Neurological Cases Research Articles

Overcoming Barriers to Accessing Surgery and Rehabilitation in Low and Middle-Income Countries: An Innovative Model of Patient Navigation in Nepal

BackgroundInjury and disability are prominent public health concerns, globally and in the country of Nepal. Lack of locally available medical infrastructure, socioeconomic barriers, social marginalization, poor health literacy, and cultural barriers prevent patients from accessing surgical and rehabilitative care. Overcoming these barriers is an insurmountable challenge for the most vulnerable and marginalized, resulting in absence of treatment or even death.MethodsSundar Dhoka Saathi Sewa (SDSS), a non-government organization, provides a patient navigation service which facilitates referrals to tertiary centers from Nepal’s most remote areas. Specific criteria ensure that patient referrals are appropriate in regard to clinical and socioeconomic need, while comprehensive counselling helps guide the patient and family. The SDSS staff meet patients upon arrival in Kathmandu and facilitate admission to the appropriate tertiary hospital. They advocate for the patient, provide medicine, supply food and cover all treatment costs.ResultsThis project has enabled access to treatment for more than 1200 children for conditions leading to long-term disability and/or congenital heart disease. Interventions include a wide range of surgical and rehabilitative procedures such as complex orthopedics, cleft lip and palate, congenital talipes equinovarus, burn contractures, neurological cases, and cardiac surgery for valvular disease, septal defects and other congenital malformations.DiscussionThe SDSS model of patient navigation is effective in overcoming the barriers to access surgical care and rehabilitation in Nepal. The success is owed to committed international donors, capacity building, effective counselling, advocacy, compassion, and community. We believe that this model could be replicated in other LMICs.

The risk of renal and neurological complications after reconstructive surgery of the aortic arch in newborns

When reconstructing the aortic arch (AA), it is necessary to select a method that provides optimal protection of the internal organs and the brain. It was previously believed that the hypothermic circulatory method was optimal. However, recently, the application of antegrade cerebral perfusion with moderate hypothermia has proved preferable when performing reconstructive operations on the aorta on adult patients and some children. In these instances, continuous cerebral perfusion reduces the incidence of neurological complications. However, the degree of damage to the organ systems distal to the AA remains unclear.The objective of this study was to assess the effectiveness and safety of various methods for protecting the brain and internal organs during reconstructive operations on the AA in small children. A retrospective analysis of 60 patients who had received reconstructive operations on the AA was undertaken. The neurological status and the degree of damage to internal organs in the short- and long-term, combined with the application of various methods for protecting the brain, were assessed. Surgical correction of the congenital pathology of the AA under deep hypothermic circulatory arrest conditions was performed in 26 patients (Group I) and antegrade unilateral selective perfusion of the brain was used for 34 patients (Group II). Nervous system complications were detected in 28.5% of patients in Group I, whereas it affected 7.9% of patients in Group II. Thus, the odds ratio for development of the neurological case was signiϐicantly lower for Group II: 0.17 (0.06–0.69), p = 0.02. However, in this Group, patients with renal dysfunction equated to 58.7%, whereas this ϐigure was 23.7% for Group I, p = 0.02

