Non-specific Neurological Symptoms Research Articles

Contrast-enhanced 3D black-blood magnetic resonance imaging for diagnosis of cerebral venous thrombosis

Purpose Cerebral venous thrombosis (CVT) is often under-recognized on routine magnetic resonance imaging (MRI) examinations without concomitant magnetic resonance venography (MRV). Contrast-enhanced black-blood MRI (BBMRI) based on a three-dimensional T1-weighted variable-flip-angle turbo spin echo sequence, one of the sequences used routinely in our practice, has the potential for detection of thrombi in patients with CVT. The aim of this study is to evaluate the diagnostic performance and enhancement patterns of contrast-enhanced three-dimensional BBMRI for the diagnosis of CVT. Materials and methods Contrast-enhanced BBMRI and contrast-enhanced MRV sequences of 64 patients, acquired from June 2018 to January 2021, were retrospectively reviewed by neuroradiologists for detection of CVT in each venous sinus segment. Diagnostic performance values were calculated for contrast-enhanced BBMRI based on enhancement patterns. Results Of 749 venous segments from 64 patients analyzed, CVT was demonstrated in 41 venous segments from 12 patients on contrast-enhanced MRV (CE MRV). Thick wall enhancement and total enhancement patterns were dominantly demonstrated in thrombosed segments. Compared with contrast-enhanced MRV, contrast-enhanced BBMRI had a patient-based sensitivity and specificity of 100% and 98.1%, respectively, and a segment-based sensitivity and specificity of 87.8% and 96.2%, respectively. The positive predictive value of contrast-enhanced BBMRI in detecting CVT was 92.3% (patient-based) and 57.1% (segment-based), and the negative predictive value was 100% (patient-based) and 99.3% (segment-based). Conclusion Contrast-enhanced BBMRI has high diagnostic performance in detection and diagnosis of CVT. This sequence may be useful to recognize CVT when dedicated CE MRV was not performed in patients with nonspecific neurological symptoms.

Nondysraphic intramedullary spinal cord lipoma: a case report

Introduction: Intramedullary nondysraphic spinal lipomas are extremely rare among primary spinal cord tumors. These patients present with nonspecific sensory symptoms followed by deterioration of motor symptoms. As the safety margins for neurological preservation are thin, meticulously locating the extent of the tumor and choosing the resection modalities is essential. Case report: The authors report a rare case of a 35-year-old male who presented with progressive difficulty in walking for 6 months associated with numbness and tingling sensation in the bilateral upper and lower limbs. He was diagnosed with nondysraphic intramedullary cervicothoracic lipoma and underwent subtotal resection of the tumor. Conclusion: Nondysraphic intramedullary spinal cord lipomas are rare and may present as nonspecific neurological symptoms. Hence, they should be considered differentials of intramedullary spinal cord tumors. Surgery appears to be the mainstay of treatment.

A Review of Neurological Disorders Caused by Hormonal Abnormalities

Endocrine dysfunction can considerably impact the nervous system. Various nonspecific neurological symptoms can manifest, including headache, muscle weakness, involuntary movements, and impaired consciousness. Because of their lack of specificity, endocrine abnormalities underlying neurological symptoms may not be recognized and making the diagnosis may be challenging. It is essential that clinicians not overlook endocrine disorders when diagnosing neurological symptoms, as prompt and appropriate treatment, such as hormone replacement therapy, can improve a patient's general condition and neurological symptoms.

