Clinical features and outcomes of patients with myasthenia gravis affected by COVID-19: A single-center study.

INTRODUCTION: Myasthenia Gravis (MG) is an autoimmune disorder that can exacerbate for various reasons including infections. In this study, we describe clinical symptoms, outcomes, and management of MG patients affected by COVID-19 infection. METHODS: This observational retrospective study was performed on patients previously diagnosed as MG, presenting with COVID-19 in the clinic or emergency department between April 2020 and August 2021. The clinical data, outcome, and therapeutic interventions were assessed in 83 patients with MG and COVID-19 infection. RESULTS: Seventy-seven patients performed PCR testing for COVID-19, of which 73 (94.8 %) were positive. Seven patients had the positive serologic test for COVID-19 (IgG and IgM). Fifty-seven (68.7 %) patients had lung involvement. Thirty-five (42.1 %) of patients were admitted to the hospital. Twelve (14.5 %) patients needed hospitalization in an intensive care unit (ICU), with a mean stay of 7.36 ± 5.6 days (rang: 2-20 days). Four (4.8 %) patients were intubated and required mechanical ventilation. Sixteen (19.3 %) patients experienced an exacerbation of myasthenia gravis and were treated with PLEX (n = 2), IVIG (n = 7), and intravenous (IV) methylprednisolone (n = 7). The outcome was favorable in 79 patients and fatal in four patients, three of whom had other comorbidities. One patient died due to severe COVID-19 involvement. CONCLUSION: The findings from our study demonstrated that patients with previous MG concurrence with COVID-19 have favorable clinical outcomes. Most patients did not need to be hospitalized and more than 80 % of patients did not display MG exacerbation.

Validity and reliability of the Persian version of the Montreal Cognitive Assessment (MoCA-P) scale among subjects with Parkinson's disease.

Parkinson's disease (PD) is a progressive multifactorial degenerative disorder that has both motor and nonmotor features. Among the nonmotor features of PD, cognitive impairment; Mild Cognitive Impairment (MCI) and dementia, poses one of the most significant implications for disability. Because of the high possibility of developing Dementia in PD, it is essential to obtain a reliable cognitive screen. Two commonly used cognitive measures include the Mini Mental Status Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). The MoCA is a more sensitive tool for the detection of MCI in compared to the MMSE. Because of the cultural differences, in this study, we evaluated the psychometric properties of the Persian version of the MoCA (MoCA-P) in a group of participants with PD in Iran. Participants were assessed by MMSE, Geriatric Depression Scale (GDS), and Functional Assessment Staging Test (FAST). If they met study eligibility, the MoCA-P scale was administered. Receiver Operating Characteristic (ROC) curve analyses showed that the MoCA-P scale produced significant discrimination of PD with Dementia (PDD) from PD with MCI (PD-MCI). It seems that the MoCA-P has adequate psychometric properties as a screening instrument for the detection of PD-MCI and PDD in Iranian patients. As near to 30% of patients with PD go on to develop dementia, the MoCA-P can be useful in the detection of cognitive impairment in patients with PD and is suitable for executive function assessment.

The use of brain stimulation in the rehabilitation of walking disability in patients with multiple sclerosis: A randomized double-blind clinical trial study.

Background: Transcranial direct current stimulation (tDCS) of the primary motor cortex of the lower limb has been exploited in the treatment of patients with stroke and spastic lower limb paresis. We examined this stimulation efficacy in the treatment of multiple sclerosis (MS)-related walking disability. Methods: In a single-center randomized double-blind clinical trial study, 13 patients with MS and walking disability and Expanded Disability Status Scale (EDSS) score of 3 to 6 were randomized to the real and sham stimulation groups. In the real tDCS stimulation, 7 patients received anodal 2.5 mA stimulation at 1 cm anterior to the Cz point for 30-minute daily sessions in 7 consecutive days. The other group received sham stimulation with the same protocol. The primary outcome of the trial was change in the Timed 25-Foot Walk (T25-FW) from before to after the stimulation. We also assessed the Multiple Sclerosis Walking Scale-12 (MSWS-12). We employed linear mixed effects model to examine the efficacy of tDCS stimulation on changing the outcomes. Results: On average, patients who received real tDCS stimulation walked faster after 7 sessions of stimulation [Estimate = -2.7, standard error (SE) = 1.3, P = 0.049], while walking speed of sham stimulation recipients did not change. For every session of stimulation, recipients of real tDCS stimulation spent 2.7 seconds less for walking the 25 feet. Real tDCS stimulation was not effective in improving MSWS-12 scores. Conclusion: tDCS stimulation of the lower limb motor cortex speeded up patients with MS in walking, but without improvement in patients' mobility in daily activities.

