Focal Symptoms Research Articles

Dermatographism with vulvar symptoms.

Dermatographism (DG) is characterized by a localized, inducible, wheal-and-flare response along the distribution of mechanical pressure. We report an illustrative case of DG with vulvar symptoms (DG-VS) and review the literature on this rarely recognized but easily treated etiology of vulvar complaints. A 35-year-old woman presented with a 1-year history of vulvar pruritus unresponsive to antifungal, antibacterial, and steroid treatments. A prior punch biopsy was nondiagnostic. Vulvar examination revealed normal architecture and no cutaneous abnormalities. She was markedly dermatographic with a scratch test. DG-VS was diagnosed. The patient achieved complete symptomatic control on low-dose hydroxyzine. She maintains excellent control at 3.5 years. In the literature, a typical patient with DG-VS is of reproductive age, with several years’ history of vulvar symptoms (itching, burning, pain, or swelling) and repeated empiric treatment for infectious/inflammatory etiologies. Exacerbation with sexual activity, menstruation, or wearing tight clothing is characteristic and supports the role of mechanical pressure in inducing focal symptoms. Dermatologic changes to the vulvar skin are rarely noted. DG-VS is diagnosed based on clinical findings, symptom patterns, and a positive scratch test and is treated with antihistamines. DG-VS remains absent from current vulvar disease guidelines. In the complex world of vulvar pain and itch, an etiology so easily screened for and readily treated warrants consideration.

Diagnosis and Management of Cerebral Venous Sinus Thrombosis With Vaccine-Induced Immune Thrombotic Thrombocytopenia.

Diagnosis and Management of Cerebral Venous Sinus Thrombosis With Vaccine-Induced Immune Thrombotic Thrombocytopenia.

Tumour markers with clinically controlled cut-offs for suspected cancer.

Due to insufficient scientific evidence, panels of tumour markers (TMs) are currently not recommended for use in suspected cancer. However, recent well-designed studies have revealed a potential clinical value in lung cancer. We analysed the diagnostic accuracy of a panel of 11 circulating TMs with clinically controlled thresholds in the differentiation of cancer from nonmalignant diseases. We prospectively recruited 4776 consecutive patients presenting with focal or nonspecific symptoms suggestive of cancer who underwent testing for 11 serum TMs before diagnosis was known. The study abided by 2015 STARD guidelines. Tumour markers included, among others, carbohydrate antigen 19-9, carcinoembryonic antigen, alpha-fetoprotein, squamous cell carcinoma-associated antigen, prostate-specific antigen (males), neuron-specific enolase, progastrin-releasing peptide and carbohydrate antigen 125. Thresholds were adjusted for the presence of kidney failure, liver disease, effusions and dermatological disorders. Results showing ≥1 TMs with concentrations above threshold were considered positive. Benign diseases were diagnosed in 3281 (68.7%) patients and cancer in 1495 (31.3%), with epithelial cancers in 1214 (77% at stage IV). When applying criteria for controlled thresholds, overall specificity was 98%. Overall sensitivity of the panel in epithelial cancers was 72.2%, positive predictive value 93% and negative predictive value 90.5%. The area under the receiver operating characteristic curve was 0.920 (95% confidence interval, 0.902-0.924). By using clinically controlled cut-offs, the combined panel demonstrated an excellent ability to discriminate epithelial cancers from nonmalignant diseases. However, its use in clinical practice would need formal validation through a multicentre controlled trial assessing a panel-guided strategy vs. standard diagnosis.

Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis

SummaryBackgroundDiagnosis of transient ischaemic attacks (TIAs) can be difficult. There is consensus on classic symptoms (eg, motor weakness, dysphasia, hemianopia, monocular visual loss) but no consensus on several monosymptomatic events with sudden-onset, non-progressive, focal negative symptoms (eg, isolated diplopia, dysarthria, vertigo, ataxia, sensory loss, and bilateral visual disturbance), with much variation in investigation and treatment.MethodsWe prospectively ascertained and investigated all strokes and sudden onset transient neurological symptoms in a population of 92 728 people (no age restrictions) from Oxfordshire, UK, who sought medical attention at nine primary care practices or at the John Radcliffe Hospital, Oxford, UK (Oxford Vascular Study). Patients classified at baseline with minor ischaemic stroke (National Institutes of Health Stroke Score <5), classic TIA, or non-consensus TIA were treated according to secondary prevention guidelines. Risks of stroke (7-day, 90-day, and 10-year risks) and risks of all major vascular events (from the time of first event, and from the time of seeking medical attention) were established by face-to-face follow-up visits and were compared with the risk expected from age and sex-specific stroke incidence in the underlying study population.FindingsBetween April 1, 2002, and March 31, 2018, 2878 patients were identified with minor ischaemic stroke (n=1287), classic TIA (n=1021), or non-consensus TIA (n=570). Follow-up was to Oct 1, 2018 (median 5·2 [IQR 2·6–9·2] years). 577 first recurrent strokes after the index event occurred during 17 009 person-years of follow-up. 90-day stroke risk from time of the index event after a non-consensus TIA was similar to that after classic TIA (10·6% [95% CI 7·8–12·9] vs 11·6% [95% CI 9·6–13·6]; hazard ratio 0·87, 95% CI 0·64–1·19; p=0·43), and higher than after amaurosis fugax (4·3% [95% CI 0·6–8·0]; p=0·042). However, patients with non-consensus TIA were less likely to seek medical attention on the day of the event than were those with classic TIA (336 of 570 [59%] vs 768 of 1021 [75%]; odds ratio [OR] 0·47, 95% CI 0·38–0·59; p<0·0001) and were more likely to have recurrent strokes before seeking attention (45 of 570 [8%] vs 47 of 1021 [5%]; OR 1·77, 95% CI 1·16–2·71; p=0·007). After excluding such recurrent strokes, 7-day stroke risk after seeking attention for non-consensus TIA (2·9% [95% CI 1·5–4·3]) was still considerably higher than the expected background risk (relative risk [RR] 203, 95% CI 113–334), particularly if the patient sought attention on the day of the index event (5·0% [2·1–7·9]; RR 300, 137–569). 10-year risk of all major vascular events was similar for non-consensus and classic TIAs (27·1% [95% CI 22·8–31·4] vs 30·9% [27·2–33·7]; p=0·12). Baseline prevalence of atrial fibrillation, patent foramen ovale, and arterial stenoses were also similar for non-consensus TIA and classic TIA, although stenoses in the posterior circulation were more frequent with non-consensus TIA (OR 2·21, 95% CI 1·59–3·08; p<0·0001).InterpretationPatients with non-consensus TIA are at high early and long-term risk of stroke and have cardiovascular pathological findings on investigation similar to those of classic TIA. Designation of non-consensus TIAs as definite cerebrovascular events will increase overall TIA diagnoses by about 50%.FundingWellcome Trust, National Institute for Health Research Oxford Biomedical Research Centre, Wolfson Foundation, Masonic Charitable Foundation, and British Heart Foundation.

Abstract P224: Management of TIA Over Time in the Greater Cincinnati Northern Kentucky Stroke Study

