Functional brain networks in Developmental Topographical Disorientation

Despite a decade-long study on Developmental Topographical Disorientation, the underlying mechanism behind this neurological condition remains unknown. This lifelong selective inability in orientation, which causes these individuals to get lost even in familiar surroundings, is present in the absence of any other neurological disorder or acquired brain damage. Herein, we report an analysis of the functional brain network of individuals with Developmental Topographical Disorientation ($n = 19$) compared against that of healthy controls ($n = 21$), all of whom underwent resting-state functional magnetic resonance imaging, to identify if and how their underlying functional brain network is altered. While the established resting-state networks (RSNs) are confirmed in both groups, there is, on average, a greater connectivity and connectivity strength, in addition to increased global and local efficiency in the overall functional network of the Developmental Topographical Disorientation group. In particular, there is an enhanced connectivity between some RSNs facilitated through indirect functional paths. We identify a handful of nodes that encode part of these differences. Overall, our findings provide strong evidence that the brain networks of individuals suffering from Developmental Topographical Disorientation are modified by compensatory mechanisms, which might open the door for new diagnostic tools.

A neural circuit for spatial orientation derived from brain lesions

There is disagreement regarding the major components of the brain network supporting spatial cognition. To address this issue, we applied a lesion mapping approach to the clinical phenomenon of topographical disorientation. Topographical disorientation is the inability to maintain accurate knowledge about the physical environment and use it for navigation. A review of published topographical disorientation cases identified 65 different lesion sites. Our lesion mapping analysis yielded a topographical disorientation brain map encompassing the classic regions of the navigation network: medial parietal, medial temporal, and temporo-parietal cortices. We also identified a ventromedial region of the prefrontal cortex, which has been absent from prior descriptions of this network. Moreover, we revealed that the regions mapped are correlated with the Default Mode Network sub-network C. Taken together, this study provides causal evidence for the distribution of the spatial cognitive system, demarking the major components and identifying novel regions.

Acute confusional state in HaNDL syndrome

OBJECTIVE

To assess epidemiological, clinical and neuroimaging features of acute confusional state in the Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis (HaNDL) syndrome.

BACKGROUND

HaNDL is an increasingly recognized syndrome in which migraine-like headache episodes accompanied by hemiparaesthesia and/or hemiparesis and/or dysphasia are associated to CSF lymphocytic pleocytosis. The International Classification of Headache Disorders (ICHD-3) includes HaNDL syndrome in group 7 "headache attributed to non-vascular intracranial disorder" code 7.3.5, and lists the HaNDL-associated signs/symptoms that may be found less frequently. Confusional state is not mentioned in the 7.3.5-ICHD-3 "notes" or "comments" section as part of the HaNDL neurological spectrum. Moreover, the acute confusional state pathogenesis in HaNDL syndrome remains still uncertain and debated.

METHODS

Here, we report a 32-year-old male who complained episodes of migraine-like headache and left hemiparaesthesia complicated by confusional state which led to discovering CSF lymphocytosis. Since other workup to determine the cause of his symptoms was otherwise negative, he was diagnosed as having HaNDL syndrome. We also ascertained and reviewed all available reports of HaNDL to assess the significance of confusional state in this syndrome.

RESULTS

The search yielded 159 HaNDL cases among single reports and small/large series. Out of 159 patients who fulfilled the inclusion criteria for HaNDL according to the current ICHD at the time of diagnosis, 41 (25.7%) presented with acute confusional state. Among 41 HaNDL patients with confusional state, 16 (66.6%) out of 24 who underwent spinal tap had increased opening pressure.

CONCLUSION

We propose that a mention of acute confusional state may be included in the "comments" section of "7.3.5-syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL)," when ICHD-3 diagnostic criteria will be updated. Moreover, we speculate that intracranial hypertension may play a role in the pathogenesis of the acute confusional state associated to HaNDL syndrome. Larger case series are needed to evaluate this hypothesis.

A 66-Year-Old Man with Fever and Confusion

A 66-Year-Old Man with Fever and ConfusionA 66-year-old man with Parkinson's disease and hypertension presented to the ED with fever and confusion after returning to the U.S. from Cambodia. He was febrile with diaphoresis and rigors. What was the diagnosis?