Results of posterior only approach for adolescent idiopathic scoliosis

Introduction: Adolescent Idiopathic Scoliosis (AIS) is most common type of scolisis which is affecting girls more than boys. Affecting children between age 10 to18. AIS curves progress during radip growth period of child. Locate usually at thoracic level and involves right convex curve. Due to cosmetic reasons, pain and in some cases due to neurological involvement such cases needs operative involvement. In this study involves 20 such patients operated with posterior spinal approach and fixation for the same and followed up for one months for radiographic and clinical outcomes.Materials and Methods: 20 patients out of which 5 male and 15 female with AIS were managed with posterior spinal pedicle screws instrumentations and follow-up with various criteria regarding its outcomes such as postoperative pain relief, cobb’s angle, average screws insertion, average level of fixation, mean duration of surgery, blood loss, and post operative complications such as neurological deficit, infection or implant failure.Results: In this study which was done on 20 patient. Most common type of lenke’s curve is Type-1. Average Pre operative VAS score was 8.5 that Reduced to 1.9 Post operative. Average Pre operative cobb’s angle in all patients were 57.15 which is average 11.65 post operative, after 1 year of follow-up average cobb’s angle were 17.2 degrees. So average loss in correction after 1 year is 5.55. Average screw needed in this fixation is 15.6. Range minimum of 12 to maximum 19 screws required in fixation. In all 20 patients average 1.35 screws were fixed per level vertebrae. So basically, it is low density pedicle screw fixation. Average duration of surgery time is mean 6 hours 25 minutes. Range from minimum of 5 hours to max 9 hours. Mean age was 16.1. Mean blood loss was 773.5 mL. one patient developed post operative neurological deficit which progressively recovered within six months, no other significant complication in any patient was observed.Conclusion: Based upon the results obtained from this review of 20 patients of AIS with minimum one year of follow-up we suggest that the all-screw method is efficient and safe.The outcomes in three-dimensional correction are satisfactory and comparable.The curve maintenance is good with minimal loss of correction. Compared with age-matched healthy populations, these patients did present some limitations on their physical health, as assessed by the SRS-30 questionnaire.

Clinical spectrum of symptoms in cerebral Toxocariasis (Review).

Human helminth zoonosis is one of the most encountered helminthiases worldwide. Representative diseases include Toxocara canis and Toxocara cati, which are common nematodes prevalent in dogs and cats. The infiltration of these roundworms in the human body through contaminated food or nematode eggs could lead to central nervous system injury as the roundworms can cross the blood-brain barrier leading to neurotoxocariasis. Among the neurological and neuropsychological disturbances produced by Toxocara infection, in humans, the most representative are meningitis, encephalitis, myelitis and cerebral vasculitis, but asymptomatic central nervous system infection is probably the most prevalent. The present review examines the clinical symptomatology of neurotoxocariasis in case reports in the literature in the last 7 decades (1950-2020). The available evidence was retrieved from PubMed and Medline electronic databases. The present review reports the most prevalent clinical symptomatology in the cases of detected and diagnosed Toxocara infection with neuroinvasion. Thus, the present review aims to raise the awareness of neurological cases of Toxocara infection with the potential to at least establish differential diagnosis of neurotoxocariasis.

Acute and Post-Acute Neurological Complications of COVID-19.

Coronavirus disease 2019 (COVID-19) is an emerging global health emergency caused by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The global outbreak of SARS-CoV-2 infection has been declared a global pandemic by the World Health Organization (WHO). The clinical presentation of SARS-CoV-2 infection depends on the severity of the disease and may range from an asymptomatic infection to a severe and lethal illness. Fever, cough, and shortness of breath are among the most common symptoms associated with SARS-CoV-2 infection. Accumulating evidence indicates that COVID-19 patients commonly develop neurological symptoms, such as headache, altered mental status, anosmia, and myalgia. In this comprehensive literature review, we have summarized the most common neurological complications and reported neurological case studies associated with COVID-19, and neurological side effects associated with COVID-19 treatments. Additionally, the post-acute COVID-19 syndrome and long-term neurological complications were discussed. We also explained the proposed mechanisms that are involved in the pathogenesis of these neurological complications.

Clinical translation of computational brain models: understanding the salience of trust in clinician–researcher relationships

ABSTRACT Computational brain models use machine learning, algorithms and statistical models to harness big data for delivering disease-specific diagnosis or prognosis for individuals. While intended to support clinical decision-making, their translation into clinical practice remains challenging despite efforts to improve implementation through training clinicians and clinical staff in their use and benefits. Drawing on the specific case of neurology, we argue that existing implementation efforts are insufficient for the responsible translation of computational models. Our research based on a collective seven-year engagement with the Human Brain Project, participant observation at workshops and conferences, and expert interviews, suggests that relationships of trust between clinicians and researchers (modellers, data scientists) are essential to the meaningful translation of computational models. In particular, efforts to increase model transparency, strengthen upstream collaboration, and integrate clinicians' perspectives and tacit knowledge have the potential to reinforce trust building and increase translation of technologies that are beneficial to patients.

