Leg Weakness Research Articles

Early locomotor activity in broilers and the relationship with body weight gain

Fast-growing broilers are relatively inactive and this is thought to be a result of selection for high growth rates. This reduced activity level is considered a major cause of leg weakness and associated leg health problems. Increased activity, especially early in life, is suggested to have positive effects on leg health, but the relationship between early activity and growth is unclear. A clearer understanding of the relationship between activity early in life and body weight gain could help determine how selecting on increased early activity could affect body weight gain in broilers. Here, a radio frequency identification (RFID) tracking system was implemented to record daily individual broiler activity throughout life, in 5 production rounds. As mean activity levels alone do not capture the variation in activity over time, multiple (dynamic) descriptors of activity were determined based on the individual birds’ daily distances moved, focusing on the period from 0 to 15 days old. The mean, skewness, root mean square error (RMSE), autocorrelation, and entropy of (deviations in) activity were determined at the individual level, as well as the average daily gain (ADG). Relationships between activity descriptors and ADG were determined for 318 birds. Both when combining the data from the different production rounds and when taking production round and start weight into account, a negative relationship between ADG and RMSE was observed, indicating that birds that were more variable in their activity levels had a lower ADG. However, the activity descriptors, in combination with recording round and start weight, explained only a small part (8%) of the variation in ADG. Therefore, it is recommended for future research to also record other factors affecting ADG (e.g., type of feed provided and feed intake) and to model growth curves. Overall, this study suggests that increasing early activity does not necessarily negatively affect body weight gain. This could contribute to improved broiler health and welfare if selecting for increased activity has the expected positive effects on leg health.

Bilateral Cerebral Infarctions Secondary to Unilateral ICA Stenosis

A 76-year-old diabetic man presented to us with complaints of sudden-onset right-sided weakness for the last 4 days. On evaluation, he was found to have right hemiparesis (Modified Medical Research Council grade 4-/5) along with left leg weakness (4+/5). Neuroimaging revealed acute infarcts in the right anterior cerebral artery (ACA) territory and left cerebral external watershed territory. Magnetic resonance (MR) angiogram of the brain showed a hypoplastic right A1-ACA with bilateral A2-ACA arising from the left A1-ACA (bi-hemispheric A1-ACA). MR angiogram of the neck revealed significant left internal carotid artery (ICA) origin stenosis. It was concluded that the origin of right A2-ACA from left ACA was the probable because of right ACA infarcts, along with left cerebral watershed infarcts (embolic phenomenon). This represents a very important variation, as in these cases, even a unilateral ICA stenosis can lead to bilateral ACA stroke and thus necessitates urgent revascularization.

Potential Risk Factors and Association of Significant Factors of Blood Cancer in Bangladesh Using Data Mining Techniques

Cancer is now one of the leading causes of death globally and in Bangladesh. This research is focused on the blood cancer patients because there are only a few studies in Bangladesh on blood cancer. Initially, we collected 340 data (blood cancer and non-blood cancer) from BSMMU hospital. Then we use data mining to rank 30 factors associated with blood cancer. Our data mining methods include classification, chi-square (χ2) test, P-value, and association rule mining. The most potent predictors (P-value < .001) were muscle pull, inability to control the bladder, unusual bleeding, fever/raised temperature, and weakness in the legs. To predict an association between these significant elements, popular rule mining algorithms such as Apriori or Tertius are used. The results of the experiment show that weakness in the legs, fever and inability to control the bladder are common rules of blood cancer. Again, unusual bleeding, rapid illness, and muscle pull are likely to be associated. A fair skin tone with rapid breathing and leg weakness may also be a danger. Journal of Engineering Science 13(1), 2022, 9-20