Need for Standardization of Measurement of Time to Reorientation as a Predictor of Cognitive Adverse Effects of Electroconvulsive Therapy

ABSTRACT

Testing for time to reorientation (TRO) after electroconvulsive therapy (ECT) has been one of the most predictive measures for cognitive adverse effects of ECT. However, measuring TRO varies between clinical trials, and there is no standardized approach on its measurement between studies. The objective of this report is to systematically review the literature on the different ways of measuring TRO. This would be a first step to establish a consensus on a standard method for TRO. We performed a systematic literature review from 1968 to October 2019 for clinical trials with a sample size of more than 50 and published in English that describe measures of TRO. We searched both PubMed and Web of Science databases. The literature search generated 12 clinical trials, which met the inclusion criteria. Studies measured TRO using 3-, 5-, or 10-item questionnaires. Most studies measured full orientation as answering 4/5 questions. Other studies smaller than 50 required 14/14 items to be answered correctly. There was wide variation between studies on how often and when orientation questions were initiated. These factors have obvious implications to the results and interpretation of the ECT literature.There was no clear consensus on measuring TRO in a uniform fashion. Research and clinical care would benefit from a standardized approach to measuring TRO. Measuring TRO using a 4/5 method seems the most common and quickest way, whereas using a 14/14 method seems to be the most rigorous and sensitive to change in trials.

Neurological Manifestations in COVID-19 Infection: A Systematic Review and Meta-Analysis

BACKGROUND

Growing evidence showed that coronavirus disease 2019 (COVID-19) infection may present with neurological manifestations. This review aimed to determine the neurological manifestations and complications in COVID-19.

METHODS

We conducted a systematic review and meta-analysis that included cohort and case series/reports involving a population of patients confirmed with COVID-19 infection and their neurologic manifestations. We searched the following electronic databases until April 18, 2020: PubMed, Embase, Scopus, and World Health Organization database (PROSPERO registration number: CRD42020180658).

RESULTS

From 403 articles identified, 49 studies involving a total of 6,335 confirmed COVID-19 cases were included. The random-effects modeling analysis for each neurological symptom showed the following proportional point estimates with 95% confidence intervals: "headache" (0.12; 0.10-0.14; I2 = 77%), "dizziness" (0.08; 0.05-0.12; I2 = 82%), "headache and dizziness" (0.09; 0.06-0.13; I2 = 0%), "nausea" (0.07; 0.04-0.11; I2 = 79%), "vomiting" (0.05; 0.03-0.08; I2 = 74%), "nausea and vomiting" (0.06; 0.03-0.11; I2 = 83%), "confusion" (0.05; 0.02-0.14; I2 = 86%), and "myalgia" (0.21; 0.18-0.25; I2 = 85%). The most common neurological complication associated with COVID-19 infection was vascular disorders (n = 23); other associated conditions were encephalopathy (n = 3), encephalitis (n = 1), oculomotor nerve palsy (n = 1), isolated sudden-onset anosmia (n = 1), Guillain-Barré syndrome (n = 1), and Miller-Fisher syndrome (n = 2). Most patients with neurological complications survived (n = 14); a considerable number of patients died (n = 7); and the rest had unclear outcomes (n = 12).

CONCLUSION

This review revealed that neurologic involvement may manifest in COVID-19 infection. What has initially been thought of as a primarily respiratory illness has evolved into a wide-ranging multi-organ disease.

Neurological complications in critical patients with COVID-19

Introduction

We analysed the neurological complications of patients with severe SARS-CoV-2 infection who required intensive care unit (ICU) admission.

Patients and methods

We conducted a retrospective, observational, descriptive study of consecutive patients admitted to the ICU due to severe respiratory symptoms secondary to SARS-CoV-2 infection between 1 April and 1 June 2020.

