Clinical characteristics of 365 hospitalized COVID-19 patients with neurological symptoms: an observational study

OBJECTIVE

Since the beginning of the COVID-19 pandemic, a number of COVID-related neurological manifestations have been reported. We aimed to categorize the features of hospitalized COVID-19 patients who experienced neurological symptoms.

METHODS

In this descriptive, cross-sectional study, we enrolled all patients hospitalized with COVID-19 who experienced neurological symptoms in two hospitals in Tehran. Diagnosis of COVID-19 was established by PCR tests or computed tomography of the chest combined with COVID-19 clinical findings. The clinical characteristics, laboratory data, and imaging findings from 365 patients were analyzed.

RESULTS

The average patient age was 59.2 ± 16.7 years and included 213 males and 152 females. The most prevalent neurological symptoms were headache (56.2%), impaired consciousness (55%), and dizziness (20.5%). During hospitalization, most of the patients did not require mechanical ventilation (81.9%). The percentage of patients with end-organ damage was 9% and mortality was 15%. Regression analysis on the neurological symptoms indicated that the mortality rate of patients with headaches was 84% lower than for the other neurological symptoms. Hyperglycemia was significantly related with end-organ damage and mortality (p = 0.029, p = 0.08, respectively). New vascular lesions were evident on brain MRIs of 9 patients and brain CTs of 16 patients.

CONCLUSION

Among the neurological symptoms of patients with COVID-19, headache appeared to indicate a protective factor against development of end-organ damage as well as mortality.

Anti-leucine-rich glioma-inactivated 1 encephalitis: two case reports and a review of the literature

Background

Anti-leucine-rich glioma-inactivated 1 encephalitis is a newly emerged entity characterized by frequent faciobrachial dystonic seizures and a wide spectrum of subacute clinical symptoms such as other seizure types, mood and behavioral changes, and memory loss. We should be aware of differentiating this diagnosis from psychogenic nonepileptic seizures. Mesial temporal, limbic structures, and basal ganglia are the most commonly involved regions.

Case presentation

Here we review the available data, and report on two young Iranian (White) females, 24 and 18 years old, who represent distinct aspects of the disease. The clinical presentation and degree of tissue involvement varies to some extent in the two reported cases. Case 1 had prominent neuropsychiatric symptoms and suffered from frequent faciobrachial dystonic seizures with more significant basal ganglia involvement, whereas case 2 suffered from severe memory decline and dialeptic seizures along with mesial temporal involvement. Symptoms were refractory to usual treatment and prompt immunotherapy was needed.

Conclusions

This disease has a rather favorable outcome provided that treatment is initiated early. However, resistance to first-line treatment, relapses, and long-term complications highlight the need to establish reliable biomarkers to distinguish different subtypes of this disorder to predict the clinical outcome and prognosis, and to refine management.

Automatic detection of epileptic seizures using Riemannian geometry from scalp EEG recordings

This paper proposes a new framework for epileptic seizure detection using non-invasive scalp electroencephalogram (sEEG) signals. The major innovation of the current study is using the Riemannian geometry for transforming the covariance matrices estimated from the EEG channels into a feature vector. The spatial covariance matrices are considered as features in order to extract the spatial information of the sEEG signals without applying any spatial filtering. Since these matrices are symmetric and positive definite (SPD), they belong to a special manifold called the Riemannian manifold. Furthermore, a kernel based on Riemannian geometry is proposed. This kernel maps the SPD matrices onto the Riemannian tangent space. The SPD matrices, obtained from all channels of the segmented sEEG signals, have high dimensions and extra information. For these reasons, the sequential forward feature selection method is applied to select the best features and reduce the computational burden in the classification step. The selected features are fed into a support vector machine (SVM) with an RBF kernel to classify the feature vectors into seizure and non-seizure classes. The performance of the proposed method is evaluated using two long-term scalp EEG (CHB-MIT benchmark and private) databases. Experimental results on all 23 subjects of the CHB-MIT database reveal an accuracy of 99.87%, a sensitivity of 99.91%, and a specificity of 99.82%. In addition, the introduced algorithm is tested on the private sEEG signals recorded from 20 patients, having 1380 seizures. The proposed approach achieves an accuracy, a sensitivity, and a specificity of 98.14%, 98.16%, and 98.12%, respectively. The experimental results on both sEEG databases demonstrate the effectiveness of the proposed method for automated epileptic seizure detection, especially for the private database which has noisier signals in comparison to the CHB-MIT database. Graphical Abstract Block diagram of the proposed epileptic seizure detection algorithm.

