Unilateral Weakness Research Articles

Pairing Transcutaneous Auricular Vagus Nerve Stimulation & Constraint-Induced Movement Therapy to Improve Motor Function in Infants

Abstract Date Presented 04/20/2023 Children with unilateral weakness may demonstrate improved functional goal achievement with less dosage requirement when constraint-induced movement therapy (CIMT) is paired with transcutaneous auricular vagus nerve stimulation (taVNS), indicating less burden to participants and encouraging translation to OT clinical practice. Primary Author and Speaker: Patricia Coker-Bolt Additional Authors and Speakers: Elizabeth Humanitzki Contributing Authors: Kelly McGloon, Julia Schoeder Brennan, Annie Cribb, Bashar W. Badran, Mark George, Dorothea Jenkins

Automated assessment of facial nerve dysfunction

BACKGROUND: Facial neuropathy at the peripheral level (unilateral muscular weakness of the entire half of the face) is a common neurological disorder. Assessment of the facial nerve dysfunction grade is necessary to track the dynamics of treatment and monitor the effectiveness of rehabilitation. For this purpose, worldwide clinical practice uses grading systems, the most popular of which are the House-Brackmann, Yanagihara, and Nottingham scales. Such methods are non-universal and based on visual diagnosis, which relies solely on the subjective experience of the physician. Consequently, objective measurements and automation are needed to track the dynamics of recovery. With the use of image processing and computer vision techniques, this task became feasible.
 AIM: To develop a method of automated assessment of the facial nerve dysfunction grade by biometric facial analysis to monitor the patients recovery dynamics.
 METHODS: As part of the collaboration with the Herzen Moscow Research Institute of Oncology, a database of target group patients with grades IV (4 people), V (4 people), and VI (11 people) of facial nerve disfunction according to the Haus-Brackmann scale was compiled. A control group consisted of 20 students from the Bauman Moscow State Technical University. During registration, subjects were asked to perform a series of following mimic tests: raising the eyebrows, closing the eyes, smiling, smiling with effort, inflating the cheeks, pouting the lips, and articulating with effort. Control points of the eyebrow, eye, and mouth areas were used to assess the degree of facial asymmetry. The two-dimensional MultiPIE model, implemented in the dlib library and containing 68 control points, was used as a facial model. A program code in Python was written, which calculates asymmetry coefficients based on changes in the coordinates of control points when the patient performs mimic tests.
 RESULTS: A study was conducted to determine statistically significant differences between asymmetry coefficients in the control group and patients. Based on the Mann-Whitney criterion, asymmetry parameters during some mimic tests showed statistically significant differences (p 0.05). Thus, asymmetries in the forehead when raising the eyebrows (0.00 0.05), in the mouth when smiling (0.026 0.05), in the mouth when smiling with effort (0.00 0.05), in the mouth when pouting the lips (0.039 0.05), and in the mouth when articulating with effort (0.004 0.05) were revealed.
 CONCLUSIONS: The results prove the performance of the proposed method and show the need for additional research, particularly the search for differences between groups of patients with different severity and the development of a classification model for machine learning.

Further exploration of the classification and clinical value of head-shaking nystagmus

