Neurological Examination Research Articles

Quality of medical care for patients with arterial hypertension and type 2 diabetes mellitus in outpatient medical organizations

BACKGROUND: The course of arterial hypertension and diabetes mellitus depends on the medical care quality since its poor provision increases the risk of unfavorable outcomes. Identifying and analysing defects in the management of such patients is an urgent task. AIM: To assess the medical care quality provided to patients with hypertension and type 2 diabetes mellitus on an outpatient medical organizations. MATERIALS AND METHODS: The assessment of the medical care for patients with hypertension and type 2 diabetes mellitus in outpatient medical organizations in St. Petersburg and the Leningrad region was carried out by analyzing primary medical records for 175 cases. RESULTS: The quality of medical care is recognized as appropriate only in 25% of the cases. The errors in collecting information were the most common (95% of the cases of poor quality medical care): in cases of hypertension and type 2 diabetes mellitus no information about the course of the disease, previous treatment, risk factors, anthropometry, ophthalmoscopy or referral to an ophthalmologist; neurological examination and assessing cognitive functions - in the patients with hypertension; foot examination – in the patients with diabetes. The most common defects of the examination included the absence of lipidogram, uric measurement and electrolyte levels in hypertension, determination of albuminuria in diabetes mellitus, electrocardiography and echocardiography. Diagnosis errors were detected in 7–15% of the cases, treatment defects — in 33–53%. The information collection error is the most common defect in case of the patients with hypertension and type 2 diabetes mellitus, which is comparable with the previously published data. Treatment errors mainly consisted in the absence of lifestyle modification recommendations necessary for the treatment of hypertension and type 2 diabetes mellitus since these measures reduce the risk of complications and improve the prognosis.The revealed defects in medication therapy were comparable to the previous data and consisted in the appointment of insufficient doses of medications and in the use of monotherapy in the presence of indications for combination therapy. CONCLUSIONS: The assessment of the medical care revealed an insufficiently high level of outpatient medical care for the patients with hypertension and type 2 diabetes mellitus, which requires a detailed analysis of the causes for future prevention.

Neuroprotective component of outpatient rehabilitation of patients with lumbosciatica and depression

The aim of the study was to investigate the effectiveness of including cytoflavin in complex outpatient rehabilitation therapy for patients suffering from lumboschialgia and depression .Material and methods. 86 patients (38 men and 48 women, average age — 53.2 ± 5.9 years) with lumboschialgia and depression were examined. All patients underwent dynamic somatic and neurological status examination (before and after therapy), laboratory and instrumental studies were performed. To assess the neurological profile, the following were used: digital rating scale (DRS) of pain, Oswestry questionnaire (version 2.1a), hospital anxiety and depression scale (HADS), CGI-S scale, DN4 and SF-36 questionnaires. All patients underwent dynamic diagnostics of spinal mobility using the following parameters: Thomayer test (spinal flexion, distance floor – fingers (FF)), distance fingers legs (FL), backward bend while standing and lying on the stomach. In addition to standard treatment, patients in the main group (n = 44) were prescribed cytoflavin: 2 tablets 2 times a day regardless of food intake, 30-day course. The subjects from the control group (n = 42) received only standard treatment.Results. Inclusion of cytoflavin in the regimens contributed to a more pronounced reduction in pain syndrome compared to the control group: by 5 times according to the Oswestry questionnaire (version 2.1a), by 1.7 times versus 1.3 times according to the DN4 questionnaire, respectively (p < 0.05). The disappearance or significant reduction of pain syndrome contributed to the expansion of motor activity due to the increase in mobility in the spine — a more pronounced positive dynamics in terms of extension: 34.2 % and 22.9% in the main group versus 15.9% and 17.7% in the control group (p < 0.05). The inclusion of the drug contributed to a more significant reduction in neurological symptomatology disorders than in patients in the control group: anxiety indicators (according to the HADS scale) in the control group decreased by 5.3 times, while in the control group they decreased only by 1.75 times (p < 0.05); signs of depression — by 2 and 1.5 times, respectively (p < 0.05). At the same time, the subjects to a greater extent noted a decrease in fatigue, an improvement in night sleep, an increase in activity and performance. The effectiveness of the presented outpatient rehabilitation scheme was confirmed by the positive dynamics of the patients’ quality of life indicators on all SF-36 scales: the most significant increase on the scales of “role functioning due to physical condition” and “pain intensity” — on average by 25.9 points in the control and 26.3 points in the main, respectively (p ≥ 0.05).Conclusion. The inclusion of cytoflavin in the complex treatment of patients with this pathology helps to reduce the intensity of pain, increase spinal mobility and eliminate the neuropathic component, which improves the quality of life of patients. The results obtained can serve as a basis for further research in this area.

