Focal Syndromes Research Articles

Diagnostic and prognostic biomarkers in immune checkpoint inhibitor-related encephalitis: a retrospective cohort study

Immune checkpoint inhibitor-related encephalitis (ICI-encephalitis) is not well characterised and diagnostic and prognostic biomarkers are lacking. We aimed to comprehensively characterise ICI-encephalitis and identify diagnostic biomarkers and outcome predictors. This retrospective observational study included all patients with ICI-encephalitis studied in the French Reference Centre on Paraneoplastic Neurological Syndromes (PNS) and Autoimmune Encephalitis (2015-2023). ICI encephalitis was considered definite in case of inflammatory findings at paraclinical tests and/or well-characterised neural antibodies. Predictors of immune-related adverse event (irAE) treatment response, defined as a Common Terminology Criteria for Adverse Events v5.0 grade<3at any time after therapeutic intervention, were assessed by logistic regression analysis, and predictors of mortality by Cox regression analysis. Neurofilament light chain (NfL) was measured by enzyme-linked immunosorbent assay. Sixty-seven patients with definite encephalitis were identified (median age, 69 years; 66% male). A focal syndrome was observed in 43/67 patients (64%; limbic encephalitis, cerebellar ataxia, and/or brainstem encephalitis), while 24/67 (36%) had meningoencephalitis, a non-focal syndrome with altered mental status (22/24 patients, 92%) and pleocytosis (24/24 patients, 100%). Patients with focal encephalitis more frequently had abnormal brain MRI (26/42, 62% versus 8/24, 33%, p=0.025), PNS-related antibodies (36/43, 84% versus 1/24, 4%, p<0.001), and neuroendocrine cancers (22/43, 51% versus 1/24, 4%; p<0.001) than patients with meningoencephalitis. Focal encephalitis patients had a lower rate of irAE treatment response (7/39, 18%) and higher mortality (27/43, 63%) compared to meningoencephalitis patients (12/22, 77% and 5/24, 21%, respectively, p<0.001 each). PNS-related antibodies were associated with less irAE treatment response, independently of age, sex, and baseline severity (adjusted OR 0.05; 95%CI [0.01; 0.19]; p<0.001) as well as higher mortality, independently of age and cancer type (adjusted HR 5.07; 95% CI [2.12; 12.12]; p<0.001). Serum NfL discriminated patients with definite ICI-encephalitis (n=27) from cancer-matched controls (n=16; optimal cut-off >273.5pg/mL, sensitivity 81%, specificity 88%, AUC 0.87, 95% CI [0.76; 0.98]) and irAE treatment responders (n=10) from non-responders (n=17, optimal cut-off >645pg/mL, sensitivity 90%, specificity 65%; AUC 0.75, 95% CI [0.55; 0.94]). ICI-encephalitis corresponds to a set of clinically-recognisable syndromes. Patients with focal encephalitis, PNS-related antibodies, and/or higher serum NfL have low irAE treatment response rates. Research is needed on the underlying immunopathogenesis to foster therapeutic innovations. Agence Nationale de la Recherche.

Histological and neuroimaging comparison of SMART syndrome versus focal neuronal gigantism.

Two of the rarest radiation-induced adverse effects are focal neuronal gigantism (FNG) and SMART syndrome (stroke-like migraine attacks after radiation therapy). Both conditions develop years, and sometimes decades, after receipt of therapeutic radiation to the brain. To date, there are only 3 previously reported cases of FNG, all of which describe cortical thickening, enlarged "hypertrophic" neurons, and neuronal cytological changes. No detailed studies exist of histological features of SMART or the comparison between FNG and SMART. In this study, we contrast histological and neuroimaging features of 3 FNG vs. 4 SMART cases, the latter diagnosed by a neuroradiologist, neurooncologist, and/or neurosurgeon. We confirm the cortical thickening, dyslamination, neuronal cytomegaly, and gliosis in FNG vs. cortical architectural preservation and normal neuronal cytology in SMART, although both showed gliosis, scattered neurons with cytoplasmic accumulation of tau and neurofibrillary protein and variable co-existence of other radiation-induced lesions. Both conditions lacked significant inflammation or consistent small vessel hyalinization throughout the entire resection specimen. The absence of pathognomonic histologic alterations in SMART cases suggests underlying vascular dysregulation. Despite differing histology, some overlap may exist in neuroimaging features. Molecular assessment conducted in 2 cases of FNG was negative for significant alterations including in the MAPK pathway.

