Peripheral Nerve Stimulation in Postoperative Analgesia: A Narrative Review

PURPOSE OF REVIEW

Recent research has shown the effectiveness of peripheral nerve stimulators (PNS) in managing chronic pain conditions. Ongoing studies aim to explore its potential application in treating acute postoperative pain states. The purpose of this systematic review is to assess the role of PNS in providing relief for postoperative pain.

RECENT FINDINGS

Clinical studies investigating the use of peripheral nerve stimulators (PNS) for analgesia following various surgeries, such as total knee arthroplasty, anterior cruciate ligament repair, ankle arthroplasty, rotator cuff repair, hallux valgus correction, and extremity amputation, have shown promising results. Lead placement locations include the brachial plexus, sciatic, femoral, tibial, genicular, perineal, sural, radial, median, and ulnar nerves. These studies consistently report clinically significant reductions in pain scores, and some even indicate a decrease in opioid consumption following PNS for postoperative pain. PNS involves the subcutaneous placement of electrode leads to target peripheral nerve(s) followed by delivery of an electric current via an external pulse generator. While the precise mechanism is not fully understood, the theory posits that PNS modulates electrical stimulation, hindering the signaling of nociceptive pain. PNS presents itself as an alternative to opioid therapy, holding promise to address the opioid epidemic by offering a nonpharmacologic approach for both acute and chronic pain states.

Evolving role of VIADISC for chronic low back and discogenic pain: a narrative review

INTRODUCTION

Chronic lower back pain is a leading cause of disability and healthcare spending worldwide. Discogenic pain, pain originating from the intervertebral disk, is a common etiology of chronic lower back pain. Currently, accepted treatments for chronic discogenic pain focus only on the management of symptoms, such as pain. There are no approved treatments that stop or reverse degenerating intervertebral discs. Biologic therapies promoting disc regeneration have been developed to expand treatment options. VIADISC™ NP, is a viable disc allograft supplementation that, in a recent trial, demonstrated a significant reduction in pain and increased function in patients suffering from symptomatic degenerative disc disease.

AREAS COVERED

This manuscript summarizes the epidemiology and etiology of low back pain, the pathophysiology of degenerative disc disease, current treatments, and a need for newer therapies. The rationale behind intradiscal biologics for the treatment of symptomatic degenerative disc disease is also discussed.

EXPERT OPINION

Characterization of the biology leading to disc degeneration has allowed for the development of intradiscal biologics. They may soon be capable of preventing and reversing disc degeneration. Clinical trials have shown promise, but further research into efficacy and safety is needed before these therapies are widely employed.

Recent Advances in Management of Neuropathic, Nociceptive, and Chronic Pain: A Narrative Review with Focus on Nanomedicine, Gene Therapy, Stem Cell Therapy, and Newer Therapeutic Options

PURPOSE OF REVIEW

This manuscript summarizes novel clinical and interventional approaches in the management of chronic, nociceptive, and neuropathic pain.

RECENT FINDINGS

Pain can be defined as a feeling of physical or emotional distress caused by an external stimulus. Pain can be grouped into distinct types according to characteristics including neuropathic pain, which is a pain caused by disease or lesion in the sensory nervous system; nociceptive pain, which is pain that can be sharp, aching, or throbbing and is caused by injury to bodily tissues; and chronic pain, which is long lasting or persisting beyond 6 months. With improved understanding of different signaling systems for pain in recent years, there has been an upscale of methods of analgesia to counteract these pathological processes. Novel treatment methods such as use of cannabinoids, stem cells, gene therapy, nanoparticles, monoclonal antibodies, and platelet-rich plasma have played a significant role in improved strategies for therapeutic interventions. Although many management options appear to be promising, extensive additional clinical research is warranted to determine best practice strategies in the future for clinicians.

Liquid biopsy in the setting of leptomeningeal metastases: a systematic review and meta-analysis

PURPOSE

The blood-brain barrier can prevent circulating tumor DNA (ctDNA) derived from the central nervous system from entering the blood making it challenging to evaluate molecular features of leptomeningeal metastasis (LM). Accordingly, we sought to systematically compare the diagnostic power or significance of ctDNA derived from cerebrospinal fluid (CSF) compared to plasma ctDNA in patients with LM.

METHODS

A systematic review and meta-analysis was performed under the PRISMA guideline. We used PubMed, EMBASE, and the EuroPMC to search the literature using combinations of the following terms: circulating tumor DNA, ctDNA, circulating tumor cell, brain metastasis, leptomeningeal metastasis, outcome(s), and prognosis. We included all available English language studies that compared the diagnostic significance of CSF derived and serum ctDNA. All eligible studies level of bias was assessed using the New Castle Ottawa Scale (NOS).

RESULTS

Our meta-analysis from 6 included studies (n = 226) that confirmed the diagnostic power of liquid biopsies in detecting genomic alteration is better when taking a CSF-derived samples than from the plasma (RR 1.46 [0.93; 2.29]; I2 = 92%; p-value < 0.01).

CONCLUSION

CSF ctDNA is better at describing molecular landscape for LM; such an understanding may ultimately help inform patient treatment and responses to therapy.

Cebranopadol for the Treatment of Chronic Pain

PURPOSE OF REVIEW

Regardless of the etiology, if pain persists chronically, it can detrimentally impact multiple aspects of a patient's well-being. Both physical and psychological effects are significant in many chronic pain patients. In this regard, psychological consequences can alter a patient's quality of life, functionality, and social functioning. Opioids have been the long-established gold standard for acute pain treatment in settings such as the postoperative period. An alternative to opioids in pain management has been highly sought after. Through a non-selective mechanism, cebranopadol is a first-in-class oral drug which combines agonism of the mu and nociceptin opioid peptide (NOP) receptors to provide improved analgesia, while reducing the occurrence of many typically opioid side effects. This manuscript is a narrative review of the possible use of cebranopadol in pain management.

