Corticosteroids in patients with vestibular neuritis: An updated meta-analysis.

Vestibular neuritis is a common neuro-otological entity. Therapeutically, corticosteroids are advised, although the evidence is limited. The objective of this review is to update meta-analyses of clinical trials that address the question of whether patients with vestibular neuritis treated with corticosteroids show better recovery than control patients. The electronic databases Medline, Scopus and Cochrane were searched for clinical trials for the years 1970-2020 without language restriction. Data were extracted, and outcome parameters were subjected to conventional and cumulative meta-analysis using a commercially available software program (www.meta-analysis.com). Finally, 15 trials with 363 participants in the treatment and 489 in the control groups were identified and could be included. Eight studies were judged to be at high risk of bias. The odds ratio (OR) for good outcome in the acute phase was 3.1 (95% CI 1.2-7.8; p = .015) in favour of steroid treatment leading to the number needed to treat (NNT) = 6 (95% CI 4-23). The odds ratio (OR) for restoration of vestibular function in the follow-up was 2.4 (95% CI 1.3-4.4; p = .004) for the benefit of steroid treatment resulting in a NNT = 7 (95% CI 5-18). The results of the cumulative statistics did not differ. The risk of adverse effects was higher in patients treated with steroids with an OR of 10.9 (95% CI 1.3-93.8; p = .015) and an estimated number needed to harm (NNH) = 4 (95% CI 3-19). The advantage for corticosteroids remained when differentiating between patients who participated in randomized or non-randomized clinical trials. Steroid treatment in vestibular neuritis resulted in a statistically significant benefit compared to control therapies. However, broad heterogeneity of the studies, mostly low-grade quality of studies, high risk of bias and broad confidence intervals put the findings into perspective allowing only a careful judgement of some benefit of corticosteroids. The findings, however, support the call for an adequately powered and well-designed randomized controlled trial to re-evaluate the effectiveness of corticosteroids.

LGI-1 encephalopathy following ChAdOx1 nCov-19 vaccination.

A 71-year-old male patient was diagnosed with LGI1 encephalopathy 4 weeks following a first ChAdOx1 nCov-19 vaccination. Extensive work-up including analysis of CSF and PET examination did not reveal a tangible cause so that a vaccine-associated encephalopathy was considered as differential diagnosis. Under steroid treatment, the faciobrachial dystonic seizures subsided.

Dexamethasone in Patients with Spontaneous Intracerebral Hemorrhage: An Updated Meta-Analysis.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is a frequent cerebrovascular disorder and still associated with high mortality and poor clinical outcomes. The purpose of this review was to update a 15-year-old former meta-analysis on randomized clinical trials (RCTs) addressing the question of whether ICH patients treated with dexamethasone have better outcomes than controls. METHODS: The electronic databases PubMed, SCOPUS, and Cochrane as well as web platforms on current clinical trials were searched for the years 1970-2020 without constriction on language. Data were extracted and outcomes were pooled for conventional and cumulative meta-analysis using a commercial software program (www.Meta-Analysis.com). RESULTS: Finally, 7 RCTs were identified and analyzed including 248 participants in the dexamethasone groups and 242 in the control groups. Five studies showed a high risk of bias. The overall relative risk (RR) for death was 1.32 (95% confidence interval [CI] 0.99-1.76; p = 0.06) and did not differ significantly between the 2 groups. After exclusion of studies with high risk of bias, the RR for death was 1.37 (95% CI 0.54-3.42; p = 0.51). The RR for poor outcome did not differ significantly between the 2 groups analyzed for all included studies (RR = 0.69; 95% CI 0.47-1; p = 0.05) and after exclusion of studies with high risk of bias (RR = 0.7; 95% CI 0.45-1.08; p = 0.11). The RR for complications did not differ significantly including all studies (RR = 1.29; 95% CI 0.77-2.17; p = 0.34) and after exclusion of studies with high risk of bias (RR = 1.27; 95% CI 0.18-8.89; p = 0.81). The cumulative statistics delivered no other results; however, it pointed out fewer complications over time in the dexamethasone group. CONCLUSION: Clear evidence of a beneficial or negative effect of dexamethasone is still lacking. Modern RCTs or observational studies with propensity design are necessary to evaluate the efficacy and safety of treatment with dexamethasone in patients with ICH.

The Diagnosis and Treatment of Idiopathic Facial Paresis (Bell's Palsy).

