Severity Of Neurological Involvement Research Articles

Neurological Involvement in Children with COVID-19 and MIS-C: A Retrospective Study Conducted for More than Two Years in a Pediatric Hospital.

This study aimed to evaluate the type and severity of neurological involvement in children with SARS-CoV-2 infection or multisystem inflammatory syndrome in children (MIS-C) and compare these findings between the two groups. Children hospitalized with the diagnosis of COVID-19 or MIS-C at Meyer Children's Hospital between February 2020 and June 2022 were retrospectively studied. One hundred twenty-two patients were enrolled, 95 in the COVID-19 group and 27 in the MIS-C group. In the COVID-19 group, impairment of consciousness was found in 67.4% of patients, headache in 18.9% and about 16.8% of patients experienced seizures. In this group, three patients were diagnosed with arterial ischemic stroke and one patient was diagnosed with Guillain-Barré syndrome (GBS). In the MIS-C group, about 70% of patients experienced consciousness impairment, about 20% behavioral changes, and another 20% mood deflection. Neurological symptoms and signs were highly heterogeneous and could be differentiated in COVID-19 and MIS-C. Consciousness impairment remained the most frequent manifestation in both groups, potentially underlying an encephalopathy. We also highlight the importance of considering psychiatric symptoms in children with COVID-19 and/or MIS-C. Most neurological manifestations were mild in our series; however, severe complications such as ischemic stroke and GBS are worthy of note.

Spectrum of Ocular Findings in Closed Head Injuries, Correlation With Severity of Neurological Involvement, and Treatment Outcome: A Hospital-Based Cross-Sectional Study.

Purpose: To study the various ocular findings in patients with closed head injuries, to find any association with the degree of neurological involvement, and to analyze the treatment outcome after the necessary intervention.Setting: Tertiary referral hospital in Eastern India.Design: Prospective observational study.Methods: Patients with closed head injuries attending our Outpatient department as well as referred from the Neurosurgery department for ophthalmic evaluation between October 2017 and September 2019 were recruited for the study. All patients meeting the inclusion criteria were examined by an experienced ophthalmologist. The Glasgow coma scale (GCS) was applied to grade the neurological involvement by the neurosurgery team. Ocular findings were recorded and necessary imaging was requested. Appropriate neurosurgery consultations were done in patients with neurological findings. All ocular injuries were managed as per institutional protocol. Descriptive statistics were used for analysis with p< 0.05 taken as statistically significant.Results: A total of 207 patients (414 eyes) were included in the study. The mean age was 33.82 years, with the prevalence of male patients (82.12%). The most common cause of head injury was RTA (57.01%) followed by assault (11.59%). The majority of patients (53.14%) were classified as having moderate, 46.37% patients with mild, and 0.48% with severe neurological involvement as per GCS scoring. Isolated ocular findings were seen in 70.04% of patients while 29.95% of patients had both neurological and ophthalmic features. Ocular adnexal involvement was observed in 38.6%, anterior segment involvement in 86%, neuro-ophthalmic manifestations in 33.3%, and posterior segment involvement in 38.6% of patients. Ocular signs were resolved over due course of time in 48.8% of patients, completely resolved in 28%, while there was no improvement in 6.28% of patients. The final best-corrected visual acuity of >6/18 was achieved in 51.69% of patients. Statistical significance was observed in the correlation between the GCS scoring and general ocular findings (p= 0.02) as well as a relative afferent pupillary defect (p=0.003). The association between age > 50 years and neuro-ophthalmic features was not found to be statistically significant (p=0.56).Conclusion: Poor visual acuity at presentation, optic canal fractures, the presence of multiple fractures of orbital walls, no improvement in vision within 48 hours of starting intravenous corticosteroids, were indicators of a poor visual prognosis in this study. The GCS, neuro-deficit, and ocular signs contribute significantly to the prediction of outcomes. Prompt treatment and referral can lead to a good resolution of symptoms and signs.