RECENT FINDINGS

In pre-clinical studies, cebranopadol was similar to morphine in its pain control efficacy. In a phase IIa trial, cebranopadol was superior to placebo in reducing pain. In a randomized clinical trial, cebranopadol was superior to morphine. Another study concluded that cebranopadol had a lower misuse potential when compared to hydromorphone. In summary, cebranopadol offers new opportunities in treating chronic moderate to severe pain, while also countering risks of addiction. Additional studies are warranted to further evaluate the safety and efficacy of cebranopadol. In this regard, cebranopadol could prove to be a promising alternative to current pain treatment options.

The Use of Oxytocin for the Treatment of Opioid Use Disorder

Nearly 27 million people have an opioid use disorder (OUD) according to the 2016 Global Burden of Disease study, most of which occur in the US where opioids are a common class of medication used to treat acute and chronic pain. In 2016 alone, more than 60 million patients had at least one prescription for opioids filled or refilled. Over the past decade, prescription rates have risen astronomically and have created an epidemic in the US dubbed the "opioid crisis." In this regard, there has been an increase in overdoses and OUD diagnoses. Several studies have found dysregulation of balance between several neurotransmitters involved in the neural circuitry that subserves several behavioral domains, such as reward recognition, motivation, learning, and memory, affect, stress, and executive function, that contribute to the manifestation of craving. On the horizon is a new treatment approach consisting of the neuropeptide oxytocin, which may be involved in the overlapping mechanisms of stable attachment formation and coping with stress. Through this mechanism, it can shift processing from novelty and reward-seeking to an appreciation of familiarity and thus reduce stress and increase resilience in the face of addiction. It has been hypothesized that there is a connection between the glutaminergic and oxytocinergic systems, making oxytocin a possible therapeutic agent in reducing drug-induced actions seen in OUD patients. This manuscript will review the potential and feasible use of oxytocin in treating OUD.

Literature Review: Pericranial Nerve Blocks for Chronic Migraines

Purpose of Review

Headaches, especially migraines, are one of the most pervasive neurological disorders affecting up to 15.9% of the population. Current methods of migraine treatment include lifestyle changes, pharmacologic, and minimally invasive techniques such as peripheral nerve stimulation (PNS) and pericranial nerve blocks (PNB).

Recent Findings

PNBs are used to treat and prevent migraines and involves injection of local anesthetics with or without corticosteroids. PNBs include the greater occipital, supraorbital, supratrochlear, lesser occipital, auriculotemporal, sphenopalantine ganglion, and cervical root nerve blocks. Of the PNBs, the most extensively studied is the greater occipital nerve block (GONB) which has been shown to be an efficacious treatment for migraines, trigeminal neuralgia, hemi-crania continua, and post-lumbar puncture, post-concussive, cluster, and cervicogenic headaches but not medication overuse and chronic tension type headaches.

Summary

In this review, we aim to summarize the recent literature on PNBs and their efficacy in the treatment of migraines including a brief discussion of peripheral nerve stimulation.

Viloxazine for the Treatment of Attention Deficit Hyperactivity Disorder

Purpose of Review

Attention deficit hyperactivity disorder (ADHD) is a widely diagnosed neurodevelopmental disorder giving rise to symptoms of hyperactivity, impulsivity, and inattentiveness that can impair daily functioning. Stimulants, such as methylphenidate and amphetamines, are the mainstay of treatment for ADHD. However, nonstimulant drugs such as viloxazine, atomoxetine, guanfacine, and clonidine are becoming more popular due to minimal adverse effects when compared to stimulants.

Recent Findings

Viloxazine is a selective norepinephrine reuptake inhibitor (NRI) originally used to treat depression in adults with activity in both the noradrenergic as well as serotonergic pathways. Studies have demonstrated its efficacy for its use in the treatment of ADHD. Unlike stimulants, viloxazine has a decreased chance of substance abuse, drug dependance, and withdrawal symptoms upon the cessation of therapy. Additionally, dopamine levels in the nucleus accumbens after treatment with viloxazine are elevated considerably less in comparison with traditional stimulant ADHD treatments. Viloxazine provides an alternative, nonstimulant approach to treating ADHD.

Summary

Viloxazine is a recently approved, non-stimulant medication functions by inhibiting the uptake of norepinephrine which has been seen to be decreased in patients with ADHD. When patients do not respond to first-line stimulants, cannot tolerate the side effects, or have contraindications to stimulants, viloxazine may be a nonstimulant option offering patients an increasing arsenal of medications to treat ADHD.

Daridorexant for the Treatment of Insomnia

Purpose of Review

Insomnia is a complex sleeping disorder that affects the lives of many individuals worldwide. Insomnia often occurs in the presence of coexisting comorbidities making it a complex disorder that requires a multifactorial approach to therapy. First-line therapy is cognitive-behavioral therapy for insomnia (CBT-I). Pharmacotherapy for insomnia falls into four classes based on mechanism of action: benzodiazepine receptor agonists (BZRAs), histamine receptor antagonists, melatonin receptor agonists, and dual orexin receptor antagonists (DORAs).

Recent Findings

Daridorexant is a dual orexin type 1 and types 2 (OX₁ and OX₂) receptor antagonist that was recently approved by the US FDA for the treatment of adults suffering from insomnia. It was shown to be effective in reducing insomnia symptoms, increasing daytime functioning, and improving the overall quality of sleep. Daridorexant offers patients relief from insomnia while avoiding the severe side effects and dependency issues of traditional treatments like benzodiazepines and sedatives.

Summary

In this article, we review the most recent data on insomnia treatments and summarize the safety and efficacy of daridorexant in treating insomnia.

COVID-19-Induced Seizures: A Meta-Analysis of Case Series and Retrospective Cohorts

The adverse events and complications of coronavirus disease 2019 (COVID-19) continue to challenge the medical profession despite the worldwide vaccination against the severe acute respiratory coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19. Other than typical respiratory manifestations, COVID-19 also presents a wide range of neurological manifestations. This article underlines the pooled incidence of COVID-19-induced seizures in patients with epilepsy and without epilepsy. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols, we conducted a bibliographical search, and an initial search revealed 1,375 articles. In total, 21 articles were included in the final analysis by following the inclusion criteria. A total of 11,526 patients from 21 published articles that met the predetermined search criteria were included. The median age of the patients was 61.9 years, of whom 51.5% were males. A total of 255 patients presented with seizures as the first manifestation of COVID-19 with a prevalence of 2.2% (95% confidence interval = 0.05-0.24, p < 0.01) (I² = 97%), of which 71 patients had previously been diagnosed with epilepsy. Among patients with epilepsy, 49 patients had seizures as an initial presentation of SARA-CoV-2 with an incidence of 72% (0.54-0.85, p = 0.1) (I² = 34). Although the incidence of COVID-19-induced seizures is not high compared to other neurological manifestations, seizure incidence in epileptic patients with COVID-19 is remarkably high. New-onset seizures in any patient should be considered a presentation of COVID-19 in the absence of other causative factors.

