Reversible cerebral vasoconstriction syndrome in a patient with COVID-19

COVID-19 infection is well-known to produce different neurological complications, including cerebrovascular diseases. Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by transient segmental vasoconstriction of the cerebral vasculature, has been rarely reported in association with COVID-19 infection. The causative agent, the novel coronavirus (SARS-CoV-2), binds to the angiotensin-converting enzyme 2 (ACE-2) receptors for its entry into the host cell. This leads to downregulation of the ACE-2 and increased activity of the renin-angiotensin-aldosterone (RAAS) axis resulting in sympathetic overactivity and vasoconstriction. This might be the possible mechanism of RCVS in COVID-19. We hereby report a case of RCVS occurring in a SARS-CoV-2 infected patient. This was a 38-year-old male without any comorbidities or risk factors, who presented with headache and confusion. His SARS-CoV-2 RT-PCR was positive. MRI of the brain was normal but cerebral angiography revealed segmental vasoconstriction in bilateral middle cerebral arteries and the terminal part of the internal carotid arteries, which resolved almost completely after 2 weeks. He was treated with oral nimodipine 60 mg every 6 hourly. A database search revealed 2 previous cases of RCVS associated with COVID-19. In conclusion, RCVS is a rare complication of COVID-19. It is possibly under-recognized as only a few COVID-19 patients with headaches undergo cerebral angiography especially when parenchymal brain imaging is normal.

Investigation of autonomic dysfunction in primary Raynaud’s phenomenon with sympathetic skin response (SSR), R-R interval variation (RRIV) and composite autonomic symptom score (COMPASS)-31

Background: In this study, we aimed to investigate the autonomic dysfunction in patients with primary Raynaud’s phenomenon with using sympathetic skin response (SSR) as a neurophysiologic test, R-R interval variation analysis and composite autonomic symptom score (COMPASS)-31 questionnaire. Methods: Palmar SSR to median nerve electrical stimulation was recorded in 38 patients with 36 healthy age and sex-matched control subjects. The SSR was recorded from the palmar surface of both left and right hands for patients and control groups. The amplitudes and latencies formed as a result of electrical stimulation were calculated and compared between the two groups. Additionally, R-R interval variability was examined during normal breathing, deep breathing, standing up and Valsalva maneuver in both groups. Furthermore, we asked to complete the COMPASS-31 questionnaire, a validated tool to assess symptoms of autonomic dysfunction. And by calculating total COMPASS-31 scores, the relationship between the two groups was investigated. Results: The Raynaud’s phenomenon and control groups were similar in age (37.4 ± 11.6 vs. 34.9 ± 13.0 years), had identical gender ratios and similar body mass index (24.5 ± 6.1 vs. 25.7 ± 4.6%). Palmar SSR to median nerve stimulation of RP patients shows significantly delayed latency (1890 ± 146) (p=0.03). And no difference between amplitudes in comparison to the control group. In the patient and control groups, R-R interval measurements were evaluated during rest and deep breathing, standing up and Valsalva maneuver. When the R-R interval measurements of the patient and control groups at rest and deep breathing were compared, there was no statistically significant difference between the groups. In addition, COMPASS-31 questionnaire scoring system was applied to both groups. The mean COMPASS-31 score was higher in patient group (22.8 ± 13.8), than from healthy controls (8.9 ± 7.8) (p=0.02) Conclusions: Autonomic dysfunction plays a role in the etiology of Raynaud’s phenomenon, due to latency prolongation in the sympathetic skin response and significant difference between COMPASS-31 tests, and these tests can be used in the diagnosis stage of this disease.