Objective:To investigate the classification of head shaking nystagmus（HSN） and its clinical value in vestibular peripheral diseases. Methods:Clinical data of 198 patients with peripheral vestibular disorders presenting with HSN were retrospectively analyzed. Video Nystagmograph（VNG） was applied to detect spontaneous nystagmus（SN）, HSN, and Caloric Test（CT）. The intensity and direction of SN and HSN as well as the unilateral weakness（UW） and direction preponderance（DP） values in caloric test was analyzed in patients. Results:Among the 198 patients with vestibular peripheral disease, there were 105 males and 93 females, with an average age of（49.1±14.4） years （range: 14-87 years）. One hundred and thirty seven patients were diagnosed as Vestibular Neuritis（VN）, 12 as Meniere's Disease（MD）, 41 as sudden deafness（SD） and 8 as Hunt's syndrome accompanied by vertigo. Among them, there were 116 patients in the acute phase, including 68 cases（58.6%） with decreased HSN, 4 cases（3.4%） with increased HSN, 5 cases（4.3%） with biphasic HSN, 38 cases（32.8%） with unchanged HSN, and 1 case（0.9%） with perverted HSN. There were 82 cases in the non-acute phase, 51 cases（62.2%） with decreased HSN, 3 cases（3.6%） with increased HSN, 9 cases（11.0%） with biphasic HSN, and 19 cases（23.2%） with unchanged HSN. In biphasic HSN, the intensity of phase I nystagmus was usually greater than that of phase II, and the difference was statistically significant（P<0.01）. There was no correlation between HSN type and course of disease or DP value. The intensity of HSN was negatively correlated with the course of disease（r=-0.320, P<0.001） and positively correlated with DP value（r=0.364, P<0.001）, respectively. The intensity of unchanged nystagmus and spontaneous nystagmus were（8.0±5.7） °/s and（8.5±6.4）°/s, respectively. There was no statistically significant difference in the intensity of nystagmus before and after shaking the head. Conclusion:HSN can be classified into five types and could be regarded as a potential SN within a specific frequency range （mid-frequency）. Similarly, SN could also be considered as a common sign of unilateral vestibular impairment at different frequencies. HSN intensity can reflect the dynamic process of vestibular compensation, and is valuable for assessing the frequency of damage in peripheral vestibular diseases and monitoring the progress of vestibular rehabilitation.

A Case Report of Hirayama Disease Revealed by Upper Limb Weakness and Wasting

Hirayama disease is a rare entity characterized by unilateral or asymmetrical bilateral focal weakness and wasting of muscles innervated by C7, C8, and T1. We report the case of a 20-year-old male who presented with gradual left upper limb weakness and wasting, confirmed by electrophysiological and radiological studies showing detachment of the posterior longitudinal ligament with dilatation of the epidural veins. Anterior displacement with flattening of the medullary cord from C4 to C7 was observed, where there was a T2 hypersignal abnormality involving the anterior horns and producing a "snake eye" appearance. The disease is believed to result from the forward displacement of the cervical dural sac and spinal cord induced by neck flexion, and should be suspected in male patients presenting with unilateral or asymmetrical bilateral lower motor weakness of hands and forearms.

Intravenous tPA administration in patients with negative diffusion-weighted imaging (DWI) study on the MRI brain (P1-4.006)

<h3>Objective:</h3> To identify and analyze the clinical characteristics of the patients that had stroke-like symptoms (stroke mimics) on presentation and received IV tPA but subsequently were found not to have an ischemic stroke. <h3>Background:</h3> Intravenous tissue plasminogen activator (tPA) administration within 4.5 hours of last known normal to the patients presenting with symptoms of stroke is the standard of care. Stroke mimics are a diverse group that is difficult to identify. They present with acute-onset focal neurological deficits, however further work up including MRI (magnetic resonance imaging) of the brain show no evidence of stroke or TIA. The aim of our study is to identify such patients and understand their clinical characteristics. <h3>Design/Methods:</h3> We retrospectively reviewed the medical records and analyzed all the patients in a span of one year that presented with stroke like symptoms and received IV tPA. <h3>Results:</h3> We identified a total of 107 pts that received tPA in a span of year at our institute. Among them there were 11 patients that showed no changes in the DWI sequence of MRI imaging and did not have stroke as their discharge diagnosis. Overall, we found that stroke mimics compromise 10.2 % of the pts that got administered tPA. The age of this group ranged from 38–73. There were seven women and four men. The NIHSS at the time of presentation ranged from 3–19. We identified three patients with hypertensive crisis, two with cervical radiculopathy, two with suspicion of conversion disorder: one each with normal pressure hydrocephalus, sepsis with neurosyphilis, pulmonary embolism with aortic regurgitation and methamphetamine abuse. Majority of them presented with unilateral weakness along with facial weakness and speech difficulties. <h3>Conclusions:</h3> We conclude that in our patient population, only few patients were found to be stroke mimics. <b>Disclosure:</b> Dr. Badugu has nothing to disclose. Dr. PANDEY has nothing to disclose. Dr. Chappidi has nothing to disclose. Dr. Kelley has nothing to disclose.

