Sports-Related Neurologic Injuries: More Than Just Concussion

ObjectiveDescribe important patterns of neurologic injury in sports related trauma.BackgroundSports related neurologic trauma represents a unique, complex pattern of injury with potential significant impactful morbidity. An estimated 8.6 million sports injuries occur annually, 300,000 of which result in traumatic brain injury (TBI). The incidence of other nervous system injury is underreported.Design/MethodsRetrospective analysis of consecutive patients who presented to an emergency department between January 1, 2015 and January 1, 2020 with a sports related injury. Characterization of neurologic vs non-neurological bodily injury, sports activity, and demographic data were collected.ResultsOut of 15,525 patients with sports injuries, 390 sustained neurologic involvement of which 50% were between 1-18 years of age. Although TBI represented the majority (85%) of neurologic injury, 5.6% sustained spinal cord involvement and 5.1% had peripheral nerve injury. Spinal cord and peripheral nerve involvement were associated with prolonged hospitalization when compared to those with mild-moderate concussion X2 (1, N = 199) = 5.73, p = 0.0167.ConclusionsSpinal cord and peripheral nerve injury represent the minority of sports related neurologic involvement, however, may lead to significant prolonged hospitalization, morbidity and mortality.

CLINICO-EPIDEMIOLOGICAL STUDY OF LEPROSY IN TERTIARY CARE INSTITUTE IN CHHATTISGARH

INTRODUCTION – Leprosy is a chronic bacterial infection. India has achieved an elimination target of less than one case per ten thousand population in December 2005. Even after elimination leprosy is remaining a major health issue in a few states like Chhattisgarh and union territories like Dadra and Nagar haveli. AIMS AND OBJECTIVE –To study the clinico-epidemiological pattern of leprosy in a tertiary care institute at Chhattisgarh. MATERIAL AND METHOD- A retrospective descriptive study was performed at LSLAM medical college, Raigarh, Chhattisgarh. All the cases of leprosy attending skin OPD from January 2020 to December 2020 were recruited for the study. Data was collected in MS excel sheet and analyzed using SPSS software version 20. RESULT – A total of 92 patients were diagnosed as leprosy. 4 (4.35%) patients were children less than 14 years of age. 67 patients were male and 25 were female with male to female ratio was 2.68:1. Commonest age group of presentation was 21 to 40 years. The most common type of leprosy was Borderline Tuberculoid Hansen Disease (BTHD) (43.48%). 64 patients (69.57%) were diagnosed as multibacillary (MB) leprosy. The most common nerve found thickened was ulnar nerve. 30 patients (32.60%) presented with lepra reaction at the time of diagnosis. Out of 30 Lepra reaction cases, 21 (70%) were diagnosed as type1 lepra reaction and the rest 9 (30%) cases were diagnosed as type 2 lepra reaction cases. 59 patients (64.13%) presented with peripheral nerve involvement at the time of diagnosis. 23 (25%) patients were having grade 2 disability at the time of diagnosis. CONCLUSION – Even after achieving the target of elimination leprosy remains a major health problem especially in endemic states of India like Chhattisgarh.

Association of Peripheral Neuropathy in Hepatitis C Infection with and without Cryoglobulineamia