Neurologic Involvement in Children and Adolescents Hospitalized in the United States for COVID-19 or Multisystem Inflammatory Syndrome

Coronavirus disease 2019 (COVID-19) affects the nervous system in adult patients. The spectrum of neurologic involvement in children and adolescents is unclear. To understand the range and severity of neurologic involvement among children and adolescents associated with COVID-19. Case series of patients (age <21 years) hospitalized between March 15, 2020, and December 15, 2020, with positive severe acute respiratory syndrome coronavirus 2 test result (reverse transcriptase-polymerase chain reaction and/or antibody) at 61 US hospitals in the Overcoming COVID-19 public health registry, including 616 (36%) meeting criteria for multisystem inflammatory syndrome in children. Patients with neurologic involvement had acute neurologic signs, symptoms, or diseases on presentation or during hospitalization. Life-threatening involvement was adjudicated by experts based on clinical and/or neuroradiologic features. Severe acute respiratory syndrome coronavirus 2. Type and severity of neurologic involvement, laboratory and imaging data, and outcomes (death or survival with new neurologic deficits) at hospital discharge. Of 1695 patients (909 [54%] male; median [interquartile range] age, 9.1 [2.4-15.3] years), 365 (22%) from 52 sites had documented neurologic involvement. Patients with neurologic involvement were more likely to have underlying neurologic disorders (81 of 365 [22%]) compared with those without (113 of 1330 [8%]), but a similar number were previously healthy (195 [53%] vs 723 [54%]) and met criteria for multisystem inflammatory syndrome in children (126 [35%] vs 490 [37%]). Among those with neurologic involvement, 322 (88%) had transient symptoms and survived, and 43 (12%) developed life-threatening conditions clinically adjudicated to be associated with COVID-19, including severe encephalopathy (n = 15; 5 with splenial lesions), stroke (n = 12), central nervous system infection/demyelination (n = 8), Guillain-Barré syndrome/variants (n = 4), and acute fulminant cerebral edema (n = 4). Compared with those without life-threatening conditions (n = 322), those with life-threatening neurologic conditions had higher neutrophil-to-lymphocyte ratios (median, 12.2 vs 4.4) and higher reported frequency of D-dimer greater than 3 μg/mL fibrinogen equivalent units (21 [49%] vs 72 [22%]). Of 43 patients who developed COVID-19-related life-threatening neurologic involvement, 17 survivors (40%) had new neurologic deficits at hospital discharge, and 11 patients (26%) died. In this study, many children and adolescents hospitalized for COVID-19 or multisystem inflammatory syndrome in children had neurologic involvement, mostly transient symptoms. A range of life-threatening and fatal neurologic conditions associated with COVID-19 infrequently occurred. Effects on long-term neurodevelopmental outcomes are unknown.

Surgical outcome and risk factors for cervical spinal cord injury patients in chronic stage: a 2-year follow-up study

This study aims to assess the nerve function deficient recovery in surgically treated patients with cervical trauma with spinal cord injury (SCI) in chronic stage and figure out prognostic predictors of improvement in impairment and function. We reviewed the clinical and radiological data of 143 cervical SCI patients in chronic stage and divided into non-operative group (n = 61) and operative group (n = 82). The severity of neurological involvement was assessed using the ASIA motor score (AMS) and Functional Independence Measure Motor Score (FIM MS). The health-related quality of life was measured using the SF-36 questionnaire. Correspondence between the clinical and radiological findings and the neurological outcome was investigated. At 2-year follow-up, surgery resulted in greater improvement in AMS and FIM MS than non-operative group. Regression analysis revealed that lower initial AMS (P = 0.000), longer duration after injury (P = 0.022) and injury above C4 level (P = 0.022) were factors predictive of lower final AMS. Longer duration (P = 0.020) and injury above C4 level (P = 0.010) were associated with a lower FIM MS. SF-36 scores were significantly lower in higher age (P = 0.015), female patients (P = 0.009) and patients with longer duration (P = 0.001). It is reasonable to consider surgical decompression in patients with cervical SCI in chronic stage and persistent spinal cord compression and/or gross cervical instability. Initial AMS, longer duration, injury above C4 level, higher age and female patients are the five major relevant factors of functional recovery.

Bone status and fractures in 85 adults with Wilson's disease.

Wilson's disease is characterized by copper deposition, especially in the liver and central nervous system. We assessed the prevalent fractures and bone mineral density (BMD) and related risk factors in 85 patients. BMD was normal, but patients with severe neurological involvement, low BMI, and/or amenorrhea are at risk for fractures. Wilson's disease (WD) is characterized by copper deposition, especially in the liver and central nervous system. Two studies showed a high prevalence of osteoporosis in WD patients. We wanted to assess the prevalent fractures and bone mineral density (BMD) and to identify risk factors for bone loss and fractures in a large group of WD patients. In this prospective cross-sectional survey at National center of reference for WD, we included 85 patients, 47 women, and 38 men, with a mean age of 35 ± 10 years, and mean time from diagnosis to study of 21 ± 9 years; 57 (67%) patients had neurological signs. Peripheral fractures, prevalent radiological vertebral fractures (VFx), and dual-energy X-ray absorptiometry BMD measurements at the femoral neck (FN) and lumbar spine (LS) were studied. Mean LS and FN Z-score was normal (-0.37 ± 1.20 at LS and -0.06 ± 1.20 at FN). BMI <19 kg/m(2) and amenorrhea were associated with low BMD. Prevalent peripheral fractures were noted in 43 (51%) and VF in 7 (8%) patients. Severity of neurological involvement and male sex was associated with peripheral fractures, whereas older age, severe neurological involvement, and low BMD and Z-score values were associated with VF. Our data showing normal BMD overall do not support routine bone status evaluation in adults with WD. However, patients with severe neurological involvement, low BMI, and/or amenorrhea are at risk factors for fractures and may require specific monitoring.

