted fluid-attenuated inversion recovery, and apparent diffusion coefficient images from local patients with GBM. A total of 1316 features on the raw MR images were selected for each annotated area. A leave-one-out cross-validation was performed on the whole dataset, the different machine learning and deep learning techniques tested; random forest achieved the best performance (average accuracy: 93.6% necrosis, 90.4% solid part, 95.8% peritumoral tissue, and 90.4% peritumoral edema). The features from the enhancing tumor and the tumor shape elongation of peritumoral edema region for high-risk groups from T1-CE. The multiparametric MRI-based radiomics model showed the efficient classification of tumor subregions of GBM and suggests that prognostic radiomic features from a routine MRI exam may also be significantly associated with key biological processes that affect the response to chemotherapy in GBM.

The Added Value of Cerebral Imaging in Patients With Pyogenic Spinal Infection.

Background: The incidence of pyogenic spinal infection has increased in recent years. In addition to treatment of the spinal infection, early diagnosis and therapy of coexisting infections, especially of secondary brain infection, are important. The aim of this study is to elucidate the added value of routine cerebral imaging in the management of these patients.Methods: This was a retrospective single-center study. Cerebral imaging consisting of cerebral magnetic resonance imaging (cMRI) was performed to detect brain infection in patients with a primary pyogenic spinal infection.Results: We analyzed a cohort of 61 patients undergoing cerebral imaging after diagnosis of primary pyogenic spinal infection. The mean age in this cohort was 68.7 years and the gender distribution consisted of 44 males and 17 females. Spinal epidural abscess was proven in 32 (52.4%) patients. Overall positive blood culture was obtained in 29 (47.5%) patients, infective endocarditis was detected in 23 (37.7%) patients and septic condition at admission was present in 12 (19.7%) Patients. Coexisting brain infection was detected in 2 (3.3%) patients. Both patients revealed clinical signs of severe sepsis, reduced level of consciousness (GCS score 3), were intubated, and died due to multi-organ failure.Conclusions: Brain infection in patients with spinal infection is very rare. Of 61 patients with pyogenic spinal infection, two patients had signs of cerebral infection shown by imaging, both of whom were in a coma (GCS 3), and sepsis.

The Clinical Spectrum and Outcome of Uveomeningitis: A Comprehensive Analysis of 110 Cases

ABSTRACT Purpose: Uveitis can be associated with meningitis (uveomeningitis) and the inflammation shared with the central nervous system. We aimed to describe the characteristics and outcome of uveomeningitis. Methods: We retrospectively analyzed 110 consecutive adult patients with uveomeningitis. Results: The main causes of uveomeningitis were Vogt–Koyanagi–Harada (31%), syphilis (16%), sarcoidosis (12%), Behçet’s disease (7%), and multiple sclerosis (5%). Sixteen percent of uveomeningitis remained of undetermined origin. Compared to etiology-matched uveitis without meningitis, patients with uveomeningitis were younger, had more frequent neurological manifestations, and had more frequent abnormal cerebral magnetic resonance imaging findings. In contrast, no ocular feature upon examination was significantly associated with the presence of meningitis. Patients with uveomeningitis were more frequently treated with immunosuppressants but uveitis relapse and systemic complications did not differ between groups. Conclusion: Uveomeningitis is associated with a limited spectrum of diseases. Meningitis does not seem to impact ocular and extraocular outcomes. Therefore, lumbar puncture should be performed on an individual basis during the diagnostic workup of uveitis.

Brain cooling reduces the risk of postneonatal epilepsy in newborns affected by moderate to severe hypoxic-ischemic encephalopathy.

BACKGROUND Neonatal hypoxic-ischemic encephalopathy is still a significant cause of neonatal death and neurodevelopmental disabilities, such as cerebral palsy, mental delay, and epilepsy. After the introduction of therapeutic hypothermia, the prognosis of hypoxic-ischemic encephalopathy has improved, with reduction of death and disabilities. However, few studies evaluated whether hypothermia affects rate and severity of postneonatal epilepsy. We evaluated rates, characteristics and prognostic markers of postneonatal epilepsy in infants with moderate to severe hypoxic-ischemic encephalopathy treated or not with therapeutic hypothermia. METHODS We analyzed clinical data, EEG recordings, cerebral Magnetic Resonance Imaging (MRI) and outcome in 23 cooled and 26 non-cooled asphyxiated neonates (≥36 weeks' gestation), admitted from 2004 to 2012. RESULTS Among 49 neonates 11 (22%) had postneonatal epilepsy, of which 9 (18%) were non-cooled and 2 (4%) were cooled (P=0.05). Six of 11 infants (55%) had West syndrome, 4 (36%) had focal epilepsy and 1 (9%) had Lennox-Gastaut Syndrome. At multiple logistic regression analysis MRI pattern significantly correlated with postneonatal epilepsy (OR 0.19, 95% CI 0.04-0.88, P=0.03). Extensive lesions in basal ganglia and thalami plus cortical and white matter were associated with postneonatal epilepsy. CONCLUSIONS Only perinatal asphyxia with extensive lesions in basal ganglia and thalami plus cortical and white matter lesion conveys a high risk for early and severe postneonatal epilepsy. Moreover, therapeutic hypothermia is associated with a decrease of the risk of developing postneonatal epilepsy.

