Unexplained Headache Research Articles

Comparison of the Application Value of Transthoracic Echocardiography in Diagnosing Patent Foramen Ovale Under Different States of Stimulation: A Retrospective Study.

This study aims to evaluate the application value of contrast-enhanced transthoracic echocardiography (cTEE) in the diagnosis of patent foramen ovale (PFO) under different states of stimulation, with the goal of enhancing the accuracy and efficiency of PFO diagnosis. This research consecutively enrolled patients suspected of having PFO from October 2022 to February 2024, presenting primary clinical symptoms such as unexplained syncope, headache, dizziness, and stroke. Patients underwent standard transthoracic echocardiography (TTE) and cTEE under three different states of stimulation (resting state, coughing, and Valsalva maneuver). Based on the presence of microbubbles in the left heart and their initial appearance time, patients were classified into PFO and control groups, with further diagnostic confirmation via transesophageal echocardiography (TEE) or foramen ovale closure procedures. The study results revealed significant differences between the PFO and control groups regarding age (p = 0.034) and headache symptoms (p = 0.001). In the PFO group, TTE showed a higher positivity rate both at rest and during coughing, highlighting the association between PFO and specific clinical symptoms. The number of microbubbles observed during TTE increased significantly under various stimulation states, particularly during the Valsalva maneuver (p < 0.05). This increase became more pronounced as the duration of the maneuver was extended, underscoring the differential response of PFO patients under varied physiological testing conditions, especially during prolonged Valsalva maneuvers. The study confirms the significant value of cTEE in diagnosing PFO under different stimulation states, particularly emphasizing the application of the Valsalva maneuver to significantly improve the sensitivity and specificity of PFO detection. Thus, incorporating cTEE examinations under various stimulation states holds significant clinical importance for enhancing the accuracy and efficiency of PFO diagnosis.

Neurological manifestations among Egyptian children with familial Mediterranean fever

BackgroundFamilial Mediterranean fever (FMF) is an auto-inflammatory periodic disorder resulting from mutations in the Mediterranean fever gene. Although it is considered a polyserositis disease, neurological-associated symptoms were also reported among different populations.Aim of the workTo detect the frequency of neurological manifestations among Egyptian children with FMF and to investigate its association with various disease characteristics and various FMF gene mutations.Patients and methodsThis is an analytical cross-sectional study that enrolled 300 FMF children. Neurological manifestations such as headache, paresthesia, convulsions, tremors, breath-holding attacks, and syncope were reported. The dose, duration, and compliance with colchicine and the international severity scoring system for FMF (ISSF) were recorded. Serum amyloid A and gene mutations were recorded from patients’ files.ResultsThe mean age of the patients was 10.35 ± 2.89 years; 158 (52.7%) were females, and 142 (47.3%) were males (F:M, 1.1:1), age at onset 4.67 ± 2.35 years and disease duration 3.28 ± 1.31 years. Genetic testing revealed positive MEFV gene mutation in 89.3%. Serum amyloid A was elevated in 33.7%. All patients were treated with colchicine, and 81.3% were compliant. Neurological manifestations were detected in 160 (53.3%) patients. Headache was the most common symptom in 136 (45.3%), followed by paraesthesia in 76 (25.3%). Epilepsy was present in 7 (2.3%) cases. Headaches were most frequent among patients with compound heterozygous mutation, severe ISSF scores, and poor compliance with colchicine.ConclusionEgyptian children with FMF present with various neurological manifestations. Headache and paresthesia were the most frequent, especially with the compound heterozygous mutations, severe ISSF score, and among colchicine non-compliant patients. Rheumatologists and neurologists should be aware of these manifestations and address the importance of disease control and adherence to colchicine to avoid or decrease these manifestations. Persistent unexplained headache or other neurological manifestations, in the presence of other symptoms suggestive of FMF or high serum amyloid A, should raise suspicion of FMF, and genetic testing should be requested. A multidisciplinary approach must be considered when managing these children.

