Neurological features and outcome in COVID-19: dementia can predict severe disease.

The COVID-19 pandemic has infected more than 22 million people worldwide. Although much has been learned about COVID-19, we do not know much about its neurological features and their outcome. This observational study was conducted on the patients of Imam Hossein Hospital, and 361 adult patients (214 males) with confirmed diagnosis of COVID-19 from March 5, 2020 to April 3, 2020, were enrolled. Data was gathered on age, sex, comorbidities, initial symptoms, symptoms during the disease course, neurological symptoms, and outcome. The mean age of the patients was 61.90 ± 16.76 years. The most common initial symptoms were cough, fever, and dyspnea. In 21 patients (5.8%), the initial symptom was neurological. History of dementia was associated with severe COVID-19 disease (odds ratio = 1.28). During the course of the disease, 186 patients (51.52%) had at least one neurological symptom, the most common being headache (109 [30.2%]), followed by anosmia/ageusia (69, [19.1%]), and dizziness (54, [15%]). Also, 31 patients had neurological complications (8.58%). Anosmia, ageusia, dizziness, and headache were associated with favorable outcome (P < 0.001), while altered mental status and hemiparesis were associated with poor outcome. The mortality rate of patients who had neurological complications was more than twice than that of patients without neurological complication (P = 0.008). Almost half of the patients experienced at least one neurological symptom, which may be the initial presentation of COVID-19. Dementia appears to be associated with severe COVID-19. Mortality was higher in patients with neurological complications, and these patients needed more intensive care.

Stroke Burden in Rwanda: A Multicenter Study of Stroke Management and Outcome.

BACKGROUND: Cerebrovascular accidents or stroke constitute the second leading cause of mortality worldwide. Low- and middle-income countries bear most of the stroke burden worldwide. The main objective of this study is to determine the burden of stroke in Rwanda. METHODS: This was a prospective observational study in 2 parts: 6 months baseline data collection and outcome assessment sessions at 1 year. RESULTS: A total of 96 patients were enrolled in our series. Stroke constituted 2100 per 100,000 population. Of all patients, 55.2% were male and most (60%) were 55 years and older. Of all patients and/or caretakers, 22% were not aware of their previous health status and 53.5% of hypertensive patients were not on treatment by the time of the event. Median presentation delay was 72 hours for patients with ischemic stroke and 24 hours for patients with hemorrhagic stroke. Most patients had hemorrhagic stroke (65% vs. 35%), and more patients with hemorrhagic stroke presented with loss of consciousness (80% vs. 51%). Many patients (62% ischemic group and 44% hemorrhagic group) presented with severe stroke scores, and this was associated with worst outcome (P = 0.004). At 1 year follow-up, 24.7% had no or mild disability, 14.3% were significantly disabled, and 61% had died. CONCLUSIONS: Our results show that stroke is a significant public health concern in Rwanda. Risk factor awareness and control are still low and case fatality of stroke is significantly high. The significant delay in presentation to care and presentation with severe stroke are major contributors for the high mortality and severe disability rates.

Focal Neurological Deficit at Onset of Aneurysmal Subarachnoid Hemorrhage: Frequency and Causes.

BACKGROUND AND AIM: Focal neurological deficit (FND) is a recognized presenting symptom of aneurysmal subarachnoid hemorrhage (SAH). However, little is known on how often aneurysmal SAH patients present with FND and what the responsible mechanisms are. The aim of this study was to examine the frequency and causes of FND at onset in aneurysmal SAH. METHODS: We reviewed the records of consecutive aneurysmal SAH patients over 5 years and identified those who presented with FND. We developed several potential mechanisms for FND based on consensus between 2 separate evaluating neurologists. We then compared the characteristics of aneurysmal SAH patients who presented with and without FND. Logistic regression models were used to assess for association of FND with poor outcome. RESULTS: Of a total of 213 patients, 10.3% presented with FND. The junction of the internal carotid and posterior communicating arteries was the most common aneurysm location in patients with FND (36.4%). Causes of FND at presentation were intraparenchymal hematoma in 45.5%, early cerebral infarction in 22.7%, parenchymal compression by subarachnoid thrombus in 18.2%, and seizure with Todd's paralysis in 13.6%. Patients with FND were older (P = .001) and had higher rates of in-hospital death and severe disability at discharge (P < .0001), compared to those without focal deficit. FND was independently associated with poor outcome (odds ratio: 4.62, confidence interval: 1.41-15.14; P = .01). CONCLUSION: One in every 10 aneurysmal SAH patients presents with FND. FND at presentation has diverse mechanisms, is not associated with a specific aneurysm location, and is independently associated with poor outcome.