Optical Coherence Tomography and Visual Field Findings in Patients With Friedreich Ataxia

To investigate the optical coherence tomography (OCT) and visual field findings in Friedreich ataxia (FRDA). Ten eyes of 10 patients with genetically confirmed FRDA were included in this study. Twenty-two eyes of 22 age- and sex-matched volunteers served as controls. All eyes were examined with spectral domain OCT (Retinascan Advanced RS-3000; NIDEK) and Humphrey Field Analyzer (HFA II 750; Zeiss-Humphrey Systems). OCT measurements of the average peripapillary retinal nerve fiber layer (RNFL) thickness, average peripapillary retinal thickness (RT), and foveal RT showed a statistically significant reduction in patients with FRDA (P < 0.0001). There was no statistically significant difference in choroidal thickness. OCT measurements of horizontal cup-to-disc (C/D) ratio, vertical C/D ratio, and average cup area were significantly increased in patients with FRDA. Visual acuity was significantly correlated with age at onset (P = 0.021) and average RNFL value (P = 0.045). There was a significant correlation between foveal thickness and disease duration (P = 0.014). Mean RNFL thickness was significantly correlated with the severity of neurological involvement (P = 0.039). Visual field testing (VFT) revealed a generalized reduction of sensitivity in the patients. Patients with FRDA may have a measurable degree of retinal thinning as determined by OCT and a generalized reduction of sensitivity in VFT. Combining structural and functional findings may be used in the follow-up of patients with FRDA.

Brain and Spinal MR Imaging Findings in Mucopolysaccharidoses: A Review

MPS represents a group of rare hereditary disorders characterized by multisystem involvement due to intralysosomal GAG accumulation. Among various tissues, both the central and peripheral nervous system are affected in almost all types of the disease. Thus, brain and spinal MR imaging are valuable tools for the assessment of neurologic involvement, and there is evidence that they might be reliable markers demonstrating disease severity and efficacy of treatment options currently used in patients with MPS. We aimed to review the most prominent MR imaging features of patients with MPS, paying attention to the physiopathologic mechanisms responsible for these alterations. Along with the description of neuroimaging findings, existing data in relation to their correlation with the severity of neurologic involvement is discussed, while another topic of great importance is the effect of various therapeutic regimens in the progression of brain and spinal MR imaging alterations. Finally, recent data concerning MR spectroscopy studies in MPS are also critically discussed.

Surgical treatment of hip dislocation in patients with infantile cerebral palsy

The results of 63 operations on 52 patients with cerebral palsy, which were performed between 1978 and 1988 to correct a subluxation or dislocation of the hip, were reviewed. The innominate pelvic osteotomy was preferably combined with intertrochanteric femoral osteotomy and soft tissue release. The average age at time of surgery was 7 years/2 months. Surgical intervention was indicated irrespective of the severity of neurologic involvement. The mean follow-up period is 3 years/4 months. The results show, that by a combinations of these surgical procedures a permanent stability of the hip joint can be achieved. Retrospectively the 5 cases of reluxation can be explained by insufficient surgical technique. The postoperative development of the CE-angle and the acetabular index reveal, that after adequate reduction of the femoral head the acetabulum is able to remodel its dysplasia. From a functional point of view actually patients with diplegia gained the most benefit from a stable hip joint, because they showed the most progress in motor activity. In tetraplegic patients the long-term success of these surgical procedures must be seen in the prevention of a painful hip in adult life, the maintenance of sitting-stability and the improvement of perineal care condition.

Multiple sclerosis in childhood and adolescence: clinical features and management.