COVID-19-related refractory status epilepticus with the presence of SARS-CoV-2 (RNA) in the CSF: a case report

Amongst the neurologic complications of COVID-19 disease, very few reports have shown the presence of the virus in the cerebrospinal fluid (CSF). Seizure and rarely status epilepticus can be associated with COVID-19 disease. Here we present a 73-year-old male with prior history of stroke who has never experienced seizure before. He had no systemic presentation of COVID-19 disease. The presenting symptoms were two consecutive generalized tonic-clonic seizures that after initial resolution turned into a nonconvulsive status epilepticus despite antiepileptic treatment (a presentation similar to NORSE (new-onset refractory status epilepticus)). There was no new lesion in the brain magnetic resonance imaging (MRI). The CSF analysis only showed an increased protein levels and positive reverse transcription polymerase chain reaction (RT-PCR) of 2019-nCoV. Patient recovered partially after anesthetic, IVIG, steroid, and remdesivir. To our knowledge, this is the first report of a refractory status epilepticus with the presence of SARS-CoV-2 ribonucleic acid (RNA) in the CSF.

Ischemic Stroke in Patients with COVID-19 Disease: A Report of 10 Cases from Iran

Ischemic stroke seems to be one of the most serious neurologic complications in patients with COVID-19 infection. Herein, we report a series of 10 ischemic stroke patients with concomitant COVID-19 disease. Out of 10, 8 had large infarcts (3 massive middle cerebral artery, 2 basilar artery, 2 posterior cerebral artery, and 1 internal carotid artery infarct territory). Two had cardiogenic embolic stroke due to atrial fibrillation. Almost half of our patients did not have a vascular risk factor. Nine did not have fever and were diagnosed with COVID-19 upon admission for stroke. Stroke occurred in the first week of respiratory symptoms with moderate pulmonary involvement. Most Patients did not have hypoxia and did not establish respiratory failure or acute respiratory distress syndrome. The blood pressures were low and hemorrhagic transformation did not occur even after antiplatelet or anticoagulant therapy. Patients had markedly increased levels of lactate dehydrogenase, C-reactive protein, and D-dimer. Three patients died. It seems that ischemic strokes in COVID-19 patients tend to occur as large infarct and can be seen in patients with mild to moderate pulmonary involvement.

Identification of Serum Biomarkers for Differentiating Epileptic Seizures from Psychogenic Attacks Using a Proteomic Approach; a Comparative study

INTRODUCTION

Differentiating actual epileptic seizures (ESs) from psychogenic non-epileptic seizures (PNES) is of great interest. This study compares the serum proteomics of patients diagnosed with ESs and PNES.

METHODS

Eight patients with seizure (4 with PNES and 4 with TLE (temporal lope epilepsy)) were enrolled in this comparative study. Venous blood samples were drawn during the first hour following the seizure. Standard protein purification technique was employed and proteins were subsequently separated via 2-D electrophoresis. After comparison of the serum proteomes from the two groups, protein expression was analyzed. The differentially expressed bands were determined using both matrix-assisted laser ionization time-of-flight (MALDI/TOF) and electrospray ionization quadruple mass spectrometry (MS).

RESULTS

This study identified 361 proteins, the expression of 110 proteins increased, and 87 proteins decreased in the PNES group compared with TLE group. Four separate proteins were finally identified with MALDI/TOF MS analysis. Compared with PNES group, alpha 1-acid glycoprotein, ceruloplasmin, and S100-β were down-regulated and malate dehydrogenase 2 was up-regulated in the serum of TLE patients.