ORTHOSTATIC HYPOTENSION AS A NON-MOTOR SYMPTOM OF PARKINSON’S DISEASE

The objective of our research was to raise awareness of neurologists about orthostatic hypotension (OH) in Parkinson’s disease (PD) and to explore the current approach to the problem. Materials and methods. This work was performed by searching for current information on OH in PD, reflecting the pathophysiology, classification, symptoms, diagnosis, and treatment. PubMed and Google Scholar resources were used to write the review. Results. An important task in the management of patients with PD is diagnostic and treatment of OH due to the negative impact of the syndrome on somatic, psychological and cognitive status. According to recent data, the prevalence of OH among PD patients is 30-50% [1] with no association with the stage of the disease [2]. OH in PD is neurogenic (NOH); it results from neurodegenerative damage to the central and peripheral structures of the sympathetic nervous system, which leads to reduced postganglionic release of epinephrine [3]. It is often asymptomatic, as a result of compensatory tolerance mechanisms [1]. In about of 50% of patients [4], OH is associated with supine hypertension [2] and may have a connection with REM-sleep disorders [5]. Classification features of OH include: onset period under orthostatic stress, the relationship of OH to different parts of the cardiac cycle, mechanism of pathophysiology, clinical course, presence of symptoms and clinical severity [20, 31, 32]. OH symptoms usually occur during orthostatic stress. They include dizziness, blurred vision, cognitive slowing, syncope, coat-hanger pain, difficulty breathing, leg buckling or leg weakness, general weakness and fatigue [1, 5, 17, 18]. Bedside orthostatic test with blood pressure measurement at the 1st, 3rd and 5th minutes of standing and ambulatory blood pressure monitoring (ABPM) are used for diagnosis [6]. The treatment strategy is to evaluate the medications taken by the patient and obligatory inclusion of non-pharmacological treatment. Pharmacological treatment for supine hypertension and OH is only given if necessary [1, 2]. Conclusions. OH is a widespread non-motor symptom of PD [1], which should be timely diagnosed and treated because of the negative impact on quality of life with increased risk of death and injuries due to falls [31, 32, 33]. The relationship between OH and other non-motor symptoms of PD should be further explored, and optimal therapeutic strategies for different functional classes and a combination of non-pharmacological and pharmacological treatments for OH should be found as well.

Acute leg pain and weakness in pregnancy: A new diagnosis of myotonic dystrophy

We present a unique case of a 44-year-old woman who presented at 29 weeks’ gestation with proximal limb pain and elevated creatine kinase. This occurred in the background of premature cataracts, atrial fibrillation and abnormal liver function. Clinical, pathological and neurodiagnostic findings supported a diagnosis of myotonic dystrophy, confirmed by genetic testing which revealed dystrophia myotonica protein kinase gene expansion. Muscle biopsy found both recent necrotising and chronic myopathic processes. Following delivery, the mother's myalgia resolved and creatine kinase quickly declined. The fetus was diagnosed with congenital myotonic dystrophy. We review the impact of myotonic dystrophy on pregnancy and discuss potential explanations for this patient's clinical course. This case emphasises the importance of considering myotonic dystrophy as a differential diagnosis in the right clinical context and the need for pre-pregnancy assessment and genetic counselling in women with known myotonic dystrophy.

Intramedullary schwannoma at the thoracic level in a geriatric patient: a case report

Intramedullary schwannoma, a disease that primarily occurs in middle-aged individuals, is a very rare tumor that occurs inside the spinal cord, constituting only 0.3% of spinal cord tumors. These tumors have most often been reported to involve a single lesion in the spinal cord. A magnetic resonance imaging (MRI) examination and histopathological report can confirm the diagnosis of intramedullary schwannoma. We describe a case of intramedullary schwannoma in a 71-year-old female patient. The tumor was evaluated using MRI and through a pathophysiological assessment. The lesion showed diffuse bulbous thickening with an ill-defined central signal change of the spinal cord from C6 to T6 on T2-weighted MRI. During surgery, a reddish and adhesive mass was removed. After the operation, the patient's leg weakness improved. Despite the rarity of the disease, we should consider intramedullary schwannoma as a possible tumor in the differential diagnosis of intramedullary lesions in elderly patients, for which surgical treatment should be considered.

Antibody-Positive Neuromyelitis Optica Spectrum Disorder After Second COVID-19 Vaccination: a Case Report

In the era of the COVID-19 pandemic declared in March 2020, widespread vaccination protocols were initiated to mitigate the severity and spread of COVID-19. Although COVID-19 vaccines have been generally considered safe, adverse events post-vaccination have been reported, including the development of demyelinating disease. We report a rare case of de novo aquaporin-4-positive neuromyelitis optica spectrum disorder (NMOSD) in an 80-year-old man following BNT162b SARS-CoV-2 vaccination to raise the awareness of this possible severe adverse event in an older adult. An 80-year-old South Asian man presented 2 days following his second dose of the Pfizer-BioNTech COVID-19 mRNA BNT162b2 vaccine with progressive left-sided leg weakness and numbness resulting in falls. MRI of the spine revealed a longitudinally extensive transverse myelitis from T3–T4 to T9–T10. Serum antibody testing revealed positive aquaporin-4 (AQP4) antibodies. He was diagnosed with AQP4-positive NMOSD and was treated with high-dose intravenous methylprednisolone and plasma exchange with some improvement. He was subsequently treated with mycophenolate mofetil and a slow steroid wean. This case report adds to the existing literature and suggests that COVID-19 vaccinations may trigger de novo NMOSD or NMOSD relapses in some individuals. Although rare, our patient presented with new-onset NMOSD in his 80 s following COVID-19 vaccination. As such, it is relevant to consider AQP4 testing in those presenting with a post-vaccination myelitis, regardless of age. Ongoing vaccine surveillance and research are needed to understand the risk of NMOSD post-COVID-19 vaccinations further.