Botulinum toxin preparations in complex therapy of infantile cerebral palsy (literature review)

The relevance of the topic is confirmed by statistical data related to primary childhood disabilities, according to which a number of congenital developmental anomalies and disorders of the nervous system are especially common. Cerebral palsy (CP) occupies a leading position in this regard. It is obvious that complex therapy for patients with cerebral palsy is effective, but it is not of economic benefit to the state, which to a certain extent provides support in the rehabilitation of this category of patients. In this connection, budgetary allocations and contributions from insurance companies both in the Russian Federation and other countries are distributed in a rational manner. Botulinum toxin preparations, used in standard clinical practice to combat focal spasticity syndrome in patients with cerebral palsy, have proved to be a feasible and economically beneficial medical technology. A similar therapy strategy has demonstrated a positive clinical effect. It is also the least expensive technology in the medical armamentarium used for the treatment and rehabilitation of patients with infantile cerebral palsy.

Increasing of spinal cord volume after surgical correction of ventral cord herniation: Case illustrations

Ventral cord herniation is a rare cause of focal myelopathy due to ventral displacement of the thoracic cord through a dural defect. Classically presented with Brown-Sequard syndrome. Despite being treated with surgical intervention, not all the patients’ neurological outcome were improved. In classic cases making a diagnosis before the patients develop advanced myelopathy is crucial. These case reports demonstrate a significantly increasing spinal cord volume in segmented disease after surgical correction in both cases at disease level, which is correlated to the good surgical outcome. This volumetric of the spinal cord can be the predictor of this myelopathic syndrome. Timing of surgery from the onset of symptom should be as early as possible to reversible, restorative this focal myelopathic syndrome.

Brain Tumour Related Headache: Features, Pathophysiology and Management Strategies

Introduction. Brain tumours constitute approximately 1% of all newly diagnosed cancers. Their manifestation typically involves headache, neurological impairment, focal onset seizures and syndromes related to tumour location. Severe headache presents as a prevailing symptom and occurs in over 50% of patients. Brain tumour associated headache exerts significant effect on quality of life in cancer patients. The following article aims to provide a comprehensive overview of most common and promising brain tumour related headache treatment strategies.&#x0D; State of knowledge. Headache in brain tumour patients arises from traction or displacement of intracranial pain-sensitive structures, such as vascular tissue, dura mater or periosteum. This can be caused by tumour’s mass itself, by tumour associated oedema or as a sequela of anti-tumour treatment. Most common therapeutic modalities include tumour surgical resection, cerebral oedema management, radiotherapeutic interventions and administration of analgesic agents. Complete removal of the tumour stands as the most effective approach, often bringing substantial alleviation in majority of cases.&#x0D; Conclusion. Headache affects the majority of individuals afflicted by brain tumours. Not all patients are suitable candidates for the resection of the underlying neoplasm. In such instances, the application of alternative approaches might be beneficial. Ongoing and future investigations may enhance the development of novel treatment strategies, possibly influencing the well-being of cancer patients, especially within palliative care area.