Objective: The purpose of this study was to find out the association of peripheral neuropathy in hepatitis C infection with and without cryoglobulineamia. Study Design: Cross sectional study Place and Duration: Conducted in Liver Transplant Unit, Gambat Institute of Medical Sciences, Gambat Khairpur Mirs, Sindh for the duration of six months from November 2020 to April 2021. Methods: Total 50 patients who had hepatitis C infection and peripheral neuropathy were included in this study. Patients were aged between 18- 60 years. Detailed demographics of patients including age, sex and body mass index were recorded after taking informed written consent. When symptoms and evidence of peripheral sensory or motor involvement were evident, clinical neuropathy was diagnosed. Sural nerve biopsy was done on patients and the biopsy specimen was evaluated morphologically and morphometrically. Multiple neuropathy, cranial neuropathy, and polyneuropathy are all terms used to describe peripheral nerve involvement. Our research focused on the motor conduction of the median, ulnar, and common peroneal nerves, measuring MCV, CMAP amplitude, and distal latency (DL) in both patients with and without cryoglobulinaemia for each nerve. The SPSS 20.0 version was used to analyze the data. Results: Mean age of the patients was 46.23±9.87 years with mean BMI 29.16±11.27 kg/m2. There were 30 (60%) females and 20 (40%) were males. We found that 35 (70%) patients had CG involvement with peripheral neuropathy and 15 (30%) cases were without CG. Prevalence of polyneuropathy was higher 19 (54.3%) in CG patients as compared to non CG 2 (13.3%). Mononeuropathy or multiple neuropathy was higher in HCV CG patients 13 (37.1%) as compared to HCV non CG patients 4 (26.7%). 25 patients underwent nerve biopsy (20 CG patients and 5 non CG). Prevalence of epineurial vasculitis and fascicular loss of axons was higher in non CG patients while demyelination + axonal degeneration were prevalent in CG patients. MCV of the deep peroneal nerve in patients with CG+ was low as compared to CG. Even though no statistically significant differences were detected, the other neurophysiological measures pointed to a more extensive and severe involvement of peripheral nerve in CG+ patients. Conclusion: We concluded in this study that the association of peripheral neuropathy in HCV patients with cryoglobulinaemia was greater as compared to non-CG HCV patients. It appears that both CG+ and CG patients suffer from peripheral nerve injury via a vasculitic mechanism, as evidenced by clinical and morphological observations. Serum CG levels indicate a more severe and broad neuropathic involvement, however research suggests that cryoglobulins are not the only element in the vasculitic process. Keywords: Cryoglobulinemia, Peripheral Neuropathy, HCV

CNS Imaging Characteristics in Fibromyalgia Patients With and Without Peripheral Nerve Involvement

We tested the hypothesis that reduced skin innervation in fibromyalgia syndrome is associated with specific CNS changes. This prospective case-control study included 43 women diagnosed with fibromyalgia syndrome and 40 healthy controls. We further compared the fibromyalgia subgroups with reduced (n=21) and normal (n=22) skin innervation. Brains were analysed for cortical thickness, for white matter integrity, and for functional connectivity. Compared to controls, cortical thickness was decreased in the left pars opercularis in the fibromyalgia group as a whole, and decreased in the left superior frontal and left rostral middle frontal cortex in the fibromyalgia subgroup with reduced skin innervation. Diffusion tensor imaging revealed a significant increase in fractional anisotropy in the corona radiata, the corpus callosum, cingulum and fornix in patients with fibromyalgia compared to healthy controls. Using resting-state fMRI, the fibromyalgia group as a whole showed functional hypoconnectivity between the right midfrontal gyrus and the posterior cerebellum and the right crus cerebellum, respectively. The subgroup with reduced skin innervation showed hyperconnectivity between the right cuneal cortex and the anterior parahippocampal gyrus, between the left thalamus and the lateral parietal region in the default mode network and hypoconnectivity between the left frontal lobe and the right cerebellum crus 1. Our results suggest that the subgroup of fibromyalgia patients with pronounced pathology in the peripheral nervous system shows distinctly altered morphology, structural and functional connectivity also at the level of the brain. We propose considering these subgroups when conducting clinical trials.

Peripheral neuropathy in systemic lupus erythematosus: what can neuromuscular ultrasonography (NMUS) tell us? A cross-sectional study

ObjectiveTo evaluate peripheral nerve involvement in patients with SLE with neuromuscular ultrasonography (NMUS) and understand its role in investigating SLE-related peripheral neuropathy.MethodsThis is an observational cross-sectional study on patients with SLE and healthy controls. Five nerves in each patient were examined bilaterally with NMUS, and the cross-sectional area (CSA) of each nerve at certain sites was estimated. The mean CSA at each site, for each nerve, in each group was statistically analysed and compared between groups.Results370 nerves were evaluated in 37 patients. By nerve conduction study (NCS), 36 patients had polyneuropathy (80.6% mixed type, 19.4% sensory). Significant mean CSA enlargement was present among the ulnar nerve at the Guyon’s canal and mid-humerus (both p=0.001); tibial nerve at the distal leg and proximal to the tarsal tunnel (p=0.003 and p=0.001, respectively); and peroneal nerve at the popliteal fossa (p=0.042). The mean CSA showed high specificity compared with NCS.ConclusionOur study shows that CSA could be a complementary tool to NCS for studying peripheral neuropathy in SLE. Furthermore, NMUS provides data on the different pathophysiological aspects of nerve involvement in SLE. Future studies using more than one sonographic parameter in combination with NCS and nerve histopathology are recommended to further investigate SLE-related neuropathy.Trial registration numberNCT04527172.

