Guillain–Barré Syndrome Associated with SARS-CoV-2 Toscano, Gianpaolo; Palmerini, Francesco; Ravaglia, Sabrina ...
New England journal of medicine/The New England journal of medicine,
06/2020, Letnik:
382, Številka:
26
Journal Article
Recenzirano
Odprti dostop
Five patients who had Guillain–Barré syndrome 5 to 10 days after the onset of Covid-19 are described. Three had severe weakness and an axonal pattern on electrophysiological studies, and two had ...normal protein levels in the cerebrospinal fluid. The virus was not found in CSF.
Purpose of review
The purpose of this review was to discuss the currently available pharmacologic and non-pharmacologic treatment options for parasomnias.
Recent findings
Recent pathophysiological ...findings about sleep structure in parasomnias helped understanding several drug mechanisms of action. Serotoninergic theory accounts for the effect of serotoninergic drugs. Study about spectral analysis of sleep showed the effect of clonazepam on spectral bands. Cannabinoids proved to be effective in some of parasomnias, as in many other neurological disorders.
Summary
A series of therapeutic strategies were analyzed and compared. Benzodiazepines, antidepressant drugs, and
l
-5-hydroxytryptophan may be beneficial in DOA. SSRI and topiramate are effective in SRED. RBD responds to clonazepam, melatonin, and to a lesser extent to dopaminergic and anticholinergic agents. Prazosin and cannabinoids are effective in nightmare disorder. Sleep paralysis may respond to antidepressant agents. Tricyclic antidepressant may be effective in sleep-related hallucinations and exploding head syndrome. Sleep enuresis may be successfully treated with desmopressin, anticholinergic drugs, and imipramine.
•Visual analysis of HD-EEG is an excellent tool to explore the epileptogenic focus.•ESI remains the gold standard for presurgical evaluation of the cortical source.•ESI at 50% slope/ESI at peak ...discordance could predict worse surgical outcome.
In this study, we sought to determine whether visual analysis of high density EEG (HD-EEG) would provide similar localizing information comparable to electrical source imaging (ESI).
HD-EEG (256 electrodes) recordings from 20 patients suffering from unifocal, drug-resistant epilepsy (13 women, mean age 29.1 ± 2.62 years, 11 with temporal lobe epilepsy) were examined. In the visual analysis condition, we identified the 5 contacts with maximal spike amplitude and determined their localization with respect to the underlying cortex. ESI was computed using the LAURA algorithm of the averaged spikes in the patient’s individual MRI. We considered the localization “correct” if all 5 contacts were concordant with the resection volume underneath or if ESI was located within the resection as determined by the postoperative MRI.
Twelve patients were postoperatively seizure-free (Engel Class IA), while the remaining eight were in class IB to IV. Visual analysis and ESI showed sensitivity of 58% and 75%, specificity of 75% and 87%, and accuracy of 65% and 80%, respectively. In 70% of cases, visual analysis and ESI provided concordant results.
Localization of the electrodes with maximal spike amplitude provides very good estimation of the localization of the underlying source. However, ESI has a higher accuracy and adds 3D information; therefore, it should remain the tool of choice for presurgical evaluation.
The present study proposes the possibility to analyze HD-EEG visually, in tandem with ESI or alone, if ESI is not accessible.
To search for a specific neuropsychological profile in idiopathic REM sleep behavior disorder (iRBD), able to predict the onset of neurodegenerative disorders.
In a longitudinal follow-up study of 63 ...consecutive iRBD patients (follow-up duration 6.7 ± 3.8 years), the baseline cognitive profile of converters to neurodegenerative disease was compared with that of the nonconverters. Five cognitive domains were assessed: memory, attention-working memory, executive functions, visuospatial abilities, language. Mild cognitive impairment (MCI) was diagnosed according to the Movement Disorder Society's diagnostic criteria for Parkinson's disease.
30 subjects (47.6%) developed a neurodegenerative disease (latency to conversion 60.33 ± 44.81 months). MCI was found in 50% of the converters and 12% of the nonconverters (p = .001), and its presence conferred a neurodegenerative disease risk of 10% at 3 years, 36% at 5 years, and 73% at 10 years (p = .002). Pathological equivalent scores on at least one neuropsychological test were detected in 46.7% of the converters versus 21.2% of the nonconverters in the memory domain (p = .032), in 40.0% versus 6.1% in that of executive functions (p = .002), and in 20.0% versus 3% in the visuospatial abilities domain (p = .047). On multivariate analysis, impaired executive functions significantly correlated with phenoconversion (p = .018). Lower Mini Mental State Examination (MMSE) scores (p = .004) and memory deficits (p = .031) were found in patients who developed dementia first.
Cognitive profile is useful for stratifying risk of phenoconversion in patients with iRBD. The presence of MCI and impaired executive functions, memory, and visuospatial abilities discriminated the converters. Lower MMSE scores and memory deficits may characterize those subjects who first develop dementia.