0851 Longitudinal Management of Narcolepsy with Atypical presentation of Cataplexy (unilateral with symptoms only on the right side for the past 13 years)

Abstract Introduction Narcolepsy with atypical unilateral cataplexy is a rare phenotype. We would like to share single center, single patient experience over the last 13 years of managing this patient. Report of Cases: 64-year-old female diagnosed with narcolepsy with unilateral cataplexy in 2008 with MSLT. Her cataplexy syndrome has been atypical, in that it has a strictly unilateral presentation for the past 13 years, with right face, arm, and leg weakness with strong emotions(anger/laughter). Her right-side extremities go limp for a few seconds to a minute. Her cataplexy syndrome has never evolved to become bilateral or unilaterally on her left side. Her physical examination has been largely unremarkable. For Narcolepsy, was on Modafinil (2008) which was up titrated to 600 mg with no side effects, eventually switched to Armodafinil 250 mg (2013). Eventually did not control EDS fully, methylphenidate (2014) was added. The patient reported cognitive impairment with gradual memory loss on stimulants (starting in 2012) and nocturnal insomnia on methylphenidate SR. Due to worsening cognition and memory, stimulants were discontinued in 2014 and patient referred to neurology and had neuropsychiatric evaluation for memory loss. Dementia lab workup and MRI with spectroscopy were unremarkable. Due to continuation of EDS was restarted on Modafinil until May 2021. In May 2021, she reported no longer fully controlled daytime sleepiness and Pitolisant was added with improvement in ESS from 17/24 to 9/24. For the management of unilateral cataplexy, patient was well controlled initially on venlafaxine (2008), eventually up titrated with an additional dose a few times. After cognitive impairment, patient stopped refilling it in 2014 and subsequently slept better without the venlafaxine. She reported that she would fall when she got very upset/mad so learnt not to get mad at people. She had many episodes of unilateral cataplexy mainly with laughing or excitement so was started on Fluoxetine 20 mg and eventually up titrated to 40 mg. Her unilateral cataplexy symptoms have been well controlled with the addition of Pitolisant. Conclusion Management of Narcolepsy with atypical unilateral cataplexy is challenging and requires use of multiple medications with different sites of action. Support (If Any)

A Meta-Analysis on the Significance of Dietary Omega-3 Fatty Acids on Bone Development and Quality in Egg- and Meat-Type Chickens

Poultry egg and meat production continue to be optimized for productivity and efficiency. However, genetic selection focusing on production efficiency has overlooked other aspects critical to bird wellbeing, such as skeletal development. As a result, modern birds are more prone to leg weakness, osteoporosis, and, subsequently, fractures. Dietary omega-3 polyunsaturated fatty acid (n-3 PUFA) enrichment has been proposed to benefit bone development, quality, and strength. However, there is a lack of conclusive and quantitative results across studies. Therefore, a meta-analysis approach was used to evaluate published studies to determine the effects of dietary n-3 PUFA enrichment on bone quality in laying- and meat-type birds. Publications were retrieved from multiple sources (databases and hand searching), and ten studies were selected for inclusion in the final dataset. A model to predict tibial bone ash content (BAC) was developed in Proc MIXED of SAS, treating the study as a random effect. The dietary concentration of n-3 PUFA, n-3 PUFA:n-6 PUFA ratio, calcium (Ca), phosphorus and feeding duration (days) were used as independent variables to predict BAC. The final model included the dietary n-6:n-3 FA ratio and the calcium concentration in the diet. The final model was selected based on the corrected Akaike Information Criteria, the root mean square prediction error (0.999) and its components, and the concordance correlation coefficient (CCC) (0.99). In laying-type birds, BAC was reduced by n-3 PUFA (p = 0.001) but was increased by Ca (p = 0.014). In contrast, in broiler chickens, BAC was increased by n-3 PUFA (p = 0.001) and decreased by Ca (p = 0.014). The influence of n-3 PUFA:n-6 PUFA ratio on tibia BAC in laying-type birds was not statistically significant (p = 0.505), whereas in meat-type birds, the influence of PUFA ratio was significant (p < 0.05). These results may indicate a low biological significance in laying-type birds but not in meat-type birds.