Introduction: The availability of rapid tissue and vessel imaging for TIA has increased, but the utilization rates of these and other diagnostic and management strategies for TIA over time are unknown. Objective: To investigate trends in TIA diagnostic and management strategies over time in the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS). Methods: The GCNKSS is a population-based study of 1.3 million people living in a 5-county area of southern Ohio and Northern Kentucky. For this study, all physician-adjudicated, first-ever cases of TIA (defined clinically as sudden onset of focal symptoms lasting &lt; 24 hours) presenting to an emergency department over five study periods (1993/4, 1999, 2005, 2010, 2015) were included. Use of AHA-recommended aspects of TIA management as well as disposition of TIA patients (admission to hospital or discharge from ED) and length of stay were compared across study periods. Rates of acute infarct on MRI were also reported. Trends were examined using the Cochran-Armitage test for trend. Results: In total, over all study periods, there were 2251 first-ever TIAs. Overall, 14% (n=311) occurred in Black individuals, and 57% (n=1275) occurred in women. Utilization of diagnostic modalities [non-contrast CT brain, vascular imaging (CTA, MRA, or carotid dopplers), tissue imaging (MRI), and echocardiogram] increased significantly over time (all p&lt;0.0001). In terms of management, both admission to the hospital and discharge from the hospital on an antiplatelet agent increased over time (both p&lt;0.0001; Table). Conclusions: The management of TIA has changed significantly over time. Utilization of tissue and vessel imaging as well as echocardiogram during the hospital stay has increased; in 2015, the vast majority of patients with TIA in this population-based study received each of these testing modalities and were admitted to a hospital for TIA work-up. Further work is needed to understand the best practices for work-up of suspected TIA.

Effect of Mild Traumatic Brain Injury on Behavioral Reactions and Neocortical Morphology in Rats.

The original weight-drop model was employed to examine the effect of mild traumatic brain injury (TBI) on behavioral phenotype and neocortical morphology in rats. The neurological examination of rats with moderate TBI revealed the focal symptoms corresponding to pronounced neurological disorders, whereas in rats after mild TBI, there were only minor coordination disorders. On day 7 after injury, the rats with mild TBI demonstrated enhanced anxiety assessed by conditioned passive avoidance response. The morphometric analysis of the brain tissues revealed narrowing of the capillaries and increased score of hyperchromic neocortical neurons, which attested to cerebral hypoxia. The manifestations of mild TBI in original rat model demonstrated a close similarity to the symptoms of TBI in humans.

Vulvar cancer: brain metastases. Clinical observation

Introduction. Brain metastases can occur in almost all gynecological malignancies and, despite modern therapeutic options, have a poor prognosis. Brain metastases from vulvar cancer are considered to be rare. In the literature, the reports on these cases have identity character. The aim is to show clinical observation of the patient with vulvar cancer with brain metastases. Results. Patient S., 60 years old, with stage I р T1N0M0 vulvar cancer underwent vulvectomy in January 2018. During the histological study in the subepithelial layers were the areas of kraurosis with the growth of squamous cell keratinous carcinoma. Taking into account the prevalence of the tumor process, adjuvant treatment was not carried out. Two years later, in January 2020, there were focal symptoms in form of weakness in the left upper and lower limbs, an unsteady gait, a generalized weakness. During magnetic resonance imaging (MRI) of the brain in the occipital lobe paraventricular with intensive perifocal edema to the right was determined cystic-solid formation with rough edges which size was 293365 mm without clinically significant mass-effect. The middle structures were not displaced. Positron emission tomography-computed tomography (PET/CT) was performed to detect the prevalence of the tumor process. Data on the presence of the active specific process at the time of study were not received. Taking into account the absence of other indicators of generalization process, whole brain radiation therapy (single fraction dose of 3 Gy, total radiation dose of 30 Gy) was carried out, followed by the application of Temodal. The patient was examined in 6 months. There were no signs of progression. Conclusion. Brain metastases from vulvar cancer are considered to be rare. This clinical case is interesting because brain metastases have been the only manifestation of the progression of the tumor process in the absence of regional lymph nodes damage. The main diagnostic method is MRI of the brain. The use of PET/CT helps to detect the prevalence of the tumor process. The metastases have been detected after 36 months from the date of the initial diagnosis of the cancer. Radiation therapy is a method of choice of brain metastases treatment.