Клинические и нейрофизиологические корреляты когнитивных нарушений у пациентов с атеросклеротическим поражением сонных артерий

INTRODUCTION: Cognitive disorders often do not come to the fore in the interpretation of clinical manifestations in hemodynamically significant stenoses of brachiocephalic arteries. In this regard, the objectification of cognitive disorders based on a battery of tests, as well as of their neurophysiological correlates, is an important task of both angiology and neurology. Endogenous evoked potential P300 is a frequently used neurophysiological phenomenon characterizing the psychophysiological functions of perception, attention, and thinking. AIM: To study the dynamics of cognitive functions and their neurophysiological correlates in patients with hemodynamically significant carotid artery stenosis before and after carotid endarterectomy. MATERIALS AND METHODS: An open prospective study included 60 patients divided to two groups. Group A included 30 ‘symptomatic’ patients with a hemodynamically significant lesion (stenosis) of the internal carotid artery and a history of acute cerebrovascular accident. Group B included 30 ‘asymptomatic patients’ without a history of cerebrovascular events. Within the study, before surgery for carotid stenosis and 6 months after, the following parameters were assessed: cognitive status (according to the MMSE, FAB, MoCA, NIHSS scales), and also clinical and neurophysiological correlates of cognitive functions (P300 evoked potential). RESULTS: In the group of patients with neurological disorders (group A), a reliably greater number of errors (p = 0.048), as well as a decrease in the amplitude (p = 0.006) and increase in latency (p = 0.022) of P2 component of P300 cognitive evoked potential were determined. Based on the parameters of P300 event-related potential, a logit regression model was created that permitted to classify patients to the above-mentioned groups. The cluster analysis of dynamics of cognitive functions was additionally performed before and after surgery. In cluster 1, there were 45% of symptomatic patients, 55% of asymptomatic ones, in cluster 2 — 58% and 32%, respectively, no reliable differences were found (chi-square 0.58; p = 0.445). Cluster 1 was characterized by initially higher level of test performance with some increase in this parameter after surgery; Cluster 2 was characterized by a lower level of these parameters, with the greatest differences found in frontal assessment battery (FAB) characteristics. Reliable differences in the level of P300 were found only after surgery: the greatest differences were recorded in the amplitude of P2, P3, N2 components. CONCLUSION: The factor of cognitive impairment is a separate phenomenon, not closely related to focal neurological syndrome in patients with carotid atherosclerosis. An objective neurophysiological criterion for cognitive impairment in these patients is the endogenous evoked potential P300. With this, the greatest differences between the neurophysiological correlates of cognitive disorders are determined 6 months after the operation for carotid stenosis.

Protocolo diagnóstico del estado confusional agudo en el anciano

Acute confusional state, acute confusional syndrome, or delirium is a syndrome characterized by the acute involvement of attention and other cognitive functions. The etiology is diverse and multifactorial, with a variable presentation and fluctuating nature. In older adults over 65 years of age, acute confusional state is frequent, severe, little recognized, and on occasion can have a fatal outcome. The diagnosis is based on the one hand on confirmation of the clinical syndrome by means of a case history and examination and, on the other hand, on identification of the etiology, with the rational use of additional tests. A differential diagnosis must be performed with dementia, some focal neurological syndromes, epileptic seizures, and psychiatric diseases.

Cognitive disorders with epilepsy: clinical-psychopathological and neuropsychological characteristics, non-pharmacological correction