New onset of ataxic dysarthria with CSF overdrainage syndrome: A case report

Cerebrospinal fluid (CSF) overdrainage syndrome occurs when excessive CSF drainage from the cranial cavity results from a spinal CSF leak or overdrainage through a ventriculoperitoneal (VP) or lumboperitoneal (LP) shunt. Symptoms include severe orthostatic headache, worsening with sitting or standing but improving when recumbent. The headache is typically dull, throbbing, and bilateral and may be exacerbated by Valsalva maneuver, coughing, or straining. Additional symptoms can include dizziness, nausea, vomiting, gait disturbances, diplopia, back pain, and seizures. We present a case of overdrainage syndrome following LP shunt placement for idiopathic intracranial hypertension in a 38-year-old woman with Ehlers–Danlos syndrome (EDS). One year post-surgery, she reported worsening headaches and nausea after prolonged upright positioning. Neurological examination revealed cerebellar dysfunction, including dysdiadochokinesia, intention tremor, and ataxic dysarthria. This condition gradually emerged 6 months post-LP shunt placement and was attributed to chronic overdrainage. After 1 day of observation, the patient underwent surgery to clamp the LP shunt outflow, resulting in overnight symptom resolution, including ataxic speech. This case underscores the importance of recognizing ataxic dysarthria in conjunction with low intracranial pressure syndromes, particularly in patients with EDS. It emphasizes the need to be aware of the diverse clinical manifestations of EDS and their relationship to altered CSF pressure syndromes.

Case report: A CLCN1 complex variant mutation in exon 15 in a mixed-breed dog with hereditary myotonia

At 4 months of age, a male dog was presented with a complaint of a stiff gait following a startle response. Neurological examination revealed no deficits, but clinical myotonia was easily induced upon requesting the patient to jump. Additionally, myotonia of the upper lip muscles was observed upon manipulation. Hereditary myotonia was suspected, and electromyography confirmed the presence of myotonic potentials. Genetic testing of the myotonic patient identified a complex of mutations, including c.[1636_1639 delins AACGGG] and c.[1644 A>T], both located in exon 15 of the CLCN1 gene leading to the formation of a premature stop codon. Genetic investigations of the mother and four littermates revealed that, except for one littermate who was wild type, all others carried a copy of the mutated gene. To the best of the authors' knowledge, these mutations have not been previously reported.

Effects of acepromazine, xylazine and propofol on spinal reflexes in healthy dogs.

In the neurological examination, it is crucial to identify the possible location of the lesion in order to determine the appropriate treatment process. In aggressive animals, chemical restraint may be necessary due to their non-cooperative behaviour. However, sedatives may distort the results of examinations. Therefore, a drug should be found that has minimal impact on the examination results. To investigate the effects of acepromazine, xylazine, and propofol on spinal reflexes in healthy dogs. In a randomized, blinded study, ten native adult mixed-breed dogs were participated in three groups with a 1-week washout period between each group. Before performing each step, the spinal reflexes were evaluated. Then, in the first group, acepromazine (0.05mg/kg, IM), in the second group, xylazine (1mg/kg, IM), and in the third group, propofol (3mg/kg, IV for initial bolus and 0.1mg/kg/min for maintenance) were injected for sedation. The spinal reflexes were reevaluated at maximum sedation and at 15, 30, and 45 min thereafter. Acepromazine increased the patellar reflex and decreased the panniculus reflex. Xylazine increased the cranial tibial reflex and decreased the panniculus reflex, while propofol decreased the withdrawal, and extensor carpi radialis reflexes, and suppressed the palpebral and gag reflexes. The drugs used in the present study did not have a significant impact on the most important reflexes evaluated in neurological examinations. Among the drugs, acepromazine has the least effects compared to other drugs, making it a suitable choice for sedation.