Background
Myasthenia gravis (MG) is an autoimmune disease that targets acetylcholine receptor (AChR) of the neuromuscular junction. New-onset MG after SARS-CoV-2 vaccination has rarely been ...reported.
Case presentation
We report about three patients who presented new-onset myasthenia gravis after receiving mRNA SARS-CoV-2 vaccination. The patients were all males and older than 55 years. All the patients presented with ocular and bulbar symptoms. The interval between vaccine administration and MG onset ranged from 3 days after the first dose to 10 days after the second dose. All the patients had elevated serum AChR antibodies and responded to pyridostigmine. Two out of three patients were successfully treated with IVIG or plasma exchange and with long-term immunosuppression.
Conclusions
MG is a rare disease; clinicians should be aware of possible new-onset MG after SARS-CoV-2 vaccination, especially with the current recommendation of booster doses. The hyperstimulation of the innate immune system or the exacerbation of a subclinical pre-existing MG could be possible explanations.
For patients who are not seizure-free despite adequate therapy with antiepileptic drugs, surgery is an important option for seizure resolution or significant improvement. Electrical source ...localization (ESI) of the Interictal Epileptiform Discharges (IEDs) based on high density EEG (HD-ESI) is considered a good estimator of the epileptogenic zone and its resection is associated to post-operative seizure control. With the help of sophisticated algorithms results are displayed as 3D images; however, not all centers have access to manpower or programs to carry out these algorithms. In this study, we were interested to determine the yield of localizing the epileptogenic area by visual analysis of the 256 EEG channels, and to compare the results with the 3D solution.
We analysed HD-EEG long term recordings of 20 operated patients suffering from drug-resistant, unifocal epilepsy (11 temporal lobe epilepsy, 13 women, age mean 29.1 ± 2.62 years). We compared the performance of ESI and visual HD-EEG analysis in terms of correctness with respect to the resected structures. In the visual analysis condition, we identified the 5 contacts with largest spikes. Furthermore, the population was divided in 3 groups: seizure-free patients (Engel IA), almost seizure-free patients (Engel IB-IID), no seizure-free (all other Engel classes). In a second part of the analysis, we correlated the outcome of patients with results of HD-ESI of two different parts of IEDs (50% of the rising phase of the IED, peak of the IED).
Both ESI and visual analysis provided correct results for the detection of the epileptogenic area in the majority of cases (ESI accuracy = 80% versus HD-EEG analysis accuracy = 65%). In one case (left fronto-parietal dysplasia), ESI indicates a wrong localization while visual-inspection localizes correctly the IZ. In 12/20 patients the same source was found at the 50% of the rising phase of the IED and at the peak (75% of the seizure-free patients; 50% of almost seizure-free patients; 25% of no seizure-free patients).
Visual HD-EEG analysis provided correct localization on sublobar level in 65% of the patients, which is superior to localization with 19–32 electrodes, but inferior to ESI. Visual identification of the 5 most active channels is an easy localization tool, if technical support or specific computer skills are not available. Findings of visual HD-EEG represent a very good surrogate marker of the epileptogenic region. If available, ESI should be obtained, possibly after a first visual analysis. Moreover, we noted that different sources at the 50% of the rising phase of the spike and at its peak could be a negative predictor of the outcome of the surgery.
A paradigm shift in the management of acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) occurred after 2015 when 7 randomized controlled trials demonstrated better outcomes using ...second-generation thrombectomy devices combined with best medical management than did stand-alone intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA). All recently published landmark trials were designed to study the outcome of mechanical thrombectomy (MT); therefore, the majority of the patients enrolled in these trials received intravenous tPA. Currently, initiating IVT before MT is a matter of debate. Recent trials (DIRECT-MT, DEVT) exploring this clinical question showed noninferiority of MT alone compared with the combined treatment. With this uncertainty, the authors aimed to explore real-world data through the latest National Inpatient Sample (NIS) to compare the safety and outcomes of MT alone with bridging IVT and MT in AIS due to LVO in the middle cerebral artery (MCA).
NIS data from 2017 to 2018 were analyzed to compare the outcomes and safety profiles of patients who underwent MT+IVT with those who underwent MT alone.
