eNeurologicalScieNeurologicalSci Vol 23

June 2021

Review Article

The role of optic nerve sheath diameter ultrasound in brain infection

Gavin A. Stead, Fiona V. Cresswell, Samuel Jjunju, Pham K.N. Oanh, ... Joseph Donovan

  • Article 100330
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  • https://doi.org/10.1016/j.ensci.2021.100330
  • Abstract

    Brain infections cause significant morbidity and mortality worldwide, especially in resource-limited settings with high HIV co-infection rates. Raised intracranial pressure [ICP] may complicate brain infection and worsen neurological injury, yet invasive ICP monitoring is often unavailable. Optic nerve sheath diameter [ONSD] ultrasound may allow detection of raised ICP at the bedside; however, pathology in brain infection is different to traumatic brain injury, in which most studies have been performed. The use of ONSD ultrasound has been described in tuberculous meningitis, cryptococcal meningitis and cerebral malaria; however correlation with invasive ICP measurement has not been performed. Normal optic nerve sheath values are not yet established for most populations, and thresholds for clinical intervention cannot be assumed to match those used in non-infective brain pathology. ONSD ultrasound may be suitable for use in resource-limited settings by clinicians with limited ultrasound training. Standardisation of scanning technique, consensus on normal ONSD values, and action on abnormal results, are areas for future research.

    This scoping review examines the role of ONSD ultrasound in brain infection. We discuss pathophysiology, and describe the rationale, practicalities, and challenges of utilising ONSD ultrasound for brain infection monitoring and management. We discuss the existing evidence base for this technique, and identify knowledge gaps and future research priorities.

Management dilemmas in acute ischemic stroke and concomitant acute pulmonary embolism: Case series and literature review

Faddi G. Saleh Velez, Jorge G. Ortiz Garcia

  • Article 100341
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  • https://doi.org/10.1016/j.ensci.2021.100341
  • Abstract

    Pulmonary embolism (PE) and acute ischemic stroke (AIS) are common disorders with high morbidity and mortality, rarely presenting simultaneously. There is a paucity of data regarding the management of this uncommon presentation. The treatment of these two entities is complex in the acute phase due to the concomitant need for thrombolysis in AIS and anticoagulation for PE.

    AIS and PE stand for a challenge when they present simultaneously. The evaluation of risks and benefits of therapies such as intravenous thrombolysis, mechanical thrombectomy, and catheter-directed-thrombolysis in the clinical context is essential. According to our review, the ischemic stroke burden guides systemic anticoagulation decisions over interventional procedures when the hemodynamic status remains unaffected.


Original Articles

Impact of country self citation on the ranking of the top 50 countries in clinical neurology

Anas M. Bardeesi, Aimun A.B. Jamjoom, Momen A. Sharab, Abdulhakim B. Jamjoom

  • Article 100333
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  • https://doi.org/10.1016/j.ensci.2021.100333
  • Abstract

    To examine the factors that influence country self-citation rate (SCR) in clinical neurology and to assess the impact of self-citation on the ranking of the top 50 countries.

    Self-citation can be appropriate and reflect an expansion on earlier research. Highly cited productive countries tend to have high country SCR. Excluding self-citations had minimal impact on the ranking of the top 50 countries. Our findings indicate that self-citation is unlikely to influence country standing amongst the top 50 and does not support the argument for eliminating self-citations from citation-based metrics. A more globalization through international collaboration in research is encouraged.

Neurological manifestations of patients with mild-to-moderate COVID-19 attending a public hospital in Lima, Peru

Marco H. Carcamo Garcia, Diego D. Garcia Choza, Brenda J. Salazar Linares, Monica M. Diaz

  • Article 100338
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  • https://doi.org/10.1016/j.ensci.2021.100338
  • Abstract

    To determine the prevalence and characteristics of the most common neurological manifestations in Peruvian patients with mild-to-moderate COVID-19, we conducted a single-center prospective, cross-sectional study at an isolation center functioning as a public acute-care hospital during the COVID-19 pandemic in Lima, the capital city of Peru.