Multiple Sclerosis Relapse Following COVID-19 Vaccination: A Case Report and Literature Review

Mass vaccination against coronavirus disease 19 (COVID-19) has effectively controlled the pandemic and has been remarkably effective and safe. Reports of a few adverse events have been reported after post-marketing surveillance. We present a rare case of multiple sclerosis (MS) relapse in a female who presented with fatigue, involuntary eye movements, and numbness; autoimmunity following the COVID-19 vaccine has also been described. She was diagnosed with MS six years back and was in remission. She received her COVID-19 vaccine 18 days ago. Her clinical and radiological features confirmed the MS relapse. Her serology for COVID-19 immunoglobulin G (IgG) and IgM was positive, and she was managed with intravenous methylprednisolone and symptomatic management. Our case provides a possible association of vaccine-associated MS relapse; however, more evidence is warranted from future studies.

Neuropsychiatric Systemic Lupus Erythematosus: A 2021 Update on Diagnosis, Management, and Current Challenges

Patients with systemic lupus erythematosus (SLE) experience neuropsychiatric symptoms. The term neuropsychiatric SLE (NPSLE) is a generic term that refers to a series of neurological and psychiatric symptoms directly related to SLE. In approximately 30% of patients with neuropsychiatric symptoms, SLE is the primary cause (NPSLE), and symptoms manifest more frequently around SLE onset. Neurovascular and psychotic conditions can also lead to NPSLE. Pathogenesis of NPSLE is implicated in both neuroinflammatory and ischemic mechanisms, and it is associated with high morbidity and mortality. After diagnosing and assigning causality, NPSLE treatment is individualized according to the type of neuropsychiatric manifestations, type of the predominant pathway, activity of SLE, and severity of the clinical manifestations. There are many problems to be addressed with regards to the diagnosis and management of NPSLE. Controlled clinical trials provide limited guidance for management, and observational cohort studies support symptomatic, antithrombotic, and immunosuppressive agents. The purpose of this review was to provide a detailed and critical review of the literature on the pathophysiology, diagnosis, and treatment of NPSLE. This study aimed to identify the shortcoming in diagnostic biomarkers, novel therapies against NPSLE, and additional research needs.

Multiple Sclerosis Following SARS-CoV-2 Infection: A Case Report and Literature Review

Coronavirus disease 19 (COVID-19) is caused by severe acute respiratory coronavirus 2 (SARS-CoV-2). Apart from respiratory manifestations, COVID-19 can affect the nervous system due to its neurotropic features. Neurological manifestations and complications include headache, polyneuropathies, cerebrovascular accidents, seizures, encephalopathy, and demyelinating disease. We describe a case of multiple sclerosis, a demyelinating disease following COVID-19 infection, rarely reported in the literature. A 47-year-old female presented with fatigue, blurry vision, numbness, and signs of upper motor neuron lesions that had occurred three weeks after COVID-19 infection. Magnetic resonance imaging of the brain revealed demyelinating lesions in the periventricular area of both hemispheres, suggesting a demyelinating disease. A provisional diagnosis of multiple sclerosis was made. Her condition improved after the commencement of methylprednisolone.

Efficacy of Daratumumab-Based Regimens Compared to Standard of Care in Transplant-Eligible Multiple Myeloma: A Meta-Analysis

Daratumumab (dara) belongs to a class of monoclonal antibodies that target CD38 receptors expressed on multiple myeloma (MM) cells. It was first approved for MM treatment in 2015. The efficacy and safety of dara have been reported in many studies. In this analysis, we assessed the outcome of dara addition to standard of care for transplant-eligible newly diagnosed (ND) MM. We conducted a comprehensive search using PubMed, ClinicalTrial.gov, and Embase. Out of 435 articles, we included two randomized clinical trials. We computed the odds ratio (OR) of response rates and risk ratio (RR) of adverse effects using Cochrane RevMan version 5.4. A total of 1,292 patients were enrolled in both trials. The patients were randomized into the control group and the dara group. The dara group included 647 patients and the control group included 645 patients. The CASSIOPEIA trial reported the outcomes using dara, bortezomib (V), thalidomide (T), and dexamethasone (d) versus VTd. The GRIFFIN trial underlined the efficacy of dara, lenalidomide (R), and Vd in the dara group versus RVd in the control group. A pooled analysis of included studies showed an increased overall response rate (OR: 1.60; 95% CI: 1.06-2.41; p = 0.02; I ² = 65%), stringent complete response (OR: 1.59; 95% CI: 1.24-2.05; p = 0.03; I ² = 0%), and negative status for minimal residual disease (OR: 2.47; 95% CI: 1.97-3.10; p < 0.01; I ² = 66%) in the dara group as compared to the control group. However, an increased risk of neutropenia (RR: 1.80; 95% CI: 1.60-2.03; p < 0.01) and decreased risk of peripheral neuropathy (RR: 0.92; 95% CI: 0.86-0.99; p = 0.02; I ² = 52%) were observed in the dara group. Dara addition to the standard of care regimen for transplant-eligible NDMM has promising outcomes with increased efficacy and safety profile and manageable toxicity.