The p.D417N variant of TUBB4A as a possible cause of hereditary spastic paraplegia: a case report

BackgroundTubulins are dimeric proteins expressed in all eukaryotic cells, serving as the fundamental building blocks of microtubule filaments. The TUBB4A gene encodes the protein β-tubulin. Mutations of TUBB4A have been associated with two neurodegenerative diseases with very different clinical characteristics: dystonia type 4 (DYT4) and Hypomyelination with Atrophy of the Basal Ganglia and Cerebellum (H-ABC). Several cases of patients with H-ABC or unclassified leukoencephalopathy show spastic ataxia with or without leukodystrophy in association with mutations in exon 5 of TUBB4A gene.Case presentationWe report the case of a 65-year-old woman who has been complaining of progressive difficulty in walking since childhood. The neurological examination revealed, among all, a spastic gait, difficulties in standing on the toes and heels, brisk deep tendon reflexes at upper limbs, clonic patellar reflexes, brisk ankle reflexes, as well as bilateral Babinski and Hoffmann sign, brisk jaw jerk and severe lower limb spasticity. NGS studies for inherited cases of spastic paraplegia revealed a novel variant of unknown significance (VUS) (c.1249A > G, p.D417N), in TUBB4A. To the best of our knowledge, this variant has not been reported in the literature or any databases in association with these diseases.ConclusionWe report the case of a patient carrying a variant of uncertain significance (VUS) of the TUBB4A gene, showing a progressive, spastic paraparesis, supporting the extension of the phenotypic spectrum up to include spastic paraplegia.

Neurobrucellosis complicated with cerebral venous sinus thrombosis in a young Syrian male: a case report

Introduction and importance Neurobrucellosis occurs when Brucella affects the nervous system and it has several presentations. One of its rarest complications is cerebral venous sinus thrombosis (CVST). Case presentation: A 16-year-old male patient complaining of a sudden onset of bilateral pulsatile headache accompanied by fever, dizziness, nausea, vomiting, and blurred vision. On neurological examination the patient had neck stiffness and a bilateral 2nd degree papilledema. Brain computed tomography did not reveal any space-occupying lesions. Lumbar puncture showed an elevated lymphocyte count in the CSF and the Brucella PCR was positive. MRI with contrast and magnetic resonance venography revealed a left transverse sinus thrombosis and a diagnosis of neurobrucellosis complicated with CVST was made. Discussion: CVST is a rare but serious complication of neurobrucellosis, it has been described in only a handful of cases. The diagnosis mainly consists of establishing the presence of neurobrucellosis using the CSF analysis and the Brucella PCR, and proving the existence of CVST using the brain MRI. Although, the management of this complication remains a controversy, the use of an antibiotic combination and anticoagulation therapy may improve the symptoms greatly. Conclusion: Although Brucella seldom affects the nervous system, with CVST being an extremely rare complication. Physicians should consider brucella as the cause of CVST, in endemic areas. Usually, it is treated with a combination of antibiotics. However, anticoagulation should be considered in some cases and future studies must be conducted to assess the role of anticoagulation treatment.

Reperfusion injury case following cervical fusion with OPLL: a case report and literature review

IntroductionSpinal cord ischemic reperfusion injury is characterized by an abrupt decline in neurological function and only a few cases have been published in literature. Herein, we present a white cord syndrome following anterior decompression cervical fusion.Case ReportA 54-year-old Jewish male patient was diagnosed with disc herniation among the intervertebral discs at C2, C3, C4, C6, and C7, along with ossification of the posterior longitudinal ligament, pressuring more to the right side of the spinal canal, ruling-out cervical myelopathy. Under general anesthesia and multimodal intraoperative monitoring, he underwent laminectomy surgery from C3 to C6 and cervical fixation from C3 to C7. No blood pressure fluctuations occurred during surgery, and complete pressure release was achieved on the spinal cord and the nerve roots. In addition, neuromonitoring did not indicate any nerve damage during the surgery. A neurologic exam in the post-anesthesia care unit revealed weakness in his right hand and leg. A brain computed tomography scan ruled out cerebrovascular accident, neck computed tomography revealed optimal implant position, and magnetic resonance imaging ruled out spinal cord distress or injury. We treated him with intravenous fluids, steroids, painkillers, and anticoagulants. Following surgery, we involved the occupational therapy department. After a few days, we observed a significant improvement in motor function in the right leg; however, there was no change in the right hand.ConclusionWhite cord syndrome likely arises from reperfusion injury subsequent to surgical decompression of a compressed spinal cord segment. Although infrequent, it is imperative for spine surgeons to recognize this potential complication and apprise patients of it prior to the procedure.

