Neurological Examination Research Articles

Neurologic Clinical, Electrophysiologic, and Pathologic Characteristics of Primary vs Secondary Neurolymphomatosis.

Neurolymphomatosis (NL) is characterized by lymphomatous infiltration of the peripheral nervous system presenting as the initial manifestation of a lymphoma (primary NL [PNL]) or in relapse of a known lymphoma (secondary NL [SNL]). This report details and compares the neurologic clinicopathologic characteristics of these 2 groups. This retrospective study was performed on patients diagnosed with pathologically confirmed NL in nerve between January 1, 1992, and June 31, 2020. Patient clinical characteristics, neurologic examination, imaging studies, EMG, and nerve biopsy data were collected, analyzed, and compared between PNL and SNL. A total of 58 patients were identified (34 PNL and 24 SNL). Time from neurologic symptom onset to diagnosis was longer in PNL at 18.5 months compared with 5.5 months in SNL (p = 0.01). Neurologic symptoms were similar in both patient groups and included primarily sensory loss (98%), severe pain (76%), and asymmetric weakness (76%). A wide spectrum of EMG-confirmed different neuropathy patterns were observed, but patients with SNL had increased numbers of mononeuropathies (n = 8) compared with PNL (n = 1, p = 0.01). MRI studies detected NL more frequently (86%) compared with fluorodeoxyglucose (FDG)-PET CT imaging studies (60%) (p = 0.007). Nerve biopsies revealed B-cell lymphoma (PNL n = 32, SNL n = 22), followed by T-cell lymphoma (PNL n = 2, SNL n = 2), with increased demyelination in both groups and increased axonal degeneration (p = 0.01) and multifocal myelinated fiber loss (p = 0.04) significant in SNL vs PNL. Identifying SNL resulted in patient treatment modifications but a worse prognosis compared with PNL (p = 0.025). While PNL and SNL are both primarily painful and asymmetric neuropathies with axonal and demyelinating features on EMG and nerve biopsy, SNL presents somewhat differently than PNL with fulminant, asymmetric often mononeuropathies better detected on MRI than FDG-PET/CT. The focal pattern of SNL is likely a result of residual cancer cells that evaded initial chemotherapy, which does not cross the blood-nerve barrier, and these cells can later recur and result in fulminant disease. Although still resulting in a poorer prognosis, identifying SNL is important because this changed treatment and management in every SNL case.

Obsessive-compulsive disorder as a first manifestation of Ataxia with Oculomotor Apraxia type 2 due to a novel mutation of SETX gene.

Ataxia with oculomotor apraxia type 2 (AOA2) is an autosomal recessive disorder presenting with cerebellar ataxia, sensory-motor axonal neuropathy, oculomotor apraxia, cerebellar atrophy and high alpha-fetoprotein (AFP) serum level. AOA2 is due to coding mutations of the SETX gene, mapped to chromosome 9q34. Seldom noncoding mutations affecting RNA processing have been reported too. To date psychiatric symptoms have never been reported in AOA2. A 19 years-old man came to our attention for progressive gait ataxia debuted five years earlier. His past medical history was unremarkable, while his parents were consanguineous. On neurological examination, he had bilateral horizontal gaze-evoked nystagmus with hypometric saccades and saccadic horizontal smooth pursuit, appendicular ataxia, limbs and trunk myoclonic involuntary movements with hands' dystonic postures and dance of the tendons. Psychological evaluation described intrusive and obsessive thoughts experienced by the patient, then diagnosed as obsessive-compulsive disorder. Blood tests detected an elevated AFP level. Brain MRI showed cerebellar atrophy, while electroneuromyography revealed an axonal sensory-motor polyneuropathy. In the suspicion of a pathology belonging to the autosomal recessive cerebellar ataxias (ARCA) spectrum disorder, a direct search of point mutations by whole-exome sequencing was performed revealing a novel biallelic variant in SETX gene (c.6208+2dupT), which was classified as likely pathogenic. The present case expands the genotypic and phenotypic spectrum of AOA2, reporting a novel likely pathogenic SETX mutation (c.6208+2dupT) and highlighting an early psychiatric involvement in AOA2, suggesting the need for psychiatric assessment in these neurologic patients.