BACKGROUND: Peripheral facial nerve palsy is the most com- mon functional disturbance of a cranial nerve. 60-75% of cases are idiopathic. METHODS: This review is based on a selective literature search proceeding from the current, updated German-language guideline on the diagnosis and treatment of idiopathic facial nerve palsy. RESULTS: The recommended drug treatment consists of prednisolone 25 mg bid for 10 days, or 60 mg qd for 5 days followed by a taper to off in decrements of 10 mg per day. This promotes full recovery (number needed to treat [NNT] = 10; 95% confidence interval [6; 20]) and lessens the risk of late sequelae such as synkinesia, autonomic disturbances, and contractures. Virostatic drugs are optional in severe cases (intense pain or suspicion of herpes zoster sine herpete) and mandatory in cases of varicella-zoster virus (VZV) infection. Corneal protection with dexpanthenol ophthalmic ointment, artificial tears, and a nocturnal moisture- retaining eye shield has been found useful in practice. In cases of incomplete recovery with residual facial weakness, both static and microsurgical dynamic methods can be used to restore facial nerve function. CONCLUSION: Because 25-40% of cases of facial nerve palsy are not idiopathic, differential diagnosis is very important; key diagnostic methods include a clinical neurological examin- ation, otoscopy, and a lumbar puncture for cerebrospinal fluid examination. High-level evidence supports corticosteroid treatment for the idiopathic form of the disorder.

[Cranial nerve palsies: ganglioside autoantibodies indicating an immunoneuropathy]. / Isolierte Hirnnerven-Läsionen: Gangliosid-Autoantikörper als Hinweis auf Immunneuropathie.

BACKGROUND: Cranial neuropathies are not infrequent and need a broad differential diagnostic approach. Etiologically autoimmune processes have to be considered. METHOD: In five patients with cranial neuropathy (in two cases lesion of the abducens nerve, in one case bilateral facial palsy, in one case abducens, facial and bilateral vestibular lesion, in one case bilateral glossopharyngeal lesion) IgG and IgM autoantibodies directed against most relevant gangliosides were quantitatively analyzed (Bühlmann Laboratories AG, Schönenbuch, Switzerland). All patients underwent lumbar puncture and cranial imaging. RESULTS: Trauma, tumor, elevated intracranial pressure and vascular lesion could be excluded. In one patient varicella infection as a cofactor was probable, in the remaining patients direct infection could be excluded. In one patient a prominent cyto-albumin dissociation of the CSF was found. In all patients autoantibodies directed against gangliosides were detected with positive antibodies against GD1a and GD1b in all patients. Prior to the cranial neuropathy one patient reported an infection of the upper airway and one reported an infection of the gastrointestinal tract. One patient was treated with steroids and one patient with intravenous immunoglobulin, the other patients were been carefully observed. All patients recovered well. CONCLUSION: Autoimmune processes with positive autoantibodies directed against gangliosides can be found in cranial neuropathy. Based on these observations an immunomodulating therapy should be considered.

Implant therapy following liver transplantation: clinical and microbiological results after 10 years.

BACKGROUND: The number of immunocompromised patients is increasing as a consequence of successful organ transplantation. Placing dental implants in these patients has been questioned because of their increased risk for infections. The 10-year follow-up data of a 71-year-old liver transplant recipient with long-term immunosuppressive therapy is reported. Six months after liver transplantation, two interforaminal implants were inserted in the edentulous mandible, and an overdenture using non-rigid telescopic attachments was fabricated 3 months later. METHODS: Oral clinical parameters included the modified plaque index, sulcus fluid flow rate, modified bleeding index, probing depth, distance implant mucosa, attachment level, width of the keratinized mucosa and mobility values. The distance implant bone (DIB) was determined on digital panoramic radiographs. The levels of eight periodontal marker organisms were established using DNA probe technology. Additionally, swabs of the edentulous oral mucosa were taken for microbiological culture and antimicrobial resistance testing. RESULTS: The peri-implant parameters were within normal ranges indicating a stable osseointegration with moderate vertical bone loss. Actinobacillus actinomycetemcomitans, Tannerella forsythensis, Campylobacter rectus, and Treponema denticola were not detected. Low levels of Porphyromonas gingivalis, Fusobacterium nucleatum, and Eikenella corrodens were found. Prevotella intermedia was the only bacterium with a level higher than 10(4). The mucosal swabs indicated the presence of an abundant normal oral flora, including Escherichia coli and Candida albicans. The antibiogram revealed multiple resistance to antibiotics. CONCLUSION: This case report suggests that immunocompromised patients can be successfully rehabilitated with dental implants.