A rare case of atraumatic CSF leak into brachial plexus elements

We present the case of a patient with unexplained postural headaches who was found to have an atraumatic Cerebrospinal Fluid (CSF) leak from the foraminal and extraforaminal epidural spaces at the levels of C5-C6, C6-C7, C7-T1, and T1-T2, with contrast tracking along the brachial plexus elements as well as the bilateral scalene and paraspinal musculature. This is a rare presentation as the etiology was not connected to brachial plexus injury or surgical trauma but rather was a spontaneous occurrence. The patient was successfully treated with a CT-guided epidural blood patch that conferred complete resolution of the symptoms. We hope this case study offers clinical utility with the diagnosis and management of patients with orthostatic headaches.

Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome presenting as recurrent aseptic peritonitis in a patient receiving peritoneal dialysis: a case report

BackgroundVacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is caused by mutations in the ubiquitin-activating enzyme1 (UBA1) gene and characterised by an overlap between autoinflammatory and haematologic disorders.Case presentationWe reported a case of a 67-year-Japanese man receiving peritoneal dialysis (PD) who had recurrent aseptic peritonitis caused by the VEXAS syndrome. He presented with unexplained fevers, headache, abdominal pain, conjunctival hyperaemia, ocular pain, auricular pain, arthralgia, and inflammatory skin lesions. Laboratory investigations showed high serum C-reactive protein concentration and increased cell count in PD effluent. He was treated with antibiotics for PD-related peritonitis, but this was unsuccessful. Fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography images demonstrated intense FDG uptake in his left superficial temporal artery, nasal septum, and bilateral auricles. The working diagnosis was giant cell arteritis, and he was treated with oral prednisolone (PSL) 15 mg daily with good response. However, he was unable to taper the dose to less than 10 mg daily because his symptoms flared up. Since Tocilizumab was initiated, he could taper PSL dose to 2 mg daily. Sanger sequencing of his peripheral blood sample showed a mutation of the UBA1 gene (c.122 T > C; p.Met41Thr). We made a final diagnosis of VEXAS syndrome. He suffered from flare of VEXAS syndrome at PSL of 1 mg daily with his cloudy PD effluent. PSL dose of 11 mg daily relieved the symptom within a few days.ConclusionsIt is crucial to recognise aseptic peritonitis as one of the symptoms of VEXAS syndrome and pay attention to the systemic findings in the patients.

The association between patent foramen ovale and unexplained syncope in pediatric patients

BackgroundPatent foramen ovale (PFO) is associated with transient ischemia attack (TIA) or stroke, paradoxical embolism, and migraines. PFO closure decreases the recurrent incidence of cerebral ischemic events and reduces the incidence of syncope in adults. However, whether PFO is associated with syncope in pediatric patients has not been investigated.Methods1001 pediatric patients (aged 4 to 17 years, mean age 10.31 ± 2.61 years, 519 males) who complained of unexplained syncope, palpitation, headache, dizziness and chest pain and were hospitalized in the Syncope Ward, The Second Xiangya Hospital, Central South University between January 2013 and April 2022 were recruited. Children with definite etiology of syncope, neurological, cardiogenic, psychological and other system diseases were excluded. PFO was measured by transthoracic echocardiography and right-heart contrast echocardiography was performed to identify the presence of right-to-left shunting. The demographic data and medical records were retrospectively reviewed and analyzed.Results276 cases were included in the simple syncope group, 379 cases in the headache/dizziness group, 265 cases in the chest pain group, and 81 cases in the palpitation group. The incidence of PFO between the four groups was insignificant (4.71%, 4.74%, 4.15%, 6.17%, respectively, P = 0.903). Multivariate Logistic regression demonstrated that PFO is not associated with the increased risk of syncope (P = 0.081).ConclusionPFO may not increase the risk of syncope in pediatric patients. Further study may include a large and multicenter sample to investigate the association between PFO and unexplained syncope.

The Risks associated with treating S.M.A.R.T syndrome using Blood Thinners for pediatric patients who received Cranial/Spinal irradiation. A case study.