Somatosound: A review with report of 9 cases with long-term follow-up

Somatosound (somatic tinnitus) is associated with vascular, musculoskeletal, respiratory, or temporomandibular joint disorders. Several studies of its management have been widely reported, but only few presented long-term follow-up results. The purposes of this paper are to review the causes and management, present cases with long-term follow-up, together with previously reported cases in literatures. We treated nine patients with somatosound of vascular, hematologic, endocrinologic, muscular, and cervical origin. Follow-up were conducted routinely, and the final results were collated in 3 to 11 years. Patients with non-life-threatening causes were given counseling and palliative management. Their tinnitus becomes tolerable, gradually decreased, and even disappeared. Patients with life-threatening causes were treated immediately. Among all, there were three cases which to the best of our knowledge, are the first reported of its causes. One case was caused by a compensatory of increasing blood flow in internal carotid artery (ICA) secondary to contralateral ICA stenosis. Another had a combination of anemia and an ipsilateral jugular bulb diverticulum. The tinnitus disappeared after the anemia treated. The last was patient with hyperthyroidism. The tinnitus disappeared by controlling the condition. Even when the causes are benign and the available treatments may carry risks, the patients should not be left unmanaged. Symptomatic treatment should be given, such as counseling, sound therapy, and palliative management. Our long-term observation indicated that overall outcomes are positive when the etiologies are identified early and managed properly.

LGI1 positive paraneoplastic limbic encephalitis: A case report of atypical presentation

Limbic encephalitis is a rare disorder mainly affecting the medial temporal lobe and is classically paraneoplastic. Autoimmune etiologies also exist, such as antibodies against leucine-rich glioma activated 1 (LGI1). Most cases of anti-LGI1 encephalitis are not associated with tumors. Subacute memory loss is the predominant feature, and most patients develop focal seizures, especially faciobrachial dystonic seizures (FBDSs). Immunotherapies usually show a good response, but are less effective in paraneoplastic cases. We report a case of steroid-responsive anti-LGI1 encephalitis with atypical presentations of sensory aphasia during relapse from rectal carcinoma, an atypical site.

Tenecteplase versus alteplase for acute ischemic stroke thrombolysis: a systematic review and meta-analysis

Background: Intravenous thrombolysis is the preferred clinical treatment for acute ischemic stroke. Alteplase is an intravenous thrombolytic drug used in clinical practice. Recently, studies have shown the efficacy of another intravenous thrombolytic drug, tenecteplase, and have reported that the risk of bleeding is low. However, at present, Chinese and international research has yielded controversial results regarding the efficacy and risks of tenecteplase. Therefore, this systematic review and meta- analysis of the efficacy and safety of tenecteplase were performed. Methods: PubMed, the Cochrane Library, MEDLINE, the Wanfang Database and CNKI were searched for all studies on the thrombolytic treatment of acute ischemic stroke. All studies published in English prior to March 2021 were retrieved. The studies were screened and selected based on the inclusion and exclusion criteria. Then, the data were extracted and recorded by trained researchers. RevMan 5.4 statistical software was used to analyze the data on the 24h recanalization rate, early neurological improvement (24h reduction in the National Institutes of Health Stroke Scale [NIHSS] score of at least 8 points or 24 h NIHSS score of 0~1 point), mRS score at 90 days, intracranial hemorrhage, symptomatic intracranial hemorrhage and mortality in the tenecteplase group and alteplase group. Results: A total of 565 related studies were identified through the initial searches in each database. The citations of meta-analyses and related reviews were screened for additional eligible articles. Eventually, 9 high-quality English-language articles that included 2149 patients with acute ischemic stroke (including 1035 in the tenecteplase group and 1046 in the alteplase group)were included in this meta-analysis. The meta-analysis results were as follows: (1) Efficacy: The 24 h recanalization rate with regard to vascular recanalization was significantly better in the tenecteplase group than in the alteplase group(OR = 1.83, 95% CI: 1.23~2.72, z = 2.97, P = 0.003). There was significantly greater improvement in early neurological function in the tenecteplase group than in the alteplase group (OR= 1.34, 95% CI: 1.11~1.63, Z=3.00, P =0.003). There were no significant differences in 90-day mRS scores between the two groups (mRS score =0-1, OR = 1.20, 95% CI: 0.99~1.46, z = 1.82, p = 0.07; mRS score =0-2, OR = 1.17, 95% CI: 0.94~1.45, z = 1.38, p = 0.17). However, the subgroup analysis showed that the 90-day mRS score of the 0.25 mg/kg tenecteplase group was significantly different from that of groups treated with other doses of tenecteplase (OR = 1.48, 95% CI: 1.01~2.03, z = 2.03, p = 0.04). (2) Safety: The incidences of any intracranial hemorrhage (OR = 0.91, 95% Ci: 0.55~1.49, z = 0.39, p = 0.70), symptomatic intracranial hemorrhage (OR = 1.21, 95% CI: 0.63~2.32, z = 0.56 P = 0.57), and mortality (OR = 0.85, 95% CI: 0.57~1.26, z = 0.82, p = 0.41) were not significantly different between the tenecteplase and alteplase groups. Conclusions: Tenecteplase can significantly increase the 24-hour vascular recanalization rate and improve the neurological prognosis of patients with acute ischemic stroke and it does not increase the risk of intracranial hemorrhage or mortality.