IntroductionCognitive dysfunction affects the development, treatment compliance, significantly worsens the quality of life and social functioning of the patients with epilepsy.Objectives146 patients with epilepsy aged 18 to 65 participated in the study (М-40.7±2.42) were diagnosed with focal, idiopathic epilepsy and epileptic syndromes (G40.1, G40.2, G40).MethodsClinical-anamnestic, social-demographic, clinical-psychopathological, psycho-diagnostic and statistical.ResultsThe study of the attention selectivity was carried out using the Munsterberg test. Only 9 examined patients (6.16%) of the total group had sufficient indices, 35 (23.97%) patients refused from the test, while the rest – 102 (69.87%) had low test results. The overall treatment group score was 7.72, which is by 13.28 lower than in the control group, where the attention selectivity index was 21 (р&lt;0,001), which shows a considerable attention selectivity decrease in patients with epilepsy compared to the healthy persons. According to the МоСА test results, the first treatment group patients showed better cognitive functions (1.4, р&lt;0.001), higher attention selectivity under the Munsterberg test (0.63, р&lt;0.001), lower anxiety level under HARS (1.45, р&lt;0.001), lower depression level under HDRS (1.7, р&lt;0.001) and higher subjective assessment of the life quality (2.77, р&lt;0.05). According to the МоСА test results, the second treatment group patients showed better cognitive functions (0.73, р&lt;0.001), higher attention selectivity under the Munsterberg test (0.27, р&lt;0,05), lower anxiety level under HARS (4.27, р&lt;0.05), lower depression level under HDRS (2.32, р&lt;0.05) and higher subjective assessment of the life quality (1.21, р&lt;0.05). According to the МоСА test results, the comparison group patients demonstrated lower cognitive functions (0.22, р&lt;0.05), higher attention selectivity under the Munsterberg test (0.15, р&lt;0.05), lower anxiety level under HARS (2.61, р&lt;0.001), lower depression level under HDRS (2.49, р&lt;0.001) and higher subjective assessment of the life quality (1.0, р&lt;0.05). The cognitive training showed its effectiveness in healthy persons of the control group: according to the МоСА test results, cognitive functions improved (0.79, р&lt;0.001), compared to the treatment group 2 patients (0.73, р&lt;0.001).ConclusionsAccording to the follow-up study data 12 months after the cognitive training and psychoeducation, follow-up study showed better values under depression and anxiety scales, and improved life quality levels in the patients of treatment groups. Patients with epilepsy show a reliable cognitive functioning improvement after a 3-month computerized cognitive training. The study results indicate a more significant cognitive functioning improvement in the patients provided the combined use of the methods of psychoeducation and cognitive training, compared to the use of a cognitive training only.Disclosure of InterestNone Declared

Subacute isolated cortical vein thrombosis in systemic sclerosis

ICVT, infrequent and serious, has a varied aetiology and clinical presentation. Focal syndrome with seizures is common. CT showing cord sign is early and accurate. Rapid management promises good prognosis, evading criticality. Although prothrombotic states pose great risk, inflammatory diseases, rarely SSc, are equally important. They must be evaluated.

A clinical case report: stroke in a young patient with systemic lupus erythematosus on the background of secondary antiphospholipid syndrome

The article describes a clinical case report of a young patient with ischemic stroke on the background of antiphospholipid syndrome (APLS). The uniqueness of this case lies in the complex diagnostic search that we performed. On admission, the patient had general cerebral, general infectious and focal syndromes. We suspected encephalitis due to the peculiarities of the onset of the disease and the results of computed tomography. However, after the results of lumbar puncture, the diagnosis of encephalitis required careful differential diagnosis. We performed an extensive diagnostic search. Based on clinical-laboratory, instrumental and immunological data the patient had the following final diagnosis: “Ischemic cardioembolic stroke in the right middle cerebral artery pool (15.10.17) (ICD 11: 8B11.5). Acute period with left pyramidal reflex insufficiency and changes in magnetic resonance imaging. Systemic lupus erythematous (ICD 11: 4A40.0), subacute course, activity II, with the lesion of skin (transient erythematous rash), kidneys (proteinuria, transient impaired renal function), lungs (bilateral pleurisy with immunological disorders). Secondary APLS (ICD 11: 4A45) (Acute iliofemoral thrombosis, May 2017; chronic thrombosis of the inferior vena cava, iliac veins, positive IgG to cardiolipin, beta 2 glycoproteins). Thus, we have to link thrombotic complications in young patients with APLS and to examine the patients for antiphospholipid antibody presence.