S.M.A.R.T Syndrome (Stroke-like Migraine Attacks after Radiation Therapy) is a late complication after cranial radiation, along with seizures, and white matter lesions. SMART syndrome is diagnosed in patients who previously received craniospinal irradiation presenting with unexplained headaches, seizures and hemiparesis (weakness on one side of the body which is revirsable) few years after irradiation. M.R.I (Magnetic resonance imaging) is usually helpful in diagnosis. In such cases, blood thinners such as Aspirin are prescribed as a medication to decrease the potential risks associated with radiation induced brain infarction/necrosis to avoid further deterioration. However blood thinners such as Aspirin have been linked to sudden hematoma occurring in the brain. The case reported was observed in a patient with vasculopathy/S.M.A.R.T syndrome who previously underwent high dose chemotherapy, and craniospinal irradiation (CSI) and was prescribed baby aspirin which may have contributed to epidural hematoma/hemorrhage.

Limitations of Telemedicine Vs. Face-to-face Eye Examination in a Patient with New Headaches

Background: During the emergence and rise of COVID-19, precaution directives and limitations on in-person eye examinations re-routed a significant portion of care to telemedicine and virtual modalities. While these technologies allowed for healthcare communications that otherwise could not occur during such trying times, there are major limitations to these sanctioned applications. This report will present a seemingly benign case that could have easily been re-routed from an in-person examination to a telemedicine version due to the patient’s seemingly “routine” vision complaints. Case Report: A 50-year-old male patient contacted the eye clinic with a complaint of a minor, new, unexplained headache that he felt may have been related to a change in his vision. The patient requested a telehealth examination with the eye clinic to avoid exposure to COVID-19. After due consideration, the optometry clinic recommended an in-person eye examination despite the very heavy limitations requiring “emergency only” patients in the hospital. On examination it became evident that the cause of the headaches was a rebound hypertensive crisis and the patient did require emergency medical services to stabilize his condition. Conclusion: This case was ultimately a serious emergency that would have been missed via a remote evaluation. The patient was fortunate to have been given a face-to-face appointment during a time of heavy restrictions and essentially emergency-only appointments. This should serve as a reminder to all eye care practitioners that new headaches are a symptom requiring an in-person evaluation, should a future event require similar clinical limitations. Despite the rarity, even a light headache in an early presbyope, as seen in this case, could be the only overt sign of an emergent condition.

PS-R04-4: A CASE OF PHEOCHROMOCYTOMA IN A 17-YEAR-OLD MALE

Background: Pheochromocytoma is a rare catecholamine secreting tumor arising from the adrenal medulla and produces signs and symptoms due to excessive catecholamine secretion from the tumor. It is a rare cause of secondary hypertension and a delay in recognition and treatment can present serious consequences to the patient. Case Summary: We present a case of a 17-year-old male with a history of hypertension for 4 years with episodic headache, palpitations, and sweating. He does not have any history of serious illnesses, hospitalizations, or trauma. He was not on any medications. He has a family history of hypertension. He does not drink alcohol, smoke cigarettes, or do any illicit drugs. Upon arrival to the ER, he was conscious, coherent with BP of 170/140mmHg, PR 111bpm, RR 26cpm, and afebrile. Laboratory work-up showed proteinuria, elevated BUN and creatinine levels, hyponatremia, hypokalemia, and hypocalcemia. A 2D echocardiography showed left ventricular hypertrophy. The whole abdominal CT scan demonstrated a fairly defined hypodense mass in the left suprarenal measuring 4.8 x 6.4 x 4.7 cm. Pheochromocytoma was confirmed by biochemical tests that showed elevated plasma normetadrenaline and 24-hour urine metanephrine. The patient was initially started on an alpha-adrenergic blocker, Terazosin, and a beta-blocker, Propranolol. Blood pressure was still uncontrolled hence calcium-channel blocker, Nicardipine drip was also given to control the blood pressure. During surgery, they noted the mass to be 8x5 cm invading the superior pole to mid pole and renal hilum hence the patient underwent left open adrenalectomy with left radical nephrectomy. Immediately upon removal of the mass, the patient had a hypotensive episode, which was addressed immediately. The histopathologic finding showed no extension of the mass to the kidneys and it is consistent with pheochromocytoma. Blood pressure control without medication was achieved 13 days post-operatively. The patient is regularly monitored for the recurrence of hypertension due to the increased risk of recurrence. The patient is now living with a solitary kidney hence should also be followed up through. Conclusion: Although it is a rare condition, pheochromocytoma should be considered a differential diagnosis in young patients presenting with unexplained hypertension, headache, and palpitations. A multidisciplinary approach is the best way to achieve success in the management of a patient with pheochromocytoma.