FLAIR-Hyperintense Lesions in Anti-MOG-Associated Encephalitis with Seizures: A Case Report

Introduction: Myelin oligodendrocytic glycoprotein antibody-associated disease (MOGAD) is an immune-mediated demyelinating disorder of the central nervous system. We described, a case of encephalitis associated with anti-MOG antibodies with hyperintense lesions on FLAIR and seizures (FLAMES). Case Report: We report a case of a 5-year-old girl, with no significant personal or family history, who entered the emergency room with paroxysmal events and anarthria, in a febrile context. On neurological examination she presented right sided facial paresis and pyramidal signs on the right. Lumbar puncture (LP), showed pleocytosis, hyperproteinorrhaquia and the absence of oligoclonal bands. Electroencephalogram revealed encephalopathy and slow paroxysmal left frontal activity. The brain MRI detected hyperintense lesions, however, with an area of left frontal cortico-subcortical hyperintense signal on T2/FLAIR and diffusion restriction. Anti-MOG antibody was detected. These findings pointed to the diagnosis of FLAMES. She completed 7 days of methylprednisolone (30mg/kg/day), with a good response. On the day of discharge, a repeat EEG was conducted, demonstrating significant improvement compared to the initial one, with slightly slow wake and sleep patterns for her age, and no evidence of epileptic activity. She was assessed approximately four months post-hospitalisation and was found to be asymptomatic, with no focal neurological deficits. A further EEG was performed, which showed a structurally age-appropriate wake and sleep pattern with no abnormal graphoelements. Conclusion: We highlight a rare clinical-radiological entity, which is still poorly described, particularly in the paediatric population, known as FLAMES, with a favourable response to steroids. Early recognition and timely diagnosis of his condition improve clinical and therapeutic management and minimize neurological damage. Immediate initiation of appropriate treatment is important for achieving a favorable outcome.

Case Report: Unmasked: Deceptive pediatric spinal meningioma

Introduction Pediatric meningiomas are rare tumors originating from the meninges’ arachnoid cap cells, representing a small fraction of all meningiomas. The clinical presentation of pediatric meningiomas varies widely depending on their location within the central nervous system. We report a case of pediatric spinal meningioma revealed by gait disturbance. We emphasize clinical and imaging features, as well as therapeutic management of spinal meningiomas. Case presentation We present the case of a 15-year-old boy with a one-year history of chronic thoracic back pain, worsening gait disturbances, and difficulty walking. Neurological examination revealed a spastic gait with increased muscle tone and bilateral pyramidal syndrome. Magnetic resonance imaging (MRI) demonstrated a posterior intradural extramedullary mass at the T6-T7 level, causing dorsal spinal cord compression. The patient underwent complete resection of the tumor, and histological examination confirmed the diagnosis of a WHO grade I psammomatous spinal meningioma. Conclusion This case highlights the clinical and imaging characteristics of spinal meningiomas in pediatric patients. MRI remains the gold standard for diagnostic imaging, effectively narrowing down differential diagnoses. However, a definitive diagnosis requires histological examination. The primary therapeutic approach for pediatric meningiomas is surgical resection.

Cerebral Embolic Protection by Geographic Region

Transcatheter aortic valve replacement (TAVR) is an established treatment option for many patients with severe symptomatic aortic stenosis; however, debris dislodged during the procedure can cause embolic stroke. The Sentinel cerebral embolic protection (CEP) device is approved for capture and removal of embolic material during TAVR but its efficacy has been debated. To explore regional differences in the association of CEP utilization with stroke outcomes in patients undergoing TAVR. This post hoc analysis of a prospective, postmarket, randomized clinical trial evaluating TAVR performed with or without the CEP took place at 51 hospitals in the US, Europe, and Australia from February 2020 to January 2022. Patients with symptomatic aortic stenosis treated with transfemoral TAVR were included. Randomization was stratified according to center, operative risk, and intended TAVR valve type. Patients were excluded if the left common carotid or brachiocephalic artery had greater than 70% stenosis or if the anatomy precluded placement of the CEP device. Data for this post hoc study were analyzed from August to October 2024. TAVR with or without CEP. The primary end point was the rate of all stroke events at hospital discharge or 72 hours post-TAVR, whichever came first. Neurological examinations were performed at baseline and postprocedure to identify stroke, disabling stroke, and other neurological outcomes. The Stroke Protection With Sentinel During Transcatheter Aortic Valve Replacement (PROTECTED TAVR) trial enrolled and randomized 3000 patients (1803 [60.1%] male; mean [SD] age, 78.9 [7.8] years): 1833 in the US cohort (TAVR alone: 919, TAVR with CEP: 914) and 1167 patients in the outside the US (OUS) cohort (TAVR alone: 580, TAVR with CEP: 587). Patients in the US cohort were younger, more predominantly male, had a lower prevalence of atrial fibrillation, and had a higher prevalence of bicuspid aortic valve, diabetes, and peripheral vascular disease compared with the OUS cohort. In the main trial, the incidence of stroke within 72 hours after TAVR or before discharge did not differ significantly between the CEP group and the control group, and there was no interaction by geographic region. In this post hoc analysis, patients treated with CEP in the US cohort exhibited a 50% relative risk reduction for overall stroke and a 73% relative risk reduction for disabling stroke compared to TAVR alone; a treatment effect on stroke risk reduction was not observed in the OUS cohort. The PROTECTED TAVR trial could not show that the use of CEP had a significant effect on the incidence of periprocedural stroke during TAVR. Although there was no significant interaction by geographic region, this exploratory post hoc analysis suggests a trend toward greater stroke reduction in the US cohort but not in the OUS cohort. These findings are hypothesis generating, and further research is needed to determine if regional differences in patient characteristics or procedural practices affect CEP efficacy. ClinicalTrials.gov Identifier: NCT04149535.

