Neurological Manifestations in a Cohort of Egyptian Patients with COVID-19: A Prospective, Multicenter, Observational Study.

BACKGROUND: The COVID-19 pandemic has reached over 276 million people globally with 5.3 million deaths as of 22nd December 2021. COVID-19-associated acute and long-term neurological manifestations are well recognized. The exact profile and the timing of neurological events in relation to the onset of infection are worth exploring. The aim of the current body of work was to determine the frequency, pattern, and temporal profile of neurological manifestations in a cohort of Egyptian patients with confirmed COVID-19 infection. METHODS: This was a prospective study conducted on 582 hospitalized COVID-19 patients within the first two weeks of the diagnosis of COVID-19 to detect any specific or non-specific neurological events. RESULTS: The patients' mean (SD) age was 46.74 (17.26) years, and 340 (58.42%) patients were females. The most commonly encountered COVID-19 symptoms were fever (90.72%), cough (82.99%), and fatigue (76.98%). Neurological events (NE) detected in 283 patients (48.63%) and were significantly associated with a severe COVID-19 at the onset (OR: 3.13; 95% CI: 2.18-4.51; p < 0.0001) and with a higher mortality (OR: 2.56; 95% CI: 1.48-5.46; p = 0.019). The most frequently reported NEs were headaches (n = 167) and myalgias (n = 126). Neurological syndromes included stroke (n = 14), encephalitis (n = 12), encephalopathy (n = 11), transverse myelitis (n = 6) and Guillain-Barré syndrome (n = 4). CONCLUSIONS: Neurological involvement is common (48.63%) in COVID-19 patients within the first two weeks of the illness. This includes neurological symptoms such as anosmia, headaches, as well as a constellation of neurological syndromes such as stroke, encephalitis, transverse myelitis, and Guillain-Barré syndrome. Severity of acute COVID-19 illness and older age are the main risk factors.

Intra-Carpal Injection of Ozone versus Methylprednisolone in Carpal Tunnel Syndrome of Systemic Sclerosis Patients: A Randomized Single-Blind Clinical Trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most entrapment syndrome in general and is the most frequent peripheral nervous system involvement in systemic sclerosis (SSc). Local injection of steroid hydrodissection or ozone-oxygen showed favourable outcome in CTS in general. OBJECTIVES: To compare the clinical efficacy of ozone versus methylprednisolone intracarpal injection upon pain, functional status, and nerve conduction in patients with CTS due to SSc. STUDY DESIGN: A randomized single-blinded trial. SETTING: Anesthesia, pain, and rheumatology clinics in a university hospital. METHODS: Fifty CTS patients with > 3 months duration of SSc were equally randomized into either group O (injection of ozone/oxygen 25 mu-g/mL in 20 mL) or group M (methylprednisolone acetate 40mg, and 40 mg lidocaine in 20 mL). Visual analog scale (VAS) was measured pre-injection, then re-evaluated post-injection at 4 time points (1 week, 1 month, 3 months , and 6 months); Cochin Hand Function Scale (CHFS); and a median nerve electrophysiologic study was done before injection, then by the end of 3 months and 6 months. RESULTS: VAS was significantly lower in group M after 1 week (P = 0.01). Group O showed significantly lower VAS after 3 and 6 month (P < 0.001). Additionally, there was a significant decrease in the VAS during the whole study period within each group, in comparison to its baseline value. CHFS was significantly lower in the ozone group after 6 months (P < 0.001). The sixth month's sensory conduction was significantly higher in group O (P = 0.002). The motor distal latency was significantly lower in the ozone group after 3 and 6 months (P < 0.001). LIMITATIONS: Follow-up period could be furtherly extended. CONCLUSION: Both intracarpal ozone or methylprednisolone afford favorable effects upon CTS in patients with SSc. However, ozone alleviates pain much more, enhances the hand functional status, and improves median nerve conduction in study with over six months duration.

Electrophysiological differences in cortical excitability in different forms of dementia: A transcranial magnetic stimulation and laboratory biomarkers study.