Neuropsichiatric Manifestations of Systemic Lupus Erythematosus: Diagnosis and Treatment Approach

Abstract Neuropsychiatric involvement in systemic lupus erythematosus includes heterogeneous manifestations involving both the central and peripheral nervous system. A major issue in clinical evaluation is the attribution of neuropsychiatric symptoms to systemic lupus erithematosus. Antiphospholipid antibodies, immune complex, microangiopathy, early and accelerated arteriosclerosis are factors that have the main role in pathogenesis of neuropsychiatric manifestations of systemic lupus erithematosus. There are no neurological symptoms specific to systemic lupus erithematosus, but they can also occur very commonly in the general population. Lesions of nervous system can be focal or diffuse and may be due to systemic lupus erithematosus itself (primary lesions), but it also may be caused by other diseases or disbalances. Therapy of the neuropsychiatric manifestations depends on the nature of the pathological process (dominant inflammation or thrombosis). If it is result of an inflammatory neurotoxic process and in the presence of an increased activity of systemic lupus erithematosus, therapy includes glycocorticoids independently or in combination with immunosuppressives. Focal neuropsychiatric syndrome with antiphospholipid antibodies positivity should be treated with anticoagulant and/or antiplatelet therapy. In addition, control of classical cardiovascular risk factors, stop smoking, and treatment with hydroxychloroquine is recommended.

Age‐at‐Onset and APOE Related Heterogeneity in the Clinical, Plasma Biomarker, and Neuropathologic Presentation of Alzheimer’s Disease (AD)

AbstractBackgroundPatients with sporadic early‐onset AD (EOAD) show less pronounced memory impairment, faster cognitive decline, and greater likelihood of focal cortical syndromes than those with later onset (LOAD), while often lacking the APOE ε4 allele classically associated with younger onset. This heterogeneity could arise from differences in the distribution of AD pathology or presence of concomitant pathologies.MethodWe examined clinical and cognitive heterogeneity in relation to age‐at‐onset, APOE genotype, and concomitant neuropathology (Lewy body, TDP‐43, and vascular) in patients with autopsy‐confirmed severe AD from the National Alzheimer’s Coordinating Center database (N=1750). In patients from the UCSD Alzheimer’s Disease Research Center (N=121) we examined how age‐related heterogeneity relates to differences in distribution of neurofibrillary tangle (NFT) pathology and plasma biomarkers of AD.ResultAge‐at‐onset distribution in APOE ε4‐ patients was bimodal with best separation at age 63. Patients with EOAD (age ≤63) had faster cognitive and functional decline than LOAD regardless of APOE genotype; and were more likely to present with nonmemory cognitive complaints (OR=5.56, 99%CI: 3.32‐9.39), show greater executive dysfunction (β=2.59 SD, 99%CI: 2.10‐3.09), and receive a non‐AD clinical diagnosis (OR=1.54, 99%CI: 1.19‐1.97), particularly for ε4‐ EOAD (p’s&lt;0.01, APOE × age‐at‐onset interactions). Despite this atypicality, groups did not differ in their high rates of AD biomarker positivity, and ε4‐ EOAD patients were most likely to have pure AD without concomitant pathology. TDP‐43 (OR=0.37; 99%CI: 0.18–0.72) and microvascular (OR=0.65; 99%CI: 0.47–0.88) pathology were less common in EOAD, while Lewy pathology was more common in ε4+ (OR=1.48; 99% CI, 1.02–2.17). Midfrontal NFT density was higher in EOAD than LOAD (β= 0.87 SD, 99%CI: 0.44‐1.29). Greater hippocampal NFT density was associated with APOE ε4+ (β=0.49 SD, 99%CI: 0.02‐0.96). Mediation analyses suggest that differences in midfrontal/hippocampal NFT ratio, rather than concomitant neuropathology, mediate the atypical cognitive profiles and decline of EOAD (p&lt;0.01).ConclusionA relatively more neocortical NFT distribution, rather than concomitant non‐AD pathology, accounts for the atypical, non‐memory dominant clinical presentation and rapid progression in EOAD. This suggests that selective cortical vulnerability may explain the earlier‐than‐expected onset and atypical profile in these individuals without the APOE ε4 risk allele.

Outcomes after superficial temporal artery-middle cerebral artery anastomosis combined with multiple burr hole surgery and dural inversion synangiosis for moyamoya disease in adults.