Homonymous hemianopia due to cerebral venous thrombosis: A case report

Rationale: Diagnosing cerebral venous thrombosis (CVT) can be difficult because of nonspecific symptoms, such as headache and homonymous hemianopia (HH). Herein, we present a case of delayed CVT diagnosis due to nonspecific neurological symptoms and nonprominent lesions in a patient with HH. Patient concern: A 65-year-old woman presented with a sudden onset headache accompanied by right HH that lasted for 1 day. Brain computed tomography and magnetic resonance imaging were initially performed due to suspicion of ischemic lesions or hemorrhage in the left postchiasmal visual pathway; however, no remarkable acute brain lesions were detected. Ophthalmological examinations revealed no notable findings, except for a definite field defect in the Humphrey visual field test. The headaches then waxed and waned but recurred 3 days after the initial symptom. A repeat brain magnetic resonance imaging was performed, which revealed left sectoral gyral swelling and vascular enhancement in the occipital lobe. To further evaluate venous drainage, additional 3-dimensional cerebral computed tomography angiography and 4-vessel angiography were conducted, revealing a partial filling defect in the left transverse sinus and superior venous drainage impairment. These findings suggested the presence of venous thrombosis in the left transverse sinus. Diagnosis: The patient was diagnosed with thrombosis of the left transverse sinus, which subsequently caused the right HH. Intervention: Anticoagulation therapy with parenteral heparin was started as soon as the diagnosis of CVT was confirmed. Eventually, the patient was solely managed with oral warfarin administration. Outcomes: Following 3 days of treatment, her headache resolved, and a subsequent visual field testing conducted 2 weeks later revealed a definite improvement in the field defect. Lessons: Despite its favorable prognosis, CVT can be challenging to diagnose. CVT should be considered as a differential diagnosis when diagnosing patients who present with headaches accompanied by HH without prominent brain lesions.

"Progressive myoclonic ataxia and developmental/epileptic encephalopathy associated with a novel homozygous mutation in TCN2 gene".

Transcobalamin II (TCN2) defect is a rare metabolic disorder associated with a range of neurological manifestations, including mild developmental delay, severe intellectual disability, ataxia, and, in some cases, seizures. Cobalamin, an essential nutrient, plays a crucial role in central nervous system myelination. We present a family with an index patient who exhibited progressive neurodevelopmental regression starting at 9 months of age, accompanied by myoclonic seizures, ataxia, and tremor. No significant hematological abnormalities were observed. Exome sequencing analysis identified a novel homozygous mutation, c.3G>A - P(Met1I), affecting the acceptor site of intron 4 of the TCN2 gene (chromosome 22: 31003321, NM_000355.4), leading to likely pathogenic variant potentially affecting translation. Following treatment with hydroxocobalamin, the patient demonstrated partial clinical improvement. He has a sibling with overt hematological abnormalities and subtle neurological abnormalities who is homozygous to the same mutation. Both parents are heterozygous for the same mutation. In infants presenting with unexplained non-specific neurological symptoms, irrespective of classical signs of vitamin B12 deficiency, evaluation for TCN2 defect should be considered. Early diagnosis and appropriate management can lead to favorable outcomes.

Posterior Reversible Encephalopathy Syndrome in a Patient with Septic Shock: A Case Report.

Posterior reversible encephalopathy syndrome (PRES) is a reversible condition with nonspecific neurologic and characteristic radiologic findings. Clinical presentation may include headache, nausea, vomiting, altered mental status, seizures, and vision changes. Diagnosis is confirmed through T2-weighted brain magnetic resonance imaging (MRI) showing bilateral hyperintensities in the white matter of posterior circulatory regions. We report a case of PRES in a patient suffering from complicated diverticulitis. Following medical management in the emergency department, the patient deteriorated, becoming hypotensive and altered. Bowel resection under general anesthesia was performed. Postoperative brain MRI demonstrated bilateral and symmetric T2 signal hyperintensities suggestive of PRES. Following supportive treatment, the patient was discharged from the surgical intensive care unit on postoperative day 21 with no residual deficits. It is important to recognize the nonspecific neurologic symptoms associated with PRES. Emergency physicians should suspect acute PRES when managing patients with prolonged or unexplained encephalopathy, while recognizing that hypertension need not be present.

Brain Renin-Angiotensin System: From Physiology to Pathology in Neuronal Complications Induced by SARS-CoV-2.

