COVID-19-associated Guillain-Barré syndrome in the early pandemic experience in Lombardia (Italy).

OBJECTIVE: To estimate the incidence and describe clinical characteristics and outcome of GBS in COVID-19 patients (COVID19-GBS) in one of the most hit regions during the first pandemic wave, Lombardia. METHODS: Adult patients admitted to 20 Neurological Units between 1/3-30/4/2020 with COVID19-GBS were included as part of a multi-center study organized by the Italian society of Hospital Neuroscience (SNO). RESULTS: Thirty-eight COVID19-GBS patients had a mean age of 60.7 years and male frequency of 86.8%. CSF albuminocytological dissociation was detected in 71.4%, and PCR for SARS-CoV-2 was negative in 19 tested patients. Based on neurophysiology, 81.8% of patients had a diagnosis of AIDP, 12.1% of AMSAN, and 6.1% of AMAN. The course was favorable in 76.3% of patients, stable in 10.5%, while 13.2% worsened, of which 3 died. The estimated occurrence rate in Lombardia ranges from 0.5 to 0.05 GBS cases per 1000 COVID-19 infections depending on whether you consider positive cases or estimated seropositive cases. When we compared GBS cases with the pre-pandemic period, we found a reduction of cases from 165 to 135 cases in the 2-month study period in Lombardia. CONCLUSIONS: We detected an increased incidence of GBS in COVID-19 patients which can reflect a higher risk of GBS in COVID-19 patients and a reduction of GBS events during the pandemic period possibly due to a lower spread of more common respiratory infectious diseases determined by an increased use of preventive measures.

Guillain-Barré syndrome and COVID-19: A 1-year observational multicenter study.

BACKGROUND AND PURPOSE: Many single cases and small series of Guillain-Barré syndrome (GBS) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were reported during the coronavirus disease 19 (COVID-19) outbreak worldwide. However, the debate regarding the possible role of infection in causing GBS is still ongoing. This multicenter study aimed to evaluate epidemiological and clinical findings of GBS diagnosed during the COVID-19 pandemic in northeastern Italy in order to further investigate the possible association between GBS and COVID-19. METHODS: Guillain-Barré syndrome cases diagnosed in 14 referral hospitals from northern Italy between March 2020 and March 2021 were collected and divided into COVID-19-positive and COVID-19-negative. As a control population, GBS patients diagnosed in the same hospitals from January 2019 to February 2020 were considered. RESULTS: The estimated incidence of GBS in 2020 was 1.41 cases per 100,000 persons/year (95% confidence interval 1.18-1.68) versus 0.89 cases per 100,000 persons/year (95% confidence interval 0.71-1.11) in 2019. The cumulative incidence of GBS increased by 59% in the period March 2020-March 2021 and, most importantly, COVID-19-positive GBS patients represented about 50% of the total GBS cases with most of them occurring during the two first pandemic waves in spring and autumn 2020. COVID-19-negative GBS cases from March 2020 to March 2021 declined by 22% compared to February 2019-February 2020. CONCLUSIONS: Other than showing an increase of GBS in northern Italy in the "COVID-19 era" compared to the previous year, this study emphasizes how GBS cases related to COVID-19 represent a significant part of the total, thus suggesting a relation between COVID-19 and GBS.

Guillain-Barré syndrome and COVID-19: an observational multicentre study from two Italian hotspot regions.