    This cross-sectional study found that headaches, and smell and taste dysfunction are common among patients presenting with mild-to-moderate acute COVID-19 in Lima, Peru. International longitudinal studies are needed to determine the long-term neurological sequelae of COVID-19 during the acute and post-infectious period.

Post-COVID seizure: A new feature of "long-COVID"

Keith J. Kincaid, Justin C. Kung, Alexander J. Senetar, David Mendoza, ... Alexis N. Simpkins

  • Article 100340
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  • https://doi.org/10.1016/j.ensci.2021.100340
  • Abstract

    Novel coronavirus SARS-CoV-2 has created unprecedented healthcare challenges. Neurologic deficits are often an important presenting symptom. To date, the only reported post-infectious COVID-19 manifestations of neurologic disease include cognitive deficits and dysfunction of the peripheral nervous system. Here we report that seizure can also be a post-COVID-19 or "long-COVID" complication. We present a 71-year-old man with hypertension, diabetes mellitus, and COVID-19 diagnosed by RT-PCR who initially presented with posterior circulation stroke-like symptoms, which completely resolved after emergent thrombolysis. Six days later, the patient returned with seizure activity, supported by radiographic and electroencephalographic studies. Notably, he was negative for SARS-CoV-2, and no other provoking factor was uncovered after a comprehensive work-up. To our knowledge, this is the first report of post-infectious seizures after a case of COVID-19, highlighting the potential importance of monitoring for neurologic symptoms in COVID-19 patients, even after convalescence

Voxel-based correlation of 18F-THK5351 accumulation with gray matter structural networks in cognitively normal older adults

Yoko Shigemoto, Daichi Sone, Norihide Maikusa, Yukio Kimura, ... Hiroshi Matsuda

  • Article 100343
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  • https://doi.org/10.1016/j.ensci.2021.100343
  • Abstract

    The aim of this study was to evaluate tau-related structural network metrics derived from gray matter magnetic resonance imaging (MRI) scans in cognitively normal (CN) older adults.

    We recruited 47 amyloid-negative CN older adults (mean age ± standard deviation, 65.0 ± 7.9 years; 26 women). All participants underwent 3D T1-weighted MRI and 11C-Pittsburgh compound-B and 18F-THK5351 positron emission tomography scans. Four local network metrics (betweenness centrality, clustering coefficient, characteristic path length, and degree) were computed and rendered on individual brain images. We then evaluated the correlations between 18F-THK5351 positron emission tomography images and local network metric images at the voxel level.

    Significant positive correlations of the four local network metrics with 18F-THK5351 were detected in the bilateral caudate.

    Our findings suggest that tau and neuroinflammation in CN older adults may influence the gray matter structural network in the caudate.


Case Reports

Pulse-gated noncontrast thoracic magnetic resonance angiography for acute aortic dissection with transient ischemic attack: A case report

Takeshi Bo, Yasuhito Kawana, Itsuki Soejima, Eiichiro Amano, ... Akira Machida

  • Article 100329
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  • https://doi.org/10.1016/j.ensci.2021.100329
  • Abstract

    Aortic dissection is a rare cause of an acute ischemic stroke or transient ischemic attack (TIA). Aortic dissection is particularly challenging in stroke patients who are eligible for thrombolysis secondary to the diagnostic difficulty within a narrow time window (4.5 h) and have a risk of developing life-threatening hemorrhagic complications following thrombolysis. Computed tomographic angiography (CTA) has been the mainstay of imaging when evaluating acute aortic syndrome. However, it cannot be routinely performed for pregnant patients and those with renal failure or iodine-contrast media allergy. We report a case of a 72-year-old woman who developed transient right-hand paralysis without any chest symptoms. Brain magnetic resonance imaging (MRI) showed no recent infarction; however, the brachiocephalic trunk was not well visualized on carotid magnetic resonance angiography (MRA). Subsequent thoracic pulse-gated noncontrast three-dimensional balanced steady-state free precession MRA (bSSFP-MRA) detected a Stanford type A acute aortic dissection (TAAAD). This was confirmed by CTA, leading to the diagnosis of TIA due to Stanford TAAAD. Pulse-gated noncontrast thoracic bSSFP-MRA was acquired a few minutes after a series of brain MRI scans. This imaging modality is expected to be used as a screening platform to rule out Stanford TAAAD during the hyperacute phase of stroke