Results

We included 30 patients with neurological symptoms; 21 were men (72.40%), and mean age (standard deviation [SD]) was 57.41 years (11.61). The mean duration of ICU stay was 18.83 days (14.33). The neurological conditions recorded were acute confusional syndrome in 28 patients (93.33%), neuromuscular disease in 15 (50%), headache in 5 (16.66%), cerebrovascular disease in 4 (13.33%), and encephalopathies/encephalitis in 4 (13.33%). CSF analysis results were normal in 6 patients (20%). Brain MRI or head CT showed alterations in 20 patients (66.6%). EEG was performed in all patients (100%), with 8 (26.66%) showing abnormal findings. In 5 of the 15 patients with clinical myopathy, diagnosis was confirmed with electroneuromyography. We found a correlation between older age and duration of ICU stay (P = 0.002; 95% CI, 4.032–6.022; OR).

Conclusions

Severe COVID-19 mainly affects men, as observed in other series. Half of our patients presented acute myopathy, and almost all patients left the ICU with acute confusional syndrome, which fully resolved; no correlation was found with EEG or neuroimaging findings. Older age is associated with longer ICU stay.

[Neurological complications in critical patients with COVID-19]

Introduction

We analysed the neurological complications of patients with severe SARS-CoV-2 infection who required intensive care unit (ICU) admission.

Patients and methods

We conducted a retrospective, observational, descriptive study of consecutive patients admitted to the ICU due to severe respiratory symptoms secondary to SARS-CoV-2 infection between 1 April and 1 June 2020.

Results

We included 30 patients with neurological symptoms; 21 were men (72.40%), and mean age (standard deviation [SD]) was 57.41 years (11.61). The mean duration of ICU stay was 18.83 days (14.33). The neurological conditions recorded were acute confusional syndrome in 28 patients (93.33%), neuromuscular disease in 15 (50%), headache in 5 (16.66%), cerebrovascular disease in 4 (13.33%), and encephalopathies/encephalitis in 4 (13.33%). CSF analysis results were normal in 6 patients (20%). Brain MRI or head CT showed alterations in 20 patients (66.6%). EEG was performed in all patients (100%), with 8 (26.66%) showing abnormal findings. In 5 of the 15 patients with clinical myopathy, diagnosis was confirmed with electroneuromyography. We found a correlation between older age and duration of ICU stay (P = .002; 95% CI: 4.032-6.022; OR: 3,594).

Conclusions

Severe COVID-19 mainly affects men, as observed in other series. Half of our patients presented acute myopathy, and almost all patients left the ICU with acute confusional syndrome, which fully resolved; no correlation was found with EEG or neuroimaging findings. Older age is associated with longer ICU stay.

Virtual Reality in Anatomy: A Pilot Study Evaluating Different Delivery Modalities

Technologies such as virtual reality are used in higher education to develop virtual learning resources (VLRs). These VLRs can be delivered in multiple modalities, from truly immersive involving wearable devices to less immersive modalities such as desktop. However, research investigating perceptions of VLRs in anatomy has mainly focused on a single delivery modality and a limited-demographic participant cohort, warranting a comparison of different modalities and a consideration of different cohorts. This pilot study aimed to compare perceptions of highly immersive and less immersive VLR deliveries among anatomy students and tutors and evaluate the impact of prior university experience on students' perceptions of VLRs. A skull anatomy VLR was developed using the Unity^® gaming platform and participants were voluntarily recruited to assess highly immersive stereoscopic and less immersive desktop deliveries of the VLR. A validated survey tool was used to gather perceptions of both deliveries. Most participants agreed that both VLR deliveries were interesting and engaging and provided an immersive experience. Anatomy students perceived the stereoscopic delivery to be significantly more useful for understanding (P = 0.013), while anatomy tutors perceived the desktop delivery as more useful. A degree of physical discomfort and disorientation was reported by some participants for both deliveries, although to a greater extent for the stereoscopic delivery. The stereoscopic delivery was also found to be more mentally taxing than desktop delivery. These results suggest that desktop VLR delivery may minimize the risk of discomfort and disorientation associated with more immersive modalities while still providing a valuable learning experience.