A Case of Hematomyelia in a Teenager with Behcet’s Disease due to both Warfarin and Intramedullary Cavernous Malformation (P6-5.029)

<h3>Objective:</h3> Highlight the importance of recognizing bleeding of intramedullary cavernous malformation or cavernoma as a cause of spinal cord lesion. <h3>Background:</h3> Intramedullary spinal cord hemorrhage, or hematomyelia, is a rare cause of acute myelopathy. Vascular malformations, anticoagulation therapy, and other bleeding diathesis are the most common causes. Cavernoma is a vascular malformation made of closely clustered, enlarged capillaries with a single layer of endothelium and without the elements of normal vascular structure or normal intervening brain parenchyma. Although they can bleed, cavernomas have a relatively benign prognosis. Hemorrhage of an intramedullary cavernoma during anticoagulation with warfarin was not previously reported. <h3>Design/Methods:</h3> Nineteen-year-old man with Behçet’s disease taking warfarin for intraventricular thrombus and multiple pulmonary emboli complained of acute back pain, unilateral leg weakness, and urinary retention. He had no personal or family history of vascular malformations. Examination was remarkable for paraplegia, a sensory level at T10, lower limb hyporeflexia and Babinski reflex bilaterally. INR was supratherapeutic at 3.6. CT of head, cervical and thoracic spine was unremarkable. <h3>Results:</h3> MRI of spine showed an enhancing intramedullary lesion at T8–T9, 3.8 cm in length, with surrounding edema. The mixed T1 hyperintensity and T2 hypointensity was suggestive of hemorrhage caused by a cavernoma. Warfarin was reversed with prothrombin complex concentrate. He was not a candidate for neurosurgical intervention. At discharge, the patient had not regained any motor or sensory function. <h3>Conclusions:</h3> This case highlights the need to suspect hematomyelia as a cause of acute myelopathy in a patient taking anticoagulation. While anticoagulation is not contraindicated in patients with known cavernoma, there should be a low threshold for considering the presence of a bleeding intramedullary cavernoma in a patient with acute myelopathy. <b>Disclosure:</b> Dr. Sacks has nothing to disclose. Dr. Treidler has nothing to disclose.

Motor Blockade After Erector Spinae Plane Block for Lumbar Spinal Surgery: A Case Report

BACKGROUND: Regional anesthetic techniques, including the erector spinae plane block (ESPB), decrease pain scores while reducing opioid consumption. Given their high safety profile and analgesic efficacy, ESPBs offer an alternative to neuraxial anesthetic techniques for perioperative analgesia. CASE REPORT: Transient unilateral dense L3 motor weakness occurred as a complication of the ESPB performed intraoperatively for an L2-L5 laminectomy and L2-L3 discectomy at the L3 level. The motor weakness was concerning for spinal cord injury and confounded the postoperative neurologic examination. CONCLUSIONS: Lesson learnt from this case suggests the lumbar ESPB should be performed preoperatively in awake patients to avoid confounding physical exam findings in the postoperative anesthesia care unit; this also reduces the need for further emergent imaging and workup. During a lumbar ESPB, a local anesthetic should be deposited at the tip of the transverse process, and not breach the intertransversarii muscle and ligament to favor the dorsal spread and sparing of ventral rami motor fibers. KEY WORDS: Erector spinae plane block, ultrasound, regional anesthesia, spine surgery