Several forms of cerebral revascularization have been carried out to treat moyamoya disease, however, the existing methods are accompanied by a variety of complications. In this study, the authors aimed to evaluate the clinical and angiographic outcomes of a new surgical procedure: superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis combined with multiple burr hole (MBH) surgery and dural inversion synangiosis for the treatment of moyamoya disease in adults. Patients treated for moyamoya disease from August 2019 to July 2021 were retrospectively reviewed. Clinical data, including perioperative complications and follow-up outcomes, were noted. Preoperative and postoperative angiograms were compared, and the diameters of the frontal branch of the superficial temporal artery (F-STA), the deep temporal artery (DTA), the distal superficial temporal artery (STA) before the bifurcation and the middle meningeal artery (MMA) were measured on preoperative and postoperative angiograms. Meanwhile, a Matsushima score was assigned from postoperative angiograms. This study included 66 patients (67 hemispheres). During the follow-up period, a median of 18 (IQR, 13-21) months, no stroke or death occurred in any of the patients. The clinical outcomes were excellent in 27 patients (40.9%), good in 34 patients (51.6%), fair in 4 patients (6.0%), and poor in 1 patient (1.5%); the overall rate of favorable clinical outcomes (excellent and good) was 92.5%. The modified Rankin Scale (mRS) score was significantly improved at follow-up (P < 0.001). There were 41 hemispheres imaged by cerebral angiography after the operation, at a median postoperative interval of 9 (IQR, 8-12) months; among them, 34 (82.9%) hemispheres had Matsushima scores of grade A and grade B. The average postoperative diameters in the STA, DTA and MMA were increased significantly in 41 hemispheres at follow-up (P < 0.001). Sixteen (24.2%) patients suffered from perioperative complications, including focal hyperperfusion syndrome (HS) in 8 (12.2%) patients, cerebral infarction in 3 (4.5%) patients (including one case accompanied by wound infection), cerebral hemorrhage in 2 (3.0%) patients, seizures in 2 (3.0%) patients, and subdural effusion in 1 (1.5%) patient. The procedure of STA-MCA anastomosis combined with MBH surgery and dural inversion synangiosis may be a safe and effective treatment for adult patients with moyamoya disease.

Regional distribution and maturation of tau pathology among phenotypic variants of Alzheimer's disease.

Alzheimer's disease neuropathologic change (ADNC) is clinically heterogenous and can present with a classic multidomain amnestic syndrome or focal non-amnestic syndromes. Here, we investigated the distribution and burden of phosphorylated and C-terminally cleaved tau pathologies across hippocampal subfields and cortical regions among phenotypic variants of Alzheimer's disease (AD). In this study, autopsy-confirmed patients with ADNC, were classified into amnestic (aAD, N = 40) and non-amnestic (naAD, N = 39) groups based on clinical criteria. We performed digital assessment of tissue sections immunostained for phosphorylated-tau (AT8 detects pretangles and mature tangles), D421-truncated tau (TauC3, a marker for mature tangles and ghost tangles), and E391-truncated tau (MN423, a marker that primarily detects ghost tangles), in hippocampal subfields and three cortical regions. Linear mixed-effect models were used to test regional and group differences while adjusting for demographics. Both groups showed AT8-reactivity across hippocampal subfields that mirrored traditional Braak staging with higher burden of phosphorylated-tau in subregions implicated as affected early in Braak staging. The burden of phosphorylated-tau and TauC3-immunoreactive tau in the hippocampus was largely similar between the aAD and naAD groups. In contrast, the naAD group had lower relative distribution of MN423-reactive tangles in CA1 (β = -0.2, SE = 0.09, p = 0.001) and CA2 (β = -0.25, SE = 0.09, p = 0.005) compared to the aAD. While the two groups had similar levels of phosphorylated-tau pathology in cortical regions, there was higher burden of TauC3 reactivity in sup/mid temporal cortex (β = 0.16, SE = 0.07, p = 0.02) and MN423 reactivity in all cortical regions (β = 0.4-0.43, SE = 0.09, p < 0.001) in the naAD compared to aAD. In conclusion, AD clinical variants may have a signature distribution of overall phosphorylated-tau pathology within the hippocampus reflecting traditional Braak staging; however, non-amnestic AD has greater relative mature tangle pathology in the neocortex compared to patients with clinical amnestic AD, where the hippocampus had greatest relative burden of C-terminally cleaved tau reactivity. Thus, varying neuronal susceptibility to tau-mediated neurodegeneration may influence the clinical expression of ADNC.