Clinical Characteristics and Outcomes of COVID-19 in West Virginia

This study examines the clinical characteristics, outcomes and types of management in SARS-CoV-2 infected patients, in the hospitals affiliated with West Virginia University. We included patients from West Virginia with SARS-CoV-2 infection between 15 April to 30 December 2020. Descriptive analysis was performed to summarize the characteristics of patients. Regression analyses were performed to assess the association between baseline characteristics and outcomes. Of 1742 patients, the mean age was 47.5 years (±22.7) and 54% of patients were female. Only 459 patients (26.3%) reported at least one baseline symptom, of which shortness of breath was most common. More than half had at least one comorbidity, with hypertension being the most common. There were 131 severe cases (7.5%), and 84 patients (4.8%) died despite treatment. The mean overall length of hospital stay was 2.6 days (±6.9). Age, male sex, and comorbidities were independent predictors of outcomes. In this study of patients with SARS-CoV-2 infection from West Virginia, older patients with underlying co-morbidities had poor outcomes, and the in-hospital mortality was similar to the national average.

Impact of Chronic Kidney Disease on Severity and Mortality in COVID-19 Patients: A Systematic Review and Meta-analysis

Coronavirus disease 19 (COVID-19) has affected over 180 countries, resulting in global mass death. It has been reported that patients with underlying disease are more likely to contract the disease and become critically ill. The impact of chronic kidney disease (CKD) on the severity of COVID-19 has been underlined in the literature. In this analysis, we have provided evidence of an association between CKD and COVID-19. We followed the PRISMA protocol and conducted a literature search using Google Scholar, EMBASE, PubMed, and Clinical trail.gov. The initial search yielded 2102 articles. We included 20 cohorts based on inclusion criteria reporting an association between CKD and COVID-19 after excluding irrelevant articles, including review articles and duplicates. We conducted pooled prevalence of CKD and meta-analysis to estimate the odds ratio (OR), 95% confidence interval (CI) using Cochrane RevMan (version 5.4, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration), and R programming language version 4.16-2 (University of Auckland, New Zealand). Our study involved 4350 patients from different countries, and 212 (4.9%) patients had CKD. Among 20 cohorts, 57.27% were male with a median age of 55.5 years. Eight hundred sixty-six patients developed severe COVID-19, and out of which, 39 (4.5%) were CKD patients. CKD patients had a significantly increased risk of severe disease as compared to non-CKD patients with a pooled OR of 2.15 (95% CI 1.16-4.01) (I2=41; p=0.02). Out of 443 COIVD-19 patients who died, 85 patients had CKD, with a prevalence of 19.18%. CKD patients had an increased risk of death as compared to non-CKD patients with a pooled OR of 5.58 (95% CI 3.27-9.54) (I2=0; p<0.00001). CKD is manifested as a common underlying disease in COVID-19 patients who had a worse prognosis, including mortality.

The Association of Acute Kidney Injury With Disease Severity and Mortality in COVID-19: A Systematic Review and Meta-Analysis

Background and objective

The coronavirus disease 2019 (COVID-19) pandemic has become a global healthcare emergency. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, has a wide range of clinical manifestations ranging from subclinical infection to multi-organ failure. In addition to the respiratory system, COVID-19 also adversely affects the kidneys. In this study, we aimed to measure the prevalence of acute kidney injury (AKI) in COVID-19 and its association with the disease severity and mortality in COVID-19 patients.

Materials and methods

We conducted our study by following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. A comprehensive literature search using four databases (PubMed, EMBASE, Google Scholar, and clinicaltrial.gov) was performed. Our initial search returned 2,771 articles. After excluding review articles, duplicates, and non-relevant studies, we included 20 articles that reported an association between COVID-19 and AKI. We subsequently performed a random effect analysis to find the pooled prevalence, pooled odds ratio (OR) estimates, and 95% confidence intervals for severe COVID-19 and mortality outcomes in AKI using Cochrane RevMan (version 5.4) and R programming language (version 4.16-2).

Results

A total of 14,415 patients from various countries were included. Among the 20 cohorts, the median age was 55.8 ±8.39 years (range: 43-72 years), and 43.78% of the subjects were female. Out of a total of 14,415 patients, 3,820 developed AKI with a pooled prevalence of 11% (95% CI: 0.07-0.15; p<0.01; I²=98%). AKI was found to have a significant association with severe COVID-19 disease, with a pooled OR of 8.45 (95% CI: 5.56-12.56; p<0.00001; I²=0%). AKI was associated with significantly higher mortality in patients with COVID-19 with an OR of 13.52 (95% CI: 5.43-33.67; p<0.00001; I²=88%).

Conclusion

AKI manifests as a common COVID-19 complication, and COVID-19 patients with AKI generally have poor outcomes in terms of disease severity and mortality.

A Comprehensive Systematic Review of CSF analysis that defines Neurological Manifestations of COVID-19

BACKGROUND

Limited literature exists on Cerebrospinal fluid (CSF) findings in COVID-19 patients with neurological symptoms. In this review, we conducted a descriptive analysis of CSF findings in patients with COVID-19 to understand prognosis and explore therapeutic options.

METHODS

We searched PubMed, Google Scholar, and Scopus databases using the keywords "SARS-CoV-2 in cerebrospinal fluid" and "SARS-CoV-2 and CNS Complications"" for reports of CSF findings in COVID-19 related neurological manifestations. Descriptive analyses were conducted to observe the CSF protein and cell counts based on age, gender, severity, fatality of COVID-19, and whether central (CNS) or peripheral nervous system (PNS) was associated.

RESULTS

A total of 113 patients were identified from 67 studies. Of these, 7 patients (6.2%) were fatal COVID-19 cases and 35 patients (31%) were considered severe COVID-19 cases. CSF protein was elevated in 100% (7/7) of the fatal cases with an average of 61.28 mg/dl and in 65.0% (52/80) in non-fatal cases with an average 56.73 mg/dl. CSF protein levels were elevated in 74.5% (38/51) patients with non-severe COVID-19 and 68.6% (24/35) in those with a severe COVID-19 infection. CSF cell count was increased in 43% of fatal cases, 25.7% severe cases, and 29.4% of non-severe cases.

CONCLUSION

Our analysis showed that the most common CSF findings situation in COVID-19 infection is elevated protein with, very occasionally, mild lymphocyte predominant pleocytosis. Further studies to elucidate the pathophysiology of neurological complications in COVID-19 are recommended.

Acute transverse myelitis with Dysautonomia following SARS-CoV-2 infection: A case report and review of literature

Objective

To report a unique case and literature review of post COVID-19 associated transverse myelitis and dysautonomia with abnormal MRI and CSF findings.