CEREBROVASCULAR DISORDERS IN PATIENTS WITH COVID-19

COVID−19 is an acute respiratory viral disease caused by the RNA virus of the SARS−CoV−2 (2019 nCoV) coronavirus family and can have both mild course in the form of acute respiratory viral infection and severe one with frequent complications such as pneumonia, thrombosis, cerebrovascular disorders and high mortality. Hypoxia of the brain and spinal cord is associated with impaired gas exchange in the pulmonary alveoli, progressive respiratory failure with subsequent decompensation of function and structural damage to all organs and systems. Neurological disorders in COVID−19, observed in almost a half of patients, can be divided into three groups: manifestations of the central nervous system, lesions of the peripheral nervous system, myopathy. In order to study the lesion of the nervous system in patients with COVID−19, a history of acute cerebrovascular disorders and clinical picture of stroke without the emergence of new foci in neuroimaging, three clinical cases were analyzed. All patients complained of speech impairment, disorientation in time and space, numbness and weakness in the extremities on the background of acute cerebrovascular accident in the anamnesis, accompanied by general weakness and fever to subfebrile figures. COVID−19 pneumonia was observed during computed tomography of the lungs. However, during neuroimaging new foci of infarction were not identified. Thus, given the lack of new foci of infarction during neuroimaging, lack of hypercoagulation and cardiac causes, it can be concluded that focal symptoms in patients with COVID−19 with a history of stroke cause hypoxia of brain cells in the area around the necrotic foci resulted from previous heart attacks. Key words: nervous system, lesions, COVID−19, coronaviruses, encephalopathy, hypoxia.

Does diagnostic mammography need to be a routine component of the initial evaluation of a breast symptom in women 30‐39 years of age?

Diagnostic mammography is routinely ordered, along with targeted breast ultrasound, to evaluate breast symptoms in women 30-39years of age. However, in this age group, mammography is often limited by breast density and the probability of detecting an occult malignancy is low. We sought to evaluate whether diagnostic mammography detected any new incidental malignancies in women aged 30-39years presenting with focal breast symptoms. This retrospective study included women 30-39years of age who had a diagnostic mammogram performed for focal breast symptoms at a single institution from 2002 to 2017. Descriptive analyses were performed to determine the rate of incidental mammographic findings outside of the region of the presenting symptom that 1) led to additional imaging and/or biopsies and 2) were found to be malignant. During the 16-year study period, 1770 evaluations were performed, of which 249 (14.1%) were found to have an additional incidental mammographic abnormality. Further diagnostic imaging was required in 211 (11.3%), core biopsy in 67 (3.8%), and excisional biopsy in 8 (0.5%). None of the mammographically detected incidental findings resulted in a new diagnosis of breast cancer. In the evaluation of focal benign breast symptoms in women 30-39years of age, diagnostic mammography did not detect any new incidental malignancies outside of the area of interest, but instead led to additional unavailing imaging and biopsy procedures. The mammography component of the diagnostic evaluation of younger average-risk women may potentially be omitted if the presenting symptom is determined to be benign with ultrasound alone.

Antibodies Contributing to Focal Epilepsy Signs and Symptoms Score.

ObjectiveDiagnosing autoimmune encephalitis (AIE) is difficult in patients with less fulminant diseases such as epilepsy. However, recognition is important, as patients require immunotherapy. This study aims to identify antibodies in patients with focal epilepsy of unknown etiology, and to create a score to preselect patients requiring testing.MethodsIn this prospective, multicenter cohort study, adults with focal epilepsy of unknown etiology, without recognized AIE, were included, between December 2014 and December 2017, and followed for 1 year. Serum, and if available cerebrospinal fluid, were analyzed using different laboratory techniques. The ACES score was created using factors favoring an autoimmune etiology of seizures (AES), as determined by multivariate logistic regression. The model was externally validated and evaluated using the Concordance (C) statistic.ResultsWe included 582 patients, with median epilepsy duration of 8 years (interquartile range = 2–18). Twenty patients (3.4%) had AES, of whom 3 had anti–leucine‐rich glioma inactivated 1, 3 had anti–contactin‐associated protein‐like 2, 1 had anti–N‐methyl‐D‐aspartate receptor, and 13 had anti–glutamic acid decarboxylase 65 (enzyme‐linked immunosorbent assay concentrations >10,000IU/ml). Risk factors for AES were temporal magnetic resonance imaging hyperintensities (odds ratio [OR] = 255.3, 95% confidence interval [CI] = 19.6–3332.2, p < 0.0001), autoimmune diseases (OR = 13.31, 95% CI = 3.1–56.6, p = 0.0005), behavioral changes (OR 12.3, 95% CI = 3.2–49.9, p = 0.0003), autonomic symptoms (OR = 13.3, 95% CI = 3.1–56.6, p = 0.0005), cognitive symptoms (OR = 30.6, 95% CI = 2.4–382.7, p = 0.009), and speech problems (OR = 9.6, 95% CI = 2.0–46.7, p = 0.005). The internally validated C statistic was 0.95, and 0.92 in the validation cohort (n = 128). Assigning each factor 1 point, an antibodies contributing to focal epilepsy signs and symptoms (ACES) score ≥ 2 had a sensitivity of 100% to detect AES, and a specificity of 84.9%.InterpretationSpecific signs point toward AES in focal epilepsy of unknown etiology. The ACES score (cutoff ≥ 2) is useful to select patients requiring antibody testing. ANN NEUROL 2021;89:698–710