Pneumonia in patients with severe head injury: incidence, risk factors, and outcomes.

OBJECT: The reported incidence of hospital-acquired bacterial pneumonia in critically ill trauma patients varies from as low as 4% to as high as 87%, with fatality rates varying from 6% to 59%. Clinical studies have identified the risk factors for pneumonia. The authors undertook this retrospective study to evaluate the incidence, risk factors, and outcomes of hospital-acquired bacterial pneumonia in a group of patients with severe head injuries. METHODS: This was a retrospective review of consecutive adult patients admitted to the neurosurgical ICU in the authors' hospital because of severe head injury (Glasgow Coma Scale scores ≤ 8) between January 2008 and December 2010. RESULTS: During the study period, 290 patients were admitted to the neurosurgical ICU. Multivariate Cox regression analysis showed that age (HR 1.01, 95% CI 1.001-1.02), nasogastric tube insertion (HR 4.56, 95% CI 1.11-18.64), and hemiplegia or hemiparesis (HR 3.79, 95% CI 2.01-7.17) were significantly associated with the development of pneumonia. CONCLUSIONS: The authors identified 3 risk factors (age, nasogastric tube insertion, and hemiplegia or hemiparesis) associated with the development of pneumonia in patients with severe head injury. This finding constituted the basis for developing a simple screening tool that can be used to assess the risk of occurrence of pneumonia in such patients.

The underlying factor structure of National Institutes of Health Stroke scale: an exploratory factor analysis.

The underlying structure of National Institutes of Health Stroke Scale (NIHSS) as the most widely used scale in clinical trials has been the focus of little attention. The aim of the current study was to elucidate the clustering pattern of NIHSS items in ischemic stroke patients. A series of 152 consecutive patients with first-ever ischemic strokes admitted to a university affiliated hospital were enrolled. NIHSS score was estimated on admission and correlation coefficients between its items were calculated. Further, exploratory factor analysis was used to study the clustering pattern of NIHSS items. Extinction neglect, visual field, and facial palsy were weakly associated with other NIHSS items. Factor analysis led to a four-factor structure. Factors 1 and 3 were determined by left brain function as items of right arm and leg motor, language and dysarthria loaded on both of them. By contrast, factor 2 reflected right brain involvement. Since visual field and ataxia loaded on factor 4, this factor was primarily associated with posterior strokes. Our study shows that a four-factor structure model is plausible for NIHSS. Further, for the first time, a single distinct factor is identified for posterior strokes.

Phalaris arundinacea (reed canarygrass) grass staggers in beef cattle.

Four adult mixed-breed beef cows from a cow-calf operation in West Virginia were referred to the Virginia-Maryland Regional College of Veterinary Medicine in March 2009 with weakness, ataxia, hind limb paresis progressing to lateral recumbency, and death within 2-3 days. Histologically, there was accumulation of light brown, granular pigment in neurons of the ventral gray horns of the spinal cord (more severe in thoracic and lumbar sections), brain stem, and pons, resulting in distortion and bulging of the cell body and displacement of the Nissl substance, suggestive of Phalaris sp. grass toxicosis. The most severely affected cow had accumulation of dark green-brown pigment in renal tubular epithelial cells. Reed canarygrass (Phalaris arundinacea) was identified in pastures, and the concentration of tryptamine alkaloids in new leaf blades was approximately 0.2% on a wet weight basis. These alkaloids are serotonergic receptor agonists, resulting in neurologic "staggers" in ruminants. Delayed onset times of up to 4-5 months have been reported in sheep after removal from Phalaris sp. pastures. Distribution of pigment in serotonergic tracts of the midbrain, brain stem, and spinal cord with Phalaris sp. toxicoses is distinct and differs from lipofuscin. Electron microscopy confirmed that the pigment was not lipofuscin. From these findings, a diagnosis of delayed P. arundinacea toxicosis was made. Over a 2-month period, 18 cows died with similar clinical signs.