Angiotensin-converting enzyme 2 (ACE2), a key enzyme in the renin-angiotensin system (RAS), is expressed in various tissues and organs, including the central nervous system (CNS). The spike protein of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease-2019 (COVID-19), binds to ACE2, which raises concerns about the potential for viral infection in the CNS. There are numerous reports suggesting a link between SARS-CoV-2 infection and neurological manifestations. This study aimed to present an updated review of the role of brain RAS components, especially ACE2, in neurological complications induced by SARS-CoV-2 infection. Several routes of SARS-CoV-2 entry into the brain have been proposed. Because an anosmia condition appeared broadly in COVID-19 patients, the olfactory nerve route was suggested as an early pathway for SARS-CoV-2 entry into the brain. In addition, a hematogenous route via disintegrations in the blood-brain barrier following an increase in systemic cytokine and chemokine levels and retrograde axonal transport, especially via the vagus nerve innervating lungs, have been described. Common nonspecific neurological symptoms in COVID-19 patients are myalgia, headache, anosmia, and dysgeusia. However, more severe outcomes include cerebrovascular diseases, cognitive impairment, anxiety, encephalopathy, and stroke. Alterations in brain RAS components such as angiotensin II (Ang II) and ACE2 mediate neurological manifestations of SARS-CoV-2 infection, at least in part. Downregulation of ACE2 due to SARS-CoV-2 infection, followed by an increase in Ang II levels, leads to hyperinflammation and oxidative stress, which in turn accelerates neurodegeneration in the brain. Furthermore, ACE2 downregulation in the hypothalamus induces stress and anxiety responses by increasing corticotropin-releasing hormone. SARS-CoV-2 infection may also dysregulate the CNS neurotransmission, leading to neurological complications observed in severe cases of COVID-19. It can be concluded that the neurological manifestations of COVID-19 may be partially associated with changes in brain RAS components.

Symptoms associated with headache in youth.

To determine the underlying relationships between a broad range of headache-associated symptoms and how they relate to headache burden. Symptoms associated with head pain inform classification of headache disorders. However, many headache-associated symptoms are not included in the diagnostic criteria, which is largely based on expert opinion. Large symptom databases can assess headache-associated symptoms irrespective of pre-existing diagnostic categories. We conducted a large single-center cross-sectional study on youth (6-17 years old) assessing patient-reported outpatient headache questionnaires between June 2017 and February 2022. Multiple correspondence analysis, an exploratory factor analysis, was applied to 13 headache-associated symptoms. 6662 participants (64% female; median age 13.6 years) were included. Multiple correspondence analysis dimension 1 (25.4% of the variance) captured the absence or abundance of headache-associated symptoms. A greater number of headache-associated symptoms correlated with greater headache burden. Dimension 2 (11.0% of the variance) revealed three symptom clusters: (1) cardinal features of migraine (light, sound, and smell sensitivity, nausea, and vomiting), (2) nonspecific global neurologic dysfunction symptoms (lightheadedness, trouble thinking, blurry vision), (3) vestibular and brainstem dysfunction symptoms (vertigo, balance problems, ear ringing, double vision). Assessing a broader range of headache-associated symptoms reveals clustering of symptomatology and a strong relationship with headache burden.

Neurosarcoidosis in a young male presenting with intractable migraines, blurry vision, and other nonspecific neurological symptoms case report

BackgroundNeurosarcoidosis can have various neurological outcomes and presentations. It is an uncommon diagnosis, especially in young Caucasian males presenting with predominantly migraine headaches.Case presentationA Caucasian male in his 20s with no medical history presented with 1 month of intractable migraine headaches associated with left sided blurry vision, nausea and vomiting. He has also been having intermittent paresthesia’s in the left upper extremity. He reports lightheadedness when moving from sitting to standing and occasionally feels unsteady on his feet. He also endorses night sweats, generalized malaise, and fatigue. On admission, CT chest, abdomen, and pelvis showed diffuse lymphadenopathy above and below the diaphragm, as well as widespread pulmonary nodules. MR head and spine showed multiple and diffuse nodular leptomeningeal enhancements and enhancement foci along the cervical, thoracic, and lumbar spine. Lumbar puncture showed elevated total nucleated cells and protein. Surgical pathology from a right inguinal lymph node showed many scattered multinucleated giant cells and epithelioid histiocytes consistent with non-necrotizing granulomas seen in sarcoidosis. He was treated with high dose steroids with significant improvement in symptoms.ConclusionsThe diagnosis of neurosarcoidosis may be challenging, and the differential may include other infectious, neoplastic, and inflammatory conditions. Neurosarcoidosis may present in a young Caucasian male with a constellation of nonspecific neurological symptoms such as cranial nerve palsies, gait imbalance, paresthesia’s, and headaches, among other presentations. Neurosarcoidosis may present similarly to lymphoma with constitutional symptoms of night sweats, fatigue, as well as widespread lymphadenopathy. Histopathology may be useful in diagnosis. Neurosarcoidosis may initially respond well to steroid treatment.