ID:16474 Relating Neurocognition and Connectivity Between Arousal Structures and Intrinsic Connectivity Networks in Temporal Lobe Epilepsy

Despite temporal lobe epilepsy (TLE) being a focal syndrome, patients experience widespread brain deficits. It has been shown previously that intrinsic connectivity networks (ICNs) have abnormal connectivity in epilepsy patients. Additionally, we have previously shown abnormal connectivity in arousal structures in TLE. Arousal structures may modulate these ICNs. Here, we investigate if patients with TLE have perturbations in functional connectivity (non-directed and directed) between arousal structures and ICNs.

ID:16060 Dorsal Root Ganglion Stimulation to Treat Focal and Diffuse Pain After Minimally Invasive Spine Surgery

Dorsal root ganglion stimulation (DRG-S) is an accepted neuromodulatory technique for the treatment of focal and dermatomal pain syndromes, and emerging evidence is demonstrating its efficacy in non-dermatomal syndromes such as failed back surgery syndrome (FBSS). Chronic pain patients often present with more than one source of pain1 and patients that experience a surgical complication are more likely to experience a second complication2. Here we present a patient who lost efficacy with SCS, leading to an extreme lateral interbody fusion (XLIF), which was complicated by flank hernia and severe focal neuropathic pain post-surgical repair. A year after XLIF, she was diagnosed with FBSS. DRG-S was successfully used to treat both conditions.

Dorsal Root Ganglion Stimulation to Treat Focal Postsurgical and Diffuse Chronic Pain: A Case Report

Dorsal root ganglion stimulation (DRG-S) is widely accepted for treating focal pain syndromes. We present the case of a 46-year-old woman with severe lumbar radiculopathy with an implanted spinal cord stimulator (SCS) that had lost efficacy. She developed an incisional hernia after undergoing a minimally invasive, extreme lateral interbody fusion and SCS explant. After herniorrhaphy, she presented with severe pain at the T10-T11 dermatomes, which we treated with DRG-S. One-year after lumbar fusion, her refractory lumbar and radicular pain returned, which we ultimately treated with bilateral T12+S1 DRG-S. DRG-S was thus used to successfully treat focal postsurgical and diffuse chronic pain.

Characterizing Differences in Functional Connectivity Between Posterior Cortical Atrophy and Semantic Dementia by Seed-Based Approach.

BackgroundPosterior cortical atrophy (PCA) and semantic dementia (SD) are focal syndromes involving different cerebral regions. This study aimed to demonstrate the existence of abnormal functional connectivity (FC) with an affected network in PCA and SD.MethodsA total of 10 patients with PCA, 12 patients with SD, and 11 controls were recruited to undergo a detailed clinical history interview and physical examination, neuropsychological assessments, and PET/MRI scan. Seed-based FC analyses were conducted to construct FC in language network, visual network, and salience network. The two-sample t-test was performed to reveal distinct FC patterns in PCA and SD, and we further related the FC difference to cognition. Meanwhile, the uptake value of fluorodeoxyglucose in regions with FC alteration was also extracted for comparison.ResultsWe found a global cognitive impairment in patients with PCA and SD. The results of FC analyses showed that patients with PCA present decreased FC in left precentral gyrus to left V1 and increased FC in right inferior frontal gyrus to right V1 in the visual network, right medial frontal gyrus and left fusiform to left anterior temporal lobe and post-superior temporal gyrus in the language network, and left superior temporal gyrus to left anterior insula in the salience network, which were related to cognitive function. Patients with SD had decreased FC from right superior frontal gyrus, right middle frontal gyrus and right superior frontal gyrus to left anterior temporal lobe, or post-superior temporal gyrus in the language network, as well as left superior frontal gyrus to right anterior insula in the salience network, positively relating to cognitive function, but increased FC in the right superior temporal gyrus to left anterior temporal lobe in the language network, and right insula and left anterior cingulum to right anterior insula in the salience network, negatively relating to cognitive function. Most of the regions with FC change in patients with PCA and SD had abnormal metabolism simultaneously.ConclusionAbnormal connectivity spread over the cortex involving language and salience networks was common in patients with PCA and SD, whereas FC change involving the visual network was unique to patients with PCA. The FC changes were matched for cognitive deficits.