Cognitive impairments in patients with cerebrovascular risk factors: a comparison of Mini Mental Status Exam and Montreal Cognitive Assessment.

OBJECTIVE AND BACKGROUND: Recent evidence suggests that cerebrovascular risk factors are contributing factors, not only to vascular cognitive decline, but also for Alzheimer's disease. The study aim was to compare Montreal Cognitive Assessment (MoCA) and MMSE tests in subjects with cerebrovascular risk factors. PATIENTS AND METHODS: Fifty patients with cerebrovascular risk factors were administrated the MMSE and MoCA tests. Data collected for all subjects and the results were compared. RESULTS: Cognitive impairments revealed on both tests were more frequent in females, and correlated with the level of education (for MoCA r=0.75, p=0.001 and for MMSE r=0.662, p=0.001). Mean values of MoCA score were significantly lower in patients with two or more cerebrovascular risk factors compared with those with only one risk factor (19.92±5.99 versus 23.81±4.06; p=0.049), a finding that was not evidenced by MMSE. CONCLUSIONS: The most frequent impaired domain in MMSE (for scores both less and more than 26) was attention; but in MoCA the most frequent impaired domains were delayed recall (for scores above 26), and visuo-executive (for scores≤26), which is a common domain involved in vascular cognitive decline. MoCA may be superior to MMSE in early detection of cognitive decline in patients with vascular risk factors.

Impacts of normal aging on different working memory tasks: implications from an fMRI study.

PURPOSE: To evaluate patterns of activation, convergence and divergence of three functional magnetic resonance imaging (fMRI) Working Memory (WM) tasks in two different age groups. We want to understand potential impact of task and subjects' age on WM activations as well as most important areas with regard to WM functions. MATERIALS AND METHODS: Thirty-five healthy volunteers completed visual, verbal, and novel auditory WM tasks. The subjects were selected from age extremes to depict possible impact of normal aging. General Linear Model was used to report significant activations and the effect of group. One-to-one comparison of the tasks and Combined Task Analysis was also performed. RESULTS: Most of the observed differences between the tasks were seen in areas that were responsible for feature processing. Frontal regions were mainstay activation areas, regardless of the utilized stimulus. We found an age-related reduction in activity of visual (in visually-presented tasks) and auditory (in auditory task) cortices but an age-related increase in prefrontal cortex for all tasks. CONCLUSION: Regardless of the type of the task stimuli, frontal regions are the most important activation areas in WM processing. These areas are also main targets of age-related changes with regard to activation patterns. Our results also indicate that prefrontal overactivity in working memory might be a compensatory effort to mask age-related decline in sensory processing.

Age-related frontal hyperactivation observed across different working memory tasks: an fMRI study.

PURPOSE: To evaluate patterns of activation, convergence and divergence of three functional magnetic resonance imaging (fMRI) Working Memory (WM) tasks in two different age groups. We want to understand potential impact of task and subjects' age on WM activations as well as most important areas with regard to WM functions. MATERIALS AND METHODS: Thirty-five healthy volunteers completed visual, verbal, and novel auditory WM tasks. The subjects were selected from age extremes to depict possible impact of normal aging. The General Linear Model was used to report significant activations and the effect of age group. Contrasts revealed differences in activation between tasks, and Combined Task Analysis was performed to determine common regions of activation across tasks. RESULTS: Most of the observed differences between the tasks were seen in areas that were responsible for feature processing. Frontal regions were mainstay activation areas, regardless of the utilized stimulus. We found an age-related reduction in activity of visual (in visually-presented tasks) and auditory (in auditory task) cortices but an age-related increase in prefrontal cortex for all tasks. CONCLUSION: Regardless of the type of the task stimuli, frontal regions are the most important activation areas in WM processing. These areas are also main targets of age-related changes with regard to activation patterns. Our results also indicate that prefrontal overactivity in working memory might be a compensatory effort to mask age-related decline in sensory processing.

Etiopathophysiological assessment of cases with chronic daily headache: A functional magnetic resonance imaging included investigation.