CONCLUSION

Our results indicated that changes in serum levels of S100-β, ceruloplasmin, alpha 1-acid glycoprotein 1, and malate dehydrogenase 2 after seizure could be introduced as potential markers to differentiate ES from PNES; however, more advanced studies are required to reach a better understanding of the underlying mechanisms.

Proteomic Analysis of patients with Epileptic Seizure and Psychogenic Non-epileptic Seizure; a Cross-Sectional Study

INTRODUCTION

There is an increasing interest in the use of different biomarkers to help distinguish psychogenic non-epileptic seizure (PNES) from epileptic seizures (ES). This study aimed to evaluate the patterns of differentially expressed serum proteins in ES and PNES cases.

METHODS

In this cross-sectional study, 4 patients with mesial temporal lobe epilepsy and 4 patients with PNES were selected from patients with history of recurrent seizures. Venous blood samples were obtained within 1 hour after seizure and serum proteomes as well as the extent of protein expression were analyzed.

RESULTS

361 proteins were identified; of these, expression of 197 proteins had altered. 110 (55.9%) proteins were down-regulated and 87 (44.1%) were up-regulated in the PNES samples compared to ES samples. The mean pI for deregulated proteins with 1.5 to 3 fold changes were 6.69 ± 1.68 in proteins with increasing expression in ES group and 5.88 ± 1.39 in proteins with increasing expression in PNES group (p = 0.008). The median and interquartile range (IQR) of molecular weight changes in proteins with 1.5 to 3 fold changes were 64 (22.0-86.0) in proteins whose expression had increased in ES group and 39.5 (26.0-61.5) in proteins whose expression had increased in PNES cases (p = 0.05).

CONCLUSION

Several spots with differential expression were observed by comparing patients with ES against the PNES groups, which could be potential biomarkers of the disease. Damage to the blood-brain barrier is the most important difference between the two groups, thus identifying total protein changes offers a key to the future of differentiating ES and PNES patients.

Total Corpus Callosotomy for Medically Refractory Status Epilepticus Due to Progressive Myoclonic Epilepsy: A Clinically Challenging Case

BACKGROUND

Progressive myoclonic epilepsy (PME) is a syndrome characterized by development of progressive myoclonus, cognitive impairment, and other neurologic deficits. Despite major advances in medical treatment of epilepsy, some PME patients remain refractory to antiepileptic drugs. This may further accentuate cognitive impairment and deteriorate functional capacity. Corpus callosotomy (CC) is used in patients with drug-resistant epilepsy who are not candidates for either excisional epilepsy surgery or neurostimulation. We report the application of the standard complete callosotomy to control medically refractory status epilepticus in a patient with PME.

CASE DESCRIPTION

A 16-year-old boy was referred to the emergency department with generalized tonic-clonic seizures. He was known to have PME since 5 years earlier, with frequent generalized seizures requiring hospitalization and reloading of the drugs. The patient was discussed by the epilepsy surgery working group, and corpus callosotomy was considered as a last resort to control the refractory status epilepticus. The patient experienced no generalized seizures during the 3-month postoperative period (Engel class IIIB).

CONCLUSIONS

Inasmuch as surgery was the last resort to control severe disabling status epilepticus, because most of the epileptogenic discharges were originating from the parieto-occipital regions and profound cognitive impairment was present, we decided to perform a complete rather than just an anterior callosotomy. CC may be considered to prevent secondary generalized seizures as the most disabling attacks in patients with certain epilepsy syndromes. Nevertheless, the impact of palliative surgical intervention on the overall disease course of patients with an underlying diffuse pathologic state remains to be determined.