Aerospace Implications of Key Neurological Conditions.

INTRODUCTION: The neurological impact (or lack thereof) of certain medical histories and imaging findings is important to understand in the context of air and spaceflight. There are a number of neurological conditions that, if present in pilots and astronauts, carry variable (and sometimes adverse) functional implications for safety and overall mission success. In this systematic overview, the authors will refer to the relevant clinical and radiological features of brain tumors and vascular anomalies, cerebral edema and intracranial hypertension, concussion and the traumatic brain injury (TBI) spectrum, hematomas, cerebrospinal fluid circulation anomalies including hydrocephalus and sequestrations, spinal degenerative changes, and cerebral ischemia and demyelination. It is notable that these last two conditions have recently been reported to be a complication in some people with coronavirus disease 2019 (COVID-19). A paradigm for practical neurological workup of symptomatic pilots and astronauts will be discussed, as will the controversial notion of pre-emptive radiological screening (vs. not screening) in asymptomatic or clinically occult situations. The concepts of medical surveillance in the setting of known or diagnosed pathologies, and expert panel review and simulator and flight checks in complex neurological cases, are also elaborated on in this paper. We believe this overview will contribute toward the enhancement of a broad understanding of neurological conditions, their clinical workup, and their precautionary management in the setting of aviation and aerospace.Khurana VG, Jithoo R, Barnett M. Aerospace implications of key neurological conditions. Aerosp Med Hum Perform. 2021; 92(2):113119.

Disaster Neurology Update: Focus on the COVID-19 Pandemic.

In 2013, the term disaster neurology was introduced to describe a new practice opportunity for neurologists interested in providing needed, nonsurgical neurologic care in regions affected by natural or human-influenced disasters. Although previously presented as an option for interested neurologists, the coronavirus disease 2019 (COVID-19) pandemic has made it clear that every neurologist should be prepared to take on the unique challenges of disaster neurology. Examining the role of neurologists on the frontlines of the COVID-19 pandemic response represents an opportunity to review and apply key features of disaster neurology, including recognizing the categories of neurologic cases expected to be seen during a disaster, adapting inpatient and outpatient workflows, and accommodating the needs of vulnerable populations. Relating principles of disaster neurology to the response of neurologists to the current pandemic informs best practices for neurologic care as COVID-19 cases continue to surge throughout the United States and abroad.

Verification Of Molecular And Conventional Techniques Used In The Diagnosis Of Equine Herpes Virus In Some Egyptian Governorates

Equid herpesviruses (EHVs) affect equine health and can cause significant economic losses to the equine industry worldwide. In the current study, the circulation of two infectious equid herpesviruses (EHV-1 and EHV-4) among different horse populations in some farms was monitored. In the present study, 50 samples of nasal secretions and tissue homogenates from neurological disease cases, abortion, neonatal foal deaths, and 36 serum samples. Samples of swabs and organs inoculated in embryonated chiken egg and Madin darby bovine kidney cell line. 29samples were positive in egg injection but no detected CPE in cell line for three passages. DNA was extracted and subjected to conventional PCR to detect the two herpesviruses' presence using specific primers. Three isolates of EHV-1 and four were detected. One EHV-1 and two EHV-4 were subjected to phylogenetic analysis. Phylogenetic analysis confirmed the existence of the isolated EHV-1 and EHV-4. They were more closely related to other previously isolated EHV-1 and EHV-4 from Egypt and other countries. Antibodies against EHV-1 and EHV-4 were tested using ELISA. The results showed that EHV-1 and EHV-4 are endemic and can be a continuous threat for horses in the absence of vaccination programs and frequent virus reactivation.

Neuroimmunological adverse events associated with immune checkpoint inhibitor: a retrospective, pharmacovigilance study using FAERS database.