BACKGROUND: Chronic daily headache (CDH) has gained little attention in functional neuro-imaging. When no structural abnormality is found in CDH, defining functional correlates between activated brain regions during headache bouts may provide unique insights towards understanding the pathophysiology of this type of headache. METHODS: We recruited four CDH cases for comprehensive assessments, including history taking, physical examinations and neuropsychological evaluations (The Addenbrooke's Cognitive Evaluation, Beck's Anxiety and Depression Inventories, Pittsburg Sleep Quality Index and Epworth Sleepiness Scale). Visual analogue scale (VAS) was used to self-rate the intensity of headache. Patients then underwent electroencephalography (EEG), transcranial Doppler (TCD) and functional magnetic resonance imaging (fMRI) evaluations during maximal (VAS = 8-10/10) and off-headache (VAS = 0-3/10) conditions. Data were used to compare in both conditions. We also used BOLD (blood oxygen level dependent) -group level activation map fMRI to possibly locate headache-related activated brain regions. RESULTS: General and neurological examinations as well as conventional MRIs were unremarkable. Neuropsychological assessments showed moderate anxiety and depression in one patient and minimal in others. Unlike three patients, maximal and off-headache TCD evaluation in one revealed increased middle cerebral artery blood flow velocity, at the maximal pain area. Although with no seizure history, the same patient's EEG showed paroxysmal epileptic discharges during maximal headache intensity, respectively. Group level activation map fMRI showed activated classical pain matrix regions upon headache bouts (periaqueductal grey, substantia nigra and raphe nucleus), and markedly bilateral occipital lobes activation. CONCLUSION: The EEG changes were of note. Furthermore, the increased BOLD signals in areas outside the classical pain matrix (i.e. occipital lobes) during maximal headaches may suggest that activation of these areas can be linked to the increased neural activity or visual cortex hyperexcitability in response to visual stimuli. These findings can introduce new perspective towards more in-depth functional imaging studies in headaches of poorly understood pathophysiology.

Chronic meningitis as the first presentation of sarcoidosis: an uncommon finding.

We describe a 40-year-old woman presenting with headache, nausea, episodic amnesia and blurred optic disc. Brain MRI disclosed diffuse leptomeningeal enhancement. CSF analysis showed aseptic meningitis with elevated ACE level. Neurosarcoidosis was diagnosed based on granulomatosis changes on tissue biopsy.

Using functional Magnetic Resonance Imaging to differentiate between healthy aging subjects, Mild Cognitive Impairment, and Alzheimer's patients.

BACKGROUND: Alzheimer's disease is the most common form of dementia which is still difficult to be differentiated from other types of brain disorders. Moreover, Mild Cognitive Impairment refers to the presence of cognitive impairments that is not severe enough to meet the criteria of Alzheimer's, and its diagnosis in early stages is so critical. There is currently no distinct method available for diagnosing Alzheimer's or Mild Cognitive Impairment, and their diagnosis needs a combination of different methods and assessments. METHODS: The aim of this study was to evaluate the effectiveness of functional Magnetic Resonance Imaging (fMRI) in differentiating between Alzheimer's, Mild Cognitive Impairment (MCI) and healthy aging. To prove fMRI's ability, resting-state brain activation patterns between these three groups of subjects were compared using Independent Component Analysis (ICA) algorithm. Forty age- and sex-matched subjects, 15 elderly, 11 MCI and 14 Alzheimer's subjects were examined. RESULTS: The results showed that during a certain resting-state session, healthy aging brain benefits from larger area and greater intensity of activation (compared with MCI and Alzheimer's group) in Posterior Cingulate Cortex (PCC) region of the brain, as part of Default Mode Network. CONCLUSIONS: This difference in activation pattern can be used as a diagnostic criterion in using fMRI for differentiating between Alzheimer's Disease (AD), MCI and healthy aging.

Wilson's disease: a great masquerader.

BACKGROUND: Wilson's disease (WD) is a treatable autosomal recessive metabolic disorder which could lead to protean hepatic or neurologic manifestations. WD could mimic many neurologic disorders and is often diagnosed with a long delay. This study describes central nervous system manifestations of a group of Iranian patients with neurologic WD. METHODS: Data from case records of patients with neurologic WD presenting at a referral university hospital and a private clinic in Tehran from 1984 to 2004 were analyzed. RESULTS: Fifty patients from 44 unrelated families with WD were identified, whose mean duration of follow-up was 51.8 (+/-58.5) months. The median age of onset of neurologic symptoms in 37 patients with primary neurologic or simultaneous hepatic-neurologic presentation was 16 (10-38) years, whereas in 13 patients with prior hepatic damage, this was 18.5 (11-34) years. The 6 most common manifestations were dysarthria (80%), drooling (48%), tremor in limbs (44%), abnormal gait (44%), psychiatric and/or sleep symptoms (44%), and dystonia in limbs (42%). CONCLUSION: Neurologic WD has heterogeneous manifestations and should be considered in young patients presenting with dysarthria, drooling, any kind of movement disorders or psychiatric symptoms.