Evaluation of the relationship between thrombophilia gene mutations and demographic data, imaging findings and stroke subtypes in young patients followed up with a diagnosis of stroke

Aims: A stroke is defined as a focal or generalized neurological deficit that develops suddenly, lasts for more than 24 hours, or ends in death within this period, with a cause other than a vascular cause. Stroke is among the leading causes of morbidity and mortality in the general population. In our study, we examined the prevalence of all prothrombotic gene mutations observed in patients with and without predisposing risk factors for young patients with stroke and discussed their roles in stroke formation in the context of existing literature. Methods: In the present study, we conducted a retrospective review of the medical records of 300 patients aged 18 to 49 years who were hospitalized in the neurology clinic of our hospital between June 2023 and June 2024 and diagnosed with acute arterial ischemic stroke based on anamnesis, neurological examination, and radiological imaging (CT and MRI) results. The study cohort comprised 47 patients (23 males, 24 females) aged between 18 and 49 years with a diagnosis of ischemic stroke. In our study, we examined ischemic stroke-related gene polymorphisms in patients with early-onset ischemic stroke (before the age of 50 years). This study aims to investigate the prevalence of Factor V-Leiden, prothrombin-G20210A, methylenetetrahydrofolate reductase (MTHFR) C677T, MTHFR A1298C, SERPIN 1, and Factor II polymorphisms in young patients with ischemic stroke. Results: A total of 47 patients, comprising 23 males and 24 females, were included in the study. The mean age of the patients was 40.34 ± 6.37 years. According to the TOAST classification system, 17 patients (36.2%) were diagnosed with large artery atherothrombosis, one patient (2.1%) had a cardioembolic infarction, and 29 patients (61.7%) had a small artery occlusion. In our study, when evaluating the thrombophilia mutation subtypes in young ischemic stroke patients, 23.4% (n=11) of the patients were found to be heterozygous for the FVL mutation, while 76.6% (n=36) had no mutation. Concerning the SERPIN 1 mutation, 40.4% (n=19) of the patients were heterozygous, 23.4% (n=11) were homozygous, and 36.2% (n=17) exhibited no mutation. The distribution of patients according to MTHFR C677T mutation revealed that 57.4% (n=27) were heterozygous, 19.1% (n=9) were homozygous, and 23.4% (n=11) had no mutation. Considering the distribution of patients according to the MTHFR A1298C gene mutation, a total of 38.3% (n=18) of the patients were heterozygous, 14.9% (n=7) were homozygous, and 46.9% (n=22) had no mutation. Upon analysis of the distribution of patients according to factor XIII mutation, it was identified that 19.1% (n=9) were heterozygous, 2.1% (n=1) were homozygous, and 78.7% (n=37) of the patients exhibited no mutation. Upon analysis of the distribution of patients according to prothrombin (Factor II) mutation, it was identified that 8.5% (n=4) were heterozygous, while 91.5% (n=43) exhibited no mutation. Conclusion: Although stroke is less prevalent in young adults, the underlying etiology is highly varied. Further research, including the investigation of genetic and prothrombotic mutations, is vital for the prevention of recurrent strokes in young adults.