Endoscopic fenestration of arachnoid cyst of posterior cranial fossa through third ventriculostomy

Arachnoid cysts (AC) are spaces with cerebrospinal fluid covered with arachnoid membrane. Most cysts are supratentorial and only 10-12% of ACs are found in posterior cranial fossa. This disease is usually diagnosed in childhood. In adults, ACs make up 1.4% of all focal lesions. ACs of posterior cranial fossa are often localized behind the cerebellum or in cerebellopontine angle. Most patients with cysts do not have permanent symptoms and should be followed-up. Surgery is indicated for cysts complicated by focal and hydrocephalic-hypertension symptoms. Microsurgical or endoscopic procedures are used. Surgical approach is determined by the closest location of cyst to brain surface. The authors report non-standard surgical approach for giant AC of posterior cranial fossa complicated by obstructive hydrocephalus, intracranial hypertension and visual function impairment. Endoscopic third ventriculostomy was followed by AC fenestration through ventriculostomy. Symptoms disappeared within 6 months after surgery.

Development of a Risk Predictive Scoring System for Epilepsy in Infants with Paroxysmal Motor Events: A Retrospective Single-Center Study

Purpose: Paroxysmal motor events are common clinical symptoms in infants visiting pediatric neurology clinics. Due to the heterogeneous clinical symptoms and the difficulty of interpreting electroencephalography (EEG) in infants, differentiating paroxysmal motor events from epileptic events is challenging. This study aimed to investigate the risk factors for the diagnosis of epilepsy in infants and to develop a scoring system that predicts the risk of epilepsy.Methods: We retrospectively analyzed data from patients who presented with paroxysmal motor events in infancy between January 2008 and December 2009 at Asan Medical Center. Electronic medical records were reviewed for patients’ demographics, medical history, clinical characteristics associated with specific situations, and motor symptoms. Laboratory findings, EEG, and brain magnetic resonance imaging were also reviewed. Results: In total, 111 infants with paroxysmal motor events were enrolled. Non-epileptic paroxysmal motor events (NEPMs) were associated with specific situations (P&lt;0.001). Patients with epilepsy were likely to have focal motor symptoms (P=0.08), a medical history of a neurologic disorder, and/or a family history of epilepsy (P&lt;0.05). A risk scoring system was developed based on these risk factors; using this system, infants with 2 or more points could be diagnosed with epilepsy with 61.76% sensitivity and 88.31% specificity.Conclusion: Infants with paroxysmal motor events were more likely to be diagnosed with NEPMs than with epilepsy. An absence of specific situations for paroxysmal events, focal motor seizures, and a medical history of another illness were associated with the final diagnosis of epilepsy.

Yield of Head Imaging in Ambulatory and Hospitalized Patients With SARS-CoV-2: A Multi-Center Study of 8675 Patients.