OBJECTIVE: Single cases and small series of Guillain-Barré syndrome (GBS) have been reported during the SARS-CoV-2 outbreak worldwide. We evaluated incidence and clinical features of GBS in a cohort of patients from two regions of northern Italy with the highest number of patients with COVID-19. METHODS: GBS cases diagnosed in 12 referral hospitals from Lombardy and Veneto in March and April 2020 were retrospectively collected. As a control population, GBS diagnosed in March and April 2019 in the same hospitals were considered. RESULTS: Incidence of GBS in March and April 2020 was 0.202/100 000/month (estimated rate 2.43/100 000/year) vs 0.077/100 000/month (estimated rate 0.93/100 000/year) in the same months of 2019 with a 2.6-fold increase. Estimated incidence of GBS in COVID-19-positive patients was 47.9/100 000 and in the COVID-19-positive hospitalised patients was 236/100 000. COVID-19-positive patients with GBS, when compared with COVID-19-negative subjects, showed lower MRC sum score (26.3±18.3 vs 41.4±14.8, p=0.006), higher frequency of demyelinating subtype (76.6% vs 35.3%, p=0.011), more frequent low blood pressure (50% vs 11.8%, p=0.017) and higher rate of admission to intensive care unit (66.6% vs 17.6%, p=0.002). CONCLUSIONS: This study shows an increased incidence of GBS during the COVID-19 outbreak in northern Italy, supporting a pathogenic link. COVID-19-associated GBS is predominantly demyelinating and seems to be more severe than non-COVID-19 GBS, although it is likely that in some patients the systemic impairment due to COVID-19 might have contributed to the severity of the whole clinical picture.

Electrophysiological features of acute inflammatory demyelinating polyneuropathy associated with SARS-CoV-2 infection.

OBJECTIVE: To assess whether patients with acute inflammatory demyelinating polyneuropathy (AIDP) associated with SARS-CoV-2 show characteristic electrophysiological features. METHODS: Clinical and electrophysiological findings of 24 patients with SARS-CoV-2 infection and AIDP (S-AIDP) and of 48 control AIDP (C-AIDP) without SARS-CoV-2 infection were compared. RESULTS: S-AIDP patients more frequently developed respiratory failure (83.3% vs. 25%, P=0.000) and required intensive care unit (ICU) hospitalization (58.3% vs. 31.3%, P=0.000). In C-AIDP, distal motor latencies (DMLs) were more frequently prolonged (70.9% vs. 26.2%, P=0.000) whereas in S-AIDP distal compound muscle action potential (dCMAP) durations were more frequently increased (49.5% vs. 32.4%, P=0.002) and F waves were more often absent (45.6% vs. 31.8%, P=0.011). Presence of nerves with increased dCMAP duration and normal or slightly prolonged DML was elevenfold higher in S-AIDP (31.1% vs. 2.8%, P=0.000);11 S-AIDP patients showed this pattern in 2 nerves. CONCLUSION: Increased dCMAP duration, thought to be a marker of acquired demyelination, can also be oserved in critical illness myopathy. In S-AIDP patients, an increased dCMAP duration dissociated from prolonged DML, suggests additional muscle fiber conduction slowing, possibly due to a COVID-19-related hyperinflammatory state. Absent F waves, at least in some S-AIDP patients, may reflect α-motor neuron hypoexcitability because of immobilization during the ICU stay. These features should be considered in the electrodiagnosis of SARS-CoV-2 patients with weakness, to avoid misdiagnosis.

Neurologic manifestations in 1760 COVID-19 patients admitted to Papa Giovanni XXIII Hospital, Bergamo, Italy.