Neurologic involvement in seronegative primary Sjögren's syndrome with positive minor salivary gland biopsy: a single-center experience.

To assess the demographics, neurologic manifestations, comorbidities, and treatment of patients with seronegative primary Sjögren's syndrome (pSS). We conducted a retrospective chart review on patients with seronegative pSS evaluated by a neurologist at the University of Utah Health between January 2010 and October 2018. The diagnosis was based on characteristic symptoms, positive minor salivary gland biopsy according to the American-European Consensus Group 2002 criteria, and seronegative antibody status. Of 45 patients who met the study criteria, 42 (93.3%) were Caucasian, and 38 (84.4%) were female. The patients' mean age at diagnosis was 47.8 ± 12.6 (range 13-71) years. Paresthesia, numbness and dizziness, and headache were noted in 40 (88.9%), 39 (86.7%), and 36 patients (80.0%), respectively. Thirty-four patients underwent brain magnetic resonance imaging. Of these, 18 (52.9%) showed scattered nonspecific periventricular and subcortical cerebral white matter T2/fluid-attenuated inversion recovery hyperintense foci. Twenty-nine patients (64.4%) presented to the neurology clinic prior to pSS diagnosis, and the median delay in diagnosis from the first neurology clinic visit was 5 (interquartile ranges 2.0-20.5) months. Migraine and depression were the most common comorbidities in 31 patients (68.9%). Thirty-six patients received at least one immunotherapy, and 39 were on at least one medication for neuropathic pain. Patients often display various nonspecific neurological symptoms. Clinicians should express a high degree of skepticism regarding seronegative pSS and consider minor salivary gland biopsy to avoid delaying diagnosis, as undertreatment can affect patients' quality of life.

Coronavirus Disease 2019-Associated Neurological Manifestations in Children: A Large Single-Center Experience With Rare Cases

BackgroundWe aimed to analyze pediatric patients with coronavirus disease 2019 (COVID-19) with a diverse spectrum of neurological manifestations in a single center since neurological involvement in children is still poorly understood. MethodsWe performed a retrospective study on 912 children aged between zero and 18 years who had a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test result and symptoms of COVID-19 from March 2020 to March 2021 in a single center. ResultsAmong 912 patients, 37.5% (n = 342) had neurological symptoms and 62.5% (n = 570) had no neurological symptoms. The mean age of patients with neurological symptoms was significantly higher (14.2 ± 3.7 vs 9.9 ± 5.7; P < 0.001). Three hundred and twenty-two patients had nonspecific symptoms (ageusia, anosmia, parosmia, headache, vertigo, myalgia), whereas 20 patients had specific involvement (seizures/febrile infection-related epilepsy syndrome, cranial nerve palsy, Guillain-Barré syndrome and variants, acute disseminated encephalomyelitis, central nervous system vasculitis). The mean age of the patients with nonspecific neurological symptoms was significantly higher (14.6 ± 3.1 vs 7.7 ± 5.7; P < 0.001). ConclusionThis study presents a large number of patients with a diverse spectrum of neurological manifestations. The rare neurological manifestations reported in our study will contribute to better understanding the neurological involvement of SARS-CoV-2 in children. The study also points out the differences of SARS-CoV-2-related neurological manifestations between patients at different ages. Physicians should be alert about recognizing the early neurological manifestations of the SARS-CoV-2 in children.

Neurologic Manifestation in Children with Coronavirus Disease 2019 at Prof. Dr. I.G.N.G Ngoerah Tertiary Hospital

AIM: The objective of the study is to describe neurologic manifestation in children with coronavirus disease-2019 (COVID-19) at Prof. Dr. I.G.N.G Ngoerah Hospital. METHODS: This was a retrospective descriptive study using the medical record with a total sampling of children with confirmed COVID-19 that manifests neurologic symptoms. Exclusion criteria were pre-existing neurologic comorbidities and incomplete medical records. RESULTS: From March 2020 to December 2021, from 308 children with confirmed cases of COVID-19, 106 had neurologic symptoms, 17 were excluded (16 pre-existing comorbidities, and 1 incomplete medical record), and total samples were 89 (28.8%) from inpatient and outpatient. Most children were male (57.3%) with a median age of 13 years. Most symptoms found were anosmia (73%), followed by a decrease in consciousness (19.1%) and seizure (10.1%). Children with anosmia median age were 14 years. There were 84 (94.3%) children with specific neurological symptoms (encephalopathy, seizures, and anosmia) and 5 (5.7%) with non-specific neurological symptoms (headache). CONCLUSION: There were 28.8% confirmed cases of COVID-19 with a neurologic manifestation, and most symptoms found were anosmia (73%).