A total of 2895 patients were included in the final analysis (MT, n = 1669; MT+IVT, n = 1226). The mean National Institutes of Health Stroke Scale score was 16.2 (SD 6.1) in the MT group and 16.6 (SD 5.97) in the MT+IVT group (p = 0.04). With respect to comorbidities, the two groups did not differ in rates of hypertension (p = 0.730), atrial fibrillation/flutter (p = 0.828), and smoking status (p = 0.914). The rate of diabetes mellitus was significantly higher in the MT group (28%) than in the MT+IVT group (22.1%) (p < 0.001). The frequency of intracerebral hemorrhage (ICH) in the MT group was 17.7% (n = 296) and 21.5% (n = 263) in the MT+IVT group (p = 0.012). Intraventricular hemorrhage (p = 0.875), subarachnoid hemorrhage (p = 0.99), and vasospasm (p = 0.976) did not differ significantly between the groups. The primary outcome considered was disability status between the groups; 23.8% of patients in the MT+IVT group had minimal disability versus 18.2% in the MT group (p = 0.001). The risk of progressing to severe disability from minimal disability decreased with the addition of IVT to MT (OR 0.762, 95% CI 0.637-0.912). The adjusted odds ratio for ICH in the MT+IVT group was 1.28 (95% CI 1.043-1.571, p = 0.018) and 2.676 (95% CI 1.259-5.686, p = 0.01) for access-site hemorrhages.
In the analysis of the NIS database, the MT+IVT group had significantly higher rates of minimal disability at the time of hospital discharge versus the MT-alone group, despite a higher rate of ICH. The question of whether to treat patients with MT+IVT rather than MT alone is currently being addressed in ongoing prospective clinical trials (SWIFT-DIRECT NCT03494920, MR CLEAN-NO IV ISRCTN80619088, and DIRECT-SAFE NCT03494920). The results of these studies will contribute to greater understanding and progressive improvement in outcomes for AIS patients.
OBJECTIVE Different etiologies of extracranial internal carotid artery steno-occlusive lesions (ECLs) in patients with acute ischemic stroke (AIS) and tandem occlusion (TO) have been pooled together ...in randomized trials. However, carotid atherosclerosis (CA) and carotid dissection (CD), the two most common ECL etiologies, are distinct nosological entities. The authors aimed to determine if ECL etiology has impacts on the endovascular management and outcome of patients with TO. METHODS A multicenter, retrospective study of prospectively collected data was conducted. AIS patients were included who had TO due to internal CA or CD and ipsilateral M 1 middle cerebral artery occlusion and underwent endovascular treatment (EVT). Comparative analyses including demographic data, safety, successful recanalization rates, and clinical outcome were performed according to EVT and ECL etiology. RESULTS In total, 214 AIS patients with TOs were included (77.6% CA related, 22.4% CD related). Patients treated with a retrograde approach were more often functionally independent at 3 months than patients treated with an antegrade approach (OR 0.6, 95% CI 0.4–0.9). Patients with CD-related TOs achieved 90-day clinical independence more often than patients with CA-related TOs (OR 1.4, 95% CI 1.1–2.0). Emergency stenting use was associated with good 3-month clinical outcome only in patients with CA-related TOs (OR 1.4, 95% CI 1.1–2.1). Symptomatic intracranial hemorrhage (sICH) occurred in 10.7% of patients, without differences associated with ECL etiology. CONCLUSIONS ECL etiology impacts both EVT approach and clinical outcome in patients with TOs. Patients with CD-related TO achieved higher 3-month functional independence rates than patients with CA-related TOs. A retrograde approach can be desirable for both CA- and CD-related TOs, and emergency stenting is likely better justified in CA-related TOs.
Background
The optimal management of patients with acute ischemic stroke (AIS) due to tandem occlusion (TO) and underlying carotid dissection (CD) remains unclear.
Objective
We present our ...multicenter-experience of endovascular treatment (EVT) approach used and outcomes for AIS patients with CD-related TO (CD-TO).
Methods
Consecutive AIS patients underwent EVT for CD-TO at five Italian Neuro-interventional Tertiary Stroke Centers were retrospectively identified. TO from atherosclerosis and other causes of, were excluded from the final analysis. Primary outcome was successful (mTICI 2b-3) and complete reperfusion (mTICI 3); secondary outcome was patients’ 3-months functional independence (mRS≤2).
Results
Among 214 AIS patients with TO, 45 presented CD-TO. Median age was 54 years (range 29–86), 82.2% were male. Age <65 years (p < 0.0001), lower baseline NIHSS score (p = 0.0002), and complete circle of Willis (p = 0.0422) were associated with mRS ≤ 2 at the multivariate analysis. Comparisons between antegrade and retrograde approaches resulted in differences for baseline NIHSS scores (p = 0.001) and number of EVT attempts per-procedure (p = 0.001). No differences in terms of recanalization rates were observed between antegrade and retrograde EVT approaches (p = 0.811) but higher rates of mTICI3 revascularization was observed with the retrograde compared to the antegrade approach (78.6% vs 73.3%), anyway not statistically significant. CD management technique (angioplasty vs aspiration vs emergent stenting) did not correlate with 3-months mRS≤2.
Conclusion
AIS patients with CD-TO were mostly treated with the retrograde approach with lower number of attempts per-procedure but it offered similar recanalization rates compared with the antegrade approach. Emergent carotid artery stenting (CAS) proved to be safe for CD management but it does not influence 3-months patients’ clinical outcomes.
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