Hormonal status and ICU-acquired paresis in critically ill patients.

BACKGROUND: The pathogenesis of intensive care unit-acquired paresis (ICUAP), a frequent and severe complication of critical illness, is poorly understood. Since ICUAP has been associated with female gender in some studies, we hypothesized that hormonal dysfunction might contribute to ICUAP. OBJECTIVE: To determine the relationship between hormonal status, ICUAP and mortality in patients with protracted critical illness. DESIGN: Prospective observational study. SETTING: Four medical and surgical ICUs. PATIENTS: ICU patients mechanically ventilated for >7 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Plasma levels of insulin growth factor-1 (IgF1), prolactin, thyroid stimulating hormone (TSH), follicular stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, testosterone, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulphate (DHEAS) and cortisol were measured on the first day patients were awake (day 1). Mean blood glucose from admission to day 1 was calculated. ICUAP was defined as Medical Research Council sum score <48/60 on day 7. RESULTS: We studied 102 patients (65 men and 37 women, 29 post-menopausal), of whom 24 (24%) died during hospitalization. Among the 86 patients tested at day 7, 39 (49%) had ICUAP, which was more frequent in women (63% versus men 36%, p = 0.02). Mean blood glucose was higher in patients with ICUAP. Estradiol/testosterone ratio was greater in men with ICUAP. CONCLUSION: ICUAP 7 days after awakening was associated with increased blood glucose and with biological evidence of hypogonadism in men, while an association with hormonal dysfunction was not detected in women.

Outcome three years after motor stroke.

There are few well-designed descriptive studies that focus exclusively on the long-term outcomes of patients after motor stroke. This study reports mortality rates and describes the psychological and functional outcomes 3 years after motor stroke. A description of the variables during acute care and at 3 months that best explain function 3 years after motor stroke is also provided. Home visits were made to 30 patients and another 19 were interviewed by phone. The four instruments used to measure the outcomes were the Center for Epidemiological Studies Depression Scale (CES-D), the Neurobehavioral Cognitive Status Examination (COGNISTAT), the Mini-Mental State Examination (MMSE), and the Functional Independence Measure (FIM). Eleven of the 60 patients contacted had died by the 3-year follow up. The main outcome measures were 3-month FIM of 117.07 (+/- 12.53) and 3-year outcomes for CES-D (6.70 [+/- 7.29]), COGNISTAT (69.67 [+/- 15.62]), MMSE (27.53 +/- 2.74]), and FIM (114.57 +/- 19.00]). A number of multiple regression models were examined; in the best model, the FIM at 3 months accounted for 46% of the variance in function 3 years following the stroke. It is important for rehabilitation nurses to know that the mortality rate was low, psychological outcome was improved, and function was stable 3 years after a motor stroke.

Presence and severity of intensive care unit-acquired paresis at time of awakening are associated with increased intensive care unit and hospital mortality.