Risk factors of cerebral microbleeds in young and middle-aged patients with hypertension

Background & Objectives: This study aimed to explore the incidence and potential risk factors of cerebral microbleeds (CMBs) in young and middle-aged patients with hypertension. Methods: We retrospectively analyzed the clinical data of young and middle-aged patients with hypertension in the Department of Neurology, General Hospital of Western Theater Command, Chengdu, China between August 2018 and December 2020. The demographic baseline, laboratory parameters and clinical imaging data were collected. Microbleed anatomical rating scale (MARS) was applied to evaluate the presence, amount, and topographical distributions of CMBs. Results: Among 196 young and middle-aged patients with hypertension, 84 (42.9%) patients had CMBs. CMBs were more likely to occur in the deep brain tissue regions (41.8%), followed by lobar or infratentorial region. White matter hyperintensity (OR, 5.262; 95%CI, 1.314-21.075; P=0.019), abnormal lipid metabolism (OR, 3.832; 95%CI, 1.578-9.306; P=0.003), usage of anti-platelet aggregation drugs (OR, 2.947; 95%CI, 1.138-7.632; P=0.026), smoking history (OR, 3.218; 95%CI, 1.073-9.651; P=0.037), and hyperhomocysteinemia (OR, 1.415; 95%CI, 1.018-1.967; P=0.039) were independently associated with deep or infratentorial CMBs in young and middle-aged patients with hypertension. However, the occurrence of strictly lobar CMBs was only independently associated with abnormal lipid metabolism (OR, 4.162; 95%CI, 1.685-10.282; P=0.002). Conclusions: The rate of CMBs was high in young and middle-aged patients with hypertension, most commonly occurring in the deep brain tissue region. While multiple risk factors were identified to be associated with deep or infratentorial CMBs, the occurrence of strictly lobar CMBs was only associated with abnormal lipid metabolism.

The establishment of a stroke-associated pneumonia predictive scoring system

Background & Objective: Stroke-associated pneumonia (SAP) is a common complication of ischemic stroke, increasing the length of hospital stay and costs, and affecting prognosis. This study aimed to determine the incidence of SAP, investigate the risk factors that lead to SAP to facilitate a more targeted response to the prevention of SAP. Methods: A retrospective study was performed to analyze the factors that predict SAP in an acute stroke population from a university affiliated hospital in Fujian, China. A SAP risk score table was constructed. Results: A total of 1,016 patients with acute cerebral infarction were enrolled. The incidence of SAP was 13.58%. Multivariate regression analysis found that age, NIHSS, GCS scores, dysphagia, heart failure, creatinine, and proton pump inhibitors (PPIs) use were independently associated with SAP. Based on the data, a SAP risk score table was constructed with age > 75 years -2 points, NIHSS ≥ 16 -2 points, GCS score ≤ 8 -1.5 points, dysphagia - 5 points, heart failure - 1.5 points, creatinine - 1 point, PPIs use - 1.5 points, a total of 14.5 points. The optimal value was 3 points. Conclusions: Age, NIHSS, GCS score, dysphagia, heart failure, creatinine, and PPIs use were predictive of SAP.