Background and Purpose:To describe the neurological and cerebrovascular findings in patients who tested positive for SARS-CoV-2 and underwent head imaging in ambulatory and inpatient settings.Methods:Consecutive patients aged ≥18 years with SARS-CoV-2 infection diagnosed or treated at Mayo Clinic sites from 3/11/2020 to 7/23/2020 with head CT or brain MRI within 30 days of SARS-CoV-2 diagnosis were included. Demographics, medical history, indication for SARS-CoV-2 testing, neurologic symptoms, indication for brain imaging, neuroimaging findings, etiology of cerebrovascular events, and hospital course were abstracted from medical records.Results:Of 8,675 patients with SARS-CoV-2, 180 (2.07%) had head imaging. Mean age of the entire cohort was 42 ± 18 years, whereas mean age of those with head imaging was 62 ± 19 years. Common indications for imaging were headache (34.4%), encephalopathy (33.4%), focal neurologic symptom (16.7%), and trauma (13.9%). While 86.1% of patients who underwent head imaging had normal exams, cerebrovascular events occurred in 18 patients (0.21% of the total cohort). Of patients with cerebrovascular events, 8 (44.5%) had acute infarct; 6 (33.3%), acute intracranial hemorrhage; 5 (2.8%), subacute infarct; and 1 (0.6%) posterior reversible encephalopathy syndrome. In the thirteen patients with ischemic stroke, 6 (46.2%) had cryptogenic stroke; 3 (23.1%), other defined causes; 2 (15.4%), small vessel stroke; 1 (7.7%), large vessel stroke; and 1 (7.7%) cardioembolic stroke.Conclusion:In ambulatory and hospitalized patients with SARS-CoV-2 infection, the rate of head imaging is low, with common indications of encephalopathy and headache. Cerebrovascular events occurred rarely, and cryptogenic stroke was the most common stroke mechanism.

QOL-05. TUMOR LOCATION IS LESS LIKELY INFLUENCE ON COGNITIVE DYSFUNCTION IN CHILDREN

INTRODUCTIONThough several factors are known to influence on long-term cognitive function in children with brain tumor, the impact of tumor localization to specific cognitive function was not well known. Here we investigated the influence of local brain resection by surgery on postoperative cognitive outcome in school-aged children.METHODSParticipants were seven pediatric patients who underwent craniotomy for tumor resection in our hospital (mean age, 13.9 years). Their diagnosis were WHO grade 1 or 2 glioma (n=6) and hemangioma (n=1). Tumor were mainly located in following regions; frontal, n=2; parietal, n=2; temporal, n=3 (These lesions included hippocampus or were located very close to it). Temporal assessments for cognitive function of several functional domains were performed according to tumor location until post-op 1 year. Based on MRI, we estimated cognitive dysfunctions and compared them to observational symptoms.RESULTSPreoperative cognitive function was normal in all patients. Cognitive dysfunctions estimated from resected area were as follows (cumulative total number); memory or working memory disorder, n=4; visuospatial cognitive disorder, n=3; disorder of processing speed, n=2; facial or topographical agnosia, n=2; Gerstman syndrome, n=1. Just after surgery, cognitive function was declined in two functional domains of two patients, which were only 16.7% of estimated deficit from resected region. They recovered completely until 3 months postoperatively, and returned to school without any deficits.CONCLUSIONSIn pediatric lower-grade tumor, focal cognitive symptom was unlikely to be induced by local resection.