OBJECTIVES: To assess whether the presence and severity of intensive care unit-acquired paresis are associated with intensive care unit and in-hospital mortality. DESIGN: Prospective, observational study. SETTING: Two medical, one surgical, and one medico-surgical intensive care units in two university hospitals and one university-affiliated hospital. PATIENTS: A total of 115 consecutive patients were enrolled after > 7 days of mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The Medical Research Council score (from 0-60) was used to evaluate upper and lower limb strength at time of awakening, identified as the ability to follow five commands. Intensive care unit-acquired paresis was defined as a Medical Research Council score <48. Patients were followed-up until hospital discharge. The primary end point was hospital mortality. At awakening, median Medical Research Council score was 41 (interquartile range, 21-52), and 75 (65%) patients had intensive care unit-acquired paresis. Hospital non-survivors had a significantly lower Medical Research Council score at awakening (21 [11-43]) vs. 41 [28-53]; p = .008) and a significantly higher rate of intensive care unit-acquired paresis (85.1% vs. 58.4%; p = .02) compared to survivors. After multivariate risk adjustment, intensive care unit-acquired paresis was independently associated with higher hospital and intensive care unit mortality (odds ratio for hospital mortality, 2.02; 95% confidence interval, 1.03-8.03; p = .048). Each Medical Research Council point decrease was associated with a significantly higher hospital mortality (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; p = .033). CONCLUSIONS: Both the presence and severity of intensive care unit-acquired paresis at the time of awakening are associated with increased intensive care unit and hospital mortality; the mechanisms underlying this association need further study.

Ataxia and paralysis in cats in Australia associated with exposure to an imported gamma-irradiated commercial dry pet food.

Between June 2008 and March 2009, 87 cats in Australia developed symmetrical hindlimb ataxia, paraparesis, tetraparesis, paraplegia or tetraplegia in association with eating an imported, irradiated dry pet food. This communication reports the clinical signs and outcomes of those cats.

Acquired weakness, handgrip strength, and mortality in critically ill patients.

RATIONALE: ICU-acquired paresis (ICUAP) is common in survivors of critical illness. There is significant associated morbidity, including prolonged time on the ventilator and longer hospital stay. However, it is unclear whether ICUAP is independently associated with mortality, as sicker patients are more prone and existing studies have not adjusted for this. OBJECTIVES: To test the hypothesis that ICUAP is independently associated with increased mortality. Secondarily, to determine if handgrip dynamometry is a concise measure of global strength and is independently associated with mortality. METHODS: A prospective multicenter cohort study was conducted in intensive care units (ICU) of five academic medical centers. Adults requiring at least 5 days of mechanical ventilation without evidence of preexisting neuromuscular disease were followed until awakening and were then examined for strength. MEASUREMENTS AND MAIN RESULTS: We measured global strength and handgrip dynamometry. The primary outcome was in-hospital mortality and secondary outcomes were hospital and ICU-free days, ICU readmission, and recurrent respiratory failure. Subjects with ICUAP (average MRC score of < 4) had longer hospital stays and required mechanical ventilation longer. Handgrip strength was lower in subjects with ICUAP and had good test performance for diagnosing ICUAP. After adjustment for severity of illness, ICUAP was independently associated with hospital mortality (odds ratio [OR], 7.8; 95% confidence interval [CI], 2.4-25.3; P = 0.001). Separately, handgrip strength was independently associated with hospital mortality (OR, 4.5; 95% CI, 1.5-13.6; P = 0.007). CONCLUSIONS: ICUAP is independently associated with increased hospital mortality. Handgrip strength is also independently associated with poor hospital outcome and may serve as a simple test to identify ICUAP. Clinical trial registered with www.clinicaltrials.gov (NCT00106665).

Stroke, a major and increasing risk factor for femoral neck fracture.