Vincenzo Neri (1880-1960) and his sign to detect leg weakness due to corticospinal tract injury.

The Italian neurologist Vincenzo Neri (1880-1960), a pupil of Joseph Babiński (1857-1932), greatly contributed to refining the semiotics of neurological examination and was a pioneer in medical cinematography. In 1909, Neri proposed a sign to diagnose leg paresis due to a pyramidal tract lesion. According to Neri, if a patient standing with the legs apart and the arms crossed on the chest bends the trunk of the pelvis, when the trunk has almost reached the horizontal line, the leg on the paralyzed side flexes, whereas the unaffected leg remains extended. This sign reflects a spinal hyperfunctioning emerging after a pyramidal lesion, and should be interpreted as a part of a triple flexion reflex. Beyond the acute stage, it could reflect an unusual pattern of flexor spasticity involving the lower limb due to corticospinal tract injury. The sign described by Neri retains its validity in identifying this organic leg weakness due to pyramidal lesions, particularly when it is mild or in its early stages.

Cutoff values for the best management strategy for magnetic resonance-guided focused ultrasound ablation for essential tremor.

The efficacy of magnetic resonance-guided focused ultrasound (MRgFUS) ablation for essential tremor (ET) is well known; however, no prognostic factors have been established. The authors aimed to retrospectively investigate MRgFUS ablation outcomes and associated factors and to define the cutoff values for each prognostic factor. Sixty-four Japanese patients who underwent unilateral ventral intermediate nucleus thalamotomy with MRgFUS for ET were included. Follow-up evaluations were performed at 1 week and 1, 3, 6, 12, and 24 months postoperatively. Tremor suppression was evaluated using the Clinical Rating Scale for Tremor (CRST), and adverse effects were recorded postoperatively. Outcome-associated factors were examined preoperatively, intraoperatively, and postoperatively using multivariate analyses. The cutoff values for the prognostic factors were calculated using receiver operating characteristics. Percentage improvements in the CRST scores of the affected upper limb were 82.4%, 72.2%, 68.6%, and 65.9% at 1, 3, 6, and 12 months, respectively. Preoperatively, a high skull density ratio (SDR) (p ≤ 0.047), low CRST part B score (used to assess tremors during several tasks) (cutoff value 25, p ≤ 0.041), and nonoccurrence of resting tremors (p = 0.027) were significantly associated with improved tremor control. An intraoperatively high maximum mean temperature (cutoff value 52.5°C, p ≤ 0.047), postoperatively large lesion (cutoff value 3.9 mm in the anterior-posterior direction, p ≤ 0.002; cutoff value 5.0-5.55 mm in the superior-inferior direction, p ≤ 0.026), and small transducer focus correction (p ≤ 0.015) were also associated with improved tremor control. No valid cutoff value was found for SDR. Adverse effects (limb weakness, sensory disturbance, ataxia/walking disturbance, dysgeusia, dysarthria, and facial swelling) occurred transiently and were associated with high SDR, high temperature, high number of sonication sessions, large lesion, and occurrence of resting tremor. Patients who developed leg weakness experienced greater percentage improvement in tremors at 3 months postoperatively than those who did not. MRgFUS ablation could be used to achieve good tremor control with acceptable adverse effects in Japanese patients with ET. The relatively low SDR in Asian ethnic groups as compared with that of Western populations makes treatment difficult; however, the cutoff values obtained in this study may be useful for achieving good treatment outcomes even in such patients. Clinical trial registration no.: UMIN000026952 (University Hospital Medical Information Network). ACPC = anterior commissure-posterior commissure; AP = anterior to posterior; CRST = Clinical Rating Scale for Tremor; ET = essential tremor; MRgFUS = magnetic resonance-guided focused ultrasound; PC = posterior commissure; PSA = posterior subthalamic area; RL = right to left; ROC = receiver operating characteristic; SDR = skull density ratio; SI = superior to inferior; T2WI = T2-weighted imaging; VIM = ventral intermediate nucleus.