The presentation of multiple sclerosis (MS) in childhood has traditionally been thought to be rare. However, more paediatric cases are now being reported, as a result of progress in diagnostic techniques with the use of sensitive imaging modalities of the brain and spinal cord. Management from an early age and the availability of new treatment options have changed the outcome of paediatric MS. Drugs currently available for treatment, such as beta-interferons, copolymer-1 and intravenous immunoglobulin G, have been found to reduce relapse rate, disease severity and progression to disability in adults, but have not been investigated in children and adolescents. The overall outcome of MS in children is apparently no worse than in adults and the disease may even be less aggressive in children. In juvenile MS, disease progression does not appear to be related to age of onset, severity of neurological involvement or mono/polysymptomatic involvement at presentation. The potential to treat MS has significantly changed the prognosis. Early diagnosis is important, as early treatment can prevent or delay the development of disability.

Prevalence and Characteristics of Dysarthria in a Multiple-Sclerosis Incidence Cohort: Relation to Neurological Data

Few attempts have been made to use degree and type of multiple sclerosis (MS) dysarthria in neurological evaluation. In the present study, 77 individuals drawn from an MS population were examined both by a speech pathologist and a neurologist, and data from three sources of information were subsequently combined: (1) a clinical dysarthria test procedure, (2) a perceptual analysis of speech characteristics in continuous speech, and (3) neurological deficit scoring. The speech of 15 age- and gender-matched healthy control subjects was also investigated. It was concluded that: (1) the prevalence of mild to severe dysarthria in this cohort was 51% and occurred in all components of speech production: respiration, phonation, prosody, articulation and nasality. (2) The clinical dysarthria test was sensitive in detecting subclinical speech signs. The prevalence of pathologic speech signs found on the basis of the test was found to be 62%. The prevalence of dysarthria based on the neurological evaluation alone was 20%. (3) The dysarthria of MS was a predominantly mixed dysarthria, with both ataxic and spastic speech signs frequently present in the speech of a given individual. (4) Furthermore, when a predominant type of dysarthria existed, it was not generally associated with a characteristic profile of neurological deficits. Rather, severity of speech deviation was positively correlated to overall severity of neurological involvement, type of disease course, and number of years in progression.

Factors Predicting Postoperative Complications Following Spinal Fusions in Children with Cerebral Palsy

A retrospective review of 107 patients with cerebral palsy who had undergone a posterior spinal fusion with unit rod instrumentation by the same two surgeons was done to determine what factors cause complications that lead to delayed recovery time and a longer than average hospital stay. The operative risk score was developed with scores for the child's ability to walk and talk, oral feeding ability, cognitive ability, and medical problems within the year prior to surgery. Operative risk score is primarily a measure of degree of neurologic involvement. The postoperative complication score (POCS) is a combined measure of all postoperative complications including factors for prolonged intubation, intensive care unit stay, hospital stay, and delayed feeding. The mean age at surgery was 14.3 years. The mean weight was 29.5 kg, with 89 of 107 patients below the fifth percentile for weight compared with age. The mean degree of spinal deformity was 75.2 degrees (range 43-120 degrees ). The mean weight for age was -1.96 SD below the normal. The mean operative time was 4.3 h, with estimated blood loss of 1.2 blood volumes. The mean length of hospitalization was 23 days 2 h, with 5 days 2 h in the intensive care unit. The operative risk score and weight for chronological age below the fifth percentile showed statistical significance (p = 0.05) in regard to increased POCS. The weight for height-age and deficient total lymphocyte count, both factors that measure nutritional status, showed no statistical significance (p > 0.05) compared with POCS. Curves with deformity of >70 degrees had statistically significant high POCS (p = 0.03). Complications for patients having a posterior and an anterior surgery versus those who had a posterior fusion alone were not statistically different (p > 0.05). The factors that led to a greater rate of complications were the severity of neurologic involvement, severity of recent history of significant medical problems, and severity of scoliosis.

Juvenile multiple sclerosis: Clinical features and prognostic characteristics

In a retrospective study we analyzed clinical features and their prognostic significance in 72 patients with onset of multiple sclerosis by the age of 21 years. In juvenile multiple sclerosis disease progression does not depend on age of onset, severity of neurologic involvement, or polysymptomatic or monosymptomatic involvement at presentation. (J Pediatr 1998;132:735-7)

Neurological State, Infarct Size and Clinical Outcome Are Related to Early Platelet Count Decrease in Stroke

We performed this study in order to verify the existence of a correlation between early platelet count reduction and initial neurological impairment, infarct extension and mortality or clinical outcome in an established ischemic cerebral infarction. The results demonstrate that the platelet consumption and/or accumulation in the infarct area, expressed by circulating platelet decrease, is related to the severity of neurological involvement, infarct size and poor clinical outcome.