Long-term outcome of cervical artery dissection

ObjectiveThe aim of the study is to evaluate the natural history of extracranial cervical artery dissection (CAD) including comorbidities, symptoms at presentation, recurrence of symptoms, and long-term outcome following different treatment approaches. MethodsA retrospective review of patients treated for acute CAD was performed over a 5-year period from January 2017 to April 2022. ResultsThirty-nine patients were included in the study, 25 (64.1%) with acute internal carotid artery dissection and 14 (35.9%) with acute vertebral artery dissection. Thirty-four patients (87.1%) had spontaneous CAD, and five patients (12.8%) had traumatic CAD. The mean age of the cohort was 54.2 years. The mean time from symptom onset to presentation was 4.34 days. The most common symptoms in internal carotid artery dissection were unilateral weakness (44%), headache (44%), slurred speech (36%), facial droop (28%), unilateral paraesthesia (24%), neck pain (12%), visual disturbance (8%), and Horner’s syndrome (8%). The most common symptoms in vertebral artery dissection were headache (35.7%), neck pain (35.7%), vertigo (28.57%), ataxia (14.28%), and slurred speech (14.28%). The imaging modalities used for diagnosis included computed tomography angiography (48.7%), magnetic resonance angiography (41%), and duplex ultrasound (10.2%). In patients with carotid artery dissection, 57% had severe stenosis, 24% had moderate stenosis, and 20% had mild stenosis. All patients treated were managed conservatively with either anticoagulation or antiplatelets. Long-term clinical follow-up was available for 33 patients (84.6%). Thirty patients (90.9%) reported complete resolution of symptoms, and three patients (9%) reported persistent symptoms. Anatomic follow-up with imaging was available for 17 patients (43.58%). Thirteen patients (76.47%) had complete resolution of dissection, two patients (11.76%) had partial resolution of dissection, and two patients (11.76%) had persistent dissection. There was one death unrelated to CAD in a multi-trauma patient. There were four early recurrent symptoms in the first 3 to 8 weeks post discharge. The mean follow-up time was 308.27 days. ConclusionsThe majority of CADs can be managed conservatively with good clinical and anatomical outcome and low rates of recurrence.

Microcervical Foraminotomy for Cervical Juxtafacet Cysts: Case Series and Literature Review.

Juxtafacet cysts are located near or contiguous with the facet joints, and their occurrence is rare in the cervical spine. We report 4 cases of cervical juxtafacet cysts operated by microcervical foraminotomy (MCF) or a combination of MCF and laminoplasty. We simultaneously review previously reported cases in terms of location, clinical findings, and surgical technique. Among the patients who underwent spine surgery at our hospital from 2015 to 2019, 4 had cervical juxtafacet cysts. The images and clinical records of the patients were retrospectively assessed. Relevant previous English literature was searched and reviewed using PubMed. In our series, all 4 patients presented with unilateral upper extremity muscle weakness preoperatively. Two patients underwent MCF, and the other 2 underwent a combination of MCF and laminoplasty with resection of the cyst. All showed improvement in muscle strength. In previously reported cases, the rate of muscle weakness was high. A review of previous cases showed that 75 of 139 patients had cysts at C7-T1. The most common surgical techniques consisted of a hemilaminectomy or laminectomy with the addition of posterior fusion in 28 patients. The number of male patients was twice that of female patients; however, the male-to-female ratio was almost the same in patients with cysts in C7-T1. On pathological diagnosis, there were 3 times more synovial cysts than ganglion cysts. The percentage of synovial cysts was higher in patients with radiculopathy, and the percentage of ganglion cysts was higher in patients with myelopathy. Cervical juxtafacet cysts tend to occur in C7-T1 and cause muscle weakness. Surgical therapy is strongly recommended due to good postoperative improvement. The results of this study suggest that microcervical foraminotomy for cervical juxtafacet cysts can provide favorable symptomatic improvement.

Validating Existing Scales for Identification of Acute Stroke in an Inpatient Setting.