Telehealth of Infants at Risk During the COVID-19 Pandemic: Physical Therapists’ and Caregiver’s Perceptions and Costs

Aim We aimed to describe telehealth used to detect infants at risk of neurodevelopmental delay and assess the assessors’ and caregivers’ perceptions and costs. Methods This was an observational study in which five physical therapists applied the General Movement Assessment, the neurological exam based on the Hammersmith Infant Neurological Examination, and the Alberta Infant Motor Scale via telehealth in 65 infants at risk of neurologic delay during the COVID-19 pandemic. The perceptions of assessors and caregivers were assessed using a questionnaire. We tabulated the family’s costs (internet access) and the therapist’s expenses (internet access and professional fees). Results In general, assessors felt comfortable and reported good quality of teleassessment. They highlighted the significant effort they and caregivers required for synchronous methods, challenges in clearly guiding caregivers on infant positioning, difficulties in adjusting the camera’s position, and unstable internet connections. Most assessors expressed a willingness to continue using telehealth. Caregivers displayed high satisfaction, and the costs were minimal. Conclusion Teleassessment during the COVID-19 pandemic was feasible, although implementing this method of health service in general clinical practice still requires further scrutiny.

The impact of intravenous agitated saline contrast echocardiography on subclinical neuronal injury determined by neuron-specific enolase

Abstract Introduction Patent foramen ovale (PFO) is a congenital defect in interatrial septum with 25-30% prevelance. Diagnostic methods include transesophageal echocardiography (TEE), magnetic resonance imaging (MRI), and computed tomography (CT), but transthoracic echocardiography (TTE) is the primary diagnostic method. TTE involves the injection of agitated saline intravenously, and the passage of microbubbles from the right atrium to the left atrium is monitored. The reliability of this method has been questioned in various case series, with a low incidence (0.062%) of generally transient, mild clinical cerebrovascular events reported. Silent cerebral ischemia (SSI) is asymptomatic, radiographically identified acute neuronal damage. SSI is associated with an increased risk of stroke, dementia, and cognitive impairment. Neuron-specific enolase (NSE) with high specificity for neural cells can be used to detect SSI. While symptomatic patients have been evaluated in reported case series, there is no study determining the relationship and reliability of intravenous agitated saline echocardiography (SCE) with SSI. This study aims to determine whether TTE, performed on patients with PFO without neurological history and a healthy control group, can cause SSI by evaluating NSE with SCE. Materials and methods 52 patients undergoing SCE for color flow through interatrial septum or prominent interatrial septal aneurysm and are diagnosed with PFO were included. Additionally, 51 control patients without detected PFO or ASA were also included. Serum samples were taken from the patients before and 12 hours after the SCE test, and NSE levels were measured by the ELISA method. Results The mean baseline NSE level was 12.7 ng/mL with a median of 5.3 ng/mL in the PFO group, and in the control group, the mean was 9.1 ng/mL with a median of 6.4 ng/mL. At 12 hours, the mean NSE levels in the PFO group were 9.8 ng/mL with a median of 6.6 ng/mL, and in the control group, the mean was 12.7 ng/mL with a median of 5.8 ng/mL. The increase in NSE levels after SCE, was not statistically significant when comparing the PFO and control groups (p=0.77). No relationship was found between age, presence of interatrial septal aneurysm, presence of mitral annulus calcification, the number of bubbles passed in the SCE test, and the basal and 12-hour change in NSE levels (p=0.926). NSE level changes were found to be correlated between groups (p<0.001). Conclusion This study is the first to evaluate whether SCE causes subclinical neuronal damage. Our study suggests that when evaluated with NSE, the SCE method is safe and does not cause subclinical neuronal damage in patients without underlying neuronal susceptibility.results

Meningeal Dissemination and Drop Metastasis From Glioma Presenting With Non-Epileptic Myoclonus and Minipolymyoclonus

We describe the case of a 36-year-old woman with a past medical history of low grade right frontal lobe glioma and focal epilepsy presenting with subacute, progressive, multifocal myoclonus and neck and back pain. Unlike her typical seizures, the myoclonus exhibited a distinct semiology, involving both positive and negative muscle jerks affecting multiple limb muscles while sparing the face. In addition, neurological examination revealed low-amplitude, arrhythmic movements of the hands and fingers, resembling minipolymyoclonus. There were no other neurological exam findings, including mental status changes, extrapyramidal signs or signs of myelopathy. Brain and spine MRI indicated leptomeningeal and spinal “drop” enhancing lesions, suggesting likely malignant evolution of the glioma. EEG ruled out a cortical origin of the myoclonus. Pharmacological trials with benzodiazepines and other antiepileptic medications were ineffective. The patient’s myoclonus was most likely spinal segmental in origin from meningeal spread of glioma. The spinal roots or anterior horns of the spinal cord may have represented a focus of hyperexcitability responsible for generating minipolymyoclonus. Our case expands the etiological spectrum of non-epileptic myoclonus and minipolymyoclonus to encompass meningeal carcinomatosis and drop metastases from glioma. These cases may occur even without overt signs of myelopathy. Recognizing such presentations holds significance due to the poor prognosis associated with meningeal spread of glioma and the limited response of non-epileptic myoclonus to symptomatic treatments.