A comprehensive assessment of self-reported symptoms among patients harboring an unruptured intracranial aneurysm.

Approximately 3.2%-6% of the general population harbor an unruptured intracranial aneurysm (UIA). Ruptured aneurysms represent a significant healthcare burden, and preventing rupture relies on early detection and treatment. Most patients with UIAs are asymptomatic, and many of the symptoms associated with UIAs are nonspecific, which makes diagnosis challenging. This study explored symptoms associated with UIAs, the rate of resolution of such symptoms after microsurgical treatment, and the likely pathophysiology. A retrospective review of patients with UIAs who underwent microsurgical treatment from January 1, 2014, to December 31, 2020, at a single quaternary center were identified. Analyses included the prevalence of nonspecific symptoms upon clinical presentation and postoperative follow-up; comparisons of symptomatology by aneurysmal location; and comparisons of patient demographics, aneurysmal characteristics, and poor neurologic outcome at postoperative follow-up stratified by symptomatic versus asymptomatic presentation. The analysis included 454 patients; 350 (77%) were symptomatic. The most common presenting symptom among all 454 patients was headache (n = 211 [46%]), followed by vertigo (n = 94 [21%]), cognitive disturbance (n = 68[15%]), and visual disturbance (n = 64 [14%]). Among 328 patients assessed for postoperative symptoms, 258 (79%) experienced symptom resolution or improvement. This cohort demonstrates that the clinical presentation of patients with UIAs can be associated with vague and nonspecific symptoms. Early detection is crucial to prevent aneurysmal subarachnoid hemorrhage. It is imperative that physicians not rule out aneurysms in the setting of nonspecific neurologic symptoms.

Evaluation of under-testing and under-diagnosis of tick-borne encephalitis in Germany

BackgroundTick-borne encephalitis (TBE), a viral infectious disease affecting the central nervous system, potentially resulting in prolonged neurological symptoms and other long-term sequelae. Case identification can be challenging as TBE can be associated with non-specific symptoms, and even in cases consistent with typical TBE symptoms, the rate of laboratory testing to confirm cases is unknown. This study assessed real-world TBE laboratory testing rates across Germany.MethodsIn this retrospective cross-sectional study, physicians provided data on TBE decision-making, laboratory testing (serological), and diagnostics behavior via in-depth qualitative interviews (N = 12) or a web-based quantitative survey of their patient medical records (N = 166). Hospital-based physicians who specialized in infectious disease, intensive care unit, emergency room, neurology, or pediatrics with experience managing and ordering testing for patients with meningitis, encephalitis, or non-specific central nervous system symptoms in the past 12 months were included. Data were summarized via descriptive statistics. TBE testing and positivity rates were assessed for the aggregate sample of 1400 patient charts and reported by presenting symptoms, region, and tick bite exposure.ResultsTBE testing rates ranged from 54.0% (non-specific neurological symptoms only) to 65.6% (encephalitis symptoms only); the percentage of TBE positive results ranged from 5.3% (non-specific neurological symptoms only) to 36.9% (meningitis symptoms only). TBE testing rates were higher among those with a tick bite history and/or who presented with headache, high fever, or flu-like symptoms.ConclusionsThe findings of this study suggest that patients with typical TBE symptoms are likely under-tested, thus likely leading to under-diagnosis in Germany. To ensure appropriate case identification, TBE testing should be consistently integrated into routine practice for all patients who present with relevant symptoms or exposure to common risk factors.

Neurological consequences of SARS-CoV-2 infections in the pediatric population.