Background

Coronavirus disease have been reported to be associated with several neurological manifestations such as stroke, Guillain-Barré syndrome, meningoencephalitis amongst others. There are only few reported cases of transverse myelitis with the novel coronavirus (n-CoV-2) and only one reported case identifying dysautonomia in COVID-19 patient. Here, we identify a COVID-19 patient diagnosed with acute transverse myelitis in addition to dysautonomia following with complete resolution of symptoms.

Method

A retrospective chart review of a patient diagnosed with post SARS-CoV-2 infection acute transverse myelitis and dysautonomia, and a review of literature of all the reported cases of transverse myelitis and COVID-19, from December 1st, 2019 till December 25th, 2020, was performed.

Conclusion

To our knowledge, this is the first reported case of transverse myelitis and dysautonomia in a patient with SARS-CoV-2 infection, who responded to intravenous methyl prednisone and bromocriptine. Follow-up imaging of the spine showed complete resolution of the lesion. Further studies would be recommended to identify the underlying correlation between COVID-19 and transverse myelitis.

Guillain Barré Syndrome and its variants as a manifestation of COVID-19: A systematic review of case reports and case series

BACKGROUND

The COVID-19 pandemic caused by SARS-COV-2 began in Wuhan, China in December 2019. Reports of COVID-19 with central (CNS) and peripheral nervous (PNS) system manifestations are emerging. In this systematic review, we compared and summarized the demographics, clinical features, Brighton criteria, immunological and laboratory findings with a focus on modified Erasmus GBS Outcome Score (mEGOS) in SARS-CoV-2 patients with GBS and its variants.

METHODS

Based on PRISMA guidelines, we searched three databases (PubMed, Scopus, and Google Scholar) for studies on COVID-19 and GBS between December 1, 2019 to July 15, 2020. For descriptive analysis, we studied two groups with: 1) acute inflammatory demyelinating polyradiculoneuropathy (AIDP) variant, and 2) Non-AIDP/Other variants. We compared mEGOS scores for patients in both groups along with other key clinical features.

RESULTS

Of the 50 GBS cases identified from 37 studies, 33 (66%) had acute inflammatory demyelinating polyradiculopolyneuropathy (AIDP) while 17 (34%) were of other (non-AIDP) variants. There mEGOS scores did not differ between AIDP patients and AMAN/AMSAN patients. Majority of the AIDP (66.7%) and AMAN/AMSAN (57.2%) patients belonged to Brighton level 1 indicating maximum diagnostic certainty.

CONCLUSION

To our knowledge, this is among the first reviews that includes GBS variants and the clinical prediction tool mEGOS for prognostication in COVID-19 patients. Further research is needed to assess whether IVIG is preferable over plasmapheresis in this population of GBS patients. It would also be crucial to follow these patients over time to identify the long-term disability as well as treatment outcomes.

Relevance and Clinical Significance of Magnetic Resonance Imaging of Neurological Manifestations in COVID-19: A Systematic Review of Case Reports and Case Series

We performed a systematic literature review of neuroimaging, predominantly focusing on magnetic resonance imaging (MRI) findings associated with neurological manifestations of coronavirus disease-2019 (COVID-19). We screened articles from PubMed, Google Scholar and Scopus, looking for reports that would potentially have neuroimaging findings in patients with COVID-19. Data analysis was performed with patient-based data based on the availability of clinical characteristics and outcomes for each individual patient from the studies. Chi square and Wilcoxon rank-sum tests were used to report COVID-19 severity and outcomes based on neurological imaging indicators and pathophysiology. A total of 171 patients with COVID-19 having neurological complications, from 134 studies, were identified in our review. The most common neuroimaging finding was ischemic stroke (62, 36.2%) cases, followed by CNS inflammatory disorder (44, 25.7%), and hemorrhagic stroke (41, 24.0%). Around 51% of all the fatal COVID-19 cases had an ischemic stroke. Among patients with ischemic stroke, the mean age of those who suffered from COVID-19 infection was 57.5 years (SD = 15.4) whereas it was 50.7 years (SD = 15.1) among those without stroke/other diagnosis. Fatality was more common in patients with ischemic stroke compared to those with other diagnosis (40% vs. 22%, p = 0.011). The most frequently published neuroimaging findings in patients with COVID-19 were ischemic stroke, CNS inflammatory disorder, and hemorrhagic disorder. In those studies, ischemic stroke was associated with fatality, and was more frequently seen in older patients. Based on our findings, early usage of MRI in COVID-19 patients may be recommended.

A case series and literature review of multiple sclerosis and COVID-19: Clinical characteristics, outcomes and a brief review of immunotherapies

BACKGROUND

In view of the emerging coronavirus pandemic, the demand for knowledge about the impact of SARS-CoV-2 on people with Multiple Sclerosis (MS) continues to grow. Patients receiving disease modifying therapy (DMT) for MS have a higher background risk of infection-related health care utilization when compared to the general population. Therefore, there is a need of evidence-based recommendations to reduce the risk of infection and also managing MS patients with SARS-CoV-2.

CASE DESCRIPTION

We present three patients with history of Multiple Sclerosis (MS) on DMTs presenting with worsening MS symptoms likely pseudo exacerbation who were diagnosed with COVID-19.

DISCUSSION

An extensive review of 7 articles was performed, in addition to a brief review on DMTs use in MS patients with COVID-19. In our cases, all patients were on DMT and severe course of disease was noted in 2 cases. No fatality was observed.

CONCLUSIONS

This review provides a base on the clinical characteristics, outcomes and the roles of DMTs in MS patients suffering from n-cov-2. Physicians need to be vigilant about considering COVID-19 infection related relapse in the MS patients, especially in this COVID-19 pandemic era and look for pseudo-exacerbation. As most cases are found to have mild course and full recovery on DMTs, further research is needed to formulate evidence-based guidelines. This review will particularly be helpful for the researchers and registries to collect future data on MS and COVID-19.