Atypical posterior reversible encephalopathy syndrome following craniotomy for a metastatic lesion: illustrative case.

An 80-year-old male was found to have a metastatic lesion in his cerebrum. He underwent uncomplicated resection with prolonged inhalational anesthesia due to issues with intravenous access prior to surgery. Postoperatively, the patient had persistent altered mental status. Immediate postoperative head computed tomography and continuous electroencephalography were negative for possible causes. Standard brain magnetic resonance imaging (MRI) after metastatic resection demonstrated the development of edema in his pons and thalami, concerning for posterior reversible encephalopathy syndrome (PRES). Tight blood pressure control was initiated. His neurological examination returned to baseline. Follow-up MRI showed the resolution of edema. This is a report of PRES hypothesized to be attributable to prolonged inhalational anesthetic. PRES is a disorder in which patients present with altered mentation, seizures, visual impairment, or headache. PRES often occurs due to acute uncontrolled hypertension; however, other conditions, including autoimmune disease and cancer chemotherapy, have been linked. In severe cases, permanent brain damage and death have been reported. The authors present a case of PRES as the cause of severe neurological decline following craniotomy without severe or sustained hypertension. The authors hypothesize that PRES could be caused by blood pressure variability in the perioperative period and prolonged anesthesia. https://thejns.org/doi/10.3171/CASE24245.

Magnetic Resonance Imaging Parameters in the Subacute Phase after Traumatic Cervical Spinal Cord Injury: A Prospective, Observational Longitudinal Study. Part 1: Conventional Imaging Characteristics.

Magnetic resonance imaging (MRI) remains the gold standard for evaluating spinal cord tissue damage after spinal cord injury (SCI). Several MRI findings may have some prognostic potential, but their evolution over time, especially from the subacute to the chronic phase has not been studied extensively. We performed a prospective observational longitudinal study exploring the evolution of MRI parameters from the subacute to chronic phase after human traumatic cervical SCI. The study, conducted between 2016 and 2021, involved standardized neurological examinations and MRI scans 1 month, 3 months, and 1 year after SCI. The study cohort comprises 52 patients with cervical SCI. Patients were classified into AIS grades (American Spinal Injury Association Impairment Scale), and neurological recovery was assessed using the Integrated Neurological Change Score. The MRI protocol included various routine sequences, allowing the evaluation of established parameters such as intramedullary hemorrhage, lesion dimensions, maximum spinal cord compression, and various grading scales. The persistence of intramedullary hemorrhage one month after injury was associated with worse lower extremity motor scores and pinprick values after 3 months, and also in the chronic phase. In addition, dorsal column T2-weighted hyperintensities detected 3 months post-injury and in the chronic phase were related to lower pinprick sensory scores. The basic score and Sagittal Grade at 1 month were predictive for motor function 3 months after SCI and for neurological recovery between 1 and 3 months after injury. The study contributes valuable insights into the utility of routine MRI sequences for evaluating traumatic cervical SCI during the subacute to chronic phase. The identified MRI parameters and scores offer prognostic information and could support clinical decision-making.

Normative values and factors affecting saphenous nerve responses in a south Asian population: a cross-sectional neurophysiological study at a tertiary care hospital in Pakistan

BackgroundThe saphenous nerve, a sensory branch of the femoral nerve, is not commonly included in routine lower extremity nerve conduction studies due to a high frequency of non-recordable responses in healthy subjects. However, saphenous nerve conduction studies are sometimes utilized for the diagnostic assessment of isolated lumbosacral plexus, femoral, or saphenous mononeuropathies. Our study aims to determine normative saphenous nerve response values in a healthy Pakistani population and to investigate their associations with patient body mass index, age, and gender.MethodsThis cross-sectional descriptive study was undertaken over a 3‑month period (May to July 2021) at a neurophysiology department of a tertiary care center in Pakistan. Healthy subjects underwent neurological examination, anthropometric measurements, and bilateral SN nerve conduction studies, with recording of peak-latency, peak-to-peak amplitude and conduction velocity. Statistical analyses and linear regression were conducted to evaluate associations between nerve conduction study variables and patient characteristics. Statistical analyses were also run to assess patient characteristics affecting recordability of saphenous nerve responses. A p-value < 0.05 was considered statistically significant.ResultsAmong 117 subjects, 79.5% (n = 93) had recordable saphenous nerve responses. Median peak-latency, amplitude, and conduction velocity were 3.2 (3.0-3.3) m/s, 7.7 (5.8–9.9) uV, and 44.0 (42.0–47.0) m/s, respectively. Bilaterally absent responses were observed in 20.5% (n = 24) of subjects. Obese participants had a significantly higher number of absent saphenous responses (p = 0.033). Females had shorter peak-latency (p = 0.006) and higher conduction velocity (p = 0.012).ConclusionsSaphenous nerve responses can be used to assess unilateral femoral and saphenous nerve pathologies, provided they are recordable on the asymptomatic side for comparison. Absent bilateral saphenous nerve responses should be interpreted with caution given their prevalence in healthy individuals. Patient characteristics should be taken into consideration when interpreting recordable and nonrecordable saphenous nerve responses.