Giant cell arteritis in conditions of coronavirus infection (clinical case)

The complexity of timely diagnosis of giant cell arteritis (GCA), as the most common form of systemic vasculitis in the elderly, is due to the nonspecificity of clinical manifestations and the absence of specific immunological markers. New difficulties arise during the period of coronavirus infection, which manifests itself in similar syndromes and at the same time can provoke immuno-inflammatory rheumatic disease. In this regard, it is extremely important to make a correct differential diagnosis between persistent viral infection and the development of systemic vasculitis. This article presents a clinical observation demonstrating the complex process of diagnosis and differential diagnosis of GCA in the conditions of the COVID-19 pandemic. The patient was hospitalized due to a confirmed coronavirus infection. However, despite the standard therapy and the achieved eradication of the coronavirus, the symptoms characteristic of GCA and polymyalgia rheumatica (PR) persisted. A precision analysis of the clinical picture allowed us to establish that the typical manifestations of GCA and PR occurred in the period preceding COVID-19 infection. Subsequent in-depth examination made it possible to verify the diagnosis of GCA and PR based on the current classification criteria. The therapy with glucocorticoid and methotrexate made it possible to achieve remission. The presented observation will help to raise awareness of general practitioners and related specialties about the need to rule out GCA and PR in the case of prolonged unexplained fever, myalgia, headache, joint pain and swelling, transient visual disturbances, jaw claudication in elderly patients in the setting or after coronavirus infection.

Dual-Echo magnetic resonance imaging pulse sequence in diagnosis of temporomandibular disorders

Objective: This study was conducted to assess the diagnostic accuracy of different MRI pulse sequence dual-echo-PD in the diagnosis of temporomandibular disorders. Subjects and methods: Twenty seven patients (54 Temporomandibular joints) with painful joints or limited mouth opening or unexplained longstanding headache were enrolled in the study to examine the diagnostic accuracy of magnetic resonance imaging sequence dual-echo in delineation of the articular disc position, the disc morphology, and the cortical bone in comparison to the gold standard of MRI scanning sequence: proton density weighted images. Results: Dual-echo-PD weighted image showed 94.7% sensitivity and 96.3% diagnostic accuracy in identifying articular disc position. Dual-echo-PD showed no statistically significant difference than proton-density in delineation of disc morphology or cortical bone. Conclusions: The dual-echo imaging sequence can be used instead of using PD to delineate disc position, morphology, and cortical bone.

Assessment of the Availability of Public Health Veterinary Services towards Rabies, Namibia 2020

Background: Rabies is a neglected zoonotic viral disease that occurs worldwide expects Antarctica. Rabies is an endemic throughout the world and they mostly affect poor and vulnerable population who live in remote areas. Death is rarely reported and human vaccine and immunoglobulins exist for rabies, however they are not accessible to the needy people. About 60 000 people die per year mostly in Africa. Domestic animal especially dogs are responsible for transmission of the virus through bites, scratches or saliva. Clinical symptoms may include unexplained tingling, fever, headache, and confusion. As the virus spreads to the central nervous system fatal inflammation of the spinal cord and brain develops. Rabies cause short and long term illness such as paralytic, hydrophobia. Methods: a scoping reviewed and data were collected from five databases namely: PubMed central, biomedical central, HINARI, Google scholar and EBS Cohost. Only articles from 2010-2020 were used and only ten articles were search or meet the objectives of the study. Results: The studies conducted revealed that more effort was done on delivering vaccine to the communities, the educational campaigns were done accordingly. Although educational programs were provided and other public health services it’s discovered that 74% of dog’s owners expressed their knowledge and 24% have never heard about rabies and never took their dogs for vaccine. Conclusion: Local vaccination campaign should make an effort to eliminate the spread of rabies between dogs and human, dog to dogs. Awareness campaign and educational programs should focus more on providing the right and updated information in order to reduce the spread of rabies in human and dogs. In a view of the Public Health importance of rabies, the government, NGOs and community people need to put more effort on the prevention and controlling rabies by making sure dogs are vaccinated against rabies, dog’s owners are given all the information on rabies so that they can help meet the government halfway on fighting rabies.