Case series: COVID-19 in patients with mild to moderate myasthenia gravis in a National Referral Hospital in Indonesia

Fitri Octaviana, Hardito Puspo Yugo, Ahmad Yanuar Safri, Luh Ari Indrawati, ... Manfaluthy Hakim

  • Article 100332
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  • https://doi.org/10.1016/j.ensci.2021.100332
  • Abstract

    During the COVID-19 pandemic, patients with myasthenia gravis (MG) are most likely to be affected by this situation. Corticosteroids and immunosuppressant agents increase the risk of severe infection. Furthermore, viral infection and some medications in COVID-19 may exacerbate MG symptoms.

    We presented three patients with MG who contracted COVID-19. All of the patients had a favourable outcome. Only one patient who was not treated with corticosteroids or immunosuppressant therapy experienced deterioration of MG symptoms, while the other patients who received immunosuppressant therapy did not develop MG exacerbation. Surprisingly, azithromycin did not provoke myasthenic crisis (MC) in patients with normal MGFA classification.

    Using immunosuppressant agents may not lead to MG deterioration and may not be related to unfavourable outcomes.

Severe orthostatic hypotension associated with lesions of the area postraema in neuromyelitis optica spectrum disorder

Setsu Sawai, Masahiro Mori, Takahiro Makino, Yoshikazu Nakano, ... Ikuo Kamitsukasa

  • Article 100335
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  • https://doi.org/10.1016/j.ensci.2021.100335
  • Abstract

    Hiccups, nausea and vomiting are known as the clinical manifestations of neuromyelitis optica spectrum disorder (NMOSD) linked to lesions of the area postraema in the medullary tegmentum. Here, we describe a 74-year-old male patient with NMOSD who presented with recurrent syncope due to severe orthostatic hypotension (OH) following symptoms of hiccups, nausea and vomiting.

    Brain magnetic resonance imaging revealed the lesion of the area postraema and it could be responsible for the symptom of OH. Considering the numerous related reports, we suspect that the prevalence of OH is underreported in the patients with NMOSD. OH may transition into more serious conditions, so it should be evaluated carefully in all patients with NMOSD, particularly when there is a lesion of the area postraema.

Ti.: "High" vagus nerve lesions in varicella Zoster infection

Wolfgang Grisold, Josef Schwarzmeier, Klemens Frei, Gerhard Neumüller, Friedrich Breier

  • Article 100337
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  • https://doi.org/10.1016/j.ensci.2021.100337
  • Abstract

    "High" vagus nerve lesions are rare and refer to the region of the nerve from the jugular foramen through the branching of the auricular (Arnold's branch) and the pharyngeal branch. Rapid onset of vagus nerve palsy is observed predominantly in trauma, and rarely in inflammation. An insidious onset points to a neoplastic cause.

    The acute "high" vagus nerve lesion is characterized by a unilateral paralysis of the recurrent laryngeal nerve, an incomplete paresis of the soft palate and a transient inability to swallow.This is a case description of a 79-year-old woman who presented with painful swelling of the left ear and occipital headache, followed by inability to swallow for 3 weeks. A markedly elevated Varicella Zoster titer suggested a herpes virus infection.