Idiopathic intracranial hypertension following childbirth: a case report and management strategies

Introduction: A postpartum headache, also known as pseudotumor cerebri, is defined as a headache and shoulder or neck pain that occur in the first six weeks following childbirth. Common causes of headaches during puerperium include pre-eclampsia, subarachnoid hemorrhage, cerebral venous thrombosis, meningitis, brain tumors, cerebrovascular diseases, and posterior reversible encephalopathy syndrome. Pseudotumor cerebri is an extremely rare cause of postpartum severe headache with visual disturbance with or without papilledema. Case Presentation: Here we present a 32-year-old postpartum female patient who presented with a severe headache and visual disturbance for 10 days. Neurological examination did not show any focal or lateralizing deficit. However, a fundus examination showed severe bilateral papilledema. A contrast-enhanced brain MRI did not reveal a space-occupying mass lesion. MRV excluded venous occlusion. A lumbar puncture demonstrated high opening pressure of 75 cmH2O with a normal cell count and protein and glucose levels. The patient was diagnosed with idiopathic intracranial hypertension. After 8 weeks of treatment with diazomid and topiramate, the patient improved clinically and her papilledema regressed. Clinical Discussion: The occurrence of IIH is very rare among postpartum females. To our knowledge, very few cases of postpartum IIH have been reported in the medical literature. Although rare, patients with postpartum headache with visual disturbances should have a fundoscopic examination. The patient was diagnosed and managed in time, which led to significant clinical improvement and salvage of her vision. Conclusion: As described in this case, idiopathic intracranial hypertension can cause severe headaches with and without visual disturbance during the postpartum period (despite being rare in this period), it should be considered in the differential diagnosis.

Norms for neuropsychological tests in cognitively healthy French oldest old adults.

Normal aging often leads to cognitive decline, and oldest old people, over 80 years old, have a 15% risk of developing neurodegenerative diseases. Therefore, it is important to have appropriate tools to assess cognitive function in old age. The study aimed to provide new norms for neuropsychological tests used to evaluate the cognitive abilities in people aged 80 years and older in France, focusing on the impact of education and gender differences. 107 healthy participants with an average age of 85.2 years, with no neurological history or major cognitive deficits were included. A comprehensive neuropsychological assessment was performed, covering several cognitive functions such as memory, visuospatial abilities, executive functions, attention, processing speed, and praxis. Individuals with lower levels of education performed poorly on some tests and took longer to complete. Gender differences were observed, with women outperforming men in verbal episodic memory, while men showed better performance in visuoconstructive tasks. The participants showed lower performance in verbal episodic memory compared to norms established in previous French studies. In relation to executive functions, participants were slower to perform complex tasks than participants in previous studies. This study provides cognitive norms specifically adapted to the oldest old population, which differ from established norms for younger aging adults. It highlights the importance of including these norms in future clinical and scientific investigations. The findings underscore the importance of education on cognitive abilities and emphasize the need to consider gender differences when assessing cognitive functions in aging populations.

A data science-based analysis of socioeconomic determinants impacting pediatric diagnostic radiology utilization during the COVID-19 pandemic.

Research on healthcare disparities in pediatric radiology is limited, leading to the persistence of missed care opportunities (MCO). We hypothesize that the COVID-19 pandemic exacerbated existing health disparities in access to pediatric radiology services. Evaluate the social determinants of health and sociodemographic factors related to pediatric radiology MCO before, during, and after the COVID-19 pandemic. The study examined all outpatient pediatric radiology exams at a pediatric medical center and its affiliate centers from 03/08/19 to 06/07/21 to identify missed care opportunities. Logistic regression with the least absolute shrinkage and selection operator (LASSO) method and classification and regression tree (CART) analysis were used to explore factors and visualize relationships between social determinants and missed care opportunities. A total of 62,009 orders were analyzed: 30,567 pre-pandemic, 3,205 pandemic, and 28,237 initial recovery phase. Median age was 11.34years (IQR 5.24-15.02), with 50.8% females (31,513/62,009). MCO increased during the pandemic (1,075/3,205; 33.5%) compared to pre-pandemic (5,235/30,567; 17.1%) and initial recovery phase (4,664/28,237; 16.5%). The CART analysis identified changing predictors of missed care opportunities across different periods. Pre-pandemic, these were driven by exam-specific factors and patient age. During the pandemic, social determinants like income, distance, and ethnicity became key. In the initial recovery phase, the focus returned to exam-specific factors and age, but ethnicity continued to influence missed care, particularly in neurological exams for Hispanic patients. Logistic regression revealed similar results: during the pandemic, increased distance from the examination site (OR 1.1), residing outside the state (OR 1.57), Hispanic (OR 1.45), lower household income ($25,000-50,000 (OR 3.660) and $50,000-75,000 (OR 1.866)), orders for infants (OR 1.43), and fluoroscopy (OR 2.3) had higher odds. In the initial recovery phase, factors such as living outside the state (OR 1.19), orders for children (OR 0.79), and being Hispanic (OR 1.15) correlate with higher odds of MCO. The application of basic data science techniques is a valuable tool in uncovering complex relationships between sociodemographic factors and disparities in pediatric radiology, offering crucial insights into addressing inequalities in care.