BACKGROUND: The aim of the present study was to identify neurophysiologic markers to differentiate between Alzheimer dementia (AD), Vascular dementia (VaD), and Parkinson's disease dementia (PDD), and to examine their relationship to levels of transforming growth factor ß1 (TGFß1). METHODS: The study included 15 patients with each type of dementia (AD, VaD, PDD) and 25 control subjects. Dementia patients were diagnosed according to the DiagnosticandStatisticalManualofMentalDisorders4thedition-revised(DSM-IV-R). Modified Mini Mental State Examination (MMMSE), motor cortex excitability including resting and active motor thresholds (rMT, aMT), input-output (I/O) curve, contralateral and ipsilateral silent periods (cSP, iSP), short-interval intracortical inhibition (SICI) at 1,2 and 4ms, and serum levels of TGFß1 were examined. RESULTS: There were no significant differences between groups with regards to age, sex, education or socioeconomic level. There was significant neuronal hyperexcitability in the form of reduced rMT and aMT and a shallower I/O curve in all three groups of dementia compared with the control group. The durations of cSP and iSP were longer in AD and PDD groups compared with the control group, whereas there were no significant differences in VaD. SICI was less effective in the three dementia groups than in the control group at intervals of 4ms. Serum levels of TGFß1 were significantly elevated in all dementia groups in comparison with the control group. There was a significant negative correlation between serum level of TGFß1 and cSP, iSP, and SICI across all patients and a significant negative correlation between serum level of TGFß1 and iSP duration in AD. CONCLUSION: Although motor thresholds were reduced in all patients, measures of SICI, cSP and iSP could distinguish between dementia groups. Serum level of TGFß1 negatively correlated with iSP specifically in the AD group. This suggests that levels of TGFß1 may relate to GABAergic dysfunction in dementia.

The effect of repetitive transcranial magnetic stimulation on cognitive impairment in Parkinson's disease with dementia: Pilot study.

BACKGROUND: The exact mechanism of cognitive impairment in PD is not known. Repetitive transcranial magnetic stimulation (rTMS) has been proposed as a possible treatment for cognitive impairment and to treat the motor symptoms in Parkinson's disease (PD) where its effects seem additive to those of dopaminergic medications. OBJECTIVE: In this pilot study we investigated whether repeated sessions of rTMS have an effect on measures of cognitive impairment in patients with PD dementia. METHODS: 33 patients with PD dementia were randomly assigned sham or real rTMS (2000 pulses; 20 Hz; 90% RMT; 10 trains of 10 s with 25 s between each train) over the hand area of each motor cortex (5 min between hemispheres) for 10 days (5 days/week) followed by 5 booster sessions every month for 3 months. Assessments included the Unified Parkinson's Disease Rating Scale part III (UPDRS), Montreal Cognitive Assessment (MoCA); Mini Mental State Examination (MMSE), Clinical Dementia Rating Scale (CDR); Memory and Executive Screening (MES) and Instrumental activity of Daily Living (IADL). Event related potentials (P300) and cortical excitability were measured before treatment and after the last session. RESULTS: There were no significant differences in the effects of rTMS between groups. Although rTMS improved motor function in the active group it had only a minor effect on two of the dementia rating scores (the MMSE and MoCA) but not the others (CDR and MES). There was also a reduction in the latency of the P300 in the active group. CONCLUSIONS: rTMS over M1 is useful for motor function and may have a small positive effect on cognition. However, better approaches for the latter are necessary, may be require multisite rTMS to target both motor and frontal cortical region.

Cerebellar inhibition in hepatic encephalopathy.

OBJECTIVE: Previous animal work reported that hyperammonemia leads to opposing changes of GABAergic neurotransmission in terms of increase in the cerebellum and decrease in the cerebral cortex. In this study, we investigate GABAergic tone in the cerebellum in patients with hepatic encephalopathy (HE) at different stages of the disease and its relation to critical flicker frequency (CFF) and ataxia. METHODS: Cerebellar inhibition using transcranial magnetic stimulation was investigated in 15 patients with different stages of HE and 15 healthy controls. All patients were assessed using CFF and the score for assessment and rating of ataxia (SARA). RESULTS: Decreased cerebellar inhibition (CBI) was observed in manifest HE at interstimulus interval from 5 to 7 ms. However, the degree of CBI at 7 ms correlated significantly with disease severity measured with SARA and with CFF by trend. CONCLUSION: Reduced CBI in HE patients indicates affection of the cerebellar efferent pathway. The disease severity dependent increase of CBI magnitude supports the notion of disease stage dependent increase of GABAergic neurotransmission in Purkinje cells. SIGNIFICANCE: The results support previous animal experiments showing increase of GABA-ergic neurotransmission in the cerebellum and decrease in the motor cortex in HE.

Construction of standardized Arabic questionnaires for screening neurological disorders (dementia, stroke, epilepsy, movement disorders, muscle and neuromuscular junction disorders).

A screening questionnaire is an important tool for early diagnosis of neurological disorders, and for epidemiological research. This screening instrument must be both feasible and valid. It must be accepted by the community and must be sensitive enough. So, the aim of this study was to prepare different Arabic screening questionnaires for screening different neurological disorders. This study was carried out in three stages. During the first stage, construction of separate questionnaires designed for screening the five major neurological disorders: cerebrovascular stroke, dementias, epilepsy, movement disorders, and muscle and neuromuscular disorders were done. Validation of the screening questionnaires was carried out in the second stage. Finally, questionnaire preparation was done in the third stage. Questions with the accepted sensitivity and specificity in each questionnaire formed the refined separate questionnaires.