POS-588 CHRONIC HYPOTENSION REVEALING AN ANTERIOR PITUITARY DEFICIENCY IN HEMODIALYSIS PATIENT: A CASE REPORT

Chronic kidney disease (CKD) naturally progresses with hormonal disorders. However, disturbances in the hypothalamic-pituitary-gonadal axis in hemodialysis patients remains underdiagnosed and commonly interpreted as harmless uremia effects. We here report an unusual case of a patient undergoing long-term hemodialysis who exhibited Adrenocorticotropic Hormone Deficiency, hypogonadotrophic hypogonadism and primary hypothyroidism. A 43-year-old male with end-stage renal disease secondary to primitive hyperoxaluria, undergoing hemodialysis for 16 years, with a history of primary infertility for 9 years, developed 9 months ago severe weakness and lethargy, more frequent hypoglycemic episodes in hemodialysis sessions, with the onset of a severe chronic hypotension (systolic blood levels at 70-80mmHg before hemodialysis sessions). Examination revealed gynecomastia. He did not exhibit electrolyte imbalances, such as hyponatremia or hyperkalemia, had normal morning blood levels of cortisol and a correct heart function. Endocrinological examinations tests showed an adrenocorticotropic hormone deficiency, a primary hypothyroidism, gonadotrophic hormones deficiency with low testosterone levels and high prolactin levels (ACTH=2,64pg/l, TSH=0,24uUI/ml, LH=3,35mUI/ML, testosterone= 1,83ng/l, prolactin=58,4ng/ml). After commencement of corticosteroid replacement therapy, his symptoms resolved without complications. A cerebral magnetic resonance imaging, and an adrenal scan were undergoing to determine the etiology. We don’t have the results yet. Even though endocrine disorders are common in hemodialysis patients and frequently not associated with apparent diseases, disorders in the hypothalamic-pituitary axis may increase cardiovascular and metabolic risk. Therefore, they should be screened and treated rapidly.

Prognostic value of electroencephalography in hypoxic-ischemic encephalopathy

Background: Hypoxic-ischemic encephalopathy (HIE) is one of the main causes of neurodevelopmental disorders. We developed a model that has diagnostic and prognostic value in predicting the neurodevelopmental outcomes in newborns with HIE. HIE staging allows us to start therapeutic interventions early in newborns with suspected encephalopathy.&#x0D; Methods: This was a retrospective study in a cohort of 58 full-term neonates with clinical suspicion of HIE. We assessed electroclinical variables at birth [etiology of hypoxia, neonatal seizures, HIE stages based on Sarnat criteria, use of therapeutic hypothermia, neuroimaging tests and electroencephalography (EEG) findings] and two years of follow up (EEG findings, development of epilepsy, the presence of cognitive deficits, behavioral issues, language problems, visual or hearing disturbances, and cerebral palsy).&#x0D; Results: There was a high electro-clinical correlation to severe HIE (88.8%) and moderate HIE (50%). There was a considerable proportion of patients affected by mild HIE, based on clinical examination, who presented with an abnormal EEG (32.3%). There is a relationship between the onset of neonatal seizures, epilepsy, and severe HIE diagnosed with EEG (88.9%). A higher percentage of patients with moderate and severe HIE, based on EEG findings, present abnormal results in cranial ultrasound and cerebral magnetic resonance imaging (62.5%). At two years of age, functional neurodevelopment disturbances were observed most frequently in patients affected with severe and moderate HIE based on EEG.&#x0D; Conclusions: This study shows a model with diagnostic and prognostic value in predicting newborns' neurodevelopmental outcomes with suspected HIE. This knowledge allows us to assess the role of performing serial EEG in patients with suspected HIE and the relevance of EEG findings in the prognosis of neurodevelopmental disorders.