A significant proportion of strokes occur while patients are hospitalized for other reasons. Numerous stroke scales have been developed and validated for use in pre-hospital and emergency department settings, and there is growing interest to adapt these scales for use in the inpatient setting. We aimed to validate existing stroke scales for inpatient stroke codes. We retrospectively reviewed charts from inpatient stroke code activations at an urban academic medical center from January 2016 through December 2018. Receiver operating characteristic analysis was performed for each specified stroke scale including NIHSS, FAST, BE-FAST, 2CAN, FABS, TeleStroke Mimic, and LAMS. We also used logistic regression to identify independent predictors of stroke and to derive a novel scale. Of the 958 stroke code activations reviewed, 151 (15.8%) had a final diagnosis of ischemic or hemorrhagic stroke. The area under the curve (AUC) of existing scales varied from .465 (FABS score) to .563 (2CAN score). Four risk factors independently predicted stroke: (1) recent cardiovascular procedure, (2) platelet count less than 50 × 109 per liter, (3) gaze deviation, and (4) presence of unilateral leg weakness. Combining these 4 factors into a new score yielded an AUC of .653 (95% confidence interval [CI] .604-.702). This study suggests that currently available stroke scales may not be sufficient to differentiate strokes from mimics in the inpatient setting. Our data suggest that novel approaches may be required to help with diagnosis in this unique population.

Abstract TP47: Impact Of Prehospital Care And Patient Presentation On In-hospital Treatment Of Acute Ischemic Stroke

Background: Emergency Medicine Service (EMS) provider compliance with American Heart Association (AHA) guidelines for acute stroke care is low. While early recognition improves in-hospital quality of care, including door-to-computed tomography (CT) time, the impact of compliance with individual recommendations on in-hospital outcomes is unknown. Methods: We identified 410 acute ischemic stroke patients who presented to a Comprehensive Stroke Center via EMS between January 1, 2018, and December 31, 2019. Guideline concordant care was defined as encounters in which EMS documented: a blood glucose, a 12-lead electrocardiogram, a stroke scale result, and time of the last known well; were enroute within less than 2 minutes from dispatch and spent less than 15 minutes on scene. We used a multivariable linear regression model to determine the effect of individual metrics, race/ethnicity, sex, and age on door-to-CT times. Results: There was low compliance with all quality-of-care metrics (37/410 encounters, 9%), but most encounters met at least 4 metrics (60.3%). Compliance with recommendations to maintain short dispatch-to-enroute times and to obtain a blood glucose were the highest (88.1% and 74.5%, respectively). Only 44.5% of encounters documented a stroke scale, but 95.9% documented a neurological exam. A linear regression model identified documentation of classic symptoms (unilateral weakness, facial droop, or speech changes) (parameter estimate -16.6, 95% CI -21.8 to -11.5) and documentation of the last known well time (parameter estimate -15.9, 95% CI -21.6 to -10.1) as significant predictors of door-to-CT times. However, documentation of a last known well occurred only in 59.9% encounters. Conclusions: Like prior studies, this study finds similarly low compliance with AHA stroke guideline and also identifies two key EMS actions that are associated with shorter door-to-CT times - documentation of last known well and recognition and documentation of classic stroke symptoms. Further education is needed to reinforce the importance of individual recommendations such as documentation of last known well and its impact on in-hospital care. Broader analysis of EMS practices is needed to fully understand the impact on additional patient outcomes.