To investigate the characteristics and risk factors for neurologic adverse events (AEs) induced by immune checkpoint inhibitors (ICIs). An observational, retrospective, and pharmacovigilance study based on the FAERS database collected between January 2014 and December 2019 was conducted. ICI-related AEs were defined as adverse reactions in patients using anti-PD-1 (nivolumab and pembrolizumab), anti-PD-L1 (atezolizumab, avelumab, and durvalumab), and anti-CTLA-4 (ipilimumab and tremelimumab). Neurologic AEs previously reported to be associated with ICI were evaluated in the disproportionality analysis using the reporting odds ratio (ROR). Among 50,406 ICI-related reports, 3619 (7.2%) neurological case was found: 1985 with anti-PD-1, 372 with anti-PD-L1, 366 with anti-CTLA-4, and 896 with the combination of ICIs. In comparison to non-ICI drug use, ICI use demonstrated higher risk for neurologic complication, including hypophysitis/hypopituitarism, myasthenia gravis, encephalitis/myelitis, meningitis, Guillain-Barre syndrome, vasculitis, and neuropathy. The risk of neurologic AEs associatedwith ICI combination therapy was as high as or even higher than ICI monotherapy, most significantly in hypophysitis/hypopituitarism. The proportion of serious neurological events and death related to combination therapy has been decreasing in recent years. Older age, male and female sex, and metastasis were not significant risk factors for the incidence of neurologic ICI-related AEs. Patients at older age, with melanoma or non-small cell lung cancer, or on dual ICI therapy may be at higher risk of fatal neurologic AEs. ICI use is associated with a higher risk of neurological complications, with dual ICI therapy posing a higher risk, while older age, sex, or metastasis were not. Patients at older age, with certain cancer types, or on dual ICI therapy may be at higher risk of fatal neurologic AEs.

Shuni Virus in Cases of Neurologic Disease in Humans, South Africa.

We describe Shuni virus (SHUV) detection in human neurologic disease cases in South Africa. SHUV RNA was identified in 5% of cerebrospinal fluid specimens collected during the arbovirus season from public sector hospitals. This finding suggests that SHUV may be a previously unrecognized cause of human neurologic infections in Africa.

Long-Segmental Posterior Fusion Combined With Vertebroplasty and Wiring: Alternative Surgical Technique for Kummell's Disease With Neurologic Deficits-A Retrospective Case Series.

Purpose:Various surgical methods have been reported for Kummell’s disease with neurologic deficits. The aim of this study was to introduce long-segmental posterior fusion (LPF) combined with vertebroplasty (VP) and wiring as an alternative surgical technique.Material and Methods:We retrospectively analyzed 10 patients undergoing posterior decompression and LPF combined with VP and wiring for Kummell’s disease with neurologic deficits from January 2011 to December 2014. The radiologic outcomes included the local kyphotic angle (LKA) and segmental kyphotic angle (SKA). Clinical outcomes, including the visual analog scale (VAS), the Oswestry Disability Index (ODI) and the Frankel grade were assessed. Surgery-related complications were also evaluated.Results:The mean age of the included patients was 77 ± 8 years with a mean follow-up period of 31.4 ± 4.9 months and a mean bone mineral density of −3.5 ± 0.7 (T-score). The mean operation time was 220 ± 32.3 minutes with a mean blood loss of 555 ± 125.7 mL. The preoperative LKA and SKA were significantly corrected postoperatively (37.9 ± 8.7° vs. 15.3 ± 5.3°, p = 0.005 for LKA; 21.3 ± 5.1° vs. 7.6 ± 2.8°, p = 0.005 for SKA) without a loss of correction at the last follow-up. The VAS and ODI were also significantly improved (7.7 ± 1.1 vs. 3.0 ± 1.6, p = 0.007 for VAS; 90.3 ± 8.9 vs. 49.6 ± 22.7, p = 0.007 for ODI). The Frankel grade of all patients was improved by at least 1 or 2 grades at the last follow-up. Surgery-related complications such as intraoperative cement leakage and implant loosening during the follow-up were not observed.Conclusions:LPF combined with VP and wiring might be an effective surgical option for Kummell’s disease with neurologic deficits, especially for the elderly patients with morbidities.Level of Evidence:level IV.