Neurological Predictors of Functional Outcome in Cortical Venous Sinus Thrombosis.

Objectives Cerebral venous sinus thrombosis (CVST) has a wide clinical spectrum. Despite favorable prognosis, identifying CVST patients with a possible poor functional outcome can be challenging. This study aims to establish the neurological predictors of outcome in CVST. Materials and Methods We analyzed 70 patients of CVST and categorized them into three groups: Group I with isolated intracranial hypertension; Group II—focal syndrome of neurological deficit; Group III—subacute encephalopathy. Demographic, disease characteristics, and radiological parameters were also analyzed for prediction of hospital course. Functional outcome was assessed by modified Rankin scale (mRS) dichotomized as good (mRS: 0–2) or poor outcome (mRS ≥ 3). Statistical Analysis Univariate and multivariate logistic regression analyses were performed to find out the independent effects of prognostic factors to be used for outcome prediction. Results The mean age was 36.71 ± 14.9 years with 40 (68.8%) males. Most common presenting complaints were headache 35 (50%), hemiparesis 14 (20%), and seizures 12 (17.4%). Group I included 44 (62.9%), group II 17 (24.3%) and group III 12 (12.9%) patients. During hospitalization 28 (40%) patients needed intensive care unit (ICU) care, among them 7 (10%) required ventilation. There were eight times more chances of ICU care (odds ratio [OR]: 7.4; 2.5–24.4) and 23 times more need for ventilation (OR: 23; 2.5–88.9) whenever patients were in group II or III. Good outcome (mRS < 2) was noted in 52 (74.2%) patients. Headache was associated with good functional outcome, whereas hemiparesis with poor outcome. Neurological grouping was the independent predictor of functional outcome; patients with focal neurological deficit (group II) were 20 times more likely to have dependent life at the time of discharge ( p < 0.05) with the mortality rate of 2.9%. Conclusions Neurological grouping is a practical tool for prediction of function outcomes. Early anticipation of prognosis helps in decision-making in the clinical practice.

Prolonged migraine aura resembling ischemic stroke following CoronaVac vaccination: an extended case series

BackgroundAfter the initiation of the COVID-19 vaccination program in Thailand, thousands of patients have experienced unusual focal neurological symptoms. We report 8 patients with focal neurological symptoms after receiving inactivated virus vaccine, CoronaVac.Case seriesPatients were aged 24–48 years and 75% were female. Acute onset of focal neurological symptoms occurred within the first 24 h after vaccination in 75% and between 1-7d in 25%. All presented with lateralized sensory deficits, motor deficits, or both, of 2–14 day duration. Migraine headache occurred in half of the patients. Magnetic resonance imaging of the brain during and after the attacks did not demonstrate any abnormalities suggesting ischemic stroke. All patients showed moderately large regions of hypoperfusion and concurrent smaller regions of hyperperfusion on SPECT imaging while symptomatic. None developed permanent deficits or structural brain injury.DiscussionsHere, we present a case series of transient focal neurological syndrome following Coronavac vaccination. The characteristic sensory symptoms, history of migraine, female predominant, and abnormal functional brain imaging without structural changes suggest migraine aura as pathophysiology. We propose that pain related to vaccine injection, component of vaccine, such as aluminum, or inflammation related to vaccination might trigger migraine aura in susceptible patients.