Abstract TP64: Characterization Of Stroke Mimics Treated With Thrombolytics

Background: Stroke is a medical emergency. The effectiveness of stroke treatment is time dependent. Due to the urgency of treatment and the challenge of rapidly assessing stroke-like symptoms, patients with stroke mimics (non-stroke etiologies of focal neurologic symptoms) may be treated with thrombolysis. We aimed to understand characteristics of patients treated with IV tPA with a final diagnosis of stroke versus a stroke mimic. Methods: This retrospective cohort study identified patients who received tPA for stroke-like symptoms in the emergency department at a single urban Comprehensive Stroke Center over 26 months. Final diagnosis was based on ICD-10 codes. Demographic data, medical history and presenting symptoms were obtained through electronic medical record review. Characteristics of patients with strokes and mimics were compared using Chi-squared and t-tests. Results: Of 202 patients presenting with stroke-like symptoms who received tPA, final diagnosis was ischemic stroke in 166 (82%) and mimic in 36 (18%). A statistically significant difference was noted between the stroke and mimic groups in age (64 ±16.9 vs 57 ±13.8 years, p=0.015) and neared significance in sex (38% vs 56% female, p=0.052). There was no difference in initial NIHSS (7.8 ±7.2 vs 5.8 ±5.2, p=0.109), Hispanic ethnicity (13% vs 22%, p=0.170), presence of stroke risk factors (79% vs 78%, p=0.880), or race distribution (white 54% vs 61%, Black 28% vs 14%, multiple/other 18% vs 25%, p=0.199). The most common mimic symptoms included unilateral weakness (61%), unilateral numbness (53%), dysarthria (33%), ataxia (28%), vertigo (22%), and gait impairment (17%). The most common clinical diagnoses in mimics were headache, functional neurologic disorder, and toxic/metabolic disturbances (17% each). Conclusion: Of patients receiving tPA at our facility, stroke mimics comprised 18% and were significantly younger than patients with ischemic stroke. Further analysis of demographics within these two groups could identify characteristics that distinguish strokes from mimics, which may lower the rate of tPA administration to non-stroke presentations.

The role of vestibular cold caloric tests in the presence of spontaneous nystagmus.

The bithermal caloric test is commonly used to detect a canal paresis. However, in case of spontaneous nystagmus, this procedure can provide results of non-univocal interpretation. On the other hand, confirming the presence of a unilateral vestibular deficit can help to differentiate between central and a peripheral vestibular involvement. We studied 78 patients suffering from acute vertigo and showing spontaneous horizontal unidirectional nystagmus. All patients were submitted to bithermal caloric tests, and the results were compared with those obtained using a monothermal (cold) caloric test. We demonstrate the congruence between the bithermal and monothermal (cold) caloric test through mathematical analysis of the results of both tests in patients with acute vertigo and spontaneous nystagmus. We propose to perform the caloric test in the presence of a spontaneous nystagmus using a monothermal cold assuming that the prevalence of the response to the cold irrigation on the side towards which the nystagmus beats is a sign of the presence of pathological unilateral weakness and therefore more likely peripheral in its origin.

Outcome of Endoscopic Management of Chronic Subdural Haematoma: A Retrospective Study

Introduction: Chronic Subdural Haematoma (CSDH) is a condition with a collection of liquefied blood in the subdural space, which usually develops at least three weeks after an injury. Endoscopic evacuation of CSDH is a minimally invasive technique that has been shown to be effective in reducing the need for surgical dissection. Aim: To evaluate the outcome of endoscopic evacuation for CSDH. Materials and Methods: This retrospective study was conducted at the Department of Neurosurgery, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India and its affiliated hospitals from January 2021 to December 2022. All patients with CSDH on non contrast CT were included, except those with incomplete records, organised CSDH, secondary CSDH within six months of neurosurgery or meningitis, and those with an injury-to-procedure interval of less than 15 days. At admission, socio-demographic data (age, gender), clinical variables (headache, forgetfulness, hemiparesis, giddiness, speech difficulties), and co-morbidities were recorded. Pre and post-assessment were done by Glasgow Coma Scale (GCS). Descriptive statistics was used and results were expressed in terms of frequency and percentages. Results: A total of 20 patients with unilateral CSDH (predominantly on the left-side) were included, among which 16 were males and 4 females with a mean age of 64.45 years. The most common presenting complaints were headaches, forgetfulness, and unilateral weakness. Most patients had a GCS score of 14-15, and four had co-morbidities such as diabetes and hypertension. No brain tissue injury was observed during the endoscopic evacuation, and all patients achieved complete recovery (GCS score: 15) without any recurrence, infection, fresh bleeding, or brain or membrane injury. Rapid brain expansion occurred in 16 patients; Subdural Drains (SDD) was kept for five days in four patients. Conclusion: Endoscopic evacuation of CSDH is a safe and effective technique for improving clot removal and reducing the recurrence rate.