OBJECTIVES: Evidences from either small series or spontaneous reporting are accumulating that SARS-CoV-2 involves the Nervous Systems. The aim of this study is to provide an extensive overview on the major neurological complications in a large cohort of COVID-19 patients. METHODS: Retrospective, observational analysis on all COVID-19 patients admitted from February 23rd to April 30th, 2020 to ASST Papa Giovanni XXIII, Bergamo, Italy for whom a neurological consultation/neurophysiological assessment/neuroradiologic investigation was requested. Each identified neurologic complication was then classified into main neurologic categories. RESULTS: Of 1760 COVID-19 patients, 137 presented neurologic manifestations that manifested after COVID-19 symptoms in 98 pts and was the presenting symptom in 39. Neurological manifestations were classified as: (a) cerebrovascular disease [53 pts (38.7%)] including 37 ischemic and 11 haemorrhagic strokes, 4 transient ischemic attacks, 1 cerebral venous thrombosis; (b) peripheral nervous system diseases [31 (22.6%)] including 17 Guillain-Barrè syndromes; (c) altered mental status [49 (35.8%)] including one necrotizing encephalitis and 2 cases with RT-PCR detection of SARS-Cov-2 RNA in CSF; (d) miscellaneous disorders, among whom 2 patients with myelopathy associated with Ab anti-SARS-CoV-2 in CSF. Patients with peripheral nervous system involvement had more frequently severe ARDS compared to patients with cerebrovascular disease (87.1% vs 42%; difference = 45.1% 95% CI 42.0-48.2; χ2= 14.306; p < 0.0002) and with altered mental status (87.1% vs 55.6%; difference = 31.5% 95% CI 27.5-37.5%; χ2= 7.055; p < 0.01). CONCLUSION: This study confirms that involvement of nervous system is common in SARS-CoV-2 infection and offers clinicians useful information for prevention and prompt identification in order to set the adequate therapeutic strategies.

Multicenter study report: electrophysiological monitoring procedures for subthalamic deep brain stimulation surgery in Parkinson's disease.

Despite the wide diffusion of subthalamic deep brain stimulation (STN-DBS) for Parkinson's disease, systematic practical recommendations for intraoperative electrophysiological monitoring are still lacking. In this paper, a shared protocol for intraoperative electrophysiological monitoring arising from the meetings of a panel of neurophysiologists of the DBS Study Group of the Italian Neurological Society is proposed. Intraoperative monitoring is composed by microrecordings and functional stimulation. In microrecordings, it is recommended to use at least 2-3 electrodes, descending with steps of 0.5-1 mm and waiting at least 60 s before changing the position. Functional stimulation is used to assess the clinical efficacy and the side effects induced by STN-DBS at different positions. Based on the therapeutic window, an algorithm to find the optimal target is proposed. The procedures for intraoperative monitoring for STN-DBS proposed here are safe, relatively cheap, take approximately 30-40 min per side and could offer valuable additional information to the surgeon.

Predictive Value of Preoperative and Intraoperative Neurophysiology in Evaluating Long-term Facial Function Outcome in Acoustic Neuroma Surgery.

OBJECTIVE: To determine the role of neurophysiological preoperative and intraoperative parameters in providing prognostic information regarding facial nerve (FN) function at 1 year after translabyrinthine acoustic neuroma (AN) resection surgery. STUDY DESIGN: Prospective observational study in a tertiary referral center. Patients treated via translabyrinthine surgical approach for sporadic AN microresection between December 2015 and 2018. METHODS: Patients underwent preoperative (electroneurography-ENG, electromyography-EMG, and Blink Reflex-BR) and intraoperative (FN motor action potential-MAP and continuous EMG traces) neurophysiological studies. FN function was graded postoperatively at 1 year using House-Brackmann Scoring System. RESULTS: Sixty-two patients were included in the analysis. Mean age was 53±10 years and average tumor diameter was 23 ±â€Š9 mm. At 1 year a normal facial function was observed in 68% of patients. In the univariate analysis a pathologic BR, low FN MAP values and ratios, and the presence of pathological neurotonic tracing (A-trains) on continuous EMG were associated with a poor facial nerve function outcome at 1 year postoperatively. Pathological preoperative BR testing and intraoperative A-trains showed a statistical significance also in the multivariable analysis, regardless of tumor size. CONCLUSIONS: Preoperative pathological BR testing and A-train activity on intraoperative EMG are correlated with poor FN outcomes at 1 year postoperative. This may provide important prognostic information to both patients and treating neuro-otologists. In the future this may guide preoperative and postoperative patient counselling and possibly optimize timing of facial nerve reanimation in selected patients.

Acute and Subacute Outcome Predictors in Moderate and Severe Traumatic Brain Injury: A Retrospective Monocentric Study.