SingHealth Radiology Archives pictorial essay Part 1: cardiovascular, respiratory and neurological cases.

The Singapore Health Services cluster (SingHealth) radiology film archives are a valuable repository of local radiological cases dating back to the 1950s. Some of the cases in the archives are of historical medical interest, i.e. cerebral angiography in the workup of patients with hemiplegia. Other cases are of historical social interest, being conditions seen during earlier stages of Singapore's development, i.e. bound feet. The archives form a unique portal into the development of local radiology as well as the national development of Singapore. A selection from the archives is published in 2020 in commemoration of the 20th anniversary of the formation of SingHealth, the 55th National Day of Singapore, and the 125th anniversary of the International Day of Radiology. This pictorial essay comprises cardiovascular, respiratory and neurological cases from the archives.

Implementation of next-generation sequencing for virus identification in veterinary diagnostic laboratories.

The value of next-generation sequencing (NGS)-based applications for testing purposes in human medicine is widely recognized. Although NGS-based metagenomic screening may be of interest in veterinary medicine, in particular for intensively farmed livestock species such as pigs, there is a lack of protocols tailored to veterinary requirements, likely because of the high diversity of species and samples. Therefore, we developed an NGS-based protocol for use in veterinary virology and present here different applications in porcine medicine. To develop the protocol, each step of sample preparation was optimized using porcine samples spiked with various RNA and DNA viruses. The resulting protocol was tested with clinical samples previously confirmed to be positive for specific viruses by a diagnostic laboratory. Additionally, we validated the protocol in an NGS viral metagenomics ring trial and tested the protocol on viral multiplex reference material (NIBSC, U.K.). We applied our ViroScreen protocol successfully for 1) virus identification, 2) virus characterization, and 3) herd screening. We identified torque teno sus virus and atypical porcine pestivirus in a neurologic case, determined the full-length genome sequence of swine influenza A virus in field samples, and screened pigs using pen floor fecal samples and chewing rope liquid.

Lymphocytic Choriomeningitis Virus Infections and Seroprevalence, Southern Iraq.

Acute febrile neurological infection cases in southern Iraq (N = 212) were screened for lymphocytic choriomeningitis virus (LCMV). Two LCMV IgM–positive serum samples and 2 cerebrospinal fluid samples with phylogenetically distinct LCMV strains were found. The overall LCMV seroprevalence was 8.8%. LCMV infections are common and associated with acute neurological disease in Iraq.

Lymphocytic Choriomeningitis Virus Infections and Seroprevalence, Southern Iraq

Acute febrile neurological infection cases in southern Iraq (N = 212) were screened for lymphocytic choriomeningitis virus (LCMV). Two LCMV IgM-positive serum samples and 2 cerebrospinal fluid samples with phylogenetically distinct LCMV strains were found. The overall LCMV seroprevalence was 8.8%. LCMV infections are common and associated with acute neurological disease in Iraq.

A Cluster of Neurobrucellosis at King Hussein Medical Center, Jordan - A Comprehensive Analysis And Review.

In this retrospective review, we describe the neurological clinical manifestations in five cases diagnosed with neurobrucellosis over two years between 2018 and 2020, and the application of different proposed criteria for establishing the diagnosis and treatment of neurobrucellosis. All cases were confirmed to have brucellosis with laboratory tests, and all were living in Jordan, which is considered part of a highly endemic area within the Middle East. The neurobrucellosis proposed criteria was applied, which requires signs and symptoms consistent with neurobrucellosis, presence of anti-Brucella antibodies in cerebrospinal fluid and serum with or without isolation of Brucella species in CSF and serum, cerebrospinal fluid analysis shows: lymphocytosis, high protein level, and low glucose level and radiological findings on MRI or CT. In all five cases, we have confirmed direct contact with animals or animal products either as a consumer or as a farmworker. Their signs and symptoms were consistent with brucellosis. In all cases, haematological and CSF results, in addition to imaging findings using magnetic resonance and computed tomography, were highly coherent with neurobrucellosis. Neurobrucellosis can present with different clinical manifestations, either as a sole site of infection like acute or subacute meningitis or myelitis, or in context of a multi variable systemic disease. In patients with unusual neurological clinical presentations, and those with persistent chronic symptoms like headache, malaise, or depression, neurobrucellosis should be highly suspected, especially in endemic areas. Such patients must have a prolonged course of antibiotics between 6 to 18 months with close monitoring of their serum and CSF examination

Author response: Therapeutic benefits of early electrophysiological testing in a functional neurology case.