Upper and lower limb fractures with concomitant arterial injury.

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage.

The odontoid process in Morquio-Brailsford's disease. The effects of occipitocervical fusion

High definition computed cervical myelograms have been made in flexion and extension in 13 patients with Morquio-Brailsford's disease. We observed that: 1) odontoid dysplasia was present in every case, with a hypoplastic dens and a detached distal portion which was not always ossified; 2) atlanto-axial instability was mild, and anterior atlanto-axial subluxation was absent in most cases; 3) severe spinal cord compression, when present, was due to anterior extradural soft-tissue thickening; 4) this compression was not relieved by flexing or extending the neck and was manifested early in life; 5) posterior occipitocervical fusion resulted in disappearance of the soft-tissue thickening and normalisation of subsequent development of the dens. We conclude that the severity of neurological involvement at the craniovertebral junction was determined by soft-tissue changes, not by the type of odontoid dysplasia nor by subluxation. Posterior occipitocervical fusion proved to be an effective treatment.

Prognostic Significance of Computed Tomography of the Brain in Thrombotic Thrombocytopenic Purpura

We studied the prognostic value of computed tomography (CT) of the brain for neurologic morbidity in patients with thrombotic thrombocytopenic purpura. On review of Mayo Clinic records for 1975 through 1985, we found 32 patients with thrombotic thrombocytopenic purpura, 20 of whom had undergone CT of the brain during their hospitalization. Despite major neurologic symptoms and signs, normal CT findings were associated with complete neurologic recovery. Seventy percent of patients with normal results of CT of the brain recovered and had no neurologic deficits, whereas 80% of patients with CT abnormalities died or had permanent neurologic sequelae. A review of the literature supports these conclusions. Thus, we suggest that CT of the brain be done in any patient with thrombotic thrombocytopenic purpura and neurologic deficits. Regardless of the severity of neurologic involvement, normal CT findings should encourage continued vigorous treatment of the patient because a normal scan supports the possibility of full clinical recovery.

The Untreated Unstable Hip in Severe Cerebral Palsy

The incidence of pain and other complications associated with the untreated spastic dislocated or subluxed hip was investigated in 80 institutionalized patients. The average patient age was 19 years, and the average length of follow-up study was 12 years. Eighty-five percent of the patients had scoliosis, and 56% had significant pelvic obliquity. A dislocated hip predisposed to lower extremity fractures but did not present problems of pain, decubitus ulcers, or difficulties with perineal hygiene. The loss of sitting balance, scoliosis, and pelvic obliquity are correlated with the severity of neurologic involvement rather than with the mechanics of a dislocated hip.

Integrative functions in parkinsonism.

The effects of neurological involvement upon integrative performance were assessed through visual-motor, perceptual, and cognitive test performance of parkinsonian and cardiac patients. No significant differences were obtained between the test results of parkinsonian and cardiac patients. For parkinsonian patients no significant variations in “higher integrative” functions could be attributed to differences in sex, age, extent of voluntary movement impairment, and laterality or severity of neurological involvement. Degree of autonomic nervous system impairment was related to psychological performance only in one test (“Odd Words” test). It was suggested that perceptual-cognitive performance of groups of parkinsonian Ss does not necessarily qualify as “organic” in the usual psychological sense.

Cerebral Blood Flow and Metabolism in Pernicious Anemia

Abstract1. Cerebral blood flow and metabolism were measured in 16 patients with pernicious anemia. Seven of the patients were restudied in various stages of therapy.2. The patients fell into two equal groups, those with severe anemia and those with moderate or no anemia. In the first group, cerebral blood flow was increased and cerebral vascular resistance decreased; in the second group, cerebal blood flow was decreased and vascular resistance increased. In both groups, cerebral oxygen and glucose consumption was decreased, as was cerebral venous oxygen tension.3. There was a good correlation between the mental status defects and cerebral oxygen consumption and between severity of neurologic involvement and cerebral oxygen consumption. There was no correlation between cerebro-vascular resistance and cerebral oxygen consumption, nor between degree of anemia and cerebral oxygen consumption.4. Specific therapy resulted in a moderate increase in cerebral oxygen consumption and cerebro-vascular resistance. In no instance did cerebral oxygen consumption become normal.5. The disparity between the functional ability of the patients and the low values for cerebral metabolism is discussed.6. It is concluded that pernicious anemia results in specific nervous system involvement not related to the anemia, and that this damage is at least partially irreversible in many patients.