Socio-psychological factors of personnel management in the context of tourist enterprises development

In modern conditions, which have had a devastating effect on the activities of tourism enterprises, the main tasks remain their preservation and development. Tourism as an industry has a great contribution to the national economy, as it not only provides paid services to the population, but also increases the number of jobs in such industries as transport, construction, hotel and restaurant industry, crafts, museums and more. Personnel management at tourism enterprises should be carried out taking into account the changing environmental conditions, changes in legislation, the ability to carry out tourism activities through hostilities in general. Characteristics of personnel management in crisis conditions of tourist enterprises functioning are considered and social and psychological factors as indicators of activity efficiency are allocated. The article considers the main trends in the functioning of tourist enterprises in the pre-war period, as the war caused almost complete destruction of the tourism sector. Taking into account the current circumstances, the possibilities of forming a motivational mechanism in tourism enterprises, which should be based not on material motivation and wages, but more on labor and status motivation and provide various forms of career advancement, corporate training, development of flexible work schedules and work seats optimization. Psychological factors of personnel management are proposed to be considered in terms of increasing the stress resistance of workers in changing conditions. Among the proposed measures are low-cost opinion polls on the characteristics of stress (loss of appetite or excessive appetite, sleep disturbances, chronic fatigue, rapid speech, loss of humor, irritability, frequent mistakes, unexplained headaches, stomach upset, alcoholism and smoking etc.) at enterprises that allow to identify the level of stress and stress resistance of employees, as well as measures to overcome stress, which are part of corporate culture and promote the tourism enterprises development.

A rare presentation of Carnitine palmitoyltransferase II (CPT-2) deficiency with normal acylcarnitine profile in a 10-year-old boy with muscle weakness and bilateral hearing loss; a case report.

Carnitine palmitoyltransferase II (CPT-2) deficiency is a rare and autosomal recessive disorder of long-chain fatty acids oxidation. Here, we reported a 10-year-old boy with bilateral hearing loss and a myopathic form of CPT II deficiency, which was confirmed by a molecular genetic test. He was admitted to our hospital with unexplained headaches, vomiting, and fever. Furthermore, he developed seizures, muscle weakness, neck stiffness and pain, mild respiratory distress, and an icteric appearance. The laboratory test results also showed severely elevated lactate dehydrogenase levels (LDH) and creatine phosphokinase (CPK) levels. He also had an icteric appearance with unexplained indirect hyperbilirubinemia. Further examinations revealed a normal heart and liver without any neurological disorders. Muscle pathological examination reported normal pathology without neuromuscular and mitochondrial disorders and storage diseases. Finally, molecular test analysis with next-generation sequencing (NGS) revealed CPT-II deficiency fatty acid oxidation disorder. Furthermore, we identified a homozygous pathogenic variant in theADGRV1gene, c.15736C>T p. (Arg5246*), which suggests the Usher syndrome type 2C and the reason for sensorineural hearing loss in this case. Our finding indicates that CPT-II can be associated with multiple symptoms and clinical features. Therefore, evaluation of CPT-II deficiency with molecular test analysis may be helpful in cases with unexplained icteric appearance, muscle weakness, and rhabdomyolysis.

Pneumocephalus secondary to a spinal surgery: A literature review and a case report.

IntroductionWe report a case of pneumocephalus, which is identified as the presence of air in the cranial cavity and is a rare complication after spinal surgeries, in addition to a literature review of similarly reported cases.Case presentationThe patient is a 63-year-old male who developed pneumocephalus after undergoing a minimally invasive left side decompression at L3-L4 with left L4 foraminotomy even though there were no signs of dural tears or Cerebrospinal Fluid (CSF) leaks. After the diagnosis of pneumocephalus using brain Magnetic Resonance Imaging (MRI), the patient was treated conservatively and was discharged after 3 weeks without developing further complications.DiscussionPneumocephalus is defined as an abnormal accumulation of air within the cranial cavity. It can occur due to a variety of causes but rarely due to gas forming bacteria. Many theories are suggested concerning the pathophysiology of pneumocephalus, the inverted bottle theory, the ball valve theory, the Nitrous Oxide (N2O) theory, and as we outweigh in our case, gas forming bacteria theory. Pneumocephalus can be treated surgically, nevertheless, conservative management methods of such cases are usually followed.ConclusionThe aim of this study is to draw further attention to the management and diagnosis of such surgical complication. A more extended research is needed to provide a full comprehensive approach to deal with this problem if faced in the future. To the best of our knowledge, this study reports the first pneumocephalus case induced by a postoperative bacterial infection in the global English based medical literature.