Secondary Central Nervous System Lymphoma as a Complication from a Systemic Non-Hodgkin Lymphoma

Secondary central nervous system lymphoma is a complication from non-Hodgkin lymphoma not very well known. NHL can present in a variety of neurological clinical presentations varying from primary central nervous system lymphoma to complications from a systemic disease like metastasis or peripheral nerve involvement. We present a case of a 78-year-old male with Diffuse large B-cell lymphoma, treated with Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone. Six months later of the diagnosis, the patient presented to the emergency department, complaining of five days with progressive weakness in the left upper limb, and two days before the weakness developed in the left lower limb. On the neurologic examination with inattention, dysarthria, left central facial nerve palsy, severe weakness on the left hemibody with hyperreflexia, and left extensor plantar response. Brain Magnetic resonance imaging reported three metastatic lesions, with a final diagnosis of secondary central nervous system lymphoma.

Prevalence and Characteristics of Polyneuropathy in Atypical Parkinsonian Syndromes: An Explorative Study

(1) Background: Peripheral nerve involvement is increasingly recognized in Parkinson’s disease (PD). Although non-motor symptoms and postural instability are early features of atypical parkinsonian syndromes (APS), peripheral neuropathies in APS have not been addressed in detail thus far. Therefore, the aim of this study was to investigate the prevalence and characteristics of polyneuropathies (PNP) in multiple system atrophy (MSA) and progressive supranuclear palsy (PSP), as representative syndromes of APS. (2) Methods: In total, 8 MSA and 6 PSP patients were comprehensively analyzed regarding subjective, clinical (motor and non-motor) and paraclinical PNP features using nerve conduction studies and high resolution nerve ultrasounds (HRUS). (3) Results: A total of 87.5% of MSA and 66.7% of PSP patients complained of at least one neuropathic symptom, with electrophysiological confirmation of PNP in 50.0% of both, MSA and PSP patients. PNP symptom severity in PSP and motor nerve amplitude in MSA were associated with compromised motor function. Morphologic nerve examination by HRUS showed few alterations according to the axonal type of PNP. (4) Conclusions: The overall high PNP symptom burden may be partially credited to the significant prevalence of electrophysiologically diagnosed PNP, and impact motor aspects of APS. The findings of this exploratory study reinforce further investigations on a larger scale, in order to elucidate peripheral nerve involvement and the underlying pathophysiological mechanisms of APS.

A rare case of posterior reversible encephalopathy syndrome in a patient with severe leptospirosis complicated with rhabdomyolysis and acute kidney injury; a case report

Background Leptospirosis is a zoonotic spirochetal disease caused by Leptospira interrogans. The clinical presentation ranges from an asymptomatic state to a fatal multiorgan dysfunction. Neurological manifestations including aseptic meningitis, spinal cord and peripheral nerve involvement, cranial neuropathies and cerebellar syndrome are well recognized with varying frequencies among patients with this disease. Posterior reversible encephalopathy syndrome is a very rare occurrence in leptospirosis and only two cases are reported in the medical literature up to now. We report a case of posterior reversible encephalopathy syndrome in a patient with leptospirosis with rhabdomyolysis and acute kidney injury. Case presentation A 21 year-old male presented with fever and oliguric acute kidney injury with rhabdomyolysis. A diagnosis of leptospirosis was made and he was being managed according to the standard practice together with regular hemodialysis. The clinical condition was improving gradually. On day 8 of the illness, he developed headache and sudden painless complete bilateral vision loss followed by several brief generalized tonic clonic seizure attacks. Examination was significant for a Glasgow Coma Scale of 14/15, blood pressure of 150/90 mmHg and complete bilateral blindness. The findings of magnetic resonance imaging of the brain were compatible with posterior reversible encephalopathy syndrome. He was managed with blood pressure control and antiepileptics with supportive measures and standard treatment for leptospirosis and made a complete recovery. Conclusion Posterior reversible encephalopathy syndrome, though very rare with leptospirosis, should be considered as a differential diagnosis in a patient with new onset visual symptoms and seizures, especially during the immune phase. Optimal supportive care together with careful blood pressure control and seizure management would yield a favourable outcome in this reversible entity.