Idiopathic Aortic Thrombosis and Thromboembolism in Young Women

Introduction: Spontaneous aortic thrombosis causing distal embolization and acute limb ischemia is an ominous medical condition with a poor prognosis. Herein are reported the clinical courses of two women who presented with severe lower extremity ischemia caused by distal embolization of spontaneous aortic thrombus without obvious antecedent arterial disease. This unusual diagnosis should be expected in patients presenting with persistent lower extremity pain and numbness even in the absence of overt physical findings. Case 1: A 42 year-old woman with mild hyperlipidemia complained of left leg numbness and weakness. She was treated with analgesia but her symptoms worsened. Lower extremity ultrasound revealed a significant infra-inguinal perfusion defect; computed tomography revealed mural thrombus in a normal aorta along with extensive thrombotic occlusion of the left popliteal and tibial arteries. Attempts at endovascular recanalization were unsuccessful; the patient underwent successful left popliteal-to-plantar artery bypass with autologous vein. Case 2: A 57 year-old woman without medical history presented to a local Emergency Room with a five-day history of numbness in the right lower extremity. Computed tomographic angiography revealed complete infrarenal aortic occlusion in a 3 cm diameter area of mild aortic ectasia along with iliac and distal right infrainguinal thromboembolism. The patient was treated with aortobifemoral bypass grafting with right leg fasciotomy, which restored perfusion and function. Conclusion: Spontaneous aortic thrombosis causing distal embolization and acute limb ischemia is an ominous medical condition with a poor prognosis. Episodes of embolization may be intermittent and asymptomatic such that, when symptoms finally occur, the distal thrombus is often chronic and inaccessible. The diagnosis should be suspected in patients with unexplained lower extremity symptoms and pulse deficits; it can be readily established with computed tomography.

A Rare Case of Primary B Cell Lymphoma of the Spine

Spinal non-Hodgkin’s lymphomas are rare and often present late when the disease is in an advanced stage. We describe a case of primary B cell lymphoma diagnosed in a 74-year-old male, who presented with worsening back pain and unilateral leg weakness. Radiological imaging identified an abnormality within the T6 vertebral body, but analysis of initial vertebral body biopsies showed no clear evidence of malignancy. The diagnosis of high-grade B-cell lymphoma was only made following repeated bone biopsies and subsequent histopathological analysis. The patient’s care has since been transferred to Haematology and is currently undergoing intensive chemotherapy.

Neurosarcoidosis of the Cauda Equina: Clinical Course, Radiographic and Electrodiagnostic Findings, Response to Treatment, and Outcomes.

Background and ObjectivesSarcoidosis is a multisystem granulomatous disease affecting the nervous system in 3%–5% of cases. It can affect almost any component of the nervous system. Involvement of the cauda equina is an understudied phenotype, and questions remain regarding its natural history and optimal approach to management. This study aims to study the long-term clinical evolution of neurosarcoidosis affecting the cauda equina, response to treatment, and clinical and radiographic outcomes.MethodsPatients with neurosarcoidosis treated at Emory University between January 1, 2011, and December 8, 2021, were retrospectively evaluated for manifestations of cauda equina disease and included if disease of the cauda equina could be substantiated by MRI or EMG.ResultsOf 216 cases, 14 (6.5%) involved the cauda equina. The median age was 49.5 years, and most were female (85.7%) and African American (64.3%). Chronic (>28 days) presentations were most common (78.6%), but acute (<7 days, 14.3%) and subacute (7–28 days, 7.1%) were also seen. The median modified Rankin Scale (mRS) score at nadir was 3 (range 2–4). Symptoms were asymmetric in 78.6% and included leg numbness (85.7%), leg weakness (64.3%), perineal numbness (35.7%), pain (42.3%), and incontinence (21.4%). On MRI, the cauda equina enhanced in 100%, appeared nodular in 78.6%, and was diffusely involved in 71.4%. Coexisting myelitis was common (cervical 28.6%, thoracic 35.7%, and conus medullaris 28.6%). Intracranial inflammation included leptomeningitis (71.4%) and cranial neuropathies (57.1%). Electrodiagnostic studies were conducted in 3 with only one showing features consistent with a radicular process. Serum and CSF angiotensin-converting enzyme levels were elevated in 38.5% and 0.0%, respectively. CSF white blood cell and protein were elevated in 92.9%. Corticosteroids were tried in all patients with durable stabilization or improvement in only 3 (21.4%). Second-line agents associated with improvement included methotrexate/infliximab (3/4, 75%), methotrexate (3/4, 75.0%), and azathioprine (1/1, 100%). During a median follow-up of 22.5 months, the final median mRS score was 3. Relapses occurred at a median of 6 months in 21.4%. In 9 patients with MRI follow-up, 6 improved (66.7%), 1 stabilized (11.1%), and 2 worsened (22.2%).DiscussionCharacteristic features of cauda equina involvement by neurosarcoidosis include chronically delayed presentations, nodular enhancement on MRI, poor response to corticosteroids, and substantial resultant neurologic disability.