Trends in the seeking of emergency service for ischemic stroke and its risk factors during the COVID-19 pandemic, a study from Taiwan

Background & Objectives: COVID-19 may influence the health seeking behavior of acute ischemic stroke patients. This study aimed to determine the characteristics of the patients who visited the emergency room in a centre designated for stroke care in Taiwan. Methods: This was a retrospective database-based study comparing the severity of ischemic stroke, intracerebral hemorrhage (ICH), and risk factors of patients seen between 2019 and 2020 in the National Taiwan University Hospital Yunlin Branch. Patients with or without thrombolysis therapy were analysed. Results: The median NIHSS of ischemic stroke patients were lower in 2019 than in 2020 (p = 0.015). The difference was seen in non-thrombolysis patients (2019: 3[1-6] vs. 4 [2-7.5], p = 0.012) but not in thrombolysis patients. The frequency of minor stroke was higher in 2019 (45.1%) than in 2020 (37.9%, p = 0.038). The discharge mRS was lower overall (p = 0.004) and in non-thrombolysis patients (0.003), but not in thrombolysis patients in 2019. As for the ICH patients, the severity of ICH score (p = 0.021) and discharge mRS (p = 0.001) were also lower in 2019. The frequencies of risk factors of stroke were higher in 2019 than in 2020, including smoking (24% vs. 18.2%, p = 0.046), alcohol (11.9% vs. 7.5%, p = 0.039), hypertension (72.9% vs. 66.2%, p = 0.039), history of stroke (16.5% vs. 11.6%, p = 0.047), and atrial fibrillation (11.9% vs. 7.5%, p = 0.039). Conclusions: This study in Taiwan revealed a decline in the willingness to seek emergency services under the influence of COVID-19 among patients with lower stroke severity, especially those with more risk factors.

Questionnaires can reflect the severity of electrophysiological findings In diabetic patients

Objective: The aim of this study was to determine whether a relationship exists between pain questionnaires, diabetic peripheral neuropathy, and the severity of electrophysiological findings. Methods: Patients with diabetes mellitus (DM) whose clinical signs and symptoms were found to be consistent with diabetic neuropathy were included in the present study in Ankara City Hospital Neurology Department between June 2020-January 2021. It was designed as a prospective cross-sectional study. Demographic characteristics, type and duration of DM, the onset of neuropathic complaints, systemic diseases, and DM treatments were noted. Blood tests were performed on all patients. Participants were administered the Douleur Neuropathique 4 Questions (DN4), Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), and Numerical Rating Scale (NRS) questionnaires and an electrophysiological examination. Results: The study included 108 patients. A statistically significant correlation was found between the severity of electrophysiological findings and the age of patients, duration of diabetes, and treatment modality. Additionally, a statistically significant correlation was found between the severity of electrophysiological findings and blood urea nitrogen (BUN) levels and monocyte and platelet counts. According to the NRS, a significant relation was found between BUN values and the severity of pain experienced. The LANSS predicted the severity of electrophysiological findings at a significantly higher accuracy than other questionnaires. Conclusion: Questionnaires can detect diabetic neuropathy, which is mostly asymptomatic, before the onset of DM complications. The LANSS questionnaire reflects the electrophysiological findings severity.

The effectiveness of sphenopalatine ganglion blockade in chronic migraine resistant to medical treatment

Objective: To assess the effectiveness of sphenopalatine ganglion blockade (SPGB) as an alternative treatment for patients with chronic migraine resistant to medical treatment. Methods: In total, 23 patients with chronic migraine resistant to medical treatment underwent 4 sessions of bilateral transnasal SPGB bi-weekly, and the monthly number of headache days, duration, and numerical rating scale (NRS) response results were recorded. Results: Compared with before SPGB, the frequency of migraine attacks per month (23.66 ± 9.8 vs. 10.5 ± 11.9 days), duration of headaches (31.3 ± 16.8 vs. 18.4 ± 9.8 h), and NRS score (9 ± 0.99 vs. 5.1 ± 2.1) all improved significantly (p < 0.05) eight weeks after intervention. Conclusion: Transnasal SPGB is an alternative to conventional therapy because it benefits patients with chronic migraine resistant to medical treatment, is easy to administer, and has few side effects.