Lesson of the month: Severe leukoencephalopathy by SARS-CoV-2.

Neurological manifestations associated with SARS-CoV-2 infection as well as its pathogenesis are insufficiently explained. We present two cases of severe COVID-19 who required hospitalisation in the intensive care unit with persistently depressed mental status and severe leukoencephalopathy. We discuss the clinical and radiological findings and also propose the possible pathogenesis involved.

Diffusion Tensor Imaging Measures of Brain Connectivity for the Early Diagnosis of Alzheimer's Disease.

The prognostic capacity of the diffusion tensor imaging measures fractional anisotropy (FA) and mean diffusivity (MD) to detect mild cognitive impairment (MCI) progression to Alzheimer's disease (AD) was assessed in 135 MCI patients and 72 healthy subjects over a median follow-up of 40 months. Forty-nine MCI patients (36.3%) developed AD. The factors MD left hippocampus, FA left cingulate, and FA left hippocampus emerged as predictors of progression. Age (hazard ratio [HR] 1.21), delayed text recall (HR 0.89), FA left uncinate (HR 1.90), FA left hippocampus (HR 2.21), and carrying at least one ApoE4 allele (HR 2.86) were associated with a high conversion rate. FA measures revealed the greatest discriminative capacity (Harrell's C = 0.73 versus 0.65 without FA; p = 0.034). The inclusion of FA structural connectivity data in our model improved discrimination between subjects with MCI progressing or not to dementia.

Catastrophic outcome of patients with a rebound after Natalizumab treatment discontinuation.

INTRODUCTION: Natalizumab (NTZ) is an effective drug for the treatment of relapsing-remitting multiple sclerosis. In some patients discontinuation is mandatory due to the risk of progressive multifocal leukoencephalopathy. However, severe clinical and radiological worsening has been described after drug cessation. Our aim was to describe the clinical and radiological features of the rebound phenomenon. MATERIAL AND METHODS: Patients switched from NTZ to Fingolimod (FTY) who had presented a rebound after discontinuation were selected. Clinical and magnetic resonance imaging (MRI) data were collected. RESULTS: Four JC virus positive patients were included. The mean disease duration was 9.5 years (SD: 4.12) with a mean time of 3.1 years on NTZ. All patients started FTY within 3-4 months. Neurological deterioration started in a mean time of 3.5 months (SD: 2.08) with multifocal involvement: 75% motor disturbances, 50% cognitive impairment, 25% seizures. The average worsening in Expanded Disability Status Scale [EDSS] was of 3.25 points (SD: 2.33). The MRI showed a very large increase in T2 and gadolinium-enhanced lesions (mean: 23.67, SD: 18.58). All patients received 5 days of IV methylprednisolone, one patient required plasma exchange. All the patients presented neurological deterioration with an EDSS worsening of 1.13 points (SD: 0.48). After the rebound three patients continued treatment with FTY, only one patient restarted NTZ. CONCLUSION: Discontinuation of NTZ treatment may trigger a severe rebound with marked clinical and radiological worsening. A very careful evaluation of benefit-risk should be considered before NTZ withdrawal, and a close monitoring and a short washout period is recommended after drug withdrawal.

Unresectable Recurrent Multiple Meningioma: A Case Report with Radiological Response to Somatostatin Analogues.

Medical treatment of meningiomas is reserved for cases in which surgery and radiotherapy have failed. Given that a high percentage of meningiomas express somatostatin receptors, treatment with somatostatin analogues has been proposed. In addition, these medications have been shown to have an antiproliferative and antiangiogenic effect in vitro. To date, very few cases with clinical response and none with radiological response have been described. The case described here is the first to report a radiological response. A 76-year-old Caucasian male was first diagnosed with unresectable meningioma at age 47. The patient experienced multiple recurrences and underwent three surgeries and radiotherapy over the years from the initial diagnosis. Despite treatment, the disease continued its progression. Based on an Octreoscan positive for tumour uptake, therapy with extended-release somatostatin analogues was started. Although no clinical neurological improvement was observed, magnetic resonance imaging scans revealed a discreet but continuous radiological response over time. After >2 years of continuous administration of lanreotide, the patient remains progression free. In highly selected cases, somatostatin analogue treatment for meningioma may be beneficial. Based on our findings, treatment with somatostatin analogues should be maintained longer than previously described before evaluating treatment response.