P055 Granulomatosis with polyangiitis presenting as compressive cervico-thoracic myelopathy

Abstract Background/Aims Granulomatosis with polyangiitis (GPA), a subgroup of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), is a small vessel vasculitis, characteristically associated with granulomatous inflammation. It demonstrates an increased propensity for pulmonary and renal involvement, in addition to ear, nose and throat disease. Central nervous system involvement is rare. Methods We present the case of a 64-year-old male who presented with a 6-week history of upper back pain and gradual deterioration in his gait, with associated lower limb paraesthesia and leg weakness. Results His background medical history is significant for a right sided mastoidectomy, in addition to recurrent episodes of sinusitis, with nasal crusting. He also had a history of frequent epistaxis requiring cauterisation. Neurological examination was significant for a spastic paraparesis, with MRC grade 3/5 weakness in lower limb flexors bilaterally, bilateral lower limb hypertonia, sustained clonus, hyperreflexia, and extensor plantar responses. Sensory examination revealed a mid-thoracic sensory level. Other systems examination were normal. Routine blood tests revealed normal full blood count, renal and liver indices. Inflammatory markers were elevated: C-reactive protein 43 mg/L (0-5 mg/L) and erythrocyte sedimentation rate 80 mm/hr (0-15 mm/hr). Gadolinium enhanced MRI spine and brain revealed a circumferential enhancing mass-like lesion extending from C5 to T9 with compression of the spinal cord at T2 and T3 levels, with normal brain parenchyma. There was evidence of mild sinusitis in the maxillary sinuses. CT of the thorax, abdomen and pelvis was normal. Urinalysis was normal, as was his urinary protein creatinine ratio, and there was no evidence of red cell casts. ANCA revealed a strongly positive perinuclear pattern (p-ANCA) with a markedly elevated myeloperoxidase (MPO) autoantibody, 117 (0-10 units/mL). Proteinase-3 (PR3) was negative. On identification of spinal cord compromise, the patient underwent urgent neurosurgical evaluation, and surgical exploration. During surgery, direct visualisation revealed the lesion to be solid and mass-like and samples of the tissue excised were sent for pathological analysis. Histopathological studies revealed a dense lymphocytic infiltrate, with fibrinoid necrosis of blood vessel wall consistent with vasculitis. There was no evidence of granuloma formation. A diagnosis of MPO positive GPA causing compressive myelopathy was made. He was commenced on high dose glucocorticoids which were tapered as per PEXIVAS reduced dose regimen. In tandem, he was commenced on pulsed intravenous cyclophosphamide. Within days of treatment initiation his neurological status improved, and he is currently engaging in rehabilitation. At his most recent review he was walking independently with crutches. Conclusion Our case highlights a rare cause of myelopathy but one that should enter the differential diagnosis when assessing a patient presenting with myelopathy, particularly with a mass-like lesion on neuroimaging. It should be treated aggressively and as part of the life-threatening organ involvement algorithm. Disclosure P. Harkins: None. R. Field: None. S. Hutchinson: None. R. Conway: None.

Acute Ischemic Stroke in a Young Woman with an Otherwise Asymptomatic SARS-CoV-2 Infection