Hemi-parkinsonism and return of essential tremors after MRgFUS thalamotomy: Case report and review of procedural complications affecting ventral thalamic nuclei

Aditi Vian Varma-Doyle, Nicole R. Villemarette-Pittman, Brian J. Copeland

  • Article 100339
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  • https://doi.org/10.1016/j.ensci.2021.100339
  • Abstract

    Magnetic resonance guided focused ultrasound (MRgFUS) thalamotomy targets the ventral intermediate nucleus of the thalamus and has been shown to be safe and effective to treat medication-resistant essential tremors. Improvement in tremor scores, posture and action scores, disability scores and quality of life scores have been reported in patients treated with this procedure. Adverse events are usually transient and non-severe. We present a patient who underwent MRgFUS thalamotomy of the left VIM and developed new-onset parkinsonian features predominantly on the right side and return of essential tremors a few years after the procedure. Changes in speech (hypophonia and dysarthria), gait imbalance and postural instability, bradykinesia, and cogwheeling rigidity occurred, likely due to involvement of the fiber tracts through the ventrolateral subnuclei and the adjacent ventral anterior thalamic nuclei and other surrounding structures. We describe side effects of MRgFUS thalamotomy in our patient compared to previous reports and review the thalamic nuclei and surrounding structures that can be affected during procedure, causing these effects.

Stroke in a child with SARS-CoV-2 infection: A case report

Bkhtiar Khosravi, Borhan Moradveisi, Masomeh Abedini, Shirin Behzadi, Awat Karimi

  • Article 100345
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  • https://doi.org/10.1016/j.ensci.2021.100345
  • Abstract

    Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Some patients with COVID-19 show widely neurological manifestations including stroke. We report a child who was hospitalized due to seizures and was later diagnosed with COVID-19. Acute infarction was seen in the right putamen, globus pallidus, and the posterior part of the insula. A small focal dilatation within M1 segment of the left middle cerebral artery (MCA) was also observed. According to the present case report, COVID-19 infection may contribute to the occurrence and development of ischemic stroke.


Letters to the Editor

D-penicillamine in Wilson's disease; recognizing the transition from benefit to harm

Yihui Goh, Benjamin Yong-Qiang Tan, Nicole Ya-Yuan Chong, Margaret Ma, ... Joy Vijayan

Case report and ten-year follow-up of episodic ataxia type 2 due to a novel variant in CACNA1A

Lorenzo Verriello, Paola Carrera, Giada Pauletto, Andrea Bernardini, ... Gian Luigi Gigli

Familial hypercholesterolemia and statins in the COVID-19 era: Mitigating the risk of ischemic stroke

Alpo Vuorio, Markku Kaste, Petri T. Kovanen

  • Article 100344
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  • https://doi.org/10.1016/j.ensci.2021.100344
  • Abstract

    There is a continuing need for research about the underlying mechanisms behind ischemic strokes in COVID-19 patients. Pre-existing endothelial dysfunction, especially if it is accompanied by a viral infection of the endothelial cells may present an important mechanism behind the immunothrombotic/thromboembolic complications of the COVID-19 illness. Here we emphasize that pharmacotherapy with statins could partly counteract such pathophysiological scenarios. Accordingly, using familial hypercholesterolemia (FH) as a pertinent example of a lifelong endothelial dysfunction, we aim to make the clinicians and consulting neurologists aware of statins as a possible adjuvant therapy in the context of an increased risk of ischemic stroke in patients with COVID-19. Based on recent clinical evidence, there is a need to encourage clinicians and consulting neurologists to continue or initiate effective statin treatment to prevent an ischemic stroke, particularly when they encounter a hypercholesterolemic COVID-19 patient with FH.

Disease reactivation in a patient with secondary progressive multiple sclerosis after switching treatment from fingolimod to siponimod

Kensuke Senzaki, Hirofumi Ochi, Masayuki Ochi, Yoko Okada, ... Yasumasa Ohyagi



Corrigendum to 'Encephalopathy in COVID-19 patients; viral, parainfectious, or both?' [eNeurologicalScic(Volume 21), December 2020, 100275]

Thirugnanam Umapathi, Wei Ming Jason Quek, Jia Min Yen, Hnin Su Wai Khin, ... Wai-Yung Yu

Erratum to "Impact of COVID-19 on Future Ischemic Stroke Incidence" [eNeurologicalSci, 22C (2021) 100325]

Aisha Elfasi, Franklin D. Echevarria, Robert Rodriguez, Yoram A. Roman Casul, ... Alexis N. Simpkins