Exploring the Utility of High-Resolution Ultrasonography and Color Doppler of Peripheral Nerves in Monitoring Response to Treatment in Leprosy Patients: A Prospective, Observational Study.

Diagnosis and monitoring of nerve function impairment (NFI) presents an ongoing challenge in global leprosy control. This was a prospective, observational study in leprosy patients receiving treatment with cutaneous and neurological examinations done every 3 months for 1 year. High-resolution ultrasonography and color Doppler (HRUS-CD) was performed in all patients at baseline, completion of treatment, and anytime during the study period if a patient had deterioration of nerve function noted clinically. All peripheral nerves were assessed, and parameters studied were cross-sectional area (CSA), length of thickening, endoneural flow signals (ENFS), and distortion in fascicular symmetry. Of 54 treatment-naive leprosy patients, loss of sensation was noted in 37 (68.5%), paresthesia in 20 (37.0%), and neuropathic pain in 7 (12.9%) at baseline presentation. At end of treatment of leprosy, maximum improvement in NFI across all clinical criteria was seen in ulnar and radial nerves (P <0.05). The number of impairments on HRUS-CD decreased consistently, significantly for ulnar (P = 0.009 right ulnar, P = 0.012 left ulnar) and right radial (P = 0.025) nerves, and significant improvements in CSA and ENFS were seen across multiple nerves, which correlated with improvement in NFI as well. Abnormal HRUS-CD findings in the target nerves were significantly associated with multibacillary cases (odds ratio [OR]: 4.33; 95% CI: 0.62-30.31), those in reaction (OR: 9.42; 95% CI: 1.51-58.66), and those older than 40 years (OR: 3.14; 95% CI: 0.49-19.93). This study provides objective evidence of improvement in NFI with anti-leprosy treatment, supporting integration of HRUS-CD imaging in monitoring nerve involvement in leprosy.

Unveiling the disease progression in developmental and epileptic encephalopathies: Insights from EEG and neuropsychology.

Developmental and epileptic encephalopathies (DEEs) are neurological disorders characterized by developmental impairment and epilepsy. Our study aims to assess disease progression by comparing clinical findings, electroencephalography (EEG), and neuropsychological data from seizure onset to the last follow-up evaluation. We retrospectively reviewed patients with genetic DEEs who were followed-up at the epilepsy unit of Bambino Gesù Children's Hospital, Rome. We collected information regarding gender, family history, genetic variant, age at onset and at last follow-up, neurological examination, type of seizure, drug resistance, occurrence of status epilepticus, and movement and cognitive and behavioral disorders. We compared EEG background activity, epileptiform abnormalities, and cognitive functions between seizure onset and the last follow-up evaluation using the McNemar-Bowker test (α = 5%). A total of 160 patients (94 female) were included. Genetic analysis revealed a spectrum of pathogenic variants, with SCN1A being the most prevalent (25%). The median age at seizure onset and at the last follow-up was 0.37 (interquartile range [IQR]: 0.09-0.75) and 8.54 years (IQR: 4.32-14.55), respectively. We documented a statistically significant difference in EEG background activity (p = .017) and cognitive impairment (p = .01) from seizure onset to the last follow-up evaluation. No significant differences were detected for epileptiform abnormalities (p = .2). In addition, high prevalence rates were observed for drug resistance (81.9%), movement disorders (60.6%), behavioral and autism spectrum disorders (45%), neurological deficits (31.3%), and occurrence of status epilepticus (23.1%). Our study provides evidence that a clinical progression may appear in genetic DEEs, manifesting as development or worsening of cognitive impairment and disruption of EEG background activity. These results highlight the challenging clinical course and the importance of early intervention and personalized care in the management of patients with DEEs.

Pediatric Charcot-Marie-Tooth disease and peripheral nerve blocks:a retrospective cohort study of 25 patients.