ИНТРАДУРАЛЬНАЯ ШВАННОМА ПОДЪЯЗЫЧНОГО НЕРВА БЕЗ ПАРЕЗА И АТРОФИИ ЯЗЫКА: КЛИНИЧЕСКОЕ НАБЛЮДЕНИЕ И ОБЗОР ЛИТЕРАТУРЫ

Hypoglossal nerve (HyN) schwannomas are uncommon tumors. The leading symptoms are unilateral tongue weakness and atrophy. The neoplasms are diagnosed by MRI imaging. The surgical treatment of hypoglossal schwannomas (HS) is challenging because the tumor is closely related to brainstem structures, cranial nerves, and arteries of the vertebrobasilar system. Their removal is associated with a high risk of patient disability. This report presents a clinical case study of a 68-year-old patient with an unusual clinical presentation of intradural HS. There were no signs of tongue weakness or atrophy observed in the patient. After the tumor was diagnosed, it was radically removed. This case highlights the importance of early detection and complete microsurgical resection of schwannoma to prevent neurological deficits and ensure a favorable postoperative outcome, thus maintaining the patient's quality of life. Keywords: Hypoglossal nerve, schwannoma, tongue weakness and atrophy, microsurgery.

Expressionless Physiognomy–A Case of Moebius Syndrome

Moebius syndrome (MBS) is a rare neurological disorder which characterized by bilateral or unilateral facial nerve weakness with bilateral abducens nerve palsy. It can affect multiple cranial nerves with an incidence of 2–20 cases per million births. We report a 6 years female child with MBS with morpho-functional deficits and developmental problems.

Comparison of laser therapy and galvanic stimulation on facial appearance and function in Bell’s palsy among south Indian population

Introduction and Aim: Bell’s palsy is an instantaneous lower motor neurons injury of 7th cranial nerve associated with infection and swelling. It produces unexpected unilateral weakness of facial muscles, progresses rapidly and attains peak symptoms within a week. The most common age of incidence is between 20 to 40 years. Although facial paralysis in Bell’s palsy is self-limited, only 80% of the patients make a full recovery. There are studies stating that both galvanic electrical stimulation and laser therapy speed up the recovery of facial paralysis, but the extent of complete recovery is unknown. Hence, this study is an attempt to understand and compare how laser therapy and galvanic electrical stimulation affect facial appearance and facial muscle functions in Bell's palsy. Materials and Methods: This study included thirty subjects with acute onset of Bell’s palsy aged between 20-40 years. They were randomly grouped into A and B. Galvanic electrical stimulation and low-level laser therapy were given to group A and group B respectively for 6 weeks (3 sessions/week) along with facial exercises. Facial disability index scale was used to measure facial muscle function and Sunny brook scale was used to measure facial symmetry in pre- and post-treatment periods. Results: When comparing the pre- and post-mean values of groups A and B on the Sunny Brook facial grading and the facial disability index (physical, social), group B (with low level laser therapy) showed a highly significant difference in mean values at p 0.001. Conclusion: Low-level laser therapy can be used as an adjective in treating the patients with Bell’s palsy.

A novel frameshift variant in the ADA2 gene of a patient with a neurological phenotype: a case report