COVID-19 in the pediatric population is mostly asymptomatic. However, 1 out of 5 children presents non-specific neurologic symptoms such as headache, weakness, or myalgia. Furthermore, rarer forms of neurological diseases are increasingly being described in association to a SARS-CoV-2 infection. Encephalitis, stroke, cranial nerves impairment, Guillain-Barré syndrome or acute transverse myelitis have been reported and account for around 1% of pediatric COVID-19 cases. Some of these pathologies may occur during or after the SARS-CoV-2 infection. The pathophysiological mechanisms range from direct invasion of the central nervous system (CNS) by SARS-CoV-2 itself to postinfectious immune-mediated CNS inflammation. In most cases, patients presenting neurological pathologies related to SARS-CoV-2 infection are at greater risk of life-threatening complications and should be closely monitored. Further studies are needed to acknowledge the potential long-term neurodevelopmental consequences of the infection.

Echinococcus Infestation of the Central Nervous System as the Primary and Solitary Manifestation of the Disease: Case Report and Literature Review

Introduction: Hydatid disease of the central nervous system, especially when there is no involvement of other organs, is a rare occurrence and it accounts for 2–3% of all the hydatid cyst cases that are recorded worldwide. Echinococcus is considered as an endemic disease, mainly encountered in sheep and cattle-raising regions, with a large proportion of patients living in Mediterranean countries, as well as Turkey and Syria. Pediatric neurosurgeons in nonendemic countries are facing a differential diagnostic challenge when a patient with hydatid cyst of the central nervous system is admitted to their department, mainly due to lack of awareness. Materials and Methods: We report the case of an eleven years old patient, coming from a village, who was admitted to our hospital due to progressive hemiparesis, hemianopsia, headache and episodes of vomiting. A thorough laboratory and neuroimaging investigation was performed, which revealed the presence of a hydatid cyst at the right fronto-parietal region. An en-block total resection was performed and the patient neurological signs and symptoms were immediately relieved. Conclusions: The clinical features related to hydatid cyst involving the central nervous system are largely nonspecific. Nevertheless, MRI has proved to be a very important diagnostic tool, significantly enhancing the diagnostic aid of neuroimaging and supporting our pre-operative diagnostic accuracy. Laboratory investigation with immunological tests may be indicative, but negative results should be interpreted with caution. En block removal of the cyst without interruption of its wall and avoidance of any spillage of content is our ultimate therapeutic goal. Infection with Echinococcus granulosus should be included in the differential diagnosis for non-specific neurologic symptoms such as progressive headache, especially in pediatric patients who are coming from regions which are considered as endemic for such parasitic diseases. In addition, the adjuvant therapy with albendazole is strongly indicated. The majority of misdiagnoses or delayed diagnoses may have resulted from confusing clinical features and atypical radiographic findings.

Клиническое наблюдение криптококкового менингита у пациента с системной красной волчанкой

The risk of serious infectious diseases is significantly increased in individuals with systemic lupus erythematosus (SLE). The article describes a clinical case of meningoencephalitis caused by Cryptococcus neoformans, in a 33-year-old female patient with SLE. The diagnosis was based on the results of cerebrospinal fluid analysis, brain magnetic resonance imaging scans, and retrospective analysis of chest computed tomography features. The antifungal therapy comprising liposomal amphotericin B and fluconazole was used successfully. Distinctive features of this clinical case include a delayed diagnosis due to the slow development and the presence of non-specific neurological symptoms, as well as the onset of acute renal disorders amid the use of antifungal therapy. The authors discuss the issues of diagnosing infectious complications in patients with SLE, particularly fungal infections, and the up-to-date approaches to therapy of cryptococcal meningitis. The presented clinical report could help therapists and rheumatologists to improve timely recognition of cryptococcal infections in SLE patients. The authors emphasized that CSF examination plays the key role in diagnosing cryptococcal meningitis. KEYWORDS: cerebral cryptococcosis, opportunistic infection, meningoencephalitis in patients with systemic lupus erythematosus, clinical case, fungal infection, systemic lupus erythematosus. FOR CITATION: Kuzminykh D.A., Eliseev Yu.V., Matrosova M.S. et al. A clinical case of cryptococcal meningitis in patient with systemic lupus erythematosus. Russian Medical Inquiry. 2023;7(3):174–180 (in Russ.). DOI: 10.32364/2587-6821-2023-7-3-174-180.