Motor cortical excitability in obsessive-compulsive disorder: Transcranial magnetic stimulation study.

OBJECTIVES: Transcranial magnetic stimulation is a non-invasive method of stimulating the brain that is increasingly being used in neuropsychiatric research. Previous work has suggested that the pathophysiology of obsessive-compulsive disorder (OCD) may involve dysfunction of excitatory and/or inhibitory brain function. This study aimed to extend those findings. METHODS: The study included 45 OCD patients and 15 age- and sex-matched healthy volunteers. Clinical evaluation was conducted using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Hamilton Anxiety Rating Scale (HAM-A), and Clinical Global Impression rating scale (CGI). Physiological measures were resting and active motor thresholds (RMT and AMT), motor evoked potential (MEP) amplitude, cortical silent period (CSP) and transcallosal inhibition (TCI) durations, short-interval intracortical inhibition (SICI), and intracortical facilitation. RESULTS: RMT and AMT were significantly lower in patients than in the control group. The mean duration of the CSP and TCI were also significantly shorter. Obsessive trait was associated with significant reduction of TCI duration compared to compulsive trait. There was significant reduction in SICI in OCD patients compared to controls. There were no significant correlations between the Y-BOCS, HAM-A and CGI scores and the cortical excitability parameters. CONCLUSION: These results provide further evidence for inhibitory deficits or increased facilitation in cortical circuits of patients with OCD.

Changes in motor cortical excitability in patients with Sydenham's chorea.

BACKGROUND AND PURPOSE: The neurophysiological characteristics of motor cortex have been well characterized in patients with Huntington's disease. We present the first data on cortical excitability in patients with Sydenham's chorea. METHODS: Motor cortex excitability was examined using transcranial magnetic stimulation in 16 patients in the early clinical stages of Sydenham's chorea and in 17 age- and sex-matched control subjects. Investigations included resting and active motor threshold, motor evoked potential, input-output curves, contralateral silent period, and transcallosal inhibition. RESULTS: Resting and active motor threshold were significantly higher and motor evoked potentials were significantly smaller in patients in comparison with controls. The input-output curves were shallower in both hemispheres of patients with chorea compared with controls. No significant differences were seen in silent period or transcallosal inhibition duration. CONCLUSION: Sydenham's chorea is characterized by reduced excitability of corticospinal output similar to that observed in Huntington's disease.

A community based epidemiological study of epilepsy in Assiut Governorate/Egypt.

BACKGROUND: The aim of the study was to estimate the prevalence of different types of epilepsy and their possible risk factors in the region of the Assiut Governorate/Egypt. MATERIAL AND METHODS: A community based study with random sampling of 7 districts, involving 6498 inhabitants. Out of this sample, 578 dropped out leaving 3066 males (51.8%) and 2854 females (48.2%). There were 3660 (61.8%) urban residents and 2260 (38.2%) from the rural community. Patients were evaluated using a screening questionnaire for epilepsy, and then referred to the hospital to be re-evaluated by a qualified neurologist and with electroencephalography (EEG) and computed tomography of the brain (CT). RESULTS: Seventy-five cases were diagnosed with epilepsy giving an overall the crude lifetime prevalence rate (CPR) for epilepsy of 12.67/1000 (95% CI: 9.8-15.54). The active prevalence rate was 9.3/1000 and the incidence rate was 1.5/1000 (95% confidence interval: 0.53-2.51). Fifty-six cases (75%) had idiopathic epilepsy (CPR 9.5/1000). Symptomatic epilepsy was recorded in 19 (25%) cases (CPR 3.2/1000). Generalized seizures were more common (CPR 6.75/1000) than partial seizures (CPR 2.5/1000). The prevalence rate of partial seizures evolving to secondary generalization was 0.84/1000 while simple partial and complex partial seizures had CPR 1.4/1000 and 0.34/1000, respectively. The CPR of mixed seizures was 0.17/1000. Epilepsy was slightly but not significantly more common among males than females (CPR of 14.4 and 10.9 per 1000 population, respectively). The CPR was higher in rural than urban populations (17.7/1000, with 95% CI 12.2-23.18 and 9.56/1000, with 95% CI: 6.39-12.7, respectively) and in the illiterate group than the literate population (12.02/1000 and 9.94/1000, respectively). The highest prevalence rate was recorded in the early and late childhood period (69.78/100,000 and 43.78/100,000, respectively). Prenatal insults and infection represented major causes of symptomatic epilepsy. CONCLUSIONS: We found a high prevalence rate of epilepsy (comparable with that in other Arabic and European countries) in our community particularly among children and teenagers. Overall the prevalence was higher in the rural than in the urban population. A family history of epilepsy, prenatal insults, and infection represented major risk factors of symptomatic epilepsy.