Therapeutic apheresis in neurological, nephrological and gastrointestinal diseases

Therapeutic plasma exchange (TPE) is a process in which plasma containing antibodies, immune complexes, inflammatory moderators, paraproteins and other toxins which are believed to be the cause of disease is removed from a patient. TPE is the first-line treatment (category I, level 1A) in all forms of Acute inflammatory demyelinating polyradiculoneuropathy disease (axonal, demyelinating and miller-fisher variant) as well as in acute myasthenic crisis, chronic inflammatory demyelinating polyradiculoneuropathy and Paraproteinemic neuropathies (category I, level 1B). Moreover, TPE in kidney diseases, for instance: desensitization in renal transplantation(ABO compatible) (living donor)and desensitization in deceased donor, desensitization in renal transplantation(ABO incompatible) (living donor), thrombotic microangiopathy complement Mediated (Factor H autoantibodies), Focal segmental glomerulosclerosis(recurrent in transplanted kidney), ANCA-associated rapidly progressive glomerulonephritis(Dialysis dependence, DAH), Anti-Glomerular basement membrane disease Goodpasture's syndrome)(DAH,Dialysis-independence,) has been utilized as an initial treatment. (category I) TPE has been used as the key therapeutic modality to reduce anti-A or anti-B antibody titers in the liver peri-transplant period with the goal of preventing rejection and facilitating graft survival. Also, plasma exchange is the first-line therapy in Wilson's disease (category I, level1C).

Simvastatin treatment in patients with relapsing-remitting multiple sclerosis receiving interferon beta 1a: a double-blind randomized controlled trial

OBJECTIVES

This study was conducted to evaluate the effect of simvastatin (40 mg/day) as an adjuvant therapy to interferon beta (IFNb 1a, 30 microg once weekly) in relapsing-remitting multiple sclerosis patients, compared with placebo.

METHODS

We enrolled 85 patients with relapsing-remitting multiple sclerosis (71% female) who were already receiving IFNb 1a (Avonex), with Expanded Disability Status Scale score of less than 5.0. The patients were assigned (in random and double-blinded fashion) into the two groups of simvastatin and placebo. All patients continued to receive their current IFNb treatment. The outcome measures were total relapse rate, Expanded Disability Status Scale score, and the number of gadolinium-enhanced (Gd+) and new T2 lesions in magnetic resonance imaging after a 1-year follow-up. We used Mann-Whitney and one-way multivariate analysis of variances to analyze the data.

RESULTS

Four patients in the placebo and two in the simvastatin group prematurely withdrew from the study due to experiencing two attacks. The total attack number in the simvastatin group was significantly lower than placebo group (moderate effect size r = 0.29) (p = 0.01). The final Expanded Disability Status Scale scores were lower in the simvastatin group (1.01 +/- 1.40, mean +/- SD) than in the placebo group (1.73 +/- 1.49, mean +/- SD), but this difference was not significant after controlling the baseline Expanded Disability Status Scale score (p = 0.07). In the simvastatin group, the mean +/- SD of gadolinium-enhanced and new T2 lesions were 0.66 +/- 1.18 and 3.39 +/- 3.55, respectively, (compared with 0.74 +/- 1.21 and 3.39 +/- 3.55 in the placebo group). Although there was a decreasing trend in lesions on magnetic resonance imaging, this difference was not statistically significant (p = 0.62). The combination therapy was safe and well tolerated, and no serious adverse effect was noted.

CONCLUSION

Our study supports the safety and efficacy of simvastatin as an add-on therapy to INFb 1a in patients with relapsing-remitting multiple sclerosis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00668343. This interventional study provides Class I evidence stating that adding simvastatin 40 mg/day to IFNb 1a 30 microg a week in patients with relapsing-remitting multiple sclerosis may reduce the relapse rate (moderate effect size r = 0.29) (p = 0.01) compared with treatment with IFNb 1a alone.

Lamotrigine and twin pregnancy, incidental event or possible correlation?

Lamotrigine is frequently used to manage epilepsy during pregnancy. However, some major and minor birth defects are reported with lamotrigine monotherapy. This study is a case series report on 20 epileptic women who were receiving lamotrigine in their pregnancy. Apart from the normal pregnancies and births, in our study three patients gave birth to healthy twins, two vanished twin syndromes occurred and one patient had abortion. Twin pregnancy in association with lamotrigine therapy has not been clearly described before. Our observational study raises the idea that lamotrigine may induce twin pregnancy but larger studies need to investigate the presence or absence of such association more decently.