Neurological Manifestations of Hospitalized COVID-19-Infected Patients: A Single-Center Cohort Study

Background: Although COVID-19 preferentially affects the respiratory system, it has been demonstrated that coronaviruses frequently invade the nervous system. Objectives: We aimed to report the frequency and type of neurological manifestations in hospitalized patients with COVID-19. Methods: This is a retrospective, prospective observational cohort study. Data were collected from April to July 2020 at Bu-Ali Sina University Hospital, Sari, Iran. Demographic data and clinical symptoms were recorded at the onset of the disease. Neurological manifestations were recorded into 5 categories: nonspecific central nervous system (CNS) manifestations, acute cerebrovascular disease (CVD), meningitis/encephalitis, peripheral nervous system manifestations, and inflammatory disorders (myelitis and acute disseminated encephalomyelitis). Results: A total of 420 patients were admitted to the hospital with confirmed SARS-CoV-2 infection. Of the 420 patients hospitalized with COVID-19, 282 (67%) showed some form of neurological symptoms, of whom 48.33% had nonspecific neurological symptoms. Further, 35 (8.3%) patients had acute CVD, 2 patients had encephalitis (the RNA of SARS-CoV-2 was detected in cerebrospinal fluid (CSF), 1 patient had myelitis, and 83 (19.76%) patients had peripheral nervous system manifestations. Conclusions: Neurologic symptoms (from mild symptoms to life-threatening CNS disorders) are common in admitted patients with COVID-19. As a result of coagulation disorder in patients with COVID-19, some conditions (such as stroke) can be seen, even during recovery.

An outbreak of neurologic symptoms among patients exposed to an unknown stench in a high school near an industrial complex: an epidemiological investigation.

Seven students at a high school in Korea visited the emergency room with non-specific neurological symptoms after a stench was noticed during a school entrance ceremony. In relation to this incident, 105 patients visited medical institutions over 5 days. A team of environmental and epidemiological experts was assembled to investigate the incident. Our team of experts participated in the investigation 1 month post-incident. Previously, only air samples had been analyzed. We received results of air samples analyzed by other investigators, medical records of some students, and data from police interviews of patients. Additional investigation and interviews were conducted, and the events were reconstructed in spatial and temporal order. A cluster of patients was observed on the south side and parts of the north side of the upper floor. A stench like that reported during the incident had been noticed for about 2 years near the school. Students consistently described a similar stench occurring frequently in the vicinity of the school. According to student statements, the odor mainly resembled something burning. The carboxyhemoglobin levels of some students were observed to be >1.5%. In the investigation, 2 suspected sources were identified: a science room storing chemicals downstairs from the auditorium and various industrial facilities near the school. Combining the scattered evidence, we considered a toxic puff of gas, perhaps from brief incineration or leakage in a specific area, to be the likely cause of the incident. We describe our approach and the limitations encountered during the investigation.

The Two-Week-Wait Referral Pathway: Not Fit for Purpose

Abstract AIMS The two-week-wait (2WW) referral pathway was set up by the Department of Health to improve early diagnosis and overall survival of cancer. Brain tumours, however, present with non-specific neurological symptoms. As such, this study set out to evaluate the efficacy of the 2WW pathway in detecting brain cancer in patients referred by primary care. METHOD Data from 217 patients referred via the 2WW pathway from January to September 2021 were extracted retrospectively, using the electronic health record system within the University College London NHS Foundation Trust. Details of the diagnoses, imaging results, and follow-up treatments were analysed. RESULTS Of the 217 patients referred with a suspected brain tumour, 0 patients received a new diagnosis of brain cancer. However, 4 cases of benign tumours were newly diagnosed through the 2WW pathway, with an additional 17 cases of benign tumours being referred for further management, having been detected on previous external imaging. 9 cases of known malignant brain tumours were referred for on-going management, having been treated previously elsewhere. CONCLUSION The 2WW pathway does not detect new cases of brain cancer. It is rather being used as a means of rapid referral of patients in primary care with benign tumours or previously identified brain cancer. This study therefore suggests that the initial aspiration of detecting brain cancer earlier via this pathway has not been fulfilled, but it is a useful tool for GPs to refer patients with brain tumours into Neuro-oncology services.