The Leukodystrophy Spectrum in Saudi Arabia: Epidemiological, Clinical, Radiological, and Genetic Data

Background: Leukodystrophies (LDs) are inherited heterogeneous conditions that affect the central nervous system with or without peripheral nerve involvement. They are individually rare, but collectively, they are common. Thirty disorders were included by the Global Leukodystrophy Initiative Consortium (GLIA) as LDs.Methods: We conducted a retrospective chart review of a consecutive series of patients diagnosed with different types of LD from four large tertiary referral centers in Riyadh, Saudi Arabia. Only those 30 disorders defined by GLIA as LDs were included.Results: In total, 83 children from 61 families were identified and recruited for this study. The male-to-female ratio was 1.5:1, and a consanguinity rate of 58.5% was observed. An estimated prevalence of 1:48,780 or 2.05/100,000 was observed based on the clinical cohort, whereas a minimum of 1:32,857 or 3.04/100,000 was observed based on the local genetic database. The central region of the country exhibited the highest prevalence of LDs (48.5%). The most common LD was metachromatic leukodystrophy (MLD), and it accounted for 25.3%. The most common disorder based on carrier frequency was AGS. Novel variants were discovered in 51% of the cases, but 49% possessed previously reported variants. Missense variants were high in number and accounted for 73% of all cases. Compared with other disorders, MLD due to saposin b deficiency was more common than expected, Pelizaeus-Merzbacher-like disease was more prevalent than Pelizaeus-Merzbacher disease, and X-linked adrenoleukodystrophy was less common than expected. The mortality rate among our patients with LD was 24%.Conclusion: To the best of our knowledge, this is the largest cohort of patients with LD from Saudi Arabia. We present epidemiological, clinical, radiological, and genetic data. Furthermore, we report 18 variants that have not been reported previously. These findings are of great clinical and molecular utility for diagnosing and managing patients with LD.

The radiologic (CT/MRI)-pathological correlations of the salivary duct carcinoma (SDC) with hyaline degeneration and peripheral nerve invasion

Objectives: Salivary duct carcinoma is an aggressive tumour commonly showing local invasion and/or nerve palsy. However, their CT/MRI findings, especially, regarding T2WI, and the diffusion-weighted-image (DWI), were not well known. In this study, we correlated the CT/MRI appearance and the pathological findings containing the nerve invasion cases such as a facial nerve. Methods: We reviewed 14 cases of SDC (parotid = 11, submandibular = 2, minor salivary gland = 1) pathologically proven peripheral nerve involvement. Their CT findings of all patient including dynamic contrast-enhancement study､MRI (n = 9) and DWI (n = 6) were also analyzed with histopathological correlation. Results: On contrast-enhanced CT, the solid component was moderately enhanced. On MRI, T2WI central low signal core (n = 6) with peripheral high intensity rim (n = 5) was frequently observed except heterogeneous low and high (n = 1), diffuse low (n = 1), and high (n = 1) signal cases. The hyaline degenerative area located in the tumour core was poorly enhanced. Eleven tumours had an ill-defined margin, reflecting invasive tumour growth. On DWI, they showed high signal [the central low and peripherally high (n = 4), and diffuse (n = 1), heterogeneously high signal (n = 1)]. The mean ADC value was 1.148 ~ 0.961 x 10–3 mm2/s. With pathological correlation, the central low signal area on T2WI reflected hyaline degeneration. The sites of gross nerve involvement were revealed as tubular or branching structures on CE-CT (n = 3), and MRI (n = 1). Conclusions: (1) We frequently observed a central low signal area on T2WI/DWI in SDC. With histopathological correlation, it corresponded to the central hyaline degeneration with the peripheral viable tumour. 2) The gross nerve involvement might be detected as a strongly enhancement structure.