Clinical and Radiological Parameters Affecting the Yield of Routine Electroencephalography in Various Indications.

To highlight the significance of various clinical and radiological parameters in association with specific electroencephalographic (EEG) patterns in order to prioritize EEG referrals. This retrospective, cross-sectional study was conducted in the neurology department of King Fahad University Hospital, Alkhobar, and involved a review and analysis of EEG and medical records pertaining to 604 patients referred for routine EEG. The data were analyzed using SPSS version 22. An association between various parameters and EEG yield was established. Factors associated with the yield of abnormal EEG patterns were diverse, like generalized tonic-clonic seizures (GTCs) (P =.05), status epilepticus (SE) (P =.05), altered level of consciousness (ALC) (P =.00), abnormal movement (P =.00), cardiac arrest (P =.00), prior history of epilepsy (P =.04), chronic renal disease (CRD) (P =.03), abnormal neurological exam (P =.00), and cortical lesions on brain imaging (P =.00). Among the abnormal EEG patterns, epileptiform activity (EA) in EEG was associated with focal seizures (P =.03), GTCs (P =.00), falls (P =.05), cardiac arrest (P =.00), a history of epilepsy (P =.00), and hypoxic ischemic injury (P =.03). Encephalopathy in EEG was also associated with focal sz (P =.02), GTCs (P =.00), SE (P =.01), ALC (P =.00), cardiac arrest (P =.00), history of stroke (P =.01), and epilepsy (P =.00). Among the studied parameters, patient level of consciousness, neurological exam findings, and neuroimaging findings, with some discrepancies, were found to be the most consistent in predicting the EEG yield. The study demonstrated the value of a proper neurological exam and careful selection of patients to gain the optimum benefit from the routine EEG.

CLCN2-related leukoencephalopathy with novel compound heterozygous variants followed with magnetic resonance imaging over 17 years: a case report

BackgroundCLCN2-related leukoencephalopathy (CC2L) is a rare autosomal recessive disorder caused by biallelic variants of CLCN2, which encodes chloride channel 2. Although CC2L is associated with distinct radiological features, it presents with a wide range of clinical features.Case presentationA 34-year-old woman presented to our hospital with a sudden onset of vertigo with headache. The patient reported intermittent headaches and tingling in both arms since the age of 31 years. On the first visit, the patient was alert and neurologically intact, except for slight hyperreflexia of the limbs without laterality. Head magnetic resonance imaging (MRI) showed high-intensity signals on axial T2-weighted fluid-attenuated inversion recovery and diffusion-weighted images bilaterally in the posterior limbs of the internal capsules, cerebral peduncles, superior and middle cerebellar peduncles, decussation of superior cerebellar peduncles, and central tegmental tract. All the patient’s symptoms were resolved or eased following supportive care. The patient stopped attending our hospital at the age of 46 years. At 51 years of age, the patient revisited our hospital because of the recurrence of vertigo, headache, and nausea. She did not present with any abnormalities by neurological examination. Head MRI showed widespread high-intensity signals similar to those 17 years ago. Genetic testing revealed compound heterozygous variants in CLCN2 (NM_004366.6): a novel variant c.1828 C > T, p.(Arg 610*) from her father and c.61dup, p.(Leu21Profs*27) from her mother. The patient was finally diagnosed with CC2L. She received supportive treatment, which made her symptoms manageable.ConclusionsThis is a detailed report of a patient with adult-onset CC2L who was successfully diagnosed and followed up with head MRI. This report provides new insights into CC2L and highlights its persistent, distinct, and stable characteristics observed in head MRI over one decade and the difficulty in forming a diagnosis without MRI when patients have minimal and common symptoms, such as in the present case.