Charcot-Marie-Tooth (CMT) disease is an inherited neurologic disorder characterized by progressive peripheral neuropathies. The use of peripheral nerve blocks (PNB) in patients with CMT disease has been controversial because of concerns about exacerbating existing neurologic impairments and the "double hit" hypothesis. We aimed to assess the use of PNB in pediatric patients with CMT disease undergoing orthopedic surgery to address the limited data available in the literature on this topic. In this retrospective cohort study, we included all pediatric patients with CMT disease scheduled for orthopedic surgery receiving PNB at our centre. All of the patients had preoperative neurologic exams and received one or more ultrasound-guided regional anesthesia techniques. Data extracted included details of anesthesia technique, surgical procedure, opioid consumption, and pain scores during the first three postoperative days. We also reviewed any complications such as neurologic deficits and local anesthetic toxicity. We used descriptive statistics to summarize the findings. We included 25 patients, 14 of whom (56%) presented with pre-existing neurologic deficits, primarily in the lower extremities. Postoperative assessments revealed no new neurologic impairments in 24/25 (96%) patients, with only one patient experiencing a nerve injury possibly related to the surgical procedure. Opioid consumption was low in the postanesthesia care unit and on the day of surgery. No additional complications were noted in the first 72hr after surgery. Despite concerns, PNB showed favourable outcomes in a pediatric cohort with CMT disease, with low opioid consumption and pain scores and minimal complications during follow-up. These findings match previous reports of adult patients with CMT disease and suggest that the benefits of PNB may outweigh the perceived risks in pediatric patients with CMT disease.

A Retrospective Study on Botulinum Toxin Injection in Patients With Multiple Sclerosis Related Tremor: A Treatment Option Worth Trying

Objectives Multiple sclerosis (MS)-related tremor remains a disabling problem that often responds poorly to medical treatments. This study aims to evaluate the effect of botulinum toxin type A on MS-related upper limb tremor. Methods This retrospective observational cohort study included 8 patients who received intramuscular injections of onabotulinum toxin type A for medically refractory MS-related tremor. Hospital records before and 4–6 weeks after treatment, including the Fahn-Tolosa-Marin Tremor rating scale (FTM-TRS), electrophysiological tremor analysis, neurological examination findings, and videos, were reviewed retrospectively. Results There was significant improvement after botulinum toxin injection in the FTM TRS part A score for tremor (P = 0.011), FTM TRS part B score for hand function (P = 0.011), FTM Part score for activities of daily living (P = 0.012), and FTM TRS total score for overall evaluation (P = 0.012). Electrophysiological tremor analysis revealed maximal tremor amplitudes between 700–2000 μV (before treatment) and between 300–1000 μV (after treatment). The mean tremor amplitudes before and after treatment were 1350 μV and 725 μV, respectively. No adverse reactions were observed after botulinum toxin treatment. Conclusions BoNT may improve upper limb tremor and functionality in MS-related tremor. The treatment involved administering BoNT under EMG guidance, with careful muscle selection based on clinical assessment and EMG findings. This approach aimed to optimize treatment efficacy while minimizing potential adverse effects. Further studies are warranted to confirm these findings.

Spinocerebellar ataxia type 7: A case report

Introduction: Spinocerebellar ataxia type 7 is part of a rare group of neurodegenerative diseases, characterized by lesions in the brainstem, cerebellum, spinal cord, and retina, manifesting as motor disturbances associated with signs of pyramidal involvement and amaurosis. The dysfunction is caused by autosomal dominant genetic alterations, with disease severity and the age of symptom onset being directly linked to the patient’s genetic expression. Case Report: We present the case of a 24-year-old woman, previously healthy, who denied smoking, drinking alcohol, or taking any other drugs. She reported that approximately nine months, she had experienced a decline in dexterity for tasks requiring fine motor skills. She also exhibited impaired gait, frequent falls, and difficulties in performing basic activities of daily living (ADLs). On neurological examination, she presented with an ataxic and staggering gait, tremor during movement, dysmetria, dysdiadochokinesia, movement decomposition, dysarthria (scanning speech), dysphagia, dystasia, dysbasia, and nystagmus, all of which are indicative of cerebellar impairment. A genetic panel revealed the presence of 44 cytosine-adenine-guanine nucleotide repeat expansions on allele 2 of the ATXN7 gene, confirming the diagnosis of spinocerebellar ataxia type 7. Conclusion: In this case report, the diagnosis of spinocerebellar ataxia was established through a comprehensive assessment of the patient’s clinical history, neurological examination, imaging studies, and genetic profiling, all of which are essential for reaching a definitive diagnosis. The prognosis for this disease varies due to ongoing research into its pathophysiology. Furthermore, discussions within the scientific community regarding potential cures for this condition continue

Physical medicine and rehabilitation clinical experiences: A narrative review of curricula and educational interventions.