It was well-observed that SARS-CoV-2 may cause a hypercoagulable state in hospitalized patients. Often these hospitalized patients exhibit severe upper respiratory symptoms with hypoxia, requiring high amounts of oxygen support. In this study, we report a young healthy 30-year-old woman with no medical problems, who experienced an embolic stroke due to an otherwise asymptomatic SARS-CoV-2 infection in July 2020. The patient presented to the emergency department after experiencing sudden slurred speech, dizziness, and acute left leg weakness during a social gathering on a river boat the day prior to admission. She also vomited once, non-bilious. The patient had no upper respiratory symptoms and had not been practicing social distancing nor wearing a mask. She did not have any sick contacts or significant travel history. Patient used oral contraceptives but never smoked. The workup included a Computed Tomography (CT) angiogram, an Magnetic Resonance Imaging (MRI) and an Magnetic Resonance Angiography (MRA) of the brain. It was significant for acute stroke with acute intraluminal thrombus causing partial occlusion of the distal basilar artery with left pontine stroke. Given that the onset of symptoms was greater than 4 hours, she was outside of the tissue Plasminogen Activator (tPA) administration window. Patient was also not a candidate for embolectomy as National Institute of Health Stroke Scale (NIHSS) was 3 and the occlusion was partial. SARS-CoV-2 PCR test was positive. D-Dimer level was elevated but CRP was normal. Echocardiogram was unremarkable. The patient had no history of autoimmune disorder. Patient was initially treated with antiplatelet medications aspirin and clopidogrel (Plavix). Her condition improved and she could ambulate with a front wheel walker and stand by to assist. She was discharged four days later with anticoagulation medication rivaroxaban (Xarelto) for 3 months. This case illustrates that patients with an otherwise asymptomatic SARS-CoV-2 infection may still suffer from complications of SARS-CoV-2. Do women on oral contraceptives have higher risk of arterial embolism when infected with SARS-CoV-2? More study is needed.

Long-term health-related quality of life and neurocognitive functioning after treatment in skull base meningioma patients.

Patients with skull base meningioma (SBM) often require complex surgery around critical neurovascular structures, placing them at high risk of poor health-related quality of life (HRQOL) and possibly neurocognitive dysfunction. As the survival of meningioma patients is near normal, long-term neurocognitive and HRQOL outcomes are important to evaluate, including evaluation of the impact of specific tumor location and treatment modalities on these outcomes. In this multicenter cross-sectional study including patients 5 years or more after their last tumor intervention, Short-Form Health Survey (SF-36) and European Organisation for Research and Treatment of Cancer (EORTC) QLQ-BN20 questionnaires were used to assess generic and disease-specific HRQOL. Neurocognitive functioning was assessed with standardized neuropsychological assessment. SBM patient assessments were compared with those of 1) informal caregivers of SBM patients who served as controls and 2) convexity meningioma patients. In addition, the authors compared anterior/middle SBM patients with posterior SBM patients and anterior/middle and posterior SBM patients separately with controls. Multivariable and propensity score regression analyses were performed to correct for possible confounders. Patients with SBM (n = 89) with a median follow-up of 9 years after the last intervention did not significantly differ from controls (n = 65) or convexity meningioma patients (n = 84) on generic HRQOL assessment. Statistically significantly but not clinically relevantly better disease-specific HRQOL was found for SBM patients compared with convexity meningioma patients. Anterior/middle SBM patients (n = 62) had significantly and clinically relevantly better HRQOL in SF-36 and EORTC QLQ-BN20 scores than posterior SBM patients (n = 27): physical role functioning (corrected difference 17.1, 95% CI 0.2-34.0), motor dysfunction (-10.1, 95% CI -17.5 to -2.7), communication deficit (-14.2, 95% CI -22.7 to -5.6), and weakness in both legs (-10.1, 95% CI -18.8 to -1.5). SBM patients whose primary treatment was radiotherapy had lower HRQOL scores compared with SBM patients who underwent surgery on two domains: bodily pain (-33.0, 95% CI -55.2 to -10.9) and vitality (-18.9. 95% CI -33.7 to -4.1). Tumor location and treatment modality did not result in significant differences in neurocognitive functioning, although 44% of SBM patients had deficits in at least one domain. In the long term, SBM patients do not experience significantly more sequelae in HRQOL and neurocognitive functioning than do controls or patients with convexity meningioma. Patients with posterior SBM had poorer HRQOL than anterior/middle SBM patients, and primary treatment with radiotherapy was associated with worse HRQOL. Neurocognitive functioning was not affected by tumor location or treatment modality.

Lower limb muscle performance during a closed chain single leg squat and a squat jump in people with leg weakness after stroke: A comparative study