Subacute cerebellar ataxia following respiratory symptoms of COVID-19: a case report

BackgroundSevere acute respiratory syndrome virus 2 (SARS-CoV-2) is spreading globally and causes most frequently fever and respiratory symptoms, i.e. Coronavirus disease 2019 (COVID-19), however, distinct neurological syndromes associated with SARS-CoV-2 infection have been described. Among SARS-CoV-2-infections-associated neurological symptoms fatigue, headache, dizziness, impaired consciousness and anosmia/ageusia are most frequent, but less frequent neurological deficits such as seizures, Guillain-Barré syndrome or ataxia may also occur.Case presentationHerein we present a case of a 62-year-old man who developed a subacute cerebellar syndrome with limb-, truncal- and gait ataxia and scanning speech 1 day after clinical resolution of symptomatic SARS-CoV-2 infection of the upper airways. Apart from ataxia, there were no signs indicative of opsoclonus myoclonus ataxia syndrome or Miller Fisher syndrome. Cerebral magnetic resonance imaging showed mild cerebellar atrophy. SARS-CoV-2 infection of the cerebellum was excluded by normal cerebrospinal fluid cell counts and, most importantly, absence of SARS-CoV-2 RNA or intrathecal SARS-CoV-2-specific antibody production. Other causes of ataxia such as other viral infections, other autoimmune and/or paraneoplastic diseases or intoxication were ruled out. The neurological deficits improved rapidly after high-dose methylprednisolone therapy.ConclusionsThe laboratory and clinical findings as well as the marked improvement after high-dose methylprednisolone therapy suggest a post-infectious, immune-mediated cause of ataxia. This report should make clinicians aware to consider SARS-CoV-2 infection as a potential cause of post-infectious neurological deficits with an atypical clinical presentation and to consider high-dose corticosteroid treatment in case that a post-infectious immune-mediated mechanism is assumed.

Brain abscess in a rheumatoid arthritis patient treated with leflunomide – A case presentation and review

Background: Immunosuppression is a significant parameter in the pathogenesis of brain abscesses (BA) and it could be the result of severe infections such as acquired immunodeficiency syndrome or drug-induced, by several medications used for systemic autoimmune diseases. Leflunomide is a pyrimidine synthesis inhibitor that affects the proliferation of lymphocytes and is used as a disease-modifying antirheumatic drug. Mild infections, particularly those of the respiratory tract and herpes zoster, are one of its most common adverse effects. However, atypical and severe infections have also been reported under treatment with leflunomide.Case Description: A 70-year old female was referred to our hospital with headache, aphasia, and right-sided hemiparesis and a lesion of the left parietal lobe initially interpreted as a malignancy. Her medical history revealed a 12-year old history of rheumatoid arthritis under current treatment with leflunomide. A cerebral magnetic resonance imaging (MRI) revealed typical findings for a BA. She subsequently underwent a left craniotomy, which confirmed the MRI-based diagnosis. The abscess was evacuated and cultures were obtained intraoperatively. In the postoperative examination, the patient showed no neurological deficit.Conclusion: The differential diagnostic considerations in immunocompromised patients with neurologic deficits should include focal central nervous system infections such as a BA, even in the absence of fever or immunosuppressant-induced leukopenia. It also demonstrates the importance of early neurosurgical intervention for the prevention of sequelae. To the best of our knowledge, this is the second-to-date reported case of a BA under immunomodulatory therapy with leflunomide.

Acute Labyrinthitis Revealing COVID-19.

An 84-year-old man presented to the emergency department for acute vomiting associated with rotational vertigo and a sudden right sensorineural hearing loss. A left peripheral vestibular nystagmus was highlighted. The patient was afebrile, without respiratory signs or symptoms. Blood sampling at admission showed lymphopenia, thrombopenia and neutrophil polynucleosis, without elevation of C reactive protein. Cerebral magnetic resonance imaging eliminated a neurovascular origin. Vestibule, right semicircular canals and cochlear FLAIR hypersignals were highlighted, leading to the diagnosis of right labyrinthitis. A nasopharyngeal swab sampled at admission returned positive for SARS CoV2 by polymerase chain reaction. The etiologic investigation, including syphilitic and viral research, was otherwise negative. An oral corticotherapy (prednisone 70 mg daily) was introduced, followed by a progressive clinical recovery. Although acute otitis media have already been highlighted as an unusual presentation of COVID-19, radiology-proven labyrinthitis had to our knowledge, never been described to date.