The Value of NOTCH2NLC Gene Detection and Skin Biopsy in the Diagnosis of Neuronal Intranuclear Inclusion Disease.

The clinical manifestations of neuronal intranuclear inclusion disease (NIID) are heterogeneous, and the premortem diagnosis is mainly based on skin biopsy findings. Abnormal GGC repeat expansions in NOTCH2NLC was recently identified in familial and sporadic NIID. The comparison of diagnostic value between abnormal GGC repeat expansions of NOTCH2NLC and skin biopsy has not been conducted yet. In this study, skin biopsy was performed in 10 suspected adult NIID patients with clinical and imaging manifestations, and GGC repeat size in NOTCH2NLC was also screened by repeat primed-PCR and GC-rich PCR. We found that five cases had ubiquitin-immunolabelling intranuclear inclusion bodies by skin biopsy, and all of them were identified with abnormal GGC repeat expansions in NOTCH2NLC, among whom four patients showed typical linear hyperintensity at corticomedullary junction on DWI. Five (5/10) NIID patients were diagnosed by combination of NOTCH2NLC gene detection, skin biopsy or combination of NOTCH2NLC, and typical MRI findings. The diagnostic performance of NOTCH2NLC gene detection was highly consistent with that of skin biopsy (Kappa = 1). The unexplained headache was firstly reported as a new early phenotype of NIID. These findings indicate that NOTCH2NLC gene detection is needed to be a supplement in the diagnose flow of NIID and also may be used as an alternative method to skin biopsy especially in Asian population.

Thyroid Paraganglioma- An Unusual Head and Neck Tumour

Paragangliomas are neuroendocrine tumour originating from the neural crest-derived paraganglia with majority arising from the head and neck. (1)Thyroid paraganglioma are exceedingly rare neuroendocrine tumours accounting for <0.1% of thyroid malignancy (1)We present a 57 years old gentleman who was referred to ENT surgeon following discovery of a two month history of lump on his left neckIt has not changed in size and not caused any symptoms such as anxiety, sweats, palpitations, dizziness or unexplained headaches. He has a Past medical history of epilepsy following a Road traffic accident 28 years ago leaving him seizure prone. He has no family history of neuroendocrine tumours His ultrasound scan of his thyroid gland showed a 25 x 23 x 15mm lesion lying anteriorly within the left thyroid lobe. There are two highly reflective foci which could represent microcalcification. It was classified as U5 lesion He proceeded with fine needle aspiration which confirmed carcinoma of the left thyroid gland with no clear differentiation between follicular or papillary carcinoma. He undergone a total thyroidectomy and left central level VI lymph node dissection His histology confirmed a thyroid paraganglioma staining strongly positive for neuroendocrine markers (Synaptophysin and chromogranin) while S-100 shows positivity in the sustentacular cells. He was referred for genetic testing which demonstrate no evidence of mutation in FH, SDHAF2, SDHB/C/D, RET, MAX, TMEM127 and VHL gene. He was commenced on levothyroxine replacement at a dose of 150micrograms OD. His urine metanephrines is 178.1pmol/L (0-510), urine normetanephrines 192.9pmol/L (0-1180) and 3-methoxytyramine <75pmol/ L (0-180) (all normal). His MRI neck revealed no synchronous tumour. He continues to be followed up under our endocrine clinic.Conclusion: Due to the rarity of these tumours, their natural history is mostly unknown. Nevertheless, postoperative surveillance should include plasma or urinary metanephrines and ultrasonography.

New onset neurologic events in people with COVID-19 in 3 regions in China.