Sectra 3 D Human Body Visualization Table Use in Brain Abscess Diagnostics in a Child: A Case Report

Summary Brain abscess in children is a rare and particularly severe complication of acute otitis media/Chronic suppurative otitis media (CSOM). Presenting a child with brain abscess, which was developed as a pre-surgical complication of CSOM with cholesteatoma. Visualization of the abscess on a 3-D Sectra Visualization table was performed. An 8-year-old child who often suffered from untreated runny ear was admitted in a critical state. The history and clinical and laboratory data suggested severe chronic inflammation of the right middle ear. The examination did not reveal signs of meningeal irritation, increased intracranial pressure, excitation, sensory disorders, or focal symptoms. Surgical treatment was performed as a radical mastoidectomy with the removal of a cholesteatoma. After a three-day uneventful postoperative period, the patient worsened. A CT scan visualized a brain abscess in the right temporal lobe. A craniotomy was performed by opening the brain abscess, with an aspiration of pus, and lavage of the cavity. After surgical and conservative treatment, the child was discharged clinically healthy on the fourteenth day. Processing the image check-ups on a Sectra 3-D visualization table helped determine the size and localization of the abscess and the choice of surgical access.

Detection of cytokine-induced sickness behavior after ischemic stroke by an optimized behavioral assessment battery

Stroke causes severe and long-lasting symptoms in patients. Besides focal deficits such as speech impairment and limb weakness, stroke also results in neuropsychiatric symptoms, including fatigue, anxiety, and depression, which are debilitating and often impair post-stroke rehabilitation. However, in experimental stroke research, the study of neuropsychiatric symptoms and their therapeutic targeting has so far been largely neglected, which can be mainly attributed to the lack of appropriate tools to investigate such deficits in mice.Here, we report that neuropsychiatric symptoms can be differentiated from focal deficits and specifically modulated independent of treating the primary lesion. In order to achieve this, we developed a novel behavior analysis tool by assessing test performance of various tests, combining outcome parameters to cover functional domains of focal and neuropsychiatric symptoms, and finally weighted results into a time point-specific score. This weighted score enabled us to clearly differentiate focal deficits and neuropsychiatric symptoms and detect these until the chronic phase after stroke. Using this analysis tool, we detected that neutralizing systemic cytokines (TNF-α, IL-1β and IL-6) specifically ameliorated neuropsychiatric symptoms but did not affect focal deficits or lesion volume. Hence, most conventional studies analyzing only focal deficits and lesion volume as primary outcome measures would have missed these significant and translationally relevant therapeutic effects. We anticipate that these findings will encourage more detailed analyses of neuropsychiatric symptoms particularly for anti-inflammatory therapies in stroke and that the presented weighted composite score will facilitate this development.

The clinical presentation, treatment and outcome of serologically confirmed paediatric Lyme disease in the Republic of Ireland over a 5-year period: a retrospective cohort study.

Lyme disease (LD) is the most common tick-borne illness in Europe. Population-based studies in European children are few. This study aimed to assess the incidence, clinical presentation, treatment and outcome of serologically confirmed paediatric LD in the Republic of Ireland over a 5-year period. A retrospective review of records from accredited laboratories performing Borrelia burgdorferi serological testing was undertaken. Proformas were distributed to clinicians of children and adolescents with positive Lyme serology. Data were requested regarding clinical presentation, treatment and outcome. Updated NICE guidelines were used to classify clinical cases. Serology testing for B. burgdorferi was performed on 2908 samples. Sixty-three (2.2%) children were two-tier positive, generating a crude annual incidence rate of 1.15/100,000. Proformas were returned for 55 (87%) and 47 met clinical and laboratory criteria for LD. Twenty-seven (57%) presented with non-focal symptoms (erythema migrans and/or influenza-like symptoms), and 20 (43%) with focal symptoms (cranial nerve involvement, 11; CNS involvement, 8; arthritis, 1). Median age at presentation was 8.2 (2.5-17.9) years. Seventeen (36%) acquired LD overseas. Twenty-five (83%) of the remaining 30 children acquired infection in the West/Northwest of Ireland. Full resolution of symptoms was reported in 97% of those with available data. Serologically confirmed LD in children is relatively rare in the Republic of Ireland. Ninety-eight percent of children tested were seronegative. Of the seropositive cases, 40% could have been diagnosed based on clinical findings alone. Neurological presentations (40%) were common. Full resolution of symptoms occurred in almost all (97%) where data were available.