Physical medicine and rehabilitation (PM&R) is a specialty of medicine that focuses on function and the care of people with disabilities. Many medical schools offer PM&R content by means of PM&R clerkships for career development purposes with varying curricula and assessments; however, there is limited information regarding the optimal way to teach clinical skills relating to the field of PM&R. This narrative review study was performed to evaluate PM&R specific clinical curricular interventions. The review included a PubMed search that yielded 63 articles and a Cumulated Index to Nursing and Allied Health Literature (CINAHL) search of 175 articles. A total of 14 articles were selected for review. PM&R clerkships were found to have a variety of educational interventions, including inpatient and outpatient clinical experiences, lectures, Objective Structured Clinical Examinations (OSCEs), case discussions, written examinations, physical examination sessions, cadaver sessions, small group discussions, and virtual education. PM&R rotations can improve neurologic and musculoskeletal physical examination skills, PM&R specific knowledge, and confidence in PM&R skills. More research is needed to determine the optimal methods to teach and assess PM&R knowledge and skills in the clinical setting to drive future PM&R curriculum development and educational innovations.

Neurodevelopmental Outcomes in Children Vertically Exposed to Chikungunya Virus: A Two Years Follow-up Study.

To monitor by the first 24 months of life, children born to mothers with laboratory evidence of chikungunya virus (CHIKV) infection during pregnancy or up to 8 weeks before it, and to describe abnormalities in head circumference (HC), auditory and ophthalmological assessments and neuroimaging tests during the follow-up period. This is a observational, descriptive, longitudinal and prospective study of children born to mothers who had a rash and a positive test for CHIKV during pregnancy or up to 8 weeks before it. They were admitted between November 2015 and May 2019 in the outpatient multidisciplinary clinic to investigate acute exanthematous disease. The exposed children were followed up by a multidisciplinary team and underwent periodic measurements of the HC. The Denver II test was applied, in addition to transfontanellar ultrasound (TU) to evaluate neurodevelopmental outcomes during the study period. Ophthalmological and auditory examinations, echocardiography and laboratory tests were also included. We included in the study 27 children vertically exposed to CHIKV. All children had a negative polymerase chain reaction test for the virus collected at the first outpatient visit (mean age of 16.8 days and standard deviation of 8 days). No clinical condition compatible with congenital infection at birth was reported. A change in HC characterized by macrocephaly and mild global delay development was observed in a 1-year-old child whose mother was infected in the peripartum, but with normal TU. Changes in the TU were observed in 2 other children with nonspecific subependymal cystic malformation that was not evident by the cranial computed tomography. The other children monitored showed normal results in the Denver II test, in the HC and TU. No changes were identified on ocular ophthalmoscopy or auditory brainstem response test. Two children had an increase in serum ferritin levels during the first year of life, with the others' inflammatory disease markers normal. Our study added knowledge about the neurodevelopment of children exposed to CHIKV during pregnancy by a longitudinal and prospective follow-up, throughout their first 24 months of life. We did not observe a negative impact of exposure to the virus on the neurological examination, global developmental test or measurements of the HC of these children.

A - 44 Value of Repeat Neuropsychological Assessments in Children with Complex Birth and Neurological Injuries

Abstract Objective Extremely low birth weight, in-utero insult, and PVL are associated with an array of neurodevelopmental complications. PVL is most common in very premature. Associated complications in this case study include diffuse demyelination, cerebellar atrophy, and arthrogryposis. Data from serial assessments reveal preservation of intelligence, decoding, and social skills. Implications for the role of repeat assessments in guiding education and intervention are discussed. Method The subject was an 18-year-old male with extremely low birth weight, in-utero insult, PVL, cerebellar atrophy, delayed myelination, and arthrogryposis. His presentation also included craniosynostosis. Three outpatient neuropsychological assessments were completed over eight years. Assessments included measures of intellectual, academic, neurocognitive, and emotional functions. Results Despite multiple physical and neurological impairments, assessments revealed preserved verbal and nonverbal intelligence, phonemic awareness, computation skills, and social cognition. Deficits were evident in processing speed, rapid naming, math fluency, word fluency, working memory, and executive functions. Academic strengths were evident in reading and written expression. Checklists revealed inattention and impulsivity with strengths in social cognition (See data tables). Conclusions This study demonstrates both variability in outcome following a complex birth history and neurological history and the value of repeat neuropsychological assessments. Assessment data was used to identify and build upon preserved skills and focus intervention strategies. Maintained verbal and nonverbal reasoning skills, in the context of strong social cognition, significantly contributed to progress, self-esteem, and future goals. Repeat neuropsychological assessment is well-suited for such cases. Access to such assessments is critical and should be regarded as medically necessary to guide intervention and promote positive outcomes.