An Unusual Presentation of Multiple Sclerosis in a Middle-Aged Woman: A Case Report and Literature Review

An intense itching localized to dermatomes is a rare symptom of multiple sclerosis (MS). Herein, we report a case of a 45-year-old female who presented with severe itching and tingling sensation, gait disturbance, and bilateral paresthesia for one week. She also had a history of multiple admission in the hospital due to recurrent walking abnormalities and numbness and tingling of both hands associated with intermittent psychiatric symptoms. The neurological examination revealed spastic quadriparesis with lower limb muscles affected more than the upper limbs, numbness, and sensory loss in the upper extremities in the glove and stocking pattern. Magnetic resonance imaging (MRI) revealed multiple small rounded periventricular plaques in both hemispheres and along the long axis of the corpus callosum (fluid-attenuated inversion recovery/FLAIR sequence), and cerebrospinal fluid analysis revealed the presence of oligoclonal bands, suggestive of MS. She was commenced on methylprednisolone and carbamazepine, leading to progressive resolution of her signs and symptoms. She was discharged with monthly natalizumab, and she was doing well on her follow-up.

Cardiovascular and Hematological Risk Factors and Mortality Risk in Pediatric Arterial Ischemic Stroke: Analysis Report From Hospitals in the United States

Objective We aimed to analyze the differences in demographics, comorbidities, and the risk of in-hospital mortality in pediatric arterial ischemic stroke (PAIS) inpatient population by hematological (HEM) and cardiovascular (CV) risk factors. Methods A total of 4,036 inpatients (1-18 years of age) from the Nationwide Inpatient Sample (NIS) with a primary diagnosis of PAIS were included. Descriptive statistics, linear-by-linear association test, and logistic regression models were utilized to analyze differences in demographics, comorbidities, and their impact on mortality in PAIS inpatients by CV and HEM risk factors. Results The cumulative in-hospital mortality rate in the entire PAIS inpatient cohort was 3.6%. The mortality rate was higher in the CV cohort (57.4%) as compared to the HEM cohort (29.7%). When compared with the cohort with no risk factors, HEM and CV were associated with four times (95% CI: 2.36-8.03) and seven (95% CI: 4.03-12.61) times higher odds for in-hospital mortality respectively. CV risk factors like cardiomyopathy and diabetes, and HEM risk factors like blood disorders, coagulation disorders, and deficiency anemias were associated with a significantly increased risk of in-hospital mortality. Conclusion The in-hospital mortality risk in PAIS patients was increased by 613% by CV risk factors and by 336% by HEM risk factors. Early identification and effective management of associated CV and HEM risk factors in the PAIS patient population can pave the way for increased survival and improved clinical outcomes.

Multiple embolic stroke on magnetic resonance imaging of the brain in a COVID-19 case with persistent encephalopathy

The pulmonary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or coronavirus disease 2019 (COVID-19) are well known. The literature on neurological manifestations and complications in patients with COVID-19 has been increasing but is still sparse. At present, there are only a few reported case reports and clinical studies on neurological manifestations of COVID-19, of which ischemic stroke is one of the most common ones. Coagulopathy and vascular endothelial dysfunction have been proposed as the complications of COVID-19 which can ultimately lead to ischemic stroke. In this case report, we present a case of multifocal ischemic stroke in a patient with COVID-19. This patient had persistent encephalopathy and dysarthria after recovering from hypoxic respiratory failure and subsequently developed ischemic stroke in multiple vascular territories during hospital admission.

•

Hypercoagulopathy and vascular endothelial dysfunction have been proposed as complications of COVID 19 which can lead to stroke.

•

Diagnoses of stroke in critically ill patients hospitalized with COVID-19 using MRI brain can be challenging due to multiple factors.

•

Patient with COVID-19 with stroke in multiple vascular territories after he had persistent encephalopathy and dysarthria.

•

MRI brain is more sensitive and specific modality to detect brain tissue that has been damaged by an ischemic stroke than a CT head.

Multiple cerebral cavernous hemangiomas masquerading as hemorrhagic brain metastases

Intracranial hemorrhagic metastases are a relatively common finding in patients with thyroid carcinoma. Consequently, more unusual vascular lesions may be overlooked in contemplating a differential diagnosis in this patient group. A 50-year-old female with previously treated papillary thyroid carcinoma presented to the emergency department following new onset seizures. Her work up revealed multiple intraparenchymal brain lesions, hyperdense on computed tomography and demonstrating susceptibility effect, T1 shortening and contrast enhancement on magnetic resonance imaging, suggestive of metastases. Subsequent studies revealed lesional architecture consistent with multiple cavernous malformations, made evident by resolution of edema and evolution of blood products. Clinicians should be aware of the possibility of unusual intracranial hemorrhagic lesions in oncology patients which may only become evident on serial imaging evaluation. Cavernous hemangioma has typical MRI characteristic features which includes “mulberry” appearance on T2-weighted and fluid attenuation inversion recovery images with varying internal signal intensity which indicates multiple stages of blood products within the cavernous hemangioma. The lesions commonly have a typical T2-weighted dark hemosiderin rim. Blood sensitive demonstrates prominent surrounding hypointensity representing blooming secondary to internal blood products and/or calcification, if present. Cavernous hemangioma may rarely demonstrate some degree of contrast enhancement. Perfusion imaging may show alteration in capillary permeability involving cavernous malformations which has been previously described in the literature.

West Nile virus encephalitis: A report of two cases and review of neuroradiological features

West Nile virus (WNV) is a single-stranded RNA arbovirus of Flavivirus genus that is endemic to the United States and known to cause neuroinvasive disease. Diagnosis is confirmed by the presence of WNV-specific IgM antibodies within serum or cerebrospinal fluid (CSF). Radiologically, it presents as hyperintense T2 signal within deep brain structures (ie, thalami and mid-brain) with or without cerebral peduncle and substantia nigra involvement. On diffusion-weighted imaging, restricted diffusion is reported in basal ganglia and disseminated throughout the white matter. In this report, we describe the imaging findings for 2 cases of WNV from our institution; a 56-year-old female and a 34-year-old female. Increased vigilance for WNV is warranted, particularly in immunosuppressed patients presenting with a clinical picture of viral meningoencephalitis despite initial negative magnetic resonance imaging or CSF analysis. A high suspicion for WNV disease should prompt repeat imaging or laboratory workup.