BackgroundAdenosine deaminase 2 (ADA2) deficiency is an inherited autoinflammatory syndrome caused by a defect in the ADA2 gene. Most common manifestations include peripheral vasculopathy, early-onset stroke, immunodeficiency, and haematological manifestations. Patients with pathogenic variants that are more detrimental to ADA2’s enzymatic function (e.g. frameshift) have been reported to be prone to developing hematological phenotype. We report here the case of a 13-year-old Caucasian girl with a novel frameshift variant in the ADA2 gene and a clinical phenotype of early-onset stroke.Case presentationThe patient was admitted to hospital with complaints of weakness in her right arm, unilateral facial weakness and speech problems. Her initial laboratory workup was normal; however, magnetic resonance imaging of her brain confirmed acute/subacute ischaemic changes in the posterior limb of the left-sided internal capsule and in the apical part of the thalamus. She also had manifestations of immunodeficiency – recurrent skin infections and otitis, chronic Molluscum contagiosum infection in anamnesis and B cell deficiency with a low level of serum IgA. The patient’s DNA was analysed and two pathogenic variants were identified in the ADA2 gene, confirming a diagnosis of adenosine deaminase 2 (ADA2) deficiency. While one of the variants (c.506G > A (p.Arg169Gln)) has been reported previously, the other one is a novel frameshift variant, namely, c.464del (p.Pro155Hisfs*29). The patient received stroke rehabilitation, which significantly improved her functional state. Tumour necrosis factor inhibitor and methotrexate treatment was commenced, and the patient has remained stable with no further ischaemic events.ConclusionsAlthough rare, ADA2 deficiency should be considered in patients with early-onset stroke, especially with concomitant manifestations of inflammatory features or immunodeficiency. This case report extends the genotypic spectrum of ADA2 deficiency.

Peripheral facial nerve palsy in children: clinical manifestations, treatment and prognosis.

Sudden onset of unilateral weakness of the upper and lower muscles of one side of the face is defined as peripheral facial nerve palsy. Peripheral facial nerve palsy is often idiopathic and sometimes it could be due to infectious, traumatic, neoplastic, and immune causes. This study aimed to report the clinical manifestation, evaluation, and prognosis in children with peripheral facial nerve palsy. 57 children under 18years of age diagnosed with peripheral facial nerve palsy at Çukurova University, Balcalı Hospital, between January 2018 and September 2021, were included in the study. The mean age of the children at the time of diagnosis was 9.6 ± 7, 4years. Thirty-two (56.1%) of the patients were female and 25 (43.9%) were male. A total of 57 patients were diagnosed with peripheral facial nerve palsy and categorized into many groups by etiology: idiopathic Bell's palsy in 27 (47.5%), infectious in 11 (19.2%), traumatic in 6 (10.5%), and others (due to congenital, immune, neoplastic, Melkersson-Rosenthal syndrome, drug toxicity, and iatrogenic causes) in 13 (22.8%). Forty-six of the children achieved full recovery under oral steroids within 1-7months. Four patients with acute leukemia, myelodysplastic syndrome, Mobius syndrome and trauma did not recover and two patients (schwannoma, trauma) showed partial improvement. Five patients could not come to follow-up control. Peripheral facial nerve palsy is a rare condition in children with different causes. It could be idiopathic, congenital, or due to infectious, traumatic, neoplastic, and immune reasons. So, when a child presents with facial palsy, a complete clinical history and a detailed clinical examination are recommended. Giving attention to the red flag is very important. Peripheral facial nerve palsy in children is considered to have a good prognosis.

Effects of Compression Stockings on Body Balance in Hemiplegic Patients with Subacute Stroke

(1) Background: Stroke patients with hemiplegia have an increased risk of developing deep vein thrombosis (DVT). DVT increases the risk of life-threatening pulmonary embolism and is associated with poor prognosis. The early wearing of compression stockings can help prevent DVT. This study aimed to assess the impact of compression stockings on body balance in stroke patients with unilateral lower extremity muscle weakness; (2) Methods: Hemiplegic stroke patients in the subacute phase who were able to walk with assistance were recruited. The patients were divided into two groups: one group received rehabilitation treatment with compression stockings, and the other received treatment without compression stockings. The rehabilitation treatment involved hospitalization for 4 weeks, the Trunk Control Test (TCT), the Trunk Impairment Scale (TIS), and the Berg Balance Scale (BBS). The patients were evaluated before and 4 weeks after the start of treatment. The differences in BBS, TCT, and TIS before and after treatment between the two groups were compared; (3) Results: Altogether, 236 hemiplegic stroke patients were recruited. There was an improvement in body balance after treatment in both groups, and BBS, TCT, and TIS scores significantly increased in the group that received rehabilitation treatment with compression stockings; (4) Conclusions: In patients with hemiplegic stroke in the subacute period, rehabilitation while wearing compression stockings appears to improve body balance.