Idiopathic Distal Sensory Polyneuropathy and Fibromyalgia Syndrome: A Comparative Phenotyping Study.

Painful idiopathic distal sensory polyneuropathy (IDSP) and fibromyalgia syndrome (FMS) are cryptogenic chronic pain syndromes. The contribution of small fibre pathology (SFP) in FMS remains controversial. This study aims to quantify small nerve pathology in participants with IDSP and FMS and identify relationships of SFP with sensory phenotypes. In this study, 73 individuals (FMS: 25, IDSP: 23, healthy volunteers: 25) underwent comprehensive assessment, including neurological exams, questionnaires, sensory tests, and corneal confocal microscopy. IDSP participants displayed lower wind-up ratio (WUR) relative to FMS (p<0.001), loss of function to thermal and mechanical stimuli and elevated neuropathy disability scores compared to FMS and healthy volunteers (all p<0.001). FMS participants demonstrated gain of function to heat and blunt pressure pain responses relative to IDSP, and healthy volunteers (heat: p=0.002 and p=0.003; pressure: both p<0.001) and WUR (both p<0.001). FMS participants exhibited reduced corneal nerve fibre density (p=0.02), while IDSP participants had lower global corneal nerve measures (density, branch density, and length) relative to healthy volunteers (all p<0.001). Utilising corneal nerve fibre length, SFP was demonstrated in 66.6% of participants (FMS: 13/25; IDSP: 22/23). Participants with SFP,in both FMS and IDSP, reported symptoms indicative of small nerve fibre disease. Although distinctions in pain distributions are evident between individuals with FMS and IDSP, over 50% of participants between the two conditions displayed both a loss and gain of thermal and mechanical function suggestive of shared mechanisms. However, sensory phenotypes were associated with the presence of SFP in IDSP but not in FMS.

Neuropsychiatric manifestations of hospitalized patients with coronavirus disease 2019 during the second wave in Egypt

BackgroundStudies suggested that COVID-19 virus causes neurological and psychiatric manifestations with different mechanisms. However, prevalence of neurological and psychiatric manifestations among COVID-19 patients varies across studies from 18.1%: 82.3%. The objective of this study was to determine neuropsychiatric manifestations in a sample of Egyptian COVID-19 hospitalized patients during the second wave of the pandemic and to detect factors affecting neurological and psychiatric prevalence. This cross-sectional study was conducted at Ain Shams university isolation hospitals and included 110 hospitalized COVID-19 patients, over a 2-month period from June 2021 to August 2021. Patients underwent a careful history taking, full neurological examination including Mini-Mental State Examination, the Structured Clinical Interview for DSM-IV (SCID I), COVID-19 severity criteria. Any available imaging and laboratory tests were recorded.Results83 (75.5%) patients had neurological manifestations. The most common neurological manifestations were headache (50.9%), hypogeusia (24.5%), hyposmia, paresthesia (23.6% each) and coma (15.5%). After exclusion of 17 patients who could not be examined by Mini-Mental State Examination, psychiatric manifestations were seen in 56 patients (61.5%) out of the remaining 91 patients. The most prevalent psychiatric disorders were delirium (30.8%), depression (19%), and adjustment disorder (17.5%). Moreover, hypertension, COVID-19 severity, place of admission, and high levels of LDH and ALT affected neurological manifestations prevalence.ConclusionsCOVID-19 infection and its immune reaction along with its social and psychological effects have a great impact on mental and physical health. Hence, neuropsychiatric evaluation cannot be ignored in any case with COVID-19 infection.

Evaluation and management of dyspnea as the dominant presenting feature in neuromuscular disorders.