To investigate new-onset neurologic impairments associated with coronavirus disease 2019 (COVID-19). A retrospective multicenter cohort study was conducted between January 18 and March 20, 2020, including people with confirmed COVID-19 from 56 hospitals officially designated in 3 Chinese regions; data were extracted from medical records. New-onset neurologic events as assessed by neurology consultants based on manifestations, clinical examination, and investigations were noted, in which critical events included disorders of consciousness, stroke, CNS infection, seizures, and status epilepticus. We enrolled 917 people with average age 48.7 years and 55% were male. The frequency of new-onset critical neurologic events was 3.5% (32/917) overall and 9.4% (30/319) among those with severe or critical COVID-19. These were impaired consciousness (n = 25) or stroke (n = 10). The risk of critical neurologic events was highly associated with age above 60 years and previous history of neurologic conditions. Noncritical events were seen in fewer than 1% (7/917), including muscle cramp, unexplained headache, occipital neuralgia, tic, and tremor. Brain CT in 28 people led to new findings in 9. Findings from lumbar puncture in 3 with suspected CNS infection, unexplained headache, or severe occipital neuralgia were unremarkable. People with COVID-19 aged over 60 and with neurologic comorbidities were at higher risk of developing critical neurologic impairment, mainly impaired consciousness and cerebrovascular accidents. Brain CT should be considered when new-onset brain injury is suspected, especially in people under sedation or showing an unexplained decline in consciousness. Evidence of direct acute insult of severe acute respiratory syndrome coronavirus 2 to the CNS is lacking.

Symptomatic pneumocephalus following spine surgery: An institutional experience and review of literature

Purpose: The objective of this study was to alert spine surgeons about possibility of pneumocephalus after spine surgery and elaborate its causes, pathophysiology, symptomatology, and management. Materials and Methods: Four patients identified to have symptomatic pneumocephalus after spinal surgery (out of total 7940 operated spine cases over a period of 5 years from January 2013 to December 2017), were included in the study. Compiled data of medical records, operative notes, in-patient treatment records, and radiological findings of these patients were evaluated. Results: All four patients had dural injury with cerebrospinal fluid (CSF) leak. Dura was repaired in two patients and was covered with fat graft in other two. Bifrontal pneumocephalus occurred in three patients while one had intraparenchymal pneumocephalus. All patients were managed conservatively with Trendelenburg position, O2 inhalation, and intravenous hydration along with supportive measures. Conclusion: Pneumocephalus is a rare but serious complication following spine surgery and should be considered in the differential diagnosis in patients presenting in postoperative period with unexplained headache, confusion, and altered sensorium. A high index of suspicion is required to make a diagnosis. Computed tomography scan or magnetic resonance imaging of the brain is required to establish the diagnosis. Most cases respond favorably to conservative treatment. However, occurrence of tension pneumocephalus is a life-threatening condition and might require urgent neurosurgical intervention.