Screening for cognitive impairment with the Montreal Cognitive Assessment in Spanish patients with minor stroke or transient ischaemic attack

ObjectiveThe symptoms of minor stroke and transient ischemic attack (TIA) are temporary and mild. Despite the transient nature of the focal symptoms and the absence of visible brain lesions in some patients, many experience persistent cognitive problems subsequently. We aimed to establish the discriminant capacity of the Montreal Cognitive Assessment (MoCA) in screening for cognitive impairment (CI) within 90 days of TIA. MethodsA total of 50 patients with minor stroke or TIA were recruited. Patients were administered the MoCA test and a formal neuropsychological test battery. CI was defined clinically according to neuropsychological test findings. ResultsThe average age of recruited patients was 57.7±8.0 years; 70.0% were men; all patients had completed at least primary education. Thirty-seven patients (74.0%) presented CI. Receiver operating characteristic curve analysis obtained an optimal MoCA cut-off point of 25 for discriminating between patients with CI and those without, with an area under the curve of 0.835 (95% confidence interval [CI], 0.720-0.949), sensitivity of 78.4% (95% CI, 62.8%-88.6%), specificity of 76.9% (95% CI, 49.7%-91.8%), positive predictive value of 90.6% (95% CI, 81.0%-95.6%), and negative predictive value of 55.6% (95% CI, 39.5%-70.4%). ConclusionsMore than half of the patients presented CI as determined by the formal battery of neuropsychological tests. A MoCA cut-off point of 25 is sufficiently sensitive and specific for detecting CI after minor stroke or TIA, and may be implemented as a screening technique in routine clinical practice.

Depressive Symptoms in Danish Patients With Glioma and a Cancer-Free Comparison Group.

It is well established that patients with glioma may experience adverse general (eg, headache) or focal symptoms (eg, personality changes) and neurocognitive deficits (eg, planning), but they may also experience severe emotional distress. We investigated the prevalence of depressive symptoms in patients with newly diagnosed glioma and in matched cancer-free persons. For this study, we recruited patients with glioma diagnosed within 12 months at all 4 neurosurgical clinics in Denmark. The cancer-free comparison group was identified through the Danish Central Person Register and matched on sex and age. Participants' depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression Scale (CES-D; score range, 0-60), with a cutoff score ≥16 indicating moderate-to-severe depressive symptoms. In this study, 363 of 554 patients with glioma and 481 of 1,304 cancer-free persons participated. Mean age of all patients was 55 years and 60% of the population was male. Mean scores for depressive symptoms were statistically significantly higher among patients with glioma, with a mean CES-D score of 10.9 (95% CI, 10.1-11.8) compared with 5.3 (95% CI, 4.7-5.8) among cancer-free persons (P<.0001). Overall, 92 patients with glioma (25%) and 30 cancer-free persons (6%) had moderate-to-severe depressive symptoms. After adjustment for marital status, education level, and comorbidity, the prevalence of depressive symptoms was 5 times higher among patients with glioma compared with cancer-free persons. A substantially higher prevalence of moderate-to-severe depressive symptoms was identified in patients with glioma compared with cancer-free persons. This indicates the importance of programs to systematically identify and manage depressive symptoms in patients with glioma.

Late effects of cancer treatment: consequences for long-term brain cancer survivors.

Late adverse effects of cancer treatments represent a significant source of morbidity and also financial hardship among brain tumor patients. These effects can be produced by direct neurologic damage of the tumor and its removal, and/or by complementary treatments such as chemotherapy and radiotherapy, either alone or combined. Notably, young adults are the critical population that faces major consequences because the early onset of the disease may affect their development and socioeconomic status. The spectrum of these late adverse effects is large and involves multiple domains. In this review we classify the main long-term adverse effects into 4 sections: CNS complications, peripheral nervous system complications, secondary neoplasms, and Economic impact. In addition, CNS main complications are divided into nonfocal and focal symptoms. Owing to all the secondary effects mentioned, it is essential for physicians to have a high level of clinical suspicion to prevent and provide early intervention to minimize their impact.