Dyspnea is a common symptom in neuromuscular disorders and, although multifactorial, it is usually due to respiratory muscle involvement, associated musculoskeletal changes such as scoliosis or, in certain neuromuscular conditions, cardiomyopathy. Clinical history can elicit symptoms such as orthopnea, trepopnea, sleep disruption, dysphagia, weak cough, and difficulty with secretion clearance. The examination is essential to assist with the diagnosis of an underlying neurologic disorder and determine whether dyspnea is from a cardiac or pulmonary origin. Specific attention should be given to possible muscle loss, use of accessory muscles of breathing, difficulty with neck flexion/extension, presence of thoraco-abdominal paradox, conversational dyspnea, cardiac examination, and should include a detailed neurological examination directed at the suspected differential diagnosis. Pulmonary function testing including sitting and supine spirometry, measures of inspiratory and expiratory muscle strength, cough peak flow, sniff nasal inspiratory pressure, pulse oximetry, transcutaneous CO2, and arterial blood gases will help determine the extent of the respiratory muscle involvement, assess for hypercapnic or hypoxemic respiratory failure, and qualify the patient for noninvasive ventilation when appropriate. Additional testing includes dynamic imaging with sniff fluoroscopy or diaphragm ultrasound, and diaphragm electromyography. Polysomnography is indicated for sleep related symptoms that are not otherwise explained. Noninvasive ventilation alleviates dyspnea and nocturnal symptoms, improves quality of life, and prolongs survival. Therapy targeted at neuromuscular disorders may help control the disease or favorably modify its course. For patients who have difficulty with secretion clearance, support of expiratory function with mechanical insufflation-exsufflation, oscillatory devices can reduce the aspiration risk.

A - 39 The Physical and Neurological Examination of Subtle Signs (PANESS) as a Predictor of ADHD

Abstract Objective The Physical and Neurological Examination of Subtle Signs (PANESS) is a pediatric neuromotor exam. Prior research shows children with attention deficit hyperactivity disorder (ADHD) may exhibit neurological soft signs. This study investigates the predictability of PANESS performance on other ADHD measures. Methods Subjects included 52 children aged 8–16 seen clinically for evaluation at Austin Neuropsychology. Dependent variables included Digit Span (DS), Test of Everyday Attention (TeaCh), Conners Continuous Performance Test (CCPT-3), and Delis-Kaplan Executive Function System (DKEFS). The raw scores of PANESS tasks were the independent variables. Results DS was significantly predicted by the foot tap (FT) (p = 0.017), foot heel-toe tap (FH) (p = 0.028), hand pat (HP) (p = 0.018), finger tap (FinT) (p &amp;lt; 0.001), and appose finger succession (AFS) (p = 0.012) tasks on the PANESS. The Category Fluency (CF) subtest on DKEFS Verbal Fluency was also significantly predicted by the FT (p = 0.043), FH (p &amp;lt; 0.001), hand pronate/supinate (HPS) (p = 0.003), FinT (p = 0.003), FA (p &amp;lt; 0.001) tasks. All PANESS tasks significantly predicted performance on Trial 2 of DKEFS Color-Word (FT: p = 0.012; FH: p = 0.015; HP: p = 0.002; HPS: p = 0.009; FinT: p = 0.003; FA: p = 0.002). The FA task was a significant predictor of all trials of CWI (T1: p &amp;lt; 0.001; T2: p = 0.002; T3: p &amp;lt; 0.001; T4: p &amp;lt; 0.001). Conclusion The PANESS predicts performance on some ADHD tasks, though not others. This finding prompts further investigation into how PANESS can be integrated into clinical settings to enhance ADHD diagnosis and understanding.

Characterization of spatiotemporal and kinetic gait variables in dogs with hindlimb ataxia and bilateral hindlimb lameness

BackgroundDiscriminating the underlying cause of gait abnormalities can be challenging in a clinical setting, especially in the presence of bilateral disease. Pressure-sensitive walkways (PSWs) have been utilized to characterize the gait of dogs with various neurologic or orthopaedic conditions. The potential use of the PSW includes the discrimination of conditions that can be similar in clinical presentation, such as bilateral hindlimb lameness and hindlimb ataxia. The primary aim of this study was to describe the spatial, temporal, and kinetic gait parameters of dogs with hindlimb ataxia or bilateral hindlimb lameness and compare them to those of normal dogs. Forty-six dogs were prospectively recruited. The normal group included 20 dogs with normal neurologic and orthopaedic exams. The orthopaedic group included 15 dogs with bilateral hindlimb orthopaedic diseases with weight-bearing hindlimb lameness and normal neurologic exams. The neurologic group included 11 dogs with ambulatory paraparesis and normal orthopaedic exams. Each dog was walked across the PSW, and at least 3 valid trials were collected. The stride time, stance time, swing time, stride length, gait velocity, peak vertical force (PVF), vertical impulse (VI), and limb symmetry were recorded. The mean values of all parameters from the valid trials were calculated and used for data analysis. The outcomes were compared among all groups.ResultsCompared with the normal group, the orthopaedic group had a significantly greater percent body weight distribution (%BWD) and vertical impulse distribution (VID) in the forelimbs. When comparing the spatiotemporal parameters, the neurologic group showed an increase in forelimb stance time compared to that of the normal group. Compared with that in the normal group, the stride velocity in the forelimbs in the orthopaedic group was greater. There were no significant differences in the kinetic parameters between the neurologic group and the normal group, nor in stride time or stride length among the groups.ConclusionThe gait parameters obtained by PSW demonstrated that the orthopaedic and neurologic groups may have different compensatory mechanisms for their gait deficiencies. These parameters can potentially be used to construct a predictive model to evaluate PSW as a diagnostic tool in future studies.