We entirely agree with the comments expressed by Professor Hallett et al. in response to our article1 regarding the use of electrophysiology to investigate probable functional neurologic disorders (FNDs). We point out in our article that electrophysiology is typically normal in FNDs and, indeed, is important evidence to support that diagnosis. However, we also mention that a small proportion of FNDs can demonstrate transient electrophysiologic abnormalities and that these seem consistent with other reported abnormal functional imaging, perfusion, and morphometric MRI studies in this group. FNDs are unlikely to be homogeneous disorders, and it may be that these exceptional cases provide insights into underlying mechanisms. This was precisely the reason for reporting this case of abnormal electrophysiology because, in our opinion, there was very robust evidence supporting a FND diagnosis: an incongruous clinical picture, pristine MRI imaging of whole spine and brain, absence of relevant signs, presence of positive phenomena, and rapid recovery.

Reader response: Therapeutic benefits of early electrophysiological testing in a functional neurology case.

We read the article by Powell et al.1 with interest. We advocate using clinical neurophysiology to help make the diagnosis of functional neurologic disorders (FND). Such testing can improve diagnostic certainty. We agree that the testing is valuable but for the opposite reason that the authors suggest. The clinical findings themselves were suggestive of FND. The neurophysiology points to a cerebral abnormality of motor and sensory functions. Despite the normal neuroimaging, this still could have been an episode of demyelination or another disorder. Functional disorders are often seen together with other neurologic disorders,2 a situation often referred to as functional overlay. These abnormal evoked responses could be the consequence of FND. However, many more clinical neurophysiologic studies of FND have shown normal central motor and sensory conductions.3 If the findings were normal, that would be good evidence for a functional disorder. As they were abnormal, the interpretation is less certain. From a clinical point of view, the patient had positive features of FND, so it was reasonable to treat those aspects of his presentation, but not—in our view—using the clinical neurophysiology as evidence of that diagnosis.

Training in Neurology: Diagnostic Accuracy Among Neurology Residents: The "Close the Loop" Project.

To describe cases presented by junior neurology residents and to evaluate resident diagnostic patterns to help address individual and systemic educational needs. For 6 academic years, details of all morning report cases assessed and presented by junior neurology residents were logged, including the resident's independent initial diagnostic impression. Cases were later revisited at subsequent morning reports to "close the loop" on a final diagnosis. We conducted retrospective review to quantify case demographics and to determine resident diagnostic accuracy based on prespecified localization pathways. Demographic analysis included 1,472 cases; of these, 1,301 qualified for accuracy analysis due to diagnostic uncertainty at time of morning report. Non-neurologic etiologies represented 26.0% of cases. CNS etiologies were the majority (86.0%) of neurologic cases. The most frequent diagnoses were ischemic stroke and seizure. Overall resident diagnostic accuracy was 64.0%. Accuracy was similar between central and peripheral etiologies. Of 1,301 cases, 15.3% were overcalled as neurologic, while neurologic disease was rarely mistaken as non-neurologic (5.1%). Most diagnostic errors (49.1%) occurred when determining whether a case was neurologic. Where in the localization pathway errors occurred varied between etiologies. Overall diagnostic accuracy for neurology junior residents in our cohort was similar to prior work conducted in smaller samples. Analysis of errors, particularly at the critical "neurologic or non-neurologic" decision point, warrants further investigation. Close the loop methodology is simple to employ and can guide educational and quality initiatives to improve neurology resident clinical acumen.