Night-time confusion in an elderly woman post-stroke

For patients with acute ischaemic stroke, faster recanalisation improves the chances of a disability-free life and a quick discharge from the hospital. Hospital discharge, certainly after suffering a major life-changing event such as a stroke, is a complex and vulnerable phase in the patient's journey. Elderly are particularly vulnerable to the stressors caused by hospitalisation. Recently hospitalised patients are not only recovering from their acute illness; they also experience a period of generalised risk for a range of adverse events. At the same time, elderly generally prefer living in their own homes and should be discharged from the hospital and return home as quickly as possible. Both premature and delayed discharge are potential threats to patient well-being. We present a 90-year-old patient who underwent successful thrombectomy but suffered from night-time confusion at the hospital and discuss the transition process from hospital to home.

How to Use Cognitively Diagnostic Assessments of Student Performance as a Method for Monitoring and Managing the Instructional Quality in Undergraduate Medical Education

PURPOSE

Course evaluations by students are a standard tool that U.S. universities use to monitor the quality of their product. Here, the authors examine an alternative method of monitoring instructional quality that differs from traditional approaches in that it does not rely on students' ratings. The authors sought to glean relevant diagnostic information about course effectiveness from in-class exams used to assess students' learning progress (i.e., cognitively diagnostic assessments that explicitly target instructional content).

METHOD

The authors used data from an end-of-course, cumulative exam given in 2015 and in 2016 to 200 first-year medical students. They mapped the exam questions to 4 attributes and analyzed the students' overall mastery of the content tested and the percentage of students mastering each attribute.

RESULTS

Analyses of the cognitively diagnostic assessment data revealed the percentage of the cohort who achieved/failed to achieve mastery of each of the attributes, discreet mastery profiles that distinguish among students with similar scores, and the percentage of the cohort within each of the 16 attribute mastery profiles. Analysis allowed the authors to evaluate how well the course content was delivered.

CONCLUSIONS

Cognitively diagnostic assessments enable in-class tests to appraise which skills specified in the curriculum have/have not been mastered by the students and how many students have mastered/failed to master which particular skills. Hence, if the learning goals have been well defined at the beginning of a course, then cognitively diagnostic assessments can show to what degree the instructional objectives have actually been accomplished.

[Acute neuropsychiatry: a confused patient and a puzzled doctor]

BACKGROUND

Anti-NMDA-receptor-encephalitis is a progressive autoimmune disease with significant mortality if left untreated.

CASE DESCRIPTION

A 58-year-old man without previous psychiatric or neurologic history presented at the emergency department after brief loss of consciousness at work. Within a few hours, the patient developed acute neuropsychiatric symptoms, including altered levels of consciousness, aggression, incoherence, change in behaviour, and psychomotor agitation. Initially, additional blood, cerebrospinal fluid and EEG tests showed no abnormalities. Over the course of the following days, catatonia, orofacial dyskinesia and autonomic-function disorder developed, eventually with respiratory insufficiency, necessitating transfer to the intensive-care unit. At this stage, the EEG did show abnormalities, and cerebrospinal fluid analysis showed marginal pleocytosis. The patient was treated with intravenous methylprednisolone and immunoglobins. Anti-NMDA-receptor antibodies were present in the blood and cerebrospinal fluid. Screening for malignancy identified small-cell lung carcinoma, for which the patient was treated with cytostatic agents.

CONCLUSION

Acute neuropsychiatric symptoms in a middle-aged patient with no psychiatric medical history are suggestive of an underlying somatic cause. Timely recognition and treatment of anti-NMDA-receptor encephalitis is essential to improve the prognosis.

You're The Flight Surgeon

Beauvais A, Tate J, Kluesner JK. You're the flight surgeon: hypoglycemia. Aerosp Med Hum Perform. 2019; 90(9):826-829.

The usefulness of symptoms alone or combined for general practitioners in considering the diagnosis of a brain tumour: a case-control study using the clinical practice research database (CPRD) (2000-2014)

OBJECTIVES

To evaluate the utility of different symptoms, alone or combined, presented to primary care for an adult brain tumour diagnosis.

DESIGN AND SETTING

Matched case-control study, using the data from Clinical Practice Research Datalink (2000-2014) from primary care consultations in the UK.

METHOD

All presentations within 6 months of the index diagnosis date (cases) or equivalent (controls) were coded into 32 symptom groups. Sensitivity, specificity, positive predictive values (PPVs) and positive likelihood ratios were calculated for symptoms and combinations of symptoms with headache and cognitive features. Diagnostic odds ratios were calculated using conditional logistic regression, adjusted for age group, sex and Charlson comorbidity. Stratified analyses were performed for age group, sex and whether the tumour was of primary or secondary origin.