BACKGROUND: Prognostic factors affecting outcome of traumatic brain injury (TBI), despite their importance, are still under discussion. The purpose of this study was to describe risk factors of in-hospital mortality and outcome at 1 year in a homogeneously treated population of patients with moderate/severe TBI. METHODS: A total of 193 consecutive patients with moderate or severe TBI (Glasgow Coma Scale [GCS] score 13-3, including patients with initial GCS score of 13 at high risk for subsequent neurologic deterioration), admitted to the intensive care unit, were retrospectively analyzed. In-hospital mortality and unfavorable outcome at 1 year, based on a Glasgow Outcome Scale-Extended score ≤4, were considered as primary and secondary outcomes. RESULTS: At 1 year, unfavorable outcome occurred in 47.2%, including an in-hospital mortality of 19.7%. Increasing age, GCS motor score <3, coagulation disorders, and intracranial hypertension were acute risk factors of in-hospital mortality. In the 155 remaining survivors, Oxford Handicap Scale (OHS), posttraumatic cerebral infarction, cerebrospinal fluid disturbances, and length of intensive care unit stay were associated with unfavorable outcome at 1 year, in univariate analysis. A cutoff OHS score ≥3 discriminated the probability of an unfavorable outcome (area under the curve, 0.87; P < 0.001; specificity, 74%; sensitivity, 84%). Combining the effect of acute and subacute variables in a multivariate analysis, increasing age and OHS score were independent predictors of outcome. CONCLUSIONS: The results of this retrospective study confirmed age as the main acute risk factor and identified OHS as new potential subacute predictor of unfavorable outcome in moderate and severe TBI.

Transarticular laser discal fragmentectomy. A new minimally invasive surgical approach for challenging disc herniations in the elderly.

This report describes two elderly patients with large disc fragments extruded into lumbar radicular recesses not treatable by any conventional conservative, minimally invasive or surgical approach. Direct access to the disc fragments was obtained crossing the articular zygapophyseal cavity instead of the interlaminar space and spinal canal, using a small needle through which a laser fibre was inserted to deliver energy for tissue ablation. The procedures obtained regression of both symptoms and the bulk of the fragments at early and late clinical and MR follow-ups.

Platinum-iridium subdermal magnetic resonance imaging-compatible needle electrodes are suitable for intraoperative neurophysiological monitoring during image-guided surgery with high-field intraoperative magnetic resonance imaging: an experimental study.

BACKGROUND: Neurosurgery aims to achieve maximal tumor resection while preserving neurological function. Tools such as neuronavigation, high-field intraoperative magnetic resonance imaging (iMRI), and intraoperative neurophysiological monitoring (IOM) have consistently helped to achieve this goal, but integration has often been difficult. Surgery of eloquent areas requires IOM, which in an operating theater equipped with high-field (1.5-T) iMRI could present several issues. OBJECTIVE: To identify the electrodes types more suitable for IOM in a high-field iMRI operating theater by performing an experimental study on phantoms, to report our experience with platinum-iridium (Pt/Ir) electrodes during surgery, and to prove that integration between IOM with Pt/Ir electrodes and high-field iMRI is safe and reliable. METHODS: Electrodes of different materials (gold, Pt/Ir, and stainless steel) were tested on jelly phantom and apples to evaluate their safety and compatibility. Subsequently, electrodes were tested on 5 healthy volunteers before being used on patients. RESULTS: None of the different electrodes presented thermal instability, and no damage to the volunteers' skin occurred. Stainless steel electrodes caused severe imaging distortion. Gold electrodes had no distortion, but their high cost makes their use in routine surgery unaffordable. Pt/Ir electrodes are significantly less expensive than gold electrodes and were completely safe, compatible, and suitable for use in an operating theater with high-field iMRI, providing excellent IOM and mild interference that did not affect the quality of intraoperative imaging. CONCLUSION: We suggest the use of Pt/Ir electrodes for IOM in 1.5-T iMRI suites. ABBREVIATIONS: DTI, diffusion tensor imagingiMRI, intraoperative magnetic resonance imagingIOM, intraoperative neurophysiological monitoring.