BACKGROUND AND PURPOSE: Patients with stroke have up to a 4-fold increased risk of hip fracture because of their high incidence of falls and loss of bone mass in the paretic side, ie, hemiosteoporosis. The purpose of this study was to investigate the prevalence of previous stroke among patients with femoral neck fracture. METHODS: The study included all 568 patients, aged >/=65 years, who underwent surgery for femoral neck fracture in 1980, 1983, 1987, 1993, and 1997 at the orthopedic clinic of Umeå University Hospital, Umeå, Sweden. RESULTS: The prevalence of previous strokes ranged from 16.4% to 38.5% (P<0.001); this finding is only partly explained by the increased incidence of stroke in the corresponding population, and there was no significant increase in the overall incidence of femoral neck fracture. Fractures occurred 5.4+/-6.4 years after stroke (median 2.9 years, range 0 to 33 years). In stroke patients with unilateral stroke and persisting paresis at the time of fracture, 62.5% had their fracture on the paretic side (P=0. 034). Survival was significantly reduced in patients with previous stroke (P<0.001). In patients previously independently mobile, 69.2% with no previous stroke and 38.1% with previous stroke were still mobile at discharge from the orthopedic unit (P<0.001). CONCLUSIONS: Attention must be focused on stroke as a major and increasing risk factor for femoral neck fracture and also on the poor postfracture outcome and reduced survival of these patients. Prevention of poststroke fractures is necessary and is aimed at reducing the risk of poststroke fall and preventing the development of hemiosteoporosis.

Causes of losses including a Borna disease paralytic syndrome affecting young ostriches of one breeding organization over a five-year period (1989-1993).

Necropsy records and causes of mortality of ostriches up to 3 months old over a 5-year period (1989-1993) are presented. The data relate to one ostrich enterprise that comprises 10 breeding flocks, five rearing farms, and one hatchery. Causes of mortality are classified into nine major categories. The annual mortality percentages of all hatched ostriches over the 5-year period were 61%, 58%, 30%, 29%, and 16.6%, and the most significant cause of death was a paresis syndrome that accounted for 20%, 11%, 16%, 10.1%, and 2% mortality, respectively. Limb deformities and gastroenteritis were the other principal specific causes of mortality. The paresis syndrome was caused by an agent serologically related to Borna disease virus. Brain extracts from paralyzed ostriches, when given orally or intramuscularly to 5-week-old birds, reproduced the clinical signs and microscopic lesions. The mean time to death was less than 3 weeks for the intramuscularly infected group and was almost twice as long for the orally infected group.

Outcome of sixth nerve palsy or paresis in young children.

This study evaluated the ophthalmological outcome following sixth nerve palsy or paresis in 64 children 7 years of age and younger. The outcomes considered were vision, residual strabismus and the need for strabismus surgery. Etiologies included tumor, hydrocephalus, trauma, infection, malformation, and idiopathic and miscellaneous causes. Strabismus surgery was performed on 24% of the patients, with residual strabismus present in 66% of the patients. Neurologists and ophthalmologists should monitor visual acuity in these young children at frequent intervals be prepared to institute amblyopia therapy early in the course of the ocular misalignment if permanent visual disability is to be avoided.

[Comparative study of long-term mortality in the mentally ill]. / Etude comparative de la mortalité à long terme dans les maladies mentales

The mortality in mental illness has been studied after an average follow-up period of 3-4 decades in a material of 5661 former in-patients of the Psychiatric University Hospital of Lausanne (Switzerland), from which 3520 probands were dead at the date of reference. By use of an improved method, the calculations showed in all diagnostic groups, and generally more marked in women than in men, a 1,34 to 9,72 times higher mortality than in the general population, increasing in the following order: head injuries, psychogenic and psychopathic disorders, manic syndromes, schizophrenia, depressions, mental retardation, alcoholisme, other psychosis, epilepsy, general paralysis, other cerebro-organic conditions. Several possible explanations of these results are discussed.

Temporal lobe surgery around the world. Results, complications, and mortality.

This survey covers 2,282 published temporal lobe resections, performed from 1928-1973, all over the world, as treatment of invalidating, drug-resistant epilepsy. At follow-up, two-thirds of the patients were free or almost free from seizures; and over half of those patients who were mentally abnormal before the operation were normalized or had obtained a marked improvement. The operative mortality has always been very low. No operative mortality has been recorded within the last decade. The risk of severe complications such as persistent hemiparesis and/or a complete homonymous hemianopia has decreased markedly, and is now only a few per cent.