Abstract Objective: To determine if the intention to perform an exercise at speed leads to beneficial alterations in kinematic and kinetic components of the movement in people with post-stroke hemiplegia. Design: Comparative study. Setting: Subacute metropolitan rehabilitation hospital. Participants: Convenience sample of patients admitted as an inpatient or outpatient with a diagnosis of stroke with lower limb weakness, functional ambulation category score ≥3, and ability to walk ≥14metres. Methods: Participants performed a single leg squat exercise on their paretic and nonparetic legs on a leg sled under three conditions: 1) self-selected speed (SS), 2) fast speed (FS), 3) jump squat (JS). Measures of displacement, flight time, peak concentric velocity, and muscle excitation (via electromyography) were compared between legs and conditions. Results: Eleven participants (age: 56 ± 17 years; median time since stroke onset: 3.3 [IQR 3,41] months) were tested. All participants achieved a jump during the JS, as measured by displacement and flight time respectively, on both their paretic (0.25 ± 0.16 m and 0.42 ± 0.18 s) and nonparetic (0.49 ± 0.36 m and 0.73 ± 0.28 s) legs; however it was significantly lower on the non-paretic leg (p &lt; 0.05). Peak concentric velocity increased concordantly with intended movement speed (JS-FS paretic: 0.96 m/s, non-paretic: 0.54 m/s; FS-SS paretic 0.69 m/s, nonparetic 0.38 m/s; JS-SS paretic 1.66 m/s, non-paretic 0.92 m/s). Similarly, muscle excitation increased significantly (p &lt; 0.05) with faster speed for the paretic and nonparetic vastus lateralis. For gastrocnemius, the only significant difference was an increase during nonparetic JS vs. SS and FS. Conclusions: Speed affects the kinematic and kinetic components of the movement. Performing exercises ballistically may improve training outcomes for people post-stroke.

Lower limb muscle performance during a closed chain single leg squat and a squat jump in people with leg weakness after stroke: A comparative study

Objective: To determine if the intention to perform an exercise at speed leads to beneficial alterations in kinematic and kinetic components of the movement in people with post-stroke hemiplegia. Design: Comparative study. Setting: Subacute metropolitan rehabilitation hospital. Participants: Convenience sample of patients admitted as an inpatient or outpatient with a diagnosis of stroke with lower limb weakness, functional ambulation category score ≥3, and ability to walk ≥14metres. Methods: Participants performed a single leg squat exercise on their paretic and nonparetic legs on a leg sled under three conditions: 1) self-selected speed (SS), 2) fast speed (FS), 3) jump squat (JS). Measures of displacement, flight time, peak concentric velocity, and muscle excitation (via electromyography) were compared between legs and conditions. Results: Eleven participants (age: 56 ± 17 years; median time since stroke onset: 3.3 [IQR 3,41] months) were tested. All participants achieved a jump during the JS, as measured by displacement and flight time respectively, on both their paretic (0.25 ± 0.16 m and 0.42 ± 0.18 s) and nonparetic (0.49 ± 0.36 m and 0.73 ± 0.28 s) legs; however it was significantly lower on the non-paretic leg (p &lt; 0.05). Peak concentric velocity increased concordantly with intended movement speed (JS-FS paretic: 0.96 m/s, non-paretic: 0.54 m/s; FS-SS paretic 0.69 m/s, nonparetic 0.38 m/s; JS-SS paretic 1.66 m/s, non-paretic 0.92 m/s). Similarly, muscle excitation increased significantly (p &lt; 0.05) with faster speed for the paretic and nonparetic vastus lateralis. For gastrocnemius, the only significant difference was an increase during nonparetic JS vs. SS and FS. Conclusions: Speed affects the kinematic and kinetic components of the movement. Performing exercises ballistically may improve training outcomes for people post-stroke.

Spinal subdural hematoma from a ventral dural puncture after percutaneous vertebroplasty: illustrative case.

BACKGROUNDPercutaneous vertebroplasty (PVP) is a common procedure, but cement leaks are not uncommon. Leakages do not always have consequences, but rarely complications do occur. Spinal subdural hematomas (sSDHs) are rare and even rarer presented as a complication after PVP. The best management for sSDH is, therefore, difficult to decide.OBSERVATIONSThe patient first received PVP for acute low back pain after falling. Cement leakages were noted after the procedure, but a sudden new-onset leg weakness only developed later. An emergency lumbar computed tomography scan showed cement leakages anterior to the dural sac; lumbar magnetic resonance imaging revealed a subdural spinal hematoma, and a decompressive laminectomy was performed. During the operation, a small cement mass in the shape of a horn was seen and was believed to have caused the sSDH. Postoperatively, the patient recovered to leg strength 5/5.LESSONSPVP is considered a low-risk procedure, and cement leaks rarely give rise to complications. However, when leakages present anterior to the dural sac, they may cause dural tear and possible sSDH, regardless of size. This possibility draws attention to keeping awareness of such rare but possible complications after routine PVP procedures. Timely intervention for sSDH is necessary to ensure meaningful recovery.