RESULTS

We included 8,184 cases and 28,110 controls. Seizure had the highest PPV of 1.6% (95% CI 1.4% to 1.7%) followed by weakness 1.5% (1.3 to 1.7) and confusion 1.4% (1.3 to 1.5). Combining headache with other symptoms increased the PPV. For example, headache plus combined cognitive symptoms PPV 7.2% (6.0 to 8.6); plus weakness 4.4% (3.2 to 6.2), compared with headache alone PPV 0.1%. The diagnostic ORs were generally larger for patients <70 years; this was most marked for confusion, seizure and visual symptoms.

CONCLUSION

We found seizure, weakness and confusion had relatively higher predictive values than many other symptoms. Headache on its own was a weak predictor but this was enhanced when combined with other symptoms especially in younger patients. Clinicians need to actively search for other neurological symptoms such as cognitive problems.

Acute presentation of dementia with Lewy bodies

Acute presentations for dementia, particularly dementia with Lewy bodies (DLB), are rare and can pose diagnostic challenges.We present a case of a 75-year-old woman who was previously fit, well and independent in all activities of daily living. She had no history of psychiatric, cognitive or memory problems. She presented with 2 weeks of sudden onset confusion, paranoia, dizziness and reduced oral intake. Thorough investigations for causes of delirium including blood tests, cerebrospinal fluid analysis obtained via lumbar puncture, electroencephalography, computed tomography, and magnetic resonance imaging were within normal limits. Further neurological examination demonstrated she had subtle Parkinsonian signs (cogwheel rigidity, bradykinesia) and was hypersensitive to small doses of antipsychotic (haloperidol and risperidone). A positive dopamine transporter scan was done confirming a diagnosis of an acute presentation of DLB. She has been commenced on a cholinesterase inhibitor (rivastigmine) and is presently settled in care.

Auditory Verbal Working Memory Load Effects on a Simulator-Induced Spatial Disorientation Event

INTRODUCTION: Working memory is an essential executive function for flying an aircraft and its limitations may jeopardize flight safety. This function is particularly critical when pilots have to struggle with spatial disorientation (SD) cues. This research aimed to assess the combined effect of the auditory N-back task (NBT) and simulator-induced SD cues on pilots' flight performance.METHODS: Using an SD simulator, 39 male military pilots (control N = 20; age M = 31.6; SD = 8.22, experimental N = 19; age M = 26.9; SD = 8.67) were exposed to 12 flight sequences, where 6 contained an SD conflict-3 with vestibular illusions and 3 with visual illusions. Additionally, the pilots from the experimental group were asked to perform an auditory NBT involving sound stimuli (the sequential letter memory task) as they performed during oriented and disoriented flight conditions.RESULTS: Pilots' flight performance from the NBT group were significantly worse than the control group in the approach and landing profiles involving visual illusions (for both nonconflict and conflict flight), and in the profile involving the false horizon illusion (only for the conflict flight). No increase in a pilot's susceptibility to SD was observed with any other profiles.DISCUSSION: The current study provides support that pilots' cognitive workload can negatively impact flight performance. Pilots are not always aware of altered flight parameters, which may indicate that they have lost spatial orientation, mainly as a result of visual illusion. If problems occur in maintaining proper flight parameters, pilots should direct all available mental resources to regain their orientation and withdraw from any other parallel tasks.Lewkowicz R, Stróżak P, Bałaj B, Francuz P. Auditory verbal working memory load effects on a simulator-induced spatial disorientation event. Aerosp Med Hum Perform. 2019; 90(6):531-539.

MR-Brain Causing Confusion

An 82-year-old lady was found on the floor of her home, confused and surrounded by vomitus. She had a past medical history of type II diabetes, hypothyroidism, previous left total hip replacement, and previous hip fracture treated with right dynamic screw fixation. Prior to the current presentation she had been living alone, mobilizing independently with a walking stick and self-caring for her activities of daily living. She was last seen by her daughter on the previous day, and reported no concerning symptoms.