38. Bilateral internuclear ophthalmoplegia and third nerve palsy in giant cell arteritis

IntroductionWe present a case of a gentleman with atypical headache symptoms clinically diagnosed as giant cell arteritis (GCA) and initiated on high dose oral steroids. He subsequently developed progressive neurological deficit including bilateral internuclear ophthalmoplegia (INO), as well as third cranial nerve involvement despite above treatment. He received IV methylprednisolone and demonstrated clinical response, temporal artery biopsy confirmed histological evidence of GCA. The nature of his presentation was atypical of cranial giant cell arteritis. Few reported cases describe INO in the context of GCA, with bilateral manifestation being rarer, especially with additional third cranial nerve involvement.Case descriptionA 66-year-old gentleman presented with a 7-day history of bilateral temporal headaches. He noted prominence of both temporal arteries with mild tenderness during this period. He denied any visual changes, PMR symptoms, and jaw claudication or weight loss. He had been experiencing generalised fatigue and myalgia for the preceding 4 months.He was noted to have raised inflammatory markers (CRP 194, ESR 74) and due to the non-specific nature of headache, concern was for possible meningitis. CT head scan was unremarkable and lumbar puncture and CT-CAP did not demonstrate any abnormality including evidence of infection.He was assessed by the rheumatology team and a clinical diagnosis of GCA was made. He was initiated on prednisolone 60mg daily, and described clinical improvement of headaches over the subsequent day. Inflammatory markers also initially responded to treatment.After 2 days of oral therapy, he developed double vision as well as intermittent headache. CRP remained static at 40. He was seen with the neurology team and was found to have divergent gaze of the left eye with ptosis. Eye movements demonstrated bilateral internuclear opthalmoplegia with involvement of the left third cranial nerve. MRI head scan demonstrated small vessel ischaemic changes but no obvious focal pathology. Due to new visual involvement despite prednisolone 60mg, IV methylprednisolone was administered for a period of 3 days. Ophthalmological symptoms did not progress and CRP reduced to 8. Temporal artery biopsy reported findings consistent with GCA.He was re-established on prednisolone 60mg however intermittent headache recurred and CRP gradually increased. Decision was made to increase prednisolone to 80mg (1mg/kg). At this dose headache resolved and CRP decreased to normal range. Methotrexate was introduced at 20mg weekly in order to facilitate with prednisolone weaning.Within 3 weeks of initial IV methylprednisolone administration, ophthalmological symptoms slowly improved to complete resolution.DiscussionTypical manifestion of cranial GCA consists of unilateral temporal headache. Patients can however exhibit other symptoms including bilateral involvement and features of systemic inflammation which may be non-specific.Cases of neurological involvement have also been described, with diplopia and cranial nerve involvement being widely reported. Few case reports have described bilateral internuclear ophthalmoplegia which is syndrome involving the medial longitudinal fasciculus of the brainstem. This is usually associated with multiple sclerosis however any pathology of this anatomical region can result in this clinical picture. This gentleman additionally demonstrated features of third nerve palsy of the left eye which would be in keeping with a more typical cranial nerve involvement in GCA. The hypothesis for his clinical picture would be of reversible localised ischaemia to the brain stem secondary to active inflammation of the supplying vessel. MRI imaging did not identify any focal pathology and as mentioned previously, following treatment, his clinical findings fully resolved in a gradual manner over a period of weeks.In regards to the management of his case, following exclusion of infection and in the absence of visual findings on presentation, he was started on prednisolone 60mg daily (40-60mg dose suggested within current BSR guidelines). He described improvement of his headache and CRP was seen to improve initially. Despite this treatment, he developed features of INO and third nerve palsy as described. Implementation of IV methylprednisolone therapy prevented further progression of his symptoms and subsequent resolution of raised CRP. However restarting prednisolone at 60mg after this appeared to demonstrate incomplete control of his condition, thus it was increased to 80mg. Decision to introduce methotrexate at an early stage was made in anticipation of likely difficulties in weaning prednisolone.He remains under close follow-up to monitor prednisolone weaning. He currently has not had any recurrence of his symptoms.Key learning pointsGCA can present in an atypical manner and should remain a differential in cases of unexplained headache with associated inflammation. A combination of INO and third nerve palsy is an atypical manifestation of this condition. Due to the nature of his presentation, our gentleman was seen by various specialties including the acute-medical team, rheumatologists and neurologists. Fortunately, a probable diagnosis of GCA was made early and appropriate treatment was initiated. However as this case demonstrates, response to treatment can vary and such adjustments were made to accommodate for this, potentially preventing long term disability.Conflicts of interestThe authors have declared no conflicts of interest.

Ametropia in children with headache.

Objective:To measure the frequency of uncorrected ametropia in children with 2 to 8 weeks of persistent headache referred to ophthalmic outpatient department for evaluation.Methods:This cross sectional study was conducted at CMH Gujranwala from March 2018 to November 2018.A total of 262 children, aged from 5 to 16 years, with 2 to 8 weeks history of persistent headache underwent detailed ophthalmic assessment for refractive errors, and other ophthalmic evaluation. Children with ametropia, confirmed with cycloplegic refraction and post-mydriatic testing were prescribed with glasses. Patients without any ophthalmic findings were referred back to pediatrics department for further evaluation.Results:Mean age of study population was 8.97 ± 3.16 years. Mean duration of headache was 5.03 ± 1.81 weeks. Ametropia was found in 56 (21.4%) children, while 206 (78.6%) had no refractive error. Out of children with ametropia, 20 (35.7%) had myopia, 24 (42.8%) had astigmatism and 12 (21.5%) had hypermetropia. There was no difference in ametropic children and children without ametropia with respect to gender (p=0.73), age (p=0.54) and duration of headache (p=0.71).Conclusion:A significant proportion of children with ametropia have initial symptoms of headache. Any child with un-explained headache must undergo ophthalmic evaluation to diagnose refractive error, if any.