A Rare Case of Atypical Pleomorphic Neoplasm of Pineal Region in a Child: A Case Report

A 10-year-old boy with no past medical history presented with complaints of nausea and vomiting associated with morning headache for the last month. Ophthalmic nerve and eye exam showed diplopia and strabismus with no other significant findings on physical and neurological examination. Magnetic resonance imaging (MRI) of the brain revealed a homogenous hyperdense and enhancing mass in the pineal region. The endoscopic biopsy of the pineal region demonstrated the cells with highly pleomorphic and hyperchromatic nuclei with an increase in mitotic activity. There were many vessels but no area of vascular proliferation and necrosis. Granular bodies with eosinophilia were identified. Immunohistochemistry was positive for class III b-tubulin with epidermal growth factor receptor (EGFR) staining and glial fibrillary acidic protein (GFAP). Immunostaining was positive for p53, Phosphatase and Tensin homolog (PTEN), and oligodendrocyte transcription factor (OLIG2), while staining for cluster of differentiation (CD)34, cytokeratin (CK), human melanoma black (HMB)45, and isocitrate dehydrogenase (IDH)-R132H mutation was negative, consistent with atypical pleomorphic neoplasm of the pineal region. The patient underwent tumor resection via a sub-occipital trans-tentorial approach, followed by one dose of chemotherapy. The patient experienced a resolution of the symptom and was doing well on his bi-monthly follow up. 

Coronavirus Disease 2019-Related Acute Ischemic Stroke: A Case Report

Coronavirus disease 2019 (COVID-19) is an active worldwide pandemic with diverse presentations and complications. Most patients present with constitutional and respiratory symptoms. Acute ischemic stroke remains a medical emergency even during the COVID-19 pandemic. Here we present a case of a patient with COVID-19 who presented with acute ischemic stroke in the absence of common risk factors for cerebrovascular accidents. A 70-year-old male patient, with no prior comorbidities, presented to the emergency department (ED) with fever, cough, and shortness of breath for four days, and altered level of consciousness and right-sided weakness with the sensory loss for one day. On examination, the patient had a score of 8/15 on the Glasgow coma scale (GCS). There was a right-sided sensory loss and weakness in both upper and lower limbs with a positive Babinski's sign. The pulmonary examination was remarkable for bilateral crepitation. On blood workup, there was leukocytosis and raised c-reactive protein (CRP). D-dimer, ferritin, thyroid-stimulating hormone (TSH), vitamin B12, and hypercoagulability workup were normal. Transthoracic echocardiography was also normal. COVID-19 polymerase chain reaction (PCR) detected the virus. Chest x-ray showed infiltrations in the left middle and both lower zones of the lungs in the peripheral distribution. Computed tomography (CT) scan of the chest showed peripheral and mid to basal predominant multilobar ground-glass opacities. CT scan of the head showed a large hypodense area, with a loss of gray and white matter differentiation, in the left middle cerebral artery territory. Magnetic resonance imaging (MRI) of the head showed abnormal signal intensity area in the left parietal region. It appeared isointense on T1 image and hyperintense on T2 image. It also showed diffusion restriction on the diffusion-weighted 1 (DW1) image with corresponding low signals on the apparent diffusion coefficient (ADC) map. These findings were consistent with left middle cerebral artery territory infarct due to COVID-19. The patient was intubated in the ED. He was deemed unfit for thrombolysis and started on aspirin, anti-coagulation, and other supportive measures. Patients with COVID-19 should be evaluated early for neurological signs. Timely workup and interventions should be performed in any patient suspected of having a stroke to reduce morbidity and mortality.

Cocaine-Induced Headache: A Review of Pathogenesis, Presentation, Diagnosis, and Management

Cocaine is a vasoactive substance, and its consumption has increased throughout the world. There are many neurological complications caused by chronic cocaine use, which include headache, aneurysmal formation, ischemic stroke, hemorrhagic stroke (subdural and subarachnoid hemorrhage), seizures, etc. Headache is one of the most common symptoms that appear after cocaine use. It may occur due to dopaminergic and serotoninergic system impairment. Cocaine causes vasoconstriction by stimulation of the sympathetic nervous system and decreases the reuptake of epinephrine, norepinephrine, serotonin, and dopamine. Reversible cerebral vasoconstriction syndrome (RCVS) is well accepted with cocaine use, which occurs most commonly in middle-aged adults and females. The relation between cocaine consumption and time of occurrence of headache has been described according to which some people suffer from headaches immediately after the cocaine use, some within 40 to 90 minutes of a cocaine binge, and some even after the cocaine abstinence for long period. The diagnosis of a cocaine-induced headache depends on history, physical examination, and cerebrovascular imaging findings. And its management is done according to cause that is responsible for headache.

Primary Periodic Paralyses: A Review of Etiologies and Their Pathogeneses

Periodic paralyses are a group of disorders characterized by episodes of muscle paralyses. They are mainly divided as primary (hereditary) and secondary (acquired) periodic paralyses. Primary periodic paralyses occur as a result of mutations in genes encoding subunits of muscle membrane channel proteins such as sodium, calcium, and potassium channels, resulting in impairment of their properties. Primary periodic paralyses are further classified on the basis of affected ion channels and other associated complications. Some of these periodic paralyses are hyperkalemic periodic paralysis (Na-channel mutation), hypokalemic periodic paralysis (Na- or Ca-channel mutation), Andersen’s syndrome (K-channel mutation), etc.