Prehospital neurological emergencies– a survey on the state of prehospital neurological assessment by emergency medical professionals

BackgroundNeurological emergencies are one of the major diagnosis groups in the Emergency Medical Services (EMS) with the highest rate of misdiagnosis. Despite the knowledge of time sensitivity and the importance of prehospital factors, prehospital delay is common. Although several stroke triage scales have been developed, a gold standard in the prehospital setting is lacking.ObjectivesOur aim was to evaluate the perception of neurological emergencies by EMS personnel and to identify current problems, difficulties and opportunities for improvement in the prehospital management of stroke, seizure, non-specific neurological symptoms, and paediatric neurological emergencies.MethodsThe study was conducted as an online survey through SoSci Survey and was made available from March 1st to June 30th 2023 to all personnel working in emergency medical services. The access link was distributed through snowballing, social media, and through a QR code on a promotional poster. The survey was completed anonymously. The final survey consisted of 30 questions in German on the topics of neurological emergencies, general neurological assessment, specific neurological examination including paediatric assessment, stroke, and seizures, and finally suggestions for improvement.ResultsThe largest group of participants were paramedics, who estimated to encounter neurological emergencies at a general rate of 20–60%. When unease was felt, the main reasons were ambiguity of symptoms and insufficient admission capacity of hospitals. The biggest challenges were highly varied. Almost 80% of participants assumed that the neurological assessment would be omitted in difficult patient groups such as demented, intoxicated or children. 75% felt uncomfortable making a paediatric assessment, 50% were unfamiliar with the Paediatric Glasgow Coma Scale.ConclusionsSupport through more standardized practical training and defined, uniform guidelines is needed. There was also a clear need for peer collaboration, feedback and case sharing. Digitalization, the usage of telemedicine and updated versions of the documentation protocols including paediatric adaptations to current guidelines could further improve current neurological assessment in the prehospital setting.

Analysis of predictors of hemorrhagic transformation after reperfusion therapy with recombinant tissue plasminogen activator in patients with acute ischemic stroke: a single-center experience

BackgroundHemorrhagic transformation (HT) is a serious complication of thrombolytic therapy for acute ischemic stroke, limiting its indications and affecting treatment plans and clinical prognosis. Identifying risk factors for HT could help improve the risk–benefit ratio of thrombolytic therapy. We aimed to analyze the predictors of HT after reperfusion therapy with recombinant tissue plasminogen activator (rTPA) in patients with acute ischemic stroke. This study included 115 patients who received rTPA. All patients underwent history taking, clinical examination, neurological examination including Glasgow Coma Scale and National Institutes of Health Stroke Scale scores (NIHSS), radiological investigation, and cardiac investigation. Patients were followed up strictly every 2 h for 1st 24 h then for two weeks clinically using the NIHSS and radiologically using CT or MRI to detect HT.ResultsPatients with HT represented 21.7% of all patients receiving rTPA, while symptomatic intracranial hemorrhage (sICH) represented 6.9%. Patients with HT had significantly higher blood pressure, respiratory rate, atrial fibrillation rate, NIHSS score, INR, prothrombin time, neutrophil-to-lymphocyte ratio (NLR), and lower platelet count, LDL level, higher Fazekas score, lower ASPECT score, and prolonged onset-to-needle time.ConclusionPredicting HT in acute ischemic stroke patients is crucial for optimizing management and potentially improving outcomes. In our study, six predictors were associated with HT: higher respiratory rate, higher atrial fibrillation rate, higher NLR, lower LDL level, higher Fazekas score, lower ASPECT score, and onset-to-needle time greater than 180 min.