Aortic Stenosis Patients With Transcatheter Aortic Valve Replacement: Caution Recommended With Renal Failure During Hospitalization

Objective Our study aimed to assess the risk of in-patient mortality due to renal failure and other comorbidities in aortic stenosis (AS) patients undergoing transcatheter aortic valve replacement (TAVR). Methods We conducted a cross-sectional study using a Nationwide Inpatient Sample (NIS, January 2010 to December 2014) from the United States and included 33,325 patients with a primary diagnosis of AS. Logistic regression was used to evaluate the odds ratio (OR) for in-hospital mortality in AS by comorbidities including renal failure. Results The prevalence of renal failure in AS patients is 29.2%, and a higher proportion were males (60.1%) and non-white (14.1%). Major loss of function (96.6%) and in-hospital mortality (5.1%) were also proportionally higher in prevalence. Female patients (OR 1.35, 95% CI 1.20-1.51) had higher odds of in-patient mortality in AS patients. Race was a non-significant predictor for mortality risk. Patients with comorbid coagulopathy (OR 2.02, 95% CI 1.79-2.27) and heart failure (OR 1.62, 95% CI 1.39-1.89) have increased mortality in AS inpatients. After controlling confounders, renal failure was significantly associated with increased in-hospital mortality (OR 1.43, 95% CI 1.28-1.61) in AS patients. Conclusion Renal failure was prevalent in AS patients and was an independent factor that increases the risk of in-hospital mortality by 43%. Due to worse outcomes, more studies are required to evaluate risk-benefit ratio and strategies to improve health-related quality of life in post-TAVR patients with renal failure, and optimally decrease inpatient mortality.

Trigeminal Neuralgia Induced Headache: A Case Report and Literature Review

A 51-year-old woman with a past medical history of migraine presented with severe headache for the last three weeks. The pain was intermittent and throbbing in nature. She has not experienced any headaches in the past several years. She took her migraine pills and over-the-counter analgesics, but the pain did not resolve. Initial evaluation including physical exam and neurological exam was normal. Her serum chemistry was unremarkable and CT scan of the brain was nonsignificant. The patient was diagnosed with possible trigeminal neuralgia and the pain resolved after being started on tegral (carbamazepine). Unilateral headache is a typical presentation of atypical trigeminal neuralgia and is rarely reported in literature.

COVID-19 Induced Acute Pancreatitis: A Case Report and Literature Review

A 49-year-old female with no history of past medical illness presented to the emergency department with complaints of fever, dry cough, and shortness of breath. Initial evaluation revealed a temperature of 101°F, and on auscultation, the patient had scattered wheezing and rales in left lung fields. CT of the chest revealed pneumonic patches in the upper and lower segment of the left lung. Her COVID-19 testing came positive. On the second day of hospital admission, the patient experienced nausea, vomiting, and severe epigastric pain radiating to back. Laboratory analysis revealed a marked elevation of lipase and amylase. CT of the abdomen showed an edematous pancreas with diffuse enlargement. She was diagnosed with acute pancreatitis due to COVID-19 after carefully ruling out other causes. She was managed symptomatically, and improvement in her clinical condition was observed and was discharged with outpatient follow-up. Although acute pancreatitis is rare in patients with COVID-19, it should be considered as a differential diagnosis in patients with severe epigastric pain and respiratory symptoms.

A Case Report on Charcot-Marie-Tooth Disease with a Novel Periaxin Gene Mutation

Charcot-Marie-Tooth (CMT) disease is one of the most common primary hereditary neuropathies causing peripheral neuropathies. More than 60 different gene mutations are causing this disease. The PRX gene codes for Periaxin proteins that are expressed by Schwann cells and are necessary for the formation and maintenance of myelination of peripheral nerves. Dejerine-Sottas neuropathy and Charcot-Marie-Tooth type 4F (CMT4F) are the two different clinical phenotypes observed in association with PRX gene mutation. This article describes a case of an elderly male with a novel mutation involving the PRX gene.

Synchrotron-based phase-sensitive imaging of leaves grown from magneto-primed seeds of soybean

Experiments were conducted to study the effects of static magnetic fields (SMFs) on the venation network of soybean leaves using the synchrotron-based X-ray micro-imaging technique. The seeds of soybean (Glycine max, variety JS-335) were pretreated with different SMFs from 50 to 300 mT in steps of 50 mT for 1 h. The phase-contrast images obtained showed that, as the strength of the SMF increased, the area, width of the midrib, area of the midrib and minor vein of the middle leaflets of third trifoliate leaves also increased up to the SMF strength of 200 mT (1 h) and decreased thereafter. Quantification of the major conducting vein also showed the differences in the major and minor vein structures of the soybean leaves as compared with control leaves. Further, the phase-retrieval technique has been applied to make the segmentation process easy and to quantify the major and minor veins in the venation network. The width and area of midrib enhancement by pre-treatment with SMF implies an enhancement in the uptake of water, which in turn causes an increased rate of photosynthesis and stomatal conductance.

Synchrotron X-ray phase contrast imaging of leaf venation in soybean (Glycine max) after exclusion of solar UV (280-400 nm) radiation

The hydraulic efficiency of a leaf depends on its vascular structure as this is responsible for transport activities. To investigate the effect of exclusion of UVAB and UVB radiation from the solar spectrum on the micro-structure of leaves of soybean (Glycine max, variety JS-335), a field experiment was conducted using synchrotron-based phase contrast imaging (PCI). Plants were grown in specially designed UV exclusion chambers, and wrapped with filters that excluded UVB (280-315 nm) or UVAB (280-400 nm), or transmitted all the ambient solar UV (280-400 nm) radiation (filter control). Qualitative observation of high-resolution X-ray PCI images obtained at 10 keV has shown the differences in major and minor vein structures of the leaves. The mid-rib width of the middle leaflet of third trifoliate leaves, for all treatments, were obtained using quantitative image analysis. The width of the mid-rib of the middle leaflet of third trifoliate leaves of UVB excluded plants was found to be more compared to leaves of filter control plants, which are exposed to ambient UV. The mid-rib or the main conducting vein transports water and sugars to the whole plant; therefore, mid-rib enhancement by the exclusion of solar UV radiation possibly implies enhancement in the leaf area which in turn causes an increased rate of photosynthesis.

Effect of pneumoperitoneum on intracranial pressure during supratentorial craniotomy: a case report

Laparoscopic surgery has become the method of choice for many procedures previously performed by open techniques. However, its use in patients with a potentially decreased intracranial compliance warrants caution. We report a case of combined glioma excision and laparoscopic cholecystectomy procedures with evaluation of the effects of pneumoperitoneum on ICP and operative field. The clinical implications, safety and recommendations of conducting laparoscopic surgeries in neurosurgical patients are discussed. Performing pneumoperitoneum in patients with marginal intracranial compliance needs interdisciplinary discussions and ICP monitoring is mandatory.